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Chapter 5, Part 1

Medical Science Publication No. 4, Volume II

WEDNESDAY MORNING SESSION
28 April 1954

MODERATOR
STANLEY M. LEVENSON, M. D.


NUTRITION OF THE INJURED*

STANLEY M. LEVENSON, M. D.

Last week, in the discussions of the care of patients with severe battle wounds and renal failure, mention was made of the serious nutritional problems encountered in these patients. You will recall that weight losses of 20 to 30 pounds in 2 to 4 weeks were frequent and losses up to 45 pounds in the same period of time were not uncommon (table 1).

Table 1. Wound Healing in Patients with Renal Dysfunction

Group

Number of patients

Weight loss (lbs.)

Number of deaths

Average day of death

Patients with unimpaired wound healing

11

20-30

0

-----

Patients with impaired wound healing

31

30-45

16

15

Malnutrition was not limited, however, to wounded soldiers with concomitant renal failure but was observed in many seriously wounded patients with renal failure. In general, the more severe the injury, the greater the nutritional disturbance. Where malnutrition developed, a number of complications ensued: Gastrointestinal and hepatic functions were impaired, wound healing was delayed, infection was more serious, morbidity was prolonged and mortality was increased.

Several factors are involved in the development of malnutrition following injury. Derangements in water, electrolyte, vitamin, fat carbohydrate and protein metabolism occur. Characteristically, an injured individual excretes excessive amounts of nonprotein nitrogen in his urine for 3 to 7 weeks following injury. During this time he is in negative nitrogen balance and is gradually losing body protein. The intensity and duration of this period of protein depletion depends on a number of factors, among which are the extent of the injury and the state of the individual at the time of injury. However, we still are not entirely clear as to what the basic mechanism is for


*Presented 28 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington,
D. C.


198

FIGURE 1.

the metabolic derangements after injury. There are a number of factors involved, including imbalance of endocrine activity, immobilization and reduced dietary intake. The possibility that a disturbance in the metabolism of one or more of the essential amino acids is one of the important factors in the pathogenesis of the increased catabolism following injury was suggested a number of years ago by various investigators. However, there have been no conclusive data in this regard. Plasma amino acids have been little studied in the past for lack of appropriate methods. In the past few years, with the advent of ion exchange chromatography, it has become possible to separate quantitatively each of 18 amino acids, and to study their quantitative relations to the other plasma NPN components.


199

We have been investigating these problems in battle injuries with and without associated renal failure. Samples of plasma were collected at the 46th MASH and at the 11th Evacuation Hospital. These samples were immediately frozen and shipped in the frozen state to the Army Medical Service Graduate School.

It has been previously thought that trauma of various types is followed by a general rise in plasma amino acids. We have found that such is not the case. For example, in patients with battle wounds and renal dysfunction, the total nitrogen of the free amino acids remained very close to normal, in spite of extremely high NPN's-some higher than 400 mg. per 100 cc. (fig. 1). Examination of the individual amino acids reveals that each of the plasma amino acids reacts to injury of the organism in its own fashion (figs. 2, 3, 4, 5, 6).

FIGURE 2.


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Some of these patients were dialyzed by the artificial kidney. Analyses done on plasma taken immediately before and after dialysis indicate that a homeostatic mechanism operates to keep the plasma amino acid concentrations extremely constant despite the washing-out process of dialysis (fig. 7).

FIGURE 3.

Although the total free amino acid concentrations remain near normal, large quantities of an amino acid conjugate characteristically appear in the plasma of patients with injury and renal dysfunction. On hydrolysis, this component consists of glycine, threonine and glutamic acid, in normal individuals. Amino acids appear on hydrolysis which are not found in measurable amounts in the normals


201

(fig. 8). The ratios of the amino acids of the conjugates may vary from patient to patient, and from day to day in the same patient, suggesting heterogeneity of the substance (fig. 9). Further studies are in progress to determine the nature of this component, its metabolic origin, and its physiologic activity.

FIGURE 4.

From the practical point of view, we know that one of the most important factors which influence the metabolic response to injury and the extent of subsequent nutritional depletion is the food intake. The intake of the seriously injured patient is normally decreased in the early period following trauma and this accentuates the nitrogen loss. If the dietary intake of the seriously injured individual were maintained at an adequate level, beginning shortly after trauma, many


202

of the problems associated with the development of malnutrition would be averted. This was not usually obtained during the Korean conflict.

Situation at the MASH Level

The following remarks are based on observations made at the 46th MASH during January and February 1953. The majority of patients remained at the MASH for only a few days, and were chiefly on

FIGURE 5.

intravenous fluids (blood, dextran, glucose, water, saline) during this time. A lesser number of patients remained 7 to 10 days. Adequate nutrient intake was often not provided these patients. Neither special foods nor individuals with special knowledge of dietetics were available. The food offered them was the same as that prepared for the MASH personnel and was often cold by the time it was served to the patients. So-called "nourishing drinks" (cocoa, fruit juices, etc.) were offered most patients between meals.


203

Vitamins were not given during the preoperative period. In the postoperative period, patients on oral intake were occasionally given one or more multivitamin capsules daily. Those patients receiving intravenous fluids were given 500 mg. of vitamin C and 50 mg. of thiamine once or twice a day. Vitamin K preparations were occasionally given when there appeared to be a specific indication, for example, a decreased plasma prothrombin concentration. This type of vitamin therapy is imbalanced.

It was the impression of the nurses and the staff that most of the patients ate fairly well, but it would appear that the patients who


FIGURE 6.

ate well were the ones with the less severe injuries; the patients with extensive injuries usually ate poorly. A close check of the dietary intake of some severely injured patients revealed a totally inadequate intake. Body weights were measured only occasionally, but some patients apparently lost as much as 20 pounds in 10 days. The neurosurgeons were particularly firm in their conviction that serious weight loss occurred very rapidly in their patients.

Experiences at the Renal Center

As already mentioned, serious malnutrition developed rapidly and was an important complication in the patients with severe battle


204

wounds and renal failure. All these patients lost weight rapidly. Impairment of wound healing and mortality paralleled weight loss. What the weight loss specifically represents in terms of body tissue, water, fat, etc., is not known. However, data of apparent nonprotein nitrogen production obtained in a few patients reveals a very large nitrogen "loss." In one patient, this amounted to about 45 gm. N per day. This represents the daily breakdown of 2.5 lbs. fat-free tissue.

FIGURE 7.

Providing an adequate nutrient intake was a very difficult problem in these patients. Many were unable to take food orally over long periods of time. Parenteral alimentation was limited by the policy of rigid fluid restriction during the period of oliguria which in some cases persisted for 2 or 3 weeks. The problem was futher complicated by the policy of no protein administration during this same period. This was based on the consideration that in renal failure administration of dietary protein may be harmful. Consequently, the nutrient intake of these patients was very low and grossly inadequate. The


205

FIGURE 8.

FIGURE 9.


206

average daily caloric intake when the patient was on only parenteral fluids was 500 to 1,000 calories per day-supplied as 25 or 50 percent glucose. The only parenteral vitamin preparations available were vitamin C (in 500 mg. ampules), thiamine chloride (50 mg./cc.), and various vitamin K preparations. As mentioned, this resulted in a markedly imbalanced vitamin intake.

It is not possible to determine the exact oral dietary intake of these patients from the available records, but it appears that the oral food intake was low until long in the convalescent period. Both the diminished caloric and protein intake of these patients undoubtedly contributed to their rapid body tissue loss. This may be illustrated by table 2 which depicts data on two patients of similar age with almost identical injuries. The injuries were full-thickness burns involving about 12 percent of the body surface.

Table 2. Effect of Protein Intake on Nitrogen Loss Following Injury Cumulative Nitrogen Balance (gm.)

Days

Patient A

Patient B

1-13

- 6

- 110

14-25

- 16

- 175

The patients were placed on constant diets supplying to each 45 calories per kilogram body weight but no protein was included in the diet of patient A, whereas patient B ingested 11/2 grams of protein per kilogram body weight. The net losses of body nitrogen by the two patients are strikingly different. The patient ingesting protein had a net loss of 16 grams of nitrogen in the first 25 days after injury, while the net loss of the patient receiving no dietary protein was 175 grams of nitrogen or 10 times as much.

It is clear that inadequate food intake is one of the important factors in the pathogensis of the malnutrition observed following injury. In any future conflict, attention should be paid to insure adequate dietary intake.

We do not yet know what the optimal intake should be for the severely wounded soldier, but from studies carried out in patients with extensive burns, it would appear that 4 grams of protein and 55 to 65 calories per kilogram body weight is desirable for the patient with extensive wounds and without renal failure. Now what does this mean quantitatively? It means that a seriously injured young adult male weighing 70 kilograms may need about 275 grams of protein and 4,000 calories daily. About 40 percent of the calories ought to be supplied by fat, 30 percent by carbohydrate and 30 percent by pro-


207

tein. Considerably less protein would, of course, be given patients with renal dysfunction. We do not know what the optimal requirements are of the patients with serious wounds and renal failure.

The vitamin requirements of the seriously injured are not known, but we have been using 5 times the normal requirements of the B vitamin, about 10 times that of vitamin C, and 1 or 2 times the normal requirements of the fat-soluble vitamins.

As far as the routes for feeding patients are concerned, all would agree that the oral route, when possible, is most satisfactory. No blanket statement can be made as to how soon after injury oral diets can be started. This time would vary depending upon the severity and type of injury. Certain severe abdominal injuries, prolonged circulatory failure and marked renal dysfunction adversely affect gastrointestinal tract function. In such patients oral feedings would have to be delayed. In most other patients, diets can usually be started by the second to fourth day after injury. It is well to take a number of days to increase the food intake gradually since sudden increases are likely to be followed by gastrointestinal upsets.

Since personnel, equipment and food supplies are limited at the forward and evacuation hospitals, we feel that a liquid diet is the dietary treatment of choice under these circumstances.

A palatable formula that contains all of the food elements needed is of course necessary. The ingredients should be simple, inexpensive and well tolerated. Milk solids are a useful source of proteins. Ordinary milk powders, whole or skimmed, can be used. Additional carbohydrate, fat, minerals, water and vitamins are added to the protein base to make the preparations essentially complete. Fat emulsions have proved to be a very useful source of fat. They are bland, stable, well tolerated, blend easily and do not separate from the other ingredients upon standing. For a carbohydrate source, dextrimaltose and lactose are useful. Gavage feedings may be indicated in instances where the gastrointestinal tract is functioning but the patient for one reason or another is not ingesting the proper quantity or amounts of food. However, gavage feeding should be undertaken only if a reasonable amount of supervision is possible. Aspiration of the stomach should be done before each feeding.

Forcing the diet orally or by tube may not always be beneficial. Nausea, vomiting, distention and diarrhea are limiting factors. Further, certain patients may not be able to take food orally. Under these conditions, supplementation by the intravenous route is indicated. There are certain fundamental considerations which hold for intravenous as well as for oral feeding. It is obvious that the intravenous preparation should be nutritionally complete and the infusion carried out at a rate suitable for optimal utilization. At present, it is usually


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impossible to supply adequate calories by the preparations of glucose, fructose and alcohol now available. There is no preparation of fat for intravenous infusion available for general use but it is hoped that such a preparation will soon be available. When hypoproteinemia is present and there is a specific indication for raising the plasma protein concentration quickly (e. g., to reduce gastrointestinal tract edema), the best way of accomplishing this is by the infusion of plasma or albumin. Albumin should be used in preference to plasma because of the complications of plasma therapy (homologous serum jaundice; anemia). If anemia is present, it should be corrected by whole blood or red cell transfusions, but one should not overtransfuse a patient with the expectation of improving the general bodily nutrition of the individual. The nitrogen in the infused compatible red cells will enter the body nitrogen pool only when the infused red cells are destroyed-and the average survival of normal cells is about 120 days.

The high nutrient intake must be continued at a sufficient level not only to maintain the patient in nutritional equilibrium but also to restore at a rapid rate all tissues that have been depleted. Testosterone propionate in doses of 25 mg./day intramuscularly has been used with some success in the late stages of convalescence. Cognizance should be taken of the possible systemic changes brought about by such therapy when continued over long periods of time.