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OBJECTIVES: Diacylglycerol acyltransferase (DGAT) catalyzes the final step in triglyceride synthesis. DGAT1 is expressed in human enterocytes and is essential for fat absorption. Homozygous DGAT1 deficiency often presents with severe diarrhea and protein-losing enteropathy (PLE) in the 1st weeks of life. Because severe restriction of fat intake controls diarrhea and decreases PLE, total parenteral nutrition (TPN) was the initial standard therapy in infants and children. We present tertiary center experience managing infants and children with DGAT1 deficiency resulting in the development of a nutritional approach that minimizes the use of TPN. METHODS: From 2014 to 2020, 12 infants with DGAT1 deficiency were treated. Stool output, growth, and development, as well as essential fatty acid status, were monitored. This retrospective experience formed the basis for treatment recommendations, which include an ultralow fat formula with intermittent peripheral intravenous lipid infusions during the 1st year of life. RESULTS: All patients with prolonged intestinal fat exposure had PLE, which resolved when treated with the nutrition protocol. Essential fatty acid status as measured by triene:tetraene ratios normalized in all treated patients. Over time, early genetic diagnosis and prompt initiation of an ultralow fat diet with peripheral intravenous lipid infusions replaced the need for TPN. CONCLUSIONS: Children with DGAT1 deficiency respond to dietary restriction of lipids. Management with a novel nutritional approach provides effective treatment for infants with DGAT1 deficiency, treats diarrhea and PLE, promotes growth and development, avoids TPN dependency, and decreases the potential for essential fatty acid deficiency.
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Diacilglicerol O-Acetiltransferasa , Diarrea , Niño , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Diacilglicerol O-Acetiltransferasa/genética , Diacilglicerol O-Acetiltransferasa/deficiencia , Diarrea/dietoterapia , Diarrea/genética , Grasas de la Dieta/administración & dosificación , Homocigoto , Mutación , Nutrición Parenteral Total/métodos , Estudios RetrospectivosRESUMEN
Total Parenteral Nutrition (TPN) is a method of providing nutrients directly into the bloodstream for individuals who are unable to meet their nutritional needs through the normal digestive process or gastrointestinal system. It provides macronutrients and micronutrients in a single container, reducing handling and contamination risks and making it more cost-effective. TPN has the potential to be used as a drug delivery system, with applications in combination therapies, personalized medicine, and integrating advanced technologies. It can enhance drug dosage precision and provide nutritional assistance, potentially reducing hospitalization and improving patient outcomes. However, implementing new applications requires thorough testing and regulatory approval. TPN could be particularly useful in pediatric and geriatric care and could also contribute to global health by combating malnutrition in areas with limited medical resources. Healthcare professionals prepare a sterile solution tailored to each patient's nutritional needs, and administration involves a central venous catheter. However, the simultaneous administration of medications with PN admixtures can result in pharmacological incompatibility, which can impact the stability of the oil-in-water system. The European Society for Clinical Nutrition and Metabolism and the American Society for Parenteral and Enteral Nutrition recommendations advise against including non-nutrient drugs in PN admixtures due to safety concerns. This review focuses on the utilization of Total Parenteral Nutrition (TPN) as a method for delivering drugs. It discusses the benefits and difficulties associated with its commercial application and offers suggestions for future research endeavors.
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Sistemas de Liberación de Medicamentos , Nutrición Parenteral Total , Humanos , Nutrición Parenteral Total/métodos , Preparaciones Farmacéuticas/administración & dosificaciónRESUMEN
Introduction: Introduction: the stability of total parenteral nutrition admixtures for neonates (TPNAn) has been questioned in relation to the interaction between calcium and fish oil emulsions. Aim: the aim of this study was to check the stability (particle size < 1 µm) of different individualized TPNAn prepared with fish-oil emulsion and containing calcium at concentrations ranging from 10 to 20 mmol/L. Methods: admixtures analyzed: twelve different formulations with SMOFlipid® 20 % (conserved for 24 h and for 96 h), three formulations with Lipoplus® 20 % (conserved for 96 h) and three formulations with SMOFlipid® 20 % with Multi-12K1® Pediatric (conserved for 96 h). Two bags were compounded for each formulation and conservation period. Measurements on each admixture bag: particle standardized diameter by laser diffraction technique and pH by a calibrated pH-meter. Data analysis with mixed linear regression models. Results: maximum particle size was < 0.8 µm for all investigated admixtures. Lipid concentration of 5 g/L and sodium and potassium concentration of 100 mmol/L slightly increased the proportion of particles > 0.6 µm. Ninety six hours storage also increased the percentage of particles > 0.6 µm (+0.143 ± 0.07; p = 0.038) but did not influence other parameters. No association with calcium composition was observed. Amino acid content was inversely correlated with pH (-0.83; p < 0.0001). Conclusions: the studied individualized parenteral nutrition admixtures for newborns that contain fish oil emulsions and meet cation requirements are stable for at least 96 hours.
Introducción: Introducción: existe controversia sobre la estabilidad de las mezclas de nutrición parenteral total para recién nacidos (TPNAn) con emulsiones de omega-3 y alto contenido en calcio. Objetivo: estudiar la estabilidad (tamaño de partículas < 1 µm) de diferentes TPNAn individualizadas preparados con una emulsión lipídica que contiene w3 y concentraciones de calcio entre 10 y 20 mmol/L. Métodos: se analizaron doce formulaciones diferentes con SMOFlipid® 20 % (conservadas durante 24 h y por 96 h), tres formulaciones con Lipoplus® 20 % (conservadas durante 96 h) y tres formulaciones con SMOFlipid® 20 % con Multi-12K1® Pediatric (conservadas durante 96 h). Se prepararon dos bolsas por cada formulación y período de conservación. Se midieron el diámetro de partícula estandarizado mediante técnica de difracción láser y el pH con un pH-metro calibrado. Análisis de datos con modelos de regresión lineal mixta. Resultados: el tamaño máximo de partícula fue < 0,8 µm para todas las mezclas investigadas. La concentración de lípidos de 5 g/L y la concentración de sodio y potasio de 100 mmol/L aumentaron ligeramente la proporción de partículas > 0,6 µm. El almacenamiento de noventa y seis horas también aumentó el porcentaje de partículas > 0,6 µm (+0,143 ± 0,07; p = 0,038) pero no influyó en otros parámetros. No se observó asociación con la concentración de calcio. El contenido de aminoácidos se correlacionó inversamente con el pH (-0,83; p < 0,0001). Conclusiones: las TPNAn individualizadas estudiadas con emulsiones de omega-3 que incluyen los requerimientos de cationes son estables durante al menos 96 horas.
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Aceites de Pescado , Humanos , Aceites de Pescado/química , Aceites de Pescado/análisis , Recién Nacido , Calcio/análisis , Calcio/química , Emulsiones Grasas Intravenosas/química , Estabilidad de Medicamentos , Nutrición Parenteral Total/métodos , Nutrición Parenteral/métodos , Tamaño de la Partícula , Emulsiones , Soluciones para Nutrición Parenteral/química , Aceite de Oliva , Aceite de Soja , TriglicéridosRESUMEN
The use of total parenteral nutrition (TPN) in patients with gastrointestinal cancers is a well-established practice, yet there is substantial variability in its use across institutions. Decision-making around the initiation of TPN is complex. An interdisciplinary team can help identify patient factors and clinical situations that influence whether a patient is likely to benefit from parenteral nutrition. We present the case of a woman with a gastrointestinal cancer who benefited from the initiation of TPN as a bridge therapy to further cancer treatment. This case highlights the importance of establishing a plan for nutrition with specific goals in mind, such as optimizing patients for more cancer-directed therapy. Although patients with gastrointestinal cancers may be candidates for TPN, many patient-specific factors, such as functional status and opportunities for future treatments, must be considered prior to the initiation of parenteral nutrition. An interdisciplinary approach should be used to make recommendations based on patient goals, with a focus on patient and cancer characteristics that are associated with positive outcomes after initiation of TPN. These characteristics include functional status, nutritional status, degree of symptom control, and ability to safely administer nutrition. It is important to continually assess whether parenteral nutrition is beneficial in respect to a patient's preferences and prognosis.
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Neoplasias Gastrointestinales , Nutrición Parenteral Total , Femenino , Humanos , Neoplasias Gastrointestinales/terapia , Estado Nutricional , Nutrición Parenteral Total/métodosRESUMEN
BACKGROUND: Total Parenteral Nutrition (TPN) provides lifesaving nutritional support to patients unable to maintain regular enteral nutrition (EN). Unfortunately, cholestasis is a significant side effect affecting 20-40% of paediatric patients. While the aetiology of TPN-associated injury remains ill-defined, an altered enterohepatic circulation in the absence of gut luminal nutrient content during TPN results in major gut microbial clonal shifts, resulting in metabolic endotoxemia and systemic inflammation driving liver injury and cholestasis. HYPOTHESIS: To interrogate the role of gut microbiota, using our novel ambulatory TPN piglet model, we hypothesized that clonal reduction of bacteria in Firmicutes phylum (predominant in EN) and an increase in pathogenic Gram-negative bacteria during TPN correlates with an increase in serum lipopolysaccharide and systemic inflammatory cytokines, driving liver injury. METHODS: Upon institutional approval, 16 animals were allocated to receive either TPN (n = 7) or EN only (n = 9). The TPN group was subdivided into a low systemic inflammation (TPN-LSI) and high systemic inflammation (TPN-HSI) based on the level of serum lipopolysaccharide. Culture-independent identification of faecal bacterial populations was determined by 16S rRNA. RESULTS: Piglets on TPN, in the TPN-HSI group, noted a loss of enterocyte protective Firmicutes bacteria and clonal proliferation of potent inflammatory and lipopolysaccharide containing pathogens: Fusobacterium, Bacteroidetes and Campylobacter compared to EN animals. Within the TPN group, the proportion of Firmicutes phylum correlated with lower portal lipopolysaccharide levels (r = -0.89). The TPN-LSI had a significantly lower level of serum bile acids compared to the TPN-HSI group (7.3 vs. 60.4 mg/dL; p = .018), increased day 14 weight (5.67 vs. 5.07 kg; p = .017) as well as a 13.7-fold decrease in serum conjugated bilirubin. CONCLUSION: We demonstrate a novel relationship between the gut microbiota and systemic inflammation in a TPN animal model. Pertinently, the degree of gut dysbiosis correlated with the severity of systemic inflammation. This study underscores the role of gut microbiota in driving liver injury mechanisms during TPN and supports a paradigm change in therapeutic targeting of the gut microbiota to mitigate TPN-related injury. KEY MESSAGESThis study identified a differential link between gut microbiota and inflammation-the higher the dysbiosis, the worse the systemic inflammatory markers.Higher levels of Firmicutes species correlated with reduced inflammation.
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Colestasis , Disbiosis , Animales , Niño , Colestasis/etiología , Disbiosis/complicaciones , Firmicutes , Humanos , Inflamación/complicaciones , Lipopolisacáridos , Hígado , Nutrición Parenteral/efectos adversos , Nutrición Parenteral Total/efectos adversos , Nutrición Parenteral Total/métodos , ARN Ribosómico 16S , PorcinosRESUMEN
RATIONALE: Fetal brain hemorrhage is rare. It is caused mainly by maternal trauma or fetal coagulation disorder, but in some cases, vitamin K deficiency may be the cause. PATIENT CONCERNS: We describe the case of a pregnant woman with bowel obstruction who was susceptible to vitamin K deficiency due to oral diet restriction, decreased intestinal absorption, and limited intravenous vitamin K supplementation. DIAGNOSIS: After 18âdays of intermittent total parenteral nutrition, acute onset of severe fetal brain hemorrhage developed. INTERVENTIONS: After acute onset of fetal brain hemorrhage, the patient underwent an emergency cesarean section at 25â+â3âweeks of gestation due to fetal non-reassuring fetal monitoring. OUTCOMES: The Apgar score at birth was 0/0, and despite cardiopulmonary resuscitation, neonatal death was confirmed. After the baby was delivered, we checked the maternal upper abdominal cavity and found a massive adhesion in the small bowel to the abdominal wall near the liver and stomach with an adhesion band. The adhesion band, presumably a complication of previous hepatobiliary surgery, appeared to have caused small bowel obstruction. Adhesiolysis between the small bowel and abdominal wall was performed. LESSONS: This case demonstrates that even relatively short-term total parenteral nutrition can cause severe fetal brain hemorrhage. Vitamin K supplementation is required for mothers who are expected to be vitamin K deficient, especially if they are on total parenteral nutrition for more than 3âweeks.
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Obstrucción Intestinal/etiología , Hemorragias Intracraneales/etiología , Nutrición Parenteral Total/efectos adversos , Deficiencia de Vitamina K/complicaciones , Adulto , Cesárea/efectos adversos , Femenino , Enfermedades Fetales , Humanos , Recién Nacido , Nutrición Parenteral Total/métodos , Embarazo , Vitamina K/administración & dosificaciónRESUMEN
AIM: This study was aimed to analyze the incidence, risk factors, and management of chylous ascites (CA) after radical D3 resection for colorectal cancer, and to construct a predicting nomogram for prolonged resolution of CA. METHOD: Consecutive colorectal cancer patients who underwent radical D3 resection were included. Logistic analysis was used to identify risk factors of postoperative CA, as well as prolonged CA resolution. A predictive nomogram for prolonged resolution of CA was developed and validated internally. RESULTS: Among 7167 patients included, 277 (3.8%) patients developed CA. Logistic regression analysis demonstrated that laparoscopic operation (OR 1.507; P = 0.017) and tumors fed by the superior mesenteric artery (SMA, OR 2.456; P < 0.001) were independent risk factors of postoperative CA following radical D3 surgery for colorectal cancer. Open operation (OR 0.422; P = 0.027), drainage output on the first day of treatment (OR 1.004; P = 0.016), time to oral intake (OR 1.273; P = 0.042), and time to onset (OR 1.231; P = 0.024) were independently associated with prolonged resolution of postoperative CA (≥7 days). A predictive nomogram for prolonged CA resolution was developed with a C-index of 0.725. CONCLUSION: The incidence of CA after radical D3 surgery of colorectal cancer was 3.8%. Open operation, drainage output on the first day of treatment, time to oral intake, and time to onset were independently associated with prolonged resolution of postoperative CA. A nomogram may assist in tailored treatment decision-making and counseling patient with treatment strategies.
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Adenocarcinoma/cirugía , Ascitis Quilosa/epidemiología , Colectomía , Neoplasias Colorrectales/cirugía , Escisión del Ganglio Linfático , Complicaciones Posoperatorias/epidemiología , Anciano , Ascitis Quilosa/fisiopatología , Ascitis Quilosa/terapia , Grasas de la Dieta/uso terapéutico , Femenino , Hospitales de Alto Volumen , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Nutrición Parenteral Total/métodos , Complicaciones Posoperatorias/fisiopatología , Complicaciones Posoperatorias/terapia , Medición de Riesgo , Somatostatina/uso terapéuticoRESUMEN
BACKGROUND/AIM: Surgical stress significantly decreases serum diamine oxidase (DAO), a marker of intestinal mucosal maturation and integrity. This study aimed to determine the effects of postoperative enteral and total parenteral nutrition (EN and TPN, respectively) in patients with esophageal cancer. PATIENTS AND METHODS: This prospective randomized trial compared serum DAO activities, nutritional states, trace elements and complications between patients who underwent esophagectomy and received EN or TPN for seven days thereafter. RESULTS: Fifty-one patients were randomized to receive EN or TPN. The rates of change in serum DAO activity from the day before surgery were 0.79, 0.89 and 0.91 on postoperative days (POD) 1, 3 and 7, respectively, in the EN group, and 0.64, 0.76 and 1.06, respectively, in the TPN group, with no significant differences. Furthermore, the rates of changes in indicators of nutritional status, namely total protein, albumin, total cholesterol, trace element concentrations and infectious and non-infectious complications did not significantly differ between the groups. CONCLUSION: EN and/or TPN can be administered for early nutritional management until resumption of oral intake after esophagectomy according to the postoperative status of individual patients with esophageal cancer.
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Nutrición Enteral/métodos , Neoplasias Esofágicas/terapia , Nutrición Parenteral Total/métodos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios , Estudios Prospectivos , Adulto JovenRESUMEN
Trends in nutritional science are rapidly shifting as information regarding the value of eating unprocessed foods and its salutary effect on the human microbiome emerge. Unravelling the evolution and ecology by which humans have harboured a microbiome that participates in every facet of health and disease is daunting. Most strikingly, the host habitat has sought out naturally occurring foodstuff that can fulfil its own metabolic needs and also the needs of its microbiota, each of which remain inexorably connected to one another. With the introduction of modern medicine and complexities of critical care, came the assumption that the best way to feed a critically ill patient is by delivering fibre-free chemically defined sterile liquid foods (that is, total enteral nutrition). In this Perspective, we uncover the potential flaws in this assumption and discuss how emerging technology in microbiome sciences might inform the best method of feeding malnourished and critically ill patients.
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Cuidados Críticos/historia , Dieta/historia , Alimentos Formulados/historia , Microbioma Gastrointestinal , Apoyo Nutricional/historia , Atención Perioperativa/historia , Cuidados Críticos/métodos , Enfermedad Crítica/terapia , Dieta/efectos adversos , Dieta/métodos , Fibras de la Dieta/microbiología , Fibras de la Dieta/uso terapéutico , Alimentos Formulados/efectos adversos , Historia del Siglo XX , Humanos , Desnutrición/dietoterapia , Desnutrición/historia , Desnutrición/microbiología , Apoyo Nutricional/métodos , Nutrición Parenteral Total/efectos adversos , Nutrición Parenteral Total/historia , Nutrición Parenteral Total/métodos , Atención Perioperativa/efectos adversos , Atención Perioperativa/métodos , Estados UnidosRESUMEN
We aimed to analyze the risk factors of positive peripherally inserted central catheter (PICC)-related fungal colonization in preterm infants. This retrospective study collected data from 2018 to 2020. The enrolled infants who underwent PICC insertion were born at < 32 weeks' gestation or birth weight < 1500 g. The demographics, PICC-related characteristics, and treatment information were collected. Univariate and multivariate analyses were performed to investigate risk factors for PICC-related fungal colonization. The receiver operating characteristic (ROC) curve was used to determine the optimal cut-off values for the duration of antibiotics and parenteral nutrition. In total, 124 premature infants underwent PICC insertion. Among them, 19 patients had positive results of fungi on the PICC tips. The duration of antibiotics (odds ratio [OR] 1.16, 95% confidence interval [CI] 1.02-1.31), parenteral nutrition infusion (OR 1.27, 95% CI 1.05-1.54), and postnatal glucocorticoid exposure (OR 9.48, 95% CI 1.06-84.98) were independent risk factors for fungal colonization in PICCs. The ROC curves showed that the risk increased after 15 days of antibiotic use and 28 days of parenteral nutrition infusion. Appropriate clinical management should be used to prevent fungal colonization and fungemia.
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Infecciones Relacionadas con Catéteres/etiología , Infecciones Relacionadas con Catéteres/microbiología , Cateterismo Venoso Central/efectos adversos , Cateterismo Periférico/efectos adversos , Catéteres de Permanencia/efectos adversos , Enfermedades del Prematuro/etiología , Enfermedades del Prematuro/microbiología , Peso al Nacer/fisiología , Femenino , Edad Gestacional , Humanos , Recién Nacido , Recien Nacido Prematuro , Masculino , Oportunidad Relativa , Nutrición Parenteral/métodos , Nutrición Parenteral Total/métodos , Factores de RiesgoRESUMEN
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.
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Contaminación de Equipos/prevención & control , Escherichia coli/aislamiento & purificación , Emulsiones Grasas Intravenosas/administración & dosificación , Infusiones Intravenosas/instrumentación , Nutrición Parenteral Total/instrumentación , Escherichia coli/crecimiento & desarrollo , Nutrición Parenteral Total/métodosRESUMEN
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.
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Desnutrición/etiología , Desnutrición/terapia , Neoplasias Ováricas/terapia , Nutrición Parenteral Total/métodos , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoAsunto(s)
Toma de Decisiones Clínicas/métodos , Tratamiento Conservador/métodos , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Divertículo , Enfermedades Duodenales , Perforación Intestinal , Tomografía Computarizada por Rayos X/métodos , Anciano de 80 o más Años , Antibacterianos/administración & dosificación , Diagnóstico Diferencial , Divertículo/complicaciones , Divertículo/diagnóstico por imagen , Drenaje/métodos , Enfermedades Duodenales/complicaciones , Enfermedades Duodenales/diagnóstico por imagen , Endoscopía del Sistema Digestivo/métodos , Humanos , Perforación Intestinal/diagnóstico , Perforación Intestinal/fisiopatología , Perforación Intestinal/terapia , Masculino , Nutrición Parenteral Total/métodos , Ajuste de Riesgo/métodos , Medición de Riesgo , Rotura Espontánea/diagnóstico , Rotura Espontánea/fisiopatología , Rotura Espontánea/terapia , Resultado del TratamientoRESUMEN
INTRODUCTION: Refeeding syndrome occurs with the reintroduction of food after an individual has undergone a substantial period of malnutrition. The development of this condition is not uncommon but is neglected in most cases. OBJECTIVE: To identify the incidence of refeeding syndrome in hospitalized patients undergoing total parenteral nutrition and factors that may be associated with this condition. MATERIALS AND METHODS: Observational retrospective and prospective cohort study. Data collection took place at the Hospital de Clínicas de Porto Alegre, from 2015 to 2018. Data was collected consecutively from patient electronic medical records. All hospitalized individuals aged 18 years or more and having a prescription for total parenteral nutrition were included in the study. Exclusion criteria included patients with diabetic ketoacidosis; receiving renal replacement therapy or chronic kidney disease with a glomerular filtration rate <30 mL/min; severe metabolic acidosis or any disease that could affect serum phosphorus levels. WinPepi software, version 11.65, was used to calculate sample size. Data analysis was performed using SPSS version 20.0. A 5% significance level was considered for the established comparisons. The project was approved by the Research Ethics Committee of Hospital de Clínicas de Porto Alegre (number 17-0313). RESULTS: Data from 97 patients was collected. The incidence of refeeding syndrome in our sample was 43.3% (n = 42). Factors positively associated with the syndrome were use of standard parenteral nutrition (p < 0.01), advancing age (mean 62.8 yr versus 55.1 yr; p = 0.013), and amount of total energy administered, which were 25.6 kcal/kg/day versus 23.6 kcal/kg/day for patients with and without refeeding syndrome, respectively (p < 0.01). CONCLUSION: The incidence of refeeding syndrome in individuals using total parenteral nutrition was high. The supply of a greater quantity of total energy in the first week of nutritional therapy, the absence of electrolytes in the parenteral nutrition solution and advancing age were all factors associated with the emergence of refeeding syndrome.
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Nutrición Parenteral Total/métodos , Síndrome de Realimentación/epidemiología , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Electrólitos , Ingestión de Energía , Femenino , Hospitales Universitarios , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estado NutricionalRESUMEN
BACKGROUND: Patients with obesity are at higher risk for community-acquired and nosocomial infections. However, no study has specifically evaluated the relationship between obesity and ventilator-associated pneumonia (VAP). RESEARCH QUESTION: Is obesity associated with an increased incidence of VAP? STUDY DESIGN AND METHODS: This study was a post hoc analysis of the Impact of Early Enteral vs Parenteral Nutrition on Mortality in Patients Requiring Mechanical Ventilation and Catecholamines (NUTRIREA2) open-label, randomized controlled trial performed in 44 French ICUs. Adults receiving invasive mechanical ventilation and vasopressor support for shock and parenteral nutrition or enteral nutrition were included. Obesity was defined as BMI ≥ 30 kg/m2 at ICU admission. VAP diagnosis was adjudicated by an independent blinded committee, based on all available clinical, radiologic, and microbiologic data. Only first VAP episodes were taken into account. Incidence of VAP was analyzed by using the Fine and Gray model, with extubation and death as competing risks. RESULTS: A total of 699 (30%) of the 2,325 included patients had obesity; 224 first VAP episodes were diagnosed (60 and 164 in obese and nonobese groups, respectively). The incidence of VAP at day 28 was 8.6% vs 10.1% in the two groups (hazard ratio, 0.85; 95% CI 0.63-1.14; P = .26). After adjustment on sex, McCabe score, age, antiulcer treatment, and Sequential Organ Failure Assessment at randomization, the incidence of VAP remained nonsignificant between obese and nonobese patients (hazard ratio, 0.893; 95% CI, 0.66-1.2; P = .46). Although no significant difference was found in duration of mechanical ventilation and ICU length of stay, 90-day mortality was significantly lower in obese than in nonobese patients (272 of 692 [39.3%] patients vs 718 of 1,605 [44.7%]; P = .02). In a subgroup of patients (n = 123) with available pepsin and alpha-amylase measurements, no significant difference was found in rate of abundant microaspiration of gastric contents, or oropharyngeal secretions between obese and nonobese patients. INTERPRETATION: Our results suggest that obesity has no significant impact on the incidence of VAP.
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Índice de Masa Corporal , Unidades de Cuidados Intensivos , Obesidad/complicaciones , Neumonía Asociada al Ventilador/etiología , Respiración Artificial/efectos adversos , Choque/terapia , Anciano , Femenino , Francia/epidemiología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Nutrición Parenteral Total/métodos , Neumonía Asociada al Ventilador/epidemiología , Prevalencia , Pronóstico , Factores de Riesgo , Tasa de Supervivencia/tendenciasRESUMEN
Total parenteral nutrition (TPN) is a life-saving therapy administered to millions of patients. However, it is associated with significant adverse effects, namely liver injury, risk of infections, and metabolic derangements. In this review, the underlying causes of TPN-associated adverse effects, specifically gut atrophy, dysbiosis of the intestinal microbiome, leakage of the epithelial barrier with bacterial invasion, and inflammation are first described. The role of the bile acid receptors farnesoid X receptor and Takeda G protein-coupled receptor, of pleiotropic hormones, and growth factors is highlighted, and the mechanisms of insulin resistance, namely the lack of insulinotropic and insulinomimetic signaling of gut-originating incretins as well as the potentially toxicity of phytosterols and pro-inflammatory fatty acids mainly released from soybean oil-based lipid emulsions, are discussed. Finally, novel approaches in the design of next generation lipid delivery systems are proposed. Propositions include modifying the physicochemical properties of lipid emulsions, the use of lipid emulsions generated from sustainable oils with favorable ratios of anti-inflammatory n-3 to pro-inflammatory n-6 fatty acids, beneficial adjuncts to TPN, and concomitant pharmacotherapies to mitigate TPN-associated adverse effects.
Asunto(s)
Sistemas de Liberación de Medicamentos/métodos , Gastritis/prevención & control , Hepatitis/prevención & control , Lípidos/administración & dosificación , Nutrición Parenteral Total/efectos adversos , Ácidos y Sales Biliares/metabolismo , Disbiosis/etiología , Emulsiones/administración & dosificación , Emulsiones/química , Gastritis/etiología , Hepatitis/etiología , Humanos , Insulina/metabolismo , Lípidos/farmacología , Nutrición Parenteral Total/métodos , Receptores Citoplasmáticos y Nucleares/metabolismoRESUMEN
SCOPE: The aim of this study is to test whether the choice of the lipid emulsion in total parenteral nutrition (TPN), that is, n-3 fatty acid-based Omegaven versus n-6 fatty acid-based Intralipid, determines inflammation in the liver, the incretin profile, and insulin resistance. METHODS AND RESULTS: Jugular vein catheters (JVC) are placed in C57BL/6 mice and used for TPN for 7 days. Mice are randomized into a saline group (saline infusion with oral chow), an Intralipid group (IL-TPN, no chow), an Omegaven group (OV-TPN, no chow), or a chow only group (without JVC). Both TPN elicite higher abundance of lipopolysaccharide binding protein in the liver, but only IL-TPN increases interleukin-6 and interferon-γ, while OV-TPN reduces interleukin-4, monocyte chemoattractant protein-1, and interleukin-1α. Insulin plasma concentrations are higher in both TPN, while glucagon and glucagon-like peptide-1 (GLP-1) were higher in IL-TPN. Gluconeogenesis is increased in IL-TPN and the nuclear profile of key metabolic transcription factors shows a liver-protective phenotype in OV-TPN. OV-TPN increases insulin sensitivity in the liver and skeletal muscle. CONCLUSION: OV-TPN as opposed to IL-TPN mitigates inflammation in the liver and reduces the negative metabolic effects of hyperinsulinemia and hyperglucagonemia by "re-sensitizing" the liver and skeletal muscle to insulin.
Asunto(s)
Gastritis/etiología , Hepatitis/etiología , Insulina/metabolismo , Lípidos/administración & dosificación , Nutrición Parenteral Total/métodos , Animales , Emulsiones/administración & dosificación , Emulsiones/química , Emulsiones/farmacología , Ácidos Grasos Omega-6/farmacología , Aceites de Pescado/farmacología , Incretinas/metabolismo , Insulina/sangre , Resistencia a la Insulina , Interferón gamma/metabolismo , Interleucina-6/metabolismo , Lípidos/química , Síndromes de Malabsorción/etiología , Masculino , Ratones Endogámicos C57BL , Músculo Esquelético/efectos de los fármacos , Músculo Esquelético/metabolismo , Nutrición Parenteral Total/efectos adversos , Fosfolípidos/administración & dosificación , Fosfolípidos/farmacología , Aceite de Soja/administración & dosificación , Aceite de Soja/farmacología , Triglicéridos/farmacologíaRESUMEN
BACKGROUND: Lipaemic interference on automated analysers has been widely studied using soy-based emulsion such as Intralipid. Due to the greater adoption of fish oil-based lipid emulsion for total parenteral nutrition in view of improved clinical outcomes, we seek to characterize the optical properties of SMOFlipid 20% (Fresenius Kabi, Bad Homburg, Germany), a fish oil-based emulsion, on the Roche Cobas 6000 chemistry analyser (Roche Diagnostic, Basel, Switzerland). METHOD: Various amounts of SMOFlipid were spiked into pooled serums. We plotted Roche Cobas Serum Index Gen.2 Lipaemia Index (L-index) against the amount of SMOFlipid added. We then studied the interference thresholds for aspartate aminotransferase, alanine aminotransferase, albumin and renal panel analytes using SMOFlipid. We subjected five levels of spiked lipaemia to high-speed centrifugation and analysed the specimens pre- and post-centrifugation. To postulate whether fish oil-based lipid emulsion interferes with laboratory results in the clinical setting, we calculated concentrations of SMOFlipid post-lipid rescue therapy and steady-state concentration of a typical total parenteral nutrition regime using pharmacokinetic principles. RESULTS: SMOFlipid optical behaviour is similar to Intralipid using the Serum Index Gen.2 L-index, with 1 mg/dL of SMOFlipid representing 1 unit of L-index. Manufacturer-stated interference thresholds are accurate for alanine aminotransferase, aspartate aminotransferase, albumin, urea and creatinine. High-speed centrifugation at 60 min 21,100g facilitates the removal of fish oil-based SMOFlipid. CONCLUSION: Based on the interference thresholds we verified and pharmacokinetics parameters provided by SMOFlipid manufacturer, total parenteral nutrition may not interfere with chemistry analytes given sufficient clearance, but lipid rescue therapy will interfere. Further studies assessing lipaemic interference on immunoassays are needed.