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Parenteral hyperalimentation in gynecologic oncology patients
GYNECOLOGIC
ONCOLOGY
1,
70-75 (1972)
Parenteral Hyperalimentation in Gynecologic Oncology Patients JOHN H. FORD, JR., M.D., RONALD C. DUDAN, M.D.,' JEFFREY S. BENNETT, M.D.,2 AND HERVY E. AVERETTE, M.D. Unizjersity
Gynecologic Oncology Service, Department of Obstetrics und Gynecology, of Miumi School of Medicine, Jackson Memo&l Hospital, Miami, Florida
33152
Received June 21, 1972 Pare&era1 hyperalimentation has been introduced as an adjunct in the care and management of the patient with gynecologic cancer. Our indications for parenteral hyperalimentation and results of therapy are presented. The complications of this form of therapy are reviewed and measures to prevent complications are suggested. In selected patients, with proper monitoring, parenteral hyperalimentation may prove to be a lifesaving measure.
For many years physicians have recognized that preoperative and postoperative malnutrition is associated with an increased morbidity and mortality. During preceding decades, surgeons have attempted to obtain an anabolic state by utilizing a variety of parenteral solutions. At best, only short-term positive nitrogen balance could be attained. In 1968, Dr. Stanley Dudrick and his associates at the University of Pennsylvania School of Medicine reported that long-term positive nitrogen balance could be attained over extended periods of time by infusing high concentrations of essential amino acids and dextrose through a catheter inserted into the subclavian vein and threaded into the superior vena cava [1,2]. This method of intravenous feeding has since been referred to as “parenteral hyperalimentation” and is currently in use in most major hospitals. MATERIALS
AND
METHODS
The Gynecologic Oncology Service of the Department of Obstetrics and Gynecology at the University of Miami School of Medicine adopted the use of parenteral hyperalimentation for selected patients in 1969. Table 1 shows the basic hyperalimentation solution we have used. Each unit contains a total volume of 1100 cc with approximately 1000 cal and 5.25 g of nitrogen. The ratio of nitrogen to calories is a critical factor in the body’s ability to utilize the glucose and amino acids at the cell level. A bolus of either alone usually results in a loss through the urine. By gradually increasing the volume of solution infused, 4000 or more calories and 21 g or more of nitrogen can be given daily. Essential water and fat-soluble vitamins are added to one unit of the solution each day. Electrolytes are added based on daily electrolyte determinations. Vitamin K, B,2, folic acid, iron, calcium, and phosphorus may be ’ Advanced Clinical Fellow, L Clinical Fellow, American
American Cancer Society. Cancer Society. 70
Copyright @ 1972 by Academic Press, Inc. All riehts of renrodnctian in anv form reserved.
PARENTERAL
71
HYPERALIMENTATION TABLE
1
BASIC HYPERALIMENTATION SOLUTION 5% Protein hydrolyzate 50% Glucose Total one unit Each unit provides: Calories Dextrose Nitrogen Ratio nitrogen/calories
750 cc 350 cc 1100 cc
in 5% dextrose
1000 212 5.25 1:190
utilized as needed. Trace elements may be supplied by the administration of 1 unit of fresh frozen plasma each week. Four patients have been selected for review who represent problems peculiar to the gynecologic oncologist and illustrate some of our indications for the use of parenteral hyperalimentation. Conditions
Rendering
the Gastrointestinul
Truct Functionless
A.F. is a 41-year-old white female with Stage III carcinoma of the cervix treated with radiation. She developed a pelvic abscess secondary to radiation changes in the rectosigmoid with perforation of the sigmoid colon. A diverting transverse loop colostomy was performed. No cancer was found at laparotomy. Postoperatively the patient developed a cecal-sigmoid-rectal-cutaneous fistula. She received 44 days of hyperalimentation for a total of 161 liters. During parenteral hyperalimentation she had a weight gain of 13 lb with a rise in serum proteins from 6.0 to 7.3 g/l00 ml. This patient had complete closure of the fistulas with return of function of the colostomy. One year later she had a surgical closure of the colostomy and has returned to a normal functioning life. Support
of the Debilitated
Patient
Who Requires
Chemotherapy
M.A. is a 51-year-old white female who presented with a large abdominal mass and was found to have Stage III ovarian cancer. At operation, hysterectomy, bilateral salpingo-oophorectomy, segmental resection of the sigmoid colon, and terminal sigmoid colostomy were performed. Postoperatively she developed small bowel and large bowel cutaneous fistulas with wound dehiscence. During hyperalimentation she had complete closure of the fistulas with return of function of the colostomy. Although deprived of oral intake she gained 8 lb and had a rise in serum proteins from 4.5 to 7.2 g/l00 ml. During hyperalimentation chemotherapy was started and was well tolerated despite the multiple complications this patient experienced. She was subsequently discharged from the hospital to continue chemotherapy as an outpatient. Postoperative
Support
ufter Extended
Radical
Pelzjic Surgery
G.B. is a 69-year-old white female who presented with a central Stage IV squamous cell carcinoma of the cervix with extensive bladder invasion. This patient had a primary total pelvic exenteration and was placed on hyperali-
72
FORD
ET AL.
mentation during the postoperative period. At the time hyperalimentation was started she was becoming progressively debilitated with a steady downhill course. She responded rapidly to parenteral hyperalimentation with a weight gain of 5 lb and a rise in total serum proteins from 4.2 to 7.2 g/100 ml. This elderly patient was able to be ambulated during hyperalimentation and experienced a rapid recovery after this extensive surgical procedure. She currently is doing well 2 years after operation with no evidence of recurrent disease.
Preoperative Prepwrwtion of the Debilitated
Putient
J.D. is a 50-year-old white female with Stage IB carcinoma of the cervix previously treated with radiation. She was admitted for vesicovaginal, rectovaginal, and small bowel perineal fistulas. Recurrent cancer was found at exploration. For palliation ileotransverse colostomy and terminal sigmoid colostomy was performed. Hyperalimentation was instituted for support during the pre- and postoperative periods. This patient had an initial response to hyperalimentation during the preoperative period but later developed progressive deterioration and protein loss despite vigorous hyperalimentation. This patient subsequently died. RESULTS A graphic review of five hyperalimentation patients in respect to total proteins is shown in Fig. 1. This figure represents patients who survived. They responded from depleted serum protein levels to normal serum protein levels while receiving nothing by mouth and receiving hyperalimentation. Of the patients who responded, four of five were free of cancer at the time of hyperalimentation. In contrast, four patients did not respond and showed depletion of serum proteins as seen in Fig. 2. Two of the four had persistent cancer and the other two had insurmountable complications resulting from therapy. These patients initially responded to hyperalimentation but subsequently could not utilize the hyperalimentation solution and continued to deplete their serum proteins until their demise.
lllr
ADMISS.PRE DURINGPOST DISCHARGED HA H.A. H.A. FIG. 1. Rise of
total serum proteins in patients responding
to parenteral
PARENTERAL
73
HYPERALIMENTATION
,” *-ADMISS.PRE DURlN6POST EXPIRED HA FIG. 2. Fall of total serum proteins tion.
in patients
HA.
HA.
who fail to respond to parenteral
hyperalimenta-
DISCUSSION Parenteral hyperalimentation has added an important new dimension to the metabolic care of the severely ill patient. We do not recommend its use as a routine measure since the process is hazardous and unusual complications of therapy with hypertonic solutions may arise. Complications
Related to the Subclavian
Catheter
The hazards of therapy begin with the placement of the subclavian catheter. In the usual patient we expect that the indwelling catheter will be in place for several days so strict surgical aseptic technique is used at the time of subclavian venipuncture. The most experienced physician available is called upon to either assist with or perform the venous cannulation. In this way the complications of pneumothorax, hemothorax, air embolization, catheter embolization, or subclavian artery or vein laceration are minimized. After insertion the catheter is sutured in place and an occlusive sterile surgical dressing is applied. Chest X-ray is then obtained to be certain the catheter tip is in the superior vena cava and as a further safeguard against pneumothorax. Infection Sepsis is the most frequent complication of prolonged parenteral hyperalimentation which carries an l&25% infection rate [3]. We recommend replacing the intravenous infusion tubing daily and changing the sterile dressings every 48 hr with a repeat of the surgical preparation of the area. In addition we apply an antibiotic ointment to the cutaneous puncture site and the sterile occlusive dressing is reapplied. If signs of sepsis do occur, the catheter is withdrawn, the catheter tip cultured, blood cultures performed, and appropriate antibiotic therapy is instituted. Complications
Related to the Hyperalimentation
Solution
A second source of infection is the hypertonic nutrient solution as it may serve as an excellent culture medium. Our pharmacy is able to supply us with fresh solutions prepared daily under laminar flow hoods, using membrane filtration techniques. All solutions are kept under refrigeration until ready for
74
FORD
ET AL.
use and any solution over 24 hr old is discarded. Using the precautions of catheter care and solution preparation, our infection rate has been well below the expected level. We have experienced one instance of monilia septicemia with prolonged hyperalimentation. This patient responded to removal of the subclavian catheter with no further therapy. The next consideration in parenteral hyperalimentation is a constant rate of infusion. The nutrient solution represents a concentration approximately six times the tonicity of standard intravenous fluids. Too rapid infusion results in an osmotic diuresis and dehydration while infusion rates that are too slow fail to supply the necessary nutrition to produce positive nitrogen balance. We use the gravity drip system of infusion and our nursing staff has been fully oriented in the hazards of rapid infusion. When infusion rates fall behind the prescribed level the rate is adjusted but no attempt is made to “catch up.” Strict intake and urinary output are recorded in an attempt to diagnose osmotic diuresis in an early stage. Metwholic
Complicutions
The remaining complications of hyperalimentation may be classifed as metabolic. Glucose can be readily metabolized when infused at a rate of 0.7-0.8 g per kg body weight per hour in the normal resting individual [3]. Severely ill patients frequently develop relative glucose intolerance as part of the metabolic response to stress [3]. When hypertonic glucose solutions are administered a progressive hyperglycemia may occur leading to gradual osmotic diuresis, dehydration, increased serum osmolarity, contraction of all fluid compartments, loss of body sodium, and acidosis. With a continued hyperosmolar state, hypernatremia occurs with serum sodium levels reaching 160-170 meq/liter. Loss of consciousness, stupor, coma, and convulsions may result [4]. To prevent this complication the infusion of hyperalimentation solution is started at low levels (1000-2000 cc daily) with frequent monitoring of blood glucose levels, serum electrolytes, serum osmolarity, and urine sugar concentrations. If persistent urine sugars are in the 3+ to 4+ range, exogenous insulin is administered. When the period of relative glucose intolerance has been passed the quantity of solution may gradually be increased to a level of 4000 cc daily. This volume of soltuion will supply approximately 4000 calories and 21 g of nitrogen. Electrolytes are added to our hyperalimentation solution based on daily serum electrolyte determinations. In the early phases of hyperalimentation mobilization of cellular sodium and water may result from the activation of cell membrane pumps that follow the administration of exogenous energy sources [3]. The intracellular movement of glucose is accompanied by cellular transport of potassium. Increased needs for water, sodium, and potassium may be supplied by additional parenteral solutions infused through a peripheral vein during the early days of hyperalimentation to compensate for this increased fluid and electrolyte need of the patient. Electrolyte solutions containing 5% dextrose should be avoided when fluid supplement is needed since this may alter the optimum calorie-to-nitrogen ratio.
PARENTEIUL
HYPERALIMENTATION
75
SUMMARY The Gynecologic Oncology Service of the University of Miami School of Medicine has found parenteral hyperalimentation an extremely valuable adjunct in the care and management of the cancer patient. Our greatest success has been in the closure of intestinal fistulas that occur secondary to extended radical surgery and in the metabolic support of the debilitated patient after surgery, radiation, or chemotherapy. Patients who are free of cancer or who have minimal residual disease usually respond well to hyperalimentation. Patients with extensive cancer frequently are unable to utilize the hyperalimentation solution and experience progressive deterioration. This observation is consistent with the experience of Dudrick in the management of the terminal cancer patient [5]. We would not recommend the use of parenteral hyperalimentation as a routine measure because of the many hazards and complications that may accompany its use. However, in selected patients, with cautious monitoring, parenteral hyperalimentation may prove to be a lifesaving measure. REFERENCES 1. DUDRICK, S. J., WILMORE, D. W., VARS, H. M., AND RHOADS, J. E. Long term parenteral nutrition with growth development and positive nitrogen balance, Surgery 64, 134 (1968). 2. DUDRICK, S. J., VARS, H. M., AND RHOADS, J. E. Long term intravenous hyperalimentation, Fed. PTOC. 27, 486 (1968). 3. WILMORE, D. W. Guarding against complications in subclavian vein catheterization, Hosp. Physician Vol. 6, 82 (1970). 4. WYRICK, W. J., RAE, W. J., AND MCCLELLAND, R. N. Rare complications with I.V. hyperosmotic alimentation, J. Amer. Med. Ass. 211, 1967-1968 (1970). 5. DUDRICK, S. J. Intravenous feeding as an aid to nutrition in disease, Co 26, I99 (1970).
ONCOLOGY
1,
70-75 (1972)
Parenteral Hyperalimentation in Gynecologic Oncology Patients JOHN H. FORD, JR., M.D., RONALD C. DUDAN, M.D.,' JEFFREY S. BENNETT, M.D.,2 AND HERVY E. AVERETTE, M.D. Unizjersity
Gynecologic Oncology Service, Department of Obstetrics und Gynecology, of Miumi School of Medicine, Jackson Memo&l Hospital, Miami, Florida
33152
Received June 21, 1972 Pare&era1 hyperalimentation has been introduced as an adjunct in the care and management of the patient with gynecologic cancer. Our indications for parenteral hyperalimentation and results of therapy are presented. The complications of this form of therapy are reviewed and measures to prevent complications are suggested. In selected patients, with proper monitoring, parenteral hyperalimentation may prove to be a lifesaving measure.
For many years physicians have recognized that preoperative and postoperative malnutrition is associated with an increased morbidity and mortality. During preceding decades, surgeons have attempted to obtain an anabolic state by utilizing a variety of parenteral solutions. At best, only short-term positive nitrogen balance could be attained. In 1968, Dr. Stanley Dudrick and his associates at the University of Pennsylvania School of Medicine reported that long-term positive nitrogen balance could be attained over extended periods of time by infusing high concentrations of essential amino acids and dextrose through a catheter inserted into the subclavian vein and threaded into the superior vena cava [1,2]. This method of intravenous feeding has since been referred to as “parenteral hyperalimentation” and is currently in use in most major hospitals. MATERIALS
AND
METHODS
The Gynecologic Oncology Service of the Department of Obstetrics and Gynecology at the University of Miami School of Medicine adopted the use of parenteral hyperalimentation for selected patients in 1969. Table 1 shows the basic hyperalimentation solution we have used. Each unit contains a total volume of 1100 cc with approximately 1000 cal and 5.25 g of nitrogen. The ratio of nitrogen to calories is a critical factor in the body’s ability to utilize the glucose and amino acids at the cell level. A bolus of either alone usually results in a loss through the urine. By gradually increasing the volume of solution infused, 4000 or more calories and 21 g or more of nitrogen can be given daily. Essential water and fat-soluble vitamins are added to one unit of the solution each day. Electrolytes are added based on daily electrolyte determinations. Vitamin K, B,2, folic acid, iron, calcium, and phosphorus may be ’ Advanced Clinical Fellow, L Clinical Fellow, American
American Cancer Society. Cancer Society. 70
Copyright @ 1972 by Academic Press, Inc. All riehts of renrodnctian in anv form reserved.
PARENTERAL
71
HYPERALIMENTATION TABLE
1
BASIC HYPERALIMENTATION SOLUTION 5% Protein hydrolyzate 50% Glucose Total one unit Each unit provides: Calories Dextrose Nitrogen Ratio nitrogen/calories
750 cc 350 cc 1100 cc
in 5% dextrose
1000 212 5.25 1:190
utilized as needed. Trace elements may be supplied by the administration of 1 unit of fresh frozen plasma each week. Four patients have been selected for review who represent problems peculiar to the gynecologic oncologist and illustrate some of our indications for the use of parenteral hyperalimentation. Conditions
Rendering
the Gastrointestinul
Truct Functionless
A.F. is a 41-year-old white female with Stage III carcinoma of the cervix treated with radiation. She developed a pelvic abscess secondary to radiation changes in the rectosigmoid with perforation of the sigmoid colon. A diverting transverse loop colostomy was performed. No cancer was found at laparotomy. Postoperatively the patient developed a cecal-sigmoid-rectal-cutaneous fistula. She received 44 days of hyperalimentation for a total of 161 liters. During parenteral hyperalimentation she had a weight gain of 13 lb with a rise in serum proteins from 6.0 to 7.3 g/l00 ml. This patient had complete closure of the fistulas with return of function of the colostomy. One year later she had a surgical closure of the colostomy and has returned to a normal functioning life. Support
of the Debilitated
Patient
Who Requires
Chemotherapy
M.A. is a 51-year-old white female who presented with a large abdominal mass and was found to have Stage III ovarian cancer. At operation, hysterectomy, bilateral salpingo-oophorectomy, segmental resection of the sigmoid colon, and terminal sigmoid colostomy were performed. Postoperatively she developed small bowel and large bowel cutaneous fistulas with wound dehiscence. During hyperalimentation she had complete closure of the fistulas with return of function of the colostomy. Although deprived of oral intake she gained 8 lb and had a rise in serum proteins from 4.5 to 7.2 g/l00 ml. During hyperalimentation chemotherapy was started and was well tolerated despite the multiple complications this patient experienced. She was subsequently discharged from the hospital to continue chemotherapy as an outpatient. Postoperative
Support
ufter Extended
Radical
Pelzjic Surgery
G.B. is a 69-year-old white female who presented with a central Stage IV squamous cell carcinoma of the cervix with extensive bladder invasion. This patient had a primary total pelvic exenteration and was placed on hyperali-
72
FORD
ET AL.
mentation during the postoperative period. At the time hyperalimentation was started she was becoming progressively debilitated with a steady downhill course. She responded rapidly to parenteral hyperalimentation with a weight gain of 5 lb and a rise in total serum proteins from 4.2 to 7.2 g/100 ml. This elderly patient was able to be ambulated during hyperalimentation and experienced a rapid recovery after this extensive surgical procedure. She currently is doing well 2 years after operation with no evidence of recurrent disease.
Preoperative Prepwrwtion of the Debilitated
Putient
J.D. is a 50-year-old white female with Stage IB carcinoma of the cervix previously treated with radiation. She was admitted for vesicovaginal, rectovaginal, and small bowel perineal fistulas. Recurrent cancer was found at exploration. For palliation ileotransverse colostomy and terminal sigmoid colostomy was performed. Hyperalimentation was instituted for support during the pre- and postoperative periods. This patient had an initial response to hyperalimentation during the preoperative period but later developed progressive deterioration and protein loss despite vigorous hyperalimentation. This patient subsequently died. RESULTS A graphic review of five hyperalimentation patients in respect to total proteins is shown in Fig. 1. This figure represents patients who survived. They responded from depleted serum protein levels to normal serum protein levels while receiving nothing by mouth and receiving hyperalimentation. Of the patients who responded, four of five were free of cancer at the time of hyperalimentation. In contrast, four patients did not respond and showed depletion of serum proteins as seen in Fig. 2. Two of the four had persistent cancer and the other two had insurmountable complications resulting from therapy. These patients initially responded to hyperalimentation but subsequently could not utilize the hyperalimentation solution and continued to deplete their serum proteins until their demise.
lllr
ADMISS.PRE DURINGPOST DISCHARGED HA H.A. H.A. FIG. 1. Rise of
total serum proteins in patients responding
to parenteral
PARENTERAL
73
HYPERALIMENTATION
,” *-ADMISS.PRE DURlN6POST EXPIRED HA FIG. 2. Fall of total serum proteins tion.
in patients
HA.
HA.
who fail to respond to parenteral
hyperalimenta-
DISCUSSION Parenteral hyperalimentation has added an important new dimension to the metabolic care of the severely ill patient. We do not recommend its use as a routine measure since the process is hazardous and unusual complications of therapy with hypertonic solutions may arise. Complications
Related to the Subclavian
Catheter
The hazards of therapy begin with the placement of the subclavian catheter. In the usual patient we expect that the indwelling catheter will be in place for several days so strict surgical aseptic technique is used at the time of subclavian venipuncture. The most experienced physician available is called upon to either assist with or perform the venous cannulation. In this way the complications of pneumothorax, hemothorax, air embolization, catheter embolization, or subclavian artery or vein laceration are minimized. After insertion the catheter is sutured in place and an occlusive sterile surgical dressing is applied. Chest X-ray is then obtained to be certain the catheter tip is in the superior vena cava and as a further safeguard against pneumothorax. Infection Sepsis is the most frequent complication of prolonged parenteral hyperalimentation which carries an l&25% infection rate [3]. We recommend replacing the intravenous infusion tubing daily and changing the sterile dressings every 48 hr with a repeat of the surgical preparation of the area. In addition we apply an antibiotic ointment to the cutaneous puncture site and the sterile occlusive dressing is reapplied. If signs of sepsis do occur, the catheter is withdrawn, the catheter tip cultured, blood cultures performed, and appropriate antibiotic therapy is instituted. Complications
Related to the Hyperalimentation
Solution
A second source of infection is the hypertonic nutrient solution as it may serve as an excellent culture medium. Our pharmacy is able to supply us with fresh solutions prepared daily under laminar flow hoods, using membrane filtration techniques. All solutions are kept under refrigeration until ready for
74
FORD
ET AL.
use and any solution over 24 hr old is discarded. Using the precautions of catheter care and solution preparation, our infection rate has been well below the expected level. We have experienced one instance of monilia septicemia with prolonged hyperalimentation. This patient responded to removal of the subclavian catheter with no further therapy. The next consideration in parenteral hyperalimentation is a constant rate of infusion. The nutrient solution represents a concentration approximately six times the tonicity of standard intravenous fluids. Too rapid infusion results in an osmotic diuresis and dehydration while infusion rates that are too slow fail to supply the necessary nutrition to produce positive nitrogen balance. We use the gravity drip system of infusion and our nursing staff has been fully oriented in the hazards of rapid infusion. When infusion rates fall behind the prescribed level the rate is adjusted but no attempt is made to “catch up.” Strict intake and urinary output are recorded in an attempt to diagnose osmotic diuresis in an early stage. Metwholic
Complicutions
The remaining complications of hyperalimentation may be classifed as metabolic. Glucose can be readily metabolized when infused at a rate of 0.7-0.8 g per kg body weight per hour in the normal resting individual [3]. Severely ill patients frequently develop relative glucose intolerance as part of the metabolic response to stress [3]. When hypertonic glucose solutions are administered a progressive hyperglycemia may occur leading to gradual osmotic diuresis, dehydration, increased serum osmolarity, contraction of all fluid compartments, loss of body sodium, and acidosis. With a continued hyperosmolar state, hypernatremia occurs with serum sodium levels reaching 160-170 meq/liter. Loss of consciousness, stupor, coma, and convulsions may result [4]. To prevent this complication the infusion of hyperalimentation solution is started at low levels (1000-2000 cc daily) with frequent monitoring of blood glucose levels, serum electrolytes, serum osmolarity, and urine sugar concentrations. If persistent urine sugars are in the 3+ to 4+ range, exogenous insulin is administered. When the period of relative glucose intolerance has been passed the quantity of solution may gradually be increased to a level of 4000 cc daily. This volume of soltuion will supply approximately 4000 calories and 21 g of nitrogen. Electrolytes are added to our hyperalimentation solution based on daily serum electrolyte determinations. In the early phases of hyperalimentation mobilization of cellular sodium and water may result from the activation of cell membrane pumps that follow the administration of exogenous energy sources [3]. The intracellular movement of glucose is accompanied by cellular transport of potassium. Increased needs for water, sodium, and potassium may be supplied by additional parenteral solutions infused through a peripheral vein during the early days of hyperalimentation to compensate for this increased fluid and electrolyte need of the patient. Electrolyte solutions containing 5% dextrose should be avoided when fluid supplement is needed since this may alter the optimum calorie-to-nitrogen ratio.
PARENTEIUL
HYPERALIMENTATION
75
SUMMARY The Gynecologic Oncology Service of the University of Miami School of Medicine has found parenteral hyperalimentation an extremely valuable adjunct in the care and management of the cancer patient. Our greatest success has been in the closure of intestinal fistulas that occur secondary to extended radical surgery and in the metabolic support of the debilitated patient after surgery, radiation, or chemotherapy. Patients who are free of cancer or who have minimal residual disease usually respond well to hyperalimentation. Patients with extensive cancer frequently are unable to utilize the hyperalimentation solution and experience progressive deterioration. This observation is consistent with the experience of Dudrick in the management of the terminal cancer patient [5]. We would not recommend the use of parenteral hyperalimentation as a routine measure because of the many hazards and complications that may accompany its use. However, in selected patients, with cautious monitoring, parenteral hyperalimentation may prove to be a lifesaving measure. REFERENCES 1. DUDRICK, S. J., WILMORE, D. W., VARS, H. M., AND RHOADS, J. E. Long term parenteral nutrition with growth development and positive nitrogen balance, Surgery 64, 134 (1968). 2. DUDRICK, S. J., VARS, H. M., AND RHOADS, J. E. Long term intravenous hyperalimentation, Fed. PTOC. 27, 486 (1968). 3. WILMORE, D. W. Guarding against complications in subclavian vein catheterization, Hosp. Physician Vol. 6, 82 (1970). 4. WYRICK, W. J., RAE, W. J., AND MCCLELLAND, R. N. Rare complications with I.V. hyperosmotic alimentation, J. Amer. Med. Ass. 211, 1967-1968 (1970). 5. DUDRICK, S. J. Intravenous feeding as an aid to nutrition in disease, Co 26, I99 (1970).