-
BMC Pediatrics Aug 2022Despite the wide use of parenteral nutrition (PN) in neonatal intensive care units (NICU), there is limited evidence regarding the optimal time to commence PN in term...
BACKGROUND
Despite the wide use of parenteral nutrition (PN) in neonatal intensive care units (NICU), there is limited evidence regarding the optimal time to commence PN in term and late preterm infants. The recommendations from the recently published ESPGHAN/ESPEN/ESPR/CPEN and NICE guidelines are substantially different in this area, and surveys have reported variations in clinical practice. The aim of this randomised controlled trial (RCT) is to evaluate the benefits and risks of early versus late PN in term and late preterm infants.
METHODS/DESIGN
This study is a single-centre, non-blinded RCT in the NICU of Perth Children's Hospital, Western Australia.A total of 60 infants born ≥34 weeks of gestation who have a high likelihood of intolerance to enteral nutrition (EN) for at least 3-5 days will be randomised to early (day 1 or day 2 of admission) or late commencement (day 6 of admission) of PN after informed parental consent. In both groups, EN will be commenced as early as clinically feasible. Primary outcomes are plasma phenylalanine and plasma F-isoprostane levels on Day 4 and Day 8 of admission. Secondary outcomes are total and individual plasma amino acid profiles, plasma and red blood cell fatty acid profiles, in-hospital all-cause mortality, hospital-acquired infections, length of hospital/NICU stay, z scores and changes in z scores at discharge for weight, height and head circumference, time to full EN, duration of respiratory (mechanical, non-invasive) support, duration of inotropic support, the incidence of hyper and hypoglycaemia, incidence of metabolic acidosis, liver function, blood urea nitrogen, and C-reactive protein (CRP).
DISCUSSION
This RCT will examine the effects of early versus late PN in term and late preterm infants by comparing key biochemical and clinical outcomes and has the potential to identify underlying pathways for beneficial or harmful effects related to the timing of commencement of PN in such infants.
TRIAL REGISTRATION
ANZCTR; ACTRN12620000324910 (3rd March 2020).
Topics: Enteral Nutrition; Humans; Infant, Newborn; Infant, Premature; Intensive Care Units, Neonatal; Parenteral Nutrition; Parenteral Nutrition, Total; Randomized Controlled Trials as Topic
PubMed: 36042439
DOI: 10.1186/s12887-022-03569-8 -
Nutricion Hospitalaria Jun 2017
Review
Topics: Adolescent; Child; Child Nutritional Physiological Phenomena; Child, Preschool; Humans; Infant; Infant, Newborn; Parenteral Nutrition; Parenteral Nutrition, Total; Pediatrics; Prescriptions
PubMed: 29154665
DOI: 10.20960/nh.1379 -
Asia Pacific Journal of Clinical... 2015The mortality and morbidity of geriatric patients is much higher than for younger patients, especially when critically ill. This may be attributed to a lower reserve...
The mortality and morbidity of geriatric patients is much higher than for younger patients, especially when critically ill. This may be attributed to a lower reserve capacity in most organs and systems, reduced ability to deal with physical stress and the presence of acute or chronic co-mobidities. Parenteral and enteral nutrition support can improve the clinical condition of the elderly patient and result in better outcomes, such as lower mortality, reduced hospital stay and reduced medical costs. There is a need to standardize nutrition screening and assessment, and the implementation of appropriate evidence based nutritional support of geriatric patients in China. The Chinese Medical Association's Group of Geriatric Nutrition Support has developed guidelines by researching the present situation in Chinese hospitals and by referring to the guidelines from both American Society for Parenteral and Enteral Nutrition (ASPEN) and the European Society for Clinical Nutrition and Metabolism (ESPEN).
Topics: Aged; Aged, 80 and over; China; Dietary Supplements; Enteral Nutrition; Geriatrics; Humans; Malnutrition; Nutrition Assessment; Nutritional Status; Parenteral Nutrition
PubMed: 26078252
DOI: 10.6133/apjcn.2015.24.2.11 -
Asia Pacific Journal of Clinical... 2015Although several large-scale clinical trials shave examined the relationship between early parenteral nutrition (ePN) and critically ill patients, a consensus has not... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Although several large-scale clinical trials shave examined the relationship between early parenteral nutrition (ePN) and critically ill patients, a consensus has not been reached. In addition, no meta-analysis in this area has yet been published. The objective of this meta-analysis was to examine the effect of ePN, alone or accompanying enteral nutrition, in critically ill patients.
METHODS
A meta-analysis was performed to evaluate risk ratios (RR) and mean differences with 95% confidence intervals (CIs) between the ePN and control groups. Subgroup analyses were conducted to evaluate combinations of early enteral nutrition (eEN).
RESULTS
Five randomized control trials (RCTs) were included. Compared with controls, ePN had no effect on mortality (RR: 1.05, 95% CI: 0.96, 1.16). Secondary outcomes were variable: compared with the control group, the ePN group required fewer days of ventilation (p=0.007, RR: -0.95, 95% CI: -1.64, -0.27), but a longer hospital stay (p<0.001, RR: 3.76, 95% CI: 2.25, 5.28).
CONCLUSION
Overall, this meta-analysis from RCTs indicates that provision of ePN within 24-48 hours has no benefit on the survival rate in critically ill patients. Thus, provision of ePN in patients is not needed in those who have contraindications to enteral nutrition or can tolerate a low volume of enteral nutrition.
Topics: Critical Illness; Enteral Nutrition; Humans; Length of Stay; Parenteral Nutrition; Time Factors
PubMed: 26078239
DOI: 10.6133/apjcn.2015.24.2.07 -
Nutrients Nov 2017The feeding of critically ill patients has recently become a controversial issue, as several studies have provided unexpected and contradictory results. Earlier beliefs... (Review)
Review
The feeding of critically ill patients has recently become a controversial issue, as several studies have provided unexpected and contradictory results. Earlier beliefs regarding energy requirements in critical illness-especially during the initial phase-have been challenged. In the current review, we summarize existing evidence about fasting and the impact of early vs. late feeding on the sick organism's responses. The most important points are the non-nutritional advantages of using the intestine, and recognition that early endogenous energy production as an important player in the response must be integrated in the nutrient prescription. There is as of yet no bedside tool to monitor dynamics in metabolism and the magnitude of the endogenous energy production. Hence, an early "full-feeding strategy" exposes patients to involuntary overfeeding, due to the absence of an objective measure enabling the adjustment of the nutritional therapy. Suggestions for future research and clinical practice are proposed.
Topics: Critical Illness; Enteral Nutrition; Humans; Intensive Care Units; Nutritional Status; Nutritional Support; Parenteral Nutrition
PubMed: 29168739
DOI: 10.3390/nu9121278 -
Nutrition in Clinical Practice :... Apr 2022Parenteral nutrition (PN) is a therapy that delivers essential nutrients intravenously to patients who are unable to meet their nutrition requirements via standard... (Review)
Review
Parenteral nutrition (PN) is a therapy that delivers essential nutrients intravenously to patients who are unable to meet their nutrition requirements via standard enteral feeding. This methodology is often referred to as PN when accompanied by minimal or no enteral nutrition (EN). Although PN is lifesaving, significant complications can arise, such as intestinal failure-associated liver disease and gut-mucosal atrophy. The exact mechanism of injury remains ill defined. This review was designed to explore the available literature related to the drivers of injury mechanisms. The Farnesoid X receptor and fibroblast growth factor 19 signaling pathway seems to play an important role in gut-systemic signaling, and its alteration during PN provides insights into mechanistic links. Central line infections also play a key role in mediating PN-associated injury. Although lipid reduction strategies, as well as the use of multicomponent lipid emulsions and vitamin E, have shown promise, the cornerstone of preventing injury is the early establishment of EN.
Topics: Humans; Lipids; Liver Diseases; Parenteral Nutrition; Parenteral Nutrition, Total
PubMed: 35124837
DOI: 10.1002/ncp.10830 -
JPEN. Journal of Parenteral and Enteral... Jan 2018Parenteral nutrition (PN) administered via central venous catheter has been identified as an independent risk factor for central line-associated bloodstream infections...
BACKGROUND
Parenteral nutrition (PN) administered via central venous catheter has been identified as an independent risk factor for central line-associated bloodstream infections (CLABSIs). The aim of this study was to provide an updated description of the relationship between PN and CLABSI and assess temporal trends in CLABSI rates for individuals who received PN from 2009-2014, after the Centers for Medicare & Medicaid declared CLABSI a "never event."
METHODS
Using data obtained from all adult patient discharges between January 1, 2009, and December 31, 2014, from 2 affiliated hospitals in a large health system in New York City, univariate and multivariate analyses were performed to examine the relationship between PN and CLABSIs as well as temporal trends.
RESULTS
Among 38,674 patients with central lines, 3517 developed CLABSIs and 767 patients were prescribed PN. PN was an independent risk factor for developing CLABSI among our patients (odds ratio [OR], 2.65; 95% confidence interval [CI], 2.20-3.19). The incidence of CLABSI among patients who were prescribed PN was not significantly different across the years of this study, even after adjusting for severity of illness.
CONCLUSION
PN remains a significant risk factor for CLABSIs; further work is needed to identify effective strategies to reduce rates of CLABSI among patients receiving PN.
Topics: Catheter-Related Infections; Central Venous Catheters; Female; Humans; Incidence; Intensive Care Units; Male; Middle Aged; New York City; Parenteral Nutrition; Risk Factors
PubMed: 29505142
DOI: 10.1177/0148607116688437 -
Nutrients Jun 2024Choline is an essential nutrient, with high requirements during fetal and postnatal growth. Tissue concentrations of total choline are tightly regulated, requiring an... (Review)
Review
Choline is an essential nutrient, with high requirements during fetal and postnatal growth. Tissue concentrations of total choline are tightly regulated, requiring an increase in its pool size proportional to growth. Phosphatidylcholine and sphingomyelin, containing a choline headgroup, are constitutive membrane phospholipids, accounting for >85% of total choline, indicating that choline requirements are particularly high during growth. Daily phosphatidylcholine secretion via bile for lipid digestion and very low-density lipoproteins for plasma transport of arachidonic and docosahexaenoic acid to other organs exceed 50% of its hepatic pool. Moreover, phosphatidylcholine is required for converting pro-apoptotic ceramides to sphingomyelin, while choline is the source of betaine as a methyl donor for creatine synthesis, DNA methylation/repair and kidney function. Interrupted choline supply, as during current total parenteral nutrition (TPN), causes a rapid drop in plasma choline concentration and accumulating deficit. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) defined choline as critical to all infants requiring TPN, claiming its inclusion in parenteral feeding regimes. We performed a systematic literature search in Pubmed with the terms "choline" and "parenteral nutrition", resulting in 47 relevant publications. Their results, together with cross-references, are discussed. While studies on parenteral choline administration in neonates and older children are lacking, preclinical and observational studies, as well as small randomized controlled trials in adults, suggest choline deficiency as a major contributor to acute and chronic TPN-associated liver disease, and the safety and efficacy of parenteral choline administration for its prevention. Hence, we call for choline formulations suitable to be added to TPN solutions and clinical trials to study their efficacy, particularly in growing children including preterm infants.
Topics: Choline; Humans; Dietary Supplements; Parenteral Nutrition; Infant, Newborn; Infant; Choline Deficiency; Child; Parenteral Nutrition, Total; Child, Preschool
PubMed: 38931230
DOI: 10.3390/nu16121873 -
Nutricion Hospitalaria Jul 2017Home parenteral nutrition (HPN) is a technique that has allowed the survival in the community of those patients with serious diseases resulting in an intestinal failure...
Home parenteral nutrition (HPN) is a technique that has allowed the survival in the community of those patients with serious diseases resulting in an intestinal failure that made their nutrition impossible by other methods. It is indicated if there is a documented intestinal failure (understood by the reduction of the intestinal function to the minimum to the point that intravenous supplementation is required to maintain health and/or growth) with impossibility for oral or enteral exclusive nutrition, provided that there is the possibility of managing the patient at home and that there is no short-term survival expectancy. It requires taking into account the patient's quality of life, family environment and the capacity of the patient and/or their caregivers to be trained for HPN therapy. In low prevalence health topics, as intestinal failure, where the available scientific evidence is of poor quality, consensus documents add value in decision-making. Furthermore, HPN is a complex process and, although there is extensive experience in its application and even clinical practice guidelines, in daily practice there are uncertainties about its suitability, usefulness, rational use and associated costs. For this reason, this document of consensus has been carried out, using the GRADE method. With this document we intend to define our position with regard to the current use of HPN in our country and answer several controversial questions related to this treatment.
Topics: Consensus; Humans; Parenteral Nutrition, Home; Quality of Life; Short Bowel Syndrome; Spain; Survival Analysis
PubMed: 29094999
DOI: 10.20960/nh.881 -
Blood Transfusion = Trasfusione Del... Jul 2017Patients on parenteral nutrition require a central venous access and are at risk of catheter-related thrombosis, pulmonary embolism, and vena cava syndrome. Parenteral... (Review)
Review
BACKGROUND
Patients on parenteral nutrition require a central venous access and are at risk of catheter-related thrombosis, pulmonary embolism, and vena cava syndrome. Parenteral nutrition guidelines suggest anticoagulation for the primary prevention of catheter-related thrombosis during long-term parenteral nutrition. We conducted a systematic review of the efficacy, safety and feasibility of anticoagulant use for preventing and treating catheter-related thrombosis during parenteral nutrition.
MATERIALS AND METHODS
We searched for interventional and observational studies on adults and children receiving systemic anticoagulants during either short- or long-term parenteral nutrition delivered via central venous access. Primary outcomes were: objectively-confirmed catheter-related thrombosis, pulmonary embolism and bleeding. Secondary outcomes were: heparin-induced thrombocytopenia, prevalence of anticoagulation, and quality of International Normalised Ratio management in vitamin K antagonist-treated patients.
RESULTS
We identified 1,199 studies, of which 23 were included. Seven interventional studies of short-term parenteral nutrition (adult population, n=5) were classified as low-quality: in those, intravenous unfractionated heparin did not prevent catheter-related thrombosis if compared to saline. No interventional studies were conducted in patients on long-term parenteral nutrition. Observational data were sparse, rarely focusing on anticoagulation, and overall of low quality. The reported use of anticoagulants was between 22 and 66% in recent multicentre cohorts.
DISCUSSION
The amount and quality of data in this area are very suboptimal: most studies are outdated and involved heterogeneous populations. Currently, there is insufficient evidence to allow conclusions to be reached regarding the efficacy and safety of anticoagulants in this setting.
Topics: Adolescent; Adult; Anticoagulants; Catheters; Child; Child, Preschool; Female; Humans; Infant; Male; Observational Studies as Topic; Parenteral Nutrition; Thrombosis; Time Factors
PubMed: 27483479
DOI: 10.2450/2016.0031-16