Clinical Guidelines For the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients: applying the GRADE system to development of A.S.P.E.N. clinical guidelines

Guidelines for parenteral nutrition in preterm infants: The American Society for Parenteral and Enteral Nutrition

BACKGROUND

Parenteral nutrition (PN) is prescribed for preterm infants until nutrition needs are met via the enteral route, but unanswered questions remain regarding PN best practices in this population.

METHODS

An interdisciplinary committee was assembled to answer 12 questions concerning the provision of PN to preterm infants. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) process was used. Questions addressed parenteral macronutrient doses, lipid injectable emulsion (ILE) composition, and clinically relevant outcomes, including PNALD, early childhood growth, and neurodevelopment. Preterm infants with congenital gastrointestinal disorders or infants already diagnosed with necrotizing enterocolitis or PN-associated liver disease (PNALD) at study entry were excluded.

RESULTS

The committee reviewed 2460 citations published between 2001 and 2023 and evaluated 57 clinical trials. For most questions, quality of evidence was very low. Most analyses yielded no significant differences between comparison groups. A multicomponent oil ILE was associated with a reduction in stage 3 or higher retinopathy of prematurity (ROP) compared to an ILE containing 100% soybean oil. For all other questions, expert opinion was provided.

CONCLUSION

Most clinical outcomes were not significantly different between comparison groups when evaluating timing of PN initiation, amino acid dose, and ILE composition. Future clinical trials should standardize outcome definitions to permit statistical conflation of data, thereby permitting more evidence based recommendations in future guidelines. This guideline has been approved by the ASPEN 2022-2023 Board of Directors.

Nutritional support in the critical ill patient: Requirements, prescription and adherence

INTRODUCTION

In critically ill patients, nutritional support is a challenge in terms of both estimating their requirements and ensuring adherence to the prescribed treatment.

OBJECTIVE

To assess the association between requirements, prescription and adherence to energy and protein supplementation based on the phase of disease in critically ill patients.

SAMPLE AND METHODS

We conducted a prospective, observational and analytical study in patients aged 0-18 years admitted to the paediatric intensive or intermediate care unit in 2020-2021. We collected data on demographic and anthropometric characteristics and the phase of disease (acute phase [AP] vs. non-acute phase [nAP]), in addition to prescribing (P) (indication of nutritional support), basal metabolic rate (BMR, Schofield equation), adherence to nutritional support (A) and protein requirements (R), and calculated the following ratios: P/BMR, P/R, A/BMR, A/R, and A/P.

RESULTS

The sample included 131 participants with a median age of 16 (4.5) months, of who 128 (97.7%) had comorbidities and 13 (9.9%) were in the AP. Comparing the phases of disease (AP vs. nAP), the median values for energy supplementation were P/BMR, 0.5 (IQR, 0.1-1.4) vs. 1.3 (IQR, 0.9-1.8) (P = 0.0054); A/BMR, 0.4 (IQR, 0-0.6) vs. 1.2 (IQR, 0.8-1.7) (P = 0.0005); A/P, 0.7 (IQR, 0-0.9) vs. 1 (IQR, 0.8-1) (P = 0.002), and for protein were P/R, 0.7 (IQR, 0-1.1) vs. 1.2 (0.9-1.6) (P = 0.0009); A/R 0.3 (IQR, 0-0.6) vs. 1.1 (IQR, 0.8-1.5) (P = 0.0002); A/P 0.7 (IQR, 0-1) vs. 1(IQR, 0.8-1) (P = 0.002). We found AP/nAP ratios greater than 110% for energy in the P/BMR (4 patients [30.8%]/72 patients [61%]; P = 0.007), A/BMR (3 [23%]/63 [53.4%]; P = 0.009) and A/P (1 [7%]/3 [2.5%]; P = 0.007). As for protein, more than 1.5 g/kg/day was prescribed in 3 patients (23.1%) in the AP and 71 (60.1%) in the nAP. We found adherence to the prescribed intake in 2 (15.4%) patients in the AP and 66 (56%) in the nAP. We found a correlation coefficient of 0.6 between the energy P/R and the protein P/R. Prescribed support was discontinued in 7 patients (53.8%) in the AP and 31 (26.3%) in the nAP (P = 0.002).

CONCLUSIONS

The proportion of adherence to prescribed nutritional support was high in patients in the nAP of the disease. Overfeeding was frequent, more so in the nAP. We identified difficulties in adhering to prescribed support, chief of which was the discontinuation of feeding.

Nutritional Management of Patients with Head and Neck Cancer-A Comprehensive Review

While surgical therapy for head and neck cancer (HNC) is showing improvement with the advancement of reconstruction techniques, the focus in these patients should also be shifting to supportive pre and aftercare. Due to the highly sensitive and anatomically complex region, these patients tend to exhibit malnutrition, which has a substantial impact on their recovery and quality of life. The complications and symptoms of both the disease and the therapy usually make these patients unable to orally intake food, hence, a strategy should be prepared for their nutritional management. Even though there are several possible nutritional modalities that can be administrated, these patients commonly have a functional gastrointestinal tract, and enteral nutrition is indicated over the parenteral option. However, after extensive research of the available literature, it seems that there is a limited number of studies that focus on this important issue. Furthermore, there are no recommendations or guidelines regarding the nutritional management of HNC patients, pre- or post-operatively. Henceforth, this narrative review summarizes the nutritional challenges and management modalities in this particular group of patients. Nonetheless, this issue should be addressed in future studies and an algorithm should be established for better nutritional care of these patients.

Ethical Implications of Nutrition Therapy at the End of Life

PURPOSE OF REVIEW

Provide an evidence-based resource to inform ethically sound recommendations regarding end of life nutrition therapy.

RECENT FINDINGS

• Some patients with a reasonable performance status can temporarily benefit from medically administered nutrition and hydration(MANH) at the end of life. • MANH is contraindicated in advanced dementia. • MANH eventually becomes nonbeneficial or harmful in terms of survival, function, and comfort for all patients at end of life. • Shared decision-making is a practice based on relational autonomy, and the ethical gold standard in end of life decisions. A treatment should be offered if there is expectation of benefit, but clinicians are not obligated to offer non-beneficial treatments. A decision to proceed or not should be based on the patient's values and preferences, a discussion of all potential outcomes, prognosis for given outcomes taking into consideration disease trajectory and functional status, and physician guidance provided in the form of a recommendation.

J-SUPPORT research policy for oral mucositis associated with cancer treatment

BACKGROUND

Oral mucositis is one of the main areas of research in supportive and palliative care of cancer patients. However, the methodology of prospective clinical trials on oral mucositis has not been established, despite its uniqueness. Here, we propose a novel research policy on oral mucositis, including an implementable set of recommendations for researchers conducting clinical trials.

METHODS

The first draft was developed by an expert panel of six specialists from the Japanese Supportive, Palliative, and Psychosocial Care Study Group. A provisional draft was developed after review by the following medical societies: the Japanese Association of Supportive Care in Cancer, the Japanese Association of Oral Supportive Care in Cancer, the Japanese Cancer Association, and the receipt of public comments.

RESULTS

The research policy on oral mucositis mainly consists of the following components: (i) definition of oral mucositis; (ii) characteristics of oral mucositis; (iii) characteristics of oral mucositis research; (iv) target population for oral mucositis research; (v) endpoints and assessment measures in oral mucositis; (vi) eligibility criteria; (vii) research design; (viii) minimally recommended intervention in oral mucositis research as a supplement. The final policy (Ver1.0) was completed on August 16, 2021.

CONCLUSIONS

This policy may serve as a significant reference for planning and conducting clinical trials for the management of oral mucositis.

Effects of enteral nutrition on heart function, inflammatory markers and immune function in elderly patients with chronic heart failure

Objectives:

To evaluate the effect of enteral nutrition on heart function, inflammatory markers and immune function in elderly patients with chronic heart failure and its clinical significance.

Methods:

Eighty patients with moderate and severe heart failure admitted to the Cardiology Intensive Care Unit (CCU) of Baoding First Central Hospital from May 2019 to May 2020 were included in this study and randomly divided into two groups: the experimental group and the control group, with 40 patients in each group. The experimental group was given enteral nutrition support therapy on the basis of conventional therapy for one month, while the control group was given restricted salt and water intake on the basis of conventional therapy, and patients were given free diet according to their wishes. The changes in heart function before and after treatment, changes in inflammatory factors such as TNF-a, CRP, IL-6, changes in levels of immunoglobulins such as IgA, IgM, and IgG, and the improvement of the performance status of the two groups were compared and analyzed.

Results:

After treatment, indicators such as BNP, LVEDD, LVEF and 6min walking distance in the experimental group were significantly improved compared with the control group, with statistically significant differences (p<0.05), and the levels of inflammatory factors such as TNF-a, CRP and IL-6 in the experimental group were significantly reduced compared with those in the control group (p=0.00). The levels of IgG, IgA, IgM and other immunoglobulins in the experimental group improved more significantly after treatment than those in the control group, with statistically significant differences (IgG, IgA, p=0.00; IgM, p=0.01). Moreover, the experimental group was significantly superior to the control group in the improvement rate of performance status score (ECOG) after treatment (p=0.04); The incidence of gastrointestinal adverse reactions in the experimental group was 20%, and that in the control group was 15%. No statistically significant difference can be observed in the gastrointestinal tolerance of both groups (p=0.56).

Conclusions:

Reasonable enteral nutrition boasts a variety of benefits for the recovery of elderly patients with chronic heart failure. With reasonable enteral nutrition, the heart function of elderly patients with chronic heart failure can be significantly improved, inflammatory factors can be reduced, immunity and performance status can be enhanced, and gastrointestinal tolerance can be ameliorated without obvious gastrointestinal reactions.

Evidence-based recommendations of the Andalusian Group for Nutrition Reflection and Investigation (GARIN) for the management of adult patients with short bowel syndrome

Introduction

In order to develop evidence-based recommendations and expert consensus for the nutritional management of patients with short bowel syndrome (SBS), we conducted a systematic literature search using the PRISMA methodology plus a critical appraisal following the GRADE scale procedures. Pharmacological treatment with antisecretory drugs, antidiarrheal drugs, and somatostatin contributes to reducing intestinal losses. Nutritional support is based on parenteral nutrition; however, oral intake and/or enteral nutrition should be introduced as soon as possible. In the chronic phase, the diet should have as few restrictions as possible, and be adapted to the SBS type. Home parenteral nutrition (HPN) should be individualized. Single-lumen catheters are recommended and taurolidine should be used for locking the catheter. The HPN's lipid content must be greater than 1 g/kg per week but not exceed 1 g/kg per day, and omega-6 fatty acids (ω6 FAs) should be reduced. Trace element vials with low doses of manganese should be used. Patients with chronic SBS who require long-term HPN/fluid therapy despite optimized treatment should be considered for teduglutide treatment. All patients require a multidisciplinary approach and specialized follow-up. These recommendations and suggestions regarding nutritional management in SBS patients have direct clinical applicability.

Guidelines for the provision of nutrition support therapy in the adult critically Ill patient: American society for parenteral and enteral nutrition

BACKGROUND

New randomized controlled trials have been conducted since publication of the 2016 ASPEN/SCCM critical care nutrition guideline. This guideline updates recommendations for foundational questions central to critical care nutrition support.

METHODS

The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process was used to develop and summarize evidence for clinical practice recommendations. Clinical outcomes were assessed for (1) higher vs lower energy dose (2) higher vs lower protein dose (3) exclusive isocaloric PN vs EN (4) supplemental PN (SPN) plus EN vs EN alone (5a) mixed oil lipid injectable emulsions (ILE) vs soybean oil, and (5b) Fish oil (FO) containing ILE vs non-FO ILE. To assess safety, weight based energy intake was plotted against hospital mortality when study heterogeneity precluded meaningful Forest plot inferences.

RESULTS

Between 1/1/2001 and 07/15/2020, 2,320 citations were identified and data were abstracted from 39 trials, including 20,578 participants. Patients receiving FO had decreased pneumonia rates of uncertain clinical significance. Otherwise, there were no differences for any outcome in any question. Due to lack in certainty regarding harm, the energy prescription recommendation was decreased to 12-25kcal/kg/day.

CONCLUSION

No differences in clinical outcomes were identified among numerous nutritional interventions, including higher energy or protein intake, isocaloric PN or EN, supplemental PN, or different ILEs. As more consistent critical care nutrition support data become available, more precise recommendations will be possible. In the meantime, clinical judgment and close monitoring are needed. This paper was approved by the ASPEN Board of Directors.  This article is protected by copyright. All rights reserved.

Manganese Toxicity Associated With Total Parenteral Nutrition: A Review

Objective: To review hypermanganesemia-induced toxicities in adult patients receiving parenteral nutrition (PN) therapy. Data Sources: A comprehensive literature review was conducted from June 2020 to May 2021 on PubMED, MEDLINE, Scopus, ProQuest, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Web of Science. Study Selection and Data Extraction: Keyword and Boolean phrase searches were conducted using the following terminology: "manganese" OR "manganesemia" OR "manganism" or "hypermanganesemia" AND "total parenteral nutrition" OR "PN" or "parenteral nutrition" AND "toxicity" OR "accumulation." Appropriate filters, including "humans" and "English" and NOT "reviews," were utilized on all databases to improve search outcomes. Data Synthesis: A total of 4 reports detailing hypermanganesemia in 57 patient encounters were included in this review. Significant heterogeneity exists with regard to the duration of manganese supplementation and the dose of manganese. Toxicity associated with manganese was observed in as few as 15 days. The dose of manganese, though likely governed by content in commercially available products, may regularly exceed the recommendations of clinical guidelines and should be limited to 55 µg/day. Select patients with underlying malignancy, those with significant and prolonged Vitamin D deficiency, or those who have acquired a SLC30A10 genetic mutation may be at an increased risk of developing manganese toxicity. Conclusions: Clinicians must be cognizant of the concentration of trace elements added to PN, as manganese, and perhaps other biometals, may accumulate when dosed above the recommended daily allowances.

Clinical guidelines for the management of gastrointestinal fistula – developed by experts of the Polish Surgical Society

Introduction: Gastrointestinal fistula is one of the most difficult problems in gastrointestinal surgery. It is associated with high morbidity and mortality, numerous complications, prolonged hospitalization, and high cost of treatment. </br>Aim: This project aimed to develop recommendations for the treatment of gastrointestinal fistulas, based on evidence-based medicine and best clinical practice to reduce treatment-related mortality and morbidity. </br>Material and methods: The preparation of these recommendations is based on a review of the literature from the PubMed, Medline, and Cochrane Library databases from 1.01.2010 to 31.12.2020, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. Recommendations in the form of a directive were formulated and assessed using the Delphi method. </br>Results and conclusions: Nine recommendations were presented along with a discussion and comments of experts. Treatment should be managed by a multidisciplinary team (surgeon, anesthetist, clinical nutritionist/dietician, nurse, pharmacist, endoscopist).

Impact of a nutrition support therapy on hospital-acquired infections: A value analysis

BACKGROUND

Hospital-acquired conditions (HACs) have a direct impact on value, as they decrease quality and increase costs. Numerous interventions have been tried, including nutrition support therapy, with unknown effect on value. Therefore, a value analysis of nutrition support therapy on HACs was performed.

METHODS

An extensive literature search was performed. Using the Medicare Parts A and B Claims 5% Sample data set, analytic claims modeling was conducted.

RESULTS

The search identified 1099 studies, with eight meeting the inclusion criteria. All studies were performed on adult critically ill patients and focused on HA infections (HAIs) as the HAC. One study underwent Medicare claims modeling and revealed nutrition therapy has the potential of saving at least $104 million annually in Medicare patients with HAIs.

CONCLUSION

Nutrition support therapy has the potential to reduce costs of Medicare spending in respect to HAIs.

Home parenteral nutrition patients on mixed oil lipid emulsion have a higher rate of hospitalizations compare to those on soybean oil- a prospective 2-year cohort study

BACKGROUND & AIMS

Mixed oil intravenous lipid emulsion (MO ILE) that contains 30% soybean oil (SO), 30% medium chain triglycerides, 25% olive oil and 15% fish oil can benefit hospitalized patients receiving parenteral nutrition (PN) but there are very few studies on its long-term use. Our goal was to evaluate the clinical outcomes of adults receiving home PN (HPN) with MO versus those receiving SO ILE over a 2-year period.

METHOD

This is a retrospective analysis of data collected prospectively from a cohort of patients recorded in the Canadian HPN Registry over a 2-year period. HPN patients from academic programs across Canada were entered in the Registry according to a validated protocol. For this study, demographic, nutritional, laboratory and clinical data were extracted from January 1st 2015, when MO lipid emulsion became available in Canada, to July 24th 2019. Clinical data for each patient included: number of hospitalizations, number of hospitalizations related to HPN and number of hospitalization days related to HPN, over a year; incidence of line sepsis per 1000 catheter days and mortality. Data are presented as median (1st, 3rd quartile) for continuous variables and frequency (percentage) for categorical variables. Comparisons between groups were performed using two sample t-test or Wilcoxon Rank Sum tests for continuous variables and Chi-square tests or Fisher's exact tests for categorical variables. Univariate and multiple linear regressions were also carried out. Statistical significance is set at a p-value <0.05.

RESULTS

A total of 120 patients were included (MO n = 68, SO n = 52). Significant differences at baseline between the two groups were a higher use of Hickman line (62.12% vs 42%, p = 0.038) and more western Canada based hospital care with MO (75% vs 42.31%, p = 0.0002). The MO group had significantly more hospitalizations (p = 0.001), more hospitalizations related to HPN (p = 0.012) and more hospitalization days related to HPN (p = 0.016) per patient per year compared to SO patients. There was no significant difference between groups for line sepsis per 1000 catheter days (MO: 0.05 (0.0, 1.0) vs SO: 0.0 (0.0, 0.22), p = 0.053) or mortality. All other variables, including biochemical variables, were similar between groups. In a multiple regression analysis, the following factors were significantly associated with a greater number of hospitalizations per patient per year: use of MO, high blood glucose from the last recorded value and having died by the end of the study period.

CONCLUSION

This 2-year prospective cohort study suggests an increased risk of hospitalization in HPN patients receiving MO lipid emulsion. The long-term effect of using MO lipid emulsion in HPN patients should be further evaluated using a large randomized controlled trial. THE STUDY WAS REGISTERED IN CLINICALTRIALS.GOV: (NCT02299466).

Evaluating the risk of manganese-induced neurotoxicity of parenteral nutrition: review of the current literature

INTRODUCTION

Several diseases and clinical conditions can affect enteral nutrition and adequate gastrointestinal uptake. In this respect, parenteral nutrition (PN) is necessary for the provision of deficient trace elements. However, some essential elements, such as manganese (Mn) may be toxic to children and adults when parenterally administered in excess, leading to toxic, especially neurotoxic effects.

AREAS COVERED

Here, we briefly provide an overview on Mn, addressing its sources of exposure, the role of Mn in the etiology of neurodegenerative diseases, and focusing on potential mechanisms associated with Mn-induced neurotoxicity. In addition, we discuss the potential consequences of overexposure to Mn inherent to PN.

EXPERT OPINION

In this critical review, we suggest that additional research is required to safely set Mn levels in PN, and that eliminating Mn as an additive should be considered by physicians and nutritionists on a case by case basis in the meantime to avoid the greater risk of neurotoxicity by its presence. There is a need to better define clinical biomarkers for Mn toxicity by PN, as well as identify new effective agents to treat Mn-neurotoxicity. Moreover, we highlight the importance of the development of new guidelines and practice safeguards to protect patients from excessive Mn exposure and neurotoxicity upon PN administration.

The effects of implementation of a stepwise algorithmic protocol for nutrition care process in gastro-intestinal surgical children in Pediatric Intensive Care Unit (PICU)

INTRODUCTION

Malnutrition is known as one of the major health problems among critically ill children; optimum nutrition support is considered as a therapeutic strategy to improve clinical outcomes and minimize the length of Pediatric Intensive Care Unit (PICU) staying as well as its costs. Implementation of an algorithmic protocol can result in the upgrade of the quality of nutrition support system in PICU.

METHOD

In this study, we developed a stepwise algorithmic nutrition care protocol for PICU patients in two phases as follows: a critical review of past literature and an expert discussion panel. The final structured protocol includes three following steps for the nutrition care process: 1) Initial nutrition screening and assessment, 2) Nutritional intervention and 3) Nutritional monitoring. Pre and post-implementation audits were carried out in a 23 bed medical/surgical PICU in a children's hospital affiliated to Mashhad University of Medical Sciences over two 4-week periods to evaluate the impact of the algorithm implementation. The post-implementation audit was performed by passing 12 weeks from the protocol implementation. Critically ill children aged between 1month and 10 years, and PICU length of stay>24 h who were in post gastrointestinal surgery state, were enrolled.

RESULTS

Totally, 34 eligible critically ill gastrointestinal surgical children in post-implementation audit were compared with 30 patients with similar eligibility criteria in the pre-implementation audit. Notably, there were no significant differences in gender, median age, length of PICU stay, and mechanical ventilation requirement in the two audits. The comparison of our pre and post-implementation audits showed a significant increase in the proportion of energy delivery goal achievement following performing our intervention (56.7%, and 85.3%, for pre and post-implementation audits, respectively; p-value = 0.01).Additionally, time of achieving energy and protein goals were significantly decreased (5.5 vs. 3 days; p-value = 0.008 and 4 vs 3 days; p-value = 0.002, for energy and protein delivery goal achievements, respectively).

CONCLUSION

The implementation of the algorithm have significantly improved the adequacy ratio of energy delivery and also decreased the time to achieve the goal in energy and protein intake among critically ill children in post-gastrointestinal state. In this regard, further prospective studies are needed for continuing the evaluation of the algorithm implementation outcomes in critically ill children with different surgical and internal underlying diseases.

Clinical observation of individualized nutritional formula on inflammation index, immune status and gastrointestinal tolerance in patients with severe head injury

Objectives:

To evaluate the clinical significance of individualized nutritional formulas on inflammatory factors, immune status and gastrointestinal tolerance in patients with severe head injury.

Methods:

A total of 80 patients with severe head injury who were hospitalized in Baoding No.1 Central Hospital from March 2017 to March 2020 were randomly divided into two groups with 40 cases in each group. Patients in both groups were given enteral nutrition (EN), the control group was given conventional enteral nutrition formula through nasointestinal tube, and the experimental group was given individualized nutrition formula. All patients were tested for tumor necrosis factor(TNF-α), C-reactive protein(CRP), interleukin 6(IL-6), IgA, IgM, IgG, serum intestinal fatty acid binding protein(I-FABP) and D-lactic acid concentration before and after enteral nutrition treatment. The incidence of adverse reactions such as abdominal distension, diarrhea, constipation, and gastric retention within seven days after treatment of two groups were compared and analyzed.

Results:

There was no significant difference in inflammatory factors such as TNF-a, CRP, IL-6, immunoglobulin levels, I-FABP and D-lactic acid concentration between the two groups before treatment (p>0.05). After treatment, the above indicators of the two groups of patients were better than before treatment, the difference was statistically significant (p<0.05), and the experimental group was significantly better than the control group (p<0.05). The experimental group had a gastrointestinal adverse reaction rate of 10%, and the control group had 27.5%, the difference was statistically significant (p=0.04).

Conclusions:

Individualized nutritional formula has more significant advantages than conventional nutritional formula for patients with severe head injury, which can reduce inflammatory response, increase the patient’s immune level, improve the intestinal mucosal barrier function, have good gastrointestinal tolerance, and have a low incidence of adverse reactions.

Parenteral Provision of Micronutrients to Pediatric Patients: An International Expert Consensus Paper

INTRODUCTION

Micronutrients (vitamins and trace elements) are essential to all nutrition. For children and neonates who are dependent upon nutrition support therapies for growth and development, the prescribed regimen must supply all essential components. This paper aims to facilitate interpretation of existing clinical guidelines into practical approaches for the provision of micronutrients in pediatric parenteral nutrition.

METHODS

An international, interdisciplinary expert panel was convened to review recent evidence-based guidelines and published literature to develop consensus-based recommendations on practical micronutrient provision in pediatric parenteral nutrition.

RESULTS

The guidelines and evidence have been interpreted as answers to 10 commonly asked questions around the practical principles for provision and monitoring of micronutrients in pediatric patients.

CONCLUSION

Micronutrients are an essential part of all parenteral nutrition and should be included in the pediatric nutrition therapy care plan.

Planning for the Pandemic: A Community Hospital Story

When the Covid 19 pandemic affected New York State, Federal and mostly State, mandates were given to hospitals to prepare for the expected influx of patients. This is a community hospital's planning journey that includes preparing for placing patients, educating caregivers, matching the abilities of the available caregivers with the needs of the patients, securing needed equipment and supplies, and caring for the caregivers. Planning for patient placement resulted in a phased-in guide, accommodating seriously and critically ill affected patients. Education and training were initial and ongoing, rapidly changing as new information became available. Effective care delivery models that focused on team were modified depending on the needs of patients and staff competence. Securing and maintaining equipment and supplies were challenging and caring for the caregivers was a priority. Working as a team, this community hospital developed a road map that was effective in planning for the surge and allowed the hospital to maintain a safe environment for staff and patients who received quality care in difficult time.

[de la evidencia y algoritmo adaptado Immunonutrition in fast-track surgical patients - Evidence review and adapted algorithm]

Introduction

Surgical stress predisposes patients to have immune dysfunction and an increased risk of infection. Malnourished surgical patients have higher postoperative morbidity and mortality rates, higher readmission rates, and higher hospital costs. The use of an immunomodulatory formula is associated in the ESPEN guidelines with a reduction in wound healing problems, suture failure, and infectious and global complications. Several authors have suggested that, since most clinical trials evaluating the efficacy of immunonutrition have been carried out in a traditional perioperative setting, it would be interesting to investigate its efficacy in a more controlled setting, such as in the ERAS (Enhanced Recovery after Surgery) protocol. The objective of this work was: a) to define the role that immunonutrition should play in ERAS protocols based on the best scientific evidence available; b) to analyze the difficulties that continue to exist in real-life clinical practice to screen the nutritional risk of patients; c) to make a proposal of algorithms adapted to the characteristics of our environment regarding the screening, assessment, and nutritional treatment of surgical patients in fast-track surgery.

Defining the needs of patients with recurrent and/or metastatic head and neck cancer: An expert opinion

The clinical and biological heterogeneity of head and neck cancer (HNC) is paralleled by a plethora of different symptoms that affect the patient's quality of life. These symptoms include, for instance, pain, fatigue, nutritional issues, airways obstruction, voice alterations and psychological distress. In addition, patients with HNC are prone to a high risk of infection, and may also suffer from acute complications, such as hypercalcemia, spine compression by bone metastasis or bleeding. Prolonging survival is also an inherent expectation for all patients. Addressing the above needs is crucial in all patients with HNC, and especially in those with recurrent and/or metastatic (RM) disease. However, research on how to address patients' needs in RM-HNC remains scarce. This paper defines patients' needs for RM HNC and presents an Expert Opinion on how to address them, proposing also some lines of research.

Development of venous thrombi in a pediatric population of intestinal failure

BACKGROUND/PURPOSE

Although pediatric intestinal failure (IF) is now a survivable diagnosis, children are still at risk for complications. Loss of venous access persists as a leading indication for intestinal transplantation. The goal of this study was to identify risk factors for loss of venous access in a pediatric intestinal failure population on long-term PN.

METHODS

We identified all patients who were PN dependent.

RESULTS

Patients that developed venous thrombosis had significantly more lines placed in the first 2 years of life compared to those who did not develop thrombosis. Multivariate regression analysis revealed that diagnosis (NEC and gastroschisis) and parental education were significant predictors of venous thrombosis.

CONCLUSION

By identifying potential risk factors for thrombus development, interventions can be developed to improve the overall outcome in pediatric IF patients.

TYPE OF STUDY

Diagnostic LEVEL OF EVIDENCE: III.

Enteral Nutrition in Adult Crohn's Disease: Toward a Paradigm Shift

Medical and surgical treatments for Crohn's disease are associated with toxic effects. Medical therapy aims for mucosal healing and is achievable with biologics, immunosuppressive therapy, and specialised enteral nutrition, but not with corticosteroids. Sustained remission remains a therapeutic challenge. Enteral nutrition, containing macro- and micro-nutrients, is nutritionally complete, and is provided in powder or liquid form. Enteral nutrition is a low-risk and minimally invasive therapy. It is well-established and recommended as first line induction therapy in paediatric Crohn's disease with remission rates of up to 80%. Other than in Japan, enteral nutrition is not routinely used in the adult population among Western countries, mainly due to unpalatable formulations which lead to poor compliance. This study aims to offer a comprehensive review of available enteral nutrition formulations and the literature supporting the use and mechanisms of action of enteral nutrition in adult Crohn's disease patients, in order to support clinicians in real world decision-making when offering/accepting treatment. The mechanisms of actions of enteral feed, including their impact on the gut microbiome, were explored. Barriers to the use of enteral nutrition, such as compliance and the route of administration, were considered. All available enteral preparations have been comprehensively described as a practical guide for clinical use. Likewise, guidelines are reported and discussed.

AAST Critical Care Committee clinical consensus: ECMO, nutrition

The American Association for the Surgery of Trauma Critical Care Committee has developed clinical consensus guides to help with practical answers based on the best evidence available. These are focused in areas in which the levels of evidence may not be that strong and are based on a combination of expert consensus and research. Overall, quality of the research is mixed, with many studies suffering from small numbers and issues with bias. The first two of these focus on the use of extracorporeal membrane oxygenation in trauma patients and nutrition for the critically ill surgical/trauma patient.

Incorporating the latest pediatric nutrition support guidelines into clinical practice

Optimal nutrition support in critically ill children is associated with improved outcomes and decreased mortality. Nutrition provision often competes with other care priorities in critically ill patients. The 2017 Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient supplement clinician knowledge and inform best practices for nutrition therapy in this vulnerable patient population.

American Society for Parenteral and Enteral Nutrition Guidelines for the Selection and Care of Central Venous Access Devices for Adult Home Parenteral Nutrition Administration

This document represents the American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines to describe best practices in the selection and care of central venous access devices (CVADs) for the infusion of home parenteral nutrition (HPN) admixtures in adult patients. The guidelines targeted adults >18 years of age in which the intervention or exposure had to include HPN that was administered via a CVAD. Case studies, non-English studies, or studies of CVAD no longer available in the United States were excluded. In total, 564 abstract citations, 350 from Medline and 214 from PubMed/non-MEDLINE databases, were scanned for relevance. Of the 564 citations, 13 studies addressed at least 1 of the 6 guideline-related questions, and none of the studies were prospective and randomized. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria were used to adjust the evidence grade based on assessment of the quality of study design and execution. Recommendations for the CVAD type, composition, or number of lumens to minimize infectious or mechanical complications are based on a limited number of studies and expert opinion of the authors, all very experienced in home infusion therapy. No studies were found that compared best solutions for routine flushing of lumens (eg, heparin versus saline) or for maintaining catheters in situ while treating CVAD mechanical or infectious complications. It is clear that studies to answer these questions are very limited, and further research is needed. These clinical guidelines were approved by the ASPEN Board of Directors.

Effects of Early Enteral Nutrition on Immune Function and Prognosis of Patients With Sepsis on Mechanical Ventilation

OBJECTIVE

To explore the therapeutic effects of early enteral nutrition (EEN) on patients with sepsis on mechanical ventilation.

METHODS

Patients with sepsis on mechanical ventilation in the medical intensive care unit (ICU) from January 2013 to March 2016 were treated with enteral nutrition. Patients treated within 48 hours of initiation of mechanical ventilation were assigned to the EEN group, and the rest were assigned to the delayed enteral nutrition (DEN) group. Peripheral blood Th17 cells and Treg cells, endotoxin (ET) level, 28-day mortality, duration of mechanical ventilation, lengths of ICU stay and hospital stay, and incidence of ICU-acquired weakness (ICU-AW) were analyzed between the 2 groups.

RESULTS

The proportion of Th17 cells and ET levels in the EEN group were significantly lower than those in the DEN group, whereas the proportion of Treg cells in the EEN group was remarkably higher than that in the DEN group (P < .05). The duration of mechanical ventilation, lengths of ICU stay and hospital stay, and incidence of ICU-AW were higher in the DEN group than in the EEN group (P < .05), but there was no significant difference in the 28-day mortality between the 2 groups.

CONCLUSION

Patients with sepsis mainly present with an increased proportion of Th17 cells in the early stage, manifesting as enhanced immune response. Early enteral nutrition can inhibit the excessive immune response, shorten the duration of mechanical ventilation, lengths of ICU stay and hospital stay, and reduce the incidence of ICU-AW, but it has no obvious effect on 28-day mortality.

Technology in Parenteral Nutrition Compounding

Technology is constantly being used in novel ways, and its use in the practice of medicine is no exception. Examples of this include computer physician order entry, barcode-medication scanning, electronic health records (EHRs), and bedside patient charts, to name a few. Compounding parenteral nutrition has been included in this technological revolution, with improvements such as barcode-assisted medication preparation systems and EHR-to-compounder interfaces. Along with some of these electronic advancements come the inevitable improvements and challenges, which are explored in this article.

Nutrition Management for the Head and Neck Cancer Patient

Head and neck cancer (HNC) patients often face multiple nutritional challenges before, during, and after treatment due to the close proximity of the cancer to organs that are vital for normal eating function. Common treatment-related side effects, such as dysphagia, odynophagia, dysgeusia, xerostomia, thick saliva, mucositis, nausea, and vomiting, all further impair the patient's ability to maintain adequate oral intake. Malnutrition and unintentional weight loss in HNC patients during and after treatment are associated with poorer treatment outcomes, increased morbidity and mortality, and poor quality of life, even in overweight and obese patients whose Body Mass Index (BMI) is not suggestive of malnutrition. The main nutrition goal for HNC patients is thus to maximize nutrition intake either orally or through nutrition support therapy in order to prevent or limit weight loss, preserve lean body mass, minimize treatment delays and unplanned hospitalizations, and improve treatment outcomes. This chapter will discuss nutrition interventions to manage common symptoms before, during, and after treatment for HNC. Guidelines will be provided for patients that require enteral nutrition or less commonly, parenteral nutrition.

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition

This document represents the first collaboration between two organizations, American Society of Parenteral and Enteral Nutrition and the Society of Critical Care Medicine, to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric (> 1 mo and < 18 yr) critically ill patient expected to require a length of stay greater than 2 or 3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2,032 citations were scanned for relevance. The PubMed/Medline search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1,661 citations. In total, the search for clinical trials yielded 1,107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer one of the eight preidentified question groups for this guideline. We used the Grading of Recommendations, Assessment, Development and Evaluation criteria to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutritional assessment, particularly the detection of malnourished patients who are most vulnerable and therefore potentially may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery is an area of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.

Evidence-based recommendations and expert consensus on enteral nutrition in the adult patient with diabetes mellitus or hyperglycemia

OBJECTIVE

The aim of this study was to develop evidence-based recommendations for glycemic control of patients with diabetes mellitus or stress hyperglycemia who are receiving enteral nutrition (EN).

METHODS

A Delphi survey method using Grading Recommendations Assessment, Development and Evaluation criteria was utilized for evaluation of suitable studies.

RESULTS

In patients with diabetes or stress hyperglycemia who were on EN support, the following results were found: CONCLUSIONS: These recommendations and suggestions regarding enteral feeding in patients with diabetes and hyperglycemia have direct clinical applicability.

ASPEN-FELANPE Clinical Guidelines

BACKGROUND

The management of patients with enterocutaneous fistula (ECF) requires an interdisciplinary approach and poses a significant challenge to physicians, wound/stoma care specialists, dietitians, pharmacists, and other nutrition clinicians. Guidelines for optimizing nutrition status in these patients are often vague, based on limited and dated clinical studies, and typically rely on individual institutional or clinician experience. Specific nutrient requirements, appropriate route of feeding, role of immune-enhancing formulas, and use of somatostatin analogues in the management of patients with ECF are not well defined. The purpose of this clinical guideline is to develop recommendations for the nutrition care of adult patients with ECF.

METHODS

A systematic review of the best available evidence to answer a series of questions regarding clinical management of adults with ECF was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group. An anonymous consensus process was used to develop the clinical guideline recommendations prior to peer review and approval by the ASPEN Board of Directors and by FELANPE.

QUESTIONS

In adult patients with enterocutaneous fistula: (1) What factors best describe nutrition status? (2) What is the preferred route of nutrition therapy (oral diet, enteral nutrition, or parenteral nutrition)? (3) What protein and energy intake provide best clinical outcomes? (4) Is fistuloclysis associated with better outcomes than standard care? (5) Are immune-enhancing formulas associated with better outcomes than standard formulas? (6) Does the use of somatostatin or somatostatin analogue provide better outcomes than standard medical therapy? (7) When is home parenteral nutrition support indicated?

Early enteral nutrition vs parenteral nutrition following pancreaticoduodenectomy: Experience from a single center

AIM: To analyze and compare postoperative morbidity between patients receiving total parenteral nutrition (TPN) and early enteral nutrition supplemented with parenteral nutrition (EEN + PN).

METHODS: Three hundred and forty patients receiving pancreaticoduodenectomy (PD) from 2009 to 2013 at our center were enrolled retrospectively. Patients were divided into two groups depending on postoperative nutrition support scheme: an EEN + PN group (n = 87) and a TPN group (n = 253). Demographic characteristics, comorbidities, preoperative biochemical parameters, pathological diagnosis, intraoperative information, and postoperative complications of the two groups were analyzed.

RESULTS: The two groups did not differ in demographic characteristics, preoperative comorbidities, preoperative biochemical parameters or pathological findings (P > 0.05 for all). However, patients with EEN + PN following PD had a higher incidence of delayed gastric emptying (16.1% vs 6.7%, P = 0.016), pulmonary infection (10.3% vs 3.6%, P = 0.024), and probably intraperitoneal infection (18.4% vs 10.3%, P = 0.059), which might account for their longer nasogastric tube retention time (9 d vs 5 d, P = 0.006), postoperative hospital stay (25 d vs 20 d, P = 0.055) and higher hospitalization expenses (USD10397 vs USD8663.9, P = 0.008), compared to those with TPN.

CONCLUSION: Our study suggests that TPN might be safe and sufficient for patient recovery after PD. Postoperative EEN should only be performed scrupulously and selectively.

[Parenteral Nutritional Support in Gastrointestinal and Liver Diseases]

Protein-calorie malnutrition and deficiencies of specific nutrients could commonly occur in various types of gastrointestinal diseases. These nutritional problems could delay recovery from diseases, resulting in increased morbidity and mortality, and impairment of quality of life. Parenteral nutrition (PN) is one of the methods of nutritional support through which macronutrients (glucose, amino acids, and triglycerides), micronutrients (vitamins and trace elements), water, and electrolytes are administered via peripheral or central venous route. PN could play an important role for patients for whom enteral/oral feeding is contraindicated or cannot meet the patients' requirement for adequate nutrition due to anatomical and/or functional problems. Since insufficient and excessive PN supplement could both be harmful for patients, it is very important to adhere to correct indication, optimal timing, and dosage/composition of PN. In this article, the current role of PN for various gastrointestinal diseases will be reviewed and discussed.

Clinical guidelines from the American Society for Parenteral and Enteral Nutrition: best practice recommendations for patient care

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is an interdisciplinary society whose vision is to ensure that every patient receives safe, efficacious, and high-quality nutrition care. The society has produced clinical guidelines to assist practitioners in enteral and parenteral nutrition decision making. A.S.P.E.N. clinical guideline development has evolved through the years, and recently has incorporated a rigorous and transparent development process using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) process. This article will examine A.S.P.E.N.'s guideline development process, discuss current population- and disease-specific practice guidelines, and highlight recommendations useful for the clinician involved in nutrition therapy decision making.

ESPGHAN position paper on management of percutaneous endoscopic gastrostomy in children and adolescents

OBJECTIVES

This European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) position statement provides a comprehensive guide for health care providers to manage percutaneous endoscopic gastrostomy tubes in a safe, effective, and appropriate way.

METHODS

Relevant literature from searches of PubMed, CINAHL, and recent guidelines was reviewed. In the absence of evidence, recommendations reflect the expert opinion of the authors. Final consensus was obtained by multiple e-mail exchange and during 3 face-to-face meetings of the gastroenterology committee of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

RESULTS

Endoscopically placed gastrostomy devices are essential in the management of children with feeding and nutritional problems. The article focuses on practical issues such as indications and contraindications.

CONCLUSIONS

The decision to place an endoscopic gastrostomy has to be made by an appropriate multidisciplinary team, which then provides active follow-up and care for the child and the device.

Significant publications for pharmacy nutrition support practice in 2013

PURPOSE

To assist the pharmacy clinician engaged in nutrition support in staying current with the most pertinent literature.

METHODS

Several experienced board-certified clinical pharmacists in nutrition support compiled a list of publications published in 2013 that they considered to be important to their practice. The citation list was compiled into a Web-based survey whereby pharmacist members of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), GI-Liver-Nutrition Practice Research Network of the American College of Clinical Pharmacy, and the Pharmacy and Pharmacology Section of the Society of Critical Care Medicine were asked to rank each article according to level of importance in their practice.

RESULTS

A total of 30 articles were identified by the author group. Thirty-six participants responded to the survey. The top-ranked papers by participants from the Web-based survey were reviewed by the authors. Due to its high level of importance, the parenteral nutrition safety consensus recommendations article, to be published in 2014 by A.S.P.E.N., was also reviewed.

CONCLUSION

It is recommended that the informed pharmacist, who is engaged in nutrition support therapy, be familiar with the majority of these publications.

Early enteral nutrition within 24 hours or between 24 and 72 hours for acute pancreatitis: evidence based on 12 RCTs

Background

Although (EEN) is a relatively safer route by which to feed patients with severe acute pancreatitis (SAP) or predicted SAP (pSAP) compared to total parental nutrition (TPN), the appropriate starting time for EEN administration after admission is still controversial. This study pooled all relevant studies to assess the complications associated with EEN by stratifying relevant RCTs into subgroups according to the starting time (<24 h or between 24 and 72 h after admission).

Material/Methods

Relevant studies were searched for among 5 databases. The association between intervention and complications, including pancreatic infection, mortality, hyperglycemia, organ failure, and catheter-related septic complications, were assessed by using pooled risk ratio (RR) and the corresponding 95% confidential interval (CI).

Results

Twelve RCTs were identified through our literature search. Pooled analysis showed that EEN, but not TPN or delayed enteral nutrition (DEN), is associated with reduced risk of pancreatic infection, mortality, organ failure, hyperglycemia, and catheter-related septic complications. EEN within 24 h of admission presented significantly better outcome in morality than EEN between 24 and 72 h. However, no significant heterogeneity was observed in the risk of pancreatic infection, organ failure, hyperglycemia, and catheter-related septic complications between the 2 subgroups.

Conclusions

If the patients are reasonably expected to have high compliance to EN therapy, it could be considered as early as possible.

A.S.P.E.N. clinical guidelines: support of pediatric patients with intestinal failure at risk of parenteral nutrition-associated liver disease

BACKGROUND

Children with severe intestinal failure and prolonged dependence on parenteral nutrition are susceptible to the development of parenteral nutrition-associated liver disease (PNALD). The purpose of this clinical guideline is to develop recommendations for the care of children with PN-dependent intestinal failure that have the potential to prevent PNALD or improve its treatment.

METHOD

A systematic review of the best available evidence to answer a series of questions regarding clinical management of children with intestinal failure receiving parenteral or enteral nutrition was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group. A consensus process was used to develop the clinical guideline recommendations prior to external and internal review and approval by the American Society for Parenteral and Enteral Nutrition Board of Directors.

QUESTIONS

(1) Is ethanol lock effective in preventing bloodstream infection and catheter removal in children at risk of PNALD? (2) What fat emulsion strategies can be used in pediatric patients with intestinal failure to reduce the risk of or treat PNALD? (3) Can enteral ursodeoxycholic acid improve the treatment of PNALD in pediatric patients with intestinal failure? (4) Are PNALD outcomes improved when patients are managed by a multidisciplinary intestinal rehabilitation team?

A.S.P.E.N. clinical guidelines: parenteral nutrition ordering, order review, compounding, labeling, and dispensing

BACKGROUND

Parenteral nutrition (PN) is a high-alert medication available for patient care within a complex clinical process. Beyond application of best practice recommendations to guide safe use and optimize clinical outcome, several issues are better addressed through evidence-based policies, procedures, and practices. This document provides evidence-based guidance for clinical practices involving PN prescribing, order review, and preparation.

METHOD

A systematic review of the best available evidence was used by an expert work group to answer a series of questions about PN prescribing, order review, compounding, labeling, and dispensing. Concepts from the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) format were applied as appropriate. The specific clinical guideline recommendations were developed using consensus prior to review and approval by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. The following questions were addressed: (1) Does education of prescribers improve PN ordering? (2) What is the maximum safe osmolarity of PN admixtures intended for peripheral vein administration? (3) What are the appropriate calcium intake and calcium-phosphate ratios in PN for optimal neonatal bone mineralization? (4) What are the clinical advantages or disadvantages of commercially available premade ("premixed") multichambered PN formulations compared with traditional/customized PN formulations? (5) What are the clinical (infection, catheter occlusion) advantages or disadvantages of 2-in-1 compared with 3-in-1 PN admixtures? (6) What macronutrient dosing limits are expected to provide for the most stable 3-in-1 admixtures? (7) What are the most appropriate recommendations for optimizing calcium (gluconate) and (Na- or K-) phosphate compatibility in PN admixtures? (8) What micronutrient contamination is present in parenteral stock solutions currently used to compound PN admixtures? (9) Is it safe to use the PN admixture as a vehicle for non-nutrient medication delivery? (10) Should heparin be included in the PN admixture to reduce the risk of central vein thrombosis? (11) What methods of repackaging intravenous fat emulsion (IVFE) into smaller patient-specific volumes are safe? (12) What beyond-use date should be used for (a) IVFE dispensed for separate infusion in the original container and (b) repackaged IVFE?

Going with the flow or swimming against the tide: should children with central venous catheters swim?

Children who require long-term parenteral nutrition (PN) have central venous catheters (CVCs) in place to allow the safe and effective infusion of life-sustaining fluids and nutrition. Many consider recreational swimming to be a common part of childhood, but for some, the risk may outweigh the benefit. Children with CVCs may be at increased risk of exit site, tunnel, and catheter-related bloodstream infections (CRBSIs) if these catheters are immersed in water. The purpose of this review is to evaluate the current literature regarding the risk of infection for patients with CVCs who swim and determine if there is consensus among home PN (HPN) programs on this controversial issue. A total 45 articles were reviewed and 16 pediatric HPN programs were surveyed regarding swimming and CVCs. Due to the limited data available, a firm recommendation cannot be made. Recreational water associated outbreaks are well documented in the general public, as is the presence of human pathogens even in chlorinated swimming pools. As a medical team, practitioners can provide information and education regarding the potential risk, but ultimately the decision lies with the parents. If the parents decide swimming is worth the risk, they are encouraged to use products designed for this use and to change their child's dressing immediately after swimming. Due to our experience with a fatal event immediately after swimming, we continue to strongly discourage patients with CVCs from swimming. Further large and well-designed studies regarding the risk of swimming with a CVC are needed to make a strong, evidence-based recommendation.