End Of Parenteral Nutrition Research Articles

Factors associated with all-cause mortality at 90 days in hospitalized adult patients who received parenteral nutrition.

Objective: this study aimed to assess the main factors related to mortality in a cohort of hospitalized adult patients who required parenteral nutrition (PN) considering their characteristics, type of admission, procedures, nutritional data, and adverse events. Methods: a retrospective study was performed in a 400-bed university hospital. All adult inpatients that had received ≥ 4 days as first course of PN within 24 months were included. Patients with long-term (> 90 days) or home PN were excluded. The main variable was all-cause mortality at 90 days after the end of PN. Initial independent variables were anthropometric and demographic data, admission characteristics, severity, comorbidity, surgical/medical procedures, baseline biochemical parameters, nutritional risk, and other nutritional data, medications, and adverse events during PN. A Cox proportional hazards regression model was planned to analyze time-to-event data. Results: a total of 634 patients entered the study and 140 (22.1 %) died. Patients were mainly: surgical 471 (74.3 %), male 393 (62.0 %), and age 69.0 (67.8-70.1) years old. The survival time for the entire cohort was 74.0 (95 % CI: 71.6-76.6) days. The final model included 14 variables, with severity and comorbidity being the main ones, but including also anastomotic suture dehiscence, sepsis during PN, days with hyperglycemic events, use of potent opioids, failed attempts at enteral nutrition, and, as a protective one, energy provided in PN. Conclusions: the factors related to mortality in hospitalized adult patients who required PN were mainly severity and comorbidities, but several other important factors were also relevant and could be modified to maximize outcomes in these patients.

The incidence of osteopenia of prematurity in preterm infants without phosphate supplementation: A prospective, observational study.

To meet their requirements for bone mineralization, it is recommended that preterm infants receive nutritional support containing calcium and phosphate. There are no clear data on the incidence of osteopenia of prematurity (OFP) in preterm infants without phosphate supplementation.This study aimed to investigate the incidence of OFP in preterm infants without phosphate supplementation and its relationship with the duration of parenteral nutrition (PN).This was a prospective and observational study.This study included 30 infants aged <32 gestational weeks and weighed <1500 g at birth. All infants received PN according to a standard protocol, beginning on day 1 with calcium, without phosphate. Starting from the first day of life, all infants received human milk without fortifiers. Oral vitamin D (400 IU/d) was administered when enteral nutrition reached 100 mL/kg/d.The diagnosis of OFP was based on radiographs that were taken of both wrists. Serum alkaline phosphatase (ALP) was measured 3 times: at the start of PN (ALP 1), at the end of PN (ALP 2), and at discharge or the expected due date (ALP 3). Radiographs were obtained on the same day as ALP 3. The duration of PN was analyzed in the presence of OFP using receiver operating characteristic curve analysis.Among the 30 infants, 13 (43%) were diagnosed with OFP. The duration of PN was significantly longer in the OFP group than in the group without OFP (16 vs 12 days; P < .05). The provision of PN for >15 days significantly increased the risk of OFP (odds ratio, 5.40; 95% confidence interval, 1.12–26.04; P = .035).We found a high incidence of OFP in preterm infants without phosphate supplementation. An association was found between the duration of PN and the incidence of OFP. Further research is needed to prevent the development of osteopenia in preterm infants.

Nutritional risk in allogeneic stem cell transplantation: rationale for a tailored nutritional pathway.

Hematopoietic stem cell transplantation carries nutrition-related risks. Therefore, nutritional therapy needs to be initiated before transplantation even takes place. We assessed nutritional risk among patients who underwent allogeneic stem cell transplantation. We assessed nutrient supply (calorie supply and protein supply) by chart review. Assessments were made from the pretreatment phase of transplantation to after the end of parenteral nutrition in 51 patients who underwent allogeneic stem cell transplantation at Shizuoka Cancer Center between 2007 and 2012. We compared nutrition-related adverse events and parameters between two groups: those in whom % loss of body weight was ≥7.5 and those in whom % loss of body weight was <7.5. A correlation was observed between changes in weight and skeletal muscle mass (r=0.89; P<0.0001). A weak correlation was observed between % loss of body weight and nutrient supply of calories (r=0.517; P=0.0001). There were significant differences between the % loss of body weight ≥7.5 group and the % loss of body weight <7.5 group in the following variables: % loss of body weight, nutrient supply from calories and protein; orally ingested nutrient supply from calories and protein; start day of oral intake; and acute graft-versus-host disease. Orally ingested calories were negatively correlated with nutrition-related adverse events in both groups. Early and customized nutritional intervention may be optimal for all patients who undergo allogeneic stem cell transplantation to ameliorate body weight loss associated with nutrition-related adverse events.

The relationship between the parenteral dose of fish oil supplementation and the variation of liver function tests in hospitalized adult patients.

BackgroundHepatic dysfunction is a complication associated with parenteral nutrition (PN). Our primary objective was to study the relationship between doses of intravenous fish oil (FO) emulsion in PN and the variation in the main liver function tests (LFTs) in hospitalized PN-treated adults. As a secondary objective, we studied the safety of FO administration.MethodsWe conducted a retrospective study in adult patients receiving FO supplementation in PN. Demographic, nutritional and safety variables were collected. Variation of LFTs was defined as the difference between values just before the first administration of FO and values at the end of PN. A multiple linear regression was performed to study the association between PN-lipids (FO or vegetable) and the variation of each LFT; the following variables were used to adjust the effect of lipids: sepsis, length of stay in the intensive care unit and lipids dose. Student t-test was used to study safety variables. Data were analyzed using SPSS 19.0.ResultsPatients (53, median age 68 years (24–90); 62 % men) with the principal diagnosis of digestive neoplasm (42 %) received PN for a median of 19 (7–75) days. In the multivariate analysis, the amount of FO was related to a decrease in gamma-glutamyl transferase (GGT) (B = −2.23;CI95 % = −4.41/-0.05), a decrease in alkaline phosphatase (AP) (B = −1.23;CI95 % = −2.07/-0.37), and a decrease in alanine aminotransferase (ALT) (B = −0.82; CI95 % = −1.19/-0.44). No differences were found in safety variables.ConclusionsGGT, AP and ALT improved with FO PN-supplementation. Moreover, the improvement was greater when the doses of FO were higher. FO administration in PN is safe.

Aumento de peso después de soporte nutricional en una unidad de cuidado intensivo neonatal

Background. Fasting in the new-born leads to a deterioration of their nutritional status and stunts their short- and long-term growth. Objective. Determining weight gain in the critically-ill newborn without oedema following parenteral nutrition (PN). Materials and methods. This cross-sectional observational study involved 110 critically-ill full-term and preterm newborn from both genders being treated by Social Security in Bucaramanga, Colombia. They received central or peripheral parenteral nutrition. Data was obtained concerning gender, gestational age, weight, grams/kg/day of carbohydrate, protein and fat, kcal/kg/day baseline and final days of parenteral nutrition and underlying pathology. Statistical analysis included measures of central tendency and position, frequencies, univariate and bivariate tests, comparing means and medians and Chi Square and Fisher tests (0.05 level of significance). Results. The study included 63 full-term newborn and 47 preterm newborn whose main diagnosis was necrotising enterocolitis (40 newborn: 36.4%). The average by the end of parenteral nutrition was 1.3g/kg/day protein and 2.5g/kg/day fat. Base to final weight increased by 14.2g/day and statistically significant differences were recorded regarding progression from baseline to final weight in full-term newborn (p=0.015) and preterm newborn (p=0.000) and even for those weighing < 1,500 g (p=0.000) and those between 1,500 and 2,500 g (p=0.004). Conclusions. The nutritional status of all critically-ill newborn receiving PN (at lower doses than those currently recommended) from the first day of life improved, this being measurable by daily weight variation/gain.

Nutritional support with parenteral nutrition. Course and associated complications

Abstract Introduction Parenteral nutrition (PN) is an integral part of medical management of patients who do not have a functioning or accessible gastrointestinal tract. This paper discusses the clinical characteristics of patients receiving PN in a 420-bed hospital from 2009 to 2011. In addition, nutritional parameters were assessed at the start and end of PN and associated complications were analyzed. Material and methods Retrospective, observational study of PN episodes in adults conducted at the Nutrition Unit of Hospital Universitario de Guadalajara. Variables collected included epidemiological and clinical data, number and type of routes used, anthropometric data, analytical data, number of days on PN, reason for withdrawal, caloric provision, prevalence of phlebitis, metabolic complications (hypertriglyceridemia, abnormal liver function tests, hyperglycemia, and refeeding syndrome), and prevalence of bacteremia associated with central venous catheter (BAC). Results There were 312 episodes of PN. The immediate indication was postoperative ileus in 53.8% of the episodes. There was a statistically significant improvement in all analytical parameters assessed (albumin, prealbumin, retinol binding protein, transferrin, cholesterol, and lymphocytes). Caloric provision (kcal per kg) was 25.1 ± 6.6. No metabolic complication occurred in 16.3% of the episodes, and hyperglycemia was the most common complication (79.8%). There were 10 cases of phlebitis (32.2%) and 30 episodes of BAC (8.7%). Bacteremia rate was 8.1 per 1000 days of PN. Discussion Although PN is an effective nutritional support technique, it is associated with complications of varying severity. Use of PN should therefore comply with the instructions accepted in the main clinical practice guidelines and requires careful monitoring by experienced professionals.

Strong Variability of Di(2‐ethylhexyl)phthalate (DEHP) Plasmatic Rate in Infants and Children Undergoing 12‐Hour Cyclic Parenteral Nutrition

Medical devices such as perfusion materials in polyvinyl chloride may contain di(2-ethylhexyl)phthalate (DEHP). Several studies have questioned the harmlessness of phthalates, which have been shown to have toxic effects on the reproductive system and general development. This study was designed to assess DEHP exposure in infants and children benefitting from cyclic parenteral nutrition (PN). The results are compared with those obtained from children used as controls and receiving no PN, to estimate the potential risk to this pediatric population, taking into account exposure levels and already published data. Plasmatic concentrations of DEHP were assessed by high-performance liquid chromatography from blood samples taken from 22 children at the start and finish of a 12-hour cyclic PN period and compared with those obtained from 20 control children of comparable age and gender. After a 12-hour cyclic PN period, DEHP migration varied widely among the patients. The concentrations were not quantifiable in 4 children at the start of PN. In 1 child, they were quantifiable neither at the start nor at the end of PN. However, for 17 children, DEHP concentrations were quantifiable at the start of PN and were very variable from one child to another. At the end, DEHP concentrations had significantly but variably increased in these children. No trace of DEHP was found in the blood samples from 20 healthy controls. Considering published data on phthalate toxicity, it would appear advisable to encourage the use of medical devices that are either phthalate or DEHP free.

Taurolidine lock solution in the secondary prevention of central venous catheter-associated bloodstream infection in home parenteral nutrition patients

Central venous catheter-associated bloodstream infection (CBSI) is a serious complication in patients on home parenteral nutrition (HPN). The aim was to analyze the impact of taurolidine-citrate lock solution (TLS) on CBSI rate in HPN patients with a high risk of catheter infection. This retrospective study compared CBSI rates 12 months before and 12 months after implementation of TLS. In the first period, only standardized strategies were used to reduce the CBSI rate. In the second period, TLS was injected into the catheter at the end of parenteral nutrition. The CBSI rate with a confident interval was calculated as Poisson event rates, and compared by testing for homogeneity of rates. 15 patients were included. During the 24 months, the CBSI rate was 6.58/1000 catheter-days in the first period and 1.09/1000 catheter-days in the second period (p < 0.001). In patients with TLS once a week (n = 8), the CBSI rate decreased from 4.8/1000 catheter-days to 1.37/1000 catheter-days (p = 0.02) and in patients with TLS after each TPN (n = 7), the CBSI rate decreased from 8.61/1000 catheter-days to 0.78/1000 catheter-days (p = 0.001). In HPN patients, TLS associated with standardized precautions significantly reduced the CBSI rate.

Comparative effects of olive oil-based and soyabean oil-based emulsions on infection rate and leucocyte count in critically ill patients receiving parenteral nutrition

Soyabean oil-based emulsions high in linoleic acid used in parenteral nutrition (PN) could interfere with immune function and may increase the risk of septic complications. Olive oil-based emulsions, high in oleic acid, could have fewer immune effects. We compared the effects of a soyabean oil-based emulsion v. an olive oil-based emulsion on infection rate, appearance of new infection episodes, leucocyte count (peak and evolution), acute-phase proteins, and major health outcomes in intensive care unit (ICU) adult patients receiving PN. The study was designed as an observational, retrospective, single-centre, cohort study in a general ICU. Patients in the SOYA cohort (n 16) received a soyabean oil-based emulsion and patients in the OLIVE cohort (n 23), an olive oil-based emulsion. Both cohorts had similar basal characteristics and received a similar energy load. The SOYA cohort received an oleic acid:linoleic acid ratio of 0.43 and the OLIVE cohort 2.99 (P < 0.001). No differences were observed in infection rate and appearance, acute-phase proteins, and major health outcomes. At the end of PN, blood leucocyte count decreased by 3.25 x 109 cells/l in the SOYA cohort and increased by 4.51 x 109 cells/l in the OLIVE cohort from baseline values (P = 0.036). Peak leucocyte count presented a trend for a higher value in the OLIVE cohort v. the SOYA cohort (18.86 v. 15.28 x 109 cells/l; P = 0.078). The use of an olive oil-based emulsion in PN had no effect on infection, acute-phase proteins, major health outcomes, and presented higher leucocyte count at the end of PN and a trend to higher peak leucocyte count when compared with soyabean oil-based emulsion in ICU patients.

Total parenteral nutrition delays platelet engraftment in patients who undergo autologous hematopoietic stem cell transplantation

OBJECTIVES: One of the major challenges in the post-transplant period is nutrition. In this prospective, non-randomized study, total parenteral nutrition (TPN) was given to 31 patients and partial parenteral nutrition (PPN) was given to 30 patients undergoing autologous hematopoietic stem cell transplantation for solid tumors or hematologic malignancies to compare the effects of these parenteral nutrition modalities on post-transplant hematological engraftment, blood chemistry, and supportive therapy requirements. METHODS: All patients in the TPN group and 17 patients in the PPN group received growth factor in the post-transplant period. Both groups did not differ with respect to sex, age, and reinfused CD34 + cell numbers. RESULTS: After transplantation body mass index and body weight decreased significantly in both groups ( P < 0.001). Whereas serum albumin concentrations did not decrease significantly in the TPN group, it fell markedly in the PPN group at the end of parenteral nutrition ( P = 0.019). After parenteral nutrition, blood chemistry was also remarkable for serum urea and glucose levels, which were elevated significantly in the TPN group ( P < 0.001 and P = 0.03, respectively). Patients receiving TPN had a higher incidence of positive microbial cultures and clinical infection than did patients receiving PPN (64.5% versus 40%, P = 0.05). The most striking result was a delay in platelet engraftment for the TPN group compared with the PPN group (15.54 and 12.93 d, respectively; P = 0.014). This difference was also noted in patients using growth factor in the PPN group ( P = 0.017). Parallel to these results, platelet transfusion requirement increased in the TPN group compared with the PPN group (1.93 versus 1.16 U, P = 0.004). Both groups were unremarkable for leukocyte recovery and red blood cell transfusion requirement. CONCLUSIONS: Consequently, TPN has some pitfalls of hyperglycemia, infection tendency, delayed platelet engraftment, and increased platelet transfusion requirement. Therefore, it should not be used as a standard nutrition support for patients undergoing autotransplantation.

A New Model of Intraabdominal Abscess: Usefulness for Hydrosaline Metabolism Studies in Parenteral Nutrition Associated with Sepsis

The present study was set up to develop a new model of intraabdominal abscess (IAA) useful for hydrosaline metabolism studies based on the ligation of the appendix (AL) and wrapping of the appendix tip with omentum. Two experiments were designed: (1) to characterize the model and (2) to investigate extracellular volume (ECV) changes during parenteral nutrition (PN). Four groups of rabbits were studied at 3 (3DA) and 7 days (7DA) after AL or sham operation. PN was given for 6 days to two groups of septic rabbits: high volume (HV) and low volume (LV) groups received 100 and 70 ml/kg · day of water with 7 and 0 meq/day of CINa, respectively. Serum albumin (SA), ECV, and weight, water and sodium balances were determined. In 3DA, weight loss, reduced spontaneous intake, negative water balance, and reduction in SA were noted. Low SA, higher weight loss, and reduced intake were still observed in 7DA. SA correlated with ECV ( r 2 = 0.61, P = 0.003) in 7DA. Positive nitrogen balance was achieved during PN. The HV group had higher water and sodium balances than LV. In the HV group only, SA negatively correlated with sodium balance and with ECV at the end of PN ( r 2 = 0.87, P = 0.0007 and r 2 = 0.9, P = 0.0001). The impact on hydrosaline metabolism of IAA in this model resembles that of moderate sepsis in humans. SA decrease appears to have two major components: escape around the inflammatory area and dilution. ECV expansion after PN is influenced by the initial SA concentration.