Internal Jugular Route Research Articles

Sustained low catheter related infection (CRI) incidence in an observational follow-up study of 9924 catheters using automated data scripts as quality assurance for central venous catheter (CVC) management

To maintain a low incidence of Catheter Related Infections (CRI) and Catheter Related Bloodstream Infections (CRBSI), continuous follow-up studies on catheter management are necessary. The aims of the present study were to investigate the incidence of catheter tip colonisation, CRI and CRBSI in the Region, to further explore the feasibility of automatic data collection and to investigate associations between independent variables and CRI. Data from electronic patient charts on all documented central venous catheter (CVC) insertions from multiple hospitals in southern Sweden, between March 2019 and August 2020, were automatically extracted. Multivariable regression analyses were used to identify associated risk factors. In total, 9924 CVC insertions were included. The prevalence of CRI and CRBSI were 0.7% (n= 74) and 0.02% (n= 20) with incidences of 1.2/1000 catheter days and 0.3/1000 catheter days, respectively. We found a sustained low incidence of CRI and CRBSI in the Region. Catheter tips were less likely to be colonised when the subclavian route was used compared to the internal jugular route and male sex as well as increased number of catheter lumens were associated with both catheter tip colonisation and CRI. By using automated scripts, data extraction was efficient and feasible but also demonstrated that real-time quality assurance should be recommended, since this is superior to current standard.

Comparison of Complications in Patients with Central Venous Catheter Placement Via Internal Jugular, Subclavian and Femoral Route at Intensive Care Unit

Central venous lines are passed in almost all patients admitted in intensive care unit and a need still exist to look for best route for this purpose. Objective: To compare the complications in patients with central venous catheter passed via internal jugular, subclavian and femoral route at intensive care unit. Methods: A comparative cross-sectional study was conducted on 380 patients admitted in intensive care unit of Bahria International Hospital RWP from January 2022 to June 2022. Central venous catheters were passed by consultant critical care specialist on call at the time of reception of patient in unit. All the patients were observed for one week for presence of any local or systemic complications. Results: Out of 380 patients, 240 (63.2%) were male while 140 (36.8%) were female. Central venous catheter was passed via internal jugular vein in 220 (57.8%) patients, via subclavian route in 60 (15.8%) patients and via femoral route in 100 (26.3%) patients. Failed attempts were seen statistically significantly more in internal jugular route (p-value-0.041) while local cellulitis was seen more in femoral route (p-value-0.012). Conclusions: Internal Jugular vein was the route most commonly used for insertion of central venous catheter in patients admitted in our intensive care unit. Complications were seen more not very common in our setting. Failed attempts were more seen in internal jugular route while local cellulitis was seen more in femoral route.

Superior Vena Cava Syndrome from Percutaneous Right Ventricular Assist Device Use in Right Ventricular Failure

Percutaneous right ventricular assist device (RVAD) support with right internal jugular (IJ) vein access has emerged as a viable solution for treating refractory RV failure. Recent reports have shown that RVAD support with this approach can be beneficial in a variety of clinical scenarios including post cardiotomy RV failure, cardiogenic shock, and severe acute hypoxemic respiratory failure with associated RV dysfunction, as well as decreased mortality compared to surgically implanted RVADs. However, the safety profile of such devices has not been characterized. A comprehensive retrospective review was completed for all patients receiving percutaneous RVAD support via a right internal jugular route with either 28 or 31F cannula at our institution between April 2017 and December 2018. Preoperative patient demographics, intraoperative, and postoperative outcomes, with specific focus on device related complications. Fourty patients (27 men, 67.5%) with mean age of 52 years ± 15.6 and refractory RV failure were managed with a percutaneous RVAD inserted through the right IJ. Of these 40 patients, 3 (7.5%) patients demonstrated device related superior vena cava (SVC) syndrome resulting from obstruction of the SVC with the RVAD cannula. One patient managed by head of bed elevation and early removal of the device (I believe). Two were treated by connecting a "venting" tubing to the side port on the introducer sheath and placing into the ECMO circuit to for decompression. Symptoms resolved in all 3 patients and no deaths resulted from SVC syndrome. SVC syndrome related to percutaneous RVAD placement is an important, but previously undescribed postoperative complication of RVAD use. Early identification allows safe management of this complication, which does not detract from the safety of percutaneous RVAD support.

Paediatric Central Venous Access: Experience in the Largest South African Paediatric Surgical Centre

ABSTRACT Background: Percutaneous central venous catheterization (CVC) in the paediatric population is a relatively common procedure but local data in South Africa are extremely limited. Objective: To describe percutaneous CVC in the local setting with regard to patient population demographics, health care professionals performing the procedure, techniques, and immediate complications of the procedure. Methods: A prospective descriptive study of CVC was performed at Chris Hani Baragwanath Academic Hospital from 1 May 2017 to 31 July 2017. Results: A total of 129 CVCs were inserted. Complete data were collected on 95 placements. Median patient age was 60 days (range: 1–5760). The majority of CVCs occurred in surgical patients (78/95, 82%). Irritant drugs (31/95, 33%), fluid administration (27/95, 28%), and failure to establish peripheral intravenous access (16/95, 17%) were the most common indications for CVC. The immediate mechanical complication rate was 13% (12/95). No statistical difference was found in complication rates between line placement by junior and senior staff, between the subclavian and internal jugular routes, between patients with previous CVC access and those without, and between intubated and awake patients. The majority of CVC were placed in the neonatal unit (55%, 52/95), without the use of ultrasound guidance (100%, 95/95), and outside of the operating theatre (74%, 70/95). Conclusions: Immediate mechanical complication rates are comparable to international figures. The high number of CVCs necessitates the establishment of a vascular access service that identifies those patients at high risk of requiring CVC early, relieves the paediatric surgical service of the high burden of CVC, and actively pursues safer and less resource intensive alternatives to CVC.

Single Center Experience with a Percutaneous Right Ventricular Assist Device in the Management of Right Ventricular Failure

Purpose Right ventricular assist device (RVAD) support can be beneficial in a variety of clinical scenarios including post cardiotomy RV failure, cardiogenic shock, and severe acute hypoxemic respiratory failure with associated RV dysfunction. Reported mortality after RVAD insertion ranges from 37% to 46%. Percutaneous RVAD support via right internal jugular vein has emerged with the potential for enhanced weaning and ambulation strategies. However, the experience with such an approach remains limited. Methods A comprehensive retrospective review was completed for all patients receiving percutaneous RVAD support via a right internal jugular route at our institution between April 2017 and September 2018. Successful weaning from support, in-hospital mortality, and freedom from device related complications were assessed. Results Percutaneous RVAD support was instituted in 31 patients (22 men, 71%) with a median age of 58 years (19 to 77 years). Indications for implantation were divided into 3 groups. Group 1: Post cardiotomy support (n=18, 58%) including following LVAD insertion, pulmonary thromboendarterectomy, bilateral lung transplant, or cardiac transplantation, Group 2: Cardiogenic shock (n=7, 23%), and Group 3: Primary respiratory failure (n=6, 19 %). There were no failures to wean RVAD in Group 1, compared with 67% failure to wean in Group 2 and 33% in Group 3. Median duration of support in Group 1 was 16 (7-36) days, 5 (1-16) days in Group 2, and 13 (8-18) days in Group 3. All-cause mortality for the entire cohort was 29%. Mortality in Group 1 was 2/18 (11%), Group 2 was 4/7 (57%), and Group 3 was 3/6 (50%). Complications included postoperative bleeding requiring reoperation in 7 (23%) patients, device related superior vena cava obstruction in 3 patients (10%), and device migration in 2 (6%) patients. There were no device-related infections, DVT, valvular damage, or pulmonary emboli observed in this cohort. No patients required transition to implantable long-term RVAD. Conclusion Percutaneous RVAD support appears to be a versatile and effective tool for treating patients with severe RV failure, with best outcomes in the post cardiotomy group. The ability to ambulate these patients while on support and remove the device at the bedside without surgery may permit a more liberal use of this technology with improvements in outcomes in RV failure.

Central venous access sites for the prevention of venous thrombosis, stenosis and infection.

Central venous access (CVA) is widely used. However, its thrombotic, stenotic and infectious complications can be life-threatening and involve high-cost therapy. Research revealed that the risk of catheter-related complications varied according to the site of CVA. It would be helpful to find the preferred site of insertion to minimize the risk of catheter-related complications. This review was originally published in 2007 and was updated in 2011. 1. Our primary objective was to establish whether the jugular, subclavian or femoral CVA routes resulted in a lower incidence of venous thrombosis, venous stenosis or infections related to CVA devices in adult patients.2. Our secondary objective was to assess whether the jugular, subclavian or femoral CVA routes influenced the incidence of catheter-related mechanical complications in adult patients; and the reasons why patients left the studies early. We searched CENTRAL (The Cochrane Library 2011, Issue 9), MEDLINE, CINAHL, EMBASE (from inception to September 2011), four Chinese databases (CBM, WANFANG DATA, CAJD, VIP Database) (from inception to November 2011), Google Scholar and bibliographies of published reviews. The original search was performed in December 2006. We also contacted researchers in the field. There were no language restrictions. We included randomized controlled trials comparing central venous catheter insertion routes. Three authors assessed potentially relevant studies independently. We resolved disagreements by discussion. Dichotomous data on catheter-related complications were analysed. We calculated relative risks (RR) and their 95% confidence intervals (CI) based on a random-effects model. We identified 5854 citations from the initial search strategy; 28 references were then identified as potentially relevant. Of these, we Included four studies with data from 1513 participants. We undertook a priori subgroup analysis according to the duration of catheterization, short-term (< one month) and long-term (> one month) defined according to the Food and Drug Administration (FDA).No randomized controlled trial (RCT) was found comparing all three CVA routes and reporting the complications of venous stenosis.Regarding internal jugular versus subclavian CVA routes, the evidence was moderate and applicable for long-term catheterization in cancer patients. Subclavian and internal jugular CVA routes had similar risks for catheter-related complications. Regarding femoral versus subclavian CVA routes, the evidence was high and applicable for short-term catheterization in critically ill patients. Subclavian CVA routes were preferable to femoral CVA routes in short-term catheterization because femoral CVA routes were associated with higher risks of catheter colonization (14.18% or 19/134 versus 2.21% or 3/136) (n = 270, one RCT, RR 6.43, 95% CI 1.95 to 21.21) and thrombotic complications (21.55% or 25/116 versus 1.87% or 2/107) (n = 223, one RCT, RR 11.53, 95% CI 2.80 to 47.52) than with subclavian CVA routes. Regarding femoral versus internal jugular routes, the evidence was moderate and applicable for short-term haemodialysis catheterization in critically ill patients. No significant differences were found between femoral and internal jugular CVA routes in catheter colonization, catheter-related bloodstream infection (CRBSI) and thrombotic complications, but fewer mechanical complications occurred in femoral CVA routes (4.86% or 18/370 versus 9.56% or 35/366) (n = 736, one RCT, RR 0.51, 95% CI 0.29 to 0.88). Subclavian and internal jugular CVA routes have similar risks for catheter-related complications in long-term catheterization in cancer patients. Subclavian CVA is preferable to femoral CVA in short-term catheterization because of lower risks of catheter colonization and thrombotic complications. In short-term haemodialysis catheterization, femoral and internal jugular CVA routes have similar risks for catheter-related complications except internal jugular CVA routes are associated with higher risks of mechanical complications.

Simultaneous transjugular renal biopsy and hemodialysis catheter placement in patients with ARF

Background: Previous studies have evaluated transjugular renal biopsy in patients with contraindications to percutaneous renal biopsy or those undergoing simultaneous renal and hepatic biopsies. We sought to evaluate transjugular renal biopsy in patients with acute renal failure (ARF) or ARF in the presence of chronic renal insufficiency (CRI) who required venous catheter placement for hemodialysis (HD). Methods: Ten consecutive patients (6 patients, ARF; 4 patients, ARF on CRI) at a single tertiary-care medical center, while undergoing placement of HD access through the internal jugular route, also underwent transjugular renal biopsy using the Quick-Core (Cook, Bloomington, IN) system to delineate the cause of ARF. Transjugular renal biopsy was performed because it was the opinion of the attending nephrologist that a histological diagnosis might alter management. Results: Renal biopsy findings were diabetic nephropathy (3 patients), acute tubular necrosis (ATN; 2 patients), nephrosclerosis (2 patients), immunoglobulin A nephropathy (1 patient), lupus nephritis with focal crescents and ATN (1 patient), and pauci-immune necrotizing glomerulonephritis (1 patient). There were no major complications from the procedures. Among the 6 patients with ARF, management was directly affected in 3 patients (either initiation of appropriate immunosuppressive therapy or withholding of such therapy). In the remaining 3 patients with ARF and in patients with ARF on CRI, performing transjugular renal biopsy at the time of HD access placement obviated additional testing and/or unnecessary therapy. Four patients recovered renal function and HD therapy was discontinued, 2 patients died, and 1 patient was lost to follow-up. Conclusion: Simultaneous transjugular renal biopsy/HD catheter placement should be considered in patients with ARF requiring HD therapy for whom knowledge of the renal histological diagnosis may alter patient management. Background: Previous studies have evaluated transjugular renal biopsy in patients with contraindications to percutaneous renal biopsy or those undergoing simultaneous renal and hepatic biopsies. We sought to evaluate transjugular renal biopsy in patients with acute renal failure (ARF) or ARF in the presence of chronic renal insufficiency (CRI) who required venous catheter placement for hemodialysis (HD). Methods: Ten consecutive patients (6 patients, ARF; 4 patients, ARF on CRI) at a single tertiary-care medical center, while undergoing placement of HD access through the internal jugular route, also underwent transjugular renal biopsy using the Quick-Core (Cook, Bloomington, IN) system to delineate the cause of ARF. Transjugular renal biopsy was performed because it was the opinion of the attending nephrologist that a histological diagnosis might alter management. Results: Renal biopsy findings were diabetic nephropathy (3 patients), acute tubular necrosis (ATN; 2 patients), nephrosclerosis (2 patients), immunoglobulin A nephropathy (1 patient), lupus nephritis with focal crescents and ATN (1 patient), and pauci-immune necrotizing glomerulonephritis (1 patient). There were no major complications from the procedures. Among the 6 patients with ARF, management was directly affected in 3 patients (either initiation of appropriate immunosuppressive therapy or withholding of such therapy). In the remaining 3 patients with ARF and in patients with ARF on CRI, performing transjugular renal biopsy at the time of HD access placement obviated additional testing and/or unnecessary therapy. Four patients recovered renal function and HD therapy was discontinued, 2 patients died, and 1 patient was lost to follow-up. Conclusion: Simultaneous transjugular renal biopsy/HD catheter placement should be considered in patients with ARF requiring HD therapy for whom knowledge of the renal histological diagnosis may alter patient management.

Simultaneous transjugular renal biopsy and hemodialysis catheter placement in patients with ARF

Previous studies have evaluated transjugular renal biopsy in patients with contraindications to percutaneous renal biopsy or those undergoing simultaneous renal and hepatic biopsies. We sought to evaluate transjugular renal biopsy in patients with acute renal failure (ARF) or ARF in the presence of chronic renal insufficiency (CRI) who required venous catheter placement for hemodialysis (HD). Ten consecutive patients (6 patients, ARF; 4 patients, ARF on CRI) at a single tertiary-care medical center, while undergoing placement of HD access through the internal jugular route, also underwent transjugular renal biopsy using the Quick-Core (Cook, Bloomington, IN) system to delineate the cause of ARF. Transjugular renal biopsy was performed because it was the opinion of the attending nephrologist that a histological diagnosis might alter management. Renal biopsy findings were diabetic nephropathy (3 patients), acute tubular necrosis (ATN; 2 patients), nephrosclerosis (2 patients), immunoglobulin A nephropathy (1 patient), lupus nephritis with focal crescents and ATN (1 patient), and pauci-immune necrotizing glomerulonephritis (1 patient). There were no major complications from the procedures. Among the 6 patients with ARF, management was directly affected in 3 patients (either initiation of appropriate immunosuppressive therapy or withholding of such therapy). In the remaining 3 patients with ARF and in patients with ARF on CRI, performing transjugular renal biopsy at the time of HD access placement obviated additional testing and/or unnecessary therapy. Four patients recovered renal function and HD therapy was discontinued, 2 patients died, and 1 patient was lost to follow-up. Simultaneous transjugular renal biopsy/HD catheter placement should be considered in patients with ARF requiring HD therapy for whom knowledge of the renal histological diagnosis may alter patient management.

Branched‐Chain Amino Acids in Patients With Hepatic Encephalopathy

Hospitalized patients with hepatic insufficiency often suffer from severe catabolic states and are in urgent need of nutrition support during their acute illness. Protein intolerance, however, remains a significant problem with respect to the provision of adequate nutrition, either enterally or parenterally. The following report is an anecdotal series of 63 consecutive patients in a large urban hospital treated prospectively with nutrition support using a prototype high branched‐chain amino acid solution (FO80) given by technique of total parenteral nutrition (TPN) by the subclavian or internal jugular route with hypertonic dextrose. Sixty‐three patients, of which 42 had chronic liver disease (cirrhosis) with acute decompensation and 17 with acute hepatic injury and four with hepatorenal syndrome, are the subject of this report. All required IV nutrition support and were either intolerant to commercially available parenteral nutrition solutions or were in hepatic encephalopathy at the time they were initially seen. The cirrhotic patients had been hospitalized for a mean of 14.5 ± 1.9 days before therapy, had a mean bilirubin of 13 mg/100 mL, and had been in coma for 4.8 ± 0.7 days despite standard therapy. Patients with acute hepatitis had been in the hospital for 16.2 ± 4.1 day before therapy, had a mean bilirubin of 25 mg/100 mL, and had been in coma 5.2 ± 1.6 days before therapy. Routine tests of liver function, blood chemistries, amino acids, EEGs, and complex neurologic testing including Reitan trailmaking tests were used in the evaluation of these patients. Up to 120 g of synthetic amino acid solution with hypertonic dextrose was tolerated in these patients with improvement noted in encephalopathy of at least one grade in 87% of the patients with cirrhosis and 75% of the patients with hepatitis. Nitrogen balance was achieved when 75 to 80 g of synthetic amino acids were administered. Survival was 45% in the cirrhotic group and 47% in the acute hepatitis group. Encephalopathy appeared to correlate with individual amino acids differentially in the various groups and with the ratio between the aromatic and the branched‐chain amino acids. Ammonia did not correlate with either the degree of encephalopathy or improvement therefrom. In 24 patients therapy for hepatic encephalopathy was limited to infusion of the branched‐chain enriched amino acid solution only, with wake‐up in 66% of this group. The results strongly suggest that in protein intolerant patients requiring nutrition support, infusion with branched‐chain enriched amino acid solutions is well tolerated with either no worsening of or improvement in hepatic encephalopathy coincident with the achievement of nitrogen equilibrium and adequate nutrition support.

Another neurological complication of central venous cannulation

Another neurological complication of central venous cannulation

Central Vein Catheter-Related Thrombosis in Intensive Care Patients: Incidence, Risks Factors, and Relationship With Catheter-Related Sepsis

To evaluate the incidence and risk factors for catheter-related central vein thrombosis in ICU patients. Observational prospective multicenter study. An 8-bed surgical ICU, a 10-bed surgical cardiovascular ICU, and a 10-bed medical-surgical ICU. During an 18-month period, 265 internaljugular or subclavian catheters were included. Veins were explored by duplex scanning performed just before or < 24 h after catheter removal. Suspected risk factors of catheter-related central vein thrombosis were recorded. None. Fifty-seven catheters were excluded from the analysis. Therefore 208 catheters were analyzed. Mean age of patients was 64+/-15 years, simplified acute physiologic score was 12+/-5, organ system failure score at insertion was 1+/-1, and mean duration of catheterization was 9+/-5 days. A catheter-related internal jugular or subclavian vein thrombosis occurred in 33% of the cases (42% [95% confidence interval (CI), 34 to 49%] and 10% [95% CI, 3 to 18%], respectively). Thrombosis was limited in 8%, large in 22%, and occlusive in 3% of the cases. Internal jugular route (relative risk [RR], 4.13; 95% CI, 1.72 to 9.95), therapeutic heparinization (RR 0.47; 95% CI, 0.23 to 0.99), and age >64 years (RR, 2.44; 95% CI, 2.05 to 3.19) were independently associated with catheter-related thrombosis. Moreover, the risk of catheter-related sepsis was 2.62-fold higher when thrombosis occurred (p=0.011). Catheter-related central vein thrombosis is a frequent complication of central venous catheterization in ICU patients and is closely associated with catheter-related sepsis.

Short communication: tunnelled central venous catheter insertion via the internal jugular vein using a dedicated portable ultrasound device.

We describe the use of a purpose-built portable ultrasound device to assist puncture of the internal jugular vein during percutaneous insertion of tunnelled central venous catheters such as Hickman lines. In many situations the internal jugular route is safer, faster and less costly in comparison with the subclavian approach. The use of ultrasound allows an accurate initial venous puncture with fewer complications, in the hands of both experienced operators and those less familiar with the internal jugular vein approach.

Interpleural Placement of Central Venous Catheter: Failure of Preventive Practices

An attempt to access the central venous circulation in a patient with a persistent left pleural effusion resulted in positioning the catheter within the pleural space. Chest roentgenograms with injection of contrast material revealed catheter location. Compliance with standard preventive practices may not assure correct placement of a central venous catheter via the internal jugular route in a patient with a hemothorax or effusion of unknown composition.

Post Catheterisation Vein Stenosis in Haemodialysis: Comparative Angiographic Study of 50 Subdavian and 50 Internal Jugular Accesses

From January 1986 to December 1990 we studied angiographically the subclavian-brachiocephalic vein of 100 patients dialysed by subclavian catheter for 50 (first group) and by internal jugular catheter for the 50 others (second group). These two groups were not statistically different as regards age (61.6 +/- 11.3 years in the first and 61 +/- 11.1 in the second), sex (48% and 56% were women), duration of catheter insertion (31 +/- 21.8 and 31.7 +/- 16 days), and the number of dialysis sessions (13.5 +/- 9.1 and 13.6 +/- 7.1). The type of catheters, the frequency of removal for poor flow (16% in both groups) or infections (6% in both groups), and the local nursing were similar in the two groups. The only difference was the side of cannulation: the right side in 58% of cases in group 1 and 78% in group 2. The angiographic study revealed a stenosis of the vein in 42% of the subclavian group and in 10% of the internal jugular group: a dramatic difference in favour of the internal jugular route, whose superiority over the subclavian route is asserted in respect of venous access of dialysed patients.

Superiority of the Internal Jugular over the Subclavian Access for Temporary Dialysis

We studied angiographically the access route 1-27 months after the insertion temporary dialysis catheters in 52 patients: 32 subclavian and 20 internal jugular. The two groups were statistically similar with respect to age, sex and race. The subclavian catheters were left in for a mean of 11.5 days (2-22) while the internal jugular ones were inserted for 15.8 days (5-25; p = 0.0015). One hundred percent of the internal jugular patients were free of any venogram abnormalities in their venous access return. In marked contrast, 50% of the subclavian sites had mild to severe stricutures with 90% having 70-100% occlusion of the subclavian vein. Six patients had bilateral severe strictures. The long-term stricture rate of subclavian catheters in the subclavian vein was unacceptably high compared to the internal jugular route.

Pulmonary artery catheterization

We compared complications of pulmonary artery catheter (PAC) insertion and maintenance at internal jugular (IJ) vs. subclavian (SC) sites. Patients were randomized into groups using an IJ or SC route, and insertions were timed. An air-permeable dressing and anticontamination shield were used. Catheters were removed 72 h after insertion. If PAC monitoring was still needed, a new catheter was either inserted over a guidewire at the initial insertion site or inserted at a new site. On removal, the catheter tip, introducer-sheath tip, and catheter within the shield were submitted for semiquantitative culture. Sixty-six catheters were initially inserted, and 26 were changed. No determinative differences in the time for venous cannulation were found, but the IJ route was slightly faster. In 3% of the catheterizations, serious complications arose. The infection rate was 2% for initial catheters, 8% for second catheters placed over a guidewire, and 15% for second catheters placed at a new site. These differences were not consequential. No local infection or catheter-related sepsis occurred. Thus, using a standard, sterile-insertion technique and a catheter-maintenance protocol yielded a low risk of insertion and infectious complications at either the IJ or SC site. Our data indicated that PACs can be changed safely over a guidewire at 72 h, avoiding further insertion risks without increasing infectious complications.

Infusion of branched-chain enriched amino acid solution in patients with hepatic encephalopathy.

Hospitalized patients with hepatic insufficiency often suffer from severe catabolic states and are in urgent need of nutritional support during their acute illness. Protein intolerence, however, remains a significant problem with respect to the provision of adequate nutrition, either enterally or parenterally. The following report is an anecdotal series of 63 consecutive patients in a large urban hospital treated prospectively with nutritional support using a prototype high branched-chain amino acid solution (FO80) given by technique of total parenteral nutrition by the subclavian or internal jugular route with hypertonic dextrose. Sixty-three patients, of which 42 had chronic liver disease (cirrhosis) with acute decompensation and 17 with acute hepatic injury as well as four with hepatorenal syndrome, are the subject of this report. All required intravenous nutritional support and were either intolerant to commercially available parenteral nutrition solutions or were in hepatic encephalopathy at the time they were initially seen. The cirrhotic patients had been hospitalized for a mean of 14.5 +/- 1.9 days before therapy, had a mean bilirubin of 13 mg/100 ml, and had been in coma for 4.8 +/- 0.7 days despite standard therapy. Patients with acute hepatitis had been in the hospital for 16.2 +/- 4.1 days before therapy, had a mean bilirubin of 25 mg/100 ml, and had been in coma 5.2 +/- 1.6 days before therapy. Routine tests of liver function, blood chemistries, amino acids, EEGs, and complex neurological testing including Reitan trailmaking tests were used in the evaluation of these patients. Up to 120 grams of synthetic amino acid solution with hypertonic dextrose was tolerated in these patients with improvement noted in encephalopathy of at least one grade in 87% of the patients with cirrhosis and 75% of the patients with hepatitis. Nitrogen balance was achieved when 75 to 80 grams of synthetic amino acids were administered. Survival was 45% in the cirrhotic group and 47% in the acute hepatitis group. Encephalopathy appeared to correlate with individual amino acids differentially in the various groups and with the ratio between the aromatic and the branched-chain amino acids. Ammonia did not correlate with either the degree of encephalopathy or improvement therefrom. In 24 Patients therapy for hepatic encephalopathy was limited to infusion of the branched-chain enriched amino acid solution only, with wake-up in 66% of this group. The results strongly suggest that in protein intolerant patients requiring nutritional support, infusion with branchedchain enriched amino acid solutions is well tolerated with either no worsening of or improvement in hepatic encephalopathy coincident with the achievement of nitrogen equilibrium and adequate nutritional support.