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Full text of "DTIC ADA1031206: Investigation of Intermediary Metabolism and Energy Exchange Following Human Trauma."

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REPORT DOCUMENTATION PAGE 


1. REPORT NUMBER 


4. TITLE (end Subtitle,) 


i : 



Investigation of Intermediary Metabolisn and 
Energy Exchange FoHewing Human Trauma > 


ft) 



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 
Ccttmand 


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BEFORE COMPLETING FORM 


3. RECIPIENT'S CATALOG NUMBER 

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5.'TYPE of REPFRT a PERIOD covered 

Annual 

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 

9 


*• 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 


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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. 



Unclassified 


SECURITY CLASSIFICATION OF THIS PAOEfFTi»n E nfnd) 







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AD 


INVESTIGATION OF INTERMEDIARY METABOLISM AND 
ENERGY EXCHANGE FOLLOWING HUMAN TRAUMA 


Annual Summary Report 


John M. Kinney, M.D. 


October 7, 1976 


Supported by 


U. S. ARMY MEDICAL RESEARCH AND DEVELOPMENT COMMAND 
Washington, D. C. 20314 


Contract No. DA-49-193-MD-2552 

College of Physicians & Surgeons 
Columbia University 
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 
authorized documents 


Unclassified 




w *» 

i 

■ October 7, 1976 

DA 49-193KD-2552 

. John M. Kinney, M.D. 

212-694-5814 

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 

PH PORTAL 



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T 









O 

<5 55 
< 

O 50 
ID 

d 45 
< «o 

% 35 

3 30 
a 



TIME (min) 


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 
by 60%. 

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 
weight. 


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 
and urea. 

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. 

, a 

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 
be calculated. 

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 




m 49-193MD-2L.52 
John M. Kinney, M.D. 


(if present) between acute injury, major sepsis and chronic depletion will 
be apparent. 

' The splanchnic output of insulin and glucagon, the hormones concerned 
with nutrient homeostasis, can be determined by hepatic vein catheterization 
techniques. 

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 
state. 


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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DA 49-193MD-2552 
John M. Kinney, M.D 


g / 100 ml 



TIME 

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) 







DA 49-193MD-2552 
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 



DA 49-193MD-2552 
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. 


REFERENCES 


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. 


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