Intravenous Hyperalimentation Research Articles

Clinical studies of fluconazole in patients with deep-seated fungal infection in intravenous hyperalimentation (IVH)

Clinical efficacy of fluconazole on fungal infections was evaluated. Fluconazole was administrated orally or intravenously to 16 cases with fungal infections (chronic renal failure 4, congestive heart failure 2, cerebral infarction 2, etc). All cases were suspected of mycosis. The details of those administrated were 16 cases of pneumonia 3 cases, fungemia 9 cases (suspected 7 cases) and urinary tract infection 3 cases. Clinical efficacy rate was 71.4%. Side-effects were observed in only 1 case, and this consisted of transient increase of leukocytes and thrombocytes. Fluconazole is considered to be a potent, safe antifungal agent for the treatment of suspected fungal infection during intravenous hyperalimentation.

Bombesin affects mucosal immunity and gut-associated lymphoid tissue in intravenously fed mice.

Our prior studies show that intravenous (IV) total parenteral nutrition (TPN) produces atrophy of the small intestine-related gut-associated lymphoid tissue and significant decreases in intestinal IgA levels, the major system of mucosal immunity. Others have noted increased small intestinal permeability, bacterial adherence and translocation, and decreased IgA levels in TPN-fed animals. Bombesin, a neuropeptide, may play a regulatory role in mucosal immunity. It is not clear whether bombesin attenuates the TPN-associated gut-associated lymphoid tissue atrophy. To examine the effect of bombesin on gut-associated lymphoid tissue integrity and function during IV TPN feeding. Randomized animal study. A university laboratory. Male ICR mice weighing 25 to 30 g were randomized to chow plus IV saline solution (n = 12), IV TPN (n = 12), or IV TPN plus bombesin (15 micrograms/kg, administered intramuscularly three times a day) (n = 12). Animals were killed after 5 days of receiving the experimental diet. Total small intestinal IgA level was quantified by enzyme-linked immunosorbent assay. Lymphocytes were isolated from Peyer's patches, intraepithelial spaces, and lamina propria and were stained with specific antibodies for B and T cells and for T-cell expression of CD4 and CD8 by flow cytometric analysis. Data were analyzed by analysis of variance. Bombesin prevented the IV TPN decreases in (1) total cell yield and B-cell yield from the Peyer's patches, intraepithelial spaces, and lamina propria; (2) T-cell yield in the intraepithelial spaces and lamina propria; and (3) small intestinal IgA levels. Bombesin also reversed IV TPN decreases in CD4+ and CD8+ T cells in the intraepithelial spaces and Peyer's patches and prevented the decrease in the CD4/CD8 ratio in the lamina propria. Bombesin prevents the TPN-associated atrophy and dysfunction of gut-associated lymphoid tissue, supporting the concept of close neuroimmunologic interaction.

Nutrition and Hydration for the Terminally III-Reply

<h3>In Reply.</h3> —We appreciate the comments of Dr Fainsinger. The articles we cited that failed to show a benefit of nutritional support in cancer patients used total parenteral nutrition that included adequate hydration. In the study by Clamon et al,¹the use of intravenous hyperalimentation in cancer patients at a relatively early stage in their illness failed to show any benefit in survival or amelioration of toxicity. Fainsinger is correct that hydration was not addressed separately. We did not advocate "giving no fluids at all" in our study, but rather letting the patients determine the amount of fluids that they would ingest. The patients that were excluded from our study did not have the capacity to make their needs known consistently or for a long enough portion of their stay (&gt;25% of admission days) to be included in our study. Most of these were obtunded (seven patients) and died

Tube jejunostomy in liver transplant recipients

Nutritional support after liver transplantation most often uses intravenous hyperalimentation followed by nasoduodenal tubes until adequate intake is achieved. Because of difficulties with nasoduodenal tubes, we place jejunostomy tubes (j-tube) at the time of the transplantation, allowing immediate postoperative enteral nutrition. This review analyzes the complications of this procedure in transplant recipients. J-tubes were placed in 108 of 119 adults who underwent liver transplantation between October 1989 and June 6, 1994. These patients were retrospectively reviewed for the type and frequency of j-tube-related complications. J-tube feeds with a semielemental formula were started within 24 to 48 hours after transplantation. Eighteen complications occurred in 16 patients. Six were mechanical obstructions of the j-tube because of kinking by the fascia. Six exploratory laparotomies were required, two each for infection, small bowel obstruction, or catheter displacement. Four other infections were treated by local incision and drainage or percutaneous drainage. One tube required surgical removal in the operating room. Tube jejunostomies can be safely placed at the time of liver transplantation with a low risk of serious complications. We recommend the routine use of j-tubes in patients receiving a liver transplant for the immediate posttransplantation institution of enteral nutrition.

マルチビタミンを添加した高カロリー輸液中でのチアミンの安定性

As intravenous hyperalimentation (IVH) prepared from IVH basic solution and amino acid solution has become popular, lactic acidosis is receiving attention as a serious adverse reaction. Therefore, thiamine is added to IVH in order to prevent this adverse reaction. However, sodium sulfite (SS), added as a stabilizer to many IVH basic solutions and most amino acid solutions, degrades thiamine. Recently, since an amino acid solution without SS has been developed, it is now possible to prepare IVH without SS.In this study, we measured the time courses of the residual concentrations of both SS and thiamine in the 12 kinds of IVH containing multivitamin and investigated the relationship between the SS concentration and the stability of thiamine from the viewpoint of degradation kinetics.From the kinetic analysis results, the degradation rate of SS in the IVH stored in a bag was faster than that stored in a glass bottle. The degradation rate of SS in the IVH was very fast when SS is not included in the IVH basic solution.The degradation of thiamine in IVH was regarded as the apparent first-order degradation process and the degradation rate as being proportional to the SS concentration. The secondorder degradation rate constant of thiamine by SS was not affected by the pH of IVH. Stabilization of thiamine by glucose was inferred by comparing the degradation rate of thiamine caused by SS in IVH and that in buffered solution without glucose.

アンプルカット時に生じるガラス片のＩＶＨ調製者顔面への飛散

Intravenous hyperalimentation (IVH) treatment has been used in Japan since 1970, many hospitals applying this treatment to patients and receiving good results. Since the introduction of IVH treatment, its prescription and technique of this treatment have improved as a result of the many experiments and clinical reasearch conducted.In this study on the pharmacist's safety while adjusting IVH, it was forcused mainly on the amount and the size of the scattering glass fragments and the distance they traveled when an ampoule is opened.The results of the experiment were follows.(1) The number of glass fragments for those larger than 30μm only Scattered was from a minimum of 2 to a maximum of 33. The largest glass fragment found in each of the three samples used was 182.7μm, 238.3μm, and 126.1μm for Ohtsuka MV® Sohvita®, and distilled water, respectively.(2) Many fragment were from 30μm to 40μm in size, with fragments of this size were contained in each sample as follows: 53.50%, 46.30%, and 57.95% in Ohtsuka MV®, SohvitaR, and distilled water, respectively.(3) It was found that glass fragments could scatter up to 80cm in distance away from the ampoule.

Decrease of nosocomial bacteremia and nosocomial pneumonia after introduction of preventive measures of hospital infection

In the early 1980's methicillin-resistant staphylococcus aureus (MRSA) was reported as a major pathogenic organism of geriatric hospital infection in Japan. At the same time in the A geriatric hospital MRSA infection was prevalent. To decrease nosocomial infections some active preventive measures against hospital infection were taken since Oct. 1991. About a year before introduction of prevention of hospital infection in the geriatric ward (190 beds) of A hospital 193 episodes of nosocomial bacteremia were observed. However a year after introduction of preventive measures episodes of nosocomial bacteremia were decreased to less than a half (45.6%) in comparison to the number before introduction of prevention. As a causative organism gram-positive bacteria including MRSA were markedly decreased. Major portals of entry of bacteremia (74.9%) were urinary-tract system, intravenous hyperalimentation (IVH) catheter, and pressure sores. MRSA-positive pressure sores were decreased to 20.4% of those before prevention. On the other hand 87 episodes of nosocomial pneumonia were observed before prevention. However a year after introduction of preventive measures episodes of nosocomial pneumonia were decreased to less than a half (44.8%) in comparison to the number before introduction of prevention. After prevention MRSA and mixed infection of P. aeruginosa and MRSA were markedly decreased. The decrease of bacteremia and nosocomial pneumonia were caused by cleaning hands, the preventive measures for decrease and improvement of pressure sores, cleaning the upper respiratory tract for prevention of lower respiratory-tract infection cleaning floors and education of the staff, etc.

Pancreatojejunal Sutural Insufficiency Occurring after Pancreatoduodenectomy and Countermeasures.

Pancreatojejunal sutural insufficiency occurring after pancreatoduodenectomy and countermeasures are discussed. In the Department of Surgery at Kurume University School of Medicine, 318 patients underwent pancreatoduodenectomies. The present study includes 15 of these patients, all of whom had pancreatojejunal sutural insufficiency. The frequency of sutural insufficiency was 4.7%. Five patients had bile duct cancer, 5 had cancer of the papilla of Vater, 2 had a carcinoma of the pancreatic head, 1 each had gallbladder cancer, chronic pancreatitis, and papillitis. Six (40%) of the 15 patients died during hospitalization. The presence or absence of sutural insufficiency was confirmed mainly by radiography and determining the properties and amylase levels of the drainage fluid. There was no significant difference due to the method of anastomosis. End-to-side anastomosis had a rate of 5 (5.9%) of 85 patients, while end-to-end had 10 (4.3%) of 233 patients. The sutural insufficiency was manifested as a major leakage in 6 patients and a minor leakage in 9. The degree of lymph node dissection was D0 in 6.1%, D1 in 1.4%, D2 in 4.8% and D3 in 10.8%, with a high incidence of sutural insufficiency in D3 patients. The pancreatic duct diameter was smaller than 4 mm in 10, 5-7 mm in 4 and over 8 mm in 1 patient. The intraoperative pancreatic findings were a soft pancreas in 8, slightly hard in 3, and hard in 4 patients. Fibrosis of the pancreas was normal to slight in 11 and moderate in 4 patients. Drainage by relaparotomy was performed in 4 of the 6 patients with major leakages to control sutural insufficiency, and the other 2 underwent continuous aspiration with an intraperitoneal drain inserted during the operation. The 9 patients with minor leakage underwent conservative treatment including continuous aspiration via an intraperitoneal drain inserted during surgery, fasting, intravenous hyperalimentation, and antibiotic administration. All of the patients with major leakage died from an associated occurrence of hepatic insufficiency, renal insufficiency, intraperitoneal hemorrhage or diffuse peritonitis during hospitalization. However, 8 of the 9 patients with minor leakage had some healing, and the 1 remaining patient developed a pancreatic fistula. The frequency of pancreatojejunal sutural insufficiency was high in patients with minimal pancreatic fibrosis, with soft pancreatic tissue without dilatation of the pancreatic duct, and with relatively good pancreatic function.

短期ステロイド治療で軽快したCronkhite-Canada症候群の1例

A 59-year-old male was admitted to the hospital complaining of lower abdominal pain, diarrhea of one month duration, and melena. In this case, numerous and uniform gastrointestinal polyposis, alopecia, onychotrophia, skin pigmentation, and mild hypoproteinemia were found. Histological examination of biopsy specimens from colonic polyps revealed cystic dilatation of the glans and edematous stroma. Cronkhite-Canada syndrome (CCS) was diagnosed. No especial changes of clinical manifestations were seen with conventional treatment (intra-venous hyperalimentation, t-AMCHA) , but diarrhea and polyposis improved remarkably with 10-days steroid therapy. Short-term steroid therapy may effective to CCS with uniform gastrointestinal polyposis, and one of its early phase.

CLINICAL STUDIES OF POSTOPERATIVE HYPERBILIRUBINEMIA FOLLOWING RESECTION OF ESOPHAGEAL CANCER

Risk factors of postoperative hyperbilirubinemia (POHB) following resection of esophageal cancer in 102 cases were studied. The cases were divided into three groups according to the highest value of total bilirubin (T-Bil) after the operation: Group 1; T-Bil<2.0mg/dl. Group 2; 2.0_??_T-Bi1<3.5mg/dl, and Group 3; T-Bil _??_3.5mg/dl. The incidence of POHB, showing more than 2.0mg/dl of T-Bil was extremely high (49.1%). Coexistence of diabetes mellitus, intravenous hyperalimentation and radiation therapy before the operation, clinical labolatory data before and after the operation, volume of intraoperative blood transfu. sion and kind of anesthetics, and postoperative complications did not contribute POHB. On the other hand, the frequency of preoperative administration of anticancer drugs was significantly higher (90.6%) in group 3. Durations of operation in Groups 2 and 3 were significantly longer than Group 1, and volume of intraoperative hemorrhage in Group 3 was significantly more than the others. As to operative procedures, right thoracotomy was more frequently employed in Group 3, and blunt esophagectomy (without thoracotomy) was less frequently done in Group 2 and 3 with significant difference. Moreover, the frequency of lymph node dissection, extending more than 2 regions was significantly high in Groups 2 and 3. These results have demonstrated that the intensity of surgical operation might strongly contribute to POHB and preoperative administration of anticancer drugs would be one of the risk factors of POHB.

Candidemia in non-neutropenic patients with an intravenous hyperalimentation catheter: good prognosis of Candida parapsilosis infection.

Positive blood cultures reported between 1986 and 1993 at the Tokyo Metropolitan Komagome Hospital were evaluated and all patients with an intravenous hyperalimentation catheter who developed candidemia, a total of 94 patients, were analyzed further, while patients with neutropenia were excluded. The primary diagnosis was malignancy in 87.2% of the cases, and Candida albicans and C. parapsilosis were the main organisms detected. A total of 17 patients died from candidemia. The patients who were positive for C. parapsilosis, however, all survived in spite of the fact that their main treatment was only removal of the catheter (20/32 cases), while eight of 25 patients who developed fungemia due to C. albicans died from the fungemia (p = 0.001). There were no significant differences in their risk factors. Because of the better outcome for the patients who developed candidemia due to C. parapsilosis, we might be able to consider less aggressive treatment for such patients.

A CASE OF FLAIL CHEST ASSOCIATED WITH LINEAR FRACTURE OF THE STERNUM AND MULTIPLE FRACTURE OF THE BILATERAL RIBS

With a recent development of artificial respirator and intensive care, patients with severe chest trauma associated with flail chest can be increasingly saved. This time we experienced a 68-year-old woman with flail chest associating with linear fracture of the sternum and multiple fracture of the bilateral ribs who was successfully cured by 13-day internal fixation. In general, multiple fracture of the bilateral ribs with sternum fracture often becomes anterior type flail chest in the chest wall to cause delayed fixation, leading to a critical condition. Treatments of flail chest include (1) internal fixation due to an artificial respirator, (2) intermittent rib fixation (external fixation), and (3) combinated use of (1) and (2). For traumatic patients in an acute phase, we have employed the internal fixation as the first choice, because it is least invasive; permits to devote ourselves to the treatment of other important organs; and recent development of artificial respiratory and intravenous hyperalimentation affords a long-term management with artificail respirator. In patients with flail chest with fracture of the sternum like this case, the internal fixation appears valuable.

咽後間隙血腫の２症例

An 84-year-old female and a 76-year-old female with retropharyngeal hematoma are reported. Both patients visited our hospital because of dyspnea and dysphagia following neck injury. In both patients, the hematoma developed in the retropharyngeal space from the cranial base to the superior mediastinum. The first case underwent in emergent tracheostomy, and was fed with a nasogastric tube. Her hematoma regressed spontaneously in about two weeks. The second case did not need a tracheostomy, but required intravenous hyperalimentation, and her hematoma disappeared itself in about 25 days.

Variation in the Enteric Distribution of Cryptosporidia in Acquired Immunodeficiency Syndrome

Clinical observation suggests that the natural history of intestinal cryptosporidiosis in patients with acquired immunodeficiency syndrome varies greatly. The relation between clinical, small-bowel functional, and nutritional status and the intestinal distribution of the organism was studied in 41 patients who had acquired immunodeficiency syndrome and cryptosporidiosis and who had undergone both proximal small-bowel and colonic biopsies. Two patterns of enteric cryptosporidiosis were identified: severe clinical disease with malabsorption in patients with cryptosporidia in proximal small-bowel biopsy specimens (61% of cases) and less severe clinical disease in patients with cryptosporidia only in the colon or stool (39% of cases). Patients with cryptosporidia in proximal small-bowel biopsy specimens had small-bowel crypt hyperplastic villous atrophy, lamina propria inflammatory infiltrates, poorer D-xylose absorption, greater weight loss, and shorter survival and more often needed intravenous hydration or hyperalimentation. Patients with cryptosporidia in the small-bowel villi only had less severe disease than those with cryptosporidia in the small-bowel crypts. In conclusion, the anatomic distribution of intestinal cryptosporidia in patients with acquired immunodeficiency syndrome varies, and this variation may explain differences in clinical course. Cryptosporidial infection of the proximal small bowel correlates with mucosal injury, malabsorption, dehydration, weight loss, and shortened survival.

The role of MRSA (methicillin-resistant Staphylococcus aureus) adherence and colonization in the upper respiratory tract of geriatric patients in nosocomial pulmonary infections.

The mechanism of nosocomial respiratory infections caused by MRSA (methicillin-resistant Staphylococcus aureus) in geriatric patients was investigated. Seriously ill patients (SIP) undergoing naso-gastric tube feeding or intravenous hyperalimentation and moderately ill patients (MIP) who were orally fed, were examined for their colonization and infection by Staphylococcus aureus (S. aureus) in the respiratory tract. Colonization of MRSA in the upper respiratory tract in SIP was from six to ten times higher than that in MIP and was associated with a high incidence of MRSA pulmonary infections. In vitro S. aureus adherence to nasal or oropharyngeal cells demonstrated that bacteria binding to nasal cells was higher, which probably can be interpreted as an elevated occurrence of S. aureus colonization in the nasal cavity than in the throat. The binding activity of MRSA was not superior to that of MSSA (methicillin-sensitive S. aureus). Though MRSA binding to the nasal cells from SIP was not higher than those from MIP, MRSA colonization in the upper respiratory tract was more frequently seen in SIP (P < 0.01). A higher incidence of total infectious episodes (P < 0.02-0.001) and more frequent use of antibiotics (P < 0.02-0.001), which were potent against MSSA might be the basis for selection of MRSA in these patients. In fact, the rate of MRSA colonization on the skin (pressure sores) was also higher in SIP (P < 0.01). A low nutritional state in SIP (P < 0.01-0.02) might also be associated with MRSA colonization.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic pylorus-preserving pancreatoduodenectomy

A case of chronic pancreatitis localized in the head of the pancreas with pancreas divisum was treated by laparoscopic pylorus-preserving pancreatoduodenectomy. The laparoscopic technique of resection and reconstruction with a gastrojejunostomy, hepaticojejunostomy, and pancreaticojejunostomy is described. The postoperative period was complicated by a jejunal ulcer and delayed gastric emptying necessitating a prolonged hospitalization and intravenous hyperalimentation. No fistulas occurred, a follow-up CT scan revealed no pancreatic abnormalities, and the patient was discharged in good condition on the 30th postoperative day. Although technically feasible, the laparoscopic Whipple procedure may not improve the postoperative outcome or shorten the postoperative recovery period.

Vascular Access Device for Treatment of Cancer Patients

Vascular access devices that are completely implanted have been used for treatment of cancer patients. Vascular access devices are useful for transarterial infusion of anticancer drugs, intravenous hyperalimentation, and drainage of bile juice in obstructive jaundice. These systems have several advantages in the care of patients: they are sealed, they have no external tubes, and they may be useful for blood or biliary sample and intravenous hyperalimentation or chemotherapy. There are only minimal discomforts related to the implantation procedure and no need for routine external catheter care. Most importantly, the quality of the patient's life is dramatically improved without external tubes. For these reasons, we believe that vascular access devices should be indicated for patients with malignant tumors as much as placement of these devices is technically feasible.

Arginine Deficiency Accompanies Persistent Pulmonary Hypertension of the Newborn

Persistent pulmonary hypertension of the newborn (PPHN) is a life-threatening disorder of neonates manifested by vasoconstriction of the pulmonary arteries. Recently, the gas nitric oxide (NO) has been used with some success in the management of infants with PPHN. Exogenous administration of NO selectively dilates the pulmonary vascular bed. NO is naturally synthesized in the body from the amino acid L-arginine. Here we report our findings that infants with PPHN are deficient in arginine and achieve normal or elevated plasma arginine concentrations with intravenous hyperalimentation. We prospectively identified and studied 10 infants with PPHN who were not receiving protein or amino acids for at least 24 h and compared their plasma arginine concentrations to 8 control infants without PPHN given similar nutrition. Plasma arginine concentrations were 32 +/- 14 and 52 +/- 20 mumol/l in infants with PPHN and control infants, respectively (p = 0.02). There were no other statistically significant differences in plasma amino acid concentration for any of the 22 other amino acids determined. Infants with PPHN who were subsequently treated with amino acid infusions had plasma arginine concentrations of 115 +/- 48 mumol/l (mean of ten determinations at 86 +/- 27 h after initiation of intravenous amino acids in five PPHN infants).

A CASE OF ESOPHAGEAL PERFORATION DUE TO A PARTIAL DENTURE PRESENTING WITH THREE PERFORATIONS AND BILATERAL PNEUMOTHORAX

We experienced an extremely rare case of esophageal perforation due to a partial denture presenting with 3 perforations and bilateral pneumothorax, which was successfully managed by conservative treatments. This paper describes the case with a review of such perforated cases due to a partial denture seen in the Japanese literature for the past three decades. A 60-year-old man was seen at the hospital, because he accidentally swallowed a partial denture. It was impossible to take out under a hardscope, but was successfully taken out by using a balloon catheter for sclerotherapy under a fiberscope. Immediately after that remarkable bilateral pneumothorax, mediastinal emphysema, and subcutaneous emphysema developed. In addition esophagography revealed extramural leakages of contrast medium in the vicinity of the second physiologic stenosis of the esophagus and just above the diaphragm. A diagnosis of esophageal perforation was made. Conservative treatments including intermittent suction of the esophagus, intravenous hyperalimentation, and administration of antibiotics were performed. The clinical course was uneventful and the perforations were completely closed on the 15th hospital day. The patient was discharged from the hospital on the 19th day.

AN EFFECTIVE TREATMENT BY INTRAPERITONEAL OK-432 FOR INTRACTABLE HEPATIC LYMPHORRHEA AFTER RADICAL GASTRECTOMY FOR EARLY GASTRIC CANCER WITH LIVER CIRRHOSIS-A CASE REPORT-

A 54-year-old male with liver cirrhosis was transfered to the department for operation on early gastric cancer and cholelitiasis. After radical gastrectomy with lymph node dissection and cholecystectomy, a large amount of non-chylous high protein ascites appeared. Intravenous hyperalimentation, diuretics and reinfusion of the steralized cellfree and concentrated ascitic fluid were not effective. Four times intraperitoneal OK-432 were successfully administered. It is difficult to ligate the lymphatic vessels in the second operation, and the possibility of conservative therapy for intractable hepatic lymphorrhea is described.