An Analysis of Factors Contributing to the Development of Total Parenteral Nutrition-Induced Cholestasis

Abstract

The risk of developmental of total parenteral nutrition (TPN)-associated cholestatic jaundice in neonates receiving intravenous hyperalimentation is high. Numerous factors have been cited as contributing to TPN cholestasis; however, the exact etiology remains obscure. This retrospective study was undertaken in order to identify any factors which might contribute to this syndrome.

The hospital records of 172 neonates requiring TPN for a minimum of 1 week were reviewed. In addition, a subgroup of 32 infants requiring TPN for a minimum of 7 weeks was also examined. Cholestasis was defined as a direct serum bilirubin greater than 2.0 mg/dl during the course of TPN therapy.

Significant factors for the development of cholestasis in both groups (n = 172, n = 32) included: number of operations (2.56 vs. 1.08, p = 0.0000), the number of days the patients received antibiotics (40.3 vs 12.9, p = 0.0000), and delayed start of enteral feedings (33.8 vs 14.1, p = 0.0000).

Fifteen of the 32 patients who received TPN for at least 7 weeks did not develop cholestasis. In this subgroup (n = 32), there were no differences in birth weight, gestational age, days from birth to the start of TPN, or respiratory distress between those who developed cholestasis and those who remained anicteric. In contrast, there were significant differences between the cholestasis and noncholestasis groups in number of operations (13 vs 6, p = 0.0407), and days until enteral feedings were started (33.1 vs 18.9, p = 0.0289).

This study suggests that the factor(s) contributing to the development of TPN-associated cholestasis are likely multifactorial. There appears to be a direct correlation between increasing severity of cholestatic jaundice and duration of TPN. This review does add a new parameter to the various causative factors suggested, namely the number of operative procedures. This new variable could be related to the stress of surgery itself or to the repeated administration of anesthetic agents. (Journal of Parenteral and Enteral Nutrition 13:586-589, 1989)