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O.23 Substrate fuel kinetics in enterally fed trauma patients supplemented with ornithine alphaketoglutarate (OKG)
0.22 Postoperative nitrogen excretion after amino acid-induced thermogenesis under anaesthesia E. Selld~n, and S. G. E. Lindah/
Department of Anaesthesia and Intensive Care, Karo/inska Hospital, S- 171 76 Stockholm, Sweden.
Purpose of the study: Amino acid infusions have in previous studies under general anaesthesia been shown to induce augmented thermogenesis and to prevent postoperative hypothermia. The effects of this on nitrogen balance have not been examined. Methods: In the present study, the effect of perioperative amino acid infusions on postoperative nitrogen excretion was studied in 24 patients, scheduled for hysterectomy. Seven volunteers, not subjected to anaesthesia or surgery, were used as awake controls (Group A). During isoflurane anaesthesia, 8 patients (Group B) had saline, and 16 patients (Groups C and D) received an i.v. amino acid mixture, 240 kJ/h, before/during anaesthesia. Rectal temperature and energy expenditure were measured. The urinary nitrogen content was calculated from urea, creatinine, and urate, during the day before surgery and four postoperative days. Diets were recorded. Results: Anthropometric data did not differ significantly between the groups, the subjects ranging between 45-55 years of age and 55-69 kg of body mass. Similarly, the preoperative nitrogen excretion was not differing significantly between the study groups. Postoperative nitrogen excretion decreased by 31% (P < 0.05) below preoperative levels in Group B, who also experienced the greatest fall in core body temperature, 1.67 _+ 0.07°C (P < 0.001). All had postoperative shivering. In Groups C and D, who received amino acid infusions, the temperature drop during anaesthesia was less pronounced than in Group B, 1.03 _+ 0.11 °C (P < 0.001 ), and postoperative shivering disappeared. In addition, the nitrogen excretion was unchanged postoperatively, maybe indicating an increase in protein turnover, known to generate heat. The mechanisms behind the increased thermic effect of amino acids under anaesthesia are not fully understood. The splanchnic contribution to this thermogenesis is reduced during anaesthesia, which may focus the interest on skeletal muscle with its capacity of considerable variations in oxygen consumption and possibly heat production. Conclusion: It is concluded that the increase in heat production induced by amino acids reduced hypothermia, abolished shivering, and attenuated/normalised the postoperative nitrogen saving that occurred in patients not given amino acids.
0.23 Substrate fuel kinetics in enterally fed trauma patients supplemented with ornithine alphaketoglutarate (OKG) M. Jeevanandam and S. R. Petersen
St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
Background: When nutritional support is aimed at counteracting catabolism in the early post-traumatic period, preservation of body proteins is an important goal. OKG is a promising, novel anabolic agent and the mechanisms of its potential use in trauma patients is not clearly understood. Aim: To determine the altered whole-body protein, lipid and glucose substrate kinetics in trauma victims in the early flow-phase of injury when they were fed enterally with or without OKG. Methods: Fourteen adult (10M/4F, 54 _+6 years) multiple trauma (ISS = 27 _+2) patients who were highly catabolic (daily N loss = 15.9 _+2.2 g/d) and hypermetabolic (REF__JBEE= 1.40 _+0.07) were studied. Whole-body
protein (lSN glycine), fat (2 stage glycerol infusion) and glucose (3H glucose) kinetics (t/o) and plasma parameters were measured once (A) within 48-60 hours after injury before starting nutritional support and then (B) after 4 days of enteral feeding. Group II (n = 7) received a defined enteral formula (Two Cal HN, 1.4 times BEE calories) and Group I (n = 7) received isonitrogenous diet replacing 2.62 gN/d from the enteral diet by OKG-N (20g/d OKG). Results (Mean -+SEM): Protein t/o is significantly (P_< 0.05) increased in OKG treated patients (4.68 _+0.15 vs 3.90 + 0.23, gP/kg/day) and glycerol t/o is decreased (0.87 _+0.16 vs 1.46 + 0.16, p mole/kg/min). Glucose t/o is not changed. Significant (P_< 0.05) increases in circulating plasma levels of hormones (insulin, 44.2 + 8.4 vs 15.7 _+5.0 ulU/ml, growth hormone 1.68 ± 0.33 vs 0.92 _+0.16, ng/ml and IGF-1,106 _+13 vs 75 • 18, ng/ml) and free amino acids (glutamine, 383 _+20 vs 306 _+25, Proline, 203 _+18 vs 146 -+ 13 and ornithine, 164 + 27 vs 49 _+5 IJ mole/I) rate are found in Group I, OKG treated patients, compared to non-OKG, Group II patients. Conclusion: Increased hormone secretion due to OKG may be responsible for altered substrate fuel kinetics.
0.24 Malnutrition (PEM): an independent factor to predict length of stay (LOS) among HIV* in-patients A. Mij&n, A. Perez-Garc[a* J. F.. Lorenzo and J. Locutura
Department of Internal Medicine, Hospital Genera/ YagEte and *C. S. Garc[a Lorca, Burgos, Spain.
Aim: To check the impact of PEM as an independent factor on the LoS in HIV+'s, while controlling both confounding-intermediate factors of the study. Methods: Since February 1992, 152 HIV ÷ in-patients [79.7% M, 20.3% W, mean age 30 (16-74)] entered a follow-up study. When first admitted, according to a nutritional assessment protocol, they were classified as being PEM [69(45%)] and non-PEM [83(55%)]. Among malnourished patients, PEM-degree was mild in 11 (15.9%), moderate in 36 (52.2%) and severe in 22 (31.9%). All patients were orally, enterally or parenterally fed. Clinical, demographical, biological, immunological and dietetical variables which could interfere in final analysis, were also registered. In January 1995, the influence of PEM and other variables on the LoS were checked either by Kruskall-Wallis and Scheff6 tests or by linear regression. Through a multivariate analysis (stepwise-regression), a LoS final model was selected, thus reflecting both exposure (PEM) and control variables. Significance was reached at P < 0.05. Results: Median LoS in the cohort was 14 days (4-53). It showed to be significantly different not only between non-PEM [11 days (4-31)] and PEM patients [26 days (6-72)] (95% CI for difference: 11-21 days), but also between non-PEM and moderate-PEM [25 days (6-66)], non-PEM and severe-PEM [36 days (6-85)], and mild [14 days (10-49)] and severe-PEM. Individually, number of CD4 ÷, sex, haemoglobin and calcium plasma levels, risk factor for HIV, type of PEM, AIDS' criteria and opportunistic infection (OI) were also significantly related to the cohort's LoS. These variables, together with PEM were introduced in a multivariate regression model that, after being adjusted, gave the final equation: y
= 19.3 + 6.8 (CI95%:4.8-8.8) PEM+ 4.9 (C195%:0.24-9.54) OI - 6.4 (C195%:-11.9--0.9) Sex. (R2 = 0.317, F = 20.54, P< 0.0001), where: y = LoS (days); PEM (P < 0.0001): non-PEM = 0, mild = 1, moderate = 2, severe = 3; OI (P= 0.039): no = 0, yes = 1; Sex (P= 0.023): M = 1, W = 2. Conclusions: 1) PEM acts as an independent prognostic factor, being positively associated with LoS. 2) A Dose-Response effect is reflected: the higher the intensity of PEM, the higher the LoS. 3) Presence of OI and male-sex were also related to a prolonged LoS.
Department of Anaesthesia and Intensive Care, Karo/inska Hospital, S- 171 76 Stockholm, Sweden.
Purpose of the study: Amino acid infusions have in previous studies under general anaesthesia been shown to induce augmented thermogenesis and to prevent postoperative hypothermia. The effects of this on nitrogen balance have not been examined. Methods: In the present study, the effect of perioperative amino acid infusions on postoperative nitrogen excretion was studied in 24 patients, scheduled for hysterectomy. Seven volunteers, not subjected to anaesthesia or surgery, were used as awake controls (Group A). During isoflurane anaesthesia, 8 patients (Group B) had saline, and 16 patients (Groups C and D) received an i.v. amino acid mixture, 240 kJ/h, before/during anaesthesia. Rectal temperature and energy expenditure were measured. The urinary nitrogen content was calculated from urea, creatinine, and urate, during the day before surgery and four postoperative days. Diets were recorded. Results: Anthropometric data did not differ significantly between the groups, the subjects ranging between 45-55 years of age and 55-69 kg of body mass. Similarly, the preoperative nitrogen excretion was not differing significantly between the study groups. Postoperative nitrogen excretion decreased by 31% (P < 0.05) below preoperative levels in Group B, who also experienced the greatest fall in core body temperature, 1.67 _+ 0.07°C (P < 0.001). All had postoperative shivering. In Groups C and D, who received amino acid infusions, the temperature drop during anaesthesia was less pronounced than in Group B, 1.03 _+ 0.11 °C (P < 0.001 ), and postoperative shivering disappeared. In addition, the nitrogen excretion was unchanged postoperatively, maybe indicating an increase in protein turnover, known to generate heat. The mechanisms behind the increased thermic effect of amino acids under anaesthesia are not fully understood. The splanchnic contribution to this thermogenesis is reduced during anaesthesia, which may focus the interest on skeletal muscle with its capacity of considerable variations in oxygen consumption and possibly heat production. Conclusion: It is concluded that the increase in heat production induced by amino acids reduced hypothermia, abolished shivering, and attenuated/normalised the postoperative nitrogen saving that occurred in patients not given amino acids.
0.23 Substrate fuel kinetics in enterally fed trauma patients supplemented with ornithine alphaketoglutarate (OKG) M. Jeevanandam and S. R. Petersen
St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
Background: When nutritional support is aimed at counteracting catabolism in the early post-traumatic period, preservation of body proteins is an important goal. OKG is a promising, novel anabolic agent and the mechanisms of its potential use in trauma patients is not clearly understood. Aim: To determine the altered whole-body protein, lipid and glucose substrate kinetics in trauma victims in the early flow-phase of injury when they were fed enterally with or without OKG. Methods: Fourteen adult (10M/4F, 54 _+6 years) multiple trauma (ISS = 27 _+2) patients who were highly catabolic (daily N loss = 15.9 _+2.2 g/d) and hypermetabolic (REF__JBEE= 1.40 _+0.07) were studied. Whole-body
protein (lSN glycine), fat (2 stage glycerol infusion) and glucose (3H glucose) kinetics (t/o) and plasma parameters were measured once (A) within 48-60 hours after injury before starting nutritional support and then (B) after 4 days of enteral feeding. Group II (n = 7) received a defined enteral formula (Two Cal HN, 1.4 times BEE calories) and Group I (n = 7) received isonitrogenous diet replacing 2.62 gN/d from the enteral diet by OKG-N (20g/d OKG). Results (Mean -+SEM): Protein t/o is significantly (P_< 0.05) increased in OKG treated patients (4.68 _+0.15 vs 3.90 + 0.23, gP/kg/day) and glycerol t/o is decreased (0.87 _+0.16 vs 1.46 + 0.16, p mole/kg/min). Glucose t/o is not changed. Significant (P_< 0.05) increases in circulating plasma levels of hormones (insulin, 44.2 + 8.4 vs 15.7 _+5.0 ulU/ml, growth hormone 1.68 ± 0.33 vs 0.92 _+0.16, ng/ml and IGF-1,106 _+13 vs 75 • 18, ng/ml) and free amino acids (glutamine, 383 _+20 vs 306 _+25, Proline, 203 _+18 vs 146 -+ 13 and ornithine, 164 + 27 vs 49 _+5 IJ mole/I) rate are found in Group I, OKG treated patients, compared to non-OKG, Group II patients. Conclusion: Increased hormone secretion due to OKG may be responsible for altered substrate fuel kinetics.
0.24 Malnutrition (PEM): an independent factor to predict length of stay (LOS) among HIV* in-patients A. Mij&n, A. Perez-Garc[a* J. F.. Lorenzo and J. Locutura
Department of Internal Medicine, Hospital Genera/ YagEte and *C. S. Garc[a Lorca, Burgos, Spain.
Aim: To check the impact of PEM as an independent factor on the LoS in HIV+'s, while controlling both confounding-intermediate factors of the study. Methods: Since February 1992, 152 HIV ÷ in-patients [79.7% M, 20.3% W, mean age 30 (16-74)] entered a follow-up study. When first admitted, according to a nutritional assessment protocol, they were classified as being PEM [69(45%)] and non-PEM [83(55%)]. Among malnourished patients, PEM-degree was mild in 11 (15.9%), moderate in 36 (52.2%) and severe in 22 (31.9%). All patients were orally, enterally or parenterally fed. Clinical, demographical, biological, immunological and dietetical variables which could interfere in final analysis, were also registered. In January 1995, the influence of PEM and other variables on the LoS were checked either by Kruskall-Wallis and Scheff6 tests or by linear regression. Through a multivariate analysis (stepwise-regression), a LoS final model was selected, thus reflecting both exposure (PEM) and control variables. Significance was reached at P < 0.05. Results: Median LoS in the cohort was 14 days (4-53). It showed to be significantly different not only between non-PEM [11 days (4-31)] and PEM patients [26 days (6-72)] (95% CI for difference: 11-21 days), but also between non-PEM and moderate-PEM [25 days (6-66)], non-PEM and severe-PEM [36 days (6-85)], and mild [14 days (10-49)] and severe-PEM. Individually, number of CD4 ÷, sex, haemoglobin and calcium plasma levels, risk factor for HIV, type of PEM, AIDS' criteria and opportunistic infection (OI) were also significantly related to the cohort's LoS. These variables, together with PEM were introduced in a multivariate regression model that, after being adjusted, gave the final equation: y
= 19.3 + 6.8 (CI95%:4.8-8.8) PEM+ 4.9 (C195%:0.24-9.54) OI - 6.4 (C195%:-11.9--0.9) Sex. (R2 = 0.317, F = 20.54, P< 0.0001), where: y = LoS (days); PEM (P < 0.0001): non-PEM = 0, mild = 1, moderate = 2, severe = 3; OI (P= 0.039): no = 0, yes = 1; Sex (P= 0.023): M = 1, W = 2. Conclusions: 1) PEM acts as an independent prognostic factor, being positively associated with LoS. 2) A Dose-Response effect is reflected: the higher the intensity of PEM, the higher the LoS. 3) Presence of OI and male-sex were also related to a prolonged LoS.