509 - Reduction in Cholestasis Through Introduction of Multidisciplinary Surgical Nutrition Guidelines

Publication Number: 509.6291

Audrianna Atencio, Miller Children's & Women's Hospital Long Beach, HUNTINGTON BEACH, CA, United States; Ching Ching Tay, MemorialCare Miller Children's & Women's Hospital, Cypress, CA, United States; nam Nguyen, Keck of USC School of Medicine, Los Angeles, CA, United States; Leon Chen, Miller Children's & Women's Hospital Long Beach, Long Beach, CA, United States; Barry A. Steinmetz, Enter confirmation #130, Costa Mesa, CA, United States; Peggy Chen, Miller Children's & Women's Hospital Long Beach, Los Angeles, CA, United States

Background: Neonates that undergo intestinal surgery are at increased risk of developing intestinal failure associated liver disease (IFALD). The incidence of cholestasis among surgical neonates is high and is associated with decreased survival, reduced probability of achieving enteral autonomy, and malnutrition. Potential strategies to mitigate the progression of IFALD include modifying the composition and schedule of total parenteral nutrition (TPN), early enteral nutrition, and establishing early bowel continuity. However, literature assessing these interventions in neonates is limited, thus the ideal postoperative nutrition management of surgical neonates remains unclear.

Objective: Our urban 96-bed level IV NICU was part of the California Perinatal Quality Care Collaborative (CPQCC) Growth Advancement In the NICU (GAIN) Surgical Patients Collaborative to improve nutritional outcomes in surgical infants. Due to the high prevalence of cholestasis in our surgical neonates, our center has continued to implement strategies to reduce IFALD in these patients.

Design/Methods: A multidisciplinary team of neonatologists, pediatric surgeons, pediatric gastroenterologists, NICU nurses, and NICU dietitians developed guidelines to optimize postoperative nutrition management of surgical neonates. Neonates who underwent intestinal surgery were included. Patients who had separate anatomic or physiologic abnormalities that may impact cholestasis, such as biliary atresia, were excluded. Interventions for surgical infants were introduced stepwise over two years through multiple PDSA cycles which included a feeding guideline with 4 surgical risk categories and a new goal of reconnecting infants after 5 weeks, an updated feeding intolerance algorithm, a surgical patient TPN guideline, introduction of weekly surgical nutrition rounds for dedicated multidisciplinary nutrition planning for each surgical patient, and transition to SMOFlipid® as the primary lipid emulsion. Our primary outcome measure was the maximum post-operative direct bilirubin level.

Results: A total of 47 pre-intervention and 67 post-intervention infants of similar gestational age and birthweight were analyzed. We saw a reduction in maximum post-operative direct bilirubin level from a pre-intervention average of 4.1±3.3 mg/dL to an active phase average of 2.9±2.8 mg/dL (p=0.04) and a sustainment phase average of 2.2±2.6 mg/dL (p=0.007).

Conclusion(s): Implementation of a multidisciplinary approach to post-operative nutritional management of surgical neonates led to a significant reduction in severity of IFALD in our unit.