Initiation Of Enteral Nutrition Research Articles

A precise temperature control during hyperthermic intraperitoneal chemotherapy promises an early return of bowel function

ABSTRACT Introduction The hyperthermic intraperitoneal chemotherapy (HIPEC) has been widely applied in clinical practice for peritoneal carcinomatosis (PC). The temperature is one of the important elements affecting the efficacy of HIPEC, and it can become fluctuant by several factors. This study is aimed to explore the role of a stable perfusion temperature in promoting bowel recovery of PC patients due to gastrointestinal malignancies. Methods Between January 2012 and July 2013, 59 PC patients undergoing cytoreductive surgery and three-cycle HIPEC were included. Patients having stable perfusion temperature for all cycles were assigned into the study group, with the rest having unstable temperature into the control group. Time of flatus and defecation passage and initiation time of enteral nutrition were compared between both groups to detect the significance in bowel function recovery, with visual analogue scale (VAS) pain intensity and overall survival (OS) compared meanwhile. Results In sum, 33 (55.9%) patients obtained stable temperature during HIPEC, and the rest of 26 (44.1%) developed fluctuant perfusion temperature. Average time of flatus (2.3 ± 1.2 vs 3.9 ± 2.2 days, P =.002), defecation passage (5.2 ± 2.1 vs 7.1 ± 2.9 days, P =.004) and enteral nutrition initiation (4.3 ± 1.5 vs 6.7 ± 2.3 days, P <.001) were much shorter in the study group than the control group. Additionally, the VAS score (4.5 ± 2.3 vs 6.3 ± 1.3, P <.001) and 5-year OS rate (17.8% vs 11.1%, P=.135) were both improved, with significance observed in postoperative pain control. Conclusions During HIPEC, a precise temperature control could promise an early recovery of bowel function and reduce postoperative pain, without survival significance found based on the current cohort.

Early Use of Antibiotics Is Associated with a Lower Incidence of Necrotizing Enterocolitis in Preterm, Very Low Birth Weight Infants: The NEOMUNE-NeoNutriNet Cohort Study

To determine whether commencement of antibiotics within 3 postnatal days in preterm, very low birth weight (VLBW; ≤1500g) infants is associated with the development of necrotizing enterocolitis (NEC). Preplanned statistical analyses were done to study the association between early antibiotic treatment and later NEC development, using the NEOMUNE-NeoNutriNet cohort of VLBW infants from 13 neonatal intensive care units (NICUs) in 5 continents (n=2831). NEC incidence was compared between infants who received early antibiotics and those who did not, with statistical adjustments for NICU, gestational age, birth weight, sex, delivery mode, antenatal steroid use, Apgar score, and type and initiation of enteral nutrition. The incidence of NEC was 9.0% in the group of infants who did not receive early antibiotics (n=269), compared with 3.9% in those who did receive early antibiotics (n=2562). The incidence remained lower in the early antibiotic group after stepwise statistical adjustments for NICU (OR, 0.57; 95% CI, 0.35-0.94, P<.05) and other potential confounders (OR, 0.25; 95% CI, 0.12-0.47; P<.0001). In this large international cohort of preterm VLBW infants, a small proportion of infants did not receive antibiotics just after birth, and these infants had a higher incidence of NEC. It is important to better understand the role of such variables as time, type, and duration of antibiotic treatment on NEC incidence, immune development, gut colonization, and antibiotic resistance in the NICU.

Acute mesenteric ischaemia in refractory shock on veno-arterial extracorporeal membrane oxygenation.

Acute mesenteric ischaemia is a severe complication in critically ill patients, but has never been evaluated in patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO). This study was designed to determine the prevalence of mesenteric ischaemia in patients supported by V-A ECMO and to evaluate its risk factors, as well as to appreciate therapeutic modalities and outcome. In a retrospective single centre study (January 2013 to January 2017), all consecutive adult patients who underwent V-A ECMO were included, with exclusion of those dying in the first 24 hours. Diagnosis of mesenteric ischaemia was performed using digestive endoscopy, computed tomography scan or first-line laparotomy. One hundred and fifty V-A ECMOs were implanted (65 for post-cardiotomy shock, 85 for acute cardiogenic shock, including 39 patients after refractory cardiac arrest). Overall, median age was 58 (48-69) years and mortality 56%. Acute mesenteric ischaemia was suspected in 38 patients, with a delay of four (2-7) days after ECMO implantation, and confirmed in 14 patients, that is, a prevalence of 9%. Exploratory laparotomy was performed in six out of 14 patients, the others being too unstable to undergo surgery. All patients with mesenteric ischaemia died. Independent risk factors for developing mesenteric ischaemia were renal replacement therapy (odds ratio (OR) 4.5, 95% confidence interval (CI) 1.3-15.7, p=0.02) and onset of a second shock within the first five days (OR 7.8, 95% CI 1.5-41.3, p=0.02). Conversely, early initiation of enteral nutrition was negatively associated with mesenteric ischaemia (OR 0.15, 95% CI 0.03-0.69, p=0.02). Acute mesenteric ischaemia is a relatively frequent but dramatic complication among patients on V-A ECMO.

Role of Nutrition in Prevention of Neonatal Spontaneous Intestinal Perforation and Its Complications: A Systematic Review.

Background: Spontaneous intestinal perforation (SIP) is a devastating complication of prematurity, and extremely low birthweight (ELBW < 1000 g) infants born prior to 28 weeks are at highest risk. The role of nutrition and feeding practices in prevention and complications of SIP is unclear. The purpose of this review is to compile evidence to support early nutrition initiation in infants at risk for and after surgery for SIP. Methods: A search of PubMed, EMBASE and Medline was performed using relevant search terms according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. s and full texts were reviewed by co-first authors. Studies with infants diagnosed with SIP that included information on nutrition/feeding practices prior to SIP and post-operatively were included. Primary outcome was time to first feed. Secondary outcomes were incidence of SIP, time to full enteral feeds, duration of parenteral nutrition, length of stay, neurodevelopmental outcomes and mortality. Results: Nineteen articles met inclusion criteria—nine studies included feeding/nutrition data prior to SIP and ten studies included data on post-operative nutrition. Two case series, one cohort study and sixteen historical control studies were included. Three studies showed reduced incidence of SIP with initiation of enteral nutrition in the first three days of life. Two studies showed reduced mortality and neurodevelopmental impairment in infants with early feeding. Conclusions: Available data suggest that early enteral nutrition in ELBW infants reduces incidence of SIP without increased mortality.

Factors associated with early phosphate levels in preterm infants.

To investigate perinatal factors and early morbidities associated with early serum phosphate (sPhos) levels in a cohort of preterm infants. Retrospective data were obtained from the medical records of a cohort of 454 infants born at < 32weeks gestational age. Serum phosphate levels were directly associated with gestational age, body weight z-score, and Apgar scores and inversely associated with timing of enteral nutrition initiation and diet consisting of mostly breast milk. Maternal hypertension, lactate levels, early symptomatic hypotension, and total protein supplemented on days 1 to 3 were also inversely associated with sPhos. Morbidities that were found to be associated with sPhos did not persist after adjustment for confounding factors.Conclusions: We report a novel association between early sPhos and timing and content of enteral nutrition, as well as with the early neonatal hemodynamic condition of preterm infants. This information may help identify infants at risk for low sPhos and aid in the nutritional strategy utilized in these patients. This study did not identify early morbidities associated with sPhos. What is Known: • High initial amino acid intake is associated with increased risk of Refeeding like syndrome and hypophosphatemia, among preterm infants. What is New: • Early enteral nutrition, starting within the first 72h of life, is associated with higher serum phosphate (sPhos) compared to nothing per os (NPO). • sPhos was not associated with early adverse neonatal outcomes.

Impact of Nutrition Support Team on Postoperative Nutritional Status and Outcome of Patients with Congenital Gastrointestinal Anomalies.

BACKGROUND The aim of this study was to evaluate postoperative nutritional status in patients who underwent operations due to congenital gastrointestinal anomalies in surgical neonatal intensive care units (NICUs) and to investigate the role of nutrition support teams (NSTs) on the outcome. METHODS A retrospective clinical study was carried out at two NICUs in Dr. Sheikh Pediatric Hospital, Mashhad, Iran. One of the NICUs was supported by NST and the other was not. A total of 120 patients were included through a non-random simple sampling. Different variables such as age, sex, prematurity, type of anomaly, birth weight, use of vasoactive drugs, weight gain in NICU, length of NICU stay, postoperative enteral nutrition initiation, duration of mechanical ventilation, mortality rate, maximum of blood sugar, the amount of calorie delivered to the calorie requirement ratio, and distribution of energy from enteral or parenteral roots were compared between the patients of two NICUs. RESULTS Median weight gain and the amount of calorie delivered during NICU stay in subjects of NSTsupported NICU was significantly more than other NICU. There was no significant difference in the length of NICU stay, enteral nutrition initiation after the operation, ventilation days, and percent of mortality between the two groups. The percentage of enteral feeding was also increased by about 2.8%, which was not significant. CONCLUSION NST could increase post-operative weight gain and calorie delivery in patients as well as providing an increase in enteral feeding rather than parenteral.

Rapid Advancement in Enteral Nutrition Does Not Affect Systemic Inflammation and Insulin Homeostasis Following Pediatric Cardiopulmonary Bypass Surgery.

To determine impact of enteral nutrition delivery on the relationship among inflammation, insulin resistance, and outcomes following pediatric cardiopulmonary bypass surgery. Pilot, randomized study analyzed according to intention-to-treat analysis. Pediatric cardiac ICU. Infants (≤ 6 mo) undergoing cardiopulmonary bypass. Patients randomly assigned to receive rapid escalation to enteral nutrition reaching goal feeds by 27 hours or standard feeding practice reaching goal feeds by 63 hours. Feeds were initiated on the first postoperative day. Fifty patients were randomized equally to study arms. Patients were a median (interquartile range) of 16 days old (7-110 d old), undergoing biventricular surgery (88%) with a median cardiopulmonary bypass time of 125 minutes (105-159 min). Serial blood samples were drawn before and after cardiopulmonary bypass, cardiac ICU admission, and every 12 hours (up to 96 hr) for glucose, insulin, and cytokines (interleukin-1α, interleukin-6, interleukin-8, interleukin-10, and tumor necrosis factor-α) levels. Glucose-insulin ratio was calculated to quantify insulin resistance. Patient characteristics, time to enteral nutrition initiation, enteral nutrition interruptions, and insulin administration were similar across intervention arms. FF reached goal feeds at similar intervals as standard feeding (39 hr [30-60 hr] vs 60 hr [21-78 hr]; p = 0.75). No difference in cytokine, insulin, or glucose-insulin ratio was noted between groups. Higher inflammation was associated with increased glucose-insulin ratio and higher risk of adverse events. In multivariable models of interleukin-8, FF was associated with increased glucose-insulin ratio (estimate of effect [95% CI], 0.152 [0.033-0.272]; p = 0.013). Although higher interleukin-8 was associated with an elevated risk of adverse event, this relationship was possibly mitigated by FF (odds ratio [95% CI], 0.086 [0.002-1.638]; p = 0.13). A FF strategy was not associated with changes to early enteral nutrition delivery. Inflammation, insulin resistance, and morbidity were similar, but FF may modify the relationship between inflammation and adverse event. Multicenter nutrition studies are possible and necessary in this vulnerable population.

Evaluating the Safety and Efficacy of Intraoperative Enteral Nutrition in Critically Ill Burn Patients: A Systematic Review and Meta-analysis.

Major burn injuries incite a hypermetabolic response, and the initiation of early enteral nutrition is the standard of care in patients with large burns and contributes to improved outcomes. Perioperative fasting is a common cause of caloric deficits in burn patients and can be obviated with intraoperative enteral nutrition. However, the risks and benefits of this practice are unknown, and there is a concern for aspiration. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of intraoperative enteral nutrition. We performed a systematic literature search using PubMed, Scopus, and OvidSP MEDLINE databases. We identified studies that evaluated the effects of intraoperative enteral nutrition in adult burn patients compared to those undergoing routine perioperative fasting. We performed a meta-analysis on the incidence of mortality, pneumonia, wound infections, and aspiration in burn patients receiving intraoperative enteral nutrition. We identified seven articles for qualitative review and four for quantitative review (N = 83 patients). There were no statistically significant increases in the risk of mortality (odds ratio [OR] = 1.28, 95% confidence interval [CI]: 0.49, 3.31), wound infections (OR = 0.71, 95% CI: 0.16, 3.24), pneumonia (OR = 2.1, 95% CI: 0.7, 6.1), and aspiration (OR = 1.14, 95% CI: 0.07, 18.75) in patients receiving intraoperative enteral nutrition. Within individual studies, intraoperative enteral nutrition patients received significantly more calories than standard fasting patients. Intraoperative enteral nutrition may increase nutritional intake in burn patients without an increase in complications; however, this is based on limited studies. Randomized controlled trials are needed before recommendations on intraoperative enteral nutrition practice can be made.

708 Enteral Nutrition Initiation During Periods of Vasopressor Requirements and Elevated Lactate Levels

Abstract Introduction Nutrition is a core component of care for the critically ill burn patient. The Society for Critical Care Medicine recommends initiating enteral nutrition (EN) within 4–6 hours of injury for burn patients, while simultaneously recommending waiting until hemodynamic stability is achieved for critical care patients. The goal of this analysis was to evaluate tolerance of EN during periods of different pressor requirements and lactate levels. Methods We performed a retrospective evaluation on all burn patients admitted to our intensive care unit in 2018 who received EN. This performance improvement project was approved by our regulatory compliance division. Lactate levels and vasopressor use just prior to EN initiation, the highest EN rates and gastric residual volumes during the 24 hours after initiation, and ischemic bowel and aspiration after EN initiation were recorded. Significance was accepted at p&amp;lt; 0.05. Results EN was initiated at 30 ± 20 hours after admission in 58 patients with the following characteristics: 47 ± 19 years old, 29 ± 24% TBSA burn, 13 mechanical ventilator days (IQR: 5–30), 15% mortality. The highest EN rate reached was 100 ± 49 mL/hr during the first 24 hours after initiation. Lactate levels were 1.9 mmol/L at the time of EN initiation (IQR: 1.6–2.4 mmol/L), with a maximum of 4.9 mmol/L. Lactate levels did not have a significant correlation with gastric residual volumes (p=0.532). Most (59%) patients did not have vasopressor requirements, but 21% required vasopressin only, 2% required norepinephrine only, and 19% required a combination of vasopressin and norepinephrine. Those who received norepinephrine received 3.3 ± 1.7 mcg/min, with a maximum of 7 mcg/min. There was a significant difference in gastric residual volumes between patients who had no vasopressor requirements compared to those who required vasopressors [13 mL (IQR: 0–200 mL) vs. 240 mL (IQR: 21–430 mL), p=0.014)]; however, the number of patients with gastric residual volumes over 500 mL was not significantly different (3% vs. 17%, p=0.149). When examining patients receiving vasopressin alone, there was a significant but weak correlation between vasopressin dose and gastric residual volumes (p=0.047, R2=0.339); however, when examining only patients receiving norepinephrine, there was no correlation between norepinephrine dose and gastric residual volumes (p=0.905, R2=0.002). There was 1 episode of aspiration and 1 episode of ischemic bowel, both of which occurred 3 days after EN initiation. EN was initiated without vasopressors running and lactate levels were normal in both cases. Conclusions The majority of patients tolerated EN initiation with vasopressor dosing of norepinephrine up to 7 mcg/min and lactate up to 4.9 mmol/L. Applicability of Research to Practice We found no indication for holding EN for lactate levels under 5 mmol/L and norepinephrine under 8 mcg/min.

668 Early Enteral Nutrition in Geriatric Burn Patients: Is There a Benefit?

Abstract Introduction Nutrition is a critical component of acute burn care and wound healing. There is no consensus over the appropriate timing of initiating enteral nutrition (EN) in geriatric burn patients. The aim of our study was to assess the impact of early EN on outcomes in geriatric burn patients. We hypothesized that early EN is associated with improved outcomes. Methods We performed a 2-year (2015–2016) analysis of the ACS-TQIP and included all older adult (age ≥65years) burn patients who received EN. Patients were stratified into two groups based on timing of initiation of EN: Early-EN (&amp;lt; 24 hrs) vs. Late-EN (≥ 24 hrs). We performed propensity score matching (1:2 ratio) to control for possible confounding variables including demographics, comorbidities, injury parameters, height and body weight. Outcome measures were in-hospital; complications, hospital and ICU length of stay, and mortality. Results A total of 593,818 trauma patients were analyzed, of which 447 patients were matched (Early-EN: 159 vs Late-EN: 318). Mean age was 44±22, 75% were males, and median ISS was 29 [26–36] and mean total body burn surface area (TBSA) was 15±5%. There was no significant difference between the two groups in terms of age (p=0.99), gender (p=0.60), race (p=0.91), ISS (p=0.43), GCS (p=0.85), TBSA (p=0.51), height (p=0.71), and weight (p=0.61). Overall, the complications rate was 40%, median hospital LOS was 25 [15–36] days, median ICU LOS was 15 [8–26] days and mortality rate was 16%. Patients in the early ED group had significantly lower rate of complications and mortality Table 1. At the same time, patients in the early group had lower hospital length of stay (23[12–36] vs. 26[16–38], p=0.013) and ICU length of stay (12[8–24] vs. 16[8–26], p=0.025). Conclusions In our propensity matched cohort of geriatric burn patients, early EN was associated with improvement in outcomes. The cumulative benefits observed may warrant incorporating early EN as part of intensive care protocols. Applicability of Research to Practice Geriatric patients are a special subset of the population that require additional considerations. Our research highlights the impact of early enteral nutrition on different in hospital outcomes. This is an area of constant debate, our study shows that early enteral nutrition in geriatric burn patients is associated with improved outcome. We found this applicable in most of our patients and thus it might warrant further incorporation in ICU burn protocols.

Clinical nutrition for the gastroenterologist: bedside strategies for feeding the hospitalized patient.

The timing, advancement, and use of appropriate monitors determine whether the hospitalized patient experiences the full benefit of nutritional therapy. This article reviews management strategies in delivering the optimal nutrition regimen capable of improving outcomes in the hospitalized patient. Enteral nutrition should be initiated in the first 24-36 h after admission. Determination of nutritional risk helps guide the urgency with which nutritional therapy is provided and predicts the likelihood for difficulties in delivering the prescribed regimen. Feeds should be advanced slowly over 3-4 days to meet 70-80% of goal for calories (20 kcal/kg/day) and 100% for protein (2.0 gm/kg/day). Reaching protein goals early on may be more important than achieving energy goals. Patients should be monitored for hemodynamic stability, evidence of refeeding syndrome, and tolerance in the setting of gastrointestinal dysfunction. Parenteral nutrition should be utilized in select high-risk patients where the feasibility of full enteral nutrition is questioned. Timing with early initiation of enteral nutrition, avoidance of overfeeding, and step-wise advancement of feeds are required to safely realize the benefits of such therapy.

Abstract No. 592 Early (

To report placement parameters, feeding protocols, and adverse events for inpatients undergoing initiation of early (<12 hours) enteral nutrition following primary percutaneous ≥16-French gastrostomy placements. Such practices have been reported in outpatient oncology patients and after endoscopic gastrostomy placements, but not regarding inpatient placements by interventional radiology. A total of 2573 encounters containing “gastrostomy placement” were screened between 2015 and 2019. 236 inpatients, including 148 (62.7%) males and 88 (37.3%) females with mean age 59.4 ± 17.4 years, underwent early (<12 hour) enteral nutrition via ≥16-French gastrostomy tubes. Indications for placement included: neurologic (n = 159; 67.4%), malignancy (n = 50; 21.2%), miscellaneous (n = 23; 9.7%), and malnutrition (n = 4; 1.7%). Tubes were cleared for use 4 hours after placement. Placement parameters, immediate (intraprocedural) adverse events, early nutrition protocols, 30-day adverse events, and mortality were recorded. Most interventions were performed using 3 gastropexy sutures (n = 231; 98.9%) and a 16-French gastrostomy tube (n = 180; 76.3%). Pigtail and balloon-type gastrostomy tubes were placed in 156 (66.1%) and 98 (41.5%) patients, respectively. Immediate adverse events occurred in 2 (0.8%) patients, including broken gastropexy sutures without (category A; minor) and with arterial injury requiring embolization (category D; major). Mean time to enteral nutrition initiation was 7.5 ± 3.0 hours with mean rate of 104 ± 150 mL/hour. There were 14 (5.9%) adverse events within 30 days, including 3 category A (minor), 7 category B (minor), 3 category D (major), and 1 category F (major) complications. There were no differences in gastrostomy size (P = 0.45), tube type (P = 0.93), mean time to enteral nutrition initiation (P = 0.58), or mean initial tube feed rate (P = 0.09) between those without and with 30-day adverse events. Early (<12 hours) enteral nutrition after percutaneous large-bore (≥16-French) gastrostomy placement is safe in inpatients with adverse events within previously reported standards (0.4-22.5%).

Bedside Postpyloric Tube Placement and Enteral Nutrition Delivery in the Pediatric Intensive Care Unit.

Enteral nutrition (EN) delivery may be more effective via a postpyloric (PP) feeding tube in critically ill children, but tube placement can be challenging. We aimed to describe PP tube placement and EN practices in a multidisciplinary pediatric intensive care unit (PICU) after the implementation of a nurse-led bedside PP tube-placement program. In a single-center retrospective study, we identified 100 consecutive patients admitted to the PICU for >48 hours and for whom PP tube placement was attempted. Demographics, clinical characteristics, and details of PP tube placement and EN delivery were examined. The study cohort had a median age (25th, 75th percentiles) of 3.89 years (0.55, 14.86); 66% were male. Respiratory illness was the primary diagnosis of admission (55%); 92% were on respiratory support. Risk of aspiration was the primary indication for PP tube placement (48%). Bedside placement was the initial technique for PP tube placement in 93% of patients (successful for 84.9%) and was not associated with serious complications. Eighty-seven patients with a PP tube started EN and received a median 73.9% (12.3%, 100%) of prescribed energy goal on day 3 after EN initiation. PP EN allowed 14 of 39 patients receiving parenteral nutrition (PN) to transition off PN 7 days after EN initiation. Thirty-five percent of EN interruptions were due to feeding-tube dysfunction. Bedside PP tube placement is safe and feasible and allows for effective EN delivery and decreased PN use when applicable. Interruptions in PP EN due to tube malfunction are prevalent.

Effect of aging on the availability of amino acids from an immune-enhancing diet (IED) after a surgical stress in rats.

Dietary amino acid (AA) requirements increase after a surgical stress while the systemic AA availability from the diet decreases with age, due to splanchnic sequestration. While immune-enhancing diets (IEDs) have been recommended for the nutritional management of surgical patients, the systemic bioavailability of their AA supply has not been evaluated in elderly surgical patients. This was determined in surgically-stressed IED-fed aged rats. Thirty-four 5-month- or 21-month-old male Sprague-Dawley rats were used. After a gastrostomy and placement of a jugular vein catheter and a one-week recovery period, the animals underwent two 24h-enteral feedings with an arginine-enriched IED (Impact®, Nestlé Health Science) before (healthy state) and 18h after a standardized laparotomy, used as a model of surgical stress. During enteral nutrition, blood samples were repeatedly collected to measure plasma AA bioavailability (incremental areas under the curve) at 2, 5 and 24h. Surgical stress was evaluated from urinary catecholamines and plasma protein profile. Whatever the age or stress situation, IED feeding was associated with decreased plasma glycine and increased alanine, proline and arginine. Aging was mainly associated with a delayed plasma AA accumulation in the first hours after the initiation of enteral nutrition. Stress was associated with higher plasma arginine increase and lower histidine, methionine, phenylalanine and tyrosine accumulation. Age and stress interactions seem limited. AA bioavailability from an arginine-enriched IED seems to be maintained whatever age and stress situation. Aging appears to be mainly associated with a delay in plasma AA accumulation probably related to age-associated splanchnic sequestration of AAs. Additional effects of surgical stress per se seem limited.

The patient needing prolonged mechanical ventilation: a narrative review

Background: Progress in management has improved hospital mortality of patients admitted to the intensive care&#x0D; units, but also the prevalence of those patients needing weaning from prolonged mechanical ventilation, and of&#x0D; ventilator assisted individuals. The result is a number of difficult clinical and organizational problems for patients,&#x0D; caregivers and health services, as well as high human and financial resources consumption, despite poor long-term&#x0D; outcomes. An effort should be made to improve the management of these patients. This narrative review&#x0D; summarizes the main concepts in this field.&#x0D; Main body: There is great variability in terminology and definitions of prolonged mechanical ventilation.&#x0D; There have been several recent developments in the field of prolonged weaning: ventilatory strategies, use of&#x0D; protocols, early mobilisation and physiotherapy, specialised weaning units.&#x0D; There are few published data on discharge home rates, need of home mechanical ventilation, or long-term survival&#x0D; of these patients.&#x0D; Whether artificial nutritional support improves the outcome for these chronic critically ill patients, is unclear and&#x0D; controversial how these data are reported on the optimal time of initiation of parenteral vs enteral nutrition.&#x0D; There is no consensus on time of tracheostomy or decannulation. Despite several individualized, non-comparative&#x0D; and non-validated decannulation protocols exist, universally accepted protocols are lacking as well as randomised&#x0D; controlled trials on this critical issue. End of life decisions should result from appropriate communication among&#x0D; professionals, patients and surrogates and national legislations should give clear indications.&#x0D; Conclusion: Present medical training of clinicians and locations like traditional intensive care units do not appear&#x0D; enough to face the dramatic problems posed by these patients. The solutions cannot be reserved to professionals&#x0D; but must involve also families and all other stakeholders. Large multicentric, multinational studies on several aspects&#x0D; of management are needed.

Influence of Early versus Late supplemental ParenteraL Nutrition on long-term quality of life in ICU patients after gastrointestinal oncological surgery (hELPLiNe): study protocol for a randomized controlled trial

BackgroundNutrition plays a major role in intensive care unit (ICU) treatment, influencing ICU length of stay and patient’s survival. If preferable enteral nutrition administration is not feasible, ESPEN and ASPEN guidelines recommend initiation of a supplemental parenteral route between the first and seventh day, but exact timing remains elusive. While rapid development in critical care enabled significant reduction in the mortality rate of ICU patients, this improvement also tripled the number of patients going to rehabilitation. Thus, it is quality of life after ICU that has become the subject of interest of clinicians and healthcare policy-makers. A growing body of evidence indicates that protein turnover in the early phase of critical illness may play a crucial role in the preservation of lean body mass. A negative protein balance may lead to muscle wasting that persists weeks and months after ICU stay, resulting in deterioration of physical functioning. Folliwing oncological gastrointestinal tract surgery, patients are threatened with negative protein turnover due to cancer and extensive surgical insult.MethodsThis is a multi-centre, single-blinded, randomised controlled trial. The study population includes patients admitted to ICU units after major oncological gastrointestinal surgery that require supplemental parenteral nutrition. After initiation of enteral nutrition, the intervention group receives remaining daily requirement via supplemental parenteral nutrition on the first day of ICU stay while the control group is not supplemented parenterally until the seventh day of ICU stay while enteral nutrition is gradually increased.Primary endpoint: long-term quality of life measured in the physical component score (PCS) of SF-36 questionnaire at 3 and 6 months after ICU admission.DiscussionTo our knowledge, this is the first trial to investigate the influence of early supplemental parenteral nutrition on long-term quality of life after major oncological gastrointestinal surgery. We assume that, particularly in this population of patients, early supplemental parenteral nutrition may increase the long-term quality of life. The study construction also allows establishment of patients’ PCS SF-36 score prior to surgery and mean change in PCS SF-36 score during the recovery period, which is rarely seen in studies on critically ill patients.Trial registrationClinicalTrials.gov: NCT03699371 registered on 12 October 2018.

Volume-Based Feeding Enhances Enteral Delivery by Maximizing the Optimal Rate of Enteral Feeding (FEED MORE).

The importance of enteral nutrition (EN) in critically ill patients is well documented. However, actual administration of EN frequently does not amount to prescribed nutrition goals. Persistent underfeeding may lead to impaired immune response, increased mortality, and higher costs. Traditionally, EN uses a rate-based approach, utilizing slow titration to goal and a final fixed hourly rate, regardless of interruptions in feeding. Volume-based feeding (VBF) establishes a 24-hour EN goal volume, and the rate varies to achieve this daily goal when interruptions occur. This was a retrospective, single-center, quasi-experimental study comparing traditional rate-based feeding (RBF) to VBF in adult patients admitted to the medical and neurosurgical intensive care units (ICUs). The primary outcome was mean percentage of total goal energy received after EN initiation until 7 days, transfer from ICU, removal of feeding tube, or oral diet order placed. Secondary outcomes included mean percentage of total goal protein received, percentage of patients meeting 80% of nutrition goals, incidence of gastric residual volumes >400mL, and incidence of moderate hyperglycemia (>250mg/dL). The study enrolled 189 patients. Mean percentage of goal energy delivered (75% RBF, 102% VBF; P < .001) and goal protein delivered (68% RBF, 87% VBF; P < .001) was significantly higher with VBF compared with RBF. VBF demonstrated a significant increase in energy and protein delivery with no major safety or tolerability issues. VBF should be considered for use in ICU patients to optimize nutrition delivery.

Enteral nutrition in critically ill adults: Literature review of protocols.

Managing nutrition in critically ill patients is an important intervention to promote healing. It is unknown whether the implementation of a protocol that guides enteral nutrition (EN) support is effective in improving the outcomes of critically ill patients. Furthermore, it is unknown whether a nurse-driven protocol is more or less effective than a protocol not managed by nurses. The purpose of this literature review is to determine the current state of the science regarding evidence-based protocols for the administration and management of EN in critically ill patients. Studies were identified by searching the Cumulative Index to Nursing and Allied Health Literature Plus database for the terms "enteral nutrition AND nursing." Studies with EN protocols for adult, critically ill patients published since 2011 were included. Studies without a protocol and those pertaining to paediatric, disease-specific, medical-surgical, or community-based populations were excluded. A total of 10 studies meeting the inclusion criteria were identified. Defining and implementing both early initiation of EN and adequate titration to goal are important for achieving the maximum nutritional advantage. The highest benefit is also derived from identifying and delivering an individualized caloric and/or protein goal. A protocol increases standardization of practice in relation to these themes as well as the management of gastric residual volume, complications, and potentially for managing feeding interruptions. Because of the significant effects of nursing care on nearly all aspects of the management and delivery of EN, a nurse-driven protocol may yield higher compliance and greater effectiveness than a protocol that is not nurse driven. Nurses are at the forefront of EN administration, although interprofessional collaboration remains paramount. Current practice must align with the best practice in the development and implementation of an EN protocol.

Enteral and parenteral nutrition considerations in pediatric patients

Current clinical practice guidelines on management of enteral nutrition (EN) and parenteral nutrition (PN) in pediatric patients are reviewed. The provision of EN and PN in pediatric patients poses many unique considerations and challenges. Although indications for use of EN and PN are similar in adult and pediatric populations, recommended EN and PN practices differ for pediatric versus adult patients in areas such as selection of EN and PN formulations, timing of EN and PN initiation, advancement of nutrition support, and EN and PN goals. Additionally, provision of EN and PN to pediatric patients poses unique compounding and medication administration challenges. This article provides a review of current EN and PN best practices and special nutrition considerations for neonates, infants, and other pediatric patients. The provision of EN and PN to pediatric patients presents many unique challenges. It is important for pharmacists to keep current with pediatric- and neonatal-specific guidelines on nutritional management of various disease states, as well as strategies to address compounding and medication administration challenges, in order to optimize EN and PN outcomes.

Feeding During Resuscitation After Burn Injury.

Burn injury results in a sustained hypermetabolic state with resulting increased caloric and protein requirements to support the stress and immune responses; augmented protein, fat, and carbohydrate catabolism; oxidative stress; and exudative losses. Along with surgical debridement, nutrition and resuscitation are the foundations of patient management after severe burn injury. Recent literature has demonstrated a clear benefit to early enteral nutrition initiation during the resuscitation period. This review aims to examine recent literature discussing both physiologic impact of burn injury and approaches to feeding during resuscitation after burn injury; including methods of determining nutrition requirements, routes, timing, and monitoring response and the associated benefits and consequences thereof.