Foods for Special Medical Purposes in Home Enteral Nutrition-Clinical Practice Experience. Multicenter Study.

Background: Enteral nutrition (EN) with foods for special medical purposes (FSMP) is recommended for most patients on home enteral nutrition (HEN). Although there are disease-specific guidelines for energy, protein, and micronutrient provision, only a few studies are showing real-life experience in the long-term use of FSMP. Methods: In a multicenter study, the influence of the FSMP composition and administration technique (bolus vs. continuous) on protein and energy provision in HEN was analyzed. Provision of vitamins and minerals was compared to recommended daily allowance (RDA) and upper tolerable limit (UL). Results: Approximately, 772 patients on HEN, mostly (88.6%) with oncological and neurological diseases, were enrolled. The patients on standard FSMP received less protein and energy than those on hypercaloric and protein enriched despite receiving higher volumes of EN (p < 0.05). No differences were observed in jejunal feeding with oligomeric vs. polymeric FSMP in terms of energy, protein, and volume. Continuous gastric feeding provided more protein, energy, and volume vs. bolus feeding (p < 0.05). Significant number of patients received less than 100% RDA of vitamin D (50.5%), vitamin B3 (49%), vitamin K (21.8%), vitamin B5 (64.3%), vitamin B9 (60%). Majority of the patients received less than 100% RDA of sodium (80.2%), potassium (99%), chloride (98%), calcium (67%), magnesium (87%), fluoride (99%), and iodine (43%). Approximately, 43.63% of cancer and 49.9% of neurological patients received less than 1 g/kg/day of protein and 51.7% of cancer and 55.5% of neurological patients received less than 25 kcal/kg/day. Conclusion: Awareness of the available compositions of FSMP and advantageous profiles of specific diets may lead to the implementation of recommendations for EN. HEN professionals need to analyze all the patient's needs and requirements to provide more tailored matching of nutritional support.

Organizational issues of home parenteral nutrition during COVID-19 pandemic: Results from multicenter, nationwide study.

OBJECTIVES: Patients on home parenteral nutrition (HPN) are prone to severe complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The pandemic requires adaptation of the health care standards, including epidemiologic surveillance, logistics of home supply, and monitoring. Potential lack of medical professionals may worsen the standard of care. The aim of this study was to evaluate the medical staff resources in HPN units. RESULTS: The study was conducted by major Polish scientific societies in clinical nutrition. A questionnaire was distributed among all Polish adult HPN centers concerning statistics from the first 3 mo of the pandemic (March through May 2020). Data on medical staff resources and organizational issues of the units were collected. Modifications of the home procedures, SARS-CoV-2 infection rates of HPN patients and health care workers (HCW) were analyzed. Influence of the pandemic on the rates of new qualifications for home artificial nutrition (HAN) was estimated. Fourteen of 17 adult Polish HPN units took part in the study. The point prevalence of HPN in Poland was 30.75/1 million citizens. Of HCWs, 344 were involved in patient care in Polish HPN units; 18.9% were physicians (49% surgeons, 18.46% internal medicine specialists, 15.38% anesthesiologists, 7.69% pediatricians, 1.54% palliative care specialists), 32.27% nurses, 5.23% dietitians, 9.01% pharmacists, 4.94% pharmacy technicians, 3.2% pharmacy assistants, 5.81% administrative workers, 3.49% physiotherapists. HAN patient-to-HCW ratios for physicians, nurses, pharmacists, dietitians were 49.5, 29.15, 111.6, and 181.6, respectively. Medium ages of physicians and nurses were 45.6 and 44.15 y, respectively. Slightly less than half (53.8%) of physicians and 31.53% of nurses worked parallelly in hospital wards. Thirty-one pharmacists overall were working in all HPN units (2.21 per unit) as were 18 dietitians (1.3 per unit). Nine patients had a confirmed COVID-19 infection (four HPN, five home enteral nutrition). All the units introduced telemedicine solutions in the first months of the pandemic. The number of new qualifications for HPN and home enteral nutrition in the units did not significantly decline from March through May in comparison with a similar period in 2019. CONCLUSIONS: A shortage of HPN medical professionals requires attention when planning health care organization, especially during a pandemic. Severe restrictions in public health systems may not reduce the number of new qualifications for the HPN procedure. There is a need for the continuation of data collection during the evolution of the pandemic as it may have a detrimental effect on HPN including serious issues with access to professional HCWs.

Home medical nutrition during SARS-CoV-2 pandemic - A position paper.

BACKGROUND: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a worldwide rapidly spreading illness, Coronavirus Disease 2019 (COVID-19). Patients fed enterally and parenterally at home are exposed to the same risk of infection as the general population, but more prone to complications than others. Therefore the guidance for care-givers and care-takers of these patients is needed. METHODS: The literature search identified no relevant systematic reviews or studies on the subject. Therefore a panel of 21 experts from 13 home medical nutrition (HMN) centres in Poland was formed. Twenty-three key issues relevant to the management of SARS-CoV-2 infection or COVID-19 in the HMN settings were identified and discussed. Some statements diverge from the available nutrition, surgical or ICU guidelines, some are based on the best available experience. Each topic was discussed and assessed during two Delphi rounds subsequently. Statements were graded strong or weak based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. RESULTS: the panel issued 23 statements, all of them were graded strong. Two scored 85.71% agreement, eleven 95.23%, and ten 100%. The topics were: infection control, enrolment to HMN, logistics and patient information. CONCLUSIONS: the position paper present pragmatic statements for HMN to be implemented in places without existing protocols for SARS-CoV-2 pandemic. They represent the state of knowledge available at the moment and may change should new evidence occurs.

Home Enteral Nutrition in Adults-Nationwide Multicenter Survey.

Home enteral nutrition (HEN) is an important part of the health care system, with a growing population of patients around the world. The aim of our study was to analyze one of the largest cohorts of HEN patients to provide the most recent data available in European literature. A multicenter, nation-wide survey in the period of 1 January 2018-1 January 2019 was performed in Poland. Data concerning adult patients on HEN in 2018 during 1 year of observation time were analyzed: demographic characteristics, primary disease, technique of enteral feeding, diet formulation and amount of energy provided. A total of 4586 HEN patients (F: 46.7%, M: 53.3%) were included in the study. The primary diseases were: 54.5% neurological (17.4%-neurovascular, 13.7%-neurodegenerative), 33.9% cancer (20.2%-head and neck, 11.7%-gastrointestinal cancer), 2.5%-gastroenterology, 1.5%-inherited diseases. Of new registrations in 2018-cancer patients 46.3%, neurological patients 45.1%. The median age overall was: 64 yr., BMI-20.2 kg/m2, NRS 2002 score-4.28. A total of 65% of patients were treated with PEG, 11.6% with surgical gastrostomy, 14.3% with naso-gastric tube and 7% with jejunostomy. Boluses were the most common method of feeding (74.4%). Gravity flow was used in 17.6% and peristaltic pump was used in 8% patients. The median energy provision was 1278 kcal/day and 24 kcal/kg/day. The most commonly used diets were: isocaloric (28.1%), protein-enriched isocaloric (20%) and protein-enriched hypercaloric (12%). The median overall duration of HEN was 354 days, 615 days for neurological and 209 days for cancer patients. A number of new registrations of cancer patients was significant and long duration of HEN in this group is encouraging. A developing spectrum of enteral formulas available enables more specified nutritional interventions.

Analysis of occurrence of bacteraemia with pathogens from gastrointestinal tract in patients fed parenterally and enterally in the intensive care unit.

INTRODUCTION: Bacterial translocation is a migration of microorganisms and their toxins from the intestinal lumen to the mesenteric lymph nodes, blood, and abdominal organs. It can lead to local inflammatory response and a potential increase in intestinal permeability leading to systemic infections and multiple organ failure. Enteral nutrition stimulates gastrointestinal motility, increases blood flow, and improves the integration of the intestinal barrier. AIM: The impact of enteral (EN) and parenteral (PN) nutrition on occurrence of bacteraemia caused by pathogens from the gastrointestinal tract. MATERIAL AND METHODS: It was a retrospective analysis of medical documentation of 254 patients. Microbiological tests were analysed, assessing the presence of bacteraemia or sepsis pathogens from the gastrointestinal tract. In 52 patients gastrointestinal pathogens in blood were found: 29 patients were fed enterally (I group - EN and EN + PN) and 23 only parenterally (II group - PN). RESULTS: The mean length of stay in hospital until the occurrence of bacteraemia in group I was 14, and in group II it was 13 days. Mean time without EN was 4 days (first group) and 12 days (second group). Time of stay in ICU and mortality in the group of patients fed parenterally was observed: group I - 25 days, mortality 34%; group II - 37 days, mortality 56%. In the analysed group the EN and the length of the absence of this kind of feeding did not affect the occurrence of bacteraemia by gastrointestinal pathogens. CONCLUSIONS: However, patients fed only parenterally who had bacteraemia required a longer stay in the ICU and had a higher rate of mortality than the patients with EN.

Occurrence of gastrointestinal side effects associated with early use of commercial diets in ITU patients.

BACKGROUND: The purpose of this retrospective study was to analyse the occurrence of gastrointestinal side effects in enterally fed ITU patients. METHODS: We analysed the records of 195 ITU patients fed enterally, over at least five days, with commercial mixtures administered as 20-h infusions. Gastric retention, the number of defecations, and incidents requiring discontinuation of enteral feeding, were noted during the first 3 days of nutrition. RESULTS: Enteral nutrition was usually started during the first week of treatment (median 4, range: 1-33). In 118 patients receiving parenteral nutrition, the median day of implementing enteral feeding was day 5; some received enteral mixtures much earlier (day 2). The mean infusion rates of enteral mixtures were: 33 mL h-1 on day 1, 58 mL h-1 on day 2, and 68 mL h-1 on day 3. Gastric retention was observed in 49 (25.1%) patients during the first day, in 37 (19.0%) on day 2, and in 25 (12.8%) on day 3. Discontinuation of enteral nutrition was necessary in 6 patients due to: surgery (1), high gastric retention (4), gastrointestinal bleeding (1). A statistically significant correlation was found between the occurrence of gastric retention, infusion rates and CRP, and between the number of defecations and infusion rates. CONCLUSIONS: Enteral feeding with commercial diets is well tolerated when implemented gradually. Intolerance and the need for the discontinuation of enteral feeding were usually associated with a worsening of the patient's general condition and progression of the underlying disease.

Home enteral nutrition in children--2010 nationwide survey of the Polish Society for Clinical Nutrition of Children.

Published epidemiologic data on the administration rates of enteral/parenteral home nutrition is very limited. The aim of this first nationwide study was to assess the availability of pediatric home enteral nutrition (HEN) services in Poland. The questionnaire was sent to all regional centers providing pediatric HEN services in Poland (n = 14). The analysis included the number of pediatric patients who received HEN in 2010, their demographic characteristics and geographical distribution. Furthermore, the distributions of indications and methods of enteral nutrition administration were analyzed, along with the reasons of withdrawal from the HEN program. The number and fraction of children receiving HEN increased in 2010, from 433 (11.34 per 1 million inhabitants) on January 1st to 525 (13.75) on December 31st. Marked differences were observed in geographical distribution of this parameter, from zero to up to 30 pediatric patients per 1 million inhabitants. Median age of patients was 6 years (range: 9 months-18 years). In most cases, HEN was prescribed due to neurological disorders (n = 337, 64.2%), and administered by means of gastrostomy (n = 450, 85.71%). This study revealed the dynamic development of pediatric HEN services in Poland but also documented their potential regional shortages.

Analysis of nutrition mixtures in ITU patients.

BACKGROUND: The aim of this study was to analyse the composition of parenteral nutrition (PN) mixtures used in the ITU. METHODS: Restrospective analysis involved 2124 prescriptions for individual PN bags. They were administered over an 18-month period, to 160 ITU patients with the mean APACHE II score of 26 points (range: 5-61), calculated on admission. The mortality rate was 40%. Nutrition programs were prepared individually following the 2009 ESPEN guidelines. The prescription was modified according to the individual patient's clinical condition. One hundred and sixty prescriptions were analysed on the first day of PN (T1), 139 - on the second day (T2) and 1825 on the third and subsequent days (T3). RESULTS: The mean energy supplies were: 1381 kcal/day (range: 456-2612) on T1, 1467 kcal/day (range: 524-2860) on T2, and 1654 kcal/day (range: 390-2969) on T3. The mean supplies of amino acids, glucose and lipids were as follows: amino acids 68.3 g/day (range:20-120) on T1; 71.6 g/ day (range:27.5-125) on T2; 88.0 g/day (range:11-196) on T3; glucose 210.25 g/day (range: 120- 400) on T1; 218.34 g/day (range: 65-480) on T2; 278.5 g/day (range: 18-520) on T3; lipids 34.9 g/ day (range: 0-100) on T1; 38.7 g/day (range: 0-100) on T2; 52.66 g/day (range: 0-117) on T3. The percentages of non-protein energy from lipids were: 29.25 (0-73) on T1; 31.58 (range: 0-60) on T2; 33.5 (0-60) on T3. The following statistically significant differences were found: T2-T3- (p<0.05). CONCLUSIONS: The compositions of nutrition bags prepared for ITU patients were consistent with the ESPEN guidelines. The composition varied on different days of nutrition. The differences in the supply of nutrition components indirectly confirm the need for individual prescriptions for ITU patients.

Current management of congenital diaphragmatic hernia.

The treatment of congenital diaphragmatic hernia (CDH) still represents a challenge, even for the specialised multidisciplinary teams in centres that provide treatment for CDH. Despite significant progress in the fields of pathophysiology, prenatal diagnosis, surgical techniques and intensive care, CDH is a disease still burdened with a high mortality. Due to the paucity of randomised studies, there are no standard guidelines for treatment. The present review looks at existing diagnostic and therapeutic principles based on the available literature.

[Is suxamethonium still useful for paediatric anaesthesia?]. / Czy suksametonium ma ciagle miejsce we wspólczesnej amestezologii dzieciecej?

Suxamethonium is the only depolarising neuromuscular blocking agent, which is still being widely used during general anaesthesia. Some of its unique properties rank suxamethonium as an ideal neuromuscular blocking agent i.e. the fast onset of muscle paralysis and spontaneous neuromuscular block reversal. However, the agent may trigger malignant hyperthermia, hyperkaliaemia, severe bradycardia and other complications, which have to be considered. Due to differences in postsynaptic nicotine receptor structure and functional insufficiency of the neuromuscular junction, paediatric patients when compared to adults, are more sensitive to potential side effects when suxamethonium is administered. Malignant hyperthermia is an important risk factor. Ryanidine receptors located in the sarcoplasmic/endoplasmic reticulum membrane are responsible for the release of Ca2+ from intracellular stores and trigger this complication.The risk of hyprethermia increases in children when some neurologic and muscle diseases coexist. Nowadays, in rapid sequence induction of anaesthesia, suxamethonium may be replaced with rocuronium - a non-depolarising muscle relaxant which provides the intubating conditions similar to suxamethonium. The rocuronium-induced neuromuscular blockade, which lasts longer than blockade following suxamethonium, is reversed with sugammadex - a new selective relaxant binding agent. Despite new agents and methods, suxamethonium still remains the drug of choice for muscle relaxation for intubation in children.

[Multiple organ failure in a severely malnourished patient with chromosome aberration]. / Skrajne niedoiywienie jako przyczyna niewydolnosci wielonarzadowej u chorej z aberracja chromosomalna.

BACKGROUND: Pneumonia and malnutrition are two of the biggest killers in childhood, as defined by the World Health Organisation. Although common in the developing world, these conditions can also be observed in more advanced countries, as a result of negligence and lack of proper care in disabled children. We describe a case in which severe malnutrition resulted in multiple organ failure. CASE REPORT: A 16-yr-old retarded girl with +14q chromosome aberration, was admitted to hospital because of severe anaemia and dyspnea. She was extremely malnourished. Her body weight was 32 kg with a height of 152 cm (BMI 13.9). Her Hb concentration was 1.12 mmol L(-1), Ht 7%, and RBC 0.93 T L(-1). RBC transfusion resulted in transfusion-related acute lung injury (TRALI) and multiple organ failure. She was treated with mechanical ventilation, inotropic support and parenteral nutrition, complicated by the refeeding syndrome and gastrointestinal haemorrhage. After recovery, a gastrostomy was performed, but due to gastric retention she required a laparotomy for adhesiolysis.The girl recovered and remains under home care. DISCUSSION: In a case of a girl with retardation, multiple organ failure resulting from ten years of malnutrition was observed. She was especially difficult to treat because of a prolonged dysfunction of homeostasis, hypoproteinemia, hypophosphatemia and SIRS. Such patients require careful treatment in ICU settings.

[Iatrogenic pleuropneumonia complicating central venous cannulation in a very low birth weight infant]. / Jatrogenna pleuropneumonia jako powilkanie cewnikowania zyl centralnych u noworodka.

BACKGROUND: Central venous cannulation is necessary for long-term parenteral nutrition in premature infants. Peripherally inserted long catheters are commonly used in these patients but even this relatively simple technique can end in serious complications. We present a case in which perforation of the vena cava and migration of the catheter to the intrapleural space resulted in multiple organ failure and death. CASE REPORT: A 700 g bw. infant, born at 28 weeks of gestation, was referred to our centre because of suspected bowel perforation. In the referring hospital, the infant had a central venous catheter inserted peripherally. The catheter migrated to the right intrapleural space, and parenteral formula was delivered over several hours to the right pleura, resulting in hydrothorax with serious compression of the lung and atelectasis. Emergency laparotomy did not reveal any pathology and a chest tube was inserted into the right pleura; the effusion fluid contained a large number fat particles. The child's condition worsened and he died 16 days after surgery because of multiple organ failure and sepsis. CONCLUSION: Accidental migrations of central venous catheters to the pleural space have been described by many authors. It can result in severe pneumonia, cardiac tamponade or sepsis and is often fatal. We conclude that central venous catheters in premature infants should be inserted under ultrasonography or fluoroscopy. Catheters should never be forced along vessels; their size ought to be adjusted to age, and a free outflow of blood should be obtained before they are used.

[Iatrogenic pleuropneumonia as a complication of nutritional treatment of preterm-delivery newborn]. / Jatrogenna pleuropneumonia jako powiklanie leczenia zywieniowego u noworodka urodzonego przedwczesnie.

Our study presents a case of pleuropneumonia caused by a leak of nutritional formula to pleural cavity, which was caused by perforation of the oesophagus. The child was born in 28 hbd with 1400 g birth weight and was fed with mother's milk by a nasogastric tube. From day 11 of life general state of the neonate worsened and on chest X-ray the contrast showed leaking into the right pleural cavity and the end of gastric tube was seen in the right lung area. With this diagnosis the child was admitted to the University Hospital in Bydgoszcz. The child was conservatively treated and in two contrast X-ray examinations there was no pathology of the oesophagus. CT of chest showed pleural empyema which was repeatedly punctured. On the 19th day of hospitalization thoracotomy with resection of interior pulmomery lobe was performed. From the 14th day after surgery, the child was again enterally fed and in good general state. He was discharged on the 51st day of hospitalization. This case should pay our attention to the fact that respiratory distress syndrome of preterm-delivery newborns may be caused by iatrogenic proceedings not only infections and lack of surfactant. Some complications can be accomplished with the nutrition treatment in every dimension.

[Twenty-two months old girl with haemorrhagic gastritis as a complication after the nonsteroid anti-inflammatory drugs application--case report]. / Krwotoczne zapalenie blony sluzowej zoladka u 22-miesiecznej dziewczynki jako powiklanie zastosowania niesterydowych leków przeciwzapalnych--opis przypadku.

The aim of case report was to pay attention for possibility of side effects of nonsteroid anti-inflammatory drugs. Child of young and healthy parents was born after normal pregnancy, natural delivery. The disease started in two days before the admission, child had fever, cough and sneezing. Mother gave her two doses of ibuprofen. On the time of admission general state of patient was moderate; girl was apathic. In physical examination features of upper respiratory tract infection were shown. In the course of treatment antibiotic and symptomatic drugs including paracetamol (3x5 ml) were delivered. During the second day of treatment child had no appetite, started to vomit with fresh and haemolized blood. Parenteral hydratation was started. Emergency gastroscopy was done and features of haemorrhagic gastritis were shown. Anti-inflammatory drugs were no more used and delivery of omeprazole was started. Parenteral hydratation was continued. General state of patient was better. In the sixth day after bleeding child was excripted in good general state with order of use of omeprazole. Parents were informed about the restriction of anti-inflammatory drugs use. The aim of case report was to pay attention that haemorrhagic gastritis may be one of side effects of nonsteroid anti-inflammatory drugs used accordingly to actual standards.

[Does the intensity of acid gastroesophageal reflux influence chosen parameters of physical development in children and youth?]. / Czy stopien nasilenia kwasnego refluksu zoladkowo-przelykowego ma wplyw na wybrane parametry rozwoju fizycznego u dzieci i mlodziezy?

UNLABELLED: THE AIM OF THE STUDY was to analyse physical development of children and youth with gastroesophageal reflux disease. MATERIAL AND METHODS: one hundred thirteen patients between 2 and 18 years of age, with gastroesophageal reflux disease were included in the study. Height and weight were also analysed using the percentile chart of Warsaw children from 1999. Patients were divided into three groups according to the intensity of gastroesophageal reflux in 24-hours pH-metry: group I: minimal degree of gastroesophageal reflux - 3,4-9,9% total time (n=52), group II: moderate degree of gastroesophageal reflux - 10-19,9% total time (n=39), group III: significant degree of gastroesophageal reflux > 20% total time (n=22). RESULTS: in group I, weight less than 3 percentile was found in 1,9% patients, height in 5,76%, weight between 3 and 10 percentile in 11,53%, height in 3,80%, weight between 90-97 percentile in 3,80%, height in 15,38% and weight above 97 percentile in 11,53%, height in 15,38%. In group II weight less than 3 percentile was found in 2,56% patients, height less than 3 percentile was not observed, weight between 3 and 10 percentile in 11,53%, height in 2,56%, weight above 97 percentile in 7,69%, height in 12,82% and weight between 90-97 percentile in 5,12%, height in 10,24%. In group III, weight and height less than 3 percentile was found in 13,63%, weight between 3 and 10 percentile in 13,63%, height in 4,54%, weight above 97 percentile in 4,54%, height in 13,63%, weight between 90-97 percentile in 18,18%, height in 22,72%. CONCLUSION: no statistically significant correlations between the intensity of gastroesophageal reflux and the weight and height in children and youth were found.

[Role of interview in diagnosis of gastroesophageal reflux in children]. / Znaczenie badania podmiotowego w rozpoznawaniu refluksu-zoladkowo-przelykowego u dzieci.

THE AIM: Of the study was to establish the most frequent clinical symptoms of gastroesophageal reflux (GER) disease in children. MATERIAL AND METHODS: 214 children aged from 4 months to 15 years with symptoms suggested GER. The medical documentation of children was analyzed with regard to results of clinical symptoms and 24-hour pH-monitoring. RESULTS: The most frequent symptom in newborn was spitting, in children aged 1-3 was vomiting, in children aged 4-15 was stomach pain. Amongst children to 3 years recurrent bronchitis was frequent co-existent disease, in older children duodenitis or/and gastritis. Based on positive result of 24-hour pH-monitoring gastroesophageal disease was diagnosed in 184 (86%) patients. Preliminary diagnosis of GER based on the medical interview with high percentage of positive results of 24-hour pH-monitoring. The introduced results prove the medical interview to be still significant part of GER diagnosis.