parenteral nutrition techniques in cancer patients1techniques, normal nutritional status can be...

[CANCER RESEARCH 37, 2440-2450, July 1977]

Summary

If a patient is expected to respond optimally to one ormore forms of oncologic therapy, he should simultaneouslybe in the best possible nutritional and metabolic condition.When the alimentary tract cannot be used effectively forfeeding cancer patients, panenteral nutrition can be lifesaving. Moreover, patients who are poor candidates on noncandidates for any antineoplastic therapy because of theirdebility or cachexia can be converted to reasonable candidates following a course of iv. hyperalimentation. This i.v.hyperalimentation can significantly reduce the morbidityand mortality of cancer patients without stimulating tumorgrowth when applied conscientiously according to the established principles and techniques and when integratedwith specific tumor therapy.

With the use of ambulatory or home hyperalimentationtechniques, normal nutritional status can be restored ormaintained during prolonged periods of antineoplastictherapy on a practical and relatively economical outpatientbasis. It is anticipated that specific nutrient substrate formulas and parenteral therapy techniques will be developedto maintain optimal host nutrition while adversely affectingthe neoplasm.

Introduction

Nutrient substrates are required by the human body insufficient quantity and of adequate quality to supply basalmetabolic needs and to support a state of nutritional equilibnium and positive nitrogen balance under a wide varietyof conditions associated with catabolism. Moreover, nequirements can be significantly accentuated by majortrauma, burns, sepsis, metabolic disorders and, possibly,malignant diseases. For many years it has been postulatedthat metabolic demands are increased in patients with malignant neoplasms, but this has never been clearly documented. When the diagnosis of cancer is made initially,patients are usually adequately nourished. However, vanioUs forms of effective antineoplastic therapy often result insevere nutritional deficits and are associated with weightloss, protein malnutrition, and inanition. On the other hand,loss of body mass can be the initial clinical sign in patientswith specific cancers such as leukemia, lymphoma, and oat

I Presented at the Conference on Nutrition and Cancer Therapy, Novem

ber 29 to December 1, 1976, Key Biscayne, Fla.2 To whom requests for reprints Should be addressed, at Department of

Surgery, The University of Texas Medical School, 6400 West Cullen Street,Houston, Texas 77030.

cell carcinoma of the lung. In such patients, tumor bulk canachieve rather large proportions before symptoms becomemanifest, and weight loss may in part reflect the increasednutritional demands imposed upon the host by the prognessive tumor burden. Conversely, breast cancer, malignantmelanoma, most soft tissue sarcomas, and the majority ofgastrointestinal cancers produce early signs and symptoms(such as bleeding or a palpable mass) while the tumor massis relatively small, and any weight loss secondary to thedemands of the neoplasm can be identified on appreciated.Some specific alimentary tract cancers, particularly those ofthe onopharynx and esophagus, induce weight loss becauseof reduced p.o. intake secondary to obstruction or dysphagia. Similarly, lymphoma of the small bowel and certainhormone-secreting tumors, such as carcinoma of the pancreatic islet cells, can result in malnutrition secondary tomalabsorption. Nevertheless, the malnutrition seen in patients with cancer is usually iatrogenic as a result of oncological therapy, unless the patient has neglected his symptoms for several months and has become cachectic secondany to diminished p.o. intake and increased tumor mass.

During oncobogical treatment, malnutrition and inanitioncan be prevented, minimized, or corrected by the appropniate use of currently available iv. and enteral nutrient regimens. Whenever possible, the gastrointestinal tract shouldbe utilized for digestion, absorption, and assimilation ofnutrients. The most natural and practical method of nutrientadministration is p.o. , and the next most feasible method ofnutrient delivery is via nasogastnic or nasoduodenal feedingtubes. However, operative insertion of a gastrostomy orjejunostomy tube may be necessary for long-term nutnitional maintenance in some patients. Unfortunately, optimalnutritional rehabilitation via the alimentary tract can requirean inordinate amount of time, and specific antineoplastictherapy cannot always be deferred until protein and energystones have been replenished adequately by this route.

During the past decade, IVH3has become available to theoncologist as a safe, effective, and practical method ofnutritional rehabilitation. The concept of concentrated i.v.nutrients to meet the high caloric and protein requirementsof critically ill patients was originally tested in 1966 (6). Inthe initial experiment, beagle puppies fed exclusively byvein with a 30% nutrient solution consisting primarily ofglucose and protein hydrolysates via the superior vena cavagrew and developed normally for periods up to 9 months.Following this experience the technique of IVH was successfully adapted for use in pediatric and adult humans (7).

3 The abbreviation used is: IVH, iv. hyparalimentation.

2440 CANCERRESEARCHVOL. 37

Parenteral Nutrition Techniques in Cancer Patients1

Stanley J. Dudrick,2 Bruce V. MacFadyen, Jr., Eduardo A. Souchon, DeAnn M. Englert, and Edward M.Copeland, Ill

Department of Surgery (5. J. 0. , B. V. M. , E. A. S. , E. M. C.], The University of Texas Medical 5chool at Houston, The University of Texas System CancerCenter, M. D. Anderson Hospital and Tumor Institute, and Hermann Hospital/The University Hospital (D.M.E.J, Houston, Texas 77030

on August 8, 2020. © 1977 American Association for Cancer Research. cancerres.aacrjournals.org Downloaded from

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Parenteral Nutrition

tions.Indeed,the1streportedoccurrenceofhypophosphatemia during hyperalimentation was in a patient receivingcasein hydnolysate as the nitrogen source. Fibnin hydrolysate, prepared by the acid hydrolysis of bovine or porcinefibnin, contains no significant amounts of phosphorus, andadditions of this crucial intracellular element must be madeto solutions of this nitrogen source.

The amino acids in the i.v. crystalline amino acid products currently commercially available in this country arepresent as the acetate and chloride or hydrochloride salts.These preparations are acidic and the addition of inordinateamounts of sodium and/or potassium chloride can result inhyperchbonemic metabolic acidosis in some patients, particularly those in pediatric and geriatric age groups. Therefore, sodium and potassium should be added to the basesolution as the acetate, bicarbonate, chloride, lactate, oracid phosphate salt as dictated by the patient's acid-basestatus and serum electrolyte concentrations. Despite thefact that phosphorus has been added to some of the morerecent commercially available amino acid solutions in moderate amounts, our experience indicates that an additional15 to 20 mEq of phosphate, as the potassium acid phosphate salt, must be added to each liter of solution to maintam normal serum phosphate concentrations, especiallyduring the 1st week of therapy.

Hypomagnesemia will often occur within 10 days of initiating IVH if sufficient quantities of magnesium have notbeen added to the solutions. Similarly, hypocalcemia willresult if adequate quantities of calcium are not provided,usually in dosages of 4 to 9 mEq calcium gluconate penday.Both the fat- and water-soluble vitamins must be added to 1liter of IVH solution pen day, and folic acid, vitamin K, andvitamin B,2are usually administered i.m. on i.v. once a week.In patients with bone marrow depression following chemotherapy on radiotherapy, addition of these vitamins to theIVH solutions is preferable to i.m. injection in order to avoidhematoma formation secondary to impaired coagulationmechanisms. Serum albumin concentrations below 3 g/100ml should be connected to levels of at least 3.5 g/100 ml bythe daily administration of 12.5 to 50 g of salt-poor humanalbumin, which can be added directly to the bottles or bagsof IVH solution. Colboid osmotic pressure thereby can berestored promptly, and protein nutrition will be supplemented. In most patients, albumin synthesis in the liver willbe restored to normal within 7 to 10 days of IVH administration, and exogenous serum albumin will no longer be requmred.The formulationofrepresentativeIVH solutionsforinfusion into adult patients with normal concentrations ofserum electrolytes, magnesium, phosphorus, and calciumis given in Table 1. The formulation of IVH solutions for usein infants is outlined in Table 2.

The minimum daily energy requirement necessary tomaintain an adult patient in the basal metabolic state isapproximately 1500 cal/day. In the absence of adequateexogenous calories, energy is generated primarily by lipolysis and the conversion of tissue protein into glucose viagluconeogenesis. The work of Cuthbertson (5) on the catabolic response following trauma in humans demonstratedthat infusion of 150 g of dextrose per day can result in asignificant nitrogen-sparing effect. These data have beensubsequently confirmed by many groups and extended to

Although many individual patients with malignant disordens had received nutritional support via parenteral hyperalimentation, extensive applications of this technique to thenutritional rehabilitation of cancer patients in a prospectiveclinical study were pioneered at the M. D. Anderson Hospital and Tumor Institute (4). Since the hyperalimentationteam was established in 1972, more than 2000 patients inour series have received IVH as a means of nutritionalmaintenance or restoration prior to, during, and/or following treatment with chemotherapy, radiotherapy, on surgery.Because of IVH, the gastrointestinal tract can be bypassedand nested in a basal state while positive nitrogen balanceand a state of anabolism can be attained within 7 to 10 days.This technique of total parentenal nutrition has proven to besafe and effective, and stimulation of tumor growth has notbeen observedas a consequenceofthei.v.feeding.

A national approach to nutritional rehabilitation is to replenish the cancer patient rapidly, using IVH until the alimentary tract can be used effectively. The patient can bemaintained with a chemically defined diet or other acceptable formulation until ingestion, digestion, absorption, andassimilation of adequate quantities of normal foodstuffs arepossible entenally.

The purpose of this paper is to describe and discuss thecomposition and preparation of IVH solutions; the technique of central venous catheter insertion and long-termcatheter maintenance; the principles of IVH administrationand patient monitoring; the prevention, recognition, andmanagement of complications during IVH therapy; the institution of an IVH team; and the application of ambulatory orhome hyperalimentation.

Compositionand Preparationof the NutrientSolution

IVH solutions prepared in our institutions are quite hypentonic, having an osmolanity of 1800 to 2400 mOsmoles/liter.They are admixed in the pharmacy under laminar-flow, fibtered-air hoods, either by mixing 500 ml of 50% dextrosewith 500 ml of an 8.5% crystalline amino acid solution on bymixing 350 ml of 50% dextrose with 750 ml of 5 to 10%proteinhydrolysatein5% dextrose.Such solutionsprovideapproximately 1000 Cal pen liter and between 5.25 and 10.0g of nitrogen pen liter. Electrolytes and vitamins must beadded to these base solutions in appropriate dosages tosatisfy daily requirements. Although the protein hydrolysatesolutions (casein on fibnin based) contain various electrobytesand trace elements as contaminants of their processing and storage in glass containers, the major electrolytesmust be added to these solutions prior to infusion. Theusual electrolyte additives to the hypertonic nutrient mixtunes derived from the protein hydnolysate solutions includeapproximately 40 to 50 mEq sodium chloride, 20 to 40 mEqpotassium chloride, 10 to 15 mEq magnesium sulfate and 15to 20 mEq potassium acid phosphate pen liter. Although thecasein hydrolysates that are prepared by the enzymatichydrolysis of the phosphoprotein casein contain largeamounts of phosphorus (20 to 40 mmoles/liter), the phosphorus apparently is bound to the peptides and/or aminoacids in such a manner as to be neither available nor effective in maintaining normal serum phosphorus concentra

JULY 1977 2441



Compositionof standard IVHsolutions foradultsSingleunitmethodStock

solution method: 350ml50%dextrose + 750 ml5%Bulk

method: 165 g anhydrous dextrose U.S.P. protein hydrolysate in 5% Kit method: 500 ml 8.5% Fream+ 860 ml 5% fibrin hydrolysate in 5% dex- dextrose me II + 500 ml 50% dex

trose. Aseptic mixing technique un-troseSterilizationthrough 0.22-u membrane fil- der laminar-flow, filtered- Aseptic mixing with transfer

ter under laminar-flow, filtered-air hood air hoodapparatusVolume1,000 (ml) 1,1001000Calories1 000 (Kcal) 1 0001006Dextrose

208 (g) 21 2250Hydrolysates43 (g)37Amino

acids42.5Nitrogen6.0 (g) 5.256.25Sodium8 (mEq) 75Potassium

14 (mEq)13Phosphate10Additions

to each unit of base solution (av.adult):Sodium(acetate,lactate, chloride, and/or bicarbonate),40â€”50mEqPotassium

(acetate, lactate, chloride, acid phosphate), 20â€”40mEqMagnesium(sulfate),10-15mEqPhosphate

(potassiumacid salt), 15-20mEqAdditionsto only 1 unitdaily:VitaminA, 5000-10,000U.S.P.unitsVitaminD, 500-1,000 U.S.P.unitsVitaminE, 2.5-5.0IUVitaminC, 250-500mgThiamine,

25-50mgRiboflavin,5-10mgPynidoxine,7.5-15mgNiacin,

50-100mgPantothenicacid,12.5-25mgCalcium

(gluconate), 4.8-9.6mEqOptional

additions to dailyration:0VitaminK, 5-10 mg â€˜@

VItam1flB12,10-@30 units@ Alternatively may be given i.m. in appropriate daily or weekly dosages

Iron, 2.0-3.0 mg

Composition of pediatric IVH solutionsFinal pH of 5.2 to 5.5 may be adjusted to neutrality immediately prior to infusion with sodium bicarbonate or sodium hydroxide.

Additional sodium, chloride, or other electrolytes are added as indicated by metabolic studies. Trace element solutions must be speciallyformulated from zinc sulfate, manganesechloride, potassium iodide, copper sulfate, or molybdenumchloride compounds or may begiven as contained in plasma transfusion, 10 mI/kg twice weekly. Infusion of final solution given at rate of 145 mI/kg/day to deliver 130 cal/kg/day.Bulk

method ml Single unit methodmlDextrose

5% in protein hydrolysate5% 12,000 Dextrose 5% in protein hydrolyAnhydrous dextrose U.S.P. (20% solution) 2,200 sate 5% (20 g dextrose, 20 g 400Calcium gluconate 10% 150 hydrolysate)Multiple Vitamin Infusion 100 Dextrose50% 250Potassium phosphate monobasic (2 mEq/ml) 30 Sodium chloride (2 mEq/ml) 10Magnesiumsulfate 50%(4 mEq/ml) 5 Potassium acid phosphate (2 13Phytonadione (10 mg/mI) 2 mEq/mI)Cyanocobalamin(100units/mI) 2 Calcium gluconate 10% (0.45Folic acid (15 mg/mI) 2 mEq/ml)Imferon (50 mg elemental iron/mI) 1 Magnesiumsulfate 50% (4 mEq/ 2 4Traceelements(optional) 7 ml)

Multiple Vitamin Infusion@ 4Total volume per lot â€”14,500 Cyanocobalamin (vitamin B12)Ã§ Added to solution daily

FolIc acid , , t orweeklyorgiven i.m.Phytonadlone (vitamin K) , intermittentlImferon(iron)Total

volume per unit â€”750

S. J. Dudrick et a!.

Table 1

a Micronutrients such as cobalt, copper, iodine, manganese, and zinc are present as contaminants in hydrolysate

solutions but may be given in plasma transfusion (10 mI/kg) once or twice weekly if desired.

Table 2

2442 CANCER RESEARCH VOL. 37



Parentera! Nutrition

show that infusions of greater quantities of dextrose willresult in only minor increases in nitrogen sparing. Moreover, infusions of fat emulsions to provide additional cabnies will result primarily in fat deposition with little on nofurther protein sparing unless nitrogen in the form of aminoacids or protein hydrolysates is administered in adequatequantities simultaneously (8). When amino acids are infused together with the concentrated dextrose solutions inIVH, glycogenolysis is minimized and lean tissue synthesisis augmented . However, if the provision of potential caloriesin the form of dextrose greatly exceeds energy expenditurein a given patient, excess quantities of glycogen and fat canbe deposited in the liver with the result that hepatomegaly,right upper quadrant tenderness on pain, and disorderedhepatic function can ensue. For the average patient, a ratioof 150 to 200 cal/g of administered nitrogen appears to bethe optimal ratio. Of course, under conditions in whichenergy expenditure is increased, relatively high quantitiesof calories must be provided. Finally, protein synthesis depends somewhat upon the activity of the patient, and physical exercise is essential for adequate regeneration of skeletabmuscle. Forthis reason, it is recommended that patientsreceiving IVH engage in a daily program of physical rehabilitation and graduated activity as early as their clinical conditions will allow.

Nitrogen and potassium deficits often coexist during penods of catabolism, in part because the muscle mass contains 75% of the body's total potassium stores. During gluconeogenesis, when skeletal muscle is lost for conversionto energy substrates, potassium is released to the extraceblular fluid compartment and is excreted in increased quantities by the kidneys. It has been shown that, if a mixture ofprotein hydrolysates and hypertonic dextrose is given to apotassium-depleted animal without sufficient potassium replenishment, growth and positive nitrogen balance will notoccur optimally (3). In order to achieve positive nitrogenbalance and tissue synthesis, the intracellular requirementsof potassium must be met without producing excessiveextracellular hypokalemia. Indeed , catastrophic myocardialdysfunction and arrhythmias can accompany serum potassium concentrations below 2 mEq/Iiten. The degree of potassium depletion generally parallels the degree of proteincalorie malnutrition, but the total body potassium is notreflected accurately or finitely by the serum potassium concentration in emaciated patients. Not until adequate i.v.nutritional therapy is begun with the stimulation of anabolism and its accompanying movement of potassium into thecells does hypokalemia and a realization of the true magnitude of the total body deficit of potassium become manifest.Therefore, the severely malnourished patient may requirean initial dose of as much as 60 to 100 mEq of potassium per1000 cal in order to maintain potassium equilibrium. Asanabolism progresses and stabilization occurs, proteinturnover returns to normal and potassium requirements willbe reduced commensurately.

Phosphorus and magnesium depletion parallel potassiumand protein depletion in the catabolic patient, and it ishypothesized that the mechanism for their loss is similar tothat for potassium. Magnesium concentration is muchhigher in the intracellular than in the extracelbular compartment, and loss of body cell mass probably results in a

relative magnesium deficiency. The body stores energywithin the high-energy phosphate bonds of ATP. Althoughphosphate is found in high concentrations within bone, itapparently is not sufficiently labile on available for nedistnibution rapidly throughout the body because hypophosphatemia will result regularly if adequate quantities of phosphorus are not administered simultaneously with the other nutrients in IVH solutions. As dextrose and amino acids areinfused in sufficient quantities to promote tissue synthesis,high-energy phosphate bonds probably are replenished bythe utilization of extnaosseous as well as osseous phosphorus. If exogenous phosphorus is not given during IVH thenapy, severe symptomatic hypophosphatemia may result.

As anabolism is promoted by IVH administration, an increased daily intake of calcium may become necessary. Ingeneral, the calcium requirement is greater in a hypophosphatemic patient than in one who has normal serum phosphate bevels. However, because of the reciprocal relationshipbetweencalciumand phosphorus,theserum calciumlevel may remain normal or rise slightly as hypophosphatemia is induced. However, as increasing doses of phosphate are added to correct the hypophosphatemia, rapidand significant hypocalcemia, with its attendant untowardreactions, will ensue unless adequate quantities of calciumare infused simultaneously with the phosphate.

One ampub of a mixture of fat- and water-soluble vitaminssuitable for panentenabadministration is added to any singleunit of the daily regimen. Because the vitamins present ineach ampul of Multiple Vitamin Infusion are generally in thetherapeutic dose range, it is neither necessary nor advisableto administer more than 1 ampub/day to a patient. Hypervitaminosis A and hypervitaminosis D can occur within a fewdays on weeks if more than 1 ampub of multiple vitamins aregiven pen day. Because there is no commercially availableparenteral vitamin preparation that contains vitamin B,2,vitamin K, on folic acid, each of these must be added inappropriate dosages in addition to the other required vitamins. Failure to administer folic acid has resulted in fulminating megaboblastic anemia in some patients within 2weeks after initiation of total parenteral nutrition.

Iron can be added to the solution on a daily or weeklybasis in appropriately calculated doses or can be given bydeep i.m. injection. In patients with less than 10 g of hemogbobin per 100 ml, it is advisable to restore the normal RBCmass by transfusion of packed erythrocytes or whole bloodprior to IVH. In some patients it may be necessary to giveoccasional transfusions of packed erythrocytes during thecourse of prolonged total parenteral nutrition, particularly ifthey are simultaneously undergoing chemotherapy or radiotherapy. Trace elements such as cobalt, copper, iodine,manganese, and zinc are present as contaminants in mostparentenalsolutions,particularlyin proteinhydrobysates,and are therefore not added routinely to the IVH infusate. Innewborn infants and in severely debilitated adults, however,the trace elements may be infused intermittently as speciallyprepared additives or provided alternatively by the administration of 10 ml of plasma or albumin per kg body weightper week. In the near future, a commercially available preparation of trace elements suitable for use in the IVH regimenwill simplify the administration of these essential micronutnients.

JULY 1977 2443




Maintenance of sterility is of utmost importance in thepreparation of iv. nutrient solutions. Aseptic mixing of thevarious components and additives under a laminar-flow,filtered-air hood is essential for maximal safety. Final formulation of the solution should be accomplished in thepharmacy immediately priorto infusion in onderto minimizegrowth and reproduction of any microorganisms that mightinadvertently gain entry to the solution. After the solutionsare prepared, they should be refrigerated and infused within24 hr. Periodically, aliquots of IVH solutions should betaken and cultured for aerobic and anaerobic bacteria andfungi in order to monitor quality control oven the asepticmixing of the solutions.

CentralVenousCatheterization

Thnombophlebitis, cellulitis, and damage to the formedelements of the blood can result if the hypertonic IVH sobutions are infused through a peripheral vein. For safe andeffective delivery of the nutrient solutions, accurate cathetenization of a lange-diameter vein is essential. Our hyperalimentation team has used the superior vena cava almostexclusively for infusion of IVH solutions. Access to thisvessel is obtained preferably by percutaneous cathetenization of the subclavian vein by the infraclavicular approach.Superior vena cava catheterization via an external or internabjugular vein is possible and at times acceptable, but thecatheter exit site and its occlusive dressing interferes withmaximum freedom of neck motion and is uncomfortable tomost patients. Moreover, it is difficult to anchor the deliverytubing to the patient's neck or to the side of his face.Catheter dressings are easier to apply, more secure, andless inconvenient for the patient when they lie on the upperthorax.Successfulpercutaneoussubclavianvenipunctureisde

pendent primarily upon the physician's knowledge of theanatomy of the subclavian vein and its related structures,his technical skill, and adequate filling and dilation of thevein. The latter requirement can be fulfilled by restoringcirculating blood volume with cobboid and/or crystalloidfluid administered by peripheral vein and by positioning thepatient supine in the Trendelenburg position prior to attempting venipuncture. A rolled sheet is placed under thethonacic spine between the scapulae to facilitate hyperextension of the shoulders. The head is turned away from theproposed site of catheter insertion. The skin is prepared byshaving the hair from the upper thorax, neck, and shoulderon the side of catheter insertion. This skin area is thendefatted with ether, acetone, or some other organic solventand scrubbed for 3 mm with povidone-iodine, thimerosal, on2% tincture of iodine. The surgeon dons a pain of sterilegloves and places sterile towels around the prepared fieldas in any other surgical procedure.

Essential items of equipment for percutaneous subclavian vein cathenization include a pair of sterile scissors anda hemostat, a 2- on 3-mI syringe, 26- and 22-guage needles,a vial of local anesthetic solution, a 2-inch-bong 14-gaugeneedle through which an 8-inch-long 16-gauge radiopaqueTeflon, polyvinyl, or Silastic catheter can pass, and 3-0 silkor nylon suture on a straight- or curved-cutting-edge skinneedle. A wheal is raised using 1% lidocaine on procaine at

the inferior border of the middle of the clavicle, and theanesthetic is injected into the deep tissues along the proposed tract of the catheter including the peniosteum of theclavicle. A nurse or assistant attaches a microdnip infusionapparatus to a bottle of 5% dextrose in water or otherisotonic solution. A sterile extension tubing is connected tothe solution administration set, and air is purged from thetubing. Meanwhile, the 14-gauge needle is attached to the2- or 3-mI syringe, and the length of catheter to be insertedis estimated by approximating the course of the catheterfrom the skin entrance site to the middle of the superiorvena cava at the 2nd intercostal space. The total length ofthe catheter is 8 inches, and in the average adult about 5.5to 6.0 inches of catheter lie deep to the skin and 2.0 to 2.5inches lie external to the puncture site. This is importantbecause the catheter tip should not lie within the rightatrium on across the tricuspid valve. If it does, fibnin andother clot-forming elements of the blood are more likely tobe deposited on the catheter, and the endocardial structunes are more likely to become secondarily infected byhematogenously borne microorganisms. Moreover, thecatheter itself may cause direct trauma or even puncturethese intracardiac structures with potentially disastrousconsequences.

A fingertip is pressed firmly into the suprasternal notch toserve as an aiming point. The needle is inserted through theskin at the inferior border of the junction of the medial andmiddle third of the clavicle, and it is advanced in a coronalon frontal plane parallel to the patient's bed toward thefingertip in the suprastennal notch. If slight negative pressure is generated within the syringe as the needle is forwarded, a flashback of venous blood will be visible in thesyringe when the needle is within the subclavian vein. Theentire 1-cm length of the beveled tip of the needle should bepositioned into the lumen of the vein, and the open space ofthe bevel should be pointing caudad rather than anteriorlyon cephalad in order to minimize the chances for the catheten to be misdirected into vessels other than the superiorvena cava. The patient is then asked to hold his breath indeep inspiration or to perform a Valsalva manueven in orderto prevent inadvertent air embolism when the hub of theinserted needle is detached from the syringe and open toatmospheric pressure. The syringe is detached from theneedle while it is held securely with a hemostat, and the 16-gauge radiopaque catheter is inserted through the needleand threaded its entire length into the superior vena cava.When the hub of the catheter has been interlocked with thehub of the needle, the catheter and needle are withdrawn asa unit so that approximately 1 to 2 cm of catheter areexposed between the skin and the needle tip. If difficulty inadvancing the catheter through the needle is encounteredduring any part of this procedure, further manipulationshould be avoided, and the catheter and needle should bewithdrawn as a unit to minimize the risk of shearing aportion of the catheter by the sharp edges of the beveled tip.For this reason, the catheter must never be withdrawnthrough the needle after it has been advanced more than 2inches of its length. After accurate placement, a plastic clipis placed around the sharp point of the needle to preventaccidental laceration or severance of the catheter, and thecatheter is secured to the skin with a 3-0 silk or nylon





suture. Antimicrobial ointment (povidone-iodine, Polysponin, on Neosponin) is placed around the catheter exit site;a small sterile dressing is applied; tincture of benzoin ispainted or sprayed on the skin; and the dressing is securedby water-repellent adhesive tape. All tubing and catheterconnections are taped securely to prevent inadvertent separation with resultant contamination of the hyperabimentation delivery system, loss of blood, and possible air embolism. A portable chest noentgenogram is obtained to confirm the proper position of the feeding catheter within thecentral venous system with its tip lying in the middle of thesuperior vena cava. If the catheter has been malpositioned,e.g., directed into an internal or external jugular vein, it

should be removed and replaced. Otherwise, thrombophbebitis and its accompanying discomfort will usually promptlyensue. Following confirmation of correct catheter placement, infusion of the concentrated nutrient solution canbegin.

When the platelet count is below 40,000/cu mm , 3 units ofplatelets are infused rapidly immediately before and afterinsertion of the subclavian vein catheter in order temporanily to correct the thrombocytopenia. If the prothrombintime is 3 sec above the control value on the partial thromboplastin time is prolonged beyond normal upper limits, 10 to30 mg of vitamin K are given i.m. during the 24-hr period preceding central venous catheterization to minimize bleeding.

In infants weighing less than 10 Ib, the small diameter ofthe subcbavian vein and the high apex of the lung can makepercutaneous subclavian cannulation very difficult and dangerous. Long-term i.v. catheterization in such patients isachieved more safely by inserting the catheter via externalon internal jugular vein cutdown, using a 1-cm incisioneither at the base of the neck on at the angle of the mandible. After proper placement of its tip into the superior venacava, the catheter is secured to the vein by two or three 4-0silk sutures, and the proximal end is tunnelled s.c. cephaladbehind the ear to emerge through a tiny stab wound in thepanietal area of the scalp. The skin exit site is therebyremoved to a point distant from the phlebotomy site, thusreducing the risk of infection and mechanical obstruction,and making aseptic catheter maintenance easier. The neckwound is closed, and the catheter is sutured at the scalpexit site with 4-0 silk. An antibiotic or antiseptic ointment isapplied, and the scalp is dressed in a manner similar to thatused in the infraclaviculan subclavian catheterization technique.

Any use of the central venous feeding catheter and IVHdelivery system other than to supply i.v. nutrients should bediscouraged on forbidden. At least 3 times a week, thedressing should be removed, the skin around the catheterexit site should be neprepared with a defatting agent and anantiseptic solution, an antimicrobial ointment should bereapplied, and a new sterile dressing should be placed overthe catheter exit site. Aseptic technique must be usedthroughout the dressing change procedure. The hyperalimentation delivery system should not be used for infusionof blood on blood products, for intermittent or regular injection of bolus medication, or for routine central venouspressure monitoring unless an absolute emergency situation arises. It must be considered the patient's â€œlifelineâ€•and

regarded by all who care for the patient with due respect.The IVH delivery system consists of a plastic bag or glass

bottle connected to a microdnip administration set and anextension tubing that inserts directly into the.catheter hub.Whenever possible, a plastic bag is preferable to a glassbottle as the reservoir for the IVH solution. The advantagesof a plastic bag are that it is relatively unbreakable, it is lesslikely to interact with the components of the nutrient solution, it is associated with less particulate matter, it virtuallyobviates the risk of air embolism if the system is intact, andit greatly reduces the risk of solution contamination because by its use a truly closed delivery system can beconstituted.

Administration of other i.v. solutions during IVH shouldbe accomplished preferably through a peripheral venoussite, if possible. If necessary, other i.v. solutions may occasionally be administered simultaneously through the sidearm adapter of the central venous delivery tubing, providedthat the connection is made via firm male-to-female fittingsrather than with the use of a needle. Moreover, the connection should be covered with antiseptic ointment and Secured with adhesive tape. This method is particularly applicable to the intermittent administration of chemotherapyand/on antibiotics. The IVH delivery system, including thetubing of any simultaneous i.v. infusions, is changed routineby every Monday, Wednesday, and Friday on every Tuesday, Thursday, and Saturday by a nursing member of theIVH team. At the termination of a course of hypenabimentation, every catheter is removed aseptically, and the mostdistal 1-inch length of the catheter is transected and immediately cultured for aerobic and anaerobic bacteria andfungi. If the patient is febnile at the time of catheter removal,a sample for blood culture is first withdrawn through thesubclavian catheter.

Central venous feeding catheters are removed if the patient becomes febnile and no obvious source of sepsis otherthan the catheter can be identified. Fever per se is not anabsolute indication for discontinuing IVH. The febnibe patient should first be evaluated thoroughly in an attempt todiscover the precise etiology of the fever. If a source ofinfection is discovered elsewhere, it should be treated appropniately, and the hyperalimentation catheter may be allowed to remain in place. However, blood cultures shouldbe obtained routinely in any febnile patient who has a central venous feeding catheter. Regardless of the source ofinfection, the subclavian catheter must be removed if theblood culture results are positive. The catheter should notbe reinserted until the results are negative and/on until thetemperature has returned to normal. However, the clinicalsituation sometimes dictates that a new central venouscatheter be inserted for monitoring, fluid administration, onother i.v. therapy while the patient is still apparently septic.Such a decision requires judgment and experience on thepart of the hyperalimentation team. Routine catheterchanges have not been necessary, and the longest time thata single catheter has remained in place is 139 days. Approximately 9% of our cancer patients have required catheterchanges during their courses of IVH, usually because of anunexplained fever on mechanical problem with the deliverysystem.

JULY 1977 2445




be added directly to the IVH solutions rather than given s.c.in order to ensure that the insulin is administered to thetissues at the same rate as is the dextrose. A minimum of2000 ml of IVH solution should be administered virtually toall malnourished adult patients if nitrogen equilibrium is arealistic expectation. If endogenous pancreatic insulin output is not adequate for cellular incorporation of the dextroseand amino acidrationadministeredtherein,crystalline insulin should be added to the IVH solutions in initialdoses of 5 to 10 units/1000 ml, and the dosage should begradually increased until blood sugar levels fall within thenormal range. It is well known that some of the crystallineinsulin adheres to the bottle or bag and the administrationtubing. However, the quantity of insulin lost in this mannerwhen it is added to IVH solutions is extremely small, andsufficient insulin is added until the desired metabolic effectis achieved . If the insulin is in the IVH bottle and the infusionstops, insulin administration also ceases. If insulin has beenadministered s.c., however, and the infusion is interrupted,marked hypoglycemia with secondary catastrophic clinicalresultsmightoccur.

Because pancreatic islet cells produce insulin virtually tomaximum capacity in response to the continuous dextroseload during IVH, the abrupt cessation of IVH may lead toâ€œreboundâ€•insulin shock. Although the sudden terminationof IVH can be tolerated without untoward incident in mostpatients receiving between 2000 and 3000 cab/day, a few willexperience profound reactive hypoglycemia. For this reason, IVH administration should be tapered gradually over a24- to 48-hr period. More rapid weaning from the nutrientsolution can be accomplished with relative safety over a 4-to 6-hr period if a 5 to 10% dextrose infusion is administeredthrough a peripheral vein after the IVH has been stopped orif the patient is already ingesting adequate quantities of p.o.carbohydrate. Hyperabimentation should be tapered or discontinued prior to administration of a general anesthetic.Additionally, all fluids administered i.v. during and immediately after operation should contain at least 5% dextrose. Ifreactive insulin hypoglycemia occurs while the patient isanesthetized on incoherent, it may not be recognized andpermanent brain damage may result.

Serum electrolyte, blood urea nitrogen, and blood sugarconcentrations are determined routinely every Monday,Wednesday, and Friday. Once a week, liver function testsare performed, and serum albumin, magnesium, calcium,phosphorus, and creatinine concentrations are measured.A complete blood count and differential are also obtainedonce weekly. A metabolic scale is used to weigh the patientaccurately each morning. In a severely depleted patient, aninitial weight gain of 3 to 4 lb can be expected during the 1st48 to 72 hr of treatment primarily because of rehydration.On the other hand, in severely malnourished patients whoare edematous, weight loss may be observed during the 1st48 hr as diuresis occurs in response to increased colboidosmotic pressure. Thereafter, accumulation of lean bodymass generally cannot exceed 0.5 lb/day. If daily weightgain exceeds 1 lb/day, excessive fluid retention must besuspected, and the delivery rate of the nutrient solutionmust be reduced and/on diuretics should be administered.

In pediatric patients, the nutrient solution can be debivened continuously at a constant rate by means of various


Administrationof IVHSolutionsand MetabolicMonitoring

The hypertonic IVH solutions must be delivered at a constant rate continuously throughout each 24-hr period inorder to allow maximal assimilation of dextrose, aminoacids, and the other nutrients by the body cell mass. Endogenous insulin output increases gradually following the initiation of IVH, and the blood sugar concentrations will subsequently fall to normal levels after an initial rise. Although2000 or 3000 ml of IVH solutioncan be administeredtosome adult patients during the 1st day of parenterab nutnitional repletion, dextrose rations of such magnitude mayresult in hyperglycemia and excessive glycosunia in otherpatients because of relative pancreatic endocrine insufficiency and inadequate quantities of endogenous insulin. Inthe average cancer patient, it is our recommendation toadminister 1000 ml of IVH solution during the 1st 24 hr,followedby 1000 ml every12 hr forthe next48 hr.Thisinfusion schedule minimizes the risk of hypenosmolanity andhyperglycemia because the pancreatic islet cells have theopportunity to adapt with increased insulin output in response to the continuous dextrose infusion. Within the 1st 3to 5 days of parentenal nutritional rehabilitation, the averageadult will generally tolerate a daily nation of 3000 ml of IVHsolution. This may not be possible, however, with thechronically ill, severely cachectic cancer patient. Until dextrose and water tolerances have been clearly establishedclinically, only 2000 ml of IVH solution per day should beadministered to the cancer patient who has lost 20% ormore of his usual body weight in order to avoid significantmetabolic problems.

Fractional urine sugar concentrations are obtained every6 hr in order to monitor glycosunia. It is usually possible toregulate the microdnip delivery system satisfactorily formaintenance of a reasonably constant infusion nate, andpumps are not absolutely necessary for treating an adultpatient with IVH. A widely fluctuating rate of delivery on abolus infusion of IVH solution will often be signaled byglycosunia. It is of paramount importance that all nursingpersonnel on each unit be fully informed of the necessity forconstant infusion of IVH solutions. Prolonged chronic glycosuniacan resultinan excessiveosmoticdiuresis,hypertonic dehydration, and coma; acute massive glycosunia canresult in severe rapid diuresis, dehydration, and convubsions. If constant glycosunia is encountered in a patient withnormal blood sugar concentrations, the rate of infusionshould be tapered until the glycosunia is minimal. If constant glycosunia is encountered in a patient with elevatedblood sugar concentrations, the patient's capacity for metabolizing the administered dextrose has been exceeded,and either the IVH delivery rate must be reduced on exogenous insulin must be added. An occasional isolated 4+urine sugar concentration does not necessarily require insulin administration, because it often reflects only that abolus of IVH fluid has been inadvertently administered.Moreover, it is vitally important after significant glycosuniahas occurred during IVH to measure the blood sugar concentration before administering insulin in order to avoid theinduction of severe hypoglycemia.

If exogenous insulin is deemed helpful on necessary duning routine infusion, our experience indicates that it should



Parenteral Nutrition

pumps with variable speed and fine adjustment controls.Syringe pumps must never be used with nutrient solutionsbecause the risk of solution contamination is too great withsuch apparatus. Between the pump and the catheter, theinfusion tubing is attached to a 0.22-j@ cellulose membrane filter. This in-line final filter protects against transmission of contaminants that may be introduced into the solution on tubing and prevents inadvertent air embolism because air cannot pass through the pores after the filter hasbeen moistened by the solution. The filter and administration sets are replaced at beastevery other day, on more oftenas required . Three-way stopcocks must never be placed inthe central venous feeding line because there is no way tokeep them from being contaminated as they are used.

Complicationsof IVH

Catheter-related clinical sepsis is the most feared andserious complication of IVH (Table 3). However, the mcidence of catheter-related sepsis in the 1st 1000 cancerpatients who received IVH at our institution was 2.2%. Wehave continued to culture all central venous feeding cathetens upon removal for all reasons, and our rate of catheterrebated sepsis has remained at that same level. As in mostother published reports, Candida albicans was the organism grown most frequently from the catheters. Nevertheless, amphotenicin flush of the IVH delivery tubing , as advocated by some workers (1) in this area, has been neithernecessary non advisable.

The incidence of thrombogenesis is increased in cancerpatients, but evidence of subclavian vein thrombosis hasoccurred in only 6 patients in our series. In each patient, theipsibateral arm and neck became edematous, but the edemaresolved spontaneously within 1 week of removing the sub

clavian vein catheter. The use of hepanin was not necessary,and no documented episodes of pulmonary emboli occunred. Two other patients did develop evidence of documented pulmonary embolus while receiving IVH, but theclots were demonstrated by venography to originate fromthe pelvis in each instance.

Hypenchboremic metabolic acidosis has not been a significant problem since new formulations of amino acids havebecome available. Symptomatic hypophosphatemia has occurned in only I patient, although as many as 20% ofpatients may have a low serum phosphate concentrationrecorded at least once during their hospitalization. Twopatients early in our experience developed transient pulmonary edema because of fluid overload. The etiology for thiscomplication was the lack of adequate coordination between the water required for infusion of chemotherapydrugs and that required for infusion of the IVH nutrients.This problem has been obviated now that the members ofthe IVH team are responsible for the total water and electrobyte content of all parenteral and enteral fluids during penods of IVH. A list of potential metabolic hazards related tototal parenteral nutrition is outlined in Table 4.

The HyperalimentationTeam

At our 2 hospitals, an average of approximately 60 patients are receiving IVH at any time. In order to administerIVH safely and properly to this barge population of patientssimultaneously, the team approach is absolutely necessary.The hypenalimentation team consists primarily of an attending physician(s), house staff and fellows, hyperalimentationnurse(s), rehabilitation therapist(s), pharmacist(s), and re

search technician(s). The attending physician is responsibleultimately for evaluating each patient's nutritional status

Table 3

Potential complications of IVH related to central venous catheterization

Infectious Technical

PneumothonaxTension pneumothoraxHemothoraxHydnomediastinumCardiac tamponadeBrachial plexus injuryHomer's syndromePhrenic nerve paralysisCarotid artery injurySubclavian artery injurySubclavian hematomaThrombosis, subclavian vein or supeniorvenacava

ArteriovenousfistulaVenobronchial fistulaAir embolismCatheter embolismThromboembolismCathetermisplacementCardiac perforationEndocarditisThoracic duct lacerationInnominate or subclavian vein lacer

ation

1 . Insertion site contaminationa. Contamination during insertionb. Contamination during routine care

2. Cathetercontaminationa. Improper technique inserting catheter

b. Administration of blood via feeding cathetar

c. Useof catheter to measurecentral venouspressure

d. Use of catheter to obtain blood samples

e. Useof catheter to administer medications

f. Contaminated solution during preparationoradditives

g. Contaminated tubing via connections

h. 3-way stopcocks in system

3. Secondarycontaminationa. Septicemia,bacterial or fungalb. Septic emboliC. Osteomyelitis of clavicle

d. Septic arthritise. Endocarditis

JULY 1977 2447




Table 4

Potential metabolic hazards of total parenteral nutrition

Potential complications

Glucose metabolismA. Hyperglycemia, glycosunia, osmotic di

uresis, nonketotic hyperosmolar dehydration and coma

B. Ketoacidosis of diabetes mellitus

C. Postinfusion (rebound)hypoglycemia

II. Amino acid metabolismA. Hyperchloremic metabolic acidosis

B. Serum amino acid imbalance

C. Hyperammonemia

D. Prerenal azotemia

Ill. Calcium and phosphorus metabolismA.Hypophosphatemia

1. Decreased erythrocyte 2,3-diphosphoglycerate

2. Increased affinity of hemoglobin for oxygen

3. Aberrations of erythrocyte intermediarymetabolites

B. Hypocalcemia

C. Hypercalcemia

D. Vitamin D deficiency; hypervitaminosis D

IV. Essential fatty acid metabolism: serum deficiencies of phospholipid linoleic and/or arachidonic acids, serum elevations of @-5,8,11-eicosatrienoic acid

V. MiscellaneousA. Hypokalemia

B. Hyperkalemia

C,Hypomagnesemia

D. HypermagnesemiaE. Anemia

F. BleedingG. HypervitaminosisAH. Elevations in serum glutamic-oxaloacetic

transaminase , serum glutam ic-pyruvictransaminase, and serum alkaline phosphatase

I. Cholestatic hepatitis

Possibleexplanations

Excessivetotal dose or rate of infusion of dextrose; inadequateendogenousinsulin; glucocorticoids; sepsis

Inadequateendogenousinsulinresponse;inadequateexogenousinsulintherapy

Persistence of endogenous insulin production secondary to prolonged stimulation of islet cells by high-carbohydrate infusion

Excessive chloride and monohydrochboride content of crystalline amino acidsolutions

Unphysiobogical amino acid profile of the nutrient solution; different amino acidutilization with various disorders

Excessive ammonia in protein hydrolysate solutions; deficiencies of arginine,ornithine, aspartic acid, and/or glutamic acid in crystalline amino acid solutions; primary hepatic disorder

Excessive total dose or rate of infusion of protein hydrolysate or amino acidsolution

Inadequate phosphoruÃ¨ administration, redistribution of serum phosphorus intocells and/or bone

Inadequate calcium administration; reciprocal response to phosphorus repletion without simultaneous calcium infusion ; hypoalbuminemia

Excessive calcium administration with or without high doses of albumin; excessive vitamin D administration

Inadequate or excessive vitamin D administration

Inadequate essential fatty acid administration; inadequate vitamin E administration

Inadequate potassium intake relative to increased requirements for proteinanabolism; diuresis

Excessivepotassiumpotassiumadministrationespeciallyin metabolicacidosis;renal decompensation

Inadequate magnesium administration relative to increased requirements forprotein anabolism and glucose metabolism

Excessivemagnesiumadministration; renal decompensationIron deficiency; folic acid deficiency; vitamin B,2 deficiency; copper deficiency;

other deficienciesVitamin K deficiencyExcessivevitamin A administrationEnzyme induction secondary to amino acid imbalance; excessive glycogen and/

or fat deposition in the liver

Decreased water content of bile

and indications for receiving IVH. A patient with significantnutritional depletion is arbitrarily defined as one who hassustained a weight loss of 10 lb or 10% of his usual bodyweight or more within 2 months, has a serum albuminconcentration of less than 3.4 g/100 ml, and/or is anergic toa battery of standard recall skin test antigens (Denmatophytin, Vanidase, Candida, intermediate purified protein denivative, and keyhole limpet hemocyanin). Obvious malnutni

tion, however, is not the only indication for using IVH incancer patients. The treatment protocol for a patient who iswell nourished may include a major surgical procedure,prolonged radiotherapy, or multiple courses of chemo

therapy, alone on in combination with radiation thenapy and/or surgery. If the patient is expected to remain areasonable candidate for suc@jextensive combination treatment, he should maintain an adequate body mass throughout the course of treatment, on it might necessarily besignificantly compromised or abandoned because of secondary malnutrition. Because most chemothenapeuticdrugs and high doses of radiation to the alimentary tractcan induce anorexia, nausea and, at times, diarrhea withresultantreducedp.o.intakeand weightloss,adequatelynourished patients who receive intensive oncobogicaltreatment may require hyperabimentation in order to main





tam their nutritional status throughout therapy.An IVH manual is issued to the residents and fellows as

they rotate onto the hyperalimentation team at 3- to 4-monthintervals. Although most physicians in training today arefamiliar with a technique of subclavian vein catheterizationand some have previously used IVH, it is imperative thatthere be uniformity of patient management by all membersof the team. Accordingly, the house staff and fellows areinstructed in the principles and techniques of IVH as practiced in our institution. The staff nurses are familiarwith ourroutine methods, and significant deviation from the established protocols can be confusing to them and detrimentalto patient care. The specially trained nurses assigned to thehyperalimentation team are responsible for daily cathetercare and quality control of the administration of the nutrient

solutions. They change the catheter dressing and IVH deliv-.ery tubing on Monday, Wednesday, and Friday or on Tuesday, Thursday, and Saturday, inspecting the entire systemmeticulously for leakage or other mechanical failures. Thenurses also provide valuable in-service instruction to thestaff nurses regarding the administration of the IVH fluidsand the principles underlying their use. They are also availsble or on call throughout the entire 24-hr day to answerquestions or solve problems related to IVH. Because theteam nurses assist the physician with each central venouscatheter insertion, they maintain the consistency of theestablished techniques in our central venous feeding protocob. Since the hyperabimentation nurses see the patientsregularly and attend them for significant periods of timedaily, they provide therapeutically beneficial psychological

B

Fig. 1. This 65-year-old woman lost her entire jejunum, ileum, right colon, and transverse colon during resection of a large retroperitoneal tumor. A, after14 months of ambulatory hyperalimentation via a specially designed vest and infusion apparatus. B, the delivery system effectively concealed by her dress.

JULY 1977 2449




support for the patients as they explain procedures, caneforthem, and interrelate with them professionally. Finally, thehyperalimentation nurse is a key contnibutorto the researchaspects of the nutritional therapy because she is the finalcommon pathway through which all of the efforts of theother members of the team must flow to the patient.

The research technician is responsible for maintenanceof a daily flow sheet that includes: body weight; caloricintake; serum electrolyte, magnesium, calcium, phosphorus, and albumin concentrations; hemoglobin and leukocyte count; temperature; intake and output; immunosurveillance; chemotherapy and/on other forms of treatment; andtumor response. The research technician is also responsible for maintenance of the technical aspects of the variousactive research protocols and their integration with the IVH.

Although no specific pharmacist is singled out as a membenof the hyperalimentation team, the safety and efficacy ofi.v. nutritional repletion in cancer patients is dependent to a

great extent upon the skills and efforts of the pharmacypersonnel. In our institutions, they are all familiar with theformulation of IVH solutions, and constant communicationbetween the pharmacy and the rest of the team is essential.In addition to maintaining quality control of solution prepanation and impeccable records of solution administration,their knowledge of incompatibilities and other aspects ofclinical pharmacology are crucial to consistently successfulIVH.

Dietary and physical therapy are important for optimalnutrition and for rehabilitation of the muscuboskeletal system. A patient who remains inactive during a course of IVHtherapy is more likely to synthesize fat and less likely tosynthesize lean tissue than is a patient who is actively exercising. Finally, the ingenuity and persistence of a skilleddietician is of incalculable value in making a smooth andeffective transition from i.v. nutrition to p.o. and otherforms of alimentary tract feeding.

Although it is possible for one person to carry out all ofthe many, complicated, and continuous facets of IVH in agiven patient under ideal conditions, it is impractical andunreasonable to provide this highly effective but complicated and potentially hazardous form of nutritional therapyto a seriously ill patient or group of patients for bongperiodsof time without a skilled and sophisticated team.

Ambulatoryand HomeHyperalimentation

An absolute indication for IVH is the provision of nutritionto a patient who has lost more than 95% of the absorptivesurface of his gastrointestinal tract. Fortunately, this doesnot occur frequently, but when it does the technique of IVHis clearly lifesaving. Some cancer patients have lost almostall of their small and/or barge bowel as a result of mesentenic arterial on venous thrombosis, netnopenitoneabtumorsinvolving these vessels, and major complications secondaryto abdominal operations or radiotherapy. Such patients

have been maintained for as long as 5 years by varioushome hypenabimentation techniques. Moreover, patientswho may require prolonged courses of chemotherapyand/or radiotherapy may be fed i.v. on an ambulatory basisduring periods when they cannot eat effectively or at all. Inordertominimizetheexpense,inconvenience,and psychological impact of inpatient tneatment,such patients can bemanaged to great advantage on an ambulatory basis. Theycan be fed at home, at an economical nearby hotel or at aminimal health care facility while reporting daily, or as oftenas necessary, to the designated inpatient center for theirantineoplastic therapy, for supervision of their IVH therapyand for monitoring the effects of both . For the past year, ourhyperabimentation team has gained experience with a specially designed vest which is comfortable, attractive, andpractical for the continuous or intermittent central venousfeeding on an ambulatory basis. A lightweight pump andaccessory battery. pack propels the solution continuouslythrough special tubing attached either to a standard subclavian catheter on through a more permanent Broviac orScnibner catheter (2). The pump can be powered indefinitelyvia AC current from a standard 120-V outlet onfor up to 15 hrvia the DC rechargeable battery pack (Fig. 1).

When the patient is resting, the entire vest and its contents can be removed and hung in proximity to his bed orchair. If entirely unencumbered motility is required or desired for feasible periods of time, the entire delivery apparatus and vest can be removed completely, the indwellingcatheter can be fibbedwith hepanin, and a sterile plug can beinserted into the hub of the catheter.

Use of such systems has great potential for increasing theuse of i.v. nutritional therapy in cancer patients who otherwise would be denied optimal nutrition during prolongedcourses of oncological therapy. Moreover, ambulatory hyperabimentation is more economical and generally betteraccepted than is long-term inpatient hyperalimentation.

References

1. Brennan, M. F., Goldman, M. H., O'Connell, R. C., Kundsin, R. B., andMoore, F. 0. Prolonged Parenteral Alimentation: Candida Growth andthe Prevention of Candidamia by Amphotericin Installation. Ann. Surg.,175: 265-272, 1972.

2. Broviac, J. W., and Scrlbner, B. H. Prolonged Parenteral Nutrition in theHome. Surg. Gynecol. Obstet., 139: 24â€”28,1974.

3. Cannon, P. R., Frazier, L. E., and Huges, R. H. Influence of Potassium onTissue Protein Synthesis. Metabolism, 1: 49â€”57,1952.

4. Copaland, E. M., and Dudrick, S. J. Nutritional Aspects of Cancer. In: R.C. Hickey (ed), Currant Problems in Cancer, vol. 1, No. 3, pp. 1-51.Chicago: Yearbook Medical Publishers, Inc., 1976.

5. Cuthbertson, D. P. Further Observations on the Disturbance of MataboIism Caused by Injury, with Particular Reference to Dietary Requirementsof Fracture Cases. Brit. J. Surg., 23: 505-520, 1936.

6. DudriÃ³k, S. J., Rhoads, J. E., and vars, H. M. Growth of PuppiesReceiving All Nutritional Requirements by vein. In: K. Lang (ad.).Fortschritte der Parenteralen Emahrung, pp. 2-4. Lochham bei Munchen,West Germany: Pallas verlag, 1967.

7. Dudrick, S. J., Wilmore, D. W., vars, H. M. and Rhoads, J. E. Long-TermTotal Parenteral Nutrition with Growth , Development and Positive Nitrogen Balance. Surgery, 64: 134-142, 1968.

8. Long, J. M., Wilmore, D. W., and Pruitt, B. A. Comparison of Carbohydrate and Fat as Caloric Sources. Surg. Forum, 26: 108-110, 1975.




1977;37:2440-2450. Cancer Res Stanley J. Dudrick, Bruce V. MacFadyen, Jr., Eduardo A. Souchon, et al. Parenteral Nutrition Techniques in Cancer Patients

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