bluuebunny/crossref_metadata_2025 huggingface dataset:
Tube Feeding in Mechanically Ventilated Critically Ill Patients: A Prospective Clinical Audit
Authors: Ravasco Paula , Camilo Maria Ermelinda
Published: May 2008

Background: When and whether early enteral nutrition (EN) benefits critically ill patients is debatable. This prospective clinical audit aimed to evaluate the feasibility of an early EN protocol and to identify factors that may hinder EN delivery in critically ill patients. Methods: Thirty‐six medical patients with severe respiratory failure under invasive ventilation and scheduled to receive early EN, with a length of ICU stay> 72 hours, were included. As asserted by the Society of Critical Care Medicine, 8% of patients were priority 1, 72% priority 2, and 20% priority 3 for intensive therapeutic and vital support interventions. Results: Overall, because of gastrointestinal complications, only 39% of the prescribed EN was administered; only 8 (22%) patients did tolerate EN within the first 48 hours after admission and did achieve their minimum nutritional requirements. The most frequent complication (78%) was high volume of gastric residuals followed by abdominal distention (61%), both associated with hemodynamic instability (HI). Gastrointestinal dysfunction was associated with high Acute Physiologic and Chronic Health Evaluation II score (p = .01), total calorie intake (p = .02), total carbohydrate intake (p = .02), HI (p = .03), malnutrition (p = .04), volume of IV saline (p = .04), and concurrent vasoactive drug administration (p = .05). Conclusions: This audit in extremely severe intensive care patients identified several factors that impair gastrointestinal function and preclude EN at any stage, namely early EN. Nutrition management must take into account concurrent therapies, given their potential interference with nutrition and organ function.
The Role of Probiotics in Gastrointestinal Disease
Authors: Matarese Laura E. , Seidner Douglas L. , Steiger Ezra
Published: May 2008

Patients with intestinal failure often have diarrhea for a variety of reasons. Treatment of diarrhea has centered on the use of antidiarrheal medications and antibiotic therapy. Recently, there has been interest in the oral administration of probiotics for these patients with small bowel bacterial overgrowth, inflammatory bowel disease, and radiation enteritis. This paper reviews the studies that have used probiotics to treat patients with short bowel syndrome and gastrointestinal disorders. Additionally, some of the specific issues regarding probiotics are addressed.
Strategies in Managing Chronic Pancreatitis–Placement of Direct Percutaneous Endoscopic Jejunostomy Feeding Tubes
Authors: Fang John C. , DiSario James A.
Published: May 2008

Patients with chronic pancreatitis (CP) often have maldigestion and malnutrition. Nutrition support during acute and CP traditionally has been provided by parenteral nutrition. In acute pancreatitis, jejunal feeding may accelerate resolution of the inflammatory process, protect against infection, and improve outcomes at a reduced cost when compared with parenteral nutrition. Jejunal feeding may also be beneficial for patients with CP. Prolonged jejunal access may be achieved via a direct percutaneous endoscopic jejunostomy (DPEJ). This article will review the rationale and evidence for jejunal feeding, indications and contraindictions for DPEJ placement, and the technique and outcomes of DPEJ in patients with CP.
Effect of Laparoscopic Roux‐en‐Y Gastric Bypass on Type 2 Diabetes Mellitus
Authors: Schauer PR , Burguera B , Ikramuddin S , Cottam D , Gourash W , Hamad G , Eid GM , Mattar S , Ramanathan R , Barinas‐Mitchel E , Rao RH , Kuller L , Kelley D
Published: May 2008

Objective: To evaluate pre‐ and postoperative clinical parameters associated with improvement of diabetes up to 4 years after laparoscopic Roux‐en‐Y gastric bypass (LRYGBP) in patients with type 2 diabetes mellitus (T2DM). Summary background data: The surgical treatment of morbid obesity leads to dramatic improvement in the comorbidity status of most patients with T2DM. However, little is known concerning what preoperative clinical factors are associated with postoperative long‐term improvement in diabetes in the morbidly obese patient with diabetes. Methods: We evaluated pre‐ and postoperative data, including demographics, duration of diabetes, metabolic parameters, and clinical outcomes, in all patients with impaired fasting glucose (IFG) and type T2DM undergoing LRYGBP from July 1997 to May 2002. Results: During this 5‐year period, 1160 patients underwent LRYGBP, and 240 (21%) had IFG or T2DM. Follow‐up was possible in 191 of 240 patients (80%). There were 144 women (75%) with a mean preoperative age of 48 years (range, 26–67 years). After surgery, weight and body mass index decreased from 308 lbs and 50.1 kg/m2 to 211 lbs and 34 kg/m2 for a mean weight loss of 97 lbs and mean excess weight loss of 60%. Fasting plasma glucose and glycosylated hemoglobin concentrations returned to normal levels (83%) or markedly improved (17%) in all patients. A significant reduction in use of oral antidiabetic agents (80%) and insulin (79%) followed surgical treatment. Patients with the shortest duration (<5 years), the mildest form of T2DM (diet controlled), and the greatest weight loss after surgery were most likely to achieve complete resolution of T2DM. Conclusion: LRYGBP resulted in significant weight loss (60% percent of excess body weight loss) and resolution (83%) of T2DM. Patients with the shortest duration and mildest form of T2DM had a higher rate of T2DM resolution after surgery, suggesting that early surgical intervention is warranted to increase the likelihood of rendering patients euglycemic.
Management of Blood Glucose and Diabetes in the Critically Ill Patient Receiving Enteral Feeding
Authors: Charney Pamela , Hertzler Steven R.
Published: May 2008

Diabetes mellitus causes profound alterations in nutrient metabolism, leading to long‐term systemic complications, particularly in individuals with poorly controlled disease. Nutrition support clinicians need to be aware of the effect of acute illness on stress‐induced and established diabetes mellitus and the appropriate management strategies. Because enteral feeding is a vital component of critical care for many patients with diabetes mellitus, it is important to develop techniques to best manage metabolic control during enteral feeding. This article will review mechanics of blood glucose regulation, evaluation of energy sources for patients with diabetes mellitus, selection of enteral formulas and infusion routes, and glycemic control in patients receiving tube feeding. At this point, it is appropriate to use a standard formula to initiate feedings in most patients with blood glucose abnormalities. Close monitoring and judicious use of insulin are key in maintaining glucose control and avoiding complications.
Management of Diabetic Gastroparesis
Authors: Jones Michael P.
Published: May 2008

Diabetic patients with nausea and vomiting need evaluation to determine symptom etiology; diabetic gastroparesis should never be the default diagnosis. If no other etiology for nausea and vomiting is found after an appropriate evaluation, treatment focuses on effectively relieving symptoms while maintaining adequate nutritional status. Therapy for patients with nausea and vomiting consists of restoring volume, glycemic, and electrolyte status and providing antiemetics generously in both a remittive and prophylactic fashion. Prokinetics are best used to treat gastric stasis or clinically significant delayed gastric emptying. A gastrostomy is rarely indicated, but a jejunostomy may be helpful in maintaining nutrition. Parenteral nutrition should generally be avoided because of high complication rates in this setting. Surgical intervention is essentially unstudied in this population and cannot be recommended. Gastric electrical stimulation is an interesting and novel therapy, but its efficacy beyond placebo remains to be conclusively shown.
Glucose Control and Mortality in Critically Ill Patients
Authors: Finney SJ , Zekveld C , Elia A , Evans TW
Published: May 2008

Objective: Hyperglycemia is common in critically ill patients, even in those without diabetes mellitus. Aggressiveglycemic control may reduce mortality in this population. However, the relationship between mortality, the control of hyperglycemia, and the administration of exogenous insulin is unclear. The objective was to determine whether blood glucose level or quantity of insulin administered is associated with reduced mortality in critically ill patients. Methods: This was a single‐center, prospective, observational study of 531 patients (median age, 64 years) newly admitted over the first 6 months of 2002 to an adult intensive care unit (ICU) in a UK national referral center for cardiorespiratory surgery and medicine. The primary end point was intensive care unit (ICU) mortality. Secondary end points were hospital mortality, ICU and hospital length of stay, and predicted threshold glucose level associated with risk of death. Results: Of 531 patients admitted to the ICU, 523 under‐went analysis of their glycemic control. Twenty‐four‐hour control of blood glucose levels was variable. Rates of ICU and hospital mortality were 5.2% and 5.7%, respectively; median lengths of stay were 1.8 (interquartile range, 0.9 to 3.7) days and 6 (inter‐quartile range, 4.5 to 8.3) days, respectively. Multivariable logistic regression demonstrated that increased administration of insulin was positively and significantly associated with ICU mortality (odds ratio, 1.02 [95% confidence interval, 1.01 to 1.04] at a prevailing glucose level of 111 to 144 mg/dL [6.1 to 8.0 mmol/L] for a 1‐IU/day increase), suggesting that mortality benefits are attributable to glycemic control rather than increased administration of insulin. Also, the regression models suggest that a mortality benefit accrues below a predicted threshold glucose level of 144 to 200 mg/dL (8.0 to 11.1 mmol/L), with a speculative upper limit of 145 mg/dL (8.0 mmol/L) for the target blood glucose level. Conclusions: Increased insulin administration is positively associated with death in the ICU, regardless of the prevailing blood glucose level. Thus control of glucose levels rather than of absolute levels of exogenous insulin appears to account for the mortality benefit associated with intensive insulin therapy demonstrated by others.
Parenteral Nutrition–Associated Hepatotoxicity
Authors: Fulford Andrea , Scolapio James S. , Aranda‐Michel Jaime
Published: May 2008

Background: Parenteral nutrition has been associated with the development of several hepatobiliary complications. The aim of this article was to review the current available literature associated with parenteral nutrition–induced hepatotoxicity. Methods: We performed a literature search and reviewed all related articles published within the past 5 years, from 1999 to 2003. Results: As a result of this review, we were able to determine the suspected etiology and pathogenesis, commonly used diagnostic tests and procedures, and current methods used for prevention and treatment of parenteral nutrition–associated hepatotoxicity. Conclusions: Regardless of current advances in research, much is left to be determined in the areas of etiology, pathogenesis, prevention, and treatment of parenteral nutrition–induced hepatobiliary complications. Practitioners should be encouraged to participate in further research, particularly in studies involving human subjects.
The Biology of Human Immunodeficiency Virus Infection
Authors: Kotler Donald P.
Published: May 2008

The aim of this article is to review the basic biology of infection with HIV‐1 and the development of the acquired immunodeficiency syndrome. The discussion will include epidemiology, general description of the retroviruses, pathogenesis of the immune deficiency, clinical consequences, treatment, and treatment outcomes. Aspects of the infection that affect protein and energy balance will be identified.
Enhancing Interpretation of Gastric Residual Volume by Refractometry
Authors: Chang Wei‐Kuo , McClave Stephen A. , Chao You‐Chen
Published: May 2008

The traditional practice of gastric residual volumes (GRVs) is flawed in its design and conception, is poorly standardized in its technique, is an inaccurate measure of gastric emptying, and serves as an insensitive marker for regurgitation and aspiration. The refractive index of a solution (like an enteral formula) is a physical property of that solution, which is remarkably constant and reproducible under varying conditions of concentration, pH, and temperature. Refractometry may be performed quickly and easily at the bedside, requires only a small representative sample of aspirated solution, and provides valuable measurements that can be used to calculate both the true total volume of contents and the specific volume of formula remaining in the stomach. Refractometry complements the use of GRVs as a monitor for patients receiving enteral feeding and should improve the accuracy with which patients at risk for aspiration may be identified.
Monitoring Enteral Nutrition Support Tolerance in Infants and Children
Authors: Weckwerth Jody A.
Published: May 2008

Enteral nutrition support is used extensively in the care of infants and children, both for acute and chronic conditions. Monitoring a child's tolerance of enteral feedings is an ongoing challenge. Monitoring routines vary significantly between institutions, practitioners, and patient settings, and a number of definitions are used for “intolerance.” Some guidelines have scientific basis and others are passed along in a more anecdotal fashion. This review describes commonly used monitors for tolerance to enteral nutrition for infants and children and discusses pertinent data relevant to practice.
Nutritional Management of the Patient With Chronic Obstructive Pulmonary Disease
Authors: Mallampalli Antara
Published: May 2008

The prevalence and prognostic importance of malnutrition in chronic obstructive pulmonary disease (COPD), the factors that contribute to development of nutritional depletion, and the available evidence regarding effects of nutrition support in these patients are the subjects of this review. Nutritional depletion, as indicated by weight loss and loss of lean body mass, is a common complication of advanced COPD (particularly, but not limited to, the emphysematous type). Low body weight or recent weight loss and in particular depleted lean body mass in patients with COPD have been shown to be independent predictors of mortality, outcomes after acute exacerbations, hospital admission rates, and need for mechanical ventilation. The factors thought to contribute to nutritional depletion in these patients include elevated resting and activity‐related energy expenditure, reduced dietary intake relative to resting energy expenditure, accelerated negative nitrogen balance, particularly during acute exacerbations of COPD, medication effects, and perhaps most importantly an elevated systemic inflammatory response. Studies to date suggest that, although it can help limit weight loss and negative energy balance in these patients, the effect of nutritional supplementation alone on clinically significant outcomes such as pulmonary function and exercise capacity is minimal. However, nutritional supplementation may have a role in the management of COPD when provided as part of an integrated rehabilitation program incorporating a structured exercise component as an anabolic stimulus.
Aspiration and the Risk of Ventilator‐Associated Pneumonia
Authors: Parker Chris M. , Heyland Daren K.
Published: May 2008

Ventilator‐associated pneumonia (VAP) is a major concern in the intensive care unit. It is estimated that the risk of developing VAP may be as high as 1% per ventilated day, and the attributable mortality approaches 50% in some series. A growing body of evidence implicates the role of microaspiration of contaminated oropharyngeal and perhaps gastroesophageal secretions into the airways as an integral step in the pathogenesis of VAP. In patients who have been intubated and mechanically ventilated for >72 hours, the majority of VAP is caused by enteric gram‐negative organisms, presumably of gastrointestinal origin. As a result, strategies designed to minimize the risk of these contaminated secretions into the normally sterile airways are of paramount importance in terms of VAP prevention. This review highlights the important etiological role of the gut in the development of VAP and also discusses the evidence behind interventions that may modulate the risk of both aspiration and subsequent VAP.
Current Literature: Caloric Intake in Medical ICU Patients: Consistency of Care With Guidelines and Relationship to Clinical Outcomes
Authors: Canada Todd
Published: May 2008

Objectives: To assess the consistency of caloric intake with American College of Chest Physicians (ACCP) recommendations for critically ill patients and to evaluate the relationship of caloric intake with clinical outcomes. Design: Prospective cohort study. Setting: Adult intensive care units (ICUs) at 2 teaching hospitals. Participants: Patients with an ICU length of stay of at least 96 hours. Measurements and results: On ICU admission, severity of illness (ie, simplified acute physiology score II) and markers of nutritional status (ie, serum albumin level and body mass index) were recorded. The route of feeding (ie, enteral or parenteral), actual caloric intake (ie, percentage of ACCP recommendations: 0% to 32% [tertile I]; 33% to 65% [tertile II]; ≥66% [tertile III]), and evidence of GI intolerance (ie, gastric aspirate levels, ≥100 mL) were recorded daily. The following outcomes were assessed: status on hospital discharge (alive vs dead); spontaneous ventilation before ICU discharge (yes vs no); and ICU discharge without developing nosocomial sepsis (yes vs no). The average caloric intake among 187 participants was 50.6% of the ACCP targets and was similar in both hospitals. Caloric intake was inversely related to the mean number of gastric aspirates≥ 100 mL/d (Spearman ρ =–.04; p = .06), but not to severity of illness, nutritional status, or route of feeding. After accounting for the number of gastric aspirates ≥100 mL, severity of illness, nutritional status, and route of feeding, tertile II of caloric intake (vs tertile I) was associated with a significantly greater likelihood of achieving spontaneous ventilation before ICU discharge. Tertile III of caloric intake (vs tertile I) was associated with a significantly lower likelihood of both hospital discharge alive and spontaneous ventilation before ICU discharge. Conclusions: Study participants were underfed relative to ACCP targets. These targets, however, may overestimate needs because moderate caloric intake (ie, 33% to 65% of ACCP targets; approximately 9 to 18 kcal/kg per day) was associated with better outcomes than higher levels of caloric intake.
Current Literature: Standardization of IV Insulin Therapy Improves the Efficiency and Safety of Blood Glucose Control in Critically Ill Adults
Authors: Canada Todd
Published: May 2008

Objective: Aggressive glycemic control improves mortality and morbidity in critically ill adults; however, implementation of such a strategy can be logistically difficult. This study evaluates the efficiency and safety of a nurse‐managed insulin protocol in critically ill adults. Design: Combined retrospective‐prospective before‐after cohort study. Setting: Twenty‐one bed medical/surgical intensive care unit (ICU) in a tertiary care hospital. Patients: Two cohorts of 50 consecutive ICU patients requiring insulin infusions. Intervention: Patients in the control cohort received insulin infusions titrated according to target blood glucose ranges and sliding scales at the physician's discretion. Patients in the interventional cohort received an insulin infusion adjusted using a standardized protocol targeting a blood glucose of 4.5 to 6.1 mmol/L (81 to 110 mg/dL). Measurements and main results: Efficiency was measured by comparing the time to reach, and the time spent within, the target range between cohorts. Safety was assessed by comparing the incidence of severe hypoglycemia, the frequency of rescue dextrose administration, and the cumulative time that the infusion was held for hypoglycemia between cohorts. Patients in the interventional cohort reached their target more rapidly (11.3± 7.9 vs 16.4 ± 12.6 hours; p = .028) and maintained their blood glucose within the target range longer (11.5 ± 3.7 vs 7.1 ± 5.0 hours/day; p < .001) than controls. The standardized protocol yielded a 4‐fold reduction in the incidence of severe hypoglycemia (4 vs 16%; p = .046) and reduced the median frequency of dextrose rescue therapy (0 [0 to 0.91] vs 0.17 [0 to 1.2] episodes/patient per day; p = .01) as compared with controls. Conclusion: Standardization of intensive insulin therapy improves the efficiency and safety of glycemic control in critically ill adults.
Management of a Traumatic Gastric Ulcer With a Low‐Profile Gastrostomy Tube
Authors: Seidner Douglas L. , Ghanta Ravi K.
Published: May 2008

Since the advent of percutaneous endoscopic gastrostomy (PEG) tubes in 1980, they have become the device of choice for providing long‐term enteral nutrition. Despite their overall safety, a number of complications can occur after PEG placement. Bleeding is usually a minor complication associated with PEG placement that occurs soon after the procedure and is most often caused by puncture of an abdominal wall vessel. More severe bleeding can occur when a branch of one of the gastric arteries is punctured. There are only a few case reports of traumatic gastric ulceration secondary to the internal bolster of a PEG. The internal bolsters are either balloons or dome shaped, and are 1.5–2.0 cm in height. We report a case in which a patient developed hemorrhage from a gastric ulcer induced by a balloon‐type PEG tube that was resolved only after replacement with a tube manufactured with a low‐profile internal bolster that was only 0.3 mm in height. The protruding tip of a balloon‐type gastrostomy tube was believed to have caused traumatic injury to the gastric mucosa in our patient, causing ulceration. Usually, removal of the tube and placement in a different location may solve the problem. However, we believe that the PEG tube fashioned with a low‐profile internal bumper is a safer option.
Electrolytes and Fluid Management in Hemodialysis and Peritoneal Dialysis
Authors: Nanovic Lisa
Published: May 2008

The kidney is a complex and vital organ, regulating the electrolyte and fluid status of the human body. As hemodialysis (HD) and peritoneal dialysis (PD) are forms of renal replacement therapy and not an actual kidney, they do not possess the same physiologic regulation of both fluid and electrolytes. Precise regulation of fluid and electrolytes in the HD and PD population remains a constant challenge. In this review, fluid status of both HD and PD will be examined, as well as sodium, potassium, phosphorous, and calcium. Each electrolyte will be analyzed by its physiological significance, the complications that arise when a proper balance cannot be maintained, and methods to correct these imbalances. An overview of the fluid compartments and volume of distribution within the body will be discussed. Ultrafiltration, a modality used in both forms of renal replacement therapy, will be defined, along with its impact on fluid status. Fluid assessment will be addressed, along with proper maintenance of fluid homeostasis. By having an understanding of the pathophysiology behind the fluid and electrolyte abnormalities that occur in end‐stage renal disease, one can direct proper management with medications, diet, and alterations in dialysis to provide patients with the most optimal form of renal replacement therapy available.
Integrating Clinical Nutrition Practice Guidelines in Chronic Kidney Disease
Authors: Kent Pamela S.
Published: May 2008

Chronic kidney disease (CKD) is a permanent, progressive loss of kidney function characterized by a decline in glomerular filtration rate (GFR). Early identification of CKD risk factors provides an opportunity to prevent or delay the progression of kidney disease and decrease morbidity and mortality. There is increasing evidence to suggest that the adverse outcomes of CKD can be delayed or prevented by early detection and treatment. Current literature suggests that a low‐protein, low‐phosphorus diet may retard the progression of kidney disease. Other modifiable risk factors affecting CKD include proteinuria, hypertension, hyperglycemia, dyslipidemia, bone disease, anemia, and obesity. This discussion will review the current clinical nutrition guidelines for managing adult patients with CKD.
Probiotics: A Practical Review of Their Role in Specific Clinical Scenarios
Authors: Jenkins Barry , Holsten Steven , Bengmark Stig , Martindale Robert
Published: May 2008

The use of probiotics (live viable microbial organisms) in the treatment of specific diseases has evolved into an extremely valuable option yet to be optimally used in clinical medicine. Probiotics have been shown to have immunomodulating properties and enhance the mucosal barrier. This review will briefly discuss the use of probiotics in inflammatory bowel disease, pancreatitis, liver transplantation, and various uses in diarrhea. When using probiotics, one must be cautious of the sometime overzealous claims that are commonly made when dealing with medical foods. As we begin to appreciate the degree of complexity that our indigenous microbial population has on health, it is only then that we can begin to understand the importance in disease. In the arena of probiotics, numerous fundamental questions remain unanswered.
Evidence‐Based Clinical Practice: Dispelling the Myths
Authors: Hise Mary E. , Kattelmann Kendra , Parkhurst Melissa
Published: May 2008

Evidence‐based practice merges the best and most relevant clinical research data with clinician experience, pathophysiology of disease state, and the specifics of individual patient care. Currently, there is a significant gap between the best research evidence in healthcare and application of this evidence to clinician practices. Consistent with this finding, nutrition support is not always applied effectively or consistently, despite available scientific evidence that could be used to enhance a given treatment protocol. Cited obstacles that prevent the incorporation of research evidence into daily practice include lack of time, inadequate research skills, and information overload. Identification and application of the most valid primary research and evidence summaries (clinical guides to practice and meta‐analyses) should, however, be an integral part of appropriate nutrition care. Consequently, it is important that clinicians develop and improve upon the basic skills required to allow efficient and accurate searches and evaluations of the literature. This review describes the basic and practical components of evidence‐based medicine and provides tools to determine whether current nutrition practices are based upon an analysis of valid clinical evidence or anecdotal nutrition traditions and myths.
Is Statistical Significance Always Significant?
Authors: Koretz Ronald L.
Published: May 2008

One way in which we learn new information is to read the medical literature. Whether or not we do primary research, it is important to be able to read literature in a critical fashion. A seemingly simple concept in reading is to interpret p values. For most of us, if we find a p value that is <.05, we take the conclusion to heart and quote it at every opportunity. If the p value is >.05, we discard the paper and look elsewhere for useful information. Unfortunately, this is too simplistic an approach. The real utility of p values is to consider them within the context of the experiment being performed. Defects in study design can make an interpretation of a p value useless. One has to be wary of type I (seeing a “statistically significant” difference just because of chance) and type II (failing to see a difference that really exists) errors. Examples of the former are publication bias and the performance of multiple analyses; the latter refers to a trial that is too small to demonstrate the difference. Finding significant differences in surrogate or intermediate endpoints may not help us. We need to know if those endpoints reflect the behavior of clinical endpoints. Selectively citing significant differences and disregarding studies that do not find them is inappropriate. Small differences, even if they are statistically significant, may require too much resource expenditure to be clinically useful. This article explores these problems in depth and attempts to put p values in the context of studies.
Albumin Therapy in Clinical Practice
Authors: Mendez Christian M. , McClain Craig J. , Marsano Luis S.
Published: May 2008

Albumin is the predominant product of hepatic protein synthesis and one of the more abundant plasma proteins. Among its multiple physiologic roles, it plays an essential part in the generation of colloid‐oncotic pressure. In the United States, the indications for which albumin therapy are considered include hypovolemia or shock, burns, hypoalbuminemia, surgery or trauma, cardiopulmonary bypass, acute respiratory distress syndrome, hemodialysis, and sequestration of protein‐rich fluids. The use of this relatively expensive therapy accounts for up to 30% of the total pharmacy budget in certain hospitals. The use of albumin therapy in different clinical situations and its influence in morbidity and mortality have been reviewed in multiple randomized controlled trials and meta‐analyses. Despite frequent reviews, the use of albumin remains controversial in several clinical situations. At the same time, these valuable reviews seem to have documented the advantages of albumin therapy in the management of ascites and clarified the use of albumin in volume resuscitation. More studies have been recommended to investigate the use of albumin in different doses and its role in hypoalbuminemia. This article will provide an overview of albumin metabolism, use of albumin for volume expansion, the potential therapeutic role of albumin in liver disease, and the role of albumin therapy in nutrition.
Is There a Role for Nonprotein Calories in Developing and Evaluating the Nutrient Prescription?
Authors: Skipper Annalynn , Tupesis Nicole
Published: May 2008

The concept of nonprotein calories has been used in a variety of ways by nutrition support clinicians. Nonprotein calories may refer to the combined energy from lipid and carbohydrate but are also used to describe the balance between energy and protein in the form of the nonprotein calorie‐to‐nitrogen ratio. Nonprotein calories have been used as the basis for calculating nutrient needs, but this practice is no longer recommended as it may result in overfeeding. The purpose of this paper is to examine the nonprotein calorie concept using a clinical scenario and review of the literature.
The Efficacy of an Enteral Access Protocol for Feeding Trauma Patients
Authors: Wooley Jennifer , Pomerantz Richard
Published: May 2008

Background: Proper enteral access to deliver specialized nutrition support in critically injured patients can be difficult, time consuming, and costly. We designed a protocol with interdisciplinary input to facilitate early enteral access in our trauma patients. Our primary objective was to determine if the protocol improved our ability to obtain small‐bowel access in patients within 48 hours of their admission to the surgical intensive care unit (SICU). Secondary objectives were to examine the efficacy of the protocol by evaluating parenteral nutrition (PN) use, adequacy of enteral caloric delivery, and clinical outcomes including pneumonia and sepsis rates, SICU length of stay (LOS), hospital LOS, and mortality before and after its implementation. Methods: The medical records of 51 trauma patients admitted to the SICU, who met inclusion criteria, were reviewed retrospectively and divided into 2 groups. Patients in group 1 were admitted before protocol implementation (1997–1998, n = 17). Patients in group 2 were admitted after protocol implementation (1998–2000, n = 34). Results: Small‐bowel access was achieved earlier in group 2 compared with group 1 [2.2 ± 2 days vs 5.4 ± 8 days, respectively (p = .04)]. PN was used less frequently in group 2 at 41.2% (14/34) as opposed to 64.7% (11/17) in group 1 (p = .05). There was a reduction in the number of days to reach caloric goal from 4.9 days in group 1 to 3.9 days in group 2 (n.s.). Clinical outcomes were similar in both groups. Conclusions: The use of a protocol was effective in the achievement of prompt small bowel access. The number of days to reach caloric goal decreased after protocol implementation, but not to a statistically significant degree. However, we were able to detect a significant reduction in the use of PN.
Hyperemesis Gravidarum: Outcomes and Complications With and Without Total Parenteral Nutrition
Authors: Folk JJ , Leslie‐Brown HF , Nosovitch JT , Silverman RK , Aubry RH
Published: May 2008

Objective: To evaluate the obstetric and medical complications with hyperemesis gravidarum, comparing those who were supported with total parenteral nutrition (TPN group) and those who did not receive TPN (non–TPN group). Study Design: The medical records of women with a diagnosis of hyperemesis gravidarum (ICD‐9 code 643) admitted to Crouse Hospital, Syracuse, New York, between January 1995 and December 1998 were reviewed. A total of 166 subjects were identified and 192 admissions reviewed. Information was gathered for age, gestational age, gravity and parity, marital status, length of stay, and number of admissions, and a review of electrolyte, albumin, and thyroid function was performed. An assessment of pregnancy complications and outcomes was undertaken. Results: Of the cases reviewed, 16% (27/166) were treated with PN. The 2 groups were similar regarding incidence of pregnancy‐related and maternal medical complications. The groups were similar when comparing objective measures, such as serum potassium, bicarbonate, albumin, and thyroid function. The PN group had a significantly increased incidence of complications directly attributed to parenteral therapy. Among multiparous patients in both groups, 69% had a prior pregnancy that had ended in spontaneous or induced abortion. Conclusion: The PN group had a marked and significant increase in serious complications directly related to PN use. These data suggest that great care should be taken to assess the need for parenteral therapy in patients with hyperemesis gravidarum. A history of loss in the antecedent pregnancy may be a risk factor for a subsequent pregnancy complicated by hyperemesis gravidarum.
Folate During Antifolate Chemotherapy: What We Know… and Do Not Know
Authors: Robien Kim
Published: May 2008

The nutrient folate is essential for normal cell growth and development. Enzymes that require folate as a cofactor have been common targets for chemotherapeutic agents. Limited clinical guidance is available regarding optimal levels of dietary or supplemental folate intake during antifolate chemotherapy to meet the goals of minimizing treatment‐related toxicity yet preserving treatment effectiveness. Patients with higher folate intake may experience less treatment‐related toxicities; however, the concern is that folate may interfere with the effectiveness of the antifolate treatment and possibly support tumor growth. This article will review folate and antifolate metabolism and review the current body of knowledge regarding the interactions between folates and antifolates. Future research in this area should include evaluation of pretreatment folate status and dietary and supplemental folate intake before, during, and after treatment.
Short Bowel Syndrome: Clinical Guidelines for Nutrition Management
Authors: Matarese Laura E. , O'Keefe Stephen J. , Kandil Hossam M. , Bond Geoffrey , Costa Guilherme , Abu‐Elmagd Kareem
Published: May 2008

Intestinal failure is a condition in which inadequate digestion or absorption of fluid, electrolytes, and nutrients leads to dehydration or malnutrition. The most common cause of intestinal failure is short bowel syndrome (SBS) defined as <200 cm of functional small intestine. SBS may result from congenital abnormalities or from surgical resection. For the past 3 decades, patients with severe SBS were managed with home parenteral nutrition (HPN). With the emergence of new therapies, the clinician now has multiple options to treat these patients. These include intestinal rehabilitation regimens whereby patients are treated with specialized oral diets, soluble fiber, oral rehydration solutions (ORS), and trophic factors to enhance absorption. There are also a variety of surgical techniques available to preserve intestinal length. Small bowel and multivisceral transplantation has evolved during the last decade to be a valid therapeutic option for those patients who cannot be rehabilitated or who fail HPN. These are interrelated services designed to offer the patient the best therapeutic options to meet their individual needs. This article reviews the principles associated with the nutrition management of this very complex and diverse group of patients.
Criteria for the Use of Recombinant Human Growth Hormone in Short Bowel Syndrome
Authors: Parekh Neha R. , Steiger Ezra
Published: May 2008

Extensive resection of the intestinal tract with resulting malabsorption is known as short bowel syndrome (SBS). Adaptation and rehabilitation of the remaining small bowel occurs spontaneously after resection and can be enhanced by diet, medications, and use of intestinal trophic factors such as recombinant human growth hormone (r‐hGH). Many trials have been published on the influence of r‐hGH therapy in SBS patients, with varying results. Analysis of the trials has produced a set of criteria that can be used to define the patient most likely to benefit from r‐hGH therapy.
Dumping Syndrome: Pathophysiology and Treatment
Authors: Ukleja Andrew
Published: May 2008

Anatomic and physiologic changes introduced by gastric surgery result in clinically significant dumping syndrome in approximately 10% of patients. Dumping is the effect of alteration in the motor functions of the stomach, including disturbances in the gastric reservoir and transporting function. Gastrointestinal hormones play an important role in dumping by mediating responses to surgical resection. Treatment options of dumping syndrome include diet, medications, and surgical revision. Poor nutrition status can be anticipated in patients who fail conservative therapy. Management of refractory dumping syndrome can be a challenge. This review highlights current knowledge about the mechanisms of dumping syndrome and available therapy.
When to Feed the Patient With Gastrointestinal Bleeding
Authors: McClave Stephen A. , Chang Wei‐Kuo
Published: May 2008

Whether to provide artificial enteral nutrition therapy to a patient with evidence of gastrointestinal bleeding (GIB) creates a difficult clinical dilemma. Concern that enteral feeding may contribute to the morbidity associated with GIB leads to delays in initiating enteral therapy or to cessation of feeding in the patient in whom artificial nutrition support has already been started. Surprisingly, evidence of GIB is not an automatic contraindication to further enteral feeding. Depending on the etiology of the GIB, enteral nutrition may protect the gut mucosa and reduce further bleeding in some patients, actually increase risk for rebleeding in other patients, or serve as a moot point with no relation to further bleeding or morbidity in still other patients. In many cases, an endoscopic evaluation is needed to distinguish the differential etiology of the GIB. The nutrition support specialist needs a full understanding of the physiology behind the varying diagnoses for GIB to know whether feedings can be initiated or continued or whether enteral feedings need to be withheld for 48–72 hours until risk for rebleeding and further morbidity is minimized.
The Use of Parenteral Nutrition in a Severely Malnourished Hemodialysis Patient With Hypercalcemia
Authors: Ohlrich Heather , Barco Kathy , Silver Marcia R.
Published: May 2008

There is a high prevalence of protein‐energy malnutrition (PEM) in chronic dialysis patients. Causes of PEM include the catabolic effects of hemodialysis treatments, acidemia associated with end‐stage renal disease, common comorbid conditions, and uremia‐induced anorexia. Morbidity and mortality increase with PEM. Before considering parenteral nutrition (PN) as a nutrition intervention in a maintenance dialysis patient, all other efforts to promote optimal nutrition need to be exhausted. The first step is careful evaluation of protein‐energy status, followed by intensive nutrition counseling. If necessary, this is followed by oral nutrition supplementation, appetite stimulation, enteral tube feedings, and finally PN.

Short‐term parenteral nutrition (PN) became a crucial component of the management of a 38‐year‐old hemodialysis (HD) patient who endured serious complications after kidney transplant rejection. A profound and prolonged malnourished state followed her treatment for necrotizing pancreatitis. She had developed persistent hypercalcemia believed secondary to tertiary hyperparathyroidism (HPT) and immobilization. Later, she developed hungry bone syndrome (HBS) after parathyroidectomy (PTX). She also developed refeeding syndrome after initiation of PN. The patient's persistent, poorly understood hypercalcemia did not resolve even after PTX and removal of all other sources of vitamin D and calcium from her feedings, medications, and dialysis bath. The close communication of the inpatient and outpatient dialysis multidisciplinary teams became a key component to the successful outcome in this complex patient.
Twenty‐five Years of Advances in Vascular Access: Bridging Research to Clinical Practice
Authors: Krzywda Elizabeth A. , Andris Deborah A.
Published: May 2008

Vascular access has become a key component for a multitude of IV therapies, including parenteral nutrition. Access of the central venous system has been long recognized for its associated complications of infection, thrombosis, and occlusion. Over the past 25 years, clinical practice based on research and innovation has attempted to decrease complication rates and therefore improve the safety of vascular access. This article highlights the research and its influence on catheter care procedures, technology, and education that has led to advances in vascular access. An improved understanding of the pathophysiology associated with catheter‐related complications and an ongoing evaluation of new treatment modalities has provided clinicians today with new options for improved patient care and the ability to preserve vascular access options for patients.
Review of the Refeeding Syndrome
Authors: Kraft Michael D. , Btaiche Imad F. , Sacks Gordon S.
Published: May 2008

Refeeding syndrome describes a constellation of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved or severely malnourished. Patients can develop fluid and electrolyte disorders, especially hypophosphatemia, along with neurologic, pulmonary, cardiac, neuromuscular, and hematologic complications. We reviewed literature on refeeding syndrome and the associated electrolyte abnormalities, fluid disturbances, and associated complications. In addition to assessing scientific literature, we also considered clinical experience and judgment in developing recommendations for prevention and treatment of refeeding syndrome. The most important steps are to identify patients at risk for developing refeeding syndrome, institute nutrition support cautiously, and correct and supplement electrolyte and vitamin deficiencies to avoid refeeding syndrome. We provide suggestions for the prevention of refeeding syndrome and suggestions for treatment of electrolyte disturbances and complications in patients who develop refeeding syndrome, according to evidence in the literature, the pathophysiology of refeeding syndrome, and clinical experience and judgment.
Alterations in Lipid Profiles in HIV‐Infected Patients Treated With Protease Inhibitor Therapy Are Not Influenced by Diet
Authors: Wanke Christine , Gerrior Jül , Hendricks Kristy , McNamara Judith , Schaefer Ernest
Published: May 2008

Background: The use of protease inhibitor (PI) –based highly active antiretroviral therapy (HAART) in patients infected with human immunodeficiency virus (HIV) has been linked to alterations in lipid profiles. Methods: Longitudinal cohort study. Lipid profiles were evaluated pre‐ and post‐PI therapy in 49 HIV‐infected patients. Diet was also evaluated to determine any contribution to alterations in lipid levels. Results: Pre‐ and post‐PI‐based HAART samples were examined from 42 men and 7 women, mean age 40.6 years. Mean CD4 count pre‐PI was 242 ± 205 cells/mm3; HIV RNA was 4.2 log10 copies/mL; body mass index (BMI) was 24.7 ± 3.6 kg/m2; body fat was 17.1± 9.1 kg by bioelectrical impedance analysis (BIA), dietary intake was 2654 ± 732 kcal/day. Post‐PI samples were collected 5.7 ± 1.66 months after starting therapy. CD4 counts increased to 384 ± 323 cells/mm3 and RNA decreased 1 log post‐PI. Post‐PI BMI (25.2 kg/m2), percent body fat (17.4%) and caloric intake (2656 kcal/day) were unchanged. Pre‐PI total cholesterol (TC) in men was 167.6 ± 42.4 mg/dL; TC increased (190.4 ± 47.9 mg/dL) post‐PI (p < .0001). Pre‐PI triglycerides (TG) were 154.5 ± 109.4 mg/dL; TG increased post‐PI (266.1 ± 363.6 mg/dL, p < .03). Low‐density lipoprotein (LDL) ‐C was 97.8 ± 31 mg/dL pre‐PI and rose to 107.1± 34.7 mg/dL post‐PI (p < .05). High density lipoproteins (HDLs) were below desired levels before initiation of PI therapy and remained low. Conclusions: PI therapy significantly alters lipid profiles in HIV‐infected patients. Dietary intake did not contribute to changes in lipid profile. More longitudinal studies are needed to demonstrate whether these alterations contribute to additional cardiovascular risk.
Nutrition Management of Chronic Diarrhea and Malabsorption
Authors: Schiller Lawrence R.
Published: May 2008

Diet often is blamed for digestive symptoms, particularly diarrhea, and patients with diarrhea and malabsorption usually request guidance about what to eat. Food‐induced symptoms are very common. Although many recommendations have been made for dietary management in diarrheal diseases, there is little supportive evidence for efficacy for any of them. Knowledge of gastrointestinal physiology and the physiologic effects of foods can be used to design a dietary program for individual patients. Coordination of diet with drug therapy is an important part of a comprehensive treatment plan for these patients.