Preventing bloodstream infection in patients receiving home parenteral nutrition.

Patients receiving home parenteral nutrition (HPN) are at particularly high risk of meticillin-sensitive Staphylococcus aureus (MSSA) catheter-related bloodstream infections (CRBSI). We developed a multidisciplinary enhanced care pathway encompassing a number of minimal cost interventions involving line/exit site care, training for staff and parents, multidisciplinary discharge planning, and monitoring compliance. Implementation reduced the mean rates of MSSA CRBSI (from 0.93, 95% CI 0.25-1.61, to 0.23, 95% CI -0.06 to 0.52, per 1000 parenteral nutrition [PN] days) and all-cause CRBSI (from 1.98, 95% CI 0.77-3.19, to 0.45, 95% CI 0.10-0.80, per 1000 PN days). A similar approach could be applied to preventing health care-associated infections in other complex, vulnerable patient groups.

Vitamin C in Home Parenteral Nutrition: A Need for Monitoring.

To date, there are no recommendations about screening plasma vitamin C concentration and adjust its supplementation in patients on long-term home parenteral nutrition (HPN). The aim of this study was to evaluate vitamin C status and determine if a commercial multivitamin preparation (CMVP) containing 125 mg of vitamin C is sufficient in stable patients on HPN. All clinically stable patients receiving HPN or an intravenous fluid infusion at least two times per week for at least 6 months, hospitalized for nutritional assessment, were retrospectively included, for a total of 186 patients. We found that 29% of the patients had vitamin C insufficiency (i.e., <25 µmol/L). In univariate analysis, C-reactive protein (CRP) (p = 0.002) and intake of only 125 mg of vitamin C (p = 0.001) were negatively associated with vitamin C levels, and duration of follow-up in our referral center (p = 0.009) was positively associated with vitamin C levels. In multivariate analysis, only CRP (p = 0.001) and intake of 125 mg of vitamin C (p < 0.0001) were independently associated with low plasma vitamin C concentration. Patients receiving only CMVP with a low plasma vitamin C level significantly received personal compounded HPN (p = 0.008) and presented an inflammatory syndrome (p = 0.002). Vitamin C insufficiency is frequent in individuals undergoing home parenteral nutrition; therefore, there is a need to monitor plasma vitamin C levels, especially in patients on HPN with an inflammatory syndrome and only on CMVP.

Canadian home total parenteral nutrition registry: preliminary data on the patient population.

BACKGROUND: Long-term administration of home total parenteral nutrition (HTPN) has permitted patients with chronic intestinal failure to survive for prolonged periods of time. However, HTPN is associated with numerous complications, all of which increase morbidity and mortality. In Canada, a comprehensive review of the HTPN population has never been performed. OBJECTIVES: To report on the demographics, current HTPN practice and related complications in the Canadian HTPN population. METHODS: This was a cross-sectional study. Five HTPN programs in Canada participated. Patients' data were entered by the programs' TPN team into a Web site-based registry. A unique confidential record was created for each patient. Data were then downloaded into a Microsoft Excel (Microsoft Corp, USA) spreadsheet and imported into SPSS (SPSS Inc, USA) for statistical analysis. RESULTS: One hundred fifty patients were entered into the registry (37.9% men and 62.1% women). The mean (+/- SD) age was 53.0+/-14 years and the duration requiring HTPN was 70.1+/-78.1 months. The mean body mass index before the onset of HTPN was 19.8+/-5.0 kg/m(2). The primary indication for HTPN was short bowel syndrome (60%) secondary to Crohn's disease (51.1%), followed by mesenteric ischemia (23.9%). COMPLICATIONS: over one year, 62.7% of patients were hospitalized at least once, with 44% of hospitalizations related to TPN. In addition, 28.6% of patients had at least one catheter sepsis (double-lumen more than single-lumen; P=0.025) and 50% had at least one catheter change. Abnormal liver enzymes were documented in 27.4% of patients and metabolic bone disease in 60% of patients, and the mean Karnofsky score was 63. CONCLUSIONS: In the present population sample, the data suggest that HTPN is associated with significant complications and health care utilization. These results support the use of a Canadian HTPN registry to better define the HTPN population, and to monitor complications for quality assurance and future research.

Prevalence of life-threatening complications in pediatric patients affected by intestinal failure.

Intestinal failure (IF) is defined as the reduction of functional gut mass necessary to maintain health and growth in children. Causes of IF include short bowel syndrome (SBS), neuromuscular intestinal disorders (NID), and severe protracted diarrhea (SPD). If patients require long-term parenteral nutrition (PN); they can now be discharged on home PN (HPN), thus improving their quality of life. Children requiring long-term PN are at high risk of developing life-threatening IF complications that hinder HPN, namely, IF associated liver disease (IFALD), catheter-related infections (CRI), and thrombosis. The goal of our study was to retrospectively evaluate the prevalence of life-threatening complications among IF patients according to the HPN indication. From January 1989 to May 2006, 60 IF patients (41 boys and 19 girls) underwent prolonged HPN. Total program duration was 46,391 days (127 total years, mean 2.1 years per patient). Indications for HPN were SBS in 36 cases, SPD in 19 cases, or NID in 5 cases. In our experience patients affected by SBS displayed a significantly higher prevalence of life-threatening complications than patients with other IF causes. Sixteen (27%) among 60 patients developed IFALD. CRI and thrombosis prevalence were 1.4/1000 central venous catheter (CVC) days and 0.2/1000 CVC days respectively. SBS seemed to lead to life-threatening complications more often than other HPN indications. SBS patients on long-term PN therefore require careful management to identify complications early, and they seem to be the candidates for early referral to small bowel transplantation centers.

Pregnancy is possible on long-term home parenteral nutrition in patients with chronic intestinal failure: Results of a long term retrospective observational study.

BACKGROUND & AIMS: Home parenteral nutrition (HPN) improves survival and quality of life in patients with chronic intestinal failure (IF). Few cases of pregnancy on HPN have been published. The aim of this study was to report pregnancy cases on long-term HPN in benign IF. METHODS: This retrospective study included all pregnant patients on HPN from 4 HPN referral centers. Data on demographics, ongoing pathology, HPN type, maternal and newborn complications were collected. RESULTS: From 1984 to 2014, 21 pregnancies occurred in 15 patients (short bowel syndrome (n = 11), motility disorders (n = 3), mucosal disease (n = 1)) of whom 14 occurred after 2010. Median follow-up was 12 years. Median HPN duration before pregnancy was 8 years. HPN was adapted monthly during pregnancy, with close monitoring and supplementations. Energy intake was regularly increased and median maternal weight gain was 10 kg. Median age at the first pregnancy was 27 years. In 55% of cases, the newborn was preterm. Maternal complications occurred in 67% of cases (mainly due to underlying disease or HPN complications). There were 3 post-partum hemorrhages and 6 hypotrophic newborns. Eighteen infants were healthy and 2 chronic intestinal pseudo-obstruction (CIPO) were suspected. CONCLUSION: Our series, the largest reported to date, shows that pregnancy is possible in HPN patients but the complication rate is high. A specific support is necessary, particularly in CIPO patients. As pregnancies have increased over the last 15 years, physicians practicing in HPN referral centers should be aware of the need for implementing a specific multidisciplinary monitoring in HPN patients considering pregnancy.

[From starving to life-threatening nutrition--the history of an intestinal pseudoobstruction]. / Vom Verhungern zur lebensbedrohlichen Ernährung--Kranken-Geschichte einer chronischen intestinalen Pseudoobstruktion.

It is the story of a 70-year-old lady, who suffered from chronic intestinal pseudoobstruction since her adolescence. In the early 90ies progressive cachexia developed. In 1994 parenteral nutrition was begun via a port-à-cath-system with good success in the first years. Later, various complications occurred: thrombotic events, several catheter-related infections with various bacterial strains, an endocarditis of the aortic valve, which was replaced by a bioprosthesis, and finally a relapsing endocarditis of this artificial valve with a life-threatening paravalvular abscess and regurgitation. She also survived this second heart surgery and is currently under parenteral nutrition again, with a more than uncertain future.

[Treatment of intestinal failure by total parenteral nutrition at home in children and adults]. / De behandeling van darmfalen met parenterale thuisvoeding bij kinderen en volwassenen.

Intestinal failure is characterised by inability of the intestine to absorb sufficient nutrients to maintain the integrity and function of the body. This can be caused by malabsorption due to too short an intestine or an abnormality of the mucosa, or by a severe motility disorder. In addition to dietary measures, the prescription of total parental nutrition (TPN) at home is sometimes necessary. This treatment is a burden on the patient and the risk of complications must be reduced to a minimum. The risks of long-term parenteral nutrition can be limited and the quality of the provision of services can be increased if the co-ordination is in the hands of a centre for home parenteral nutrition. In the Netherlands there are two centres for home-TPN: the St Radboud University Medical Centre in Nijmegen and the University Medical Centre (AMC) in Amsterdam. In both children and adults, the most common indications are the short bowel syndrome and motility disorders. However, the syndromes that cause this are clearly different in the different age groups. Parenteral nutrition can be given for long periods of time. A large variety of complications can occur, related especially to the equipment or the nutrients. When the nutrition is given via a central venous catheter, then sepsis is a serious and possibly life-threatening complication. In case of administration via an arteriovenous shunt, thrombosis of the shunt is the most frequent problem. If the treatment by means of home-TPN fails, then transplantation of the small intestine should be considered.

Efficacy of 2-month total parenteral nutrition in AIDS patients: a controlled randomized prospective trial. The French Multicenter Total Parenteral Nutrition Cooperative Group Study.

OBJECTIVE: To evaluate the efficacy of total parenteral nutrition in AIDS patients. DESIGN: A prospective, randomized, controlled, multicentre trial. METHODS: Over a period of 2 months, 31 malnourished and severely immunodepressed AIDS patients were assigned to receive either dietary counselling (n = 15) or home total parenteral nutrition (TPN; n = 16) via a central venous access after an educational program. Results were analysed by intent-to-treat basis. RESULTS: Bodyweight change was +8 kg (+13 +/- 3%) in the TPN group and -3 kg (-6 +/- 2%) in the control group (P < 0.0006). Lean body mass increased in the TPN group (+9 +/- 3%) and decreased in the control group (-5 +/- 3%; P < 0.004) while body cell mass increased in the former (+15 +/- 4%) and decreased in the latter (-12 +/- 6%; P < 0.002). Nutritional subjective global assessment, subjective self-reported health feeling and Karnofsky index were also improved by TPN. Infection line sepsis incidence remained low (0.26 per 100 patient-days). However, no difference in survival rate was exhibited between the two groups by the log-rank test. CONCLUSION: We conclude that home TPN is an efficient treatment of malnutrition in severely immunodepressed AIDS patients.

Incidence, prognosis, and etiology of end-stage liver disease in patients receiving home total parenteral nutrition.

BACKGROUND: Elevations in liver function tests have been reported in patients receiving total parenteral nutrition (TPN). The clinical aspects of end-stage liver disease (ESLD) associated with the prolonged use of home TPN have not been fully clarified. In previous series patients with duodenocolostomies appeared to be at higher risk than persons with some jejunum or ileum remaining in situ. METHODS: The records of 42 patients treated with home TPN for more than 1 year were examined. This constituted 283 person-years of home TPN. Patients with duodenocolostomies were examined as a separate group on the basis of the literature experience. RESULTS: Six of 42 patients who received chronic home TPN had ESLD with 100% subsequent mortality, at an average of 10.8 +/- 7.1 months after the initial bilirubin elevation. Thirteen of 42 patients had superior mesenteric artery or vein thrombosis (SMT) leading to duodenocolostomy. In 8 of these 13 patients with SMT and underlying inflammatory or malignant disorder, 2 had ESLD. The remaining 5 SMT patients who had only minimal liver enzyme elevation over 13.6 +/- 6.7 (range 3 to 19) years of home TPN were significantly younger (36 +/- 7 years vs 64 +/- 13 years) and did not have underlying inflammation either by clinical diagnosis or as reflected in the high normal serum albumin level (> or = 4.0 g/dL). Despite their extreme short bowel syndrome and long exposure to home TPN, ESLD did not develop. CONCLUSIONS: Approximately 15% of patients who receive prolonged TPN have ESLD with a high rate of morbidity and mortality. The combination of chronic inflammation and the short bowel syndrome appears to be necessary for the development of ESLD with prolonged home TPN.

The routine microbiological screening of central venous catheters in home parenteral nutrition patients.

BACKGROUND & AIMS: Catheter-related bloodstream infection (CRBSI) is a major complication for patients receiving home parenteral nutrition (HTPN). Endoluminal sampling techniques allow the diagnosis of CRBSI without catheter removal and may allow the screening of asymptomatic patients. METHODS: Over a 5-year period, patients receiving HTPN were offered screening on a 3 monthly basis. All patients had tunnelled cuffed Hickman lines. All were asymptomatic at the time of screening, which took the form of either endoluminal brushing or quantitative cultures on through-line blood. RESULTS: Thirty-two patients were suitable for inclusion within the study period (10 male, median age 51 (iqr 46-61)) years with 30 of these having a least one screening performed. Four had positive screening results and underwent appropriate treatment. Of the remainder, 12 presented with at least one clinical episode of CRBSI and 14 had neither clinical CRBSI nor a positive screening result. The combined clinical and screening CRBSI rate was 0.39 episodes per catheter year. CONCLUSION: Although routine microbiological catheter screening can detect subclinical infections in HTPN patients the positive rate is low with the majority of patients still presenting clinical. Identification of higher risk patients and appropriate alterations to screening frequency may improve its value further.

Warfarin and reduced central venous thrombosis in home total parenteral nutrition patients.

Central venous thrombosis is a potentially life-threatening complication in patients on long-term home total parenteral nutrition (HTPN). Lack of venous access due to recurrent thromboses can prevent delivery of life-saving nutritional support. The long-term anticoagulation management to prevent thromboses in patients with central venous catheters for HTPN has not been well established. We have reviewed the role of warfarin in reducing the incidence of thromboses and its safety in our HTPN patients. Ninety consecutive HTPN patients were studied retrospectively. Twenty-two thromboses occurred during 1312 patient-mo in 53 HTPN patients on minidose warfarin. A minidose of warfarin is defined as 1-2 mg and does not prolong the prothrombin time. Seven thromboses occurred over 619 mo in 18 patients on a therapeutic dose of warfarin (minidose compared to therapeutic dose, p > 0.05). A therapeutic dose of warfarin is a dose that increases the prothrombin time to 1.2-1.5 times that of control. Twelve patients who had 18 thromboses in 323 patient-mo while on minidose warfarin were subsequently converted to therapeutic warfarin. The incidence of thromboses decreased to 2 in 369 patient-mo (p < 0.005). There were no hemorrhagic complications in the minidose warfarin group and four nonfatal hemorrhagic complications in the therapeutic dose warfarin group (p > 0.05). A therapeutic dose of warfarin is effective in reducing the incidence of thromboses in patients who experience central venous thrombosis despite minidose warfarin with a minimal increase in hemorrhagic complications.

Essential fatty acid deficiency and home total parenteral nutrition patients.

The requirements for essential fatty acids in patients on home parenteral nutrition are not well described. We therefore studied the needs of 12 patients receiving parenteral nutrition for at least 4 mo (range: 4 mo-17.3 yr; mean 7.0 +/- 5.2 yr). Prior to the study, each patient had been receiving intravenous lipids either weekly or biweekly and had a triene to tetraene ratio (TTR) on plasma phospholipids performed at least annually. A TTR > or = 0.2 was considered diagnostic for essential fatty acid deficiency (EFAD). The purpose of this study was to determine the required intravenous lipid supplementation in patients on home total parenteral nutrition (HTPN). Patients with an initial TTR of < 0.2 had their intravenous lipid stopped and changes in their serum phospholipid fatty acids were followed every 3-4 wk. Nine of 12 patients had TTRs > 0.2 at some point in the study. Phase I consisted of patients who at initiation of the study had normal TTRs and were taken off lipid supplementation until their TTR became abnormal. Phases II, III, IV, and V consisted of lipid delivered in total nutrient admixtures in biweekly doses of 0.6, 1.2, 1.8, and 2.4 g of fat/kg bodyweight, respectively. Eight patients normalized their TTRs on the biweekly lipid regimens; one patient expired before his ratio normalized; and three patients could not be made deficient in essential fatty acids after 26 or more wk of fat-free parenteral nutrition. Most patients required 1.2 to 2.4 g of lipid/kg bodyweight/biweekly to correct serologic EFAD. The clinical background, as well as the length of small bowel remaining, did not seem to identify those patients who required lipid supplementation nor the final dose of lipid needed to normalize their TTRs.

Arginine deficiency-induced hyperammonemia in a home total parenteral nutrition-dependent patient: a case report.

BACKGROUND: Patients with short bowel syndrome and renal dysfunction with TPN dependence are at high risk for developing hyperammonemia if the TPN does not contain sufficient quantities of arginine. Providing proper nutrition support is essential in the management of these patients. METHODS: We report on a patient with short bowel syndrome, TPN dependence, and normal renal function who developed hyperammonemic encephalopathy due to inadvertent lack of arginine in his TPN. RESULTS: The patient was successfully treated with hemodialysis and an IV arginine infusion to resolve the hyperammonemia. His home TPN was also adjusted such that arginine was added to his subsequent solutions. CONCLUSIONS: Our patient underscores the importance of adequate and sustained arginine supplementation to avoid hyperammonemia in TPN dependent patients with short bowel syndrome.

Pulmonary embolism as a complication of long-term total parenteral nutrition.

Although much has been written concerning the complications of long-term total parenteral nutrition, little or no mention of pulmonary embolism is made in the literature. We present two patients maintained on home total parenteral nutrition who suffered pulmonary emboli, one while receiving standard heparin therapy. No potential source other than their indwelling total parenteral nutrition catheter was identified. Studies have revealed catheter-related thrombosis in up to 50% of patients with indwelling central venous catheters. Although early surgical literature suggested that upper extremity deep vein thromboses rarely embolize, more recent investigations have proven this false. In fact, the risk of pulmonary emboli appeared to be greatest in those thrombi that were catheter related. Because of this risk, we suggest a hypercoaguable work-up in any patient with a history of recurrent thrombosis. Heparin is central to the current preventive regimens; however, further study is needed to determine the most efficacious dose. Future development of less thrombogenic catheters will also be of assistance. Thrombolytic agents currently have an expanding role in the treatment of thrombotic complications. Whether they will have a future role in prevention remains unknown.

Long-term central venous access vs other home therapies: complications in patients with acquired immunodeficiency syndrome.

One hundred and forty silicone catheters were inserted in 127 patients for long-term intravenous access with a cumulative follow-up time of 21,125 catheter-days (58 patient-years). Fifty-six patients had acquired immunodeficiency syndrome (AIDS); 44 were not AIDS patients and were receiving ambulatory home parenteral nutrition, whereas the remaining 27 did not have AIDS and were receiving home antibiotic therapy. Patients had a mean of 1.1 catheters inserted, and the rate of Hickman catheter-related sepsis was 0.18 per 100 catheter days or 0.6 septic episodes per patient year of treatment. Catheter-related sepsis was higher in AIDS patients (p < .01) and in patients receiving parenteral nutrition (p < .05) compared with those receiving antibiotic therapy. Prior catheter infection and AIDS were the most significant predictors of catheter infection (p < .01). Staphylococcus aureus was the most commonly isolated pathogen (61%) in AIDS patients. Fever (p < .001) and relative leukocytosis (p < .02) were the most common signs of infection. Only 14 infected catheters (37.8%) were salvaged by antibiotic therapy after the initial infection episode, and 6 of these catheters (42.9%) had recurrent multiple infections. In addition, inflammatory bowel disease was found to be a risk factor for venous thrombosis (p = .018). We conclude that because immunocompromised patients have a high risk of infection, catheter-related sepsis in these patients should be treated by catheter removal and antibiotics.

Choline and vitamin B12 deficiencies are interrelated in folate-replete long-term total parenteral nutrition patients.

BACKGROUND: Choline has recently been recognized as an essential nutrient, in part based on deficiency data in long-term home total parenteral nutrition (TPN) patients. Choline, a methyl donor in the metabolism of homocysteine, is intricately related to folate status, but little is known about choline and vitamin B12 status. Long-term TPN patients are also subject to vitamin B12 deficiency. OBJECTIVE: The objective of the study was to evaluate any interaction between choline, vitamin B12, and folate in patients with severe malabsorption syndromes, requiring long-term TPN. DESIGN: Plasma free choline, serum and red blood cell (RBC) folate, serum vitamin B12 methylmalonic acid, B6, and plasma total homocysteine concentrations were assayed by standard methods. Low choline was defined as values that fall 1 to < or =3 and marked low choline concentration as >3 SD below the control mean. RESULTS: Both low choline concentrations (52% were marked low, 33% low, 14% normal) and elevated methylmalonic acid concentrations (47%) were prevalent. Choline concentration was significantly lower and RBC folate higher in patients with elevated methylmalonic acid. Total homocysteine elevations were rare (3 of 21) and mild. CONCLUSIONS: These data suggest a strong interaction between vitamin B12 and choline deficiencies and folate status in this population, which may be due in part to variations in vitamin and choline delivery by TPN. Folate adequacy may increase B12 use for homocysteine metabolism, thus limiting B12 availability for methylmaIonic acid metabolism. Choline use may also increase, and choline deficiency may worsen if choline substitutes when the vitamin B12 side of the homocysteine metabolic pathway cannot be used.

Catheter-related infections associated with home parenteral nutrition and predictive factors for the need for catheter removal in their treatment.

The inpatient and outpatient records were reviewed for 527 patients, including 138 children, who were discharged on home total parenteral nutrition and followed by the University of California, Los Angeles, home total parenteral nutrition service for a minimum of 1 week between April 1973 and October 1991. The total follow-up time was 1154 patient years; the median follow-up time was 206 days (range 7 to 6344 days). Thirty-six patients were followed for more than 10 years (median 12.7 years). Three hundred fifteen adults (but only four children) were never infected. A total of 427 catheter-related infections occurred, giving an overall infection rate of 0.37 per patient year (0.51 per patient year in children and 0.28 per patient year in patients followed for more than 10 years). Seventy percent of the infections overall were sepsis (0.26 per patient year); of those, 17% were exit site (0.06 per patient year), and 2% were tunnel (0.01 per patient year) infections. In children, 67% of the infections were sepsis (0.37 per patient year) and 24% were exit site (0.13 per patient year). Fifty-four different organisms were responsible, and 12% of the infections were polymicrobial in origin. Sixty percent of sepsis in all patients was caused by Gram-negative organisms (44% of the catheters were removed). Forty-three percent of sepsis in children was caused by Gram-negative organisms. Twenty-six percent of sepsis in all patients was caused by Gram-positive organisms (40% of the catheters were removed). Thirty-six percent of sepsis in children was caused by Gram-positive organisms.(ABSTRACT TRUNCATED AT 250 WORDS)

Prolonged parenteral nutrition for cystic fibrosis patients.

To evaluate the clinical impact of prolonged parenteral nutritional (PN) therapy on patients with advanced cystic fibrosis, we conducted a retrospective chart review of 25 cystic fibrosis patients who underwent prolonged PN (median course 295 days) at our institution between August 1988 and May 1992. The patients' survival status, change in percentage of ideal body weight, need for ongoing nutritional intervention, pulmonary function test changes, i.v. antibiotic use, and complication rates were assessed. Patients gained significant weight while receiving PN, but they lost weight when PN was discontinued. PN did not clearly improve pulmonary status. IV antibiotic therapy nearly doubled during PN. Central venous catheter sepsis rates rose from 1.29 to 3.45 per 1000 catheter days during PN therapy. In conclusion, prolonged PN promotes weight gain in cystic fibrosis patients with severe disease; however, the effect is transient and involves a significantly increased risk of sepsis.

[A practical nursing guide for the planning and evaluation of the care of the patient with domiciliary parenteral nutrition. The planning of patient care with DPN]. / Guía práctica de enfermería para la planificación y evaluación de los cuidados del paciente con nutrición parenteral domiciliaria. Planificación de cuidados del paciente con NPD.

We present a proposal for the planning of nursing care for the patient with home parenteral nutrition (HPN). In this proposal the problems, goals, and actions to be taken by the nurse are defined. In this working guide, it is explained what the diverse aspects are that the nurse taking care of a patient with HPN needs to know, as well as the care to be given and the evaluation of the same, in order to insure that the patient with HPN is given a good preparation in his self-care, giving the patient an acceptable degree of independence and quality of life, as well as a lower risk of complications.

[The administration of intermittent outpatient total parenteral nutrition via a subcutaneous reservoir]. / Administración de una nutrición parenteral total intermitente ambulatoria mediante reservorio subcutáneo.

The development of artificial nutrition has made it possible to maintain the nutritional condition and survival of patients with large intestinal resections along with therapeutic support in certain pathological processes. As such patients have become aware of their potential and the prolonged life expectancy offered, they have increased their demands for enhanced comfort and independence. The experience with a patient with short gut syndrome following quasi-total intestinal resection due to necrosis, and with another with post-esophagocoloplasty necrosis, and the administration of intermittent outpatient total parenteral nutrition through a subcutaneous reservoir in both cases, enabled us to appreciate the advantages of the reservoir in administration of the nutrition. The ease of administration, reduced risk of infection and the positive psychological effect seen in these patients, enabled to lead a "practically normal" life, all vindicate the use of this method.