To Total Parenteral Nutrition Research Articles

Pausing TPN to Decrease Abnormal Newborn Screens: A NICU Quality Initiative.

Introduction:Detection of metabolic and genetic disorders via the newborn screen (NBS) remains a great diagnostic achievement in medicine. Unfortunately, many false positives for neonates due to acute illness lead to repeat testing. For example, the rate of abnormal NBS in very low birth weight (VLBW) neonates at the University of Virginia was 66%, with 23% due to total parenteral nutrition (TPN) on the amino acid profile.Methods:This study describes a quality improvement (QI) initiative completed in the NICU at a quaternary care center. The primary and secondary outcomes were the percentage of abnormal NBSs in VLBWs and all admissions. The intervention required a pause in TPN, and a dextrose-containing fluid ran for 4 hours before collecting the NBS. During PDSA cycle 1, the TPN pause occurred at 1400, and the collection of the NBS occurred at 1800. During PDSA cycle 2, we aimed to decrease the number of blood draws per neonate and, thus, paused the TPN at 0000 to enable NBS collection at 0400 with routine morning laboratory work.Results:The rate of abnormal screens in VLBWs decreased from 66% to 49%; P < 0.006; 95% CI, 0.04–0.27, and the rate of abnormal screens in all admissions dropped from 45.2% to 28.8%; P < 0.0001; 95% CI, 0.06–0.51. Hospital costs decreased from $244.79 to $170.86 per patient in the cost of the NBS cards alone.Conclusion:By pausing TPN for 4 hours before drawing the NBS, we decreased the number of abnormal NBS in all admissions while also decreasing hospital costs.

FUNGAL PERITONITIS IN THE SETTING OF NECROTIZING PANCREATITIS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Spontaneous fungal peritonitis (SFP) is a fungal infection of ascitic fluid, defined as over 250 polymorphic neutrophils (PMNs) and fungal growth on culture. It has a high mortality rate and often is recognized late in clinical courses. SFP is commonly associated with cirrhosis or advanced end stage liver disease. This is due to perturbation of mucosal blood flow and bacterial growth in the intestines, and changes in the permeability of the mucosal wall of the gastrointestinal tract (1-3). However, amongst patients without cirrhosis, there is limited data describing patients with SFP. Herein we describe a patient with no history of cirrhosis presenting with necrotizing pancreatitis and ileus who developed SFP. CASE PRESENTATION: A 60-year-old woman with a past medical history of hypertension presented to our hospital unresponsive with septic shock. She was intubated, resuscitated, placed on vasopressors and treated with broad spectrum antibiotics. Further evaluation with laboratory data demonstrated a lipase > 4000 u/L. Computed tomography imaging was consistent with necrotizing pancreatitis, ileus and small bowel obstruction. Her course was complicated by development of a large phlegmon requiring cystogastrostomy for drainage, in addition to total parenteral nutrition (TPN). Despite drainage and antibiotics she continued to have worsening abdominal distension and vasopressor requirement. An abdominal ultrasound demonstrated loculated ascites with septations (a). An abdominal drain was placed with subsequent drainage of 2.2 liters of moss-colored ascitic fluid (b), with over 2000 PMNs and growth of Candida albicans, Enterococcus faecalis and Stenotrophomonas maltophilia. Her antibiotics were adjusted to fluconazole, oxacillin and minocycline. With subsequent drainage and appropriate antibiotics, her vasopressor requirement resolved, she was liberated from the ventilator and her mental status improved. DISCUSSION: We describe a patient who develops SFP without its commonly known risk factors. We suspect the use of broad-spectrum antibiotics during the patient's hospital course, in conjunction with mucosal breakdown of the enteral tract in the setting of ileus and severe necrotizing pancreatitis created a favorable environment for fungal overgrowth. TPN is not known to cause SFP specifically, but with fungal infections in general. Antibiotics in the setting of TPN use may have caused further alterations of microbial balance, increased fungal dominance (4-6) and resulted in microbial translocation and polymicrobial peritonitis. CONCLUSIONS: It is critical to recognize SFP in patients without liver disease. Other less common risk factors such as antibiotics, perturbation of the enteral tract with diseases such as pancreatitis, ileus and TPN can increase one's risk of SFP. Early recognition and treatment can improve patient outcomes in patients presenting with septic shock. REFERENCE #1: Patel D. et al. Spontaneous fungal peritonitis as a rare complication of ascites secondary to cardiac cirrhosis: a case report. Am J Case Report. 2019; 20:1526-1529. REFERENCE #2: Shizuma T. Spontaneous bacterial and fungal peritonitis in patients with liver cirrhosis: a literature review. World J Hepatol. 2018 Feb 27; 10(2): 254-266. REFERENCE #3: Lahmer T., Brandi A., Rasch S., Schmid RM., Huber W. Fungal peritonitis: underestimated disease in critically ill patients with liver cirrhosis and spontaneous peritonitis. PLoS ONE. 2016 July 8; 11(7).4. Van Leeuwen PA, et al. Clinical significance of translocation. Gut. Jan 1994; 31(1 Suppl):S28-34). Doi: 10.1136/gut.35.1_suppl.s28.5. Bernhardt H, Zimmermann K, Knoke M. The continuous flow culture as an in vitro model in experimental mycology. Mycoses. 1999;42 Suppl 2:29-32. PMID: 10865900.6. Yang S. et al. A risk factor analysis of healthcare-associated fungal infections in an intensive are unit: a retrospective cohort study. BMC Infectious Diseases. 2013; 13(10) DISCLOSURES: No relevant relationships by Andrew Deitchman, source=Web Response No relevant relationships by Austin Hager, source=Web Response No relevant relationships by Diane Wang, source=Web Response

Anaphylaxis to parenteral nutrition in a pediatric oncology patient treated with induction of drug tolerance protocol

Anaphylaxis to total parenteral nutrition (TPN) in pediatrics is rarely reported.1,2 TPN includes dextrose, amino acids, electrolytes (sodium, potassium, phosphate, magnesium, calcium, chloride/acetate), trace elements, multi-12/K1 Ped multivitamins, heparin, and lipids (intralipid/SMOF [soybean oil, medium-chain triglycerides, olive oil, fish oil]/omegaven). Oncology patients depend on TPN for nutritional support. Understanding TPN reactions and identifying methods of overcoming hypersensitivity are crucial.

Enteral versus parenteral nutrition in the conservative treatment of upper gastrointestinal fistula after surgery: a multicenter, randomized, parallel-group, open-label, phase III study (NUTRILEAK study)

BackgroundPostoperative upper gastrointestinal fistula (PUGIF) is a devastating complication, leading to high mortality (reaching up to 80%), increased length of hospital stay, reduced health-related quality of life and increased health costs. Nutritional support is a key component of therapy in such cases, which is related to the high prevalence of malnutrition. In the prophylactic setting, enteral nutrition (EN) is associated with a shorter hospital stay, a lower incidence of severe infectious complications, lower severity of complications and decreased cost compared to total parenteral nutrition (TPN) following major upper gastrointestinal (GI) surgery. There is little evidence available for the curative setting after fistula occurrence. We hypothesize that EN increases the 30-day fistula closure rate in PUGIF, allowing better health-related quality of life without increasing the morbidity or mortality.Methods/designThe NUTRILEAK trial is a multicenter, randomized, parallel-group, open-label phase III trial to assess the efficacy of EN (the experimental group) compared with TPN (the control group) in patients with PUGIF. The primary objective of the study is to compare EN versus TPN in the treatment of PUGIF (after esophagogastric resection including bariatric surgery, duodenojejunal resection or pancreatic resection with digestive tract violation) in terms of the 30-day fistula closure rate. Secondary objectives are to evaluate the 6-month postrandomization fistula closure rate, time of first fistula closure (in days), the medical- and surgical treatment-related complication rate at 6 months after randomization, the fistula-related complication rate at 6 months after randomization, the type and severity of early (30 days after randomization) and late fistula-related complications (over 30 days after randomization), 30-day and 6-month postrandomization mortality rate, nutritional status at day 30, day 60, day 90 and day 180 postrandomization, the mean length of hospital stay, the patient’s health-related quality of life (by self-assessment questionnaire), oral feeding time and direct costs of treatment. A total of 321 patients will be enrolled.DiscussionThe two nutritional supports are already used in daily practice, but most surgeons are reluctant to use the enteral route in case of PUGIF. This study will be the first randomized trial testing the role of EN versus TPN in PUGIF.Trial registrationClinicalTrials.gov: NCT03742752. Registered on 14 November 2018.

Diagnosis of Carnitine Deficiency in Extremely Preterm Neonates Related to Parenteral Nutrition: Two Step Newborn Screening Approach.

Currently, there is no evidence in the literature to support the routine supplementation of all parenterally fed premature infants with l-carnitine. In our study, we found that about 8.56% of extremely preterm neonates are diagnosed with carnitine deficiency secondary to malnutrition, either due to reduced stores at birth or related to total parenteral nutrition (TPN). Our two step approach of performing newborn screening (NBS) again at 32 weeks gestational age (GA) equivalent helps to diagnose 81.4% more preterm babies with carnitine deficiency—who would otherwise be missed—and supplement them with l-carnitine for optimal growth. We performed a retrospective cohort study to diagnose carnitine deficiency related to malnutrition in two groups: those presenting at birth and those presenting later in life. We found that there was a statistically significant difference in the median GA and birth weight (BW) between the two groups, but there was no difference in the free carnitine levels.

Hypersensitivity reactions to high osmolality Total Parenteral Nutrition: a case report

BackgroundThe full range of allergic reactions to Total Parenteral Nutrition (TPN) remains unknown. Additionally, beyond individual allergens, there may be other factors contributing to TPN hypersensitivity reactions.Case presentationWe present a case of a patient with negative skin testing to common TPN allergens who had recurrent urticarial reactions to TPN. Her skin reactions resolved once TPN was stopped. Following a literature review, we postulated that the reactions could be due to the high osmolality of her TPN. Consequently, lowering her TPN from 2785 to 1928 mOsm/kg and premedicating with cetirizine resulted in resolution of her urticaria.ConclusionsWhen looking at patients who have hypersensitivity reactions to TPN, one must consider that their reactions may be due to factors other than allergens. More studies are needed to clarify the relationship between high osmolality TPN infusions and non-IgE mediated hypersensitivity reactions.

Clinical outcome in low socioeconomic patients with severe acute pancreatitis treated either with early nasogastric tube or total parenteral nutrition: a randomized controlled trial

Background: Early nasogastric feeding has shown beneficial effect in the low socioeconomic group of patient with severe acute pancreatitis (SAP). The current randomized controlled study was performed to assess the effect of early nasogastric feeding as compared to total parenteral nutrition (TPN).Methods: Fifty patients admitted with diagnosis of SAP were randomly allocated to receive nnteral feeding (EF) (at the rate of 25 ml/hour and was gradually increased up to 100 ml/hr) or TPN within 24 hours of hospital admission. The nutritional regimen was aimed to be iso-caloric between the two groups. Patient’s demographics, hospital stay, nutrition, total cost, complication, and mortality were observed for 1 month in follow up.Results: All fifty patients were completed the study. Patient demographics were similar in both groups. 38/50 belonged to low socioeconomic status in the study group (Twenty in EF and eighteen in TPN group). The complications were significantly lower in EF group (pancreatic infection (11 vs. 4, p=0.037), central venous catheter infection (EF=0 vs. TPN=8, p=0.002), multiorgan failure (EF=5, TPN=12, p=0.037). Early recovery in EF group was significant with the mean duration of hospital stay of 6.76 days as compared to 10.4 days in the TPN group. The mean expenditure in the EF group was 1268 as compared to 13688 Indian rupees in the TPN group.Conclusions: This study shows that early EF improves early recovery, lower complications and cost effective measure in SAP especially in low socioeconomic group of patients.

Plasma non-esterified fatty acids (NEFA) concentrations may decrease with a glucose based parenteral nutrition regime

Aim: Lipolysis is accelerated during the acute phase of critical illness. The mechanisms related to total parenteral nutrition (TPN) remain elusive and we therefore measured NEFA concentrations in a random set of patients from a larger ongoing clinical trial comparing metabolic changes in critically ill patients randomized to receive TPN containing nonprotein calories entirely from glucose or in combination with a fat emulsion (SMOFlipid).

The Utility of HIDA Scans for the Evaluation of Cholestasis in Premature Infants, a Case Series

Background: Jaundice and hyperbilirubinemia are common conditions in neonates. Prolonged direct hyperbilirubinemia/cholestasis is less common. Biliary atresia, a primary cause of cholestasis in infancy, is a rare condition in the NICU compared to total parenteral nutrition (TPN) related cholestasis. A hepatobiliary scintigraphy with imindiacetic acid (HIDA) scan may be performed as part of the evaluation for cholestasis. HIDA scans have high sensitivity but variable specificity. There is little data on HIDA scans in preterm infants. Objective: To describe a series of infants in the NICU, …

Choice of Allograft in Patients Requiring Intestinal Transplantation: A Critical Review.

Intestinal transplantation (ITx) is indicated in patients with irreversible intestinal failure (IF) and life-threatening complications related to total parenteral nutrition (TPN). ITx can be classified into three main types. Isolated intestinal transplantation (IITx), that is, transplantation of the jejunoileum, is indicated in patients with preserved liver function. Combined liver-intestine transplantation (L-ITx), that is, transplantation of the liver and the jejunoileum, is indicated in patients with liver failure related to TPN. Thus, patients with cirrhosis or advanced fibrosis should receive a combined allograft, while patients with lower grades of liver fibrosis can usually safely undergo ITx. Reflecting their degree of sickness, the waitlist mortality rate and the early posttransplant outcomes of patients receiving L-ITx are worse than IITx. However, L-ITx is associated with better long-term graft and patient survival. Multivisceral transplantation (MVTx), that is, transplantation of the organs dependent on the celiac axis and superior mesenteric artery, can be classified into full MVTx if it includes the liver and modified MVTx if it does not. The most common indications for MVTx are extensive portomesenteric thrombosis and diffuse gastrointestinal pathology such as motility disorders and polyposis syndrome. Every patient with IF should undergo a multidisciplinary evaluation by an experienced ITx team.

A global perspective of the roles of the pharmacist in the NICU.

To describe pharmacist practice and roles performed in the neonatal intensive care unit (NICU) worldwide and to map these findings along the medicines management pathway (MMP). Quasi-systematic review. Google Scholar, Medline/PubMed and Embase were searched utilising the selected MeSH terms. Thirty sources of information were reviewed. Overall, pharmacist practice in the NICU involves a wide-range of roles, with the most commonly reported involving patient medication chart review, therapeutic drug monitoring and the provision of medication information. Studies highlight that pharmacist contribution to total parenteral nutrition (TPN) regimens and patient medication chart review is beneficial to patient outcomes. Roles beyond the regular scope of practice included involvement in immunisation programmes and research. Most of the data were collected from the USA (13 of 30), followed by the UK (6 of 30) and reports from other countries. The American, British, South African and Australian articles have reported very similar roles, with a pharmacist firmly integrated into the overall structure of the NICU team. The literature identifies that there is insufficient evidence to describe what roles are currently performed in NICUs worldwide. This is due to the lack of recently published articles leading to a large gap in knowledge in understanding what contemporary pharmaceutical services in the NICU comprise. Further research is required to address these gaps in knowledge, and identify the impact of the pharmacist's role on neonatal patient outcomes as well as to determine how to better resource NICUs to access pharmacy services.

Quantitative analysis of insulin in total parenteral nutrition bag in Taiwan

Regular insulin can reduce hyperglycemia when directly added to total parenteral nutrition (TPN) solutions. Insulin is not routinely added to all TPN solutions. For patients who require insulin prior to the initiation of TPN supplement, one-third to one-half of the usual total daily dose can be added to the TPN bag as regular human insulin. However, an incorrect dose or an interaction between insulin and the TPN bag material may affect blood sugar control in clinical practice. Therefore, it is important to quantitatively determine the final dose of insulin in the TPN bag. High performance liquid chromatography is a very powerful technique for determining the purity of proteins. The goal of this study was to use high-performance liquid chromatography to perform quantitative analysis of insulin in a TPN bag. The analysis was performed under different light conditions (UV, fluorescent, and darkness) and different temperatures (25°C and 2–8°C). The results show that adsorption of insulin on an ethylene vinyl acetate TPN bag is significantly higher than that on glass. Based on the results, it is evident that regular insulin should be administered separately from TPN to reduce cost and eliminate wasteful disposal of TPN solutions.

Chronic intestinal pseudo-obstruction as an expression of inflammatory enteric neuropathy

Chronic intestinal pseudo-obstruction (CIPO) is characterised by inadequate digestive tract motility and can lead to severely disordered motility. CIPO manifests as recurrent episodes of intestinal sub-occlusion without an anatomical obstruction. We present the case of a 41-year-old female, with severe chronic constipation and several episodes of intestinal sub-occlusion. Investigation revealed colonic inertia and marked distension of the small bowel and colon with no evidence of stenosis or obstructive lesions, compatible with CIPO. After several treatments were tried (domperidone, erythromycin, cisapride, octreotide, total enteral nutrition), with partial or no response, further work-up was done trying to identify an etiology. Gastrointestinal manometry showed neuropathic type abnormalities, transmural biopsy of the jejunum revealed degenerative enteric neuropathy and anti-HU antineuronal antibody screen was positive, suggesting an autoimmune type neuropathy with diffuse involvement of the digestive tract. Corticosteroids showed partial improvement of short duration and azathioprine was also tried but discontinued due to intolerance. Marked dietary intolerance and malnutrition lead to total parenteral nutrition (TPN) at home since October 2011. Since then, symptoms and nutritional status improved, with rare episodes of pseudo-obstruction, not requiring hospitalisation.

Nasogastric nutrition is efficacious in severe acute pancreatitis: a systematic review and meta-analysis.

In patients with severe acute pancreatitis (AP), enteral nutrition is delivered by nasojejunal (NJ) tube to minimise pancreatic stimulation. Nasogastric (NG) feeding represents an alternative route. The primary objective of this systematic review and meta-analysis was to evaluate the efficacy of NG feeding. Secondary objectives were to compare the NG and NJ routes and assess the side effects of the former. The primary endpoint was exclusive NG feeding with delivery of 75% of nutritional targets. Additional outcomes included change to total parenteral nutrition (TPN), increased pain or disease severity, vomiting, diarrhoea, delivery rate reduction and tube displacement. Among the retrieved studies, six were found to be eligible for the qualitative review and four for the meta-analysis. NG nutrition was received by 147 patients; exclusive NG feeding was achieved in 90% (133/147). Of the 147 patients, 129 (87%) received 75% of the target energy. In studies where all subjects received exclusive NG nutrition, 82% (seventy-four of the ninety patients) received >75% of the intended energy. Compared with NJ nutrition, there was no significant difference in the delivery of 75% of nutritional targets (pooled risk ratio (RR) 1.02; 95% CI 0.75, 1.38.) or no increased risk of change to TPN (pooled RR 1.05; 95% CI 0.45, 2.48), diarrhoea (pooled RR 1.28; 95% CI 0.62, 2.66), exacerbation of pain (pooled RR 1.10; 95% CI 0.47, 2.61) or tube displacement (pooled RR 0.44; 95% CI 0.11, 1.73). Vomiting and diarrhoea were the most common side effects of NG feeding (13.3 and 12.9%, respectively). With respect to the delivery of nutrition, 11.2% of the patients required delivery rate reduction and 3.4% dislodged the tube. Other side effects included elevated levels of aspirates (9.1%), abdominal distension (1.5%), pain exacerbation (7.5%) and increased disease severity (1.6%). In conclusion, NG feeding is efficacious in 90% of patients. Further research is required to optimise the delivery of NG nutrition and examine 'gut-rousing' approaches to nutrition in patients with severe AP.

PS-188 Intestino-trophic Effects Of Minimal Enteral Nutrition In Preterm And Term Piglets

Background and aims In preterm infants, slow advancement of minimal enteral nutrition (MEN), combined with parenteral nutrition (PN), may be important to increase food tolerance and minimise the risk of necrotizing enterocolitis (NEC). We hypothesised that MEN for five days would increase gut growth and gut hormone release relative to total parenteral nutrition (TPN). Methods Preterm and term piglets were delivered by caesarean section and fed TPN or PN+MEN (MEN: 0–64 mL bovine colostrum /kg/d) for five days. From day 5–26 all pigs were fed total enteral nutrition with milk-replacer. Pigs were euthanized at 0, 5 or 26 days of age, and gut weight, mucosal volume, L-cell density and plasma levels of GIP and GLP-2 were measured. Results Body weight gain was markedly reduced in preterm vs. term (P Conclusion Despite the compromised growth in preterm pigs, the intestine is highly growth-responsive to MEN just after birth in both preterm and term pigs. The effects of MEN on gut dimensions and gut peptide release are minimal after few weeks of full enteral nutrition. MEN provision may be important for short term gut maturation in preterm infants.

Discordant Presentation of Biliary Atresia in Premature Monozygotic Twins

Discordant Presentation of Biliary Atresia in Premature Monozygotic Twins

L-carnitine and cancer cachexia. I. L-carnitine distribution and metabolic disorders in cancer cachexia

Cancer cachexia (CC), a progressive loss of body mass, is associated with decreased energy production. Abnormally low levels of L-carnitine (LC) in skeletal muscle means that mitochondrial β-oxidation of long-chain fatty acids (LCFA) does not occur efficiently in patients with CC. We assessed the influence of CC on LC distribution and the effects of parenteral lipid emulsions on plasma LC levels and urinary excretion. Fifty patients with CC were randomly assigned to total parenteral nutrition (TPN) with long-chain triglycerides (LCTs), or LCTs plus medium-chain triglycerides (MCTs) as 50/50. Patients were further separated into those with body-mass index (BMI) ≤ 19 kg/m(2) and BMI >19 kg/m(2). Plasma concentrations of total LC (TC) and free LC (FC) and their urinary excretion were measured, along with skeletal muscle LC levels. On average, plasma FC and TC were higher than reference values in all patients. Patients with BMI ≤ 19 kg/m(2) had lower plasma FC and TC than those with BMI >19 kg/m(2). Skeletal muscle FC in the BMI ≤ 19 kg/m(2) group was lower than reference value, but within the normal range in others. LC and FC urinary excretion was higher than reference values. Plasma LC and its urinary excretion were higher in patients administered pure LCTs relative to those given MCTs/LCTs. A decrease in skeletal muscle LC in cancer patients with CC (BMI ≤ 19 kg/m(2)) correlates with an increase in its plasma levels and increased renal excretion. A diet of MCTs/LCTs reduces LC release from muscle to plasma and urine more effectively than LCTs.

Chapter 16. Glucose and nutrition

Chapter 16. Glucose and nutrition

The Comparison between Early Enteral Nutrition and Total Parenteral Nutrition after Total Gastrectomy in Patients with Gastric Cancer: The Randomized Prospective Study

Early enteral nutrition (EEN) has benefits in reducing infectious complication, length of stay (LOS) and preserving liver function. There are few data about the effect of EEN in the patients who had total gastrectomy. The aim of this randomized and prospective study was to evaluate the effect of EEN after total gastrectomy on nutritional status, liver function, complications and LOS, compared to total parenteral nutrition (TPN) in patients with gastric cancer. Among 56 patients with gastric cancer, 36 and 20 were randomly assigned to EEN and TPN groups, and finally 17 and 16 completed EEN and TPN schedules, respectively. The nutritional parameters, liver function, LOS and abdominal symptoms were compared between 2 groups on pre-operative day and post-operative 7th day. There was no significant difference in the nutritional parameters, liver function between EEN and TPN groups. Vomiting and abdominal distention were more frequent in EEN than TPN group (2 vs. 0 cases, p=0.485; 1 vs. 0 case, p=1.000, respectively), while increased AST, ALT and total bilirubin were more common in TPN than EEN group (4 vs. 2 cases, p=0.398; 1 vs. 0 case, p=0.485, respectively without statistical significance). LOS was shorter in EEN than TPN group without statistical significance (12 vs. 13 days, p=0.289). No significant differences were found in the nutritional status parameters, liver function, complications and LOS between EEN and TPN groups on 7th day after total gastrectomy. Further large scale studies on the advantages and disadvantages of EEN after total gastrectomy are warranted.

Intestinal Epithelial Cell Responses to Total Parenteral Nutrition (TPN) Are Under Complex Regulation by ADAM17

Intestinal Epithelial Cell Responses to Total Parenteral Nutrition (TPN) Are Under Complex Regulation by ADAM17