Cyclic Total Parenteral Nutrition Research Articles

Impact of a multidisciplinary intervention program on quality and safety of parenteral nutrition

BackgroundParenteral nutrition is a live-saving therapy but it is associated with complications.PurposeDescribe the results of a monitoring and intervention program (MIP) in patients with total parenteral nutrition (TPN).Materials and methodsPatients...

A Practical Guideline for Calculating Parenteral Nutrition Cycles

Both physiologic and psychological reasons for cycling total parenteral nutrition (TPN) have been well established. Despite widespread acceptance of this practice, the only previously published method for calculating TPN cycle rates is inherently flawed. A mathematical formula was derived to facilitate reliable calculation of cyclic TPN flow rates as a function of total volume and cycle time. A publicly accessible website was subsequently developed to expedite rapid determination of TPN cycles. A fail-safe method of calculating TPN cycle flow rates can be expressed as F = V/(4T-10), where F is equal to the basal flow rate (mL/h), T is equal to the desired cycle time (hours), and V is equal to the total volume of TPN (mL) to be delivered in 24 hours. The basal flow rate and twice the basal flow rate are used for the first and last 2 hours of the TPN cycle, and the remainder of the cycle runs at 4 times the basal flow rate. TPN cycles may be easily calculated online using this formula at http://peds.stanford.edu/tpn.html. We have developed a fail-safe method of calculating TPN cycle flow rates that will consistently deliver the desired volume and have made an online implementation of this formula publicly available.

Effect of age on substrate oxidation during total parenteral nutrition

OBJECTIVE: Parenteral nutrition is increasingly used in the elderly. Aging is accompanied by metabolic changes that can modify substrate use. We compared substrate oxidation during cyclic total parenteral nutrition (TPN) in elderly and middle-aged patients. METHODS: Twelve elderly patients (eight women, four men; 72 ± 5 y) and 12 middle-aged patients (nine women, three men; 39 ± 13 y) who were on cyclic TPN for intestinal failure were investigated while in stable condition after at least 15 d of TPN. No patient was diabetic. Indirect calorimetry was performed during fasting and every 30 min during the 3 h of TPN infusion and 3 h after infusion, allowing the measurement of nutrient oxidation. Blood samples were obtained every hour for the measurement of glucose, insulin, triacylglycerols, and free fatty acids. RESULTS: In the fasting state, resting energy expenditure was significantly higher in the elderly patients than in the middle-aged patients (39.3 ± 8.1 versus 31.9 ± 4.3 kcal/kg of fat-free mass per day, P = 0.008). During TPN, lipid oxidation was significantly higher in the elderly patients than in the middle-aged patients (1.09 ± 0.17 versus 0.84 ± 0.27 mg · kg −1 · min −1, P = 0.011); glucose oxidation was significantly lower in the elderly patients than in the middle-aged patients (2.19 ± 0.93 versus 3.22 ± 1.54 mg · kg −1 · min −1, P = 0.038). Areas under the curves of glycemia and free fatty acids were significantly higher in the elderly patients. CONCLUSION: In the elderly, TPN was associated with significantly higher lipid oxidation and lower glucose oxidation than in younger patients. TPN formulas and flow rates should therefore be adapted in the elderly.

Twenty-Four-Hour Profile of Growth Hormone in Cyclic Nocturnal Total Parenteral Nutrition

To detect the effect of the loss of alimentation rhythmicity on a circadian rhythm of human growth hormone (HGH) secretion, a 24-hour profile of HGH was studied in a growing child on cyclic nocturnal total parenteral nutrition (TPN). Twenty-four-hour profiles of substrates and metabolic hormones were also studied to evaluate the efficiency of cyclic nocturnal TPN on childhood growth. Periodic blood samples from a child with megacystis-microcolon-intestinal-hypoperistalsis syndrome were obtained on five occasions, at ages 6, 7, 8, 9, and 11, when she was on cyclic nocturnal TPN. Peak HGH secretion appeared with the onset of deep sleep despite the concomitant hyperglycemia and hyperinsulinemia induced by TPN at night. Smaller peaks of HGH were also observed during the noninfusion period during the day. Twenty-four-hour profiles of substrates and metabolic hormones indicated a switch from glucose use during the infusion phase to an oxidation of lipids during the noninfusion period. The fact that the patient's growth curve remains within normal limits suggests that cyclic nocturnal TPN would be an efficient method of nutritional support. During cyclic nocturnal TPN, regular rhythm of HGH secretion occurs, and normal childhood growth is achieved.

Tolerance to starvation in children on long-term total parenteral nutrition

To evaluate the consequences of long-term cyclic total parenteral nutrition (TPN) on metabolicpathways which contribute to energy metabolism, adaptation to starvation was studied in a group of seven children 2–7 years old, on long-term cyclic TPN. In addition to clinical monitoring, the following biological parameters were measured: blood levels of glucose, free fatty acids, ketone bodies and carnitine, and urinary excretion of dicarboxylic acids. Five of the seven children had good clinical tolerance up to 30 h of fasting. This indicated that metabolic changes arising from prolonged cyclic TPN are easily reversed when such children are fasting. The other two children had to be refed after 22 and 24 h, respectively. Both had metabolic signs of impaired hepatic fatty acid oxidation or ketogenesis. These metabolic changes might reflect the liver failure caused by TPN in these children, and stresses the fact that prolonged starvation has to be carefully monitored in patients with liver dysfunction secondary to TPN.

Effects of Cyclic Total Parenteral Nutrition on Circadian Rhythmicity of Serum Parameters, Organ Weight and Histological Findings of Liver, Kidney, and Lung in Rats.

Effects of Cyclic Total Parenteral Nutrition on Circadian Rhythmicity of Serum Parameters, Organ Weight and Histological Findings of Liver, Kidney, and Lung in Rats.

Metabolic and thermogenic response to continuous and cyclic total parenteral nutrition in traumatised and infected patients

16 traumatised or infected patients on mechanical ventilation were randomised to continuous TPN or to cyclic TPN after a 24-h period of glucose infusion (1.25 kJ × kg BW −1 × h −1). Energy supply was equivalent to 1.3 × baseline energy expenditure. Glucose, fat and amino acids were administered at a constant rate over 24 h in the continuous TPN group and over 12 h, followed by glucose (1.25 kJ × kg BW −1 × h −1), in the cyclic TPN group. Nutrient-induced thermogenesis was lower during continuous than during cyclic TPN (5 ± 4 vs. 12 ± 7%, mean ± SD, p < 0.05), as was the increase in CO 2 elimination (13 ± 11 vs. 30 ± 7%, respectively, p < 0.01). Energy balance was more positive during continuous TPN. In both groups, energy expenditure reached a plateau during the first 12 h of TPN infusion. The lower nutrient-induced thermogenesis and more positive energy balance, indicates a more efficient utilisation of nutrients during continuous than during cyclic TPN. The lower CO 2 production during continuous TPN, may be advantageous when respiratory function is compromised. The plateau in energy expenditure in response to TPN infusion may be useful as a guideline for nutritional therapy.

Cyclic total parenteral nutrition for surgical neonates; comparison of cyclic TPN with continuous TPN for complication of liver dysfunction and nutritional assessment

Cyclic total parenteral nutrition for surgical neonates; comparison of cyclic TPN with continuous TPN for complication of liver dysfunction and nutritional assessment

The effect of artificial feeding on cholestasis, gallbladder sludge and lithiasis in infants: correlation with plasma cholecystokinin levels

The occurrence of hepatic cholestatis (judged by fasting serum bile acid levels), gallbladder sludge formation and lithiasis (ultrasonography) and their correlation with plasma cholecystokinin (CCK) levels was studied in a group of children on continuous total parenteral nutrition (TPN) (n = 95), and later in 40 of these children on cyclic TPN (cTPN). After resumption of oral feeding, 75 were studied on partial oral feeding (2–4 meals) and 40 on constant rate enteral nutrition (CREN) then 45 on total oral feeding (4–6 meals). Gallbladder sludge occurred in 23% of the children on TPN for 1 month and 32% of those on cTPN for 3 months. On CREN, the sludge rate was unchanged, but dropped significantly (17%) on partial oral feeding, and disappeared in children on total oral feeding. Serum bile acids were abnormal in 80% of children on TPN or cTPN and diminished significantly on total oral feeding only. Plasma CCK levels on TPN, cTPN and CREN were identical to fasting levels of children on total oral feeding. Plasma CCK levels increased significantly 1 h post-prandially during both partial (p < 0.02) and total oral feeding (p < 0.001). There was a significant negative correlation between the gallbladder sludge rate and CCK levels for all methods of feeding. This study demonstrates the frequent occurrence of hepatic cholestasis in infants, and the much lower frequency of gallbladder sludge in children compared to adults on TPN. Plasma CCK levels obtained during the different methods of feeding could explain the reduction and eventual disappearance of sludge following stimulation of CCK secretion by discontinuous feeding.

Calcium Metabolism in Children During Long‐Term Total Parenteral Nutrition

SummaryHypercalciuria and bone disease are frequently associated with total parenteral nutrition (TPN) in children and adults. The aim of this study was to assess the influence of calcium, phosphorus, and vitamin D intakes on hypercalciuria. We observed seven children aged 4–13 years receiving home cyclic TPN for 4 consecutive years. Calcium and phosphorus intakes, constant during the 1st year, were reduced during the last 3 years to 50 and 30% of the initial intakes, and vitamin D was stopped during the 3rd and the 4th years. All children had hypercalciuria and one of them had acute painful osteopenia and nephrocalcinosis at the beginning of the study. Hypercalciuria was corrected and painful bone disease did not occur during the three following years, with TPN daily intakes of calcium, 0.35 mmol/kg, and phosphorus, 0.70 mmol/kg. Cessation of vitamin D administration during 48 months led to no further decrease in calciuria nor to the occurrence of clinical or biological signs of vitamin D deficiency. However, we hypothesize that excessive vitamin D intake may have facilitated the occurrence of the TPN‐related bone disease in one patient and should be avoided. The possible role of parenteral aluminum loading is also discussed.

Calcium Metabolism in Children During Long-Term Total Parenteral Nutrition

Hypercalciuria and bone disease are frequently associated with total parenteral nutrition (TPN) in children and adults. The aim of this study was to assess the influence of calcium, phosphorus, and vitamin D intakes on hypercalciuria. We observed seven children aged 4-13 years receiving home cyclic TPN for 4 consecutive years. Calcium and phosphorus intakes, constant during the 1st year, were reduced during the last 3 years to 50 and 30% of the initial intakes, and vitamin D was stopped during the 3rd and the 4th years. All children had hypercalciuria and one of them had acute painful osteopenia and nephrocalcinosis at the beginning of the study. Hypercalciuria was corrected and painful bone disease did not occur during the three following years, with TPN daily intakes of calcium, 0.35 mmol/kg, and phosphorus, 0.70 mmol/kg. Cessation of vitamin D administration during 48 months led to no further decrease in calciuria nor to the occurrence of clinical or biological signs of vitamin D deficiency. However, we hypothesize that excessive vitamin D intake may have facilitated the occurrence of the TPN-related bone disease in one patient and should be avoided. The possible role of parenteral aluminum loading is also discussed.

Effect of fat-emulsion phospholipids on serum lipoprotein profile during 1 mo of cyclic total parenteral nutrition

Changes in serum lipoprotein determined by selective precipitation were investigated in 11 adult patients during 1 mo of parenteral nutrition. Patients were divided into two groups that received a similar nutrient regimen except for Intralipid (IL) phospholipid, which was higher in group A (10% IL, n = 5) than in group B (20% IL, n = 6), 139 +/- 15 vs 71 +/- 0.5 mg.kg-1.d-1 (P less than 0.01). Lipoprotein X (LPX) detected soon after IL infusions were started reached its highest concentrations in group A. LPX concentrations correlated with phospholipid intakes on days 7 and 15 but not on day 29. Significant increases in the cholesterol and phospholipid content of low-density-lipoprotein-very-low-density-lipoprotein fractions were observed only in group A. It is suggested that these changes were induced by the twofold-higher intake of phospholipids in group A. With regard to the possible involvement of LPX in lipid overloading of the reticuloendothelial system and hepatocytes, administration of 20% IL seems preferable to 10% IL.

Cyclic Total Parenteral Nutrition

Cyclic Total Parenteral Nutrition

Comparison of substrate utilization by indirect calorimetry during cyclic and continuous total parenteral nutrition

Five male adult home patients were studied in a randomized order under continuous (24 h/d) and nocturnal cyclic (15 h/d) isocaloric, isonitrogenous total parenteral nutrition (TPN). They received 2626 +/- 265 total kcal/d as 60% dextrose and 40% lipids; the 3-h lipid infusion was followed by the dextrose amino acid infusion on both regimens. Substrate oxidation was measured by indirect calorimetry during four periods on the fourth day of each regimen. During cyclic TPN net lipogenesis occurred with a nonproteic respiratory quotient (npRQ) greater than 1 during dextrose amino acid infusion followed by net lipolysis with an npRQ less than 1 during the nonnourishing phase. In contrast, during continuous TPN net lipogenesis persisted with an npRQ greater than 1 over the 21 h of dextrose amino acid infusion. During the 3-h lipid infusion, fat oxidation was observed during both regimens but was more pronounced during cyclic TPN (p less than 0.05). As a consequence, 24-h lipid oxidation was higher and 24-h dextrose utilization lower during cyclic vs continuous TPN (p less than 0.05). These results suggest that cyclic TPN when alternating between substrate storage and oxidation, mimics the physiological pattern of oral feeding.

Jejunal motility during cyclic total parenteral nutrition in patients with Crohn's disease.

Our aim was to study the jejunal motility (a) in seven patients receiving longterm (median: 24 days) cyclic total parenteral nutrition (CTPN) for an acute exacerbation of Crohn's disease involving the ileum and/or the colon without any sign of occlusion and (b) in six healthy volunteers undergoing the same parenteral nutrition for one day after an overnight fast. Continuous recordings, lasting 20 hours, were carried out in patients after correction of their nutritional status and significant improvement of the Crohn's disease activity index. In five of the seven patients, we recorded seven to 14 phase III episodes (PIII) (median: 10), both more frequent and slower during the nocturnal part of the recording time as compared with diurnal. Seven to 18 PIIIs (median: 12) were found in controls. The overall duration of the motor activity was not different between these five patients and controls. In the remaining two patients, no PIII episode was recorded and 79% and 57% respectively of the whole recording time consisted of irregular motor activity. Our work therefore, shows that: (a) PIIIs remain and have a circadian variation in their periodicity and propagation velocity, in most of our patients undergoing longterm CTPN (b) CTPN does not determine a longer duration of motor rest of the small bowel in patients than in controls submitted for a short period of time to the same parenteral intake.

Acetate and hypercalciuria during total parenteral nutrition.

Hypercalciuria and negative calcium balance are complications of total parenteral nutrition (TPN). Because metabolism of the TPN formula generates an acid load that can induce hypercalciuria, we evaluated the effect of supplementing the formula with acetate. In a randomized crossover study six patients on continuous and six on cyclic TPN received no added acetate or 160 mmol acetate/d replacing 160 mmol chloride/d for 3 d each. Blood and urine measurements were obtained on day 3 of each formula. Acetate, which is metabolized to bicarbonate, increased blood pH and decreased renal acid excretion. Urinary Ca decreased in every patient from 422 +/- 63 to 240 +/- 46 mg/d (10.5 +/- 1.6 to 6.0 +/- 1.4 mmol/d) and from 468 +/- 68 to 285 +/- 54 mg/d (11.7 +/- 1.7 to 7.1 +/- 1.3 mmol/d) during continuous and cyclic TPN, respectively. Filtered Ca load decreased slightly whereas renal tubular Ca reabsorption increased significantly with acetate. Serum parathyroid hormone, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, and urinary cyclic AMP were not different.

The effect of exclusive parenteral nutrition, constant rate enteral nutrition, partial meal feeding, normal oral feeding and etiology on the plasma pancreatic polypeptide levels in children

Plasma pancreatic polypeptide (PP) levels were determined by radioimmunoassay in 100 children. Of the 81 children on Total Parenteral Nutrition (TPN), 32 were studied after cyclic TPN (cTPN), 66 after Partial Meal Feeding plus Parenteral Nutrition, 25 after Constant Rate Enteral Nutrition and 18 during Normal Oral Feeding. Nineteen controls received normal alimentation. PP levels during TPN (172 ± 17 pg/ml), cTPN (150 ± 23) and Constant Rate Enteral Nutrition (200 ± 27) were similar to each other and to pre-prandium (p), Normal Oral Feeding (198 ± 22) and controls (196 ± 40). PP increased (p < 0.05) in post-prandium (pp), Partial Meal Feeding (233 ± 23) compared to TPN, cTPN, p Normal Oral Feeding and p controls, but remained at half that of pp Normal Oral Feeding (387 ± 58) and pp controls (410 ± 91, p < 0.001). The p PP levels were significantly reduced in chronic intestinal pseudo-obstruction (CIPO) (90 ± 22, p < 0.02) and short bowel (length < 100 cm) (76 ± 17, p < 0.001), as compared to controls. This study indicates that TPN or Constant Rate Enteral Nutrition do not modify basal PP levels. Normal Oral Feeding and Partial Meal Feeding produce a significant pp stimulation of PP release. Intestinal pathology can interfere with p plasma PP levels.

Effect of total parenteral nutrition, constant rate enteral nutrition, and discontinuous oral feeding on plasma cholecystokinin immunoreactivity in children.

Plasma cholecystokinin (CCK) levels were measured by radioimmunoassay in 100 children (mean age: 20 months) on various types of artificial nutrition. Of the 81 children given total parenteral nutrition (TPN), 32 were studied while on cyclic TPN (cTPN), 66 while on partial fractioned feeding completed by parenteral nutrition, 25 while on constant rate enteral nutrition, and 18 while on total discontinuous oral feeding. The remaining 19 control cases were on normal alimentation. Plasma CCK levels during TPN (21.4 +/- 1.6 pg/ml), cTPN (21.8 +/- 2.7 pg/ml), and constant rate enteral nutrition (26.4 +/- 2.8 pg/ml) were not significantly different from each other and were similar to preprandial total discontinuous feeding (21 +/- 2 pg/ml) and control (22.6 +/- 3.5 pg/ml) levels. The postprandial CCK level increased significantly in partial fractionated feeding (33.6 +/- 3.3 pg/ml, p less than 0.02) but remained half that of postprandial total discontinuous oral feeding (75.6 +/- 6.6 pg/ml, p less than 0.001) and postprandial controls (75 +/- 7 pg/ml, p less than 0.001). Thus, basal and stimulated CCK levels are similar in children and adults, and the use of long-term artificial nutritional techniques does not modify the feeding stimulation of CCK. Plasma CCK levels during TPN and constant rate enteral nutrition are similar to fasting values, indicating a possible role for CCK in the biliary sludge.

Effect of Total Parenteral Nutrition, Constant Rate Enteral Nutrition, and Discontinuous Oral Feeding on Plasma Cholecystokinin Immunoreactivity in Children

SummaryPlasma cholecystokinin (CCK) levels were measured by radioimmunoassay in 100 children (mean age: 20 months) on various types of artificial nutrition. Of the 81 children men total parenteral nutrition (TPN). 32 were studied while on cyclic TPN (cTPN). 66 while on partial fractioned feeding completed by parenteral nutrition. 25 while on constant rate enteral nutrition, and 18 while on total discontinuous oral feeding. The remaining 19 control cases were on normal alimentation. Plasma CCK levels during TPN (21.4 ± 1.6 pg ml), cTPN (21.8 ± 2.7 pg ml), and constant rate enteral nutrition (26.4 ± 2.8 pg ml) were not significant different from each other and were similar to preprandial total discontinuous feeding (21 ± 2 pgml) and control (22.6 ± 3.5 pg ml) levels. The postprandial CCK level increased significantly in partial fractioned feeding (33.6 ± 3.3 pg ml. p 0.02) but remained half that of postprandial total discontinuous oral feeding (75.6 ± 6.6 pg ml. p 0.001) and postprandial controls (75 ± 7 pg ml. p 0.001). Thus, basal and stimulated CCK levels are similar in children and adults, and the use of long‐term artificial nutritional techniques does not modify the feeding stimulation of CCK. Plasma CCK levels during TPN and constant rate enteral nutrition are similar to fasting values, indicating a possible role for CCK in the biliary sludge.

Plasma and red blood cells fatty acids in total parenterally fed children: Changes induced by intravenous fat emulsion

Plasma and RBC phospholipids were studied twice in six children on long term cyclic total parenteral nutrition (TPN) (mean 15 months): First on fat free TPN and following 5–8 months (x = 7) of fat infusion (1.5–2 g/kg/day); cyclic TPN does not alleviate the development of essential fatty acid (EFA) deficiency in RBC as soon as the 4th month of fat free TPN. In response to fat infusion n-6 series FA improved in both tissues. However 20:4 n-6 reached normal levels only in plasma, while 18:2 n-6 accumulated in RBC. The mechanism of such a discrepancy remains speculative. These results point out the poor value of plasma levels to assess the body EFA status and the need of separate biochemical and biological studies of each target organ of EFA.