bluuebunny/crossref_metadata_2025 huggingface dataset:
Home Initiation of Parenteral Nutrition
Authors: Newton Alyce F. , DeLegge Mark H.
Published: May 2008

Parenteral nutrition (PN) has been successfully initiated in the home since the early 1990s. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Standards for Specialized Nutrition Support: Home Care Patients, Safe Practices for Parenteral Nutrition, and Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients do not contain specific information on the initiation of home PN (HPN). Peer‐reviewed, published guidelines are necessary to provide safe and appropriate initiation of HPN. Certain patients should not have PN initiated in the home, such as those with organ failure, uncontrolled diabetes, or uncorrectable electrolyte abnormalities. Excellent candidates for initiation of HPN include patients who have failed enteral feedings, have gastrointestinal (GI) diseases without excessive GI losses, or those with an oncology diagnosis and inability to tube feed. One concern of initiation of HPN is the potential for refeeding syndrome. Refeeding syndrome can be prevented when patients are properly evaluated and managed before initiation of PN. Refeeding syndrome can be avoided by rehydration with fluid and electrolytes before initiation of HPN to normalize blood chemistry when necessary and by starting with a moderate‐volume, low‐carbohydrate HPN solution compounded with optimal potassium, phosphorus, and magnesium content, and slowly advanced to goal. The “start low and go slow” motto of nutrition support should continue to be followed, but more specific guidelines are needed to assist nutrition support clinicians with safe and appropriate initiation of HPN.
Modulation of Lipid Rafts by Ω‐3 Fatty Acids in Inflammation and Cancer: Implications for Use of Lipids During Nutrition Support
Authors: Siddiqui Rafat A. , Harvey Kevin A. , Zaloga Gary P. , Stillwell William
Published: May 2008

Current understanding of biologic membrane structure and function is largely based on the concept of lipid rafts. Lipid rafts are composed primarily of tightly packed, liquid‐ordered sphingolipids/cholesterol/saturated phospholipids that float in a sea of more unsaturated and loosely packed, liquid‐disordered lipids. Lipid rafts have important clinical implications because many important membrane‐signaling proteins are located within the raft regions of the membrane, and alterations in raft structure can alter activity of these signaling proteins. Because rafts are lipid‐based, their composition, structure, and function are susceptible to manipulation by dietary components such as ω‐3 polyunsaturated fatty acids and by cholesterol depletion. We review how alteration of raft lipids affects the raft/nonraft localization and hence the function of several proteins involved in cell signaling. We focus our discussion of raft‐signaling proteins on inflammation and cancer.
Enteral Nutrition in Critically Ill Children: Are Prescription and Delivery According to Their Energy Requirements?
Authors: Iglesias Simone Brasil de Oliveira , Leite Heitor Pons , Meneses Juliana Fernandez Santana e , de Carvalho Werther Brunow
Published: May 2008

Background: The purpose of this study was to compare the differences between prescribed and delivered energy among critically ill children and to identify the factors that impede the optimal delivery of enteral nutrition in the first 5 days of nutrition support. Methods: In a prospective cohort study, we evaluated 55 critically ill children aged 8.2 ± 11.4 months (0–162.3 months), who were fed for ≥2 days through a gastric or postpyloric tube. The patients were followed from admission until day 10 of enteral nutrition. Prescribed and delivered energy were recorded daily and compared with each other and with the estimated basal metabolic rate (BMR). The Paediatric Index of Mortality 2 (PIM 2) was used to estimate illness severity. Results: The ratio of delivered:required energy was <90% in 55.7% of the enteral nutrition days. Low prescription was the main reason for not achieving the energy goal in the first 5 days of enteral nutrition. Discrepancies between prescribed and delivered: energy were attributable to interruptions in feeding caused by clinical instability, airway management, radiologic and surgical procedures, and accidental feeding tube removal. The other factors associated with the delivery of less than required energy were PIM 2 ≥15%, gastrointestinal complications, dialysis, and use of α‐adrenergic vasoactive drugs. The latter was the only variable in multivariate analysis that was associated with not ultimately achieving energy goal. Conclusions: The prescription and delivery of energy were not adequate in >50% of enteral nutrition days. The gap between the effective administration and energy requirements can be explained by both underprescription and underdelivery. Administration of vasoactive drugs was the only variable independently associated with a low energy supply.
Ideal Body Weight in Children
Authors: Phillips Sharon , Edlbeck Angela , Kirby Midge , Goday Praveen
Published: May 2008

There is no clear consensus on the correct definition of ideal body weight (IBW) in children or on the best method used to calculate IBW. There are at least 3 ways of obtaining IBW in children. They are (1) the McLaren method, (2) the Moore method, and (3) the body mass index method. In children under the age of 8 years, all of these methods provide relatively similar results across all percentiles. In older children, especially at the lowest and highest percentiles, the different methods provide widely disparate results for IBW. It is important to be consistent in the method used as the different methods will provide different results for IBW.
Parenteral Nutrition (PN) Use for Adult Hospitalized Patients: A Study of Usage in a Tertiary Medical Center
Authors: DeLegge Mark H. , Basel Mary D. , Bannister Chris , Budak Amanda R.
Published: May 2008

The use of parenteral nutrition (PN) is essential for patients who are unable to meet their nutrition requirements through oral or enteral nutrition. Many earlier studies have noted that PN is often inappropriately used in the hospital setting, thereby increasing the risk of associated complications and costs. A prospective study was performed at the Medical University of South Carolina (MUSC), using a nutrition support database to determine the appropriateness of PN use and the associated hospital costs for patients on 3 surgical services over a 6‐month period. Appropriateness of PN therapy was determined according to the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines. A total of 139 new PN therapies were initiated in the 6‐month period. Forty percent of the cases were deemed inappropriate. A total of 573 PN days ($80,000 hospital PN costs) could have been saved if inappropriate PN therapy had not been ordered. The avoidable costs only reflect the PN solution and not the additional costs associated with laboratory monitoring, central line placement and maintenance care, nursing administration, and ongoing pharmacy and dietitian clinical management. This study illustrated that PN was not always being provided according to A.S.P.E.N. guidelines. In addition, cost savings could be achieved if PN was provided only to MUSC patients who meet these guidelines.
Patient Assessment in the Diagnosis, Prevention, and Treatment of Osteoporosis
Authors: Lata Paul F. , Elliott Mary E.
Published: May 2008

Assessment of the patient with osteoporosis includes history and physical examination, laboratory testing, and imaging studies. Information gathered during this assessment assists clinicians in targeting strategies to prevent fractures. The medical history should contain items such as personal and family history of fractures, lifestyle, intake of substances such as vitamin D, calcium, corticosteroids, and other medications. The physical examination can reveal relevant information such as height loss and risk of falls. Bone mineral density (BMD), most commonly determined by dual‐energy x‐ray absorptiometry, best predicts fracture risk in patients without previous fracture. BMD testing is most efficient in women over 65 years old but is also helpful for men and women with risk factors. Serial BMD tests can identify individuals losing bone mass, but clinicians should be aware of what constitutes a significant change. Laboratory testing can detect other risk factors and can provide clues to etiology. Selection of laboratory tests should be individualized, as there is no consensus regarding which tests are optimal. Biochemical markers of bone turnover have a potential role in fracture risk assessment and in gauging response to therapy, but are not widely used at present. Clinicians should be aware of problems with vitamin D measurement, including seasonal variation, variability among laboratories, and the desirable therapeutic range. Careful assessment of the osteoporotic patient is essential in developing a comprehensive plan that reduces fracture risk and improves quality of life.
Old World Meets Modern: A Case Report of Scurvy
Authors: Wang Alan H. , Still Christopher
Published: May 2008

Scurvy is a rarely seen disease resulting from a deficiency of vitamin C. We present a case of scurvy in a 65‐year‐old man. The patient reported heavy alcohol abuse over the last several years. He also reported that his diet consisted of cheese pizzas only. On physical examination, he was noted to have spontaneous ecchymosis of his lower extremities (denying any history of trauma); poor dentition; and corkscrew hairs on his chest, abdomen, and legs, with associated perifollicular petechia. Punch biopsy of his skin lesions revealed perivascular lymphohistiocytic inflammation, with some focal perifollicular erythrocyte extravasation. A serum ascorbic acid level was<0.12 mg/dL (normal range, 0.20–1.9 mg/dL). A diagnosis of vitamin C deficiency was made. The patient was successfully treated with 1 g/d vitamin C for the first 5 days, followed by a dose of 500 mg/d. Though scurvy is rarely seen in modern times, it is important to identify who is at risk and to recognize the clear and classic signs and symptoms associated with scurvy. Failure to diagnose this disease can potentially lead to expensive and unnecessary medical tests, as well as missing a very simple treatment that can prevent infection and even death.
Pancreatic Islet Cell Transplantation: Update and New Developments
Authors: Onaca Nicholas , Naziruddin Bashoo , Matsumoto Shinichi , Noguchi Hirofumi , Klintmalm Goran B. , Levy Marlon F.
Published: May 2008

Pancreatic islet cell transplantation is a treatment alternative for patients with type 1 diabetes who experience hypoglycemic unawareness despite maximal care. The good results obtained by the group from Edmonton and other centers, with 80% insulin independence at 1 year posttransplant, are not sustainable over time, with 5‐year insulin independence achieved in only 10% of patients. However, persistent graft function, even without insulin independence, results in improved glucose control and avoidance of hypoglycemic events. Changes in organ preservation, islet processing technique, and immunosuppression regimens can result in improvement of results in the future. Islet autotransplantation is an option for patients who undergo total pancreatectomy for chronic pancreatitis with debilitating pain, in which reinfusion of the islets from the resected pancreas can result in avoidance of postsurgical diabetes or enhanced glucose control.
Fistuloclysis: Case Report and Literature Review
Authors: Ham Maggie , Horton Kelli , Kaunitz Jonathan
Published: May 2008

Enterocutaneous fistulae are a common postoperative entity, causing serious complications such as sepsis, malnutrition, and electrolyte and fluid abnormalities. Because sepsis coupled with malnutrition is the leading cause of death in these patients, it is especially important to provide nutrition support. Although parenteral nutrition (PN) is widely used in these patients, it is not without risks, because PN is known to cause liver dysfunction, among other problems. We report a case in which a male patient with an enterocutaneous fistula, having experienced increased liver enzymes receiving PN, began receiving enteral nutrition (EN) via a feeding tube placed in the fistula. Known as fistuloclysis, this method provided adequate nutrition and improved his serum albumin and prealbumin levels, body weight, and liver function tests. Upon stabilization of his nutrition status, he was able to undergo successful surgical repair of the enterocutaneous fistula. According to our experience and that of others, we recommend that patients with high‐output enterocutaneous fistulae be considered for EN via fistuloclysis after nutrition stabilization with PN; then the fistulae can be surgically repaired if not spontaneously healed. Use of EN via fistuloclysis, if used appropriately, avoids the complications of long‐term PN and may promote faster fistula healing.
The Bits and Bytes to Advanced Graduate Degree Programs
Authors: Radler Diane Rigassio , Touger‐Decker Riva
Published: May 2008

Lifelong learning may afford the dietetics professional more opportunities for career advancement, a richer self‐satisfaction, and a revived confidence regarding career choices. The avenue to lifelong learning is a process unique to every health professional because of individual differences in interest and work arenas. Learning activities may take the form of continuing education conferences or certificate programs, advanced or specialty training, or academic degree programs. These programs may be in one's local community or may be accessed via distance learning. This paper will focus on advanced‐degree academic programs using the distance education route. Characteristics of technologically savvy programs and learners will be addressed.
Inflammatory Mediators and Home Parenteral Nutrition
Authors: Hise Mary , Compher Charlene , Brown John
Published: May 2008

Individuals who have sustained intestinal failure due to trauma or disease are able to survive through the use of parenteral nutrition (PN). Although home PN (HPN) is a lifesaving therapy, patients may, over the long term, be at risk for liver, bone, and immune dysfunction. A limited number of human studies and a large number of animal studies suggest that there may be a chronic inflammatory condition and additionally a potentially lower T‐lymphocyte immune function associated with PN administration. This article will primarily focus on a review of the limited clinical literature that examines the effect of long‐term PN on the occurrence of inflammatory mediators in HPN patients, and will discuss the factors that are currently hypothesized to contribute to the potential inflammatory sequelae.
A Review of Complementary and Alternative Approaches to Immunomodulation
Authors: Clarke John O. , Mullin Gerard E.
Published: May 2008

Current Western therapies for inflammatory diseases are suboptimal; increasingly, patients are turning to complementary and alternative medicine for symptom relief and improved quality of life. There is emerging evidence that many of these therapies have the ability to modulate the immune system and disrupt the proinflammatory cascade through a variety of mechanisms, including antioxidant effects, alterations in cell signaling (in particular the nuclear factor (NF)‐κB pathway), cytokines, proinflammatory mediators, and disruption of bacterial flora. Using inflammatory bowel disease (IBD) as a model of inflammation, we explore the principal complementary and alternative medicine treatments that show promise in this regard, namely, resveratrol, green tea, curcumin, boswellia, fish oil, vitamin D, and probiotics. With each agent, we detail the mechanisms that have been described with regard to immune modulation, discuss the medical conditions for which it has been evaluated, and explore the data to date for the prevention or treatment of IBD.
Invited Review: Nutrition for Adult Burn Patients: A Review
Authors: Ireton‐Jones Carol S. , Baxter Charles R.
Published: May 2008

Adequate nutritional support is an important aspect of burn therapy. To accomplish this goal, nutrition assessment must be conducted, with particular attention given to the determination of energy and macronutrient needs. Providing these nutrients by the enteral route is recommended.
Invited Review: Enteral Feeding and Infection in the Immunocompromised Patient
Authors: Moe Gaile
Published: May 2008

Evidence is accumulating that immunocompromised individuals are at an increased risk of infection from foodborne pathogens including Campylobacter jejuni, Listeria monocytogenes, Salmonella spp. Normal bacterial flora and contaminants of foods and enteral feeds can also result in nosocomial infection in susceptible individuals. Safe food handling, low‐microbial diets, and measures to reduce bacterial contamination of enteral foods can reduce exposure to potential pathogens in the food supply.
Quality Assurance for a Nutritional Support Service
Authors: Geibig Charles B. , Mirtallo Jay M. , Owens Julie
Published: May 2008

Quality assurance programs may significantly influence patient care by providing a systematic mechanism of self‐assessment. An effective program should improve the level of care and have a positive effect on the fiscal base of a health care institution. The design of a useful quality assurance program is not a trivial matter. This report describes the details of a functioning quality assurance program developed for a multidisciplinary nutrition support service. The effect that such a program may have on patient care is also illustrated.
Collecting Data for Clinical Indicators
Authors: Skipper Annalynn
Published: May 2008

The Joint Commission for Accreditation of Healthcare Organizations is currently testing clinical indicators that will become an important part of hospital quality assurance programs. Implementation of clinical indicators may necessitate more extensive data collection than is now being done. This article reviews important considerations in the development of a data collection system that facilitates the evaluation of indicators of clinical performance. The evolution of the system currently used by the Nutritional Support Service at Pennsylvania Hospital is provided.
Medication‐Nutrient Interactions: Hypophosphatemia Associated With Sucralfate in the Intensive Care Unit
Authors: Miller Sarah Johnston , Simpson Jeff
Published: May 2008

Clinically significant medication‐nutrient interactions are of concern to the nutritional support practitioner. To emphasize the possible effect of the aluminum‐containing medication sucralfate on serum phosphorus levels, patients admitted to the intensive care unit of a small private hospital were monitored for a 4‐week period. Sixteen patients demonstrated low serum phosphorus levels; eight (50%) of these were receiving sucralfate. Eighteen patients had no low phosphorus levels measured; five (28%) patients in this group were receiving sucralfate. The hypophosphatemia observed in these patients was probably multifactorial; respiratory alkalosis and dextrose feeding as well as sucralfate use are consistent with hypophosphatemia.
Animal Models in Human Nutrition Research
Authors: Gallaher Daniel D.
Published: May 2008

Animal models are used extensively in nutritional research. Studies with animal models may not provide a discussion of the applicability of the model to humans, and seldom do such studies discuss the limitations of the model. This article presents information that is targeted toward the nutrition support practitioner about the use of animal models in nutritional research. The rationale for using animal models and the applicability to humans, the limitations of applicability, and the unique opportunities related to animal models is presented.
Selenium Deficiency in Long‐Term Total Parenteral Nutrition
Authors: Abrams C.K. , Siram S.M. , Galsim C. , Johnson‐Hamilton H. , Munford F.L. , Mezghebe H.
Published: May 2008

Although selenium is an essential trace element, it is often not routinely added to total parenteral nutrition (TPN) formulations. When selenium is not added, patients are at risk for selenium deficiency. This report describes such a patient. He had several operations for colon cancer, including a massive resection of the small bowel that resulted in a short bowel and a fistula. TPN was started after his last operation. After he was discharged, he had a normal, active lifestyle, except that he limited oral intake to water and an occasional soft drink. After 3 years of almost exclusive nourishment by TPN, he developed whitened nail beds. Investigation for possible trace element deficiency resulted in a finding that he had very low levels of selenium in his blood. He did not have any of the cardiac or skeletal muscle abnormalities that have been associated with selenium deficiency. After supplementation with selenium, his blood levels of selenium rose and the nail bed changes were reversed.
Nitrogen Balance Studies in Clinical Nutrition
Authors: Konstantinides Frank N.
Published: May 2008

Nutrition support is recognized as an important cofactor in altering morbidity and mortality of hospitalized patients. Paramount in delivering proper nutrition support is the accurate determination of baseline metabolic and nutritional status, thus influencing necessary protein requirements. After nutritional intervention, routine laboratory monitoring is used to measure the efficacy and to reassess metabolic stress level. Accurate determination of nitrogen excretion (and nitrogen balance) remains the standard in prescribing and monitoring the protein and nutritional treatment regimen. This article examines nitrogen excretion determinations in the clinical setting, including proper collection techniques, laboratory measurements, and analyses and their effect upon nitrogen balance studies.
Nutrition Support in Bone Marrow Transplant Recipients
Authors: Herrmann Virginia M. , Petruska Paul J.
Published: May 2008

Bone marrow transplantation is a complex therapy designed as curative for a variety of malignant and nonmalignant diseases. It is a highly invasive procedure that uses high‐dose chemotherapy and may also include radiation treatment. This results in immunosuppression that is often followed by infection, graft‐vs‐host disease, pulmonary complications, veno‐occlusive disease of the liver, and metabolic and nutritional abnormalities. Parenteral nutrition has been the mainstay of nutrition support in patients undergoing bone marrow transplantation. Parenteral nutrition has not been uniformly successful in improving nutritional status or outcome. Enteral nutrition offers many theoretical advantages but is often not well tolerated. Coordinated efforts of the health care team are needed to optimize the nutrition support of these complicated cases.
Home Nutrition Support Patient Education Materials
Authors: Evans Mary Ann , Liffrig Therese K. , Nelson Jennifer K. , Compher Charlene
Published: May 2008

The practice of providing specialized enteral and parenteral nutrition to patients in the home setting has expanded nationwide during the past decade. Accompanying this growth has been an increased need for education of patients, families, and care providers in techniques of administering intravenous and tube feedings safely after discharge from the hospital.

To meet this demand for information, written home nutrition support (HNS) education materials have been developed by hospital nutrition support teams, patient education specialists, home care providers, and formula manufacturers. The time and financial costs of developing these materials may be prohibitive in certain institutions that need HNS education resources. A directory of the printed materials available has been compiled to facilitate communication and exchange of HNS education information among institutions. The directory is presented with this article, with important characteristics to consider in the development of HNS education materials.
Invited Review: Nutrition Support for the Elderly
Authors: Karkeck Joan M.
Published: May 2008

The increasing size and longevity of the geriatric patient population dictates that all health care practitioners become more cognizant ofthe unique requirements for nutritional assessment and support of the elderly. This review summarizes recent advances in the understanding of the nutrition support needs of the old and oldest‐old patients requiring enteral or parenteral feeding. When a nutrition support formula individualized for the geriatric patient is being developed, there is a fine line between excess and deficit, requiring the involvement of the entire support team in monitoring the success of feeding. Indications for choosing enteral or parenteral feeding are considered excessively invasive by some and necessarily “heroic” by others. The patient and his or her family should be part of the decision‐making process.
Team Treatment of Eating Disorders
Authors: Landau‐West Debra , Kohl Debra , Pasulka Patrick
Published: May 2008

The treatment of eating disorders requires the expertise of a multidisciplinary team. This case presents the psychologic and physiologic challenges observed in managing these patients. Attention must be directed toward the use of techniques to obtain a commitment from patients to meet a therapeutic goal. Care must be taken to avoid overaggressive feeding of patients with eating disorders to avoid the refeeding syndrome.
Drug Use Evaluation Approach to Monitoring Use of Total Parenteral Nutrition: A Review of Criteria for Use in Cancer Patients
Authors: Mattox Todd W.
Published: May 2008

Monitoring of total parenteral nutrition (TPN) by drug use evaluation appears to be a reasonable approach to characterizing use of parenteral nutrition within an institution. Development of specific criteria for use of TPN may be difficult because of the broad nature of published guidelines. Criteria for use of TPN in tumor‐bearing patients is controversial. Results from recent investigations conflict with previous generally accepted guidelines for providing TPN in cancer patients. This article reviews published guidelines for use of TPN as well as application of these guidelines for drug use evaluation. Criteria for use of TPN and results of a subsequent drug use evaluation in a cancer institution are presented.
Invited Review: Trace Elements in Clinical Nutrition
Authors: Baumgartner Thomas G.
Published: May 2008

Although the nearly 20 essential trace elements in humans constitute a small fraction of total body weight (less than 4%), the effect of their presence on well‐being is enormous. Enteral nutrition, whether oral or by tube, is fraught with problems that influence nutrient absorption, distribution, metabolism, and ultimately, excretion. Parenteral nutrition, although delivered to the intravascular milieu, carries with it no guarantee that the trace mineral will indeed reach the target site for action. With the questionable nature of dietary histories and their unavailability in the setting of relatively emergent nutrition therapy, it behooves the clinician to begin complete nutrition and to include recommended trace elements early on. The clinician must also be ever vigilant about delivering sufficient full‐strength commercially available enteral formula to provide the recommended dietary allowances of trace minerals.
Invited Review: Nutrition Care of Patients With Acute and Chronic Respiratory Failure
Authors: Grant John P.
Published: May 2008

Nutrition is intimately linked to pulmonary function and an understanding of these relationships have therapeutic utility. Malnutrition is known to be associated with impaired mechanical function of the lung in both chronic and acute respiratory insufficiency. Refeeding results in improvement in functional characteristics and may be critical in the weaning of patients from mechanical ventilation. In contrast, overfeeding may result in an increased ventilatory demand resulting in the inability to wean from respiratory support. This article considers the background as well as recommendations for the nutritional care of patients with acute and chronic respiratory failure.
Nutrition Support in Specific Diseases: Back to Basics
Authors: Andris Deborah A. , Krzywda Elizabeth A.
Published: May 2008

The nutrition care of a patient is complicated by the recent proliferation of commercially available specialty products. Rational and objective guidelines are necessary to direct formula selection for use in specific diseases. Consideration of the patient's nutritional status, functioning of major organ systems, and alterations in nutrient metabolism are essential. The diagnosis of a specific disease does not necessitate the use of a specialty product in all instances. Many times modification of a standard formula can result in safe and effective nutrition. Basic nutrition principles should continue to guide the clinician as the definitive answers to the issues surrounding metabolic support in patients with specific disease states become available.
Use of Cyclic Parenteral Nutrition in Infants Less Than 6 Months of Age
Authors: Collier Sharon , Crouch Jean , Hendricks Kristy , Caballero Benjamin
Published: May 2008

Cyclic parenteral nutrition is the technique of infusing the intravenous solution in less than 24 hours, during a portion of the day or night, allowing the patient freedom from the intravenous tubing and pump apparatus. In addition, adverse effects oflong‐term parenteral therapy, such as liver complications, were reported to be decreased with the use of cyclic parenteral nutrition in adult patients. Literature on the method and effects of cycling in young infants is minimal. This report describes cyclic parenteral nutrition use with guidelines for cycling and the potential beneficial metabolic effects in 10 infants less than 6 months of age who required long‐term parenteral nutrition support. Diagnosis, gestational age, length of time on parenteral nutrition, macronutrient intake, growth, and biochemical parameters for the patients are presented. Overall, cyclic parenteral nutrition was well tolerated without clinical symptoms of hypoglycemia, elevated capillary blood glucose concentrations, or abnormal urine glucose levels. The direct bilirubin concentrations showed a decrease or stabilization after cycling was initiated in eight of 10 patients.
Femoral Venous Catheters: A Safe Alternative for Dehvering Parenteral Alimentation
Authors: Friedman Bruce , Kanter Gary , Titus Danielle
Published: May 2008

Femoral vein catheterization is an alternative method of obtaining central venous access. Placement of femoral venous catheters (FVCs) is possible in the majority of patients, suitable for most indications, and associated with a low complication rate during insertion. We wished to determine the incidence of infections or other complications resulting when parenteral nutrition was delivered through FVCs. Fifty‐two patients were followed from a hospital‐wide population including patients in the critical care units. Triple‐lumen catheters were placed by using the sterile Seldinger technique, and sites were examined daily for inflammation. Bacteriologic surveillance was accomplished by submitting the catheter tip for semiquantitative cultures. If catheter line sepsis was suspected, blood samples for cultures were drawn through the catheter and peripherally. The rate of occurrence of colonized catheters was 9.6% (five of 52), and catheter sepsis was found in one case (1.9%). Other than inflammation at six (11.5%) of 52 catheter sites, noninfectious complications of FVCs were not found. On the basis of these findings, we consider FVC‐delivered parenteral alimentation a safe and effective alternative to other forms of central venous access.
Invited Review: Nutrition Support in Critical Illness
Authors: Barton Richard G.
Published: May 2008

Sepsis, shock, multiple trauma, and burns are often associated with altered metabolism characterized by severe catabolism, wasting of the lean body mass, immune dysfunction, and compromised wound healing. Nutrition support is one of the mainstays in the management of these critically ill patients and is aimed at minimizing these complications. The purpose of this article is to compare stress hypermetabolism and starvation metabolism, to review current recommendations for the provision of energy and substrate to the critically ill patient, and to review pertinent literature regarding enteral vs parenteral nutrition. Finally, this article will provide a brief overview of new and future therapies with emphasis on specific substrates and growth factors and the potential for their use in the critically ill patient.
Possible Folate Deficiency With Postsurgical Infection
Authors: Stolzenberg Rachael
Published: May 2008

A 51‐year‐old obese woman was transferred to our hospital for management of a complicated laparoscopic cholecystectomy accompanied by fever and malaise. A liver abscess was discovered. On postoperative day 52 it was noted that the patient's tongue was magenta and sore and that she had altered taste, pallor, severe weight loss, diarrhea, and poor appetite and mood. A dermatology consult suggested that her tongue abnormalities were most likely nutrition‐related, and a hematologic blood smear was suggestive of folate deficiency. Premorbidly, the patient had consumed a diet chronically low in folate and had received estrogen therapy for 15 years. Throughout the patient's hospitalization, she had bouts of fever and received numerous antibiotics. Within a month of initiating nutrition support and vitamin/ mineral supplements, her nutritional status improved dramatically. This patient's poor diet, long‐term estrogen use, surgical stress, infection, and lack of early nutrition support may have contributed to her possible folate deficiency and her prolonged hospital stay.
Regulation of Medical Foods: Toward a Rational Policy
Authors: Mueller Charles , Nestle Marion
Published: May 2008

Medical foods are enterally administered formulas used as complete or supplemental nutrition support in the treatment of diseases and clinical disorders of hospitalized or incapacitated adult patients. Because clinical trials have failed to demonstrate a consistent benefit of these products on morbidity and mortality rates, it has been difficult to reach consensus on their primary role. Are medical foods components of supportive care or should they be considered pharmacologic treatment? To date, the US Congress has defined medical foods, but the Food and Drug Administration has not developed regulatory statutes for them beyond those designed to ensure the sanitary manufacture of all processed foods. Before effective regulations can be developed, medical foods need to be defined further in order to distinguish them from each other and from other classes of nutritional products such as parenteral nutrients or infant formulas. Because we believe that the role of medical foods is in supportive care rather than pharmacologic therapy, we argue that these products should be subject to regulations similar to those that apply to conventional foods.
The Prevalence of Nausea and Vomiting in Pediatric Patients Receiving Home Parenteral Nutrition
Authors: Nicol Jennie J. , Hoagland Rebecca L. , Heitlinger Leo A.
Published: May 2008

We have observed that many home parenteral nutrition (HPN) recipients experience nausea, vomiting, or both during cyclic parenteral nutrition infusions. The current investigation was performed to determine the prevalence and course of these symptoms and effectiveness of therapeutic maneuvers. Eighty‐nine recipients of HPN were contacted and 53 families (60%) responded. Thirty‐five patients (66%) reported complaints of nausea, vomiting, or both associated with their HPN infusion. Patients with cancer (82%) or cystic fibrosis (83%) reported symptoms at similar rates, while patients with gastrointestinal disease (46%) reported symptoms less often (p < .05, chi‐square). Within each diagnostic group, prevalence of symptoms did not vary with age. The majority of patients were symptomatic in the morning when being weaned or soon after completing the HPN infusion. Response rates to a variety of therapies were also similar. In conclusion, nausea and vomiting associated with cyclic HPN infusions appear to be common. The precipitating events and efficacy of interventions await identification and prospective evaluation.
Nutrition Support Clinical Pathways
Authors: Lykins Terri Clark
Published: May 2008

With growing concerns over cost containment, hospitals are using clinical pathways to standardize health care and reduce costs. Clinical pathways designate the actions and services that patients should receive at specified time intervals throughout the hospital stay. Although most clinical pathways have been created for specific diseases or diagnoses, the nutrition support team at Tallahassee Memorial Regional Medical Center has developed clinical pathways for enteral and parenteral therapies. These pathways allow the team to track patient outcomes related to nutrition and to document variances when provisions fall outside the pathways. Variances are tallied on a quarterly basis and reported to the hospital Nutrition Support Committee. As data collection continues, trends emerge that guide the team to take appropriate corrective actions. Patient care is continuously improved by incorporating these corrective actions into the pathways.
Diarrhea Associated With Lorazepam Solution in a Tube‐Fed Patient
Authors: Shepherd Michele F. , Felt‐Gunderson Patricia A.
Published: May 2008

A 43‐year‐old patient with adult respiratory distress syndrome, alcoholic hallucinosis, and delirium required significant amounts of lorazepam, morphine, and midazolam for management of agitation and increased peak airway pressures. Broad‐spectrum antibiotics and intermittent pancuronium therapy were instituted. A nasoenteral feeding tube was placed for nutrition and medication administration during mechanical ventilation. Tube feedings were well tolerated except for intermittent bouts of large amounts of diarrhea. Clostridium difficile culture and toxin results were negative. Lorazepam and morphine administration were converted from the IV to enteral route to decrease the amount of fluid administered. The tube feeding was changed to an electrolyte rehydration solution and eventually discontinued. A search for drug‐related contributing factors to the diarrhea revealed polyethylene glycol present in the lorazepam solution. It was postulated that this could be a contributing cause to the diarrhea. The lorazepam solution was changed to enterally administered crushed tablets with subsequent resolution of diarrhea.
Incorporating Nutritional Risk Screening With Case Management Initiatives
Authors: Kerekes Jon , Thornton Olga
Published: May 2008

Keystone 65, the Medicare Program of Keystone Health Plan East, has designed case management programs around the needs of America's seniors. Keystone 65 utilizes a health risk assessment tool to aid in determining a member's health risk profile. This tool, the Health Risk Assessment Form, consists of the Short Form 36, the Nutrition Screening Initiative Nutrition Checklist, self‐reported disease questions, and questions related to the health plan. Preliminary analysis has led Keystone to believe that the use of such an assessment tool will aid in identifying those members who need proactive case management and intervention. The increased use of the Checklist may provide the case management department with an important element in the assessment of Keystone 65 members.
Invited Review: Parenteral Iron Supplementation
Authors: Kumpf Vanessa J.
Published: May 2008

Indications for the use of parenteral iron are limited to conditions in which the oral supplementation of iron is not possible or fails. An overview of iron balance and iron requirements is presented to describe situations in which iron supplementation may be required. When parenteral iron supplementation is required, careful attention to proper dosing and administration is necessary to optimize efficacy and safety. The purpose of this article is to review the literature regarding the clinical use of parenteral iron therapy and provide guidelines on dosing and administration. Methods of iron dextran administration, including the IV and intramuscular injection of undiluted drug and total dose infusion, are compared. Complications associated with the use of parenteral iron are also be reviewed. Finally, the use of iron supplementation in patients receiving parenteral nutrition care explored.
The Effects of Rinsing Enteral Delivery Sets on Formula Contamination
Authors: Kohn‐Keeth Carol , Shott Susan , Olree Kelley
Published: May 2008

This study investigated whether rinsing enteral delivery sets before formula addition affects formula contamination. Both a simulated and a clinical phase were conducted. In the simulated phase, Osmolite (Ross Laboratories, Columbus, OH) was infused continuously through 52 delivery sets into a flask via enteral infusion pumps for 24 hours. The delivery sets were randomly assigned to two groups of equal size. One group was rinsed with tap water before new formula was added at 8 and 16 hours, and the other group was not rinsed. At 8, 16, and 24 hours, samples of formula were collected from the delivery sets, and bacteria counts were obtained. In the clinical phase, 23 critically ill patients receiving Osmolite continuously were randomly assigned to a rinse or no‐rinse group. The same formula addition and rinse protocol from phase I was used. Formula samples were obtained at 24 hours. In both phases, there were no significant differences between the rinse and no‐rinse groups with respect to bacteria counts at any time period. The findings suggest that rinsing may be unnecessary if delivery sets are used continuously for 24 hours or less; however, the possibility of a type II error because of the small sample size of this study must be recognized.
Pulmonary Aspiration in Hospitalized Adults
Authors: Elpern Ellen H.
Published: May 2008

Until recent years, pulmonary aspiration attracted remarkably little clinical investigation. Although aspiration was considered a common occurrence in hospitalized individuals, with serious and even fatal consequences, clinicians had limited scientific data to guide practice. Consequently, approaches to this problem were based largely on unsystematic observations, intuition, and tradition. Recent investigations on the subject of aspiration have increased our understanding of patients at risk for aspiration, the value of diagnostic methods, and the efficacy of interventions to prevent or limit aspiration. Results of these studies call to question many time‐honored adages and practices. Considerable uncertainty remains and more investigation is necessary before management decisions can be characterized clearly and clinical strategies defined. This review focuses on pulmonary aspiration and enteral feeding in the critically ill adult. Factors implicated in aspiration in this population are highlighted and evidence to support the application of interventions prescribed commonly is presented.
Nutrition Risk Classification: A Reproducible and Valid Tool for Nurses
Authors: Kovacevich Debra S. , Boney Anthony R. , Braunschweig Carol L. , Perez Anne , Stevens Mary
Published: May 2008

Background:

Incorporating the nursing staff to assist with the screening process on admission will allow patients who are at nutritional risk to be assessed by registered dietitians earlier in their hospital stay. The goal of this study was to develop an objective, valid, reproducible nutrition screen for use by registered nurses (RNs) to allow for nutrition classifications of hospitalized patients.

Methods:

The current nursing admission assessment form was modified to contain questions on weight loss history, percentage of ideal body weight, and alterations in dietary intake and gastrointestinal function. Assessments were completed within 48 hours of admission. On the basis of the answers to these questions, patients were classified as “at nutritional risk” or “low nutritional risk.” In phase 1, to assess reproducibility of the form, a prospective study between staff RNs and a nutritionist was undertaken on 186 consecutive adult admissions. Nutrition screening and classification was done independently by both practitioners. In phase 2 of the study, prospective validation of the form contrasting prealbumin (PAB) levels with RN nutritional risk classification (n = 56) was investigated.

Results:

Interobserver agreement of nutrition classification between RN and nutritionist was 97.3% (p = .95). Twenty‐nine patients were classified at low nutritional risk (27 normal PAB and 2 low PAB); 27 patients were classified as at nutritional risk (16 normal PAB and 11 low PAB) (χ3= 8.9, p > .003, power 0.8). The sensitivity of the tool was 84.6%.

Conclusion:

To our knowledge, this is the first nutrition screening tool designed for staff RNs that has been tested for both validity and reproducibility.
Perioperative Total Parenteral Nutrition in Malnourished, Gastrointestinal Cancer Patients: A Randomized, Clinical Trial
Authors: Bozzetti Federico , Gavazzi Cecilia , Miceli Rosalba , Rossi Nicoletta , Mariani Luigi , Cozzaglio Luca , Bonfanti Giuliano , Piacenza Sabrina
Published: May 2008

Background: Clinical trials investigating the potential benefits of perioperative total parenteral nutrition (TPN) for reducing the risk of surgery in malnourished cancer patients have yielded controversial results. Methods: Ninety elective surgical patients with gastric or colorectal tumors and weight loss of 10% or more of usual body weight were randomly assigned to 10 days of preoperative and 9 days of postoperative nutrition us a simple control group. The daily per kilogram body weight TPN regimen included 34.6 ± 6.3 kcal nonprotein and 0.25 ± 0.04 g nitrogen per kilogram in a volume of 42.6 ± 7.3 mL of fluid. The glucose‐to‐fat calorie ratio was 70:30. Control patients did not receive preoperative nutrition but received 940 kcal nonprotein plus 85 g amino acids postoperatively. Results: Complications occurred in 37% of the patients receiving TPN us 57% of the control patients (p =.03). Noninfectious complications mainly accounted for this difference, which was 12% us 34%, respectively (p =.02). Mortality occurred in only 5 of the control group patients (p =.05). The total length of hospitalization for TPN patients was longer than for control (p =.00), whereas the length of postoperative stay in the two groups did not differ significantly. Conclusions: This study shows that 10 days of preoperative TPN that is continued postoperatively is able to reduce the complication rate by approximately one third and to prevent mortality in severely malnourished patients with gastrointestinal cancer. (Journal of Parenteral and Enteral Nutrition 24:7–14, 2000)