- [Show abstract] [Hide abstract] ABSTRACT: Malabsorptive bariatric surgery is rapidly becoming a major cause of copper deficiency given the increasing prevalence of these procedures for morbid obesity. Acquired copper deficiency can present with clinically significant hematologic and neurological manifestations. Although hematologic manifestations of copper deficiency are rapidly reversible, significant neurological improvement after copper supplementation therapy is unusual and many patients remain debilitated and may only experience, at best, stabilization of the neurological manifestations. Here we present a case of an undiagnosed copper deficiency several years after bariatric gastric bypass surgery, in a patient who concomitantly used zinc-containing denture cream for several years, associated with anemia, neutropenia, myelopathy, respiratory failure, and bilateral optic neuropathy, which caused major vision loss. This patient was also a heterozygote carrier of the 5,10-methylenetetrahydrofolate reductase A1298C gene polymorphism, which may affect copper metabolism. Intravenous copper repletion resulted in rapid correction of hematologic indices. However, neurological manifestations, including vision loss responded only modestly to copper supplementation, despite achieving normal blood copper concentrations. Clinicians should consider copper deficiency in patients at risk, as in this case, as a delayed diagnosis can lead to irreversible disability due to neurological manifestations.
Chapter: Parenteral Nutrition[Show abstract] [Hide abstract] ABSTRACT: Protein–calorie malnutrition (PCM), which encompasses major loss of lean body mass and body fat stores, with or without concomitant depletion of essential micronutrients (vitamins, minerals, trace elements) remains common in hospitalized surgical (and medical) patients in developed countries. The prevalence of various degree of malnutrition among total hospital admissions and in intensive care unit (ICU) settings have reported to occur in 20 % to as high as 60 % of surgical and medical patients. Generally, the majority of surgical patients will advance to oral diet shortly after operation and require minimal nutritional intervention; however, major surgery or postoperative complications can delay advancement to a full oral diet. Eventually, the degree of PCM worsens in those patients secondary to the stress of operation, increased nutritional needs for wound healing, and increased metabolic rate related to postoperative recovery, insufficient food intake and repeated catabolic insults. PCM prior to and during hospitalization are each associated with increased morbidity and mortality, length of hospital stay, and added cost of care.
- [Show abstract] [Hide abstract] ABSTRACT: Objective: Limited data are available on the incidence and risk factors for infection in patients requiring home parenteral nutrition (HPN). Methods: A retrospective study was conducted in 101 consecutive adults (63 female, 38 male) discharged on HPN from the Emory University Hospital, Atlanta, GA. New bloodstream infections (BSIs) requiring rehospitalization and other infections were evaluated. Results: Most infections (75%) developed during the initial 6 mo after hospital discharge; rates of BSI were particularly high during the first 4 mo. Fifty-six patients (55.4%) developed 102 BSIs (11.5 BSIs/1000 catheter-days). Most BSIs were attributed to gram-positive organisms (46%), including coagulase-negative Staphylococcus, Staphylococcus aureus, Enterococcus species, and others, followed by Candida species (20%) and gram-negative organisms (13%). Twenty-one percent of BSIs were polymicrobial. The BSI incidence rate ratio was significantly increased for patients with mean prehospital discharge blood glucose concentrations in the highest quartile versus the lowest quartile (incidence rate ratio 2.4, P = 0.017). Patients with a peripherally inserted central catheter versus non-peripherally inserted central catheter central venous catheters had significantly higher rates of BSI (P = 0.018). Thirty-nine patients (38.6%) developed 81 non-BSIs, including pneumonia, urinary tract infections, and surgical site infections. Postdischarge PN dextrose, lipid, and total calorie doses were unrelated to BSI but were variably related to the rate of non-BSIs. Conclusions: Adult patients on HPN exhibit a very high incidence of post-hospital infections. Higher mean blood glucose levels during predischarge hospitalization and the use of peripherally inserted central catheters at discharge are associated with an increased risk of BSI in the postdischarge home setting.
- [Show abstract] [Hide abstract] ABSTRACT: IntroductionNutritional AssessmentNutrient Intake GoalsEnteral Nutrition SupportParenteral Nutrition SupportFuture DirectionsReferences
- [Show abstract] [Hide abstract] ABSTRACT: Parenteral nutrition has been associated with metabolic and infectious complications in intensive care unit patients. The underlying mechanism for the high risk of complications is not known but may relate to the proinflammatory effects of soybean oil-based lipid emulsions, the only Food and Drug Administration-approved lipid formulation for clinical use. Prospective, double-blind, randomized, controlled trial. Medical-surgical intensive care units from a major urban teaching hospital and a tertiary referral university hospital. Adult medical-surgical intensive care unit patients. Parenteral nutrition containing soybean oil-based (Intralipid) or olive oil-based (ClinOleic) lipid emulsions. Differences in hospital clinical outcomes (nosocomial infections and noninfectious complications), hospital length of stay, glycemic control, inflammatory and oxidative stress markers, and granulocyte and monocyte functions between study groups. A total of 100 patients were randomized to either soybean oil-based parenteral nutrition or olive oil-based parenteral nutrition for up to 28 days. A total of 49 patients received soybean oil-based parenteral nutrition (age 51 ± 15 yrs, body mass index 27 ± 6 kg/m2, and Acute Physiology and Chronic Health Evaluation II score 15.5 ± 7 [±SD]), and a total of 51 patients received olive oil-based lipid emulsion in parenteral nutrition (age 46 ± 19 yrs, body mass index 27 ± 8 kg/m2, and Acute Physiology and Chronic Health Evaluation II score 15.1 ± 6 [±SD]) for a mean duration of 12.9 ± 8 days. The mean hospital blood glucose concentration during parenteral nutrition was 129 ± 14 mg/dL, without differences between groups. Patients treated with soybean oil-based and olive oil-based parenteral nutrition had a similar length of stay (47 ± 47 days and 41 ± 36 days, p = .49), mortality (16.3% and 9.8%, p = .38), nosocomial infections (43% vs. 57%, p = .16), and acute renal failure (26% vs. 18%, p = .34). In addition, there were no differences in inflammatory and oxidative stress markers or in granulocyte and monocyte functions between groups. The administration of parenteral nutrition containing soybean oil-based and olive oil-based lipid emulsion resulted in similar rates of infectious and noninfectious complications and no differences in glycemic control, inflammatory and oxidative stress markers, and immune function in critically ill adults.
- [Show abstract] [Hide abstract] ABSTRACT: The frequency of copper deficiency and clinical manifestations following roux-en-y gastric bypass (RYGB) surgery is not yet clear. Objectives were to determine the prevalence and incidence of copper deficiency in patients who have undergone RYGB. We sought to determine the number of RYGB patients undergoing medical and nutritional follow-up visits at the Emory Bariatric Center who experienced copper deficiency and associated hematological and neurological complaints (n=136). Separately, in patients followed longitudinally before and during 6 and 24 months following RYGB surgery, we obtained measures of copper status (n=16). Systemic blood cell counts and measures of copper, zinc and ceruloplasmin were determined using standardized assays in reference laboratories including atomic absorption spectrometry and immunoassays. Thirteen patients were identified to have copper deficiency suggesting a prevalence of copper deficiency of 9.6%, and the majority of these had concomitant complications including anemia, leukopenia and various neuro-muscular abnormalities. In the longitudinal study, plasma copper concentrations and ceruloplasmin activity decreased over 6 and 24 months following surgery, respectively (P<0.05), but plasma zinc concentrations did not change. A simultaneous decrease in white blood cells was observed (P<0.05). The incidence of copper deficiency in these subjects was determined to be 18.8%. The prevalence and incidence of copper deficiency following RYGB surgery was determined to be 9.6% and 18.8%, respectively, with many patients experiencing mild-to-moderate symptoms. Given that copper deficiency can lead to serious and irreversible complications if untreated, frequent monitoring of the copper status of RYGB patients is warranted.
- [Show abstract] [Hide abstract] ABSTRACT: Home parenteral nutrition (HPN) is lifesaving for children with intestinal failure. Catheter-associated bloodstream infections (CA-BSI) are common in hospitalized patients receiving parenteral nutrition (PN), but data evaluating CA-BSI in children receiving HPN are limited. Objective: To determine the incidence and characteristics of CA-BSI in children receiving HPN. Medical records of 44 children receiving HPN during a 3-year period were reviewed. End points were CA-BSI during the initial 6 months after discharge. CA-BSI was defined as isolation of pathogens from blood requiring antimicrobial therapy. The primary indication for HPN was short bowel syndrome (46%), and 59 BSI were documented during the initial 6 months of HPN in 29 (66%) children. Of CA-BSI, polymicrobial infections accounted for 52%; gram-positive, 29%; gram-negative, 17%; and fungal, 2%. CA-BSI incidence per 1000 catheter-days was highest during the first month posthospital discharge (72 episodes; 95% confidence interval [CI], 45.4-109.6). CA-BSI incidence density ratio for children receiving HPN for >90 days compared with those receiving HPN for <30 days was 2.2 (P < .05). Logistic regression revealed that Medicaid insurance and age <1 year were associated with increased risk for CA-BSI (odds ratio [OR], 4.4 [95% CI, 1.13-16.99] and 6.6 [1.50-28.49], respectively; P < .05). The incidence of CA-BSI in children receiving HPN is highest during the first month posthospital discharge. Strategies to address care in the immediate posthospital discharge period may reduce the burden of infectious complications of HPN.
- [Show abstract] [Hide abstract] ABSTRACT: Complete parenteral nutrition solutions contain mixed amino acid products providing all nine essential amino acids and a varying composition of nonessential amino acids. Relatively little rigorous comparative efficacy research on altered parenteral nutrition amino acid composition has been published in recent years. Limited data from randomized, double-blind, adequately powered clinical trials to define optimal doses of total or individual amino acids in parenteral nutrition are available. An exception is the growing number of studies on the efficacy of glutamine supplementation of parenteral nutrition or given as a single parenteral agent. Parenteral glutamine appears to confer benefit in selected patients; however, additional data to define optimal glutamine dosing and the patient subgroups who may most benefit from this amino acid are needed. Although some promising studies have been published, little data are available in the current era of nutrition support on the clinical efficacy of altered doses of arginine, branched chain amino acids, cysteine, or taurine supplementation of parenteral nutrition. Despite routine use of parenteral nutrition, surprisingly little clinical efficacy data are available to guide total or specific amino acid dosing in adult and pediatric patients requiring this therapy. This warrants increased attention by the research community and funding agencies to better define optimal amino acid administration strategies in patient subgroups requiring parenteral nutrition.
- [Show abstract] [Hide abstract] ABSTRACT: Protein-calorie malnutrition is common in end-stage liver disease, irrespective of cause, and adversely affects clinical outcomes. Early diagnosis is important to allow appropriate intervention to prevent malnutrition-associated complications. Correction of nutrient deficiencies through oral supplementation, enteral tube feeding, or parenteral feeding can improve clinical outcomes in this patient population. This article addresses the causes of malnutrition, methods used to assess nutritional status, and treatment strategies in end-stage liver disease.
- [Show abstract] [Hide abstract] ABSTRACT: Introduction Protein–energy malnutrition (PEM), which includes significant loss of lean body mass and fat stores, and depletion of micronutrients (including essential vitamins and trace elements), is common among hospitalized surgical patients [1–7]. Various studies among total hospital admissions and in intensive care unit (ICU hereafter) settings have reported that varying degrees of malnutrition can occur in 20% to as high as 60% of surgical and medical patients [1–3]. While most patients gradually progress to an oral diet shortly following surgery and require little or no nutritional intervention, major surgery or postoperative complications can delay the progression of an oral diet. The extent of PEM worsens over time in such patients due to the stress of surgery, increased nutritional needs to support wound healing, and increased metabolic rate associated with postoperative recovery, insufficient ad libitum dietary intake and repeated catabolic insults [8,9]. Protein–energy malnutrition prior to, and inadequate nutritional intake during, hospitalization are each associated with increased morbidity and mortality, as well as longer hospital stay and cost [9–15]. In 1936, Studley was the first to recognize a direct correlation between preoperative weight loss and operative mortality rate, independent of age, impaired cardio/respiratory function, and types of surgery . Giner et al. subsequently confirmed that malnutrition is a major determinant for the development of postoperative complications . In highly catabolic surgical ICU patients, nutritional depletion has been associated with higher incidence of infectious complications, poor wound healing, impaired skeletal muscle strength, and the need for postsurgical mechanical ventilation [4,5,10–15]. Multiple pathophysiologic challenges may compromise nutritional status in patients undergo elective or major surgery (Table 2.1) . Ensuring adequate nutritional intake has been a major focus among surgeons. Nutritional interventions can be safely performed either with enteral nutrition (EN; enteral nutrient supplements and tube feedings) or with complete parenteral nutrition (PN) . Both EN and PN provide fluid, calories (as carbohydrate, protein/amino acids, and fats) and known essential amino acids, fats, electrolytes, vitamins, and trace elements. The delivery of these interventions is the focus of this chapter.
Atlanta, Georgia, United States
- School of Medicine