Recurrent sepsis in home parenteral nutrition patients: an analysis of risk factors.

Septicemia is the major cause of morbidity in home parenteral nutrition patients, accounting for approximately 70% of rehospitalizations. To identify risk factors, the incidence of infection was examined in 41 current home parenteral nutrition patients, 30 with short-bowel syndrome (including 16 with inflammatory bowel disease and 11 with bowel infarction) and 11 with chronic obstructive disorders. Management, which was followed for a mean duration of 78.6 months (range, 1 to 15 1/2 years), was standardized by protocol. Ten patients never experienced infection during the average follow-up of 61 months (range, 14 to 174 months), whereas seven patients experienced frequent infections during the mean follow-up of 77 months (range, 24 to 180 months). Significant distinguishing features in the frequent-infection group were younger age (45 +/- 12 vs 66.9 +/- 14.3 years, p < .05), Crohn's disease (in five of seven vs zero of 10 subjects, p < .05), jejunostomies (in seven of seven vs one of 10 subjects, p < .0005), and central vein thrombosis (in five of seven vs zero of 10 subjects, p < .05). A greater proportion of the frequent-infection group had poor catheter-care technique and more were smokers. One hundred fifty septicemias were confirmed by blood culture, giving an average infection rate of one every 31 months, 52% caused by Gram-positive organisms (chiefly coagulase-negative staphylococci and Staphylococcus aureus), 30% caused by Gram-negative organisms, and 16% caused by fungus (chiefly Candida albicans).(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous separation and migration of a metal splice segment of a repaired Hickman catheter.

Repairs to the external silicone central venous catheter segment are done to correct mechanical defects caused by natural wear and tear or traumatic catheter injury. The ability to repair a damaged catheter obviates the need for surgical replacement. Complications specific to repaired Hickman catheters have not been reported. We report a case in which the metal piece separated from the replacement segment of a Hickman catheter. This metal piece lodged 1 cm from the catheter entrance to the anterior chest and caused incomplete catheter occlusion.

Home parenteral nutrition--a 3-year analysis of clinical and laboratory monitoring.

We report a 3-year analysis (1986 to 1989) of the management of 63 home parenteral nutrition patients, 40 with short-bowel syndrome and 23 with chronic intestinal obstruction with or without intestinal resection. Intravenous fluid requirements varied from 0.9 to 6 L/day, and the content of glucose varied between 46 and 531 g/day, protein varied from .0 to 85 g/day, fat from .0 to 100 g/day, sodium from 37 to 695 mEq/day, potassium from 30 to 220 mEq/day, chloride from 60 to 760 mEq/day, and acetate from 0 to 200 mEq/day. Body weight was normalized and well maintained in the majority of patients, but using the strict definition of deficiency as the presence of one abnormal value during 3 years, more than half had abnormal plasma chloride, glucose, alkaline phosphatase, serum glutamic oxaloacetic transaminase, total protein, albumin, selenium, and iron concentrations, and more than a third had low calcium, magnesium, vitamin D, and vitamin C levels. Normochromic anemia was seen in 73% and high blood creatinine associated with low urine volumes in 42%. Most (78%) returned to relatively normal lifestyles, but employability was occasionally impaired by loss of third-party insurance coverage resulting from a therapy that may cost $100,000 per year. Overall mortality was low (5% per year), but 73% needed readmission to hospital, mainly for suspected catheter sepsis. The results indicate that home parenteral nutrition has allowed many patients to survive gut failure and return to work but problems with chronic fluid, electrolyte and micronutrient deficiencies, catheter sepsis, and insurance coverage often restrict optimal rehabilitation.

A randomized prospective trial comparing a defined formula diet, corticosteroids, and a defined formula diet plus corticosteroids in active Crohn's disease.

Although defined formula diets may be useful for initial episodes of Crohn's disease, the effects of these diets on subsequent attacks of Crohn's disease or in conjunction with corticosteroids are unknown. To evaluate these issues, we studied 27 patients in a randomized prospective trial. Ten patients received only prednisone (group I), nine received only a defined formula diet (Vital HN [high nitrogen]) (group II), and eight received a combination of prednisone and Vital HN (group III). At the time of entry into the study, the groups were similar with respect to age, sex, Crohn's Disease Activity Index, previous and current treatments, anatomic site of disease, and nutritional status. After 1 month of treatment, we noted seven successes (70%) and three failures in group I (prednisone only), three successes (33%) and six failures in group II (Vital HN only), and six successes (75%) and two failures in group III (combination therapy). Four patients randomized to receive only Vital HN were unable or unwilling to tolerate the defined formula diet. Of the five patients who were able to take the defined formula diet for 1 month, however, three (60%) were successfully treated. The patients who received prednisone (groups I and III) responded better than did the patients who received only the defined formula diet. These results may be attributable to the use of a nonelemental diet or the treatment of patients who were not experiencing an initial attack of Crohn's disease or who had previously received corticosteroids. The expensive and often poorly tolerated defined formula diets should not be considered as a substitute for standard therapy with corticosteroids in Crohn's disease.