Cytomegalovirus (CMV) is a serious complication of immunosuppressed patients receiving bone marrow transplantation. Foscarnet, a pyrophosphate analog, has been used in the treatment of CMV infections. Renal impairment and electrolyte abnormalities are potential adverse reactions associated with the use of foscarnet. We report a case of significant electrolyte changes after initiation of foscarnet in a bone marrow transplant patient receiving parenteral nutrition.

Adult↗

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Exerience with the Broviac catheter for prolonged parenteral alimentation.

Home hyperalimentation is now recognized as a technique which allows patients with severe short bowel syndrome or inflammatory bowel disease to return to a near normal life style. The success of this program is dependent on the longterm use of a catheter through which intravenous fluids are infused. In the past 20 months, we have inserted 32 catheters into 22 patients for purposes of home parenteral nutrition. In a 1 to 20-month follow-up, the average duration of catheter insertion was 6 months, the longest has been 19 months in 2 patients. One patient with superior vena cava thrombosis has had a catheter inserted via a femoral vein which has been functioning well for 5 months. Thirteen catheters have been removed: 3 for obstruction, 2 for sepsis, 1 due to breakage of the catheter, 4 for slippage (3 were pulled out by the patient, and 1 was removed because of inability to psychologically accept the presence of the catheter). The removal of 6 of these 13 catheters was necessitated by breaks in the proper techniques of catheter care, which include daily dressing changes and heparinization of the catheter at least once daily. Techniques of catheter insertion and catheter care will be presented

Arm↗

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The effect of intravenous fat emulsions in patients with pancreatic fistula.

Three patients with pancreatic fistulae were given parenteral 10% fat emulsion (Intralipid) to study the effect of intravenous fat on pancreatic fistula output. Each patient received nutritional support with isovolumetric, isonitrogenous, and isocaloric solutions containing either hypertonic dextrose and amino acids, or hypertonic dextrose, amino acids, and a fat emulsion. Measurements of fistula volume, fistula amylase, lipase, and chloride concentrations, and fistula trypsin activity were performed. The patients were studied for periods of 10 to 26 days. No significant increases in any of the above parameters were noted during the periods when the fat emulsions were infused. In one patient the fistula closed spontaneously. We conclude that intravenous fat emulsions may be used to provide nutritional support for patients with pancreatic fistula without increasing pancreatic juice volume or enzyme content.

Adult↗

PubMedDate not supplied

The effect of intravenous doxycycline hyclate on total parenteral nutrition in protein malnourished rats.

To study the effects of intravenous doxycycline hyclate on protein malnourished rats, 20 male Sprague-Dawley rats, weighing 234 to 277 g, were protein depleted for 6 weeks then randomly assigned to one of two groups: group I (10 rats), total parenteral nutrition with intravenous doxycycline hyclate injections, group II (10 rats), total parenteral nutrition with normal saline injections. Both groups were then protein repleted for 7 days. Body weight; fluid intake; urine output; liver, spleen, and lung weights; nitrogen content; and serum proteins were measured. The antibiotic dosage given was 10 mg/kg body weight/day or 0.1688 +/- 0.0046 mg/kg. There was no significant difference in starting weight, weight after 6 weeks of protein depletion, weight at sacrifice, or weight gain between groups I and II. Average fluid intake/day for groups I (50 +/- 2 ml) and II (51 +/- 3 ml) were not statistically significant. There was no significant difference in average urine output/day nitrogen balance, liver weight, and liver nitrogen, spleen and lung weights, or serum albumin levels (Groups I, 2.84 +/- 0.48 g%, Group II, 2.72 +/- 0.24 g+). Intravenous doxycycline hyclate does not appear to have a protein catabolic effect on protein malnourished rats receiving total parenteral nutrition.

Animals↗

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Use of an intercostal vein for central venous access in home parenteral nutrition: a case report.

A key factor in the success of a home parenteral nutrition program is prolonged and safe access to the central venous system. There are some patients, however, in whom the cephalic, external jugular, internal jugular, subclavian, and saphenous veins cannot be used. In these patients, cannulation of an intercostal vein can be useful for central venous access. Such a patient was recently presented to our medical care facility with bilateral subclavian vein thrombosis, left external iliac vein thrombosis, and superior vena cava obstruction above the level of the azygous vein. A Broviac catheter was successfully introduced via a right intercostal vein cutdown with the catheter tip lying in the azygous arch. This is the first known description in an adult patient in the use of an intercostal vein to gain access into the central venous system.

Adult↗

PubMedDate not supplied

Four years of North American registry home parenteral nutrition outcome data and their implications for patient management.

The OASIS Registry started annual collection of longitudinal data on patients on home parenteral nutrition (HPN) in 1984. This report describes outcome profiles on 1594 HPN patients in seven disease categories. Analysis showed clinical outcome was principally a reflection of the underlying diagnosis. Patients with Crohn's disease, ischemic bowel disease, motility disorders, radiation enteritis, and congenital bowel dysfunction all had a fairly long-term clinical outcome, whereas those with active cancer and acquired immunodeficiency syndrome (AIDS) had a short-term outcome. The long-term group had a 3-year survival rate of 65 to 80%, they averaged 2.6 complications requiring hospitalization per year, and 49% experienced complete rehabilitation. The short-term group had a mean survival of 6 months; they averaged 4.6 complications per year and about 15% experienced complete rehabilitation. The registry data also indicated HPN was used for 19,700 patients in 1987 with therapy growth averaging about 8% per year. This growth was chiefly from new cancer patients. The number of new patients with long-term disorders in whom HPN was initiated appeared rather constant. We conclude that these clinical outcome assessments justify HPN for long-term patients, but the utility and appropriateness of HPN for the cancer and AIDS patients remains uncertain and requires further study. Medical, social, and fiscal aspects of HPN management in long-term and short-term patients appear to involve quite separate considerations.

Acquired Immunodeficiency Syndrome↗

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Long-term silastic catheters and chest pain.

There are multiple reports in the literature of vascular erosion in the innominate vein or superior vena cava from the use of temporary central venous catheters. Catheter malposition is likely to precede the development of superior vena cava perforations, a catastrophic complication of central venous catheters. Catheter malposition after initial adequate placement is a very unusual long-term complication and delayed recognition of this complication may have disastrous consequences. Should the catheter change position so the tip is angled toward the sidewall, the repetitive movement of the catheter tip that occurs with respiratory excursion and the cardiac cycle may lead to endothelial injury and eventual erosion of the vein. These problems are thought to be alleviated in the patient receiving long-term intravenous therapy by using a soft Silastic catheter, which may not cause as much damage to the endothelium of the vein. We report three patients with left-sided long-term indwelling Silastic catheters that had changed position over time who presented with chest pain upon infusion of their total parenteral nutrition solutions. In each case, chest x-ray revealed that the tip of the catheter had migrated and was directed against the sidewall of the superior vena cava. In each case, catheter removal and replacement with a new catheter into the right side (subclavian and jugular systems) led to prompt relief of the patient's symptoms.

Aged↗

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Case management in home total parenteral nutrition: a cost-identification analysis.

BACKGROUND: Home parenteral nutrition (HPN) requires intensive medical case management by practitioners with expertise in the provision of nutrition support. There is expenditure of considerable time and resources for management of these patients not covered by any of the traditional reimbursement mechanisms. The costs associated with this unreimbursed input and follow-up are most often borne by the Nutrition Support Team or individual practitioners. Reimbursement by home care agencies to physicians for management of patients after discharge cannot be done because this may be construed as a "kick-back" for referral of patients to particular home care agencies. METHODS: Time and costs associated with management of HPN patients after discharge from the hospital were assessed using a cost-identification analysis of 24 different factors. Daily activity logs were kept by the Nutrition Support Team members over a 2-week period. Costs of space and furnishings were calculated. RESULTS: On average, a total of 25 h/d was spent by members of the Nutrition Support Team on our HPN patients. Variable activities accounted for 5640.1 hours of time with fixed support at 890.3 hours. This computes to a total annual personnel cost of $168,482 ($1982 per patient). If costs of furnishings and space are also included, the overall cost of all resources was $175,989 per year or $2070 per patient. CONCLUSION: Significant and currently nonreimbursed costs are involved in HPN patient management. These costs are most often absorbed by the Nutrition Support Team and should be considered when evaluating total costs of HPN.

Case Management↗

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Tunneled right atrial catheter infection presenting as renal failure.

We report two cases of progressive renal failure secondary to membranoproliferative glomerulonephritis associated with subclinical septicemia from a tunneled right atrial catheter used for home parenteral nutrition administration. Although the occurrence of line infection and septicemia is a common complication of central venous catheters, a review of the literature reveals only one case report of renal failure secondary to an infected implanted central venous device. Both patients presented with azotemia and had biopsy-proven membranoproliferative glomerulonephritis, accompanied by leukocytoclastic vasculitis. In both cases, removal of the right atrial catheter and prolonged antibiotic therapy was effective in resolving the ongoing infection and resulted in marked improvement in renal function. A high index of suspicion for catheter sepsis should be maintained in patients with tunneled right atrial catheters presenting with subacute renal failure.

Aged↗

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Rapid identification of the external jugular vein.

The authors describe a rapid technique to identify the course of the external jugular vein based on the location of the cephalic vein or the deltopectoral groove.

Catheterization, Central Venous↗