Management of glucose abnormalities in patients receiving total parenteral nutrition

A patient who developed extreme fluctuations in serum glucose concentrations while receiving total parenteral nutrition (TPN) is described, and etiologies of hyperglycemia and hypoglycemia, as well as a rational approach to preventing and managing these disorders in patients receiving TPN, are presented. A 40-year-old white man with a 29-year history of insulin-dependent diabetes mellitus was hospitalized after he had an episode of rejection related to a cadaveric kidney transplant. During the hospitalization, his right leg was amputated because of cellulitis, and he developed septicemia with respiratory failure. A renal biopsy revealed cytomegalovirus inclusion disease, the kidney was removed, and intermittent hemodialysis was begun. Control of the patient's serum glucose concentration included four routes of insulin administration: a continuous titratable insulin infusion, subcutaneous sliding-scale insulin, insulin incorporated into the TPN solution, and intravenous bolus insulin. Further, glucose management was being coordinated by three teams: intensive care, nutrition support, and the renal service, with physicians from each service prescribing insulin therapy. The patient also received prednisone daily. The sporadic approach to this patient's glucose control, complicated by the extensive disease profile of the patient, resulted in precipitous fluctuations in his serum glucose concentrations. Patients receiving parenteral nutrition are subject to widely varying serum glucose concentrations related not only to the nutrition support provided but also to various underlying metabolic and physiologic complications commonly present. Common etiologies of, and ways to prevent and manage, hypoglycemia and hyperglycemia are reviewed. Clinicians should be aware of the risk of hyperglycemia and hypoglycemia in patients receiving TPN and monitor patients appropriately for alterations in glucose homeostasis.     

肿瘤晚期患者静脉营养支持治疗经外周静脉穿刺中心静脉置管相关并发症分析及护理对策

目的探讨肿瘤晚期患者静脉营养支持治疗经外周静脉穿刺中心静脉置管(PICC)相关并发症的原因以及护理对策。方法回顾性分析189例肿瘤晚期静脉营养支持治疗患者,经PICC置管术后并发症的发生情况,针对并发症发生情况提出相应的护理对策。结果 189例患者PICC置管术后,发生PICC侧手臂水肿103例,静脉炎12例,导管感染10例,导管堵塞8例,穿刺点渗血1例,心律失常1例,导管脱出2例,并发症发生率为72.5%。结论 PICC置管为患者提供了一条有效的静脉通道,对PICC并发症的预防和正确处理,可以有效延长导管使用时间,为病人带来便利。     

Effect of nitrogen intake on urea appearance in patients receiving total parenteral nutrition and hemodialysis

Hemodialysis results in significant amino acid and protein losses and increases the patient's need for, and tolerance to, standard doses of protein. Since urea accumulation increases proportionately with increasing doses of protein in patients with normal renal function, urea accumulation may result when protein intake is increased to offset losses occurring in the dialysate. As a consequence, an increased requirement for dialysis may occur that might be poorly tolerated by the critically ill patient. This study was designed to determine the relationship between nitrogen intake and urea appearance in five patients requiring hemodialysis and total parenteral nutrition. Daily caloric and nitrogen intakes were determined. Urea appearance was calculated from measures of urine urea nitrogen excretion and daily body urea accumulation. Results of 108 measurements in treatment courses ranging from 23-79 days found that the average caloric intake (1984 +/- 55 calories/d) and nitrogen intake (11.0 +/- 0.4 g/d) resulted in a positive nitrogen balance (0.8 +/- 0.4 g/d) and a urea appearance rate of 9.4 +/- 0.8 g/d. Nitrogen intake correlated both with urea appearance (r = 0.59, p less than 0.001) and nitrogen balance (r = 0.49, p less than 0.001). Positive nitrogen balance was associated with improvements in measures of total iron binding capacity (p less than 0.05). Nitrogen intake directly relates to urea appearance, and positive nitrogen balance can be achieved without increasing dialysis requirements. In this group of patients, 28.3 calories per kg ideal body weight and 0.8 g of protein per kg ideal body weight were required to achieve nitrogen equilibrium.     

Chromium and zinc concentrations in pediatric patients receiving long-term parenteral nutrition.

Serum, urine, and parenteral nutrition (PN) chromium and zinc concentrations in pediatric patients receiving long-term PN were studied. Serum, urine, and PN chromium and zinc concentrations were measured at baseline and four to six months later in four infants (less than 1 year old) and seven children (1-12 years old) receiving long-term PN. In the children, serum, urine, and PN solution zinc concentrations were measured monthly after the amino acid product was changed from a standard to a pediatric product with monthly dosages of 0, 20, 30, and 40 mg of cysteine hydrochloride per gram of amino acids. The mean +/- S.D. baseline serum chromium concentration was 4.9+/-1.9 microg/L (normal value, <0.3 microg/L); the urine chromium concentration ranged from 3.4 to 32.2 microg/L. The mean +/- S.D. prescribed chromium dosage was 0.18+/-0.05 microg/kg/day, and the dosage delivered in PN solutions was 0.41+/-0.23 microg/ kg/day. At baseline, the mean +/- S.D. serum zinc concentration was 1383+/-472 microg/L (normal range, 430 to 940 microg/L), and the prescribed and delivered zinc dosages were 177+/-10 and 238+/-145 microg/kg/ day, respectively. With 20, 30, and 40 mg of cysteine per gram of amino acids, the mean +/- S.D. serum zinc concentration was 1728+/-782, 1664+/-349, and 1685+/-268 microg/L, respectively, and the actual zinc dosages delivered were 209+/-10, 270+/-148, and 322+/-194 microg/kg/day, respectively. Serum and urine chromium concentrations were abnormally high in infants and children receiving PN solutions supplemented with normal doses of these trace elements; an escalating dosage of cysteine in the children tended to increase serum and urine zinc concentrations.     

含脂肪乳全成分胃肠外营养在肝功能不全中应用进展

当肝脏由于某些致病因素的损害而引起机体明显的物质代谢障碍、解毒功能降低、胆汁形成和排泄障碍及出血倾向等肝功能异常改变时,称为肝功能不全(Hepatic insufficiency,HI).肝功能不全是全成分胃肠外营养(TPN)的适应证之一,脂肪乳剂作为TPN的重要供能物质越来越受到重视.     

200例肿瘤患者全肠外营养药物处方分析

目的分析肿瘤患者全肠外营养(TPN)处方医嘱,为临床合理使用TPN提供参考。方法自行设计TPN处方点评表,采用回顾性调查方法 ,从本院2013年1-12月所有使用TPN处方的肿瘤患者的病历中随机抽出200份,填写TPN处方点评表,利用Excel表格数据自动筛选、分类汇总等方法 ,对各项研究指标进行统计分析,评价TPN处方的合理性。结果我院TPN处方基本合理,主要在脂肪供能比例、非蛋白热氮比、处方组分不全等方面存在不足。结论临床医生应针对患者的营养状况准确评定,合理设计TPN配方,药师应强化审方意识,并加强与临床医生的沟通,进一步提高合理应用TPN的水平。     

Clinical-pharmacological aspects, application and effectiveness of total parenteral nutrition in surgical patients.

The term "total parenteral nutrition" (TPN) refers to the maintenance of an adequate nutritional status, normal body weight and positive nitrogen balance solely by intravenous means. It requires solutions providing calories, amino acids and other nutrients in amounts much greater than those indicated for maintenance of normal body weight. Nutrient solutions have been studied, selected and prepared in our Hospital Pharmacological Service utilizing a sterile closed system, which allows large-volume filtering, sterilizing and bottling devices. For maintenance of weight gain in adults, a basic formula is employed, which provides 1,100 Kcal/1 with pure crystalline amino acids mixed with 50% anhydrous dextrose in water in a ratio of 5.8:1 (160 Kcal:1 g nitrogen). Minerals and vitamins are added to the base solution prior to use and may be increased or decreased by simple addition or omission depending on the patient's condition. This paper is based on 192 surgical patients who received TPN and have been followed in strict cooperation between the Hospital Pharmacological Service and the Surgical Department. The patients, ranging from 23 to 79 years of age, with life threatening diseases and unable to maintain adequate nutrition by the oral route, received TPN through a central catheter inserted via subclavian puncture (146 cases) or through a surgically created internal A-V fistula (46 cases). The condition of the patients generally improved within a few days after starting TPN; and weight gain, wound healing, general improvement and a shorter period of hospitalization were observed. TPN could be efficiently combined with oncologic treatment, and a significant improvement of the patients' performance status and decrease of toxic side-effects due to chemotherapeutic agents were observed. TPN has been successfully applied also in patients with fistulas of the alimentary tract obtaining spontaneous closure and in patients with ulcerative colitis, showing its beneficial effect in allowing complete bowel rest for healing. No major complications or deaths could be attributed to TPN or to the route of administration.     

胃癌全切术后早期肠内外混合营养与单纯肠外营养支持的疗效观察

目的探讨胃癌患者全胃切除术后早期肠内外混合营养和单纯肠外营养支持的临床疗效差异。方法回顾性分析我院2006年1月～2009年10月收治的144例老年胃癌手术患者,随机分为肠内外混合营养组(82例)和肠外营养组(62例)。比较观察两组患者不良反应及血清白蛋白(ALB)、转铁蛋白(TF)和前白蛋白(PA)、淋巴细胞总数(TLC)等临床指标的变化。结果混合营养组肺部感染和咽部不适发生率低于肠外营养组(P<0.05);而在切口感染、排气时间及住院时间的比较上,两组数据没有显著性差别(P>0.05)。混合营养组的TLC、TF、PA等临床指标改善明显,与肠外营养组比较均有显著性意义(P<0.05)。结论胃癌患者术后应用肠内外混合营养支持具有改善营养状态提高机体免疫水平,有利于减少术后肺部感染及咽部不适等并发症,对胃癌患者全胃切除术后恢复有重要意义。     

Stability of somatostatin in total parenteral nutrition

The stability of somatostatin, added to a total parenteral nutrition formula, in glass containers and in plastic ethylene vinyl acetate containers was investigated. The somatostatin concentration decreased immediately from 3μg/ml to 0.3–0.6μg/ml after addition to the emulsion. In spite of this rapid decrease, somatostatin concentrations remained stable with values of 0.4–0.7μg/ml during the follow-up period (24 h). These findings could be explained assuming adsorption to the surface of the container.     

Quality of life of patients receiving home parenteral or enteral nutrition support

Limited data are available on the impact of enterally or parenterally supplied home nutritional support on quality of life. Data from national registries have been useful in identifying the outcome of different patient groups in terms of their functional capacity and rehabilitation status. Results in patients with inflammatory bowel disease are used as the 'gold standard' for this type of therapy. The annual cost of home parenteral nutrition can range from $US100 000 to $US150 000 per patient, depending on the frequency of feeding. Only one cost-utility analysis has been reported in the literature, based on a Canadian home parenteral nutrition programme which suggested that the estimated quality-adjusted survival of patients receiving this treatment is 4 times greater than if they had not been treated. There are many controversial areas associated with the use of home parenteral and enteral nutrition, including the treatment of patients with terminal malignant disease or severe dementia, and those infected with human immunodeficiency virus. To date, the clinical benefit of providing this type of nutritional support for these patient groups has not been clearly demonstrated. Prospective randomised controlled trials are necessary to evaluate the costs and benefits of this expensive high technology treatment.     

Effect of total parenteral nutrition and choline on hepatic flavin-containing and cytochrome P-450 monooxygenase activity in rats.

Total parenteral nutrition provides nutrition by infusion into the systemic circulation. Bypassing the intestine and processes associated with absorption can cause additional pathophysiological changes to occur. For example, in rats, normal gut and pancreatic cell function may change, absorptive capacity may be altered, and enzyme functional activity including drug metabolism may be affected. The objective of this study was to examine the effects of a control diet or a diet of total parenteral nutrition in the presence or absence of choline on urinary biomarkers and hepatic microsome functional activity from rats. Selective functional markers of cytochrome P-4502E1 (CYP2E1) and flavin-containing monooxygenase (FMO) were examined in vitro. The N-oxygenation of trimethylamine was used as an in vivo selective functional marker for FMO. After the administration of total parenteral nutrition plus choline for 5 days, the urinary excretion of trimethylamine and trimethylamine N-oxide declined approximately 7- and 3-fold, respectively, compared with rats treated with control diet. The concentration of urinary biogenic amines was also significantly affected by total parenteral nutrition. Compared with control animals, rats administered total parenteral nutrition plus choline for 5 days showed a decrease of approximately 5- and 2-fold in urinary dopamine and norepinephrine concentration, respectively. To examine a molecular basis for the influence of total parenteral nutrition +/- choline on monooxygenase regulation, hepatic microsomal activity of the FMO and CYP2E1 was examined. Compared with animals treated with a control diet, total parenteral nutrition plus choline in rats caused a 3-fold increase in hepatic microsomal FMO and a 2-fold increase in hepatic cytochrome CYP2E1 functional activity, respectively. Although the data did not reach statistical significance, selective immunoblot studies using hepatic microsomes from rats treated with total parenteral nutrition + choline showed that compared with controls, FMO1 protein was decreased 1.4-fold and FMO3 increased 1.3-fold, respectively. In hepatic microsomes from rats treated with total parenteral nutrition + choline, compared with control animals, FMO4 immunoreactivity was increased 1.6-fold. The data suggest that total parenteral nutrition has a detectable effect on modulating rat FMO3, FMO4, and CYP2E1 monooxygenase functional activity. The clinical relevance of these results is unknown but may be of significance for individuals receiving total parenteral nutrition and those afflicted with trimethylaminuria.     

谷氨酰胺强化的TPN在大肠癌患者术后的应用

目的 :探讨谷氨酰胺 ( Gln)强化的肠外营养 ( TPN )对大肠癌术后患者的作用。方法 :4 0例大肠癌患者随机分为实验组 ( TPN+ Gln)和对照组 (常规 TPN) ,观察氮平衡、血浆白蛋白水平、术后疲劳评分等各项指标的变化。结果 :对照组的术后平均住院时间为 ( 13.12± 3.2 1) d,而实验组为 ( 10 .90± 2 .81) d,两者比较有显著性差异 ( P<0 .0 5) ;两组患者术前血浆白蛋白水平相似 ,在术后第 8天实验组白蛋白水平普遍高于对照组 ,但两者之间无统计学差异 ;术后8d实验组氮平衡明显改善 ,与对照组相比差异显著 ( P<0 .0 1) ;术后第 8天实验组患者主观感觉好于对照组 ( P<0 .0 5)。结论 :大肠癌患者术后予以 Gln强化的 TPN支持 ,比常规 TPN更有利于术后负氮平衡的改善及血浆白蛋白的恢复 ,缩短住院时间、减少术后并发症 ,并能显著改善术后疲劳