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Over a 3-year period, 156 of 815 patients admitted to a single institution with acute pancreatitis received total parenteral nutrition (TPN) for 2,572 patient days. Seventy had "simple" acute pancreatitis (group I) and 86 (group II) developed local complex disease (pseudocyst, abscess, or necrotic gland). In groups I and II, respectively, days without oral intake (NPO) were 13.6 +/- 1.5 (SEM) and 24.0 +/- 2.1 (p less than 0.005), hospital days were 19.8 +/- 1.7 and 35.8 +/- 3.2 (p less than 0.005), and duration of TPN was 10.9 +/- 1.0 and 21.0 +/- 2.3 days (p less than 0.005). Thirty-three patients in group I and 53 in group II required exogenous insulin. Alteration of standard formulas was necessary in 87 patients, but cessation of therapy was necessary in only one instance. Twenty catheters were removed for suspected sepsis with only 3 confirmed cases. Fat-based formulas were well tolerated in 15% of patients. During TPN, body weight rose from 95.0 +/- 2.4% to 97.4 +/- 4.3% of ideal in group I and remained at 90.5 +/- 1.8% in group II. Albumin rose from 3.36 +/- 0.10 to 3.50 +/- 0.08 g/dl in group I and from 3.01 +/- 0.07 to 3.35 +/- 0.07 g/dl in group II. The entire cohort differed from 10 randomly chosen patients who did not receive TPN in terms of days NPO (2.8 +/- 0.3) and hospital days (5.5 +/- 0.6). Variables associated with prolongation of hospital stay and time NPO were number of prognostic criteria, local complex disease, and underlying chronic pancreatitis only in select groups. We conclude that during acute pancreatitis, TPN can be administered safely but with careful monitoring and we recommend early aggressive therapy in the subgroups noted above and when underlying malnutrition exists. In the borderline patient, TPN may be administered by peripheral vein until the severity of disease is manifest.

Congenital diaphragmatic hernia is a rare occurrence in the adult population. We present herein a patient with blunt abdominal trauma who presented with a bilious right pleural effusion. Bile from a m

A recent case of posttraumatic splenic abscess in an HIV-positive intravenous drug abuser following a splenic salvage procedure is reported. With the recent trend toward splenic preservation and the ever-increasing population of HIV-positive, immune-compromised patients, the complication of splenic abscess may become more common.

Free fatty acid (FFA) metabolism was studied in 18 traumatized and/or septic patients. Each patient was studied while receiving 5% dextrose (D5W) and after 4 to 7 days of total parenteral nutrition (TPN). Nonprotein energy during TPN was given either entirely as glucose (Glucose System) or as equal portions of intravenous fat and glucose (Lipid System). Plasma FFA concentrations were in the normal range on D5W and decreased markedly with TPN. FFA turnover was higher than normal on D5W and did not decrease significantly with TPN. The poor correlation between these two variables emphasizes the need to perform kinetic studies to characterize FFA metabolism in trauma and sepsis. Plasma FFA oxidation and net whole body fat oxidation measured by indirect calorimetry were in the normal range on D5W, 35 and 82%, respectively, of resting energy expenditure (REE). With a glucose intake averaging 108% of REE, plasma FFA oxidation and net fat oxidation decreased to 17 and 13%, respectively, of REE. Nonprotein RQ increased only to 0.94 despite administration of glucose in excess of REE, indicating an abnormal persistence of fat oxidation. During D5W administration, plasma FFA accounted for less than one half of total fat oxidation, indicating that unlabeled fat, such as tissue or plasma triglycerides not in rapid equilibrium with plasma FFA, accounted for the bulk of fat oxidation. Glucagon concentrations which were high on D5W did not decrease significantly with TPN. Insulin concentrations were normal on D5W and increased in response to TPN. The abnormal hormonal milieu may account for much of the abnormal fat metabolism. Administration of large amounts of glucose decreased FFA oxidation much more than FFA mobilization. Thus, the infused glucose acts to increase the rate of "futile cycling" of FFA in these acutely ill patients.

Parenteral nutrition has been one of the major advances in clinical medicine in the 20th century. By maintaining or re-establishing optimal nutritional status, one can help to ensure an optimal response to appropriate medical or surgical management of the primary disease process. In order to plan an appropriate nutritional regimen, the health-care provider must be equipped to pursue the following thought processes: Understand the consequences of malnutrition. Identify the patient who may benefit from nutritional support. Assess the underlying clinical and metabolic setting. Assess the current nutritional status. Formulate a goal of nutritional intervention--a therapeutic plan. Determine the route and method of administration; the quantity and source of energy and nitrogen; and requirements for fluid, electrolytes, minerals, vitamins, and trace elements. Monitor the patient. Evaluate the efficacy and determine the duration of therapy.

Eight nutritionally depleted and five injured patients were studied prior to and during total parenteral nutrition (TPN). Five additional injured patients were studied at intervals while receiving only 5% dextrose. Fatty acid kinetics and oxidation were determined using an infusion of [1-14C]palmitate. Net substrate oxidation was calculated by indirect calorimetry. During TPN, resting energy expenditure rose from 109 to 119% and from 89 to 103% of predicted in injured and depleted patients, respectively. Free fatty acid (FFA) flux was unaffected, FFA oxidation and net fat oxidation (NFO) decreased by 60%. However NFO began higher in injured subjects (20.7 +/- 2.8 vs 14.6 +/- 0.9 kcal/kg/day, P less than 0.05) and remained higher during TPN (8.3 +/- 1.2 vs 5.6 +/- 0.9 kcal/kg/day, P less than 0.05). The proportion of NFO derived from immediate oxidation of circulating FFA was approximately 35%. The results indicate that, with glucose-based TPN, there is a discrepancy between suppression of FFA production and oxidation. We further conclude that sources of fatty acid which are not in rapid equilibrium with circulating plasma FFA contribute substantially to whole body fat oxidation.

A new technique for measuring glycerol turnover in human subjects is presented using a staged infusion of unlabeled glycerol. A total of 105 measurements was made in normal subjects and postoperative or acutely ill patients. The relation between glycerol turnover rate (Rt) and concentration (C) (Rt = 31 + 2.07C) from 80 staged infusion measurements in 21 normal subjects did not differ significantly from observations of others made by isotope dilution. In 11 patients, glycerol turnover was also measured by dilution of isotopic glycerol. Mean values did not differ significantly between the two methods. The average difference, regardless of sign, for individual values was 17%. This agreement tends to validate the assumptions of both methods. Advantages of the staged infusion method are that it is quicker and easier to perform and does not entail a risk due to administration of radioactive materials. Evidence obtained in this study from a three-stage procedure indicates that satisfactory information may be obtained from a two-stage infusion at successive rates of 250 and 600 μmol/min for 70 min each, with a prime of 2 mmol given as a bolus at the start of each stage. isotope dilution; glycerol clearance; glycerol concentration; lipolysis; futile cycle Submitted on December 27, 1983 Accepted on April 18, 1984

Total parenteral nutrition (TPN) is now widely available, but there is a relatively little data relating to the optimal substrate support in different types of patients. In critically ill patients who require parenteral nutrition, underlying metabolic alterations will influence the capacity for substrate utilization; in them, fat emulsion may serve as a useful energy source but may also have deleterious effects. The intravenous fat tolerance test has been widely used as a measure of the capacity of the organism to clear exogenous fat from the bloodstream. We have devised and employed a three-stage lipid clearance test using Intralipid-10% as a substrate. The rates of infusion are such that first order kinetics are followed during the first two stages yielding fractional removal rates, and zero order kinetics are followed during the third infusion yielding maximal clearance rates. Six injured and 6 infected patients displayed a greater capacity for lipid clearance than 13 normal subjects. Four injured patients who also had received multiple transfusions failed to show this response. Fractional removal rates were influenced by injury and infection to a greater extent than maximal clearance rates. Models are presented utilizing enzyme saturation kinetics and treating endogenous triglyceride as a competitive inhibitor (for the enzyme-substrate system of lipoprotein lipase-Intralipid triglyceride). The importance of employing enzyme saturation kinetics in the interpretation of lipid clearance tests is noted. The calculated apparent Michaelis-Menten constant for Intralipid triglyceride during the lipid clearance test is 521 +/- 38 (SEM) micromole/liter. In vitro systems utilizing Intralipid triglyceride as a substrate have yielded values in this range.

A policy of selective management of anterior abdominal stab wounds was evaluated in 333 consecutive patients. Laparotomy was performed based upon initial clinical assessment in 165 patients. There were six deaths (3.6%), major complications in 23 patients (14%), and 28 negative laparotomies (17%). Eighteen patients developed indications for laparotomy after 10.7 +/- 2.2 hours of observation. There were no deaths, major complications in two patients (11%), and four negative laparotomies (22%). One hundred fifty patients were observed and discharged after 1.8 +/- 0.1 days. Sensitivity, specificity, and positive and negative predictive values for initial clinical evaluation were 91%, 85%, 92%, and 83%, respectively. Length of hospitalization in the initially operated and in the delayed group was 9.5 +/- 0.6 and 10.6 +/- 2.6 days (NS), respectively. Most serious intra-abdominal injuries will declare themselves on initial clinical assessment. The remainder are less severe injuries and these patients can be safely observed without undue sequelae due to delay. The use of clinical assessment alone to prompt laparotomy is also cost effective based on analysis of hospital days for initial illness. No procedures are necessary to define penetration.

Measurement of whole body substrate oxidation requires prolonged isotope infusion to attain plateau specific activity (SA) of expired CO/sub 2/. We have investigated in 13 hospitalized patients a technique whereby plateau /sup 14/CO/sub 2/ SA is extrapolated using computer curve fitting based upon the early exponential rise. A primed-constant infusion of albumin-bound 1-/sup 14/C-palmitate was continued for 260 minutes with isotope priming of the secondary bicarbonate pool at 70 minutes. Plasma free fatty acid (FFA) SA reached steady state by 40 minutes and was 91% +/- 4% (SE) of values obtained at 190 to 260 minutes. At 70 minutes /sup 14/CO/sub 2/ SA reached only 44% +/- 1% of the 190 to 260 minute values, which were consistently at plateau. The predicted steady state /sup 14/CO/sub 2/ SA from the 40 to 70 minute curves and the FFA oxidation rates calculated from those values were 94% +/- 2% and 102% +/- 4%, respectively, of values measured at steady state (190 to 260 minutes). The relationship between predicted and measured values approximated the line of identity for /sup 14/CO/sub 2/ SA (y = 0.90x + 0.14, r = .98, P less than .001) and FFA oxidation (y = 1.02x, r =more » .98, P less than .001). The results suggest that FFA oxidation can be accurately calculated using a short infusion of labeled FFA without bicarbonate pool priming, thus avoiding overpriming or underpriming and possibly allowing multiple studies and diminished radioisotope exposure.« less

The effect of nutritional therapy on the utilization of an intravenous fat emulsion was studied in patients with injury, infection, and nutritional depletion using I-14C-trioleate labeled Intralipid. The plasma fractional removal rate and 14C-Intralipid oxidation rate was 55% ad 25% higher, respectively, in patients following trauma and during periods of infection receiving 5% dextrose than in healthy control subjects. Total parenteral nutrition (TPN) was administered as either 1) nonprotein calories given as glucose (Glucose System) or 2) equal proportions of glucose and intravenous fat emulsion (Lipid System). In comparison to TPN with the Lipid System, administration using the Glucose System resulted in higher plasma clearance rates and lower oxidation rates in both acutely ill and depleted patients. There was no correlation between the rates of plasma removal and oxidation of the intravenous fat emulsion (r = -0.04; NS) indicating that the removal of exogenous fat from plasma cannot be used as an indicator of oxidation. A negative linear relationship was seen between the oxidation rate of intravenous fat and carbohydrate intake (r = -0.92; p less than 0.001). Glucose intakes exceeding energy expenditure did not totally inhibit oxidation of the fat emulsion. The oxidation rate of 14C-Intralipid was linearly related to net whole body fat oxidation calculated using indirect calorimetry (r = -0.90; p less than 0.001) suggesting that the fat emulsion was oxidized in a similar manner to endogenous lipids. This study suggests that intravenous fat emulsions are utilized as an energy substrate in patients with major injury, infection or nutritional depletion. This observation, along with a relative unresponsiveness to glucose in surgical patients suggests that fat emulsions may be useful as a calorie source in patients receiving parenteral nutrition.

Nitrogen balance and energy expenditure were measured in 18 traumatized and/or septic patients and five depleted patients during different dietary conditions. Total parenteral nutrition (TPN) was given with nonprotein energy entirely as hypertonic glucose solutions (glucose system) or as half glucose-half intravenous fat emulsion (lipid system). In acutely ill patients, the change from 5% dextrose to TPN resulted in a prompt improvement of nitrogen balance to maintenance levels. There were no significant differences between patients given the glucose or lipid system. The five depleted patients were given the lipid and glucose systems alternately for a total of 19 one-week periods. A highly positive N balance, 80 mg N/kg . day, was attained on both diets. There was no significant difference between diets and no period of adaptation after switching from one diet to the other. On comparable intravenous diets, the acutely ill patients had higher plasma concentrations of glucose, glycerol, triglycerides, insulin, and glucagon than did the depleted patients. The study shows that the nitrogen-sparing effects of the lipid and the glucose systems are similar in moderately traumatized or infected as well as in malnourished patients. Factors other than nitrogen balance are of greater importance when choosing between the lipid and the glucose system for intravenous support.

The immediate effect of intravenous fat emulsion on neutrophil oxidant release was studied. Opsonized nonencapsulated S. aureus was used to stimulate neutrophil activity. Luminol enhanced chemiluminescence was followed over 15 min and recorded as peak output (P; mV), integral under the curve (I; V-sec) and rate of increase (R; mV/sec). Eighteen chronically ill patients receiving glucose based total parenteral nutrition were studied before and after a 4- to 6-hr test infusion of 500 ml of 10% fat emulsion. P decreased from 719 +/- 46 to 461 +/- 42 mV (p less than 0.001), I decreased from 169 +/- 17 to 111 +/- 12 V-sec (p less than 0.001) and R decreased from 6.9 +/- 1.0 to 4.0 +/- 0.6 mV/sec (p less than 0.001). Preincubation of normal whole blood with fat emulsion in vitro did not adversely affect chemiluminescence (11 studies), nor did incubation of normal neutrophils with patient postinfusion plasma (10 studies). We conclude that fat emulsion infusion acutely suppresses neutrophil chemiluminescence. The suppression is not a direct effect of the fat emulsion per se and is not due to inhibitory substances in the plasma following infusion.

Forty-five consecutive patients with penetrating thoraco-abdominal trauma underwent surgical exploration to evaluate the ability of peritoneal lavage to detect peritoneal penetration. Eight patients fulfilled standard criteria for operation and did not undergo lavage. The remaining 37 patients underwent diagnostic peritoneal lavage using a closed technique before exploratory laparotomy. Using 10,000 RBC/mm3 as our previously established criterion for peritoneal penetration, there were seven true positive, one false positive, 28 true negative, and one false negative lavage for an overall accuracy of 94.6% with 87.5% sensitivity and 96.6% specificity as determined by subsequent laparotomy. While 33% of this patient cohort were found to have significant injuries (four had isolated diaphragmatic injuries, all detected by peritoneal lavage), 67% were subjected to negative surgical exploration, as accurately predicted by peritoneal lavage. Negative laparotomy carried a 10.7% operative morbidity. Based on these data we advocate diagnostic peritoneal lavage in patients with thoraco-abdominal penetrating trauma who otherwise lack operative indications.

We studied the influence of hospital bypass on prehospital times and Level 1 trauma patient survival. During the nine-month study period, 251 Level 1 trauma patients were transported to the Cook County Hospital trauma unit by Chicago Fire Department (CFD) paramedics. The prehospital times and survival rates in the 203 (81%) patients who arrived with vital signs were analyzed. In this group, 64 (32%) had a hospital Trauma Score (TS) of 12 or less, 74 (39%) had at least one Abbreviated Injury Score (AIS) of 4 or more, and 58 (30%) had an Injury Severity Score (ISS) of more than 20. There were 66 (32%) directly transported patients and 137 (68%) patients who required hospital bypass. The time from CFD contact (by 911) to trauma center arrival (total run time) was on the average three minutes longer in the bypass group than in the direct group (36 +/- 11 vs 33 +/- 10 minutes, P less than .05). The travel time from the scene to the hospital (transport time) also was three minutes longer in the bypass group (7 +/- 3 vs 4 +/- 2 minutes, P less than .005). The need for bypass did not significantly influence survival. Survival was 86% in the bypass group and 85% in the direct group. The elapsed time between the injury and CFD contact (delay time) averaged 27 +/- 26 minutes and contributed 43% to the 63-minute mean overall time from the injury event to arrival at the trauma center. Total run time in directly transported patients accounted for 52% of the mean overall prehospital time.(ABSTRACT TRUNCATED AT 250 WORDS)

Derangements of posttraumatic glucose metabolism have long been recognized, with observed changes implicating abnormal action of insulin on target tissues. Insulin is important as well in fat metabolism, and "resistance" to insulin's effects on lipid metabolism after injury has been demonstrated. Although fat-derived fuels are the body's major energy source during starvation and after injury, most studies of posttraumatic insulin "resistance" have focused on carbohydrate metabolism. This study investigated adipose tissue response to insulin in vitro in rats subjected to starvation and/or trauma. Relationships between various parameters, including adipocyte size and weight, plasma glucose, insulin, and glycerol, and basal and insulin-suppressed lipolytic rates, were also studied. Results observed include a decrease in adipocyte size and an increase in basal lipolysis in both starved and traumatized rats, with both decreased sensitivity (T greater than S) and responsiveness (S greater than T) to insulin. These results support the concept that adipocytes of injured animals retain the ability to respond to insulin but lipolytic rates at maximal suppression are still quite high as compared to fed controls. Only minor differences were observed between starved animals and those with starvation and superimposed trauma.

Ninety-seven traumatized patients had blood samples taken immediately upon admission before any resuscitation. Microaggregate (MA) formation was measured by the screen filtration pressure (SFP) technique. Plasma fibronectin levels (Fn) were measured by immunoturbimetric assay. An Injury Severity Score (ISS) was calculated for each patient. The results show a highly significant correlation between severity of trauma, amount of MA formation, and amount of Fn depletion. We conclude that the highly significant correlation between MA formation and Fn depletion following trauma suggests a role for the reticuloendothelial system (RES) in the clearance of MA that form following trauma. Further, enhancement of RES clearance of MA may be possible by purified Fn or cryoprecipitate administration early in the treatment of trauma patients, thereby preventing the adverse sequelae of end organ MA deposition.

This study examines the influence of total parenteral nutrition (TPN) compared with 5% dextrose (D5) infusion on skeletal muscle and adipose tissue lipoprotein lipase (LPL) activity in nutritionally depleted, injured and infected patients. The plasma concentrations of glucose, free fatty acid (FFA), triglyceride and insulin were also measured. During TPN, nutritionally depleted subjects showed an increase in adipose tissue LPL activity, "fat cell size," and plasma insulin concentration. Skeletal muscle LPL activity and plasma FFA concentration decreased. In comparison, trauma patients showed a less marked rise in adipose tissue LPL activity and skeletal muscle LPL activity increased. Infected patients had a much smaller rise in adipose tissue LPL activity than either of the other groups, and muscle activity rose. The depleted and injured patients showed a linear relationship between adipose tissue LPL activity and plasma insulin concentration and an inverse hyperbolic relationship between adipose tissue LPL activity and plasma FFA concentration.

Previous reports from this hospital documented a splenic preservation rate of 50% (18/36) in adults after blunt and penetrating trauma. Recently (January through December 1984), use of an absorbable mesh helped to attain a 67% (22/33) salvage rate. The mesh is applied in such a fashion that it acts by tamponade. It proved useful in patients with bleeding from a large surface area or from deep parenchymal injuries, even those extending into the hilum. No deaths occurred in the splenic salvage patients. There was no difference in postoperative complications among the splenectomy, conventional splenorraphy, or mesh wrap splenorraphy groups. However, workup of persistent postoperative fevers in two splenic wrap patients revealed perisplenic fluid collections on CT scan. Aspiration yielded sterile fluid. Possible cause and effect relationship is being studied in the dog lab. We conclude that splenic wrapping is both a safe and efficacious method of splenic preservation.