Route Of Nutritional Support Research Articles

Jejunostomy tube feeding in patients undergoing esophagectomy

Surgical jejunostomy tubes are a routine part of elective esophagectomies in patients with carcinomas and provide a route for nutritional support in those who experience complications. We wished to determine how frequently oral intake is delayed and the amount of nutrition delivered via the jejunostomy tube. We reviewed the charts of all adults undergoing esophagectomy for carcinoma between January 2000 and June 2008. We determined the proportion of patients unable to resume oral nutrition after 8 days and the amount of nutrition delivered in each of the 8 days. In all, 111 patients underwent elective esophagectomy for carcinoma, and 103 had a jejunostomy tube placed. The mean age was 67 ± 10.8 years. The median time to oral intake was 7 (interquartile range 7-11) days. Seventy-four (67%) patients resumed oral intake within 8 days. The mean nutrition delivered by jejunostomy within the first 8 days as a percentage of the target was 45.6% (95% confidence interval 41.2%-49.9%). Six (5.4%) patients experienced complications attributable solely to the jejunostomy tube; 3 (2.9%) required surgery. Forty (38.8%) patients had abdominal issues serious enough to warrant delaying the progression of feeding. Two-thirds of patients undergoing elective esophagectomy were tolerating oral intake by the end of the eighth postoperative day, and less than half of the target nutrition was delivered over the first 8 days. We now selectively place surgical jejunostomy tubes in patients undergoing elective esophagectomies.

Terapia nutricional precoce no trauma: após o A, B, C, D, E, a importância do F (FEED)

A significant number of deaths in trauma occurs days to weeks after the initial injury, being caused by infection and organ failure related to hypercatabolism and consequent acute protein malnutrition. Nutritional therapy should be planned and included with other routines of resuscitation for patients with multiple trauma and severe burns. The rapid acquisition of a route for nutritional support is important to start early nutritional therapy within 48 hours of care. The enteral route is the preferred option in traumatized postoperative patients but the parenteral route should be prescribed when enteral feeding is contraindicated or inadequate. After the initial measures dictated by ATLS, synthesized in the A (airway), B (breathing), C (circulation), D (disability) and E (exposure), we include the letter F (feed) to emphasize the importance of early nutritional care in trauma.

Nutrition in the hospitalized patient

Almost 50% of patients are malnourished on admission; many others develop malnutrition during admission. Malnutrition contributes to hospital morbidity, mortality, costs, and readmissions. The Joint Commission requires malnutrition risk screening on admission. If screening identifies malnutrition risk, a nutrition assessment is required to create a nutrition care plan. The plan should be initiated early in the hospital course, as even patients with normal nutrition become malnourished quickly when acutely ill. While the Harris-Benedict equation is the most commonly used method to estimate calories, its accuracy may not be optimal in all patients. Calculating the caloric needs of acutely ill obese patients is particularly problematic. In general, a patient's caloric intake should be slightly less than calculated needs to avoid the metabolic risks of overfeeding. However, most patients do not receive their goal calories or receive parenteral nutrition due to erroneous practices of awaiting return of bowel sounds or holding feeding for gastric residual volumes. Patients with inadequate intake over time may develop potentially fatal refeeding syndrome. The hospitalist must be able to recognize the risk factors for malnutrition, patients at risk of refeeding syndrome, and the optimal route for nutrition support. Finally, education of patients and their caregivers about nutrition support must begin before discharge, and include coordination of care with outpatient facilities. As with all other aspects of discharge, it is the hospitalist's role to assure smooth transition of the nutrition care plan to an outpatient setting.

Ingluviotomy Tube Placement for Lead-induced Crop Stasis in the California Condor (Gymnogyps californianus)

Six free-flying California condors (Gymnogyps californianus) were diagnosed with acute lead toxicosis that caused crop distension and stasis. Between January 2006 and January 2007, the birds were referred to the Phoenix Zoo in Arizona for emergency treatment. In 5 birds, an ingluviotomy was performed to place a feeding tube from the crop to the proventriculus, which allowed a temporary bypass of the dysfunctional esophagus until normal function and motility were regained. A crop-support pressure bandage was placed in 4 birds to improve crop emptying into the proventriculus and to prevent crop distension. Although chelation therapy is the gold standard treatment for lead toxicosis, severe cases of lead-induced crop stasis are not acutely reversible with pharmaceuticals. In these condors, placement of a feeding tube was deemed prudent to ensure a viable enteric route of nutritional support during the standard treatment and recovery period in acute lead toxicosis with crop stasis.

What are the factors that influence the attainment of satisfactory energy intake in pediatric intensive care unit patients receiving enteral or parenteral nutrition?

ObjectiveChildren admitted to the intensive care unit (ICU) are at risk of inadequate energy intake. Although studies have identified factors contributing to an inadequate energy supply in critically ill children, they did not take into consideration the length of time during which patients received their estimated energy requirements after having achieved a satisfactory energy intake. This study aimed to identify factors associated with the non-attainment of estimated energy requirements and consider the time this energy intake is maintained. MethodsThis was a prospective study involving 207 children hospitalized in the ICU who were receiving enteral and/or parenteral nutrition. The outcome variable studied was whether 90% of the estimated basal metabolic rate was maintained for at least half of the ICU stay (satisfactory energy intake). The exposure variables for outcome were gender, age, diagnosis, use of vasopressors, malnutrition, route of nutritional support, and Pediatric Index of Mortality and Pediatric Logistic Organ Dysfunction scores. ResultsSatisfactory energy intake was attained by 20.8% of the patients, within a mean time of 5.07 ± 2.48 d. In a multivariable analysis, a diagnosis of heart disease (odds ratio 3.62, 95% confidence interval 1.03–12.68, P = 0.045) increased the risk of insufficient energy intake, whereas malnutrition (odds ratio 0.43, 95% confidence interval 0.20–0.92, P = 0.030) and the use of parenteral nutrition (odds ratio 0.34, 95% confidence interval 0.15–0.77, P = 0.001) were protective factors against this outcome. ConclusionA satisfactory energy intake was reached by a small proportion of patients during their ICU stay. Heart disease was an independent risk factor for the non-attainment of satisfactory energy intake, whereas malnutrition and the use of parenteral nutrition were protective factors against this outcome.

Nutritional support in patients with acute pancreatitis

Pancreatitis is a diffuse systemic immuno-inflammatory response to a localized process of auto-digestion within the pancreatic gland, caused by premature activation of proteolytic digestive enzymes. According to the ATLANTA criteria (1992) we recognized a mild and a severe acute pancreatitis (SAP ) . Mortality rate in SAP account up to the 20 percent and most complications and deaths are due to an inflammatory immune response to pancreatic necrosis and/or infection. Patients affected by SAP rapidly incur accelerated catabolism and thus nutritional support is essential, especially in the earliest period of the disease. Recent observations show that the route of nutritional support may also affect disease severity and its course. In this view several important questions about nutritional support need to be addressed : indication , timing, enteral vs parenteral and composition . With this review we analyze the state-of-the-art and we present a decisional flow chart to better manage the nutritional support in SAP.

Nutritional support in patients with acute pancreatitis

Pancreatitis is a diffuse systemic immuno-inflammatory response to a localized process of auto-digestion within the pancreatic gland, caused by premature activation of proteolytic digestive enzymes. According to the ATLANTA criteria (1992) we recognized a mild and a severe acute pancreatitis (SAP ) . Mortality rate in SAP account up to the 20 percent and most complications and deaths are due to an inflammatory immune response to pancreatic necrosis and/or infection. Patients affected by SAP rapidly incur accelerated catabolism and thus nutritional support is essential, especially in the earliest period of the disease. Recent observations show that the route of nutritional support may also affect disease severity and its course. In this view several important questions about nutritional support need to be addressed : indication , timing, enteral vs parenteral and composition . With this review we analyze the state-of-the-art and we present a decisional flow chart to better manage the nutritional support in SAP.

Nutritional support outcomes in critical care

To revise the effect of our nutritional support practices on outcomes from critical care patients and propose new study hypothesis. Retrospective observational study was conducted in all critically ill patients who had been prescribed nutritional support, through a year time, in an Intensive Care Unit. The nutritional support practices are described. Severity of illness (Simplified Acute Physiology Score II), timing and route of nutritional support, prescribed and delivered daily caloric intake for a maximum of 7 days, medical or surgical patient, length of stay in ICU, incidence rate and incidence density of nosocomial infections, and presence of gastrointestinal complications were recorded. Relationships between timing and route of nutritional support and percentage of received/ prescribed calories with mortality, nosocomial infections, days of mechanical ventilation and length of stay in the Intensive Care Unit were studied. 102 patients of our intensive care patients received nutritional support and were selected for the study. EN was used in 42 patients (41%), 41 (40%) received TPN and 19 patients (19%) received mixed nutrition. Timing of nutritional support showed a mean of 3.1 ± 1.9 days and was statistically different between patients who survived or died (2.82 ± 1.65 vs. 3.74 ± 2.33 days). Patients received 58 ± 28% of their requirements but this data did not show any difference with mortality and morbidity. There was a statistical difference between the route of nutrition and the following data: type of patient, caloric intake in the study period, length of stay in ICU and days of mechanical ventilation. Our study demonstrates that nutritional support patients are more severely ill than nonnutritional support patients. Timing of nutritional support was shorter in survivors. Our study confirms a low caloric input in the critically ill patient during the first week of illness, especially in the enteral nutrition group. However this finding was not associated with mortality or morbidity. Parenteral route did show better clinical outcomes than enteral or mixed nutrition. Our findings suggest that a moderate and early caloric intake could obtain better outcomes, independently of the route of nutritional support.

Resultados del soporte nutricional en una UCI polivalente

Background & aims: To revise the effect of our nutritional support practices on outcomes from critical care patients and propose new study hypothesis. Methods: Retrospective observational study was conducted in all critically ill patients who had been prescribed nutritional support, through a year time, in an Intensive Care Unit. The nutritional support practices are described. Severity of illness (Simplified Acute Physiology Score II), timing and route of nutritional support, prescribed and delivered daily caloric intake for a maximum of 7 days, medical or surgical patient, length of stay in ICU, incidence rate and incidence density of nosocomial infections, and presence of gastrointestinal complications were recorded. Relationships between timing and route of nutritional support and percentage of received/ prescribed calories with mortality, nosocomial infections, days of mechanical ventilation and length of stay in the Intensive Care Unit were studied. Results: 102 patients of our intensive care patients received nutritional support and were selected for the study. EN was used in 42 patients (41%), 41 (40%) received TPN and 19 patients (19%) received mixed nutrition. Timing of nutritional support showed a mean of 3.1 ± 1.9 days and was statistically different between patients who survived or died (2.82 ± 1.65 vs. 3.74 ± 2.33 days). Patients received 58 ± 28% of their requirements but this data did not show any difference with mortality and morbidity. There was a statistical difference between the route of nutrition and the following data: type of patient, caloric intake in the study period, length of stay in ICU and days of mechanical ventilation. Conclusions: Our study demonstrates that nutritional support patients are more severely ill than nonnutritional support patients. Timing of nutritional support was shorter in survivors. Our study confirms a low caloric input in the critically ill patient during the first week of illness, especially in the enteral nutrition group. However this finding was not associated with mortality or morbidity. Parenteral route did show better clinical outcomes than enteral or mixed nutrition. Our findings suggest that a moderate and early caloric intake could obtain better outcomes, independently of the route of nutritional support.

Cost‐analysis of nutrition support in patients with severe acute pancreatitis

The purpose of this research was to assess the preferred route of nutrition support (enteral versus parenteral) for treatment of severe acute pancreatitis in the acute care setting. Further, in cases when enteral nutrition is the preferred route, is nasal-bridling a lower-morbidity and cost-effective method? A retrospective review of pre-existing data from an 870-bed hospital system. Medical records were reviewed via an online database system (n = 25 patients) with severe acute pancreatitis. Length of stay and cost were analyzed. More patients received TPN versus the nasal-jejunal (post-pyloric) tube feeds group. No significant relationship was found between total cost and number of co-morbidities or between either of the two treatment groups. However, a medium to large effect size was shown which could indicate a significant relationship in a larger sample size. The findings of this research add to the literature already available and will be of interest to those who specialize in this area.

A retrospective study about the influence of early nutritional support on mortality and nosocomial infection in the critical care setting

To determine whether early nutritional support reduces mortality and the incidence of nosocomial infection, in critically ill patients in the current practice. A retrospective observational study was conducted in all critically ill patients who had been prescribed nutritional support, throughout one year, in an Intensive Care Unit. The time to start and the route of delivery of nutritional support were determined by the attending clinician's assessment of gastrointestinal function and hemodynamic stability. Age, gender, severity of illness, start time and route of nutritional support, prescribed and delivered daily caloric intake for the first 7 days, whether they were a medical or surgical patient, length of stay in ICU, incidence rate of nosocomial infections and ICU mortality were recorded. Patients were classified according to whether or not they received nutritional support within 48 h of their admission to ICU and Binary Logistic Regression was performed to assess the effect of early nutritional support on ICU mortality and ICU nosocomial infections after controlling for confounders. Ninety-two consecutive patients were included in the study. Start time of nutritional support showed a mean of 3.1 ± 1.9 days. Patients in the early nutritional support group had a lower ICU mortality in an unadjusted analysis (20% vs. 40.4%, p = 0.033). Early nutritional support was found to be an independent predictor of mortality in the regression analysis model (OR 0,28; 95% confidence interval, 0.09 to 0,84; p = 0.023). Our study did not demonstrate any association between early nutritional support and the incidence of nosocomial infection (OR 0.77; 95%. confidence interval, 0.26 to 2,24; p = 0.63), which was related to the route of nutritional support and the caloric intake. The delayed nutritional support group showed a longer length of stay and nosocomial infections than the early group, although these differences were not statistically significant. Our study shows that early nutrition support reduces ICU mortality in critically ill patients, although it does not demonstrate any influence over nosocomial infection in the current practice in intensive care.

Effect of Preoperative Nutritional Deficiency on Mortality After Radical Cystectomy for Bladder Cancer

Poor preoperative nutritional status is a risk factor for adverse outcomes after major surgery. We evaluated the effect of preoperative nutritional deficiency on perioperative mortality and overall survival in patients undergoing radical cystectomy for bladder cancer. A total of 538 patients underwent radical cystectomy for urothelial carcinoma between January 2000 and June 2008, and had nutritional parameters documented. Patients with preoperative albumin less than 3.5 gm/dl, body mass index less than 18.5 kg/m(2) or preoperative weight loss greater than 5% of body weight were considered to have nutritional deficiency. Primary outcomes were 90-day mortality and overall survival. Survival was estimated using Kaplan-Meier analysis and compared using the log rank test. Cox proportional hazards models were used for multivariate survival analysis. Of 538 patients 103 (19%) met the criteria for nutritional deficiency. The 90-day mortality rate was 7.3% overall (39 deaths), with 16.5% in patients with nutritional deficiency and 5.1% in the others (p < 0.01). Nutritional deficiency was a strong predictor of death within 90 days on multivariate analysis (HR 2.91; 95% CI 1.36, 6.23; p < 0.01). Overall survival at 3 years was 44.5% (33.5, 54.9) for nutritionally deficient patients and 67.6% (62.4, 72.2) for those who were nutritionally normal (p < 0.01). On multivariate analysis nutritional deficiency cases had a significantly higher risk of all cause mortality (HR 1.82; 95% CI 1.25, 2.65; p < 0.01). Nutritional deficiency, as measured by preoperative weight loss, body mass index and serum albumin, is a strong predictor of 90-day mortality and poor overall survival. Prospective studies are needed to demonstrate the best indices of preoperative nutritional status and whether nutritional intervention can alter the poor prognosis for patients treated with radical cystectomy who have nutritional deficiencies.

Nutrition Considerations in Traumatic Brain Injury

The provision of adequate nutrition support for patients with traumatic brain injury (TBI) has been a clinical challenge for decades. The primary and secondary injuries create unique metabolic derangements along with accompanying issues such as optimal timing and route of nutrition, appropriate fluid and electrolytes, drug administration, rehabilitation, and dysphagia. Enteral nutrition is clearly established as the preferential route of nutrition support for this population vs parenteral nutrition. There appears to be a consensus on early initiation of enteral nutrition, but less definitive are recommendations on advancement timing and formula components. Nutrition therapies should include exact fluid resuscitation goals specific for TBI and strict electrolyte monitoring to avoid extreme fluid, electrolyte, or glucose shifts that could be detrimental to the patient. While the critical care patient often tolerates small bowel feeding, the long-term rehabilitation patient should transition to and tolerate gastric feeding. Drug-nutrient and adverse drug reactions such as diarrhea should be routinely evaluated in patients receiving enteral nutrition. Monitoring for dysphagia is critical to avoid the costly negative aspects associated with aspiration and to capitalize on quality of life and appropriate oral nutrition. Emphasizing the priority of early nutrition support within a multi-disciplinary team may be the critical key for successful provision and tolerance of nutrition support in the TBI population.

Percutaneous Endoscopic Gastrostomy Tube Insertion via Gastro-Gastric Fistula in a Gastric Bypass Patient

Enteral feedings are the preferred route of nutritional support for malnourished or critically ill patients. Recent progress in flexible endoscopic and interventional radiological techniques has allowed adaptation of numerous new procedures. Anatomic and functional rearrangement of the gastrointestinal tract often precludes traditional percutaneus endoscopic gastrostomy tube placement. Insertion of a gastroscope through the nose, via open pharynx, or neck fistula have been described, but there are no reports in the English literature describing introduction of the gastroscope through a dilated gastro-gastric fistula in a patient with previous open Roux en Y gastric bypass.

Parenterale, enterale oder kombinierte Ernährung

Perioperatively early oral food intake is achieved in most cases. A temporary protein and energy deficit is rarely associated with increased complication rates. Concerning the route of nutritional support there is no difference in mortality but in complication rates. The enteral food ingestion (oral, gastral, jejunal) seems to be superior the intravenous one. But in case of gastrointestinal failure nutritional support is limited to the intravenous route. Increasingly a combined parenteral and enteral nutrition is proposed in cases of malnutrition or expected perioperative complications with delayed enteral food ingestion. Up to now there is no good scientific evidence for such approach.

The Importance of Nutrition Status Assessment: The Case of Severe Acute Pancreatitis

Severe acute pancreatitis is associated with high mortality. Adequate nutrition support improves clinical outcome. Nevertheless, several recent trials have focused primarily on the route of nutrition support and neglected the role of nutrition status assessment in tailoring nutrition support to individual needs.

Food fight! Parenteral nutrition, enteral stimulation and gut-derived mucosal immunity.

Nutrition support is an integral component of modern patient care. Type and route of nutritional support impacts clinical infectious outcomes in critically injured patients. This article reviews the relationships between type and route of nutrition and gut-derived mucosal immunity in both the clinical and laboratory settings.

Nutrition Support in the Critically Ill: A Physician Survey

Current clinical practice guidelines delineate optimal nutrition management in the intensive care unit (ICU) patient. In light of these existing data, the authors identify current physician perceptions of nutrition in critical illness, preferences relating to initiation of feeding, and management practices specific to nutrition after initiation of feeding in the ICU patient. The authors electronically distributed a 12-question survey to attending physicians, fellows, and residents who routinely admit patients to medical and surgical ICUs. On a scale ranging from 1 to 5 (1 = low, 5 = high), the attending physician's mean rating for importance of nutrition in the ICU was 4.60, the rating for comfort level with the nutrition support at the authors' institution was 3.70, and the rating for the physician's own understanding of nutrition support in critically ill patients was 3.33. Attending physicians, fellows, and residents reported waiting an average of 2.43, 1.79, and 2.63 days, respectively, before addressing nutrition status in an ICU patient. Fifty-two percent of attending physicians chose parenteral nutrition as the preferred route of nutrition support in a patient with necrotizing pancreatitis. If a patient experiences enteral feeding intolerance, physicians most commonly would stop tube feeds. There was no significant difference in responses to any of the survey questions between attending physicians, fellows, and residents. This study demonstrates a substantial discordance in physician perceptions and practice patterns regarding initiation and management of nutrition in ICU patients, indicating an urgent need for nutrition-related education at all levels of training.

Maximizing efficacy from parenteral nutrition in critical care: Appropriate patient populations, supplemental parenteral nutrition, glucose control, parenteral glutamine, and alternative fat sources

The gastrointestinal tract is the preferred route for nutritional support in hospitalized patients. Patients with a functioning gastrointestinal tract, including those with pancreatitis or inflammatory bowel disease and those receiving chemotherapy, should be fed enterally. Parenteral nutrition (PN) should be limited to patients with gastrointestinal failure, including those with short gut syndrome, high-output fistula, prolonged ileus, or bowel obstruction. PN is associated with numerous complications, most notably increased risk of serious infection. Emerging data suggest that immunologic complications of PN may result from hyperglycemia and use of n-6 polyunsaturated fatty acids. Safety may be improved with a low-calorie formula and ensuring tight glycemic control with an insulin protocol. A lipid emulsion containing fish oil, olive oil, or both should replace soybean-containing emulsions. Supplemental glutamine, 0.2 g/kg/d to 0.5 g/kg/d, has been shown to reduce the risk of infection and to improve glycemic control.

Review: timing or administration route of nutritional support does not affect death or disability in head injury

Review: timing or administration route of nutritional support does not affect death or disability in head injury