Increased intestinal permeability associated with infection in burn patients

Thermal injury may be associated with disruption of normal gut barrier integrity. To test this hypothesis, we assessed intestinal permeability with the nonmetabolizable, poorly absorbed disaccharide lactulose, which is efficiently excluded by the normal intestinal mucosa. Permeability studies were performed in 15 burned patients (aged 18 to 67 years; mean burn size, 40%) and 11 healthy controls. Lactulose, 10 g, was administered enterally, together with 5 g of mannitol as a control, and urinary excretion rates were determined. Lactulose excretion and the lactulose/mannitol excretion ratio increased threefold (160 +/- 30 vs 57 +/- 7 mumol and 0.113 +/- 0.033 vs 0.035 +/- 0.005) in the infected patients (sepsis score, 10 +/- 2; burn size, 38% +/- 6%). In contrast, noninfected burn patients (sepsis score, 0) had permeability values similar to those of controls (66 +/- 10 mumol and 0.036 +/- 0.007). Permeability increased as the severity of infection increased. Infection in burn patients is associated with increased bowel permeability. The intestine may be a primary source of sepsis. Alternatively, the systemic response to infection may alter gut barrier function, which could facilitate translocation of bacteria and absorption of endotoxin.     

Prebiotic ingestion does not improve gastrointestinal barrier function in burn patients

Prebiotics increase intestinal levels of health-promoting bacteria implicated in decreasing pathogen colonization, stimulating immune functions and stabilizing gut barrier functions, parameters which are altered in burn patients. We propose that regular intake of a prebiotic, oligofructose (OF), might help to improve the altered gastrointestinal (GI) permeability observed in burn patients. A randomized, double-blind, controlled clinical trial was carried out in 41 burn patients (mean burn surface area=17.1+/-8.2%) who ingested daily 6 g of oligofructose (OF group) or sucrose as placebo (Control group) during 15 days. Gastrointestinal permeability to sucrose and lactulose/mannitol (L/M) was evaluated on days 1 (before treatment) 3, 7, 14 and 21. A permeability test was also performed in 18 healthy subjects as controls. Thirty-one patients completed the protocol (dropout rate=24.4%). Healthy subjects had a basal sucrose excretion of 21.3 mg (14.0-32.5 mg) and a basal L/M ratio of 0.017% (0.009-0.022%). Sucrose excretion increased 5-fold and L/M ratio 4.4-fold in burn patients on day 1 and these high levels of marker excretion decreased significantly throughout the study (p=0.016 and 0.000001, respectively). No differences between the OF and Control groups were observed for sucrose excretion or L/M ratio. In conclusion, the normalization of gastrointestinal permeability is not accelerated by prebiotic intake.     

Impaired cell-mediated immunity in the first week after burn injury: investigation of spontaneous blastogenic transformation, PHA, IL-2 response and plasma suppressive activity

This study investigated alterations of cell-mediated immunity induced by trauma, operative treatment and infections in a group of 19 burned patients with a mean burn size of 42 +/- 22 per cent of the body surface area. We tested peripheral mononuclear blood cells (PMBC) for spontaneous blastogenic transformation (SBT), phytohaemagglutinin (PHA) and interleukin-2 (IL-2) responsiveness. Plasma samples were also assayed for inhibition of mitogen stimulation of control PMBCs. Mean values were calculated for the acute postburn period (days 0-3) and the following 4 days, before the development of septic complications. SBT was significantly increased in all patients during the second period of investigation (days 4-7) in comparison to normal controls and during the acute phase. The response to mitogen stimulation (PHA) was significantly suppressed during days 0-7 and the plasma samples showed high suppressive activities following PHA stimulation of control lymphocytes during the course of the study. No significant differences in rates of SBT, PHA responsiveness and plasma suppressive activity were found between those patients who developed bacteraemia and those with negative blood cultures. The latter group showed higher reactivity to added IL-2 in comparison to normal controls. Surgical treatment immediately after trauma (fasciotomy; day 0 or 1) resulted in further increased immunosuppression (PHA and IL-2 response), whereas after necrectomy (days 4-7) the immunological parameters showed no significant differences. It can be concluded that neither rates of SBT nor response to PHA can be used to identify patients at high risk for infection during the first week postburn.(ABSTRACT TRUNCATED AT 250 WORDS)     

Topical flurbiprofen decreases burn wound-induced hypermetabolism and systemic lipid peroxidation

We studied the effect of the topical application of the nonsteroidal anti-inflammatory agent, flurbiprofen, on postburn hypermetabolism and systemic lipid peroxidation. Twelve sheep with a 15% total body surface third-degree burn were monitored over a 4-day postburn period. In six sheep, a single application of a 5% flurbiprofen cream was placed on the burn wound on day 3. Data were compared to both burned and nonburned controls (n = 6). All animals were killed on day 4. Oxygen consumption was increased at day 3 by 28% +/- 10% over the preburn value in all animals. Flurbiprofen significantly attenuated the increase in oxygen consumption, returning the value essentially to baseline by 12 hours after application. Lung and liver peroxidation, as measured by malondialdehyde, was significantly increased in the burned, nontreated sheep at day 4 from a control value of 45 +/- 9 and 110 +/- 12 to 60 +/- 6 and 310 +/- 71 nmol/gm tissue, respectively. In flurbiprofen-treated animals, values were 42 +/- 8 and 160 +/- 18 nmol/gm at day 4, significantly attenuated from burn alone. Protein-rich burn lymph flow remained fourfold increased in both groups, indicating a persistent increase in burn tissue vascular permeability, not modified by flurbiprofen. Burn wound biopsies revealed bacterial contents of less than 10(4) organisms/gram tissue in all animals. We conclude that topical flurbiprofen significantly decreases burn wound-induced systemic hypermetabolism and oxidant-induced lipid peroxidation seen at 3 days after burn injury, but does not attenuate the remaining local burn-wound vascular permeability.     

重组胰高血糖素样多肽2对烧伤大鼠肠黏膜的保护作用

目的验证重组胰高血糖素样多肽2（GLP-2）对严重烧伤大鼠的肠道保护作用。方法将SD大鼠随机分为正常对照组；烧伤对照组；重组GLP-2治疗组（重组治疗组），烧伤后4h皮下注射重组GLP-2，100nmol·kg^-1·d^-1；化学合成GLP-2治疗组（合成治疗组），烧伤4h后皮下注射合成GLP-2，剂量同上。每组6只大鼠。伤后第7天检测各致伤组大鼠肠黏膜通透性、肠黏膜湿质量与肠段及躯壳质量比、肠黏膜蛋白含量以及观察肠道组织病理学变化，正常对照组观察指标相同。结果重组治疗组及合成治疗组与烧伤对照组[（0．350±0．040）mg／m1]比较，大鼠肠黏膜通透性明显降低（P〈0．01），分别为（0．250±0．026）、（0．243±O．008）mg／ml；肠黏膜湿质量与躯壳质量比及肠黏膜蛋白含量明显增加，重组治疗组大鼠肠黏膜蛋白含量为（57．9±2．8）mg／g，高于合成治疗组（48．9±4．1）mg／g。与正常对照组比较，各致伤组大鼠伤后第7天肠黏膜绒毛明显变短脱落、排列紊乱、基底层变薄。重组治疗组损伤较烧伤对照组有所减轻，与合成治疗组大鼠无明显区别。结论重组GLp02与合成GLP-2，能减轻烧伤大鼠肠道损伤，具有明显的肠道保护作用。     

Suppressor T-cell levels are unreliable indicators of the impaired immune response following thermal injury.

The presence of increased levels of suppressor T cells after thermal injury and their relevance remain controversial. It is unclear whether suppressor T cells are the cause or result of sepsis complicating thermal injury. Spleen cells from a standardized murine burn model and sham burn controls were studied and the relationship between the levels of suppressor cytotoxic T cells (CD8, Lyt-2+), helper T cells (CD4, L3T4+), response to concanavalin A (ConA) and to phytohemagglutinin (PHA) and interleukin-2 (IL-2) production was examined. Mortality following infection via cecal ligation and puncture (CLP) of matched controls was also studied. At day 7 postburn, mean ConA (70 +/- 12% of control) and PHA response (58% +/- 5.2% of controls) and IL-2 production (43% +/- 5.4%) were significantly less than sham burn values (100%; p less than 0.05). However, the mean percentage of cells staining with anti-Lyt-2 and anti-L3T4 (9.1 +/- 0.59 and 13.9 +/- 0.65) was similar to the mean percentage in sham burn animals (9.4 +/- 0.65 and 16.6 +/- 1.1). Furthermore, no significant differences were observed between burned mice and controls in helper (17.3% +/- 1.8% burn vs. 21.2% +/- 1.7% sham) or suppressor cell levels (7.8% +/- 1.2% burn vs. 8.6% +/- 0.7% sham) or helper-suppressor ratios on day 10 postburn. Mortality of 20 litter-matched controls subjected to CLP on day 10 postburn was 90%, which was significantly greater than the sham burn mortality of 20%.(ABSTRACT TRUNCATED AT 250 WORDS)     

Testing intestinal permeability in rats with burns and administration of early enteral nutrition

Damaged intestinal mucosa in patients with extensive burns is one of the causes of the development of SIRS and MOFS. No unequivocal method has been established so far for assessment of the extent of damage of the intestinal mucosa. In the presented work the authors focus their attention on assessment of intestinal permeability in rats with burns. As their experimental method they used the lactulose-mannitol test (LAMA test). The animals were subjected to a deep burn with an extent of 20% body surface (TBSA). Then the LAMA test was performed 24, 48 and 72 hours after the burn. The rats were divided into groups: the first with a burn without enteral nutrition, the second with a burn and polymeric enteral nutrition and the last with oligomeric enteral nutrition. From the conclusions it is evident that a burn extending over 20% TBSA causes in the laboratory rat to experience impaired intestinal permeability. The work did not prove a significant difference between groups with and without enteral nutrition. Due to its simplicity speed, repeatability and high yield the LAMA test is a method which can be used in patients with burns in departments for the treatment of burns.     

Intestinal permeability is increased in burn patients shortly after injury

There is increasing direct experimental and indirect clinical evidence to indicate that under certain conditions intestinal barrier function may be lost in trauma victims. No direct measurements, however, have been performed in patients to determine whether intestinal permeability is increased shortly after a major thermal injury in the absence of infection. Fifteen hemodynamically stable burn patients with burns on more than 20% of their body surface (39% +/- 12%) had their intestinal permeability measured within 24 hours of injury with use of the two nonmetabolizable sugars lactulose and mannitol as permeability markers. Lactulose absorption was fourfold higher in the patients (223 +/- 54 mumol) than in the controls (58 +/- 11 mumole; p less than 0.02), whereas the lactulose/mannitol ratio was threefold higher (5.2 vs 1.7; p less than 0.05). Thus intestinal permeability was increased in patients with moderate to major burn injuries shortly after injury.     

Dynamic observation of the fibronectin content in plasma and subeschar tissue following burn

Plasma and subeschar Fn levels were measured by one-dimension rocket immunoelectrophoresis and hemagglutination assay. In 16 healthy individuals, the mean value of plasma Fn was 318.7 +/- 82 micrograms/ml. In 16 burn patients with burn extent over 50% there was a significant lower plasma Fn value in all cases on the 1 day postburn (197.2 +/- 69.5) and 1 week postburn (189.4 +/- 84). It returned to within normal range on the 2 or 3 weeks postburn. Plasma Fn decreased progressively before death in 7 non-survivors. In another 19 patients with minor burns (less than 50%) plasma Fn values were all within normal range. Fn level of subeschar tissue shown by the study, Fn sequestration at sites of tissue injury may serve as a physiologic role in wound healing, this may also contribute to a deficiency of Fn in the plasma that may decrease host defense function. The causes of reduction of plasma Fn in major burned patients with sepsis were briefly discussed.     

Effect of partial burn excision and closure on postburn oxygen consumption

We studied the effect of partial excision and wound closure on the postburn hypermetabolic state. A 25% of total body surface burn was produced in seven sheep. Oxygen consumption (VO2) was significantly increased to 215 +/- 44 ml/min/M2 by day 3 compared with baseline of 125 +/- 21 ml/min/M2. The calculated increase was the result of the increased cardiac index as the average oxygen (AvO2) difference remained relatively constant. Body temperature was not significantly increased. Plasma and burn lymph thromboxane B2 were significantly increased. On day 7, 60% of the burn was completely excised to fascia and covered with a full-thickness graft from a donor animal. The VO2 decreased to below preburn levels during the period of anesthesia but returned completely to the preexcision hypermetabolic state by 2 hours after anesthesia and remained at this level for the remaining 2-day postexcision period. Quantitative cultures of burn hide at day 7 postburn and of the remaining 10% of total body surface burn at 2 days after excision revealed values less than 10(5) bacteria/gram eschar. No positive blood cultures were evident. We conclude that postburn hypermetabolism, once developed, may be perpetuated by a burn of lesser size. Partial excision, therefore, does not appear to significantly decrease the hypermetabolic state if a substantial inflammatory wound remains. Infection is not necessary to perpetuate the increased VO2.     

The effect of short-term growth hormone treatment on growth and energy expenditure in burned children.

Delays in growth are commonly observed in children who have sustained a severe cutaneous burn. The reasons for this growth delay are not completely known, but in adults, plasma growth hormone (GH) levels have been shown to decrease after thermal injury. If this is also the case in severely burned children, the low GH levels may contribute to their chronic growth delay. We propose that treatment with rhGH may prevent this burn-induced growth delay. Height velocities were measured for up to 2 years after injury in 38 burned children (age 7+/-1 years) with a 64+/-2% total burn surface area (TBSA) burn and a 59+/-3% third-degree burn who received 0.2 mg/kg/day rhGH during hospitalization. These height velocities were compared to 41 burned children (age 8+/-1 years) with a 64+/-3% TBSA burn and a 60+/-3% TBSA third-degree burn who were treated similarly but did not receive rhGH. Height velocities and height percentiles were compared to standard height velocity and percentile nomograms of unburned children. To determine the effect of rhGH on energy requirements, resting energy expenditures (REE) were measured by indirect calorimetry and compared to values calculated from the Harris-Benedict equation. All data are presented as mean+/-S.E.M. No differences in average height percentile could be shown between those receiving GH and controls at admission and 6 months after burn. There was, however, a significant difference (P<0.05) in height velocity during the first 2 years after burn between GH (47th+/-6 percentile) and controls (32nd+/-5 percentile). For rhGH-treated children, the REE was elevated by 34+/-4% versus 35+/-5% for controls. Recombinant human GH, given during acute hospitalization, maintained growth in severely burned children who would otherwise experience a significant growth delay. Treatment with rhGH did not atttenuate their elevated REE.     

Protein loss across burn wounds

One factor contributing to negative nitrogen balance in burned patients is protein loss through the burn wound. There is, however, little information on the amount and type of protein lost by this route. This study was designed to quantitate protein loss through burn wounds. Multiple full- and partial-thickness burns on 29 patients were studied. Sampled burn sites were dried and occlusive sponge dressings (2' X 2') were applied and left in place for 1 hour. The central 1 square-inch portion of the dressing was then removed, rinsed in distilled water, and total protein, albumin, and globulin were measured in the water wash. Considerable protein losses were measured. These losses were greatest in the first 3 postburn days, being somewhat greater in full-thickness burns (0.98 +/- 0.82 mg/cm2/hr) compared to partial-thickness burns (0.59 +/- 0.41 mg/cm2/hr) during this period mean +/- SD). Subsequent to the first 3 postburn days, protein loss in all burn types decreased to a relatively steady rate of loss of approximately 0.25 mg/cm2/hr. Based upon these data, average daily protein losses during the first postburn week can be estimated by the following equation: 24-hour protein loss through burn surface (gm) = 1.2 X body surface area (m2) X % burn (%). On subsequent days, protein is lost at approximately half this rate. These data demonstrate significant protein losses through burn wounds greater than recent studies have considered. It is possible that inadequate nutritional replacement of these protein losses is partly responsible for the marked negative nitrogen balance of the early postburn period.     

烧伤早期口服谷胺酰胺颗粒剂对肠道黏膜保护作用的临床观察

目的观察烧伤患者早期口服谷胺酰胺(glutamine,Gln)颗粒剂对肠道黏膜的保护作用以及可能发生的不良反应.方法采用随机对照法,将患者分为实验组和对照组,每组10例,分别给予Gln颗粒剂和安慰剂,每日30g,分3次口服,共10d.实验前后分别测定血液中Gln水平、二胺氧化酶活性、肠黏膜通透性、内毒素水平,同时观察血、尿常规及肝肾功能等变化.结果两组患者用药前后的一般情况及肝肾功能间的差异无显著性意义;实验组用药前血浆Gln水平(361.17±169.98)μmol/L与用药后(582.22±180.80)μmol/L相比差异有非常显著性意义(P＜0.01),与对照组(250.78±81.27)umol/L相比,差异有显著性意义(P＜0.05);实验组用药前后及用药后两组的二胺氧化酶活性、肠黏膜通透性、内毒素水平相比较,其差异均有显著性意义(P＜0.05～0.01).结论Gln颗粒剂是安全有效的肠道保护药物,适宜在烧伤早期应用.     

Urinary excretion of carnitine in burned patients

Urinary excretion of carnitine was studied in 14 patients with burns. Both free and total carnitine were monitored during an 8-day period following the burn and in some of the patients during a longer period of time. The mean value of total urinary carnitine was increased six-fold on day 2 compared with controls. The mean values decreased during the 8-day period post burn although they were still significantly higher on the eighth day compared to the mean value of controls. Increased carnitine excretion was also observed after the first post-traumatic week. A significant relationship was found between the percentage burned surface area and the individual mean value of carnitine excretion during the 8-day period. The percentage of free carnitine in urine was higher in the patients than in the normal subjects. A significant negative correlation was found for the regression of the ratio of acyl carnitine to free carnitine and total carnitine in urine both in the patients and in the controls.     

Effects of granulocyte-macrophage colony-stimulating factor in burn patients.

We studied the effects of granulocyte-macrophage colony-stimulating factor in burn patients. Serial measurements of granulocyte oxidative function were obtained in treated patients and in a group of controls matched for age and total burn size. The administration of granulocyte-macrophage colony-stimulating factor resulted in a 50% increase in mean leukocyte counts. Both groups showed significant baseline increases in granulocytic cytosolic oxidative function. Treated patients showed normal stimulated cytosolic oxidative function, which was significantly depressed compared with that of untreated patients. Myeloperoxidase activity was increased in treated patients during the first postburn week but then declined to normal levels. Untreated patients had a significant increase in myeloperoxidase activity for the first 3 weeks following injury. Untreated patients exhibited a significant decrease in superoxide activity during the second 3 weeks following injury. Treated patients demonstrated normal superoxide activity.     

Serious wound infections in burned patients

Wound infections are a major problem in burned patients. To determine the rate of wound infection associated with initial wound size and the amount of open full-thickness wound, we prospectively studied all patients admitted within 1 week of burn injury during a 2-year period using weekly wound cultures. Wounds were treated with topical silver sulfadiazine and occlusive dressings. Burn wound excision and immediate grafting were initiated during the first postburn week. One thousand five hundred twenty-three patient weeks (483 patients) were evaluated. Serious burn wound infections developed during 55/185 patient weeks (42.3%) when the initial total burn (ITB) was greater than 40% body surface area (BSA). This decreased to 27/304 (8.9%) when the ITB was 21% to 40% and 60/1034 (5.8%) when the ITB was less than 20% BSA. Burn wound infections developed during 57/211 patient weeks (27.0%) when the initial full-thickness burn (IFB) was greater than 20% BSA. The rate of wound infection decreased to 73/776 (9.4%) when the IFB was 1% to 20% and to 12/536 (2.2%) when no IFB was present. We further analyzed the prevalence of serious wound infections in relation to the open wound size during the hospital course. Wound infections occurred during 47 of 96 patient weeks (49.0%) when the current full-thickness wound was greater than 10% BSA. The infection rate decreased to 76 of 594 (12.8%) and 17 of 833 patient weeks (2.0%) when the remaining full-thickness wound was reduced to 1% to 10% and less than 1% BSA, respectively (p less than 0.05). Early wound closure would appear to reduce the risk of serious wound infections, especially in patients with full-thickness burns.     

Atrial natriuretic polypeptide after burn injury: blood levels and physiological role in rats

To define the relationship between atrial natriuretic polypeptide and the physiological changes of water and electrolytes after burns, the changes in plasma hormonal levels, including atrial natriuretic polypeptide, and urinary water and sodium excretions were examined in burned rats. Further, to elucidate the physiological significance of atrial natriuretic polypeptide after burns, the effects of a specific antiserum against atrial natriuretic polypeptide were determined in burned rats. Plasma atrial natriuretic polypeptide levels in rats following 30 per cent BSA full skin thickness burns were elevated for sustained periods (432.3 +/- 156.5 pg/ml, P less than 0.01 on day 1 postburn, 244.5 +/- 73.7 pg/ml, P less than 0.05 on day 3 postburn). Urine volume and sodium excretion decreased significantly during the first 72 h after burns. On day 3 postburn, urine volume and sodium excretion began to increase significantly. Specific rabbit antiserum against atrial natriuretic polypeptide was injected into the burned rats during this diuretic phase. Significant inhibition of diuresis and natriuresis was observed after the injection of antiserum (27.5 +/- 2.4 per cen decrease in urine volume, 57.1 +/- 10.4 per cent decrease in sodium excretion). These results suggest that atrial natriuretic polypeptide plays a physiological role in the regulation of urinary water and sodium excretion after burns.     

荷负电气溶胶治疗Ⅱ度烧伤创面的临床效果及病理学观察

目的观察荷负电气溶胶(下称气溶胶)治疗Ⅱ度烧伤创面的效果。方法选择单纯浅Ⅱ、深Ⅱ度烧伤患者,随机分为:(1)气溶胶组:浅Ⅱ度180例、深Ⅱ度100例,伤后6h~2d开始用气溶胶治疗创面,l~2次/d,1.5h/次。(2)对照组:浅Ⅱ、深Ⅱ度患者各30例,常规治疗。(3)自身对照组:浅Ⅱ、深Ⅱ度患者各10例,同上用气溶胶治疗,但同一患者部分创面覆盖无菌金属片屏蔽气溶胶(屏蔽组),部分创面不屏蔽(非屏蔽组)。观察气溶胶治疗过程中患者创面的大体变化,治疗前后进行创面细菌培养,并监测其肝、肾功能及血生化指标有无改变。记录各组患者创面愈合时间。另制作深Ⅱ度烫伤大鼠模型,同前分为气溶胶组和对照组并治疗。取两组大鼠治疗前及治疗后1、2、3周的创面组织标本,作病理学观察。结果气溶胶治疗后患者创面渗出少,治疗前后均无细菌生长。总体来讲,气溶胶治疗前后患者肝、肾功能及血生化指标无明显改变。气溶胶组患者浅Ⅱ度创面伤后(6.3±1.6)d愈合,深Ⅱ度创面(15.1±3.1)d愈合,明显短于对照组相同深度创面[(11.3±1.4)、(21.2±1.4)d,P<0.01]。自身对照组中,相同烧伤深度的非屏蔽组与屏蔽组比较,创面愈合时间也明显缩短(P<0.01)。病理学检查显示,气溶胶组大鼠治疗后第3周皮肤结构已基本恢复正常,而对照组此时恢复较差。结论气溶胶能有效促进Ⅱ度烧伤创面的愈合且使用安全。     

Peripheral blood lymphocytes immunophenotype and serum concentration of soluble HLA class I in burn patients

The level of the soluble form of histocompatibility class I antigens, associated with beta(2)-microglobulin (sHLA-I) has been determined by an ELISA sandwich method in serum from burned patients (n=42) and healthy volunteers (n=30). The sHLA-I level was insignificantly increased in burn patients at the stage of burn shock (1284+/-324U/ml, mean+/-S.E.M.) and after day 28 postburn (1368+/-258U/ml) compared to volunteers (1150+/-90U/ml). At the same time a decrease of sHLA-I levels between 4 and 14 days (638+/-178U/ml) was determined (P<0.05). Increased levels of sHLA, though not significant, were detected in patients with TBSAB >70% in comparison to patients with TBSAB from 30 to 70% during burn shock (1493+/-528 and 1075+/-339U/ml, respectively). Expression of membranous HLA class I antigens (mHLA-I) in peripheral blood lymphocytes (PBLs) was assayed simultaneously by indirect immunofluorescence. The number of CD3(+), CD4(+), CD8(+), CD25(+), CD71(+) and CD26(+) lymphocytes was also evaluated. The expression of mHLA-I in PBLs was increased significantly in patients with TBSAB <70% at early postburn period. Daily monitoring showed that the relative numbers of CD25(+) and CD71(+) lymphocytes in patients varied greatly within short intervals of time during burn shock. The data obtained suggest that mHLA-I expression can reflect postburn lymphocyte activation. The serum content of sHLA-I does not depend on lymphocyte number or activated lymphocyte number in peripheral blood at burned patients.     

Glutamine supplementation of parenteral nutrition does not improve intestinal permeability, nitrogen balance, or outcome in newborns and infants undergoing digestive-tract surgery: results from a double-blind, randomized, controlled trial

OBJECTIVE: To assess the effect of isocaloric isonitrogenous parenteral glutamine supplementation on intestinal permeability and nitrogen loss in newborns and infants after major digestive-tract surgery. SUMMARY BACKGROUND DATA: Glutamine supplementation in critically ill and surgical adults may normalize intestinal permeability, attenuate nitrogen loss, improve survival, and lower the incidence of nosocomial infections. Previous studies in critically ill children were limited to very-low-birthweight infants and had equivocal results. METHODS: Eighty newborns and infants were included in a double-blind, randomized trial comparing standard parenteral nutrition (sPN; n = 39) to glutamine-supplemented parenteral nutrition (GlnPN; glutamine target intake, 0.4 g kg day; n = 41), starting on day 2 after major digestive-tract surgery. Primary endpoints were intestinal permeability, as assessed by the urinary excretion ratio of lactulose and rhamnose (weeks 1 through 4); nitrogen balance (days 4 through 6), and urinary 3-methylhistidine excretion (day 5). Secondary endpoints were mortality, length of stay in the ICU and the hospital, number of septic episodes, and usage of antibiotics and ICU resources. RESULTS: Glutamine intake plateaued at 90% of the target on day 4. No differences were found between patients assigned sPN and patients assigned GlnPN regarding any of the endpoints. Glutamine supplementation was not associated with adverse effects. CONCLUSIONS: In newborns and infants after major digestive-tract surgery, we did not identify beneficial effects of isonitrogenous, isocaloric glutamine supplementation of parenteral nutrition. Glutamine supplementation in these patients therefore is not warranted until further research proves otherwise.