Current uses of total parenteral nutrition
Michael M. Meguid
Total parenteral nutrition provides intravenous carbohydrates in the form of glucose, protein in the form of amino acids, lipids in the form of triglycerides, and vitamins, minerals and trace elements. The primary indication for its use is therapy for the patient who cannot eat, should not eat, will not eat or cannot eat enough. When given in amounts necessary to meet a patient’s metabolic needs, this therapy is generally referred to as total parenteral nutrition; when given in amounts exceeding metabolic needs, it is called hyperalimentation.
Before the availability of lipid emulsions, glucose-based parenteral nutrients were generally administered through a central vein, most commonly the subclavian vein, to prevent chemical thrombophlebitis caused by the high osmolality of the infusion. Iso-osmotic lipid emulsions allow parenteral nutrients to be given as a mixed-fuel solution in which the three macronutrients–glucose, lipids and amino acids–and the micronutrients are mixed together (total parenteral admixture or TPA) in a single delivery system that more closely resembles a physiologic situation. A hypertonic, glucose-based nutrient system, in which lipids are given twice weekly via piggyback infusion, however, is still used to deliver parenteral nutrition.
Despite widespread application of total parenteral nutrition during the past two decades, it is commonly accepted today that it should be used only in situations where nutritional support has been proved efficacious.
Effects of Malnutrition
The relationship between preoperative weight loss and postoperative mortality in patients undergoing operation for benign peptic ulcer disease was first reported in the early 1930s. Patients with a preoperative weight loss of more than 20 percent had a postoperative mortality rate of 33.3 percent, versus a 3.5 percent rate in patients with a smaller amount of weight loss. In the mid-1930s and early 1940s, hypoproteinemia was documented as a cause of delayed gastric emptying and prolonged ileus, an increased incidence of wound dehiscence, delayed bone callus formation and an increased risk of infection.
These early observations were extended to show that postoperative complications were more frequent in hypoproteinemic surgical patients, that malnourished burned children had an increased risk of sepsis and that hemorrhagic shock was not as well tolerated by patients in a state of protein depletion as by well-nourished control subjects. Thus, similar results were obtained in a variety of situations and with different physiologic insults, leading to the common conclusion that complications are more likely to occur in poorly nourished patients. More recent studies have once again demonstrated this association in a variety of clinical settings.
The mechanisms by which malnourished patients are more prone to postoperative complications are often synergistic. Mechanical breakdown of the skin and mucosal barriers by surgical incision and manipulation leads to unavoidable contamination by microorganisms. Consequently, a normal host defense mechanism is essential to prevent septic complications. Impaired immunologic functions accompanying the malnourished state include reduced cell-mediated immunity and inflammatory response, with decreases in humoral or antibody components (B lymphocytes), cell-mediated components (T lymphocytes), phagocytic components (polymorphonuclear neutrophils, macrophages and the reticuloendothelial system) and complement (direct or alternate pathway). The consequence of this impaired immunologic state is an increased susceptibility to postoperative infection.
Malnutrition affects the resumption of gastrointestinal tract function after surgery; a considerable delay occurs in the malnourished patient relative to the well-nourished patient. Malnutrition also affects skeletal muscle function. Muscle bulk and muscle metabolism are reduced; this reduction is the most recognizable aspect of gross malnutrition. Impairment of the respiratory muscles leads to reduction of both vital capacity and resting minute ventilation. Moderate starvation alone has been shown to cause a significantly impaired hypoxic ventilatory response. Cardiac mass and contractility are reduced.
Renal function may be impaired from a fall in glomerular filtration rate secondary to the malnutrition-related decrease in circulatory volume. Fibroplasia is also reduced in malnourished patients, with a resultant delay in wound healing.
Starvation decreases brain neurotransmitters, leading to a state of apathy, with a diminished sense of self-motivation. Since malnutrition has a deleterious effect on every major system in the body, it is not surprising that morbidity and mortality increase in malnourished patients following surgical trauma or hospitalization for medical conditions.
The paramount use of total parenteral nutrition should be to prevent or correct malnutrition that occurs secondary to a disease state or therapy. The definition and quantification of malnutrition have recently been reviewed[3,6,7] and will not be discussed in this article. However, it is important to emphasize that the presence of malnutrition or the anticipation that a patient’s nutritional status will deteriorate should form the basis for a clinical decision to start total parenteral nutrition, independent of the patient’s underlying disease or required treatment. The clinical settings in which total parenteral nutrition is currently accepted are summarized in Table 1.
Short-bowel syndrome probably represents the best example of the impact of total parenteral nutrition on a life-threatening disease state. Survival on oral intake is precluded if less than 2 feet of intestine remain beyond the duodenum. Before the availability of parenteral nutrition, patients undergoing extensive resection of the small intestine because of infarction, trauma, Crohn’s disease, radiation enteritis or neoplasia inevitably died because of their inability to absorb nutrients.
Total parenteral nutrition ensures survival, and a relatively normal life, in patients with short-bowel syndrome. It also assists the residual intestine to undergo adaptive changes–small bowel dilatation, villous enlargement, epithelial hyperplasia and enhanced absorption–that eventually permit subsequent use of the gastrointestinal tract for a home enteral nutrition program.
Preoperative. The rationale for preoperative use of total parenteral nutrition is based on the evidence that 40 to 70 percent of patients undergoing surgery for malignant or nonmalignant disease of the gastrointestinal tract are malnourished.[9-11] Randomized studies have been performed to clarify whether preoperative total parenteral nutrition is effective in reducing postoperative morbidity and mortality.[10,12-16] From these studies, it can be concluded that two to three days of total parenteral nutrition before surgery does not improve surgical outcome. An improvement in outcome is seen only after five to seven days of total parenteral nutrition. A statistically significant reduction in major postoperative complications and mortality is achieved when total parenteral nutrition is given for at least seven to 10 days before surgery.
Postoperative. After surgery, patients generally enter a period of poor or inadequate oral intake. The decision to provide total parenteral nutrition for supportive purposes immediately following surgery, in the absence of conclusive data,[17-19] is based on clinical judgment. Most patients with adequate preoperative nutrition are able to tolerate a limited postoperative period (three to five days) without nutrient intake. The malnourished patient, however, is unable to withstand this type of controlled starvation, particularly if a complication arises.
INFLAMMATORY BOWEL DISEASE
A high incidence of malnutrition has been reported in patients with inflammatory bowel disease. The frequency of acute malnutrition is 33 to 48 percent in Crohn’s disease and 58 to 72 percent in ulcerative Colitis.[20,21] Chronic malnutrition, however, is more common in Crohn’s disease because the small bowel is often affected, whereas ulcerative colitis affects the colon.
Despite the high frequency of malnutrition in this situation, the primary role of nutritional support (total parenteral or enteral nutrition) in influencing the outcome of inflammatory bowel disease remains largely unclear. Uncontrolled clinical studies during the past 15 years have shown that in-hospital remission of ulcerative colitis in patients receiving total parenteral nutrition ranges from 9 to 100 percent, while long-term remission is 60 percent. For Crohn’s disease, in-hospital remission has varied from 23 to 100 percent; long-term remission has been 69 percent. In inflammatory bowel disease, total parenteral nutrition is used primarily to prevent or reverse malnutrition and its associated complications.
Results from prospective trials evaluating the efficacy of total parenteral nutrition as compared with other treatments for ulcerative colitis and Crohn’s disease are inconclusive. In one study, total parenteral nutrition as an adjunct to prednisone was as effective as prednisone alone in patients with ulcerative colitis. In another study, patients receiving steroids for colitis due to Crohn’s disease or ulcerative colitis localized to the colon had a remission rate comparable to that in patients treated with total parenteral nutrition or maintained on an oral diet. However, the response to parenteral nutrition and bowel rest was found to be significantly higher in patients with Crohn’s disease than in patients with ulcerative colitis. In a study of patients with long-standing Crohn’s disease who were maintained solely on total parenteral nutrition for a prolonged period, parenteral nutrition was not a valid alternative to surgery in the treatment of the complications of Crohn’s disease. Similarly, recent randomized studies[26,27] led to the conclusion that bowel rest achieved with total parenteral nutrition does not significantly influence remission or long-term outcome in patients with Crohn’s disease.
Enterocutaneous fistula is associated with high morbidity and a lengthy hospitalization. Malnutrition occurs in 53 percent of patients with gastric or duodenal fistulas, 74 percent with jejunal or ileal fistulas and 20 percent with large bowel fistulas. Studies have demonstrated overall mortality rates (with and without definitive therapy) of 62 percent for gastric or duodenal fistulas, 59 percent for jejunal or ileal fistulas and 64 percent for large bowel fistulas.
The indications for total parenteral nutrition in patients with enterocutaneous fistulas are the high risk of malnutrition and the need for bowel rest to decrease intestinal secretion and fistula drainage, resulting in earlier closure. In the absence of prospective randomized trials to evaluate the therapeutic effects of total parenteral nutrition on the clinical outcome of patients with enterocutaneous fistulas, the current view is that the role of total parenteral nutrition is primarily supportive, to treat malnutrition, to prevent further deterioration of the nutritional state and to decrease the incidence of postoperative complications in patients who eventually need surgery. Somatostatin (Reducin), a potent inhibitor of intestinal secretions, has dramatically improved the outcome for patients with enterocutaneous fistula by promoting spontaneous closure.
The role played by the pancreas in the digestive process is so crucial that acute or chronic failure of this organ results in rapid deterioration of the nutritional state. Furthermore, acute pancreatitis is accompanied by severe catabolic stress and increased metabolic demand, and many patients with pancreatic disease are alcoholics who already have underlying malnutrition. Based on recent uncontrolled and prospective studies of the efficacy of total parenteral nutrition in reversing pancreatic disorders,[30,31] total parenteral nutrition, although not curative, appears to be of benefit in cases of severe necrotizing pancreatitis. It is also useful following complications such as fistulas, pseudocysts or pancreatic ascites. Although still debated, evidence indicates that the use of lipid solutions is well tolerated in patients with pancreatitis, even in the presence of hyperlipidemia.[31,33]
Malnutrition is frequent in cancer patients. It is usually caused by anorexia. A series of metabolic alterations that lead to a catabolic state contribute further to malnutrition, which adversely influences patient outcome. In addition, adjuvant medical, surgical and radiation treatments tend to aggravate malnutrition.
Despite numerous randomized prospective studies of the effect of total parenteral nutrition on the outcome of cancer patients, it should be emphasized that total parenteral nutrition is not a treatment for cancer itself. Data clearly indicate that total parenteral nutrition is effective for preventing or treating the malnutrition that accompanies neoplastic disease or results f rom antitumor therapy.
Currently, total parenteral nutrition is used as an adjunct to antineoplastic therapy and for supportive care if it is expected that treatment will produce or worsen malnutrition. Some studies have shown that total parenteral nutrition increases tolerance and/or response to chemotherapy, radiation therapy and surgery. However, recent reports suggest that its use in cancer patients with a good or only mildly deteriorated nutritional state who have surgery, radiation therapy or chemotherapy is of no benefit and may be associated with a higher incidence of infection.
Whether total parenteral nutrition stimulates tumor growth is a question that remains unanswered. The general consensus is that in the absence of total parenteral nutrition, the tumor, which has an autonomous metabolism, continues to grow. Total parenteral nutrition merely ensures that the host remains nutritionally replete. Further studies are needed to determine if total parenteral nutrition, in combination with antitumor therapy, may significantly influence therapeutic response and general outcome, as suggested by some studies.
BONE MARROW TRANSPLANTATION
Bone marrow transplantation has serious nutritional consequences, including anorexia, nausea, vomiting, diarrhea, malabsorption, negative nitrogen balance and weight loss. These nutritional disabilities result from pretransplant chemotherapy and radiation therapy used in cytoreduction treatment and from post-transplant complications such as infection and graft-versus-host disease. As a result, at least 50 percent of patients undergoing bone marrow transplantation have malnutrition.
The debilitated condition of the gastrointestinal tract predisposes these patients to viral, bacterial and fungal infections of the bowel, which lead to further mucosal damage and malabsorption. Increased nitrogen loss is compounded by relative immobilization, infection and graft-versus-host disease.
Because of the unreliability of the enteral route in these patients, total parenteral nutrition has become routine. Early nutritional support is important in bone marrow transplantation, because patients show a loss of lean body tissue during the first few weeks after the transplantation.
Providing total parenteral nutrition to well-nourished bone marrow transplant recipients enhances survival, diminishes relapse and shortens the post-transplant hospital stay. Total parenteral nutrition, however, does not influence engraftment, duration of overall hospitalization and the occurrence of acute and chronic graft-versus-host disease or bacteremia. Thus, total parenteral nutrition has a positive effect on long-term outcome. Total parenteral nutrition is indicated even for well-nourished individuals during the cytoreduction process and bone marrow transplantation.
Cardiac glycogen levels are an indicator of myocardial nutrition status. Increasing cardiac glycogen concentration through intravenous glucose and fat loading in the immediate preoperative period favorably affects cardiac glycogen levels. Providing total parenteral nutrition overnight before coronary artery bypass surgery increases the myocardial glycogen concentration, resulting in fewer severe postoperative ventricular arrhythmias, less vasopressor dependency, fewer transmural myocardial infarctions and greater postoperative survival.
Two percent of all patients receiving total parenteral nutrition are women with obstetric problems. Total parenteral nutrition is used in pregnancy for two main reasons: (1) to provide adequate nutrition for a woman with prolonged, severe hyperemesis gravidarum and (2) when there is diminished absorption or assimilation of adequate nutrients secondary to exacerbation of preexisting illnesses, such as inflammatory bowel disease and recurrent pancreatitis.
Total parenteral nutrition is used primarily in the second half of pregnancy and is usually discontinued well before delivery. An appropriately sized infant is delivered in 61 percent of patients who require total parenteral nutrition. It is believed that many infants who are small for gestational age at birth were already growth-retarded before total parenteral nutrition was initiated.
ACUTE RENAL FAILURE
A sudden hypercatabolic decrease of renal function, with serum creatinine levels greater than 3 mg per dL (260 [Mu]mol per L) for two or more days following surgery, major trauma or multiple organ failure, is fatal in about 50 percent of patients. Protein and calorie requirements in patients with acute renal failure are significantly increased and are further increased by frequent dialysis. The survival rate in acute renal failure correlates significantly with adequate caloric intake. Total parenteral nutrition markedly contributes to improved outcome in patients with acute renal failure.
Unconfirmed is a claim that patients with acute renal failure benefit from parenteral formulas containing a mixture of eight essential amino acids, which would allow better nitrogen utilization and decreased urea production. Although based on a very solid rationale, this theory has not been confirmed in randomized controlled trials.
HEPATIC FAILURE AND ENCEPHALOPATHY
The aim of nutritional support in patients with chronic hepatic failure should be to correct or prevent malnutrition without worsening–or even improving–the metabolic effects of advanced liver disease. Metabolic effects include hyperaldosteronism with reduced tolerance to sodium and water, impaired tolerance to carbohydrates, elevated muscular protein breakdown and reduced tolerance to protein loads with pending or overt hepatic encephalopathy.
These metabolic changes make the nutritional approach to the treatment of chronic liver failure extremely complex. Fluid overload should be prevented by the infusion of hypertonic glucose; exogenous insulin is recommended to promote peripheral glucose assimilation and to prevent hyperglycemia. Lipid solutions, which provide high amounts of calories in a smaller volume, have been discouraged because of the inability of cirrhotic patients to adequately metabolize exogenous fat. However, plasma clearance of exogenous triglycerides in the amounts currently administered in total parenteral formulas has been shown in both compensated and decompensated cirrhotic patients to be similar to that found in normal subjects.
The characteristic plasma amino acid profile seen in patients with cirrhosis–high aromatic and low branched-chain amino acid (BCAA) levels–is involved in the pathogenesis of hepatic encephalopathy. The ability of BCAA-enriched solutions to normalize the plasma amino acid pattern in chronic liver failure and to reverse hepatic encephalopathy has been shown in several studies[53,54] but has not been accepted unequivocally. Strong support for the efficacy of BCAA-enriched total parenteral nutrition in the treatment of hepatic encephalopathy is based on data from nine controlled clinical trials.
ACQUIRED IMMUNODEFICIENCY SYNDROME
Malnutrition is common in patients with acquired immunodeficiency syndrome and is caused by both the disease and the opportunistic infections that cause diarrhea, malabsorption and caloric deficit, resulting in loss of body fat, muscular protein breakdown and a decrease in lean body mass. A poor nutritional state further contributes to increased susceptibility to infection in these patients.
It has been postulated that the wasting syndrome in AIDS is due to a lack of essential fatty acids, particularly gamma linoleic acid and/or isopentoic acid, brought about by deficient dietary intake, malabsorption and the presence of inhibitors of delta-6-desaturase enzyme activity in the gastrointestinal tract. The essential free fatty acid deficiency causes immunosuppression, increasing the susceptibility to viral infection.
According to the Task Force on Nutritional Support in AIDS, nutritional therapy is mandatory when the wasting syndrome starts. If intestinal absorption is conserved, enteral feeding is possible. Total parenteral nutrition is indicated in the presence of chronic diarrhea or weight loss that occurs despite normal oral intake. Total parenteral nutrition is also indicated during the early course of AIDS to prevent progressive weight loss, to reduce the frequency of secondary infection, to augment response to chemotherapy, to improve the quality of life and sense of well-being and, ultimately, to retard progressive immunologic deterioration. Randomized prospective data to refute or support the role of aggressive nutritional support are pending.
In addition to being a caloric resource, fat emulsions are thought to have other beneficial effects. For example, fluidization of human immunodeficiency virus (HIV) membranes through cholesterol extraction may decrease the infectivity of the virus. Thus, long-term intravenous nutrition may be more than a treatment for malabsorption and depletion. It may have direct pharmacologic effects that enhance the immune system and inactivate HIV.
A number of major metabolic alterations contribute to the muscle wasting that occurs with critical illness. Among these are glucose intolerance, increased fat mobilization and increased protein breakdown. The effects of these changes are compounded because critically ill patients are frequently unable to take in nutrients through the gastrointestinal tract. Nutrition depletion may be further worsened if overwhelming septic complications are present.
Total parenteral nutrition can prevent loss of body mass and maintain or restore an optimal nutrition status. It is difficult, however, to define the role of total parenteral nutrition in modifying morbidity and mortality, except in patients with closed head injuries. In this situation, the early use of total parenteral nutrition has been found to result in fewer complications and enhanced survival, as compared with that in control subjects receiving oral feeding.
It has been shown that BCAA-enriched total parenteral nutrition decreases muscular protein breakdown, increases protein synthesis in the liver and improves nitrogen retention in surgically stressed and post-trauma patients. Because glucose intolerance may preclude the administration of high doses of glucose, 30 to 50 percent of nonprotein energy should be provided by fat.
NEONATAL AND PEDIATRIC PATIENTS
Infants and children are less tolerant to starvation than adults, so any nutritional insult may exert a severe negative influence on organ development, especially the brain. For this reason, independent of an underlying disease, total parenteral nutrition is usually started sooner in pediatric patients than in adults.
Most of the reports on total parenteral nutrition in pediatric patients deal with low-birth-weight infants, in whom an immature intestinal tract is unable to process full nutrition loads. The general conclusion of these studies is that the use of total parenteral nutrition as an adjunct to different enteral formulas has a positive effect on weight gain but does not alter morbidity or duration of survival in low-birth-weight infants. Conversely, total parenteral nutrition is effective in reducing the mortality rate in a variety of disorders, including gastroschisis, short-bowel syndrome and necrotizing enterocolitis. Other indications for the use of total parenteral nutrition in infants and children are similar to those encountered in adults.
The decision to initiate home use of total parenteral nutrition depends on the patient’s primary diagnosis and clinical condition, and a support system for maintaining care in the home.
On the basis of the OASIS report on parenteral and enteral nutrition, an estimated 14,300 patients were receiving home nutritional support in 1986. Home therapy was used in patients with cancer, Crohn’s disease, short-bowel syndrome and other gastrointestinal tract motility disorders. Nutrition support in patients with non-malignant diseases tends to be for years; in patients with cancer, AIDS and neurologic disorders, the duration is usually less than one year. The survival rate of patients receiving home nutrition support for non-neoplastic diseases is estimated at 60 to 80 percent at three years, with an 85 to 100 percent rate of rehabilitation.
In the absence of controlled clinical trials carefully evaluating the cost-effectiveness of home nutrition support, the guidelines for its use should take into account not only the general indications outlined for in-hospital total parenteral nutrition but also the motivation of both the patient and family to assume the responsibility of learning how to safely administer this complex treatment modality.
Nutrition support teams have had a great impact on reducing the complications from total parenteral nutrition. In a study conducted before the development of these teams, mechanical, septic and metabolic complications averaged 33 percent, 21 percent and 36 percent, respectively. After institution of these teams, complication rates fell dramatically to 3.2 percent, 6.5 percent and 3.0 percent, respectively.
The rate of mechanical complications is directly related to the skill and experience of the person inserting the catheter. Other factors contributing to complications include the site of catheter insertion and the catheter material. Of 39,180 central venous catheters, mechanical complications were most frequent with a subclavian central venous insertion, as shown in Table 2. The death rate related to central venous catheter complications was 1.2 percent. The safest method of obtaining central venous access is through the internal jugular vein, although this is not the most widely used route.
Complications Associated with Total Parenteral Nutrition
Complication Nature Frequency
Mechanical Catheter tip malposition 6
Arterial laceration 1.4
Pneumothorax, hydrothorax or 1.1
Subclavian or superior vena 0.3
Catheter embolism 0.1
Septic Catheter-related sepsis 7.4
Acute metabolic Hyperglycemia/hypoglycemia Avoidable
Blood electrolyte abnormalities
Related to Metabolic bone disease Rare
prolonged use Alteration in bile composition
Deterioration of liver function
The frequency of catheter sepsis is 7.4 percent. Quantitative blood culture is the most effective method for determining in situ catheter-related sepsis. In one study of catheter sepsis, catheter removal was followed by improvement in the patient’s condition when the catheter was incriminated by culture data. In no instance when the central venous catheter was deemed “innocent” did its removal lead to clinical improvement.
Since total parenteral nutrition can be regarded as a sophisticated form of fluid and electrolyte therapy, many of the metabolic complications that were reported resulted from errors of omission. Thus, complications due to an excess or deficit of electrolytes, vitamins or trace elements are potentially avoidable. The introduction of a safe and reliable fat source has obviated metabolic complications derived from glucose-based parenteral nutrition, such as hyperglycemia, hypoglycemia, hyperosmolar syndromes, hypertriglyceridemia, hyperlipidemia, hyperinsulinemia, elevated epinephrine, elevated liver function tests, hypercarbia, essential fatty acid deficiencies and venous thrombosis.
Guidelines for the Use of Total Parenteral Nutrition Short-bowel syndrome Essential to achieve long-term stability in the critical
postoperative period; ensures survival. May be used temporarily or throughout life, depending on
adaptation of remaining functional gut. Perioperative Preoperative: two to three days of total parenteral nutrition
before surgery does not improve surgical outcome. Some improvement is observed with five to seven days of use. A significant reduction in major postoperative complications
and mortality is achieved with seven to 10 days of use before
surgery. Postoperative: when the anticipated period of postoperative
functional starvation exceeds five days. Inflammatory bowel disease For patients with Crohn’s disease who have gut failure and in
pediatric patients with growth failure. Can induce remission in 60 to 70 percent of patients with acute
flare-ups of Crohn’s disease but does not influence outcome
in severe complications of Crohn’s disease or the severe flare-ups
of chronic ulcerative colitis. Is indicated as adjuvant therapy in patients with chronic
ulcerative colitis and malnutrition who cannot otherwise
meet their nutritional needs. Enteral feeding with a defined formula diet is beneficial and
preferred to total parenteral nutrition in patients with active
Crohn’s disease. Enterocutaneous fistula Can control and reduce fistula output in conjunction with
somatostatin (Reducin), while preventing or treating local
skin complications and systemic metabolic and septic
complications. Prevents malnutrition and corrects volume, electrolyte and
acid-base deficits with intravenous fluid and electrolytes
when oral intake is stopped. Pancreatitis Is not required if the anticipated period of administration is less
than five to seven days. Is effective as nutritional support in necrotizing pancreatitis
and beneficial if complications arise. Data indicate safety of lipid emulsions in patients with acute
pancreatitis who have increased cholesterol and triglyceride
levels. Cancer Is not routinely indicated in well-nourished or mildly
malnourished patients undergoing surgery, chemotherapy
or radiation therapy. Useful for severely malnourished patients or patients whose
severe gastrointestinal or other toxicities preclude adequate
enteral intake for seven days or longer. Should be given prior to or in conjunction with the institution
of cancer therapy. Seldom indicated in patients with advanced cancer who have
significant deterioration of performance status or in patients
unresponsive to antineoplastic therapy. Not indicated in terminal disease or when no further
antineoplastic therapy is available. Beneficial in malnourished patients with cancer who can be
expected to have a normal or near-normal period of greater
than six months. Bone marrow transplantation In patients undergoing bone marrow transplantation, enhances
survival, diminishes relapse and shortens hospital stay. Cardiac surgery Overnight administration before coronary artery bypass graft
surgery increases myocardial glycogen content and
decreases postoperative morbidity and mortality. Obstetrics For patients with hyperemesis gravidarum. Is useful in exacerbations of preexisting conditions, such as
inflammatory bowel disease and pancreatitis, and in cases of
traumatic maternal death with a viable fetus. Acute renal failure Assists patients in coping with the abnormal intermediate
metabolism of acute renal failure until satisfactory renal
function returns. Formulas enriched with essential amino acids are not
unequivocally accepted. Advanced chronic liver failure For nutritionally depleted patients who are unable to tolerate
enteral nutrition. Prevents the secondary effects of starvation on general
metabolism and the liver. BCAA-enriched solution can be used to achieve proper
amino acid intake and avoid complications of hepatic
encephalopathy in patients unable to tolerate 60 to 80 g
of amino acids in regular solutions because of grade 3 or
4 hepatic encephalopathy. Acquired immunodeficiency syndrome For patients with malnutrition caused by anorexia or impaired
intestinal absorption, if enteral nutrition is unsuccessful. Routine use is discouraged because of a lack of data
documenting a positive influence on morbidity and
mortality. Critical care For well-nourished critically ill patients with a survivable
injury who are unable to eat or attain adequate enteral intake
within five to seven days or in previously malnourished
patients for whom it would be beneficial before the
hypermetabolic phase of recovery in a critical illness. Is of little benefit in critically ill patients whose hypermetabolic
phase is less than four or five days or when adequate enteral
nutrition is anticipated during this time. Is of no benefit in patients with a nonsurvivable injury, where
its use might prolong life unnecessarily. Pediatrics To prevent a severe negative influence on growth and organ
development in the absence of sufficient enteral nutrition. Use after three days if adjunctive enteral feedings are not well
tolerated and minimal caloric requirements cannot be met. Home use Improves quality of life and decreases cost of treatment.
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MICHAEL M. MEGUID, M. D., PH. D. is professor of surgery and director of the Surgical Metabolism and Nutrition Laboratory at the State University of New York Health Science Center, Syracuse, N.Y. Dr. Meguid graduated from University College Hospital Medical School at the University of London, England, and completed a residency in surgery and a fellowship in surgical metabolism at Peter Bent Brigham University Hospital/Harvard Medical School, Boston.
MAURIZIO MUSCARITOLI, M.D. is assistant professor at State University of New York Health Science Center. He graduated f rom the University of Rome La Sapienza School of Medicine, where he also completed a residency in internal medicine and nephrology. Dr. Muscaritoli completed a fellowship in nutrition and metabolism at the Italian Ministry for Public Instruction in Rome.
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