- Email: [email protected]
P.9 Total parenteral nutrition does not increase the riskof nosocomial infections in critically ill patients
enteral nutrition supplemented by arginine, omega-3-fatty-acids and nucleotides in order to improve the outcome in critically ill patients.
P.8 Effects of early enteral nutrition with arginine, omega-3-fatty acids and nucleotides supplemented on the systemic inflammatory response syndrome and immune function in severe multiple injury
P.9 Total parenteral nutrition does not increase the risk of nosocomial infections in critically ill patients T. Grau Carmona, S. Zubillaga Mu~oz, E. Calve Herranz, P. Garcfa
A, W e i m a n n ~, L. Bastian 2, M. Grotz 2, M. Hansel~, H. J. Schlitt 1 and
G. Regel2 Klinik for Abdominal- und Transplantationschirurgie und 2Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Hannover, Germany.
Hierro*, S. Casado Hoces, S. Bias Obispo and D. Ayuso Murillo Depts of Intensive Care and *Microbiology, University of Getafe, Madrid, Spain.
Aim: Previous studies showed in critically ill patients beneficial effects of
Objective: To determine if total parenteral nutrition (TPN) increases the frequency of nosocomial infections (NI) and mortality compared with enteral nutrition (EN) in a prospective cohort of critically ill. Methods: During a 15-month period 298 patients entered in the study. Reasons for exclusion were early discharge (fewer than 3 days in the ICU) and/or fewer than 3 days of artificial nutrition. Data collected included age, sex, length of stay (LOS), days of mechanical ventilation (MV) and outcome. The risk factors for NI registered were sepsis and cancer on admission, previous gastrointestinal (GI) surgery, APACHE II and TPN. The NI considered included pneumonia, bacteriemia, catheterrelated sepsis, infected catheter and septic shock. Definitions of NI, sepsis and septic shock have been published elsewhere [1-3]. Univariate analysis was performed using X2 test, relative risk (RR) and Student's ttest. The risk factors were tested for their ability to predict NI with a stepwise logistic regression model. Results: Of the 197 patients eligible for analysis, 135 received EN and 62 TPN or both. There were no statistical differences in sex, APACHE II, LOS, days of MV and mortality. TPN group was older (66y vs 58y, P< 0.005) and had more cancer on admission (27.4% vs 5.2%, P < (:).001), sepsis on admission (50% vs 20.7%, P < 0.001) and previous GI surgery (64.5% vs 14.8%, P < 0.001 ). RR for penumonia, bacteriemia, catheterrelated sepsis, infected catheter and overall NI was not increased in TPN group. RR for septic shock in the TPN group was 5.4 (CI95%: 2.6-10.9; P < 0.001). APACHE II was the sole significant independent variable for NI in the logistic regression model analysis (P < 0.05). Conclusions: The APACHE II is the sole significant risk factor for nosecomial infection. TPN seems not to be an independent risk factor fer NI in critically ill. Septic shock is more frequent in this group but seems to be related with the clinical status before admission at the ICU.
early enteral nutrition supplemented with arginine, omega-3-fatty acids and nucleotides (IMPACT) on immunologic response, infection rate and hospital length of stay. There are no specific data for patients with severe multiple injury presenting a high risk for septic complications and multiorgan failure (MOF). Patients and methods: Prospective, randomized, double-blind placebo controlled clinical study in patients after severe trauma (Hannover Polytrauma score: PTS > 25). Patients were randomized to receive either IMPACT or an isonitrogenous isocaloric placebo diet. Enteral nutrition was started on the second day after trauma via endoscopically placed nasoduodenal or -jejunal feeding tubes. Primary study endpoints were the incidence of the systemic inflammatory response syndrome (SIRS), respectively, sepsis and MOF (definitions: Society of Critical Care Medicine and Goris). Secondary variables included several immune function parameters (fluorescence-activated cell scan flow cytometry). From 32 patients enrolled in the study, 29 were eligible for analysis: IMPACT (n = 16), placebo (n = 13). Both groups were comparable according to age, body mass index, severity of trauma (IMPACT: 38.8 _+ 12.5; placebo: 40.8 + 15.5). Statistical analysis: Mann-Whitney U-Test: P < 0.05. Results: The experimental diet was safe and well tolerated. During the first week after trauma the volume of enteral feeding was about 2000 ml without significant difference. Patients fed IMPACT developed significantly less frequent SIRS between day 1 and 28 (8 vs 13.3; P < 0.05) and especially between day 8 and 14 (3 vs 6.2; P < 0.001). MOF score was significantly lower on day 3, 4, 6, 7, 10, 11 and 16. Neither mortality rate differed significantly (IMPACT 2/16; placebo 4/13), nor did length of ICU or hospital stay. With regard to immune function parameters, no significant difference could be observed for CD4/CD8 ratio, CD45 isotope on activated T-cells and lymphocytic interleukin-2 receptor activity during the study period. However, HLA-DR antigen presentation on peripheral monocytes was significantly elevated on day 7 in the I M PACT group. Conclusions: The study provides further evidence for clinical benefit of
References: [1] Maki NEJM 1977. [2] Garner. Am J Infect Control 1988. [3] SCCM Consensus. Crit Care Med 1992.
2nd Session - PROTEIN METABOLISM
protein synthesis (calculated from the tracer leucine incorporation) was unchanged (0.062 _+ 0.019 %/h) from that observed before the flood. Synthesis measured using the flooding dose of [1-13C]glycine was 0.044 _+0.008 %/h, based on intramuscular glycine labelling. This was not significantly different from either value obtained with leucine. These data are consonant with our recent results showing that flooding with arginine (also a non-essential amino acid) did not increase incorporation of leucine tracer. The results suggest that the stimulatory effect may be a property of essential but not non-essential amino acids, tt may be that flooding with non-essential amino acids may overcome the current limitations caused by artefacts introduced when flooding with essential amino acids.
P.10 The effect of flooding with the non-essential amino acid glycine on the incorporation of constantly infused tracer leucine into skeletal muscle K. Smith, N. Reynolds, A. Pate/and M. J. Rennie
Dept of Anatomy & Physiology, University of Dundee, Dundee, UK. We have previously shown that administration of a flooding dose of essential amino acids (i.e. leucine, valine, phenylalanine and threonine) all result in an apparent increase in human skeletal muscle protein synthesis in the post-absorptive state. Consequently, we have now investigated whether flooding with a non-essential amino acid, i.e. glycine, has the same effect upon the incorporation of constantly infused tracer leucine into muscle. Four healthy male volunteers (29.5 + 3 years, 72.3 _+ 8.3 kg), studied after an overnight fast, were given a primed, constant infusion (1.0 mg/kg body weight, 1.0 mg/kg/h [1J3C]leucine, 99 Atoms % over 7.5h. After 6h, the subjects received a flooding dose of [1-13C]glycine (20 Atoms %, 0.10g/kg body weight). Plasma samples were taken throughout for the measurement of amino acid concentrations and 13C-enrichment of leucine, glycine and serine and of c~-ketoisocaproate (o~-KIC) (the labelling of which was taken to represent the precursor pool for protein synthesis). Muscle was sampled (1) after 45 min, (2) immediately before the flood and (3) 90 min postfiood for the measurement of [1J3C]amino acid incorporation into muscle protein and labelling in the intramuscular pool. The rate of muscle protein synthesis during the preflood period, calculated from the incorporation of leucine tracer and the labelling of plasma ~-KIC, was 0.054 _+0.008 %/h (means _+SD). As a result of administration of the glycine flood, the rate of muscle
P.11 The effect of acute and chronic IL-5 suppression on muscle cathepsin activity on turpentine oil injection M, Kishibuchi, M. Yano, T. Tsujinaka, J. Fujita, M. Morimoto, C.
Ebisui, A. Ogawa, S. Morita, S. Shiozaki, T. Taniguchi and M. Monden Department of Surgery II, Osaka University Medical School, Suita, Japan. We previously reported that in interleukin (IL)-6 transgenic mice, severe muscle atrophy and increased muscle cathepsin activities were observed and that this muscle atrophy and induction of cathepsin activities were completely inhibited by IL-6 receptor antibody. Likewise, the local injection of turpentine oil into the muscle, which induces IL-6, increased mus25
P.8 Effects of early enteral nutrition with arginine, omega-3-fatty acids and nucleotides supplemented on the systemic inflammatory response syndrome and immune function in severe multiple injury
P.9 Total parenteral nutrition does not increase the risk of nosocomial infections in critically ill patients T. Grau Carmona, S. Zubillaga Mu~oz, E. Calve Herranz, P. Garcfa
A, W e i m a n n ~, L. Bastian 2, M. Grotz 2, M. Hansel~, H. J. Schlitt 1 and
G. Regel2 Klinik for Abdominal- und Transplantationschirurgie und 2Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Hannover, Germany.
Hierro*, S. Casado Hoces, S. Bias Obispo and D. Ayuso Murillo Depts of Intensive Care and *Microbiology, University of Getafe, Madrid, Spain.
Aim: Previous studies showed in critically ill patients beneficial effects of
Objective: To determine if total parenteral nutrition (TPN) increases the frequency of nosocomial infections (NI) and mortality compared with enteral nutrition (EN) in a prospective cohort of critically ill. Methods: During a 15-month period 298 patients entered in the study. Reasons for exclusion were early discharge (fewer than 3 days in the ICU) and/or fewer than 3 days of artificial nutrition. Data collected included age, sex, length of stay (LOS), days of mechanical ventilation (MV) and outcome. The risk factors for NI registered were sepsis and cancer on admission, previous gastrointestinal (GI) surgery, APACHE II and TPN. The NI considered included pneumonia, bacteriemia, catheterrelated sepsis, infected catheter and septic shock. Definitions of NI, sepsis and septic shock have been published elsewhere [1-3]. Univariate analysis was performed using X2 test, relative risk (RR) and Student's ttest. The risk factors were tested for their ability to predict NI with a stepwise logistic regression model. Results: Of the 197 patients eligible for analysis, 135 received EN and 62 TPN or both. There were no statistical differences in sex, APACHE II, LOS, days of MV and mortality. TPN group was older (66y vs 58y, P< 0.005) and had more cancer on admission (27.4% vs 5.2%, P < (:).001), sepsis on admission (50% vs 20.7%, P < 0.001) and previous GI surgery (64.5% vs 14.8%, P < 0.001 ). RR for penumonia, bacteriemia, catheterrelated sepsis, infected catheter and overall NI was not increased in TPN group. RR for septic shock in the TPN group was 5.4 (CI95%: 2.6-10.9; P < 0.001). APACHE II was the sole significant independent variable for NI in the logistic regression model analysis (P < 0.05). Conclusions: The APACHE II is the sole significant risk factor for nosecomial infection. TPN seems not to be an independent risk factor fer NI in critically ill. Septic shock is more frequent in this group but seems to be related with the clinical status before admission at the ICU.
early enteral nutrition supplemented with arginine, omega-3-fatty acids and nucleotides (IMPACT) on immunologic response, infection rate and hospital length of stay. There are no specific data for patients with severe multiple injury presenting a high risk for septic complications and multiorgan failure (MOF). Patients and methods: Prospective, randomized, double-blind placebo controlled clinical study in patients after severe trauma (Hannover Polytrauma score: PTS > 25). Patients were randomized to receive either IMPACT or an isonitrogenous isocaloric placebo diet. Enteral nutrition was started on the second day after trauma via endoscopically placed nasoduodenal or -jejunal feeding tubes. Primary study endpoints were the incidence of the systemic inflammatory response syndrome (SIRS), respectively, sepsis and MOF (definitions: Society of Critical Care Medicine and Goris). Secondary variables included several immune function parameters (fluorescence-activated cell scan flow cytometry). From 32 patients enrolled in the study, 29 were eligible for analysis: IMPACT (n = 16), placebo (n = 13). Both groups were comparable according to age, body mass index, severity of trauma (IMPACT: 38.8 _+ 12.5; placebo: 40.8 + 15.5). Statistical analysis: Mann-Whitney U-Test: P < 0.05. Results: The experimental diet was safe and well tolerated. During the first week after trauma the volume of enteral feeding was about 2000 ml without significant difference. Patients fed IMPACT developed significantly less frequent SIRS between day 1 and 28 (8 vs 13.3; P < 0.05) and especially between day 8 and 14 (3 vs 6.2; P < 0.001). MOF score was significantly lower on day 3, 4, 6, 7, 10, 11 and 16. Neither mortality rate differed significantly (IMPACT 2/16; placebo 4/13), nor did length of ICU or hospital stay. With regard to immune function parameters, no significant difference could be observed for CD4/CD8 ratio, CD45 isotope on activated T-cells and lymphocytic interleukin-2 receptor activity during the study period. However, HLA-DR antigen presentation on peripheral monocytes was significantly elevated on day 7 in the I M PACT group. Conclusions: The study provides further evidence for clinical benefit of
References: [1] Maki NEJM 1977. [2] Garner. Am J Infect Control 1988. [3] SCCM Consensus. Crit Care Med 1992.
2nd Session - PROTEIN METABOLISM
protein synthesis (calculated from the tracer leucine incorporation) was unchanged (0.062 _+ 0.019 %/h) from that observed before the flood. Synthesis measured using the flooding dose of [1-13C]glycine was 0.044 _+0.008 %/h, based on intramuscular glycine labelling. This was not significantly different from either value obtained with leucine. These data are consonant with our recent results showing that flooding with arginine (also a non-essential amino acid) did not increase incorporation of leucine tracer. The results suggest that the stimulatory effect may be a property of essential but not non-essential amino acids, tt may be that flooding with non-essential amino acids may overcome the current limitations caused by artefacts introduced when flooding with essential amino acids.
P.10 The effect of flooding with the non-essential amino acid glycine on the incorporation of constantly infused tracer leucine into skeletal muscle K. Smith, N. Reynolds, A. Pate/and M. J. Rennie
Dept of Anatomy & Physiology, University of Dundee, Dundee, UK. We have previously shown that administration of a flooding dose of essential amino acids (i.e. leucine, valine, phenylalanine and threonine) all result in an apparent increase in human skeletal muscle protein synthesis in the post-absorptive state. Consequently, we have now investigated whether flooding with a non-essential amino acid, i.e. glycine, has the same effect upon the incorporation of constantly infused tracer leucine into muscle. Four healthy male volunteers (29.5 + 3 years, 72.3 _+ 8.3 kg), studied after an overnight fast, were given a primed, constant infusion (1.0 mg/kg body weight, 1.0 mg/kg/h [1J3C]leucine, 99 Atoms % over 7.5h. After 6h, the subjects received a flooding dose of [1-13C]glycine (20 Atoms %, 0.10g/kg body weight). Plasma samples were taken throughout for the measurement of amino acid concentrations and 13C-enrichment of leucine, glycine and serine and of c~-ketoisocaproate (o~-KIC) (the labelling of which was taken to represent the precursor pool for protein synthesis). Muscle was sampled (1) after 45 min, (2) immediately before the flood and (3) 90 min postfiood for the measurement of [1J3C]amino acid incorporation into muscle protein and labelling in the intramuscular pool. The rate of muscle protein synthesis during the preflood period, calculated from the incorporation of leucine tracer and the labelling of plasma ~-KIC, was 0.054 _+0.008 %/h (means _+SD). As a result of administration of the glycine flood, the rate of muscle
P.11 The effect of acute and chronic IL-5 suppression on muscle cathepsin activity on turpentine oil injection M, Kishibuchi, M. Yano, T. Tsujinaka, J. Fujita, M. Morimoto, C.
Ebisui, A. Ogawa, S. Morita, S. Shiozaki, T. Taniguchi and M. Monden Department of Surgery II, Osaka University Medical School, Suita, Japan. We previously reported that in interleukin (IL)-6 transgenic mice, severe muscle atrophy and increased muscle cathepsin activities were observed and that this muscle atrophy and induction of cathepsin activities were completely inhibited by IL-6 receptor antibody. Likewise, the local injection of turpentine oil into the muscle, which induces IL-6, increased mus25