Journal of Parenteral and Enteral Nutrition

We used a sensitive whole body counter which measures potassium-40 ( ⁴⁰K) to determine total body potassium and to estimate body cell mass (BCM) in 104 previously untreated patients with upper gastrointestinal malignancies, 233 normal volunteers, and 18 patients with anorexia nervosa. BCM was greater in normal males than in females. In both normal males and females, the BCM tended to decrease with age, both as an absolute measure and as a percentage of body weight. Anorexia nervosa patients experienced marked weight loss (30.5%), and had significant depletion of absolute BCM, but exhibited relative sparing of BCM as indicated by a rise in BCM as a percentage of body weight. This may reflect a normal adaptation and predominant fat utilization in chronic malnutrition. The cancer patients, on the other hand, had significant weight loss (12.7% for females, 13.9% for males) and demonstrated a proportional decline in BCM, with no change in BCM as a percentage of body weight. These findings support the contention that, in the cancer-bearing patient, weight loss consists of a significant depletion of both fat and BCM. The challenge to the clinicians caring for cancer patients is repletion of this supremely functional body compartment. (Journal of Parenteral and Enteral Nutrition 11: 219-222, 1987)

Knowledge of the amino acid requirements of a neoplasm is valuable in determining optimal nutritional support and antineoplastic therapy for the tumor-bearing host. The standard human tumor stem cell assay (HTSCA) was modified by reducing an individual amino acid below the normal plasma concentration of the Fischer 344 rat. All other amino acids were maintained at levels sufficient for normal HTSCA tumor colony growth. Twenty-two amino acids were tested at a mean concentration of 12% (range 3% to 35%) of their normal plasma level. Results indicated that all amino acids except L-glutamine and L-asparagine were present in sufficient quantity for normal tumor growth. Dose-response curves have shown more than 70% inhibition of tumor growth with a glutamine concentration of 50% and an asparagine concentration of 25%. Glutamine and asparagine levels of 4% and 1%, respectively, resulted in 100% inhibition. The data indicate that rat sarcoma stem cells are sensitive to decreased glutamine and asparagine concentrations. (Journal of Parenteral and Enteral Nutrition 11:223-228, 1987)

To determine the prevalence of abnormal vitamin levels in an adult hospitalized population requiring total parenteral nutrition (TPN) and to assess the effect of routine parenteral vitamin therapy on vitamin levels, we studied 35 general surgical patients. Assays for 12 vitamins were performed both before and after a standard 10-day course of TPN. Patients were given nothing by mouth. The first 25 patients received a daily parenteral vitamin mixture tailored to the recommendations of the Nutrition Advisory Group of The American Medical Association (maintenance dose). The final 10 patients were given a parenteral multivitamin dose providing substantially greater amounts of most vitamins (repletion dose). Only 58% (190/324) of pre-TPN vitamin levels were normal, 25% were low, and 17% were high. No patient had fewer than two abnormal baseline levels. Vitamin levels did not correlate with serum albumin, body weight, or nitrogen balance. After 10 days of treatment, only 39% of low pre-TPN vitamin levels improved; most (45/62) of the low posttreatment levels were low at baseline. The higher repletion dose resulted in a significantly (p < 0.01) greater percent increase in vitamin A, C, and pyridoxine levels.

The prevalence of abnormal vitamin levels in this population is high (42%). Standard parenteral vitamin therapy leads to marginal improvement in abnormally low pre-TPN vitamin levels. (Journal of Parenteral and Enteral Nutrition 11:229-237, 1987)

Complete nutritive mixtures (CNM) of all intravenous nutrients including fat emulsions are being used increasingly because of their convenience. However, this may lead to chemical interactions and reduce the amount of active vitamins and trace elements made available to the patient. We have studied the effects on micronutrient status of provision of all nutrients in one 3-liter bag (CNM: amino acids, dextrose, Intralipid 20%, a nine-element trace metal mixture, and complete fat- and water-soluble vitamin mixtures) in 10 postoperative surgical patients [median intravenous nutrition (IVN) 14.5 days, range 7-38]. A similar group received the fat emulsion plus water- and fat-soluble vitamins as a separate infusion (SI) from a 3-liter bag (median IVN 14.0 days, range 8-28). Serum and urine magnesium, zinc, copper, manganese, chromium, and selenium, serum vitamins A, E, C, folate, and B₁₂, RBC B ₁, B₂ B₆, and folate and leukocyte vitamin C were measured at weekly intervals. All patients in both groups maintained or improved their status for all the micronutrients analyzed. No significant differences between the CNM and SI groups were found in blood concentrations of any of the elements or vitamins. Only for urine copper did the CNM lead to increased excretion (1.51 ± 0.59 μmol/24 hr; copper input 20 μmol/day), compared to SI (1.00 ± 0.70 μmol/day, p < 0.001 Mann-Whitney test) suggesting possible interaction. It is concluded that micronutrient status was maintained during short-term IVN with the CNM and that it did not lead to a significantly greater loss of vitamins or essential trace elements than the SI system. (Journal of Parenteral and Enteral Nutrition 11: 238-242, 1987)

Forty-three patients with mild weight loss were studied prospectively to determine whether the parenteral water-soluble vitamin doses in a commercially available preparation (MVI concentrate; USV Laboratories, Tarrytown, NY) maintained serum, red blood cell (RBC), and urinary concentrations of water-soluble vitamins in stressed cancer patients receiving total parenteral nutrition (TPN). Patients were divided into three groups: (1) oral diet, no intravenous vitamins given; (2) TPN plus 5 ml MVI; and (3) TPN plus 10 ml MVI. Vitamins C, B₁, B₂, B₃, B₆, and niacin were measured initially and weekly during a 6-week study period. Caloric and nitrogen balances were quantified. Most of the patients in all three groups had normal blood or urine levels of all water-soluble vitamins. No clinical evidence of vitamin deficiency or MVI toxicitv was detected. The recommended parenteral dosages of vitamin C (100 mg/day) and B₃ (15 mg/day) provided measurably adequate levels in all patients. Levels of vitamins B₁, B₂, B₆, and niacin that were less than the normal range were noted in 4-40% of patients receiving the recommended daily dosages of 3 mg, 3.6 mg, 4 mg, and 40 mg, respectively. These deficiencies appeared to improve in group III patients who received twice the recommended parenteral vitamin dosages, although they did not completely disappear. Niacin deficiency appeared to be the most prevalent, occurring in 40% of patients studied. Since intravenous doses of B₁ , B₂, B₆, and niacin are safe and well tolerated, it appears that increased daily amounts of these vitamins should be given to cancer patients on parenteral nutrition. (Journal of Parenteral and Enteral Nutrition 11:243-249, 1987)

The metabolism of the hydrogenated disaccharide maltitol was compared to that of sucrose in a group of eight normal subjects. On two separate days, with an interval of at least one week each subject ingested a load of 30 g of either substance. The evolution of the levels of plasma glucose, insulin, and free fatty acids was followed during the 6 hr following the oral load. Carbohydrate and lipid oxidation rates were assessed simultaneously by continuous indirect calorimetry during the 6 hr following the oral load. Plasma glucose and insulin peaks occurred 30 min after ingestion of the load for both sugars. The peak of the delta glucose concentration was significantly smaller after maltitol than after sucrose (21 ± 4 us 38 ± 4 mg/100 ml, p < 0.02), as was the peak of the delta insulin concentration (9.3 ± 2.7 μU/ml after maltitol vs 25.5 ± 5.0 μU/ml after sucrose, p < 0.001). The peak of the stimulation of glucose oxidation occurred 60 min after the load of sucrose and 90 min after the load of maltitol. The delta glucose oxidation was significantly lower with maltitol than with sucrose during the first 90 min after the ingestion of the load. It was slightly higher (although not significantly) with maltitol than with sucrose starting from the 210th min. Maltitol resulted in a cumulated suprabasal glucose oxidation which amounted to 40% that obtained with sucrose after 180 min. (Journal of Parenteral and Enteral Nutrition 11:250-254, 1987)

Determining an individual's "ideal" body weight is fundamental in nutritional therapy. A simulation of the human body to a cylindrical volumetric model permits the calculation of the ideal body weight from the measured height, interacromioclavicular distance, and humeral length. A group of 189 healthy normal volunteers were assessed. The calculated "Pitt" ideal body weight correlated closely (r = 0.88 for males, r = 0.72 for women) with values obtained from the Metropolitan tables. The technique provides an estimate of ideal body weight based upon reproducible, easily obtained measurements of fixed bony landmarks. ( Journal of Parenteral and Enteral Nutrition 11:255-258,1987)

The recent introduction of triple lumen catheters has facilitated the care of seriously ill patients by providing multipurpose central venous access through a single percutaneous 7 French catheter. This prospective study was performed to examine the complications associated with the use of these catheters in patients receiving long-term total parenteral nutrition (TPN).

Seventy-five patients undergoing catheterization were randomly separated into two groups: 36 patients underwent placement of a single lumen catheter (SLC), and 39 patients, a triple lumen catheter (TLC). The two groups were comparable with respect to concomitant infections, treatment with antibiotics, and need for intensive care. Patients in the SLC group received TPN for a mean of 9.7 days and in the TLC group, for a mean of 8.5 days (p = 0.427). However, after 5 days of catheterization, there was a marked increase in the number of TLC removed because of skin entry site infections. SLC were more likely to be used for the full duration of TPN administration (p = 0.025). Catheter tips were cultured by semiquantitative techniques. A higher incidence of catheter sepsis was seen with TLC, 12.8% vs 0% with SLC (p = 0.055).

TLC used for TPN are associated with higher rates of catheter entry site infections and systemic sepsis. SLC should be used for TPN administration. (Journal of Parenteral and Enteral Nutrition 11: 259-262, 1987)

An analysis of catheter-related complications in a study group consisting of 83 patients, each of whom arrived at a major marrow transplant center after having had a large bore right atrial catheter (RAC) inserted by the referring institution, was compared to a similar analysis of catheter-related complications in 357 patients who had their RAC inserted at the transplant center just before the transplant procedure was begun (control group). Fourteen (17%) patients in the study group had their original catheter removed for complications (five for septicemia and nine for mechanical complications) compared to 57 (16%) of the patients in the control group. Thirteen (16%) of the 83 catheters in the study group were double lumen and only two of these (15%) were replaced due to complications. Sixteen of 59 patients (27%), 13 years old or older, who arrived with a single lumen RAC already inserted, required an additional catheter during the transplant procedure because of an increased need for intravenous access. From this study, we concluded that patients who arrived for marrow transplantation with a RAC already inserted did not routinely need the catheter replaced. However, it is recommended that double lumen catheters be inserted in adult patients if marrow transplantation is anticipated. (Journal of Parenteral and Enteral Nutrition 11 :263-266, 1987)

While on total parenteral nutrition (TPN), 37 patients underwent replacement of a central venous catheter (CVC), during which a wire introducer was used, according to the Seldinger technique. In 25 patients, the CVC was placed in the superior cava via the subclavian, and, in 12, via the jugular vein.

Overall, 82 CVC changes were performed.: 74 for assumed CVC sepsis, 6 as preventive treatment, and 2 for partial catheter displacement. Catheter tip culture proved to be positive in 25 of 119 CVC examined.

The catheters were defined as sterile when the tip culture was negative; contaminated, when the tip culture was positive and peripheral blood culture was either negative or positive for different bacteria; septic when both tip and blood were positive for the same bacteria.

The results indicated that 10 catheters were contaminated and 17 were septic. Eight previously sterile CVC were found positive after the exchange: 3 were removed at the end of TPN in asymptomatic patients, and 5 were successfully resterilized by means of one more change.

Guidewire replacement allowed CVC sterilization of 22 of 24 catheters (91.6%). No complications due to the catheter-changing method were seen. (Journal of Parenteral and Enteral Nutrition 11:267-270, 1987)

Twenty-five insulin-treated diabetic patients were randomly assigned postoperatively to 5 days of intravenous infusions of ProcalAmine (3% amino acids, 3% glycerol, and electrolytes) or FreAmineIII + dextrose and electrolytes. The solutions were given isocalorically and isonitrogenously. Insulin was adjusted to keep glycemia at the level of 150-200 mg/dl. The ProcalAmine group by the 5th day had plasma glucose of 158 ± 25 mg/dl and required 1.20 ± 0.10 U/hr insulin. The FreAmine + dextrose group had plasma glucose of 169 ± 53 mg/dl and required 2.28 ± 0.13 U/hr. At all time points postsurgically, the ProcalAmine group required less insulin. (Journal of Parenteral and Enteral Nutrition 11:274-274, 1987)

Although young infants are at greater risk for total parenteral nutrition (TPN)-related liver disease than adults, previous studies on the effect of the TPN energy source on the development of hepatic steatosis have been carried out in adult rats and adult humans. We studied the effect of a glucose and a glucose/fat TPN energy regimen on hepatic chemical composition and the development of steatosis in newborn miniature pigs. Twenty miniature pigs were randomized at 10 days of age to receive a TPN regimen which utilized either glucose (group A) or glucose/fat (group B) as the non-nitrogen energy source. After 8 days, blood was drawn for insulin, glucagon, SGPT, albumin, and bilirubin determinations. Samples of liver were obtained at 9 days. Plasma insulin levels were significantly higher and glucagon levels lower in group A piglets than in those in group B. Normal values were obtained for SGPT, albumin, and bilirubin, and no differences were found between groups. Chemical analysis of the livers revealed no differences between groups in the concentrations of glycogen, fat, protein, DNA, and RNA. Group A animals had significantly higher concentrations of water than group B (group A: 0.75 ± 0.01 liter/kg; group B: 0.74 ± 0.01; p < 0.03). A significant correlation was found in group B between the plasma insulin/glucagon ratio and the hepatic glycogen concentration (r = 0.73, p < 0.05). Group A animals had fat vacuoles in centrilobular hepatocytes, in contrast with group B animals who had visible fat only in Kupffer cells. Thus, in the newborn miniature pig, the different TPN energy sources affected the chemical composition of the livers similarly, except for water. Similar chemical composition did not preclude the histologic development of steatosis. (Journal of Parenteral and Enteral Nutrition 11:275-279, 1987)

Two groups of five conscious dogs received total parenteral nutrition (about 100 kcal/kg body weight per 24 hr) continuously for 96 hr (0.28 g triglycerides/kg body weight per hr, constituting more than 55% of the energy supply). The only difference between the two groups was the nature of the 20% lipid emulsion. In one group, this emulsion contained only long-chain triglycerides (LCTs), and in the other it contained a mixture (vol/vol) of medium chain triglycerides (MCTs) and LCTs. MCTs thus were given in an amount of about 30% of the total energy supplied.

During infusion with the MCT/LCT mixture, C8, C10, and C12 fatty acids appeared in the total plasma fatty acids. When the infusion was stopped, the medium-chain fatty acids disappeared; those with shorter chains did so more rapidly. The plasma triglyceride clearance was faster for the MCT/LCT mixture than for the LCTs, whereas phospholipid and cholesterol clearance seemed slower for the MCT/LCT mixture. With this mixture, there was a slight increase in the plasma concentrations of ketone bodies, lactate, and pyruvate, and a slight decrease in plasma glucose. The MCT/LCT mixture was well tolerated, causing no discernible problems, and, in particular, no signs of narcosis or encephalopathy. (Journal of Parenteral and Enteral Nutrition 11:280-286, 1987)

We assessed the trace metal status of 10 children (3.5 to 13.3 yr) with phenylketonuria (PKU) who were successively treated for at least 6 months with a semi-synthetic formula restricted in phenylalanine, then for 6 months with a reformulated formula. The reformulated product contained higher concentrations of magnesium (Mg), potassium (K), phosphorus (P), selenium (Se), and zinc (Zn) and lower concentrations of calcium (Ca), sodium (Na), and unsaturated fats. Diet records, blood samples, and urine specimens were collected from each subject. Mean intakes of Mg, K, and Zn increased significantly when subjects were switched to the reformulated product. The subject's mean intakes of Se (for all age groups) and Zn (children 11 to 14 yr old) were below 67% of recommended intakes while they were ingesting the original formula. The mean trace metal concentrations of urine, blood, and serum did not differ significantly during the two periods. Mean serum Zn, Se, and Cu concentrations of the subjects were less than those reported for normal children. Significant negative correlations were obtained between serum Zn concentrations and the molar ratio of dietary (Ca + P):Zn, and the molar ratio of dietary Fe:Zn. No significant differences in mean urinary Cu and Zn excretion (mg/g creatinine) were observed in subjects after they were changed to the reformulated product. Individuals whose primary source of energy and protein is derived from semi-synthetic elemental diets are especially at risk for multiple trace element deficiencies. (Journal of Parenteral and Enteral Nutrition 11:287-292, 1987)

Cholestasis is a common complication of total parenteral nutrition (TPN) in infants. A contributing factor to the hepatic dysfunction may be a contaminant of the TPN solution, such as aluminum, that accumulates in liver and may act as a hepatotoxin. To study the hepatic effects of aluminum, growing piglets were given daily intravenous injections of aluminum, 1.5 mg/kg, for 50 days; pair-fed controls were given heparinized saline. At sacrifice, liver and serum were obtained. Liver was analyzed for histopathology and for aluminum content and localization. The hepatocyte lysosomes of the experimental group showed aluminum peaks by x-ray microanalysis, whereas the control group did not. No differences in ultrastructure were noted between the two groups when examined by electron microscopy. Mean serum total bile acid levels (27.8 ± 15.9 SD vs 6.3 ± 1.5 μmol/liter, p < 0.05), mean alkaline phosphatase (309 ± 108 vs 180 ± 27 lU/liter, p = NS), and mean hepatic copper content (24.8 ± 4.5 vs 14.4 ± μg/g dry weight, p < 0.01), were elevated in the aluminum-loaded piglets, indicating that cholestasis may have been produced. Also, a small but significant reduction in serum levels of 25 hydroxyvitamin D was found in the aluminum-loaded piglets, suggesting that vitamin D hydroxylation may be impaired. Inasmuch as lysosomal contents are excreted into the bile, aluminum accumulation in lysosomes may alter lysosomal function and possibly affect bile flow or content. (Journal of Parenteral and Enteral Nutrition 11:293-297, 1987)

Nutritional parameters obtained at hospital admission were studied to determine whether they would predict which surgical patients would develop pressure ulcers during a period of up to three weeks of hospitalization. Nutrition parameters were serum albumin, total protein, lymphocyte count, mid-arm muscle circumference, triceps skin fold, and weight change. Lymphocyte count was significant (p = 0.007, adjusted r2 = 0.019) in predicting the development of a pressure ulcer during hospitalization. Because lymphocyte count accounted for less than 2% of the variance, it is not a clinically significant predictor. When nonnutritional pressure ulcer risk factors were controlled for in the regression, no nutritional factors were predictive of ulcer development. (Journal of Parenteral and Enteral Nutrition 11:298-301, 1987)

The influence on pancreatic secretion of four enteral feeding products was evaluated in a unique patient with an isolated duodenal fistula for whom enteral feeding access was obtained via a gastrostomy with a small Silastic catheter passed through the gastrostomy and through a surgically created gastrojejunostomy. The patient was totally supported by intravenous nutrition during the study. Each enteral feeding solution was administered at full strength at 50 ml/hr for 2 days with a 24-hr collection of pancreatic secretions by the duodenal cutaneous fistula taken on the second day Infusion of the enteral feeding solutions did not alter volume of fistula drainage. All solutions decreased bicarbonate and amylase secretion but increased lipase and total nitrogen excretion. From this study, it would appear reasonable to administer Vivonex HN and Criticare HN via the jejunum in patients with pancreatic disease, whereas Osmolite would appear less satisfactory, due to its much stronger stimulation of lipase secretion. (Journal of Parenteral and Enteral Nutrition 11: 302-304, 1987)

Resting energy expenditure (REE) was measured in 10 patients with end-stage liver disease (ELD) and in 31 normal controls. Basal energy expenditure (BEE) was also predicted by the Harris-Benedict equation. In order to correlate REE to lean body mass, the 24-hr urinary creatinine was measured in patients with ELD and in normal controls and expressed as kcal/g urinary creatinine. Linear regression analysis showed a statistically significant (p < 0.0001 ) correlation (r = 0.72) between the REE and the 24-hr urinary creatinine in normal controls, irrespective of age and sex. Mean BEE (1580 ± 160 vs 1575 ± 210) and REE (1755 ± 215 vs 1800 ± 330) were not significantly different between patients with ELD and controls. However, the mean REE was 1900 ± 610 kcal/g creatinine in patients with ELD and 1180 ± 260 (p < 0.0001) in controls. When related to lean tissue, patients with ELD had increased energy expenditure, confirming the hypermetabolic state suggested on clinical grounds. The use of urine creatinine to estimate energy expenditure may be a simple clinical technique to predict dietary energy needs in malnourished, unstressed patients. When this estimated energy expenditure/g creatinine (EEE) is compared to measured energy expenditure/g creatinine in malnourished, stressed patients, the EEE provides an index of the extent of hypermetabolism. (Journal of Parenteral and Enteral Nutrition 11:305-308, 1987)

Protein-calorie malnutrition (PCM) adversely affects more or less all immune competent cells. Nonspecific immunity is impaired, particularly adherence and chemotaxis of phagocytes, although the responsiveness of circulating cells may not be the same as that of noncirculating cells. PCM results in numerical and functional impairment in lymphocytes. PCM markedly affects IgG class antibodies which have the highest affinity when directed against T-dependent antigens. These impairments are interrelated, since cooperation between T-helper cell and B-cells is depressed, and the antigen presentation to T-helper cells by macrophages is deficient. (Journal of Parenteral and Enteral Nutrition 11:309-313, 1987)

A case report of a 4-yr-old child who developed an anaphylactic reaction to parenteral nutrition is presented. Dermal allergy tests demonstrated a sensitivity to Travasol solution and Armour multivitamin 2 solution. This is the first reported case known to us of such a response to elemental parenteral nutrition. (Journal of Parenteral and Enteral Nutrition 11:314-315, 1987)

Intravenous lipids have been shown to have varying effects on coagulation parameters. A patient with short bowel syndrome and recurrent thrombotic episodes who required both intravenous lipids and anticoagulation is described. A constant infusion of a soybean oil emulsion (Intralipid) in his parenteral nutrient solution was demonstrated to interfere with the anticoagulant effect of warfarin. Termination of the infusion and rechallenge with warfarin resulted in prolongation of his prothrombin time to the therapeutic range. Reinstitution of a lipid-free parenteral nutrition regimen has allowed for successful continuation of warfarin therapy. (Journal of Parenteral and Enteral Nutrition 11:316-318, 1987)

Perforation of the heart by central venous catheters is an uncommon but life-threatening complication in the neonatal age group. Prevention requires an open insertion technique, the use of soft Silastic catheters, and the maintenance of the catheter tip above the right atrium. Rapid clinical deterioration with signs of tamponade suggests the diagnosis. Catheter withdrawal, early pericardiocentesis, and pericardiotomy with myocardial repair in selected cases contribute to survival. (Journal of Parenteral and Enteral Nutrition 11:319-321,1987)

An 8-year-old girl with chronic idiopathic intestinal pseudo-obstruction (CIIP), who is the first case of CIIP in Japan, has been receiving total parenteral nutrition (TPN) for more than 6 years. During this time, she experienced deficiencies of copper, zinc, vitamin A, vitamin B₁₂, folic acid, and biotin, and an excess of vitamin A; she exhibited a series of signs and symptoms due to these deficiencies and vitamin A overdosage. Nevertheless, careful monitoring of serum levels of trace elements and vitamins and appropriate therapy have almost solved these problems. She has achieved normal physical and mental development and goes to school, while receiving home parenteral nutrition with an ambulatory infusion system. (Journal of Parenteral and Enteral Nutrition 11:322-325,1987)

The chest tube is presented as a device for the tunneling of central venous catheters. It offers several advantages over currently recommended tunneling devices. It is readily available in multiple sizes to accommodate different diameter catheters, produces lengthy atraumatic tunnels, and can be bent into various shapes to facilitate passage through the subcutaneous tissues. (Journal of Parenteral and Enteral Nutrition 11:326-327, 1987)