Table 76Elective pre-operative/perioperative parenteral nutrition support in surgical patients

Bibliographic referenceStudy TypeEvidence levelNo. of patientsPatients characteristicsInterventionComparisonLength of follow upOutcome measuresEffect sizeComments (including source of funding)
Muller et al 1982240RCT1+Total no: n=125

PPN gp:
n=66

Cont gp: n=59
Patients with carcinoma of the oesophagus, stomach, colon, rectum, or pancreas admitted to the surgical department. Patients considered malnourished if the weight loss in the 3mo before admission was more than 5kg, the serum albumin was below 3.5g/dl & the responses to five skin tests were negative.

Mean age ± SD (yr):
PPN: 58.9 ± 11.5
Cont: 59.4 ± 12.6

Sex ratio (M:F):
PPN: 43:23
Cont: 34:25

Type of operation:

Curative procedures:
PPN: n=45 (68.2%)
Cont: n=45 (76.3%)

Oesophagectomy:
PPN: n=3
Cont: n=3

Gastrectomy:
PPN: n=23
Cont: n=21

Colectomy:
PPN: n=9
Cont: n=9

Abdominoperineal/low anterior resection:
PPN: n=10
Cont: n=12

Palliative procedures:
PPN: n=21 (31.8%)
Cont: n=14 (23.7%)

Mean duration of the operation ± SD (min):
PPN: 229 ± 80
Cont: 235 ± 95
PPN gp: received 10days of PPN (1.5g amino acids/kg body weight, 11g glucose/kg body weight, electrolytes, trace elements & vitamins) by a CVC.Cont gp: Regular hospital diet of 2400kcal/day. Those patients with partial obstruction were given a liquid diet.Not statedWound infection:PPN: n=14/66
Cont: n=15/59
The postop infusion regimen was identical for both gps but if a complication occurred the scheduled was altered as necessary.

Complications related to the central catheter occurred 4 times.
There was 1 puncture of the subclavian artery, 1 pneumothorax & 2 episodes of catheter sepsis. None of the complications delayed the planned operation.

13/14 patients who died postop underwent necropsy. 11/13 deaths were caused by a major complication affecting the site of broncho-pneumonia. The 14th patient had an anastomotic leakage on the 5th day after abdominothoracic gastrectomy & died 4 days later of sepsis with pulmonary & renal insufficiency.

The postop infusion scheme had to be altered for 8/59 control patients because sepsis was followed by renal failure (6 times) or liver failure (twice).
Pneumonia:PPN: n=20/66
Cont: n=23/59
Of those patients with pneumonia, no. of patients who needed artificial respiration:PPN: n=4/66
Cont: n=12/59 [p<0.05]
Major complications (intra-abdominal abscess, peritonitis, anastomotic leakage, ileus):PPN: n=11/66
Cont: n=19/59 [p<0.05]
Mortality:PPN: n=3/66
Cont: n=11/59 [p<0.05]
For individual complications affecting the site of operation – intra-abdominal abscess, peritonitis, anastomotic leakage or ileus:NS between the 2 gps.
Mean weight gain (kg) between admission & surgery:PPN: 1.98
Mean weight loss (kg) between admission & surgery:Cont: 1.04
Total serum protein (on day of admission & on day before operation):PPN: Stayed constant
Cont: Dropped
Fan et al 1994100RCT1+124 patients

Periop: n=64
Cont: n=60
Patients undergoing resection of hepatocellular carcinoma.

Weight loss >10% (%of patients):
Periop: 18
Cont: 14

Sex (M:F):
Periop: 56:8
Cont: 53:7

Age (yr) (range):
Periop: 54 (28–72)
Cont: 53 (33–79)
Periop gp: All patients had Broviac catheters implanted in the superior vena cava by surgical cutdown of the external jugular vein for PN. Patients given PN 12hrs a night for 7 nights before hepatectomy & was continued around the clock for 7days immediately after hepatectomy. The nutritional therapy consisted of a solution enriched with 35% branched-chain amino acids, at a dosage of approx. 1.5g of amino acid per kg of body weight per day & dextrose & lipid emulsion (50% medium-chain triglycerides) providing 30kcal per kg per day. Vitamins & trace minerals were added to the PN fluid daily. The total volume of PN fluid was limited to 1.75 litres per day.Usual oral diet preoperatively. In postop period, patients received 5% dextrose & normal saline with a volume & sodium content approx. equal to those of the fluid given to the patients in the periop-nutrition gp.Not statedTotal Septic complications:Periop: 11/64 (17%)
Cont: 22/60 (37%) [p=0.01]
Breakdown of septic complications-
Pulmonary infection:Periop: 5/64
Cont: 15/60
Wound infection:Periop: 3/64
Cont: 5/60
Subphrenic abscess:Periop: 4/64
Cont: 5/60
UTI:Periop: 0/64
Cont: 2/60
Infected ascites:Periop: 1/64
Cont: 2/60
Biliary fistula:Periop: 4/64
Cont: 5/60
Central-catheter sepsis:Periop: 1/64
Cont: 0/60
Other complications-
Wound dehiscence:Periop: 1/64
Cont: 1/60
Myocardial infarction:Periop: 0/64
Cont: 3/60
Intraabdominal bleeding:Periop: 4/64
Cont: 1/60
Variceal bleeding:Periop: 1/64
Cont: 0/60
Peptic ulcer bleeding:Periop: 1/64
Cont: 2/60
Intestinal obstruction:Periop: 1/64
Cont: 0/60
Pleural effusion:Periop: 9/64
Cont: 12/60
Hepatic coma:Periop: 4/64
Cont: 4/60
Renal failure:Periop: 2/64
Cont: 1/60
Ascites requiring diuretic agent for control:Periop: 16/64 (25%)
Cont: 30/60 (50%)
[p=0.004]
Overall postop morbidity:Periop: 22/64 (34%)
Cont: 33/60 (55%)
[p=0.02]
Hospital mortality:Periop: 5/64 (8%)
Cont: 9/60 (15%)
[p=0.30]
Weight loss (kg) (median/range):Periop: 0 (−6.5 to 10)
Cont: 1.4 (−1.7 to 7.0)
[p=0.01]
Subgp analysis (patient gps) –
Cirrhosis – no. of patients:Periop: n=39
Cont: n=33
Overall postop morbidity (%):Periop: 31%
Cont: 61%
[p=0.01]
Need for diuretic agents (%):Periop: 28%
Cont: 71%
[p=0.006]
Body weight loss (kg) median (range):Periop: 0 (−6.5 to 12.5)
Cont: 1.45 (−1.7 to 6.6)
[p=0.006]
Mortality (%):Periop: 8%
Cont: 15%
Chronic active hepatitis
no. of patients:Periop: n=18
Cont: n=12
Overall postop morbidity (%):Periop: 50%
Cont: 25%
[NS]
Need for diuretc agents (%):Periop: 18%
Cont: 42%
[NS]
Body weight loss (kg) median (range):Periop: 0.3 (−3.1 to 3)
Cont: 2.25 (0 to 7)
[NS]
Mortality (%):Periop: 5%
Cont: 25%
Normal liver - no. of patients:Periop: n=7
Cont: n=15
Overall postop morbidity (%):Periop: 14%
Cont: 60%
[p=0.045]
Need for diuretc agents (%):Periop: 29%
Cont: 36%
[NS]
Body weight loss (kg) median (range):Periop: −0.3 (−3.5 to 0.8)
Cont: 1.0 (−4 to 4)
[NS]
Mortality (%):Periop: 14%
Cont: 6.7%
Major hepatectomy -
no. of patients:Periop: n=47
Cont: n=42
Overall postop morbidity (%):Periop: 36%
Cont: 60%
[p=0.03]
Need for diuretc agents (%):Periop: 20%
Cont: 59%
[p=0.002]
Body weight loss (kg) median (range):Periop: 0.3 (−6.5 to 12.5)
Cont: 1.65 (−4 to 7)
[p=0.002]
Mortality (%):Periop: 11%
Cont: 17%
Minor hepatectomy -
no. of patients:Periop: n=17
Cont: n=18
Overall postop morbidity (%):Periop: 29%
Cont: 44%
[NS]
Need for diuretc agents (%):Periop: 41%
Cont: 33%
[NS]
Body weight loss (kg) median (range):Periop: −0.15 (−3.2 to 30)
Cont: 1.0 (−1.7 to 4)
[NS]
Mortality (%):Periop: 0%
Cont: 11%
Cirrhosis & major hepatectomy
no. of patients:Periop: n=27
Cont: n=21
Overall postop morbidity (%):Periop: 33%
Cont: 67%
[p=0.02]
Need for diuretc agents (%):Periop: 22%
Cont: 79%
[p<0.001]
Body weight loss (kg) median (range):Periop: 0.5 (−6.5 to 12.5)
Cont: 1.7 (−2 to 6.6)
[p=0.016]
Mortality (%):Periop: 11%
Cont: 14%
Cirrhosis & minor
hepatectomy
no. of patients:Periop: n=12
Cont: n=12
Overall postop morbidity (%):Periop: 25%
Cont: 50%
[NS]
Need for diuretc agents (%):Periop: 42%
Cont: 42%
[NS]
Body weight loss (kg) median (range):Periop: −0.5 (−3.2 to 2.7)
Cont: 1.0 (−1.7 to 4)
[NS]
Mortality (%):Periop: 0%
Cont: 16%
Fan et al 198999RCT1+40 patients

Preop PN (PPN) gp: n=20

Cont gp: n=20
Patients with oesophageal cancer

Sex (M:f):
PPN: 19:1
Cont: 16:4

Mean age ± SD:
PPN: 64.95 ± 8.99
Cont: 64.55 ± 9.56

Dysphagia duration (wks) – median (range)
PPN: 6.0 (3–12)
Cont: 5.5 (3–12)

Weight loss (kg) mean ± SD:
PPN: 7.68 ± 5.44
Cont: 5.66 ± 4.18

No. of patients who were malnourished:
PPN: n=16
Cont: n=15
Patients received synthetic amino acid (Vamin 250mg N/kg/day), glucose & lipid emulsion (40kcal/kg/day), electrolytes, trace elements & vitamins via CVC’s for 14 days before surgery. Postop, no patient was allowed feeding & all received PN until a gastrografin swallow on day 7 showed no leakage from anastomoses.Oral feeding alone.2 weeksPatients who developed one or more postop complication:PPN: 17/20 (85%)
Cont: 15/20 (75%)
The incidence of respiratory, anastomotic & septic complications were similar in the 2 gps, with no difference in the gp of patients considered as malnourished (>10% body weight loss).
Postop complications –
Respiratory
Infection:PPN: 10/20
Cont: 11/20
Failure:PPN: 7/20
Cont: 6/20
Mortality:PPN: 3/20
Cont: 3/20
Anastomotic leakage –
Clinical:PPN: 3/20
Cont: 6/20
Subclinical:PPN: 1/20
Cont: -
Septic complications –
Wound infection:PPN: 3/20
Cont: 1/20
Intraperitoneal abscess:PPN: 0/20
Cont: 1/20
Intrapleural sepsis:PPN: 1/20
Cont: 2/20
Septicaemia:PPN: 1/20
Cont: 2/20
Duration of hospital (median/days):PPN: 15 days
Cont: 16 days
Mortality:Similar rates for both gps.
Smith and Hartemink 1988b327RCT1+34 Patients

Preop: n=17 Cont: n=17
Patients undergoing major GI surgery who had a Prognostic Nutritional Index (PNI) score of greater than 30%.

Age (yrs):
Preop: 67 ± 4
Cont: 68 ± 3

Sex (M:F):
Preop: 12:5
Cont:15:2
IVN was carried out for at least 10 days through a CVC, infusing 50–60 kcal/kg/day of glucose/amino acid IVN mixture containing 150 kcal/1g of nitrogen. Normal replacement of electrolytes, trace elements, vitamins & essential fatty acids was also given. After 10days the PNI was repeated & the patients were scheduled for their operation.Patients did not receive any preop nutritional support but were scheduled for the next convenient operating list & received nutritional support postop if the surgeon caring for the patient felt it was indicated.Not statedWeight gain (kg):Preop: 3.2 ± 2.3
[p<0.01]
All the deaths were associated with respiratory failure: 3 due to respiratory infection & 1 due to pulmonary emboli. The patient in the preop gp who died of respiratory failure had a PNI of 56% prior to treatment & this had only improved to 52% after treatment. Of the other 3 control patients who had major complications, 2 had major respiratory infection requiring ventilation therapy & 1 had septicaemia.
Minor Complications:
Febrile episodes:Preop: 2/17
Cont: 0/17
Respiratory:Preop: 5/17
Cont: 2/17
Wound infections:Preop: 2/17
Cont: 2/17
Episodes of ileus:Preop: 2/17
Cont: 0/17
Major complications:Preop: 3/17
Cont: 6/17
Mortality:Preop: 1/17
Cont: 3/17
Overall hospital stay excluding patients who died (day):Preop: 44 ± 13 days
Cont: 38 ± 10 days
Bozzetti et al 2000a42RCT1+90 Patients

Periop: n=43
Cont: n=47
Elective surgical patients with gastric or colorectal tumours & weight loss of 10% or more of usual body weight in the previous 6mo.

Sex (M:F):
TPN: 21:22
Cont: 24:23

Weight loss (%)Median (min.max):
TPN: 15 (10,37)
Cont: 17 (10,32)

Excl: Patients older 80yrs of age, as were those requiring urgent surgery because of severe bleeding or obstruction or those with severe organ failure (jaundice, cardiac or respiratory failure, etc).
Patients received either TPN for 10days periop & 9days postop. The artificial nutritional regimen was planned at 1.5-fold the resting energy expenditure, as estimated by the Harris Benedict equation. The nonprotein calorie source included glucose & fat (Intralipid 20%) which accounted for 70% & 30% of the energy intake, respectively. The calorie/nitrogen ratio was 143.0 (±26.9):1. The protein source was supplied by a free amino acid solution (Freamine III). Electrolytes, vitamins & trace elements were administered according to current recommendations. The daily nutritional regimen included an average of 34.6 ± 6.3 kcal nonprotein per kg body weight & 0.25 ± 0.04g of nitrogen per kg body weight. The TPN mixture was delivered through a CVC in a subclavian vein, using a ethyl vinyl acetate “all-in-one” bag, while vitamins only were infused through a separate line. During preop TPN, patients consumed very few calories by the oral route. TPN was administered postop in addition to the oral feeding that was provided gradually as bowel function normalised.Patients were given a standard hospital oral diet before surgery & a hypocaloric parental solution (940kcal nonprotein & 85g amino acid) in the postop period, until GI function had recovered quickly. The majority of the patients received IV feeding through a CVC 7 the nutritive solution was compounded in a single bag.Not statedInfectious complications-The most frequent complication was pulmonary tract infection.

Both minor & major complications, either infectious or non-infectious were less frequent in the TPN group.
Abdominal wound abscess:Minor-
TPN: 3/43
Cont: 1/47
Major -None
Abdominal abscess:Minor-
TPN: 4/43
Cont: 6/47
Major-
TPN: -
Cont: 2/47
Pulmonary tract infection:Minor-
TPN: 7/43
Cont: 14/47
Major-
TPN: 3/43
Cont: 4/47
UTI:Minor-
TPN: 2/43
Cont: 1/47
Major -None
Noninfectious-
Abdominal wound dehiscence:Minor-TPN: 1/43 Cont: -Major -None
Anastomotic leakage:Minor-
TPN: -
Cont: 2/47
Major-
TPN: 1/43
Cont: 2/47
Respiratory insufficiency:Minor-
TPN: 1/43
Cont: 4/47
Major-
TPN: 2/43
Cont: 3/47
Circulatory insufficiency:Minor-
TPN: -
Cont: 1/47
Major-
TPN: -
Cont: 1/47
Renal insufficiency:Minor-
TPN: -
Cont: 2/47
Major-
TPN: -
Cont: 1/47
Liver failure:Minor-
TPN: -
Cont: 1/47
Major-
TPN: -
Cont: 1/47
Clotting problems:TPN: 16/43 (37%)
Cont: 27/47 (57%)
[p=0.03]
Overall complication rate:[p=0.03]
p values when considering complications –TPN: 12%
Cont: 34%
[p=0.02]
of any type:[p=0.22]
Noninfectious:[p-0.11]
Infectious:TPN: 0/43
Cont: 5/47
Major ones only:[p=0.05]
Mortality:TPN: 33 (18–161) & 14 (7–143)
Cont: 27 (15–103) & 14 (6–59)
[p=0.00]
Total periop & postop median length of hospitalisation (days):Length of postop hospitalisation in the 2 gps did not differ.
Thompson et al 1981348RCT1+21 Patients

Periop: n=9 Cont: n=12
Male surgical patients with GI cancer.
Patients had significant weight loss, an average of 14% of their normal weight.

Periop gp-
Mean age: 63.7 ± 10.7 > than 10 lb weight loss.

Cont gp-
Mean age: 65.8 ± 12.0 > than 10 lb weight loss over 3 to 6mo prior to admission.

Patients were admitted for:

Colon resection:
TPN: n=6
Cont: n=5

A-P resection:
TPN: n=0

Cont: n=3
Esophageal gastrectomy:
TPN: n=3
Cont: n=0

Biliary bypass:
TPN: n=0
Cont: n=1

Laparotomy, no resection:
TPN: n=3
Cont: n=0
Patients received IV PN consisting of crystalline amino acids in 25% Dextrose (Travasol, 4.2% with electrolytes) beginning at least 5 days preop & continuing until the patient was tolerating a regular diet (1500cal) postop. Infusion rates were calculated to provide 40–50 kcal/kg/day, or approx 2000–4000cal per day. Patients were allowed to continue a standard preop oral diet, usually clear liquids for 2days prior to operation.Patients received conventional intravenous therapy & diet as indicated for their operation.Not statedTotal course of PN (average/days):TPN: 18daysMajority of patients has colon resections.

Very small number of subjects in this trial within each arm.
Mean preop course (days) (range):TPN: 8days (5–14)
Major Complications (intraabdominal abscess, pelvic abscess & empyema):TPN: 1/12 (17%)
Cont: 1/9 (11%)
[NS]
Minor Complications (UTI, prolonged ileus, superficial wound infection & prolonged atelectasis):TPN: 3/12 (25%)
Cont: 2/9 (22%)
[NS]
Mortality:None
Postop weight changes (lb):TPN: +0.1 ± 4.8
Cont: −8.4 ± 6.1
[p<0.01]
von Meyenfeldt et al 1992366RCT1+101 Patients

TPN: n=51 Depleted cont: n=50
Patients with newly, detected, histologically proven gastric or colorectal carcinoma requiring surgical treatment who had not undergone treatment for other malignant tumours.

Excl: Patients over 80yrs & patients with a normal nutritional status.

Mean age (yrs) (±SEM):
TPN: 67.3 ± 10.2
Depleted cont: 65.8 ± 7.5

Age range (yrs):
TPN: 41–80
Depleted cont: 49–79

Gastric/Colorectal cancer:
TPN: 15/36
Depleted cont: 14/36
Sex (M:F):
TPN: 29:22
Depleted cont: 32:18
TPN: Received 150% of basal energy expenditure (BEE), as non-protein calories from a PN stock solution that contained 7g N/I (Synthamin 14) % 25% dextrose. Trace elements & vitamins (MVI) were added to conform to today’s standards. Electrolytes were added according to the individual patient’s needs. 500ml of an IV fat emulsion (Intralipid 20%) were administered at least 3 times per week. Preop nutrition lasted at least 10days. PN support was continued postop until the patients had resumed an oral diet providing 120% BEE.Received no nutritional support & underwent surgery without surgery. Postop, patients were allowed increasing amounts of liquids & solids as tolerated. Only in the event of a major postop complication was PN started in this control gp.Not statedWound infection:TPN: 8/51
Cont: 8/50
[NS]
No significant difference between gps for the complication rates.
Hospital stay for TPN gp was no longer than that of the control gp, despite a longer preop hospital stay in the TPN gp.

Analysis of the patients with complications as a gp did not reveal a beneficial effect of periop nutrition on total hospital stay.

The subgp analysis showed a significant decrease in the no. of patients developing an intra-abdominal abscess in the TPN gp. The differences became more pronounced in the subset of patients suffering major preop blood loss. The patient characteristics were not different between gps in either of these subset analyses.

Funding: Wander Research & Clintec (formerly Travenol)
UTI:TPN: 16/51
Cont: 10/50
[NS]
Respiratory tract infection:TPN: 14/51
Cont: 7/50
[NS]
Wound dehiscence:TPN: 2/51
Cont: 2/50
[NS]
Anastomotic leakage:TPN: 5/51
Cont: 7/50
[NS]
Fistula:TPN: 2/51
Cont: 1/50
[NS]
Intra-abdominal abscess:TPN: 4/51
Cont: 8/50
Sepsis:TPN: 1/51
Cont: 4/50
Respiratory insufficiency:TPN: 0/51
Cont: 2/50
[NS]
Circulatory insufficiency:TPN: 1/51
Cont: 0/50
[NS]
Renal insufficiency:TPN: 0/51
Cont: 0/50
[NS]
Mortality:TPN: 2/51
Cont: 2/50 [NS]
Sepsis related mortality:TPN: 1/51
Cont: 2/50 [NS]
No complications:TPN: 24/51 (47.1%)
Cont: 32/50 (64%) [NS]
Minor complications:TPN: 19/51 (37.2%)
Cont: 9/50 (18%) [NS]
Major complications:TPN: 6/51 (11.8%)
Cont: 7/50 (14%) [NS]
Length of Hospitalisation (days):TPN: 36.3 (± 17.7)
Cont: 31.7 (± 22.1)
The stratification of weight loss (%weight loss >10% of body weight) allowed for performance of a subset analysis in the patient gp displaying more severe depletion.
No. of patients in each gp:TPN: n=18 Cont: n=11
Anastomotic leakage:TPN: 1/18 Cont: 3/11
Intra-abdominal abscess:TPN: 0/18
Cont: 4/11 [p<0.05]
Sepsis:TPN: 0/18
Cont: 2/11
Subset analysis of complication rates of septic complications in patients with blood loss over 500ml during surgical procedure.
No. of patients in each gp:TPN: n=25
Cont: n=20
Anastomotic leakage:TPN: 3/25
Cont: 6/20
Intra-abdominal abscess:TPN: 2/25
Cont: 7/20 [p<0.05]
Sepsis:TPN: 1/25
Cont: 4/20 [p<0.05]
The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group 1991346RCT1+395 Patients

TPN: n=192
Cont: n=203
All patients were (95%male) >21yrs old, undergoing non- emergency laparotomy or thoracotomy.

Excl: Patients who were expected to die of their primary disease within 90days, had received TPN in the preceding 15days or had undergone an operation in the preceding 30days. Patients were considered malnourished if they met either or both of 2 criteria:
1) A score of 100 or less on the Nutrition Risk Index (NRI) or
2) Any 2 of the following:
- a current weight that was 95% of the ideal weight or less;
- a serum albumin level of 39.2g per litre or less;
- or a serum prealbumin level of 186mg per litre or less.
TPN: Received periop TPN through a CVC in doses increasing for 72hrs to daily caloric goal of 1000kcal above the resting metabolic expenditure. 550kcal were provided as lipid (Intralipid) & the remainder as dextrose. Crystalline amino acids (Freamine) were provided at a calorie:nitrogen ratio of 150kcal:1g of nitrogen. Vitamins (MV1-12 (10ML)), & trace elements (trace-element mix (1.0ml)) were provided daily & electrolytes was provided as clinically indicated. The daily TPN intake was considered adequate if the intake of macronutrients was ≥ 85% of the calculated goal. Optimal TPN was defined as 7 to 15days of preop treatment at adequate levels. Patients were permitted to eat as clinically indicated. Postop TPN was continued for 72hrs (or forced enterally feedings) before surgery or for the first 72hrs after surgery. Thereafter, TPN or tube feeding could be instituted if clinically indicated. Patients underwent surgery after receiving adequate TPN for at least 7days.Control: Received oral diet. Patients underwent surgery at least 3 days.30days & 90days after surgery.Complications observed within 30days of surgery (No. of patients episodes/no. of patients).Of the 192 patients receiving TPN who underwent surgery, 130 completed an optimal course of TPN, 49 received suboptimal TPN, & 13 received no TPN after an initial attempt to place a central line failed & the patient refused further attempts. Of the 203 control patients who underwent surgery, 3 who could not eat were given preop TPN when clinical conditions required that surgery be delayed by five or more days. The remaining control patients received no preop TPN or forced enteral feedings.

Postop, 11 patients in the TPN gp received TPN for more than the 3days required by the protocol & TPN was instituted after postop day 3 in 24 control patients.

There were more infectious complications in the TPN gp than in the control gp, but slightly more non-infectious complications in the control gp. The increased rate of infections was confined to patients categorised as either borderline or mildly malnourished, according to SGA or an objective nutritional assessment & these patients had no demonstrable benefit from TPN. Severely malnourished patients who receive d TPN had fewer non- infectious complications than controls with no concomitant increase in infectious complications.
Major, infectious -
Pneumonia or empyema:TPN: 17/16
Cont: 9/9
Abdominal abscess:TPN: 2/2
Cont: 2/2
Extra-abdominal abscess:TPN: 1/1
Cont: 0
Fasciitis:TPN: 3/3
Cont: 0
Bacteremia or fungemia:TPN: 8/7
Cont: 5/5
Other septic complications:TPN: 0
Cont: 1/1
Total:TPN: 31/27
Cont: 17/13
Patients affected (%):TPN: 14.1
Cont: 6.4
Relative Risk (RR)
(TPN:Control) = 2.20
95% CI = 1.19–4.05
RR with control for SGA (Subjective Global Assessment) = 2.23
Major, non-infectious -
Anastomotic leak:TPN: 7/6
Cont: 12/11
Bronchopleurocutan eous fistula:TPN: 4/3
Cont: 6/6
Wound dehiscence:TPN: 1/1
Cont: 1/1
Decubitus ulcer:TPN: 1/1
Cont: 1/1
Chronic respiratory failure (≥ 4days)TPN: 14/13
Cont: 12/11
GI complications (includes bleeding, obstruction, perforation & ischemia):TPN: 11/10
Cont: 17/14
Cardiovascular complications (includes myocardial infraction, cardiogenic shock, cardiac arrest & stroke):TPN: 15/15
Cont: 18/15
Pulmonary embolus:TPN: 0
Cont: 1/1
Renal failure:TPN: 0
Cont: 3/3
Total:TPN: 53/32
Cont: 71/45
Patients affected (%):TPN: 16.7
Cont: 22.2
RR (TPN:Control) = 0.75
95% CI = 0.50–1.13
RR with control for SGA = 0.71
Minor, infectious -
Wound infection:TPN: 14/12
Cont: 5/4
UTI:TPN: 17/13
Cont: 19/14
Minor, non-infectious -
Uncomplicated arrhythmia:TPN: 14/11
Cont: 22/20
Atelectasis:TPN: 6/6
Cont: 13/8
Transient respiratory failure (respiratory failure requiring the use of a ventilator for ≤ 3days postop) :TPN: 6/6
Cont: 6/6
Catheter-related -
Pneumothorax:TPN: 4/4
Cont: 0
Mediastinal hematoma:TPN: 1/1
Cont: 0
Hydrothorax:TPN: 2/2
Cont: 0
Air or catheter embolus:TPN: 3/3
Cont: 1/1
Thrombosis:TPN: 1/1
Cont: 1/1
Rates of major complications during the first 30 postop days:TPN: 49/192 (25.5%)
Cont: 50/203 (24.6%) [NS]
Overall rates of complications (major or minor) after 30days:TPN: 37%
Cont: 36.5%
Rate of major complications after 90days:TPN: 28%
Cont: 28%
30day postop mortality rate:TPN: 14/192 (7.3%)
Cont: 10/203 (4.9%) [NS]
90day postop mortality rate:TPN: 21/192 (10.9%)
Cont: 19/203 (9.4%) [NS]
Bellantone et al 198829RCT1+66 Patients
Preop 1: n=20
Cont 1: n=17

Preop 2: n=15
Cont 2: n=14
Malnourished patients undergoing major GI surgery.

Preop 1 & cont 1: 37 patients with serum albumin <3.5g/100ml or serum transferring <230 mg/100ml, or weight loss >10% of usual weight.

Preop 2 & cont 2: 29 patients with serum albumin <3.0g/100ml or serum transferring <200 mg/100ml, or weight loss >10% of usual weight.

Age (yrs) (mean):
Preop 1: 56
Cont 1: 59
Preop 2: 56
Cont 2: 60

Sex (M:F):
Preop 1: 12:8
Cont 1: 10:7
Preop 2: 10:5
Cont 2: 9:5
PN support was given as supplement to the peroral diet for at least 7days before surgery, providing 30cal/kg/day as glucide (20% dextrose solution) & 30% as lipidic calories (Intralipid 10%) & 200mg/kg/day of nitrogen (Solamin 7.5%).Received only standard hospital peroral diet.Not statedMortality rates:Preop 1: 0/20
Cont 1: 0/17
Preop 2: 0/15
Cont 2: 0/14 [NS]
Incidence of septic complications:Preop 1: 2/20 (10%)
Cont 1: 7/17 (41.4%) [p<0.05]
Preop 2: 2/15 (13.3%)
Cont 2: 7/14 (50%) [p<0.05]
Incidence of serious sepsis (sepsis score ≥ 10):Preop 1: 0/20
Cont 1: 3/17 (17.6%) [P=0.08]
Preop 2: 0/15
Cont 2: 3/14 (21.4%) [p=0.09]

From: Appendix Four, Evidence Tables

Cover of Nutrition Support for Adults
Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition.
NICE Clinical Guidelines, No. 32.
National Collaborating Centre for Acute Care (UK).
Copyright © 2006, National Collaborating Centre for Acute Care.

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