^ j uy nr i Tff JM.U1.1!1.1AJ!IU
REPORT DOCUMENTATION PAGE
1. REPORT NUMBER
4. TITLE (end Subtitle,)
Investigation of Intermediary Metabolisn and
Energy Exchange FoHewing Human Trauma >
9. PERFORMING ORGANIZATION NAME AND ADDRESS
College of Physicians & Surgeons of Columbia
University; 630 W. 168th Street, New York,
II. CONTROLLING OFFICE NAME ANO AODRESS
U.S. Army Medical Research and Development
BEFORE COMPLETING FORM
3. RECIPIENT'S CATALOG NUMBER
5.'TYPE of REPFRT a PERIOD covered
1/1/75 - 12/31/75
6. PERFORMING ORG. REPORT NUMBER
8. CONTRACT OR GRANT NUMBERfpJ
I DA-49-193-MD-2552( //
10. PROGRAM ELEMENT. PROJECT. TASK
AREA * WORK UNIT NUMBERS
12. REPORT OATE
October 7, 1976 /
13. NUMBER OF PAGES
*• MONITORING AGENCY NAME 4 ADDRESS^// different from Controlling Office) 15. SECURITY CLASS, (of thla report)
Uncla f sified
!•. SUPPLEMENTARY NOTE
81 8 18 129
IS. KEY WORDS (Continue on reverie aide ff necaaaary and Identity by block number)
Insulin, glucagon, portal blood, amino acids, glucose, regional metabolism,
fatty acids, triglycerides, parenteral nutrition
20. ABSTRACT (Continue me rereree It rrecooeory and Identity by block number)
Insulin to glucagon (I/G) ratios were found to be higher in portal than in
peripheral blood in human subjects in the postabsorptive state and after
injections of glucose or alanine. This reflects greater removal of insulin than
of glucagon by the liver. Nevertheless, peripheral I/G ratio provides an index
of the portal ratio since there is good correlation between the two.
Studies are in progress of the effects of total parenteral nutrition on
transport of glucose, amino acids, fatty acids and other substrates between
EDITION OF • NOV 88 IS OBSOLETE
_ Unclassified _
SECURITY CLASSIFICATION OF THIS PAGE (Whm Data Enlarcd)
SECURITY CLASSIFICATION OF THIS PAGEfK?t*n Data Enfarad)
liver and leg in depleted or septic human subjects. Coterminous measurements
are also rrade of nitrogen and energy balance and hormone concentrations.
Vfe plan to initiate studies of oxidation and clearance in human
subjects of intravenous fat emulsions labelled with C.
SECURITY CLASSIFICATION OF THIS PAOEfFTi»n E nfnd)
INVESTIGATION OF INTERMEDIARY METABOLISM AND
ENERGY EXCHANGE FOLLOWING HUMAN TRAUMA
Annual Summary Report
John M. Kinney, M.D.
October 7, 1976
U. S. ARMY MEDICAL RESEARCH AND DEVELOPMENT COMMAND
Washington, D. C. 20314
Contract No. DA-49-193-MD-2552
College of Physicians & Surgeons
New York, N. Y. 10032
Approved for public release; distribution unlimited
The findings in this report are not to be construed as an official
Department of the Army position unless so designated by other
■ October 7, 1976
. John M. Kinney, M.D.
I. REGIONAL SUBSTRATE UTILIZATION IN HUMAN INJUR* AND INFECTION
A. PORTAL AND PERIPHERAL INSULIN AND GLUCAGON
Gump, F. E., Gusberg, R. J. and Kinney, J. M.
(In collaboration with Dr. P. Felig,
Dept, of I>tedicine, Yale University)
Studies designed to evaluate substrate utilization have continued during
the past year. We have also utilized the molar-ratio between insulin and glucagon
(I:G ratio) in an effort to better define the balance between catabolism and anabolisn
in patients being fed by intravenous techniques. However, the IG ratio in peripheral
blood has not been as useful in assessing the nutrition state of patients cn total
parenteral nutrition (TPN) as originally hoped. Since the effects of glucagon are
primarily hepatic the IG ratio of portal as well as peripheral blood requires study.
The portal vein was catheterized via the obliterated umbilical vein in 5
patients during minor upper abdominal operations. The catheter was kept patent by
saline infusion and studies were performed on the 5th postoperative day at which time
the patients were afebrile, ambulatory and on a regular diet. Simultaneous determi¬
nations of portal and peripheral levels of glucose, insulin and glucagon were made
in the post absorptive state as in our previous studies and also after peripheral
injections of glucose (0.5g/kg) or L-alanine (0.15g/kg).
PORTAL-PERIPHERAL GLUCAGON RESPONSE TO GLUCOSE
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In all subjects the baseline I/G ratios were higher in portal than in peri¬
pheral blood (2.5 + 1.0 vs. 1.1 + 0.3, p ^.05). Following the injection of glucose
the I/G ratio increased as anticipated but this was far more marked in portal than
in peripheral blood (+1285% vs 853%). In the 2 patients receiving alanine, the
peripheral I/G ratio showed no significant increase while the portal ratio increased
The I:G ratios in portal and peripheral blood following injection of glucose
are shewn in Fig. 1. Fig. 2 shows the same ratios following the injection of alanine.
It as clear from these studies that the post absorptive I :G ratio in portal
blood is higher than in peripheral blood. In other words, even though the effect of
glucagon on carbohydrate metabolism is hepatic rather than peripheral, this is not
because of hepatic trapping of the hormone. In fact, glucagon passes through the
liver more readily then does insulin. After substrate infusion the portal I:G
ratio is more responsive than the peripheral ratio. This become evident after
alanine injection which resulted in a significant increase of the ratio in portal
but not in peripheral blood. However, the portal-pberipheral gradient for glucagon
was reasonably consistent with a mean value of 1.3 ± 0.1. The portal peripheral ratio
for insulin was 2.5 ± 0.3 and this is why the I:G ratio was higher in pcartal than
in peripheral blood. However, despite the higher portal I:G ratio, a significant
direct linear correlation was observed between portal and peripheral I :G ratios so
the peripheral ratio does reflect events in portal blood.
1W AO -, M 'b2
John M. Kinney, M.D.
B. HEPATIC AND PERIPHERAL SUBSTRATE Ui’ILl ZATION
Gunp, F.E., Elwyn, D.H. and Gusberg, R.J.
Vfe are currently extending these studies of substrate infusion with studies
of patients on TPN. The protocol calls for a least 13 days of 'iTN and patients
are selected for study only if they fall into one of three categories. The first
consists of acutely injured patients and this includes both traumatic and elective
surgical (greater than 5 on a scale of 10) injury. All studies have to be started
within 1 week of the injury, and there should be no evidence of significant infec¬
tion. Furthermore, the patients have to be in a normal nutritional state prior to
operation or injury. The second category v.ould be septic patients. Vte defined
this as patients with significant infections but not necessarily associated with
positive blood culture. All patients will be febrile with an elevated resting
metabolic rate (greater than 20% above the predicted normal value).
The third category consists of nutritionally depleted patients that are
afebrile with normal or below normal resting metabolic expenditure. Depletion will
be defined as weight loss of greater than 15% form the patient's normal or preinjury
Patients will be selected for the study because they are candidates for TPN.
For this reason no normal controls can be included although data for comparison will
be available from similar studies to be carried out in normal volunteers.
Initial studies are designed to provide quantitative information on the move¬
ment of specific substrates between the periphery (leg) and the splanchnic bed in
the three categories of patients listed above.
Prior Lw the actual study the patient will be on calorie and nitrogen balance
and be placed in the gas exchange canopy for indirect calorimetry. After an overnight
fast, hepatic, femoral vein and femoral arterial catheterization will be carried out.
The hepatic vein catheter will be passed through a small right antecubital cutdown
and passed into a major hepatic vein using a portable image intensifier. Splanchnic
blood flew (ESBF) will be determined by the indirect Fick technique using ICG.
Extremity blood flow will be estimated by an impedance technique. Calibration is
imperfect but Ganges in flow in the same patient would be readily detectable with
this method and even though more precise techniques have been deocribed, we feel
that this represents a reasonable approach in this clinical study. In seme instances
blood flow across a leg will be measured by dilution of ICG. The flew measurements
will be combined with splanchnic and extremity arterio-venous differences of glucose,
lactate, pyruvate, glycerol, amino acids, non-esterified fatty acids, ketone bodies
Approximately 15 ml of blood will be required for each sample from each
catheter. Hematocrits will be measured and aliquots of whole blood, plasma or red
cells will be taken immediately for the following determinations:
Amino Acids will be determined in picric acid or sulfosalicylic acid extracts
of whole blood, plasma, or red cells. An automated amino acid analyzer will be used,
modified from that previously described. A single column (Durrum DC-6, resin,
30 x 0.9 cm) is eluted with lithium citrate buffers. Qatput from two photocolori-
meters is converted to digital form, punched on paper tape and processed on a digital
computer using a Fortran program. The instrument can analyze 4 Samples per day.
Reproducibility (coefficient of variation is 5% or less for most amino acids. The
extract from 1 ml of plasma or blood is sufficient for duplicate determinations.
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a\ 49 -] 9 ':-D-rr>52
Jolin M. Kinney, M
Glucose will be determined in plasma or whole blood by a glucose oxidase
procedure (Glucostat, Vforthington Biochcsnicals).
Glycerol will be determined by an enzymatic procedure in plasma. Lactate
and pyruvate will be determined colorimetrically in perchloric acid extracts of
viiole blood by microenzymatic procedures.
Non-esterified fatty acids will be measured by titration of heptane
extracts of plasma according to the method of Dole.
Acetoacetate and B-hydroxybutrate will be determined enzymatically by 1 3
the methods of Williamson and ISellsnhy.
Urea will be determined using an automated colorimetric procedure for
the Technicon Auto Analyzer.
Arterial and hepatic venous levels of insulin and glucagon, arterial
levels of growth hormone and cortisol, and urinary excretion of catecholamines
will be determined.
Three sets (arterial, femoral venous and hepatic venous) of bloods will
be sampled over a 30 minute baseline period and then TPN will be initiated
at a rate of 2000 calories and 12 grams of nitrogen/24 hours. Blood sampling
frem the 3 catheters will be continued at hourly intervals for 4-6 hours
after which the catheters will be removed.
Arterial and femoral vein samples will then be taken at 1,2,4,8, and
14 days and weekly thereafter and analyzed for the same substrates and hor¬
mones. An effort will be made to study all patients for at least two weeks.
In selected patients a second hepatic vein catheterization will be
performed after the first week of TPN. In this way the serial determination
of lower --^i-i'cmity uptake or release of substrates can be correlated with
the splanchnic data at 3 points: prior to TPN, at the time of initiation
of TPN and after one week on TPN.
These measurements will provide a quantitative pattern cf hepatic
(splanchnic and extremity uptake and release of the substrates mentioned
in three categories of surgical catabolism. In addition the associated
splanchnic secretory pattern of insulin and glucaton in Units/minute can
Significance of the Work
Major research efforts have been devoted to characterizing the meta¬
bolic response to starvation, injury and sepsis and to develop ' rationale
for treatment programs based on this characterization. The studies described
above should advance these efforts in several ways: Combination of whole
body calorie and nitrogen balance studies with quantitative exchange of
substrates between skeletal muscle and the splanchnic bed. V3iile these are
primarily descriptive studies, they represent work that has yet to be carried
out in a systematic fashion in injured or septic man. Of equal importance
is the fact that the patients will be characterized so that differences
John M. Kinney, M.D.
(if present) between acute injury, major sepsis and chronic depletion will
' The splanchnic output of insulin and glucagon, the hormones concerned
with nutrient homeostasis, can be determined by hepatic vein catheterization
The long term significance of this work relates to the hypothesis
that the release of amino acid frcm muscle is actually desirable because it
provides the hepatotropic factors necessary for production of acute phase
proteins needed following injury. Quantitation of substrate movements and
the associated changes in hormone levels ard splanchnic output represents
the first step. The effect of exogenous hormones and a quantitative approach
to the role of the liver in providing the various circulating proteins and
enzymes necessary for a favorable response to injury should make it possible
to test this hypothesis.
II. TRACER STUDIES OF SUBSTRATE UTILIZATION
A. 14C-3OTRALIPID - CLEARANCE VS OXIDATION
Kinney, J.M., King, T.C. and Gurrp, F.E.
Intror* 1 v*-1 «n. .
'me metabolic response to injury and infection ccmmonly involves hyper¬
metabolism, hyperglycemia, increased nitrogen loss associated with shrinkage
of muscle tissue, and variable degrees of weight loss. During the past decade
there has a growing awareness of the importance of providing intravenous
nutrients uu offset the depletion which develops during this acute catabolic
The European experience with an intravenous fat preparation has been
confirmed by many countries as being beneficial but no intravenous fat prepara¬
tion is currently available in the United States. The effective utilization
of this material in acute surgical conditions scans wll established, however
the details of altered fat metabolism in acute catabolic states are poorly
understood. We prepose to use snail amounts of ^C-Intralipid as a test
material to assay the severity of change in specific reactions that are thought
to be sensitive to catabolic influences.
Basic Assumptions :
1. The clearance of chylcmicra frcm the blood stream of experimental
animals (dogs) follows a predictable and reproducible pattern. (1)
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John M. Kinney, M.D
g / 100 ml
Fig. CL Disappearance curves of 10% Intralipid R
in a healthy volunteer (T) and in a patient with
hypcrlipidacmia (II). The respective figures for the
exponential elimination rate k 2 ± S.E.M. and 1
Student’s t-value are given.
With some identifiable alterations, similar characteristic decay
curves are observed in humans. (2)
Trauma increases the clearance rate in man. (3,4)
An exogenous infusion of an emulsion of soybean triglyceride
(Intralipid) has clearance characteristics which, for practical
purposes, are identical with the chylcrrdcra. (1,4)
John M. Kinney, M.D.
5. /analysis of the clearance characteristics of ^-^C-labelled
Intralipid will allow a rapid and reasonably accurate indicator
of the decay curve of the Intralipid, hence chylamicra, in
various injured states.
6. Hie implications of accelerated clearance of chylcmicra frem
the bloodstream are quite different if the rate of oxidation
is also accelerated than if this is rot true.
Proposed Research :
We propose to admit surgical patients in one of the following
four categories for study.
1) Postoperative uncomplicated
2) Major skeletal trauma
3) Major sepsis
4) Depletion (loss of over 15% body wt.)
The studies will be performed in our Surgical Metabolism Unit and
related laboratories. The study of tracers doses of (40 uc) Intralipid
will include measures of expired as well as isolation and counting
of serial samples of blood, chylanira, glucose and perhaps fatty acids or other
circulating lipid materials if the degree of labelling permits.
Quest ions f or Investigation :
i. In what ways can the changing slope of the clearance rate curve
be correlated with varying types and extent of trauma?
? Do changes in slope of the clearance curves reflect other changes
in catabolic states: oxygen consumption, nitrogen excretion, etc?
3. Can the ratio of the transfer of label from fatty acid to expired
OC >2 and perhaps to circulating glucose be used as an indication
of the severity of catabolism?
4. Can the turnover of glycerol in the plasma and transfer of label
from glyceride labelled intralipid into circulating glucose be used
as a measure of the catabolic influence?
5. Is the transfer of carbon frem glycerol labelled triglyceride to
glucose increased whenever gluconeogenesis is accelerated frem
amino acids ( at times of increased urea systhesis and excretion)?
Ultimate Objectives :
A large body of experimental and clinical data has been developed by
Wretlind, Hellberg and associates which support the concept that a soybean
John M. Kinney, M.D.
emulsion (Intralipid) can provide an effective calorie source for intravenous
nutrition. However, there is general lack of information concerning the optimum
intake of calories with nitrogen to treat or offset the protein breakdown in
severe catabolic states. There is the additional need to establish what differ¬
ences exist betwaen carbohydrate ard fat in inproving a negative N balance.
1. Carlson, L.A. and Hallberg, D. Acta Physiol. Scand ., 59: 52-61, 1965.
2. Hallberg, D. Acta Physiol. Scand . Suppl. 254: 1-23, 1965.
3. Hallberg, D. Acta Physiol. Scand . 65: 153-63, 1965.
4. Carlson, L.A. In: Porter, R. and Knight J. Energy Metabolism in Trauma.
London: J. and A. Churchill, p. 161, 1970.
5. Wilmore, D.W., Moylan, J.A., Helmkamp, G.M. and Pruitt, B.A. Clinical
evaluation of a 10% intravenous fat emulsion for parenteral nutrition
in thermally injured patients. Ann. Surg . 178: 4, p. 503, 1973.