bluuebunny/crossref_metadata_2025 huggingface dataset:
Body Mass Index as a Predictor of Complications and Length of Hospital Stay after Thoracic Surgery
Authors: Barrera Rafael , Arslan Vittoria , Gebrayel Nehme , Melendez Jose
Published: June 2009

Background: Body mass index (BMI) has been correlated to complications and outcome in surgical patients at the two extremes of the nutrition spectrum. Objective: To study the relationship between BMI, outcome, hospital length of stay and complications in oncology patients undergoing thoracic surgery. Design: The study population was divided according to BMI in normal weight patients (BMI = 18 to 25) and ovenveight patients (BMI > 25) and prospectively followed postoperative cardiac complications, pulmonary complications, and death. Charts were reviewed for length of hospital stay. Results: One hundred thirty‐seven patients were studied. There were a total of 53 complications in 39 of 137 patients (BMI 26 ± 4). Thirty‐five (25%) were pulmonary and 18 (13%) were cardiac complications. There was no correlation between BMI and either cardiac, pulmonary or all complications. Ovenveight patients spent an average of 6.8 ± 0.4 days and 20.5 ± 5.3 days if they had a complication, which was 8.0 ± 3.0 days more than compared with patients with normal BMI who had complications. Conclusions: Our data suggest that BMI has a strong correlation with length of hospital stay in surgical thoracic patients. Complications in a patient with an elevated BMI are associated with an increased length of stay after thoracic resection.
Children with Cancer: Measurements of Nutritional Status at Diagnosis
Authors: Pietsch John B. , Ford Connie
Published: June 2009

We reviewed anthropometric data from 133 consecutive children diagnosed with cancer at our institution over the past 2 years. Complete information was obtained in 127 cases. Using these data, body mass index (BMI) and weight for height (WT/HT), WT/HT percentile, WT/HT percent for median, weight for age (WT/AGE), WT/AGE percentile, WT/AGE percent of median, height for age (HT/AGE), HT/AGE percentile and HT/AGE percent of median, BMI and WT/HT z scores were calculated. The present study could be interpreted as demonstrating an overall malnutrition incidence ranging between 1% (WT/HT z score < −2.0) and 46% (WT/HT percentile < 50). Despite reports of malnutrition being more common in children with solid vs hematological malignancies, only in the 5‐ to 10‐year age group was a significant difference between hematological malignancies and solid tumors demonstrated using WT/HT or BMI z scores. In summary, the definitions of malnutrition in children with cancer based on anthropometric measurements vary widely. WT/HT z score for ages 0 to 5 years and the BMI z score for ages 10 to 18 years are the preferred indices. For ages 5 to 10 years, either z score may be used. Presented in part at the 23rd Clinical Congress of the American Society of Parenteral and Enteral Nutrition in January 1999 in San Diego, California.
Economic Implications of an Early Postoperative Enteral Feeding Protocol
Authors: Wooley Jennifer A.
Published: June 2009

Objective: To study the cost‐effectiveness of an early postoperative feeding protocol for patients undergoing bowel resections. Design: A nonrandomized, prospective, clinical trial. Surgeons elected to participate in the treatment arm before the study's outset. Subjects/setting: Treatment (n = 66) and control (n = 159) patients were admitted to a nonprofit general teaching hospital in the Texas Medical Center for similar diagnoses and subsequent bowel resections during an 18‐month period. Intervention: Treatment patients who met specific inclusion criteria had a jejunal feeding tube placed during surgery. Tube feedings were initiated within 12 hours after surgery. Control patients who met the same inclusion criteria received usual care. Outcomes: A successful outcome was defined as a patient developing no postoperative infection. The average cost of a nosocomial infection is presented. Variable direct and total costs (fixed plus variable) are compared between patient groups. Statistical Analysis: Mean cost was adjusted for rate of success in each patient group according to an analytic model. The mean cost difference between groups was analyzed by independent‐samples t tests. Nonparametric Mann‐Whitney rank sum tests were used to determine the cost significance of a nosocomial infection. Results: The average variable direct cost savings per successful treatment patient was $1,531, which required an additional variable cost of $108.30 for the dietitian's time. The protocol resulted in a total cost savings of $4,450 per success in the treatment group. Conclusion: An early postoperative enteral feeding protocol as part of an outcomes management program for patients undergoing bowel resection is cost‐effective. (J Am Diet Assoc 99:802–807, 1999)
Methodological issues in the Development and Use of Instruments to Assess Patient Nutritional Status or the Level of Risk of Nutritional Compromise
Authors: Lyman Beth
Published: June 2009

This paper presents the results of an appraisal of the evidence for the effectiveness of methods of nutritional assessment currently in use by nurses and from this develops concepts which may be applied to many areas of nursing practice. The paper first shows how the approach to nutritional assessment by nurses has changed over time, producing the present search for methods which are relatively quick and easy to use. It then describes the limited nature of the evidence of effectiveness of these methods and considers the reasons for this situation. It suggests that the difficulty of validation is an important factor and describes the three most common approaches to validation, showing how problems arise from lack of clarity in the definition of terms and the assumption of a simple relationship between the level of risk of nutritional compromise and actual nutritional status. In conclusion, it is suggested that these difficulties illustrate principles applicable to many areas of nursing care, and a definition of “segments” of care processes, each with well‐defined purposes and outcome measures, is proposed. Such an approach will help to demonstrate the complexity and value of nursing activity. (J Adv Nurs 30:835–842, 1999)
Prospective, Long‐Term Study of Fat‐soluble Vitamin Status in Children with Cystic Fibrosis Identified by Newborn Screen
Authors: Angelini Andrea l.
Published: June 2009

Objective: To prospectively evaluate the biochemical status of vitamins A, D, and E in children with cystic fibrosis (CF). Subjects: A total of 127 infants identified by the Colorado CF newborn screening program. Design: Vitamin status (serum ret‐inol, 25‐hydroxy vitamin D, ratio of alpha‐tocopherol/total lipids) and serum albumin were assessed at diagnosis (4 to 8 weeks), ages 6 months, 12 months, and yearly thereafter, to age 10 years. Results: Deficiency of 1 or more vitamins was present in 44 (45.8%) of 96 patients at age 4 to 8 weeks as follows: vitamin A 29.07c, vitamin D 22.5%, and vitamin E 22.8%. Of these patients with initial deficiency, the percent that was deficient at 1 or more subsequent time points, despite supplementation, was vitamin A 11.1%, vitamin D 12.5%, and vitamin E 57.1%. Of the initial patients with vitamin sufficiency, the percent who became deficient at any time during the 10‐year period was as follows: vitamin A 4.5%, vitamin D 14.4%, and vitamin E 11.8%. The percent of patients deficient for 1 or more vitamins ranged from
Is There a Role for Indirect Calorimetry in Maximizing Patient Outcome from Nutritional Alimentation in the Long‐Term Nursing Care Setting?
Authors: Kleber Melissa J. , Lowen Cynthia C. , McClave Stephen A. , Jung Laura Y. , Looney Stephen W.
Published: June 2009

Background: Patients in a long‐term nursing care center (NCC) are at risk for the complications of malnutrition because of altered mental status and reduced mobility. Objective: This prospective study sought to determine the need for accurately measuring energy expenditure by indirect calorimetry (IC) and providing sufficient nutrition support, by evaluating the effect of energy balance on nutrition‐related complications in the NCC. Design: Patients residing in one NCC were included in this study if there was evidence of hypoalbuminemia, pressure sores, weight loss, actual/ideal body weight less than 85% or more than 150%, or the need for enteral tube feeding or total parenteral nutrition (TPN). After 4 weeks of initial monitoring, patients were evaluated weekly by IC for 8 weeks. Caloric requirements were defined by the measured resting energy expenditure with 10% to 15% added for an activity factor. Monitors included: daily temperature and stool frequency; weekly calorie count, Norton scale (NS), weight, pressure sore number/stage, and serum prealbumin level; and monthly quality of life measure by Minimum Data Set. Results: Of 110 patients screened, 41 met study criteria but 17 were excluded for reasons of agitation, refusal to participate, discharge from the NCC, or death. Of the 24 patients completing the study, 20.8% were male with a mean age of 77.1 years (range 29 to 104 years) and could be grouped on the basis of energy balance. Group 1 (n = 13) had positive cumulative energy balance for the 8 weeks of the study, 30.8% lost weight, 53.8% showed a slight increase in their risk for pressure sores (as evidenced by decreases in NS score) but only 15.4% developed pressure sores. Group 2 (n = 11) had negative cumulative energy balance for the 8 weeks of the study, 63.6% lost weight (odds ratio [OR] = 0.25; 95%
Supplemental Zinc in Wound Healing: Is It Beneficial?
Authors: Malone Ainsley M.
Published: June 2009

The role of nutrition in wound healing is well documented. Malnourished individuals demonstrate impaired wound healing. Specific nutrients are known to be essential in the wound‐healing process. Zinc, a component of multiple enzymes, is important in the formation of collagen, a critical component in the healing wound. The practice of providing supplemental zinc to patients with wounds is not uncommon. This article outlines the role of zinc in wound healing and reviews studies evaluating the use of supplemental zinc to enhance the wound‐healing process. Potential adverse effects of zinc supplementation also are described.
Pharmacologic Options for the Treatment of Cachexia
Authors: Herrington Annie M. , Herrington Jon D. , Church Charlene A.
Published: June 2009

Anorexia and cachexia are prevalent and devastating complications of acquired immunodeficiency syndrome (AIDS) and cancer. Cachexia causes not only loss of body mass, but also decreased energy, decreased therapy tolerance, and increased infection susceptibility, all of which lead to a decreased quality of life. Metabolic abnormalities and decreased appetites seem to be responsible for weight loss in cachectic individuals. The release of cytokines has been found to correlate with weight loss and severe anorexia in animal models. The data in humans is not strong as there are problems in the technical aspects of measuring cytokine levels. Agents such as corticosteroids, anabolic steroids, appetite stimulants, progestational agents, metabolic inhibitors, and anticytokine therapy have been studied for AIDS wasting syndrome and cancer cachexia. Megestrol acetate, a progestational appetite stimulant, has shown the most promise for the treatment of both cancer and AIDS‐related cachexia. Recent literature suggests that agents such as growth hormone, insulin‐like growth factor, and thalidomide may stimulate lean body mass gain rather than fat mass gain. Further study is needed to define the roles of these agents for the treatment of cachexia.
Complications and Costs of Early Postoperative Parenteral Versus Enteral Nutrition in Trauma Patients
Authors: Trice Shana , Melnik George , Page Carey P.
Published: June 2009

The objective of this paper is to compare the complications and costs of early postoperative parenteral and enteral nutrition in trauma patients. The research plan was to review the relevant prospective, randomized, clinical trials comparing parenteral with enteral nutrition in trauma patients. Data were pooled and analyzed for infectious and gastrointestinal complications reported in the trials. Economic costs were used to evaluate the therapeutic expense associated with each route of nutrition support. The results indicated that parenteral nutrition has greater infectious complications and greater associated therapeutic costs than enteral nutrition and thus should be used only in cases in which it is truly indicated.
Monitoring Postnatal Growth in the Neonatal Intensive Care Unit
Authors: Lair Cheryl S. , Kennedy Kathleen A.
Published: June 2009

Standards for growth of premature infants have often been based on in utero growth rates even though infants born prematurely do not exhibit in utero growth patterns after birth. These growth charts do not allow for daily recording of data and are prone to error in recording data as a function of postmenstrual age. Other growth curves based on observations in preterm infants do not extend beyond 40 to 105 days of age, although these infants are often hospitalized for longer periods of time. To address these practical limitations of available growth charts, we devised a method of plotting growth parameters in the neonatal intensive care unit on the basis of previously published standards of growth and estimates of expected growth. Compared with previously published curves, the monitoring system we present offers the following advantages: (1) weight tracking based on postnatal age and head circumference and length tracking based on postmenstrual age; (2) daily recording of weight for 168 days; and (3) recording of postnatal age in conjunction with the length and head circumference measurements to minimize error.
Nutrition Support of Obese Hospitalized Patients
Authors: Choban Patricia S. , Burge Jean C. , Flancbaum Louis
Published: June 2009

Obesity is a chronic disease that affects 33% of the adult population and 30% to 40% of the hospitalized adult population. Obesity can be defined with the use of percent of ideal body weight, but because of a number of problems associated with this method, body mass index has become the accepted measure. Nutrition assessment and selection of route of nutrition support are similar in the obese and normal weight patient. A variety of methods for estimating energy and protein needs in the obese patient are available but become increasingly unreliable as the degree of obesity increases. Measuring energy needs becomes appropriate as obesity becomes more severe. A strategy that uses hypocaloric nutrition support in the obese hospitalized patient is reviewed.
Osmolality of Commonly Used Medications and Formulas in the Neonatal Intensive Care Unit
Authors: Jew Rita K. , Owen Darryl , Kaufman David , Balmer Dorene
Published: June 2009

The objective of the study was to measure the osmolality of medications and special infant formulas commonly used in contemporary neonatal intensive care units. The osmolalities of 75 medications and 20 infant formulas were determined in triplicate by freezing point depression, and the means were reported. A majority of the medications (54 of 75) analyzed had a measured osmolality in excess of 2000 mOsm/kg. Most infant formulas possessed an osmolality within American Academy of Pediatrics (AAP) recommendations (400 mOsm/L), with the exception of powder‐fortified human milk and a protein hydrolysate formula concentrated to 30mL. Final osmolality of infant feedings should be measured or calculated when medications are added and when calories are concentrated beyond 24 kcal/oz. Oral administration of medications, powdered fortification of human milk, and the concentration of some infant formulas may potentiate adverse gastrointestinal effects associated with hyperosmolar feedings and should be postponed until full volume enteral nutrition has been established.
Bioelectrical Impedance Analysis: Implications for Clinical Practice
Authors: Jacobs Danny O.
Published: June 2009

Bioelectrical impedance analysis (BIA) has received significant attention as a means of studying body composition and the relationship of changes in the body's conductive and other electrical properties to changes in body water or its distribution. The application of this technology to the care of patients with nutritional and metabolic disorders is presently under investigation. In this review, a broad overview of recent literature is provided, after the background and rationale for BIA and factors affecting the accuracy of measurements are reviewed.
Pressure Necrosis: Implications and Interventions for PEG Tubes
Authors: Heximer Betsy
Published: June 2009

Pressure necrosis is sometimes related to the use of internal and external bumpers or retention devices. Excessive compression between the two bumpers can cause abdominal and/or gastric wall necrosis. Excessive traction can occur not only at the time of placement, but also long term. Pressure necrosis can occur with all types of feeding tubes but is reported in this article with PEG tubes. Progressive migration of the bumper into the gastric wall can result in “buried bumper” and displacement of the tube. Three case studies will illustrate different possible causes for pressure necrosis and “buried bumper.” Strategies for prevention and interventions for existing ulcer will be presented.
Herbal and Related Remedies
Authors: Bartels Cathy L. , Miller Sarah J.
Published: June 2009

Herbal and related remedies are becoming increasingly popular in the United States. Although some of these products have been promoted as panaceas with little scientific data to support their use, clinical data are starting to accumulate showing the benefit of specific products. For the herbal products, English translation of the German Commission E monographs greatly increases the availability of credible information. Under the 1994 Dietary Health Supplement and Education Act, these products are considered as dietary supplements rather than drugs; regulation by the Food and Drug Administration is therefore limited. This lack of regulation has contributed to drug misadventures; such adverse events should be reported to the MedWatch program of the Food and Drug Administration. One suggestion to improve the status of these products in the United States would be to adopt the German philosophy that the products be approved as drugs based on absolute proof of safety and reasonable proof of efficacy.
Development of a Clinical Pathway for Enteral Nutrition
Authors: Main Barbara J. , Morrison Donna L.
Published: June 2009

Clinical pathways illustrate, sequentially, the most efficient interventions for reaching desired outcomes for various disease states or treatment modalities. With the increasing demand for high‐quality, costeffective nutrition care, the Enteral Nutrition Service developed a clinical pathway for enteral feedings. The purpose was to coordinate multidisciplinary efforts to ensure comprehensive, goal‐oriented nutrition care. The pathway has two phases. Phase one focuses on initiating and optimizing inpatient enteral nutrition support. Phase two addresses the transition to oral diet and discharge planning. This pathway was designed to augment disease specific pathways already in place. In the model developed at William Beaumont Hospital, the Registered Dietitian is designated as the case manager to monitor compliance and record variances. Corresponding continuous quality improvement indicators include nutritional adequacy, complications, compliance to hospital policies, and trial of the proposed home regimen before discharge. The variances and outcomes are presented routinely to the Hospital Nutrition Committee for review and adaptation of the pathway. From both a legal and quality perspective, clinical pathways allow a proactive, multidisciplinary approach to designing the optimal treatment course.
A Diagnostically Reasoned Case Study With Particular Emphasis on B6 and Zinc Imbalance Directed by Clinical History and Nutrition Physical Examination Findings
Authors: Kelly Mary Pat , Kight Mary Ann , Rodriguez Rudolph , Castillo Steve
Published: June 2009

Despite a large body of literature documenting micronutrient requirements, vitamin and mineral imbalance remains an unappreciated player in altered body composition and functional integrity. The absence of routine biochemical determination of nutrient status contributes in part to the inability of the clinical staff to validate recognizable signs and symptoms of deficiency or toxicity. Disciplined use of Nutrition Physical Examination (NPE) procedures enables assessment of tissues known to reflect nutrient imbalance in a cost‐effective way, which can assist clinical history taking and direct nutrition intervention. Macrophotography documenting lesions observed at baseline and after nutrient supplementation, along with laboratory monitoring, can ensure objective, advanced level, outcome‐based nutrition therapy. This case illustrates use of the NPE and nutrition diagnostic reasoning in a relational manner to B6 and zinc imbalance evidenced by (1) mild lip desquamation with ecchymotic‐like lesions; (2) angular stomatitis; (3) seborrheic‐like dermatitis of the scalp and eyebrows; (4) dry, flaky skin with sparse, wiry hair and scattered corkscrew and swan‐neck hairs; and (5) somatic wasting with peripheral neuropathy.
Success Using PEG Tubes in Marrow Transplant Recipients
Authors: Roberts Susan R. , Miller Jan E.
Published: June 2009

Marrow transplant (MT) recipients can develop posttransplantation complications resulting in the need for long‐term nutrition support. Medical records of 16 MT recipients were reviewed retrospectively to determine patient characteristics, hematologic and metabolic abnormalities, complications (bleeding, infection, and gastrointestinal complaints), graft‐versus‐host disease (GVHD) status, nutrition data, and survival after percutaneous endoscopic gastrostomy (PEG) placement. Eleven patients received allogeneic transplants and 5 were autologous recipients. The mean age was 42 years, with PEG placement occurring 5 months (mean) after transplantation. No significant bleeding or metabolic abnormalities developed as a result of PEG placement. Eleven of 16 patients acquired infections, and 8 of these patients were immunocompromised by medications or disease status. Patients did experience intermittent nausea, diarrhea, and high gastric residuals but these usually did not prohibit further feedings. Chronic GVHD was present in 8 patients and was the precipitating factor for PEG placement in 6 patients. Weight maintenance, a common nutritional goal, was achieved. Survival was 81% and 62% at 30 days and 1 year after transplantation, respectively. Nutrition support via PEG tube is viable in MT patients.
Enteral Nutrition Challenges in Home Case
Authors: Silkroski Marcia , Ericson Martha
Published: June 2009

Dietitians are now providing more in‐home visits for patients receiving enteral nutrition. Some of the current and typical challenges are summarized in this case presentation of a 45‐year‐old man being cared for at home by his mother. This patient had brain injury after a stroke and had been at home on tube feeding for ≥10 years. The home care dietitian was able to acquire pharmacologic information and the tube feeding regimen from the family. However, laboratory values, recent weight, and documentation of the patient's progress were unavailable. Home care visits by the nursing agency were infrequent, and the patient saw the primary care physician only if there was a problem. The majority of information obtained by the dietitian was through physical assessment of nutritional status, talking with family members, and observation of care. This case dealt with multiple issues including chronic constipation, poor pharmacologic management, oral feeding by the family with risk of aspiration, fluid management, underfeeding and poor sanitation as a result of limited financial resources, and inability to assess accurately the patient's tolerance and response to changes in tube feeding. The dietitian was able to provide the home care agency and the family with some practical changes in the patient's regimen to improve his overall physical status. As is often the case, the home care agency allowed only one visit by the dietitian, so follow‐up care was not available.
A CQI Program for Prescribing and Dispensing Total Parenteral Nutrition
Authors: Quercia Robert A. , Keating Kevin P.
Published: June 2009

An increase in total parenteral nutrition (TPN) prescribing errors at Hartford Hospital provided the impetus for implementing a continuous quality improvement (CQI) program for prescribing and dispensing TPN. The CQI process identified a number of problems in the prescribing and dispensing system. A severalpronged approach that incorporated education, revision of the TPN order form, and institution of dispensing safeguards was undertaken to resolve these problems. The cornerstone of this program was the unique coupling of a drug utilization evaluation (DUE) process for TPN with an automated TPN intervention program. The computerized intervention program enabled pharmacists to prospectively document, intervene, and track TPN prescribing errors. Through the DUE feedback mechanism, individual physicians received educationally oriented feedback specific to their prescribing errors by the director of the nutrition support team (NST). Six months after implementing the CQI program, the average daily error rate decreased from 4.27% to 1.75%/d.
Improving Timeliness of Nutrition Intervention Through a Collaborative Quality Improvement Program in a Pediatric Intensive Care Unit
Authors: Abad‐Sinden Ana R. , Vittone Sarah B. , Willson Douglas F. , Zaglul Horacio F.
Published: June 2009

The monitoring of the quality of patient care in today's health care environment may be best accomplished through collaborative continuous quality improvement (CQI) programs using the efforts of physicians, nurses, dietitians, and other health care professionals. The CQI Committee of the Pediatric Intensive Care Unit (PICU), a 10‐bed combined medical and surgical unit, developed a collaborative CQI audit to monitor whether critically ill PICU patients should receive nutrition therapy (oral, enteral, or parenteral) in a timely manner. Timely nutrition support was defined as initiation of nutrition therapy within 72 hours of admission for previously well‐nourished patients (category A) or within 48 hours of admission for patients with a history of chronic illness, malnutrition, or trauma (category B). Whether pediatric nutrition support team consultations on category B patients were completed within 72 hours of admission to the PICU also was monitored. An evaluation goal of 80% was set to meet the indicator criteria.
Nutrition and Breast Cancer
Authors: Klimberg V. Suzanne
Published: June 2009

The strongest predictor of breast cancer risk is family history, although the relationship of many dietary factors in regards to increased or decreased risk of future breast cancer appears to be related to their modification of estrogenic exposure. Another major mechanism of nutrients may be through their effect on the immune system. Inconsistencies in studies, their methodologies, and in some cases the lack of human data make it difficult to discern which nutrients may or may not be effective in the prevention of breast cancer, much less their mechanism of action. This review discusses the possible mechanisms of action of nutrients, types of nutrition studies and their respective merit, and available data in major areas of research—fat, alcohol, fiber, antioxidants, protein, phytoestrogens and phytochemicals, and ongoing trials.
The Ketogenic Diet in Pediatric Epilepsy
Authors: Phelps Stephanie J. , Hovinga Collin A. , Rose Douglas F. , Vaughn Carolyn , Olsen‐Creasy Karen
Published: June 2009

Although the ketogenic diet (KD) was first proposed as treatment for epilepsy in 1921, it fell into disuse with the advent of commercially available antiepileptic medications. Over the past decade, there has been renewed interest in the KD for those patients whose epilepsy is refractory to standard anticonvulsant therapy. Although the KD has met with some success, effectiveness depends on a working knowledge of the diet by all health care providers, proper patient selection, and strict adherence to the diet by the patient, patient's family, and those interacting with the child (ie, bus drivers, teachers, and friends). Although the classical KD has existed for >75 years, the exact mechanism of action remains elusive. Likewise, little information exists to serve as a guideline for newcomers to this therapeutic modality. The purpose of this article is to provide health care professionals with practical knowledge concerning the KD and its role in the treatment of epilepsy.
Tube Feeding Audit Reveals Hidden Costs and Risks of Current Practice
Authors: Silkroski Marcia , Allen Francine , Storm Heidi
Published: June 2009

A multidisciplinary audit at 11 teaching hospitals assessed hidden costs and quality issues related to tube feeding. Data were collected on 417 tube‐fed patients via interviews and review of departmental records. Hospitals averaged 38 tube‐fed patients per day and 13 different formulas. Average tube feeding duration was 8.1 days. Hidden costs were identified: 18% to 62% of formulas were wasted per patient per day. The mean annual cost of wasted tube feeding formula per facility was $26,846. Open systems required 14 min/patient/d to manage, compared with 2 min/patient/d for closed systems; the open system required additional administration sets, which cost each facility an average of $47,744 per year; 33% of feedings required additional labor for manipulations. Risks identified included underfeeding of prescribed volume, exceeding hang‐time policy, and practices associated with bacterial risk. The audit addressed the need for multidisciplinary evaluation of tube feeding programs to reveal hidden costs and true practices.
Specialized Nutrition Management of Patients Receiving Hematopoietic Stem Cell Transplantation
Authors: Mattox Todd W.
Published: June 2009

The use of hematopoietic stem cell transplantation (HSCT) continues to increase as a treatment for a variety of malignant and nonmalignant disorders. Metabolic and nutrition management of HSCT patients is dependent on the underlying disease, the conditioning regimen, and other transplant‐related complications. Supportive care for HSCT patients may include specialized nutrition support. Altered metabolism associated with the conditioning regimen and other transplant‐related complications will dictate the route of nutrition intervention and changes in macronutrient and micronutrient requirements. Although many patients are poor candidates for nasoenteric feeding early after HSCT, the best candidate for parenteral nutrition has not been defined. This article reviews the role of specialized nutrition support in adults receiving HSCT, with a focus on clinical application.
Home Enteral Tube Feeding in Children After Chemotherapy or Bone Marrow Transplantation
Authors: Ford Connie , Pietsch John B.
Published: June 2009

Total parenteral nutrition (TPN) has been the standard method of nutrition support for children with cancer receiving intensive chemotherapy or bone marrow transplantation who are taking inadequate calories at the time of hospital discharge. In an effort to reduce costs and improve outcome, we have been using enteral tube feedings in these children, both in hospital and at home. Between 1995 and 1997, 10 children with cancer and 1 child receiving intensive chemotherapy for disseminated Langerhan's cell histiocytosis received home enteral tube feedings. Small (6F or 8F) nasogastric (NG) tubes were used in 9 (82%) children, and 2 (18%) children were fed via percutaneous gastrostomies (G‐tube). Home enteral tube feedings were administered for a total of 512 days (NG = 188 and G‐tube = 324). The tubes were well tolerated, and the children had minimal complications despite neutropenia and thrombocytopenia. The cost of the home enteral tube feedings in these 11 children was $31,315 less than the cost of TPN.
How Well Do Critically Ill Patients Tolerate Early, Intragastric Enteral Feeding? Results of a Prospective, Multicenter Trial
Authors: Heyland Daren K. , Konopad Elsie , Alberda Cathy , Keefe Laurie , Cooper Carmelle , Cantwell Barbara
Published: June 2009

Objective: To evaluate whether critically ill patients tolerate early, intragastric enteral feedings. Design: Multicenter, prospective cohort study. Setting: Eight mixed intensive care units at tertiary care hospitals. Patients: We recruited mechanically ventilated critically ill patients expected to remain ventilated >48 hours. We enrolled 120 patients; the feeding protocol was used in 95. Forty percent were women, the mean age was 55.1 ± 18.9 years, and the mean APACHE II score was 21.6 ± 70.6. Interventions: We used a standardized feeding protocol that initiated enteral nutrition (EN) within 48 hours of admission at 25 mL/h and checked gastric residuals every 4 hours. At every 4‐hour interval, the feeding rate was increased by 25 mL/h to the target rate, if the residual volume was <200 mL. If the residual volume was >200 mL, the feedings were discontinued temporarily. All patients were fed in the stomach. Motility agents were allowed if the patient had high gastric residuals. Main outcomes: Time elapsed from admission to the intensive care unit (ICU) to initiation of EN, tolerance (amount of EN received over the amount needed to receive to meet energy requirements), gastrointestinal dysfunction (eg, high gastric residuals), and ICU‐acquired pneumonia. Results: Patients were started on EN 35.2 ± 15.6 hours after admission. Fifty‐nine of 95 (62%) received >90% of their energy requirements for >2 consecutive days. Over the entire study period the average tolerance was 65.9%. Reasons why EN was interrupted or delayed included high gastric residuals, procedures, feeding tube problem, and diarrhea. The incidence of pneumonia in this cohort was 10 of 95 or 10.5%. Conclusions: Early intragastric EN is safe and feasible and is tolerated in a majority of critically ill patients. High gastric residuals represents a major obstacle to success.
Audit of the Treatment of Malnutrition Due to Chronic Intestinal Pseudo‐Obstruction With Enteral Nutrition
Authors: Scolapio James S. , Camilleri Michael , Weckwerth Jody A. , Romano Michelle
Published: June 2009

Purpose: Chronic intestinal pseudo‐obstruction (CIP) can result in significant malnutrition and weight loss. Although parenteral nutrition can be a useful adjunct in the management of CIP, it is expensive and not without complications. Aim: To determine the outcome of enteral nutrition with nonelemental isotonic formulas in patients with CIP in a tertiary referral center, over the time period 1980 to 1998. Methods: A retrospective medical record review of patients with CIP receiving enteral nutrition. Median follow‐up was 3 years (range, 1 to 8 years) Results: 30 patients (20 women, 10 men; mean age at diagnosis, 49 years) with scleroderma (n = 10), amyloidosis (n = 10), and idiopathic CIP (n = 10) were studied. All had failed oral feeding and had a feeding tube placed. Jejunal tubes were placed in 19 patients and gastric tubes in 11 patients. Continuous feedings were used in 24 patients, and 6 patients received intermittent gravity feedings. Initially, the goal rate of delivery using a standard isotonic enteral formula (mean, 70 mL/h) was met in all patients. Hydration and body weights were maintained. Complications: Documented aspiration related to tube feeding occurred in 3 patients receiving gastric feeding and in none of the patients fed via the jejunal tube. Mild diarrhea occurred in 7 patients (4 jejunal fed and 3 gastric fed). At last follow‐up skin irritation of the tube site occurred in 3 patients with a surgically placed jejunal tube and 1 patient with a gastrostomy. At the time of the last follow‐up, 10 patients (scleroderma, n = 4; idiopathic pseudo‐obstruction, n = 5; amyloidosis, n = 1) developed worsening abdominal pain, were unable to meet their goal of formula delivery, and were placed on parenteral nutrition. These 30 patients were managed successfully on enteral nutrition for a mean of 2 years, (range, 1 to 8 years). Conclusions: Enteral nutrition with a standard nonelemental isotonic formula is a safe and effective means of nutrition delivery in patients with CIP who fail oral intake. Jejunal feeding using a continuous infusion is associated with less complications and is the preferred route of nutritional delivery in CIP.
Nutrition Support Practices in a Pediatric Intensive Care Unit
Authors: Torres Adalberto , Wiggins Pat A.
Published: June 2009

A.S.P.E.N. and others have recommended early enteral nutrition (EN) as the optimal route for nutrition support. We reviewed our experience with 100 children admitted to a pediatric intensive care unit (PICU) to assess what proportion of children received early EN and whether they achieved their caloric goal (Recommended Dietary Allowance [RDA]) within the first 72 hours of admission to the PICU. By the end of their third day in the PICU, 86% of subjects received some form of nutrition. EN was the predominant form of nutrition support started (72%). However, only half the subjects received ≤50% of RDA by the end of their third PICU day. Subjects who did not achieve 50% of their caloric goal received less total fluid and less fluid with nutritional value than those children who achieved at least half their goal. Attention to nutritional content of total fluids administered and systematic advancement of rate of EN administration is warranted.
Postnatal Body Weight Curves for Infants Below 1000 g Birth Weight Receiving Early Enteral and Parenteral Nutrition
Authors: Han‐Markey Theresa L.
Published: June 2009

No body weight curves are available for preterm infants <1000 g birth weight receiving early enteral and parenteral nutrition. Postnatal weight changes of 136 infants with a birth weight <1000 g were analyzed retrospectively. Body weight curves for the first 30 days of life were generated for five separate birth weight groups (430–599, 600–699, 700–799, 800–899, and 900–999 g). All infants had received intravenous glucose and amino acids from day 1 and intravenous lipids from day 2. Enteral feeding was started on day 1. Thus, caloric intake (±SD) was advanced to 384 46 kJ/kg per day (92 ± 11 kcal/kg/d) in the 1st week of life. In 136 preterm infants mean postnatal weight loss was 10.1% ± 4.6% of birth weight; birth weight was regained at a mean postnatal age of 11 ± 3.7 days but significantly earlier (7.8 ± 3.5 days) in the lowest compared to the highest weight group. Mean subsequent weight gain was 15.7 ± 7.2 g/kg per day. This was accomplished by exclusive enteral nutrition from day 20 (median). Conclusion: Our body weight curves are more adequate to evaluate growth of preterm infants than older published reference values, because they are based on infants treated according to current nutrition standards.
Comparison of Tacrolimus Absorption in Transplant Patients Receiving Continuous Versus Interrupted Enteral Nutritional Feeding
Authors: Boullata Joseph I.
Published: June 2009

Objective: To determine the effect of enteral nutritional feeding on the absorption of tacrolimus administered through a nasoduodenal tube to organ transplant patients. Methods: A nonrandomized, prospective study of tacrolimus absorption was performed in 10 liver or lung transplant patients who received Osmolite enteral nutrition through a nasoduodenal feeding tube. Multiple blood samples were collected just prior to and at 30 minutes, 1, 2, 3, 4, 6, 8, 10, and 12 hours after nasoduodenal administration of tacrolimus on 2 consecutive days, once when tacrolimus was administered along with the continuous enteral feeding and the other time when the enteral feeding was withheld 1 hour prior to and 8 hours after tacrolimus administration, to assess tacrolimus absorption. The whole blood tacrolimus concentrations were measured by the microparticulate enzyme immunoassay method. Pharmacokinetic parameters between the two time periods were compared by using a paired t‐test at a significance level of a p value of 0.05 or less. Results: The time to reach peak blood concentrations (p = 0.055), dose‐normalized trough concentrations (p = 0.617), maximum blood concentrations (p = 0.197), and dose‐normalized AUC (p = 0.755) were not significantly different between two study periods. Conclusions: This study demonstrated that simultaneous administration of Osmolite enteral feedings and tacrolimus did not interfere with tacrolimus absorption in transplant patients.
Acute Nutrition Interventions Help Identify Indicators of Quality in a Trauma Service
Authors: Klein Catherine J. , Henry Sharon M.
Published: June 2009

Clinical indicators of nutrition care are needed to help improve patient outcomes. To identify potential indicators of nutrition care, 1 dietitian in a trauma service prospectively documented every immediate action she undertook to prevent or correct an adverse, nutrition‐related outcome. A total of 101 acute nutrition interventions were provided with 93 (5.2%) of the 1777 nutrition evaluations conducted over the 10‐month period. Patient overfeeding triggered 1 of every 3.5 acute nutrition interventions. Most instances of overfeeding were linked to the lack of an interdisciplinary plan of nutrition care. This was troubling because of the severity of illness among the overfed patients (25% mortality). Other categories that necessitated acute intervention included electrolyte imbalance and underfeeding. Several nutritional problems identified by this study are appropriate for use as rate‐based and sentinel event indicators to improve the quality of nutrition care.
Adjustment of Nutrition Support With Continuous Hemodiafiltration in a Critically Ill Patient
Authors: Kaufman David C. , Haas Curtis E. , Spencer Sharon , Veverbrants Egils
Published: June 2009

Glucose‐containing dialysis solutions are commonly used for continuous renal replacement therapy. A significant portion of this glucose is transferred across the dialysis membrane, which necessitates a change in the carbohydrates being provided by alternative nutrition support. Glucose transfer usually is estimated empirically, but glucose absorption across a dialysis membrane can be measured easily during continuous dialysis because the quantity of glucose from the patient (Gluout. BFR [blood flow rate]) plus the quantity that is absorbed across the dialysis membrane (Gluadded) must be equal to the quantity going back to the patient (Gluin. BFR): Gluadded = (Gluin ‐ Gluout) X BFR X k, where k is a conversion factor to correct for different units. This teaching case describes the course of an 83‐year‐old man receiving continuous dialysis, for whom adjustments to his nutrition support were made on multiple occasions on the basis of direct measurement of the amount of glucose absorbed from the dialysis solution. The described method is easy to apply at the bedside and should allow for appropriate prescription of carbohydrate calories during continuous dialysis when glucose‐containing solutions are used.
Tolerance and Efficacy of Enteral Nutrition for Neurosurgical Patients in Pentobarbital Coma
Authors: Magnuson Barbara , Hatton Jimmi , Williams Suzy , Loan Theresa
Published: June 2009

This retrospective study examined the tolerance of enteral nutrition in 32 of 67 consecutive, neurosurgical patients placed into pentobarbital‐induced coma for intractable intracranial hypertension. Patients who had received at least 4 days of enteral nutrition were included. Patients with <4 days of enteral nutrition were excluded for reasons unrelated to feeding tolerance. All patients were fed by a 10‐French, small‐bore feeding tube placed blindly or endoscopically. Feeding‐tube location was in the small bowel in 26 of 32 patients, intragastric in 4 patients, and not documented in 2 patients. Intolerance (>500 ml watery stool for 2 days, abdominal distention, or duodenal‐gastric reflux) was observed in 3 of 32 patients. The patients received daily, on average, 92% ± 24% calories of their measured energy expenditure. This study demonstrates that patients placed into barbiturate coma can be successfully fed by the enteral route.
Evaluation of Bacterial Contamination of a Sterile, Non‐Air‐Dependent Enteral Feeding System in Immunocompromised Patients
Authors: Rupp Mark E. , Weseman Rebecca A. , Marion Nedra , Iwen Peter C.
Published: June 2009

Background: Bacterial contamination of enteral feeding solutions has been associated with a variety of infectious complications. In order to minimize contamination of enteral feeding solutions, it is recommended that their infusion times be limited. This leads to wasted product and inefficient use of personnel time. The contamination rate for sterile, non‐air‐dependent, closed system enteral feeding solutions and the length of time over which they can be safely infused in immunocompromised patients is not known. Methods: Enteral feeding was administered to 15 liver transplant recipients via a sterile, closed, non‐airdependent system. At the conclusion of infusion of each bag of enteral feeding solution, the residual solution was quantitatively cultured. Subjects were also monitored for infectious complications. Results: The mean infusion time per 1.5‐L bag of enteral feeding solution was 22.7 hours (range 10 hours to 35 hours). None of the 52 samples harbored bacteria. No subject developed a nosocomial infection that could be associated with contamination of the enteral feeding solution. Conclusions: When properly handled, sterile, non‐air‐dependent, closed system, enteral feeding solutions can be administered over prolonged infusion times without bacterial contamination.
Influence of Different Fat Emulsions With 10 or 20% MCT/LCT or LCT on Lipoproteins in Plasma of Patients After Abdominal Surgery
Authors: Stalo Kristin
Published: June 2009

In patients after elective abdominal surgery, different fat emulsions were used to compare their efficacy in total parenteral nutrition and in normalizing plasma lipoprotein levels. In five different groups with 5 patients each, half of the nonprotein calories were given as medium‐chain triglycerides/ long‐chain triglycerides (1:1) or as long‐chain triglycerides alone in 10 or 20% fat emulsions or as glucose alone in a control group for 7 days. After surgery, an initial decrease of all plasma lipoprotein components was followed by a different behavior of glyceride‐glycerol, cholesterol, phospholipids, and apolipoproteins. Glyceride‐glycerol in very‐low‐density lipoproteins and high‐density lipoproteins is increasing during infusion of fat emulsions and decreasing during overnight interruption of infusions. After the 7‐day infusion period, there was no significant difference in very‐low‐density lipoprotein glyceride‐glycerol as compared with the values before different infusions. Low‐density lipoprotein cholesterol is reaching and exceeding preoperative concentrations between the 4th and the 7th day, most during infusion of 10% fat emulsion and especially due to an increase of free cholesterol. High‐density lipoprotein cholesterol and apolipoprotein A‐I reach preoperative levels during infusion of fat emulsions but not with glucose alone. Higher than preoperative values are reached in phospholipids with all fat infusions already on day 4. Abnormal lipoprotein X occurred least with the medium‐chain/long‐chain triglyceride 20% fat‐infusion. This fat emulsion is suggested as having the best normalizing effect on plasma lipoproteins and best tolerance in patients after surgery.