Gallbladder distention in premature neonates receiving parenteral nutrition

Contraction of the gallbladder is mediated through the release of cholecystokinin from duodenal cells secondary to enteral feedings. Premature infants are often nourished by parenteral hyperalimentation leading to prolonged inactivation of the gallbladder. Such inactivation probably accounts for the increased incidence of gallbladder distention observed in premature neonates. Two cases of premature infants are described in whom distention of the gallbladder occurred during parenteral hyperalimentation. The distention resolved spontaneously secondary to the introduction of enteral feedings. A trial period of oral or tube feeding is recommended in such cases prior to any attempt to release the distention by a surgical intervention.     

Rapid replacement of serum albumin in patients receiving total parenteral nutrition

The albumin deficit (AD) of 13 malnourished patients with serum albumin concentrations (SAC) of less than 3.0 grams per deciliter was estimated using a simple equation. The AD was replaced over a period of 24 to 72 hours as a component of the formulation of total parenteral nutrition (TPN). AD was estimated assuming a volume of distribution of 3 deciliters per kilogram of actual body weight and a minimum acceptable SAC of 3.5 grams per deciliter. The mean AD was 200 +/- 94 grams (mean +/- standard deviation), the average dose administered was 206 +/- 97 grams. TPN regimens provided 42.0 +/- 8.5 nonprotein kilocalories per kilogram with a nonprotein calorie to nitrogen ratio of 125 to 150:1. The SAC increased from 2.36 +/- 0.38 grams per deciliter to 3.46 +/- 0.26 grams per deciliter immediately after replacement. At follow-up study, the SAC at 6.4 +/- 1.5 days yielded a SAC value of 3.35 +/- 0.30 grams per deciliter, indicating no significant decrease from immediate replacement values. AD can be easily estimated, rapidly replaced and maintained with adequate nutritional support.     

Essential fatty acid deficiency associated with total parenteral nutrition.

Essential fatty acid deficiency is a clinical and biochemical entity encountered in both adults and children. Especially at risk are those patients maintained by fat-free total parenteral nutrition. Linoleic acid is the substance most responsible for the deficien state and essential to its correction. A ratio of trienoic-tetraenoic fatty acids of 0.4 or greater is diagnositc of a chemical deficiency. A severe deficiency affects polyunsatured fatty acids, in both plasma and tissues and, thus, many systems of the body. Mulitple blood transfusions have not proved sufficient to correct chemical deficiency. A recently marketed, commercially available fat supplement, however, may be useful in preventing the problem.     

Serum zinc and copper during long-term total parenteral nutrition.

Changes in serum zinc and copper levels were studied in 17 patients who received 18 courses of total parenteral nutrition for 28 to 89 days. Mean serum zinc levels decreased significantly after 4 weeks of therapy in the group without zinc supplementation when compared with pretreatment levels (p less than 0.05) and in a second group who received about 1.5 mg of zinc per day (p less than 0.05). Serum copper levels fell consistently and significantly in patients of both groups. However, no obvious clinical signs or symptoms of zinc or copper deficiencies were observed. Blood transfusions were not able to significantly change the serum levels of zinc or copper. Although serum alkaline phosphatase has been suggested as a functional indicator of zinc deficiency, the concomitant hepatic or skeletal dysfunction of the patients made its interpretation difficult. These findings indicate that a decrease in serum zinc and copper is common during TPN using solutions unsupplemented with these trace elements. Supplementation of TPN solutions with zinc, copper, and other trace elements is recommended.     

Maternal total parenteral nutrition in chronic cholecystitis. A case report

A pregnancy was complicated by recurrent episodes of cholecystitis unresponsive to medical management. Total parenteral nutrition (TPN), rather than surgery, was elected to minimize fetal and maternal morbidity.     

Hyperemesis gravidarum: outcomes and complications with and without total parenteral nutrition

OBJECTIVE: To evaluate the obstetric and medical complications with hyperemesis gravidarum, comparing those who were supported with total parenteral nutrition (TPN group) and those who did not receive TPN (non-TPN group). STUDY DESIGN: The medical records of women with a diagnosis of hyperemesis gravidarum (ICD-9 code 643) admitted to Crouse Hospital, Syracuse, New York, between January 1995 and December 1998, were reviewed. A total of 166 subjects were identified and 192 admissions reviewed. Information was gathered for age, gestational age, gravity and parity, marital status, length of stay and number of admissions, and a review of electrolyte, albumin and thyroid function was performed. An assessment of pregnancy complications and outcomes was undertaken. RESULTS: Of the cases reviewed, 16% (27/166) were treated with TPN. The 2 groups were similar regarding incidence of pregnancy-related and maternal medical complications. The groups were similar when comparing objective measures, such as serum potassium, bicarbonate, albumin and thyroid function. The TPN group had a significantly increased incidence of complications directly attributable to parenteral therapy. Among multiparous patients in both groups, 69% had a prior pregnancy that had ended in spontaneous or induced abortion. CONCLUSION: The TPN group had a marked and significant increase in serious complications directly related to TPN use. These data suggest that great care should be taken to assess the need for parenteral therapy in patients with hyperemesis gravidarum. A history of loss in the antecedent pregnancy may be a risk factor for a subsequent pregnancy complicated by hyperemesis gravidarum.     

Case report: total parenteral nutrition extravasation associated with spinal cord compression and necrosis.

A preterm infant, whose course was complicated by sepsis, necrotizing enterocolitis with jejunal perforation, intraventricular hemorrhage and cerebellar hemorrhage, suffered permanent and total paralysis below the neck from extravasation of parenteral nutrition fluids through a femoral venous catheter. MRI imaging revealed extravasation of fluid into the paraspinus musculature with extension into the spinal canal. This fluid was identified as hyperalimentation and intralipid. Postmortem examination found evidence of necrosis of the spinal cord as well as perforation of the right iliac vein.     

Peripheral arterial and venous concentrations of various androgens in patients with and without hirsutism.

The mean peripheral arteriovenous difference for dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEA-S), androstenedione (A), testosterone (T), 5ALPHA-dihydrotestosterone (DHT), and 17-hydroxyprogesterone (17-P) has been calculated in 7 nonhirsute and 9 hirsute women. No significant difference was found between peripheral artery and vein concentrations for all steroids measured in both groups of women studied. Since steroid concentrations in peripheral arterial samples are not expected to differ from those from ovarian and adrenal arteries, it is concluded that peripheral venous steroid levels adequately represent the steroid concentrations of arterial blood delivered to steroid-producing tissue.     

Fetal growth response to total parenteral nutrition in pregnancy. A case report

Although clinical experience with total parenteral nutrition (TPN) in pregnancy is accumulating, assessment of the fetal growth response to this therapy has been limited primarily to birth weight. We performed serial ultrasonographic measurements of the fetal biparietal diameter (BPD), femur length (FL) and abdominal circumference (AC) in a patient who received TPN because of chronic malnutrition. BPD and FL were within normal limits before and after TPN. Consistent with asymmetric growth retardation, the AC was low prior to TPN and increased significantly after TPN was administered. Estimated fetal weight increased accordingly. These data suggest that TPN can reverse subnormal fetal growth secondary to maternal nutritional deprivation.     

Arginine vasopressin in amniotic fluid, arterial and venous cord plasma and maternal venous plasma

High concentrations of arginine vasopressin (AVP) in arterial umbilical cord blood at the time of delivery have been attributed to either a generalized increase in the activity of the fetal endocrine system at the onset of labor or to fetal asphyxia. We measured AVP in amniotic fluid, arterial and venous cord blood and in maternal venous blood from 13 patients at 38-40 weeks of gestation at the time of elective cesarean section with a nonasphyxic fetus (group I), in amniotic fluid from 19 patients at 15-17 weeks of gestation (group II) and in venous blood from 13 nonpregnant control subjects (group III). Our results showed a high concentration of AVP in the amniotic fluid both in the middle and at the end of normal pregnancy and at the same level as in arterial cord blood, whereas AVP in the venous cord blood was significantly lower and at the same level as in the maternal venous blood and in the control group. It is concluded that the fetus produces AVP and this is at least not solely caused by fetal asphyxia or related to parturition.     

One hundred and fourteen fistulas of the gastrointestinal tract treated with total parenteral nutrition

During a period of five years, all patients with fistulas of the gastrointestinal tract who received total parenteral nutrition as a part of the therapy were evaluated retrospectively. One hundred and eight patients with 114 fistulas of the gastrointestinal tract were studied. There were 58 male and 50 female patients. The mean age of the patients was 58 years old. Fifty-one per cent (58) of all fistulas resulted from surgical complications and 30 per cent from inflammatory disease. The most common origin of the fistula was the small intestine (48 per cent), with the large intestine being the next most common origin (26 per cent). Ninety-eight of the fistulas were treated successfully. The mean time for closure from the time of diagnosis was 30.9 days. Sixty-one per cent (69) of all fistulas closed spontaneously, the use of parenteral nutrition resolved 37 per cent (42) and 24 per cent (27) resolved after surgical control of sepsis. Twenty-five per cent (29) of the fistulas required definitive surgical closure. Sixteen patients died prior to resolution of the fistula, 11 deaths were directly related to septic complications of the fistula and one died as a result of hemorrhage of the fistula tract. The direct fistula-related mortality rate was 10.5 per cent. Whereas the mortality rate for fistulas remained stable, spontaneous closure rates continue to improve. This is attributed to improved "para-surgical" care, appropriate nutritional support and early and aggressive control of sepsis. Ninety to 95 per cent of fistulas that spontaneously resolve will do so within four to five weeks. Inflammatory disease of the intestine and radiation induced fistulas continue to respond poorly to medical management.     

Tolerance of fat emulsions in very-low-birthweight neonates. Monitoring of plasma lipid concentrations

Tolerance to parenterally administered fat emulsions was studied in 45 normally grown neonates ranging from 820 to 1550 gm in birthweight, from 27 to 34 weeks in gestational age, and from 2 to 10 days postnatal age. Concentrations of total lipids, free glycerol, true triglycerides, free fatty acids, and cholesterol in plasma were studied over an 8-day period. The aim was to determine whether the concentrations of any one lipid fraction could be used to predict those of other fractions. With 650 pairs of data being correlated, the best correlation coefficients were obtained between total lipids and triglycerides (r = 0.67), total lipids and cholesterol (r = 0.63), free glycerol and free fatty acids (r = 0.55), total lipids and free fatty acids (r = 0.54), and triglycerides and free fatty acids (r = 0.50). Although all correlation coefficients were highly significant statistically (P less than 0.001), the very large standard errors precluded using any of these relationships to make clinical predictions. Problems and limitations of currently available techniques are discussed in order to provide a lead for further research.     

The impact of total parenteral nutrition support on pregnancy outcome in women with hyperemesis gravidarum

Abstract

Objective: To assess pregnancy outcome among women with hyperemesis gravidarum (HEG) with and without total parenteral nutrition (TPN) support.

Study design: A retrospective study of all pregnant women with singleton pregnancies who were hospitalized due to HEG between 1997 and 2011. Pregnancy outcome was compared with a control group without HEG matched by maternal age and parity in a 3:1 ratio.

Results: Overall 599 women were admitted during the study period with the diagnosis of HEG and subsequently delivered in our center. Of those, 122 (20.4%) received TPN support. Women in the HEG group were characterized by a higher rate of severe preeclampsia (1.3% versus 0.5%, p?=?0.04), and a higher rate of preterm delivery at less than 37 and 34 weeks (10.9% versus 6.9%, p?<?0.001 and 4.7% versus 1.6%, p?<?0.001, respectively). Neonates in the HEG group were characterized by a lower birth weight (3074?±?456?g versus 3248?±?543?g, p?<?0.001), higher rate of birth weight?<?10th percentile (12.7% versus 6.8%, p?<?0.001), and a higher rate of neonatal morbidity (8.7% versus 3.8%, p?<?0.001). These associations persisted after adjustment for potential confounders, and were of most notable among women with HEG who did not receive TPN support.

Conclusion: HEG is an independent risk factor for adverse pregnancy outcome. TPN support during early pregnancy is associated with a decreased risk for perinatal morbidity.     

Comparison of protein carbonyl and total plasma thiol concentrations in patients with complete hydatidiform mole with those in healthy pregnant women

BACKGROUND: Normal pregnant women are known to have increased oxidative stress and lipid peroxidation (which can be estimated by protein carbonyl concentration) but offsetting antioxidant protection (of which plasma thiols are an important component). AIM: This study set out to compare levels of these markers in normal pregnant women and patients with complete hydatidiform mole (CHM). METHODS: Blood was taken from 41 healthy pregnant women and 39 patients with CHM attending a university hospital, and protein carbonyl and thiol levels determined spectrophotometrically on plasma. Statistical analysis of the results was performed using Student's t-test and Pearson's correlation. RESULTS: Patients with CHM were found to have significantly higher levels of protein carbonyls and lower (but non-significant) levels of thiols. CONCLUSION: The results may indicate oxidative stress as a feature of CHM.     

Intrauterine growth restriction impacts tolerance to total parenteral nutrition in extremely low birth weight infants.

BACKGROUND: Hepatobiliary dysfunction is well recognized as a complication of long-term total parenteral nutrition (TPN). Because intrauterine growth restriction (IUGR) alters a number of metabolic and physiologic variables in the fetus that probably affect the hepatocyte function and tolerance to feedings in the IUGR extremely low birth weight (ELBW), we hypothesized that this group of babies would have an increased incidence of TPN-associated cholestasis and chronic liver failure. METHODS: We performed a review of all ELBW infants (birth weight <1000 g) that received TPN for >7 days. RESULTS: Among 1768 infants admitted to the neonatal intensive care unit there were 103 ELBW who received TPN >7 days, 38 (37%) of them developed TPN cholestasis. Among 69 appropriate for gestational age (AGA)-ELBW infants, 19 (27%) developed cholestasis compared to 19/34 small for gestational age (SGA)-ELBW infants (56%) (p<0.0009). Maximum direct bilirubin values and days on TPN were similar in both groups. SGA-ELBW infants had an increased incidence and earlier onset of cholestasis when compared to AGA-ELBW patients. Liver biopsies and/or autopsies of infants that developed liver failure (four AGA/four SGA) showed extensive sinusoidal/portal fibrosis compatible with "TPN lesion". In the other 30 cases, liver function eventually returned to normal after TPN discontinuation. CONCLUSIONS: When compared, SGA-ELBW infants who received TPN >7 days, despite being more mature than AGA-ELBW infants, have an increased risk for TPN cholestasis and developed this complication earlier in life. However, the incidence of chronic liver failure was not different in these two groups.     

Prediction of arterial blood gas values from venous blood gas values in patients with acute respiratory failure receiving mechanical ventilation.

BACKGROUND AND PURPOSE: Arterial blood gas (ABG) analysis is useful in evaluation of the clinical condition of critically ill patients; however, arterial puncture or insertion of an arterial catheter may cause many complications. This study evaluated whether pH, partial pressure of carbon dioxide (PCO2) and bicarbonate (HCO3-) values of venous blood gas (VBG) could accurately predict their ABG analogs for patients with acute respiratory failure treated by mechanical ventilation in an intensive care unit (ICU). METHODS: Forty six patients who were admitted to the ICU due to acute respiratory failure and treated by mechanical ventilation were included in this study. Blood for VBG analysis was sampled from the cubital or dorsal palmar veins, while ABG was sampled simultaneously from the radial or brachial arteries via an arterial catheter at the other upper extremity. Regression equations and mean percentage-difference equations were derived to predict arterial pH, PCO2, and HCO3- values from their VBG analogs. The equations were validated by evaluating VBG and ABG samples from a separate group of 11 patients. RESULTS: A total of 46 paired samples from 46 patients were evaluated. The mean percentage differences between the venous and arterial values divided by venous values for pH, PCO2, and HCO3- were (mean +/- SD): deltapH (%), 0.50 +/- 0.45; deltaPCO2 (%), 17.09 +/- 9.60; and deltaHCO3- (%), 9.72 +/- 7.73; respectively. Regression equations for prediction of pH, PCO2 and HCO3- values were: arterial pH (pHa) = 0.45 + 0.94 x venous pH (pHv) [r = 0.83, p < 0.0001]; partial pressure of arterial CO2 (PaCO2) = 3.06 + 0.76 x partial pressure of venous CO2 (PvCO2) [r = 0.86, p < 0.0001]; and arterial HCO3- (HCO3-a) = 2.34 + 0.82 x venous HCO3- (HCO3-v) [r = 0.91, p < 0.0001]. The predicted ABG values from the mean percentage-difference equations were derived as follows: pHa = pHv x 1.005; PaCO2 = PvCO2 x 0.83; and HCO3-a = HCO3-v x 0.90. Validation of the regression equations and mean percentage-difference equations revealed only a small (clinically insignificant) variation between the actual and predicted ABG values. CONCLUSIONS: Venous blood gas can accurately predict the ABG values of pH, PCO2 and HCO3- for patients with acute respiratory failure being treated with mechanical ventilation.     

Clinical improvement following home parenteral nutrition in pediatric patients with intestinal failure.

BACKGROUND/PURPOSE: Home parenteral nutrition (HPN) is being increasingly used to treat children with intestinal failure. This study evaluated the long-term growth, outcome and complications in Taiwanese pediatric patients with intestinal failure who were treated with HPN. METHODS: This retrospective study included 27 consecutive pediatric patients with intestinal failure who received long-term HPN between 1987 and 2002. These patients were categorized into two groups according to whether they had short bowel syndrome or a bowel motility disorder. Growth, prognosis and complications, including cholestasis, hypoglycemia, hyperglycemia and infections were compared between the two groups. RESULTS: The median age of starting HPN was significantly younger in patients with short bowel syndrome (5 months) than in patients with motility disorders (1.9 years). The median duration of HPN treatment in the overall group was 13.5 months (range, 2.1-113.1 months); weight and height increased 1.7 +/- 2.3 and 1.0 +/- 1.6 in z score, respectively. The most common complications were cholestatic liver disease (52%), hypoglycemia (15%) and hyperglycemia (33%). All patients maintained stable serum glucose levels at follow-up. Cholestatic liver disease developed after 2.3 +/- 2.0 months of total HPN in 13 patients, which subsided after 9.7 +/- 6.9 months in 11 patients, while two patients died. The mean incidence of central venous infection was 3.0 +/- 3.3 per 1000 HPN days. The most common pathogens were Staphylococcus spp. (50%) and Candida spp. (30.6%). CONCLUSION: HPN treatment can successfully provide a bridge to enteral nutrition in pediatric patients with intestinal failure. The metabolic disturbances and cholestasis are usually transient, but infection control is important throughout the period of HPN treatment.     

Utility of hepatobiliary scintigraphy in diagnosing or excluding biliary atresia in premature neonates and full-term infants with conjugated hyperbilirubinemia who received parenteral nutrition

Purpose: Hepatobiliary scintigraphy (HBS) is used to aid in the diagnosis of Biliary Atresia in full-term infants with conjugated hyperbilirubinemia. There is little information on the utility of the HBS in premature infants with conjugated hyperbilirubinemia and infants with parenteral nutrition associated cholestasis (PNAC). The purpose of this study is to assess the utility of HBS in differentiating Biliary Atresia and PNAC in premature neonates and full-term infants who received parenteral nutrition (PN).

Materials and methods: Retrospective data collection and analysis on infants who developed conjugated hyperbilirubinemia and had HBS performed during their stay at level IV neonatal intensive care unit between 2005 and 2015.

Results: A total of 20 patients with exposure to PN had HBS; two patients were confirmed to have Biliary Atresia. There were no statistically significant differences between patients with Biliary Atresia versus PNAC in demographics, days on PN, or gamma glutamyl-transferase levels. Stool color was statistically significantly different between the two groups; patients with Biliary Atresia had acholic stools more consistently than patients without Biliary Atresia. HBS had 100% sensitivity, 17% specificity, positive-predictive value of 12%, and a negative-predictive value (NPV) of 100%.

Conclusions: These data indicate that the ability of HBS to aid in diagnosing Biliary Atresia is poor in a population of preterm neonates and full-term infants with PNAC. Although there is 100% sensitivity, the poor specificity (17%) should be acknowledged when utilizing HBS to diagnose Biliary Atresia in this vulnerable patient population. NPV of 100% is helpful in ruling out Biliary Atresia in this population.