Early initiation of supplemental parenteral nutrition associated with better outcomes for patients undergoing major abdominal surgery

1. Initiating supplemental parenteral nutrition (PN) at 3 days after major abdominal surgery was associated with fewer nosocomial infections and fewer days on antibiotic therapy, compared to PN initiation at 8 days post-op, for patients at risk of malnutrition and with suboptimal EN intake.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Malnutrition is a common occurrence after major abdominal surgery, affecting an estimated 20-70% of patients. Enteral nutrition (EN) is the recommended form of nutrient provision, since the alternative parenteral nutrition (PN), is associated with higher rates of postoperative infections and mortality. However, EN relies on a functioning gastrointestinal tract for sufficient nutrients to be absorbed. When EN is suboptimal, there are varying recommendations on when to initiate supplemental PN postoperatively. European guidelines recommend starting PN 7 days after surgery when EN provides less than 50% of a patient’s energy requirement, whereas the American guidelines recommend PN within 3-5 days for those at nutritional risk or when EN meets less than 60% of energy requirements. Therefore, this multicentre randomized controlled trial examined infection rates and outcomes for patients at risk of malnutrition, with early PN initiation on post-op day 3 (E-SPN) compared to late PN initiation on post-op day 8 (L-SPN). The results showed that those in the E-SPN group had significantly fewer post-op infections, and fewer days on antibiotic therapy. However, there were no significant differences in adverse events and noninfectious complications.

Click here to read the study in JAMA Surgery

Relevant Reading: Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial

In-Depth [randomized controlled trial]: The study population consisted of 229 patients, 61.1% of whom were male, and with a mean (SD) age of 60.1 (11.2) years: 115 patients were in the E-SPN group and 114 were in the L-SPN group. All patients underwent an elective gastric, colorectal, hepatic, or pancreatic resection, for reasons unrelated to trauma. As well, they had an expected length of stay longer than 7 days, had a score of 3 or higher on the Nutritional Risk Screening 2002 (NRS-2002. Additionally, all patients had EN initiated 24 hours post-op, but had received less than 30% of their energy requirement through EN by day 2 post-op. The results showed that the E-SPN group had fewer rates of nosocomial infections than the L-SPN group, with 8.7% compared to 18.4% (risk difference 9.7%, 95% CI 0.9-18.5%, p = 0.04). Specifically, a significantly fewer major infectious complications were found in the E-SPN group (7.0% vs 15.8%, 95% CI 0.7-17.0%, p = 0.04), whereas no significant difference in minor infectious complications were found (1.7% vs 2.6% in E-SPN and L-SPN respectively, 95% CI -2.9 to 4.7%, p = 0.68). Furthermore, the E-SPN group also had fewer mean (SD) days on therapeutic antibiotics, with 6.0 (0.7) compared to 7.0 (1.1) days (95% CI 0.2-1.9%, p = 0.1). No significant differences were found for noninfectious complications between the E-SPN and L-SPN groups (27.0% vs 33.3% respectively, 95% CI -5.5 to 18.2%, p = 0.32) nor for adverse events (65.2% vs 71.9% respectively, 95% CI -5.3 to 18.7%, p = 0.32). Overall, this study found that initiating supplemental PN at 3 days following major abdominal surgery was associated with fewer infectious complications compared to initiation at 8 days, in patients at risk of malnutrition and with energy requirements not being met by EN solely.

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