Peripheral Total Parenteral Nutrition Research Articles

A randomized translational study on protein- and glucose metabolism in skeletal muscles evaluated by gene-ontology, following preoperative oral carbohydrate loading compared to overnight peripheral parenteral nutrition (PPN) before major cancer surgery

BackgroundEffects of preoperative drinks on muscle metabolism are unclear despite general recommendations. The aim of the present study was therefore to compare metabolic effects of a preoperative oral nutrition drink, recommended by protocols for enhanced recovery after surgery (ERAS), compared to overnight preoperative peripheral total parenteral nutrition (PPN) on skeletal muscle metabolism in patients aimed at major gastrointestinal cancer surgery.MethodsPatients were randomized, based on diagnosis and clinical characteristics, to receive either a commercial carbohydrate-rich nutrition drink (Drink); or overnight (12 h) peripheral parenteral nutrition (PPN) as study regimens; compared to isotone Ringer-acetate as Control regimen. Arterial blood- and abdominal muscle tissue specimens were collected at start of surgery. Blood chemistry included substrate- and hormone concentrations. Muscle mRNA transcript analyses were performed by microarray and evaluated for changes in gene activities by Gene Ontology algorithms.ResultsPatient groups were comparable in all measured preoperative assessments. The Nutrition Drink had significant metabolic alterations on muscle glucose metabolism (p < 0.05), without any significant effects on amino acid- and protein metabolism. PPN showed similar significant effects on glucose metabolism as Drinks (p < 0.05), but indicated also major positive effects on amino acid- (p < 0.001) and protein anabolism (p < 0.05), particularly by inhibition of muscle protein degradation, related to both ubiquitination of proteins and autophagy/lysosome pathways (p < 0.05).ConclusionConventional overnight preoperative PPN seems effective to induce and support improved muscle protein metabolism in patients aimed at major cancer surgery while preoperative oral carbohydrate loading, according to ERAS-protocols, was ineffective to improve skeletal muscle catabolism and should therefore not be recommended before major cancer surgery.Trial registration Clinical trials.gov: NCT05080816, Registered June 10th 2021- Retrospectively registered. https://clinicaltrials.gov/study/NCT05080816

Micronutrient deficiencies in inflammatory bowel disease: trivial or crucial?

Patients with IBD, especially those with CD, are at a risk for a variety of nutritional deficiencies because of reduced nutrient intake or absorption, or increased nutrient losses.1 Nutritional deficiencies in IBD patients can be divided into those involving macronutrients (nutrients needed in large amounts) and those involving micronutrients (nutrients required in small quantities).2 In adults, deficiencies of micronutrients, including several water- and fat-soluble vitamins, and minerals including calcium, iron, and other trace minerals, are a common problem.3 Although the nutritional issues in IBD have become less common with advances in treatment and the greater proportions of patients attaining clinical remission, micronutrient deficiencies are still relatively common, particularly in CD patients with active small bowel disease or multiple resections. The major micronutrient deficiencies in IBD patients are associated with anemia (iron, folate, and vitamin B12), bone disease (calcium, vitamin D, and possibly vitamin K), hypercoagulability (folate, vitamin B6, and vitamin B12), wound healing (zinc, vitamin A, and vitamin C), and colorectal cancer risk (folate and possibly vitamin D and calcium).3 There are multiple mechanisms that can contribute to micronutrient deficiencies in IBD, such as decreased nutrient intake, increased intestinal loss, malabsorption, hypermetabolic state, drug interactions, and long-term total parenteral nutrition (TPN).4 Numerous vitamin and mineral deficiencies have been reported in IBD patients, with varying degrees of clinical significance.2 Vitamins and minerals are naturally occurring compounds that are required for diverse bodily functions, and must be obtained from the diet as they are not sufficiently synthesized by humans. Vitamins are organic compounds that can be classified as either water-soluble or fat-soluble. Water-soluble vitamins include thiamine (B1), riboflavin (B2), nicotinic acid/niacin (B3), pyridoxine (B6), cobalamin (B12), biotin, pantothenic acid, folic acid, and vitamin C (ascorbic acid). The fat-soluble vitamins (A, D, E, and K) are hydrophobic substances that are dissolved within fat droplets and must be broken down by lipases and combined with bile salts in the duodenum to form mixed micelles.3 In the current article, the authors reported two patients with CD who developed Wernicke's encephalopathy (WE) after prolonged TPN.5 WE is a serious neurologic complication due to vitamin B1 (thiamine) deficiency. Thiamine deficiency also can cause peripheral neuropathy and cardiomyopathy. Thiamine is found in multiple dietary sources (eggs, meats, bread, and nuts), and its absorption mainly occurs in the jejunum through varying degrees of active and passive transport, depending on body stores and the luminal concentrations of the vitamin.3 A recent study showed that thiamine deficiency may be more common in CD patients than in controls.6 This study was performed on 54 CD patients whose disease was in clinical remission, and were compared with 25 healthy controls. In CD patients, dietary thiamine intake was significantly lower than that in controls and low serum vitamin B1 was found in around one-third of CD patients. Both of the two cases of the present report had extensive small bowel involvement and severe malnutrition state, with a very low BMI.5 Although multiple factors contribute to micronutrient deficiencies in IBD, some nutrients are digested and absorbed within specific locations in the gastrointestinal tract, and the activity and location of a patient's intestinal disease determines the risk for specific micronutrient deficiencies. Normally, more than 95% of vitamins and minerals from food are absorbed in the proximal small bowel, usually by the mid-jejunum.3 Patients who had undergone small bowel resection are also at a risk for micronutrient deficiencies, the nature of which depends on the extent and location of the resected bowel.7 The two patients of the present report had a relatively short duration of fasting and peripheral TPN (3 weeks and 17 days, respectively).5 As the authors mentioned, despite the relatively short period of fasting, the active inflammation caused by active CD, underlying malnourished state, infection, and surgery led to an increased thiamine requirement and to the development of WE. The use of long-term parenteral nutrition can lead to deficiencies in any micronutrient not added in sufficient quantities, and the reported deficiencies include those of vitamins, minerals, and trace elements such as Zn2+, Cu2+, selenium, and chromium.3 Fortunately, the symptoms in the two patients of the current report resolved without any neurologic sequelae after thiamine replacement.5 As the authors also mentioned, WE is diagnosed clinically and is a disease with no characteristic and pathognomonic abnormalities in diagnostic studies. Thus, the development of neurologic disability in IBD patients with malnutrition should raise the suspicion of thiamine deficiency. Micronutrient deficiencies, especially those of vitamins and essential trace elements, in IBD patients are common and associated with a complicated course of disease. IBD patients usually do not present overt symptoms of vitamin or micronutrient deficiency. Therefore, a high suspicion for micronutrient deficiencies is advocated for the timely treatment and prevention of irreversible complications.

Total Parenteral Nutrition (TPN) via Peripheral Veins in Neonatal Surgical Patients

【Parenteral nutrition has been an essential part of postoperative care of neonates requiring major surgery who are unable to tolerate enteral feeding for long periods during the postoperative period. However, TPN via central venous catheters(central TPN), used in increasing trend, still presents significant morbidity. To find out whether TPN via peripheral veins(peripheral TPN) could be used as a viable alternative for postoperative parenteral nutrition in neonates, a clinical study was carried out by a retrospective analysis of 53 neonates subjected to peripheral TPN for more than 7 days after surgery. Operations consisted of procedures for esophageal atresia with tracheoesophageal fistula, gastroschisis and omphalocele. Surgery was performed at the Division of Pediatric Surgery, Department of Surgery, Hanyang University Hospitall, from 1983 to 1994. The mean total duration of TPN was 13.3 days (range; 7-58 days), the average daily total fluid intake was 117.6 ml/kg during TPN and 158.6 ml/kg during subsequent oral feeding. The average daily total calorie intake was 57.7 kcal/kg during full strength TPN and 101.3 kcal/kg during subsequent oral feeding. The mean urine output was maintained at 3.5 ml/kg/ hour during TPN and at 3.6 ml/kg/hour during subsequent oral feeding. The increment of body weight observed during TPN was 132 g in TEF, 53 g in gastroschisis and 3 g in omphalocele patients, while loss of body weight was not observed. The mortality rate was 5.7 %(3/53) and was related to the underlying congenital anomalies, not the TPN. The most common complication of peripheral TPN observed was laboratory findings suggestive of liver dysfunction in 23 cases(43.4 %) with no significant clinical symptom or signs in any case, transient pulmonary edema in one case, and generalized edema in one case. None of the major complications usually expected associated with central TPN were observed. The result of this study suggest that peripheral TPN can be used for adeguate postoperative nutritional support in neonates requiring 2 to 3 weeks of TPN.】

Protein and energy balance following femoral neck fracture in geriatric patients

To elucidate the effect of total peripheral parenteral nutrition (TPPN) on protein kinetics following injury, we compared the whole-body leucine kinetic response using a primed-constant infusion of l-[1- 14C]leucine in 33 elderly patients (aged 82 ± 1.0 years) following hip fracture and 33 healthy elderly control subjects (aged 75 ± 0.7 years). Following a 36-hour fast, leucine release from protein breakdown was 1.2 ± 0.10 μmol · kg −1 · min −1 and leucine incorporation into protein was 0.94 ± 0.095 μmol · kg −1 · min −1 in control subjects, and in injured subjects leucine release from protein breakdown was 1.3 ± 0.14 μmol · kg −1 · min −1 and leucine incorporation into protein was 0.97 ± 0.092 μmol · kg −1 · min −1. Control and injured subjects were then administered TPPN (protein, 1.5 g amino acids · kg −1; carbohydrate, 10.0 kcal · kg −1; lipid, 15.0 kcal · kg −1) for 24 hours, and leucine kinetics were redetermined. Compared with protein kinetics in the fasting state, leucine release from protein decreased to 1.0 ± 0.14 μmol · kg −1 · min −1 and leucine incorporation into protein increased to 1.16 ± 0.097 μmol · kg −1 · min −1 in control subjects. Injured patients also responded to TPPN with a decrease in leucine release from protein breakdown (1.12 ± 0.156 μmol · kg −1 · min −1) and an increase in leucine incorporation into protein (1.29 ± 0.164 μmol · kg −1 · min −1). These results indicate that in a geriatric population, whole-body leucine kinetics following hip fracture and the anabolic response to TPPN are not significantly altered from those of uninjured subjects. The overall metabolic response of energy expenditures and efficiency of nitrogen retention does suggest a mild catabolic response that may be reversed by nutritional intervention.

Plasma amino acid concentrations in geriatric control and hip-fracture patients

Changes in plasma amino acids, 24-h nitrogen balances, and resting metabolic expenditures (RMEs) were measured in 10 geriatric patients (aged 70-92 y) with hip fracture 1 d after surgical fixation during both a 24-h fasting state and while receiving total peripheral parenteral nutrition (TPPN) for 24 h at 1.5 g amino acids.kg-1.d-1 and 29-30 kcal.kg-1.d-1 and compared with 19 healthy volunteer subjects (aged 70-84 y). RME and 24-h urinary nitrogen losses were also elevated in the trauma patients during both fasting and TPPN. Positive nitrogen balances were evident in both groups during TPPN. Plasma total amino acid concentration was significantly lower in the trauma patients because of lower plasma concentrations of the nonessential amino acids. Phenylalanine and methionine concentrations were significantly higher and lysine lower in the trauma group. In addition, evaluation of the essential amino acid ratios after fasting and TPPN reveal that there are no limiting amino acids during TPPN.

Transdermal Glyceryl Trinitrate to Allow Peripheral Total Parenteral Nutrition: A Double-Blind Placebo Controlled Feasibility Study

Seventy-two consecutive patients requiring total parenteral nutrition (TPN) were randomized to two groups. Group A received daily a peripheral intravenous regimen which provided 10 g nitrogen and 1400 non-nitrogen kcal (5.9 MJ). Group B received daily a peripheral intravenous regimen which delivered 9.4 g nitrogen and 1900 non-nitrogen kcal (8.0 MJ). Each group was further randomized to receive a self-adhesive patch of transdermal glyceryl trinitrate (GTN) or an identical placebo. Infusion survival was the main end-point. For group A, the median time of infusion survival was 74 h (range: 58-100) in the control group compared with 108 h (range: 68-156) in the group that received transdermal GTN (P less than 0.001). For group B, the median infusion survival was 67 h (range: 46-92) in the control group compared with 103 h (range: 66-151) in the treatment group (P less than 0.001). TPN is feasible via peripheral veins and the incidence of infusion failure can be effectively reduced by transdermal GTN.

A 24-year follow-up of a large omphalocele: From silon pouch to pregnancy

In 1970, this patient was first reperted after her massive ventral hernia was repaired. Her large omphalocele was initially covered with skin flaps as a newborn, and at 3 years of age the resulting ventral hernia was completely repaired using the staging technique described by Schuster, and modified by Plzak and Gross. Silon sheeting was used as a temporary prosthesis. She remained well until 1988 (age 23 years) when she became pregnant with the expected date of confinement January 10, 1989. The first two trimesters were uneventful with sonograms showing a normal male fetus who was gaining weight appropriately. By the third trimester the abdominal girth did not increase coincident with the baby's size, vomiting prevented adequate caloric intake, and pelvic pressure from the baby's head caused increasing discomfort. She spent 7 weeks in the hospital on intravenous therapy, including peripheral total parenteral nutrition, and delivered vaginally, with the aid of forceps, a 2.9-kg normal boy 5 weeks prematurely. This is the first reported case of a large omphalocele patient conceiving and delivering a normal fetus. It also demonstrates the potential problems related to multiple surgical procedures to close a large congenital abdominal wall defect.

Total Peripheral Parenteral Nutrition in Pregnancy

Twenty pregnant patients needing nutritional support for various indications received hypercaloric, hyperosmotic, "3 in 1," peripheral parenteral nutrition as a bridge to enteral therapy. This system, named total peripheral parenteral nutrition, was evaluated as to tolerance and efficacy in pregnant patients. Patients were in various stages of pregnancy and had an average weight loss of 10.4 pounds prior to admission. Patients were maintained on total peripheral parenteral nutrition for an average of 5 days and gained an average of 4.1 pounds. Good tolerance with minimal side effects of the treatment was noted. Intravenous sites were changed an average of 1.1 times per patient during the course of therapy and only one serious complication was noted in 20 patients. Patients were followed through delivery and this information is presented. Total peripheral parenteral nutrition appears to be an acceptable alternative to conventional total parenteral nutrition to pregnant patients needing nutritional support. These hypertonic solutions can supply total caloric/metabolic needs without unacceptable side effects.

Venous dilatation to reduce the incidence of infusion failure in peripheral total parenteral nutrition (TPN) : [formula omitted], P.C. Weaver, St. Mary's Hospital, Portsmouth, United Kingdom

Venous dilatation to reduce the incidence of infusion failure in peripheral total parenteral nutrition (TPN) : [formula omitted], P.C. Weaver, St. Mary's Hospital, Portsmouth, United Kingdom

Peripheral total parenteral nutrition for premature infants with the respiratory distress syndrome: A controlled study

In 40 premature infants, in whom severe respiratory distress precluded oral feeding, peripheral total parenteral nutrition consisting of casein hydrosylate, dextrose, and soybean emulsion was compared to nutrition with dextrose and electrolytes. The TPN group received more calories, and the total serum protein in them increased significantly. Metabolic complications did not occur. Transient thrombocytosis occurred in six infants who received TPN and eosinophilia occurred in nine. The case fatality rate in the TPN group (three of 20) was not significantly less than in the glucose group (six of 20). The differences suggested that infants who weigh less than 1,500 gm may receive the greater benefit from TPN.

Peripheral total parenteral nutrition employing a lipid emulsion (intralipid): Complications encountered in pediatric patients

The clinical records of 180 pediatric patients who received Intralipid via peripheral veins at a single institution (1964–1977) were retrospectively analyzed, with particular reference to the complications of this form of therapy. Intralipid was used in a dose range of 2–4 g/kg/day in order to supply 40% of the daily calorie requirements. The patients were neonates, infants, children, and adolescents with a wide range of clinical diagnoses. Local complications associated with Intralipid therapy were minimal. Transient elevations in serum enzyme levels (SGOT, SGPT, and LDH) were observed in 4% of patients, but all of these returned to the normal range after cessation of therapy. Ten patients had histologic evidence of cholestasis, the significance of which is discussed. The lipid emulsion was employed in patients with preexisting hyperbilirubinemia with concomitant resolution of jaundice. Intralipid was administered to patients with known severe thrombocytopenia (secondary to sepsis or myelosuppression) with return of the platelet counts to normal levels during the course of infusion therapy. The use of Intralipid in patients with established sepsis did not delay its response to conventional surgical or antibiotic therapy. There were no instances of the “overloading” syndrome observed.

Supportive use of total peripheral parenteral alimentation in children with severe pancreatic injuries

Although blunt abdominal trauma is common during childhood, experience with major pancreatic injuries is rare. Three such cases were recently treated at the Montreal Children's Hospital. Because of the complicated problems related to these injuries, these children needed prolonged nutritional support. Total peripheral parenteral nutrition was used to provide complete rest of the pancreas and avoid the risks of sepsis associated with central venous feeding. This technique enables the maintenance of caloric intake and weight gain during difficult complications and was instrumental in the early complete recovery of these children.