Parenteral Nutrition

1) R-151: Is the intravenous infusion of lipid emulsion harmful in the patients with disseminated intravascular coagulation? Yu Koyama (1), Mayuko Yoshizawa (1), Naoko Manba (1), Katsuyoshi Hatakeyama (1). (1) Division of Digestive & General Surgery, Niigata University Graduate School of Medical & Dental Sciences, Niigata, Japan

2) R-208: Complications associated with subclavian vein catheter insertion: the role of nutrition support team. John Kotsikoris, Vassilios Alivizatos, Pavlos Athanasopoulos, Mathiew Souchlakis. Department of Surgery, Nutrition Unit, “St. Andrew General Hospital, Patras, Greece

3) R-219: Design the standard operation procedure of an instant Brix assay to confi rm the accuracy of fi nal dextrose concentration in compounding parenteral nutrition solutions. Lie-Jane Lin (1,4) , Fee-Ying Liao (1), Fe-Ling Wu Lin (1,2) Ming-Tsan Lin (3,4) Hong-Shee Lai (3,4) Fang-Yu Lin (3) Wei-Jao Chen (3). Dept. of Pharmacy (1), Graduated School of Clinical Pharmacy (2), Dept. of Surgery (3), Nutrition Support Team (4) , Dept. of Surgery (2), Dept. of Pediatrics (3), College of Medicine, National Taiwan University Hospital

4) R-231: Lipidemic complication and awareness in the use of all-in-one parenteral nutrition. Jinda Preechaverakul (1), Putisak Putawibul (2), Saipin Panbumrung (3). Department of Pharmacy (1), Surgery (2), and Nursing (3); Faculty of Medicine, Prince of Songkhla University, Han Yai, Songkhla, Thailand.

5) R-242: Outcome benefi t of parenternal nutrition for patients undergoing gastrointestinal surgery. Pi-Wen Liou (1), Mei-Due Yang (1,2), Jing-Yi Lee (1), Hsiuchen Tung (3), Walter Chen (4). Department of Clinical Nutrition (1), Department of Surgery (2), Division of Medical Affair (3), China Medical University Hospital, China Medical University Beigang Hospital (4), Taichung, Taiwan.

6) R – 320: Heparin-induced thrombocytopenia in patients receiving total parenteral nutrition: a report of three cases Soo An Choi1, Hyoung Uk Namgung2, Eun Sook Lee3, Do Joong Park4, Ho Seoung Han5/* 1,2,3 Department of Pharmacy, Seoul National University Bundang Hospital, Sungnam, Republic of Korea; 4,5 Department of Surgery, Seoul National University Bundang Hospital, Sungnam, Republic of Korea, *Seoul National University College of Medicine

R –151 (top)
Is the intravenous infusion of lipid emulsion harmful in the patients with disseminated intravascular coagulation?
Yu Koyama(1), Mayuko Yoshizawa(1), Naoko Manba(1), Katsuyoshi Hatakeyama(1)
(1)Division of Digestive & General Surgery, Niigata University Graduate School of Medical & Dental Sciences, Niigata, Japan

Objectives: There have been several reports on adverse effects of intravenous administration of lipid emulsions for coagulation activity. However, a recently developed anesthetic agent containing 1% propofol and 10% soybean oil (Diprivan®) is now popularly used for sedation in intubated, mechanically ventilated patients, including DIC patients. The aim of this study was to examine the safety of the use of this fat containing drug under severe coagulopathic condition as a surrogate for the administration of lipid emulsions during nutritional therapy in critical care patients.
Methods: Among 378 patients admitted to the intensive care unit of Niigata University Hospital during January-June, 2006, 20 with the diagnosis of DIC were analyzed retrospectively. These 20 patients were divided into 2 groups: Diprivan®- administered (Group D) and Diprivan®-free (Group N) patients. The Japanese criteria of DIC were introduced, and severity of DIC was scored. The DIC score, parameters on coagulation and blood chemistry were assessed during the clinical course of each patient. Clinical outcome, DIC score and the parameters were compared between the 2 groups by using F-test, Bonferroni test or Chisquare test, and the statistical signifi cance was defined as P<0.05.
Results: Among the 20 patients whit the diagnosis of DIC, Diprivan® was used in 12 cases. Nine of the 20 patients died, for an overall mortality rate of 45%, 5 in Group D (42%) and 4 in Group N (50%), without statistical difference in mortality between the 2 groups. Further, there was also no statistical difference on DIC score, parameters of both coagulation and blood chemistry between the 2 groups.
Conclusion: Our results showed that a fat containing anesthetic drug infusion in DIC patients caused no signifi cant adverse effect on prognosis, coagulation or blood chemical parameters, it seems to be safe to administer lipid emulsions intravenously under severe coagulopathic conditions for nutritional therapy.

R - 208 * (top) / Oral presentation
Complications associated with subclavian vein catheter insertion: the role of nutrition support team
John Kotsikoris, Vassilios Alivizatos, Pavlos Athanasopoulos, Mathiew Souchlakis
Department of Surgery, Nutrition Unit, “St. Andrew General Hospital, Patras, Greece

Background/Aim: Complications directly attributable to central venous catheter insertion occur in 3 – 12% of cases. The aim of this study was to determine the incidence of such complications, as well as to evaluate the role of a Nutrition Support Team to preventing or keeping
the incidence to a minimum.
Methods: During a two-year period (8/2005 – 7/2007), 350 consecutive patients requiring central venous access mainly for parenteral nutrition support were prospectively studied. In all the patients, the insertion of the central venous catheter was done in the subclavian vein
by percutaneous puncture. Catheterization was made by 4 experienced medical doctors, forming a Nutrition Support Team, in all the cases. There was determined the incidence of technical complications related to catheter insertion.
Results: Complications related to catheter insertion were presented in 9 patients (overall incidence 2.5%); out of these, in 4 patients (1.1%)
was noted malposition of the catheter requiring reinsertion, in 3 patients (0.8%) artery injury requiring no specifi c treatment, and in 2 patients (0.6%) a local haematoma requiring no specific treatment also. There was not any case of pneumothorax neither any other complication.
Conclusion: The results of this study suggest that the complication rate of subclavian vein catheter insertion can be minimized by careful attention to technique and concentrating experience in the hands of a few dedicated individuals forming a Nutrition Support Team.

R - 219 (top)
Design the standard operation procedure of an instant Brix assay to confi rm the accuracy of fi nal dextrose concentration in compounding parenteral nutrition solutions
Lie-Jane Lin(1,4) , Fee-Ying Liao(1), Fe-Ling Wu Lin(1,2) Ming-Tsan Lin(3,4) Hong-Shee Lai(3,4) Fang-Yu Lin(3) Wei-Jao Chen(3)
Dept. of Pharmacy(1), Graduated School of Clinical Pharmacy(2), Dept. of Surgery(3), Nutrition Support Team(4) , Dept. of Surgery(2), Dept. of Pediatrics(3), College of Medicine, National Taiwan University Hospital

Background/Objectives: To verify the accuracy of fi nal dextrose concentration in neonate and pediatric TPN solutions is especially important to avoid adverse events. Currently there are precise but time consuming chemical analysis and gravimetric analyses through the programmed software of the automated compounder. We try to design an instant, objective, credible method and to establish the SOP of Brix assay to verify dextrose concentration in the TPN solutions compounded.
Methods: We carried out a series of refractometric analysis and set up the SOP. a. Using 0.5mL Water for injection to calibrate the refractometer (scope: dextrose 0-32%, amino acid 4%) to the Brix zero. b. Sampling and dripping 0.5 mL of TPN solution on the glass plate of refractometer, replace the cover piece and read the Bxix value. c. Turn over the TPN bag at least 20 times, sample 0.5 mL, drip on the glass plate and replace the cover piece, read the actual Brix value (TA) and record. d. Set up equation A and B as: A = 0.82 (% dextrose)+1.3 (% amino acid); B = 0.82 (% dextrose) +1.3 (% amino acid)X (fi nal volume/base solution volume) e. Fill in the dextrose concentration (%) and the amino acid concentration (%) to have Brix value calculated (A and B). f. If the difference between TA and A is within + 1 unit (maximum variations), the dextrose concentration of TPN solution compounded is accurate. g. If the difference is > 1 unit, then TA should
be compared with the corresponding Brix B. If the difference is within + 1 unit, the dextrose concentration of TPN solution is accurate.
Results: Among the 27 TPN bags tested, 96.3% (26/27) met the requirement of accuracy.
Conclusion: Refractometric analysis is useful to verify the accuracy of TPN compounded.

R –231* (top) / Oral presentation
Lipidemic complication and awareness in the use of all-in-one parenteral nutrition
Jinda Preechaverakul(1), Putisak Putawibul(2), Saipin Panbumrung(3)
Department of Pharmacy(1), Surgery(2), and Nursing(3); Faculty of Medicine, Prince of Songkhla University, Han Yai, Songkhla, Thailand

Background: All-in-one (AIO) parenteral nutrition (PN) is widely used because of its convenience and adequate provision of calorie replacement through lipid. The short term use of parenteral fat emulsion is safe, but the effect of long term use is unknown. The awareness of lipidemia among clinicians could prevent complication.
Objective: To study the clinicians’ awareness of lipidemia from the use of AIO solution and the occurrence of complications.
Methods: Prospective study was conducted in 174 surgical patients receiving AIO PN at Songkhlanagarind hospital during January 2005 to July 2006. Patient care team (PCT) collected the data on indication for PN, lipidemic complication, awareness of complication. The team also gave suggestion for safe practices on PN administration.
Results: One hundred and seventy four patients (112 male with average age of 63) received AIO PN because of NPO (N=80), inadequate intake (N=80). Mean duration of PN therapy was 8 days. Thirteen patients (7.55% of total patients) had hypertriglyceridemia. Serum lipid
before PN therapy had not been monitored in 126 patients. Forty patients (23% of total patients) were monitored serum lipid after PCT’s recommendation and 86 patients (50% of total patients) had not been monitored serum lipid after received PN.
Conclusion(s): Fifty percent of physicians did not investigate serum lipid both before and after order of PN. Thirteen patients had lipidemic
complication. There were no adverse effects of all patients.

R - 242 (top)
Outcome benefi t of parenteral nutrition for patients undergoing gastrointestinal surgery
Pi-Wen Liou(1), Mei-Due Yang(1,2), Jing-Yi Lee(1), Hsiu-chen Tung(3), Walter Chen(4)
Department of Clinical Nutrition(1), Department of Surgery(2), Division of Medical Affair(3), China Medical University Hospital, China Medical University Beigang Hospital(4), Taichung, Taiwan.

Objectives: We retrospectively reviewed our experience with gastrointestinal surgery patients early and long-term outcomes.
Methods: Clinical information was reviewed for patients undergoing gastrointestinal surgery during an 6 year period (2002~2007) at the China Medical University Hospital in Taichung Taiwan. Patient characteristics, nutrition index, operative mortality, PN duration, and length of hospital stay were reviewed.
Result: A total of 644 patients underwent gastrointestinal surgery. Among these,296(45.9%) were 65 years old or older and 348(54.1%) were aged 64 years or younger. The average length of hospitalization in elderly groups was 43.27±26.76days and 36.29±27.83days in the middle age group,which was statistically signifi cant.(p=0.04). Mortality rate was 6.13% in elderly patients compared to 5.15%.Albumin level and prealbumin level are scientifi c difference. There results were statistically signifi cant.
Conclusion: Our fi ndings support the conclusion that: 1) Parenternal nutrition warrants gastrointestinal surgery because the benefi t to
these patients early and long-term outcomes; 2) Prealbumin level can be considered to be the nutrition index.

R – 320 (top)
Heparin-induced thrombocytopenia in patients receiving total parenteral nutrition: a report of three cases
Soo An Choi(1), Hyoung Uk Namgung(2), Eun Sook Lee(3), Do Joong Park(4), Ho Seoung Han(5/*)
(1,2,3) Department of Pharmacy, Seoul National University Bundang Hospital, Sungnam, Republic of Korea; (4,5) Department of Surgery, Seoul National University Bundang Hospital, Sungnam, Republic of Korea, *Seoul National University College of Medicine

Background: Thrombocytopenia is common in hospitalized patients receiving unfractionated heparin (UFH), yet only a minority has heparin induced thrombocytopenia (HIT). HIT is a complication of heparin therapy that can have serious outcome. One to 3% of patients who receive therapeutic intravenous doses of heparin develop this complication. Although much smaller doses of heparin are also recognized to cause
thrombocytopenia, only a limited number of cases have been described in the literature and the true incidence is unknown. A recent study found that 12 of 19 critically ill surgical patients diagnosed with HIT had only been exposed to 120 to 240 units/day of heparin via catheter flushed. Furthermore, Laster et al. reported HIT associated with exposure to heparin-coated catheters. However, in clinical assessment, heparin use for fl ushing of vascular access devices or as TPN components may be overlooked. Even if these cases are rare, the widespread use of TPN suggests that clinicians are likely to encounter this problem. Furthermore, since patients who are receiving TPN usually have serious medical conditions, the appearance of thrombosis or thrombocytopenia may not seem surprising. Therefore, a high index of suspicion and reliance upon confi rmatory laboratory tests are important in establishing the diagnosis.
Objective: The case studies presented may introduce the experience of Nutrition Support Team (NST) of Seoul National University Bundang
Hospital and help readers in the evaluation and recognition of this complicated syndrome.
Methodology and Result: We encountered three patients with clinical evidence of HIT secondary to daily TPN supplementation. When the ‘4 T’ scoring system of Lo et al. was applied to our HIT patients. Cases include typical and unusual presentations of the syndrome, and commonly encountered problems and pitfalls of therapy. When thrombocytopenia occurs, heparin as TPN components may not be suspected initially as a cause of thrombocytopenia and may go unnoticed. This oversight may postpone the treatment of HIT and could result in serious morbidity and mortality.
Observation(s): a) Effective therapy of HIT involves both the prompt recognition of the syndrome and its proper management. With prompt recognition and treatment of the syndrome, thrombotic complications of HIT may avoid in patients receiving TPN. B) NST should consider the occurrence of HIT in patients who experience a platelet count decreases while receiving TPN. Heparin as TPN components should be discontinued if HIT is suspected, with or without evidence of thrombosis, and alternative anticoagulation should be started. c) Recent studies demonstrated disappearance of antibodies to heparin after more than 100 days following prior to heparin exposure.
Recommendation: Therefore, we suggest that not only the prompt recognition of HIT in receiving TPN during admission but also the prediction of possibility, when the patient develop the early onset HIT, through the management of TPN history are another important role of NST.