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Parenteral Nutrition: Current Use, Complications, and Nutrition Delivery in Critically Ill Patients.Nutrients Nov 2023Parenteral nutrition (PN) is needed to avoid the development of malnutrition when enteral nutrition (EN) is not possible. Our main aim was to assess the current use,... (Observational Study)
Observational Study
BACKGROUND
Parenteral nutrition (PN) is needed to avoid the development of malnutrition when enteral nutrition (EN) is not possible. Our main aim was to assess the current use, complications, and nutrition delivery associated with PN administration in adult critically ill patients, especially when used early and as the initial route. We also assessed the differences between patients who received only PN and those in whom EN was initiated after PN (PN-EN).
METHODS
A multicenter ( = 37) prospective observational study was performed. Patient clinical characteristics, outcomes, and nutrition-related variables were recorded. Statistical differences between subgroups were analyzed accordingly.
RESULTS
From the entire population ( = 629), 186 (29.6%) patients received PN as initial nutrition therapy. Of these, 74 patients (11.7%) also received EN during their ICU stay (i.e., PN-EN subgroup). PN was administered early (<48 h) in the majority of patients (75.3%; = 140) and the mean caloric (19.94 ± 6.72 Kcal/kg/day) and protein (1.01 ± 0.41 g/kg/day) delivery was similar to other contemporary studies. PN showed similar nutritional delivery when compared with the enteral route. No significant complications were associated with the use of PN. Thirty-two patients (43.3%) presented with EN-related complications in the PN-EN subgroup but received a higher mean protein delivery (0.95 ± 0.43 vs 1.17 ± 0.36 g/kg/day; = 0.03) compared with PN alone. Once adjusted for confounding factors, patients who received PN alone had a lower mean protein intake (hazard ratio (HR): 0.29; 95% confidence interval (CI): 0.18-0.47; = 0.001), shorter ICU stay (HR: 0.96; 95% CI: 0.91-0.99; = 0.008), and fewer days on mechanical ventilation (HR: 0.85; 95% CI: 0.81-0.89; = 0.001) compared with the PN-EN subgroup.
CONCLUSION
The parenteral route may be safe, even when administered early, and may provide adequate nutrition delivery. Additional EN, when possible, may optimize protein requirements, especially in more severe patients who received initial PN and are expected to have longer ICU stays. NCT Registry: 03634943.
Topics: Adult; Humans; Critical Illness; Intensive Care Units; Parenteral Nutrition; Nutritional Status; Nutritional Support
PubMed: 37960318
DOI: 10.3390/nu15214665 -
Nutrients Jul 2021Neonates with preterm, gastrointestinal dysfunction and very low birth weights are often intolerant to oral feeding. In such infants, the provision of nutrients via... (Review)
Review
Neonates with preterm, gastrointestinal dysfunction and very low birth weights are often intolerant to oral feeding. In such infants, the provision of nutrients via parenteral nutrition (PN) becomes necessary for short-term survival, as well as long-term health. However, the elemental nutrients in PN can be a major source of oxidants due to interactions between nutrients, imbalances of anti- and pro-oxidants, and environmental conditions. Moreover, neonates fed PN are at greater risk of oxidative stress, not only from dietary sources, but also because of immature antioxidant defences. Various interventions can lower the oxidant load in PN, including the supplementation of PN with antioxidant vitamins, glutathione, additional arginine and additional cysteine; reduced levels of pro-oxidant nutrients such as iron; protection from light and oxygen; and proper storage temperature. This narrative review of published data provides insight to oxidant molecules generated in PN, nutrient sources of oxidants, and measures to minimize oxidant levels.
Topics: Antioxidants; Atrophy; Cysteine; Enteral Nutrition; Glutathione; Humans; Infant, Newborn; Infant, Very Low Birth Weight; Lipid Peroxidation; Liver Diseases; Oxidants; Oxidative Stress; Parenteral Nutrition; Parenteral Nutrition, Total; Premature Birth; Reactive Oxygen Species; Vitamins
PubMed: 34444799
DOI: 10.3390/nu13082631 -
Cellular and Molecular Gastroenterology... 2022
Topics: AMP-Activated Protein Kinases; Humans; Non-alcoholic Fatty Liver Disease; Parenteral Nutrition; Parenteral Nutrition, Total
PubMed: 35810785
DOI: 10.1016/j.jcmgh.2022.06.005 -
Nutrients Mar 2020The right amount and quality of amino acids (AAs) supplied to patients on parenteral nutrition (PN) reduces muscle mass loss, may preserve or even increase it, with... (Review)
Review
The right amount and quality of amino acids (AAs) supplied to patients on parenteral nutrition (PN) reduces muscle mass loss, may preserve or even increase it, with significant clinical benefits. Several industrial PN mixtures are available so that nutrition specialists can choose the product closest to the patient's needs. In selected cases, there is the possibility of personalizing compounded mixtures in a hospital pharmacy that completely meets the individual nutritional needs of PN patients. This narrative review deals with the AA solutions used in PN mixtures. The physiology, the methods to calculate the AA needs, and the AA and energy requirements suggested by scientific guidelines for each patient type are also reported.
Topics: Amino Acids; Humans; Nutrients; Nutritional Requirements; Parenteral Nutrition Solutions; Parenteral Nutrition, Total
PubMed: 32183395
DOI: 10.3390/nu12030772 -
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 -
American Journal of Health-system... Jun 2024Parenteral nutrition (PN) is an established therapy when oral/enteral feeding is not sufficient or is contraindicated, but nevertheless PN remains a complex, high-alert... (Review)
Review
PURPOSE
Parenteral nutrition (PN) is an established therapy when oral/enteral feeding is not sufficient or is contraindicated, but nevertheless PN remains a complex, high-alert medication that is susceptible to errors that may affect patient safety. Over time, considerable progress has been made to make PN practices safer. The purpose of this article is to address ongoing challenges to improve the PN use process from prescription to administration and monitoring, and to outline practical aspects fostering the safety, quality, and cost-effectiveness of PN, as discussed at the International Safety and Quality of PN Summit.
SUMMARY
Opportunities to improve the PN use process in clinical practice include the promotion of inter-disciplinary communication, vigilant surveillance for complications, staff education to increase competency, and more consistent use of advanced technologies that allow automated safety checks throughout the PN process. Topics covered include considerations on PN formulations, including the value of intravenous lipid emulsions (ILEs), trends in compounding PN, the current and future role of market-authorized multi-chamber PN bags containing all 3 macronutrients (amino acids, glucose/dextrose, and ILE) in the United States and in Europe, and strategies to cope with the increasing global problem of PN product shortages.
CONCLUSION
This review outlines potential strategies to use in clinical practice to overcome ongoing challenges throughout the PN use process, and ultimately promote PN patient safety.
Topics: Humans; Parenteral Nutrition; Patient Safety; Fat Emulsions, Intravenous; United States; Internationality; Europe
PubMed: 38869257
DOI: 10.1093/ajhp/zxae079 -
Seminars in Fetal & Neonatal Medicine Jun 2022Nutritional support is a fundamental component of the care of the extremely preterm infant, including the "micro preemie" (here defined as a baby born weighing less than... (Review)
Review
Nutritional support is a fundamental component of the care of the extremely preterm infant, including the "micro preemie" (here defined as a baby born weighing less than 500 g), but goes beyond considerations of milk as a food. This is because milk from an infant's own mother, unlike currently available substitutes, additionally provides invaluable non-nutritive benefits. Nutritional support requires suitable devices or techniques to administer nutrients enterally or intravenously, products shown to be safe in preterm populations, and efficacy demonstrated in respect of important functional outcomes. Sadly, preterm feeding remains characterised by a deficit of evidence. In this chapter, we will briefly describe the history of preterm nutrition, discuss current enteral and parenteral practice, important evidence gaps, a summary of approaches for evaluating nutritional practice, and key considerations for future endeavour. Our discussion refers to all extremely preterm infants and it not confined to the micro preemie.
Topics: Enteral Nutrition; Humans; Infant; Infant Formula; Infant Nutritional Physiological Phenomena; Infant, Newborn; Infant, Premature; Milk, Human; Nutritional Status; Parenteral Nutrition
PubMed: 35718688
DOI: 10.1016/j.siny.2022.101344 -
BMJ Paediatrics Open May 2024There is limited evidence regarding the optimal time to commence parenteral nutrition (PN) in term and late preterm infants. (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
There is limited evidence regarding the optimal time to commence parenteral nutrition (PN) in term and late preterm infants.
DESIGN
Single-centre, non-blinded, exploratory randomised controlled trial.
SETTING
A level-3 neonatal unit in a stand-alone paediatric hospital.
PATIENTS
Infants born ≥34 weeks of gestation and ≤28 days, who needed PN. Eligible infants were randomised on day 1 or day 2 of admission.
INTERVENTIONS
Early (day 1 or day 2 of admission, N=30) or late (day 6 of admission, N=30) PN.
MAIN OUTCOME MEASURES
Plasma phenylalanine and F-isoprostane levels on day 4 and day 8 of admission. Secondary outcomes were amino-acid and fatty-acid profiles on day 4 and day 8, and clinical outcomes.
RESULTS
The postnatal age at randomisation was similar between the groups (2.3 (SD 0.8) vs 2.3 (0.7) days, p=0.90). On day 4, phenylalanine levels in early-PN infants were higher than in late-PN (mean (SD) 62.9 (26.7) vs 45.5 (15.3) µmol/L; baseline-adjusted percentage difference 25.8% (95% CI 11.6% to 39.9%), p<0.001). There was no significant difference in phenylalanine levels between the two groups on day 8. There was no significant difference between the groups for F-isoprostane levels on day 4 (early-PN mean (SD) 389 (176) vs late-PN 419 (291) pg/mL; baseline-adjusted percentage difference: -4.4% (95% CI -21.5% to 12.8%) p=0.62) and day 8 (mean (SD) 305 (125) vs 354 (113) pg/mL; adjusted mean percentage difference -16.1 (95% CI -34.1 to 1.9) p=0.09).Postnatal growth restriction for weight was less severe in the early-PN group (change in weight z-score from baseline to discharge: -0.6 (0.6) vs -1.0 (0.6); p=0.02). The incidence of hyperglycaemia was greater in the early-PN group (20/30 (66.7%) vs 11/30 (36.7%), p=0.02).
CONCLUSIONS
The timing of the commencement of PN did not seem to affect the degree of oxidative stress in critically ill term and late preterm infants. The effect of transiently high plasma phenylalanine with early PN on clinical outcomes requires further investigation.
TRIAL REGISTRATION NUMBER
ACTRN12620000324910.
Topics: Humans; Infant, Premature; Infant, Newborn; Parenteral Nutrition; Male; Female; Phenylalanine; Time Factors; F2-Isoprostanes; Gestational Age
PubMed: 38735834
DOI: 10.1136/bmjpo-2024-002579 -
American Journal of Health-system... Jun 2024
Topics: Humans; Parenteral Nutrition; Patient Safety
PubMed: 38869254
DOI: 10.1093/ajhp/zxae076 -
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 (held November 8-10, 2021, at...
PURPOSE
This article is based on presentations and discussions held at the International Safety and Quality of Parenteral Nutrition (PN) Summit (held November 8-10, 2021, at Charleston, SC, and Bad Homburg, Germany) and aims to raise awareness concerning unresolved issues associated with the PN process and potential future directions, including a greater emphasis on patients' perspectives and the role of patient support.
SUMMARY
Ensuring that every patient in need receives adequate PN support remains challenging. It is important to have a standardized approach to identify nutritional risk and requirements using validated nutritional screening and assessment tools. Gaps between optimal and actual clinical practices need to be identified and closed, and responsibilities in the nutrition support team clarified. Use of modern technology opens up opportunities to decrease workloads or liberate resources, allowing a more personalized care approach. Patient-centered care has gained in importance and is an emerging topic within clinical nutrition, in part because patients often have different priorities and concerns than healthcare professionals. Regular assessment of health-related quality of life, functional outcomes, and/or overall patient well-being should all be performed for PN patients. This will generate patient-centric data, which should be integrated into care plans. Finally, communication and patient education are prerequisites for patients' commitment to health and for fostering adherence to PN regimes.
CONCLUSION
Moving closer to optimal nutritional care requires input from healthcare professionals and patients. Patient-centered care and greater emphasis on patient perspectives and priorities within clinical nutrition are essential to help further improve clinical nutrition.
Topics: Humans; Parenteral Nutrition; Patient Safety; Patient-Centered Care; Quality Improvement; Quality of Life; Congresses as Topic
PubMed: 38869258
DOI: 10.1093/ajhp/zxae077