Successful management of severe hypoglycemia induced by total parenteral nutrition in patients with hepatocellular injury: Three cases reports

BACKGROUND Glucose imbalance is common in total parenteral nutrition(TPN).Hypoglycemia seems to be less frequent than hyperglycemia,but it influences the clinical outcome to a greater extent.Therefore,it should be effectively prevented and treated.However,there is no relevant report on how to treat hypoglycemia caused by TPN in patients with liver cell injury.CASE SUMMARY We present three patients with liver cell injury who developed severe hypo-glycemia during or after TPN infusion.The causes of severe hypoglycemia and glucose-raising strategies were discussed.According to the physiological charac-teristics of the hepatocellular injury,the ratio of nutrition components prescribed in TPN was appropriately adjusted for the three cases.We simultaneously reduced the dose of insulin and fat emulsion,and increased the dose of glucose in TPN.The blood glucose level was restored to normal range and clinical symptoms were eliminated.CONCLUSION When hypoglycemia occurs during or after TPN in patients with hepatocellular injury,physicians need to simultaneously reduce insulin and fat emulsion,and increase glucose,and correct severe hypoglycemia in time to reduce its adverse consequences.

S-adenosylmethionine in treatment of cholestasis after total parenteral nutrition: laboratory investigation and clinical application

Objective: To observe the effects of S-adenosylmethio-nine (SAMe) in the treatment of cholestasis after totalparenteral nutrition (TPN).Methods: Thirty SD rats were randomly divided intocontrol group, hypercalorie group, hypercalorie+SAMegroup, sepsis group and sepsis+SAMe group to com-pare their states of cholestasis. Sixteen patients re-ceived SAMe because of cholestasis after prolongedTPN, and the therapeutic efficacy was observed.Results: Bile flow was obviously decreased and theserum levels of total bile acid and gamma-glutamyltranspeptidase(γ-GT) were markedly increased in thehypercalorie and sepsis groups. Meanwhile, hepatocytefatty degeneration, dilatation of cholangioles, and bilesludge could be seen microscopically. SAMe adminis-tration in the hypercalorie+SAMe and sepsis+SAMegroups could increase the bile flow, decrease theserum levels of total bile acid and γ-GT, reduce thepathological damage to the liver, and clear the bilesludge in the cholangioles. Cholestasis and abnormalliver function were the main manifestations of the 16patients before SAMe administration. After SAMe treat-ment for 3 weeks, serum levels of total bilirubin, al-kaline phosphatase(AKP), γ-GT, alanine aminotrans-ferase(ALT), and aspartate aminotransferase(AST)were obviously decreased, and normalized in the 4thweek.Conclusion: SAMe could prevent and treat cholestasiswithout discontinuation of TPN.

Exploring choices of early nutritional support for patients with sepsis based on changes in intestinal microecology

BACKGROUND Sepsis exacerbates intestinal microecological disorders leading to poor prognosis.Proper modalities of nutritional support can improve nutrition,immunity,and intestinal microecology.AIM To identify the optimal modality of early nutritional support for patients with sepsis from the perspective of intestinal microecology.METHODS Thirty patients with sepsis admitted to the intensive care unit of the General Hospital of Ningxia Medical University,China,between 2019 and 2021 with indications for nutritional support,were randomly assigned to one of three different modalities of nutritional support for a total of 5 d:Total enteral nutrition(TEN group),total parenteral nutrition(TPN group),and supplemental parenteral nutrition(SPN group).Blood and stool specimens were collected before and after nutritional support,and changes in gut microbiota,short-chain fatty acids(SCFAs),and immune and nutritional indicators were detected and compared among the three groups.RESULTS In comparison with before nutritional support,the three groups after nutritional support presented:(1)Differences in the gut bacteria(Enterococcus increased in the TEN group,Campylobacter decreased in the TPN group,and Dialister decreased in the SPN group;all P<0.05);(2)different trends in SCFAs(the TEN group showed improvement except for Caproic acid,the TPN group showed improvement only for acetic and propionic acid,and the SPN group showed a decreasing trend);(3)significant improvement of the nutritional and immunological indicators in the TEN and SPN groups,while only immunoglobulin G improved in the TPN group(all P<0.05);and(4)a significant correlation was found between the gut bacteria,SCFAs,and nutritional and immunological indicators(all P<0.05).CONCLUSION TEN is recommended as the preferred mode of early nutritional support in sepsis based on clinical nutritional and immunological indicators,as well as changes in intestinal microecology.

Impact of fish oil enriched total parenteral nutrition on elderly patients after colorectal cancer surgery

Background Polyunsaturated omega-3 fatty acids may beneficially influence healing processes and patient outcomes.The aim of this research was to study the clinical efficacy of fish oil enriched total parenteral nutrition in elderly patients after colorectal cancer surgery.Methods Fifty-seven elderly patients with colorectal cancer were enrolled in this prospective,randomized,double-blind,controlled clinical trial.All patients received isocaloric and isonitrogenous total parenteral nutrition by continuous infusion （20-24 hours per day） for seven days after surgery.The control group （n=28） received 1.2 g/kg soybean oil per day,whereas the treatment group （n=29） received 0.2 g/kg fish oil and 1.0 g/kg soybean oil per day.Blood samples were taken pre-operatively,and at days one and eight after the operation.The plasma levels of CD4,CD8,CD4/CD8,interleukin 6 （IL-6） and tumor necrosis factor a （TNF-a） were measured.Clinical outcomes were then analysed.Results Patient characteristics were comparable between the two groups.At day eight post-surgery,IL-6,TNF-α and CD8 titres were lower in the treatment group when compared to the control group; these results reached statistical significance.In the treatment group,there were fewer infectious complications and incidences of systemic inflammatory response syndrome （SIRS）,and shorter lengths of hospital stay were observed.The total cost of medical care was comparable for the two groups.No serious adverse events occurred in either group.Conclusions Fish oil 0.2 g/kg per day administrated to elderly patients after colorectal surgery was safe and may shorten the length of hospital stay and improve clinical outcomes.

Glycemic Variation in Tumor Patients with Total Parenteral Nutrition

Background：Hyperglycemia is associated with poor clinical outcomes and mortality in several patients.However,studies evaluating hyperglycemia variation in tumor patients receiving total parenteral nutrition （TPN） are scarce.The aim of this study was to assess the relationship between glycemia and tumor kinds with TPN by monitoring glycemic variation in tumor patients.Methods：This retrospective clinical trial selected 312 patients with various cancer types,whose unique nutrition treatment was TPN during the monitoring period.All patients had blood glucose （BG） values assessed at least six times daily during the TPN infusion.The glycemic variation before and after TPN was set as the indicator to evaluate the factors influencing BG.Results：The clinical trial lasted 7.5 ± 3.0 days adjusted for age,gender,family cancer history and blood types.There were six cancer types：Hepatic carcinoma （HC,21.8%）,rectal carcinoma （17.3%）,colon carcinoma （CC,14.7%）,gastric carcinoma （29.8%）,pancreatic carcinoma （11.5%）,and duodenal carcinoma （DC,4.8%）.The patients were divided into diabetes and nondiabetes groups.No statistical differences in TPN glucose content between diabetes and nondiabetes groups were found;however,the tumor types affected by BG values were obvious.With increasing BG values,DC,HC and CC were more represented than other tumor types in this sequence in diabetic individuals,as well as in the nondiabetic group.BG was inclined to be more easily influenced in the nondiabetes group.Other factors did not impact BG values,includiug gender,body mass index,and TPN infusion duration time.Conclusions：When tumor patients are treated with TPN,BG levels should be monitored according to different types of tumors,besides differentiating diabetes or nondiabetes patients.Special BG control is needed for DC,HC and CC in both diabetic and nondiabetic patients.If BG overtly increases,positive measurements are needed to control BG values.The ClinicalTrials.gov ID is NCT02024321.

Recurrent ciprofloxacin induced hypoglycemia in a non-diabetic patient:A case report

BACKGROUND Fluoroquinolones are a class of broad-spectrum antimicrobials used for various bacterial infections.Frequent use of fluoroquinolones has been questioned due to severe associated adverse effects,including dysglycemia(hypoglycemia or hyperglycemia)due to an alternation in glucose metabolism.Recent clinical trials showed the association of poor clinical outcomes with hypoglycemia in critically ill patients without diabetes.Many predisposing factors worsen fluoroquinolone-induced hypoglycemia,including diabetes,concomitant medication use like sulfonylureas or insulin,renal disease,and the elderly.CASE SUMMARY We report a case of recurrent hypoglycemia after ciprofloxacin initiation for a 71-year-old,non-diabetic,critically ill patient despite the presence of total parenteral nutrition and nasogastric tube feeding.The adverse drug reaction probability(Naranjo)scale was completed with a probable adverse drug reaction.The hypoglycemia resolved entirely after ciprofloxacin discontinuation.CONCLUSION Although ciprofloxacin-induced hypoglycemia is rare,special consideration is needed for the elderly due to their higher susceptibility to adverse side effects.

Characteristics and outcomes of avoidant/restrictive food intake disorder in Japanese elementary-school students on total parenteral nutrition

The clinical outcomes of adolescents with avoidant/restrictive food intake disorder(ARFID)remain unclear.Furthermore,no report has compared the characteristics of ARFID and restricting-type anorexia nervosa(R-AN)in elementary-school students on total parenteral nutrition(TPN).This study retrospectively reviewed inpatients diagnosed with ARFID or R-AN between 2005 and 2019.Patients with ARFID(two boys and seven girls)and R-AN(13 girls)were hospitalized because of rapid physical deterioration,and nutrition therapy was continued without withdrawal.The ARFID group exhibited significantly lower body weights at admission than the R-AN group and gained an average of 6.5 kg during hospitalization;furthermore,the monthly weight gain during hospitalization was significantly higher,and no relapse was observed.Early physical improvement in ARFID resulted in good recovery.In conclusion,TPN can be easily introduced to patients with ARFID,in whom aversive eating is a concern,and is a suitable treatment for ARFID.

Omega-3 fatty acid improves the clinical outcome of hepatectomized patients with hepatitis B virus(HBV)-associated hepatocellular carcinoma

Omega-3 fatty acid supplemented total parenteral nutrition improves the clinical outcome of patients undergoing certain operations; however, its benefits for patients with hepatitis type B virus (HBV)-associated hepatocellular carcinoma (HCC) who have undergone hepatectomy are still not clear. The aim of this study was to evaluate the effect of omega-3 fatty acid supplemented total parenteral nutrition on the clinical outcome of patients with HBV- associated HCC who underwent hepatectomy at our institution. A total of 63 patients with HBV-associated HCC who underwent hepatectomy were included in this study. These patients were randomly assigned to receive stand- ard total parenteral nutrition (the control group, n = 31) or omega-3 fatty acid supplemented total parenteral nutri- tion (the omega-3 fatty acid group, n = 32) for at least 5 d. The study endpoints were the occurrence of infection- related complications, recovery of liver function and length of hospital stay. The results showed that the omega-3 fatty acid group had a lower infection rate (omega-3 fatty acid, 19.4% vs control, 43.8%, P 〈 0.05), a better liver function after hepatectomy: alanine transaminase (omega-3 fatty acid, 48.23__+ 18.48 U/L vs control, 73.34 q-40.60 U/L, P 〈 0.01), aspartate transaminase (omega-3 fatty acid, 35.77_ 14.56 U/L vs control, 50.53 4-24.62 U/L, P 〈 0.01), total bilirubin (omega-3 fatty acid, 24.29___7.40 mmol/L vs control, 28. 374-8.06 mmol/L, P 〈 0.05) and a shorter length of hospital stay (omega-3 fatty acid, 12.71 ___2.58 d vs control, 15.91 ___3.23 d, P 〈 0.01). The serum contents of IL-6 (omega-3 fatty acid, 23.98___5.63 pg/mL vs control, 35.55___7.5 pg/mL, P 〈 0.01) and TNF-a (ome- ga-3 fatty acid, 4.43___1.22 pg/mL vs control, 5.96___1.58 pg/mL, P 〈 0.01) after hepatectomy were significantly lower in the omega-3 fatty acid group than those of the control group. In conclusion, administration of omega-3 fatty acid may reduce infection rate and improve liver function recovery in HBV-associated HCC patients after hepatectomy. This improvement is associated with suppressed production of proinflammatory cytokines in these patients.

Endoscopic nasojejunal feeding tube placement in patients with severe hepatopancreatobiliary diseases:a retrospective study of 184 patients

BACKGROUND: Total parenteral nutrition (TPN) has been recognized as the mainstay of nutritional support in patients with severe hepatopancreatobiliary (HPB) diseases for decades. However, recent studies advocate the utilization of endoscopic nasojejunal feeding tube placement (ENFTP), rather than the conventional approach. This study was designed to compare the clinical value of ENFTP and TPN in patients with severe HPB diseases. METHODS: Two groups of patients with severe HPB diseases were analyzed retrospectively. One group of 88 patients received ENFTP, and the other 96 received TPN. Routine blood levels, serum glucose and prealbumin, hepatic and renal function, serum lipid, and calcium were measured at baseline and after 1, 2, and 4 weeks of nutritional support. Also, complication rate, mortality, nutritional support time, mechanical ventilation time, mean length of time in intensive care unit, and duration of hospital stay were analyzed. RESULTS: After 4 weeks of nutritional support, the degree of recovery of red blood cells, prealbumin, and blood glucose was greater in the ENFTP than in the TPN group (P<0.05). Furthermore, the ENFTP group showed a lower incidence of septicemia, multiple organ dysfunction syndrome, peripancreatic infection, biliary infection, and nosocomial infection, in addition to shorter nutritional support time and hospital stay (P<0.05). CONCLUSIONS: ENFTP is much more effective than TPN in assisting patients with severe HPB diseases to recover from anemia, low prealbumin level, and high serum glucose, as well as in decreasing the rates of various infections (pulmonary infection excluded), multiple organ dysfunction syndrome rate, nutrition support time, and length of hospital stay. Therefore, ENFTP is safer and more economical for clinical application.

术前全胃肠外营养可改善行主要腹部手术的克罗恩病患者的手术疗效

背景:尽管克罗恩病(CD)的药物治疗取得了重大进展,但仍有相当一部分患者在诊断后5年内需要接受外科手术治疗。营养不良是胃肠手术疗效欠佳的独立危险因素。术前全胃肠外营养(TPN)在CD患者中的应用价值,各项研究数据并不一致,而且缺少生物治疗时代的相关研究数据。本研究旨在明确TPN在CD手术患者中的应用价值。方法:这是一项在一家三级转诊中心完成的回顾性队例研究。纳入接受主要腹部手术的CD患者,按术前有无接受TPN治疗分为TPN组与非TPN组。比较两组患者术后30天感染性与非感染性并发症发生率。结果:纳入2007年3月至2017年3月间行主要腹部手术的144例CD患者,其中55例接受术前TPN治疗,非TPN组89例。21例(14.6%)患者术后出现感染性并发症,其中TPN组与非TPN组发生率分别为18.2%和12.3%(P=0.34);23例(15.9%)术后发生非感染性并发症,其中TPN组与非TPN组发生率分别为14.5%和16.9%(P=0.71)。采用多因素分析校正两组间基线疾病严重度和营养不良程度的差异后,术前TPN治疗≥60天的患者,其术后发生非感染性并发症的风险显著降低(OR=0.07,95%CI:0.01-0.80,P=0.03)。近6个月内体重下降>10%则是术后并发症的危险因素。结论:对于营养不良的CD患者,TPN是安全的,而且可以使其获得与营养正常CD患者相当的手术疗效。术前行≥60天TPN治疗可减少术后非感染性并发症的发生,而且并不会增加感染性并发症的发生概率。