STUDY - Technical - New Dacian's Medicine
Parenteral
and Enteral Nutritional Therapy (2)
Translation Draft
Let's continue yesterday's post by addressing liver failure! Malnutrition is common in advanced liver damage. Patients with acute or chronic liver failure have low levels of aromatic amino acids (AAA) in plasma and cerebrospinal fluid. Prospective research has shown that the administration of preparations for enteral and parenteral nutrition with a low ad content of AAR and AAA has led to improved nitrogen balance and a decrease in the risk of developing encephalopathy. An extensive multicenter study has shown improved survival. AAR-enriched preparations are expensive and are used only for patients with encephalopathy or who do not tolerate a standard protein formula (which brings 0.8 g/kg/day) without developing encephalopathy.
Renal failure, as it is associated with impaired nitrogen excretion, makes sense to assume that protein restriction could be beneficial to patients with chronic renal failure and a more severe protein restriction would improve the progression of acute renal failure. However, the progression of kidney disease in chronically dialysis patients is not slowed by the oral hypoprotein diet. Decrease in the incidence of infectious complications and hospital time has been shown to decrease in patients receiving parenteral essential amino acids and glucose compared to patients with acute renal impairment who have received glucose-only infusion treatment.
An earlier study showed the benefit that essential amino acids bring when they are the sole source of nitrogen, but subsequent studies have shown similar beneficial effects through treatment with standard solutions containing both essential and non-essential amino acids. The superiority of expensive formulas containing essential amino acids or their ketone analogues has not been demonstrated. 15-20% of dialysis patients for chronic renal failure have significant nutritional disorders, usually due to severe anorexia. Sometimes anorexia is improved by advanced dialysis or the treatment of gastritis, but usually persists.
Growth disorders that occur in young patients have been treated with additional enteral nutrition. This attitude has not been prevalent in older patients, but parenteral nutrition providing an energy and amino acid supplement can be administered within the last 90 minutes of hemodialysis (this method is said to improve appetite, serum protein levels and body weight).
Studies have not been able to demonstrate improved survival, so the effectiveness of this regimen could not be established. Standard methods of continuous peritoneal dialysis, under ambulatory conditions, use glucose to provide osmotic load, so that certain amounts of glucose can be absorbed. Amino acids can replace glucose and therefore be absorbed, replacing amino acid loss in dialysis. This method also awaits a full study.
In the case of pancreatitis, parenteral nutrition does not improve the medical healing of patients with medium or moderate forms of pancreatitis. However, severe pancreatitis is associated with nutritional impairment and survival is inversely proportional to malnutrition. When parenteral nutritional support is delayed to more than 72 hours, patients with severe pancreatitis have three times as many complications as patients whose treatment was initiated earlier. In the absence of severe hyperlipidemia or thrombocytopenia complicating pancretitis, intravenous lipid administration is not a risk and is extremely useful when glucose intolerance exists. Several studies report jejunal enteral feeding with good results in acute pancreatitis.
In inflammatory bowel disease (IBI), the highlighting of nutritional deficiencies such as weight loss, delayed growth, anemia and hypoalbuminemia, is common, usually more pronounced in Crohn's disease than in ulcer-hemorrhagic colitis. Nutritional support has a role in remedying these nutritional deficiencies, especially before surgery. Given that BII often improves by diverting fecal flow, the question arises whether intestinal rest and parenteral nutrition play a role in primary treatment.
Prospective studies have not shown special benefits in the case of intestinal rest. Basic diets can be used in place of glucocorticoids to produce remission in acute Crohn's disease, but recurrences are common when resuming normal diet. Controlled studies have found that the removal of cereals, yeast and dairy products from the diet of patients suffering from Crohn's disease can prolong the duration of remission. Due to the possibility that specific dietary lipids have a beneficial effect in several immune disorders, probably by influencing prostaglandin sway, diets rich in omega3 fatty acids are investigated in BII. While some studies suggest the beneficial effect of fibers in BII, they may pose problems if there are strictures.
In short bowel syndrome, before the onset of parenteral nutrition, the survival of patients with short bowel syndrome resulting from mesenteric infarctions or surgical resections was exceptional. Parenteral therapy made it possible to unlimited survival even of patients who had only 30-60 cm of the remaining intestine. In some cases, the remaining intestine adapts, so that parenteral only hydro-electrolytic supplementation is administered or even gradually reaches total enteral nutrition.
For lung diseases, weight loss in patients with advanced lung disease is due to increased respiratory stress and inadequate food intake. Patients with chronic lung disease with body weight of less than 90% of their ideal weight have a higher expressable mortality at 5 years, regardless of lung status. The recommended energy intake for these patients is 1.7 times higher than basic energy expenditure.
In cystic fibrosis, malnutrition can accelerate lung damage, while enteral nutrition through gastrostoma improves growth and stabilizes or improves lung function, especially in young children. The criteria for the selection of patients and the psychological cost of these treatments have not been defined. The use of a low-carbohydrate formula is useful in the attempt to give up assisted ventilation, but the superiority of this formula in patients with chronic lung disease in the ambulatory has not been established.
Let's move on to acquired immunodeficiency syndrome (AIDS)! The role of nutritional support specialized in weight loss associated with AIDS has not been established. Studies by Kotler have shown that parenteral nutrition replaces muscle mass when weight loss is due to inadequate oral intake, either due to oral cavity problems or esophageal disease or is due to inadequate absorption as a result of small intestine disease. However, emaciation associated with systemic infections and excessive cytokine secretion is not effectively recovered through parenteral nutrition. In patients with systematic infections, any weight gain is due to water or fat rather than protein mass. Slow enteral infusion is often well tolerated, and its role in the early phase of weight loss associated with AIDS is under observation.
In pregnancy, severe severe severe hyperemesis may make oral or enteral feeding impossible through the tube, with high weight loss and ketosis affecting the fetus. Gravid hyperemesis ceases after abortion or postpartum, the intimate mechanisms of its production not understood. There are numerous reports of continued pregnancy until term through temporary support through parenteral nutrition, but despite intestinal rest, nausea and vomiting persist.
In the end, there'd be a few clarifications to be made. Nutritional support is not suitable in terminal cases, but is to be taken into account when the patient's life expectancy is several months. Such therapy must be understood by the patient, who must have sufficient help so that the course of outpatient treatment does not occur unwanted events. Both outpatient therapies are relatively safe, with a mortality of less than 5%.
And, i might have to move on to designing individual diets. I'll start with the fluid requirements. These are calculated by summarizing the daily requirement (129 ml/kg body in children and 35 ml/ kg body in adults) with any pathological loss. If the patient is under parenteral therapy, any enteral intake should be decreased from the amount of pathological losses. Since abnormal fluid loss also involves significant mineral losses, it is essential to add them to the price prepared with parenteral or enteral administration. I will now give some examples of necessary estimates.
The estimate of the daily fluid requirement can be made according to the "formula": A. normal man of 70 kg by 1. intake: the normal requirement is 35 x 70 = 2,000 ml/day (out of 1,200 ml of oral fluid, or 5 cups/ cups per day and solid foods providing 1,300 ml, 1,000 ml of the water contained in the food, 300 ml of the water generated by food metabolism) and 2. elimination: urine 1,600 ml/ day, insensitive losses 800 ml/day and stool 100 ml/day (sweat losses can be around 2 l/ day and each degree celsius of fever attracts the loss of another 200 ml/day); B. patient with enteral tube - we will take the case of a woman of 58 kg during the recovery period after total gastrectomy for gastric cancer, fed by jejunostomy, who is not given anything orally or intravenously, but who experiences losses of 600 ml/day through diarrhea - normal needs are 35 x 58 = approx. 2,000 ml/day, abnormal losses are 600 - 100 = 500 ml/day causing total needs of 2,500 ml; C. parenterally fed patient - we will take the case of a 66 kg man with high jejunostomy, following a massive intestinal resection for Crohn's disease, with oral intake of 2,000 ml/day and 4,000 ml/day jejunostomy losses - normal needs are 35 x 66 = 2,300 ml/day, abnormal losses are 4,000 - 100 minus oral intake of 2,000 equal to 1,900 ml/day, resulting in total needs of 4,200 ml/day.
And I could continue but I do not think that is the case because from the previous example you can see that everything is customized on a case-by-case basis and you cannot "insert" a balance solution of the panacea type.
In case of energy needs we will reach the same situation and I will not insert elements of its calculation. Long-term energy expenditure dictates needs, but in the initial phase of nutritional replacement the needs do not always reflect expenditure. For example, malnourished patients are almost always hypometabolic, and can use only 20 kcal/kg daily, but more calories are needed for nutritional loading, because with refuelling increases the rate of metabolism and the caloric supplement is necessary for tissue repair.
A patient with severe trauma (burn, trauma) can spend 40 kcal/kg daily, a significant proportion of calories from protein catabolism and gluconeogenesis and catecholamine-induced lipolysis. Oxygen glucose oxidation reaches a plateau of 25 kcal/day daily, with a glucose supplement inducing hepatic steatosis. In addition, providing additional calories in the form of exogenous fats does not suppress endogenous lipolysis. This is because artificial chilomicrons in fatty parenteral solutions are vegetable oils (from soybeans, sunflowers) emulsified with egg phospholipids, devoid of apoproteins and therefore not metabolized as lipoproteins.
For this reason, the subject with acute trauma is safer to use hypocaloric parenteral diet with modest amounts of glucose and fat. Lipid solutions for parenteral use are available in the form of 10 and 20% emulsions, transformed into isotone solutions. They can be infused independently or in the form of a "three in one" solution, containing amino acids and glucose. These solutions are well tolerated and it is no longer necessary to use separate infusion devices. However, these solutions are not as stable as the traditional mixture of glucose and amino acids, the destabilized lipid particles having the potential for covalescence, forming large drops and thus causing fatty embolisms.
In order to be stable, "three-in-one" solutions must be prepared by a pharmacist who is well aware of the optimal proportion of the components, as well as the quantities of bivalent cations and microelements to be added. Patients who need parenteral iron or large amounts of zinc will benefit from these parenteral solutions without lipid content. Polyunsaturated oils are used in most enteral preparations, due to their proper absorption by the compromised gastrointestinal mucosa.
Regardless of the route of administration, lipids should ensure the need for essential fatty acids (1-4% of the energy intake is represented by linoleic and linolenic acid). In relatively stable patients, providing 30% of the energy requirement in the form of lipids reduces the problems caused by excess caloric through carbon hydrates (e.g. in hepatic steatosis). Replacing polyunsaturated vegetable fats with omega3 polyunsaturated fish oil likely decreases the inflammatory response in burns, trauma and irradiation, by reducing the synthesis of prostaglandins that aggravate the inflammatory response.
And, that's enough for today... we'll see more next time.
Let's continue yesterday's post by addressing liver failure! Malnutrition is common in advanced liver damage. Patients with acute or chronic liver failure have low levels of aromatic amino acids (AAA) in plasma and cerebrospinal fluid. Prospective research has shown that the administration of preparations for enteral and parenteral nutrition with a low ad content of AAR and AAA has led to improved nitrogen balance and a decrease in the risk of developing encephalopathy. An extensive multicenter study has shown improved survival. AAR-enriched preparations are expensive and are used only for patients with encephalopathy or who do not tolerate a standard protein formula (which brings 0.8 g/kg/day) without developing encephalopathy.
Renal failure, as it is associated with impaired nitrogen excretion, makes sense to assume that protein restriction could be beneficial to patients with chronic renal failure and a more severe protein restriction would improve the progression of acute renal failure. However, the progression of kidney disease in chronically dialysis patients is not slowed by the oral hypoprotein diet. Decrease in the incidence of infectious complications and hospital time has been shown to decrease in patients receiving parenteral essential amino acids and glucose compared to patients with acute renal impairment who have received glucose-only infusion treatment.
An earlier study showed the benefit that essential amino acids bring when they are the sole source of nitrogen, but subsequent studies have shown similar beneficial effects through treatment with standard solutions containing both essential and non-essential amino acids. The superiority of expensive formulas containing essential amino acids or their ketone analogues has not been demonstrated. 15-20% of dialysis patients for chronic renal failure have significant nutritional disorders, usually due to severe anorexia. Sometimes anorexia is improved by advanced dialysis or the treatment of gastritis, but usually persists.
Growth disorders that occur in young patients have been treated with additional enteral nutrition. This attitude has not been prevalent in older patients, but parenteral nutrition providing an energy and amino acid supplement can be administered within the last 90 minutes of hemodialysis (this method is said to improve appetite, serum protein levels and body weight).
Studies have not been able to demonstrate improved survival, so the effectiveness of this regimen could not be established. Standard methods of continuous peritoneal dialysis, under ambulatory conditions, use glucose to provide osmotic load, so that certain amounts of glucose can be absorbed. Amino acids can replace glucose and therefore be absorbed, replacing amino acid loss in dialysis. This method also awaits a full study.
In the case of pancreatitis, parenteral nutrition does not improve the medical healing of patients with medium or moderate forms of pancreatitis. However, severe pancreatitis is associated with nutritional impairment and survival is inversely proportional to malnutrition. When parenteral nutritional support is delayed to more than 72 hours, patients with severe pancreatitis have three times as many complications as patients whose treatment was initiated earlier. In the absence of severe hyperlipidemia or thrombocytopenia complicating pancretitis, intravenous lipid administration is not a risk and is extremely useful when glucose intolerance exists. Several studies report jejunal enteral feeding with good results in acute pancreatitis.
In inflammatory bowel disease (IBI), the highlighting of nutritional deficiencies such as weight loss, delayed growth, anemia and hypoalbuminemia, is common, usually more pronounced in Crohn's disease than in ulcer-hemorrhagic colitis. Nutritional support has a role in remedying these nutritional deficiencies, especially before surgery. Given that BII often improves by diverting fecal flow, the question arises whether intestinal rest and parenteral nutrition play a role in primary treatment.
Prospective studies have not shown special benefits in the case of intestinal rest. Basic diets can be used in place of glucocorticoids to produce remission in acute Crohn's disease, but recurrences are common when resuming normal diet. Controlled studies have found that the removal of cereals, yeast and dairy products from the diet of patients suffering from Crohn's disease can prolong the duration of remission. Due to the possibility that specific dietary lipids have a beneficial effect in several immune disorders, probably by influencing prostaglandin sway, diets rich in omega3 fatty acids are investigated in BII. While some studies suggest the beneficial effect of fibers in BII, they may pose problems if there are strictures.
In short bowel syndrome, before the onset of parenteral nutrition, the survival of patients with short bowel syndrome resulting from mesenteric infarctions or surgical resections was exceptional. Parenteral therapy made it possible to unlimited survival even of patients who had only 30-60 cm of the remaining intestine. In some cases, the remaining intestine adapts, so that parenteral only hydro-electrolytic supplementation is administered or even gradually reaches total enteral nutrition.
For lung diseases, weight loss in patients with advanced lung disease is due to increased respiratory stress and inadequate food intake. Patients with chronic lung disease with body weight of less than 90% of their ideal weight have a higher expressable mortality at 5 years, regardless of lung status. The recommended energy intake for these patients is 1.7 times higher than basic energy expenditure.
In cystic fibrosis, malnutrition can accelerate lung damage, while enteral nutrition through gastrostoma improves growth and stabilizes or improves lung function, especially in young children. The criteria for the selection of patients and the psychological cost of these treatments have not been defined. The use of a low-carbohydrate formula is useful in the attempt to give up assisted ventilation, but the superiority of this formula in patients with chronic lung disease in the ambulatory has not been established.
Let's move on to acquired immunodeficiency syndrome (AIDS)! The role of nutritional support specialized in weight loss associated with AIDS has not been established. Studies by Kotler have shown that parenteral nutrition replaces muscle mass when weight loss is due to inadequate oral intake, either due to oral cavity problems or esophageal disease or is due to inadequate absorption as a result of small intestine disease. However, emaciation associated with systemic infections and excessive cytokine secretion is not effectively recovered through parenteral nutrition. In patients with systematic infections, any weight gain is due to water or fat rather than protein mass. Slow enteral infusion is often well tolerated, and its role in the early phase of weight loss associated with AIDS is under observation.
In pregnancy, severe severe severe hyperemesis may make oral or enteral feeding impossible through the tube, with high weight loss and ketosis affecting the fetus. Gravid hyperemesis ceases after abortion or postpartum, the intimate mechanisms of its production not understood. There are numerous reports of continued pregnancy until term through temporary support through parenteral nutrition, but despite intestinal rest, nausea and vomiting persist.
In the end, there'd be a few clarifications to be made. Nutritional support is not suitable in terminal cases, but is to be taken into account when the patient's life expectancy is several months. Such therapy must be understood by the patient, who must have sufficient help so that the course of outpatient treatment does not occur unwanted events. Both outpatient therapies are relatively safe, with a mortality of less than 5%.
And, i might have to move on to designing individual diets. I'll start with the fluid requirements. These are calculated by summarizing the daily requirement (129 ml/kg body in children and 35 ml/ kg body in adults) with any pathological loss. If the patient is under parenteral therapy, any enteral intake should be decreased from the amount of pathological losses. Since abnormal fluid loss also involves significant mineral losses, it is essential to add them to the price prepared with parenteral or enteral administration. I will now give some examples of necessary estimates.
The estimate of the daily fluid requirement can be made according to the "formula": A. normal man of 70 kg by 1. intake: the normal requirement is 35 x 70 = 2,000 ml/day (out of 1,200 ml of oral fluid, or 5 cups/ cups per day and solid foods providing 1,300 ml, 1,000 ml of the water contained in the food, 300 ml of the water generated by food metabolism) and 2. elimination: urine 1,600 ml/ day, insensitive losses 800 ml/day and stool 100 ml/day (sweat losses can be around 2 l/ day and each degree celsius of fever attracts the loss of another 200 ml/day); B. patient with enteral tube - we will take the case of a woman of 58 kg during the recovery period after total gastrectomy for gastric cancer, fed by jejunostomy, who is not given anything orally or intravenously, but who experiences losses of 600 ml/day through diarrhea - normal needs are 35 x 58 = approx. 2,000 ml/day, abnormal losses are 600 - 100 = 500 ml/day causing total needs of 2,500 ml; C. parenterally fed patient - we will take the case of a 66 kg man with high jejunostomy, following a massive intestinal resection for Crohn's disease, with oral intake of 2,000 ml/day and 4,000 ml/day jejunostomy losses - normal needs are 35 x 66 = 2,300 ml/day, abnormal losses are 4,000 - 100 minus oral intake of 2,000 equal to 1,900 ml/day, resulting in total needs of 4,200 ml/day.
And I could continue but I do not think that is the case because from the previous example you can see that everything is customized on a case-by-case basis and you cannot "insert" a balance solution of the panacea type.
In case of energy needs we will reach the same situation and I will not insert elements of its calculation. Long-term energy expenditure dictates needs, but in the initial phase of nutritional replacement the needs do not always reflect expenditure. For example, malnourished patients are almost always hypometabolic, and can use only 20 kcal/kg daily, but more calories are needed for nutritional loading, because with refuelling increases the rate of metabolism and the caloric supplement is necessary for tissue repair.
A patient with severe trauma (burn, trauma) can spend 40 kcal/kg daily, a significant proportion of calories from protein catabolism and gluconeogenesis and catecholamine-induced lipolysis. Oxygen glucose oxidation reaches a plateau of 25 kcal/day daily, with a glucose supplement inducing hepatic steatosis. In addition, providing additional calories in the form of exogenous fats does not suppress endogenous lipolysis. This is because artificial chilomicrons in fatty parenteral solutions are vegetable oils (from soybeans, sunflowers) emulsified with egg phospholipids, devoid of apoproteins and therefore not metabolized as lipoproteins.
For this reason, the subject with acute trauma is safer to use hypocaloric parenteral diet with modest amounts of glucose and fat. Lipid solutions for parenteral use are available in the form of 10 and 20% emulsions, transformed into isotone solutions. They can be infused independently or in the form of a "three in one" solution, containing amino acids and glucose. These solutions are well tolerated and it is no longer necessary to use separate infusion devices. However, these solutions are not as stable as the traditional mixture of glucose and amino acids, the destabilized lipid particles having the potential for covalescence, forming large drops and thus causing fatty embolisms.
In order to be stable, "three-in-one" solutions must be prepared by a pharmacist who is well aware of the optimal proportion of the components, as well as the quantities of bivalent cations and microelements to be added. Patients who need parenteral iron or large amounts of zinc will benefit from these parenteral solutions without lipid content. Polyunsaturated oils are used in most enteral preparations, due to their proper absorption by the compromised gastrointestinal mucosa.
Regardless of the route of administration, lipids should ensure the need for essential fatty acids (1-4% of the energy intake is represented by linoleic and linolenic acid). In relatively stable patients, providing 30% of the energy requirement in the form of lipids reduces the problems caused by excess caloric through carbon hydrates (e.g. in hepatic steatosis). Replacing polyunsaturated vegetable fats with omega3 polyunsaturated fish oil likely decreases the inflammatory response in burns, trauma and irradiation, by reducing the synthesis of prostaglandins that aggravate the inflammatory response.
And, that's enough for today... we'll see more next time.
Love, Understanding and
Gratitude!!!
Dorin, Merticaru