Robert Bower

Disease-Specific Amino Acid Infusion (F080) in Hepatic Encephalopathy: A Prospective, Randomized, Double-Blind, Controlled Trial

Seventy-five patients with acute hepatic decompensation superimposed on chronic alcoholic cirrhosis were prospectively randomized for a blinded trial of the treatment of hepatic encephalopathy. The control group received 4 g of enteral neomycin daily along with 25% dextrose by a central venous catheter. The experimental group received a placebo resembling neomycin and isocaloric dextrose plus a modified amino acid mixture enriched with branched-chain amino acids to 36% and deficient in aromatic amino acids and methionine. Thirty patients in the F080 group and 29 in the control group completed the trial. The group receiving the modified amino acid mixture demonstrated a statistically significant improvement in encephalopathy as compared to the neomycin group, while maintaining nitrogen equilibrium. Survival and discharge from the hospital were statistically greater in the group treated with the modified amino acid solution and hypertonic dextrose. Treatment of hepatic encephalopathy in the presence of hepatic decompensation with an amino acid solution formulated for its treatment seems to produce faster, more complete recovery with improved capacity for nutritional support.

Postoperative enteral versus parenteral nutritional support in gastrointestinal surgery: A matched prospective study*

The effects of an elemental-enteral diet administered by a needle catheter jejunostomy or central total parenteral nutrition were prospectively studied in 15 patients undergoing abdominal operations. Infusions were started 1 day after operation and continued for 7 to 10 days. The two nutrient modalities were matched to deliver equal amounts of nitrogen and calories. Both promoted positive nitrogen balance and preserved body weight and serum proteins (albumin, transferrin, thyroxine-binding prealbumin, and retinol-binding protein). Both enteral and parenteral nitrogen caused a similar increase in plasma insulin levels. Pancreatic glucagon, total glucagon, gastrin, and pancreatic polypeptide were also maintained at similar levels in both groups. Plasma vasoactive intestinal polypeptide levels declined in patients receiving total parenteral nutrition but remained stable in the patients who were fed enterally. Both routes caused modest, inconsequential elevations in liver enzymes, but were otherwise equally safe. Patients tolerated total parenteral nutrition far better in the early postoperative period. Patients whose needs are great are probably better treated by total parenteral nutrition. Needle catheter jejunostomy feeding, however, is much less expensive. These studies do not support the commonly held belief that enteral nutrition is a more efficient route for administration of calories and protein.

Implementation of a clinical pathway decreases length of stay and hospital charges for patients undergoing total colectomy and ileal pouch/anal anastomosis

BACKGROUND Clinical pathways are increasingly being used by hospitals to improve efficiency in the care of certain patient populations; however, little prospective data are available to support their use. This study examined whether using a clinical pathway for patients undergoing ileal pouch/anal anastomosis, a complex procedure in which we had extensive practical experience, affected hospital charges or length of stay (LOS). METHODS A clinical pathway was developed to serve patients undergoing elective total colectomy and ileal pouch/anal anastomosis. All operations were performed by two attending physicians (J.E.F., M.S.N.). Before implementation, 10 pilot patients were prospectively monitored to ensure that hospital charges were accurately generated. In addition, charge audits were performed by an outside agency to verify the accuracy of the hospital bills. The pathway was then implemented, and 14 patients were prospectively analyzed. RESULTS In all patients the principal diagnosis was ulcerative colitis, with the exception of three patients with familial polyposis. Mean external audit charges were within 2% of the hospital bills; therefore the hospital bills were used in all calculations. The mean LOS decreased from 10.3 days to 7.5 days (p = 0.046) for patients on the pathway versus pilot patients. Mean hospital charges also decreased significantly, from

Use of a branched chain amino acid enriched solution in patients under metabolic stress.

21,650 to

Intestinal placement of pH-sensing nasointestinal feeding tubes

17,958 per patient (p = 0.005). CONCLUSIONS Implementation of a clinical pathway, even for an operation in which the surgeon has much experience, is an effective method for reducing LOS and charges for patients. This is likely the result of interdisciplinary cooperation, elimination of unnecessary interventions, and streamlined involvement of ancillary services. These results support the development of clinical pathways for procedures that involve routine preoperative and postoperative care. In addition, the benefits of clinical pathways should increase proportionally with increasing case volume for a particular procedure.

Nutritional Support in Liver Disease

The metabolic response to stress results in proteolysis, increased gluconeogenesis, and negative nitrogen balance. Infusion of BCAA has been shown experimentally to decrease protein degradation and stimulate protein synthesis. Such infusion may modify the response of patients to metabolic stress. An amino acid solution containing 45 percent BCAA as a component of central vein parenteral nutrition was infused into 20 moderately to severely stressed postoperative patients in a prospective, nonrandomized fashion. Infusion was begun within 24 hours postoperatively and continued for 7 to 14 days. Patients received 1.6 g protein equivalents per kg body weight daily and 30 kcal/kg body weight daily. Nutritional indexes as measured by albumin and transferrin values were maintained during the study period. Nitrogen balance became increasingly positive over the period of infusion without an increase in the urinary excretion of 3-methylhistidine. There were no serious clinical or biochemical side effects of the BCAA infusion, although a statistically significant increase in alkaline phosphatase was observed. These results suggest that central vein parenteral nutrition utilizing a 45 percent BCAA enriched solution can promote nitrogen retention without serious side effects in moderately to severely stressed patients.

Nutritional Management of Hepatic Encephalopathy

Intestinal access for enteral nutrition can be achieved by spontaneous intestinal nasogastric tube passage or by endoscopic, fluoroscopic, or surgical placement methods. Each of these methods has limitations that may compromise clinical utility. pH-sensing nasointestinal feeding tubes allow active placement with minimal equipment and expertise; however, this method requires an acidic gastric pH. We sought to determine whether antiulcer regimens used at our institution would preclude intestinal pH-sensing tube placement. Twenty-five patients had 25 (81%) successful intestinal placements in 31 attempts. Observed pH values and calculated pH changes were compared within and between successful and unsuccessful groups by using a Students t test. Initial, lowest, and final pH values did not differ significantly between groups. The pH change initial-to-lowest (4.7 +/- 0.18 vs 3.6 +/- 0.59, p < .03) and lowest-to-final (5.0 +/- 0.18 vs 3.0 +/- 0.47, p < .0001) differed significantly between groups, whereas the pH change initial-to-final did not. Cost analysis of endoscopic (

Combined Intradialytic and Peripheral Parenteral Nutrition: A Case Report

782), fluoroscopic (

Clinical benefits of an immune-enhancing diet for early postinjury enteral feeding

341 to

Postoperative Enteral vs Parenteral Nutrition: A Randomized Controlled Trial

382), spontaneous (