Long-term total parenteral nutrition in infants

A proposed combination of flat-panel detector and mobile X-ray systems for low-dose image-guided central venous catheter insertion

A central venous catheter (CVC) should be inserted at the optimum position to infuse medicines, blood products, nutrients, or fluids. Positioning of the catheter tip is commonly performed under landmark or fluoroscopic guidance. However, Japanese regulations do not allow the performing of fluoroscopy-guided procedures outside of the fluoroscopy room. We hypothesized that a new image-guided CVC placement technique by combining a wireless flat-panel detector (FPD) and a mobile X-ray system could be applied at the bedside to support CVC insertion. A CVC attached to a chest phantom in conjunction with the polymethyl methacrylate (PMMA) phantom was imaged, contrast-to-noise ratio (CNR) was measured with images, and radiologists and emergency physicians rated the catheter images using a Likert scale for visual evaluation. The minimum dose of the FPD and mobile X-ray system was reduced by at least 98% compared with that of the X-ray fluoroscopy system. The CNR decreased with the increasing PMMA phantom thickness. However, results of the visual evaluation were maintained at the clinically usable score with low-dose imaging up to a 6-cm thickness of the PMMA phantom. In conclusion, the combination of FPD and mobile X-ray systems is particularly effective in the emergency room setting where such procedures are required to be performed with urgency.

The Development of Total Parenteral Nutrition

The first patient to receive complete nourishment of a patient by intravenous infusion independent of the alimentary tract was an infant girl born with near-total small bowel atresia. Total parenteral nutrition, the intravenous infusion of nutrients, has been attempted since Harvey's description of the circulatory system in the early 17th century. The modern era of parenteral nutrition began in the early 20th century, when infusions of glucose, plasma, and emulsified fat into humans proved feasible. Robert Elman, working in the 1930s and 1940s, demonstrated that carefully prepared protein hydrolysates could be safely infused intravenously and incorporated by the body. Stanley Dudrick and Douglas Wilmore, surgeon researchers at the University of Pennsylvania, worked through the many details of preparation, administration, and clinical monitoring in beagle puppies before testing them on adult patients malnourished from a variety of surgical complications and gastrointestinal conditions. They applied their techniques and formulations on a newborn wasting away from congenital absence of the small bowel, the baby growing and developing for several months while being nourished completely by total parenteral nutrition. Their techniques, inspired by patients with progressive malnutrition from devastating intestinal conditions and malformations, form the basis of the practice of intravenous nutrition practiced today.

Migration of jugular or subclavian venous catheters into inferior tributaries of the brachiocephalic veins or into the azygos vein, with possible complications

Six children are reported in whom a central venous catheter from the internal jugular or the subclavian vein migrated to an anomalous position: the left superior intercostal vein in the first two cases, the thymic vein in the third, and the azygos vein in the last three. Resultant complications in five cases were: extravasation of the infusate in the first and third case; local vascular stenosis or complete vascular occlusion in the second and fifth case; and obstruction of the azygos arch due to local thrombosis and possible stenosis, with a likely extravasation of the infusate, in the sixth case. The mediastinal vascular anatomy related to these central venous catheters is reviewed with reference to similar and related cases in the literature.

The pivotal role of the surgeon in the results achieved in gastroschisis

A single neonatal surgical unit treated 42 cases of gastroschisis over a 12-year period (1981-1993). The surgical management of each case was individualised, but every attempt was made to perform a primary repair when possible, based on the premise that this strategy gave the best outcome. The eviscerated intestine was evaluated with the patient under general anaesthesia. Serosal peel was not removed and intestinal atresias were not repaired. Gangrenous intestine was resected. The contents of the bowel were emptied proximally via a large naso-gastric tube and distally via the anus with warm saline lavage. The anterior abdominal wall was stretched and then reduction of the prolapse attempted. Following maximal enlargement of the peritoneal cavity, it was left to the operator to decide whether primary repair was possible and, indeed, permissible in each instance. Staged repairs necessitated the use of silastic pouches. Respiratory and intestinal insufficiency were managed by intermittent positive-pressure ventilation and total parenteral nutrition (TPN). Over one-half of the cases (24 of 42) were under 2.5 kg at birth. Intra-uterine growth retardation was unusual. Ten babies were delivered for obstetrical indications by Caesarean section: 50% were pre-term and in 4 pre-natal diagnosis of a ventral abdominal wall anomaly had been made. The transmural defects were all sited at the umbilicus and were to the right of a consolidated cord in 41 instances. Midgut necrosis due to torsion was encountered in 1 case; 3 further cases with intestinal atresia occurred. Primary closure was obtained in 30 (71%) of the cases reviewed. A prosthetic pouch was used in 12 patients for on everage 10 days in 10 uncomplicated cases. The average length of time in days of tertiary care given to 25 uncomplicated cases treated by primary fascial closure was: ventilatory support 4; intensive care treatment 8; and nutritional source TPN 20. There were 5 deaths (12%): 1 was unpreventable due to prenatal intestinal infarction; 2 were due to abdominal compartment syndrome with renal failure, and, intestinal ischaemia complicating primary and planned staged repairs; 1 caused by intestinal infarction due to torsion of bowel in a pouch; and 1 due to invasive infection. The role played by the strategy taken by the surgeon in the management of gastroschisis is crucial to the outcome. The creation of a compartment-like syndrome produced uncorrectable complications in this series of cases in both primary and staged abdominal wall closures. Minor degrees of this complication proved to be reversible in some patients, which was the reason for the wait-and-see attitude adopted in the management of this problem, often with fatal outcome. Where intra-peritoneal pressure monitoring is not used, the operating surgeon relies on unscientific observations for decision-making at the operating table. The time from birth to operation in 25 of the reviewed cases was on average 5 1/2 h. Of this group, 20 were outborn babies. This is unsatisfactory, but as shown by this review, even in the absence of prenatal management, which should ensure prompt repair, satisfactory results are still possible.

Amino acid and energy needs of pediatric patients receiving parenteral nutrition

The technique of parenteral nutrition has become such an established part of modern pediatric care that it is difficult to imagine how pediatricians, as recently as 25 years ago, managed a large group of very difficult patients; however, despite its obvious nutritional advantages, the technique is not without problems. Many of these can be circumvented or controlled by careful attention to all aspects of the technique. Certainly the incidence of these problems can be maintained at a level sufficiently low that the benefits of the technique far outweigh its risks; however, the technique clearly can be further improved. One requirement for doing so is to recognize that the technique is deceptively simple and that it should not be used indiscriminantly without careful consideration of indications and alternative strategies for nutritional management. Additional research also is required. As discussed earlier, the available parenteral amino acid mixtures and lipid emulsions, although considerably improved over earlier versions, remain far from optimal. Some of the actual and theoretic problems that should be addressed in the near future are discussed in the preceding sections; there also are many others.

Postobstructive enteropathy in infants with transient enterostomy: its consequences on the upper small intestinal functions

Repeated or prolonged organic obstruction of the small intestine in the neonatal period can lead to severe refeeding problems, despite a transient ostomy. These problems are thought to result from a postobstructive enteropathy (POE) of the apparently normal small intestine segment above the obstruction. Ten infants with a POE, characterized by limited oral caloric and carbohydrate intakes and increased ostomy effluent, were compared with 8 controls with an enterostomy and a normal postoperative refeeding pattern. There was no statistical difference in the histomorphometric appearance of the mucosa or its digestive or absorptive capacity (brush-border hydrolases, glucose transport) between the two groups. The effluent and duodenal floras of the two groups were similar. However, all POE patients showed significant abnormal peristalsis characterized by barium and carmin transit times. This suggests that repeated or prolonged obstruction in the neonatal period could lead to a POE, caused by chronic motricity abnormalities of the small intestine above the obstruction. Although this POE is more frequent after small bowel atresia, it may also occur with other conditions causing prenatal and postnatal intestinal obstruction.

Metabolism of intravenous fat emulsion in the surgical newborn

The metabolism of an intravenous (IV) fat emulsion was investigated by the combination of chemical balance and computerized indirect calorimetry techniques in 21 newborns (birth weight, 3.0 +/- 0.1 kg; mean +/- SE). All babies were appropriate for gestational age and received total parenteral nutrition after a major surgical procedure. The study was divided into two consecutive periods. Phase 1 consisted of infusion of 10% glucose and 2% amino acid solutions for 24 hours, and phase 2 involved the "Intralipid utilization test" (isocaloric and isovolemic infusion of Intralipid 10% for four hours). The caloric intake was 67.1 +/- 1.9 kcal/kg/d during both phases of the study. The resting energy expenditure was 44.8 +/- 1.6 and 46.5 +/- 1.8 kcal/kg/d during phases 1 and 2 respectively. During glucose/amino acid infusion, 12 patients oxidized endogenous fat, and de novo lipogenesis from glucose was observed in nine. During the Intralipid infusion, there was a significant and progressive decrease of carbon dioxide production, respiratory quotient, and carbohydrate utilization (oxidation plus conversion to fat). Net lipogenesis ended and fat utilization significantly increased. By the second hour of Intralipid infusion, 58% of energy expenditure was derived from fat oxidation. The drop in carbon dioxide production correlated positively with the decrease in carbohydrate utilization (r = .07; P less than .001). During the third and fourth hours of phase 2, the percentage of fat utilized was negatively correlated with the amount of fat given (r = -.07; P less than .01). The surgical neonate showed rapid metabolic adaptation to Intralipid infusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Characteristics of protein sparing effect of total parenteral nutrition in the surgical infant

To determine the best formula to prevent protein depletion, 31 surgical infants on intravenous (IV) diet were studied. The study was divided into two phases. Phase I diet included 5% glucose and 1.5% or 2% amino acid infusion; phase II diet consisted of 5% glucose and 1.5% or 2% aminoacid plus 10% Intralipid. In each phase, oxygen consumption, carbon dioxide production, and energy expenditure were determined. The utilization of carbohydrate, fat, and protein was calculated from urinary nitrogen excretion and nonprotein respiratory quotient. The mean caloric intake during phase I and phase II was 62 and 94 kcal/kg/d, respectively. A positive nitrogen balance was obtained in infants receiving fat-free total parenteral nutrition (TPN) with a mean protein intake of 2.6 g/kg/d and a mean energy intake exceeding the energy expenditure by 24%. Infusion of more calories as Intralipid (phase II) caused a significant reduction in protein oxidation, thus protein contribution to the energy expenditure and an increase in protein retention. We conclude that supplementation of low-calorie TPN diets with Intralipid increases protein sparing and is preferable to the administration of very high glucose loads.

Efficacy and safety of low-dose intravenous versus intramuscular vitamin K in parenteral nutrition patients

Efficacy and safety of intravenous and intramuscular vitamin K were compared prospectively in patients receiving total parenteral nutrition. Sixty patients randomly received either a 1-mg daily iv injection (iv group) or a 10-mg weekly injection group (im group). Efficacy was determined by the prolongation of twice-weekly prothrombin (PT) and activated partial thromboplastin (APTT) times. The prolongation of both was not significantly different between the im and iv groups. The percent of PTs outside the normal range was not different for the two groups, although the iv group had more APTT values outside the range than did the im group (p = 0.002). The number of adverse reactions reported in the iv (5) and im (4) groups was also similar. Reactions were minor, not reproducible, and all patients recovered without sequelae. PT results from the iv and im groups were combined and compared to values from 28 patients in an earlier study who did not receive vitamin K. PTs in the no-vitamin K group were significantly prolonged over the vitamin K group (p = 0.0004). The results confirm that regular addition of vitamin K to TPN regimens decreases the incidence of elevated PTs. When administered appropriately, iv and im administration of vitamin K appear to be equally safe and effective in maintaining normal PTs and APTTs.

Central venous catheters for children with malignant disease: surgical issues

The use of long-term central venous catheters has eliminated the fear and pain of repeated venopunctures for children with malignant disease, but problems still exist for the surgeon. Issues include choice of catheter, site and technique of placement, prevention of infection and accidental displacement, and removal. Five years' experience with 102 catheter placements in 81 children with leukemia or malignant tumors has been reviewed. These catheters remained in place an average of 318 days (32,481 patient days), maintained at home under close nursing supervision. Six months after the last entry in this series, 14 catheters are functioning and 35 patients have died with catheters intact. Fifty-three catheters have been removed because of completion of treatment (29), infection (10), dislodgement (11), and other reasons (3). In these immunocompromised patients, infectious episodes were common (186 episodes) but only ten episodes required removal of the catheter for control (1/3,248 days of use). Central venous catheters are of great help in treatment of children with malignant disease, and with careful attention to detail complications can be minimized. The advantages of central venous catheters are so great that almost all parents now agree to their use from the time the diagnosis is made, despite the possible problems with maintenance, dislodgement, and infection.

Vitamin D requirement in infants receiving parenteral nutrition

The adequacy of low dose vitamin D (25 IU/dl) parenteral nutrition (PN) solution was studied in 18 infants. All infants had surgical indications for PN. The birth weights were 2810 +/- 135 g and gestational ages 37.4 +/- 0.5 wk (mean +/- SEM). Duration of study ranged from 5 to 175 days. Thirteen infants were studied for up to 6 weeks and five infants for 71 to 175 days. Results showed that studied infants maintained growth along normal percentiles for weight, length, and head circumference. Vitamin D status as indicated by serum 25 hydroxyvitamin D (25 OHD) rose from 15 +/- 1.9 ng/ml to 26 +/- 2.8 ng/ml, mean +/- SEM (p less than 0.001) after 9 days, and remained normal up to 6 months. Five infants with biochemical liver dysfunction also had normal serum 25 OHD concentrations, indicating the hepatic 25 hydroxylation process was not severely impaired. Serum total and ionized calcium, phosphorus, and vitamin D-binding protein concentrations were normal. Serum magnesium was mildly elevated in five infants (2.6 to 3 mg/dl) on one occasion and resolved spontaneously. Serum alkaline phosphatase (AP) concentrations rose above baseline values in 12 of 17 infants, but remained within normal range (less than 400 IU/liter at 30 degrees C). Another infant with markedly elevated AP values died from liver dysfunction. Radiographs of the forearms were normal except for marked demineralization in one infant in spite of normal 25 OHD concentrations. We conclude that 25 IU vitamin D/dl of nutrient infusate is adequate to maintain normal vitamin D status, as indicated by normal serum 25 OHD concentrations in infants receiving PN for as long as 6 months.

Caval catheterization in the intensive care nursery: a useful means for providing parenteral nutrition to the extremely low birth-weight infant

We provided parenteral nutrition to 40 very low birth-weight premature infants (birth weight 815 +/- 17 grams, gestational age 27 +/- 2 weeks) with a superior vena cava catheter. To avoid the risk of transport, catheterization was performed under sterile conditions in the intensive care nursery. The central venous catheter facilitated administration of calories to sustain growth, especially in infants whose catheters remained in place for 3 weeks or longer. The overall incidence of catheter related sepsis was high (30%) but the majority of cases were due to Staphylococcus epidermidis and resolved without incident. Other complications of parenteral nutrition were minimal. This approach is a safe and effective means of providing nutrition to the very low birth-weight infant.

Clinical outcome as assessed by anthropometric parameters, albumin, and cellular immune function in high-risk infants receiving parenteral nutrition

Twelve infants with underlying gastrointestinal tract disorders receiving 16 courses of total parenteral nutrition were retrospectively studied. Stratification according to calorie intake provided the best means for discriminating among different outcomes. Infants receiving greater than 110 calories/kg/d experienced significantly greater increases in weight, mid-arm muscle circumference, and triceps and subscapular skinfold thicknesses than did infants receiving less than 110 calories/kg/d. Catch-up growth was only seen in infants with intakes of greater than 110 calories/kg/d. In nine of these 12 infants, in vitro cellular immune parameters were assayed. Infants in both the high- and low-calorie groups experienced similar increases in transformational responses to pokeweed mitogen (PWM) and phytohemagglutinin (PHA) and in the percentage of peripheral blood T lymphocytes. No increase in serum albumin was seen regardless of calorie intake.

Follow-up studies of children treated with a long-term intravenous nutrition (IVN) during the neonatal period

The outcome of the 28 children treated with intravenous nutrition (IVN) for more than 4 wk during the neonatal period was investigated. Ten of the 28 children had a normal length of small bowel (group 1) and the other 18 children had a short bowel (group 2). Eight of these 28 children (4 in group 1 and 4 in group 2) died during or after cessation of IVN; three died from complication of IVN and 5 died from their initial disease. On physical examination, delay in catch-up growth was observed in the early postoperative period, particularly in children in group 2, but this diminished with time. Mental and emotional development showed both groups to be within the normal range, except for two children. Intellectual function was also normal in five children over the age of 4 yr who were examined. Hepatic dysfunction was noticed during IVN in 30.0% in group 1 and 66.7% in group 2, indicating that the longer the duration of IVN, the higher the incidence of liver damage. Furthermore, histologic abnormalities in these neonates lasted for a longer time. These results imply that long-term IVN during the neonatal period in surgical patients does not interfere with physical and developmental growth. However, careful and long-term follow-up of liver function after IVN is necessary.

Total parenteral nutrition in low-birth-weight neonates with complicated surgical disorders; effects and difficulties

Twenty low-birth-weight, surgical neonates were given total parenteral nutrition (TPN). They were divided into two groups according to birth-weights. Group A consisted of 8 patients weighing less than 2,000 gm, and group B consisted of 12 patients weight between 2,000 and 2,500 gm. The infusate of TPN consisted of 15% glucose and 3% amino acids solution, and 10% fat emulsion. The dosage administered was usually 120 ml/kg/day in the amino acid glucose solution and 15 ml/kg/day in the fat emulsion, but varied depending on the clinical condition of the patients. The duration of parenteral nutrition was from 3 to 76 days with an average of 34.3 days. Four patients in group A survived. Three of the four who died had already been in severe septicemia due to the original disease before the initiation of parenteral nutrition. Ten in group B survived. The intake of 500 mg/kg/day of nitrogen as crystalline amino acids and calories of more than 80 Cal./dg/day produced a gain of body weight and a positive nitrogen balance. However, the weight gain in the patients in group A lagged behind. Furthermore, severe hepatic dysfunction was induced in four in group A. We conclude that TPN will improve the general condition, weight gain and positive nitrogen balance, even in low-birth-weight neonates with complicated surgical disorders.

The inferior epigastric vein as an alternate site for central venous hyperalimentation

The inferior epigastric vein is a good access site when central venous nutrition cannot be delivered through the usual routes. The babies can remain mobile without angulating the catheter and, by tunneling above the diaper line, contamination can be avoided.

Gastroschisis update

Sixty-four infants with gastroschisis have been managed in the 9-yr period, 1970-1979, with four postoperative deaths. The silo technique has been the standard method of management in this series, permitting initial expansion of the abdominal cavity without increased abdominal pressure and respiratory embarassment. Removal of the silo and complete closure of the abdominal wall deficit were possible 5-12 days later. A high proportion of the infants were below 2500 g in weight at birth (61%); and although 3 of the 4 postoperative deaths occurred in the low birth weight group, this did not appear to be a factor in mortality. Associated anomalies occurred in 25 of the 64, but only the coincident intestinal atresias (6) were of major significance. These additional anomalies were not responsible for deaths. Two deaths occurred from problems dating from birth, one from aspiration and the second from sepsis. The other two resulted from postoperative complications resulting in infarction of the midgut. Both were caused in part by failure to adequately enlarge the abdominal wall defect at the time of the initial procedure. Other postoperative complications were relatively few. Although all required intravenous nutritional support, the long term results in terms of growth and development and of intestinal function were quite satisfactory.

A safer system for percutaneous subclavian venous catheterization in newborn infants

Percutaneous infraclavicular cannulation of the subclavian vein in even the tiniest infants can be performed with safety and ease using a plastic cannula metal needle stylet and following plastic catheter. This route for achieving superior vena caval catheterization provides a most satisfactory method for central pressure monitoring, long term antibiotic administration, total parenteral nutrition, and exchange transfusion. Few serious complications have been noted in over a hundred infant cannulations. The procedure can be performed in the intensive care nursery with a success rate of over 95%. Sepsis rates in clean cases are acceptably low. Most sepsis is due to other clearly identifiable sources of infection in these already critically ill infants.

Total parenteral nutrition in pediatrics

Parenteral nutrition (p.N.) is indicated whenever oral food intake is partly or completely disturbed. The objective of this type of treatments is to provide the organism with sufficient nutrients and maintain the structure and growth. The supply of an optimum mixture of water, protein, carbohydrates, fats, minerals, vitamins and trace elements is a prerequisite for this. In the following parts of this study the indications for p.N., the technique and requirements for different nutrients, minerals, trace elements and vitamins are presented. A type of amino acid mixture especially prepared for pediatric use is prevented and new results of t.p.N. are discussed. In the following parts of this study the indications for p.N., the technique and practice of the infusion programme, the clinical and laboratory investigation of t.p.N., the complications and their prophylaxis during the p.N. are discussed. The goal of better total parenteral nutrition is approached when dosage, infusion rate, contraindications and the guidelines discussed here are observed. We will, however, continue the work for a further improvement of intravenous nutrition.

Total parenteral nutrition in infants. Blood levels of glucose, lactate, pyruvate, free fatty acids, glycerol, d-beta-hydroxybutyrate, triglycerides, free amino acids and insulin

Two regimens (A and B) for TPN were designed to meet the requirements of newborn infants for calories, amino acids, fatty acids, electrolytes, trace elements and vitamins. Both "A" and "B" included fat emulsion (Intralipid). "A" contained fructose and glucose, "B" glucose only. "A" provided amino acids (Vamin) in proportions similar to those of whole egg, "B" similar to those of human milk. All nutrients were given simultaneously into peripheral veins by constant infusion. Nineteen patients (11 newborns, 8 infants) were studied for 1-28 days. Twelve infants recovered, 7 died. In none could TPN be regarded as the cause of death. Treatment was complicated by sepsis in 5 infants. During the course of treatment, blood levels of substrates and insulin were measured before, during and 30 min after discontinuation of TPN. Highly raised concentrations of circulating substrates seen in 3 infants seemed to be related to a poor clinical condition rather than to the regimen used. Infants in good condition tolerated TPN well. Low levels of branch-chained amino acids and tendency to ketonemia, when infusion was stopped, suggested that minimal rather than optimal supply of energy and of amino acids in relation to energy was provided with both regimens. Low insulin levels associated with elevated blood levels of substrates suggested that insulin administration to selected cases might be indicated. Fructose (0.30 g/kg X hour-1) given with regimen A increased blood lactate concentrations. Homocystinaemia appeared in 2 cases; disappearance after excess vitamin B6 administration indicated increased B6 requirement.

Computer utilization for intravenous nutrition in surgical neonates preliminary report

A program was developed to store important numerical clinical data such as daily weights, intravenous caloric intake, and laboratory test results on surgical neonates who required total intravenous nutrition. Preliminary experience with the data from the first 5 surgical neonates requiring intravenous nutrition indicated that this data processing is easily achieved. Data retrieval by the development of output programs provided rapid access to stored records, rapid data tabulation, and graphic print-out of parameters, such as intravenous calories per kilogram per day and weight gain, that can be placed in the patient's record.

Peripheral intravenous nutrition without fat in neonatal surgery

During a 1 yr period, 19 infants less than 2 mo of age were fed intravenously with an infusate composed of glucose, amino acids, electrolytes, and vitamins. The solution was infused at a rate of 200 ml/kg/day or more for periods ranging from 5-247 days. No central venous catheters were utilized; the solutions were always administered through a needle in a peripheral vein. Weight gains similar to those seen with other techniques of intravenous nutrition were observed in all of the patients studied. No instance of fluid overload in the form of pulmonary edema, peripheral edema, or congestive heart failure was seen, and osmotic diuresis was not observed because of the lower tonicity of the infusate. Phlebitis was seen in 1/5 of the infusions, but was reversed by stopping the infusion and applying warm soaks. Three cases of skin slough were observed and two of these healed spontaneously without the need of skin grafting. The advantages of this technique over central venous nutrition are the elimination of the complications related to the central venous catheter, namely, sepsis and superior vena cava thrombosis.

Oral cholestyramine and paregoric therapy for intractable diarrhea following surgical correction of catastrophic disease of the GI tract in neonates

Ten surgical neonates with postoperative intractable diarrhea and secondary weight loss were treated with combination cholestyramine and paregoric therapy. Within 3-5 days all infants except two showed significant clinical improvement with a decreasing number of stools, an increase in the consistency of the stool, and gradual weight gain. The exact mechanism of action of cholestyramine is not clear. It may act by binding with bile salts and/or endotoxins in the bowel lumen or decreasing the motility of the bowel. Used in combination with paregoric, a known bowel motility depressant, the doses of each medication can be kept quite low thus avoiding undesirable side effects. Medium chain triglyceride formula is helpful in some of these infants to improve fat absorption further. Medication in all of these infants has been discontinued without any adverse effects.

The effect of fat emulsion (Intralipid) on essential fatty acid deficiency in infants receiving intravenous alimentation

Thirteen infants who received IVA in four different ways were studied. The serum fatty acid composition of the infants who received fat-free IVA showed EFA deficiency within 1 wk. This deficiency was cured by administering fat emulsion which accounted for 4% of the total caloric content of the infusate. Fat emulsion which accounted for 2% of the total calories neither improved nor prevented EFA deficiency. This means that intravenous fat emulsion, Intralipid, which accounted for 2% of the total calories as linoleic acid, still satisfies the essential fatty acid requirement.

[Investigations on the utilization of parenterally administered amino acids by premature and hypotrophic neonates (author's transl)]

The composition of an amino acid solution for intravenous use in newborns is discussed in the light of the metabolic kinetics of its constituents. Such a solution would be optimal when based on the transfer characteristics of the single amino acids used. Under these circumstances one would avoid imbalances in the respective blood levels. In particular, the average amount of such a solution needed, and the maximal turnover rates per hour of the specific amino acids during the first 4 weeks of life are discussed.

Intravenous feeding of young infants with persistent diarrhoea

42 infants with persistent diarrhoea were fed intravenously using a simplified regime based on Intralipid and an aminoacid, Fructose and ethanol solution. Peripheral veins were used for up to 56 days, and with scalp veins complications were few and minor. The use of arm and leg veins caused more frequent local problems and is not advised. Central venous lines became necessary in 5 infants, and 3 developed septicaemia. The regime was well tolerated with adequate weight gain when intake was adjusted to the infants' needs. Rates of infusion of 1 g Intralipid/kg hourly over 2 hours and up to 1 g fructose/kg hourly over 14 hours did not cause persistent lipaemia (except transiently in 2 infants) nor metabolic acidosis. Infants must be fully rehydrated with correction of acidosis and electrolyte imbalance before starting intravenous feeding, or acidosis and dehydration from osmotic diuresis may occur. Intravenous feeding should be started gradually and cautiously in severely malnourished infants, and should not be used where liver function is abnormal.

Phosphorus depletion in children on long-term total parenteral nutrition

The retention of nitrogen, calcium and phosphorus was studied in nine infants on total parenteral nutrition. The amounts of calcium, nitrogen and phosphorus were varied singly or simultaneously. The results demonstrate close interrelationships in the retention of these three elements. Not only the absolute amount of phosphorus perfused daily but also the amounts of nitrogen and/or calcium perfused simultaneously account for the phosphorus depletion that may lead to severe hypophosphatemia. The decrease in serum phosphorus concentration with a simultaneous fall of urinary phosphorus excretion to undetectable levels and a rise in urinary calcium output to 10 mg/kg/24 hours or more are warning symptoms of phosphorus depletion. Such a complication was observed in our first seven children on total parenteral nutrition. Phosphorus depletion can be prevented by using the following amounts of these elements in the perfusate: per 100 Kcal/kg/24 hours, 400 mg/kg/24 hours of nitrogen, 35 mg/kg/24 hours of calcium and 40 mg/kg/24 hours of phosphorus. With such a technique no phosphorus depletion was observed in any of the 63 subsequent patients whom we treated with total parenteral nutrition for periods varying from 20 days to 9 months.

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.