Artificial Nutritional Support Research Articles

Improving artificial nutrition support for intensive care patients in a district general hospital – how well have we done?

Improving artificial nutrition support for intensive care patients in a district general hospital – how well have we done?

The patient needing prolonged mechanical ventilation: a narrative review

Background: Progress in management has improved hospital mortality of patients admitted to the intensive care
 units, but also the prevalence of those patients needing weaning from prolonged mechanical ventilation, and of
 ventilator assisted individuals. The result is a number of difficult clinical and organizational problems for patients,
 caregivers and health services, as well as high human and financial resources consumption, despite poor long-term
 outcomes. An effort should be made to improve the management of these patients. This narrative review
 summarizes the main concepts in this field.
 Main body: There is great variability in terminology and definitions of prolonged mechanical ventilation.
 There have been several recent developments in the field of prolonged weaning: ventilatory strategies, use of
 protocols, early mobilisation and physiotherapy, specialised weaning units.
 There are few published data on discharge home rates, need of home mechanical ventilation, or long-term survival
 of these patients.
 Whether artificial nutritional support improves the outcome for these chronic critically ill patients, is unclear and
 controversial how these data are reported on the optimal time of initiation of parenteral vs enteral nutrition.
 There is no consensus on time of tracheostomy or decannulation. Despite several individualized, non-comparative
 and non-validated decannulation protocols exist, universally accepted protocols are lacking as well as randomised
 controlled trials on this critical issue. End of life decisions should result from appropriate communication among
 professionals, patients and surrogates and national legislations should give clear indications.
 Conclusion: Present medical training of clinicians and locations like traditional intensive care units do not appear
 enough to face the dramatic problems posed by these patients. The solutions cannot be reserved to professionals
 but must involve also families and all other stakeholders. Large multicentric, multinational studies on several aspects
 of management are needed.

HOW MUCH IS ENOUGH? PROTEIN REQUIREMENTS IN CRITICALLY ILL PATIENTS

SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: The early and appropriate caloric and protein provision for critically ill patients has been associated with a decreased incidence of nosocomial infections, decreased mortality, and decreased ICU length of stay (LOS); however, the ideal amount of protein to deliver has not been identified. Our objective is to determine if providing a goal of 1 gram/kg/day of protein via artificial enteral nutritional support (AENS) decreases the incidence of catheter-associated urinary tract infections (CAUTI), central line-associated bloodstream infections (CLABSI), and ventilator-associated pneumonia (VAP). METHODS: We designed a prospective observational study for patients admitted to the intensive care unit (ICU) of a university hospital in Spain from January to December 2015. Patients with an expected AENS duration greater than 96 hours (as defined by diagnosis at presentation and comorbidities) were included and followed until the tenth day of AENS or hospital discharge, whichever occurred earlier. Complications were followed until ICU discharge and mortality was followed until hospital discharge. Categorical variables are expressed as frequencies and percentages and continuous as mean and standard deviation (SD) when data followed a normal distribution, or median and interquartile range (IQR = 25th – 75thpercentile) when distributions departed from normality. The percentages were compared using the chi-square (χ2) test, the means by the t-test and medians by Wilcoxon test. RESULTS: In the study period, 84 of 1318 patients admitted to the ICU met the inclusion criteria; of the 84, 30 met the protein goal of 1 g/kg/day and 54 did not meet the protein goal. There were no differences between the groups in the incidence of CAUTI (1 vs 4; p=0.45), CLABSI (2 vs 2; p=0.816), VAP (4 vs 5; p=0.53), and mortality (13 vs 22; p=0.817). Variables were adjusted for severity using the APACHE II score. Patients who did not reach the protein goal had an increased ICU LOS (14.9 vs 11.3 days; p=0.050) and more invasive mechanical ventilation (IMV) days(12.5 vs 8, p=0.030). Using protein deficit as a continuous quantitative variable we found a higher incidence of acute renal failure (p=0.008) in patients with a greater cumulative protein deficit. CONCLUSIONS: Although achieving a goal of 1g/kg/day of protein did not lead to a decrease in the incidence of CAUTI, CLABSI, VAP, or mortality, it was associated with a statistically significant decrease in ICU LOS and fewer days on IMV. It was further concluded that a higher protein deficit resulted in an increased incidence of acute renal failure. CLINICAL IMPLICATIONS: The results of our study suggest providing at least 1 g/kg/day of protein to critically ill patients can have a positive impact with regards to ICU LOS and time on IMV without affecting the incidence of mortality or CAUTI/CLABSI/VAP. Further investigation is necessary to determine the ideal amount of protein to deliver. DISCLOSURES: No relevant relationships by Abilio Arrascaeta Llanes, source=Web Response No relevant relationships by Miguel Ángel García-Martínez, source=Web Response

NUTRITIONAL SUPPORT IN HOSPITALIZED PATIENTS UNDERGOING ALLOGENIC HEMATOPOIETIC STEM CELL TRANSPLANTATION

Assessment of the need of parenteral nutrition (PN) for patients undergoing allogeneic Haematopoietic Stem Cell Transplantation (HSCT) and effectiveness of nutritional support. 41 consecutive patients (20 females, 21 males) undergoing allogenic HSCT at the Transplant Center of the AOU Federico II of Naples in the years 2014-2016. Anthropometric parameters, biochemical indices and artificial / parenteral nutrition requirements were evaluated at admission and discharge. Total or supportive PN due to several disease and therapy related complications was indicated for 68.3% of patients (89.3% galenic, 35.7% glutamine enriched, indication reported in table 1). Median duration of nutritional support was 13 days, median timing for start support was 8 days. 87.5% of patients in PN received a TBF conditioning scheme (thiotepa, busulfan, fludarabine), 57.1% immunosuppressive therapy with high-dose cyclophosphamide, 53.6% hematopoietic stem cells from a haploidentical donor (67.9% bone marrow source). Average length of hospitalization, biochemical nutritional and hematological indices and anthropometric parameters observed at discharge are shown in table 2. 42.2% of the patients had home artificial nutrition support (71.5% oral nutritional supplement, 28.5% PN). PN (personalized nutritional intervention) allows patients undergoing allogenic HSCT who have developed more severe complications to achieve a clinical-haematological recovery such as patients without or with minor complications.

Associations between nutritional energy delivery, bioimpedance spectroscopy and functional outcomes in survivors of critical illness.

Patients who survive critical illness frequently develop muscle weakness that can impact on quality of life; nutrition is potentially a modifiable risk factor. The present study aimed to explore the associations between cumulative energy deficits (using indirect calorimetry and estimated requirements), nutritional and functional outcomes. A prospective single-centre observational study of 60 intensive care unit (ICU) patients, who were mechanically ventilated for at least 48h, was conducted. Cumulative energy deficit was determined from artificial nutrition delivery compared to targets. Measurements included: (i) at recruitment and ICU discharge, weight, fat-free mass (bioimpedance spectroscopy) and malnutrition (Subjective Global Assessment score B/C); (ii) at awakening and ICU discharge, physical function (Physical Function in Intensive Care Test-scored) and muscle strength (Medical Research Council sum-score (MRC-SS). ICU-acquired weakness was defined as a MRC-SSscore of less than 48/60. The median (interquartile range) cumulative energy deficit compared to the estimated targets up to ICU day 12 was 3648 (2514-5650)kcal. Adjusting for body mass index, age and severity of illness, cumulative energy deficit (per 1000kcal) was independently associated with greater odds of ICU-acquired weakness [odds ratio (OR)=2.1, 95% confidence interval (CI)=1.4-3.3, P=0.001] and malnutrition (OR=1.9, 95% CI=1.1-3.2, P=0.02). In similar multivariable linear models, cumulative energy deficit was associated with reductions in fat-free mass (-1.3kg; 95% CI=-2.4 to -0.2, P=0.02) and physical function scores (-0.6 points; 95% CI=-0.9 to -0.3, P=0.001). Cumulative energy deficit from artificial nutrition support was associated with reduced functional outcomes and greater loss of fat-free mass in ventilated ICU patients.

The impact of a nutrition support team over a 8 year period on the management of parenteral nutrition in type 1 intestinal failure

Rationale: Every hospital should have a nutrition support team (NST) to manage patients on artificial nutrition support. The demand for the input has increased over 8 years because of tertiary services for surgery, gastroenterology and the introduction of a regional trauma centre. In 2009, the NST was introduced in our hospital primarily to address catheter-related blood stream infection (CRBSI) rates in patients with type 1 intestinal failure (IF).

Nutrition support and glycaemic variability in critically ill patients

Rationale: Glycaemic variability (GV) is associated with excess mortality.1 The aims of this study were to determine associations between GV and clinical outcomes (mortality, duration of ventilation and intensive care unit (ICU) length of stay) as well as between GV and nutrition provision, particularly carbohydrate provision, from artificial nutrition support.

Malabsorption and artificial nutrition in patients with gut GvHD post allogenic stem cell transplantation: Home parenteral nutrition affects survival significantly

Rationale: Gut graft versus host disease (GvHD) in patients post stem cell transplantation is associated with malabsorption and malnutrition. The purpose of this study was to examine the causes of malnutrition and assess modes of delivery of artificial nutritional support.

Glycaemic variability and its association with enteral and parenteral nutrition in critically ill ventilated patients

Extremes of dysglycaemia as well as glycaemic variability are associated with excess mortality in critically ill patients. Glycaemic variability is an increasingly important measure of glucose control in the intensive care unit (ICU) due to this association; however, there is limited data pertaining to the relationship between exogenous glucose from nutrition and glycaemic variability and clinical outcomes. The primary aim of this study was to determine if glycaemic variability is associated with an increase in mortality. Secondary objectives were to investigate any factors affecting glycaemic variability, and to characterise the role nutrition, particularly carbohydrate, plays as a contributing factor to glycaemic variability and other clinical outcomes (duration of ventilation and ICU length of stay). Data on patients in a combined medical/surgical tertiary Australian Intensive Care Unit (ICU), ventilated for >24h and exclusively fed by artificial nutrition support was extracted from a clinical database of prospectively collected information over an 18 month period. Glycaemic variability was defined as the coefficient of variation (GV; standard deviation/mean of blood glucose levelsx100). Statistical analysis was performed using logistic regression, zero-truncated negative binomial and linear regression as appropriate to the distribution of the outcome variable using R software. Data on up to 759 subjects was available. The average age of the study cohort was 56.9 years with a mean (standard deviation) APACHE III score of 72 (28). 66% of the study subjects were male. Glycaemic variability was associated with an increase in mortality (odds ratio 1.02; 95% CI: 1.00-1.04, p=0.03). Factors associated with glycaemic variability included Acute Physiology and Chronic Health Evaluation III score (0.09, 0.06-0.11, p<0.001), being male (-1.67,-2.97 to-0.38), p=0.01) and mean units of insulin per day (0.08, 0.06-0.09, p<0.001). There was no effect of any nutritional factor on glycaemic variability. Further exploratory analyses though showed that for those patients who required insulin during ICU admission, increased insulin dose was associated with increasing carbohydrate (incidence rate ratio (IRR) 1.003, 1.001-1.005, p=0.001). Mean daily carbohydrate provision (grams) was associated with an increase in ventilation hours (IRR, 95% CI: 1.009, 1.008-1.009, p<0.001) and length of intensive care unit stay (IRR, 95% CI: 1.007, 1.006-1.008, p<0.001). This study confirms that GV was associated with excess mortality. Furthermore, administration of increasing doses of insulin was associated with increased GV. Increased carbohydrate intake was associated with an increased insulin requirement, as well as increased duration of mechanical ventilation and ICU length of stay. These findings provide important context for further prospective trials investigating the effect of carbohydrate provision in mechanically ventilated critically ill patients requiring artificial nutritional support.

Nutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS)

The optimal nutritional therapy in the field of pancreatic surgery is still debated. An international panel of recognized pancreatic surgeons and pancreatologists decided that the topic of nutritional support was of importance in pancreatic surgery. Thus, they reviewed the best contemporary literature and worked to develop a position paper to provide evidence supporting the integration of appropriate nutritional support into the overall management of patients undergoing pancreatic resection. Strength of recommendation and quality of evidence were based on the approach of the grading of recommendations assessment, development and evaluation Working Group. The measurement of nutritional status should be part of routine preoperative assessment because malnutrition is a recognized risk factor for surgery-related complications. In addition to patient's weight loss and body mass index, measurement of sarcopenia and sarcopenic obesity should be considered in the preoperative evaluation because they are strong predictors of poor short-term and long-term outcomes. The available data do not show any definitive nutritional advantages for one specific type of gastrointestinal reconstruction technique after pancreatoduodenectomy over the others. Postoperative early resumption of oral intake is safe and should be encouraged within enhanced recovery protocols, but in the case of severe postoperative complications or poor tolerance of oral food after the operation, supplementary artificial nutrition should be started at once. At present, there is not enough evidence to show the benefit of avoiding oral intake in clinically stable patients who are complicated by a clinically irrelevant postoperative pancreatic fistula (a so-called biochemical leak), while special caution should be given to feeding patients with clinically relevant postoperative pancreatic fistula orally. When an artificial nutritional support is needed, enteral nutrition is preferred whenever possible over parenteral nutrition. After the operation, regardless of the type of pancreatic resection or technique of reconstruction, patients should be monitored carefully to assess for the presence of endocrine and exocrine pancreatic insufficiency. Although fecal elastase-1 is the most readily available clinical test for detection of pancreatic exocrine insufficiency, its sensitivity and specificity are low. Pancreatic enzyme replacement therapy should be initiated routinely after pancreatoduodenectomy and in patients with locally advanced disease and continued for at least 6 months after surgery, because untreated pancreatic exocrine insufficiency may result in severe nutritional derangement. The importance of this position paper is the consensus reached on the topic. Concentrating on nutritional support and therapy is of utmost value in pancreatic surgery for both short- and long-term outcomes.

Impact of route and adequacy of nutritional intake on outcomes of allogeneic haematopoietic cell transplantation for haematologic malignancies

Allogeneic haematopoietic cell transplantation (HCT) is often associated with poor oral intake due to painful mucositis and gastrointestinal sequalae that occur following a preparative regimen of intensive chemotherapy and/or total body radiation. Although attractive to assume that optimal nutrition improves HCT outcomes, there are limited data to support this. It is also unclear whether artificial nutrition support should be provided as enteral tube feeding or parenteral nutrition (PN). We analysed day-100 non-relapse mortality (NRM), incidence of acute graft-versus-host disease (GvHD), acute gastrointestinal GvHD, 5-year survival and GvHD-free/relapse-free survival (GRFS) according to both route and adequacy of nutritional intake prior to neutrophil engraftment, together with other known prognostic factors, in a retrospective cohort of 484 patients who underwent allogeneic HCT for haematologic malignancy between 2000 and 2014. Multivariate analyses showed increased NRM with inadequate nutrition (hazard ratio (HR) 4.1; 95% confidence interval (CI) 2.2-7.2) and adequate PN (HR 2.9; 95% CI 1.6-5.4) compared to adequate enteral nutrition (EN) both P<.001. There were increased incidences of gastrointestinal GvHD of any stage and all GvHD≥grade 2 in patients who received PN (odds ratio (OR) 2.0; 95% CI 1.2-3.3; P=.006, and OR 1.8; 95% CI 1.1-3.0; P=.018, respectively), compared to adequate EN. Patients who received adequate PN and inadequate nutrition also had reduced probabilities of survival and GRFS at 5 years. Adequate EN during the early transplantation course is associated with reduced NRM, improved survival and GRFS at 5 years. Furthermore, adequate EN is associated with lower incidence of overall and gut acute GvHD than PN, perhaps because of its ability to maintain mucosal integrity, modulate the immune response to intensive chemo/radiotherapy and support the gastrointestinal tract environment, including gut microflora.

Malnutrition and refeeding syndrome prevention in head and neck cancer patients: from theory to clinical application.

The goal of this review is to raise awareness about refeeding syndrome (RFS) and to give a comprehensive presentation of recent guidelines and latest scientific data about nutritional management among head and neck cancer (HNC) patients while focusing on RFS prevention. A review of literature for nutritional assessment and RFS management was conducted. Electronic searches of Medline, Cochrane, PubMed and Embase databases for articles published in peer-reviewed journals were conducted from February to September 2017 using the keywords: "nutrition assessment", "head and neck cancer", "refeeding syndrome" and "guidelines". Articles, reviews, book references as well as national and international guidelines in English and French were included. The prevalence of malnutrition is high in HNC patients and a large number of them will need artificial nutritional support or refeeding intervention. RFS is characterized by fluid and electrolyte imbalance associated with clinical manifestations induced by rapid refeeding after a period of malnutrition or starvation. Regarding risk factors for malnutrition and RFS, HNC patients are particularly vulnerable. However, RFS remains unrecognized among head and neck surgeons and medical teams. Practical data are summarized to help organizing nutritional assessment and refeeding interventions. It also summarizes preventive measures to reduce RFS incidence and morbidity in HNC population. Nutritional assessment and early refeeding interventions are crucial for HNC patients care. As prevention is the key for RFS management, early identification of patients with high risks is crucial and successful nutritional management requires a multidisciplinary approach.

Advances of nutritional support therapy in critical illness

In recent years, the scientific literatures have revealed exponential advances in the understanding of molecular basis of nutritional support therapy and evolution of clinical protocols aimed at treating artificial nutritional support as a therapeutic intervention, preventing loss of lean body mass and metabolic deterioration to improve clinical outcomes in the critical illness. According to the evidence-based medicine, this review will summarize recent findings, highlight areas of consensus and controversy and define priorities for further researches. Key words: Critical illness; Nutritional support therapy; Parenteral nutrition; Enteral nutrition; Supplemental parenteral nutrition

Biochemical Markers of Nutrition Support in Critically Ill Trauma Victims.

In critically ill patients, plasma serum albumin and transthyretin concentrations are thought to reflect the effects of acute illness, including resuscitation and inflammation. Their use as markers for preexisting nutrition status is, therefore, not recommended. Whether they can be used to assess subsequent effectiveness of artificial nutrition support is unclear. We sought to determine if these biomarkers are associated with enteral caloric intake in critically ill trauma patients. We analyzed data from adult trauma victims who required ≥2 days of mechanical ventilation and ≥7 days of intensive care. We categorized patients into low, middle, or high enteral calorie delivery groups (2, 9, or 17 kcal/kg/d during the first week). We compared serial concentrations of serum albumin, transthyretin, and C-reactive protein. Multiple linear and Poisson regression were used to determine relationships between calorie intake and nutrition biomarkers. In total, 1056 patients were analyzed. Their median age was 44 (interquartile range [IQR], 28-57) years, and median injury severity score was 34 (IQR, 26-41). Calorie intake during the first week was not related to biomarkers during the first or second week. However, by the beginning of the third week, the highest calorie group showed greater changes in concentrations of transthyretin (+3.0mg/dL relative to initial concentration, P=.01) and serum albumin (+0.17g/dL, P=.05) compared with the lowest calorie group. In trauma patients requiring 1 or more weeks of intensive care, changes in transthyretin were associated with enteral caloric intake. Our data suggest that transthyretin could be used to monitor nutrition support after 2 weeks in intensive care.

A survey of bolus feeding practices in the UK home enteral feeding population

The British Artificial Nutrition Survey (2011) suggests that over 26,600 adult patients receive home enteral tube feeding (HETF) in the UK [1], and that this population is a mix of those who are bed bound/sedentary and those who are very active. Anecdotal evidence from clinicians suggests that the use of bolus feeding regimens is increasing compared to continuous/overnight feeding, allowing feeding to fit in with patient and carer lifestyles, however there is very little published evidence and understanding of this growing practice in HETF in the UK. Therefore a preliminary survey to investigate and characterise the numbers and types of adult HETF patients receiving a bolus feeding regimen was undertaken. A survey of adult (≥18 years) tube fed patients (total n=1833), who were receiving part or all of their tube feeding via a bolus feeding regimen, was undertaken across 10 HETF services in the UK between November 2015 and May 2016. A standardised questionnaire, which included patient demographics (age, gender, primary diagnosis, residential status, working status, activity level), tube type and feeding regimen details (type of feed, method, duration) and reasons for bolus feeding, was completed for each patient from their dietetic notes. Patients with bolus tube feeding regimens represented 33% (n=609) of the total HETF population surveyed. Bolus fed patients (mean age 58 years (SD 20, range 18–97), 59% male), had an average time on tube feeding of 4 years 1 month (SD 4 years 6 months, range 2 months–23 years 7 months) and an average time on a bolus feeding regimen of 3 years 6 months (SD 3 years 11 months, range 26 days–20 years 4 months). The majority of patients (73%) were fed via percutaneous endoscopic gastrostomy (PEG), resided in their own/family homes (70%) or in nursing homes (23%), and most patients were either bed/chair bound or very sedentary (69%), with the majority of patients not working (61%) or being retired (34%). Only 2% of patients were working. The most common primary diagnosis was head and neck cancer (21%), followed by stroke (16%) and cerebral palsy (12%). The head and neck cancer population were found to be much more active (78%) than the rest of the bolus fed population (30%), (seated work – moderate exercise). Of the patients surveyed, the large majority (74%) were using bolus feeding as their primary method of tube feeding either via syringe (51%) or by gravity feeding (40%). The most common reasons for choosing a bolus feeding regimen were: to top up the oral diet (20%), to mimic meal times (16%), easy (15%) and quick (12%) to use. The most commonly used feeds for bolus feeding were oral nutritional supplements (59%), with the highest proportion of these (51%) being 2.4 kcal/ml compact-style supplements. We understand this to be the largest survey of its kind specifically assessing the demographics and feeding practices of adult bolus fed patients in the UK, and showing that 1/3 of HETF patients are bolus fed. This survey largely demonstrates similarities between the demographics of those on bolus feeding regimens and the total HETF population as reported in BANS [1], although there does appear to be a dominant subgroup of head and neck cancer patients, who may be bolus feeding for different reasons. Further research is required to understand this patient group, possibly with the inclusion of specific questions regarding bolus feeding being included in future BANS surveys. Reference [1] Smith T, Micklewright A, Hirst A, Stratton RJ, Baxter J. Annual BANS Report 2011. Artificial Nutrition Support in the UK 2000–2010. BAPEN.

Incidence of hypophosphatemia in not critically ill patients with enteral feeding

Up to 30-40% of the patients starting artificial nutritional support develop hypophosphatemia. In general, patients with mild and moderate hypophosphatemia do not have symptoms, but severe hypophosphatemia is the hallmark of refeeding syndrome. To determine the incidence of hypophosphatemia in not critically ill patients receiving enteral feeding. Prospective study. We assessed during seven days 181 not critically ill patients started on enteral artificial nutrition support during seven days. 51.9% of the patients were considered to be at risk of developing refeeding syndrome (United Kingdom National Institute for Health and Clinical Excellence criteria). The incidence of hypophosphatemia was 31.5%, but only 1.1% of the patients developed severe hypophosphatemia. Older age and lower plasma proteins were significantly associated with hypophosphatemia. The incidence of severe hypophosphatemia in our study is low, so we can't offer robust conclusions about the risk of hypophosphatemia in the type of patients receiving enteral nutrition.

How is the patient’s nutrition after a stroke?

Neurological conditions usually cause altered levels of consciousness or swallowing mechanisms which make artificial nutritional support necessary. International guidelines recommend nutritional screening to detect malnutrition in patients with neurological diseases. Dysphagia is a common problem after a stroke, however, it is a treatable pathology, and swallowing rehabilitation allows for improving patients’ nutritional status. Awareness of this problem is required among healthcare professionals both for its diagnosis and for the implementation of nutritional intervention measures. Patients should be tested for dysphagia within the first 24 hours of the stroke onset; this swallowing assessment as well as malnutrition screening should never be delayed by more than 72 hours. The present study addresses diagnostic and therapeutic approaches, the indications of the different nutritional treatments available and the transition to oral feeding in patients who have had a stroke episode.

Nutrition Needs for Patients With Head &amp; Neck Cancer

Nutrition Needs for Patients With Head &amp; Neck Cancer

Parenteral and enteral nutrition in surgical critical care: Plasma metabolomics demonstrates divergent effects on nitrogen, fatty-acid, ribonucleotide, and oxidative metabolism.

Artificial nutrition support is central to the care of critically ill patients and is primarily provided enterally (EN). There are circumstances when parenteral nutrition (PN) is considered necessary. We are uncertain how each of these approaches confer clinical benefits beyond simply providing calories. We sought to better understand how each of these techniques influence metabolism in critically ill patients using a broad-based metabolomics approach. Metabolic responses to EN and PN may differ in ways that could help us understand how to optimize use of these therapies. We prospectively enrolled subjects over 7 months in 2015 at an urban, Level I trauma center. Subjects were included before starting either EN or PN during their inpatient admission. Plasma samples were obtained between 1 and 12 hours before initiation of artificial nutrition, and 3 and 7 days later. All samples were analyzed with liquid chromatography/mass spectrometry-based metabolomics. Differences in metabolite concentrations were assessed via principal component analyses and multiple linear regression. We enrolled 30 subjects. Among the critically ill subjects, 10 received EN and 10 received PN. In subjects receiving EN, amino acid and urea cycle metabolites (citrulline, p = 0.04; ornithine, p = 0.05) increased, as did ribonucleic acid metabolites (uridine, p = 0.04; cysteine, 0 = 0.05; oxypurinol, p = 0.04). Oxidative stress decreased over time (increased betaine, p = 0.05; decreased 4-pyridoxic acid, p = 0.04). In subjects receiving PN, amino acid concentrations increased over time (taurine, p = 0.04; phenylalanine, p = 0.05); omega 6 and omega 3 fatty acid concentrations decreased over time (p = 0.05 and 0.03, respectively). EN was associated with amino acid repletion, urea cycle upregulation, restoration of antioxidants, and increasing ribonucleic acid synthesis. Parenteral nutrition was associated with increased amino acid concentrations, but did not influence protein metabolism or antioxidant repletion. This suggests that parenteral amino acids are used less effectively than those given enterally. The biomarkers reported in this study may be useful in guiding nutrition therapy for critically ill patients. Therapeutic study, level III; prognostic study, level II.

Artificial Nutrition in Therapeutic Approach of Acute Caustic Poisonings

Acutes corrosive poisonings can cause serious chemical injuries of the upper gastrointestinal tract, and they are localized most frequently in the esophagus and the stomach because the poison remains there a long time. Treatment of the acute corrosive intoxications include: neutralization of corrosive agents, antibiotics, corticosteroids, anti-secretory therapy, nutritional support, collagen synthesis inhibitors, esophageal dilation and stent placement, and surgery.The damaged mucosa, submucosa and muscle layer regenerate with great difficulty because of the surrounding inflammation, necrosis and secondary complications. Tissue fibrosis, adhesions or circular stenosis appear, which greatly disturb the normal functioning (impeded peristaltic, impeded passage). All these complicate the entire general condition of the patient, including inadequate normal food intake, loss of body weight, prostration, cachexia. These patients are also into a severe general condition due to hypercatabolic state and negative alkali balance. Therefore, early nutritional support is of substantial importance in treatment of these patients. Nutritional support can be given by parenteral way in peripheral or central vein and by enteral way through specially designed tubes inserted in the stomach or intestines, prepyloric or postpyloric.The type of artificial nutritional support will depend on the grade of esophageal or gastric damage determined by endoscopy.