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Clinical Nutrition (Edinburgh, Scotland) Sep 2023Following the new ESPEN Standard Operating Procedures, the previous 2019 guideline to provide best medical nutritional therapy to critically ill patients has been...
Following the new ESPEN Standard Operating Procedures, the previous 2019 guideline to provide best medical nutritional therapy to critically ill patients has been shortened and partially revised. Following this update, we propose this publication as a practical guideline based on the published scientific guideline, but shortened and illustrated by flow charts. The main goal of this practical guideline is to increase understanding and allow the practitioner to implement the Nutrition in the ICU guidelines. All the items discussed in the previous guidelines are included as well as special conditions.
Topics: Humans; Parenteral Nutrition; Intensive Care Units; Nutritional Status; Critical Illness
PubMed: 37517372
DOI: 10.1016/j.clnu.2023.07.011 -
The New England Journal of Medicine Sep 2023Randomized, controlled trials have shown both benefit and harm from tight blood-glucose control in patients in the intensive care unit (ICU). Variation in the use of... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Randomized, controlled trials have shown both benefit and harm from tight blood-glucose control in patients in the intensive care unit (ICU). Variation in the use of early parenteral nutrition and in insulin-induced severe hypoglycemia might explain this inconsistency.
METHODS
We randomly assigned patients, on ICU admission, to liberal glucose control (insulin initiated only when the blood-glucose level was >215 mg per deciliter [>11.9 mmol per liter]) or to tight glucose control (blood-glucose level targeted with the use of the LOGIC-Insulin algorithm at 80 to 110 mg per deciliter [4.4 to 6.1 mmol per liter]); parenteral nutrition was withheld in both groups for 1 week. Protocol adherence was determined according to glucose metrics. The primary outcome was the length of time that ICU care was needed, calculated on the basis of time to discharge alive from the ICU, with death accounted for as a competing risk; 90-day mortality was the safety outcome.
RESULTS
Of 9230 patients who underwent randomization, 4622 were assigned to liberal glucose control and 4608 to tight glucose control. The median morning blood-glucose level was 140 mg per deciliter (interquartile range, 122 to 161) with liberal glucose control and 107 mg per deciliter (interquartile range, 98 to 117) with tight glucose control. Severe hypoglycemia occurred in 31 patients (0.7%) in the liberal-control group and 47 patients (1.0%) in the tight-control group. The length of time that ICU care was needed was similar in the two groups (hazard ratio for earlier discharge alive with tight glucose control, 1.00; 95% confidence interval, 0.96 to 1.04; P = 0.94). Mortality at 90 days was also similar (10.1% with liberal glucose control and 10.5% with tight glucose control, P = 0.51). Analyses of eight prespecified secondary outcomes suggested that the incidence of new infections, the duration of respiratory and hemodynamic support, the time to discharge alive from the hospital, and mortality in the ICU and hospital were similar in the two groups, whereas severe acute kidney injury and cholestatic liver dysfunction appeared less prevalent with tight glucose control.
CONCLUSIONS
In critically ill patients who were not receiving early parenteral nutrition, tight glucose control did not affect the length of time that ICU care was needed or mortality. (Funded by the Research Foundation-Flanders and others; TGC-Fast ClinicalTrials.gov number, NCT03665207.).
Topics: Humans; Blood Glucose; Glucose; Hypoglycemia; Insulin; Intensive Care Units; Glycemic Control; Parenteral Nutrition; Algorithms; Critical Illness
PubMed: 37754283
DOI: 10.1056/NEJMoa2304855 -
JPEN. Journal of Parenteral and Enteral... Sep 2023Parenteral nutrition (PN) is prescribed for preterm infants until nutrition needs are met via the enteral route, but unanswered questions remain regarding PN best...
BACKGROUND
Parenteral nutrition (PN) is prescribed for preterm infants until nutrition needs are met via the enteral route, but unanswered questions remain regarding PN best practices in this population.
METHODS
An interdisciplinary committee was assembled to answer 12 questions concerning the provision of PN to preterm infants. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) process was used. Questions addressed parenteral macronutrient doses, lipid injectable emulsion (ILE) composition, and clinically relevant outcomes, including PNALD, early childhood growth, and neurodevelopment. Preterm infants with congenital gastrointestinal disorders or infants already diagnosed with necrotizing enterocolitis or PN-associated liver disease (PNALD) at study entry were excluded.
RESULTS
The committee reviewed 2460 citations published between 2001 and 2023 and evaluated 57 clinical trials. For most questions, quality of evidence was very low. Most analyses yielded no significant differences between comparison groups. A multicomponent oil ILE was associated with a reduction in stage 3 or higher retinopathy of prematurity (ROP) compared to an ILE containing 100% soybean oil. For all other questions, expert opinion was provided.
CONCLUSION
Most clinical outcomes were not significantly different between comparison groups when evaluating timing of PN initiation, amino acid dose, and ILE composition. Future clinical trials should standardize outcome definitions to permit statistical conflation of data, thereby permitting more evidence based recommendations in future guidelines. This guideline has been approved by the ASPEN 2022-2023 Board of Directors.
Topics: Child, Preschool; Infant; Humans; Infant, Newborn; Infant, Premature; Enteral Nutrition; Amino Acids; Enterocolitis, Necrotizing; Liver
PubMed: 37610837
DOI: 10.1002/jpen.2550 -
Nutrition in Clinical Practice :... Dec 2023Prior to the 1970s, blending food and liquids and putting them through an enteral access device (EAD) was the most common form of enteral nutrition (EN). However, in the...
Prior to the 1970s, blending food and liquids and putting them through an enteral access device (EAD) was the most common form of enteral nutrition (EN). However, in the 1970s, blenderized tube feedings (BTFs) became less popular due to the emergence of modern commercial enteral formulas (CEFs). Recently, a cultural shift toward consuming a natural diet, consisting of whole foods, has led to a resurgence in the use of BTF. The increasing use of BTF in a variety of patient care settings identifies a need for practice recommendations that provide guidance for nutrition professionals and patients. Members of the American Society for Parental and Enteral Nutrition (ASPEN) Enteral Nutrition Committee identified salient clinical questions concerning BTF, conducted a comprehensive literature search, and subsequently developed practice recommendations pertaining to the use of BTF. This paper was approved by the ASPEN 2022-2023 Board of Directors.
Topics: Humans; Enteral Nutrition; Food, Formulated; Diet; Nutritional Status; Parenteral Nutrition
PubMed: 37787762
DOI: 10.1002/ncp.11055 -
Journal of Pediatric Gastroenterology... Aug 2023Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The preferred treatment for IF is parenteral nutrition which may be required...
Nutrition and Intestinal Rehabilitation of Children With Short Bowel Syndrome: A Position Paper of the ESPGHAN Committee on Nutrition. Part 2: Long-Term Follow-Up on Home Parenteral Nutrition.
Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The preferred treatment for IF is parenteral nutrition which may be required until adulthood. The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their expertise. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. This second part of the position paper is dedicated to the long-term management of children with SBS-IF. The paper mainly focuses on how to achieve intestinal rehabilitation, treatment of complications, and on possible surgical and medical management to increase intestinal absorption.
Topics: Child; Humans; Adult; Short Bowel Syndrome; Gastroenterology; Retrospective Studies; Follow-Up Studies; Systematic Reviews as Topic; Parenteral Nutrition, Home
PubMed: 37256821
DOI: 10.1097/MPG.0000000000003850 -
Current Opinion in Organ Transplantation Aug 2023Medical intestinal rehabilitation is a part of the very complex management of patients with intestinal failure. The goal is to achieve enteral autonomy and minimize need... (Review)
Review
PURPOSE OF REVIEW
Medical intestinal rehabilitation is a part of the very complex management of patients with intestinal failure. The goal is to achieve enteral autonomy and minimize need for parenteral nutrition and hydration. In this manuscript, we will review the strategies to achieve this goal with dietary optimization and pharmacologic interventions.
RECENT FINDINGS
We will review the most updated recommendations on medical management of patients with intestinal failure.
SUMMARY
Medical intestinal rehabilitation is just a portion of a multistep strategy that aims to minimize need of parenteral support in patients with intestinal failure, with the ultimate goal of achieving enteral autonomy. This needs to be done by a multidisciplinary team via dietary and pharmacologic optimization.
Topics: Humans; Intestinal Failure; Short Bowel Syndrome; Intestines; Parenteral Nutrition; Intestinal Diseases
PubMed: 37352891
DOI: 10.1097/MOT.0000000000001077 -
Clinics in Perinatology Sep 2023Congenital gastrointestinal disorders and other surgical diagnoses share many common problems: increased nutritional requirements to prevent catabolism, enhance wound... (Review)
Review
Congenital gastrointestinal disorders and other surgical diagnoses share many common problems: increased nutritional requirements to prevent catabolism, enhance wound healing, and provide optimal growth; impaired motility and altered intestinal flora leading to feeding intolerance requiring long-term parenteral nutrition; gastroesophageal reflux and poor feeding mechanics requiring tube feedings and support; growth failure; poor barrier function and risk of infection; and other long-term sequelae. Consequently, the surgical "at-risk" infant requires specialized nutritional support to meet their increased requirements to ensure adequate growth and meet the increased demands from critical illness.
Topics: Infant, Newborn; Infant; Humans; Parenteral Nutrition; Infant Nutritional Physiological Phenomena; Enteral Nutrition; Gastroesophageal Reflux
PubMed: 37536774
DOI: 10.1016/j.clp.2023.04.008