Metabolism and Artificial Nutrition in the Critically Ill

233 Pages·1999·5.62 MB·English

by  R. R. Wolfe (auth.)

Metabolism and Artificial Nutrition in the Critically Ill
Springer
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G. Guarnieri
F. Iscra (Eds)
Metabolism and
Artificial Nutrition
in the Critically Ill
Series edited by
Antonino Gullo
Springer
G. GUARNIERI, MD
Institute of General Clinical Medicine
Cattinara Hospital, Trieste -Italy
F. ISCRA,MD
Department of Anaesthesia, Intensive Care and Pain Therapy
Cattinara Hospital, Trieste -Italy
Series of Topics in Anaesthesia and Critical Care edited by
A.GULLO,MD
Department of Anaesthesia, Intensive Care and Pain Therapy
University of Trieste, Cattinara Hospital, Trieste -Italy
© Springer-Verlag Italia, Milano 1999
ISBN 978-88-470-0042-1 ISBN 978-88-470-2901-9 (eBook)
DOI 10.1007/978-88-470-2901-9
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SPIN 10697760
Foreword
The critically ill patient in intensive care may present with serious metabolic
alterations caused directly by the illness or secondarily by complications (e.g.
infections, organ failure or sepsis) developing within a few hours of hospitaliza
tion or in the following days. Among the situations which maintain and further
trigger rapidly evolving altered metabolism are complex hormonal reactions,
particularly those of the hypothalamus-hypophysis-adrenal axis, and abnormal
stimulation of the autonomic nervous system. In fact, the sympathetic nervous
system is known to cause significant metabolic alterations.
For example, a surgery patient afflicted by septic complications may become
hypercatabolic and experience significant nitrogen loss; the altered protein
metabolism may in turn heavily influence carbohydrate and lipid metabolism as
well. Thus, it is apparent that for optimal care of patients with altered metabolic
functions, further knowledge is necessary regarding the physiopathology of
metabolism and the physiopathological mechanisms, which alter the consump
tion of principal energy substrates.
Many experimental and clinical studies have investigated the metabolic
aspects of individual organs or organ systems. However, for a correct evaluation
of such metabolic events, in addition to studying the roles of metabolic enzymes,
active metabolites, and the glutathione system, it is interesting to consider the
use of indirect calorimetry as a valid and important investigative technique.
The critically ill patient with major alterations in nutritional status may
require artificial nutritive support administered through either parenteral or
enteral routes.
Relevant research activities, both experimental and clinical, focus on the
study of hormones, growth factors, and especially the immune system. In addi
tion, the metabolic changes occurring in the critically ill are certainly affected by
the presence of antioxidants, although their role is not clearly understood. The
intense basic research in these fields should lead in the near future to more
appropriate treatments. These guidelines will not simply be quantitative in
terms of the necessary daily calories, but must also be qualitative by indicating
the most effective nutritional substrates to administer to the critically ill.
November 1998 Antonino Gullo, MD
Contents
BASICS AND METHODS
Chapter 1 -Substrate metabolism in critical illness
R.R. Wolfe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Chapter 2 -Measurement of the body composition
S.J.S. Ryde . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Chapter 3 -Energy and ATP: costs and benefits
J.P. Flatt. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Chapter 4 -Indirect calorimetry in the critically ill:
theoretical aspects and practical problems
L.S. Brandi, L. Santini, R. Bertolini . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
LOCAL AND SYSTEMIC EFFECTS ON METABOLISM
Chapter 5 -Hormonal response of the hypothalamo-pituitary-adrenal
axis in injury
R. Chiolero, F. Pralong, R. Gaillard. .. . .. . .. . .. . .. . .. . . .. . .. . .. . .. . . .. . 61
Chapter 6 -Sympathetic nervous system and metabolism
G.L. Carlson, R.A. Little. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Chapter 7 -Regional and systemic metabolic effects after surgical injury
G. Sganga, I. Giovannini, C. Chiarla, M. Castagneto . . . . . . . . . . . . . . . . . . . . . 85
Chapter 8 -What about metabolism and the glutathione system?
J. Wernerman, J.-L. Luo, F. Hammarqvist .............................. 93
Chapter 9 -Carbohydrate and insulin activity in critically ill patients
R.R. Wolfe ........................................................ 101
Chapter 10 -Muscle catabolism, amino acid flux and protein turnover
in injury
G. Biolo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
VIII Contents
TPN VS ENT NUTRITION -COST AND BENEFITS
Chapter 11 -Total parenteral nutrition vs total enteral nutrition in
critically ill patients: costs and benefits
F. Iscra, A. Randino, G. Sermann ................................... 115
NEW STRATEGIES ON METABOLISM AND NUTRITION
Chapter 12 -Hormone and growth factors in intensive care patients:
anabolic strategy or utopia?
C. Pichard, P. Jolliet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 125
Chapter 13 -Which metabolic strategies in the early phase of injury?
G. Iapichino, A. Pezzi, D. Radrizzani, S. Marzorati ...................... 133
Chapter 14 -Effects of artificial nutrition on the immune system cells
M. Braga, O. Gentilini, 1. Gianotti, A. Vignali ........................... 147
Chapter 15 -Selective antioxidants and early artificial nutrition as
prevention of multiple organ failure
D.W. Wilmore ..................................................... 161
Chapter 16 -Pharmacological nutrition in ICU patients
G. Guarnieri, G. Biolo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
NUTRITION -STEPS FOR THE FUTURE
Chapter 17 -Metabolism and nutrition in the critically ill:
steps for the future
D.W. Wilmore..................................................... 177
GUT AND NUTRITION
Chapter 18 -The gut in healthy conditions
1. Pironi, F. Paganelli, M. Miglioli ................................... 187
Chapter 19 -The gut in local and systemic disease
M. Zanello, 1. Di Mauro, C. Santoro................................... 193
Chapter 20 -Bacterial translocation
G. Sganga, M. Castagneto . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 203
Chapter 21 -Gut and nutrients
G. Toigo, R. Situlin, B. Ciocchi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 211
Contents IX
OLD DILEMMA OR NEW STRATEGIES
Chapter 22 -Parenteral vs enteral nutrition
R. Tufano, M. Pezza, L. Ughi ......................................... 225
Main symbols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 233
Subject index ................................................... 235
List of contributors
Bertolini R.
Intensive Care Unit, S. Chiara Hospital, Pisa, Italy.
BioloG.
Department of Clinical Medicine, University of Trieste, Italy.
BragaM.
Department of Surgery, Scientific Institute S. Raffaele Hospital, University of
Milan, Italy.
BrandiL.S.
Department of Surgery, School of Anaesthesia and Intensive Care, University of
Pisa, Italy.
Castagneto M.
Department of Surgery, Division of Organ Transplantation, Catholic University
and CNR, Rome, Italy.
Chiarla C.
Department of Surgery, Division of Organ Transplantation, Catholic University
and CNR-Centro Studio Fisiopatologia Shock, Rome, Italy.
Chiolero R.
Surgical Intensive Care Unit, University Hospital (CHUV), Lausanne, Switzerland.
Carlson G.L.
North Western Injury Research Centre (MRC Trauma Group), University of
Manchester, UK.
Ciocchi B.
Department of Clinical Medicine, University of Trieste, Italy.
DiMauroL.
Department of Neurological Science, Division of Anaesthesia and Critical Care,
Bellaria Hospital, AUSL, Bologna, Italy.
Flatt J.P.
Department of Biochemistry & Molecular Biology, University of Massachussets
Medical Center, Worcester, USA.
XII Contributors
GaillardR.
Division of Endocrinology, Diabetes and Metabolism, University Hospital (CHUV),
Lausanne, Switzerland.
Gentilini O.
Department of Surgery, Scientific Institute S. Raffaele Hospital, University of
Milan, Italy.
Giannotti L.
Department of Surgery, Scientific Institute S. Raffaele Hospital, University of
Milan, Italy.
Giovannini I.
Department of Surgery, Division of Organ Transplantation, Catholic University
and CNR-Centro Studio Fisiopatologia Shock, Rome, Italy.
Guarnieri G.
Department of Clinical Medicine, University of Trieste, Italy.
Hammarqvist F.
Department of Anesthesiology and Intensive Care, Hudding Hospital, Karolinska
Institute, Stockholm, Sweden.
Iapichino G.
Department of Anaesthesia and Intensive Care, San Paolo Hospital, University
of Milan, Italy.
Iscra F.
Department of Anaesthesia, Intensive Care and Pain Therapy, University of Trieste,
Italy.
Jolliet P.
Division of Medical Intensive Care, University Hospital, Geneva, Switzerland.
Little R.A.
North Western Injury Research Centre (MRC Trauma Group), University of
Manchester, UK.
Luo J.-L.
Department of Anesthesiology and Intensive Care, Hudding Hospital, Karolinska
Institute, Stockholm, Sweden.
Marzorati S.
Department of Anaesthesia and Intensive Care, San Paolo Hospital, University
of Milan, Italy.