Need For Parenteral Nutrition Research Articles

Assessing Appropriateness of Parenteral Nutrition Usage in an Acute Hospital

Although parenteral nutrition (PN) has become an integral component of patient care, the risks and costs associated with this therapy must be weighed against the benefits. The Department of Nutrition and Dietetics at our tertiary referral, university-affiliated hospital has audited the use of enteral nutrition and PN based on criteria devised from guidelines developed by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). We aimed to examine the use of PN over time and in particular to investigate the appropriate and inappropriate use of this feeding method. Each patient referred for PN was assessed by a dietitian and need for PN evaluated. The appropriateness of the PN was categorized according to predefined criteria. A total of 1191 patients had 1409 episodes of PN during the study period. According to the predefined criteria, 82% of PN episodes were considered "appropriate." PN was "appropriate but avoidable" in 13% of cases. In 5% of episodes, the commencement of PN was considered "inappropriate." The use of appropriate PN increased significantly over the study period (P = .018). Most PN episodes were deemed appropriate. We saw 5% inappropriate usage, which is lower than reported in comparable studies. This study underlines the importance of continuous audit and evaluation of practice to maintain appropriate and evidence-based practice in nutrition support.

Bovine Colostrum to Children With Short Bowel Syndrome

Management of short bowel syndrome (SBS) aims to achieve intestinal autonomy to prevent fluid, electrolyte, and nutrient deficiencies and maintain adequate development. Remnant intestinal adaptation is required to obtain autonomy. In the newborn pig, colostrum has been shown to support intestinal development and hence adaptive processes. The efficacy of bovine colostrum to improve intestinal function in children with SBS was evaluated by metabolic balance studies. Nine children with SBS were included in a randomized, double-blind, crossover study. Twenty percent of enteral fluid intake was replaced with bovine colostrum or a mixed milk diet for 4 weeks, separated by a 4-week washout period. Intestinal absorption of energy and wet weight was used to assess intestinal function and the efficacy of colostrum. Colostrum did not improve energy or wet weight absorption compared with the mixed milk diet (P = 1.00 and P = .93, respectively). Growth as measured by weight and knemometry did not differ between diets (P = .93 and P = .28). In these patients, <150% enteral energy absorption of basal metabolic rate and 50% enteral fluid absorption of basal fluid requirement suggested intestinal failure and a need for parenteral nutrition (PN). Inclusion of bovine colostrum to the diet did not improve intestinal function. Metabolic nutrient and wet weight balance studies successfully assessed intestinal function, and this method may distinguish between intestinal insufficiency (non-PN-dependent) and intestinal failure (PN-dependent) patients.

Management of Gastrointestinal Mucositis Due to Cancer Therapies in Pediatric Patients: Results of a Case Series with SAMITAL ®

Gastrointestinal mucositis is a common debilitating complication of chemotherapy and one for which there is currently no effective long-term treatment. To report our experience with the use of SAMITAL(®), a new oral suspension formulation based on the combination of three standardized extracts from Vaccinium myrtillus, Macleaya cordata fruits and Echinacea angustifolia roots in the prevention and treatment of chemotherapy-induced gastrointestinal mucositis in pediatric patients. 20 pediatric patients undergoing chemotherapy for a range of oncological conditions were followed. Patients initially received oral SAMITAL(®) to treat gastrointestinal mucositis and were then given SAMITAL(®) prophylactically to prevent recurrences with successive cycles of chemotherapy. SAMITAL(®) significantly decreased gastrointestinal mucositis grade after the first episode with a reduction of mean scores from 3.2 ± 0.7 at baseline to 0.4 ± 0.6 at the end of treatment (p < 0.001). SAMITAL(®) reduced pain, mucosal erosions, bleeding and dysphagia/feeding impairment. SAMITAL(®) improved patients' overall condition and quality of life after the first administration and lowered the need for parenteral nutrition. Importantly, it allowed chemotherapy cycles to be continued without complications. Results from this case series suggest that SAMITAL(®) may play an important role in the prevention and treatment of chemotherapy-induced gastrointestinal mucositis in children and adolescents and as such warrants investigation in controlled studies.

PMO-073 Post-operative enteral nutrition and recirculation of jejunal effluent in the management of a paraduodenal hernia: a case report

IntroductionShort gut secondary to surgical resection often requires post-operative total parenteral nutrition. We present a case of ischaemic gut secondary to a paraduodenal hernia. Post-operative nutritional requirements were met using...

Alta frecuencia de pancreatitis aguda asociada a patología biliar en niños chilenos

Elevated frequency of Acute Pancreatitis Associated to biliary Illness in Chilean Children Acute Pancreatitis (AP) in children presents signifi cant morbimortality. Most common etiologies in this age group are trauma, systemic illness and idiopathic pancreatitis. This is different from adult AP, where lithiasis and alcohol consumption are the predominant causes. In Chile, where billiary disease is highly prevalent, there is little information regarding AP among children. Objective: To determine the main clinical characteristics of acute pancreatitis in a group of chilean children. Patients and Methods: A retrospective study (1998-2008) of patients hospitalized with the diagnosis of AP. The diagnosis was confi rmed by elevation of pancreatic enzymes and through images. Demographic data, etiology, complications and resolutions, need for parenteral nutrition, and use of antibiotics were examined. Results: Eighteen patients were identifi ed (8,3 ± 4 y.o.). Etiology of AP was listed as: lithiasis and alterations of biliary duct: 38,8%, idiopathic: 22,2%, secondary to medications: 22,2% and other: 16.8%. Two patients presented peripancreatic infected collections; a similar number formed pancreatic pseudocysts. Six patients (33,3%) required one type of surgical procedure as part of their treatment. Two-thirds of all patients required treatment in ICU. One half of the patients required parenteral nutrition, and two thirds received IV antibiotics. The median length of hospital stay was 20 days (ave 24,9 ± 14,3 ds). There was no mortality in this serie. Conclusions: Unlike previously described, biliary AP was the most common cause in this serie. Biliary pathology should be actively studied among chilean children with AP. (Key words: Acute pancreatitis, cholelithiasis, children). (Rev Chil Pediatr 2011; 82 (6): 525-530

Teduglutide for the treatment of short bowel syndrome

Extensive resection of the intestine impairs its absorptive capacity and results in short bowel syndrome when the nutritional equilibrium is compromised. The remnant intestine adapts structurally to compensate, but nutritional autonomy cannot be achieved in patients with intestinal failure, requiring intravenous fluids and parenteral nutrition (PN) for sustenance of life. PN is expensive and associated with serious complications. Efforts to minimize or eliminate the need for PN heralded research focusing on the therapeutic utility of intrinsic gut factors involved in the postresection adaptation process. With the breakthrough recognition of the intestinotrophic properties of glucagon-like peptide-2, teduglutide, a recombinant analogue of glucagon-like peptide-2, is being investigated as a promising hope to mitigate the requirement of PN. Clinical studies to date have demonstrated a desirable benefit-to-risk profile in regards to its safety and efficacy. If approved for marketing, it will be the first of its class in short bowel syndrome management, offering an innovative therapeutic modality for this debilitating condition.

Predictors of Intestinal Failure and Outcome Following Necrotizing Enterocolitis

Background and Aim: Necrotizing enterocolitis (NEC) is the most common serious, acquired gastrointestinal (GI) disorder affecting newborns. The aim of this study was to identify predictors of intestinal failure (IF) following NEC. Design/Methods: Retrospective study of all neonates treated for NEC Stage II or greater, between 2000 and 2009 at the Hospital for Sick Children, Toronto, a tertiary referral NICU covering 65,000 births per year. Need for surgery, residual bowel length and rates of IF, defined as need for parenteral nutrition > 42 days after NEC and other outcomes were examined. Results: In the 10 year period, 301 patients were treated for NEC. 71 (23%) died within 42 days of NEC diagnosis. In infants surviving >42 days 97/230 (42%) developed IF. There was a significant relationship between IF and gram negative bacteremia, cholestasis, liver failure and mortality. In the infants requiring surgery, mortality was highest in the peritoneal drain group (67%) compared to 34 % in the laparotomy group. Table Conclusions: IF developed in 42% of infants following NEC and was fatal in 21/97 (22%). Predictors for IF are low birth weight, low gestational age, gram negative bacteremia, and need for surgical intervention.

Incidence and risk factors for infections after liver transplant: single‐center experience at the University Hospital Fundación Santa Fe de Bogotá, Colombia

The incidence of infections in liver transplant patients is higher compared with recipients of other organs, and infections are one of the major complications after transplantation. The aim of our study was to evaluate the incidence, presentation and risk factors of infections in liver transplant recipients in a Latin-American population, and to compare the results with data worldwide. We performed a retrospective analysis of 94 consecutive patients undergoing liver transplantation between 2004 and 2008 at the University Hospital Fundación Santa Fe de Bogotá, Colombia. The patients contributed a total of 64.4 person years (PY). Fifty-two patients (55.3%) developed one or more infections, in total 83 events (128.9 infections/100 PY). Bacterial infections represented the most frequent event (71.1%), followed by viral (19.3%) and fungal infections (8.4%). In 1%, no causative organism was identified. More than one-third of infections (37%) occurred during the first 30 days, whereas 83% of all events were seen during the first 6 months. The most common site of pathogen localization was the bloodstream (25.3%), followed by the urinary tract (15.7%), liver with bile tract (14.5%), abdomen (10.8%), surgical site (7.2%), and lungs (9.6%). The overall mortality after 1 year was 14.9%, and 57.1% of the deaths were attributed to infections. We found that risk factors significantly associated with increased incidence rate ratio for infection were prolonged stay at the intensive care unit, the need for parenteral nutrition, and blood transfusion requirement. Our data provide additional information about etiology and epidemiology of infections after liver transplantation.

The influence of dental care associated with laser therapy on oral mucositis during allogeneic hematopoietic cell transplant: retrospective study.

To verify decrease in frequency and severity of oral mucositis in patients submitted to dental care and laser therapy during allogeneic hematopoietic cell transplant. Medical records of patients submitted or not to dental care associated with laser therapy during allogeneic transplant were reviewed. The following data were collected: sex, age, underlying disease, myeloablative conditioning regimens, prophylaxis for graft versus host disease, extension and severity of oral mucositis, pain in the oral cavity and when swallowing, diarrhea, need of peripheral parenteral nutrition and presence of acute graft versus host disease. Significant reduction in extension and severity of oral mucositis, as well as in frequency of oral cavity pain, was observed in patients with dental care/laser therapy (p < 0.01). There were no statistically significant differences regarding frequency of diarrhea, pain when swallowing, and need of parenteral nutrition among the groups. Significant association was found between acute graft versus host disease and pain when swallowing (p < 0.01). Acute graft versus host disease was not associated with oral mucositis severity, oral cavity pain, and diarrhea. Dental care associated with laser therapy reduces the extension and severity of oral mucositis in patients with allogeneic hematopoietic transplant. Further studies are necessary to clarify the isolate efficacy of laser therapy in these conditions, mainly regarding the influence of reduced oral mucositis on the graft versus host disease.

Efficacy of the glucagon-like peptide-1 agonist exenatide in the treatment of short bowel syndrome

Short bowel syndrome (SBS) is a serious clinical disorder characterized by diarrhea and nutritional deprivation. Glucagon-like peptide-1 (GLP-1) is a key hormone, produced by L-cells in the ileum, that regulates proximal gut transit. When extensive ileal resection occurs, as in SBS, GLP-1 levels may be deficient. In this study, we test whether the use of GLP-1 agonist exenatide can improve the nutritional state and intestinal symptoms of patients with SBS. Five consecutive patients with SBS based on ≤90 cm of small bowel and clinical evidence of nutritional deprivation were selected. Baseline SBS symptoms, demographic and laboratory data were obtained. Antroduodenal manometry was performed on each subject. Each patient was then started on exenatide and over the following month, the baseline parameters were repeated. The subjects consisted of four males and one female, aged 46-69 years. At baseline, all had severe diarrhea that ranged from 6 to 15 bowel movements per day, often occurring within minutes of eating. After exenatide, all five patients had immediate improvement in bowel frequency and form; bowel movements were no longer meal-related. Total parenteral nutrition was stopped successfully in three patients. Antroduodenal manometry revealed continuous low amplitude gastric contractions during fasting which completely normalized with exenatide. Exenatide is a novel and safe treatment option for SBS. It produced substantial improvement in the bowel habits, nutritional status and quality of life of SBS patients. Successful treatment with exenatide may significantly reduce the need for parenteral nutrition and small bowel transplant.

Direct right atrial insertion of a Hickman catheter in an 11-year-old girl

Central venous lines are of particular importance in seriously ill children that require parenteral nutrition, chemotherapy, or other medications. The jugular or subclavian veins are ordinarily used for primary access. Alternatives include the femoral veins, the intercostal veins, and transhepatic approaches. If the use of these standard sites of placement is made impossible, due, for example, to chronic thrombosis, an alternative approach has to be found. The following report presents the case of an 11-year-old girl with short-bowel syndrome and a desperate need for parenteral nutrition. Over the course of her treatment, she developed chronic thrombosis of the jugular, subclavian, and femoral veins, as well as thrombosis of the inferior vena cava. As an alternative route for central venous access, we describe a successful direct placement of a tunnelled catheter into the right atrium via a right anterolateral thoracotomy.

Abnormal Doppler enteral prescription trial study: the results of a trial of feeding in a high risk group of premature babies

BackgroundAbnormal antenatal Dopplers with intrauterine growth restriction (IUGR) are associated with increased adverse outcomes in premature infants. Anxiety about necrotising enterocolitis (NEC) often results in delay in enteral feeding.Babies of...

Can bedside criteria predict complications after Ileal Pouch-Anal Anastomosis for chronic Ulcerative Colitis?

Truelove and Witts' criteria remains the gold standard for assessment of disease severity in ulcerative colitis, but it's clinical use is not ideal given its reliance on the combination of clinical, laboratory, and radiographic variables. In a recent study reporting the feasibility of minimally invasive subtotal colectomy and ileal pouch-anal anastomosis (IPAA) for fulminant colitis, we described surgical selection criteria which can be assessed at the bedside, including 1) recent (prior 6 weeks) hospitalization, 2) recent transfusion, 3) malnutrition (weight loss, hypoalbuminemia, or need for parenteral nutrition), or 4) immunosuppression (corticosteroids or infliximab). We aimed to determine if these criteria were associated with overall or infectious complications when present in a cohort of patients who underwent 2-stage IPAA. We identified all adult patients with CUC who underwent hand-assisted laparoscopic total proctocolectomy TPC-IPAA (stage 1 of 2) at our institution from 2004 - 2009 using a prospectively maintained database. Disease extent and severity was assessed according to the Montreal classification. Univariate analysis was performed to assess associations with overall or infectious complications after IPAA. Multivariate logistic regression analysis was performed to assess associations with overall 30-day complications. Data are frequency (proportion), median (interquartile range). Over 5-years, 212 patients underwent HALS-IPAA. Overall age was 35 (26 - 46) years, 88 (41%) women, BMI 25.3 (21.3 - 28.4) kg/m2. According to the Montreal classification of extent, 172 (80%) had pancolitis (E3), 34 (16%) had left-sided colitis (E2), and 8 (3.7%) had ulcerative proctitis (E1), and severity was classified as follows: 7 (3.2%) had severe colitis (S3), 84 (39%) moderate colitis (S2), 100 (48%) mild colitis (S1), and 23 (11%) asymptomatic (S0). A total of 169 (79%) were receiving steroids or infliximab, 49 (23%) had been recently hospitalized, 27 (13%) had evidence of malnourishment, and 16 (7.4%) had recent transfusion. Median operative time was 290 (241 - 354) minutes, 16 (7.4%) were converted to laparotomy, and the median post-operative length of stay was 5 (4 - 7) days. Overall 81 (38%) of patients developed a complication of any grade; 29 of these (13.5% overall) were infectious complications. On univariate analysis, neither Montreal classification extent or severity, nor any of the 4 clinical criteria were associated with overall complications; recent hospitalization (p= 0.5), transfusions (p= 0.82), immunosuppression (p= 0.96) were not associated with infectious complications, while malnutrition was associated with post-operative infections (p= 0.04). When stratified by the number of selection criteria present (2 or more, 3 or more) no statistically significant associations were noted with either overall or infectious complications on univariate analysis. On multivariate analysis of predictors for overall complications, including adjustment for disease severity, no statistically significant associations were noted; multivariate analysis of infectious complications was limited by the absolute number of events. In patients undergoing 2-stage ileal pouch-anal anastomosis, malnutrition appears to be a risk factor for post-operative infectious complications. Further study in a larger cohort is needed to determine if this association is independent of disease severity, extent, or other clinically important variables.

Plasma citrulline is a biomarker of enterocyte mass and an indicator of parenteral nutrition in HIV-infected patients

BackgroundPlasma citrulline is a biomarker of enterocyte mass and function in humans. ObjectiveWe evaluated citrulline in the reemerging context of diarrhea in HIV-infected patients receiving highly active antiretroviral therapy. DesignThis study prospectively measured citrulline in 6 groups of HIV-1 patients (n = 115): 1) undetectable viral load without chronic diarrhea (a; n = 40) and with protease inhibitor–associated toxic chronic diarrhea (b; n = 26), 2) detectable viral load and CD4 > 200/mm3 without (a; n = 6) and with (b; n = 11) chronic diarrhea, and 3) detectable viral load and CD4 <200/mm3 without chronic diarrhea (a; n = 7) and with opportunistic intestinal infections or HIV enteropathy (b; n = 25). The influence of diarrhea on citrulline was assessed by comparing the a and b subgroups with healthy control subjects (n = 100). ResultsCitrulline was slightly decreased (22–30 μmol/L) in groups 1b and 2b and was <22 μmol/L in 19 of 25 patients in group 3b. In group 3b, a citrulline concentration <10 μmol/L was associated with a clinical indication for parenteral nutrition (n = 6 of 8 compared with 2 of 17 if the citrulline concentration was >10 μmol/L; P < 0.05). Citrulline correlated positively with albumin (P < 0.01) and BMI (P < 0.05) and negatively with C-reactive protein (P < 0.01). When antiinfectious and nutritional therapies were successful (n = 18 of 25), citrulline normalized in 2–12 wk. Neither chronic hepatic or pancreatic disease nor lipodystrophy and the metabolic syndrome affected citrulline. Compared with control subjects (38 ± 8 μmol/L), patients without chronic diarrhea (groups 1a, 2a, and 3a) had normal citrulline concentrations (36 ± 6 μmol/L). ConclusionsPlasma citrulline is a reliable biomarker of enterocyte functional mass in HIV patients. Citrulline does not allow the etiologic diagnosis of enteropathy, but it can discriminate between protease inhibitor toxic diarrhea and infectious enteropathy and quantify the functional consequences, which makes it an objective tool for indicating the need for parenteral nutrition.

Prematuros tardíos: una población de riesgo infravalorada

Background and objective There has been a gradual rise in prematurity rates recent years, almost exclusively at the expense of the late preterm (34 to 36 weeks). This population, although with less risk than smaller preterm gestational age, has a morbidity rate significantly higher than term infants. However, there is some underestimation regarding developments in the short and long term. The aim of this study was to look at the incidence of prematurity in our institution and to analyze morbidity and mortality in late preterm compared with term infants Subjects and methods We performed a retrospective review of newborns in our Hospital from January 1992 until December 31, 2008. Late preterm group was defined as between 34 0/7 and 36 6/7 weeks gestation (N=2003) and term infants from 37 to 42 weeks gestation (N=32015). We formed 2 subgroups according two time periods (1992–1998 and 2000–2008). The morbidity and mortality for each of the groups and subgroups, and the morbidity from week 34 to 42, were analysed and compared. Results During the period studied, the prematurity rate increased from 3.9% to 9.8%, exclusively at the expense of the late preterm (79%). The rate of mortality in late preterm was 5 ‰ compared to 1.1 ‰ in the term ( P <0.0001, OR 4.71, 95% CI 2.3–9.5). The incidence of admission to the Neonatal Unit, Cesarean rate, twin, respiratory disorders, need for respiratory support in the form of nasal CPAP or mechanical ventilation, incidence of apnea, jaundice requiring phototherapy, hypoglycaemia and need for parenteral nutrition were significantly higher ( P<0.0001) in the late preterm group compared with term infants. The morbidity rate decreased significantly as gestational age increased, with the lowest value from 39 weeks. Conclusions Morbidity and mortality in late preterm infants is significantly higher than in term infants. The guidelines for these near term premature babies need to be reviewed, looking for possible causes of prematurity, and trying to reduce their impact, as well as developing a protocol for their care and close monitoring to minimize the associated morbidity. There should be long-term monitoring to find out the consequences on their psychomotor development. The obstetrics group should be made aware of the true risks of births in the near-term gestational ages.

Oral Insulin Supplementation in Paediatric Short Bowel Disease: A Pilot Observational Study

Insulin is present in human milk, and oral insulin supplementation causes a dramatic adaptive gut growth in a rat model of short bowel syndrome (SBS). We conducted an open-label pilot observational study to examine whether oral insulin supplementation to paediatric patients with SBS decreases the need for parenteral nutrition (PN). Between April 2004 and March 2006, 10 premature infants and children were recruited from 8 paediatric gastroenterology centres in Israel, Croatia, and Germany. Enrolled subjects received 1 unit of insulin (Actrapid, Novonordisk, Denmark)/kg body weight per dose x 4/day (every 6 hours) for 28 days. We monitored glucose blood levels, weight, enteral and parenteral intake of calories, carbohydrates, and lipids. In addition, blood levels of albumin, ALT, AST, GGT, ALP, total cholesterol, triglycerides, and anti-insulin antibodies were recorded. On average, enteral intake increased from 45.6% +/- 30.6% to 58.9% +/- 28.2% (not statistically significant), and ALT blood levels decreased from 194 +/- 128 U to 136 +/- 79 U (not statistically significant). Two (2/10) infants were weaned off PN. None of the children developed insulin antibodies. Oral insulin supplementation in paediatric SBS is not associated with short-term side effects. Although clinical improvement was observed in a subset of children, whether these effects are due to insulin administration is uncertain. The efficacy of oral insulin remains to be determined in a double-blind manner using a preparation that is resistant to degradation in the stomach.

Candida Isolation in Patients Hospitalized on a Surgical Ward: Significance and Mortality‐Related Factors

Infections caused by Candida are an emerging pathology on surgical wards. The aim of the present study was to evaluate the incidence, characteristics, and predictive factors of mortality in patients colonized and/or infected by Candida spp. in this setting. A consecutive series of 105 patients hospitalized on a general surgery ward between 2000 and 2004 were included, and 118 positive cultures for Candida were identified. The variables age, sex, previous medical history, current disease, anemia, ICU stay, type and localization of the microorganism, need for parenteral nutrition, and transfusions were recorded. The primary outcome was in-hospital mortality. A univariate analysis was performed to determine which of these variables were associated with mortality. With a logistic regression model, independent prognostic factors of mortality were determined. The prevalence of patients colonized and/or infected by Candida on our surgical ward was 0.98% (CI 95%: 0.79-1.17), and the incidence was 49 cases per 1,000 patient-years. Of the 105 patients in this series, 56 were men (53%) and 49 women (47%); the mean age was 63.8 years (SD +/- 15.7). Twelve patients (11.4%) had candidemia. Crude mortality was 23% (24 patients), whereas the mortality attributable to candidemia was 25% (3/12 cases). Anemia (p = 0.001); transfusions (p = 0.003), and an ICU stay (p = 0.002) were associated with mortality. Candidemia was associated with neoplasms (p = 0.02) and the infection caused by Candida parapsilosis (p = 0.04). The only independent factor related to mortality was the anemia (p = 0.028; Odds Ratio: 6.43; 95% CI: 1.23-33.73). Colonization and/or infection by Candida spp. in non-ICU hospitalized surgical patients implies a relative high mortality. Anemia is an independent factor for mortality.

ESPEN Guidelines on Parenteral Nutrition: Geriatrics

Older subjects are at increased risk of partial or complete loss of independence due to acute and/or chronic disease and often of concomitant protein caloric malnutrition. Nutritional care and support should be an indispensable part of their management. Enteral nutrition is always the first choice for nutrition support. However, when patients cannot meet their nutritional requirements adequately via the enteral route, parenteral nutrition (PN) is indicated. PN is a safe and effective therapeutic procedure and age per se is not a reason to exclude patients from this treatment. The use of PN should always be balanced against a realistic chance of improvement in the general condition of the patient. Lower glucose tolerance, electrolyte and micronutrient deficiencies and lower fluid tolerance should be assumed in older patients treated by PN. Parenteral nutrition can be administered either via peripheral or central veins. Subcutaneous administration is also a possible solution for basic hydration of moderately dehydrated subjects. In the terminal, demented or dying patient the use of PN or hydration should only be given in accordance with other palliative treatments.

Epidemiology of bloodstream infection associated with parenteral nutrition

Catheter-related bloodstream infections (CR-BSIs) occur in 1.3% to 26.2% of patients with central venous catheters used to administer parenteral nutrition (PN). Because of their nutritional components, PN solutions can support microbial growth. Contamination during preparation and handling is rare in hospitals and home-infusion pharmacies but may be difficult to control in a home setting. The risk of infection is increased in hospitalized patients because of malnutrition-associated immunosuppression, hyperglycemia exacerbated by dextrose infusion, microbial colonization/contamination of catheter hubs and the skin surrounding insertion site, and poor nursing care. During long-term catheter use for PN, an intraluminal biofilm, catheter-tip fibrin sheath or tail, or central venous thrombosis creates sites for microbial seeding and infection. Chronic conditions and psychosocial issues also increase the risk of infection. In hospitalized patients with BSIs, the most common organisms are coagulase-negative staphylococcus, Staphylococcus aureus, Enterococcus, Candida spp, Klebsiella pneumoniae, and Pseudomonas aeruginosa. In the long-term PN population, approximately 60% of CR-BSIs are caused by coagulase-negative Staphylococcus. The best plan of care for a suspected or known infected catheter in a hospitalized patient is to reinsert a new central line after 48 hours of antibiotic treatment and negative blood cultures. In patients who receive long-term PN, hospitalization increases the risk of a nosocomial infection because the catheter can be contaminated by staff. A patient with fungemia must always be admitted and catheter removed. With gram-positive and gram-negative organisms, the catheter may not need to be removed. In most patients receiving PN at home, removing a long-term venous-access device is challenging. Peripheral vein access or peripherally inserted central catheters are needed until a new permanent device can be inserted after negative blood cultures are obtained. Evaluation of remote site infection also is necessary. Strategies to reduce or prevent infection include catheter lock therapy, daily evaluation of continued need for PN, enteral rather than PN support, and avoiding overfeeding. More studies are needed to demonstrate conclusively the benefits of immunonutrition, such as the use of omega-3 or glutamine supplements to reduce CR-BSIs in patients receiving PN.

A light and scanning electron microscope study of the albino rat ileum after partial obstruction

Induction of an obstruction could be resorted to as a definitive line of management in some cases of short bowel syndrome (SBS). The goal of this study has been to elucidate histological and morphometric alterations in the albino rat ileum after surgically induced partial obstruction. Thirty adult male albino rats (240-250 g) were used in this investigation. They were divided into two equal groups: control and experimental. Small pieces of the ileum of the control and experimental animals were processed for histological and scanning electron microscope study. The ileum of the experimental animals proximal to the site of obstruction showed an apparent enlargement in the Peyer's patches and an increase in the thickness of both the mucosa and muscle layers. The villi showed significant elongation and thickening. Both widening and deepening of the crypts were detected. There was an apparent increase in the goblet cell number and lymphocytic infiltration in both the corium and submucosa. In scanning electron microscopic examination, the microvilli showed scattered areas of shortening and irregular orientation. The surface was more frequently interrupted by goblet cell orifices. Partial ileal obstruction resulted in hypertrophy of the ileal wall with considerable structural alterations oral to the obstruction site. Thus, the procedure apparently increased the absorptive surface area together with reduction in the speed of intestinal transit. These effects could support taking this technique into consideration as one of the suggested lines of treatment of some cases of SBS to eliminate the patient's need for parenteral nutrition and all of its associated complications.