Early Parenteral Nutrition Research Articles

Parenteral nutrition in intensive care patients: medicoeconomic aspects.

Parenteral nutrition (PN) alone or as supplemental parenteral nutrition (SPN) has been shown to prevent negative cumulative energy balance, to improve protein delivery and, in some studies, to reduce infectious morbidity in ICU patients who fail to cover their needs with enteral nutrition (EN) alone. The optimization of energy provision to an individualized energy target using either early PN or SPN within 3-4 days after admission has recently been reported to be a cost-saving strategy mediated by a reduction of infectious complications in selected intensive care patients. EN alone is often insufficient, or occasionally contraindicated, in critically ill patients and results in growing energy and protein deficit. The cost benefit of using early PN in patients with short-term relative contraindications to EN has been reported. In selected patients SPN has been associated with a decreased risk of infection, a reduced duration of mechanical ventilation, a shorter stay in the ICU. Altogether four studies have investigated the costs associated with these interventions since 2012: two of them from Australia and Switzerland have shown that optimization of energy provision using SPN results in cost reduction, conflicting with other studies. The latter encouraging findings require further validation.

Intervenciones para prevenir la anemia ferropénica del niño prematuro. Controversias

The third trimester of gestation is the period of highest accretion of macro and micronutrients. Preterm newborns present a lower weight than full-term newborns. They should have a postnatal growth pace to allow them to reach a normal fetus composition of that conception age. To do so, an early nutritionshould be set up to contribute several more amounts of nutrients than normally needed for full-term newborns, preventing complications during hospital stay. Nutritional deficit is difficult to compensate despite of early enteral and parenteral nutrition with fortified human milk. Iron plays an essential role and its depletion generates iron deficiency anemia which is common among this population as well as neurodevelopmental disorders. There are preventive measures such as delayed cord clamping and blood extraction control during hospitalization. However, there are some controversial issues in relation to iron doses, treatment duration, administration ways, transfusion criteria, the association with enterocolitis. In order the risk of angiogenic effect in the increase incidence of retinopathy on preterm infants. In current practice, the pediatrician faces the dilemma of deciding among different strategies to administer iron amounts so as to avoid iron deficiency anemia and also the excess related problems, so as to get rid of economic and social costs on the short and long terms, enhancing the development and health on childhood, teenage and adulthood.

Parenteral nutrition for preterm infants: Issues and strategy

Due to transient gut immaturity, most very preterm infants receive parenteral nutrition (PN) in the first few weeks of life. Yet providing enough protein and energy to sustain optimal growth in such infants remains a challenge. Extrauterine growth restriction is frequently observed in very preterm infants at the time of discharge from hospital, and has been found to be associated with later impaired neurodevelopment. A few recent randomized trials suggest that intensified PN can improve early growth; whether or not such early PN improves long-term neurological outcome is still unclear. Several other questions regarding what is optimal PN for very preterm infants remain unanswered. Amino acid mixtures designed for infants contain large amounts of branched-chain amino acids and taurine, but there is no consensus on the need for some nonessential amino acids such as glutamine, arginine, and cysteine. Whether excess growth in the first few weeks of life, at a time when very preterm infants receive PN, has an imprinting effect, increasing the risk of metabolic or vascular disease at adulthood continues to be debated. Even though uncertainty remains regarding the long-term effect of early PN, it appears reasonable to propose intensified initial PN. The aim of the current position paper is to review the evidence supporting such a strategy with regards to the early phase of nutrition, which is mainly covered by parenteral nutrition. More randomized trials are, however, needed to further support this type of approach and to demonstrate that this strategy improves short- and long-term outcome.

Early parenteral nutrition in enterectomized dogs

ABSTRACT: The aim of this study was to explore the role of early central parenteral nutrition support with and without lipid emulsion in enterectomized dogs undergoing small bowel partial resection. Enterectomized dogs often cannot be fed properly via an oral or enteral route immediately post-surgery. After enterectomy, the animals received parenteral nutrition or crystalloid solution until they were able to voluntarily take in an oral diet. All dogs were recruited at the University of Sao Paulo veterinary teaching hospital. Eighteen dogs with intussusception, a foreign intestinal body, linear foreign intestinal body, or intussusception associated with a foreign intestinal body underwent enterectomy surgery and were randomly assigned to receive one of three treatments: crystalloid solution (CS group), parenteral nutrition with a mix of glucose and amino acids (GA group) or parenteral nutrition with a mix of glucose, amino acids and lipids (GAL group). A serum chemistry panel and complete blood count were collected prior to surgery and at the end of the study. Albumin increased in the GA and GAL group (p=0.042 and p=0.038 respectively) after hospitalization, but no significant differences were identified among the groups. Body weight decreased by 4.9% (p=0.042) in the CS group, but there were no significant changes in the GAL and GA groups. There was a significant decrease in the recovery scores in the GA and GAL groups during hospitalization (p=0.039 in both groups). Early parenteral nutrition was beneficial for patient recovery in post-surgical small bowel partial resection, indicating better quality, and no major complications or side effects were observed during the hospitalization period in the studied dogs.

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.

Hypophosphatemia in preterm infants: a bimodal disorder

New nutritional approaches to treat extreme premature babies have demonstrated relevant eviden ce of metabolic disturbances with early hypophosphatemia, especially in patients with intrauterine growth restriction (IUGR). They have shown late hypophosphatemia, as well, which is characteristic in the metabolic bone disease. A sytematic search of literature describing metabolic disturbances of phosphorus in preterm newborns is presented, related to the use of early parenteral nutrition and also in the context of metabolic bone disease. The articles were gathered from electronic data bases, such as PubMed and Rima. We include articles in english and spanish which were selected by titles and abstracts. Several strategies for early nutrition have been proposed in order to ensure an adequate amount of nutrients to accomplish the development and growth of preterm babies. Patients with parenteral nutrition support with different doses of phosphate, or inadequate calcium phosphate relation, or an increased amino acid content, may present hypophosphatemia, hypercalcemia, hy pomagnesemia, hypokalemia and hyperglycemia, all of these are additionally noteworthy in the pre sence of intrauterine growth restriction. Furthermore, said alterations are associated with prolonged mechanical ventilation, as well as bronchopulmonary dysplasia and increase in late onset sepsis. The late hypophosphatemia, described several years ago, arises as normocalcemia and as an increment of alkaline phosphatases in the metabolic bone disease in preterm babies, and also with an inadequate mineralization in different grades, secondary to an inadequate supply due to high nutritional requi rements in these patients. When early or late hypophosphatemia appears in preterm babies, it shall require timely control of phosphemia and will need to adjust the nutritional intake in order to correct it. In case of preterm babies with early parenteral nutrition it will also need a control of calcemia in the first week of birth, especially if those belonging to the IUGR group. Adjustment must be made along with metabolic follow up, as well. In late hypophosphatemia, a weekly or every two weeks fo llow up will be a must for all preterm babies in risk and they should be given supplements to get an optimum mineral supply.

Cost-effectiveness study of early versus late parenteral nutrition in critically ill children (PEPaNIC): preplanned secondary analysis of a multicentre randomised controlled trial

BackgroundThe multicentre randomised controlled PEPaNIC trial showed that withholding parenteral nutrition (PN) during the first week of critical illness in children was clinically superior to providing early PN. This study describes the cost-effectiveness of this new nutritional strategy.MethodsDirect medical costs were calculated with use of a micro-costing approach. We compared the costs of late versus early initiation of PN (n = 673 versus n = 670 patients) in the Belgian and Dutch study populations from a hospital perspective, using Student’s t test with bootstrapping. Main cost drivers were identified and the impact of new infections on the total costs was assessed.ResultsMean direct medical costs for patients receiving late PN (€26.680, IQR €10.090–28.830 per patient) were 21% lower (-€7.180, p = 0.007) than for patients receiving early PN (€33.860, IQR €11.080–34.720). Since late PN was more effective and less costly, this strategy was superior to early PN. The lower costs for PN only contributed 2.1% to the total cost reduction. The main cost driver was intensive care hospitalisation costs (-€4.120, p = 0.003). The patients who acquired a new infection (14%) were responsible for 41% of the total costs. Sensitivity analyses confirmed consistency across both healthcare systems.ConclusionsLate initiation of PN decreased the direct medical costs for hospitalisation in critically ill children, beyond the expected lower costs for withholding PN. Avoiding new infections by late initiation of PN yielded a large cost reduction. Hence, late initiation of PN was superior to early initiation of PN largely via its effect on new infections.Trial registrationClinicalTrials.gov, NCT01536275. Registered on 16 February 2012.

Feasibility of initiating enteral nutrition support with first 24 hours of congenital heart repairs in neonates and Infants and its impact on outcomes following surgery : A Pilot study

Background : Optimum nutrition status is crucial for proper function of cells and organs, and for wound healing. The neonates undergoing cardiac surgery requiring cardiopulmonary bypass (CPB) experiences a more profound metabolic response to stress as compared to older children and adults undergoing surgery. However neonates have less metabolic reserves as compared to older children and adults leaving them extremely vulnerable to the negative metabolic impact induced by stress. This can potentially lead to suboptimal wound healing and growth failure. Some institutes start early parenteral nutrition in all infants post cardiac surgery. However, the impact and feasibility of enteral nutrition immediately following congenital heart repairs is not well documented. Methods : All patients with the cyanotic congenital heart disease with increase pulmonary blood flow, weighing less than 5 kg and undergoing congenital heart repair during the study period were included in the study. Patients with single ventricle status, those undergoing palliative procedures (PA band),open chest, requiring ECMO before leaving operating room, having any other contraindication for starting enteral feeding or those who refuse for consent were excluded from study. INTERVENTIONS-The patients were randomized into two groups. Group 1 received trophic feeds ( 10-20 ml/kg/day) starting 4-6 hours after surgery while feeds children in group 2 were kept NPO and received feeds after 48 hours after surgery. Results : 15 children enrolled in both the groups. Both pre-operative and intraoperative variables were comparable in both the groups. There was no complication (vomiting, diarrhea, NEC, bowel necrosis) noted in the children who received feeds after surgery. Mean duration of mechanical ventilation in the feeds group was 58.2±4.71 hours, which was less then significantly less than those in the NPO group (P value 0.05). Similarly, duration of ICU stay was only 179.04 ±41.28 hours in feeds group as compared to 228.72 ± 85.44 hours in the NPO group. Conclusion : Neonates and Infants tolerate feeds immediately following congenital heart repairs. Moreover, feeds appear to decrease duration of mechanical ventilation and duration of ICU stay

Similar Mortality Is Seen with Early Enteral vs. Parenteral Nutrition in Critically Ill Patients

How and when to feed critically ill patients remains a subject of hot debate. The data supporting U.S. and European guideline recommendations for early

Two-Year Follow-up of a Randomized Controlled Nutrition Intervention Trial in Very Low-Birth-Weight Infants.

Very low-birth-weight (VLBW) infants are at risk for neurodevelopment impairment. This study assessed the effect of early aggressive parenteral nutrition (PN) on long-term outcome in VLBW infants. Directly after birth, VLBW infants (birth weight <1500 g, n = 142) were randomized to 5 different PN regimes. Controls (n = 46) received glucose and standard-dose amino acids (AAs; 2.4 g/[kg·d]) from birth onward and pure soybean oil fat emulsion (SOY) on the second day of life. Two intervention groups received glucose, standard-dose AAs, and lipids from birth onward: SOY (n = 24) or mixed fat emulsion (MIX, n = 25). The 2 other intervention groups received glucose, high-dose AAs (3.6 g/[kg·d]), and lipids from birth onward: SOY (n = 24) or MIX (n = 23). The primary outcome of this follow-up study was the composite outcome of "death or major disability" at 2 years corrected age. Secondary outcomes were death, major disabilities, neurodevelopmental scores, and anthropometry. Follow-up rate was 92% (n = 134). Thirty-five (26%) infants had died or had a major disability, with no differences between intervention groups and controls. Increased odds for death were observed in the standard-dose AA-MIX group (odds ratio, 5.4; 95% confidence interval [CI], 1.1-27.0). Neurodevelopmental scores and incidence of major disabilities did not differ between groups. Growth in the high-dose AA-MIX group was enhanced compared with growth in controls at 2 years corrected age (+0.51 [0.01-1.02] weight SDS). This randomized controlled hypothesis-generating study demonstrated no beneficial effect of early high-dose AA administration and mixed fat emulsions on survival and neurodevelopmental outcome in VLBW infants, although growth was enhanced.

Early optimal parenteral nutrition and metabolic acidosis in very preterm infants.

BackgroundIt is currently recognized that an optimized nutritional approach, consisting of an early and substantial supply of protein and energy by parenteral route, may be beneficial for very low birth weight infants and recent guidelines endorse this strategy. However, the impact of the enhanced parenteral nutrition (PN) on acid-basic balance has never been investigated. The aim of the present study is to assess the effect of nutrient intake on acid-base homeostasis in a large population of preterm infants on PN.MethodsThis observational study described the acid-base profile of very preterm infants (≤29 week’s gestation) receiving PN during the first week of life. For this purpose three different cohorts of infants who received increasing (group 1 to group 3) nutritional intakes were considered. Nutrition data were recorded daily and correlated to acid-base data (pH, base excess, and lactate). The outcome measure to assess metabolic acidosis was the base excess (BE).Results161 infants were included. 1127 daily nutritional records and 795 blood gas data were analyzed. The three groups were different with regard to nutritional intravenous intakes. Group 3 in particular had a higher mean intake of both amino acids (3.3 ± 0.8 g/kg/d) and lipids (2.8 ± 1.4 g/kg/d) during the first week of life. Metabolic acidosis was more severe in the group with the highest parenteral intake of amino acids and lipids: mean BE = -8.7 ± 3.4 (group 3); -6.4 ± 3.4 (group 2); -5.1 ± 3.0 (group 1)]. At the multivariate analysis the significant risk factors for metabolic acidosis were: gestational age, initial base excess, amino acid and lipid intravenous intakes.DiscussionAcid-base homeostasis was influenced by the nutritional intake. Earlier and higher intravenous amino acid and lipid intakes particularly increased the risk of metabolic acidosis. The nutritional tolerance was different depending on gestational age, and the smaller infants (24–26 week’s gestation) displayed greater acidotic disequilibrium and a higher need of bicarbonate.

Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2)

Whether the route of early feeding affects outcomes of patients with severe critical illnesses is controversial. We hypothesised that outcomes were better with early first-line enteral nutrition than with early first-line parenteral nutrition. In this randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2 trial) done at 44 French intensive-care units (ICUs), adults (18 years or older) receiving invasive mechanical ventilation and vasopressor support for shock were randomly assigned (1:1) to either parenteral nutrition or enteral nutrition, both targeting normocaloric goals (20-25 kcal/kg per day), within 24 h after intubation. Randomisation was stratified by centre using permutation blocks of variable sizes. Given that route of nutrition cannot be masked, blinding of the physicians and nurses was not feasible. Patients receiving parenteral nutrition could be switched to enteral nutrition after at least 72 h in the event of shock resolution (no vasopressor support for 24 consecutive hours and arterial lactate <2 mmol/L). The primary endpoint was mortality on day 28 after randomisation in the intention-to-treat-population. This study is registered with ClinicalTrials.gov, number NCT01802099. After the second interim analysis, the independent Data Safety and Monitoring Board deemed that completing patient enrolment was unlikely to significantly change the results of the trial and recommended stopping patient recruitment. Between March 22, 2013, and June 30, 2015, 2410 patients were enrolled and randomly assigned; 1202 to the enteral group and 1208 to the parenteral group. By day 28, 443 (37%) of 1202 patients in the enteral group and 422 (35%) of 1208 patients in the parenteral group had died (absolute difference estimate 2·0%; [95% CI -1·9 to 5·8]; p=0·33). Cumulative incidence of patients with ICU-acquired infections did not differ between the enteral group (173 [14%]) and the parenteral group (194 [16%]; hazard ratio [HR] 0·89 [95% CI 0·72-1·09]; p=0·25). Compared with the parenteral group, the enteral group had higher cumulative incidences of patients with vomiting (406 [34%] vs 246 [20%]; HR 1·89 [1·62-2·20]; p<0·0001), diarrhoea (432 [36%] vs 393 [33%]; 1·20 [1·05-1·37]; p=0·009), bowel ischaemia (19 [2%] vs five [<1%]; 3·84 [1·43-10·3]; p=0·007), and acute colonic pseudo-obstruction (11 [1%] vs three [<1%]; 3·7 [1·03-13·2; p=0·04). In critically ill adults with shock, early isocaloric enteral nutrition did not reduce mortality or the risk of secondary infections but was associated with a greater risk of digestive complications compared with early isocaloric parenteral nutrition. La Roche-sur-Yon Departmental Hospital and French Ministry of Health.

Nutrition in the ICU: sometimes route does matter

The NUTRIREA-2 trial by Jean Reignier and colleagues 1 Reignier J Boisramé-Helms J Brisard L et al. for the NUTRIREA-2 Trial Investigators and the Clinical Research in Intensive Care and Sepsis (CRICS) groupEnteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2). Lancet. 2017; (published online Nov 8.)http://dx.doi.org/10.1016/S0140-6736(17)32146-3 Summary Full Text Full Text PDF PubMed Scopus (261) Google Scholar in The Lancet provides an important piece in the puzzle of intensive-care unit (ICU) nutrition management. This pragmatic multicentre study done at 44 French ICUs randomly assigned patients aged 18 years or older requiring invasive mechanical ventilation and vasopressors (median 0·5 μg/kg per min) to receive either enteral nutrition (n=1202) or parenteral nutrition (n=1208), both targeting normocaloric goals (20–25 kcal/kg per day), within 24 h after intubation or ICU admission. The primary endpoint of early survival (mortality on day 28 after randomisation) was comparable in both study groups. By day 28, 443 (37%) patients in the enteral group and 422 (35%) patients in the parenteral group had died (absolute difference estimate 2·0% [95% CI −1·9 to 5·8]; p=0·33). Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2)In critically ill adults with shock, early isocaloric enteral nutrition did not reduce mortality or the risk of secondary infections but was associated with a greater risk of digestive complications compared with early isocaloric parenteral nutrition. Full-Text PDF

Evaluation of nutrition support practices: Results from a nationwide survey

Multiple clinical guidelines are available to improve and standardize the delivery of nutrition support. However, recommendations are not being universally applied at the bedside due to challenges of resources and barriers of knowledge. Assessing the current level of nutrition support practice is the first step to understand the barriers and ultimately implement potential strategies to increase guideline adherence and promote quality nutrition support in hospitals. There are no published data concerning the practice of nutrition support in Lebanese hospitals. The objective of our study is to investigate for the first time the current clinical practice pertinent to nutrition support across Lebanon. A survey was developed by The Nutrition Board of the Lebanese Society of Critical Care Medicine (LSCCM) to determine nutrition support practices in hospitals with an Intensive Care Unit (ICU) across Lebanon. The 28-question survey assesses the delivery of feeding methods such as oral nutrition supplements (ONS), enteral nutrition (EN), and parenteral nutrition (PN). Fourty-one hospitals from 116 total completed the survey. The majority of the hospitals (92.6%) do not systematically use a screening system for malnutrition. Seventy six percent of hospitals reported less than 5% of their patients are kept for more than 7 days with no nutrition support. Early EN is used in preference over PN in ICUs, as 72% of hospitals start early EN (within 48h) in more than 10% of cases while only 30% of hospitals start early PN (within the first week) in more than 10% of cases. Fifty-one percent of the hospitals use ready prepared formula while the rest (49%) use kitchen prepared formula. Our study is the first of its kind in Lebanon aiming at describing the current clinical practice in nutrition support at a national level. Working toward the use of a nutritional screening tool on admission and the exclusive use of ready made formula for enteral feeding will have the most significant and immediate impact on improving quality of nutritional care for hospitalized patients. This can be achieved mainly through the education of the concerned staff.

SUN-P024: Early Parenteral Nutrition in Critically Ill Adult Patients: an Observational Study

SUN-P024: Early Parenteral Nutrition in Critically Ill Adult Patients: an Observational Study

OR49: Cost Study of the Multicenter Randomized Controlled Trial ‘Early Versus Late Parenteral Nutrition in Critically Ill Children’

OR49: Cost Study of the Multicenter Randomized Controlled Trial ‘Early Versus Late Parenteral Nutrition in Critically Ill Children’

OR38: Does Early Total Parenteral Nutrition Improve Post-Operative Outcome for Intestinal Obstruction? – A Randomized Controlled Trial

OR38: Does Early Total Parenteral Nutrition Improve Post-Operative Outcome for Intestinal Obstruction? – A Randomized Controlled Trial

MON-P024: The Effect of Early or Late Parenteral Nutrition Support on the Clinical Outcome in the Patients with Acute Surgical Abdomen

MON-P024: The Effect of Early or Late Parenteral Nutrition Support on the Clinical Outcome in the Patients with Acute Surgical Abdomen

A short-time economic evaluation of various modalities of glutamine dipeptide-enriched parenteral nutrition support in patients undergoing elective surgery for gastrointestinal tumors using decision-tree model

Objective To assess the short-time economics of various glutamine dipeptide-enriched parenteral nutrition (PN) for patients undergoing elective surgery for gastrointestinal tumors, with an attempt to provide evidence for decision makers on clinical nutrition support. Methods A prospective cohort study was designed. From payer/disburser's perspective, a cost-effectiveness decision-tree model was developed to assess the clinical outcomes and short-time economic effects of glutamine dipeptide-enriched PN that used in different time points (early postoperative or perioperative). Cost-effectiveness analysis, cost-utility analysis, and incremental cost-effectiveness analysis were adopted in the decision-tree model. One-way sensitivity analysis was performed to determine the robustness of the results. Results Totally 107 patients were included. There was no significant difference between the perioperative alanine(Ala) glutamine(Gln) nutrition support (group A) and early postoperative Ala-Gln nutrition support (group B) in the ratio of 5% weight declines on the 8th day after surgery and infection-related postoperative complications (72.1% vs. 78.1%, χ2=0.509, P=0.498 and 2.32% vs. 4.69%, χ2=0.060, P=0.806). The levels of prealbumin (PA) and albumin(Alb) and the level of total lymphocyte count(TLC) also the time of recovering gastrointestinal function, length of stay nutritional discharge index(LOSNDI), and direct costs were significantly different [PA: (208.19±56.92)mg/L vs. (187.97±62.05)mg/L, t=2.283, P=0.039; Alb: (33.82±3.91)×109vs. (31.96±4.57)×109,t=2.184, P=0.036; TLC: (1.19±0.55)×109vs. (0.89±0.66)×109,t=2.461, P=0.015; the time of recovering gastrointestinal function(3.06±0.28)d vs. (3.39 ± 0.34)d, t=-3.675, P=0.000; LOSNDI: (16.84±2.92)d vs. (18.52 ±3.47)d, t=-2.613, P=0.011; direct costs: ￥(17 029.05±317.28) vs. ￥(15 610.64±292.56), t=23.764, P=0.000]. When LOSNDI and quality-adjusted life years (QALYs) were estimated as indicators of effectiveness, the incremental cost-effectiveness ratios and incremental cost-utility ratios of group A were ￥844.3 and ￥70 920.5, respectively. Net monetary benefit of group B was more than that of group A. One-way sensitivity analysis showed that parameters had no significant effect on the model. Conclusion When using local per capita gross domestic product as threshold, early postoperative Ala-Gln PN was more economical than perioperative Ala-Gln PN strategy evaluation. Key words: Parenteral nutrition; Decision trees; Glutamine dipeptide; Gastro-intestinal tumors; Health economic evaluation

Impact of early aggressive nutrition on retinal development in premature infants.

The normal retinal development is interrupted by preterm birth and a retinopathy of prematurity (ROP) may develop as its consequence. ROP is characterized by aberrant vessel formation in the retina as a response to multiple risk factors influencing the process of retinal angiogenesis. Insulin-like growth factor I (IGF-1) and vascular endothelial growth factor (VEGF) play an important role in the process of normal retinal vascularization. Insufficient nutrition during the first 4 postnatal weeks results in low serum levels of IGF-1, which is essential for correct retinal vessels formation, ensuring survival of the newly formed endothelial cells. Low IGF-1 level results in stop of angiogenesis in the retina, leaving it avascular and prompting the onset of ROP. Keeping the newborns in a positive energetic balance by providing enough nutrients and energy has a beneficial impact on their growth, neurodevelopment and decreased incidence of ROP. The best way to achieve this is the early parenteral nutrition with the high content of nutrients combined with early enteral feeding by the own mother´s breast milk. Multiple studies confirmed the safety and efficacy of early aggressive nutrition but information about its long-term effects on the metabolism, growth and development is still needed.