Standard Parenteral Nutrition Research Articles

Pharmacoeconomics of Parenteral Nutrition with ω-3 Fatty Acids in Hospitalized Adults.

The inclusion of ω-3 fatty acids as part of parenteral nutrition is associated with clinical benefits such as a reduced likelihood of infectious complications and shorter hospital and intensive care unit (ICU) stays. As healthcare resources are limited, pharmacoeconomic analyses have been performed, typically modeling studies, using cost and outcomes data to investigate the cost-effectiveness of parenteral nutrition regimens including ω-3 fatty acids from fish oil compared with standard parenteral nutrition without such ω-3 fatty acids. This review covers pharmacoeconomic studies encompassing Italian, French, German, and UK hospitals for ICU and non-ICU hospitalized patients, and for ICU patients in China. The results show that the use of parenteral nutrition including ω-3 fatty acids more than offsets any additional acquisition costs in all national scenarios investigated to date, indicating that parenteral nutrition including ω-3 fatty acids is a clinically and economically beneficial strategy compared with standard parenteral nutrition.

Can we meet patients’ energy and nitrogen requirements with standard peripheral parenteral nutrition bags?

Can we meet patients’ energy and nitrogen requirements with standard peripheral parenteral nutrition bags?

Neonates treated with individualized parenteral nutrition who are candidates to receive standardized parenteral nutrition

Objetive: to quantify the number of neonates treated with individualized parenteral nutrition (IPN) who were candidates to receive standardized parenteral nutrition (SPN), and to calculate their treatment duration. Material and methods: this was a prospective, observational, descriptive cohort study. Inclusion criteria were: neonates with indication of parenteral nutrition (PN) and individualized prescription. Exclusion criteria included: patients who had not started diuresis, with specific nutritional needs, altered acid-base balance, and/or contraindication to receive SPN. Included variables were patient-related (gender, weight, weeks of gestation, and days of life) and treatment-related regarding IPN composition. Setting the volume of PN as the conversion criterion, theoretical contributions were calculated with the SPN. The criterion for a patient to be a candidate to receive SPN was that all the theoretical contributions calculated were within the reference requirements range. Results: a total of 33 neonates (9 women) received IPN with 94 prescriptions. The median weight of the patients included in the study was 2.14 (IQR, 0.9) kg, and they were born at 35 (IQR, 3) weeks of gestation. PN began between 0 and 4 days of life. In all, 71 % (22/31) of the patients in 54.1 % of their (46/85) prescriptions were candidates to receive SPN via central administration for 1 to 8 days, whereas no patient was candidate to receive SPN via peripheral administration. Conclusions: in our center, 71 % of neonates treated with central administration of IPN are candidates to receive SPN, thus promoting the normalization of nutritional support in this population.

Clinical conditions and complications associated with parenteral nutrition use in critically ill patients admitted to an intensive care unit of a general hospital.

Objective: the aim of this study was to evaluate the clinical conditions, the existing complications, and the drug prescription profile of patients who received parenteral nutrition in the intensive care unit. Material and methods: this retrospective, analytical cohort study was carried out among individuals admitted to a public general hospital ICU. For data collection, the electronic medical records for the entire period of inpatient treatment were analyzed. Results: in total, 213 individuals who had received parenteral nutrition for a period greater than 48 hours were included in the study. Most participants were male and mean age was < 60 years; death occurred in 75 % of patients, and abdominal surgery was the main indication for parenteral nutrition. Hyperglycemia was the most common complication. The Mann-Whitney test showed that the individuals who died were using a higher number of medications. The increased use of medications correlated with use of PN and led to an increase in hospital length of stay and death rate (p-value < 0.001). There was a higher proportion of deaths among patients using standard parenteral nutrition solutions (76.9 %) as compared to the period when patients started receiving custom-made parenteral nutrition solutions (71.7 %). However, there was no statistical evidence of the association between type of nutrition and the outcome of death (p-value = 0.395). Conclusions: custom-made parenteral nutrition may result in benefits for the patients, such as a decrease in the number of medications used. The relationship between type of nutrition and the outcome of death did not prove to be statistically significant.

Adipose tissue protects against sepsis-induced muscle weakness in mice: from lipolysis to ketones

BackgroundICU-acquired weakness is a debilitating consequence of prolonged critical illness that is associated with poor outcome. Recently, premorbid obesity has been shown to protect against such illness-induced muscle wasting and weakness. Here, we hypothesized that this protection was due to increased lipid and ketone availability.MethodsIn a centrally catheterized, fluid-resuscitated, antibiotic-treated mouse model of prolonged sepsis, we compared markers of lipolysis and fatty acid oxidation in lean and obese septic mice (n = 117). Next, we compared markers of muscle wasting and weakness in septic obese wild-type and adipose tissue-specific ATGL knockout (AAKO) mice (n = 73), in lean septic mice receiving either intravenous infusion of lipids or standard parenteral nutrition (PN) (n = 70), and in lean septic mice receiving standard PN supplemented with either the ketone body 3-hydroxybutyrate or isocaloric glucose (n = 49).ResultsObese septic mice had more pronounced lipolysis (p ≤ 0.05), peripheral fatty acid oxidation (p ≤ 0.05), and ketogenesis (p ≤ 0.05) than lean mice. Blocking lipolysis in obese septic mice caused severely reduced muscle mass (32% loss vs. 15% in wild-type, p < 0.001) and specific maximal muscle force (59% loss vs. 0% in wild-type; p < 0.001). In contrast, intravenous infusion of lipids in lean septic mice maintained specific maximal muscle force up to healthy control levels (p = 0.6), whereas this was reduced with 28% in septic mice receiving standard PN (p = 0.006). Muscle mass was evenly reduced with 29% in both lean septic groups (p < 0.001). Lipid administration enhanced fatty acid oxidation (p ≤ 0.05) and ketogenesis (p < 0.001), but caused unfavorable liver steatosis (p = 0.01) and a deranged lipid profile (p ≤ 0.01). Supplementation of standard PN with 3-hydroxybutyrate also attenuated specific maximal muscle force up to healthy control levels (p = 0.1), but loss of muscle mass could not be prevented (25% loss in both septic groups; p < 0.001). Importantly, this intervention improved muscle regeneration markers (p ≤ 0.05) without the unfavorable side effects seen with lipid infusion.ConclusionsObesity-induced muscle protection during sepsis is partly mediated by elevated mobilization and metabolism of endogenous fatty acids. Furthermore, increased availability of ketone bodies, either through ketogenesis or through parenteral infusion, appears to protect against sepsis-induced muscle weakness also in the lean.

250.6: Results of a Multicentric Retrolective Study of Teduglutide Treatment in Benign Short Bowel Syndrome in Germany

Introduction: Teduglutide (TED) is a medical treatment for intestinal functional rehabilitation of short bowel syndrome (SBS) patients with chronic intestinal failure (cIF). Its application and effectivity is routinely monitored in a structured home care service program by a multicentric approach in Germany. From these prospectively documented data, a retrolective data base was generated in order to study treatment characteristics and outcome parameters in a clinical routine setting of TED-treated cIF-patients. Methods: For the present interim analysis, prospectively collected clinical data until December 2018 were retrolectively analyzed. Statistical analyses were performed with SPSS using repeated measures ANOVA and Friedman-Test with subsequent Bonferroni-adjusted post-hoc analyses for TED treatment characteristics up to one year. Results: So far, 29 patients (f:17 / m:12, median age 52 years) were included in this interim analysis. Causes of SBS included vascular (n=12) and inflammatory diseases (n=6), ileus (n=4), injury (n=4) and others (n=3). Median time on parenteral support (PS) before TED was 30 months. At TED start, 72% of patients (21/29) received individually compounded parenteral nutrition (PN); the remaining 28% received standardized PN. PS was administered by patients themselves (n=15), by relatives (n=3), by nurses (n=8) or others (n=3). TED treatment resulted in a significant reduction in PN calories and volume requirements as well as reduced infusion days per week and shortened infusion times (see Table 1). The reduction of infusion time was positively correlated with the reduction of PN volume (p<0.001; r=0.75) and calories (p=0.003; r=0.59) after one year of TED treatment. After one year, 22 of 29 (76%) patients were considered responders to TED treatment (with a minimum of 20% i.v.-volume reduction). Conclusion: In this multicentric real-world analysis of severely PS-dependent SBS/cIF-patients, TED displays effectivity with regards to improvement of intestinal absorptive function as indicated by significantly reduced weekly i.v.-volume and calorie requirements. In addition, the findings demonstrate a reduction of effective infusion days and times, which both importantly affect patients’ wellbeing. These data indicate the effectivity of TED treatment in a national routine treatment setting in concordance with clinical trial data and guideline recommendations.

ω‐3 Fatty‐Acid Enriched Parenteral Nutrition in Hospitalized Patients: Systematic Review With Meta‐Analysis and Trial Sequential Analysis

This systematic review and meta‐analysis investigated ω‐3 fatty‐acid enriched parenteral nutrition (PN) vs standard (non‐ω‐3 fatty‐acid enriched) PN in adult hospitalized patients (PROSPERO 2018 CRD42018110179). We included 49 randomized controlled trials (RCTs) with intervention and control groups given ω‐3 fatty acids and standard lipid emulsions, respectively, as part of PN covering ≥70% energy provision. The relative risk (RR) of infection (primary outcome; 24 RCTs) was 40% lower with ω‐3 fatty‐acid enriched PN than standard PN (RR 0.60, 95% confidence interval [CI] 0.49‐0.72; P < 0.00001). Patients given ω‐3 fatty‐acid enriched PN had reduced mean length of intensive care unit (ICU) stay (10 RCTs; 1.95 days, 95% CI 0.42‐3.49; P = 0.01) and reduced length of hospital stay (26 RCTs; 2.14 days, 95% CI 1.36‐2.93; P < 0.00001). Risk of sepsis (9 RCTs) was reduced by 56% in those given ω‐3 fatty‐acid enriched PN (RR 0.44, 95% CI 0.28‐0.70; P = 0.0004). Mortality rate (co‐primary outcome; 20 RCTs) showed a nonsignificant 16% reduction (RR 0.84, 95% CI 0.65‐1.07; P = 0.15) for the ω‐3 fatty‐acid enriched group. In summary, ω‐3 fatty‐acid enriched PN is beneficial, reducing risk of infection and sepsis by 40% and 56%, respectively, and length of both ICU and hospital stay by about 2 days. Provision of ω‐3‐enriched lipid emulsions should be preferred over standard lipid emulsions in patients with an indication for PN.

OR20-6 Ketones and Sepsis-Induced Muscle Weakness: Signal or Fuel for Protection?

Background: Septic patients often develop muscle weakness, contributing to ICU morbidity and mortality. We recently observed that obese septic mice and patients do not develop such weakness, explained by increased lipolysis and hepatic conversion of fatty acids into the ketone bodies. Furthermore, in lean septic mice, supplementing nutrition with 3-hydroxybutyrate (3HB) reproduced the protection against muscle weakness seen with obesity. The aim of the current study was to investigate underlying mechanisms of the 3HB-protection. Methods: We performed a mouse study (n=49) in a centrally-catheterized fluid-resuscitated model of prolonged (5 days) abdominal sepsis (cecal ligation and puncture). Lean septic mice received standard parenteral nutrition (PN) supplemented with either D,L-3HB (5 mg/kg/day) or isocaloric glucose (gluc). Healthy pair-fed mice served as controls. The use of 3HB as energy substrate in the muscle was assessed by quantifiying protein, triglyceride and glycogen content and markers of muscle ketolysis, proteolysis and fatty acid oxidation (FAO). Signaling function of 3HB was assessed by markers of muscle autophagy activation, inflammation and regeneration. Results: Although 3HB infusion abated sepsis-induced upregulation of ubiquitin-proteasome system marker Fxbo32 (p=0.002), loss of muscle mass was not prevented (p=0.8). Sepsis reduced triglyceride content (p≤0.01) equally in PN+gluc and PN+3HB mice (p=0.9), but did not affect markers of muscle FAO (Cd36, Cpt1b, Acadl, Hadha mRNA) in PN+gluc and PN+3HB mice (p≥0.2). Muscle glycogen content was unaltered by sepsis (p=0.1), and the illness-induced decrease in plasma glucose concentrations at day 5 (p≤0.004) was similar in PN+gluc and PN+3HB mice (p=1). Gene expression of the ketolysis enzyme Oxct1 was lower in PN+3HB compared to PN+gluc septic mice and healthy controls (p≤0.05). Also, ketone body transporter Mct1 mRNA was elevated by sepsis (p≤0.01) but attenuated by 3HB (p=0.05) compared to glucose. Sepsis-induced elevation of inflammation markers (Tnfα, IL-1β, Nlrp3 mRNA levels; p≥0.4) and autophagy (Atg5, Atg7 mRNA; p≥0.4; LC3 II/I, p-ULK1/ULK1 protein; p≥0.4) were not countered by 3HB infusion compared to glucose. However, PN+3HB septic mice did show enhanced markers of muscle regeneration (Myod1, Myf5 and Myog mRNA; p≤0.04) compared to PN+gluc septic mice and healthy controls. Also, sepsis-induced elevation of expression of Hdac4, an inhibitor of myoblast differentiation stimulator Mef2c, was reduced by 3HB (p=0.03) and resulted in increased Mef2c mRNA levels (p=0.01) compared to glucose. Conclusion: In conclusion, the observed protection against sepsis-induced muscle weakness with 3HB infusion coincided with enhanced markers of muscle regeneration, but not with changes in substrate handling. Supplemented 3HB during sepsis thus acted as a signaling molecule rather than as an energy source.

Role of heat shock protein and cytokine expression as markers of clinical outcomes with glutamine-supplemented parenteral nutrition in surgical ICU patients

Nutrients, such as glutamine (GLN), have been shown to effect levels of a family of protective proteins termed heat shock proteins (HSPs) in experimental and clinical critical illness. HSPs are believed to serve as extracellular inflammatory messengers and intracellular cytoprotective molecules. Extracellular HSP70 (eHSP70) has been termed a chaperokine due to ability to modulate the immune response. Altered levels of eHSP70 are associated with various disease states. Larger clinical trial data on GLN effect on eHSP expression and eHSP70's association with inflammatory mediators and clinical outcomes in critical illness are limited. Explore effect of longitudinal change in serum eHSP70, eHSP27 and inflammatory cytokine levels on clinical outcomes such as pneumonia and mortality in adult surgical intensive care unit (SICU) patients. Further, evaluate effect of parenteral nutrition (PN) supplemented with GLN (GLN-PN) versus GLN-free, standard PN (STD-PN) on serum eHSP70 and eHSP27 concentrations. Secondary observational analysis of a multicenter clinical trial in 150 adults after cardiac, vascular, or gastrointestinal surgery requiring PN support and SICU care conducted at five academic medical centers. Patients received isocaloric, isonitrogenous PN, with or without GLN dipeptide. Serum eHSP70 and eHSP27, interleukin-6 (IL-6), and 8 (IL-8) concentrations were analyzed in patient serum at baseline (prior to study PN) and over 28 days of follow up. eHSP70 declined over time in survivors during 28 days follow-up, but non-survivors had significantly higher eHSP70 concentrations compared to survivors. In patients developing pneumonia, eHSP70, eHSP27, IL-8, and IL-6 were significantly elevated. Adjusted relative risk for hospital mortality was reduced 75% (RR=0.25, p=0.001) for SICU patients with a faster decline in eHSP70. The area under the receiver operating characteristic curve was 0.85 (95% CI: 0.76 to 0.94) for the final model suggesting excellent discrimination between SICU survivors and non-survivors. GLN-PN did not alter eHSP70 or eHSP27 serum concentrations over time compared to STD-PN. Our results suggest that serum HSP70 concentration may be an important marker for severity of illness and likelihood of recovery in the SICU. GLN-supplemented-PN did not increase eHSP70.

Overnight Steady-State Infusions of Parenteral Nutrition on Myosin Heavy Chain Transcripts in Rectus Abdominis Muscle Related to Amino Acid Transporters, Insulin-like Growth Factor 1, and Blood Amino Acids in Patients Aimed at Major Surgery.

Evaluation of improvements by nutrition support to severely ill patients requires sensitive methods to demonstrate activation of protein synthesis in various tissues from groups with a limited number of patients to be statistically efficient. This study examines effects of standard parenteral nutrition (PN) on abdominal muscle transcripts of amino acid (AA) transporters, myosin heavy chains (MHCs), and the insulin-like growth factor 1 and its receptor (IGF-1/IGF-1R) in patients aimed at major surgery. Twenty-two randomized patients received steady-state PN (0.16 gN/kg/d, 30 kcal/kg/d) or saline infusions for 12 hours before operation. Blood samples and muscle biopsies were obtained at operation start. Muscle messenger RNA (mRNA) levels of AA transporters (solute carrier family members SNAT2, LAT1, LAT3, LAT4, TAUT, PAT1, CD98), IGF-1, IGF-1R, MHC isoforms (MHC1, MHC2A, MHC2X), and LAT3 protein were quantified and related to concentrations of AA, IGF-1, insulin, and metabolic substrates in blood. Muscle mRNA LAT3, LAT4, IGF-1R, and MHC2A increased by PN infusion, with correlations to specific AA transporters and MHC isoforms (P < .01-.05). TAUT and LAT3 correlated to slow (MHC1) and fast (MHC2A, MHC2X) isoforms (P < .001-.02). Muscle IGF-1 mRNA correlated to plasma essential AAs, whereas IGF-1R mRNA was related to LAT3, MHC2A, and serum IGF-1 (P < .001-.03). The results confirm that short-term preoperative PN activates transcription of AA transporters and myosin isoforms. Thus, combinations of methods on gene transcription and translation of muscle proteins can be applied to define efficient combinations of nutrition and hormones to catabolic patients in preoperative and postoperative settings.

PRM16 - Cost-Effectiveness of Parenteral Nutrition in Hospitalized Adult Patients

Management of severely malnourished adults often requires parenteral nutrition (PN) as a life-sustaining feeding mode in patients with intestinal failure. Different types of PN are commercially available. The choice of an optimal treatment should be made considering their benefits, harms and costs. This study aimed to establish cost-effectiveness of different types of PN based on a systematic review. A comprehensive literature search was performed in PubMed/Medline and Tufts registry for economic evaluations published since 2000 through 2017. Full economic evaluations that compared different parenteral fluids in malnourished adults published in English were included. Quality of the studies was assessed using 24-item Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Forty-seven potentially relevant articles were found, with 6 satisfying predefined inclusion criteria. The studies evaluated different PN formulations enriched with either omega-3 fatty-acid lipid emulsions (n=4), glutamine (n=2) or structured triglyceride (STG)-based emulsions (n=1) compared to standard PN. The studies captured patient (n=3), hospital (n=2) and healthcare provider perspective (n=1), analyzing context of European countries (n=3) or China (n=3) and most of them were cost-effectiveness analyses (n=5). Five studies were model-based economic evaluations with four of them applying discrete event simulation. None of the studies reported cost per quality-adjusted life year. Special PN formulations appeared to be cost-effective when compared to standard PN. The CHEERS assessment resulted in total score of 16.3 (SD=4.42), with none of the studies reporting discount rates or measurement and valuation of preference based outcomes and with only one study characterizing heterogeneity. Addition of omega-3 lipids, glutamines or structured triglyceride-based emulsions into parenteral fluids appear to be generally cost-effective from the study perspectives. The lack of a well-designed pharmacoeconomic analysis highlights the need for further economic evaluations, which will provide a rationale for the informed healthcare decision-making.

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.

The use of standard parenteral nutrition bags in advanced cancer patients

The use of standard parenteral nutrition bags in advanced cancer patients

Physical stability of an all-in-one parenteral nutrition admixture for preterm infants upon mixing with micronutrients and drugs

ObjectivesThe main objective was to investigate Y-site compatibility of intravenous drugs with one standard total parenteral nutrition (TPN) admixture for preterm infants. Since micro-precipitation was observed in the water phase...

Comparison of 2 Perioperative Management Protocols and Their Influence on Postoperative Recovery after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Standard Parenteral Nutrition, Selective Bowel Decontamination and Suprapubic Catheters?

Background: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is associated with considerable postoperative morbidity, including ileus and infectious complications. Perioperative care is believed to be an important factor for the development and treatment of postoperative morbidity. Patients and Methods: Data on case-matched patients from a retrospective database of 2 Dutch HIPEC centres was compared. Patient selection and procedures were identical in both hospitals although perioperative management items differ slightly. In centre B, immediate total parenteral nutrition (TPN), suprapubic urine bladder catheter placement (SPCs) and selective decontamination of the digestive-tract are standard care for CRS-HIPEC patients, while in centre A, they are not. Results: From a total of 223 patients, 68 consecutive patients from centre B were compared to 68 matched patients from centre A. TPN was administered to 54.4% of patients in centre A because of prolonged ileus, whereas it was standard of care in centre B. In all, 105 (77.2%) patients experienced postoperative complications including 17.6% who had a grades III–IV complication. The incidence of grade III-V complications was 18 (26.4%) in centre A and 8 (11.8%) in centre B (p = 0.03). Median hospital stay was 12 days (7–84) in A and 11(6–80) in centre B (p = 0.546). Conclusions: Gastrointestinal recovery after CRS-HIPEC seems to take longer as compared to other surgical procedures. Between the 2 centres, a significant difference in severe complications was found, while standard TPN, selective bowel decontamination and SPCs were the only identified differences in perioperative care.

Standardized Parenteral Nutrition for the Transition Phase in Preterm Infants: A Bag That Fits.

The optimal composition of standardized parenteral nutrition (SPN) is not yet known, contributing to nutrient deficit accrual and growth failure, with the period of parenteral nutrition weaning, i.e., transition (TN) phase, being identified as particularly vulnerable. We created a comprehensive nutrition database, representative of the nutritional course of a diverse range of preterm infants (n = 59, birth weight ≤ 1500 g, gestation < 34 weeks) by collecting hourly macronutrient intake data as part of a prospective, observational study over 19 months. Using a nutrient modeling technique for the TN phase, various amino acid (AA) concentrations of SPN were tested within the database, whilst acknowledging the nutritional contribution from enteral feeds until target AA intakes were consistently achieved. From the modeling, the AA composition of SPN was determined at 3.5 g/100 mL, which was the maximum to avoid exceeding target intakes at any point in the TN phase. However, in order to consistently achieve target AA intakes, additional nutritional strategies were required, which included increasing the exclusion of enteral feeds in fluid and nutrient calculations from <20 mL/kg/day to <40 mL/kg/day, and earlier fortification of breastmilk at 80 mL/kg/day. This data-driven nutrient modeling process supported the development of an improved SPN regimen for our preterm population in the TN phase.

Effect of immunonutrition on colorectal cancer patients undergoing surgery: a meta-analysis

PurposeImmunonutrition has been used to prevent the complications after colorectal elective surgery. This systematic review aimed to analyze and assess the effect of immunonutrition on colorectal cancer patients who received elective surgery.MethodsThree electronic databases (Medline, Embase, Cochrane) were used to search the latent studies which investigated the effects of enteral immunonutrition (EIN) compared with standard enteral nutrition (EN) or parenteral immunonutrition (PIN) compared with standard parenteral nutrition (PN) on colorectal cancer patients who are undergoing surgery until 21st of April, 2017. Meta-analysis was conducted to calculate odd risk (OR), mean difference (MD), or standard mean difference (SMD) with 95% confidence interval (CI), and heterogeneity was tested by Q test.ResultsNine publications were included. The meta-analysis results presented that EIN improved the length of hospital stay (pooled MD, 2.53; 95% CI, 1.29–3.41), infectious complications (pooled OR, 0.33; 95% CI, 0.21–0.53) which contains the Surgical Site Infections (pooled OR, 0.25; 95% CI, 0.22–0.58) and Superficial/Deep incisional infections (pooled OR, 0.27; 95% CI, 0.12–0.64); meanwhile, PIN improved the length of hospital stay (pooled MD, 2.66; 95% CI, 0.62–4.76), IL-6 (pooled MD, − 6.09; 95% CI, − 10.11 to − 2.07), CD3 (pooled MD, 7.50; 95% CI, 3.57–11.43), CD4 (pooled MD, 5.47; 95% CI, 2.54–8.40), and CD4/CD8 (pooled MD, 0.50; 95% CI, 0.22–0.78); the level of CD8 was lower (pooled MD, − 4.32; 95% CI, − 7.09 to − 1.55) in PIN.ConclusionImmunonutrition could be an effective approach to enhance the immune function of colorectal cancer patients undergoing elective surgery and to improve the clinical and laboratory outcomes.

Production and stability study of a hospital parenteral nutrition solution for neonates

Standard parenteral nutrition solutions are mixtures comprising interacting components that may degrade themselves over time. The objective of this study was to investigate the physicochemical and microbiological stability of a hospital preparation for parenteral nutrition in neonatology. The analyses were performed throughout the storage of the preparations at 2–8 °C (up to 4 months). The extent of stability was based on the determination of amino acids dosage, visual and physicochemical properties (glucose and electrolytes concentrations, pH and osmolality measurements, particle counting) and microbiological analysis (sterility test). A thermal degradation of ascorbic acid was conducted to evaluate the antioxidant properties of the parenteral mixture. Physicochemical and microbiological controls were found to comply with the specifications. Amino acids showed a good stability throughout the 4months storage except for cysteine, which was progressively degraded to cystine, conferring a yellow coloration to parenteral solutions. Parenteral nutrition standards solutions remain stable for 4 months at 2–8 °C, ensuring safe administration in preterm infants.

Compatibility of intravenous ibuprofen with lipids and parenteral nutrition, for use as a continuous infusion.

There is increasing interest to administer ibuprofen as a continuous infusion instead of a traditional bolus for treating Patent Ductus Arteriosus (PDA). However, its compatibility data with commonly used drugs in the neonatal period, including parenteral nutrition (PN) and lipids is unavailable. The aim is to determine the compatibility of intravenous ibuprofen lysine with various ANZNN parenteral nutrition consensus group standard neonatal PN formulations and lipids. The PN and lipid solutions used in a tertiary neonatal unit were obtained. These included a Starter, Standard Preterm and low carbohydrate PN, and IV SMOF lipid admixture (SMOFLipid 20% 15 mL; Vitalipid N infant 4 mL, Soluvit N 1 mL) plus vitamin mixtures. 10% glucose was used as a control. 1:1 mixtures of different concentrations (1.25 to 5mg/mL) of ibuprofen lysine and each of the PN/glucose/lipid formulations were made. Samples were taken at hourly intervals for a total of 4 hours and tested for both physical (visual assessment, pH and microscopy) and chemical compatibility (High Performance Liquid Chromatography analysis). Zeta potential and particle diameter were measured for SMOF lipid admixture and ibuprofen combination to assess emulsion stability. 24 hour stability of ibuprofen dilution in 5 mL BD Luer-lok polypropylene syringes at 25°C was also assessed. Most PN formed opaque solutions when mixed with ibuprofen 2.5 and 5mg/mL solutions. However, ibuprofen dilution of 1.25mg/mL produced clear, colourless solutions with no microscopic particles when mixed with all PN/glucose/lipid formulations tested. Ibuprofen was chemically stable with all PN and SMOF lipid admixture, for a period of 4 hours. The zeta potential and particle diameter were within acceptable limits. Ibuprofen lysine was stable over 24 hours in Luer-lok polypropylene syringes. Ibuprofen 1.25mg/mL is physically and chemically compatible with 10% glucose, starter PN, standard preterm and low carbohydrate PN, and SMOF lipid admixture plus vitamins for a period of four hours, which is the maximum time they could be in an admixture during a continuous infusion.

Physicochemical stable standard all-in-one parenteral nutrition admixtures for infants and children in accordance with the ESPGHAN/ESPEN guidelines.

Because there are almost no standard all-in-one parenteral nutrition admixtures available for infants and children, the aim was to develop standard two-compartment parenteral nutrition bags for different weight categories based on the ESPGHAN/ESPEN (European Society of Paediatric Gastroenterology, Hepatology and Nutrition/European Society for Clinical Nutrition and Metabolism) guidelines. The 1 g/kg/d lipid version for the 3 to 10 kg weight category (PED1) was assessed for short- and long-term physicochemical stability with the ability to add additional electrolytes (PED1+E). The lipid compartment A and the all-in-one admixture of A + B + vitamins + trace elements were assessed physically by visual inspection, Sudan red test, pH measurement, and lipid droplet size distribution. Chemical stability for compartment A was evaluated by quantitative analyses of non-esterified fatty acids and peroxide content. The glucose-amino acid-electrolyte compartment B was evaluated physically by visual inspection, measuring particle contamination and pH. Chemical stability was assessed by discoloration, quantitative analyses of glucose, and the amino acids L-cysteine, L-tyrosine, and L-tryptophan. No phase separation or coalescence occurred, and the mean droplet size diameter did not exceed 0.5 µm. Peroxide content and non-esterified fatty acids concentration of compartment A remained well below the limit of acceptation. No precipitation was detected for compartment B; only a slight yellow discoloration was noted at 80 d. Concentrations of glucose, L-tyrosine, and L-tryptophan remained stable; only L-cysteine decreased significantly from its initial concentration. The two-compartment PED1 and PED1+E admixtures are stable up to 80 d 2° to 8°C + 24 h room temperature (RT) with an additional 7 d 2° to 8°C + 48 h RT after mixing and addition of vitamins and trace elements.