Initiation Of Parenteral Nutrition Research Articles

Impact of Omega-3 Fatty Acid Supplementation in Parenteral Nutrition on Inflammatory Markers and Clinical Outcomes in Critically Ill COVID-19 Patients: A Randomized Controlled Trial.

The heightened inflammatory response observed in COVID-19 patients suggests that omega-3 fatty acids (O3FA) may confer anti-inflammatory benefits. This randomized, double-blind, single-center clinical trial aimed to evaluate the effect of O3FA supplementation in parenteral nutrition (PN) on inflammatory markers in COVID-19 patients admitted to the intensive care unit (ICU). A total of 69 patients were randomized into three groups: one received standard lipid emulsion, and two received O3FA (Omegaven®) at doses of 0.1 g/kg/day and 0.2 g/kg/day, respectively, in addition to Smoflipid®. The primary outcomes measured were serum levels of C-reactive protein (CRP) and interleukin-6 (IL-6) on days 1, 5, and 10 of PN initiation. Secondary outcomes included additional inflammatory markers (TNF-α, IFN-γ, IL-1Ra, CXCL10), hepatic function, triglyceride levels, and clinical outcomes such as mortality and length of ICU and hospital stay. Results indicated a significant reduction in CRP, IL-6, and CXCL10 levels in the group receiving 0.1 g/kg/day O3FA compared to the control. Additionally, the higher O3FA dose was associated with a shorter ICU and hospital stay. These findings suggest that O3FA supplementation in PN may reduce inflammation and improve clinical outcomes in critically ill COVID-19 patients.

Prokinetic effect of erythromycin in the management of gastroparesis in critically ill patients-our experience and literature review.

Gastroparesis is a disorder characterized by impaired gastric emptying and the accumulation of food in the intestines without any clear mechanical cause. Gastroparesis in critical care patients is a prevalent issue in the intensive care unit. The disruption of normal gastrointestinal motility in critically ill patients is linked to a significant risk of intolerance to enteral feeding, colonization of the gastrointestinal tract with pathogenic bacterial strains, increased permeability of the intestinal wall, translocation of the intestinal microbiota, leading to progressive malnutrition, and potential development of bacterial infection. The literature was reviewed to assess the benefits and risks associated with the use of this medication. The aim of the study was to treat the symptoms of gastroparesis and stimulate gastrointestinal motility. Consequently, the aim was to reduce the amount of backed-up food content in the stomach, accelerate gastrointestinal motility, and return to intestinal feeding. Gastroparesis is a frequent issue among patients in the intensive care unit. Critical illness can lead to gastrointestinal motility disorders, causing slowed gastric emptying. This increases the risk of problems such as intolerance to enteral feeding, regurgitation, and aspiration of gastrointestinal contents into the respiratory tract, as well as colonization of the gastrointestinal tract by pathogens. Over time, impaired intestinal absorption can result in malnutrition, necessitating the initiation of parenteral nutrition. After analysis of the literature and published scientific reports, as well as considering their own research, it is evident that erythromycin, as a prokinetic drug, effectively enhances gastrointestinal motility. This contributes to stimulating gastric emptying in critically ill patients with gastroparesis who are hospitalized in an intensive care unit. The use of erythromycin in combination with metoclopramide and/or itopride hydrochloride allows for a synergistic effect, leading to the quickest possible return to enteral feeding.

Early parenteral nutrition is associated with improved growth in very low birth weight infants: a retrospective study

ObjectiveTo assess the association between early initiation of parenteral nutrition (PN) and body growth in preterm infants with very low birth weight (VLBW).DesignCausal inference analysis with confounders preselected by causal...

Vietnam National Survey on Parenteral Nutrition Practice in Preterm Neonates: Practice Status, Barriers, and Implications.

Due to high risks of feeding intolerance, preterm infants often receive parenteral nutrition (PN) to ensure sufficient nutrition and energy intake. However, there is a lack of data on the status of clinical PN practice and barriers among neonatal care units in low- to middle-income countries like Vietnam. This extensive survey explores the status and barriers of PN practice for preterm infants in neonatal units across Vietnam and identifies the practical implications of enhancing nutritional outcomes in preterm infants. A multicenter nationwide web-based survey on PN practice in preterm infants was conducted across 114 neonatal units from 61 provinces in Vietnam. Among 114 neonatal units receiving a request for surveys, 104 units (91.2%) from 55 provinces participated. Neonatal units were categorized as level I (2/104, 1.9%), II (39/104, 37.5%), III (56/104, 53.8%), and IV (7/104, 6.8%). We found that the initiations of PN within the first hour and the first two hours of life occurred in 80.8% (84/104) and 95.2% (99/104) of the units, respectively. The early provision of amino acids, or AA (within the first day of life) and lipids (within two days of life) were documented by 85% (89/104) and 82% (84/104) of the respondents, respectively. The initial dose of AA ranged from 0.5 to 3 g/kg/day; the dose of AA less than 1 g/kg/day was reported by 7.7% (8/104) of the respondents; the maximum dose of AA ranged from 2 to over 4.5 g/kg/day, with 4 g/kg/day reported by 47.1% (49/104) of the respondents. The initial dose of lipids was between 0.5 and 2 g/kg/day, frequently 1 g/kg/day, reported by 51.9% (54/104) of the respondents; the target lipid dose ranged from 3 to 4 g/kg/day in 93.3% (97/104) respondents; the maximum target dose for lipid was 4 g/kg/day in 36.5% (38/104) of the respondents. The initial glucose dose was distributed as follows: 46.2% of respondents (48/104) administered 4 mg/kg/minute, 21.2% (22/104) used 5 mg/kg/minute, 28.8% (30/104) used 6 mg/kg/minute, and 3.8% (4/104) used 3 mg/kg/minute. Additionally, 48.1% of respondents (50/104) reported a maximum glucose infusion rate above 13 mg/kg/min and 19.2% (20/104) above 15 mg/kg/min. Nineteen percent (20/104) of the respondents reported a lack of micronutrients. Barriers to PN initiation included difficulty in establishing intravenous lines, the absence of standardized protocols, the lack of lipids and micronutrients, infections, and unavailable software supporting neonatologists in calculating nutrition paradigms. This study's findings highlight the highly variable PN practice across neonatal units in Vietnam. Deviations from current practical guidelines can be explained by various barriers, most of which are modifiable. A monitoring network for nutritional practice status and a database to track the nutritional outcomes of preterm infants in Vietnam are needed.

Growth and Neurodevelopmental Outcomes of Preterm Infants Born < 26 Weeks Gestation before and after Implementation of a Nutrition-Care Bundle.

This study aimed to assess the impact of a nutrition-care bundle on growth and neurodevelopmental outcomes of micro-preterm infants born in a level III neonatal intensive care unit (NICU) by two years corrected age. A nutrition-care bundle emphasizing the prompt initiation of parenteral nutrition at birth, initiation of enteral feeds within 6 h after birth, and early addition of human milk fortifiers was implemented in 2015 for infants born < 26 weeks gestation. This before-and-after study evaluated growth and neurodevelopmental outcomes in infants born between 2012-2013 (before-nutrition-bundle, BNB) and 2016-2017 (after-nutrition-bundle, ANB). A total of 145 infants were included in the study. Infants in the ANB group (n = 73) were smaller (birthweight and gestational age), and there were more male infants and multiples included compared to the BNB group (n = 72). Enteral feeds and fortifiers started earlier in the ANB group. Growth velocity and weight z-score changes were similar in both groups during NICU stay and post-discharge. Systemic steroid use, but not cohort, was linked to lower Bayley scores across all domains. Implementing a nutrition-care bundle was not consistently associated with improved weight gain and neurodevelopmental outcomes in the micro-preterm infant population, possibly due to ongoing high-quality nutritional care by the clinical team.

Changes in Global Nutrition Practices in Critically Ill Children and the Influence of Emerging Evidence: A Secondary Analysis of the Pediatric International Nutrition Studies, 2009-2018

BackgroundThe timeline of the 3 Pediatric International Nutrition Studies (PINS) coincided with the publication of 2 major guidelines for the timing of parenteral nutrition (PN) and recommended energy and protein delivery dose. ObjectiveThe study's main objective was to describe changes in the nutrition delivery practice recorded in PINS1 and PINS2 (PINS1-2) (conducted in 2009 and 2011, preexposure epoch) vs PINS3 (conducted in 2018, postexposure epoch), in relation to the published practice guidelines. DesignThis study is a secondary analysis of data from a multicenter prospective cohort study. Participants/settingData from 3650 participants, aged 1 month to 18 years, admitted to 100 unique hospitals that participated in 3 PINS was used for this study. Main outcome measuresThe time in days from pediatric intensive care unit admission to the initiation of PN and enteral nutrition delivery were the primary outcomes. Prescribed energy and protein goals were the secondary outcomes. Statistical analyses performedA frailty model with a random intercept per hospital with stratified baseline hazard function by region for the primary outcomes and a mixed-effects negative binomial regression with random intercept per hospital for the secondary outcomes. ResultsThe proportion of patients receiving enteral nutrition (88.3% vs 80.6%; P < .001) was higher, and those receiving PN (20.6% vs 28.8%; P < .001) was lower in the PINS3 cohort compared with PINS1-2. In the PINS3 cohort, the odds of initiating PN during the first 10 days of pediatric intensive care unit admission were lower, compared with the PINS1-2 cohort (hazard ratio 0.8, 95% CI 0.67 to 0.95; P = .013); and prescribed energy goal was lower compared with the PINS1-2 cohort (incident rate ratio 0.918, 95% CI 0.874 to 0.965; P = .001). ConclusionsThe likelihood of initiation of PN delivery significantly decreased during the first 10 days after admission in the PINS3 cohort compared with PINS1-2. Energy goal prescription in children receiving mechanical ventilation significantly decreased in the postguidelines epoch compared with the preguidelines epoch.

Approximately 50% of acute intestinal failure (AIF) patients on short-term parenteral nutrition (PN) have intestinal failure-associated liver disease (IFALD) without effect on hospital length of stay and mortality

Patients with intestinal failure (IF) are often dependent on PN for provision of calories and nutrients for survival. Similar to chronic intestinal failure (CIF) patients, those who have AIF are also at risk of IFALD, which is a poorly understood but potentially fatal condition. The local incidence of IFALD amongst AIF patients is not known. The primary objective of this study was to determine the incidence of IFALD in AIF patients on short-term PN. Secondary objectives were to analyse patient and PN risk factors of IFALD, and clinical outcomes of length of stay (LOS) and inpatient mortality. This was a retrospective cross-sectional cohort study of hospitalised adult patients with AIF prescribed with short-term PN. All adult patients aged 21 years and above who received PN for at least 5 consecutive days and had normal liver function tests (LFTs) at the time of PN initiation were included in this study. A total of 171 patients were enrolled in this study, with 77 (45%) having deranged LFTs at the end of PN therapy and categorised under the IFLAD group. The patient cohort was predominantly male (92 [54%]) and had a median age of 68 years (IQR 59-76). Patients with IFALD at the end of PN therapy had higher diabetes prevalence (36% vs 26%, p=0.2) and were on PN for a longer duration (median [IQR]: 12 [8-17] vs 8 [6-15] days, p=0.003) than those without IFALD. There were no significant differences in patient and PN characteristics between the IFLAD and non-IFALD group. The multivariable models showed that the IFALD cohort had longer hospital stays (HR 0.90, 95% CI 0.65-1.23) and lower odds ofinpatient death (OR 0.75, 95% CI 0.12-4.60), though both findings are not statistically significant (p=0.5, 0.7). In this study, IFALD is a common phenomenon in AIF and the incidence was found to be an estimated 50% amongst patients on short-term PN with similar clinical outcomes between the two groups.

Association between energy delivery from parenteral nutrition and refeeding syndrome in hospitalized adults: A retrospective cohort study.

Patients receiving parenteral nutrition (PN) may develop refeeding syndrome (RFS). This study determined RFS prevalence in hospitalized adultson PN and evaluated whether higher energy delivered by PN on day 1 of PN initiation wasassociated with RFS development. We reviewed the medical records of adult patients receiving PN at a Thai quaternary hospital from June 2019 to May 2022. RFS was defined based on the Nutrition Management Clinical Practice Recommendation by the Society of Parenteral and Enteral Nutrition of Thailand. The association between PN energy delivery and RFS development was determined using a generalized estimating equation for multiple logistic regression analysis adjusted for NICE guideline risk factors. A total of 547 patients was included (mean age 59.8 ± 17.2 years, mean body mass index 20.7 ± 4.8 ). The prevalence of RFS was 45%. Factors associated with RFS included energy from PN on the first day of PN initiation (adjusted odds ratio [aOR] 1.17; 95% CI 1.04-1.33; for every 5 kcal/kg/day increase), starvation >5 days prior to PN (aOR 1.54; 95% CI 1.04-2.26), concomitant diuretic use (aOR 1.81; 95% CI 1.25-2.64), low baseline potassium level (aOR 1.79; 95% CI 1.19-2.70), and individual compounding PN (aOR 1.61; 95% CI 1.04-2.51). RFS was common among hospitalized patients receiving PN. The amount of energy delivered on the first day of PN was independently associated with RFS, raising a concern regarding initiation of PN with higher energy.

Reducing Procedural Pain and Avoiding Peripheral Intravenous Catheters by Implementing a Feeding Protocol for Late Preterm Infants: A Quality Improvement Project.

Late preterm births account for a large portion of preterm births, yet the optimal method of nutrition and enteral feeding in this population remains unclear and often involves intravenous (IV) fluids. To develop and implement a late preterm feeding protocol in order to decrease the necessity of IV access, decrease the use of starter parenteral nutrition (PN), and reduce the pain endured by an infant in the neonatal intensive care unit. The Plan-Do-Study-Act quality improvement model was utilized as a framework for the implementation of this quality improvement project. A literature review was conducted and subsequently, a feeding protocol was developed and included the more judicious use of starter PN. This protocol was implemented, evaluated, and adopted. A second Plan-Do-Study-Act cycle was completed with the addition of an auto-text reminder incorporated into admission notes in the electronic medical record. The implementation of the protocol significantly reduced placement of IV access and the use of starter (PN) in late preterm infants without considerable differences in balancing measures. The percentage of infants who received peripheral IV access declined considerably from 70% to 42% ( P = .0017) subsequently, less pain endured by the infants. There was a decrease in the initiation of starter PN from 55% to 7% ( P < .00001). Administering enteral feedings on admission to stable, late preterm infants reduced the need for peripheral IV access and thus decreased pain from this procedure.

Associations between In-Hospital Mortality and Prescribed Parenteral Energy and Amino Acid Doses in Critically Ill Patients: A Retrospective Cohort Study Using a Medical Claims Database.

Some critically ill patients completely rely on parenteral nutrition (PN), which often cannot provide sufficient energy/amino acids. We investigated the relationship between PN doses of energy/amino acids and clinical outcomes in a retrospective cohort study using a medical claims database (≥10.5 years, from Japan, and involving 20,773 adult intensive care unit (ICU) patients on mechanical ventilation and exclusively receiving PN). Study patients: >70 years old, 63.0%; male, 63.3%; and BMI < 22.5, 56.3%. Initiation of PN: third day of ICU admission. PN duration: 12 days. In-hospital mortality: 42.5%. Patients were divided into nine subgroups based on combinations of the mean daily doses received during ICU days 4-7: (1) energy (very low <10 kcal/kg/day; low ≥10, <20; and moderate ≥20); (2) amino acids (very low <0.3 g/kg/day; low ≥0.3, <0.6; and moderate ≥0.6). For each subgroup, adjusted odds ratios (AORs) of in-hospital mortality with 95% confidence intervals (CIs) were calculated by regression analysis. The highest odds of mortality among the nine subgroups was in the moderate calorie/very low amino acid (AOR = 2.25, 95% CI 1.76-2.87) and moderate calorie/low amino acid (AOR = 1.68, 95% CI 1.36-2.08) subgroups, meaning a significant increase in the odds of mortality by between 68% and 125% when an amino acid dose of <0.6 g/kg/day was prescribed during ICU days 4-7, even when ≥20 kcal/kg/day of calories was prescribed. In conclusion, PN-dependent critically ill patients may have better outcomes including in-hospital mortality when ≥0.6 g/kg/day of amino acids is prescribed.

Supplemental parenteral nutrition initiation timing and clinical outcomes in critically ill patients: An exploratory data analysis

Supplemental parenteral nutrition initiation timing and clinical outcomes in critically ill patients: An exploratory data analysis

Routine laboratory parameters to support decision on parenteral nutrition in palliative care.

Parenteral nutrition (PN) is widely used in palliative care (PC), but there is limited evidence to support its use at the end of life (EOL). This aim of this was to investigate the relationship between routine laboratory parameters and survival in patients receiving PN, and to develop a decision tree model to support clinicians decide whether to start or forgo PN. The laboratory parameters of 113 patients with advanced diseases who were admitted to a specialized palliative care unit (PCU) were analyzed at two points in time: T0 = before PN, T1 = two weeks after initiation of PN. Univariate Mann-Whitney U-tests and multivariate linear regression models, as well as a decision tree analysis were computed; all in relation to survival time. The final regression model was significant with p = 0.001 (adjusted R2 = 0.15) and included two predictors for survival time after PN initiation: the CRP/albumin ratio and urea at T1 (ps = 0.019). Decision tree analysis revealed three important predictors for classification of survival time after PN initiation: CRP, urea, and LDH (all at T0). The decision tree model may help to identify patients likely to benefit from PN, thus supporting the clinical decision whether or not to start PN.

Changes in serum prealbumin as a marker for nitrogen balance in surgical oncology patients.

Serum prealbumin has long been used as a marker of nutritional status. However, prealbumin is a negative acute phase reactant influenced by several non-nutritional-related factors including surgery, infection, and cancer. An increasing prealbumin has been correlated with a positive nitrogen balance in general surgery patients receiving parenteral nutrition (PN) with 88% specificity and 70% sensitivity. To date, no trial has evaluated the effect of concurrent cancer and surgery on the value of prealbumin in predicting nitrogen balance. This study is a concurrent retrospective design of post-operative patients (≥ 19years of age) identified by the nutrition support service who received PN for ≥ 5days, had a baseline and follow-up serum prealbumin and C-reactive Protein (CRP) measured, as well as a 24-h urinary urea nitrogen (UUN) performed between days 5-10 of PN. Exclusion criteria include anuric renal failure, Child-Pugh Class C liver failure, pregnancy, and corticosteroid use. Prealbumin was correlated to nitrogen balance, measuring sensitivity, specificity, and negative and positive predictive values. Information was collected regarding patient demographics and presence or absence of metastatic cancer. Thirty patients were identified and evaluated for this study from December 1st, 2010 to July 15th, 2011. Patients included in the study had a mean age of 57years old (range 20-82), 53% male, with a mean weight of 84kg (range 42-140) and body mass index (BMI) of 29kg/m2 (range 14.9-56.8). The mean daily caloric dose of PN per actual body weight was 21kcal/kg (range 10-34) and the mean daily protein dose was 1.4g/kg (range 1-2). Forty seven percent of patients were obese (BMI > 30kg/m2) and were prescribed high-protein hypocaloric PN. The most common indication for PN was post-operative ileus (23/30 patients). 24-h urine collection for UUN was performed on average of day 8 after PN initiation (range 5-10days). Nitrogen balance as calculated from 24-h UUN was positive in 17/30 patients. A positive prealbumin change of greater than 2.8 mg/dL was found to have a statistically significant association with positive nitrogen balance (p = 0.02). At the cut off level of positive 2.8 mg/dL, the likelihood of a positive nitrogen balance had a sensitivity of 82% (95% confidence interval (CI) 64-100%); specificity of 62% (95% CI 35-88%); positive predictive value of 74% (95% CI 54-93%); negative predictive value of 73% (95% CI 46-99%). No absolute value for prealbumin level (e.g., > 20 mg/dL) was found to be a significant predictor of positive nitrogen balance. CRP levels at initiation of PN were significantly elevated with a mean level of 147mg/dL. These results indicate a positive change in serum prealbumin (> 2.8mg/dL) has sufficient sensitivity (82%) to predict positive changes in nitrogen balance in the surgical oncology population. However, the low specificity (62%) makes it less useful in predicting a negative nitrogen balance. Absolute prealbumin levels were greatly affected by inflammation, as evidenced by CRP levels, and single values were not useful in predicting positive nitrogen balance. Positive changes in serum prealbumin levels have previously been associated with a positive nitrogen balance (NB) in surgical patients receiving parenteral nutrition (PN); however, it is unclear if this is true in oncologic surgery patients. This study highlights how changing levels of serum prealbumin and C-reactive protein correlates to NB for cancer patients in the post-operative period requiring PN. Changes in prealbumin levels from baseline showed sufficient sensitivity, but not specificity to utilize routinely for predicting NB in this population.

Association between dextrose-containing maintenance fluids and phosphorus supplementation during total parenteral nutrition initiation in adult patients who were hospitalized: A retrospective cohort study.

Use of dextrose-containing maintenance fluids prior to parenteral nutrition (PN) initiation is speculated to reduce the risk for refeeding syndrome. We aimed to assess if the use of dextrose vs nondextrose maintenance fluids before PN initiation changes electrolyte supplementation requirements and shifts during initiation. This retrospective cohort study included patients who received nothing by mouth but received maintenance fluids ≥72 h before PN. The major end point was phosphorus supplementation over 48 h following nutrition initiation. Minor end point included other electrolyte supplementation, changes in electrolyte levels, time to discharge, and goal kilocalories per day. Fifty-three patients between August 1, 2019, and August 26, 2020, met criteria for analysis; 60% (n = 32) used a dextrose and 40% (n = 21) used a nondextrose maintenance fluid. Baseline characteristics were similar between fluid groups except for body mass index (25.1 dextrose vs 27.5 kg/m2 nondextrose), sex (43.8% female vs 52.4% male), and severe malnutrition (46.9% vs 28.6%), respectively. Phosphorus (52.5 vs 50 mmol; P = 0.33) and magnesium (24 vs 22 g; P = 0.63) supplementation 48 h following nutrition initiation were similar between groups; however, potassium supplementation was lower in the dextrose group (165.0 vs 208.7 mEq; P = 0.01). No difference was observed between groups for time to discharge following nutrition initiation or time to goal kilocalories per day. After controlling for patients who were malnourished between fluid groups using linear regression, phosphorus repletion differences remained nonsignificant. This study did not detect a difference in phosphorus supplementation between groups, even after controlling for patients who were malnourished.

Timing of enteral nutrition and parenteral nutrition in the PICU.

The timing of nutrition support initiation has the potential to positively impact nutrition and clinical outcomes in infants and children with critical illness. Early enteral nutrition within 24-48 h and attainment of both a 60% energy and protein goal by the end of the first week of pediatric intensive care unit admission are reported to be significantly associated with improved survival in large observational studies. The results of one randomized controlled trial demonstrated increased morbidity in infants and children with critical illness assigned to early vs delayed supplemental parenteral nutrition. Observational studies in this population also suggest increased mortality with exclusive parenteral nutrition and worse nutrition outcomes when parenteral nutrition is delayed. Subsequently, current nutrition support guidelines recommend early enteral nutrition and avoidance of early parenteral nutrition, although the available evidence used to create the guidelines was inadequate to inform bedside nutrition support practice to improve outcomes. These guidelines are limited by the included studies with small numbers and heterogeneity of patients and research design that confound study outcomes and interpretation. This article provides a narrative review of the timing of nutrition support on outcomes in infants and children with critical illness, strategies to optimize timing and adequacy of nutrition support, and literature gaps, including the timing of parenteral nutrition initiation for children with malnutrition and those with contraindications to enteral nutrition and accurate measurement of energy requirements.

Total parenteral nutrition for patients with gastrointestinal cancers: a clinical practice review.

The use of total parenteral nutrition (TPN) in patients with gastrointestinal cancers is a well-established practice, yet there is substantial variability in its use across institutions. Decision-making around the initiation of TPN is complex. An interdisciplinary team can help identify patient factors and clinical situations that influence whether a patient is likely to benefit from parenteral nutrition. We present the case of a woman with a gastrointestinal cancer who benefited from the initiation of TPN as a bridge therapy to further cancer treatment. This case highlights the importance of establishing a plan for nutrition with specific goals in mind, such as optimizing patients for more cancer-directed therapy. Although patients with gastrointestinal cancers may be candidates for TPN, many patient-specific factors, such as functional status and opportunities for future treatments, must be considered prior to the initiation of parenteral nutrition. An interdisciplinary approach should be used to make recommendations based on patient goals, with a focus on patient and cancer characteristics that are associated with positive outcomes after initiation of TPN. These characteristics include functional status, nutritional status, degree of symptom control, and ability to safely administer nutrition. It is important to continually assess whether parenteral nutrition is beneficial in respect to a patient's preferences and prognosis.

Guidelines for parenteral nutrition in preterm infants: The American Society for Parenteral and Enteral Nutrition.

Parenteral nutrition (PN) is prescribed for preterm infants until nutrition needs are met via the enteral route, but unanswered questions remain regarding PN best practices in this population. An interdisciplinary committee was assembled to answer 12 questions concerning the provision of PN to preterm infants. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) process was used. Questions addressed parenteral macronutrient doses, lipid injectable emulsion (ILE) composition, and clinically relevant outcomes, including PNALD, early childhood growth, and neurodevelopment. Preterm infants with congenital gastrointestinal disorders or infants already diagnosed with necrotizing enterocolitis or PN-associated liver disease (PNALD) at study entry were excluded. The committee reviewed 2460 citations published between 2001 and 2023 and evaluated 57 clinical trials. For most questions, quality of evidence was very low. Most analyses yielded no significant differences between comparison groups. A multicomponent oil ILE was associated with a reduction in stage 3 or higher retinopathy of prematurity (ROP) compared to an ILE containing 100% soybean oil. For all other questions, expert opinion was provided. Most clinical outcomes were not significantly different between comparison groups when evaluating timing of PN initiation, amino acid dose, and ILE composition. Future clinical trials should standardize outcome definitions to permit statistical conflation of data, thereby permitting more evidence based recommendations in future guidelines. This guideline has been approved by the ASPEN 2022-2023 Board of Directors.

Utilization of parenteral nutrition in major gastrointestinal surgery: An opportunity for quality improvement

Parenteral nutrition (PN) is commonly utilized to support patients in the perioperative period of major gastrointestinal (GI) surgeries. This study sought to evaluate PN utilization based on malnutrition status and duration of PN use in a single academic institution to evaluate baseline ASPEN recommendation concordance and identify opportunities for quality improvement. Patients who had undergone major GI surgical oncology operations and received PN were identified over six months. The medical charts were reviewed for clinicopathologic variables, nutrition status, and the initiation and duration of PN. The cohort was stratified by PN recommendation concordance, and intergroup comparisons were made to identify factors associated with non-concordant utilization of PN. Eighty-one patients were identified, 38.3% of patients were initiated on PN due to dysmotility. Other indications were: intra-abdominal leak (27.2%), mechanical obstruction (18.5%), and failure to thrive (16.0%). Non-concordant PN utilization was identified in 67.9% (55/81) of patients. The most frequent reason for non-concordance was initiation outside the recommended time frame due to severity of malnutrition; well-nourished patients started "too soon" accounted for 29.0% (16/55), and 61.8% started "too late," most of whom were moderately or severely malnourished (34/55). In 16.0% (13/81) of the overall cohort, PN was administered for fewer than five days. PN use during the perioperative period surrounding major GI oncologic operations is clinically nuanced and frequently not concordant with established ASPEN recommendations. Quality improvement efforts should focus on reducing delayed PN initiation for nutritionally at-risk patients without increasing premature PN use in well-nourished patients.

Timing of parenteral nutrition initiation in critically ill children: a randomized clinical trial.

The optimal timing of parenteral nutrition (PN) initiation in critically ill children remains controversial. To identify the optimal timing of PN initiation in critically ill children. This randomized clinical trial was conducted in the pediatric intensive care unit (PICU) of Menoufia University Hospital. A total of 140 patients were randomized to receive early or late PN. The early PN group consisted of 71 well-nourished and malnourished patients who received PN on the first day of PICU admission. Malnourished (42%) and well-nourished children randomized to the late PN group (42%) started PN on the fourth versus seventh day after admission, respectively. Mechanical ventilation (MV) was the primary outcome, while PICU length of stay and mortality were secondary outcomes. Patients who received early PN started enteral feeding significantly earlier (median, 6 days; interquartile range, 2-20 days) than those not provided early PN (median, 12 days; interquartile range, 3-30 days; P<0.001) and had a significantly lower risk of feeding intolerance (5.6% vs.18.8%, P=0.035). The median time required to obtain full calories enterally was shorter in the early versus late PN group (P=0.004). Furthermore, patients in the early versus late PN group had a significantly shorter median PICU stay (P<0.001) and were less likely to require MV (P=0.018). Patients who received early PN had a lower MV need and duration than those who received later PN and had more favorable clinical outcomes in terms of morbidity.

Two cases of MEGDHEL syndrome diagnosed with hyperammonemia

MEGDHEL [3-methylglutaconic aciduria (MEG), deafness (D), hepatopathy (H), encephalopathy (E), and Leigh-like disease (L)] syndrome is an autosomal recessive disorder caused by mutations in the serine active site-containing protein 1 (SERAC1) gene. MEGDHEL syndrome is clinically characterized by sensorineural hearing loss, encephalopathy, hepatopathy, 3-methylglutaconic aciduria, and Leigh-like lesions on cranial magnetic resonance imaging. During theneonatal period, it has been reported to present with hypoglycemia, hyperammonemia, impaired liver functions, cholestasis, metabolic acidosis, and sepsis-like clinical findings. However, clinical findings in the neonatal period were reported as a result of the retrospective evaluation of patients diagnosed at an older age. Herein we reported two cases diagnosed as MEGDHEL syndrome during neonatal period in two different clinics with sepsis-like findings, impaired liver functions, and ammonia levels high enough torequire dialysis. One of the cases was born 37weeks of gestation with a birth weight of 2,060g and initially presented with respiratory distress and feeding difficulties. The othercase admitted to the neonatal intensive care unit hadfedproblems together with respiratory distress and circulatory failure within the first 24h after initiation of parenteral nutrition. MEGDHEL syndrome should be suspected in patients with sepsis-like clinical features and hyperammonemia.