J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website http://www.jocmr.org

Original Article

Volume 9, Number 10, October 2017, pages 831-837

Intravenous Carnitine Administration in Addition to Parenteral Nutrition With Lipid Emulsion May Decrease the Inflammatory Reaction in Postoperative Surgical Patients

Figure 1. Changes in C-reactive protein (CRP) from postoperative day (POD) 3 to POD7 in patients receiving peripheral parenteral nutrition (PPN) alone (group L) or intravenous carnitine in addition to PPN (group LC). The decrease in CRP from POD3 to POD7 was significantly greater in group LC than in Group L (P = 0.011). The boxes show the interquartile range, with the median value indicated by the horizontal line; whiskers show the range. Circles show outliers.

**Table 1.** Patient Characteristics Before and After Surgery
	Group L (n = 8)	Group LC (n = 8)	P-value
Data are given as the mean ± SD or as n (%). Group L: peripheral parenteral nutrition (PPN); Group LC: intravenous carnitine in addition to PPN; BMI: body mass index.
Age (years)	69.3 ± 10.0	66.8 ± 9.2	0.611
Gender			0.315
Male	3 (37.5)	6 (75.0)
Female	5 (62.5)	2 (25.0)
BMI (kg/m²)
Preoperative	21.4 ± 3.0	24.8 ± 2.9	0.038
POD7	20.8 ± 3.4	24.3 ± 2.5	0.073
Tumor location			0.767
Gastric	1 (12.5)	1 (12.5)
Colorectal	7 (87.5)	7 (87.5)
Tumor stage			0.282
I	4 (50.0)	7 (87.5)
II	1 (12.5)	0 (0)
III	3 (37.5)	1 (12.5)
Surgical procedure			0.696
Open	3 (37.5)	3 (37.5)
Laparoscopic	5 (62.5)	5 (62.5)
Intravenous administration
Total energy (kcal/kg/day)	19.0 ± 3.2	16.2 ± 3.0	0.092
Amino acids (g/kg/day)	1.1 ± 0.2	0.9 ± 0.2	0.106

Table 1. Patient Characteristics Before and After Surgery

Group L (n = 8)

Group LC (n = 8)

P-value

Data are given as the mean ± SD or as n (%). Group L: peripheral parenteral nutrition (PPN); Group LC: intravenous carnitine in addition to PPN; BMI: body mass index.

Age (years)

69.3 ± 10.0

66.8 ± 9.2

0.611

Gender

0.315

Male

3 (37.5)

6 (75.0)

Female

5 (62.5)

2 (25.0)

BMI (kg/m²)

Preoperative

21.4 ± 3.0

24.8 ± 2.9

0.038

POD7

20.8 ± 3.4

24.3 ± 2.5

0.073

Tumor location

0.767

Gastric

1 (12.5)

Colorectal

7 (87.5)

Tumor stage

0.282

4 (50.0)

7 (87.5)

1 (12.5)

0 (0)

III

3 (37.5)

1 (12.5)

Surgical procedure

0.696

Open

3 (37.5)

Laparoscopic

5 (62.5)

Intravenous administration

Total energy (kcal/kg/day)

19.0 ± 3.2

16.2 ± 3.0

0.092

Amino acids (g/kg/day)

1.1 ± 0.2

0.9 ± 0.2

0.106

**Table 2.** Preoperative Laboratory Characteristics
	Group L (n = 8)	Group LC (n = 8)	P-value
Data are given as the mean ± SD or as the median (interquartile range). Group L: peripheral parenteral nutrition (PPN); Group LC: intravenous carnitine in addition to PPN; WBC: white blood cell count; TLC: total lymphocyte count; RBC: red blood cell count; Hb: hemoglobin; Hct: hematocrit; Plt: platelet count; Alb: serum albumin; TTR: transthyretin; RBP: retinol-binding protein; AST: aspartate aminotransferase; ALT: alanine aminotransferase; ChE: cholinesterase; ALP: alkaline phosphatase; T-bil: total bilirubin; BUN: blood urea nitrogen; Cre: creatinine; TG: triglycerides; TC: total cholesterol; HOMA-IR: homeostasis model assessment of insulin resistance.
WBC (/µL)	5,153 ± 1,661	6,263 ± 1,908	0.235
TLC (/µL)	1,560 (1,428 - 1,783)	1,838 (1,620 - 2,311)	0.014
RBC (× 10⁴/µL)	402 ± 63	446 ± 35	0.108
Hb (g/dL)	12.0 ± 2.7	13.8 ± 1.1	0.096
Hct (%)	36.1 ± 6.5	40.9 ± 3.1	0.780
Plt (× 10⁴/µL)	22.6 ± 4.1	27.2 ± 9.0	0.215
Alb (g/dL)	4.1 ± 0.4	4.2 ± 0.3	0.459
TTR (mg/dL)	30.1 ± 2.6	26.8 ± 8.0	0.325
RBP (mg/dL)	5.1 ± 0.8	4.9 ± 1.5	0.702
AST (U/L)	21.8 ± 5.0	21.1 ± 4.8	0.763
ALT (U/L)	17.3 ± 4.4	19.4 ± 5.2	0.417
ChE (U/L)	264.6 ± 57.0	333.4 ± 62.4	0.037
ALP (U/L)	232.4 ± 38.7	254.8 ± 84.5	0.507
T-bil (mg/dL)	0.8 (0.7 - 0.9)	0.6 (0.4 - 0.8)	0.130
BUN (mg/dL)	14.5 ± 3.8	16.1 ± 3.4	0.369
Cre (mg/dL)	0.6 ± 0.2	0.8 ± 0.2	0.179
TG (mg/dL)	126.2 ± 71.1	104.1 ± 35.4	0.483
TC (mg/dL)	190.2 ± 22.8	186.1 ± 18.7	0.733
HOMA-IR	0.9 (0.8 - 2.4)	1.8 (1.1 - 2.1)	0.613
Total carnitine (µmol/L)	56.0 ± 13.0	60.0 ± 7.6	0.470
Free carnitine (µmol/L)	44.8 ± 11.1	50.2 ± 8.0	0.291
Acyl carnitine (µmol/L)	11.3 ± 3.7	9.8 ± 3.0	0.410

Table 2. Preoperative Laboratory Characteristics

Group L (n = 8)

Group LC (n = 8)

P-value

Data are given as the mean ± SD or as the median (interquartile range). Group L: peripheral parenteral nutrition (PPN); Group LC: intravenous carnitine in addition to PPN; WBC: white blood cell count; TLC: total lymphocyte count; RBC: red blood cell count; Hb: hemoglobin; Hct: hematocrit; Plt: platelet count; Alb: serum albumin; TTR: transthyretin; RBP: retinol-binding protein; AST: aspartate aminotransferase; ALT: alanine aminotransferase; ChE: cholinesterase; ALP: alkaline phosphatase; T-bil: total bilirubin; BUN: blood urea nitrogen; Cre: creatinine; TG: triglycerides; TC: total cholesterol; HOMA-IR: homeostasis model assessment of insulin resistance.

WBC (/µL)

5,153 ± 1,661

6,263 ± 1,908

0.235

TLC (/µL)

1,560 (1,428 - 1,783)

1,838 (1,620 - 2,311)

0.014

RBC (× 10⁴/µL)

402 ± 63

446 ± 35

0.108

Hb (g/dL)

12.0 ± 2.7

13.8 ± 1.1

0.096

Hct (%)

36.1 ± 6.5

40.9 ± 3.1

0.780

Plt (× 10⁴/µL)

22.6 ± 4.1

27.2 ± 9.0

0.215

Alb (g/dL)

4.1 ± 0.4

4.2 ± 0.3

0.459

TTR (mg/dL)

30.1 ± 2.6

26.8 ± 8.0

0.325

RBP (mg/dL)

5.1 ± 0.8

4.9 ± 1.5

0.702

AST (U/L)

21.8 ± 5.0

21.1 ± 4.8

0.763

ALT (U/L)

17.3 ± 4.4

19.4 ± 5.2

0.417

ChE (U/L)

264.6 ± 57.0

333.4 ± 62.4

0.037

ALP (U/L)

232.4 ± 38.7

254.8 ± 84.5

0.507

T-bil (mg/dL)

0.8 (0.7 - 0.9)

0.6 (0.4 - 0.8)

0.130

BUN (mg/dL)

14.5 ± 3.8

16.1 ± 3.4

0.369

Cre (mg/dL)

0.6 ± 0.2

0.8 ± 0.2

0.179

TG (mg/dL)

126.2 ± 71.1

104.1 ± 35.4

0.483

TC (mg/dL)

190.2 ± 22.8

186.1 ± 18.7

0.733

HOMA-IR

0.9 (0.8 - 2.4)

1.8 (1.1 - 2.1)

0.613

Total carnitine (µmol/L)

56.0 ± 13.0

60.0 ± 7.6

0.470

Free carnitine (µmol/L)

44.8 ± 11.1

50.2 ± 8.0

0.291

Acyl carnitine (µmol/L)

11.3 ± 3.7

9.8 ± 3.0

0.410

**Table 3.** Postoperative Changes in Laboratory Parameters on PODs 1, 3, and 7 in Patients Receiving Peripheral Parenteral Nutrition (PPN) Alone (Group L) or Intravenous Carnitine in Addition to PPN (Group LC)
	POD1	POD3	POD7	P-value
Data are given as the mean ± SD or as the median (interquartile range). P < 0.05, P < 0.01 compared with group L (repeated-measures ANOVA with Bonferroni post hoc* correction or Friedman test); ^†P < 0.05, ^††P < 0.01 compared with POD1; ^‡P < 0.05, ^‡‡P < 0.01 compared with POD3. WBC: white blood cell count; TLC: total lymphocyte count; RBC: red blood cell count; Hb: hemoglobin; Hct: hematocrit; Plt: platelet count; Alb: serum albumin; TTR: transthyretin; RBP: retinol-binding protein; AST: aspartate aminotransferase; ALT: alanine aminotransferase; ChE: cholinesterase; ALP: alkaline phosphatase; T-bil: total bilirubin; BUN: blood urea nitrogen; Cre: creatinine; TG: triglycerides; TC: total cholesterol; HOMA-IR: homeostasis model assessment of insulin resistance; CRP: C-reactive protein.
WBC (/µL)	8,125 (6,313, 10,028)	10,450 (7,645, 13,043)	7,090 (5,253, 7,535)	7,480 (6,575, 9,248)	6,505 (5,078, 9,753)	6,765 (5,863, 7,390)^†	0.651
TLC (/µL)	1,112 ± 398	1,376 ± 507	1,141 ± 203	1,148 ± 411	1,166 ± 447	1,241 ± 401	0.529
RBC (× 10⁴/µL)	367 (334, 450)	397 (371, 409)	365 (329, 449)	425 (388, 442)	383 (333, 449)	422 (374, 436)	0.506
Hb (g/dL)	11.3 ± 2.7	11.9 ± 1.5	11.3 ± 2.7	12.6 ± 1.6	11.5 ± 2.3	12.5 ± 1.8	0.365
Hct (%)	34.1 ± 6.5	35.6 ± 4.5	33.6 ± 6.9	37.4 ± 4.8	34.2 ± 5.8	36.6 ± 4.9	0.358
Plt (× 10⁴/µL)	20.0 (15.3, 24.6)	18.9 (14.0, 28.0)	20.7 (17.4, 25.0)^†	22.7 (16.5, 25.3)	29.9 (22.1, 28.8)	29.6 (24.1, 39.0)^‡‡	0.798
Albumin (g/dL)	3.1 ± 0.4	3.0 ± 0.3	3.0 ± 0.4	3.0 ± 0.4	3.2 ± 0.6	3.2 ± 0.5	0.773
TTR (mg/dL)	19.0 ± 3.3	18.1 ± 3.7	12.1 ± 7.7	13.1 ± 4.6^†	18.1 ± 7.9	22.3 ± 6.4^‡	0.470
RBP (mg/dL)	2.8 ± 1.0	2.7 ± 0.8	2.8 ± 0.9	2.6 ± 0.8	3.4 ± 1.4	4.1 ± 1.2^††	0.708
AST (U/L)	21.0 (15.3, 47.8)	27.0 (19.5, 34.8)	17.5 (13.3, 22.0)	19.0 (16.5, 20.8)^†	24.5 (13.3, 27.8)	30 (22.3, 50.5)	0.376
ALT (U/L)	15.5 (12.0, 44.5)	22.5 (14.8, 23.0)	15.5 (11.5, 21.5)	19 (12.8, 24.3)	26 (12.7, 34.8)	54.5 (32.8, 109.8)	0.428
ChE (U/L)	212.0 ± 57.7	254.1 ± 64.5	202.6 ± 70.2	241.3 ± 66.4	204.0 ± 76.0	237.3 ± 69.0	0.264
ALP (U/L)	173.5 (156.5, 182.5)	160.5 (129.8, 203.8)	170 (151.0, 197.8)	159 (131.0, 200.8)	212.5 (187.3, 269.3)	301.5 (218.3, 567.0)	0.271
T-bil (mg/dL)	0.9 (0.8, 1.4)	0.9 (0.8, 1.2)	0.8 (0.6, 1.3)^†	0.6 (0.5, 0.7)^††	0.6 (0.5, 0.9)	0.5 (0.4, 0.8)	0.781
BUN (mg/dL)	10.0 (7.3, 16.3)	13.5 (9.3, 15.8)	13.0 (11.0, 16,5)	14.0 (11.3, 21.3)	18.0 (13.5, 20.0)^‡††	20.5 (14.8, 23.0)^††	0.447
Cre (mg/dL)	0.60 ± 0.19	0.77 ± 0.25	0.56 ± 0.19	0.69 ± 0.19	0.63 ± 0.20	0.68 ± 0.17	0.252
TG (mg/dL)	66.7 ± 10.5	80.2 ± 17.2	83.0 ± 6.0	109.7 ± 24.4^†	89.6 ± 22.1	106.0 ± 24.1	0.061
TC (mg/dL)	139.4 ± 26.9	134.2 ± 15.5	153.9 ± 26.6	152.8 ± 17.9^††	164.4 ± 29.3	153.8 ± 13.4	0.639
HOMA-R	1.77 (1.05, 4.63)	2.41 (1.44, 2.81)	2.49 (1.33, 7.03)	3.51 (1.99, 6.74)	2.18 (0.68, 3.82)	2.22(1.85, 5.29)	0.711
Total carnitine (µmol/L)	59.0 (41.9, 78.1)	65.8 (58.6, 270.7)	54.3 (40.1, 59.5)	252.0 (95.6, 646.0)**	63.7 (51.2, 76.5)^‡	86.6 (81.4, 94.9)*	0.069
Free carnitine (µmol/L)	50.3 (36.3, 66.3)	57.9 (50.9, 263.4)	44.4 (35.6, 52.9)	236.2 (85.0, 630.3)**	53.2 (46.2, 60.6)^‡	74.3 (70.7, 83.1)**	0.074
Acyl carnitine (µmol/L)	6.8 (4.8, 9.3)	7.5 (7.3, 8.0)	7.4 (6.4, 9.3)	13.55 (7.7, 17.1)*	10.9 (5.0, 13.7)	12.0 (11.1, 13.0)^†	0.115
CRP (mg/dL)			3.74 (1.82 - 8.89)	7.78 (4.37 - 17.80)	2.45 (0.32, 8.38)	3.36 (0.75, 13.55)^‡	0.440
Nitrogen balance (g/day)			-0.4 (-1.6, 2.7)	2.8 (-5.9, 8.7)	-4.3 (-11.3, -0.9)	-4.8 (-17.0, -4.2)	0.714

Table 3. Postoperative Changes in Laboratory Parameters on PODs 1, 3, and 7 in Patients Receiving Peripheral Parenteral Nutrition (PPN) Alone (Group L) or Intravenous Carnitine in Addition to PPN (Group LC)

POD1

POD3

POD7

P-value

Group L

Group LC

Group L

Group LC

Group L

Group LC

Data are given as the mean ± SD or as the median (interquartile range). *P < 0.05, **P < 0.01 compared with group L (repeated-measures ANOVA with Bonferroni post hoc correction or Friedman test); ^†P < 0.05, ^††P < 0.01 compared with POD1; ^‡P < 0.05, ^‡‡P < 0.01 compared with POD3. WBC: white blood cell count; TLC: total lymphocyte count; RBC: red blood cell count; Hb: hemoglobin; Hct: hematocrit; Plt: platelet count; Alb: serum albumin; TTR: transthyretin; RBP: retinol-binding protein; AST: aspartate aminotransferase; ALT: alanine aminotransferase; ChE: cholinesterase; ALP: alkaline phosphatase; T-bil: total bilirubin; BUN: blood urea nitrogen; Cre: creatinine; TG: triglycerides; TC: total cholesterol; HOMA-IR: homeostasis model assessment of insulin resistance; CRP: C-reactive protein.

WBC (/µL)

8,125 (6,313, 10,028)

10,450 (7,645, 13,043)

7,090 (5,253, 7,535)

7,480 (6,575, 9,248)

6,505 (5,078, 9,753)

6,765 (5,863, 7,390)^†

0.651

TLC (/µL)

1,112 ± 398

1,376 ± 507

1,141 ± 203

1,148 ± 411

1,166 ± 447

1,241 ± 401

0.529

RBC (× 10⁴/µL)

367 (334, 450)

397 (371, 409)

365 (329, 449)

425 (388, 442)

383 (333, 449)

422 (374, 436)

0.506

Hb (g/dL)

11.3 ± 2.7

11.9 ± 1.5

11.3 ± 2.7

12.6 ± 1.6

11.5 ± 2.3

12.5 ± 1.8

0.365

Hct (%)

34.1 ± 6.5

35.6 ± 4.5

33.6 ± 6.9

37.4 ± 4.8

34.2 ± 5.8

36.6 ± 4.9

0.358

Plt (× 10⁴/µL)

20.0 (15.3, 24.6)

18.9 (14.0, 28.0)

20.7 (17.4, 25.0)^†

22.7 (16.5, 25.3)

29.9 (22.1, 28.8)

29.6 (24.1, 39.0)^‡‡

0.798

Albumin (g/dL)

3.1 ± 0.4

3.0 ± 0.3

3.0 ± 0.4

3.2 ± 0.6

3.2 ± 0.5

0.773

TTR (mg/dL)

19.0 ± 3.3

18.1 ± 3.7

12.1 ± 7.7

13.1 ± 4.6^†

18.1 ± 7.9

22.3 ± 6.4^‡

0.470

RBP (mg/dL)

2.8 ± 1.0

2.7 ± 0.8

2.8 ± 0.9

2.6 ± 0.8

3.4 ± 1.4

4.1 ± 1.2^††

0.708

AST (U/L)

21.0 (15.3, 47.8)

27.0 (19.5, 34.8)

17.5 (13.3, 22.0)

19.0 (16.5, 20.8)^†

24.5 (13.3, 27.8)

30 (22.3, 50.5)

0.376

ALT (U/L)

15.5 (12.0, 44.5)

22.5 (14.8, 23.0)

15.5 (11.5, 21.5)

19 (12.8, 24.3)

26 (12.7, 34.8)

54.5 (32.8, 109.8)

0.428

ChE (U/L)

212.0 ± 57.7

254.1 ± 64.5

202.6 ± 70.2

241.3 ± 66.4

204.0 ± 76.0

237.3 ± 69.0

0.264

ALP (U/L)

173.5 (156.5, 182.5)

160.5 (129.8, 203.8)

170 (151.0, 197.8)

159 (131.0, 200.8)

212.5 (187.3, 269.3)

301.5 (218.3, 567.0)

0.271

T-bil (mg/dL)

0.9 (0.8, 1.4)

0.9 (0.8, 1.2)

0.8 (0.6, 1.3)^†

0.6 (0.5, 0.7)^††

0.6 (0.5, 0.9)

0.5 (0.4, 0.8)

0.781

BUN (mg/dL)

10.0 (7.3, 16.3)

13.5 (9.3, 15.8)

13.0 (11.0, 16,5)

14.0 (11.3, 21.3)

18.0 (13.5, 20.0)^‡††

20.5 (14.8, 23.0)^††

0.447

Cre (mg/dL)

0.60 ± 0.19

0.77 ± 0.25

0.56 ± 0.19

0.69 ± 0.19

0.63 ± 0.20

0.68 ± 0.17

0.252

TG (mg/dL)

66.7 ± 10.5

80.2 ± 17.2

83.0 ± 6.0

109.7 ± 24.4^†

89.6 ± 22.1

106.0 ± 24.1

0.061

TC (mg/dL)

139.4 ± 26.9

134.2 ± 15.5

153.9 ± 26.6

152.8 ± 17.9^††

164.4 ± 29.3

153.8 ± 13.4

0.639

HOMA-R

1.77 (1.05, 4.63)

2.41 (1.44, 2.81)

2.49 (1.33, 7.03)

3.51 (1.99, 6.74)

2.18 (0.68, 3.82)

2.22(1.85, 5.29)

0.711

Total carnitine (µmol/L)

59.0 (41.9, 78.1)

65.8 (58.6, 270.7)

54.3 (40.1, 59.5)

252.0 (95.6, 646.0)**

63.7 (51.2, 76.5)^‡

86.6 (81.4, 94.9)*

0.069

Free carnitine (µmol/L)

50.3 (36.3, 66.3)

57.9 (50.9, 263.4)

44.4 (35.6, 52.9)

236.2 (85.0, 630.3)**

53.2 (46.2, 60.6)^‡

74.3 (70.7, 83.1)**

0.074

Acyl carnitine (µmol/L)

6.8 (4.8, 9.3)

7.5 (7.3, 8.0)

7.4 (6.4, 9.3)

13.55 (7.7, 17.1)*

10.9 (5.0, 13.7)

12.0 (11.1, 13.0)^†

0.115

CRP (mg/dL)

3.74 (1.82 - 8.89)

7.78 (4.37 - 17.80)

2.45 (0.32, 8.38)

3.36 (0.75, 13.55)^‡

0.440

Nitrogen balance (g/day)

-0.4 (-1.6, 2.7)

2.8 (-5.9, 8.7)

-4.3 (-11.3, -0.9)

-4.8 (-17.0, -4.2)

0.714

**Table 4.** Postoperative Complications in Patients Receiving Peripheral Parenteral Nutrition (PPN) Alone (Group L) or Intravenous Carnitine in Addition to PPN (Group LC)
	Group L	Group LC	P-value
Data show the number of patients in each group, with percentages in parentheses.
Postoperative complications			0.715
Yes	2 (25.0)	2 (25.0))
No	6 (75.0)	6 (75.0)
Infectious complications
Yes	1 (12.5)	1 (12.5)	0.767
No	7 (87.5)	7 (87.5)
Mechanical complications			0.500
Yes	1 (12.5)	2 (25.0)
No	7 (87.5)	6 (75.0)

Table 4. Postoperative Complications in Patients Receiving Peripheral Parenteral Nutrition (PPN) Alone (Group L) or Intravenous Carnitine in Addition to PPN (Group LC)

Group L

Group LC

P-value

Data show the number of patients in each group, with percentages in parentheses.

Postoperative complications

0.715

Yes

2 (25.0)

2 (25.0))

6 (75.0)

Infectious complications

Yes

1 (12.5)

0.767

7 (87.5)

Mechanical complications

0.500

Yes

1 (12.5)

2 (25.0)

7 (87.5)

6 (75.0)