Evaluation of outcomes for patients with AIDS receiving home total parenteral nutrition.

This study evaluated the outcomes of patients with acquired immunodeficiency syndrome (AIDS) provided home total parenteral nutrition (HTPN) when specific criteria were used to initiate HTPN. Fifteen males who received HTPN and seven males who consumed only an oral diet were studied. The HTPN patients received an average of 55 kcal.kg-1.d-1 and 2.0 g of protein.kg-1.d-1 from HTPN and oral diet. Non-HTPN patients consumed an average of 35 kcal.kg-1.d-1 and 1.2 g protein.kg-1.d-1. Body weight (BW), lean body mass (LBM), and serum albumin (SA) were measured when HTPN was initiated or initial nutrition counseling was provided to the non-HTPN patients and again at the end of the study period. Over the study period, the HTPN patients gained an average 5.5 kg of BW and 3.0 kg of LBM, whereas the non-HTPN lost an average of 5.0 kg of BW and 3.0 kg of LBM. BW and LBM may be used to assess the response to HTPN in AIDS patients.

Obesity: nutrition support practice and application to critical care.

Much controversy exists regarding the nutritional care of obese, hospitalized patients. There is no real agreement among health care professionals in the nutritional support of obese patients. A survey was designed to determine the methods used to provide for the nutritional needs of obese, hospitalized patients. The survey included questions on definition of obesity, equations used to calculate energy and protein needs, and body weight used for calculations. The information received from this survey describes the variability of nutritional care for obese, hospitalized patients. In addition, a review of the current literature is provided regarding the metabolic response of the obese.

Resting energy expenditures measured by indirect calorimetry are higher in preadolescent children with cystic fibrosis than expenditures calculated from prediction equations.

OBJECTIVE: This study compared measured resting energy expenditures to resting energy expenditures calculated using Harris-Benedict equations (HBEs) and the Cystic Fibrosis Consensus Committee equations (CFCCEs). DESIGN: We studied 31 preadolescent boys and girls with cystic fibrosis who ranged in age from 3.25 to 12.75 years old. The patients were afebrile and not in pulmonary distress. Measured resting energy expenditures were determined using a portable metabolic measurement cart with fully automated calibration and data management. The measured resting energy expenditures obtained were compared with values obtained using HBEs and CFCCEs. RESULTS: For each patient, the measured resting energy expenditure value was above the predicted resting energy expenditure values derived from HBEs (P < or = .0001) and CFCCEs (P < or = .01). APPLICATIONS: The HBEs and the CFCCEs underestimated the energy expenditures of the study population by 13% and 8%, respectively. These findings support the usefulness of the measurement of energy expenditures in determining the energy needs of preadolescent patients with cystic fibrosis. In clinical practice, the resting energy expenditures would be multiplied by activity coefficients to determine the total daily energy expenditures of this population.

Nutrition considerations in the management of ventilator-dependent patients.

Nutrition support of the patient with ventilatory failure is an important adjunct to recovery. Malnutrition and respiratory failure are frequently interrelated. Ventilator dependence occurs when the patient cannot independently sustain oxygenation, carbon dioxide removal, or acid-base balance. Nutrition assessment, determination of energy requirements, and provision of nutrient solutions utilizing the most appropriate route of administration should be initiated early in the ventilator-dependent patient's hospital course. Careful assessment will identify patients needing repletion along with maintenance calories, as well as special macronutrient and micronutrient needs. The nutrient prescription is designed to provide carbohydrate, protein, and fat in amounts for optimal substrate utilization. Body fluid balance, micronutrient needs, electrolyte homeostasis, and acid-base balance affect respiratory muscle function and must also be considered in developing the nutrition regimen. Properly constructed enteral or parenteral nutrition plans begun early offer the best support for ventilator-dependent patients.

Does the use of an enteral feeding tube with a pH-sensitive tip facilitate enteral nutrition?

Enteral feedings are often used to achieve adequate, cost-effective nutritional support. Placement of feeding tubes is accomplished by either a trained nurse or physician form a nutritional support team. A radiographic examination is required to confirm proper placement. These examinations are expensive and delay initiation of feeding while radiographs are taken and evaluated. A new enteral feeding tube (pH-FT) that incorporates a permanent pH-sensitive tip into a small-bore feeding tube has been developed. A detachable meter is used to monitor pH. This study was undertaken to determine if the pH-FT was reliable in determining placement as compared with radiograph interpretation. Twenty inpatients (14 males and six females) with diagnoses including major burn, trauma, and gastrointestinal disease were intubated with the use of pH-FT. Measurement of pH was taken at the time the radiographic examination was done. Reference pHs used include the following: stomach, 1.1 to 2.0; stomach in the presence of antacids/H2 blockers, 3.5 to 5.0; and the duodenal, 6.0 to 7.3. Of the 20 patients studied, there were four in whom the pH assessment indicated stomach placement with 100% radiograph confirmation. Sixteen patients had duodenal placement indicated by pH assessment, with radiograph confirmation in 88% (14) of the patients. Two patients had a pH indicating duodenal placement, and radiographic examination showed placement to the pH-FT in the stomach. Two benefits of the pH-FT would be decreased cost and earlier initiation of enteral feeding when the radiographic examination and interpretation are eliminated.

Equations for the estimation of energy expenditures in patients with burns with special reference to ventilatory status.

There are advantages to the use of easily assessed variables for the prediction of energy expenditures of patients with burns. The purpose of this study was to determine whether height, age, sex, weight, ventilatory status, and diagnosis could be correlated with measured energy expenditures of hospitalized patients. With the use of data from 200 patients, stepwise, multivariate regression analysis derived the following equations: EEE(v) = 1925 - 10(A) + 5(W) + 281(S) + 292(T) + 851(B) (R2 = 0.43); EEE(s) = 629 - 11(A) + 25(W) - 609(O) (R2 = 0.50); where EEE = estimated energy expenditure (kcal/day), v = ventilatory dependency, s = spontaneously breathing, A = age (yr), W = body weight (kg), S = sex (male = 1, female = 0), diagnosis of T = trauma, B = burn, O = obesity present = 1, absent = 0). The equations were tested on 100 patients. Measured energy expenditures were not significantly different from calculated EEE(s) or EEE(v) (paired t test, p greater than 0.25). Energy expenditures can be accurately estimated in a variety of patients, including those with major burns with the use of easily attained information.

Actual or ideal body weight: which should be used to predict energy expenditure?

Assessing energy expenditure in obese people is problematic. Two questions arise: Can we predict energy expenditure accurately? Does actual or ideal body weight better predict energy expenditure? Two groups of obese subjects--65 hospitalized adults and 65 nonhospitalized adults--were studied. Both groups had actual body weights that were at least 30% above ideal body weights. For both groups, energy expenditure was measured by indirect calorimetry and calculated using the variables sex, actual and ideal body weight, age, and ventilatory status. All but three patients were receiving nutrition support by the enteral route (either orally or by tube) or by the parenteral route (with hypertonic dextrose, amino acid, and fat). The nonhospitalized subjects fasted during measurements of energy expenditure. Regression equations were derived to predict energy expenditure. Actual body weight better predicted energy expenditure than did ideal body weight. We conclude that actual weight should be used to predict energy expenditure in obese individuals.

Nutrition for adult burn patients: a review.

Adequate nutritional support is an important aspect of burn therapy. To accomplish this goal, nutrition assessment must be conducted, with particular attention given to the determination of energy and macronutrient needs. Providing these nutrients by the enteral route is recommended.

Energy expenditure and the abnormal eating pattern of a bulimic: a case report.

Bulimia nervosa has been characterized by binge eating, which is often followed by either vomiting or laxative use. However, some bulimic individuals restrict caloric intake rather than purge as a means of controlling their weight. Treatment may include psychiatric evaluation, drug therapy, and nutrition counseling. This study evaluated the eating pattern of a bulimic woman from food records made before and while she was receiving nutrition counseling at an eating disorders clinic. Energy expenditure was also determined and examined in relation to patterns of eating behavior. The Harris-Benedict equation was used to estimate basal energy expenditure (BEE). Actual measured energy expenditure (MEE) was determined by indirect calorimetry. On initial assessment, this woman was eating 600 to 3,800 kcal/day, reflecting the range from a semi-fast to a binge day. At this time, her BEE was significantly higher than her MEE. Following modification of her eating pattern to three meals a day, providing approximately 1,200 kcal, there was a 50% increase in her MEE, which closely approximated her BEE. Modification of eating pattern appeared to be associated with a normalization of energy expenditure in this woman; however, each case must be considered individually. These results imply that certain eating patterns in bulimic individuals cause a decrease in energy expenditure that may resemble starvation.

The effect of burn wound excision on measured energy expenditure and urinary nitrogen excretion.

The effect of wound closure on the metabolic response to burn injury is uncertain. Energy expenditures were measured in 20 patients by indirect calorimetry (MEE) and estimated initially by the Curreri formula (CEE) and subsequently by a modification of the Curreri formula (MCEE), adjusted for changes in open wound size and body weight. Urinary urea nitrogen (UUN) excretions were measured over 24 hours. Second- and third-degree burns, initially involving 31% to 74% of the body surface areas, were reduced in size to less than 15% by excisions and grafting procedures. The correlations among percentage open wounds, MEE's, CEE's, and MCEE's were low. UUN excretions were not correlated with percentage open wounds or with MEE's. Estimates of energy expenditures using the Curreri formula appear to be of limited usefulness in prescribing caloric intakes in burned patients. Serial UUN's are useful in determining protein requirements, but were not correlated with MEE's or with the extent of open wounds.

The use of respiratory quotient to determine the efficacy of nutrition support regimens.

Respiratory quotient (RQ) is an indicator of fuel utilization. This study examined the RQs of patients receiving intensive nutrition support to assess the frequency with which net fat synthesis occurred, as determined by RQs greater than 1.0. One hundred twelve RQs were calculated from data obtained using indirect calorimetry. Seventy-four measurements were made while patients were receiving parenteral nutrition--55 with glucose and amino acid (GAAPN) and 19 with glucose, fat, and amino acid (GFAAPN). Thirty-eight measurements were made while patients were receiving either oral or nasoenterally administered carbohydrate, fat, and protein in the form of standard hospital diets or liquid defined formula diets (CFPEN). The mean RQ of the GAAPN patients was significantly higher than those of both the GFAAPN and the CFPEN patients. RQs were greater than 1.0 in a significantly greater number of the GAAPN patients than the GFAAPN or CFPEN patients. The route of nutrient intake did not influence energy nutrient utilization, as determined by RQ. This study suggests that nutrition support regimens containing fat, in addition to carbohydrate and protein, are more efficiently utilized to meet the energy requirements of hospitalized patients than are regimens containing only glucose and amino acid.