Intravenous feeding

Serum albumin levels in cancer patients receiving total parenteral nutrition

Serum albumin concentration is commonly used as an index of nutritional status and as an indicator of nutritional response in hospitalized patients receiving total parenteral nutrition (TPN). One hundred thirty-nine cancer patients receiving TPN for at least two weeks were studied. Albumin intake, serum albumin, fluid balance, and weight change was monitored from 14 to 100 days of TPN. Patients were classified into three groups: A) patients receiving no exogenous albumin; B) patients receiving less than 25 grams of exogenous albumin; and C) patients receiving at least 25 grams of exogenous albumin during their course of TPN. Linear regression analysis of serum albumin levels vs. time on TPN showed a minimal positive correlation for patients in groups B and C (r = 0.154 and r = 0.183, respectively). Further analysis showed a significant elevation of serum albumin levels only in patients in group C (p less than or equal to 0.05). Contingency table analysis showed statistically significant increase in the incidence of sepsis in patients treated with exogenous albumin (X2 = 10.50, df = 2, p less than 0.01). There was no relationship between the change in serum albumin concentrations and the number of patient deaths. In addition, no relationship between tumor burden and subsequent response of serum albumin levels were identified. Serum albumin levels do not increase in cancer patients receiving TPN, unless exogenous albumin is given. Serum albumin appears to be a poor index of nutritional response in cancer patients receiving TPN.

Treatment of central venous silastic catheter infections using hydrochloric acid

Patients receiving long-term home parenteral nutrition through a subcutaneously tunnelled central venous silastic catheter underwent a trial of 1.5 ml of 2M hydrochloric acid instilled into the catheter each time an episode of catheter sepsis was diagnosed. Four patients had eleven episodes of central venous catheter infection, with the hydrochloric acid clearing the infection on seven occasions, and unblocking the catheter once. The mainstay of therapy for catheter sepsis is removal of the catheter. However, in patients with subcutaneously tunnelled central venous silastic catheters, if reinserting the catheter is anticipated to be a major problem then a small dose of hydrochloric acid in an attempt to clear the infection may be worth a trial.

Biotin-responsive in vivo carboxylase deficiency in two siblings with secretory diarrhea receiving total parenteral nutrition

Two siblings with a congenital syndrome of secretory diarrhea and seizures developed progressive skin rash, alopecia, and mucocutaneous candidiasis while receiving biotin-free total parenteral nutrition. Abnormally low urinary biotin excretion was associated with these clinical findings, but the serum concentration of biotin was within the normal range. There was also increased urinary excretion of lactic acid, 3-hydroxyisovaleric acid, 3-hydroxypropionic acid, and 3-methylcrotonylglycine. The younger of the two children subsequently died with severe metabolic acidosis. In the oder sibling, intravenous treatment with biotin (200 micrograms/day) resulted in resolution of the organic aciduria. A larger dose (10 mg/day) appeared to be required for rapid improvement in the skin lesions. These cases suggest that clinically significant biotin deficiency can occur in patients with chronic diarrhea receiving biotin-free total parenteral nutrition.

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.

Experimental infusion thrombophlebitis. Importance of the pH of glucose solutions

An experimental method is presented, which compares the tendency of different infusions to cause thrombophlebitis. It is based ona quantitative histological analysis of the inflammatory changes in the veins of rabbit ears after infusions under standardized conditions. By means of this method the inflammatory changes in the veins have been shown to be significantly less pronounced when the pH of glucose solutions is altered from 3.0 to 3.6. This pH change has been prescribed in the 1971 corrections to Pharmacopoea Nordica 1963. By complete neutralization of 5% glucose a further reduction of the damage to the veins has been obtained. For this purpose phosphate buffer is recommended.

Minimizing systemic infection during complete parenteral alimentation of small infants

A regimen of parenteral alimentation for infants was designed to eliminate as many factors responsible for infection as possible. The most important features of the feeding regimen were as follows. (1) Infants were fed via indwelling silastic catheters inserted into the superior vena cava or the right atrium by a cutdown operation. (2) The parenteral feeding was fat free to simplify the administration system. Y connectors and 2- or 3-way taps were avoided. (3) Extreme care was taken of junctions within the infusion system. Only certain members of the hospital staff were allowed to break such junctions, e.g. during the changing of packs of solution or of the giving sets. These junctions were sprayed with antibacterial aerosols. (4) The hypertonic solutions of nutrients were prepared in plastic packs, which do not require ventilation. The infusion system was therefore not contaminated by the entry of unsterile outside air. (5) The infused solutions were passed through 0·22 μm millipore filters before entering the patient's blood stream. There was an infection rate of 9% which was less than the 25 to 45% infection rate previously reported during parenteral feeding through indwelling venous catheters, and is also less than that associated with ventriculoatrial shunts for hydrocephalus. There was no case of systemic candidiasis, which is the most frequent and most serious infection associated with parenteral feeding.