Never Too Early: Parenteral Nutrition Administration in Elderly Emergency General Surgery Patients

Objectives: Elderly patients requiring emergency general surgery (EGS) are at high risk for complications due to preexisting malnutrition. Thus, correcting nutritional deficits perioperatively is essential to improve outcomes. However, even in patients unable to tolerate enteral nutrition, initiation of parenteral nutrition (PN) is often delayed due to concerns of associated complications. In this study, we hypothesized that in elderly EGS patients with relative short-term contraindications to enteral nutrition, early administration of PN is as safe as delayed administration. Furthermore, early PN may improve outcomes by enhancing caloric intake and combatting malnutrition in the immediate perioperative period. Design and Setting: A single-institution, retrospective review was performed at a quaternary academic medical center. Participants: Participants consisted of 58 elderly patients >65 years of age admitted to the EGS service who required PN between July 2017 and July 2020. Measurements: Postoperative outcomes of patients started on PN on hospital day 0-3 (early initiation) were compared to patients started on PN on hospital day 4 or later (late initiation). Bivariate analysis was conducted using the Chi-square or Fisher’s exact test for categorical variables and the Wilcoxon-Mann-Whitney test and F-test for continuous variables. Results: Fifty-eight patients met inclusion criteria, with 27 (46.6%) patients receiving early PN and 31 (53.4%) receiving late PN. Both groups shared similar baseline characteristics, including degree of frailty, body mass index, and nutritional status at time of admission. Complications associated with PN administration were negligible, with no instances of central venous catheter insertion-related complications, catheter-associated bloodstream infection, or factors leading to early termination of PN therapy. A significantly higher proportion of patients in the early administration group met 60% of their caloric goal within 72 hours of admission (62.9% versus 19.5%, p=0.0007). Patients receiving late PN demonstrated a significantly higher rate of unplanned admission to the intensive care unit (38.7% versus 14.8%, p=0.04). Moreover, there was a 21.5% reduction in mortality among patients in the early initiation group compared to patients in the late initiation group (33.3% versus 54.8%, p=0.10). Conclusions: Early initiation of PN in hospitalized elderly EGS patients was not associated with increased adverse events compared to patients undergoing delayed PN administration. Furthermore, patients receiving early PN demonstrated a 2.6-fold decrease in the rate of unplanned admission to the intensive care unit and trended toward improved mortality. Based on these results, further prospective studies are warranted to further explore the safety and potential benefits of early PN administration in elderly surgical patients unable to receive enteral nutrition.

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Impact of Propofol Sedation upon Caloric Overfeeding and Protein Inadequacy in Critically Ill Patients Receiving Nutrition Support

Pharmacy ◽

10.3390/pharmacy9030121 ◽

2021 ◽

Vol 9 (3) ◽

pp. 121

Author(s):

Roland N. Dickerson ◽

Christopher T. Buckley

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Enteral Nutrition ◽

Parenteral Nutrition ◽

Critically Ill Patients ◽

Protein Intake ◽

Lipid Emulsion ◽

Caloric Intake ◽

Nutrition Therapy ◽

Nutrition Support

Propofol, a commonly used sedative in the intensive care unit, is formulated in a 10% lipid emulsion that contributes 1.1 kcals per mL. As a result, propofol can significantly contribute to caloric intake and can potentially result in complications of overfeeding for patients who receive concurrent enteral or parenteral nutrition therapy. In order to avoid potential overfeeding, some clinicians have empirically decreased the infusion rate of the nutrition therapy, which also may have detrimental effects since protein intake may be inadequate. The purpose of this review is to examine the current literature regarding these issues and provide some practical suggestions on how to restrict caloric intake to avoid overfeeding and simultaneously enhance protein intake for patients who receive either parenteral or enteral nutrition for those patients receiving concurrent propofol therapy.

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The Benefits of Parenteral Nutrition (PN) Versus Enteral Nutrition (EN) Among Adult Critically Ill Patients: What is the Evidence? A Literature Review

Journal of Intensive Care Medicine ◽

10.1177/0885066619843782 ◽

2019 ◽

Vol 35 (7) ◽

pp. 615-626 ◽

Cited By ~ 2

Author(s):

Angel Joel Cadena ◽

Sara Habib ◽

Fred Rincon ◽

Stephanie Dobak

Keyword(s):

Health Care ◽

Intensive Care Unit ◽

Intensive Care ◽

Enteral Nutrition ◽

Parenteral Nutrition ◽

Clinical Outcomes ◽

Critically Ill ◽

Nutrition Support ◽

Mechanical Ventilation Duration ◽

The Impact

Malnutrition is frequently seen among patients in the intensive care unit. Evidence shows that optimal nutritional support can lead to better clinical outcomes. Recent clinical trials debate over the efficacy of enteral nutrition (EN) over parenteral nutrition (PN). Multiple trials have studied the impact of EN versus PN in terms of health-care cost and clinical outcomes (including functional status, cost, infectious complications, mortality risk, length of hospital and intensive care unit stay, and mechanical ventilation duration). The aim of this review is to address the question: In critically ill adult patients requiring nutrition support, does EN compared to PN favorably impact clinical outcomes and health-care costs?

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Sixty Golden Minutes

Neonatal Network The Journal of Neonatal Nursing ◽

10.1891/0730-0832.31.5.289 ◽

2012 ◽

Vol 31 (5) ◽

pp. 289-294 ◽

Cited By ~ 16

Author(s):

Kimberly Jane Doyle ◽

Wanda T. Bradshaw

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Parenteral Nutrition ◽

Neonatal Intensive Care ◽

Premature Baby ◽

Early Administration ◽

Suspected Sepsis ◽

Golden Hour ◽

The Difference ◽

And Task

The golden hour concept started in the trauma setting but is becoming more familiar in the neonatal intensive care unit (NICU). For a premature baby, the first hour of life can make the difference between a good outcome, a poor outcome, and death. The golden hour is 60 minutes of team-oriented and task-driven protocols. The focus is on resuscitation, thermoregulation, early administration of antibiotics for suspected sepsis, early intravenous parenteral nutrition, hypoglycemia management, and completed admission within one hour of life. To a premature baby, the first 60 minutes of life are golden and can last a lifetime.

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Late initiation of parenteral nutrition reduced length of intensive care unit stay

Annals of Internal Medicine ◽

10.7326/0003-4819-155-10-201111150-02011 ◽

2011 ◽

Vol 155 (10) ◽

pp. JC5 ◽

Cited By ~ 1

Author(s):

Daren K. Heyland

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Parenteral Nutrition ◽

Intensive Care Unit Stay ◽

Late Initiation

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The Significance of Enteral Nutrition in the Intensive Care Unit Patient

Critical Care Nursing Clinics of North America ◽

10.1016/s0899-5885(18)30581-1 ◽

1993 ◽

Vol 5 (1) ◽

pp. 23-29 ◽

Cited By ~ 7

Author(s):

Joyce K. Keithley ◽

Patti Eisenberg

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Enteral Nutrition ◽

Intensive Care Unit Patient

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SARS-CoV-2 Persistent Viral Shedding in the Context of Hydroxychloroquine-Azithromycin Treatment

Viruses ◽

10.3390/v13050890 ◽

2021 ◽

Vol 13 (5) ◽

pp. 890

Author(s):

Michel Drancourt ◽

Sébastien Cortaredona ◽

Cléa Melenotte ◽

Sophie Amrane ◽

Carole Eldin ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Elderly Patients ◽

Rare Event ◽

Viral Shedding ◽

Qrt Pcr ◽

Viral Culture ◽

D Dimer

SARS-CoV-2 nasopharyngeal shedding contributes to the spread of the COVID-19 epidemic. Among 3271 COVID-19 patients treated at the Hospital University Institute Méditerranée Infection, Marseille, France from 3 March to 27 April 2020, tested at least twice by qRT-PCR, the median SARS-CoV-2 nasopharyngeal shedding duration was 6 days (range 2–54 days). Compared with short shedders (qRT-PCR positivity < 10 days), 34 (1.04%) persistent shedders (qRT-PCR positivity ≥ 17 days; mean ± SD: 23.3 ± 3.8 days) were significantly older, with associated comorbidities, exhibiting lymphopenia, eosinopenia, increased D-dimer and increased troponin (p < 0.05), and were hospitalized in intensive care unit in 17.7% vs. 1.1% of cases (p < 0.0001). Viral culture was positive in six persistent shedders after day 10, including in one patient after day 17, and no viral co-pathogen was detected in 33 tested patients. Persistent shedders received azithromycin plus hydroxychloroquine ≥ 3 days in 26/34 (76.5%) patients, a figure significantly lower than in short shedders (86.6%) (p = 0.042). Accordingly, mortality was 14.7% vs. 0.5% (p < 0.0001). Persistent shedding was significantly associated with persistent dyspnea and anosmia/ageusia (p < 0.05). In the context of COVID-19 treatment, including treatment with azithromycin plus hydroxychloroquine, the persistence of SARS-CoV-2 nasopharyngeal shedding was a rare event, most frequently encountered in elderly patients with comorbidities and lacking azithromycin plus hydroxychloroquine treatment.

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Technology to inform delivery of enteral nutrition in the intensive care unit

Journal of Parenteral and Enteral Nutrition ◽

10.1002/jpen.2137 ◽

2021 ◽

Author(s):

Adam M. Deane ◽

Marianne J. Chapman

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Enteral Nutrition

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Postoperative delirium after cardiac surgery of elderly patients as an independent risk factor for prolonged length of stay in intensive care unit and in hospital

Aging Clinical and Experimental Research ◽

10.1007/s40520-021-01842-x ◽

2021 ◽

Author(s):

Andrea Kirfel ◽

Jan Menzenbach ◽

Vera Guttenthaler ◽

Johanna Feggeler ◽

Andreas Mayr ◽

...

Keyword(s):

Intensive Care Unit ◽

Cardiac Surgery ◽

Intensive Care ◽

Length Of Stay ◽

Elderly Patients ◽

Postoperative Delirium ◽

Confusion Assessment Method ◽

Assessment Method ◽

Hospital Length Of Stay ◽

Confusion Assessment

Abstract Background Postoperative delirium (POD) is a relevant and underdiagnosed complication after cardiac surgery that is associated with increased intensive care unit (ICU) and hospital length of stay (LOS). The aim of this subgroup study was to compare the frequency of tested POD versus the coded International Statistical Classification of Diseases and Related Health Problems (ICD) diagnosis of POD and to evaluate the influence of POD on LOS in ICU and hospital. Methods 254 elective cardiac surgery patients (mean age, 70.5 ± 6.4 years) at the University Hospital Bonn between September 2018 and October 2019 were evaluated. The endpoint tested POD was considered positive, if one of the tests Confusion Assessment Method for ICU (CAM-ICU) or Confusion Assessment Method (CAM), 4 'A's Test (4AT) or Delirium Observation Scale (DOS) was positive on one day. Results POD occurred in 127 patients (50.0%). LOS in ICU and hospital were significantly different based on presence (ICU 165.0 ± 362.7 h; Hospital 26.5 ± 26.1 days) or absence (ICU 64.5 ± 79.4 h; Hospital 14.6 ± 6.7 days) of POD (p < 0.001). The multiple linear regression showed POD as an independent predictor for a prolonged LOS in ICU (48%; 95%CI 31–67%) and in hospital (64%; 95%CI 27–110%) (p < 0.001). The frequency of POD in the study participants that was coded with the ICD F05.0 and F05.8 by hospital staff was considerably lower than tests revealed by the study personnel. Conclusion Approximately 50% of elderly patients who underwent cardiac surgery developed POD, which is associated with an increased ICU and hospital LOS. Furthermore, POD is highly underdiagnosed in clinical routine.

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