Jeffrey L. Nelson

Enteral nutrition with eicosapentaenoic acid, γ-linolenic acid, and antioxidants reduces alveolar inflammatory mediators and protein influx in patients with acute respiratory distress syndrome

ObjectivePreviously, we showed that acute respiratory distress syndrome patients fed an enteral diet containing eicosapentaenoic acid and &ggr;-linolenic acid and elevated antioxidants (EPA+GLA; Oxepa) had significantly reduced pulmonary inflammation, increased oxygenation, and improved clinical outcomes. In a subset of acute respiratory distress syndrome patients from this trial, we performed a preliminary examination of the potential mechanisms underlying these clinical improvements by retrospectively testing the hypothesis that enteral feeding with EPA+GLA could reduce alveolar-capillary membrane protein permeability and the production of interleukin (IL)-8, IL-6, tumor necrosis factor-&agr;, and leukotriene B4 that are responsible, in part, for pulmonary inflammation. DesignProspective, randomized, double-blind, controlled clinical trial. SettingIntensive Care Unit of the Ohio State University Medical Center. PatientsA total of 67 patients were enrolled who met defined criteria for acute lung injury/acute respiratory distress syndrome. InterventionsA total of 43 of 67 evaluable patients randomly received either EPA+GLA or an isonitrogenous, isocaloric standard diet that was tube fed at a minimum caloric delivery of 75% of basal energy expenditure times 1.33 for at least 4 to 7 days. Measurements and Main ResultsBronchoalveolar lavage (BAL) was performed at baseline and study days 4 and 7 to obtain BAL fluid (BALF) for measurement of total protein, ceruloplasmin, and transferrin, total neutrophil count, IL-8, IL-6, tumor necrosis factor-&agr;, and leukotriene B4. Oxygenation, measured as Pao2/Fio2, was assessed before BAL. Patients fed EPA+GLA had a significant reduction in BALF ceruloplasmin and IL-8 during the study as compared with patients fed the control diet. BALF levels of total protein, neutrophils, and leukotriene B4 tended to decrease in EPA+GLA patients over the course of the study as compared with control patients. BALF levels of IL-6 declined similarly during the study in both groups. A trend toward a reduction in BALF tumor necrosis factor-&agr; was observed on study day 7 in the EPA+GLA group as compared with control patients. Significant improvements in oxygenation (Pao2/Fio2) occurred in EPA+GLA patients on study day 4 as compared with controls. Correlation analysis revealed significant relationships between BALF neutrophil counts and indices of alveolar-capillary membrane protein permeability, IL-8, and leukotriene B4. ConclusionsThis preliminary investigation showing a decrease in BALF levels of IL-8 and leukotriene B4 and the associated reduction of BALF neutrophils and alveolar membrane protein permeability in acute respiratory distress syndrome patients fed EPA+GLA support, in part, the potential mechanisms underlying the previously described clinical improvements with this diet. Additional controlled studies are needed to confirm these findings.

Role of early enteral feeding and acute starvation on postburn bacterial translocation and host defense: prospective, randomized trials

ObjectivesTo investigate the effect of: a) starvation during the preburn period and b) immediate postburn enteral nutrition on the permeability of the gut to microorganisms and the ability of the host to kill translocated bacteria. DesignProspective, randomized, experimental trials. SettingLaboratory. SubjectsBalb/c mice and Hartley guinea pigs. InterventionsIn the first experiment, mice were starved for 0, 6, 12, 18, or 24 hrs before receiving gavage with 1010 14C-labeled Escherichia coli and a 20% burn injury. In the second experiment, guinea pigs received a 40% burn injury and were randomized to receive a complete enteral diet (175 kcal/kg/day) or infusion of an equal volume of lactated Ringers solution via a previously placed gastrostomy for 6, 24, or 48 hrs. After each feeding period, 1010 10C Escherichia coli were infused intragastrically. In both experiments, the animals were killed 4 hrs after gavage, and mesenteric lymph nodes, spleen, liver, lungs, peritoneal fluid, and blood were harvested aseptically. MeasurementsFor each tissue or fluid, the number of viable E. coli and radionuclide counts of the 14C E. coli were measured and the percentage of translocated bacteria that remained alive was calculated. Main ResultsIn mice, 18 and 24 hrs of preburn starvation increased translocation only to the mesenteric lymph nodes, but it also enhanced bacterial killing in all tested tissues. Guinea pigs that were fed enterally for 6, 24, and 48 hrs postburn had significantly lower bacterial translocation in all tissues compared with animals infused with lactated Ringers solution. Additionally, enhanced killing of translocating organisms was observed after 24 and 48 hrs of feeding. ConclusionsStarvation preburn has different consequences than starvation postburn on translocation and bacterial killing. Postburn enteral nutrition decreases the load of viable bacteria in the tissues via a double mechanism: an initial decreased translocation and a subsequent improved ability to kill bacteria that do translocate. (Crit Care Med 1994; 22:265–272)

Neurotransmitter alterations associated with feeding and satiety

Chronically malnourished rats were sacrificed in a food-deprived state, following eating a small amount of food, or following feeding to satiation. Regional analysis of brain neurotransmitter, neurotransmitter precursor and metabolite concentrations revealed significantly elevated levels of dopamine metabolites in the corpus striatum and nucleus accumbens of the satiated rats. Food-deprived and both refed groups exhibited elevated concentrations of the serotonin metabolite, 5-hydroxyindoleacetic acid, in most brain areas examined. These results suggest increased metabolism of dopamine to be associated with satiety rather than with the act of feeding alone. Increased serotonin metabolism appears to reflect overall nutritional status rather than the onset of satiety.

Effect of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants on antioxidant status in patients with acute respiratory distress syndrome.

BACKGROUND We previously showed that enteral feeding of a diet containing eicosapentaenoic acid, gamma-linolenic acid, and elevated antioxidants improved clinical outcomes compared with a control diet in acute respiratory distress syndrome (ARDS) patients. It has been suggested that oxidative stress may overwhelm endogenous antioxidant levels and allow free radicals to further damage lung tissue. Therefore, we determined whether these ARDS patients were under oxidative stress and whether the experimental diet could improve antioxidant status. METHODS Ninety-eight ARDS patients received either the experimental or control diet (minimum of 75% of basal energy expenditure x 1.3) for at least 4 to 7 days. Total radical antioxidant potential (TRAP), lipid peroxide levels (LPO), and plasma antioxidant concentrations were determined at baseline and study days 4 and 7. Sixty-two normal individuals were assessed for reference values. RESULTS At baseline, ARDS patients had significantly lower plasma beta-carotene, retinol, and alpha-tocopherol, lower TRAP, and higher LPO values compared with normals. After 4 days of feeding, beta-carotene and alpha-tocopherol levels were normalized and significantly increased in the experimental group compared with controls. TRAP and LPO were not significantly different between groups and study day 4 and 7 values were not different from baseline values. Retinol levels increased equally in both groups. CONCLUSIONS Before treatment, ARDS patients were found to be in a state of oxidative stress and had reduced levels of antioxidants. Although enteral nutrition with the experimental diet for at least 4 to 7 days did not reduce oxidative stress as measured, it did restore plasma levels of beta-carotene and alpha-tocopherol to normal or higher levels and appeared to protect ARDS patients from further lipid peroxidation.

Reduction of tumor growth following treatment with a glutamine antimetabolite

Assessment of arterial-venous differences across transplanted methylcholanthrene-induced sarcomas in rats revealed significant decreases in plasma concentrations of glutamine, serine and glucose. Treatment with the glutamine antimetabolite, acivicin, significantly reduced tumor weights by 65% at the conclusion of the experiment 34 days after tumor induction. These results suggest that glutamine is an essential metabolic substrate for tumor growth and that blockade of glutamine utilization can inhibit the growth of these transplantable sarcomas.

Effect of pentoxifylline on survival and intestinal cytokine messenger RNA transcription in a rat model of ongoing peritoneal sepsis

OBJECTIVE Septic animals receiving high-protein liquid diets have increased mortality and increased production of cytokines by the gut compared with animals receiving low-protein diets. The purpose of this study was to evaluate the ability of pentoxifylline to alter gut cytokine production in a rat model of prolonged acute peritonitis, to determine its effect on survival in such animals, and to determine whether alteration of gut cytokine production was associated with survival. DESIGN Prospective, randomized animal study. SETTING Research laboratory. SUBJECTS Male Lewis rats weighing between 250 and 300 g. INTERVENTIONS Anesthetized rats had placement of a gastrostomy, followed 1 wk later by implantation of a bacteria-filled osmotic minipump into the peritoneal cavity. Rats were fed a high-protein (20% total energy) enteral diet. Saline or pentoxifylline (5 or 20 mg/kg im) was administered daily beginning at the time of pump implantation. MEASUREMENTS AND MAIN RESULTS Septic rats fed the high-protein liquid diet and given pentoxifylline in a dose of 5 mg/kg/day demonstrated improved survival compared with saline-treated animals or animals given the high dose (20 mg/kg/day) of pentoxifylline (p< .05). Administration of pentoxifylline at 5 mg/kg/day also down regulated the production of IL-6 messenger RNA (mRNA) in liver and lipopolysaccharide binding protein mRNA in the liver and intestine of septic animals given the high-protein liquid diet. CONCLUSION Low-dose (but not high-dose) pentoxifylline administration reduced production of some, but not all, cytokines studied in the gut and liver in a rat model of acute peritonitis and this reduced production was associated with an improved survival in such animals.

Diets and Infection: Composition and Consequences

Abstract. This brief review focuses on the effects of nutrient composition of enteral diets on the outcome of surgical patients and experimental models of infection. Complete enteral diets containing combinations of immunonutrients (arginine, glutamine, RNA, omega-3 fatty acids), when given postoperatively or after trauma to surgical patients, can reduce hospital stay, overall costs, and the incidence of wound complications and acquired infections. Immunonutrient diets can also reduce the length of hospital stay when given to patients admitted to the surgical intensive care unit. A high protein diet is usually required for optimal benefit, although administration of high protein immunoenhancing diets may have adverse effects in animals with severe untreated peritonitis because of a sustained overproduction of cytokines.

Hyperammonemia in anorectic tumor-bearing rats

Plasma ammonia concentrations were significantly elevated by 150% in anorectic rats bearing methylcholanthrene sarcomas. Assessment of ammonia levels in blood draining these sarcomas indicated nearly a 20-fold increase as compared with venous blood in control rats, suggesting the tumor mass as the source of this increase in ammonia. Infusing increasing concentrations of ammonium salts produced anorexia and alterations in brain amino acids in normal rats that were similar to those observed in anorectic tumor-bearing rats. Therefore, these results suggest that ammonia released by tumor tissue may be an important factor in the etiology of cancer anorexia.

Reversal of neurochemical aberrations after tumor resection in rats

Assessment of biochemical parameters in methylcholanthrene sarcoma-bearing rats 2 days after the onset of anorexia revealed several biochemical aberrations in blood and brain. Plasma levels of glucose were decreased and lactate concentrations were increased. The plasma and brain amino acid profiles were also greatly altered in these rats, characterized by increased brain concentrations of glutamine and large neutral amino acids. Analysis of regional neurotransmitter and metabolite levels by high-performance liquid chromatography suggested increases in the neuronal activity of dopamine and serotonin in each brain region examined. Surgical removal of the tumors in another group of anorectic tumor-bearing rats was followed by the return of normal feeding within 6 days. Associated with the normalization of food intake was the reversal of these biochemical aberrations in blood and brain. It is hypothesized that the utilization of glutamine and excretion of ammonia by tumor tissue is the precursor of these alterations in brain amino acids and neurotransmitters, which may be causing anorexia.

The relationship of burn-induced hypermetabolism to central and peripheral catecholamines.

The role of brain and circulating catecholamines as mediators of burn-induced hypermetabolism was investigated in two experiments. Following a 30% body surface area full-thickness open-flame burn, rats exhibited a short period (3 to 4 days) of anorexia followed by a more prolonged (several weeks) hyperphagic-hypermetabolic response. During this hypermetabolic period, norepinephrine concentrations were increased in the brain and circulating epinephrine levels were elevated. Depletion of brain norepinephrine using 6-hydroxydopamine led to increased body weight gain, but did not increase resting energy expenditure in burned rats. Similarly, the reduction of circulating catecholamines through removal of the adrenal medulla resulted in a decreased loss of body weight and only slight reductions in resting energy expenditure. Therefore, these results suggest that although brain norepinephrine and circulating epinephrine have a role in the full expression of hypermetabolism, these compounds do not appear to be major mediators of this response to burn trauma.