Parenteral Nutrition Infusion Research Articles

Uso de cateteres venosos totalmente implantados para nutrição parenteral: cuidados, tempo de permanência e ocorrência de complicações infecciosas

Cateteres venosos totalmente implantados são utilizados em pacientes com síndrome do intestino curto, para realizar o suporte nutricional parenteral, o qual mantém estes pacientes vivos, pois fornece-lhes nutrientes que são absorvidos pela via digestiva. No entanto, estes cateteres não são isentos de complicações. As infecções relacionadas aos cateteres venosos são as complicações mais temidas e sua incidência varia de 3% a 20%, aumentando em pacientes mais graves. O objetivo do presente estudo é descrever as complicações infecciosas em pacientes recebendo nutrição parenteral por meio de cateteres venosos totalmente implantados. Tais cateteres são utilizados pela Divisão de Nutrição Clínica do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, para realizar o suporte nutricional parenteral em pacientes submetidos a ressecções extensas de intestino delgado. Foram avaliadas as complicações infecciosas ocorridas com 21 cateteres, implantados em 16 pacientes. O tempo de permanência dos cateteres foi de 768±664,3 dias (mediana 529 dias) e a taxa de infecção foi de 0,029 infecções/paciente/ano, resultados que se comparam às taxas de infecção observadas em países desenvolvidos. Concluiu-se que os cuidados observados no manuseio destes cateteres foram de fundamental importância para diminuir a incidência de infecção nestes pacientes.

Efficacy and safety of an olive oil‐based intravenous fat emulsion in adult patients on home parenteral nutrition

The most frequently used intravenous lipid emulsions are composed of 100% long chain triacylglycerols from soybean oil or of 50% long chain triacylglycerols-50% medium chain triacylglycerols. A newer emulsion, ClinOleic 20% containing 80% olive oil and 20% soybean oil, was suggested to reduce lipid peroxidation and immune function impairment. To assess ClinOleic 20%'s efficacy, safety and effect upon systemic inflammatory parameters in adults on home parenteral nutrition. In stable home parenteral nutrition patients, the initial intravenous lipid emulsion was changed for ClinOleic 20%. Nutritional status, clinical and biological tolerance, and systemic inflammatory markers were analysed before and after 1 and 3 months of home parenteral nutrition, with ClinOleic 20% as intravenous lipid emulsion. Clinical and biological nutritional markers and inflammatory parameters did not differ between day 0 and month +3. There was no essential fatty acids deficiency. No side-effects were reported. Three of five patients presenting with migraine during home parenteral nutrition infusion at day 0 felt consistently better at month +3. ClinOleic 20% is safe and efficient in adult home parenteral nutrition. It maintains normal essential fatty acids status and did not influence inflammatory parameters. In contrast to studies in preterm infants or paediatric patients, no effect on vitamin E concentration or lipid peroxidation was observed.

Accuracy of body composition measurements by dual energy x-ray absorptiometry in underweight patients with chronic intestinal disease and in lean subjects

BackgroundTo assess the accuracy of Dual-energy X-ray absorptiometry (DXA) in underweight patients with chronic gastrointestinal disease, we investigated the ability of DXA to detect variations in body composition induced by infusion of parenteral nutrition (PN). Furthermore, the influence of a low body weight per se on the accuracy of DXA was studied by placing packets of lard on lean healthy subjects.MethodsThe hydration study included 11 patients with short bowel syndrome on long-term home parenteral nutrition (9 women and 2 men), and (mean ± SD) 49.5 ± 17.1 yr., 19.3 ± 3.1 kg/m2. The lard study, where packets of lard were placed either over the thighs or the trunk region, was performed in 8 healthy lean male volunteers, 26.4 ± 7.4 yr., and 21.0 + 0.9 kg/m2. Body composition, including measures of the total mass (TM), soft tissue mass (STM), lean tissue mass (LTM), fat mass (FM), and total body mineral content (TBBMC), was assessed by DXA. The fat fraction of the lard packets (3.49 kg), measured in triplicate by chemical fat extraction, was 52.2%.ResultsHydration study; The increase in scale weight (BW) of approximately 0.90 kg due to infusion of PN correlated significantly to the increase in TM (R-square = 0.72, SEE 0.36 kg, p < 0.01), and the increase in STM (R-square = 0.69, SEE 0.38 kg, p < 0.01), however not with the increase LTM (R-square = 0.30, SEE 1.06 kg, p = 0.08). Mean changes in TM (0.88 kg), STM (0.88 kg), and LTM (0.81 kg) were not significantly different from changes in BW (p > 0.05). Lard study; Regardless of position, measurements of FM and LTM of the added lard were not significantly different from expected values. However, the composition of the lard packets into FM and LTM was more accurately detected when the packets were placed over the thighs than over the trunk region. The accuracy of DXA in individual subjects, expressed as the SD of the difference between expected and measured values, was 1.03 kg and 1.06 kg for the detection of changes in LTM and FM, respectively, and 0.18 kg for the detection of changes in STM and TM.ConclusionsOn a group level, DXA provided sufficient accuracy to detect small changes in body composition in underweight patients with chronic gastrointestinal disease. However, the accuracy errors were higher than reported in normal weight subjects. The accuracy was not influenced by a low body weight per se.

Central venous catheters: a survey of ICU practices.

This paper describes the current infection control practices for CVC care and compares these to evidence-based practice guidelines. Intensive care patients with central venous catheters (CVCs) are at risk of catheter-related infection, which increases morbidity, mortality and health care costs. Infection control practices, including care of intravenous administration sets and catheter sites, are undertaken by nurses in an attempt to avoid infection. Although practice guidelines are available, infection control practices may vary between practitioners and institutions; however, current practice has not been formally surveyed. A prospective, cross-sectional descriptive survey was carried out. Intensive care units (n = 14) in Australia were surveyed about their infection control policies for CVC care. Results were tabulated and compared with evidence-based practice guidelines. A wide variety of responses was received about duration of administration set use for standard, parenteral nutrition and propofol (lipid-based anaesthetic) infusions; ad hoc administration set connection technique; dressing frequency, materials and solutions; and barrier precautions used during procedures. There was inconsistent adherence to the guidelines. There is variation in the infection control approach to CVC care. Greater adherence to existing Centers for Disease Control Guidelines would assist in the standardization of best practice and facilitate evidence-based care.

Cecal ligation and puncture with total parenteral nutrition: A clinically relevant model of the metabolic, hormonal, and inflammatory dysfunction associated with critical illness

Standard rat cecal ligation and puncture (CLP) results in only transient hyperglycemia, making an examination of the effects of glucoregulatory agents, such as insulin, on the morbidity and mortality of CLP problematic. Accordingly, we sought to develop a model of rat CLP with prolonged hyperglycemia through continuous infusion of total parenteral nutrition (TPN) post CLP. Polyethylene catheters were implanted into the femoral vein of female Sprague Dawley rats (245-265 g) which were subsequently subjected to CLP. TPN was initiated at different intervals following CLP, and mortality, bacteremia, blood glucose, hormonal, and inflammatory responses were monitored. Without TPN, CLP resulted in significantly lower blood glucose at 22 h post CLP. In contrast, CLP rats receiving TPN exhibited significant prolonged hyperglycemia that was responsive to insulin treatment. Mortality and hyperglycemia tended to increase with puncture size in CLP TPN rats, with early initiation of TPN leading to poorer outcome. There were time-dependent differences in bacteremia and mortality based on time of TPN initiation. Levels of insulin, leptin, and glucagon were significantly elevated in CLP TPN rats, as were many inflammatory markers. Organ damage was evident as early as 12 h post CLP and blood cell kinetics indicated significantly depressed neutrophil and lymphocyte counts. Our results indicate that addition of TPN to CLP provides a clinically relevant animal model of critical illness with associated hyperglycemia that may provide utility for the testing of glucoregulatory and other therapeutic modalities.

Endotoxin and cytokine released during parenteral nutrition.

Apart from its benefits, parenteral nutrition (PN)-related complications have been reported. Studies have shown that PN could alter cytochrome P450 (CYP) activity. One of the possible mechanisms is through cytokine and nitrite release, which is triggered by endotoxin. The purpose of this study is to investigate the potential release of endotoxin, cytokines, and nitrite during PN. Rats were randomly assigned into either (a) the PN group, which received continuous PN infusion only; or (b) the control group, which received normal chow with saline infusion. The infusions were administered continuously for 7 days, and then blood was collected and microsomes were prepared from the excised livers. Endotoxin levels in the PN group were significantly higher in portal vein but not in inferior vena cava when compared with those of the controls. TNF-alpha and IL-6 levels were significantly higher in the PN group (p < .05). However, IL-1 beta levels were not significantly different in the 2 groups (p > .05). The nitrite levels, the end product of nitric oxide formation, were found to be almost 2 times higher after PN (p < .05). It is confirmed that a 7-day infusion treatment of PN in rat may be linked to bacterial translocation, which leads to increased levels of endotoxin. This increase could trigger cytokine release, which could down regulate CYP activities.

Prospective randomized trial to assess caloric and protein needs of critically Ill, anuric, ventilated patients requiring continuous renal replacement therapy

Objectives We measured the energy and protein needs in 50 sequential, critically ill, ventilated patients requiring continuous renal replacement therapy (CRRT) for renal failure by using indirect calorimetry and three sequential isocaloric protein-feeding regimes of 1.5, 2.0, and 2.5 g · kg −1 · d −1. We also assessed the compliance of actual feeding with target feeding and correlated the predictive energy requirements of the formulae with the actual energy expenditure (EE) measured by indirect calorimetry. We also determined whether these feeding regimes affected patient outcome. Methods The energy and protein needs of 50 consecutive, critically ill patients (31 male; age 53.3 ± 17.4 y; Acute Physiology and Chronic Health Evaluation (APACHE II) score: 26.0 ± 8.0; Acute Physiology and Chronic Health Evaluation score predicted risk of death: 50.0 ± 25.0%) were assessed by using indirect calorimetry and ultrafiltrate nitrogen loss. Entry into this study was on commencement of CRRT. To eliminate any beneficial effect from the passage of time on nitrogen balance, 10 of the 50 patients were randomized to receive 2.0 g · kg −1 · d −1 throughout the study, and the others received an escalating isocaloric feeding regime (1.5, 2.0, and 2.5 g · kg −1 · d −1) at 48-h intervals. Enteral feeding was preferred, but if this was not tolerated or unable to meet target, it was supplemented or replaced by a continuous infusion of total parenteral nutrition. Energy was given to meet caloric requirements as predicted by the Schofield equation corrected by stress factors or based on the metabolic cart readings of EE and was kept constant for all patients throughout the trial. Patients were stabilized on each feeding regime for at least 24 h before samples of dialysate were taken for nitrogen analysis at 8-h intervals on the second day. CRRT was performed by using a blood pump with a blood flow of 100 to 175 mL/min. Dialysate was pumped in and out counter-currently to the blood flow at 2 L/h. A biocompatible polyacrylonitrile hemofilter was used in all cases. Results EE was 2153 ± 380 cal/d and increased by 56 ± 24 cal/d ( P < 0.0001) throughout the 6-d study period to 2431 ± 498 cal/d. At study entry, the mean predicted (Schofield) caloric requirement was 2101 ± 410. Patients received 99% of the predicted energy requirements. However, the mean EE was 11% higher at 2336 ± 482 calories. This difference was not uniform. If the predicted caloric requirement was less than 2500, the EE exceeded the predicted by an average of 19%. If the predicted caloric requirement was greater than 2500, the EE on average was 6% less than predicted. This relation was significant ( P = 0.025) and has not been described previously. Nitrogen balance was inversely related to EE ( P = 0.05), positively related to protein intake ( P = 0.0075), and more likely to be attained with protein intakes larger than 2 g · kg −1 · d −1 ( P = 0.0001). Nitrogen balance became positive in trial patients over time but were negative in control patients over time ( P = 0.0001). Nitrogen balance was directly associated with hospital outcome ( P = 0.03) and intensive care unit outcome ( P = 0.02). For every 1-g/d increase in nitrogen balance, the probability of survival increased by 21% ( P = 0.03; odds ratio, 1.211; 95% confidence limits, 1.017,1.443). Further, although enterally and parenterally fed patients had lower mortalities than predicted, the presence of enteral feeding, even after adjusting for predicted risk of death, had a statistically significant benefit to patient outcome ( P = 0.04). Conclusions This study found that a metabolic cart can improve the accuracy of energy provision and that a protein intake of 2.5 g · kg −1 · d −1 in these patients increases the likelihood of achieving a positive nitrogen balance and improving survival. Enteral feeding is preferable, but if this is not possible or does not achieve the target, then it should be supplemented by parenteral feeding.

Chest Pain Associated With Total Parenteral Nutrition Infusion

Chest Pain Associated With Total Parenteral Nutrition Infusion

Staphylococcus Epidermidis (SE) Proliferation, Biofilm Production and Risk of Infection Is Remarkably Enhanced by Blood-Contamination of Parenteral Nutrition Infusions (PN) except for Pure Glucose 10%

Staphylococcus Epidermidis (SE) Proliferation, Biofilm Production and Risk of Infection Is Remarkably Enhanced by Blood-Contamination of Parenteral Nutrition Infusions (PN) except for Pure Glucose 10%

Histoire naturelle du moignon pancréatique après duodénopancréatectomie céphalique (DPC)

Major complications following pancreaticoduodenectomy are thought to be chiefly associated with exocrine secretion of the pancreatic remnant which is not well known. This work aims to assess the exocrine secretion of the pancreatic remnant within the early post-operative period. Patients and methods: Seventy-five patients undergoing pancreaticoduodenectomy for presumed tumour were included in a prospective multicentre study. A tube was inserted in the pancreatic duct at the time of construction of the pancreatic anastomosis. Peripancreatic drainage was routinely used. Pancreatic juice and peripancreatic drainage fluid were collected and measured and pancreatic enzyme monitored. For 7 days patients received total parenteral nutrition and continuous infusion of randomly Somatostatin 14 (S-14) at a dose of 6 mg/24 h (days 1–6) and 3 mg/24 h (day 7) or matching placebo. Pancreatic fistula was defined as a daily drainage of more than 100 cc of amylase-rich fluid after day 3, persisting after day 12 or associated with symptoms or needing specific treatment. Results: Daily output of pancreatic juice was low during the first postoperative day and then increased gradually until day 5. A high enzyme concentration was observed in pancreatic juice on the first post-operative day. S-14 infusion resulted in a significant decrease of both pancreatic fistula rate and enzyme concentration in peripancreatic fluid. Conclusions: During the first postoperative days, the outflow of the exocrine secretion of the pancreatic remnant is low but contains a high enzyme concentration with significant leaks within the peripancreatic area. S-14 infusion results in a decrease of pancreatic juice leaks from the pancreatic remnant.

Lipids in Parenteral Nutrition

After completing this article, readers should be able to: 1. Identify clinical indicators for the use of medium-chain triglycerides as an enteral lipid source. 2. Describe appropriate infusion rates, rates of advancement, and methods of monitoring tolerance of intravenous lipids. ### Composition and Metabolism Early initiation of intravenous lipid administration is important because it increases energy intake through a small volume of parenteral fluid with low osmolality, provides essential fatty acids, and reduces carbon dioxide production relative to glucose as an energy substrate. The most widely available intravenous lipids are prepared from soybean oil or a combination of soybean and safflower oil. All of the emulsions are emulsified with egg yolk phospholipid, with glycerol added to achieve an isotonic solution (Table 1⇓). Emulsions containing mixtures of olive and soybean oil and medium-chain triglycerides (MCTs) and soybean oil are also available. Infusion of intravenous lipid and parenteral nutrition in the same line may protect against phlebitis and loss of the intravenous vein, possibly due to physical coating of the vein with the lipid particles or the reduced osmolality of the infused solutions. The osmolality of intravenous lipid solutions, irrespective of the lipid concentration, is 268 mOsm/L, making them safe for both central and peripheral lines. View this table: Table 1. Composition of Intravenous Lipids The intravenous lipid particles have similar diameters to chylomicrons and acquire apo C11 from native lipoproteins after infusion. Clearance of intravenous lipid triglycerides proceeds by lipoprotein lipase, as described in Figure 1. However, dyslipoproteinemia, characterized by elevation of serum cholesterol and phospholipid secondary to infusion of 10% intravenous lipid emulsions, is well-known. This can occur even in the absence of elevated serum triglycerides and is largely the result of accumulation of abnormal particles containing phospholipid and cholesterol. These particles are generally known as lipoprotein (Lp) X. LpXs are formed from phospholipid present in the emulsion in excess …

Dexamethasone decreases serum and liver IGF-I and maintains liver IGF-I mRNA in parenterally fed rats.

Insulin-like growth factor-I (IGF-I) gene expression is regulated by nutritional and hormonal factors. High-dose glucocorticoids decrease food intake, and this confounds studies addressing glucocorticoid effects on IGF-I gene regulation. We investigated alterations in the hepatic IGF-I endocrine system induced by a catabolic dose of dexamethasone (Dex) in rats given adequate nutrition by continuous infusion of total parenteral nutrition (TPN) solution with or without IGF-I administration. The four TPN groups included control, +Dex, +IGF-I, and +IGF-I + Dex (n = 9-11/group). Dex induced a 12% loss of body weight in association with a 50% decrease in hepatic immunoreactive IGF-I, a 10% decrease in serum IGF-I, and no change in steady-state liver IGF-I mRNA or growth hormone (GH) receptor binding. Exogenous IGF-I increased serum IGF-I, attenuated Dex-induced catabolism, and did not reduce hepatic levels of IGF-I and IGF-I mRNA despite decreased serum GH. These data suggest that Dex-induced catabolism is associated with downregulation of the hepatic IGF-I endocrine system at the translational or posttranslational level when adequate nutrition is provided.

Central venous catheterization and fatal cardiac tamponade

Cardiac tamponade is a poorly recognized complication of central venous catheterization associated with a high mortality. We present a case of fatal cardiac tamponade after intra- pericardial infusion of total parenteral nutrition in a patient who had two central venous catheters. We suggest that catheter tip position should always be confirmed before use of a catheter. Tamponade should be suspected in a patient who deteriorates when a central venous catheter is used and resuscitation via the catheter should be avoided.

Light protection during parenteral nutrition infusion: is it really necessary?

Many nutrient compounds incorporated into parenteral nutrition (PN) mixtures are sensitive to light. The most light-sensitive compounds can be found in the vitamin group, in particular retinol (vitamin A),1 tocopherol (vitamin E),2 vitamin K,3 and riboflavin.4 Some amino acids are also potentially sensitive to light. One of the most common questions asked of pharmacists is whether or not PN bags should be covered in a light-protecting overwrap during administration, and, if so, should the administration set also be protected. It is clearly somewhat illogical to recommend the need to protect the bag and not the administration set from light, if there is indeed a risk of degradation when PN is exposed to light. Despite the obvious response, that light protection should be mandatory, a range of issues is ignored, in particular the desire by care staff to be able to “observe” the infusion at all times, and the practicalities, especially of covering the administration set, or the non-availability of light-protecting sets in practice. And, as in all matters scientific, answers are far from simple. Here are a few questions to illustrate the pharmaceutical complexity of the issue: Which ingredients are light sensitive, and how rapid is the photoreaction that results in loss of biological activity? What intrinsic factors affect degradation (e.g., PN composition [Does fat emulsion provide a barrier to light?], the total volume of the PN mixture, frequency of mixing during infusion, flow rate, type of bag [ethyl vinyl acetate or multilayered], the composition, length, and thickness of the administration set tubing, and exposure time)? What contribution to total loss is due to infusion? Is the source of the light important (e.g., is it dependent on particular wavelengths)? If daylight causes degradation, how are losses influenced by the time of day, the season, weather conditions, and even geographic location? Even the position of the infusion in relation to a nearby window is significant.1 Then there are the difficulties associated with accurately determining losses likely to occur in practice, especially as the light (daylight) source cannot be controlled and there is no artificial-light–source alternative available that exactly reproduces the same wavelength distribution and intensity of daylight. It can also prove difficult to measure the range of light intensity in daylight because it differs across the wavelength spectrum. This spectrum is related to the photochemical reactions caused by daylight. Is it any wonder that the literature is confusing? For example, Billion-Rey et al.3 reported a 90% degradation of vitamin A in All-in-One PN mixtures during exposure to light, but Dahl et al.5 suggested that vitamin A is unaffected under such conditions. A similar contrast can be found with tocopherol. Drott et al.2 reported an approximate 30% loss in daylight, whereas Billion-Rey et al.3 observed no losses under similar conditions.

Parenteral amino acid intake alters the anabolic actions of insulin-like growth factor I in rats.

The anabolic properties of insulin-like growth factor (IGF) I are attenuated by oral diets that are low in protein. However, it is not known whether parenteral nutrition (PN) providing a low amino acid (AA) input will influence IGF-I action. With the use of a rat model, this study examined the interaction between AA input (1.27 and 0.62 g N. kg body wt(-1). 24 h(-1), AA and 1/2AA groups, respectively) and recombinant human IGF-I (rhIGF-I, 2.5 mg. kg body wt(-1). 24 h(-1)) infusion on the composition of the carcass and organs and on plasma insulin, IGF-I, IGF-binding protein 1 (IGFBP-1), and acid-labile subunit (ALS) concentrations. Carcass protein deposition only occurred in the AA groups (P < 0.003) and was not influenced by administration of rhIGF-I. However, visceral protein loss persisted in the AA group but was prevented by rhIGF-I infusion. The changes in water content of the carcass and the organs were generally in the expected proportion of normal lean tissue. The accumulation of lipid that follows the infusion of the AA-deficient PN was prevented by rhIGF-I infusion, which may indicate an improved energy utilization. Neither serum insulin nor ALS concentrations were influenced by the level of AA infusion but were reduced by rhIGF-I administration. However, plasma IGF-I levels were elevated by higher AA infusion and by IGF-I administration. Also, IGFBP-1 concentrations were reduced by the higher AA infusion and increased with rhIGF-I administration. Interestingly, there was a significant interaction effect between both of these influences. It is concluded that free IGF-I concentration, which may be regulated by IGFBP-1 through a direct effect of AAs on the liver, may have an important role in regulating anabolism in visceral and possibly skeletal tissue during PN.

末梢静脈栄養輸液に起因する血管痛の防止策に関する検討 タンデム法における検討

A study on the prevention of angialgia induced by the high osmotic pressure of Peripheral Parenteral Nutrition infusion: Influence on the infusion system using Tandem method.During peripheral parenteral nutrition (PPN) infusions, angialgia more frequently occures than during other types of peripheral infusion. This is probably caused by the low pH, infusion speed and high osmotic pressure of PPN. We hypothesized that we could prevent angialgia by attenuating the osmotic pressures during PPN infusion. We therefore attempted examinations using the Tandem method as follows; It was possible to control the osmotic pressure in the effuent solution by changing the joining method of these infusions, thus suggesting that the specific gravity of these infusions affected the osmotic pressure.Specifically, we connected a hypotonic infusions (e.q., Soldem-3 A) with a low specific gravity to a PPN infusion (e.q., Amicaliq) with a high specific gravity, and the osmotic pressure of the effluent solution was maintained at a high level during the first 15 min, but thereafter gradually decreased. On the other hand, We connected a PPN infusion to a hypotonic infusion, and thus were able to maintain a low and constant osmotic pressure in the effluent solution.These results suggest that the Tandem method is useful in preventing angialgia due to the high osmotic pressure of PPN infusion. PPN infusion should thus be connected to a hypotonic infusion that has a lower specific gravity than that of the PPN infusion.

Parenteral nutrition associated cholestasis in the newborn

Parenteral nutrition associated cholestasis in preterm infants and newborn children is a frequent and serious disease with an incidence of 23% depended on duration of parenteral nutrition and birthweight. The incidence of liver cirrhosis is 40% when parenteral nutrition is given 74-242 days. The pathogenesis remains unclear. Several predisposing factors are discussed like immaturity, lack of hormonal stimulation by oral feeding, bacterial infection, liver toxicity of aminoacids and their products of photooxidation, lack of taurine, lack of antioxidation substances, hypermanganesaemia and pollution of infusion solutions. Furthermore sepsis during parenteral nutrition seems to multiply the risk of cholestasis. For prevention controlled studies recommend: 1. Early enteral nutrition. 2. The reduction of parenteral amino acids to less than 3 g/kg/d. 3. Light protection for parenteral solutions. 4. Cyclic infusion of parenteral nutrition. 5. The application of antibiotics (metronidazole, gentamicin) during parenteral nutrition. The most important therapeutic intervention is the beginning of oral feeding. Most of the time this leads to a decrease of icterus within two weeks. An icterus persisting longer than 3 weeks should be treated because of the risk of liver cirrhosis. Further therapeutic interventions are: 1. Cholecystokinin, good results in case studies which still has to be verified by a controlled study. 2. Ursodeoxycholic acid, its choleretic effectiveness is verified in several liver diseases by controlled studies, but it is not proven in parenteral nutrition associated cholestasis. 3. Laparoscopic biliary irrigation, successful in several case studies.

Effect of Enteral versus Parenteral Nutrition on Leptin Gene Expression and Release into the Circulation

Leptin, a putative satiety hormone in rodents, is acutely regulated by fasting and refeeding. To determine the role of satiety hormones that are secreted by the gastrointestinal tract on leptin regulation, leptin mRNA and serum concentrations were measured after feeding rats similar calories with standard chow or infusion of total parenteral nutrition into the duodenum or intravenously. We have demonstrated that leptin gene expression and hormone secretion into the circulation are stimulated equally in the three experimental paradigms; it is unlikely that satiety factors secreted by the intestinal tract play a significant role in leptin regulation. Furthermore, intravenous infusion of individual components of TPN demonstrated that intravenous glucose infusion was mostly responsible for stimulation of the leptin gene and hormone secretion.

Hemiplegia caused by inadvertent intra-carotid infusion of total parenteral nutrition

A 24 year-old woman developed acute hemiplegia and a seizure following accidental catheterization of the right common carotid artery and total parenteral nutrition infusion. Magnetic resonance imaging of the brain showed lesions in the frontal lobe and putamen consistent with an ischemic stroke. Angiography through the central venous catheter confirmed its intra-arterial location. The patient's weakness improved after hyperbaric oxygen treatment. We concluded that stroke or seizures during total parenteral nutrition administration through a central venous catheter should alert one to the possibility of inadvertent intra-arterial infusion, especially in patients who have had central lines inserted several times previously.

Effects of light-exposed parenteral nutrition on hepatic function and lidocaine metabolism: a study using isolated rat liver perfusion.

Effects of light-exposed parenteral solutions on hepatic function and lidocaine metabolism were studied. Male rats (190-220 g) were randomly assigned to one of the three isocaloric treatment groups: parenteral nutrition (PN) (+L) group (n = 6), animals received a solution of 24.2% dextrose and 5.2% amino acids with light exposure; PN(-L) group (n = 5), animals received the same solution without light exposure; and CF group, chow-fed animals (n = 6) that received rat chow and water. Average energy intake in these animals was approximately 33 kcal/100 g/d. Lidocaine metabolism was studied in livers isolated from animals 7 d after treatment. Liver morphology indicated that five livers from PN(+L) animals developed steatosis. The lidocaine metabolism rate was the slowest in PN(+L) animals; this is marked by changes in the steady state levels (% dose) of lidocaine [PN(+L), 47.9 +/- 17.6; PN(-L), 25.9 +/- 2.1; versus CF, 11.3 +/- 5.3; p < 0.05]. The extraction ratio and intrinsic clearance values were reduced by 41 and 86% in PN(+L) group and 16 and 70% in PN(-L) group, respectively, when compared with CF (p < 0.05). Metabolite to drug ratios indicated that N-dealkylation, ring-hydroxylation, and aryl methyl hydroxylation of lidocaine were severely impaired, particularly in the PN(+L) animals. The extents of reduction in metabolic pathways were in the ranges 79-95% in the PN(+L) group and 44-90% in the PN(-L) (p < 0.05). These findings suggest that parenteral nutrition infusion induces steatosis and reduces the rate of lidocaine metabolism and exposure of parenteral nutrition solutions to light exacerbates this change.