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journal of the royal society of medicine volu me 84 february 1991 69 transdermal glyceryl trinitrate to allow peripheral total parenteral nutrition a double blind placebo controlled feasibility study htkhawaja ...

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                                                                     Journal of the Royal Society of Medicine Volu'me 84 February 1991   69
        Transdermal glyceryl trinitrate to
        allow peripheral total parenteral nutrition:
        a double-blind placebo controlled feasibility study
        HTKhawaja MSFRCS'              J D Williams MSC2         P C Weaver MDFRCS'            'Department ofSurgery,
        St Mary's Hospital, Portsmouth P03 6AD and2Department ofMedical Statistics and Computing, Southampton
        University, Southampton General Hospital, Southampton S09 4XY
        Keywords: parenteral nutrition; peripheral infusion; glyceryl trinitrate
        Summary                                                   Table 1. Comparability ofinfusion regimens               Paper awarded
        Seventy-two consecutive patients requiring total                                                                   the Section of
        parenteral nutrition (TPN) were randomized to                                     Regimen A*     Regimen B*        Surgery
        two groups. Group A received daily a peripheral                                                                    Norman Tanner
        intravenous regimen which provided 10g nitrogen                                                                    Prize for 1989/90
        and 1400non-nitrogen kcal(5.9MJ). GroupBreceived          Volume (ml)             3035           3040              Session
        dailyaperipheralintravenousregimenwhichdelivered          Non-N energy (kcal)     1400 (5.9 MJ)  1900 (8.0 MJ)
        9.4 g nitrogen and 1900 non-nitrogen kcal (8.0MJ).        Non-N kcal/N ratio       140/1          202/1
        Eachgroupwasfurtherrandomizedtoreceive a self-            Sodium (mmol)             80             65
        adhesive patch of transdermal glyceryl trinitrate         Potassium (mmol)          75             55
        (GTN)or an identical placebo. Infusion survival was       Calcium (mmol)             5              7.5
        the main end-point. For group A, the median time of       Magnesium (mmol)          11.5            3
        infusion survival was 74 h                     in the     Chloride (mmol)           31             88
                                     (range: 58-100)              Phosphorus (mmol)         22.5           35
        control group compared with 108h(range: 68-156) in        Osmolality (mosmol/kg)   495            720
        the group that received tranadermal GTN (P<0.001).
        For group B, the median infusion survival was             N=nitrogen
        67 h (range: 46-92) in the control group compared         *Bothregimenshaveaddedtraceelements andfatandwater
        with 103 h (range: 66-151) in the treatment group         soluble vitamins
        (P<0.001). TPN is feasible via peripheral veins and
        the incidence of infusion failure can be effectively      mixture had atotal osmolality of490 mosmol/kg and
        reduced by transdermal GTN.                               provided 10g nitrogen and 1400 non-protein kcal
        Introduction                                              (5.9MJ) over 24h (Table 1). Regimen B consisted
        Total parenteral nutrition       via                      of 1000 ml Vamin 9 Glucose        (KabiVitrum Ltd,
        is             but vein    (TPN)     peripheral veins     UK), 1000ml Dextrose 10% (Travenol Laboratories
           appealing,            tolerance- remains a major       Ltd, UK), and 1000ml Dextrose 10% (Travenol
        problem. It hasbeen suggestedthatinfusionphlebitis        Laboratories Ltd, UK), and 1000ml Intralipid
        is initiated by venoconstriction at the infusion site',   10%lo (KabiVitrum Ltd, UK). It had an osmolality of
        hence treatment with a vasodilator may reduce its         720mosmollkg and delivered 9.4 g nitrogen and 1900
        incidence. We have tested this hypothesis and             non-protein kcal (8.0 MJ) daily (Table- 1). Both
        reported that the use oftransdermal glyceryl trini-       regimenshad added electrolytes, trace elements, and
        trate (GTN) reduced the failure rate of peripheral        water- and fat-soluble vitamins. Daily regimens,
        intravenous infusions2. This finding, coupled with        provided in 3-litre bags, were infused over 24 h by
        the availability ofhigh-calorie containitng iso-osmolar   meteredvolumetric pumps(lmied 9270). Within each
        lipid solutions has raised the possibility of infusing    regimen, the patients were randomized to receive
        parenteral feeding regimens via peripheral veins.         a self-adhesive patch of either Transiderm-Nitro
                                                                  50(Ciba-Geigy Pharmaceuticals)whichreleases 5 mg
        Patients, materials and methods                           of GTN daily at a continuous rate, or an identical
        All patients between 16 and 80 years ofage requiring      placebo. Thepatches were applied immediately after
        parenteral nutrition were considered. Patients with       venouscannulation, distal and as-close aspossible to
        renal function impairment, glautoma and/or an             the cannulation site and replaced daily. Forcannulae
        unstable cardiovascular system, thosereceiving anti-      sited on the dorsum of the hand, the patches were
        inflammatory or vasodilator drugs -and those who          placed alongside the cannulae.
        wereknowntobeallergictoGTNorElastoplastwere                 The same-make of delivery systems (KabiVitrum
        not entered in the study. All patients gave written       Ltd, UK)and 18GTefloncannulae(Venflone2, Viggo
        informed consent.                                         AB)-were inserted by a team offivejunior surgeons       0141-0768/91/
          Seventy-two consecutive patients were randomly          according to standard procduresforskinpreparation,      020069-04/$02.00/0
        allocated to two regimens. Regimen A consisted of         cannula insertion, and care of intravenous sites2.       © 1991
        2000ml of Perifusin0 (E Merck Ltd, UK), 500ml             Only one infusion site-was studied per patient in an    The Royal
        dextrose 20% (Travenol Laboratories Ltd, UK) and          upper limb which had not been used for any form of      Society of
        500ml Intralipid 20%0 (Kabivitrum Ltd, UK). This          intravenoustherapy intheprevious 2weeks. Thetwo         Medicine
                       70            Journal of the Royal Society of Medicine Volume 84 February 1991
                       Table 2. Comparability ofgroups                                                                                                                                                       100            ...........................              lTet              nt( =      8                   ___Treatment (n = 18)
                                                                                                                                                                                                                                                                                                                  .........   Control (n = 18)
                                                                                                                                                                                            -J                 80                                               8
                                                                              Regimen A                                          Regimen B                                                 >                   60
                                                                              Control/lTreatment Control/Treatment
                       Age and sex distribution                                                                                                                                            w
                                                                                                                                                                                           4                  4
                            Median age (year) 59/59                                                                              60/59                                                                        20-.
                            (range)                                                (38-71)/(35-72)                                    (40-71)/(42-69)                                                          20
                            Male                                                 7/9                                              10/7                                                              HOURS              0              20             40              60              80            100              120            140             160
                            Female                                             11/9                                                 8/11
                       Site of cannulation                                                                                                                                                   Figure1. Relative survival ofinfusions in the treatment and
                            Dominant limb                                        2/3                                                 1/2                                                     control groups in infusion regimen A
                            Non-dominant                                       16/15                                              17/16
                                 limb                                                                                                                                                                         100                                                                                            -Treatment (n = 18)
                            Dorsum of hand                                        3/4                                                3/2                                                    -                                                                                                                            .Control (n = 18)
                            Forearm                                            15/14                                              15/16                                                     -                   80
                                                                                                                                                                                                               60 [
                       Table 3. Reasons for removal ofcannulae                                                                                                                             4                   40 [
                                                                                                       A                                                  B                                -J                  20
                                                                              Regimen                                            Regimen                                                   w
                                                                              Control/Treatment Control/Treatment                                                                                                OL                                                                                                                                                                                     I
                                                                                                                                                                                                     HOURS 0                        20              40              60              80             100             120             140             160
                       Phlebitis                                               17/16                                              16/15                                                      Figure2. Relative survival ofinfusions in the treatment and
                       Irregular drip rate                                       0/1                                                 1/1                                                     control groups in infusion regimen B
                       Extravasation                                             0/0                                                 1/0
                       More than one                                              1/1                                               0/1
                            reason*                                                                                                                                                          phlebitis being the commonest cause of infusion
                       Accidental removal                                        0/0                                                0/1                                                      failure (Table 3). The cannulation sites recovered
                                                                                                                                                                                             within 5 days in all patients, with the exception of
                       *Acombination ofphlebitis, extravasation and/or irregular                                                                                                             one patient who had extravasation ofthe infusate. For
                       drip rate                                                                                                                                                             infusion regimen A, the median time of cannula
                                                                                                                                                                                             survival was 74 h (range: 58-100, n=18) in the control
                       infusion groups were studied simultaneously to avoid                                                                                                                  group compared with 108 h(range: 68-156, n=18) in
                       a possible time-related effect.                                                                                                                                      the group that received Transiderm-Nitro 5® (Figure
                            The infusion was discontinued and the cannula                                                                                                                    1; log rank x2=26.7, P<0.001). For infusion regimen
                       removed when it was no longerrequired fortreatment                                                                                                                    B, the median time of cannula survival was 67 h
                       or when it failed. Failure of infusion was defined as                                                                                                                (range: 46-92, n=18) in the control group compared
                       the occurrence of phlebitis, extravasation or an                                                                                                                      with 103 h (range: 66-151, n=18) in the treatment
                       irregular drip rate. Phlebitis was defined as the                                                                                                                     group (Figure 2; log rank x2=32.5, P<0.001). This
                       presence oftwo or more ofthe following signs: pain,                                                                                                                   significantly increased cannula survival, associated
                       erythema, swelling, excessive warmth, or a palpable                                                                                                                  with the treatment group, is apparent for both
                       venous cord.                                                                                                                                                          infusion regimens. Combining the data from both
                            Venepuncture sites were inspected by the same                                                                                                                   regimens, we obtain estimated 96-h cannula sur-
                       investigator, together with a trained nurse, 12 hourly                                                                                                                vival rate of 5.9% and 82.4% for the control and
                       or when an irregularity ofdrip rate or the patient's                                                                                                                 treatment groupsrespectively(difference=76.5%, 95%
                       discomfort were reported. Routine haematological and                                                                                                                  confidence interval (CI) for difference from 61.4%
                       biochemical monitoring for patients receiving TPN                                                                                                                    to 91.5%). A 95% CI for the proportion of cannulae
                       wascarried out in all cases. Data and adverse effects                                                                                                                 surviving in the treatment group at 96 h is 69.5%
                       were recorded on a standard form for each patient.                                                                                                                   to 95.2%. Comparison ofthecontrol groups in infusion
                            Incidence of infusion failure was analysed by life-                                                                                                             regimens A and B showed that cannula survival
                       table methods. In particular, cannula survival was                                                                                                                   was greater in regimen A (log rank x2=4.7, df=1,
                       estimated using the method of Kaplan and Meier3                                                                                                                       P=0.031). However, there was no significant differ-
                       andbetween group comparisons were made usingthe                                                                                                                       ence in cannula survival between the treatment
                       log rank test4. Cox's proportional hazard technique5                                                                                                                  groups in both infusion regimens (log rank x2=0.3,
                       was used to assess the independent association of                                                                                                                     df=1, P=0.593).
                       treatment and regimen with cannula survival,                                                                                                                               Differences in infusion survival between control and
                       adjusting for confounding effects of age, sex, site of                                                                                                               treatment groups, within each regimen, remained
                       cannulation and insertor.                                                                                                                                             significant when allowance was made for differences
                                                                                                                                                                                            between the five doctors who inserted the cannulae,
                       Results                                                                                                                                                               age and sex ofpatients, and cannulae site using Cox's
                       The treatment and control groups in each infusion                                                                                                                     proportional hazard technique (relative risk offailure
                       regimen were comparable for age, sex, and site of                                                                                                                     in the treatment group=0.0039, 95% CI 0.0009 to
                       cannulation. The non-dominant limb was used more                                                                                                                      0.0162).                                         skin rash were the                                                      side effects
                       frequently than the dominant one with the forearm                                                                                                                          Headache and                                                                                         only
                       being the commonest site of cannulation (Table 2).                                                                                                                    noted and showed nobetween group difference (Table
                       Furthermore,therewerenosignificantbetween-group                                                                                                                       4). One patient had a subcutaneous haematoma at the
                       differences in the reasons for removing the cannulae,                                                                                                                 site of cannulation, and venous cannulation, in two
                                                                        Journal of the Royal Society of Medicine Volume 84 February 1991        71
         Table 4. Adverse reactions                                   incidence ofheadache in patients receiving TPN has
                                                                      not been reported and it may be greater than in
                           Regimen A          Regimen B              the normal population. However, the incidence of
                           Control/Treatment Control/Treatnent        headache in the treatment group (11.1% in regimen
                                                                      A; 5.5% in regimen B) is not different from that
         Headache           1/2               1/1                    reported previously2'6. In all cases, the headache
         Skin rash          1/0               0/0                    responded to analgesia and the patients opted to carry
                                                                      onwiththetrial. Onlyonepatientinthecontrolgroup
                                                                      of regimen A had a skin rash which is, therefore,
                                                                      likely to be due to the adhesive part of the patch.
                                                                       Blackburn et al.16 advocated the use of isotonic
         patients, was not achieved after two venepuncture            aminoacids for peripheral intravenous feeding. Since
         attempts. However, all three patients went on to have       then, manyworkershaveinvestigatedthe metabolic
         successful cannulation in the other upper limb. There       effects of exogenous energy substrates, and have
         was no clinical evidence ofcatheter sepsis, and none        concluded that isotonic amino acids alone have no
         ofthe patients had significant changes intheir blood         significant protein-sparing effect'7"8 and that an
         haematology andbiochemistry overthe studyperiod.            ideal regimen should provide amino acids, fat and
                                                                     glucose together with electrolytes, trace elements and
         Discussion                                                  vitamins'8"9. However, the hypertonicity of such
         The above results demonstrate the feasibility ofTPN         mixtures has compelled clinicians to use central
         via peripheral veins, and confirmthe previous reports       rather than peripheral veins in order to avoid
         that transdermal GTN reduces the incidence of               peripheral venous phlebitis. Central venous cannu-
         peripheral intravenous infusion failure26.                  lation requires skill and may be time consuming.
           The aetiology of infusion phlebitis is multi-             In our institution, we site all central venous feeding
         factorial7. Duration and site of infusion, rate of          lines under strict sterile conditions in the operating
         flow, nature ofinfusate and drug additives including        room. The complications of such technique are
         the pH and particulate matter, size ofvein, cannula         well documented20. Therefore, the use of paren-
         size and material, trauma at venepuncture and               teral feeding regimens employing a simpler, safer,
         infection  have all been incriminated. Several              and cheaper method of venous access is appealing,
         regimens have been suggested for prophylaxis                buthas until recently not been considered practicable.
         including in-line filtration, neutralization of acid          There have been a few reports of peripheral
         solutions and the addition ofsteroids and/or heparin        intravenous administration ofTPNregimens. The use
         to the infusate. However, these prophylactic measures       of hyperosmolar solutions necessitated frequent
         have their limitations and have not gained wide             change of the infusion site due to phlebitis21.
         approval.                                                   Addition of heparin (1 IU/ml), hydrocortisone (5 mg/
           In clinical practice, hyperosmolar solutions and          ml) or heparin (1 IU/ml) and hydrocortisone (5 mg/I),
         irritant drugs are usually given via central rather         and sodium hydroxide as a buffer (1.8 mEq/1) to
         thanperipheral veinsbecause the greater blood flow          the infusate resulted in improved vein tolerance22.
         in central veins rapidly dilutes the infusate. Thus, the    The reasons why these measures didn't gain wide
         concept of increasing the blood flow in peripheral          approval require further investigations. Furthermore,
         veins is appealing and-may reduce the incidence of          there is evidence that the addition ofheparin to the
         infusion phlebitis. Transdermal GTN hasbeen shown           infusate may result in creaming of lipid emulsions
         to induce local vasodilatation8'9, and sublingual GTN       due to the formation of calcium-heparin-lipid
         has been reported to increase blood flow whilst             complex23.
         decreasing vascular resistance and venous tone inthe          Thenon-protein calories intheregimensusedinthis
         forearm'0. The drug has also been shown to stimu-           study were relatively low. Elwyn?A and Macfie25
         late synthesis of prostacyclin by cultured human            haveshownthatestimations ofcalorierequirements
         endothelial cells". Prostacyclin relaxes smooth             have been excessive in the past and their work
         muscle cells in vein walls and is also apotent inhibitor    suggests that the energy inputs in our study are
         of platelet aggregation. The maintenance of an              adequate to meet the needs of many postoperative
         effective concentration of prostacyclin at infusion         patients. We did not carry out metabolic studies.
         sites may prevent venoconstriction and platelet             However, our patients remained clinically well and
         aggregation; thereby possibly reducing the incidence        biochemically stable throughout the study period.
         of infusion phlebitis.                                      Wilson et al.26 have reported good metabolic profiles
          AnothercontributoryfactorenablingperipheralTPN             in ±0 patients who were intravenously fed with a
         maybetheuseoffatemulsions.Intralipid (KabiVitrum            regimen similarto regimen A. Furthermore, it is now
         Ltd, UK) contributed 71% and 58% of the non-                well accepted that fat is a beneficial energy source.
         nitrogen energy in regimens A and B respectively.           We have recently reported good utilization of
         It has been reported that the addition ofIntralipid® to     intravenous lipid emulsions, when given as 50% of
         a glucose solution buffers the vein wall and reduces        non-nitrogen     energy,   with good intravascular
         endothelial injury'2"3. Furthermore, a number of            lipolysis, presumably due to activation of intra-
         irritant drugs are now made up in lipid media, with         vascular lipoprotein lipase27.
         great improvement in vein tolerance (eg diazepam as           The cannulae survived longer than 4 days in the
         diazemuls®14, and etomidate15).                             majority ofpatients who received transdermal GTN,
          Thepopulations inthetreatment andcontrol groups            thus obviating the need for frequent changes of the
         were comparable in terms of age, sex, and site of           cannulation site. This fact, coupled with the early
         cannulation.                                                recovery ofthe infusion site, has relevance bothto the
           The incidence of headaches and skin rashes were           comfort of the patient and to the convenience of
         similar in the control and treatment groups. The            medical and nursing staff.
         72   Journal of the Royal Society of Medicine Volume 84 February 1991
           Wearenotadvocatingthatperipheral TPN should                    7 Khawaja LIT. Infusion phlebitis (letter). Intensive Ther
         replace central venous total parenteral nutrition                   Clin Monitoring 1988;9:190
         in the hypercatabolic patients where the energy                  8 Franks AG. Topical glyceryl trinitrate as adjunctive
         requirements are great, or inthose patients requiring               treatment in Raynaud's disease. Lancet 1982;i:76-7
         parenteral nutritional support for a long time.                  9 Hecker JF, Lewis GBH, Stanley H. Nitroglycerine
         However, there are a number of patients in whom                     ointment as an aid to venepuncture. Lancet 1983;i:332-3
         intravenous nutrition is indicated, butcentral venous           10 Mason DT, Braunwald E. The effects ofnitroglycerine
         cannulation is not desirable. Such patients- include                and amyl nitrite on arteriolar and venous tone in the
         those who demonstrate signs of venous thrombosis,                   human forearm. Circulation 1965;32:755-66
         those who need preservation of central lines for                11 Levin RI, Jaffe EA, Welzsler BB, Jack-Goldman K.
                                                                             Nitroglycerine stimulates synthesis ofprostacyclin by
         other clinical reasons, those with -complications                   cultured human endothelial cells. J Clin Invest 1981;
         necessitating removal ofthe central line, and those                 67:763-9                                     Reduction
         who have commenced enteral feeding but in whom                  12 FujiwaraT,Kawarasaki H,FonkalsrudEW.
         the degree of absorption is not established. A                      ofpostinfusion venous endothelial injury with intralipid.
         prospective survey in our hospital of248 consecutive                Surg Gynecol Obstet 1984;158:57-65         Basaillon S.
         patients who received central venous nutrition                  13 Pineault M, Chessex P, Piedboeuf B,
         showed that only 42 patients (17%) required feeding                 Beneficial effect ofcoinfusing a lipid emulsion on venous
         for longer than 10 days(personal data). Therefore, we               patency. JPEN 1989;13:637-40
         now use peripheral nutrition as a holding regimen               14 Mattila MAK, Rossi ML, Ruoppi MK. Reduction of
         pending reappraisal of nutritional needs. This                      venous sequelae of i.v. diazepam with a fat emulsion
                                                                             as a solvent. Br J Anaesth 1981;53:1265-8
         avoids complications ofcentral venous cannulation,              15 GranL,BleieH,JeppssonR,Maartmann-Moe. Etomidat
         simplifies nursing care, reduces costs and may                       mit intralipid - ein losung zur schmerzfreien injection.
         prevent delay in initiating nutritional support.                    Anaesthetist 1983;32:475-7
         Furthermore, this route ofdelivery ofnutrients was              16 Blackburn GL, FlattJP, Clowes GHA, etal. Peripheral
         widely accepted by the nursing staff and patients                    intravenous feeding with isotonic amino acid solutions.
         alike.                                                              AmJSurg 1973;125:447-51
           Webelievethatperipheral TPN is asafe alternative              17 Greenberg GR, Marliss EB, Anderson GH, etal. Protein
         to central venous feedingformost patientsrequiring                   sparing therapy in postoperative patients. Effects of
         short term intravenous nutrition and should be                       added hypocaloric glucose or lipid. N Engl J Med
         considered when planning nutritional therapy. The                    1976;294:1411-14                        et al. Effect of
                                                                         18 Khawaja HT, Jackson JM, Talbot ST,
         use oftransdermal GTN makes such an alternative                     exogenous energy substrates on the metabolic response
         feasible by improving vein tolerance. This technique                to surgery (abstr.). Eur SurgRes 1986;18 (suppl 1): 1
         ofperipheral intravenous feeding is certainly superior          19 Askanazi J, Carpentier YA, Elwyn DH. Influences of
         to central venous TPN in terms of risks and                         total parenteral nutrition on fuel utilisttion in injury
         complications. Whether or not it will prove meta-                    and sepsis. Ann Surg 1980;191:40-6
         bolically adequate awaits further investigations.               20 Mughal MM. Complications of intravenous feeding
                                                                              catheters. Br J Surg 1989;76:15-21
         Acknowledgment: Wethankthenursingstaffofthegeneral              21 FraserI, Slater N, Howard P, etal. Peripheral parenteral
         surgical wards at St Mary's Hospital for their cooperation,     22 nutrition. Br J Parenteral Ther 1986;7:144-8 R. Pre-
         MrMRThompson, Consultant Surgeon, and Dr M Ford of                  Makarewicz PA, Freemen JB, Fairfull-Smith
         Ciba Geigy UK for supply ofTransiderm-Nitro 5®/placebo               vention of superficial phlebitis during peripheral
         patches.                                                             parenteral nutrition. Am J Surg 1986;151:126-9
                                                                         23 Rattenbury JM, Timmins JG, Cawthorne EA, et al.
         References                                                           Identification of the cause of separation (creaming) of
                                                                              lipid emulsions in intravenous infusion. J Pediatr
         1  Hecker JF, Fisk GC, Lewis GBH. Phlebitis and extra-               Gastroenterol Nutr 1989;8:491-95
            vasation ("tissuing") with intravenous infusions. Med J      24 ElwynDH,KinneyJM,AskanaziJ. Energyexpenditure
            Aust 1984;140:658-60                                              in surgical patients. Surg Clin North Am 1981;61:545-56
         2 Khawaja HT, Campbell MJ, Weaver PC. Effect of                 25 MacFie J. Active metabolic expenditure of gastro-
            transdermal glyceryl trinitrate on the survival of peri-          intestinal surgical patients receiving intravenous
            pheral intravenous infusions: a double-blind prospective          nutrition. JEPN 1984;8:371-6
            clinical study. Br J Surg 1988;75:1212-15                    26 WilsonA, GoodeAW, KirkCJC, SugdenM. Parenteral
         3 Kaplan EL, Meier P. Non-parametric estimation for                  nutrition via peripheral veins: a feasibility study. JR
            incomplete observations. JAm StatAssoc 1958,53:475-81             Soc Med 1987;80.430-3
         4 Peto R, Pike MC, Armitage P. Design and analysis of           27 JacksonJM, KhawajaHT,TalbotST,LeeHA.Theeffect
            randomizedclinical trials requiringprolonged observation          ofsurgery andnutritional regimen onplasma lipoproteins
            ofeach patient. (ii). Analysis and examples. Br JCancer           and fat metabolites in man. Clin Nutr 1990;9:1-7
            1977;35:1-39
         5 Cox DR. Regression models and life tables (with               NB:Furtherreferencescanbeobtainedfromtheauthor
            discussion). J R Stat Soc B 1972;34:187-220
         6 Wright A, Hecker JF, Lewis GBH. Use oftransdermal             (Accepted31 July1990. Correspondence to MrHTKhawqaa,
            glyceryl trinitrate to reduce failure of intravenous         Department ofSurgery, King's College School ofMedicine
            infusion due to phlebitis and extravasation. Lancet          and Dentistry, Rayne Institute, 123 Coldharbour Lane,
            1985;ii:1148-50                                              London SE5 9NU)
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...Journal of the royal society medicine volu me february transdermal glyceryl trinitrate to allow peripheral total parenteral nutrition a double blind placebo controlled feasibility study htkhawaja msfrcs j d williams msc p c weaver mdfrcs department ofsurgery st mary s hospital portsmouth ad anddepartment ofmedical statistics and computing southampton university general xy keywords infusion summary table comparability ofinfusion regimens paper awarded seventy two consecutive patients requiring section tpn were randomized regimen b surgery groups group received daily norman tanner intravenous which provided g nitrogen prize for non kcal mj groupbreceived volume ml session dailyaperipheralintravenousregimenwhichdelivered n energy ratio eachgroupwasfurtherrandomizedtoreceive self sodium mmol adhesive patch potassium gtn or an identical survival was calcium main end point median time magnesium h in chloride range phosphorus control compared with osmolality mosmol kg that tranadermal...

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