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Critical Care (London, England) Feb 2020Nutrition therapy during critical illness has been a focus of recent research, with a rapid increase in publications accompanied by two updated international clinical... (Review)
Review
Nutrition therapy during critical illness has been a focus of recent research, with a rapid increase in publications accompanied by two updated international clinical guidelines. However, the translation of evidence into practice is challenging due to the continually evolving, often conflicting trial findings and guideline recommendations. This narrative review aims to provide a comprehensive synthesis and interpretation of the adult critical care nutrition literature, with a particular focus on continuing practice gaps and areas with new data, to assist clinicians in making practical, yet evidence-based decisions regarding nutrition management during the different stages of critical illness.
Topics: Adult; Critical Care; Critical Illness; Enteral Nutrition; Humans; Nutritional Status; Nutritional Support; Parenteral Nutrition
PubMed: 32019607
DOI: 10.1186/s13054-020-2739-4 -
Nutrients May 2023Short-bowel syndrome (SBS) in pediatric age is defined as a malabsorptive state, resulting from congenital malformations, significant small intestine surgical resection... (Review)
Review
Short-bowel syndrome (SBS) in pediatric age is defined as a malabsorptive state, resulting from congenital malformations, significant small intestine surgical resection or disease-associated loss of absorption. SBS is the leading cause of intestinal failure in children and the underlying cause in 50% of patients on home parental nutrition. It is a life-altering and life-threatening disease due to the inability of the residual intestinal function to maintain nutritional homeostasis of protein, fluid, electrolyte or micronutrient without parenteral or enteral supplementation. The use of parenteral nutrition (PN) has improved medical care in SBS, decreasing mortality and improving the overall prognosis. However, the long-term use of PN is associated with the incidence of many complications, including liver disease and catheter-associated malfunction and bloodstream infections (CRBSIs). This manuscript is a narrative review of the current available evidence on the management of SBS in the pediatric population, focusing on prognostic factors and outcome. The literature review showed that in recent years, the standardization of management has demonstrated to improve the quality of life in these complex patients. Moreover, the development of knowledge in clinical practice has led to a reduction in mortality and morbidity. Diagnostic and therapeutic decisions should be made by a multidisciplinary team that includes neonatologists, pediatric surgeons, gastroenterologists, pediatricians, nutritionists and nurses. A significant improvement in prognosis can occur through the careful monitoring of nutritional status, avoiding dependence on PN and favoring an early introduction of enteral nutrition, and through the prevention, diagnosis and aggressive treatment of CRSBIs and SIBO. Multicenter initiatives, such as research consortium or data registries, are mandatory in order to personalize the management of these patients, improve their quality of life and reduce the cost of care.
Topics: Child; Humans; Quality of Life; Short Bowel Syndrome; Intestine, Small; Intestines; Parenteral Nutrition; Multicenter Studies as Topic
PubMed: 37242224
DOI: 10.3390/nu15102341 -
Nutrients Sep 2020Enteral nutrition (EN) is considered the first feeding route for critically ill patients. However, adverse effects such as gastrointestinal complications limit its... (Comparative Study)
Comparative Study Meta-Analysis
Effect of Supplemental Parenteral Nutrition Versus Enteral Nutrition Alone on Clinical Outcomes in Critically Ill Adult Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
Enteral nutrition (EN) is considered the first feeding route for critically ill patients. However, adverse effects such as gastrointestinal complications limit its optimal provision, leading to inadequate energy and protein intake. We compared the clinical outcomes of supplemental parenteral nutrition added to EN (SPN + EN) and EN alone in critically ill adults. Electronic databases restricted to full-text randomized controlled trials available in the English language and published from January 1990 to January 2019 were searched. The risk of bias was evaluated using the Jadad scale, and the meta-analysis was conducted using the MedCalc software. A total of five studies were eligible for inclusion in the systematic review and meta-analysis. Compared to EN alone, SPN + EN decreased the risk of nosocomial infections (relative risk (RR) = 0.733, = 0.032) and intensive care unit (ICU) mortality (RR = 0.569, = 0.030). No significant differences were observed between SPN + EN and EN in the length of hospital stay, hospital mortality, length of ICU stay, and duration of mechanical ventilation. In conclusion, when enteral feeding fails to fulfill the energy requirements in critically ill adult patients, SPN may be beneficial as it helps in decreasing nosocomial infections and ICU mortality, in addition to increasing energy and protein intakes with no negative effects on other clinical outcomes.
Topics: Adult; Combined Modality Therapy; Critical Care Outcomes; Critical Illness; Cross Infection; Dietary Supplements; Enteral Nutrition; Female; Hospital Mortality; Humans; Intensive Care Units; Length of Stay; Male; Parenteral Nutrition; Randomized Controlled Trials as Topic; Time Factors; Treatment Outcome
PubMed: 32998412
DOI: 10.3390/nu12102968 -
Annals of Palliative Medicine Oct 2021Nutritional support is very important in the treatment of severe acute pancreatitis, this study aimed to investigate the effect of total parenteral nutrition (TPN) and... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Nutritional support is very important in the treatment of severe acute pancreatitis, this study aimed to investigate the effect of total parenteral nutrition (TPN) and enteral nutrition (TEN) on the prognosis of patients with acute pancreatitis.
METHODS
The databases of PubMed, Embase, Cochrane Library, and Ovid were searched using the keywords acute pancreatitis, enteral nutrition, and parenteral nutrition to obtain the reports of randomized controlled trials (RCTs) published after 2000. After screening the articles according to the inclusion criteria, risk of bias of the included literatures was evaluated using the Cochrane Handbook for Systematic Reviews. The software RevMan 5.3.5 was used for analysis and the creation of a forest plot and funnel plot.
RESULTS
A total of 488 literatures were preliminarily searched in this study, from which 10 articles were included into the final quantitative analysis, involving a total of 699 participants. A total of 6 literatures (n=329 participants) reported the infection rate indicators. The obtained statistic value [odds ratio (OR) =0.25, 95% confidence interval (CI): 0.10 to 0.62] showed TEN had less infection rate that TPN (P=0.003). A total of 8 studies (654 participants) reported the incidence rate indicators of multiple organ failure rate indicator, the obtained statistic value (OR =0.50, 95% CI: 0.24 to 1.08) showed no statistical difference between TEN and TPN (P>0.05). A total of 7 studies (550 participants) reported the mortality indicators. The obtained statistic value (OR =0.59, 95% CI: 0.37 to 0.94) showed TEN had less mortality than TPN (P=0.03). A total of 3 studies reported the length of hospital stay indicators. The obtained statistic value [mean difference (MD) -4.18, 95% CI: -5.07 to -3.30] showed the length of hospital stay for TEN was shorter that TPN (P<0.001).
DISCUSSION
Compared with TPN, TEN can reduce the incidence of infection, reduce the development of multiple organ failure, reduce mortality, and shorten the length of hospital stay in patients with severe acute pancreatitis (SAP). However, attention should be paid to prevent the occurrence of complications during the implementation of nutritional intervention.
Topics: Enteral Nutrition; Humans; Pancreatitis; Parenteral Nutrition; Parenteral Nutrition, Total; Prognosis
PubMed: 34763439
DOI: 10.21037/apm-21-2469 -
The Cochrane Database of Systematic... Oct 2019Early enteral nutrition support (within 48 hours of admission or injury) is frequently recommended for the management of patients in intensive care units (ICU). Early... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Early enteral nutrition support (within 48 hours of admission or injury) is frequently recommended for the management of patients in intensive care units (ICU). Early enteral nutrition is recommended in many clinical practice guidelines, although there appears to be a lack of evidence for its use and benefit.
OBJECTIVES
To evaluate the efficacy and safety of early enteral nutrition (initiated within 48 hours of initial injury or ICU admission) versus delayed enteral nutrition (initiated later than 48 hours after initial injury or ICU admission), with or without supplemental parenteral nutrition, in critically ill adults.
SEARCH METHODS
We searched CENTRAL (2019, Issue 4), MEDLINE Ovid (1946 to April 2019), Embase Ovid SP (1974 to April 2019), CINAHL EBSCO (1982 to April 2019), and ISI Web of Science (1945 to April 2019). We also searched Turning Research Into Practice (TRIP), trial registers (ClinicalTrials.gov, ISRCTN registry), and scientific conference reports, including the American Society for Parenteral and Enteral Nutrition and the European Society for Clinical Nutrition and Metabolism. We applied no restrictions by language or publication status.
SELECTION CRITERIA
We included all randomized controlled trials (RCTs) that compared early versus delayed enteral nutrition, with or without supplemental parenteral nutrition, in adults who were in the ICU for longer than 72 hours. This included individuals admitted for medical, surgical, and trauma diagnoses, and who required any type of enteral nutrition.
DATA COLLECTION AND ANALYSIS
Two review authors extracted study data and assessed the risk of bias in the included studies. We expressed results as risk ratios (RR) for dichotomous data, and as mean differences (MD) for continuous data, both with 95% confidence intervals (CI). We assessed the certainty of the evidence using GRADE.
MAIN RESULTS
We included seven RCTs with a total of 345 participants. Outcome data were limited, and we judged many trials to have an unclear risk of bias in several domains. Early versus delayed enteral nutrition Six trials (318 participants) assessed early versus delayed enteral nutrition in general, medical, and trauma ICUs in the USA, Australia, Greece, India, and Russia. Primary outcomes Five studies (259 participants) measured mortality. It is uncertain whether early enteral nutrition affects the risk of mortality within 30 days (RR 1.00, 95% CI 0.16 to 6.38; 1 study, 38 participants; very low-quality evidence). Four studies (221 participants) reported mortality without describing the timeframe; we did not pool these results. None of the studies reported a clear difference in mortality between groups. Three studies (156 participants) reported infectious complications. We were unable to pool the results due to unreported data and substantial clinical heterogeneity. The results were inconsistent across studies. One trial measured feed intolerance or gastrointestinal complications; it is uncertain whether early enteral nutrition affects this outcome (RR 0.84, 95% CI 0.35 to 2.01; 59 participants; very low-quality evidence). Secondary outcomes One trial assessed hospital length of stay and reported a longer stay in the early enteral group (median 15 days (interquartile range (IQR) 9.5 to 20) versus 12 days (IQR 7.5 to15); P = 0.05; 59 participants; very low-quality evidence). Three studies (125 participants) reported the duration of mechanical ventilation. We did not pool the results due to clinical and statistical heterogeneity. The results were inconsistent across studies. It is uncertain whether early enteral nutrition affects the risk of pneumonia (RR 0.77, 95% CI 0.55 to 1.06; 4 studies, 192 participants; very low-quality evidence). Early enteral nutrition with supplemental parenteral nutrition versus delayed enteral nutrition with supplemental parenteral nutrition We identified one trial in a burn ICU in the USA (27 participants). Primary outcomes It is uncertain whether early enteral nutrition with supplemental parenteral nutrition affects the risk of mortality (RR 0.74, 95% CI 0.25 to 2.18; very low-quality evidence), or infectious complications (MD 0.00, 95% CI -1.94 to 1.94; very low-quality evidence). There were no data available for feed intolerance or gastrointestinal complications. Secondary outcomes It is uncertain whether early enteral nutrition with supplemental parenteral nutrition reduces the duration of mechanical ventilation (MD 9.00, 95% CI -10.99 to 28.99; very low-quality evidence). There were no data available for hospital length of stay or pneumonia.
AUTHORS' CONCLUSIONS
Due to very low-quality evidence, we are uncertain whether early enteral nutrition, compared with delayed enteral nutrition, affects the risk of mortality within 30 days, feed intolerance or gastrointestinal complications, or pneumonia. Due to very low-quality evidence, we are uncertain if early enteral nutrition with supplemental parenteral nutrition compared with delayed enteral nutrition with supplemental parenteral nutrition reduces mortality, infectious complications, or duration of mechanical ventilation. There is currently insufficient evidence; there is a need for large, multicentred studies with rigorous methodology, which measure important clinical outcomes.
Topics: Combined Modality Therapy; Critical Illness; Enteral Nutrition; Humans; Intensive Care Units; Malnutrition; Parenteral Nutrition; Randomized Controlled Trials as Topic; Time Factors
PubMed: 31684690
DOI: 10.1002/14651858.CD012340.pub2 -
American Journal of Health-system... Jun 2024Some diseases require that patients receive parenteral nutrition (PN) over a prolonged time period. Long-term administration of PN can further complicate an already... (Review)
Review
PURPOSE
Some diseases require that patients receive parenteral nutrition (PN) over a prolonged time period. Long-term administration of PN can further complicate an already complex therapy, posing additional risk of potential complications. This article is based on presentations and discussions held at the International Safety and Quality of PN Summit, providing insights into aspects of home PN (HPN) and examples of good HPN practice.
SUMMARY
One critical step in the HPN process is when patients transition from a hospital to a home setting, and vice versa. Generally, electronic PN ordering is not feasible in an HPN setting, leading to potential difficulties in communication and coordination. HPN requires that patients (or their home caregivers) administer PN, and thus their education and competency are crucial. Likewise, the choice of PN formulation is of great importance. For example, using more modern intravenous lipid emulsions containing medium-chain triglycerides, olive oil, and/or fish oil can provide benefits in terms of liver function during long-term HPN. Internationally, there are wide variations in delivery of HPN, with compounded PN dominating in some countries while others make greater use of market-authorized multichamber bags (MCBs). Patient-related factors, institutional considerations, and the availability of different MCB formulations, are also contributing factors guiding formulation and delivery system preferences.
CONCLUSION
Education and communication remain key components of a successful HPN process. The information shared here may help to motivate efforts to improve HPN processes and to consider the often-differing perspectives of patients and their healthcare professionals.
Topics: Humans; Parenteral Nutrition, Home; Time Factors
PubMed: 38527076
DOI: 10.1093/ajhp/zxae081 -
American Family Physician Dec 2021Nutrition support therapy is the delivery of formulated enteral or parenteral nutrients to restore nutritional status. Family physicians can provide nutrition support...
Nutrition support therapy is the delivery of formulated enteral or parenteral nutrients to restore nutritional status. Family physicians can provide nutrition support therapy to patients at risk of malnutrition when it would improve quality of life. The evidence for when to use nutrition support therapy is inconsistent and based mostly on low-quality studies. Family physicians should work with registered dietitian nutritionists to complete a comprehensive nutritional assessment for patients with acute or chronic conditions that put them at risk of malnutrition. When nutrition support therapy is required, enteral nutrition is preferred for a patient with a functioning gastrointestinal tract, even in patients who are critically ill. Parenteral nutrition has an increased risk of complications and should be administered only when enteral nutrition is contraindicated. Family physicians can use the Mifflin-St Jeor equation to calculate the resting metabolic rate, and they should consult with a registered dietitian nutritionist to determine total energy needs and select a nutritional formula. Patients receiving nutrition support therapy should be monitored for complications, including refeeding syndrome. Nutrition support therapy does not improve quality of life in patients with dementia. Clinicians should engage in shared decision-making with patients and caregivers about nutrition support in palliative and end-of-life care.
Topics: Enteral Nutrition; Humans; Malnutrition; Mass Screening; Nutritional Support; Parenteral Nutrition; Referral and Consultation
PubMed: 34913658
DOI: No ID Found -
Journal of Pediatric Gastroenterology... Sep 2023Our objective was to evaluate the short- and long-term safety and efficacy of teduglutide treatment in infants and children with short bowel syndrome with intestinal... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVES
Our objective was to evaluate the short- and long-term safety and efficacy of teduglutide treatment in infants and children with short bowel syndrome with intestinal failure (SBS-IF).
METHODS
Two open-label phase 3 studies and 1 extension study investigated the short- and long-term safety and efficacy of teduglutide (0.05 mg/kg/day) in infants and children with SBS-IF: NCT03571516, 24-week study of infants who were randomized to receive teduglutide or standard of care (SoC); NCT02980666, 24-week study of infants and children who all received teduglutide; and NCT03268811, 24-week extension study of patients who completed NCT02980666 (patients could receive up to 48 weeks of total treatment).
RESULTS
Twelve infants and 8 children enrolled in the core studies, and 2 infants and 7 children in the extension study. After 24 weeks of treatment, parenteral support (PS) requirements reduced by ≥20% from baseline for 4 infants (57.1%) and 4 children (66.7%) receiving teduglutide and for 2 infants receiving SoC (50.0%). One infant (50.0%) and 4 children (80.0%) receiving teduglutide maintained the ≥20% reduction in PS at 48 weeks of treatment. Two children receiving teduglutide achieved enteral autonomy, after 12 weeks and 28 weeks of treatment, respectively. All adverse events (AEs) were in line with known impacts of SBS-IF and adverse reactions to teduglutide. Only one serious AE (abdominal pain) was considered related to teduglutide.
CONCLUSIONS
Short- and long-term treatment with teduglutide resulted in clinically meaningful reductions in PS requirements for infants and children with SBS-IF. Teduglutide was well tolerated, and efficacy improved with longer-term treatment.
Topics: Humans; Infant; Child; Short Bowel Syndrome; Parenteral Nutrition; Intestine, Small; Peptides; Gastrointestinal Agents
PubMed: 37364133
DOI: 10.1097/MPG.0000000000003867 -
Nutrients Dec 2020Critically ill patients in the intensive care unit (ICU) have a high risk of developing malnutrition, and this is associated with poorer clinical outcomes. In clinical... (Review)
Review
Critically ill patients in the intensive care unit (ICU) have a high risk of developing malnutrition, and this is associated with poorer clinical outcomes. In clinical practice, nutrition, including enteral nutrition (EN), is often not prioritized. Resulting from this, risks and safety issues for patients and healthcare professionals can emerge. The aim of this literature review, inspired by the Rapid Review Guidebook by Dobbins, 2017, was to identify risks and safety issues for patient safety in the management of EN in critically ill patients in the ICU. Three databases were used to identify studies between 2009 and 2020. We assessed 3495 studies for eligibility and included 62 in our narrative synthesis. Several risks and problems were identified: No use of clinical assessment or screening nutrition assessment, inadequate tube management, missing energy target, missing a nutritionist, bad hygiene and handling, wrong time management and speed, nutritional interruptions, wrong body position, gastrointestinal complication and infections, missing or not using guidelines, understaffing, and lack of education. Raising awareness of these risks is a central aspect in patient safety in ICU. Clinical experts can use a checklist with 12 identified top risks and the recommendations drawn up to carry out their own risk analysis in clinical practice.
Topics: Critical Illness; Databases, Factual; Enteral Nutrition; Humans; Intensive Care Units; Malnutrition; Nutritional Status; Parenteral Nutrition; Patient Safety; Risk Management
PubMed: 33383941
DOI: 10.3390/nu13010082 -
Nutrients Feb 2022Teduglutide has been described as an effective treatment for parenteral support (PS) reduction in patients with short bowel syndrome (SBS). However, a quantitative... (Meta-Analysis)
Meta-Analysis Review
Teduglutide has been described as an effective treatment for parenteral support (PS) reduction in patients with short bowel syndrome (SBS). However, a quantitative summary of the available evidence is still lacking. PubMed/Medline, EMBASE, Cochrane library, OVID, and CINAHL databases were systematically searched up to July 2021 for studies reporting the rate of response (defined as a ≥20% reduction in PS) to teduglutide among PS-dependent adult patients. The rate of weaning (defined as the achievement of PS independence) was also evaluated as a secondary end-point. Ten studies were finally considered in the meta-analysis. Pooled data show a response rate of 64% at 6 months, 77% at 1 year and, 82% at ≥2 years; on the other hand, the weaning rate could be estimated as 11% at 6 months, 17% at 1 year, and 21% at ≥2 years. The presence of colon in continuity reduced the response rate (-17%, 95%CI: (-31%, -3%)), but was associated with a higher weaning rate (+16%, 95%CI: (+6%, +25%)). SBS etiology, on the contrary, was not found to be a significant predictor of these outcomes, although a nonsignificant trend towards both higher response rates (+9%, 95%CI: (-8%, +27%)) and higher weaning rates (+7%, 95%CI: (-14%, +28%)) could be observed in patients with Crohn's disease. This was the first meta-analysis that specifically assessed the efficacy of teduglutide in adult patients with SBS. Our results provide pooled estimates of response and weaning rates over time and identify intestinal anatomy as a significant predictor of these outcomes.
Topics: Adult; Gastrointestinal Agents; Humans; Parenteral Nutrition; Peptides; Short Bowel Syndrome
PubMed: 35215445
DOI: 10.3390/nu14040796