Randomized Controlled Study of Glycerol Versus Dextrose in Postoperative Hypocaloric Peripheral Parenteral Nutrition

Peripheral parenteral nutrition in surgery - a systematic review and meta-analysis

BACKGROUND

Peripheral parenteral nutrition (PPN) refers to the delivery of artificial nutrition via a peripheral intravenous cannula. As a nutritional intervention it remains under-utilised in peri-operative care. This is despite purported advantages which includes avoiding the risks associated with central venous lines and preventing potential delays to the initiation of nutrition support. This systematic review and meta-analysis will detail the available evidence for PPN use in surgery.

METHODS

A comprehensive search of the EMBASE and Medline databases was undertaken to identify randomised control trials (RCTs) involving PPN use in surgical patients published until July 30th 2022. Three domains of PPN use were reviewed including: PPN compared to crystalloid intravenous fluids on nutritional and clinical outcomes; PPN compared to Central PN (CPN) on nutritional outcomes and complications; and strategies to prevent thrombophlebitis associated with PPN.

RESULTS

The meta-analysis included 8 studies which included 698 patients. Use of PPN led to reduced post-operative weight loss (% body weight change) with a mean difference of -1.45% (95% CI -2.9 to -0.01, p = 0.05). There was no statistically significant difference in terms of length of stay, infectious/non-infectious complications, surgical site infections or phlebitis. 42 RCTs were included in the systematic review. 14 RCTs compared PPN to crystalloid infusion. There was significant heterogeneity in the trial populations, interventions and measured outcomes. Most trials found that PPN may improve nitrogen balance and positively impact nutritional markers. Quality of life and post-operative complications were either improved or no difference found in trials assessing these outcomes. Four RCTs showed that PPN is a safe and feasible alternative to CPN. 22 RCTs reported on measures that may impact on thrombophlebitis rates associated with PPN. These included lower osmolality of PPN solution, cyclical PPN delivery, use of a small gauge polyurethane cannula in an upper limb vein, addition of heparin/hydrocortisone to PPN solutions and placement of a GTN patch over infusion sites.

CONCLUSION

PPN is a safe and effective mode of delivery of peri-operative nutrition. It is a feasible short-term alternative to central-line delivered PN. There are a number of strategies to reduce thrombophlebitis associated with PPN use. Further high-quality RCTs are required to assess the use of PPN in contemporary surgical practice.

Retrospective evaluation of ProcalAmine administration in a population of hospitalized ICU dogs: 36 cases (2010-2013)

OBJECTIVE

To describe the use of ProcalAmine as a source of parenteral nutrition in hospitalized dogs and to report complications possibly referable to its use.

DESIGN

Retrospective study.

SETTINGS

Private veterinary teaching hospital.

ANIMALS

Thirty-six dogs hospitalized in ICU receiving ProcalAmine between October 2010 and March 2013.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The most common underlying disease process in this population of dogs was trauma (n = 8). Median duration of administration was 4 days and median resting energy requirement provided via ProcalAmine was 33%. ProcalAmine was administered via central catheters in 86% of cases and via peripheral catheters in 14% of cases. The overall mechanical complication rate was 19%. Metabolic complications possibly associated with ProcalAmine administration were documented in 12/36 dogs. Hyponatremia was most commonly identified (n = 6) followed by hyperglycemia (n = 4), hypochloremia (n = 2), azotemia (n = 2), metabolic alkalosis (n = 2), hyperchloremia (n = 1), and metabolic acidosis (n = 1).

CONCLUSION

ProcalAmine appears to be relatively safe and a viable option for parenteral nutrition in ill and injured dogs. Due to the potential for electrolyte derangements and other metabolic complications, daily monitoring of these parameters is advisable.

Treatment with growth hormone, somatostatin, and insulin in combination with hypocaloric parenteral nutrition in gastrointestinal cancer patients after surgery

OBJECTIVE

The metabolic response to gastrointestinal cancer in patients undergoing surgery is associated with hypermetabolism and insulin resistance. The potential use of synergetic anabolic hormones in conjunction with hypocaloric parenteral nutrition (HPN) has become a significant area of investigation. The presented study was performed to determine the clinical efficiency and safety of hormone therapy combined with HPN in patients with gastrointestinal cancer.

METHODS

One hundred patients with a Nutrition Risk Screening score of 3 or 4 undergoing surgery for gastrointestinal cancer were randomized into two groups. The patients in the control group received standard total parenteral nutrition and systemic insulin. The patients in the study group received HPN and systemic insulin in addition to pretreatment with recombinant human growth hormone and octreotide. Clinical efficiency and safety were evaluated by the measurement of hormones and protein metabolites, immune function, clinical outcome, and adverse events. Follow-ups were performed to determine the influence on prognosis.

RESULTS

Treatment with recombinant human growth hormone, octreotide, and insulin in combination with HPN significantly increased protein synthesis, immune function, and metabolic tolerance, decreased infectious complications, and shortened postoperative hospital stays, but did not increase the risk of tumor development and recurrence in the study group compared with the control group.

CONCLUSION

The proper short-term perioperative administration of growth hormone, somatostatin, and insulin in combination with HPN can overcome the postoperative stress response through the increase of protein synthesis to improve immune function in patients with gastrointestinal cancer after surgery.

Vitamin C supplementation in patients receiving peripheral parenteral nutrition after gastrointestinal surgery

OBJECTIVE

We investigated an adequate vitamin C dose during peripheral parenteral nutrition therapy in patients after gastrointestinal surgery by measuring blood concentrations and urine excretions of vitamin C. We also sought to identify the effects of vitamin C on the oxidative status.

METHODS

In a randomized trial, 2 d after undergoing gastrointestinal surgery, 16 patients started to receive a 5-d continuous intravenous infusion of vitamin C, either 100 or 500 mg/d. Blood concentrations of vitamin C and inflammatory and immunologic parameters were measured preoperatively, the day after surgery, and 3 and 5 d after starting administration of vitamin C (day 3 and day 5). Also, excretions of vitamin C and oxidative stress markers in 24-h, cumulative urine samples, collected and stored under light protection at 0°C, were measured on day 3 and day 5.

RESULTS

Mean blood vitamin C concentration decreased markedly after surgery. The concentration returned to normal on day 3 and on day 5 in the 500-mg group and only on day 5 in the 100-mg group. Concentrations differed significantly between the groups on day 3 and on day 5 (P < 0.001 for both days). Urinary vitamin C excretion was above normal on both days in the 500-mg group, but it never reached normal in the 100-mg group (P < 0.001 for both days). Urinary excretion of 8-isoprostane, a marker of oxidative stress, was significantly lower in the 500-mg than in the 100-mg group on day 3 (P = 0.002).

CONCLUSION

Vitamin C dose of 500 mg/d, not 100 mg/d, is adequate for patients undergoing gastrointestinal surgery and receiving peripheral parenteral nutrition therapy. Vitamin C may decrease postsurgical oxidative stress.

Hypocaloric peripheral parenteral nutrition with lipid emulsion in postoperative gastrointestinal cancer patients

AIM: To investigate the use of lipid emulsion substituting for glucose in postoperative hypocaloric peripheral parenteral nutrition (HPPN).

METHODS: This prospective, randomized study was conducted on 20 postoperative gastrointestinal cancer patients. They were randomized and equally divided into interventional group and control group, and both were administered isocaloric and isonitrogenous diets with for lipid emulsion substituting for partial glucose loads in the interventional group.

RESULTS: Nutritional parameters and biochemical data were compared between the two groups before and after 6-d of HPPN. Most investigated variables showed no significant changes after administration of HPPN with lipid emulsion. However, the postoperative triglyceride level was significantly lower in the interventional group than in the control group (P < 0.05). In comparison with lipid emulsion, glucose administration resulted in less decrease in postoperative prealbumin level (P < 0.05).

CONCLUSION: In addition to supplementing with essential fatty acid, it seems that HPPN with lipid emulsion is well-tolerated and beneficial to postoperative gastrointestinal cancer patients.

Enteral vs. parenteral nutrition for the critically ill patient: a combined support should be preferred

PURPOSE OF REVIEW

Current recommendations suggest starting enteral feeding as soon as possible whenever the gastrointestinal tract is functioning. The disadvantage of enteral support is that insufficient energy and protein coverage can occur. This review focuses on some recent findings regarding the nutritional support of critically ill patients and evaluates the data presented.

RECENT FINDINGS

An increasing nutritional deficit during a long ICU stay is associated with increased morbidity (infection rate, wound healing, mechanical ventilation, length of stay, duration of recovery), and costs. Evidence shows that enteral nutrition can result in underfeeding and that nutritional goals are frequently reached only after 1 week. Contrary to former beliefs, recent meta-analyses of ICU studies showed that parenteral nutrition is not related to a surplus mortality and may even be associated with improved survival.

SUMMARY

Early enteral nutrition is recommended for critically ill patients. Supplemental parenteral nutrition combined with enteral nutrition can be considered to cover the energy and protein targets when enteral nutrition alone fails to achieve the caloric goal. Whether such a combined nutritional support provides additional benefit on the overall outcome has to be proven in further studies on clinical outcome, including physical and cognitive functioning, quality of life, cost-effectiveness, and cost-utility.