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In today’s society, cardiovascular disease (CVD) is the number 1 killer of Americans, followed by cancer. Cardiovascular, coronary heart disease, or simply heart disease all refer to the same condition, a serious disease whose progression often requires surgeries that Americans are all too familiar with - bypass surgery, angioplasty, stent placements, or even heart transplants.

Given this sad state of affairs, it’s no surprise that thousands of recovering surgery patients would, and should, regard heart surgery and post operative nutrition key elements to rehabilitation after such major medical intervention. Nutrition which is time and again under-appreciated in this country is absolutely critical to recovery from any major surgery, heart surgery is no exception. In the case of heart surgery, post operative nutrition can help reduce the painful symptoms associated with the healing from the procedure AND perhaps more importantly post operative nutrition can insure that one will not have to under go surgery again! Nobody who suffers the ordeal of undergoing hearty surgery, relishes the idea of having to repeat the procedure once if not twice more. Aside from the emotional and physical stress involved in surgery, the financial drain is considerable, especially in this country with skyrocketing healthcare costs which increase annually with no end in sight.

Regarding heart surgery, post operative nutrition in the form of fresh fruits and vegetables, whole grain foods, and minimal intake of animal proteins loaded with saturated fats is a MUST if one wants to really “get a new lease on life.” Supplementation with Omega-3 fatty acids, Vitamin E, and Vitamin C is also important and has been validated by literally thousands upon thousands of scientific studies. One protocol regarding heart surgery, post operative nutrition that is not well known but absolutely impressive and validated by science and real life testimonials is the Pauling Protocol, popularized by famous two time Nobel Prize Winner Linus Pauling. Pauling recommended a combination of Vitamin C and the amino acids Lysine and Proline for recovery from Cardiovascular Disease. Folks, this is a very inexpensive protocol backed by scientific data that works to heal the cardiovascular system. The pharmaceutical companies don’t want you to know about it because it’s cheap and it works - unlike most of the drugs being peddled by doctors today.

To enhance performance and increase endurance effectively, each young athlete and their parents should make proper nutrition, on and off the field, a high priority. Proper nutrition takes planning and preparation and begins at home. Proper nutrition will not only help build strong bodies, but also strong minds. And it will set each young athlete on the road to a healthy adulthood.

Game day nutrition is especially important because the proper nutrients will help regulate blood sugar and keep energy levels up. Whey protein will help build lean muscle and assist in recovery. Staying hydrated will also help with recovery from exertion.

1-2 hours prior to workout, conditioning, practice or event: Prepare for exercise by hydrating your body and consuming a small amount of carbs to provide adequate fuel during exercise and prevent fatigue while still allowing the stomach to be relatively empty at start of competition/workout, preventing GI distress and discomfort during exercise.

Recommendations: Drink 16 oz of a hydrating sports drink and consume a low sugar, protein bar.

During workout, conditioning, practice or event: Each athlete needs carbs, protein and electrolytes to prevent dehydration, support the immune system, and delay muscle fatigue and stress responses caused by exercise.

Recommendations: Drink 16 oz. of hydrating sports drink and 4 oz. of a whey protein supplement mixed in a water bottle.

Post Workout or Event: Each athletes needs whey protein to rapidly recover, maximize glycogen stores and facilitate muscle tissue repair. It also relieves muscle aches caused by lactic acid buildup after a workout and provides nutrients to maximize the effects of conditioning. Re-hydrating also provides adequate fluid to support proper bodily functions.

There are numerous vitamins, minerals, and essential acids that not only aid the body in its everyday function, but that also can help the human machine perform at optimum levels. We are bombarded on a daily basis with vitamin and mineral information, so it is always interesting when you can actually glean a nutrition fact or two from the wide array of vitamin education.

For instance, Vitamin C is a required vitamin for healthy function of the circulatory, skeletal, and musculature systems. Basically, Vitamin C is a vital ingredient to the production of collagen, which is used to build all kinds of things in the body. Another nutrition fact of Vitamin C is that it is a critical component of brain activity. Vitamin C helps the cells in the brain keep firing, much like a tune up helps your spark plugs fire up your car engine. Vitamin C, then, aids in the productivity of the brain, and can even help out in the regulation of certain mood-affecting brain chemicals.

Another nutrition fact beyond this is that Vitamin C is what is known as an antioxidant, meaning it has a protective effect. Antioxidants are those things, like Vitamin C, that guard cells and proteins from harmful external forces, like UV rays, cigarette smoke, and alcohol. The blood and skin are vulnerable to damage, so the defense system that Vitamin C puts up can help you keep your blood and skin as healthy as possible.

Interestingly, being deficient in Vitamin C actually causes a disease called scurvy, in which all of those systems that rely on Vitamin C for structural soundness literally fall apart without this essential building block. Scurvy results in teeth and hair loss, easy bruising and bleeding, and a whole host of other problems. Scurvy used to be quite prevalent, especially in the military where proper nutrition was almost unheard of. All of a sudden, though, they figured out that fresh citrus consumption seemed to prevent scurvy, and suddenly, a huge Vitamin C benefit was found. How’s that for a nutrition fact? Nowadays, scurvy rarely happens in the Western world.

It is also a nutrition fact that Vitamin C may help to prevent flare-ups of chronic diseases, and probably does so with a boost to the immune system. So taking the recommended daily dose of Vitamin C can keep your body from falling apart, and keep you feeling good.

In many cases regarding weight loss, nutrition is always taken for granted. However, even when it comes to weight loss, nutrition should still become a priority to ensure that your body remains healthy even if you are trying to lose weight. Here are some weight loss nutrition tips.

Foods for weight loss

You do not have to turn yourself into a vegetarian. However, a weight loss nutrition tip to ensure proper health involves loading up with healthy foods that include vegetables, fruits, nuts, seeds, whole grains, and legumes. Remember that it is important to consume healthy foods to combat disease and to help promote healthy eating habits.

Don’t miss out on carbs

Contrary to common belief, carbohydrate intake do not necessarily equate to weight gain. Carbohydrates can be found in a variety of foods that we love to eat, including fruits and vegetables that provide you with fiber and antioxidants, and whole grain products. Try to eat at least 3 servings of whole grains in a day but remember to keep the fat intake low.

On low-carb diets

Some low-carb diets cut down your intake of carbohydrates but your fat intake is high. Some low-carb diets may even tell you that you can eat as much cream and butter as you want. Remember that even if you are decreasing your carbohydrate intake, any other food that is high in saturated fat can contribute to risks of heart diseases and other complications.

Better choices

Making better food choices can help promote nutrition and weight loss. In fact, by choosing to eat low-fat dairy products, lean meats and unprocessed foods, you can be on your way to losing weight the healthy way.

Physical activity

Finally, part of maintaining proper health while losing weight involves regular physical activity which can be done by exercising, playing sports, or simply by doing chores. Increased physical activity can also help provide you with more energy and can also help boost your immune system.

Searching for mineral nutrition information is much easier today than ever before. I remember when we’d have to search manuals, books and do it at the library and also searching the encyclopedia. Thanks to Senate document 264 the truth finally comes out. Much buried of course as its information doesn’t support the bottom line of retailers. But, to find the truth sometimes takes digging and especially mineral nutrition.

We’ve come to discover that many serious health issues including life threatening can be at the source of lack of minerals in our diet. Most of us haven’t been taught that without these vital nutritional nutrients taking vitamins is useless. Since vitamins are such a large marketing item with plenty of resources we seldom read or see much about anything else.

It is critical to our health to understand that the depleted soils today do not yield its fruits and vegetables with the nutrients they once did years ago. Fast foods haven’t helped either, and now we even read of a national epidemic about overweight child. Our kids are starving from the lack of good nutrition and most of us aren’t doing anything about it.

Research online can be the resource of choice that let’s us do the research work rather easily. Armed with some good up to date education and information goes a long way towards correcting one’s path to optimum health. The responsibility falls on us for self preservation, not the doctors when it’s perhaps too late.

We may also need to adjust our thinking for days of old. Our parents who didn’t have the information available today taught us what they could, but may not in fact be the most effective approach today. When you gather your information you may very well be shocked, so stay open minded and be patient. Correcting the sorry state of affairs with good mineral nutrition isn’t difficult or over expensive.

ABSTRACT. Background: Metabolic bone disease (MBD) is a significant complication in patients receiving long-term home parenteral nutrition (HPN). Pamidronate has been poorly studied in this population. We examine the prevalence and risk factors for MBD and examine changes in bone mineral density (BMD) after pamidronate administration. Methods: First, a chart review of patients receiving HPN for >1 year was performed, and Pearson correlations were used to assess associations between MBD (defined as t score
The incidence of metabolic bone disease (MBD) in patients receiving long-term home parenteral nutrition (HPN) is unknown. Reports from 20 years ago suggested a high prevalence of both osteoporosis and osteomalacia directly related to the administration of HPN.1-3 One recent study suggested a prevalence of MBD of 84% in patients receiving HPN.4 Other recent studies, however, suggest that perhaps MBD in patients receiving long-term HPN may primarily be a consequence of the underlying medical illness as opposed to toxicity of HPN.5

Traditional risk factors for MBD include female gender, advancing age, low body weight, glucocorticoids, excessive alcohol consumption, smoking, and physical inactivity.6 Multiple parenteral nutrition (PN) factors contribute toward MBD. These include calcium, vitamin D, and phosphate deficiencies; aluminum toxicity; acidosis; vitamin D toxicity; and amino acid infusions. Amino acid infusion increases urinary calcium excretion. Particularly, infusions exceeding 2 g/kg enhance urinary calcium loss to degrees greater than that originally infused.7 Phosphate enhances calcium reabsorption by the renal tubules.8 Adequate amounts of phosphorus must be present in PN in order to achieve a positive calcium balance. Chronic metabolic acidosis is known to impair vitamin D metabolism, leading to MBD similar to osteomalacia.9 Additionally, acidosis can lead to bone loss directly. In the early days of HPN, aluminum toxicity had a role in contributing toward MBD. Aluminum contamination resulted from contamination of amino acid solutions prepared from protein hydrolysates.10 Aluminum toxicity reduces parathyroid hormone (PTH) secretion and decreases serum levels of 1,25 dihydroxyvitamin D. In the past few years, there has been minimal contamination of amino acid with aluminum; hence, MBD resulting from aluminum toxicity should be far lower. However, there is still aluminum present in various trace elements, but in such low quantities that it is not felt to contribute to MBD to any significant degree. Vitamin D toxicity is possibly associated with MBD in patients receiving long-term HPN.2

Multiple studies have demonstrated that the risk of fractures increases with declining bone mineral density (BMD).11,12 The European Prospective Osteoporosis Study showed the risk of vertebral fracture increased by a factor of 1.5 per 0.1 g/cm^sup 2^ decrease in the BMD of the spine.13 There are no prospective trials assessing the relationship between dual energy x-ray absorptiometry (DEXA) and fracture risk in patients receiving HPN.

Nishikawa et al14 showed that IV pamidronate improved BMD in the lumbar spine after pamidronate infusion in patients receiving HPN for short bowel syndrome.

No recent Canadian study has evaluated the prevalence of MBD in patients receiving long-term HPN, nor have there been many studies evaluating the efficacy of IV pamidronate in this population. Due to the controversial issue of PN as a risk factor of MBD, we sought to examine the prevalence and risk factors for MBD in patients who are currently receiving long-term HPN in the Toronto General Hospital HPN program, and we also evaluated the change in bone density after administration of pamidronate in this patient population.

METHODS

First, a retrospective chart review of 25 patients enrolled in the HPN program for a minimum of 1 year was performed. The 25 patients studied represented all of the patients receiving HPN in our program for at least 1 year. Ethics approval was obtained from the University Health Network Research Ethics Board. All patients signed informed consent forms. Twenty patients receiving long-term HPN had BMD of the lumbar spine, femoral neck, and hip evaluated using DEXA scan. Not all patients had their DEXA performed with the same machine. Although all patients are part of the Toronto General Hospital program, some are scattered throughout the province. Hence, most of these patients’ investigations were performed closer to their home and not at Toronto General Hospital. The DEXA machines used for this study were not calibrated between centers.

Protein hydrolysate solutions were changed to free amino acid solutions with a much lower aluminum contamination in 1985. Two patients began receiving HPN before this date. One patient had been receiving HPN for 13 years, whereas the other patient started receiving HPN 6 months before 1985.

Osteopenia was defined according to the most recent WHO criteria oft score -2.5

Second, changes in BMD after administration of pamidronate were analyzed prospectively from 1998 to 2005. A subgroup of 11 patients with established osteoporosis received IV pamidronate. BMD was performed before receiving pamidronate and after 22.15 ± 5.44 months of therapy. Pamidronate was infused at home over 2 hours at a dose of 30 mg every 3 months.

ABSTRACT. Background: Mild liver dysfunction is common after prolonged use of parenteral nutrition (PN), but end-stage liver failure occurs only rarely. Few treatment options other than combined liver-intestine transplantation exist for patients with liver failure associated with PN use, however. Herein, we report the results of a cohort of patients undergoing isolated orthotopic liver transplantation (OLT) for PN-associated liver injury. Methods: A retrospective cohort study of 80 patients (73 pediatric patients and 7 adults) who have undergone isolated OLT for PN-associated liver injury as the primary indication for transplantation was performed. Results: At the time of OLT, the mean total serum bilirubin was 19.5 mg/dL and the mean serum albumin level was 2.9 mg/dL. Severe hepatic encephalopathy was seen in 5%, spontaneous bacterial peritonitis was seen in 6.3%, and respiratory failure requiring mechanical ventilation was seen in 14% of patients at the time of OLT. Overall 1- and 5-year survival rates were 72% and 52%, respectively, with infection being the most common cause of death after OLT. Retransplantation was required in 25% of patients, and the 5-year posttransplant patient survival rate only reached 35% in these cases. Conclusions: Patients with end-stage liver disease associated with PN administration often have very severe liver disease, multiple comorbidities, and poor prognosis by the time they are listed for OLT. Nonetheless, isolated OLT is associated with good long-term survival and should be considered for selected patients with combined intestine-liver failure. (Journal of Parenteral and Enteral Nutrition 30:526-529, 2006)

Parenteral nutrition (PN) has become an essential means of supporting patients who are be unable to sustain themselves on enterai feedings or intravenous (FV) carbohydrate solutions alone. Although lifesaving, PN is often associated with significant complications, including liver injury that can range from self-limited cholestasis to end-stage cirrhosis.1″5 Few good treatment options exist once cirrhosis has developed from long-term PN use. Perhaps the best option for those with PN-associated cirrhosis and continuing need for PN is a combined liver-intestine transplant, an option associated with 49%-55% long-term survival.6,7 Isolated orthotopic liver transplantation (OLT) exists as an option for selected patients, but in contrast to the combined liver-intestine procedure, the outcomes of OLT for PN-associated liver injury have only been described for single cases and single-institution series of no more than 10 patients.8,11 The current study was undertaken to estimate the long-term patient survival in pediatric and adult patients undergoing OLT for this rare indication.

MATERIALS AND METHODS

Patients enrolled in this study were identified through the United Network for Organ Sharing (UNOS) Organ Procurement and Transplant Network liver transplant database. This database contains patient and graft outcome data for >62,000 patients who underwent OLT in the United States between January 1988 and December 31, 2003. Patients with a primary diagnosis of PN-associated liver injury were selected for study. Patients who had received previous small intestine transplants or simultaneous multiorgan transplant were excluded.

Descriptive statistics for each cohort were calculated using all available pretransplant and peritransplant variables. Patient and allograft survival was assessed using Kaplan-Meier survival analysis, and survival rates of subgroups were compared with the log rank test. All statistical analyses were performed with SPSS version 11.0 (SPSS Corporation, Chicago, IL). A p value of

RESULTS

Patient Characteristics

Since 1988, a total of 80 patients have undergone isolated OLT, with PN-associated liver injury listed as the primary indication for transplantation. These patients were predominantly pediatric at the time of initial OLT. Specifically, 40 (50%) were

At the time of OLT, the mean total serum bilirubin was 19.5 mg/dL (range, 0.6-54.0 mg/dL), the mean serum creatinine was 0.58 mg/dL (range, 0.10-9.0 mg/dL), and the mean serum albumin was 2.9 mg/dL (range, 1.9-4.5 mg/dL). Eleven patients (14%) required mechanical ventilation at the time of OLT, and at least 1 had required dialysis in the week before OLT. Four patients (5.0%) had a history of spontaneous bacterial peritonitis, and 5 patients (6.3%) had a history of grade III or IV hepatic encephalopathy.

Twenty-three of the 73 pédiatrie recipients (32%) have been transplanted since the Pédiatrie End-Stage Liver Disease (PELD) model has been used to rank candidates awaiting OLT. Of these, 12 (52%) were listed as status 1 (high urgency, expected survival without transplantation of

Transplant and Allograft Characteristics

The median time from a candidate’s addition to the waiting list to the time of OLT was 35 days (range, 0-684 days). Of the 80 initial OLTs performed for PN-associated liver failure, whole-liver allografts obtained from cadaveric donors were used in 52 (65%), partial or reduced allografts from cadaveric donors were used in 9 (11%), and split-liver allografts from cadaveric donors were used in 7 (8.8%). Segmentai allografts from living donors were used in 10 (13%); 7 of these were obtained from the patient’s parents. The source of the remaining 2 allografts (3%) was unknown. The median length of posttransplant hospitalization was 38 days (range, 2-308 days).

ABSTRACT. Background: We devised a consistent approach to instituting and advancing enteral nutrition among neonatal intensive care unit (NICU) patients

Developing consistent approaches to various practices and procedures in neonatology has been suggested as a means of improving outcomes.1-3 As an example, the Vermont Oxford Network “Got Milk” focus group developed guidelines for enterai nutrition that were tested by Kuzma-O’Reilly et al3 and found to improve nutrient intake and growth, with a reduced length of stay and reduced costs. As part of an overall effort to improve outcomes, we used a multidisciplinary consensus development process to devise a consistent approach to enteral nutrition of low-birthweight infants. The multidisciplinary group produced a set of feeding guidelines for neonates

Details of the feeding guidelines are posted on the Intermountain Healthcare website. Briefly, the guidelines give specific instructions to the bedside nurses, according to the birth weight of the patient, categorized as

We analyzed data from all patients

The day of birth was termed “day of life 0,” and the day beginning 1 minute after their first midnight was termed “day of life 1.” The time to reach 80 mL/k/d was selected as a significant outcome because of an IHC systemwide program to reduce line-associated infections in the NICU, calling for consideration of removing central catheters when 80 mL/k/d of enterai intake is reached.4 PN was defined as an amino-acid-containing, multivitamin-containing, IV solution ordered on the IHC “PN program” and prepared by the hospital pharmacy PN team.

Descriptive statistics were calculated using Stata 8.3 (College Station, TX). Between-group means were tested using independent-sample t- tests when parametric assumptions were met, with Wilcoxon ranksum tests used for nonparametric comparisons. Proportions were compared between groups using ?^sup 2^ tests with Yate’s continuity correction or, when expected counts were small, Fisher’s exact test. Between-group variances were tested using independent-samples standard deviation F tests. For demographic features, two-tailed tests were used. Otherwise, one-tailed tests were conducted. For all tests, ? was set at .05.

RESULTS

In period 1, 301 patients were admitted to the NICU, of which 58 (19.3%) weighed

Of the 58 patients admitted to the NICU in period 1, 2 died; a 700-g male infant (23 weeks’ gestation) who died on day O, and a 720-g female infant (26 weeks) who died after 6 weeks. The first of these was not considered in the feeding and growth calculations (Table III), because no feedings were given, but the second was included because that patient survived for 37 days and received enterai feedings. Of the 68 patients in period 2, 2 died; a 657-g male patient (23 wks) and a 990-g female patient (24 weeks). Both died on day of life 1. Neither received any enterai feedings, and neither was included in the feeding-outcome data (Table III).

In periods 1 and 2, the median days to first milk feedings was 1. However, the variability (range, 0-24 days in period 1 vs 0-6 days in period 2) was far less in period 2 (p

DISCUSSION

During the 6-month period after implementing feeding guidelines, we observed fewer NPO days and fewer days where PN was used. Although these improvements were statistically significant, they were relatively minor improvements compared with those observed by Kuzma-O’Reilly et al3 after they implemented feeding guidelines. They found that adopting feeding guidelines greatly reduced the initial NPO days, improved nutrient intake and growth, and reduced the length of hospital stay. Perhaps one reason we failed to see such marked improvements was that our baseline rates were quite different than theirs. For instance, implementing their guidelines was associated with a reduction in days to start enterai feedings from day of life 8.9 before guidelines to day 4.7 after. In contrast, before instituting guidelines our enterai feeding was begun on (median) day of life 1. Similarly, before guidelines were instituted their neonates required 19 days to achieve an enterai intake of 80 kcal/k/d, and this fell to 6.5 days after. In contrast, before guidelines our neonates required only 7 days to reach an enterai intake of 100 kcal/k/d. Thus, our patients already had very early initiation of feedings and quite rapid escalation of feedings, even before the guidelines were adopted.

Although the magnitude of our improvements, after adopting written feeding guidelines, was not as great as those of Kuzma-O’Reilly et al,3 our trends were similar. Perhaps if we had a much larger sample size, the reduction in NPO days and days to achieve various feeding milestones would have been more impressive. However, the fact that we observed less variability in all feeding-related outcomes measured suggests that adopting guidelines can produce benefits even among NICUs that have already instituted early enterai nutrition and relatively rapid feeding escalation practices.

ABSTRACT. Background: Parenteral nutrition (PN) is known to induce villus atrophy, epithelial cell (EC) apoptosis, and increase mucosal permeability. The study hypothesized that increasing amounts of energy delivery to mice would result in the best outcome, with the least effects on the mucosa. Methods: Mice were randomized to enteral controls (saline infusion with ad libitum enteral food) or to 1 of 3 PN groups (with no enteral nutrition): full (100% of daily average energy intake for the mouse), reduced (75% of energy intake) or very low (50% of energy intake). Mice received PN for 7 days. Mucosal morphology, EC apoptosis, and bacterial translocation were assessed. Results: Villus height decreased significantly with decreasing levels of caloric intake and was significantly lower in all PN groups compared with controls. Body weight loss was significantly greater in PN groups vs controls and was greatest in mice with the lowest caloric delivery. A consistent trend toward a higher EC apoptotic index with decreasing caloric intake was observed, and apoptosis in all PN groups exceeded controls (2-fold). All PN groups demonstrated greater bacterial translocation than controls. Conclusions: PN induces intestinal EC apoptosis and villus and crypt atrophy, even at 100% of predicted energy needs, and such changes increased with greater reduction of energy intake. This study supports a concept that lack of enteral nutrition, rather than absolute caloric levels, is responsible for many of the adverse effects of PN. The study also allows the investigators to better optimize a mouse model of PN delivery. (Journal of Parenteral and Enteral Nutrition 30:474-479, 2006)

Patenterai nutrition (PN) is known to induce significant changes in mucosal structure and function. These changes include villus atrophy, epithelial cell (EC) apoptosis, and altered mucosal permeability. PN administration is associated not only with morphologic changes in the intestine but also with bacterial translocation and a loss of mucosal barrier function.1″3 The mechanisms of PN-associated loss of epithelial integrity and morphologic changes have been studied extensively using a mouse model.1″6 The use of a mouse model can offer great insights into these PN-associated effects on the gastrointestinal tract. Recent work by our group has helped to identify mechanisms that contribute to the occurrence of bacterial translocation and villus atrophy.1-3,6 Unlike other animal models, the use of mice is relatively inexpensive, allows for an extensive study of the alterations in their immune system, and can be managed in a small laboratory setting. Delivery of PN to mice, however, is a challenge and has been associated with a moderate mortality.7 To address this problem, this study was designed to determine the amount of energy delivery via PN using a mouse model, whereby the closest approximation to energy needs is met and with the fewest number of complications. We also sought to determine whether different levels of energy delivery, administered as PN, correlated with PN-associated intestinal changes. We further attempted to determine the most optimal amount of energy delivery while optimizing mouse survival and morbidity. We hypothesized that higher energy delivery via PN would result in fewer aberrations in intestinal morphology and improved survival.

MATERIALS AND METHODS

Animals

C57BL/6J male specific-pathogen-free mice (8 weeks old) were obtained from Jackson Laboratory (Bar Harbor, ME) and were maintained under temperature-, humidity-, and light-controlled conditions. Mice were initially fed ad libitum with standard mouse chow and water and allowed to acclimate. During the administration of IV solutions, mice were housed in metabolic cages to prevent coprophagia. The studies reported here conformed to the guidelines for the care and use of laboratory animals established by the University Committee on Use and Care of Animals at the University of Michigan, and protocols were approved by that committee (No. 7703).

Operative Procedures and Study Groups

Mice were anesthetized with sodium pentobarbital (50 mg/kg/body weight, intraperitoneal). All surgical procedures were performed under magnification in a sterile fashion. The left jugular vein was exposed and cannulated with a silicone rubber catheter (0.012-inch ID, 0.025-inch OD; Dow Corning, Midland, MI). The distal end of the catheter was tunneled subcutaneously and exited between the scapulae. The catheter was attached to a swivel spring, which allowed the mice freedom of movement in their individual cages (Metamount System, Instech Corp, Plymouth Meeting, MA). Catheterized mice were immediately connected to an infusion pump (AIM pain provider pump, generously donated by Abbott Laboratories, Abbott Park, IL) and saline (dextrose 5% in 0.45 NS with 20 mEq KCVL) was infused at an initial rate of 4.8 mL/d. After 24 hours, the animals were randomized to control or PN groups. Of note, the AIM pain provider pump is one of the most accurate available to date. Nevertheless, the delivery is cyclical and not continuous. Thus, as infusion rates increased, we found that some mice developed extravasation of IV PN. These mice were not included in the study results.

ABSTRACT. Background: There is a paucity of data evaluating the efficacy of nutrition support in traumatic brain-injured patients induced into barbiturate coma for refractory intracranial hypertension. Our objective was to evaluate the efficacy of enteral nutrition in a select group of trauma patients. Methods: Prospective data were collected on severe traumatic brain-injured patients over a 4-year period. Patients were stratified by whether or not they were induced into a barbiturate coma. Barbiturate coma was defined as per American Association of Neurological Surgeons (AANS) guidelines. All patients were initially fed via the enteral route via a nasogastric feeding tube. Patients who did not tolerate feedings within 48 hours started receiving prokinetic agents. Feeding tolerance was defined as ability to tolerate enterai feedings with 72 hours. Results: Fifty-seven patients were induced into a barbiturate coma. All were victims of blunt-force trauma. Forty-two of 57 (74%) patients were men, with a mean age of 37 ± 12 years and a mean injury severity score of 24 ± 10. Thirty-eight of the 57 (67%) patients had an isolated traumatic brain injury. All 57 patients failed enteral nutrition via the nasogastric route after the first 48 hours of nutrition initiation after barbiturate coma was fully achieved by protocol criteria. Prokinetic agents demonstrated no improvement in feeding tolerance after the subsequent 48-72 hours. Of the 12 patients who had a postpyloric feeding tube placed, only 25% tolerated enteral nutrition for >48 hours. Conclusions: Patients with traumatic brain injury induced into barbiturate coma develop a significant ileus that is refractory to prokinetic agents. Only a marginal improvement is seen when the postpyloric route is obtained. Early parenteral nutrition should be considered in this patient population. (Journal of Parenteral and Enteral Nutrition 30:503-506, 2006)

Nutrition support in the traumatic brain-injured patient continues to be a very important factor in the care of these unique high-risk patients. Because of various factors, including multiple surgeries and aggressive treatment modalities, that may hinder gastric emptying, nutrition support is often compromised. This increases the risk of poor outcome and, thus, may negatively affect outcome. The traumatic braininjured patient who has intractable intracranial hypertension represents a unique patient population that is at the far end of the spectrum in terms of risk and adverse outcome.

The traumatic brain-injured patient rapidly becomes the paradigm of unchecked metabolism and catabolism.1 A hypermetabolic and hypercatabolic state ensues, and daily caloric and protein needs may be in excess of twice the normal predicted basal caloric and protein needs. Impaired immune function may result as a consequence of this hypermetabolic response and inadequate nutrition, leading to increased susceptibility to infection and adverse outcome.2 Early nutrition in these patients has been demonstrated to ameliorate the profound negative nitrogen balance caused by this excessive protein catabolism.1′3

The ability to provide adequate nutrition support is often hindered when patients require neuromuscular blockers and other sedative agents as major components of their clinical management.4′5 Both traumatic brain injury and these classes of medications impair gastric emptying and thus lead to intolerance of gastric feeding.6 Pentobarbital-induced coma is a treatment strategy reserved for the traumatic brain-injured patient with refractory intracranial hypertension. This treatment modality decreases the tone and amplitude of contractions of the gastrointestinal tract and is mediated centrally and peripherally. Therefore, patients are more likely to not tolerate enterai nutrition.

There is a paucity of data evaluating the efficacy of nutrition support in traumatic brain-injured patients induced into barbiturate coma for refractory intracranial hypertension. Our objective was to evaluate the efficacy of enterai nutrition in a select group of trauma patients.

METHODS

Prospective data were collected over a 4-year period (1999-2003) on 57 consecutive severely traumatic brain-injured patients admitted to the R. Adams Cowley Shock Trauma Center who were induced into a barbiturate coma due to refractory intracranial hypertension. Barbiturate coma was denned as per American Association of Neurological Surgeons (AANS) guidelines (Table I). Feeding tolerance was not evaluated until there was a physical examination consistent with barbiturate coma (no cough or gag reflex) or burst suppression by electroencephalogram (EEG) measurements. All patients were initially fed with an immuneenhanced formula via the enterai route using a nasogastric feeding tube. Patients who did not tolerate enterai feedings within 48 hours of barbiturate coma initiation began receiving a standard prokinetic regimen (Reglan, AH Robins Co., Division of American Home Products, Madison, NJ; 10 mg IV every 6 hours) and switched over to a semielemental or elemental formula as per the staff clinical nutritionist. Placement of nasal-jejunal tubes, either blindly or endoscopically assisted, in patients that failed to tolerate enterai feedings despite prokinetic therapy was at the discretion of the intensive care unit (ICU) attending physician. Feeding tolerance was defined as the ability to tolerate enterai feedings with 72-hour period from initiation of barbiturate coma. Patients who did not tolerate gastric feedings within 72 hours started receiving parenteral nutrition (PN) via the central venous route. Caloric requirements and rates of nutrition infusion were determined in a multidisciplinary fashion by the critical care physician, critical care nutritionist, and trauma physician.