Intravenous hyperalimentation: a review of two and one-half years' experience

The future of inpatient diabetes management: glucose as the sixth vital sign

Diabetes is an ever increasing health problem in our society. Due to associated small and large vessel conditions, patients with diabetes are two- to four-fold more likely to require hospitalization than nondiabetic individuals. Furthermore, hyperglycemia in hospitalized patients results in increased susceptibility to wound infections, worse outcomes postcardiac and cerebrovascular events, longer hospital length of stay and increased inpatient mortality. Several studies suggest that tight control of glucose levels yields improvement in these factors. Conversely, other studies have suggested increased mortality after tight glucose management, perhaps as a result of an increased incidence of hypoglycemic events. The most reasonable approach to control of hyperglycemia is to normalize glucose levels as much as possible without triggering hypoglycemia. In the hospital, insulin therapy of hyperglycemia is preferred due to the ability to flexibly manage glucose levels without side effects associated with many alternative antidiabetic agents. Due to the increasing burden of inpatient diabetes, and the detrimental effects of both hyper and hypoglycemia, the authors predict that blood-glucose levels will become the sixth vital sign to be frequently monitored in hospitalized patients and controlled in a narrow range. The future is in the use of insulin pumps controlled by continuous glucose monitors. This technology is complex and has not yet become standard. The development of future inpatient diabetes care will depend on adaptation of hospital systems to advance the new technology.

The consequences of a cavalier approach to central venous catheterization

A cavalier approach on the part of some physicians, and poor research on the part of some equipment manufacturers, has made central venous catheterization more dangerous to the patient than it need be. Here, the relationship between these factors is discussed, with special reference to the fact that central venous catheterization is an invasive surgical operation which should not be taken lightly by its practitioners.

Caloric requirements of the critically ill patient receiving intravneous hyperalimentation

The caloric requirements of the critically ill patient was defined by body composition measurements performed in thirty-five patients before and after a course of total parenteral nutrition (TPN). A positive and statistically significant (p less than 0.001) correlation was observed between the number of kcal/kg/day infused and the mean daily change in Ke, which is a measure of the body cell mass. The intercept of the regression line was 46 kcal/kg/day indicating that balance is achieved when calories are infused at this rate. Fifteen of the thirty-five patients studied received less than 46 kcal/kg/day. In this group an average of 38.1 +/- 1.5 kcal/kg/day of TPN was infused for 13.3 +/- 1.2 days. The body composition of these patients was unchanged after TPN and was characteristic of malnutrition both before and after TPN. TPN was administered at a mean rate of 57.2 +/- 2.0 kcal/kg/day for 16.7 +/- 1.8 days in the twenty patients who all received more than 46 kcal/kg/day. The body composition of these patients before TPN was also characteristic of malnutrition. However, a marked improvement of body composition was observed after the course of TPN. In all the patients in both groups the amino acids were infused at a rate that exceeded the minimal amount required to achieve nitrogen balance. The data indicate that the average patient receiving TPN requires at least 46 kcal/kg/day for balance. In the depleted patient infusion of calories in excess of this amount results in a rebuilding of the body cell mass.

Early and late obstruction of the small bowel after abdominoperineal resection

A series of patients with early or late obstruction of the small bowel after abdominoperineal resection is studied. Immediate intervention is recommended in patients with early obstruction; adhesions and defects of the pelvic floor are the most common etiologic factors in this group. Recurrent pelvic carcinoma with associated obstruction of the small bowel is the primary etiologic factor in patients with late obstruction. Bypass operation provides the best palliation. Simple adhesions continue to be a significant etiologic factor. No obstruction related to spaces created by colostomy was encountered.

Nitrogen balance in patients receiving either fat or carbohydrate for total intravenous nutrition

Eighteen pre and/or postoperative patients underwent TIN using either fat or carbohydrate as a caloric substrate source for a similar period. Positive nitrogen balance was achieved with either solution for an equal number of days when balance studies were complete. Both groups demonstrated weight gain but it was more marked in the carbohydrate TIN group. One patient in the carbohydrate TIN group was changed to Intralipid because of a catheter related complication. This patient continued to show positive nitrogen balance while on Intralipid. There were 4 deaths in the 18 patients unrelated to TIN. It is concluded that Intralipid, when given through a peripheral vein with a nitrogen source, can produce positive nitrogen balance and is a safe and effective means for doing this.

Spontaneous resolution of endogenous Candida endophthalmitis complicating intravenous hyperalimentation

Untreated patients with endogenous Candida endophthalmitis who have not died of disseminated disease have required enucleation. A 57-year-old woman had endogenous Candida endophthalmitis developing subsequent to catheter sepsis during hyperalimentation, in which no antimycotic therapy was employed. The endophthalmitis resolved, and good visual acuity was preserved.

Elemental balances during intravenous hyperalimentation of underweight adult subjects

Intravenous hyperalimentation was done in 11 underweight adults whose body weight (body wt) was less than 85 percent of ideal. For the first 6 days, "complete formula" was infused furnishing per kilogram ideal body wt per day: 15 g glucose, 0.40 g N, 0.018 g P, 2.4 meq K, 3.0 meq Na, 2.3 meq C1, 0.5 meq Mg, 0.45 meq Ca, and 50 ml H20. Patients gained weight at an average rate of 9.0 g/kg ideal body wt/day and showed average balances/kilogram ideal body wt/day as follows: plus 0.14 g N; plus 0.012 g P; plus 0.43 meq K; plus 0.49 meq Na; plus 0.37 meq Cl; and plus 0.085 meq Ca. Application of standard equations to the elemental balances indicated weight gain consisted of 35-50 percent protoplasm, 35-50 percent extracellular fluid, 5-25 percent adipose tissus, and less than 1 percent bone. Withdrawas of N, P, Na, or K impaired or abolished retention of other elements. Removal of N halted retention P, K, Na and C1; withdrawal of K stopped retention of N and P; and removal of Na or P interrupted retention of all other elements. Weight gain continued at a rate of 1.4-3.1 g/kg ideal body wt/day despite zero or negative elemental balances of N, K, P, and sometimes Na and C1. Calculations showed that weight gain during infusion of fluids lacking N, P, K, or Na consisted largely of adipose tissue, with little or no contribution by protoplasm or extracellular fluid. Data show that repletion of protoplasm and extracellular fluid of wasted adults by intravenous hyperalimentation is retarded or abolished if N, P, Na, or K is lacking. Repletion of bone mineral does not occur in absence of Na or P but proceeds in absence of N, P, K, or Na. Thus, quality of weight gained by underfed adult patients during hyperalimentation depends on elemental composition of the infusate.

Effect of malnutrition on colonic healing

It has been suggested that colonic healing is impaired in malnourished subjects, but there have been no biochemical studies of the effect of malnutrition on colonic healing. The effects of malnutrition on the colon and the healing of colonic anastomoses were studied in rats fed a protein-free diet. Test animals were compared with control animals of similar age, and control animals of similar weight. There was a significant reduction in the body weight, total serum proteins and serum albumin of animals starved of protein. Malnutrition resulted in a reduction in the weight of the uninjured colon, and an increase in the colonic collagen concentration. There was a significant reduction in the collagen content of the colon in animals starved of protein for seven weeks, and the collagen content of anastomoses in these animals was significantly lower than the value in control animals. Anastomotic edema occurred during colon healing in animals starved for seven weeks. Measurements of colonic bursting pressure were an inaccurate guide to colonic healing. It is concluded that severe malnutrition resulting in 34% loss of body weight had an adverse effect on colonic healing.