Plasma Aluminum Concentrations in Pediatric Patients Receiving Long‐Term Parenteral Nutrition

Background: Patients receiving long‐term parenteral nutrition (PN) are at increased risk of aluminium (Al) toxicity because of bypass of the gastrointestinal tract during PN infusion. Complications of Al toxicity include metabolic bone disease (MBD), Al‐associated encephalopathy in adults, and impaired neurological development in preterm infants. Unlike the United States, there are no regulations regarding Al content of large‐ and small‐volume parenterals in Canada. We, therefore, aimed to present our data on plasma Al concentration and Al intake from our cohort of pediatric patients receiving long‐term PN. Methods: Plasma Al concentration was retrospectively gathered from the patient charts of all 27 patients with intestinal failure (IF) receiving long‐term PN at The Hospital for Sick Children, Toronto, Canada, and compared with age‐ and sex‐matched controls recruited for comparison. In addition, Al concentration was measured in PN samples collected from 10 randomly selected patients with IF and used to determine their Al intake. Results: The plasma Al concentration of patients with IF receiving long‐term PN was significantly higher than that of control participants (1195 ± 710 vs 142 ± 63 nmol/L; P < .0001). In the subgroup of 10 patients for whom Al intake from their PN solution was determined, mean ± SD Al intake from PN was 15.4 ± 15 µg/kg, 3 times the Food and Drug Administration upper recommended intake level, and Al intake was significantly related to plasma Al concentration (P = .02, r² = 0.52). Conclusion: Pediatric patients receiving long‐term PN for IF in Canada are at risk for Al toxicity.     

Performance Status,Prognostic Scoring,and Parenteral Nutrition Requirements Predict Survival in Patients with Advanced Cancer Receiving Home Parenteral Nutrition

We describe a cohort of Home Parenteral Nutrition (HPN) patients with advanced cancer in order to identify factors affecting prognosis. Demographic, anthropometric, biochemical and medical factors, Karnofsky Performance Status (KPS), Glasgow Prognostic Score (GPS), and PN requirements were recorded. Univariate and multivariate analyses were performed including Kaplan–Meier curves, Cox Regression, and correlation analyses. In total, 107 HPN patients (68 women, 39 men, mean age 57 yr) with advanced cancer were identified. The main indications for HPN were bowel obstruction (74.3%) and high output ostomies (14.3%). Cancer cachexia was present in 87.1% of patients. The hazard ratio (HR) for upper gastrointestinal and “other” cancers vs. gynaecological malignancy was 1.75 (p = 0.077) and 2.11 (p = 0.05), respectively. KPS score, GPS, PN volume, and PN potassium levels significantly predicted survival (HR_{KPS ≥50 vs <50} = 0.47; HR_{GPS = 2 vs. GPS = 0} = 3.19). In multivariate analysis, KPS and GPS remained significant predictors (p < 0.05), whilst PN volume reached borderline significance (p = 0.094). Survival was not significantly affected by the presence of metastatic disease, previous or concurrent surgery, chemo-radiotherapy, or indication for HPN (p > 0.05). Most patients passed away in their homes or hospice (77.9%). Performance status, prognostic scoring, and PN requirements may predict survival in patients with advanced cancer receiving HPN.     

Prevalence and Contents of Advance Directives in Patients Receiving Home Parenteral Nutrition

Background: Ethical issues may arise with patients who receive home parenteral nutrition (HPN) and have a change in their overall health status. We sought to determine the extent of advance care planning and the use of advance directives (ADs) by patients receiving HPN. Materials and Methods: Retrospective review of the medical records of adult patients newly started on HPN at the Mayo Clinic, Rochester, Minnesota, between January 1, 2003, and December 31, 2012, to determine the prevalence and contents of their ADs. Results: A total of 537 patients met the inclusion criteria. Mean (SD) age at commencement of HPN was 52.8 (15.2) years, and 39% (n = 210) were men. Overall, 159 patients (30%) had ADs. Many mentioned specific life‐prolonging treatments: cardiopulmonary resuscitation (44 [28%]), mechanical ventilation (43 [27%]), and hemodialysis (19 [12%]). Almost half mentioned pain control (78 [49%]), comfort measures (65 [41%]), and end‐of‐life management of HPN (76 [48%]). Many also contained general statements about end‐of‐life care (no “heroic measures”). The proportion specifically addressing end‐of‐life management of HPN (48%) was much higher than that previously reported in other populations with other life‐supporting care such as cardiac devices. The primary diagnosis or the indication for HPN was not correlated with whether or not the patient had an AD (P = .07 and .46, respectively). Conclusion: Although almost one‐third of the patients had an AD, less than half specifically mentioned HPN in it, which suggests that such patients should be encouraged to execute an AD that specifically addresses end‐of‐life management of HPN.     

Bloodstream Infections in Patients Receiving Manufactured Parenteral Nutrition With vs Without Lipids

Background: This study compared overall bacterial and bloodstream infection rates in patients receiving premixed parenteral nutrition (PN) with vs without lipid emulsion. Methods: Data from hospitalized patients who were ≥18 years of age and receiving premixed PN between 2005 and 2007 were extracted from the Premier Perspective database. Data were categorized into 2 groups: patients who received premixed PN only and those receiving premixed PN with lipids. Multiple logistic regression was used to adjust for risk factors and potential confounders, reporting the probability of risk for an infection. Results: The group without lipids was observed to have lower rates of both overall bacterial infection (43.5% vs 53.5%) and bloodstream infection (14.5% vs 18.9%). However, after adjusting for baseline characteristics, there were no significant differences in overall risk of bacterial infections (51.4% vs 53.5%; odds ratio [OR] = 1.11; 95% confidence interval [CI], 0.96–1.27) or bloodstream infections (19.6% vs 19.2%; 0.97; 0.81–1.16). In a subset of patients in the intensive care unit for ≥3 days, lower overall bacterial infection rates (58.3% vs 67.3%) and bloodstream infection rates (31.0% vs 37.0%) were observed in the group without lipids. After adjustment, there were no significant differences in risk of overall bacterial infection (OR = 0.95; 95% CI, 0.75–1.22) or bloodstream infection (0.92; 0.71–1.19) between the 2 groups. Conclusions: When administered with premixed PN, lipid emulsion was not significantly associated with an increase in the risk of infectious morbidity when compared to omitting lipids from therapy.     

Impact of an Intravenous Magnesium Shortage on Potassium Doses in Adult Surgical Patients Receiving Parenteral Nutrition

Background: Shortages of parenteral nutrition (PN) components have been common in recent years. Effects on patient management and outcomes have not been well documented. This study aimed to determine the effect of a parenteral magnesium shortage, and an institutional decision to omit magnesium from adult PN, on magnesium and potassium doses and serum concentrations. Materials and Methods: This was a retrospective cohort study of adult surgical patients during two 6‐month periods: prior to the magnesium shortage (2011) and during the shortage (2012). The relation between study period and electrolyte doses was evaluated by unadjusted and adjusted mixed models, while the relation between study period and hypokalemia and hypomagnesemia exposure was evaluated by Student's t tests and multiple linear regression. Results: During the shortage, patients received more supplemental magnesium (0.11–0.12 mEq/kg/d, P < .0001) but received less total daily magnesium (0.08–0.09 mEq/kg/d, P < .0001) and had greater exposure to hypomagnesemia (9.6–14.2 h·mcg/dL/h, P < .05 for all comparisons except multivariate analysis in a matched subpopulation). Patients received similar amounts of potassium in PN (0.06–0.08 mEq/kg/d less, P < .05 for full cohort but P > .05 for matched cohort), in supplemental doses (0.01–0.05 mEq/kg/d less, P > .05), and in total (0.07–0.14 mEq/kg/d less, P > .05), and they had similar exposure to hypokalemia. Conclusion: Daily magnesium doses were lower and hypomagnesemia exposure was greater during the shortage, but the differences were numerically small and their clinical significance was questionable. Potassium doses and hypokalemia exposure were not higher during the shortage. This supports the strategy of omitting magnesium from PN of select patients and supplementing as clinically necessary.     

Risk Factors for Predicting Hypoglycemia in Patients Receiving Concomitant Parenteral Nutrition and Insulin Therapy

The occurrence of hypoglycemia in patients receiving parenteral nutrition (PN) is low, yet its consequences can be detrimental. Treatment of hyperglycemia with insulin to achieve optimal blood glucose control is challenging and potentially associated with increased risk of the development of hypoglycemia. The objective of this study was to determine the association of patient characteristics on the risk of hypoglycemia among patients receiving concomitant PN and insulin therapy. This retrospective cohort study was conducted from January 1, 2008, to December 31, 2011, and included 1,657 patients who received PN. There was a significant decrease in the occurrence of hypoglycemia observed over time: 9.1% (43 of 475) in 2008, 6.4% (30 of 468) in 2009, 5.8% (20 of 347) in 2010, and 3.5% (13 of 367) in 2011 (P=0.013). Patients in whom hypoglycemia developed had a significantly longer duration on PN (18.0 vs 8.1 days, P<0.0001) as well as more days requiring insulin in the PN (16.1 vs 2.7 days, P<0.0001). The strongest predictors of hypoglycemia were: receiving PN in the ICU (OR 1.86, 95% CI 1.16 to 3.01), history of diabetes (OR 2.10, 95% CI 1.26 to 3.51), days on PN (OR 0.93, 95% CI 0.91 to 0.95), and an insulin drip (OR 3.14, 95% CI 1.81 to 5.42). With the identification of patient factors that contribute to an increase in hypoglycemia, existing protocols can be modified to treat hyperglycemia and prevent hypoglycemia.     

Metabolic Bone Disease in Total Parenteral Nutrition

Approximately two-thirds of adolescent girls at any age are dissatisfied with their weight, the proportion increasing with actual weight. Slightly more than half of all girls are dissatisfied with the shape of their bodies, an attitude which also is positively correlated with body weight. Girls are most likely to be distressed about excess size of their thighs, hips, waist and buttocks, and inadequate size of their breasts. Those who are dissatisfied with their bodies are more likely to engage in potentially harmful weight control behaviors, such as dieting, fasting, self-induced vomiting, diuretic use, laxative use and diet pill use. Those who diet are more likely to begin in early adolescence, to be white than black, to be of higher socioeconomic status, to engage in other eating-related practices and to have a poor body image and self esteem. Boys who are underweight are most likely to be dissatisfied with their weight and many with normal weight wish to weigh more. Approximately one-third of boys are dissatisfied with their body shape, desiring larger upper arms, chest and shoulders. Dieting and purging are less likely than exercise to be chosen by boys as methods of weight control. Dieting among boys is more likely to be associated with increased body weight and some sports, such as wrestling. Body consciousness and altered body image are widespread among adolescents, and may be associated with potentially harmful eating practices in both sexes, but more so in girls.     

Hypothyroidism and Iodine Deficiency in an Infant Requiring Total Parenteral Nutrition

While iodine deficiency remains a relatively rare cause of thyroid dysfunction in the United States, little is known about iodine status and deficiency in children requiring parenteral nutrition (PN). This population may be at an elevated risk of thyroid dysregulation and neurodevelopmental sequelae due to low concentrations in typical PN formulations. Furthermore, with the widespread practice of switching from iodine‐based antiseptics to chlorhexadine, previous inadvertent sources of iodine are being eliminated as well.     

全胃肠外营养医院感染经济损失的病例对照研究

目的 认识全胃肠外营养（TPN）患者医院感染经济损失。方法 用前瞻性和回顾性相结合的调查方法对60对患者进行病例对照研究。结果 病例组平均每例住院天数比对照组延长13．67d,两级显著性差异（P＜0．01）;住院费用病例组比对照组平均每例多花费9573．99元,且多部位感染比单一部位感染住院费用高。结论 TPN医院感染显著增加患者住院时间和费用,应加强医院感染管理为医院创造无形效益,以引医院领导的重视,从而促进医院感染管理的发展。     

Survival of Patients with Multi-Level Malignant Bowel Obstruction on Total Parenteral Nutrition at Home

Home parenteral nutrition (HPN) may improve the survival in selected patients with malignant bowel obstruction. This retrospective, medical registry-based study aimed to identify clinical and laboratory markers predicting short survival, which would allow a more accurate selection of patients that would benefit from HPN in inoperative bowel obstruction. In a retrospective analysis of 114 patients receiving HPN, the median survival was 89 days after discharge home, and the three and six-month survival probability was 48% and 26%, respectively. Parenteral nutrition was provided during 98% of overall survival time and ended on a median of one day before the patient’s death. Discontinuing chemotherapy, anemia, severe hypoalbuminemia, and water retention appeared correlated with survival shorter than three months. In these cases, routine initiation of HPN should be discouraged, as it may not bring any benefits to the patient. The decision on the initiation of HPN should be made along with continuing or initiating chemotherapy.     

In Vivo Degradation of Cholesterol to Bile Acids Is Reduced in Patients Receiving Parenteral Nutrition

Background. Artificial nutrition is frequently associated with hepatobiliary complications, probably due to the inherent derangement of the gastrointestinal tract physiology. Alterations of hepatic lipid metabolism are likely to be involved. The aim of the present study was to investigate the effect of artificial nutrition on bile acid production, a key event in cholesterol homeostasis, in humans. Patients and Methods. Eleven patients receiving artificial nutrition, either parenteral nutrition (PN; n = 6) or enteral nutrition (EN; n = 5) with no previous history of liver disease, underwent analysis of cholesterol 7α‐hydroxylation rates in vivo, a measure of bile acid formation, by isotope release analysis after intravenous injection of [7α‐³H]cholesterol. The results were compared with those obtained in a population of 16 age‐matched control subjects. Results. Hydroxylation rates were lower in patients with artificial nutrition (PN: 94 ± 13 mg/d; EN: 230 ± 39 mg/d, mean ± SEM) when compared with controls (385 ± 47 mg/d) (P < .01, 1‐way analysis of variance). In a patient receiving EN, hydroxylation rates increased 3.5‐fold after treatment with the cholecystokinin analogue ceruletide (20 µg bid for 2 weeks intramuscularly). Serum lathosterol‐to‐cholesterol ratio, a marker of cholesterol synthesis, was also significantly reduced in artificial nutrition, whereas serum levels of fibroblast growth factor 19 (FGF19) were increased. Conclusion. In vivo 7α‐hydroxylation is suppressed in artificial nutrition, particularly in PN. The finding associates with reduced cholesterol production, possibly as a metabolic consequence. The data suggest a regulatory role of gastrointestinal hormones and FGF19 on bile acid production and might suggest a pathophysiological basis for some common complications of artificial nutrition, such as gallstone disease and cholestasis.     

丙氨酰-谷氨酰胺在全合一肠外营养液中的稳定性

目的 观察丙氨酰-谷氨酰胺对全合一肠外营养液稳定性尤其是脂肪乳剂稳定性的影响。方法将丙氨酰-谷氨酰胺分别加入3种不同配方的全合一肠外营养液中，在不同温度下、24小时内取样观察外观变化，测定pH值、渗透压值。观察脂肪乳剂在加入丙氨酰-谷氨酰胺后颗粒大小及形态有无改变并计算平均粒径。结果不同配方全合一肠外营养液加入丙氨酰-谷氨酰胺后，其外观、pH值、渗透压值未见明显改变，脂肪乳剂颗粒大小及形态亦无明显变化。临床应用100人次，未见不良反应。结论丙氨酰-谷氨酰胺可加入全合一肠外营养液中进行配伍使用。     

消化道术后肠内营养与肠外营养联合应用与单纯肠外营养的比较

目的 探讨消化道恶性肿瘤术后早期肠内营养（EN）和肠外营养（PN）联合应用对患者恢复的影响，并与完全胃肠外营养（TPN）进行比较。方法 将2002年1月-2004年3月择期行消化道恶性肿瘤手术的患者65例随机分为二组：EN-PN组（35例）和TPN组（30例），于术后24小时开始营养治疗。分别于术前和术后第7天测定血清白蛋白（ALB）、前白蛋白（PA）、转铁蛋白（TFN）及白细胞介素6（IL-6）、肿瘤坏死因子α（TNFα）水平，同时测定血清内毒素水平和尿乳果糖/甘露醇（L/M）评价肠黏膜通透性，测定血清IgA、IgG、IgM、CD4、CD8及CD4/CD8评价免疫功能，比较二组患者感染等并发症的发生率和平均住院时间。结果 术后第7天，EN-PN组的尿L/M、血清内毒素、IL-6及TNFα水平均明显低于TPN组（P〈0．05），而EN-PN组的IgG及CD4/CD8水平均明显高于TPN组（P〈0．05），EN-PN组TFN及PA明显高于TPN组（P〈0．05），EN-PN组患者感染并发症和住院时间亦明显降低（P〈0．01）。结论 消化道恶性肿瘤患者术后早期应用肠内和肠外营养相结合的营养方式是安全有效的，可提高患者的免疫功能，促进患者恢复。     

Parenteral Amino Acid Intakes in Critically Ill Children

Background: Parenteral and enteral amino acid requirements for nutrition balance and function have not been defined in critically ill children or adults. In addition to playing a role in protein synthesis, amino acids trigger signaling cascades that regulate various aspects of fuel and energy metabolism and serve as precursors for important substrates. Amino acids can also be toxic. In this study, parenteral intakes of essential and nonessential amino acids (EAAs and NEAAs) supplied to critically ill children were assessed as an initial step for further studies aimed at establishing parenteral amino acid requirements. Methods: A retrospective review was conducted to assess intakes of parenteral amino acid for 116 critically ill children, and these intakes were compared with EAA intakes recommended by the Institute of Medicine. Because there are no recommended intakes for NEAA, NEAA intakes were compared with mixed muscle protein content in the older children and breast milk amino acid content in the infants. Results: Parenteral EAAs were provided in amounts that exceeded recommended intakes for healthy children, except for phenylalanine and methionine, which although excessive, were given in less generous amounts. NEAAs were supplied in lower or higher amounts than the content of mixed muscle proteins or breast milk. Parenteral amino acid formulas are limited in taurine, glutamine, and asparagine despite the fact that inflammatory/immune proteins are rich in these amino acids. Conclusions: Amino acid composition of parenteral formulas is variable and lacks scientific support. Parenteral amino acid intakes should be based on measured requirements to maintain nutrition and functional balance and on knowledge of toxicity.