bluuebunny/crossref_metadata_2025 huggingface dataset:
Invited Review: The Substance Abuser and Home Intravenous Therapy: Above All Else, Do No Harm
Authors: Krzywda Elizabeth A. , Andris Deborah A. , Ausman Robert K.
Published: May 2008

Home care therapy is being challenged by changes in patient populations and technologic advances. The selection of appropriate candidates for home intravenous therapy is a critical issue faced by health care professionals. This process is more complex when the patient has a history of intravenous drug abuse. The issues concern patient compliance, safety, ethics, and legal responsibilities. Safe care depends on the ability of the patient to demonstrate a predetermined level of competence with catheter use. The potential use of illicit drugs may influence the ability of the patient to be compliant. Ethical principles of the patient's autonomy and free choice are weighed against the health professional's sense of beneficence. Legal guidelines stress informed consent, standards of care, and adequate documentation. An exploration of each of these factors outlines the potential risks and benefits and provides a basis for making clinical judgments.
Severe Hypophosphatemia in Postoperative Patients
Authors: Dwyer Kathryn , Barone James E. , Rogers J. Forbes
Published: May 2008

Severe hypophosphatemia may develop in postoperative patients for several reasons including alcohol withdrawal, diabetic ketoacidosis, nutritional recovery (refeeding) syndrome, and severe respiratory alkalosis. Severe hypophosphatemia may result in central nervous system abnormalities, muscle weakness, and renal, hepatic, cardiac, and respiratory dysfunction. Hypophosphatemia may be prevented by close monitoring of phosphorus concentrations in serum, especially in patients predisposed to developing this problem. Proper techniques for the maintenance and repletion of phosphate for both enteral and parenteral use are described.
Bedside Postpyloric Placement of Weighted Feeding Tubes
Authors: Ugo Patricia J. , Mohler Pamela A. , Wilson Gary L.
Published: May 2008

A pilot study to evaluate a technique for the bedside placement of small‐bore, weighted feeding tubes past the pylorus in critically ill patients is described. The technique involves the use of a #8 or #10 French small‐bore, tungsten‐weighted feeding tube, specific patient positioning, and defined insertion techniques, including gastric distention with air. The tubes were placed at the bedside in the intensive care unit by the nutrition support team nurse. Successful postpyloric placement was achieved in 85 (83%) of 103 patients. Approximate time for successful insertion was 30 minutes. A follow‐up study to define factors influencing success or failure of this technique is planned.
Invited Review: The Current Role of Small‐Bowel Transplantation in Intestinal Failure
Authors: Hiyama Darryl T.
Published: May 2008

Short bowel syndrome is the clinical manifestation of a fundamental reduction in the functional intestinal absorptive surface area and malabsorption. The development of total parenteral nutrition has improved the natural course of this disease. Home parenteral nutrition‐related complications continue to generate significant morbidity and mortality for these patients. Small‐bowel transplantation is an alternative to home parenteral nutrition. There are significant risks of graft rejection and the potential complications oflong‐term immunosuppression. Small‐bowel transplantation is an option, but it should be reserved for patients no longer considered candidates for continued home parenteral nutrition.
Invited Review: A Review of Nutrition Support for Transplant Patients
Authors: Baron Pedro , Waymack J. Paul
Published: May 2008

Renal, hepatic, and cardiac transplantation are now recognized as acceptable methods for treating end‐stage organ failure. Obtaining optimum results in such patients requires not only skillful surgical technique and postoperative immunosuppression but also stabilization of the patient preoperatively. This stabilization includes a number of physiologic parameters. One of the most important of these is the correction of preexisting nutritional deficits. Each type of end‐stage organ disease creates unique nutritional problems. This article reviews these deficiencies and makes recommendations as to the appropriate nutrition protocols that can optimize results in the patient who undergoes organ transplantation.
Treatment of Hyperemesis Gravidarum With Nasogastric Feeding
Authors: Gulley R. Michael , Vander Pleog Nancy , Gulley Joshua M.
Published: May 2008

Hyperemesis gravidarum, an antepartem disorder characterized by severe nausea and vomiting, is usually a benign condition with a favorable outcome. Although no increase in fetal or maternal morbidity results, the disorder has deleterious effects on both nutrition and everyday life. The authors describe a treatment protocol for hyperemesis gravidarum that uses continuous infusion of an iso‐osmolar tube‐feeding product and their experiences with its use in 30 patients. Uniformly good symptom relief was obtained by this technique, thus avoiding the need for more invasive therapy. It is proposed that this treatment is a safe and effective means of managing severe nausea and vomiting during early pregnancy.
Invited Review: Cytokine Mediators of Malnutrition: Clinical Implications
Authors: Hardin Thomas C.
Published: May 2008

During the past decade, the relationships that exist between inflammatory cytokines and the metabolic changes associated with critical illness have been the focus of extensive research efforts. Alterations in protein metabolism, characterized by increased peripheral protein catabolism and increased hepatic synthesis of acute‐phase proteins, have been reported with tumor necrosis factor, interleukin‐1, and interleukin‐6 administration in animals and humans. Hyperlipoproteinemia has also been observed, particularly in association with increases in very‐low‐density lipoproteins and hepatic fatty acid synthesis. The release of counter‐regulatory hormones in response to cytokine activity contributes to these metabolic changes as well. An understanding of the complex interactions of cytokines as mediators of intermediary metabolism is important to clinicians caring for critically ill patients.
Nutrition Considerations in the Management of Ventilator‐Dependent Patients
Authors: Ireton‐Jones Carol S. , Borman Karen R. , Turner William W.
Published: May 2008

Nutrition support of the patient with ventilatory failure is an important adjunct to recovery. Malnutrition and respiratory failure are frequently interrelated. Ventilator dependence occurs when the patient cannot independently sustain oxygenation, carbon dioxide removal, or acid‐base balance. Nutrition assessment, determination of energy requirements, and provision of nutrient solutions utilizing the most appropriate route of administration should be initiated early in the ventilator‐dependent patient's hospital course. Careful assessment will identify patients needing repletion along with maintenance calories, as well as special macronutrient and micronutrient needs. The nutrient prescription is designed to provide carbohydrate, protein, and fat in amounts for optimal substrate utilization. Body fluid balance, micronutrient needs, electrolyte homeostasis, and acid‐base balance affect respiratory muscle function and must also be considered in developing the nutrition regimen. Properly constructed enteral or parenteral nutrition plans begun early offer the best support for ventilator‐dependent patients.
Influence of Dietary Fatty Acids on Cytokine Production and Its Clinical Implications
Authors: Meydani Simin Nikbin , Dinarello Charles A.
Published: May 2008

Cytokines and eicosanoids are important biologic mediators with tightly regulated production. Overproduction contributes to pathogenesis of chronic and acute inflammatory, autoimmune, atherosclerotic, and neoplastic diseases. Animal and human studies have shown that production of cytokines and eicosanoids can be reduced by certain dietary fatty acids, specifically those containing long‐chain (n‐3) polyunsaturated fatty acids (PUFAs). This in turn results in reduction of the severity of certain autoimmune, inflammatory, and atherosclerotic diseases. Because these cytokines are also involved in control of the host defense, substantial reduction in their production could also result in the impairment of normal immune response. Increased intake of (n‐3) PUFAs without adequate antioxidant protection could result in increased free radical formation and lipid peroxidation. Thus, when (n‐3) PUFAs are used to reduce the pathogenesis of these diseases, its possible adverse effects should be considered and prevented.
Invited Review: The Potential Use of Parenter Dipeptides in Clinical Nutrition
Authors: Fürst Peter , Stehle Peter
Published: May 2008

The metabolic effects of intravenous peptides have undergone extensive investigation in recent years. Dipeptide solutions provide a mechanism for the provision of selected amino acids that may be conditionally indispensable under certain clinical conditions. In particular, amino acids such as cystine, glutamine, and tyrosine may be difficult to provide in their free form, but their availability can be increased substantially when they are supplied in the form of a dipeptide. Animal and human studies have demonstrated that parenteral dipeptides are cleared rapidly from the plasma compartment and favorably influence nitrogen equilibrium in healthy volunteers and catabolic patients. Certain dipeptides offer the potential for tailoring tissue‐specific nutrition therapy. It seems likely that parenteral peptides will offer a major change in the delivery of intravenous nutrients.
Invited Review: Dipeptides in Parenteral Nutrition: From Basic Science to Clinical Applications
Authors: Vazquez Jorge A. , Daniel Hannelore , Adibi Siamak A.
Published: May 2008

The use of intravenous dipeptides shows great promise as an avenue for the provision of amino acids that may otherwise be difficult to deliver via nutrient infusions. The physical/chemical properties and metabolism of numerous dipeptides have now been explored in experimental and human studies. It has been found that these agents have the capacity to spare nitrogen and support serum protein levels in a fashion equivalent to that of intravenous free amino acids. An additional benefit is the ability to deliver certain amino acids that are relatively unstable or poorly soluble in aqueous solutions. These various aspects of intravenous dipeptides are considered in this review.
Principles of Nutrition Therapy for Short‐Bowel Syndrome
Authors: Bernard Denise K.H. , Shaw Michael J.
Published: May 2008

Short‐bowel syndrome is characterized by maldigestion, malabsorption, dehydration, electrolyte abnor‐malities, and both macronutrient and micronutrient deficiencies. Nutritional and hydration status are difficult to maintain without the provision of specialized nutrition support when more than 75% of the small intestine has been resected. Each patient's response to small‐bowel resection is unique; therefore, the type of therapy must be tailored to each individual's bowel resection, complications that ensue, and specific nutrient needs. Clinical management should be guided by principles of nutrition assessment and treatment of nutrient deficiencies as well as routine monitoring of the patient's clinical course and response to therapy.
Basic Concepts of Immunology and Its Application to Clinical Nutrition
Authors: Shronts Eva P.
Published: May 2008

In recent years, evidence has accumulated on the effects of nutrients on metabolic processes. The role of specific nutrients in modulating immune function has received much attention because of the significant role of the immune system in a variety of disease states. The immune system depends on the complex interactions of its various parts. In response to an “antigen” or foreign substance that penetrates the external protective barriers of the human body, nonspecific (phagocytes, complement) defense mechanisms and antigen‐specific factors are activated. The antigen‐specific immune system relies on both humoral (antibodies and B cells) and cellular (T cells and lymphokines) defenses. Malnutrition causes a decline in all aspects of host defense. Correction of malnutrition in hospitalized patients and restoration of immunocompetence has become a goal of nutrition support practitioners today. The application of current research findings to patient care requires a basic understanding of immunology.
Invited Review: Pediatric Nutrition Support
Authors: Marian Mary
Published: May 2008

Pediatric patients now survive and thrive because of advancements made in nutrition support. Growth and development is of paramount importance in this population and adequate nutrition is necessary. Growth of premature infants receiving nutrition support mirrors intrauterine rates. Survival without nutrition support is not always assured because of inadequate nutrient stores. Institution of nutrition support in children with chronic illnesses also promotes growth and development. Enteral nutrition is preferred because of immunologic benefits, lower cost, and less frequent infectious complications. Parenteral nutrition should be considered when enteral nutrition fails or is contraindicated. Successful nutrition rehabilitation can result if both enteral and parenteral nutrition are initiated slowly and advanced as tolerated. Ongoing monitoring is essential while promoting “normal” growth and development.
Superior Mesenteric Artery Syndrome in a Burn Patient
Authors: Milner Elizabeth A. , Cioffi William G. , Mcmanus William F. , Pruitt Basil A.
Published: May 2008

Weight loss resulting from the hypermetabolic response to burn injury is not unusual and is often unavoidable. The loss of retroperitoneal fat has been postulated as a major factor in the cause of the uncommon complication of superior mesenteric artery syndrome. This syndrome is frequently treated nonoperatively with aggressive nutrition support. Nasojejunal feeding past the point of obstruction should be considered as the primary method of nutrition support. Alternatively, total parenteral nutrition or a combination of enteral and parenteral feeding may be necessary to meet nutritional needs until the duodenal obstruction resolves. This case study describes the nutrition management of a burn patient who developed superior mesenteric artery syndrome.
Molybdenum: An Essential Trace Element
Authors: Sardesai Vishwanath M.
Published: May 2008

Molybdenum is found in most foods, with legumes, dairy products, and meats being the richest sources. This metal is considered essential because it is part of a complex called molybdenum cofactor that is required for the three mammalian enzymes xanthine oxidase (XO), aldehyde oxidase (AO), and sulfite oxidase (SO). XO participates in the metabolism of purines, AO catalyzes the conversion of aldehydes to acids, and SO is involved in the metabolism of sulfur‐containing amino acids. Molybdenum deficiency is not found in free‐living humans, but deficiency is reported in a patient receiving prolonged total parenteral nutrition with clinical signs characterized by tachycardia, headache, mental disturbances, and coma. The biochemical abnormalities in this acquired molybdenum deficiency include very low levels of uric acid in serum and urine (low XO activity) and low inorganic sulfate levels in urine (low SO activity). Inborn errors of isolated deficiencies of XO, SO, and molybdenum cofactor are described. Although XO deficiency is relatively benign, patients with isolated deficiencies of SO or molybdenum cofactor exhibit mental retardation, neurologic problems, and ocular lens dislocation. These abnormalities seem to be caused by the toxicity of sulfite and/or inadequate amounts of inorganic sulfate available for the formation of sulfated compounds present in the brain. XO and AO may also participate in the inactivation of some toxic substances, inasmuch as studies suggest that molybdenum deficiency is a factor in the higher incidence of esophageal cancer in populations consuming food grown in molybdenum‐poor soil.
Invited Review: Nutrition and the Kidney: How to Manage Patients With Renal Failure
Authors: Oldrizzi Lamberto , Rugiu Carlo , Maschio Giuseppe
Published: May 2008

Nutrition is believed to play a key role in the management of chronic and acute renal failure. Considerable evidence suggests that unrestricted protein diets accelerate the progression of chronic renal failure. As a result, recommendations have evolved limiting the quantity and quality of nitrogen intake with the goal of slowing the progression to dialysis dependency. Acute renal failure offers different challenges in view ofits common association with hypermetabolic states. With respect to nitrogen substrate administration, the use of mixed formulations of essential plus nonessential amino acids seems to be as effective as essential amino acids alone.
A Case of Retrograde Jejunoduodenal Intussusception Caused by a Feeding Gastrostomy Tube
Authors: Ciaccia Donato , Quigley Robert L. , Shami Paul J. , Grant John P.
Published: May 2008

A case is presented of migration of a gastrostomy feeding tube (Foley type) through the pylorus with duodenal obstruction and subsequent retrograde intussusception. Although feeding tube migration is not uncommon, retrograde intussusception of the jejunum into the duodenum is rare. In this case, surgery was required with resection of a segment of necrotic bowel. Recommendations are given for treatment of this unusual complication with emphasis on its avoidance through use of a retaining bar or disc at the tube's skin exit site.
Nutrition Considerations in the Neonatal Extracorporeal Life Support Patient
Authors: Brown Rebeccah L. , Wessel Jacqueline , Warner Brad W.
Published: May 2008

Extracorporeal life support (ECLS) is a type of heart‐lung bypass commonly used to support neonates with life‐threatening respiratory or cardiac failure. These patients are among the most critically ill patients in the neonatal intensive care unit and are at significant nutritional risk. Unfortunately, there is a paucity of literature regarding guidelines for nutrition support of the neonatal ECLS patient. The purpose of this article is to provide an overview of the indications, techniques, and complications of ECLS and to address the approach to nutrition support of these patients. Emphasis will be placed on issues unique to the neonatal ECLS patient.
Invited Review: Intravenous Feeding Kinetics and Its Effects on Energy and Nitrogen Metabolism
Authors: Hyltander Anders
Published: May 2008

Various modes of intravenous nutrient administration may be associated with characteristic alterations in physiologic and metabolic host responses. Notably, cyclic parenteral nutrition produces greater short‐term thermic effects than continuous nutrient infusion. This may increase the metabolic burden upon patients who exhibit cardiopulmonary insufficiency. On the other hand, nitrogen accretion seems to be more efficient with cyclic total parenteral nutrition, making it quite attractive as an intravenous form of nutrition support. This article details these aspects of cyclic intravenous feeding and considers its optimal applicability to different patient populations.
Invited Review: Nutrition Support in Patients With Cancer: What Do the Data Really Show?
Authors: Klein Samuel , Koretz Ronald L.
Published: May 2008

Although more than 70 prospective randomized controlled trials have evaluated the use of nutrition support in patients with cancer, the indications for nutrition therapy in this patient population remain controversial. We reviewed the published prospective randomized controlled trials that evaluated clinically important endpoints (morbidity, mortality, and duration of hospitalization). Many trials had serious shortcomings in study design that limit the ability to draw definitive conclusions from the data. In general, the data failed to demonstrate the clinical efficacy of providing nutrition support to most patients with cancer. Therefore, the indications for using nutrition therapy should be the same as those for patients with benign disease.
Vitamin E Supplementation in the Critically Ill Patient: Too Narrow a View?
Authors: Kelly Frank J.
Published: May 2008

Oxidative stress plays an important contributory role in a number of diseases. In critically ill patients, oxidative stress is a major problem that results from a number of compounding factors such as supportive oxygen therapy, pulmonary inflammation, and the nutritional inadequacies of these patients. It has been known for some time that the circulating concentration of vitamin E, the primary lipid‐soluble antioxidant, is low in critically ill patients. However, supplementation with vitamin E by oral loading has not been successful in improving clinical status. A better understanding of the bioavailability of vitamin E in these patients and of the synergistic action of other antioxidant nutrients such as vitamin C and glutathione with vitamin E has provided new opportunities to reexamine the use of antioxidant supplementation for the critically ill.
Pentobarbital Coma in Neurosurgical Patients: Nutrition Considerations
Authors: Magnuson Barbara , Hatton Jimmi , Zweng Thomas N. , Young Byron
Published: May 2008

Neurosurgical patients in pentobarbital coma are a complex nutrition support population. Physiologic changes associated with the primary injury to the brain, combined with the pharmacodynamic influences of barbiturate therapy, contribute to the difficulties of initiating aggressive nutrition support. Early nutritional repletion is important to the overall outcome of traumatically injured patients. Consequently, factors that influence nutrition support decisions must be understood to assure appropriate intervention. The metabolic changes associated with traumatic head injury, pentobarbital therapy, and nutrition support strategies are reviewed.
Superior Mesenteric Artery Syndrome in a Tube‐Fed Patient
Authors: Smith J. Stanley , Cooney Robert N.
Published: May 2008

Obstruction resulting from superior mesenteric artery syndrome is not often considered a possible cause for gastrostomy‐tube complications in tube‐fed patients. This case report details our experience with a patient who had had a feeding gastrostomy tube in place for 2 years. She then developed continuous leakage around the area of the gastrostomy insertion site associated with pain and inability to tolerate feedings. Her gastrointestinal series revealed compression of the third portion of the duodenum with delayed emptying of the stomach and dilatation of the proximal duodenum. After resection of the necrotic gastrostomy site, takedown of the ligament of Treitz to free the fourth portion of the duodenum, and insertion of a feeding jejunostomy, the patient was again able to gain weight and tolerate her tube feedings. We present this as an unusual complication occurring in a tube‐fed patient.
Invited Review: Clinical Applications of Enteral Nutrition
Authors: Kudsk Kenneth A.
Published: May 2008

Clinical and experimental evidence confirms that delivery of nutrients via the gastrointestinal tract reduces septic morbidity in critically injured patients. Early enteral feeding seems to maintain mucosal integrity and to support the gut as an important immunologic organ that may affect other areas of the body. There is increasing evidence to suggest that specific nutrients are especially beneficial in maintaining intestinal host‐defense function in times of critical illness and injury.
pH Testing of Feeding‐Tube Aspirates to Determine Placement
Authors: Metheny Norma A. , Clouse Ray E. , Clark Joan M. , Reed Lisa , Wehrle Mary A. , Wiersema Laurel
Published: May 2008

Although radiologic confirmation of tube placement remains the “gold standard,” there is growing evidence that pH testing of feeding‐tube aspirates can reduce (although not totally eliminate) reliance on x‐rays used for this purpose. This article describes that evidence and tells how it was obtained. Reducing the number of x‐rays needed to confirm tube position can have far‐reaching financial benefits.
Torsade de Pointes and Elevated Magnesium and Calcium Requirements Associated With Intravenous Pentamidine
Authors: Olree Kelley , Stein‐Gocken J.
Published: May 2008

We present a report of markedly elevated calcium and magnesium requirements in an AIDS patient receiving central venous nutrition. These increased requirements were attributed to urinary magnesium losses associated with intravenous pentamidine therapy. The combination of intravenous pentamidine and electrolyte abnormalities resulted in the development of the dysrhythmia, torsade de pointes, in the patient. A review of literature presenting similar cases is included. Nutrition practitioners should be aware of the often prolonged effect of intravenous pentamidine on magnesium and calcium homeostasis so that adequate supplementation will be provided, perhaps preventing the development of life‐threatening torsade de pointes.
Drug‐Lab Interactions: Implications for Nutrition Support
Authors: Holcombe Beverly J. , Messick Chad R.
Published: May 2008

It is important that health care professionals be aware of the potential for medications to interfere with clinical laboratory tests. Medications can cause in vivo effects when the concentration or activity of the analyte is altered before the analysis and therefore the assay result is true and accurate. An in vitro effect occurs when the medication interferes with the assay, and the result is erroneous and cannot be interpreted. This report describes a recently identified case of interference of acetylcysteine with the urine test for ketones and demonstrates the importance of a thorough medication review in evaluating abnormal laboratory tests.
Practice Parameters Versus Outcome Measurements
Authors: Hirshfeld Edward B.
Published: May 2008

There have been increasing efforts to manage quality and costs in health care. Two tools that are used to do this are practice parameters and outcome measurements. Practice parameters are strategies for patient management to assist clinicians in clinical decision making. Outcome measurements inform clinicians and the public about performance in the delivery of care. Federal and state health care legislation make use of these two concepts as a way to monitor and improve quality and costs, reduce liability, and in some cases, promote competition. Practice guidelines are more limiting to clinicians, but may reduce their liability and help some meet expected clinical outcomes. Outcome criteria alone provide more flexibility to clinicians in deciding how to improve clinical outcome and reduce costs, and enable patients to select care givers on the basis of performance.
The Nutrition Support Team Surviving and Thriving in an Era of Reform
Authors: Martin Annette Lenzi
Published: May 2008

Nutrition support teams today are being buffeted by the winds of change in the health care system. With the emphasis shifting from whether to deliver care to how to do so and to how much that care will cost, nutrition support professionals must stay attuned to their institution's needs—and be prepared to adapt to those needs. This article reviews the types of data collection necessary for teams to remain solid as well as offering tips from experts about ways to harness, and even capitalize on, the changes.
Nutrition Support for Lung Transplant Patients
Authors: Holcombe Beverly J. , Resler Rosemary
Published: May 2008

Lung transplantation has emerged as an established and accepted therapy for patients with end‐stage pulmonary disease. Very little information has been published about the nutrition management of these patients during the period after transplantation. We conducted a retrospective review of the nutrition support records of 52 adult patients who had undergone lung transplantation at our institution. In addition to patient demographics, data were collected on baseline nutritional status, energy and protein goals, type of specialized nutrition support therapy, length of therapy, and incidence of metabolic complications. More than 50% of the patients receiving lung transplants had a diagnosis of cystic fibrosis. Compared with patients having other diagnoses, this group of patients had a greater incidence of malnutrition. The mean energy goal was 127% ± 0.07% of basal energy expenditure, and the protein goal was 1.37% ± 0.25 g/kg/d. All patients received parenteral nutrition therapy, which was begun by postoperative day 2 for more than 70% of the patients. Therapy was short‐term (mean, 9 days), and patients then received oral diet. The most common metabolic complications were azotemia, hyperglycemia, and hypomagnesemia. Our experience should provide assistance to other health care professionals who are involved in the nutrition and metabolic management of patients undergoing lung transplantation.
Use of Vitamin E and Glutamine in the Successful Treatment of Severe Veno‐Occlusive Disease Following Bone Marrow Transplantation
Authors: Nattakom Thomas V. , Charlton Angela , Wilmore Douglas W.
Published: May 2008

Veno‐occlusive disease of the liver is a common complication following the administration of conditioning regimens to patients undergoing bone marrow transplantation. Free‐radical damage to the liver is believed to be the cause of the hepatic outflow occlusion, and maintenance of adequate antioxidant stores of glutathione and vitamin E may be a means of counteracting the hepatotoxicity. We report the case of a 44‐year‐old woman who developed severe veno‐occlusive disease after bone marrow transplantation and was treated with vitamin E, the major antioxidant of the cell membrane, and glutamine, a precursor of glutathione. The administration of this therapy was associated with reversal of the clinical and biochemical signs of severe hepatic dysfunction.
Nutrition Care Given New Importance in JCAHO Standards
Authors: Dougherty Darlene , Bankhead Robin , Kushner Robert , Mirtallo Jay , Winkler Marion
Published: May 2008

The 1995 standards developed by the Joint Commission on Accreditation of Healthcare Organizations are now in effect. In an unprecedented shift, the manual focuses on performance rather than structure and process. It emphasizes the interdisciplinary delivery of care, including nutrition care. This article describes the new standards as they relate to nutrition support professionals.
Total Nutrient Admixtures: Theory and Practice
Authors: Driscoll David F.
Published: May 2008

The use of total nutrient admixtures (TNA) has increased dramatically in both the clinical and home care setting since 1983. The popularity of these dosage forms rests in supplying all the nutrients in one container that meets the nutritional goals of the patient. In addition, TNA formulations obviate the need for either separate peripheral venous catheters or co‐infusions into the primary venous line, thus simplifying this complex therapy. Moreover, the clinical benefits derived from this practice are related to a reduction in glucose‐associated complications that assume particular importance in the acutely ill patient. Although much experience has been gained over the last 12 years, practice standards vary with the institution. Despite this, TNA therapy has been successful in the U.S. This paper attempts to delineate the important physicochemical variables that influence emulsion stability as they relate to clinical practice.
Invited Review: Metabolic Effects of Structured Triglycerides in Humans
Authors: Hyltander A. , Sandström R. , Lundholm K.
Published: May 2008

This review considers the development of structured triglycerides as an IV nutrient source. The replacement of a portion of long‐chain fatty acids in the conventional fat emulsion triglycerides confers favorable qualities on these lipids and renders them attractive as an energy source, particularly in critically ill patients. This report considers the features of structured triglycerides that may make them competitive or even more efficient as an energy source compared with conventional fat emulsions.
Enteral Nutrition Support in a Child After Bone Marrow Transplantation
Authors: Ringwald‐Smith Karen , Krance Robert , Stricklin Lisa
Published: May 2008

Bone marrow transplantation (BMT) has been associated with numerous negative side effects, which include prolonged anorexia. Historically, parenteral nutrition has been the method of choice for nutrition support. The possibility that enteral feedings may be a practical form of nutrition therapy for those BMT patients who have prolonged anorexia and who have adequate gastrointestinal function was investigated. RR, a 10‐year‐old male, was diagnosed with acute lymphocytic leukemia in March 1989. The patient received a bone marrow transplant in July 1992 from a human leukocyte antigen genotype‐matched sibling. Because of the patient's prolonged anorexia, he was started on enteral feedings via a percutaneous endoscopic gastrostomy feeding tube on day +63. Over the next 300 days of enteral nutrition support the patient's nutritional status improved as demonstrated by an increased weight and height and the maintenance of normal visceral protein stores. This suggests that enteral feedings may be beneficial for those BMT patients who have prolonged anorexia and have adequate gastrointestinal function.
Invited Review: Nutrition Support Teams: Past, Present, and Future
Authors: Wesley John R.
Published: May 2008

Nutrition support teams have evolved rapidly and grown in numbers since the early 1970s. While not all hospitals have or need nutrition support teams, the team approach has been demonstrated to be an excellent mechanism for identifying patients in need of nutrition support, reducing the complications associated with enteral and parenteral nutrition, and providing cost‐effective nutrition support in a variety of hospital environments. The organization of a nutrition support team is reviewed, and suggestions are outlined for team survival in this uncertain era of health care reform. New JCAHO standards are reported which require performance‐based interdisciplinary delivery of nutrition support, and make it more likely that efficiently organized nutrition support teams will thrive and continue to make important contributions to safe and cost‐effective health care now and in the immediate future.
Intradialytic Parenteral Nutrition After Small Bowel Resection
Authors: Jones Susan A. , Bushman Marcy , Cohen Raphael
Published: May 2008

Malnutrition is frequently observed in the hemodialysis patient population. It may be associated with increased morbidity and mortality as well as affect overall quality of life, which may already be compromised from dialytic physical and psychological demands. In the past, intradialytic parenteral nutrition (IDPN) has been available to hemodialysis patients as an adjunct to their dietary intake. In this time of cost containment and the increasing need to scientifically justify the benefit of such therapies to have them paid for by third party reimbursers, IDPN is coming under much scrutiny. This report describes a case of inadequate enteral nutrient absorption in a malnourished hemodialysis patient. This is a case in which IDPN was beneficial and without which other alternatives would have proven more costly physically, emotionally, and economically to the patient.
Invited Review: Malabsorption Associated With Surgical Procedures and Its Treatment
Authors: Grant John P. , Chapman Gayle , Russell Mary K.
Published: May 2008

Signs and symptoms of malabsorption after surgical procedures can be subtle and recognized late. This article reviews some of the more common surgical procedures potentially associated with malabsorption and suggests techniques of nutrition intervention. Early recognition, and preferably preventative care, should result in improved patient outcome.
Application of A.S.P.E.N. Clinical Guidelines: Parenteral Nutrition Use at a University Hospital and Development of a Practice Guideline Algorithm
Authors: Anderson Cathy F. , Macburney Maureen M.
Published: May 2008

Few studies have attempted to implement the 1993 A.S.P.E.N. Guidelines into clinical practice. We retrospectively studied parenteral nutrition (PN) use over a 3‐month period in 148 patients. Forty‐three percent of PN starts lasted ≤5 days. This short‐term use of PN was more likely to occur when peripheral access for PN was used. Overall, short‐term use of PN was found over a wide variety of diagnoses for a large number of reasons given in the medical record. Next, an algorithm was developed for the decision to initiate PN based on the 1993 A.S.P.E.N. Guidelines and was used to evaluate the use of PN. Several potential means for reducing overuse of PN were identified: using established criteria for malnutrition, restricting PN to known conditions in which the gastrointestinal (GI) tract cannot be used, and recognizing the transitory nature of many GI disorders.
Care of Central Venous Catheters for Total Parenteral Nutrition
Authors: Collins Eileen , Lawson Lauren , Lau Mary Theresa , Barder Louise , Weaver Frances , Bayer Denise , Schulz Margaret , Byrne Ray , Hauser Marion , Neubia Alvin , Dries David
Published: May 2008

This report summarizes data obtained via a mailed questionnaire from 129 Department of Veterans Affairs (VA) hospitals regarding current practices in the care of central venous catheters (CVCs) used for total parenteral nutrition (TPN). The size of VA hospitals' acute medical‐surgical beds ranged from 14 to 1320 (median 168) beds. Over 6000 patients annually received CVCs for TPN. Hospitals reported using triple‐lumen catheters most frequently as their CVC for TPN (80.3%). A povidone‐iodine scrub was used to prepare the skin for CVC insertion by 72.6% of reporting hospitals. Sixty percent of hospitals used transparent polyurethane dressings. Care of CVCs varied among hospitals. Catheter‐related infection and sepsis rates were within the national average, although <50% of responding hospitals provided data on these outcomes. The results of this survey point to the need for a national standardized database relative to patients receiving TPN via a CVC.
Nutrition Support Billing Practices: Results of a Nationwide Survey and Responses From the Health Care Financing Administration
Authors: Flancbaum Louis , Burge Jean C. , Choban Patricia S.
Published: May 2008

In response to numerous changes in reimbursement for physician services, a survey was conducted of physician directors of nutrition support services to obtain information about current physician billing practices and reimbursement for nutrition support. Demographic data were obtained concerning the type of practice and institution, percent of time and income derived from nutrition support, and the source of individual billing practices. Responses to six clinical scenarios provided information about billing practices. The responses were collated, analyzed, and then compared with those of a senior official at the Health Care Financing Administration (HCFA). This report summarizes the results of the survey and the responses from HCFA. It is hoped that this information will be useful to nutrition support practitioners and administrators in understanding various aspects of billing for physician services for nutrition support.
Hyperglycemia Associated With High, Continuous Infusion Rates of Total Parenteral Nutrition Dextrose
Authors: Rosmarin D. Kathryn , Wardlaw Gordon M. , Mirtallo Jay
Published: May 2008

A retrospective study was performed to determine whether there is an increased incidence of hyperglycemia in patients not predisposed to hyperglycemia (n = 102) who receive total parenteral nutrition (TPN) dextrose in excess of 4 to 5 mg/kg/min. Of the 37 subjects administered dextrose at >5 mg/kg/min, 18 exhibited hyperglycemia. None did so who received dextrose at ≤4 mg/kg/min (n = 19). TPN dextrose infusion rate was positively correlated with blood glucose concentration, over and above other variables considered in a multiple regression, including kcal/kg administered, furosemide or dopamine use, gender, age, or diagnosis. Thus, TPN dextrose infusion rates > 4 to 5 mg/kg/min increase risk of hyperglycemia.
Invited Review: Nutrition Support of Pediatric Patients
Authors: Ford Edward G.
Published: May 2008

Nutritional management in pediatric patients is often considered to be complex and difficult. We review the basic rationale and principles of IV nutrition support in pediatric patients. The unique differences between children and adults are outlined. The nutritional support solution is then divided into the distinct sections of energy, protein, volume, electrolytes, minerals and vitamins. Each of these parts is considered separately to allow understanding in a sequential fashion. Different routes of intravenous access are also discussed to include placement, maintenance, treatment of infections and management of catheter thrombosis.
An Oncology Patient's Choice to Forgo Nonvolitional Nutrition Support: Ethical Considerations
Authors: Chapman Gayle
Published: May 2008

A 76‐year‐old patient with metastatic carcinoid tumor who had difficulty tolerating an oral diet and jejunostomy feedings became dehydrated and failed to thrive. His jejunostomy feeding regimen was manipulated to improve tolerance without success. Although his medical condition was untreatable, he was not considered terminally ill, and he was determined to be a reasonable candidate for home total parenteral nutrition (HTPN). However, he thought HTPN was an “excessive measure,” and despite lengthy discussions with him by members of both the Hematology/Oncology and Nutrition Support services about the potential benefits of HTPN, he refused any further interventions involving nonvolitional nutrition support (jejunostomy feedings and HTPN). He was discharged to home receiving an oral diet as tolerated in the care of his family and hospice. This case illustrates the ethical considerations surrounding a patient's decision to forgo medical care that might prolong life.
Aspiration in a Patient Receiving Enteral Nutrition
Authors: Schwartz Denise Baird , Dominguez‐Gasson Linda
Published: May 2008

This case was selected to illustrate the advantages of an interdisciplinary team approach when the aspiration risks of enteral tube feeding are examined for patients with multisystem involvement. The case reviews a 79‐year‐old widowed woman with a cervical 6 to 7 spinal cord injury requiring mechanical ventilation and enteral feeding. The patient had multiple complications that prolonged her hospital course and required interdisciplinary involvement of medical, nutrition, nursing, respiratory, and speech pathology services. After an initial stay at another hospital, she was admitted to Providence Saint Joseph Medical Center (PSJMC) Acute Rehabilitation and Intensive Care Units. The patient was transferred home with PSJMC Home Health Services, and her case was part of a continuous quality improvement (CQI) project population group of ventilator‐dependent patients. The purpose of the interdisciplinary CQI team was to enhance nutrition intervention, improve patient outcomes, and reduce costs. This teaching case has added to the body of information being evaluated by the CQI team on nutrition intervention of ventilator‐dependent patients.
The Effect of Changing the Total Parenteral Nutrition Order Form on Resident Physician Ordering Behavior
Authors: Foulks Charles J. , Krenek Greg , Maxwell Karen
Published: May 2008

The quality assurance process at Scott and White Hospital, Temple, Texas, identified a marked variation in total parenteral nutrition (TPN) prescriptions compared with recommendations by the Nutrition Support Service (NSS). A TPN order form with additive guidelines was designed to assist physicians in ordering TPN specific to patient needs. The effect of the change was assessed by comparing 50 TPN patients using the old form (1990) with 50 patients for whom the new form (1992) was used. The groups demonstrated no difference in demographics, mortality, length of stay, or biochemical parameters and were reflective of all TPN patients treated (1990, n = 280; 1992, n = 392). A significant decrease was noted in overfeeding of kilocalories when resident orders were compared with NSS recommendations (125% ± 24% versus 110% ± 29%, p = .017;and amino acids (120% ± 32% versus 105% ± 29%, p = .017, mean ± SD). This resulted in a decrease of 8% in the cost of delivering a patient‐day of TPN. We conclude that changing the TPN order form to a teaching vehicle results in decreased overfeeding and costs.
Banana Flakes Control Diarrhea in Enterally Fed Patients
Authors: Emery Elizabeth A. , Ahmad Syed , Koethe John D. , Skipper Annalynn , Perlmutter Shelley , Paskin David L.
Published: May 2008

Diarrhea occurs frequently in the critically ill tube‐fed population and may result from a multitude of causes. Despite the availability of antidiarrheal medications, diarrhea associated with enteral feedings remains a problem for clinicians and for the patients affected by it. We tested the hypothesis that administration of banana flakes would control diarrhea in critically ill patients receiving enteral feedings. Thirty‐one patients with diarrhea and receiving enteral feedings were randomized to receive either banana flakes or medical treatment for diarrhea. Medical treatments included the use of pharmacological agents according to the discretion of the patient's physician or reducing feeding rates. Both banana flakes and medical treatments reduced the severity of diarrhea in critically ill tube‐fed patients. Over the course of treatment, mean diarrhea scores were 21.64 ± 7.81 for the banana flake group and 25.41 ± 9.76 for the medical group. These differences were not statistically significant. Both groups achieved similar levels of nutrition support. The banana flake group had less diarrhea clinically, with 57% of the subjects diarrhea free on their last study day as opposed to 24% of the medically treated subjects. This occurred despite a threefold increase in the number of patients testing positive for Clostridium difficile toxin in the banana flake group. We conclude that banana flakes can be used as a safe, cost‐effective treatment for diarrhea in critically ill tube‐fed patients. Banana flakes can be given concurrently with a workup for C. difficile colitis, thereby expediting treatment of diarrhea.
Clinical Pathway for Pediatric Parenteral Nutrition
Authors: Fisher Amy Andolina , Poole Robert L. , MacHie Rose , Tsang Carrie , Baugh Nancy , Utley Kathryn , Kerner John A.
Published: May 2008

The nutrition support team at Lucile Salter Packard Children's Hospital at Stanford developed a clinical pathway for infants and children receiving parenteral nutrition (PN). Use of clinical pathways for health care delivery is one way in which clinicians and institutions are responding to pressure from managed care organizations to reduce costs and maintain or improve quality. This pathway was developed to standardize the process for ordering, implementing, and monitoring PN. Specific goals for the pathway are as follows: to decrease the number of patients receiving PN inappropriately, to decrease the duration of PN for those patients who require it, to determine complication rates, and to monitor outcomes of therapy. Such comprehensive monitoring will help identify areas for improvement. By developing and implementing action plans to address these issues, we expect to improve continuously the processes and outcomes associated with PN therapy.