Parenteral Nutrition Support Research Articles

Effect of a fish oil-based lipid emulsion on intestinal failure-associated liver disease in children

The aim of this study was to assess the effects of a fish oil-based lipid emulsion on intestinal failure-associated liver disease (IFALD) in children. From January 2014 through June 2017, we enrolled 32 children with IF on long-term parenteral nutrition (PN). When the levels of any three of seven liver indicators (TBA, alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase, gamma glutamyl transferase (γ-GT), total bilirubin (TB), or direct bilirubin (DB)) were two times higher than normal levels, we switched a 50:50 mix of soybean oil and medium-chain triglycerides (MCT) lipid emulsion (with an average dose of 1.30 g/kg/day) to a fish oil-based lipid emulsion (1 g/kg/day) and measured liver function in the children. Meanwhile, inflammation and oxidative stress-related markers were also measured. The average fish oil therapy duration was 26 ± 21 days, and the median duration of PN support was 84 days. With fish oil therapy, levels of TBA, ALT, AST, γ-GT, TB, and DB all significantly decreased. Enteral nutrition was introduced following fish oil resulting in higher energy intake (99.88 ± 31.06 kcal/kg/day) compared with before fish oil (67.90 ± 27.31 kcal/kg/day, P = 0.001). No significant difference was found in average PN energy (P = 0.147). In addition, levels of inflammatory indicators like tumor necrosis factor-alpha (TNF-α), C-reactive protein (CRP), and white blood cell (WBC) significantly decreased. Fish oil therapy alleviates IFALD in children.

Effect of high-dose second-generation fat emulsion usage on very low birth weight infants

Objective To explore the efficacy and safety of high-dose second-generation fat emulsion usage on the very low birth weight premature infants. Methods A total of 88 premature infants with very low birth weight(VLBW) in Neonatal Intensive Care Unit (NICU)of Fujian Provincial Maternity and Children Hospital, Affiliated Hospital of Fujian Medical University from December 2013 to December 2014 were randomly divided into experimental group and control group, with 44 cases in each group according to the table of random number.The experimental group received intravenous nutrition with 200 g/L second-generation fat emulsion within 24 hours after birth, the initial dose was 2.0 g/(kg·d) with an increase of (0.5-1.0) g/(kg·d) daily, the maximum dose was 3.5 g/(kg·d); the control group received intravenous nutrition with 200 g/L second-generation fat emulsion 24 hours later after birth, the initial dose was 0.5 g/(kg·d) with an increase of 0.5 g/(kg·d) daily, the maximum dose was 3.5 g/(kg·d). The other intravenous nutrition methods were same.The general conditions at birth, blood biochemical parameters, growth parameters and complications were compared between the 2 groups. Results The mean value of intravenous nutrition duration, length of stay, the glucose infusion rates of postnatal days 6 and 7, the serum triglyceride levels of postnatal days 7, chest circumference of the fourth weeks, the incidence of the low triiodothyronine(T3) syndrome and parenteral nutrition associated cholestasis(PNAC) were (22.27±7.17) d, (37.75±12.28) d, (8.10±0.92) mg/(kg·min), (8.49±1.06) mg/(kg·min), 0.18(0.03-0.59) mmol/L and (27.21±1.62) cm in the experimental group respectively, but (27.36±11.37) d, (44.36±16.45) d, (7.98±0.79) mg/(kg·min), (8.22±0.76) mg/(kg·min), 0.28(0.07-0.99) mmol/L and (26.56±0.96) cm in the control group, respectively, and the differences were statistically significant between the 2 groups(t=2.512, 5.403, 4.314, 9.705, 696.500, 6.668, all P 0.05). Conclusions The high-dose second-generation fat emulsion usage[the initial dose 2.0 g/(kg·d)]in VLBW infants is safe and well tolerated.Advisable parenteral nutrition support strategy can promote growth of VLBW infants, shorten the intravenous nutrition duration and length of stay, reduce the incidence of the low T3 syndrome and PNAC, which has no influence on the incidence rates of other complications. Key words: Infant, premature; Very low birth weight; Parenteral nutrition; Growth; Complication

Presentation and outcome of treatment of jejunoileal atresia in Nigeria.

Background:Intestinal atresia is a common cause of neonatal intestinal obstruction. Previous reports from Nigeria have indicated a high mortality rate. This is a report of current outcome review from one tertiary center.Patients and Methods:A retrospective analysis of infants managed for jejunoileal atresia in 10 years (2005–2014). The information retrieved from patients’ records was analyzed using SPSS 17.Results:There were 38 patients (19 boys and 19 girls) aged 1–28 days (median 4 days). Twenty-four patients (63.2%) presented after 48 h of life. Twenty-five (65.8%) had jejunal atresia and 13 (34.2%) had ileal atresia. Six patients had associated anomalies. The most common atresia was type III (39.5%, 15 patients). Twenty-eight (73.7%) patients had a resection of the atresia and anastomosis and others had enterostomies. Total parenteral nutrition and neonatal intensive care support were not available during the period of the study. Bowel function was established within 1 week and 27 (71.1%) patients commenced oral feeding. Twenty-six (68.4%) patients had postoperative complications resulting in prolonged hospital stay of 2–44 days (median = 13). Mortality was 34.2% (13 patients). Factors that significantly affected mortality were intestinal necrosis at presentation, postoperative complications, and severe malnutrition.Conclusion:Intestinal atresia is still associated with unacceptably high morbidity and mortality, due to late presentation, and lack neonatal intensive care services and parenteral nutritional support. Efforts need to be intensified to address these factors to improve outcome.

Postoperative complications and management of minimally invasive esophagectomy

Postoperative complications of esophageal cancer are important factors that affect the prognosis of esophageal cancer. With the development of minimally invasive esophagectomy (MIE), the incidence of postoperative complications has decreased significantly. In this article, we introduce the main postoperative complications and the etiology, diagnosis, and treatment of complication. Anastomotic leakage is one of the most serious surgical complications, which always has been a problem for esophageal surgeons. With the development of minimally invasive techniques, mechanical staplers, and the application of enteral and parenteral nutritional support, the incidence of anastomotic leakage is reduced. Due to more thorough lymph node dissection, the recurrent laryngeal nerve injury was not significantly reduced. But most of them were temporary and clinical symptoms caused by recurrent laryngeal nerve injury can be improved soon after surgery. In this period, the incidence of chylothorax, gastrointestinal tracheal and bronchial fistula is low. On the contrary, the incidence of pulmonary complications and gastrointestinal reflux is still high.

The abdominal cocoon: A management dilemma

Abdominal cocoon is a rare entity with no known aetiology and is a clinical curiosity in the surgical field, and a management dilemma for surgeons. Treatment may include excision of the accessory peritoneal sac with lysis of the inter-loop adhesions. Bowel resection is unnecessary unless a nonviable segment is found. However, if there are no signs of acute abdominal symptoms after diagnosing abdominal cocoon syndrome pre-operatively, surgery is unnecessary. We presenting a case of a 47-year-old male who had laparotomy noted an entirely frozen abdomen which was depicted as a cocoon. The stomach was only identified due to feeling the position of the NGT, no other anatomy was delineated. A peritoneal biopsy was taken prior to closure. Post operatively he was given parenteral and trickle enteral nutritional support and was discharged home with PEG gastrostomy for feeding.

Multimodal Surgical Approach for Adult Patients With Chronic Intestinal Pseudo-Obstruction: Clinical and Psychosocial Long-term Outcomes

BackgroundClinical and psychosocial outcomes of a multimodal surgical approach for chronic intestinal pseudo-obstruction were analyzed in 24 patients who were followed over a 2- to 12-year period in a single center after surgery or intestinal/multivisceral transplant (CTx). MethodsThe main reasons for surgery were sub-occlusion in surgery and parenteral nutrition–related irreversible complications with chronic intestinal failure in CTx. ResultsAt the end of follow-up (February 2015), 45.5% of CTx patients were alive: after transplantation, improvement in intestinal function was observed including a tendency toward recovery of oral diet (81.8%) with reduced parenteral nutrition support (36.4%) in the face of significant mortality rates and financial costs (mean, 202.000 euros), frequent hospitalization (mean, 8.8/re-admissions/patient), as well as limited effects on pain or physical wellness. ConclusionsThrough psychological tests, transplant recipients perceived a significant improvement of mental health and emotional state, showing that emotional factors were more affected than were functional/cognitive impairment and social interaction.

Effects of early enteral nutrition support on the clinical efficacy and surgical safety of patients with severe acute pancreatitis

Objective To investigate the effects of early enteral nutrition support on the clinical efficacy and surgical safety of patients with severe acute pancreatitis (SAP). Methods From January 2015 to June 2017, one hundred and twenty-six cases with SAP in Xiaochang First People ′s Hospital were selected as the research object, and were randomly divided into the observation group and the control group, with 63 cases in each group.All patient were treated with CT guided puncture and drainage treatment, the control group was given postoperative parenteral nutrition support from 1 d after operation, the observation group was given postoperative nutritional support from 1 d after operation, all the nutritional support for 14 d. Results All patients completed the operation successfully and no serious complications occurred during the operation, the operation time of the observation group was (156.33±16.39) min, and the operation time of the control group was (151.02±14.99) min, the difference was not statistically significant (t=1.898, P=0.060); the intraoperative blood loss of the observation group was (45.02±11.95) ml, and the intraoperative blood loss of the control group was (46.04±18.44) ml, the difference was not statistically significant (t=0.368, P=0.713); the postoperative hospital stay was (7.20±1.55) d in the observation group and (14.88±2.15) d in the control group, the difference was statistically significant (t=22.999, P=0.000); at 14d after the surgery, the observation group had 1 case of bile leakage, 1 case of pancreatic pseudocyst, 1 case of digestive tract fistula, at 14d after the surgery, the control group had 2 cases of hemorrhage, 3 cases had bile leakage, 3 cases had pancreatic pseudocyst, 3 cases had digestive tract fistula, the incidence of complications was statistically significant (χ2=5.143, P=0.023); in the observation group, 50 cases were cured, 12 cases were improved, 1 cases were ineffective, in the control group, 35 cases were cured, 20 cases were improved, 8 cases were ineffective, the difference between the two groups was statistically significant(χ2=5.863, P=0.016); the ALB value of the observation group was (30.95±5.11) g/L at 1 d after surgery, the ALB value of the control group was (30.58±6.96) g/L at 1 d after surgery, the difference was not statistically significant (t=0.340, P=0.734), the albumin value of the observation group was (36.65±3.00) g/L at 14 d after surgery, higher than that at 1 d after surgery, the difference was statistically significant (t=7.635, P=0.000), the albumin value of the control group was (33.36±3.85) g/L at 14 d after surgery, higher than that at 1 d after surgery, the difference was statistically significant (t=2.774, P=0.007), the difference in albumin value at 14d after surgery between the two groups was statistically significant (t=5.350, P=0.000); the prealbumin value of the observation group was (155.36±52.12) mg/L at 1 d after surgery, the prealbumin value of the control group was (154.63±41.96) mg/L at 1 d after surgery, the difference was not statistically significant (t=0.087, P=0.931), the Prealbumin value of the observation group was (193.52±55.88) mg/L at 14 d after surgery, higher than that at 1 d after surgery, the difference was statistically significant (t=3.964, P=0.000), the prealbumin value of the control group was (171.52±50.85) mg/L at 14 d after surgery, higher than that at 1 d after surgery, the difference was statistically significant (t=2.033, P=0.044), the difference of PA value at 14 d after surgery between the two groups was statistically significant (t=2.311, P=0.022). Conclusion Early enteral nutrition support treatment of SAP can improve the clinical efficacy, reduce postoperative complications, improve the nutritional status of the body and promote the rehabilitation of patients. Key words: Enteral nutrition; Severe acute pancreatitis; Complications; Nutritional status

Nutrition in oncology and palliative care – desideratum versus reality

Nutrition is an indispensable element in everyone’s existence, being essential for preventing complications in oncological patients. Weight loss and malnutrition are factors of poor prognosis, multimodal cancer therapy being inefficient in patients with nutritional deficiency. Nutritional support in cancer patients is one of the main cornerstones of curative cancer treatment, but also represents an indispensable component of palliative care. Enteral nutritional support can assure a proper metabolic status in patients with normal digestive system who can no longer feed per os. Parenteral nutrition is initiated in patients with severe digestive issues. Enteral nutritional support can be provided by gastrostomy or jejunostomy performed with formal surgery or percutaneous endoscopic gastrostomy (PEG) and other similar procedures. After the parenteral nutrition devices is installed, nutritional formulae are directly introduced in the patient’s stomach. There are different formulae, based on the patient’s needs, and different volumes introduced per meal, depending on the procedure (PEG allows a larger volume than classic gastrostomy). The parenteral nutritional support requires a central venous catheter and multiple formulae containing amino acids, glucose, lipids, salts and vitamins that are directly introduced in the patient’s blood flow. The main disadvantage of this procedure is that it can be sustained for maximum 15 days. A significant percent of the patients diagnosed with cervical cancer will require enteral nutritional support during oncological treatment and one year afterwards. PEG is a superior to classic gastrostomy,and it represents the ideal choice when it comes to oncological patients at risk of malnutrition. The devices used in this procedure allow a faster recovery, they have a low rate of complication, they are economically advantageous and the patient can resume the nutrition in 24-48 hours.

A review of best evidenced-based enteral and parenteral nutrition support practices for preterm infants born <1,500 grams

Nutrition monitoring must remain a priority for very low birth weight infants who are at high risk for nutritional deficiencies and growth failure. Research demonstrates that as many as 50% of North American infants experience extrauterine growth failure, primarily attributable to inadequate nutrition delivery. Consequently, the purpose of this review is to identify the best enteral and parenteral nutrition management practices for preterm infants born <1,500 grams. Nutrition recommendations set forth for preterm infants by leading references were reviewed and compared. Infant nutrition and growth studies identified by extensive literature review were also assessed in comparison to current recommendations, neonatal clinical experience, and gaps within clinical practice. Modern literature demonstrates that more aggressive parenteral nutrition provision, early enteral feeding initiation, more rapid enteral feeding advancement, and early human milk fortification are well tolerated and promote improved nutrition, growth, and clinical outcomes. This review identifies clinically feasible and evidenced-based enteral and parenteral nutrition support practices that promote best outcomes for very low birth weight infants.

Case Report of an Adult Patient Who Underwent a Serial Transverse Enteroplasty Procedure for Short Bowel Syndrome Following an Esophagectomy and Total Gastrectomy

Since its introduction as an alternative intestinal lengthening technique, the serial transverse enteroplasty (STEP) procedure has been used increasingly as the surgical treatment of choice for children with short bowel syndrome (SBS). On the other hand, there are few report of its efficacy in adults with SBS, particularly those who have previously undergone a gastrectomy. This case report describes a 34-year-old woman with a short bowel after an esophagectomy and total gastrectomy due to lye ingestion followed by an extensive intestinal resection due to small bowel strangulation. The STEP procedure was performed successfully and the small intestine was lengthened from 55 to 75 cm. The patient tolerated the procedure well and was weaned off total parenteral nutrition. The frequency and characteristics of diarrhea improved, and her weight remained acceptable via management with intermittent parenteral nutritional support for 6 months postoperatively. This case suggests that the STEP procedure should be considered for gastrectomized patients with SBS.

Distinct Effects of Growth Hormone and Glutamine on Activation of Intestinal Stem Cells.

For patients with short bowel syndrome under parenteral nutrition support, growth hormone (GH) and glutamine (GLN) have been found to help the growth of intestinal mucosa. In this research, we studied the effects of GH and GLN on intestinal stem cells (ISCs). The in vitro and in vivo effects of GH and/or GLN on ISCs were evaluated by observing the ability of ISCs to form organoids in a Matrigel culture system. The expression levels of stemness and differentiation markers in ISCs and organoids were assessed using quantitative real-time polymerase chain reaction, immunofluorescence assay, and immunohistochemistry staining. In vitro administration of GH activated the stemness of ISCs, whereas GLN enhanced the expression of chromogranin A and Muc2, which are differentiation markers in enteroendocrine and goblet cells, respectively. Administration of GH or GLN in mice showed that GH, but not GLN, upregulated the proliferative activity of ISCs with increased formation of crypt organoids. In addition, GH increased the expression of Lgr5 and GLN enhanced expression of Muc2 in the crypt fractions of the intestines in mice. These results suggest that GH mainly enhances proliferative activities, whereas GLN promotes the differentiation potential of ISCs.

Survey of Nutrition Management Practices in Centers for Pediatric Intestinal Rehabilitation.

Nutrition management of pediatric intestinal failure (IF) requires interdisciplinary coordination of parenteral nutrition (PN) and enteral nutrition (EN) support. Nutrition strategies used by specialists in pediatric intestinal rehabilitation to promote gut adaptation and manage complications have not been previously summarized. A practice survey was distributed to members of the dietitian subgroup of the American Society for Parenteral and Enteral Nutrition Pediatric Intestinal Failure Section. The survey included 24 open-ended questions related to PN and enteral feeding strategies, nutrition management of PN-associated liver disease, and laboratory monitoring. Dietitians from 14 centers completed the survey. Management components for patients at risk for cholestasis were consistent and included fat minimization, trace element modification, avoiding PN overfeeding, and providing EN. Parenteral amino acid solutions designed for infants/young children are used in patients <1 or 2 years of age. Trace minerals are dosed individually in 10 of 14 centers. Eleven centers prescribe a continuous infusion of breast milk or elemental formula 1-2 weeks after resection while 3 centers determine the formula type by the extent of resection. Most (86%) centers do not have a protocol for initiating oral/motor therapy. Laboratory panel composition varied widely by center. The selection and frequency of use depended on clinical variables, including cholestatic status, exclusive vs partial PN dependence, postrepletion verification vs routine monitoring, intestinal anatomy, and acuity of care. EN and PN management strategies are relatively consistent among U.S. centers. Collaborative initiatives are necessary to define better practices and establish laboratory monitoring guidelines.

Parenteral nutrition during neoadjuvant chemotherapy for patients with non-metastatic gastric or esophago-gastric cancer to reduce postoperative morbidity (PERCOG): study protocol for a randomized controlled trial

BackgroundThe majority of patients with gastric or esophago-gastric cancer are at risk for malnutrition. Preoperative malnutrition was shown to increase the incidence of postoperative complications following abdominal surgery. However, it remains unclear if preoperative parenteral nutritional support during neoadjuvant chemotherapy (NACT) may be effective to reduce the rate of postoperative complications in these patients.Methods/DesignThe PERCOG trial is a randomized controlled multicenter observer-blinded trial, investigating if the improvement of the general condition of patients with non-metastasized gastric cancer or cancer of the esophago-gastric junction during NACT by supplemental parenteral nutrition can decrease the postoperative Comprehensive Complication Index (CCI). Statistical analysis of the primary endpoint measure (CCI on postoperative day 30) will be based on the intention-to-treat population. The global level of significance is set at 5% and the sample size (n = 150) is determined to assure a power of 80%.DiscussionThe results of the PERCOG trial will provide high-level evidence for clinical recommendations regarding the administration of preoperative supportive parenteral nutrition and provide all participating patients the opportunity of an improved treatment.Trial registrationGerman Clinical Trials Register, DRKS00009451. Registered on 3 July 2017.

Supplementary choline attenuates olive oil lipid emulsion-induced enterocyte apoptosis through suppression of CELF1/AIF pathway.

Enterocyte apoptosis induced by lipid emulsions is a key cause of intestinal atrophy under total parenteral nutrition (TPN) support, and our previous work demonstrated that olive oil lipid emulsion (OOLE) could induce enterocyte apoptosis via CUGBP, Elav‐like family member 1 (CELF1)/ apoptosis‐inducing factor (AIF) pathway. As TPN‐associated complications are partially related to choline deficiency, we aimed to address whether choline supplementation could attenuate OOLE‐induced enterocyte apoptosis. Herein we present evidence that supplementary choline exhibits protective effect against OOLE‐induced enterocyte apoptosis both in vivo and in vitro. In a rat model of TPN, substantial reduction in apoptotic rate along with decreased expression of CELF1 was observed when supplementary choline was added to OOLE. In cultured Caco‐2 cells, supplementary choline attenuated OOLE‐induced apoptosis and mitochondria dysfunction by suppressing CELF1/AIF pathway. Compared to OOLE alone, the expression of CELF1 and AIF was significantly decreased by supplementary choline, whereas the expression of Bcl‐2 was evidently increased. No obvious alterations were observed in Bax expression and caspase‐3 activation. Mechanistically, supplementary choline repressed the expression of CELF1 by increasing the recruitment of CELF1 mRNA to processing bodies, thus resulting in suppression of its protein translation. Taken together, our data suggest that supplementary choline exhibits effective protection against OOLE‐induced enterocyte apoptosis, and thus, it has the potential to be used for the prevention and treatment of TPN‐induced intestinal atrophy.

Early enteral nutrition on the nursing of elderly patient with gastric cancer after total gastrectomy

Objective To discuss the clinical effects of early enteral nutrition on elderly patient with gastric cancer after total gastrectomy. Methods A total of 138 elderly patients with gastric cancer after total gastrectomy in Renji Hospital Shanghai Jiaotong University School of Medicine from September 2014 to September 2016 were selected using purposive sampling. They were divided into the observation (n=73) and control (n=65) groups using random number table. Patients in the control group were given parenteral nutritional support. The energy was 125 KJ/ (kg.d) ; nitrogen content was 0.15 g/ (kg.d) ; total fluid amount was 50 ml/ (kg.d) . They were prepared to bags of 3 L and given by intravenous dripping through internal jugular vein. After the anal exhaust and removing gastric tube, patients were routinely given from water to clear fluid diet, fluid diet, semi-fluid diet until normal diet. Patients in the observation group received indwelling three-lumen gastrojejunal tube. At 12 h after the operation, heating 100 ml 5% glucose were given through three-lumen gastrojejunal tube. At 24 h after the operation, Ruidai (enteral nutritional suspension-TPF) were given at the total 500 ml and increased by 500 ml/d until 1 500 ml at 4 d after the operation. The drop speed increased from 20 ml/h to 100 ml/h. The incidence of postoperative complications, the anal exhaust time, the leaving bed time, hospital days and nutritive indexes were compared between the two groups. Results The hospital days, anal exhaust time and the leaving bed time in the observation group were (12.9±5.9) d, (70.3±16.7) h and (15.24±13.28) h, which were significantly lower than those in the control group [ (18.6±6.9) d, (97.5±22.3) h and (29.95±15.23) h] (P<0.05) . There was 1 case of diarrhea in the observation group, while 2 cases of anastomotic leakage, 2 case of infection, 1 case of obstruction and 2 cases of diarrhea were observed in the control group. The incidence of postoperative complications in the observation group was significantly lower than that in the control group (P<0.05) . The nutritive indexes at 7 d and 14 d after the operation in the observation group were statistically significantly better than those in the control group (P<0.05) . Conclusions Early enteral nutrition on elderly patient with gastric cancer after total gastrectomy can reduce the incidence of postoperative complications, improve the postoperative nutrition status, shorten the time of anal exhaust and leaving bed, and reduce the hospital days. Key words: Aged; Gastric neoplasms; Total gastrectomy; Early enteral nutrition

Enterocolitis Neutropénica en Nińos

Neutropenic Enterocolitis (NE) is a heterogeneous disease with wide range of clinical presentation that can affect any segment of the gastrointestinal tract, with varying severity. It is a complication in patients with high-dose chemotherapy for hematologic and solid tumors. NE typically presents with fever and abdominal pain, but diagnosing is still challenging because symptoms can be varied and elusive. A high index of suspicion must be maintained. The early study with computed tomography directs diagnosis. Most patients benefit from conservative treatment consisting on bowel rest, nasogastric tube placement, parenteral nutritional support, analgesic and broad-spectrum antibiotic coverage. However, the surgical intervention is uncommon and is limited to perforation, peritonitis or gastrointestinal bleeding despite correction of coagulopathy.

MON-P024: The Effect of Early or Late Parenteral Nutrition Support on the Clinical Outcome in the Patients with Acute Surgical Abdomen

MON-P024: The Effect of Early or Late Parenteral Nutrition Support on the Clinical Outcome in the Patients with Acute Surgical Abdomen

A short-time economic evaluation of various modalities of glutamine dipeptide-enriched parenteral nutrition support in patients undergoing elective surgery for gastrointestinal tumors using decision-tree model

Objective To assess the short-time economics of various glutamine dipeptide-enriched parenteral nutrition (PN) for patients undergoing elective surgery for gastrointestinal tumors, with an attempt to provide evidence for decision makers on clinical nutrition support. Methods A prospective cohort study was designed. From payer/disburser's perspective, a cost-effectiveness decision-tree model was developed to assess the clinical outcomes and short-time economic effects of glutamine dipeptide-enriched PN that used in different time points (early postoperative or perioperative). Cost-effectiveness analysis, cost-utility analysis, and incremental cost-effectiveness analysis were adopted in the decision-tree model. One-way sensitivity analysis was performed to determine the robustness of the results. Results Totally 107 patients were included. There was no significant difference between the perioperative alanine(Ala) glutamine(Gln) nutrition support (group A) and early postoperative Ala-Gln nutrition support (group B) in the ratio of 5% weight declines on the 8th day after surgery and infection-related postoperative complications (72.1% vs. 78.1%, χ2=0.509, P=0.498 and 2.32% vs. 4.69%, χ2=0.060, P=0.806). The levels of prealbumin (PA) and albumin(Alb) and the level of total lymphocyte count(TLC) also the time of recovering gastrointestinal function, length of stay nutritional discharge index(LOSNDI), and direct costs were significantly different [PA: (208.19±56.92)mg/L vs. (187.97±62.05)mg/L, t=2.283, P=0.039; Alb: (33.82±3.91)×109vs. (31.96±4.57)×109,t=2.184, P=0.036; TLC: (1.19±0.55)×109vs. (0.89±0.66)×109,t=2.461, P=0.015; the time of recovering gastrointestinal function(3.06±0.28)d vs. (3.39 ± 0.34)d, t=-3.675, P=0.000; LOSNDI: (16.84±2.92)d vs. (18.52 ±3.47)d, t=-2.613, P=0.011; direct costs: ￥(17 029.05±317.28) vs. ￥(15 610.64±292.56), t=23.764, P=0.000]. When LOSNDI and quality-adjusted life years (QALYs) were estimated as indicators of effectiveness, the incremental cost-effectiveness ratios and incremental cost-utility ratios of group A were ￥844.3 and ￥70 920.5, respectively. Net monetary benefit of group B was more than that of group A. One-way sensitivity analysis showed that parameters had no significant effect on the model. Conclusion When using local per capita gross domestic product as threshold, early postoperative Ala-Gln PN was more economical than perioperative Ala-Gln PN strategy evaluation. Key words: Parenteral nutrition; Decision trees; Glutamine dipeptide; Gastro-intestinal tumors; Health economic evaluation

Enteral and Parenteral Nutritional Support - test

Malnutrition among the critically ill is widely prevalent, resulting in impaired ventilator drive, prolonged ventilator dependence, impaired immunologic function, and increased risk of infection. The initiation of early nutrition therapy, specifically enteral nutrition, decreases the early loss of lean mass, provides calories, and improves patients’ immunity and healing, which is critical for improving morbidity and mortality in patients suffering from critical illness. Determining nutritional risk using the Nutrition Risk in Critically Ill (NUTRIC) score; assessing nutritional needs, including protein and calorie needs, with ongoing reassessments; gaining gastrointestinal access for initiating early enteral therapy with a standard polymeric isotonic or near-isotonic 1 to 1.5 kcal/mL formula for surgical critically ill patients within 24 to 48 hours of admission to the intensive care unit; monitoring for gastrointestinal intolerance and complications; and selecting immunonutrition, specifically arginine and omega-3 fatty acids, for the postoperative surgical critical care patient are key strategies in overcoming malnutrition and improving overall morbidity and mortality in critically ill patients. This review contains 1 figure, 3 tables, and 52 references. Key words: enteral nutrition, immunonutrition, nutritional assessment, nutritional risk, refeeding syndrome

Case 4: A Preterm Infant with a Necrotic Ulcer Over the Perianal Area

A 1.07-kg male infant with severe growth restriction is born at 30 weeks’ gestational age to a 36-year-old gravida 3, para 2 mother by emergency cesarean delivery for nonreassuring heart tracing. The parents are of low socioeconomic status and are first-degree consanguineous relatives. The mother received steroids and her membranes ruptured at delivery. At birth, the infant’s cord clamping was delayed, and after an initial weak cry he underwent intubation for poor respiratory efforts. Apgar scores were 4 and 7 at 1 and 5 minutes, respectively. His initial stabilization included surfactant administration, mechanical ventilation with volume guarantee, catheter line placement (umbilical venous and arterial catheters), initiation of total parenteral nutrition, antibiotics, and inotropic support. On day 3, he underwent extubation and received noninvasive intermittent positive pressure ventilation (NIPPV), inotropic support was discontinued, and antibiotics were stopped, because his blood culture was sterile. He demonstrated steady clinical improvement in the next 3 days, was weaned from NIPPV to nasal continuous positive pressure, and nasogastric feeds progressed gradually. On day 6, the bedside nurse noticed a small macule and blister with surrounding erythema over the lateral aspect of his right thigh, which progressed rapidly in hours to blackish-gray discoloration of skin in an area 4 × 1 cm in size with a small hemorrhagic lesion in the center (Fig 1). The infant’s clinical condition worsened rapidly in the next 24 hours; he became lethargic, hypothermic, tachycardic, hypotensive with poor perfusion, and apneic with increased oxygen requirement. He underwent elective reintubation for recurrent apnea and mixed respiratory and metabolic acidosis. A limited sepsis screening (complete blood cell count and cultures from blood, skin wound, and urine) was performed. Empiric antibiotic treatment with piperacillin-tazobactam was commenced. The infant received a bolus of normal saline, and dopamine treatment was commenced for low mean blood pressure. …