Metabolism and Artificial Nutrition in the Critically Ill Springer Milano Berlin Heidelberg New York Barcelona Hong Kong London Paris Singapore Tokyo G. Guarnieri F. Iscra (Eds) Metabolism and Artificial Nutrition in the Critically Ill Series edited by Antonino Gullo Springer G. GUARNIERI, MD Institute of General Clinical Medicine Cattinara Hospital, Trieste -Italy F. ISCRA,MD Department of Anaesthesia, Intensive Care and Pain Therapy Cattinara Hospital, Trieste -Italy Series of Topics in Anaesthesia and Critical Care edited by A.GULLO,MD Department of Anaesthesia, Intensive Care and Pain Therapy University of Trieste, Cattinara Hospital, Trieste -Italy © Springer-Verlag Italia, Milano 1999 ISBN 978-88-470-0042-1 ISBN 978-88-470-2901-9 (eBook) DOI 10.1007/978-88-470-2901-9 Library of Congress Cataloging-in-Publication Data: Applied for This work is subject to copyright. 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In every individual case the user must check such information by consulting the relevant literature. Cover design: Simona Colombo, Milan Typesetting: Graphostudio, Milan SPIN 10697760 Foreword The critically ill patient in intensive care may present with serious metabolic alterations caused directly by the illness or secondarily by complications (e.g. infections, organ failure or sepsis) developing within a few hours of hospitaliza tion or in the following days. Among the situations which maintain and further trigger rapidly evolving altered metabolism are complex hormonal reactions, particularly those of the hypothalamus-hypophysis-adrenal axis, and abnormal stimulation of the autonomic nervous system. In fact, the sympathetic nervous system is known to cause significant metabolic alterations. For example, a surgery patient afflicted by septic complications may become hypercatabolic and experience significant nitrogen loss; the altered protein metabolism may in turn heavily influence carbohydrate and lipid metabolism as well. Thus, it is apparent that for optimal care of patients with altered metabolic functions, further knowledge is necessary regarding the physiopathology of metabolism and the physiopathological mechanisms, which alter the consump tion of principal energy substrates. Many experimental and clinical studies have investigated the metabolic aspects of individual organs or organ systems. However, for a correct evaluation of such metabolic events, in addition to studying the roles of metabolic enzymes, active metabolites, and the glutathione system, it is interesting to consider the use of indirect calorimetry as a valid and important investigative technique. The critically ill patient with major alterations in nutritional status may require artificial nutritive support administered through either parenteral or enteral routes. Relevant research activities, both experimental and clinical, focus on the study of hormones, growth factors, and especially the immune system. In addi tion, the metabolic changes occurring in the critically ill are certainly affected by the presence of antioxidants, although their role is not clearly understood. The intense basic research in these fields should lead in the near future to more appropriate treatments. These guidelines will not simply be quantitative in terms of the necessary daily calories, but must also be qualitative by indicating the most effective nutritional substrates to administer to the critically ill. November 1998 Antonino Gullo, MD Contents BASICS AND METHODS Chapter 1 -Substrate metabolism in critical illness R.R. Wolfe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Chapter 2 -Measurement of the body composition S.J.S. Ryde . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Chapter 3 -Energy and ATP: costs and benefits J.P. Flatt. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Chapter 4 -Indirect calorimetry in the critically ill: theoretical aspects and practical problems L.S. Brandi, L. Santini, R. Bertolini . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 LOCAL AND SYSTEMIC EFFECTS ON METABOLISM Chapter 5 -Hormonal response of the hypothalamo-pituitary-adrenal axis in injury R. Chiolero, F. Pralong, R. Gaillard. .. . .. . .. . .. . .. . .. . . .. . .. . .. . .. . . .. . 61 Chapter 6 -Sympathetic nervous system and metabolism G.L. Carlson, R.A. Little. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Chapter 7 -Regional and systemic metabolic effects after surgical injury G. Sganga, I. Giovannini, C. Chiarla, M. Castagneto . . . . . . . . . . . . . . . . . . . . . 85 Chapter 8 -What about metabolism and the glutathione system? J. Wernerman, J.-L. Luo, F. Hammarqvist .............................. 93 Chapter 9 -Carbohydrate and insulin activity in critically ill patients R.R. Wolfe ........................................................ 101 Chapter 10 -Muscle catabolism, amino acid flux and protein turnover in injury G. Biolo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 VIII Contents TPN VS ENT NUTRITION -COST AND BENEFITS Chapter 11 -Total parenteral nutrition vs total enteral nutrition in critically ill patients: costs and benefits F. Iscra, A. Randino, G. Sermann ................................... 115 NEW STRATEGIES ON METABOLISM AND NUTRITION Chapter 12 -Hormone and growth factors in intensive care patients: anabolic strategy or utopia? C. Pichard, P. Jolliet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 125 Chapter 13 -Which metabolic strategies in the early phase of injury? G. Iapichino, A. Pezzi, D. Radrizzani, S. Marzorati ...................... 133 Chapter 14 -Effects of artificial nutrition on the immune system cells M. Braga, O. Gentilini, 1. Gianotti, A. Vignali ........................... 147 Chapter 15 -Selective antioxidants and early artificial nutrition as prevention of multiple organ failure D.W. Wilmore ..................................................... 161 Chapter 16 -Pharmacological nutrition in ICU patients G. Guarnieri, G. Biolo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 NUTRITION -STEPS FOR THE FUTURE Chapter 17 -Metabolism and nutrition in the critically ill: steps for the future D.W. Wilmore..................................................... 177 GUT AND NUTRITION Chapter 18 -The gut in healthy conditions 1. Pironi, F. Paganelli, M. Miglioli ................................... 187 Chapter 19 -The gut in local and systemic disease M. Zanello, 1. Di Mauro, C. Santoro................................... 193 Chapter 20 -Bacterial translocation G. Sganga, M. Castagneto . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 203 Chapter 21 -Gut and nutrients G. Toigo, R. Situlin, B. Ciocchi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 211 Contents IX OLD DILEMMA OR NEW STRATEGIES Chapter 22 -Parenteral vs enteral nutrition R. Tufano, M. Pezza, L. Ughi ......................................... 225 Main symbols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 233 Subject index ................................................... 235 List of contributors Bertolini R. Intensive Care Unit, S. Chiara Hospital, Pisa, Italy. BioloG. Department of Clinical Medicine, University of Trieste, Italy. BragaM. Department of Surgery, Scientific Institute S. Raffaele Hospital, University of Milan, Italy. BrandiL.S. Department of Surgery, School of Anaesthesia and Intensive Care, University of Pisa, Italy. Castagneto M. Department of Surgery, Division of Organ Transplantation, Catholic University and CNR, Rome, Italy. Chiarla C. Department of Surgery, Division of Organ Transplantation, Catholic University and CNR-Centro Studio Fisiopatologia Shock, Rome, Italy. Chiolero R. Surgical Intensive Care Unit, University Hospital (CHUV), Lausanne, Switzerland. Carlson G.L. North Western Injury Research Centre (MRC Trauma Group), University of Manchester, UK. Ciocchi B. Department of Clinical Medicine, University of Trieste, Italy. DiMauroL. Department of Neurological Science, Division of Anaesthesia and Critical Care, Bellaria Hospital, AUSL, Bologna, Italy. Flatt J.P. Department of Biochemistry & Molecular Biology, University of Massachussets Medical Center, Worcester, USA. XII Contributors GaillardR. Division of Endocrinology, Diabetes and Metabolism, University Hospital (CHUV), Lausanne, Switzerland. Gentilini O. Department of Surgery, Scientific Institute S. Raffaele Hospital, University of Milan, Italy. Giannotti L. Department of Surgery, Scientific Institute S. Raffaele Hospital, University of Milan, Italy. Giovannini I. Department of Surgery, Division of Organ Transplantation, Catholic University and CNR-Centro Studio Fisiopatologia Shock, Rome, Italy. Guarnieri G. Department of Clinical Medicine, University of Trieste, Italy. Hammarqvist F. Department of Anesthesiology and Intensive Care, Hudding Hospital, Karolinska Institute, Stockholm, Sweden. Iapichino G. Department of Anaesthesia and Intensive Care, San Paolo Hospital, University of Milan, Italy. Iscra F. Department of Anaesthesia, Intensive Care and Pain Therapy, University of Trieste, Italy. Jolliet P. Division of Medical Intensive Care, University Hospital, Geneva, Switzerland. Little R.A. North Western Injury Research Centre (MRC Trauma Group), University of Manchester, UK. Luo J.-L. Department of Anesthesiology and Intensive Care, Hudding Hospital, Karolinska Institute, Stockholm, Sweden. Marzorati S. Department of Anaesthesia and Intensive Care, San Paolo Hospital, University of Milan, Italy.