Early Initiation Of Parenteral Nutrition Research Articles

Early parenteral nutrition is associated with improved growth in very low birth weight infants: a retrospective study

ObjectiveTo assess the association between early initiation of parenteral nutrition (PN) and body growth in preterm infants with very low birth weight (VLBW).DesignCausal inference analysis with confounders preselected by causal...

Changes in the growth of very preterm infants in England 2006–2018

ObjectiveTo compare weight gain from birth to term equivalent age in very preterm infants in England born during two eras (2006–2011 and 2014–2018); to assess demographic and care factors influencing...

Early Initiation of Parenteral Nutrition in Elderly Emergency General Surgery Patients

Early Initiation of Parenteral Nutrition in Elderly Emergency General Surgery Patients

Early Versus Later Initiation of Parenteral Nutrition for Very Preterm Infants: A Propensity Score Matched Observational Study

Background: A current standard of care based on expert opinion is to commence parenteral nutrition (PN) within hours of birth in very preterm infants. Trials in critically ill adults and children, including term infants have found short and long-term harms from early initiation of PN. Methods: We included all infants born below 31 weeks gestation between January 2008 and December 2019 and admitted to National Health Service neonatal units in England and Wales. The source of data was the National Neonatal Research Database. The exposure was PN initiated within the first two days after birth (early) versus after the second postnatal day (late). We used propensity matched analysis to balance the two groups on background variables. The primary outcome was survival to discharge without major morbidity. Findings: Of 65,033 infants included, 16,294 infants formed the matched cohort, 8147 in each group. There was no evidence of a difference in survival to discharge without major morbidity (absolute rate difference (ARD) between early versus late 0·50%; 95% Confidence Interval (CI), -1·45, 0·45; p=0·29). Survival to discharge was higher in the early group (ARD -3·25%; 95% CI, -3·82 to -2·68; p<0·001) but they also had higher rates of late-onset sepsis (ARD -0·84%; 95% CI, -1·20 to -0·48; p<0·001), bronchopulmonary dysplasia (ARD -1·24%; 95% CI, -2·17 to -0·30; p=0·01), treatment for retinopathy of prematurity (ARD (-0·5%; 95% CI, -0·84 to -0.17; p<0·001), surgical procedures (ARD -0·8%; 95% CI, -1·40 to -0·20; p=0·01) and greater drop in weight z-score between birth and discharge (absolute difference 0·019; 95% CI, 0·003 to 0·039; p=0·02). Among infants that died the median age (days) at death was shorter in the late group (ARD 6; 95% CI, 6; p<0.001). Interpretation: These observational data justify the need for a randomised controlled trial of early versus late PN powered to detect differences in long-term functional outcomes. Funding Information: No specific funding. Declaration of Interests: NM is the Chief Investigator for the National Neonatal Research Database at Imperial College London. SU, NL, CB, KO, JL declare no conflict of interest involving the work under consideration for publication. Ethics Approval Statement: The Health Research Authority, and Health and Care Research Wales, approved the study (ID 273001). All neonatal units agreed to the inclusion of their data in the study.

Never Too Early: Parenteral Nutrition Administration in Elderly Emergency General Surgery Patients

Objectives: Elderly patients requiring emergency general surgery (EGS) are at high risk for complications due to preexisting malnutrition. Thus, correcting nutritional deficits perioperatively is essential to improve outcomes. However, even in patients unable to tolerate enteral nutrition, initiation of parenteral nutrition (PN) is often delayed due to concerns of associated complications. In this study, we hypothesized that in elderly EGS patients with relative short-term contraindications to enteral nutrition, early administration of PN is as safe as delayed administration. Furthermore, early PN may improve outcomes by enhancing caloric intake and combatting malnutrition in the immediate perioperative period. Design and Setting: A single-institution, retrospective review was performed at a quaternary academic medical center. Participants: Participants consisted of 58 elderly patients &gt;65 years of age admitted to the EGS service who required PN between July 2017 and July 2020. Measurements: Postoperative outcomes of patients started on PN on hospital day 0-3 (early initiation) were compared to patients started on PN on hospital day 4 or later (late initiation). Bivariate analysis was conducted using the Chi-square or Fisher’s exact test for categorical variables and the Wilcoxon-Mann-Whitney test and F-test for continuous variables. Results: Fifty-eight patients met inclusion criteria, with 27 (46.6%) patients receiving early PN and 31 (53.4%) receiving late PN. Both groups shared similar baseline characteristics, including degree of frailty, body mass index, and nutritional status at time of admission. Complications associated with PN administration were negligible, with no instances of central venous catheter insertion-related complications, catheter-associated bloodstream infection, or factors leading to early termination of PN therapy. A significantly higher proportion of patients in the early administration group met 60% of their caloric goal within 72 hours of admission (62.9% versus 19.5%, p=0.0007). Patients receiving late PN demonstrated a significantly higher rate of unplanned admission to the intensive care unit (38.7% versus 14.8%, p=0.04). Moreover, there was a 21.5% reduction in mortality among patients in the early initiation group compared to patients in the late initiation group (33.3% versus 54.8%, p=0.10). Conclusions: Early initiation of PN in hospitalized elderly EGS patients was not associated with increased adverse events compared to patients undergoing delayed PN administration. Furthermore, patients receiving early PN demonstrated a 2.6-fold decrease in the rate of unplanned admission to the intensive care unit and trended toward improved mortality. Based on these results, further prospective studies are warranted to further explore the safety and potential benefits of early PN administration in elderly surgical patients unable to receive enteral nutrition.

The role of parenteral nutrition in paediatric critical care, and its consequences on recovery

: The goal of nutritional support during critical illness is to provide the appropriate amount of nutrition accounting for the acute, stable and recovery phase in order to accelerate recovery and to improve short-term and long-term outcomes. Although the preferred route to provide nutritional support during paediatric critical illness is via enteral route, reaching target intakes is often difficult due to (perceived) feeding intolerance, fluid restriction, and interruptions around procedures. Because undernourishment in these children has been associated with impaired outcome, parenteral nutrition (PN) has therefore been viewed as an optimal alternative for reaching early and high nutritional targets. However, PN recommendations regarding timing, dose and composition varied widely and were based on studies using intermediate or surrogate endpoints and observational studies. It was not until the paediatric early versus late PN in critically ill children (PEPaNIC) randomized controlled trial (RCT) that the advice to reach high and early macronutrient goals via PN was challenged. The PEPaNIC study showed that omitting supplemental PN during the first week of paediatric intensive care unit (PICU) admission as compared with early initiation of PN (<24 hours) reduced new acquired infections and accelerated recovery. The provision of amino acids in particular was negatively associated with short-term outcomes, probably explained by the suppression of the activation of autophagy. Autophagy is an evolutionary conserved intracellular degradation process and it is crucial for maintaining cellular integrity and function, which becomes even more important during acute stress. Results of the long-term PEPaNIC follow-up study showed that withholding early PN did not negatively affect anthropometrics and health status but improved neurocognitive and psychosocial development 2 and 4 years later. Current guidelines therefore advise to consider withholding parenteral macronutrients for the first week of PICU admission, while providing micronutrients. Although parenteral restriction during the first week of critical illness has been found beneficial, further research beyond the acute phase is warranted to determine the best role of PN in terms of optimal timing, dose and composition in order to improve short-term recovery and long-term developmental outcomes.

Congenital Short Bowel Syndrome

Congenital short bowel syndrome (SBS) is a rare congen.it.al disease, Only about 37 cases were reported. Infants usually present with failure to 'thrive, recurrent vomiting and or diarrhoea. It is associated with significant mortality and morbidity, High degree of suspicion is necessary to diagnose this condition promptly. Early initiation of parenteral nutrition or surgery may result in a favorable outcome. We treated a case of infant aged eight-weeks presented with recurrent bilious vomiting and failure to thrive. On Laparotomy it was found that the baby had very short small bowel with malrotation. This case was reported and reviewed.&#x0D; Journal of Surgical Sciences (2014) Vol. 18 (1) : 35-37

Effect of late versus early initiation of parenteral nutrition on weight deterioration during PICU stay: Secondary analysis of the PEPaNIC randomised controlled trial

Critically ill children are at increased risk of weight deterioration in the paediatric intensive care unit (PICU). Whether early initiation of parenteral nutrition (PN) prevents weight deterioration is unknown. The aims of this study were to assess the effect of withholding supplemental PN during the first week on weight Z-score change in PICU and to evaluate the association between weight Z-score change in the PICU and clinical outcomes. This is a secondary analysis of the Paediatric Early versus Late Parenteral Nutrition in Intensive Care Unit (PEPaNIC) randomised controlled trial (N=1440), which focused on the subgroup of patients with longitudinal weight Z-scores available on admission and on the last day in PICU. Patients were randomly allocated to initiation of supplemental PN after one week (Late-PN) or within 24h (Early-PN) when enteral nutrition was insufficient. The effect of Late-PN versus Early-PN on the change in weight Z-score was investigated, adjusted for risk factors. Moreover, the association between weight Z-score change and clinical outcomes was explored, adjusted for risk factors. Longitudinal weight Z-scores were available for 470 patients. Enteral nutrition intake was equal in the Early-PN and Late-PN group. Less weight Z-score deterioration during PICU stay was associated with a lower risk of new infections (adjusted OR per Z-score increase 0.72 [0.55-0.96], p=0.02), and with a higher likelihood of an earlier discharge from PICU alive (adjusted HR per Z-score increase 1.22 [1.10-1.37], p<0.001). During PICU-stay, the change in weight Z-score did not differ among both groups (Late-PN median 0.00 [-0.34-0.12] vs Early-PN median-0.03 [-0.48-0.01], adjusted β=0.10 [-0.05-0.25], p=0.18). Weight deterioration during the PICU stay was associated with worse clinical outcomes. Withholding supplemental PN during the first week did not aggravate weight Z-score deterioration during PICU stay. clinicaltrials.gov NCT01536275.

Impact of the Time to Initiation of Parenteral Nutrition on Patient Outcomes in Critically Ill Adults.

Background:The optimal time to initiate parenteral nutrition (PN) in critically ill adults in whom enteral nutrition is not feasible is controversial.Objective:The objectives were to compare in-hospital mortality and hospital length of stay in patients initiated on PN within 7 days or after 7 days of poor nutrient intake.Methods:This single-center, retrospective study included critically ill adult patients who received at least 2 consecutive days of PN during hospitalization from May 2014 to July 2016.Results:The median duration of PN (interquartile range) was 8 (5-13) days. In total, 110 patients received PN within 7 days of poor nutrient intake while 49 patients received PN after 7 days of poor nutrient intake. There was no statistically significant difference in in-hospital mortality between groups (29.09% vs 18.37%, P = .1535). Patients initiated within 7 days had a significantly shorter median hospital length of stay than patients initiated after 7 days (20 days vs 27 days, P = .0013). There were 69 patients who were classified as obese. Obese patients initiated within 7 days had a significantly shorter median hospital length of stay than obese patients initiated after 7 days (17 days vs 33 days, P = .0007).Conclusions:Time to initiation of PN did not impact in-hospital mortality. However, there was an association between early initiation of PN and a shorter hospital length of stay that was most pronounced among obese patients.

Leukocyte telomere length in paediatric critical illness: effect of early parenteral nutrition

BackgroundChildren who have suffered from critical illnesses that required treatment in a paediatric intensive care unit (PICU) have long-term physical and neurodevelopmental impairments. The mechanisms underlying this legacy remain largely unknown. In patients suffering from chronic diseases hallmarked by inflammation and oxidative stress, poor long-term outcome has been associated with shorter telomeres. Shortened telomeres have also been reported to result from excessive food consumption and/or unhealthy nutrition. We investigated whether critically ill children admitted to the PICU have shorter-than-normal telomeres, and whether early parenteral nutrition (PN) independently affects telomere length when adjusting for known determinants of telomere length.MethodsTelomere length was quantified in leukocyte DNA from 342 healthy children and from 1148 patients who had been enrolled in the multicenter, randomised controlled trial (RCT), PEPaNIC. These patients were randomly allocated to initiation of PN within 24 h (early PN) or to withholding PN for one week in PICU (late PN). The impact of early PN versus late PN on the change in telomere length from the first to last PICU-day was investigated with multivariable linear regression analyses.ResultsLeukocyte telomeres were 6% shorter than normal upon PICU admission (median 1.625 (IQR 1.446–1.825) telomere/single-copy-gene ratio (T/S) units vs. 1.727 (1.547–1.915) T/S-units in healthy children (P < 0.0001)). Adjusted for potential baseline determinants and leukocyte composition, early PN was associated with telomere shortening during PICU stay as compared with late PN (estimate early versus late PN –0.021 T/S-units, 95% CI −0.038; 0.004, P = 0.01). Other independent determinants of telomere length identified in this model were age, gender, baseline telomere length and fraction of neutrophils in the sample from which the DNA was extracted. Telomere shortening with early PN was independent of post-randomisation factors affected by early PN, including longer length of PICU stay, larger amounts of insulin and higher risk of infection.ConclusionsShorter than normal leukocyte telomeres are present in critically ill children admitted to the PICU. Early initiation of PN further shortened telomeres, an effect that was independent of other determinants. Whether such telomere-shortening predisposes to long-term consequences of paediatric critical illness should be further investigated in a prospective follow-up study.Trial registrationClinicalTrials.gov, NCT01536275. Registered on 16 February 2012.

Biological Impact of Recent Guidelines on Parenteral Nutrition in Preterm Infants.

Recent guidelines for preterm neonates recommend early initiation of parenteral nutrition (PN) with high protein and relatively high caloric intake. This review considers whether these changes could influence homeostasis in very preterm infants during the first few postnatal weeks. This systematic review of relevant literature from searches of PubMed and recent guidelines was reviewed by investigators from several perinatal centers in France. New recommendations for PN could be associated with metabolic acidosis via the increase in the amino acid ion gap, hyperchloremic acidosis, and ammonia acidosis. The introduction of high-intake amino acids soon after birth could induce hypophosphatemia and hypercalcemia, simulating a "repeat feeding-like syndrome" and could be prevented by the early intake of phosphorus, especially in preterm infants born after fetal growth restriction. Early high-dose amino acid infusions are relatively well tolerated in the preterm infant with regard to renal function. Additional studies, however, are warranted to determine markers of protein intolerance and to specify the optimal composition and amount of amino acid solutions. Optimal PN following new guidelines in very preterm infants, despite their demonstrated benefits on growth, may induce adverse effects on ionic homeostasis. Clinicians should implement appropriate monitoring to prevent and/or correct them.

Withholding parenteral nutrition during critical illness increases plasma bilirubin but lowers the incidence of biliary sludge

Cholestatic liver dysfunction (CLD) and biliary sludge often occur during critical illness and are allegedly aggravated by parenteral nutrition (PN). Delaying initiation of PN beyond day 7 in the intensive care unit (ICU) (late PN) accelerated recovery as compared with early initiation of PN (early PN). However, the impact of nutritional strategy on biliary sludge and CLD has not been fully characterized. This was a preplanned subanalysis of a large randomized controlled trial of early PN versus late PN (n = 4,640). In all patients plasma bilirubin (daily) and liver enzymes (alanine aminotransferase [ALT], aspartate aminotransferase [AST], gamma-glutamyl transpeptidase [GGT], alkaline phosphatase [ALP], twice weekly; n = 3,216) were quantified. In a random predefined subset of patients, plasma bile acids (BAs) were also quantified at baseline and on days 3, 5, and last ICU-day (n = 280). Biliary sludge was ultrasonographically evaluated on ICU-day 5 (n = 776). From day 1 after randomization until the end of the 7-day intervention window, bilirubin was higher in the late PN than in the early PN group (P < 0.001). In the late PN group, as soon as PN was started on day 8 bilirubin fell and the two groups became comparable. Maximum levels of GGT, ALP, and ALT were lower in the late PN group (P < 0.01). Glycine/taurine-conjugated primary BAs increased over time in ICU (P < 0.01), similarly for the two groups. Fewer patients in the late PN than in the early PN group developed biliary sludge on day 5 (37% versus 45%; P = 0.04). Tolerating substantial caloric deficit by withholding PN until day 8 of critical illness increased plasma bilirubin but reduced the occurrence of biliary sludge and lowered GGT, ALP, and ALT. These results suggest that hyperbilirubinemia during critical illness does not necessarily reflect cholestasis and instead may be an adaptive response that is suppressed by early PN.

Is gastric residual volume monitoring in critically ill patients receiving mechanical ventilation an evidence-based practice?

Sir, Nutritional support in intensive care units (ICUs) is widely accepted as an integral part of patient care, when oral food intake is inadequate or not possible; however, feeding often receives lower priority compared with other ICU treatments such as hemodynamic and ventilation control.[1] Nutritional status is an important factor in health maintenance and disease recovery, particularly in critically ill patients during the mechanical ventilation (MV).[2] Many critically ill patients, especially those who require MV, are unable to eat normally; hence, “artificial nutrition” is provided through enteral or parenteral route.[3] Underfeeding and malnutrition are prevalent in critically ill patients receiving invasive MV. It is estimated that the overall incidence of malnutrition in ICU could be as high as 50%.[4] Moreover, more than 35% of ICU patients are reported to be malnourished upon admission to the ICU.[5] Underfeeding in patients receiving MV can decrease regeneration of respiratory epithelium, respiratory muscles strength and therefore, prolong MV.[2] Furthermore, underfeeding and malnutrition in these patients have an adverse effect on all physiological processes. It increases the risk for infection and pulmonary edema, decreases phosphorus levels needed for cellular energy (adenosine triphosphate) production, reduces ventilatory drive and impairs production of surfactant.[6] Although, enteral nutrition (EN) is the preferred method for nutritional support in ICU patients, patients with enteral feeding are at great risk of malnutrition due to insufficient nutritional intake, primarily due to frequent interruptions in enteral feedings.[7] One of the most important factors for frequent interruptions in enteral feeding in these patients is an increased gastric residual volume (GRV).[6] It is believed that in critically ill patients receiving EN, high GRVs may result in aspiration of gastric contents and increase the risk of ventilator-associated pneumonia (VAP).[8] The practice of monitoring GRVs to assess the safety of enteral tube feeding has been a routine part of enteral feeding protocols in the ICUs. However, little scientific evidence indicates that their use, improves patient outcomes.[9] A study done by Reignier et al. found that the absence of GRV monitoring was not inferior to routine performance of this practice in terms of development of VAP or new infections, lengths of ICU and hospital stay, organ failure scores, or mortality rates in mechanically ventilated patients.[10] Furthermore, the result of another study by Poulard et al., have shown that early EN without GRV measuring in mechanically ventilated patients improves the delivery of enteral feeding, without increasing the rate of vomiting or VAP in these patients.[11] They concluded that the routine GRV monitoring of mechanically ventilated patients during EN may be discontinued in most patients.[10,11] Eliminating GRV monitoring from routine part of enteral feeding protocols in the ICUs may have beneficial effects such as improved EN delivery, prevent underfeeding and consequently can decrease the morbidity and mortality rates in critically ill patients. Also, considering that there are several pathogenetic mechanisms associated with VAP removing interventions such as GRV monitoring with no proven beneficial effects, would allow critical care nurses to focus on interventions of proven value.[11] It should be noted that although the importance of adequate nutritional support in critically ill patients is well-established, in recent years, there has been increasing interest in the concept of ‘permissive underfeeding’ that may be associated with clinical benefit in these patients.[12] A study by Krishnan et al. found that a therapeutic window for caloric intake in medical ICU patients (33-65% of caloric intake requirements calculated using the American College of Chest Physicians (ACCP); approximately 16-18 kcal/kg/day) was associated with better outcome compared to highest (>65%) and lowest (0-32%) tertiles of caloric intake in these patients.[13] Moreover, the results of a study by Casaer et al. have been shown that in critically ill patients, high caloric intake by early initiation of parenteral nutrition to supplement EN during the 1st week after ICU admission is associated with worse prognosis.[14] In sum, in the current climate of evidence-based practice, there is a paucity of scientific information to support GRV monitoring as a routine part of enteral feeding protocols in critically ill patients receiving MV. The use of GRVs monitoring is often based on tradition rather than best evidence, which often guides critical care nurses in the managing enteral feeding with unnecessary interruptions of EN delivery. Therefore, it seems that this practice can be removed from the usual care of these patients. Future research in this regard is strongly recommended.

Impact of Early Parenteral Nutrition on Muscle and Adipose Tissue Compartments During Critical Illness*

The goal of enhanced nutrition in critically ill patients is to improve outcome by reducing lean tissue wasting. However, such effect has not been proven. This study aimed to assess the effect of early administration of parenteral nutrition on muscle volume and composition by repeated quantitative CT. A preplanned substudy of a randomized controlled trial (Early Parenteral Nutrition Completing Enteral Nutrition in Adult Critically Ill Patients [EPaNIC]), which compared early initiation of parenteral nutrition when enteral nutrition was insufficient (early parenteral nutrition) with tolerating a pronounced nutritional deficit for 1 week in ICU (late parenteral nutrition). Late parenteral nutrition prevented infections and accelerated recovery. University hospital. Fifteen EPaNIC study neurosurgical patients requiring prescheduled repeated follow-up CT scans and six healthy volunteers matched for age, gender, and body mass index. Repeated abdominal and femoral quantitative CT images were obtained in a standardized manner on median ICU day 2 (interquartile range, 2-3) and day 9 (interquartile range, 8-10). Intramuscular, subcutaneous, and visceral fat compartments were delineated manually. Muscle and adipose tissue volume and composition were quantified using standard Hounsfield Unit ranges. Critical illness evoked substantial loss of femoral muscle volume in 1 week's time, irrespective of the nutritional regimen. Early parenteral nutrition reduced the quality of the muscle tissue, as reflected by the attenuation, revealing increased intramuscular water/lipid content. Early parenteral nutrition also increased the volume of adipose tissue islets within the femoral muscle compartment. These changes in skeletal muscle quality correlated with caloric intake. In the abdominal muscle compartments, changes were similar, albeit smaller. Femoral and abdominal subcutaneous adipose tissue compartments were unaffected by disease and nutritional strategy. Early parenteral nutrition did not prevent the pronounced wasting of skeletal muscle observed over the first week of critical illness. Furthermore, early parenteral nutrition increased the amount of adipose tissue within the muscle compartments.

Withholding parenteral nutrition during the first week of critical illness increases plasma bilirubin but lowers the incidence of cholestasis and gallbladder sludge

Cholestatic liver dysfunction (CLD) during critical illness, defined by hyperbilirubinemia, often occurs and is associated with poor outcome. Parenteral nutrition (PN) is assumed to aggravate CLD. However, hyperbilirubinemia more frequently occurred when the start of PN was delayed until day 8 in the ICU (late PN) [1]. Late PN accelerated recovery as compared with early initiation of PN.

Critical illness induces nutrient-independent adipogenesis and accumulation of alternatively activated tissue macrophages

IntroductionWe previously reported that in artificially-fed critically ill patients, adipose tissue reveals an increase in small adipocytes and accumulation of M2-macrophages. We hypothesized that nutrient-independent factors of critical illness explain these findings, and that the M2-macrophage accumulation may not be limited to adipose tissue.MethodsIn a long-term cecal ligation and puncture (CLP) mouse model of sepsis, we compared the effect of parenteral nutrition (CLP-fed, n = 13) with nutrient restriction (CLP-restricted, n = 11) on body composition, adipocyte size and macrophage accumulation in adipose tissue, liver and lungs. Fed healthy mice (n = 11) were studied as controls. In a human study, in vivo adipose tissue biopsies were studied from ICU patients (n = 40) enrolled in a randomized control trial which compared early initiation of parenteral nutrition (PN) versus tolerating nutrient restriction during the first week of ICU stay. Adipose tissue morphology was compared with healthy human controls (n = 13).ResultsIrrespective of nutritional intake, critically ill mice lost weight, fat and fat-free mass. Adipocyte number, proliferation marker Proliferating Cell Nuclear Antigen (PCNA) and adipogenic markers PPARγ and CCAAT/enhancer binding protein-β (C/EBPβ) increased with illness, irrespective of nutritional intake. M2-macrophage accumulation was observed in adipose tissue, liver and lungs of critically ill mice. Macrophage M2-markers correlated with CCL2 expression. In adipose tissue biopsies of critically ill patients, increased adipogenic markers and M2 macrophage accumulation were present irrespective of nutritional intake.ConclusionsAdipogenesis and accumulation of tissue M2-macrophages are hallmarks of prolonged critical illness, irrespective of nutritional management. During critical illness, M2-macrophages accumulate not only in adipose tissue, but also in the liver and lungs.

Early Versus Late Parenteral Nutrition in Critically Ill Adults

A b s t r ac t Background Controversy exists about the timing of the initiation of parenteral nutrition in critically ill adults in whom caloric targets cannot be met by enteral nutrition alone. Methods In this randomized, multicenter trial, we compared early initiation of parenteral nutrition (European guidelines) with late initiation (American and Canadian guidelines) in adults in the intensive care unit (ICU) to supplement insufficient enteral nutrition. In 2312 patients, parenteral nutrition was initiated within 48 hours after ICU admission (early-initiation group), whereas in 2328 patients, parenteral nutrition was not initiated before day 8 (late-initiation group). A protocol for the early initiation of enteral nutrition was applied to both groups, and insulin was infused to achieve normoglycemia. Results Patients in the late-initiation group had a relative increase of 6.3% in the likelihood of being discharged alive earlier from the ICU (hazard ratio, 1.06; 95% confidence interval [CI], 1.00 to 1.13; P = 0.04) and from the hospital (hazard ratio, 1.06; 95% CI, 1.00 to 1.13; P = 0.04), without evidence of decreased functional status at hospital discharge. Rates of death in the ICU and in the hospital and rates of survival at 90 days were similar in the two groups. Patients in the late-initiation group, as compared with the early-initiation group, had fewer ICU infections (22.8% vs. 26.2%, P = 0.008) and a lower incidence of cholestasis (P<0.001). The late-initiation group had a relative reduction of 9.7% in the proportion of patients requiring more than 2 days of mechanical ventilation (P = 0.006), a median reduction of 3 days in the duration of renalreplacement therapy (P = 0.008), and a mean reduction in health care costs of €1,110 (about $1,600) (P = 0.04). Conclusions Late initiation of parenteral nutrition was associated with faster recovery and fewer complications, as compared with early initiation. (Funded by the Methusalem program of the Flemish government and others; EPaNIC ClinicalTrials.gov number, NCT00512122.)

Early versus Late Parenteral Nutrition in Critically Ill Adults

Controversy exists about the timing of the initiation of parenteral nutrition in critically ill adults in whom caloric targets cannot be met by enteral nutrition alone. In this randomized, multicenter trial, we compared early initiation of parenteral nutrition (European guidelines) with late initiation (American and Canadian guidelines) in adults in the intensive care unit (ICU) to supplement insufficient enteral nutrition. In 2312 patients, parenteral nutrition was initiated within 48 hours after ICU admission (early-initiation group), whereas in 2328 patients, parenteral nutrition was not initiated before day 8 (late-initiation group). A protocol for the early initiation of enteral nutrition was applied to both groups, and insulin was infused to achieve normoglycemia. Patients in the late-initiation group had a relative increase of 6.3% in the likelihood of being discharged alive earlier from the ICU (hazard ratio, 1.06; 95% confidence interval [CI], 1.00 to 1.13; P=0.04) and from the hospital (hazard ratio, 1.06; 95% CI, 1.00 to 1.13; P=0.04), without evidence of decreased functional status at hospital discharge. Rates of death in the ICU and in the hospital and rates of survival at 90 days were similar in the two groups. Patients in the late-initiation group, as compared with the early-initiation group, had fewer ICU infections (22.8% vs. 26.2%, P=0.008) and a lower incidence of cholestasis (P<0.001). The late-initiation group had a relative reduction of 9.7% in the proportion of patients requiring more than 2 days of mechanical ventilation (P=0.006), a median reduction of 3 days in the duration of renal-replacement therapy (P=0.008), and a mean reduction in health care costs of €1,110 (about $1,600) (P=0.04). Late initiation of parenteral nutrition was associated with faster recovery and fewer complications, as compared with early initiation. (Funded by the Methusalem program of the Flemish government and others; EPaNIC ClinicalTrials.gov number, NCT00512122.).

Case report: Congenital short bowel syndrome

Congenital short bowel syndrome (SBS) is a relatively rare condition as compared to acquired SBS. It is associated with significant mortality and morbidity. Infants usually present with failure to thrive, recurrent vomiting, and diarrhea. It is important to suspect and diagnose this condition promptly, as early initiation of parenteral nutrition or surgery, if necessary, may result in a favorable outcome. We discuss a case of an infant aged 26 days, who presented with failure to thrive, recurrent vomiting, and weight loss. A contrast study of the gastrointestinal tract revealed a short small bowel, with malrotation. The infant was started on parenteral nutrition, but succumbed shortly thereafter to severe disseminated sepsis.