Hélio M Kimura

Nutritional follow-up of critically ill infants receiving short term parenteral nutrition

Few studies have tried to characterize the efficacy of parenteral support of critically ill infants during short period of intensive care. We studied seventeen infants during five days of total parenteral hyperalimentation. Subsequently, according to the clinical conditions, the patients received nutritional support by parenteral, enteral route or both up to the 10th day. Evaluations were performed on the 1st, 5th, and 10th days. These included: clinical data (food intake and anthropometric measurements), haematological data (lymphocyte count), biochemical tests (albumin, transferrin, fibronectin, prealbumin, retinol-binding protein) and hormone assays (cortisol, insulin, glucagon). Anthropometric measurements revealed no significant difference between the first and second evaluations. Serum albumin and transferrin did not change significantly, but mean values of fibronectin (8.9 to 16 mg/dL), prealbumin (7.7 to 18 mg/dL), and retinol-binding protein (2.4 to 3. 7 mg/dL) increased significantly (p < 0.05) from the 1st to the 10th day. The hormonal study showed no difference for insulin, glucagon, and cortisol when the three evaluations were compared. The mean value of the glucose/insulin ratio was of 25.7 in the 1st day and 15. 5 in the 5th day, revealing a transitory supression of this hormone. Cortisol showed values above normal in the beginning of the study. We conclude that the anthropometric parameters were not useful due to the short time of the study; serum proteins, fibronectin, prealbumin, and retinol-binding protein were very sensitive indicators of nutritional status, and an elevated glucose/insulin ratio, associated with a slight tendency for increased cortisol levels suggest hypercatabolic state. The critically ill patient can benefit from an early metabolic support.

CORTICAL HYPEROSTOSIS SECONDARY TO PROLONGED USE OF PROSTAGLANDIN E1

The echocardiography revealed Ebstein’s anomaly, with a dysplastic tricuspid valve, nonrestrictive atrial septal defect (ostium secundum) of 7.5 mm, single aortic outlet from the left ventricle, and patent ductus arteriosus. The systolic function of the left heart was normal, with a left ventricular ejection fraction (LVEF) of 65%. Intravenous infusion of PgE1 was started on the first day of life, at a dosage of 0.05 µg/kg/minute. The child progressed with mechanical ventilation dependency and had systemic and respiratory infections, requiring use of antibiotics. On 60 th day, he underwent a tracheostomy procedure. Despite the use of multiple and prolonged empirical antibiotic treatments, the infant sustained a persistent fever and had a C-reactive protein (CRP) level of 188 mg/L. At this time, the clinical and laboratory diagnosis of persistent nosocomial sepsis was made, due to positive blood cultures that isolated an uncataloged, nonfermenting, Gramnegative bacillus. The patient had a number of positive blood and catheter cultures with the same bacillus. At the time, the antibiotic schedule included piperacillin and tazobactam associated with trimethoprim-sulfamethoxazole guided by the antibiogram. The cardiac surgical correction was delayed, and the time of utilization of PgE1 was increased.