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Principles of intravenous hyperalimentation
Principles of int ravenous hyperalimentation DeAnn M Englerf, RN Stanley J Dudrick, MD
The mechanisms of ingestion, digestion, absorption, and assimilation of nutrient substrates are a n intricate biochemical and physiological series of complex functions essential for normal growth and development, reproduction, and maintenance of homeostasis. The principal nutrients from which the human body extracts energy are carbohydrates, fats, and proteins. All cellular protoplasm contains protein, which normally constitutes 10% to 200/0 of the cell mass. Since nitrogen is the primary component that differentiates protein from other basic nutrient moieties, nitrogen balance can be employed as a reasonable index for measurement of nutritional status. More specifically, the level of protein metabolism can be estimated by measuring nitrogen balance. Negative nitrogen balance implies catabolism, or greater protein utilization than protein intake. When exogenous intake of foodstuffs is inadequate, the healthy person can use endogenous fat reserves to compensate for a transient calorie deficit; however, the patient sustaining a severe traumatic or septic insult cannot use his stored fat optimally. According to its severity,
protein depletion is associated with general debilitation, inanition, indolent wound healing, delayed convalescence, increased susceptibility to infection and hypovolemic shock, and numerous other pathophysiologic conditions. In a state of negative nitrogen balance, metabolic aberrations are more likely to occur because the organism’s intake of nutriments is significantly less than its total energy expenditure. Basal energy expenditure, physical activity, and stresses of illness impose demands of mechanical andlor chemical work, which determine net daily caloric requirements. When adequate nutrition is contraindicated or compromised via the enteral route, intravenous hyperalimentation (IVH) is efficacious in achieving restoration of normal metabolism during various phases of diagnosis, operation, or rehabilitation. Successful adjunctive parenteral nutrition basically imposes a shift in the patient’s obligatory response to stress from the catabolic to the anabolic mode. Parenteral alimentation-usually hyperalimentation (ie, in excess of the Recommended Dietary Allowances of
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~~
Table 7 Constituents of the “typical” IVH solution (Herrnann Hospital) Base solution 500 ml of 50% dextrose in water 500 rnl of 8.5% crystalline amino acid solution Other additives 40-50 mEq sodium chloride 20-30 mEq potassium acetate 10-15 rnEq potassium acid phosphate 15 mEq magnesium sulfate *5 ml Multiple Vitamin Infusion concentrate t 1 gm calcium gluconate Optional additives 12.5-50gm albumin 5-40 units regular insulin t0.5 ml imferon trace elements (requirements not fully established) *Added to only one unit per day ~~
the National Research Council)+an benefit as much as 20% of the average hospital population.’ The minimal reasonable goal of IVH support is t o promote meaningful life and not merely to prolong inevitable death. The technique of total parenteral feeding has proven to be lifesaving during a host of catastrophic clinical situations, and it is crucial in decreasing significantly the morbidity and mortality associated with many critical complications of surgery. In 1967, Dudrick and associates first demonstrated positive nitrogen balance and normal growth and development in an infant with massive congenital intestinal atresia.2 Since that time, the applications of IVH therapy have increased with dramatic results for a variety of patients when it is in-
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adequate, ill-advised, or impossible to use the gastrointestinal tract for nutri tional replenishment.
Classification of candidates for ZVH therapy Patients with fistulas of the alimentary tract. Prior to the advent of hyperalimentation therapy, patients with enterocutaneous and enteroenteric fistulas of the gastrointestinal pathway were relatively resistant to both nonoperative and operative intervention. The premature elimination of food and body fluid from the gut via a fistulous tract impaired gastrointestinal absorption, and the anatomical origin of the fistula determined the type and severity of subsequent nutritional derangements. For example, patients with proximal fistulas of the duodenum and jejunum could succumb rapidly to malnutrition; therefore, prompt surgical closure or resection of the affected bowel was necessary even though operative mortality was high. Distal fistulas were managed more successfully when dietary requirements were provided enterally, but mortality rates of 20% to 60% were not uncommonly reported. A treatment regimen involving total deprivation of oral intake and concomitant intravenous hyperalimentation will promote spontaneous closure of the vast majority of such fistulas. Total bowel rest reduces peristalsis to the absolute minimum, decreases the quantity of bacterial flora in the bowel, and eliminates the passage of roughage. Based on experience gained from a series of more than 100 consecutive fistula patients, Dudrick, et al, reported spontaneous healing without surgery in three out of four fistulas during an average treatment period of 35 days.3 Moreover, the overall mortality rate has been only 6% with a
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Fig 1. This 6dyear-old woman is an IVH outpatient at Hermann Hospital, The University of Texas Medical School at Houston. The vest, which supports the bags of nutrient solution, administration tubing, pump, and battery pack, is worn throughout the day when the patient is ambulatory, or can be hung from a rolling IV pole. As can be seen in the second photograph, the vest can be concealed, if desired, under appropriate clothing. Although nutrient absorption is virtually nil in this patient with a duodeno-transverse colostomy, she is allowed to ingest food for the purpose of oral gratification. Her electrolytes are monitored routinely because persistent diarrhea can result in hypokalemia, dehydration, and insidious metabolic acidosis.
postoperative mortality rate of only 3.6%. Additionally, the data suggest that an enterocutaneous fistula is more amenable to closure than a n internal fistula. Certain conditions are detrimental to spontaneous healing of these lesions and render nonoperative treatment ineffective. These include distal bowel obstruction, epithelialization of a fistulous tract, presence of a foreign body or an adjacent abscess, severe irradiation effects, and presence of malignancy a t the fistula site. When IVH
and total bowel rest do not induce spontaneous closure and surgery is indicated for definitive management of the fistula, preoperative nutritional repletion is therapeutic in minimizing the incidence of recurrent postoperative fistulization along the anastomotic suture line. Patients with inflammatory bowel disease. Idiopathic inflammatory bowel disease is a chronic relapsing condition characterized by mucosal damage in ulcerative colitis and transmural involvement in granulo-
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matous enterocolitis (Crohn’s disease). Although the patient’s symptoms are directly proportional to the severity of the inflammatory process, malaise, abdominal pain, vomiting, diarrhea, anorexia, and anemia are typical findings. Depending on the location and extent of the involved bowel segment, malabsorption and profound cachexia may appear early in the disease process, sometimes before surgical complications are manifest. Partial or complete bowel obstruction may occur when fibrosis and/or infection compromise the lumen of the gut. The internal and external fistulas associated with Crohn’s disease and infection with abscesses and bowel perforations frequently compound existing nutritional disorders. Moreover, the administration of antibiotics, steroids, and other anti-inflammatory or immunosuppressive agents that are sometimes indicated for treatment of inflammatory bowel disease may further adversely affect the nutritional status of the patient. Patients with acute exacerbations or who experience prolonged periods of active inflammatory bowel disease cannot tolerate an enteral diet without aggravation of gastrointestinal symptoms and malabsorption. The therapeutic results achieved by an IVH program in conjunction with total bowel rest have been documented in a series of 52 patients reported by Dudrick, et ala4In general, patients with Crohn’s disease responded more favorably than those with ulcerative colitis. In approximately 55% of these severe cases, the disease became quiescent within a few weeks, and an operation was not required. In another 25%, the disease became inactive; however, an operation was indicated to alleviate secondary complications such as bowel obstruction, stricture, or perforation
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with abscess. The remaining 20% of the patients did not experience a remission within two weeks of IVH treatment and required some form of operative management. However, persons who are well nourished are more tolerant of surgical trauma, and they usually recover with a lower incidence of postoperative complications. Patients with the short gut syndrome. Patients with the short bowel syndrome may have undergone massive intestinal resection(s) as a consequence of infection, inflammatory bowel disease, or vascular catastrophe involving the superior or inferior mesenteric artery. When the length of residual small bowel is less than 100 cm, the net result is persistent diarrhea, diminished absorptive capacity secondary to inadequate surface area, fluid and electrolyte imbalances, and weight loss. For at least two months after operation, the patient is not allowed oral intake, and he is nourished exclusively by parenteral means. Sufficient calories in the form of dextrose and protein moieties, along with electrolytes, minerals, vitamins, and other essential additives (Table 1) are infused into the patient to sustain or induce weight gain. Meanwhile, gut adaptation occurs through hypertrophy of the villi and increased absorptive area of the mucosal surface. During the third postoperative month, enteral intake is instituted until the patient has been weaned from the IVH to a relatively normal diet. Maximum bowel adaptation usually occurs approximately two years after resection, and the patient may require intermittent hospitalizations for WH during this time should intercurrent illness adversely affect normal gastrointestinal tract function. Patients with the “artificial gut.”
AORN Journal, June 1977, Vol25, No 7
HERMANN HOSPITAL PHARMACY
NAME: RM#
BASE:
Doe, John 53-98743 ~ Freami ne E.. , 2 5 0 ~INFUSION#
SCMB
.
LOT# ( % ( 4 \ ~ \ p C
D-50-W........5 0 0 ~ ~
LOT#
6 37 3 7 fi
-I% CONC:
-gm/100 ml)
901
TOTAL NITROGEN
3.46gm
ADDITIVES:
DOSAGE
March 8, 1977 8:lO A.M. INFUSE FILLEDBY: OVER 12 hours FLOW RATE. 86cc/hr TOTAL VOL. 1028cc
’p
TOTAL LYTES
rnl
Sterile W t
DATE:
1
CONC
-
Freami ne. ......1 . 2 2 % Dextrose ......22.03% TIME:
TOTAL CALORIES
LOT#
-
..250cc
63ik681
30 mEq NaCl 10 mEd KC1 15 mEq KHPO4 10 mEq MgS04 5 cc MVI Conc.
.
00 NOT START I N N S O N AFTER:
24 hours
Fig 2. This solution label is representative of the typical daily ration of a patient receiving IVH during renal failure.
Whenever a pathophysiologic dilemma necessitates sacrifice of the entire small intestine, the patient’s only chance for prolonged survival is total parenteral nutrition for life. S ~ r i b n e r , ~ Jeejeebhoy,6 and other investigators have designed various techniques for provision of a n “artificial gut.” After the permanent Silastic central venous feeding catheter has been inserted aseptically, the patient is instructed on proper procedures for self-maintenance of the system. When body weight and metabolic status have been stabilized, the individual is discharged from the hospital and managed chronically on a n outpatient basis. The IVH team a t Hermann Hospital, The University of Texas Medical School at Houston, has added a new dimension to home parenteral feeding with the concept and development of the ambulatory hyperalimentation
vest (Fig 1). Persons who otherwise would be dependent upon a rolling intravenous pole now have an opportunity for increased mobility and exercise and can return relatively unencumbered to many normal activities. The importance of fat as an integral part of prolonged intravenously supported metabolism should be emphasized. Fatty acids form basic units of the cellular membranes, which actively transport metabolites. Serum. essential fatty acid (EFA) deficiency has been documented in some longterm parenteral hyperalimentation patients. The EFA syndrome can be manifest by scaly skin, alopecia, poor wound healing, increased capillary fragility, morphologic liver and kidney changes, mitochondria1 aberrations, thrombocytopenia, and growth retardation in children. Alleviation andlor prevention of EFA symptoms in per-
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sons receiving IVH continuously can be accomplished by intermittent intravenous administration of a 10%~ soybean oil emulsion stabilized with egg yolk phosphatides in a solution of 2.5% glycerol. Ordinarily, two or three 500 ml units of this emulsion per week will prevent EFA deficiency in the average adult patient. If the patient is able to absorb even minimal quantities of food via his shortened gut, he might be able to satisfy his essential fatty acid requirement by ingesting 30 to 60 ml of safflower oil daily, thus avoiding the high cost of parenteral fat. In addition to supplemental fat, the patient who has less than six inches of terminal ileum must receive intramuscular doses of folic acid and cyanocobalamin (vitamin B12) indefinitely. Dietary sources of vitamin K are absorbed in the small intestine, and bacterial flora in the colon synthesize and absorb additional vitamin K. Persons with short gut syndrome are given weekly intramuscular doses of vitamin K to avoid deficiency that could result in abnormal blood coagulation. Patients with severe burns. Massive tissue destruction in the severely burned patient triggers a hormonemediated response to stress that is maladaptive and results in phenomenal increases of energy expenditure, protein catabolism, and rapid loss of body weight. In simple starvation over prolonged periods of time, the body can tolerate 50% reduction in lean body tissue before death supervenes. Without hyperalimentation, a patient with a third-degree burn may lose 30% of his body weight within several weeks. When coupled with sepsis and impaired immunocompetence, this magnitude of weight loss is often incompatible with life,
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Large amounts of protein lost through the burn wound, radiated heat loss, insensible water loss, fever, inflammation, and infection induce a state of chronic negative nitrogen balance in the patient. The catabolic response to the trauma may be so overwhelming that persons with fullthickness burns may require more than 10,000 kilocalories per day to meet energy losses. Hyperalimentation does not abolish the stress response; however, it can help significantly to meet the increased nutrient substrate demands and replace the increased losses of the burned patient. Daily dietary requirements will not return to normal ranges until the entire burned surface is covered with epithelium. The inert individual can seldom consume more than 4,000 kilocalories per day via the gastrointestinal tract without discomfort, while a forced intake of 5,000 kilocalories would be likely to result in vomiting and/or diarrhea. With adjunctive diuretic therapy as required to excrete excess water, some severely burned individuals have received a s many as 7,000 kilocalories per day via the hyperalimentation technique without complications. Hence, when gastrointestinal and parenteral feeding are combined, 10,000 calories can be administered to some patients in hypermetabolic states. Control of infection with topical antimicrobial agents, optimum surgical treatment involving wound debridement and autogenous skin grafting, and provision of adequate protein and calories are necessary to minimize catabolic activities. Tissue granulation occurs earlier in burned patients receiving IVH, increasing the probability that autogenous skin grafts will survive. Additionally, respiratory
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complications and sepsis, which could delay recovery, are less frequent in patients who are fed adequately by vein compared with those who are not. Patients in renal failure. Catabolic body wasting in the presence of excessive nitrogen retention characterizes the clinical course of the patient in
is restricted to those food products having high biologic or nitrogen value. A specialized IVH formulation of essential L-amino acids and other nonnitrogenous micronutrients (Fig 2) has been therapeutic in the management of renal failure patients. When essential amino acids are
Fig 3. Percutaneous infraclavicular subclavian venipuncture.
acute or chronic renal failure. The azotemic individual experiences anorexia, nausea, vomiting, stomatitis, fatigue, muscular irritability, and uremic gastroenteropathy that may preclude nourishment via the gastrointestinal tract. When permissible, the traditional oral nutritional regimen for such patients is a high calorie, low protein diet. Protein consumption
supplied parenterally, the protein synthetic mechanisms of the body are capable of utilizing urea as a source of nonessential. nitrogen for return to functional lean tissue. The net result is reduction in the total body urea nitrogen, alleviation of azotemic symptoms, and sustenance of nutritional balance. Patients with malignant disease.
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Cancer patients with normal eating habits have been reported to lose weight while their malignancies gain in bulk. Neoplastic cells extract nutrient substrates from their host, and as nutritional depletion ensues, the host's ability to increase caloric ingestion on the basis of need seems to be impaired. As a general axiom, weight loss of the host parallels the extent of tumor burden; however, loss of body mass is often the presenting symptom in persons with leukemia, lymphoma, or oat-cell carcinoma of the lung. Chemotherapy and abdominal radiation treatment have emerged as therapeutic modalities for eradication or palliation of tumor growth. These oncologic measures can result in a nutritional insult to the patient that may enhance malnutrition. Most chemotherapeutic drug protocols produce toxic side effects such as anorexia, nausea, vomiting, diarrhea, and/or stomatitis. Depending on which antineoplastic drug is used, the gastrointestinal side effects are equally or better tolerated in a patient receiving intravenous hyperalimentation. For instance, vinblastine and bleomycin in combination produce marked stomatitis that is no less severe in the IVH patient than in the non-IVH patient. Conversely, nausea, vomiting, and stomatitis secondary to administration of 5-fluorouracil are reduced in the IVH patient. Often multiple courses of cytotoxic drugs may be given during one hospitalization, and two to three times the usual dosage can be delivered to the patient per unit time. To date, intravenous hyperalimentation has had no documented effect on the duration of leukocyte depression in any chemotherapy regimens. A positive correlation between nutritional status and potential for response to chemotherapy has been
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noted by Lanzotti and Samuels.' Persons whose tumors responded by a 50% or greater reduction in size gained an average of 8% of their body weight, while patients who did not respond to chemotherapy gained little or no weight. When IVH is administered during abdominal radiation therapy, symptoms of radiation-induced enteritis abate. Oropharyngeal mucositis associated with head and neck radiation is less irritating when the patient is nourished exclusively by vein. Weight loss is typical when a malignant lesion results in malabsorption, obstruction of the gut lumen, or production of pain with ingestion of foodstuffs. Some cancers achieve a large size before they metastasize and are anatomically resectable. Adequate nutrition for proper wound healing becomes critical when extensive curative surgical procedures are undertaken. Malnutrition depresses established cell-mediated immunity, and thereby one of the body's most potent defenses against bacteria, fungi, and viruses is compromised. When leukocyte depression secondary to chemotherapy is superimposed, the body is almost defenseless against infection. Many malnourished cancer patients are anergic to a battery of skin test antigens. After several weeks or months of IVH therapy, a significant number of persons convert to positive skin reactions. In only those patients with positive skin reactivity did chemotherapy result in tumor regression. There were no episodes of sepsis in those persons who developed or retained positive responses. The conclusion follows that adequate nutrients must be available to the body for optimal immunological reactivity.8 Infants with failure to thrive and congenital anomalies. Shneour has
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Fig 4. Central venous feeding catheter and hyperalimentation delivery system in an
emphasized that severe malnutrition in the perinatal period reduces brain size relative to body weight and possibly impairs intelligence p e r m a n e n t l ~ . ~ IVH is especially applicable for promotion of normal growth and development in infants with idiopathic diarrhea and congenital anomalies such as tracheoesophageal fistula, omphalocele, gastroschisis, small bowel atresia, cystic fibrosis, meconium ileus, diaphragmatic hernia, volvulus, malrotation of the gut, and annular pancreas. Premature infants weighing less than 700 gm a t birth have benefited from intravenous hyperalimentation. The immaturity of the infant’s liver may limit his capacity to process nitrogenous wastes into urea, and he may become hyperammonemic. The proportion of the amino acids in the IVH infusate can be reduced to onehalf concentration and then gradually increased as tolerance improves. The
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IVH preparation is fortified with additional arginine since this amino acid appears to improve the liver’s capacity to process ammonia. Miscellaneous indications for IVH. The high incidence of aspiration pneumonia in geriatric patients with senile dementia may be attributed t o
as they vary during the course of therapy. Procedure for delivery of IVH solution Hyperalimentation fluid has approximately six times the solute concentration of blood and exerts an osmotic pressure of 1800 to 2400 mOsm per liter, depending on the additives. Infu-
Fig 5. Implantation of Silastic feeding catheter for permanent parenteral hyp eralimentation.
regurgitation of oral or tube feedings. This can be obviated by IVH until the patient is sufficiently alert and capable of ingesting his nutrient ration safely and effectively. Debilitation can occur in numerous pathophysiologic conditions such as anorexia nervosa, hyperemesis gravidarum, nonterminal coma, peritonitis, sepsis, celiac disease, protein-losing enteropathies, and following multiple surgical procedures. Individual metabolic requirements should be met as precisely as possible
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sion of concentrated nutrients is caustic to the intima of peripheral veins and has been associated with development of phlebitis, sclerosis, and/or thrombosis. To achieve prompt, adequate dilution of the hypertonic substrates, IVH solution must be infused into the circulatory system through a large-bore, high-flow blood vessel, preferably the superior vena cava. Percutaneous subclavian venipuncture. Based on our extensive clinical
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experience, percutaneous infraclavicular subclavian venipuncture has been the safest and most effective technique for long-term catheterization of the superior vena cava in adults and in infants weighing more than 10 pounds. With care, subclavian cannulation is a relatively safe, simple surgical procedure performed most often in the patient’s room, but also in the operating room or the recovery room. Unless there is a specific contraindication, such as previous radical neck dissection, clavicular fracture, or radical mastectomy, either the right or left subclavian vein can be catheterized. Despite the theoretical possibility of thoracic duct injury on the left side, this complication has rarely been observed. In the past 4% years at Hermann Hospital, only 2 of 749 IVH patients suffered thoracic duct injury. In both cases, cessation of lymphatic drainage and spontaneous closure of the fistula were accomplished by removal of the central venous line and subsequent administration of IVH through a right subclavian vein catheter. The patient is placed supine in the Trendelenburg position to allow maximum dilatation and filling of the subclavian vein and to increase central venous pressure to avoid air embolism during catheter insertion. A rolled sheet or towel is placed longitudinally along the thoracic spine to allow the shoulders to be hyperextended. (In the extremely cachectic person, this roll is not placed between the scapulae because hyperextension augments the possibility of inadvertent puncture of the apical pleura.) The patient’s head is then rotated to the side opposite that of venipuncture. The skin over the neck, shoulder, and entire upper thorax is shaved, defatted with ether or acetone, and pre-
pared with povidone-iodine solution for a minimum of five minutes. The bacteriocidal scrub is of utmost importance because residual skin contaminants can be transported from the puncture site into the lumen of the vein and induce nosocomial infection. The nurse can identify breaks in sterile technique as she assists the physician during the catheterization procedure. After the surgical field is draped with sterile towels, a local anesthetic agent (1%lidocaine) is infiltrated into the skin, subcutaneous tissue, and periosteum a t the midpoint of the inferior border of the clavicle. More than 3 ml of lidocaine may displace the subclavian vein and render successful venipuncture difficult. A 2-inch, 14gauge needle attached to a 3-ml syringe is inserted into the skin wheal and directed in a frontal plane immediately beneath the medial onethird of the clavicle and toward a finger pressed firmly into the suprasternal notch (Fig 3). After the needle punctures the skin surface, slight negative pressure is applied to the syringe to ascertain accuracy of the venipuncture by a backflow of venous blood. When blood first appears in the syringe, the needle is advanced a few millimeters further to insure placement of the entire bevel of the needle within the vein lumen. While the needle is held securely in place with a hemostat, the syringe is detached with caution. At the same time, the patient is asked to perform a Valsalva maneuver to increase intrathoracic pressure and to minimize the possibility of air embolism. An %inch, 16-gauge radiopaque polyvinyl, silicone rubber, or Teflon catheter is advanced entirely into the central vein. After the catheter has been directed a few inches within the vein,
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the patient can turn his head toward the venipuncture site to decrease the diameter of the subclavian-jugular junction and reduce the possibility of advancing the catheter tip into the jugular vein. If difficulty is encountered when threading the catheter, the needle may be cautiously advanced a few millimeters into the vein and then rotated a few degrees. Should further resistance occur, the catheter and needle are withdrawn as a unit to prevent severance and embolization of the catheter tip. For this reason, the catheter must never be withdrawn through the needle after it has been advanced past the needle point. The needle is retracted until approximately 2 cm of catheter are exposed between the beveled tip of the needle and the puncture site. Sterile intravenous tubing containing an isotonic solution is plugged into the catheter hub, and the catheter is immediately flushed. The solution bottle or bag is momentarily lowered below the level of the superior vena cava and then raised several feet above the patient’s head. Prompt flashback followed by forward flow of blood into the venous system indicates proper catheter placement in the superior vena cava. A plastic clip is placed around the beveled needle tip to prevent shearing of the catheter and embolization into the circulatory system. The catheter is sutured t o the skin lateral to the skin entrance site using 3-0 silk, and povidone-iodine ointment is applied over the puncture site. A small sterile dressing is affixed to the skin using tincture of benzoin and adhesive tape to maintain occlusiveness of the system. The administration tubing is looped and secured with adhesive tape to guard against unintentional traction, which might detach the tubing
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from the hub or pull out the catheter. All connections are reinforced with adhesive tape to prevent inadvertent separation with resultant loss of blood, sepsis, and/or air embolism. A chest roentgenogram is obtained to confirm proper catheter location in the middle of the superior vena cava and to rule out the possibility of a pneumothorax. When hyperalimentation fluid is infused into the right atrium, there is increased risk of clotting and endocarditis. Thus, the catheter tip must never be allowed to rest within the heart. Should an attempt at subclavian venipuncture be futile, the patient’s chest should be examined to rule out the possibility of pneumothorax prior to attempting insertion of the venous line on the contralateral side. In the Hermann Hospital IVH population, pneumothorax has been a relatively infrequent complication (1.4%). All patients responded promptly and without sequelae to simple, closed tube thoracostomy. After verification of proper catheter position, the IVH solution is infused into the patient’s superior vena cava. When meticulous attention is paid to anatomical details and to aseptic technique, complications such as pneumothorax, tension pneumothorax, hemothorax, hydrothorax, subcutaneous emphysema, subclavian hematoma, thoracic duct injury, hydromediastinum, air embolism, catheter embolism, brachial plexus injury, arteriovenous fistula, endocarditis, venobronchial fistulization, and osteomyelitis of the clavicle are rarely reported. If a patient is susceptible to periodic bacteremia, eg, when the clavicular area is burned, the catheter is changed twice weekly to prevent buildup of thrombin or fibrin, which could serve as a secondary focus of sepsis if seeded from elsewhere in the
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body. A subclavian catheter cannot be placed within a radiated field without increased possibility of sepsis. Jugular vein cutdown. When an infant weighs less than 10 pounds, his small subclavian vein and high apex of the lung make subclavian venipuncture difficult and hazardous. The neonatal patient is taken to the operating room, and a silicone rubber or Teflon catheter is inserted through the external or internal jugular vein. The internal jugular vein can be catheterized via its common facial vein branch at the angle of the jaw or directly through a purse-string of 5-0 silk. The external jugular vein is exposed for direct catheterization by making a 1cm incision, approximately a centimeter above the base of the neck a t the midclavicular line. The vein is ligated proximally, and a small venotomy is made using a number 11 knifeblade. After the tip of an 18-gauge catheter has been inserted into the lumen of the vein, gentle traction on the ligatures may facilitate the advancement of the catheter into the superior vena cava. The catheter is advanced a length equal to the distance from the cutdown site to the second intercostal space. After proper placement into the superior vena cava has been confirmed by roentgenographic examination, the catheter is secured to the vein using several 4-0 silk ligatures. Finally, the catheter is tunneled subcutaneously in the postauricular area to emerge through a tiny stab wound in the parietal scalp. This can be accomplished by directing it through the lumen of a Vim Silverman needle or threading it onto a modified Kirschner wire. The external portion of the catheter is thus removed from the searching hands of the infant, and the risk of sepsis and mechanical kinking
is reduced. The neck wound is closed, and the catheter is sutured at the scalp site using 4-0 silk. Antimicrobial ointment is applied, and a sterile, occlusive bandage is fixed to the skin. IVH fluid is delivered to the infant via a constant infusion pump, and a 0.22 micron in-line filter is inserted between the central catheter and the pediatric buret tubing (Fig 4). Insertion of a permanent Silastic catheter. The Scribner and Broviac silicone rubber catheters have enhanced long-term indwelling catheterization. Insertion is performed in the operating room with the use of local anesthesia. After the skin area has been prepared as for percutaneous subclavian catheterization, a small stab wound is made in the skin of the anterior chest wall lateral to the xiphoid. The patient must have easy, comfortable access to this puncture site if he is to maintain the infusion system independently. A second incision is made in close proximity t o the vein that will be cannulated. When the subclavian veins are thrombosed, any vein in the area such as the jugular or cephalic can be used, and the catheter can be threaded beneath the clavicle. The silicone rubber catheter is tunneled subcutaneously through a trocar and is sutured to the skin with 3-0 silk. Firm tissue ingrowth into the Dacron cuff with secondary catheter fixation occurs in two to three weeks, and the cuff then serves as a barrier against bacterial or fungal invasion along the catheter tract. After proximal ligation of the vein, a small venotomy is made, and the catheter is advanced into the superior vena cava with fluoroscopic control. The venotomy skin wound is sutured (Fig 5 ) , and two small sterile dressings are applied. When infusion of IVH solution is
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desirable on a n intermittent basis, a heparin lock will maintain the patency of the intravenous line. Following injection of 1 ml of sodium heparin (1,000 units per milliter), the hub is plugged with a sterile cap. The nurse’s role in hyperalimentation therapy Adherence to rigid aseptic practices during insertion and maintenance of the infusion cannula will insure a low incidence of catheter-related sepsis (1.05% at Hermann Hospital). To augment catheter longevity after insertion, application of a sterile, occlusive dressing every Monday, Wednesday, and Friday is strongly recommended. When this task is performed by the same person, comparative observations of changes in skin appearance are easy to make. Erythema, inflammation, pain, or purulence a t the puncture site may be indicative of catheter-related infection. The operating room nurse should never violate the aseptic integrity of the IVH “lifeline.” Unnecessary manipulation of the delivery tubing increases the opportunity for contamination and is thus avoided whenever possible. No blood or blood products are infused through the venous catheter, nor is blood aspirated for the purposes of laboratory testing except during a life-threatening situation. The subclavian line is not used routinely for the injection of bolus medication or for monitoring of central venous pressure. Should the subclavian dressing become soiled or wet during operation, it should be replaced promptly. Infusions of hypertonic solutions are delivered initially a t a slow constant rate not to exceed the patient’s inherent rate of metabolic utilization of the individual micronutrients. Without sufficient circulating insulin, glucose is not transported effectively across 1266
the cell membrane. Whenever a n administered glucose load exceeds the renal threshold of the kidneys, sugar appears in the urine. Titrating against the indices of blood glucose levels and glycosuria, the carbohydrate load is cautiously increased to a maximum dose. The average ill adult usually tolerates 3 liters per day of 25% dextrose without utilization problems. During major operations, the ability of patients to metabolize glucose is diminished. Prior to surgery, patients should be “weaned” from the concentrated nutrients in a manner similar but opposite to the successive advancement during the first few days of IVH. Hypoglycemia may occur after abrupt cessation of the infusate, and symptoms of this condition include muscular weakness, anxiety, mental confusion, restlessness, diaphoresis, vertigo, pallor, and tremor. Delivery of 5% dextrose in water or in lactated Ringer’s solution during operation will generally avoid occult hypoglycemia under anesthesia and its serious consequences. It is important not to allow IVH fluid to be infused into patients intraoperatively. Inadvertent rapid infusion of the hypertonic solution can lead to serious hyperglycemia, hyperosmolar dehydration, hypovolemic shock, and/or irreversible central nervous system injury. For comparative evaluation, each patient is weighed daily a t the same time, on the same scale, and wearing the same amount of clothing. In general, 1/4 to 1 pound weight gain per day is indicative of a reasonable accumulation of lean body tissue. Accurate intake and output data are recorded every eight hours, and significant variations from the acceptable range are reported to the physician. As a member of the IVH team, the nurse contributes a great deal to the successful management of the patient
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receiving parenteral hyperalimentation. Her role can be summarized by classification into four major areas: (1) maintenance of the integrity of the central venous catheter, (2) regulation of fluid intake, (3) monitoring of fluid balance, and (4) development of a therapeutic nurse-patient relationship. Conclusion. An integrated physicochemical organism, man functions on a digestive-absorptive-metabolic continuum. Whenever homeostasis of this indigenous process is disrupted during various phases of illness, the established technique of total parenteral nutrition can support normal growth and development in infants and anabolism in adults for indefinite periods of time. When the patient's nutritional status is maintained in positive nitrogen balance throughout the diagnostic, preopertive, operative, postoperative, convalescent, and rehabilitation periods, his prognosis is markedly improved. Current principles and practices of IVH therapy, including expanded indications, improved methods and materials for catheter insertion and maintenance, and the nurse's responsibilities will undoubtedly undergo changes and modifications with future application of current clinical research in the rapidly advancing field of total parenteral nutrition.
0
Notes 1. Stanley J Dudrick, Edward M Copeland 111, Bruce V MacFadyen, Jr, "Long-term parenteral nutrition: Its current status," Hospital Practice (May 1975) 47. 2. Douglas W Wilmore, Stanley J Dudrick, "Growth and development of an infant receiving all nutrients exclusively by vein," Journal of the American Medical Association 203 (March 4, 1968) 140-144. Stanley J Dudrick, et al, "Experimental aspects of total parenteral alimentation," in Total Parenteral Alimentation, C Manni, S I Magalini, E Scrascia, eds. (New York: American Elsevier Publishing CO, Inc, 1976) 8. 4. Stanley J Dudrick, B V MacFadyen, Jr, John M Daly, "Management of inflammatory bowel disease with parenteral hyperalimentation," in Gas-
trointestinal Emergencies, The Thirty-fourth Hahnemann Symposium. Harris R Clearfield, Vicente P Dinoso, Jr, eds. (New York: Grune and Stratton Publishers, March 1976). 5. J W Broviac, J J Cole, B H Scribner, "A silicone rubber atrial catheter for prolonged parenteral alimentation," Surgery, Gynecology, and Obstetrics 136 (April 1973) 1-5. 6. K N Jeejeebhoy, et al, "Total parenteral nutrition at home for 23 months, without complications and with good rehabilitation," Gastroenterology 65 (November 1973) 81 1-820. 7. Edward M Copeland 111, et al, "Intravenous hyperalimentation as an adjunct to cancer chemotherapy," The American Journal of Surgery 129 (February 1975) 172. E. Edward M Copeland, Bruce V MacFadyen, Stanley J Dudrick, "Effects of intravenous hyperalimentation on established delayed hypersensitivity in the cancer patient," Annals of Surgery 184 (July 1976) 63. 9. Elie A Shneour, The Malnourished Mind (Garden City, NY: Anchor Press, 1974) 6.
DeAnn M Englert, R N , is hyperalimentation nurse coordinator, Hermann Hospital, T h e University of Texas Medical School at Houston. S h e is also a n instructor i n surgery, T h e University o f Texas Medical School at Houston. S h e has a B S N from T h e University of Texas System-wide School o f Nursing. Stanley J Dudrick, MD, is professor and chairman, Department of Surgery, University of Texas Medical School at Houston; chief of surgical services, Hermann Hospital, and consultant i n surgery, T h e University of Texas System Cancer Center, MD Anderson Hospital and Tumor Institute. H e is a graduate of Franklin and Marshall College and the University of Pennsylvania School of Medicine.
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The mechanisms of ingestion, digestion, absorption, and assimilation of nutrient substrates are a n intricate biochemical and physiological series of complex functions essential for normal growth and development, reproduction, and maintenance of homeostasis. The principal nutrients from which the human body extracts energy are carbohydrates, fats, and proteins. All cellular protoplasm contains protein, which normally constitutes 10% to 200/0 of the cell mass. Since nitrogen is the primary component that differentiates protein from other basic nutrient moieties, nitrogen balance can be employed as a reasonable index for measurement of nutritional status. More specifically, the level of protein metabolism can be estimated by measuring nitrogen balance. Negative nitrogen balance implies catabolism, or greater protein utilization than protein intake. When exogenous intake of foodstuffs is inadequate, the healthy person can use endogenous fat reserves to compensate for a transient calorie deficit; however, the patient sustaining a severe traumatic or septic insult cannot use his stored fat optimally. According to its severity,
protein depletion is associated with general debilitation, inanition, indolent wound healing, delayed convalescence, increased susceptibility to infection and hypovolemic shock, and numerous other pathophysiologic conditions. In a state of negative nitrogen balance, metabolic aberrations are more likely to occur because the organism’s intake of nutriments is significantly less than its total energy expenditure. Basal energy expenditure, physical activity, and stresses of illness impose demands of mechanical andlor chemical work, which determine net daily caloric requirements. When adequate nutrition is contraindicated or compromised via the enteral route, intravenous hyperalimentation (IVH) is efficacious in achieving restoration of normal metabolism during various phases of diagnosis, operation, or rehabilitation. Successful adjunctive parenteral nutrition basically imposes a shift in the patient’s obligatory response to stress from the catabolic to the anabolic mode. Parenteral alimentation-usually hyperalimentation (ie, in excess of the Recommended Dietary Allowances of
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~~
Table 7 Constituents of the “typical” IVH solution (Herrnann Hospital) Base solution 500 ml of 50% dextrose in water 500 rnl of 8.5% crystalline amino acid solution Other additives 40-50 mEq sodium chloride 20-30 mEq potassium acetate 10-15 rnEq potassium acid phosphate 15 mEq magnesium sulfate *5 ml Multiple Vitamin Infusion concentrate t 1 gm calcium gluconate Optional additives 12.5-50gm albumin 5-40 units regular insulin t0.5 ml imferon trace elements (requirements not fully established) *Added to only one unit per day ~~
the National Research Council)+an benefit as much as 20% of the average hospital population.’ The minimal reasonable goal of IVH support is t o promote meaningful life and not merely to prolong inevitable death. The technique of total parenteral feeding has proven to be lifesaving during a host of catastrophic clinical situations, and it is crucial in decreasing significantly the morbidity and mortality associated with many critical complications of surgery. In 1967, Dudrick and associates first demonstrated positive nitrogen balance and normal growth and development in an infant with massive congenital intestinal atresia.2 Since that time, the applications of IVH therapy have increased with dramatic results for a variety of patients when it is in-
1254
adequate, ill-advised, or impossible to use the gastrointestinal tract for nutri tional replenishment.
Classification of candidates for ZVH therapy Patients with fistulas of the alimentary tract. Prior to the advent of hyperalimentation therapy, patients with enterocutaneous and enteroenteric fistulas of the gastrointestinal pathway were relatively resistant to both nonoperative and operative intervention. The premature elimination of food and body fluid from the gut via a fistulous tract impaired gastrointestinal absorption, and the anatomical origin of the fistula determined the type and severity of subsequent nutritional derangements. For example, patients with proximal fistulas of the duodenum and jejunum could succumb rapidly to malnutrition; therefore, prompt surgical closure or resection of the affected bowel was necessary even though operative mortality was high. Distal fistulas were managed more successfully when dietary requirements were provided enterally, but mortality rates of 20% to 60% were not uncommonly reported. A treatment regimen involving total deprivation of oral intake and concomitant intravenous hyperalimentation will promote spontaneous closure of the vast majority of such fistulas. Total bowel rest reduces peristalsis to the absolute minimum, decreases the quantity of bacterial flora in the bowel, and eliminates the passage of roughage. Based on experience gained from a series of more than 100 consecutive fistula patients, Dudrick, et al, reported spontaneous healing without surgery in three out of four fistulas during an average treatment period of 35 days.3 Moreover, the overall mortality rate has been only 6% with a
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Fig 1. This 6dyear-old woman is an IVH outpatient at Hermann Hospital, The University of Texas Medical School at Houston. The vest, which supports the bags of nutrient solution, administration tubing, pump, and battery pack, is worn throughout the day when the patient is ambulatory, or can be hung from a rolling IV pole. As can be seen in the second photograph, the vest can be concealed, if desired, under appropriate clothing. Although nutrient absorption is virtually nil in this patient with a duodeno-transverse colostomy, she is allowed to ingest food for the purpose of oral gratification. Her electrolytes are monitored routinely because persistent diarrhea can result in hypokalemia, dehydration, and insidious metabolic acidosis.
postoperative mortality rate of only 3.6%. Additionally, the data suggest that an enterocutaneous fistula is more amenable to closure than a n internal fistula. Certain conditions are detrimental to spontaneous healing of these lesions and render nonoperative treatment ineffective. These include distal bowel obstruction, epithelialization of a fistulous tract, presence of a foreign body or an adjacent abscess, severe irradiation effects, and presence of malignancy a t the fistula site. When IVH
and total bowel rest do not induce spontaneous closure and surgery is indicated for definitive management of the fistula, preoperative nutritional repletion is therapeutic in minimizing the incidence of recurrent postoperative fistulization along the anastomotic suture line. Patients with inflammatory bowel disease. Idiopathic inflammatory bowel disease is a chronic relapsing condition characterized by mucosal damage in ulcerative colitis and transmural involvement in granulo-
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matous enterocolitis (Crohn’s disease). Although the patient’s symptoms are directly proportional to the severity of the inflammatory process, malaise, abdominal pain, vomiting, diarrhea, anorexia, and anemia are typical findings. Depending on the location and extent of the involved bowel segment, malabsorption and profound cachexia may appear early in the disease process, sometimes before surgical complications are manifest. Partial or complete bowel obstruction may occur when fibrosis and/or infection compromise the lumen of the gut. The internal and external fistulas associated with Crohn’s disease and infection with abscesses and bowel perforations frequently compound existing nutritional disorders. Moreover, the administration of antibiotics, steroids, and other anti-inflammatory or immunosuppressive agents that are sometimes indicated for treatment of inflammatory bowel disease may further adversely affect the nutritional status of the patient. Patients with acute exacerbations or who experience prolonged periods of active inflammatory bowel disease cannot tolerate an enteral diet without aggravation of gastrointestinal symptoms and malabsorption. The therapeutic results achieved by an IVH program in conjunction with total bowel rest have been documented in a series of 52 patients reported by Dudrick, et ala4In general, patients with Crohn’s disease responded more favorably than those with ulcerative colitis. In approximately 55% of these severe cases, the disease became quiescent within a few weeks, and an operation was not required. In another 25%, the disease became inactive; however, an operation was indicated to alleviate secondary complications such as bowel obstruction, stricture, or perforation
1256
with abscess. The remaining 20% of the patients did not experience a remission within two weeks of IVH treatment and required some form of operative management. However, persons who are well nourished are more tolerant of surgical trauma, and they usually recover with a lower incidence of postoperative complications. Patients with the short gut syndrome. Patients with the short bowel syndrome may have undergone massive intestinal resection(s) as a consequence of infection, inflammatory bowel disease, or vascular catastrophe involving the superior or inferior mesenteric artery. When the length of residual small bowel is less than 100 cm, the net result is persistent diarrhea, diminished absorptive capacity secondary to inadequate surface area, fluid and electrolyte imbalances, and weight loss. For at least two months after operation, the patient is not allowed oral intake, and he is nourished exclusively by parenteral means. Sufficient calories in the form of dextrose and protein moieties, along with electrolytes, minerals, vitamins, and other essential additives (Table 1) are infused into the patient to sustain or induce weight gain. Meanwhile, gut adaptation occurs through hypertrophy of the villi and increased absorptive area of the mucosal surface. During the third postoperative month, enteral intake is instituted until the patient has been weaned from the IVH to a relatively normal diet. Maximum bowel adaptation usually occurs approximately two years after resection, and the patient may require intermittent hospitalizations for WH during this time should intercurrent illness adversely affect normal gastrointestinal tract function. Patients with the “artificial gut.”
AORN Journal, June 1977, Vol25, No 7
HERMANN HOSPITAL PHARMACY
NAME: RM#
BASE:
Doe, John 53-98743 ~ Freami ne E.. , 2 5 0 ~INFUSION#
SCMB
.
LOT# ( % ( 4 \ ~ \ p C
D-50-W........5 0 0 ~ ~
LOT#
6 37 3 7 fi
-I% CONC:
-gm/100 ml)
901
TOTAL NITROGEN
3.46gm
ADDITIVES:
DOSAGE
March 8, 1977 8:lO A.M. INFUSE FILLEDBY: OVER 12 hours FLOW RATE. 86cc/hr TOTAL VOL. 1028cc
’p
TOTAL LYTES
rnl
Sterile W t
DATE:
1
CONC
-
Freami ne. ......1 . 2 2 % Dextrose ......22.03% TIME:
TOTAL CALORIES
LOT#
-
..250cc
63ik681
30 mEq NaCl 10 mEd KC1 15 mEq KHPO4 10 mEq MgS04 5 cc MVI Conc.
.
00 NOT START I N N S O N AFTER:
24 hours
Fig 2. This solution label is representative of the typical daily ration of a patient receiving IVH during renal failure.
Whenever a pathophysiologic dilemma necessitates sacrifice of the entire small intestine, the patient’s only chance for prolonged survival is total parenteral nutrition for life. S ~ r i b n e r , ~ Jeejeebhoy,6 and other investigators have designed various techniques for provision of a n “artificial gut.” After the permanent Silastic central venous feeding catheter has been inserted aseptically, the patient is instructed on proper procedures for self-maintenance of the system. When body weight and metabolic status have been stabilized, the individual is discharged from the hospital and managed chronically on a n outpatient basis. The IVH team a t Hermann Hospital, The University of Texas Medical School at Houston, has added a new dimension to home parenteral feeding with the concept and development of the ambulatory hyperalimentation
vest (Fig 1). Persons who otherwise would be dependent upon a rolling intravenous pole now have an opportunity for increased mobility and exercise and can return relatively unencumbered to many normal activities. The importance of fat as an integral part of prolonged intravenously supported metabolism should be emphasized. Fatty acids form basic units of the cellular membranes, which actively transport metabolites. Serum. essential fatty acid (EFA) deficiency has been documented in some longterm parenteral hyperalimentation patients. The EFA syndrome can be manifest by scaly skin, alopecia, poor wound healing, increased capillary fragility, morphologic liver and kidney changes, mitochondria1 aberrations, thrombocytopenia, and growth retardation in children. Alleviation andlor prevention of EFA symptoms in per-
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sons receiving IVH continuously can be accomplished by intermittent intravenous administration of a 10%~ soybean oil emulsion stabilized with egg yolk phosphatides in a solution of 2.5% glycerol. Ordinarily, two or three 500 ml units of this emulsion per week will prevent EFA deficiency in the average adult patient. If the patient is able to absorb even minimal quantities of food via his shortened gut, he might be able to satisfy his essential fatty acid requirement by ingesting 30 to 60 ml of safflower oil daily, thus avoiding the high cost of parenteral fat. In addition to supplemental fat, the patient who has less than six inches of terminal ileum must receive intramuscular doses of folic acid and cyanocobalamin (vitamin B12) indefinitely. Dietary sources of vitamin K are absorbed in the small intestine, and bacterial flora in the colon synthesize and absorb additional vitamin K. Persons with short gut syndrome are given weekly intramuscular doses of vitamin K to avoid deficiency that could result in abnormal blood coagulation. Patients with severe burns. Massive tissue destruction in the severely burned patient triggers a hormonemediated response to stress that is maladaptive and results in phenomenal increases of energy expenditure, protein catabolism, and rapid loss of body weight. In simple starvation over prolonged periods of time, the body can tolerate 50% reduction in lean body tissue before death supervenes. Without hyperalimentation, a patient with a third-degree burn may lose 30% of his body weight within several weeks. When coupled with sepsis and impaired immunocompetence, this magnitude of weight loss is often incompatible with life,
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Large amounts of protein lost through the burn wound, radiated heat loss, insensible water loss, fever, inflammation, and infection induce a state of chronic negative nitrogen balance in the patient. The catabolic response to the trauma may be so overwhelming that persons with fullthickness burns may require more than 10,000 kilocalories per day to meet energy losses. Hyperalimentation does not abolish the stress response; however, it can help significantly to meet the increased nutrient substrate demands and replace the increased losses of the burned patient. Daily dietary requirements will not return to normal ranges until the entire burned surface is covered with epithelium. The inert individual can seldom consume more than 4,000 kilocalories per day via the gastrointestinal tract without discomfort, while a forced intake of 5,000 kilocalories would be likely to result in vomiting and/or diarrhea. With adjunctive diuretic therapy as required to excrete excess water, some severely burned individuals have received a s many as 7,000 kilocalories per day via the hyperalimentation technique without complications. Hence, when gastrointestinal and parenteral feeding are combined, 10,000 calories can be administered to some patients in hypermetabolic states. Control of infection with topical antimicrobial agents, optimum surgical treatment involving wound debridement and autogenous skin grafting, and provision of adequate protein and calories are necessary to minimize catabolic activities. Tissue granulation occurs earlier in burned patients receiving IVH, increasing the probability that autogenous skin grafts will survive. Additionally, respiratory
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complications and sepsis, which could delay recovery, are less frequent in patients who are fed adequately by vein compared with those who are not. Patients in renal failure. Catabolic body wasting in the presence of excessive nitrogen retention characterizes the clinical course of the patient in
is restricted to those food products having high biologic or nitrogen value. A specialized IVH formulation of essential L-amino acids and other nonnitrogenous micronutrients (Fig 2) has been therapeutic in the management of renal failure patients. When essential amino acids are
Fig 3. Percutaneous infraclavicular subclavian venipuncture.
acute or chronic renal failure. The azotemic individual experiences anorexia, nausea, vomiting, stomatitis, fatigue, muscular irritability, and uremic gastroenteropathy that may preclude nourishment via the gastrointestinal tract. When permissible, the traditional oral nutritional regimen for such patients is a high calorie, low protein diet. Protein consumption
supplied parenterally, the protein synthetic mechanisms of the body are capable of utilizing urea as a source of nonessential. nitrogen for return to functional lean tissue. The net result is reduction in the total body urea nitrogen, alleviation of azotemic symptoms, and sustenance of nutritional balance. Patients with malignant disease.
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Cancer patients with normal eating habits have been reported to lose weight while their malignancies gain in bulk. Neoplastic cells extract nutrient substrates from their host, and as nutritional depletion ensues, the host's ability to increase caloric ingestion on the basis of need seems to be impaired. As a general axiom, weight loss of the host parallels the extent of tumor burden; however, loss of body mass is often the presenting symptom in persons with leukemia, lymphoma, or oat-cell carcinoma of the lung. Chemotherapy and abdominal radiation treatment have emerged as therapeutic modalities for eradication or palliation of tumor growth. These oncologic measures can result in a nutritional insult to the patient that may enhance malnutrition. Most chemotherapeutic drug protocols produce toxic side effects such as anorexia, nausea, vomiting, diarrhea, and/or stomatitis. Depending on which antineoplastic drug is used, the gastrointestinal side effects are equally or better tolerated in a patient receiving intravenous hyperalimentation. For instance, vinblastine and bleomycin in combination produce marked stomatitis that is no less severe in the IVH patient than in the non-IVH patient. Conversely, nausea, vomiting, and stomatitis secondary to administration of 5-fluorouracil are reduced in the IVH patient. Often multiple courses of cytotoxic drugs may be given during one hospitalization, and two to three times the usual dosage can be delivered to the patient per unit time. To date, intravenous hyperalimentation has had no documented effect on the duration of leukocyte depression in any chemotherapy regimens. A positive correlation between nutritional status and potential for response to chemotherapy has been
1260
noted by Lanzotti and Samuels.' Persons whose tumors responded by a 50% or greater reduction in size gained an average of 8% of their body weight, while patients who did not respond to chemotherapy gained little or no weight. When IVH is administered during abdominal radiation therapy, symptoms of radiation-induced enteritis abate. Oropharyngeal mucositis associated with head and neck radiation is less irritating when the patient is nourished exclusively by vein. Weight loss is typical when a malignant lesion results in malabsorption, obstruction of the gut lumen, or production of pain with ingestion of foodstuffs. Some cancers achieve a large size before they metastasize and are anatomically resectable. Adequate nutrition for proper wound healing becomes critical when extensive curative surgical procedures are undertaken. Malnutrition depresses established cell-mediated immunity, and thereby one of the body's most potent defenses against bacteria, fungi, and viruses is compromised. When leukocyte depression secondary to chemotherapy is superimposed, the body is almost defenseless against infection. Many malnourished cancer patients are anergic to a battery of skin test antigens. After several weeks or months of IVH therapy, a significant number of persons convert to positive skin reactions. In only those patients with positive skin reactivity did chemotherapy result in tumor regression. There were no episodes of sepsis in those persons who developed or retained positive responses. The conclusion follows that adequate nutrients must be available to the body for optimal immunological reactivity.8 Infants with failure to thrive and congenital anomalies. Shneour has
AORN Journal,June 1977,Vol25, No 7
Fig 4. Central venous feeding catheter and hyperalimentation delivery system in an
emphasized that severe malnutrition in the perinatal period reduces brain size relative to body weight and possibly impairs intelligence p e r m a n e n t l ~ . ~ IVH is especially applicable for promotion of normal growth and development in infants with idiopathic diarrhea and congenital anomalies such as tracheoesophageal fistula, omphalocele, gastroschisis, small bowel atresia, cystic fibrosis, meconium ileus, diaphragmatic hernia, volvulus, malrotation of the gut, and annular pancreas. Premature infants weighing less than 700 gm a t birth have benefited from intravenous hyperalimentation. The immaturity of the infant’s liver may limit his capacity to process nitrogenous wastes into urea, and he may become hyperammonemic. The proportion of the amino acids in the IVH infusate can be reduced to onehalf concentration and then gradually increased as tolerance improves. The
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IVH preparation is fortified with additional arginine since this amino acid appears to improve the liver’s capacity to process ammonia. Miscellaneous indications for IVH. The high incidence of aspiration pneumonia in geriatric patients with senile dementia may be attributed t o
as they vary during the course of therapy. Procedure for delivery of IVH solution Hyperalimentation fluid has approximately six times the solute concentration of blood and exerts an osmotic pressure of 1800 to 2400 mOsm per liter, depending on the additives. Infu-
Fig 5. Implantation of Silastic feeding catheter for permanent parenteral hyp eralimentation.
regurgitation of oral or tube feedings. This can be obviated by IVH until the patient is sufficiently alert and capable of ingesting his nutrient ration safely and effectively. Debilitation can occur in numerous pathophysiologic conditions such as anorexia nervosa, hyperemesis gravidarum, nonterminal coma, peritonitis, sepsis, celiac disease, protein-losing enteropathies, and following multiple surgical procedures. Individual metabolic requirements should be met as precisely as possible
1262
sion of concentrated nutrients is caustic to the intima of peripheral veins and has been associated with development of phlebitis, sclerosis, and/or thrombosis. To achieve prompt, adequate dilution of the hypertonic substrates, IVH solution must be infused into the circulatory system through a large-bore, high-flow blood vessel, preferably the superior vena cava. Percutaneous subclavian venipuncture. Based on our extensive clinical
AORN Journal, June 1977, Vol25, No 7
experience, percutaneous infraclavicular subclavian venipuncture has been the safest and most effective technique for long-term catheterization of the superior vena cava in adults and in infants weighing more than 10 pounds. With care, subclavian cannulation is a relatively safe, simple surgical procedure performed most often in the patient’s room, but also in the operating room or the recovery room. Unless there is a specific contraindication, such as previous radical neck dissection, clavicular fracture, or radical mastectomy, either the right or left subclavian vein can be catheterized. Despite the theoretical possibility of thoracic duct injury on the left side, this complication has rarely been observed. In the past 4% years at Hermann Hospital, only 2 of 749 IVH patients suffered thoracic duct injury. In both cases, cessation of lymphatic drainage and spontaneous closure of the fistula were accomplished by removal of the central venous line and subsequent administration of IVH through a right subclavian vein catheter. The patient is placed supine in the Trendelenburg position to allow maximum dilatation and filling of the subclavian vein and to increase central venous pressure to avoid air embolism during catheter insertion. A rolled sheet or towel is placed longitudinally along the thoracic spine to allow the shoulders to be hyperextended. (In the extremely cachectic person, this roll is not placed between the scapulae because hyperextension augments the possibility of inadvertent puncture of the apical pleura.) The patient’s head is then rotated to the side opposite that of venipuncture. The skin over the neck, shoulder, and entire upper thorax is shaved, defatted with ether or acetone, and pre-
pared with povidone-iodine solution for a minimum of five minutes. The bacteriocidal scrub is of utmost importance because residual skin contaminants can be transported from the puncture site into the lumen of the vein and induce nosocomial infection. The nurse can identify breaks in sterile technique as she assists the physician during the catheterization procedure. After the surgical field is draped with sterile towels, a local anesthetic agent (1%lidocaine) is infiltrated into the skin, subcutaneous tissue, and periosteum a t the midpoint of the inferior border of the clavicle. More than 3 ml of lidocaine may displace the subclavian vein and render successful venipuncture difficult. A 2-inch, 14gauge needle attached to a 3-ml syringe is inserted into the skin wheal and directed in a frontal plane immediately beneath the medial onethird of the clavicle and toward a finger pressed firmly into the suprasternal notch (Fig 3). After the needle punctures the skin surface, slight negative pressure is applied to the syringe to ascertain accuracy of the venipuncture by a backflow of venous blood. When blood first appears in the syringe, the needle is advanced a few millimeters further to insure placement of the entire bevel of the needle within the vein lumen. While the needle is held securely in place with a hemostat, the syringe is detached with caution. At the same time, the patient is asked to perform a Valsalva maneuver to increase intrathoracic pressure and to minimize the possibility of air embolism. An %inch, 16-gauge radiopaque polyvinyl, silicone rubber, or Teflon catheter is advanced entirely into the central vein. After the catheter has been directed a few inches within the vein,
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the patient can turn his head toward the venipuncture site to decrease the diameter of the subclavian-jugular junction and reduce the possibility of advancing the catheter tip into the jugular vein. If difficulty is encountered when threading the catheter, the needle may be cautiously advanced a few millimeters into the vein and then rotated a few degrees. Should further resistance occur, the catheter and needle are withdrawn as a unit to prevent severance and embolization of the catheter tip. For this reason, the catheter must never be withdrawn through the needle after it has been advanced past the needle point. The needle is retracted until approximately 2 cm of catheter are exposed between the beveled tip of the needle and the puncture site. Sterile intravenous tubing containing an isotonic solution is plugged into the catheter hub, and the catheter is immediately flushed. The solution bottle or bag is momentarily lowered below the level of the superior vena cava and then raised several feet above the patient’s head. Prompt flashback followed by forward flow of blood into the venous system indicates proper catheter placement in the superior vena cava. A plastic clip is placed around the beveled needle tip to prevent shearing of the catheter and embolization into the circulatory system. The catheter is sutured t o the skin lateral to the skin entrance site using 3-0 silk, and povidone-iodine ointment is applied over the puncture site. A small sterile dressing is affixed to the skin using tincture of benzoin and adhesive tape to maintain occlusiveness of the system. The administration tubing is looped and secured with adhesive tape to guard against unintentional traction, which might detach the tubing
1264
from the hub or pull out the catheter. All connections are reinforced with adhesive tape to prevent inadvertent separation with resultant loss of blood, sepsis, and/or air embolism. A chest roentgenogram is obtained to confirm proper catheter location in the middle of the superior vena cava and to rule out the possibility of a pneumothorax. When hyperalimentation fluid is infused into the right atrium, there is increased risk of clotting and endocarditis. Thus, the catheter tip must never be allowed to rest within the heart. Should an attempt at subclavian venipuncture be futile, the patient’s chest should be examined to rule out the possibility of pneumothorax prior to attempting insertion of the venous line on the contralateral side. In the Hermann Hospital IVH population, pneumothorax has been a relatively infrequent complication (1.4%). All patients responded promptly and without sequelae to simple, closed tube thoracostomy. After verification of proper catheter position, the IVH solution is infused into the patient’s superior vena cava. When meticulous attention is paid to anatomical details and to aseptic technique, complications such as pneumothorax, tension pneumothorax, hemothorax, hydrothorax, subcutaneous emphysema, subclavian hematoma, thoracic duct injury, hydromediastinum, air embolism, catheter embolism, brachial plexus injury, arteriovenous fistula, endocarditis, venobronchial fistulization, and osteomyelitis of the clavicle are rarely reported. If a patient is susceptible to periodic bacteremia, eg, when the clavicular area is burned, the catheter is changed twice weekly to prevent buildup of thrombin or fibrin, which could serve as a secondary focus of sepsis if seeded from elsewhere in the
AORN Journal, June 1977, V o l 2 5 , No 7
body. A subclavian catheter cannot be placed within a radiated field without increased possibility of sepsis. Jugular vein cutdown. When an infant weighs less than 10 pounds, his small subclavian vein and high apex of the lung make subclavian venipuncture difficult and hazardous. The neonatal patient is taken to the operating room, and a silicone rubber or Teflon catheter is inserted through the external or internal jugular vein. The internal jugular vein can be catheterized via its common facial vein branch at the angle of the jaw or directly through a purse-string of 5-0 silk. The external jugular vein is exposed for direct catheterization by making a 1cm incision, approximately a centimeter above the base of the neck a t the midclavicular line. The vein is ligated proximally, and a small venotomy is made using a number 11 knifeblade. After the tip of an 18-gauge catheter has been inserted into the lumen of the vein, gentle traction on the ligatures may facilitate the advancement of the catheter into the superior vena cava. The catheter is advanced a length equal to the distance from the cutdown site to the second intercostal space. After proper placement into the superior vena cava has been confirmed by roentgenographic examination, the catheter is secured to the vein using several 4-0 silk ligatures. Finally, the catheter is tunneled subcutaneously in the postauricular area to emerge through a tiny stab wound in the parietal scalp. This can be accomplished by directing it through the lumen of a Vim Silverman needle or threading it onto a modified Kirschner wire. The external portion of the catheter is thus removed from the searching hands of the infant, and the risk of sepsis and mechanical kinking
is reduced. The neck wound is closed, and the catheter is sutured at the scalp site using 4-0 silk. Antimicrobial ointment is applied, and a sterile, occlusive bandage is fixed to the skin. IVH fluid is delivered to the infant via a constant infusion pump, and a 0.22 micron in-line filter is inserted between the central catheter and the pediatric buret tubing (Fig 4). Insertion of a permanent Silastic catheter. The Scribner and Broviac silicone rubber catheters have enhanced long-term indwelling catheterization. Insertion is performed in the operating room with the use of local anesthesia. After the skin area has been prepared as for percutaneous subclavian catheterization, a small stab wound is made in the skin of the anterior chest wall lateral to the xiphoid. The patient must have easy, comfortable access to this puncture site if he is to maintain the infusion system independently. A second incision is made in close proximity t o the vein that will be cannulated. When the subclavian veins are thrombosed, any vein in the area such as the jugular or cephalic can be used, and the catheter can be threaded beneath the clavicle. The silicone rubber catheter is tunneled subcutaneously through a trocar and is sutured to the skin with 3-0 silk. Firm tissue ingrowth into the Dacron cuff with secondary catheter fixation occurs in two to three weeks, and the cuff then serves as a barrier against bacterial or fungal invasion along the catheter tract. After proximal ligation of the vein, a small venotomy is made, and the catheter is advanced into the superior vena cava with fluoroscopic control. The venotomy skin wound is sutured (Fig 5 ) , and two small sterile dressings are applied. When infusion of IVH solution is
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desirable on a n intermittent basis, a heparin lock will maintain the patency of the intravenous line. Following injection of 1 ml of sodium heparin (1,000 units per milliter), the hub is plugged with a sterile cap. The nurse’s role in hyperalimentation therapy Adherence to rigid aseptic practices during insertion and maintenance of the infusion cannula will insure a low incidence of catheter-related sepsis (1.05% at Hermann Hospital). To augment catheter longevity after insertion, application of a sterile, occlusive dressing every Monday, Wednesday, and Friday is strongly recommended. When this task is performed by the same person, comparative observations of changes in skin appearance are easy to make. Erythema, inflammation, pain, or purulence a t the puncture site may be indicative of catheter-related infection. The operating room nurse should never violate the aseptic integrity of the IVH “lifeline.” Unnecessary manipulation of the delivery tubing increases the opportunity for contamination and is thus avoided whenever possible. No blood or blood products are infused through the venous catheter, nor is blood aspirated for the purposes of laboratory testing except during a life-threatening situation. The subclavian line is not used routinely for the injection of bolus medication or for monitoring of central venous pressure. Should the subclavian dressing become soiled or wet during operation, it should be replaced promptly. Infusions of hypertonic solutions are delivered initially a t a slow constant rate not to exceed the patient’s inherent rate of metabolic utilization of the individual micronutrients. Without sufficient circulating insulin, glucose is not transported effectively across 1266
the cell membrane. Whenever a n administered glucose load exceeds the renal threshold of the kidneys, sugar appears in the urine. Titrating against the indices of blood glucose levels and glycosuria, the carbohydrate load is cautiously increased to a maximum dose. The average ill adult usually tolerates 3 liters per day of 25% dextrose without utilization problems. During major operations, the ability of patients to metabolize glucose is diminished. Prior to surgery, patients should be “weaned” from the concentrated nutrients in a manner similar but opposite to the successive advancement during the first few days of IVH. Hypoglycemia may occur after abrupt cessation of the infusate, and symptoms of this condition include muscular weakness, anxiety, mental confusion, restlessness, diaphoresis, vertigo, pallor, and tremor. Delivery of 5% dextrose in water or in lactated Ringer’s solution during operation will generally avoid occult hypoglycemia under anesthesia and its serious consequences. It is important not to allow IVH fluid to be infused into patients intraoperatively. Inadvertent rapid infusion of the hypertonic solution can lead to serious hyperglycemia, hyperosmolar dehydration, hypovolemic shock, and/or irreversible central nervous system injury. For comparative evaluation, each patient is weighed daily a t the same time, on the same scale, and wearing the same amount of clothing. In general, 1/4 to 1 pound weight gain per day is indicative of a reasonable accumulation of lean body tissue. Accurate intake and output data are recorded every eight hours, and significant variations from the acceptable range are reported to the physician. As a member of the IVH team, the nurse contributes a great deal to the successful management of the patient
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receiving parenteral hyperalimentation. Her role can be summarized by classification into four major areas: (1) maintenance of the integrity of the central venous catheter, (2) regulation of fluid intake, (3) monitoring of fluid balance, and (4) development of a therapeutic nurse-patient relationship. Conclusion. An integrated physicochemical organism, man functions on a digestive-absorptive-metabolic continuum. Whenever homeostasis of this indigenous process is disrupted during various phases of illness, the established technique of total parenteral nutrition can support normal growth and development in infants and anabolism in adults for indefinite periods of time. When the patient's nutritional status is maintained in positive nitrogen balance throughout the diagnostic, preopertive, operative, postoperative, convalescent, and rehabilitation periods, his prognosis is markedly improved. Current principles and practices of IVH therapy, including expanded indications, improved methods and materials for catheter insertion and maintenance, and the nurse's responsibilities will undoubtedly undergo changes and modifications with future application of current clinical research in the rapidly advancing field of total parenteral nutrition.
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Notes 1. Stanley J Dudrick, Edward M Copeland 111, Bruce V MacFadyen, Jr, "Long-term parenteral nutrition: Its current status," Hospital Practice (May 1975) 47. 2. Douglas W Wilmore, Stanley J Dudrick, "Growth and development of an infant receiving all nutrients exclusively by vein," Journal of the American Medical Association 203 (March 4, 1968) 140-144. Stanley J Dudrick, et al, "Experimental aspects of total parenteral alimentation," in Total Parenteral Alimentation, C Manni, S I Magalini, E Scrascia, eds. (New York: American Elsevier Publishing CO, Inc, 1976) 8. 4. Stanley J Dudrick, B V MacFadyen, Jr, John M Daly, "Management of inflammatory bowel disease with parenteral hyperalimentation," in Gas-
trointestinal Emergencies, The Thirty-fourth Hahnemann Symposium. Harris R Clearfield, Vicente P Dinoso, Jr, eds. (New York: Grune and Stratton Publishers, March 1976). 5. J W Broviac, J J Cole, B H Scribner, "A silicone rubber atrial catheter for prolonged parenteral alimentation," Surgery, Gynecology, and Obstetrics 136 (April 1973) 1-5. 6. K N Jeejeebhoy, et al, "Total parenteral nutrition at home for 23 months, without complications and with good rehabilitation," Gastroenterology 65 (November 1973) 81 1-820. 7. Edward M Copeland 111, et al, "Intravenous hyperalimentation as an adjunct to cancer chemotherapy," The American Journal of Surgery 129 (February 1975) 172. E. Edward M Copeland, Bruce V MacFadyen, Stanley J Dudrick, "Effects of intravenous hyperalimentation on established delayed hypersensitivity in the cancer patient," Annals of Surgery 184 (July 1976) 63. 9. Elie A Shneour, The Malnourished Mind (Garden City, NY: Anchor Press, 1974) 6.
DeAnn M Englert, R N , is hyperalimentation nurse coordinator, Hermann Hospital, T h e University of Texas Medical School at Houston. S h e is also a n instructor i n surgery, T h e University o f Texas Medical School at Houston. S h e has a B S N from T h e University of Texas System-wide School o f Nursing. Stanley J Dudrick, MD, is professor and chairman, Department of Surgery, University of Texas Medical School at Houston; chief of surgical services, Hermann Hospital, and consultant i n surgery, T h e University of Texas System Cancer Center, MD Anderson Hospital and Tumor Institute. H e is a graduate of Franklin and Marshall College and the University of Pennsylvania School of Medicine.
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