Normalization of Serum Lipase Levels Versus Resolution of Abdominal Pain: A Comparison of Preoperative Management in Children With Biliary Pancreatitis

BACKGROUND

Controversy exists over the timing of cholecystectomy for biliary pancreatitis in children. Some surgeons await normalization of serum lipase levels while others are guided by resolution of abdominal pain; however, there are minimal data to support either practice. We hypothesized that resolution of abdominal pain is equivalent in outcome to awaiting normalization of lipase levels in patients undergoing cholecystectomy for biliary pancreatitis.

METHODS

After institutional review board (IRB) approval, the medical record was retrospectively queried for all cases of cholecystectomy for biliary pancreatitis at our institution from 2007 to 2017. Patients undergoing chemotherapy, admitted for another cause, or who had severe underlying comorbidities like ventilator dependence were excluded. Patients were stratified into two cohorts: those managed preoperatively by normalization of serum lipase levels versus resolution of abdominal pain. Demographics, serum lipase levels, postoperative complications, cost of stay, readmissions, and return to the emergency department were collected and analyzed using multivariate regression.

RESULTS

Seventy-four patients met inclusion: 29 patients had lipase levels trended until normalization compared with 45 patients who had resolution of abdominal pain prior to cholecystectomy. Among the two cohorts there was no statistical difference in age, gender, race, ethnicity, or type of preoperative imaging used. Trended patients were found to have more serum lipase levels tested (8.5 ± 6.2 versus 3.4 ± 2.5, P < 0.0001). The trended lipase cohort was significantly more likely to require preoperative total parenteral nutrition (48% versus 11%, P = 0.007) and consequently a longer time before resuming a diet (10 ± 7.3 versus 4.6 ± 2.4 d, P < 0.0001). When comparing the two groups, we found no significant difference in the duration of surgery, postoperative complications, or readmissions. Lipase trended patients had a significantly longer length of stay compared with nontrended patients (11.5 ± 8.1 versus 4.2 ± 2.3 d, P < 0.0001) and had a higher total cost of stay ($38,094 ± 25,910 versus $20,205 ± 5918, P = 0.0007).

CONCLUSIONS

Our data suggest that in children with biliary pancreatitis, proceeding with cholecystectomy after resolution of abdominal pain is equivalent in outcomes to trending serum lipase levels but is more cost-effective with a decreased length of stay and decreased need for preoperative total parenteral nutrition.

Reconstructive operations for enteric and colonic fistulas: Low mortality and recurrence in a single-surgeon series with long follow-up

BACKGROUND

The aim of the study was to evaluate the outcomes of 100 consecutive patients undergoing reconstructive operation for enteric and colonic fistulas. These fistulas cause dramatic morbidity and profoundly diminish quality of life. Fistula takedown has been associated with high rates of recurrence.

METHODS

Consecutive patients undergoing definitive fistula reconstruction by a single surgeon were reviewed retrospectively. Major adverse outcomes included bowel leak, fistula recurrence, death, total parenteral nutrition dependence, and incidence of new stomas.

RESULTS

Among the 100 patients, median follow-up was 2.7 years. A total of 11 patients had postoperative leaks that evolved to 5 fistula recurrences. Of these patients 3 underwent successful secondary or tertiary takedown. The 30-day mortality rate was 1%, and the combined postoperative and fistula-related mortality rate at follow-up was 3%. New postoperative total parenteral nutrition dependence occurred in 2 patients (2%), and 9 (9%) had placement of a new stoma. Leaks were more frequent for patients who had a history of open abdomen than for patients who did not.

CONCLUSIONS

With minimal patient selection and a methodic approach to evaluation and management, we achieved a 96% fistula-free survival rate. Few patients acquired new total parenteral nutrition dependence or a new stoma. These results compare favorably with outcomes published elsewhere.

THE MANAGEMENT OF HYPERGLYCEMIA IN NONCRITICALLY ILL HOSPITALIZED PATIENTS TREATED WITH CONTINUOUS ENTERAL OR PARENTERAL NUTRITION

OBJECTIVE

Hyperglycemia is a common problem in hospitalized patients receiving artificial nutrition, and this development of hyperglycemia during parenteral nutrition therapy (PNT) and enteral nutrition therapy (ENT) increases the risks of hospital-related complications and mortality. This review aims to discuss the pathogenesis of hyperglycemia from artificial nutrition in the hospital, summarize current evidence on the treatment of hyperglycemia with insulin in these patients, and review current guidelines.

METHODS

A systematic literature review using PubMed and the Medical Subject Headings (MeSH) terms "hyperglycemia," "enteral nutrition," and "parenteral nutrition" were used to evaluate the current evidence available for treating noncritically ill patients with hyperglycemia who were receiving artificial nutrition.

RESULTS

The literature review showed that few randomized control trials exist regarding treatment of hyperglycemia in this cohort of patients, and the multiple retrospective evaluations that have addressed this topic provided varied results. In general, intravenous (IV) continuous insulin infusion offers the best glycemic control; however, this route of insulin administration is often burdensome for floor patients and their care teams. Administration of scheduled subcutaneous (SQ) insulin in patients on ENT or PNT is a safe and effective way to manage hyperglycemia, however limited data exist on an appropriate insulin regimen.

CONCLUSION

Further prospective, randomized control trials are necessary to determine the optimal treatment of hyperglycemia for patients receiving ENT or PNT.

ABBREVIATIONS

BG = blood glucose; CG = conventional glycemic control; ENT = enteral nutrition therapy; GIP = glucose-dependent insulinotropic polypeptide; GLP-1 = glucagon-like peptide 1; IG = intensive glycemic control; IV = intravenous; NPH = neutral protamine Hagedorn; PNT = parenteral nutrition therapy; SQ = subcutaneous; T2DM = type 2 diabetes mellitus; TDD = total daily dose; TPN = total parenteral nutrition.

Neonatal Outcome of the Late Preterm Infant (34 to 36 Weeks): The Singapore Story

INTRODUCTION

Late preterm (LP) neonates (34 to 36 weeks gestation) are often managed like term neonates though current literature has identified them to have greater complications. The primary objective of our study was to evaluate and compare morbidity and resource utilisation in LPs especially in view of paucity of Asian studies in this regard.

MATERIALS AND METHODS

A retrospective audit was carried out on 12,459 neonates born in KK Women's and Children's Hospital (KKWCH). The chief outcome measures were hypoglycaemia, hypothermia, respiratory morbidity, feeding problems and neonatal jaundice. Resource utilisation included neonatal intensive care unit (NICU) admission, mechanical ventilation, parenteral nutrition and length of hospitalisation.

RESULTS

Of 12,459 deliveries, 1221 (10%) were LP deliveries with a significantly increasing trend of 8.6% to 10% from 2002 to 2008 (P = 0.001). Neonatal morbidity in the form of hypoglycaemia (34 weeks vs 35 to 36 weeks vs term: 26% vs 16% vs 1%); hypothermia (5% vs 1.7% vs 0.2%); feeding difficulties (30% vs 9% vs 1.4%); respiratory distress syndrome (RDS) (4% vs 1% vs 0.1%); transient tachypnea of the newborn (TTNB) (23% vs 8% vs 3%) and neonatal jaundice (NNJ) needing phototherapy (63% vs 24% vs 8%), were significantly different between the 3 groups, with highest incidence in 34-week-old infants. Resource utilisation including intermittent positive pressure ventilation (IPPV) (15% vs 3.5% vs 1%), total parenteral nutrition/intravenous (TPN/IV) (53% vs 17% vs 3%) and length of stay (14 ± 22 days vs 4 ± 4.7 days vs 2.6 ± 3.9 days) was also significantly higher (P <0.001) in LPs.

CONCLUSION

LP neonates had significantly higher morbidity and resource utilisation compared to term infants. Among the LP group, 34-week-old infants had greater complications compared to infants born at 35 to 36 weeks.

Comparative outcomes of total parenteral nutrition use in patients aged greater or less than 80 years of age

OBJECTIVES

Total-parenteral-nutrition (TPN) can act as a bridge to enteral nutrition. The current study aims to explore the outcomes of TPN use in older adults which are at present poorly defined.

DESIGN, SETTING AND PARTICIPANTS

Data on 172 patients who received TPN between January-December 2011 were prospectively recorded and examined.

RESULTS

Mean age was 62.7 ± 16.8 years (12.8% ≥ 80 years). Those ≥ 80 years were less often male (31.8% Vs 57.3%, P=0.038) and had no history of hepatic dysfunction (0.0% Vs 16.7%, P=0.025). In those ≥ 80 years the indication was more often suspected ileus (40.9% Vs 13.3%, P=0.004). Patients ≥ 80 years developed hypertriglyceridaemia less frequently (7.7% Vs 36.2%, P=0.031). There was no difference in the duration of TPN administration, the rate of TPN line sepsis, serum electrolyte derangement or glycaemic control. Change in serum albumin over the course of treatment did not differ (≥ 80 Vs <80 years, -0.28 ± 0.62 mg/dL Vs -2.00 ± 1.57 mg/dL, P=0.323).

CONCLUSIONS

These data suggest TPN use is safe in patients aged ≥ 80 years and advanced age alone should not preclude TPN use.

[Changes in clinical condition and causes of death of inpatients with Duchenne muscular dystrophy in Japan from 1999 to 2012]

To elucidate changes in medical treatment for Duchenne muscular dystrophy (DMD) in Japan, we analyzed the clinical courses and causes of death of inpatients with DMD registered in the muscular dystrophy ward database of 27 hospitals in Japan specializing in muscular dystrophy treatment since 1999. The total number of hospitalized cases in 1999 was 873, which gradually reduced to 733 in 2012. The mean age of DMD patients in 1999 was 23.6 years old, while that was 30.1 years old in 2012, with patients 40 years and older accounting for 94 cases in the latest year. The respirator dependent rate gradually increased from 58.6% in 1999 to 86.1% in 2012. Artificial respiration therapy was introduced earlier in more recent years and the mean age in recent years was shown to be 17.2 years old. The oral nutritional supply rate in 1999 was 95.1%, which fell to 66.8% in 2012, while gastrostomy feeding gradually increased to 129 cases in 2012. The rate of clinical diagnosis of DMD was 52.3% in 1999 and decreased to 43.7% in 2012, which showed progress towards more accurate diagnosis of DMD. From 2000 to 2012, 521 deaths were reported, with approximately half of the causes heart related, followed by respiratory related. The mean age of death gradually increased to 32.4 years old in 2012 from 26.7 years old in 2000. The mean age of survival of all DMD patients was 37.5 years old. Progress in multidisciplinary medical care for respiratory failure, cardiomyopathy, nutritional problems, and other related factors has extended the lifespan of DMD patients.

Total colectomy for ulcerative colitis in children: when are we operating?

PURPOSE

Ulcerative colitis (UC) in children is frequently severe and treatment-refractory. While medical therapy is well standardized, little is known regarding factors that contribute to surgical indications. Our aim was to identify factors associated with progression to colectomy in a large cohort of pediatric UC patients.

METHODS

We conducted a retrospective cohort study using the Pediatric Health Information System database. We identified all patients under age 18 discharged between January 1, 2004 and September 30, 2011 with a primary diagnosis of UC. Primary outcome was odds of total colectomy.

RESULTS

Of 8,688 patients, 240 (2.8 %) underwent colectomy. Compared with non-operative patients, a greater proportion of colectomy patients received advanced therapies during admission, including corticosteroids (84.2 vs. 71.3 %) and biological therapy (25.4 vs. 13.6 %). Odds of colectomy were increased with malnutrition (OR 1.86), anemia (OR 2.17), electrolyte imbalance (OR 2.31), and Clostridium difficile infection (OR 1.69). TPN requirement also independently predicted colectomy (OR 3.86). Each successive UC admission significantly increased the odds of colectomy (OR 1.08).

CONCLUSION

These data identify factors associated with progression to colectomy in children hospitalized with UC. Our findings help to identify factors that should be incorporated into future studies aiming to reduce the variability in surgical treatment of childhood UC.

Contemporary 2-year outcomes of complex gastroschisis

PURPOSE

Outcomes of gastroschisis are influenced by associated intestinal complications. We present a detailed analysis of complex gastroschisis.

METHODS

A retrospective study of all patients with gastroschisis treated at 2 university neonatal intensive care units between January 1, 2001, and March 31, 2007, was performed.

RESULTS

Of 83 patients, 19 (23%) had complex gastroschisis, including atresias (68%), gangrene (37%), closing gastroschisis (32%), perforation (21%), strictures (21%), and volvulus (11%). Prenatal ultrasound did not predict complications. Fifty-three percent underwent primary closure. Duration of mechanical ventilation and total parenteral nutrition (TPN) was 14.4 ± 1.9 days and 90.7 ± 9.0 days, respectively. Enteral feeds started at 35.9 ± 4.6 days. Hospital stay was 104.4 ± 9.6 days. Patients underwent a median of 3 abdominal procedures (range, 2-5) before discharge. Ninety-five percent survived to discharge; 33% and 67% were discharged on TPN and gastrostomy feeds, respectively. Two-year survival was 89%, with 82% on full oral feeding, 12% on a combination of oral and gastrostomy feeding, and 1 patient (who received a liver/bowel transplant) on a combination of enteral and parenteral nutrition.

CONCLUSIONS

Complex gastroschisis continues to produce significant morbidity. However, most of the patients are TPN free by 2 years of age.

The gastroschisis prognostic score: reliable outcome prediction in gastroschisis

BACKGROUND/PURPOSE

Disease-specific outcome predictors are required for gastroschisis. We derived and validated a gastroschisis prognostic score (GPS) based on bowel appearance after birth.

METHODS

Visual scoring of bowel matting, necrosis, atresia, and perforation generated a novel gastroschisis bowel injury score recorded in a national database. Reweighting of score components by regression analysis led to assessments of model calibration and goodness of fit. The GPS was validated in subsequent cases.

RESULTS

Records from 225 infants were used for model derivation. Only intestinal necrosis independently predicted mortality by regression analysis (odds ratio, 11.5; 95% confidence interval, 4.2-31.4). Model recalibration identified that a GPS of 4 or more predicted mortality in 75% of nonsurvivors and 99% of survivors (P = .0001). A GPS of 2 or more demonstrated significantly worse survival outcomes compared with scores of 0 or 1 (length of stay: P = .011, days to first enteral feed: P = .013, days on total parenteral nutrition: P = .006). Model validation with 184 new patients yielded continued high-quality discrimination of outcomes. The GPS demonstrated "near-perfect" interobserver reliability between 2 surgeons (κ ≥ 0.86).

CONCLUSIONS

The GPS allows the accurate and reliable identification of high-risk groups for mortality and morbidity based on bowel appearance at birth. This information can drive discussions regarding family counseling, resource allocation, and new therapies for these patients.

Gastroschisis: one year outcomes from national cohort study

OBJECTIVE

To describe one year outcomes for a national cohort of infants with gastroschisis.

DESIGN

Population based cohort study of all liveborn infants with gastroschisis born in the United Kingdom and Ireland from October 2006 to March 2008.

SETTING

All 28 paediatric surgical centres in the UK and Ireland.

PARTICIPANTS

301 infants (77%) from an original cohort of 393.

MAIN OUTCOME MEASURES

Duration of parenteral nutrition and stay in hospital; time to establish full enteral feeding; rates of intestinal failure, liver disease associated with intestinal failure, unplanned reoperation; case fatality.

RESULTS

Compared with infants with simple gastroschisis (intact, uncompromised, continuous bowel), those with complex gastroschisis (bowel perforation, necrosis, or atresia) took longer to reach full enteral feeding (median difference 21 days, 95% confidence interval 9 to 39 days); required a longer duration of parenteral nutrition (median difference 25 days, 9 to 46 days) and a longer stay in hospital (median difference 57 days, 29 to 95 days); were more likely to develop intestinal failure (81% (25 infants) v 41% (102); relative risk 1.96, 1.56 to 2.46) and liver disease associated with intestinal failure (23% (7) v 4% (11); 5.13, 2.15 to 12.3); and were more likely to require unplanned reoperation (42% (13) v 10% (24); 4.39, 2.50 to 7.70). Compared with infants managed with primary fascial closure, those managed with preformed silos took longer to reach full enteral feeding (median difference 5 days, 1 to 9) and had an increased risk of intestinal failure (52% (50) v 32% (38); 1.61, 1.17 to 2.24). Event rates for the other outcomes were low, and there were no other significant differences between these management groups. Twelve infants died (4%).

CONCLUSIONS

This nationally representative study provides a benchmark against which individual centres can measure outcome and performance. Stratifying neonates with gastroschisis into simple and complex groups reliably predicts outcome at one year. There is sufficient clinical equipoise concerning the initial management strategy to embark on a multicentre randomised controlled trial comparing primary fascial closure with preformed silos in infants suitable at presentation for either treatment to determine the optimal initial management strategy and define algorithms of care.

Central venous catheter database: an important issue in quality assurance

BACKGROUND/PURPOSE

The purpose of this study was to analyze the factors that affect the longevity of central venous catheters.

METHODS

Comprehensive clinical data recorded during insertion and removal of totally implantable devices (TID) and tunneled lines (TL) from October 1988 to January 2009 were analyzed. Univariate and multivariate Cox proportional hazards regression models were used to identify clinical factors that predict catheter longevity.

RESULTS

Information was available for 1167 central venous catheter insertions in 858 patients, 648 TID and 509 TL. Univariate analysis detected longer device longevity in the following: TID longer than TL (P < .0001), catheter tip in the superior vena cava (SVC)/right atrial junction (P < .0001), and right side greater than left (P = .002). Shorter device longevity was observed in lines used for total parenteral nutrition (P < .0001) and young age (P < .0001). Multivariate model detected the following: hazard of removal for TID is 0.304 that of TL (P < .0001) and SVC is 0.525 that of other locations (P = .0005). Hazard decreases by 5.4% for every 1-year increase in patient age (P < .0004).

CONCLUSION

Multiple confounding factors were encountered. However, the single most important factor in catheter longevity that is influenced by the surgeon is tip location in the SVC/right atrial junction.

[Is there an indication for parenteral nutrition support in the terminally ill cancer patient?]

Cancer cachexia is mediated by cytokines affecting intermediate metabolism of energy, proteins, carbohydrate and lipid. It is aggravated by common therapeutic measures: surgery, chemotherapy and radiotherapy that reduce oral intake as well as increase catabolism. Enteral or parenteral nutrition support decreases the catabolic rate of the patient, helping the patient withstand the side effects of the therapeutic measures, but do not reverse to anabolism. Terminally ill cancer patients who are refractory to the different therapeutic measures need palliative care. Nutrition is a basic human right and is conceived by the patient and his family, as well as by the medical community and human society, to be vital for survival. We obviously make every effort to feed our cancer patients as long as they can tolerate food via the alimentary system. However, we are reluctant to administer parenteral feeding, due to fear of accelerated tumor growth, complications, cost and futility, thereby leading to unnecessary prolongation of suffering. However, there is a group of patients who, although they are not candidates for any antineoplastic therapy, are still in good physical and mental condition, with expected life spans of three months or more, suffering from conditions such as intestinal obstruction, fistulas or any condition which makes the preferred route of enteral nutrition impossible. In these specific patients, palliative parenteral nutrition should be considered. The functional status of the patient has to be reasonable (Karnofsky status > 50, ECOG< 3). The decision should be taken after careful multidisciplinary discussion. The patient and caregivers should be aware that this is not a cancer-specific treatment and probably will not prolong the patient's life. Total parenteral nutrition (TPN) in this situation is best if provided at the patient's home.

Validation of the oral mucositis assessment scale in pediatric cancer

BACKGROUND

Our objective was to examine the construct validity of the Oral Mucositis Assessment Scale (OMAS) in children receiving doxorubicin chemotherapy.

METHODS

Children between 6 and 18 years of age with cancer receiving doxorubicin-containing chemotherapy were included. OMAS was measured on days 7, 10, 14, and 17 after chemotherapy. Other measures of mucositis obtained concurrent with OMAS were the World Health Organization (WHO) mucositis scale and pain visual analogue scale (VAS). We also recorded analgesia administration.

RESULTS

Sixteen children were studied for 45 post-chemotherapy cycles and 156 OMAS assessments were performed. OMAS was moderately correlated with WHO scores (r = 0.56; P = 0.0006) whereas correlation with the pain VAS was fair (r = 0.37; P = 0.002). OMAS also had fair correlation with the number of doses of topical analgesia (r = 0.43; P = 0.001) and with the cumulative dose of opioid analgesia (r = 0.38; P = 0.003).

CONCLUSIONS

The OMAS is valid for use in mucositis clinical trials for children at least 6 years of age.

[Clinical features and prognosis of terminally ill patients in a geriatric long-term care hospital with particular regard to the implications of artificial nutrition]

AIM

To clarify the clinical features of terminally ill patients in our hospital and elucidate the implications of administering artificial nutrition.

METHODS

Between April 2004 and March 2005, we assessed 155 patients who died in Nishimaruyama Hospital--a geriatric long-term care facility in Sapporo. We analyzed their clinical backgrounds on admission, the clinical course up to the terminal stage of the illness, and the outcome of patients who received artificial nutrition.

RESULTS

In 95 patients, the main cause of the terminal illness was infection. The symptoms of these patients, such as cerebral infarction and cognitive dysfunction, deteriorated progressively, and eventually, eating became difficult. At this point, alternative methods for providing nutrition were discussed. For 60 patients (41 died of acute disease and 19, of advanced cancers), artificial nutrition was not considered. Artificial nutrition was administered to 63 patients; tube feeding was carried out in 30 patients. Because of repeated aspiration pneumonia, 14 of these 30 patients eventually underwent intravenous hyperalimentation (IVH). Thirty-three patients directly underwent IVH. Thirty-two patients did not undergo any feeding course. The mean survival times of the tube feeding and non-artificial nutrition groups were 827 and 60 days, respectively. The difference in the survival times was statistically significant.

CONCLUSION

The outcome of patients who were placed on tube feeding was good. This may be because we selected those patients considered most suitable for tube feeding or IVH. The criteria that were used to select an appropriate method for providing nutrition varied, although the patients in our hospital requested palliative care.

Clinical features of head and neck cancer patients with methicillin-resistant Staphylococcus aureus

CONCLUSIONS

The risk factors for methicillin-resistant Staphylococcus aureus (MRSA) detection in head and neck cancer patients are the duration of hospitalization, intravenous hyperalimentation, prior antibiotic use, and the coexistence of other pathogens.

OBJECTIVES

To shed light on the clinical characteristics of MRSA-positive inpatients with head and neck cancers. The secondary goal was to evaluate risk factors for MRSA detection in comparison with methicillin-sensitive S. aureus (MSSA).

PATIENTS AND METHODS

Sixty-one consecutive inpatients with head and neck cancers with S. aureus detection were analyzed based on their medical records. The antimicrobial susceptibility of isolated S. aureus was tested by the broth microdilution method.

RESULTS

MRSA and MSSA were detected in 46 (75.4%) and 15 (24.6%) of the 61 patients, respectively. There was no significant difference in the male/female ratio, age, primary site, comorbidity, cancer stage, cancer treatment, or 5-year survival rate between the MRSA and MSSA groups. Compared with the MSSA group, the MRSA group had significantly longer hospitalization periods and intervals between admission and MRSA detection, as well as significantly greater likelihood of intravenous hyperalimentation, prior antibiotic use, and co-isolation of other pathogens. Isolated strains of MRSA were thoroughly sensitive to vancomycin and arbekacin and moderately sensitive to minocycline.

[Selenium and cardiovascular disease: selected issues]

The paper presents current knowledge of the role of selenium in the development of cardiovascular system disease (CSD). Already known mechanisms of selenium action in the cardiovascular system are described, whilst underlining the fact that they do not explain all relevant observations and need to be clarified by more studies. Clinical, epidemiological, and experimental studies devoted to the relationship between the progression of CSD and selenium status indices are then reviewed. It could be expected that any explanation of the pathophysiological mechanisms of the influence of tobacco smoking (as one of the classical risk factors for CSD) on selenium status might help to bring about a better understanding of the progression of cardiovascular disorders. Based on studies conducted on animal models, the role of selenium in the antioxidant defense of cardiac muscle is described. Particular attention is paid to a dilated cardiomyopathy known as Keshan disease, for which it has been shown that selenium deficiency is an environmental factor predisposing to the onset of this disease. Similar symptoms of cardiomyopathy are also observed in patients on total parenteral nutrition and patients with AIDS.

Neonatal short bowel syndrome: a cohort study

BACKGROUND

To date, our knowledge of morbidity and mortality in neonatal short bowel syndrome (SBS) is based on individual case series. Shortcomings of the published literature include long patient recruitment time, selection bias, variable SBS definitions, failure to account for gestational age, and incomplete follow-up. By applying more rigorous methodology, our aim was to determine outcomes of SBS neonates compared with a control group of neonates without SBS.

METHODS

A cohort study of all neonates with abdominal pathology requiring laparotomy between January 1, 1997, and December 31, 1998, with observation through July 1, 2001. Short bowel syndrome was defined as patients requiring parenteral nutrition for more than 42 days or residual small bowel length of less than 25% predicted by gestational age. Student's t test, Mann-Whitney U test, and chi2 were used where appropriate. Kaplan-Meier curves were used to determine cumulative survival. Covariates important in the development of SBS were examined using forward step-wise logistic regression.

RESULTS

There were 175 patients (with SBS = 40, without SBS = 135) with a mean gestational age of 30.7 +/- 4.6 weeks vs 35.9 +/- 4.8 weeks, respectively (P < .0005). The patients with SBS suffered significantly more morbidity than the group without SBS in all categories of investigation (surgical complications, septic events, central venous line complications, duration to adaptation and parenteral nutrition independence, cholestasis and liver failure, and duration of hospitalization). The case fatality rate was 37.5% in patients with SBS vs 13.3% in patients without SBS (P = .001). Most of the deaths were caused by liver failure or sepsis and occurred within 1 year from the date of surgery. Presence of an ileostomy (exp(B) = 12.29; P < .0005) and a residual small bowel length less than 50% of the original length (exp(B) = 26.84; P < .0005) were the only 2 variables in a logistic regression analysis found to be independently associated with the development of SBS.

CONCLUSION

This cohort study clearly illustrates the tremendous morbidity experienced by infants with SBS relative to other surgical neonates. Accurate estimates of the morbidity associated with SBS enables clinicians to appropriately counsel parents, allocate resources and initiate therapeutic trials.

Palifermin for oral mucositis after intensive therapy for hematologic cancers

BACKGROUND

Oral mucositis is a complication of intensive chemotherapy and radiotherapy with no effective treatment. We tested the ability of palifermin (recombinant human keratinocyte growth factor) to decrease oral mucosal injury induced by cytotoxic therapy.

METHODS

This double-blind study compared the effect of palifermin with that of a placebo on the development of oral mucositis in 212 patients with hematologic cancers; 106 patients received palifermin (60 microg per kilogram of body weight per day) and 106 received a placebo intravenously for three consecutive days immediately before the initiation of conditioning therapy (fractionated total-body irradiation plus high-dose chemotherapy) and after autologous hematopoietic stem-cell transplantation. Oral mucositis was evaluated daily for 28 days after transplantation.

RESULTS

The incidence of oral mucositis of World Health Organization (WHO) grade 3 or 4 was 63 percent in the palifermin group and 98 percent in the placebo group (P<0.001). Among patients with this degree of mucositis, the median duration of mucositis was 6 days (range, 1 to 22) in the palifermin group and 9 days (range, 1 to 27) in the placebo group. Among all patients, regardless of the occurrence of mucositis, the median duration of oral mucositis of WHO grade 3 or 4 was 3 days (range, 0 to 22) in the palifermin group and 9 days (range, 0 to 27) in the placebo group (P<0.001). As compared with placebo, palifermin was associated with significant reductions in the incidence of grade 4 oral mucositis (20 percent vs. 62 percent, P<0.001), patient-reported soreness of the mouth and throat (area-under-the-curve score, 29.0 [range, 0 to 98] vs. 46.8 [range, 0 to 110]; P<0.001), the use of opioid analgesics (median, 212 mg of morphine equivalents [range, 0 to 9418] vs. 535 mg of morphine equivalents [range, 0 to 9418], P<0.001), and the incidence of use of total parenteral nutrition (31 percent vs. 55 percent, P<0.001). Adverse events, mainly rash, pruritus, erythema, mouth and tongue disorders, and taste alteration, were mild to moderate in severity and were transient.

CONCLUSIONS

Palifermin reduced the duration and severity of oral mucositis after intensive chemotherapy and radiotherapy for hematologic cancers.

A nutrition support team led by general surgeons decreases inappropriate use of total parenteral nutrition on a surgical service

The purpose of this study was to decrease the number of inappropriate orders for total parenteral nutrition (TPN) in surgical patients. From February 1999 through November 2000 and between July 2001 and June 2002, the surgeon-guided adult nutrition support team (NST) at a university hospital monitored new TPN orders for appropriateness and specific indication. In April 1999, the NST was given authority to discontinue inappropriate TPN orders. Indications, based on the American Society for Parenteral and Enteral Nutrition (ASPEN) standards, included short gut, severe pancreatitis, severe malnutrition/catabolism with inability to enterally feed > or =5 days, inability to enterally feed >50 per cent of nutritional needs > or =9 days, enterocutaneous fistula, intra-abdominal leak, bowel obstruction, chylothorax, ischemic bowel, hemodynamic instability, massive gastrointestinal bleed, and lack of abdominal wall integrity. The number of inappropriate TPN orders declined from 62/194 (32.0%) in the first 11 months of the study to 22/168 (13.1%) in the second 11 months (P < 0.0001). This number further declined to 17/215 (7.9%) in the final 12 months of data collection, but compared to the second 11 months, this decrease was not statistically significant (P = 0.1347). The involvement of a surgical NST was associated with a reduction in inappropriate TPN orders without a change in overall use.

[Pharmaceutical procedures in patients under treatment with total parenteral nutrition]

OBJECTIVE

To describe and analyse pharmaceutical care activities, medication errors and/or drug-related problems in patients with total parenteral nutrition.

METHODS

A prospective study was carried out over a six-month period. All pharmaceutical care activities for patients in treatment with total parenteral nutrition were registered and classified. Daily patient medical and pharmacotherapy chart review plus patient interviews allowed the identification of medication errors and/or drug-related problems associated with both total parenteral nutrition and other pharmacological treatments.

RESULTS

During the study period, 49 patients received total parenteral nutrition. 415 pharmaceutical care activities were carried out, representing a median of 8 pharmaceutical care activities per patient (rank: 4-18). In 33 patients, at least one medication error was detected (n= 63), therefore representing 1 medication error per patient with total parenteral nutrition every 5 days. Most frequent errors were: wrong dose (n= 46, 73%), incorrect treatment duration (n= 9, 14.3%) and wrong drug (n= 5, 7.9%). All these errors originated a potential drug-related problem which affected indication in 50.8% of the cases; safety in 41.3% and effectiveness in 7.9%.

CONCLUSION

Results obtained during this study show a high demand for pharmaceutical attention in patients with total parenteral nutrition treatment. Identification and classification of medication errors and drug-related problems help to identify system points that can be improved, thus increasing assistential quality.

A multicenter, prospective, randomized, comparative evaluation of dual- versus triple-lumen catheters for hemodialysis and apheresis in 485 patients

BACKGROUND

The purpose of this study is to compare a new temporary triple-lumen catheter (TLC) for dialysis that has a third lumen devoted to fluid and medication administration or blood sampling with a marketed dual-lumen catheter (DLC).

METHODS

Four hundred eighty-five patients referred for acute hemodialysis or apheresis were randomly assigned to either a TLC or DLC in a multicenter, prospective, randomized trial.

RESULTS

Analysis of blood flow rates was completed on 464 patients (228 patients, DLC; 236 patients, TLC) with a total of 1,681 hemodialysis (808 treatments, DLC; 873 treatments, TLC) and 82 apheresis treatments (37 treatments, DLC; 45 treatments, TLC). During hemodialysis, a median achieved flow rate (AFR) of 267 mL/min was realized for both groups (P = 0.58). During apheresis, a median AFR of 72.5 mL/min (range, 50 to 150 mL/min) was achieved in the DLC group, and 87 mL/min (range, 60 to 150 mL/min), in the TLC group (P = 0.14). Three hundred ninety-three patients (193 patients, DLC; 200 patients, TLC) had blood and catheter tip cultures performed on removal, and catheter-related bloodstream infection (CRBSI) status was determined. Thirty-one patients (7.9%) had a CRBSI: 16 patients (8.3%), DLC; and 15 patients (7.5%), TLC (P= 0.77). Incidence densities of CRBSI were 12.4/1,000 DLC-days and 10.2/1,000 TLC-days (P = 0.59). The CRBSI incidence of 18.2/1,000 catheter-days for femoral sites was significantly greater than the 7/1,000 catheter-days for jugular sites (P = 0.02) and 6.6/1,000 catheter-days for combined jugular and subclavian sites (P = 0.01). In multivariate analysis, antibiotic use was the only factor related to CRBSI (odds ratio, 0.30; 95% confidence interval, 0.12 to 0.76). There were no statistically significant differences in rates of other complications between the 2 catheters.

CONCLUSION

Results show that the new TLC is similar to the marketed DLC.

Retinopathy of prematurity in VLBW and extreme LBW babies

OBJECTIVE

This is a hospital-based, prospective clinical study to determine the incidence, risk factors, and outcome of extreme low birth weight and very low birth weight pre-term babies with retinopathy of prematurity (ROP) at the Sultan Qaboos University Hospital, Oman.

METHODS

All babies with a birth weight =/< 1500 g and gestational age =/< 32 weeks admitted in the Neonatal Unit, were screened for ROP between 4 to 6 weeks of age and staged according to the international classification and were followed up until complete vascularization of the retina. Fifty nine babies formed the study group.

RESULTS

The overall incidence of ROP was 25.4% (15 out of 59), of which 6 babies had severe ROP and underwent cryotherapy/laser. All babies with ROP had a birth weight < 1250 g and were born before 31 weeks of gestation.

CONCLUSION

ROP is a multifactorial disease, the immature retina of the pre-term baby being the primary factor. Incidence and severity was inversely proportional to birth weight and gestational age. Multiple logistic regression analysis showed that sepsis and total parenteral nutrition to be highly significant risk factors. Repeated blood transfusions, hypotension and congenital heart disease with left to right shunt were seen to be considerably associated with the development of ROP. A decrease in overall incidence and severity of ROP was observed in this study.

Improved outcomes in the treatment of gastroschisis using a preformed silo and delayed repair approach

BACKGROUND/PURPOSE

The aim of this study was to critically evaluate the clinical outcomes of two different surgical treatment approaches for infants born with gastroschisis.

METHODS

The medical records of 65 infants with gastroschisis treated at one institution from 1991 to 2000 were available. Infants in group I (prior to December 1998) underwent attempted early repair of the gastroschisis defect on their first day of life. Infants in group II had delayed repair after the initial placement of a preformed silo.

RESULTS

Group I had 39 patients; group II had 26 patients. The two groups were equal with respect to maternal age, gestational age, and birth weight. Complete reduction and fascial closure were accomplished for 32 patients (82%) in group I and 25 patients (96%) in group II (P <.02). Median time on the ventilator was significantly less for group II (P <.0001). Infants in group II had shorter times until first postoperative feeding (P <.01) and full feedings (P <.006). Group II had fewer complications than group I (23% v 56%; P <.01). There appeared to be less necrotizing enterocolitis in group II. The average length of hospital stay was 14 days less for group II.

CONCLUSIONS

The use of a preformed silo initially followed by delayed fascial closure in infants with gastroschisis is associated with improved fascial closure rates, fewer ventilator days, more rapid return of bowel function, and fewer complications compared with attempts at initial early repair.

Wandel der perioperativen Therapie bei elektiven kolorektalen Resektionen in Deutschland 1991 und 2001/2002

BACKGROUND

To assess changes in perioperative treatment of patients undergoing elective colorectal resections, surveys were sent to all German surgical departments in 1991 and 2001/2002.

METHODS

1,207 chairmen of departments for general or visceral surgery were asked to answer a survey concerning the principles of perioperative treatment of patients undergoing elective colorectal resection. The results of this questionnaire were compared to a survey that had been performed in 1991.

RESULTS

616 chairmen (51.0%) responded to the survey (1991: 76.4%). In 2001/2002 preoperative parenteral alimentation was utilized routinely in only 10.3% (1991: 40.0%) of all hospitals. Preoperative i.v.-pyelography was used only in 24.7% of the hospitals (1991: 79.7%). Intraoperative testing of colorectal anastomoses was more common in 2001/2002 (63.7%) than in 1991 (40.1%). At the same time the incidence of "single-shot"-antibiotic prophylaxis increased from 24.0% to 70.4 %. Orthograde bowel lavage, perioperative antibiotic prophylaxis and postoperative parenteral alimentation were use as often in 2001/2002 as in 1991. Intraperitoneal drains were routinely inserted in most of the surgical departments after left-sided colonic resections (2001/2002: 86.2%; 1991: 88.2%) or rectal resections (2001/2002: 90.5%; 1991: 94.4%).

CONCLUSION

During the last decade, perioperative therapy for patients undergoing elective colorectal resection has changed substantially. Most of these changes occurred in the perioperative medical treatment. However, surgical traditions like intraperitoneal drainage are still very frequently utilized.

Home care during the pancytopenic phase after allogeneic hematopoietic stem cell transplantation is advantageous compared with hospital care

After myeloablative treatment and allogeneic stem cell transplantation (SCT), patients are kept in isolation rooms in the hospital to prevent neutropenic infections. During a 3-year period, patients were given the option of treatment at home after SCT. Daily visits by an experienced nurse and daily phone calls from a physician from the unit were included in the protocol. We compared 36 patients who wished to be treated at home with 18 patients who chose hospital care (control group 1). A matched control group of 36 patients treated in the hospital served as control group 2. All home care patients had hematologic malignancies and 19 were in first remission or first chronic phase. Of the donors, 25 were unrelated. The patients spent a median of 16 days at home (range, 0-26 days). Before discharge to the outpatient clinic after SCT, patients spent a median of 4 days (range, 0-39 days) in the hospital. In the multivariate analysis, the home care patients were discharged earlier (relative risk [RR] 0.33, P =.03), had fewer days on total parenteral nutrition (RR 0.24, P <.01), less acute graft-versus-host disease (GVHD) grades II-IV (RR 0.25, P =.01), lower transplantation-related mortality rates (RR 0.22, P =.04), and lower costs (RR 0.37, P <.05), compared with the controls treated in the hospital. The 2-year survival rates were 70% in the home care group versus 51% and 57% (not significant) in the 2 control groups, respectively (P <.03). To conclude, home care after SCT is a novel and safe approach. This study found it to be advantageous, compared with hospital care.

Audit of total parenteral nutrition in an adult surgical intensive care

INTRODUCTION

A preliminary one-year review of total parenteral nutrition (TPN) in the adult surgical intensive care unit (SICU) in view of its complications, cost and lack of consistent benefits in the critically ill.

MATERIALS AND METHODS

All the case records of patients receiving TPN in the SICU starting from first January to end December 1998 were studied.

RESULTS

Fifty patients received TPN during the study period. Four case records were unavailable. The indications for starting TPN were comparable with those set up by the Stanford University Hospital. Sepsis with gastrointestinal failure at 30.5% [95% CI, 17.7% to 45.8%] was one of the major indicators for TPN use and also the biggest contributor to mortality (50%) [95% CI, 35% to 65%]. Hyperglycaemia and line sepsis increased with duration of TPN use. Pneumonia, bacteraemia and wound infection peaked by the second week. Patients receiving TPN for inadequate and delayed enteral feeding fared better with 45.8% survival [95% CI, 30.9% to 61%]. None of the patients with polytrauma or malignancy cachexia died. 52.2% [95% CI, 37% to 67.1%] survived to be discharged from hospital. Caloric requirements were calculated using Harris-Benedect's equation and estimated using 30 to 35 kcal/kg/day. 64.3% were overfed and 50% received excessive non-protein calorie-to-nitrogen ratio. Ninety-eight per cent and 81% received less than the recommended amino-acid and glucose, respectively. Fifty-eight per cent received adequate lipids.

CONCLUSION

This audit highlights the shortcomings in TPN prescription and characteristics of the attendant complications. Efforts must be directed towards encouraging uniformity and level of practice standards.

Trends in the management and outcome of jejuno-ileal atresia

The aim of this study was to evaluate contemporary patterns of presentation and trends in the management and outcome of newborn infants with jejuno-ileal atresia at a regional paediatric surgical centre in the United Kingdom. The hospital neonatal surgical registry was used to identify patients with jejuno-ileal atresia (n = 83) admitted between 1976 - 1998, excluding those associated with gastroschisis. The clinical records were reviewed and antenatal information, patient demographics, associated anomalies, operative treatment, post-operative management and outcomes were analysed in three time periods to identify trends in management and survival: Group 1 1976 - 1982 (n = 32), Group 2 1983 - 1990 (n = 21), and Group 3 1991 - 1998 (n = 30). Overall survival was 90 %. The number of patients with associated anomalies were Group 1, 10 (31 %); Group 2, 7 (33 %); and Group 3, 11 (37 %). Cystic fibrosis was encountered in 4 (13 %), 1 (5 %) and 4 (13 %) patients, respectively. Resection with primary anastomosis was the definitive management in most of patients: Group 1, 25 (78 %); Group 2, 17 (81 %); and Group 3, 27 (90 %). Initial stoma followed by delayed primary anastomosis was performed in 14 infants; eight patients had divided stomas while 6 had Bishop-Koop stoma. Tapering was used in 10 patients (12 %) with proximal jejuno-ileal atresia. Parenteral nutrition was increasingly utilised over the three time periods studied. There were no deaths in Group 3 compared to 6 deaths in Group 1 and 2 in Group 2 (P = 0.02). Most of the deaths were due to overwhelming sepsis. Mortality did not correlate significantly with the TYPE of atresia, presence of associated anomalies or the need for long-term total parenteral nutrition. The overall complication rate in survivors was 18 %. In the infants undergoing Bishop-Koop operation the complication rate was 50 %. This study has shown a significant reduction in mortality from jejuno-ileal atresia, which may be attributed primarily to advances in perioperative management, including parenteral nutrition. Generous resection of the atretic segment with primary anastomosis is more frequently employed in preference to initial stoma formation. Cystic fibrosis remains an important co-morbid condition that must be excluded promptly in all newborns.

Prevalence of nosocomial infections in neonatal intensive care unit patients: Results from the first national point-prevalence survey

OBJECTIVES

Patients admitted to neonatal intensive care units (NICUs) are at high risk of nosocomial infection. We conducted a national multicenter assessment of nosocomial infections in NICUs to determine the prevalence of infections, describe associated risk factors, and help focus prevention efforts.

STUDY DESIGN

We conducted a point prevalence survey of nosocomial infections in 29 Pediatric Prevention Network NICUs. Patients present on the survey date were included. Data were collected on underlying diagnoses, therapeutic interventions/treatments, infections, and outcomes.

RESULTS

Of the 827 patients surveyed, 94 (11.4%) had 116 NICU-acquired infections: bloodstream (52.6%), lower respiratory tract (12.9%), ear-nose-throat (8.6%), or urinary tract infections (8.6%). Infants with infections were of significantly lower birth weight (median 1006 g [range 441 to 4460 g] vs 1589 g [range 326 to 5480 g]; P <.001) and had longer median durations of stay than those without infections (88 days [range 8 to 279 days] vs 32 days [range 1 to 483 days]; P <.001). Most common pathogens were coagulase-negative staphylococci and enterococci. Patients with central intravascular catheters (relative risk = 3.81, CI 2.32-6.25; P <.001) or receiving total parenteral nutrition (relative risk = 5.72, CI 3.45-9.49; P <.001) were at greater risk of bloodstream infection.

CONCLUSIONS

This study documents the high prevalence of nosocomial infections in patients in NICUs and the urgent need for more effective prevention interventions.

[The quality of the care in parenteral nutrition: the benefits after the incorporation of a nutritional support team]

GOALS

The purpose of the study was to analyze the quality of the prescription and follow-up of the total parenteral nutrition (PNT) before and after the incorporation of a nutritional support team (NST).

MATERIAL AND METHODS

A random sample of 96 patients was selected retrospectively, with 48 prior to the incorporation of the NST (the Non-NST group) and 48 after its incorporation (the NST group), to whom TPN was prescribed. The following points were assessed: 1. The existence of a minimum analytical and nutritional assessment, prior to the incorporation of TPN; 2. The follow-up of the same.

RESULTS

The average duration of TPN per patient was 13.8 days without differences between the two groups. There is a written record of the weight and height in 15% and 10% of cases, respectively, in the Non-NST group as opposed to 100% and 99% in the NST group (p < 0.0001). Prior to the incorporation of the NST, the nutritional requirement was not verified in any patients (0%) as opposed to 97% afterwards. Statistically significant differences were detected in the measurement of albumin prior to the start of TPN (p < 0.01). During the analytical follow-up, statistically significant differences were detected in the measurement of: blood tests (p < 0.05); basic biochemistry (p < 0.01); general biochemistry, magnesium, zinc, pre-albumin, transferrin and nitrogen balance (p < 0.0001). In the TPN follow-up, the Non-NST group did not change any of the components contained in it (in terms of volume, macro or micronutrients) in 81% of patients, while 17% had one change and 2% had 2 or more changes, as opposed to 27%, 42% and 31%, respectively in the NST group (p < 0.0001). There were no significant differences in metabolic complications between the two groups.

CONCLUSIONS

The implementation of a nutritional support team in charge of the prescription and follow-up of TPN has notably improved the quality of these follow-up studies.

[The effect of fatty emulsions with distinct triglyceride compositions on the lipid metabolism of the septic patient]

OBJECTIVE

To assess the effects on the intravascular lipid mechanism of fatty emulsions with an identical lipid concentration and a different triglyceride composition administered as part of the total parenteral nutrition (TPN) in septicemic patients hospitalized in the intensive care unit (ICU). One emulsion will be made up of long chain triglycerides, LCT (20% Intralipid) (group I) and the other will be made up by a mixture of medium- and long-chain triglycerides, MCT/LCT (1:1) (20% Lipofundina) (group II). AREA: Vall d'Hebrón General University Hospital. Intensive care unit, Biochemistry laboratory, nutritional support unit, and Department of Pharmacy.

PATIENTS

12 septicemic patients who required TPN were studied, and these patients were randomly given one of the two lipid emulsions for a five day period. Prior to initiating the TPN and before ending it, blood samples were drawn for the analysis of the lipoprotein components VLDL, LDL, and HDL isolated by ultracentrifugation, and the basic lipid and nutritional parameters.

RESULTS

The baseline statistical analysis shows that even though both groups are not comparable, the composition of the VLDL, LDL, and HDL lipoproteins differs from the reference values. After five days of TPN, the metabolic behavior of the groups is different, in group I the concentrations of reactive C protein (RCP) decreased as did the HDL phospholipids, while group II presented an increase in the plasma triglyceride levels, the VLDL cholesterol, the LDL triglycerides, and the HDL proteins.

CONCLUSIONS

Septicemic patients present in altered lipoprotein pattern that tends to normalize after 5 days of lipid emulsions administration.

Caregiving effectiveness in families managing complex technology at home: replication of a model

BACKGROUND

Original testing of the Caregiving Effectiveness Model, in a randomly drawn national sample (n = 111) of family caregivers, explained variance in the home care outcomes of patient physical condition, technology side effects, and quality of life. The variables in the resulting model reflected the challenges specific to family caregivers managing complex home care for the growing populations of technology-dependent patients.

OBJECTIVE

To seek further empirical verification of the relationships among home care outcomes and the variables in the original trimmed model.

METHOD

Data were collected from family caregivers (n = 31) and adult patients (n = 31) requiring lifelong daily total parenteral nutrition (TPN) infusion technology for nonmalignant bowel disease. Hierarchical regression was used with variables entered in the two stages that coincided with the model configuration of Caregiving and Adaptive concepts, with a criteria of alpha = .05 at a power of > .80.

RESULTS

The model variables explained variance in all four outcomes. Specifically, Caregiving and Adaptive concept variables contributed to the explained variance in quality of life of both caregivers (R2 = .559, F = 4.65, p = .003) and patients (R2 = .464, F = 5.17, p = .04). Variance in patients' physical condition (R2 = .345, F = 6.37, p = .032) and the technological side effects outcomes (R2 = .357, F = 3.60, p = .018) were accounted for by variables in the model.

CONCLUSIONS

In this sample, the Caregiving Effectiveness Model concepts accounted for significant variance in home care outcomes (quality in patients' and caregivers' lives, patients' physical condition, and technological side effect). Longitudinal study of this sample will determine if variables explain variance over time, as in the original model testing.

Gastroschisis: a ten year review

From 1983 to 1993, 30 cases of gastroschisis were managed at the Mayaguez Medical Center. Ninety percent of these patients underwent primary closure of their abdominal wall defect. Three of 30 patients (10%) required silastic or goretex silos with final closure in an average of 8 days. There was no sex predilection, the average birth weight was 2.4 kg and the mean gestational age was 36 weeks. Thirty percent had associated anomalies, the majority were intestinal atresia, and/or undescended testicles. Twenty one (70%) of infants were delivered vaginally. Nine children (30%) were delivered via cesarean section. Four cesarean sections were done solely after prenatal ultrasonic identification of gastroschisis. There was no improvement in hospital stay, complications, or days until enteral feeds were tolerated when vaginally delivered patients were compared to those born by c-sections. In seven patients mesh sheeting (Marlex) was used for closure of late hernia defects. The mean hospital stay was 50 days and the mean time to enteral feedings 20 days. All patients required postoperative mechanical ventilation for an average of 4 days. There was no mortality. Our data and review of the literature do not support gastroschisis prenatal diagnosis as a sole indication for cesarean section. Our data showed favorable prognosis for most babies. Primary fascial closure can be accomplished safely in the majority of patients. No single operative strategy is ideal for all patients, and treatment of individual defects should be tailored to the degree of visceroabdominal disproportion.

Total enteral nutrition versus total parenteral nutrition during pediatric extracorporeal membrane oxygenation

OBJECTIVE

To evaluate the adequacy, tolerance, and complications of enteral nutrition, compared with parenteral nutrition, in pediatric patients requiring extracorporeal membrane oxygenation (ECMO).

DESIGN

A retrospective chart review of all patients placed on extracorporeal life support from January 1991 through December 1995.

SETTING

Medical/surgical pediatric intensive care unit at Egleston Children's Hospital, a tertiary care pediatric center.

PATIENTS

Twenty-nine consecutive pediatric patients who required ECMO and were provided nutritional support, either enterally or parenterally. Group A consisted of 14 patients who were provided nutritional support using total parenteral nutrition. Group B consisted of 15 patients. Two patients were excluded from group B because their ECMO run was <36 hrs, leaving insufficient data for analysis. The remaining 13 patients were provided total enteral nutrition during ECMO.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Both groups were similar in age, weight, pre-ECMO oxygenation index, alveolar-arterial oxygen difference, type, and duration of ECMO (p = NS). Comparison of percent ideal body weight on admission did not show a statistical difference between groups A and B (p = .883). There was no difference between the two groups in the time needed to achieve caloric goal (p = .536) from the initiation of ECMO. No complications were associated with the utilization of enteral feedings. Savings for the nutritional supplement was estimated to be $170 per day for the enterally fed group. The percentage of patients surviving was higher in the enterally fed patients compared with the parenterally fed group (79% vs. 100%), although this difference was not statistically significant (p = .47).

CONCLUSIONS

Enteral nutrition in patients receiving either venoarterial or venovenous ECMO is well tolerated, provides adequate nutrition, is cost effective, and is without complications, as compared with parenteral nutrition. These data suggest that total enteral nutrition can be safely administered for nutritional support in pediatric patients undergoing either venoarterial or venovenous ECMO.

Patterns and problems of adult total parenteral nutrition use in US academic medical centers

OBJECTIVE

To determine the pattern of total parenteral nutrition (TPN) use in US academic medical centers because TPN in adults may be associated with complications related to excessive glucose (dextrose) administration and a respiratory quotient greater than 1.0.

DESIGN

Two surveys of the University HealthSystems Consortium (n = 106, 74 members and 32 network partners using TPN) to determine TPN formulas and amounts of TPN nutrients given to 2 hypothetical abdominal trauma patients (1 man and 1 woman), each of whom weighed 70 kg.

MAIN OUTCOME MEASURES

Amounts of dextrose, amino acids, and fat and rates of administration of TPN.

RESULTS

In the first survey, 80% (59/74) of members and 41% (13/32) of network partners of the University HealthSystems Consortium reported using TPN formulas with more than 20% dextrose; half used 25% dextrose. In the second survey, the mean (+/-SD) TPN dextrose concentrations were 190+/-43 and 170+/-45 g/L (902+/-204 and 807+/-214 mmol/L), with amino acid concentrations at 40 to 50 g/L, in the male and female patients, respectively. The amounts of amino acids and glucose given, when referred to body cell mass in the male and female patients, were equivalent. In 26% (22/86) of the institutions surveyed, the amounts of glucose given in TPN were high enough (>4.48 mg/kg per minute) to produce a respiratory quotient greater than 1.0. A standard TPN formula was derived as 4.25% amino acids, 15% dextrose, and 20% fat emulsion, at a rate to provide required calories.

CONCLUSION

Excessive TPN glucose administration, found in at least one fourth of US academic medical centers, suggests use of a TPN formula with no more than 15% dextrose, administered at a rate to provide no more than 4 mg/kg of glucose per minute.

[The effect of intravenous amino acids in total parenteral nutrition on the healing of experimental colonic anastomoses in the rat]

The authors present a study in two groups of Wistar rats, which were given two different parenteral nutritions with two different amounts of proteins, during different periods of time (4, 7 and 11 days), with the objective of evaluating their influence on the healing of a colonic anastomosis which was performed prior to the initiation of the TPN. To asses the condition of the colonic anastomosis, we studied the rupture pressure of the colon containing the anastomosis, the hydroxyproline concentration of said anastomosis, and the histological study of the same. The results indicate that the group of animals which were fed with a hyperproteinic diet during a longer period of time, showed a better degree of healing than the rest of the study groups.

[An infection study of total parenteral nutrition catheters for Y-site drug administration]

When faced with the frequent use of parenteral nutrition (TPN) and the multiple problems which the maintenance of venous pathways presents, we initiated this study to try and show that the use of TPN catheters for the perfusion of drugs in "Y", does ot increase the incidence of infection. 70 patients subjected to TPN were studied, divided into 3 groups: I: TPN with exclusive use catheter (23 patients). II: TPN with a catheter through which antibiotic medication is administered in "Y" (22 patients). III: TPN with a catheter through which non-antibiotic medication is administered in "Y" (25 patients). Despite there being no extra manipulation in group I, when applying Cramer's "Y" we did not find any significant differences between the three groups as to incidence of infection. When relating the variables of infection and number of manipulations by means of chi-squared, we did not find significant differences either. There is no increase in the incidence of infection with the increase of manipulation. When we relate the variables of infection and number of days of treatment with TPN by chi-squared, we did not find significant differences either. There were no more infections of the catheters with more days of treatment. Neither did we find significant differences with respect to the number of manipulations, according to the calculation done by the Student T-rest, between groups II and III. Therefore, we have reached the conclusion that although the use of TPN for the administration of other drugs should not be used indiscriminately, it is absolutely valid for concrete cases, with a difficulty of multiple venolysis, as long as the drugs that shall be administered are stable with TPN and as a long as the norms form the correct administration and the aseptic techniques are observed.

A prospective audit of total parenteral nutrition at a major teaching hospital

OBJECTIVE

To examine patterns of use and clinical outcomes of total parenteral nutrition (TPN).

DESIGN

A prospective six-month audit (December 1992-June 1993).

PATIENTS AND SETTING

All inpatients administered TPN at a metropolitan teaching hospital during the audit period.

MAIN STUDY MEASURES

Process measures included data about TPN initiation (bodyweight, period not receiving oral/nasogastric feeding, serum albumin level, compliance with hospital guidelines), TPN delivery data (kilojoules, and nutrient and electrolyte content), and bases for cessation or changes of TPN (biochemistry data, gastric and intestinal function). Outcome measures included body mass change, infection rate, detection of biochemical abnormalities, and death.

RESULTS

During the audit 168 consecutive patients received 175 TPN courses. These patients were followed until discharge or death; 49 patients (29%) died. Intensive care units accounted for 57.7% of TPN use. Deviations from approved hospital guidelines for initiation of TPN were common. Only a minority of patients were malnourished on objective audit criteria; 18% of men and 13% of women were underweight by body mass index criteria and 36% were malnourished when serum albumin level (< 30 g/L) was considered. Early initiation of TPN outside accepted guidelines was common. Complications included bacteraemia (9.1% of patients tested) and catheter-tip sepsis (55.2% of 87 catheters tested). Four patients died; line sepsis caused one death and probably a further two. The incidence of glucose intolerance was 36.5%, and 25% had markers of abnormal liver function.

CONCLUSIONS

TPN use is associated with a high risk of morbidity, and a 1.7% mortality. We recommend better patient selection for TPN, more appropriate use of enteral feeding, better infection control procedures, avoidance of substrate overload (particularly glucose), and earlier change to enteral nutrition.

Nutritional support in intensive care units in England and Wales: a survey

OBJECTIVE

To assess current practice in nutritional support in intensive care units (ICUs) in England and Wales.

DESIGN

A three-section questionnaire about feeding practice was sent to all adult ICUs in England and Wales; this requested information on nutritional support provided for all patients during a single designated 24-h study period.

RESULTS

66% of the questionnaires were completed and returned. 43% of patients received nutritional support. Of these, 46% received only parenteral nutrition, 34% only enteral nutrition, 4% received sip feeds and the remaining 16% received more than one form of feeding. 81% of patients fed by the nasogastric route had a large-bore tube in place. More than 40% of patients were fed parenterally via the central route, of these 54% had a dedicated feeding line.

CONCLUSIONS

Despite the complications of central venous feeding and the advantages of and developments in enteral feeding these findings suggest there could be further improvement in our provision of nutrition for the critically ill patient.

A profile of nutritional practices and its cost in an intensive care in India

In a retrospective study fifty patients admitted to a combined medical and surgical intensive care unit were surveyed to see the pattern of nutritional support. The routine practices of initial assessment and monitoring of the nutritional state, ordering and technique of feeding, routes of administration and complications were noted over a 3 week period. This gives an idea of the pattern of care and problems associated with nutritional support of the critically ill in this part of the world. The average cost of parenteral nutrition for three weeks was approximately Rs. 25,960 ($865 approx.) per patient.

Perioperative use of total parenteral nutrition. Variations in guidelines and practice in three Norwegian hospitals

In a cross-sectional, retrospective study of 604 cases, variations among three Norwegian hospitals in use of perioperative parenteral nutrition (TPN) after gastrointestinal surgery was determined. Postoperative TPN rates were 25%, 34% (p = .05) and 56% (p < .0001), respectively. However, a substantial part of the variation was explained by differences in patient characteristics.

[Quality control of total parenteral nutrition in the 1991-1992 biennium]

OBJECTIVE

To assess the degree of compliance with standards defined for Total Parenteral Nutrition (TPN) quality control in our hospital in the two-year period 1991-1992.

MATERIAL AND METHODS

All available information was assessed concerning 52 patients (32 men and 17 women) for whom a TPN course was prescribed in relation with certain pre-set indications. These patients received a total of 1140 TPN units with the TPN lasting an average of 21.9 days (range, 1-73 days). Monitoring was done by the Nutrition and Diet Section. The degree of compliance was assessed with the standards model proposed by the Providence Medical Center, Portland (USA) (PMCP) with 24 parameters (PM): indications, initiation in the first 24 hours, nutritional assessment in the first 24 hours, period of the TPN, metabolic complications (14 PM), septic complications (3 PM), nutritional consequences (2 PM) and TPN losses. All parameters were appraised and admitted, except for urea, which was corrected to standard values of our Laboratory (< 44 mg/dl), with Transferrin evaluation instead of iron binding capacity (TIBC), taking as compliance standard a figure of > 190 mg/dl. All analytical calculations were carried out in our Central Laboratory Service.

RESULTS

Of all the parameters, the following were discarded, not being calculated on a routine basis: total CO2, serous magnesium, urinary uric nitrogen, nitrogen balance, positive hemocultures, catheters and TPN losses. Levels of compliance varied between 31.9% and 100%, with 8 parameters within the standards (Initiation, 100%; evaluation in first 24 hours, 100%; extent, 100%; creatinine, 100%; total bilirubin, 92.2%; cholesterol, 99.5%; transferrin, 35.9%). Seven parameters fell short (Na, 88.1%; K, 92.9%; Cl, 89.3%; Urea, 54.4%; Glucose, 96.4%; P, 94.1%; Triglycerides, 71.9%).

CONCLUSIONS

We infer from our study that there is a need to make use of a large part of the indicators described in the literature as indicators for quality guarantee of a TPN program, and the use of new parameters must be assessed in normal monitoring.

Improved total parenteral nutrition therapy management by a nutritional support team

This study was performed to identify and document the benefits associated with a multidisciplinary consult-based nutritional support team. The adequacy of nutritional support and incidence of metabolic complications were prospectively studied in 28 adult patients receiving total parenteral nutrition in a large private tertiary care institution during a 2-week period. Estimated daily caloric and protein requirements were met significantly more often in patients followed by our NST than in control group patients. Chloride and bilirubin abnormalities occurred significantly less often in the NST group than in the control group. The incidence of blood urea nitrogen, creatinine, and glucose abnormalities were also decreased in the NST patients, but these differences were not statistically significant. Patients followed by the NST were more likely to receive adequate nutrition and experience fewer metabolic abnormalities than when TPN therapy was guided solely by a physician.

[Total parenteral nutrition in critical patients. The metabolic-nutritional aspects and effects on immune function of 2 different isocaloric-isonitrogenous regimens]

The aim of this investigation was to compare, in a randomized short-term study the effects on some parameters evaluating lipid metabolism, nutritional status and immune function of two different patients. Particularly, the influence of the intravenous (i.v.) infusion of a fat emulsion on above-mentioned parameters was evaluated. The two regimens (G and GL) were isocaloric (about 30 kcal.kg-1.d-1 non protein energy) and isonitrogenous (about 0.27 g.kg-1.d-1 nitrogen); the only difference was the source of non-protein calories administered. Regimen G consisted of glucose-based TPN (100% of non-protein energy as glucose) whereas, in regimen GL (glucose-lipid-based TPN), the 55% of non-protein caloric supply was given as glucose and 45% as lipids. 9 of the patients were randomly assigned to receive regimen GL (group GL) and 8 to receive regimen G (group G). TPN was delivered through a central vein catheter for 8 days; during this period no hepatic or metabolic complications have been observed. Clinical and laboratory tests were performed at day 0 (enrollment), at day 4 (after 4 days of TPN) and at day 8 (at the end of TPN). Both regimens of TPN were able to induce an improvement of the nutritional status and serum prealbumin (TBPA) significantly increased in all patients (p < 0.05). The results of the immune measurements showed that no significant change in immune function during the administration of either regimen occurred. However, in group GL, we observed a slight, non significant change in the percentage numbers of T-cells subpopulations that resulted in a decrease in the ratio of helper to suppressor T-cells (H:S). Serum lipids and lipoprotein profile didn't change significantly in group GL. On the contrary, in group G, we observed a significant decrease in serum concentrations of HDL cholesterol (p < 0.05), LDL cholesterol and apo A1 (p < 0.01) while total cholesterol remained unchanged; a non significant rise in serum triglyceride also occurred, These results show that the two regimens had a similar impact on nutritional status in both groups. The i.v. infusion of the fat emulsion didn't alter lipid profile and was not associated with an impairment of some aspects of the immune function. In conclusion, our results confirm that fat emulsions represent an important component of i.v. nutritional support regimens and should continue to be used when and where indicated in short-term TPN. However, long-term effects of i.v. infusion of fat emulsions on the immune systems should be further investigated, in a more substantial number of patients.

[Total parenteral nutrition in the absence of kidney function for the treatment of the complications of gastrointestinal surgery]

This is a preliminary report on an eight-year-old child with uremia (terminal renal failure) on chronic dialysis, that developed a postoperative high output small bowel fistula associated with sepsis and malnutrition. She was successfully treated with a Total Parenteral Nutrition (TPN) scheme including an amino acid solution with 60% essential amino acids and 40% non-essential amino acids, now available in Peru, without increasing the frequency of hemodialysis for a 72-day period on TPN. Attention is drawn to Nutritional Support Team Approach.

[The nutritional aspects in autologous bone marrow transplantation]

The use of total parenteral nutrition (TPN) in bone marrow transplant recipients is well recognized. These patients, as a result of treatment with chemotherapy and immunosuppressive agents, undergo catabolic stress. In stressed patients attention has been focused on the optimal calorie: nitrogen ratio of total parenteral nutrition formulations. Theoretically, TPN formulas of low calorie: nitrogen ratio impede body protein catabolism. In bone marrow transplant patients negative nitrogen balance may persist despite high nitrogen intake. The purpose of the present study is to determine the effect of increasing nitrogen intake on nutritional and metabolic parameters in bone marrow transplant patients. The metabolic effect of an increased nitrogen dose during TPN was studied in 33 bone marrow transplant patients, divided into 2 groups. Patients were given total parenteral nutrition formulas providing a protein intake of 1.4 +/- 0.2 g of protein/kg IBW/day for the first group, and 2.3 +/- 0.12 g of protein/kg IBW/day for the II group. Total calories, non protein and protein, were held constant at 40 kcal/kg IBW/day for all patients. Data have been calculated for 4 weeks starting from the first week pretransplant. As we had expected, the patients who are the object of the present study were well nourished at the time of hospital admission, confirming the description of bone marrow transplant recipients published by other transplant centers. Relative body weight, total serum protein, albumin, prealbumin and cholesterol were not significantly different at any study period.(ABSTRACT TRUNCATED AT 250 WORDS)

Total parenteral nutrition-associated cholestasis: clinical and histopathologic correlation

Cholestatic jaundice is the major complication of total parenteral nutrition (TPN) in infants and children. The pathogenesis of this syndrome is poorly understood. The aims of this study were: (1) to define the histologic liver injury in relation to the clinical course of infants on TPN and (2) to determine whether enteral feeding will reverse or halt these changes. We identified 31 infants treated for severe gastrointestinal disease for whom liver histology was available from 1987 to 1991. Clinical records and liver biopsy (23) or autopsy specimens (13) were reviewed. Five patients had biopsies at two subsequent operations. The clinical diagnosis was necrotizing enterocolitis (24), atresia or stenosis (3), midgut volvulus (2), Hirschsprung's disease (1), and sepsis (1). Twenty-one of 31 infants were premature and had a mean birth weight of 1,868 g. Twenty-five of 31 were on TPN and 28 of 31 had received some enteral feeding by the time of the biopsy. Enteral feeding was begun as early as possible in all infants even if continued TPN was necessary for full support. Cholestasis occurred in 71% of premature infants versus 22% of full-term babies. Infants with cholestasis had been on TPN for a longer time (37 days v 18) with a correspondingly shorter period of enteral feeding (17 days v 27). Mean total bilirubin level was 14 in patients with cholestasis and 5 in those without, but the bilirubin level did not correlate with the extent of histological injury and was frequently normal despite marked histological damage.(ABSTRACT TRUNCATED AT 250 WORDS)