Nutrition and Metabolism Research Paper Sessions - ASPEN and Metabolism Research Paper Sessions ... necessary to sustain normal growth, ... compromised protection against intestinal

ASPEN 2018 Nutrition Science & Practice Conference 1

Nutrition and Metabolism Research Paper Sessions

Session Title Page

Parenteral Nutrition 1

Enteral Nutrition 12

Malnutrition, Obesity, and Practice Concepts

25

Critical Care and Other Critical Health Issues

33

GI and Other Metabolic Topics 42

Pediatric and Neonatal 48

Parenteral Nutrition TRAINEE AWARD INTERNATIONAL ABSTRACT OF DISTINCTION 2834469 - Catheter Related Complications in Central Venous Catheters Locked with Taurolidine vs Ethanol in Pediatric Patients with Intestinal Failure. Jaclyn C. Strauss, MD, PhD1; Dana Boctor, MD2; Jason Silverman, MD3; Linda Casey, MD4 1Pediatrics, University of British Columbia, Vancouver, Canada; 2Gastroenterology, Alberta Children's Hospital, Calgary, Canada; 3Gastroenterology, Stollery Children's Hospital, Edmonton, Canada; 4Gastroenterology, Hepatology and Nutrition, BC Children's Hospital, Vancouver, Canada

Purpose: Intestinal Failure (IF) is a devastating condition characterized by parenteral nutrition dependence due to the inability of the gastrointestinal tract to absorb adequate nutrients and water necessary to sustain normal growth, development and health. Central venous catheters (CVCs) are lifelines for children with IF, and given the limited number of anatomic sites available for line placement, preserving long-term venous access is critically important. CVC complications, including infection, occlusion and line breakage lead to increased morbidity and mortality and contribute to loss of venous access sites. Ethanol lock therapy (ELT) has become the cornerstone of CRBSI prevention, but increasing clinical experience and publications have suggested that ELT may increase the risk of line occlusion and breakage, potentially increasing the risk of loss of vascular access sites. Thus, the search for alternative lock solutions is ongoing. Taurolidine is a non-toxic, broad-spectrum antimicrobial with similar efficacy to ELT at reducing rates of CRBSIs. A direct head-to-head comparison between ethanol and taurolidine lock therapy in the pediatric


IF population does not currently exist in the literature and taurolidine is not currently licensed for use as a locking solution in Canada. Due to a recent shortage of ethanol, Health Canada granted temporary approval for use of taurolidine in several IF patients managed by the Western Canadian Children’s Hospital Intestinal Rehabilitation Program Network (CHIRP-Net). The clinical experience of this patient cohort presents a unique opportunity to directly compare the effects of ethanol on central line complications in patients exposed to both ELT and taurolidine. Objective: Compare rates of CVC complications, including CRBSIs, line occlusions, thrombus, breakages, repairs, replacements (CVC-Rs) and line survival time using taurolidine (TLT) vs ethanol locks (ELT). Methods: Data was collected in a retrospective chart review of pediatric IF patients managed by Western Canadian CHIRP-Net centres (BC Children’s Hospital, Alberta Children’s Hospital and Stollery Children’s Hospital) where taurolidine locks were used. The Wilcoxon signed-rank test was used to compare differences in event rates in patients who used both ELT and TLT during the study period (January 1, 2012 to June 1, 2016). Results: Analysis for nine children with 8041 catheter days (CDs) from two study sites who received both ELT and TLT has been completed. ELT (vs TLT) had higher rates of CVC line breaks (7.49 vs 2.29/1000 CDs, P =0.01), CVC repairs (8.36 vs 3.64/1000 CDs, P=0.01) and occlusions due to thrombus (2.75 vs 0.21/1000 CDs, P=0.05). An increased rate of CVC-Rs due to mechanical problems was also found with ELT (5.88 vs 0.63/1000 CDs, P= 0.005), and lines had significantly shorter mean survival. There was no difference in rates of CRBSIs. Preliminary analysis of patient data from a third site supports these trends. Conclusions: TLT and ELT are equally effective in preventing CRBSIs; however, ELT is associated with higher rates of mechanical complications and related CVC-R’s compared to TLT. While analysis of our experiences with taurolidine is ongoing, these results suggest that taurolidine may be a suitable alternative to ethanol in preventing CRBSIs while preserving CVC line integrity in the pediatric IF population.

Financial support received from: N/A


BEST OF ASPEN-PARENTERAL TOPICS ABSTRACT OF DISTINCTION 2834841 - Towards Therapeutic Strategies to Improve Patient Outcome with Total Parenteral Nutrition: Clues from Cell Signaling Networks Katherine D. Walton, PhD2; Deepa Chandhrasekhar, BS 2; Julia J. Patton, undergraduate student2; Daniel Teitelbaum, MD1; Deborah L. Gumucio, PhD2 1Surgery, University of Michigan, Ann Arbor, MI; 2Cell and Developmental Biology, University of Michigan Medical School, Ann Arbor, MI

Purpose: Villi are composed of an epithelial layer and a mesodermal core that includes vascular networks. Loss of intestinal length (surgical or congenital) or loss of villi due to inflammation can result in malabsorption. Parenteral nutrition provides life-saving support, however the villi of patients receiving TPN undergo atrophy, shortening/ flattening of villi and decreased barrier function resulting in compromised protection against intestinal flora. Atrophy is accompanied by remodeling of the vascular core, and activation of cell signaling networks used to communicate between the vasculature and epithelial cells of the intestine during development and homeostasis. Understanding how these signaling networks drive villus morphogenesis will aid in identifying therapeutic strategies towards generating villus growth in patients. In the fetal mouse, villi emerge from a flat epithelium following the formation of mesodermal cell clusters that grow with the emerging villus and become part of the villus core. Nascent clusters contain vascular elements, without which, villi fail to form. Here we: 1)


define the timing of vascular development relative to cluster formation; 2) alter vascular development through modulation of Notch signaling to reveal the importance of vasculature in villus development; 3) characterize FoxF1 as a marker of mesenchymal clusters; 4) identify FoxF1+; PDGFRa+ cluster cells as potential telocytes, support cells in stem cell niches that contribute to tissue recovery. Methods: Vasculature, epithelium and clusters were stained with antibodies to examine their relationships at key stages of development. Notch signaling was perturbed by deleting Rbpj, a required co-factor, specifically in the vasculature or in the mesenchymal cluster cells prior to cluster formation. Activation of NICD increased Notch signaling in the endothelium. FoxF1-TdTomato and FoxF1-CreERT2; R26R-RFP mouse lines were examined at key stages relative to PDGFRa, a cluster marker and proposed telocyte marker. Results: Vasculature first appears as individual cells at E10.5; by E12.5 sprouts from the vascular plexus reach toward the epithelium and interact with subepithelial mesenchymal cells (Figure 1 A,B). Clusters are first detected at E14 and are intimately associated with two vascular sprouts (Figure 1C). At E14.5 clusters have grown to about 25 cells and continue to be tightly associated with the vasculature (Figure 1D). By E15, the clusters contain about 50 cells (Figure 1 E). Intestines with loss of Notch signaling in the cluster cells appear to have normal villi with clusters and vasculature similar to control littermates. However, loss of Notch signaling in endothelial cells results in abnormal villi with multiple, large clusters and vascular overgrowth (Figure 2). Conversely, gain of Notch signaling in endothelial cells results in decreased vascular sprouting and a loss of cluster formation and villus emergence (Figure 3). FoxF1-TdTomato is highly expressed in mesenchymal clusters and is co-expressed with PDGFRa (Figure 4). FoxF1-CreERT2 drives recombination of floxed alleles in mesenchymal clusters (Figure 4). Conclusions: 1) Notch signaling regulates vascular pattern and development in the embryonic intestine. 2) Loss of endothelial Notch signaling increases vascular sprouting resulting in larger villi with multiple clusters. 3) Increased Notch signaling decreases vascular sprouting and cluster formation resulting in loss of villi. 4) Vascular sprouts may provide a cue for the initiation of cluster formation. 5) FoxF1 is a novel marker of mesenchymal clusters; FoxF1+; PDGFRa+ cells give rise to telocytes that define the stem cell niche and contribute to tissue recovery.

Financial support received from: A.S.P.E.N. Rhoads Research Foundation; NIH P01 DK62041


Figure 1. Intimate interaction of the vasculature with the epithelium and cluster cells during villus development. Vasculature is marked with VEGFR2 or PECAM (red). PDGFRa marks cluster cells (green). Ecadherin or DAPI highlight epithelial cells (blue).

Figure 2. Loss of endothelial Notch signaling increases vascular growth and alters cluster and villus patterning. Rbpj was deleted in clusters with Gli1CreERT2 or in endothelium with Gata2-CreERT2. Vasculature is marked in purple and mesenchymal clusters in green.


Figure 3. Gain of Notch signaling decreases vascular sprouting and alters vascular patterning. A) Control littermate at E15.5. B) RosaNICD/+; Gata2-CreERT2 mutant at E15.5. Vasculature is marked in red, epithelium is outlined in purple, and mesenchymal clusters are green.

Figure 4. Foxf1-TdTomato (red) reporter labels FoxF1 expressing cells in the mesenchymal clusters and sub-epithelial mesenchyme and Foxf1-CreERT2 induces recombination of floxed alleles in mesenchymal clusters. A,B) Expression in the mesenchymal clusters during fetal development at E17.5. C,D) Co-expression of FoxF1 (red) with PDGFRa (green) in nascent mesenchymal clusters at E15. Epithelium is outlined in purple. E) FoxF1 (red) in adult jejunum. F) Co-expression of FoxF1 (red) and PDGFRa (green nuclei) in adult Jejunum. G,H) Magnifications of Panel F showing villus tips (G) and lamina propria around crypts (H). I-J) Expression of Rosa-RFP driven by FoxF1-CreERT2 in FoxF1 expressing cells of the adult small intestine following two weeks of induction with Tamoxifen chow. FoxF1 (red) phalloidin is shown to provide contrasting background (green). 2834755 - Improved Liver Function Test Results in Long-term Home Parenteral Nutrition Patients Converted to Four Oil Lipid Emulsion.


Casey P. Cooper, PharmD, CNSC1; Deborah L. Stevenson, MS, RDN2 1Pharmacy, Amerita, Inc, Amarillo, TX; 2Pharmacy, Amerita, Inc, Rochester Hills, MI

Purpose: Soybean oil-based lipid emulsions have been identified as a factor contributing to parenteral nutrition associated liver disease (PNALD). The high omega-6 polyunsaturated fatty acids (FA) and phytosterols are implicated in promoting inflammation and hepatic toxicity with the use of 100% soybean oil lipid emulsions. Four oil lipid emulsions containing omega-3 polyunsaturated FA have been shown to reverse PNALD in neonates. Long-term use of four oil lipid emulsion appears safe in the adult home parenteral nutrition (HPN) patient. There is insufficient data to support the use of four oil lipid emulsions to treat PNALD in the adult home care patient. Given the prevalence of PNALD occurring in the HPN population, the purpose of this retrospective study is to identify if use of four oil lipid emulsion in place of soybean oil lipid emulsion improves liver function tests (LFTs) in long-term HPN patients. Methods: The retrospective study design was approved by the Amerita, Inc clinical compliance team. Protected health information was not included, and informed consent was not required. Adult men and women >18 years of age HPN patients at the above home infusion pharmacy who had orders changed from Nutralipid (100% Soybean Oil, B Braun Medical Inc.) to SMOFlipid, four oil lipid emulsion (30% soybean oil, 30% medium-chain triglycerides, 25% olive oil, 15% fish oil, Fresenius Kabi) were identified from 8/1/2016-8/15/2017. The liver function labs observed included Alkaline Phosphatase (ALP), Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT), and Total Bilirubin (Tbili). The lab values prior to initiation of the four oil lipid emulsion were used to represent baseline, and subsequent data was tracked weekly over four weeks after initiation of the four oil lipid emulsion. Patients included in the study received identical doses and frequencies of the four oil lipid emulsion compared with soybean oil lipid emulsion following product conversion. A paired T-test with 2-tailed P values was utilized to determine statistical significance. Patients with incomplete data, those who did not receive soybean oil lipid emulsion prior to conversion, and those with advancing metastatic disease were excluded from the study. Results: A total of eleven patients met inclusion criteria. Marked reductions in all LFTs from baseline were seen in the first 1-2 weeks after conversion to a four oil lipid emulsion. The mean results of each liver enzyme at baseline and at weeks 1, 2, 3, and 4 are listed in Table 1. Statistical significance (p<0.05) was demonstrated for ALP at Week 2 (p=0.036), AST at week 3 (p=0.019), and ALT at week 2 (p=0.03). The benefit of LFT reduction following conversion to a four oil lipid emulsion appeared to begin leveling off at Week 4. While TBili was reduced overall compared with baseline, the reduction did not achieve statistical significance during the 4 week study period. Conclusions: The reduced omega-6 content and other potential anti-inflammatory properties of four oil lipid emulsion appears to reverse LFT rises in patients converted from standard 100% soybean oil emulsions. The authors postulate that four oil lipid emulsions may have a positive outcome on the incidence and severity of PNALD in long term HPN patients. Further studies examining long-term data and incidence rates of PNALD in patients receiving four oil lipid emulsions are warranted.

Financial support received from: Amerita, Inc.

Mean LFT Value Over Time

Lab Baseline Week 1 Week 2 Week 3 Week 4 % Wk 1 % Wk 2 % Wk 3 % Wk 4

ALP 315 313 252 232 223 -2.8% -18.8% -24.6% -27.0%

AST 79 59 53 44 44 -14.8% -12.1% -32.9% -32.9%

ALT 133 107 69 65 63 -8.3% -32.4% 32.7% 37.6%

Tbili 0.9 0.9 0.8 0.8 0.8 -7.0% -7.4% -7.7% -8.2%

2834592 - Microorganisms and Antibiotic Resistance Patterns in Parenteral Nutrition-Dependent Pediatric Patients with Central Line-Associated Bloodstream Infections.


Bennet S. Cho, BA Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Boston, MA

Purpose: Parenteral nutrition (PN) is a critical requirement for pediatric patients unable to absorb nutrients enterally due to insufficient bowel length and/or absorptive capacity. Long-term PN administered via a central venous catheter places patients at risk for central line-associated bloodstream infections (CLABSI). Prompt diagnosis and treatment of CLABSI is essential in preventing multiorgan failure and life-threatening sepsis. At Boston Children’s Hospital (BCH), PN-dependent children with suspected CLABSI are administered empiric broad spectrum antibiotics and admitted for 48 hours of monitoring while awaiting blood culture results. The purpose of this analysis is to identify microbial species and describe antibiotic resistance from CLABSI events in children with intestinal failure that occurred from April 2015 to August 2017 at BCH. Methods: This is a retrospective analysis utilizing CLABSI data from an ongoing prospective study. Pediatric patients receiving home PN (HPN) and followed at the Center for Advanced Intestinal Rehabilitation and the HPN Clinic at Boston Children’s Hospital are consented and enrolled into a 3-year observational study. When patients present to the Emergency Department for CLABSI evaluation, blood is drawn from the central line for microbiology studies, followed by the administration of broad-spectrum empiric antibiotics. The study team administers a symptom survey and records patient data that includes admission vital signs, physical exam findings, and laboratory test results. The primary outcome for this analysis is the identification of microbial species from positive cultures. Secondary outcomes include antibiotic resistance and sensitivities of each microorganism grown in culture. Data are reported as number (percent). Results: Out of 107 admissions for suspected CLABSI, 40 (37.4%) were true infections as determined by positive blood culture growth. Cultures grew 29 (51.8%) gram-positive species, 23 (41.1%) gram-negative species, and 4 (7.1%) fungal species (Figure 1). Twelve (30.0%) of the CLABSI incidents were positive for more than 1 microbial species (Figure 1). Among the organisms speciated, the Staphylococcus genus was the most prevalent and accounted for 44.6% of all cultures (Table 1). The most common microbial species were Klebsiella pneumoniae (17.9%) and Escherichia coli (16.1%) (Table 1). Among gram-positive species, 10 of 29 (34.5%) organisms were resistant to ampicillin/sulbactam, 10 (34.5%) were resistant to oxacillin, and 12 (41.4%) were resistant to 1st and 3rd generation cephalosporin antibiotics (Figure 2). Among gram-negative species, 15 of 23 (65.2%) organisms were resistant to ampicillin, 5 (21.7%) to ampicillin/sulbactam, and 2 (8.7%) to piperacillin/tazobactam (Figure 2). Fungal species did not demonstrate antibiotic resistance. Conclusions: Empiric vancomycin covered all gram-positive cultures, which constituted the majority of microorganisms. Although two gram-negative cultures were resistant to piperacillin/tazobactam, antibiotic sensitivity data allowed for appropriate antibiotic adjustment. Utilizing sensitivity data promotes antibiotic and antifungal stewardship by safely permitting the selection of narrower spectrum medications, thus minimizing the development of resistant microbes. Overall, obtaining microbial species data may help determine the most effective empiric antibiotics as well as inform any patterns of emerging antibiotic resistant species.


Table 1: Microbial Organisms

SPECIES GROUP NUMBER (%)

Klebsiella pneumoniae Gram-negative 10 (17.9)

Escherichia coli Gram-negative 9 (16.1)

Citrobacter freundii Gram-negative 1 (1.8)

Enterobacter cloacae Gram-negative 1 (1.8)

Proteus mirabilis Gram-negative 1 (1.8)


Moraxella osloensis Gram-negative 1 (1.8)

Methicillin-sensitive Staphylococcus aureus Gram-positive 6 (10.7)*

Methicillin-resistant Staphylococcus aureus Gram-positive 5 (8.9)*

Other Staphylococcus spp. Gram-positive 14 (25.0)*

Other Enterococcus spp. Gram-positive 2 (3.6)

Streptococcus spp. Gram-positive 1 (1.8)

Bacillus cereus Gram-positive 1 (1.8)

Candida spp. Fungal 4 (7.1)

*Total Staphylococcus genus = 25 (44.6%)

2834848 - Intestinal Failure on an Acute Care Surgery Service – Costs and Complications. Michelle B. Mulder, MD1,2; Patricia Byers, MD3,2; Matthias Eikermann, MD4; Lindsey Gass, RD, LD/N 2; Rishi Rattan, MD2,1; Gerd D. Pust, MD2,1; Joyce I. Kaufman, MD2,1; Valerie Hart, DO2,1; Ruiz Gabriel, MD5,2; D. D. Yeh, MD3,2


1General Surgery , University of Miami Hospital , Miami, FL; 2Ryder Trauma Center , Jackson Memorial Hospital, Miami , FL; 3Surgery, University of Miami, Miami, FL; 4Anesthesiology , Beth Israel Deaconess Medical Center, Boston , MA; 5Surgery, University of Miami, Miami , FL

Purpose: The European Society of Clinical Nutrition and Metabolism (ESPEN) has recently proposed a conceptual framework and classification system for intestinal failure (IF) in adults. The purpose of this study is to define the prevalence of IF on an Acute Care Surgery (ACS) service and compare clinical outcomes to those without IF. Methods: All admissions to the ACS service of a level 1 academic center in 2016 were retrospectively reviewed. Exclusions were hospital length of stay (LOS) < 3 days, appendicitis, cholecystitis, and inguinal hernias. IF was defined as the need for parenteral nutrition. Data are expressed as M±SD if parametric or median (interquartile range) if not. Difference was assessed at p<0.05. Results: The study population was comprised of 286 patients (Table 1). The IF group (n=31; 11%) was older (59.0 ± 14.4 vs. 52.4 ± 14.5 years, p=0.018) and more commonly admitted for intestinal obstruction (42% vs. 24%, p=0.039). The IF group had longer ICU LOS (3 [0-28] vs. 0 [0 – 0] days, p<0.001), hospital LOS (29 [14-64] vs. 7 [4-13] days, p<0.001), was less commonly discharged home (71% vs. 91%, p<0.001), and had higher 30 day readmission rates (32% vs. 15%, p=0.022). Conclusions: This is the first description of the prevalence and clinical outcome of patients with IF managed by an ACS service. Optimization of IF management may significantly improve patient care through improvements and redistribution of hospital resources.



2830602 - Central Venous Catheters for Home Parenteral Nutrition: Characteristics and Outcomes of Devices in Place for Five Years or Greater. Marianne Opilla, RN, CNSC1; Rodney Okamoto, R Ph3; Reid Nishikawa, PharmD2 1Nutrishare, Midlothian, VA; 2Nutrishare, Inc., Elk Grove, CA; 3President, Nutrishare, Inc., Elk Grove , CA

Purpose: Intestinal failure patients may require home parenteral nutrition (HPN) for a lifetime. HPN is administered through a central venous catheter (CVC), and an important goal is to extend the dwell time many years without complications leading to loss. The aim of this study was to examine a group of HPN patients and report characteristics and outcomes of CVCs in place for at least five years. Methods: All charts of adult and pediatric patients from one home infusion pharmacy were retrospectively


reviewed for CVCs in place for at least 5 years. Data collected included CVC type, days in place, number of lumens, material, and if removed, reason for loss. HPN regimen was also reported including infusion days per week, cycle time, volume infused, and intravenous lipid emulsion (ILE) administration. Care routines were studied, such as, use of protective alcohol cap, lock therapy, antimicrobial site patch, dressing type, lab draw method and frequency, and identification of primary caregiver. Demographic data included age, gender, diagnosis for HPN, and years on HPN. Results: Sixty-one patients, age 13 to 91 years were identified as having at least one CVC lasting 5 years or more. Females represented at 62%. The primary diagnosis was short bowel syndrome (70.5%). Total HPN years were 1,495 averaging 24.5 years. Tunneled CVCs were most common (n=51). There were 9 infusion ports and one PICC. Total CVC days were 241,219 with an average of 3954 days (10.8 years). Most CVCs were single lumen (95%) and made of silicone (87%). HPN averaged 6 days per week, 2050 ml over a 10 hour cycle, and 85% infused ILE at least one day per week. Catheter related bloodstream infection (CRBSI) was the most frequent complication resulting in CVC loss (n=20). The infection rate was 0.08 per 1000 CVC days. The second most frequent cause of loss was catheter material damage (n=8), and the third was skin site failure (n=7). There were no obvious CVC losses related to infusion regimens. The most frequently used CRBSI prevention strategy was the antimicrobial site patch (34.4%), followed by protective alcohol caps (18%), and alcohol lock (11.4%). The majority of the patients were self care (85.2%) and used transparent dressings (75.4%). Labs were drawn from the CVC 41% of the time but none more frequently than once per month. Twenty of the 61 devices were still in place at the completion of the data collection. Conclusions: This cohort demonstrated that there is a subset of CVCs which remain in place at least 5 years without complications requiring removal. CRBSI was the most frequent reason for CVC loss, the CRBSI incidence was very low, and few patients used CRBSI preventative strategies. Use of transparent dressings and self care may have impacted CRBSI incidence, but more studies would be needed to confirm this finding. The years of lived experience, education, and acquired catheter care knowledge in this unique group of HPN patients probably contributed to the low CRBSI rate. The material damage and skin site breakdown may be attributed to wear and tear as the CVC aged. HPN infusion regimens, thrombosis, occlusion, and blood draws from CVC did not impact the CVC dwell time. Silicone, single lumen tunneled CVCs provided the greatest longevity with the fewest complications, making this device the best choice for most HPN patients.


Enteral Nutrition BEST OF ASPEN-ENTERAL TOPICS ABSTRACT OF DISTINCTION 2824943 - Enteral Nutrition May be Delivered Safely without Bowel Ischemia in Septic Trauma Patients with Ongoing Fluid Resuscitation and Vasopressor Requirements Megan Post, MD2; Karen Safcsak, RN1; Kojo Agyabeng-Dadzie, MD1; Indermeet Bhullar, MD, FACS1 1Surgery, ORMC, ORLANDO, FL; 2Surgery, ORMC, Orlando, FL

Purpose: The role of enteral nutrition (EN) in trauma patients with septic shock requiring ongoing fluid resuscitation and intravenous vasopressor support remains controversial. The 2016 American Society for Parenteral and Enteral Nutrition (ASPEN) Guidelines in the Critically ill recommend that in the setting of hemodynamic compromise or instability, EN should be withheld until the patient is fully resuscitated and/or stable and vasopressors are being weaned. However, whether EN is a contributor to the bowel ischemia or just a confounding variable remains to be determined. The purpose of this study was to determine if EN in trauma patients with septic shock requiring ongoing fluid resuscitation and vasopressor support lead to a significantly higher rate of bowel ischemia and mortality as compared to patients kept NPO.


Methods: A retrospective chart review was performed on all adult (age ≥16 years) trauma patients diagnosed with septic shock and requiring fluid resuscitation and vasopressor support over a two year period (2013-2014). All patients had a positive culture or gross intra-abdominal contamination. Patients were excluded if vasopressors were required for hemorrhagic, neurogenic, or cardiogenic shock, isolated adrenal insufficiency, or to meet perfusion pressure goals in the setting of spinal cord injury, traumatic brain injury or intra-abdominal hypertension. Patients were stratified into two groups: no enteral feeding (NOEF) vs. enteral feeding on vasopressors (EFOV). Demographics, Injury Severity Score (ISS), and outcomes were recorded. Rate of bowel ischemia requiring surgical resection and overall mortality was compared for the two groups. Data were analyzed using Mann-Whitney U and Fisher’s Exact tests and reported as median with interquartile range (IQR) or percentage. Results: 53 adult trauma patients met the above criteria. Of these, 10 (19%) were in the NOEF group and 43 (81%) were in the EFOV group. The groups were well matched with no significant difference in age, gender, or ISS score [NOEF vs. EFOV, 22 (16-28) vs. 22 (13-29); p=0.75]. Patients in the EFOV group were on both vasopressors and EN for a median of 4 (2-7) days. The NOEF group received more intravenous crystalloids during the first 24 hours of septic shock [NOEF vs. EFOV, 4.0 (1.4 -6.7) vs. 2.0 (1.1-3.2) liters; p=0.03]. There was no difference between the highest norepinephrine dose [NOEF vs. EFOV; 0.6 (0.07-1) vs. 0.5 (0.2-1) mcg/kg/min; p=0.72] and percent of patients receiving vasopressin in addition to norepinephrine [NOEF vs. EFOV; 30% vs. 16%, p=0.38]. However, the EFOV group received vasopressors for a significantly longer time [EFOV vs. NOEF, 79 (32-173) vs. 14 (7-34) hours; p=0.003]. One patient in the NOEF group developed bowel ischemia based on CT scan; the family refused surgery and patient was withdrawn. No patients in the EFOV group underwent bowel resection for ischemia. There was no difference between the two groups in hospital length of stay (LOS) [EFOV vs. NOEF; 32 (19-44) vs. 19(9-41) days; p=0.14] however, ICU LOS was significant longer in the EFOV group [EFOV vs. NOEF, 17.0 (11-24) vs. 9.5 (7-14) days; p=0.03]. There was no difference in overall mortality (EFOV vs. NOEF; 30% vs. 40%, p=0.71). Conclusions: Enteral nutrition may be delivered safely in trauma patients with septic shock and ongoing fluid resuscitation and vasopressor support without the previously proposed risk of bowel ischemia. Further large scale randomized studies are needed to verify if EN is more a confounding variable rather than a causative agent toward developing bowel ischemia.


INTERNATIONAL ABSTRACT OF DISTINCTION 2833597 - Endoscopic Versus Radiological Percutaneous Gastrostomy: Perioperative and Postoperative Complications at a Tertiary Hospital in Spain. Sara Valle, MD1; Rebeca Sánchez, MD1; Estrella Diego, MD1; Pedro González, MD1; Ana Manchón, RN1; María Inmaculada Ortiz, RN1; Javier Izquierdo, MD2; David Coto, MD3 1Endocrinology and Nutrition, Cruces University Hospital, Barakaldo, Spain; 2Interventional Radiology, Cruces University Hospital, Barakaldo, Spain; 3Gastroenterology, Cruces University Hospital, Barakaldo, Spain

Purpose: Percutaneous gastrostomy is the preferred route of artificial nutrition in patients unable to maintain adequate caloric intake orally for a prolonged period of time when gut function is maintained. The aim of this study was to investigate the perioperative and postoperative complications of percutaneous gastrostomy at a tertiary university hospital in Spain, and to compare these complications between the two most common methods used for its placement: percutaneous endoscopic gastrostomy (PEG) vs percutaneous radiological gastrostomy (PRG). Methods: This was a retrospective, observational review of 270 adults who underwent a gastrostomy procedure from January 1, 2011 to December 31, 2016. Patients who had initial PEG (20 French, rigid internal bumper) or PRG (14 French, internal balloon) inserted for nutritional purposes were included in the study. The patient selection for each technique was made using a protocol-based strategy: PRG was placed in patients with stenotic lesions which could make the advance of the endoscope difficult, and PEG in the remaining patients. Data on sex, age, date and reason for the tube insertion, placement


technique used, date and type of peri and postoperative complications and date of the last consultation or death were collected. Statistical analysis was performed using independent t test and χ2 test (SPSS version 23.0). Results: Baseline characteristics of patients are shown in Table 1. The median follow-up period from the tube insertion until the last consultation or death date for the entire cohort was 18.9 ± 17.7 months (range: 0.03–71.71). There were no differences in mortality between PRG (65.6%) and PEG (60.2%) groups, but the follow-up period from the tube placement until the death date was significantly different, 14 ± 15.1 months in the PEG group vs 9 ± 8.6 months in the PRG group. The gastrostomy was removed due to lack of use in 22.3% of patients in the PRG group vs 14.2% in the PEG group with no significant differences between them. It should be noted that 107 patients in the PRG group (68.2%) had at least one complication compared to 51 patients in the PEG group (45.1%), P = .0001. The type of complications observed are detailed in Table 2. Hypergranulation tissue appeared 7.2 ± 5.6 months after tube insertion in the PEG group vs 4.1 ± 4.2 months in the PRG group, mean difference 3.1 (95% CI, 0.98–5.33). The gastrostomy broke down 13.1 ± 3.4 months after PEG placement vs 8.2 ± 6 months after PRG, mean difference 4.9 (95% CI, 0.26–9.5). There were no more significant differences in the time of appearance of other complications between the both groups. It should be pointed out that 3 gastrostomy-related deaths were observed, all three in the PEG group. The causes of these deaths were colonic perforation, upper gastrointestinal hemorrhage caused by esophagitis and airway obstruction due to aspiration. All were perioperative complications. Conclusions: The number of postoperative complications in our hospital were appreciable, especially the formation of hypergranulation tissue, stoma infection, gastrostomy clogging and dislodgement, all observed mainly after PRG insertion. Both tube clogging and dislodgement could be secondary to the gastrostomy design. Few perioperative complications were observed, but as opposed to the postoperative complications, they were found particularly after PEG placement. It should be noted that some of them were life-threatening.


Table 1. Baseline Patient Characteristics.

Characteristic PRG (N = 157) PEG (N = 113)

Age, y

Mean 65.5 68

SD 11.5 15.4

Range 39–90.1 18–95.8

Sex, No. (%) Male 128 (81.5) 59 (52.2)

Female 29 (18.5) 54 (47.8)

Type of dysphagia, No. (%) Oropharyngeal 115 (73.2) 111 (98.2)

Esophageal 42 (26.8) 2 (1.8)

Causes of dysphagia, No. (%)

Structural 149 (94.9) 3 (2.7)

Neurological 7 (4.5) 106 (93.7)

Myopathic 1 (0.6) 3 (2.7)

Iatrogenic 0 (0) 1 (0.9)

Table 2. Type of complications.

Complication, No. (%) PRG (N = 157) PEG (N = 113) P Value

Hypergranulation tissue 77 (49) 33 (29.2) .001

Stoma infection 37 (23.6) 13 (11.5) .012

Dislodgement of the tube 35 (22.3) 10 (8.8) .003


Clogging 25 (15.9) 2 (1.8) .0001

Tube break down 21 (13.4) 8 (7.1) n.s

Enlarging tract diameter 5 (3.2) 4 (3.5) n.s

Abdominal wall abscess 3 (1.9) 1 (0.9) n.s

Perioperative complication 1 (0.6) 6 (5.3) .023

n.s, not significant (P < .05).

ABSTRACT OF DISTINCTION 2833548 - Outcomes in critically ill hemodynamically unstable postoperative cardiac surgery patients with the implementation of Cardiovascular Intensive Care Unit (CVICU) enteral nutrition guidelines. Ranna Modir, MS, RD, CNSC, CDE1; Charles Hill, MD2; Philip Oyer, MD3 1Clinical Nutrition , Stanford Hospital , Stanford, CA; 2Anesthesia-Cardiac, Stanford University, Stanford, CA; 3Cardiothoracic Surgery-Adult Cardiac Surgery, Stanford University , Stanford, CA

Purpose: Postoperative cardiothoracic surgery patients are challenging to feed enterally when hemodynamically unstable, on high doses of vasoactive medications or requiring mechanical circulatory support. The lack of expert consensus on management of nutrition in this patient population may enhance the risk of bowel complications and suboptimal enteral nutrition (EN). The variability in enteral feeding initiation, duration and cessation in the setting of hemodynamic instability is associated with onset of malnutrition and gastrointestinal (GI) complications including postoperative ileus and bowel ischemia. Most clinical nutrition guidelines for hypo-perfused patients focus on septic shock as the etiology for hemodynamic compromise. Currently, there is limited guidance for nutrition in postoperative cardiothoracic surgery patients with circulatory compromise. To address the need for optimizing nutrition in this patient population, we created High Risk Enteral Nutrition Guidelines to provide clinical nutrition decision support for hemodynamically unstable post cardiothoracic surgery patients. Methods: The High Risk EN Guidelines included specifics on route, timing, type of formula, feeding rate, progression, monitoring, and energy targets for enteral nutrition. Additionally, guidelines for when to initiate total parenteral nutrition (TPN) were included. CVICU staff were educated about the High Risk EN Guidelines and a laminated pocket-sized card was created as a reference and visual aid. The guidelines were utilized on critically ill CVICU patients that met at least two of the following criteria: cardiogenic shock requiring ECMO cannulation, low cardiac output on high dose vasopressor/inotrope support, open chest, mechanical ventilation >48 hours and signs of end organ dysfunction. Tube feeds were initiated on postoperative day 2-3 if the following hemodynamic parameters were met: vasopressor and inotrope requirements were stable or declining to support MAP goals >60-70 mm/hg, epinephrine dose 0.08 mcg/kg/min or less, vasopressin 0.04 units/min or less, cardiac index >2.2, mixed venous oxygen saturation >60%. EN tolerance was monitored via abdominal exams and nasogastric tube output q 8 hrs. EN was held in the setting of hypotension (MAPS <60-70 mm/hg with increasing vasopressor support) and signs and symptoms of worsening GI function (abdominal distension, rapid increase in gastric tube output). Guidance was provided on the appropriateness of TPN initiation to prevent excessive calorie and protein deficits. Results: Prior to implementation of the High Risk EN guidelines retrospective chart data analysis for post cardiac critically ill CIVCU patients in 2016 revealed inconsistent post op feeding practices in addition to several cases of severe GI complications. The High Risk EN guidelines were implemented in March 2017 and utilized on fourteen CVICU critically ill patients. CVICU team adherence rate to the all High Risk EN guidelines criteria (including initiation of EN, RN titration of EN of 10 ml q 12-24 hours, appropriate EN holds and TPN initiation) by the CVICU team was 86%. No patients developed GI complications such as bowel ileus or ischemia. The implementation of these guidelines enhanced the CVICU multidisciplinary


team discussion around identifying patients at high risk for GI complications and promoting the safe provision of EN. Conclusions: Feeding the critically ill hemodynamically unstable post-cardiac surgery patient remains a controversial topic among CVICU practitioners and nutrition support clinicians. Implementation of EN guidelines targeted for post cardiothoracic surgery patients with circulatory compromise may align feeding practices amongst critical care teams, improve nutrient delivery and decrease EN related complications.



2834818 - Comparison of Syringe Compression Force with ENFit and Legacy tubes Manpreet Mundi, MD2; Wanda Duellman, RDN4; Lisa Epp, RDN3; Ryan Hurt, MD1 1Mayo Clinic, Rochester, MN; 2Division of Endocrinology, Mayo Clinic, Rochester, MN; 3Endocrinology, Mayo Clinic Rochester, Rochester, MN

Purpose: Enteral tube misconnections resulting in morbidity and mortality have led to the introduction of standard small-bore connector (International Organization for Standards 80369-8; ENFit). During this


time, multiple large surveys have indicated increasing prevalence of blenderized tube feeding (BTF). The full impact of transition to ENFit for both syringe feeding and BTF is currently not known. Methods: Working with major manufacturers and Food and Drug Administration, we obtained ENFit and Legacy tubes of varying sizes including 14 French (Fr), 18 Fr, 20 Fr, 24 Fr, and low-profile. Formulas including commercially available as well as our own recipe were then placed in a 60-ml syringe and the force (Newtons) required to compress the syringe was captured. The formulas tested included Jevity 1cal, Nourish, Real Food Blends, as well as Mayo Clinic standard blended tube feeding recipe blended for both 3 minutes and 6 minutes with three commercially available blenders. In addition to assessing the force, least squares regression analysis was performed to assess the impact of tube size, recipe, blender and blended time on force. Results: Each respective formula and tube size were tested in triplicate for all of the legacy and ENFit tubes. The data for all legacy tubes and all ENFit tubes was combined in aggregate and analyzed for statistical significance (Table 1). For Jevity 1Cal, the 20 Fr tubes reached statistical significance with the ENFit tubes having lower syringe compression force than the legacy tubes. For the Mayo Clinic Recipe, the 14 Fr tube reached significance with the legacy tubes having lower syringe compression force when compared to ENFit tubes. All remaining comparisons did not reach significance. For the Least squares analysis, Model 1 included all recipes, tube sizes, and variable of legacy versus ENFit and noted that Recipe and tube size remained significant while legacy versus ENFit did not. Similarly, in Model 2, Mayo Clinic Recipe was analyzed for impact of tube size, blender utilized, blend time of 3 minutes versus 6 minutes, as well as legacy versus ENFit tubes. Again, all variables except for Legacy versus ENFit were significant. Conclusions: Transition to ENFit (standard small-bore connector) is one of the largest changes to take place in Home Enteral Nutrition. In order to analyze the impact of this transition for patients who provide enteral nutrition (commercial formula or BTF) through syringe feedings, we analyzed the syringe compression force required and noted no major difference between ENFit and Legacy tubes except with 20 Fr tubes and Jevity as well as Mayo Clinic recipe and 14 Fr tubes. Regression analysis also revealed that Legacy versus ENFit did not make a significant impact on force measurements, while tube size, choice of recipe, blender, and time of blending remained significant.



Table 1: Aggregate force data (newtons) of legacy versus ENFit tubes.

Figure 1: Fit Model comparing formula, tube size, and legacy versus ENFit.


Figure 2: Fit Model comparing tube size, blender, time of blending, and legacy versus ENFit. 2834215 - PEPuP (Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol) in Surgical Patients – A Multicenter Pilot Randomized Controlled Trial. D. D. Yeh, MD, CNSC2; Luis A. Ortiz, MSc3; Jae M. Lee, BA3; Jeffrey Chan, MD4; Katherine McKenzie, DO5; Brian Young, MS, RD, CNSC6; Lindsay Chetelat, RD, CDN, CNSC4; Bryan Collier, DO, CNSC7; Andrew Benson, BS 8; Daren K. Heyland, MD1 1Queen's University, Kingston, Canada; 2Surgery, University of Miami, Miami, FL; 3Surgery, Massachusetts General Hospital, Boston, MA; 4Surgery, Jamaica Hospital Medical Center, New York, NY; 7Surgery, Carilion Clinic, Roanoke, VA

Purpose: Standard nutrition practice in the ICU results in an average 40-50% delivery of prescribed nutritional requirements. In mostly medical patients, PEPuP has been shown to be feasible, safe, and effective in delivering significantly more calories and protein, though PEPuP has not been well studied in surgical and trauma patients. We hypothesized that PEPuP will be safe, acceptable, and effectively increase protein and energy delivery to critically ill surgical patients. Methods: This multicenter, prospective, randomized controlled study included adult patients expected to require mechanical ventilation for >24 h and require ICU care for > 72 h. Patients with limitations in goals of care, death expected within 24 h, and a contraindication to enteral nutrition (EN) were excluded. Subjects were randomized in a 1:1 ratio to PEPuP or standard of care (SOC). The PEPuP protocol includes: initiation at goal rate, semi-elemental formula, prophylactic prokinetic agents, 24 h volume-based goals, modular protein supplementation. The primary outcome was nutritional adequacy over the first 12 ICU days. If a subject vomited during a 12-h period, that was counted as one vomiting occurrence. The vomiting rate was defined as incidence of such occurrences as a percentage of total 12-h periods observed. Because of the novelty of the protocol, the first 2 to 5 subjects enrolled at each site were classified as “run-in” phase and were excluded from analysis. Results: A total of 832 patients were screened, 236 met inclusion criteria, 128 were approached, and 36 subjects were enrolled and randomized (10 run-in patients). Three sites participated and the screening


rate/month was 2.9, 1.4, and 1.5. The recruitment rate/month was 1.2, 0.05, and 0.6. Twenty-seven subjects (27% of goal) were enrolled before the trial was terminated early by the sponsor for slow recruitment. Most eligible patients (92 of 128) approached for consent were not enrolled and the most common reasons were: no next of kin (48) and refused consent (22). There were no baseline differences between subjects randomized to PEPuP and SOC (Table 1). PEPuP protocol violations were common: 2 (15.4%) did not receive prokinetics, 3 (23.1%) did not receive volume-based feeds as ordered, and 4 (30.8%) did not receive supplemental protein. Despite these violations, PEPuP patients received more protein (119.5± 32.2 vs. 80.3± 31.6 g, p=0.004) than SOC; the difference in absolute calories was clinically important, but did not reach statistical significance (1502.9±368.2 vs. 1211.5±456.2 kcal, p=0.09). The weight-normalized protein delivery was significantly greater in PEPuP patients (1.3± 0.3 vs. 1.0± 0.3 g, p=0.03), but the weight-normalized caloric difference was not significant (16.2± 4.6 vs. 14.7± 5.4 kcal, p=0.45). There was one severe adverse event in the PEPuP arm: temporary QTC prolongation, possibly related to metoclopramide, which resolved upon med discontinuation. Vomiting was more common in the PEPuP patients (46% vs. 8%, p=0.03). Conclusions: In surgical/trauma patients, PEPuP was difficult to implement but it seemed to improve protein and caloric delivery in this underpowered trial.

Financial support received from: Nestle Health

Table 1 - Baseline characteristics and nutrition


Table 2 - Primary and Secondary Outcomes 2835222 - Nutrition delivery in neurocritical care –below recommendations, but not associated with mortality Kelly Roehl, MS, RDN, LDN, CNSC1; Courtney Schuchmann, MS, RDN, LDN3; Sarah Peterson, PhD, RDN, LDN, CNSC2 1Rush University Medical Center, Chicago, IL; 2Clinical Nutrition, Rush University Medical Center, Chicago , IL; 3University of Chicago Medical Center, Chicago, IL

Purpose: Objective: Nutrition support is a common feeding modality in the neurocritical care unit; however, there is a lack of consistency in feeding recommendations and practices with this population. There is a lack of correlation between feeding and mortality, likely due to of a lack of research. The objective of this quality improvement (QI) project was to determine adequacy of enteral nutrition (EN) delivery among neurocritical care patients. Methods: Methods: Adult patients aged >18 years, admitted to the neuroscience intensive care unit (NSICU) at a large academic medical center between 7/1/14 to 7/1/16 for >72 hours, requiring mechanical ventilation and enteral nutrition (EN) support at any time during NSICU admission were included in the analysis. Frequency and descriptive statistics were used to describe the sample and chi-square and t-tests were used to determine differences in categorical and continuous variables, respectively. Pearson correlation was used to assess linear relationships between continuous variables. Associations between mortality and nutrition delivery were determined by logistic regression. Results: Results: Of the 700 encounters, 250 were randomly selected as part of the QI review, and 196 met inclusion criteria. The sample was primarily male (57%), aged 61+14 years, and obese (BMI 31+10


kg/m2). Despite obesity, 31% were deemed malnourished upon admission based on subjective global assessment (SGA) scores of B/C; Table 1. Admission diagnoses included intracranial hemorrhage (ICH) (29%), status epilepticus (SE) (16%), subarachnoid hemorrhage (SAH) (11%), ischemic stroke (10%), subdural hematoma (SDH) (8%) and brain mass (5%). Mean ICU and hospital LOS were 17.6+9.6 and 12.5+7.5, days, respectively, and 12-month mortality was 30% (n=58); Table 2. A total of 74% received nutrition (EN or PO) within 72 hours of NSICU admission, with mean EN and NPO days of 8.5+3.7 and 3.1+1.9 days, respectively. Enteral nutrition was ordered during 48% of total hospital days, though only delivered for 41%, with 18% of hospital days having zero nutrition delivery. Mean energy delivery via EN was 11.6+5.1 kcal/kg/day, mean protein 0.6 g protein/kg/day. A total of 22% of patients received only trophic feeds of <500 kcal/day through duration of stay, while 45% received >50% of goal energy, and 33% received >80%. Early EN within first 72 hours was not associated with high total kcal/kg/day delivery, but was associated with higher total EN days (P<0.001). Average kcal/kg/day delivery was associated with longer ICU LOS (r=.153, P=0.03), but not hospital LOS. Neither nutrition delivery nor timing were associated with mortality. Conclusions: Conclusion: More recent guidelines recommend that patients at high nutrition risk receive EN within 48 hours of ICU admission, and goal nutrition within 72 hours, nutrition delivery among neurocritically ill patients in our sample failed to reach this target, and was well below that of previously reported literature. Neither nutrition timing nor delivery (either low or high) appears to be associated with mortality in the current sample or previous literature. More research is needed to better understand appropriate timing and dosing recommendations for the unique neurocritical care population.




Malnutrition, Obesity, and Practice Concepts BEST OF ASPEN-MALNUTRITION, OBESITY, AND PRACTICE CONCEPTS ABSTRACT OF DISTINCTION 2821521 - Sarcopenia Supersedes Subjective Global Assessment as a Predictor of Survival in Colorectal Cancer. Pankaj Vashi, MD; Kim Gorsuch , BSN, RN; Danielle Hill, RD, LDN; Amie Nader, RT; Digant Gupta, MD, MPH Gastroenterology/Nutrition, Cancer Treatment Centers of America, Zion, IL

Purpose: Sarcopenia, an objective marker of muscle mass depletion, is classified according to sex-specific international consensus definitions based on the skeletal muscle index (SMI), which may be reproducibly measured using cross-sectional imaging modalities such as computed tomography (CT). Subjective Global Assessment (SGA), on the other hand, is a widely utilized subjective instrument to assess nutritional status (a large component of which is muscle mass). Our prior research has shown a weak correlation between these two measures, such that a significant proportion of patients identified as well-nourished by SGA were found to be sarcopenic. Both CT-assessed sarcopenia and SGA-assessed malnutrition, in isolation, have been identified as poor prognostic factors of overall survival in a wide range of cancers. However, there is little to no research evaluating the independent prognostic significance of both sarcopenia and malnutrition as part of the same analysis. We therefore investigated the impact of sarcopenia on overall survival in colorectal cancer specifically controlling for the effects of malnutrition. Methods: This was a retrospective study of a consecutive case series of 79 patients with colorectal cancer first seen at our institution between August 2012 and July 2016. Using CT imaging, the cross-sectional area of muscles at the L3 vertebral level was measured and then divided by height squared to calculate the SMI – a measure of sarcopenia. In accordance with previously published literature, sarcopenia was defined as SMI ≤38.5 cm2/m2 for women and ≤52.4 cm2/m2 for men. Overall survival was defined as the time interval between the date of first contact at our institution and the date of death from any cause or the date of last contact. The effect of sarcopenia on overall survival was expressed as hazard ratios (HRs) with 95% confidence intervals (CIs) using Cox regression analyses after adjusting for relevant confounders. Results: Mean age at presentation was 52.3 years. Forty-one (51.9%) patients were males while 38 (48.1%) were females. Fifty-six (70.9%) patients had colon cancer while 23 (29.1%) had rectal cancer. Fifty-two (65.8%) patients had metastatic disease at diagnosis. Forty-eight (60.8%) patients were newly diagnosed while 31 (39.2%) were previously treated. The mean BMI was 29.1 kg/m2. Using SMI, 34 (43%) patients were sarcopenic while 45 (57%) were non-sarcopenic. Using subjective global assessment (SGA), 48 (60.8%) patients were well-nourished while 29 (36.7%) were malnourished. A total of 19 (24.1%) patients were both sarcopenic and malnourished. At the time of this analysis (July 2017), 45 (57%) patients had expired while 34 (43%) were considered censored. On univariate analysis (Table 1), only sarcopenia demonstrated a statistically significant association with survival. The median survival in sarcopenic and non-sarcopenic patients was 17.8 and 30.3 months respectively (p=0.007), as shown in Figure 1. On multivariable analysis (Table 2), after adjusting for age, gender, tumor stage, BMI, treatment history and SGA, patients with sarcopenia had 3.6 times greater risk of mortality compared to those without sarcopenia (p=0.001). The median survival of patients with both sarcopenia and malnutrition was 13.5 months (95% CI: 10.6 to 16.3) as compared to the median survival of 36.8 months (95% CI: 27.6 to 32.9) in patients who were either sarcopenic or malnourished but not both (p=0.009). Conclusions: The presence of sarcopenia supersedes the presence of malnutrition as a predictor of survival in colorectal cancer. Co-existence of sarcopenia and malnutrition is associated with worse survival in colorectal cancer compared to just either one of those conditions being present.



Table 1: Univariate Survival Analysis


Table 2: Multivariable Survival Analysis


Figure 1: Overall survival stratified by baseline sarcopenia 2830080 - Relationship between resting energy expenditure and muscle mass among critically ill patients Faith Doan, MS, RD 2; Sarah Peterson, PhD, RD, CNSC1; Kristen Lach, MS, RD 1; Sharon Foley, PhD, RD2 1Clinical Nutrition, Rush University Medical Center, Chicago , IL; 2Clinical Nutrition, Rush University, Chicago, IL

Purpose: Indirect calorimetry is the gold standard for determining resting energy expenditure (REE) in the intensive care unit (ICU). However due to difficulties with this technology, predictive equations are used despite the possibility of inaccurate estimation of energy requirements. The variability between measured and estimated calorie requirements may result from differences in body composition, specifically muscle mass at it is a significant predictor of resting energy expenditure. Methods: A retrospective convenience sample of critically ill, mechanically ventilated patients with REE


measured via indirect calorimetry between August 2007 – August 2016 and a diagnostic abdominal computed tomography (CT) scan were included. Age,height, weight and body mass index (BMI) were recorded. Estimated energy requirements were calculated. Cross-sectional muscle area (cm2) was determined and skeletal muscle index (SMI, cm2/height (m2)) was used to categorize low muscle mass (BMI <25kg/m2: <43 cm2/m2, men/women BMI >25kg/m2: SMI <53cm2/m2 and <41cm2/m2), respectively. Pearson’s correlation coefficient was utilized to describe the relationship between REE and muscle mass. Linear regression was used to determine the predictors of resting energy expenditure. Results: 47 mechanically ventilated ICU patients were used in the analysis. Resting energy expenditure and muscle mass were significantly correlated (r=0.610, p<0.001). Skeletal muscle index (r=0.437, p=0,001), BMI (r=0.310, p=0.034) and age (r= -0.387, p<0.007) were also correlated with REE. Linear regression revealed 37% of the variation in REE was attributed to muscle mass (r2) =0.37) with each centimeter square increase raising the REE by 8.67 calories (p<0.001). When cross sectional muscle area, BMI, and age were entered into the regression model, only cross-sectional muscle area and age were found to be significant independent predictors of REE (r2) =0.43). After controlling for age, each centimeter square increase in skeletal muscle cross sectional area increased REE by 7.75 calories (p<0.001). Conclusions: This data demonstrates a significant relationship between REE measured by indirect calorimetry and muscle mass determined by CT imaging in mechanically ventilated, ICU patients. In the current sample, it appears REE is influenced by age in addition to cross-sectional muscle area. Knowing the predictors of REE in critically ill patients may better inform calorie dosing in this population, especially as routinely used predictive equations inaccurately estimates energy needs. However, an abdominal CT scan is not routinely ordered for every patient in the ICU, which indicates future investigation into the relationship of muscle mass and REE in other types of patients.


2835165 - A retrospective evaluation of the relationship between skeletal muscle mass and clinical outcomes in enterocutaneous fistula patients undergoing fistula takedown. Jamie E. Basham, PharmD2; Daniel P. Griffith, RPh3; Vivian M. Zhao, PharmD4; Nisha J. Dave, PharmD5; Andrew B. Lemmon, MD7; Thomas Ziegler, MD1; John R. Galloway, MD6 1Emory University, Atlanta, GA; 2Pharmacy, Iredell Memorial Hospital, Davidson, NC; 3Pharmacy, Emory University Hospital, Atlanta, GA; 4Pharmacy, Emory University Hospital , Atlanta, GA; 6Surgery, Emory University Hospital , Atlanta, GA; 7Radiology, Emory University, Atlanta, GA

Purpose: High output fistulae result in fluid, electrolyte, and nutrient losses causing consequent malnutrition. Enterocutaneous fistula (ECF) takedown is a common surgical treatment option for these patients. Several recent studies have shown that low skeletal muscle mass area is a risk factor for mortality in mechanically ventilated critically ill patients. One study found that low skeletal muscle mass area assessed by computerized tomography (CT) during the early stage of critical illness is a risk factor for mortality independent of sex and APACHE II score. Measurement of skeletal muscle mass allows for the early identification of at-risk patients who may benefit from aggressive and multidisciplinary nutrition and rehabilitative strategies. Currently, there is a lack of literature available looking at skeletal muscle mass area in ECF patients. The purpose of this study is to determine if low skeletal muscle mass area at the L3 position, measured by CT scan, is a predictor of postoperative clinical outcomes after ECF takedown. Methods: The primary objective of this study was to determine whether preoperative low skeletal muscle mass area is a risk factor for postoperative hospital length of stay in ECF patients undergoing fistula takedown. Secondary objectives were to assess all-cause mortality at 30 days, 60 days and 6 months after ECF takedown, parenteral nutrition requirements, intensive care unit (ICU) length of stay, incidence of refistulization at 30 days and 6 months, hospital readmissions within 6 months, incidence of postoperative dialysis requirements, and the incidence of postoperative infection. A retrospective chart review was conducted to include patients at least 18 years old who were admitted for ECF takedown from January 1, 2011 to June 30, 2015 and had an abdominal CT scan available within 2 months prior to their


surgery. Exclusion criteria included missing height or body weight information or death within 48 hours post-operation. Patients were divided into three different groups based on CT-determined skeletal muscle mass: low (≤ to 110cm2), medium (111-150 cm2), and high (>150 cm2) skeletal muscle mass area, respectively. Results: A total of 56 patients met inclusion criteria. Twenty-three, 27, and 7 patients were in the low, medium, and high skeletal muscle mass groups, respectively. Days on parenteral nutrition after ECF takedown was highest in the low skeletal muscle mass group (35.1 days) versus 26.6 and 28.7 days for the medium and high skeletal muscle mass groups, respectively. All cause mortality, hospital length of stay, postoperative infection and incidence of refistulization was similar between groups. The number of patients with ICU readmissions within 6 months after ECF takedown was highest in the low skeletal muscle mass group (39.1%) versus 23.1% and 14.3% in the medium and high skeletal muscle mass groups, respectively. Conclusions: Low skeletal muscle mass may be a predictor of parenteral nutrition requirements and ICU readmission rates in adults undergoing ECF takedown. Prospective, controlled studies are needed to confirm these findings and to assess the impact of nutrition support regimens on postoperative skeletal muscle mass and clinical outcomes in this extremely catabolic patient population.


2830644 - Dietary Effects of Polyunsaturated Fatty Acids on Bone Lorenzo Anez-Bustillos, MD3; Maria B. Cubria, MD5; Amin Mohamadi, MD MPH1; Duy T. Dao, MD3; Amy Pan, BA4; Meredith A. Baker, MD3; Gillian L. Fell, MD PhD3; Kathleen M. Gura, PharmD2; Ara Nazarian, PhD1; Mark Puder, MD PhD6 2Pharmacy, Boston Children's Hospital, Boston, MA; 3Vascular Biology Program and The Department of Surgery, Boston Children's Hospital, Boston, MA; 5Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Boston, MA

Purpose: Altering the lipid component in diets may affect the incidence of metabolic bone disease in patients dependent on parenteral nutrition. Consumption of polyunsaturated fatty acids (PUFA) can impact bone health by modulating calcium metabolism, prostaglandin synthesis, lipid oxidation, osteoblast formation, and osteoclastogenesis. The purpose of this study was to evaluate the dietary effects of PUFA on murine bone health. Methods: Three-week-old male (n=30) and female (n=30) C57BL/6J mice were randomized into one of three dietary groups. The diets differed only in fat composition: soybean oil (SOY), rich in ω-6 PUFA; docosahexaenoic acid alone (DHA), an ω-3 PUFA; and DHA with arachidonic acid, an ω-6 PUFA, at a 20:1 ratio (DHA/AA). After 9 weeks of dietary treatment, femurs were harvested for micro-computed tomographic analysis (microstructure) and mechanical testing via 3-point bending (Figure 1). Separate mice from each group were used solely for blood draws on days 1, 32, and 63 after diet initiation, for measurement of biomarkers of bone formation (N-terminal propeptide of type 1 procollagen - P1NP) and resorption (N-telopeptide of type 1 collagen - CTX). Groups were compared within gender with one-way ANOVA, considering p<0.05 as statistically significant. Results: At the microstructural level, female mice in the DHA group had higher cortical bone area, although this group had lower cortical mineral density when compared to SOY. There were no differences in cortical thickness or in any of the parameters assessing trabecular bone except for apparent mineral density, which was higher in SOY compared to DHA/AA. Cortical bone parameters in male mice did not differ across dietary groups. However, trabecular number and separation were significantly higher and lower, respectively, in the DHA/AA and DHA groups compared to SOY. Trabecular thickness was higher in the SOY group compared to DHA. At the mechanical level, no differences were noted across dietary groups within gender (stiffness, Young’s modulus, yield load, and ultimate load). There were no differences across dietary groups within gender at any of the timepoints evaluating P1NP and CTX. Conclusions: Subtle differences were noted at the bones’ microstructural level that may suggest a beneficial effect of diets enriched with ω-3 fatty acids. Changes in trabecular bone, which is more metabolically active, are more likely to be seen given the relatively short-term exposure of PUFA in this


experiment, as occurred in male mice. These differences were not seen at the mechanical level, nor were they reflected in blood-based biomarkers of bone metabolism. Future research will focus on the effects of long-term exposure of dietary PUFA, as well as their role in preventing bone deterioration in pathologic states.


INTERNATIONAL ABSTRACT OF DISTINCTION 2833720 - Randomised controlled trial shows ready-made low volume energy dense oral nutritional supplements reduce health care use in malnourished free living older people. Trevor R. Smith, DM FRCP1; Natasha Guildford, BSc (hons) RD2; Abbie L. Cawood, PhD, RNutr3; Emily R. Walters, MSc, RD4; Jacqui Cotton, PhD, RD, RPHNutr2; Rebecca J. Stratton, PhD, RD, RNutr3 1Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; 2Department of Dietetics and Speech and Language Therapy, Southampton, United Kingdom; 3Faculty of Medicine, University of Southampon, Southampton, United Kingdom; 4Faculty of Health Sciences, University of Southampton, Southampton, United Kingdom

Purpose: Disease-related malnutrition continues to be a common and costly public health problem especially in older community based adults, with 90% of malnutrition orginating in the community and older adults accounting for 52% of the total costs of malnutrition1. There remains a lack of large randomised trials in free living older people assessing the effect of oral nutrition support on nutritional and economic outcomes. This randomised controlled trial investigated the effect of energy dense oral nutritional supplements (ONS) and simple dietary advice (DA) on intake, weight and health care use in older free living individuals. Methods: 308 free living older people (>50years) recruited through General Practitioners in England (mean age 71.5±10.7years; Body Mass Index 19.4±2.5kg/m2, Charleston Comorbidity Index (CCI) 1.02±0.93, 67% female) at risk of malnutrition (according to the Malnutrition Universal Screening Tool ‘MUST’2) were randomised to receive readymade low volume ONS (Fortisip Compact range, Nutricia;


2.4kcal/ml) plus DA (n154) or DA alone (as a diet sheet) (n154) for 12 weeks. Over the intervention period, total nutritional intake (24 hour recalls) and weight was measured. Health care use (hospital admissions, length of stay and health care professional (HCP) visits) was recorded in a participant diary and confirmed by researchers at scheduled home visits. Results were analysed on a per protocol (PP) and intention to treat (ITT) basis, controlled for baseline values, age, gender, ‘MUST’ category and CCI. Outcomes did not differ between groups at baseline. Results: The ONS+DA group had significantly greater total energy (+401kcal/d) and protein intakes (+15g/d) and a significantly greater increase in body weight (+0.8kg) than the DA group alone over 12 weeks (ITT). There were significantly fewer GP and HCP visits (ITT), emergency admissions (PP) and shorter length of stay (PP) with ONS+DA compared to DA alone (table 1). Overall in the ONS+DA group compared with the DA group, GP and HCP visits were reduced by 34%, emergency admissions reduced by 50% and length of hospital stay reduced by 62% (ITT). Conclusions: This large randomised trial shows that readymade, low volume, energy dense oral nutritional supplements are effective at increasing total nutritional intakes and weight and reducing health care use with possible economic benefits in malnourished free living older people. References: [1] Elia M, 2015 (on behalf of the Malnutrition Action Group of BAPEN and the National Institute for Health Research Southampton Biomedical Research Centre). The cost of malnutrition in England and potential cost savings from nutritional interventions. (<a href="http://www.bapen.org.uk/pdfs/economic-report-full.pdf">http://www.bapen.org.uk/pdfs/economic-report-full.pdf</a>) [2] The ‘MUST’ report. Nutritional screening for adults: a multidisciplinary responsibility. 2003, Elia M, editor, (<a href="http://www.bapen.org.uk/screening-and-must/must/must-report">http://www.bapen.org.uk/screening-and-must/must/must-report</a>)

Financial support received from: This clinical trial was sponsored by University Hospital Southampton NHS Foundation trust, and was funded with support from NIHR (National Institute of Health Research) and an unrestricted educational grant from Nutricia Ltd.

2835087 - A Survey of Nutrition Screening Practices in Pediatric Hospitals Across the United States. Coral Rudie, RD, LDN1; Sabrina Persaud, MPH1; Michelle Raymond, RD, LDN, CDE1; Susanna Huh, MD, MPH1,2 1Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Roslindale, MA; 2Department of Pediatrics, Harvard Medical School , Boston , MA

Purpose: The Joint Commission requires nutrition screening to occur on admission, and both ASPEN and ESPEN have published guidelines recommending inpatient nutrition screening. Limited data exist regarding the processes and criteria used in pediatric hospitals to screen inpatients for nutritional risk.


Our study goal was to characterize nutrition screening practices in pediatric hospitals in the United States. Methods: We identified 239 pediatric hospitals in the United States using data from the Children’s Hospitals Association (n=220), internet searches, public hospital phone directories, and social networking groups. At each pediatric hospital, we identified one potential respondent, either a clinical nutrition manager or registered dietitian, and contacted each respondent by email or phone inviting them to participate in the survey. We emailed participants a link to an electronic survey created using a secure web research electronic data capture (REDCap) system. Respondents without email addresses were mailed paper surveys with self-addressed stamped envelopes. To improve response rates, we offered a participant incentive of inclusion into 3 drawings for a gift card. We also emailed reminders to non-respondents at 2, 4 and 6 weeks after the initial email and followed up by phone. The 33-question survey queried hospital characteristics, admission nutrition screening practices, use of validated screening instruments, and methods of obtaining heights/lengths on admission. Results: Of 95 respondents with completed surveys at the time of this abstract submission, 91 (96%) reported that nutrition screening occurs at admission. Of the 91 respondents, 66% were dietitian managers, 26% were staff dietitians, and 8% were department directors. Half of the survey respondents (49%) worked at general pediatric hospitals, 16% worked at specialty pediatric hospitals, and 35% worked at pediatric units in adult hospitals. In most hospital screening protocols, nurses conducted the initial nutrition screen (92%), which occurred within 24 hours of admission (91%) and was completed in less than 5 minutes (79%). Screening criteria included anthropometrics (84%), nutritional status (64%), diet order (62%), and diagnosis (60%). In the 34 pediatric hospitals that used at least one validated nutrition screening instrument, instruments used included the PNST (n=9), MST (n=5), STAMP (n=3), SGNA (n=3), and PNRS (n=2); 12 respondents did not know which validated instrument was in use. Barriers to compliance with nutrition screening included the lack of a standard screening procedure (14%) and insufficient staff to conduct screening (10%). 52 (57%) respondents reported a desire to change their hospital’s nutrition screening process, through the use of a validated nutrition screening instrument (n=18), revised screening criteria/ process (n=15), automation (n=6), improved accuracy (n=7), mandatory screen (n=4), and increased staff available to screen patients (n=3). Conclusions: Almost all pediatric hospitals are following the Joint Commission’s recommendation for nutrition screening on hospital admission, but nutrition screening practices vary with regard to screening criteria used. Among the minority of respondents who used a validated screening instrument, a variety of screening instruments were used. Substantial variations in screening practice are likely to persist until further evidence clarifies whether specific screening criteria or instruments optimally identify malnutrition and correlate with related health outcomes.

Financial support received from: Project was supported by Provider-Payor Quality Initiative.

Critical Care and Other Critical Health Issues BEST OF ASPEN-CRITICAL CARE TOPICS ABSTRACT OF DISTINCTION 2830699 - Association Between Calorie and Protein Intake on Change in Lean Body Mass Measured by Bedside Ultrasound in Surgical Intensive Care Unit Patients. Christan Bury, MS, RD, LD, CNSC1; Robert DeChicco, MS, RD, CNSD1; Diane L. Nowak, RD, LD, CNSC1; Desiree Gordillo, MS, RD, LD, CNSC1; Nadeem Rahman, MD1; Donald F. Kirby, MD, FACP, FACN, FACG, AGAF, FASPEN, CNSC, CPNS1; Lulu He, DO1,2; Sandhya Jacob, MD1; Gail Cresci, PhD, RD1 1Cleveland Clinic , Cleveland , OH; 2Radiology, University of Pennsylvania, Philadelphia, PA

Purpose: Critical illness is physiologically and metabolically taxing resulting in hypercatabolism, loss of lean body mass (LBM) and poor clinical outcomes. Not only is it challenging to conveniently and reliably


assess LBM in the critical care setting, it remains uncertain whether nutrient delivery impacts LBM. This study’s primary aim estimated LBM changes via quadriceps muscle layer thickness (QMLT) in adult Surgical Intensive Care Unit (SICU) patients with bedside ultrasound (US), and validated QMLT measurements against healthy controls (HC). The secondary aim tested the hypothesis that calorie and protein intake is associated with QMLT changes in SICU patients. Methods: Patients expected to be fed solely via nutrition support (NS) for at least 3 days in the SICU were enrolled. Trained Registered Dietitians (RD) measured QMLT via US using previously established protocols. Measurements were taken at the mid- and one-third distance between the top of the patella and the anterior superior iliac spine. Ultrasound measurements were taken upon enrollment (day 1) and repeated 1-2 times (on average, days 4-5 & 8-10) with a maximum enrollment period of 10 days. Consistency of QMLT measurement was ensured amongst 3 RDs. Patient’s nutritional status was assessed throughout the study using the A.S.P.E.N./Academy Guidelines. Total daily energy received was calculated, differentiating between calories and protein. Fifteen HC were enrolled to validate QMLT and compare changes in LBM. Intake records were not kept for HC. De-identified ultrasounds were interpreted by a musculoskeletal radiologist. Results: Forty-seven SICU patients completed the study of which 33 had 3 total QMLT assessments. Median QMLT (% cm/day) decreased during the study period. Between the first and second US, there was a loss of 3.4% (0, 7.6; p<0.001) and 4.2% (-0.81, 7.7; p=0.05) for the mid- and one-third point, respectively. Between the second and third US, there was a loss of 8.6% (3.4, 11.9; p<0.001) and 5.5% (-1.05, 14.7; p=0.003) for the mid- and one-third point, respectively. Male gender was associated with a higher rate of QMLT decrease at the one-third point (p=0.033). On average, patients received 71% of protein and 59% of calorie needs between the first and second US measurement; and 100% of protein and 95% of calorie needs between the second and third US. Despite patients being fed better between the second and third US measurement, neither total calories nor protein were found to be associated with changes in QMLT. Because delayed feeding was prevalent, a subgroup analysis was performed on 21 subjects who started NS by ICU day 3. In this group, the average % cm loss/day at the mid-point for those receiving <60% of calorie needs trended higher compared to those receiving >80% (p=0.062). Although protein intake was not found to associate with loss of LBM, incidence of malnutrition did. Patients who were moderately or severely malnourished lost an average of 0.04 cm/day more at the mid-point compared to those with no or mild malnutrition (p=0.037). No significant change in QMLT was found among the HC. Conclusions: Assessing QMLT via US to determine LBM in SICU patients was validated as repeated ultrasounds in HC did not change. In contrast to HC, SICU patients significantly lost QMLT over a 10 day period, with greater % loss occurring after 5 days in the SICU. Those who were moderately and/or severely malnourished lost more than their SICU counterparts with no or mild malnutrition. In addition, subgroup analysis indicated early feeding may have an impact on QMLT loss. Larger, prospective randomized investigations are warranted to evaluate the effect initiation, quantity and delivery of feeding (enteral vs. parenteral; continuous vs. bolus) have on QMLT and patient outcomes.


INTERNATIONAL ABSTRACT OF DISTINCTION 2830646 - Association of calorie adequacy with 30-day mortality in critically ill surgical patients with high modified NUTRIC score Myoung Jun Kim, MD; Jae Gil Lee, MD, PhD; Yun Tae Jung, MD Department of Surgery, Division of Critical Care and Trauma Surgery, Yonsei University College of Medicine, Seoul, Korea (the Republic of)

Purpose: Patients at high risk of malnutrition benefit more from nutritional support than those at low risk. In critically ill postoperative patients with mechanical ventilation (MV) support, modified NUTRIC (mNUTRIC) score is useful in nutritional risk assessment. The aim of this study is to identify association of post-operative calorie adequacy with 30-day mortality and surgical outcomes in patients with high mNUTRIC score


Methods: We reviewed medical records of 249 patients who required ICU stay with MV support for more than 24 hours after emergency gastro-intestinal surgery for intra-abdominal infection between January 2007 and December 2016. mNUTRIC score and calorie adequacy (Calorie intake in maximum of 5 days ÷ calorie requirement x 100) were calculated for each patient. Calorie adequacy was defined as a caloric supplementation more than 70% of the required calorie. The propensity score matching was performed to adjust baseline differences of the patients in each group Results: Nutritional adequacy was assessed in both high (5-9) and low (0-4) mNUTRIC score groups. The calorie inadequacy in high mNUTRIC score group was associated with higher 30-day mortality (35.6% vs 13.3%; p = 0.014, hazard ratio 2.731 [1.068-6.986]; p = 0.036) than patients with adequate supplementation; this was not observed in low mNUTRIC score group. The result was also shown in Kaplan-Meier survival curve (p = 0.028). Calorie inadequacy in this group was not associated with postoperative leakage (13.3% vs 11.1%; p = 0.748), wound complication (31.1% vs 35.6%; p = 0.655), nor pulmonary complication (53.3% vs 60.0%; p = 0.523). Conclusions: Inadequate calorie supplementation after GI surgery is associated with higher 30-day mortality in patients with high mNUTRIC score. Adequate supplementation of calorie for critically ill post-operative patients in high nutritional risk could contribute to improvement in their survival.


TRAINEE AWARD ABSTRACT OF DISTINCTION 2834893 - Association of nutritional deficit with functional status at the time of discharge from the intensive care unit in critically ill surgical patients Shu Lu, MD2; Tiffany Otero, MD2; D. D. Yeh, MD1; Sadeq A. Quraishi, MD, MHA, MMSc2 1Massachusetts General Hospital, Boston, MA; 2Anesthesia, Critical Care and Pain Medicine, Massachusetts general hospital , Boston, MA

Purpose: Low functional status at the time of discharge from the intensive care unit (ICU) is increasingly being recognized as a risk factor for long-term morbidity and short-term mortality in critically ill patients. And although nutrition is often thought of as a modifiable risk factor for adverse outcomes in hospitalized patients, the relationship between nutritional deficit and functional status has not been well characterized in ICU patients. Therefore, our goal was to investigate whether caloric or protein deficit over the course of critical illness was associated with functional status at the time of discharge from the ICU. Methods: We performed a retrospective analysis of data from two surgical ICUs at the Massachusetts General Hospital, a large teaching hospital in Boston, MA. Nutritional deficit was categorized as either caloric or protein deficit during ICU length of stay (LOS), and estimated using the Society of Critical Care Medicine and American Society of Enteral and Parenteral Nutrition Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. Functional status was assessed using the Functional Status Score for the ICU (FSS-ICU) within 24 hours of ICU discharge. To investigate the association of caloric deficit with FSS-ICU we constructed a linear regression model, while controlling for age, sex, race, body mass index (BMI), Nutrition Risk in the Critically Ill (NUTRIC) score, and ICU LOS. A similar model was constructed to investigate the association of protein deficit with FSS-ICU. Based on previous work from our group, we then dichotomized caloric deficit (<6000 vs. ≥6000 kcal) as well as protein deficit (<300 vs. ≥300 grams), and performed logistic regressions to investigate their association with functional status, while controlling for the same variables in the previous models. Results: 976 patients comprised the analytic cohort. Mean age and BMI were 62 ± 16 years and 29 ± 7 kg/m2, respectively. The mean NUTRIC score in this cohort was 4 ± 2. In the linear rgerssion models, each unit decrement in FSS-ICU score was associated with a caloric deficit of 238 kcal (237.88; 95%CI 75.13-400.63) and a protien deficit of 14 grams (14.23; 95%CI 4.46-24.00). In the logistic regression models, each unit decrement in FSS-ICU was associated with a 6% likelihood (1.06; 95%CI 1.01-1.14) of caloric deficit ≥6000 vs. <6000 kcal and a 8% likelihood (1.08; 95%CI 1.01-1.15) of protien deficit ≥300 vs. <300 grams.


Conclusions: In our cohort of surgical patients, nutritional deficit over the course of critical illness was associated with functional status at the time of discharge from the ICU. Future studies are needed to determine whether aggressive nutritional supplementation can improve functional status in critically ill patients.


2832646 - Whole-Food Enteral Nutrition but Not Standard Chemically-Defined Formulas Improves Outcomes and Prevents Gut Dysbiosis in a Murine DSS-Colitis Model. Andrew Yeh, MD1,2; Eric Conners, BSc2; Brian Firek, MS 2; Matthew B. Rogers, PhD2; Richard Cheek, MD2; Michael J. Morowitz, MD2 1Surgery, University of Pittsburgh, Pittsburgh, PA; 2Division of Pediatric General and Thoracic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA

Purpose: Critically ill patients that cannot eat are almost universally fed with chemically-defined enteral formulas containing added sugar, additives such as emulsifiers, and a low fiber content. Such diets have been shown to promote gut dysbiosis that may worsen gut and systemic inflammation. Whole-food enteral formulas that are composed of natural ingredients may mitigate these effects and contribute to improved clinical outcomes. We hypothesize that whole-food enteral formulas will restore a healthy gut microbiota and reduce inflammation in critically ill patients. To test this hypothesis, we used a murine model of chemically-induced colitis as a surrogate for the gut inflammation seen commonly during critical illness. Methods: C57BL/6 mice (3 randomized groups of 16 mice) received either chemically-defined formulas Vital (V) or Pediasure (P; Abbott Nutrition), or plant-based whole-food formula Liquid Hope (LH; Functional Formularies) for 7 days. Diets were isocaloric and available ad libitum. All mice were then given 4% dextran sodium sulfate (DSS) water or control water for 4 days, during which time they continued their experimental diets. Weights and disease activity indices (DAI) were measured daily. Upon sacrifice, plasma IL-6, fecal lipocalin-2, and colon length were measured. Fecal samples were collected from each group at three defined time points. Bacterial 16S rRNA gene sequences in each sample were


amplified, sequenced on the Illumina MiSeq, and analyzed with QIIME. Cecal contents were analyzed for metabolites using ultra-performance liquid chromatography coupled with tandem mass spectrometry. Results: The volume of consumed formula was not different across groups. After DSS exposure, weight loss was more severe (p<0.01) and DAIs were higher (p<0.01) in mice fed V or P compared to LH (Figure). Increased IL-6 plasma levels (p<0.01), decreased colon length (p<0.01), and a trend towards elevated fecal lipocalin-2 were observed in mice fed V and P compared to LH indicating more severe inflammation. The gut microbiome of mice fed V and P demonstrated reduced species diversity and altered species composition compared to LH (p<0.05). Specifically, LH mice compared to V and P contained a lesser abundance of Enterobacteriaceae (p<0.05), a family containing many Gram-negative pathogens and associated with gut inflammation, and higher abundance of Clostridiales (p<0.05), an order containing many commensal bacteria associated with immune homeostasis. The cecal contents of mice fed LH compared to V and P contained a significantly higher concentration of several beneficial anti-inflammatory compounds produced or metabolized by the microbiota, including lithocholic acid, a secondary bile acid, and hydroxycinnamic acid, a plant-derived polyphenol (p<0.05). Conclusions: Mice fed LH in this model of gut inflammation had superior outcomes compared to mice fed V and P. LH maintained a healthy gut microbiota and stimulated production of anti-inflammatory metabolites in the gut. Future work will establish which microbiome alterations and metabolites resulting from whole-food nutrition protect against dysregulated inflammation, and whether the use of these diets can improve outcomes in critically ill or chronically ill tube-fed patients.

Financial support received from: Functional Formularies provided Liquid Hope for this experiment at no cost.


Percentage of weight loss from baseline in mice fed LH, V, and, P after exposure to 4% DSS water or control water. Asterisk denotes significance (p<0.05, ANOVA, post-hoc Tukey's HSD test).

INTERNATIONAL ABSTRACT OF DISTINCTION 2829969 - Dose-dependent effects of glepaglutide, a long-acting glucagon-like peptide 2 analog, on fecal output in patients with short bowel syndrome. Rahim M. Naimi, MD2,3; Mark Hvistendahl, MSc2; Mark B. Hansen, MD, PhD1; Palle B. Jeppesen, MD, PhD2 1Research & Development, Zealand Pharma, Glostrup, Denmark; 2Medical Gastroenterology, CA-2121, Rigshospitalet, Copenhagen, Denmark; 3Clinical Development, Zealand Pharma, Glostrup, Denmark

Purpose: It is estimated that more than 30,000 patients worldwide suffer from short bowel syndrome (SBS) associated intestinal failure (SBS-IF) and at least as many suffer from SBS-associated intestinal insufficiency (SBS-II). GLP-2 analog treatment has previously been shown to improve intestinal fluid and electrolyte absorption and reduce the need for parenteral volume support in SBS-IF patients. We aimed to evaluate efficacy and safety of three different doses of glepaglutide, a 39-amino acid, long-acting GLP-2 analog in development for SBS, on fecal wet weight output in patients with SBS-II and SBS-IF. Methods: This was a double-blind, randomized, proof-of-concept, dose-finding, single-center, phase 2 trial. Glepaglutide was given subcutaneously once daily to 18 SBS patients (9F, 9M; 13 SBS-IF and 5 SBS-II). Mean age was 62 years, mean short bowel length was 110 cm, and two SBS-IF patients had > 50% colon in continuity. In a cross-over fashion, patients received two of three doses (0.1 mg, 1 mg and 10 mg) of glepaglutide for 3 weeks. A wash-out period of 4 - 8 weeks separated the two treatment periods (See Trial Design). The primary endpoint was absolute change from baseline in wet weight of fecal output as measured by metabolic balance studies prior to and on the last 3 days of each treatment period. Sodium and potassium were measured by flame photometry. Results: Of the 18 patients randomized and treated with glepaglutide, 16 completed the trial. Key results are tabulated below (Table 1). In the 1 mg/day and 10 mg/day dose groups, glepaglutide significantly reduced fecal wet weight output (-592 g/day [95% CI -913, -272] and -833 g/day [95% CI -1152, -515], respectively) compared to baseline and increased absolute wet weight absorption (+650 g/day [95% CI 385, 914] and +786 g/day [95% CI 523, 1049]) as well as urine weight (+530 g/day [95% CI 245, 816] and +368 g/day [95% CI 82, 654]). The improvements in intestinal absorption were also reflected by increase in body weight as well as intestinal absorption of sodium and potassium. Effect on kidney function assessed by creatinine clearance was not demonstrated. The improvements in intestinal absorption were of the same magnitude in patients with SBS-II and SBS-IF, with or without colon in continuity, and reversed to baseline after the drug-free period. No significant effects on any of the assessments were seen in the 0.1 mg group. The most common adverse events were injection site reactions, nausea, abdominal pain and stoma complications; most were mild or moderate in severity. One patient withdrew consent due to tachycardia and hot flushes, and another experienced an episode of prolonged abdominal pain and subsequently sepsis and was discontinued due to destabilization. Conclusions: Glepaglutide, at all three dose levels, was well tolerated. In daily doses of 1 mg and 10 mg, glepaglutide significantly decreased fecal wet weight output and increased intestinal wet weight absorption in patients with SBS-IF and SBS-II. Glepaglutide is a promising new medicine for SBS patients. Follow-up trials will further assess the potential of this drug.

Financial support received from: This trial was sponsored by Zealand Pharma.

Table 1. Adjusted means and 95% CI are estimated in an ANCOVA model including treatment period, parenteral support and total oral intake at baseline as covariates.


Changes from baseline in: (Adjusted means [95% CI])

0.1 mg (n=10)

1 mg (n=11)

10 mg (n=11)

Absolute Fecal Wet Weight Output (g/day) 173 [-160, 506]

p=0.274 -592 [-913, -272]

p=0.002 -833 [-1152, -515]

p=0.0002

Relative Fecal Wet Weight Output (%) 10 [-3, 22] p=0.113

-23 [-35, -11] p=0.002

-30 [-42, -19] p=0.0002

Absolute Wet Weight Absorption (g/day) -211 [-487, 64]

p=0.119 650 [385, 914]

p=0.0003 786 [523, 1049]

p<0.0001

Sodium Absorption (mmol/day) -17 [-58, 24]

p=0.368 47 [7, 86] p=0.025

40 [1, 80] p=0.045

Potassium Absorption (mmol/day) 0.4 [-16, 17]

p=0.954 16 [0.2, 31]

p=0.048 10 [-5, 25] p=0.172

Absolute Urine Wet Weight (g/day) 90 [-208, 389]

p=0.515 530 [245, 816]

p=0.002 368 [82, 654]

p=0.017

Relative Urine Weight (%) 11 [-11, 34]

p=0.293 40 [18, 61] p=0.002

32 [11, 54] p=0.008

2820246 - Incidence of Clostridium difficile infections associated with Lactobacillus rhamnosus GG administration in the Trauma/Surgery ICU: a QI study. Alexa Halling, MS, RD ; Marilyn Shelton, RD Food and Nutrition Services, Harborview Medical Center, Seattle, WA

Purpose: Clostridium difficile (C.difficile) infection (CDI) is common in healthcare facilities and becoming more difficult to treat. Some research suggests probiotics may help prevent incidence of C.difficile or even mitigate recurrence. However there is minimal data supporting probiotic use in a Trauma/Surgery Intensive Care Unit (TSICU) setting. The objective of this quality improvement study was to determine if providing a probiotic reduces CDI rates in the TSICU compared to current standard of care. Methods: Between March 2017 and May 2017 patients on one TSICU team (Team A/probiotic group) received probiotic supplementation while patients on Team B did not (standard of care group). The probiotics provided were 10 billion CFUs of Lactobacillus rhamnosus GG administered twice daily. Development of C.difficile was measured via liquid stuarts media swabs, which are ordered on admission


for all patients on TSICU as part of a surveillance screen protocol. Patients who were C.difficile negative on admission but presented with liquid stools later during their length of stay (LOS) were ordered for a C.difficile Toxin B polymerase chain reaction (PCR) laboratory test. Patients were excluded from this QI study for an ICU LOS less than 3 days; a positive C.difficile result on admission screen; or if probiotics were not started until after a positive C.difficile result was found. Patients transitioning to Comfort Measures Only were also excluded. CDI is defined as a positive C.difficile test. Results: In total, 84 patients were included in the analysis: 31 patients in the probiotic group, and 53 patients in the standard of care group. In the probiotic group, 3 patients developed CDI during their hospital LOS (9.7%). In the standard care group, 8 developed CDI during their hospital LOS (15.1%). The average number of days before CDI was 13 days for the probiotic group, and 20.9 days for the standard of care group. The probiotic group received probiotics for an average of 12.2 days. The +CDI patients in the standard of care group had a longer overall hospital LOS (+28.3 days), which is a risk factor for CDI. However two outliers with long LOS (average 67.5 days) likely skewed the data in the standard of care group. When these outliers were removed, the average time until +CDI in the standard of care group decreased from 20.9 days to 6.7 days. Conclusions: The results of this QI study suggest incidence of CDI may be decreased, and time until CDI might be delayed when probiotics are given and when patients are adjusted for LOS. This supports further study in our trauma/surgery ICU.


Table 1. Patient characteristics by study group

Team A

(probiotics) (n=31)

Team B (standard of care)

(n=53)

Age (years), mean 49.8 46.2

Probiotic days, mean 12.2 N/A

Antibiotic days, mean 12.4 9.2

PPI days, mean 2.5 3.4

ICU length of stay, mean 8.9 9.8

Hospital length of stay, mean 22.7 22.8

Mortality (%) 16 11.8

Table 2. Patient outcomes by study group

Team A

(probiotics) (n=31)

Team B (standard of care)

(n=53)

% patients +CDI 9.7 15.1

Days before +CDI, mean 13 20.9



GI and Other Metabolic Topics 2834329 - Benefits of A Preoperative Low Dose Complex Carbohydrate L- Citrulline Solution within a Colectomy Enhanced Recovery Program Theodor Asgeirsson, MD1; Anthony Senagore, MD2; Tabitha Ongstad, MD1 1Surgery, Mercy Health, St Mary's, Grand Rapids, MI; 2Colorectal Dept Galviston TX, Galviston, TX

Purpose: Endothelial end organ-dysfunction due to impaired nitric oxide availability after non-cardiac surgery significantly increases postoperative morbidity and mortality, (infection, renal, cardiovascular). This pathophysiology is primarily due to surgical stress induced reduction in the L-arginine/ asymmetric dimethylarginine ratio (L-Arg/ADMA). L-citrulline supplementation is a an effective and safe way to increase this ratio. The goal of this study was to assess a strategy of adding a combined preoperative low dose complex carbohydrate (CC) loading with L-citrulline (CIT) with respect to outcomes in elective colorectal surgery Methods: This was a retrospective review of our institutional Michigan Surgical Quality Collaborative (MSQC) data comparing the use of 3 doses of a CC/CIT drink to our historical data (non CC/CIT drink) within a well established ERP. Elective colectomies from a single surgeon were included. O/E ratios and Chi-square is used for statistical analysis with a p value set at 0.05 Results: There were 84 pts in the non-CC/CIT group and 52 pts in the CC/CIT group. The incidence of renal insufficiency and severe sepsis both decreased to zero after CC/CIT with adjusted rates of renal insufficiency being significantly lower than the MSQC comparison cohort (1.96% vs 2.83% p=0.023). Treatment reversed our high outlier status for severe sepsis (2.7% vs 1.87%; p=0.048 to 1.8% vs 1.13% p=0.18) Prior to protocol change we had other complications with O/E ratios above 1, deep infection (1.62); organ space infection(1.28); and unplanned intubation (2.71) and all reduced to a zero event rate. LOS (4.76d vs 3.86d: O/E 0.72 vs 0.41,) ED visits (9.64% vs 9.62%: O/E 0.97 vs 0.83)and reoperation(9.64% vs 0%: O/E 1.38 vs NA) improved. Readmissions remain a challenge (15.6% vs 17.3%: O/E 0.62 vs 1.38), Conclusions: These are the first data demonstrating the added benefits related to the combination of preoperative supplementation with a low dose complex carbohydrate solution with L-citrulline within an established ERP. The combined benefits of reduced hyperglycemic events and safe improvement in L-Arg/ADMA may significantly improve arginine bioavailability with reductions in infection complications and end organ dysfunction following colorectal surgery.


INTERNATIONAL ABSTRACT OF DISTINCTION 2825899 - Treadmill exercise improves survival and ameliorates organ injury after gut ischemia reperfusion in mice Kazuya Higashizono, MD1,3; Kazuhiko Fukatsu, PhD3; ayako watkins, RD3; TOMOKI Watanabe, MS 2,3; Midori Noguchi, MD3; Satoshi Murakoshi, MD3; Hiroshi Yasuhara, PhD3; Yasuyuki Seto, PhD1 1Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; 2Surgery, National Defense Medical College, Tokorozawa city, Japan; 3Surgical Center, The University of Tokyo Hospital, Tokyo, Japan

Purpose: Exercise training before surgery is now expected to accelerate patient recovery through improvement of muscular strength and mass. However, it is unclear whether exercise training protects organs and thereby ultimately improves survival after severe surgical insults. Herein, we examined the effects of treadmill running on survival and organ injury in a murine gut ischemia reperfusion model. First, we explored the optimal frequency and duration of the exercise. Then, the best intensity was determined in terms of the exercise completion rate and survival after gut I/R. Finally, influences of the exercise on


organ injury were examined at various time points. Methods: Male C57BL/6J mice received treadmill exercise according to the following protocols. Exp.1) Sixty-min treadmill running at 20.0 m/min. The bouts were performed 5d/w for 2 weeks, 3d/w for 2 weeks or 3d/w for 3 weeks. Sedentary mice did not receive treadmill exercise. After finishing each protocol, all mice (n=16) underwent 45-min superior mesenteric artery (SMA) occlusion and reperfusion. Survival after gut IR was observed for 48 hours. Exp.2) According to the results of Exp.1, training frequency and duration were set at 3 d/w for 3 weeks. To determine the appropriate running speed, mice (n=94) received 60-min treadmill running at 12, 15 or 18 m/min. Sedentary mice (n=25) did not receive treadmill running. Then, the mice underwent gut I/R as in Exp. 1 and survival was observed. Exp.3) Mice (n=92) were randomized to sedentary and exercise groups. After completion of the exercise (60min at 12m/min and 3 d/w 3 weeks), mice underwent gut I/R as in Exp.1. The small intestine, lung, liver and gastrocnemius muscle were harvested at 0, 3, 6, or 24 hours after reperfusion. Histological

analysis of organs was performed by H＆E staining and organ damage was scored (small intestine 0-5,

lung 0-9, liver 0-4, muscle 0-3). Results: Exp.1) Exercise by the 3d/w for 3w protocol resulted in the highest survival rate. However, the completion rate of each exercise group was only 50-60%. Exp.2) 12 m/min and 15 m/min exercise equally improved survival as compared to the sedentary group (p<0.05). None of the 12 m/min group dropped out the protocol. Exp.3) The treadmill exercise protocol determined based on the results of Exp. 1 and 2 reduced gut and lung injury at 3h and liver injury at 6h (p<0.05). Conclusions: An appropriate exercise protocol improves survival and attenuates organ injury after gut I/R in mice. Pre-habilitation might contribute to early recovery for patients after severe surgical insults by enhancing resistance to gut ischemia reperfusion injury.


Experiment 1 and 2

Experiment 1 Sedentary 5 d/w for 2w 3 d/w for 2w 3 d/w for 3w

Completion rate (%) NA 50 55.6 60

Survival rate (%) 33.3 20 20 50

Experiment 2 Sedentary 12 m/min 15 m/min 18 m/min

Completion rate (%) NA 100 90.3 90.6

Survival rate (%) 52 77.4* 78.6* 68.9

Experiment 3

Intestine Before 0h 3h 6h 24h

Sed 0 0.4±0.2 3.0±0.7 3.5±0.6 2.0±0.3

Exe 0 0.6±0.2 1.8±0.3* 2.5±1.3 1.5±0.6

Lung Before 0h 3h 6h 24h

Sed 0 0.8±0.2 5.0±2.1 6.0±1.5 3.4±1.1

Exe 0 0.3±0.1 3.4±1.5* 3.9±1.5 2.8±1.5

Liver Before 0h 3h 6h 24h

Sed 0.1±0.0 0.6±0.2 1.4±0.4 3.0±0.9 2.3±0.8

Exe 0 0.3±0.1 1.4±0.7 2.0±1.2* 1.3±0.4

Muscle Before 0h 3h 6h 24h


Sed 0 0.3±0.1 0.6±0.2 0.6±0.2 1.0±0.3

Exe 0 0.5±0.2 0.4±0.1 0.6±0.2 1.3±0.3

2834856 - Factors Influencing the Rate of Intestinal Adaptation in Pediatric Patients with Intestinal Failure. Lauren Lowes, .1; Breanna Borg, BS 1; May Saba, Pharm.D, BCNSP2; Joseph Lelli, MD3 1Surgery, Wayne State University School of Medicine, Royal Oak, MI; 2Pharmacy , Children's Hospital of Michigan , Detroit , MI; 3Surgery, Children's Hospital of Michigan, Detroit , MI

Purpose: Intestinal failure is characterized by a reduced amount of functional gut capacity that is necessary for adequate digestion and absorption of nutrients for optimal growth and development. Our investigation sought to evaluate the achievement of intestinal adaptation to ensure proper management that supports the development of intestinal autonomy. Due to the heterogeneity in pediatric intestinal failure, the process of reaching adaptation in each patient is different. However, the goal is the same; independence from total parenteral nutrition (TPN) for more than three months thereby reaching intestinal autonomy. We predicted that plasma citrulline level is not a reliable indicator of intestinal function and bowel length does not affect a patient’s rate of adaptation. Moreover, that a higher occurrence of line infections acquired during treatment delays the rate of intestinal adaptation. In addition, we hypothesized that the children who reach adaptation before 24-months have a better prognosis. Methods: A retrospective chart review was performed on 29 patients seen at a multidisciplinary pediatric intestinal rehabilitation program from 2010-2017. Patients seen in this clinic are managed for conditions of intestinal failure, including anatomically shortened bowel, complex malabsorption and motility disorders. Patients with incomplete charts due to late enrollment in our program and non-rehabilitative bowel were excluded from the study. The variables examined were demographics, bowel length, measures of plasma CIT, number of infections, and rate of adaptation. A patient reached adaption when she/he received 100% of their daily caloric intake from EN. Results: We identified 22 patients as eligible for this study, separating them into two cohorts: adapted (N=7) and non-adapted (N=15). The mean age was 4.8 years with a range of 13 months – 13.5 years and a 50% gender distribution of males and females. There was not a significant difference between the adapted (m=18.2 μmol/L) and non-adapted (m= 14.0 μmol/L) patients for CIT levels. Half of the patients had a bowel length greater than 40cm. However, there was no significant difference between the bowel lengths of adapted (m=89.43 cm) and non-adapted (m=60.53 cm) groups. An independent groups t-test was conducted to assess mean differences between adaptation and number of infections. There was a significant difference between adapted (M = 1.71) and non-adapted (M = 10.66) groups, t (20) = 3.72, p =0.001 (Figure 1). For the adapted patients, the mean age of adaptation was 28.38 months with a range of 11 months - 4.08 years. Of those who adapted before 24-months, the mean age was 15.5 months, whereas the mean for patients who adapted after 24-months was 3.44 years. There is a significant difference between these two means, t (5)= -6.34, p =0.001. Furthermore, for the adapted less than 24-months group, 75% have a bowel length of more than 40 cm, mean CIT of 20.2 μmol/L and an average of 1.5 infections. Whereas in the adapted more than 24-months group, 66.7% have a bowel length of more than 40 cm, mean CIT of 15.5 μmol/L and an average of 2.3 infections. Conclusions: From our review, we conclude that bowel length and plasma citrulline levels do not affect the rate of intestinal adaption in pediatric patients. However, the number of infections interferes with a patient’s ability to wean off TPN. We are interested in examining whether other environmental factors such as parental stress, coping behaviors, and family resources has an influence on the rate of infections and thus the time to reach adaptation. Examining these factors in children who adapt before 24-months in comparison to after may lead to opportunities for early intervention and management of children with intestinal failure.

Financial support received from: None.


2833802 - Iso-caloric/fructose restricted diets results in improvements in hepatic fat and some markers of liver and cardio-metabolic dysfunction in obese adolescents with non-alcoholic liver disease (NAFLD): preliminary results from an RCT. Diana Mager, PhD MSc RD1,2; Leslie Seto, MSc RD1; Vera Mazurak, PhD3; Richard Thompson, PhD4; Ravi Bhargava, MD FRCPC5; Jason Yap, MBBS FRCPC6 1Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Canada; 2Department of Pediatrics, University of Alberta, Edmonton, Canada; 43Department of Biomedical Engineering, University of Alberta, Edmonton, Canada; 54Department of Radiology & Diagnostic Imaging, University of Alberta., University of Alberta, Edmonton, Canada

Purpose: NAFLD is a chronic liver disease that spans from a fatty liver to more serious disease that includes fibrosis and inflammation. NAFLD is highly prevalent in obese children with high sugar (fructose) intakes, physical inactivity, visceral adiposity and insulin resistance. While lifestyle modification is the main treatment for NAFLD, no evidenced-based guidelines exist regarding specific dietary treatments. The study purpose was to assess the impact of two iso-caloric diets that were characterized by different levels of fructose intake (5% total energy intake [TEI] vs 10% TEI) on markers of adiposity, liver dysfunction and cardio-metabolic dysregulation in youth with NAFLD. We hypothesized that iso-caloric/low-fructose diets (5% vs 10%) over 12 weeks would result in significant reductions in adiposity


and improvements in laboratory markers of cardio-metabolic and liver dysfunction in obese youth with NAFLD. Methods: A total of 11 children (15.8 ± 1.8 years; 7 M/4F) obese children (BMI-z: 2.9 ± 0.3) with clinically diagnosed NAFLD were randomized to either an iso-caloric low-fructose (5% of total energy intake [TEI]; n=6) or an iso-caloric higher-fructose (10% TEI: n=5) diet for 12 weeks. Demographic, anthropometric (weight, height, BMI, waist circumference [absolute/z-scores]), laboratory markers (ALT, AST, GGT, insulin, glucose, HOMA-IR, TG, HDL-LDL-and-total cholesterol) and 1H-MRS for assessment of visceral fat (VAT), subcutaneous fat (SAT), hepatic fat (HF) and intermuscular adipose tissue (IMAT) were measured at baseline and 12 weeks. Macro-and-micronutrient and fructose intake using 3-day food records were reviewed with participants weekly to ensure consistency in assigned caloric/fructose intake. Results: No significant differences in age, anthropometric, fructose intake, laboratory markers, VAT, SAT, IML or hepatic fat between groups were noted at baseline (p>0.05). Total fructose intake in the entire cohort (% TEI) was 9.4 ± 3.5 % (baseline) and 5.3 ± 2.2% (12 weeks) (p=0.045). Hepatic fat (%) was 19.4 ± 2.6 (baseline) and 11.8 ± 1.9 (12 weeks) (p=0.05). No significant changes in VAT, SAT or IML were noted after 12 weeks, although a trend towards a reduction in %IMAT (5.2% vs 4.1%; p=0.06) after 12 was observed. Lower fructose intakes (5% TEI) were associated with greater improvements in serum ALT (10 U/L reduction [low] vs 5 U/L reduction [high], p=0.05) and TG (0.6 mmol/L reduction [low] vs 0.1 mmol/L reduction [high]; p=0.006) than higher fructose intakes (10% TEI). Conclusions: Iso-caloric/low fructose diets over 12 weeks resulted in significant reductions in hepatic fat, but only modest improvements in some markers of liver and cardio-metabolic dysregulation in obese children with NAFLD.

Financial support received from: Canadian Institutes of Health Research 2827685 - Wilson disease: The effect of choline supplementation on epigenetic regulation in a murine model and DNA methylation profiles in patients. Dorothy A. Kieffer, PhD1; Charles E. Mordaunt, BS 2; Noreene M. Shibata, BS 1; Anna Czlonkowska, PhD3; Tomasz Litwin, MD, PhD3; Karl H. Weiss, MD4; Janine M. LaSalle, PhD2; Valentina Medici, MD1 1Internal Medicine, Division of GI and Hepatology, University of California, Davis, Davis, CA; 2Department of Medical Microbiology and Immunology, Genome Center, and MIND Institute, University of California, Davis, Davis, CA; 32nd Department of Neurology, Institute Psychiatry and Neurology, Warsaw, Poland; 4Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany

Purpose: Maternal diet during pregnancy has been shown to impact disease risk in offspring. We hypothesized that the phenotypic presentation of the genetic disorder, Wilson disease (WD), which is caused by mutations in the copper transporter, ATP7B, leading to copper accumulation in the liver resulting in varying degrees of liver dysfunction, can be altered by maternal and continued choline supplementation.To test our hypothesis, the methyl donor, choline, alone or combined with the copper chelator, D-penicillamine (PCA), will alter hepatic expression of genes relevant to DNA methylation in the Jackson toxic milk (tx-j) mouse model of WD. Furthermore, we posited the liver DNA methylation profile of genes relevant to epigenetic regulation will differ in WD patients compared to healthy control subjects. Methods: Mice were randomized to 1 of 6 treatment groups: 1) normal choline in dam and progeny; 2) high choline in dam, normal choline in progeny; 3) high choline in dam and progeny; 4) normal choline in dam, normal choline in progeny + PCA; 5) high choline in dam, normal choline in progeny + PCA; 6) high choline in dam, high choline in progeny + PCA. PCA was provided from 12 wks of age through the duration of the study. Mice were euthanized at 24 wks of age. In humans, DNA isolated from liver biopsies (control: 3M/3F; WD: 5M/5F) was bisulfite converted and used to prepare libraries for whole genome bisulfite sequencing on an Illumina HiSeq4000. Samples were matched by age and sex. Results: In mice, hepatic transcript levels of DNA methytransferase 1 (Dnmt1a) were significantly lower (22-49%) in male and female mice receiving maternal and continued choline or PCA treatment compared to untreated mice or those only receiving maternal choline. In humans, pathway analysis of significantly differentially methylated regions of DNA revealed hypermethylation of the promoter region of genes related to methylation pathways (e.g. MIR4761, COMT, MAT1A, PNMT) in WD compared to healthy


controls. Conclusions: Maternal and continued choline supplementation impacts hepatic transcript levels of DNA methylation related genes in tx-j mice and WD patients exhibit altered liver DNA methylation profiles of genes relevant to epigenetic regulation compared to healthy controls. These findings indicate WD is subject to epigenetic regulation and may explain why WD presents with a highly variable hepatic phenotype.

Financial support received from: National Institutes of Health

2834193 - Characteristics of a French Cohort of Patients With Short Bowel Syndrome With Intestinal Failure Who Weaned Off Parenteral Support Under Teduglutide Treatment Francisca Joly, MD, PhD1; Aurelie Malgras, MD2; Alexandre Nuzzo, MD1; David Seguy, MD, PhD3; Didier Quilliot, MD, PhD2 1Gastroenterology and Nutrition Support, Hopital Beaujon, PARIS, France; 2Nutrition Support, CHU Nancy, Nancy, France; 3Nutrition Support, CHU Lille, Lille, France

Purpose: Vascular catastrophes and inflammatory bowel disease (IBD) are the principals underlying conditions for massive intestinal resection and failure associated with short bowel syndrome (SBS-IF). This analysis reports the baseline characteristics of patients diagnosed with SBS-IF in a French cohort and who weaned off parenteral support (PS) at 6 months (M6) of treatment with teduglutide (TED). TED, a glucagon-like peptide-2 analog available in France since October 2015, is used to restore intestinal function in SBS-IF adults. The objective of this analysis is to describe the main characteristics of patients with SBS-IF who weaned off PS at M6 under TED treatment. Methods: This is a French national multicenter prospective “real-world” observational study that included 74 SBS-IF patients treated with TED (0.05 mg/kg/day) between October 2015 and September 2017. Fifty-four patients have reached M6 of treatment, of which 13 (24%) have weaned off PS. Data collected at baseline included demographics; postsurgical bowel anatomy and length of remaining bowel; primary diagnosis leading to resection; anthropometrics; PS duration, volume, energy, and frequency; as well as oral energy intake and fecal output. Descriptive summary statistics are presented with standard deviations (SDs). Results: A total of 13 patients between the ages of 23-72 (mean=55.3; SD=13.2), 6 women (46%), weaned off PS at M6 of TED in the study. The etiologies for SBS were vascular disease (n=7), IBD (n=4), volvulus (n=1), and radiation enteritis (n=1). The Table describes the baseline (BL) characteristics for the patients who had weaned off PS. The predictive factors for wean-off at M6 were a low PS volume at BL (P=0.001), a low PS volume at M3 (P< 0.001), a high percentage of PS volume reduction at M3 (P<0.001), a response (defined as ≥20% PS volume reduction from BL) at M3 (P=0.021), a jejunocolic anastomosis (P=0.007), and a higher oral energy intake at BL (P=0.018). Conclusions: In a real-world French cohort of SBS-IF patients treated with TED, the BL characteristics and predictive factors identified for the patients who weaned off PS at M6 clearly demonstrated that patients without a stoma and with a colon-in-continuity and with low PS volume at BL and high oral energy intake who had a very early response to the drug at M3 are the patients most likely to wean off early in the course of TED treatment for SBS-IF. Further studies are required to confirm those findings.


Patients Who Weaned Off at Month 6

Characteristic N=13

Body weight, kg 59 (9)*

Colon-in-continuity, % 85


Stoma presence, % 15

Small bowel lenght, cm 65.8 (32.5)

Colon remaining, % 63.8 (29.9)

PS duration, years 9.3 (8.9)

PS volume/week, ml 5164.6 (1904.5)

Number of PS days/week 3.3 (1.1)

Oral energy intake, Kcal/24 hours 2845.5 (787)

Stools weight mg/24 hours 1206.7 (920.1)

Steatorrhea, g/24 hours 38.3 (32.3)

*(): SD

Pediatric and Neonatal 2821480 - Effects of implementing the PEGASUS pathway on nutrition delivery in pediatric critically ill patients with traumatic brain injury. Megan Nordlund, MS, RD ; Monica Vavilala, MD; Mary King, MD; Brian Johnston, MD; Martine Perrigue, PhD, MS, RD; Randall Chesnut, MD; Carolyn Blayney, RN Harborview Medical Center, Seattle, WA

Purpose: Timely provision of nutrition support is vital to the recovery of pediatric critically ill patients with traumatic brain injury (TBI). Barriers arise because of frequent operations, hemodynamic instability and the chaos of multiple consulting services. The Pediatric Guideline Adherence and Outcomes care pathway (PEGASUS) was developed at Harborview Medical Center (HMC) to improve care based on the 2003 and 2012 Brain Trauma Foundation standards. Nutrition support is an integral component of the PEGASUS pathway. The aim of the present study was to determine whether implementation of PEGASUS was associated with improved nutrition delivery. Methods: We performed a retrospective review of all pediatric critically ill patients < 18 y with TBI admitted to HMC between December 2007 and October 2016. Patients were divided in to 2 groups, pre-PEGASUS pathway (pre-PEG; admitted prior to 2014) and post-PEGASUS pathway (PEG; admitted 2014 and after). Patients with hospital mortality <72 h were excluded from analysis (n = 7). The registered dietitian (RD) attended daily medical rounds, providing nutrition recommendations and monitoring the adequacy of nutrition support, as part of the standard of care for both groups. Assessment included demographic characteristics, patient outcomes, time to initiation of enteral feeding, percentage of nutrition goal received, and use of total parenteral nutrition (TPN). Statistical analyses were completed using t-test, chi-squared, logistic regression, and Bartlett’s F test. Results: A total of 105 patients were included in the analysis (pre-PEG n = 43; PEG n = 62) (Table 1). There were no differences in pre-PEG vs. PEG groups in age, length of stay (LOS), mortality, or % discharged home. Pre-PEG patients had significantly higher Injury Severity Scores (ISS) and lower Glasgow Coma Scale scores (GCS) at admission and discharge. Enteral nutrition was initiated within 72 h in 87% of pre-PEG vs. 95% of PEG patients; this difference was not statistically significant (p > 0.05) (Table 2). Variance in the time to initiate TF was significantly higher in the pre-PEG vs. PEG group (p = 0.015). TPN was received in 10.5% of pre-PEG vs. 5.3% of PEG patients (difference not significant; p > 0.05). The percentage of goal TF received in weeks 1 and 2 was similar between groups (p = 0.86 and p = 0.84, respectively). Conclusions: Implementation of the PEGASUS care pathway was associated with improvements in percentage of patients fed enterally within 72 h, lower variance in time to initiation of enteral feeding, and less frequent use of TPN. Our analysis revealed excellent time to provision of early nutrition support prior to PEGASUS, leaving little room for more substantial improvement with PEGASUS implementation.


Although most differences detected did not reach statistical significance, the demonstrated improvements hold clinical relevance.


Table 1. Patient characteristics by study group

Variable Pre-PEG PEG

(n = 43) (n= 62)

Age (years) 12.0 ± 5.2 10.5 ± 6.0

Admission GCS 3.9 ± 1.6 5.1 ± 2.7*

Discharge GCS 11.7 ± 2.6 13.5 ± 2.9**

Injury Severity Score 37.9 ± 9.8 29.9 ± 11.6**

ICU Length of Stay 12.0 ± 8.7 9.3 ± 7.1

Mortality (%) 9% 10%

Discharged Home (%) 9% 24%

Values are mean ± Standard Deviation; SD *p < 0.05 **p < 0.005 Table 2. Nutrition outcomes for patients who received nutrition support

Variable Pre-PEG PEG

(n = 38) (n = 38)

TF started within 48 hrs 74% 70%

TF started within 72 hrs 87% 95%

Time to TF start (hrs) 40.6 ± 27.3 40.4 ± 17

% of goal TF received in week 1 49.5 ± 23.5 48.5 ± 16.7

% of goal TF received in week 2 73.6 ± 19.8 74.9 ± 14.3

% of patients received TPN 10.5% 5.3%

Values are mean ± Standard Deviation; SD *p < 0.05

ABSTRACT OF DISTINCTION 2832194 - Underfeeding is Associated with Better Clinical Outcomes in Critically Ill Children with Hyperglycemia Than Target Feeding or Overfeeding. Vijay Srinivasan, MD3,7; Natalie Hasbani, MPH8; Nilesh M. Mehta, MD1; Sharon Y. Irving, PhD, RN 6; Sarah Kandil, MD10; Helen C. Allen, MD2; Katri Typpo, MD5; Natalie Cvijanovich, MD4; Edward V. Faustino, MD, MHS10; David Wypij, PhD9; Michael Agus, MD8; Vinay M. Nadkarni, MD, MS3,7 1Critical Care Medicine, Dept. of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA; 2Pediatric Critical Care , University of Oklahoma, Norman, OK; 3Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; 4UCSFBenioff Children's Hospital Oakland, Oakland, CA; 5Pediatrics, University of Arizona, Tucson, AZ; 6Family & Community Health, University of Pennsylvania, School of Nursing, Philadelphia, PA; 7Anesthesiology and Critical Care, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA; 8Boston Children's Hospital, Boston, MA; 10Yale New Haven Children's Hospital, New Haven, CT

Purpose: Permissive underfeeding may be beneficial in selected critically ill adults, but evidence for similar benefits in critically ill children is lacking. Using data from the Heart And Lung Failure – Pediatric


INsulin Titration (HALF-PINT) trial that enrolled critically ill children, we hypothesized that underfeeding (UF: average daily caloric intake < 60% of predicted goal) is independently associated with better clinical outcomes compared to target feeding (TF: average daily caloric intake 60-100% of predicted energy goal) and overfeeding (OF: average daily caloric intake >100% of predicted energy goal). Methods: Secondary analysis of data from the HALF-PINT trial that enrolled critically ill children on inotropic support and/or invasive mechanical ventilation with hyperglycemia who received enteral nutrition (EN) and/or parenteral nutrition (PN). The study protocol encouraged enteral feeding but did not specifically control nutrition delivery. Predicted energy goals were derived from age and gender-specific Schofield energy equations. The associations of UF, TF, and OF during study enrollment with clinical outcomes (ICU-free days, ventilator-free days, hospital-free days, organ dysfunction, any infection, and mortality at 28 days and 90 days) were reported using appropriate regression methods after adjusting for age, body mass index (BMI) z-score, PN exposure, inotropic support and pediatric risk of mortality (PRISM III-12). Results: Of 680 subjects with complete nutrition data for at least 24 hours during study enrollment, UF occurred in 184 (27%), TF occurred in 235 (35%) and OF occurred in 261 (38%). The overall median duration of study enrollment was 7 days for the entire cohort. Compared to UF and TF groups, OF group was younger (p<0.001), less overweight (p=0.02), received less inotropic support (p=0.01) and had lower PRISM III-12 (p<0.001). Median average daily caloric intake during study enrollment (kcal/kg/day) was 13.5 in UF group, 31.6 in TF group and 59.9 in OF group (p<0.001). Median average daily protein intake during study enrollment (g/kg/day) was 0.2 in UF group, 1.0 in TF group and 1.9 in OF group (p<0.001). PN exposure was 16% in UF group, 52% in TF group and 65% in OF group (p<0.001). In children less than 6 years of age, median average glucose infusion rate (GIR, mg/kg/min) from EN and PN was 3.0 in UF group, 4.9 in TF group and 6.6 in OF group (p<0.001). In children 6 years and older, median average GIR (mg/kg/min) from EN and PN was 1.7 in UF group, 2.7 in TF group and 4.0 in OF group (p<0.001). UF group received less study guided insulin compared to TF and OF groups (p=0.002). There were no differences in median time weighted average blood glucose (BG) across the groups (p=0.67). After adjusting for age, BMI z-score, PN exposure, inotropic support and PRISM III-12, UF (compared to both TF and OF) was independently associated with more ICU-free days (median 24 vs 17 vs 17, p<0.001), more ventilator-free days (median 25 vs 19 vs 19, p<0.001), more hospital-free days (median 16 vs 3 vs 2, p<0.001), less organ dysfunction (maximum PELOD: median 11 vs 12 vs 13, p=0.01) and less infections (3% vs 12% vs 11%, p=0.004). There were no differences in mortality at 28 days and 90 days across groups. Conclusions: In this secondary analysis of the HALF-PINT trial of critically ill children with hyperglycemia, after adjusting for age, BMI z-score, PN exposure, inotropic support and PRISM III-12, underfeeding was independently associated with better clinical outcomes compared to target feeding and overfeeding. Prospective studies are needed to examine the impact of permissive underfeeding strategies on clinical outcomes in critically ill children.

Financial support received from: NIH NHLBI U01HL107681 (PI: Michael Agus, Vinay Nadkarni)

Clinical characteristics of groups.

Underfeeding (average daily caloric intake

<60% of predicted goal)

N = 184

Target feeding (average daily caloric

intake 60-100% of predicted goal)

N = 235

Overfeeding (average daily caloric intake

>100% of predicted goal)

N = 261

p-value

Age, years- median (IQR) 8.6 (4.0-13.8) 7.8 (2.5-14.0) 2.9 (0.9-9.0) <0.001

Underweight (BMI z-score < -2), n(%)

Normal (BMI z-score -2 to +1), n(%)

20 (11) 86 (47) 78 (42)

13 (6) 116 (49) 106 (45)

20 (8) 154 (59) 87 (33)

0.02


Overweight (BMI z -score > +1), n(%)

Any EN, n(%) Any PN, n(%)

120 (65) 30 (16)

210 (89) 123 (52)

217 (83) 169 (65)

<0.001 <0.001

Duration of study enrollment, days – median, IQR

3 (2-6) 9 (5-16) 9 (5-16) <0.001

Inotropic support, n (%) 103 (56) 126 (54) 112 (43) 0.01

PRISM III-12 score – median (IQR)

14 (7-20) 12 (7-20) 10 (5-16) <0.001

Risk of death in the ICU, per PRISM III-12 score – median

(IQR) 16.6 (3.4-40.7) 11.3 (2.9-40.0) 6.2 (2.1-24.2) 0.003

Any exposure to study guided insulin, n (%)

130 (71) 194 (83) 219 (84) 0.002

Time-weighted BG average, mg/dL – median (IQR)

114 (103-128) 113 (104-124) 115 (104-130) 0.67

IQR – interquartile range; BMI – body mass index; EN – enteral nutrition; PN – parenteral nutrition; PRISM – pediatric risk of mortality; BG – blood glucose. P-values determined using Kruskal-Wallis test for continuous variables and Fisher’s Exact test for categorical variables


Average daily caloric and protein intakes by groups from study randomization to Day 8.

ABSTRACT OF DISTINCTION 2834369 - The Use of Urine Sodium to Creatinine Ratio as a Measure of Sodium Deficiency in Children After Intestinal Resection. Cameron Casson, BA3; Jesse Pace, RD4; Hannah Piper, MD1,2 1Surgery , Univeristy of British Columbia, Vancouver , Canada; 2Pediatric Surgery , BC Children's Hospital , Vancouver , Canada; 3University of Texas Southwestern, Dallas , TX; 4Children's Health, Dallas, TX

Purpose: Children who have undergone significant small bowel resection frequently have difficulty growing due to high sodium losses in their stool. Urine sodium concentration (UNa) is often used as a measure of total body sodium, with < 30 mmol/L considered low. However, UNa is dependent on urine flow and may be misleading when used in isolation. The urine sodium to creatinine ratio (UNa:Cr) is a non-invasive measure that compensates for urine flow rate with reported normal values of 10-14 in healthy infants and 17-52 in children. The purpose of this study was to determine if there are instances in which the UNa:Cr is discordant with UNa and could potentially change management in children after significant intestinal resection.


Methods: Children (2 months to 17 years) from a single institution who underwent significant small bowel resection (requiring parenteral nutrition for > 6 weeks post-operatively), from 2013-2016 were reviewed retrospectively. Patient characteristics, intestinal anatomy, nutritional intake, anthropometric measurements, and urine and serum electrolytes were collected. UNa:Cr (UNa mmol/L)/(UCr mg/dL)(0.0883) was compared to UNa measures at identical time points to determine discrepancies, with a UNa:Cr <10, and UNa < 30 considered low requiring supplementation. Growth at each time point was also assessed. Statistical analysis was completed using Mann-Whitney and Pearson’s correlation coefficient, providing both 95% confidence intervals and p-values. Results: Thirty-eight children were included in the study. Patients had a median small bowel length of 50 cm (5-315cm) and median % small bowel length remaining of 27% (2-91%). The most common etiology for small bowel resection was necrotizing enterocolitis (30%), intestinal atresia (23%), and midgut volvulus (20%). The median UNa was 44 mmol/L, and 10 patients (26%) had a UNa < 30 mmol/L. There was a positive correlation between UNa and both sodium intake (0.32, 95% CI [0.01, 0.57], p=.04), and body mass index (0.35, 95% CI [0.05, 0.60], p=.03), but no significant correlation with small bowel length. Children with UNa < 30mmol/L had significantly lower Z-scores for weight (median -2.5 vs. -0.44, p=.0252) compared to those with UNa > 30mmol/L. Twelve children had concominant UNa and UCr measures, accounting for 28 separate UNa:Cr calculations. The two values correlated most of the time (82%), however in 3 cases when the UNa was < 30 (43%), the UNa:Cr was not low (>10). Simiarly, there were 2 occasions where the UNa:Cr ratio was low (<10) but the UNa was normal (>60). Conclusions: Although UNa and UNa:Cr values often correlate and serve as non-invasive markers of sodium deficiency in children after significant bowel resection, approximately 18% of the time these values were discrepant in this series. UNa:Cr should be considered in the management of these patients to establish normative values and help guide sodium supplementation.

Financial support received from: N/A 2830604 - Nutritional status and nutrition support in children after liver transplantation. Andrea Marroquín, BS 1,4; Stacey S. Beer, RD5; Jaime C. Silva, MD1,4; Ryan Himes, MD5,4; Tamir MIloh, MD5,4; Moreshwar Desai, MD1,4; John A. Goss, MD2,3; Jorge Coss-Bu, MD1,4 1Intensive Care, Texas Children's Hospital, Houston, TX; 2Surgery, Texas Children's Hospital, Houston, TX; 3Michael E. DeBakey, Department of Surgery, Baylor College of Medicine, Houston, TX; 4Pediatrics, Baylor College of Medicine, Houston, TX; 5Nutrition & GI, Texas Children's Hospital, Houston, TX

Purpose: Malnutrition is common in end-stage-liver disease (ESLD) and it is associated with increased morbidity and mortality. Adequate perioperative nutritional support is important for children undergoing orthotopic liver transplantation (OLT) and is associated with improved outcomes. The aim of this study was to assess nutritional status and support in children with ESLD the first week after OLT. Methods: Records of patients with an OLT (6/2011-11/2016) were reviewed. Nutritional status assessed by weight for age (WFA: underweight), height for age (HFA: stunting), and weight for length (WFL/Body mass index (BMI): wasting), z-scores by WHO and CDC after admission to the pediatric intensive care unit (PICU). Malnutrition defined as mild, and moderate-severe if z-scores were > -1, >-2, respectively. Nutritional intake recorded the first week after OLT. Caloric (CI) and protein intakes (PRO) calculated from I.V. fluids and parenteral and enteral nutrition for the first 7 days of admission. Energy and protein needs estimated by Schofield and American Society of Parenteral and Enteral Nutrition Guidelines, respectively. Hospital and PICU length of stay (LOS) were obtained. Age stratification (< 2 yr vs. older) was utilized to assess association between malnutrition status and nutrition support after OLT. Results: A total of 185 patients were included, age 3.0 yr. median [(1.1-9.7 (25-75th IQR)]; M/F: 79/106; PICU length of stay: 4.0 (2-11) days; Hospital LOS: 19 (9-43) days; with the following diagnoses: Biliary atresia (n=69), Cholestatic disease (n=26), Acute Liver Failure (n=25), Metabolic disease (n=25), Oncology (n=23), Cystic Fibrosis (n=9), and others (n=8). The WFA, HFA, and WFL/BMI z scores were: -0.16±1.54 (SD), -1.05±1.67, and 0.64±1.33, respectively. The prevalence of underweight, acute and chronic malnutrition at time of OLT was 25%, 50%, and 12%, respectively. Patients < 2 yr. vs. > 2 yr.: had PICU and hospital LOS of: 8.5 days (3-29) vs. 3 days (2-4) (p < 0.0001); 33.5 days (18-97) vs. 12 days


(7-25) (p < 0.0001), respectively. There was no association between age < 2 yr. and underweight [0.51 OR (95% CI: 0.25-1.04)], acute [0.98 OR (95% CI: 0.55-1.76)] or chronic malnutrition [0.76 odds ratio (OR) (95% CI: 0.30-1.91)]. Patients < 2 yr. vs. > 2 yr. were more likely to receive > than 100% and 50% of 5 days average of recommended caloric and protein intake: 5.59 OR (95% CI: 1.89-16.5) (p<0.005) and 3.04 OR (95% CI: 1.23-7.49) (p<0.05), respectively. There was an association between moderate-severe chronic malnutrition and ICU and hospital LOS; [1.01 OR (95% CI: 1.00-1.03)] (p <0.05); [1.01 OR (95%CI: 1.00-1.01)] (p<0.05), respectively. Patients with moderate-severe (n=48) vs. mild/no chronic malnutrition (n=128) had an average CI and PRO intake on days 1-3 of 33±23 vs. 21±19 kcal/kg/d (p <0.005) and 1.03±0.88 vs. 0.66±0.75 g/kg/d, (p <0.01) respectively. Conclusions: Malnutrition is prevalent in children awaiting liver transplant for ESLD and was not associated with younger age when compared to older children. Moderate and severe chronic malnutrition was associated with longer ICU and hospital stay. Patients with moderate and severe chronic malnutrition and children less than 2 years of age received better nutrition support after OLT. Significant caloric over supplementation and protein under supplementation was present at end of first week with approximately half of the nutrition intake provided by enteral route.


Nutrition Support the first week after OLT

Day 1 Day 3 Day 5 Day 7

n=185 n=167 n=90 n=64

CI kcal/kg/d 16 ± 1.5 33 ± 2.1 52 ± 2.7 61 ± 3.1

CI balance kcal/kg/d -29 ± 1.5a -12 ± 1.9a 6 ± 2.4a 14 ± 2.7a

Needs met (%) 34 ± 3a 68 ± 4a 110 ± 5a 127 ± 6a

Enteral CI (%) 0 15 ± 2 28 ± 4 42 ± 5

PRO g/kg/d 0.36 ± 0.05 1.18 ± 0.09 1.84 ± 0.10 2.05 ± 0.12

Pro balance g/kg/d -2.0 ± 0.05b -1.2 ± 0.07b -0.72 ± 0.09b -0.61 ± 0.11b

Needs met (%) 14 ± 2b 46 ± 3b 71 ± 4b 77 ± 5b

Enteral PRO (%) 0 26 ± 4 30 ± 4 41 ± 5

Values are mean ± SE. CI: caloric intake; PRO: protein intake; a p < 0.05 vs. estimated caloric needs by Schofield; b p < 0.05 vs. estimated protein requirements by A.S.P.E.N. guidelines, by paired t-test. 2830622 - Cholestasis and Long-term Neurodevelopmental Outcomes of Preterm Infants on Parenteral Nutrition therapy Wenjing Zong, M.D1; Bree Andrews, M.D.2; Kristin Wroblewski, M.S.3; Joseph Hageman, M.D2,4; Timothy Sentongo, M.D5 1Gastroeneterology, Children's Hospital of Philadelphia, Philadelphia, PA; 2Pediatrics, University of Chicago, Chicago, IL; 3Statistics, University of Chicago, Chicago, IL; 4Pediatrics, NorthShore University HealthSystem, Chicago, IL; 5Pediatric Gastroenterology, University of Chicago, Chicago, IL

Purpose: Parenteral Nutrition (PN) therapy is a life-saving method of administering nutrition in preterm and critically ill newborn infants when enteral feeding is delayed or not possible. However, prematurity and prolonged duration on PN are also major predictors of poor long-term neurodevelopmental outcomes (NDO). This study assessed the clinical characteristics that affected long-term NDO in preterm infants who required PN therapy. Methods: Subjects were preterm infants who required PN therapy and were also managed with inhaled nitric oxide therapy to improve NDO. The subject characteristics were collected, including gestational age, birth weight, history of BPD, IVH, NEC, Bayley scores at age 18 and 24 months, lipid dose, PN duration


and cholestasis (direct bilirubin ≥2 mg/dL) during PN therapy. Statistical comparisons and logistical regressions were performed and significance was set at p< 0.05. Results: A total of 94 infants were identified and the 56 (54% male) with at least one Bayley score were enrolled. The clinical characteristics were (median, IQR): gestation age 27 weeks (25,29); birth weight 973 g (760, 1130) and; birth weight z-score: -0.2 (-1.1, 0.3). Five infants (9%) developed cholestasis during PN therapy. The median duration on PN therapy in the infants with cholestasis was 7.4 weeks (6.4, 8.6) vs 2.7 weeks (2.0, 4.4) in the infants without cholestasis (n = 51). Children with history cholestasis had lower Bayley scores for motor and cognition compared to those who did not develop cholestasis (mean±sd): 76±22 vs. 96±15 and; 76±23 vs. 97±14 respectively (see Figure 1). Logistic regression showed that the association between cholestasis, lower cognition and lower motor scores persisted even after controlling for birth weight, gestation age, duration on PN, average PN calories and lipid dose. Conclusions: Although there are limitations, our data shows that in this cohort of former preterm infants the presence of cholestasis during PN therapy had a more consistent association with poorer long-term NDO than duration of PN therapy. This suggests that the traditional thought that PN duration is associated with poor outcomes should be modified to occurrence of cholestasis during PN therapy as the predictor of poor NDO.


Bayley scores in cholestatic vs. non-cholestatic group 2830566 - Age-based energy and protein delivery and threshold for supplemental parenteral nutrition in pediatric intensive care units world-wide Lori J. Bechard, PhD, MEd, RD2; Nilesh M. Mehta, MD1 1Critical Care Medicine, Dept. of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA; 2Critical Care Medicine, Boston Children's Hospital, Boston, MA

Purpose: Background: There is increasing emphasis on the best amount, composition and route of nutrient delivery during critical illness. The optimal amounts of energy and protein delivery for best outcomes in mechanically ventilated children in pediatric intensive care units (PICUs) remains unclear, and are expected to be


variable across different age-groups. An ideal calorie–to-nitrogen ratio of 130-150 kcal per gram of nitrogen has been proposed for critically ill children, however, achievement of these ranges at the bedside may be challenging. Furthermore, the timing and threshold for initiating supplemental parenteral nutrition (PN) in this population is not known. Objective: To describe the prescription and delivery of energy and protein (per kg weight) in relation to age groups, and to determine the threshold of enteral nutrient delivery adequacy that prompted supplemental PN, in mechanically ventilated children. Methods: We completed a planned secondary analysis of the combined cohort of critically ill children enrolled in 2 international, multicenter studies of nutrition practices (2009 and 2011). Energy and protein prescriptions, route(s) and amounts of daily nutrient delivery, and relevant clinical data over the first week of PICU admission were recorded by 90 PICU sites from 16 countries. Patients were divided into 5 age-based categories to approximate physiologic changes and growth-related macronutrient requirements. Adequacy was defined as the average % of the prescribed energy or protein goal that was actually delivered over 7 days. On the day of PN initiation, energy adequacy from enteral nutrition was documented. When protein intake was >0, the ratio of calories to grams of nitrogen intake was calculated. Results: A total of 1724 eligible subjects, median age 2.0 years (IQR 7) were included in the analysis. 693 subjects (40.2%) were 12 months of age or younger (Figure 1). 1715 patients were included in the analysis of daily macronutrient intake; 9 subjects were excluded due to invalid data. Of the 1715 patients, 1109 (65%) remained in the PICU for 7 or more days, and 487 of these subjects (28%) received PN during the first week. PN was started at a median 3 days (IQR 2.0) after PICU admission. At the time of initiation of PN, 77% of subjects were fasting, 21% received ≤50% of prescribed energy from EN, and 2% received >50% of prescribed energy from EN. Median (IQR) EN protein intake was 0.30 g/kg (1.2) on PICU day 3 and 0.86 g/kg (1.6) on PICU day 7. Prescribed and delivered energy and protein, percent adequacy, and calorie-to-nitrogen ratio by age group are presented in Table 1. Total protein intake by age group and PICU day is shown in Figure 2. The median calorie to nitrogen ratio in the cohort was greater than 210 on each day, and exceeded 150 over the 7 day period for all age groups. Conclusions: Prescription and delivery of energy and protein in the PICU varied daily and by age group. Actual delivered nutrients, particularly via the enteral route, were lower than the prescribed values, and proportionally lower among adolescents compared to younger children. Calorie to nitrogen ratio was higher than recommended among all age groups and throughout the first week of PICU admission, suggesting a high carbohydrate intake with suboptimal protein intake. PN was used as a supplement in the first week, if EN delivery failed to exceed half the prescribed value. Strategies for optimal protein provision during acute critical illness in mechanically ventilated children and its impact on outcomes must be examined.




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