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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.
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Activity of alpha-fucosidase and beta-glucuronidase in serum and urine of patients administered parenteral nutrition.
Raczkowska, K, Szajda, SD, Raczkowski, K, Zasadowska, W, Chojnowska, S, Kepka, A, Zalewska-Szajda, B, Waszkiewicz, N, Knaś, M, Snarska, J, et al
Roczniki Panstwowego Zakladu Higieny. 2013;(3):235-41
Abstract
BACKGROUND In hospital patients suffering from adverse clinical and biochemical symptoms of malnutrition, it is often necessary to employ parenteral nutrition to avoid the body's tissue becoming broken down by being metabolised. Thus, the patient's welfare and survival can be supported throughout any periods of medical crisis. Two of the enzymes responsible for metabolising glycoconjugates are alpha-fucosidase (FUC) and beta-glucuronidase (GLU), present in lysosomes. They release fucose or glucuronic acid from the non-reducing end of oligosaccharide chains. OBJECTIVE To determine the effect of parenteral nutrition administered to ill patients, on glycoconjugate metabolism, by measuring serum and urinary activities of FUC and GLU. Material and methods. Blood samples and the daily urine collection were taken from 23 patients' who had been undergoing parenteral nutrition for either 5 or 10 days, as well as from a baseline sample. Enzyme activities in serum and urine were determined by the method of Zwierz et al. RESULTS Serum FUC activities were significantly lower after 10 days compared to 5, (p< 0.0172), whereas GLU activities were significantly lower after both 5 and 10 days, (p< 0.0007 and p< 0.0208 respectively), compared to levels before starting parenteral nutrition. GLU activities were however higher after 10 days than those after 5 days, (p< 0.0023). In urine, FUC activities were significantly decreased after 10 days compared to 5 days after starting parenteral nutrition, (p< 0.0245). Urine GLU activities were unaffected by parenteral nutrition nor was any effect seen on FUC or GLU activities when calculated per 1mg creatinine. CONCLUSIONS Serum FUC and GLU activities can be used for assessing the effect of parenteral nutrition on glycoconjugate metabolism. The significant decreases of serum GLU activity observed after 5 and 10 days, may serve to indicate that the components of parental nutrition are appropriate and that the body has become suitably adapted to this form of nutrition.
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Parenteral nutrition support for patients with pancreatic cancer. Results of a phase II study.
Pelzer, U, Arnold, D, Gövercin, M, Stieler, J, Doerken, B, Riess, H, Oettle, H
BMC cancer. 2010;:86
Abstract
BACKGROUND Cachexia is a common problem in patients (pts) suffering from upper gastrointestinal cancer. In addition, most of these patients suffer from malabsorption and stenosis of the gastrointestinal tract due to their illness. Various methods of supplementary nutrition (enteral, parenteral) are practised. In patients with advanced pancreatic cancer (APC), phase angle, determined by bio-electrical impedance analysis (BIA), seems to be a survival predictor. The positive influence of BIA determinate predictors by additional nutrition is currently under discussion. METHODS To examine the impact of additional parenteral nutrition (APN) we assessed outpatients suffering from APC and progressive cachexia. The assessment based on the BIA method. Assessment parameters were phase angle, ECM/BCM index (ratio of extracellular mass to body cell mass), and BMI (body mass index). Patients suffering from progressive weight loss in spite of additional enteral nutritional support were eligible for the study. RESULTS Median treatment duration in 32 pts was 18 [8-35] weeks. Response evaluation showed a benefit in 27 pts (84%) in at least one parameter. 14 pts (43.7%) improved or stabilised in all three parameters. The median ECM/BCM index was 1.7 [1.11-3.14] at start of APN and improved down to 1.5 [1.12-3.36] during therapy. The median BMI increased from 19.7 [14.4-25.9] to 20.5 [15.4-25.0]. The median phase angle improved by 10% from 3.6 [2.3-5.1] to 3.9 [2.2-5.1]. CONCLUSIONS We demonstrated the positive impact of APN on the assessed parameters, first of all the phase angle, and we observed at least a temporary benefit or stabilisation of the nutritional status in the majority of the investigated patients. Based on these findings we are currently investigating the impact of APN on survival in a larger patient cohort. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00919659.
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Standardized parenteral nutrition in preterm infants: early impact on fluid and electrolyte balance.
Iacobelli, S, Bonsante, F, Vintéjoux, A, Gouyon, JB
Neonatology. 2010;(1):84-90
Abstract
BACKGROUND Parenteral nutrition is commonly given to premature infants. It has previously been suggested that standardized parenteral nutrition (SPN) may offer nutritional advantages compared to individualized parenteral nutrition (IPN). However, whether the same level of biochemical control is assured with SPN and with IPN remains uncertain. OBJECTIVES To compare fluid and electrolyte balance in preterm infants receiving IPN versus SPN in the first week of life. METHODS 107 infants born at <33 weeks gestation were prospectively evaluated. Serum and urinary creatinine and electrolyte concentration, urine volume, body weight, fluid, electrolyte and energy intakes were recorded daily. RESULTS 40 infants received IPN and 67 SPN. Infants in IPN had significantly more water and less sodium intake than those receiving SPN. Energy and amino acid intakes were significantly lower in IPN than in SPN groups. Incidence of hypernatremia and hyponatremia was similar in both groups. Nonoliguric hyperkalemia (NOHK) was significantly more frequent in IPN than in SPN (20.0 vs. 2.9%) and mean serum K(+) peak over the first 3 days was higher in IPN than in SPN (5.63 +/- 1.05 vs. 4.91 +/- 0.78 mmol/l). Weight loss (% of birth weight) at day 7 was significantly higher in IPN than in SPN (7.7 +/- 5.8 vs. 4.2 +/- 6.5) without differences in urine output/input fluid intake ratio and glomerular renal function between the two groups. CONCLUSIONS There were no significant differences in water and sodium balance in preterm infants who received IPN versus SPN. The risk of NOHK was higher in IPN. Also, SPN significantly increased amino acid and caloric intakes, and it reduced early weight loss.
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[Clinical and laboratory evaluation of the efficiency of parenteral nutrition in destructive forms of acute calculous cholecystitis].
Zhurikhin, AV, Kitiashvili, IZ, Kutukov, VV
Klinicheskaia laboratornaia diagnostika. 2010;(10):26-9
Abstract
A clinical and laboratory studies were undertaken to evaluate the efficiency of perioperative parenteral nutrition in destructive forms of acute calculous cholecystitis. Based on the general and biochemical blood analyses and the time course of changes in humoral immunological parameters, the authors concluded that enteral tube nutrition had a positive impact on the postoperative period. A nasojejunal access reducing the risk of acute pancreatitis, which was used during tube feeding, showed benefits.
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Olive oil-based intravenous lipid emulsion in pediatric patients undergoing bone marrow transplantation: a short-term prospective controlled trial.
Hartman, C, Ben-Artzi, E, Berkowitz, D, Elhasid, R, Lajterer, N, Postovski, S, Hadad, S, Shamir, R
Clinical nutrition (Edinburgh, Scotland). 2009;(6):631-5
Abstract
BACKGROUND & AIMS Parenteral nutrition (PN) is an important component of the supportive care of children undergoing bone marrow transplantation (BMT). The study aimed to assess short-term safety and metabolic effects of an olive oil-based (OO) lipid emulsion compared with a MCT/LCT (M/L) emulsion in the clinical setting of pediatric BMT. METHODS Twenty-eight pediatric BMT patients (age 1-18 years) expected to need PN support for at least 2 weeks, were prospectively enrolled and randomly assigned to receive either OO or M/L lipid emulsions within PN. Clinical and routine laboratory parameters, plasma fatty acids profile, vitamin E and peroxidation status were recorded at baseline and after 14 days of PN. RESULTS No significant differences were found for hematological parameters, liver enzymes, vitamins, plasma peroxidation status, percentage and time to engraftment. Taking into consideration the baseline fatty acids levels, the OO group showed higher oleic acid (p=0.012), linoleic (p=0.012) and arachidonic acid (p=0.002) enrichment but similar eicosapentanoic and docosahexanoic acids levels compared to the M/L group at day 14. Cholesterol levels decreased significantly in the OO group after 14 days on PN (p=0.017). CONCLUSIONS OO lipid emulsion was well tolerated, maintained essential fatty acids and peroxidation status, and generated a favorable plasma lipid profile. In this study short-term use of OO intravenous lipid emulsions was safe in children who needed PN support during BMT.
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Lower insulin secretory response to glucose induced by artificial nutrition in children: prolonged and total parenteral nutrition.
Beltrand, J, Colomb, V, Marinier, E, Daubrosse, C, Alison, M, Burcelin, R, Cani, PD, Chevenne, D, Marchal, CL
Pediatric research. 2007;(5):624-9
Abstract
Long-term parenteral nutrition (TPN) in children is associated with sustained hyperinsulinemia due to a high nutriment infusion flow 12 h/24 h, with plausible lipotoxicity secondary to repeated lipid infusions and with changes in incretin hormone release. The aim of this study was to test whether long-term TPN can lead to an alteration in beta-cell function. Thirteen children (age 9.5 +/- 3.9 y) on total TPN without obvious alternation in glucose tolerance were included. beta-Cell function was quantified with an intravenous glucose tolerance test (IVGTT) and a graded glucose infusion. First phase insulin release (FPIR) was low in five patients. The same demonstrated a lower insulin release under graded glucose infusion, although plasma glucose reached values as high as 15 mM. These data emphasize that metabolic conditions induced by TPN can lead to lower insulin secretory response to glucose. Patients who remain dependent on TPN are at risk of developing glucose tolerance disorders.