Home parenteral nutrition: Westmead Hospital experience

Home parenteral nutrition (HPN) has been used in 13 patients over a 7 year period for intervals ranging from 14 to 608 days with a mean of 255 days. This represents a total experience of 3315 patient days or 9.1 patient years. The commonest causes for intestinal failure requiring HPN were short bowel syndrome following massive small bowel resection for mesenteric ischaemia (four patients), and radiation enteritis (three patients). Four patients died, including three of four who had presented with mesenteric ischaemia and one from disseminated malignancy. One of the deaths was from massive pulmonary embolus and may have been catheter-related. Seven patients were able to cease HPN after a mean of 200.7 days because of treatment and/or improvement in the underlying cause of their intestinal failure. Central venous thrombosis was the commonest complication and occurred in six patients, including the four who died.     

Long-term parenteral nutrition in pediatric autoimmune enteropathies

Severe and protracted or persistent diarrhea (SPD) is the most severe form of diarrhea in infancy and has also been defined as intractable diarrhea when it leads to dependence on total parenteral nutrition (TPN). One of the rare causes of SPD is represented by autoimmune enteropathy that is characterized by life-threatening diarrhea mainly occurring within the first years of life, persistent villous atrophy in consecutive biopsies, resistance to bowel rest, and evidence of antigut autoantibodies. We evaluated 10 patients (seven boys, mean age at diagnosis 18 months; range: 0 to 160 months) fulfilling criteria of autoimmune enteropathy to assess dependence on TPN. TPN was first required in all patients to avoid dehydration and electrolytic imbalance. All patients were dependent on immunosuppressive therapy (steroid, azothioprine, cyclosporine, tacrolimus). Three patients died of sepsis: two during TPN while in the hospital, and one at home after he was weaned off TPN. Five patients are weaned off TPN after a mean period of 18 months; they are actually on oral alimentation with a cow milk-free diet after a period of enteral nutrition with elemental formula. One underwent total colectomy and bone marrow transplantation and one developed an IPEX syndrome. One patient is still dependent on TPN for 24 months. She is on home parenteral nutrition. Patients with diagnosis of IPEX syndrome require parenteral support with three or four infusion per week. TPN represents a fixed step in the management of autoimmune enteropathy, but it may be considered as an interim treatment while waiting for intestinal adaptation, at least in some selectioned case of autoimmune enteropathy. Bone marrow transplantation should be considered and reserved for those patients with severe complications due to home parenteral nutrition, or in those that are really dependent on parenteral nutrition.     

Total parenteral nutrition in the pediatric patient

Over the past 50 years, tremendous advances have been made in the management of children who cannot receive enteral nutrition. Challenges for the future include devising techniques to decrease catheter sepsis, particularly in children with a short bowel, who have a disproportionate number of septic episodes, possibly related to bacterial translocation. The delineation of risk factors for cholestasis associated with total parenteral nutrition and refinement of administration of such nutrition in premature neonates to decrease the incidence of this complication, as well as the morbidity of osteopenia, will extend our ability to help these children.     

Home parenteral nutrition support for intestinal failure

Home parenteral nutrition is a life-saving treatment for many patients with intestinal failure. Expert placement and care of the vascular access device reduces the incidence of access-related complications. Careful monitoring of fluid, electrolyte, and macronutrient and micronutrient status can minimize major organ dysfunction and metabolic complications. A multidisciplined, integrated nutrition support team can allow patients with intestinal failure who need home parenteral nutrition maintain a near-normal life.     

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.     

Vitamin requirements in patients receiving total parenteral nutrition.

This study represents an initial attempt to define intravenous vitamin requirements in adult patients receiving total parenteral nutrition (TPN). We have investigated two different vitamin formulations for their ability to maintain normal circulating blood levels of vitamins A, C, E, B12, folic acid and riboflavin. Administration of 1.1 ml of Multi-Vitamin Infusion (MVI) solution supplemented with 100 microgram of folic acid, 10 microgram of vitamin b12, and 100 mg of vitamin C, per liter of TPN infusate (patients received an average of about 3 liters/day), maintained normal or higher than normal levels of vitamins C, B12, and riboflavin, but resulted in less-than-normal levels of vitamins A, E, and folic acid. Increasing the amount of MVI to 1.4 ml and the folic acid to 200 microgram, and decreasing the ascorbic acid to 70 mg and vitamin B12 to 5 microgram/liter of TPN infusate, resulted in normal blood levels of all tested vitamins within two weeks after initiating TPN therapy, and normal blood levels were then maintained at this dosage for additional periods of time up to three weeks.     

Complications of home parenteral nutrition in a large pediatric series

When adequate nutrition cannot be provided by enteral route as a consequence of failure of intestinal functions, parenteral nutrition (PN) become the only way to maintain adequate nutrition; however, prolonged periods of PN can lead to severe complications. Furthermore, long hospital admissions for this form of nutrition can be detrimental for the child and the family. In the past 20 years, home parenteral nutrition (HPN) programs have been developed. The aim of our study was to retrospectively evaluate the kind and the frequency of complications in a HPN pediatric case series. We had 61 patients on HPN. Total duration of the program was 27,740 days (76 total years, mean 1.2 years per patient). We observed a total of 58 complications; mean 0.79 per patient per year with a prevalence of central venous catheter-related complications (mechanical, 52%; infective, 26%). We had a very low incidence of metabolic complications (3%) and a low incidence of PN-related hepatic complications (19%). None of the complications described was the cause of death. Half of our patients have been able to stop the program. We had a low incidence (0.20 per patient per year) of septic episodes, lower than we had in patients on hospital PN in the same period (0.38 per patient per year). We had to replace 20 catheters, 18 of them for mechanical problems. Our study shows that HPN still can be a valid alternative to small intestinal transplantation in patients affected by intestinal failure and that only patients with PN-related liver disease must be considered early candidates for combined liver-small bowel transplant.     

肠内营养与肠内营养联合肠外营养在胰十二指肠切除术后患者中的应用比较

目的比较肠内营养(EN)、EN联合肠外营养(PN)在胰十二指肠切除术(PD)后患者中的应用。方法回顾性分析2005年1月~2014年1月我院87例PD后患者的临床资料,根据术后营养方式分为EN组(37例)及EN+PN组(50例),比较两组患者术后恢复情况、手术及术后营养相关并发症发生率、血生化相关性指标。结果两组患者术后恢复情况及手术相关并发症发生率比较,差异无统计学意义(P0.05),EN组与EN+PN组营养支持相关并发症率分别为30%、12%,差异有统计学意义(P0.05),EN+PN组血清总胆红素、丙氨酸转氨酶高于EN组(均P0.05),但两组均在正常值范围内。结论 PD患者术后应用EN联合PN安全性及实用性均与单独应用EN相似,但可明显减少营养相关并发症,是PD术后更好的营养方式。     

Total parenteral nutrition.

Total parenteral nutrition has evolved as a distinct therapeutic reality within the past decade. Starvation or malnutrition need no longer be accepted as a necessary component of prolonged illness. Though current TPN techniques can be both safe and effective, the prevention of potential complications must always have a high priority. Changes in technique are to be anticipated as further knowledge and improved materials allow the pursuit of more basic clinical problems. The recent experience with the use of high caloric TPN solutions for prolonged gastrointestinal failure in 73 patients at the Loyola University Medical Center has been summarized. The need for the involvement of an experienced TPN team in the care of these patients cannot be overemphasized if the numerous and diverse potential complications of the TPN system are to be minimized.     

严重多发性创伤胃肠外营养的疗效分析

作者分析了４７例严重多发性创伤伤员（ＩＳＳ≥１６）全胃肠外营养（ＴＰＮ）的治疗效果。随机选择了４７例严重多发伤伤员，ＩＳＳ平均２０．１６。经过１周以上的中心静脉的正规ＴＰＮ治疗后，末梢血淋巴细胞计数，血浆白蛋白水平提高（ｔ检验Ｐ＜０．０５）。另外设对照非ＴＰＮ组６６例，ＩＳＳ平均２０．５０。具有同等的创伤严重程度，ＩＳＳ评分与ＴＰＮ组相比无差异（Ｐ＞０．０５）。两组病例均对原发创伤进行了积极的治疗，而对照组无ＴＰＮ治疗。疗效对比如下：ＴＰＮ与非ＴＰＮ组病死率之比为２．１３％比１３．６７％（Ｘ２＝４．５８，Ｐ＜０．０５）差异有统计学意义。结果表明：ＴＰＮ是严重多发性创伤重要的有效支持治疗措施。     

Osteoporosis in patients on long-term home parenteral nutrition: a longitudinal study.

The prevalence of osteoporosis was investigated in 88 patients with intestinal failure (IF). Osteoporosis was found in 67%, dependent of body mass index and age when IF occurred. In 56 patients on HPN, followed prospectively, changes in bone density were dependent on the duration of HPN; older patients had a higher increase. INTRODUCTION: It has been suggested that low bone mass and negative bone balance may occur in adult patients receiving home parenteral nutrition (HPN). The aim of this study was to assess prospectively the prevalence of osteoporosis in intestinal failure (IF) patients and the changes in bone mineral density in those on long-term HPN and to analyze the factors that may influence the occurrence and evolution of osteoporosis. MATERIALS AND METHODS: Bone mineral density was measured at the lumbar spine and femoral neck in 88 IF patients. RESULTS: At the first bone mineral density determination (baseline), the prevalence of osteoporosis was 67% in this population (median age, 52 years). Ten percent of the patients with osteoporosis experienced fragility fractures. Osteoporosis was independent of age and gender but occurred earlier in patients who had received corticosteroids. At baseline, the lumbar Z-score was positively correlated mainly to body mass index and age when IF occurred; these two parameters explained 34% of the Z-score. Repeated measurements were performed in 56 patients during long-term HPN (mean duration, 5.5 +/- 1.2 years). The changes in Z-score at the lumbar spine were dependent on the age when IF occurred and on the duration of HPN, with a synergistic effect between them. The older the patients, the higher the increase in Z-score during HPN. CONCLUSION: HPN had no deleterious effect on cortical bone and actually improved trabecular bone in patients whose intestinal disease started after the age of 21 years.     

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目的 研究肠内营养（EN）和肠外营养（PN）支持对外科危重病人的治疗效果。方法 将80例不能进食的研究对象随机分成EN组和PN组,比较营养指标、免疫功能指标、病人耐受性指标的变化。结果在治疗10d后,两组病人均由负氮平衡转为正氮平衡,营养指标及免疫功能指标明显增高,且EN组免疫功能指标增高更显著;病人耐受性指标中,EN组无显著变化而PN组血糖明显增高。结果 EN和PN对外科危重病人均有营养支持和提高机体免疫功能的作用。耐受性强,且EN支持在提高机体免疫功能优于PN支持,病人耐受性较好。     

实施长期肠外营养和家庭肠外营养的体会

为探讨长期肠外营养和家庭肠外营养的实施。我们采用经中心静脉导管输全合一营养液行长期肠外营养30例，其中10例经住院治疗后转为家庭肠外营养。每例行肠外营养6～120个月，平均12.4个月。10例家庭肠外营养者每例行家庭肠外营养6～114个月，平均95．2个月。共置上腔静脉导管71根，每根留置时间1～18个月，平均4．6个月。平均每留管26．3个月发生1次导管性感染。我们认为长期肠外营养和家庭肠外营养是肠衰竭病人维护生命的有价值治疗，可在我国安全、有效地应用。