[Expert consensus on clinical practice of parenteral nutrition therapy for critically ill patients in China (2024)].

Critical patients have a high incidence of malnutrition, which can lead to adverse outcomes such as infections and ICU-acquired weakness. Improving the nutritional status of critically ill patients is currently an important challenge. Parenteral nutrition (PN) is an important component of medical nutrition, but there is still much controversy over how to implement a reasonable and standardized PN for critically ill patients. To further standardize the PN strategy for critically ill patients, the Critical Care Medicine Branch of the Zhejiang Medical Association convened experts in the field of critical care medicine and formulated the Expert consensus on clinical practice of parenteral nutrition therapy for critically ill patients in China (2024). This consensus is based on the GRADE evidence quality grading standard, problem oriented, and summarizes evidence-based medicine evidence from multiple aspects such as PN timing, suitable population, nutritional plan, and ingredient ratio, providing professional suggestions for the standardization and implementation of PN in clinical nutrition practice.

Transthyretin and Nutritional Status in Critically Ill Adults on Parenteral Nutrition: A Prospective Cohort Study.

BACKGROUND AND AIMS: Correctly characterizing malnutrition is a challenge. Transthyretin (TTR) rapidly responds to adequate protein intake/infusion, which could be used as a marker to identify malnutrition. Nutritional therapy is used to prevent malnutrition. Parenteral nutrition (PN) requires daily monitoring to determine whether what is being offered is adequate. This article aims to investigate whether the practice of measuring TTR is justified. METHODS: Data from patients admitted to the ward or intensive care unit (ICU) were collected at three different times: within the first 72 h (T1) of PN use, on the 7th day (T2), and the 14th day (T3) after the initial assessment. RESULTS: 302 patients were included; the average age was 48.3 years old; the prevalence of death was 22.2%, and 61.6% of the sample were male. TTR values and the effectiveness of nutritional support in these patients were not associated with the outcome; however, meeting caloric needs was related to the outcome (p = 0.047). No association was found when TTR values were compared to the nutritional status. Thus, TTR was not a good indicator of nutritional risk or nutritional status in hospitalized patients. CONCLUSIONS: Undoubtedly, the TTR measurement was inversely proportional to CRP measurements. It was possible to conclude in this follow-up cohort of hospitalized patients that TTR values were not useful for determining whether the patient was malnourished, predicting death or effectiveness of nutritional support, yet based upon our analyses, a decrease in TTR greater than 0.024 units for every 1 unit increase in CRP might be due to ineffective nutritional supply.

Incidence and Risk Factors of Refeeding Syndrome in Preterm Infants.

This study aimed to evaluate the incidence and risk factors associated with refeeding syndrome (RFS) in preterm infants (≤32 weeks gestational age) during their first week of life. Infants (gestational age ≤ 32 weeks; birth weight < 1500 g) who were admitted to the neonatal intensive care unit (NICU), level III, and received parenteral nutrition between January 2015 and April 2024 were retrospectively evaluated. Modified log-Poisson regression with generalized linear models and a robust variance estimator was applied to adjust the relative risk of risk factors. Of the 760 infants identified, 289 (38%) developed RFS. In the multivariable regression analysis, male, intraventricular hemorrhage (IVH), and sodium phosphate significantly affected RFS. Male infants had significantly increased RFS risk (aRR1.31; 95% CI 1.08-1.59). The RFS risk was significantly higher in infants with IVH (aRR 1.71; 95% CI 1.27-2.13). However, infants who received higher sodium phosphate in their first week of life had significantly lower RFS risk (aRR 0.67; 95% 0.47-0.98). This study revealed a notable incidence of RFS among preterm infants aged ≤32 gestational weeks, with sex, IVH, and low sodium phosphate as significant risk factors. Refined RFS diagnostic criteria and targeted interventions are needed for optimal management.

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The "Guidelines for parenteral nutrition in preterm infants: the American Society for parenteral and enteral nutrition" were developed by the American Society for Parenteral and Enteral Nutrition and published in the Journal of Parenteral and Enteral Nutrition in September 2023. The guidelines provide recommendations on 12 key clinical questions regarding parenteral nutrition (PN) for preterm infants. In comparison to similar guidelines, this set offers more detailed perspectives on PN for preterm infants. It presents evidence-based recommendations for the commencement time, nutrient dosage, and composition of PN, considering primary outcomes such as growth and development, as well as secondary outcomes like sepsis, retinopathy of prematurity, parenteral nutrition-related liver disease, and jaundice. This article aims to interpret the guidelines to provide a reference for colleagues in the field.

Nutritional therapy among adult patients with severe burns: A retrospective observational study.

BACKGROUND AND OBJECTIVES: The objective of this study was to examine the effects of nutritional therapy in adult patients with severe burns. METHODS AND STUDY DESIGN: Sixty adult patients with severe burns were enrolled. Data on nutritional intake through enteral nutrition (EN) or parenteral nutrition (PN) on days 7, 14, 21, and 28 post-injury were collected. Patients were divided into target and non-target groups according to whether their energy or protein intake reached the target. Age, length of ventilation, and total bilirubin (TBIL), albumin (ALB), prealbumin (pALB), and C-reactive protein (CRP) concentrations of patients were recorded. RESULTS: The percentage of protein targets with protein delivery was lower than that of energy target with energy delivery. The ratio of PN protein to total protein was lower than that of PN energy to total energy on days 7, 14, 21, and 28 (p<0.001, p<0.001, p=0.001, and p=0.003, respectively). Compared to the non-target group on day 21, the target group was younger, had lower TBIL on day 7, higher ALB and pALB on day 21, and lower CRP on day 14 (p=0.025, p=0.021, p=0.028, p=0.029, and p=0.049, respectively). Multivariate logistic regression analysis showed that older age and longer ventilation were independent risk factors in patients who did not meet the nutritional target on day 21 (p=0.026 and p=0.043, respectively). CONCLUSIONS: The protein intake of adult patients with severe burns was low. Compared to the non-target group, the target group had better laboratory test results. Older age and longer ventilation were independent risk factors for patients not meeting the nutritional target.

[Comparison of prognosis of elderly patients with gastric and colorectal tumors receiving different nutritional support treatments].

Objective: To compare the prognosis of elderly patients with gastric and colorectal cancer treated with different nutritional support methods. Methods: Elderly patients with gastrointestinal tumors who received surgical treatment in Beijing Hospital from January 2019 to June 2020 were retrospectively included and divided into malnourished group and non-malnourished group according to the Global Leadership Initiative on Malnutrition (GLIM). The patients were divided into parenteral nutrition (PN) group, enteral nutrition (EN) group and enteral+parenteral nutrition (EN+PN) group according to the nutritional support. The prognosis of patients with different nutritional support treatment was compared. Results: A total of 426 elderly patients with gastric and colorectal tumors underwent surgical treatment were included, including 287 males and 139 females, aged 65-91 (72±6) years. There were 186 cases in malnourished group and 240 cases in non-malnourished group. A total of 257 patients received nutritional support therapy, including 108 cases in PN group, 48 cases in EN group and 101 cases in EN+PN group. The body mass index (BMI) of malnutrition group was lower than that of non-malnutrition group [(20.5±3.4) vs (23.7±2.8) kg/m2, P<0.001], and the score of nutritional risk screening 2002 (NRS 2002) [M (Q1, Q3)] was higher than that of non-malnutrition group [4 (4, 5) vs 2 (2, 3) points, P<0.001]. The total hospitalization time of patients in EN group was shorter than that in PN group and EN+PN group [(11.9±4.0) vs (16.5±6.5) and (19.2±7.1) d, all P<0.001]. The total hospitalization time in PN group was shorter than that in EN+PN group [(16.5±6.5) vs (19.2±7.1) d, P=0.005]. The total incidence of complications in EN group was lower than that in PN group [0 vs 9.3% (10/108), P=0.030] and EN+PN group [0 vs 19.8% (20/101), P<0.001]. The incidence of total complications in PN group was lower than that in EN+PN group [9.3% (10/108) vs 19.8% (20/101), P=0.030]. Conclusion: Among the three nutritional supportive treatment modalities: EN, PN, and EN+PN, patients receiving EN support treatment have a shorter total hospitalization time and a lower complication rate.

[Chinese expert consensus on the application of electrolytes in parenteral nutrition (2024 edition)].

As essential nutrients for human beings, electrolytes play a central role in nutritional and metabolic support treatment. To further standardize the use of electrolyte preparations in parenteral nutrition, the China International Exchange and Promotive Association for Medical and Health Care Clinical Nutrition Health Branch, Chinese Medical Doctor Association Nutritionist Professional Committee, Chinese Society of Parenteral and Enteral Nutrition, and Chinese Nutrition Society Branch of Clinical Nutrition, invited authoritative experts in the fields of critical medicine, emergency medicine, internal medicine, surgery, and pharmacology in China to create this expert consensus. This consensus was based on the latest guidelines and evidence-based medicine at home and abroad, and combined with the actual clinical medical environment in China. This consensus covered the following topics: electrolytes monitoring during parenteral nutrition, risk assessment and nutritional treatment of refeeding syndrome, electrolytes supplementation during parenteral nutrition for various diseases (including severe diseases, heart failure, post-surgical short bowel syndrome, perioperative period, trauma, diabetic foot, chronic kidney disease, liver disease, neonates), and the compatibility principles of electrolyte preparations in parenteral nutrition. Finally, 13 clinical questions and 26 recommendations were proposed aiming at providing scientific, standardized, and practical guidance for the rational application of electrolytes in parenteral nutrition.

Prognostic factor of patients with short bowel syndrome due to nonCrohn disease: A single institution observational study.

Short bowel syndrome (SBS) is a severely disabling and potentially life-threatening condition. Survival data for patients with SBS are limited. This study aimed to investigate prognostic factors in patients with SBS undergoing surgery. We reviewed the medical records of 27 consecutive patients with SBS who were treated at our hospital between January 2018 and December 2022. SBS was defined as a remaining small bowel length <200 cm, excluding patients with Crohn disease. Of the 27 patients identified, 17 were males and 10 were females, with a median age of 77 (46-90) years and a total observation time of 137 (2-1628) days. All patients underwent surgery and received parenteral nutrition (PN) and follow-up in our hospital. Superior mesenteric artery stenosis (44.4%) and nonocclusive mesenteric ischemia (25.9%) most commonly caused SBS. The median residual small bowel length and postoperative hospital stay were 50 (5-150) cm and 48 (2-104) days, respectively. Jejunostomy was performed in 17 (62.9%) patients, and 4 (14.8%) patients were weaned off their PN. Death occurred in 14 (51.8%), and the median survival time was 209 days. The survival outcome was compared between the survival (n = 13) and the death groups (n = 14). Jejunostomy and PN rates were significantly higher in the death group (P < .01, P = .03, respectively). SBS is associated with significantly higher mortality rates. Jejunostomy and long PN duration are significantly associated with death in patients with SBS.

The role of lipid emulsions containing omega-3 fatty acids for medical and surgical critical care patients.

In critical illness the regulation of inflammation and oxidative stress can improve patient outcomes, and thus omega-3 polyunsaturated fatty acids (PUFAs) have been used as part of parenteral nutrition (PN) owing to their potential anti-inflammatory effects. The international lipids in PN Summit, encompassed discussions and the production of consensus guidelines concerning PN intravenous lipid emulsion (ILE) use in critical care. The Lipid Summit participants agreed that the inclusion of fish oil in ILEs is associated with meaningful clinical benefits without signals of harm, based on a strong biological rationale and current clinical evidence. Decisions concerning ILE choice should be made based on current evidence, thus addressing clinical requirements for guidance, particularly as further definitive evidence seems unlikely to occur. In addition, a future of individualized ICU care is envisioned, yielding better clinical outcomes. This approach will require the greater use of intelligent study designs incorporating the use of biomarkers of omega-3 derivatives, inflammatory-resolving processes, and/or muscle protein breakdown.

Usefulness of central venous catheter replacement with a guidewire in patients with intestinal failure: a single-center study.

PURPOSE: Patients with intestinal failure (IF) require long-term parenteral nutrition using central venous catheters (CVCs), which often require replacement. We adopted a less fallible guidewire replacement (GWR) method and verified its effectiveness and validity. METHODS: We enrolled 108 cases that underwent a CVC replacement with "GWR" method with IF at our department between 2013 and 2023. We retrospectively reviewed patients' clinical details with tunneled CVC (Hickman/Broviac catheter). For the analysis, we compared for the same time period the catheter exchange method "Primary placement"; newly inserted catheter by venipuncture. RESULTS: The success rate of catheter replacement using GWR was 94.4%. There were six unsuccessful cases. A log-rank test showed no significant difference in catheter survival between primary placement and the GWR, and the time to first infection was significantly longer in the GWR (p = 0.001). Furthermore, no significant differences were observed between the two methods until the first infection, when the exchange indication was limited to infections. In the same way, when the indication was restricted to catheter-related bloodstream infection, there was no significant difference in catheter survival between the two approaches. CONCLUSION: Our GWR procedure was easy to perform and stable, with a high success rate and almost no complications. Moreover, using a guidewire did not increase the frequency of catheter replacement and the infection rate.

Can we improve the management of inoperable malignant bowel obstruction? Results of a feasibility study of elemental diet as an alternative to parenteral nutrition in patients with advanced gynaecological cancer.

PURPOSE: Nutrition support in inoperable bowel obstruction (IBO) remains challenging. Parenteral nutrition (PN) is recommended if the prognosis is > 2 months. An elemental diet (ED) is licensed for strictures in Crohn's disease but has not been used in malignant bowel obstruction. The aim of this study was to evaluate the use of ED in patients with IBO and provide a proof of concept of ED as an acceptable feeding option. METHODS: This was a mixed-methods single-arm feasibility study. The primary endpoint was to provide a 'proof of concept' of ED as an acceptable feeding option for patients with IBO. Secondary endpoints included taste acceptability, incidences of vomiting and pain, the proportion of women who tolerated ED, the number of cartons drunk, quality of life (QOL) and the number of women treated with chemotherapy. Patients (> 18 years) with CT-confirmed IBO who could tolerate 500 ml of liquid in 24 h remained on the trial for 2 weeks. RESULTS: A total of 29 patients were recruited; of those, 19 contributed to the analysis for the primary endpoint; 13 (68.4%) participants tolerated the ED; 26 patients contributed to MSAS and EORTC QLQ questionnaires at baseline to allow for the assessment of symptoms. At the start of the study, 18 (69%) of patients experienced vomiting, reducing to 4 (25%) by the end of day 15 of the study; 24 (92%) of patients reported pain at consent, reducing to 12 (75%) by the end of day 15. QOL scores improved from 36.2 (95% CI 27.7-44.7) at baseline to 53.1 (95% CI 40.3-66) at the end of day 15; 16 (84%) participants commenced chemotherapy within the first week of starting ED. The number of cartons across all participants showed a median of 1.3 cartons per day (range 0.8 to 2.5). CONCLUSION: ED is well tolerated by patients with IBO caused by gynaecological malignancies and may have a positive effect on symptom burden and QOL.

Lipid Emulsion Type and Liver Function in Parenteral Nutrition Patients: A Retrospective Study of Patients and Prescribing Practices.

Parenteral nutrition (PN) is a life-sustaining method to provide adequate nutrients to patients unable to receive oral or enteral nutrition. PN typically contains a mixture of macro- and micro-nutrients, although the lipid composition has been identified as a concern for liver disease. Therefore, the study of the intravenous lipid emulsion (ILE) prescribing practices in home-based PN (HPN) patients and whether differing lipid PN alters liver function tests (LFTs) is needed. METHODS: A retrospective study of monthly LFTs from a random sample of 105 adult HPN patients in the U.S. over a 6-month period was conducted. Patients were receiving olive oil/soy oil (n = 53, Clinolipid), mixed ILE (n = 39, SMOF Lipid), soy oil (SO; n = 4, Intralipid), or none (n = 7). LFTs monitored were alkaline phosphatase (ALP), alanine transaminase (ALT), aspartate transaminase (AST), and total bilirubin (T Bili). RESULTS: No differences were observed in baseline LFTs across groups (all, p > 0.25, η2 < 0.04), nor were there differences in age, body mass index, days of PN, or mean PN volume (all, p > 0.36, η2 < 0.05). There were no significant interactions between ILE type and time (all p > 0.64, ηp2 < 0.03), no effect of ILE type (all p > 0.60, ηp2 < 0.03), and no effect of time (all p > 0.69, ηp2 < 0.01) in terms of LFTs. Average LFTs over six months were also not different between ILE types (all p > 0.30, η2 < 0.04). CONCLUSION: These findings suggested that patients were mostly prescribed mixed or ILE PN containing more than one lipid source and that differing ILEs in long-term HPN patients did not alter LFTs over a six-month period.

Gut microbiota and intestinal rehabilitation: a prospective childhood cohort longitudinal study of short bowel syndrome (the MIRACLS study): study protocol.

INTRODUCTION: Short bowel syndrome (SBS) is the predominant cause of paediatric intestinal failure. Although life-saving, parenteral nutrition (PN) is linked to complications and may impact quality of life (QoL). Most children will experience intestinal rehabilitation (IR), but the mechanisms underpinning this remain to be understood. SBS is characterised by abnormal microbiome patterns, which might serve as predictive indicators for IR. We aim to characterise the microbiome profiles of children with SBS during IR, concurrently exploring how parental perspectives of QoL relate to IR. METHODS AND ANALYSIS: This study will enrol a minimum of 20 paediatric patients with SBS (0-18 years). Clinical data and biological samples will be collected over a 2-year study period. We will apply 16S rRNA gene sequencing to analyse the microbiome from faecal and gut tissue samples, with additional shotgun metagenomic sequencing specifically on samples obtained around the time of IR. Gas chromatography with flame ionisation detection will profile faecal short-chain fatty acids. Plasma citrulline and urinary intestinal fatty acid binding proteins will be measured annually. We will explore microbiome-clinical covariate interactions. Furthermore, we plan to assess parental perspectives on QoL during PN and post-IR by inviting parents to complete the Paediatric Quality of Life questionnaire at recruitment and after the completion of IR. ETHICS AND DISSEMINATION: Ethical approval was obtained from the East Midlands-Nottingham 2 Research Ethics Committee (22/EM/0233; 28 November 2022). Recruitment began in February 2023. Outcomes of the study will be published in peer-reviewed scientific journals and presented at scientific meetings. A lay summary of the results will be made available to participants and the public. TRIAL REGISTRATION NUMBER: ISRCTN90620576.

Incorporating ultrasonography to the nutritional assessment process in intensive care settings to improve the prescription of enteral and parenteral nutrition: Benefits, practicality, and challenges.

The validity of the traditional nutritional assessment tools in intensive care settings might be compromised when the patient has conditions such as oedema and inflammation. Ultrasound (US) is considered a non-invasive, bedside tool that can be utilized to assess changes in muscle mass. Hence, US could guide healthcare practitioners in identifying the varying degrees of malnutrition and adjusting the nutritional prescription accordingly. This review discusses the currently available data regarding the feasibility and practicality of using US measurements in intensive care settings. Overall, the data suggest that using US as part of the standard anthropometric assessment for critically ill patients is a promising tool to track variations in muscle mass. This has the potential to enhance nutritional prescription and tailor the provision of protein and energy to critically ill patients based on their lean body mass measurements. Therefore, it is recommended to train dietitians on utilizing US for body composition measurements.

The influence of parenteral nutrition on the condition of the oral cavity: literature review.

Oral health plays a pivotal role in the overall well-being of patients. This article delves into the intricate interplay between oral health and systemic health outcomes in various patient populations, including those undergoing parenteral nutrition in childhood, individuals with impaired swallowing function, and those reliant on long-term enteral or parenteral nutrition. Through a comprehensive review of existing literature, the multifaceted role of oral health maintenance in optimizing nutritional therapy outcomes and enhancing overall quality of life is explored. Alternative forms of nutrition have a profound impact on Oral microbiota, which in turn is reflected in general health and wellbeing. Despite its significance, the importance of systematic oral health assessments and nurse involvement in providing holistic care to patients with complex medical needs has been underestimated. By elucidating critical connections between oral health and systemic health outcomes, this article aims to underscore the significance of oral health in comprehensive patient care and stimulate further research to advance our understanding of this crucial aspect of healthcare management.

Comparison of nasojejunal nutrition and intravenous nutrition supplementation in patients with upper gastrointestinal tract strictures and analysis of risk factors for malnutrition.

This study examines the effectiveness of nasojejunal and intravenous nutrition in supplementing nutrition for patients with upper gastrointestinal (GI) strictures and analyzes the risk factors associated with malnutrition to provide references for clinical nutrition strategies. A retrospective analysis was conducted on 71 patients with upper GI strictures caused by esophageal and gastric cancers, who received nutritional support from January 2015 to January 2023. Out of these, 53 patients had complete baseline and follow-up data. We collected general clinical and perioperative data for comparison of the efficacy between nasojejunal nutrition and intravenous nutrition. Risk factors for malnutrition were analyzed using univariate and multivariate logistic regression. Malnutrition occurred in 24.53% (13/53) of the patients with upper GI strictures. The incidence of malnutrition was 6.06% (2/33) in the nasojejunal nutrition group compared to 55.00% (11/20) in the intravenous nutrition group, with a statistically significant difference (P < .001). Univariate and multivariate regression analyses identified diabetes (P < .001), initial blood K (P = .011), pathological staging (P < .001), and pathological grading (P < .001) as risk factors for malnutrition in patients with upper GI strictures. Diabetes (P = .028), initial blood K (P = .018), and pathological staging (P = .011) were found to be independent risk factors. Nasojejunal nutrition results in a lower incidence of malnutrition compared to intravenous nutrition in patients with upper GI strictures. Diabetes, initial blood K, pathological staging, and pathological grading are risk factors for malnutrition, with diabetes, initial blood K, and pathological staging serving as independent risk factors.