Perioperative Total Parenteral Nutrition Research Articles

Peri-operative management of children with spinal muscular atrophy

Background and Aims:Current multi-disciplinary management of children with spinal muscular atrophy (SMA) often requires the surgical management of spinal deformities. We present the outcomes of our peri-operative experience around the time of their spinal surgery and share our neuromuscular perioperative protocol.Methods:A single-centre retrospective chart review was performed to evaluate all children with SMA types I and II that underwent thoracolumbar spinal deformity correction (posterior spinal fusion or growing rod insertion) from 1990 to 2015. Electronic medical records were reviewed to assess pre-operative, intraoperative, and postoperative variables. T-tests, Wilcoxon Rank Sum, Fisher's Exact tests were performed as appropriate.Results:Twelve SMA I and twenty-two SMA II patients were included. Type I patients tended to be smaller and had a higher percentage (36.4% vs 4.5%) of American Society of Anesthesiologists (ASA) class 4 patients. Preoperative total parenteral nutrition (TPN) was utilised in 75.0% of type I and 18.2% type II patients. A difficult intubation was experienced in around 25% of the patients (20.0% SMA I, 27.3% SMA II). Approximately two hours of anaesthetic time was required in addition to the actual surgical time in both types. The intensive care unit (ICU) length of stay averaged 6 (4.0-7.5) days for type I and 3 (3-5) days for type II (p = 0.144). Average post-operative length of stay was (8 (7-9) vs. 7 (6-8)) P = 1.0.Conclusion:Children with type I and II SMA have similar hospital courses. The surgical and anaesthesia team should consider perioperative TPN and NIPPV (non-invasive positive-pressure ventilation), anticipate difficult intubations, longer than usual anaesthetic times, and potentially longer ICU stays in both SMA type I and II.

Analysis of clinical effect of involvement of clinical pharmacists in perioperative total parenteral nutrition prescription for cancer patients

Objective To evaluate the effect of the intervention of involving clinical pharmacists in perioperative total parenteral nutrition (TPN) prescription, including rationality of prescriptions, the length of hospital stay and economic evaluation. Methods We respectively selected TPN prescriptions in September to November 2015 (pre-intervention) and December 2015 to February 2016 (post-intervention) from a surgery department of Harbin Medical University Cancer Hospital. The data regarding rationality of prescription, length of hospital stay, and economic benefit were analyzed in order to evaluate the effect of involvement of clinical pharmacists in TPN prescriptions. Results A total of 81 patients with 115 TPN prescriptions before the intervention and 92 patients with 124 TPN prescriptions after the intervention were recruited. Through comparative analysis, the rationality of TPN prescriptions increased significantly after the participation of clinical pharmacists in terms of the rational glucose: fat ratio, energy: nitrogen ratio, electrolyte concentration, and the choice of vitamin preparations; and the utilization of controversial treatments such as invert sugar and other drugs into ready-to-use TPN solution was decreased significantly; average daily cost of TPN was decreased from (1 021±218) yuan to (860±176) yuan (P 0.05). Compared with the data before the intervention, serum albumin levels after the intervention showed no statistically significant difference but pre-albumin levels were significantly higher after the participation of clinical pharmacists[(175.0±77.9)g/L vs.(153.2±64.8)g/L, P 0.05). Conclusion Engaging clinical pharmacists in TPN prescription can improve prescription rationality, ensure clinical drug safety, reduce the daily cost of nutrition treatment and thus reduce the economic burden of patients. Key words: Pharmacists; Parenteral nutrition; Inappropriate prescription; Intervention

The effects of perioperative total parenteral nutrition on postoperative mortality and morbidity

It is known that postoperative complication ratios at severely malnourished patients were higher than nonseverely malnourished patients according to the data in literature reviews. The goal of this prospective study is to investigate the effects of per ioperative nutritional support on postoperative morbidity and mortality in severely malnourished gastrointestinal tract cancer patients. Seventyone patients with the diagnosis of gastrointestinal tract cancer were included in this study. Subjective Global Assessment index was applied for patients' nutritional state. The patients were divided into two groups, severely malnourished (Group 1) and nonseverely malnourished (Group 2: well-nourished and mildly malnourished). The daily energy requirement of 36 patients in Group 1 was calculated and total parenteral nutrition was applied 30-35 kcal/kg/day by average for preoperative 7 days and postoperative 3 days to these 36 patients. Perioperative total parenteral nutrition was not given to 35 patients in Group 2. Patient morbidity and mortality was followed during the hospitalization period. Total morbidity was defined as; major complications, minor complications and complications related to total parenteral nutrition. Major complications occurred in 7 patients (19.41%) in Group 1 and 6 patients (17.11%) in Group 2 (p=0.80). Total morbidity was in 16 patients (44.40%) in Group 1, and 17 patients (48.57%) in Group 2 (p=0.727). Mortality was seen as one patients in each group postoperatively. In this study, it was concluded that morbidity and mortality ratio of severely malnourished patients can be decreased to the morbidity and mortality ratio of nonseverely malnourished patients with perioperative nutrition.

Effect of Preoperative Nutritional Deficiency on Mortality After Radical Cystectomy for Bladder Cancer

Poor preoperative nutritional status is a risk factor for adverse outcomes after major surgery. We evaluated the effect of preoperative nutritional deficiency on perioperative mortality and overall survival in patients undergoing radical cystectomy for bladder cancer. A total of 538 patients underwent radical cystectomy for urothelial carcinoma between January 2000 and June 2008, and had nutritional parameters documented. Patients with preoperative albumin less than 3.5 gm/dl, body mass index less than 18.5 kg/m(2) or preoperative weight loss greater than 5% of body weight were considered to have nutritional deficiency. Primary outcomes were 90-day mortality and overall survival. Survival was estimated using Kaplan-Meier analysis and compared using the log rank test. Cox proportional hazards models were used for multivariate survival analysis. Of 538 patients 103 (19%) met the criteria for nutritional deficiency. The 90-day mortality rate was 7.3% overall (39 deaths), with 16.5% in patients with nutritional deficiency and 5.1% in the others (p < 0.01). Nutritional deficiency was a strong predictor of death within 90 days on multivariate analysis (HR 2.91; 95% CI 1.36, 6.23; p < 0.01). Overall survival at 3 years was 44.5% (33.5, 54.9) for nutritionally deficient patients and 67.6% (62.4, 72.2) for those who were nutritionally normal (p < 0.01). On multivariate analysis nutritional deficiency cases had a significantly higher risk of all cause mortality (HR 1.82; 95% CI 1.25, 2.65; p < 0.01). Nutritional deficiency, as measured by preoperative weight loss, body mass index and serum albumin, is a strong predictor of 90-day mortality and poor overall survival. Prospective studies are needed to demonstrate the best indices of preoperative nutritional status and whether nutritional intervention can alter the poor prognosis for patients treated with radical cystectomy who have nutritional deficiencies.

Effects of perioperative total parenteral nutrition support on cyclin D1 expression, recurrence and metastasis of colorectal cancer cells

To evaluate the effects of perioperative total parenteral nutrition on cyclin D1, recurrence and metastasis of colorectal cancer cells. A total of 120 patients with colorectal carcinoma were randomly divided into two groups, namely group A(total parenteral nutrition, TPN,60 cases) and group B(non total parenteral nutrition, NTPN, 60 cases). In group A, the patients were given with TPN(including glucose, intralipid, amino acid, and vitamins, etc.) for 10 days perioperation (7 days preoperatively and 3 days postoperatively). In group B, the patients did not receive any nutrition support perioperative nutrition support. The samples were obtained by colonoscopy preoperatively or during operation. Apoptosis was detected by terminal deoxynucleotidyl transferase-mediated nick end labeling (TUNEL) technique,expression of proliferating cell nuclear antigen (PCNA) by immunohistochemical staining, and the expression of cyclin D1 by in situ hybridization. The apoptotic index (AI), the proliferating index (PI), and the expression of cyclin D1 were calculated perioperatively and postoperatively. After perioperative nutrition support, the expression rates of cyclin D1, PI and AI in group A and group B were (35.23+/-5.12)% and (37.53+/-5.31)%, (7.21+/-2.56)% and (8.75+/-3.84)%, (53.45+/-7.74)% and (56.74+/-8.02)% respectively. There were no significant difference of PI, AI and the expression of cyclin D1(all P>0.05) between two groups. The 3-year recurrent rates in two groups were 16.7% and 15.0%( P>0.05). Perioperative TPN can not promote proliferation and apoptosis of carcinoma cells, and has no significant impact on the expression of cyclin D1, recurrence or metastasis of colorectal cancer.

Nutrition support to patients undergoing gastrointestinal surgery.

Nutritional depletion has been demonstrated to be a major determinant of the development of post-operative complications. Gastrointestinal surgery patients are at risk of nutritional depletion from inadequate nutritional intake, surgical stress and the subsequent increase in metabolic rate.Fears of postoperative ileus and the integrity of the newly constructed anastomosis have led to treatment typically entailing starvation with administration of intravenous fluids until the passage of flatus. However, it has since been shown that prompt postoperative enteral feeding is both effective and well tolerated. Enteral feeding is also associated with specific clinical benefits such as reduced incidence of postoperative infectious complications and an improved wound healing response. Further research is required to determine whether enteral nutrition is also associated with modulation of gut function.Studies have indicated that significant reductions in morbidity and mortality associated with perioperative Total Parenteral Nutrition (TPN) are limited to severely malnourished patients with gastrointestinal malignancy. Meta-analyses have shown that enteral nutrition is associated with fewer septic complications compared with parenteral feeding, reduced costs and a shorter hospital stay, so should be the preferred option whenever possible.Evidence to support pre-operative nutrition support is limited, but suggests that if malnourished individuals are adequately fed for at least 7–10 days preoperatively then surgical outcome can be improved.Ongoing research continues to explore the potential benefits of the action of glutamine on the gut and immune system for gastrointestinal surgery patients. To date it has been demonstrated that glutamine-enriched parenteral nutrition results in reduced length of stay and reduced costs in elective abdominal surgery patients. Further research is required to determine whether the routine supplementation of glutamine is warranted.A limitation for targeted nutritional support is the lack of a standardised, validated definition of nutritional depletion. This would enable nutrition support to be more readily targeted to those surgical patients most likely to derive significant clinical benefit in terms of improved post-operative outcome.

Anastomotic leak in colorectal surgery: a single surgeon's experience.

Anastomotic leakage following colorectal resection and anastomosis has been proposed as a colorectal surgical indicator. Leak rates after elective surgery vary and tend to be higher as anastomoses become lower. The present study audits leak rates and outcomes of patients undergoing colorectal surgery, under the care of a single surgeon, in two geographically different centres. Patients presenting to the University Colorectal Service in Wellington between 1975 and 1990 and patients presenting to the colorectal service at King Faisal Specialist Hospital (KFSH) between 1990 and 1999 were recorded in computerized databases. These databases were searched for patients who developed anastomotic leakage. The records of patients identified were examined in relation to diagnoses, presentation, primary operation, further surgery performed, and final outcome. Two thousand and 11 patients were entered into the Wellington database and 1,348 were entered into the Riyadh database. Twenty-nine patients with a leaking anastomosis (3.6%) were identified. There were 19 male patients. The postoperative mortality rate in patients who did not leak was 1.7% but in patients who developed a leak after the same operation this rate was 24.1%. Most patients who sustained a leak had an original diagnosis of colorectal cancer. More non-leaking anastomoses were sutured. Sixteen patients with leaks (55.2%) received perioperative total parenteral nutrition (TPN) (9.2% in the no-leak group). Leaking anastomoses were associated with more postoperative respiratory problems (55.2% vs 24.0%) and wound infections (65.5% vs 14.8%). Of the 22 living patients, seven had no surgical intervention, 14 had stomata (two stomata were retained) and one patient with a localized leak was drained percutaneously. Five other patients in addition to having a stoma constructed were drained percutaneously. No patient developed an enteric fistula following leakage. Anastomotic leakage may be minimized by ensuring that patients are as fit as possible prior to surgery, stomata are used liberally, particularly in emergency patients, and a good anastomotic technique is utilized at all times. Despite these precautions some patients will still develop a leak and if timely and appropriate action is taken the majority will survive and have their stomata closed.

Nutritional support of the cancer patient.

Malnutrition, a common problem in cancer patients, adversely affects survival and quality of life. It results from several factors that alter nutritional intake and cause massive metabolic disturbances. Anticancer therapies may compound the malnutrition. Optimal nutrition improves therapeutic modalities and the clinical course and outcome. Oral nutrition should be used whenever possible; in patients unable to ingest adequate amounts orally, enteral and parenteral feedings are safe and effective.

The management of colorectal perforation and peritonitis.

Surgical outcomes in patients presenting with colonic perforation or peritonitis tend to be poor. This study was undertaken to determine outcomes in such patients at a time before multiple re-laparotomies were performed. Retrospective analysis of computer records of all patients presenting acutely to the University Surgical Unit (Wellington School of Medicine) with colonic perforation or peritonitis over a 15-year period. Seventy-three patients, 33 males and 40 females were admitted with either perforation or localized peritonitis of colorectal origin. Of these, 78% were managed as emergencies, but six were admitted electively and found incidentally. Consultant surgeons performed surgery slightly more frequently than registrars. Two patients were managed non-operatively. Forty-one per cent received peri-operative blood transfusion and 22% peri-operative total parenteral nutrition. The majority of patients presented with either peritonitis or free perforation in association with diverticular disease. The site of perforation was either ileocolic or sigmoid colonic in the majority of patients. Hartmann's operation was the most commonly performed resection. Respiratory, urinary and wound infections were the most commonly observed postoperative complications. Two patients developed anastomotic leaks (6.3%). The overall persistent intra-abdominal infection rate was 5.5%. Seven patients died following surgery. Resection of the perforated bowel is mandatory and this should be followed by anastomoses in the case of right-sided lesions and a Hartmann's operation or resection, colostomy and mucous fistula in distally situated lesions.

Effect of parenteral l-glutamine on muscle in the very severely Ill

Glutamine (Gln)-supplemented perioperative total parenteral nutrition (TPN) has been reported to reduce the loss of intramuscular glutamine following routine surgery. This study investigates whether glutamine-supplemented TPN can alter muscle biochemistry acutely in the very severely ill patient. Thirty-eight patients (age 19–77 yr; mean 55 yr), critically ill (APACHE II range 8–31; median 17) admitted to the intensive care unit (ICU) were recruited to receive either conventional TPN (CTPN) or an isonitrogenous, isoenergetic feed supplemented with 25 g crystalline l-glutamine per 24 h (GTPN) in a prospective, double blind, block-randomized study. In a representative sample of these patients, relatives consented to a paired muscle biopsy taken before feeding (10 GTPN/9 CTPN patients; ICU Day 2–4) and repeated 5 days later (16 patients; ICU Day 7–9). Muscle biopsies and matching plasma samples were analyzed using a coupled glutaminase-glutamate dehydrogenase enzymatic assay. A correction was made using sodium to account for the massive changes in extracellular fluid volume. The average muscle Gln content before feeding was very low. Between biopsies no consistent pattern of change was seen with or without exogenous Gln. It also proved difficult in these very sick patients to correct a low plasma Gln with l-Gln-TPN during the initial phase of the severe illness. TPN supplementation with 25 g/24 h, l-glutamine appears inadequate in the acute period to counteract the muscle and plasma biochemical changes seen in these patients. It is unknown whether any larger dose could alter this state.

Comparison of eligible randomized patients with two groups of ineligible patients: Can the results of the VA total parenteral nutrition clinical trial be generalized?

The recently reported VA Cooperative Study “A Randomized Clinical Trial of Total Parenteral Nutrition (TPN) in Malnourished Surgical Patients” randomized 395 pre-operative patients to TPN treatment or control. The study concluded that the use of perioperative TPN should be limited to the most severely malnourished patients. The study also followed 233 patients eligible for the study who refused to give informed consent for randomization (Eligible Refusers) as well as 1220 patients who were ineligible because they were not sufficiently malnourished (Index Group). Patients in the Index Group were determined to be significantly healthier than those in the two eligible groups of patients. Those in the Eligible Refuser group were shown to be slightly less malnourished than the Randomized Patients. The 395 patients randomized to the study (Randomized Patients) showed the highest rate of septic complications at 30 days and at 90 days (10% and 13% respectively) with rates for the Eligible Refusers slightly lower (8% and 9%) and Index Group rates still lower (4% and 4%). Nonseptic complication rates showed the same pattern (19% and 22% for the Randomized group, 12% and 12% for Eligible Refusers, and 10% and 10% for the Index Group). Because (a) the beneficial effect of TPN is attained only in severely malnourished patients, (b) there is increased risk of septic complications with TPN use in patients not severely malnourished, (c) Index Group patients, and presumably the population of patients from which they are drawn, are not severely malnourished, it follows that unless specifically indicated, TPN should not be used in nonseverely malnourished patients.

Total parenteral nutrition, intestinal translocation, and host immune function

Perioperative total parenteral nutrition (TPN) in surgical patients results in increased infectious complications compared with enteral nutrition support. The underlying mechanisms are unclear but do not appear due to energy deficiency. This study evaluated the effects of TPN on splenocyte and peritoneal macrophage (PM~) functions. Male Wistar rats (n = 26) underwent central vein cannulation and were randomized to receive isocaloric feeding of regular chow diet (RD) plus saline infusion or TPN for 7 days. Splenocytes and PMr were harvested to assess concanavalin A (con A) mitogenesis and superoxide production (-O2), Candida albicans phagocytosis (CAP), and nitric oxide (N:O) release after stimulation with LPS. Bacteria-positive mesenteric lymph nodes (MLN) were found in 77% (10 of 13) of TPN-fed rats compared with 17% (2 of 12) of RD-fed rats (p <0.01, Table I).

Perioperative Total Parenteral Nutrition in Surgical Patients

Survey of Anesthesiology is an authoritative source of information on advances in the science and practice of anesthesiology as reported throughout the world literature. Every bimonthly issue contains 50 or more condensed articles selected by the journal’s distinguished Editorial Board from more than 100 international periodicals. Each condensed article carries a critique by a reviewing editor to provide an expert perspective on the material presented.

Perioperative Total Parenteral Nutrition in Surgical Patients

Perioperative Total Parenteral Nutrition in Surgical Patients

Total parenteral nutrition did not reduce major complications of nonemergent major abdominal or thoracic surgery in malnourished patients

TherapeuticsJanuary 1, 1992Total parenteral nutrition did not reduce major complications of nonemergent major abdominal or thoracic surgery in malnourished patientsPatrick L. Ergina, MD, MPHPatrick L. Ergina, MD, MPHMcGill University, Montreal, Quebec, Canada (P.L.E.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/ACPJC-1992-116-1-011 SectionsAboutFull Text ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookTwitterLinkedInRedditEmail Source CitationThe Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. Perioperative total parenteral nutrition in surgical patients. N Engl J Med. 1991 Aug 22;325:525-32. Author, Article, and Disclosure InformationAffiliations: McGill University, Montreal, Quebec, Canada (P.L.E.) PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails January 1, 1992Volume 116, Issue 1Page: 11KeywordsAbdominal surgeryAmino acidsFistulasGlucoseLaparotomyLipidsMalnutritionNutritionPneumoniaSurgeryThoracic surgeryThoracotomy ePublished: 9 March 2020 Issue Published: January 1, 1992 Copyright & PermissionsCopyright © 1992 by American College of Physicians. All Rights Reserved.Loading ...

Perioperative Total Parenteral Nutrition in Surgical Patients

We undertook this study to test the hypothesis that perioperative total parenteral nutrition (TPN) decreases the incidence of serious complications after major abdominal or thoracic surgical procedures in malnourished patients. We studied 395 malnourished patients (99 percent of them male) who required laparotomy or noncardiac thoracotomy. They were randomly assigned to receive either TPN for 7 to 15 days before surgery and 3 days afterward (the TPN group) or no perioperative TPN (the control group). The patients were monitored for complications for 90 days after surgery. The rates of major complications during the first 30 days after surgery in the two groups were similar (TPN group, 25.5 percent; control group, 24.6 percent), as were the overall 90-day mortality rates (13.4 percent and 10.5 percent, respectively). There were more infectious complications in the TPN group than in the controls (14.1 vs. 6.4 percent; P = 0.01; relative risk, 2.20; 95 percent confidence interval, 1.19 to 4.05), but slightly more noninfectious complications in the control group (16.7 vs. 22.2 percent; P = 0.20; relative risk, 0.75; 95 percent confidence interval, 0.50 to 1.13). The increased rate of infections was confined to patients categorized as either borderline or mildly malnourished, according to Subjective Global Assessment or an objective nutritional assessment, and these patients had no demonstrable benefit from TPN. In contrast, severely malnourished patients who received TPN had fewer noninfectious complications than controls (5 vs. 43 percent; P = 0.03; relative risk, 0.12; 95 percent confidence interval, 0.02 to 0.91), with no concomitant increase in infectious complications. The use of preoperative TPN should be limited to patients who are severely malnourished unless there are other specific indications.

Operative and perioperative treatment of patients with inflammatory bowel disease

The ileal–anal pouch continues to be the most significant advance in the operative treatment of patients with ulcerative colitis during the past decade. Reports no longer question the efficacy of this innovative operation and now focus on improvements in operative technique and postoperative management. The goal of operative management of patients with Crohn's disease continues to be a conservative one. Recent evidence demonstrates that histologic recurrence of disease at the anastomosis occurs very soon after resection. Transplantation of the small intestine is an operative treatment on the horizon for patients with short-bowel syndrome due to conditions such as Crohn's disease. Advances continue in perioperative nutritional-metabolic management of patients with inflammatory bowel disease. Use of perioperative total parenteral nutrition is becoming more restrictive in patients with ulcerative colitis. Because of its significant enterotrophic effect, reduced cost, and comparable outcome benefit when compared with total parenteral nutrition, perioperative enteral nutrition is being prescribed more frequently. Observations in experimental models of enterocolitis have demonstrated enhancement of gut growth and function due to the provision of intestinal nutrients such as glutamine for the small intestine and short-chain fatty acids for the colon.

Study protocol: a randomized clinical trial of total parenteral nutrition in malnourished surgical patients

CSP #221 is a randomized multiinstitutional clinical trial to assess the efficacy of 10 d of perioperative total parenteral nutrition (TPN) in reducing morbidity and mortality in malnourished patients undergoing intraperitoneal and/or intrathoracic operations. In this paper a detailed protocol for the clinical efficacy trial is presented primarily as a reference document for use in interpretation of the results of the clinical trial. It is also anticipated, however, that review of this protocol may be useful to other investigators planning future clinical nutrition intervention trials.

Measuring the economic impact of perioperative total parenteral nutrition: principles and design

Although the use of total parenteral nutrition (TPN) has been increasing in recent years, few studies have been performed on both its costs and its effectiveness or benefits. This paper provides a general review of the methods of cost-effectiveness and cost-benefit analysis, summarizes briefly the existing cost-analysis studies of TPN, and outlines the authors' proposed study design for their economic assessment of TPN.

Perioperative total parenteral nutrition in patients with gastrointestinal cancer

Forty-one male surgical patients with gastrointestinal cancer were randomized into three groups on the basis of preoperative weight loss: Group I (20 patients)—mean age 64.1 ± 11.0 years, less than 10-lb weight loss, no TPN; Group II (9 patients)—mean age 65.8 ± 12.0 greater than 10 pound weight loss, no TPN; Group III (12 patients)—mean age 63.7 ± 10.7 years, greater than 10-lb weight loss, TPN. Group III received greater than 2000 cc of D25/4.25% Travasol for at least 5 days preoperatively and 8 days postoperatively. Major postoperative complications included abscess, anastomotic leak, or wound infection. Results: Preoperative immunocompetence was no different between any group ( P > 0.05). Postoperative weight loss was significantly greater in Group I than in Group III ( P < 0.01) and Group II than in Group III ( P < 0.01). Postoperative changes in serum albumin were not significant between any of the groups ( P > 0.05). Rate of major complications was not significantly different between any of the groups ( P > 0.05). Mortality was 10% in Group I, 0% in Group II, and 0% in Group III. Conclusion: An 18-day duration of perioperative TPN in comparable randomized patients based on preoperative weight loss does not alter the rate of major postoperative complications or mortality, but allows patients to maintain weight.