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The American Journal of Clinical... Sep 2023Multiple systematic reviews and meta-analyses (SRMAs) on various nutritional interventions in hospitalized patients with or at risk of malnutrition are available, but... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Multiple systematic reviews and meta-analyses (SRMAs) on various nutritional interventions in hospitalized patients with or at risk of malnutrition are available, but disagreements among findings raise questions about their validity in guiding practice.
OBJECTIVES
We conducted an umbrella review (a systematic review of systematic reviews in which all appropriate studies included in SRMAs are combined) to assess the quality of reviews, identify the types of interventions available (excluding enteral and parenteral nutrition), and re-analyze the effectiveness of interventions.
METHODS
The databases MEDLINE/PubMed, CINAHL, Embase, The Cochrane Library, and Google Scholar were searched. AMSTAR-2 was used for quality assessment and GRADE for certainty of evidence. Updated meta-analyses with risk of bias (ROB) by Cochrane ROB 2.0 were performed. Pooled effects were reported as relative risk (RR), with zero-events and publication bias adjustments, and trial sequential analysis (TSA) performed for mortality, readmissions, complications, length of stay, and quality of life.
RESULTS
A total of 66 randomized controlled trials were cited by the 19 SRMAs included in this umbrella review, and their data extracted and analyzed. Most clinical outcomes were discordant with variable effect sizes in both directions. In trials with low ROB, interventions targeting nutritional intake reduce mortality at 30 d (15 studies, n: 4156, RR: 0.72, 95% CI: 0.55, 0.94, P: 0.02, I: 6%, Certainty: High), 6 mo (27 studies, n: 6387, RR: 0.81, 95% CI: 0.71, 0.92, P = 0.001, I: 4%, Certainty: Moderate), and 12 mo (27 studies, n: 6387, RR: 0.80, 95% CI: 0.67, 0.95, P: 0.01, I: 33%, Certainty: Moderate), with TSA verifying an adequate sample size and robustness of the meta-analysis.
CONCLUSION
Existing evidence is sufficient to show that nutritional intervention is effective for mortality outcomes at 30 d, 6 mo, and 12 mo. Future clinical trials should focus on the effect of nutritional interventions on other clinical outcomes.
TRIAL REGISTRATION NUMBER
The protocol is registered on PROSPERO (CRD42022341031).
Topics: Adult; Humans; Enteral Nutrition; Hospitals; Malnutrition; Parenteral Nutrition; Quality of Life; Systematic Reviews as Topic
PubMed: 37437779
DOI: 10.1016/j.ajcnut.2023.07.003 -
The New England Journal of Medicine Apr 2024Most moderate-to-late-preterm infants need nutritional support until they are feeding exclusively on their mother's breast milk. Evidence to guide nutrition strategies... (Randomized Controlled Trial)
Randomized Controlled Trial Comparative Study
BACKGROUND
Most moderate-to-late-preterm infants need nutritional support until they are feeding exclusively on their mother's breast milk. Evidence to guide nutrition strategies for these infants is lacking.
METHODS
We conducted a multicenter, factorial, randomized trial involving infants born at 32 weeks 0 days' to 35 weeks 6 days' gestation who had intravenous access and whose mothers intended to breast-feed. Each infant was assigned to three interventions or their comparators: intravenous amino acid solution (parenteral nutrition) or dextrose solution until full feeding with milk was established; milk supplement given when maternal milk was insufficient or mother's breast milk exclusively with no supplementation; and taste and smell exposure before gastric-tube feeding or no taste and smell exposure. The primary outcome for the parenteral nutrition and the milk supplement interventions was the body-fat percentage at 4 months of corrected gestational age, and the primary outcome for the taste and smell intervention was the time to full enteral feeding (150 ml per kilogram of body weight per day or exclusive breast-feeding).
RESULTS
A total of 532 infants (291 boys [55%]) were included in the trial. The mean (±SD) body-fat percentage at 4 months was similar among the infants who received parenteral nutrition and those who received dextrose solution (26.0±5.4% vs. 26.2±5.2%; adjusted mean difference, -0.20; 95% confidence interval [CI], -1.32 to 0.92; P = 0.72) and among the infants who received milk supplement and those who received mother's breast milk exclusively (26.3±5.3% vs. 25.8±5.4%; adjusted mean difference, 0.65; 95% CI, -0.45 to 1.74; P = 0.25). The time to full enteral feeding was similar among the infants who were exposed to taste and smell and those who were not (5.8±1.5 vs. 5.7±1.9 days; P = 0.59). Secondary outcomes were similar across interventions. Serious adverse events occurred in one infant.
CONCLUSIONS
This trial of routine nutrition interventions to support moderate-to-late-preterm infants until full nutrition with mother's breast milk was possible did not show any effects on the time to full enteral feeding or on body composition at 4 months of corrected gestational age. (Funded by the Health Research Council of New Zealand and others; DIAMOND Australian New Zealand Clinical Trials Registry number, ACTRN12616001199404.).
Topics: Female; Humans; Infant; Infant, Newborn; Male; Amino Acids; Breast Feeding; Enteral Nutrition; Gestational Age; Glucose; Infant, Premature; Milk, Human; Parenteral Nutrition; Smell; Taste; Nutritional Support; Parenteral Nutrition Solutions; Adiposity
PubMed: 38657245
DOI: 10.1056/NEJMoa2313942 -
American Journal of Health-system... Jun 2024This article is based on presentations and discussions held at the International Safety and Quality of Parenteral Nutrition (PN) Summit concerning the acute care...
PURPOSE
This article is based on presentations and discussions held at the International Safety and Quality of Parenteral Nutrition (PN) Summit concerning the acute care setting. Some European practices presented in this article do not conform with USP general chapter <797> requirements. Nevertheless, the purpose is to cover the challenges experienced in delivering high-quality PN within hospitals in the United States and Europe, in order to share best practices and experiences more widely.
SUMMARY
Core issues regarding the PN process within an acute care setting are largely the same everywhere: There are ongoing pressures for greater efficiency, optimization, and also concurrent commitments to make PN safer for patients. Within Europe, in recent years, the use of market-authorized multi-chamber bags (MCBs) has increased greatly, mainly for safety, cost-effectiveness, and efficiency purposes. However, in the US, hospitals with low PN volumes may face particular challenges, as automated compounding equipment is often unaffordable in this setting and the variety of available MCBs is limited. This can result in the need to operate several PN systems in parallel, adding to the complexity of the PN use process. Ongoing PN quality and safety initiatives from US institutions with various PN volumes are presented. In the future, the availability of a greater selection of MCBs in the US may increase, leading to a reduction in dependence on compounded PN, as has been seen in many European countries.
CONCLUSION
The examples presented may encourage improvements in the safety and quality of PN within the acute care setting worldwide.
Topics: Humans; Europe; Hospitals; Parenteral Nutrition; Parenteral Nutrition Solutions; Patient Safety; Pharmacy Service, Hospital; United States; Congresses as Topic
PubMed: 38869256
DOI: 10.1093/ajhp/zxae080 -
Nutrition in Clinical Practice :... Feb 2024Short bowel syndrome (SBS) is a rare gastrointestinal disorder associated with intestinal failure (SBS-IF) and poor health-related outcomes. Patients with SBS-IF are... (Review)
Review
Short bowel syndrome (SBS) is a rare gastrointestinal disorder associated with intestinal failure (SBS-IF) and poor health-related outcomes. Patients with SBS-IF are unable to absorb sufficient nutrients or fluids to maintain significantly metabolic homeostasis via oral or enteral intake alone and require long-term intravenous supplementation (IVS), consisting of partial or total parenteral nutrition, fluids, electrolytes, or a combination of these. The goal of medical and surgical treatment for patients with SBS-IF is to maximize intestinal remnant absorptive capacity so that the need for IVS support may eventually be reduced or eliminated. Daily subcutaneous administration of the glucagon-like peptide 2 analog, teduglutide, has been shown to be clinically effective in reducing IVS dependence and potentially improving the health-related quality of life of patients with SBS-IF. The management of patients with SBS-IF is complex and requires close monitoring. This narrative review discusses the use of teduglutide for patients with SBS-IF in clinical practice. The screening of patient eligibility for teduglutide treatment, initiation, monitoring of efficacy and safety of treatment, adapting or weaning off IVS, and the healthcare setting needed for SBS-IF management are described, taking into consideration data from clinical trials, observational studies, and clinical experience.
Topics: Adult; Humans; Short Bowel Syndrome; Intestinal Failure; Quality of Life; Parenteral Nutrition; Gastrointestinal Agents; Peptides
PubMed: 37294295
DOI: 10.1002/ncp.11015 -
Nutrition (Burbank, Los Angeles County,... Jul 2024Parenteral nutrition represents a therapeutic option for patients with type 3 intestinal failure. If used exclusively, parenteral nutrition has to be complete to provide...
OBJECTIVE
Parenteral nutrition represents a therapeutic option for patients with type 3 intestinal failure. If used exclusively, parenteral nutrition has to be complete to provide all essential nutrients. The aim was to assess the availability of parenteral nutrition in all parts of the world, to better comprehend the global situation, and to prepare an action plan to increase access to parenteral nutrition.
METHODS
An international survey using an electronic questionnaire was conducted in August 2019 and repeated in May 2022. An electronic questionnaire was sent to 52 members or affiliates of the International Clinical Nutrition Section of the American Society for Parenteral and Enteral Nutrition. Questions addressed the availability of parenteral nutrition admixtures and their components, reimbursement, and prescribing pre- and post-COVID-19 pandemic. All participating countries were categorized by their economic status.
RESULTS
Thirty-six country representatives responded, answering all questions. Parenteral nutrition was available in all countries (100%), but in four countries (11.1%) three-chamber bags were the only option, and in six countries a multibottle system was still used. Liver-sparing amino acids were available in 18 (50%), kidney-sparing in eight (22.2%), and electrolyte-free in 11 (30.5%) countries (30.5%). In most countries (n = 28; 79.4%), fat-soluble and water-soluble vitamins were available. Trace elements solutions were unavailable in four (11.1%) countries. Parenteral nutrition was reimbursed in most countries (n = 33; 91.6%). No significant problems due to the coronavirus pandemic were reported.
CONCLUSIONS
Despite the apparent high availability of parenteral nutrition worldwide, there are some factors that may have a substantial effect on the quality of parenteral nutrition admixtures. These shortages create an environment of inequality.
Topics: Humans; COVID-19; Parenteral Nutrition; Surveys and Questionnaires; Global Health; SARS-CoV-2; Pandemics; Health Services Accessibility; Parenteral Nutrition Solutions
PubMed: 38554461
DOI: 10.1016/j.nut.2024.112396 -
JPEN. Journal of Parenteral and Enteral... Aug 2023Distinguishing primary bloodstream infections (BSIs) related to central venous access devices (CVADs) from those that occur through other mechanisms, such as a damaged... (Randomized Controlled Trial)
Randomized Controlled Trial
Association between parenteral nutrition-containing intravenous lipid emulsion and bloodstream infections in patients with single-lumen central venous access: A secondary analysis of a randomized trial.
BACKGROUND
Distinguishing primary bloodstream infections (BSIs) related to central venous access devices (CVADs) from those that occur through other mechanisms, such as a damaged mucosal barrier, is difficult.
METHODS
Secondary analysis was conducted on data from patients with CVADs that were collected for a large, randomized trial. Patients were divided into two groups: those who received parenteral nutrition (PN)-containing intravenous lipid emulsion (ILE) and those who did not have PN-containing ILE. This study investigated the influence of PN-containing ILE (ILE PN) on primary BSIs in patients with a CVAD.
RESULTS
Of the 807 patients, 180 (22%) received ILE PN. Most (627/807; 73%) were recruited from the hematology and hematopoietic stem cell transplant unit, followed by surgical (90/807; 11%), trauma and burns (61/807; 8%), medical (44/807; 5%), and oncology (23/807; 3%). When primary BSI was differentiated as a central line-associated BSI (CLABSI) or mucosal barrier injury laboratory-confirmed BSI (MBI-LCBI), the incidence of CLABSI was similar in the ILE PN and non-ILE PN groups (15/180 [8%] vs 57/627 [9%]; P = 0.88) and the incidence of MBI-LCBI was significantly different between groups (31/180 [17%] ILE PN vs 41/627 [7%] non-ILE PN; P < 0.01).
CONCLUSION
Our data indicate that twice as many primary BSIs in ILE PN patients are due to MBIs than CVADs. It is important to consider the MBI-LCBI classification, as some CLABSI prevention efforts aimed at CVADs for the ILE PN population may be better directed to gastrointestinal tract protection interventions.
Topics: Humans; Fat Emulsions, Intravenous; Catheter-Related Infections; Sepsis; Mucous Membrane; Parenteral Nutrition; Central Venous Catheters; Retrospective Studies; Catheterization, Central Venous
PubMed: 37288612
DOI: 10.1002/jpen.2530 -
American Journal of Physiology.... Aug 2023Alcoholic liver cirrhosis (ALC) is accompanied by sarcopenia. The aim of this study was to investigate the acute effects of balanced parenteral nutrition (PN) on...
Alcoholic liver cirrhosis (ALC) is accompanied by sarcopenia. The aim of this study was to investigate the acute effects of balanced parenteral nutrition (PN) on skeletal muscle protein turnover in ALC. Eight male patients with ALC and seven age- and sex-matched healthy controls were studied for 3 h of fasting followed by 3 h of intravenous PN (SmofKabiven 1,206 mL: amino acid = 38 g, carbohydrates = 85 g, and fat = 34 g) 4 mL/kg/h. We measured leg blood flow and sampled paired femoral arteriovenous concentrations and quadriceps muscle biopsies while providing a primed continuous infusion of [ring-d]-phenylalanine to quantify muscle protein synthesis and breakdown. Patients with ALC exhibited shorter 6-min walking distance (ALC: 487 ± 38 vs. controls: 722 ± 14 m, < 0.05), lower hand-grip strength (ALC: 34 ± 2 vs. controls: 52 ± 2 kg, < 0.05), and computed tomography (CT)-verified leg muscle loss (ALC: 5,922 ± 246 vs. controls: 8,110 ± 345 mm, < 0.05). Net leg muscle phenylalanine uptake changed from negative (muscle loss) during fasting to positive (muscle gain) in response to PN (ALC: -0.18 ± +0.01 vs. 0.24 ± 0.03 µmol/kg muscle·min; < 0.001 and controls: -0.15 ± 0.01 vs. 0.09 ± 0.01 µmol/kg muscle·min; < 0.001) but with higher net muscle phenylalanine uptake in ALC than controls ( < 0.001). Insulin concentrations were substantially higher in patients with ALC during PN. Our results suggest a higher net muscle phenylalanine uptake during a single infusion of PN in stable patients with ALC with sarcopenia compared with healthy controls. Muscle protein turnover responses to parenteral nutritional (PN) supplementation have not previously been studied in stable alcoholic liver cirrhosis (ALC). We applied stable isotope tracers of amino acids to directly quantify net muscle protein turnover responses to PN in sarcopenic males with ALC and healthy controls. We found a higher net muscle protein gain in ALC during PN, thereby providing the physiological rationale for future clinical trials of PN as a potential countermeasure to sarcopenia.
Topics: Humans; Male; Amino Acids; Liver Cirrhosis; Liver Cirrhosis, Alcoholic; Muscle Proteins; Muscle, Skeletal; Parenteral Nutrition; Phenylalanine; Sarcopenia; Case-Control Studies
PubMed: 37339940
DOI: 10.1152/ajpgi.00242.2022 -
Current Opinion in Critical Care Aug 2023Critically ill patients usually develop insulin resistance and hyperglycemia, which is aggravated by early parenteral nutrition. In observational studies, the lowest... (Review)
Review
PURPOSE OF REVIEW
Critically ill patients usually develop insulin resistance and hyperglycemia, which is aggravated by early parenteral nutrition. In observational studies, the lowest mortality risk associates with glucose concentrations close to the antecedent average glucose level. This review summarizes the most recent evidence regarding glucose control in critical illness.
RECENT FINDINGS
Although pioneer randomized controlled trials showed morbidity and mortality benefit by normalizing blood glucose in intensive care, the largest multicenter randomized controlled trial found increased mortality. Differences in glucose targets, the accuracy of the glucose control protocol, and differences in feeding strategy may explain these differences.Recent randomized controlled trials investigating the impact of individualized glucose control did not show benefits of targeting individualized or looser glucose values in critically ill patients with poorly controlled diabetes.
SUMMARY
It remains unclear whether tight glucose control in critical illness is beneficial or not in the absence of early parenteral nutrition, which is currently being studied in the multicenter TGC-fast randomized controlled trial. Without new evidence, it seems prudent to avoid severe hyperglycemia and hypoglycemia in all patients.
Topics: Humans; Blood Glucose; Insulin Resistance; Glucose; Critical Illness; Hyperglycemia; Critical Care; Parenteral Nutrition; Insulin; Hypoglycemic Agents; Multicenter Studies as Topic
PubMed: 37306527
DOI: 10.1097/MCC.0000000000001055 -
The Surgical Clinics of North America Apr 2024Enteral nutrition should be initiated within 24 to 48 hours of injury, starting at a trophic rate and increasing to goal rate after hemodynamic stability is achieved.... (Review)
Review
Enteral nutrition should be initiated within 24 to 48 hours of injury, starting at a trophic rate and increasing to goal rate after hemodynamic stability is achieved. The modified Nutritional Risk in the Critically Ill score can help identify patients who will benefit most from aggressive and early nutritional intervention. In the first week of critical illness, the patient should receive only 70% to 80% of estimated calories and protein should be targeted to 1.5 to 2 g/kg. Parenteral nutrition can be provided safely without increased adverse events. Peri-operative (and intra-operative) feeding has been shown to be safe in selected patients.
Topics: Humans; Critical Illness; Nutritional Support; Enteral Nutrition; Parenteral Nutrition; Energy Intake
PubMed: 38453310
DOI: 10.1016/j.suc.2023.10.002 -
Current Opinion in Critical Care Aug 2023Critical care nutrition guidelines primarily focus on patients receiving invasive mechanical ventilation, yet noninvasive ventilation (NIV) is an increasingly common... (Review)
Review
PURPOSE OF REVIEW
Critical care nutrition guidelines primarily focus on patients receiving invasive mechanical ventilation, yet noninvasive ventilation (NIV) is an increasingly common intervention. The optimal route of nutrition delivery in patients receiving NIV has not been established. This review aims to describe the implications of NIV on the route of feeding prescribed.
RECENT FINDINGS
Five small, mostly observational, studies have quantified energy or protein intake in patients receiving NIV in critical care, which demonstrate intake to be poor. No study has assessed the impact of feeding route on outcomes. The predominant route of feeding observed is oral intake, yet nutrition intake via this route is lower than that from enteral or parenteral nutrition. Barriers to oral intake include fasting for intubation, the inability to remove NIV apparatus to eat, breathlessness, fatigue and poor appetite, while barriers to enteral nutrition include the impact of the naso-enteric tube on the mask seal and potential aspiration.
SUMMARY
Until evidence to support the optimal route of feeding is developed, patient safety should be the key driver of route selection, followed by the ability to achieve nutrition targets, perhaps utilizing a combination of routes to overcome barriers to nutrition delivery.
Topics: Humans; Respiration, Artificial; Noninvasive Ventilation; Nutritional Support; Enteral Nutrition; Parenteral Nutrition; Critical Illness
PubMed: 37306535
DOI: 10.1097/MCC.0000000000001053