Letters to the Editor Total Peripheral Parenteral Nutrition in Pregnancy To the Editor: I have studied the observations by Watson et all with interest. I have some difficulty, however, in accepting their conclusions. First, the authors describe &dquo;good tolerance with a minimum of side effects.&dquo; However, 42 IV sites were changed for irritation, swelling, redness, or fever, all of which were obviously related to the peripheral IVs used for parenteral nutrition (Table II). Unfortunately the authors did not have a control group who received only D5W or saline through peripheral IVs for an identical period with which to compare incidence of IV site irritation.
receiving lipid? Did the
woman with a triglyceride level of 36 mg/dL also have an &dquo;improvement&dquo;? In addition, the authors state that all patients had normal-length gestations without preterm deliveries. The implication is that the large lipid doses were administered safely with-
inducing pharmacologic prostaglandin synthesis. However, it is implied that the PPN was administered early in the pregnancy as one patient even required three subsequent hospital admissions. Although I am unaware of any indisputable report in humans associating preterm labor with parenteral lipids, the study by Watson et aP seems to be of too short duration and too early in pregnancy to be of value in evaluating parenteral lipid safety in pregnancy. Fourth, the authors note PPN is cost effective. How
out
was
this measured? How does it compare to total par-
Second, the patients were maintained on peripheral enteral nutrition through a central catheter? How can parenteral nutrition (PPN) for an average of 5 days only PPN that is given only 5 days be cost effective? Accordand they gained an average of 4.1 pounds. I suspect a ing to Katz and Oye,~ it would have been more cost large portion of this weight gain in such a short period effective not to have fed the patients at all during this is fluid alone. Furthermore, I wonder why patients would short time course. In conclusion, I do not feel that hypertonic PPN has be given PPN for such a short period of time (including at least one patient for only 1 day) when they were been proven safe or effective in pregnancy. It should be rapidly converted to enteral feeding. The authors note used only when absolutely indicated and when at least 7 that albumin levels improved after PPN.’ With a serum days of nothing by mouth are anticipated. half-life of 20 days, I do not see how this finding can be ALAN L. BUCHMAN, MD related to their nutritional support.’ D10W is the most Division of Digestive Diseases hypertonic dextrose solution generally administered rouEmory University School of Medicine tinely through peripheral veins yet it still causes vein Atlanta, GA 30322 sclerosis (unpublished observations). The final dextrose concentration administered by Watson et ah was only REFERENCES D10W or D15W which is hardly a change from standard medical practice. Moreover, because many IV sites were 1. Watson LA, Bommarito AA, Marshall JF: Total peripheral parnot changed routinely, but because the sites became enteral nutrition in pregnancy. JPEN 14:485-489, 1990 I this is evidence that inflamed, suggest actually paper 2. Mobarhan S: The role of albumin in nutritional support. JACN even relatively hypertonic dextrose solutions should not 7:445—452, 1988 be administered via peripheral vein if possible. 3. Katz SJ, Oye RK: Parenteraal nutrition use at a University hospital—Factors associated with inappropriate use. West J Med Third, if a lower dextrose concentration solution is 152:683—686, 1990 used (ie, D10 as opposed to D25) it follows that lipid must make up a higher percentage of total caloric support. Watson et all note that triglyceride levels ranged Response to Dr Buchman’s Letter from 36 to 263. There are no units listed, but I assume it to be milligrams per deciliter. Additionally, the impli- To the Editor: cation is that these are baseline data, before lipid infuFirst, the tolerance associated with peripherally adsion. What is important is whether the patients have an ministered hypertonic total peripheral parenteral nutriimpaired ability to hydrolyze and clear what may be a tion (TPPN) is very acceptable from our experience. Not relatively large lipid dose. Unfortunately, no data are only in the pregnant patient but from our experience, presented. I especially wonder if the patient with a pre- the internal medicine and surgical patient populations sumed fasting baseline triglyceride level of 263 mg/dL benefit as well. Our patient utilization records over a 3had difficulty with lipid tolerance. The authors go on to year plus period with this technique encompass over 1000 state that &dquo;patients demonstrated improvements in patients. In addition, testing was done on two individual serum levels of triglycerides.&dquo; What does that mean? patients who received Dextrose 5~c and 1/2 normal saline Were the levels decreased? How could that be after plus 40 KCL simultaneously with the hypertonic TPPN,
189 Downloaded from pen.sagepub.com at OAKLAND UNIV on May 2, 2015
receiving lipid? Did the
woman with a triglyceride level of 36 mg/dL also have an &dquo;improvement&dquo;? In addition, the authors state that all patients had normal-length gestations without preterm deliveries. The implication is that the large lipid doses were administered safely with-
inducing pharmacologic prostaglandin synthesis. However, it is implied that the PPN was administered early in the pregnancy as one patient even required three subsequent hospital admissions. Although I am unaware of any indisputable report in humans associating preterm labor with parenteral lipids, the study by Watson et aP seems to be of too short duration and too early in pregnancy to be of value in evaluating parenteral lipid safety in pregnancy. Fourth, the authors note PPN is cost effective. How
out
was
this measured? How does it compare to total par-
Second, the patients were maintained on peripheral enteral nutrition through a central catheter? How can parenteral nutrition (PPN) for an average of 5 days only PPN that is given only 5 days be cost effective? Accordand they gained an average of 4.1 pounds. I suspect a ing to Katz and Oye,~ it would have been more cost large portion of this weight gain in such a short period effective not to have fed the patients at all during this is fluid alone. Furthermore, I wonder why patients would short time course. In conclusion, I do not feel that hypertonic PPN has be given PPN for such a short period of time (including at least one patient for only 1 day) when they were been proven safe or effective in pregnancy. It should be rapidly converted to enteral feeding. The authors note used only when absolutely indicated and when at least 7 that albumin levels improved after PPN.’ With a serum days of nothing by mouth are anticipated. half-life of 20 days, I do not see how this finding can be ALAN L. BUCHMAN, MD related to their nutritional support.’ D10W is the most Division of Digestive Diseases hypertonic dextrose solution generally administered rouEmory University School of Medicine tinely through peripheral veins yet it still causes vein Atlanta, GA 30322 sclerosis (unpublished observations). The final dextrose concentration administered by Watson et ah was only REFERENCES D10W or D15W which is hardly a change from standard medical practice. Moreover, because many IV sites were 1. Watson LA, Bommarito AA, Marshall JF: Total peripheral parnot changed routinely, but because the sites became enteral nutrition in pregnancy. JPEN 14:485-489, 1990 I this is evidence that inflamed, suggest actually paper 2. Mobarhan S: The role of albumin in nutritional support. JACN even relatively hypertonic dextrose solutions should not 7:445—452, 1988 be administered via peripheral vein if possible. 3. Katz SJ, Oye RK: Parenteraal nutrition use at a University hospital—Factors associated with inappropriate use. West J Med Third, if a lower dextrose concentration solution is 152:683—686, 1990 used (ie, D10 as opposed to D25) it follows that lipid must make up a higher percentage of total caloric support. Watson et all note that triglyceride levels ranged Response to Dr Buchman’s Letter from 36 to 263. There are no units listed, but I assume it to be milligrams per deciliter. Additionally, the impli- To the Editor: cation is that these are baseline data, before lipid infuFirst, the tolerance associated with peripherally adsion. What is important is whether the patients have an ministered hypertonic total peripheral parenteral nutriimpaired ability to hydrolyze and clear what may be a tion (TPPN) is very acceptable from our experience. Not relatively large lipid dose. Unfortunately, no data are only in the pregnant patient but from our experience, presented. I especially wonder if the patient with a pre- the internal medicine and surgical patient populations sumed fasting baseline triglyceride level of 263 mg/dL benefit as well. Our patient utilization records over a 3had difficulty with lipid tolerance. The authors go on to year plus period with this technique encompass over 1000 state that &dquo;patients demonstrated improvements in patients. In addition, testing was done on two individual serum levels of triglycerides.&dquo; What does that mean? patients who received Dextrose 5~c and 1/2 normal saline Were the levels decreased? How could that be after plus 40 KCL simultaneously with the hypertonic TPPN,
189 Downloaded from pen.sagepub.com at OAKLAND UNIV on May 2, 2015
