Heitor Pons Leite, Werther Brunow de Carvalho, Mauro Fisberg
Nutritional and metabolic assessment
o f c ritic a lly ill c h ild re n
P e d ia tr iclCU
o f th e H o s p ita l d o S e r v id o r P llb lic o E s ta d u a l d e S lio P a u lo " F r a n c is c o M o r a to d e O liv e ir a " a n d H o s p ita lS lio P a u lo - U n iv e r s id a d e F e d e r a l d e S lio P a u lo , E s c o la P a u lis ta d e J t.1 e d ic in a - S lio P a u lo , B r a z il
In a p r o s p e c tiv e s tu d y , w ith th e o b je c tiv e o f d e te r m in in g th e m e ta b o lic p r o file , r e s p o n s e to n u tr ie n t s u p p ly , a n d r o le o f n u tr itio n a l a n d m e ta b o lic a s s e s s m e n t p a r a m e te r s in c h ild r e n a d m itte d to a p e d ia tr ic IC U , 1 1 p a tie n ts in th e a g e g r o u p 2 - 1 2 w e r e s tu d ie d . T h e a s s e s s m e n t w a s c a r r ie d o u t d u r in g th e fir s t 7 2 h o u r s o f a d m is s io n , a n d a g a in s e v e n d a y s la te r , a n d in c lu d e d th e fo llo w in g p a r a m e te r s : c a lo r ic s u p p ly ; n itr o g e n s u p p ly ; p r e a lb u m in s e r u m le v e l; u r in a r y u r e a n itr o g e n ; n itr o g e n b a la n c e a n d c r e a tin in e - h e ig h t in d e x . T h e e v o lu tio n o f th e p a r a m e te r s in th e tw o s ta g e s o f th e s tu d y s h o w e d th e fo llo w in g r e s u lts : T h e u r in a r y u r e a n itr o g e n m e d ia n v a lu e a t a d m is s io n w a s 7 .5 g/m2
o f c o r p o r e a l s u r fa c e , a n d d id n o t p r e s e n t s ig n ific a n t c h a n g e s s e v e n d a y s la te r . T h e r e w a s a s ig n ific a n t in c r e a s e in c a lo r ic s u p p ly fr o m 4 2 .9 to 7 0f3 k c a l/k g , a n d in n itr o g e n s u p p ly , fr o m 4 .7 to 1 0 .2g/m2 o f c o r p o r e a l s u r fa c e p 0 .0 1 . T h e le v e l o f n itr o g e n b a la n c e r o s e fr o m - 5 .6 to 2 .5 g /2 4 h ( p < 0 .0 3 ) , a n d th a t o f p r e a lb u m in , fr o m 1 6 .7 to 2 6 .3 mg/dl ( p < 0 .0 3 ) . T h e r e w a s a s ig n ific a n t r e d u c tio n in th e c r e a tin in e - h e ig h t in d e x , fr o m 8 6 .2 p e r c e n t to 5 5 .0 p e r c e n t p 0 .0 1 . T h e m a g n itu d e o f u r in a r y u r e a n itr o g e n e x c r e tio n a t a d m is s io n v a r ie d 2 .5 - 1 3 .8 g/m2 o f c o r p o r e a l s u r fa c e . B a s e d o n th is p a r a m e te r , it w a s n o t p o s s ib le to e s ta b lis h a c h a r a c -te r is tic m e ta b o lic p r o file fo r th e c o n d itio n s s tu d ie d . N o tw ith s ta n d in g a n in c r e a s e in th e p r o -te in a n d c a lo r ic s u p p ly , p r e a lb u m in le v e l a n d n itr o g e n b a la n c e o b s e r v e d in th e s e c o n d s ta g e o f th e s tu d y , th e p a tie n ts lo s t m u s c le m a s s a n d e n te r e d in to a m a ln u tr itio n p r o c e s s , p r o b a b ly d u e to in te n s e p r o te in c a ta b o lis m a n d th e p o o r r e s p o n s e to n u tr itio n s u p p ly th a t o c c u r s in m e ta b o lic s tr e s s .
U N IT E R M S : N u tr itio n a l a s s e s s m e n t. N u tr itio n a l s u p p o r t. N itr o g e n b a la n c e . P r e a lb u m in .
IN T R O D U C T IO N
T
h ep a r e n te r a ld e v e lo p m e n tn u tr itio no f n e wh a s le d to a n im p r o v e m e n tte c h n iq u e s in e n te r a l a n dinth e th e r a p e u tic s u p p o r t f o r c h ild r e n w ith a c u te
c o n d itio n s , a llo w in g th e b e n e f its o f n u tr itio n a l s u p p o r t
to b e f a v o r a b ly r e f le c te d in th e p a r a m e te r s o f h o s p ita l
e v o lu tio n . T h is h a s r a is e d in te r e s t in a n o b je c tiv e
Address for correspondence:
Heitor Pons LeiteDisciplina de Nutri9ao e Metabolismo
Depto de Pediatria - Escola Paulista de Medicina
Universidade Federal de Sao Paulo
Rua Loefgreen, 1 6 4 7 - Vila Clementino
Sao Paulo/SP - Brasil - CEP 04040-032
m e ta b o lic a n d n u tr itio n a l a s s e s s m e n t, w ith th e p u r p o s e
o f o p tim iz in g th e s u p p ly o f n u tr itio n a l s u p p o r t to th e s e
p a tie n ts .
T h e m e ta b o lic c h a n g e s r e s u ltin g f r o m in f e c tio u s
p r o c e s s e s o r a c u te in ju r ie s le a d to a m e ta b o lic r e s p o n s e
th a t d e e p ly a f f e c ts th e p r o d u c tio n , u s e a n d d e m a n d f o r
n u tr ie n ts a t th e c e llu la r le v e l. T h is r e s u lts in a r a p id
p r o c e s s o f m a ln u tr itio n , w ith s e v e r e c o n s e q u e n c e s f o r
th e p a tie n t.l I n th is s itu a tio n , a n u tr itio n a l a s s e s s m e n t
d o e s n o t o n ly d e te c t th e c h a n g e s in c o r p o r e a l
c o m p o s itio n a n d o r g a n ic f u n c tio n , c o n s e q u e n t to a p o o r
f o o d in ta k e , b u t a ls o id e n tif ie s th e c h a n g e s c a u s e d b y
a n in c r e a s e in th e c o n s u m p tio n , d e g r a d a tio n a n d lo s s
o f n u tr ie n ts , a n d th u s c a n b e c o n s id e r e d a n u tr itio n a l
a n d m e ta b o lic a s s e s s m e n t.
I n c lin ic a l p r a c tic e , th e r e s o u r c e s u s e d to a s s e s s
th e a d e q u a c y o f n u tr itio n a l s u p p o r t in a d u lt p a tie n ts
w ith m e ta b o lic s tr e s s a r e b a s e d o n a n a n th r o p o m e tr ic
S a o P a u lo M e d ic a l J o u r n a l/R P M 1 1 4 ( 3 ) : 1 1 5 6 - 1 1 6 1 , 1 9 9 6 L E IT E , H .P .; C A R V A L H O , W .B . & F IS B E R G , M . - N u tr itio n a l a n d
1 1 5 7
S T A T IS T IC A L A N A L Y S IS
T a b le 1
P a tie n ts a c c o rd in g to d ia g n o s is , u rin a ry u re a n itro g e n v a lu e s
(g/m2
o f c o rp o re a l s u rfa c e ) a n dn u tritio n a l s ta tu s a t a d m is s io n .
T h e W ilc o x o n l) te s t w a s u s e d in o rd e r to a n a ly z e th e v a ria tio n o f v a lu e s o f b io c h e m ic a l p a ra m e te rs , a n d th e c a lo ric a n d n itro g e n s u p p ly o b ta in e d in b o th p h a s e s o f th e s tu d y . V a lu e s a re e x p re s s e d in m e d ia n . T h e le v e l s e t fo r re je c tin g th e h y p o th e s is o f e q u a lity w a s 0 .0 5 (5 p e rc e n t). d i ffe re n c e b e tw e e n th e n itro g e n s u p p
I
y a n d th e m e a s u re d u ri n a ry e x c re tio n p lu s e s ti m a te d fe c a l e x c re tio n , w a s c a lc u la te d a c c o rd in g to W IL M O R E ? T h e c re a tin in e h e ig h t in d e x w a s e x p re s s e d b y th e fo rm u la : (m g o f c re a tin in e e x c re te d in 2 4 -h o u r u rin e b y th e p a tie n t d iv id e d b y m g o f c re a tin in e in 2 4 -h o u r u rin e o f a n o rm a l c h ild o f th e s a m e h e ig h t) x 1 0 0 . F o r in te rp re tin g v a lu e s o f c re a tin in e h e ig h t in d e x , th e s ta n d a rd o f n o rm a lity d e s c rib e d b y M E R R IT & B L A C K B U R N !! w a s a d o p te d . U rin a ry c re a tin in e w a s m e a s u re d b y th e a u to m a te d a lk a lin e p ic ra te m e th o d . S e ru m p re a lb u m in w a s m e a s u re d b y th e s im p le ra d ia l im m u n o d ifu s io n m e th o d , u s in g M -P a rtig e n p la q u e s (B o e h rin g @ ).U .U .N . N u tritio n a l s ta tu s
3 .9 W a s te d
7 .2 E u tro p h y
1 2 .5 E u tro p h y
6 .8 E u tro p h y
9 .7 E u tro p h y
1 0 .2 E u tro p h y
3 .4 W a s te d
7 .5 W a s te d
6 .9 W a s te d
1 3 .9 E u tro p h y
1 0 .5 E u tro p h y D ia g n o s is
G u illa in B a rre S y n d ro m e
C e re b e la r a s tro c y to m a p o s to p .
B o n e m a rro w a p la s ia /s e p s is
C e re b ra l a b s c e s s
H e a d tra u m a
P o ly tra u m a /h e a d tra u m a
H e a d tra u m a
M e n in g itis
M e n in g itis
P o lytra u m a /h e a d tra u m a
M e d u Ilo b la s to m a /p o s to p .
U .U .N .: U rin a ry u re a n itro g e n
P A T IE N T S A N D M E T H O D S
C h ild re n a d m itte d to th e p e d ia tric in te n s iv e c a re u n its o f th e H o s p ita l d o S e rv id o r P u b lic o E s ta d u a l d e S a o P a u lo a n d th e H o s p ita l S a o P a u lo - E s c o la P a u lis ta d e M e d ic in a w e re a s s e s s e d a s to th e ir m e ta b o lic a n d n u tritio n a l s ta tu s , a n d s u p p ly o f n u trie n ts . T h e s tu d y w a s a p p ro v e d b y th e e th ic s c o m m itte e s o f th e s e h o s p ita ls a n d w a s c o n d u c te d b e tw e e n S e p te m b e r 1 9 9 1 a n d J a n u a ry 1 9 9 3 . T h e a s s e s s m e n t w a s c a rrie d o u t d u rin g th e firs t 7 2 h o u rs o f a d m is s io n to th e IC U a n d a g a in s e v e n d a y s la te r. It in c lu d e d th e fo llo w in g p a ra m e te rs :
• a n th ro p o m e tric a s s e s s m e n t: w e ig h t a n d h e ig h t a t a d m is s io n .
• la b o ra to ria l a s s e s s m e n t: p re a lb u m in , u rin a ry u re a n itro g e n , n itro g e n b a la n c e , a n d c re a tin in e -h e ig h t in d e x (a t a d m is s io n a n d a g a in s e v e n d a y s la te r). C h i ld re n w h o h a d th e p ro s p e c t o f u n d e rg o i n g p a re n te ra l a n d /o r e n te ra l n u tritio n fo r a p e rio d o f s e v e n o r m o re d a y s w e re in itia lly in c lu d e d in th e s tu d y . T h e c rite ria fo r e x c lu s io n w e re : a g e u n d e r 3 m o n th s ; p a tie n ts w ith re n a l in s u ffic ie n c y ; h e p a tic in s u ffic ie n c y o r d ia rrh e a ; a n d th o s e w h o , in th e s e c o n d s ta g e o f a s s e s s m e n t, h a d h a d th e ir p ro te in a n d c a lo ric s u p p ly in te rru p te d o r re d u c e d in th e p re v io u s 4 8 h o u rs . O f th e 1 5 p a tie n ts in itia lly in c lu d e d , fo u r d id n o t c o m p le te th e s e c o n d s ta g e o f a s s e s s m e n t, a n d 1 1 p a tie n ts e ffe c tiv e ly p a rtic ip a te d . T h e a g e g ro u p ra n g e d fro m 4 to 1 2 y e a rs , w ith a m e d ia n o f 9 y e a rs . E ig h t w e re m a le a n d th re e w e re fe m a le .
T h e H o llid a y & S e g a r3 m e th o d w a s u s e d to
e s tim a te c a lo ric n e e d s . T h e p ro te in a n d c a lo ric s u p p ly a d m in is tra te d p a re n te ra lly a n d /o r e n te ra lly w a s re c o rd e d d a ily d u rin g th e c o m m itm e n t p e rio d in th e IC U . W e ig h t a n d h e ig h t a n d re s p e c tiv e ra tio s w e re c o m p a re d to W o rld H e a lth O rg a n iz a tio n s ta n d a rd s .4 A m o d ifie d W a te rlo w c rite ria w a s a d o p te d to c la s s ify n u tritio n a l s ta tu s .s ,c ,
U rin a ry u re a n itro g e n a n d c re a tin in e w e re m e a s u re d in 2 4 -h o u r u rin e (th e fo rm e r b y a u to m a te d u re a s e m e th o d ). N itro g e n b a la n c e , o b ta in e d b y th e a s s e s s m e n t, p la s m a tic p ro te in d o s a g e , n itro g e n b a la n c e a n d im m u n o lo g ic a l fu n c tio n te s ts .2
T h is s tu d y a im s to e v a lu a te th e n u tritio n a l a n d m e ta b o lic p ro file in re s p o n s e to a s u p p ly o f n u trie n ts a n d th e ro le o f m e ta b o lic a n d n u tritio n a l a s s e s s m e n t p a ra m e te rs in c h ild re n a d m itte d to a n in te n s iv e c a re u n it.
L E IT E , H .P .; C A R V A L H O , W .B . & F IS B E R G , M . - N u tritio n a l a n d m e ta b o lic a s s e s s m e n t o f c ritic a lly ill c h ild re n
Prealbum in
Nitrogen balance
Creatinin-height index
Adm ission
7
thday
Adm ission
7
thday
Adm ission
7
thday
11.4
10.0
-1.12
-2.5
68.9
55.0
41.0
43.0
-1.0
2.9
68.3
51.9
16.0
21.0
-1.5
-4.0
100,0
53.0
11.0
36.0
-10.0
-5.5
42.5
32.9
24.0
39.0
-2.7
-3.3
59.9
44.5
17.5
20.8
-12.4
5.7
99.3
55.9
41.0
43.0
-1.6
2.7
73.0
69.0
20.8
26.3
-8.8
0.3
100.0
74.2
16.7
14.3
-7.0
-4.1
86.2
99.6
14.3
12.1
-15.8
-4.9
90.0
41.6
11.4
31.2
-5.6
1.7
100.0
100.0
RESULTS
T a b l e
I
d i v i d e s p a t i e n t s a c c o r d i n g t o d i a g n o s i s a t a d m i s s i o n , u r i n a r y u r e a n i t r o g e n v a l u e s , a n d n u t r i t i o n a ls t a t u s a t a d m i s s i o n . P a t i e n t s s u f f e r i n g f r o m a s t r o c y t o m a ,
m e d u l l a r a p l a s i a , a n d m e d u l l o b l a s t o m a h a d b e e n g i v e n
c o r t i c o s t e r o i d s . T a b l e 2 s h o w s i n d i v i d u a l v a l u e s o f
b i o c h e m i c a l p a r a m e t e r s o b t a i n e d i n b o t h p h a s e s o f t h e
s t u d y . T a b l e 3 s h o w s t h e e v o l u t i o n o f n u t r i t i o n a l
p a r a m e t e r s a n d t h e r e s u l t s o f s t a t i s t i c a l a n a l y s i s . T h e
m e d i a n v a l u e o f u r i n a r y u r e a n i t r o g e n a t a d m i s s i o n w a s
7 . 5 g / m 2 o f c o r p o r e a l s u r f a c e , v a r y i n g f r o m 3 . 4 t o 1 3 . 9
g / m 2 . P r o t e i n a n d c a l o r i c s u p p l y a n d s e r u m p r e a l b u m i n
l e v e l s s h o w e d a s i g n i f i c a n t i n c r e a s e i n t h e s e c o n d p h a s e
o f t h e s t u d y , a s d i d n i t r o g e n b a l a n c e , a l t h o u g h i t
c o n t i n u e d t o b e a n e g a t i v e v a l u e . T h e r e w a s a s i g n i f i c a n t
r e d u c t i o n i n t h e c r e a t i n i n e - h e i g h t i n d e x . T h e e x c r e t i o n
o f u r e a n i t r o g e n i n u r i n e d i d n o t c h a n g e s i g n i f i c a n t l y i n
t h e s e c o n d s t a g e o f a s s e s s m e n t ; t h a t i s , p a t i e n t s
r e m a i n e d h y p e r c a t a b o l i c .
DISCUSSION
I n e i t h e r n u t r i t i o n a l o r m e t a b o l i c a s s e s s m e n t s , t h e
i d e a l p a r a m e t e r s h o u l d p r e s e n t g o o d s e n s i t i v i t y a n d
s p e c i f i c i t y b o t h i n t h e a s s e s s m e n t p r i o r t o t r e a t m e n t a n d
Sao Paulo M edical Journal/RPM 114(3): 1156-1161, 1996
i n t h e m o n i t o r i n g o f t h e r e s p o n s e t o n u t r i t i o n a l
i n t e r v e n t i o n . A t t h i s t i m e , t h i s p a r a m e t e r h a s n o t b e e n
d e v e l o p e d .
A l t h o u g h a n t h r o p o m e t r i c m e a s u r e m e n t s a r e
u s e f u l t o e v a l u a t e n u t r i t i o n a l c h a n g e s p r i o r t o
a d m i s s i o n a n d t o d o c u m e n t l o n g - t e r m t h e r a p e u t i c
e f f e c t s , t h e y d o n o t a d e q u a t e l y r e f l e c t t h e a c u t e
n u t r i t i o n a l c h a n g e s w h i c h o c c u r i n m e t a b o l i c s t r e s s
s i t u a t i o n s , s u c h a s t r a u m a , s e p s i s , a n d i m m e d i a t e
p o s t o p e r a t i v e p e r i o d o f m a j o r s u r g e r i e s . A l t h o u g h
t h e s e s i t u a t i o n s l e a d t o a r e d u c t i o n i n c e l l u l a r m a s s ,
t h e r e i s a n a b s o l u t e e x p a n s i o n o f e x t r a c e l l u l a r f l u i d
w h i c h r e s u l t s i n a n u n d e r e s t i m a t e d w e i g h t l o s s . W e i g h t
g a i n m a y a c t u a l l y o c c u r , c a u s e d b y f l u i d a c c u m u l a t i o n
i n t h e t h i r d s p a c e , d u e t o a n i n c r e a s e i n t h e p e r m e a b i l i t y
o f c a p i l l a r y e n d o t h e l i u m w h i c h o c c u r s i n t h e s e
s i t u a t i o n s . T h i s " e x t r a " f l u i d i s e l i m i n a t e d w i t h i n a
f e w d a y s , u n l e s s t h e r e i s a p e r s i s t e n c e o r e x a c e r b a t i o n
o f t h e m e t a b o l i c r e s p o n s e t o s t r e s s .
W e k n o w t h a t t h e u r i n a r y e x c r e t i o n o f p r o d u c t s
o r i g i n a t i n g f r o m t h e d e g r a d a t i o n o f s k e l e t a l m u s c l e
r e f l e c t s t h e i n t e n s i t y o f h y p e r c a t a b o l i s m a n d t h e e x t e n t
o f m e t a b o l i c r e s p o n s e t o s t r e s s .IO T h e u s e o f t h e f o r m u l a b a s e d o n t h e 2 4 - h o u r u r i n e u r e a n i t r o g e n i s u s e f u l i n
e s t i m a t i n g t o t a l l o s s e s o f n i t r o g e n , II a n d h a s b e e n u s e d t o a s s e s s t h e m a g n i t u d e o f m e t a b o l i c r e s p o n s e t o s t r e s s
i n a d u l t p a t i e n t s .'2
T h e m a g n i t u d e o f u r i n a r y u r e a n i t r o g e n e x c r e t i o n
o b s e r v e d a t a d m i s s i o n o f t h e s t u d i e d p a t i e n t s v a r i e d ,
d e p e n d i n g o n t h e i r p a t h o l o g i e s , b e i n g g r e a t e r i n
Table 3
Evolution of nutritional and metabolic parameters*.
P a ra m e te r A d m is s io n 7th d a y p
E n e rg y s u p p ly (k c a l/k g ) 4 2 .9 7 0 .3 p > 0 .0 1
N itro g e n s u p p ly (g /m2
) 4 .7 1 0 .2 p < 0 .0 1
P re a lb u m in (m g /d l) 1 6 .7 2 6 .3 p < 0 .0 3
U .U .N . (g /m2
2 4 h ) 7 .5 6 .9 N S
N itro g e n b a la n c e (g /2 4 h ) -5 .6 -2 .5 p < 0 .0 3
C re a tin in -h e ig h t in d e x (% ) 8 6 .2 5 5 .0 p < 0 .0 1
* M e d ia n v a lu e s N S : n o s ig n ific a n c e
p a tie n ts w ith s e v e ra l in ju rie s , a n d re fle c te d th e e x te n t
o f m u s c le p ro te in b re a k d o w n a n d h y p e rc a ta b o lis m . A
s tu d y o f h y p e rc a ta b o lic c h ild re n s h o w s c o m p a ra b le
v a lu e s , a n d a w id e v a ria tio n w a s a ls o o b s e rv e d , w ith
v a lu e s ra n g in g fro m 0 .9 9 to 1 3 .7 g /m 2 o f c o rp o re a l
s u rfa c e in 2 4 h o u rs .13
T h e h ig h v a lu e s o b s e rv e d in a
c h ild w ith m e d u lla r a p la s ia /s e p s is a n d in a n o th e r c h ild
w ith p o s to p e ra tiv e m e d u llo b la s to m a c a n b e e x p la in e d
b y th e fa c t th a t th e s e c h ild re n h a d b e e n g iv e n
c o rtic o s te ro id s , w h ic h m u s t b e ta k e n in to a c c o u n t w h e n
in te rp re tin g v a lu e s o f th is p a ra m e te r. C o rtic o th e ra p y
in c re a s e s th e u rin a ry e x c re tio n o f n itro g e n 14 a n d , in
th e p a tie n ts m e n tio n e d a b o v e , p ro b a b ly c a u s e d a n
a d d itio n a l e ffe c t o f th e d ru g o n th e h y p e rc a ta b o lis m
c a u s e d b y th e s e p s is a n d c ra n io to m y , re s p e c tiv e ly . T h e
u rin a ry u re a n itro g e n v a lu e o b ta in e d in a c h ild
s u ffe rin g fro m G u illa in -B a rre s y n d ro m e s u g g e s ts th e
e x is te n c e o f a h y p e rc a ta b o lic s ta te , p ro b a b ly trig g e re d
b y e n d o c rin e a n d in fla m m a to ry c o m p o n e n ts o f th e
d is e a s e . A n in c re a s e in u rin a ry u re a n itro g e n e x c re tio n
w a s a ls o o b s e rv e d b y R O U B E N O F F e t a l. 1 2 in a d u lts
w ith G u illa in -B a rre s y n d ro m e . In th a t s tu d y , th e
a u th o rs d ra w a tte n tio n to th e fa ls e im p re s s io n o f th e
m a in te n a n c e o f a g o o d n u tritio n a l s ta tu s in p a tie n ts
s u ffe rin g fro m th is d is e a s e ; ~ h is o fte n d e la y s th e o n s e t
o f a n a d e q u a te n u tritio n a l s u p p o rt.
N itro g e n b a la n c e , d e s p ite th e d iffic u ltie s in
c o lle c tin g u rin e fo r 2 4 h o u rs a n d in th e p re s e n c e o f
d ia rrh e a (fa c to rs w h ic h lim it its u s e w ith c h ild re n ), is
s tiII th e s i m p le s t a n d fa s te s t m e th o d to a s s e s s s h o
rt-te rm p ro te in m e ta b o lis m a n d to e v a lu a te th e e ffic a c y
o f n u tritio n a l tre a tm e n t in h y p e rc a ta b o lic p a tie n ts .
T ra n s p o rt p la s m a o r v is c e ra l p ro te in s a re in d ic a ti v e
o f p ro te in a n d c a lo ric m a ln u tritio n , a n d c a n b e u s e d
(p a rtic u la rly , th e p re a lb u m in ) to a s s e s s s u rg ic a l ris k s in
c h ild re n w h o u n d e rg o m a jo r s u rg e rie s . IS T h is p ro te in ,
1159
w h o s e 2 -d a y h a lf-life p ro v id e s a fa s t re s p o n s e to
c h a n g e s in p ro te in a n d c a lo ric s u p p ly , h a s b e e n s h o w n
to b e a g o o d p a ra m e te r in m o n ito rin g th e re s p o n s e to
n u tritio n a l s u p p o rt s u p p ly .1 6 .1 7
H o w e v e r, th e c o n c e n tra tio n s o f th e s e p ro te in s
d ro p ra p id ly in re s p o n s e to m e ta b o lic s tre s s .IX O th e r
fa c to rs , a p a rt fro m th e a v a ila b ility o f n u trie n ts , m a y
a ffe c t s e ru m c o n c e n tra tio n s o f v is c e ra l p ro te i n s .
T h e m o s t s ig n ific a n t fa c to r is th e re le a s e o f
m e d ia to rs o f m e ta b o lic re s p o n s e to s tre s s , w h ic h
re g u la te p ro te i n s y n th e s i s in h e p a to c y te s . A ti s s ~ e
le s io n s e e m s to p ro m o te th e p ro d u c tio n o f c y to k in e s
b y m a c ro p h a g e s , w h ic h in tu rn in d u c e s h e p a to c y te s
to in c re a s e p ro d u c tio n o f a c u te p h a s e p ro te in s a t
th e e x p e n s e o f th e tra n s p o rt p ro te in s y n th e s is . In
th is s tu d y , th e v is c e ra l p ro te in s y n th e s is , IS is
re p re s e n te d b y a n in c re a s e in p re a lb u m in le v e ls a n d
fo llo w e d th e p ro te in c a lo ric s u p p ly , b u t m ig h t h a v e
a ls o re fle c te d a d e c re a s e in th e in te n s ity o f th e a c u te
p h a s e re s p o n s e .
In s p ite o f th e in c re a s e s o b s e rv e d in : th e p ro te in
c a lo ric s u p p ly ; p re a lb u m in le v e ls ; a n d n itro g e n b a la n c e
in th e s e c o n d p h a s e o f th e s tu d y , p a tie n ts lo s t m u s c le
m a s s , a n d e n te re d in to a p ro c e s s o f m a ln u tritio n , w h ic h
w a s d e m o n s tra te d b y a d e c re a s e in th e ir c re a tin in e
-h e ig -h t in d e x . T h is m a ln u tritio n is d u e m a in ly to th e
in te n s e p ro te in c a ta b o lis m th a t o c c u rs in m e ta b o lic
s tre s s , a n d to th e p o o r re s p o n s e to n u tritio n a l tre a tm e n t.
T h e e ffe c ts o f h y p e rc a ta b o lis m m a y b e p a rtia lly
c o m p e n s a te d fo r b y a n in c re a s e in c a lo ric p ro te in
s u p p ly ,l,IlJ .2 o w h ic h , h o w e v e r, d o e s n o t g e n e ra lly m e e t
th e re q u ire m e n ts o f a n in c re a s e in m e ta b o lic d e m a n d s ,
a n d in tu rn s le a d s to lo s s o f m u s c le m a s s . T h e n e c e s s i ty
to re d u c e h y d ra tio n , fre q u e n t in g ra v e ly ill p a tie n ts ,
m a y lim it th e a d m in is tra tio n o f n u trie n ts , a n d
a g g ra v a te th e im b a la n c e b e tw e e n s u p p ly a n d d e m a n d .
In th is s tu d y , a s th e p a tie n ts w e re m a in ly c h ild re n
s u ffe rin g fro m c e n tra l n e rv o u s s y s te m c o n d itio n s
p re s e n tin g c e re b ra l e d e m a , it w a s n e c e s s a ry to re d u c e
flu id a d m in is tra tio n . T h is lim ite d th e ir n u trie n t s u p p ly
a n d d e m o n s tra te d th a t it is d iffic u lt to p ro v id e a d e q u a te
n u tritio n a l s u p p o rt to p a tie n ts u n d e r h y d ric re s tra in t.
C o n s id e rin g th e v a ria b ility o f p a th o lo g ie s a n d th e
s m a ll n u m b e r o f c h ild re n s tu d ie d in th is p a p e r, it w a s
n o t p o s s ib le to e s ta b lis h a c h a ra c te ris tic m e ta b o lic
p ro file . E v e n ta k in g in to a c c o u n t th e lim ita tio n s o f
a v a ila b le m e th o d s a n d th e e x is tin g d iffic u ltie s in
a p p ly in g th e m , a n o b je c tiv e n u tritio n a l a n d m e ta b o lic
a s s e s s m e n t is a n e s s e n tia l p a rt in n u tritio n a l s u p p o rt
p la n n in g , w h ic h , in te g ra te d w ith o th e r th e ra p e u tic
m e a s u re s , m a y c o n trib u te to re d u c in g m o rta lity a n d
L E IT E , H .P .; C A R V A L H O , W .B . & F IS B E R G , M .• N u tritio n a l a n d
m e ta b o lic a s s e s s m e n t o f c ritic a lly ill c h ild re n
m o rb id ity in c h ild re n a d m itte d to in te n siv e c a re u n its.
F u rth e r stu d ie s u sin g la rg e r a n d m o re h o m o g e n e o u s
sa m p le s a re n e e d e d to d e te rm in e th e m e ta b o lic p ro file
a n d to id e n tify m o re se n sitiv e a n d sp e c ific p a ra m e te rs
to a sse ss th e a d e q u a c y o f n u tritio n a l su p p o rt in c ritic a lly
ill c h ild re n .
ACKNOWLEDGMENT
T h e a u th o rs w ish to th a n k D r. S e rg io M a la m a n , o f
th e D e p a rtm e n t o f C lin ic a l P a th o lo g y a t th e H o sp ita l d o
S e rv id o r P u b lic o E sta d u a l d e S a o P a u lo , fo r h is su p p o rt.
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