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Background: Malnutrition is associated with poor outcomes in surgical patients and corrective enteral feeding may not be possible. This is a particular problem in the acute setting where malnutrition is prevalent. The aim of this systematic review was to evaluate the use of parenteral nutrition (PN) in critically ill surgical patients., Methods: This review was registered with PROSPERO (CRD42017079567). Searches of the CENTRAL, EMBASE, and MEDLINE databases were performed using a predefined strategy. Randomised trials published in English since 1995, reporting a comparison of PN vs any comparator in a critically ill surgical population were included. The primary outcome was mortality. Risk of bias was assessed using the Cochrane risk of bias tool and the Grading of Recommendations Assessment, Development and Evaluation assessment. Meta-analysis was performed using a random effects model to assess variation in mortality and length of stay., Results: Fourteen RCTs were identified; standard PN was compared vs other forms of PN in ten studies, to PN with variable dose amino acids in one, and to enteral nutrition (EN) in three. In trials comparing glutamine-supplemented PN (PN-GLN) to PN, a non-significant reduction in mortality was noted (risk difference - 0.08. 95% CI - 0.17, 0.01, p = 0.08). A trend for a reduction in length of stay was seen in PN-GLN to PN comparator (mean reduction - 2.4, 95% CI - 7.19 to 2.32 days, I 2 = 92%). Impact on other outcome measures varied in direction of effect., Conclusions: PN may offer benefit in critically ill surgical patients. The size and quality of studies lead to uncertainty around the estimates of clinical effect, meaning a robust trial is required.

Background and Aims: Use of extracorporeal membrane oxygenation (ECMO) in children is increasing. Yet, little is known about optimal nutritional practices in these children. We aim to describe the nutritional adequacy, factors associated with enteral nutrition, and the association between nutritional adequacy and mortality in children supported on ECMO., Methods: We conducted a retrospective review of all children (1 month-18 years) requiring ECMO between 2010 and 2016. Data on enteral and parenteral energy and protein intake in the first 7 days of ECMO were collected. Adequacy of nutrition intake was defined as total intake vs. total requirements, expressed as a percentage., Results: 51 patients were included, of which 43 (84.3%) were supported on veno-arterial ECMO. Median ECMO duration was 8.6 days [interquartile range (IQR) 6.1-16.2]. Overall energy and protein adequacy across the first 7 days of ECMO were 48.3% (IQR 28.0-67.4) and 44.8% (IQR 26.9-67.0) respectively. Parenteral nutrition provided majority of calories [median 88.0% (IQR 62.9-100)] and protein [median 91.0% (IQR 62.3-100)] intake. Enteral nutrition (EN) was initiated in 33 (64.7%) patients. Time to EN initiation, vasoactive-inotropic score just before ECMO initiation, veno-arterial ECMO mode and continuous renal replacement therapy in the first week of ECMO were factors associated with EN energy adequacy. Hospital mortality rate was 55% (28/51). Compared to survivors, non-survivors had lower adequacy of EN energy intake [0.5% (IQR 0-4.4) vs. 11.8% (IQR 0-24.5), p = 0.034]. After correcting for ECMO duration, need for continuous renal replacement therapy and number of vasoactive drugs required on ECMO, greater EN energy adequacy remained associated with lower risk of mortality [adjusted odds ratio 0.93 (95% confidence interval: 0.86-0.99), p = 0.048]., Conclusions: Nutritional adequacy, especially that of EN, remains low in children supported on ECMO. EN energy adequacy was found to be associated with lower mortality. Further studies on nutritional adequacy in pediatric ECMO, as well as strategies to optimize EN in these children, are warranted., (Copyright © 2018 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.)

Background: Parenteral nutrition (PN) prescription can be challenging in patients with complex conditions and has potential complications., Objective: To assess PN prescription, monitoring, and PN-related complications in a Canadian acute care setting., Methods: This was a prospective cohort study in which patients receiving PN were assessed by an auditor for nutritional status, PN-related prescription, monitoring, and complications. In addition, length of stay and mortality were recorded., Results: 147 patients (mean ± SD 56.1 ± 16.4 y) with complex diseases (Charlson comorbidity index, median [p25-p75] 2 [1-4]) were enrolled. Before starting PN, 18.6%, 63.9%, and 17.5% of patients were classified as subjective global assessment A, B, and C, respectively. Body mass index remained unchanged during the period on PN. On average, 89% and 73% of patients received <90% of their energy and protein requirements, respectively, but 65% received oral or enteral nutrition at some point during PN. The average daily energy provided by PN increased and stabilized on day 10, reaching 87.2 ± 20.1% of the requirements. Line sepsis (6.8% of patients) and hyperglycemia (6.9%) were the most common complications. The overall mortality was 15.6%. For those alive, length of stay was 30 (range: 4-268) d. PN was discontinued because of transitioning to an oral diet (56.6%), enteral nutrition (17.6%), home PN (14.7%), palliative care (5.1%), death (4.4%), or other (1.5%)., Conclusion: Most patients were malnourished at the start of PN. Energy and protein provided from PN were less than requirements, and the goals were reached with delay. Mortality was high, possibly as a result of complex diseases., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Preoperative nutritional status has an impact on patients' clinical outcome. For pancreatic surgery, however, it is unclear which nutritional assessment scores adequately assess malnutrition associated with postoperative outcome., Methods: Patients scheduled for elective pancreatic surgery at the University of Heidelberg were screened for eligibility. Twelve nutritional assessment scores were calculated before operation, and patients were categorized as either at risk or not at risk for malnutrition by each score. The postoperative course was monitored prospectively by assessors blinded to the nutritional status. The primary endpoint was major complications evaluated for each score in a multivariable analysis corrected for known risk factors in pancreatic surgery., Results: Overall, 279 patients were analysed. A major complication occurred in 61 patients (21·9 per cent). The proportion of malnourished patients differed greatly among the scores, from 1·1 per cent (Nutritional Risk Index) to 79·6 per cent (Nutritional Risk Classification). In the multivariable analysis, only raised amylase level in drainage fluid on postoperative day 1 (odds ratio (OR) 4·91, 95 per cent c.i. 1·10 to 21·84; P = 0·037) and age (OR 1·05, 1·02 to 1·09; P = 0·005) were significantly associated with major complications; none of the scores was associated with, or predicted, postoperative complications., Conclusion: None of the nutritional assessment scores defined malnutrition relevant to complications after pancreatic surgery and these scores may thus be abandoned., (© 2017 BJS Society Ltd Published by John Wiley & Sons Ltd.)

Parenteral nutrition offers the possibility of increasing or ensuring nutrient intake in patients in whom normal food intake is inadequate and enteral nutrition is not feasible, is contraindicated or is not accepted by the patient. These guidelines are intended to provide evidence-based recommendations for the use of parenteral nutrition in cancer patients. They were developed by an interdisciplinary expert group in accordance with accepted standards, are based on the most relevant publications of the last 30 years and share many of the conclusions of the ESPEN guidelines on enteral nutrition in oncology. Under-nutrition and cachexia occur frequently in cancer patients and are indicators of poor prognosis and, per se, responsible for excess morbidity and mortality. Many indications for parenteral nutrition parallel those for enteral nutrition (weight loss or reduction in food intake for more than 7-10 days), but only those who, for whatever reason cannot be fed orally or enterally, are candidates to receive parenteral nutrition. A standard nutritional regimen may be recommended for short-term parenteral nutrition, while in cachectic patients receiving intravenous feeding for several weeks a high fat-to-glucose ratio may be advised because these patients maintain a high capacity to metabolize fats. The limited nutritional response to the parenteral nutrition reflects more the presence of metabolic derangements which are characteristic of the cachexia syndrome (or merely the short duration of the nutritional support) rather than the inadequacy of the nutritional regimen. Perioperative parenteral nutrition is only recommended in malnourished patients if enteral nutrition is not feasible. In non-surgical well-nourished oncologic patients routine parenteral nutrition is not recommended because it has proved to offer no advantage and is associated with increased morbidity. A benefit, however, is reported in patients undergoing hematopoietic stem cell transplantation. Short-term parenteral nutrition is however commonly accepted in patients with acute gastrointestinal complications from chemotherapy and radiotherapy, and long-term (home) parenteral nutrition will sometimes be a life-saving maneuver in patients with sub acute/chronic radiation enteropathy. In incurable cancer patients home parenteral nutrition may be recommended in hypophagic/(sub)obstructed patients (if there is an acceptable performance status) if they are expected to die from starvation/under nutrition prior to tumor spread.