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European Journal of Hospital Pharmacy :... Sep 2020For newborn and preterm infants, standardised and individual parenteral nutrition (PN) is used. PN preparation is at risk for contamination and dosing errors. The...
BACKGROUND
For newborn and preterm infants, standardised and individual parenteral nutrition (PN) is used. PN preparation is at risk for contamination and dosing errors. The quality of PN is crucial for infants and has a direct impact on their health status and safety.
PURPOSE
The aim of this study is to evaluate the physicochemical and microbial quality of PN for newborn and preterm infants prepared on a neonatal ward.
METHODS
Sampling of various individual PN prepared by nurses on a neonatal ward was performed. Formulations included maximal four electrolytes, variable dextrose and amino acid concentrations. Depending on the sample volume, up to three quality analyses were performed: (1) test for bacterial endotoxins by kinetic-chromogenic method, (2) sterility according to the European and US Pharmacopoeia, and (3) quantification of electrolytes by capillary electrophoresis and of dextrose by ultraviolet detection after enzymatic reaction of hexokinase. The concentrations obtained were evaluated based on the US and Swiss Pharmacopoeia specifications for compounded preparations and compared to the widened pharmacy specifications.
RESULTS
The composition of 86% of the 110 analysed PN prepared by nurses on the neonatal ward corresponded to their medical prescription. 14% were out of the acceptable widened pharmacy ranges. We found no microbial contamination in the samples. All PN were free from endotoxins.
CONCLUSION
Component concentrations of PN prepared on wards by nurses differed frequently and significantly from their medical prescription, and the deviation can be critical depending on the component and its mode of action. The sample size is too small to evaluate the microbial contamination.
Topics: Drug Contamination; Electrophoresis, Capillary; Humans; Infant Health; Infant, Newborn; Infant, Premature; Nurse's Role; Parenteral Nutrition; Parenteral Nutrition Solutions; Quality Control
PubMed: 32839262
DOI: 10.1136/ejhpharm-2018-001788 -
American Journal of Physiology.... Feb 2020Bile acid receptors regulate the metabolic and immune functions of circulating enterohepatic bile acids. This process is disrupted by administration of parenteral...
Bile acid receptors regulate the metabolic and immune functions of circulating enterohepatic bile acids. This process is disrupted by administration of parenteral nutrition (PN), which may induce progressive hepatic injury for unclear reasons, especially in the newborn, leading to PN-associated liver disease. To explore the role of bile acid signaling on neonatal hepatic function, we initially observed that Takeda G protein receptor 5 (TGR5)-specific bile acids were negatively correlated with worsening clinical disease markers in the plasma of human newborns with prolonged PN exposure. To test our resulting hypothesis that TGR5 regulates critical liver functions to PN exposure, we used TGR5 receptor deficient mice (TGR5). We observed PN significantly increased liver weight, cholestasis, and serum hepatic stress enzymes in TGR5 mice compared with controls. Mechanistically, PN reduced bile acid synthesis genes in TGR5. Serum bile acid composition revealed that PN increased unconjugated primary bile acids and secondary bile acids in TGR5 mice, while increasing conjugated primary bile acid levels in TGR5-competent mice. Simultaneously, PN elevated hepatic IL-6 expression and infiltrating macrophages in TGR5 mice. However, the gut microbiota of TGR5 mice compared with WT mice following PN administration displayed highly elevated levels of and , and possibly responsible for the elevated levels of secondary bile acids in TGR5 animals. Intestinal bile acid transporters expression was unchanged. Collectively, this suggests TGR5 signaling specifically regulates fundamental aspects of liver bile acid homeostasis during exposure to PN. Loss of TGR5 is associated with biochemical evidence of cholestasis in both humans and mice on PN. Parenteral nutrition is associated with deleterious metabolic outcomes in patients with prolonged exposure. Here, we demonstrate that accelerated cholestasis and parental nutrition-associated liver disease (PNALD) may be associated with deficiency of Takeda G protein receptor 5 (TGR5) signaling. The microbiome is responsible for production of secondary bile acids that signal through TGR5. Therefore, collectively, these data support the hypothesis that a lack of established microbiome in early life or under prolonged parenteral nutrition may underpin disease development and PNALD.
Topics: Animals; Bile Acids and Salts; Cholestasis; Female; Gastrointestinal Microbiome; Gene Expression Regulation; Humans; Infant, Newborn; Interleukin-6; Liver Diseases; Liver Function Tests; Male; Mice; Mice, Inbred C57BL; Mice, Knockout; Organ Size; Parenteral Nutrition; Receptors, G-Protein-Coupled; Signal Transduction
PubMed: 31905022
DOI: 10.1152/ajpgi.00216.2019 -
Archivos de Cardiologia de Mexico 2023Nutritional support in adult patients receiving extracorporeal membrane oxygenation (ECMO) therapy is controversial. Although there are guidelines for the NS...
Nutritional support in adult patients receiving extracorporeal membrane oxygenation (ECMO) therapy is controversial. Although there are guidelines for the NS (Nutritional support) in pediatric patients with ECMO, in adults these guidelines are not available for the use, type, route and timing of nutritional therapy. In critically ill patients it is well known that early enteral nutrition is beneficial, however there is the possibility that in patients with ECMO early enteral nutrition leads to gastrointestinal complications. Likewise, there have not been established caloric targets, proteins and doses or types of micronutrients to use for this specific population being a challenge for the clinician. In addition, patients with ECMO are some of the most seriously ill in intensive care units, where malnutrition is associated with increased morbidity and mortality. Regarding the use of parenteral nutrition (NP) it has not been described if it implies a risk of circuit failure at the time of introducing lipids to the oxygenator. Therefore, a correct evaluation and specific nutritional intervention by experts in the field is imperative to improve the prognosis and quality of life in this population, which is a primary goal in the care of adult patients receiving extracorporeal membrane oxygen.
Topics: Adult; Humans; Child; Extracorporeal Membrane Oxygenation; Quality of Life; Malnutrition; Parenteral Nutrition; Intensive Care Units
PubMed: 37562137
DOI: 10.24875/ACM.22000109 -
Sichuan Da Xue Xue Bao. Yi Xue Ban =... Sep 2022With the improvements in medical technology, more premature infants and infants with congenital intestinal malformations or other conditions who need parenteral... (Review)
Review
With the improvements in medical technology, more premature infants and infants with congenital intestinal malformations or other conditions who need parenteral nutrition (PN) support can survive. PN technology has become an important therapeutic strategy in neonatal intensive care units. Due to differences in the qualifications of medical staffs, hospital pharmacy management, hospital level, etc, the composition and preparation methods of PN prescription vary greatly in different regions and hospitals in China. In addition, delays in the starting time of PN, unreasonable formula of nutrition components, poor prescription review, large workload involved in the preparation of PN for nurses, and waste of drugs are prone to happen. In view of these issues, our hospital independently developed standardized formulas of neonatal PN solution, which has been approved in Australia as a patented invention. Herein, we reported the composition and application protocol of this standardized PN solution for newborns.
Topics: China; Drug Compounding; Humans; Infant; Infant, Newborn; Infant, Premature; Parenteral Nutrition
PubMed: 36224701
DOI: 10.12182/20220960107 -
Nutrients Apr 2022Teduglutide (TED) is widely used in patients with short-bowel-syndrome-associated intestinal failure (SBS-IF) to enhance intestinal adaptation and reduce the need for...
Teduglutide (TED) is widely used in patients with short-bowel-syndrome-associated intestinal failure (SBS-IF) to enhance intestinal adaptation and reduce the need for parenteral support (PS). There are limited data on the effects of discontinuing TED. In this study, we describe the changes in parenteral nutrition (PN) requirements and body mass index (BMI) in a 9-year follow-up of patients receiving home parenteral nutrition after discontinuation of the TED treatment. We performed a retrospective analysis of changes in weekly PN orders and BMI in all patients with PN-dependent SBS from two Polish home parenteral nutrition (HPN) centers who received teduglutide between 2009 and 2013 and still required HPN 9 years after discontinuation of the TED treatment. Data included in the analysis were collected prospectively at mandatory visits to the HPN centers at 12, 24, 60, 84, and 108 months after drug discontinuation and compared with values before and after TED treatment. Weekly PN volume values varied significantly between all of the above time points from baseline to 9 years after TED discontinuation (χ2 = 34.860, p < 0.001). After an initial increase within the first year after treatment discontinuation (not statistically significant), the PN volume requirements remained stable for 4 years and increased 5−9 years after treatment discontinuation. The rate of patients requiring an increase in PN volume was 84.62% at 60 and 84 months and 92.30% at 108 months. At 9 years after cessation of the TED treatment, 53.85% of the study group required a 21.21% increase in PN volume compared with values before treatment. The need for PN volume in patients with PN-dependent SBS who discontinued the TED treatment increased within the first year and 4−5 years after treatment cessation, and in some cases might even exceed pretreatment values after 9 years.
Topics: Body Mass Index; Follow-Up Studies; Gastrointestinal Agents; Humans; Nutritional Requirements; Parenteral Nutrition, Home; Peptides; Retrospective Studies; Short Bowel Syndrome
PubMed: 35458196
DOI: 10.3390/nu14081634 -
Asia Pacific Journal of Clinical... 2023Home parenteral nutrition (HPN) is a life sustaining therapy for patients with chronic intestinal failure. Reported outcomes for Asian HPN patients are scarce. We aim to...
BACKGROUND AND OBJECTIVES
Home parenteral nutrition (HPN) is a life sustaining therapy for patients with chronic intestinal failure. Reported outcomes for Asian HPN patients are scarce. We aim to review the clinical outcomes of adult and paediatric HPN patients in our cohort which caters for 95% of Singaporean HPN patients.
METHODS AND STUDY DESIGN
This is a retrospective review of HPN patients from an adult (2002-2017) and paediatric cohort (2011-2017) from the largest tertiary PN centres in Singapore. Patient demographics and clinical outcomes were reviewed.
RESULTS
There were 41 adult and 8 paediatric HPN patients. Mean age was 53.0(±15.1) (adults) and 8(±1.8) years-old (paediatrics). Mean duration of HPN was 2.6(±3.5) and 3.5(±2.5) years. Leading indications for adult HPN were short bowel syndrome (SBS) (n=19,46.3%), mechanical obstruction (n=9,22.0%), and gastrointestinal dysmotility disorders (GID) (n=5,12.2%). Thirteen adult (31.7%) patients had underlying malignancy, with seven (17.3%) receiving palliative HPN. Indications for HPN amongst paediatric patients was GID (n=5,62.5%) and SBS (n=3,37.5%). Central line-associated bloodstream infection (CLABSI)/1000catheter-days was 1.0(±2.1) and 1.8(±1.3). Catheter associated venous thrombosis (CAVT)/1000catheter-days was 0.1(±0.4) and 0.7(±0.8). Biochemical Intestinal Failure Associated Liver Disease (IFALD) was found in 21.9% and 87.5%. For adults, median overall survival was 90-months (4.3,175.7,95%CI), with actuarial survival of 70.7%(1-year) and 39.0%(5-years). Median survival for adult patients with malignancy was 6-months (4.2,7.7,95%CI), actuarial survival of 85.7%(3-months) and 30.7%(1-year). One adult patient died from PN related complications. No paediatric deaths were noted.
CONCLUSIONS
Whilst patient numbers were modest, we report comparable complication and survival rates to other international centres in both our adult and paediatric cohorts.
Topics: Adult; Child; Humans; Middle Aged; Asian People; Intestinal Failure; Liver Failure; Parenteral Nutrition, Home; Singapore; Aged
PubMed: 37382326
DOI: 10.6133/apjcn.202306_32(2).0011 -
Arquivos Brasileiros de Cirurgia... 2021Enterocutaneous fistulas represent a connection between the gastrointestinal tract and adjacent tissues. Among them, there is a subdivision - the enteroatmospheric... (Review)
Review
BACKGROUND
Enterocutaneous fistulas represent a connection between the gastrointestinal tract and adjacent tissues. Among them, there is a subdivision - the enteroatmospheric fistulas, in which the origin is the gastrointestinal tract in connection with the external environment through an open wound in the abdomen. Due to the high output in enterocutaneous fistulas, the loss of fluids, electrolytes, minerals and proteins leads to complications such as sepsis, malnutrition and electrolyte derangements. The parenteral nutrition has its secondary risks, and the fistuloclysis, that consist in the infusion of enteral feeding and also the chyme through the distal fistula, represents an alternative to the management of these patients until the definitive surgical approach.
AIM
To evaluate the current evidence on the fistuloclysis technique, its applicability, advantages and disadvantages for patients with high output fistulas.
METHOD
A systematic literature search was conducted in May 2020 with the headings "fistuloclysis", "chyme reinfusion" and "succus entericus reinfusion", in the PubMed, Medline and SciELO databases. Results: There were 29 articles selected for the development of this narrative synthesis, from 2003 to 2020, including reviews and case reports.
CONCLUSION
Fistuloclysis is a safe method which optimizes the clinical, nutritional, and immunological conditions of patients with enteroatmospheric fistulas, increasing the chances of success of the reconstructive procedure. In cases where the definitive repair is not possible, chances of reducing or even stopping the use of nutrition through the parental route are increased, thus representing a promising modality for the management of most challenging cases.
Topics: Enteral Nutrition; Humans; Intestinal Fistula; Nutritional Status; Parenteral Nutrition; Sepsis
PubMed: 34669893
DOI: 10.1590/0102-672020210002e1605 -
JPEN. Journal of Parenteral and Enteral... May 2022Coronavirus disease 2019 (COVID-19) has created challenges for intensivists, as high ventilatory demands and prolonged hypermetabolism make it difficult to sustain...
BACKGROUND
Coronavirus disease 2019 (COVID-19) has created challenges for intensivists, as high ventilatory demands and prolonged hypermetabolism make it difficult to sustain nutrition status. The purpose of this survey was to determine current practices in nutrition therapy and identify barriers to its delivery.
METHODS
A survey about delivering nutrition therapy to critically ill patients with COVID-19 was sent to clinicians at academic and community hospitals from September to December 2020.
RESULTS
Of 440 who viewed the survey, 199 (45%) completed the questionnaire. Respondents were composed of 30%, physicians and 70% registered dietitians, with 51% representing community programs, 43% academic institutions, and 6% Veterans Affairs centers. Half (49%) had protocols for managing critically ill patients with COVID-19, and 21% had a protocol for nutrition therapy. Although most respondents (83%) attempted to feed by the intragastric route, only 9% indicated that energy/protein needs were met. The biggest barriers to delivery of enteral nutrition (EN) involved the patients unpredictable clinical course and fear of aspiration given the lack of respiratory reserve. Intensivists were reluctant to add supplemental parenteral nutrition (PN) because of perceived lack of benefit.
CONCLUSION
The survey results would suggest that strategies for nutrition therapy based on the intragastric infusion of EN are unsuccessful in meeting the energy/protein needs of critically ill patients with COVID-19. It is likely these barriers exist in providing nutrition to non-Covid-19 critically ill patients. Intensivists need protocols that optimally deliver intragastric EN, consider early postpyloric infusion, and address adding supplemental PN in a deteriorating nutrition status.
Topics: COVID-19; Critical Illness; Enteral Nutrition; Humans; Nutritional Support; Parenteral Nutrition
PubMed: 34486137
DOI: 10.1002/jpen.2263 -
Journal of Pediatric Gastroenterology... Jul 2021With improved survival of children with intestinal failure (IF), it is important to examine the impact on long-term physical function, physical activity (PA), and...
OBJECTIVES
With improved survival of children with intestinal failure (IF), it is important to examine the impact on long-term physical function, physical activity (PA), and fatigue and identify clinical factors that may be predictive of impairment.
METHODS
Cross-sectional study in children with IF on parenteral nutrition (PN) compared with healthy age- and sex-matched controls (HCs). Assessments included: Paediatric Quality of Life (PedsQL) Physical Function subscale, PedsQL Multi-Dimensional Fatigue Scale, and PA Perceived Benefits and Barriers scale. PA was measured using an accelerometer. Medical data was collected by chart abstraction.
RESULTS
Participants included 21 children with IF (14 girls), median age 8.33 (interquartile range [IQR] 6.96-11.04) years and 33 HCs (20 boys), 8.25 (6.67-10.79) years. In those with IF, 13 (62%) were born prematurely with a median of 15 (7.5-24.5) in-patient hospitalizations. There was a significant difference (P = 0.033) in mean steps/day in children with IF (9709 +/- 3975) compared with HCs (13104 +/- 5416), and a correlation between moderate-to-vigorous PA and gestational age (r = 0.642, P = 0.010). Child and parent proxy scores indicate poorer physical function and greater fatigue in the IF group, along with a correlation between greater fatigue (r = -0.538, P = 0.012), poorer physical function (r = -0.0650, P = 0.0001) in children with more hospitalizations. Barriers to PA include "I am tired" and "I am worried about my line."
CONCLUSIONS
Children with IF present with lower levels of PA and physical function and greater fatigue compared with their peers. Ongoing development of medical and rehabilitation intervention strategies is vital to optimize outcomes.
Topics: Child; Cross-Sectional Studies; Exercise; Fatigue; Female; Humans; Male; Parenteral Nutrition; Quality of Life
PubMed: 33797448
DOI: 10.1097/MPG.0000000000003138 -
Annals of Surgery Oct 2023To determine whether the use of an immobilized lipase cartridge (ILC) to hydrolyze fats in enteral nutrition (EN) reduces parenteral nutrition (PN) dependence in a...
OBJECTIVE
To determine whether the use of an immobilized lipase cartridge (ILC) to hydrolyze fats in enteral nutrition (EN) reduces parenteral nutrition (PN) dependence in a porcine model of short bowel syndrome with intestinal failure (SBS-IF).
BACKGROUND
SBS-IF occurs after intestinal loss resulting in malabsorption and PN dependence. Limited therapeutic options are available for achieving enteral autonomy.
METHODS
Eleven Yorkshire piglets underwent 75% jejunoileal resection and were randomized into control (n=6) and treatment (n = 5) groups. PN was initiated postoperatively and reduced as EN advanced if predefined clinical criteria were fulfilled. Animals were studied for 14 days and changes in PN/EN calories were assessed. Intestinal adaptation, absorption, and nutrition were evaluated at the end of the study (day 15). Comparisons between groups were performed using analysis of covariance adjusted for baseline.
RESULTS
ILC animals demonstrated a 19% greater reduction in PN calories ( P < 0.0001) and higher mean EN advancement (66% vs 47% of total calories, P < 0.0001) during the 14-day experiment. Treatment animals had increased intestinal length (19.5 vs 0.7%, P =0.03) and 1.9-fold higher crypt cell proliferation ( P =0.02) compared with controls. By day 15, ILC treatment resulted in higher plasma concentrations of glucagon-like peptide-2 ( P = 0.02), eicosapentaenoic acid ( P < 0.0001), docosahexaenoic acid ( P = 0.004), vitamin A ( P = 0.02), low-density lipoprotein ( P = 0.02), and high-density lipoprotein ( P = 0.04). There were no differences in liver enzymes or total bilirubin between the two groups.
CONCLUSIONS
ILC use in conjunction with enteral feeding reduced PN dependence, improved nutrient absorption, and increased bowel growth in a porcine SBS-IF model. These results support a potential role for the ILC in clinical SBS-IF.
Topics: Animals; Swine; Animals, Newborn; Intestine, Small; Short Bowel Syndrome; Intestines; Intestinal Neoplasms; Parenteral Nutrition
PubMed: 36924229
DOI: 10.1097/SLA.0000000000005839