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Chapple LAS, Ridley EJ, Chapman MJ. Trial Design in Critical Care Nutrition: The Past, Present and Future. Nutrients 2020; 12:nu12123694. [PMID: 33265999 PMCID: PMC7760682 DOI: 10.3390/nu12123694] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 11/19/2020] [Accepted: 11/26/2020] [Indexed: 12/26/2022] Open
Abstract
The specialty of nutrition in critical care is relatively modern, and accordingly, trial design has progressed over recent decades. In the past, small observational and physiological studies evolved to become small single-centre comparative trials, but these had significant limitations by today’s standards. Power calculations were often not undertaken, outcomes were not specified a priori, and blinding and randomisation were not always rigorous. These trials have been superseded by larger, more carefully designed and conducted multi-centre trials. Progress in trial conduct has been facilitated by a greater understanding of statistical concepts and methodological design. In addition, larger numbers of potential study participants and increased access to funding support trials able to detect smaller differences in outcomes. This narrative review outlines why critical care nutrition research is unique and includes a historical critique of trial design to provide readers with an understanding of how and why things have changed. This review focuses on study methodology, population group, intervention, and outcomes, with a discussion as to how these factors have evolved, and concludes with an insight into what we believe trial design may look like in the future. This will provide perspective on the translation of the critical care nutrition literature into clinical practice.
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Affiliation(s)
- Lee-anne S. Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA 5000, Australia;
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, SA 5005, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, SA 5005, Australia
- Correspondence: ; Tel.: +61-428-269-179
| | - Emma J. Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC 3004, Australia;
- Nutrition Department, Alfred Health, Melbourne, VIC 3004, Australia
| | - Marianne J. Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA 5000, Australia;
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, SA 5005, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, SA 5005, Australia
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Al-Zebeidi J, Agdi M, Lary S, Al-Obaid S, Salim G, Al-Jaroudi D. Effect of empiric intravenous intralipid therapy on pregnancy outcome in women with unexplained recurrent implantation failure undergoing intracytoplasmic sperm injection-embryo transfer cycle: a randomized controlled trial. Gynecol Endocrinol 2020; 36:131-134. [PMID: 31220957 DOI: 10.1080/09513590.2019.1631280] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
To evaluate the effect of empiric intralipid infusion therapy on pregnancy outcomes for patients with unexplained recurrent implantation failure (RIF) undergoing intracytoplasmic sperm injection (ICSI). A total of 142 patients with a history of unexplained RIF (3 or more cycles) were included in this randomized controlled trial. Patients were randomized into two groups, study group (n = 71) and control group (n = 71). The study group received intralipid 20% infusion on the day of embryo transfer (ET) and a second dose on the day of pregnancy test. The clinical pregnancy rate in the study group was 36.6% (n = 26) compared to 28.2% (n = 20) in the control group (OR 1.47, CI 0.72-2.98, p = .282). The live birth rate in the study group was 18.3% (n = 13) and 14.1% (n = 10) in the control group (OR 1.37, CI 0.55-3.36, p=.49). No side effects of intralipid therapy were reported in the study period. There was improvement in the pregnancy rate among women with unexplained RIF who received empiric intralipid infusion therapy; however, this improvement did not reach statistical significance.
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Affiliation(s)
- Jawharah Al-Zebeidi
- Reproductive Endocrine and Infertility Medicine Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mohammed Agdi
- Reproductive Medicine, Bnoon Medical Center, Riyadh, Saudi Arabia
| | - Sahar Lary
- Reproductive Endocrine and Infertility Medicine Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Solaiman Al-Obaid
- Reproductive Endocrine and Infertility Medicine Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Gamar Salim
- Reproductive Endocrine and Infertility Medicine Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Dania Al-Jaroudi
- Reproductive Endocrine and Infertility Medicine Department, King Fahad Medical City, Riyadh, Saudi Arabia
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Wooley JA, Btaiche IF, Good KL. Metabolic and Nutritional Aspects of Acute Renal Failure in Critically Ill Patients Requiring Continuous Renal Replacement Therapy. Nutr Clin Pract 2017; 20:176-91. [PMID: 16207655 DOI: 10.1177/0115426505020002176] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Acute renal failure (ARF) is rarely an isolated process but is often a complication of underlying conditions such as sepsis, trauma, and multiple-organ failure in critically ill patients. As such, concomitant clinical conditions significantly affect patient outcome. Poor nutritional status is a major factor in increasing patients' morbidity and mortality. Malnutrition in ARF patients is caused by hypercatabolism and hypermetabolism that parallel the severity of illness. When dialytic intervention is indicated, continuous renal replacement therapy (CRRT) is a commonly used alternative to intermittent hemodialysis because it is well tolerated by hemodynamically unstable patients. This paper reviews the metabolic and nutritional alterations associated with ARF and provides recommendations regarding the nutritional, fluid, electrolyte, micronutrient, and acid-base management of these patients. The basic principles of CRRT are addressed, along with their nutritional implications in critically ill patients. A patient case is presented to illustrate the clinical application of topics covered within the paper.
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Affiliation(s)
- Jennifer A Wooley
- St Joseph Mercy Hospital, Clinical Nutrition/Pharmacy, 5301 East Huron River Dr, PO Box 995, Ann Arbor, MI 48106, USA.
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Anez-Bustillos L, Dao DT, Baker MA, Fell GL, Puder M, Gura KM. Intravenous Fat Emulsion Formulations for the Adult and Pediatric Patient: Understanding the Differences. Nutr Clin Pract 2016; 31:596-609. [PMID: 27533942 DOI: 10.1177/0884533616662996] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Intravenous fat emulsions (IVFEs) provide essential fatty acids (EFAs) and are a dense source of energy in parenteral nutrition (PN). Parenterally administered lipid was introduced in the 17th century but plagued with side effects. The formulation of IVFEs later on made it a relatively safe component for administration to patients. Many ingredients are common to all IVFEs, yet the oil source(s) and its (their) percentage(s) makes them different from each other. The oil used dictates how IVFEs are metabolized and cleared from the body. The fatty acids (FAs) present in each type of oil provide unique beneficial and detrimental properties. This review provides an overview of IVFEs and discusses factors that would help clinicians choose the optimal product for their patients.
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Affiliation(s)
- Lorenzo Anez-Bustillos
- Vascular Biology Program and the Department of Surgery. Boston Children's Hospital, Boston, Massachusetts, USA
| | - Duy T Dao
- Vascular Biology Program and the Department of Surgery. Boston Children's Hospital, Boston, Massachusetts, USA
| | - Meredith A Baker
- Vascular Biology Program and the Department of Surgery. Boston Children's Hospital, Boston, Massachusetts, USA
| | - Gillian L Fell
- Vascular Biology Program and the Department of Surgery. Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mark Puder
- Vascular Biology Program and the Department of Surgery. Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kathleen M Gura
- Department of Pharmacy, Boston Children's Hospital, Boston, Massachusetts, USA
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Wanten GJA. Parenteral Lipid Tolerance and Adverse Effects. JPEN J Parenter Enteral Nutr 2015; 39:33S-8S. [DOI: 10.1177/0148607115595973] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 05/08/2015] [Indexed: 01/18/2023]
Affiliation(s)
- Geert J. A. Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
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Fettiplace MR, Akpa BS, Ripper R, Zider B, Lang J, Rubinstein I, Weinberg G. Resuscitation with lipid emulsion: dose-dependent recovery from cardiac pharmacotoxicity requires a cardiotonic effect. Anesthesiology 2014; 120:915-25. [PMID: 24496123 PMCID: PMC4077021 DOI: 10.1097/aln.0000000000000142] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Recent publications have questioned the validity of the "lipid sink" theory of lipid resuscitation while others have identified sink-independent effects and posed alternative mechanisms such as hemodilution. To address these issues, the authors tested the dose-dependent response to intravenous lipid emulsion during reversal of bupivacaine-induced cardiovascular toxicity in vivo. Subsequently, the authors modeled the relative contribution of volume resuscitation, drug sequestration, inotropy and combined drug sequestration, and inotropy to this response with the use of an in silico model. METHODS Rats were surgically prepared to monitor cardiovascular metrics and deliver drugs. After catheterization and instrumentation, animals received a nonlethal dose of bupivacaine to produce transient cardiovascular toxicity, then were randomized to receive one of the four treatments: 30% intravenous lipid emulsion, 20% intravenous lipid emulsion, intravenous saline, or no treatment (n = 7 per condition; 28 total animals). Recovery responses were compared with the predictions of a pharmacokinetic-pharmacodynamic model parameterized using previously published laboratory data. RESULTS Rats treated with lipid emulsions recovered faster than did rats treated with saline or no treatment. Intravenous lipid emulsion of 30% elicited the fastest hemodynamic recovery followed in order by 20% intravenous lipid emulsion, saline, and no treatment. An increase in arterial blood pressure underlay the recovery in both lipid emulsion-treated groups. Heart rates remained depressed in all four groups throughout the observation period. Model predictions mirrored the experimental recovery, and the model that combined volume, sequestration, and inotropy predicted in vivo results most accurately. CONCLUSION Intravenous lipid emulsion accelerates cardiovascular recovery from bupivacaine toxicity in a dose-dependent manner, which is driven by a cardiotonic response that complements the previously reported sequestration effect.
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Affiliation(s)
- Michael R Fettiplace
- From the Department of Anesthesiology, University of Illinois College of Medicine, Chicago, Illinois (M.R.F., R.R., and G.W.); Research and Development Service, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois (M.R.F., R.R., I.R., and G.W.); University of Illinois College of Medicine, Chicago, Illinois (M.R.F. and B.Z.); Department of Chemical Engineering, University of Illinois at Chicago, Chicago, Illinois (B.S.A.); University of Illinois College of Medicine, Peoria, Illinois (J.L.); and Section of Pulmonary, Critical Care, Sleep, and Allergy Medicine, Department of Medicine, University of Illinois College of Medicine, Chicago, Illinois (I.R.)
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He RR, Yao N, Wang M, Yang XS, Yau CC, Abe K, Yao XS, Kurihara H. Effects of histamine on lipid metabolic disorder in mice loaded with restraint stress. J Pharmacol Sci 2010; 111:117-23. [PMID: 19834283 DOI: 10.1254/jphs.09090fp] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The present study was conducted to investigate the effects of histamine on the lipid metabolic disorder in mice loaded with restraint stress. When Kun Ming (KM) mice were exposed to restraint stress for 20 h, the histamine level in both plasma and cerebral regions significantly increased (P<0.01). Moreover, when a lipid emulsion (10% Intralipid) was injected intravenously into the mice, the elimination period of plasma triglyceride was prolonged in the restraint group. Plasma triglyceride was 523 +/- 44 mg/dl at 35 min after the Intralipid administration in the restraint stress group, while it was 436 +/- 41 mg/dl in the restrained mice given histamine at a dose of 50 mg/kg. The improved plasma triglyceride metabolism was well explained by the observations of the significantly up-regulated hepatic triglyceride lipase (HTGL) activity and mRNA expression in response to histamine. These results suggested that the effects of stress-induced histamine on lipid metabolic disorder in mice loaded with restraint stress arose from its anti-stress action and promotion of lipase activity.
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Affiliation(s)
- Rong Rong He
- Institute of Traditional Chinese Medicine & Natural Products, Jinan University, Guangzhou, China
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Singer P, Berger MM, Van den Berghe G, Biolo G, Calder P, Forbes A, Griffiths R, Kreyman G, Leverve X, Pichard C, ESPEN. ESPEN Guidelines on Parenteral Nutrition: intensive care. Clin Nutr 2009; 28:387-400. [PMID: 19505748 DOI: 10.1016/j.clnu.2009.04.024] [Citation(s) in RCA: 672] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2009] [Accepted: 04/29/2009] [Indexed: 02/07/2023]
Abstract
Nutritional support in the intensive care setting represents a challenge but it is fortunate that its delivery and monitoring can be followed closely. Enteral feeding guidelines have shown the evidence in favor of early delivery and the efficacy of use of the gastrointestinal tract. Parenteral nutrition (PN) represents an alternative or additional approach when other routes are not succeeding (not necessarily having failed completely) or when it is not possible or would be unsafe to use other routes. The main goal of PN is to deliver a nutrient mixture closely related to requirements safely and to avoid complications. This nutritional approach has been a subject of debate over the past decades. PN carries the considerable risk of overfeeding which can be as deleterious as underfeeding. Therefore the authors will present not only the evidence available regarding the indications for PN, its implementation, the energy required, its possible complementary use with enteral nutrition, but also the relative importance of the macro- and micronutrients in the formula proposed for the critically ill patient. Data on long-term survival (expressed as 6 month survival) will also be considered a relevant outcome measure. Since there is a wide range of interpretations regarding the content of PN and great diversity in its practice, our guidance will necessarily reflect these different views. The papers available are very heterogeneous in quality and methodology (amount of calories, nutrients, proportion of nutrients, patients, etc.) and the different meta-analyses have not always taken this into account. Use of exclusive PN or complementary PN can lead to confusion, calorie targets are rarely achieved, and different nutrients continue to be used in different proportions. The present guidelines are the result of the analysis of the available literature, and acknowledging these limitations, our recommendations are intentionally largely expressed as expert opinions.
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Affiliation(s)
- Pierre Singer
- General Intensive Care Department and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Tikva, Israel
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Abstract
Total parenteral nutrition is the final option for nutritional support of patients with severe intestinal failure. Lipid emulsions constitute the main source of fuel calories and fatty acids (FAs) in parenteral nutrition formulations. However, adverse effects on patient outcomes have been attributed to the use of lipids, mostly in relation to impaired immune defenses and altered inflammatory responses. Over the years, this issue has remained in the limelight, also because technical advances have provided no safeguard against the most daunting problems, ie, infectious complications. Nevertheless, numerous investigations have failed to produce a clear picture of the immunologic characteristics of the most commonly used soybean oil-derived lipid emulsions, although their high content of n-6 polyunsaturated FAs (PUFAs) has been considered a drawback because of their proinflammatory potential. This concern initiated the development of emulsions in which part of the n-6 FA component is replaced by less bioactive FAs, such as coconut oil (rich in medium-chain saturated FAs) or olive oil (rich in the n-9 monounsaturated FA oleic acid). Another approach has been to use fish oil (rich in n-3 PUFA), the FAs of which have biological activities different from those of n-6 PUFAs. Recent studies on the modulation of host defenses and inflammation by fish-oil emulsions have yielded consistent data, which indicate that these emulsions may provide a tool to beneficially alter the course of immune-mediated conditions. Although most of these lipids have not yet become available on the US market, this review synthesizes available information on immunologic characteristics of the different lipids that currently can be applied via parenteral nutrition support.
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MESH Headings
- Coconut Oil
- Dietary Fats, Unsaturated/administration & dosage
- Dietary Fats, Unsaturated/immunology
- Fat Emulsions, Intravenous/adverse effects
- Fat Emulsions, Intravenous/chemistry
- Fat Emulsions, Intravenous/metabolism
- Fatty Acids, Omega-3/administration & dosage
- Fatty Acids, Omega-3/immunology
- Fatty Acids, Omega-6/administration & dosage
- Fatty Acids, Omega-6/immunology
- Fish Oils/administration & dosage
- Fish Oils/chemistry
- Fish Oils/immunology
- Humans
- Immune System/drug effects
- Lipid Metabolism/drug effects
- Lipid Metabolism/physiology
- Membrane Lipids/metabolism
- Olive Oil
- Parenteral Nutrition, Total/methods
- Plant Oils
- Soybean Oil/administration & dosage
- Soybean Oil/chemistry
- Soybean Oil/immunology
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Affiliation(s)
- Geert J A Wanten
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands.
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Ali AB, Chapman-Kiddell C, Reeves MM. Current practices in the delivery of parenteral nutrition in Australia. Eur J Clin Nutr 2006; 61:554-60. [PMID: 17106450 DOI: 10.1038/sj.ejcn.1602547] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine current practice in the delivery of parenteral nutrition (PN) in Australian hospitals. DESIGN A cross-sectional mail survey. SETTING Acute-care adult hospitals with greater than 200 beds in Australia. SUBJECTS A total of 67 hospitals (65.7% response rate). INTERVENTION Surveys were posted to hospitals. A reminder letter with a second copy of the survey was posted 3 weeks later to non-respondents. RESULTS Twenty-seven (40.3%) of the hospitals have a PN team and 50 (74.6%) have a hospital protocol for PN delivery. An inaccessible or non-functional gastrointestinal tract is the most common indicator for commencing PN. Fat infusion is calculated by 24 (38.7%) respondents with a mean (s.d.) maximum amount of fat provided of 2.0 (0.7) g/kg/day. Over half (n=35) reported calculating carbohydrate infusion at a maximum amount of 5.4 (1.0) mg/kg/min. Two-thirds (n=41) reported commencing PN at a rate of 50% or less of goal rate. Blood glucose levels (BGL) were monitored at least once per day by the majority of respondents (n=56, 83.6%). Insulin infusion was commenced at varying BGL. Most respondents (n=40, 59.7%) reported ceasing PN when at least half of the patient's requirements are being met either orally or enterally. A number of practice guidelines were identified and the results of the survey were compared with these guidelines. CONCLUSIONS Where there are clear practice guidelines, current practice appears to be in line with these recommendations, however, where evidence is lacking, practice is varied.
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Affiliation(s)
- A B Ali
- Nutrition and Dietetic Services, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
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Ton MN, Chang C, Carpentier YA, Deckelbaum RJ. In vivo and in vitro properties of an intravenous lipid emulsion containing only medium chain and fish oil triglycerides. Clin Nutr 2005; 24:492-501. [PMID: 16054521 DOI: 10.1016/j.clnu.2005.03.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2004] [Accepted: 03/03/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND & AIMS The triglyceride (TG) fatty acyl composition in lipid emulsions influences their metabolism. Little is known about the effects of long chain omega-3 polyunsaturated fatty acids (PUFA) on lipid emulsion metabolism. We investigated possible differences between omega-3 containing emulsions in their metabolism and tissue-targeting in vivo in a mouse model, and in vitro using lipolysis and cell culture experiments. METHODS Soy oil (LCT), MCT/LCT/omega-3 (5:4:1, wt/wt/wt), and MCT/omega-3 (8:2, wt/wt) emulsions were radiolabeled with nondegradable 1alpha,2alpha (n)-[3H] cholesteryl oleoyl ether to trace core particle metabolism in C57BL/6J mice following a bolus injection. Blood samples obtained over 25 min and extracted organs were used to measure the tissue distribution of lipid emulsion particles. Lipoprotein lipase (LpL)-mediated hydrolysis experiments and cell uptake studies in cultured J774 murine macrophages were also performed. RESULTS Blood clearance of 8:2 was 13.4% and 29.8% faster compared to 5:4:1 and LCT, respectively. LCT had greatest liver uptake. LpL-mediated hydrolysis was greatest in 8:2 and lowest in LCT. Overall, cell TG accumulation in the presence of apolipoprotein E was least with 8:2. CONCLUSIONS Our data shows that 8:2 had the most efficient blood clearance but less hepatic uptake in vivo. In vitro, 8:2 had both highest hydrolysis by LpL and intracellular TG utilization in the presence of apoE. Thus, an 8:2 lipid emulsion undergoes efficient blood clearance and may direct omega-3 PUFA more towards extrahepatic tissues.
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Affiliation(s)
- Mimi N Ton
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
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Abstract
Intravenous lipid emulsions often provide substance for the very low-birth weight or extremely low-birth weight infant that need total parenteral nutrition. The process used in this type of treatment as well as the effects of such treatment are discussed at length in this article. Some of the main compounds of representative lipid emulsions are listed and evaluated and the benefits and consequences of their use are presented.
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Affiliation(s)
- G Putet
- Neonatal Department, Hôpital Debrousse, Lyon, France
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Vers l'optimisation des substrats en nutrition parentérale. NUTR CLIN METAB 1999. [DOI: 10.1016/s0985-0562(99)80071-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
Substantial progress has been made in the understanding of the metabolism of intravenous lipid emulsions and the delivery of their various components to specific tissues or cells. Lipid emulsions should be considered not only as a means of providing energy substrates but also specific compounds that participate in the regulation of key metabolic functions. Such improved knowledge should find applications in the metabolic care of different types of patients.
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Affiliation(s)
- I E Dupont
- L. Deloyers Laboratory for Experimental Surgery, Free University of Brussels, Belgium
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