The purpose of this study was to ascertain the number of registered dietitians in Tennessee who perceive they are practicing at advanced levels versus those making recommendations only. Job satisfaction according to order writing privileges was also assessed. A five question survey was sent to hospitals meeting selection criteria. Thirty-three surveys (89%) were returned. Eighty-nine percent of dietitians with order writing privileges considered themselves to be advanced level practitioners compared to 60% in the group of dietitians who did not have order writing privileges. Dietitians with order writing privileges indicated greater job satisfaction compared to dietitians that did not have that privilege. Greater job satisfaction was reported with advanced level skills which included order writing privileges. This study may show the need for dietitians to pursue advanced level skills in order to be challenged by their work, which may improve job satisfaction, and advancement in the field of nutritional care.

Introduction : Les enfants prématurés ont la particularité de naître alors que leur développement est souvent incomplet et nécessite la mise en œuvre de soins intensifs visant à poursuivre leur croissance en dehors de l’environnement utérin. Souvent cependant, le stade développemental de l’enfant ne lui permet pas d’assimiler une alimentation entérale du fait de l’immaturité de son système digestif. Le recours à une voie centrale délivrant les nutriments assurant le développement devient alors une nécessité. Ce type de nutrition, appelée nutrition parentérale (NP, ou total parenteral nutrition TPN), permet l’administration de molécules simples, directement dans le sang du prématuré. Il n’est toutefois pas exempt de risques puisqu’exposée à la lumière, la NP peut s’oxyder et générer des molécules oxydantes telles que des hydroperoxydes lipidiques susceptibles de se fragmenter par la suite en hydroxy-alkénals. Ceci devient problématique au vu de l’immaturité des systèmes de défenses antioxydants du nouveau-né prématuré. L’utilisation prolongée de la NP est d’ailleurs à l’origine de maladie hépatiques dans lesquelles le stress oxydant et la nécro-inflammation sont des composantes majeures. Nous avons émis l’hypothèse que l’infusion chez les enfants prématurés, d’aldéhydes d’origine lipidique est en relation avec le développement du stress oxydant et de l’inflammation hépatique. Objectif : Notre étude a consisté à évaluer la relation entre les quantités d’hydroxy-alkénals dans la NP et les effets hépatiques engendrés sur les marqueurs de stress oxydant et les voies de signalisation responsables d’une induction de processus inflammatoire. Dans ce but, nous avons cherché à mesurer la peroxydation lipidique dans l’émulsion lipidique de la NP et la conséquence de l’infusion en continue d’hydroxy-alkénals sur les marqueurs de stress oxydant, sur la voie de signalisation médiée par le Nuclear Factor κB et sur le déclenchement du processus inflammatoire hépatique. A la suite de ce travail, nous avons également travaillé sur des alternatives à la photoprotection, qui est la seule méthode réellement optimale pour réduire la peroxydation des lipides de la NP, mais cliniquement difficilement praticable. Résultats : Nos résultats ont mis en évidence la génération de 4-hydroxynonenal in vitro dans la NP, ce phénomène est augmenté par une exposition lumineuse. Dans ce cadre, nous avons montré l’inefficacité de l’ajout de multivitamines dans l’émulsion lipidique comme alternative à la photoprotection. Dans la validation biologique qui a suivi sur un modèle animal, nos résultats ont permis de démontrer que l’augmentation des adduits glutathion-hydroxynonenal était imputable à l’augmentation de 4-hydroxynonenal (4-HNE) dans la NP, et non à une peroxydation endogène. Nos données indiquent que la probable augmentation hépatique des niveaux de 4-HNE a conduit à une activation du NFκB responsable de l’activation de la transcription des gènes pro-inflammatoires du Tumour Necrosis Factor-α (TNF-α) et de l’interleukine-1 (IL-1). Nous avons alors évalué la capacité d’une émulsion lipidique enrichie en acides gras polyinsaturés (AGPI) n-3 à baisser les concentrations de 4-HNE dans la NP, mais également à moduler le stress oxydant et les marqueurs pro-inflammatoires. Enfin, nous avons démontré, en collaboration avec l’équipe du Dr Friel, que certains peptides isolés du lait humain (par un processus mimant la digestion) permettent également une modulation du stress oxydant et du processus inflammatoire. Conclusion : Le stress oxydant exogène issu de la NP a conduit par activation de facteurs de transcription intra-hépatiques au déclenchement d’un processus inflammatoire potentiellement responsable du développement de maladies hépatiques reliées à la NP telle que la cholestase. Dans ce sens, les AGPI n-3 et les peptides antioxydants peuvent se poser en tant qu’alternatives crédibles à la photoprotection. / Introduction: Premature infants usually born before full term require intensive care to continue to grow up outside the uterine environment. Premature newborns are born with gastrointestinal systems that are too immature to absorb nutrients safely. Therefore they receive their initial nutrients through intravenous feeding, called total parenteral nutrition which delivers simple nutrients directly into bloodstream. However, light exposed-TPN can generate oxidant molecules such as lipid hydroperoxides, which can potently break up into hydroxy-alkenals. Prolonged use of TPN is also a cause of liver disease in which oxidative stress and necro-inflammation are major components. Thus, we hypothesize that lipid aldehydes contained in TPN are associated with oxidative stress and hepatic inflammation developments. Objectives: The aim of our study is to assess the relationship between quantities of hydroxyl-alkenals generated in TPN and effects on oxidative stress biomarkers and cell-signalling pathways molecules implicated in hepatic inflammation induction. To this end, we measure lipid peroxidation in the TPN lipid emulsion in and the consequence of continuous infusion of hydroxy-alkenals on markers of oxidative stress, on cell-signaling pathway mediated by the NFkB, and on liver inflammation induction. Following these data, we also worked on alternatives of photoprotection, which is the only optimal method for preventing lipid peroxidation, but unfortunately clinically impractical. Results: In vitro studies have highlighted the generation of 4-HNE in the TPN, increased under light exposure. In this context, we have demonstrated that the addition of multivitamins in the lipid emulsion cannot be a valuable alternative to photoprotection. Concerning the biological validation in our guinea pig animal model, our results demonstrated that the increase of GS-HNE adducts was due to increased 4-HNE in the TPN, and does not provide from endogenous peroxidation. Our data also indicate that the increase of hepatic 4-HNE led to an activation of NFkB, responsible for the activation of the transcription of proinflammatory genes TNF-α, IL-1. In the next study, we have evaluated the ability of a lipid emulsion enriched with n-3 polyunsaturated fatty acids (PUFA) to reduce 4-HNE concentrations generated in TPN, and to modulate oxidative stress markers and pro-inflammatory process on the same animal model. We also have demonstrated, in collaboration with Dr Friel’s team, that two antioxidant peptides (derived from a process mimicking digestion process of human milk) allow also a modulation of oxidative stress and inflammatory process in the liver. Conclusion: This form of exogenous oxidative stress from the TPN led to an inflammatory process resulting from the activation of intrahepatic transcription, which is potentially responsible of liver disease development such as cholestasis. In this sense, the n-3 PUFA and antioxidant peptides may arise as a valuable alternative of photoprotection.

Introduction: Le supplément d’oxygène et la nutrition parentérale (NP) sont les deux sources majeures de stress oxydant chez le nouveau-né. Lors de la détoxification des oxydants, le potentiel redox du glutathion s’oxyde. Notre hypothèse est que le supplément d’oxygène et la durée de la NP sont associés à un potentiel redox plus oxydé et à une augmentation de la sévérité de la dysplasie bronchopulmonaire (DBP). Patients et Méthodes: Une étude observationnelle prospective incluant des enfants de moins de 29 semaines d’âge gestationnel. Les concentrations sanguines de GSH et GSSG à jour 6-7 et à 36 semaines d’âge corrigé étaient mesurées par électrophorèse capillaire et le potentiel redox était calculé selon l’équation de Nernst. La sévérité de la DBP correspondait à la définition du NICHD. Résultats: Une FiO2≥ 25% au 7ième jour de vie ainsi que plus de 14 jours de NP sont significativement associés à un potentiel redox plus oxydé et à une DBP plus sévère. Ces relations sont indépendantes de l’âge de gestation et de la gravité de la maladie initiale. La corrélation entre le potentiel redox et la sévérité de la DBP n’est pas significative. La durée de la NP était responsable de 15% de la variation du potentiel redox ainsi que de 42% de la variation de la sévérité de la DPB. Conclusion: Ces résultats suggèrent que l’oxygène et la NP induisent un stress oxydant et que les stratégies visant une utilisation plus judicieuse de l’oxygène et de la NP devraient diminuer la sévérité de la DBP. / Introduction: oxygen supplementation and total parenteral solution (TPN) are two main clinical practices that sustain oxidative stress. Glutathione is a key molecule that detoxifies peroxides resulting in a more oxidized redox potential. We hypothesize that O2 supplementation and longer TPN duration are associated with both more oxidized redox potential and more severe bronchopulmonary dysplasia (BPD). Patients and methods: A prospective observational study including infants of less than 29 weeks gestational age. GSH and GSSG from whole blood sampled on day 6-7 and at 36 weeks of corrected age (CA) were measured by capillary electrophoresis and redox potential was calculated using Nernst equation. BPD was classified according to NICHD guidelines. Results: There was a significant association between FiO2 ≥ 25% on day 7 of life and TPN duration longer than 14 days and both more oxidized redox potential and more severe BPD. TPN duration explained both 15 % of total variation observed in redox potential and 42 % of total variation in BPD severity. These associations remained significant after adjustment for gestational age and illness severity. The relation between the severity of BPD and the redox potential in blood was not significant. The statistic power (1-β) to show an effect of redox potential on severity of BPD was 52%. Conclusion: Both redox potential of glutathione and BPD severity are both associated with early O2 supplement and TPN. Strategies targeting judicious use of O2 supplement and either decreasing the duration or using safer formulation of TPN are expected to help reducing BPD.

Introdução: Devido a diversos fatores, recém-nascidos prematuros, em sua maioria, necessitam de nutrição parenteral e uma fonte lipídica que possua um equilíbrio entre os variados tipos de ácidos graxos. SMOFlipid® 20%, uma nova emulsão lipídica pode ser mais adequada para esse equilíbrio. Objetivo: Avaliar o perfil de incorporação de ácidos graxos em eritrócitos de prematuros recebendo essa nova emulsão lipídica, comparada com outra emulsão baseada em óleo de soja. Métodos: Em um ensaio clinico controlado randomizado duplo cego avaliou-se 47 recém-nascidos pré-termo que receberam nutrição parenteral SMOFlipid® 20% (n=25) ou LIPOVENOS® MCT 20% (n=22). Foram avaliados parâmetros laboratoriais, clínicos, demográficos e o perfil de incorporação de ácidos graxos na membrana de eritrócitos. Resultados: Os parâmetros clínicos e demográficos como peso, perímetro cefálico, comprimento, idade gestacional e índice de Apgar não diferiram entre os grupos. Os valores de triglicerídeos e da lipoproteína de muito baixa densidade (VLDL) foram estatisticamente maiores no grupo SMOFLIPID® 20%. Níveis de Aspartato aminotransferase (AST) foram menores em ambos os grupos e os níveis de bilirrubina total e frações não tiveram diferenças. A emulsão SMOFlipid® 20% aumentou os níveis dos ácidos docosa-hexaenoico DHA (C 22:6 w3) e Eicosapentaenoico EPA (C 20:5 w3) na membrana dos eritrócitos. Conclusões: Neste grupo de recém-nascidos pré-termos, essa nova emulsão lipídica, além de mostrar segurança, contribuiu para uma mudança benéfica no perfil de incorporação de ácidos graxos nas membranas celulares, principalmente DHA e EPA / Introduction: Due to several factors, premature newborn infants, in most cases, require parenteral nutrition and a lipid source with balance among the different types of fatty acids. SMOFlipid® 20%, a new lipid emulsion may be more appropriate for this balance. Objectives: To evaluate the profile of fatty acids incorporation in erythrocytes of premature newborn infants receiving this new lipid emulsion compared with an emulsion based on soybean oil. Methods: In a randomized, controlled, double-blind clinical trial, 47 preterm newborn who received parenteral nutrition SMOFlipid® 20% (n=25) or Lipovenos MCT® 20% (n=22) were evaluated. Laboratorial, clinical and demographic parameters and the profile of incorporation of fatty acids in the erythrocyte membrane were evaluated. Results: The clinical and demographic parameters such as weight, head circumference, length, gestational age, and Apgar scores did not differ between the groups. The values of triglycerides and lipoprotein of very low density (VLDL) were statistically higher in the SMOFlipid® 20% group. Levels of aspartate aminotransferase (AST) were lower in both groups and levels of total bilirubin and fractions had no differences. The SMOFlipid® 20% emulsion increased the levels of the docosahexaenoic acid (DHA) and eicosapentaenoic (EPA) acid in the erythrocytes membrane. Conclusions: In this group of preterm newborn infants, this new lipid emulsion, besides showing security, contributed to a beneficial change in the incorporation profile of fatty acids cell membranes, especially DHA and EPA

1) Introdução: A subnutrição em pacientes hospitalizados é comum, independente das condições econômicas do país. Os pacientes gravemente doentes são altamente predispostos a desenvolver subnutrição. E a descontinuidade da administração da terapia nutricional (TN) em unidade de terapia intensiva pediátrica (UTIP) está associada a vários fatores como: distúrbios digestórios, interrupções para procedimentos diagnósticos/terapêuticos, bem como pausa para administração de medicamentos. Objetivo: Identificar as possíveis causas da infusão incompleta da terapia nutricional no paciente gravemente doente. Métodos: Estudo prospectivo, realizado entre abril de 2015 a abril de 2017, foi avaliado sequencialmente a oferta de terapia nutricional enteral e/ou terapia nutricional parenteral com ênfase no volume efetivamente não administrado e as possíveis causas de oferta incompleta da TN. Resultados: Foram avaliados 120 pacientes com média de Z-escore para peso/estatura (-0,5) e desvio padrão (4.12) que apresentaram perdas significativas de terapia nutricional enteral (TNE) e/ou parenteral (TNP) no primeiro e terceiro dias de administração. A principal causa de perda foi a interrupção por procedimentos ou complicações do paciente na unidade de terapia intensiva pediátrica (UTIP). Conclusões: 1) Ocorreu administração incompleta de TN no primeiro e terceiro dias de avaliação em crianças gravemente doentes. 2) Procedimentos e complicações digestivas foram causas importantes de administração incompleta de TNE. 3) Pausa para administração de medicamentos repercutiu na administração incompleta da TNP. 4) O estudo enfatizou a necessidade de envolvimento de todos os profissionais no processo para garantir o aporte de macro e micronutrientes durante a administração da TN / Introduction: Undernutrition is common among hospitalized patients regardless of the economic conditions of a given country. Severely ill patients are predisposed to experience undernutrition. And the discontinuity of nutrition therapy (NT) in the pediatric intensive care setting is associated with several factors, such as gastrointestinal disorders, interruptions for diagnostic/therapeutic procedures, and pauses for the administration of medications. Aim: To identify possible causes of incomplete infusion of nutritional therapy (NT) for severely ill patients. Methods: A prospective study, conducted between April 2015 and April 2017, was sequentially evaluated the offer of enteral nutrition therapy (ENT) and/or parenteral nutrition therapy (PNT) with emphasis on the volume not effectively administered and the possible causes of incomplete offer of (TN). Results: One hundred twenty patients with a mean Z-score for weight/height of 0.5 (standard deviation, 4.12) who presented significant losses of ENT and PNT nutrition on the first and third days of administration. The main cause of losses was interruptions due to procedures or complications of the patient in the pediatric intensive care unit (PICU). Conclusion: 1) Incomplete TN administration occurred on the first and third day of evaluation in critically ill children. 2) Digestive procedures and complications were important causes of incomplete administration of TNE. 3) Pause for administration of drugs has repercussions on incomplete administration of NPT. 4) The study emphasized the need to involve all professionals in the process to ensure macro and micronutrient inputs during TN administration

Propriedades biológicas de ácidos graxos poli-insaturados ômega-3 (AGPIs ômega-3), particularmente dos ácidos eicosapentaenoico (EPA) e docosahexanoico (DHA), sugerem seu benefício clínica em condições inflamatórias. A incorporação leucocitária de AGPIs ômega-3 é importante para que suas propriedades anti-inflamatórias ocorram. Comparado com administração por via digestiva, a infusão parenteral de emulsões lipídicas (EL) contendo AGPIs ômega-3 tem incorporação celular precoce. Experimentalmente, em ratos saudáveis, o pico de incorporação celular de AGPIs ômega-3 ocorreu 72 horas após a infusão parenteral de ELs contendo óleo de peixe como fonte de EPA e DHA. Em ratos a incorporação celular de AGPIs ômega-3 administrados por via parenteral foi mais rápida quando infundidos em conjunto com triglicérides de cadeia média (TCM) do que associados a AGPIs. Uma EL parenteral contendo quantidades elevadas de TCM (50%) em sua formulação tornou-se recentemente disponível para a prática clínica e poderia ser útil para facilitar a incorporação celular de AGPIs ômega-3. Nosso trabalho avaliou experimentalmente as modificações de incorporação leucocitária de AGPIs ômega-3 após infusão parenteral de nova EL contendo óleo de peixe e alto teor de TCM (grupo TCM / TCL / OP). Estudamos estas modificações em células mononucleares e polimorfonucleares após 48 e 72 horas de infusão e em comparação com EL experimental contendo a mesma quantidade de AGPIs ômega-3 e menor de TCM (grupo TCL / OP). Os resultados demonstraram que, após 48 h de infusão, o grupo OP apresentou menos ômega-6 do que o grupo TCM, enquanto as quantidades de ômega 3 eram similares tanto em células mono, quanto em polimorfonucleares. Após 72h, todos os grupos apresentaram diminuição no conteúdo de AGPIs ômega-6 e ômega-3. A razão entre ômega-6 / ômega-3 foi similar entre os grupos no tempo 48h e melhor no grupo OP no tempo 72h. Nossos resultados indicam que a presença de TCM na EL parenteral contendo OP parece não influenciar a dinâmica de incorporação leucocitária de AGPIs / Biological properties of omega-3 polyunsaturated fatty acids (omega-3 PUFA), particularly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), suggest its clinical benefit under inflammatory conditions. The leukocyte incorporation of omega-3PUFAs is important for its anti-inflammatory properties to occur. Compared with digestive administration, parenteral infusion of lipid emulsions (LE) containing omega-3 PUFAs has early cellular uptake. Experimentally, in healthy rats, the peak cellular uptake of omega-3 PUFAs occurred 72 hours after parenteral infusion of fish oil lipid emulsion (FOLE) as the source of EPA and DHA. In rats, the cellular uptake of parenterally administered omega-3 PUFAs was faster when infused together with medium chain triglycerides (MCT). A parenteral LE containing high amounts of MCT (50%) in its formulation become available for clinical practice and could be useful to facilitate the cellular uptake of omega-3 PUFAs. Our work experimentally evaluated the leukocyte incorporation modifications of omega-3 PUFAs after parenteral infusion of new FOLE and high MCT content (MCT / LCT / FO group). We studied these changes in mononuclear and polymorphonuclear leuckocytes after 48 and 72 hours of infusion and compared with experimental LE containing the same amount of omega-3 and lower MCT-PUFAs (LCT / FO group). The results showed that, after 48 h of infusion, the FO group had less omega-6 than the MCT group, whereas the omega 3 amounts were similar in both mono- and polymorphonuclear cells. After 72 h, all groups had a decrease in the content of PUFAs omega-6 and omega-3. The ratio of omega-6 / omega-3 was similar between the groups at time 48h and better in the FO group at time 72h. Our results indicate that the presence of MCT in FOLE does not seem to influence the leukocyte incorporation dynamics of omega-3 PUFAs

Introdução: A infusão parenteral de emulsão lipídica (EL) de óleo de peixe (OP), rica em ácidos graxos ômega-3 (AG n-3), está associada à diminuição do perfil de mediadores pró-inflamatórios em estudos experimentais e clínicos. AG n-3 se incorporam em poucas horas em membranas celulares e geralmente são administrados após a agressão inflamatória. A pancreatite aguda (PA) experimental é modelo de inflamação, local e sistêmico, bem estabelecido. Objetivo: O presente estudo avaliou o efeito da infusão parenteral de EL de OP por curto período, antes da indução de PA, sobre a modulação da resposta inflamatória sistêmica e sobrevida. Métodos: Após cateterização do sistema venoso central, ratos isogênicos Lewis receberam infusão parenteral de EL de óleo de peixe ou solução salina durante 48 horas, quando então foram submetidos à pancreatite aguda, pela injeção retrógrada de 0,5 mL de solução de taurocolato de sódio a 3% no duto pancreático. Após indução de PA, nos períodos de 2, 12 e 24 horas, os animais foram sacrificados para coleta de amostras de sangue e de tecidos para dosagem de marcadores inflamatórios e histopatológicos. Paralelamente, 20 animais de cada grupo foram observados até sete dias após indução de PA, para avaliação de sobrevida. Resultados: O tratamento com EL de óleo de peixe foi associado com diminuição de citocinas pró-inflamatórias IL-1beta (p=0,0006) e IL-6 (p=0,05), diminuição de IL-4 (p= 0,0019) e tendência no aumento de anti-inflamatória IL-10 (p= 0,06), após 24 horas de PA; e com aumento da expressão pulmonar e hepática de proteínas de choque térmico HSP 90, 2 e 12 horas após PA, respectivamente. Após infusão de EL de óleo de peixe, não foram encontrados efeitos sobre os níveis de malonaldeído no fígado e na histopatologia do pâncreas, no período de 2 e 12 horas pós pancreatite aguda; e na taxa de sobrevida, em relação aos demais grupos (p > 0,05). Conclusão: Nossos resultados sugerem que a infusão parenteral de EL de OP 48 horas antes da indução de pancreatite aguda experimental parece influenciar favoravelmente a produção de citocinas inflamatórias e HSP90 hepática e pulmonar, sem impactar sobre a histopatologia da lesão pancreática e a taxa de sobrevida / The parenteral infusion of fish oil (FO) lipid emulsion (LE), rich in omega-3 fatty acids (n-3 FA), is associated with the decrease of pro-inflammatory mediators profile in experimental and clinical studies. N-3 FA are incorporated in a few hours in cell membranes and are generally administered after the inflammatory injury. The experimental acute pancreatitis (AP) is an inflammation, local and systemic well-established model. This study evaluated the effect of parenteral infusion of fish oil LE for a short period before AP induction, on the modulation of systemic inflammatory response and survival. For this, after the central venous catheterization Lewis rats received parenteral infusion of fish oil LE or saline solution for 48 hours, when they were induced to acute pancreatitis by retrograde injection of 0.5 mL of sodium taurocholate at 3% in pancreatic duct. After AP induction, in periods of two, 12 and 24 hours, the animals were sacrificed to collect blood samples and tissues for measurement of inflammatory markers and histopathological. In parallel, 20 animals in each group were observed up to 7 days after induction of AP, for survival analysis. The treatment with fish oil LE was associated with decreased of pro-inflammatory cytokines IL-1beta (p = 0.0006) and IL-6 (p = 0.05), reduction of IL-4 (p = 0.0019) and upward trend of anti-inflammatory IL-10 (p = 0.06) after 24 hours of AP; and increased pulmonary and hepatic expression of heat shock proteins HSP 90 two and 12 hours after AP, respectively. After infusion of fish oil LE, there were no effects on malondialdehyde levels in the liver and the pancreas histopathology in the periods of 2 and 12 hours after acute pancreatitis; and survival rate, compared to the other groups (p > 0.05). Our results suggest that parenteral infusion of FOLE 48 hours before the induction of experimental acute pancreatitis appears to favorably influence the production of inflammatory cytokines; hepatic and pulmonary HSP90, without impacting on the histopathology of pancreatic injury and the survival rate

INTRODUÇÃO: Emulsões lipídicas parenterais (EL) contendo óleo de peixe podem modular favoravelmente a resposta inflamatória e manter ou promover a resposta imunológica, mas há dados insuficientes sobre seu impacto em funções de células da imunidade inata. OBJETIVO: Verificar o efeito da administração endovenosa de EL composta por mistura de triglicérides de cadeia média e óleos de soja, oliva e peixe sobre a migração e fagocitose de leucócitos de ratos, em comparação à EL composta por mistura física de triglicérides de cadeia média e cadeia longa - TCM/TCL, suplementada ou não com óleo de peixe (OP). MÉTODOS: Ratos (Lewis) isogênicos (n=40) foram submetidos à cateterização da veia jugular externa para acesso parenteral. Os animais foram randomizados em quatro grupos, de acordo com sua infusão endovenosa: grupo SMOF: EL contendo 30% de óleo de soja (TCL), 30% de TCM, 25% de óleo de oliva e 15% de OP; grupo TCM/TCL: EL contendo TCM e TCL (1:1 v/v); grupo TCM/TCL/OP: EL composta por TCM/TCL com adição de OP (8:2 v/v); grupo SF: solução fisiológica. Um grupo de animais sem cateterismo venoso também foi desenvolvido (CO-NC). No quinto dia de experimento e após injeção de carvão coloidal pela veia caudal, amostras de sangue e tecido (fígado, pulmão e baço) foram coletadas para análise quimiotática de neutrófilos (câmara de Boyden adaptada) e quantificação do número de macrófagos fagocitantes do carvão coloidal (imunohistoquímica). Os dados foram analisados por ANOVA e pós-teste de Tukey. RESULTADOS: SMOF não alterou a quimiotaxia e fagocitose nos leucócitos estudados. TCM/TCL e TCM/TCL/OP aumentaram o número de macrófagos fagocitantes do fígado e pulmão e somente TCM/TCL/OP apresentou aumento no número de macrófagos fagocitantes no baço (p<0,05). CONCLUSÕES: 1) Emulsões lipídicas, independente de sua composição, não influenciaram a quimiotaxia de neutrófilos; 2) Emulsão lipídica composta por mistura de triglicérides de cadeia média e óleos de soja, oliva e peixe apresentou efeito neutro sobre a quimiotaxia, migração espontânea de neutrófilos e recrutamento de monócitos no fígado, pulmão e baço; 3) Emulsão lipídica de mistura física de triglicérides de cadeia média e cadeia longa estimulou o recrutamento de monócitos, com aumento do número de macrófagos fagocitantes no fígado e pulmão; 4) Emulsão lipídica de mistura física de triglicérides de cadeia média e cadeia longa enriquecida com emulsão lipídica de óleo de peixe, estimulou o recrutamento de monócitos, com aumento do número de macrófagos fagocitantes no fígado, pulmão e baço. / RATIONALE: Parenteral lipid emulsions (LE) with fish oil could modulate inflammatory response and promote or maintain immunologic response, but there are insufficient data about the impact on innate immunity cells functions. AIM: To evaluate the effects of endovenous infusion of LE containing mixture of medium-chain triglycerides and soybean, olive and fish oils on leukocytes migration and phagocytosis in rats, compared to a physical mixture of medium and long-chain triglycerides - MCT/LCT LE supplemented or not with fish oil (FO). METHOD: Isogenic Lewis rats (n=40) were submitted to jugular vein catheterization for parenteral access. The animals were randomized in four groups, according to their infusion: group SMOF: LE containing 30% of soybean oil (LCT), 30% MCT, 25% olive oil and 15% fish oil; group MCT/LCT: LE containing MCT and LCT (1:1 v/v); group MCT/LCT/FO: MCT/LCT LE enriched with fish oil based LE (8:2 v/v); group SS: saline. A non-surgical control (CO-NS) was also performed. In the 5th experimental day and after colloidal carbon injection in tail vein, blood and tissue (liver, lung and spleen) samples were collected for chemotaxis assay (adapted Boyden chamber) and colloidal carbon phagocyting-macrophages quantification (immunohistochemistry). ANOVA and Tukey post test were performed. RESULTS: SMOF LE didn?t influence leukocytes chemotaxis and phagocytosis. MCT/LCT and MCT/LCT/FO LE increased liver and lung resident phagocyting-macrophages number (p<0.05) and only in MCT/LCT/FO group, spleen resident phagocyting-macrophages number was increased (p<0.05). CONCLUSION: 1) Lipid emulsion, independently of composition, has no influence on neutrophils chemotaxis; 2) Lipid emulsion with a mixture of medium-chain triglycerides, soybean, olive and fish oils has neutral effect on neutrophil chemotaxis, random migration and monocyte recruitment to the liver, lung and spleen; 3) Lipid emulsion with a physical mixture of medium and long-chain triglycerides has stimulatory effect on monocyte recruitment, with increase of phagocyting-macrophages number in liver and lung; 4) Lipid emulsion with a physical mixture of medium and longchain triglycerides supplemented with fish oil, has stimulatory effect on monocyte recruitment, with increase of phagocyting-macrophages number in liver, lung and spleen.

INTRODUÇÃO: O controle de qualidade em Terapia Nutricional Parenteral permite a identificação de processos inadequados em nutrição parenteral. O objetivo deste estudo foi avaliar a qualidade da prática de Terapia Nutricional Parenteral em um hospital geral brasileiro de grande porte com uma Equipe Multidisciplinar de Terapia Nutricional estabelecida. MÉTODOS: O presente estudo observacional, longitudinal, analítico e prospectivo analisou 100 pacientes adultos internados sob terapia nutricional parenteral e os cuidados de uma equipe multidisciplinar de terapia nutricional, durante 21 dias ou até a alta hospitalar/óbito. Durante esse período, a qualidade da terapia nutricional parenteral praticada foi avaliada em relação à conformidade de sua indicação com diretrizes internacionais (ASPEN 2007), à conformidade do volume de solução de nutrição parenteral prescrito com aquele efetivamente infundido, à conformidade com metas de indicadores de qualidade em terapia nutricional (IQTN; ILSI-Brasil) e à incidência de complicações mecânicas, metabólicas e infecciosas. A associação entre as diferentes variáveis estudadas foi testada por análise univariada, aplicando-se o teste exato de Fisher. A correlação com desfechos clínicos (alta / óbito) incluiu a análise de variância Anova (para grupos de doenças) e o teste Mann-Whitney (para adequação entre volume prescrito e volume recebido de solução parenteral). Para todas as análises adotou-se nível de significância de 5% (p < 0,05) e o programa SPSS 18,0 para Windows (SPSS, Chicago, IL, EUA) para sua condução. RESULTADOS: As indicações de terapia nutricional parenteral não estavam em conformidade com as orientações da ASPEN 2007 em 15 pacientes. Entre os 85 pacientes restantes, 48 (56,5%) não receberam terapia nutricional parenteral adequadamente (> 80% do volume total prescrita). Fatores significativamente associados com inadequação do volume de nutrição parenteral infundido (p < 0,005) foram: ordem médica independente da equipe multidisciplinar de terapia nutricional, progressão da terapia nutricional parenteral, mudanças no cateter venoso central, causas desconhecidas e desajustes operacionais (por exemplo, perda de prescrição médica, não entrega da solução de NP por atraso na farmácia, temperaturas inadequadas para infusão da solução de NP). Observou-se correlação inversa significativa entre o tempo de administração de volume adequado de nutrição parenteral com a ocorrência de óbitos; e correlação direta dessa variável com a ocorrência de alta hospitalar (p = 0,047). Os indicadores de qualidade em terapia nutricional relacionados a cálculo de necessidades energéticas e proteicas e níveis de glicemia atingiram as metas estipuladas pelos indicadores; no entanto, a taxa de sepse e infecção de cateter venoso central foi maior do que a meta por eles preconizada. As complicações associadas à terapia nutricional parenteral encontradas foram de natureza infecciosa, principalmente relacionadas a infecções do cateter venoso central (28,23%). CONCLUSÕES: Em um hospital geral brasileiro de grande porte, apesar da presença de uma equipe de suporte nutricional estabelecida, observou-se um nível moderado de inadequação na indicação, administração e monitoramento da terapia nutricional parenteral nele praticada. Alguns fatores externos ao controle da equipe multidisciplinar de terapia nutricional parecem ser responsáveis por essas inadequações. Essas observações reforçam a necessidade de rever a eficiência da equipe de suporte nutricional, principalmente quanto à sua inter-relação com os demais membros da equipe assistencial hospitalar / INTRODUCTION: Quality control in parenteral nutrition therapy allows the identification of inadequate processes in parenteral nutrition. The objective of this study was to assess the quality of parenteral nutrition therapy at a large Brazilian general hospital with an established nutrition support team. METHODS: This observational, longitudinal, analytical, and prospective study examined 100 hospitalized adult patients under parenteral nutrition therapy and the care of a nutritional support team for 21 days or until hospital discharge / death. During this period, the quality of practiced parenteral nutrition therapy was evaluated for compliance of its indication with international guidelines (ASPEN 2007), for compliance of the total volume of parenteral nutrition solution prescribed with that effectively infused, for compliance with the goals of quality nutritional therapy indicators (IQTN; ILSI-Brazil), and for the incidence of mechanical, metabolic and infectious complications. The association between the different variables was tested by univariate analysis, applying the Fisher\'s exact test. The correlation with clinical outcomes (discharge / death) included the analysis of variance ANOVA (for groups of diseases) and the Mann-Whitney test (for compliance between prescribed volume and received volume of parenteral solution). For all analyzes we adopted a significance level of 5% (p < 0.05) and applied the SPSS 18,0 for Windows (SPSS, Chicago, IL, EUA) for statistical comparisons. RESULTS: parenteral nutrition therapy indications were not in accordance with the ASPEN 2007 guidelines in 15 patients. Among the remaining 85 patients, 48 (56.5%) did not receive parenteral nutrition therapy properly (> 80% of the total volume prescribed). Non-nutritional support team medical orders, progression to and from enteral nutrition, changes in the central venous catheter, unknown causes and operational errors (e.g., medical prescription loss, parenteral nutrition non-delivery, pharmacy delays, inadequate parenteral nutrition bag temperature) were associated with parenteral nutrition therapy inadequacy (p < 0.005). There was a significant inverse correlation between the administration time of appropriate amount of parenteral nutrition with the occurrence of deaths; and a direct correlation of this variable with the occurrence of hospital discharge (p = 0.047). The Quality Indicators for Nutrition Therapy related to estimated energy expenditure and protein requirements and glycemia levels reached the expected targets; however, the central venous catheter rate was higher than 6 per 1000 catheters/day and did not meet the expected targets. Complications associated with parenteral nutrition were infectious in nature, mainly related to the central venous catheter infection (28.23%). CONCLUSIONs: In a large Brazilian general hospital, despite the presence of an established nutritional support team, there was a moderate level of inadequacy in the indication, administration and monitoring of the practiced parenteral nutrition therapy. Some factors external to the control of the multidisciplinary team of nutrition therapy appear to account for these inadequacies. These observations emphasize the need to review the effectiveness of nutritional support team, mainly regarding its interrelation with the other hospital care team members

Introdução: Devido a diversos fatores, recém-nascidos prematuros, em sua maioria, necessitam de nutrição parenteral e uma fonte lipídica que possua um equilíbrio entre os variados tipos de ácidos graxos. SMOFlipid® 20%, uma nova emulsão lipídica pode ser mais adequada para esse equilíbrio. Objetivo: Avaliar o perfil de incorporação de ácidos graxos em eritrócitos de prematuros recebendo essa nova emulsão lipídica, comparada com outra emulsão baseada em óleo de soja. Métodos: Em um ensaio clinico controlado randomizado duplo cego avaliou-se 47 recém-nascidos pré-termo que receberam nutrição parenteral SMOFlipid® 20% (n=25) ou LIPOVENOS® MCT 20% (n=22). Foram avaliados parâmetros laboratoriais, clínicos, demográficos e o perfil de incorporação de ácidos graxos na membrana de eritrócitos. Resultados: Os parâmetros clínicos e demográficos como peso, perímetro cefálico, comprimento, idade gestacional e índice de Apgar não diferiram entre os grupos. Os valores de triglicerídeos e da lipoproteína de muito baixa densidade (VLDL) foram estatisticamente maiores no grupo SMOFLIPID® 20%. Níveis de Aspartato aminotransferase (AST) foram menores em ambos os grupos e os níveis de bilirrubina total e frações não tiveram diferenças. A emulsão SMOFlipid® 20% aumentou os níveis dos ácidos docosa-hexaenoico DHA (C 22:6 w3) e Eicosapentaenoico EPA (C 20:5 w3) na membrana dos eritrócitos. Conclusões: Neste grupo de recém-nascidos pré-termos, essa nova emulsão lipídica, além de mostrar segurança, contribuiu para uma mudança benéfica no perfil de incorporação de ácidos graxos nas membranas celulares, principalmente DHA e EPA / Introduction: Due to several factors, premature newborn infants, in most cases, require parenteral nutrition and a lipid source with balance among the different types of fatty acids. SMOFlipid® 20%, a new lipid emulsion may be more appropriate for this balance. Objectives: To evaluate the profile of fatty acids incorporation in erythrocytes of premature newborn infants receiving this new lipid emulsion compared with an emulsion based on soybean oil. Methods: In a randomized, controlled, double-blind clinical trial, 47 preterm newborn who received parenteral nutrition SMOFlipid® 20% (n=25) or Lipovenos MCT® 20% (n=22) were evaluated. Laboratorial, clinical and demographic parameters and the profile of incorporation of fatty acids in the erythrocyte membrane were evaluated. Results: The clinical and demographic parameters such as weight, head circumference, length, gestational age, and Apgar scores did not differ between the groups. The values of triglycerides and lipoprotein of very low density (VLDL) were statistically higher in the SMOFlipid® 20% group. Levels of aspartate aminotransferase (AST) were lower in both groups and levels of total bilirubin and fractions had no differences. The SMOFlipid® 20% emulsion increased the levels of the docosahexaenoic acid (DHA) and eicosapentaenoic (EPA) acid in the erythrocytes membrane. Conclusions: In this group of preterm newborn infants, this new lipid emulsion, besides showing security, contributed to a beneficial change in the incorporation profile of fatty acids cell membranes, especially DHA and EPA