Parenteral Nutrition Support Research Articles

Nutrition and Hyperglycemia Management in the Inpatient Setting (Meals on Demand, Parenteral, or Enteral Nutrition).

The goal of this paper is to provide the latest evidence and expert recommendations for management of hospitalized patients with diabetes or hyperglycemia receiving enteral (EN), parenteral (PN) nutrition support or, those with unrestricted oral diet, consuming meals on demand. Patients with and without diabetes mellitus commonly develop hyperglycemia while receiving EN or PN support, placing them at increased risk of adverse outcomes, including in-hospital mortality. Very little new evidence is available in the form of randomized controlled trials (RCT) to guide the glycemic management of these patients. Reduction in the dextrose concentration within parenteral nutrition as well as selection of an enteral formula that diminishes the carbohydrate exposure to a patient receiving enteral nutrition are common strategies utilized in practice. No specific insulin regimen has been shown to be superior in the management of patients receiving EN or PN nutrition support. For those receiving oral nutrition, new challenges have been introduced with the most recent practice allowing patients to eat meals on demand, leading to extreme variability in carbohydrate exposure and risk of hypo and hyperglycemia. Synchronization of nutrition delivery with the astute use of intravenous or subcutaneous insulin therapy to match the physiologic action of insulin in patients receiving nutritional support should be implemented to improve glycemic control in hospitalized patients. Further RCTs are needed to evaluate glycemic and other clinical outcomes of patients receiving nutritional support. For patients eating meals on demand, development of hospital guidelines and policies are needed, ensuring optimization and coordination of meal insulin delivery in order to facilitate patient safety.

Feeding of preterm infants and fortification of breast milk.

The administration of the adequate amount of nutrients helps to improve a correct short-term linear growth and long-term neurocognitive development. To reduce the extra-uterine growth delay in very low birth weight infants (VLBW) the best strategy of nutrition (parenteral or enteral) should be established rapidly, since the first day of life. In preterm infants, nutrition can be administered parenterally and enterally. Prematurity is the most frequent indication for parenteral nutritional support due to intestinal functional immune deficiency, deficiency of digestive enzymatic systems and reduced nutritional reserve of these infants. In terms of enteral nutrition, breast milk is the first choice. In case of preterm and VLBW infants, fortifiers are used to overcome breast milk's protein and mineral deficiencies. When breast milk is not available, specific infant formula is the alternative.

Effect of different types of triglycerides on patients with gastric cancer after radical operation

Objective To observethe effect of different types of triglycerides on nutritional status, hepatic and renal function and prognosis of patients with gastric cancer after radical operation. Methods Structural triglyceride (STG) group included 218 patients with venous infusion of structural triglyceride, while medium chain triglyceride and long chain triglyceride (MCT/LCT) group with venous infusion of lipofundin or lipovenoes had 194 patients. The indexes of nutrition [BMI, the score of nutrition risk screening 2002, serum total protein (TP), albumin (Alb), prealbumin], hepatic and renal function [aspartate amino transferase (AST), alanine aminotransferase (ALT), total bilirubin (TBIL), serum creatinine (Cr) and serum urea] and prognosis were analyzed. Results There were no statistically significant differences between the two groups in the general data (sex, age, BMI, NRS2002 score, operation time and blood loss during operation) (P=0.750, 0.266, 0.585, 0.555, 0.058, 0.134). TP, Alb, prealbumin, AST and ALT in the two groups showed a range of variations before operation and at postoperative day 3 and 7. The change indexes of STG group were respectively from (63.67±7.97) g/L, (37.23±5.57) g/L, (174.87±58.23) g/L, (28.59±16.10) U/L and (24.08±28.75) U/L to (62.51±6.98) g/L, (4.92±4.55) g/L, (144.60±41.54) g/L, (29.59±19.22) U/L and (25.96±21.73) U/L, while the change indexes of MCT/LCT group were respectively from (64.28±8.22) g/L, (37.55±5.42) g/L, (179.08±59.79) g/L, (29.11±15.39) U/L and (24.46±28.17) U/L to (61.00±6.56) g/L, (33.09±3.89) g/L, (132.10±42.39) g/L, (40.04±46.13) U/L and (35.30±41.87) U/L, which showed statistically significant difference between the two groups (P=0.024, 0.001, 0.009, 0.038, 0.030). There were no statistically significant differences (P=0.560, 0.242, 0.954) between the two groups in range of variations of TBIL, serum urea and Cr. There were significant difference (P=0.030, 0.023) between the two groups in anal exhaust time and changes in body weight after 7 days of operation. While there were no statistically significant differences (P=0.900, 0.250, 0.696) between the two groups in level of anastomotic leakage, wound infection rate and length of hospital stay. Conclusion In parenteral nutrition support structural triglyceride is more advantageous than medium chain triglyceride and long chain triglyceride for patients with gastric cancer after radical operation. The former can effectively accelerate the synthesis of metabolism, improve the nutritional status, protect the hepatic function, promote the recovery of gastrointestinal function and promote postoperative recovery of patients with gastric cancer. Key words: Gastric cancer; Parenteral nutrition; Structured triglyceride

Nutrition support in hospitalised adults at nutritional risk.

Nutrition support in hospitalised adults at nutritional risk.

Cis-diammin-odichloroplatinum and pseudomonas aeruginosa-mannose sensitive haemagglutination combined with continuous cycle hyperthermie intraperitoneal perfusion chemotherapy in the treatment of gastric cancer with pyloric obstruction in rabbit model

Objective To establish rabbit models of VX-2 carcinoma with pyloric obstruction and explore the curative effects and safety of Cis-diammin-odichloroplatinum (DDP) and pseudomonas aeruginosa-mannose sensitive haemagglutination (PA-MSHA) combined with continuous cycle hyperthermie intraperitoneal perfusion chemotherapy (CCHIPC) on gastric cancer with pyloric obstruction in a rabbit model. Methods VX-2 tumor cell suspension was injected to establish the rabbit model of gastric cancer with obstruction. Forty-two rabbits were randomly divided into the control group and the treatment group. All rabbit models treatment blood routine, liver and kidney function, electrolytes detection forward, the control group rabbits were 21, give direct resection of gastric cancer; treatment group rabbits were 21, given preoperative combined with enteral and parenteral nutrition after reoperation. Records of chemotherapy combined with enteral and parenteral nutrition in the treatment of rabbit model of survival, all the rabbits died the day be abdominal and thoracic, determine the primary tumor size in the gastric antrum, pyloric obstruction degree, respectively in treatment before laparotomy, died that day to take primary lesions and metastasis lesions were, he staining, under optical microscope observed. After the death of rabbits, gastric cancer was taken in situ and metastatic tumor. The expression levels of vascular endothelial growth factor (VEGF) and proliferating cell nuclear antigen (PCNA) were detected by immunohistochemistry. Results Experimental group and control group of gastric cancer radical resection rate was 85. 5% (18/21) and 66. 7% (14/21), the experimental group was significantly higher than the control group, the difference was statistically significant (P=0.025). In the experimental group and control group, the amount of bleeding, operation time, and postoperative anastomotic leakage or duodenal fistula, bleeding, stress ulcer bleeding and intestinal obstruction were not statistically significant (P=0.253). In the treatment group, the incidence of postoperative abdominal infection, pulmonary infection and gastric paralysis was significantly lower than that of the control group (P=0.019). Compared with the control group, the degree of metastasis of abdominal cavity in the experimental group was less than that in the control group, and there was less liver metastasis and less metastatic nodules. Control group experimental peritoneal carcinomatosis index (ePCI) score was 18.00±1.55, the experimental group ePCI score was 12.00±1.79, the difference between the two groups was statistically significant (P=0.013). The abdominal adhesion score of control group was 3.67±0.52, the abdominal adhesion score of the experimental group was 1.17±0.75, and there was a significant difference between the two groups (P=0.016). The gray value of VEGF expression in the control group was 77.33±6.77, the gray value of the experimental group VEGF was 200.17±4.26, the gray value of the control group PCNA was 83.33±3.49, the gray value of the experimental group PCNA was 184.83±3.76. The difference between the two groups was statistically significant (P=0.006, 0.011). Conclusion Preoperative adjuvant DDP and PA-MSHA combined with enteral and parenteral nutrition support treatment to control the progression of gastric carcinoma and relieve pyloric obstruction has a better effect and higher safety. Key words: Cis-diammin-odichloroplatinum; Ppseudomonas aeruginosa-mannose sensitive haemagglutination; Continuous cycle hyperthermie intraperitoneal perfusion chemotherapy; Gastric cancer; Pyloric obstruction

13 - Clinical Characteristics of Inflammatory Bowel Disease (IBD) Patients Requiring Long-Term Parenteral Nutrition Support in the Present ERA of Immunomodulator and Biologic Therapy

13 - Clinical Characteristics of Inflammatory Bowel Disease (IBD) Patients Requiring Long-Term Parenteral Nutrition Support in the Present ERA of Immunomodulator and Biologic Therapy

Diagnosis and treatment of duodenal injury and fistula

Duodenal injury is a serious abdominal organ injury. Duodenal fistula is one of the most serious complications in gastrointestinal surgery, which is concerned for its critical status, difficulty in treatment and high mortality. Thoracic and abdominal compound closed injury and a small part of open injury are common causes of duodenal injury. Iatrogenic or traumatic injury, malnutrition, cancer, tuberculosis, Crohn's disease etc. are common causes of duodenal fistula, however, there has been still lacking of ideal diagnosis and treatment by now. The primary treatment strategy of duodenal fistula is to determine the cause of disease and its key point is prevention, including perioperative parenteral and enteral nutrition support, improvement of hypoproteinemia actively, avoidance of stump ischemia by excessive separate duodenum intraoperatively, performance of appropriate duodenum stump suture to ensure the stump blood supply, and avoidance of postoperative input loop obstruction, postoperative stump bleeding or hematoma etc. Once duodenal fistula occurs, a simple and reasonable operation can be selected and performed after fluid prohibition, parenteral and enteral nutrition, acid suppression, enzyme inhibition, anti-infective treatment and maintaining water salt electrolyte and acid-base balance. Double tube method, duodenal decompression and peritoneal drainage can reduce duodenal fistula-related complications, and then reduce the mortality, which can save the lives of patients.

WITHDRAWN: Nutrition support for bone marrow transplant patients.

This is an update of the original Cochrane review published in Issue 2, 2002. Bone marrow transplantation involves administration of toxic chemotherapy and infusion of marrow cells. After treatment, patients can develop poor appetite, mucositis and gastrointestinal failure, leading to malnutrition. To prevent this, parenteral nutrition (PN) support is often first choice but is associated with increased risk of infection. Enteral nutrition (EN) is an alternative, as is addition of substrates. To determine efficacy of EN or PN support for patients receiving bone marrow transplant. Search of The Cochrane Library, MEDLINE, EMBASE and CINAHL in November 2000 and subsequently June 2006. RCTs that compared one form of nutrition support with another, or control, for bone marrow transplant patients. Twenty nine studies were identified. Data were collected on participants' characteristics; adverse effects; neutropaenia; % change in body weight; graft versus host disease; and survival. In two studies (82 participants) glutamine mouthwash reduced number of days patients were neutropenic (6.82 days, 95%CI (1.67 to 11.98) P = 0.009) compared with placebo. Three studies reported (103 participants) that patients receiving PN with glutamine had reduced hospital stay, 6.62 d (95%CI 3.47 to 9.77, P = 0.00004) compared with patients receiving standard PN. However, in the update a further study was added (147 participants) which altered the pooled results: duration in hospital may be increased for those who receive PN with additional glutamine - 0.22 days (95%CI (1.29 to 1.72). Two other studies reported that (73 participants) patients receiving PN plus glutamine had reduced incidence of positive blood cultures (OR 0.23, 95%CI 0.08 to 0.65, P = 0.006) compared to those receiving standard PN. However, a study from the update (113 participants in total) showed the odds of having a positive blood culture have increased but are still less likely if the patient receives PN with glutamine compared to standard PN (OR 0.46, 95%CI 0.20 to 1.04). When patients were given PN versus IV hydration, (25 participants) patients receiving PN had a higher incidence of line infections (OR 21.23, 95%CI 4.15 to 108.73, P = 0.0002) compared to those receiving standard IV fluids. The update identified one study which recognised that (55 participants) those who received IV were likely to spend less time in hospital, 3.30 days (95%CI -0.38 to 6.98, P = 0.08), although this result was not significant. As reported in the original review there remains no evaluable data to properly compare PN with EN. In this update an additional study that compared PN and Glutamine versus standard PN showed that the certain benefits of parenteral nutrition with added glutamine compared to standard PN for reducing hospital stay are no longer definite. When PN with glutamine is compared with standard PN, patients may not leave hospital earlier, but do have reduced incidence of positive blood cultures, than those receiving standard PN. Where possible use of intravenous fluids and oral diet should be considered as a preference to parenteral nutrition, however, in the event of a patient suffering severe gastrointestinal failure even with a trial of enteral feeding, PN with the addition of glutamine could be considered.

Clinical value of the transluminal radiofrequency catheter ablation for malignant esophageal obstruction

Objective To investigate the clinical value of the transluminal radiofrequency catheter ablation (RFCA) for malignant esophageal obstruction. Methods The retrospective cross-sectional descriptive study was conducted. The clinicopathological data of 52 patients with malignant esophageal obstruction who underwent transluminal RFCA at the Affiliated Hospital of Shandong Academy of Medical Science between March 2013 and March 2016 were collected. Patients received the bipolar radiofrequency ablation (RFA) under dual-channel endoscopy and X-ray. Observation indicators: (1) intra- and post-operative situations: operation situations, operation time, time of RFA, postoperative complications and duration of postoperative hospital stay, (2) follow-up. Follow-up using outpatient examination and telephone interview was performed to detect the subsequent treatment, survival of patients and recurrence of esophageal obstruction up to June 2016. Measurement data with normal distribution were represented as average (range). Results (1) Intra- and post-operative situations: 52 patients underwent successful RFCA, without the occurrence of aspiration, asphyxia, hemorrhage and perforation. Esophageal obstruction was disappeared after treatment, X-ray findings showed a smooth esophagus. Average operation time and time of RFCA were respectively 58 minutes (range, 20-71 minutes) and 23 minutes (range, 8-42 minutes). Patients took liquid food at postoperative day 2 and normal food at postoperative day 3, without the sensations of esophageal obstruction. Of 52 patients, 1 with postoperative hypotension returned to normal level through rehydration and increasing blood volume. Five patients with postoperative substernal pain were improved after 2-day symptomatic treatment. And other 46 patients didn′t have postoperative complications. Average duration of postoperative hospital stay was 3 days (range, 1-5 days). (2) Follow-up: 52 patients were followed up for 3-24 months, with a median time of 13 months. Of 52 patients, 17 underwent single intravascular interventional therapy, 15 underwent intravascular interventional therapy combined with single systemic chemotherapy, 14 underwent single systemic chemotherapy and other 6 didn′t undergo antineoplastic therapy. During the follow-up, 9 patients didn′t have esophageal obstruction and 26 were complicated with esophageal obstruction again. Esophageal obstruction of 26 patients was respectively occurred at 3-8 months postoperatively, 20 patients were improved after bipolar transluminal RFCA under dual-channel endoscopy and X-ray and 6 received parenteral nutrition support therapy due to extreme exhaustion. Seventeen patients died of cachexia caused by terminal malignant tumors. Conclusion Transluminal RFCA is safe and effective for malignant esophageal obstruction, with a good short-term outcome. Key words: Esophageal neoplasms; Obstruction, malignant; Radiofrequency catheter ablation, transluminal

Student Preparation for PGY1 Residency Training by US Colleges of Pharmacy: Survey of the Residency Program Director Perspective.

Purpose: To evaluate current residents' level of preparation by US colleges of pharmacy for postgraduate year 1 (PGY1) residency training from the perspective of residency program directors (RPDs). Methods: RPDs were asked in an electronic survey questionnaire to rate PGY1 pharmacy residents' abilities in 4 domains: communication, clinical knowledge, interpersonal/time-management skills, and professionalism/leadership. Results: One hundred ninety-seven RPDs of the American Society of Health-System Pharmacists (ASHP)-accredited PGY1 programs completed the survey. The majority of RPDs strongly agreed or agreed that residents were prepared as students to effectively communicate both verbally and nonverbally, were able to appropriately respond to drug inquiries using drug resources and literature searches, and consistently displayed professionalism. Respondents were more likely to disagree or give a neutral response when asked about residents' understanding of biostatistics and their ability to provide enteral and parenteral nutritional support for patients. Conclusion: Overall, RPDs agreed that residents were prepared to perform the majority of the tasks of each of the 4 domains assessed in this survey relating to PGY1 training. RPDs may use the results of this survey to provide additional support for their residents in the areas in which residents lack adequate preparation, while colleges of pharmacy may focus on incorporating more time in their curriculum for certain areas to better prepare their students for residency training.

Parenteral nutrition combined with enteral feeding improves the outcome of cancer patients.

This study investigated whether total parenteral nutrition combined with enteral nutrition is associated with improved biochemical and clinical outcomes in cancer patients with gastrointestinal dysfunction. From January to December 2014, the clinical data of 68 patients in a cancer ward were retrospectively collected, and these patients were classified into two groups according to nutrition delivery, through parenteral nutrition, combined with enteral nutrition more (group A) or less (group B) than 250 kcal/day. The following variables were analyzed: the route and percentage of nutritional support, total caloric intake, age, gender, body weight, body mass index, diagnosis at admission, complications of intestinal failure, modified Glasgow Prognostic Score, co-morbidities, duration of total parenteral nutrition support, performance status scale, and plasma nutritional markers. A significant difference was observed between the two groups in functional capacity, including the Karnofsky index, World Health Organization/Eastern Cooperative Oncology Group score, body-weight loss, and serum albumin levels. However, no significant difference was observed in the modified Glasgow Prognostic Score. Cancer patients receiving total parenteral nutrition who were fed enterally more than 250 kcal/d exhibited more favorable clinical outcomes than those who were fed enterally less than 250 kcal/d. Enteral nutrition should be considered for these severely ill patients.

Epidemiology and outcome of acute pancreatitis in end-stage renal disease dialysis patients: a 10-year national cohort study.

The objective of this study is to determine the incidence and severity of acute pancreatitis (AP) in patients with end-stage renal disease (ESRD) on dialysis and whether the dialysis modality [hemodialysis (HD) versus peritoneal dialysis (PD)] confers a higher risk for AP as well as complications or mortality related to AP. We analyzed national health insurance claims data of 67 078 ESRD patients initiating dialysis between 1999 and 2007 in Taiwan. All patients were followed up from the start of their dialysis to first AP diagnosis, death, end of dialysis or 31 December 2008. Cox proportional hazards models were used to identify risk factors. The cumulative incidence rates of AP were 0.6, 1.7, 2.6, 3.4 and 4% at 1, 3, 5, 7 and 9 years, respectively. ESRD patients on HD and PD had an AP incidence of 5.11 and 5.86 per 1000 person-years, respectively. Independent risk factors for AP in this population were being elderly, being female, having biliary stones or liver disease, and being on PD. Severe AP occurred in 44.9% of the HD patients and in 36% of the PD patients. Patients with AP on HD had a higher incidence of upper gastrointestinal (UGI) bleeding than those on PD (P = 0.002). In contrast, those with AP on PD had a higher incidence of need for total parenteral nutrition (TPN) support than those on HD (P = 0.072). Overall in-hospital mortality was 8.1%. The risk factors for mortality after an AP attack were male gender, increased age, AP severity, and the presence of diabetes mellitus or liver disease. ESRD patients on PD were at higher risk for AP than those on HD. HD patients with AP attacks had a greater incidence of UGI bleeding and PD patients with AP attacks a more frequent need for TPN support.

Application of the Paediatric Yorkhill Malnutrition Score in nutritional risk screening in children hospitalized in general surgery department

Objective To investigate the status of nutritional risk and clinical outcome in children hospitalized in the general surgical department, which can provide basis for clinical nutritional support and selecting the screening tool. Methods Nutritional risk screening was performed on 506 children hospitalized in the general surgical department by using the Paediatric Yorkhill Malnutrition Score (PYMS). The data on incidence of complications, parenteral nutritional support during hospitalization, length of hospital stay and total hospital expenses were recorded. Results Of the 506 cases, 64.6%(327/506) had low nutritional risk, 27.1%(137/506) had moderate nutritional risk, and 8.3%(42/506) had high nutritional risk. Hepatic and gall diseases were the most common types of moderate nutritional risk (55.2%, 16/29), intestinal obstruction were the most common types of high nutritional risk (23.1%, 6/26). The incidence of complications, parenteral nutritional support during hospitalization, length of hospital stay and total hospital expenses were 10.2%(14/137), 21.9%(30/137), (9.54±4.95) d, (6 899.13±3 281.18) yuan RMB and 21.4%(9/42), 35.7%(15/42), (10.60±7.25) d, (7 521.64±6 026.23) yuan RMB in moderate or high nutritional risk children, and 0.9%(3/327), 3.1%(10/327), (17.17±4.17) d, (4 691.96±3 114.43) yuan RMB in low nutritional risk children, and there were significant differences (χ2/F=18.665-64.554, P<0.05). Conclusions Moderate or high nutritional risk is seen in children hospitalized in the surgical department. High nutritional risk score is correlated with adverse clinical outcome. PYMS can be used for nutritional risk screening in hospitalized children. Key words: General surgery; Hospitalized children; Nutritional risk; Screening; Clinical outcome

Central venous catheterization: An updated review of historical aspects, indications, techniques, and complications

Central venous catheterization has become an indispensable procedure in various situations in the intensive care unit, emergency room and operation room. There are many applications such as invasive hemodynamic monitoring, parenteral nutrition support, dialysis, chemotherapy, fluid resuscitation and drug administration, though there are some complications associated with catheter placement. There are some articles that discuss the security and advantages of the anatomic landmark technique and ultrasound (US) guidance technique. In this non-systematic review article we searched the current data in Pubmed library.

Pediatric Parenteral Nutrition-Associated Liver Disease.

Pediatric parenteral nutrition-associated liver disease (PNALD) is typically defined as a decrease in bile flow that is independent of a mechanical obstruction and of any other underlying liver disease. It is most often seen in pediatric patients receiving parenteral nutrition support. Up to 50% to 66% of children receiving long-term parenteral nutrition are reported to be diagnosed with PNALD. The goal of treatment for PNALD is advancement to full enteral nutrition and elimination of dependence on parenteral nutrition support. Achieving this goal is not always possible, especially in patients with short bowel syndrome. The following review article highlights some of the current treatment strategies focused on prevention or correction of PNALD as noted in current American Society for Parenteral and Enteral Nutrition guidelines.

Pathophysiology, prevention, treatment, and outcomes of intestinal failure-associated liver disease.

Intestinal failure-associated liver disease (IFALD) remains a serious problem in the treatment of infants with nutritional problems and short bowel syndrome. A review of the recent literature from 2010 to 2016, concentrating on articles related to the pathophysiology of IFALD and to outcomes of novel nutritional and pharmacological therapies for neonatal cholestasis in the post-surgical neonate. The pathophysiology of IFALD relates to an increase sensitivity of the neonatal liver to cholestasis in the non-fed state; prolonged cholestasis almost inevitably results in liver damage which will progress from fibrosis to cirrhosis. Clinically discerned risk factors include premature birth, inflammation, sepsis, disruption of the enterohepatic circulation by creation of a proximal stoma, and the duration and type of parenteral nutritional support. Within the hepatocyte, the regulatory enzyme farsanoid receptor X (FXR) appears to play a pivotal role in the development of cholestasis. Recent studies have shown that its activity is suppressed by sepsis, and by plant phytosterols found in soy-based lipid preparations. This paradigm is reflected in the emerging consensus for the care of post-surgical neonates, which is based around a multi-disciplinary team approach. Using an algorithm-driven approach, an appropriate balance between caloric support and prevention of IFALD can be achieved. Further prospective studies are required to further refine the optimal sequence of use of these therapies and the long-term effects on neurological development and hepatic function. However, with optimal care, the number of IF patients progressing to end-stage liver disease because of IFALD should be very low.

Ultrasound-Guided Catheter Insertion Did Not Decrease Catheter-Related Blood Stream Infection in Hematological Oncology Care Unit

Background: Central venous catheters (CVCs) are necessary for critically ill patients requiring intravenous pharmacological intervention and subsequent parenteral nutritional support. Although CVCs allow delivery of medications and nutritional support that cannot be administered safely through central venous, their use is inevitably associated with adverse events, mechanical complication and catheter-related infection. While ultrasound guide has already been proven to decrease mechanical complications, it is not fully elucidated whether ultrasound guide decrease the risk of catheter-related infection.Methods: We observed consecutive CVC insertions between April 2009 and January 2013. In total, 395 insertion cases were surveyed in the hematological oncology unit. We divided the research period into two terms: before December 2011 (early term) and after January 2012 (latter term). Between the early and latter terms, there were substantial differences regarding the use of ultrasound guides. Because insertion maneuvers changed from blind to ultrasound-guided approach after 2012. SMAC Plus MicroNeedle (15G, 13 cm or 12G, 20 cm; Covidien Tokyo, Japan) was used. Practitioners determined which CVC device and which insertion site was preferred for each patient. To determine the clinical efficacy of chlorhexidine gluconate dressing (CHGD) at catheter insertion site, we performed matched cohort analysis among the patients who underwent stem cell transplantation. Total 44 cases were included in the cohort from the total study population.Results: Underlying diseases included hematological malignancies and immunological disorders such as auto-immune diseases and solid organ malignancies. A total of 235 and 160 cases were included in early and latter terms, respectively. Insertion duration was a median 26 days (range, 2-126 days) in the early term and 18 days (range, 2-104) in the latter term. During the early term, the insertion sites were 22.6%, 40.2%, and 25.7% at the cervical, subclavian, and femoral veins, respectively, and 32.3%, 16.9%, and 25.4% in the latter term, respectively. The ultrasound-guided insertion method became a routine practice in the latter term. The frequency of catheter-related blood stream infection (CRBSI) was 8.46/person-days and 13.62/person-days in the early and latter terms, respectively. Mechanical comorbidities decreased from 0.39 (13/33) incidences/month to 0.00 (0/13) after the introduction of the ultrasound-guided insertion method. Using subgroup analysis, detected causative pathogens of CRBSI did not differ between the two terms: gram-positive coccus, gram-positive bacillus, and gram-negative bacillus were 68.9%, 11.5%, and 14.8% in the early term and 68.2%, 11.4%, and 18.2% in the latter term, respectively. Controlled-cohort study revealed CHGD decreased CRBSI caused by Staphylococcus spp. significantly, but not overall other organisms.Conclusion: Ultrasound-guided insertion did not decrease the incidence of CRBSI. However, in our survey, insertion through the cervical vein approach clearly increased after the introduction of the ultrasound-guided method, and mechanical complications decreased significantly. Ultrasound guide and cervical vein approach trended for patients with hematological diseases who required CVC and those who concurrently harbored multiple risks, including thrombocytopenia. The prevalence of CRBSI slightly increased with this trend. With respect to CRBSI, the preventative effect of CHGD in patients undergoing allogeneic stem cell transplantation was promising. We advocate trending of ultrasound-guided, cervical approach CVC with CHGD can provide the safest parental alimentation for the patients with hematological malignancies. DisclosuresNo relevant conflicts of interest to declare.

ASPEN-FELANPE Clinical Guidelines.

The management of patients with enterocutaneous fistula (ECF) requires an interdisciplinary approach and poses a significant challenge to physicians, wound/stoma care specialists, dietitians, pharmacists, and other nutrition clinicians. Guidelines for optimizing nutrition status in these patients are often vague, based on limited and dated clinical studies, and typically rely on individual institutional or clinician experience. Specific nutrient requirements, appropriate route of feeding, role of immune-enhancing formulas, and use of somatostatin analogues in the management of patients with ECF are not well defined. The purpose of this clinical guideline is to develop recommendations for the nutrition care of adult patients with ECF. A systematic review of the best available evidence to answer a series of questions regarding clinical management of adults with ECF was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group. An anonymous consensus process was used to develop the clinical guideline recommendations prior to peer review and approval by the ASPEN Board of Directors and by FELANPE. In adult patients with enterocutaneous fistula: (1) What factors best describe nutrition status? (2) What is the preferred route of nutrition therapy (oral diet, enteral nutrition, or parenteral nutrition)? (3) What protein and energy intake provide best clinical outcomes? (4) Is fistuloclysis associated with better outcomes than standard care? (5) Are immune-enhancing formulas associated with better outcomes than standard formulas? (6) Does the use of somatostatin or somatostatin analogue provide better outcomes than standard medical therapy? (7) When is home parenteral nutrition support indicated?

Do Patients With a Baseline Clinical Condition Warranting the Cautious Use of Parenteral Nutrition Develop Subsequent Metabolic Complications?

The American Society for Parenteral and Enteral Nutrition Adult Nutrition Support Core Curriculum describes clinical conditions that warrant cautious use of parenteral nutrition (CCWCPN). The Core Curriculum authors acknowledge there is no evidence for specific criteria suggested for the clinical conditions. Consequently, the purpose of this study was to determine the impact of a baseline CCWCPN on the development of subsequent metabolic complications in patients receiving parenteral nutrition (PN). Adult patients initiated on PN from May 2014 to July 2015 at Cooper University Hospital were included in this retrospective study. The impact of a CCWCPN on the development of the following was determined: acid-base disturbances, hepatobiliary complications, hypercapnia, hyperchloremia, hyperglycemia, hypernatremia, hypertriglyceridemia, hypochloremia, hypoglycemia, hypokalemia, hypophosphatemia, and refeeding syndrome. Three hundred forty-one patients were included (mean age, 61.7 years; mean duration of PN, 8.5 days; central PN, 97%). Metabolic complications occurred more frequently in patients with a baseline CCWCPN than without these conditions (77% vs 53%, P = .001). Subgroup analyses for the development of metabolic complications in patients with or without each individual baseline CCWCPN yielded the following statistically significant results: hypernatremia (93% vs 57%, P = .007) and hyperchloremia (86% vs 57%, P = .033). Hospitalized adult patients with a baseline CCWCPN were more likely to develop a metabolic complication when receiving PN. Baseline hypernatremia and hyperchloremia were associated with the development of metabolic complications. Baseline CCWCPN should be recognized upon initiation of PN; practitioners should closely monitor patients to minimize subsequent metabolic complications.

Beneficial effects of mucous fistula refeeding in necrotizing enterocolitis neonates with enterostomies

BackgroundNecrotizing enterocolitis in premature neonates often results in bowel resection and stoma formation. One way to promote bowel adaptation before stoma closure is to introduce proximal loop effluents into the mucous fistula. In this study, we reviewed our experience with distal loop refeeding with respect to control group. MethodsAll patients with necrotizing enterocolitis between 2000 and 2014 necessitating initial diverting enterostomies and subsequent stoma closure in a tertiary referral center were included. Medical records were retrospectively reviewed. Demographic data, surgical procedures, and postoperative outcomes were analyzed. Results92 patients were identified, with 77 patients receiving mucous fistula refeeding. The refeeding group showed less bowel ends size discrepancy (25 vs 53%, p=0.034) and less postoperative anastomotic leakage (3 vs 20%, p=0.029). Fewer refeeding group patients developed parenteral nutrition related cholestasis (42 vs 73%, p=0.045) and required shorter parenteral nutrition support (47 vs 135days, p=0.002). The mean peak bilirubin level was higher in the non-refeeding group (155 vs 275μmol/L, p<0.001). No major complication was associated with refeeding. ConclusionsMucous fistula refeeding is safe and can decrease risk of anastomotic complication and parental nutrition related cholestasis. It provides both diagnostic and therapeutic value preoperatively and its use should be advocated.Level III Treatment Study in a Case Control Manner.