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How to cite this article: Ríos-González R, Anaya-Florez MS, Gutiérrez-Hernández JI, Morán-Villota S. Parenteral nutrition in pediatric patients: indications and complications in third level. Rev Med Inst Mex Seguro Soc. 2015;53 Suppl 3:S262-9.

PubMed: http://www.ncbi.nlm.nih.gov/pubmed/26509302

ORIGINAL CONTRIBUTIONS

Received: August 14^th 2014

Accepted: September 1^st 2015

Parenteral nutrition in pediatric patients: indications and complications in third level

Roxana Ríos-González,^a María Salomé Anaya-Florez,^b Jorge Isaac Gutiérrez-Hernández,^c Segundo Morán-Villota^d

^aHospital de Pediatría

^bServicio de Nutrición Parenteral y Enteral, Hospital de Pediatría

cServicio de Prematuros, Hospital de Gineco-obstetricia 4

^dUnidad de Investigación Médica en Gastroenterología, Hospital de Pediatría

^a,b,dCentro Médico Nacional Siglo XXI

Instituto Mexicano del Seguro Social, Distrito Federal, México

Communication with: Roxana Ríos-González

Telephone: (52) 57 80 85 85

Email: rorg21@yahoo.com.mx

Background: Parenteral nutrition (PN) is a mixture that covers the nutritional needs when enteral nutrition is not an option; however, PN is not free of complications. The aim of our study was to determine the indication and frequency of NP complications in pediatric patients treated at a tertiary center.

Methods: Children receiving PN at the Hospital de Pediatría del Centro Médico Nacional Siglo XXI were included. Demographic and anthropometric characteristics were recorded, as well as the reason of indicating PN, the time of administration, and the complications associated to this type of nutrition.

Results: Sixty-nine pediatric patients with PN were included: 33 neonates, 18 infants (between one and 11 months of age), nine preschoolers (from 1 to 5 years of age), and nine children over five years of age. Instructions for initiating the PN were given for the treatment of 71 % of the patients with diseases of the digestive tract who were treated surgically. Complications of PN occurred in 87 % of the children and 76.7 % had more than one complication. Metabolic complications occurred in 98 % of the children while mechanical and infectious complications only in 1 %, respectively.

Conclusions: Parenteral nutrition was indicated more frequently in pediatric patients with digestive diseases treated surgically. Metabolic complications were the main concern in pediatric patients with PN.

Keywords: Parenteral nutrition, Complications, Child health services.

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Parenteral nutrition (PN) is a mixture of nutrients, fluids, and electrolytes infused through a venous catheter¹ to meet nutritional needs when this cannot be done by enteral means.^2,3,4 It can be administered via a peripheral venous line or central catheter;^3,4 however, it is not without complications.

PN complications occur in over 50% of patients5 and are related to the insertion or contamination of the catheter or with metabolic or hepatobiliary disorders.

Central venous catheters can have mechanical complications related to insertion (pneumothorax, abnormal localization),^3,4,6 rupture, occlusion, and venous thrombosis.^3,4,7 With subclavian or jugular vein accesses, the mechanical complications that occur most often in children are pneumothorax, hemothorax, and arterial puncture.⁸ Central venous thrombosis is more likely in patients with coagulopathy⁹ or cancer.^8,9 The main limitation to the use of peripheral PN is developing thrombophlebitis.¹⁰

Infection can happen in a percentage of patients ranging from 1.3 to 26.2% of those with central venous catheters for PN,¹¹ who have from four¹ to 10 times⁸ increased risk of catheter-related infection.¹ Risk factors for catheter-related bacteremia or sepsis include: duration, and type and number of lumens;¹² catheters inserted into the internal jugular are associated with a higher risk of infection than those inserted into the subclavian or femoral.¹³ The risk of infectious complications increases when catheter duration exceeds five days, and increases further after seven days.8 Peripheral catheters may be colonized up to 30% when left for more than three days.¹⁴ Coagulase-negative staphylococci are blamed for 60% of catheter-associated bacteremia;¹¹ PN administration is also recognized as a risk factor for candidemia.¹⁵

Metabolic complications derive from the deficit or excess of one of the components of PN.^2,3,4,7

Hepatobiliary complications range from increased hepatic enzymes¹⁶ to the development of cirrhosis.^6,16 Liver dysfunction associated with PN occurs two to three weeks into PN.¹⁷ Some drugs metabolized via the hepatic cytochrome P450 can be hepatotoxic.¹⁸

Three patterns of PN-related liver disease are recognized: cholestasis, steatosis, and bile duct/gallbladder dysfunction.¹⁷ Cholestasis is the most common PN-related liver dysfunction in children;¹⁶ the incidence varies between 7.4 and 84%.^16,17 Exposure to PN is one of the main factors in the development of cholestasis in preterm newborns (NB).¹⁹

The incidence of acute acalculous cholecystitis during PN can be from 4%¹⁷ to 30%.²⁰ In patients receiving long-term PN an incidence of 19-45% for cholecystitis calculosa has been reported.¹⁷ Although the frequency of complications related to PN administration is greater than 50%, the distribution of causes varies in different studies. The indications and frequency of PN complications differ across studies, probably depending on the diseases suffered by patients received in hospitals with different levels of care. The aim of this study was to determine the causes of indication of PN and the frequency of complications associated with its administration in a tertiary care hospital. 

Methods

Hospitalized patients were included prospectively in various departments of the Unidad Médica de Alta Especialidad Hospital de Pediatría of the Centro Médico Nacional Siglo XXI, during the period between March 1^st and May 31^st, 2012, with indication for PN. Patients already receiving this type of nutrition at the beginning of the study period were excluded.

The information obtained from medical records included general patient data, clinical diagnoses at the time of beginning PN, PN indication, and data related to PN, the catheter, and complications presented during the time of administration, as well as drugs used in the treatment of the patient. PN is administered through a peripheral vein or a central venous catheter and maintained until a suitable transition to oral or enteral nutrition was possible. Before initiating PN, an X-ray was taken after placing the venous catheter to determine the location of the tip. During PN administration the following biochemical parameters were monitored: serum electrolytes, liver function tests, blood chemistry, cholesterol, triglycerides, plus blood gas analysis performed on venous blood at least once a week.

For statistical analysis, the results were expressed as means (minimum-maximum) and percentages.

Results

Table I shows the demographic characteristics of the patients and changes in body weight after PN administration.

A total of 69 patients were included in the study: NB accounted for 47.8% (n = 33) of the total population, of which 48.5% (n = 16) were premature; patients between one and 11 months of age accounted for 26% (n = 18); those one to five years were 13% (n = 9), same for those more than five years old.

87% (n = 60) of patients experienced weight gain, 13% (n = 9) had no increase, and one had weight loss of 14.3 g per day.

The average time of PN administration in preterm infants was 13 days (minimum 1 day, maximum 33 days); for term infants it was 10 days (minimum 1 day, maximum 26 days); for patients one to 11 months old, 17 days (minimum 1 day, maximum 35 days); one to five years, 14 days (minimum 1 day, maximum 21 days), and age five and up, 13 days (minimum 2 days, maximum 31 days).

Table II shows the indications for PN related to diseases of the digestive tract, and Table III shows indications from other diseases.

PN was administered via central line in 97.1% (n = 67) of patients and peripherally in 2.9% (n = 2); venesection was required in 52.2% (n = 36) of cases and percutaneous in 47.8% (n = 33). Venous accesses used were: subclavian 31.9% (n = 22); internal jugular 23.2% (n = 16); saphenous 15.9% (n = 11); external jugular and basilica vein 13% (n = 9) each; and tibial vein 2.9% (n = 2). Polyurethane catheter was used 3% (n = 2) and silicone catheter 97% (n = 67) of the time; catheters had two lumens in 73.9% (n = 51), one lumen in 15.9% (n = 11), and three lumens in 10.1% (n = 7); the point was located in the atrium in 55.1% (n = 38), in the superior vena cava in 24.6% (n = 17), the inferior vena cava in 17.4%, and in the right ventricle in 2.9%. 

The catheter was used for an average of 19.39 days (minimum 1 day, maximum 141 days); the reason for its removal was transition to oral/enteral feeding in 75.4% (n = 52) of patients, death in 17.4% (n = 12), extravasation in 4.3% (n = 3), infection in 1.4% (n = 1), and accidental removal in 1.4% (n = 1).

Table IV describes complications associated with PN. Complications were presented in 87% (n = 60) of patients, and 76.7% (n = 46) had more than one complication; there were 204 total complications. 78.5% (n = 157) of complications showed in the first week of PN.

Patients had from one to nine simultaneous complications. 81.2% (n = 13/16) of preterm infants presented complications, which accounted for 24.5% (n = 50/204) of all complications; 88.2% (n = 15/17) of term infants had complications, which accounted for 24% (n = 49/204) of all complications; 88.9% (n = 6/18) of patients from one to eleven months old presented complications, accounting for 28.9% (n = 59/204) of the total; 88.9% (n = 8/9) of patients one to five years had one to five concurrent complications, which represented 9.3% of the total (n = 19/204), and in patients over five years 88.9% (n = 8/9) presented complications, accounting for 13.2% of the total (n = 27/204).

Of all complications (n ​​= 204), the metabolic type represented 98% (n = 200), mechanical 1% (n = 2), and infectious 1% (n = 2). The mechanical complications were central venous catheter occlusion within four days after placement, and cardiac perforation with tamponade in a patient who died one day after catheter placement. Catheter-related bacteremia due to Staphylococcus epidermidis was presented in two patients, three and twenty-five days after placement. In the group of metabolic complications, hypophosphatemia represented 22.5%; in the infectious category, catheter-related bacteremia constituted 100%, with Staphylococcus epidermidis isolated in the same percentage.

Discussion

The study results confirm that PN indication in a highly specialized center is mainly related to previous surgeries for congenital digestive tract and cardiovascular diseases.

87% of patients showed weight gain, although only 74% achieved between 10 and 30 g per day, 5 which is the rate reported in the literature for patients with PN. 13% had no weight gain and even showed weight loss; however, this represents a lower percentage than that reported by Perdomo et al.⁵ Patients one to 11 months old were the age group that presented the greatest weight gain.

Congenital diseases of the digestive tract surgically treated were the most frequent cause for PN indication. It should be remembered that patients with permanent dysfunction of the intestinal tract may need PN for life.⁵ This is consistent with that reported in the study by Izquierdo et al.²¹ in patients under 16 years of age, but excluding NB. As in another study made at a highly specialized hospital, surgery of the digestive tract preceded PN indication in 43.5%; in other studies extra-digestive diseases were the main indication for PN.^5,22

As for the expected time of fasting, most of patients (97.1%) received PN through a central venous line, the same as reported by Izquierdo et al.²¹

A prospective study of infants with PN reported complications in 48%,⁵ another retrolective study found 61%,²² and a retrospective study more recent than those, performed in patients under 16 years of age (excluding NB) reported 27.3%.²¹ Unlike the aforementioned studies, the present study included all age groups, which could explain the observed difference in the frequency of PN complications.

During PN administration, the majority of patients (76.7%) had more than one simultaneous complication; in our study the most vulnerable age group was that of patients one to 11 months; not only did 88.9% of them have complications, but they also had the largest number of simultaneous complications.

The most frequent complications were metabolic (98%), which had a higher percentage than that reported by Perdomo et al. (60%).⁵

Among metabolic complications, differing from other studies in which hyperglycemia was the most common metabolic complication reported in 485 and 52%,²² in this study hyperglycemia ranked third (16.5%), probably due to better control over the glucose supply as a component of PN, and therefore removal of excess infusion of this as the main cause of hyperglycemia.

Hypophosphatemia was the most common metabolic complication (22.5%); however, despite being characteristic of refeeding syndrome, it was not part of this in any of our patients. Fasting could be a major cause of depletion of serum phosphorus. Other factors that may have contributed were malabsorption and the use of diuretics or corticosteroids, among others, so it is important in future studies to identify risk factors to influence and thus reduce this frequency, in addition to monitoring the individual components of the PN solution.

The frequency of hypertriglyceridemia found in our patients (8.5%) was similar to that reported in the literature, which varies between 6 and 38%.²³ Sepsis may partially explain the increased number of cases, because in this circumstance carnitine is not produced, which is a protein necessary for the metabolism of fatty acids in mitochondria, which decreases lipid clearance.

Cholestasis was found less frequently (2.5%) compared to reports by other authors, who reported it in 11²² and 14%.⁵ We believe that the origin of cholestasis in our patients was multifactorial and was associated with a low albumin level¹⁷ and sepsis,^16,24,25 as not all patients developed it starting the second week of PN administration, and there was no clear predominance of factors such as prematurity or low weight.^{16,17,18,19,25}

The reduced frequency of infectious complications related to venous catheter (1%) is noteworthy compared to those reported in other studies, where the incidence of catheter-related bacteremia/sepsis reached 16.5%.²¹ It is worth mentioning that the average duration of the catheter was greater than seven days⁸ and a number of them were placed in the internal jugular vein (23.2%);¹³ however, the frequency of infectious complications was low, probably because catheters made of polyethylene or polypropylene were not used,² because they were removed as soon as indication for them went away, and because of improved implementation of infection prevention strategies. This confirms the need for strict adherence to programs for nosocomial infection prevention, particularly those related to the use of venous catheters, with emphasis on actions related to the international patient safety goal number five: "Reduce the risk of infections associated with patient care", through an effective handwashing program.

Staphylococcus epidermidis was the causative organism of catheter-related bacteremia, as in other studies;^2,3,4,6 the isolation of this organism in 100% of cases contrasts, however, with other series in which it was only isolated in 60%.^11,21

In our study, although most of the venous accesses were in central veins (68.1%), no mechanical complications were found related to catheter insertion (pneumothorax, hemothorax, arterial puncture),⁸ suggesting adequate placement technique. The frequency of mechanical complications associated with the duration of the catheter (1%) was lower than that reported in other studies, in which occlusion was found in 6%.⁵

Complications from the imbalance of any of the components of the PN solution^2,3,4,7 are the most frequent in pediatric patients; however, it should also be noted that the vast majority of them have complex underlying conditions, which make the children susceptible to them.

Conclusion

Based on the results, we can conclude that indication for PN in the tertiary level is primarily related to surgeries performed for the treatment of congenital diseases of the digestive tract and cardiovascular ailments, and that the most frequent complications of PN are metabolic.

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