C.R. Pennington

A comparison between oral and nasogastric nutritional supplements in malnourished patients

There is a common perception that malnutrition is an inevitable manifestation of illness, that oral nutritional supplements are not taken or reduce the consumption of oral diet, and that nasogastric feeding is poorly tolerated. This study assessed the efficacy of supplemental enteral feeding on the nutritional status of malnourished patients, to compare oral supplements (OS) with overnight supplemental nasogastric feeding (NG) on nutritional status and to determine the effect of nutritional supplements on oral diet. Malnourished hospital patients were randomized to one of three groups: control (C), OS, or NG. All patients had access to hospital diet. Supplements were prescribed to meet estimated nutritional needs. Nutritional status was recorded at the start and the end of the feeding period. The total nutritional intake was recorded. Weight gain occurred in 64% of the supplemented patients, whereas 73% of the controls lost weight with mean weight changes of +2.9% OS. +3.3% NG, and -2.5% C. There was no difference in the mean energy intake from food in the three groups. There were no documented complications of OS and three minor complications of NG. Both methods of supplementation allow weight gain without significantly affecting spontaneous oral intake.

Assessment of distal tip position of long-term central venous feeding catheters using transesophageal echocardiology.

BACKGROUND Central vein catheter position is a vital element in promoting longevity and minimizing adverse events associated with long-term parenteral nutrition. Traditionally, position has been verified using a chest radiograph. However, this mode of assessment has limitations as the catheter is placed in a dynamic system subject to forces from changes in posture and diaphragmatic movement. METHODS We compared the reported position using a chest x-ray compared with assessment using transesophageal echocardiology (TOE) in 9 patients receiving home parenteral nutrition. The x-ray was reported by a radiologist unaware of the study. RESULTS There were discordant results in 7 of the 9 cases with catheter tip placed in the right atrium or impinging in the tricuspid valve which was not evident from the chest x-ray. TOE offered greater information of catheter tip position and relationship to adjacent anatomy. CONCLUSIONS Further work is required but this observational study suggests guidelines suggesting the use of a chest radiograph to confirm catheter position may need to be re-assessed.

Manganese requirement and toxicity in patients on home parenteral nutrition

Two patients who were receiving home parenteral nutrition complained of vague neurological symptoms of such severity that they underwent full clinical appraisal. The only positive finding was that plasma manganese concentrations were greater than twice the upper 95% confidence interval of normal (7-27|nmol/l). In the light of this result all nine patients receiving home parenteral nutrition underwent evaluation for possible manganese toxicity. One other patient had serum manganese concentrations exceeding twice the upper limit (127|nmol/l). The three patients with elevated serum Mn had evidence of manganese deposition in the brain on magnetic resonance imaging scanning. In contrast two patients with normal plasma results had negative scans. Patient susceptibility appears very variable. We suggest that current amounts of trace elements provided in nutrition solutions may be a potential source of nutrient activity. The fine tuning of supply and demand may be difficult on account of a limited range of commercially available trace element solutions.

Ethanol flush for the prevention of catheter occlusion

Catheter occlusion by lipid material has been associated with the use of compounded nutrient solutions containing lipid. We have studied the incidence of catheter occlusion when either a saline or an ethanol flush has been used prior to the application of a heparin lock following an overnight infusion of such nutrients. Lipid occlusion occured in 13 of 23 catheters when a saline flush preceeded the application of a heparin lock, whereas the use of a 20% ethanol solution before the application of the heparin lock resulted in only 2 occlusoins in 28 catheters (p < 0.001). In addition there was significantly longer catheter survival in the ethanol group (p < 0.01). It is concluded that an ethanol flush may significantly reduce the incidence of catheter occlusion during the use of lipid mixes.

Taurolin for the prevention of parenteral nutrition related infection: antimicrobial activity and long-term use.

A case is described in which bis (1, 1 dioxoperhydro-1, 2, 4-thiadiazinyl-4-) methane (Taurolin) has saferly been administered on a long term basis to prevent recurrent sepsis in a patient receiving parenteral nutrition. A 26-year-old male with Crohns disease receiving parenteral nutrition suffered repeated episodes of sepsis and developed an infected intra-atrial thrombus despite repeated courses of antimicrobial chemotherapy and surgical intervention. Continued parenteral nutrition was essential du5e to intestinal failure. Taurolin was administered in the parenteral feed, as a 0.3% solution, to prevent recrudescent and recurrent infection. This concentration was shown, in vitro, to be bactericidal to a variety of pathogenic organisms. No recurrence of sepsis, nor any evidence of side effects was observed throughout the 12 month period of Taurolin administration. After 12 months the taurolin was discontinued and within 2 weeks the patient was re-admitted with recurrent septicaemia. Following re-introduction of Taurolin the infection was controlled and the patient remains well. In our experience the addition of taurolin to the nutritive feeds of a patient at risk of sepsis is a safe and effective method of preventing recurrent sepsis.

The nutritional status of patients receiving home enteral feeding

19 patients receiving home enteral nutrition (HEN) were nutritionally assessed, using anthropometry and blood analysis. Blood was taken for measurement of serum albumin, magnesium, zinc, copper, selenium and vitamins A and E. 8 patients had anthropometric evidence of protein and energy depletion, of whom 6 were severely depleted. 15 patients had biochemical evidence of trace element or vitamin depletion of whom 6 had multiple (>/= 3) depletion. Depletion occurred in all diagnostic categories, even in patients with normal anthropometric measurements, and was independent of duration, volume or method of feeding. We conclude that patients receiving HEN may be at risk of protein energy malnutrition and of developing vitamin or trace element deficiency states regardless of diagnosis, anthropometric measurements or duration of feeding. Therefore close nutritional monitoring of such patients is essential, and it is recommended that patients on HEN are supervised by clinicians with an appropriate interest.

Skin content of 7-dehydrocholesterol in patients with malabsorption

The mechanism for the development of vitamin D deficiency in patients with malabsorption remains unclear. We wished to examine the hypothesis that one factor was a reduced skin content of 7-dehydrocholesterol, the precursor for the formation of vitamin D in the presence of ultraviolet radiation. We measured 7-dehydrocholesterol in skin samples from 9 patients who had previously had vitamin D deficiency due to malabsorption (6 with Crohns disease, 2 with primary biliary cirrhosis, and 1 with idiopathic pseudo-obstruction). We found no evidence of reduced levels of 7-dehydrocholesterol in the skin in these patients. Lack of 7-dehydrocholesterol does not contribute to vitamin D deficiency in malabsorption.

Parenteral nutrition: the management of complications

Parenteral nutrition is an important therapeutic modality, used widely in the management of patients in whom the intestinal function is inadequate or unavailable. For some recipients, this form of nutritional support is life-saving, and many others benefit from a substantial improvement in their quality of life. In common with other developments in medical treatment, parenteral nutrition is associated with serious and potentially fatal complications. These complications have been described in earlier publications from centres with special interest in nutritional support, many of which focused on the problem of catheter infection (1, 2). With wider application and more prolonged treatment, other problems such as micronutrient deficiency syndromes (3), catheter occlusion (4), venous thrombosis (5), metabolic bone disease (6) and hepatobiliary disease (7) have emerged. An increased awareness of nutrient needs and the reformulation of nutrient solutions (8) mean that deficiency syndromes are now rare; however, many of the other complications continue to cause problems, particularly during longterm treatment. Furthermore, there is no consensus about their optimum management, partly because of inadequate information and research. Such complications make an important contribution to patient morbidity and the cost of treatment. This review summarises management options for the prevention and treatment of the common complications of long-term central parenteral nutrition.

Central vein thrombosis during home parenteral nutrition

Consequently CVT may occur during the hospital period, possibly preventing some patients from receiving HPN. The majority of patients commencing HPN in the USA currently suffer from terminal cancer or AIDS, most of both groups die within one year; 8 under these circumstances, the development of CVT may not prompt re-admission, which is the criterion for the inclusion of this complication in the American report. 4 Incidence The incidence of CVT in HPN may be assessed by reference to reports from HPN registries. The report from the UK register 1 included most of the UK patients undergoing HPN and may thus accurately reflect the incidence of complications. 13 (6%) of the 221 patients who had completed 2641 months of treatment developed CVT of which there were 0.063 episodes per annum. 116 of these patients were managed in one centre, 10 of whom suffered from CVT (9%) with 0.06 episodes per annum. In a report of 200 patients from various European centres, 8% of patients developed CVT with 0.07 episodes per year of treatment, 2 and in another study of HPN in children, CVT occured in 6% of patients) In contrast, the North American register which included 204 programmes and 10 000 patients describes a much lower incidence with between 0.01-0.03 episodes of CVT for each year of treatment. 4 The fact remains that CVT may lead to death; of 10 patients who died from HPN-related complications in a British study, 3 died of CVT. 5 Furthermore, these reports almost certainly underestimate the true incidence of this problem for several reasons. During central parenteral nutrition, CVT occurs relatively early at 12 or 35 days. 6,7 Although training for HPN only takes a mean time of 14 days, most patients who require this treatment often undergo parenteral feeding for prolonged periods in hospital during medical and surgical management of the underlying intestinal disorder. Pathogenesis

Potential hazards of excluded bowel and use of parenteral nutrition : A case report

This case demonstrates that excluded gut may be a reservoir for bacterial translocation and recurrent sepsis. Translocation may contribute to cholestatic hepatitis, and restoration of bowel continuity is fundamental to reversing these pathologic changes. It also emphasizes that parenteral nutrition even when used as interim supportive treatment is not without serious hazard.