Premixed vs Compounded Parenteral Nutrition: Effects of Total Parenteral Nutrition Shortage on Clinical Practice.

PURPOSE OF REVIEW: Drug shortages continue to impact our patients with intestinal failure and their ability to receive nutrition. ASPEN guidelines address the management of certain shortages in compounded total parenteral nutrition (TPN); however, some institutions have utilized premixed total parenteral nutrition (pTPN) in place of TPN. RECENT FINDINGS: Premixed TPN appears to be as safe, if not safer, as compounded TPN when comparing the risk of bloodstream infection. However, there is an increased use of supplemental electrolytes to meet patient needs. Cost-effectiveness depends on multiple factors and should be evaluated by each institution when considering the use of TPN. In light of the published information on the use of pTPN compared to TPN, institutions and nutrition clinicians should consider their current practice and opportunities to consider when pTPN may be beneficial for their patients, not only from a safety perspective, but also considering cost savings. However, close monitoring and individual patient needs should be considered as these formulas may not meet all patient nutritional and electrolyte needs.

Transanastomotic tubes reduce the cost of nutritional support in neonates with congenital duodenal obstruction.

PURPOSE: To determine the impact of intra-operative Trans-anastomotic Tube (TAT) placement on the cost of post-operative nutrition in infants with congenital duodenal obstruction (CDO). METHODS: A retrospective analysis of patients undergoing corrective surgery for CDO, with birth-weight over 1.5 kg over a 10-year period. Data are presented as median (inter-quartile range) and analysed with Mann-Whitney U test and Fisher's exact test as appropriate. RESULTS: 59 patients were included. There was no difference between TAT and non-TAT groups for baseline characteristics, age at operation and abnormality. In the TAT group there was a significant reduction in the duration of post-operative parenteral nutrition (PN) [6 (0-11) vs 12 (8-19) days, p = 0.006], the cost of PN [£750 (0-1375) vs £1500 (1000-2375), p = 0.006] and the total cost of nutrition [£765.26 (38.36-1404) vs £1387.52 (1008.23-2363.08), p = 0.015], thereby demonstrating a median cost saving of £622.26 per patient. 14% experienced TAT displacement but no other TAT complications were encountered. CONCLUSION: The use of a TAT is a safe and effective way to reduce the duration of PN required in patients with CDO. This infers a significant cost saving per patient, a factor that cannot be overlooked in this period of austerity.

Comparison of effectiveness, safety, and costs of standardized and customized parenteral nutrition support among gastric cancer patients after gastrectomy: a retrospective cohort study.

BACKGROUND AND OBJECTIVES: To compare the effectiveness, safety, and costs of commercial standardized multi-chamber bag and customized compounded total parenteral nutrition (TPN) among gastric cancer patients after gastrectomy. METHODS AND STUDY DESIGN: A retrospective cohort study was conducted among 64 gastric cancer patients who underwent gastrectomy from 2014 to 2016 in a tertiary teaching hospital in Beijing, China. Patients were categorized into standardized (s-TPN) and customized TPN (c-TPN) groups based on their TPN order after gastrectomy. Patients were followed up until discharge. The effectiveness measures (body mass index (BMI) and albumin) and safety measures (liver and renal functions and electrolytes) were compared before TPN started and after TPN finished within and between the two groups. The length of hospital stay and costs were compared be-tween the two groups. RESULTS: There were no significant differences between the two groups in BMI preserva-tion, metabolic complications, the length of hospital stay and costs, except that both total bilirubin (Tbil) and di-rect bilirubin (Dbil) were significantly higher in the s-TPN group than c-TPN (p<0.05). CONCLUSIONS: There were no significant differences in effectiveness and safety measures, the length of hospital stay and costs between s-TPN and c-TPN groups, except that s-TPN group was more likely to lead to parenteral nutrition-associated liver disease (PNALD). More studies are needed to confirm the findings of this study in other healthcare settings and study populations.

Comparison of different feeding regimes after pancreatoduodenectomy - a retrospective cohort analysis.

BACKGROUND: Delayed gastric emptying (DGE) is the most frequent pancreatic specific complication (PSC) after pancreaticoduodenectomy (PD). Several gastric decompression systems exist to manage DGE. Patients with a pancreatic tumor require prolonged nutrition; however, controversies exist concerning nutrition protocol after PD. The aim of the study was to assess the safety and efficacy of nasogastric (NG), gastrostomy (GT), and gastrojejunostomy (GJ) tubes with different feeding systems on postoperative courses. METHODS: Between January 2013 and March 2016, 86 patients underwent PD with pancreaticogastrostomy. Patients were divided into three groups: GJ group with enteral nutrition (EN, n = 12, 14%), NG (n = 31, 36%) and GT groups (n = 43, 50%), both with total parenteral nutrition (TPN). RESULTS: Patients in the GJ (n = 9, 75%) and GT (n = 18, 42%) groups had an American Society of Anesthesiologists (ASA) score of 3 more often than those in the NG group (n = 5, 16%, p ≤ 0.01). Multivariate analysis identified the GT tube with TPN as an independent risk factor of severe morbidity (p = 0.02) and DGE (p < 0.01). An ASA score of 3, jaundice, common pancreatic duct size ≤3 mm and soft pancreatic gland texture (p < 0.05) were found as independent risk factors of PSCs. Use of a GJ tube with EN, GT tube with TPN, jaundice, and PSCs were identified as independent risk factors for greater postoperative length of hospital stay (p < 0.01). Mean global hospitalization cost did not differ between groups. CONCLUSION: GT tube insertion with TPN was associated with increased severe postoperative morbidity and DGE and should not be recommended. EN through a GJ tube after PD is feasible but does not have clear advantages on postoperative courses compared to an NG tube.

Intestinal rehabilitation for children with intestinal failure is cost-effective: a simulation study.

BACKGROUND: Children with intestinal failure (IF) depend on parenteral nutrition (PN). The goal in the treatment of IF is to wean children off PN through intestinal rehabilitation (IR). Although the healthcare burden of IF is enormous, to our knowledge there has been no previous cost-effectiveness analysis in pediatric IF including IR. OBJECTIVE: We sought to determine the cost-effectiveness of IR in terms of costs and life-years. DESIGN: We simulated the treatment of IF in children in a discrete-event model. Data for this model were derived from patient records, the Dutch Registry of Intestinal Failure and Transplantation, the Intestinal Transplant Registry, and the literature. The time horizon of the model was 40 y. Simulated patients were enrolled at a rate of 40 patients/mo for 10 y. Actual costs were calculated for hospital admissions, surgical interventions, endoscopies, PN, and immunosuppressive medication. We evaluated the cost-effectiveness of IR by comparing 1 scenario with IR with 1 scenario without IR. In the scenario with IR, a proportion of patients who represented those with the ability to wean off PN were assigned to IR. In the scenario without IR, all patients progressed to home PN (HPN). In both scenarios, a proportion of patients receiving HPN were eventually eligible for an intestinal transplantation. RESULTS: IR prolonged survival; the mean number of life-years per patient was 19.4 in the scenario with IR compared with 18.2 in the scenario without IR. Average total costs per patient were €819,292 in the scenario with IR compared with €1,176,830 in the scenario without IR (equivalent to 1,129,230 US$ and 1,622,025 US$, respectively, in January 2014); costs mainly included hospital admissions and PN. CONCLUSIONS: On the basis of our simulations, we concluded that IR improved the survival of children with IF and was associated with cost savings. Therefore, we consider IR to be a cost-effective treatment for children with IF.

A protocol for sustained reduction of Total Parenteral Nutrition and cost savings by improvement of nutritional care in hospitals.

BACKGROUND AND AIMS: Malnutrition and the use of Total Parenteral Nutrition (TPN) contribute considerably to hospital costs. Recently, we reported on the introduction of malnutrition screening and monitoring of TPN use in our hospital, which resulted in a large (40%) reduction in TPN and improved quality of nutritional care in two years (2011/12). Here, we aimed to assure continuation of improved care by developing a detailed malnutrition screening and TPN use protocol involving instruction tools for hospital staff, while monitoring the results in the following two years (2013/14). METHODS: A TPN decision tree for follow up of TPN in patients and a TP-EN instruction card for caregivers was introduced, showing TPN/EN introduction schedules based on the energy needs of patients according to EB guidelines, also addressing the risk of refeeding syndrome. TPN patients were monitored by dietitians and TPN usage and costs were presented to the (medical) staff. Screening and treatment of malnourished patients by dietitians is simultaneously ongoing. RESULTS: In 2014 48% of patients, hospitalized for at least 48 h, were screened on malnutrition, 17% of them were diagnosed at risk, 7.9% malnourished and treated by dietitians. TPN usage dropped by 53% and cost savings of 51% were obtained due to 50% decrease of TPN users in 2014 versus 2010. TPN over EN ratio dropped from 2.4 in 2010 to 1.2 in 2014. CONCLUSION: Sustained improvement of nutritional care and reduction of TPN usage and costs is possible by introduction of procedures embedded in the existing structures.

Total nutrient admixtures (3-in-1): pros vs cons for adults.

Total nutrient admixture (TNA) is a complete parenteral nutrition (PN) formulation composed of all macronutrients, including dextrose, amino acids, and intravenous fat emulsions (IVFE), in one bag. The TNA may be safely administered to the patient, with all components aseptically compounded and minimal administration manipulation required, lending itself to decreases in risks of catheter contamination and patient infections. The TNA is compatible and stable at recommended concentrations, and since the IVFE is in the TNA, it is infused at slower rates, allowing for better fat clearance. The TNA offers convenience of administration and a potential cost savings to the healthcare institution both directly and indirectly. Unfortunately, the TNA is not without concerns. At low macronutrient concentrations (lower than recommended), the formulation is compromised. Greater divalent and monovalent cation amounts and increased concentrations of phosphate and calcium may destabilize the TNA or result in precipitation, respectively. With the addition of IVFE in the TNA, catheter occlusion is greater and larger pore size filters are necessary, resulting in less microbial elimination. Determining if the implementation of the TNA is appropriate for an institution requires a recognition of the advantages and disadvantages of the TNA as well as an understanding of the institution's patient population and their nutrition requirements.

Costs of multidisciplinary parenteral nutrition care provided at a distance via mobile tablets.

BACKGROUND: Determining the costs of healthcare delivery is a key step for providing efficient nutrition-based care. This analysis tabulates the costs of delivering home parenteral nutrition (HPN) interventions and clinical assessments through encrypted mobile technologies to increase patients' access to healthcare providers, reduce their travel expenses, and allow early detection of infection and other complications. METHODS: A traditional cost-accounting method was used to tabulate all expenses related to mobile distance HPN clinic appointments, including (1) personnel time of multidisciplinary healthcare professionals, (2) supply of HPN intervention materials, and (3) equipment, connection, and delivery expenses. RESULTS: A total of 20 mobile distance clinic appointments were conducted for an average of 56 minutes each with 45 patients who required HPN infusion care. The initial setup costs included mobile tablet devices, 4G data plans, and personnel's time as well as intervention materials. The initial costs were on average $916.64 per patient, while the follow-up clinic appointments required $361.63 a month, with these costs continuing to decline as the equipment was used by multiple patients more frequently over time. Patients reported high levels of satisfaction with cost savings in travel expenses and rated the quality of care comparable to traditional in-person examinations. CONCLUSION: This study provides important aspects of the initial cost tabulation for visual assessment for HPN appointments. These findings will be used to generate a decision algorithm for scheduling mobile distance clinic appointments intermittent with in-person visits to determine how to lower costs of nutrition assessments. To maximize the cost benefits, clinical trials must continue to collect clinical outcomes.

Enteral and parenteral nutrition in the perioperative period: state of the art.

Nutritional support of surgical and critically ill patients has undergone significant advances since 1936 when Studley demonstrated a direct relationship between pre-operative weight loss and operative mortality. The advent of total parenteral nutrition followed by the extraordinary progress in parenteral and enteral feedings, in addition to the increased knowledge of cellular biology and biochemistry, have allowed clinicians to treat malnutrition and improve surgical patient's outcomes. We reviewed the literature for the current status of perioperative nutrition comparing parenteral nutrition with enteral nutrition. In a surgical patient with established malnutrition, nutritional support should begin at least 7-10 days prior to surgery. Those patients in whom eating is not anticipated beyond the first five days following surgery should receive the benefits of early enteral or parenteral feeding depending on whether the gut can be used. Compared to parenteral nutrition, enteral nutrition is associated with fewer complications, a decrease in the length of hospital stay, and a favorable cost-benefit analysis. In addition, many patients may benefit from newer enteral formulations such as Immunonutrition as well as disease-specific formulations.

Extending total parenteral nutrition hang time in the neonatal intensive care unit: is it safe and cost effective?

AIM: To investigate the effects of prolonging hang time of total parenteral nutrition (TPN) fluid on central line-associated blood stream infection (CLABSI), TPN-related cost and nursing workload. METHODS: A before-after observational study comparing the practice of hanging TPN bags for 48 h (6 February 2009-5 February 2010) versus 24 h (6 February 2008-5 February 2009) in a tertiary neonatal intensive care unit was conducted. The main outcome measures were CLABSI, TPN-related expenses and nursing workload. RESULTS: One hundred thirty-six infants received 24-h TPN bags and 124 received 48-h TPN bags. Median (inter-quartile range) gestation (37 weeks (33,39) vs. 36 weeks (33,39)), mean (±standard deviation) admission weight of 2442 g (±101) versus 2476 g (±104) and TPN duration (9.7 days (±12.7) vs. 9.9 days (±13.4)) were similar (P > 0.05) between the 24- and 48-h TPN groups. There was no increase in CLABSI with longer hang time (0.8 vs. 0.4 per 1000 line days in the 24-h vs. 48-h group; P < 0.05). Annual cost saving using 48-h TPN was AUD 97,603.00. By using 48-h TPN, 68.3% of nurses indicated that their workload decreased and 80.5% indicated that time spent changing TPN reduced. CONCLUSION: Extending TPN hang time from 24 to 48 h did not alter CLABSI rate and was associated with a reduced TPN-related cost and perceived nursing workload. Larger randomised controlled trials are needed to more clearly delineate these effects.

Effectiveness and cost-effectiveness of supplemental glutamine dipeptide in total parenteral nutrition therapy for critically ill patients: a discrete event simulation model based on Italian data.

INTRODUCTION: The supplementation of alanyl-glutamine dipeptide in critically ill patients necessitating total parenteral nutrition (TPN) improves clinical outcomes, reducing mortality, infection rate, and shortening intensive care unit (ICU) hospital lengths of stay (LOSs), as compared to standard TPN regimens. METHODS: A Discrete Event Simulation model that incorporates outcomes rates from 200 Italian ICUs for over 60,000 patients, alanyl-glutamine dipeptide efficacy data synthesized by means of a Bayesian random effects meta-analysis, and national cost data has been developed to evaluate the alternatives from the cost perspective of the hospital. Simulated clinical outcomes are death and infection rates in ICU, death rate in general ward, and hospital LOSs. Sensitivity analyses are performed by varying all uncertain parameter values in a plausible range. RESULTS: The internal validation process confirmed the accuracy of the model in replicating observed clinical data. Alanyl-glutamine dipeptide on average results more effective and less costly than standard TPN: reduced mortality rate (24.6% ± 1.6% vs. 34.5% ± 2.1%), infection rate (13.8% ± 2.9% vs. 18.8% ± 3.9%), and hospital LOS (24.9 ± 0.3 vs. 26.0 ± 0.3 days) come at a lower total cost per patient (23,409 ± 3,345 vs. 24,161 ± 3,523 Euro).Treatment cost is completely offset by savings on ICU and antibiotic costs. Sensitivity analyses confirmed the robustness of these results. CONCLUSIONS: Alanyl-glutamine dipeptide is expected to improve clinical outcomes and to do so with a concurrent saving for the Italian hospital.

Multidisciplinary nutritional support for autologous hematopoietic stem cell transplantation: a cost-benefit analysis.

OBJECTIVE: The objective of the present study was to evaluate the economic and clinical efficacy of a multidisciplinary nutritional support team (NST) for autologous stem cell transplantation. METHODS: We performed a retrospective cost-benefit analysis of autologous stem cell transplantation (ASCT) in patients with and without NST intervention at a single institute. Patients (n = 120) had undergone 169 ASCTs, 67 before the commencement of NST intervention in September 2005 and 102 after September 2005. The conditioning regimens, prophylactic antibiotics, and supportive care were unchanged from 2001 through 2008. The duration of hospitalization, cost, and laboratory data were analyzed. RESULTS: With NST intervention, the duration of total parenteral nutrition, absence of oral food intake, hospitalization, and therapeutic antibiotic usage were significantly shortened by 11.4, 9.7, 8.1, and 4.5 d, respectively. With NST intervention, the incidence of hepatic adverse events and hyperglycemia was low, and the total cost of hospitalization was significantly decreased by 403 600 yen (US $4484.40). Two cases of therapy-related death were recorded before September 2005. No therapy-related mortality was observed after commencement of NST intervention; however, the difference was not significant. CONCLUSION: Multidisciplinary NST intervention has a positive effect on cost decrease, and it may decrease the incidence of adverse events associated with ASCT and total parenteral nutrition.

Endoscopic nasojejunal feeding tube placement in patients with severe hepatopancreatobiliary diseases: a retrospective study of 184 patients.

BACKGROUND: Total parenteral nutrition (TPN) has been recognized as the mainstay of nutritional support in patients with severe hepatopancreatobiliary (HPB) diseases for decades. However, recent studies advocate the utilization of endoscopic nasojejunal feeding tube placement (ENFTP), rather than the conventional approach. This study was designed to compare the clinical value of ENFTP and TPN in patients with severe HPB diseases. METHODS: Two groups of patients with severe HPB diseases were analyzed retrospectively. One group of 88 patients received ENFTP, and the other 96 received TPN. Routine blood levels, serum glucose and prealbumin, hepatic and renal function, serum lipid, and calcium were measured at baseline and after 1, 2, and 4 weeks of nutritional support. Also, complication rate, mortality, nutritional support time, mechanical ventilation time, mean length of time in intensive care unit, and duration of hospital stay were analyzed. RESULTS: After 4 weeks of nutritional support, the degree of recovery of red blood cells, prealbumin, and blood glucose was greater in the ENFTP than in the TPN group (P<0.05). Furthermore, the ENFTP group showed a lower incidence of septicemia, multiple organ dysfunction syndrome, peri-pancreatic infection, biliary infection, and nosocomial infection, in addition to shorter nutritional support time and hospital stay (P<0.05). CONCLUSIONS: ENFTP is much more effective than TPN in assisting patients with severe HPB diseases to recover from anemia, low prealbumin level, and high serum glucose, as well as in decreasing the rates of various infections (pulmonary infection excluded), multiple organ dysfunction syndrome rate, nutrition support time, and length of hospital stay. Therefore, ENFTP is safer and more economical for clinical application.

Cost-effectiveness of employing a total parenteral nutrition surveillance nurse for the prevention of catheter-related bloodstream infections.

The cost of catheter-related bloodstream infection (CRBSI) is substantial in terms of morbidity, mortality and financial resources. Total parenteral nutrition (TPN) is a recognised risk factor for CRBSI. In 1997, an intravenous nutrition nurse was promoted to TPN surveillance clinical nurse manager (CNM) and quarterly infection audit meetings were introduced to monitor trends in CRBSI. Data were prospectively collected over a 15-year period using specific TPN records in a 535-bed tertiary acute university hospital. A total of 20 439 CVC-days and 307 CRBSIs were recorded. Mean number of infections before, and after, the introduction of a dedicated TPN surveillance CNM were compared. Mean CRBSI per 1000 catheter-days+/-SD was 20.5+/-6.34 prior to 1997 and 14.64+/-7.81 after 1997, representing a mean reduction of 5.84 CRBSIs per 1000 catheter-days (95% CI: -4.92 to 16.60; P=0.05). Mean number of CRBSIs per year+/-SD was 28.3+/-4.93 prior to 1997 and 18.5+/-7.37 after 1997, representing a mean decrease of 9.8 infections per year (95% CI: 0.01 to 19.66; P<0.05). The savings made by preventing 9.8 infections per year were calculated from data on bed-days obtained from the hospital finance office. The cost in hospital days saved per annum was euro135,000. Introduction of a TPN surveillance CNM saved the hospital at least euro78,300 per annum and led to a significant decrease in CRBSIs in TPN patients.

Clinical outcomes comparing parenteral and nasogastric tube nutrition after laryngeal and pharyngeal cancer surgery.

Nasogastric tube-assisted enteral feeding and parenteral feeding are utilized for nutritional support after major surgery. Although these nutritional supports have been compared before, there have been no comparative trials following surgery for laryngeal and pharyngeal cancer. In this study, 81 patients were randomized to total parenteral nutrition (TPN) or nasogastric tube nutrition (NGTN) after laryngopharyngeal cancer surgery. The two groups were well-matched demographically and clinically. Clinical outcomes such as time of commencement of oral feeding and hospital stay and complications such as fistula were similar in both groups. One case in the TPN group had catheter-related sepsis, whereas aspiration pneumonia occurred in four cases (9.8%) in the NGTN group. The daily cost of NGTN was $11.81 cheaper than that of TPN. Subjective symptoms of nasal and pharyngeal discomfort and scores on subjective swallowing were more severe in the NGTN group within the first postoperative week but became similar thereafter. Although there was no difference in objective postoperative outcomes between both groups, these results imply that each method had particular advantages and disadvantages. Nutritional support after laryngopharyngeal cancer surgery should be determined after full consideration of each patient's conditions and surgical details along with economics.

Oral mucositis and outcomes of autologous hematopoietic stem-cell transplantation following high-dose melphalan conditioning for multiple myeloma.

The purpose of this study was to assess the relationship between oral mucositis (OM) and adverse clinical and economic outcomes of autologous hematopoietic stem-cell transplantation (HSCT) following high-dose melphalan (Alkeran) conditioning in patients with multiple myeloma. A retrospective study of 115 consecutive autologous HSCT recipients with multiple myeloma who received high-dose melphalan conditioning before transplantation was undertaken at a single academic center. OM severity was assessed twice weekly using a validated scale beginning 3-4 days following conditioning and continuing until hospital discharge or day 28, whichever occurred first. OM was graded, based on presence/extent of erythema/ulceration across eight oropharyngeal sites, as follows: 0 = no erythema or ulceration; I = erythema but no ulceration; II = ulceration, 1 site; III = ulceration, 2 sites; IV = ulceration, 3 sites; and V = ulceration, > or = 4 sites. Analyses examined the relationship between worst OM grade and selected clinical and economic outcomes, including days with fever, days of total parenteral nutrition (TPN),days of parenteral narcotic therapy, incidence of significant infection, and inpatient days and charges. The mean age of study subjects was 54 years; 19 patients (17%) received total-body irradiation, and 55 patients (48%) experienced OM grade > or = II (ie, ulceration). The worst OM grade was significantly (P < 0.05) associated with numbers of days of TPN and parenteral narcotic therapy, length of hospitalization, and total inpatient charges. Worst OM grade was not associated with the number of febrile days or the risk of significant infection. OM is associated with worse clinical and economic outcomes in multiple myeloma patients undergoing autologous HSCT following high-dose melphalan conditioning.

Small intestine transplantation today.

INTRODUCTION: Intestinal transplantation has become a life-saving therapy in patients with irreversible loss of intestinal function and complications of total parenteral nutrition. DISCUSSION: The patient and graft survival rates have improved over the last years, especially after the introduction of tacrolimus and rapamycin. However, intestinal transplantation is more challenging than other types of solid organ transplantation due to its large amount of immune competent cells and its colonization with microorganisms. Moreover, intestinal transplantation is still a low volume procedure with a small number of transplanted patients especially in Germany. A current matter of concern is the late referral of intestinal transplant candidates. CONCLUSION: Thus, patients often present after onset of life-threatening complications or advanced cholestatic liver disease. Earlier timing of referral for candidacy might result in further improvement of this technique in the near future.

What happened to total parenteral nutrition? The disappearance of its use in a trauma intensive care unit.

BACKGROUND: Total parenteral nutrition (TPN) is associated with known costs, including the use of invasive procedures, which may be necessary to optimize care. Our purpose was to document TPN use in trauma patients over time as well as concurrent changes in TPN-associated complications. METHODS: Retrospective analysis of all consecutive trauma patients admitted to the surgical intensive care unit during a period of 6 years from a Level I trauma center. Comparative cohorts and the matched case-control approaches were used to analyze the difference in outcomes between patients with and without TPN during hospitalization. Logistic regression model was used to compare the outcomes of the two groups of patients adjusting for significant risk factors. The McNemar's test was used to assess the differences in outcomes between the cases and their matched controls. RESULTS: There were 2,964 patients admitted to the surgical intensive care unit during the 6-year period and 464 patients received TPN during their hospital course. TPN use decreased significantly from 26% in the year 2000 to 3% in 2005 (p < 0.0001). Excluding those who died in the first 72 hours, the mortality rate was significantly lower (5.4% no TPN vs. 10.2% TPN, p = 0.001) in patients who were managed without TPN. Complication rates (wound infection, dehiscence, line sepsis, bacteremia, sepsis, pneumonia, renal failure, acute respiratory distress syndrome, multiple organ dysfunction syndrome, deep venous thrombosis, pulmonary embolism) were significantly higher in patients that were managed with TPN. Multivariate analysis adjusting for abbreviated injury score, injury severity score, mechanism, admission year, dialysis, ventilator use, hollow viscous injury, and solid organ injury found that TPN use was still an independent risk factor for increased complications but not death. The matched case-control approach confirmed this finding. TPN use was also associated with increase intensive care unit and hospital length of stay. CONCLUSIONS: The rate of TPN use has declined significantly from 26% to 3% during the 6-year period. The change in practice of minimizing TPN was concurrent with decreased complications and less hospital resource utilization without negatively impacting mortality.

Total parenteral nutrition in neonates.

Parenteral Nutrition (PN) allows us to meet a neonates requirement for growth and development when their size or condition precludes enteral feeding. Although feeding through the gastrointestinal tract is the preferred route for nutritional management, there are specific conditions where PN as an adjunctive or sole therapy is necessary. In very low birth weight premature infants, due to the immaturity of the gastrointestinal systems, enteral feeding cannot be established in the first few days of life. In critically ill neonates, neonates with protracted diarrhea and neonates who have had major GI surgery, PN can successfully meet the nutritional demands. Parenteral Nutrition solutions, although still evolving, have improved considerably since the early days and complications are now less common when amino acids and lipids are given in a dose of 1-3 g / kg / day. Meticulous attention to asepsis, good nursing care and close biochemical monitoring are absolutely essential for successful PN therapy.