The authors randomized patients to an enteral diet containing glutamine, arginine, omega-3 fatty acids, and nucleotides or to an isonitrogenous, isocaloric diet to investigate the effect of septic outcome. A third group of patients, without enteral access but eligible by severity of injury, served as unfed controls and were studied prospectively to determine the risk of infection. Laboratory and clinical studies suggest that diets containing specialty nutrients, such as arginine, glutamine, nucleotides, and omega-3 fatty acids, reduce septic complications. Unfortunately, most clinical trials have not compared these diets versus isonitrogenous, isocaloric controls. This prospective, blinded study randomized 35 severely injured patients with an Abdominal Trauma Index > or = 25 or a Injury Severity Score > or = 21 who had early enteral access to an immune-enhancing diet ([IED] Immun-Aid, McGaw, Inc., Irvine, CA; n = 17) or an isonitrogenous, isocaloric diet (Promote [Ross Laboratories, Columbus, OH] and Casec [Mead-Johnson Nutritionals, Evansville, IN]; n = 18) diet. Patients without early enteral access but eligible by severity of injury served as contemporaneous controls (n = 19). Patients were evaluated for septic complications, antibiotic usage, hospital and intensive care unit (ICU) stay, and hospital costs. Two patients died in the treatment group and were dropped from the study. Significantly fewer major infectious complications (6%) developed in patients randomized to the IED than patients in the isonitrogenous group (41%, p = 0.02) or the control group (58%, p = 0.002). Hospital stay, therapeutic antibiotics, and the development of intra-abdominal abscess was significantly lower in patients receiving the IED than the other two groups. This improved clinical outcome was reflected in reduced hospital costs. An IED significantly reduces major infectious complications in severely injured patients compared with those receiving isonitrogenous diet or no early enteral nutrition. An IED is the preferred diet for early enteral feeding after severe blunt and penetrating trauma in patients at risk of subsequent septic complications. Unfed patients have the highest complication rate.

Thirteen obese patients requiring parenteral nutrition for postoperative complications were studied prospectively to evaluate the efficacy of hypocaloric, high-protein parenteral feeding. Nonprotein caloric intake averaged 881 kcal/d or 51.5% of the patients' measured resting energy expenditure. Protein intake averaged 2.13 ± 0.59 g/kg IBW. Serum albumin and TIBC increased significantly (2.8 ± 0.5 g/dL to 3.2 ± 0.4 g/dL, p < 0.01, and 196 ± 39 µg/dL to 248 ± 49 µg/dL, p < 0.05, respectively), and subjects lost weight (120.0 ± 60.0 kg to 109.7 ± 32.5 kg, p < 0.05). Nitrogen balance studies in eight subjects suggested nitrogen equilibrium or positive balance can be achieved (+2.4 ± 1.9 g/d). All patients exhibited complete tissue healing of wounds and abscess cavities and closure of fistulae. In obese, protein-depleted surgical patients net protein anabolism and clinical efficacy can be achieved with hypocaloric, high-protein feeding. Abundant endogenous fat stores provide obligatory energy.

Background: Due to the high prevalence of obesity in adults, nutrition support clinicians are encountering greater numbers of obese patients who require nutrition support during hospitalization. The purpose of this clinical guideline is to serve as a framework for the nutrition support care of adult patients with obesity. Method: A systematic review of the best available evidence to answer a series of questions regarding management of nutrition support in patients with obesity was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process, that includes consideration of the strength of the evidence together with the risks and benefits to the patient, was used to develop the clinical guideline recommendations prior to multiple levels of external and internal review and approval by the A.S.P.E.N. Board of Directors. Questions: (1) Do clinical outcomes vary across levels of obesity in critically ill or hospitalized non−intensive care unit (ICU) patients? (2) How should energy requirements be determined in obese critically ill or hospitalized non‐ICU patients? (3) Are clinical outcomes improved with hypocaloric, high protein diets in hospitalized patients? (4) In obese patients who have had a malabsorptive or restrictive surgical procedure, what micronutrients should be evaluated?

Objective To assess the resting energy-expenditure of hospitalized patients with pancreatitis. Design Prospective, case-referent study. Setting Nutrition support service in a university tertiary care hospital. Patients Patients referred to the Nutrition Support Service with the diagnosis of pancreatitis. Excluded from study entry included those with cancer, obesity (>150% ideal body weight), those measured within 3 postoperative days, or patients requiring ventilator support with an Fio₂ of >0.5. Forty-eight patients with either acute pancreatitis (n = 13), chronic pancreatitis (n = 24), acute pancreatitis with sepsis (n = 7), or chronic pancreatitis with sepsis (n = 7) were studied. The two septic groups were combined into a single pancreatitis-with-sepsis group, since no significant differences among measured variables were observed between individual septic groups. Interventions None. Measurements and Main Results Resting energy expenditure was measured by indirect calorimetry and compared with the predicted energy expenditure, as determined by the Harris-Benedict equations. Resting energy expenditure (percent of predicted energy expenditure) was significantly (p < .02) greater for patients with pancreatitis complicated by sepsis (120 ± 11%) compared with the nonseptic chronic pancreatitis group (105 ± 14%). Resting energy expenditure for the nonseptic acute pancreatitis patients (112 ± 17%) was not significantly different from the other groups. The septic pancreatitis group had the largest percentage (82%) of hypermetabolic (resting energy expenditure >110% of predicted energy expenditure) patients, whereas 61% and 33% of the acute and chronic pancreatitis groups were hypermetabolic, respectively (p < .02). Conclusions Resting energy expenditure is variable in patients with pancreatitis (77% to 139% of predicted energy expenditure). The Harris-Benedict equations are an unreliable estimate of caloric expenditure. Septic complications are associated with hypermetabolism and may be the most important factor influencing resting energy expenditure in pancreatitis patients. (Crit Care Med 1991; 19:484)