Parenteral Nutrition Support Research Articles

Soporte nutricional perioperatorio

The relationship between preoperative malnutrition and morbi-mortality has been documented for years. Despite the existence of tools that allow its detection, and therefore treat this entity, their introduction into clinical practice is not wide-spread. Both perioperative insulin resistance and hyperglycemia are associated with increased perioperative morbidity and length of hospital stay. The intake of carbohydrate-rich drinks 2-4h prior to surgery reduces insulin resistance. In the immediate postoperative period, the enteral route is safe and well tolerated and its early use reduces hospital stay and postoperative complications compared with parenteral nutritional support. Inmunonutrition has been proven effective to decrease postoperative complications and hospital stay. In view of these data we opted for the adoption of these measures replacing bowel rest and the indiscriminate use of postoperative parenteral nutrition.

Nutritional management of acute pancreatitis in dogs and cats

To review current and emerging nutritional approaches in the management of acute pancreatitis (AP) in people, dogs, and cats, and to provide a framework for further investigation in this field. Veterinary retrospective studies and reviews, human prospective clinical trials and reviews, and experimental animal studies focusing on nutritional management during AP. Nutritional management is an important part of the treatment plan for patients with AP. In human medicine, the general approach for providing nutrition in patients with AP has changed in recent years and favors enteral over parenteral nutrition with an emphasis on early enteral nutrition (EN). Although there are limited data available, there is increasing evidence in the veterinary literature that supports the beneficial role of EN in AP and contradicts previous assumptions about poor tolerance to enteral feeding in this patient population. Parenteral nutrition may be appropriate alone or in combination with EN as a temporary measure in malnourished patients that do not tolerate adequate EN; however, enteral feeding should be attempted first in most cases. Immunonutrition is being investigated for its positive role in modulating pancreatic inflammation and improving gut barrier function in cases of human AP. The nutritional management of veterinary patients with AP remains challenging. Based on clinical evidence in people, experimental animal studies, and preliminary studies in dogs and cats, the choice of EN over parenteral nutritional support during AP in dogs and cats appears to be beneficial and well tolerated. Optimization of nutritional therapies in dogs and cats including the use of immunonutrition during AP warrants further investigation.

Advances in the management of children with intestinal failure

Intestinal failure is defined as the reduction of a functional gut mass below the minimal necessary for adequate digestion and absorption of nutrients and fluids. Intestinal failure is the final result of a number of different causes, being short bowel syndrome the most recognized. Its prevalence is low, but the impact in quality of life among patients and their families is critical. Furthermore, is associated with high economic costs, both for the patient and the health provider. Its main feature is the need for long-term parenteral nutritional support with high morbidity and mortality associated complications, such as line-derived bloodstream infections and liver disease. The management of these patients should be performed by a multidisciplinary team, and be aimed at promoting adaptation and recovery of bowel function to achieve intestinal autonomy.

The effects of parenteral arginine and aminoguanidine on oxidant‐antioxidant homeostasis of organs in rats with subacute peritonitis (LB339)

Evidence showed that total parenteral nutrition support and inflammatory diseases are closely related to oxidative stress. Our previous study demonstrated that parenteral arginine and aminoguanidine, a selective inhibitor of inducible nitric oxide synthase, may elevate circulating antioxidants and antioxidant enzyme activities. The aim of this study was to investigate the effects of arginine and aminoguanidine on oxidant‐antioxidant homeostasis in peritonitis‐affected organs, that is, the liver, lung, and kidneys. Male Wistar rats with cecal puncture‐induced subacute peritonitis were infused with conventional or arginine‐, aminoguanidine‐, or arginine plus aminoguanidine‐supplemented parenteral nutrition solutions for 7 days. Healthy, orally fed and sham‐operated, parenterally fed rats were included. The results showed that parenteral nutrition significantly decreased activities of glutathione peroxidase (GPx) and catalase in the liver and decreased thiol group, lipid peroxidation, and superoxide dismutase (SOD) activity in the lung. Subacute peritonitis with parenteral feeding significantly decreased glutathione and SOD and GPx activities in the liver and decreased oxidized glutathione in the lung. In rats with subacute peritonitis, parenteral arginine supplementation significantly increased glutathione levels in the liver and lung and SOD and GPx activities in the kidneys. Aminoguanidine supplementation significantly increased thiol groups, glutathione, and SOD activity in the liver and thiol groups and oxidized glutathione in the lung. Arginine plus aminoguanidine supplementation significantly increased oxidized glutathione in the lung. Taken together, parenteral arginine may have beneficial effects on oxidant‐antioxidant homeostasis in the liver, lung, and kidneys and aminoguanidine may improve peritonitis‐induced oxidative stress in the liver in rats with subacute peritonitis.Grant Funding Source: Supported by 103‐CCH‐IRP

National Trends and In‐Hospital Outcomes of Adult Patients With Inflammatory Bowel Disease Receiving Parenteral Nutrition Support

Patients with inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), are susceptible to protein-calorie malnutrition secondary to decreased oral intake, malabsorption, and increased metabolic expenditure. In this study, we seek to assess the national frequencies of parenteral nutrition (PN) use among hospitalized patients with IBD and to determine their in-hospital outcomes. We analyzed the Nationwide Inpatient Sample from 1988-2006 to determine the frequency of PN usage among patients with UC or CD and to determine their in-hospital outcomes. A multivariate analysis was performed to identify factors predictive of increased inpatient mortality in this population. From 1988-2006, the annual incidence of PN use among hospitalized patients with CD was 4.29 per 100,000 and among those with UC was 3.80 per 100,000, with trends being relatively stable through the indexed period. The mean length of hospitalization among patients with UC receiving PN was longer compared with patients with CD. Factors predictive of an increased risk for mortality include the following: age >50 years, acute kidney injury, hospital-acquired pneumonia, Clostridium difficile colitis, prolonged postoperative ileus requiring PN use, pulmonary embolism, malnutrition, and patients with UC relative to CD. Traditionally, patients with CD are at a higher risk for developing malnutrition than patients with UC; however, there is a 2-fold higher risk for inpatient mortality and a longer length of hospitalization among patients with UC compared with those with CD. This pattern suggests that the use of PN, particularly among patients with UC, serves as a surrogate marker of higher disease acuity and severity.

Effects of interventions on survival in acute respiratory distress syndrome: an umbrella review of 159 published randomized trials and 29 meta-analyses.

Multiple interventions have been tested in acute respiratory distress syndrome (ARDS). We examined the entire agenda of published randomized controlled trials (RCTs) in ARDS that reported on mortality and of respective meta-analyses. We searched PubMed, the Cochrane Library, and Web of Knowledge until July 2013. We included RCTs in ARDS published in English. We excluded trials of newborns and children; and those on short-term interventions, ARDS prevention, or post-traumatic lung injury. We also reviewed all meta-analyses of RCTs in this field that addressed mortality. Treatment modalities were grouped in five categories: mechanical ventilation strategies and respiratory care, enteral or parenteral therapies, inhaled/intratracheal medications, nutritional support, and hemodynamic monitoring. We identified 159 published RCTs of which 93 had overall mortality reported (n = 20,671 patients)--44 trials (14,426 patients) reported mortality as a primary outcome. A statistically significant survival benefit was observed in eight trials (seven interventions) and two trials reported an adverse effect on survival. Among RCTs with more than 50 deaths in at least one treatment arm (n = 21), two showed a statistically significant mortality benefit of the intervention (lower tidal volumes and prone positioning), one showed a statistically significant mortality benefit only in adjusted analyses (cisatracurium), and one (high-frequency oscillatory ventilation) showed a significant detrimental effect. Across 29 meta-analyses, the most consistent evidence was seen for low tidal volumes and prone positioning in severe ARDS. There is limited supportive evidence that specific interventions can decrease mortality in ARDS. While low tidal volumes and prone positioning in severe ARDS seem effective, most sporadic findings of interventions suggesting reduced mortality are not corroborated consistently in large-scale evidence including meta-analyses.

A prospective, randomized, controlled study of ω-3 fish oil fat emulsion-based parenteral nutrition for patients following surgical resection of gastric tumors.

BackgroundNutrients such as ω-3 fatty acids including fish oil components eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) suppress the growth and promote apoptosis of tumor cells, improve immune function and reduce the effects of systemic inflammatory response syndrome. We sought to investigate the effect of ω-3 fish oil fat emulsion-based parenteral nutrition (PN) on nutritional state, immune function, inflammatory reaction, expression of tumor factors and complication incidence in patients after surgical resection of gastric cancer.MethodsForty-eight patients after surgical operation of gastric tumor in hospital were randomly divided into the control group and intervention group. Patients in both groups were treated with iso-nitrogen and iso-caloric parenteral nutrition support. In addition, the intervention group received ω-3 fish oil fat emulsion and the control group received soybean oil. The indicators of nutrition, immune function and inflammation in the two groups were detected on the day before the operation and postoperative day 6. The rate of complication was compared between the two groups.ResultsThere was no significant difference in nutritional state, liver function and renal function between the two groups (P > 0.05). However, the levels of inflammatory markers were significantly decreased (P < 0.01), and the rate of complication was also decreased in the intervention group as compared with the control group.Conclusionsω-3 fish oil fat emulsion-based parenteral nutrition alleviates the inflammatory reaction and reduces the rate of inflammatory complications.

Pharmacologic Options for Intestinal Rehabilitation in Patients With Short Bowel Syndrome

A primary goal of intestinal rehabilitation programs is to facilitate intestinal adaptation. Adult patients with short bowel syndrome (SBS) who are dependent on parenteral nutrition and/or intravenous fluid (PN/IV) support have 2 hormonal pharmacologic treatment options available that may promote intestinal growth: a glucagon-like peptide 2 analog (teduglutide) and recombinant human growth hormone (somatropin). In two phase III clinical trials (N=169), 24 weeks of teduglutide administered to outpatients with SBS resulted in significant decreases in PN/IV volume requirements of 2.5-4.4 L/wk. In an extension study of one of these trials, patients with SBS who completed 30 months of teduglutide experienced a mean PN/IV reduction of 7.6 L/wk from baseline. Furthermore, some patients achieved independence from PN/IV support. The most common adverse events associated with teduglutide treatment in clinical trials were gastrointestinal symptoms, including abdominal distension, abdominal pain, and nausea. This safety profile is consistent with the associated underlying diseases leading to SBS or the known mechanism of action of teduglutide. A single phase III study (N=41) evaluated the safety and efficacy of a 4-week inpatient course of somatropin in combination with a glutamine-supplemented diet for adults with SBS. Somatropin treatment significantly reduced parenteral support requirements by 1.1 L/d in these patients. The most common adverse events were peripheral edema and musculoskeletal events. Large-scale, long-term follow-up studies of somatropin for SBS have not been conducted. Although treatment for patients with SBS must be individualized, teduglutide and somatropin are positive extensions to existing fluid and nutrient management strategies.

Short bowel syndrome and small bowel transplantation

The purpose of this review is to provide an update of recent advances in the areas of short bowel syndrome (SBS) and small bowel transplantation (SBT). Recent reports from two of the largest multicenter randomized, controlled trials in patients with SBS support the safety and efficacy of teduglutide as an aid to parenteral nutrition weaning. In well selected SBS patients, outcomes as diverse as survival, macronutrient absorption and parenteral nutrition weaning are improved after autologous gastrointestinal reconstructive surgery. SBT is no longer considered investigational and given improved outcomes noted in recent reports, indications for transplantation are expanding. Although SBT early survival rates are approaching those of other organ allografts, long-term graft survival remains suboptimal. Recently available trophic factors hold promise as aids in restoring freedom from parenteral nutrition support; however, their long-term benefits, preferred timing of administration in relation to the onset of SBS, optimal patient selection for use, duration of treatment and cost effectiveness require further study. Despite recent evidence of improved early survival after SBT, more dedicated research is needed to design more effective strategies to better tolerize small bowel grafts, prevent rejection and, ultimately, improve long-term outcomes. Reserved for well selected patients, autologous gastrointestinal reconstruction should be considered complementary and not antagonistic to SBT.

Evaluation of Parenteral Nutrition–Associated Liver Disease in Infants With Necrotizing Enterocolitis Before and After the Implementation of Feeding Guidelines

In 2009, an intestinal rehabilitation team implemented feeding guidelines for infants following gastrointestinal surgery at our institution. The purpose of this study was to determine the effect of enteral feeding guidelines on the incidence of parenteral nutrition (PN)-associated liver disease (PNALD) in infants with surgically managed necrotizing enterocolitis (NEC). This retrospective study included infants treated during 18-month time periods before and after the implementation of feeding guidelines. PNALD diagnosis was based on serum direct bilirubin >2 mg/dL after ≥14 days of PN exposure. Of the 140 infants identified, 64 were surgically managed and included in the analysis. The duration of PN and the time nil per os (NPO) were significantly reduced after guideline implementation from a median of 106 days to 65 days (P = .03) and from 29 days to 16 days (P = .02), respectively. The incidence of PNALD decreased from 73% before guideline implementation to 42% after guideline implementation (P = .01). Implementation of feeding guidelines resulted in decreased time NPO and duration of PN support. Significantly fewer infants developed PNALD after guideline implementation. These data suggest that feeding guidelines may expedite the transition from PN to enteral nutrition and may improve outcomes.

OHP-010 Management of parenteral nutrition in the Intensive Care Unit of a third level hospital

BackgroundCritically ill patients are characterised by hypercatabolism, representing a higher risk of malnourishment. In these patients, both nutrient deficits and overfeeding are harmful. Parenteral nutrition (PN) is an alternative approach...

A single-blinded randomised clinical trial of permissive underfeeding in patients requiring parenteral nutrition

The importance of adequate nutritional support is well established, but characterising what 'adequate nutrition' represents remains contentious. In recent years there has been increasing interest in the concept of 'permissive underfeeding' where patients are intentionally prescribed less nutrition than their calculated requirements. The aim of this study was to evaluate the effect of permissive underfeeding on septic and nutrition related morbidity in patients requiring short term parenteral nutrition (PN). This was a single-blinded randomised clinical trial of 50 consecutive patients requiring parenteral nutritional support. Patients were randomized to receive either normocaloric or hypocaloric feeding (respectively 100% vs. 60% of estimated requirements). The primary end point was septic complications. Secondary end points included the metabolic, physiological and clinical outcomes to the two feeding protocols. Permissive underfeeding was associated with fewer septic complications (3 vs. 12 patients; p=0.003), and a lower incidence of the systemic inflammatory response syndrome (9 vs. 16 patients; p=0.017). Permissively underfed patients had fewer feed related complications (2 vs. 9 patients; p=0.016). Permissive underfeeding in patients requiring short term PN appears to be safe and may results in reduced septic and feed-related complications. NCT01154179 TRIAL REGISTRY: http://clinicaltrials.gov/ct2/show/NCT01154179.

Clinical nutrition and drug interactions.

A drug's plasma level, pharmacological effects or side effects, elimination, physicochemical properties or stability could be changed by interactions of drug-drug or drug-nutrition products in patients who receive enteral or parenteral nutritional support. As a result, patients might experience ineffective outcomes or unexpected effects of therapy (such as drug toxicity, embolism). Stability or incompatibility problems between parenteral nutrition admixtures and drugs might lead to alterations in expected therapeutic responses from drug and/or parenteral nutrition, occlusion in venous catheter or symptoms or mortality due to infusion of composed particles. Compatibilities between parenteral nutrition and drugs are not always guaranteed in clinical practice. Although the list of compatibility or incompatibilities of drugs are published for the use of clinicians in their practices, factors such as composition of parenteral nutrition admixture, drug concentration, contact time in catheter, temperature of the environment and exposure to light could change the status of compatibilities between drugs and nutrition admixtures. There could be substantial clinical changes occurring in the patient's nutritional status and pharmacological effects of drugs due to interactions between enteral nutrition and drugs. Drug toxicity and ineffective nutritional support might occur as a result of those predictable interactions. Although administration of drugs via feeding tube is a complex and problematic route for drug usage, it is possible to minimise the risk of tube occlusion, decreased effects of drug and drug toxicity by using an appropriate technique. Therefore, it is important to consider pharmacological dosage forms of drugs while administering drugs via a feeding tube. In conclusion, since the pharmacists are well-experienced and more knowledgeable professionals in drugs and drug usage compared to other healthcare providers, it is suggested that provision of information and drug counselling by pharmacists in terms of detection and prevention of problems (such as interactions, stability, incompatibility) related with enteral/parenteral nutrition and drugs are invaluable in clinical practice.

Enteral Nutritional Support in Patients with Head Injuries After Craniocerebral Surgery.

To explore the effect of early enteral (EN) and parenteral nutritional (PN) support on head-injured patients after craniocerebral surgery. We randomly divided 120 head trauma patients into two groups: those receiving EN and those receiving PN support (60 patients each). Physiological and biochemical indices, monitoring time and cost, and the incidence of complications were compared between the two groups. More patients presented with complications in the PN than the EN group, and this difference was statistically significant (P < 0.05). One week after surgery, albumin (ALB), alanine aminotransferase (ALT), and blood glucose (GLU) levels were 39.6 ± 3.3 U/L, 51.4 ± 5.6 U/L, and 9.6 ± 5.2 mmol/L, respectively, in the EN group, and monitoring time and cost were 4.0 ± 1.2 days and 1.2 ± 1.0 thousand yuan, respectively. In the PN group, ALB, ALT, and GLU levels were 34.3 ± 3.4 U/L, 65.5 ± 6.1 U/L, and 15.1 ± 4.0 mmol/L, respectively, and monitoring time and cost were 6.2 ± 1.5 days and 1.8 ± 2.0 thousand yuan, respectively. We detected significant differences between the two groups (P < 0.05). Early EN support is superior to PN support in head-injured patients after craniocerebral surgery.

Percutaneous Suture-Based Closure Device for Management of Inadvertent Subclavian Artery Catheterization

Central venous catheterization is performed to secure pathways for large amounts of saline, drug infusion, parenteral nutrition support, and hemodialysis. Accidental subclavian artery cannulation is a possible complication of central venous catheterization. Here, we report two cases of 8 Fr. chemoports inadvertently inserted in subclavian arteries during internal jugular venous catheterizations. The chemoports were removed successfully, and puncture sites were repaired using suture-based closure devices (Perclose). One patient experienced minor neurological complications after the procedure. With effective management, the patient was treated with no sequelae. To our knowledge, this is the first report of stroke after procedures using suture-based devices. (Korean J Med 2014;87:200-204)

SASPEN Case Study: Nutritional management of a patient with an open abdomen

The use of the open abdomen as a technique in the management of complex surgery patients can be the result of a variety of contributing factors, including surgical or medical causes, as well as indications. 1 The early initiation of goal-directed enteral nutrition support improves wound healing, decreases intensive care unit (ICU) and hospital length of stay, and might improve survival following critical illness or injury. 1 The benefits of enteral nutrition in surgical and critical illness have been recognised since the early 1980s and are now well described. 2 Because of the nature of these patients, the establishment of sufficient enteral nutrition support can be challenging. Therefore, they might require parenteral nutrition (PN) support in the early postoperative phase until the physiological status has normalised. 2 The early use of PN is of particular importance in patients with pre-existing malnutrition. 2 Nutrition support in the patient discussed in this publication was complicated by haemodynamic instability, fluid restriction owing to renal failure and fistula formation in the open abdomen, which necessitated the long-term use of PN support.

Nutritional management of a complicated surgical patient by means of fistuloclysis

A fistula is defined as an abnormal communication between two organs, an organ and the skin, or an organ and a wound. Up to 70% of patients with fistulae present with malnutrition. Enteral nutrition (EN) has considerable advantages over parenteral nutrition (PN) support, including improved gut barrier function, a reduction in infectious morbidity and improved immune function. EN support remains the preferred route of nutrition support in patients with fistulae, unless it causes a significant increase in fistula output, abdominal pain or exacerbates diarrhoea. Fistuloclysis, i.e. enteral feeding via an intestinal fistula, is an effective means of providing nutritional support to these patients and can replace the need for PN support.

Understanding triglyceride levels related to intravenous fat administration.

Lipid is an essential macronutrient in parenteral nutrition (PN) support. intravenous (IV) lipid provides essential fatty acids and a concentrated calorie source. Preterm infants are at risk for essential fatty deficiency early in life. Lipid administration is associated with some risks, and there are guidelines for administration to minimize complications. Lipid emulsions in the United States are derived from soybean oil. Outside of the United States, lipid emulsions made from fish oil or combinations of fish, soybean, olive, and medium-chain triglycerides (MCTs) are under investigation for improved tolerance, lower plasma lipid levels, and improved fatty acid profiles, all of which are considered beneficial. Triglyceride levels are an important measurement to assess patient tolerance.

Impact of new-generation lipid emulsions on cellular mechanisms of parenteral nutrition-associated liver disease.

Parenteral nutrition (PN) is a life-saving nutritional support for a large population of hospitalized infants, and lipids make a substantial contribution to their energy and essential fatty acid (FA) needs. A challenge in the care of these infants is that their metabolic needs require prolonged PN support that increases the risk of PN-associated liver disease (PNALD). In recent years, the emergence of new parenteral lipid emulsions containing different source lipids and FA profiles has created nutritional alternatives to the first-generation, soybean oil-based lipid emulsion Intralipid. The limited U.S. introduction of the new-generation fish-oil emulsion Omegaven has generated promising results in infants with PNALD and spawned a renewed interest in how PN and lipid emulsions, in particular, contribute to this disease. Studies suggest that the lipid load and constituents, such as specific FAs, ratio of n-3 (ω-3) to n-6 (ω-6) long-chain polyunsaturated FAs, phytosterols, and vitamin E content, may be involved. There is an existing literature describing the molecular mechanisms whereby these specific nutrients affect hepatic metabolism and function via lipid and bile acid sensing nuclear receptors, such as peroxisome proliferator-activated receptor α, liver X receptor, and farnesoid X receptor, yet virtually no information as to how they interact and modulate liver function in the context of PN in pediatric patients or animal models. This article will review the recent development of parenteral lipid emulsions and their influence on PNALD and highlight some of the emerging molecular mechanisms that may explain the effects on liver function and disease.

Enteral Versus Parenteral Nutritional Support Post Allogeneic Haematopoietic Cell Transplantation – Results Of a Randomized Controlled Trial

Background / AimsNutritional support post allogeneic haematopoietic progenitor cell transplantation (HPCT) has proven efficacy in preventing malnutrition post-HPCT with resultant improved patient outcomes. However, there is no consensus as to the most efficacious approach to supplemental feeding post-allogeneic HPCT, leading to wide variation in clinical practice with respect to use of enteral (EN) vs. parenteral (PN) feeding, especially in adult units. We aimed to determine the tolerability and efficacy of EN vs.PN in adult patients undertaking allogeneic HPCT. MethodsProspective randomized controlled study in adult patients >18yrs of age undertaking allogeneic HPCT with either myeloablative or reduced intensity conditioning (RIC). Informed consent was obtained before commencing conditioning, with patients randomized to receive either EN or PN after commencing HPCT conditioning if they could not maintain adequate oral nutritional intake, defined as maintaining >60% of daily caloric requirements orally. Patients with severe gastro-intestinal toxicity, including severe mucositis, were excluded from randomisation. The primary endpoint was tolerance of route of supplemental nutritional support, defined as <30% of patients needing to change to the alternative route of support for any reason. ResultsIn total 38 patients were enrolled onto the study, including 9 patients (24%) undertaking myeloablative and 29 patients (76%) RIC HPCT. Only 19 patients (50%) required nutritional support post-HPCT. Of these 19 patients, only 9 (47%) were able to be randomized between EN (n=5) and PN (n=4), with 10 patients excluded from randomization due to presence of severe gastrointestinal toxicity in 7 (37%), markedly deranged liver function in 1 (5%), and withdrawal of consent in 2 (11%). The 5 patients randomized to EN met on average 74% of their goal nutrition and 100% required changing to PN due to (gastro-intestinal) intolerance. The 4 patients receiving PN met on average 91% of requirements, with none requiring change to EN. ConclusionsFor adult patients undertaking myeloablative or RIC allogeneic HPCT, supplemental feeding with EN commencing at failure to maintain adequate oral nutritional intake is not feasible, due to the presence of significant gastrointestinal toxicity in these patients at this time. Further study is required to determine whether prophylactic nasogastric tube placement would improve the feasibility and tolerance of EN in this patient population. Disclosures:No relevant conflicts of interest to declare.