Malnutrition-associated reactive hypoglycemia induced by TPN.

The availability and widespread use of TPN enables physicians to help patients in a way that had not been possible in the past. However, in order to best utilize this modality, we must be aware of potential hazards and metabolic complications. Many patients receiving TPN, particularly those receiving perioperative TPN, are malnourished to various extents, and careful monitoring of glucose metabolism is warranted to avoid malnutrition-associated reactive hypoglycemia.

Candida sepsis during total parenteral nutrition: An endogenous infection indicating the severity of patients' disease state.

Between 1986 and 1989 we encountered 33 episodes of candida sepsis among 1169 patients receiving TPN for a total of 23350 days (2.8% candida infection rate). Total hospital stay averaged 78 (range 10-230) days and patients received TPN for an average of 21.5 (range 3-83) days before developing candida sepsis. Candida sepsis developed in 8 patients (26.6%) hospitalised in an ICU; 6 patients (20%) receiving high doses of glucocorticoids, 5 patients (16.6%) treated by cytotoxic agents; 23 patients (76.6%) received various combinations of broad-spectrum antibiotics. The number of tubes going in or out numbered an average of 3.6/patient (peripheral and/or central I.V.; endotracheal; tracheostomy; urinary catheter; arterial line; abdominal or chest drains). 18 patients underwent 38 (2.1/patient) operative procedures. 20 patients (66%) suffered fron mono- or polymicrobial bacterial sepsis in addition to candida sepsis, 16 of them metachronously. Candida species isolated were C. albicans - 14 patients; C. tropicalis - 6 patients; C. parapsylosis - 6 patients; not specified - 4 patients. In addition to positive blood cultures we found positive candida cultures in urine, peritoneal cavity, chest cavity, wounds, respiratory tract, intravascular catheters, often in more than one site per patient. All patients were treated with Amphotericin at an average dose of 770 mg/patient. Mortality rate in patients with candida sepsis was 33%. TPN associated candida sepsis seems to be an endogenous self-infecting process in a select group of severely injured-infected-depleted-immunosuppressed patients and is thus completely different from the usual exogenous bacterial TPN associated sepsis. The major risk factors for fungaemia and candida sepsis are the combination of severe underlying disease state, multiple surgical interventions and intravascular lines, the use of broad spectrum antibiotics, TPN, injury and malnutrition associated immunosuppression, multiple tubes and catheters, and intra-abdominal or intra-thoracic infection.

[A decade of experience with home total parenteral nutrition].

Between August 1980 and October 1990 we treated 36 patients with home total parenteral nutrition (HTPN) with a cumulative treatment duration of 92 years. They included 14 females and 22 males ranging in age from newborn to 75 years, with a mean of 38 +/- 21. The 4 commonest indications for HTPN were short bowel syndrome (mainly due to mesenteric occlusion (50%), inflammatory bowel disease 14%), motility disorders (14%) and malabsorption (11%). All-in-one nutritional mixtures utilizing the big-bag technique were used for all patients. Broviac or Hickman catheters were implanted in 35 patients and an infusion port in 2. Infusions were administered during the night for 8-12 hours with a volumetric pump. 14 patients are still receiving HTPN (39%) while in 8 it was discontinued as they can maintain their nutritional status by the gastrointestinal route (22%). 14 patients have died (39%), 3 from HTPN-related causes (2 of sepsis and 1 of liver failure). Catheter-related sepsis was 0.42/year of HTPN. Other common complications were metabolic bone disease, deranged liver function and cholecystolithiasis. 80% were able to return to work, school, or housekeeping activities, or at least to take care of themselves and cope with HTPN unaided. Social rehabilitation was full or partial in 72% and only 29% were house-bound and needed major assistance. Patients with a poor life quality tended to be older and suffer from intestinal diseases as a manifestation of a systemic disorder, such as atherosclerosis or malignancy.(ABSTRACT TRUNCATED AT 250 WORDS)

Feeding jejunostomy for post-operative nutritional support.

Enteral feeding by tube jejunostomy, inserted during definitive surgery, was used in 19 adult patients operated upon in a 24 month period. Jejunostomy feeding was associated with a low rate of minor complications enabling delivery of adequate caloric and protein input shortly after major abdominal operations and up to 9 months later. We feel that the insertion of a regular size jejunostomy tube during surgery is a simple, brief and safe procedure which offers efficient and inexpensive nutritional support, and thus has an important role in the post-operative management of selected patients. It is also easily used in the home setting if needed.

Progressive bone loss during long-term home total parenteral nutrition.

Metabolic bone disease occurs in patients receiving prolonged home total parenteral nutrition (HTPN). We studied bone-mass status in 10 patients (seven males, three females, age 19-66 years) who had been receiving HTPN for 0 to 67 months (mean 24 months), mostly for short-bowel syndrome. Four patients had spinal osteoporosis on radiograms. The density of various bone components at the wrist was measured noninvasively using a novel technique based on Compton scattering effect. The density of the cancellous and cortical bone was decreased in nine and six patients, respectively. During a follow-up period of up to 19 months, a further significant decrease in the density of both bone components was found. We conclude that prolonged HTPN is associated with an ongoing bone diminution, affecting mainly the cancellous bone.