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Outcomes in relation to early parenteral nutrition use in preterm neonates born between 30 and 33 weeks' gestation: a propensity score matched observational study.
Webbe, JWH, Longford, N, Battersby, C, Oughham, K, Uthaya, SN, Modi, N, Gale, C
Archives of disease in childhood. Fetal and neonatal edition. 2022;(2):131-136
Abstract
OBJECTIVE To evaluate whether in preterm neonates parenteral nutrition use in the first 7 postnatal days, compared with no parenteral nutrition use, is associated with differences in survival and other important morbidities. Randomised trials in critically ill older children show that harms, such as nosocomial infection, outweigh benefits of early parenteral nutrition administration; there is a paucity of similar data in neonates. DESIGN Retrospective cohort study using propensity matching including 35 maternal, infant and organisational factors to minimise bias and confounding. SETTING National, population-level clinical data obtained for all National Health Service neonatal units in England and Wales. PATIENTS Preterm neonates born between 30+0 and 32+6 weeks+days. INTERVENTIONS The exposure was parenteral nutrition administered in the first 7 days of postnatal life; the comparator was no parenteral nutrition. MAIN OUTCOME MEASURES The primary outcome was survival to discharge from neonatal care. Secondary outcomes comprised the neonatal core outcome set. RESULTS 16 292 neonates were compared in propensity score matched analyses. Compared with matched neonates not given parenteral nutrition in the first postnatal week, neonates who received parenteral nutrition had higher survival at discharge (absolute rate increase 0.91%; 95% CI 0.53% to 1.30%), but higher rates of necrotising enterocolitis (absolute rate increase 4.6%), bronchopulmonary dysplasia (absolute rate increase 3.9%), late-onset sepsis (absolute rate increase 1.5%) and need for surgical procedures (absolute rate increase 0.92%). CONCLUSIONS In neonates born between 30+0 and 32+6 weeks' gestation, those given parenteral nutrition in the first postnatal week had a higher rate of survival but higher rates of important neonatal morbidities. Clinician equipoise in this area should be resolved by prospective randomised trials. TRIAL REGISTRATION NUMBER NCT03767634.
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Role of heat shock protein and cytokine expression as markers of clinical outcomes with glutamine-supplemented parenteral nutrition in surgical ICU patients.
Wischmeyer, PE, Mintz-Cole, RA, Baird, CH, Easley, KA, May, AK, Sax, HC, Kudsk, KA, Hao, L, Tran, PH, Jones, DP, et al
Clinical nutrition (Edinburgh, Scotland). 2020;(2):563-573
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Abstract
BACKGROUND Nutrients, such as glutamine (GLN), have been shown to effect levels of a family of protective proteins termed heat shock proteins (HSPs) in experimental and clinical critical illness. HSPs are believed to serve as extracellular inflammatory messengers and intracellular cytoprotective molecules. Extracellular HSP70 (eHSP70) has been termed a chaperokine due to ability to modulate the immune response. Altered levels of eHSP70 are associated with various disease states. Larger clinical trial data on GLN effect on eHSP expression and eHSP70's association with inflammatory mediators and clinical outcomes in critical illness are limited. OBJECTIVE Explore effect of longitudinal change in serum eHSP70, eHSP27 and inflammatory cytokine levels on clinical outcomes such as pneumonia and mortality in adult surgical intensive care unit (SICU) patients. Further, evaluate effect of parenteral nutrition (PN) supplemented with GLN (GLN-PN) versus GLN-free, standard PN (STD-PN) on serum eHSP70 and eHSP27 concentrations. METHODS Secondary observational analysis of a multicenter clinical trial in 150 adults after cardiac, vascular, or gastrointestinal surgery requiring PN support and SICU care conducted at five academic medical centers. Patients received isocaloric, isonitrogenous PN, with or without GLN dipeptide. Serum eHSP70 and eHSP27, interleukin-6 (IL-6), and 8 (IL-8) concentrations were analyzed in patient serum at baseline (prior to study PN) and over 28 days of follow up. RESULTS eHSP70 declined over time in survivors during 28 days follow-up, but non-survivors had significantly higher eHSP70 concentrations compared to survivors. In patients developing pneumonia, eHSP70, eHSP27, IL-8, and IL-6 were significantly elevated. Adjusted relative risk for hospital mortality was reduced 75% (RR = 0.25, p = 0.001) for SICU patients with a faster decline in eHSP70. The area under the receiver operating characteristic curve was 0.85 (95% CI: 0.76 to 0.94) for the final model suggesting excellent discrimination between SICU survivors and non-survivors. GLN-PN did not alter eHSP70 or eHSP27 serum concentrations over time compared to STD-PN. CONCLUSION Our results suggest that serum HSP70 concentration may be an important marker for severity of illness and likelihood of recovery in the SICU. GLN-supplemented-PN did not increase eHSP70.
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Nutritional bundle to improve growth outcomes among very low birth weight infants.
Khanam, S, Khan, J, Sharma, D, Chawla, D, Murki, S
The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians. 2015;(15):1851-5
Abstract
INTRODUCTION Aggressive enteral, parenteral nutrition, milk fortification and Kangaroo care are some of the interventions aimed at decreased postnatal malnutrition in very low birth weight (VLBW) infants. A bundle approach incorporating all these interventions in predominantly breast-milk fed infants to reduce postnatal malnutrition is evaluated in this study. METHODS In this before and after study, growth outcomes were evaluated in 389 infants (before nutrition bundle (BNB) n = 171, after nutrition bundle (ANB) n = 218) at corrected term gestational age (38-40weeks). The nutrition bundle consisted of starting aminoacids within hours of birth, introduction of aminoacids @ 3 g/kg/d and lipids @3 g/kg/d on day 2 and fortification of human milk. RESULTS The incidence of malnutrition at term corrected age was similar in both the epochs (57% versus 53.7%, p = 0.35; adjusted OR 0.81, 95% CI: 0.52-1.27. The weight gain in g/kg/d was comparable between the two groups. At term corrected age, the infants in the ANB period were taller by an average of 2.8 cm (95% CI: 2.1 cm-3.4 cm) but had similar weight and head size in comparison to the infants in BNB period. On linear regression analysis, use of early aminoacids and total parenteral nutrition independently improved the weight at discharge by 43 g (95% CI; 9 to 77 g) and length at discharge by 1 cm (95% CI; 0.55 to 1.4 cm). Also the length and OFC at term corrected age were increased by 2.1 cms (95% CI; 1.4 to 2.8 cm) and 0.46 cms (95% CI; 0.1 to 0.8 cm), respectively. CONCLUSION In a cohort of VLBW infants on predominant breast-milk feeds, a nutritional bundle improved weight and length at discharge and the length at term gestational age. The incidence of malnutrition at term gestational age was not affected.
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A randomized phase II study to assess the effectiveness of fluid therapy or intensive nutritional support on survival in patients with advanced cancer who cannot be nourished via enteral route.
Oh, SY, Jun, HJ, Park, SJ, Park, IK, Lim, GJ, Yu, Y, Cho, SJ, Song, A
Journal of palliative medicine. 2014;(11):1266-70
Abstract
BACKGROUND Experts advise against parenteral nutrition (PN) for patients with advanced cancer at the end of life. But because many patients and families fear starvation, many physicians administer PN to patients with terminal cancer in Korea. OBJECTIVE We designed this study to investigate the effect of PN on survival in patients with terminal cancer at the end of life. DESIGN We planned a randomized phase II study enrolling 116 patients randomized to receive either fluid or PN. SETTING/SUBJECTS Eligible patients are who could not tolerate enteral feeding and had short life expectancies (<3 months) due to progressive cancer. Patients with functioning bowels were excluded. MEASUREMENTS The primary end point was overall survival and the secondary end point was total administered calories. RESULTS We prospectively enrolled 31 consecutive patients and 16 patients were assigned to the PN group. The study ended early because many patients and families were extremely concerned about starvation. The baseline characteristics, including nutritional parameters, were not significantly different between the two groups. The mean administered calories was 374.7 (± 71.7) kcal/d for the fluid group and 1286.8 (± 108.3) kcal/d for the PN group (p<0.001). Median survival was 8 days (95% confidence interval [CI], 5.7-10.3 days) in the fluid group and 13 days (95% CI: 3.1-22.9 days) in the PN group, and this difference was not statistically significant (p = 0.982 by Log-rank test). CONCLUSIONS This study did not conclusively determine the role of PN for patients with advanced cancer, however, PN support failed to significantly prolong survival in these patients compared to similar patients receiving only fluid.