Parenteral Nutrition-related Complications Research Articles

Parenteral nutrition-related complications in older patients with acute intestinal failure: A descriptive cohort study.

Reported outcomes for parenteral nutrition (PN)-related complications in older adult patients with acute intestinal failure who are receiving PN in the acute hospital setting are limited. Our study aims to compare PN-related complications between older and younger adult patients. A retrospective descriptive study of inpatients who were administered PN from January 1, 2019, to December 31, 2019, was performed. Patients were categorized into older (≥65 years old) and younger (<65 years old) adult groups. Two hundred thirty-five patients were included. There were 103 patients in the older adult group (mean age: 73.9 [SD: 6.9] years) and 132 patients in the younger adult group (mean age: 52.4 [SD: 12.5] years). There was a significantly higher Charlson Comorbidity Index score and lower Karnofsky score in the older adult group. The older adult group received significantly lower total energy (20.8 [SD: 7.8] vs 22.8 [SD: 6.3] kcal/kg/day), dextrose (3.1 [SD: 1.4] vs 3.6 [SD: 1.4] g/kg/day), and protein (1.1 [SD: 0.4] vs 1.2 [SD: 0.3] g/kg/day) than the younger group received. The mean length of stay was significantly shorter in the older adult group (35.9 [SD: 21.3] vs 59.8 [SD: 55.3]; P < 0.05). There was no significant difference in PN-related complications and clinical outcomes (catheter-related bloodstream infections, hypoglycemia or hyperglycemia, fluid overload, or inpatient mortality) between the two groups. Despite more comorbidities in the older adult, the usage of PN in older adult patients with acute intestinal failure was associated with neither an increased rate of PN-related complications nor worse clinical outcomes when compared with that of younger patients.

A O04 Identifying Predictive Factors for Prolonged use of Nutritional Support After Oesophagogastric Cancer Resections

Abstract Background In the era of evidence-based practice, there remains significant variation in peri-operative nutritional strategies for patients undergoing oesophagogastric (OG) cancer resections. Although dietary support is accepted as essential for this patient group, the use of feeding adjuncts, such as parenteral nutrition (PN) or enteral feeding tubes, varies widely. In addition, the clinical benefit of peri-operative supplementary feeding remains uncertain, especially since the evolution to minimally invasive OG surgery, introduction of ERAS and drive for early oral intake. Despite improvements in peri-operative nutrition pathways, risks associated with feeding adjuncts remain. There are also increased financial costs associated with peri-operative nutritional support which require consideration. After analysing unit peri-operative outcomes, it was hypothesised that routine feeding adjunct use may be unnecessary for most patients who meet oral nutritional goals early and should instead be reserved for patients with an increased risk of supplementary post-operative nutritional requirement.The primary aim of this study was to evaluate which clinicopathological factors were associated with prolonged use of PN after OG surgery. The secondary aim was to evaluate the associated morbidity and healthcare costs of PN use. Methods A retrospective cohort study of 518 patients undergoing oesophagectomy or total gastrectomy for cancer at Guy's and St Thomas’ NHS Foundation Trust, London, UK, between 2015 and 2021. The standard feeding regimen after oeosphagectomy or total gastrectomy at St Thomas’ involves PN for a median of eight days post-operatively. Oral intake is initiated after a contrast swallow is performed on day three for uncomplicated patients. The primary outcome was prolonged use of post-operative PN, defined as nine-days or more PN during the index admission. Clinicopathological characteristics were compared using the Chi square test. The relationship between these characteristics and PN use was evaluated using logistic regression analysis, providing odds ratios (OR) with 95% confidence intervals (CI) adjusting for age, sex, BMI, comorbidities, histology, anastomosis location, surgical access, pre-operative weight loss, pre-operative supplementary feeding. The prognostic ability of clinicopathological characteristics to predict prolonged PN use were compared using receiver operator characteristic (ROC) analysis to calculate area under the curve (AUC). An economic model was developed using described PN related complication rates from the published literature and 2021 NHS tariffs. Results Predictive factors for prolonged PN use on adjusted analysis included age over 65 (HR 1.70 95% CI 1.14–2.52), pre-operative weight loss (0–10%: HR 1.67 95% CI 1.09–2.56, &amp;gt;10%: HR 2.21 95% CI 1.05–4.66), open surgery (HR 1.64 95% CI 1.03–2.62) and an OG anastomosis located in the neck (HR 2.50 95% CI 1.35–4.65). Patients with a BMI over 25 had a lower chance of prolonged PN use (HR 0.65 95% CI 0.43–0.98). Other characteristics were not prognostic. ROC curve analysis demonstrated that anastomosis location (AUC 0.59), age (AUC 0.57) and surgical access (AUC 0.56) were the most prognostic factors. The combination of parameters included in the adjusted model provided an AUC of 0.67. Potential PN and line related complications included: deranged liver biochemistry (18.0%), deranged blood sugars (9%), line infection (1.4%) and line thrombus (0.8%). An eight-day course of PN was calculated to cost £884 with average treatment related complication costs of £176 per patient. Using the mean number of patients treated per year over the past three years (N = 112) the projected service savings were £75,912 per year if PN was reserved for patients with high-risk characteristics. Conclusions This study has demonstrated that several patient and treatment related factors are associated with an increased risk of needing prolonged adjunctive nutritional support after OG surgery. As surgical practice has evolved to minimally invasive surgery and ERAS with subsequently low peri-operative complication rates, the clinical benefits of short course adjuvant feeding may not be seen in patients who progress promptly to appropriate oral intake. Therefore, we propose the introduction of a tailored treatment pathway, based on pre-operative characteristics which excludes the routine use of post-operative feeding for low-risk patients. The study also demonstrates that a change in practice can lead to considerable cost savings. The model demonstrated in this study can be applied to all feeding adjuncts and can therefore be universally adopted in any UK/global unit regardless of supplementary feeding route preference. It will encourage high-performance by promoting a patient-centred and individualised approach to peri-operative nutrition which is currently lacking in many aspects of our clinical practice. Further work in the form of a randomised trial may be explored to better understand the need and benefit of supplementary feeding methods after OG resection as the specialty continues to evolve.

Dosing errors in total parenteral nutrition prescriptions at a specialized cancer care hospital of Lahore: The role of clinical pharmacist

To determine the role of pharmacist in identifying the frequency of errors in total parenteral nutrition prescriptions in cancer patients for the years 2015 and 2016. Total parenteral nutrition has a high potential for medical errors because of its complex composition, thus leading to severe complications. Pharmacist review of the prescriptions reduces the risk of inappropriate prescribing, preparation, and administration of parenteral nutrition. An observational study was performed by collecting data of total parenteral nutrition prescriptions of 71 patients for the last two years from Pharmacy Department of specialized cancer care hospital. It was found that the frequency of dosing errors and incomplete prescriptions was higher in 2015 compared to 2016. Additionally, the frequency of macro and micronutrients dosing errors were higher in adults (23.4% and 66.2%) compared to pediatrics (14.6% and 46.6%). Furthermore, the frequency of illegible prescriptions was higher (5.03%) in year 2016 as compared to year 2015 (1.64%). Nevertheless, such dose interventions improved patient's weight (20%) and promoted enteral feeding (42.3%). Major complication was hypophosphatemia (39.4%) followed by hyperglycemia (10%) and catheter-induced infection, i.e. sepsis (4.2%). In conclusion, data suggested that pharmacist played instrumental role in identifying and rectifying total parenteral nutrition dosing errors for both micronutrients and macronutrients-with higher frequency in 2015 compared to 2016, leading to improvements in total parenteral nutrition-related complications and switches to enteral feeding.

1188 The Effects of Probiotics on Parenteral Nutrition-Related Complications: A Prescriber’s Dilemma

INTRODUCTION: Parenteral nutrition (PN) is a life-saving modality that carries risks for potentially life-threatening complications. The gut microbiome, which is often impaired in patients receiving PN, plays an integral role in intestinal wall integrity and immune function. Hence, restoration of a healthy microbiome may theoretically protect against various infections. Therefore, we aimed in our study to investigate the effect of probiotics on parenteral nutrition-related infectious complications. METHODS: We identified a cohort of patients with intestinal failure who received PN for &gt;2 weeks at our center for human nutrition between January 2005 and August 2016. We excluded patients &lt; 18 years of age, patients who used probiotics for &lt; 30 days, and those who had long-term antibiotic use ( &gt;30 days). Seventy-eight patient received probiotics, among them, 48% used it for small intestinal bacterial overgrowth (SIBO) treatment, 42% for SIBO prophylaxis in high-risk patients (history of recurrent SIBO, resection of the ileocecal valve, and surgically created blind loops), and 10% of the patients used non-prescription over-the-counter probiotics. Patients characteristics and other variables were determined by manual chart review. RESULTS: A total of 282 patients who received prolonged parenteral support were included. Eighty-five percent of our sample received PN, while the remaining received intravenous fluids (IVF). A total of 78 (27.7%) patients used probiotics. (Table 1) One hundred and six (37.6%) patients were diagnosed with SIBO, 31(11%) patients had at least one episode of catheter-related infection, and 88(31.2%) patients had at least one documented episode of sepsis. The prevalence of SIBO in patients who used prophylactic probiotic was 22 % vs. 30 % in patients who did not use probiotics, P = 0.5. Compared to non-users, the prevalence of sepsis and catheter-related infection among probiotics users were (26.9% vs. 32.8%; P = 0.33 and 7.7% vs. 12.3%; P = 0.27, respectively) (Figure 1) CONCLUSION: Although there was a non-significant trend toward less SIBO, sepsis and catheter-related infections among patients using probiotics, our findings don’t support the routine use of probiotics to prevent or treat PN-related complications. Interestingly, this study revealed-despite the lack of evidence- a quarter of our included patients received a medical prescription for probiotics to prevent or treat SIBO.

Parenteral nutrition use in children with cancer.

Multiple disease and treatment-related factors contribute to intestinal insult and influence the nutritional status of children with cancer. Many children with cancer will experience intestinal dysfunction during their cancer journey and children with cancer are a common referral group for inpatient parenteral nutrition. Appropriate use of parenteral nutrition in children with cancer and intestinal failure may alleviate malnutrition and associated risks. However, proper selection of patients, correct parenteral nutrition prescription, and close monitoring is important to avoid unnecessary intestinal failure or parenteral nutrition-related complications, minimize long-term nutritional sequelae or additional costs to health services, and optimize intestinal rehabilitation.

A multicenter cross­sectional survey on the use of parenteral nutrition in hospitalized patients in Beijing

Objective To investigate the use of parenteral nutrition in hospitalized patients and to examine the process of care of patients receiving parenteral nutrition (PN) in hospital, in light of EuropeanNutrition Daystudy, and to preliminarily explore the possible main risk factors for complications. Methods We recruited 314 adult hospitalized patients (≥18 years) requiring PN on a predetermined day(November 25, 2013)in 6 hospitals in Beijing and investigated their disease status, nutrition risk, the use of PN and venous infusion related complications using the European Nutrition Day survey questionnaire. Results Of the 314 patients, 311 completed the survey.In the 311 patients, the proportion of patients who received PN ofall-in-onemixed preparation was 76.2%(237/311), the proportion of patients receiving multibottle system was 23.8%(74/311); PN was administered via central vein in 56.8% (171/301) of the patients and via peripheral veins in 43.2%(130/301) of the patients. The mean duration of infusion was (12.5±5.1) hours. The ratio of glucose to fat was 0.84 and the ratio of non-protein to calories 531.1. The total energy provision was less than the recommended intake. 38.6% (120/311) of the patients reported that PN infusion would affect activity, and 33.4% (104/311) thought PN affected their sleep, and the incidence of infusion-related pain was 19.9%(62/311). Multivariate analysis result showed that the most important factors of infusion-related pain were intravenous route of PN (χ2=25.911, P=0.000) and total venous infusion volume (χ2=6.053, P=0.014). Conclusions The total energy provision of PN is generally inadequate in hospitalized patients in Beijing. The key factor for reducing transfusion-related pain and enhancing PN tolerance is to establish appropriate infusion route. Key words: Nutrition Day; Parenteral nutrition; Energy; Volume; Venous infusion related complications

Assessment and outcome of children with intestinal failure referred for intestinal transplantation

Chronic intestinal failure (CIF) requires long term parenteral nutrition (PN) and, in some patients, intestinal transplantation (ITx). Indications and timing for ITx remain poorly defined. In the present study we aimed to analyze causes and outcome of children with CIF. 118 consecutive patients referred to our institution were assessed by a multidisciplinary team and four different categories were defined retrospectively based on their clinical course: Group 1: patients with reversible intestinal failure; group 2: patients unsuitable for ITx, group 3: patients listed for ITx; group 4: patients stable under PN. Analysis involved comparison between groups for nutritional status, central venous catheter (CVC) related complications, liver disease, and outcome after transplantation by using non parametric tests, Mann-Whitney tests, Kruskal-Wallis, Wilcoxon signed rank tests and chi square distribution for percentage. 118 children (72 boys) with a median age of 15 months at referral (2 months-16 years) were assessed. Etiology of IF was short bowel syndrome [n = 47], intractable diarrhea of infancy [n = 37], total intestinal aganglionosis [n = 18], and chronic intestinal pseudoobstruction [n = 17]. Most patients (89.8%) were totally PN dependent, with 48 children (40.7%) on home-PN prior to admission. Nutritional status was poor with a median body weight at -1.5 z-score (ranges: -5 to +2.5) and median length at -2.0 z-score (ranges: -5.5 to +2.3). The mean number of CVC inserted per patient was 5.2 (range 1-20) and the mean number of CRS per patient was 5.5 (median: 5; range 0-12) Fifty-five patients (46.6%) had thrombosis of ≥2 main venous axis. At admission 34.7% of patients had elevated bilirubin (≥50 μmol/l), and 19.5% had platelets <100,000/ml, and 15% had both. Liver biopsy performed in 79 children was normal (n = 4), or showed F1 or F2 fibrosis (n = 29), bridging fibrosis F3 (n = 20), or cirrhosis (n = 26). Group 1 included 10 children finally weaned from PN (7-years survival: 100%). Group 2 included 12 children with severe liver disease and associated disorders unsuitable for transplantation (7-years survival: 16.6%). Group 3 included 66 patients (56%) who were listed for small bowel or liver-small bowel transplantation, 62/66 have been transplanted (7 years survival: 74.6%). Factors influencing outcome after liver-ITx were body weight (p < .004), length (p < .001), pre-Tx bilirubin plasma level (p < .001) and thrombosis (p < .01) for isolated ITx, Group 4 included 30 children (25.4%) with irreversible IF considered as potential candidates for isolated ITx. Four children were lost from follow up and 3 died within 2 years (survival 88.5%). Among potential candidates, the following parameters improved significantly during the first 12 months of follow up: Body weight (p.0001), length (p < .0001) and bilirubin (p < .0001). many patients had a poor nutritional status with severe complications especially liver disease. PN related complications were the most relevant indication for ITx, but also a negative predictor for outcome. Early patient referral for Tx-assessment might help to identify and separate children with irreversible IF from children with transient IF or uncomplicated long-term PN, allowing to adapt a patient-based treatment strategy including or not ITx.

Practice of enteral nutrition in very low birth weight and extremely low birth weight infants.

The perinatal period is critical for human development. The brain of very low birth weight (VLBW, <1,500 g) infants is particularly vulnerable to undernutrition. Enteral nutrition is of major importance for the growth and the development of the gastrointestinal tract, which depends on the amount and composition of feeds. Feeding intolerance and the risk of necrotizing enterocolitis (NEC) are key concerns with enteral nutrition in VLBW infants. Controversies exist on how to feed VLBW infants during the first weeks of life, particularly in extremely low birth weight (ELBW, <1,000 g) infants. Unreasonable concerns lead to iatrogenic malnutrition, gastrointestinal atrophy, and parenteral nutrition-related complications. Many studies in the field of nutrition during the past decade demonstrated that some feeding regimens have significant benefits. There is strong evidence that the use of human milk (HM) reduces the risk of NEC and provides major advantages in VLBW infants. The feeding of fortified HM should be promoted and HM banking should be further developed to allow access to pasteurized donor HM for VLBW infants with an insufficient intake of their own mother's milk. Early enteral feeding should be promoted soon after birth to enhance gastrointestinal maturation, growth and functional development. Continuous- or short-interval intermittent feeding seems to provide better gastrointestinal tolerance and faster achievement of full enteral feeding. Feeding advancements of 20-30 ml/kg/day in VLBW infants ≥1,000 g and of 15-25 ml/kg/day in ELBW infants are reasonable strategies. Any suspicion of feeding intolerance implies short-interval evaluation to decide whether interruption of enteral feeding or its restart after a transient interruption are appropriate. One should always strive for maintaining at least minimal enteral feeding, rather than complete interruption of enteral feeding.

Noninvasive measurement of intestinal epithelial damage at time of refeeding can predict clinical outcome after necrotizing enterocolitis

Reintroduction of enteral nutrition in neonates with necrotizing enterocolitis (NEC) should take place when the gut is ready for its normal function. Too early a start of oral feeding might lead to disease relapse, whereas prolonged discontinuation of enteral nutrition is associated with impaired gut function and parenteral nutrition-related complications. This study evaluated whether noninvasive urinary measurement of intestinal fatty acid binding protein (I-FABP) at the time of refeeding can predict clinical outcome in neonates with NEC. Urinary I-FABP concentrations were measured in 21 infants with NEC just before reintroducing enteral nutrition. Poor outcome was defined as unsuccessful reintroduction of enteral feeding (EF), (re)operation for NEC, or death related to NEC after reintroduction of EF. Median urinary I-FABP levels in neonates with poor outcome (n = 5) were significantly higher as compared with I-FABP levels in neonates with good outcome (n = 16) (P < 0.01). A clinically significant cutoff value of 963 pg/ml was found to discriminate between infants with poor outcome and those with good outcome (sensitivity 80%, specificity 94%). Noninvasive urinary I-FABP measurement at time of refeeding differentiates neonates with poor outcome from neonates with good outcome in NEC. Urinary I-FABP measurement may therefore be helpful in the timing of EF in neonates with NEC.

Indications et résultats de la transplantation intestinale chez l’adulte

Optimised home parenteral nutrition is still, after 35 years of progress, the "gold standard "for benign but chronic intestinal failure. better recognition of chronic intestinal failure, in its multiple facets, is needed to improve Home Parenteral Nutrition by adding associated treatments such as intestinal trophic factors, rehabilitative surgery (reestablishment of colonic continuity, reverse jejunal segment in severe short gut type II) and/or reconstructive surgery (intestinal transplantation for end-stage intestinal failure). Intestinal transplantation is now a mature therapy with formal indications, especially in case of failure of Home Parenteral Nutrition (mainly Home Parenteral Nutrition-associated severe liver disease), where combined Liver-intestine transplantation is indicated before end-stage liver failure occurs. For high-risk patients, 'preemptive' intestinal transplantation alone should be discussed before home parenteral nutrition-related complications occur. Even, if the results in terms of patient survival have improved over the past 20 years, the 5-year survival rate still does not exceed 50%. Thus, each case should be discussed in a dedicated tertiary center. The ESPEN Home Artificial Nutrition Working Group conducted a survey in 2004 to assess potential candidates for intestinal transplantation in France, among the adult population of patients with home parenteral nutrition. The prevalence of potential candidates for intestinal transplantation was estimated at about 20% (about 40 new adult cases per year). Even though surgical techniques for isolated intestine, liver-intestine, and multivisceral transplantation were developed in the 1960s, very few patients were transplanted before 1990, because of inadequate initial immunosuppressive regimens. most patients died within days or months after Intestine transplantation. The discouraging results of the first clinical trials were due to technical complications, sepsis, and the failure of conventional immunosuppression to control rejection. By 1990, the development of tacrolimus-based immunosuppression, as well as improved surgical techniques, the increased array of potent immunosuppressive medications, infection prophylaxis, and better patient selection helped to improve actuarial graft and patient survival rates for all types of intestine transplantation. In adult intestinal transplantation, three kinds of graft can be proposed: isolated small bowel, combined liver and small bowel, and multivisceral transplantation. In isolated small bowel transplantation, the length of the graft ranges between 1.5 and 2 meters, but depends on the size of the recipient (and the abdominal cavity volume, which is reduced). The graft is anastomosed with the recipient's duodenum or remnant proximal jejunum. the distal part of the small bowel graft is on a temporary stoma, in order to allow biopsies for early detection of rejection. Vascular anastomoses are usually performed directly on the aorta for the superior mesenteric artery and either the recipient's portal vein or vena cava for the donor superior mesenteric vein. In combined liver and intestinal transplantation, one venous anastomosis is avoided because the graft is in one piece. Finally, one specificity of this transplantation is the fact that it usually concerns patients with numerous previous abdominal operations and with total or subtotal enterectomy. Thus, the residual abdominal cavity is usually very small, and this can be a major problem for graft insertion. For this reason, abdominal closure is performed with a temporary prosthesis, because even cutaneous closure remains impossible if a compartment syndrome is to be avoided.

Report of Initial Experience in Small Bowel Transplantation at São José do Rio Preto Medical School Hospital

Intestinal failure is the patient's inability to maintain hydroelectric and nutritional support by the digestive route, arising from massive enterectomy or diseases in which the bowel is incapable of adequately absorbing fluids and nutrients. Patients with intestinal failure associated with short bowel syndrome (SBS) and with other functional diseases with malabsorption or with total parenteral nutrition-related complications (recurrent sepsis and thrombosis of one or more deep venous accesses) are candidates for small bowel transplantation (SBT), which can be an isolated small bowel, a combined liver and small bowel, or a multivisceral graft. At our institution, three isolated SBTs were performed as our initial experience with this transplant.

Surgery for Pediatric Patients With Chronic Intestinal Pseudo‐Obstruction Syndrome

Surgery for Pediatric Patients With Chronic Intestinal Pseudo‐Obstruction Syndrome

Twenty-Seven Consecutive Intestinal and Multivisceral Transplants in Adult Patients: A 4-Year Clinical Experience

Adult isolated intestinal and multivisceral transplantation is gaining acceptance as the standard treatment for patients with intestinal failure with life-threatening parenteral nutrition-related complications. We report our 4-year experience with intestinal and multivisceral transplantation. We performed 20 isolated small bowel and seven multivisceral ones, including three with liver. The underlying diseases were mainly short bowel syndrome due to intestinal infarction, chronic intestinal pseudo-obstruction, and Gardner syndrome. Indications for transplant were loss of central venous access in 14 patients, recurrent sepsis in eight patients, and major electrolyte and fluid imbalance in five patients. One-year patient actuarial survival rate was 94% for isolated intestinal transplants and 42% for multivisceral recipients ( P = .003), while 1-year graft actuarial survival rate was 88.4% for isolated small bowel patients and 42.8% for multivisceral ones ( P = .01). The death rate was 18.5%. Our graftectomy rate was 14.8%. Our immunosuppressive protocols were based on induction agents such as alemtuzumab, daclizumab, and antithymocyte globulins. The majority of our complications were bacterial infections, followed by rejections and relaparotomies; most rejection episodes were treated with steroid boluses and tapering. We believe that our results were due to optimal candidate and donor selection, short ischemia time, and use of induction therapy. Multivisceral transplantation is a more complex procedure with less frequent clinical indications than isolated small bowel transplant, but our data concerning multivisceral transplants include only a small number of patients and require further evaluation.

Outcomes after adult isolated small bowel transplantation: experience from a single European centre

Background. Adult isolated small bowel transplantation is considered the standard treatment for patients with life-threatening parenteral nutrition-related complications. Here, we report a 3-year experience in a single European centre between December 2000 and December 2003. Aims. To evaluate and discuss pre-transplant and post-transplant factors that influenced survival rates in our series. Patients. Fourteen patients, with a mean parenteral nutrition course of 27 months, were transplanted. In eight cases they had not experienced any major complication from parenteral nutrition. Methods. We described pre-transplant evaluation and inclusion criteria, surgical technique and clinical management after transplant. Immunosuppressive therapy was based on induction drugs and Tacrolimus. We reported survival rates, major complications and rejection events. Results. One-year actuarial survival rate was of 92.3% with a mean 21-month follow-up (range 3–36 months). We had no intraoperative deaths. One patient (7.2%) died of sepsis following cytomegalovirus enteritis. One patient underwent graftectomy (7.2%) for intractable severe acute rejection. One-year actuarial graft survival rate of 85.1%. One patient (7.2%) affected by post-transplant lymphoproliferative disease is alive and disease-free after 8 months. Conclusion. We believe candidate selection, induction therapy, donor selection and short ischemia time play an important role in survival after small bowel transplantation.

38 Opinions in Scottish Neonatal Units About Enteral Feeding of Pre-Term Infants

Background: Enteral feeding of preterm and low birth weight infants is a contentious issue. There is uncertainty about the optimum approach. Concerns relate to the competing, serious potential risks of necrotising enterocolitis and catheter-related infection associated with different feeding methods. Evidence on which clinicians can base clinical practice is weak. Research studies have been small and results conflicting. Large randomised trials are needed. To ensure that trial interventions are relevant and acceptable to clinicians and that results are generalisable, it is important to be informed about ranges of opinion influencing current practice.Aim: To document current opinion and reported practice of neonatologists in Scotland with respect to enteral feeding of preterm and low birth weight infants.Methods: Senior clinicians from 15 Scottish neonatal units participated in a survey of opinions and policies about feeding of preterm (≤32 weeks) and low birth weight (≤ 1500g) babies. A single researcher using face-to-face interviews and semi-structured questionnaires conducted the survey.Results: 8(53%) units have written guidelines for initiation of feeds, 5(33%) for the rate of increase and 3(20%) for the discontinuation of feeds. All aim to introduce maternal breast milk on day 1 or 2 of life. None delay milk introduction for >48hours in the absence of specific contraindications. If breast milk is unavailable, 1(7%) unit uses donor milk, 6(40%) use preterm formula, 5(33%) term formula and 3(20%) hydrolysed protein formula. Preferred volumes for initiating feeds are variable, ranging from 0.5ml every 6–12 hours to 1ml/hour. Criteria for discontinuing feeds based on gastric aspirates are inconsistent between units. Gastric residual volumes considered “large” vary from ≥25% of the hourly feed volume to ≥2 hourly feed volumes. Decisions to withold feeds are made by a variety of staff in most units. One clinician indicated that consultants in that unit usually make such decisions, another that decisions are most often made by nurses.Conclusion: There is wide variation in opinion among neonatologists in Scotland and variable use of feeding guidelines. This probably reflects clinical uncertainty and is likely to lead to similar disparity in practice. Such differences may influence important outcomes such as necrotising enterocolitis and line- or parenteral nutrition-related complications. There is an urgent need for large, well-designed studies to define optimum feeding strategies.

Segmental Reversal of the Small Bowel as an Alternative to Intestinal Transplantation in Patients With-Short Bowel Syndrome

This article reports the results of segmental reversal of the small bowel on parenteral nutrition dependency in patients with very short bowel syndrome. Segmental reversal of the small bowel could be seen as an acceptable alternative to intestinal transplantation in patients with very short bowel syndrome deemed to be dependent on home parenteral nutrition. Eight patients with short bowel syndrome underwent, at the time of intestinal continuity restoration, a segmental reversal of the distal (n = 7) or proximal (n = 1) small bowel. The median length of the remnant small bowel was 40 cm (range, 25 to 70 cm), including a median length of reversed segment of 12 cm (range, 8 to 15 cm). Five patients presented with jejunotransverse anastomosis, and one each with jejunorectal, jejuno left colonic, or jejunocaecal anastomosis with left colostomy. There were no postoperative deaths. Three patients were reoperated early for wound dehiscence, acute cholecystitis, and sepsis of unknown origin. Three patients experienced transient intestinal obstruction, which was treated conservatively. Median follow-up was 35 months (range, 2 to 108 months). One patient died of pulmonary embolism 7 months postoperatively. By the end of follow-up, three patients were on 100% oral nutrition, one had fluid and electrolyte infusions only, and, in the four other patients, parenteral nutrition regimen was reduced to four (range of 3 to 5) cyclic nocturnal infusions per week. Parenteral nutrition cessation was obtained in 3 of 5 patients at 1 years and in 3 of 3 patients at 4 years. Segmental reversal of the small bowel could be proposed as an alternative to intestinal transplantation in patients with short bowel syndrome before the possible occurrence of parenteral nutrition-related complications, because weaning for parenteral nutrition (four patients) or reduction of the frequency of infusions (four patients) was observed in the current study.

Auditing the effect of experience and change on home parenteral nutrition related complications

A prospective record of all patients receiving home parenteral nutrition (HPN) in Tayside since 1980 has been used to audit the effect of experience and specific policy changes on HPN related complications. Total HPN related complications fell significantly over the years from 1.59 complications per treatment year during the initial 5 years of HPN experience to the current rate of 0.36 complications per treatment year. Specific policy changes, such as modification of the glucose concentration of feed, could also be shown to produce a significant benefit in the reduction of complications. Increasing experience with HPN results in a fall in complication rates, however, continuous audit of HPN is essential to determine the effect of policy changes on complication rates.

The current role of small-bowel transplantation in intestinal failure.

Short bowel syndrome is the clinical manifestation of a fundamental reduction in the functional intestinal absorptive surface area and malabsorption. The development of total parenteral nutrition has improved the natural course of this disease. Home parenteral nutrition-related complications continue to generate significant morbidity and mortality for these patients. Small-bowel transplantation is an alternative to home parenteral nutrition. There are significant risks of graft rejection and the potential complications of long-term immunosuppression. Small-bowel transplantation is an option, but it should be reserved for patients no longer considered candidates for continued home parenteral nutrition.