Discontinuation Of Total Parenteral Nutrition Research Articles

Central catheter removal timing and growth patterns in preterm infants.

Early discontinuation of total parenteral nutrition (TPN) at 100 ml/kg/day of enteral feeds, compared with 140 ml/kg/day, led to significant delay in time to regain the birth weight in very low birth weight infants (birth weight < 1500 g, VLBW). Our aim was to compare the growth of infants in relation with timing of TPN discontinuation up to 2 years corrected gestational age (CGA). Posttrial follow-up study using review of paper medical records. Participants of the randomized controlled trial studying effect of early parenteral nutrition discontinuation on time to regain birth weight in VLBW infants were included. Growth parameters inclusive of weight, length, and occipital-frontal circumference (OFC) were collected. Z-scores were calculated at five predefined time points-birth, 0-11 weeks CGA, 12-35 weeks CGA, 36-60 weeks CGA, and 61-96 weeks CGA and compared for control and intervention groups. Regarding weight, we found lower mean Z-score in the intervention group between 0 and 11 weeks CGA, with larger difference in extremely low birth weight infants (birth weight < 1000 g, ELBW), but this did not reach the statistical significance. Regarding length, the same difference, slightly delayed to 35 weeks CGA was observed and reached statistical significance for ELBW infants between 12 and 35 weeks CGA. There was no difference in OFC mean Z-scores at any timepoint. The discontinuation of TPN at 100 ml/kg/day showed significantly lower Z-score for length in ELBW infants between 12 and 35 weeks CGA. There were no differences in Z-scores by 2 years CGA.

A Novel Case of Biliary Atresia in a Premature Neonate With 1p36 Deletion Syndrome.

We describe the case of a premature male neonate diagnosed with biliary atresia who was found to have chromosome 1p36 deletion syndrome. Our patient was born prematurely, at a gestational age of 28 weeks. Pregnancy was complicated by advanced maternal age, gestational hypertension, and intrauterine growth restriction. Physical examination revealed several dysmorphic features, prompting a genetic evaluation, which revealed chromosome 1p36 deletion syndrome. At week 7 of life, he was found to have acholic stools. Direct bilirubin was found to be elevated despite discontinuation of total parenteral nutrition at 3 weeks of life, thus raising the suspicion for biliary atresia. Biliary atresia was confirmed by constellation of clinical, imaging and intraoperative findings. First reported in 1996, 1p36 deletion syndrome has been researched increasingly and several new phenotypic associations have been reported over the years. While attempts at linking specific phenotypic abnormalities with individual gene(s) deletion(s) are being made, deletion patterns that would affect specific organ system or function remain to be fully understood. Thus, clinicians currently rely on reports of previously identified abnormalities. To our knowledge, our patient is the first report of biliary atresia in a patient with chromosome 1p36 deletion syndrome. It is important to determine the etiology of the cholestasis, when present, while caring for premature neonates with 1p36 deletion syndrome. This is necessary to avoid assuming that the cholestasis is arising from total parenteral nutrition administration and not from other gastrointestinal anomalies including biliary atresia, which is a time-sensitive diagnosis.

Variation in Enteral Feeding Practices and Growth Outcomes among Very Premature Infants: A Report from the New York State Perinatal Quality Collaborative.

Extrauterine growth restriction (EUGR) is inversely related to neurodevelopmental outcome. We analyzed growth outcomes and enteral nutrition practices among preterm infants at New York State (NYS) regional perinatal centers (RPCs) to identify practices associated with risk of EUGR. Surviving infants < 31 weeks' gestation admitted to a NYS RPC during 2010 were identified and data collected on their growth and enteral nutrition from a statewide database. Neonatologists at NYS RPCs were surveyed to identify center-specific nutritional practices. Survey responses, nutrition, and growth data were then analyzed to identify factors associated with risk of EUGR. Of the 1,387 infants, 32.6% were discharged with EUGR. Incidence of EUGR varied more than fivefold among RPCs. Nutritional practices directly related to EUGR included age at first enteral feeding and full enteral feedings. Among the surveyed nutrition practices, longer duration of trophic feeding before advancing was associated with an increased risk of EUGR while later discontinuation of total parenteral nutrition and larger trophic feeding volume were associated with lower risk. Our study found marked variation in nutrition practices and incidence of EUGR among preterm infants at NYS RPCs. A statewide quality improvement initiative to reduce practice variation and improve growth in preterm infants is underway.

404: The impact of delivery timing on neonatal outcomes of infants with gastroschisis

404 The impact of delivery timing on neonatal outcomes of infants with gastroschisis Anna Palatnik, Matthew Loichinger, Tana Kim, Randall Kuhlmann, Erica Peterson Medical College of Wisconsin, Department of Obstetrics and Gynecology, Milwaukee, WI OBJECTIVE: To assess whether earlier delivery of infants with gastroschisis minimizes intestinal damage or improves neonatal outcomes STUDY DESIGN: A retrospective study of 143 newborns born with gastroschisis between 2000-2011 in a single tertiary center was performed. They were divided in two groups: those delivered ‘’early’’ (before 36 weeks) and those delivered “late” (after 36 weeks). These groups were compared in terms of neonatal outcomes, including weight at the time of delivery, rate of primary closure, bowel atresia, necrotizing enterocolitis (NEC), respiratory distress syndrome (RDS), length of total parenteral nutrition (TPN), length of ventilation and length of neonatal intensive care unit (NICU) stay. RESULTS: 73 neonates were in the early delivery group with mean gestational age (GA) of 34.3 weeks, and 70 were in the late with mean GA of 36.4 weeks. Mean weight of the early group was 2112g and for the late group 2436g (p 0.0001). The rate of primary closure was not significantly different between the two groups (72.8% in late group vs. 67.1% in early group (p 0.54)). Bowel atresia was more frequent in the early group (10.96% vs 7.1%) as well as NEC (5.5% vs 2.9%) but that difference wasn’t significant (p 0.42, and p 0.43 ). The percentage of RDS and mean length of ventilation wasn’t significantly different between groups (p 0.19, and p 0.2). The length of TPN and NICU stay were longer in the early group (37.6 vs 29.1 days and 45.7 vs 34.3 days respectively) and both were statistically significant (p 0.01). Based on the two variables that were significantly different between the groups (length of stay and TPN), we performed survival analysis to include 3 stillbirth cases. It predicted higher probability of discharge and discontinuation of TPN for the late delivery group. CONCLUSION: Delivery before 36weeks is associated with longer NICU stay and longer time of TPN feeding. At the same time there was no significant difference in rates of primary closure or intestinal complications among the two groups of gestation.

Low-dose imatinib in the treatment of severe systemic sclerosis: a case series of six Chinese patients and literature review

Systemic sclerosis (SSc) is a progressive fibrotic disorder with no legitimate effective treatment. Several clinical trials had investigated imatinib mesylate with a target dose of 400∼600mg/day on SSc, and the efficacy is controversial with a generally poor tolerability. We herein reported six female Chinese patients with SSc administered with low-dose imatinib (200mg/day) for a median of 23months (10∼30months). Patients displayed a decreased modified Rodman skin scores (mRSS) by a mean of 6.29 points after 6months of treatment. Three patients who completed 2years of treatment achieved a reduction of mRSS by 8, 18, and 30.5 points, respectively. Pulmonary function was improved or stabilized in two patients with interstitial lung disease. Severe gastrointestinal involvement in one patient was attenuated in terms of discontinuation of total parenteral nutrition and restoration of the serum albumin level. Imatinib was well-tolerated in general, although there were two severe adverse events: a bone fracture and a cerebral hemorrhage in two individuals. Both the adverse events were probably not directly related to imatinib and were recovered uneventfully. Our limited data, along with the review of the literature, suggested that low-dose imatinib might be effective and better tolerated in severe SSc that deserves further study.

Chronic Treatment of Ménétrier’s Disease With Erbitux: Clinical Efficacy and Insight Into Pathophysiology

Ménétrier's disease is a rare premalignant hypertrophic gastropathy characterized by large rugal folds, foveolar hyperplasia with glandular atrophy, hypochlorhydria, and hypoalbuminemia. Patients with severe disease often exhibit refractory nausea and vomiting and require gastrectomy. Evidence from both mice and human beings suggests a critical role for epidermal growth factor receptor (EGFR) signaling in the pathogenesis of this disease. We previously reported significant clinical and biochemical improvement of a single patient treated for 1 month with Erbitux, a monoclonal antibody that blocks ligand binding to EGFR. We describe 2 patients who were given longer-term treatment with Erbitux as an alternative to gastrectomy. The first patient presented with nausea, hypoalbuminemia, and peripheral edema that required total parenteral nutrition (TPN) and infusions of albumin. On institution of Erbitux, there was rapid improvement in nausea and vomiting and stabilization of serum albumin with discontinuation of TPN and albumin infusions. Serum albumin remained stable during a 1-year course of Erbitux without supplemental protein. Application before and after Erbitux of the radiopaque dye ruthenium red to biopsies of the gastric oxyntic gland mucosa demonstrated prompt and persistent closure of tight junctions by electron microscopy. The second patient presented with chronic gastric bleeding that required bimonthly blood transfusions. During a 4-month course of Erbitux, his hematocrit stabilized, and transfusion requirements were eliminated. The present report demonstrates the efficacy of prolonged Erbitux therapy in patients with different presentations of severe Ménétrier's disease and also provides insight into the pathophysiology of the protein-losing gastropathy.

Effect of abrupt discontinuation of high glucose infusion rates during parenteral nutrition.

Serum glucose and insulin concentrations were measured in 15 children older than 2 years of age for 30 minutes after abrupt discontinuation of total parenteral nutrition (TPN). The children ranged in age from 2.4 to 14.2 years (mean 7.9 years). These infants were receiving &lt;10% of their caloric intake by the enteral route. Four patients were receiving corticosteroids. The glucose concentration in the TPN solutions at the time of discontinuation was 15% to 20%. The glucose infusion rate was 0.53 ± 0.23 mmol/kg/min (range 0.22 to 1.2) (9.6 ± 4.2 mg/kg/min; range 4 to 21). Paired glucose and insulin concentrations were measured before, 15, and 30 minutes after the TPN was abruptly discontinued. One child was considered an outlier because of insulin concentrations that were approximately 10‐fold higher than the other children and was not included in the analysis. The initial insulin levels were elevated and rapidly became normal. Glucose concentrations were slightly elevated at the time parenteral nutrition was stopped but were normal and remained stable after 15 minutes. Only one child had a glucose concentration decrease to &lt;3.3 mmol/L (60 mg/dL), and no child had symptomatic hypoglycemia. The investigators found no influence of glucose infusion rate, age, or use of corticosteroid on glucose or insulin concentrations.

Management of the gastrointestinal tract and nutrition in patients with cloacal exstrophy

Cloacal exstrophy is a rare condition in which there is a complex set of congenital anomalies that affect multipleorgan systems, including the gastrointestinal tract. Twenty-six patients with cloacal exstrophy have been treated at the authors' institution during the last 20 years. Gastrointestinal features usually included omphalocele, exstrophy of an everted cecal plate, a short blind-ending distal colon, imperforate anus, and, occasionally, a shortened small bowel. Additional gastrointestinal anomalies included four cases of colonic duplication, one duodenal web, and one malrotation. The average time until the initiation of enteral feeding after initial surgery was 15.6 days, and the time until discontinuation of total parenteral nutrition (TPN) was 36 days. One patient with short bowel syndrome died of TPN-associated liver failure. Five other patients exhibited short bowel physiology, but ultimately each was weaned from supplemental intravenous hyperalimentation. Four patients have under-gone posterior sagittal anorectoplasty, and one has had perineal anoplasty. Of these patients, two are continent and one is free of soilage on a bowel management program. In the authors' experience with management of the gastrointestinal tract and nutrition in patients born with cloacal exstrophy, many patients initially exhibited short bowel physiology, although most eventually adapted. However, very few patients have been able to achieve bowel control.

Abrupt discontinuation of cycled parenteral nutrition is safe

Abrupt discontinuation of total parenteral nutrition (TPN) has been recommended but is not widely practiced because of fear of hypoglycemia. To determine whether hormonal counterregulatory mechanisms prevent hypoglycemia, we studied 12 patients (10 with inflammatory bowel disease, of which 6 received dexamethasone) after both abrupt and tapered discontinuation of 3:1 TPN solution in a clinical research facility. Venous blood was drawn before reduction of TPN rate in the tapered group or 15 minutes before and at abrupt discontinuation in the abrupt group and every 15 minutes for 1.5 hours. Glucose decreased from 152 +/- 56 (baseline) to 100 +/- 22 mg/dl 90 minutes after gradual discontinuation of TPN, compared with 135 +/- 45 to 96 +/- 15 mg/dl at 90 minutes after abrupt discontinuation, with no significant differences in mean glucose values. Mean epinephrine, norepinephrine, insulin, glucagon, growth hormone, cortisol, symptom score, and vital signs were not statistically different between the two groups. Hypoglycemia does not occur after abrupt discontinuation of TPN. The same changes in counterregulatory hormones were seen whether discontinuation was tapered or abrupt. In stable patients, TPN solutions can be abruptly discontinued.

Effect of abrupt discontinuation of high glucose infusion rates during parenteral nutrition

We measured serum glucose and insulin levels in 15 children older than 2 years of age for 30 minutes after abrupt discontinuation of total parenteral nutrition. Initially high insulin levels rapidly became normal, and glucose levels were stable after 15 minutes. No patient had biochemical or symptomatic hypoglycemia. Glucose infusion rate, age, or use of steroid therapy had no apparent influence. Abrupt discontinuation of total parenteral nutrition is safe in most children older than 2 years of age. (J P ediatr 1994;124:441-4)

Glucose response to abrupt initiation and discontinuation of total parenteral nutrition.

Plasma glucose was studied during the initiation of total parenteral nutrition (TPN) and the discontinuation of TPN without a tapering schedule. Blood was sampled every 5 minutes for 2 hours after the start of TPN and 1 week later as TPN was discontinued. A total of 14 initiations and 14 discontinuations were studied in 18 patients. Severity of illness in patients ranged from stable condition postoperatively to multiple-system failure; six patients had diabetes mellitus. The TPN solution was a 3:1 admixture that provided a caloric intake equal to 1.2 times the resting energy expenditure, with 40% fat and 60% carbohydrate calories. An average of 1963 kcal was provided per day (340 g of glucose, 79 g of fat). During the initiation phase, the mean increase in plasma glucose was 60 mg/dL. The increase for diabetic patients was 79 +/- 14 mg/dL compared with 52 +/- 23 mg/dL for the nondiabetics. During the discontinuation phase, the mean plasma glucose decreased 40 +/- 20 mg/dL; two patients with high concentrations of regular insulin (50 and 100 units) showed an increase in plasma glucose when the TPN was stopped. Plasma glucose returned to the preinfusion baseline after discontinuation. During both initiation and discontinuation, plasma glucose showed little change after the first 60 minutes. No clinical symptoms of hypoglycemia were observed. In conclusion, TPN as a 3:1 admixture can be safely started as full nutrition support and stopped abruptly without a tapering schedule. Plasma glucose response is rapid, predictable, and mostly complete within 60 minutes.

Hepatic steatosis due to total parenteral nutrition: The influence of short-gut syndrome, refeeding, and small bowel transplantation

This study was undertaken to determine whether refeeding through the native small intestine or through a small bowel transplant would reverse hepatic steatosis induced by total parenteral nutrition (TPN), and of what influence a coexisting short-gut syndrome is. Three short-gut syndromes of different severity were established in Lewis rats (short-gut I, mild; short-gut II, moderate; short-gut III, severe). TPN was administered for 10 days and the animals were refed for 20 days. A liver biopsy after the TPN period confirmed a mild to moderate fatty infiltration of the liver in all groups. After the refeeding period a second liver biopsy was obtained and no evidence of hepatic steatosis was observed in Groups 1, 2, 3, and 4 (normal Lewis rat, short-gut I, II, and III). The animals in group 5 (short-gut I) received a syngeneic small bowel transplant after discontinuation of TPN. After the refeeding period the liver biopsies showed no evidence of fatty infiltration. The intestinal graft also reversed the nutritional deficiencies which were observed in the animals with short-gut and showed normal body weight gain and nitrogen and fat uptake in comparison to the normal animals (Group 1). These data show that a small bowel graft is capable of reversing the deleterious sequelae of short-gut syndrome as well as the TPN-related hepatic steatosis.

The Effect of Acute Discontinuation of Total Parenteral Nutrition

The Effect of Acute Discontinuation of Total Parenteral Nutrition

The Effect of Acute Discontinuation of Total Parenteral Nutrition L.D. WAGMAN, K.B. MILLER, R.B. THOMAS, H.H. NEWSOME, AND G.C. WEIR Department of General Oncologic Surgery, City of Hope National Medical Center, Duarte, California; Department of Surgery, Medical College of Virginia, Richmond, Virginia; and Joslin Diabetes Center, Joslin Clinic, Boston, Massachusetts

The Effect of Acute Discontinuation of Total Parenteral Nutrition L.D. WAGMAN, K.B. MILLER, R.B. THOMAS, H.H. NEWSOME, AND G.C. WEIR Department of General Oncologic Surgery, City of Hope National Medical Center, Duarte, California; Department of Surgery, Medical College of Virginia, Richmond, Virginia; and Joslin Diabetes Center, Joslin Clinic, Boston, Massachusetts

The effect of acute discontinuation of total parenteral nutrition.

The present study was undertaken to assess the impact of acute discontinuation (AD) of total parenteral nutrition (TPN) on serum glucose, insulin, and glucagon levels and on the generation of symptomatic hypoglycemia. Fifty studies were performed in 48 patients. In none of the 30 studies of 1 hour duration nor in the 20 studies of 8 hours duration was there a single episode of symptomatic hypoglycemia. One patient had a glucose below normal (60 mg/dl) during the first hour after AD. Glucose and insulin concentrations were elevated at the start of TPN discontinuation but returned to normal values within 60 minutes and remained there during the successive 7 hours of study. Although glucagon levels were slightly elevated at zero time, no significant decrease occurred. There was no evidence for counter-regulation based on the patterns of glucose and hormone levels. With some restrictions, acute discontinuation is a safe, rapid method of ending a prolonged TPN infusion.

Pancreatitis in association with hypercalcemia in patients receiving total parenteral nutrition

Six patients receiving total parenteral nutrition (TPN) developed hypercalcemia and acute pancreatitis. Four were long-term home TPN patients, and two were short-term hospital TPN patients. Causes of pancreatitis other than hypercalcemia were not found. The etiology of the hypercalcemia remained unclear and in particular was not due to calcium infusion or hyperparathyroidism. In 4 patients in whom it was measured, the plasma parathyroid hormone was normal (in 2) or nondetectable (in 2). Hypercalcemia and pancreatitis subsided with discontinuation of TPN. Thus, some patients receiving TPN develop hypercalcemia, and in some of these pancreatitis ensues.

Liver Disease in Infants Receiving Total Parenteral Nutrition

Progressive cholestasis and abnormal elevations of liver enzymes occurred in one third of 92, mostly preterm, newborn infants who received total parenteral nutrition (TPN) with protein hydrolysates, synthetic L-amino acids, and intravenous fat emulsion. The synthetic amino acid plus intravenous fat emulsion was not superior to the protein hydrolysate in preventing liver disease. The liver function returned to normal after discontinuation of TPN, which suggests a causal relationship. Hepatic microscopy was abnormal in 12 of 14 infants examined. The main features were progressive cholestasis and portal tract fibrosis and infiltration, which led to liver failure and death in two infants. In our experience, liver disease is the major metabolic complication of TPN in infants.