No abstract

The risk of complication during the insertion or exchange of central venous catheters has been well documented. The majority of complications involve mechanical problems associated with insertion. Although cardiac arrhythmia has been acknowledged as a possible complication, its incidence has never been quantified. We performed cardiac monitoring on patients during 51 central venous catheter insertions or exchanges to determine the incidence of cardiac arrhythmias during guidewire insertion. Forty-one percent of procedures resulted in atrial arrhythmias and 25% produced some degree of ventricular ectopy, 30% of these were ventricular couplets or greater. Ventricular ectopy was significantly more common in shorter patients (160 +/- 8 vs 168 +/- 11 cm, p less than 0.05) and when the catheter was inserted from the right subclavian position (43% ventricular ectopy vs 10% at the other sites). Other variables such as age, cardiac history, serum potassium, type of procedure, and catheter brand were not significant. It is our conclusion that over-insertion of the wire causes this cardiac stimulation. Despite the absence of morbidity or mortality in this study, this incidence of ventricular ectopy indicates that there is a distinct possibility of a malignant arrhythmia being precipitated by a guidewire. Some modification of the current protocol for these procedures seems indicated.

Iron-deficiency anemia is common in patients receiving chronic HPN. Regular small doses of iron in HPN formula, rather than total dose infusion, is the preferred treatment.

This study was designed to examine circulating and urine cytokine levels in patients receiving long-term home total parenteral nutrition (TPN) support. Twelve patients who had been receiving home TPN for more than 1 year (range, 1.3-19.5 years) were enrolled for study. To avoid the potential confounding effects of intercurrent infection, patients were studied during periods of clinical stability without clinical evidence of infection. Ten normal healthy volunteers served as controls. Serum levels of albumin and C-reactive protein, temperature, body weight, and blood white cell counts were determined. The levels of soluble tumor necrosis factor receptor II (sTNF-RII) and interleukin 6 (IL-6) were measured in serum and 24-hr urine. The results showed that the concentrations of sTNF-RII and IL-6 in 24-hr urine and serum were significantly higher in patients, indicating that long-term home TPN may be associated with a persistent low-grade inflammatory state.

Patients receiving home total parenteral nutrition (HTPN) are at risk for the development of essential fatty acid deficiency (EFAD). This study examined the essential fatty acid status of patients on long-term HTPN for gut failure. Serum phospholipid and triglyceride fatty acids were measured in 11 patients and 10 healthy volunteers. Patients had similar levels of linoleic acid (18:2w6) in serum triglyceride fatty acids but significantly lower levels of 18:2w6 in serum phospholipids compared to controls. Although there was accumulation of Mead acid (20:3w9) in both fatty acid fractions, the ratio of 20:3w9 to arachidonic acid (20:4w6) remained less than 0.2, reflecting an adequate essential fatty acid status in these patients. There were, however, substantial increases in 20:4w6 content in both triglyceride and phospholipid fractions in serum despite the lower levels of 18:2w6 in serum phospholipids, suggesting that an accelerated hepatic conversion of 18:2w6 to 20:4w6 occurs in HTPN patients, as well as the 20-carbon members of w3 (20:3w3) and w9 (20:3w9) families. The determination of optimal parenteral fat intakes should be investigated further as important priority in patients receiving long term HTPN.

This study examined the effects of a liquid meal on cholecystokinin (CCK) secretion in patients with severe short bowel syndrome (SSBS) receiving home total parenteral nutrition (TPN) support for 5-19 years after massive small bowel resection. Five patients with SSBS due to superior mesenteric artery or vein thrombosis were included. Five healthy volunteers served as controls. Blood was drawn before and 1 hr following consumption of 250 ml of a liquid diet containing 232 kcal with 8 g fat and 8 g protein. Plasma CCK activity was evaluated by amylase bioassay. All patients had stable weight with a normal BMI and serum albumin level, although there were mild abnormalities in their liver function tests. CCK secretion after stimulation was significantly decreased in patients. These results suggest that reduction in intestinal length influences CCK secretion in response to meal stimulation in SSBS patients.