Intravenous alimentation

The Use of Protein and Protein Hydrolyzates for Intravenous Alimentation Rolbert Elman... 

After infancy, coagulopathy due to dietary deficiency of vitamin K is extremely rare Vitamin K is present in many foods and also is synthesized by intestinal bacteria. Occasionally, the use of a broad-spectrum antibiotic may produce a hypoprothrombinemia that responds readily to small doses of vitamin K and reestablishment of normal bowel flora. Hypoprothrombinemia can occur in patients receiving prolonged intravenous alimentation. Patients on total parenteral nutrition should receive phylloquinone (1 mg/week, the equivalent of - 150 jig/day). 

Fat soluble vitamins require a much larger period for depletion in adults. However, low birth weight infants are born with relatively depleted stores of vitamin A in the liver, and supplementation probably should be given if total intravenous alimentation is to be continued for more than two weeks. 

TOTAL INTRAVENOUS ALIMENTATION IN LOW BIRTH WEIGHT PREMATURE INFANTS... 

Table I. Clinical Data Pertaining to Intravenously Alimented...

Table II. Data Pertaining to Technique of Intravenous Alimentation...

In this group of infants, total intravenous alimentation was continued for 5 to 24 days. Excluding one infant, who died after 5 days and who showed a weight loss of 16 grams per day, the average daily increase in body weight was 7.4 grams. 

Fig. 1. Weight gains of intravenously alimented infants compared to that observed in conventionally managed infants.

Fig. 2. Relationship between time required for intravenously alimented infants to achieve intake of 100 calories/ kg/day and time required to regain birth weight.

Table III. Weight Gain and Nitrogen Balances Observed in Intravenously Alimented Infants Receiving Greater than 100 cal per kg per day.

Serial acid-base determinations performed during the period of total intravenous alimentation showed a chronic respiratory acidosis in almost all the infants. None of these acid-base changes could be related to the infusate rather, they were attributed to the pulmonary insufficiency of the very immature infant. 

Fig. 3. Relationship between blood pH and plasma PCO values to degree of nitrogen balance observed in intravenously alimented infants.

No significant deviations were observed in plasma sodium, potassium, calcium and phosphorus during the period of total intravenous alimentation. This fact is attributed to close chemical monitoring with appropriate daily adjustments of the electrolyte composition of the infusate being made on the basis of this monitoring. 

Table V. Complications and Outcome of Intravenously Alimented Infants.

Table V shows the complications and outcome of the infants receiving total intravenous alimentation.

One infant died of Candida Sepsis on the 5th day of infusion no other catheter complications were encountered. Three other infants died from causes unrelated to the intravenous alimentation. 

An alternative hypothesis is that these carbohydrate-protein mixtures place an abnormal burden upon normal enzymatic liver systems. Elevations in serum enzymes would thus represent an adaptive process in the metabolic conversion of these nutrients. This concept is partially supported by the repeated observations that both clinical and chemical findings revert toward normal if parenteral nutrition is continued. We would submit that these effects are mild, and in our limited experience, have thus far not been associated with life threatening disorders. Reports of other investigators suggest similar mild abnormalities (Heird t, 1972), while one incident of an infant death occurring during intravenous alimentation with severe hepatic damage has been described (Peden, Witzleben and Skelton, 1971). 

Two patients underwent percutaneous liver biopsy during the course of intravenous alimentation because of the development of the clinical and laboratory abnormalities described previously. 

Central intravenous alimentation has been associated with many problems septicemia (Boeckman C.R. aJ., 1970), thrombosis and thrombophlebitis (Groff, 1969), hypersensitivity reaction (Rea et al., 1970), air embolism (Filler et al., 1970), and hyperosmolar coma (White j 1972). Any of these complications markedly... 

Cohen has encountered a number of patients receiving total intravenous alimentation who develop both hepatomegaly and hepatic tenderness in conjunction with elevations in serimi transaminase levels (Cohen, M. I., et al.> 1973). These changes were sometimes accompanied by elevated levels of serum bilirubin. In addition, Cohen has shown that the damage to liver explants maintained in the presence of the fibrin hydrolysate, Aminosol, is equivalent to that of explants maintained in the presence of carbon tetrachloride, a known toxin (Cohen, M. I., personal communication). 

At autopsy, premature infants who died from non-hepatic causes while receiving intravenous alimentation were found to have enlarged livers which were characterized histologically, by fibrosis, fatty infiltration, and bile stasis (Driscoll, J. M., t al., 1972). 

Table 2 MONITORING SCHEDULE FOR TOTAL INTRAVENOUS ALIMENTATION...

Dudrick, S. J., in Intravenous Alimentation of High Risk Infants, Gov t Printing Office, In Press. 

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