Enteral nutrition and enteral tube feeding. Review of the evidence

Forensic investigation on a combined death by food aspiration and acute escitalopram intoxication occurred to a psychiatric subject in a nursing home

Food aspiration is one of the major health risks for elderly people in nursing homes which could lead to death. Moreover, misconducts in pharmacotherapy may represent a potential risk of adverse drug reactions. It is reported here the toxicological evaluation of a combined death by food aspiration and acute escitalopram intoxication of a psychiatric subject, occurred in a nursing home. An 89-year-old man, suffering from dysphagia and Alzheimer's, was resident in a nursing home. He was fed with a liquid diet administered directly in mouth using a syringe. The man was also being treated with escitalopram 10 mg tablet. One evening, after receiving the meal in the usual way, the man complained of sudden illness. Carried to the emergency room, the man died about 3 h later with a diagnosis of cardiogenic shock subsequentially to ab ingestis. The histological findings revealed the presence of exogenous material, probably food, up to the finest bronchial branches. The toxicological examination revealed the presence of escitalopram and its main metabolite, desmethylcitalopram: in the blood 1972 ng/ml and 285 ng/ml, in the brain 4657 ng/g and 1025 ng/g, in the gastric content 2317 ng/g and 423 ng/g, in the lung 21,771 ng/g and 468 ng/g, respectively. The bad practice of the nurses to dissolve the escitalopram tablet in the liquefied food and to administer the therapy with a syringe directly into the mouth emerged thanks this investigation. Following food aspiration, escitalopram was absorbed by inhalation route, reaching high concentrations in blood and tissues. The death occurred due to a combined mechanism between food aspiration and the escitalopram toxic action.

Clinical update on nursing home medicine: 2013

This is the seventh article in the series of Clinical Updates on Nursing Home Care. The topics covered are antiresorptive drugs, hip fracture, hypertension, orthostatic hypotension, depression, undernutrition, anorexia, cachexia, sarcopenia, exercise, pain, and behavioral and psychological symptoms of dementia.

Unintended weight loss in older persons

Unintended weight loss has a profound effect on morbidity and mortality in older persons. A therapeutic approach to unintended weight loss in older persons depends on correct classification. A careful differential diagnostic approach is mandatory, combined with nutritional and often pharmacological interventions. While starvation due to protein-energy undernutrition is widely regarded as the primary cause of loss of fat and fat-free mass in older persons, a failure to improve with nutritional replacement should trigger a consideration of other causes. Both sarcopenia and cachexia are resistant to hypercaloric feeding. Cachexia may be amenable to suppression of proinflammatory cytokines in known inflammatory disease states.

Intensive Session: New Approaches to Medical Issues in Long-Term Care

This article, based on a series of presentations at the American Medical Directors Association, briefly highlights new advances in medical areas of interest to long-term care physicians. The areas discussed are heart failure, vitamin D, falls, new treatments for diabetes mellitus, blood pressure measurement, anemia, clinical nutrition, pressure ulcers, Clostridium difficile, insomnia, and antipsychotic therapy.

Enteral Formulary Management: A Cost-effective Approach

Although enteral formularies emerged over 30 years ago, their effectiveness remains to be clearly demonstrated. Enteral formulary (EF) development has occurred over 17 years at the Toronto Rehabilitation Institute (Toronto Rehab), and a historical account is available in the literature. At Toronto Rehab, the creative process begins with a review of specific nutrition support requirements for each patient population, which is coupled with a clinical decision-making algorithm to promote standardized clinical nutrition practices and selection of products. The requirements are translated into detailed product specifications for a streamlined array of oral and tube-feeding formulae. Despite outsourced food service systems, the feasibility of simple in-house production should be considered to help curtail overall costs. The promotion of consistent practices requires nutrition support guidelines, including indications and contraindications for each EF product. Competitive bidding practices and policies that scrutinize non-formulary requests and encourage automatic substitution for non-formulary products promote formulary adherence and contain costs. Ongoing evaluation is intended to capture changes in patient populations and product availability to target opportunities for future EF revisions.

Intestinal failure

PURPOSE OF REVIEW

The gastrointestinal tract plays a major role in critical illness. We will review four common problem areas pertaining to the gut and abdominal compartment that intensivists managing critically ill patients must deal with on an everyday basis.

RECENT FINDINGS

In the area of enteral nutrition, there have been concerns that early feeding in hemodynamically unstable patients might cause bowel infarction by increasing the gut oxygen consumption beyond splanchnic oxygen delivery. The most recent data suggest that early enteral feeding, even when patients are receiving vasopressors, is safe and may actually protect the gut by increasing gut perfusion. Although there are no new treatments for ileus, in most critically ill patients ileus primarily affects the stomach and large intestine, and most patients who are diagnosed with ileus may still be fed enterally as long as they are fed distal to the stomach. Diarrhea is a common occurrence in the intensive care unit, particularly in patients who are being fed enterally. Of most import is the realization that Clostridium difficile infection is ubiquitous and must be considered in virtually every case of diarrhea. Abdominal compartment syndrome is usually a result of shock, and its resuscitation with increased intra-abdominal pressure results in many untoward hemodynamic and respiratory events. Early recognition and treatment seem to be associated with improved outcome.

SUMMARY

Continued progress in the areas of optimal nutritional support, understanding the implications of alterations in immune function of the gut, and the avoidance of such morbid complications as abdominal compartment syndrome are expected.

Bariatric Programs in Nursing Homes

The increase in prevalence of obesity in older individuals and the association of obesity with increased morbidity, functional decline, hospitalization, and complications is expected to increase the number of individuals who have obesity requiring nursing home care, particularly subacute and short-term rehabilitation. Providing appropriate nursing home care to residents who have obesity requires environmental modifications, specialized equipment, and staff training. Effective nursing home care of residents who have obesity is interdisciplinary and requires special nursing, medical, nutritional, psychosocial, and rehabilitation considerations.