Use Of Artificial Nutrition Research Articles

Poor compliance with ACG guidelines for nutrition and antibiotics in the management of acute pancreatitis: a North American survey of gastrointestinal specialists and primary care physicians.

Despite recent updates in the treatment of acute pancreatitis emphasizing enteral nutrition over parenteral nutrition as well as minimizing antibiotic usage, mortality rates from acute pancreatitis have not improved. Data has been limited regarding physician compliance to these guidelines in the United States.A 20 question survey regarding practice patterns in the management of acute pancreatitis was distributed to physicians at multiple internal medicine and gastroenterology conferences in North America between 2009 and 2010. Responses were analyzed using the chi-square test and multivariate logistic regression.Out of 406 available respondents, 43.3% of physicians utilize total parenteral nutrition/peripheral parenteral nutrition (TPN/PPN) and 36.5% utilize nasojejunal (NJ) feedings. The preferred route of nutrition was significantly related to practice type (P<0.001): academic physicians were more likely to use NJ tube feeding than private practice physicians (52.1% vs. 19.9%) while private practitioners were more likely to utilize TPN/PPN than academic physicians (70.2% vs. 20.5%). Gastroenterologists and primary care physicians were equally non-compliant as both groups favored parenteral nutrition. Multivariate logistic regression demonstrated that practice type (P<0.001) was the only independent predictor of route of nutrition. Most survey respondents appropriately do not routinely utilize antibiotics for acute pancreatitis, but when antibiotics are initiated, they are for inappropriate indications such as fever and infection prophylaxis.Many North American physicians are noncompliant with current ACG practice guidelines for the use of artificial nutrition in the management of acute pancreatitis, with overuse of TPN/PPN and underutilization of jejunal feedings. Antibiotics are initiated in acute pancreatitis for inappropriate indications, although there are conflicting recommendations for antibiotics in severe acute pancreatitis. Improved compliance with guidelines is needed to improve patient outcomes.

Artificial nutrition and bioethics issues: medical therapy or basic assistance?

Background: Artificial nutrition provides nutrients artificially to those patients who cannot take food by mouth because of their pathological condition. Artificial nutrition is the therapeutical approach in case of protein-energy malnutrition, which is secondary to many conditions which do not allow to take food by mouth. In the last years the use of artificial nutrition has increased, both in hospitals and in the territory, because of the improvement of techniques and of the increasing knowledge of doctors and people and an increasing number of conditions benefit from it. In a temporary or permanent way, artificial nutrition sets important bioethical issues, as it substitutes the function deficit of the gastroenteric system, which is in charge of natural food intake. It is understandable that in human conscience and culture, food and drinking are very strictly related to life more than any other vital function. This concept is stressed by the phrase: ‘‘Give drink to the thirsty and food to the starving’’, that influences the Christian western culture we live in. Materials and methods: The main documents produced by laymen, Italian Catholic Religion institutions, and scientific societies and the medical ethical code have been analyzed with particular attention to whether artificial nutrition should be considered as a medical therapy or as basic assistance, together with the different ethical consequences on its suspension. Conclusions: Even if the doctor is not a specialist of the field and he has to deal with patients subject to artificial nutrition, he must be aware of the bioethical issues that this technique involves, in order to use it in the best way and to develop his own opinion towards it. The review of the documents presented here cannot be considered to be exhaustive, as this topic continuously evolves.

OHP-061 Parenteral Nutrition: Standarized Process from Prescription to Preparation

BackgroundIt is widely recognised that Total Parenteral Nutrition (TPN) is essential for the patient’s survival and not just for simple assistance. Therefore, it’s important that sufficient attention is devoted to...

A National Observational Study of the Prevalence and Use of Enteral Tube Feeding, Parenteral Nutrition and Intravenous Glucose in Cancer Patients Enrolled in Specialized Palliative Care

The use of artificial nutrition remains controversial for cancer patients in palliative care, and its prevalence is largely unknown. We therefore conducted a national study to investigate the prevalence, indications for, and perceived benefit of enteral/parenteral nutrition and intravenous glucose in this patient group. A cross-sectional study was performed within the palliative care research network in Sweden (PANIS), using a web-based survey with 24 questions on demographics, prescribed nutritional treatment, estimated survival and benefit from treatment. Data was received from 32 palliative care units throughout the country, representing 1083 patients with gastrointestinal and gynecological malignancies being the most common diagnoses. Thirteen percent of the patients received enteral/parenteral nutrition or intravenous glucose. Parenteral nutrition (PN) was significantly more common in home care units serving the urban Stockholm region (11%) than in other parts of the country (4%). Weight and appetite loss were the predominant indications for PN, with this treatment deemed beneficial for 75% of the palliative patients. Data show that there was great variation in PN use within the country. PN was predominately initiated when patients had weight and appetite loss but still had oral intake, indicating a use of PN that extends beyond the traditional use for patients with obstruction/semi obstruction.

An End-of-Life Order Set Is Associated With Improved Pain Control and Decreased Artificial Nutrition Use for Terminally Ill Pediatric Hematology-Oncology Patients At a Tertiary Cancer Center (732)

An End-of-Life Order Set Is Associated With Improved Pain Control and Decreased Artificial Nutrition Use for Terminally Ill Pediatric Hematology-Oncology Patients At a Tertiary Cancer Center (732)

Leitlinien und Standards zur Ernährung in der Geriatrie

Nutritional problems and deficiencies are widespread in geriatric institutions. On the other hand, benefits of different interventions to improve the nutritional situation of elderly people--from amelioration of mealtime ambience to the use of artificial nutrition--have been shown in many studies. In recent years, several guidelines and standards have been developed to facilitate the transfer of this scientific knowledge into practice. These are in particular the medical Guidelines for Enteral and Parenteral Nutrition in Geriatrics (DGEM/DGG and ESPEN), the DNQP Expert Standard for qualified nurses, the DGE Quality Standards for dietetic personnel, and the interdisciplinary BUKO-QS Standard. These guidelines and standards provide recommendations for adequate nutritional care and assistance for the institutionalized elderly person based on the scientific state of the art. They should be used as the basis for the development of local instructions for the management of nutritional problems and malnutrition. Elderly people will only profit, if these guidelines are used in daily routine.

Artificial nutrition and hydration: the evolution of ethics, evidence, and policy.

The debate over use of artificial nutrition and hydration (ANH) in terminal illness, including advanced dementia, remains contentious despite extensive ethical and empirical investigation. For this narrative review we undertook a focused, selective review of literature reflecting ethical analysis, empirical assessment of outcomes, legal responses, and thinking within the Roman Catholic religious tradition. The history of the debate over the past 60 years results from a complex interplay of ethical concerns, a growing empirical database, legal changes, public opinion, and financial as well as institutional concerns. Discussions of ANH today are often conducted without any understanding of this historical context. Patients' interests could be better protected through remedial action at both the individual and the policy levels.

Perspectives on Directive 58.

The United States Conference of Catholic Bishops recently revised directive 58, on the use of artificial nutrition and hydration, in its Ethical and Religious Directives for Catholic Health Care Services. Although the revision clarifies that the use of artificial nutrition and hydration is ordinary, proportionate, and therefore, in principle, morally obligatory, the ethical debate surrounding this issue continues. Furthermore, many clinicians remain confused about the implications of this directive, as well as its application to specific cases. This article seeks to clarify both the implications and the practical application of directive 58, pointing out that providing artificial nutrition and hydration is part of normal care giving, and there are few instances in which such care can be licitly withheld or withdrawn from a patient.

Withholding or withdrawing nutrition at the end of life

Food and fluids are essential to life and play important social and psychological roles. Despite increased understanding of the appropriate use of artificial nutrition, its use is particularly challenging for professionals and families. This may be complicated by misunderstanding about its likely benefits and burdens, concern about patient suffering and ambivalence regarding the moral status of feeding. When patients are unable to meet their fluid and nutritional needs orally it is necessary to consider whether artificial nutrition is appropriate. Therapeutic decisions should be based on a clear understanding of the overall goals of care and the application of ethical principles that can provide a framework to guide practice.

Whoʼs Following Guidelines? Poor Compliance Regarding Nutrition and Antibiotics in the Management of Acute Pancreatitis: 2010 ACG/AstraZeneca Fellow Award

Purpose: Mortality rates of acute pancreatitis (AP) have not improved despite the emergence of national guidelines (Banks ACG 2006, Forsmark AGA 2007). The approach to nutritional support and antibiotics in the management of AP has evolved over the past decade, with an emphasis on enteral nutrition and restricted antibiotic (ABX) use. The aim of this survey was to evaluate adherence to current guidelines with regard to the use of artificial nutrition and antibiotics. Methods: A 20 question survey was created, addressing physician attitudes toward the use of nutrition and antibiotics in AP. This survey was distributed to physicians at multiple regional and national conferences between 2009 and 2010. Results: 549 physicians completed the survey; responses were compared between: full time academic (n=180) vs. private-practice (n=188); gastroenterologists (n=180) vs. primary care physicians (PCPs)(n=260). Current guidelines recommend nasojejunal tube (NJ) feeding as the preferred route when initiating artificial nutrition in AP. 49% of academic physicians and only 20% of private-practice physicians chose NJ tube feeding as the preferred route (p<0.0001). 31% of gastroenterologists and 39% of PCPs chose NJ tube feeding as the preferred route (p=NS). Current guidelines do not recommend parenteral nutrition in the initial management of AP. Only 23% of academic physicians chose TPN/PPN as opposed to 70% of private-practice physicians (p<0.0001). 44% of gastroenterologists and 43% of PCPs chose TPN/PPN as the preferred route of initiating artificial nutrition in AP (p=NS). 53% of academic physicians state they always try to initiate enteral feeding first before using TPN/PPN compared to only 15% of private practice responders (p<0.0001). Based on current guidelines, fever and infection prophylaxis in patients (without pancreatic necrosis) are not indications to start ABX. 60% of academic physicians and 67% of private-practice responders cite fever or infection prophylaxis as primary reasons to start ABX in patients with AP. Both gastroenterologists and PCPs chose appropriate indications for starting antibiotics in severe acute pancreatitis. Gastroenterologists chose necrosis and positive cultures while PCPs chose necrosis and fever/positive cultures. Conclusion: Most physicians are not compliant with national AP guidelines with regard to nutrition and antibiotics. Gastroenterologists and PCPs are equally poor in compliance with regards to nutrition. Academic physicians adhere to guidelines more closely than private practice physicians. Greater understanding and compliance with current guidelines is necessary to reducing mortality in AP.

Artificial nutrition and hydration for patients with advanced dementia: perspectives from medical practitioners in the Netherlands and Australia

The appropriate use of artificial nutrition or hydration (ANH) for patients with advanced dementia continues to be a subject of debate. We investigated opinions of Dutch and Australian doctors about the use of ANH in patients with advanced dementia. We interviewed 15 Dutch doctors and 16 Australian doctors who care for patients with advanced dementia. We transcribed and analysed the interviews and held consensus meetings about the interpretation. We found that Dutch and Australian doctors use similar medical considerations when they decide about the use of ANH. In general, they are reluctant to start ANH. Disparities between the Dutch and Australian doctors are related to the process of decision-making: Dutch doctors seem to put more emphasis on a comprehensive assessment of the patient’s actual situation, whereas Australian doctors are more inclined to use scientific evidence and advance directives. Furthermore, Dutch doctors take the primary responsibility themselves whereas Australian general practitioners seem to be more inclined to leave the decision to the family. It seems that Dutch and Australian doctors use somewhat different care approaches for patients with advanced dementia. Combining the Dutch comprehensive approach and the Australian analytic approach may serve the interest of patients and their families best.

Nutrizione artificiale e aspetti di bioetica: terapia medica o assistenza di base?

Background Artificial nutrition provides nutrients artificially to those patients who cannot take food by mouth because of their pathological condition. Artificial nutrition is the therapeutical approach in case of protein-energy malnutrition, which is secondary to many conditions which do not allow to take food by mouth. In the last years the use of artificial nutrition has increased, both in hospitals and in the territory, because of the improvement of techniques and of the increasing knowledge of doctors and people and an increasing number of conditions benefit from it. In a temporary or permanent way, artificial nutrition sets important bioethical issues, as it substitutes the function deficit of the gastroenteric system, which is in charge of natural food intake. It is understandable that in human conscience and culture, food and drinking are very strictly related to life more than any other vital function. This concept is stressed by the phrase: “Give drink to the thirsty and food to the starving”, that influences the Christian western culture we live in. Materials and methods The main documents produced by laymen, Italian Catholic Religion institutions, and scientific societies and the medical ethical code have been analyzed with particular attention to whether artificial nutrition should be considered as a medical therapy or as basic assistance, together with the different ethical consequences on its suspension. Conclusions Even if the doctor is not a specialist of the field and he has to deal with patients subject to artificial nutrition, he must be aware of the bioethical issues that this technique involves, in order to use it in the best way and to develop his own opinion towards it. The review of the documents presented here cannot be considered to be exhaustive, as this topic continuously evolves.

The use of artificial nutrition among cancer patients enrolled in palliative home care services

In this study, patients’ views and experiences of using home artificial nutrition, and factors associated with use of home parenteral nutrition (HPN) were investigated. Structured telephone interviews with 620 cancer patients enrolled in 21 palliative home care services were analysed. HPN was more common (11%) than home enteral tube feeding (HETF, 3%). Home artificial nutrition (including HPN and HETF) was usually introduced more than four months before death. Three of four HPN recipients also had oral food intake. HPN use was associated with eating difficulties, nausea/vomiting, and fatigue rather than gastrointestinal problems per se. HETF was generally used for patients with problems related to oesophagus and head and neck tumours. In conclusion the results suggest that, contrary to existing guidelines, HPN is used to supplement oral intake, and not only for patients with a non-functioning gastrointestinal tract.

The Artificial Nutrition Debate: Still an Issue… After All These Years

Debate over withdrawal or withholding of artificial nutrition appeared a distant discussion until the furor over the Schiavo case and a Papal Allocation reignited this ethical dilemma. The purpose of this article is to provide a review of the bioethical opinion regarding artificial nutrition, as published in the Hastings Center Report from 1971 until 2007. A clinical and religious history of the evolution and use of artificial nutrition prefaces the review containing common themes and categories framed within a chronology of bioethical and legal events. Finally, an interpretative philosophical discussion is offered on the resurgence of the ethical dilemma concerning withdrawal or withholding of artificial nutrition. Through a combination of classic content analysis and grounded theory, 8 inductively derived categories emerged from a sample of 63 articles/letters with a primary focus on artificial nutrition, enteral nutrition or parenteral nutrition. These categories included illness/treatment trajectory, personhood, family, provider, cost, religion, legal, and ethics and morality. In more than 35 years, surprisingly little has changed with regard to withdrawal or withholding of artificial nutrition. As the Schiavo case revealed, despite a sense in bioethics of a firm consensus about handling the withdrawal of food and water, many are still searching for answers to this dilemma.

Artificial nutrition and hydration: the new Catholic debate

Preface: Christopher Tollefsen Part One: The Issue 1: Why Do Unresponsive Patients Still Matter?Bishop Anthony Fisher, O.P. 2: Are We Morally Obligated to Feed PVS Patients Until Natural Death?Michael Degnan 3: Caring for Persons in the 'Persistent Vegetative State' and Pope John Paul II's March 2004 Address 'On Life-Sustaining Treatments and the Vegetative State'.William E. May 4: Food and Fluids: Human Law, Human Rights and Human Interests.Jacqueline Laing Part Two: Philosophers Address the Issue.5: Quality of Life and Assisted Nutrition.Alfonso Gomez-Lobo 6: Towards Ethical Guidelines for the Use of Artificial Nutrition and Hydration.Joseph Boyle 7: Understanding the Ethics of Artificially Providing Food and Water.J.L.A. Garcia 8: The Ethics of Pope John Paul's Allocution on Care of the PVS Patient: A Response to J.L.A. Garcia.Peter Cataldo Part Three: Symposium on the Views of Fr. Kevin O'Rourke, O.P.9: Reflections on the Papal Allocution Concerning Care for PVS Patients.Fr. Kevin O'Rourke, O.P 10:The Papal Allocution Concerning Care for PVS Patients: a Reply to Fr. O'Rourke.Patrick Lee 11: Response to Patrick Lee.Fr. Kevin O'Rourke, O.P. 12: The Morality of Tube Feeding PVS Patients: A Critique of the View of Kevin O'Rourke, O.P.Mark S. Latkovic Part Four: Concluding Reflections.12: Ten Errors Regarding End of Life Issues, and Especially Artificial Nutrition and Hydration.Christopher Tollefsen.

Immunonutrition et agression : mythes et réalités

The development of immunonutrition was built on experimental and animal data, more often than clinical data. However, in perioperative period, the clinical interest of an immune-enhanced diet is now demonstrated and recognized. The use of artificial nutrition enriched in “omega fatty acids” seems promising during ARDS. In other pathologies, severe sepsis and septic shock for example, the clinical proofs delay coming. These proofs will come, probably, from tries comparing individually each of pharmaconutrients, in stressed patients with moderate severity scores.

Liver dysfunction associated with artificial nutrition in critically ill patients

IntroductionLiver dysfunction associated with artificial nutrition in critically ill patients is a complication that seems to be frequent, but it has not been assessed previously in a large cohort of critically ill patients.MethodsWe conducted a prospective cohort study of incidence in 40 intensive care units. Different liver dysfunction patterns were defined: (a) cholestasis: alkaline phosphatase of more than 280 IU/l, gamma-glutamyl-transferase of more than 50 IU/l, or bilirubin of more than 1.2 mg/dl; (b) liver necrosis: aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l, plus bilirubin of more than 1.2 mg/dl or international normalized ratio of more than 1.4; and (c) mixed pattern: alkaline phosphatase of more than 280 IU/l or gamma-glutamyl-transferase of more than 50 IU/l, plus aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l.ResultsSeven hundred and twenty-five of 3,409 patients received artificial nutrition: 303 received total parenteral nutrition (TPN) and 422 received enteral nutrition (EN). Twenty-three percent of patients developed liver dysfunction: 30% in the TPN group and 18% in the EN group. The univariate analysis showed an association between liver dysfunction and TPN (p < 0.001), Multiple Organ Dysfunction Score on admission (p < 0.001), sepsis (p < 0.001), early use of artificial nutrition (p < 0.03), and malnutrition (p < 0.01). In the multivariate analysis, liver dysfunction was associated with TPN (p < 0.001), sepsis (p < 0.02), early use of artificial nutrition (p < 0.03), and calculated energy requirements of more than 25 kcal/kg per day (p < 0.05).ConclusionTPN, sepsis, and excessive calculated energy requirements appear as risk factors for developing liver dysfunction. Septic critically ill patients should not be fed with excessive caloric amounts, particularly when TPN is employed. Administering artificial nutrition in the first 24 hours after admission seems to have a protective effect.

Resultados de la aplicación de un protocolo de valoración nutricional en un centro sociosanitario

The aim of this study was to determine nutritional status in 83 residents of a nursing home and to evaluate outcomes after the application of a nutritional assessment protocol designed by the Department of Social Welfare of the autonomous community of Valencia (Spain). The sample was classified according to body mass index (BMI), hypoalbuminemia and application of the geriatric nutritional risk index. Nutritional interventions consisted of applying general recommendations and follow-up in residents without malnutrition, providing adequate powdered diets in residents with chewing and swallowing disorders and risk of bronchoaspiration, adjusting total enteral nutrition in residents with nasogastric feeding tubes and initiating vitamin supplementation in residents with severe malnutrition. After 3 months, the mean BMI showed a nonsignificant increase ( P=.168), reducing the number of residents with malnutrition from 29% to 23%. The number of residents who received nutritional supplements without indication also decreased, resulting in an estimated saving of 965 euros. Active participation of the multidisciplinary team in the coordinated and continuous follow-up of nutritional status in residents contributed to achieving adequate nutritional status and improved the rational use of artificial nutrition in the nursing home.

Nutritional status determinants and cognition in the elderly

It is possible to identify risks or protective factors against dementia. Increased levels of homocysteine (HCY) and vitamin B deficiency, obesity and central adiposity in midlife are independent risk factors for the development of dementia. High dietary intake of antioxidants and ω-3 fatty acids lower the risk of Alzheimer disease (AD). The supplementation with single nutrients, like vitamin B, ω-3-polyunsaturated fatty acids (PUFA) or antioxidants is generally not effective in lowering the risk of dementia or in slowing the progression of the disease. It is probably necessary that these nutrients are part of a healthy diet (with at least five portions of fruit and vegetables per day and one portion of fish per week) during the lite where other factors interact with them as it happens in the Mediterranean diet. Nutritional strategies for modifying the clinical course of cognitive failure should consider the use of nutritional screening tools in the multidimensional geriatric evaluation. Moreover, the diet, oral supplementation, caregiver education could be important factors to prevent or treat weight loss and its consequences in AD while the use of artificial nutrition in demented patients may have questionable benefits.

Artificial nutrition and hydration at the end of life: Ethics and evidence

The case of Terri Schiavo resulted in substantial media attention about the use of artificial nutrition and hydration (ANH) especially by percutaneous endoscopic gastrostomy (PEG). In this article, I review ethical and legal principles governing decisions to choose or forgo ANH at the end of life, including issues of autonomy and decision-making capacity, similarities and differences between ANH and other medical treatments, the role of proxies when patients lack decision-making capacity, and the equivalence of withholding and withdrawing treatment. Evidence for palliative or life-sustaining benefits for ANH are reviewed in three disease processes: amyotrophic lateral sclerosis (ALS), cancer, and dementias, including Alzheimer's disease. Although more recent studies suggest a possible palliative role for ANH in ALS and terminal cancer, feeding tubes do not appear to prolong survival or increase comfort in advanced dementia of the Alzheimer's type.