What supports nutritional support?
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Acute Kidney Injury↗
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Nutritional and treatment-related characteristics of pediatric oncology patients referred or not referred for nutritional support.
Nutritional problems often result from malignancies and aggressive multimodal treatment. Early identification of reliable risk factors associated with malnutrition and need for nutritional support is necessary for development of preventative approaches. Nutritional and treatment-related characteristics were examined for 173 pediatric oncology patients referred for nutritional support and a comparison sample of 43 patients matched on treatment protocol and/or diagnosis who had never been referred for nutritional support. Abnormally low serum albumin levels, poor oral intake, mucositis, prior radiation therapy, and increased gastrointestinal toxicity were significantly more frequent among referred than non-referred patients. A discriminant function analysis indicated that poor oral intake was the single best predictor of need for nutritional support. Patients with solid tumors were more nutritionally depleted at the time of referral; all bone marrow transplant patients received nutritional support. Patients with central nervous system (CNS) tumors required nutritional support for longer time periods. We conclude that routine documentation of poor oral intake (i.e., observation of change in a child's eating patterns) is the most reliable indicator of children who eventually require nutritional support and who may benefit from interventions that could delay or prevent nutritional problems. Prophylactic interventions should be tailored to meet the specific needs of individual diagnostic groups.
Adolescent↗
Clinical economics review: nutritional support.
Nutritional support currently accounts for about 1% of the total health care costs in the USA. Interestingly, most of the prospective randomized controlled trials to date have not been able to demonstrate that this therapeutic intervention alters morbidity or mortality. In fact, parenteral nutritional support may predispose the recipients to developing systemic infections. There have been a few areas in which nutritional support may be of benefit. Enteral supplements given to underweight women who suffer hip fractures reduce the hospital stay and, presumably, overall cost. Preoperative parenteral nutritional support may produce a small absolute reduction in post-operative morbidity, but its cost becomes prohibitive. Preoperative enteral nutritional support, especially if carried out in the home, may be of benefit (using the most optimistic interpretation of a small number of trials); if so, it is an economically defensible intervention. Particular nutrients or diets may have specific effects on certain disease processes. Indirect comparisons have suggested that elemental diets can be used to treat flares of Crohn's disease (perhaps because putative food antigens are removed). However, corticosteroid therapy is more efficacious. Furthermore, it is less expensive to employ 6-mercaptopurine as the next modality in steroid failures. Branched-chain amino acid infusions may have some effect on hepatic encephalopathy, but again, lactulose is less expensive. Nutritional support is one area of medicine in which there has been far more enthusiasm than the data justify. Disease-associated malnutrition probably is a secondary phenomenon, not an important cause of morbidity. The widespread use of this modality cannot be justified in a cost-constrained health care system.
Critical Illness↗
What is optimal nutritional support?
Nutritional support of the seriously ill patient has evolved with time and reflects new developments in the field of critical care. Current information suggests that optimal nutritional support can be provided by supplying at least 80% of energy requirements with at least 70% of the energy given as carbohydrate and the remaining 30% or less administered as fat (with > or = 3% of energy requirements as essential fatty acids). The caloric load may be reduced to 50% of requirements if growth factors (e.g., growth hormone) are utilized and the patient has adequate fat stores. Protein should be given as 1.5 g/kg/day; more catabolic patients, such as patients with burn injury, should receive 2 g/kg/day. All protein or amino acid feeding should include glutamine. There is an increased need for vitamins (especially A, C, and E) and minerals (zinc, selenium, and magnesium). The preferred route of feeding should be enteral, followed by enteral plus supplemental parenteral nutrition. If the gastrointestinal tract cannot be used, parenteral nutrition should be given. Nutrients should be administered early in the catabolic course, especially glucose, sodium, potassium, vitamins, and minerals. Over time (approximately 7 days) amino acids should be added and approximately 50% of caloric support should be provided. Finally, full nutritional support should be provided (by 7 to 10 days) if the catabolic course is expected to continue.
Amino Acids↗
Hospital-made diet versus commercial supplement in postburn nutritional support.
Nutritional support is an important aspect of the management of burn patients. Nutrition supplementation can be achieved either by 'hospital-made' or 'commercial' diets. Commercial diets are efficacious but expensive and sometimes not easily available. This study was undertaken to compare the efficacy and tolerance of a hospital-made diet with a commercial diet. Twenty patients with burns ranging from 20-50 per cent TBSA were studied to compare the efficacy and tolerance of the 'hospital-made' diet with 'commercial' preparations. Patients were divided into two groups of 10 each and randomised within each group to receive either a hospital-made diet (five patients) or a commercial diet (five patients). Efficacy of diet was assessed by evaluation of nutritional status, graft take, number of surgical procedures and duration of hospital stay. Tolerance was assessed by recording side effects such as nausea, vomiting, abdominal distention and diarrhoea. Both diets were well tolerated by all patients. There was no significant difference in nutritional status, number of surgical procedures, percentage of graft take and duration of hospital stay on either diet, suggesting that hospital-made diets are similar in efficacy and tolerance but cheaper and more easily available. They are a good alternative to 'commercial' diets, especially in poor patients.
Adolescent↗
Alternative ways of facilitating nutritional support without a nutrition support team.
In the absence of a formal nutritional support team, a group of physicians, pharmacists, dietitians, and nurses at the authors' institution organized to devise alternative ways to facilitate nutritional support. The efforts of this group led to the redesign of the Pharmacy Department's parenteral nutrition order form into a clinical tool for the prescribing physician, and the development of a system for daily patient monitoring by dietitians and pharmacists for patients receiving specialized nutritional products. The delivery of parenteral nutrition was also streamlined to coordinate with the daily patient monitoring. A future goal is to increase three-way communication and teamwork among the physicians, dietitians, and pharmacists. These methods may be practical alternatives to facilitating nutritional support without the benefit of a support team.
Clinical Pharmacy Information Systems↗
Task Force on Nutrition Support in AIDS. Guidelines for nutrition support in AIDS.
The nutritional status of people with AIDS is challenged throughout the progression of the illness by the manifestation of symptoms such as malabsorption, diarrhea, candidiasis, and fever. As yet, there is no widely accepted method for nutritional management of AIDS. Therefore, a Task Force on Nutrition Support in AIDS was formed to develop practical recommendations for those involved in the management of this patient population. The "Guidelines for Nutrition Support in AIDS" are aimed at improving nutritional status, alleviating symptoms, and enhancing quality of life at each stage of the disease. The Task Force concluded that optimizing the nutritional status of people with AIDs, through aggressive nutritional therapy, is essential in overall medical management; nutrition intervention and education is indicated as early in the disease progression as HIV diagnosis; thorough nutritional assessment and regular monitoring is advocated; and enteral feedings should be considered the first line of nutrition support therapy.
Acquired Immunodeficiency Syndrome↗
Effect of nutritional support on routine nutrition assessment parameters and body composition in intensive care unit patients.
OBJECTIVES: To determine whether routine nutrition assessment parameters and body composition change after nutritional support in intensive care unit (ICU) patients and whether the changes, if any, are related to cumulative energy and fluid balances. DESIGN: A prospective study. SETTING: A university teaching hospital. PATIENTS: Forty-five mechanically ventilated medical and surgical patients admitted to the ICU who received nutritional support for 7 days (group 1) and 9 patients of this group who received nutritional support for 3 weeks or longer (group 2). INTERVENTIONS: Enteral and parenteral nutritional support prescribed on the basis of metabolic cart measurements of energy expenditure. OUTCOME MEASURES: Routine nutrition assessment, including determinations of weight, serum albumin and prealbumin, and lymphocyte count and body composition, including measurements of body cell mass, extracellular fluid and body fat, determined from bioelectric impedance analysis. RESULTS: In group 1 patients, weight, albumin and prealbumin levels, and extracellular mass changed, but there was no change in lymphocyte count, body cell mass or body fat. Changes in weight and extracellular mass were slightly related to cumulative fluid balance; changes in albumin and prealbumin levels were not related to cumulative energy or fluid balance. The findings were similar for group 2 patients. CONCLUSIONS: Changes in routine nutrition assessment parameters and body composition are slightly affected by fluid balance but not by energy balance; thus, they are not specific indicators of the adequacy of nutritional support in ICU patients. Improved nutrition assessment parameters are required to better monitor the response to nutritional support in critically ill patients.
Body Composition↗
Ethical issues in nutritional support nursing. Withholding and withdrawing nutritional support.
A new and controversial debate in bioethics concerns the question, "Is it ever acceptable to withhold or withdraw specialized nutritional support from the dying adult patient?" In the opinion of many, the answer to this question is yes, but for only a very small number of patients. Provision of nutrition through artificial means is an invasive medical intervention. As such, procedures for supplying nutritional support impose burdens as well as provide benefits and may, under certain circumstances, be foregone. However, the needs of the vast majority of dying patients will best be served by providing specialized nutritional support.
Adult↗
Guidelines for nutrition support in AIDS. Task Force on Nutrition Support in AIDS.
The nutritional status of people with AIDS is challenged throughout the progression of the illness by the manifestation of symptoms such as malabsorption, diarrhea, candidiasis, and fever. As yet, there is no widely accepted method for nutritional management of AIDS. Therefore, a Task Force on Nutrition Support in AIDS was formed to develop practical recommendations for those involved in the management of this patient population. The "Guidelines for Nutrition Support in AIDS" are aimed at improving nutritional status, alleviating symptoms, and enhancing quality of life at each stage of the disease. The Task Force concluded that optimizing the nutritional status of people with AIDS, through aggressive nutritional therapy, is essential in overall medical management; nutrition intervention and education is indicated as early in the disease progression as HIV diagnosis; thorough nutritional assessment and regular monitoring is advocated; and enteral feedings should be considered the first line of nutrition support therapy.
Acquired Immunodeficiency Syndrome↗
The role of nutrition support dietitians as viewed by chief clinical and nutrition support dietitians: implications for training.
OBJECTIVES: To determine current and ideal frequencies with which nutrition support dietitians perform each item on a list of 15 tasks and evaluate dietitian preparation for the practice of nutrition support. DESIGN: Data were collected using two questionnaires, one completed by the chief clinical dietitian and the other completed by the nutrition support dietitian at each hospital surveyed. Both versions of the questionnaires contained a list of 15 tasks that had been validated as being related to advanced nutrition support by a panel of 20 nutrition support experts using a modified Delphi method. Follow-up telephone calls were made to increase the number of responses. SAMPLE: Questionnaires were mailed to the chief clinical dietitian at 300 randomly selected, general medical/surgical hospitals with 300 or more beds in the United States and Puerto Rico. A total of 134 chief clinical dietitians (45%) and 129 nutrition support dietitians (43%) responded to the surveys; 124 (41%) and 120 (40%) questionnaires, respectively, were usable for statistical analyses. STATISTICAL ANALYSES: The Wilcoxon matched-pairs signed-ranks test was used to determine differences between nutrition support dietitian actual and ideal frequencies and between chief clinical dietitian actual and ideal frequencies for each of the 15 tasks. The Mann-Whitney U-Wilcoxon rank sum W test was used to determine differences between nutrition support dietitian and chief clinical dietitian actual frequencies and between nutrition support dietitian and chief clinical dietitian ideal frequencies for each of the 15 tasks. Descriptive statistics were used to analyze the questions regarding educational preparation for nutrition support practice and demographic data. RESULTS: The ideal frequency for each of the 15 tasks was significantly greater (P < .0001) than the actual frequency reported by nutrition support dietitians and chief clinical dietitians. Whereas chief clinical dietitians and nutrition support dietitians agreed on the ideal frequency for most tasks, the nutrition support dietitian ideal frequency indicated for the tasks "determines macronutrient composition of parenteral nutrition" and "performs physical examinations related to nutritional status, fluid status, and gastrointestinal function" was significantly greater (P < .001, P < .05), respectively) than the ideal frequency indicated by chief clinical dietitians. Of the nutrition support dietitians, 79% agreed and 16% somewhat agreed that experiences beyond those required for becoming a registered dietitian are needed to provide nutrition support dietitians with specialized clinical skills. APPLICATIONS/CONCLUSIONS: Nutrition support dietitians desire increased responsibility for delivering nutrition support to their patients and this desire is largely supported by chief clinical dietitians. Nutrition support dietitians appear to have a strong interest in postregistration qualifying experiences that would provide a foundation for expanding their roles. According to the results of this study, programs designed to provide practical, clinical experience in nutrition support are needed.
Attitude of Health Personnel↗
Staffing patterns in hospital clinical dietetics and nutrition support: a survey conducted by the Dietitians in Nutrition Support dietetic practice group.
The Dietitians in Nutrition Support dietetic practice group of The American Dietetic Association administered a questionnaire to evaluate changes in nutrition support services provided to hospitalized patients and home patients in 1989 and compared the results with results of a survey administered in 1986. The 1986 survey documented an increase in tube feeding to inpatients during 1984 to 1986 and greater dietitian staffing in tertiary care hospitals than in primary care hospitals and in larger hospitals in 1986. The 1989 questionnaire was mailed to clinical nutrition managers from a nationwide random sample of 1,000 hospitals from American Hospital Association members; 271 responses were received. Full-time equivalent (FTE) registered dietitians (RDs)--including clinical RDs, nutrition support service RDs, and clinical nutrition managers--decreased 11% from 1986 to 1989. FTE dietetic technicians decreased 22%. The number of FTE nutrition support service RDs and clinical nutrition managers decreased significantly (P less than .05). The mean number of FTE clinical dietitians per 100 beds decreased from 1.4 to 1.0 from 1986 to 1989. These decreases in dietetics staffing occurred despite an overall increase in total hospital FTE staff of 2.9%. Reported daily provision of nutrition support modalities to inpatients was 3.5% for parenteral nutrition, 4.9% for enteral tube feeding, and 9.6% for oral supplements. Decreased dietetics staffing was accompanied by other factors that negatively affect productivity (and therefore ability to provide adequate patient care), including inadequate delegation of technical tasks to dietetic technicians, limited availability of secretarial and computer support, and minimal provision of pocket pagers. These trends may be evidence of inadequacy of dietetics staffing to meet the needs of the US population for nutrition care.
Dietary Services↗
DRGs and specialized nutrition support. Prospective payment and nutritional support: the need for reform.
The Medicare Prospective Payment System does not recognize the use of parenteral and enteral nutrition services as an explicit factor to be used in determination of DRG payment rates. When the DRGs were originally created, the use of parenteral and enteral nutrition services (PENS) was not coded in discharge data sets. As a result, it was impossible to determine whether patients who received PENS were more expensive to treat. Data we have collected indicate that patients who receive PENS tend to have high hospital costs--costs that often exceed the DRG payments established by the Health Care Financing Administration (HCFA). The potential for a hospital to incur a financial loss as a result of treating patients who require PENS could make such patients less attractive to hospitals and thus could adversely affect patients requiring these services. In order to minimize this possibility, we suggest several alternative modifications to the DRG payment system. The modifications would provide higher payments for patients who require PENS, thereby reducing the possibility of discrimination against these patients. By readjusting the DRG prices for patients who do not require PENS, the entire payment modification can be made budget-neutral.
Costs and Cost Analysis↗
Gut mucosal nutritional support--enteral nutrition as primary therapy after multiple system trauma.
Over the past 10 years, several clinical and experimental studies report the potential benefit of enteral nutrition as primary therapy after multiple system trauma. In this study, 98 patients sustaining blunt and penetrating trauma were randomised to receive either enteral or parenteral feeding for 15 days. There were significantly fewer infectious complications in patients randomised to receive enteral feeding with particular benefit shown in the most severely injured patients. Serum protein concentrations correlated with the clinical outcome with an increase in constitutive protein and decrease in acute phase protein concentrations occurring in the enteral group through a decrease in septic complications and possible direct hepatic 'reprioritisation'. Enteral feeding serves as a primary therapy affecting the outcome of critically ill patients.
Adult↗
Gut Mucosal Nutritional Support--Enteral Nutrition as Primary Therapy? Proceedings of the Abbott Ross Research Conference. Vevey, Switzerland , 28-30 June 1992.
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Bacterial Infections↗
The outcome of surgical treatment as related to the response of the serum albumin level to nutritional support.
Selected nutritional parameters were studied in critically ill surgical patients maintained by parenteral-enteral nutritional support to delineate the nutritional deficits and relate the course of these patients to the nutritional status. Twenty-one of 34 patients had albumin levels of less than 3.5 grams per cent upon admission, and the albumin levels decreased even further after admission. The patients with traumatic injuries had the greatest loss in body weight and urinary nitrogen excretion. Although such large numbers of these patients had depressed serum albumin levels, the survivors were able to increase the serum albumin level to 3.5 grams per cent with intense nutritional support, whereas those not surviving such support were not able to increase the serum albumin level. The response of the serum albumin level to nutritional support is a good indicator as to the same factors preventing survival and effective use of the nutritional elements.
Enteral Nutrition↗
The role of the gastroenterologist in the provision of artificial nutrition support.
BACKGROUND: Nutrition support is required for the prevention or treatment of malnutrition in patients with intestinal failure and those who are unable to eat. AIMS: To determine the demands upon gastroenterologists for nutrition support, the available resources, and compliance with the British Society of Gastroenterology (BSG) guidelines. METHOD: A questionnaire was circulated to all 483 consultant physician members of the BSG. RESULTS: There were 336 (70%) replies. Fifty-three per cent of respondents reported malnutrition in 20% or more of their patients. Seventy-nine per cent of consultants supervised patients on enteral feeding, and 64% supervised parenteral feeding. Feeding jejunostomy was used by 61% of Teaching Hospital (TH) consultants but only 38% of District General Hospital (DGH) consultants (P < 0.001). Twenty-seven per cent of respondents headed, or were members of, a nutrition support team (NST). Forty-five and 38% of respondents did not follow written protocols for peripheral and central parenteral nutrition, respectively. Fifty-five per cent monitored catheter complications, of whom 44% reported catheter infections in 5% or more of their patients. Weights of inpatients were obtained by 76% of DGH consultants and 91% of TH consultants (P < 0.001). Fifty-eight per cent of respondents did not arrange for nutritional screening. Ninety-six per cent of consultants could access a dietitian, 55% had access to an NST and 36% had a nutrition nurse specialist (NNS). An NNS was available to 57% of TH consultants but only 23% of DGH consultants (P < 0.001). CONCLUSIONS: Gastroenterologists have a major role in nutrition support. Facilities are suboptimal. Observing guidelines may improve nutritional care. These findings have implications for resources and training.
Data Collection↗
Nutritional support team vs nonteam management of enteral nutritional support in a Veterans Administration Medical Center teaching hospital.
One hundred one patients receiving enteral nutritional support (ENS) by tube feeding during a 5-month period were prospectively studied. Fifty patients were managed by a nutritional support team (T) and 51 patients were managed by the nonteam approach (NT). Demographics, primary diagnosis, chronic diseases, medical service, calculated basal energy expenditure (BEE), duration of ENS, and final patient disposition were recorded. Enteral formula, formula modifications, results of laboratory tests and calories delivered were obtained daily. Results of nitrogen balance studies were obtained when available and each patient was monitored for pulmonary, mechanical, gastrointestinal, and metabolic abnormalities. No significant difference was found between the team and nonteam managed groups in regard to total feeding days, mean feeding days per patient, total laboratory tests, laboratory tests per patient or laboratory tests per day. Significantly more team patients attained 1.2 times BEE (T = 47, NT = 38, p less than 0.05) for a significantly greater period of time (T = 398 days, NT = 281 days, p less than 0.05). Significantly more team patients achieved a measured positive nitrogen balance than nonteam patients (T = 42, NT = 1, p less than 0.05). Formula modifications to correct nutritional or metabolic aberrations were made in 15 (30%) team patients and five (9.8%) nonteam patients (p less than 0.05). The number of individual abnormalities (pulmonary, mechanical, gastrointestinal, and metabolic), as well as total abnormalities occurring in the team-managed group, was significantly lower than in the nonteam managed group (160 vs 695, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗