Use Of Early Parenteral Nutrition Research Articles

Impact of Critical Care Registered Dietitian on Clinical Outcomes of Neurocritically Ill Patients

Background: To investigate the impact of early nutrition intervention and a critical care registered dietitian on the outcomes of neurocritically ill patients.Methods: Among neurosurgical patients admitted to the intensive care unit (ICU) in a tertiary hospital from January 2015 to December 2019, A critical care registered dietitian co-management was initiated on May 1, 2017. The primary endpoint was ICU mortality. Propensity score matching (PSM) was used to control selection bias and confounding factors.Results: In this study, 1,386 patients were included. In the overall study population, nutrition was provided to 719 (51.9%) patients under the supervision of a registered dietitian. Early nutrition was performed for 356 (25.7%) patients. In the overall study population and the PSM adjusted population, rates of early parenteral nutrition (EPN) were higher in the groups managed by a registered dietitian than in the group without a registered dietitian (both p <0.001). In the overall and PSM adjusted population, the rates of ICU mortality, 28-day mortality, and in-hospital mortality were not significant different between two groups (all p > 0.05), but the group managed by a registered dietitian had a shorter hospital stay than the group without a registered dietitian (both p <0.02). In the multivariable analysis of the overall population and PSM adjusted population, EPN showed an association with ICU mortality. Conclusions: The rate of EPN utilization increased after the implementation of co-management with a critical care registered dietitian, and the use of EPN was associated with lower ICU mortality in neurocritically ill patients.

Tight Blood-Glucose Control without Early Parenteral Nutrition in the ICU

BackgroundRandomized, controlled trials have shown both benefit and harm from tight blood-glucose control in patients in the intensive care unit (ICU). Variation in the use of early parenteral nutrition and in insulin-induced severe hypoglycemia might explain this inconsistency.MethodsWe randomly assigned patients, on ICU admission, to liberal glucose control (insulin initiated only when the blood-glucose level was >215 mg per deciliter [>11.9 mmol per liter]) or to tight glucose control (blood-glucose level targeted with the use of the LOGIC-Insulin algorithm at 80 to 110 mg per deciliter [4.4 to 6.1 mmol per liter]); parenteral nutrition was withheld in both groups for 1 week. Protocol adherence was determined according to glucose metrics. The primary outcome was the length of time that ICU care was needed, calculated on the basis of time to discharge alive from the ICU, with death accounted for as a competing risk; 90-day mortality was the safety outcome.ResultsOf 9230 patients who underwent randomization, 4622 were assigned to liberal glucose control and 4608 to tight glucose control. The median morning blood-glucose level was 140 mg per deciliter (interquartile range, 122 to 161) with liberal glucose control and 107 mg per deciliter (interquartile range, 98 to 117) with tight glucose control. Severe hypoglycemia occurred in 31 patients (0.7%) in the liberal-control group and 47 patients (1.0%) in the tight-control group. The length of time that ICU care was needed was similar in the two groups (hazard ratio for earlier discharge alive with tight glucose control, 1.00; 95% confidence interval, 0.96 to 1.04; P=0.94). Mortality at 90 days was also similar (10.1% with liberal glucose control and 10.5% with tight glucose control, P=0.51). Analyses of eight prespecified secondary outcomes suggested that the incidence of new infections, the duration of respiratory and hemodynamic support, the time to discharge alive from the hospital, and mortality in the ICU and hospital were similar in the two groups, whereas severe acute kidney injury and cholestatic liver dysfunction appeared less prevalent with tight glucose control.ConclusionsIn critically ill patients who were not receiving early parenteral nutrition, tight glucose control did not affect the length of time that ICU care was needed or mortality. (Funded by the Research Foundation–Flanders and others; TGC-Fast ClinicalTrials.gov number, NCT03665207.)

Long-term impact of paediatric critical illness on the difference between epigenetic and chronological age in relation to physical growth

BackgroundAltered DNA-methylation affects biological ageing in adults and developmental processes in children. DNA-methylation is altered by environmental factors, trauma and illnesses. We hypothesised that paediatric critical illness, and the nutritional management in the paediatric intensive care unit (PICU), affects DNA-methylation changes that underly the developmental processes of childhood ageing.ResultsWe studied the impact of critical illness, and of the early use of parenteral nutrition (early-PN) versus late-PN, on “epigenetic age-deviation” in buccal mucosa of 818 former PICU-patients (406 early-PN, 412 late-PN) who participated in the 2-year follow-up of the multicentre PEPaNIC-RCT (ClinicalTrials.gov-NCT01536275), as compared with 392 matched healthy children, and assessed whether this relates to their impaired growth. The epigenetic age-deviation (difference between PedBE clock-estimated epigenetic age and chronological age) was calculated. Using bootstrapped multivariable linear regression models, we assessed the impact hereon of critical illness, and of early-PN versus late-PN. As compared with healthy children, epigenetic age of patients assessed 2 years after PICU-admission deviated negatively from chronological age (p < 0.05 in 51% of bootstrapped replicates), similarly in early-PN and late-PN groups. Next, we identified vulnerable subgroups for epigenetic age-deviation using interaction analysis. We revealed that DNA-methylation age-deceleration in former PICU-patients was dependent on age at time of illness (p < 0.05 for 83% of bootstrapped replicates), with vulnerability starting from 6 years onwards. Finally, we assessed whether vulnerability to epigenetic age-deviation could be related to impaired growth from PICU-admission to follow-up at 2 and 4 years. Multivariable repeated measures ANOVA showed that former PICU-patients, as compared with healthy children, grew less in height (p = 0.0002) and transiently gained weight (p = 0.0003) over the 4-year time course. Growth in height was more stunted in former PICU-patients aged ≥ 6-years at time of critical illness (p = 0.002) than in the younger patients.ConclusionsAs compared with healthy children, former PICU-patients, in particular those aged ≥ 6-years at time of illness, revealed epigenetic age-deceleration, with a physical correlate revealing stunted growth in height. Whether this vulnerability around the age of 6 years for epigenetic age-deceleration and stunted growth years later relates to altered endocrine pathways activated at the time of adrenarche requires further investigation.

Early parenteral nutrition comparing to enteral nutrition cannot reduce 28-day mortality in critically ill patients: a retrospective comparative cohort study based on the MIMIC‑IV database.

Enteral nutrition (EN) is recommended as the first choice by guidelines for critical ill patients. But the timing of safe and effective delivery of parenteral nutrition (PN) is unclear and the results of previous studies are controversial. There is insufficient evidence for the use of early PN, so we designed this cohort study to compared the clinical outcomes of critical ill patients who received early PN with those who did not. This retrospective study conducted using the Medical Information Mart for Intensive Care (MIMIC)-IV database. Patients who received nutrition therapy within 3 days of ICU admission were included and we categorized them as patients who received any kind of PN (PN group) or only enteral nutrition (EN group). Confounding factors were adjusted by propensity-score matching (PSM). The primary outcome was the 28-day mortality rate, and secondary outcomes included length of stay (LOS) in the hospital and ICU, hospital infection, and mechanical ventilation time. A total of 5,019 patients (PN group, 357; EN group, 4,662) were included in the analyses. The 28-day mortality rates showed no significant intergroup difference (EN, 22.3% vs. PN, 20.2%; P=0.378). The PN group showed a shorter median ICU LOS (EN, 8.14 vs. PN, 6.89 days, P=0.00955), and a longer median hospital LOS (PN, 21.55 vs. EN, 15.1 days, P<0.001). After PSM, each group included 355 patients, with no significant intergroup difference in the 28-day mortality rate (EN, 18.9% vs. PN, 20.3%; P=0.705). The PN group still showed a longer hospital LOS (median LOS: PN, 21.45 vs. EN, 14.81 days, P<0.001), but the other outcomes showed no differences. PN within 3 days of ICU admission did not reduce the 28-day mortality rate and could extend hospital LOS. This study supports further fundamental and clinical research to ascertain the effect of PN for ICU patients.

Assessment of aberrant DNA methylation two years after paediatric critical illness: a pre-planned secondary analysis of the international PEPaNIC trial

ABSTRACT Critically ill children requiring intensive care suffer from impaired physical/neurocognitive development 2 y later, partially preventable by omitting early use of parenteral nutrition (early-PN) in the paediatric intensive-care-unit (PICU). Altered methylation of DNA from peripheral blood during PICU-stay provided a molecular basis hereof. Whether DNA-methylation of former PICU patients, assessed 2 y after critical illness, is different from that of healthy children remained unknown. In a pre-planned secondary analysis of the PEPaNIC-RCT (clinicaltrials.gov-NCT01536275) 2-year follow-up, we assessed buccal-mucosal DNA-methylation (Infinium-HumanMethylation-EPIC-BeadChip) of former PICU-patients (N = 406 early-PN; N = 414 late-PN) and matched healthy children (N = 392). CpG-sites differentially methylated between groups were identified with multivariable linear regression and differentially methylated DNA-regions via clustering of differentially methylated CpG-sites using kernel-estimates. Analyses were adjusted for technical variation and baseline risk factors, and corrected for multiple testing (false-discovery-rate <0.05). Differentially methylated genes were functionally annotated (KEGG-pathway database), and allocated to three classes depending on involvement in physical/neurocognitive development, critical illness and intensive medical care, or pre-PICU-admission disorders. As compared with matched healthy children, former PICU-patients showed significantly different DNA-methylation at 4047 CpG-sites (2186 genes) and 494 DNA-regions (468 genes), with most CpG-sites being hypomethylated (90.3%) and with an average absolute 2% effect-size, irrespective of timing of PN initiation. Of the differentially methylated KEGG-pathways, 41.2% were related to physical/neurocognitive development, 32.8% to critical illness and intensive medical care and 26.0% to pre-PICU-admission disorders. Two years after critical illness in children, buccal-mucosal DNA showed abnormal methylation of CpG-sites and DNA-regions located in pathways known to be important for physical/neurocognitive development.

Impact of critical illness and withholding of early parenteral nutrition in the pediatric intensive care unit on long-term physical performance of children: a 4-year follow-up of the PEPaNIC randomized controlled trial

BackgroundMany critically ill children face long-term developmental impairments. The PEPaNIC trial attributed part of the problems at the level of neurocognitive and emotional/behavioral development to early use of parenteral nutrition (early-PN) in the PICU, as compared with withholding it for 1 week (late-PN). Insight in long-term daily life physical functional capacity after critical illness is limited. Also, whether timing of initiating PN affects long-term physical function of these children remained unknown.MethodsThis preplanned follow-up study of the multicenter PEPaNIC randomized controlled trial subjected 521 former critically ill children (253 early-PN, 268 late-PN) to quantitative physical function tests 4 years after PICU admission in Leuven or Rotterdam, in comparison with 346 age- and sex-matched healthy children. Tests included handgrip strength measurement, timed up-and-go test, 6-min walk test, and evaluation of everyday overall physical activity with an accelerometer. We compared these functional measures for the former critically ill and healthy children and for former critically ill children randomized to late-PN versus early-PN, with multivariable linear or logistic regression analyses adjusting for risk factors.ResultsAs compared with healthy children, former critically ill children showed less handgrip strength (p < 0.0001), completed the timed up-and-go test more slowly (p < 0.0001), walked a shorter distance in 6 min (p < 0.0001) during which they experienced a larger drop in peripheral oxygen saturation (p ≤ 0.026), showed a lower energy expenditure (p ≤ 0.024), performed more light and less moderate physical activity (p ≤ 0.047), and walked fewer steps per day (p = 0.0074). Late-PN as compared with early-PN did not significantly affect these outcomes.ConclusionsFour years after PICU admission, former critically ill children showed worse physical performance as compared with healthy children, without impact of timing of supplemental PN in the PICU. This study provides further support for de-implementing the early use of PN in the PICU.Trial registration ClinicalTrials.gov, NCT01536275; registered on February 22, 2012.

The evolution of parenteral nutrition over the past 40 years: A bibliometric overview

Background/Aim: Malnutrition remains a significant problem in cancer patients, intensive care patients, and patients undergoing major surgery. Although the importance of nutritional support has been proven, the preferred route for nutrient delivery is still controversial. In recent years, the use of parenteral nutrition (PN) has been increasing, and the early use of PN has become widespread once again. However, there is still no bibliometric study in the literature about PN, which has increased the number of global studies in recent years. This study aimed to analyze the scientific articles on PN published between 1980 and 2020 with statistical methods and to evaluate the subject holistically. Methods: Articles on PN published between 1980 and 2020 were analyzed using statistical and bibliometric methods. Spearman correlation coefficient was used for correlation studies. Nonlinear (cubic model) regression analysis was used to estimate the number of publications in the coming years. Keyword network visualization maps were used to identify trending topics and collaborations. Results: A total of 9424 publications were found. Of these publications, 5461 (57.9%) were articles. The top 3 contributing countries to the literature were the USA (1901, 34.8%), UK (542, 10%), and France (437, 8%). The top 3 most active institutions were Harvard University (99, 1.8%), University of Toronto (98, 1.8%), and University of California, Los Angeles (84, 1.5%). The top 3 journals with the highest number of publications were Journal of Parenteral and Enteral Nutrition (894, 16.4%), Clinical Nutrition (337, 6.2%), and Nutrition (187, 3.4%). According to the average number of citations per article, the most influential journals were Annals of Surgery (88.2, 1.5%), Gastroenterology (85.8), and Gut (81.2), respectively. Conclusion: In this comprehensive study on PN, a summary of 5461 articles were presented. The trend topics in PN research are determined and it can be said that most of them related with intensive care units and cancer patients. This article may be a valuable resource for clinicians and scientists on PN global outcomes.

Effect of withholding early parenteral nutrition in PICU on ketogenesis as potential mediator of its outcome benefit

BackgroundIn critically ill children, omitting early use of parenteral nutrition (late-PN versus early-PN) reduced infections, accelerated weaning from mechanical ventilation, and shortened PICU stay. We hypothesized that fasting-induced ketogenesis mediates these benefits.MethodsIn a secondary analysis of the PEPaNIC RCT (N = 1440), the impact of late-PN versus early-PN on plasma 3-hydroxybutyrate (3HB), and on blood glucose, plasma insulin, and glucagon as key ketogenesis regulators, was determined for 96 matched patients staying ≥ 5 days in PICU, and the day of maximal 3HB-effect, if any, was identified. Subsequently, in the total study population, plasma 3HB and late-PN-affected ketogenesis regulators were measured on that average day of maximal 3HB effect. Multivariable Cox proportional hazard and logistic regression analyses were performed adjusting for randomization and baseline risk factors. Whether any potential mediator role for 3HB was direct or indirect was assessed by further adjusting for ketogenesis regulators.ResultsIn the matched cohort (n = 96), late-PN versus early-PN increased plasma 3HB throughout PICU days 1–5 (P < 0.0001), maximally on PICU day 2. Also, blood glucose (P < 0.001) and plasma insulin (P < 0.0001), but not glucagon, were affected. In the total cohort (n = 1142 with available plasma), late-PN increased plasma 3HB on PICU day 2 (day 1 for shorter stayers) from (median [IQR]) 0.04 [0.04–0.04] mmol/L to 0.75 [0.04–2.03] mmol/L (P < 0.0001). The 3HB effect of late-PN statistically explained its impact on weaning from mechanical ventilation (P = 0.0002) and on time to live PICU discharge (P = 0.004). Further adjustment for regulators of ketogenesis did not alter these findings.ConclusionWithholding early-PN in critically ill children significantly increased plasma 3HB, a direct effect that statistically mediated an important part of its outcome benefit.

Role of age of critically ill children at time of exposure to early or late parenteral nutrition in determining the impact hereof on long-term neurocognitive development: A secondary analysis of the PEPaNIC-RCT

SummaryBackground & aimsEarly use of parenteral nutrition (early-PN), as compared with withholding it for one week (late-PN), in the PICU, has shown to slow down recovery from critical illness and impair long-term development of 6 neurocognitive/behavioural/emotional functions assessed 2 years later. Given that key steps in brain maturation occur at different times during childhood, we hypothesised that age at time of exposure determines long-term developmental impact of early-PN.MethodsThe 786 children who were neurocognitively tested 2 years after participation in the PEPaNIC-RCT were included in this study. First, for each studied long-term outcome, interaction between randomisation to early-PN versus late-PN and age was assessed with multivariable linear regression analysis. Subsequently, for outcomes with an interaction p ≤ 0.15, the impact of early-PN versus late-PN was analysed, after adjustment for risk factors, for 4 subgroups defined based on developmentally-relevant age at time of exposure [≤28 days (n = 121), 29 days to 11 months (n = 239), 11 months to <5 years (n = 223) and ≥5 years (n = 203)].ResultsInteraction between randomisation and age was present for weight, and parent-reported inhibitory control, cognitive flexibility, working memory, planning/organisation, metacognition, total executive functioning, and internalising and total behavioural/emotional problems. Subgroup analyses revealed that none of the age-groups revealed benefit, whereas children aged 29 days to <11 months were most vulnerable to harm by early-PN for development of inhibitory control (p = 0.008), working memory (p = 0.009), planning/organisation (p = 0.004), metacognition (p = 0.008), and total executive functioning (p = 0.004), and for internalising (p = 0.005) and total behavioural/emotional problems (p = 0.01). Children aged 11 months to <5 years revealed harm by early-PN for development of inhibitory control (p = 0.003). In contrast, children aged ≥5 years and neonates aged ≤28 days appeared less vulnerable.ConclusionsCritically ill children aged 29 days to 11 months at time of exposure were identified as most vulnerable to developmental harm evoked by early-PN.Clinical trials.govNCT01536275.

Comportamiento del peso en recién nacidos tratados con nutrición parenteral

Antecedentes La nutrición parenteral es un aporte que debe redituar en la mejoría del crecimiento y desarrollo a corto y largo plazo de los neonatos, en especial de los prematuros. El uso temprano de la nutrición parenteral con los nutrientes en cantidad adecuada debería prevenir la pérdida considerada antes fisiológica del peso de los recién nacidos enfermos.&#x0D; Objetivo Determinar el comportamiento del peso en neonatos que reciben nutrición parenteral como único aporte nutricional.&#x0D; Materiales y métodos Estudio descriptivo observacional y prospectivo en 44 neonatos, en su mayor parte prematuros, cuyo único aporte nutricional era la nutrición parenteral vía catéter percutáneo, de ambos sexos, tratados en la unidad de cuidados intensivos de la Clínica General San Diego, de Barranquilla, Colombia. Se obtuvieron datos de sexo, edad gestacional, peso en gramos al inicio y final del uso de la nutrición parenteral, peso diario, días de nutrición parenteral y patologías asociadas. El análisis estadístico incluyó medidas de frecuencias.&#x0D; Resultados De los 44 recién nacidos incluidos, 43 fueron pretérmino y un recién nacido a término, con principal diagnóstico de prematurez y dificultad respiratoria, además de sepsis y enterocolitis necrosante. El promedio de incremento del peso al final de la nutrición parenteral fue de 5 a 15 gr/kg/día, con diferencias en cuanto a la progresión del peso basal y final.&#x0D; Conclusiones La utilización de la nutrición parenteral ayuda a promover el incremento de peso en los neonatos cuando se utiliza por más de tres días.

Management of Respiratory Distress Syndrome in Preterm Infants In Wales: A Full Audit Cycle of a Quality Improvement Project

Respiratory Distress Syndrome (RDS) is the commonest diagnosis after premature birth. We aimed to audit clinical practices before and after introduction of a national guideline in Wales on RDS management. Anonymised, prospective data on all infants born at <34 weeks of gestation and cared for at one of the participating neonatal units in Wales were collected in two six-month time periods in 2015 and 2018. A national guideline was introduced in 2016 by the Wales Neonatal Network. Data collection included areas of antenatal management, delivery room stabilisation, invasive and non-invasive respiratory support, surfactant treatment and elements of supportive care. Univariate and multivariate methods were used to compare data between the two epochs. Comparing care before and after introduction of the national guideline, areas of significant improvement include use of targeted tidal volume ventilation, use of caffeine therapy, oxygen therapy post-surfactant and increasing early use of parenteral nutrition. Areas of poorer management included levels of positive end expiratory pressures and timing of introduction of enteral feeds. Little variation was seen between level two and three units, although gestational age was a significant independent variable for several practices, including delayed cord clamping, stabilisation with intubation, early enteral feeding and caffeine administration. A national guideline for management of RDS in Wales has significantly improved practice in several areas. However, despite a large volume of high-quality evidence and robust guidance, there remains a significant variation in some elements of best practice for RDS management. Further work should focus on education and training, especially for elements requiring cross-departmental work.

Effect of early parenteral nutrition during paediatric critical illness on DNA methylation as a potential mediator of impaired neurocognitive development: a pre-planned secondary analysis of the PEPaNIC international randomised controlled trial

Early use of parenteral nutrition in the paediatric intensive care unit (PICU) negatively affects development of executive functions, externalising behaviour, and visual-motor integration 2 years later, compared with omitting parenteral nutrition until PICU day 8 (late parenteral nutrition). The molecular basis of this finding is uncertain. We aimed to test the hypothesis that DNA methylation changes occur during critical illness and that early parenteral nutrition (or a specific macronutrient component hereof) contributes to these changes, which could explain its negative effects on neurocognitive development. This pre-planned secondary analysis of the multicentre PEPaNIC trial (2012-18) included all patients with a last PICU day blood sample (n=825, aged 0-17 years at PICU admission) who were randomly allocated (1:1) to early parenteral nutrition or late parenteral nutrition, as compared with 352 demographically matched healthy children. Investigators were masked to treatment allocation. We used the Infinium Human MethylationEPIC BeadChip to determine the genome-wide peripheral blood leukocyte DNA methylation of 865 859 CpG sites, yielding high-quality results for 403 patients allocated to early parenteral nutrition and for 411 patients allocated to late parenteral nutrition. Applying a false discovery rate of less than 0·05, DNA methylation of patients on the last PICU day was compared with that of healthy children, after excluding all CpG sites differentially methylated upon PICU admission, because these reflected pre-admission conditions and altered leukocyte composition. We used bootstrapped multivariable linear and non-linear regression analyses to assess the effect of early parenteral nutrition versus late parenteral nutrition on illness-induced alterations in DNA methylation and to what extent differentially methylated CpG sites explained impaired neurocognitive development 2 years later. During PICU stay, 159 CpG sites were methylated differently in patients admitted to the PICU than in healthy children, with mean effect sizes of 2·6% (SD 2·5) up to 21·6% (p<0·02). These differentially methylated CpG sites occurred in genes involved in brain development, plasticity, and signalling; neuronal differentiation, migration, and growth; metabolism; transcriptional regulation; physical development and locomotion; and several neurodegenerative and neuropsychiatric diseases. Early parenteral nutrition and, in particular, the dose of amino acids, independently contributed to the differential methylation of 37 (23%) of these 159 CpG sites (p=0·0001 to 0·050), which could explain the adverse effect of early parenteral nutrition on neurocognitive development at 2-year follow-up (R2 0·61 [SD 0·01]). Early parenteral nutrition during paediatric critical illness altered DNA methylation, which suggests a plausible molecular basis for its negative effect on long-term neurocognitive development. Early administration of amino acids, rather than of glucose or lipids, mostly explained the aberrant DNA methylation-a finding that requires further investigation. European Research Council, Methusalem, Flanders Institute for Science and Technology, Research Foundation Flanders, Sophia Foundation, Stichting Agis Zorginnovatie, Erasmus Trustfonds, and European Society for Clinical Nutrition and Metabolism.

The GH Axis in Relation to Accepting an Early Macronutrient Deficit and Outcome of Critically Ill Patients.

Changes in the GH axis during critical illness resemble fasting in healthy adults and contribute to hypercatabolism, which potentially affects outcome. Accepting macronutrient deficits by withholding parenteral nutrition (PN) during the first week in the intensive care unit (ICU; late PN) reduced complications and accelerated recovery as compared with early use of PN (early PN). To investigate how late PN affects the GH axis in relation to its clinical outcome benefits. Preplanned subanalysis of the Early Parenteral Nutrition Completing Enteral Nutrition in Adult Critically Ill Patients randomized controlled trial. A total of 1128 patients for time-course study, 20 patients investigated for nocturnal GH pulsatility, and 600 patients investigated for muscle weakness, with early PN and late PN patients having comparable baseline characteristics. Withholding PN during the first ICU week (late PN) vs early PN. Changes in serum GH, IGF-I, IGF-binding protein (IGFBP) 3, and IGFBP1 concentrations from ICU admission to day 4 or last ICU day for patients with a shorter ICU stay (d4/LD) and association in multivariable analyses with likelihood of earlier live ICU discharge, risk of new infection, and muscle weakness. Late PN attenuated a rise in serum GH and IGF-I (P < 0.0001), did not affect IGFBP3, and attenuated a decrease in IGFBP1 concentrations from admission to d4/LD (P < 0.0001) as compared with early PN. Late PN decreased nonpulsatile (P = 0.005), but not pulsatile, GH secretion. Adjusting the multivariable models for the observed GH axis alterations increased the independent benefit of late PN for all outcomes. GH axis alterations induced by late PN were independently associated with adverse outcomes (P ≤ 0.03). Accepting macronutrient deficits early during critical illness further suppressed the GH axis, which statistically attenuated its clinical outcome benefits.

Nutrition Support and Tight Glucose Control in Critically Ill Children: Food for Thought!

Numerous studies have examined the strategy of tight glucose control (TGC) with intensive insulin therapy (IIT) to improve clinical outcomes in critically ill adults and children. Although early studies of TGC with IIT demonstrated improved outcomes at the cost of elevated hypoglycemia rates, subsequent studies in both adults and children have not demonstrated any benefit from such a strategy. Differences in patient populations, variable glycemic targets, and glucose control protocols, inconsistency in attaining these targets, heterogeneous intermittent sampling, and measurement techniques, and variable expertise in protocol implementation are possible reasons for the contrasting results from these studies. Notably, differences in modes of nutrition support may have also contributed to these disparate results. In particular, combined use of early parenteral nutrition (PN) and a strategy of TGC with IIT may be associated with improved outcomes, while combined use of enteral nutrition (EN) and a strategy of TGC with IIT may be associated with equivocal or worse outcomes. This article critically examines published clinical trials that have employed a strategy of TGC with IIT in critically ill children to highlight the role of EN vs. PN in influencing clinical outcomes including efficacy of TGC, and adverse effects such as occurrence of hypoglycemia and hospital acquired infections. The perspective afforded by this article should help practitioners consider the potential importance of mode of nutrition support in impacting key clinical outcomes if they should choose to employ a strategy of TGC with IIT in critically ill children with hyperglycemia.

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.

Parenteral nutrition in the critically ill.

Feeding guidelines have recommended early, full nutritional support in critically ill patients to prevent hypercatabolism and muscle weakness. Early enteral nutrition was suggested to be superior to early parenteral nutrition. When enteral nutrition fails to meet nutritional target, it was recommended to administer supplemental parenteral nutrition, albeit with a varying starting point. Sufficient amounts of amino acids were recommended, with addition of glutamine in subgroups. Recently, several large randomized controlled trials (RCTs) have yielded important new insights. This review summarizes recent evidence with regard to the indication, timing, and dosing of parenteral nutrition in critically ill patients. One large RCT revealed no difference between early enteral nutrition and early parenteral nutrition. Two large multicenter RCTs showed harm by early supplementation of insufficient enteral nutrition with parenteral nutrition, which could be explained by feeding-induced suppression of autophagy. Several RCTs found either no benefit or harm with a higher amino acid or caloric intake, as well as harm by administration of glutamine. Although unanswered questions remain, current evidence supports accepting low macronutrient intake during the acute phase of critical illness and does not support use of early parenteral nutrition. The timing when parenteral nutrition can be initiated safely and effectively is unclear.

Supplemental Parenteral Nutrition Is the Key to Prevent Energy Deficits in Critically Ill Patients.

This review emphasizes the role of a timely supplemental parenteral nutrition (PN) for critically ill patients. It contradicts the recommendations of current guidelines to avoid the use of PN, as it is associated with risk. Critical illness results in severe metabolic stress. During the early phase, inflammatory cytokines and mediators induce catabolism to meet the increased body energy demands by endogenous sources. This response is not suppressed by exogenous energy administration, and the early use of PN to reach the energy target leads to overfeeding. On the other hand, early and progressive enteral nutrition (EN) is less likely to cause overfeeding because of variable gastrointestinal tolerance, a factor frequently associated with significant energy deficit. Recent studies demonstrate that adequate feeding is beneficial during and after the intensive care unit (ICU) stay. Supplemental PN allows for timely adequate feeding, if sufficient precautions are taken to avoid overfeeding. Indirect calorimetry can precisely define the adequate energy prescription. Our pragmatic approach is to start early EN to progressively test the gut tolerance and add supplemental PN on day 3 or 4 after ICU admission, only if EN does not meet the measured energy target. We believe that supplemental PN plays a pivotal role in the achievement of adequate feeding in critically ill patients with intolerance to EN and does not cause harm if overfeeding is avoided by careful prescription, ideally based on energy expenditure measured by indirect calorimetry.

Analysis of Current Use of Early Parenteral Nutrition and Clinical Significance of Non-protein Calorie: Nitrogen in Surgical Critically Ill Patients

Surgical critically ill patients require adequate nutrition support and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines recommend low non-protein calorie:nitrogen ratio (NPC:N ratio, 70∼100) for critically ill pateints. In this study, we assess the current use of early parenteral nutrition of surgical critically ill patients and analyze the clinical significance of NPC:N.

How soon should we start interventional feeding in the ICU?

Nutrition in the critically ill patient remains a controversial topic. Most clinicians have viewed nutrition as part of patient care but not as a therapeutic intervention. Recent studies have looked at type and timing of nutrition to determine whether they affect important clinical outcomes. Large-scale, multicentre randomized trials have found that supplemental parenteral nutrition has a deleterious effect in comparison to enteral nutrition alone. Use of early parenteral nutrition in critically ill patients in whom enteral nutrition was contraindicated did not significantly improve clinical outcomes. Also, low-dose or trophic enteral nutrition has similar benefits with less gastrointestinal complications compared with early full dose caloric feedings. The timing of early nutrition has been defined in most large-scale studies as beginning within 48 h of intubation, though some earlier studies used a 24-h cut-off point with some improved outcomes. Although not strong, the best available data suggest that critically ill patients should be started on enteral tube feeds within 48 h of intubation whenever possible. The use of parenteral nutrition should be limited within the first 6 days, and not used to augment caloric intake. Finally, similar benefits are seen in patients receiving minimal enteral feeds versus full caloric enteral nutrition.

SASPEN Case Study: Nutritional management of a patient with an open abdomen

The use of the open abdomen as a technique in the management of complex surgery patients can be the result of a variety of contributing factors, including surgical or medical causes, as well as indications. 1 The early initiation of goal-directed enteral nutrition support improves wound healing, decreases intensive care unit (ICU) and hospital length of stay, and might improve survival following critical illness or injury. 1 The benefits of enteral nutrition in surgical and critical illness have been recognised since the early 1980s and are now well described. 2 Because of the nature of these patients, the establishment of sufficient enteral nutrition support can be challenging. Therefore, they might require parenteral nutrition (PN) support in the early postoperative phase until the physiological status has normalised. 2 The early use of PN is of particular importance in patients with pre-existing malnutrition. 2 Nutrition support in the patient discussed in this publication was complicated by haemodynamic instability, fluid restriction owing to renal failure and fistula formation in the open abdomen, which necessitated the long-term use of PN support.