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Biological Impact of Recent Guidelines on Parenteral Nutrition in Preterm Infants.
Guellec, I, Gascoin, G, Beuchee, A, Boubred, F, Tourneux, P, Ramful, D, Zana-Taieb, E, Baud, O
Journal of pediatric gastroenterology and nutrition. 2015;(6):605-9
Abstract
OBJECTIVES Recent guidelines for preterm neonates recommend early initiation of parenteral nutrition (PN) with high protein and relatively high caloric intake. This review considers whether these changes could influence homeostasis in very preterm infants during the first few postnatal weeks. METHODS This systematic review of relevant literature from searches of PubMed and recent guidelines was reviewed by investigators from several perinatal centers in France. RESULTS New recommendations for PN could be associated with metabolic acidosis via the increase in the amino acid ion gap, hyperchloremic acidosis, and ammonia acidosis. The introduction of high-intake amino acids soon after birth could induce hypophosphatemia and hypercalcemia, simulating a "repeat feeding-like syndrome" and could be prevented by the early intake of phosphorus, especially in preterm infants born after fetal growth restriction. Early high-dose amino acid infusions are relatively well tolerated in the preterm infant with regard to renal function. Additional studies, however, are warranted to determine markers of protein intolerance and to specify the optimal composition and amount of amino acid solutions. CONCLUSIONS Optimal PN following new guidelines in very preterm infants, despite their demonstrated benefits on growth, may induce adverse effects on ionic homeostasis. Clinicians should implement appropriate monitoring to prevent and/or correct them.
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2.
Electrolyte and Mineral Homeostasis After Optimizing Early Macronutrient Intakes in VLBW Infants on Parenteral Nutrition.
Senterre, T, Abu Zahirah, I, Pieltain, C, de Halleux, V, Rigo, J
Journal of pediatric gastroenterology and nutrition. 2015;(4):491-8
Abstract
OBJECTIVES The aim of the present study was to evaluate electrolyte and mineral homeostasis in very-low-birth-weight (VLBW) infants who received high protein and energy intakes with a unique standardized parenteral nutrition solution containing electrolytes and minerals from birth onward. METHODS Prospective cohort study in 102 infants with birth weight <1250 g. The evolution of plasma biochemical parameters was described during the first 2 weeks of life. RESULTS During the first 3 days of life, mean parenteral intakes were 51 ± 8 kcal · kg · day with 2.7 ± 0.4 g · kg · day of protein, 1.1 ± 0.2 mmol · kg · day of sodium and potassium, and 1.3 ± 0.2 mmol · kg · day of calcium and phosphorus. Afterwards, most nutritional intakes (parenteral and enteral) met growth requirements. No infant developed a hyperkalemia >7 mmol/L, and a hypernatremia >150 mmol/L occurred only in 15.7% of the infants. In contrast, hyponatremia <130 mmol/L and hypokalemia <3 mmol/L occurred in 30.4% and 8.8% of the infants, respectively. The initial neonatal metabolic acidosis rapidly resolved in most infants and only 2.0% developed a base deficit >10 mmol/L after day 3 of life. Early hypocalcemia <1.8 mmol/L occurred in 13.7% of the infants. In contrast, hypophosphatemia <1.6 mmol/L occurred in 37.3% and hypercalcemia >2.8 mmol/L occurred in 12.7% of the infants. CONCLUSIONS Increasing early protein and energy intakes in VLBW infants in the first week of life improves electrolyte homeostasis. It also increases the phosphorus requirements with a calcium-to-phosphorus ratio ≤1.0 (mmol/mmol) and the potassium and sodium requirements to avoid the development of a refeeding-like syndrome. These data suggest that the parenteral nutrition guidelines for VLBW infants for the first week of life need to be revised.
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3.
Nutritional Issues in the Short Bowel Syndrome - Total Parenteral Nutrition, Enteral Nutrition and the Role of Transplantation.
O'Keefe, SJ
Nestle Nutrition Institute workshop series. 2015;:75-90
Abstract
In this review, I focus on the extreme of the short bowel syndrome where the loss of intestine is so great that patients cannot survive without intravenous feeding. This condition is termed short bowel intestinal failure. The review outlines the principles behind diagnosis, assessing prognosis and management. The advent of intravenous feeding (parenteral nutrition) in the 1970s enabled patients with massive (>90%) bowel resection to survive for the first time and to be rehabilitated back into normal life. To achieve this, central venous catheters were inserted preferably into the superior vena cava and intravenous infusions were given overnight so that the catheter could be sealed by day in order to maximize ambulation and social integration. However, quality of life has suffered by the association of serious complications related to permanent catheterization - mostly in the form of septicemias, thrombosis, metabolic intolerance and liver failure - from the unphysiological route of nutrient delivery. This has led to intense research into restoring gut function. In addition to dietary modifications and therapeutic suppression of motility, novel approaches have been aimed at enhancing the natural adaptation process, first with recombinant growth hormone and more recently with gut-specific glucagon-like peptide-2 analogues, e.g. teduglutide. These approaches have met with some success, reducing the intravenous caloric needs by approximately 500 kcal/day. In controlled clinical trials, teduglutide has been shown to permit >20% reductions in intravenous requirements in over 60% of patients after 6 months of treatment. Some patients have been weaned, but more have been able to drop infusion days. The only approach that predictably can get patients with massive intestinal loss completely off parenteral nutrition is small bowel transplantation, which, if successful (1-year survival for graft and host >90%) is accompanied by dramatic improvements in quality of life.
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4.
Metabolic and nutritional support of critically ill patients: consensus and controversies.
Preiser, JC, van Zanten, AR, Berger, MM, Biolo, G, Casaer, MP, Doig, GS, Griffiths, RD, Heyland, DK, Hiesmayr, M, Iapichino, G, et al
Critical care (London, England). 2015;(1):35
Abstract
The results of recent large-scale clinical trials have led us to review our understanding of the metabolic response to stress and the most appropriate means of managing nutrition in critically ill patients. This review presents an update in this field, identifying and discussing a number of areas for which consensus has been reached and others where controversy remains and presenting areas for future research. We discuss optimal calorie and protein intake, the incidence and management of re-feeding syndrome, the role of gastric residual volume monitoring, the place of supplemental parenteral nutrition when enteral feeding is deemed insufficient, the role of indirect calorimetry, and potential indications for several pharmaconutrients.
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5.
A single-blinded randomised clinical trial of permissive underfeeding in patients requiring parenteral nutrition.
Owais, AE, Kabir, SI, Mcnaught, C, Gatt, M, MacFie, J
Clinical nutrition (Edinburgh, Scotland). 2014;(6):997-1001
Abstract
BACKGROUND & AIMS The importance of adequate nutritional support is well established, but characterising what 'adequate nutrition' represents remains contentious. In recent years there has been increasing interest in the concept of 'permissive underfeeding' where patients are intentionally prescribed less nutrition than their calculated requirements. The aim of this study was to evaluate the effect of permissive underfeeding on septic and nutrition related morbidity in patients requiring short term parenteral nutrition (PN). METHODS This was a single-blinded randomised clinical trial of 50 consecutive patients requiring parenteral nutritional support. Patients were randomized to receive either normocaloric or hypocaloric feeding (respectively 100% vs. 60% of estimated requirements). The primary end point was septic complications. Secondary end points included the metabolic, physiological and clinical outcomes to the two feeding protocols. RESULTS Permissive underfeeding was associated with fewer septic complications (3 vs. 12 patients; p = 0.003), and a lower incidence of the systemic inflammatory response syndrome (9 vs. 16 patients; p = 0.017). Permissively underfed patients had fewer feed related complications (2 vs. 9 patients; p = 0.016). CONCLUSION Permissive underfeeding in patients requiring short term PN appears to be safe and may results in reduced septic and feed-related complications. TRIAL REGISTRATION NCT01154179 TRIAL REGISTRY http://clinicaltrials.gov/ct2/show/NCT01154179.
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6.
Nutrition support in acute pancreatitis.
Ioannidis, O, Lavrentieva, A, Botsios, D
JOP : Journal of the pancreas. 2008;(4):375-90
Abstract
In the majority (80%) of patients with acute pancreatitis, the disease is self limiting and, after a few days of withholding feeding and intravenous administration of fluids, patients can again be normally fed orally. In a small percentage of patients, the disease progresses to severe necrotic pancreatitis, with an intense systemic inflammatory response and often with multiple organ dysfunction syndrome. As mortality is high in patients with severe disease and as mortality and morbidity rates are directly related to the failure of establishing a positive nitrogen balance, it is assumed that feeding will improve survival in patients with severe disease. The aim of nutritional support is to cover the elevated metabolic demands as much as possible, without stimulating pancreatic secretion and maximizing self-digestion. The administration of either total parenteral nutrition or jejunal nutrition does not stimulate pancreatic secretion. Recently, a series of controlled clinical studies has been conducted in order to evaluate the effectiveness of enteral nutrition with jejunal administration of the nutritional solution. The results have shown that enteral nutrition, as compared to total parenteral nutrition, was cheaper, safer and more effective as regards the suppression of the immunoinflammatory response, the decrease of septic complications, the need for surgery for the management of the complications of acute pancreatitis and the reduction of the total hospitalization period. It did not seem to affect mortality or the rate of non-septic complications. In conclusion, enteral nutrition should be the preferred route of nutritional support in patients with acute pancreatitis.
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7.
Refeeding syndrome in cancer patients.
Marinella, MA
International journal of clinical practice. 2008;(3):460-5
Abstract
BACKGROUND Refeeding syndrome (RFS) is a common, yet underappreciated, constellation of electrolyte derangements that typically occurs in acutely ill, malnourished hospitalised patients who are administered glucose solutions or other forms of intravenous or enteral nutrition. DISCUSSION The hallmark of RFS is hypophosphataemia, but hypokalaemia and hypomagnesaemia are also common. Patients with various types of malignancies are at-risk for RFS, but very little exists in the oncologic literature about this disorder. CONCLUSIONS As RFS can have many adverse metabolic, cardiovascular, haematologic and neurologic complications, practicing oncologist needs to be aware of the pathophysiology, risk factors and clinical manifestations to promptly recognise this important, and potentially fatal, metabolic disorder.
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8.
The use of carnitine in pediatric nutrition.
Crill, CM, Helms, RA
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2007;(2):204-13
Abstract
Carnitine is synthesized endogenously from methionine and lysine in the liver and kidney and is available exogenously from a meat and dairy diet and from human milk and most enteral formulas. Parenteral nutrition (PN) does not contain carnitine unless it is extemporaneously added. The primary role of carnitine is to transport long-chain fatty acids across the mitochondrial membrane, where they undergo beta-oxidation to produce energy. Although the majority of patients are capable of endogenous synthesis of carnitine, certain pediatric populations, specifically neonates and infants, have decreased biosynthetic capacity and are at risk of developing carnitine deficiency, particularly when receiving PN. Studies have evaluated for several decades the effects of carnitine supplementation in pediatric patients receiving nutrition support. Early studies focused primarily on the effects of supplementation on markers of fatty acid metabolism and nutrition markers, including weight gain and nitrogen balance, whereas more recent studies have evaluated neonatal morbidity. This review describes the role of carnitine in metabolic processes, its biosynthesis, and carnitine deficiency syndromes, as well as reviews the literature on carnitine supplementation in pediatric nutrition.
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9.
Metabolic complications of parenteral nutrition in adults, Part 2.
Btaiche, IF, Khalidi, N
American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. 2004;(19):2050-7; quiz 2058-9
Abstract
PURPOSE Common metabolic complications associated with parenteral nutrition (PN) are reviewed, and the consequences of overfeeding and variables for patient monitoring are discussed. SUMMARY Although PN is a lifesaving therapy in patients with gastrontestinal failure, its use may be associated with metabolic, infectious, and technical complications. The metabolic complications associated with PN in adult patients include hyperglycemia, hypoglycemia, hyperlipidemia, hypercapnia, refeeding syndrome, acid-base disturbances, liver complications, manganese toxicity, and metabolic bone disease. These complications may occur in the acute care or chronic care patient. The frequency and severity of these complications depend on patient- and PN-specific factors. Proper assessment of the patient's nutritional status; tailoring the macronutrient, micronutrient, fluid, and electrolyte requirements on the basis of the patient's underlying diseases, clinical status, and drug therapy and monitoring the patient's tolerance of and response to nutritional support are essential in avoiding these complications. Early recognition of the signs and symptoms of complications and knowledge of the available pharmacologic and nonpharmacologic therapies are essential to proper management. PN should be used for the shortest period possible, and oral or enteral feeding should be initiated as soon as is clinically feasible. The gastrointestinal route remains the most physiologically appropriate and cost-effective way of providing nutritional support. CONCLUSION PN can lead to serious complications, many of which are associated with overfeeding. Close management is necessary to recognize and manage these complications.