Showing papers in "Journal of Parenteral and Enteral Nutrition in 2011"

A.S.P.E.N. Clinical Guidelines Nutrition Screening, Assessment, and Intervention in Adults

Abstract: Background: Due to the high prevalence of obesity in adults, nutrition support clinicians are encountering greater numbers of obese patients who require nutrition support during hospitalization. The purpose of this clinical guideline is to serve as a framework for the nutrition support care of adult patients with obesity. Method: A systematic review of the best available evidence to answer a series of questions regarding management of nutrition support in patients with obesity was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process, that includes consideration of the strength of the evidence together with the risks and benefits to the patient, was used to develop the clinical guideline recommendations prior to multiple levels of external and internal review and approval by the A.S.P.E.N. Board of Directors. Questions: (1) Do clinical outcomes vary across levels of obesity in critically ill or hospita...

Vitamin D Deficiency in Patients With Inflammatory Bowel Disease: Association With Disease Activity and Quality of Life

Abstract: Background: Vitamin D deficiency is common in inflammatory bowel disease (IBD). The aim of the study was to determine the prevalence and predictors of vitamin D deficiency in an IBD cohort. It was hypothesized that vitamin D deficiency is associated with increased disease activity and lower health-related quality of life (HRQOL). Methods: This was a retrospective cohort study. Harvey-Bradshaw index and ulcerative colitis disease activity index were used to assess disease activity. Short Inflammatory Bowel Disease Questionnaire scores were used to assess HRQOL. Multivariate logistic regression was used to identify independent predictors of vitamin D deficiency and its association with disease activity and HRQOL. Results: The study included 504 IBD patients (403 Crohn’s disease [CD] and 101 ulcerative colitis [UC]) who had a mean disease duration of 15.5 years in CD patients and 10.9 years in UC patients; 49.8% were vitamin D deficient, with 10.9% having severe deficiency. Vitamin D deficiency was associate...

Gut microbiota, intestinal permeability, obesity-induced inflammation, and liver injury.

Abstract: Obesity and its metabolic complications are major health problems in the United States and worldwide, and increasing evidence implicates the microbiota in these important health issues. Indeed, it appears that the microbiota function much like a metabolic “organ,” influencing nutrient acquisition, energy homeostasis, and, ultimately, the control of body weight. Moreover, alterations in gut microbiota, increased intestinal permeability, and metabolic endotoxemia likely play a role in the development of a chronic low-grade inflammatory state in the host that contributes to the development of obesity and associated chronic metabolic diseases such as nonalcoholic fatty liver disease. Supporting these concepts are the observations that increased gut permeability, low-grade endotoxemia, and fatty liver are observed in animal models of obesity caused by either high-fat or high-fructose feeding. Consistent with these observations, germ-free mice are protected from obesity and many forms of liver injury. Last, man...

Early Versus Traditional Postoperative Feeding in Patients Undergoing Resectional Gastrointestinal Surgery A Meta-Analysis

Abstract: Background: A meta-analysis evaluating surgical outcomes following nutritional provision provided proximal to the anastomosis within 24 hours of gastrointestinal surgery compared with traditional postoperative management was conducted. Methods: Databases were searched to identify randomized controlled trials comparing the outcomes of early and traditional postoperative feeding. Trials involving gastrointestinal tract resection followed by patients receiving nutritionally significant oral or enteral intake within 24 hours after surgery were included for analysis. Results: Fifteen studies involving a total of 1240 patients were analyzed. A statistically significant reduction (45%) in relative odds of total postoperative complications was seen in patients receiving early postoperative feeding (odds ratio [OR] 0.55; confidence interval [CI], 0.35 -0.87, P = .01). No effect of early feeding was seen with relation to anastomotic dehiscence (OR 0.75; CI, 0.39-1.4, P = .39), mortality (OR 0.71; CI, 0.32-1.56, P = .39), days to passage of flatus (weighted mean difference [WMD] -0.42; CI, -1.12 to 0.28, P = .23), first bowel motion (WMD -0.28; CI, -1.20 to 0.64, P = .55), or reduced length of stay (WMD -1.28; CI, -2.94 to 0.38, P = .13); however, the direction of clinical outcomes favored early feeding. Nasogastric tube reinsertion was less common in traditional feeding interventions (OR 1.48; CI, 0.93-2.35, P = .10). Conclusions: Early postoperative nutrition is associated with significant reductions in total complications compared with traditional postoperative feeding practices and does not negatively affect outcomes such as mortality, anastomotic dehiscence, resumption of bowel function, or hospital length of stay.

The Facilitated Early Enteral and Dietary Management Effectiveness Trial in Hospitalized Patients With Malnutrition

Abstract: Background: The prevalence of malnutrition in the hospitalized setting is 30% to 55%. Previous studies reported an association of malnutrition with an increased hospital length of stay (LOS), morbidity, and mortality of patients. This study evaluated the role of early nutrition intervention on LOS, diagnosis coding of malnutrition cases, calculating case mix index, and reducing delays in implementing nutrition support to patients. Methods: Demographic data, anthropometric measurements, LOS, and serum albumin levels were collected from 400 patients in 2 medical wards to determine the prevalence of malnutrition and potential delays in nutrition consultation. Based on these results, a nutrition intervention study was conducted in 1 ward; the other ward served as a control. Patients were classified as normally nourished or malnourished. Multivariate general linear regressions were used to reveal the impact of intervention on the change in LOS, controlling for other potential confounding factors on the cohort ...

Nutrition in Burns Galveston Contributions

Abstract: Aggressive nutrition support is recommended following severe burn injury. Initially, such injury results in a prolonged and persistent hypermetabolic response mediated by a 10- to 20-fold elevation in plasma catecholamines, cortisol, and inflammatory mediators. This response leads to twice-normal metabolic rates, whole-body catabolism, muscle wasting, and severe cachexia. Thus, it is relevant to review the literature on nutrition in burns to adjust/update treatment. Failure to meet the increased substrate requirements may result in impaired wound healing, multiorgan dysfunction, increased susceptibility to infection, and death. Therefore, aggressive nutrition support is essential to ensure adequate burn care, attenuate the hypermetabolic response, optimize wound healing, minimize devastating catabolism, and reduce morbidity and mortality. Here, the authors provide nutrition recommendations gained from prospective trials, retrospective analyses, and expert opinions based on the authors' practices in Galveston, Texas, and Vienna, Austria.

Pureed by gastrostomy tube diet improves gagging and retching in children with fundoplication.

Abstract: Background: Children with feeding disorders requiring Nissen fundoplication may develop gagging and retching following gastrostomy feedings. We developed a “pureed by gastrostomy tube” (PBGT) diet in an attempt to treat these symptoms and provide adequate nutrition and hydration. Methods: Children post– fundoplication surgery with symptoms of gagging and retching with gastrostomy feedings were selected from our interdisciplinary feeding team. An individualized PBGT diet was designed to meet the child’s nutrition goals. The child’s weight gain was recorded at each follow-up visit. A telephone survey was performed to determine parents’ perceptions of the child’s symptoms and oral feeding tolerance. Results: Thirty-three children (mean age, 34.2 months) participated in the trial. Average weight gain on the PBGT diet was 6.2 g/d. Seventeen children (52%) were reported to have a 76%–100% reduction in gagging and retching. Twenty-four children (73%) were reported to have a ≥50% decrease in symptoms. No child ha...

Ethanol‐Lock Therapy for the Prevention of Central Venous Access Device Infections in Pediatric Patients With Intestinal Failure

Abstract: Background: Central venous access device (CVAD) infections are a major complication in pediatric patients receiving long-term parenteral nutrition (PN) and are particularly prevalent in patients with intestinal failure. This study evaluated the outcomes of outpatient ethanol-lock therapy (ELT) for the prevention of CVAD infections in children with intestinal failure. Methods: In this retrospective analysis, the primary outcome measure was the rate of bloodstream infection (BSI) due to CVAD infections per 1,000 catheter days, and secondary measures included type of organisms cultured and complications of ELT. Results: Over the course of 2 years, 15 patients received outpatient ELT. Sixty-seven percent were male; patients had a mean ± standard deviation age at enrollment of 5.6 ± 6.9 years and body weight of 19.9 ± 15.4 kg. Mean duration of ELT was 263 ± 190 days. Mean BSI rate per 1,000 catheter days significantly decreased from 8.0 before ELT to 1.3 after ELT (P < .01). Seventy-three percent of patients r...

Prophylactic percutaneous endoscopic gastrostomy tube placement in treatment of head and neck cancer: a comprehensive review and call for evidence-based medicine.

Abstract: Background: Patients with head and neck cancers (HNCs) are at increased risk of experiencing malnutrition, which is associated with poor outcomes. Advances in the treatment of HNCs have resulted in improved outcomes that are associated with severe toxic oral side effects, placing patients at an even greater risk of malnutrition. Prophylactic placement of percutaneous endoscopic gastrostomy (PEG) tubes before treatment may be beneficial in patients with HNC, especially those undergoing more intense treatment regimens. PEG tube placement, however, is not without risks. Methods: A comprehensive review of the literature was conducted. Results: Systematic evidence assessing both the benefits and harm associated with prophylactic PEG tube placement in patients undergoing treatment for HNC is weak, and benefits and harm have not been established. Conclusions: More research is necessary to inform physician behavior on whether prophylactic PEG tube placement is warranted in the treatment of HNC.

Effects of perioperative synbiotic treatment on infectious complications, intestinal integrity, and fecal flora and organic acids in hepatic surgery with or without cirrhosis.

Abstract: Background: The aim of this study was to assess the effect of preoperative and postoperative synbiotic treatment in hepatectomy patients with or without liver cirrhosis. Methods: Sixty-one patients with hepatic cancer were assigned randomly to receive either oral synbiotics that consisted of Bifidobacterium, Lactobacillus, and galactooligosaccharides or no synbiotics (control) preoperatively for 14 days and postoperatively for 11 days. Infectious complications, intestinal mucosal integrity as measured by serum diamine oxidase (DAO) activity, and fecal flora and organic acid concentrations were compared between synbiotic treatment (n = 32) and control (n = 29) groups. Results: Fecal flora culture and organic acid concentrations were changed after hepatectomy in both groups. The postsurgery decrease in DAO activity was less profound in the synbiotic-treated group (P < .01) and was correlated negatively with serum interleukin 6 and C-reactive protein concentrations (P < .001). Infectious complications occurr...

Obesity Epidemic: Overview, Pathophysiology, and the Intensive Care Unit Conundrum

Abstract: Obesity is one of the leading causes of preventable death in the United States, second only to smoking. The annual number of deaths attributed to obesity is estimated to be as high as 400,000. Nearly 70% of the adult U.S. population is overweight or obese. The historical viewpoint toward obesity has deemed it to be a lifestyle choice or characterological flaw. However, given the emerging research into the development of obesity and its related complications, our perspective is changing. It is now clear that obesity is a heterogeneous disease with many different subtypes, which involves an interplay between genetic and environmental factors. The current epidemic of obesity is the result of an obesogenic environment (which includes energy-dense foods and a lack of physical activity) in individuals who have a genetic susceptibility for developing obesity. The pathophysiology associated with weight gain is much more complex than originally thought. The heterogeneous nature of the disease makes the development of treatment strategies for obesity difficult. Obesity in general is associated with increased all-cause mortality and cause-specific mortality (from cardiovascular, diabetic, hepatic, and neoplastic causes). Yet despite increased overall mortality rates, current evidence suggests that when these same patients are admitted to the intensive care unit (ICU), the obesity provides some protection against mortality. At present, there is no clear explanation for this obesity conundrum in critical illness.

Nutrition Status and Risk Factors Associated With Length of Hospital Stay for Surgical Patients

Abstract: Objective: To diagnose the nutrition status of hospitalized patients and identify the risk factors associated with hospital length of stay (LOS). Methods: The subjective approach and the body mass index (BMI) were used to classify the nutrition status, and other indicators (anthropometry, biochemistry, and energy intake) were analyzed regarding their association with length of hospital stay of 350 patients. The chi-square test was used to compare proportions, and the Mann-Whitney or Kruskal-Wallis test was used to compare continuous measures. Linear association was verified using Spearman’s rank correlation coefficient. Cox’s regression model was used to investigate factors associated with LOS. Results: Disease was the factor that influenced LOS the most in the studied population. Longer LOS prevailed in males (P < .0001), patients aged ≥60 years (P = .0008), patients with neoplasms (P < .0001), patients who lost weight during their hospital stay (P < .0001), and malnourished patients (P = .0034). There w...

Pulmonary Complications of 9931 Narrow-Bore Nasoenteric Tubes During Blind Placement A Critical Review

Abstract: Introduction: A critical review of the pulmonary complications associated with blind placement of narrow-bore nasoenteric tubes (NETs) is discussed. Preventive measures and placement techniques are addressed to decrease patient morbidity and mortality. Methods: A thorough database review was conducted to identify all randomized controlled and retrospective trials specifically addressing pulmonary complications from narrow-bore NET placement. Five unique studies, comprising more than 9900 NET placements, were identified. On the basis of the literature reviewed, the authors identified 3 major complications associated with blind NET placement: patient mortality directly resulting from NET misplacement, incidence of tracheopulmonary malpositioning, and correlation between NET misplacement and mechanical ventilation. Results: Of the 9931 NET placements reviewed, there were 187 total improper tube placements in the tracheobronchial tree, which translates to a 1.9% mean overall malposition rate. Of these 187 mis...

Nutrition therapy of the severely obese, critically ill patient: summation of conclusions and recommendations.

Abstract: This report compiles the conclusions and recommendations for nutrition therapy of the obese, critically ill patient derived by the group of experts participating in this workshop on obesity in critical care nutrition. The recommendations are based on consensus opinions of the group after review of the current literature. Obesity clearly adds to the complexity of nutrition therapy in the intensive care unit (ICU). Obesity alters the incidence and severity of comorbidities, tolerance of the prescribed regimen, and ultimately patient outcome through the course of hospitalization. Although the basic principles of critical care nutrition apply to the obese ICU patient, a high-protein, hypocaloric regimen should be provided to reduce the fat mass, improve insulin sensitivity, and preserve lean body mass. The ideal enteral formula should have a low nonprotein calorie to nitrogen ratio and have a variety of pharmaconutrient agents added to modulate immune responses and reduce inflammation.

Changes in gastrointestinal hormones and leptin after Roux-en-Y gastric bypass surgery.

Abstract: Background: Roux-en-Y gastric bypass (RYGB) imparts long-term weight loss, the mechanisms for which are not well understood. Changes in leptin and gastrointestinal (GI) hormones, including glucagon-like peptide 1 (GLP-1), peptide YY (PYY), and ghrelin, may contribute to the relative success of RYGB compared with conventional weight loss methods. This study evaluated changes in GI hormones and leptin post-RYGB. The study also evaluated whether GI hormones differed after a short-term dose of protein or fat. Methods: GLP-1, PYY, ghrelin, and leptin were assessed in 16 women before RYGB and up to 1 year after RYGB. Plasma was collected before and at several times after a short-term equicaloric dose of protein or fat. Results: GLP-1 area under the curve (AUC) increased at week 6 and 1 year in the fat beverage (FAT-BEV) group compared with baseline. PYY AUC remained elevated at 1 year in the FAT-BEV group. Ghrelin AUC decreased at week 2, week 6, and 1 year in the protein beverage (PRO-BEV) group compared with ...

Estimating energy needs in nutrition support patients.

Abstract: Determination of energy needs is a fundamental part of nutrition support. The amount of metabolically active tissue mass is the major determinant of metabolic rate. The other components of total energy requirement in an adult are physical activity, diet-induced thermogenesis, and illness hypermetabolism. Measurement with indirect calorimetry is possible but not common. Measurement can capture the effect of body size, diet-induced thermogenesis, and illness on metabolic rate but usually not the effect of physical activity. More often, the energy need is calculated based on its association with body weight and composition. Many equations have been proposed over the years, as have adjustments to body weight in an attempt to capture the distorting effect of body composition in obesity and emaciation. Some equations capture the effects of illness and diet-induced thermogenesis without the need for modification; some require multiplication with various factors. None predict the energy expenditure from physical activity. In determining the energy prescription, all of the component parts must be considered, regardless of whether energy expenditure is measured or calculated.

The Role of Parenteral Lipids in the Development of Advanced Intestinal Failure–Associated Liver Disease in Infants A Multiple-Variable Analysis

Abstract: Background: Given the recent interest in the role of ω-6 lipids in the development of intestinal failure–associated liver disease (IFALD), the authors sought to examine the role of parenteral lipids in the development of a serum conjugated bilirubin >100 µmol/L (5.9 mg/dL; CB100) in infants. Method: Between 2003 and 2004, data were collected prospectively on infants undergoing an abdominal surgical procedure. Univariate logistic regression models for the prediction of CB100 by 1 year postoperatively were developed. Predictors significant at the 0.2 level on univariate analysis were entered into a backward stepwise multiple variable logistic regression. Results: Of 152 infants who received parenteral nutrition (PN) postoperatively, 22 developed CB100. Predictors that met criteria for consideration in the multiple-variable model were age, weight, small bowel length, presence of a stoma, proportion of enteral feeds postoperatively, septic episodes, days of maximal PN amino acid (>2.5 g/kg/d), days of maximal...

Determination of a Practical pH Cutoff Level for Reliable Confirmation of Nasogastric Tube Placement

Abstract: Background: Enteral feeding is a common method of nutrition support when oral intake is inadequate. Confirmation of correct nasogastric (NG) tube placement is essential. Risks of morbidity/mortality associated with misplacement in the lung are well documented. Studies indicate that pH ≤4 confirms gastric aspirate, but in pediatrics, a pH of gastric aspirate is often >4. The goal of this study was to determine a reliable and practical pH value to confirm NG tube placement, without increasing the risk of not identifying a misplaced NG tube. Methods: Pediatric inpatients older than 4 weeks receiving enteral nutrition (nasogastric or gastrostomy) were recruited over 9 months. Aspirate samples were pH tested at NG tube placement and before feedings. If pH >4, NG tube position was confirmed by chest radiograph or further investigations. In addition, intensive care unit (ICU) patients who required endotracheal suctioning were recruited, and endotracheal aspirate samples were pH tested. Results: A total of 4,330 ...

Glutamine Therapy Improves Outcome of In Vitro and In Vivo Experimental Colitis Models

Abstract: Background: Pharmacologic doses of glutamine (GLN) can improve clinical outcome following acute illness and injury. Recent studies indicate enhanced heat shock protein (HSP) expression is a key mechanism underlying GLN’s protection. However, such a link has not yet been tested in chronic inflammatory states, such as experimental inflammatory bowel disease (IBD). Methods: Experimental colitis was induced in Sprague-Dawley rats via oral 5% dextran sulfate sodium (DSS) for 7 days. GLN (0.75 g/kg/d) or sham was administered to rats by oral gavage during 7-day DSS treatment. In vitro inflammatory injury was studied using YAMC colonic epithelial cells treated with varying concentrations of GLN and cytokines (tumor necrosis factor–α/interferon-γ). Results: Pharmacologic dose, bolus GLN attenuated DSS-induced colitis in vivo with decreased area under curve for bleeding (8.06 ± 0.87 vs 10.38 ± 0.79, P < .05) and diarrhea (6.97 ± 0.46 vs 8.53 ± 0.39, P < .05). This was associated with enhanced HSP25 and HSP70 in co...

When Early Enteral Feeding Is Not Possible in Critically Ill Patients: Results of a Multicenter Observational Study

Abstract: Background: Early enteral nutrition (EN) is the preferred strategy for feeding the critically ill; however, it is not always possible to initiate EN within the recommended 24 to 48 hours. When these situations arise, controversy exists whether to start feeding early via the parenteral route or to delay feeding until EN can be provided. Methods: A multicenter, international, observational study examined nutrition practices in intensive care units (ICUs). Eligible patients were critically ill patients with a medical diagnosis who remained in the ICU for >72 hours and received EN >48 hours after admission. Data were collected on site, including patient characteristics, daily nutrition practices, and outcomes at 60 days. Nutrition and clinical outcomes were compared between 3 groups of patients: (1) early parenteral nutrition (PN) ( 48 hours after admission), (2) late PN and late EN, and (3) late EN and no PN. Results: Of the 703 patients who met our inclusion criteria,...

Nutrition therapy in a pediatric intensive care unit: indications, monitoring, and complications.

Abstract: Background: Nutrition therapy (NT) is essential for the care of critically ill children. Inadequate feeding leads to malnutrition and may increase the patient’s risk of morbidity and mortality. The aim of this study was to describe the NT used in a tertiary pediatric intensive care unit (PICU). Methods: The authors evaluated NT administered to 90 consecutive patients who were hospitalized for 7 days in the PICU of Instituto da Crianca, Hospital das Clinicas, Universidade de Sao Paulo, Brazil. NT was established according to the protocol provided by the institution’s NT team. NT provided a balance of fluids and nutrients and was monitored with a weekly anthropometric nutrition assessment and an evaluation of complications. Results: NT was initiated, on average, within 72 hours of hospitalization. Most children (80%) received enteral nutrition (EN) therapy; of these, 35% were fed orally and the rest via nasogastric or postpyloric tube. There were gastrointestinal complications in patients (5%) who needed a ...

Fluid and Electrolyte Management Putting a Plan in Motion

Abstract: Fluid and electrolyte management is challenging for clinicians, as electrolytes shift in a variety of settings and disease states and are dependent on osmotic changes and fluid balance. The development of a plan for managing fluid and electrolyte abnormalities should start with correcting the underlying condition. In most cases, this is followed by an assessment of fluid balance with the goal of achieving euvolemia. After fluid status is understood and/or corrected, electrolyte imbalances are simplified. Many equations are available to aid clinicians in providing safe recommendations or at least to give a starting point for correcting the abnormalities. However, these equations do not take into consideration the vast differences between clinical scenarios, thus making electrolyte management more challenging. The supplementation plan, whether delivered intravenously or orally, must include an assessment of renal and gastrointestinal function, as most guidelines are established under the assumption of normal digestion, absorption and excretion. After the plan is developed, frequent monitoring is vital to regain homeostasis. A fluid and electrolyte management plan developed by a multidisciplinary team is advantageous in promoting continuity of care and producing safe outcomes.

Diet‐Dependent Effects of Minimal Enteral Nutrition on Intestinal Function and Necrotizing Enterocolitis in Preterm Pigs

Abstract: Background: A rapid advance in enteral feeding is associated with necrotizing enterocolitis (NEC) in preterm infants. Therefore, minimal enteral nutrition (MEN) combined with parenteral nutrition (PN) is common clinical practice, but the effects on NEC and intestinal function remain poorly characterized. It was hypothesized that a commonly used MEN feeding volume (16—24 mL/kg/d) prevents NEC and improves intestinal structure, function, and microbiology in preterm pigs. Methods: After preterm birth pigs were stratified into 4 nutrition intervention groups that received the following treatments: (1) PN followed by full enteral formula feeding (OF group, n = 12); (2) PN supplemented with formula MEN and followed by full formula feeding (FF, n = 12); (3) PN plus colostrum MEN followed by formula feeding (CF, n = 12); (4) PN plus colostrum MEN followed by colostrum feeding (CC, n = 10). Results: NEC was absent in the CC group but frequent in the other groups (50%—67%). Compared with other groups, CC pigs showed improved mucosal structures, brush border enzyme activities, and hexose absorption (all P < .05). Relative to formula MEN, colostrum MEN thus improved gut function but did not prevent later formula-induced gut dysfunction and NEC. However, in CF pigs, intestinal lesions were restricted to the colon, compared with all regions in OF and FF pigs, which indicated proximal protection of colostrum MEN. Bacterial composition was not affected by MEN, diet, or NEC outcomes, but bacterial load and concentrations of short-chain fatty acids were reduced in the MEN groups. Conclusion: Colostrum MEN improves intestinal structure, function, and NEC resistance in preterm pigs but does not protect against gut dysfunction and NEC associated with later full enteral formula feeding.

Relationship between feeding tube site and respiratory outcomes.

Abstract: Background: It is unclear if placing feeding tubes postpylorically to prevent respiratory complications is worth the extra effort. This study sought to determine the extent to which aspiration and pneumonia are associated with feeding site (controlling for the effects of severity of illness, degree of head-of-bed elevation, level of sedation, and use of gastric suction). Methods: A retrospective analysis was performed on a large data set gathered prospectively to evaluate aspiration in critically ill, mechanically ventilated patients. Feeding site was designated by attending physicians and confirmed by radiography. Each patient participated in the study for 3 consecutive days, with pneumonia assessed by the simplified Clinical Pulmonary Infection Score on the fourth day. Tracheal secretions were assayed for pepsin in a research laboratory; the presence of pepsin served as a proxy for aspiration. A total of 428 patients were included in the regression analyses performed to address the research objectives. ...

Validation of an Equation for Resting Metabolic Rate in Older Obese, Critically Ill Patients

Abstract: Background: In previous studies, the Penn State (PSU) equation was found to be a valid way to predict resting metabolic rate (RMR) in critically ill patients, with the exception of those who were aged 60 years or older and had a body mass index (BMI) ≥30 kg/m2. A modification of the equation was proposed in this specific patient population. The current study was designed to test the validity of that equation and to retest the validity of the original equation. Methods: RMR was measured using a standardized evidence-based protocol. Metabolic rates predicted with the PSU equation and a modification of it (PSU[m]) were compared with the measured values. Fifty patients were studied prospectively. Data were used from an additional 75 subjects from previous studies that had not been used to develop either of the equations being tested in the current study. This brought the final number of subjects for each equation to 74 for PSU(m) and 106 for PSU. Results: The PSU(m) equation was found to be biased by a narrow...

Predictive Factors of Mortality After PEG Insertion Guidance for Clinical Practice

Abstract: Background: Percutaneous endoscopic gastrostomy (PEG) is considered the preferred route for long-term enteral feeding. The aim of this study was to determine predictors of an increased mortality risk after PEG insertion. Methods: A retrospective study was conducted during a 13-year period in the gastroenterology department of Erlangen University Hospital. The authors completed a questionnaire with details of demographic data, diagnosis, indication for PEG, type of tube, and cause of death. Patients were contacted regularly at scheduled appointments. Results: In total, 787 patients (574 male [72.9%]) underwent PEG placement by the pull technique. The main underlying disease was malignant (75.6%). By the end of the study period, 614 patients had died. The average survival time was 720 days. The 30-, 60-, 90-day and 1-, 3-, and 5-year mortality rates amounted to 6.5%, 9.8%, 13%, 32.1%, 59.3%, and 69.8%, respectively. Predictive factors of increased 30-day mortality were higher age, lower body mass index (BMI...

Nutrition in inflammatory bowel disease.

Abstract: The diet of industrialized nations may contribute to the pathogenesis of both ulcerative colitis (UC) and Crohn disease (CD). Malnutrition is relatively unusual in UC, but in CD, which often affects the small intestine, it is frequent and may be severe. Nutrition support is therefore frequently indicated. First principles of artificial nutrition can be applied effectively using the gut whenever possible. Parenteral nutrition is generally required only in those with short bowel syndrome. An increasing literature (especially in pediatrics) favors the use of defined exclusive enteral nutrition (EN) in the primary treatment of active CD. Controlled trials are, however, lacking, and recommendations are accordingly not of the highest rank. It appears that in this context, simple polymeric regimens are usually sufficient, and there is currently insufficient evidence to make a strong recommendation for disease-specific feeds. In the maintenance of remission in CD, controlled data demonstrate that defined EN reduc...

Verification of an Electromagnetic Placement Device Compared With Abdominal Radiograph to Predict Accuracy of Feeding Tube Placement

Abstract: Background: Use of an electromagnetic placement device (EMPD) facilitates placement of feeding tubes at the bedside. Standard practice for verification of feeding tube placement is via radiographic confirmation. The purpose of this research study was to assess the accuracy of placement of small-bore feeding tubes (SBFTs) as determined by EMPD interpretation compared with that of abdominal radiograph verification by a radiologist. Methods: This multicenter prospective study enrolled patients requiring bedside feeding tube placement. SBFTs were placed by an experienced investigator using the EMPD. Two abdominal radiographs were then obtained: one after initial SBFT placement and an additional radiograph after injection of contrast. Documentation of location based on clinician interpretation using the EMPD was then compared with radiologist interpretation. Results: The final sample size was 194 patients, including 18 pediatric patients. Patient age ranged from 12 days to 102 years. Median time for tube place...

Commercial Enteral Formulas and Nutrition Support Teams Improve the Outcome of Home Enteral Tube Feeding

Abstract: Background: The benefits of home enteral tube feeding (HETF) provided by nutrition support teams (NSTs) have been questioned recently, given the growing costs to the healthcare system. This study examined the effect of a specialized home enteral nutrition program on clinical outcome variables in HETF patients. Methods: The observational study included 203 patients (103 women, 100 men; mean age 52.5 years) receiving HETF with homemade diets for at least 12 months before starting a specialized home nutrition program for another 12 months consisting of provision of commercial enteral formulas and the guidance of an NST. Both study periods were compared regarding the number of hospital admissions, length of hospital and intensive care unit (ICU) stay, and costs of hospitalization. Results: A specialized HETF program significantly reduced the number of hospital admissions and the duration of hospital and ICU stays. The need for hospitalization and ICU admission was significantly reduced, with odds ratios of 0....

Nutrition disorders during acute renal failure and renal replacement therapy.

Abstract: The physiological and biological modifications related to acute renal failure in critically ill patients, including the current use of continuous renal replacement therapies, have dramatically changed the type and importance of the metabolic and nutrition disturbances observed during treatment of renal failure. This review summarizes the current knowledge and makes recommendations for the daily nutrition management of these patients. The filtration of water-soluble substances of low molecular weight by continuous hemodiafiltration results in significant losses of glucose, amino acids, low-molecular-weight proteins, trace elements, and water-soluble vitamins. The losses of these macronutrients and micronutrients should be compensated for. During continuous renal replacement therapy, the daily recommended energy allowance is between 25 and 35 kcal/kg, with a ratio of 60%-70% carbohydrates to 30%-40% lipids, and between 1.5 and 1.8 g/kg protein. Providing energy 25-35 kcal/kg/d with a carbohydrate/lipid ratio of 60-70/30-40 and protein 1.5-1.8 g/kg/d is recommended during continuous renal replacement therapy. Supplemental vitamin B(1) (100 mg/d), vitamin C (250 mg/d), and selenium (100 mcg/d) are also recommended.