Parenteral Nutrition Utilization Research Articles

Outcomes of parenteral nutrition in patients with advanced cancer and malignant bowel obstruction.

Malignant bowel obstruction (MBO) affects 3% to 15% of all cancer patients. In patients with advanced cancer and inoperable MBO, the average survival varies between four to nine weeks. Parenteral nutrition (PN) may improve survival in specific patient populations with malignant bowel obstruction. This retrospective, single-center cohort study aimed to review individual patient outcomes on PN in the setting of advanced cancer with a diagnosis of MBO and identify clinical and laboratory markers predictive of short- and long-term survival to further highlight patients that would benefit from PN in the setting of an inoperable MBO. In a retrospective analysis of 68 patients receiving PN for inoperable MBO, the median survival was 142 (IQR: 63.3-239.5) days. Patients experienced a median number of two hospital readmissions (range: 0-10) and spent a median of 29days (range: 0-105) in the hospital after starting PN. Eighteen (26.5%) patients developed a catheter-related bloodstream infection (CRBSI). A diagnosis of appendiceal cancer was identified as a predictive marker of improved survival (HR: 0.53, 95% CI: 0.29-0.92, p = 0.023). The use of PN in the context of end-of-life cancer care is a practice that necessitates improvement. Recognizing the outcomes and patient experiences of PN utilization is essential to physicians and patients.

The Use of Parenteral Nutrition and Disparities in Its Allocation Following Traumatic Injury

IntroductionSevere traumatic injury requires rapid and extensive deployment of resources to save the lives of the critically injured. The sequelae of traumatic injuries frequently require extensive intervention obligating patients to a complicated recovery process devoid of meaningful nutrition. In this setting, parenteral nutrition (PN) is key in enabling appropriate wound healing, recovery, and rehabilitation. We sought to examine the use of PN in adult trauma management and to highlight any disparities in the utilization of PN in adult trauma patients. MethodsWe queried the 2017-2019 Trauma Quality Improvement Program (TQIP) for adult patients (aged > 18 y) who sustained blunt or penetrating traumatic injuries and received PN as part of their hospitalization. We compared time to PN administration based on demographics. We then used a multivariable logistic regression model to identify factors associated with the use of PN. We hypothesized that PN would be less commonly employed in the uninsured and minority groups. ResultsWe identified 2,449,498 patients with sufficient data for analysis. Of these, 1831 patients were treated with PN. On univariate analysis, PN patients were more commonly male (74.7% PN versus 60.2% non-PN; P < 0.001). PN use was more frequent in the Black population (24.3% PN versus 15.5% non-PN; P < 0.001) and less frequent in the White population (72.7% PN versus 81.2% non-PN; P < 0.001). PN use was also much more common among patients covered by Medicaid. Penetrating trauma was over twice as common among PN recipients relative to non-PN patients (% PN versus % non-PN). PN patients had higher injury severity scores (ISSs), more intensive care unit days, longer hospitalizations, and increased mortality compared to non-PN patients. PN patients were half as likely to discharge home and twice as likely to discharge to a long-term care facility. Multivariable analysis including age, race, trauma mechanism, primary payer, and ISS, demonstrated an association of PN use with increasing age (OR 1.01, P < 0.001), cases of penetrating trauma (odds ratio [OR], 2.47; P < 0.001), and patients with high ISS (OR, 0.1.06; P < 0.001). There was decreased use in Uninsured patient (OR, 0.54; P < 0.001). ConclusionsPN use following traumatic injury is rarely required. Patients treated with PN typically have a resource-intense hospital course. More severe injuries, penetrating trauma, and increased age are more likely to result in PN use. Variations in PN use are apparent based on insurance payer, further examination into allocation of hospital and intensive care resources, as it pertains to patient socioeconomic status, is warranted in light of these findings.

Utilization of parenteral nutrition in major gastrointestinal surgery: An opportunity for quality improvement

Parenteral nutrition (PN) is commonly utilized to support patients in the perioperative period of major gastrointestinal (GI) surgeries. This study sought to evaluate PN utilization based on malnutrition status and duration of PN use in a single academic institution to evaluate baseline ASPEN recommendation concordance and identify opportunities for quality improvement. Patients who had undergone major GI surgical oncology operations and received PN were identified over six months. The medical charts were reviewed for clinicopathologic variables, nutrition status, and the initiation and duration of PN. The cohort was stratified by PN recommendation concordance, and intergroup comparisons were made to identify factors associated with non-concordant utilization of PN. Eighty-one patients were identified, 38.3% of patients were initiated on PN due to dysmotility. Other indications were: intra-abdominal leak (27.2%), mechanical obstruction (18.5%), and failure to thrive (16.0%). Non-concordant PN utilization was identified in 67.9% (55/81) of patients. The most frequent reason for non-concordance was initiation outside the recommended time frame due to severity of malnutrition; well-nourished patients started "too soon" accounted for 29.0% (16/55), and 61.8% started "too late," most of whom were moderately or severely malnourished (34/55). In 16.0% (13/81) of the overall cohort, PN was administered for fewer than five days. PN use during the perioperative period surrounding major GI oncologic operations is clinically nuanced and frequently not concordant with established ASPEN recommendations. Quality improvement efforts should focus on reducing delayed PN initiation for nutritionally at-risk patients without increasing premature PN use in well-nourished patients.

The Impact of Proactive Gastrostomy Tube Placement on Treatment-related Outcomes in Young Children With High-grade Central Nervous System Tumors.

Young children undergoing treatment with intensive chemotherapy for high-grade central nervous system (CNS) tumors are at risk for malnutrition, yet no guidelines exist for the placement of enteral tubes. Prior studies evaluated the impact of proactive gastrostomy tube (GT) placement with a narrow scope of outcomes, such as weight. To examine the impact of proactive GT on comprehensive treatment outcomes, we performed a single-center, retrospective study of children younger than 60 months of age with high-grade CNS tumors treated per CCG99703 or ACNS0334 between 2015 and 2022. Of 26 patients included, 9 (35%) underwent proactive GT, 8 (30%) had rescue GT, and 9 (35%) had a nasogastric tube (NGT). Clinically significant weight loss occurred in 47% of patients with NGT during induction compared with 22% with proactive GT ( P = 0.274); however, between cohorts, there was no significant difference in antibiotic or parenteral nutrition utilization, weight loss at therapy completion, and duration of hospitalization. Therefore, proactive GT placement was modestly effective at preventing significant weight loss during induction, however, there was no clear benefit for hospitalization duration, antibiotic, or parental nutrition requirements compared with NGT. We recommend an individualized approach to GT placement for young children with CNS malignancies undergoing intensive chemotherapy.

S3218 Current State of Parenteral Nutrition Utilization in Patients Hospitalized With Acute Pancreatitis

S3218 Current State of Parenteral Nutrition Utilization in Patients Hospitalized With Acute Pancreatitis

Development of a clinical practice guideline for weaning and discontinuing parenteral nutrition in hospitalized children as part of a central line-associated bloodstream infection-focused quality improvement initiative.

Overprescribing of parenteral nutrition (PN) increases costs and risks to patients, including from central line-associated bloodstream infection (CLABSI). With CLABSI reduction in mind, our children's hospital began an iterative quality improvement effort to decrease PN utilization by first ensuring appropriate initiation and then defining and ensuring appropriate discontinuation. Education was launched along with audits to evaluate for appropriate PN indications. Next, a literature review was conducted to guide the development of an algorithm to appropriately wean and discontinue PN. Lastly, all PN discontinuations were audited for agreement with the new guideline. Retrospectively, monthly PN utilization index (orders per patient-day) was plotted on a statistical process control chart to assess change over time. The presence of PN as a risk factor for CLABSI events and the overall hospital CLABSI rate were trended. Mean PN utilization index fell from 0.156 (July 2018 to January 2019) to 0.12 (February 2019 to August 2020) (P < .01). For 18 months, no PN utilization index reached the baseline lower control limit of 0.144, demonstrating special-cause variation and sustained change. PN as a risk factor for hospital CLABSI cases decreased from most prevalent (49% of cases) to fifth most prevalent (29%) as the CLABSI rate trended down. Engaging frontline staff in the development of a clinical practice guideline and increased accountability to reduce potential patient harm led to a significant and sustained reduction in PN utilization, as well as decreased prevalence of PN as a risk factor in hospital CLABSI cases.

Variability, outcomes and cost associated with the use of parenteral nutrition in children with complicated appendicitis: A hospital-level propensity matched analysis

Background/PurposeTo examine the influence of parenteral nutrition (PN) on clinical outcomes and cost in children with complicated appendicitis. MethodsRetrospective study of 1,073 children with complicated appendicitis from 29 hospitals participating in the NSQIP-Pediatric Appendectomy Pilot Collaborative (1/2013–6/2015). Mixed-effects regression was used to compare 30-day postoperative outcomes between high and low PN-utilizing hospitals after propensity matching on demographic characteristics, BMI and postoperative LOS as a surrogate for disease severity. ResultsOverall PN utilization was 13.6%, ranging from 0–10.3% at low utilization hospitals (n = 452) and 10.3–32.4% at high utilization hospitals (n = 621). Outcomes were similar between low and high utilization hospitals for rates of overall complications (12.3% vs. 10.5%, OR: 0.80 [0.46,1.37], p = 0.41), SSIs (11.3% vs. 8.8%, OR: 0.72 [0.40,1.32], p = 0.29) and revisits (14.7% vs. 15.9%, OR: 1.10 [0.75,1.61], p = 0.63). Adjusted mean 30-day cumulative hospital cost was 22.9% higher for patients receiving PN ($25,164 vs. $20,478, p < 0.01) after controlling for postoperative LOS. ConclusionFollowing adjustment for patient characteristics and postoperative length of stay, higher rates of PN utilization in children with complicated appendicitis were associated with higher cost but not with lower rates of overall complications, surgical site infections or revisits.Level of Evidence Level III: Treatment study - Retrospective comparative study

PRM18 - Total Parenteral Nutrition in Asian Countries – A Systematic Literature Review of Cost-Effectiveness Studies

An ever-growing proportion of critically ill adult patients require parenteral nutrition (PN) as a lifesaving therapy when enteral nutrition is inadequate or impossible. It is estimated that PN utilization will significantly grow in Asia Pacific region in the near future. The objective of this study was to evaluate cost-effectiveness of different PN formulations in Asian countries using systematic literature review. The literature search was conducted in PubMed/Medline and Tufts registry. Cost-effectiveness studies assessing different parenteral formulations in malnourished adults in Asian countries were included. Two independent reviewers screened and evaluated studies using the 24-item Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Four articles satisfied predefined inclusion criteria. The studies evaluated addition of omega-3 fatty acids (n=2) or structured triglycerides (n=1) to standard lipid emulsions and cost-benefit of a nutritional support team for PN (n=1). The studies were performed in Chinese (n=3) and Japanese (n=1) healthcare contexts. All of the studies analyzed healthcare costs from patients’ perspective over a short time horizon, limited to the length of hospital stay. The most commonly employed model type was discrete event simulation model (n=2). All four studies demonstrated cost-effectiveness of the new technologies vs. standard PN treatment. The mean CHEERS score for the studies was 15 (SD=4.30) and studies mostly failed to justify the choice of model and time horizon. No study reported cost per quality-adjusted life year. The present study demonstrated that only few studies assessed cost-effectiveness of PN in Asian countries. All of them showed that novel PN formulations were cost-effective in comparison to standard treatment. However, a longer time horizon and focus on subgroups with homogenous prognoses are required to provide sufficient evidence and direct PN to “all patients who need it, in a cost-effective manner”, as recommended by World Health Organization.

Total parenteral nutrition utilization in metastatic cancer patients: A nationwide 10-year analysis from 2006 to 2015.

e18693Background: TPN use in metastatic cancer patients is controversial. We aim to explore the characteristics, trend of utilization and outcome of TPN use in metastatic cancer patients. Methods: ...

9 INFECTIOUS AND THROMBOTIC RISKS OF PARENTERAL NUTRITION IN HOSPITALIZED PEDIATRIC IBD PATIENTS

Among hospitalized pediatric inflammatory bowel disease (IBD) patients, the decision to initiate parenteral nutrition (PN) involves balancing the nutritional benefits against the risks of infectious and thrombotic complications. However, the absolute risks of these complications remains unknown. We sought to 1) assess time trends in the use of PN among hospitalized pediatric patients with IBD and, 2) determine the rate of and risk factors for infectious and thrombotic complications. We performed a cross-sectional analysis of 1997–2012 data from the Healthcare Cost and Utilization Project Kids’ Inpatient Database (KID). We used ICD-9 diagnosis codes to identify pediatric patients (<18 years of age) with discharge diagnoses of Crohn’s disease (CD), ulcerative colitis (UC), PN, thrombus formation, and PN-associated infections (sepsis, septic arteritis, bacteremia, endocarditis, cellulitis). We used descriptive and bivariate statistics to evaluate PN utilization, complications, and risk factors. We then used multivariate logistic regression to evaluate the association between PN and infection/thrombotic complications, while adjusting for age, race, gender, disease type and surgical status. PN was utilized in 4,526 (11.1%) of 40,744 IBD hospitalizations. The proportion of hospitalizations requiring PN did not differ by CD vs UC or by calendar year. Overall, 8.7% of PN patients experienced an infectious complication and 1.5% experienced a thrombotic complication. In multivariate analysis, PN was an independent risk factor for infection (OR 2.9, 95% confidence interval (CI) 2.6–3.3) and thrombus (OR 4.0, 95% CI 2.9–5.6). Other factors associated with these complications are shown in Table 1. Hospitalized pediatric IBD patients receiving PN are at increased risk for infectious and thrombotic complications. Clinicians must balance these risks with the benefits of PN and consider alternatives such as enteral nutrition.

9 INFECTIOUS AND THROMBOTIC RISKS OF PARENTERAL NUTRITION IN HOSPITALIZED PEDIATRIC IBD PATIENTS

Among hospitalized pediatric inflammatory bowel disease (IBD) patients, the decision to initiate parenteral nutrition (PN) involves balancing the nutritional benefits against the risks of infectious and thrombotic complications. However, the absolute risks of these complications remains unknown. We sought to 1) assess time trends in the use of PN among hospitalized pediatric patients with IBD and, 2) determine the rate of and risk factors for infectious and thrombotic complications. We performed a cross-sectional analysis of 1997–2012 data from the Healthcare Cost and Utilization Project Kids’ Inpatient Database (KID). We used ICD-9 diagnosis codes to identify pediatric patients (<18 years of age) with discharge diagnoses of Crohn’s disease (CD), ulcerative colitis (UC), PN, thrombus formation, and PN-associated infections (sepsis, septic arteritis, bacteremia, endocarditis, cellulitis). We used descriptive and bivariate statistics to evaluate PN utilization, complications, and risk factors. We then used multivariate logistic regression to evaluate the association between PN and infection/thrombotic complications, while adjusting for age, race, gender, disease type and surgical status. PN was utilized in 4,526 (11.1%) of 40,744 IBD hospitalizations. The proportion of hospitalizations requiring PN did not differ by CD vs UC or by calendar year. Overall, 8.7% of PN patients experienced an infectious complication and 1.5% experienced a thrombotic complication. In multivariate analysis, PN was an independent risk factor for infection (OR 2.9, 95% confidence interval (CI) 2.6-3.3) and thrombus (OR 4.0, 95% CI 2.9-5.6). Other factors associated with these complications are shown in Table 1. Hospitalized pediatric IBD patients receiving PN are at increased risk for infectious and thrombotic complications. Clinicians must balance these risks with the benefits of PN and consider alternatives such as enteral nutrition.

Complications in neonatal surgery

Neonatal surgery is recognized as an independent discipline in general surgery, requiring the expertise of pediatric surgeons to optimize outcomes in infants with surgical conditions. Survival following neonatal surgery has improved dramatically in the past 60 years. Improvements in pediatric surgical outcomes are in part attributable to improved understanding of neonatal physiology, specialized pediatric anesthesia, neonatal critical care including sophisticated cardiopulmonary support, utilization of parenteral nutrition and adjustments in fluid management, refinement of surgical technique, and advances in surgical technology including minimally invasive options. Nevertheless, short and long-term complications following neonatal surgery continue to have profound and sometimes lasting effects on individual patients, families, and society.

Influencing the timing of parenteral nutrition initiation in the pediatric intensive care unit.

Background:Lack of benefit and potential harm of early parenteral nutrition (PN) initiation in critically ill children was highlighted in the 2016 published results of a large multicenter, randomized controlled trial.Objectives:The purpose of this project was to implement a process to delay PN initiation for up to five days after admission to our pediatric intensive care unit (PICU).Methods:Patients greater than thirty days of age, admitted to the PICU beginning July 1, 2016 were included in the analysis of the healthcare improvement initiative to decrease early PN initiation. A meeting was held with PICU fellows, attending physicians, dietitians, and pharmacists to reach a consensus to delay initiation of parenteral nutrition until PICU day five. The dietitian, with pharmacist support, reiterated recommendations on rounds and in formal notes.Results:A total of 2333 patients were identified in the pre-intervention group and a total of 2491 patients in the post-intervention group. The percentage of patients receiving PN prior to day five within the PICU was 5.5% in the pre-intervention group versus 3.1% in the delayed PN group (p<0.001). PICU patients receiving PN less than or equal to three days decreased from 2.6% pre-intervention to 1.5% post-intervention (p=0.01). For the subset of patients who were initiated on PN after admission to the PICU, median PICU length of stay was 7 days versus 6 days in the pre-intervention versus post-intervention group (p=0.26).Conclusions:Decrease in PN utilization was seen in the pre and post-intervention groups as assessed by percentage of patients initiated on PN prior to day five of PICU admission. Consensus among practitioners with consistent recommendations from the frontline dietitian and pharmacist, with nutrition support team collaboration, contributed to the evidence based quality initiative results. Delaying PN did not adversely affect length of stay pre versus post-intervention.

Parenteral Nutrition Utilization After Implementation of Multidisciplinary Nutrition Support Team Oversight: A Prospective Cohort Study.

Multidisciplinary nutrition teams can help guide the use of parenteral nutrition (PN), thereby reducing infectious risk, morbidity, and associated costs. Starting in 2007 at Harborview Medical Center, weekly multidisciplinary meetings were established to review all patients receiving PN. This study reports on observed changes in utilization from 2005-2010. All patients who received PN from 2005-2010 were followed prospectively. Clinical data and PN utilization data were recorded. Patients were grouped into cohorts based on exposure to weekly multidisciplinary nutrition team meetings (from 2005-2007 and from 2008-2010). Patients were also stratified by location, primary service, and ultimate disposition. In total, 794 patients were included. After initiation of multidisciplinary nutrition meetings, the rate of patients who started PN decreased by 27% (relative risk [RR], 0.73; 95% confidence interval [CI], 0.63-0.84). A reduction in the number of patients receiving PN was observed in both the intensive care unit (ICU) and on the acute care floor (RR, 0.64; 95% CI, 0.53-0.77 and RR, 0.80; 95% CI, 0.64-0.99, respectively). The rate of patients with short-duration PN use (PN duration of <5 days) declined by 30% in the ICU (RR, 0.70; 95% CI, 0.51-0.97) and by 27% on acute care floors (RR, 0.73; 95% CI, 0.51-1.03). Weekly multidisciplinary review of patients receiving PN was associated with reductions in the number of patients started on PN, total days that patients received PN, and number of patients who had short-duration (<5 days) PN use.

Variation in Practice and Resource Utilization Associated With the Diagnosis and Management of Appendicitis at Freestanding Children's Hospitals

To characterize the scope and magnitude of practice variation associated with the diagnosis and treatment of appendicitis at freestanding children's hospitals. Variation in care has been associated with poor outcomes and is believed to be a key driver of excess health care spending. Retrospective cohort study of 13,328 patients treated with appendicitis at 34 children's hospitals (9/2010-9/2011). Patients were divided into complicated and uncomplicated cohorts and examined for interhospital variation in the use of diagnostic imaging (computed tomography or ultrasonography), laboratory tests, parenteral nutrition (PN), peripherally inserted central catheters (PICC), and hospital cost. The number and distribution of statistical outliers were calculated for all measures. Significant variation was found for all measures, including a 3.5-fold difference in preoperative imaging (aggregate rate: 49.0%, range across hospitals: 21.2%-73.5%, P < 0.001) and a 5-fold difference in preoperative laboratory utilization (aggregate median: 2 tests/encounter, range: 1-5 tests/encounter, P < 0.001). For patients with complicated appendicitis, we characterized a 12-fold difference in postoperative imaging (aggregate rate: 19.4%, range: 4.9%-61.6%, P < 0.001), a 48-fold difference in PICC lines (aggregate rate: 18.9%, range: 1.7%-81.8%, P < 0.001), and a 100-fold difference in PN utilization (aggregate rate: 9.3%, range: 0.4%-42.0%, P < 0.001). Median hospital cost differed 4-fold for patients with uncomplicated disease (aggregate median: $6804, range: $4200-$16,796, P < 0.001) and 4.6-fold for patients with complicated disease (aggregate median: $13,138, range: $5419-$24,779, P < 0.001). Statistical outliers on the basis of high and low utilization were identified for all measures. Significant variation exists in practice, resource utilization, and treatment-related cost associated with the management of appendicitis at freestanding children's hospitals. Value-based measures are needed for benchmarking and to prioritize collaborative quality improvement efforts.

Parenteral Nutrition Utilization in Bone Marrow Transplant Recipients

Bone marrow transplant (BMT) recipients often require parenteral nutrition (PN) to meet their nutrient needs. While general guidelines for the provision of PN support by nutrition support teams (NSTs) have been shown to decrease inappropriate PN use, recommendations for nutrition in BMT recipients are lacking.

Effect of nutritional support team restructuring on the use of parenteral nutrition

Objective The inappropriate use of parenteral nutrition (PN) continues to be a problem, despite several decades of efforts to improve the situation. We restructured our existing nutritional support team employing methods involving the institution's systems and individual physician interaction and education. Our aim was to study the effects of these changes on the use of PN in our institution. Methods Records of all non-critically ill patients seen by our nutritional support team for PN during 2003–2004 (phase I, before restructuring) and 2005–2006 (phase II) were reviewed. Patients were classified under “appropriate,” “inappropriate,” and “marginal” categories based on published guidelines. During phase II, a new committee was formed, policies and procedures were updated, educational activities were increased, emphasis was placed on evidence-based guidelines, and periodic bedside rounds with the team physicians were initiated. Communication with referring physicians was improved. Results Three hundred three of 335 patients in phase I and 271 of 333 patients in phase II were eligible for inclusion in analysis. Appropriate PN increased from 71.3% to 83.4%; inappropriate PN decreased from 16.5% to 8.9% ( P = 0.002). Conclusion Restructuring of the nutritional support team improved the proper utilization of PN and decreased inappropriate use of PN in a public teaching hospital.

Adult Parenteral Nutrition Utilization at a Tertiary Care Hospital

Guidelines from the American Society for Parenteral and Enteral Nutrition promote appropriate use of parenteral nutrition (PN). In addition, involvement of multidisciplinary nutrition support teams (NSTs) has led to a reduction of inappropriate PN administration. This study evaluated the effect of introducing hospital-wide PN guidelines and a PN review committee on PN prescription behavior of NSTs in the authors' hospital. A PN guidelines form with established indications was developed and made available to the NSTs. A PN review committee was formed to assess the appropriateness of PN prescriptions and educate the NSTs if an inappropriate PN prescription was noted. The initial-phase PN prescriptions were compared with those in a later (established) phase. Of a total of 614 PN prescriptions, 8.1% did not meet the established indications. The initial phase recorded 312 PN prescriptions, and the established phase had 302 prescriptions. The number of inappropriate PN prescriptions decreased significantly from 11.9% in the initial phase to 4.3% in the established phase (P = .001). The incidence of inappropriate PN prescription was low when NSTs were closely involved in patient care. Availability of written guidelines and continuous oversight of NSTs promoted appropriate PN usage.

The Role of Dietitian Order-Writing Privileges in Improving Parenteral Nutrition Utilization in the Neonatal Intensive Care Unit

The Role of Dietitian Order-Writing Privileges in Improving Parenteral Nutrition Utilization in the Neonatal Intensive Care Unit

Utilization of Parenteral Nutrition Following Pancreaticoduodenectomy: Is Routine Jejunostomy Tube Placement Warranted?

Complications following pancreaticoduodenectomy (PD) often necessitate nutritional support. This study analyzes the utilization of parenteral nutrition (TPN) during the surgical admission as evidence for or against routine jejunostomy placement. The California Cancer Registry (1994-2003) was linked to the California Inpatient File; PD for adenocarcinoma was performed in 1,873 patients. TPN use and enterostomy tube placement were determined and preoperative characteristics predictive of TPN use during the surgical admission were identified. Fourteen percent of patients received TPN, 23% underwent enterostomy tube placement, and 63% received no supplemental nutritional support. TPN was associated with longer hospital stay (18 vs. 13 days, P < 0.0001). The Charlson Comorbidity Index (CCI) > or = 3 had nearly two-fold greater odds of receiving TPN (odds ratio [OR] = 1.85, P < 0.005). Approximately 1 in 6 patients undergoing PD received TPN, which was associated with prolonged hospital stay. CCI > or = 3 was associated with increased odds of TPN utilization. Selected jejunostomy placement in patients with high CCI is worthy of consideration.