1
|
Khan A, Laing E, Beaumont A, Wong J, Warrier S, Heriot A. Peripheral parenteral nutrition in surgery - a systematic review and meta-analysis. Clin Nutr ESPEN 2023; 54:337-348. [PMID: 36963880 DOI: 10.1016/j.clnesp.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 01/12/2023] [Accepted: 02/05/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Peripheral parenteral nutrition (PPN) refers to the delivery of artificial nutrition via a peripheral intravenous cannula. As a nutritional intervention it remains under-utilised in peri-operative care. This is despite purported advantages which includes avoiding the risks associated with central venous lines and preventing potential delays to the initiation of nutrition support. This systematic review and meta-analysis will detail the available evidence for PPN use in surgery. METHODS A comprehensive search of the EMBASE and Medline databases was undertaken to identify randomised control trials (RCTs) involving PPN use in surgical patients published until July 30th 2022. Three domains of PPN use were reviewed including: PPN compared to crystalloid intravenous fluids on nutritional and clinical outcomes; PPN compared to Central PN (CPN) on nutritional outcomes and complications; and strategies to prevent thrombophlebitis associated with PPN. RESULTS The meta-analysis included 8 studies which included 698 patients. Use of PPN led to reduced post-operative weight loss (% body weight change) with a mean difference of -1.45% (95% CI -2.9 to -0.01, p = 0.05). There was no statistically significant difference in terms of length of stay, infectious/non-infectious complications, surgical site infections or phlebitis. 42 RCTs were included in the systematic review. 14 RCTs compared PPN to crystalloid infusion. There was significant heterogeneity in the trial populations, interventions and measured outcomes. Most trials found that PPN may improve nitrogen balance and positively impact nutritional markers. Quality of life and post-operative complications were either improved or no difference found in trials assessing these outcomes. Four RCTs showed that PPN is a safe and feasible alternative to CPN. 22 RCTs reported on measures that may impact on thrombophlebitis rates associated with PPN. These included lower osmolality of PPN solution, cyclical PPN delivery, use of a small gauge polyurethane cannula in an upper limb vein, addition of heparin/hydrocortisone to PPN solutions and placement of a GTN patch over infusion sites. CONCLUSION PPN is a safe and effective mode of delivery of peri-operative nutrition. It is a feasible short-term alternative to central-line delivered PN. There are a number of strategies to reduce thrombophlebitis associated with PPN use. Further high-quality RCTs are required to assess the use of PPN in contemporary surgical practice.
Collapse
Affiliation(s)
- Ayman Khan
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia.
| | - Erin Laing
- Nutrition and Speech Pathology Department, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia.
| | - Anna Beaumont
- Nutrition and Speech Pathology Department, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia.
| | - Jean Wong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia.
| | - Satish Warrier
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia.
| | - Alexander Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia.
| |
Collapse
|
2
|
Lappas BM, Patel D, Kumpf V, Adams DW, Seidner DL. Parenteral Nutrition: Indications, Access, and Complications. Gastroenterol Clin North Am 2018; 47:39-59. [PMID: 29413018 DOI: 10.1016/j.gtc.2017.10.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Parenteral nutrition (PN) is a life-sustaining therapy in patients with intestinal failure who are unable to tolerate enteral feedings. Patient selection should be based on a thorough assessment to identify those at high nutrition risk based on both disease severity and nutritional status. This article reviews both the acute and chronic indications for PN as well as special formulation consideration in specific disease states, vascular access, and complications of both short-term and long-term PN.
Collapse
Affiliation(s)
- Brian M Lappas
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dhyanesh Patel
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Vanessa Kumpf
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dawn Wiese Adams
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Douglas L Seidner
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA.
| |
Collapse
|
3
|
Suryadevara S, Celestin J, DeChicco R, Austhof S, Corrigan M, Speerhas R, Steiger E. Type and Prevalence of Adverse Events During the Parenteral Nutrition Cycling Process in Patients Being Prepared for Discharge. Nutr Clin Pract 2012; 27:268-73. [DOI: 10.1177/0884533611434325] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
| | | | | | | | | | - Rex Speerhas
- From the Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ezra Steiger
- From the Cleveland Clinic Foundation, Cleveland, Ohio
| |
Collapse
|
4
|
Catton JA, Davies J, Dobbins BM, Wood JM, McMahon MJ, Burke D. The effect of heparin in peripheral intravenous nutrition via a fine-bore midline: a randomised double-blind controlled trial. Clin Nutr 2005; 25:394-9. [PMID: 16310895 DOI: 10.1016/j.clnu.2005.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2005] [Accepted: 10/03/2005] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS Peripheral intravenous nutrition (PIVN) delivered via a finebore midline offers a viable alternative to central venous feeding. The major complication is the onset of peripheral vein thrombophlebitis (PVT). Feed additives such as heparin and hydrocortisone have been advocated in its prevention. Concern over the safety of heparin has prevented its widespread use; this study examines its true benefit. METHODS A randomised, double-blind trial comparing the addition of either, Heparin 1500 units or hydrocortisone 15 mg or a combination of the two to full intravenous nutrition (IVN) (2500 ml, 13 g of nitrogen, 1190 m0sm/k) was performed. All feeds were delivered via a finebore midline inserted via an antecubital fossa vein. Feeding was terminated in the event of complication or cessation of intended nutritional support. RESULTS One hundred and twenty-three episodes of feeding occurred in 110 patients. The incidence of peripheral vein thrombosis was similar in each group (Heparin 30% (12/41), hydrocortisone 33% (14/42), combination 31% (13/41) chi(2) test P>0.05). There was a significant difference in total catheter survival with the addition of heparin to the feeds, either alone (11 days (SEM 1.79) or in combination with hydrocortisone (11.7 days (SEM 1.39) compared with those receiving only hydrocortisone (6.9 days (SEM 0.73) P=0.002 and 0.030, respectively)). CONCLUSION When intravenous feeds are delivered in to a peripheral vein via a fine-bore midline, the addition of heparin to the feed extends the total period of feeding attainable.
Collapse
Affiliation(s)
- James A Catton
- Academic Unit of Surgery, The General Infirmary at Leeds, Great George Street, Leeds, LS1 3EX, UK
| | | | | | | | | | | |
Collapse
|
5
|
Abstract
BACKGROUND Peripheral parenteral nutrition (PPN) currently accounts for almost 20 per cent of all parenteral nutrition administered in the UK. In the absence of consensus guidelines there is wide variation in practice. Heterogeneity of clinical trials has made direct comparisons difficult and meta-analysis impossible. METHODS Medline, Embase and Cochrane databases were searched for all clinical trials relating to the use of PPN in adults. Relevant papers from the reference lists of these articles and from the authors' personal collections were also reviewed. RESULTS AND CONCLUSIONS Effective PPN is possible in about 50 per cent of inpatients requiring parenteral nutrition. Evidence relating to optimal feed composition, choice of cannula, infusion technique and pharmacological manipulation is discussed, along with practical recommendations for the administration of PPN.
Collapse
Affiliation(s)
- A D G Anderson
- Combined Gastroenterology Department, Scarborough Hospital, Woodlands Drive, Scarborough YO12 6QL, UK
| | | | | |
Collapse
|
6
|
Dobbins BM, Catton JA, Tighe MJ, Miller GV, Martin IG, McMahon MJ. Randomized clinical trials to determine the role of topical glyceryl trinitrate in peripheral intravenous nutrition. Br J Surg 2003; 90:804-10. [PMID: 12854104 DOI: 10.1002/bjs.4205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The contribution of glyceryl trinitrate (GTN) to prevention of peripheral vein thrombophlebitis (PVT) during peripheral intravenous nutrition delivered by fine-bore midline intravenous catheter is unclear. The aim of this study was to establish its role. METHODS Two consecutive randomized clinical trials were conducted. In trial 1 patients were randomized to receive standard peripheral intravenous nutrition containing heparin and hydrocortisone with or without the placement of a topical GTN patch (triple therapy or dual therapy). In trial 2 patients were randomized to receive standard peripheral intravenous nutrition with either dual therapy or topical GTN alone (monotherapy). RESULTS Dual therapy was as effective as triple therapy in preventing PVT (incidence 10 of 37 versus 11 of 39 patients respectively). Dual therapy reduced the incidence and increased the time to onset of PVT compared with monotherapy (14 of 41 versus 22 of 35 patients respectively, P = 0.012; median 17.3 (95 per cent confidence interval (c.i.) 13.4 to 21.1) versus 8.9 (95 per cent c.i. 6.7 to 11.0) days, P = 0.007). CONCLUSION Use of a topical GTN patch confers no benefit when peripheral intravenous nutrition is delivered via a fine-bore midline intravenous catheter.
Collapse
Affiliation(s)
- B M Dobbins
- Academic Unit of Surgery, The General Infirmary at Leeds, Leeds, UK.
| | | | | | | | | | | |
Collapse
|
7
|
Pichard C, Mühlebach S, Maisonneuve N, Sierro C. Prospective survey of parenteral nutrition in Switzerland: a three-year nation-wide survey. Clin Nutr 2001; 20:345-50. [PMID: 11478833 DOI: 10.1054/clnu.2001.0428] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND AIMS The goals of this national survey were to determine the current PN practices and admixture formulations used in Switzerland. METHODS During three years, an annual questionnaire was sent to all heads of Swiss hospital pharmacies. RESULTS 92% of Swiss hospitals with a full-time pharmacist participated. Different PN systems were commonly used for adult patients: 2 commercial formulas in 2 or 3 compartments bags, 2 commercial formulas with/without lipid, 3 formulas compounded by the hospital pharmacy. For hospitalized adults, 83% of PN bags were administered as commercial multicompartment bags. The compounding of individualized PN admixtures takes place primarily in pharmacies of medium to large size hospitals. For pediatric PN, hospital compounding is routine because of individualized PN compositions and absence of commercially available standardized admixtures. Long-term home-PN was mostly delivered by hospital pharmacies (57%) or by private nutrition support home delivery services (37%). Most PN formula compositions complied with European guidelines and represented 2.6+/-2.0% of the hospital drug budget. Multi-disciplinary nutritional support teams were present in 52% of hospitals. CONCLUSION In Switzerland, most PN for hospitalized adults were administered as commercial multi-compartment bags. The compounding of individualized PN admixtures were still important for pediatric patients and long-term home-PN.
Collapse
Affiliation(s)
- C Pichard
- Clinical Nutrition, Geneva University Hospital
| | | | | | | |
Collapse
|
8
|
Arrowsmith H. Case study approach to peripherally inserted central catheters. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 1999; 8:1231-4, 1236-8. [PMID: 10897712 DOI: 10.12968/bjon.1999.8.18.6486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article looks at the referral of a patient (Mr H) for parenteral nutrition and the subsequent insertion of a peripherally inserted central catheter (PICC) by the nutrition nurse (NN). It explores the issues directly related to the PICC insertion including the route of intravenous access, the ability of the NN to insert the PICC, preparation, communication and consent, and prevention of the mechanical and septic complications of insertion. This case study demonstrates a good technical mastery of PICC insertion in relation to the issues raised. Mr H was satisfied with his care, offering positive feedback at follow-up visits to clinic. Critical analysis of the case study also revealed implications for further development of the role of the NN in ordering the check X-ray and the development of evidence-based standards and guidelines related to this procedure.
Collapse
MESH Headings
- Catheterization, Central Venous/adverse effects
- Catheterization, Central Venous/instrumentation
- Catheterization, Central Venous/methods
- Catheterization, Central Venous/nursing
- Catheterization, Central Venous/psychology
- Catheterization, Peripheral/adverse effects
- Catheterization, Peripheral/instrumentation
- Catheterization, Peripheral/methods
- Catheterization, Peripheral/nursing
- Catheterization, Peripheral/psychology
- Humans
- Male
- Parenteral Nutrition, Total/adverse effects
- Parenteral Nutrition, Total/instrumentation
- Parenteral Nutrition, Total/methods
- Parenteral Nutrition, Total/nursing
- Parenteral Nutrition, Total/psychology
- Patient Education as Topic
- Patient Satisfaction
Collapse
|
9
|
Kuwahara T, Asanami S, Kubo S. Experimental infusion phlebitis: tolerance osmolality of peripheral venous endothelial cells. Nutrition 1998; 14:496-501. [PMID: 9646289 DOI: 10.1016/s0899-9007(98)00037-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This study aimed to determine the osmolality that peripheral venous endothelial cells can tolerate and to clarify the relationship between tolerance osmolality and duration of infusion. Nutrient solutions of 539-917 mOsm/kg, prepared to have no acidic effect, were infused into rabbit ear veins, and the veins were examined histopathologically. In each experiment of 8-, 12-, or 24-h infusion, the higher osmolality solutions caused some phlebitic changes, such as loss of venous endothelial cells, inflammatory cell infiltration, and edema; however, the lowest osmolality solution caused few changes. Infusion of 120 mL/kg of 814 mOsm/kg solution caused phlebitis at 5 or 10 mL.kg-1.h-1, however, the same volume of the same solution scarcely caused phlebitis at 15 mL.kg-1.h-1 because of the shortened infusion duration. These results suggest that the tolerance osmolality of peripheral venous endothelial cells with poor blood flow is about 820 mOsm/kg for 8 h, 690 mOsm/kg for 12 h, and 550 mOsm/kg for 24 h, and that the tolerance osmolality falls as the duration of infusion increases. In conclusion, hypertonic solutions should be infused at as high a rate as is clinically acceptable and compatible with nutrient bioavailability because increasing the infusion rate reduces the duration of infusion and phlebitis.
Collapse
Affiliation(s)
- T Kuwahara
- Naruto Research Institute, Otsuka Pharmaceutical Factory, Inc., Tokushima, Japan
| | | | | |
Collapse
|
10
|
|
11
|
Kuwahara T, Asanami S, Tamura T, Kubo S. Dilution is effective in reducing infusion phlebitis in peripheral parenteral nutrition: an experimental study in rabbits. Nutrition 1998; 14:186-90. [PMID: 9530646 DOI: 10.1016/s0899-9007(97)00440-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
To clarify conflicting clinical results that had been reported as to whether dilution is effective or not in reducing infusion phlebitis, this study was undertaken. We undertook two experiments with the different infusion conditions in rabbits to confirm the generality and the reproducibility of the results. To test the effect of dilution, 120 mL/kg of solution A (784 mOsm/kg) was infused into rabbit ear veins at 10 mL.kg-1.h-1 for 12 h, and 144 mL/kg of 1.2-fold-diluted solution A (648 mOsm/kg) was infused at 12 mL.kg-1.h-1 for 12 h. Similarly, 120 mL/kg of solution B (718 mOsm/kg) was infused at 5 mL.kg-1.h-1 for 24 h, and 168 mL/kg of 1.4-fold-diluted solution B (514 mOsm/kg) was infused at 7 mL.kg-1.h-1 for 24 h. The infused veins were sampled 24 h after the end of the infusion and examined histopathologically. After the 12-h infusion, phlebitic changes were observed in six of eight rabbits given solution A but in only one of eight rabbits given diluted solution A, although the same quantities of the same nutrients were infused. Also, after the 24-h infusion, phlebitic changes were observed in six of eight rabbits given solution B but in no animals given diluted solution B. The same result that dilution reduced or eliminated phlebitic changes was confirmed in the different conditions. These results suggest that osmolality of the infusion solution is an important factor in the development of phlebitis regardless of infusion volume or infusion rate and that dilution is effective in reducing the phlebitic potential of infusion solutions.
Collapse
Affiliation(s)
- T Kuwahara
- Naruto Research Institute, Otsuka Pharmaceutical Factory, Inc., Tokushima, Japan
| | | | | | | |
Collapse
|
12
|
|