A 23-year-old patient diagnosed with Crohn's disease of ileal location. She initially presented with an inflammatory pattern that evolved into stenosis (occasional subocclusive crises) and later into perforation, leading to abdominal perforation with faecaloid peritonitis, which led to 3 surgical interventions during a stay abroad.
Due to numerous postoperative complications, short bowel syndrome and enteroenteric and enterocutaneous fistula, she was transferred to our hospital. On admission she presented with fever, wound infection with skin dehiscence and severe malnutrition. She had a protective ileostomy, directed fistulisation at the ileo-colic anastomosis with Petzer catheter and abdominal drains.
She was started on Total Parenteral Nutrition (TPN) from the time of admission, with gradual introduction of the new feeding. Throughout the entire period, monitoring is carried out by the Nutrition Section of the Pharmacy Service. TPN is prepared on a daily basis, adjusting the intake according to biochemical parameters and clinical evolution.
After 7 days, he developed cholestasis, so it was decided to reduce and subsequently eliminate the lipid intake in the TPN.
On day 68, TPN was withdrawn due to the onset of oral tolerance, being reintroduced 5 days later due to persistent enterocutaneous fistula that caused fever, abdominal pain and significant weight loss.
After removal of drains and Petzer tube and introduction of treatment with Infliximab, she was discharged from hospital on day 85, continuing with TPN at home until she recovered her nutritional state necessary to undergo intestinal reconstruction surgery. She is monitored on an outpatient basis by the Home Hospitalisation Unit (HADO) and the Parenteral Nutrition Section of the Pharmacy Service.
The TPN is prepared daily in the Pharmacy Service, and staff from the HADO Unit are in charge of its administration, maintenance of the infusion line and clinical follow-up of the patient. The patient and her family also received instructions on how to use the administration equipment. This allowed the patient, despite the intrinsic limitations, to adapt the administration of TPN to her daily activity. In addition, a general biochemistry was performed every week, the results of which allowed us to monitor the patient and modify the intake according to her needs.
During this period, the daily intake (mean ± standard deviation) of macronutrients was 12.2 ± 0.62 g of nitrogen and 1,400 ± 71 kcal of non-protein. The mean micronutrient intakes were: sodium 92 ± 14.2 mEq, chlorine 82.6 ± 14.6 mEq potassium 100 ± 36.4 mEq, phosphorus 10.6 ± 1.3 mEq, calcium 7 ± 0.03mEq, magnesium 11.7 ± 0.06 mEq and zinc 3 mg. Trace elements (Mn, Cr, Cu, Se) are added to the mixture once a week.
As for the evolution of biochemical parameters (mean ± standard deviation): glucose 95 ± 15.1 mg/dl (range 70-100), urea 56 ± 25.1 mg/dl (range 10-50), creatinine 1 ± 0.18 mg/dl (range 0.6-1.2), natraemia 136 ± 1, 7 mg/dl (range 135-145), chloremia 94 ± 5.5 mg/dl (range 96-110), potassemia 3 ± 0.47 mg/dl (range 3.5-5.1), albumin 4 ± 0.3 mg/dl (range 3.55.2), total protein 7 ± 2.9 mg/dl (range 6.2-8.3), phosphataemia 4 ± 0.57 mg/dl (range 2.6-4.5), calcaemia 10 ± 0.43 mg/dl (range 8.4-10.4), magnesaemia 2 ± 0.49 mg/dl (range 1.4-10.4), magnesemia 2 ± 0, 49 mg/dl (range 1.6-2.5), GOT 70 ± 27.7 mg/dl (range 4-37), GPT 150 ± 89.4 mg/dl (range 10-50), alkaline phosphatase 291 ± 163.5 mg/dl (range 80-300).
After 7 and a half months at home on TPN, the patient with a BMI = 18.63 and a prealbumin of 32.9 mg/dl (range 20-40), underwent bowel reconstruction, progressed favourably and TPN was discontinued after 9 days.