Abstract
Nutritional support is given to many patients in surgical intensive care after major trauma and serious sepsis but rarely after major elective surgery. We have quantified the changes in body composition that occur in these patients and have found that serious losses of body protein still occur after trauma and sepsis despite nutritional support. Correct nutritional management of critically ill patients in surgical intensive care depends on an understanding of the underlying physiology, drainage of sepsis, a high standard of general intensive care measures, and appreciation of sound principles of administration of intravenous nutrition.
Résumé
Dans les unités de soins intensifs de nombreux malades victimes d'un traumatisme grave ou en proie à une infection sévère bénéficient d'un apport nutritif important. Il n'en est pas toujours de même pour les opérés qui ont subi une intervention importante. Les auteurs ont mesuré les changements de la composition corporelle chez les patients traités dans l'unité de soins intensifs et ont ainsi constaté une perte protéique importante chez les blessés et les infectés malgré un apport nutritif important. Le traitement correct des malades dont l'état est critique et qui sont soignés dans les unités de soins intensifs repose sur l'appréciation exacte de l'état physiologique du malade, du drainage de l'infection, de la haute qualité des soins intensifs et d'une alimentation parentérale adéquate.
Resumen
El soporte nutricional es administrado a muchos pacientes en cuidado intensivo quirúrgico por trauma o sepsis grave, pero en muy raras ocasiones después de cirugía electiva mayor. Al cuantificar los cambios en la composición corporal que ocurren en pacientes en cuidado intensivo hemos hallado que serias pérdidas de proteína corporal continúan presentándose como consecuencia del trauma y la sepsis a pesar del soporte nutricional. El correcto manejo de pacientes en estado crítico en la unidad de cuidado intensivo depende de la comprensión de la fisiología involucrada, del drenaje adecuado de colecciones sépticas, de un alto estándar del cuidado intensivo, y de la observación de principios racionales para la administración de la nutrition intravenosa.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Garn, J.S., Lilly, M.P.: The endocrine response to injury. Prog. Crit. Care Med.1:15, 1984
Carlsson, M., Nordenstrom, J., Hedenstierna, G.: Clinical implications of continuous measurement of energy expenditure in mechanically ventilated patients. Clin. Nutr.3:103, 1984
Clifton, G.L., Robertson, C.S., Grossman, R.G., Hodge, S., Foltz, R., Garza, C.: The metabolic response to severe head injury. J. Neurosurg.60:687, 1984
Robertson, C.S., Grossman, R.G.: Energy expenditure in the head injured patient. Crit. Care Med.13:336, 1985
Bartlett, R.H., Dechert, R.E., Mault, J.R., Ferguson, S.K., Kaiser, A.M., Erlandson, E.E.: Measurement of metabolism in multiple organ failure. Surgery92:771, 1982
Nanni, G., Siegel, J.H., Coleman, B., Fader, P., Castiglione, R.: Increased lipid fuel dependence in the critically ill septic patient. J. Trauma24:14, 1984
Askanazi, J., Carpentier, Y.A., Elwyn, D.H., Nordenstrom, J., Jeevanandam, M., Rosenbaum, S.H., Gump, F.E., Kinney, J.M.: Influence of total parenteral nutrition on fuel utilisation in injury and sepsis. Ann. Surg.191:140, 1980
Shaw, J.H.F., Klein, S., Wolfe, R.R.: Assessment of alanine, urea, and glucose interrelationships in normal subjects and in patients with sepsis with stable isotopic tracers. Surgery97:557, 1985
Streat, S.J., Beddoe, A.H., Hill, G.L.: Aggressive nutritional support does not prevent protein loss despite fat gain in septic intensive care patients. J. Trauma(in press)
Hammarqvist, F., Wernerman, J., von der Decken, A., Vinnars, E.: The effect of branched chain amino acids on postoperative muscle protein synthesis and nitrogen balance. Clin. Nutr. [Suppl.]4:68, 1985
van Berlo, C.L.H., von Meyenfeldt, M.F., Rouflart, M., Soeters, P.B.: Does branched chain amino acid enrichment reduce mortality in septic and traumatised patients. Clin. Nutr. [Suppl.]4:68, 1985
Baticci, F., Bozzetti, F., Ammatuna, M., Pupa, A.: Effects of BCAA on postoperative protein metabolism. Clin. Nutr. [Suppl.]4: 69, 1985
Jelen-Esselborn, S., v. Hundeslhausen, B., Tempel, G.: Branched chain amino acids in parenteral nutrition of patients with multiple injury and sepsis. Clin. Nutr. [Suppl.]4:70, 1985
Iapichino, G., Radrizzani, D., Bonetti, G., Colombo, A., Damia, G., Della Torre, P., Ferro, A., Leoni, L., Ronzoni, G., Scherini, A.: Parenteral nutrition of injured patients: Effect of manipulation of aminoacid infusion (increasing branched chain while decreasing aromatic and sulphurated aminoacids). Clin. Nutr.4:121, 1985
Petrakos, A., Myers, M.L., Holliday, R.L., Finley, R., Driedger, A.A., Sibbald, W.J.: A systemic increase in capillary permeability in septicaemia. Crit. Care Med.9:214, 1981
Sibbald, W.J., Calvin, J.E., Holliday, R.L., Driedger, A.A.: Concepts in the pharmacologic and nonpharmacologic support of cardiovascular function in critically ill surgical patients. Surg. Clin. North Am.63:455, 1983
Fleck, A., Raines, G., Hawker, F., Trotter, G., Wallace, P.I., Ledingham, I.M., Calman, K.C.: Increased vascular permeability: A major cause of hypoalbuminaemia in disease and injury. Lancet1:781, 1985
Lucas, C.E., Ledgerwood, A.M.: The fluid problem in the critically ill. Surg. Clin. North Am.63:439, 1983
Weiner, N.: Norepinephrine, epinephrine and the sympathomimetic amines. In The Pharmacological Basis of Therapeutics, 6th edition, chapter 8, A.G. Gilman, L.S. Goodman, A. Gilman, editors, New York, Macmillan, 1980, pp. 149–150
Bessey, P.Q., Watters, J.M., Aoki, T.T., Wilmore, D.W.: Combined hormonal infusion simulates the metabolic response to injury. Ann. Surg.200:264, 1984
Bessey, P.Q., Brooks, D.C., Black, P.R., Aoki, T.T., Wilmore, D.W.: Epinephrine acutely mediates skeletal muscle insulin resistance. Surgery94:172, 1983
Ward, R.A., Shirlow, M.J., Hayes, J.M., Chapman, G.V., Farrell, P.C.: Protein catabolism during hemodialysis. Am. J. Clin. Nutr.32:2443, 1979
Long, C.L., Birkhahn, R.H., Geiger, J.W., Betts, I.E., Schiller, W.R., Blakemore, W.S.: Urinary excretion of 3-methylhistidine: An assessment of muscle protein catabolism in adult normal subjects and during malnutrition, sepsis, and skeletal trauma. Metabolism30:765, 1981.
Windsor, J.A., Hill, G.L.: Does organ dysfunction occur in protein depleted patients? Aust. N.Z. J. Surg.56:257, 1986
Hill, G.L.: Surgically created nutritional problems. Surg. Clin. North Am.61:721, 1981
Beddoe, A.H., Streat, S.J., Hill, G.L.: Evaluation of an in vivo prompt gamma neutron activation facility for body composition studies in critically ill intensive care patients: Results on 41 normals. Metabolism33:270, 1984
Streat, S.J., Beddoe, A.H., Hill, G.L.: Measurement of body fat and hydration of the fat-free body in health and disease. Metabolism34:509, 1985
Beddoe, A.H., Zuidmeer, H., Hill, G.L.: A prompt gamma in vivo neutron activation analysis facility for measurement of total body nitrogen in the critically ill. Phys. Med. Biol.29:371, 1984
Knight, G.S., Streat, S.J., Beddoe, A.H., Hill, G.L.: Body composition of two human cadavers by neutron activation and chemical analysis. Am. J. Physiol.250:E179, 1986
Beddoe, A.H., Streat, S.J., Hill, G.L.: Hydration of fat-free body in protein depleted patients. Am. J. Physiol.249:E227, 1985
Burkinshaw, L., Morgan, D.B., Silverton, N.P., Thomas, R.D.: Total body nitrogen and its relation to body potassium and fat-free mass in healthy subjects. Clin. Sci.61:457, 1981
Baker, S.P., O'Neill, B.: The injury severity score: An update. J. Trauma14:187, 1974
The Abbreviated Injury Scale, 1980 edition, Morton Grove, Illinois, American Association for Automotive Medicine, 1980
Streat, S.J., Beddoe, A.H., Hill, G.L.: Body composition after major trauma. Aust. N.Z. J. Surg.56:259, 1986
Streat, S.J., Beddoe, A.H., Hill, G.L.: Measurement of total body water in intensive care patients with fluid overload. Metabolism34:688, 1985
Report of the Task Group on Reference Man, Int. Comm. Radiol. Protection Report No. 23, Oxford, Pergamon Press, 1975
Durnin, J.V.G.A., Womersley, J.: Body fat assessed from total body density and its estimation from skinfold thickness: Measurements on 481 men and women aged from 16 to 72 years. Br. J. Nutr.32:77, 1974
Streat, S.J., Beddoe, A.H., Hill, G.L.: Changes in body nitrogen-comparison of direct measurement with nitrogen balance. Aust. N.Z. J. Surg.56:257, 1986
Norwood, S.H., Civetta, J.M.: Abdominal CT scanning in critically ill surgical patients. Crit. Care Med.13:350, 1985
Bell, R.C., Coalson, J.J., Smith, J.D., Johanson, W.G.: Multiple organ system failure and infection in adult respiratory distress syndrome. Ann. Intern. Med.99:293, 1983
Hill, G.L.: Operative strategy in the treatment of enterocutaneous fistulas. World J. Surg.7:495, 1983
Kirby, R.R., Downs, J.B., Civetta, J.M., Modell, J.H., Dannemiller, F.J., Klein, E.F., Hodges, M.: High level positive end expiratory pressure (PEEP) in acute respiratory insufficiency. Chest67:156, 1975
Kumar, A., Konrad, B.S., Falke, J., Geffin, B., Aldredge, C.F., Laver, M.B., Lowenstein, E., Pontopiddan, H.: Continuous positive-pressure ventilation in acute respiratory failure—effects on hemodynamics and lung function. N. Engl. J. Med.283:1430, 1970
Apuzzo, M.L.J., Weiss, N.H., Petersons, V., Small, R.B., Curze, T., Heyden, J.S.: Effect of positive end expiratory pressure ventilation on intracranial pressure in man. J. Neurosurg.46:227, 1977
Shapiro, H.M.: Intracranial hypertension: Therapeutic and anesthetic considerations. Anesthesiology43:445, 1975
Downs, J.B., Douglas, M.E.: Applied physiology and respiratory care. In Critical Care—State of the Art, vol. 3, W.C. Shoemaker, W.L. Thompson, editors, Fullerton, California, Society of Critical Care Medicine, 1982
Rowley, K.M., Clubb, K.S., Smith, G.J.W., Cabin, H.S.: Right-sided infective endocarditis as a consequence of flow-directed pulmonary-artery catheterisation—A clinicopathological study of 55 autopsied patients. N. Engl. J. Med.311:1152, 1984
Browning, J.A., Linberg, S.E., Turney, S.Z., Chodoff, P.: The effects of a fluctuating FIO2 on metabolic measurements in mechanically ventilated patients. Crit. Care Med.10:82, 1982
Ultman, J.S., Bursztein, S.: Analysis of error in the determination of respiratory gas exchange at varying FIO2. J. Appl. Physiol.: Respirat. Environ. Exercise Physiol.50:210, 1981
Baker, J.P., Detsky, A.S., Stewart, S., Whitwell, J., Marliss, E.B., Jeejeebhoy, K.N.: Randomized trial of total parenteral nutrition in critically ill patients: Metabolic effects of varying glucose-lipid ratios as the energy source. Gastroenterology87:53, 1984
Wolfe, R.R., Allsop, J.R., Burke, J.F.: Glucose metabolism in man: Responses to intravenous glucose infusion. Metabolism28:210, 1979
Koga, Y., Swanson, V.L., Hays, D.M.: Hepatic “intravenous fat pigment” in infants and children receiving lipid emulsion. J. Pediatr. Surg.10:641, 1975
Hageman, J.R., McCulloch, K., Gora, P., Olsen, E.K., Pachman, L., Hunt, C.E.: Intralipid alterations in pulmonary metabolism and gas exchange. Crit. Care Med.11:794, 1983
Jeppsson, R.I., Sjoberg, B.: Compatibility of parenteral nutrition solutions when mixed in a plastic bag. Clin. Nutr.2:149, 1984
Pettigrew, R.A., Lang, S.D.R., Haydock, D.A., Parry, B.R., Bremner, D.A., Hill, G.L.: Catheter-related sepsis in patients on intravenous nutrition: A prospective study of quantitative catheter cultures and guidewire changes for suspected sepsis. Br. J. Surg.72:52, 1985
Author information
Authors and Affiliations
Additional information
Supported by Medical Research Council of New Zealand, The Medical Distribution Committee of the Golden Kiwi Lottery Board, and the Auckland Savings Bank.
Rights and permissions
About this article
Cite this article
Streat, S.J., Hill, G.L. Nutritional support in the management of critically ill patients in surgical intensive care. World J. Surg. 11, 194–201 (1987). https://doi.org/10.1007/BF01656402
Issue Date:
DOI: https://doi.org/10.1007/BF01656402