John MacFie

ESPEN Guidelines on Parenteral Nutrition: Pancreas

Assessment of the severity of acute pancreatitis (AP), together with the patients nutritional status is crucial in the decision making process that determines the need for artificial nutrition. Both should be done on admission and at frequent intervals thereafter. The indication for nutritional support in AP is actual or anticipated inadequate oral intake for 5-7 days. This period may be shorter in those with pre-existing malnutrition. Substrate metabolism in severe AP is similar to that in severe sepsis or trauma. Parenteral amino acids, glucose and lipid infusion do not affect pancreatic secretion and function. If lipids are administered, serum triglycerides must be monitored regularly. The use of intravenous lipids as part of parenteral nutrition (PN) is safe and feasible when hypertriglyceridemia is avoided. PN is indicated only in those patients who are unable to tolerate targeted requirements by the enteral route. As rates of EN tolerance increase then volumes of PN should be decreased. When PN is administered, particular attention should be given to avoid overfeeding. When PN is indicated, a parenteral glutamine supplementation should be considered. In chronic pancreatitis PN may, on rare occasions, be indicated in patients with gastric outlet obstruction secondary to duodenal stenosis or those with complex fistulation, and in occasional malnourished patients prior to surgery.

Enhanced recovery after surgery protocols – compliance and variations in practice during routine colorectal surgery

Aimu2002 Although there are numerous studies on the efficacy of enhanced recovery after surgery (ERAS) protocols in reducing length of stay, the long‐term compliance to such protocols in routine clinical practice has not been well documented. The aim of this study was to review the published literature on compliance to ERAS in patients undergoing colorectal surgery in routine clinical practice.

Enhanced recovery programmes and colorectal surgery: does the laparoscope confer additional advantages?

Backgroundu2002 Enhanced recovery after surgery (ERAS) protocols aim to reduce postoperative lengths of stay (LOS). Laparoscopic surgery shares the same objective. Whether or not laparoscopic surgery conveys additional benefits over and above those achievable with ERAS alone is unclear.

Surgical manipulation of the large intestine increases bacterial translocation in patients undergoing elective colorectal surgery

Objectiveu2002 Several animal studies have suggested that surgical manipulation of the intestine alters the barrier function and promotes bacterial translocation (BT). Whether this occurs in humans has never been investigated. The aim of this study was to determine the effect of surgical manipulation of the intestine on the prevalence of BT in patients undergoing elective colorectal surgery.

A single-blinded randomised clinical trial of permissive underfeeding in patients requiring parenteral nutrition

BACKGROUND & AIMSnThe importance of adequate nutritional support is well established, but characterising what adequate nutrition represents remains contentious. In recent years there has been increasing interest in the concept of permissive underfeeding where patients are intentionally prescribed less nutrition than their calculated requirements. The aim of this study was to evaluate the effect of permissive underfeeding on septic and nutrition related morbidity in patients requiring short term parenteral nutrition (PN).nnnMETHODSnThis was a single-blinded randomised clinical trial of 50 consecutive patients requiring parenteral nutritional support. Patients were randomized to receive either normocaloric or hypocaloric feeding (respectively 100% vs. 60% of estimated requirements). The primary end point was septic complications. Secondary end points included the metabolic, physiological and clinical outcomes to the two feeding protocols.nnnRESULTSnPermissive underfeeding was associated with fewer septic complications (3 vs. 12 patients; pxa0=xa00.003), and a lower incidence of the systemic inflammatory response syndrome (9 vs. 16 patients; pxa0=xa00.017). Permissively underfed patients had fewer feed related complications (2 vs. 9 patients; pxa0=xa00.016).nnnCONCLUSIONnPermissive underfeeding in patients requiring short term PN appears to be safe and may results in reduced septic and feed-related complications.nnnTRIAL REGISTRATIONnNCT01154179 TRIAL REGISTRY: http://clinicaltrials.gov/ct2/show/NCT01154179.

Gastric colonization predisposes to septic morbidity in surgical patients: A prospective study

OBJECTIVEnSeveral previous studies have suggested that pathological colonization of the proximal gastrointestinal (GI) tract may be associated with septic morbidity. However, the prevalence of this in surgical patients is unknown and there is little information on factors that might predispose to this phenomenon. The aim of this study was to assess the preoperative variables that are associated with pathological colonization of the proximal GI tract in surgical patients.nnnMETHODSnNasogastric aspirates were obtained from 502 surgical patients to identify abnormal colonization. Several preoperative variables were tested to identify association with pathological colonization of the proximal GI tract. Postoperative septic morbidity was recorded prospectively in all patients.nnnRESULTSnEnterobacteriaceae were identified in 78 of 502 patients (15.5%), 124 of 502 (24.7%) had multiple organisms, and 157 of 502 (31.3%) had Candida in the nasogastric aspirates. Age >70 y and emergency surgery were associated with presence of Enterobacteriaceae. Age >70 y was also associated with the presence of multiple organisms (with or without Enterobacteriaceae). Colonization with Enterobacteriaceae or presence of multiple organisms in the proximal GI tract was associated with postoperative septic morbidity. Preoperative total parenteral nutrition was associated with Candida colonization in the upper GI tract, but not with sepsis.nnnCONCLUSIONnPathological colonization of the proximal GI tract with Enterobacteriaceae or multiple organisms is associated with increased incidence of postoperative sepsis. Age >70 y and emergency surgery were the two preoperative variables associated with pathological colonization in surgical patients. Preoperative total parenteral nutrition is associated with fungal colonization but this is not associated with septic morbidity.

Ethics of Artificial Nutrition

Recent decades have seen dramatic improvements in our ability as a profession to care for patients with critical illness and chronic disease. One consequence of this is that patients now more often survive to a point where nutrition becomes a limiting factor in their care. In addition, we now have the skills and technology to maintain a patients’ nutritional status indefinitely. Taken together, these factors have significantly raised the profession’s awareness of the ethical dilemmas involved in the provision of artificial nutrition. This short article suggests one approach to these vexed questions.