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Patients with acute pancreatitis have elevated nutritional needs due to increased energy expenditure and catabolism. It is a clinical challenge to provide adequate nutrition to these patients while maintaining gut function, preventing pancreatic stimulation, and minimizing the risk of septic and metabolic complications associated with nutritional support. We present the case of a patient who had severe acute pancreatitis and was initially given total parenteral nutrition. After a period of initial improvement, he developed hyperglycemia, bacteremia, and sepsis. Parenteral nutrition was discontinued and infection was treated with antibiotics. Subsequent nutritional support consisted of enteral feeding with an elemental diet infused via a nasojejunal feeding tube. His condition improved gradually and he made a full recovery. This case illustrates the difficulties encountered while managing a case of severe acute pancreatitis and provides an evidence based approach to the nutritional management of severe acute pancreatitis in the intensive care unit setting.
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PMID:Severe acute pancreatitis: nutritional management in the ICU. 1621 93

Nutrition support in the critically ill patient is challenging but is even more difficult in a morbidly obese patient. This case report chronicles the care of a 6-foot-tall, 256-kg male (body mass index 76.5 kg/m(2)) who spent over a month in the intensive care unit for respiratory failure, sepsis, and acute renal failure. Parenteral nutrition was provided throughout his critical care course. One of the major difficulties encountered was determining his nutritional needs. A hypocaloric nutritional regimen was used, along with moderate protein provisions. Numerous electrolyte imbalances occurred, including hypercalcemia that did not resolve by eliminating calcium from the parenteral nutrition solution. Enteral nutrition was desired but was not used initially because of a need for vasopressors, a diagnosis of pancreatitis, difficulty in documenting feeding tube placement because of diagnostic limitations secondary to the patient's large size, and concern about managing stools. Eventually, oral intake and supplemental enteral feeding were initiated. Nutrition support team members worked closely with the interdisciplinary care team to develop strategies to manage the nutritional problems related to his obesity. A discussion of the various nutritional issues encountered in the care of this patient is provided. Reasonable nutritional status was achieved, but this case reflects some of the challenges encountered in caring for the nutritional needs of select patient populations in clinical practice and the need for increased research and guidelines in this area.
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PMID:Nutrition support in the morbidly obese, critically ill patient. 1621 17

Current treatment options for patients suffering from intestinal insufficiency include all forms of intestinal replacement therapy (IRT). Parenteral nutrition has achieved extended success for the majority of patients requiring interval treatment, however, complications leading to failure of this treatment increases with the duration of therapy. There is currently no consensus as to the appropriate timing for transplantation of the intestine or the timing of referral for evaluation at a center experienced with this therapy. Certain patient characteristics warrant evaluation. Those patients with no jejunoileum who have guaranteed lifelong parenteral dependence, both adult and pediatric, should be immediately referred to a transplant center due to the high likelihood of the development of liver disease. Patients with metastatic infectious complications from catheter sepsis, patients with cholestasis seen intermittently with sepsis episodes, patients who are not successfully weaning and who demonstrate progressive thrombocytopenia, and patients with motility disorder experiencing deterioration should also warrant early referral to an intestinal rehabilitation and transplant program. The objective of evaluation is to maximize the opportunities for rehabilitation while not missing the critical window of opportunity for successful transplantation when needed. We favor an aggressive directed approach to rehabilitation, coupled with psychological preparation for both transplantations and other options. Early referral requires trust between the patient, referring physician, and the transplant team to assure that a rush to judgment will not lead to a premature transplant. The current wait list mortality is high, mandating early referral and listing with an approach aimed at maximizing both the success of gastrointestinal support, as well as of transplantation when necessary.
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PMID:Intestinal replacement therapy: timing and indications for referral of patients to an intestinal rehabilitation and transplant program. 1647 63

Parenteral nutrition-associated cholestasis (PNAC) is a complication not uncommon in the pediatric population. In severe cases, patients require a liver transplant. To our knowledge, we report the only case of PNAC with end-stage liver failure in a child with short bowel syndrome that resolved with a change in caretaker. Until his care was transferred from his abusive parents, he was frequently admitted for infection and sepsis. His liver function vastly improved from aspartate aminotransferase (AST) 3139 units/L, conjugated bilirubin 25.9 mg/dL to AST 47 units/L, direct bilirubin 0.3 mg/dL under the care of his attentive foster mother, and a liver transplant was no longer necessary. Bacterial infection and sepsis are risk factors correlated with patients with PNAC requiring liver transplant. Prevention of infection by a good caregiver may be a means to reduce the incidence of PNAC.
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PMID:Parenteral nutrition-associated cholestasis related to parental care. 1677 46

For many years, the increased nutritional requirements of surgical, septic and cancer patients were identified, but no effective therapy existed for averting their negative calorie and nitrogen balance. Parenteral nutrition offered an answer in many of these situations. However, abnormalities in liver function, ventilatory load, hyperglycemia and a disturbed metabolic homeostasis showed that in excessive amounts, glucose can behave as a relatively toxic substance. For cases with increased energy expenditure, new alternatives had to be devised in order to avoid excessive glucose intakes. One obvious possibility in these cases was to refrain from offering more than the basal caloric needs, until the patient had passed the period of acute injury, or other measures had effectively controlled the sepsis or cancer. Other options included the partial substitution of glucose by lipids or amino acids. Preliminary information suggests that this approach could lead to better nutritional outcome and survival rates, but additional studies are required.
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PMID:Energy replacement during parenteral nutrition in surgery, sepsis and cancer. 1682 47

The technique of the implementation of Home Parenteral Nutrition (HPN) is improving continuously so carrying minimum risk of technical complications and supplying maximum comfort for the patient. For example the HPN benefits of the recent availability of Ethil-Vinil-Acetate (EVA) bags that permit the contemporary administration of all nutrients, lipids included, and of infusion pumps which are lighter, safer and more versatile and which have rechargeable batteries. Some new types of completely implantable catheters with a subcutaneous reservoir present a better rationale compared with complications and with patient's compliance in respect of traditional percutaneous catheters used in HPN. We wanted to verify these presuppositions in a retrospective study with a completely implantable catheter, Port-A-Cath (PAC) Pharmacia, with a group of six patients already under HPN for a period of 901 patient-days with a percutaneous catheter. We compared the two methods of treatment after 1114 patient-days with the PAC. Concerning complications, we have three catheter related sepsis (3.3 1000 days) with percutaneous catheter and 1 sepsis (0.9 1000 days) with the PAC. We also had one catheter obstruction in a patient with the PAC implanted in the Inferior Vena Cava. All the patients accepted the new technique and even if they did not have the same motivation, all of them particularly appreciated the possibility of the avoidance of any external device. Our experience leads us to report that the Port-A-Cath system may be useful in long-term parenteral nutrition but other research is needed to confirm its rationale.
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PMID:Percutaneous vs. totally implantable catheters in home parenteral nutrition. 1683 46

This registry describes a multicentre experience of Home Parenteral Nutrition (HPN) in nine European countries covering 27 centres and 194 patients. The main purpose of this study was to evaluate the quality of life and prognosis of patients on HPN. Patients started HPN at 44 +/- 1 years old (mean +/- SEM), and received 200 courses of HPN for a mean of 12 +/- 1 months representing a cumulative duration of 207 years. The four commonest indications for HPN were inflammatory bowel disease (30%), mesenteric vascular disease (21%), malignancy (17%) and radiation enteritis (13%). The nutritional status during HPN was clinically normal or subnormal in 93% of cases. The yearly incidence of catheter related complications leading to a catheter change was 0.74, sepsis accounting for half of this. The duration of hospital readmission for HPN complications was 4 +/- 1% of time spent at home, which represents 2 weeks per year and 41% of the total readmission time. Mortality was mainly influenced by the underlying disease since only 3% of patients died of HPN complications. A good social rehabilitation was observed in 52% of patients who during treatment recovered their pre-HPN occupational status. The poorest social rehabilitation was observed in patients over 65 years of age, and patients with malignancies and radiation enteritis, who also had the poorest prognosis. Caution seems necessary before recommending HPN in these patients.
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PMID:Home parenteral nutrition in adults: a multicentre survey in Europe. 1683 59

Excessive or inappropriate inflammation and immunosuppression are components of the response to surgery, trauma, injury and infection in some individuals and can lead, progressively, to sepsis and septic shock. The hyperinflammation is characterised by the production of inflammatory cytokines, arachidonic acid-derived eicosanoids and other inflammatory mediators, while the immunosuppression is characterised by impairment of antigen presentation and of T-helper lymphocyte type-1 responses. Long-chain n-3 fatty acids from fish oil decrease the production of inflammatory cytokines and eicosanoids. They act both directly (by replacing arachidonic acid as an eicosanoid substrate and by inhibiting arachidonic acid metabolism) and indirectly (by altering the expression of inflammatory genes through effects on transcription factor activation). Thus, long-chain n-3 fatty acids are potentially useful anti-inflammatory agents and may be of benefit in patients at risk of hyperinflammation and sepsis. As a consequence, an emerging application for n-3 fatty acids, in which they may be added to parenteral (or enteral) formulas, is in surgical or critically-ill patients. Parenteral nutrition that includes n-3 fatty acids appears to preserve immune function better than standard formulas and appears to diminish the extent of the inflammatory response. Studies to date are suggestive of clinical benefits from these approaches, especially in patients post surgery, although evidence of clinical benefit in patients with sepsis is emerging.
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PMID:Use of fish oil in parenteral nutrition: Rationale and reality. 1692 11

The fear of necrotizing enterocolitis and feeding intolerance are major factors inhibiting the use of the enteral route as the primary means of nourishing premature infants. Parenteral nutrition may help to meet many of the nutritional needs of these infants, but has significant detrimental side effects that include intestinal atrophy, sepsis, and increased susceptibility to inflammatory stimuli and systemic inflammatory responses. Being able to minimize the use of the parenteral route and still maintain appropriate nutrition safely would be a major advance in neonatology. At the basis of our inability to use the enteral route is a poorly understood immature gastrointestinal tract. Approaches such as minimal enteral nutrition or trophic feedings may partially alleviate these problems. However, if we are to progress in greater utilization of the gastrointestinal tract, other factors need to be considered. These include the macronutrient composition of minimal enteral or trophic feedings and the microecology of the intestinal lumen. Some of the developmental aspects of the intestine, which include intestinal growth, motor activity, barrier and other innate immune functions, and the microecology of the developing intestine, are briefly reviewed here. The purpose of this review is to suggest important areas of future research in neonatal and developmental gastroenterology that could affect several conditions that are related to immaturity of the gastrointestinal tract.
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PMID:Gastrointestinal development and meeting the nutritional needs of premature infants. 1728 68

The systemic inflammatory response syndrome (SRIS) seems to be due to the activation of the toll-like receptors, specific of the inflammatory response cells, through concrete cytosolic signals which lead to a cascade of reactions acting cytokins, growing factors and others inflammatory mediators. This kind of work revewes and discusses several classifications of animals models to study the SRIS, and propose to divide these models according to concrete goals, which can be the following ones: (1) To study innate and adaptative receptors of regulatory gens in the SRIS. (2) To study signals receptors (cytokines and growing factors). (3) To study the answer to signals. (4) To study treatments through specifics antinflammatory blockage. (5) Specific models of sepsis. (6) Others inducing models of SRIS. (7) Others therapeutical models. -Antinflammatories. -Antiacoagulans: Coagulations inhibition in human assays. Phase II Anticoagulans: Antitrombine III, PCA and TFPI. -Antibiotics. -Replacing Volume Treatments. -Surgical Treatments. As to the animals models to study Parenteral Nutrition, we could make the next classifications and sum it up: (1) Animal models to study the parenteral via of administration. (2) Models to study viability, absorption and local tolerance of the administration via. (3) Study models for complications. (4) Animal models to study pharmacodynamic, metabolization and to investigate the tolerance of new molecules or substrates.
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PMID:[Animal models for the study of systemic inflammatory response and parenteral nutrition]. 1741 31


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