The delivery of nutritional support. A potpourri of new devices and methods

The Delivery of Nutritional Support

A Potpourri of New Devices and Methods

MICHAEL M. MEGUID, MD, PHD,' SAMUEL ELDAR, MD, AND ASHE WAHBA,t RPH

With continued interest and increasing awareness of nutritional support to patients, both hospitalized and at home, many new developments in the field of devices and methods of delivering nutritional support have occurred. The indications, methods of use, and the associated complications related to feeding via nasogastric tube, tube esophagostomy, gastrostomy, and jejunostomy in the light of new devices and methods are outlined. The authors' experience shows that postoperative enteral feeding is a reliable and efficient method of providing supportive nutrition, provided the appropriate patients are selected. Home enteral nutritional support via gastrostomy allows stable cancer patients to maintain their nutritional status and enjoy life independent of the hospital setting for an extended period of time. When feeding via the gastrointestinal tract is neither feasible nor desirable, for both short-term and long-term nutritional support, access to the central venous system becomes necessary because peripheral vein feeding has limited cost-effectiveness. Delivery of nutrients into the superior vena cava by long antecubital catheters has been advocated, and the use of Hickman/Broviac catheters, instead of conventional subclavian catheters, is becoming an increasingly common practice. Experience with the use of arteriovenous fistulae and the Infuse-A-Port (Infusaid Corp.) are reviewed, the method used for declot- ting infected and thrombosed catheters is outlined. Current trends in the use of three-liter bags containing a fat emulsion with glucose and amino acids are mentioned.

Cancer 5 2 7 9 - 289,1985.

UTRITIONAL SUPPORT is an important adjunct in N the management of patients who are (1 ) nonstressed and adequately nourished but who are unable or unwilling to eat; (2) in a catabolic state; or (3) malnourished and debilitated. The latter patient population are prone to a wide spectrum of complications from specific diseases, malignancy and following trauma, or the rigor of their treatments.

The purposes of nutritional support have been delin- eated by Shils' into three broad categories: (1) Support- ive role: to maintain nutritional status or rehabilitate debilitated patients while awaiting definitive treatment; (2) Adjunctive role: the use of nutrition as part of therapeutic program; and (3) Definitive role: nutrition is the modality on which the existence of the patient depends.

The most physiologic method of providing nutrition to a hospitalized patient is through voluntary eating. The average hospital diet is well balanced and provides en-

From the Department of Clinical Nutrition, Division of Surgery, City of Hope National Medical Center, California; and ?Mercer Uni- versity, Southern School of Pharmacy, Atlanta, Georgia.

* Member, Cancer Research Center, City of Hope National Medical Center.

Address for reprints: Michael M. Meguid, MD, PhD, Department of Surgery, University Hospital. Upstate Medical Center, 750 E. Adams Road, Syracuse, NY 132 10.

ergy, nitrogen, vitamins and other micronutrients in ac- cordance with RDA standards. Unfortunately, the hospital setting does not always provide an environment conducive to recreational eating; frequently patients are apprehensive, anxious, in discomfort or pain, and thus anorexic. Cancer patients may also suffer from anosmia and thus taste aversion. Up to 40% of our hospitalized surgical cancer-bearing patients are malnourished ac- cording to three of five positive criteria: a posthydra- tional serum albumin less than 3.5 g/dl plus any two of the following four factors: a recent weight loss greater than 10%; a weight for height less than 10th percentile; mid-arm muscle circumference less than 10th percentile; and triceps skinfold thickness less than 10th percentile.

The validity and usefulness of these criteria to determine the state of malnutrition in cancer patients have recently been critiqued in detail.2 The reasons for de- pending primarily on anthropometric data are as fol- lows: (1) varying degrees of dehydration are common prior to admission in our oncologic patients, thereby affecting the reliability of admission biochemical indices; and (2) Marasmus rather than adult Kwashiorkor is the most common form of protein-calorie malnutrition seen in our patients with head and neck or gastrointesti-

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280 CANCER January 1 Supplement 1985 VOl. 55

nal malignancies. Malnutrition results in atrophy of the gastrointestinal organs. Not infrequently malnutrition is associated with some degree of hepatic steatosis, decreased pancreatic enzyme function, and loss of gut mucosal hydrolytic enzymes. Another factor, and one often not appreciated, is that malnutrition is associated with anorexia, apathy and depression which interfere with motivation to self help.

In the absence ofappropriate voluntary intake to meet the nutrient requirements of the nonstressed state or the increased requirements of stress, nutritional support must be provided. The selection of the mode for providing nutritional support will be determined by the pre- vailing physiologic requirements, the patient’s degree of nutritional debilitation (nutritional status), the disease process, the anticipated duration of the inadequate oral nutrient intake period, by the facilities available for the delivery of nutritional support, and the physician’s agil- ity and ability at placing enteral or parenteral catheters. These factors determine whether enteral or parenteral nutritional support will be used. In the former, circumstances dictate which route is the most appropriate for enteral nutrition; in the latter, the physician’s level of competence and comfort with specific procedures for venous access determines the route of delivering parenteral nutrition.

Gastrointestinal Access for Enteral Nutrition

Nasogastric In 1790 John Hunter first introduced nasogastric

(NG) intubation for feeding paralyzed patients. Since then nasogastric feeding has gained increasing impor- tance. Two feeding tubes are most commonly used: the large polyvinyl decompression tube, and the softer small caliber tube. The tube is inserted through the nostril, being pushed posteriorly in a steady fashion using a well- lubricated tube. In alert patients, to minimize the gag reflex and to keep the glottis shut, the tube is advanced while the patient drinks. In comatose patients, flexion of the head closes the larynx and opens up the pharyngo- esophageal tract. Traditionally, the length of tube to be inserted is equal to the sum ofthe distances starting from the tip of the nose to the tip of the earlobe and from the earlobe to the xyphoid. Using this technique, Hanson3 determined the incidence of correct gastric placement to be 72% and developed a series of predictive criteria for length of nasogastric tube insertion based on experience in 104 subjects. He found that [Height (cm) X 0.2 + 17.11 resulted in 96% correct gastric tube placement. Irrespective of the technique used, we recommend that the final position be verified radiographically before using the tube.

The large, stiff polyvinyl tubes are easier to insert. Infusion of nutrients is also easier due to less resistance; however, they are less tolerated by the patient and carry a greater risk of injury. The small caliber tubes appear well tolerated and carry a lesser risk of injury but are more difficult to insert, tending to coil in the hypopharynx. Consequently, a variety of stilettes have been introduced to facilitate their insertion. The small bore tubes provide considerable resistance to flow of nutrients, necessitating either a low viscosity formula or the use of a pump.

The most frequent mechanical complication of NG tube insertion is mucosal injury along the introduction tract. This complication may occur at any level, but occurs most frequently in the nasopharynx and the esophagus. In the nasopharynx profuse bleeding may be induced, while perforation along the introduction tract leads to the NG tube reaching unforseen and unexpected sites. Another frequent complication is the misplace- ment of a soft silastic tube within the larynx and/or intubation of the tracheobronchial tree. This has occurred, even in the presence of a cuffed endotracheal tube, during the insertion of a silastic tube with a metal stilette. Any difficult or unsuccessful nasogastric intubation (or bloody aspirate from the tube), followed by chest or upper abdominal pain, should heighten the awareness of possible cornplicati~n.~

Padilla et al.’ have documented the subjective distresses of nasogastric tube feeding. Among the highest ranked by patients were deprivation of the tasting, drinking and chewing of food, soreness of the nose, rhin- itis, sinusitis, esophagitis; mouth breathing, and the sight of other patients who were eating.

In a prospective study of 109 successive postoperative patients requiring enteral feeding Jeffers er aL6 found that accidental extubation of operatively placed enteral tubes by disoriented or noncompliant patients occurred in 3890, while aspiration occurred in only 1%. In contrast, Olivares and associates noted aspiration to be as high as 13% in debilitated patients with a variety of neu- rologic disorders.’ Although metabolic complications are not commonly considered to occur with enteral feeding, Vanlandingham er d8 observed the following in a prospective study of lo0 patients: fluid overload, 3 1 %, electrolyte imbalance, 30%; hyperglycemia, 30%; and uremia and dehydration, 15%.

It has been our experience that abdominal bloating, cramps, and diarrhea are related to high rates of feeding and to the high caloric density (ie., high fat content) of the formula, although paralytic ileus and side effects of parasympathomimetic drugs must be excluded. These symptoms are less common when feedings are administered on a continuous basis. A distinct disadvantage of the nasoenteral route is that it increases upper airway

No. I NEW DEVICES AND METHODS OF NUTRITIONAL SUPPORT Meguid et al. 28 1

resistance, thereby interfering with ventilatory ex- change. This becomes of consequence in a patient whose respiratory status may already be borderline; under these circumstances an alternate route is best.

Recently Grant and co-workers reported their experience with the use of nasojejunal feedingg A # 8 French, 43-inch long, mercury-tipped tube with a stainless steel stylette was inserted under flouroscopic control in 141 patients with a variety ofdiseases. This type ofcatheter is especially useful for patients with high gastric output, in patients with esophageal and gastric fistulas, to minimize esophageal reflux and aspiration in patients who are comatose or have neurological deficits, and in the presence of endotracheal tubes.

Nasogastric and nasojejunal tubes are well tolerated for short periods. Prolonged intubation (greater than 6 weeks) has led to nasopharyngeal and laryngeal stenosis, and suppurative sinusitis. For long-term access to the gastrointestinal tract, the site of insertion is generally determined by the concomitant surgery that the patient undergoes.

Pharyngostomy and Esophagostomy Pharyngostomy or cervical esophagostomy (hypo-

pharyngotomy) is a simple and quick operation which can be performed under local anesthesia, using the techniques ofEnglish et al. lo or Royster et al. I I This approach is suggested when a feeding tube in the nasopharynx is intolerable or contraindicated, or when feedings are necessary for prolonged periods. It is particularly useful in patients with prior subtotal gastrectomy or esophagogas- trectomy and for head and neck operations. Formal esophagostomy (mucosal incision below the cricophar- yngeus) as described by Montgomery12 is generally performed in conjunction with head and neck procedures. In some instances, a permanent sinus can be performed, allowing the feeding tube to be removed between meals. The advantages of these procedures are that they obviate the need for a celeotomy, and feeding can be provided via a stoma whose proximity to a potentially contaminated tracheostomy does not pose a sepsis problem to the patient (compared to a subclavian catheter).

The minor problems of using these access sites include skin or soft tissue irritation, or accidental extubation because of excess length of the exteriorly placed tube. Major complications may include pulmonary aspiration due to vomiting from reflux esophagitis, stricture of the distal esophagus secondary to acid reflux around the tube, and arterial erosion with esxanguination, particularly in patients with heavily irradiated necks.

During a 1-year experience, 23 patients with tube esophagostomy following head and neck surgery, had 43 red rubber catheters placed. The mean length of postop

erative usage was 16 days. Eight patients were discharged and returned home, following training in the care and use of their catheten6 The complications included caro- tid artery erosion (in two patients who had previously received radiation therapy prior to neck dissection), infected stoma site, and tube obstruction from viscous tube feedings or the insertion of incompletely crushed pills. In contrast Balkany et al. l 3 describe the use ofa new silicon flangecollar, wide lumen esophagotomy tube in 38 patients following head and neck surgery. In their preliminary communication they report no instances of accidental extubation, esophagitis, esophageal regurgi- tation, or tube obstruction. Redness and tenderness occurred at the skin incision for the new tube in 9 of 12 patients undergoing irradiation and in 4 of 26 patients with nonirradiated necks.

Gustrostom y Over 30 different operative techniques have been de-

scribed for tube gastrostomy. Tubes are placed either at the time of other intra-abdominal procedures when postoperative use of enteral feeding is anticipated, or as a separate surgical procedure performed through a limited celiotomy under local anesthesia or light general anesthesia.

Despite the many individual methods, a few general rules are common to the placement of tube gastrostomy, all directed at obviating the most common complication, i.e., free peritonitis due to gastric leakage: (1) the insertion site through the gastrointestinal wall is sealed by either annular or plication sutures; (2) the gastrointestinal wall is approximated to the peritoneum around the site of penetration; and (3) the tube is secured outside the abdominal wall by a reliable method. Three specific points need to be emphasized: (1) the tube used should be large caliber (# 28F or greater) so as to permit the use of less expensive home blenderized diets or more viscous enteral diets for bolus feeding and a slightly smaller diameter tube to be reinserted with ease if the tube acci- dentally comes out; (2) mushroom tip catheters (e.g., Pezzar catheters) in our experience result in fewer internal migrations leading to intermittent pyloric obstruction, than do bulbous catheters (e.g.. Foley catheters); and (3) secure external fixation of the catheter cannot be overemphasized for satisfactory short-term or long-term use. (Meticulous attention to this point is pertinent in preventing intraabdominal leakage and wound disruption during the early postoperative days and migration or extubation of the gastrostomy during subsequent long-term usage.)

The advantages of a tube gastrostomy for feeding purposes include easy access to the stomach and the bypass- ing of more proximal mechanical, surgical, or functional

282 CANCER January I Supplement 1985 VOl. 5 5

obstructions. This method avoids malfunction of the esophagogastric sphincter and the secondary changes (esophagitis and stricture) that are often consequences of prolonged use of NG tubes. Although many modifications are known, two basic types are in use: The first one is the simple straight feeding gastrostomy, like Stamm’s14 Witzel’~’~ and Kaden’s16 modifications in which (with some variation) the tube goes directly out from the stomach. The tube in these cases is indispens- able since the stoma tends to close promptly when the tube has been removed. An advantage of this surgical approach is that it is simple and quick. A recent appeal- ing variation is the introduction of a combined jejunostomy feeding tube and decompression gastrostomy tube” by the same technique. The second basic gastrostomy type is the tubular gastrostomy in which a formal mucocutaneous ostomy is constructed (Depage - Janeway).’* This procedure is more complex but has the advantage of not requiring the presence of a tube between feeding. Some methods provide a valve within the gastrostomy (Spivack’s tubovalvular gastro~tomy)’~ or interpose a reversed jejunal segment between the gastric ostium and the anterior abdominal wall to maintain gastrostomy continence.20

A common mechanical problem encountered when a Foley catheter is used for gastrostomy tube feeding is progressive deflation of the balloon with consequent dislodgement of the feeding catheter. Other complications include discharge of gastric juice from the gastrostomy which imtates the surrounding skin, and anastomotic leaks that may cause local infection, abscess formation or peritonitis.

Experiences in 46 patients with short-term use of gastrostomy tube placed solely for feeding were recently reported by Meguid and Williams.2’ Most ofthe patients were malnourished and, except for an isolated case, local anesthesia was used to facilitate placement of the gastrostomy tube. Twenty patients were chronically debilitated and suffered from dementia or cerebrovascular ac- cidents, 10 patients had advanced head and neck cancer and were receiving radiation or chemotherapy, while 16 had experienced acute trauma. A total complication rate of 6.5% was due to one case each of wound infection, wound dehiscence, and gastrostomy disruption. Fifteen patients died during the postoperative period, reflecting the high risk population and their underlying debilitated condition.

Prior to gastrostomy tube placement, the average nutrient intake was 1033 Kcal and 4.5 gN/day. This rose to an average of 2494 Kcal and 15.1 gN/day with continuous enteral feeding during a 16-day period while the patients were being treated for their primary disease.

During this time the average albumin levels rose significantly from 3.1 g/dl to 3.3 g/dl. The mean total lympho- cyte count also rose significantly from 1419 to 2045/ mm3. With rehabilitation, a significant proportion of patients resumed oral feeding.

The use of tube gastrostomy for long-term enteral nutritional support in 29 patients with advanced but stable cancer, allowed patients to lead independent lives at home for a median of 94 days. Nutritional support pre- vented further deterioration of common nutritional indices and resulted in a decreased readmission rate. Hence, tube gastrostomy enabled advanced but stable cancer patients to maintain a semblance of home life independent from hospital setting for an extended period of time.22

Endoscopic percutaneous gastrostomy has recently been advocated by Ponsky and associates23 primarily for the purpose of placing gastrostomy for nutritional support in patients who are considered poor risks for lapa- rotomy or general anesthesia. They reviewed their cu- mulative experience of 150 patients who suffered from advanced head and neck cancer, cerebrovascular acci- dents and closed head trauma. The procedure was performed at the bedside or in the endoscopic suite and took an average of 20 minutes. Contraindications for percutaneous gastrostomy tube placement included ascites; morbid obesity; esophageal stricture, reflux, or obstruction; esophageal or gastric varices; and previous gastric surgery. Complications occurred in 15 patients (10%) and included instances of pneumoperitoneum, gastro- colic fistula. cutaneous stomal enlargement, and subcutaneous infections. In general, patients did well. There were no deaths in this poor-risk group of patients.

Jejunostomy

A tube jejunostomy has usually been used when there is a proximal obstruction or fistula in the gastrointestinal tract, in the abscence of a stomach, or when recovery of small bowel motility is anticipated long before recovery of gastric motility. Because metabolic requirements are maximal in the early postoperative period, early use of the jejunostomy tube is indicated. However, during this period, volume and osmolality are limiting factors in the rate of nutrient administration. Hence early administration of small volume of dilute nutrient can be gradually increased, thereby meeting the patient’s metabolic de- mands. Heymsfield et u I . ~ ~ noted several advantages of jejunostomy over gastrostomy: (1 ) less stomal leakage and skin erosion; (2) less gastric and pancreatic secretion because the stomach and duodenum are bypassed; (3) less nausea, vomiting, and bloating compared to gastric

No. I NEW DEVICES AND METHODS OF NUTRITIONAL SUPPORT Meguid et al. 283

or duodenal feeding; and (4) reduced risk of pulmonary aspiration. As with nasoduodenal or nasojejunal feedings, a continuous infusion of isotonic formula is op- t i ~ n a l . ~ ~ One potential problem with intrajejunal feeding is that there may be inadequate mixing of the nutrients with bile and pancreatic enzymes, resulting in incom- plete digestion and hence malabsorption. This problem can be obviated by the use of an elemental diet, if necessary.

The standard method of performing a jejunostomy is by the Witzel technique. The modification of Liffmann and Randall,26 which utilizes a # 8 French polyethylene catheter, seems to cause less local obstructive and leakage problems. Use of a needle catheter jejunostomy has been popularized in which a 16-gauge polyvinyl catheter is passed into the jejunum through a 14-gauge needle.z7 The catheter is first introduced into the bowel through the needle along a long intramural tunnel, and then it is brought through the anterior abdominal wall with the same needle. The catheter is secured to the bowel with a purse-string suture and to the abdominal wall with another suture. Even with operatively placed jejunostomy tubes, Gastrografin (meglumine diatrizoate) should be injected and x-rays taken postoperatively to ensure the intraluminal position of the catheter prior to the start of feedings.

The proponents of “fine needle” catheter jejunostomy emphasize the advantage of early ( 12 - 18 hours) postoperative feeding with elemental diets. Indeed, data suggest successful use of this mode of nutritional support with maintenance in body weight, lean body mass, and serum albumin and improvement in transfemn and total lym- phocyte counts.28 Contraindication to the use of “fine needle” catheter jejunostomy includes peritonitis, ascites, regional enteritis and morbid obesity. Among the long list of complications reported are free peritoneal leak, small bowel fistulization, small bowel obstruction, pneumatosis intestinalis and jejunal v a r i c e ~ . ~ ~ . ~ ~ Cath- eter dislodgement also occurs, for which Stogdill et have recently described a nonoperative method for their replacement. A recent innovation has been the introduction of a silicone jejunostomy “K-tube” (Midwest Metabolic Support Group, Biosearch Medical Products, Somerville, NJ), introduced with Dacron cuffs designed to facilitate accurate surgical placement and prevent migration or dislodgment in ambulatory patients. Experi- ence with its use, relative to needle catheterjejunostomy, is limited, but preliminary reports of its use in over 200 patients appear favorable, with erythemia at the skin exit site being the main problem reported to date.32

The advantages of enteral alimentation have been amply documented. Compared to intravenous hyperali-

mentation, enteral nutrients appear more favorable as regards efficacy, cost and achievement of therapeutic goals.33

Venous Access for Parenteral Nutrition Peripheral Vein Cannulation

The reasons given for using the peripheral venous route for parenteral nutrition are concern regarding the infectious and metabolic complications of total parenteral nutrition, the potential hazards of central venous catheter placement, and the need for patient monitoring.

Metabolic precedence for the use of peripheral vein alimentation stems from Gamble’s i n f ~ r m a t i o n , ~ ~ gained from studies on the life-raft ration, that the administration of 100 g glucose per day spared protein significantly. This coincides with the medical practice of providing 100 to 150 g glucose per day in the form of 5% dextrose in water. Extending this concept, Blackburn’s group showed that a solution of 3% amino acid in water, given to fasting subjects was more effective than glucose in sparing N mass. These observations were subse- quently confirmed by others in mildly stressed postoperative patients (Introduction, reference 34). Howard et al.34 found that the daily addition of about 100 g of amino acids to 100 g of glucose diminished N loss further, compared to starvation. Wolfe et ~ 1 . ~ ~ showed that in fasting humans, the addition of 3% glycerol to 3% amino acid, improved N balance. Furthermore, the same N-sparing effects were noted in mildly catabolic but well-nourished postoperative patients.

In an elegantly designed study, Massar et prospectively evaluated the use of three different solutions for peripheral vein alimentation in 93 patients with carcinoma of the bladder undergoing cystectomies and ileal loop diversions. As shown in Table 1, the limited num- ber of calories delivered was insufficient to meet the caloric requirements of the mildly catabolic postoperative state. Although the patients were all initially well nourished, they lost an average of 6% body weight while receiving peripheral parenteral nutrition for a mean of 9 days. The incidence of subcutaneous perivascular infiltration (56%-60%) or mild to severe phlebitis (40%) appeared unrelated to the osmolality of the infused solution. All patients received other potentially sclerosing agents which may account for the unacceptably high incidence of phlebitis.

Gazitua et al.37 found that the incidence of phlebitis increased markedly with solutions of osmolality greater than 600 m.osmol/ 1, irrespective of the duration of infusion, and found that the addition of heparin did not prevent or decrease the incidence of phlebitis. Berman et al.38 gave 1090 dextrose and 5% casein hydrolysate as

284 CANCER January 1 Supplement 1985 Vol. 55

TABLE I . Data on 93 Patients With Carcinoma of the Bladder Receiving Peripheral Vein Parenteral Nutrition*

% Ideal body weight Frequency of IV Complication frequency

Solution infused (rn.osmol/l) per day Initial Final in 9 days Infiltration Phlebitis Osmolality Total Kcal site change

3%AA/H20t (n = 33) 475 340 108 f 3 102 f 3 6.0 57% 40% 3%AA/5%DW (n = 30) 740 860 107 f 3 102 f 3 5.6 56% 44% 5%DW (n = 30) 370 510 108 f 3 103 -t 3 5.5 59% 40%

Adapted from Massar EL, Daley JM, Copeland EM et a/. Peripheral vein complications in patients receiving amino acid/dextrose solutions. J Parent Entr Nutr 1983; 7:159. Data expressed as M f SE.

t Solutions contained average 40 meq KCI and NaCI: MVI, and I g Keflin four times daily.

nutrients (osmolality = 948 m.osmol/l) by peripheral vein to 25 patients. The indications for therapy included radiation enteritis, bowel fistulas or obstruction, and support of patients during chemotherapy and radiation therapy. The incidence of soft tissue perivascular infiltration and phlebitis was reported as “occurring rarely” because catheter sites were changed every 48 hours and because 10 mg hydrocortisone and 500 units heparin were added to each liter of infusate. Care was taken to administer medications and blood products via a separate intravenous route. The mean duration of nutritional support was 16 days (range, 7-41 days) and the mean volume infused was 3.6 L/day (1810 calories). Most patients gained weight, although the composition of the weight gain (fat, water or lean body mass) was not determined.

The availability of isotonic 10% or 20% fat emulsion has permitted the caloric density of peripherally infused solution to be increased, but has not averted the problem of soft tissue infiltration and phlebitis. Bevins et al.39 recommended use of in-line filtration as an effective means of decreasing the incidence of infusion phlebitis, a method more effective in their experience than use of hydrocortisone or hepan n.

Intravenous cannulas differ greatly both in their chemical composition and in the trauma induced from their insertion. The effect of phlebitis of the type of cannula used has been examined in depth by Collin et a1.40 who randomly assigned patients to four cannulas: ( 1 ) short stainless steel “Butterfly” (Abbott Labs, North Chicago, IL); (2) short polypropylene “Medicut” (Sher- wood, St. Louis, MO); (3) a Teflon catheter (Jelco, Tampa, FL); and (4) a 12” long Intracath (Deseret, Salt Lake City, UT) cannula. A total of 206 infusions were studied. For all cannulas, the frequency of phlebitis increased significantly when duration of infusion exceeded 36 to 77 hours. Long catheters were significantly more likely to be contaminated with bacteria and associated with thrombophlebitis than all other cannulas. A low frequency of phlebitis with Butterfly stainless steel cannulas was shown to be due to their short duration of use, resulting from their frequent dislodgement. Phlebitis

was uncommon in infusions of less than 24 hours duration and absent in those lasting less than 12 hours.

Whether peripheral vein alimentation is beneficial or indicated in mildly stressed but nourished patients, for periods of up to 16 days, is of questionable therapeutic and cost benefit. There are inherent limitations to the use of peripheral alimentation by the amount of nutrients which can be delivered and by the incidence of morbidity as is evident from the summarized data in Table 1.

Deep Brachial Vein Cannulation In an effort to provide hypertonic nutrient solutions

without the potential mechanical complications from the subclavian approach to the central venous system, deep brachial vein catheterization with long-arm indwelling silastic catheters has been employed by a num- ber of clinicians as an alternative method. Success in maintaining TPN with this catheter has been well documented.

As compared to the conventional internal jugular or subclavian catheterization the indications advanced for this peripheral technique of central venous access include following radical neck dissections, during cervical node irradiation (particularly when either is associated with a tracheostomy), in patients with acute hematologic disorders accompanied by a bleeding diathesis in which blind central venipuncture can be hazardous, and in patients who have had chemotherapy injected via peripheral veins and therefore the basilic or cephalic vein may not be patent.

After visualizing the brachial artery and median nerve at the mid-arm level, the deep brachial vein is dissected out at the medial aspect of the biceps brachialis muscle. Under sterile technique, 1 Yo xylocain is used in the oper- ating room. A 5- to 8-cm long subcutaneous tunnel is created distal to the venotomy so that the catheter exit site is proximal to the antecubital fossa. Using this method, Gillette and Susini4’ cannulated 154 deep brachial veins and advanced the silicon catheter into the superior vena cava under fluoroscopic guidance. Cath- eters remained in sifu for a mean of 39 days (range,

No. 1 NEW DEVICES AND METHODS OF NUTRITIONAL SUPPORT Meguid et al. 285

14- 167 days). A 5.1Yo infection rate was reported, Staphalococcus aureas and Candida occurring in each of 2 patients. No overt clinical thromboses were reported because, it is generally claimed, the deep brachial vein is frequently comprised of adequate tributaries in the form of venae comitantes. However, the authors refer to “in- fraclinical” thrombosis, although this was not defined. Yet in other phlebitis of the upper arm was reported in 10% to 20% of patients in whom catheters were placed in the basilic vein.

Geiss and F ~ i e d m a n ~ ~ found an 8% incidence of phlebitis in the mid-upper arm region which occurred within 7 days of catheter insertion, and which only resolved with removal of the catheter. They used computerized axial tomography, to scan the upper arm, in 10 patients with indwelling deep brachial vein silastic catheters, and observed qualitative variability in the brachial vein di- ameters along the upper arm. The upper extremity veins did not increase in diameter as the vein progressed prox- imally from the elbow, as would be expected, but instead showed multiple areas of narrowing, with the brachial vein reaching a minimum diameter in the mid-upper arm region. In four of the ten patients, the silastic catheter occluded the vein thereby inducing thrombosis.

Subclavian Cannulation It is not in the scope of this presentation to review the

conventional techniques of central venous catheterization for hyperalimentation via either the subclavicular or the supraclavicular route. Furthermore, the frequency of the common mechanical, and frequently life-threat- ening, complications that occur during subclavian or internal jugular vein cannulation (pneumothorax, he- mothorax, fatal air embolism, and arterial laceration) have also been well documented. However, it is worth mentioning that isolated case reports of more esoteric mechanical complications such as cardiac perforation,44 perforation of intrathoracic veins,45 migration of venous catheters& and intracranial infusion of hyperalimentation fluids4’ have been reported.

LJsing the subclavicular approach to central venous cannulation is more commonly associated with major complications, particularly when performed by physi- cians who do not routinely practice this technique. This approach is popular because a dressing can be secured with ease at the catheter exit site on the anterior chest wall. The close proximity of the subclavian vein to: neu- rovascular structures; the apex of the lung; other vital structures, makes the large bore (1 8- to 14-gauge) steel introducing cannula with its sharp beveled leading edge) an exceptionally lethal instrument in less experienced hands.

To minimize mechanical complications, there have been two recent developments: First, percutaneous su-

praclavicular cannulation of the internal jugular vein, which is seldomly associated with pneumothorax but in which the maintenance ofexit site dressing on the neck is difficult. Krishnan et describe a modification of a previously described technique of safely cannulating the internal jugular vein, then directing the catheter from the venotomy via a subcutaneous tunnel to an exit site on the infraclavicular chest wall, thereby facilitating dressing care. Experience gained in 50 patients was favorable: no mechanical complications were reported. Two instances of positive cultures of catheter tips were recorded, which the authors related to the use of catheters for the emergency administration of drugs. They expressed the opinion that their tunneling technique of- fered no significant protection against catheter sepsis.

This contention is supported by data from von Meyenfeldt et U I . , ~ ~ who investigated the effect of a 10-cm long subcutaneous tunnel on catheter sepsis. One hundred and fifty polyvinylchloride TPN catheters were inserted via the subclavian route in critically ill patients (45 intensive care unit patients died while on the study). They randomly assigned the patients to either a tunneling technique (between the exit site and the subclavian venotomy site) or to a standard direct insertion technique. Catheters were used predominantly for TPN, but on occasion for central venous pressure monitoring. Catheter sepsis was defined as an episode of clinical sepsis for which no other cause could be identified and which resolved with catheter removal. It averaged 6.5% in the two groups. The authors conclude that tunneling of subclavian polyvinyl (PVC) catheters did not dimin- ish the incidence of catheter related sepsis.

It is interesting to note that the extravascular subcutaneous portion of the PVC catheter caused the formation of a granulation tissue tract, which facilitated back-and- forth movement of the catheter within the tract during respiration. In comparison, the use of silicon catheters (e.g., Broviac or Hickman catheters) are associated with less tissue reaction than the PVC catheters. Further- more, the growth of fibroblasts into a Teflon plug placed at the exit site of the silicon catheter firmly anchors the catheter, preventing movement with respiration, and may act as a barrier to migrating skin microorganisms.

The second recent development which minimized mechanical complications is the availability of sheath catheter introducing kits requiring only a 2 1-gauge needle for subclavian catheter i n t r o d u c t i ~ n . ~ ~ A special catheterization system (Cook Inc., Bloomington, IN) consists of the following items: (1) a 2 1-gauge thin wall- introducing needle which is 5 cm long; (2) a guide wire, 60-cm long and 0.0 18 inches (0.46 mm) in diameter, made of stiff stainless steel core wire which is gradually tapered to a thread and over which is invested a 6 cm long J-tip helical flexible spring wire; (3) a 20 cm 5 F

286 CANCER January I Supplement 1985 VOl. 55

TABLE 2. Catheter Maintenance Protocol

Cutdown site Dry sterile dressing until wound heals. Then no dressing.

Daily skin cleansing with alcohol and 3% H202. Apply povidone-iodine (Betadine) on dry sterile dressing.

Heparin flush following blood sampling. Daily change. No millipore filter.

Catheter exit site

Catheter

dilator with a closely fitting peel-away sheath specially tapered to fit snugly over the 0.018 inch wire; (4) a simi- lar 6.3 F sheath dilator, available for introduction of larger silastic catheters.

The standard approach to cannulating the subclavian or jugular vein is used. The stiff guide wire is threaded through the 2 1-gauge needle and gently.advanced. The needle is removed and the sheathed dilator is advanced over the guide wire until the sheath is most of the way into the vein. The wire and dilator are exchanged for the central venous catheter through the sheath which is then peeled off and removed. This technique is especially ap- plicable to the insertion of ## 5 or ## 6 F soft silastic catheters. The stiffer polyvinyl or polyurethane catheters, which are commonly used for central venous pressure monitoring, can be threaded directly over the fine guide wire without a sheath, provided the tract is first enlarged with the 6.3 F tapered dilator.

This technique was found to be simple, safe and effective in 22 consecutive patients ( 16 subclavian, 4 external jugular, and 2 internal jugular veins) who required the insertion or reinsertion ofa venous catheter for hyperalimentation.

Arteriovenous Shunts

During the 1970s the concept of home parenteral nutrition gained acceptance, especially for patients with short bowel syndrome. Venous access was initially achieved with external arteriovenous shunts. These thrombosed repeatedly in patients who were nutrition- ally debilitated but who did not have chronic renal disease. The main reason for the thrombosis is that the patient population had damaged veins from multiple previous infusions and venipunctures and normal he- modynamc and coagulation status in contrast to the hy- pocoagulable state of uremic patients.

Despite this problem, Engels et ~ 1 . ~ ' reported their experience in eight patients with short bowel syndrome, seven of whom were on home parenteral nutrition via arteriovenous shunts (AV shunts) and one patient via an external shunt. The patients' mean age was 41 years (range, 17 -67 years). The duration of AV shunts func-

tion, as a TPN conduit, averaged 14.3 months (range, 5 - 54 months). Despite anticoagulant therapy, 50% of the AV shunts thrombosed.

Right Atrial Catheters

A more dependable device for long-term venous access for patients requiring home nutrition or chemotherapy is the Broviac catheter and its modification the Hickman catheter or the more recently introduced dual- lumen Hickman catheter (Evermed, Medina, WA). These are placed by cut-down or percutaneous means. Numerous studies have shown that complications are infrequent even in the immunocompromised cancer patient and that the presence of the catheter as a reliable venous access route greatly outweighs its potential com- p l i ca t ion~ .~~

Meguid et aLS3 studied the propriety of using a central venous hyperalimentation catheter, such as a Broviac or Hickman catheter, for multiple purposes in 8 1 patients in whom a catheter was inserted over a I-year period. The impact of this practice with and without TPN on infection and complication rates was examined.

The patients were divided into two groups. Group I consisted of 54 patients in whom the catheter was used for multiple purposes in conjunction with TPN. Group I1 consisted of 27 patients of comparable age, sex, and type of disease in whom the catheter was used for multiple purposes without TPN. Catheters were meticulously cared for on a daily basis using an aseptic/antiseptic technique outlined in a catheter maintenance protocol (Table 2).

In both groups the catheters were used in about equal frequency for administration of blood and blood products, chemotherapeutic agents, antibiotics and medications, and blood sampling. Since TPN was given, the frequency of daily violation of catheter integrity was 2.5 in Group I, as compared to 2.0 in Group 11.

The most frequent intraoperative problem encountered, during Broviac or Hickman catheter placement, was thrombosed cephalic or subclavian veinsdue to scle- rosis from previous use of chemotherapeutic agents or because of previous cannulation. In nine patients, the internal jugular vein was cannulated instead; while in two, a catheter was placed into the inferior vena cava via the saphenofemoral junction. The use of a preoperative venogram in such patients guided the selection of an operative site, thereby decreasing operative time and morbidity. Mechanical malfunction was four times greater in Group I as compared to Group I1 and occurred at an average of 100 days after catheter insertion. This consisted of silastic fatigue and was probably associated with bolus injection into a catheter conveying TPN. Catheter-related sepsis occurred in one patient in each

No. I NEW DEVICES AND METHODS OF NUTRITIONAL SUPPOKT Meguid et al. 287

group, corresponding to 2.5% infection rate, or to one episode per 7.7 patient years.

The multiple use of a catheter in association with TPN did not lead to an increased infection rate and was a convenient mode for facilitating patient care. Provided strict adherence to the rigorous nursing protocol for catheter maintenance (Table 2), the benefits of using a hyperalimentation catheter for multiple purposes justify the potential risks.

In fuse-A- Port

An extension of the concept of immediate, continuous and ad libitum access to the venous and arterial system is a subcutaneous implantable injection port (Infuse-A- Port, Infusaid Corp., Sharon, MA). Experience with this relatively new device is limited. However, Niederhuber and his a ~ s o c i a t e s ~ ~ ~ ~ ~ reported the joint experience in 60 patients in whom an Infuse-A-Port was inserted for both venous and arterial access, primarily in debilitated patients with metastic disease who required chemotherapy. Antibiotics, blood components and intravenous solutions were also administered. Their system remained functioning for a mean of235 days. There was no significant local imtation and no Infusaport became infected. Occlusion of the small bore catheter was common (90%), however this did not occur with the large bore catheter. The authors concluded that the Infusaport was an alternate means of safe and reliable central venous access with improved patient convenience and cosmetic ac- ceptability.

Other Developments

Central Venous Thrombosis

Central venous thrombosis is a recognized clinical complication of indwelling venous catheters, occurring in up to 50% of cases examined venographically in association with the PVC type TPN catheters.56 The figure for asymptomatic nonocclusive thrombi is as high as 30%. Silastic catheters are less thrombogenic, yet despite meticulous care they are associated with occlusive thrombi because the cannula rests in the blood stream and becomes invested with a layer of blood constituents, the tip ofthe catheter being the main site ofencrustation.

Thrombotic occlusions and infection are frequent complications of indwelling intravenous catheters and frequently occur t~gether.~’ The thrombus serves as a nidus for infection resulting in systemic manifestations such as fever, chills, and bacteremia. Systemic antibiotics are useless against infected catheter encrustations since the organisms lie sheltered within the thrombus. To avoid removal of catheters and ensuing loss of yet

another venous portal, Glynn et undertook a study whereby silastic TPN catheters which were occluded, occluded and infected, or merely infected, were infused with urokinase to disperse the thrombus, making bacteria accessible to the action of systemic antibiotics and the body’s own defense mechanisms.

The procedure was done in the intensive care unit where patients could be monitored for syncope. The procedure consisted of instilling 2.5 ml urokinase (2500 IU/ml; Abbott Laboratories, N. Chicago, IL) into the occluded/infected catheter which was then clamped for 3 hours, following which 25 ml of heparin (100 U/ml) was injected into the catheter. Then saline was infused through it.

In 20 patients, the catheters were declotted, although in 5 the procedure had to be repeated within 24 hours. In seven patients, four of whom were taking antibiotics, blood cultures became negative and the patients became afebrile. In two instances syncope was a side effect. Coag- ulation factors remained normal. The urokinase procedure has also been used in a variety ofcatheters including central venous catheters. The authors recommended that in any instance in which the catheter became occluded or infected, urokinase treatment be attempted at least twice before the catheter is removed.

Three-Liter Method of Delivery Technique

The introduction of three-liter bags made of ethyl vinyl acetate has made the admixture of a fat emulsion to dextrose and amino acid possible. These mixtures can be prepared up to 30 days prior to use. Daily requirements of vitamins, trace elements and electrolytes can be added just before infusion is started. Using this method, between 30 and 50% of nonprotein calories is supplied as lipid.

Recently Paddington and Richards outlined their preliminary experience, using this technique.59 During an 8-month period, over 260 three-liter bags were prepared for home parenteral nutrition patients with no adverse reactions. Several advantages have become apparent with this method of delivery: (1 ) there was a saving of 8-hour infusion time per week and the avoidance of additional connections; (2) weaning from infusion was made easier and was achieved more rapidly because of greatly reduced circulating insulin levels and thereby the avoidance of reactive hypoglycemia; and (3) hepatic enzymes (indices of liver function) remained normal, whereas with pure glucose TPN solution they were con- siderably deranged, confirming the observations and recommendations of Meguid et a1.@ of using fat to replace one-third of glucose calories. This practice is rapidly being adapted to hospital-based nutritional support.

288 CANCER January 1 Supplement 1985 Vol. 55

Dressing Changes Much energy has been expended in attempting to de-

crease the incidence of catheter related sepsis. Goldman and Maki showed that the primary source of bacterial contamination for indwelling intravenous catheters was the skin surrounding the catheter puncture site.61

Jarrard and FreemaP reported that alternate-day mechanical cleansing of skin using the antiseptic Beta- dine (Purdue Frederick) was more effective in reducing the incidence of positive skin cultures than the applica- tion of antibiotic ointment to the catheter insertion site. Using this method their positive skin culture rate was 3.5%. In a further study they showed that daily dressing changes of the TPN site eliminated all skin organisms beneath the subclavian dressing.

In contrast Thomas63 reported that the use of a semi- permiable dressing (Opsite, Johnson and Johnson, New Brunswick, NJ), left in situ for 7 days, was not associated with an expected increase in catheter sepsis.

To resolve this question, Powell et ~ 1 . ~ prospectively evaluated Opsite dressings placed on subclavian catheters used for parenteral nutrition and compared its use in 26 1 patients who were randomly assigned to either an Opsite dressing or the standard gauze dressing. Patients in the latter group had their dressings changed every other day, while those randomized to Opsite had their dressings changed every 7 days. Eighty-four patients were stratified by absence or presence of external sites of drainage and were evaluated separately.

Catheter related sepsis was assessed by blood cultures, catheter tip culture, clinical sepsis and clinical deferves- cence of fever after catheter removal. Although no statis- tically significant difference between Opsite and standard dressings could be identified, Opsite-treated patients consistently had increased indices of catheter- related sepsis when all the study indices were compared. Hence Opsite was not recommended as a dressing for subclavian catheters used for parenteral nutrition.

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Documents

The delivery of nutritional support. A potpourri of new devices and methods