[英文版]美国临床营养学优秀论文
Clinical Nutrition Week 2010 Nutrition Practice Abstracts
Abstracts of Distinction - BEST ABSTRACT
Nutr Clin Pract. 2010 Feb;25(1):92-3.
P1 - The Prevalence of Hypoglycemia among Patients Receiving Concomitant Parenteral Nutrition Support and Insulin Therapy.Kelly Kinnare, MS RD CNSD; Sarah Peterson, MS RD CNSD; Diane Sowa, MBA RD.Food and Nutrition, Rush University Medical Center, Chicago, IL.
Introduction: Hyperglycemia is prevalent among patients requiring parenteral nutrition (PN) due to pre-existing diabetes or severe stress. The benefits of tight blood glucose (BG) control have been observed in the literature. Among patients requiring PN, hyperglycemia can be treated by continuous insulin infusion in the intensive care unit (ICU), addition of insulin to the PN solution or subcutaneous injection. Insulin therapy can be managed by the primary service, nutrition support team (NST) or Endocrinology with the aim of achieving BG ＆#118alues in an optimal range. Achievement of tight BG control is challenging and potentially associated with increased risk of hypoglycemia. The objective of this study was to determine the prevalence of hypoglycemia and identify the causes for hypoglycemia among patients receiving concomitant PN and insulin therapy. Methods: A retrospective chart review was completed to evaluate 734 adult patients requiring PN from January 1, 2008-June 30, 2009 in an academic medical center. Average blood glucose was determined using the first serum BG level of each day. All serum and point-of-care glucose ＆#118alues during PN infusion were evaluated for hypoglycemia, defined as less than 60 milligrams per deciliter (mg/dL). All methods of insulin administration were recorded: insulin drip, insulin in the PN and long-acting subcutaneous insulin. Chi-square tests were used to determine the association between hypoglycemia and patient treatment characteristics. Results: Mean serum BG was 134.2 mg/dL and mean days on PN was 9.1 days for the entire group. Sixteen percent of patients (120/734) required an insulin drip while receiving PN, while 40 percent (296/734) required the addition of insulin to the PN solution for BG management. Sixty-one patients (8%) developed at least one hypoglycemic episode; 38% (24/61), 30% (18/61) and 23% (14/61) of patient hypoglycemic events were attributed to an insulin drip, insulin in the PN solution while managed by Endocrinology and insulin in the PN solution while managed by a NST, respectively. The prevalence of hypoglycemia was significantly higher among patients: in the ICU (p<0.0001), receiving an insulin drip (p<0.0001), receiving insulin in PN (p<0.0001), receiving long acting insulin (p<0.0001), followed by an Endocrinology service (p<0.0001), on surgical floors (p=0.001) and with a previous history of diabetes (p=0.001). Upon evaluation of 2008 quality improvement results, treatment of hyperglycemia was modified by the NST. There was a trend towards a decrease in hypoglycemia: 12% (27/217) in January-June 2008 compared to 8% (19/245) in January-June 2009 (p=NS). Conclusions: Despite close BG monitoring, hypoglycemia is a complication observed in patients receiving concomitant PN support and insulin therapy. The results of this study indicate a higher prevalence of hypoglycemia among patients located in an ICU, receiving an insulin drip, receiving insulin in PN, receiving long acting insulin, followed by an Endocrinology service, on surgical floors, and with a previous history of diabetes. With the identification of patient factors which contribute to a higher prevalence of hypoglycemia, existing protocols can be modified to treat hyperglycemia and prevent hypoglycemia from occurring.
Clinical Nutrition Week 2010 Nutrition Practice Abstracts
Abstracts of Distinction
Nutr Clin Pract. 2010 Feb;25(1):93.
P2 -The Use of Prealbumin and C-Reactive Protein for Monitoring Nutrition Support in Adult Patients Receiving Enteral Nutrition in an Urban Medical Center.Cassie Davis, MS RD; Diane Sowa, MBA RD; Kathryn Keim, PhD RD; Kelly Kinnare, MS RD CNSD.Food and Nutrition, Rush University Medical Center, Chicago, IL.
Introduction: Prealbumin (PAB) is commonly used as a marker to assess protein status and is therefore also used to monitor a patient's response to nutrition support. The ability of PAB to adequately assess protein status may be influenced by the presence and severity of the inflammatory response because the liver preferentially synthesizes acute phase proteins such as C-reactive protein (CRP) at the expense of PAB in the presence of inflammation. The purpose of this study was to determine whether changes in PAB are reflective of the delivery of adequate calories and protein or of changes in inflammatory status in hospitalized adults, greater than 18 years of age, receiving enteral nutrition (EN) on all patient care units, except Maternity and Psychiatric units. Methods: A retrospective review was conducted on 154 adult patients who received EN for more than three days and had at least two measures of PAB. Calorie requirements were calculated (30-35 kcal/kg) based on actual or adjusted body weight and individualized to patients' needs. Protein requirements were calculated (0.9 -2.5 g/kg) based on body weight and clinical condition. Calorie and protein intake was compared to changes in PAB, assessed at baseline and twice a week for up to 30 days. C-reactive protein was assessed when PAB was less than 18 mg/ dL. Approval for the study was obtained from the Institutional Review Board for Human Subjects. SPSS for Windows (version 15.0, 2006, SPSS Inc, Chicago, IL) was used for statistical analysis. Results: Mean calorie and protein requirements were 1966 +/-353 kcal/day and 109.8 +/-31.4 g protein/day, respectively. Fifty-seven percent of calorie needs and 56% of protein needs were delivered. Subjects were divided into tertiles based on percent calories and protein delivered. Percent of calorie requirements delivered for the first tertile (n=52) was 4-50%, second tertile (n=54) was 51-68%, and third tertile (n=48) was 69-114%. Percent of protein requirements delivered for the first tertile (n=54) was 4-48%, the second tertile (n=52) was 49-65%, and the third tertile (n=48) was 66-143%. One-way ANOVA were conducted for both calories and protein based on tertiles of percent calories and protein delivered. There was no significant difference in change in PAB among the three tertiles for either percent calories delivered: F (2, 151)=1.005, p=0.37 or protein delivered: F (2, 151)=1.906, p=0.15. C-reactive protein was analyzed to account for the presence or absence of inflammation. Change in CRP was negatively correlated with change in PAB (r =-0.544, p<0.001). Two multiple linear regression models were fit to assess the ability of either percent calories delivered or percent protein delivered to predict changes in PAB while adjusting for CRP. Only change in CRP was able to significantly predict change in PAB levels, explaining 29.6% of the variance (R2=0.296) in change in PAB consistently, adjusting for either percent calories delivered (B=-0.051, p<0.001) or percent protein delivered (B=-0.051, p<0.001). Conclusions: These results indicate that PAB is not a sensitive marker for evaluating the adequacy of nutrition support. Change in CRP was the only variable that was able to significantly predict changes in PAB levels, suggesting that a change in inflammatory status, rather than nutrient intake, was responsible for the increases seen in PAB levels.
Clinical Nutrition Week 2010 Nutrition Practice Abstracts
Abstract of Distinction. Also appeared in Symposium W20: Glucose Control in Adult and Pediatric Critical Care Patients:Nutr Clin Pract. 2010 Feb;25(1):93-4.
P3 - A Comparison of Two Methods of Insulin Administration in Critically Ill Patients Receiving Parenteral Nutrition Yimin Chen, MS, RD, CNSD1; Jenny Lewandowski, MS, RD2; Matthew Sperry, MD3; Kathryn Keim, PhD, RD1; Diane Sowa, MBA, RD1; Sarah Peterson, MS, RD, CNSC1.1Food and Nutrition, Rush University Medical Center, Chicago, IL; 2Radiant Research, Chicago, IL; 3Intermountain Medical Group, Provo, UT.
Introduction: While hyperglycemia may be a normal response to stress, it is associated with adverse patient outcomes including increased nosocomial bloodstream infections, length of stay, need for renal replacement therapy, need for mechanical ventilation, and mortality. Although the benefits of tight glycemic control in critically ill patients have been confirmed in the literature, hypoglycemia is a detrimental complication with intensive glucose control that has also been observed by investigators. Research has yet to be conducted to explore which method of insulin administration results in optimal glycemic control in patients receiving parenteral nutrition (PN). The objective of this study was to compare glycemic control between two methods of intravenous insulin administration in critically ill patients receiving PN: 1) continuous insulin infusion (CII); 2) addition of insulin to the parenteral nutrition (IPN). Methods: Thirty-seven surgical (n = 31) and medical (n = 6) intensive care unit patients in a tertiary care urban academic medical center receiving PN were prospectively identified and randomized to either CII (n = 21) or IPN (n = 16) group with a goal glycemic control of 80 -120 mg/dL. Blood glucose was monitored via morning blood draw and four point-of-care regimen per day for both groups. Hypoglycemic events were defined as <60 mg/dL; hyperglycemic events were defined as >200 mg/dL. Mann-Whitney U was performed to assess the glycemic control between study groups. Chi-square tests were conducted to determine the association of hypo-and hyperglycemic events between study groups. Results: Baseline morning blood glucose was similar between the CII and IPN groups (120 vs. 122 mg/dL, respectively; p = NS), and increased in both groups on day 1 after PN was initiated (136 and 154 mg/dL, respectively; p = NS). The median morning blood glucose was significantly higher in the IPN group when compared with the CII group on day 2 (149 vs. 107 mg/dL, respectively; p = 0.003), day 3 (140 vs. 102 mg/dL, respectively; p < 0.0001), and day 4 (123 vs. 98 mg/dL, respectively; p < 0.05) of PN infusion (Figure 1). The median combined blood glucose (morning and point-of-care blood glucose levels) was also significantly higher in the IPN group when compared with the CII group on day 2 (154 vs. 115 mg/dL, respectively; p = 0.006) and day 3 (141 vs. 109 mg/dL, respectively; p < 0.0001) of PN infusion. Blood glucose control for all subsequent PN days (days 4 -7) was not significantly different between the two groups (Figure 2). There was a trend towards more hypoglycemic events in the CII group when compared with the IPN group (8 vs. 2, respectively; p = 0.08), as well as hyperglycemic events (11 vs. 6, respectively; p = NS). Conclusions: Based on the results of this study, the CII method reached goal glycemic control sooner than the IPN method; however, investigators from recent literature suggest increasing goal glycemic control to 150 mg/dL. Liberalizing blood glucose goals may allow adequate glycemic control with the addition of insulin in PN. More research is necessary to determine which method of insulin administration is best to achieve new goal glycemic control, while minimizing hypo- and hyperglycemic events that may result in detrimental outcomes in a larger sample size.
Clinical Nutrition Week 2010 Nutrition Practice Abstracts
Abstracts of Distinction
Nutr Clin Pract. 2010 Feb;25(1):95.
P4 - Pediatric Nutrition Risk Screening: Association With Length of Stay Catherine M. McDonald, PhD, RD, CNSD; Sarah Gunnell, MS, RD, CNSD.Dietitians, Primary Children's Medical Center, Salt Lake City, UT.
Introduction: Nutrition risk screening (NRS) identifies patients who are, or are at risk of, becoming malnourished. An NRS procedure must correctly separate patients who would benefit from medical nutrition therapy from those who would not according to the presence of factors associated with nutrition risk. A valid NRS procedure is based upon factors most strongly linked to nutrition risk. The potential for malnutrition and nutrition-related complications is increased for patients who experience longer hospitalizations. The identification of patients with potentially longer length of stay (LOS) enables the registered dietitian (RD) to intervene early with preventive medical nutrition therapy. The aim of this study was to determine any association of inpatient LOS with nutrition risk scores assigned using a standardized NRS procedure. Methods: An NRS procedure was developed with IRB approval by RDs at a pediatric tertiary care facility. Scoring of nutrition risk occurred within 24 hours of inpatient admission. The NRS score was determined with a standardized tool by evaluating nutrition risk in four categories: anthopometric, breathing (ventilated or not), clinical (admitting diagnosis), and diet. Zero to 3 risk points were assigned per category with a maximum total score of 12. Face validity and reliability for the NRS procedure were tested and found to be acceptable. A retrospective review of 1299 electronic medical records was conducted for inpatient admissions during June -August 2009. Inclusion criteria were inpatient status, LOS > 24 hours, and age <21 years. Exclusions were admission to newborn intensive care, organ donor status, and age ≥ 21 years. Admissions for new onset diabetes (n = 69) were excluded because of a relatively short inpatient stay with intensive nutrition intervention that is atypical of other diagnoses. Records without documented NSR scores (n = 44) were excluded. Results: Final analysis included 1185 records (male = 651, female = 534). Mean age = 58.7 months±68.2 months, median = 22 months, range 0-236 months (19.7 years). LOS mean = 5.5±6.5 days, median = 3 days, range 1-75 days. The mean NRS score assigned = 2.1±2.1, median = 2.0, range 0-12. A linear regression for the association between LOS and the NRS score was significant (t = 9.72, B = 0.11, p < 0.001). Conclusions: The NRS procedure was developed to screen for nutrition risk in pediatric inpatients. The significant association suggests NRS can be used to predict LOS in the context of screening for nutrition risk. Although nutrition risk does not depend solely on LOS, longer inpatient stays have been documented to contribute to increased nutrition-related complications. According to the linear regression, each risk point assigned using the NRS procedure was associated with an 11.74% increase in LOS. Because patients with higher NRS scores are likely to remain hospitalized for longer periods of time, the RD is able to triage those patients to remediate or prevent nutrition-related complications. Therefore, these results strengthen the validity of the NRS procedure for determining within 24 hours of admission which pediatric patients could benefit from medical nutrition therapy interventions.
Clinical Nutrition Week 2010 Nutrition Practice Abstracts
Abstracts of Distinction
Nutr Clin Pract. 2010 Feb;25(1):95.
P5 - Parenteral Nutrition Utilization in Patients Receiving Hematopoietic Stem Cell Transplant Cheryl Sullivan, MS,RD,CNSD; Sarah Peterson, MS,RD,CNSC; Yimin Chen, MS,RD,CNSD; Kelly Kinnare, MS,RD,CNSD; Diane Sowa, MBA,RD Rush University Medical Center, Chicago, IL.
Introduction: Patients undergoing hematopoietic stem cell transplant (HSCT) often receive parenteral nutrition (PN) during their hospitalization due to inadequate oral intake and gastrointestinal complications. Increased incidence of hyperglycemia, infection, increased hospital length of stay (LOS), greater requirements for red blood cell/platelet transfusion and delayed engraftment has been observed in HSCT patients who received PN. Current guidelines from the American Society for Parenteral and Enteral Nutrition recommend that PN be used in HSCT patients who are malnourished and expected to be unable to absorb adequate nutrients for 7-14 days. The objective of the current study was to determine the risks associated with PN utilization among patients admitted for a HSCT. Methods: A retrospective chart review was completed for 337 patients who underwent a HSCT from 2003-2008 in a tertiary care urban academic medical center. Patients were categorized as having received PN or not during their hospitalization. Patients were further categorized to compare before dietitian PN order-writing privileges (1/1/03 to 12/31/05), to after dietitian PN order-writing privileges (1/1/06 to 12/31/08). Statistical analysis was completed with Chi-square tests and Independent t-tests. Results: Of the 337 patients who received a HSCT, 104 patients (31%) were started on PN. There were no significant differences in sex (PN group: 55/104 [53%] male vs. non-PN group: 130/233 [56%] male), age (PN group: 47.2±12.9 years vs. non-PN group: 49.9±13.5 years) or BMI (PN group: 27.7±6.0 vs. non-PN group: 28.1±6.1). A higher percentage of allogeneic HSCT patients received PN compared to autologous HSCT patients (46/85 [54%] vs. 58/252 [23%], respectively; p<0.0001). A significantly higher percent of patients with a diagnosis of acute myeloid leukemia or acute lymphocytic leukemia received PN (18/38 [47%] vs. 86/299 [29%]; p=0.019) compared to patients requiring PN with all other diagnoses. Patients who received PN had a significantly higher mortality (9/104 [8.6%] vs. 3/233 [1.3%]; p=0.002), longer hospital LOS (28.8 days±16.2 vs. 19.5 days±5.9; p<0.0001) and more admits to the ICU (23/104 [22%] vs. 15/233 [6%]; p<0.0001) compared to patients who did not receive PN. There were no significant differences in ICU LOS or infectious complications between groups. Additionally, when comparing before to after dietitian PN order-writing privileges, significantly fewer patients were started on PN (63/133 [47%] vs. 41/204 [20%], respectively; p<0.0001). There were no significant differences in sex (before PN order-writing privileges: 51% male vs. after PN order-writing privileges: 56% male) and age (before PN order-writing privileges: 47.6±11.9 years vs. after PN order-writing privileges: 46.6±14.4 years). There was a statistically significant, but clinically irrelevant difference in BMI between the two groups (before PN order-writing privileges 28.9±6.3 vs. after PN order-writing privileges: 25.7±5.1; p=0.009).
Conclusions: Additional efforts are needed to further reduce total PN utilization in this highly vulnerable patient population as PN use has been associated with negative outcomes. In the current project, there was a significant decrease in PN utilization after dietitians obtained PN order-writing privileges. Additional research is needed to identify objective criteria (such as a severity of illness score or severity and duration of GI complications) for patients undergoing HSCT to determine which patients may benefit from PN.
Clinical Nutrition Week 2010 Nutrition Practice Abstracts
Abstract of Distinction. Also appeared in Symposium H40 Your Responsibility in Parenteral Nutrition Safety:Nutr Clin Pract. 2010 Feb;25(1):95-6.
P6 - Effects of Converting Macronutrients Protein and Lipids from Percentage to Grams/Kilogram Following CPOE Implementation in Pediatric PN Population.Carl W. Naessig, RPh.1; Ann Searfoss, Pharmacy Student21System Therapeutics, Geisinger Medical Center, Danville, PA; 2Nesbitt School of Pharmacy, Wilkes University, Wilkes-Barre, PA.
Introduction: The full benefit of protein administration is realized when adequate calories are provided. At Geisinger Medical Center (GMC), prior to CPOE, pediatric PN macronutrients were ordered as a percentage of the final volume. The amount of macronutrients a patient received varied based on the total volume of PN ordered. Consequently, the patient's daily nutrition was variable. Safe Practices for Parenteral Nutrition (2004) recommends that when ordering PN, the macronutrients should be ordered as grams per kilogram, not as percentages. With the implementation of computerized physician order entry (CPOE), we saw this as an opportunity to accomplish the following goals; 1) to modify ordering practices to be compliant with safe practices guidelines, 2) to utilized the order as an educational tool to provide guidance for the physician, 3) to provide a universal, easy to use order that could be utilized for all pediatric patients regardless of age, weight, and administration site (peripheral and central), 4) to meet the nutrition goals of the pediatric patient population in the absence of a pediatric NSS. A multidisciplinary team including a physician, clinical dietician, and pharmacist developed new guidelines and standard recommendation for the new PN order set to be implemented with CPOE. This was a retrospective analysis to determine if converting the order for protein and lipids from percentage to gm/kg and providing standard nutrition recommendations on the CPOE PN order set would have a beneficial effect in meeting protein and calorie needs in the hospitalized pediatric population receiving PN. Methods: All pediatric patients who received PN three months pre-and post-CPOE implementation were reviewed. Patients were excluded from this study if they were neonates, patients with incomplete charts, and patients with inadequate information provided by dietician consult. All remaining pediatric patients were reviewed and evaluated to determine what percentage of the protein and calorie needs, as determined by the clinical dietician, were being provided in each bag of PN. Averages of these percentages were then determined for all PN bags in each of the following groups; pre-CPOE TPN, pre-CPOE PPN, post-CPOE TPN, and post CPOE PPN. Results: The pre-CPOE TPN group had 84.5% of the protein needs and 78.8% of the calorie needs provided by TPN. The pre-CPOE PPN group had 71% of the protein needs and 60.4% of the calorie needs provided by PPN. Post-CPOE implementation TPN group had 100 % of the protein needs and 91.2% of the calorie needs provided by TPN. Post-CPOE PPN group had 100 % of the protein needs and 67.4% of the calorie needs provided by PPN. Conclusions: The conversion from a pediatric PN order form that utilized percentages of macronutrients to a system that utilized gram per kilogram for protein and lipids resulted in a significant improvement in the amount of protein and calories provided in both TPN and PPN. CPOE order sets are a useful tool for standardizing ordering of PN in pediatric patients in order to more accurately provided recommended nutrition.
Clinical Nutrition Week 2010 Nutrition Practice Abstracts
Abstracts of Distinction
Nutr Clin Pract. 2010 Feb;25(1):96.
P7 - The Danger of Treating a Number: A Case of Copper Overload in a Long Term Home PN Patient with Short Bowel Syndrome Elizabeth Wall, MS, RD, CNSC1; Kalyani Meduri, MD, MS2; Gilbert Cusson, RPh, BCNSP1; Carol Semrad, MD11The University of Chicago Medical Center, Chicago, IL; 2Private Practice, North Liberty, IA.
Introduction: Patients with short bowel syndrome can live for decades with parenteral nutrition (PN); however clinicians lack simple methods to measure physiologic stores of trace minerals (TM). Plasma levels of TM may not accurately reflect body stores of the nutrients. Infusion of PN, relative to blood sampling, can artificially increase plasma mineral levels while true tissue stores are low. The opposite can also occur in which low plasma levels are measured despite excess deposits of TM throughout the body. Nutrition support clinicians often assess Cu nourishment in long term PN patients with plasma levels although they are not equivalent to physiologic stores. Ninety percent of circulating Cu is bound to ceruloplasmin, but the majority of the body's Cu is found in the liver bound to metalloenzymes. Oral Cu is absorbed in the proximal small bowel and excreted mainly in bile and to a lesser extent in urine. Patients with diarrhea or high ostomy effluent are known to have greater intestinal Cu losses compared to normal controls. Patients receiving Cu in PN have higher urinary losses due to free or amino acid-bound Cu filtration through the kidneys before arriving at the liver. Methods: LH is a 53 yo man with a history of Crohn's disease and hepatitis C status post multiple small bowel resections with 3 feet of jejunum remaining to an end jejunostomy. He has been maintained on home PN since 2001, though with bowel adaptation he requires minimal macronutrients in 1.7 L fluid, 90 g dextrose, 30 g amino acids, 20 g fat emulsion, electrolytes, vitamins, and TM. Liver biopsies in 1998 and 2007 demonstrated mildly active chronic hepatitis. His PN contained standard copper (Cu) supplementation of 1 mg daily until 2004 when LH was found to have low plasma Cu. From 2005 until 2008 the PN Cu supplementation was gradually increased to maintain normal plasma Cu concentrations (see Table). In June 2008 LH had low plasma Cu levels despite 7 mg Cu daily in the PN. Results: LH's low plasma Cu was initially thought to be real given his intestinal losses of > 2L ostomy effluent daily. However, when incremental increases of parenteral Cu failed to sustain normal plasma Cu concentration, laboratory tests were performed to determine his Cu balance. Plasma Cu 50 mcg/dL (75 -155 mcg/dL), ceruloplasmin 11 mg/dL (18-36 mg/dL), and 24 hr urine Cu 111 mcg/24 hr (15 - 50 mcg/24hr) were obtained. These tests revealed a Cu profile suggestive of Wilson's disease. Therefore the PN Cu was discontinued; liver tissue from his 2007 biopsy while on supplemental Cu was stained for Cu deposition, and genetic testing for Wilson's disease was obtained. The liver biopsy demonstrated significantly elevated Cu deposition of 692 mcg/g dry wt (0-35 mcg/g). Genetic testing for Wilson's disease and ophthalmic exam (Kayser-Fliescher rings) were negative. He has since been maintained on Cu-free PN with plans to monitor his plasma and urine Cu levels as well as for clinical manifestations of Cu deficiency. Conclusions: Clinical Cu deficiency in patients receiving PN with the standard dose of 1.0 mg Cu/day is undocumented. Caution should be taken in altering PN Cu supplementation without physiologic or clinical findings of deficiency.
Clinical Nutrition Week 2010 Nutrition Practice Abstracts
Abstracts of Distinction
Nutr Clin Pract. 2010 Feb;25(1):97.
P8 - Investigation of Compliance with the Renal Diet, Biochemical Parameters and Adequacy of Nutrient Intakes in a Group of Patients with Chronic Kidney Disease (Stages 4 and 5).Laura Brennan, BSc (Human Nutrition), Senior Clinical Nutritionist1; Tracey Waldron, BSc (Human Nutrition), Senior Clinical Nutritionist1; George J. Mellotte, MB, FRCPI, MSc., Consultant Nephrologist and Senior Lecturer in Medicine2,31Clinical Nutrition, St. James's Hospital, Dublin, Ireland; 2St. James's Hospital, Dublin, Ireland; 3The Adelaide and Meath Hospital, Dublin, Ireland.
Introduction: Patients with C.K.D. must follow a complex diet, which can restrict protein, sodium, potassium and phosphorus. Compliance with the renal diet can reduce complications such as hyperkalaemia and renal bone disease, can slow progression of renal dysfunction and delay need for dialysis. However, the multiple dietary restrictions can make it difficult to adhere to the diet while maintaining adequate nutritional intake. The purpose of this investigation was to assess compliance with renal dietary restrictions, acceptability of biochemical parameters and adequacy of dietary intakes. Methods: Forty-six patients with C.K.D. were recruited. All patients had been previously educated and established on a renal diet and were not receiving dialysis. The participants completed a food diary documenting all foods and drinks consumed over a 72-hour period. Diaries were analysed using Microdiet for Windows (Version 2). Dietary compliance and biochemical indices were compared to K./D.O.Q.I. (Kidney Disease Outcomes Quality Initiative) Clinical Practice Guidelines. Statistical analysis was conducted using S.P.S.S. for Windows (Version 14.0). Results: Compliance was higher with sodium and potassium restrictions than with protein and phosphate restrictions. Compliance with protein and phosphate restrictions was similar, which is not surprising given their common dietary sources. Some patients (9%) reported protein intakes below that recommended, which is of concern. Table 2 compares biochemical parameters to current recommendations. Patients who adhered to all restrictions had serum potassium and phosphate levels within target range. However, serum potassium and phosphate levels were acceptable regardless of compliance, particularly so in those with stage 4 C.K.D. This raises the question as to whether dietary restrictions may be too strict for patients with less advanced disease. Although 83% of patients were not meeting calculated energy requirements, only 11% (n=4) of these had a BMI<20kg/m2 whereas 61% (n=23) had a BMI>25kg/ m2. Fibre (NSP) intake was insufficient in 65% (n=30) of patients and in 62% (n=8) of diabetics. Compliance with potassium and phosphate restrictions had a significant adverse affect on fibre intake (P=0.001 and 0.038 respectively) and also affected the adequacy of B vitamins, folate, iron, calcium and zinc. Conclusions: For the majority of patients, biochemical parameters were within acceptable limits. However, some patients reported dietary intakes of a number of nutrients that were below the recommended intakes, leaving them at risk for malnutrition. Intensive dietetic intervention is paramount to promote adherence to renal dietary restrictions but also to prevent nutrient deficiencies. Therefore, we advocate a more liberal and individualised approach to restriction when biochemical parameters are acceptable or patients are at nutritional risk.
Clinical Nutrition Week 2010 Nutrition Practice Abstracts
Abstracts of Distinction
Nutr Clin Pract. 2010 Feb;25(1):97-8.
P9 - Evaluation of Enteral Feeding Success in Head Injured Patients Placed in Pentobarbital Induced Comas Jane Gervasio, Pharm.D., BCNSP1; Jonathan Egel, Pharm.D.1; Joshua McGehee, Pharm.D.1; Gabriel Drew Stillabower, Pharm.D.1; Nicole Ponton, Pharm.D.1; Lawrence Bortenschlager, M.D.2; Timothy Pohlman, M.D.21Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, Indianapolis, IN; 2Clarian Health Partners at Methodist Hospital, Indianapolis, IN.
Introduction: Nutrition plays a critical role in the recovery of a traumatic brain injury. Increased caloric needs, gastric intolerance and access problems often undermine efforts to provide adequate nutrition in this population. Additionally, patients with increased intracranial pressure placed in a pentobarbital comas further challenge the administration of nutrition. Enteral nutrition (EN) is recommended for head trauma patients however controversy exists regarding the patients in pentobarbital induced comas ability to tolerate EN. At our institution, standard of practice is verified placement using bedside imaging of a transpyloric small bowel feeding tube for the administration of EN. The objective of this study was to evaluate the success of small bowel enteral feeding in head injured patients placed into pentobarbital induced comas receiving EN. Methods: This study was a retrospective charts review. Adult patients placed in a pentobarbital induced coma and initiated on EN were included. Demographic information, EN tolerance and feeding complications were recorded. Feeding complications included watery diarrhea, a distended abdomen, severe cramping, and small bowel necrosis. Gastric residual volumes were also recorded to identify tube misplacement or migration. Residual volumes greater than 200 mls for 2 consecutive measurements were considered a feeding complication and placement was reassessed. Patient outcomes were also collected and included intensive care unit (ICU) and hospital length of stay (LOS) and patient survival. Descriptive statistics were utilized to define the characteristics of the study population. A p-＆#118alue less than 0.05 was considered statistically significant. All the statistical analyses were conducted using Statistical Package for Social Sciences version 16.0. Results: Fifty-three patients were included in the study, with the majority (60.4%) being males. Data are reported as mean±standard deviation. Patient age was 40±14.7 years, weight was 82.8±22.2 kg and admission Glasgow Coma Score was 6.4±3.7. Subarachnoid and subdural hemorrhage was the primary and secondary cause of injury, occurring in 50.9% and 20.8% of the patients, respectively. Pentobarbital initiation was started within 87.6±72.7 hours with a length of infusion time of 154.8±113.1 hours. Total pentobarbital bolus doses were 457.9±775.4 mg and daily pentobarbital doses (excluding boluses) were 1941±2655 mg. EN was initiated within 53.4±59.5 hours and administered for 555.8±481.3 hours. EN therapy was tolerated in 46 (86.8%) of the patients. Feeding complications reported included gastric residuals, 15.1% (n=8) and watery diarrhea, 22.6% (n=12). A total of 7.5% of patients (n=4) had a distended abdomen that influenced feeding volumes. Small bowel necrosis was reported in 2 patients. In only one patient was EN discontinued and parenteral nutrition initiated. Fourteen patients (26.4%) were able to advance to an oral diet and 19 (35.8%) patients were discharged from the hospital to home or a rehabilitation center on EN. ICU LOS was 22.7±18.9 days and hospital LOS was 27.2±22.8 days. Death occurred in 35.8% of patients. Conclusions: Patients placed in a pentobarbital coma for a traumatic brain injury are able to receive and tolerate EN infused into the small bowel.
zyshcn edited on 2010-03-09 16:21
Clinical Nutrition Week 2010 Nutrition Practice Abstracts
Abstracts of Distinction
Nutr Clin Pract. 2010 Feb;25(1):98.
P10 - Multi-Trace Element Combinations: One Size Does Not Fit All! Abnormal Levels Drive Need for Individualization in 60% of Longer Term HPN PatientsPenny L. Allen, RD, LD, CNSC; Barbara Corey, RD, LDN, CNSC; Jana Wayne, RD, CD, CNSC; Roberta Hurley, Ph.D, RD, LD; Karen Ackerman, RD, MS, LDN, CNSD; Kara Helzer, RD, LD, CNSD; Cindi Rafoth, RD, LD; Susan Mandel, MS, RD; Nancy L. Sceery, RD, LDN, CNSD Nutrition Support, Critical Care Systems, Nashua, NH.
Introduction: The challenge of providing appropriate doses of micro-nutrients, particularly trace elements (TE) for TPN patients has received more attention in the last few years. The adequacy of multi-trace element (MTE) combinations has been called into question, most frequently with manganese and the potential for neurotoxicity in longer term PN patients. It is difficult to accurately assess TE status since plasma or serum levels often do not reflect actual body stores. Often the specimen collection for these tests require special handling in order to insure integrity of the results. These protocols can prove especially challenging outside of the hospital or clinic setting. TE levels can also be skewed by infection and acute phase responses. All of these variables raise significant concerns for the HPN patient reliant on daily TE infusions. Methods: Trace element assays were reviewed for 69 HPN patients with a total of 120 blood draws between 2008-2009. Length of stay on HPN ranged from 5 months to 24 years with patients residing in 10 different geographic markets. Serum zinc, selenium, copper, chromium and whole blood manganese levels were drawn according to individual lab requirements. Abnormal results were collected retrospectively by branch via medical records including lab reports specifying normal ranges for individual laboratories. Need for individualized TE dosing after the draw was also documented. Results: Sixty one (61) percent of patients required individualization of trace elements after abnormal levels were detected in a routine blood draw after 6 months on PN, and/or subsequent 6 month or yearly intervals. Of the 120 individual draws, manganese was elevated in 35% of the assays, followed by chromium elevated at 28%. Zinc was below normal 18% of the time followed by copper elevated 14% of the draws. Selenium followed with lower than normal levels in 10% of the panels. Conclusions: This retrospective snapshot of TE levels in a HPN population supports the argument for reformulation of the MTE preparations currently available. The high percentage of abnormal levels observed, particularly of manganese and chromium, has prompted a change in our standard of practice, recommending a panel at 3 months rather than 6 months after initiation of PN. A new Trace Element Lab Order Request form was developed with very specific instructions for the blood draw--types of tubes, powder-free gloves, spin down time-frames, etc. since many agencies in the alternate site setting are unfamiliar with correct procedures. It remains a challenge to accurately assess trace element status and assure adequacy of supplementation in the PN patient. Individualization of doses and monitoring earlier appears to be the only solution currently available considering the number of factors possibly affecting results. Better, more accurate assessment methods, as well as a reformulated MTE product line--perhaps eliminating manganese, would allow clinicians to more readily meet the HPN patient's needs without exposing them to risk of neurotoxicity.
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