Essential and non-essential amino acid requirement in injured patients receiving total parenteral nutrition.

The metabolic derangements of injury are known to influence nitrogen (N) requirements whilst less is known about individual amino acid (AA) requirements. This study was designed to investigate prospectively N vs AA requirement in 36 injured patients treated with total parenteral nutrition (TPN). The non-protein caloric input was 30 kcal kg-1 day-1 and three AA solutions were assessed containing the same AAs but in different proportion. Overall N intake was set at 0.35 g N kg-1 day-1 for solution A and B and 0.24 g N kg-1 day-1 for solution C. Solution B was similar to A, both being enriched in branched chain AAs (BCAA: 0.69 g kg-1 day-1 in B compared with 0.55 g kg-1 day-1 in A) while decreased in aromatic and sulphurated forms (1.75 times the normal need). Solution C was designed to maintain a daily input of BCAA similar to A (0.52 g kg-1 day-1) but with the supply of aromatic and sulphurated AA between solutions A and B, the supply of other AAs (lysine, theonine, histidine, arginine, glycine) being dependent on the selected N intake. For all the essential AAs the supply was always greater than normal allowances. Increasing BCAA over 0.55 g kg-1 day-1 did not improve N balance when N intake was 0.35 g kg-1 day-1, whilst nutrition with solution C was unable to maintain N balance. Moreover we found indirect evidence that this N intake, 0.52 g kg-1 day-1 was more sparing than 0.37 g kg-1 day-1 of BCAA.(ABSTRACT TRUNCATED AT 250 WORDS)

Main nitrogen balance determinants in malnourished patients.

Factors influencing nitrogen balance during total parenteral nutrition have been investigated in 38 malnourished patients studied for a cumulative period of 280 days. According to multiple regression analysis, nitrogen intake (0.213 +/- 0.004 g kg-1 day-1, mean +/- SD) proved to be the major determinant of a positive nitrogen balance (0.018 +/- 0.004 g kg-1 day-1), followed by non-protein energy intake (43.3 +/- 0.5 kcal kg-1 day-1). Total calorie intake to predicted basal energy expenditure and non protein calorie to nitrogen ratios appeared to have little significance on nitrogen balance, when corrected for the two former variables.

Parenteral nutrition of injured patients: Effect of manipulation of aminoacid infusion (increasing branched chain while decreasing aromatic and sulphurated aminoacids).

Sixteen critically ill injured patients received parenteral nutrition providing nitrogen (0.34 g kg(-1) day(-1)) and glucose (32 kcal kg(-1) day(-1)) for 5 days. They were randomly divided into two groups with respect to aminoacid supply: an essential aminoacid solution vs the same solution enriched in branched chain amino acid (BCAA) content and decreased in phenylalanine and methionine content (mean BCAA intake, 0.55 vs 0.69 g kg(-1) day(-1)). Basal values of nitrogen metabolism without treatment showed no difference between the two groups. Nitrogen losses and 3 methylhistidine (3-MEH) excretion were elevated; the plasma aminoacid pattern was altered by the trauma and except for phenylalanine, aspartate and glutamate, plasma aminoacid concentrations were decreased below normal values. Net muscular aminoacid output was demonstrated by femoral arterio-venous (av) differences that were all negative except for glutamate and citrulline TPN with both solutions improved the nitrogen balance and reduced the negative aminoacid balance across the leg. Adjusting a TPN regimen to increase the BCAA content without altering the total nitrogen infused, had no effect on overall nitrogen balance, but exerted a beneficial effect on body protein catabolism, as assessed by the urinary 3-MEH excretion rate, and a transient improvement in the aminoacid balance across the leg at the peak of the infusion. The short-lived effect of BCAA suggest a metabolic effect of these aminoacids which deserves further study.

Restoration of blood 2,3-diphosphoglycerate levels in multi-transfused patients: effect of organic and inorganic phosphate.

Blood stored in acid-citrate-dextrose (ACD) shows a progressive decrease in 2,3-diphosphoglycerate (DPG) content. Since the decrease in DPG increases hemoglobin oxygen affinity, which in turn may reduce tissue and venous PO2 and peripheral oxygen delivery, many efforts have been made to preserve or restore DPG levels in stored blood. An in vivo rejuvenating technique, employing fructose-1,6-diphosphate (FDP) at a mean dosage of 1 mmol kg-1 day-1 of phosphate, to increase the DPG circulating level in multi-transfused patients is proposed. Eighteen patients, who received at least one-third of their estimated blood volume (3990 +/- 480 (SEM) ml of ACD stored blood) in blood transfusion, were treated: nine with inorganic phosphate, and nine with FDP. Basal DPG was very low in both groups: 12.61 +/- 1.34 (SEM) and 10.42 +/- 0.98 (SEM) mumol g-1, respectively (normal value is 14.5 mumol g-1, at pH 7.40). However, DPG values increased significantly and promptly in patients receiving FDP, whereas in cases of inorganic phosphate administration, it was not significantly raised over the basal value until the third day. Phosphatemia remained normal and constant with FDP, but it rose significantly on the third day of treatment with inorganic phosphate. FDP appears to consistently and rapidly increase DPG levels after transfusion with blood stored in ACD, and to be particularly safe.

[Treatment of chest injuries in intensive care. Critical review of 54 clinical cases]. / Il trattamento del trauma toracico in rianimazione. Revisione critica di 54 casi clinici.

All 54 chest trauma patients admitted to Resuscitation II of Pavia's S. Matteo Polyclinic in the period 1974-1979 have been reviewed in a critical analysis. Particular attention was paid to mortality in relation to age, associated pathology, treatment and the complications arising during the course of the trauma. Resuscitation Centres are identified as the ideal places for treating these patients. Cranio-encephalic and superimposed abdominal lesions are the main factors pointing to an unfavourable prognosis, and protection against infectious complications is the key to therapy.

[Myasthenia gravis. Indications, aims and methods of intensive therapy]. / Miastenia gravis. Indicazioni, scopi, modalità del trattamento intensivo.

Some recent views on pathophisyology of "myasthenia gravis" are presented. The Authors explain the typical damage of myasthenia gravis, i.e. the progressively reduced muscolar function on the basis of an autoimmune derangement affecting the motor-end plates. The most commonly used types of treatment, both medical (i.e. antiChE, A.C.T.H., steroids and immunodepressant drugs) and surgical (thymectomy) are reviewed. The very important role of Intensive Care for the treatment either of myasthenia gravis "per se" or of possible consequences of some drugs (A.C.T.H. steroids) is also stressed. Finally the Authors present their results about their experience on 36 patients affected by myasthenia gravis and admitted to I.C.U. once (29 patients) or twice or more (7 patients). The Authors describe some practical problems presented by patients during their stay in I.C.U.

A homozygote for a serum albumin variant of the fast type.

A healthy, 10-year-old male born in Milano to a family from Southern Italy (Puglia) was found to be a homozygote for an albumin variant of the fast type. His parents are half-first cousins. Their common grandfather, the parents, one sister, and three brothers of the child were all heterozygotes for the same albumin variant. This seems to be the first case of a homozygote for a fast albumin variant described in Europe.