Parenteral Nutrition Support Research Articles

Refeeding Hypophosphatemia in Patients Receiving Parenteral Nutrition: Prevalence, Risk Factors, and Predicting Its Occurrence.

Patients receiving parenteral nutrition (PN) support may develop refeeding hypophosphatemia (RH), and its prevalence is highly variable in the literature. Identifying at-risk patients is crucial to minimize clinical complications. The National Institute for Health and Clinical Excellence (NICE) guidelines are used widely to assess the risk of RH, but they lack validation. We aim to (1) identify the prevalence of RH by multiple diagnostic criteria; (2) assess the predictive ability of the NICE guidelines for RH; and (3) identify important risk factors for RH and evaluate their predictive abilities for RH in a new model. This is a single-center retrospective study on adult patients with PN ≥48 hours. Prevalence of RH was determined by 4 established diagnostic criteria. Prognostic accuracy of the NICE guidelines were assessed by the area under the receiver operating characteristic (ROC) curve. Multivariable logistic regressions were performed to develop a new risk-assessment model. Of 149 enrolled patients, 23%-48% (35 to 72 of 149 patients) developed RH (depending on the diagnostic criteria used). The NICE guidelines demonstrated poor discrimination across all diagnostic criteria (ROC, 0.43-0.53). Critical illness, the use of diuretics, and hypomagnesemia prior to PN were independently associated with RH. These risk factors formed the new model for predicting RH and had good discrimination (ROC 0.74; 95% confidence interval, 0.66-0.82). Prevalence of RH varied according to established diagnostic criteria. The current NICE guidelines poorly predict the occurrence of RH, and modification is likely beneficial. A new risk-assessment model was developed; nevertheless, further validation is required.

Impact of Preoperative Short‐Term Parenteral Nutrition Support on the Clinical Outcome of Gastric Cancer Patients: A Propensity Score Matching Analysis

Nutrition status is of great significance to the clinical outcome after major abdominal surgery. However, the effect of preoperative short-term parenteral nutrition (PN) support among gastric cancer (GC) patients remains unknown and was evaluated in the current study. We retrospectively analyzed 455 nutritionally at-risk GC patients after radical resection from 2010 to 2016. We matched patients with 3-7 days of PN support to those without PN support. χ2 And Mann-Whitney U tests were used to compare differences between the PN and control groups. The propensity-matched sample included 368 GC patients (PN group, n = 184; control group, n = 184). The PN and control groups did not differ regarding postoperative complications (P = .528). The incidence of anastomotic leakage in the PN group was lower than in the control group (P = .011), whereas other complications were not found to differ between the groups. The hospitalization cost of the PN group was significantly higher than that of the control group (P < .001), whereas other outcome indicators were similar. Subgroup analysis showed that short-term PN support may have an improved benefit for patients with serum albumin level <35 g/L, but not at the level of statistical significance (P = .17). Short-term PN support did not significantly improve the short-term clinical outcomes of nutritionally at-risk GC patients, with the exception of a lower incidence of anastomotic leakage. Considering that short-term PN support increases economic burden, PN should not be the preferred method among these patients.

The effectiveness of the concept ERAS (Enhanced Recovery after Surgery) in patients of surgical intensive care unit

Introduction: The objective of the survey study is to the accessible world literature sources and comparative studies dealing with the effectivity of the ERAS concept in the patients after the surgical interventions in the surgical emergency units and to present adoption of concept in the Czech Republic. Method: For searching of the needed information and data they were used the literature sources and comparative studies from the open access and licensed database sources (Scopus, SpringerLink, Medline Complete, ScienceDirect, Web of Science, ProQuest, EBSCOhost, Wiley Online Library). The conclusions of the concrete comparative studies dealing with the conceptual effectivity of the perioperative care ERAS were analysed. On the analytical base of the gained information drawing from the accessible literature and from 8 quantitative studies published in the years 2009-2013. Results: It is clear that following of the ERAS protocol principle in the surgical workplaces in the Czech Republic is adopted only in the limitation of the routine application of the nasogastric probe, application of epidural analgesia and parenteral preoperative nutritional support if enteral not possible. Conclusion: The positive effect of the new way of the perioperative care, ERAS is proved as for the qualitative improvement of the treatment and nursing process, as for decreasing of the postoperative complications and shortening of the hospitalization period including decreasing of the economic expenditures connected to the treatment and hospitalization of the surgical patients. In comparison with established ERAS protocol, in the Czech Republic the principles are put into effect less significantly. The mentioned experiences and results can be the useful source for the next surgical workplaces.

Guidelines for parenteral and enteral nutrition in geriatric patients in China.

Based on the expert consensus on parenteral and enteral nutrition support for geriatric patients in China in 2013, domestic multidisciplinary experts were gathered to summarize the new evidence in the field of elderly nutritional support at home and abroad. The 2013 consensus was comprehensively updated and upgraded to a guideline by referring to the World Health Organization (WHO) guidelines for the Grading of Recommendations Assessment, Development, and Evaluation system for grading evidence. These guidelines were divided into two parts: general conditions and common diseases. After discussion by all members of the academic group and consultation with relevant experts, 60 recommendations were ultimately established as standardized nutritional support in the field of geriatrics in China.

Short-term preoperative parenteral nutrition benefits malnourished patients undergoing major gastrointestinal surgery

Background: Pre-operative nutritional support is of paramount in malnourished patients undergoing major gastrointestinal (GI) surgery. We aimed to investigate the outcomes of short term pre-operative parenteral nutrition in nutritionally depleted patients undergoing major GI surgeries.Methods: A retrospective study from tertiary care centre in South India, where nutritionally at risk patients undergoing major GI surgeries from 2016-2018 were identified and reviewed. Two groups –who received total or peripheral parenteral nutrition (TPN and PPN) and only enteral nutrition..Results: Of 80 patients who were nutritionally depleted underwent major GI surgery, 38 patients received pre-operative parenteral nutrition (PN) support for mean 11 days. Patients who received pre-op PN had similar outcomes (overall complication rate n=26, 68.4% vs n=32, 76.2% p=0.43), when compared to patients who received pre-op enteral nutrition conditioning. Though a small group of patients received peripheral PN supplementation, there was no difference in overall complication rate, when compared with TPN group (n=14, 58.3% vs n=12, 85.7%, p=0.08).Conclusions: Parenteral nutrition either total or supplemental is a useful adjunct pre-operatively for poorly nourished patients and should be utilized to build nutrition prior to major GI surgery. Pre-operative peripheral parenteral nutrition as supplement seems to be beneficial in patients undergoing GI surgery, pending large studies.

Practice of parenteral nutrition in hospitalized adult patients in Korea: A retrospective multicenter cross-sectional study.

There have been no studies on the characteristics of parenteral nutrition (PN) supply for adult inpatients in South Korea. The aim of this retrospective multicenter cross sectional study was to investigate the current practice and characteristics of PN support in hospitalized adult patients in South Korea for the first time. This study was conducted retrospectively for the adult patients who were hospitalized and received PN in nine hospitals on August 1st, 2017 to October 30th, 2017. We evaluated the type of PN formulation, PN administration period, administration route, calories supplied, amount of protein supplied, and laboratory results. Among the 11,580 inpatient admissions on that day, 1,439 patients received PN (12.4%). The majority of enrolled patients (96.5%) used the commercial PN, of which 86.2% were multi-chamber. 71.2% of them received PN peripherally. The average in hospital PN duration was 17.8 ± 52.6 days. Patients received only 65.4 ± 25.4% calories of their target calories. The in-hospital mortality of enrolled patients was 22%. In South Korea, commercial PN was usually administered to hospitalized adult patients and in-hospital mortality in adult patients using PN was higher in South Korea compared to other countries. This study provides the characteristics and the PN support status of hospitalized adult patients receiving PN in South Korea.

Comparison of the clinical effects of early enteral and parenteral nutrition support in patients with severe stroke

Objective To compare the clinical effects of early enteral and parenteral nutrition support in patients with severe stroke. Methods From June 2017 to July 2018, 65 patients with severe stroke admitted in the First People's Hospital of Yongkang were selected in the study, and the patients were randomly divided into control group(32 cases) and observation group(33 cases) according to the digital table.The control group received early parenteral nutrition support, while the observation group received early enteral nutrition support.The nutritional index, biochemical index, NIHSS score, CPIS score of clinical pulmonary infection and the incidence of complications were compared between the two groups. Results After nutritional support, the serum levels of total protein(TP), albumin(Alb), hemoglobin(Hb) in the observation group were (57.01±2.59)g/L, (39.98±2.64)g/L, (126.86±10.75)g/L, respectively, which were significantly higher than those in the control group [(54.28±0.76)g/L, (37.31±2.35)g/L, (120.75±13.46)g/L](t=5.727, 4.302, 2.025, all P<0.05). The serum levels of glucose(GLU), creatinine (SCr), alanine aminotransferase (ALT) in the observation group were (12.35±2.38)mmol/L, (84.37±13.62)μmol/L, (47.84±4.03)U/L, respectively, which were lower than those in the control group [(14.18±2.37)mmol/L, (91.84±13.21)μmol/L, (66.28±3.76)U/L] (t=3.106, 2.244, 19.060, all P<0.05). The levels of triglyceride(TG), serum urea nitrogen(BUN) in the observation group were (1.95±0.45)mmol/L, (5.80±0.61)mmol/L, respectively, which were higher than those in the control group [(1.66±0.30)mmol/L, (5.32±0.43)mmol/L] (t=0.341, 3.656, all P<0.05). The scores of NIHSS and CPIS in the observation group were (10.31±2.10)points and (3.00±0.76)points, respectively, which were lower than those in the control group [(14.68±2.75)points, (3.79±1.45)points](t=5.279, 2.763, P=0.001, 0.008). The incidence of complications in the observation group [9.38%(3/33)] was lower than that in the control group [31.25%(10/32)], and the difference was statistically significant(χ2=4.986, P<0.05). Conclusion Compared with early parenteral nutrition support, early enteral nutrition support can improve the nutritional status of patients with severe stroke and is safe and effective. Key words: Stroke; Enteral nutrition; Parenteral nutrition; Nutritional support; Albumins; Serum albumin; Hemoglobins; Comparative effectiveness research

Use of Lipids in Neonates Requiring Parenteral Nutrition.

Neonates have limited antioxidative capacity and are at increased risk of infection and inflammation-a situation that is exacerbated in preterm neonates. Together, oxidative stress and inflammation are implicated in many serious conditions affecting neonates, such as bronchopulmonary dysplasia and periventricular leukomalacia. Neonates requiring parenteral nutrition have certain nutritional requirements. For example, very long-chain ω-3 polyunsaturated fatty acids (PUFAs) such as docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) are regarded as conditionally essential with critical roles during early retinal and brain development, and may also have other benefits such as anti-inflammatory effects. Because of these factors, the choice of lipid emulsion used as part of parenteral nutrition support may influence clinical outcomes in neonates. There are concerns that lipid emulsions based purely on soybean oil may increase lipid peroxidation, oxidative stress, and inflammation because of their high ω-6 PUFA and low ω-3 PUFA concentrations. Composite fish-oil containing lipid emulsions may provide advantages for neonates owing to their high DHA and EPA content and high antioxidant (α-tocopherol) levels. Here, we discuss clinical trials of lipid emulsions in preterm and term neonatal populations, with a particular emphasis on markers of oxidative stress and DHA and EPA levels. Olive oil/soybean oil lipid emulsions have shown few advantages in neonates over other lipid emulsions. However, compared with either pure soybean or soybean/olive-oil based emulsions, composite fish-oil containing lipid emulsions reduce oxidative stress/lipid peroxidation and also increase DHA and EPA levels. These advantages may translate into clinical benefits for neonates requiring parenteral nutrition.

Evaluation of Fibrosis in Intestinal Failure-Associated Liver Disease in the Sustain Registry.

Intestinal failure-associated liver disease (IFALD) is one of the leading complications in type III intestinal failure (IF). Early recognition of liver-fibrosis development in IFALD is crucial to the development of strategies aimed at reducing the risk of complications secondary to IFALD. Our aim was to identify patients with advanced fibrosis using a noninvasive index and to study the risk factors for fibrosis development in the Sustain registry. Using the Sustain registry, patients requiring >3 months of parenteral nutrition (PN) support were identified. The presence or absence of advanced fibrosis was identified using the Fibrosis-4 (FIB-4) index. Risk factors for the presence of a high FIB-4 score were identified using univariable logistic regression. Two hundred seventy-one adult patients were included. Sixty-three patients (23.2%) were at risk for advanced fibrosis based on the FIB4-index. Risk factors for advanced fibrosis included short-bowel syndrome (odds ratios [ORs]: 1.84; 95% confidence interval [CI], 1.03-3.28), receipt of PN for >1 year (OR: 2.6; 95% CI, 1.46-4.64), receipt of PN for >5 years (OR: 3.05; 95% CI, 1.67-5.59), and days of lipid emulsion use (OR: 1.11; 95% CI, 1-1.24). Small-intestine-remnant length was inversely associated with advanced fibrosis (OR: 0.97, 95% CI, 0.95-0.99). Advanced fibrosis, as guided by FIB-4 index, is associated with known risk factors for IFALD. Therefore, the FIB-4 index is potentially a useful noninvasive tool for identification of individuals at risk for fibrosis in IFALD. Further studies utilizing a gold-standard fibrosis assessment will be required to validate these results.

Comparative study of early enteral feeding versus parenteral feeding in acute severe pancreatitis in JSS hospital

Background: Acute Severe acute pancreatitis is found in 20-30% of patients with pancreatitis and is associated with marked increased risk of complications, such as necrosis, abscess, formation of pancreatic pseudocyst and multiorgan failure, and also the disease manifests with a “systemic inflammatory response syndrome (SIRS) that culminates with hyper metabolism and high rate of protein catabolism; consequently, nutritional reserves are rapidly consumed and malnutrition may ensue unless a higher nutritional intake is provided, thus, early nutritional support plays a central role in the management of these patients. Parenteral nutritional support has long been the standard source of exogenous nutrients for these patients; however this is associated with many disadvantages, including dysfunction of the intestinal mucosal barrier, which, in turn, promotes sepsis of intestinal origin. Enteral nutrition, on the other hand, can maintain the integrity and function of the intestinal mucosal barrier, and thus the study intends to compare the efficacy of enteral versus parenteral feeding in influencing the outcomes in acute pancreatitis cases measured in terms of acute phase proteins, duration of ICU care, length of hospital stay.Aim: To compare the efficacy of enteral feeds versus parenteral feeding in terms of, outcomes of acute pancreatitis patients, to assess acute phase response in both types of feeding and measuring the length of hospital stay including length of ICU stay.Methods: Patients admitted with diagnosis of acute pancreatitis will be randomly grouped into group A and B by odd and even number hospital admission, Sample Size is considered as 100 with 50 in group A receiving enteral feeding and 50 in group B receiving parenteral feeding, considering the mean difference in hospital stay of 6 days and SD in each group as 12 days.Results: It was seen that patients who received early enteral nutrition had better outcomes in terms of acute phase proteins, shorter length of hospital stay (p-value:0.038, t-test:7.868) and shorter length of ICU care (p-value: 0.044, t-test:1.094) that compared with total parenteral nutrition group.Conclusion: It can be concluded that in our study, early enteral nutrition can be started safely and efficient when started “within 48 hours of admission” which had better outcomes in terms of acute phase proteins, shorter duration of ICU care and length of hospital stay and also cost effective that compared to those patients who received total parenteral nutrition where lesser patients showed better outcomes, had increased hospital stay and was costlier.

The retrospective research of enteral nutrition with medium-chain triglyceride and total parenteral nutrition support of postoperative chylothorax in adults.

Background:Chylothorax is caused by thoracic lymphatic system injuries that leads to the lymph extravasating into the thoracic cavity. There are few reports comparing the therapeutic effects of enteral nutrition with medium-chain triglyceride and total parenteral nutrition, and the results are inconsistent. Our study aimed to research the optimum nutrition support method for chylothorax.Study design:We retrospectively reviewed 35 chylothorax patients after heart and chest surgery from 2014 to 2018, at West China Hospital of Sichuan University, among them there were 27 post-heart surgery patients. We analyzed the therapeutic effects and costs of enteral nutrition with medium-chain triglyceride (E group) and total parenteral nutrition (T group) for chylothorax.Results:The results were similar in patients with all surgeries and patients with only post heart surgery. The total cost during hospitalization in E group was higher than T group (P < 0.01), whereas the nutrition support cost was lower (P < 0.001). The length of hospital stay was longer in E group than T group (P > 0.05). Time from admission to surgery was shorter and from surgery to chylothorax diagnosis was longer in E group compared with T group. Time to resolution and removal of drainage was shorter in E group than T group but the differences were not significant.Conclusion:The therapeutic effects in enteral nutrition with medium-chain triglyceride and total parenteral nutrition had no obvious differences. Moreover, enteral nutrition with medium-chain triglyceride is safer and more economical. Therefore, we suggest that enteral nutrition with medium-chain triglyceride could be the first choice to treat postoperative chylothorax when the gastrointestinal tract function is allowed, and this result could be considered for postoperative chylous ascites.

ASPEN-FELANPE Clinical Guidelines: Nutrition Support of Adult Patients with Enterocutaneous Fistula

Background: the management of patients with enterocutaneous fistula (ECF) requires an interdisciplinary approach and poses a significant challenge to surgeons, gastroenterologists, intensivists, wound/stoma care specialists, and nutrition support clinicians. Available guidelines for optimizing nutritional status in these patients are often vague, based on limited and dated clinical studies, and typically rely on individual or institutional experience. Specific nutrient requirements, appropriate route of feeding, role of immune-enhancing nutrients, and use of somatostatin analogs in the management of patients with ECF remain a challenge for the clinician. The purpose of this clinical guideline is to develop recommendations for the nutritional care of adult patients with ECF. Methods: 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 A.S.P.E.N. and FELANPE Board of Directors. Questions: in adult patients with enterocutaneous fistula: 1) What factors best describe nutritional status? 2) What is the preferred route of nutritional therapy (oral diet, EN or PN)? 3) What protein and energy intake provide best clinical outcomes? 4) Is fistuloclysis associated with better outcomes than standard care? 5) Are immune-enhancing nutrients associated with better outcomes? 6) Does the use of somatostatin provide better outcomes than standard medical therapy? 7) When is home parenteral nutrition support indicated?

Dynamic changes in blood amino acid concentrations in preterm infants in different nutritional periods.

Neonatal nutrition is critical for the growth and development of preterm infants. Dynamic changes in the amino acid profiles in preterm infants of different gestational ages and in different nutritional periods were investigated. Premature infants who received parenteral nutrition support after birth were enrolled and divided into four groups based on their gestational ages. Blood samples were collected as a dried blood spot before nutritional support, and in the total parenteral nutrition, partial parenteral nutrition, and total enteral nutrition periods. Amino acid concentrations were detected in the samples by liquid chromatography tandem mass spectrometry and compared between the different nutritional periods and gestational ages. Samples from 124 premature infants were statistically analyzed. Concentrations of all amino acids, except glutamine, were statistically different at distinct nutritional periods. Threonine and aspartic acid concentrations gradually increased, while valine, methionine, phenylalanine, and glycine concentrations gradually decreased with the transition from TPN to TEN. At different gestational ages, significant differences were observed in the concentrations of seven amino acids only in the PPN period but not in the others. The concentrations of amino acids in preterm infants vary with nutritional period.

A Comparison of Smoflipid® and Intralipid® in the Early Management of Infants with Intestinal Failure

PurposeCholestasis is problematic for infants with intestinal failure (IF). The soy-based lipid Intralipid® (IL) has been implicated. An alternative, Smoflipid® (SMOF), is increasingly used. However, its role in cholestasis prevention is unclear. This study compares the incidence and degree of cholestasis between infants with IF receiving SMOF or IL. MethodsInfants with IF receiving SMOF or IL during the first 8 weeks of parenteral nutrition (PN) support between 2014 and 2017 were reviewed. Clinical characteristics, cholestasis incidence (conjugated bilirubin (Cbili) >2 mg/dL for >2 weeks), and nutritional parameters were compared using Welch's t-test. Results91% (21/23) of IL and 76% (16/21) of SMOF babies became cholestatic (p = 0.18). There was no significant difference in median peak Cbili, but SMOF babies normalized more quickly (p = 0.04). Median z-scores for weight were similar throughout the study. SMOF patients getting full PN had a lower incidence of cholestasis compared to IL patients (78% vs. 92%, p = 0.057), but those with cholestasis had similar peak Cbili, time to resolution, and growth. ConclusionEarly use of Smoflipid® did not reduce the incidence of cholestasis compared to Intralipid® in infants with IF, but hyperbilirubinemia did resolve more quickly. SMOF may be most beneficial for infants tolerating no enteral nutrition. Level of EvidenceLevel III Retrospective Comparative Treatment Study. Type of StudyRetrospective Review.

Application value of ω-3 fish oil fat emulsion in the parenteral nutritional support treatment following radical gastrectomy for gastric cancer

Objective To investigate the application value of ω-3 fish oil fat emulsion in the parenteral nutritional support treatment following radical gastrectomy for gastric cancer. Methods The retrospective cohort study was conducted. The clinical data of 60 patients who underwent radical gastrectomy for gastric cancer in Nanjing Medical University Affiliated Wuxi Second Hospital between January 2018 and December 2018 were collected. There were 37 males and 23 females, aged from 28 to 78 years, with an average age of 64 years. Thirty patients who received parenteral nutrition containing 100 mL of ω-3 fish oil fat emulsion after radical gastrectomy and 30 patients who received parenteral nutrition containing routine fat emulsion after radical gastrectomy were allocated into experimental group and control group, respectively. Observation indicators: (1) nutritional indicators in the perioperative period; (2) inflammatory indicators in the perioperative period; (3) immune indicators in the perioperative period; (4) postoperative complications. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was evaluated using the independent-sample t test. Count data were described as absolute numbers and percentages, and comparison between groups was analyzed using the chi-square test. Repeated measurement data were analyzed by the repeated measures ANOVA. Results (1) Nutritional indicators in the perioperative period: the levels of total protein, albumin, prealbumin, and transferrin from preoperative day 1 to preoperative day 6 were respectively changed from (60.2±3.0)g/L to (57.2±3.1)g/L, from (35.3±3.1)g/L to (37.0±1.8)g/L, from (186±24)mg/L to (172±17)mg/L, from (3.0±0.7)g/L to (2.4±0.4)g/L in the experimental group and from (60.6±2.4)g/L to (55.7±4.2)g/L, from (35.0±3.8)g/L to (36.0±3.8)g/L, from (184±18)mg/L to (173±25)mg/L, from (3.1±0.6)g/L to (2.2±0.8)g/L in the control group, with no significant difference in the changing trends between the two groups (F=0.79, 2.14, 0.03, 0.36, P>0.05). (2) Inflammatory indicators in the perioperative period: the levels of white blood cells, C-reactive protein, interleukin 6, and tumor necrosis factor-α from preoperative day 1 to preoperative day 6 were respectively from (7.2±1.1)×109/L to (10.2±0.9)×109/L, from (7.2±2.3)mg/L to (25.5±6.3)mg/L, from (16±3)ng/L to (24±4)ng/L, from (17±4)ng/L to (22±5)ng/L in the experimental group and from (7.4±0.8)×109/L to (13.0±1.3)×109/L, from (6.9±2.4)mg/L to (41.6±18.9)mg/L, from (17±4)ng/L to (45±8)ng/L, from (16±4)ng/L to (43±7)ng/L in the control group, respectively, with significant differences in the changing trends between the two groups (F=63.05, 51.65, 127.82, 104.91, P 0.05). (4) Postoperative complications: 5 patients had postoperative complications, with a incidence rate of 16.7%(5/30), including 1 of abdominal infection, 1 of incisional infection, and 3 of pulmonary infection, and all the 5 patients were cured after symptomatic treatment. Nine patients had postoperative complications, with a incidence rate of 30.0%(9/30), including 2 of abdominal infection, 2 of incisional infection, and 5 of pulmonary infection, and all the 9 patients were cured after symptomatic treatment. There was no significant difference in the incidence of postoperative complications between the two groups (χ2=1.491, P>0.05). Conclusion For patients who receive gastric cancer surgery, ω-3 fish oil fat emulsion can reduce the inflammatory response, improve their immune function and not increase postoperative complications. Key words: Gastric neoplasms; Gastric cancer; ω-3 fish oil fat emulsion; Nutritional support; Perioperative period; Complications

3094 Esophageal Strictures After Ingestion of Picosulfate Powder for Colonoscopy

INTRODUCTION: Picosulfate solution is widely used as a small volume bowel cleansing agent considered to be effective and relatively safe. CASE DESCRIPTION/METHODS: A 75 - year - old woman came to our hospital with severe neck pain that occurs when she swallows food. A week before our hospital visiting, she had scheduled the EGD and colonoscopy for a health checkup. At the time of EGD, there was white exudates and hemorrhagic spots in the esophagus. But, she had any pain at that time. After 1 week she felt a severe sore throat, visited otolaryngologist, but she was told there was nothing wrong. Despite of medication, she continued to suffer severe pain and she came to our emergency room and received otolaryngologist consultation. However, she was told that she had no particular abnormal findings. She underwent an EGD to examine the cause of the neck pain. The EGD showed multiple superficial ulcers and yellowish exudates throughout the esophagus (Figure 1). We had a biopsy in the esophagus. The result was candidiasis. One week later, she had difficulty in swallowing, and she had another EGD. The esophageal lumen was narrowed at the position of upper incisor (UI) 20 ∼ 30 cm and multiple ulcers were scattered and the endoscope could not pass to the distal side of the esophagus (Figure 2). We investigated her medication history to find out why she had the esophageal strictures. She was being treated for diabetes and atrial fibrillation 20 years ago, and we found she had taken picosulfate powder for colonoscopy a week ago. She mistakenly took the picosulfate powder first, drank the water later. She felt a little uncomfortable with the epigastric area, but she thought it was nothing. During her hospital stay, she was treated conservatively, including fasting, antibiotics, and parenteral nutritional support. After her symptoms improved, she was discharged. About a month later, she came to the outpatient clinic because of dysphagia for solid food. EGD showed esophageal stricture at UI 25 cm and passed through the site using a ultrathin scope. The narrowed area of the UI 30 cm was not able to pass through the endoscope (Figure 3). Using a guide wire, a 10 cm full covered metal stent was inserted through the scope. DISCUSSION: We reported a case of esophageal ulcer and stricture caused by a picosulfate power that the patient took accidentally. When picosulfate powder is used as a bowel cleansing agent, patient should be educated to take after dissolving it more than 200 mL of water to avoid esophageal injury.

Ketogenic parenteral nutrition in three paediatric patients with epilepsy with migrating focal seizures

Epilepsy of infancy with migrating focal seizures (EIMFS) is a rare epilepsy syndrome, characterized by an onset of multifocal seizures before the age of six months and a rather typical ictal EEG pattern. The ketogenic diet (KD) has been shown to be a treatment option in these patients with variable results. The KD is generally given by enteral formula or solid food, however, patients on the KD often have coexisting medical disorders that may impair the gastrointestinal tract and, in these cases, parenteral nutrition support may be needed. We present our experience with three patients who had been on the KD because of EIMFS, who were acutely unable to absorb nutrients through the intestinal tract. For these patients, we were unable to reach ketogenic ratios higher than 1.5:1 because of the limited fat intake via the parenteral route. This ratio, nevertheless, was adequate for maintenance of seizure control while allowing short-term bowel rest. Even though our report is limited as it provides no controlled evidence, ketogenic parenteral nutrition should be considered in children on the KD when enteral nutrition is not feasible. Special care should be taken to maintain ketosis and avoid undesired carbohydrates. Patients may respond well to ketogenic parenteral nutrition in spite of a lower ketogenic ratio.

MULTIDISCIPLINARY MANAGEMENT OF A CASE OF INTESTINAL FAILURE DUE TO SHORT BOWEL SYNDROME IN GARDNER SYNDROME

Objective There still is little attention about both nutritional/metabolic consequences and multi-organ involvement after intestinal surgery. Our multidisciplinary team aimed to an integrated approach to short bowel syndrome (SBS). Research Methods & Procedures A 37-years-old man affected by Gardner Syndrome, who previously underwent colectomy and several small bowel resections elsewhere without receiving appropriate nutritional prescriptions, was admitted into our hospital to be evaluated for intestinal transplant: biochemistry showed acute renal failure and multiple critical dysionias and the patient referred habitual copious liquid output, also containing undigested food, from ileostomy; he had lost 30 kg (-40% usual body weight, BW) in the last month. He promptly underwent nutritional assessment and, consequently, nutritional treatment: firstly we corrected dysionias and immediately started thiamin supplementation, thereafter we prescribed a personalized semielemental low-fiber diet per os, parceled out on 5-6 meals, and we started a personalized admixture parenteral nutrition support (PN). Regardless of appropriate evidences, the patient finally refused to give his consent to intestinal transplant, he was then discharged in PN and personalized diet per os. Results Despite severe dehydration and malnutrition, we early achieved and maintained hydro-electrolytic balance, thus recovering renal enhancement; besides, Refeeding Syndrome was adequately prevented and, beyond rehydration, the patient also started regaining BW. Conclusions SBS can result in both intestinal and renal failure. It needs a multidisciplinary approach, including early and appropriate nutritional assessment and treatment. When intestinal transplant is not possible, even if recommended, PN remains the main therapeutic strategy.

Effect of clinical pharmacists participating in parenteral nutrition support intervention in patients hospitalized in hepatobiliary and pancreatic surgery

Objective To evaluate the effect of clinical pharmacists on parenteral nutrition support interventions, and to provide reference for clinical pharmacists to participate in the ERAS Nutrition Support Group work model. Methods A total of 490 patients hospitalized in department of hepatobiliary and pancreatic surgery from November 2016 to January 2017 were selected as control group. 521 patients hospitalized in department of hepatobiliary and pancreatic surgery from November 2018 to January 2019 were selected as intervention group. Nutritional risk, parenteral nutrition support indications, parenteral nutrition prescription energy and amino acid supply, prescription incompatibility and rationality, prescription osmotic concentration and phlebitis, parenteral nutrition and drugs in Y-tube compatibility of the above patients were analyzed to evaluate the effect of interventions by clinical pharmacists after participating in the nutritional support team. Results Patients with benign pancreatic diseases in the two groups had higher incidence of nutritional risk (78.2%, 75.6%), and patients with benign biliary diseases had lower incidence of nutritional risk (76.4%, 69.9%). Incidence of patients having parenteral nutrition support indications, namely NRS 2002≥3 points was higher in intervention group (83.6%) than in control group (56.6%); parenteral nutrition prescription energy and amino acid supply were higher in intervention group than in control group, patients in the intervention group had lower blood albumin dosage and no over-indication medication than patients in the control group; patients in both groups had no parenteral nutrition prescription safety issues such as glycolipid ratio (kJ∶kJ) 0.05). The compatibility of parenteral nutrition solution and drug in Y-tube was lower in the intervention group than in the control group. Conclusion The participation of clinical pharmacist in the ERAS nutrition treatment team, who will assist the doctor in formulating the nutritional treatment plan, monitor the patient's nutritional support and conduct regular indoor training, can effectively improve the reasonable application of parenteral nutrition support, standardize the use of therapeutic drugs, and guide patients and caregivers to use the preparations safely so that to ensure patients' safety in clinical interventions. Key words: Department of hepatobiliary and pancreatic surgery; Clinical pharmacist; Nutritional Risk; Parenteral nutrition support; Total nutrition admixture

Therapeutic experience of type Ⅲ-b congenital intestinal atresia

To summarize the clinical characteristics and treatment of type Ⅲ-b congenital intestinal atresia (CIA). The clinical data of 12 type Ⅲ-b CIA treated in the Children's Hospital of Zhejiang University School of Medicine from January 2015 to December 2017 were analyzed retrospectively. Of the 12 patients diagnosed as type Ⅲ-b CIA in operation, treatment was refused during operation by their parents in 2 cases. For one child, only the proximal intestine was partly resected in the first operation, dilatation and dysplasia of the duodenum was diagnosed and total duodenum was resected and sutured in the second operation, as the child had postoperative intestinal obstruction. For one child, due to the long distal normal intestine, distal apple-peel like intestine was partly resected without mesenteric reformation. For the rest 8 children total duodenum resection and mesenteric reformation were performed. During the postoperative follow-up, one case was early rejected for further treatment by parents, one case died from complex congenital heart disease, 5 cases had the complication of short bowel syndrome. All 8 survival children received parenteral nutrition support after operation, 5 of whom received parenteral nutrition support for more than 42 days, and they were followed up for 1-3 years after discharge. The short-time efficacy was satisfactory. For children with type Ⅲ-b CIA, the distal apple-peel like intestine should be preserved as much as possible, the mesenteric reformation should be performed and the proximal dilated bowel should be partly resected and sutured. Postoperative nutritional support and early intestinal rehabilitation contribute to the compensation for rest intestines.