Despite the fact that glutamine is not considered to be an essential amino acid, it is the amino acid found in the greatest concentration both in plasma (26%) as in skeletal muscle (75%). These levels may decrease in post-operative, trauma, or critical patients. Glutamine performs many functions in which its demand may be increased, such as: it is a precursor of the synthesis of nucleotides; it is an activator of the protein synthesis and at the same time it inhibits the degradation; it is an activator of glycogen synthesis; it is a metabolic substrate for rapidly replicating cells; it is an energy source for the enterocyte which is so important for maintaining the integrity and the function of the intestinal barrier, and the consumption thereof may be increased under conditions of stress. The administration of glutamine intravenously leads to two physical-chemical problems; the first is its low solubility in water; at 20 degrees C this is only 36 g/l, and the second problem is its low chemical stability in an aqueous solution at 22-24 degrees C, this being 11 days. This problem has led the industry to research two dipeptides of glutamine; L-alanyl-glutamine, and L-glycyl L-glutamine, both of which are much more soluble and much more stable. At present there is still a controversy regarding the dosage of glutamine and its dipeptides, with the dose being 0.19-0.29 g/kg/day of L-glutamine or its dipeptide forms, in surgical post-operative periods or to prevent bacterial translocation, and in patients who are candidates for bone marrow transplants, the administered dose has been 0.37-0.57 g/kg/day. The purpose of this study is to review the existing bibliography regarding the efficacy of L-glutamine or its dipeptides in four possible indications for its application in the daily clinical practice, such as: a) In post-operative surgical patients of major or medium surgery, glutamine or its dipeptides reduces the losses of muscular glutamine and its catabolism, showing a less negative nitrogen balance. b) Whether it avoids bacterial translocation. c) Whether it favors the response of the immunological system. d) Whether in patients who are candidates for bone marrow transplants this decreases the side effects due to chemotherapy and radiotherapy such as mucositis, or whether it decreases the number of days of neutrophil recovery. At present, on the European market there are two commercially available brands of glutamine dipeptides: Dipeptiven, by Fresenius Laboratories, Germany. A 100 ml vial which corresponds to 20 g of L-alanyl L-glutamine (8.2 g of alanine + 13.46 g of L-glutamine). This is added to the standard amino acid solution. Glamin, Pharmacia and Upjohn Laboratory, Sweden. This is an amino acid solution with 13.4% essential and non-essential amino acids which are equivalent to 22.4 g of nitrogen/l, and which contain 30.27 g L-glycyl-L-glutamine (10.27 g of glycine + 20 g of L-glutamine).
BACKGROUND: Small-bowel transplantation is an alternative to home parenteral nutrition (HPN) in patients with gut failure. Our aim was to report the indication, diagnosis, morbidity, mortality, and intestinal adaptation in the total cohort of Danish patients receiving HPN at any time during the 5 years between 1 January 1991 and 31 December 1995. The data were analysed against the option of transplantation. RESULTS: HPN was given to 129 patients; 59 (46%) had inflammatory bowel disease (15% died), 26 (20%) had cured cancers (42% died), and 44 (34%) had other diseases (dysmotility, surgical complications, infarcts, and so forth; 27% died). Of these, 60% were new in the HPN program, but only 19% received HPN all 5 years; 31 % had terminated HPN, 19% permanently, and 25% died. Only four deaths were HPN-related. In December 1995, 73 patients were receiving HPN in Denmark, for a prevalence of 13.9 per million, which is the highest in Europe but 10-fold lower than in the United States. CONCLUSIONS: Gut failure was the only indication for HPN in Denmark. Weight loss without gut failure, such as disseminated cancer and acquired immunodeficiency syndrome, was not an indication for HPN. Survival after small-bowel transplantation should be assessed against a sizeable mortality among candidates receiving HPN, and this depends on diagnosis and age. In an HPN population comparable with the Danish, a quarter is likely to die within a period of 5 years, a quarter will terminate HPN, and the others survive with HPN. Small-bowel transplantation can be a lifesaving procedure in the small fraction of foreseeable HPN-related deaths, mainly caused by liver failure. Transplantation will not improve survival in most adult HPN patients, and only an improved quality of life after transplantation justifies this procedure in most HPN patients.
Contamination of parenteral nutrition solutions with aluminum may result in accumulation of this element in bones and, in premature infants, may inhibit bone calcium uptake and induce cholestasis. We measured the aluminum concentration of small-volume parenterals, amino acid solutions, lipid emulsions, and special solutions containing glucose, amino acids, electrolytes, and trace elements (standard I for children with a body weight of 3-5 kg, standard II for children with a body weight of 5-10 kg). The method used was graphite furnace atomic absorption spectrometry GTA-AAS (SpectrAA-400 Plus, Varian, PtY Ltd., Mulgrave, Australia). Quality control was run with the use of control serum (Seronorm, Nycomed, Oslo, Norway). The aluminum contents of parenterally administered solutions were: pediatric trace elements, 130 micrograms/L, and pediatric trace elements, 3000 micrograms/L; phosphorus salts: K-phosphates, 9800 micrograms/L, and Na/K phosphates, 13,000 micrograms/L; 10% calcium gluconate, 4400 micrograms/L; 6.5% amino acids, 30 micrograms/L; 10% amino acids, 120 micrograms/L; 12.5% amino acids, 121 micrograms/L; 20% lipid emulsion, 30 micrograms/L; 20% lipid emulsion, 180 micrograms/L; water-soluble vitamins, 12 micrograms/L; lipid soluble vitamins, 360 micrograms/L; standard I, 55 micrograms/L; standard II, 90 micrograms/L; The aluminum intake from parenteral nutrition was 6.6-10.8 micrograms.kg-1.d-1--a dose exceeding the safety limit of 2 micrograms.kg-1.d-1. The possible association of aluminum not only with metabolic bone disease, but also with encephalopathy, dictates caution when dealing with the pediatric population on long-term parenteral nutrition. In the absence of reliable label information, it seems proper to monitor the aluminum concentration in parenteral nutrition products and to report it in professional journals.
Children with neurological impairments are prone to develop serious infection due to anaerobic bacteria. They often are predisposed to develop infections caused by their own indigenous bacterial flora caused by impairments of their mechanical and immunological defenses, the change in their oral flora due to poor hygiene, and the delay in recognition of acute infection. The most common anaerobic infections are decubitus ulcers, gastrectomy site wound infections, pulmonary infections (aspiration pneumonia, lung abscesses, and tracheitis), and chronic suppurative otitis media. The unique microbiology of each of the infections and their medical and surgical management were discussed in this review.
In Canada, the majority of cases of childhood hemolytic uremic syndrome (HUS) are associated with a diarrheal illness (D+) due to verotoxin-producing Escherichia coli (VTEC). Although the ingestion of undercooked beef is an important cause, we report on the largest outbreak of E. coli illness due to a contaminated supply of municipal water. We describe the clinical features and short-term outcomes of 22 children who simultaneously developed D+HUS.
In the preparation of a centralized parenteral nutrition unit project in our hospital, following the creation of a multi-disciplinary commission entrusted with the study of this project, we proceeded to evaluate parenteral nutrition protocols of national and foreign hospitals, as a first approach to the subject. This study evaluates and extracts the data we consider most relevant in a sample of 19 American hospitals. With regard to the types of parenteral diet, we observed that most of them (63%) had "standard diets", mainly formulated with 25% glucose and 4.25% crystalline amino acids. None of the protocols studied contained alternatives to glucose as a calorie-contributor, nor were there special formulae for amino acids, although many of them included it in their therapies for use if considered necessary. In all protocols, the contribution of fats was reduced to concrete situations and administered in a different way to the rest of the food in 73% of cases. With regard to additives, despite the existence of standard formulations of electrolytes and vitamins and oligoelements, in 100% of the hospitals studied, there was the possibility of formulating each element separately. Administration was done in several doses per day in 42% of cases and in 100%, using perfusion pumps. The data obtained from this review was of great value in preparing our own parenteral nutrition protocols.