Biomedical subjects
Publications and source records attributed to J Garnacho Montero.
Hemolytic-uremic syndrome is a disease of different etiology, characterized by thrombocytopenia, hemolytic anemia and renal failure. A case of lethal evolution that afflicted a 18 year old male is presented. The exceptional presentation with massive pulmonary hemorrhage highlighted.
Using the NBT-PBA test, we studied pancreatic exocrine function in two groups of patients: one group with acute pancreatitis of lithiasic origin that underwent cholecystectomy and other with pancreatitis of alcoholic origin. The test was performed at the time of the acute picture and later at one month, three months, six months and a year. Regardless of etiology, exocrine pancreatic function was always impaired after acute pancreatitis, no case showing recuperation at one month of the picture but some did at three months (64% of the lithiasis group and 25% of the alcoholic group). We also attempted to relate the recuperation of the exocrine pancreas with the amylase levels, leukocytosis and calcemia encountered in the acute phase. The only correlation found was a poorer and later recuperation in the patients with the lowest calcemia levels during the acute picture.
We have studied in a prospective manner the evolution of three urinary indices which measure protein catabolism: 3-methylhistidine, the creatinine level index, and the excretion of urinary nitrogen, the latter being calculated based on the excretion of urea in urine. These studies have been performed using healthy patients only being given parenteral nutrition. Our data shows a very significant decrease in 3-methylhistidine (p = 0.001) and in the excretion of nitrogen calculated (p = 0.026), there being a correlation among the differences between these two parameters.
The nutritional support is essential in the treatment of the septic patient, but the optimal substrates, have not been well defined, although several studies advise the use of solutions with a high proportion of branched amino acids. The use of lipids in the Parenteral Nutrition (PN) of these patients is presently accepted by all authors, although there is no consensus of the composition of the mix to be used. We have done a prospective, randomized study in a group of critical septic patients who received PN. All cases were used a solution with a high proportion of branched amino acids and glucose. 40% of the non-protein calories were administered as lipids. Based on this, two groups were formed. Group 1 medium chain triglycerides and long chain triglycerides (MCT/LCT) in a ratio of 1:1, and Group II LCT. After ten days, both groups showed an increase in hepatic cholestasis enzymes and an improvement of the parameters of protein anabolism and catabolism. Group 1 showed a significantly higher increase in the retinol birdring protein and the improvement of the nitrogen balance. Besides this, the global analysis of all the parameters of protein anabolism and catabolism showed a more favorable evolution, with statistical significance, in those who received MCT/LCT. Therefore, the MCT/LCT in the PN of the septic patient who is given a solution rich in branched amino acids, achieves a greater protein saving and a faster recevesy of the markers of protein synthesis, than those with LCT. Both groups show an increase in cholestasis enzymes.
Intravenous lipid emulsions as part of Total Parenteral Nutrition, are now standard in most centers. The most frequently used lipid formula contains predominantly long-chain triglycerides (LCT) of n-6 series . Controversy and concern exist about the immunosuppressive effects of this fuel source mainly based on experimental data because clinical studies are sparse. Some investigators have pointed out that this lipid emulsion impair monocyte, lymphocyte and neutrophil functions although these changes seem to be related to quantity and rate of lipid administration. A new lipid emulsion that contains 50% as medium chain triglycerides is available. The impact of this formula on immune function is unknown although some papers suggest that it produces less deleterious effects on immune response than the traditional lipid source. Prostaglandins and leukotrienes have numerous effects on immune functions and mediate many of the hemodynamic aspects of the metabolic response to injury. The use of n-3 fatty acids that produce less immunosuppressive eicosanoids have been studied in experimental model with hopeful results. Despite these conflicting data, almost all authors agree that there are no justification for withholding intravenous lipid therapy because they are safe and effective providing essential fatty acids with a high caloric content. Future studies are needed to define the precise composition of lipid emulsions that may vary in the different pathologic situations.
Septicemia causes multiple and often not very well understood metabolic alterations. In this sense it is controversial whether or not carnitine is decreased, which may have several implications. Our objective is to measure the plasma carnitine levels in septicemic patients, and to find out whether this is modified if there is a multi-organ dysfunction syndrome (MODS), or if it is dependent on the lipid source. For this we carried out a prospective study in septicemic patients with MODS. These were given exclusively parenteral nutrition (PN) without any carnitine supplementation. The PN of 16 patients contained long chain triglycerides (LCT's), while that of another 12 contained a 1:1 mixture of long and medium chain triglycerides (LCT's and MCT's). We measured the plasma carnitine level at the baseline, after 5 days and after 10 days, using an enzymatic method that measures the total carnitine level (free and esterified). The normal values lie between 35 and 70 mumol/l. We included 28 septicemic patients whose ages were 53.41 +/- 16.51 years, and whose APACHE II on admission was 17 +/- 4. The carnitine levels were: baseline: 60.4 +/- 23.7; 5th day 57.7 +/- 22.9; 10th day 55.7 +/- 21.2 (p = n.s.). Of these patients, 10 had an MODS of septic origins with their baseline levels being: 65.3 +/- 30.9; 5th day 60.3 +/- 23.2; 10th day 61.5 +/- 15.5; while the levels of the 18 septicemic patients without MODS, the baseline levels were 61.9 +/- 13.8; 5th day 58.6 +/- 19.1; 10th day 56.6 +/- 19.3 (p = n.s.). In the patients who were given LCT's the baseline carnitine level was 60.7 +/- 23.1, 5th day 60.1 +/- 23.8; 10th day 58.6 +/- 12.8; while those patients who were given LCT/MCT showed baseline levels of 64.3 +/- 19.5; 5th day 58.6 +/- 19.1; 10th day 57.8 +/- 10.7 (p = n.s.). In our septicemic patients the serum carnitine levels we found were within the normal range, and these remained unchanged during the ten days in those patients with MODS or with the lipid mixture used.