Complications of Parenteral Nutrition

Complications of Parenteral Nutrition

176 PREOPERATIVE AND POSTOPERATIVE THERAPY therapies and anticipated results. The discussion covers bacterial, parasitic, fungal and viral infection...

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therapies and anticipated results. The discussion covers bacterial, parasitic, fungal and viral infections. R. C. N. 4 tables, 79 references

Cyclosporine Experience in Renal Transplantation in Children A. TEJANI, K. M. H. BUTT, M. R. KHAWAR, K. PHADKE, 0. ADAMSON, J. HONG, M. FUSI AND H. TRACHTMAN, Department of Pediatrics and Transplant Surgery, Renal Division, Downstate Medical Center, State University of New York, Brooklyn, New York Kidney Int., suppl. 19, 30: S-35-S-43 (July) 1986 Physicians involved in the treatment of children who have undergone transplantation have encountered 2 problems that have plagued end results: 1) failure of the patient to grow adequately in the presence of a well functioning graft and 2) the disfiguring cushingoid features associated with steroid administration. In this study 40 children were given cyclosporin A as transplant therapy with the aim of using the proteinsparing effect of the drug to maintain the graft with cyclosporin as the sole immunosuppressant. Only children who used the drug for 6 months or who died before the 6-month expiration period were included. Cyclosporin A appears to have a steroid-sparing effect. Rejection in a nonimmunosuppressed patient is triggered by antigen stimulation of the macrophage to release interleukin 1. Release of interleukin 1 induces interleukin 2 production by T helper cells. When stimulated by interleukin 2, sensitized lymphocytes proliferate and rejection follows. Corticosteroids work by blocking interleukin 1 production, whereas cyclosporin A blocks interleukin 2 production. Cyclosporin also has an additional interleukin 1 blocking action. Group 1 patients were begun on prednisone and cyclosporin at transplantation, with the prednisone being tapered during 12 weeks. If the graft function remained stable the prednisone was discontinued during a 4 to 8-week interval. Group 2 consisted of patients who initially received conventional azathioprine/prednisone therapy and who were converted from azathioprine to cyclosporin. If graft function remained stable the steroids were discontinued during 4 to 8 weeks as in group 1. In this study the 2-yea:r actuarial patient survival rate was 94 per cent, the 1-year actuarial graft survival rate was 90 per cent and the 2-year graft survival rate was 72 per cent. For comparison, in another uncontrolled study of adults who received cadaveric grafts and cyclosporin the 1-year graft survival rate was 80 per cent, compared to 64 per cent in those receiving conventional therapy. In general, 1-year patient and graft survival rates exceed 90 and 75 per cent, respectively. A major problem with cyclosporin is nephrotoxicity. Some patients require a lower dosage. Seizures also may occur when phenobarbital and phenytoin are given. The amount of cyclosporin given must be increased, since these anticonvulsants induce rapid elimination of cyclosporin through the liver. In summary, several conclusions were reached. Children tolerated the drug well and few side effects were noted. In selected patients cyclosporin can be used as the sole maintenance immunosuppressant. The drug can be used as the sole immunosuppressive agent in selected patients who begin use at transplantation, as well as those who are converted from conventional therapy later, provided they have stable graft function. After withdrawal of prednisone all children demonstrated adequate endogenous control reserve. Most prepubertal chil-

dren who discontinued prednisone have sufficient growth hormone to provide potential for growth. R. C. N. 16 figures, 5 tables, 37 references

PREOPERATIVE AND POSTOPERATIVE THERAPY Complications of Parenteral Nutrition B. M. WOLFE, M.A. RYDER, R. A. NISHIKAWA, C.H. HALSTED AND B. F. SCHMIDT, Departments of Surgery and Medicine, University of California, Davis, Sacramento, California Amer. J. Surg., 152: 93-99 (July) 1986 The authors report the incidences of specific complication of total parenteral nutrition at the university from 1981 through 1985. Factors involved in the evolution of rates of specific complications and the potential impact on complication rates by the quality assurance program also were reported. Of 1,647 patients who received central venous total parenteral nutrition 93 per cent were adults and the duration of total parenteral nutrition was 18.9 days. The total number of patientdays of total parenteral nutrition was 31,112. There were 509 complications in these patients. Complications of catheter placement occurred in 94 patients (5. 7 per cent). There were complications in 78 of the 1,438 new venipuncture procedures (5.4 per cent) and in 16 of 881 (1.8 per cent) catheter exchanges that included a guide wire. Arterial hemorrhage occurred in 29 patients and venous hemorrhage occurred in 7. No direct treatment was required in most cases but laceration of the subclavian artery resulted in a massive chest wall hematoma in 1 patient with respiratory failure. Two thoracotomies ultimately were required to control the bleeding, which proved to be fatal. Another patient required endotracheal intubation for tracheal obstruction by a low cervical hematoma. Pneumothorax occurred in 18 patients, 2 of whom had tension pneumothorax. One patient required mechanical ventilation and died of a cardiac arrest before resolution of the pneumothorax. Other catheter placement complications that were lifethreatening included an air embolism in 1 patient and puncture of the endotracheal tube cuff in 1. Complications of catheter placement in which a guide wire was used included an unsuccessful procedure that resulted in loss of the catheter in 10 patients, and induction of arrhythmia that necessitated treatment and catheter withdrawal in 4. The annual rate of nosocomial sepsis associated with total parenteral nutrition was 2.1 per cent in 1981 and 4.4 per cent in 1982. This abrupt increase of total parenteral nutritionassociated nosocomial sepsis was statistically significant. Because of this increase the nutrition committee increased enforcement of the policy that mandated an entry in the medical record justifying the infusion of total parenteral nutrition through a multilumen catheter because such catheters accounted entirely for the increased sepsis rate. Use of such catheters decreased from 55 to 35 per cent, with a decrease in the total rate of sepsis from 10.8 to 9.2 per cent. The most common organism isolated was Staphylococcus. Major venous thrombosis was relatively common (44 patients). No patient suffered a pulmonary embolus. Air embolism as a mechanical complication resulting from tube disconnection was rare (2 patients) and resulted in major morbidity in 1 (cerebral injury). Metabolic complications were frequent, with hyperchloremic


metabolic acidosis predominating. Correction of this problem. was accomplished by alteration of the standard electrolyte additive protocol from chloride-to-acetate ratio of 7:1 to 4:1 and finally to a ratio of 2.5:L Complications of total parenteral nutrition are frequent and may be severe. Quality assurance mechanisms for identification of these complications are necessary and should form the basis for the establishment of appropriate protocols. W. W. K. 1 figure, 1 table, 22 references

SURGICAL TECHNIQUES, EQUIPMENT AND INSTRUMENTS Fine-Needle Aspiration Biopsy: Perceptions of Physicians at an Academic Medical Center

M. B.

T. R. MILLER, J.M. GONZALES, S. T. SACKS K. BOTTLES, Department of Pathology, School of Medicine, University of California, San Francisco, California COHEN,


Arch. Path. Lab. Med., 110: 813-817 (Sept.) 1986 Previously, private practitioners in San Francisco were asked about their perceptions of fine-needle aspiration biopsy. In this study the same survey was sent to clinicians in a tertiary medical center. Although the response rate to this survey was lower, it appears that fine-needle aspiration biopsy was used more often in the hospital than it was among private practitioners for the evaluation of palpable masses (53 versus 24 per cent), and that it was performed more often by pathologists. Of the fine-needle aspiration biopsy procedures done at this institution 70 per cent were performed by pathologists, while a small percentage (7 per cent) of cases (nonpalpable) were performed by a radiologist for evaluation of intrathoracic and intra-abdominal lesions. A total of 59 per cent of private practitioners performed the fine-needle aspiration biopsy themselves, and the remainder of the cases (39 per cent) were referred to pathologists, radiologists and surgeons. There are differences in perceptions concerning the use of fine-needle aspiration biopsy in a variety of specific clinical settings. W. W. K. 7 tables, 19 references

PEDIA'TRIC UROLOGY Review of 'The Dilemma of tb.e Multicystic Dys:plastic Kidney'

T. H.

STANISIC, Department of Surgery, University of Arizona Health Sciences Center, Tucson, Arizona

Amer, J. Dis. Child., 140: 865 (Sept.) 1986 Prenatal ultrasound examinations have identified multicystic kidneys that are not palpable at birth. Some lesions that are palpable at birth shrink to minimal proportions when followed for several months sonographically. Thus, many such lesions must have been left in place during the years owing to lack of detection. With this large population at risk the numbers of malignant neoplasms, causal hypertension cases and patients found with abdominal pain are extremely small. Surgery and sonographic followup offer the patient and the family low risk options. The author advocates an operation when results of noninvasive diagnostic measures are indeterminate, and when definitively diagnosed multicystic kidneys remain large after


several months of follcwup thus, the µWoH,,c;cc, are at risk for traumatic injury during childhood. Under other circumstances the decision to perform an op,era,t1c;n versus followup is made in conjunction with the wishes of the well informed family. P. M. H. 2 references

The Dilemma of the Multicystic Dyspfastic Kidney G. E. HARTMAN, L. M. SMOLIK ANDS. J. SHOCHAT, Division of Pediatric Surgery, Department of Surgery, Stanford University Medical Center, Stanford, California Amer. J. Dis. Child,, 140: 925-928 (Sept.) 1986 Multicystic dysplastic kidney represents the most common cause of an abdominal mass in neonates. Differentiation from a hydronephrotic kidney has become increasingly accurate owing to improvements in ultrasonographic and radionuclide imaging. Since this accuracy has reduced the frequency of diagnostic exploration, many investigators have suggested a nonoperative approach to the asymptomatic patient. A 4-year-old girl with a Wilms tumor arising in a multicystic dysplastic kidney, and a 3-month-old female infant with a multicystic kidney and Aspergillus species in the cyst fluid are presented. The current literature is reviewed in an attempt to clarify the potential risks to pacuousc with a multicystic plastic kidney. It is estimated that 80 per cent or greater of multicystic dysplastic kidneys are diagnosed by the time the child is 2 years old. Owing to the recent advances in current imaging techniques, the majority of infants and children present with a reasonably secure diagnosis and no symptoms referable to the mass. Data regarding the natural history of these lesions are scarce, with only 31 patients with a multicystic kidney identified beyond infancy having been described. Five well documented malignant neoplasms have been reported in previously undiagnosed multicystic dysplastic kidneys. Infection is a symptom commonly attributed to multicystic dysplastic although bacteriological and pathological confirmation is scarce. The ability of current imaging techniques to distinguish multicystic dysplasia from a cystic tumor is uncertain. Nine well documented cases of hypertension associated with multicystic kidney have been ,.,w,rn,,,ors In 3 cases the hypertension resolved after resection. Abdominal or flank presenting complaint in 14 patients with diagnosed after infancy. The rate for removal of a in infancy should be negligible-roughly about the same as the 1 in 7,000 risk of general anesthesia i.n infants. Removal of such lesions is recommended if appropriate and anesthetic facilities are available. P. M. H. 1 figure, 32 references Editorial comment. The multicystic dysplastic kidney is indeed posing a continuing dilemma in management. With the widespread advent of fetal ultrasound, it currently is clear that unilateral multicystic kidney is considerably more common than uretero pelvic junction obstruction. Ultrasonography often is diagnostic and the typical appearance of a multicystic kidney is almost as reliable as a pathological diagnosis. When the cysts appear to mimic ureteropelvic junction obstruction, with a large central cyst and smaller peripheral cysts that are reminiscent of dilated calices, a renal scan in the neonatal period almost always will resolve the question. The multicystic kidney seldom