Neonatal Intensive Care Unit Mixed Lipid Emulsion Use Associated With Reduced Cholestasis at Discharge in Surgical Patients.

INTRODUCTION: Parenteral nutrition associated cholestasis (PNAC) is a common morbidity in neonates requiring total parenteral nutrition (TPN). Previous studies in infants with intestinal failure have shown a benefit of mixed lipid emulsion (MLE) in reducing PNAC. It is not known whether this benefit extends to a general neonatal intensive care unit (NICU) population, where MLE is used on a selective basis. The objective of this study is to examine associations between MLE use and PNAC rate in the general NICU setting. METHODS: This is a retrospective review of NICU patients who received TPN for 7 or more days. We compared patients born between 1/1/2014 and 12/31/2015 (pre-MLE) to patients born between 7/1/2017 and 12/31/2018 (post-MLE). Fisher's exact test and two-sample t-test were used to compare the two groups. RESULTS: There were 353 patients in 2014-2015 and 271 patients in 2017-2018. Demographics were similar between the two groups, but there were more patients with congenital heart disease in the MLE era (P < 0.001). Mortality was similar (6.2% pre-MLE versus 6.3% post-MLE). There was no significant difference in PNAC rate between the pre-MLE (11.5%) and post-MLE (14.1%) patient cohorts (P = 0.342). Among patients receiving MLE (n = 38), 58% developed PNAC, while only 6.4% of the post-MLE cohort not receiving MLE developed PNAC. Of the patients coded with a surgical diagnosis, there was no significant difference in PNAC rates between pre-MLE and post-MLE groups. Discharge rates of PNAC did differ between pre-MLE surgical patients (13.0%) and post-MLE surgical patients (8.2%). In the subgroup of post-MLE surgical patients, PNAC rate differed significantly between those receiving MLE (43.5%) and not receiving MLE (15.4%). However, this difference was resolved by discharge (8.7% versus 7.7%). CONCLUSIONS: There were no significant differences in PNAC rates between the pre-MLE and post-MLE cohorts. However, in surgical patients, MLE was associated with reduced PNAC at discharge, with levels equivalent to those seen in neonates receiving TPN for 7 or more days, despite having a higher starting rate of PNAC. Further studies are needed to determine whether the general NICU population may benefit from MLE or certain selective subpopulations like surgical patients.

Experience, decision-making and information needs around parenteral nutrition among people with advanced cancer, and their carers: A scoping review.

BACKGROUND: The present study aims to summarise current knowledge and identify gaps in knowledge and research regarding experience, decision-making and information needs around parenteral nutrition, among people with advanced cancer, and their carers. METHODS: This review was informed by previous methods and guidance on conducting and reporting scoping reviews. A literature search was conducted in March 2021 using Embase, Medline, CINAHL, Google and Web of Science to identify studies that examined the experience, decision-making process and information needs of adults with advanced cancer, and their carers, who were making decisions around commencing and discontinuing parenteral nutrition. There were no date limitations, although only papers published in English were included. RESULTS: Of the 588 papers identified, 12 papers, all qualitative, met the eligibility criteria. Despite the reported negative aspects of home parenteral nutrition, patients and carers felt the benefits outweighed these. There was variability in whether patients and carers felt involved in decisions around commencing parenteral nutrition. No studies specifically addressed information needs. CONCLUSIONS: Research is required to explore the information that patients with advanced cancer, and their carers, need to facilitate their decision-making around commencing and discontinuing parenteral nutrition. We recommend the development of processes for obtaining written informed consent from patients commencing parenteral nutrition to ensure that core topics are discussed on initiation, enabling patients and carers to make informed decisions. Additionally, we recommend development of a national framework to inform patients and carers of the whole discharge process on PN from decision-making to discontinuing PN.

Evaluating the efficacy of a programme to educate nurses on CLABSI linked to total parenteral nutrition administration.

BACKGROUND: There is a major need to improve the knowledge and practice of critical care nurses in India regarding central line-associated bloodstream infection (CLABSI), which is a serious potential complication of total parenteral nutrition (TPN). OBJECTIVES: To develop and validate a skills competency programme; assess knowledge and practice of critical care nurses regarding prevention of CLABSI due to TPN administration; evaluate the effectiveness of the programme; find correlation between knowledge and practice scores. DESIGN: Quasi-experimental: non-equivalent pre-test post-test design. SETTINGS: Two hospitals in Meerut, India. PARTICIPANTS: 80 nurses (40 in the control group in one hospital, 40 in the experimental group in another hospital). Inclusion criteria: staff nurses from critical care units only, who were present at the time of data collection and willing to participate. Exclusion criteria: staff nurses with <6 months' work experience. METHOD: Knowledge was assessed using a structured knowledge questionnaire and interpretation scoring. To assess practice, the OSCE (objective structured clinical examination) method was used with four stations and interpretation scoring. The skills-competency programme was delivered to the experimental group only. The post test was conducted with both groups. RESULTS: The post-test knowledge and practice scores in the control group were: mean=12.55; SD=2.57 and mean=21.82; SD= 5.13 respectively. In the experimental group, the post-test knowledge and practice scores were: mean=23.75; SD=1.75 and mean=38.9; SD=2.02 respectively. The unpaired t-test in post-test knowledge between the control and experimental groups was t=22.78, with P=0.0001 at df 39, 0.05 level of significance, 95% CI; for post-test practice the results were, t=19.59, with P=0.0001 at df 39, 0.05 level of significance, 95% CI. Correlation between post-test knowledge and the practice score was r=0.7 (P<0.05), 95% CI. CONCLUSION: There was a significant difference in post-test knowledge and practice scores, therefore, the skills competency programme was effective. It also highlighted areas that institutions should focus on for effective training and professional development programmes.

Impact of computerized physician order entry system on parenteral nutrition medication errors in a teaching neonatal intensive care unit.

OBJECTIVES: Parenteral nutrition (PN) offers a quality therapeutic option when enteral feeding is non-tolerated or impossible. However, it can be associated with an increased risk of medical errors, especially in sensitive populations such as newborns. This study aimed at determining the impact of the implementation of a computerized physician order entry (CPOE) system on PN medication errors in the neonatology department in the largest teaching hospital in Tunisia. MATERIEL AND METHODS: The frequency of medication errors in PN, in a teaching neonatal intensive care unit, was prospectively reviewed by a pharmacist between December 2018 and March 2019 in a two-phase interventional study (pre and post locally developed CPOE System implementation). RESULTS: Implementation of CPOE system decreased PN order errors from 379 to 147 representing a 61.1% reduction. The decreases on PN order errors per stage, i.e. prescribing and preparation, were form 207 to 22 (89.4%), and from 117 to 66 (43.6%), respectively. Mean nutrients intakes were in conformity to the recommended daily intakes during the CPOE phase of the study. CPOE is a protective tool against prescription and preparation errors. It significantly impacted all items of the ordering process. CONCLUSIONS: In addition to the rigorous application of the recommendations, the CPOE system allows to reduce the risk of PN medication errors. This improves the safety and quality of medicines in newborns.

Exploring the malnutrition status and impact of total parenteral nutrition on the outcome of patients with advanced stage ovarian cancer.

BACKGROUND: Ovarian cancer is a common cancer type in women and is often associated with onset of malnutrition. Total parenteral nutrition (TPN) is a nutritional intervention method that has been reported to have controversial effect on cancer patients. In the present retrospective study, we sought to explore the prevalence of malnutrition assessed by the Nutritional Risk Index (NRI) and its association with survival in advanced stage ovarian cancer patients. We also compared the post-operative outcome of the malnourished patients treated with either TPN or conservative management. RESULTS: A total of 415 patients with advanced stage ovarian cancer were separated into 4 nutrition groups based on the NRI scores. We found that a number of factors were significantly different among the 4 nutrition groups, including age, serum albumin level, BMI and NRI; among which serum albumin level and NRI were identified to be independent predictors of progression-free and overall survival. In the moderately and severely malnourished patients, those who were treated with TPN had significantly shorter hospitalization period, lower serum albumin level and lower BMI after surgery. In addition, serum albumin level, use of TPN and number of patients with complications were closely related to the hospital stay duration. CONCLUSION: Malnutrition status is closely associated with survival of advanced stage ovarian cancer patients. These patients may benefit from TPN treatment for reduced hospitalization, especially with the onset of hypoalbuminemia.

Microbial growth and importance of flushing inside closed-type infusion devices during administration of lipid emulsion in vitro setting.

Background: We investigated the extent of growth of microorganisms with simultaneous administration of lipid emulsions with infusions for Total Parenteral Nutrition (TPN), assuming that the lipid emulsions contaminated with microorganisms are stagnant in a closed-type infusion device. We also investigated if bacterial growth can be prevented in the infusion device by flushing the inside of the infusion device with saline solution after the administration of lipid emulsion from the side tube in vitro setting. Methods: We made a preparation by adding Escherichia coli to the lipid emulsion and started the infusion simultaneously with the infusion solution for TPN and lipid emulsion with the piggyback method. Immediately after the completion of lipid emulsion infusion, we conducted flushing with saline solution. The volume of saline solution was none, 5, 10, or 20 mL at a flow rate of 1 mL/s. Infusion solution that was stagnant in the infusion device was collected immediately before completing the lipid emulsion infusion and 20 h after flushing, i.e., 24 h after starting the infusion for TPN, and the number of viable bacteria was determined. Results: The number of viable E. coli increased in the infusion device of all three species used in this experiment 24 h after starting the lipid emulsion infusion without flushing. We found that bacterial growth could be prevented through flushing with saline solution after the completion of lipid emulsion infusion and flushing out the stagnant infusion solution in the closed-type infusion device. Conclusions: We found that if E. coli was present in the closed-type infusion device, it would multiply. We also found that the number of viable bacteria varied according to the variety and internal structure of the closed-type infusion device as well as the liquid volume used for flushing, although flushing can prevent the growth of microorganisms. Proper management and manipulation of infusion is required to prevent infection.

[A comparative study evaluating improvements in nutritional status and zinc deficiency by oral and enteral versus parenteral nutrition in elderly inpatients discharged from the internal medicine department of an emergency hospital].

AIM: The controlling nutrition status (CONUT) score assesses the nutritional status of subjects by considering the serum albumin level, total lymphocyte count, and total cholesterol level. We estimated the efficacy of total parenteral nutrition for improving the nutritional status and zinc deficiency. METHODS: In total, 493 elderly inpatients who were admitted to the internal medicine department of an emergency hospital over 7 years were divided into 2 groups: patients who were discharged (320 patients) and those who died in the hospital (173 patients). The discharged patients were further divided to four groups according time of discharge from the hospital; oral nutrition, enteral nutrition, peripheral parenteral nutrition, and total parenteral nutrition. Using analysis of variance (ANOVA), we compared the albumin and zinc levels and the CONUT score within 10 days post-admission and before discharge from the hospital. RESULTS: Japanese society is rapidly aging. In patients who were leaving the hospital, the CONUT score improved with oral and enteral nutrition. The zinc level improved with oral, enteral, peripheral parenteral, and total parenteral nutrition. While the nutritional status of patients at the time of discharge improved with oral and enteral nutrition, total parenteral nutrition without oral or enteral nutrition did not improve the status. CONCLUSION: To discharge patients alive, efforts must be made to continue oral and enteral nutrition for as long as possible.

Effect of withholding early parenteral nutrition in PICU on ketogenesis as potential mediator of its outcome benefit.

BACKGROUND: In critically ill children, omitting early use of parenteral nutrition (late-PN versus early-PN) reduced infections, accelerated weaning from mechanical ventilation, and shortened PICU stay. We hypothesized that fasting-induced ketogenesis mediates these benefits. METHODS: In a secondary analysis of the PEPaNIC RCT (N = 1440), the impact of late-PN versus early-PN on plasma 3-hydroxybutyrate (3HB), and on blood glucose, plasma insulin, and glucagon as key ketogenesis regulators, was determined for 96 matched patients staying ≥ 5 days in PICU, and the day of maximal 3HB-effect, if any, was identified. Subsequently, in the total study population, plasma 3HB and late-PN-affected ketogenesis regulators were measured on that average day of maximal 3HB effect. Multivariable Cox proportional hazard and logistic regression analyses were performed adjusting for randomization and baseline risk factors. Whether any potential mediator role for 3HB was direct or indirect was assessed by further adjusting for ketogenesis regulators. RESULTS: In the matched cohort (n = 96), late-PN versus early-PN increased plasma 3HB throughout PICU days 1-5 (P < 0.0001), maximally on PICU day 2. Also, blood glucose (P < 0.001) and plasma insulin (P < 0.0001), but not glucagon, were affected. In the total cohort (n = 1142 with available plasma), late-PN increased plasma 3HB on PICU day 2 (day 1 for shorter stayers) from (median [IQR]) 0.04 [0.04-0.04] mmol/L to 0.75 [0.04-2.03] mmol/L (P < 0.0001). The 3HB effect of late-PN statistically explained its impact on weaning from mechanical ventilation (P = 0.0002) and on time to live PICU discharge (P = 0.004). Further adjustment for regulators of ketogenesis did not alter these findings. CONCLUSION: Withholding early-PN in critically ill children significantly increased plasma 3HB, a direct effect that statistically mediated an important part of its outcome benefit.

Omega-3 fatty acid-containing parenteral nutrition in ICU patients: systematic review with meta-analysis and cost-effectiveness analysis.

BACKGROUND: Omega-3 (ω-3) fatty acid (FA)-containing parenteral nutrition (PN) is associated with significant improvements in patient outcomes compared with standard PN regimens without ω-3 FA lipid emulsions. Here, we evaluate the impact of ω-3 FA-containing PN versus standard PN on clinical outcomes and costs in adult intensive care unit (ICU) patients using a meta-analysis and subsequent cost-effectiveness analysis from the perspective of a hospital operating in five European countries (France, Germany, Italy, Spain, UK) and the US. METHODS: We present a pharmacoeconomic simulation based on a systematic literature review with meta-analysis. Clinical outcomes and costs comparing ω-3 FA-containing PN with standard PN were evaluated in adult ICU patients eligible to receive PN covering at least 70% of their total energy requirements and in the subgroup of critically ill ICU patients (mean ICU stay > 48 h). The meta-analysis with the co-primary outcomes of infection rate and mortality rate was based on randomized controlled trial data retrieved via a systematic literature review; resulting efficacy data were subsequently employed in country-specific cost-effectiveness analyses. RESULTS: In adult ICU patients, ω-3 FA-containing PN versus standard PN was associated with significant reductions in the relative risk (RR) of infection (RR 0.62; 95% CI 0.45, 0.86; p = 0.004), hospital length of stay (HLOS) (- 3.05 days; 95% CI - 5.03, - 1.07; p = 0.003) and ICU length of stay (LOS) (- 1.89 days; 95% CI - 3.33, - 0.45; p = 0.01). In critically ill ICU patients, ω-3 FA-containing PN was associated with similar reductions in infection rates (RR 0.65; 95% CI 0.46, 0.94; p = 0.02), HLOS (- 3.98 days; 95% CI - 6.90, - 1.06; p = 0.008) and ICU LOS (- 2.14 days; 95% CI - 3.89, - 0.40; p = 0.02). Overall hospital episode costs were reduced in all six countries using ω-3 FA-containing PN compared to standard PN, ranging from €-3156 ± 1404 in Spain to €-9586 ± 4157 in the US. CONCLUSION: These analyses demonstrate that ω-3 FA-containing PN is associated with statistically and clinically significant improvement in patient outcomes. Its use is also predicted to yield cost savings compared to standard PN, rendering ω-3 FA-containing PN an attractive cost-saving alternative across different health care systems. STUDY REGISTRATION: PROSPERO CRD42019129311.

A framework to support quality of care for patients with chronic intestinal failure requiring home parenteral nutrition.

BACKGROUND AND AIM: Chronic intestinal failure requiring home parenteral nutrition (HPN) is a disabling condition that is best facilitated by a multidisciplinary approach to care. Variation in care has been identified as a key barrier to achieving quality of care for patients on HPN and requires appropriate strategies to help standardize management. METHOD: The Australasian Society for Parenteral and Enteral Nutrition (AuSPEN) assembled a multidisciplinary working group of 15 clinicians to develop a quality framework to assist with the standardization of HPN care in Australia. Obstacles to quality care specific to Australia were identified by consensus. Drafts of the framework documents were based on the available literature and refined by two Delphi rounds with the clinician work group, followed by a further two involving HPN consumers. The Oxford Centre for Evidence-Based Medicine Levels of Evidence was used to assess the strength of evidence underpinning each concept within the framework documents. RESULTS: Quality indicators, standards of care, and position statements have been developed to progress the delivery of quality care to HPN patients. CONCLUSION: The quality framework proposed by AuSPEN is intended to provide a practical structure for clinical and organizational aspects of HPN service delivery to reduce variation in care and improve quality of care and represents the initial step towards development of a national model of care for HPN patients in Australia. While developed for implementation in Australia, the evidence-based framework also has relevance to the international HPN community.

Meeting nutritional targets of critically ill patients by combined enteral and parenteral nutrition: review and rationale for the EFFORTcombo trial.

While medical nutrition therapy is an essential part of the care for critically ill patients, uncertainty exists about the right form, dosage, timing and route in relation to the phases of critical illness. As enteral nutrition (EN) is often withheld or interrupted during the intensive care unit (ICU) stay, combined EN and parenteral nutrition (PN) may represent an effective and safe option to achieve energy and protein goals as recommended by international guidelines. We hypothesise that critically ill patients at high nutritional risk may benefit from such a combined approach during their stay on the ICU. Therefore, we aim to test if an early combination of EN and high-protein PN (EN+PN) is effective in reaching energy and protein goals in patients at high nutritional risk, while avoiding overfeeding. This approach will be tested in the here-presented EFFORTcombo trial. Nutritionally high-risk ICU patients will be randomised to either high (≥2·2 g/kg per d) or low protein (≤1·2 g/kg per d). In the high protein group, the patients will receive EN+PN; in the low protein group, patients will be given EN alone. EN will be started in accordance with international guidelines in both groups. Efforts will be made to reach nutrition goals within 48-96 h. The efficacy of the proposed nutritional strategy will be tested as an innovative approach by functional outcomes at ICU and hospital discharge, as well as at a 6-month follow-up.

Parenteral nutrition in adults during acute illness: a clinical perspective for clinicians.

Parenteral nutrition (PN) is the administration of a nutritional formula by means other than the gastrointestinal (GI) tract. The formula may include carbohydrates, amino acids, lipids, electrolytes and/or micronutrients. The primary indications for PN are intestinal failure (IF) due to an underlying disease or treatment, or if the GI tract is not accessible. The goals of PN should be to ensure adequate nutrition provision to meet patient needs while minimising the risk of complications. PN should be commenced in <48 h in patients who are malnourished or otherwise within 7 days if oral or enteral nutrition is not possible or insufficient. There has been evolution in PN techniques and technology, and the risks associated with PN administration have been reduced. Monitoring clinical, laboratory and metabolic parameters in acute IF is essential to provision of safe nutritional support. When provided to appropriate patients with IF in a timely and considered manner, PN has been shown to be safe, improve nutritional parameters and reduce complications associated with malnutrition. This review aims to provide clinicians a practical guide for the management of PN in adult patients within the acute setting.

Early administration of amino acids with different doses in low birth weight premature infants.

BACKGROUND: The reasonable use of amino acids (AAs) in parenteral nutrition (PN) is very critical to the growth and development of premature infants. However, the appropriate dose of AAs has not been determined. Our study was designed to investigate the clinical effect of two different doses of AAs in PN for low birth weight premature infants. MATERIALS AND METHODS: This randomized controlled study included 191 preterm infants who admitted to the neonatal intensive care unit of the First Affiliated Hospital of Nanjing Medical University from June 2015 to December 2016 and they were randomly divided into Group 1 (n = 81) and Group 2 (n = 110). In Group 1, the starting dose of AAs dose was 1.0-1.5 g/kg/day, which was increased by 0.5 g/kg with the maximum dose at 3.5 g/kg/day. In Group 2, the starting dose of AAs was 1.8-2.5 g/kg/day and was increased by 1.0 g/kg with the maximum dose at 4.0-4.5 g/kg/day. We analyzed the clinical characteristics, body weight, body length, total calorie intake, nonprotein calorie intake, total protein intake, liver and kidney function, and complications of the two groups of preterm infants. RESULTS: The start of enteral feeding and the recovery of birth weight in Group 2 were earlier than those in Group 1 (3.83 ± 3.15 day vs. 5.53 ± 5.63 day, P = 0.016 and 6.36 ± 4.88 day vs. 8.48 ± 9.27 day, P = 0.043, respectively). The duration of PN and the time before total enteral nutrition were shorter in Group 2 than in Group 1 (16.46 ± 10.33 day vs. 21.41 ± 18.00 day, P = 0.029 and 15.47 ± 10.54 day vs. 19.47 ± 14.57 day, P = 0.038; respectively). The duration of mechanical ventilation (1.12 ± 2.62 day vs. 3.31 ± 8.13 day, P = 0.028) in Group 2 was shorter than that in Group 1. CONCLUSION: High doses of AAs in the early PN for preterm infants facilitate the promotion of early growth and development, advance recovery of birth weight, reduce the duration of PN, and reduce respiratory support without increasing the incidence of complications.

Medical Nutrition Terminology and Regulations in the United States and Europe-A Scoping Review: Report of the ISPOR Nutrition Economics Special Interest Group.

BACKGROUND: The term medical nutrition (MN) refers to nutritional products used under medical supervision to manage disease- or condition-related dietary needs. Standardized MN definitions, aligned with regulatory definitions, are needed to facilitate outcomes research and economic evaluation of interventions with MN. OBJECTIVES: Ascertain how MN terms are defined, relevant regulations are applied, and to what extent MN is valued. METHODS: ISPOR's Nutrition Economics Special Interest Group conducted a scoping review of scientific literature on European and US MN terminology and regulations, published between January 2000 and August 2015, and pertinent professional and regulatory Web sites. Data were extracted, reviewed, and reconciled using two-person teams in a two-step process. The literature search was updated before manuscript completion. RESULTS: Of the initial 1687 literature abstracts and 222 Web sites identified, 459 records were included in the analysis, of which 308 used MN terms and 100 provided definitions. More than 13 primary disease groups as per International Classification of Disease, Revision 10 categories were included. The most frequently mentioned and defined terms were enteral nutrition and malnutrition. Less than 5% of the records referenced any MN regulation. The health economic impact of MN was rarely and insufficiently (n = 19 [4.1%]) assessed, although an increase in economic analyses was observed. CONCLUSIONS: MN terminology is not consistently defined, relevant European and US regulations are rarely cited, and economic evaluations are infrequently conducted. We recommend adopting consensus MN terms and definitions, for example, the European Society for Clinical Nutrition and Metabolism consensus guideline 2017, as a foundation for developing reliable and standardized medical nutrition economic methodologies.

Intravenous Lipid Emulsions in Infants: Is Balanced Better?

Parenteral nutrition (PN) is frequently required by extremely preterm infants due to gastrointestinal immaturity and complications of prematurity. Parenteral nutrition-associated cholestasis (PNAC) and intestinal failure-associated liver disease (IFALD) are common complications of prolonged PN. Plant-based intravenous lipid emulsions, containing proinflammatory omega-6 fatty acids and phytosterols, may contribute to these conditions as well as other comorbidities such as bronchopulmonary dysplasia and retinopathy of prematurity. Intravenous lipid emulsions containing animal-based fats, such as fish oil, contain fewer proinflammatory omega-6 fatty acids and more anti-inflammatory omega-3 fatty acids and antioxidants. SMOFlipid, recently Food and Drug Administration (FDA)-approved for adult use, is a blend of plant- and animal-based lipid emulsions with a favorable omega-6:omega-3 ratio that may prevent the development and progression of PNAC/IFALD in infants. Careful review of data supporting this alternative intravenous lipid emulsion is required prior to widespread use in neonatal intensive care.

Enhanced Recovery after Surgery Protocol for Pediatric Urological Augmentation and Diversion Surgery Using Small Bowel.

PURPOSE: Enhanced recovery after surgery protocols aim to improve recovery following urological augmentation and diversion surgery. Based on the positive experiences in adult patients, we evaluated safety and outcomes after implementation of an enhanced recovery after surgery protocol in children undergoing urological augmentation and diversion using small bowel. MATERIALS AND METHODS: Complications, time to stool, time to flatus and total hospital stay of 15 consecutive patients (group 2) were recorded and compared to the data of 15 consecutive patients before the changes in protocol were effective (group 1). The groups were comparable in age (mean 10.93 vs 9.267 years, p = 0.33), gender (p = 0.71) and operative times (387.9 vs 336.5 minutes, p = 0.19). RESULTS: Compared to the previous protocol involving a mean ± SD of 7.9 ± 1.38 enhanced recovery after surgery items per patient, 15.9 ± 0.26 items per patient were implemented in the new protocol. In group 2 mild bowel related complications were less frequent (1 vs 5, p = 0.168). Time to stool was significantly shorter in group 2 (3.33 vs 5.53 days, p = 0.002), as was time to flatus (2.8 vs 4.73 days, p = 0.002). Total hospital stay in group 2 was 11.93 days, compared to 19.87 days in group 1 (p <0.001), mainly due to more rapid convalescence, although influenced by associated changes in the postoperative protocol as well. CONCLUSIONS: In pediatric augmentation and diversion surgery using small bowel the implementation of an enhanced recovery after surgery protocol is safe and effective, reinforcing faster bowel recovery. We did not observe complications or problems after introducing the new protocol.

Cost-effectiveness study of early versus late parenteral nutrition in critically ill children (PEPaNIC): preplanned secondary analysis of a multicentre randomised controlled trial.

BACKGROUND: The multicentre randomised controlled PEPaNIC trial showed that withholding parenteral nutrition (PN) during the first week of critical illness in children was clinically superior to providing early PN. This study describes the cost-effectiveness of this new nutritional strategy. METHODS: Direct medical costs were calculated with use of a micro-costing approach. We compared the costs of late versus early initiation of PN (n = 673 versus n = 670 patients) in the Belgian and Dutch study populations from a hospital perspective, using Student's t test with bootstrapping. Main cost drivers were identified and the impact of new infections on the total costs was assessed. RESULTS: Mean direct medical costs for patients receiving late PN (€26.680, IQR €10.090-28.830 per patient) were 21% lower (-€7.180, p = 0.007) than for patients receiving early PN (€33.860, IQR €11.080-34.720). Since late PN was more effective and less costly, this strategy was superior to early PN. The lower costs for PN only contributed 2.1% to the total cost reduction. The main cost driver was intensive care hospitalisation costs (-€4.120, p = 0.003). The patients who acquired a new infection (14%) were responsible for 41% of the total costs. Sensitivity analyses confirmed consistency across both healthcare systems. CONCLUSIONS: Late initiation of PN decreased the direct medical costs for hospitalisation in critically ill children, beyond the expected lower costs for withholding PN. Avoiding new infections by late initiation of PN yielded a large cost reduction. Hence, late initiation of PN was superior to early initiation of PN largely via its effect on new infections. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01536275 . Registered on 16 February 2012.

Nutrition and Hyperglycemia Management in the Inpatient Setting (Meals on Demand, Parenteral, or Enteral Nutrition).

PURPOSE OF REVIEW: The goal of this paper is to provide the latest evidence and expert recommendations for management of hospitalized patients with diabetes or hyperglycemia receiving enteral (EN), parenteral (PN) nutrition support or, those with unrestricted oral diet, consuming meals on demand. RECENT FINDINGS: Patients with and without diabetes mellitus commonly develop hyperglycemia while receiving EN or PN support, placing them at increased risk of adverse outcomes, including in-hospital mortality. Very little new evidence is available in the form of randomized controlled trials (RCT) to guide the glycemic management of these patients. Reduction in the dextrose concentration within parenteral nutrition as well as selection of an enteral formula that diminishes the carbohydrate exposure to a patient receiving enteral nutrition are common strategies utilized in practice. No specific insulin regimen has been shown to be superior in the management of patients receiving EN or PN nutrition support. For those receiving oral nutrition, new challenges have been introduced with the most recent practice allowing patients to eat meals on demand, leading to extreme variability in carbohydrate exposure and risk of hypo and hyperglycemia. Synchronization of nutrition delivery with the astute use of intravenous or subcutaneous insulin therapy to match the physiologic action of insulin in patients receiving nutritional support should be implemented to improve glycemic control in hospitalized patients. Further RCTs are needed to evaluate glycemic and other clinical outcomes of patients receiving nutritional support. For patients eating meals on demand, development of hospital guidelines and policies are needed, ensuring optimization and coordination of meal insulin delivery in order to facilitate patient safety.

The potential benefits and harms of early feeding post-surgery: a literature review.

The effect of nutrition on wound healing is widely recognized, with many studies highlighting the detrimental effect poor nutrition can have on wound healing. In addition, fasting pre-, peri- and postoperatively can contribute to further protein catabolism, leading to morbidity and mortality. By reviewing the current literature, this work evaluates the potential benefits and harms from early feeding (EF) during the early stages postsurgery. Current randomised control trials suggest that the early introduction of nutrients post-surgery may be beneficial for wound healing and recovery from surgery. Additionally, this approach does not seem to impose any increased complications post-operatively. Conversely, although there is ongoing research supporting EF and evidence showing that malnutrition can delay wound healing and recovery, healthcare professionals remain sceptical with a slow uptake in adopting EF protocols.

[Intestinal transplantation in Czech Republic]. / Transplantace tenkého streva v Ceské republice.

Intestinal transplantation represents a suitable treatment for patients with intestinal failure who then develop life-threatening complications of total parenteral nutrition and for some patients with complex abdominal disorders not suitable for conventional treatment. METHODS: prior to launch of the clinical program, preparation started in 2006 initially with extensive experimentation carried out on pigs. The clinical phase involved a specialized, multidisciplinary team who examined 23 patients being considered for transplantation. Seven patients were put on a waiting list and one female, due to the improvement of her medical status, was unlisted. The first ever intestinal transplantation was done in 2014. RESULTS: three out of six transplanted patients are alive with 380 days of actual survival; median 131 days (63-763). Two patients are on a full oral diet and nutritionally independent with an excellent quality of life. One female is nutritionally independent but with the need for partial supplemental parenteral rehydration due to the stomal output. CONCLUSION: intestinal transplantation is a suitable treatment for highly selected patients with intestinal failure who meet specific listing criteria.