P2D130: Reduction in Cholestasis with Introduction of Multidisciplinary Surgical Nutrition Guidelines

Purpose/Objectives: Neonates that undergo intestinal surgery are at increased risk of developing malnutrition, parenteral nutrition associated cholestasis (PNAC), and intestinal failure associated liver disease (IFLAD). 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 timing of TPN, early enteral nutrition, and establishing early bowel continuity. However, literature assessing these interventions in neonates is limited so the ideal postoperative nutrition management of surgical neonates remains unclear.

Our center is part of the CPQCC GAIN Surgical Collaborative to improve nutritional outcomes in surgical infants. Due to the high prevalence of cholestasis among surgical neonates in our unit, our center also implemented strategies to reduce IFALD in this vulnerable population.

Design/Methods: A multidisciplinary team of neonatologists, pediatric surgeons, pediatric gastroenterologists, NICU RNs, and dietitians was established to optimize postoperative nutrition management of surgical neonates.

This QI project was conducted in an urban 96-bed level IV NICU.

Neonates who underwent any gastrointestinal surgery per the GAIN collaborative criteria were included. Patients who had separate anatomic or physiologic abnormalities that impact cholestasis, such as biliary atresia, were excluded.

Interventions for surgical infants were introduced stepwise over the course of a year through multiple PDSA cycles including a feeding guideline with 4 surgical risk categories and a goal of reconnecting infants after 5 weeks, an updated feeding intolerance algorithm, a TPN guideline with IFLAD mitigation strategies and weaning recommendations to prevent growth failure after discontinuation of PN, and introduction of weekly surgical nutrition rounds for dedicated multidisciplinary nutrition planning for each surgical patient.

The maximum direct bilirubin level of all included neonates was tracked over time as the outcome measure.

Results: A total of 42 pre-intervention and 21 post-intervention infants of similar gestational age and birthweight were included. There was a reduction in maximum post-operative direct bilirubin level from a pre-intervention average of 5.1+3.6 mg/dL to a postintervention average of 2.8+2.7 mg/dL (p=0.007).

Conclusion/Discussion: Implementation of a multidisciplinary approach to post-operative nutritional management of surgical neonates led to a significant reduction in severity of IFLAD in our unit.