Death parenteral nutrition

In a study of catheter infection in patients treated with total parenteral nutrition a distant septic focus was present in 165 of 244 patients (188 of 269 catheters 70%). There was a colonization rate of 19% of the catheters of the patients with a distant septic focus, compared with 7.4% in patients without a distant septic focus. There was a high mortahty rate in patients with a distant septic focus and a colonized catheter sepsis was responsible for 33 of the 48 deaths (69%) in this group (33). 

Intestinal transplantation is combined with liver transplantation in 46% of cases, because of terminal liver failure (93). Of 78 patients who had received parenteral nutrition for more than 2 years n — 66) and/ or had short bowel syndrome and could not be weaned from parenteral nutrition (n = 12), 58 developed chronic cholestasis and 37 developed one or more severe liver complication (serum bilirubin concentration 60 pmol/l, factor V (proaccelerin) 50%, portal hypertension, encephalopathy, ascites, bleeding from the gastrointestinal tract, or histological findings consisting of extensive fibrosis and cirrhosis) after 6 (3-132) months and 17 (2-155) months respectively. Liver disease was responsible for deaths in 6.5% of the patients (22% of deaths). 

In a prospective prevalence study of liver disease in 90 patients with permanent intestinal failure receiving parenteral nutrition hver biopsy was performed in 57 (95). Chronic cholestasis developed in 58 patients after a median of 6 (range 3-132) months, and 37 developed comphcated liver disease after a median of 17 (range 2-155) months. Chronic cholestasis was significantly associated with a risk of liver disease independent of parenteral nutrition, a bowel remnant shorter than 50 cm, and a lipid intake of 1 g/kg/day or more hver disease related to parenteral nutrition was significantly associated with chronic cholestasis and a parenteral hpid intake of 1 g/kg/day or more. The authors concluded that the prevalence of hver disease increased with the duration of parenteral nutrition and was one of the main causes of death in patients with permanent intestinal failure. Parenteral intake of long-chain hpid emulsion should be restricted to less than 1 g/kg/day. 

Precipitates can develop in parenteral nutrition admixtures because of a number of factors such as the concentration, pH, and phosphate content of the amino acid solutions, the calcium and phosphorus additives, the order of mixing, or the mixing process. The consequences can be serious. In one cohort study of hospitalized patients who received peripheral parenteral nutrition, a subgroup developed unexplained chest pain, dyspnea, cardiopulmonary arrest, or new interstitial infiltrates on chest radiograph. A change in the amino acid source of a parenteral nutrition mixture was associated with respiratory adverse events that ranged from interstitial infiltrates to sudden death. The events apparently resulted from infusion of calcium phosphate precipitate in an opaque admixture, and the deposition of the crystals in the pulmonary microvasculature (147). 

The United States Food and Drug Administration issued a safety alert in 1994 regarding the potentially life-threatening formation of precipitates in parenteral nutrition admixtures (148). They had received reports of two deaths and at least two cases of respiratory distress during intravenous infusion of a three-in-one parenteral nutrition mixture (amino acids, carbohydrates, lipids). The mixture contained 10% FreAmine III (amino acids -I- magnesium acetate -I- phosphoric acid -I- potassium chloride -I- sodium acetate -I- sodium chloride), dextrose, calcium gluconate, potassium phosphate, other minerals, and a lipid emulsion. The solution may have contained a precipitate of calcium phosphate. Autopsies revealed diffuse microvascular pulmonary emboli containing calcium phosphate. 

Shay DK, Fann LM, Jarvis WR. Respiratory distress and sudden death associated with receipt of a peripheral parenteral nutrition admixture. Infect Control Hosp Epidemiol 1997 18(12) 814-17. 

A fish oil-based intravenous lipid emulsion in the treatment of liver disease associated with parenteral nutrition has been compared with soybean oil in an open study in 42 infants with short bowel syndrome who developed cholestasis [35 ]. There were three deaths and one liver transplantation in those who received the fish oil, compared with 12 deaths and 6 transplants in those who received soybean oil The fish oil was not associated with hypertriglyceridemia, coagulopathy, or deficiency of essential fatty acids. 

FDA Safety Alert Hazards of Precipitation Associated With Parenteral Nutrition The Food and Drug Administration warned against the risk of precipitations in parenteral nutrition mixtures in 1994 [55]. This warning occurred after two deaths and at least two patients with dyspnoea after infusion of all-in-one nutrition admixmres. The FDA suspected that these admixtures contained calcium phosphate precipitates. 

Parenteral nutrition did not cause any evident local or general complications. Three premature infants of the first Test Series died between the fourth and sixth day of life however, none of their metabolic parameters differed from those found in the surviving children. The cause of death in two of the infants was extensive amniotic aspiration one child had severe hyaline membrane disease. 

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). 

There were 19 distinct episodes of sepsis during supplemental parenteral nutrition, each with at least three positive blood cultures for the same organisms. The most common organisms cultured were Staph, aureus and Pseudomonas aeruginosa, followed by Candida species. There were eight total episodes of the 19 in which Candida albicans or Candida species were cultured. Four of the seven deaths resulted from generalized Candidiasis. 

Cardiovascular In a study of the risk of pulmonary embolism in 64 patients aged 3 months to 22 years, receiving parenteral nutrition, 25 (39%) had an abnormal ventilation-perfusion scan and 29 episodes of pulmonary embolism were diagnosed. The median age at time of diagnosis was 4.6 years [54 "]. Pulmonary embolism was bilateral in 56% and unilateral in 44% and was the main cause of two of 15 recorded deaths. 

Biliary tract In a study of 66 infants with cholestasis associated with parenteral nutrition, there were 10 deaths and one referral for liver transplant in the first year of life, all of whom had at least one positive blood culture after the onset of cholestasis [70 ]. Maximum conjugated bilirubin in these 11 infants was 270 pmol/l, compared with 145 pmol/l in babies who recovered. A maximum conjugated bilirubin concentration over 170 pmol/l was a susceptibility factor for death or transplantation. 

In a prospective study of enteral-based nutritional support regimen in bums and tramna patients, those receiving the highest amoxmts of enteral calories within the first week had the highest incidence of ventilator-assisted pneumonia and the lowest incidence of bacteraemia. PN was associated with a significantly increased risk of bacteraemia (OR=2.5 95% Cl 1.8-3.5), ventilator-assisted pneumonia (OR=2.5 95% Cl 1.7-3.3), and death (OR=1.9 95% Cl 1.1-3.1) [104 ]. A retrospective review of 12 cases of multiple sclerosis patients on home PN showed that there was no improvement in their fxmctional status there were also no significant changes in liver enzymes and bilirubin [105 ]. Five of the patients died within two years form causes unrelated to parenteral nutrition. 

Death Parenteral-nutrition-associated liver disease after intestinal perforation, with resulting/afaZifi/ has been... 

The disease is not sensitive to any medication used to treat nephrotic syndrome. Death is mostly related to lack of nutritional support or intercurrent disastrous infections even before ESRD starts at approximately 2-4 years of age. The currently most accepted treatment includes vigorous parenteral nutrition and protein replacement from birth on, bilateral nephrectomy and starting peritoneal dialysis during late infancy, and early planning of renal transplantation (Mahan et al. 1984 Holmberg et al. 1995). 

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