Use of Home Parenteral Nutrition in Post–Bariatric Surgery–Related Malnutrition

Background: Bariatric surgery is one of the most effective techniques for achieving sustained weight loss but can be associated with surgical complications or malabsorption so significant that it leads to malnutrition. Parenteral nutrition (PN) may be necessary to help treat surgical complications or malnutrition from these procedures. There are limited data describing this patient population and role for home PN (HPN). Methods: A retrospective review of our HPN database was conducted to identify patients who were initiated on HPN between January 1, 2003, and August 31, 2015, and had a history of bariatric surgery. Results: A total of 54 HPN patients (6.3%) had a history of bariatric surgery. Average age was 52.1 ± 12.8 years, and 80% were female. The most common surgical procedure was Roux‐en‐Y gastric bypass (72%), with malnutrition or failure to thrive being the most common HPN indication (57%). Weight at the time of HPN initiation was 71.9 ± 20.4 kg and significantly increased to 78.9 ± 24.4 kg by the end of treatment (P = .0001). Serum albumin levels rose from 2.8 ± 0.77 g/dL to 3.7 ± 0.58 g/dL by the end of HPN (P < .0001). Forty‐five of 54 patients (83.3%) went on to revision surgery. Conclusion: The results of this retrospective review support initiation of HPN in the malnourished post–bariatric surgery patient both nutritionally and as a bridge to revision surgery.     

An insulin protocol for management of hyperglycemia in patients receiving parenteral nutrition is superior to ad hoc management

Background: The authors investigated whether an insulin protocol for parenteral nutrition (PN)–induced hyperglycemia is superior to conventional management relying primarily on sliding‐scale insulin at a large county hospital. Methods: A prospective cohort study with historical controls was completed. Adult patients receiving PN were managed with a protocol that determined insulin doses based on carbohydrate delivery and capillary blood glucose (CBG) if half or more of CBG measurements in the first 24 hours after initiation of PN exceeded 140 mg/dL. Control data were obtained from records of patients who met study eligibility criteria but had been managed before implementation of the insulin protocol. Results: Mean CBG after the start of insulin therapy was 138 ± 37 mg/dL for protocol patients and 159 ± 46 mg/dL for controls (P < .0001). Proportion of CBG values in the target range of 80–140 mg/dL was 60% in the protocol group and 35% in the control group (P < .0001). Hypoglycemia, defined as CBG <80 mg/dL, occurred infrequently but more often in the protocol group (3% vs 1%, P = .012). There was no difference in total daily insulin between groups, although protocol patients received mostly scheduled insulin (93% total daily dose), whereas control patients received predominantly supplemental insulin (66% total daily dose). Conclusions: Protocol‐directed management of PN‐induced hyperglycemia is superior to ad hoc insulin dosing. Linking insulin to carbohydrate in PN leads to improved glycemic control with a low rate of hypoglycemia.     

Nutrition Management of Home Parenteral Nutrition Among Patients With Enterocutaneous Fistula in the Sustain Registry

Background: Home parenteral nutrition (HPN) is a vital therapy for patients who have the diagnosis of enterocutaneous fistula (ECF), yet little is known about how these patients are managed. This research compares nutrition management of adults with ECF as the indication for HPN therapy to those with other indications. Methods: This is an analysis of data from adult HPN patients in the Sustain registry enrolled between August 2011 and February 2014 who have the diagnosis of ECF or other indication for HPN who served as the control group. Differences between the ECF and control group were assessed by t test, analysis of variance, or χ² as appropriate. Results: There were 141 HPN patients with ECF and 632 control patients. Patients with ECF were older (55 vs 50 years, P < .001), more frequently had a goal for future surgery (30% vs 15%, P = .010), had greater prevalence of overweight/obesity (33% vs 20%, P = .04), and had a lower serum albumin (2.98 ± 0.65 g/dL vs 3.16 ± 0.66 g/dL, P = .006) than controls. The diet order was more frequently nil per os (NPO) in patients with ECF (48% vs 22%, P < .001), and amino acid content of HPN was greater (111.90 ± 29.11 vs 102.06 ± 27.84, P < .001) than in controls. There were no differences in patterns of weight change by ECF or control groups, although underweight patients gained, normal‐weight patients maintained, and overweight/obese patients lost weight and serum albumin increased similarly. Conclusions: The HPN management of patients with ECF is similar to other HPN patients other than greater provision of protein, more frequent NPO status, and a goal for future surgery.     

Expediting Transition to Home Parenteral Nutrition With Fast‐Track Cycling

Background. Delivery of home parenteral nutrition (PN) is typically cycled over 12 hours. Discharge to home on PN is often delayed due to potential adverse events (AEs) associated with cycling PN. The purpose was to determine whether patients requiring long‐term PN can be cycled from 24 hours to 12 hours in 1 day instead of 2 days without increasing the risk of PN‐related AEs. Methods. Hospitalized patients receiving PN at goal calories infused over 24 hours without severe electrolyte or blood glucose abnormalities were eligible. Patients were randomly assigned to a 1‐step “fast‐track” protocol or 2‐step “standard” protocol. AEs were defined as hypoglycemia or hyperglycemia, new‐onset or worsening dyspnea, tachycardia, tachypnea, lower extremity or sacral edema, pulmonary edema, or abdominal ascites and were graded as minor or major. Results. In the 63 patients studied, the most prevalent PN‐related AE was hyperglycemia, occurring in 24.2% and 30.0% of patients in the fast‐track and standard groups, respectively. Overall, there was no significant difference in the prevalence of PN‐related minor AEs between fast‐track and standard groups (33.3% and 53.3%, P = .5). No major PN‐related AEs occurred in the fast‐track group, while 1 major PN‐related AE (pulmonary edema) occurred in the standard group. Conclusions. Fast‐track cycling is as safe as standard cycling in patients without diabetes mellitus or major organ dysfunction requiring long‐term PN. Fast‐track cycling could potentially expedite hospital discharge, resulting in decreased healthcare costs and improved patient satisfaction.     

Computer‐Assisted Glucose Regulation During Rapid Step‐Wise Increases of Parenteral Nutrition in Critically Ill Patients

Background: Early delivery of calories is important in critically ill patients, and the administration of parenteral nutrition (PN) is sometimes required to achieve this goal. However, PN can induce acute hyperglycemia, which is associated with adverse outcome. We hypothesized that initiation of PN using a rapid “step‐up” approach, coupled with a computerized insulin‐dosing protocol, would result in a desirable caloric intake within 24 hours without causing hyperglycemia. Methods: In our surgical intensive care unit (ICU), glucose is regulated by a nurse‐centered computerized glucose regulation program. When adequate enteral feeding was not possible, PN was initiated according to a simple step‐up rule at an infusion rate of 10 mL/h (approximately 10 kcal/h) and subsequently increased by steps of 10 mL/h every 4 hours, provided glucose was <10 mmol/L, until the target caloric intake (1 kcal/kg/h) was reached. All glucose levels and insulin doses were collected during the step‐up period and for 24 hours after achieving target feeding. Results: In all 23 consecutive patients requiring PN, mean intake was 1 kcal/kg/h within 24 hours. Of the 280 glucose samples during the 48‐hour study period, mean ± standard deviation glucose level was 7.4 ± 1.4 mmol/L. Only 4.5% of glucose measurements during the step‐up period were transiently ≥10 mmol/L. After initiating PN, the insulin requirement rose from 1.1 ± 1.5 units/h to 2.9 ± 2.5 units/h (P < .001). Conclusions: This proof of concept study shows that rapid initiation of PN using a step‐up approach coupled with computerized glucose control resulted in adequate caloric intake within 24 hours while maintaining adequate glycemic control.     

Prevention of Subsequent Catheter‐Related Bloodstream Infection Using Catheter Locks in High‐Risk Patients Receiving Home Parenteral Nutrition

Introduction:Catheter‐related bloodstream infection (CRBSI) is a serious complication in patients receiving home parenteral nutrition (HPN). Antibiotic lock therapy (ALT) and ethanol lock therapy (ELT) can be used to prevent CRBSI episodes in high‐risk patients. Methods: Following institutional review board approval, all patients enrolled in the Mayo Clinic HPN program from January 1, 2006, to December 31, 2013, with catheter locking were eligible to be included. Patients without research authorization and <18 years old at the initiation of HPN were excluded. Total number of infections before and after ALT or ELT were estimated in all patients. Results: A total of 63 patients were enrolled during the study period. Of 59 eligible patients, 29 (49%) were female, and 30 (51%) were male. The median duration of HPN was 3.66 (interquartile range, 0.75–8.19) years. The mean age ± SD at initiation of HPN was 49.89 ± 14.07 years. A total of 51 patients were instilled with ALT, and 8 patients were instilled with ELT during their course of HPN. A total of 313 CRBSI episodes occurred in these patients, 264 before locking and 49 after locking (P < .001). Rate of infection per 1000 catheter days was 10.97 ± 25.92 before locking and 1.09 ± 2.53 after locking (P < .001). Discussion: The major findings of the present study reveal that ALT or ELT can reduce the overall rate of infections per 1000 catheter days. ALT or ELT can be used in appropriate clinical setting for patients receiving HPN.     

Canadian home parenteral nutrition (HPN) registry: validation and patient outcomes

Background: In Canada, there are an estimated 400 home parenteral nutrition (HPN) patients. In 2006, a registry was created to gather patient outcome information. The aim of this study was to validate the registry and report on HPN patient outcomes. Methods: Several demographic, clinical parameters were collected. For the validation, paired t test and intraclass correlation coefficient (ICC) were used to assess agreement between repeat entries. For the outcome report, paired t test was used to assess changes, and survival analysis was performed using the Kaplan‐Meier method. Results are expressed as mean ± SEM. Results: On validation, there was high correlation/agreement (P < .05) for most parameters except vascular access/line sepsis, liver disease (ultrasound, biopsy, diagnoses), and hospitalizations. For the outcome report, 96 patients had their data entered at 2.24 ± 0.11 years after baseline. Over the period, there was a significant reduction in PN calories (P = .001) and proteins (P < .001). There were no significant changes in nutrition parameters and laboratory results except for lower platelet counts (P = .028), lower plasma potassium (P = .030), and a trend toward an increase in bilirubin from 19.29 ± 4.65 to 29.06 ± 8.73 µmol/L (P = .071). The QOL decreased significantly over time (P < .001) and the survival on HPN was 17.67 ± 1.89 years. Conclusions: The registry is a valid tool to assess several clinical parameters. On follow‐up, HPN patients maintain good nutrition status while PN is reduced but do have a reduced quality of life.     

Glargine Insulin Use Versus Continuous Regular Insulin in Diabetic Surgical Noncritically Ill Patients Receiving Parenteral Nutrition: Randomized Controlled Study

Background: Hyperglycemia is a major complication of parenteral nutrition (PN). Guidelines for hyperglycemia management in noncritically ill patients cite basal insulin administration but do not recommend a regimen. The GLUCOSE‐in‐PN study aimed to compare the efficacy of glargine insulin versus continuously infused regular insulin in PN (RI‐in‐PN) to achieve glycemic control in noncritically ill surgical patients with diabetes who were receiving PN. Methods: This prospective randomized open‐label study was conducted at King Faisal Specialist Hospital and Research Centre. Noncritically ill surgical patients with diabetes who were receiving PN were randomized to receive basal glargine insulin or RI‐in‐PN on day 4 of PN support. Mean blood glucose levels were compared on study days 5–9. The percentages of blood glucose measurements at goal were compared between groups. Results: Sixty‐seven PN treatment episodes were analyzed. There were no statistically significant differences in mean glucose levels between groups on any study day (P > .1). Overall glycemic control rates were 52.24% (glargine insulin) and 47.76% (RI‐in‐PN; P = .06). A significantly higher percentage of hyperglycemia was observed on day 5 for glargine insulin versus RI‐in‐PN (22.39% vs 5.97%, P = .0059). Blood glucose measurements indicated 6 hypoglycemic events: 2 for glargine insulin (5.7%) and 4 for RI‐in‐PN (11.4%; P > .1). Conclusion: Both glargine insulin and RI‐in‐PN are effective basal insulin modalities for blood glucose control in noncritically ill surgical patients with diabetes who are receiving PN. Uncontrolled hyperglycemic events occurred more frequently with glargine insulin, and the rate of hypoglycemia was acceptable for both regimens.     

Iron Deficiency in Long‐Term Parenteral Nutrition Therapy

Background: Iron is not routinely added to parenteral nutrition (PN) formulations in the United States because of the risk of anaphylaxis and concerns about incompatibilities. Studies have shown that iron dextran in non‐lipid‐containing PN solutions is safe. Data are limited on iron status, prevalence of iron deficiency anemia (IDA), and efficacy of intravenous iron infusion in long‐term home PN (HPN). We aimed to determine the incidence of IDA and to examine the effectiveness of parenteral iron replacement in patients receiving HPN. Methods: Medical records of patients receiving HPN at the Mayo Clinic from 1977 to 2010 were reviewed. Diagnoses, time to IDA development, and hemoglobin, ferritin, and mean corpuscular volume (MCV) values were extracted. Response of iron indices to intravenous iron replacement was investigated. Results: Of 185 patients (122 women), 60 (32.4%) were iron deficient. Five patients were iron deficient, and 18 had unknown iron status before HPN. Of 93 patients who had sufficient iron storage, 37 had IDA development after a mean of 27.2 months (range, 2–149 months) of therapy. Iron was replaced by adding maintenance iron dextran to PN or by therapeutic iron infusion. Patients with both replacement methods had significant improvement in iron status. With intravenous iron replacement, mean ferritin increased from 10.9 to 107.6 mcg/L (P < .0001); mean hemoglobin increased from 11.0 to 12.5 g/dL (P = .0001); and mean MCV increased from 84.5 to 89.0 fL (P = .007). Conclusions: Patients receiving HPN are susceptible to IDA. Iron supplementation should be addressed for patients who rely on PN.     

Long-Term Use of Mixed-Oil Lipid Emulsion in Soybean Oil–Intolerant Home Parenteral Nutrition Patients

Background: Although home parenteral nutrition (HPN) is lifesaving for patients with chronic intestinal failure (IF), long-term use can be associated with complications such as infections, metabolic abnormalities, and IF–associated liver disease (IFALD). The key to treatment of many of these complications is prevention. Guidelines recommend avoidance of overfeeding, use of oral/enteral nutrition if possible, cyclic PN, and maintaining dose of soybean oil (SO) intravenous lipid emulsion (ILE) <1 g/kg/day as preventive strategies for IFALD. Additionally, with development of IFALD, ω-6/ω-3 polyunsaturated fatty acid ratio should be decreased in ILE. The newly available mixed-oil (MO) ILE offers such an opportunity; however, there is a paucity of long-term data available. Methods: The current study reports our long-term experience with MO ILE use in HPN patients. Results: Seventeen patients (8 female and 9 male) with an average age of 47 ± 12 years and median HPN duration of 4.6 years (1.1–32.1 years) have utilized MO ILE for >12 months after being transitioned from SO ILE because of intolerance. Use of MO ILE allowed an increase in ILE energy from 8% ± 8% to 22% ± 8% while reducing dextrose energy from 66% ± 8% to 54% ± 5%, maintaining stability in alkaline phosphatase and triglyceride levels, and achieving improvement in aspartate aminotransferase, alanine aminotransferase, total bilirubin, and α-tocopherol levels. Conclusion: In this HPN cohort with SO ILE intolerance, MO ILE was well tolerated and allowed an improvement in macronutrient composition while improving some liver parameters over a 12-month period.     

Hospital Readmissions for Catheter‐Related Bloodstream Infection and Use of Ethanol Lock Therapy

Background: Catheter‐related bloodstream infection (CRBSI) is the most serious long‐term infectious complication of long‐term home parenteral nutrition (PN). Ethanol is being used more commonly as a catheter locking solution in the home PN setting for prevention of CRBSI; however, no current literature reports the use of ethanol lock (ETL) in skilled nursing facility (SNF) patients. Methods: The authors evaluated the number of hospital readmissions for CRBSI and length of stay between SNF (not receiving ETL) and home patients (receiving or not receiving ETL) receiving PN or intravenous fluid therapy. Results: SNF patients had a significantly longer length of stay (LOS) for CRBSI hospital admissions compared with patients receiving PN at home with or without ETL (P < .001; 16 vs 8 vs 8 days). There was no LOS difference for CRBSI between home patients with or without ETL. Home PN patients not receiving ETL were more likely to have a CRBSI from Staphylococcus sp (48% vs 27%; P = .015), whereas SNF PN patients not receiving ETL were more likely to have a CRBSI from Enterococcus sp (16% vs 3%; P = .004). Conclusion: Despite different causative organisms and medical acuity likely affecting the differences observed in LOS, the SNF population is another setting ETL can be used to prevent CRBSI.     

Innate Mucosal Immune System Response of BALB/c vs C57BL/6 Mice to Injury in the Setting of Enteral and Parenteral Feeding

Background: Outbred mice exhibit increased airway and intestinal immunoglobulin A (IgA) following injury when fed normal chow, consistent with humans. Parenteral nutrition (PN) eliminates IgA increases at both sites. Inbred mice are needed for detailed immunological studies; however, specific strains have not been evaluated for this purpose. BALB/c and C57BL/6 are common inbred mouse strains but demonstrate divergent immune responses to analogous stress. This study addressed which inbred mouse strain best replicates the outbred mouse and human immune response to injury. Methods: Intravenously cannulated mice received chow or PN for 5 days and then underwent sacrifice at 0 or 8 hours following controlled surgical injury (BALB/c: n = 16–21/group; C57BL/6: n = 12–15/group). Bronchoalveolar lavage (BAL) was analyzed by enzyme‐linked immunosorbent assay for IgA, tumor necrosis factor–α (TNF‐α), interleukin (IL)–1β, and IL‐6, while small intestinal wash fluid (SIWF) was analyzed for IgA. Results: No significant increase in BAL IgA occurred following injury in chow‐ or PN‐fed BALB/c mice (chow: P = .1; PN: P = .7) despite significant increases in BAL TNF‐α and SIWF IgA (chow: 264 ± 28 vs 548 ± 37, P < .0001; PN: 150 ± 12 vs 301 ± 17, P < .0001). Injury significantly increased mucosal IgA in chow‐fed C57BL/6 mice (BAL: 149 ± 33 vs 342 ± 87, P = .01; SIWF: 236 ± 28 vs 335 ± 32, P = .006) and BAL cytokines. After injury, PN‐fed C57BL/6 mice exhibited no difference in BAL IgA (P = .9), BAL cytokines, or SIWF IgA (P = .1). Conclusions: C57BL/6 mice exhibit similar airway responses to injury as outbred mice and humans, providing an appropriate model for studying mucosal responses to injury. The BALB/c mucosal immune system responds differently to injury and does not replicate the human injury response.     

Characterization of posthospital bloodstream infections in children requiring home parenteral nutrition

Background: Home parenteral nutrition (HPN) is lifesaving for children with intestinal failure. Catheter‐associated bloodstream infections (CA‐BSI) are common in hospitalized patients receiving parenteral nutrition (PN), but data evaluating CA‐BSI in children receiving HPN are limited. Objective: To determine the incidence and characteristics of CA‐BSI in children receiving HPN. Methods: Medical records of 44 children receiving HPN during a 3‐year period were reviewed. End points were CA‐BSI during the initial 6 months after discharge. CA‐BSI was defined as isolation of pathogens from blood requiring antimicrobial therapy. Results: The primary indication for HPN was short bowel syndrome (46%), and 59 BSI were documented during the initial 6 months of HPN in 29 (66%) children. Of CA‐BSI, polymicrobial infections accounted for 52%; gram‐positive, 29%; gram‐negative, 17%; and fungal, 2%. CA‐BSI incidence per 1000 catheter‐days was highest during the first month posthospital discharge (72 episodes; 95% confidence interval [CI], 45.4–109.6). CA‐BSI incidence density ratio for children receiving HPN for >90 days compared with those receiving HPN for <30 days was 2.2 (P < .05). Logistic regression revealed that Medicaid insurance and age <1 year were associated with increased risk for CA‐BSI (odds ratio [OR], 4.4 [95% CI, 1.13–16.99] and 6.6 [1.50–28.49], respectively; P < .05). Conclusions: The incidence of CA‐BSI in children receiving HPN is highest during the first month posthospital discharge. Strategies to address care in the immediate posthospital discharge period may reduce the burden of infectious complications of HPN.     

The Association Between Home Parenteral Nutrition and Patients With FAP‐Associated Intra‐Abdominal Desmoids

Background: Intra‐abdominal desmoid tumors (IADTs) are a common complication of familial adenomatous polyposis (FAP). Treatment is not standardized for advanced disease. Medical and surgical treatments may be ineffective in preventing complications, which can cause intestinal failure. Home parenteral nutrition (HPN) can be a life‐saving treatment in these patients. The aim of this study was to investigate the association with HPN in FAP‐IADTs. Methods: A retrospective review of FAP patients with IADTs at the Cleveland Clinic (CC) between 1980 and 2009 was performed. Patients and tumor characteristics were retrieved from the CC Jagelman Registry for Inherited Neoplasms and CC HPN database. Inclusion criteria were FAP‐IADTs and 6‐month follow up at CC. Exclusion criteria were <6‐month follow‐up, lack of 3‐dimensional lesion or sheet desmoid, and/or incomplete medical records. Kaplan‐Meier curves were analyzed for HPN and non‐HPN groups. Results: One hundred fifty‐four patients were included and divided into 2 groups: HPN (n = 41, 26.6%) and non‐HPN (n = 113, 73.4%). The HPN group was more likely to have advanced‐stage disease and significantly higher incidence of chronic abdominal pain, narcotic dependency, bowel obstruction, ureteral obstruction, deep vein thrombosis, pulmonary embolism, fistulae, and sepsis (P < .05). The need for HPN represented a strong predictor of mortality (5‐year survival HPN = 72% vs non‐HPN = 95%), but duration of HPN did not affect mortality. Conclusion: HPN, although a life‐saving treatment, is an independent poor prognostic factor associated with high morbidity and mortality.     

Hypoglycemia During the Temporary Interruption of Parenteral Nutrition Infusion in Pediatric Hematopoietic Stem Cell Transplantation

Background: Parenteral nutrition (PN) is required with pediatric procedures such as hematopoietic stem cell transplantation (HSCT). However, risks associated with temporary PN infusion interruption remain unclear. Materials and Methods: We retrospectively analyzed in 22 children undergoing HSCT receiving PN with the same daily routine: temporary PN infusion interruption before breakfast for administering a saline‐diluted acyclovir drip. After correcting patients’ glucose levels, we examined minimum blood glucose levels between preparative regimen initiation and post‐HSCT day 30. Patients were divided into 2 groups according to a minimum glucose cutoff of 60 mg/dL. Patient background characteristics and hypoglycemia risk factors were compared between both groups. Results: The hypoglycemia group had a significantly lower body surface area, higher glucose infusion rate (GIR), lower cholinesterase levels, and higher zinc levels at the onset of the minimum blood glucose level (P < .05). Multivariate analyses revealed an association only between higher GIR (≥5 mg/kg/min) and hypoglycemia during the temporary PN infusion interruption. A time course analysis of blood glucose and immunoreactive insulin (IRI) levels in 1 patient revealed a combined high‐caloric and saline flush before acyclovir initiation, causing temporary increased IRI, as the etiology for hypoglycemia. Conclusions: Particular attention and several precautions are required to prevent complications associated with temporary PN infusion interruption in children with higher GIR.     

Growth hormone to improve short bowel syndrome intestinal autonomy: a pediatric randomized open-label clinical trial

Background: The ability of growth hormone (GH) to promote the weaning‐off of parenteral nutrition (PN) in short bowel syndrome (SBS) is unclear. No randomized controlled study is available in children. This study was undertaken to determine if GH could enhance the weaning off of PN in PN‐dependent children with SBS. Methods: A prospective randomized open‐label multicenter study was performed in 14 patients (mean age, 9 ± 1.4 years) with SBS (average small bowel length, 33 cm) and long‐term PN dependency (8 years) on an unrestricted diet. A standardized PN decrease with and without GH (0.14 mg/kg/d) was conducted. The patients were randomized to either a GH group (4 months of GH) or a control (CTR) group (4 months without GH, followed by 4 months with GH). Blood tests and a nutrition assessment of enteral and parenteral intakes were performed. Groups were compared with the Wilcoxon test. Results: Treatment with GH did not improve the weaning off of PN (decrease in PN caloric intake of 32.5% ± 9.6% in the GH group vs 35.2% ± 8.7% in the CTR group, nonsignificant). In the CTR group, GH treatment induced an additional but not statistically significant decrease of 8.8% ± 12.4% in daily calories. Parenteral needs returned to near basal rates 6 months after GH discontinuation (GH: 77.6% ± 10.6% vs CTR: 73.2% ± 7.4%). Weight decreased slightly in both groups. No biological parameters varied significantly. Conclusions: GH did not improve the weaning off of PN in PN‐dependent children with SBS.     

Serum vitamins in adult patients with short bowel syndrome receiving intermittent parenteral nutrition

Background: Short bowel syndrome (SBS) occurs after massive intestinal resection, and parenteral nutrition (PN) therapy may be necessary even after a period of adaptation. The purpose of this study was to determine the vitamin status in adults with SBS receiving intermittent PN. Methods: The study was conducted on hospitalized adults with SBS who were receiving intermittent PN therapy (n = 8). Nine healthy volunteers, paired by age and sex, served as controls. Food ingestion, anthropometry, plasma folic acid, and vitamins B₁₂, C, A, D, E, and K were evaluated. Results: The levels of vitamins A, D, and B₁₂ in both groups were similar. SBS patients presented higher values of folic acid (21.3 ± 4.4 vs 14.4 ± 5.2, P = .01) and lower values of vitamin C (0.9 ± 0.4 vs 1.2 ± 0.3 mg/dL, P = .03), α‐tocopherol (16.3 ± 3.4 vs 24.1 ± 2.7 µmol/L, P < .001), and phylloquinone (0.6 ± 0.2 vs 1.0 ± 0.5 nmol/L, P < .03). Eight‐seven percent of patients had vitamin D deficiency, and all patients presented with serum vitamin E levels below reference values. Conclusions: Despite all efforts to offer all the nutrients mentioned above, SBS patients had lower serum levels of vitamins C, E, and K, similar to those observed in patients on home PN. These findings suggest that the administered vitamins were not sufficient for the intermittent PN scheme and that individual adjustments are needed depending on the patient's vitamin status.