Criteria for use of total parenteral nutrition administered by a central venous catheter in adults. Presbyterian Hospital, Albuquerque, New Mexico.

Criteria for a utilization review of total parenteral nutrition administered by a central venous catheter are presented. Areas covered include: indications and contraindications for use, appropriate monitoring criteria, complications related to parenteral nutrition, dosing, and outcome of therapy.

Use of separate insulin infusions with total parenteral nutrition.

The efficacy, safety, and cost effectiveness of treating total parenteral nutrition (TPN)-induced hyperglycemia with a continuous insulin infusion, separate from the actual TPN bottle, was evaluated. A patient was included in the study if his serum glucose was greater than 200 mg/dl at a TPN infusion rate of less than 75% of the calculated caloric goal. The insulin infusion was run into the central line with the TPN via a Y-connector. At the patient's caloric goal, the infusion was stopped and the insulin was added to the TPN bottle, after the glucose was in the 100-200 mg/dl range for 24 hr. Sixteen patients including five known diabetics were studied, with data gathered retrospectively through chart review. It was estimated that 7.3 liters of TPN per patient were saved, compared to the amount used when insulin was added to newly prepared bottles of TPN each time a dosage change was required. In our institution, this amounts to a savings of $395.00 per patient (including charges for materials and an infusion pump for the insulin infusion). We conclude that separate insulin infusion is a reasonable and cost-effective alternative when treating glucose intolerance in patients receiving TPN.

Nafcillin-induced neutropenia in two children.

Two cases of nafcillin-induced neutropenia in children are discussed. A seven-year-old girl was referred to the hospital after the pain and swelling in her foot persisted despite five days of oral penicillin VK therapy. Administration of intravenous nafcillin 150 mg/kg/day was started upon admission. The patient's leukocyte count was normal upon admission; further, her leukocyte and neutrophil counts were normal on the 10th and 17th days of hospitalization. After 22 days of nafcillin therapy, her leukocyte and neutrophil counts fell to 2300 and 162/cu mm, respectively. Three days after the nafcillin was discontinued, the leukocyte count was 5800/cu mm. The patient was given dicloxacillin 50 mg/kg/day, and had no recurrence of neutropenia. The second case involved a 28-month-old girl admitted to the hospital with fever, irritability, and skin rash. Her leukocyte count was normal upon admission. She received 10 days of penicillin G 100,000 units/kg/day, followed by 10 days of nafcillin 150 mg/kg/day, before neutropenia was discovered. On the ninth day of nafcillin therapy, here leukocyte and neutrophil counts were 4200 and 822/cu mm, respectively. Nafcillin was discontinued and cefazolin therapy was initiated at 100 mg/kg/day. Blood counts returned to normal, and there was no recurrence of neutropenia. Differential blood cell counts should be performed on patients receiving nafcillin, and, if neutropenia develops, nafcillin should be discontinued and treatment with a nonpenicillin antimicrobial considered.

Chloramphenicol hemodialysis clearance.

The purpose of this study was to evaluate the dialysis clearance and plasma protein binding of chloramphenicol in a chronic renal failure patient and an acute renal/hepatic failure patient undergoing hemodialysis. Predialysis, dialysis and postdialysis plasma samples were collected and analyzed. Plasma chloramphenicol levels declined slowly during hemodialysis with measured dialysis clearance rates of 21.2 ml/min (patient C.W.) and 24.2 ml/min (patient S.T.). The protein binding of chloramphenicol, determined before and 30 min after hemodialysis, was 40 and 25% (patient C.W.) and 44 and 35% (patient S.T.), respectively. The extent to which hemodialysis removes chloramphenicol from the plasma does not appear significant enough to warrant routine dosage adjustment. The clinical significance of protein binding alterations is discussed.