Timing Of Nutritional Support Research Articles

Knowledge, attitudes, and practices of registered dietitians and nutritionists regarding enteral and parenteral nutrition support in Ghana: a needs assessment study.

There is a paucity of data on enteral and parenteral (EN and PN) nutrition support (NS) provided by nutrition and dietetic practitioners in adult acute care settings in Ghana. Furthermore, gray literature suggests that Ghanaian clinical nutrition professionals (CNPs) are seldom involved in advanced nutrition care teams. To assess the knowledge, attitudes, and practices of Ghanaian CNPs regarding EN and PN. An online cross-sectional survey was administered to Ghanaian CNPs ahead of a professional development workshop on EN and PN Support. Participants were asked questions about initiation and timing of NS, and knowledge on availability of commercial formula. A 5-point Likert scale was used to assess self-efficacy in using EN and PN. To assess practical knowledge on EN and PN, participants were asked to identify whether EN or PN was indicated for seven short case scenarios. Open-ended questions were used to assess reasons for participant self-ratings. A total of 76 dietitians, nutritionists, students, and interns completed the survey. For EN, self-efficacy scores were lowest for the calculation of enteral goal rate, and goal volume (mean 3.20 ± 1.27), and writing of EN prescriptions (mean 3.07 ± 1.29). Self-efficacy scores for the formulation of alternative formulas in lieu of commercial formula were the highest (3.63 ± 1.36). For PN, self-efficacy scores for all domains were lower than 3, with the lowest scores observed for writing PN prescriptions (2.19 ± 1.14) and determining micronutrient additives (2.12 ± 1.04). We identified limited training and lack of practical exposure to NS, limited ability to effectively monitor tube feeds, and prohibitive cost and limited availability of EN and PN formula among the barriers impacting self-efficacy scores. Given the vital role that CNPs play in the delivery of EN and PN, it is important to develop professional training programs especially focused on PN to bridge knowledge and practice gaps.

Intermittent feeding and circadian rhythm in critical illness.

Purpose of reviewCircadian rhythms, i.e., periodic oscillations in internal biological processes, modulate metabolic processes such as hormonal signalling, nutrient absorption, and xenobiotic detoxification. Meal timing is a strong entraining cue for peripheral clocks in various organs, and eating out of circadian phases can impair glucose, gastrointestinal, and muscle metabolism. Sleep/wake cycles and circadian rhythms are extremely disrupted during critical illness. Timing of nutritional support may help preserve circadian rhythms and improve post-Intensive Care Unit (ICU) recovery. This review summarises circadian disruptors during ICU admission and evaluates the potential benefits of intermittent feeding on metabolism and circadian rhythms.Recent findingsRhythmic expression of core clock genes becomes rapidly disturbed during critical illness and remains disturbed for weeks. Intermittent, bolus, and cyclic enteral feeding have been directly compared to routine continuous feeding, yet no benefits on glycaemic control, gastrointestinal tolerance, and muscle mass have been observed and impacts of circadian clocks remain untested.SummaryAligning timing of nutritional intake, physical activity, and/or medication with circadian rhythms are potential strategies to reset peripheral circadian rhythms and may enhance ICU recovery but is not proven beneficial yet. Therefore, selecting intermittent feeding over continuous feeding must be balanced against the pros and cons of clinical practice.

Nutritional Support Using Enteral and Parenteral Methods.

The purpose of this Clinical Practice Guideline is to provide an approach for optimal nutritional support in the postinjury period for those injured in combat. Indications and contraindications for enteral and parenteral nutrition are addressed. Timing of nutritional support, nutritional goals, energy requirements, and ideal formula selection for various types of traumatic injuries are addressed. Challenges encountered providing nutrional support for the traumatically injured in the deployed environment are also discussed.

Feeding During Phases of Altered Mitochondrial Activity: A Theory.

Decisions surrounding the timing and dosing of nutrition support are made for thousands of ICU patients daily and yet remain a topic of controversy. Nutrition support designed to replenish resting energy expenditure (REE) early in critical illness has led to worse clinical outcomes in at least three recent prospective randomized clinical trials. Producing sufficient energy from nutrient substrates requires use of the mitochondrial electron transport chain (ETC). This process is functionally linked to the creation of a tightly regulated series of chemical messengers known as reactive oxygen species (ROS). In health, ROS are kept at low levels by a system of mitochondrial/cellular enzymes and antioxidants, allowing ROS to act as a signal for the redox health of the cell. In inflammatory conditions, however, this system is altered, leading to changes in the physiologic function of the ETC such that its usage produces greater ROS per unit of substrate. This increased ROS is capable of deactivating antioxidant systems, as well as activating further ROS-producing pathways and stimulating localized inflammatory activity. We propose that exacerbation of this process at this time by the forced influx of exogenously acquired nutrient substrates leads to mitochondrial damage, amplified ROS production, increased inflammation, decreased ATP-productive capacity, and, eventually, the death of the cell by either apoptosis or necrosis. Knowledge of this process is vital to determining the safe dosing and timing of nutrition support in the ICU. It is possible that the physiologic cost of meeting the REE under these conditions of mitochondrial stress may simply be too high. This paper details the proposed process by which inappropriately timed feeding in critically ill patients may damage the very mitochondria required for its utilization.

Implementation of an evidenced based nutrition support pathway for haematopoietic progenitor cell transplant patients

The type of nutrition support given during haematopoietic progenitor cell transplantation (HPCT) varies greatly between transplant units and often includes enteral nutrition (EN) and/or parenteral nutrition (PN). The aims of this study were to develop an evidenced based nutrition support pathway for HPCT patients and then evaluate changes in nutrition support practices post implementation of the pathway into clinical practice. A retrospective audit of 66 consecutive patients who underwent HPCT during the six months prior to the development of the pathway was undertaken, followed by a prospective audit of 61 consecutive patients undertaking HPCT during the six months post implementation. Data collected included type and timing of nutrition support given. Post implementation of the pathway the use of PN for allogeneic HPCT patients reduced significantly from 86% to 50% (p < 0.001) and use of oral nutrition support increased significantly from 14% to 45% (p = 0.003). Autologous HPCT recipients had shorter lengths of inadequate intake with only 30% of patients having a poor intake for greater than one week compared to 72% prior to implementation of the pathway (p = 0.02). Implementation of a nutrition support pathway impacts significantly on appropriate use of nutritional support in recipients of HPCT.

Parenteral Nutrition in ICU Patients: What's the Rush?

Guidelines differ substantially in their recommendations about when to start parenteral nutrition in critically ill patients; these guidelines are based primarily on expert opinion. To evaluate prospectively the optimal timing of nutritional support, investigators in Belgium randomized 4640 nutritionally at-risk patients in the intensive care unit (ICU; ~85% surgical …

Early enteral nutrition can be successfully implemented in trauma patients with an “open abdomen”

Background The presence of an “open abdomen” after a trauma laparotomy can complicate the nutritional management of injured patients. Methods The medical records of patients admitted to an American College of Surgeons–verified level 1 trauma center were evaluated. The timing of nutritional support was noted. The method to obtain abdominal closure was also noted. Results Twenty-three patients were included in the study. Enteral nutrition was successfully initiated in 52% of patients before fascial closure. Enteral nutrition was initiated 3.8 days after the initial laparotomy in these patients. All patients successfully achieved fascial and skin closure, obviating the need for delayed hernia repair or skin grafting. Conclusions Enteral nutrition can be successfully initiated in patients with “open abdomens.” In our series, early enteral nutrition did not alter our ability to ultimately obtain fascial and skin closure.

Nutrition Support After Neonatal Cardiac Surgery

Congenital heart disease is the most common birth defect in the United States, with an estimated frequency of approximately 12-14 of 1000 live births per year. Neonates with congenital heart disease often need palliative or corrective surgery requiring cardiopulmonary bypass during the first weeks of life. The neonate undergoing cardiopulmonary bypass surgery experiences a more profound metabolic response to stress than that seen in older children and adults undergoing surgery. However, compared with older children and adults, the neonate has less metabolic reserves and is extremely vulnerable to the negative metabolic impact induced by stress, which can lead to suboptimal wound healing and growth failure. There are complications associated with the metabolic derangements of neonatal surgery requiring cardiopulmonary bypass, including but not limited to acute renal failure, chylothorax, and neurological dysfunction. This article discusses the importance of nutrition and metabolic support for the neonate undergoing cardiopulmonary bypass and the immediate postoperative nutrition needs of such a patient. Also, this article uses a case study to examine the feeding methodology used at one particular institution after neonatal cardiac surgery. The purpose of the case study is to provide an illustration of the many factors and obstacles that clinicians often face in the provision and timing of nutrition support.

The role of macronutrients in gastrointestinal blood flow

The presence of luminal nutrients after a meal increases gastrointestinal blood flow in a phenomenon called postprandial hyperemia. In many conditions related to splanchnic hypoperfusion, enteral nutrition may play a role in counterbalancing the installed splanchnic low-flow state by producing intestinal hyperemia. However, when the gut is hypoperfused there is a chance of enteral nutrition producing a mismatch of the oxygen demand: supply ratio with subsequence gut ischemia. This article aims to review the effects of macronutrients on gastrointestinal blood flow in both health and critical conditions, especially those related to hepatosplanchnic hypoperfusion. Splanchnic blood flow is related not only to the route (intravenous or enteral) and timing of nutritional support (during the course of the insult) but also to the composition of the formula. Critically ill patients with gut hypoperfusion may tolerate enteral nutrition, but this effect may be restricted to the early post-injury phase. During ischaemia reperfusion injury, immune nutrients may promote different outcomes: glutamine may protect whereas arginine may deteriorate the mucosal barrier and enhance permeability. Understanding the relationship between macronutrients and gastrointestinal blood flow is a major challenge. Ongoing research in nutritional support in hypoperfused, catecholamine-dependent patients will open the door to optimize the recovery of patients in critical care.

Hyperemesis Gravidarum: Feed the Mother, Feed the Child

The article “Hyperemesis Gravidarum and Fetal Outcome” by Paauw et al in this issue represents a fresh look at the effect of hyperemesis on maternal complications and fetal outcome. In this study, they found that infants born to women who had significant hyperemesis were more likely to be born prematurely and to have a significantly increased hospital length of stay. Of particular interest are those portions of the statistical analysis that compared outcomes in infants of mothers who were well nourished vs those who were clinically malnourished, and those who received nutrition support vs those who did not. Although the numbers were small, there were no significant differences in fetal outcome in any of the groups. This result raises an interesting question: if there are no statistically significant differences in the maternal and infant outcome in either of the groups regardless of nutritional status or nutrition therapy, then at what point should nutrition therapy be started in these patients? The risks of maternal malnutrition are well known, and the lists of both maternal and fetal complications, which can occur with this malnutrition, have been well documented in the literature. These include neural tube and other developmental defects that affect the infant long after birth, prematurity, and small-for-gestational-age infants. The American Society of Parenteral and Enteral Nutrition clinical guidelines strongly encourage the use of nutrition support in pregnant women who are at increased nutritional risk to prevent these complications and improve both maternal and infant outcome. Other sources recommend nutrition support only in those patients who fail conventional medical management without addressing nutritional status as an independent factor for starting nutrition support. With these recommendations in mind, a review of the current literature reveals a paucity of prospective studies on the effect of nutrition support on the outcome of hyperemetic patients. Most retrospective studies discuss various methods of nutrition support for these patients, including the use of enteric feeding tubes and parenteral nutrition (PN), and discuss the safety and efficacy of these methods without commenting on the effect of improved nutrition on either maternal or fetal outcome. Of interest is a recent article in the Journal of Reproductive Medicine that compared outcome and complications of hyperemetic patients who received PN vs those who received conventional nutrition therapy (antiemetics and encouragement of a bland diet). This study failed to demonstrate any benefit from PN and showed a 16% complication rate related to the central lines used for administration of the PN. The study was limited by its retrospective nature and the uncontrolled nature of the usage of PN, but it raises the specter that in some cases PN may do more harm than good. Other studies and literature reviews have also documented the use of PN without clearly demonstrating a benefit to the patient or infant. In our own institutional experience, over 15 years, many patients were treated for nutritional complications of hyperemesis with PN with a complication rate similar to that of nonpregnant patients (ie, a complication rate of approximately 1–2%). Upon review of our data, there was never any evidence to show a clear benefit to PN in the hyperemetic patient; however, similar to other studies, the data were prejudiced by selection criteria in that PN was ordered at the discretion of the obstetrician and not by the hospital nutrition service. This led to a wide variability in nutritional status of the patients, making the data unsuitable for risk-benefit analysis. In these days of evidence-based medicine and the reluctance of insurance companies to provide any treatment without proven benefit, it is of vital importance that research continue into the usage and effects of nutrition support in the hyperemetic patient. It should be noted that both enteral nutrition (EN) and PN, by providing nutrients and fluids for hydration, may make it possible for the patient to be discharged home sooner, because it will no longer be necessary for the mother to be kept in the hospital until her nausea subsides and oral intake can be resumed. The safety of PN and EN in the hyperemetic patient is well documented at this point, and research should concentrate more on the timing of nutrition support, as well as the nutrients needed by both the mother and developing fetus, and less on the methods of administration. It will be necessary to overcome the prejudice of the obstetrician against PN and EN and to encourage them to Received for publication December 3, 2003. Accepted for publication December 6, 2004. Correspondence: Lillian H. Banchik, MD, FACS, 11 Gateway Drive, Great Neck, NY 11021. Electronic mail may be sent to LHBanchik@aol.com. 0148-6071/05/2902-0134$03.00/0 Vol. 29, No. 2 JOURNAL OF PARENTERAL AND ENTERAL NUTRITION Printed in U.S.A. Copyright © 2005 by the American Society for Parenteral and Enteral Nutrition

Timing of nutritional support.

Timing of nutritional support.

Malnutrition in hospitalized elderly patients: when does it matter?

Background: Identifying the individual effects of acute illness and malnutrition on elderly patient outcome and the timing of nutritional support is still an important challenge for modern medicine.Objective: The aims of this study were to assess the practical significance of serum albumin concentrations following acute illness as a measure of nutritional status in ageing patients and also to review recently published studies related to this field.Design: Consecutive stroke patients had their nutritional status assessed from anthropometric, haematological and biochemical data during the hospital stay. Predicted energy needs and daily in-hospital energy intake were also studied in a subgroup of 24 acute stroke patients and 24 age and sex-matched hospitalized non-stroke patients. A multivariate analysis was used to measure the amount of variance in serum albumin concentrations explained by nutritional and non-nutritional clinical variables.Results: Serum albumin concentrations deteriorated steadily during the study period and there was an increase in the amount of variance in the serum albumin explained by nutritional variables between admission and week 4 of the hospital stay. Almost all patients studied were in negative energy balance during hospitalization. Evidence is provided which links low serum albumin concentrations with clinical outcomes during the hospital stay and immediately following discharge. That nutritional supplementation started one week as opposed to immediately following acute illness, and continued during the convalescent period, can improve serum albumin concentrations during the hospital stay.Conclusion: Poor nutritional status following acute illness in ageing patients may be of more prognostic significance and amenable to therapy later on during the course of hospitalization.

Standardization of nutritional support: are protocols useful?

This paper reviews the benefits that a structured format such as a protocol can bring to the delivery of nutritional support. The four main areas of influence are: (1) patient selection, in which indications for feeding and evaluation of the risk/benefit ratio are discussed; (2) timing of nutritional support, in which guidelines for initiating feeding are proposed; (3) delivery of nutrition, in which protocols to limit complications and optimize delivery are reviewed; and (4) feed content, in which guidelines for appropriate nutrients and formulation for special considerations are identified. The importance of an evidence base is stressed and some of the evidence supporting specific recommendations is reviewed.

Enteral feeding in the critically injured patient.

Metabolic support is an integral component in the care of the critically injured patient. When hypermetabolism occurs, there are increases in energy demands along with changes in substrate utilization. This article reviews the prospective randomized clinical trials that were undertaken at Denver General Hospital over the past decade that address both the timing of nutritional support and the route of administration in this critically injured population. Also discussed is a review of a meta-analysis that attests to the feasibility of early postoperative enteral feeding with the possibility of decreased septic morbidity in high-risk surgical patients. With the clinical knowledge gained from these trials, an algorithm for nutritional intervention was developed that represents our current standard of practice.