Faculty Bibliography

This guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home parenteral nutrition (HPN) providers, as well as healthcare administrators and policy makers, about appropriate and safe HPN provision. This guideline will also inform patients requiring HPN. The guideline is based on previous published guidelines and provides an update of current evidence and expert opinion; it consists of 71 recommendations that address the indications for HPN, central venous access device (CVAD) and infusion pump, infusion line and CVAD site care, nutritional admixtures, program monitoring and management. Meta-analyses, systematic reviews and single clinical trials based on clinical questions were searched according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing Scottish Intercollegiate Guidelines Network methodology. The guideline was commissioned and financially supported by ESPEN and members of the guideline group were selected by ESPEN.

In the last several weeks we have been witnessing the exponentially progressing pandemic SARS-CoV-2 coronavirus. As the number of people infected with SARS-CoV2 escalates, the problem of surgical management of patients requiring urgent surgery is increasing. Patients infected with SARS-CoV2 virus but with negative test results will appear in general hospitals and may pose a risk to other patients and hospital staff. Health care workers constitutes nearly 17% of infected population in Poland, therefore early identification of infected people becomes a priority to protect human resources and to ensure continuity of the access to a surgical care. Both surgical operations, and endoscopic procedures are considered as interventions with an increased risk of infection. Therefore, determining the algorithm becomes crucial for qualifying patients for surgical treatment, but also to stratify the risk of personnel being infected during surgery and to adequately protect staff. Each hospital should be logistically prepared for the need to perform urgent surgery on a patient with suspected or confirmed infection, including personal protective equipment. Limited availability of the equipment, working under pressure and staff shortages in addition to a highly contagious pathogen necessitate a pragmatic management of human resources in health care. Instant synchronized action is needed, and clear uniform guidelines are essential for the healthcare system to provide citizens with the necessary surgical care while protecting both patients, and staff. This document presents current recommendations regarding surgery during the COVID-19 pandemic in Poland.

The inclusion of ω-3 fatty acids as part of parenteral nutrition is associated with clinical benefits such as a reduced likelihood of infectious complications and shorter hospital and intensive care unit (ICU) stays. As healthcare resources are limited, pharmacoeconomic analyses have been performed, typically modeling studies, using cost and outcomes data to investigate the cost-effectiveness of parenteral nutrition regimens including ω-3 fatty acids from fish oil compared with standard parenteral nutrition without such ω-3 fatty acids. This review covers pharmacoeconomic studies encompassing Italian, French, German, and UK hospitals for ICU and non-ICU hospitalized patients, and for ICU patients in China. The results show that the use of parenteral nutrition including ω-3 fatty acids more than offsets any additional acquisition costs in all national scenarios investigated to date, indicating that parenteral nutrition including ω-3 fatty acids is a clinically and economically beneficial strategy compared with standard parenteral nutrition.

In hospitalized patients, lipid emulsions are an integral part of balanced parenteral nutrition. Traditionally, a single lipid source, soybean oil, has been given to patients and was usually regarded as just a source of energy and to prevent essential fatty-acid deficiency. However, mixtures of different lipid emulsions have now become widely available, including mixtures of soybean oil, medium-chain triglycerides, olive oil, and fish oil. Fish oil is high in the ω-3 polyunsaturated fatty acids docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). There is a growing body of evidence that these ω-3 fatty acids can exert beneficial immunomodulatory, anti-inflammatory, and inflammation-resolution effects across a wide range of patient groups including surgical, cancer, and critically ill patients. At least in part, these effects are realized via potent specialized pro-resolution mediators (SPMs). Moreover, parenteral nutrition including ω-3 fatty acids can result in additional clinical benefits over the use of standard lipid emulsions, such as reductions in infection rates and length of hospital and intensive care unit stay. Clinical and experimental evidence is reviewed regarding lipid emulsion use in a variety of hospitalized patient groups, including surgical, critically ill, sepsis, trauma, and acute pancreatitis patients. Practical aspects of lipid emulsion use in critically ill patients are also considered, such as how to determine and fulfill energy expenditure, how and when to consider parenteral nutrition, duration of infusion, and safety monitoring.

Lipid emulsions are an integral part of parenteral nutrition, and traditionally have been regarded as an energy-dense source of calories and essential fatty acids. For many years, lipids used in parenteral nutrition have been based on vegetable oils (eg, soybean-oil emulsions). However, soybean-oil emulsions may not have an optimal fatty-acid composition under some circumstances when used as the only lipid source, as soybean oil is particularly abundant in the ω-6 polyunsaturated fatty acid (PUFA), linoleic acid. Hence, a progressive series of more complex lipid emulsions have been introduced, typically combining soybean oil with 1 or more alternative oils, such as medium-chain triglycerides (MCTs) and/or olive oil and/or fish oil. The wide range of lipid emulsions now available for parenteral nutrition offers opportunities to alter the supply of different fatty acids, which potentially modifies functional properties, with effects on inflammatory processes, immune response, and hepatic metabolism. Fish oil has become an important component of modern, composite lipid emulsions, in part owing to a growing evidence base concerning its biological effects in a variety of preclinical models. These biological activities of fish oil are mainly attributed to its ω-3 PUFA content, particularly docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). DHA and EPA have known mechanisms of action, anti-inflammatory, immunomodulatory, and antioxidative properties. Specialized proresolving mediators, such as resolvins, protectins, and maresins, are synthesized directly from DHA and EPA, are key for the resolution of inflammation, and improve outcomes in many cell- and animal-based models and, recently, in some clinical settings.

BACKGROUND:The 2018 Lipids in Parenteral Nutrition summit involved a panel of experts in clinical nutrition, lipid metabolism, and pharmacology, to assess the current state of knowledge and develop expert consensus statements regarding the use of intravenous lipid emulsions in various patient populations and clinical settings. The main purpose of the consensus statements is to assist healthcare professionals by providing practical guidance on common clinical questions related to the provision of lipid emulsions as part of parenteral nutrition (PN). METHODS:The summit was designed to allow interactive discussion and consensus development. The resulting consensus statements represent the collective opinion of the members of the expert panel, which was informed and supported by scientific evidence and clinical experience. RESULTS:The current article summarizes the key discussion topics from the summit and provides a set of consensus statements designed to complement existing evidence-based guidelines. Lipid emulsions are a major component of PN, serving as a condensed source of energy and essential fatty acids. In addition, lipids modulate a variety of biologic functions, including inflammatory and immune responses, coagulation, and cell signaling. A growing body of evidence suggests that lipid emulsions containing ω-3 fatty acids from fish oil confer important clinical benefits via suppression of inflammatory mediators and activation of pathways involved in the resolution of inflammation. CONCLUSIONS:This article provides a set of expert consensus statements to complement formal PN guideline recommendations.

BACKGROUND:The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a worldwide rapidly spreading illness, Coronavirus Disease 2019 (COVID-19). Patients fed enterally and parenterally at home are exposed to the same risk of infection as the general population, but more prone to complications than others. Therefore the guidance for care-givers and care-takers of these patients is needed. METHODS:The literature search identified no relevant systematic reviews or studies on the subject. Therefore a panel of 21 experts from 13 home medical nutrition (HMN) centres in Poland was formed. Twenty-three key issues relevant to the management of SARS-CoV-2 infection or COVID-19 in the HMN settings were identified and discussed. Some statements diverge from the available nutrition, surgical or ICU guidelines, some are based on the best available experience. Each topic was discussed and assessed during two Delphi rounds subsequently. Statements were graded strong or weak based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. RESULTS:the panel issued 23 statements, all of them were graded strong. Two scored 85.71% agreement, eleven 95.23%, and ten 100%. The topics were: infection control, enrolment to HMN, logistics and patient information. CONCLUSIONS:the position paper present pragmatic statements for HMN to be implemented in places without existing protocols for SARS-CoV-2 pandemic. They represent the state of knowledge available at the moment and may change should new evidence occurs.

A number of topics important to the handling of intravenous lipid emulsions (ILEs) were discussed at the international summit. ILE handling includes the preparation and the administration steps in the typical use of parenteral nutrition (PN). The discussion and consensus statements addressed several issues, including standardization of the PN process, use of commercially available multi-chamber PN or compounded PN bags, the supervision by a pharmacist with expertise, limiting ILE repackaging, and infusion duration.