Nitrogen balance, 3-methylhistidine excretion, and plasma amino acid profile in infants after cardiac operations for congenital heart defects: The effect of early nutritional support

Chaloupecký, Václav; Hučín, B; Tláskal, T; Kostelka, Martin; Kučera, V.; Janoušek, Jan; Škovránek, J; Šprongl, Luděk

doi:10.1016/s0022-5223(97)70019-9

Cited by 23 publications

(31 citation statements)

References 21 publications

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“…Thus infants undergoing cardiac operations are an ideal group to study when trying to understand these phenomena. The 3MH:Cr levels in this study overall were similar to those in other published cohorts of children undergoing cardiac operations, and substantially higher than well neonates(7,35). …”

Section: Discussionsupporting

confidence: 88%

“…However, the most effective therapy to stem such catabolism remains unclear. Infants with congenital heart disease who undergo cardiac repair have substantial negative nitrogen balance and skeletal muscle loss (reflected by high urinary 3MH:Cr), which is reflected clinically by a high rate of failure to thrive(7). Thus infants undergoing cardiac operations are an ideal group to study when trying to understand these phenomena.…”

Section: Discussionmentioning

confidence: 99%

“…Nonetheless, the overall protein provision during the study period was poor and hence this essential cofactor for muscle protein preservation was likely lacking in this group. The first post-operative day was chosen for study because this is the interval during which protein loss appears to be at a maximum in this patient population(7, 44). Despite the lack of effect during the acute phase (<1 day after insult), it is possible that insulin administration during the convalescent phase of illness (which was not studied here) could preserve skeletal muscle.…”

Section: Discussionmentioning

confidence: 99%

“…The persistent negative nitrogen balance that follows is associated with impaired respiratory function, increased risk of infection, deficient wound healing, prolonged recovery time, and increased mortality(4-6). Neonates who undergo repair of congenital heart disease have substantial proteolysis and negative nitrogen balance with a peak during the first post-operative day(7). Though adequate nutritional provision improves nitrogen balance in critically ill patients, it appears to do so by increasing protein synthesis rather than minimizing protein loss, and does not completely reverse catabolism(3,8).…”

Section: Introductionmentioning

confidence: 99%

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Tight Glycemic Control With Insulin Does Not Affect Skeletal Muscle Degradation During the Early Postoperative Period Following Pediatric Cardiac Surgery*

Fisher¹,

Sparks

Khan

et al. 2015

Pediatric Critical Care Medicine

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Objective Critical illness is associated with significant catabolism and persistent protein loss correlates with increased morbidity and mortality. Insulin is a potent anti-catabolic hormone; high-dose insulin decreases skeletal muscle protein breakdown in critically ill pediatric surgical patients. However, insulin's effect on protein catabolism when given at clinically utilized doses has not been studied. The objective was to evaluate the effect of post-operative tight glycemic control and clinically-dosed insulin on skeletal muscle degradation in children after cardiac surgery with cardiopulmonary bypass. Design Secondary analysis of a two-center, prospective randomized trial comparing tight glycemic control with standard care. Randomization was stratified by study center. Patients Children 0-36 months who were admitted to the ICU after cardiac surgery requiring cardiopulmonary bypass. Interventions In the tight glycemic control (TGC) arm, insulin was titrated to maintain blood glucose between 80-110 mg/dL. Patients in the control arm received standard care. Skeletal muscle breakdown was quantified by a ratio of urinary 3-methylhistidine to urinary creatinine (3MH:Cr). Main Results A total of 561 patients were included: 281 in the TGC arm and 280 receiving standard care. There was no difference in 3MH:Cr between groups (TGC 249 ± 127 vs. standard care 253 ± 112, mean ± standard deviation in μmol/g, P=0.72). In analyses restricted to the TGC patients, higher 3MH:Cr correlated with younger age as well as lower weight, weight-for-age z-score, length, and body surface area (P<0.005 for each), and lower post-operative day 3 serum creatinine (r=-0.17, P=0.02). Sex, prealbumin, and albumin were not associated with 3MH:Cr. During urine collection, 245 patients (87%) received insulin. However, any insulin exposure did not impact 3MH:Cr (t-test, P=0.45), and there was no dose-dependent effect of insulin on 3MH:Cr (r=-0.03, P=0.60). Conclusion Though high-dose insulin has an anabolic effect in experimental conditions, at doses necessary to achieve normoglycemia, insulin appears to have no discernible impact on skeletal muscle degradation in critically ill pediatric cardiac surgical patients.

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Section: Discussionsupporting

confidence: 88%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Tight Glycemic Control With Insulin Does Not Affect Skeletal Muscle Degradation During the Early Postoperative Period Following Pediatric Cardiac Surgery*

Fisher¹,

Sparks

Khan

et al. 2015

Pediatric Critical Care Medicine

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“…Therefore, REE, but not TEE, represents the energy requirement that needs to be matched by nutrition supply in the acute phase of critial illness . Nonetheless, underfeeding to meet REE remains the norm in clinical management in children early after CPB …”

Section: Postoperative Nutrition Status Is Worsenedmentioning

confidence: 99%

Energy and Protein Requirements in Children Undergoing Cardiopulmonary Bypass Surgery: Current Problems and Future Direction

Zhang

Cui

et al. 2018

J Parenter Enteral Nutr

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Congenital heart disease (CHD) is 1 of the most common congenital malformations, and considerable numbers of infants and young children with CHD undergo cardiopulmonary bypass surgery. It has been increasingly realized that perioperative nutrition support plays an important role in improving clinical outcomes. The purpose of this review, by searching PubMed, was to examine the nutrition conditions in perioperative children with CHD and the main problems in nutrition management in the cardiac intensive care unit (CICU), based on which future directions were proposed. We found that preoperative poor nutrition status is common. This limited reserve of energy and protein is further compounded by the complex metabolic alterations with hypermetabolism, hypercatabolism, and hypoanabolism in the early postoperative course. Knowledge about energy and protein metabolism and requirements in children after cardiopulmonary bypass remains very limited. The current nutrition recommendations in the CICU are based on little evidence. Insufficient energy and protein supply to meet demands remains a norm in the immediate postoperative period. The commonly used predictive equations do not provide accurate estimate of energy requirement in individual patients during the highly dynamic postoperative course. Indirect calorimetry can provide the best estimate of energy requirements for children with CHD in the CICU. Measurement of nitrogen balance is the recommended method to determine the minimal protein requirement. During the early postoperative period, daily measurements of resting energy expenditure using indirect calorimetry and nitrogen balance in each individual child are essential to optimize energy and protein supply to meet requirements.

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Effects and Tolerance of Protein and Energy‐Enriched Formula in Infants Following Congenital Heart Surgery: A Randomized Controlled Trial

Cui

et al. 2017

J Parenter Enteral Nutr

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BackgroundNutrition support is important for clinical management to improve outcomes of infants following congenital heart surgery. Protein‐enriched and energy‐enriched formula (PE‐formula) may help provide adequate nutrition and promote wound healing. However, the effects and tolerance of increased protein and energy intakes of these infants have not been well defined.ObjectiveTo evaluate nutrition effects and tolerance of a PE‐formula compared with the standard formula (S‐formula) in infants in the first 5 days after congenital heart surgery. Methods: Fifty infants were randomly assigned to S‐formula (S‐group, n = 24) or PE‐formula (PE‐group, n = 26). Daily nutrient intakes and tolerance were recorded. Plasma amino acid concentrations were measured. Cumulative energy balance and nitrogen balance were calculated.ResultsNutrient intakes were significantly higher in the PE‐group after day 1, and all met the adequate intakes as early as day 2. Nitrogen balance in the PE‐group met positive balance from day 2, whereas in the S‐group, this was not until day 5. The PE‐group also had a significantly higher increase in many essential amino acids. With the exception of tolerable diarrhea (multivariate adjusted hazard ratio, 3.16; 95% confidence interval, 1.24–8.01), the PE‐group did not have a significantly higher incidence of intolerable events.ConclusionsIn infants during the early postoperative period after congenital heart surgery, early administration of PE‐formula was as well tolerated as S‐formula and effective in achieving higher nutrition intakes and earlier nitrogen balance. Further research is warranted to support the use of PE‐formula in this special group of infants.

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Nitrogen balance, 3-methylhistidine excretion, and plasma amino acid profile in infants after cardiac operations for congenital heart defects: The effect of early nutritional support

Abstract: Significant proteolysis and hypoaminoacidemia were observed in infants early after cardiac operations. This hypercatabolic response was blunted by parenteral nutritional support.

Cited by 23 publications

References 21 publications

Tight Glycemic Control With Insulin Does Not Affect Skeletal Muscle Degradation During the Early Postoperative Period Following Pediatric Cardiac Surgery*

Tight Glycemic Control With Insulin Does Not Affect Skeletal Muscle Degradation During the Early Postoperative Period Following Pediatric Cardiac Surgery*

Energy and Protein Requirements in Children Undergoing Cardiopulmonary Bypass Surgery: Current Problems and Future Direction

Effects and Tolerance of Protein and Energy‐Enriched Formula in Infants Following Congenital Heart Surgery: A Randomized Controlled Trial

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