Nutrition Support Team Research Articles

ABSTRACT 94

Background and aims: Nutritional support may improve outcome during Pediatric Intensive Care Unit (PICU) stay, but guidelines are limited and based on consensus rather than evidence. Aims: We aimed to study current practice in nutritional management of PICUs worldwide. Methods: An online questionnaire, composed of 59 questions, was distributed to members of the World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS). The IRB waived the need for informed consent. Results: We analysed 189 questionnaires accounting for 89000 admissions in 156 PICUs covering 52 countries. A nutritional protocol and nutrition support team (NST) are present in respectively 52% and 57% of PICUs. Presence of a NST is associated with number of beds and admissions. Energy requirements are based on various equations and few PICUs use indirect calorimetry (14%). Lipid targets range from < 1.5 to > 3.5 g/kg/day, protein targets from 0.9 to 3 g/kg/day. Glucose administration during the first 24 hours varies from <2 to >10 mg/kg/min. Enteral nutrition (EN), preferably by gastric tube (68–88%), is started within 24 hours after admission in 60% of the PICUs. In 55% of the PICUs parenteral nutrition (PN) is started within 48 hours in patients intolerable to EN. Insufficient EN, providing < 50% or < 80% of target calories, is respectively supplemented with PN in 48% and 24% of PICUs. Conclusions: Nutritional practices, in terms of requirements, timing and route, are highly variable in PICUs worldwide. Even the limited available guidelines are not consistently followed. The potential impact on outcome warrants uniform evidence based guidelines with consistent implementation.

ABSTRACT 231

Background and aims: Critically ill children are at high risk of developing nutritional deficiencies, and hospital undernutrition is known to be a risk factor for morbidity and mortality in children. Clinical guidelines are used to standardize and provide better care in the intensive care unit. Aims: The study aims were to examine nutrition support practices before and after implementation of nutrition support guidelines in the PICU. Methods: Chart review of patients admitted to PICU (Oct-Nov 2012) and prospective data collection (Oct-Nov 2013). IRB approved. Educational interventions and training by the nutrition support team to all nursing and clinical staff completed during August 2013. Process measures included: dietary intake for the first 8 days, dietitian consult by day 3, and weekly monitoring criteria that included weight and laboratory parameters. Results: 113 patients: age 4.4 ± 6 yrs. and PICU length of stay (LOS) 7.2 ± 5 days; and 107 patients, 5.7 ± 6 yrs. and PICU LOS 6.1 ± 6 days from 2012 and 2013, respectively, were included.Table: No title available.Conclusions: Implementation of clinical guidelines in conjunction with educational efforts had a positive effect in the adequacy of nutrition support in critically ill children. Continued efforts by all the practitioners are needed to ensure sustained results.

Nutrition Support Team-Led Glycemic Control Program for Critically Ill Patients.

Glycemic control is an important component of the metabolic management of the critically ill patient. Nutrition support teams are frequently challenged by complicated patients who exhibit multiple concurrent etiologies for hyperglycemia. Nutrition support teams can serve in a pivotal role in the development and evaluation of safe and effective techniques for achieving glycemic control. This review describes the efforts of a nutrition support team in achieving safe and effective glycemic control at their institution. Identification of target blood glucose concentration range, development, initiation, monitoring of a continuous intravenous insulin infusion algorithm, nursing adherence to the algorithm, modification of the algorithm based on the presence of conditions that alter insulin metabolism and glucose homeostasis, and transition of the patient who receives continuous enteral nutrition from a continuous intravenous insulin infusion to intermittent subcutaneous insulin therapy are discussed.

Prise en charge nutritionnelle d’une patiente après allogreffe de cellules souches hématopoïétiques

Patients undergoing allogeneic stem cell transplantation (ASCT) after myeloablative conditioning (MAC) have a high incidence of malnutrition that is known to increase the risk of mortality. The case of this patient hospitalized in 2007 illustrates the standard of care developed by the nutritional support team (UTNC) of Lille University Hospital since the 2000s in such patients.

PP-017 Dysphagia patients need semisolid oral dosage forms prepared by thickening liquids

BackgroundDysphagic patients are at risk of protein-energy malnutrition and dehydration as well as being incompliant to pharmacotherapy. Causes of dysphagia include neurological conditions (such as stroke, dementia, paraplegia/tetraplegia), otorhinolaryngology (ORL)...

CP-150 Implementation of an integrated multifaceted approach to improve crushing practice on hospital wards

BackgroundCrushing tablets is an important risk factor for medicines administration errors in patients with swallowing problems and feeding tubes. Information regarding patients requiring crushed medicines does not routinely reach the...

A Tutorial on Enteral Access in Adult Patients in the Hospitalized Setting

Enteral access is a cornerstone in the provision of nutrition support. Early and adequate enteral support has consistently demonstrated improved patient outcomes throughout a wide range of illness. In patients unable to tolerate oral intake, multiple options of delivery are available to the clinician. Access requires a multidisciplinary effort that involves nurses, dietitians, and physicians to be successful. These techniques and procedures are not without morbidity and even mortality. A comprehensive understanding of the appropriate management of these tubes and their inherent complications should be garnered by all those involved with nutrition support teams. This tutorial reviews available options for enteral access in addition to commonly encountered complications and their management.

Suggestions for terminology in clinical nutrition

Summary Purpose The nomenclature in clinical nutrition differs locally, among (para)medical disciplines, and both nationally and internationally. The inconsistencies hamper public, professional and scientific discussions. A working group of the German Society of Nutritional Medicine (DGEM) was established to work out definitions for the relevant terms used in nutritional support within Germany. Methods Terms were searched in (inter)national hard print technical literature (medical dictionaries, text books, (inter)national guidelines and online (PubMed, Embase, CINAHL, Google Scholar, general internet). (Inter)nationally agreed definitions published by Clinical Nutrition Societies were preferred to other reports. Results The terms were organised into four categories totaling 53 definitions: 1. Fields and structure: medical nutrition, clinical nutrition, nutrition steering committee, nutritional care, care catering, dietetics (dietary advice), obesity as part of clinical nutrition (obesity team), nutritional support (nutrition support team, malnutrition screening, nutritional support therapy), functional nutrition, nutritional assessment, nutrition therapy plan, nutritional therapy, 2. Nutritional conditions: disease-related malnutrition (starvation induced malnutrition, chronic disease-related malnutrition, acute disease-related malnutrition), cachexia, sarcopenia, specific nutrient deficiencies, refeeding syndrome, 3. Forms of nutrition: diet (regular diet, therapeutic diet, fortified food), artificial nutritional support (oral nutritional supplementation, enteral nutrition, parenteral nutrition) 4. Products: oral nutritional supplements and enteral formulas (whole protein formula, peptide-based formula, free amino acid formula, standard formula), parenteral solutions (total nutrient admixtures, multi-chamber systems, multiple bottle systems). Conclusion A comprehensive list of definitions for terms in nutritional support has been established for the first time and is made available to the international community for further development and discussions.

Nutritional therapy in hospital

1987년 Detsky 등[1]은 소화기 수술 입원 환자 중 31%가 영양실조라고 보고하였고, 2003년도 Correia 등[2]은 라틴 아메리카의 병원 영양실조 유병률이 39-62%에 달한다고 하 였다. 2001년도 브라질의 Waitzberg 등[3]의 4,000명 입원 환자를 대상으로 한 연구 결과는 고도 영양실조와 중등도의 영양실조 유병률이 각각 12.6%, 35.5%로 환자의 거의 절반 에 가까운 유병률을 보였다. 한국정맥경장영양학회(Korean Society for Parenteral and Enteral Nutrition, KSPEN)에 서 2004년도 Parenteral and Enteral Nutrition Society of Globally, the prevalence of malnutrition in hospitals is high. In Korea, a recent national survey in which 28 general hospitals throughout the country participated showed a 22% prevalence of hospital malnutrition. Malnutrition is associated with adverse outcomes including immune suppression, muscle wasting, delayed wound healing, infectious complications, longer hospital stays, high medical costs, and even increased mortality. Early implementation of nutritional therapy might improve medical outcomes. For early recognition of malnutrition and early nutritional intervention, a qualified nutrition support team (NST) is necessary. In Korea, 110 NSTs were at work as of 2013, mostly affiliated with large high-ranking hospitals. Since the activity of an NST and enteral formula are not reimbursed by the National Health Insurance Corporation, the potential for expansion of NSTs to rather small hospitals remains limited. To improve the quality of care for hospitalized patients and reduce medical expenses nationally, it is time to reform the system for alleviating in-hospital malnutrition.

Development of a tool for quality control audits in hospital enteral nutrition.

Malnutrition is very prevalent in hospitals, causing physical capacity deterioration, increasing complications and raising mortality. This scenario overloads public health costs enormously. Enteral nutrition (EN) is the first option to fight against malnutrition. Nutrition support teams (NST) work combating such conditions, promoting humanization, but also analyzing the cost benefit of EN therapy. Brazil is one of the first Latin American countries to develop EN laws. Quality control it is in the core of this legal instrument, playing an essential role in NST`s task of providing care. Nowadays, tools to access quality control represent a gap in the area. The aim of this study was to develop a quality control tool, according to Brazilian law for EN Therapy regarding multidisciplinary approach, good practices, standard operating procedures, protocol implementation, proper registration and electronic health record. A content validation method was utilized in this four stages development process: bibliographic research, expert opinion (subjective), semantic evaluation and expert opinion (objective). In the latter stage ten specialists, expressed their opinion, evaluating the tools by four different attributes: utility, simplicity, objective and low cost on a 5-point Likert scale (1-5). We elaborate three independent tools that together, represent the whole evaluation process, named: NST Activities, EN Preparation and EN Administration. Content Validation Index to the four different attributes ranged form 0,9 to 1. This tool had positive approval from experts and is of great value guiding hospital audits, or even serving as checklist to implement a plan on EN therapy.

褥瘡に対するチーム医療と形成外科治療

A refractory pressure ulcer should be treated not only by surgery but also with team medical care in order to avoid recurrence after the initial treatment. At our hospital, plastic surgeons are responsible for organizing the team care. As part of the team care strategy, physical therapists (PTs) and occupational therapists (OTs) provide education to improve the mobility of spinal-cord-injury patients, e.g., improving muscle strength of the upper extremities for adequate transfer and ability to perform wheelchair push ups. For elderly patients, nurses assess the risk of pressure ulcer development using the Braden's scale and set up a nutrition support team. Additionally, if patients have difficulty swallowing, a speech therapist treats the dysphagia. And PTs and OTs treat their impaired activities of daily living. Finally, medical social workers arrange home-health-care services when the patient returns to their home. The management of chronic wounds has progressed from merely assessing the status of the wound to understanding the underlying molecular and cellular abnormalities that prevent the wound from healing. The concept of wound bed preparation, TIME, has simultaneously evolved to provide a systematic approach to removing the barriers to natural healing and enhancing the effectiveness of advanced therapies. Wound bed preparation and the TIME framework are most likely to be successful when used alongside the wound bed preparation care cycle.

The management of venous line for infusion after nutrition support team (NST) which spread in Japan

The management of venous line for infusion after nutrition support team (NST) which spread in Japan

点滴用脂肪乳剤の使用実態および適正使用への薬剤師の関与に関する現状調査

Pharmacists need to check prescriptions of parenteral lipid emulsions from various aspects due to the many difficulties that occur when administering them. Thus, we performed a questionnaire survey on the usage of and current involvement of pharmacists in administering parenteral lipid emulsions. Pharmaceutical departments of 381 institutions in Osaka Prefecture participated in this survey between June 1 and July 31, 2012. The questionnaire contained items including the characteristics of the hospital, usage of parenteral lipid emulsions, and current prescription-checking by pharmacists. A hundred and twelve institutions (29.4%) responded to the survey; parenteral lipid emulsions were used in 96 institutions. Some institutions appropriately used them but others did not. Additionally, in some institutions, pharmacists did not check the prescriptions for detailed items, such as the dosing rate and administration route. Furthermore, we observed a trend toward more items indicating the inappropriate use of these emulsions and less involvement of pharmacists in institutions without compared to with a nutrition support team (NST). These current situations were considered to largely relate to the number of pharmacists and whether NST therapists (pharmacists) are available. In the future, pharmacists should significantly contribute to nutritional and risk management in in-hospital team medicine.

IMPROVEMENT IN GROWTH AND DEVELOPMENTAL MILESTONES WITH NUTRITIONAL INTERVENTION IN METHYLMALONIC ACIDEMIA: A CASE REPORT

Introduction: methylmalonic acidemia (MMA) is a metabolic disorder and especial nutritional support has an important role in improvement of growth and development in these patients. Case presentation: A 3-month old female infant with known MMA was admitted to emergency department of Dr Sheikh Children Hospital with primary diagnosis of pneumonia and sepsis .This patient was a full term baby; MMA was diagnosed at 3th day of her life after several episodes of tachypnea, lethargia, poor feeding and irritability. After patient was stabilized, she was referred to nutritional support team for specialized MMA medical nutritional therapy. The patient’s growth and development improved significantly after 2 months of follow up.

Nutrition therapy in the intensive care unit

Nutrition therapy is challenging in critically ill patients. Critical illness is associated with a state of catabolic stress, in which stress hormones and inflammatory mediators are activated, resulting in proteolysis. The aim of nutrition therapy in critically ill patients is to preserve lean body mass, to preserve immune function, and to avoid metabolic complications. Enteral nutrition is preferred over parenteral nutrition. Enteral nutrition should be initiated within 24 to48 hours of intensive care unit admission. However, enteral nutrition should be withheld until the patient is fully resuscitated. If enteral nutrition is not feasible within several days, supplementary parenteral nutrition is necessary. In the acute phase, energy requirements should not be over 20 to 25 kcal/kg/d, and protein should be supplemented in the range of 1.2 to 2.0 g/kg/day. Monitoring tolerance is very important in critically ill patients with artificial nutrition to avoid complications. Immunonutrition such as glutamine and omega-3 fatty acid is helpful to modulate effects on the immune system in critically ill patients. Implementation of a feeding protocol and the involvement of a nutrition support team can systemize nutrition therapy. Together, these steps will hopefully enable the integration of evidence-based guidelines into practice, leading to improvements in nutrition performance so that patients’ chances of a good outcome are optimized.

Swallowing rehabilitation with nutrition therapy improves clinical outcome in patients with dysphagia at an acute care hospital.

Dysphagia is associated with nutritional deficits and increased risk of aspiration pneumonia. The aim of the present study was to evaluate the impact of nutrition therapy for the patients with dysphagia at an acute care hospital. We also tried to clarify the factors which improve swallowing function in these patients. Seventy patients with dysphagia were included in the present study. Multidisciplinary nutrition support team evaluated swallowing function and nutrition status. Most patients were fed by parenteral or enteral nutrition at the time of the first round. Of these 70 patients, 36 became able to eat orally. The improvement of swallowing function was associated with higher BMI in both genders and higher AMC in men. Mortality was high in the patients with lower BMI and %AMC, suggesting importance of maintaining muscle mass. Thirteen (38.2%) of 34 patients who did not show any improvement in swallowing function died, but no patients who showed improvement died (p<0.001). In addition, the patients with nutrition intake about<22 kcal/kg/day during follow-up period, showed significantly poorer recovery from dysphagia and poor outcome, compared to those with about>22 kcal/kg/day. These results suggest that it is important to maintain nutritional status to promote rehabilitation in patients with dysphagia even in an acute care hospital.

The Clinical Application Methods of the Nu-tritional Support Team

Eun Young Kim, Ju Mee Kim, Mi Hyung Kim, Taek Su Kwon, Hye Seung Lee, Hee Jung Mok, Jeong Im Hong, Hye Jin Kim, Hyun Kyung Kim, Sungjin Chung, In Kyu Lee. J Clin Nutr 2013;5:117-21. https://doi.org/10.15747/jcn.2013.5.3.117

The Investigation on the Development of Nutritional Support Team through the Consciousness Questionnaire to Residents

The Investigation on the Development of Nutritional Support Team through the Consciousness Questionnaire to Residents

Commercially Premixed 3-Chamber Bags for Pediatric Parenteral Nutrition Are Available for Hospitalized Children

Hospitalized children are vulnerable to malnutrition during serious illness or recovery from injury and are at subsequent risk of increased morbidity and growth retardation. In cases in which enteral nutrition is not possible, parenteral nutrition (PN) can be used to ensure that patients at nutritional risk receive appropriate amounts of macro- and micronutrients. Nutritional needs cannot be met by 1 standard PN formulation in pediatric patients (term to 18 y) because of the wide range of needs according to age, weight, degree of maturity, and disease state. Preparation of individualized PN is associated with several limitations, including prescribing errors, stability issues, and risk of infection. These risks may be avoided by the availability of a range of pediatric PN formulations provided as commercial premixed 3-chamber bags (3-CBs). These 3-CBs were developed in conjunction with experienced neonatologists and pediatricians in accordance with international guidelines. A prospective study has previously shown the practical handling and ease of use of 2 formulations of these 3-CBs, 1 designed for term infants and toddlers up to 2 y of age and 1 for children and adolescents aged 2–18 y. The majority of pharmacists and nurses described the 3-CB as easy to use and favored it over individual bottles, bags compounded on the ward, ready-to-use compounded bags, and premixes prepared by the pharmacy and tailored to patient needs. These formulations offer a means of improving the quality of care in hospital pediatric units, particularly in the absence of a nutrition support team.

Parenteral nutrition

Parenteral nutrition is an intravenous method of providing nutrition to patients by delivering nutrients directly into the bloodstream via a venous access device. It is prescribed by a specialist nutrition support team, which may include a pharmacist, specialist nutrition nurse, dietician and doctor, to ensure that it is given appropriately and safely.