Zasada Inga Alicja, Banner Jytte, Bugge Anne
Department of Forensic Medicine, Section of Forensic Pathology, University of Copenhagen, Copenhagen, Denmark.
Forensic Sci Med Pathol. 2019 Sep;15(3):470-473. doi: 10.1007/s12024-019-00113-6. Epub 2019 Apr 22.
Total parenteral nutrition (TPN) using a central line is an invasive and widely used procedure associated with several complications. Pleural effusion secondary to the leakage of alimentation into the pleural cavity is a rare but encountered complication of central-line TPN administration. This case study focuses on a postmortem examination of an 84-year-old woman, hospitalized due to malnutrition and dysphagia. The left internal jugular vein was cannulated, with no post-procedural x-ray check-up of the catheter tip position. An autopsy revealed 800 ml of milky-white fluid in the left pleural cavity, raising the issue of whether the pleural effusion was of chylous or TPN origin. The aim of this case study was to describe the postmortem diagnostic approach of the fluid analysis. Suspecting chylothorax, we first analyzed the triglyceride (TG) levels in the fluid, which, according to the literature, is the best parameter to detect chyle when lipoprotein electrophoresis (chylomicron %) is unavailable. Biochemistry showed increased levels of TG, which can be found in both chylous and TPN fluid. We then added glucose and potassium to the biochemical analysis, again showing increased levels at 46 mmol/L and 22 mmol/L, respectively. We had no information about the given TPN, and thus, comparing the final chemical results with the TPN composition was impossible. The presence of increased levels of triglycerides, glucose, and potassium in the white fluid more strongly resembled a standard TPN than chyle. Hence, by using these three measurements, we concluded that the milky-white fluid was a leakage of TPN.
使用中心静脉置管的全胃肠外营养（TPN）是一种侵入性且广泛应用的操作，会引发多种并发症。因营养液漏入胸腔继发的胸腔积液是中心静脉置管TPN输注过程中一种罕见但会遇到的并发症。本病例研究聚焦于一名84岁女性的尸检，该女性因营养不良和吞咽困难住院。经左颈内静脉进行置管，未对导管尖端位置进行术后X线检查。尸检发现左胸腔有800毫升乳白色液体，引发了胸腔积液是乳糜性还是TPN源性的问题。本病例研究的目的是描述对液体分析的尸检诊断方法。怀疑是乳糜胸，我们首先分析了液体中的甘油三酯（TG）水平，根据文献，当无法进行脂蛋白电泳（乳糜微粒%）检测时，TG是检测乳糜的最佳参数。生化分析显示TG水平升高，在乳糜性液体和TPN液体中均可发现。然后我们在生化分析中加入了葡萄糖和钾，结果再次显示水平升高，分别为46毫摩尔/升和22毫摩尔/升。我们没有关于所给予TPN的信息，因此无法将最终化学结果与TPN成分进行比较。白色液体中甘油三酯、葡萄糖和钾水平升高的情况更符合标准TPN而非乳糜。因此，通过这三项检测，我们得出结论，乳白色液体是TPN漏出液。
