 Dangers
of growth hormone therapy in critically ill patients.
Reference: Curr Opin Clin Nutr Metab Care 2002;5(2):199-209.
Prolonged length of stay is the major challenge for modern intensive care
because of the
associated morbidity and the impact on resource utilization. Severe trauma
or infection is
associated with a catabolic response, which is characterized by increased
protein turnover and
negative nitrogen balance. Severe catabolism leads to end-organ dysfunction
and muscular
weakness, prolonging the need for mechanical ventilation. Catabolism cannot
be prevented with
standard parenteral or enteral nutritional formulas. In order to prevent
the complications of
catabolism in intensive care patients, recombinant growth hormone has been
applied as an
experimental therapy for two decades in patients requiring parenteral nutrition
and in patients with
respiratory failure. Administration of recombinant growth hormone has resulted
in positive
nitrogen balance, and studies in mechanically ventilated patients suggest
that it may shorten the
need for ventilatory support. In contrast to the results of these relatively
small studies, a recent
multinational randomized controlled trial revealed that the administration
of recombinant growth
hormone (with doses 10-20 times higher than used for replacement therapy)
increases mortality
of critically ill patients. The excessive mortality in patients treated
with recombinant growth
hormone was related to infections and development of multiple organ failure,
leading to the
conclusion that administration of high doses of recombinant growth hormone
cannot be
recommended for critically ill patients. This review reinforces that conclusion.
Parenteral
nutrition-associated liver complications in children.
Reference: Pharmacotherapy 2002; 22(2):188-211.
Parenteral nutrition is a life-saving therapy for patients with intestinal
failure. It may be associated
with transient elevations of liver enzyme concentrations, which return
to normal after parenteral
nutrition is discontinued. Prolonged parenteral nutrition is associated
with complications affecting
the hepatobiliary system, such as cholelithiasis, cholestasis, and steatosis.
The most common of
these is parenteral nutrition-associated cholestasis (PNAC), which may
occur in children and may
progress to liver failure. The pathophysiology of PNAC is poorly understood,
and the etiology is
multifactorial. Risk factors include prematurity, long duration of parenteral
nutrition, sepsis, lack
of bowel motility, and short bowel syndrome. Possible etiologies include
excessive caloric
administration, parenteral nutrition components, and nutritional deficiencies.
Several measures can
be undertaken to prevent PNAC, such as avoiding overfeeding, providing
a balanced source of
energy, weaning parenteral nutrition, starting enteral feeding, and avoiding
sepsis.
Beneficial
effects of immediate enteral nutrition after esophageal cancer surgery.
Reference: Surg Today 2001;31(11):971-8.
This study was conducted to determine the effects of immediate enteral
nutrition (EN) on
nutritional status, immunological competence, and the suppression of excessive
inflammatory
responses in patients following esophageal cancer surgery. Twenty-four
patients who underwent
the same elective operation for thoracic esophageal carcinoma were randomized
into an
immediate enteral nutrition (IEN) group who received EN from postoperative
day (POD) 1 and
a parenteral nutrition (PAN) group. Both groups received comparable volumes
and calories on
the same POD. Laboratory studies were carried out preoperatively and on
PODs 1-7. Other
nutritional and immunological assessments were repeated on PODs 1 and 7.
Plasma
concentrations of nitrate and nitrite were also measured. All of the patients
in the IEN group
tolerated enteral feeding well. There were no significant differences in
the results of nutritional
assessments, lymphocyte function, or plasma nitrate and nitrite levels
between the two groups.
The IEN group showed a significantly earlier recovery of the total lymphocyte
count. The serum
levels of total bilirubin and C-reactive protein were significantly attenuated
in the IEN group.
These results indicate that immediate EN may have beneficial effects on
immunological
competence and the suppression of excessive inflammatory responses in patients
following
esophagectomy. Patients undergoing radical esophageal surgery who are subjected
to severe
surgical stress might benefit the most from early EN.
Assessment
of nutritional status in hospital in-patients.
Reference: QJM 2002;95(2):83-87.
BACKGROUND: The King's Fund and British Association of Parenteral and Enteral
Nutrition
recommend that all hospital patients should have height and weight recorded,
to detect the need
for nutritional support. Systematic review evidence also suggests that
protein and energy
supplementation of adults in hospital with a wide range of conditions improves
outcome. AIM: To
assess the recording of weight and height in hospitals. DESIGN: Survey
(random sample).
METHODS: As part of a survey on the provision of deep venous thrombosis
prophylaxis, we
collected information on height and weight recording from medical and nursing
notes. We
randomly selected five medical, five surgical, five orthopaedic, and five
obstetrics and
gynaecology directorates from across Scotland. Six hundred case notes were
requested, and
88% were available for data extraction. Some 67% of hospital episodes provided
information
about weight, and 41% on both height and weight. General medicine directorates
had the lowest
recording of weight, and in medical and surgical directorates, both weight
and height were rarely
recorded in comparison with the other two directorates (p<0.001). DISCUSSION:
Our survey
suggests that recommendations to assess nutritional risk are not being
followed, and that many
patients at risk of malnutrition are not being detected or treated.
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