Early Total Parenteral Nutrition Research Articles

Feeding Parenteral Nutrition in the Neonatal Period Programs Dyslipidemia in Adulthood in Yucatan Miniature Pigs

BackgroundEarly nutritional challenges can lead to permanent metabolic changes, increasing risk of developing chronic diseases later in life. Total parenteral nutrition (TPN) is a life-saving nutrition regimen, used especially in intrauterine growth-restricted (IUGR) neonates. Early TPN feeding alters metabolism, but whether these alterations are permanent is unclear. Programmed metabolism is likely caused by epigenetic changes due to imbalances of methyl nutrients. ObjectivesWe sought to determine whether feeding TPN in early life would increase risk of developing dyslipidemia in adulthood and whether supplementing the methyl nutrients betaine and creatine to TPN would prevent this development. We also sought to determine whether IUGR exacerbates the effects of neonatal TPN on lipid metabolism in adulthood. MethodsFemale piglets (n = 32; 7 d old) were used in 4 treatments: 24 normal-weight piglets were randomly assigned to sow-fed (SowFed), standard TPN (TPN-control), and TPN with betaine and creatine (TPN-B+C); 8 IUGR piglets were fed control TPN (TPN-IUGR) as a fourth group. After 2 wk of treatment, all pigs were then fed a standard solid diet. At 8 mo old, central venous catheters were implanted to conduct postprandial fat tolerance tests. ResultsFeeding TPN in the neonatal period led to dyslipidemia in adulthood, as indicated by higher postprandial triglyceride (TG) levels in TPN-control (P < 0.05), compared with SowFed. IUGR piglets were particularly sensitive to neonatal TPN feeding, as TPN-IUGR piglets developed obesity and dyslipidemia in adulthood, as indicated by greater backfat thickness (P < 0.05), higher liver TG (P < 0.05), slower postprandial TG clearance (P < 0.05), and elevated fasting plasma nonhigh-density lipoprotein-cholesterol (P < 0.01), and nonesterified fatty acids (P < 0.001), compared with TPN-control. ConclusionsFeeding TPN in early life increases the risk of developing dyslipidemia in adulthood, especially in IUGR neonates; however, methyl nutrient supplementation to TPN did not prevent TPN-induced changes in lipid metabolism.

Emergency evacuation low-pressure suction for the management of extravasation injuries – a case report

Extravasation is the movement of fluid outside its conduit into the extracellular tissue, possibly leading to alocal inflammatory reaction, compartment syndrome, tissue necrosis, and full thickness skin loss at the affected area. To prevent these complications, early recognition, referral and treatment of an extravasation injury is of utter importance. We present acase, illustrating an extravasation injury into the breast managed by arenovated surgical technique - emergency evacuation low-pressure suction (EELS). A54-year-old woman attended the emergency department with 1.5 L of total parenteral nutrition leaked into her right breast via acentral portal catheter. The patient was seen within 24 hours of the incident, and presented with adiffuse swollen, tender and erythematous right breast but no overlying skin necrosis. Dry EELS via two small stab incisions was performed to evacuate the extravasated total parenteral nutrition and to minimise the aspiration of healthy fat tissue of the breast. Only afew cases of extravasation injuries into the breast have been described and most cases involve chemotherapy extravasation from acentral catheter. Presumably there is an underreporting of this complication in the literature. This case-report promotes the use of aspiration in the management of diffusely spread extravasated injuries. EELS is amore appropriate term than liposuction, as there is no intention to evacuate healthy fat tissue. This new term is less confusing and might help medical staff and patients to better understand the treatment as it will break the affiliation with an aesthetic procedure. It is an effective and cosmetically satisfactory technique to treat early total parenteral nutrition extravasation injury at the level of the breast.

Early Enteral Nutrition Preserves Intestinal Barrier Function through Reducing the Formation of Neutrophil Extracellular Traps (NETs) in Critically Ill Surgical Patients.

Background The gut was suggested as the driver of critical illness and organ injury. Recently, excessive formation of neutrophil extracellular traps (NETs) was associated with mucosal inflammation. Direct investigation of intestinal mucosa is essential to illuminate the potential mechanism of gut barrier in critically ill patients. We hypothesized that early enteral nutrition (EN) could decrease intestinal NETs and maintain the gut barrier. Methods Intestinal biopsies were obtained using biopsy forceps from critically ill surgical patients complicated with enterocutaneous fistula. Expressions of tight junction (TJ) proteins, mucosal inflammation, and apoptosis were evaluated. Moreover, NET-associated proteins were evaluated in intestinal specimens of patients by Western blot and immunofluorescence analysis. Results The intestinal barrier was significantly impaired in critically ill patients receiving early total parenteral nutrition (TPN), evidenced by intestinal villi atrophy, inflammatory infiltration, increased enterocyte apoptosis, and abnormal TJ expressions. Early EN significantly alleviated these intestinal injuries. In addition, we observed increased formation of the NET structure and elevated expressions of NET-associated proteins in intestines of critically ill surgical patients. Early EN was associated with the diminished presence of NETs and reduced expression of NET-associated proteins. Mechanically, analysis of the TLR4 pathway showed a significant increase in TLR4, NFκB, and MAPK signaling in patients receiving TPN when compared to those receiving early EN. Conclusion The intestinal barrier is disrupted in the human gut during critical illness. Our data suggests that an increased NET structure was showed in the gut of critically ill surgical patients, and early EN treatment was associated with the reduction of NET formation and the preservation of mucosal immunity.

Nutrition in the critically ill surgical patient.

The aim of this study was to discuss recent findings related to providing adequate and well tolerated nutrition to the critically ill surgical patient. The majority of nutritional studies in the critically ill have been performed on well nourished patients, but validated scoring systems can now identify high nutrition risk patients. Although it remains well accepted that early enteral nutrition with protein supplementation is key, mechanistic data suggest that hypocaloric feeding in septic patients may be beneficial. For critically ill patients unable to tolerate enteral nutrition, randomized pilot data demonstrate improved functional outcomes with early supplemental parenteral nutrition. Current guidelines also recommend early total parenteral nutrition in high nutrition risk patients with contraindications to enteral nutrition. When critically ill patients require low or moderate-dose vasopressors, enteral feeding appears well tolerated based on a large database study, while randomized prospective data showed worse outcomes in patients receiving high-dose vasopressors. Current evidence suggests early enteral nutrition with protein supplementation in critically ill surgical patients with consideration of early parenteral nutrition in high nutrition risk patients unable to achieve nutrition goals enterally. Despite established guidelines for nutritional therapy, the paucity of data to support these recommendations illustrates the critical need for additional studies.

Could early total parenteral nutrition in small bowel obstruction be cost effective?

Could early total parenteral nutrition in small bowel obstruction be cost effective?

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

Management of parenteral nutrition in intensive care units in Spain

some relevant aspects related to parenteral nutrition in the Spanish ICUs are still unclear. These aspects include: caloric and protein intake, total volume, glycemic control, the type of lipid emulsion used or the comparison of different formulations. Our objective is to know the clinical practice patterns of artificial nutrition therapeutics, particularly of parenteral nutrition in the Spanish ICUs. twelve representative ICU's participated in a nutrition survey from January to March 2012. The survey was divided in two sections: A) Management of artificial nutritional support in critically ill patients and B) Assessment of a new parenteral nutrition formulation adapted to critically ill patients. The following information was collected: percentage of patients receiving artificial nutrition; availability of enteral formulations; types of lipid emulsions; calories, amino acids and lipids supplied; addition of glutamine, vitamins and trace elements; management of volume and hyperglycemia; and comparative data between patients receiving the new formulation vs. standard formulations: glycemic control, assessment of hepatic function and infectious complications as well as the intake of total calories, proteins, volume and insulin supplied. The average number of hospital beds and ICU beds is 780 and 25 respectively; the average number of patients admitted in the ICU is 950 per year. 49% were medical patients, 31% surgical patients and 20% trauma patients. 59.75% of patients required artificial nutrition (AN), of which, 58.7% required enteral nutrition (EN), 16% total parenteral nutrition (TPN); and 25.3% suplementary parenteral nutrition (SPN). When EN was contraindicated, 83.3% of patients were started on early TPN (24 hours) and if EN was not sufficient, 66.7% were started on SPN within 48 hours. Regarding prescribers usual practice, 50% tried to reduce volume of PN and 100% of them had an insulin infusion protocol. 39% of prescribers recommended high-protein, low-volume and low-glucose TPN; 42% prescribe TPN with SMOF (soybean, MCT, olive and fish oil); and 33% with OOBE (olive oil based emulsion) as lipid emulsion. 92% added glutamine. 60% considered that the new formulation may be indicated for sepsis, trauma, burn patients and MOF (multiple organ failure) and the 30% would use it as a routine therapy at the time of admission. 40% considered that insulin requirements were reduced; 50% claimed better volume management and 60% highlighted the protein/volume ratio. Attending to patient outcome, patients receiving the specific formulation have less affected hepatic function, higher protein intake and lower volume infusion but no significant differences were observed and they required less insulin dosage (p = 0.07). In the twelve ICUs included in the survey, the clinical practice patterns related to parenteral nutrition management are adapted to the guidelines of scientific societies such as the Spanish Society of Intensive Care Medicine and Coronary Units (SEMICYUC), the Spanish Society of Parenteral and Enteral Nutrition (SENPE) and the European Society for Clinical Nutrition and Metabolism (ESPEN). The new formulations designed for critically ill patients may be indicated for these conditions.

Early Total Parenteral Nutrition in Very Low Birthweight Infants: Is It Safe? Is It Worth It?

Early Total Parenteral Nutrition in Very Low Birthweight Infants: Is It Safe? Is It Worth It?

1400 Body Fat in VLBW is Influenced by Duration of Total Parenteral Nutrition (TPN)

BackgroundAdequate postnatal nutrition and growth are essential for optimal neurodevelopment in VLBW infants. In an effort to optimize nutrition, early TPN implementation is recommended while enteral nutrition is achieved. However,...

IMPROVED GROWTH AND DECREASED MORBIDITY IN EXTREMELY LOW BIRTH WEIGHT INFANTS WITH EARLY CONTINUOUS POSITIVE AIRWAY PRESSURE AND AGGRESSIVE NUTRITION.

Purpose To investigate the clinical impact of three benchmark clinical changes in our neonatal intensive care unit introduced in the fall of 2003. Clinical changes included (1) continuous positive airway pressure (CPAP) after a dose of surfactant at delivery, (2) lower targeted oxygen saturations, and (3) early total parenteral nutrition. Methods We performed a retrospective cohort study of all premature infants with birth weight less than 1,000 g, appropriate for gestational age, without congenital anomalies, and born in the specified time period. Group I, n = 87, between January 1, 2001, and June 30, 2002, and between July 1, 2004, and December 31, 2005, group II, n = 78. Results Infants in group II averaged 17 fewer days on mechanical ventilation, 15% decrease in BPD, 70% decrease in severe BPD, 70% decrease in home oxygen, 50% decrease in pressor use in the first 24 hours of life, 67% decrease in steroid use, 15 fewer central line days, increased rate of weight gain, 10 day decrease in length of stay, and 47% decrease in inguinal hernia repairs. No changes were seen in the incidences of intraventricular hemorrhage, periventricular leukomalacia, pulmonary hemorrhage, pneumothorax, spontaneous intestinal perforations, or necrotizing enterocolitis, although this study was not adequately powered to test these morbidities. Combining cohorts, of all infants who developed BPD, 74% were exposed to mechanical ventilation in their first 48 hours of life. Conclusions Physiologically appropriate changes in the nutritional and respiratory management of the extremely low birth weight neonate are associated with improvement in multiple morbidity and growth outcomes. Decreased exposure to barotrauma, decreased oxygen toxicity, and more aggressive parenteral nutrition are associated with a reduction in morbidities associated with poor neurodevelopmental outcomes for high-risk neonates. In addition, successful management on CPAP for the first 48 hours after dosing with surfactant of life appears to be protective against the development of BPD.

Optimal Nutrition Should Improve the Outcome and Costs of Radical Cystectomy

Introduction: Nutritional support has been demonstrated to improve recovery from radical cystectomy, but is expensive and when used inappropriately may actually increase the costs and morbidity of surgery. We sought to establish national patterns of practice with regard to feeding following cystectomy in the UK. Aims and Methods: Following consultation with the specialist nutrition team, a questionnaire was designed to investigate the feeding strategy after cystectomy and dispatched by post to all UK urologists. Results: The majority (60%) of respondents employed a traditional strategy of resting the bowel and feeding orally after bowel recovery. A minority used either early total parenteral nutrition (TPN; 18.5%) or enteral nutrition (6.5%), but a larger proportion (29%) felt enteral nutrition was the ‘optimal’ feeding regime. Only 30% used guidelines and 52% felt trials would help to establish a nutrition strategy following cystectomy. Conclusion: There is little evidence that TPN improves the outcome of cystectomy and it may actually increase morbidity and costs, whereas enteral nutrition may improve recovery. Despite this evidence TPN is widely used by urologists whereas enteral nutrition is used infrequently. Implementation of an evidence-based feeding regime after cystectomy is likely to reduce the morbidity and financial costs of cystectomy.

The mode of delivery of parenteral multivitamins influences nutrient handling in an animal model of total parenteral nutrition

Very low birthweight preterm infants receive early total parenteral nutrition (TPN) to optimize protein balance. Adding multivitamins (MVP) to the lipid emulsion (MVP+LIP) rather than to the amino acid+dextrose moiety of TPN (AA+MVP) limits the effects of light exposure on lipid peroxidation and vitamin loss. Compare the effects of the mode of delivery of MVP on nutrient handling and indices of oxidant stress. Three-day old guinea pig pups were assigned to TPN containing MVP+amino acids+dextrose+heparin and electrolytes, with lipids provided separately (AA+MVP). Solutions were light exposed (LE, n = 8) or light protected (LP, n = 9). In a further group (n = 7), MVP was co-administered with the lipid moiety and light exposed (LIP+MVP). Variables measured in urine (creatinine, nitrogen, vitamin C) and in liver (protein, glutathione, isoprostane, vitamins A, E, C) were compared by ANOVA. Urinary nitrogen and vitamin C were higher (P<0.05) during LE, while hepatic levels of vitamin C were higher (P<0.05) with LIP+MVP. These results were not related to total peroxide levels in TPN or to markers of oxidant stress. CONCLUSION. Co-administration of MVP with lipid or light protected amino acids offers comparable beneficial effects on nitrogen and vitamin C metabolism.

Nutrition Practice Guidelines and Neonatal Outcomes in Elbw Infants.

Early nutritional intervention, both parenteral and enteral, is becoming a standard of care for the extremely low birth weight infant (ELBW) in many neonatal intensive care units (NICU) across the country. However, there are no published or widely accepted guidelines regarding nutrition support strategies for this population. Most NICU's have developed their own guidelines and nutritional practices vary widely. In an effort to standardize our practice, we implemented nutrition support guidelines for ELBW infants, initiating both total parenteral nutrition (TPN) and minimal enteral feedings (MEFs) within the first 24 hours of life whenever possible. Objectives: 1) Evaluate the adherence to the nutritional guidelines and 2) Compare pre- and post-guideline outcomes. Materials and Methods: The study was conducted at a Level III NICU from January 2002 until February 2003. Charts of 70 infants born ≤1250gms were reviewed as part of a quality assurance project to monitor adherence to the newly established guidelines. Another 23 charts of ELBW infants who were admitted and cared for in the NICU prior to the initiation of the nutritional guidelines were reviewed as a control group. Student t-tests were used to compare selected clinical outcomes between infants started on early nutrition support (≤24 hours of life) versus those who were started later. Results: 61.4% and 52.9% of eligible infants were started on TPN and MEF's, respectively within 24 hours of life. The average time to start TPN was 21.9 hours after the adoption of the guidelines as opposed to 64.4 hours prior to guideline implementation (p<0.01). In the post-guideline group, MEF's were initiated at mean 27.3 hours of age versus 80.3 hours in the pre-guideline group (p<0.01). Those who were started on early TPN and MEF's reached full enteral feedings significantly sooner (mean:12.8 and 13.3 days vs. 45.8 and 45.8 days, respectively; p<0.01). Early nutrition support also resulted in earlier regain of birth weight (mean day 12.7 vs. 16.0 for early vs. late TPN; p<0.01 and mean day 13.8 vs. 16.0; p<0.04 for early vs. late MEF's). While not statistically significant, infants who received earlier nutrition support showed trends toward greater overall weight gains in weeks 2–3 and 3–4 of life and a lower incidence of elevated serum blood glucose for infants who received earlier nutrition support. Conclusions: The implementation of early Nutrition support guidelines influenced the timeliness of initiating nutrition support in our unit. Early initiation of TPN and MEF's in ELBW infants produces a more rapid regain of initial weight loss, improves weight gain and, enhances earlier achievement of full enteral feedings.

Nutrition in patients with acute pancreatitis.

Acute pancreatitis is a disease with varying severity. Patients with the mild form do not require nutritional support because oral intake is resumed rapidly. Studies on nutritional support in acute pancreatitis have included patients with both mild and severe disease. In this heterogeneous group, total parenteral nutrition did not improve outcome compared with no nutrition at all. This is caused in part by an increase in septic complications during total parenteral nutrition. Likewise, no benefit from enteral nutrition was observed compared with no nutrition, probably because the group was heterogeneous or because nutritional goals were not achieved. Patients with severe acute pancreatitis become profoundly catabolic. This group undoubtedly requires nutritional support to treat undernutrition. The limited available data indicate that enteral nutrition, if well tolerated, is superior to parenteral nutrition for patients with severe acute pancreatitis. Based on current knowledge, a combination of early total parenteral nutrition and enteral nutrition is advisable as soon as enteral nutrition is tolerated. Monitoring of gut function is crucial in this situation.

The influence of early total parenteral nutrition on experimental pancreatitis in rats.

The main purpose of this study was to investigate the influence of early total parenteral nutrition on acute sodium-taurocholate-induced pancreatitis in rats. Total parenteral nutrition did not change the survival rate, serum amylase, calcium or liver transaminase level on the degree of pancreatic damage, but reduced serum acid phosphatase and lactate dehydrogenase levels. Hyperglycemia occurred during the use of total parenteral nutrition. Total parenteral nutrition is not harmful in the course of acute experimental pancreatitis, and could be used with few side effects.

Immediate enteral nutrition following multisystem trauma: a decade perspective.

Metabolic support is an integral component of surgical critical care. Although prompt restoration of oxygen availability is clearly essential, the timing, composition, and route of nutritional support may also be decisive factors. The ensuing discussion will focus on: (a) timing of substrate delivery and (b) route of administration based on our clinical investigation over the past decade. The acutely injured patient was selected as a model of ICU hypermetabolism because of relative homogeneity with respect to age, comorbid factors, and stress level. Our first study hypothesis was that early nutritional support would improve outcome in the severely injured, but previously well-nourished patient. During an 18-month period, all patients undergoing laparotomy with a abdominal trauma index (ATI) greater than 15 were randomized to a control or total enteral nutrition (TEN) group. The control patients were given total parenteral nutrition (TPN) after POD 5, whereas the TEN cohort had a needle catheter jejunostomy (NCJ) inserted at laparotomy and received an elemental diet within 12 hours. The control (n = 31) and TEN (n = 32) groups were otherwise comparable with respect to risk stratification. The TEN patients, of course, shared improved nitrogen balance (p less than 0.001), but also had significantly (p less than 0.025) less septic morbidity. Nine (29%) of the controls developed major infections, contrasted to three (9%) of the TEN patients. Acknowledging the benefit of early nutrition, the next issue we addressed was the optimal route of substrate delivery; i.e., TEN vs TPN. The hypothesis was that TEN, compared to TPN, would reduce the injury stress response as reflected by the prioritization of hepatic protein synthesis. TEN given via NCJ and a nutritionally matched TPN solution were administered during the same postoperative period. Indeed, the TEN patients (n = 23) had significantly (p less than 0.05) higher constitutive proteins and lower acute-phase proteins, whereas the TPN patients manifested the opposite protein profile as measured by crossed immunoelectrophoresis. In view of these findings, we continued the study to ascertain clinical impact. Ultimately, 75 patients were randomized, providing groups with equivalent risk factors. Eleven (37%) of the TPN patients developed septic complications compared to five (17%) of the TEN group, and the incidence of major infection was six (20%) following TPN vs one (3%) with TEN. Thus, immediate TEN provided an additional clinical benefit compared to early TPN in these high-risk surgical patients.

Early total parenteral nutrition in acute pancreatitis: Lack of beneficial effects

To determine the effect of early aggressive parenteral support in pancreatitis, 54 patients with acute pancreatitis were randomized to receive either conventional therapy (control group) or conventional therapy plus the institution of total parenteral nutrition within 24 hours. The two groups were similar demographically. The total parenteral nutrition group had a significantly higher rate of catheterrelated sepsis than did an additional group of contemporaneous patients without pancreatitis who received total parental nutrition (10.5 percent and 1.47 percent, respectively; p < 0.01). There was no advantage to the use of early total parenteral nutrition; that is, there was no difference in the number of days to oral intake, total hospital stay, or number of complications of pancreatitis. Patients with zero or one Ranson's criterion on admission were more likely to be eating by the seventh hospital day than were those with two or more Ranson's criteria (80 percent and 54 percent, respectively; p < 0.05). The early institution of total parenteral nutrition in patients with acute pancreatitis did not appear to improve the outcome. Its use should be limited to prolonged periods of no oral intake or treatment of a specific complication, such as a pseudocyst.

Canine pancreatic responses to intestinally perfused fat and products of fat digestion.

Canine pancreatic responses to intestinally perfused fat and products of fat digestion.