Effect of Early vs Late Supplemental Parenteral Nutrition in Patients Undergoing Abdominal Surgery

JAMA Surgery
Q1
Mar 2022
Citations:73
Influential Citations:2
Interventional (Human) Studies
90
S2 IconPDF Icon

Enhanced Details

Methods
Multicenter, open-label randomized clinical trial at 11 tertiary hospitals in China; 230 adults undergoing major abdominal surgery with high nutritional risk and poor tolerance to enteral nutrition (EN supplying <30% of energy targets by postoperative day 2); randomized 1:1 to E-SPN or L-SPN; mean age 60.1 ± 11.2 years; 61.1% male; all participants Han ethnicity; follow-up 2 months; randomization used permuted blocks and center stratification; follow-up assessments by blinded clinicians; statisticians blinded to group.
Intervention
Early supplemental parenteral nutrition (E-SPN): start on postoperative day 3; intravenous PN with energy density 0.88 kcal/mL; composition 15% protein, 40% lipids, 45% carbohydrates; route: peripheral or central vein; energy target = 100% of energy requirement; daily energy target = 30 kcal/kg ideal body weight for men and 25 kcal/kg for women; protein target = 1.2 g/kg; minimum 5 days of nutrition; PN continued until EN provided ≥80% of energy target, then reduced/discontinued. Late supplemental parenteral nutrition (L-SPN): start on postoperative day 8; otherwise same PN regimen as E-SPN; enteral nutrition started within 24 hours after surgery; energy from EN and PN aimed to meet 100% of energy requirement.
Results
Early SPN with EN reduced nosocomial infections compared with late SPN: 8.7% (n=10) vs 18.4% (n=21); difference 9.7% (95% CI 0.9%–18.5%), P=0.04. Fewer major infectious complications and shorter therapeutic antibiotic days with E-SPN (6.0 vs 7.0 days, P=0.01). During days 3–7, daily energy intake was higher with E-SPN (26.5 ± 7.4 vs 15.1 ± 4.8 kcal/kg/day, P<0.001) and protein intake higher (1.02 ± 0.28 vs 0.48 ± 0.17 g/kg/day, P<0.001). No significant differences in noninfectious complications or total adverse events. Authors conclude that initiating early SPN alongside EN is a favorable strategy to reduce postoperative infections and improve early nutrition in high-nutritional-risk abdominal surgery patients.
Limitations
Indirect calorimetry to measure resting energy expenditure not used; open-label design with unblinded patients and care providers (though outcome assessors were blinded); limited generalizability beyond the Han Chinese population.

Abstract

Key Points Question When should supplemental parenteral nutrition (SPN) after major abdominal surgery be considered for patients in whom energy targets cannot be met by enteral nutrition alone? Findings This multicenter randomized clinical trial comp...