Nutrition Support Practice Research Articles

Gastrointestinal Manifestations of COVID‐19: Impact on Nutrition Practices

Although Coronavirus disease 2019 (COVID‐19) is primarily a respiratory disease, growing evidence shows that it can affect the digestive system and present with gastrointestinal (GI) symptoms. Various nutrition societies have recently published their guidelines in context of the pandemic, and several points emphasize the impact of these GI manifestations on nutrition therapy. In patients with COVID‐19, the normal intestinal mucosa can be disrupted by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) virus, and this could result in GI symptoms and a compromise in nutrient absorption. Optimization of oral diet is still recommended. However, given the GI effects of COVID‐19, a fraction of infected patients have poor appetite and would not be able to meet their nutrition goals with oral diet alone. For this at‐risk group, which includes those who are critically ill, enteral nutrition is the preferred route to promote gut integrity and immune function. In carrying this out, nutrition support practices have been revised in such ways to mitigate viral transmission and adapt to the pandemic. All measures in the GI and nutrition care of patients are clustered to limit exposure of healthcare workers. Among patients admitted to intensive care units, a significant barrier is GI intolerance, and it appears to be exacerbated by significant GI involvement specific to the SARS‐CoV‐2 infection. Nevertheless, several countermeasures can be used to ease side effects. At the end of the spectrum in which intolerance persists, the threshold for switching to parenteral nutrition may need to be lowered.

Significant Published Articles for Pharmacy Nutrition Support Practice in 2019

The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2019 considered important to their clinical practice. The citation list was compiled into a single spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby at least 5 out of the 8 author participants considered the paper to be important. Guideline and consensus papers from professional organizations, important to practice but not ranked, were also included. Results: A total of 111 articles were identified; 6 from the primary literature were voted by the group to be of high importance. An additional 9 organizational guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were summarized and a narrative regarding its implications to pharmacy nutrition support practice were provided. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.

Nutrition support during allogeneic stem cell transplantation: evidence versus practice.

Enteral (EN) or parenteral nutrition (PN) is frequently required during allogeneic haematopoietic progenitor cell transplantation (HPCT), however there is limited consensus on the appropriate mode and timing of nutrition support commencement. This study aimed to investigate current nutrition support practices in Australian allogeneic transplant units and explore barriers and enablers to the use of EN and PN. All Australian adult allogeneic HPCT units were eligible to participate. A survey tool was developed, and phone interview with each unit dietitian was completed to explore current nutrition support and perceived barriers and enablers to provision of nutrition care. A total of 12 (100%) units agreed to participate. Six (50%) units reported using PN as standard care and six use EN routinely for one or more conditioning regimens. All units using EN place feeding tubes proactively with tolerance of EN reported at 50-95%. The most frequently reported barriers to the use of EN include perception of poor EN tolerance, medical team preference for PN, gastrointestinal symptoms and thrombocytopenia. Reported barriers to the use of PN include fluid overload, elevated liver enzymes, patient apprehension about PN commencement, medical team uncertainty if PN is required and patients approaching engraftment. There is wide variation in the mode and timing of nutrition support provided to patients undergoing allogeneic HPCT. Clinical guidelines should be updated to reflect recent findings on EN use and incorporate strategies to optimise EN tolerance. This will assist in standardising practice and facilitate evidence-based nutrition care.

Elimination of Routine Gastric Residual Volume Monitoring Improves Patient Outcomes in Adult Critically Ill Patients in a Community Hospital Setting.

A community hospital updated its nutrition support practices in 2016 through the elimination of monitoring gastric residual volume (GRV) in accordance with the 2016 Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. This retrospective analysis (N=61) compared incidence of feeding intolerance in 2 cohorts of adult critically ill patients pre-implementation (n=36) and post-implementation (n=25) of these guidelines into a nutrition support team's standard of practice policy. Differences in kilocalories and protein (gm) received and percent of daily prescribed kilocalories and protein received were also compared between the 2 cohorts. Mean episodes of gastrointestinal intolerance over the number of eligible days of receiving enteral nutrition in the critical care unit did not differ between the pre-implementation and post-implementation groups (P= 0.46). Compared with the pre-implementation group, the post-guideline implementation cohort was significantly more likely to meet higher percentages of both prescribed protein (71.8±22.2% vs 55.9±24.0%; P= 0.01) and energy requirements (93.4±36.9% vs 69.6±35.3%; P= 0.01), even after adjusting for potential confounders (age, body mass index, sex, and primary comorbid medical condition). Elimination of routine monitoring of GRV may result in a greater percentage of prescribed daily nutrient requirements met by patients in the critical care setting, without adverse effects on feeding intolerance.

Nutritional support practices among intensive care units in Turkey: One-day cross-sectional study

Objective: Malnutrition is a significant problem among critically ill patients and is closely associated with poorer patient outcomes. With this study, we aimed to assess nutritional support practices and to evaluate the associated patient outcomes in intensive care units (ICU) in Turkey. Methods: This one-day, cross-sectional study was conducted in November 2015. A total of 1140 patients from 120 ICUs in 46 hospitals across Turkey were included. The general characteristics of the ICUs and patients, clinical data regarding nutritional support, hospitalization courses of the patients, and patient outcomes were recorded. The study questionnaire was prepared by the investigators and was completed by health care professionals from various hospital departments. Results: The mean age of the patients (55.7% were men) was 66.8±18.0 years. The median duration of the ICU stay was 17 days. Enteral tubes were present in 649 patients, of whom 79.4% had nasogastric tubes, 15.3% had percutaneous endoscopic gastrostomy (PEG) tubes, 4% had nasojejunal tubes, and 1.4% had surgical gastrostomy/jejunostomy tubes. 68.1% of ICUs had a nutritional support team. Nutritional support applied included enteral nutrition (44.1%), oral nutrition (25.9%), parenteral nutrition (18.5%), and enteral + parenteral nutrition (11.5%). On the 60th day, the mortality rate was 39.5%. Mortality rates were significantly lower in the oral nutrition group compared with the other groups, and were significantly higher in the parenteral nutrition group compared with the other groups. Conclusion: Our findings confirm the importance of nutritional support teams to provide timely and adequate administration of nutritional support and its association with better patient outcomes. Additionally, better outcomes were obtained with enteral nutrition compared with parenteral nutrition.

Neonatal dietitian resourcing and roles in New Zealand and Australia: A survey of current practice.

Dietitian-led implementation of evidence-based nutrition support practices improves nutrient intakes, clinical outcomes and growth, decreases length of stay and related costs, and reduces intravenous nutrition costs and prescription errors. We aimed to investigate current neonatal dietitian resourcing and roles in New Zealand and Australian neonatal units, and to compare this with dietitian workforce recommendations and previously reported survey data. A two-part electronic survey was emailed to 50 Australasian Neonatal Dietitians Network members and other dietitians working in neonatal intensive care or special care baby units in New Zealand and Australia. The survey ran from July to October 2018. Descriptive statistics were used to examine the distribution of responses. Responses were compared with other similar surveys and British Dietetic Association workforce recommendations. There was an 88% response rate for Part 1. Forty-eight percent of respondents had worked in neonatology for more than 5 years. Ward rounds were attended weekly or more often by 43% of respondents. One-third regularly attended neonatal conferences or grand rounds. The majority spent less than 25% of their neonatal service allocation on teaching, developing policy or research. All respondents reported their unit had written enteral feeding guidelines. The neonatal dietitian workforce is at 23% of recommended levels. Australasian neonatal dietitians have great potential to add value in neonatal units which has not yet been fully realised. Funding reallocation, upskilling and on-going professional development are needed to ensure the neonatal dietitian workforce is at the recommended level to be safe, sustainable and effective.

Hotspot issues and countermeasures in nutritional support treatment for critically ill surgical patients

Nutritional therapy is one of the most important treatment measures for surgical critically ill patients, and it is also a difficult point in clinical nutritional support practice. In recent years, nutritional support treatment for surgical critically ill patients has achieved rapid development both in theory and practice. Many large-scale, multi-center clinical studies have been completed worldwide. Consensus has been formed on many hot issues and relevant guidelines have been issued. Based on the latest evidence-based medicine achievements, the author summarizes and interprets the hot and controversial issues of nutritional therapy for surgical critically ill patients in recent years. Key words: Critical illness; Surgery; Nutritional support; Parenteral nutrition; Enteral nutrition

Parenteral nutrition prolongs hospital stay in children with nonoperative blunt pancreatic injury: A propensity score weighted analysis

BackgroundBlunt pancreatic injury is frequently managed nonoperatively in children. Nutritional support practices – either enteral or parenteral – are heterogeneous and lack evidence-based guidelines. We hypothesized that use of parenteral nutrition (PN) in children with nonoperatively managed blunt pancreatic injury would 1) be associated with longer hospital stay and more frequent complications, and 2) differ in frequency by trauma center type. MethodsWe conducted a retrospective cohort study using the National Trauma Data Bank (2007–2016). Children (≤18 years) with blunt pancreatic injury were included. Patients were excluded for duodenal injury, mortality <4 days from admission, or laparotomy. We compared children that received versus those that did not receive PN. Logistic regression was used to model patient characteristics, injury severity, and trauma center type as predictors for propensity to receive PN. Treatment groups were balanced using the inverse probability of treatment weights. Outcomes included hospital length of stay, intensive care unit days, incidence of complications and mortality. Results554 children with blunt pancreatic injury were analyzed. PN use declined in adult centers from 2012 to 2016, but remained relatively stable in pediatric centers. Propensity-weighted analysis demonstrated longer median length of stay in patients receiving PN (14 versus 4 days, rate ratio 2.19 [95% CI: 1.97, 2.43]). Children receiving PN also had longer ICU stay (rate ratio 1.73 [95% CI: 1.30, 2.30]). There was no significant difference in incidence of complications or mortality. ConclusionsUse of PN in children with blunt pancreatic injury that are managed nonoperatively differs between adult and pediatric trauma centers, and is associated with longer hospital stay. Early enteral feeding should be attempted first, with PN reserved for children with prolonged intolerance to enteral feeds. Level of evidenceIII, Retrospective cohort.

Significant Published Articles for Pharmacy Nutrition Support Practice in 2018.

Purpose: The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2018 considered important to their clinical practice. The citation list was compiled into a single spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby the majority of author participants (at least 5 of 8) considered the paper to be important. Guideline and consensus papers from professional organizations, important to practice but not scored, were also included. Results: A total of 117 articles were identified; 8 from the primary literature were voted by the group to be of high importance. An additional 13 organizational guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were reviewed. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.

Changes in clinical practice of home enteral nutritional support in a reference pediatric hospital

Changes in clinical practice of home enteral nutritional support in a reference pediatric hospital

Significant Published Articles for Pharmacy Nutrition Support Practice in 2017.

Purpose: The purpose of the article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2017 considered important to their clinical practice. The citation list was compiled into a spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby the majority (at least 5 out of 8 authors) considered the article to be of significance. Guideline and consensus articles from professional organizations, important to practice but not scored, were also included. Results: A total of 95 articles were identified; six from the primary literature were voted by the group to be of high importance. An additional 13 organizational guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were reviewed. Conclusion: It is recommended that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.

Nutrition in the ICU: new trends versus old-fashioned standard enteral feeding?

The narrative review aims to summarize the relevant studies from the last 2 years and provide contextual information to understand findings. Recent ICU studies have provided insight in the pathophysiology and time course of catabolism, anabolic resistance, and metabolic and endocrine derangements interacting with the provision of calories and proteins.Early provision of high protein intake and caloric overfeeding may confer harm. Refeeding syndrome warrants caloric restriction and to identify patients at risk phosphate monitoring is mandatory.Infectious complications of parenteral nutrition are associated with overfeeding. In recent studies enteral nutrition is no longer superior over parenteral nutrition.Previously reported benefits of glutamine, selenium, and fish oil seem to have vanished in recent studies; however, studies on vitamin C, thiamine, and corticosteroid combinations show promising results. Studies from the last 2 years will have marked impact on future nutritional support strategies and practice guidelines for critical care nutrition as they challenge several old-fashioned concepts.

Rethink about the implement of enteral nutrition support in neurointensive care unit patients

The viewpoint of early enteral nutrition support in neurointensive care unit patients has gradually developed. In order to enable patients to achieve the nutritional goal, it is very important to give neurointensive care unit patients early enteral nutrition support and prevent gastrointestinal complications. Standard practice of enteral nutrition support in neurointensive care unit patients is imperative to effectively carry out clinical practice guidelines, optimize the nursing process, solve the clinical problems and make sure the safety of implement of enteral nutrition support. Key words: Rethink; Neurointensive care unit; Enteral nutrition; Standard practice

Can the critically ill patient generate sufficient energy to facilitate exercise in the ICU?

Trials of physical rehabilitation post critical illness have yet to deliver improved health-related quality of life in critical illness survivors. Muscle mass and strength are lost rapidly in critical illness and a proportion of patients continue to do so resulting in increased mortality and functional disability. Addressing this issue is therefore fundamental for recovery from critical illness. Altered mitochondrial function occurs in the critically ill and is likely to result in decreased adenosine tri-phosphate (ATP) production. Muscle contraction is a process that requires ATP. The metabolic demands of exercise are poorly understood in the ICU setting. Recent research has highlighted that there is significant heterogeneity in energy requirements between critically ill individuals undertaking the same functional activities, such as sit-to-stand. Nutrition in the critically ill is currently thought of in terms of carbohydrates, fat and protein. It may be that we need to consider nutrition in a more contextual manner such as energy generation or management of protein homeostasis. Current nutritional support practices in critically ill patients do not lead to improvements in physical and functional outcomes, and it may be that alternative methods of delivery or substrates are needed.

Adequacy of nutrition support during extracorporeal membrane oxygenation

The use of veno-venous extracorporeal membrane oxygenation (vv-ECMO) is increasing in adults with severe respiratory failure. Observational data suggest that there are significant challenges to providing adequate nutrition support for patients on vv-ECMO. We aimed to describe firstly the nutrition support practices in a large single-centre providing vv-ECMO to adults and secondly any association with clinical outcome. We conducted a retrospective review of patients receiving vv-ECMO on the Intensive Care Unit (ICU) of a large London teaching hospital. Adult patients admitted to the ICU with severe respiratory failure between December 2010 and December 2015 were included. Daily energy and protein delivery were compared with estimated targets and reasons for feeding interruptions were collected from electronic medical records. Adequate feeding was defined as 80-110% of estimated targets. We analysed 203 eligible patients. Median duration of ICU stay was 21.0 (IQR, 15.0-33.0) days and vv-ECMO 10.0 (IQR, 7.0-16.0) days. Although median energy (89.8% (IQR, 80.5-96.0%)) and protein (84.7% (IQR, 74.0-96.7%)) delivery was adequate, underfeeding of either energy or protein occurred on nearly one third (28.3%) of nutrition support days. A higher admission severity of illness score was associated with inadequate protein delivery (p=0.040). Patients with more severe organ dysfunction on the first day of vv-ECMO received inadequate energy (p=0.026). The most common reasons for interrupted feeding were medical procedures (39.1%) followed by poor gastric motility (22.8%). Adequate energy and protein delivery during vv-ECMO is possible but underfeeding is still common, especially in those who are more severely ill or who have more severe organ dysfunction. Patients with inadequate energy or protein delivery did not differ in ICU and 6-month survival. Prospective studies investigating optimal feeding in this patient cohort are required.

Nutritional Care in Iranian Intensive Care Units.

Intensive care units (ICUs) provides intensive treatment medicine to avoid complications such as malnutrition, infection and even death. As very little is currently known about the nutritional practices in Iranian ICUs, this study attempted to assess the various aspects of current nutrition support practices in Iranian ICUs. We conducted a cross-sectional study on 150 critically ill patients at 18 ICUs in 12 hospitals located in 2 provinces of Iran from February 2015 to March 2016. Data were collected through interview with supervisors of ICUs, medical record reviews and direct observation of patients during feeding. Our study showed that hospital-prepared enteral tube feeding formulas are the main formulas used in Iranian hospitals. None of the dietitians worked exclusively an ICU and only 30% of patients received diet counselling. Regular monitoring of nutritional status, daily energy and protein intake were not recorded in any of the participating ICUs. Patients were not monitored for anthropometric measurements such as mid-arm circumference (MAC) and electrolyte status. The nasogastric tube was not switched to percutaneous endoscopic gastrostomy or jejunostomy (PEG/PEGJ) in approximately 85% of patients receiving long-term enteral nutrition (EN) support. Our findings demonstrated that the quality of nutritional care was inappropriate in Iranian ICUs and improvement of nutritional care services within Iranian ICUs is necessary.

A review of best evidenced-based enteral and parenteral nutrition support practices for preterm infants born &lt;1,500 grams

Nutrition monitoring must remain a priority for very low birth weight infants who are at high risk for nutritional deficiencies and growth failure. Research demonstrates that as many as 50% of North American infants experience extrauterine growth failure, primarily attributable to inadequate nutrition delivery. Consequently, the purpose of this review is to identify the best enteral and parenteral nutrition management practices for preterm infants born <1,500 grams. Nutrition recommendations set forth for preterm infants by leading references were reviewed and compared. Infant nutrition and growth studies identified by extensive literature review were also assessed in comparison to current recommendations, neonatal clinical experience, and gaps within clinical practice. Modern literature demonstrates that more aggressive parenteral nutrition provision, early enteral feeding initiation, more rapid enteral feeding advancement, and early human milk fortification are well tolerated and promote improved nutrition, growth, and clinical outcomes. This review identifies clinically feasible and evidenced-based enteral and parenteral nutrition support practices that promote best outcomes for very low birth weight infants.

Maximizing Nutrition Support Practice and Measuring Adherence to Nutrition Support Guidelines in a Canadian Tertiary Care ICU.

New comprehensive guidelines for nutrition support (NS) in the intensive care unit (ICU) can be used to improve quality of care and benchmark current practice. The objective of this study was to (a) compare NS practices in our medical/surgical ICU (MSICU) to 18 recommendations described in the Canadian Clinical Practice Guidelines and Society of Critical Care Medicine/American Society of Parenteral and Enteral Nutrition guidelines, (b) determine the percentage of goal calories and protein delivered, and (c) identify the barriers to successful NS delivery. This was a prospective observation trial of up to 14 days duration. A 24-bed MSICU in a tertiary teaching hospital in Toronto, Canada. We studied 98 mechanically ventilated patients with any diagnosis who were expected to require either enteral nutrition (EN) or parenteral nutrition (PN) for >48 hours. We measured nutritional intake, barriers to nutritional intake, and parameters that allowed comparison of our practice to 18 guidelines. Mean delivery of protein and energy was 79.3% and 81.1% of goal, respectively. The average time to initiation of EN support was 29.5 ± 23.7 hours. The 3 main reasons for interruption to enteral feeding were airway management issues, procedures, and gastrointestinal intolerance. Enteral feeding during vasopressor therapy was well tolerated. Ten of the 18 guidelines were followed for ≥80% of the time. Protein goals for patients on renal replacement therapy and patients with liver disease were not reached. Head-of-bed positioning was also inadequate. The 13 patients requiring PN all had appropriate indications for this therapy, including gastrointestinal leaks, maldigestion, or malabsorption. Nutrition support delivery was successful for most patients in this study. However, only 10 of the 18 guidelines were adequately followed. This study helped identify NS practices that work well and others that require strategies for improvement.

Evaluation of nutrition support practices: Results from a nationwide survey

Multiple clinical guidelines are available to improve and standardize the delivery of nutrition support. However, recommendations are not being universally applied at the bedside due to challenges of resources and barriers of knowledge. Assessing the current level of nutrition support practice is the first step to understand the barriers and ultimately implement potential strategies to increase guideline adherence and promote quality nutrition support in hospitals. There are no published data concerning the practice of nutrition support in Lebanese hospitals. The objective of our study is to investigate for the first time the current clinical practice pertinent to nutrition support across Lebanon. A survey was developed by The Nutrition Board of the Lebanese Society of Critical Care Medicine (LSCCM) to determine nutrition support practices in hospitals with an Intensive Care Unit (ICU) across Lebanon. The 28-question survey assesses the delivery of feeding methods such as oral nutrition supplements (ONS), enteral nutrition (EN), and parenteral nutrition (PN). Fourty-one hospitals from 116 total completed the survey. The majority of the hospitals (92.6%) do not systematically use a screening system for malnutrition. Seventy six percent of hospitals reported less than 5% of their patients are kept for more than 7 days with no nutrition support. Early EN is used in preference over PN in ICUs, as 72% of hospitals start early EN (within 48h) in more than 10% of cases while only 30% of hospitals start early PN (within the first week) in more than 10% of cases. Fifty-one percent of the hospitals use ready prepared formula while the rest (49%) use kitchen prepared formula. Our study is the first of its kind in Lebanon aiming at describing the current clinical practice in nutrition support at a national level. Working toward the use of a nutritional screening tool on admission and the exclusive use of ready made formula for enteral feeding will have the most significant and immediate impact on improving quality of nutritional care for hospitalized patients. This can be achieved mainly through the education of the concerned staff.

SUN-P148: Exploring Nutritional Support Practices in Renal Nurses in Hemodialysis Units Worldwide – Results of a Pilot Study

SUN-P148: Exploring Nutritional Support Practices in Renal Nurses in Hemodialysis Units Worldwide – Results of a Pilot Study