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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.
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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.
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Waitzberg DL, Torrinhas RS, Jacintho TM. New Parenteral Lipid Emulsions for Clinical Use. JPEN J Parenter Enteral Nutr 2017; 30:351-67. [PMID: 16804134 DOI: 10.1177/0148607106030004351] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Routine use of parenteral lipid emulsions (LE) in clinical practice began in 1961, with the development of soybean oil (SO) - based LE. Although clinically safe, experimental reports indicated that SO-based LE could exert a negative influence on immunological functions. Those findings were related to its absolute and relative excess of omega-6 polyunsaturated fatty acids (PUFA) and the low amount of omega-3 PUFA and also to its high PUFA content with an increased peroxidation risk. This motivated the development of new LE basically designed along the reduction of omega-6 PUFA and the omega-3 PUFA addition in order to obtain balanced levels of the omega-6/omega-3 ratio. The new LE for clinical use (available in Europe and South America) are differentiated by their content in polyunsaturated (omega-6 and omega-3), monounsaturated, and saturated fatty acids (FA), as well as FA source of their origin, including soy, coconut, olive, and fish oil. This article presents the new LE nutrition and energy functions but also its biochemical, metabolic, and immunomodulating aspects, according to their FA content. LE at 20% when infused from 1.0 to 2.0 g/kg body weight/day rates, either alone or in association with amino acids and glucose, are safe and well tolerated in routine clinical practice. LE combining SO with medium-chain triglycerides and/or olive oil have less omega-6 PUFA and are better metabolized, with less inflammatory and immunosuppressive effects than in relation to pure SO-based LE. The omega-3 PUFA used alone or as component of a new and complex LE (soy, MCT, olive and fish oil) has demonstrated anti-inflammatory and immunomodulatory effects.
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Affiliation(s)
- Dan L Waitzberg
- Laboratório de Fisiologia e Distúrbios Esfincterianos of University of São Paulo, School of Medicine, Department of Gastroenterology, Surgical Division, São Paulo, Brazil.
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Buys M, Scheepers PA, Levin AI. Lipid emulsion therapy: non-nutritive uses of lipid emulsions in anaesthesia and intensive care. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2015. [DOI: 10.1080/22201181.2015.1095470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Park SH, Kwak SH, Yoo KY, Lee HJ, Yook KB, Kim SJ. Lipid Emulsion in the Successful Resuscitation of Local Anesthetic Toxicity after Ankle Block. Korean J Crit Care Med 2014. [DOI: 10.4266/kjccm.2014.29.3.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Sang-Hee Park
- Department of Anethesiology and Pain Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Sang-Hyun Kwak
- Department of Anethesiology and Pain Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Kyung-Yeon Yoo
- Department of Anethesiology and Pain Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Hyun-Jung Lee
- Department of Anethesiology and Pain Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Keun-Bae Yook
- Department of Anethesiology and Pain Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Seok-Jai Kim
- Department of Anethesiology and Pain Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
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Berrío Valencia MI, Vargas Silva JF. Protocol and importance of using the kit for local anesthetic systemic toxicity. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rcae.2013.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Berrío Valencia MI, Vargas Silva JF. Protocolo y necesidad de kit para toxicidad sistémica por anestésicos locales. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rca.2013.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Protocol and importance of using the kit for local anesthetic systemic toxicity☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1097/01819236-201341040-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Ozcan MS, Weinberg G. Intravenous Lipid Emulsion for the Treatment of Drug Toxicity. J Intensive Care Med 2012; 29:59-70. [DOI: 10.1177/0885066612445978] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intravenous lipid emulsion (ILE) has emerged as a powerful antidote for the treatment of drug toxicity in the past decade. Initial efficacy of ILE was shown in the setting of local anesthetic systemic toxicity (LAST), but recent case reports suggest its consideration in a variety of other drug toxicities. In this review, we will summarize the experimental evidence as well as the clinical experience in using ILE as an antidote. Specifically, we will look at the evidence for using ILE in LAST as well as toxicity due to beta-blockers, calcium-channel blockers, and tricyclic antidepressants. We will also review the current dosing recommendations as well as potential side effects of ILE as an antidote.
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Affiliation(s)
- Mehmet S. Ozcan
- Department of Anesthesiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Guy Weinberg
- Department of Anesthesiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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West PL, Mckeown NJ, Hendrickson RG. Iatrogenic lipid emulsion overdose in a case of amlodipine poisoning. Clin Toxicol (Phila) 2010; 48:393-6. [DOI: 10.3109/15563651003670843] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Mao C, Wan J, Chen H, Xu H, Yang X. The composition of oil phase modulates venous irritation of lipid emulsion-loaded diallyl trisulfide. Drug Dev Ind Pharm 2010; 36:698-704. [PMID: 20050725 DOI: 10.3109/03639040903449746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION In this study, a nanoemulsion system (LE) was investigated for intravenous delivery of diallyl trisulfide (DT), which was a lipophilic and venous irritant drug for systemic therapy of bacterial and fungal infection. METHODS Egg phospholipid was chosen as the only emulsifier, soybean oil, medium chain triglyceride (MCT), and olive oil were used as the oil phases, forming stable DT LEs (o/w) with small particle sizes. The venous irritation of DT LEs was evaluated by in vitro human umbilical cord endothelial cells (HUV-EC CRL 1730) tolerance model with the intracellular ATP and GTP concentrations as the indices. RESULTS The intracellular ATP and GTP reduction changed with the incorporation of a variety of oils, which were strongly related with the free DT concentration of DT LEs. DISCUSSION It was deduced that the free DT concentrations of LEs made of various oils depended on the particle sizes of the DT LEs. In conclusion, the oil phases modulated the free DT concentrations by forming DT LEs with different particle sizes, and optimization of the oil phase was an effective method to alleviate the venous irritation of DT LEs.
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Affiliation(s)
- Chengwen Mao
- College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, PR China
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Mao C, Wan J, Chen H, Xu H, Yang X. Emulsifiers' composition modulates venous irritation of the nanoemulsions as a lipophilic and venous irritant drug delivery system. AAPS PharmSciTech 2009; 10:1058-64. [PMID: 19669895 DOI: 10.1208/s12249-009-9295-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Accepted: 07/27/2009] [Indexed: 11/30/2022] Open
Abstract
In this study, a nanoemulsion (NE) system was investigated for intravenous delivery of lipophilic and venous irritant drugs. NEs were prepared to deliver diallyl trisulfide (DT) for systemic therapy of bacterial and fungal infection, egg phospholipid was chosen as the main emulsifier, and two co-emulsifiers were also incorporated, including Poloxamer 188 (P188) and Solutol HS 15 (S15). Soybean oil was used as the dispersed phases, forming stable DT NEs with small particle sizes. The venous irritation of DT NEs was evaluated by in vitro human umbilical cord endothelial cells (CRL 1730) compatibility model with the intracellular adenosine triphosphate (ATP) and guanosine triphosphate (GTP) concentrations as the indices. The intracellular ATP and GTP reduction changed with the incorporation of a variety of co-emulsifiers, which varied in a free DT concentration-dependent manner. It was deduced that the free DT concentrations of NEs containing co-emulsifiers were determined by the partition coefficient of DT between oil and surfactant buffer solution. In conclusion, NE was an appropriate delivery system for lipophilic and venous irritant drug, and optimization of the composition of emulsifiers was an effective method to alleviate the venous irritation of DT NEs.
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Brull SJ. Lipid Emulsion for the Treatment of Local Anesthetic Toxicity: Patient Safety Implications. Anesth Analg 2008; 106:1337-9. [DOI: 10.1213/01.ane.0b013e31816b9415] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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