Method Of Nutritional Support Research Articles

Retrospective Evaluation of Parenteral Nutrition in Alpacas: 22 Cases (2002–2008)

Parenteral nutrition is an important method of nutritional support in hospitalized animals, but minimal information has been published on its use in camelids. The purpose of this study was to characterize the use of total parenteral nutrition (TPN) in alpacas, evaluate the formulations used, and determine potential complications. Twenty-two alpacas hospitalized at the Tufts Cummings School for Veterinary Medicine (site 1: n = 8) and the Ohio State University Veterinary Teaching Hospital (site 2: n = 14). A retrospective analysis of all alpacas that received TPN between 2002 and 2008 was performed to assess clinical indications, clinical and clinicopathologic data, and outcome. The most common underlying diseases in animals receiving TPN were gastrointestinal dysfunction (n = 16), hepatic disease (n = 2), and neoplasia (n = 2). Several metabolic abnormalities were identified in animals (n = 20/22) before TPN was initiated, including lipemia (n = 12/22), hyperglycemia (11/22), and hypokalemia (n = 11/22). Median age was significantly lower for site 1 cases (0.1 years; range, 0.01-11.0) compared with those from site 2 (4.9 years; range, 0.1-13.7; P = .03). Animals at site 2 also had a longer duration of hospitalization (P = .01) and TPN administration (P = .004), as well as higher survival rate (P < .02). Twenty-one of 22 alpacas developed at least 1 complication during TPN administration. Metabolic complications were most prevalent (n = 21/22) and included hyperglycemia (n = 8/21), lipemia (n = 7/21), hypokalemia (n = 3/21), and refeeding syndrome (n = 3/21). TPN is a feasible method of nutritional support for alpacas when enteral feeding is not possible. Prospective studies are warranted to determine optimal TPN formulations for alpacas.

A rare complication of jejunostomy tube: Enteral migration

Feeding jejunal tubes provide an excellent method for enteral nutritional support in cases where the oral route is impossible or insufficient for use. However, several complications may result from the placement of the tube. Detachment of the tube and migration through the intestine is a very rare complication. We report herein a 65-year-old male patient in whom a jejunal feeding tube (28-F Pezzer catheter) was placed two months before due to unresectable gastric cancer. He presented with disappearance of the tube and abdominal pain. Radiological investigations showed the tube localized in the lumen of the small intestine and its advancement through the gut. Conservative measures were taken as there was neither intestinal obstruction nor peritonitis. The tube passed spontaneously through the rectum 18 days later. One should be careful during the placement of jejunostomy tubes, and health care providers and patients should be instructed well in the care of feeding enterostomy tubes in order to prevent this complication.

Long-Term Results of Percutaneous Radiologic Gastrostomy and Gastrojejunostomy in Children With Emphasis on Technique: Single or Double Gastropexy?

The purpose of this article is to evaluate the safety and efficacy of radiologic gastrostomy and gastrojejunostomy in children, with an emphasis on the comparison of single and double gastropexy. Between January 2000 and May 2009, a total of 91 percutaneous tubes (77 gastrostomies and 14 gastrojejunostomies) were placed in 90 patients. Patients' ages ranged from 4 months to 16.5 years. Gastropexy was performed in all cases. The first 50 children underwent double gastropexy, and 40 children underwent single gastropexy. In single gastropexy, two different punctures were performed each for the anchor and the tube. Differences in the incidence of major and minor complications and tube maintenance problems between the single- and double-gastropexy groups were retrospectively analyzed by use of Fisher's exact test. The technical success rate was 100%. No procedure-related mortality or morbidity was detected. The overall major and minor complication rates were 4.4% and 16.7%, respectively. The mean follow-up period was 463 days. Twenty-nine tube maintenance problems were detected in 17 patients. There were four major complications (two cases of aspiration pneumonia and two site infections that required hospitalization). Minor complications occurred in 15 patients (nine localized site infections, two cases of gastroesophageal reflux, and four tube maintenance problems requiring secondary intervention). In total, 26 and 22 complications and tube maintenance problems occurred in the single- and double-gastropexy groups, respectively. No statistically significant difference was detected between the two groups in terms of complications (p > 0.005). Radiologic gastrostomy and gastrojejunostomy are safe and effective methods for long-term nutritional support in children. Single gastropexy should be performed with two different punctures for each retention suture and the tube.

Nutrition in Head and Neck Cancer Patients

Anorexia and cachexia frequently complicate the late stages of malignancy and can be a prominent feature of early disease. The resulting weight loss significantly affects the morbidity and mortality of the cancer patient. A fundamental understanding of nutrition and the pathophysiology of cancer cachexia will aid in diligent treatment decisions to achieve optimal results. The pathophysiology of cancer cachexia is discussed, together with methods of nutritional assessment, nutritional requirements, and postoperative nutritional support. The advantages and disadvantages of the various modes of parenteral and enteral feeding are presented, together with information about enteral feeding in the home.

Markers of Brain Damage in Severe Concomitant Injury

The paper describes a clinical case of early enteral feeding with an immune formula in a patient with significant heart failure after cardiosurgical intervention who is on venoarterial extracorporeal membrane oxygenation. The safety and efficiency of nutritional support were monitored, by estimating blood acid-base balance and oxygenation level and by controlling the residual gastric volume, which enabled the volume of the given enteral mixture to be increased up to 2600 kcal by day 3, by providing the body’s energy needs determined by calculation techniques. On postoperative day 4 when hemodynamic parameters were satisfactory, extracorporeal membrane oxygenation was disconnected; following 7 days the patient was weaned from artificial ventilation. The length of intensive care unit stay was 14 days. The patient was discharged from hospital in a satisfactory condition. Thus, early enteral feeding may be a safe and effective method of nutritional support in patients on extracorporeal circulation. Key words: extracorporeal membrane oxygenation, early enteral feeding, immune nutrition, cardiosurgery.

PTH-056 Enteral nutritional support via the mucous fistula: feasibility and safety in post-operative patients

Introduction Abdominal surgery with small bowel (SB) resection may require delayed anastomosis with the formation of a temporary defunctioning end stoma and mucous fistula (MF). If sited proximally, this may result in a short bowel in the proximal limb with redundant longer bowel in the distal limb. Oral/nasogastric (NG) intake may induce uncontrolled stomal fluid (>2.5 l/day) and electrolyte losses leading to prolonged hospital admission or parenteral support. The distal bowel can be utilised for absorption of nutrition, fluids and electrolytes if sufficient in length and accessible via the MF. However, the viability and safety of small bowel MF enteral support has been poorly reported. We present a case series of our experience in a busy district general hospital. Methods Referred post-operative patients with a MF who demonstrated metabolic and nutritional instability on oral/NG intake due to uncontrolled stoma losses were assessed for MF feeding. A 14 French Foley catheter was inserted into the MF through a universal catheter access port placed into a windowed stoma bag and connected to standard enteral feeding apparatus. Elemental feed, rehydration fluids, electrolytes or nutritional supplements were administered to meet the patient9s requirements using standard methods of jejunal feeding. Proximal stoma output was monitored and oral dietary intake reduced if necessary. Results Between February 2007 and October 2008 eight patients were found to be appropriate for a trial of MF feeding. All patients had undergone SB resection with residual proximal small bowel length ranging from 75 to 150 cm (mean 116 cm) from the DJ flexure; all had distal SB length >1 m with a viable large bowel in continuity. Patients reported initial difficulties in assembling the feeding tube and access port via the stoma window, however with training all gained competency allowing home discharge with telephone and clinic support. The universal catheter access port allowed a water tight seal, and leakage around the feeding tube was negligible. There were no major metabolic complications of MF feeding including those patients who remained on controlled oral intake. All patients received enteral support for a minimum of 3 months prior to assessment for surgical anastomosis. In our study group 5 patients had delayed anastomosis and three died of causes unrelated to MF feeding. Conclusion MF feeding is a safe and effective method for nutritional support in appropriate patients and may allow home discharge in the presence of a high output proximal stoma. The use of a Foley catheter as a feeding tube and a simple catheter port allowed inexpensive and simple means of access. However, dedicated training, support and monitoring may be required to allow home discharge.

Endoscopic placement of enteral feeding tubes.

Malnutrition is common in patients with acute and chronic illness. Nutritional management of these malnourished patients is an essential part of healthcare. Enteral feeding is one component of nutritional support. It is the preferred method of nutritional support in patients that are not receiving adequate oral nutrition and have a functioning gastrointestinal tract (GIT). This method of nutritional support has undergone progression over recent times. The method of placement of enteral feeding tubes has evolved due to development of new feeding tubes and endoscopic technology. Enteral feeding can be divided into methods that provide short-term and long-term access to the GIT. This review article focuses on the current range of methods of gaining access to the GIT to provide enteral feed.

Factor XIII Concentrate Is Effective In Persistent Infection Of PEG Site.

Percutaneous endoscopic gastrostomy (PEG) administration of enteral feeds is the most commonly used method of nutritional support for patients in the community. PEG tube was placed by the standard technique without difficulty, but persistent infection of PEG site was discovered. Plasma factor XIII is participated in tissue remodeling and wound healing. We administrated factor XIII concentrate, as a result, the PEG site healed without intervention. We report the effect on fibrinolysis of factor XIII concentrate.

Nutritional Support To Critically Ill Patients - A Comparative Study Between Branded and Homemade Preparations

We have evaluated the effectiveness of nutritional support to critically ill patients undergoing treatment in ICU. We provided commercially prepared branded food in one group and compared this, with those of homemade preparations. Fifty adult critically ill patients getting treatment in ICU aged between 20 to 60 years having no diabetes, hypertension, ischaemic heart disease and chronic renal failure, were scheduled for providing enterai nutritional support. They were randomly allocated into two groups. Group A (n=25) received commercially prepared branded food containing balanced food consisting of protein, fat, and carbohydrate in calculated proportion. The aim was to provide 2500 Kcal of energy per day for an average adult in his/her critical state. Group B (n=25) received homemade food preparations in proper proportion of those of group A and of equal calories. The purpose of the study was to assess, formulate and compare the efficacy, tolerability and cost effectiveness of homemade prepared food with commercially formulated branded food in maintaining nutritional status of critically ill patient in ICU. Patient's nutritional assessment was done before the commencement of nutritional support, Nutritional assessment was repeated weekly for successive two weeks. Group A showed better result than Group B, significant improvement has been observed also in group B and the differences between two groups are statistically not significant Both the methods of nutritional support were adequate and effective in maintaining the nutritional status. Considering the poor socioeconomic environment in an under developed country like Bangladesh, a less costly homemade preparation can be an effective alternative over the branded food. Journal of BSA, Vol. 20, No. 1, January 2007 p.18-23

Gastric Outlet Obstruction and Pancreatitis Caused By Migrated Gastrostomy Tube: A Rare Scenario

Purpose: Percutaneous Endoscopic Gastrostomy (PEG) is a very common method of enteral nutritional support. The most common indication for PEG tube placement is oropharyngeal dysphagia secondary to cerebrovascular accident, advanced dementia, and benign and malignant oropharyngeal and esophageal obstruction. Use of PEG tube feeding has increased exponentially since its introduction in 1980. Major complications of PEG include aspiration, hemorrhage, peritonitis and rarely necrotizing fasciitis and tumor implantation. Minor complications include ileus, peri-stomal infection, stomal leakage, buried bumper, gastric ulcer, fistulous tracts and inadvertent removal. We report a case of gastric outlet obstruction and pancreatitis induced by migrated PEG tube. The migrated inner balloon of the PEG-tube blocked the duodenum causing gastric outlet obstruction and obstructed Ampulla of Vater leading to acute pancreatitis. The presenting symptoms rapidly resolved after prompt diagnosis and PEG tube repositioning. Case Report: An 83-year-old female nursing home resident with PEG tube feeding presented with two episodes of projectile vomiting. On physical examination at the time of admission, her vital signs were within normal limit and abdominal exam was benign. Admission labs showed Amylase - 460 U/L, Lipase - 291 IU/L, Total Bilirubin - 0.3 mg/dl, Direct Bilirubin - 0.1 mg/dl, ALP - 109 IU/L, AST - 102 U/L and ALT - 80 U/L. Abdominal sonogram excluded cholelithiasis or cholecystitis. However, CT abdomen revealed gastrostomy tube's balloon migrated in the duodenal bulb. The balloon was repositioned by deflating and then reinflating. Vomiting resolved and LFTs, amylase and lipase dramatically improved. Two days after admission, labs showed Amylase - 162, Lipase - 78, ALP - 80, AST - 25 and ALT - 42. Repositioning of the external bumper at mark 3-4 as needed will prevent PEG tube migration and related complications.

ESPEN Guidelines on Parenteral Nutrition: Geriatrics

Older subjects are at increased risk of partial or complete loss of independence due to acute and/or chronic disease and often of concomitant protein caloric malnutrition. Nutritional care and support should be an indispensable part of their management. Enteral nutrition is always the first choice for nutrition support. However, when patients cannot meet their nutritional requirements adequately via the enteral route, parenteral nutrition (PN) is indicated. PN is a safe and effective therapeutic procedure and age per se is not a reason to exclude patients from this treatment. The use of PN should always be balanced against a realistic chance of improvement in the general condition of the patient. Lower glucose tolerance, electrolyte and micronutrient deficiencies and lower fluid tolerance should be assumed in older patients treated by PN. Parenteral nutrition can be administered either via peripheral or central veins. Subcutaneous administration is also a possible solution for basic hydration of moderately dehydrated subjects. In the terminal, demented or dying patient the use of PN or hydration should only be given in accordance with other palliative treatments.

Actual Burn Nutrition Care Practices: An Update

In 1989, Williamson published a survey of nutrition care practices in burn centers. Nutrition practices have evolved since then; we conducted a study to determine the current scope of nutrition care in burn centers. With IRB approval, a 64 question survey was emailed to 103 burn centers listed in the Burn Care Resources in North America. Follow-up emails were sent to those who did not respond within 2 weeks. Sixty-five centers (63%) responded and included 66% of currently verified burn centers. Due to incomplete surveys, most questions had 45 to 50 responses. The centers averaged 246 annual admissions and all admitted non-burn patients. Eighty percent of dietitians had >5 years burn experience (vs 17% in 1989) and 90% also worked in other intensive care settings. Most dietitians reported advanced training or education (83%). Nutrition assessment, support and monitoring methods have changed though most centers continue to use serum proteins for assessment. Indirect calorimetry use has increased with most centers (78%) adding a 'stress factor' of 10 to 30% above measured energy needs. More centers provided specialized formulas including high-protein (82 vs 8.8%) and immune-enhancing (53 vs 12.3%) than in 1989. All gave a variety of vitamin and mineral supplements. Anabolic steroid and glutamine use was common (92 and 69%). Eighty percent of centers used glucose protocols with 54% having a goal of <or=120 mg/dl; another 42% used 121 to 150 mg/dl as a target. Burn dietitians reported more experience than previously documented but continued to work in other intensive care unit areas. The use of calorimetry and glucose control protocols increased in the past 20 years as did the use of anabolic steroids and supplements. Variability continued in assessment (particularly calorie estimates) and monitoring methods.

Medication administration through enteral feeding tubes

An overview of enteral feeding tubes, drug administration techniques, considerations for dosage form selection, common drug interactions with enteral formulas, and methods to minimize tube occlusion is given. Enteral nutrition through a feeding tube is the preferred method of nutrition support in patients who have a functioning gastrointestinal tract but who are unable to be fed orally. This method of delivering nutrition is also commonly used for administering medications when patients cannot swallow safely. However, several issues must be considered with concurrent administration of oral medications and enteral formulas. Incorrect administration methods may result in clogged feeding tubes, decreased drug efficacy, increased adverse effects, or drug-formula incompatibilities. Various enteral feeding tubes are available and are typically classified by site of insertion and location of the distal tip of the feeding tube. Liquid medications, particularly elixirs and suspensions, are preferred for enteral administration; however, these formulations may be hypertonic or contain large amounts of sorbitol, and these properties increase the potential for adverse effects. Before solid dosage forms are administered through the feeding tube, it should be determined if the medications are suitable for manipulation, such as crushing a tablet or opening a capsule. Medications should not be added directly to the enteral formula, and feeding tubes should be properly flushed with water before and after each medication is administered. To minimize drug-nutrient interactions, special considerations should be taken when administering phenytoin, carbamazepine, warfarin, fluoroquinolones, and proton pump inhibitors via feeding tubes. Precautions should be implemented to prevent tube occlusions, and immediate intervention is required when blockages occur. Successful drug delivery through enteral feeding tubes requires consideration of the tube size and placement as well as careful selection and appropriate administration of drug dosage forms.

Arteriovenous neoadjuvant FLEOX chemotherapy with nutritional support improves the resectable rate for advanced gastric cancer

To summarize the resectable rate of advanced gastric cancer characterized by abdominal lymph node metastases with the arteriovenous neoadjuvant FLEOX chemotherapy plus appropriate nutritional support. Arteriovenous neoadjuvant FLEOX chemotherapy was administered to 50 patients of gastric cancer with advanced abdominal lymph node metastases. Of the 50 patients, 42 had never received any previous therapy and preoperative CT scanning revealed unresectable tumors because of advanced lymph node (station No.3, 7, 9, 12) or distant lymph node (No.14,16) metastases. The other 8 were characterized with relapse of severe lymph node metastases or with unresectable lymph node metastases demonstrated by exploratory laparotomy. Arteriovenous neoadjuvant FLEOX chemotherapy was conducted as follows: from day 1 to day 5, 5-FU 370 mg/m(2) and leukovorin 30 mg/kg intravenously, at day 6 and day 20, CDDP 70 mg/m(2) and epotoside 70 mg/m(2) intraarterially. This FLEOX regimen was repeated every five weeks for two or three courses. Out of the 50 patients,12 malnutritional cases received parenteral and/or enteral nutritional support according to the nutritional condition. Arteriovenous neoadjuvant FLEOX chemotherapy was then administered after the improvement of nutritional state. Their nutritional support methods were adapted to their chemotherapy as well. All the patients' general conditions and symptoms were improved significantly. For the 50 cases, the imageological and histological response rate (CR+PR) was 84.0%, and curative resection rate was 78.0%. Thus, 39 patients underwent subtotal or total gastrectomy, even combined organ resection, with D(2)+alpha or D(3) lymphadenectomy. Despite neoadjuvant chemotherapy, all malnutritional cases had significant weight gain after nutritional support, and other nutritional indexes,such as serum albumin, also resumed to normal. Arteriovenous neoadjuvant FLEOX chemotherapy proves favorable therapeutic effect for gastric cancer with advanced abdominal lymph node metastases, and downstages inoperable metastatic lymph nodes for radical operation. This combined modality regimen and nutritional support may play an important role in the treatment of advanced gastric cancer.

Glutamine: More Evidence, More Promise

Pancreatitis is a nasty disease. It attacks young and old alike, often occurring without warning signs. Fortunately, most cases are rather mild and resolve spontaneously. However, a subpopulation of patients develops life-threatening disease, spending a month (usually longer) in the hospital with a large part of the stay spent in the intensive care unit (ICU). The disease poses several management problems for the clinician. First, the patients are hypermetabolic, rapidly immobilizing lean tissues in an aggressive catabolic state. Second, infectious complications—both respiratory and intra-abdominal (infected pancreatic tissue, retroperitoneal abscesses, etc)—present a difficult management problem requiring aggressive ICU care, antibiotic (often multiple) therapy, respiratory support, and frequently, surgical debridement. Although enteral access can be safely obtained during laparotomy and successfully used for postoperative enteral nutrition, 1 operative therapy occurs weeks rather than days into the course of the disease process. During the acute preoperative phase, a massive retroperitoneal phlegmon impairs gastric emptying, precluding any form of intragastric nutrition support. The inflamed, edematous duodenum usually makes advancement of a nasojejunal tube technically impossible. Hence, in addition to hemodynamic, respiratory, and other critical care therapies, parenteral nutrition provides the primary method of nutrition support for these patients, often for prolonged periods of time. Even if enteral access is obtained at laparotomy, advancement of jejunostomy feedings is often slow, requiring a very gradual transition from parenteral to enteral therapy.

P124 UPSTREAM CHYME REINFUSION INCREASES PLASMA CITRULLINE IN PATIENTS WITH SHORT BOWEL SYNDROME

postoperative enteral feeding (EN) has been proposed as the novel method for nutritional support after surgery. Nevertheless, pancreatic surgeons often prefer postoperative TPN because of concerns about the possible adverse effects of early feeding and increased risk of anastomotic leak especially pancreaticojejunostomy site. The aim of this study was to evaluate whether early postoperative enteral feeding reduced the incidence of complications and length of hospital stay in patients following pancreaticoduodenectomy Methods: Between May 2007 and March 2008, 21 patients who underwent PD for a periamullary disease at Yongdong Severance Hospital of Yonsei University College of Medicine and randomized to enteral feeding or TPN. Enteral feeding and TPN begun on postoperative 1, and advanced to a goal of 25 kcal/kg per day. Both group started to have an oral diet after stool passing. Complications was diagnosed according to the criteria developed by the International Study Group Results: Patients demographics, nutritional state, and operative factors were similar between the groups. Comparison of length of hospital stay and time to normal intake of soft diet were shorter in the EN group, but there was no statistical significance. Postoperative surgery related complication (anastomosis leak, delated gastric empting) was similar between both group, however the rate of infections complications (wound infection, pneumonia, UTI, etc) was lower in EN group. Conclusion: The postoperative early enteral feeding is safe and well-tolerated and it s could give the beneficial opportunity for patients who have underwent PD for a periampullary disease.

PERIPHERAL PARENTERAL NUTRITION IN GERIATRIC WARDS

Poor nutritional status significantly contributes to morbidity and mortality in elderly. Malnutrition and denutrition are amenable to interventions aimed to improve outcomes in acute conditions so that nutritional support is frequently initiated during hospitalisation. If the enteral route remains the first evidence-based choice when the gut is functional, this approach may be difficult to perform in some “geriatric” situations like delirium, agitation, coma or pulmonary congestion. In the first days of the acute condition, when the patient is still stable, an alternative to the enteral route may also be considered. Although there is no evidence that parenteral nutrition is better than enteral nutrition, the peripheral intravenous route may be of interest especially when the enteral route is contraindicated. Moreover, the technique of peripheral parenteral nutition reduces central cannulation-related complications like pneumothorax. We emphasize here the place of this alternative method for a short duration nutritional support when supplement of caloric intake is needed. We discuss indications, a practical approach, our experience and analyze the evidences for this complementary nutritional support.

Hospitalized mechanically ventilated patients are at higher risk of enteral underfeeding than non-ventilated patients

Enteral nutrition (EN) is the preferred method of nutrition support in hospitalized patients but only 50-90% of the required calories are actually delivered. In order to identify where our nutrition support team (NST) should focus its activity, we prospectively evaluated the level of coverage of energy and protein needs during the first 5 days of EN in intensive care unit (ICU) and non-ICU patients and the relationship of energy and protein coverage with serum albumin, transthryretin, insulin-like growth factor-1 (IGF-1) and C-reactive protein (CRP). Subjects (n=183) who required nutrition support and received EN were prospectively recruited. Calorie prescription was 20 and 25, 25 and 30 kcal/kg BW for women and men 60 years and <60 years, respectively. Protein needs were estimated as 1.2g protein/kg BW. Logistic regression analysis was used to estimate odds ratios (OR) for energy and protein delivery 66.6% and <66.6% and albumin, transthryretin, IGF-1 (low vs. normal) and CRP (high vs. normal) in ventilated vs. non-ventilated patients. Significantly more mechanically ventilated than non-ventilated patients received <66.6% of energy (71% vs. 48%) and protein (96% vs. 65%). The ventilated patients were more likely to be energy (OR 2.1, CI 1.1-4.0) and protein (OR 15.7, CI 4.9-50.8) underfed than non-ventilated patients. There was a significant association on day 5 between low protein delivery and low albumin (OR 2.9, CI 1.3-6.5), low transthyretin (OR 3.0, CI 1.4-6.5), low IGF-1 (OR 2.8, CI 1.2-6.7) and high CRP (OR 3.5, CI 1.6-7.8). The energy and protein needs of hospitalized patients are not met during the first 5 days of EN. Ventilated patients are more likely to be energy and protein underfed than non-ventilated patients and to have low plasma protein level. These findings support our decision to intensify EN monitoring by our NST in ventilated patients to optimize their nutritional coverage.

Evolving Practices in Critical Care and Potential Implications for Management of Acute Kidney Injury

Acute kidney injury (AKI) is a common complication in hospitalized patients, with an incidence of 3 to 10% (1–4). In-hospital mortality rates that are associated with AKI remain high, in the range of 30 to 70% (5–8), despite significant improvements in dialytic technology as well as important advances in critical care, which have resulted in improved survival for other critical illnesses, including acute lung injury and sepsis (9). These improvements include continuous renal replacement therapies, which allow for continuous removal of solutes and fluid and may be tolerated better from a hemodynamic standpoint, and biocompatible dialysis membranes, which are associated with reduced complement and granulocyte activation. In general, indications for dialysis in the acute care setting have been extrapolated from those that are applied in chronic kidney disease, including volume overload that is refractory to diuretic therapy; electrolyte abnormalities (in particular hyperkalemia); uremic complications (pericarditis or pleuritis); severe acidosis (pH < 7.20); and selected toxic ingestions, such as methanol, ethylene glycol, and other water-soluble agents (10,11). However, the evidence base supporting specific dialysis practices in the acute care setting is limited. For example, several studies that were completed in the 1960s and 1970s compared “early” and “late” initiation of dialysis, using blood urea nitrogen (BUN) to define early and late (Table 1). These studies primarily were cohort studies that used historical controls, not randomized, clinical trials. The results of these investigations, along with extrapolation from the ESRD population, promoted recent practice patterns. Currently, many nephrologists often delay dialysis in the acute care setting until the patient has an impending complication of AKI, such as hyperkalemia leading to cardiac arrhythmias, acidosis resulting in hypotension, or oliguria leading to volume overload or hypoxemia, or until the BUN exceeds 100 mg/dl (18). Given differences in protein catabolism, …

A guide to oral nutrition supplements for the elderly

Oral nutritional supplements, such as sip feeds, are often prescribed for older people as a method of nutritional support in the prevention and treatment of undernutrition. There is growing evidence to suggest that when used appropriately in treatment plans, individuals receiving them can improve their nutritional status and may benefit from functional and clinical improvements (National Collaborating Centre for Acute Care, 2005).