Pretreatment With an Intravenous Lipid Emulsion Increases Plasma Eicosapentanoic Acid and Downregulates Leukotriene B4, Procalcitonin,and Lymphocyte Concentrations After Open Heart Surgery in Infants

Background: The effect of providing a lipid emulsion containing medium‐chain triglyceride (MCT), soybean oil, and fish oil in critically ill infants is not widely studied. This study investigated lipid emulsion effects on plasma phospholipids and immune biomarkers. Materials and Methods: Thirty‐two infants undergoing cardiopulmonary bypass (CPB) and dependent on parenteral nutrition (PN) were randomized to receive either soybean oil (control, n = 16) or a 50:40:10 mixture of MCT, soybean oil, and fish oil (treatment, n = 16). PN was administered for 3 days preoperatively and 10 days postoperatively. Fatty acids, procalcitonin (PCT), leukotriene B₄ (LTB₄), and lymphocytes were quantified at baseline, before surgery, and days 1, 7 and 10 after surgery. Results: PCT was significantly lower in the treatment vs control group 1 day postoperatively (P = .01). The treatment group exhibited a lower ω‐6 to ω‐3 ratio (P = .0001) and a higher ω‐3 concentration at all postoperative study periods (P = .001). Treatment resulted in higher (P < .05) plasma phospholipid eicosapentaenoic acid (EPA) on days 7 and 10, while α‐linolenic acid, arachidonic acid, and docosahexaenoic acid remained constant. An increase in plasma phospholipid EPA concentration was associated with a decrease in plasma phospholipid LTB₄ concentration (P < .05). On postoperative day 10, treatment infants with high Pediatric Risk of Mortality III scores exhibited a 45% lower lymphocyte concentration (P < .05). Conclusion: These findings suggest that treating infants undergoing CPB with a lipid emulsion containing ω‐3 improves fatty acid status and results in a lower inflammatory response after surgery. Overall, this alternative ω‐3–enriched lipid emulsion may benefit clinical outcomes of critically ill infants after cardiac surgery.     

Superiority of a fish oil-enriched emulsion to medium-chain triacylglycerols/long-chain triacylglycerols in gastrointestinal surgery patients: a randomized clinical trial

ObjectiveCompared with soybean oil, a fish oil–enriched emulsion can improve the clinical outcomes of patients requiring parenteral nutrition. However, the superiority of fish oil emulsion to medium-chain triacylglycerols/long-chain triacylglycerols for short-term administration has seldom been discussed.MethodsSixty-four adult patients with gastrointestinal diseases were randomly assigned to receive isocaloric and isonitrogenous total parenteral nutrition with an ω-3 fatty acid–enriched emulsion (Lipoplus; study group, n = 32) or medium-chain triacylglycerols/long-chain triacylglycerols (Lipofundin; control group, n = 32) for 5 d after surgery. Safety and efficacy parameters were assessed on postoperative days 1, 3, and 6.ResultsClinical outcomes including infectious complications and systemic inflammatory response syndrome were comparable between the two groups. Total bilirubin decreased over time in the study group versus an increase in the control group (P = 0.017). Activated partial thromboplastin time in the study group was prolonged significantly compared with the control group from days 1 to 3 (P = 0.002), although the prolongation stopped at the study termination. There were no differences in changes of C-reactive protein, interleukin (IL)-1, IL-8, IL-10, vascular endothelial growth factor (VEGF), and the distribution of the T-cell subpopulation between the two groups. However, fish oil consumption led to an increase in leukotriene B5/ leukotriene B4 and significant decreases in IL-6, tumor necrosis factor-α, and nuclear factor-κB. Furthermore, the overall changes in tumor necrosis factor-α and nuclear factor-κB were positively associated (R² = 0.295, P < 0.001).ConclusionsGastrointestinal surgery patients benefited from a fish oil–enriched emulsion rather than medium-chain triacylglycerols/long-chain triacylglycerols in the amelioration of liver function and immune status. The positive association of tumor necrosis factor-α and nuclear factor-κB might be involved in the potential anti-inflammation mechanism of fish oil.     

Effect of Parenteral Fish Oil Lipid Emulsion in Parenteral Nutrition Supplementation Combined With Enteral Nutrition Support in Patients Undergoing Pancreaticoduodenectomy

Background: The effect of parenteral fish oil lipid emulsion in parenteral nutrition (PN) supplementation combined with enteral nutrition (EN) support on pancreaticoduodenectomy (PD) was investigated with a randomized controlled clinical trial at the Affiliated Drum Tower Hospital. Materials and Methods: Seventy‐six patients who underwent PD in the Department of Hepatobiliary Surgery were randomly divided into 2 groups: the polyunsaturated fatty acid (PUFA) group (n = 38) and control group (n = 38). Patients in the PUFA group received parenteral fish oil lipid emulsion supplementation combined with early EN support for 5 days after PD. Venous blood samples were obtained for assay on the day before surgery and on day 6 after surgery. Results: Compared with the results of the control group, a significant difference was seen in the extent of the decrease in total protein and prealbumin in the PUFA group (P < .05). Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) were significantly decreased on day 6 in the PUFA group (P < .01), and a significant difference was seen in the extent of decrease in ALT, AST, and LDH in the PUFA group (P < .05). The ratio of infectious complications in the PUFA group was significantly decreased, as well as the postoperative hospital stay (P < .05), and there was no hospital mortality in this study. Conclusion: Parenteral fish oil lipid emulsion in PN supplementation combined with EN support can greatly improve the nutrition state and liver function of patients, decrease the incidence of infectious morbidities, and shorten the postoperative hospital stay.     

Dietary Fish Oil Aggravates Paracetamol‐Induced Liver Injury in Mice

Background: Paracetamol (APAP) hepatotoxicity remains the leading cause of drug‐induced liver failure. Fish oil, which contains ω‐3 fatty acids, has demonstrated therapeutic efficacy in several models of liver disease. Evidence for its use in APAP intoxication, however, is conflicting. The effects of fish oil supplementation on APAP‐induced liver failure were investigated. Methods: Ten C57BL6/J mice were fed a diet based on menhaden fish oil (MEN) or soybean oil (SOY) for 3 weeks followed by APAP intoxication. In a second experiment, the prefeeding period was reduced to 5 days. In a third experiment, 10 mice received the study diets for 3 weeks, after which they received chronic, low‐dose APAP administration for another 4 weeks. Finally, 10 mice received oral parenteral nutrition supplemented with either intravenous (IV) soybean‐based or fish oil–based lipid emulsion for 19 days, followed by APAP intoxication. Results: The extent of hepatocellular necrosis (3.8 ± 0.2 vs 2.8 ± 0.2; P = .021) and serum alanine aminotransferase values (2807 ± 785 vs 554 ± 141 IU/L; P = .048) were significantly elevated in mice fed a MEN diet compared with SOY‐diet fed controls. Long‐term, low‐dose APAP administration did not lead to liver injury irrespective of study diet. Pretreatment with soybean‐ or fish oil–based IV lipid emulsions followed by APAP intoxication demonstrated no significant differences in hepatic injury between groups. Conclusion: Within therapeutic ranges, APAP is harmless to the liver irrespective of dietary fat composition. IV use of fish oil did not increase APAP‐induced hepatotoxicity, but animals fed a fish oil–based diet were more susceptible, rather than resistant, to APAP‐induced hepatotoxicity.     

A New Intravenous Fat Emulsion Containing Soybean Oil,Medium‐Chain Triglycerides,Olive Oil,and Fish Oil

Background: SMOFlipid 20% is an intravenous lipid emulsion (ILE) containing soybean oil, medium‐chain triglycerides, olive oil, and fish oil developed to provide energy, essential fatty acids (FAs), and long‐chain ω‐3 FAs as a mixed emulsion containing α‐tocopherol. The aim was to assess the efficacy and safety of this new ILE in pediatric patients receiving home parenteral nutrition (HPN) compared with soybean oil emulsion (SOE). Methods: This single‐center, randomized, double‐blind study included 28 children on HPN allocated to receive either SMOFlipid 20% (n = 15) or a standard SOE (Intralipid 20%, n = 13). ILE was administered 4 to 5 times per week (goal dose, 2.0 g/kg/d) within a parenteral nutrition regimen. Assessments, including safety and efficacy parameters, were performed on day 0 and after the last study infusion (day 29). Lipid peroxidation was determined by measurement of thiobarbituric acid reactive substances (TBARS). Results: There were no significant differences in laboratory safety parameters, including liver enzymes, between the groups on day 29. The mean ± standard deviation changes in the total bilirubin concentration between the initial and final values (day 29 to day 0) were significantly different between groups: SMOFlipid group ?1.5 ± 2.4 µmol/L vs SOE group 2.3 ± 3.5 µmol/L, P < .01; 95% confidence interval [CI], ?6.2 to ?1.4). In plasma and red blood cell (RBC) phospholipids, the ω‐3 FAs C20:5ω‐3 (eicosapentaenoic acid) and + C22:6ω‐3 (docosahexaenoic acid) increased significantly in the SMOFlipid group on day 29. The ω‐3:ω‐6 FA ratio was significantly elevated with SMOFlipid 20% compared with SOE group (plasma, day 29: 0.15 ± 0.06 vs 0.07 ± 0.02, P < .01, 95% CI, 0.04–0.11; and RBC, day 29: 0.23 ± 0.07 vs 0.14 ± 0.04, P < .01, 95% CI, 0.04–0.13). Plasma α‐tocopherol concentration increased significantly more with SMOFlipid 20% (15.7 ± 15.9 vs 5.4 ± 15.2 µmol/L, P < .05; 95% CI, ?2.1 to 22.6). The low‐density lipoprotein–TBARS concentrations were not significantly different between both groups, indicating that lipid peroxidation did not differ between groups. Conclusions: SMOFlipid 20%, which contains 15% fish oil, was safe and well tolerated, decreased plasma bilirubin, and increased ω‐3 FA and α‐tocopherol status without changing lipid peroxidation.     

Effects of the ω‐6:ω‐3 Fatty Acid Ratio of Fat Emulsions on the Fatty Acid Composition in Cell Membranes and the Anti‐Inflammatory Action

Background: This study investigated the effects of parenterally administered fish oil (FO) on the fatty acid composition in rats to determine the optimal ω‐6:ω‐3 polyunsaturated fatty acid (PUFA) ratio of fat emulsions to achieve an anti‐inflammatory effect. Methods: Male Sprague‐Dawley rats were infused a parenteral nutrition (PN) solution containing fat emulsions with different ω‐6:ω‐3 PUFA ratios. The fatty acid content of phospholipids in the membranes of splenocytes was analyzed by gas chromatography (experiment 1). In addition, the amounts of leukotriene (LT) B₄ and LTB₅ released from peritoneal polymorphonuclear leukocytes (PMNs) were measured by high‐performance liquid chromatography (experiment 2). Results: In experiment 1, after infusion of the fat emulsion containing FO, the ω‐3 PUFA content in cell membranes rose to 70% of the peak value on day 1 and nearly reached a plateau on day 3. The highest ratio of eicosapentaenoic acid (EPA) to arachidonic acid (AA) was achieved by administrating a PN solution with the smallest ω‐6:ω‐3 PUFA ratio. In experiment 2, a larger amount of LTB₅ was released from Ca‐ionophore‐stimulated PMNs taken from rats given a larger quantity of FO. The ratio of LTB₅:LTB₄ released from PMNs correlated positively with the EPA:AA ratio in the membranous phospholipid and in serum. Conclusions: The ω‐3 PUFAs were readily incorporated into the cell membrane within 3 days of infusion with the fat emulsion. The EPA:AA ratio in membranous phospholipid in PMNs was positively correlated with the LTB₅:LTB₄ production ratio and was a good indicator of anti‐inflammatory effects.     

Supplemental Parenteral Vitamin E Into Conventional Soybean Lipid Emulsion Does Not Prevent Parenteral Nutrition–Associated Liver Disease in Full‐Term Neonatal Piglets

Background: Parenteral nutrition–associated liver disease (PNALD) continues to cause morbidity and mortality for neonates with intestinal failure. Lipid peroxidation is one potential etiological factor. This study was designed to test if supplementing vitamin E into conventional soy‐based lipid would reduce the risk of PNALD. Methods: Sixteen piglets, aged 2–5 days and weighing 1.8–2.5 kg, were randomized to parenteral nutrition (PN) with soy lipid (SO, n = 8) or the same lipid plus α‐tocopherol, the most bioactive form of vitamin E (SO+E, n = 8). After 17 days, bile flow, liver chemistry, gene expression associated with bile acid metabolism, and bile acid composition were assessed. C‐reactive protein (CRP) and oxidative stress markers, including plasma 8‐isoprostane, were measured. All results were compared with a sow‐reared control group (CON). Results: Comparing PN‐treated groups, SO vs SO+E mean bile flow (5.91 vs 5.54 µL/g liver; P = .83), serum bile acid concentration (39.2 vs 26.6 µmol/L; P = .12), and total bilirubin (35.2 vs 26.9 µmol/L; P = .56) were not different. Gene expression related to bile acid metabolism and bile composition was not different between PN groups. There was no difference in CRP (41.8 vs 36.8 µg/mL; P = .22) or in plasma 8‐isoprostane (27.9 vs 26.1 pg/mL; P = .77). Conclusions: In term neonatal piglets, supplemental vitamin E did not prevent cholestasis. Additional vitamin E was not associated with reduced inflammation or oxidative stress. The benefit of supplementing vitamin E into conventional lipid, vs adding fish oil, to prevent early onset of PNALD requires further clarification.     

The Impact of Glutamine Dipeptide–Supplemented Parenteral Nutrition on Outcomes of Surgical Patients

Objective: To evaluate the impact of glutamine dipeptide–supplemented parenteral nutrition (GLN‐PN) on clinical outcomes in surgical patients. Methods: MEDLINE, EMBASE, Web of Science, and the Cochrane Controlled Clinical Trials Register were searched to retrieve the eligible studies. The studies were included if they were randomized controlled trials that evaluated the effect of GLN‐PN and standard PN on clinical outcomes of surgical patients. Clinical outcomes of interest were postoperative morbidity of infectious complication, mortality, length of hospital stay, and cost. Statistical analysis was conducted by RevMan 4.2 software from the Cochrane Collaboration. Results: Fourteen randomized controlled trials (RCTs) (N = 587) were included in this meta‐analysis. The results showed that glutamine dipeptide significantly reduced the length of hospital stay by around 4 days in the form of alanyl‐glutamine (weighted mean difference [WMD] = ?3.84; 95% confidence interval [CI] ?5.40, ?2.28; z = 4.82; P < .001) and about 5 days in the form of glycyl‐glutamine (WMD = ?5.40; 95% CI ?8.46, ?2.33; z = 3.45; P < .001). The overall effect indicated a significant decrease in the infectious complication rates of surgical patients receiving GLN‐PN (risk ratio = 0.69; 95% CI 0.50, 0.95; z = 2.26; P = .02). Conclusion: GLN‐PN was beneficial to postoperative patients by shortening the length of hospital stay and reducing the morbidity of postoperative infectious complications.     

Parenteral ω‐3 Fatty Acid Lipid Emulsions for Children With Intestinal Failure and Other Conditions

Background: There is growing interest in the use of ω‐3 fatty acid (n‐3FA) lipid emulsions to prevent complications associated with parenteral nutrition. The authors systematically reviewed the evidence on the benefits and safety of n‐3FA compared with standard lipid emulsions in children with intestinal disease, critical illness, trauma, or postoperative complications. Materials and Methods: The authors searched 4 bibliographic databases from their inception to March 2011, conference proceedings, trial registries, and reference lists. Two reviewers independently selected studies, assessed methodological quality, and rated the strength of the evidence. One reviewer extracted and a second reviewer verified data. The authors summarized findings qualitatively and conducted meta‐analysis when appropriate. Results: Five randomized controlled trials with unclear risk of bias and 3 high‐quality prospective cohort studies were included. The studies examined premature, low birth weight infants (n = 6) and children with heart disease (n = 1) or intestinal failure (n = 1). The strength of evidence was consistently low or very low across all lipid emulsion comparisons and outcomes. In young children, n‐3FA emulsions resulted in improvement in some biochemical outcomes of intestinal failure–associated liver disease but no difference in mortality. Few studies examined patient‐important outcomes, such as length of hospital and intensive care stay; need for transplantation, growth, and cognitive development; or the long‐term effects and potential harms associated with these therapies. Conclusions: Currently, there is a lack of sufficient high‐quality data to support the use of parenteral n‐3FA lipid emulsions in children. Future trials examining long‐term clinical outcomes and harms are needed.     

A Meta‐Analysis of Probiotic and Synbiotic Use in Elective Surgery

Background: Perioperative nutrition modulation of gut microbiota is increasingly used as a strategy for reducing the infective complications of elective surgery. This meta‐analysis assessed the effect of probiotic and synbiotic preparations on the incidence of postoperative sepsis. Methods: Randomized controlled trials that compared preoperative dosing of probiotics and synbiotics in patients undergoing elective general surgical procedures were included. The primary outcome measure was the postoperative sepsis rate. Pooled outcome measures were determined using random effects models. Results: Thirteen randomized controlled trials totaling 962 patients were included in this analysis (304 received synbiotics and 182 received probiotics). The incidence of postoperative sepsis was reduced in the probiotic group vs the control (pooled odds ratio [OR] = 0.42; 95% confidence interval [CI], 0.23–0.75; P = .003) and in the synbiotic group vs the control (pooled OR = 0.25; 95% CI, 0.1–0.6; P = .002). However, subgroup analysis failed to identify a significant reduction in the incidence of pneumonia, urinary tract infections, or wound infections in the postoperative phase for either treatment group. Synbiotics reduced the length of postoperative antibiotic use (weighted mean differences = ?1.71; 95% CI, ?3.2 to ?0.21; P = .03). Conclusion: Probiotic and synbiotic nutrition strategies reduce the incidence of postoperative sepsis in the elective general surgery setting. These effects appear more pronounced with the use of synbiotics. High‐powered, mechanistic studies are now required for the optimization of pro‐ and prebiotic regimens to further improve their efficacy.     

Platelet Arachidonic Acid Deficiency May Contribute to Abnormal Platelet Function During Parenteral Fish Oil Monotherapy in a Piglet Model

Background: Fish oil monotherapy has been an advance for treating intestinal failure–associated liver disease (IFALD). However, such patients are at risk of bleeding complications from liver disease and because fish oil can inhibit thrombosis. We have previously reported abnormal platelet function in neonatal piglets given fish oil monotherapy during parenteral nutrition (PN). The purpose of this study was to determine if abnormal fatty acid composition of the platelets could explain the prior observed antiplatelet effect. Methods: Neonatal piglets were assigned to 2 treatments: PN with fish oil monotherapy (FO; n = 4) or PN with soy oil (SO; n = 5). On day 14, plasma was collected and platelets isolated by centrifuging. The fatty acid content in plasma and platelet plug were measured using gas liquid chromatography and compared with controls (CON; n = 5). Results: The arachidonic acid (AA) content in the FO group was on average half that of the SO group, in both the platelets (FO, 3.5% vs SO, 7.6%; P = .021; CON, 4.5%–11%) and the plasma (FO, 3.8% vs SO, 9.2%; P = .002; CON, 6.1%–9.5%). No bleeding complications were observed for any piglets during PN treatment. Conclusions: Using platelet mapping, we have previously shown that neonatal piglets given fish oil monotherapy have abnormal platelet function in the AA pathway. This report demonstrates that such an abnormality can be explained by platelet AA deficiency. Platelet mapping and platelet fatty acid analysis should be undertaken in human infants treated with fish oil monotherapy during PN.     

Immunonutrition Is Associated With a Decreased Incidence of Graft‐Versus‐Host Disease in Bone Marrow Transplant Recipients: A Meta‐Analysis

Introduction: Graft‐versus‐host disease (GVHD) is a serious complication of bone marrow transplantation (BMT), requiring higher doses of glucocorticoids or immunosuppressive therapies and further straining transplant recipients. Immunonutrition, such as vitamins and amino acid supplements, increase immunity and decrease inflammation and oxidative stress. This meta‐analysis examines the impact of immunonutrition on the incidence of GVHD and postoperative infections among BMT recipients. Methods: A comprehensive literature search for all published randomized controlled trials was conducted with PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966–2016). Keywords in the search included variations of terms related to immunonutrition, such as “vitamin,” “glutamine,” and “transplant.” Outcomes included incidence of GVHD and infection. Results: Ten randomized controlled trials involving 681 BMT recipients were analyzed: 332 receiving immunonutrition and 349 receiving standard nutrition. Immunonutrition is correlated with a decreased incidence of GVHD by 19% (relative risk [RR] = 0.810, 95% CI: 0.695–0.945, P = .007). There was no significant difference in the incidence of infections with immunonutrition (RR = 1.016, 95% CI: 0.819–1.261, P = .885). Subgroup analysis of glutamine compared with N‐acetylcysteine, selenium, and eicosapentaenoic acid showed no significant difference in the incidence of GVHD or infections (RR = 0.913, 95% CI: 0.732–1.139, P = .419; RR = 0.951, 95% CI: 0.732–1.235; P = .708, respectively). Conclusion: The use of immunonutrition is associated with a reduced risk of GVHD in BMT recipients, potentially as a result of improved immune support and free radical scavenging. Providing immunonutrient supplements is a valuable adjunct in the routine care of BMT recipients, helping to alleviate a common and deadly complication.     

Parenteral Fish Oil Lipid Emulsions in the Critically Ill

Introduction: ω‐3 Polyunsaturated fatty acids contained in fish oils (FO) possess major anti‐inflammatory, antioxidant, and immunologic properties that could be beneficial during critical illness. We hypothesized that parenteral FO‐containing emulsions may improve clinical outcomes in the critically ill. Methods: We searched computerized databases from 1980–2012. We included randomized controlled trials (RCTs) conducted in critically ill adult patients that evaluated FO‐containing emulsions, either in the context of parenteral nutrition (PN) or enteral nutrition (EN). Results: A total of 6 RCTs (n = 390 patients) were included; the mean methodological score of all trials was 10 (range, 6–13). When the results of these studies were aggregated, FO‐containing emulsions were associated with a trend toward a reduction in mortality (risk ratio [RR], 0.71; 95% confidence interval [CI], 0.49–1.04; P = .08; heterogeneity I² = 0%) and a reduction in the duration of mechanical ventilation (weighted mean difference in days [WMD], ?1.41; 95% CI, ?3.43 to 0.61; P = .17). However, this strategy had no effect on infections (RR, 0.76; 95% CI, 0.42–1.36; P = .35) and intensive care unit length of stay (WMD, ?0.46; 95% CI, ?4.87 to 3.95; P = .84, heterogeneity I² = 75%). Conclusion: FO‐containing lipid emulsions may be able to decrease mortality and ventilation days in the critically ill. However, because of the paucity of clinical data, there is inadequate evidence to recommend the routine use of parenteral FO. Large, rigorously designed RCTs are required to elucidate the efficacy of parenteral FO in the critically ill.     

Impact of Providing a Combination Lipid Emulsion Compared With a Standard Soybean Oil Lipid Emulsion in Children Receiving Parenteral Nutrition

Background: Soybean oil lipid emulsion may compromise immune function and promote hepatic damage due to its composition of long‐chain fatty acids, phytosterols, high proportion of ω‐6 fatty acids, and low α‐tocopherol levels. Combination lipid emulsions have been developed using medium‐chain triglyceride oil, fish oil, and/or olive oil, which provide adequate essential fatty acids, a smaller concentration of ω‐6 fatty acids, and lower levels of phytosterols. The purpose of this systematic review is to determine if combination lipid emulsions have a more favorable impact on bilirubin levels, triglyceride levels, and incidence of infection compared with soybean oil lipid emulsions in children receiving parenteral nutrition. Methods: This study comprises a systematic review of published studies. Data were sufficient and homogeneous to conduct a meta‐analysis for total bilirubin and infection. Results: Nine studies met the inclusion criteria. Meta‐analysis showed that combination lipid emulsion decreased total bilirubin by a mean difference of 2.09 mg/dL (95% confidence interval, –4.42 to 0.24) compared with soybean oil lipid emulsion, although the result was not statistically significant (P = .08). Meta‐analysis revealed no statistically significant difference in incidence of infection between the combination lipid emulsion and the soybean oil lipid emulsion groups (P = .846). None of the 4 studies that included triglyceride as an outcome detected a significant difference in triglyceride levels between the combination lipid emulsion and soybean oil lipid emulsion groups. Conclusion: There is inadequate evidence that combination lipid emulsions offer any benefit regarding bilirubin levels, triglyceride levels, or incidence of infection compared with soybean oil lipid emulsions.     

Effects on Varying Intravenous Lipid Emulsions on the Small Bowel Epithelium in a Mouse Model of Parenteral Nutrition

Background: Injectable fat emulsions (FEs) are a clinically dependable source of essential fatty acids (FA). ω‐6 FA is associated with an inflammatory response. Medium‐chain triglycerides (MCT, ω‐3 FA), fish oil, and olive oil are reported to decrease the inflammatory response. However, the effect of these lipids on the gastrointestinal tract has not been well studied. To address this, we used a mouse model of parenteral nutrition (PN) and hypothesized that a decrease in intestinal inflammation would be seen when either fish oil and MCT or olive oil were added. Methods: Three FEs were studied in adult C57BL/6 mice via intravenous cannulation: standard soybean‐based FE (SBFE), 80% olive oil ‐supplemented FE (OOFE), or a combination of a soybean oil, MCT, olive oil, and fish oil emulsion (SMOF). PN was given for 7 days, small bowel mucosa‐derived cytokines, animal survival rate, epithelial cell (EC) proliferation and apoptosis rates, intestinal barrier function and mucosal FA composition were analyzed. Results: Compared to the SBFE and SMOF groups, the best survival, highest EC proliferation and lowest EC apoptosis rates were observed in the OOFE group; and associated with the lowest levels of tumor necrosis factor‐α, interleukin‐6, and interleukin‐1β expression. Jejunal FA content showed higher levels of eicosapentaenoic and docosapentaenoic acid in the SMOF group and the highest arachidonic acid in the OOFE group. Conclusion: The study showed that PN containing OOFE had beneficial effects to small bowel health and animal survival. Further investigation may help to enhance bowel integrity in patients restricted to PN.     

Characterization of Fatty Acid Profiles in Infants With Intestinal Failure–Associated Liver Disease

Background

The purpose of this study was to characterize fatty acid profiles (FAPs) in parenteral nutrition (PN)‐dependent infants with intestinal failure–associated liver disease (IFALD) receiving soybean oil–based lipid emulsion (SO) doses of ～3 and ～1 g/kg/d.

Methods

Prospectively collected data were retrospectively reviewed. Serum FAPs of patients <1 year old who experienced development of IFALD while receiving standard PN with SO were examined before transitioning to a fish oil–based lipid emulsion for IFALD treatment. Time on SO, dose, gestational age, and weight‐ and length‐for‐age z scores were also reviewed.

Results

Among the 49 patients analyzed, there were no differences in demographics or anthropometrics between patients who received standard SO (SO‐S) (n = 14, range of dosage 2.06–3.31 g/kg/d) and reduced SO (SO‐R) (n = 35, range of dosage 0.90–1.34 g/kg/d). Patients received SO for a median of 53 days (interquartile range 39, 73) before FAP measurement. Patients who received SO‐R had significantly higher Mead acid and lower α‐linolenic, eicosapentaenoic, linoleic, stearic, total ω‐3, and total ω‐6 fatty acid levels than patients who received SO‐S (P < .01). Triene:tetraene ratios were higher in patients who received SO‐R (P = .0009), and no patients experienced biochemical essential fatty acid deficiency (EFAD).

Conclusion

PN‐dependent infants with IFALD receiving SO‐R have different FAPs than patients receiving SO‐S. No patients in either group had biochemical EFAD.     

Effects of a Carbohydrate‐, Glutamine‐, and Antioxidant‐Enriched Oral Nutrition Supplement on Major Surgery‐Induced Insulin Resistance: A Randomized Pilot Study

Background: Insulin resistance after surgery hampers recovery. Oxidative stress is shown to be involved in the occurrence of postoperative insulin resistance. Preoperative carbohydrate‐rich oral nutrition supplements reduce but do not prevent insulin resistance. The aim of the present study was to investigate the effect of a carbohydrate‐, glutamine‐, and antioxidant‐enriched preoperative oral nutrition supplement on postoperative insulin resistance. Methods: A double‐blind randomized controlled pilot study in 18 patients with rectal cancer, who received either the supplement (S) or the placebo (P) 15, 11, and 4 hours preoperatively, was conducted. Insulin sensitivity was studied prior to surgery and on the first postoperative day using a hyperinsulinemic euglycemic 2‐step clamp. Results: Hepatic insulin sensitivity (insulin‐mediated suppression of glucose production) decreased significantly after surgery in both groups, with no differences between the groups. Peripheral insulin sensitivity (glucose rate of disappearance, Rd) was significantly decreased after surgery in both groups (S: 37.2 [19.1–50.9] vs 20.6 [13.9–27.9]; P: 23.8 [15.7–35.5] vs 15.3 [12.6–19.1] µmol/kg·min) but less pronounced in the supplemented group (P = .04). The percentage decrease in glucose Rd did not differ between the groups. Adipose tissue insulin sensitivity (insulin‐mediated suppression of plasma free fatty acids) decreased to the same extent after surgery in both groups. Conclusion: Rectal cancer surgery induced profound insulin resistance, affecting glucose and fatty acid metabolism. The preoperative nutrition supplement somewhat attenuated but did not prevent postoperative peripheral insulin resistance.     

Effect of Timing of Pharmaconutrition (Immunonutrition) Administration on Outcomes of Elective Surgery for Gastrointestinal Malignancies

Background: Pharmaconutrition has previously been reported in elective surgery to reduce postoperative infective complications and duration of hospital length of stay. Objective: To update previously published meta‐analyses and elucidate potential benefits of providing arginine‐dominant pharmaconutrition in surgical patients specifically with regard to the timing of administration of pharmaconutrition. Design: Randomized controlled trials comparing the use of pharmaconutrition with standard nutrition in elective adult surgical patients between 1980 and 2011 were identified. The meta‐analysis was prepared in accordance with Preferred Reporting of Systematic Reviews and Meta‐Analyses (PRISMA) recommendations. Results: Twenty studies yielding 21 sets of data met inclusion criteria. A total of 2005 patients were represented (pharmaconutrition, n = 1010; control, n = 995), in whom pharmaconutrition was provided preoperatively (k = 5), perioperatively (k = 2), or postoperatively (k = 14). No differences were seen in postoperative mortality with the provision of pharmaconutrition irrespective of timing of administration. Statistically significant reductions in infectious complications and length of stay were found with perioperative and postoperative administration. Perioperative administration was also associated with a statistically significant reduction in anastomotic dehiscence, whereas a reduction in noninfective complications was demonstrated with postoperative administration. Preoperative pharmaconutrition demonstrated no notable advantage over standard nutrition provision in any of the clinical outcomes assessed. Conclusions: This meta‐analysis highlights the importance of timing as a clinical consideration in the provision of pharmaconutrition in elective gastrointestinal surgical patients and identifies areas where further research is required.     

Menhaden oil administration to dogs treated with radiation for nasal tumors demonstrates lower levels of tissue eicosanoids

Docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) or menhaden oil may reduce inflammatory eicosanoids (prostaglandin E₂, thromboxane B₂, leukotriene B₄, and 11-dehydro thromboxane B₂), matrix metalloproteinases (MMPs), and blood lactate in dogs with nasal carcinomas receiving radiation therapy. We hypothesized that menhaden oil would reduce inflammation from radiation damage and lower blood lactate levels in dogs with nasal carcinoma. In a randomized, double-blind, placebo-controlled clinical study, 12 dogs with malignant carcinomas of the nasal cavity were given dietary menhaden oil (DHA and EPA) or soybean oil (control) and then received radiation therapy. Megavoltage radiation was delivered in 18 fractions to a total dose of 56 Gy. Blood levels of DHA, EPA, insulin, glucose, lactic acid, and MMPs 2 and 9; resting energy expenditure; and inflammatory eicosanoids from nasal biopsies were measured throughout radiation therapy. Samples were obtained from each patient 1 week before the start of radiation therapy, at start of radiation, and 7, 18 (end of radiation therapy), and 42 days after radiation was initiated. Dogs that are fed with menhaden oil had significantly (P < .05) higher plasma concentration of DHA by 500% and EPA by 200% and had significantly lower tissue inflammatory eicosanoids and decreased resting energy expenditure by 20% when compared with controls. Increased plasma DHA was significantly associated (P < .05) with decreased plasma lactic acid and MMPs. These data may suggest that dietary fish oil could reduce some detrimental inflammatory eicosanoids and metabolic consequences of radiation therapy.