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Home All Specialties Gastroenterology

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

byDavy LauandAlex Chan
April 25, 2022
in Gastroenterology, Surgery
Reading Time: 3 mins read
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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.

Image: PD

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