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Lopez-Delgado JC, Grau-Carmona T, Mor-Marco E, Bordeje-Laguna ML, Portugal-Rodriguez E, Lorencio-Cardenas C, Vera-Artazcoz P, Macaya-Redin L, Llorente-Ruiz B, Iglesias-Rodriguez R, Monge-Donaire D, Martinez-Carmona JF, Sanchez-Ales L, Sanchez-Miralles A, Crespo-Gomez M, Leon-Cinto C, Flordelis-Lasierra JL, Servia-Goixart L. Parenteral Nutrition: Current Use, Complications, and Nutrition Delivery in Critically Ill Patients. Nutrients 2023; 15:4665. [PMID: 37960318 PMCID: PMC10649219 DOI: 10.3390/nu15214665] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Parenteral nutrition (PN) is needed to avoid the development of malnutrition when enteral nutrition (EN) is not possible. Our main aim was to assess the current use, complications, and nutrition delivery associated with PN administration in adult critically ill patients, especially when used early and as the initial route. We also assessed the differences between patients who received only PN and those in whom EN was initiated after PN (PN-EN). METHODS A multicenter (n = 37) prospective observational study was performed. Patient clinical characteristics, outcomes, and nutrition-related variables were recorded. Statistical differences between subgroups were analyzed accordingly. RESULTS From the entire population (n = 629), 186 (29.6%) patients received PN as initial nutrition therapy. Of these, 74 patients (11.7%) also received EN during their ICU stay (i.e., PN-EN subgroup). PN was administered early (<48 h) in the majority of patients (75.3%; n = 140) and the mean caloric (19.94 ± 6.72 Kcal/kg/day) and protein (1.01 ± 0.41 g/kg/day) delivery was similar to other contemporary studies. PN showed similar nutritional delivery when compared with the enteral route. No significant complications were associated with the use of PN. Thirty-two patients (43.3%) presented with EN-related complications in the PN-EN subgroup but received a higher mean protein delivery (0.95 ± 0.43 vs 1.17 ± 0.36 g/kg/day; p = 0.03) compared with PN alone. Once adjusted for confounding factors, patients who received PN alone had a lower mean protein intake (hazard ratio (HR): 0.29; 95% confidence interval (CI): 0.18-0.47; p = 0.001), shorter ICU stay (HR: 0.96; 95% CI: 0.91-0.99; p = 0.008), and fewer days on mechanical ventilation (HR: 0.85; 95% CI: 0.81-0.89; p = 0.001) compared with the PN-EN subgroup. CONCLUSION The parenteral route may be safe, even when administered early, and may provide adequate nutrition delivery. Additional EN, when possible, may optimize protein requirements, especially in more severe patients who received initial PN and are expected to have longer ICU stays. NCT Registry: 03634943.
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Affiliation(s)
- Juan Carlos Lopez-Delgado
- Hospital Clinic, Medical ICU, Clinical Institute of Internal Medicine & Dermatology (ICMiD), C/Villarroel, 170, 08036 Barcelona, Spain
- IDIBELL (Biomedical Investigation Institute of Bellvitge), Av. de la Gran Via, 199, 08908 L’Hospitalet de Llobregat, Barcelona, Spain
| | - Teodoro Grau-Carmona
- Intensive Care Department, Hospital 12 de Octubre, Av. de Córdoba s/n, 28041 Madrid, Spain
- i+12 (Research Institute Hospital 12 de Octubre), Av. de Córdoba s/n, 28041 Madrid, Spain
| | - Esther Mor-Marco
- Intensive Care Department, Hospital Universitario Germans Trias i Pujol, Carretera de Canyet, s/n, 08916 Badalona, Barcelona, Spain
| | - Maria Luisa Bordeje-Laguna
- Intensive Care Department, Hospital Universitario Germans Trias i Pujol, Carretera de Canyet, s/n, 08916 Badalona, Barcelona, Spain
| | - Esther Portugal-Rodriguez
- Intensive Care Department, Hospital Clínico Universitario de Valladolid, Av. Ramón y Cajal, 3, 47003 Valladolid, Spain
| | - Carol Lorencio-Cardenas
- Intensive Care Department, Hospital Universitari Josep Trueta, Av. de França, s/n, 17007 Girona, Spain
| | - Paula Vera-Artazcoz
- Intensive Care Department, Hospital de la Santa Creu i Sant Pau, C/Sant Quintí, 89, 08041 Barcelona, Spain
| | - Laura Macaya-Redin
- Intensive Care Department, Complejo Hospitalario de Navarra, C/Irunlarrea, E, 31008 Pamplona, Navarra, Spain
| | - Beatriz Llorente-Ruiz
- Intensive Care Department, Hospital Universitario Príncipe de Asturias, Av. Principal de la Universidad, s/n, 28805 Alcalá de Henares, Madrid, Spain
| | - Rayden Iglesias-Rodriguez
- Intensive Care Department, Hospital General de Granollers, C/Francesc Ribas, s/n, 08402 Granollers, Barcelona, Spain
| | - Diana Monge-Donaire
- Intensive Care Department, Hospital Virgen de la Concha, Av. Requejo, 35, 49022 Zamora, Spain
| | | | - Laura Sanchez-Ales
- Intensive Care Department, Hospital de Terrassa, C/Torrebonica, s/n, 08227 Terrassa, Barcelona, Spain
| | - Angel Sanchez-Miralles
- Intensive Care Department, Hospital Universitari Sant Joan d’Alacant, N-332, s/n, 03550 Sant Joan d’Alacant, Alicante, Spain
| | - Monica Crespo-Gomez
- Intensive Care Department, Hospital Doctor Peset, Av. Gaspar Aguilar, 90, 46017 Valecia, Spain
| | - Cristina Leon-Cinto
- Intensive Care Department, Hospital Royo Villanova, Av. San Gregorio, s/n, 50015 Zaragoza, Spain
| | - Jose Luis Flordelis-Lasierra
- Intensive Care Department, Hospital 12 de Octubre, Av. de Córdoba s/n, 28041 Madrid, Spain
- i+12 (Research Institute Hospital 12 de Octubre), Av. de Córdoba s/n, 28041 Madrid, Spain
| | - Lluis Servia-Goixart
- Intensive Care Department, Hospital Universitari Arnau de Vilanova, Av. Alcalde Rovira Roure, 80, 25198 Lleida, Spain
- IRBLLeida (Lleida Biomedical Research Institute’s Dr. Pifarré Foundation), Av. Alcalde Rovira Roure, 80, 25198 Lleida, Spain
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Behrad Nasab M, Akbari ME, Rastgoo S, Gholami S, Hajipour A, Majidi N, Gholamalizadeh M, Mirzaei Dahka S, Doaei S, Goodarzi MO. Comparison of Biochemical and Pathological Parameters and Parenteral Nutrition of ICU Patients Under Supervision of Dietitians and Surgeons. Front Nutr 2021; 8:729510. [PMID: 34692745 PMCID: PMC8528958 DOI: 10.3389/fnut.2021.729510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/13/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Nutrient imbalance can frequently occur in patients with indications for parenteral nutrition (PN) after gastrointestinal surgery. This study aimed to compare the recommendations of a surgeon to those of a dietitian in the field of parenteral nutrition. Methods: This study was performed on 256 patients undergoing gastrointestinal surgery who received PN, which included 120 patients who received PN based on recommendations of the surgeons and 136 patients who were referred to receive PN under the supervision of a dietitian in Razi Hospital in Rasht, Iran. Data on PN and clinical outcomes of the patients were collected. Results: Patients under the supervision of dietitians received higher vitamin B complex and lipids and lower vitamin A and vitamin E than the surgeon-supervised patients (all P < 0.001). In the group receiving PN under the supervision of a surgeon, the level of blood glucose (207 vs. 182, P < 0.01), sodium (138 vs. 136, P = 0.01), potassium (3.97 vs. 3.53, P < 0.01), and white blood cell count (9.83 vs. 9.28, P < 0.01) increased significantly at the end of the PN compared to baseline. In the group receiving PN under the supervision of a dietician, the level of serum Cr (1.23 vs. 1.32, P = 0.04), Mg (2.07 vs. 1.84, P < 0.01), and pH (7.45 vs. 7.5, P = 0.03) significantly improved after receiving parenteral nutrition compared to baseline. Conclusion: The amounts of nutrients recommended for PN by the surgeon and dietitian were different. Implementation of dietitian recommendations in critically ill patients under PN can improve patients' clinical parameters.
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Affiliation(s)
- Mojgan Behrad Nasab
- Department of Physical Education and Sport Sciences, Faculty of Sport Science, Central Tehran Branch, Islamic Azad University, Tehran, Iran
| | | | - Samira Rastgoo
- Department of Clinical Nutrition and Dietetics, Research Institute Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Somayeh Gholami
- Razi Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Azadeh Hajipour
- Department of Health Sciences in Nutrition, School of Health, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Nazanin Majidi
- Department of Nutrition, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Maryam Gholamalizadeh
- Student Research Committee, Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Saied Doaei
- Reproductive Health Research Center, School of Health, Guilan University of Medical Sciences, Rasht, Iran
| | - Mark O Goodarzi
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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Russell MK, Wischmeyer PE. Supplemental Parenteral Nutrition: Review of the Literature and Current Nutrition Guidelines. Nutr Clin Pract 2019; 33:359-369. [PMID: 29878557 DOI: 10.1002/ncp.10096] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Parenteral nutrition has significantly and positively affected the clinical care of patients for >50 years. The 2016 Society of Critical Care Medicine/American Society for Parenteral and Enteral Nutrition guidelines for the provision of nutrition support to adult patients emphasize the role of this therapy in attenuating the stress response and impacting the immune response, among other benefits. Malnutrition in hospitalized patients remains a major problem; it is underdiagnosed and often undertreated. Malnourished patients are more likely to suffer from infections, pneumonia, and pressure ulcers, among other serious concerns. Enteral nutrition is considered first-line therapy in many of these patients; however, data suggest that many patients receive far less than prescribed amounts for a variety of reasons. Supplemental parenteral nutrition (SPN), used to augment nutrition support of appropriate adult patients and better meet nutrition goals, is not often used in the United States. The purposes of this review are to highlight selected studies in the literature that support and question the use and value of SPN in adult patients; propose consideration of 2 definitions for SPN, "early" and "traditional"; and encourage clinicians to consider SPN for appropriate patients.
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Affiliation(s)
- Mary K Russell
- Senior Manager, Medical Affairs, Baxter Healthcare Corporation, Deerfield, Illinois, USA
| | - Paul E Wischmeyer
- Professor of Anesthesiology and Surgery, Associate Vice Chair for Clinical Research, Director, Perioperative Research at the Duke Clinical Research Institute, Durham, North Carolina, USA.,Director, Nutrition and TPN Service, Duke University Medical Center and Duke University School of Medicine, Durham, North Carolina, USA
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Abstract
PURPOSE OF REVIEW The review focuses on the use of parenteral nutrition and enteral nutrition in critically ill patients to optimize the nutrition care throughout the ICU stay. The key message is: you have the choice! RECENT FINDINGS Enteral nutrition has been recommended for critically ill patients, whereas parenteral nutrition has been considered harmful and to be avoided. However, recent studies have challenged this theory. They demonstrated that enteral nutrition is frequently associated with energy and protein undernutrition, whereas parenteral nutrition becomes deleterious only if overfeeding is induced. Measuring energy expenditure by indirect calorimetry, in most cases, enables accurate determination of the energy needs to optimize the prescription of nutrition. Protein targets should also be considered for adequate feeding. Parenteral nutrition can be used as a supplement or as an alternative to enteral nutrition in case of gastrointestinal intolerance, to enable adequate energy, and protein provision. SUMMARY Parenteral nutrition is a powerful tool to optimize nutrition care of critically ill patients to improve clinical outcome, if prescribed according to the individual needs of the patients. After 3-4 days of attempt to feed enterally, enteral nutrition or parenteral nutrition can be used alternatively or combined, as long as the target is reached with special attention to avoid hypercaloric feeding.
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Hoffer LJ. High-Protein Hypocaloric Nutrition for Non-Obese Critically Ill Patients. Nutr Clin Pract 2018; 33:325-332. [PMID: 29701916 DOI: 10.1002/ncp.10091] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
High-protein hypocaloric nutrition, tailored to each patient's muscle mass, protein-catabolic severity, and exogenous energy tolerance, is the most plausible nutrition therapy in protein-catabolic critical illness. Sufficient protein provision could mitigate the rapid muscle atrophy characteristic of this disease while providing urgently needed amino acids to the central protein compartment and sites of tissue injury. The protein dose may range from 1.5 to 2.5 g protein (1.8-3.0 g free amino acids)/kg dry body weight per day. Nutrition should be low in energy (≈70% of energy expenditure or ≈15 kcal/kg dry body weight per day) because efforts to match energy provision to energy expenditure are physiologically irrational, risk toxic energy overfeeding, and have repeatedly failed in large clinical trials to demonstrate clinical benefit. The American Society for Parenteral and Enteral Nutrition currently suggests high-protein hypocaloric nutrition for obese critically ill patients. Short-term high-protein hypocaloric nutrition is physiologically and clinically sensible for most protein-catabolic critically ill patients, whether obese or not.
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Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
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Jimenez L, Mehta NM, Duggan CP. Timing of the initiation of parenteral nutrition in critically ill children. Curr Opin Clin Nutr Metab Care 2017; 20:227-231. [PMID: 28376054 PMCID: PMC5844227 DOI: 10.1097/mco.0000000000000369] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW To review the current literature evaluating clinical outcomes of early and delayed parenteral nutrition initiation among critically ill children. RECENT FINDINGS Nutritional management remains an important aspect of care among the critically ill, with enteral nutrition generally preferred. However, inability to advance enteral feeds to caloric goals and contraindications to enteral nutrition often leads to reliance on parenteral nutrition. The timing of parenteral nutrition initiation is varied among critically ill children, and derives from an assessment of nutritional status, energy requirements, and physiologic differences between adults and children, including higher nutrient needs and lower body reserves. A recent randomized control study among critically ill children suggests improved clinical outcomes with avoiding initiation of parenteral nutrition on day 1 of admission to the pediatric ICU. SUMMARY Although there is no consensus on the optimal timing of parenteral nutrition initiation among critically ill children, recent literature does not support the immediate initiation of parenteral nutrition on pediatric ICU admission. A common theme in the reviewed literature highlights the importance of accurate assessment of nutritional status and energy expenditure in deciding when to initiate parenteral nutrition. As with all medical interventions, the initiation of parenteral nutrition should be considered in light of the known benefits of judiciously provided nutritional support with the known risks of artificial, parenteral feeding.
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Affiliation(s)
- Lissette Jimenez
- aDivision of Gastroenterology, Hepatology and Nutrition bDivision of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Oshima T, Graf S, Heidegger CP, Genton L, Pugin J, Pichard C. Can calculation of energy expenditure based on CO 2 measurements replace indirect calorimetry? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:13. [PMID: 28107817 PMCID: PMC5251283 DOI: 10.1186/s13054-016-1595-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 12/22/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Methods to calculate energy expenditure (EE) based on CO2 measurements (EEVCO2) have been proposed as a surrogate to indirect calorimetry. This study aimed at evaluating whether EEVCO2 could be considered as an alternative to EE measured by indirect calorimetry. METHODS Indirect calorimetry measurements conducted for clinical purposes on 278 mechanically ventilated ICU patients were retrospectively analyzed. EEVCO2 was calculated by a converted Weir's equation using CO2 consumption (VCO2) measured by indirect calorimetry and assumed respiratory quotients (RQ): 0.85 (EEVCO2_0.85) and food quotient (FQ; EEVCO2_FQ). Mean calculated EEVCO2 and measured EE were compared by paired t test. Accuracy of EEVCO2 was evaluated according to the clinically relevant standard of 5% accuracy rate to the measured EE, and the more general standard of 10% accuracy rate. The effects of the timing of measurement (before or after the 7th ICU day) and energy provision rates (<90 or ≥90% of EE) on 5% accuracy rates were also analyzed (chi-square tests). RESULTS Mean biases for EEVCO2_0.85 and EEVCO2_FQ were -21 and -48 kcal/d (p = 0.04 and 0.00, respectively), and 10% accuracy rates were 77.7 and 77.3%, respectively. However, 5% accuracy rates were 46.0 and 46.4%, respectively. Accuracy rates were not affected by the timing of the measurement, or the energy provision rates at the time of measurements. CONCLUSIONS Calculated EE based on CO2 measurement was not sufficiently accurate to consider the results as an alternative to measured EE by indirect calorimetry. Therefore, EE measured by indirect calorimetry remains as the gold standard to guide nutrition therapy.
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Affiliation(s)
- Taku Oshima
- Clinical Nutrition, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.
| | - Séverine Graf
- Clinical Nutrition, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - Claudia-Paula Heidegger
- Adult Intensive Care, Geneva Universtiy Hospital, Rue Gabrielle-Perret-Gentil 4, Geneva 14, 1211, Switzerland
| | - Laurence Genton
- Clinical Nutrition, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - Jérôme Pugin
- Adult Intensive Care, Geneva Universtiy Hospital, Rue Gabrielle-Perret-Gentil 4, Geneva 14, 1211, Switzerland
| | - Claude Pichard
- Clinical Nutrition, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
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Weimann A, Felbinger TW. Gastrointestinal dysmotility in the critically ill: a role for nutrition. Curr Opin Clin Nutr Metab Care 2016; 19:353-359. [PMID: 27341126 DOI: 10.1097/mco.0000000000000300] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW The role of enteral nutrition on gastrointestinal dysmotility in the critically ill remains controversial. RECENT FINDINGS The mechanisms of gastrointestinal dysmotility during critical illness remain poorly investigated. Low amounts of enteral feeding stimulate motility and have trophic effects. Therefore, enteral feeding is feasible even during gastrointestinal dysmotility as seen in the hemodynamically compromised patient. Rapid 'ramp-up' of administration rate of tube feeding bears the risk of overload and even detrimental ischemic bowel necrosis. The recent American Society for Parenteral and Enteral Nutrition guidelines do not recommend the measurement of gastric residual volume. The use of concentrated enteral solutions with 1.5 kcal/ml may result in greater calorie delivery. Biomarkers like plasma citrulline and plasma or urine intestinal fatty-acid-binding protein reflect the functional integrity of the bowel and may potentially support monitoring. SUMMARY To improve enteral nutrition protocols, the definitions of gastrointestinal dysfunction, gastric dysmotility, and feeding intolerance should be clearly defined in the future. In the concept of integrity of the gut, enteral nutrition should not be stopped completely during gastrointestinal dysfunction but restricted to a 'minimal' trophic feeding rate. In malnourished and high-risk patients intolerant to enteral feeding supplemental parenteral nutrition should be started on day 4 or earlier.
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Affiliation(s)
- Arved Weimann
- aDepartment of General Surgery and Clinical Nutrition, St. George Hospital, Leipzig bDepartment of Anesthesiology, Critical Care and Pain Medicine, Neuperlach and Harlaching Medical Center, The Munich Municipal Hospitals Ltd, Munich, Germany
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