Parenteral nutrition in a premature infant with phenylketonuria

Parenteral nutrition (PN) is now an important facet of the management of the extremely premature infant. However, its effects on those with inherited metabolic disease have not been well documented. We report an infant with classical phenylketonuria (PKU) who had unusually high serum phenylalanine at 12 days of life (5200 mumol; greater than 3.2 SD above our mean for PKU at 10-15 days of age) while on parenteral nutrition, despite a relatively high tolerance for phenylalanine on oral feeds at 3-4 months of life (97-128 mg/kg/day; normal for PKU: less than 90 mg/kg/day). Identification of PKU was somewhat delayed in this child because of failure to recognize that parenteral nutrition provides a phenylalanine load equivalent to or greater than the routine oral formula feeding. Despite the high levels of phenylalanine in the first 2 wk of life, mental and motor development are normal at 16 months of age. This case, the first such reported, suggests the parenteral nutrition in the premature PKU infant is relatively safe, but draws attention to the possible need for phenylalanine-free amino acid infusates for those who require long-term treatment.     

早产儿胃肠外营养相关性胆汁淤积的影响因素分析

目的：分析影响早产儿胃肠外营养（ PN）相关性胆汁淤积的相关因素,为临床干预提供理论依据。方法回顾性分析自2010年1月至2014年4月在佛山市南海区第二人民医院进行PN治疗的146例早产儿相关资料,按照是否发生胆汁淤积分为对照组（未出现胆汁淤积,n＝110例）与观察组（出现胆汁淤积,n＝36例）,比较两组患者出生体重、PN持续时间、禁食时间、住院时间、PN营养液配比、感染、抗生素、机械通气等情况。结果两组患儿出生体重、PN持续时间、禁食时间、糖热卡比、氨基酸热卡比、脂肪乳酸热卡比、奶热卡比、总热卡比较差异有统计学意义（ t值分别为5．469、12．921、14．802、8．156、9．217、10．108、19．982、14．698,均P＜0．05）;感染发生率及机械通气率比较差异有统计学意义（χ2值分别为4．105、4．891,均P＜0．05）。多重逐步进入Logistic分析,结果表明PN持续时间长（OR＝2．147,95％CI：1．040～3．807）,禁食时间长（OR＝2．751,95％CI：1．970～4．408）、高葡萄糖热卡比（OR＝2．433,95％CI：1．583～3．901）、高脂肪乳热卡比（OR＝2．907,95％CI：2．072～5．833）、高氨基酸热卡比（OR＝2．779,95％CI：2．018～4．540）、机械通气（OR＝1．511,95％CI：1．067～3．908）及感染（OR＝1．275,95％CI：1．021～3．460）是早产儿胃肠外营养相关性胆汁淤积的危险性因素,而高出生体重（OR＝0．672,95％CI：0．070～0．759）则为保护性因素。结论早产儿胆汁淤积危害患儿的生命健康,临床医师在对早产儿进行PN时应控制早产儿感染、机械通气的使用、早日开奶,减少PN持续时间,且注意PN营养液的合理配比。     

Parenteral nutrition hypersensitivity

Total parenteral nutrition (TPN) is widely used. Although mechanical, septic, and metabolic complications are well known, hypersensitivity skin reactions are rare. We describe a 16-year-old boy with Burkitt's lymphoma who developed a urticarial skin rash when treated with TPN and vitamins. The adverse skin reaction was probably caused by the inactive component of excipient, polysorbate.     

Parenteral nutrition in obstetric patients

PN is required to maintain or restore an anabolic state when oral enteral routes are not feasible. Despite 22 years of experience with PN, its use during pregnancy has only recently been reported. Most of this information is anecdotal but suggests that this mode of therapy is safe, effective, and occasionally lifesaving. PN during pregnancy has been used most often to provide adequate nutrition for those who suffer from prolonged hyperemesis or who have difficulty absorbing adequate nutrients because of such conditions as Crohn's disease. The proper selection and administration of dextrose, fat, protein, vitamins, trace elements, and electrolytes for pregnant women have been associated with favorable perinatal outcomes. Fat emulsion use does not appear to be associated with any abnormal outcomes. Preterm deliveries and intrauterine fetal growth retardation appear to relate to preexisting or coexisting medical or obstetric complications. Principles for PN with all patients would apply during pregnancy. As with any therapy, the benefits must be weighed against the risks and costs. Sufficient favorable clinical experience over the last 10 years suggests that PN is a relatively safe and effective method for reversing maternal malnutrition and promoting normal fetal growth and development.     

Parenteral nutrition in acute renal failure

This article reviews the current practice of parenteral feeding in patients with acute renal failure. Assessment of nutritional requirements and the provision of nutrients are discussed. Practical guidelines are provided for dietitians to use in the clinical setting.     

Parenteral nutrition in bone marrow transplantation

Twenty-nine patients undergoing bone marrow transplantation (BMT) were randomised prospectively to evaluate the effect of parenteral nutrition (TPN) on morbidity and mortality. Fourteen patients received a standard regimen of TPN for 10 +/- 4 days (mean +/- SD). All patients had free access to oral diet, which was significantly reduced compared to pre-transplant intake. In the TPN group, serum bilirubin by day 14 and serum bilirubin and gamma glutamyl transferase by day 21 were significantly higher than in the controls (p < 0.05). These differences probably reflect the higher incidence of serious pyrexia (T > 38.5' C) and blood culture positive rates in the TPN group. Weight loss in the control group was significantly greater than that of the TPN group (p < 0.05). TPN did not affect time to grafting or incidence of graft-versus-host disease. The use of TPN in the nutritional support of patients in small BMT units requires careful consideration.     

Parenteral nutrition: multidisciplinary management

Parenteral nutrition may be needed to give nutritional support to patients with severe acute (temporary or reversible) or chronic intestinal failure. Parenteral nutrition needs to be given only by health workers trained in its use otherwise life-threatening complications (especially sepsis) may occur.     

胃肠外营养与肿瘤生长

由于临床上癌症病人存在不同程度的营养不良，使病人难以耐受手术，化疗及放疗，给临床治疗带来很多困难，有人从动物实验到临床应用中证实了胃肠外营养的有效性，因此，本文综述了癌症病人的营养状况，代谢变化，包括能量，蛋白质，碳水化合物，脂肪代谢，以及癌症病人ＴＰＮ的应用。     

Parenteral nutrition results in impaired lactose digestion and hexose absorption when enteral feeding is initiated in infant pigs

BACKGROUND: Preterm infants often receive total parenteral nutrition (TPN) before enteral feeding. Although TPN has been linked to mucosal atrophy, its effects on intestinal digestion, absorption, and metabolism are unknown. OBJECTIVE: Our aim was to determine the effects of TPN on rates of intestinal nutrient absorption and metabolism in infant pigs after initiation of enteral feeding. DESIGN: Piglets were surgically implanted with catheters in the carotid artery, jugular vein, portal vein, and duodenum; an ultrasonic blood flow probe was inserted in the portal vein. Piglets were given TPN (TPN group) or enterally fed formula (enteral group) for 6 d. On day 7, both groups were enterally fed a milk-based formula, and the net portal absorption and metabolism of enteral [(2)H]glucose and [(13)C]leucine were measured. RESULTS: After enteral feeding began, portal blood flow increased by 27% and 41% above the basal rate in the enteral and TPN groups, respectively; oxygen consumption remained lower in the TPN group. During enteral feeding, the net portal absorption of glucose was lower in the TPN group and that of galactose was not significantly different between the groups; lactate release was higher in the TPN group. Portal absorption accounted for only approximately 37% of galactose intake in both groups. The TPN group had lower net portal absorption of arginine, lysine, threonine, and glycine. The portal absorption of dietary leucine was not significantly different between the groups; the arterial utilization and oxidation of leucine were significantly lower in the TPN group. CONCLUSION: Short-term TPN results in decreased lactose digestion and hexose absorption and increased intestinal utilization of key essential amino acids when enteral feeding is initiated in piglets.     

Parenteral nutrition is not the false route in ICU

Large surveys auditing feeding regimen in the ICU consistently reported hypocaloric 23 enteral feedings patterns and many studies described the association between 24 energy deficit and increased complication rate. ESPEN and ASPEN experts 25 recommend early (after 48 h) or late (after 7-10 days) catch up of the 26 energy deficit with parenteral nutrition (PN) respectively, but the level of evidence 27 was poor and larger PRCT were missing. In the recent months, several ICU studies 28 have tried to answer to three critical questions: 1) how much energy to administer, 2) 29 when to start (early or late), and 3) which route should be used. However, weaknesses 30 in the study design and some mixing of the 3 questions have created confusion in the 31 message delivered. In addition, the severity of the acute illness was not always similar 32 in these studies, mixing short-term acutely ill patients (less than 4 days in the ICU) 33 with long term patients (more than 10 days in the ICU).     

Parenteral nutrition: Hospital to home

Parental nutrition support is the provision of essential nutrients intravenously, bypassing the intestinal tract. It is used in a variety of clinical settings and medical conditions. Parenteral nutrition is a complex technology that requires the input of many professionals, including dietitians. The role of the dietitian in parenteral nutrition support involves direct patient care, consultative services, education, program development, and research. Even though this field of practice is still developing, some common practices can be described. Nutrition assessment determination of macronutrient and micronutrient requirements, and monitoring are vital aspects of the provision of parenteral nutrition support that benefit from the knowledge and experience of a dietitian. The future of parental nutrition includes identification of preferred fuels for specific disease states, development of new lipid emulsions, and identification of conditionally essential nutrients.     

Parenteral nutrition with n-3 lipids in sepsis

Dietary supplements of n-3 fatty acids have long been used to influence chronic inflammatory disorders. Recent studies with an immune-enhancing diet partly based on n-3 fatty acids report beneficial effects in patients with acute hyper-inflammatory diseases, such as the sepsis syndrome or adult respiratory distress syndrome (ARDS). The possible suppression of exaggerated leucocyte activity, the improvement of microcirculatory events, as well as the opportunity to administer intravenous lipids enriched in n-3 fatty acids signal the possibility of a combination of parenteral caloric support and pharmacological intervention. Using parenteral administration of fish oil-based lipids, a new rapid and highly effective anti-inflammatory agent may allow the option to alter the immune status in hyper-inflammatory diseases such as sepsis and ARDS.     

肠外营养支持在新生儿食管闭锁术后的应用

目的 :探讨肠外营养 (PN)支持在新生儿食管闭锁术后治疗作用及与预后的关系。　方法 :PN组 12例病儿 ,平均胎龄 (39.9± 0 .7)周 ,平均出生体重 (32 11± 431) g,平均禁食时间 (8.3± 2 .8)天 ,术后 1～ 3天开始 ,平均每天给予脂肪乳剂 (1.8± 0 .6 ) g/ kg,氨基酸 (2 .1± 0 .7) g/ kg,葡萄糖 (7.8± 2 .1) g/ kg,平均热量摄入为 (2 38.5±46 ) k J/ kg,热氮比 15 0～ 2 5 0∶ 1,液量 (12 0± 12 ) ml/ kg,PN平均应用时间为 7.6天 ,以“全合一”方式经周围静脉大于 16 h均匀输入。对照组 7例病儿 ,平均胎龄 (39.4± 1.4)周 ,平均出生体重 (2 911± 2 0 4) g,平均禁食时间 (7.0±4.5 )天 ,平均热量摄入 (171.5± 37.6 ) k J/ kg。　结果 :PN组治愈 11例 ,死亡 1例 ,病死率为 8.3% ;存活儿体重增加 5例 ,不变 5例 ,下降 1例 ,平均每天体重增加 (11± 2 7) g。对照组治愈 3例 ,死亡 4例 ,病死率为 5 7.1% ;存活儿体重均下降 ,平均每天体重降低 (2 2± 2 1) g。两组病死率及体重变化经 Student s test及卡方检验统计存在显著差异 (P<0 .0 5 )。　结论 :围手术期积极而合理地应用肠外营养支持可改善食管闭锁术后病儿的营养不良 ,降低病死率 ,改善预后     

肠外营养和腹腔镜下手术治疗乳糜性腹水

目的:观察PN支持和腹腔镜治疗乳糜性腹水的作用. 方法:对l例乳糜性腹水的病人,先后应用单纯PN支持4周和PN支持+腹腔镜治疗1周,通过腹腔引流观察腹水引流量的变化,同时观察病人体质量和一般营养状况的变化. 结果:在单纯PN支持的过程中,腹水的流出量逐天减少.恢复饮食后.腹水量又逐渐增多,体质量有所增加,血清ALB水平无明显变化.经PN支持+腹腔镜治疗1周后,腹水量明显减少.恢复饮食后,腹水量亦无明显增多,体质量有明显增加;血清ALB水平有明显升高. 结论:应用PN支持和腹腔镜治疗乳糜性腹水,不仅能明显减少腹水量,而且还能较好地维持机体的营养状态.     

Parenteral nutrition support in major abdominal trauma patients

32 out of 111 patients with major abdominal trauma were studied to evaluate the effects of total parenteral nutrition (TPN). There were 24 men and 8 women with average age of 31 years. 25 cases were recorded as blunt trauma. The others had penetrating wounds. An Abdominal Trauma Index (ATI) was used to score the injury severity. 68% (22 32 ) of the patients had a score of more than 15, and 25% (8 32 ) had a score over 25. TPN was carried out in 11 patients with complicated injuries of the pancreas and duodenum, in 15 cases with small bowel fistula secondary to extended intestinal trauma, and in 6 patients with severe intraabdominal abscesses after injury. The TPN mixture contained 32-42 kcal/kg/day of nonprotein energy and 0.21-0.30 g/kg/day of nitrogen. The average period of TPN support was 26 days. No TPN-related complication developed except 2 cases of catheter-related sepsis. The results demonstrated no significant change in body weight during TPN support. Weekly cumulative nitrogen balances were increased significantly after the use of TPN (from 15.5 g/week at the first week to 48.2 g/week at the fourth week, p < 0.01). There were increases in serum albumin, prealbumin, fibronectin and transferrin following TPN support (from 30.6 g/L, 142.8 mg/L, 103.3 mg/L and 1.2 g/L at day 0 to 35.7 g/L, p < 0.01, 256.3 mg/L, p < 0.01, 184.5 mg/L, p < 0.01, and 1.9 g/L, p < 0.05, at day 21 respectively). Blood sugar, cholesterol and triglyceride remained normal. In 4 patients with duodenal fistula and 6 cases with small bowel fistula (n = 15), the fistulae closed spontaneously. There were no deaths during TPN. We conclude that total parenteral nutrition is of value in the treatment of severe abdominal traumatic patients.     

Parenteral nutrition in a pregnant cystic fibrosis patient

This case report describes a 30-year-old pregnant woman with cystsic fibrosis who had marasmus as evidenced by clinical examination. The patient was maintained on central venous hyperalimentation for 18 days in her last trimester. The patient delivered a full-term infant via cesarian section with Apgar of 8 and 9, at 1 and 5 minutes, respectively, and adverse affects.