Intravenous nutrition

Parenteral Fluids. During the past ten years interest has been renewed in the total alimentation of the infant by vein (2). The motivation for this is the fact that neonates may suffer from some congenital malformation of the intestinal tract which would require surgical resection. If this is done, then one needs some outside way for alimentation, bypassing the intestine, until the intestine is able to heal and recover its normal function. This may take many weeks. A second source of motivation is the small premature infant weighing less than a kilogram, whose immature central nervous system and gastrointestinal tract make it difficult to establish nutrition by oral intake soon after birth. These also require total intravenous nutrition for a substantial period of time. 

In addition to these two applications, intravenous nutrition and fluid therapy has been given for many years to newborns with chronic diarrhea, malabsorption for various reasons, and other problems associated with disease. 

Lyons, R.T. Carter, E.G. Lipid Emulsions for Intravenous Nutrition and Drug Delivery in Lipid Technologies and Applications, Gunstone, F.D. and Padley, F.B. (Eds.), Dekken New York, 1997, pp. 535-556. 

In a recent study of premature infants, it was found that the metabolic profiles of these patients are not dramatically different from that of other newborns if the blood sample was collected before intravenous nutrition was provided... 

A 38-year-old man presented with a 2-day history of severe abdominal pain and bloody stools after smoking cocaine 48 hours earlier (198). He had abdominal pain, guarding, rebound tenderness, and high-pitched, hypoactive bowel sounds. His white blood cell count was 31 x 109/1. Radiography showed thumb-printing in the transverse colon. Endoscopy showed friable edematous mucosa with submucosal hemorrhage and patches of yellowish fibrinous material. He recovered fully with intravenous nutrition and supportive measures after 30 days. 

Mizushima, Y. Drugs Expt Clin. Res. 1985, XI (9), 595-600. Lyons, R.T. Carter, E.G. Lipid emulsions for intravenous nutrition and drug delivery. In Lipid Technologies and... 

Macht, S.D. Three hundred years of parenteral nutrition the history of intravenous nutritional therapy. Conn. Med. 1980, 44 (1), 27-30. 

Smimiotis V, Kotsis TE, Antoniou S, Kostopanagiotou G, Labrou A, Kourias E, Papadimitriou J. Incidence of vein thrombosis in peripheral intravenous nutrition effect of fat emulsions. Chn Nutr 1999 18(2) 79-81. 

In a retrospective study of the incidence of cholestasis and liver failure in 42 patients with intestinal resection in the neonatal period who subsequently became dependent on parenteral nutrition support, the effect of various associated clinical factors on the incidence and severity of cholestasis was determined (103). Cholestasis developed in 28 while they were receiving parenteral nutrition. In 21 patients, the raised direct bilirubin concentration returned to normal while they continued to receive parenteral nutrition. Seven patients progressed to liver failure. Patients without cholestasis had been dependent on parenteral nutrition for longer than patients with cholestasis. It was clear from this study that cholestasis in neonates with intestinal resection is not simply a function of the duration of exposure to intravenous nutrition. 

The results instead suggested that infection early in life, when the developing liver may be uniquely sensitive to cholestatic injury and additionally stressed by intravenous nutrition, may play an important role. 

Madan M, Alexander DJ, MeUor E, Cooke J, et al. A randomised study of the effects of osmolality and heparin with hydrocortisone on thrombophlebitis in peripheral intravenous nutrition. Chn Nutr 1991 10 309-14. 

Wardle CA, Forbes A, Roberts NB, Jawhari AV, Shenkin A. Hypermanganesemia in long-term intravenous nutrition and chronic liver disease. J Parenter Enteral Nutr 1999 23(6) 350-5. 

Georgieff M, Moldawer LL, Bistrian BR, Blackburn GL. Xylitol, an energy source for intravenous nutrition after trauma. ] Parenter Enteral Nutr 1985 9 199-209. 

Fat emulsions are used to supply a large amount of energy in a small volume of isotonic liquid they supply the body with essential fatty acids and triglycerides. Fat emulsions for intravenous nutrition contain vegetable oil and phospholipid emulsifier. Several commercial fat emulsions are available, such as Intralipid, Lipiphysan, Lipofundin and Lipo-fundin S. They contain either cottonseed oil or soybean oil. In Intralipid, for example, purified egg-yolk phospholipids are used as the emulsifiers, and isotonicity is obtained by the addition of sorbitol, xylitol or glycerol. Intralipid has also been used as the basis of an intravenous dmg carrier, for example for diazepam (Diazemuls) and propofol (Diprivan), as an alternative to solubilisation in nonionic micellar systems such as Cremophor EL. 

Figure 30-1 Consequences of inadequate mineral or trace element Intake. (From Shenfdn AfAHwood AIC.Troce e/ements and vitamins in adult intravenous nutrition. In Rombeau JL, Rolandelli RH, eds. Clinical nutrition Parenteral nutrition. Philadelphia WB Saunders Co, 2001 60-79.)...

The recommended provision of vitamin A to adults during intravenous nutrition (IVN), whether this is partial or total parenteral nutrition (TEN), is 1000 fig retinol. This is usually provided as retinol palmitate and is supplied either with other fat-soluble vitamins in a mixture dissolved in a fat emulsion for intravenous feeding or is designed to be compatible with a mixture of all vitamins suitable for addition to other water-soluble nutrients. 

Direct determination of chromium in diet, in oral and intravenous nutritional support regimens, and in blood... 

Shenkin A, Fell GS, Halls DJ, et al. Essential trace element provision to patients receiving home intravenous nutrition in the United Kingdom. Chnical Nutrition 1986 5 91-7. 

Shenkin A. Vitamin and essential trace element recommendations during intravenous nutrition theory and practice. Proc Nutr Soc 1986 45 383-90. 

An interesting extension of these studies is to consider the cells involved in the wound healing process from an intravenous nutrition... 

By the late 1960s, Rhoads and Dudrick had documented continued growth and improvement in nutritional markers in humans with the use of central intravenous nutrition. By the early 1970s, intravenous nutrition was used to sustain growth and development in premature infants. ... 

Advances in technology for the delivery of intravenous solutions have allowed medically stable patients who require extended PN therapy to be maintained indefinitely on intravenous nutrition. An increasing concern for cost containment of health care services has fostered use of sophisticated infusion devices to provide PN at home. Numerous programs are now available outside the traditional health care setting to support patients with various long-term or permanent medical conditions. Standards have been developed to promote safe and effective care. Home PN services may be coordinated and administered through a hospital, by a commercially operated corporation, or through a joint venture between the two. 

Many patients in intensive care units receive intravenous nutrition, which is a mixture of various amino acids, sorbitol, and ethanol. In a study of 30 patients with normal preoperative folate levels who were operated on for gastrointestinal disease, the serum folate fell within 48 hours by 60-95% in 20 patients receiving intravenous nutrition (W24). Seven patients had a megaloblastic bone marrow. Daily treatment with 0.5 mg of folic acid given intravenously prevented any clinical signs of folate deficiency. These patients received between 100 and 150 g of ethanol daily as part of their parenteral nutrition, and this may have played a significant role in the development of folate deficiency. However, Tennant (T12) examined this possibility and found that acute depression of the serum folate concentration occurred with both alcohol-firee and alcohol-containing preparations used for parenteral nutrition. It was also noted that only one particular brand of... 

E., Acute folate deficiency associated with intravenous nutrition with aminoacid-sorbi-tol-ethanol Prophylaxis with intravenous folic acid. Br. J. Haematol. 37, 521-526... 

Biochemical Consequences of Intravenous Nutrition in the Newborn Gordon Dale... 

Some vehicles used for the administration of test compounds or to maintain nutritional states in intravenous pharmacological studies may alter plasma lipids. Intralipid is a source of essential fatty acids—linoleic and linolenic acids—used for intravenous nutrition in addition, it can be used to test methods for interference from lipemia. When it was given to rats, it increased plasma cholesterol, HDL, and LDL (Hajri, Ferezou, and Lutton 1990 Wasan, Grossie, and Lopez-Berestein 1994). Another vehicle, beta-cyclodextrin, also affects plasma lipids and can cause hypo-lipidemia (Trautwein et al. 1999). 

A very similar clinical presentation has been noted in adults treated for relatively prolonged periods by total intravenous nutrition, using nutrient mixtures with insufficient zinc (Kay et al., 1976). It is now accepted that zinc should be added to the nutrient mix from the start of treatment. We have found that although patient requirements can vary considerably, addition of 6.5 mg per day is effective and safe. 

---