Parenteral Nutrition Regimens Research Articles

Sodium glycerophosphate use in parenteral nutrition improves mineral metabolism in extremely low birth weight infants.

To evaluate the clinical effect of sodium glycerophosphate (NaGP) in parenteral nutrition solutions on mineral metabolism in extremely low birth weight (ELBW) infants. NaGP was introduced for use in place of potassium phosphate (K3PO4) in January 2018; this retrospective cohort study included 95 ELBW infants treated with K3PO4 between January 2015 and December 2017 and 77 infants treated with NaGP between August 2018 and January 2021. Mineral intake over the first 14days; changes in serum calcium, phosphorus, sodium, and alkaline phosphatase (ALP) levels over the first 1-3months; and the rates of electrolyte imbalance and clinical morbidity were compared. High-risk infants who had nil per os (NPO) status for >14days and prolonged parenteral nutrition exposure were further analyzed as a subgroup. The use of NaGP instead of K3PO4 significantly increased Ca and P intake, but intakes remained below the recommended range (Ca, 64-140mg/kg/day; P, 50-108mg/kg/day). Compared with levels in the K3PO4 group, the NaGP group had significantly higher serum Ca and P levels after day 14 and lower ALP levels after day 56. In the subgroup analysis, the NaGP group had significantly lower incidences of hypophosphatemia, hyponatremia, bronchopulmonary dysplasia, and ALP >500 IU/L. Although the administration of NaGP instead of K3PO4 in parenteral nutrition regimens still did not provide adequate Ca and P intake for ELBW infants, higher intake significantly improved serum Ca and P levels, especially in ELBW infants with prolonged parenteral nutrition exposure.

Superior Mesenteric Artery Syndrome: A Vicious Cycle?

CASE REPORT Superior mesenteric artery syndrome (SMAS) is a rare syndrome where the third part of the duodenum is compressed between the abdominal aorta and the superior mesenteric artery (SMA).1 The loss of the intervening mesenteric fat pad causes the aortomesenteric angle to decrease from its normal value of 38°–65° to less than 25°, decreasing the aortomesenteric distance to less than 10 mm and causing duodenal compression. Its incidence in the general population is between 0.1% and 0.3% with a female predominance.2 A 22-year-old woman presented to the emergency department of our hospital with complaints of vomiting and a marked decrease in appetite for the past 4 months. The vomiting was nonbilious and nonprojectile and would only occur postprandially. She also reported past episodes of watery diarrhea associated with anorexia and experienced intermittent episodes of fever, documented at 101°F–102°F. Since the start of her symptoms, she had lost 27 kg. An upper abdominal computed tomography scan in both plain and contrast films revealed significant gastric distention, distention of the duodenum up to the second and third parts, and a relatively collapsed small bowel distal to the presumed crossing of SMA (Figure 1). The computed tomography scan displayed downward inclination of SMA and significant compression of the left renal vein between the abdominal aorta and SMA, confirming the existence of left renal vein entrapment syndrome in our case (Figure 2). In addition, there was a reduced aortomesenteric angle of 11.8°, and a distance of 8 mm was observed (Figure 3). In lieu of the above findings, SMAS was suspected. The patient initially received conservative treatment and was started on nasogastric feeding tube. Owing to intolerance, a total parenteral nutrition regimen was used to stabilize the patient's weight. Only 2 kg were gained by the patient over the course of 4 weeks. Her symptoms continued to worsen despite her slight weight gain. Having failed to achieve a satisfactory outcome with conservative management, an exploratory laparotomy was performed. The peritoneal cavity was exposed through a midline skin incision. There was gross distention of the second part of the duodenum, and the third part of the duodenum was compressed. Owing to grossly dilated duodenum, the decision was taken to perform gastrojejunostomy instead of duodenojejunostomy. Stapled posterior gastrojejunostomy was performed to bypass the compressed duodenum, and an anastomosis was made between the stomach and the proximal loop of the jejunum (Figure 4). The intraperitoneal drain was kept in place. An uneventful recovery followed the patient's extubation.Figure 1.: Computed tomography scan showing compression of the third part of the duodenum. Arrow is pointing toward the compressed duodenum.Figure 2.: Computed tomography scan showing compression of the left renal vein. Arrow is pointing towards the compressed left renal vein.Figure 3.: Computed tomography scan showing compression of the third part of the duodenum. Angle denoting a reduced aortomesenteric angle value of 11° (normally>38°).Figure 4.: Computed tomography scan after gastrojejunostomy displaying the anastomosis made between the stomach and the proximal loop of the jejunum. Arrow pointing towards the anastomotic site.This case report presents an early preoperative diagnosis of a rare disease entity based on its radiological presentations. When women with a low body mass index present with chronic, refractory symptoms of the upper digestive system, SMAS should be suspected. It can also often be confused with other etiologies of mega duodenum such as diabetes mellitus, systemic lupus erythematosus, amyloidosis, myotonic dystrophy, scleroderma, and chronic idiopathic intestinal pseudo-obstruction. This necessitates the need of a multidisciplinary approach based on symptoms to diagnose SMAS by clinicians. DISCLOSURES Author contributions: A. Jawed collected patient information and followed up after discharge and wrote the manuscript. A. Jawed wrote the manuscript. ME Anis identified the case and treated the patient, revised the manuscript, and is the article guarantor. MA Qadeer and Z. Abbas revised the manuscript. Financial disclosure: None to report. Informed consent was obtained for this case report.

Combined procedures for surgical short bowel syndrome: experience from two European centres.

Autologous gastrointestinal reconstructive surgery (AGIR) has become a key component of intestinal rehabilitation programs. However, the best surgical option for short bowel syndrome (SBS) remains unknown. This paper presents our experience using combined procedures as primary treatment. We collected data on SBS patients who underwent surgery from 2008 to 2021 in two tertiary European Centres. Combined procedures were defined as more than one technique used on the same patient. Charts were reviewed for demographics, type of procedures, complications, and outcomes. Data are presented as median and IQR. Wilcoxon signed rank was used for all paired analyses. Twenty-one children (12 females) underwent combined procedures. Preoperative median small bowel length was 20 cm (IQR: 15-35 cm); after lengthening, it was 35.5cm (IQR: 30.75-50.50 cm) (P< 0.001). Combined procedures were simultaneous in 15 patients and sequential in 6. At a median of 9.2 years (IQR: 7.55-9.78 years) follow-up, complications were three bowel obstructions after strictures of anastomosis and two wound infections. Two patients achieved enteral autonomy, and others followed a weaning home parenteral nutrition regimen with a median of 4 nights off (IQR: 3-4 nights) starting with a median of 7 nights (IQR: 7-7 nights). Combined AGIR techniques are practical and safe in SBS treatment when tailored to meet patients' needs, combining lengthening, tailoring, and reducing transit time procedures. Therefore, combined AGIR may be considered a resource in intestinal rehabilitation units' armamentarium.

Potential for Omega-3 Fatty Acids to Protect against the Adverse Effect of Phytosterols: Comparing Laboratory Outcomes in Adult Patients on Home Parenteral Nutrition Including Different Lipid Emulsions.

the effect on liver function markers and inflammation of the different content of phytosterols in lipid emulsions (LEs) used in the parenteral nutrition (PN) regimen of adult home PN (HPN) patients is not clear. plasma phytosterol and cytokine concentrations, fatty acid composition, liver function markers, and triglycerides were measured in 58 adult HPN patients receiving one of three different LEs (soybean oil-based: Intralipid; olive oil-based: ClinOleic; containing fish oil: SMOFLipid). patients receiving Intralipid had higher plasma campesterol and stigmasterol concentrations than those receiving ClinOleic or SMOFLipid. Plasma sterol concentrations were not different between patients receiving ClinOleic and SMOFLipid. Differences in plasma fatty acids reflected the fatty acid composition of the LEs. Markers of liver function did not differ among the three groups. Blood triglycerides were higher with ClinOleic than with Intralipid or SMOFLipid. Total bilirubin correlated positively with the plasma concentrations of two of the phytosterols, ALT correlated positively with one, AST with one, and GGT with three. liver function markers correlate with plasma plant sterol concentrations in adult HPN patients. Adult HPN patients receiving SMOFLipid are more likely to have liver function markers and triglycerides within the normal range than those receiving ClinOleic or Intralipid. The omega-3 fatty acids in SMOFLipid may act to mitigate the adverse effects of plant sterols on liver function.

Higher Parenteral Electrolyte Intakes in Preterm Infants During First Week of Life: Effects on Electrolyte Imbalances.

Objectives:This study aimed to investigate the effects of a higher intake of electrolytes from parenteral nutrition (PN) on plasma electrolyte concentrations in very low birth weight (VLBW, <1500 g) infants.Methods:This was a single-center cohort study including all VLBW infants born before (n = 81) and after (n = 53) the implementation of a concentrated PN regimen. Daily nutritional intakes and plasma concentrations of sodium, chloride, potassium, phosphate, and calcium were collected from clinical charts.Results:During the first postnatal week, electrolyte intakes were higher in infants who received concentrated PN compared with infants who received original PN. Infants who received concentrated PN had a lower incidence of hypokalemia (<3.5 mmol/L; 30% vs 76%, P < 0.001) and severe hypophosphatemia (<1.0 mmol/L; 2.2% vs 17%, P = 0.02). While the relatively high prevalence of severe hypophosphatemia in infants who received original PN can be explained by a phosphorus intake below the recommendation, the potassium intake during the first 3 postnatal days (mean ± SD: 0.7 ± 0.2 mmol/kg/d) was within the recommendation. The prevalence of early hypernatremia was not affected by the different sodium intake in the 2 groups.Conclusions:In VLBW infants, a sodium-containing PN solution (about 2.7 mmol/100 mL) does not cause hypernatremia during the first days of life. Furthermore, providing at least 1 mmol potassium/kg/d during the first 3 postnatal days might be necessary to prevent early hypokalemia.

Sepsis versus anaphylaxis—differentiating shock etiology: a case report involving Smoflipid

: This case study illustrates a clinically observed interaction between Smoflipid and the development of anaphylactic shock in a patient on long-term parenteral nutrition. This patient had a history of a well-differentiated retroperitoneal liposarcoma, now resected, which was complicated by duodenal perforation and intraperitoneal drain placement; due to significant gastrointestinal tract dysfunction the patient was maintained on continuous parenteral nutrition via a peripherally inserted central catheter (PICC) line. Following a routine and drain exchange, the patient was admitted to the hospital. The patient subsequently developed anaphylactic-like shock symptomatology, necessitating admission to the critical care unit. Intermittent dual vasopressor use was required. There was also an intermittently visible rash that was noted. The etiology of the shock state was unclear. After review of the patient’s case and clinical course, a potential etiology of his shock state was the inpatient protocolized substitution of Smoflipid instead of Intralipid in the parenteral nutrition regimen. After consultation with Allergic Diseases, Nutrition, and Pharmacy the Smoflipid was discontinued and the patient’s regimen was reverted to the standing home regimen including Intralipid. Following discontinuation of Smoflipid and resumption of Intralipid, the shock physiology resolved. The patient was subsequently transferred from the critical care unit and discharged soon thereafter by the primary surgical service. A formal Allergic Disease evaluation was completed in the outpatient setting. Continuous parenteral nutrition therapy was maintained at home using the previous home Intralipid regimen without issue. This case illustrates a multidisciplinary approach including Surgery, Allergic Diseases, Nutrition, Pharmacy, and Critical Care to address the patient’s acute shock state. In addition, a review of different shock states is presented. A literature review evaluating side effects of Smoflipid and an association of shock to its use is presented.

The Effect of High Glucose Intake on Weight Gain in Very Low Birth Weight Neonates: A Randomized Controlled Trial.

This study aims at evaluating the effect of high glucose intake as a component of total parenteral nutrition on birth weight (BW) regain in very low birth weight neonates. Ninety newborns with BW <1500 g were randomized to control or experimental groups. Both groups received the same total parenteral nutrition regimens except glucose intake provided by dextrose water (DW) serum: 7 to 15 g/kg/d (10% DW) in the former versus 8.75 to 18.75 g/kg/d (12.5% DW) in the latter. Body weight as the primary outcome was monitored until the BW was regained. Results revealed that neonates who received 12.5% DW regained BW significantly faster (10.98 ± 2.46 vs 13.24 ± 4.03 days, P = .024) and needed lesser duration of respiratory support (5.34 ± 2.11 vs 7.17 ± 3.19 days, P = .003). As the proposed intervention can reduce neonatal intensive care unit admission duration, it mitigates risks of health care-associated infections, while favorably affecting the health economy.

Optimizing parenteral nutrition to achieve an adequate weight gain according to the current guidelines in preterm infants with birth weight less than 1500\u2009g: a prospective observational study

AimEuropean Society for Clinical Nutrition and Metabolism released the guidelines on pediatric parenteral nutrition in 2018. We aimed to compare the parenteral nutrition (PN) regimen with the current guidelines, evaluate weight gain and explore the correlation of parenteral macronutrient and energy intakes with weight gain outcome in preterm infants with birth weight less than 1500 g.MethodsA prospective observational study was conducted. Parenteral macronutrients and energy intakes were described. Weight gain during PN was assessed. Nutritional factors associated with weight gain outcome after PN were identified using a cox proportional hazards model.ResultsA total of 163 infants were included in this study, in which 41 were extremely low birth weight (ELBW) infants and 122 were very low birth weight (VLBW) infants. Average glucose, amino acid, lipid, and energy during the first postnatal week were 7.5 g/kg/d, 2.4 g/kg/d, 0.8 g/kg/d, 48 kcal/kg/d. Median maximum glucose, amino acid, lipid, and energy were 11.1 g/kg/d, 3.5 g/kg/d, 3 g/kg/d, 78 kcal/kg/d. Median days to maximum glucose, amino acid, lipid, and energy were 10, 9, 12, 11 days. The proportion of appropriate for gestational age (AGA) infants was 76.9%. The ratio of infants without poor weight gain outcome after PN was 38%. With every 0.1 g/kg/d decrease of maximum amino acid and average lipid during the first postnatal week, the probability of appropriate weight gain outcome decreased by 77.6 and 74.4% respectively. With each additional day to maximum glucose and energy, the probability of appropriate weight gain outcome decreased by 5.6 and 6.1% respectively.ConclusionsMost preterm infants with birth weight less than 1500 g remain below the latest recommended nutrition goals. The poor weight gain outcome of these infants after PN is related to insufficient parenteral macronutrient and energy intakes. PN strategies should be improved according to the latest evidence-based recommendations.

Non-Surgical Interventions for Hospitalized Adults with Class II or Class III Obesity: A Scoping Review.

Adult inpatients with Class II or III obesity and comorbidities have a high health burden with frequent hospitalizations. Surgical risk and patient choice can be contraindications to bariatric surgery, which is considered the gold standard treatment. The best approach to non-surgical management for this adult inpatient group is currently unknown. The aim of this scoping review was to summarize current research in the inpatient setting. The unpublished literature and six electronic database searches identified 4,582 articles, with 12 articles (reporting on 10 studies) eligible and included. The literature on the interventions and their key components in the non-surgical care of the adult inpatient with Class II or III obesity were mapped identifying service provision successes and gaps. The articles reported on intensive lifestyle interventions, comparison of oxygen administration regimes, total parenteral nutrition regimens, and pre-surgical rapid weight loss. Study designs included evaluation (n=1), before–after intervention studies (n=3), and randomized/non-randomized controlled trials (n=6). The classification of obesity as a chronic disease is not universal resulting in reduced inpatient treatment options. Recommendations for consumers, practitioner practice, health policy-makers and future research priorities are reported. Further research in the development of cost-effective inpatient models of care is indicated.

Does the use of fish oil-based lipid emulsion in the clinical setting of total parenteral nutrition and lipid rescue therapy interfere with common laboratory analytes on Roche Cobas 6000?

Lipaemic interference on automated analysers has been widely studied using soy-based emulsion such as Intralipid. Due to the greater adoption of fish oil-based lipid emulsion for total parenteral nutrition in view of improved clinical outcomes, we seek to characterize the optical properties of SMOFlipid 20% (Fresenius Kabi, Bad Homburg, Germany), a fish oil-based emulsion, on the Roche Cobas 6000 chemistry analyser (Roche Diagnostic, Basel, Switzerland). Various amounts of SMOFlipid were spiked into pooled serums. We plotted Roche Cobas Serum Index Gen.2 Lipaemia Index (L-index) against the amount of SMOFlipid added. We then studied the interference thresholds for aspartate aminotransferase, alanine aminotransferase, albumin and renal panel analytes using SMOFlipid. We subjected five levels of spiked lipaemia to high-speed centrifugation and analysed the specimens pre- and post-centrifugation. To postulate whether fish oil-based lipid emulsion interferes with laboratory results in the clinical setting, we calculated concentrations of SMOFlipid post-lipid rescue therapy and steady-state concentration of a typical total parenteral nutrition regime using pharmacokinetic principles. SMOFlipid optical behaviour is similar to Intralipid using the Serum Index Gen.2 L-index, with 1 mg/dL of SMOFlipid representing 1 unit of L-index. Manufacturer-stated interference thresholds are accurate for alanine aminotransferase, aspartate aminotransferase, albumin, urea and creatinine. High-speed centrifugation at 60 min 21,100g facilitates the removal of fish oil-based SMOFlipid. Based on the interference thresholds we verified and pharmacokinetics parameters provided by SMOFlipid manufacturer, total parenteral nutrition may not interfere with chemistry analytes given sufficient clearance, but lipid rescue therapy will interfere. Further studies assessing lipaemic interference on immunoassays are needed.

Refeeding risks in patients requiring intravenous nutrition support: Results of a two-centre, prospective, double-blind, randomised controlled trial.

Refeeding syndrome can result following excessive feeding of malnourished patients. The syndrome remains poorly defined but encompasses a range of adverse effects including electrolyte shifts, hyperglycaemia and other less well-defined phenomena. There are additional risks of underfeeding malnourished individuals. Studies of refeeding syndrome have generally focussed on critical care environments or patients with anorexia nervosa. Here we have conducted a two-centre, prospective, double-blind, randomised controlled trial amongst all patients referred to hospital nutrition support teams for intravenous nutrition support. We sought to determine whether electrolyte and other abnormalities suggestive of refeeding syndrome risk varied depending on initial rate of intravenous feeding. Patients at moderate or high risk of refeeding syndrome, as defined by United Kingdom National Institute of Health and Care Excellence guidelines, were screened for inclusion. Patients were randomised to receive either high (30kcal/kg/day, 0.25gN/kg/day) or low (15kcal/day, 0.125gN/kg/day) rate feeding for the first 48h prior to escalation to standard parenteral nutrition regimens. The primary outcome was rates of potential refeeding risks within the first 7 days as defined by electrolyte imbalance or hyperglycaemia requiring insulin. Secondary outcomes included effects on QTc interval, infections and length of hospital stay. Statistical analysis was performed with χ2 or Wilcoxon rank sum tests and all analysis was intention-to-treat. Problems with study recruitment led to premature termination of the trial. Registered on the EU Clinical Trials Register (EudraCT number 2007-005547-17). 534 patients were screened and 104 randomised to either high or low rate feeding based on risk of refeeding syndrome. Seven patients were withdrawn prior to collection of baseline demographics and were excluded from analysis. 48 patients were analysed for the primary outcome with potential refeeding risks identified in 46%. No differences in risks were seen between high and low rate feeding (p>0.99) or high and moderate risk feeding (p=0.68). There were no differences in QTc abnormalities, infection rates, or hospital length of stay between groups. In this randomised trial of rates of refeeding risk, in patients pre-stratified as being at high or moderate risk, we found no evidence of increased refeeding related disturbances in those commenced on high rate feeding compared to low rate. No differences were seen in secondary endpoints including cardiac rhythm analysis, infections or length of stay. Our study reflects real world experience of patients referred for nutrition support and highlights challenges encountered when conducting clinical nutrition research.

Omega-3 fatty acid-containing parenteral nutrition in ICU patients: systematic review with meta-analysis and cost-effectiveness analysis

BackgroundOmega-3 (ω-3) fatty acid (FA)-containing parenteral nutrition (PN) is associated with significant improvements in patient outcomes compared with standard PN regimens without ω-3 FA lipid emulsions. Here, we evaluate the impact of ω-3 FA-containing PN versus standard PN on clinical outcomes and costs in adult intensive care unit (ICU) patients using a meta-analysis and subsequent cost-effectiveness analysis from the perspective of a hospital operating in five European countries (France, Germany, Italy, Spain, UK) and the US.MethodsWe present a pharmacoeconomic simulation based on a systematic literature review with meta-analysis. Clinical outcomes and costs comparing ω-3 FA-containing PN with standard PN were evaluated in adult ICU patients eligible to receive PN covering at least 70% of their total energy requirements and in the subgroup of critically ill ICU patients (mean ICU stay > 48 h). The meta-analysis with the co-primary outcomes of infection rate and mortality rate was based on randomized controlled trial data retrieved via a systematic literature review; resulting efficacy data were subsequently employed in country-specific cost-effectiveness analyses.ResultsIn adult ICU patients, ω-3 FA-containing PN versus standard PN was associated with significant reductions in the relative risk (RR) of infection (RR 0.62; 95% CI 0.45, 0.86; p = 0.004), hospital length of stay (HLOS) (− 3.05 days; 95% CI − 5.03, − 1.07; p = 0.003) and ICU length of stay (LOS) (− 1.89 days; 95% CI − 3.33, − 0.45; p = 0.01). In critically ill ICU patients, ω-3 FA-containing PN was associated with similar reductions in infection rates (RR 0.65; 95% CI 0.46, 0.94; p = 0.02), HLOS (− 3.98 days; 95% CI − 6.90, − 1.06; p = 0.008) and ICU LOS (− 2.14 days; 95% CI − 3.89, − 0.40; p = 0.02). Overall hospital episode costs were reduced in all six countries using ω-3 FA-containing PN compared to standard PN, ranging from €-3156 ± 1404 in Spain to €-9586 ± 4157 in the US.ConclusionThese analyses demonstrate that ω-3 FA-containing PN is associated with statistically and clinically significant improvement in patient outcomes. Its use is also predicted to yield cost savings compared to standard PN, rendering ω-3 FA-containing PN an attractive cost-saving alternative across different health care systems.Study registrationPROSPERO CRD42019129311.

Compatibility of intravenous metronidazole with some all-in-one parenteral nutrition regimens

ObjectivesSupplementation of parenteral nutrition (PN) admixtures with other parenteral drugs may be desired especially in the case of polypharmacy and limited vascular access. Metronidazole (MTZ) is administered in surgical and critically ill patients often requiring concomitant nutritional therapy in the form of parenteral nutrition. The aim of the study was to evaluate the possibility of the concomitant administration of MTZ with PN admixtures from one container. MethodsMTZ (1500 mg) was combined with six different PN admixtures and stored for 7 days before the simulation of administration. The mean droplet size (MDS) of the lipid emulsion, zeta potential, color, and pH of the tested samples were determined every 24 h. The content of MTZ was determined by the high-performance liquid chromatography method within the same time frames. ResultsPN admixtures supplemented with MTZ were characterized by a pH range from 6.19 to 6.38 and zeta potential range from –21.6 mV to –8.8 mV. For all samples the pharmacopeial criteria for intravenously administered emulsions were met: The visual inspection showed no sign of emulsion destabilization or precipitation, and the MDS was <500 nm. The MTZ content remained >90% of the initial value throughout the whole study period. ConclusionsResults showed the physicochemical compatibility and stability of PN admixtures supplemented with MTZ at the dose of 1500 mg. Such formulations can be stored at a temperature of 5°C for up to 7 d before administration to the patient.

P36 Numeta G13% preterm neonatal parenteral nutrition solution – a licensed all-in-one triple chamber, ready to use and terminally sterilised parenteral nutrition for preterm newborn infants

AimsWe aim to evaluate the efficacy and safety of Numeta G13%E preterm neonatal parenteral nutrition (PN) in our neonatal population.In September 2017 a National Patient Safety Alert (NPSA) highlighted the risk of harm to babies when lipid was mistakenly run at the rate intended for the aqueous component resulting in significant lipid overdose.Although we have worked to implement many of the alert’s recommendations, we feel we can avoid this risk further by using an all-in-one PN solution.1Numeta meets current nutritional guidelines as per British Association of Perinatal Medicine (BAPM) but this project allows comparison of outcomes important to both patient and service between those achieved with our current regimen and those with the all-in-one regimen.2MethodsWe carried out a quality improvement project from April 2018 to April 2019. We collected data from 330 babies in our neonatal unit during six months before (154 babies) and after (176 babies) the adoption of the all-in-one solution.Our previous PN regimen consisted of a ‘menu’ of aqueous bags (starter, maintenance, ‘light’ and bespoke) and a separate lipid solution. All of them were suitable for peripheral or central administration. Numeta came with similar choices: starter, maintenance -for central administration only- and ‘lite’ and Numeta peripheral, suitable for peripheral administration. Bespoke bags were also available if clinically indicated. We set out our desired outcomes and measured parameters accordingly:Patient outcomesMetabolic stability: electrolyte, glucose, bilirubin and lipid measurements summarised by the need to change from standard PN regimen and/or requirement for insulin.Fluid balance summarised by the lowest weight during the first two weeks of life and time taken to regain birth weight.Growth summarised by change of standard deviation score of weight and head circumference between birth and discharge or transfer back to local hospital.Liver tolerance of lipid solutions summarised by incidence of cholestasis (&gt;25 μmol/l conjugated fraction of serum bilirubin)Days and type of PNSepsisService outcomesNursing time taken to prepare PNCostWastageAccess to productResultsAlthough we finished collecting the data in April 2019, we are still in the process of analysing it and evaluating the final results. There have been no cases of lipid overdose and our neonates (including the preterm ones) have so far tolerated well the new parenteral nutrition solution. Average nursing time preparing Numeta went down from 18.5 minutes to 8 minutes and comparison of cost came in favour of Numeta. PN wastage was higher with Numeta (4.7% Maintenance, 10% ‘light’, peripheral 50%) especially in the first month during the transition phase. There was no significant increase of bespoke bags when Numeta was introduced.ConclusionsIn summary, so far we have not identified significant clinical differences between the first six months of the project -using our old standardised nutrition regimen- and the last months -on the new all-in-one solution. We have continued with Numeta preterm solution on the basis of assumed safety.ReferencesRisk of severe harm and death from infusing total parenteral nutrition too rapidly in babies. NHS improvement patient safety alert September 2017.The Provision of Parenteral Nutrition within Neonatal Services – A Framework for Practice. British Association of Perinatal Medicine (BAPM) April 2016 www.bapm.org

P12 Evaluation of energy and protein intake in neonates using SCAMP regimen

AimsOur neonatal unit recently updated their parenteral and enteral feeding guideline and started using a standardised parenteral nutrition regimen (SCAMP).1The aim of this study was to observe the amount of energy and protein that was being delivered to patients using the SCAMP regimen and to evaluate whether it met the recommendations made by ESGPHAN in terms of energy and protein intake.2MethodsA data collection form was designed using Excel. Patients were identified using BadgerNet digital software. All required patient parameters were recorded from Badgernet. Data was anonymised and the Excel spreadsheet was password protected. A single investigator collected data over a 28 day period in October/November 2018. Only patients on the SCAMP regimen were included in the study. Patient data was collected from first day of SCAMP regimen until baby was discharged, or ceased parenteral nutrition.Results22 patients were identified for inclusion in the study. Of these, 17/22 (77%) weighed &lt; 1 kg.Majority of babies (20/22; 91%) were aged &lt; 31 weeks corrected gestational age when SCAMP was initiated.Majority of babies were on the SCAMP regimen due to prematurity; 4/22 (18%) had a surgical condition, that required PN to be initiated.1 patient had a complex congenital cardiac anomaly.Average length of time babies remained on SCAMP was 19 days (range 5–28 days).Majority of babies were enterally fed using breastmilk. Some babies were on alternative formula feeds.Mean amount of energy delivered to each patient was calculated. The amount of energy delivered increased daily over the first week, and by day 10 of life had reached the target range (110–135 kcal/kg/day). Recommended energy intake was then maintained for the rest of the 28–day study period.Target amount of protein intake varied for babies weighing &lt;1 kg and &gt;1 kg. For babies &lt;1 kg, a gradual increase occurred over the first 5 days of life. Recommended protein intake was met between days 5–10 of life, then there was a gradual decline.For babies weighing between 1–1.8 kg, the recommended protein intake was achieved within 24–48 hours. Higher than recommended amounts of protein were being delivered between days 5–10 of life. Mean protein intake remained within ESPGHAN recommendations (3.5–4 g/kg/day) during weeks 3 and 4 of life.The results are encouraging and demonstrate that neonates are managing to achieve the recommended amounts of energy intake from day 10 of life.LimitationsThis study focused solely on energy and protein intake – it did not include observations of growth. Future studies should consider looking at more patient-focused outcomes.ConclusionsSCAMP regimen is delivering the recommended amounts of energy for babies on the neonatal unit – target levels are achieved by day 10 of life.Future work should focus on observing growth in babies on SCAMPEarlier introduction of breast–milk fortifier may be helpful to increase protein intake in babies &lt; 1 kg – potential benefits need to be evaluated against risk of adverse effects.ReferencesMorgan C, Herwitker S, Badhawi I, et al. SCAMP: standardised, concentrated, additional macronutrients, parenteral nutrition in very preterm infants: a phase IV randomised, controlled exploratory study of macronutrient intake, growth and other aspects of neonatal care. BMC Pediatrics 2011;11:53.Koletzo B, Goulet O, Hunt J, et al. Guidelines on paediatric parenteral nutrition of the European society of paediatric gastroenterology, hepatology and nutrition (ESPGHAN) and the European society for clinical nutrition and metabolism (ESPEN), supported by the European society of paediatric research (ESPR). J Pediatr Gastroenterol Nutr 2005;41 (Suppl 2):S1–87.

Cost-Effectiveness of Parenteral Nutrition Containing ω-3 Fatty Acids in Hospitalized Adult Patients From 5 European Countries and the US.

Backgroundω‐3 Fatty acid (FA)–containing parenteral nutrition (PN) is associated with improvements in patient outcomes and with reductions in hospital length of stay (HLOS) vs standard PN regimens (containing non–ω‐3 FA lipid emulsions). We present a cost‐effectiveness analysis of ω‐3 FA–containing PN vs standard PN in 5 European countries (France, Germany, Italy, Spain, UK) and the US.MethodsThis pharmacoeconomic model was based on estimates of ω‐3 efficacy reported in a recent meta‐analysis and data from country‐specific sources. It utilized a probabilistic discrete event simulation model to compare ω‐3 FA–containing PN with standard PN in a population of critically ill and general ward patients. The influence of model parameters was evaluated using probabilistic and deterministic sensitivity analyses.ResultsOverall costs were reduced with ω‐3 FA–containing PN in all 6 countries compared with standard PN, ranging from €1741 (±€1284) in Italy to €5576 (±€4193) in the US. Expenses for infections and HLOS were lower in all countries for ω‐3 FA–containing PN vs standard PN, with the largest cost differences for both in the US (infection: €825 ± €4001; HLOS: €4879 ± €1208) and the smallest savings in the UK for infections and in Spain for HLOS (€63 ± €426 and €1636 ± €372, respectively).ConclusionThis cost‐effectiveness analysis in 6 countries demonstrates that the superior clinical efficacy of ω‐3 FA–containing PN translates into significant decreases in mean treatment cost, rendering it an attractive cost‐saving alternative to standard PN across different healthcare systems.

Composite Lipid Emulsion for the Infant at Risk of Intestinal Failure-associated Liver Disease: The Canadian Perspective.

Currently, in North America we are fortunate to have a number of available options for lipid emulsions to be used in the parenteral nutrition regimens for infants and children, including for long-term parenteral nutrition given intestinal failure. Neonates and infants in particular are at risk for intestinal failure-associated liver disease (IFALD). The choice of parenteral lipid emulsion will influence the risk and severity of IFALD. The purpose of this review is to discuss the rationale for the composite lipid emulsion SMOFlipid that includes soybean, medium-chain triglycerides, olive and fish oils for IFALD, with focus on the Canadian practice and experience.

Pharmacoeconomics of Parenteral Nutrition with ω-3 Fatty Acids in Hospitalized Adults.

The inclusion of ω-3 fatty acids as part of parenteral nutrition is associated with clinical benefits such as a reduced likelihood of infectious complications and shorter hospital and intensive care unit (ICU) stays. As healthcare resources are limited, pharmacoeconomic analyses have been performed, typically modeling studies, using cost and outcomes data to investigate the cost-effectiveness of parenteral nutrition regimens including ω-3 fatty acids from fish oil compared with standard parenteral nutrition without such ω-3 fatty acids. This review covers pharmacoeconomic studies encompassing Italian, French, German, and UK hospitals for ICU and non-ICU hospitalized patients, and for ICU patients in China. The results show that the use of parenteral nutrition including ω-3 fatty acids more than offsets any additional acquisition costs in all national scenarios investigated to date, indicating that parenteral nutrition including ω-3 fatty acids is a clinically and economically beneficial strategy compared with standard parenteral nutrition.

A triple-chamber parenteral nutrition solution was associated with improved protein intake in very low birthweight infants.

We evaluated the nutrient intakes of very low birthweight (VLBW) infants weighing less than 1500g and tested the hypothesis that using a triple-chamber parenteral nutrition (PN) solution, containing lipids, glucose and amino acids, would improve protein intake. This retrospective cohort study comprised 953 VLBW infants born in 2005-2013 at a gestational age of less than 32+0/7weeks and admitted to the neonatal care unit at Helsinki Children's Hospital, Finland. The infants were divided into four groups according their birth year and PN regime. Nutrient intakes were obtained from computerised medication administration records. In 2012-2013, when a triple-chamber PN solution was used, infants were more likely to reach the target parenteral protein intake of 3.5g/kg/d, and reach it 3-7days earlier, compared with infants who received individual PN or standard two-in-one PN solutions in 2005-2011. In addition, infants in the triple-chamber group had the highest median energy intake (90kcal/kg/d) during the first week. They also had higher median protein intakes in weeks one, two and three (3.1, 3.4 and 3.7g/kg/d) than infants born in 2005-2011 (P<.05). Using a triple-chamber PN solution was associated with improved protein intake, and the protein target was more likely to be achieved.

Growth and Clinical Outcome in Very Low-Birth-Weight Infants After the Introduction of a Multicomponent Intravenous Lipid Emulsion.

Very low-birth-weight (VLBW; birth weight < 1500 g) infants are often dependent on intravenous nutrition after birth. Conventional soy-based intravenous lipid emulsions (Soy LE) are associated with inflammatory and metabolic complications that may be harmful to preterm infants. Evidence to support any clinical benefit associated with newer multicomponent emulsions (Mixed LE), remains inconsistent and unsubstantiated in appropriate studies. This retrospective study aimed to determine whether growth and clinical outcomes differed between VLBW infants given Mixed LE vs Soy LE at Auckland City Hospital. Data were collected on nutrition, growth, and neonatal morbidities for the first 4 weeks after birth. Outcomes were compared between 2 lipid cohorts, Soy LE (February 2013 - August 2014) and Mixed LE (August 2014 - December 2015), using univariate and multivariate analysis. 207 infants (Soy LE, 105 vs Mixed LE, 102) were included in the study. Significantly fewer infants in the Mixed LE cohort developed any stage retinopathy of prematurity (Soy LE 59% vs Mixed LE 39%, P=.005) or intraventricular hemorrhage (Soy LE 27% vs Mixed LE 15%, P=.03) during their admission. Mixed LE was also associated with significantly lower mean (P=.01), minimum (P=.03), and maximum (P=.04) total bilirubin concentrations across the first 4 weeks after birth. There was no difference in growth velocity or weight, length, and head circumference z-score change. SMOFlipid may represent a favorable alternative to conventional lipid emulsions in neonatal parenteral nutrition regimens; however, long-term effects should be further evaluated.