Determining energy and protein needs in critically ill pediatric patients: A scoping review

INTRODUCTION

In critically ill pediatric patients, optimal energy and protein intakes are associated with a decreased risk of morbidity and mortality. However, the determination of energy and protein needs is complex. The objective of this scoping review was to understand the extent and type of evidence related to the methods used to determine energy and protein needs in critically ill pediatric patients.

METHODS

An international expert group composed of dietitians, pediatric intensivists, a nurse, and a methodologist conducted the review, based on the Johanna Briggs Institute methodology. Two researchers searched for studies published between 2008 and 2023 in two electronic databases, screened abstracts and relevant full texts for eligibility, and extracted data.

RESULTS

A total of 39 studies were included, mostly conducted in critically ill children undergoing ventilation, to assess the accuracy of predictive equations for estimating resting energy expenditure (REE) (n = 16, 41%) and the impact of clinical factors (n = 22, 56%). They confirmed the risk of underestimation or overestimation of REE when using predictive equations, of which the Schofield equation was the least inaccurate. Apart from weight and age, which were positively correlated with REE, the impact of other factors was not always consistent. No new indirect calorimeter method used to determine protein needs has been validated.

CONCLUSION

This scoping review highlights the need for scientific data on the methods used to measure energy expenditure and determine protein needs in critically ill children. Studies using a reference method are needed to validate an indirect calorimeter.

Association Between Low Serum Vitamin D Levels and Sepsis: A Single-Center Study in Tehran, Iran

Background: Vitamin D insufficiency is common in critically ill patients. It is hypothesized that vitamin D deficiency would be associated with sepsis in the critically ill. Thus, the present study aimed to investigate the association between vitamin D and sepsis severity. Method: In this cross-sectional study, patients with sepsis referring to a university hospital in Tehran, Iran, from February 2018 to March 2019 were included. Plasma concentrations of vitamin D in critically ill subjects admitted were assessed. Data were analyzed using SPSS version 20.0. P-values less than 0.05 were considered statistically significant. Results: Among the investigated patients, the mean serum level of vitamin D3 was 19.03 ± 13.08 ng/mL. The prevalence of vitamin D insufficiency in critically ill subjects with sepsis was 100% (150/150). Only sex (P = 0.01) indicated a significant association with vitamin D. Patients suffering from severe sepsis had lower levels of vitamin D compared to the patients with non-severe sepsis (P = 0.07). Conclusions: The present study showed that all critically ill patients studied had vitamin D insufficiency. In line with the biological evidence, the present study suggests that vitamin D deficiency may predispose patients to sepsis. Further studies are needed to establish the causes and mechanisms underlying these interpretations.

[The XI SENPE Jesús Culebras Lecture. Enteral nutrition in critically ill patients. History of an evolution]

Introduction

Enteral nutrition is part of the treatment plan designed for a great number of critically ill patients. After a first description in ancient Egypt, enteral nutrition was only rapidly developed during the last century. Advances in indications, tube feeding methods, enteral formula selection, diagnosis and treatment of gastrointestinal-related complications, efficacy monitorization, and use of protocols for enteral nutrition administration in clinical practice make this nutritional technique more feasible and secure for critically ill patients. Nevertheless, several issues in this field need more investigation to increase enteral nutrition development, efficacy, and safety in these patients.

Improving the quality of nutrition in pediatric trauma

Purpose

Nutrition plays a key role in the recovery of pediatric trauma patients. A catabolic state in trauma patients may hinder recovery and inadequate nutrition may increase morbidity, mortality and length of hospital stay. The purpose of this paper is to review the current nutrition support practices for pediatric trauma patients at McMaster Children’s Hospital (MCH), describe patient demographics and identify areas to improve the quality of patient care.

Design/methodology/approach

A retrospective chart review was conducted on pediatric trauma patients (age<18 years) identified through the trauma registry of MCH. Pediatric trauma patients admitted from January 2010 to March 2014 with an Injury Severity Score (ISS)=12 and a hospitalization of =24 hours were included.

Findings

In total, 130 patients were included in this study, 61.1 percent male, median age ten years (range: 0-17 years) and median ISS of 17 (range: 12-50). Blunt trauma accounted for 97.7 percent of patients admitted and 73.3 percent had trauma team activation. In total, 93 patients (71.5 percent) had ICU stays. The median time to feed was 29 hours (interquartile range: 12.5-43 hours) from the time of admission. An increased hospital length of stay was associated with longer time to initiation of nutrition support, a higher ISS and greater number of surgeries (p<0.05).

Originality/value

Local nutritional support practices for pediatric trauma patients correspond with recommended principles of early feeding and preferential enteral nutrition. Harmonization of paper-based and electronic data collection is recommended to ensure that prescribed nutritional support is being delivered and nutritional needs of pediatric trauma patients are being met.

Nutrition Support Teams: An Evidence-Based Practice

With the development of specialized nutrition support, an interdisciplinary approach was essential to translating this medical breakthrough from the laboratory to the bedside. As this new innovation was adopted, interdisciplinary nutrition support teams were created to optimize the effectiveness and safety of this therapy. The impact of standardization and the use of an interdisciplinary team to provide specialized nutrition support have been shown to improve outcomes and safety and to have a positive financial impact on healthcare institutions. Yet many hospitals do not have nutrition support teams, and the numbers that do may have decreased. To be effective, nutrition support teams need to practice at an evidence-based level and measure their performance. Nutrition support teams include many of the components of the healthcare delivery system that are advocated for the future, and nutrition support teams should be encouraged as the preferred system of providing specialized nutrition support.

The Efficacy of an Oral Elemental Diet in Patients Undergoing Hematopoietic Stem Cell Transplantation

Objective Conditioning regimens for hematopoietic stem cell transplantation (HSCT) are well known to cause severe gastrointestinal toxicities that often disturb the oral intake of the patients followed by poor nutrition and life-threatening infection. An oral elemental diet (ED) is an easily consumed and assimilated form of liquid nutrients mainly composed of amino acids. It alleviates the digestive loading from the intestine and is mainly used for enteral nutritional support in patients with Crohn's disease. We herein report, for the first time, the efficacy of ED for patients undergoing HSCT. Methods We evaluated the efficacy of ED in a prospective cohort study. The primary endpoint for this study was the hospitalization period. The secondary endpoint was the occurrence of oral mucositis, nausea, diarrhea and fever. Patients A total of 73 patients were consecutively enrolled between March 2011 and March 2013. Twenty-three patients underwent autologous HSCT and 50 patients underwent allogeneic HSCT. The first 21 patients did not receive ED (non-ED group; NEG) while in the successive 52 patients (ED group; EG), oral ED was started before conditioning and was continued until 28 days after transplantation. Results The patient characteristics were similar between the two groups. The mean duration of ED administration for EG was 28.7 days (range, 3-37 days), and the mean total-dose of ED administration was 1904 g (range, 240-2,960 g). The median hospitalization period was significantly shorter in EG compared to NEG, (34 days vs. 50 days; p=0.007). Grade 3-4 oral mucositis occurred less in EG than NEG (25% vs. 48%; p=0.06). Conclusion Oral ED may promote an early mucosal recovery and thereby shorten the duration of hospitalization.

Nutrition support of the postoperative cardiac surgery child

There may be a correlation in critically ill children between the accuracy of estimated energy requirement and infection, mortality, and length of stay. Historically, energy needs were estimated using predictive equations with stress factor adjustments. The purpose of this review is to evaluate the evidence for indirect calorimetry, predictive equations, and other clinical indicators (ie, patient outcomes) to estimate energy requirements of the postoperative, critically ill, cardiac infant. Consistent with current guidelines, indirect calorimetry provides the best estimate of energy requirements for critically ill children. Predictive equations are unreliable, either over- or underestimate energy requirements, and do not take into account the metabolic changes that occur in the postoperative cardiac infant. To address the changing metabolic state throughout the course of illness, clinicians need to individualize recommendations by implementing frequent indirect calorimetry measurements at bedside. Actual energy delivery to the postoperative cardiac surgery child in the pediatric intensive care unit (PICU) can be further hindered by many procedural and patient barriers. The provision of appropriate caloric requirements may help clinicians correct the metabolic state and promote recovery and anabolism. Therefore, optimizing nutrition intake of the postoperative, cardiac surgical child requires a paradigm shift toward individualized nutrition prescription, in the context of a PICU-specific feeding algorithm.

Management of prolonged post-operative ileus: evidence-based recommendations

BACKGROUND

Prolonged post-operative ileus (PPOI) occurs in up to 25% of patients following major elective abdominal surgery. It is associated with a higher risk of developing post-operative complications, prolongs hospital stay and confers a significant financial load on health-care institutions. Literature outlining best-practice management strategies for PPOI is nebulous. The aim of this text was to review the literature and provide concise evidence-based recommendations for its management.

METHODS

A literature search through the Ovid MEDLINE, EMBASE, Google Scholar and Cochrane databases was performed from inception to July 2012 using a combination of keywords and MeSH terms. Review of the literature was followed by synthesis of concise recommendations for management accompanied by Strength of Recommendation Taxonomy (either A, B or C).

RESULTS

Recommendations for management include regular evaluation and correction of electrolytes (B); review of analgesic prescription with weaning of narcotics and substitution with regular paracetamol, regular non-steroidal anti-inflammatory drugs if not contraindicated, and regular or as-required Tramadol (A); nasogastric decompression for those with nausea or vomiting as prominent features (C); isotonic dextrose-saline crystalloid maintenance fluids administered within a restrictive regimen (B); balanced isotonic crystalloid replacement fluids containing supplemental potassium, in equivalent volume to losses (C); regular ambulation (C); parenteral nutrition if unable to tolerate an adequate oral intake for more than 7 days post-operatively (A) and exclusion of precipitating pathology or alternate diagnoses if clinically suspected (C).

CONCLUSIONS

Recommendations have a variable and frequently inconsistent evidence base. Further research is required to validate many of the outlined recommendations and to investigate novel interventions that may be used to shorten duration of PPOI.

A.S.P.E.N. clinical guidelines: nutrition support of adult patients with hyperglycemia

BACKGROUND

Hyperglycemia is a frequent occurrence in adult hospitalized patients who receive nutrition support. Both hyperglycemia and hypoglycemia (resulting from attempts to correct hyperglycemia) are associated with adverse outcomes in diabetic as well as nondiabetic patients. This American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Clinical Guideline summarizes the most current evidence and provides guidelines for the desired blood glucose goal range in hospitalized patients receiving nutrition support, the definition of hypoglycemia, and the rationale for use of diabetes-specific enteral formulas in hospitalized patients.

METHOD

A systematic review of the best available evidence to answer a series of questions regarding glucose control in adults receiving parenteral or enteral nutrition was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process was used to develop the clinical guideline recommendations prior to external and internal review and approval by the A.S.P.E.N. Board of Directors.

RESULTS/CONCLUSIONS

1. What is the desired blood glucose goal range in adult hospitalized patients receiving nutrition support? We recommend a target blood glucose goal range of 140-180 mg/dL (7.8-10 mmol/L). (Strong) 2. How is hypoglycemia defined in adult hospitalized patients receiving nutrition support? We recommend that hypoglycemia be defined as a blood glucose concentration of <70 mg/dL (<3.9 mmol/L). (Strong) 3. Should diabetes-specific enteral formulas be used for adult hospitalized patients with hyperglycemia? We cannot make a recommendation at this time.

Selected pharmacokinetic issues of the use of antiepileptic drugs and parenteral nutrition in critically ill patients

OBJECTIVES

To conduct a systematic review for the evidence supporting or disproving the reality of parenteral nutrition- antiepileptic drugs interaction, especially with respect to the plasma protein-binding of the drug.

METHODS

The articles related to the topic were identified through Medline and PubMed search (1968-Feburary 2010) for English language on the interaction between parenteral nutrition and antiepileptic drugs; the search terms used were anti-epileptic drugs, parenteral nutrition, and/or interaction, and/or in vitro. The search looked for prospective randomized and nonrandomized controlled studies; prospective nonrandomized uncontrolled studies; retrospective studies; case reports; and in vitro studies. Full text of the articles were then traced from the Universiti Sains Malaysia (USM) library subscribed databases, including Wiley-Blackwell Library, Cochrane Library, EBSCOHost, OVID, ScienceDirect, SAGE Premier, Scopus, SpringerLINK, and Wiley InterScience. The articles from journals not listed by USM library were traced through inter library loan.

RESULTS

There were interactions between parenteral nutrition and drugs, including antiepileptics. Several guidelines were designed for the management of illnesses such as traumatic brain injuries or cancer patients, involving the use of parenteral nutrition and antiepileptics. Moreover, many studies demonstrated the in vitro and in vivo parenteral nutrition -drugs interactions, especially with antiepileptics.

CONCLUSIONS

There was no evidence supporting the existence of parenteral nutrition-antiepileptic drugs interaction. The issue has not been studied in formal researches, but several case reports and anecdotes demonstrate this drug-nutrition interaction. However, alteration in the drug-free fraction result from parenteral nutrition-drug (i.e. antiepileptics) interactions may necessitate scrupulous reassessment of drug dosages in patients receiving these therapies. This reassessment may be particularly imperative in certain clinical situations characterized by hypoalbuminemia (e.g., burn patients).

Prevalence and clinical presentation of constipation in children with severe generalized cerebral palsy

AIM

Our aim was to study the prevalence and characteristics of constipation in children with profound multiple disabilities, as data in this area are scarce.

METHOD

A cross-sectional observational study was performed in specialized day-care centres and schools in the Netherlands. The study included 152 children (81 males, 71 females; mean age 9 y 6 mo, SD 4 y 6 mo). Intellectual disability ranged from moderate (7%) to profound (52%) in all participants who also had severe motor disabilities (83% classified at Gross Motor Function Classification System level V). We collected data on defaecation characteristics, food and fluid intake, and laxative consumption using standardized bowel diaries and interviews. Constipation was defined as (1) scybalous, pebble-like, hard stools in over a quarter of defaecations in combination with a defaecation frequency of less than three times per week during a 2-week study period; (2) large stools palpable on abdominal examination; or (3) laxative use or manual disimpaction of faeces.

RESULTS

Of the studied population, 57% were constipated and 55% used laxatives, 27% of whom showed symptoms of constipation. Daily intakes of water and fibre were below the required standards in 87% and 53% of participants respectively, without a proven relation to constipation.

INTERPRETATION

Constipation is a common problem in children with severe disabilities. Laxative use is high but dosing is frequently inadequate to prevent symptoms.

Thiamine-deficient encephalopathy due to excessive intake of isotonic drink or overstrict diet therapy in Japanese children

AIM

To report on two children with encephalopathy caused by dietary thiamine deficiency due to newly developing nutritional problems in contemporary Japan.

SUBJECTS

A 1-year-old boy who had consumed 1l of isotonic drinks per day for 4 months after an episode of diarrhea, and presented with ocular movement disorder, dystonia, and unconsciousness. The other subject was an 11-month-old boy who suffered from vomiting and somnolence; he and his mother had atopic dermatitis, and he had been on a low-allergen diet that strictly restricted intake of eggs, dairy products, meat, and fish since his early infancy.

RESULTS

Both patients showed decreased blood thiamine levels and magnetic resonance imaging revealed striatal and thalamic lesions. Thiamine administration yielded prompt improvement of symptoms, but cavitiform lesions in the bilateral putamen persisted in the first patient, accompanied by residual generalized dystonia. Marked elevation of blood/cerebrospinal lactate levels and severe hyponatremia were present in this patient.

CONCLUSION

Thiamine-deficient encephalopathy in Japanese children due to excessive intake of sports drink or overstrict diet therapy for atopic dermatitis has been increasingly reported during the last decade, but is still not broadly recognized. These children may visit hospitals due to persistent vomiting as a symptom of thiamine deficiency, but glucose infusion without thiamine supplementation can aggravate their condition. Knowledge of these facts in medical and public settings is necessary to correct the erroneous impression that nutritional options given to ill children are necessarily beneficial for health, and promote awareness that they can be harmful when consumed in excess.

A guide to enteral access procedures and enteral nutrition

The advent of total parenteral nutrition in the late 1960s meant that no situation remained in which a patient could not be fed. Unfortunately, total parenteral nutrition was complicated by serious infective and metabolic side effects that undermined the beneficial effects of nutrient repletion. Consequently, creative ways of restoring upper gut function were designed, based on semielemental diets and novel feeding tube systems. The employment of specific protocols and acceptance of increased gastric residual volumes has allowed most patients in intensive care to be fed safely and early by nasogastric tube. However, nasogastric feeding is unsuitable for patients with severely compromised gastric emptying owing to partial obstruction or ileus. Such patients require postpyloric tube placement with simultaneous gastric decompression via double-lumen nasogastric decompression and jejunal feeding tubes. These tubes can be placed endoscopically 40-60 cm past the ligament of Treitz to enable feeding without pancreatic stimulation. In patients whose disorders last more than 4 weeks, tubes should be repositioned percutaneously, by endoscopic, open or laparoscopic surgery. Together, the advances in enteral access have improved patients' outcomes and led to a 70-90% reduction in the demand for total parenteral nutrition.

Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation

To assess energy balance in very sick medical patients requiring prolonged acute mechanical ventilation and its possible impact on outcome, we conducted an observational study of the first 14 d of intensive care unit (ICU) stay in thirty-eight consecutive adult patients intubated at least 7 d. Exclusive enteral nutrition (EN) was started within 24 h of ICU admission and progressively increased, in absence of gastrointestinal intolerance, to the recommended energy of 125.5 kJ/kg per d. Calculated energy balance was defined as energy delivered - resting energy expenditure estimated by a predictive method based on static and dynamic biometric parameters. Mean energy balance was - 5439 (sem 222) kJ per d. EN was interrupted 23 % of the time and situations limiting feeding administration reached 64 % of survey time. ICU mortality was 72 %. Non-survivors had higher mean energy deficit than ICU survivors (P = 0.004). Multivariate analysis identified mean energy deficit as independently associated with ICU death (P = 0.02). Higher ICU mortality was observed with higher energy deficit (P = 0.003 comparing quartiles). Using receiver operating characteristic curve analysis, the best deficit threshold for predicting ICU mortality was 5021 kJ per d. Kaplan-Meier analysis showed that patients with mean energy deficit > or =5021 kJ per d had a higher ICU mortality rate than patients with lower mean energy deficit after the 14th ICU day (P = 0.01). The study suggests that large negative energy balance seems to be an independent determinant of ICU mortality in a very sick medical population requiring prolonged acute mechanical ventilation, especially when energy deficit exceeds 5021 kJ per d.

Quality evaluation of total parenteral nutrition in an acute care setting

OBJECTIVE

To analyse the degree of compliance with internationally accepted standards defined for total parenteral nutrition (TPN) quality control in our hospital. The problems of quality which exist must be detected and possible solutions put into practice.

PATIENTS AND METHOD

Retrospective study of critically ill patients treated with TPN during two years in a university teaching hospital (n=92). Assessment of quality was performed through measurements of compliance using 20 criteria. These were evaluated both individually and gathered in three categories: appropriate, safe and accurate TPN. Three summary/indicators were also established which assessed simultaneous compliance with all the criteria in each group. Criteria compliance was compared to standards values. Patient (age, sex, diabetes) and process (TPN indication, patient's outcome, type of diet used) variables were analysed (using logistic regression models) as factors potentially associated with compliance with the quality criteria. Corrective measures aimed at resolving the quality problem were applied to the deficient criteria, paying particular attention to those criteria which presented the highest percentage of errors in the study carried out using a Pareto analysis.

RESULTS

Compliance of six criteria was significantly below standard values. Simultaneous compliance of all criteria by group was 17% in adjusted TPN, 38% in safe TPN and 94% in exact TPN. There was a negative association between an age over 65 years and both a correct indication of TPN (OR: 9.4) and the indicator compliance of all criteria in the adjusted TPN group (OR: 2.9). The absence of metabolic complications was influenced (P<0.05) by the use of standardized diets (OR: 0.3). Effects of the change: the simultaneous compliance with all the criteria of a group improved in all three groups, but this was statistically significant in the 'appropriate' TPN and 'safe' TPN groups. The criteria analysed individually improved after the corrective measures in five of the six criteria which had been below standard in the first evaluation.

CONCLUSIONS

The correct understanding and application of the indications, physiology and potential complications of TPN constitute the hub of the improvement process.

Nutrition and Infections

BACKGROUND

Patients with cancer suffer alterations of their metabolic state and nutritional depletion. This review was designed to evaluate the effect of different nutritional regimens on surgical outcomes.

METHOD

Review of the literature on parenteral and enteral nutrition and immunonutrition in patients with gastrointestinal cancer undergoing major surgery. The outcome measures were postoperative complication rate and length of hospital stay.

RESULTS

Postoperative enteral nutrition reduced significantly the rate of postoperative complications compared with parenteral feeding only in malnourished subjects. Several metaanalyses and randomized trials showed that preoperative and perioperative use of an enteral formula containing arginine and omega-3 fatty acids has a significant beneficial effect on surgical outcome in both well-nourished and malnourished patients.

CONCLUSIONS

Enteral immunonutrition should represent the first choice to nourish surgical subjects.

The state of the provision of nutritional care to hospitalized patients--results from The Elan-Cuba Study

Current nutritional care provision to 1905 patients hospitalized in 12 Cuban hospitals is presented in this article, diagnosed after conducting the Hospital Nutrition Survey (HNS), as part of the activities comprising the Cuban Study of Hospital Malnutrition (Elan-Cuba). The obtained HNS results were contrasted with standards regarding the nutritional assessment of hospitalized patient, the diagnosis of nutritional disorders occurring in the patient, and the identification of patients in need of nutritional intervention. The Elan-Cuba Study returned a 41.2% malnutrition rate [Barreto Penié J, Cuban Group for the Study of Hospital Malnutrition. State of malnutrition in Cuban hospitals. Nutrition 2005;21:487-97]. However, malnutrition was recorded as an independent diagnosis in only 0.4% of the surveyed clinical charts. It could not be shown that medical care teams were systematically applying any of the techniques and procedures recommended for the assessment of the nutritional status of hospitalized patients. In the best of the cases, only 40.6% of the surveyed patients had their height and weight recorded in their clinical charts at admission, 9.0% of those with more than 15 days of hospitalization had a prospective value of weight, and less than 20.0% of them had their serum albumin levels and/or their counts of Lymphocytes annotated on their clinical charts. Although 10.9% of the surveyed patients (median of the subcategories values; range: 3.5-41.2%) fulfilled an indication for nutritional intervention, support (enteral and/or parenteral) was only provided to less than 15.0% of them, with the exception made of patients on NPO, of whom 32.3% received either of the two modes of artificial nutrition listed above. It is to be noticed that none of the patients with chronic organic failure were on nutritional support at the time of the survey. The current nutritional care provision to the hospitalized patient might explain the increased rates of hospital malnutrition documented in the Elan-Cuba Study, and should lead to the design and urgent implementation of nutritional and metabolic intervention programs in the surveyed hospitals, given the deleterious effects of nutritional disorders upon the ultimate results of the medical and surgical actions, and the quality and costs of medical care.

Benefits of early postoperative jejunal feeding in patients undergoing duodenohemipancreatectomy

AIM: To study whether early postoperative enteral nutrition reduces the incidence of complications and/or improves nutritional status following duodenohemipancreatectomy (DHP).

METHODS: We studied 39 patients who underwent DHP for a peri-ampullary mass. Twenty-three patients received total parental nutrition and then started to have an oral intake of nutrition between postoperative day (POD) 7 and 14 [late postoperative enteral nutrition (LPEN) group]. Sixteen patients started to have enteral feeding through a jejunostomy catheter the day after the operation [early postoperative enteral nutrition (EPEN) group]. The incidence of complications and laboratory data at the early postoperative stage were studied in comparison between LPEN and EPEN groups.

RESULTS: Serum levels of albumin and total protein in the EPEN group were significantly higher than those in the LPEN group. The loss of body mass index was significantly suppressed in the EPEN group as compared to the LPEN group. The lymphocyte count decreased immediately after the operation was restored significantly faster in the EPEN group than in the LPEN group. The EPEN group showed significantly fewer incidences of postoperative pancreatic fistulas, as well as a significantly shorter length of hospitalization than the LPEN group. There were no significant differences in the incidences of other postoperative complications between the two groups, such as delayed gastric emptying, surgical site infection, cholangitis, and small bowel obstruction.

CONCLUSION: EPEN is a safe and beneficial opportunity for patients who have undergone DHP for a peri-ampullary mass.

Intermittent oro-esophageal tube feeding in acute stroke patients -- a pilot study

OBJECTIVE

Acute stroke patients with dysphagia are usually fed by nasogastric tube. However, this method sometimes causes pneumonia or diarrhea. We investigated the use of a new feeding procedure called intermittent oro-esophageal (IOE) tube feeding in acute stroke patients with severe dysphagia.

MATERIALS AND METHODS

The IOE method was used in 13 acute stroke patients (68 +/- 14 years old; 12 had a brainstem infarction), who were alert, but had severe dysphagia and a weak pharyngeal reflex. IOE tube feeding was carried out as follows. A feeding tube was passed orally into the lower portion of the esophagus, food supplements were administered through the tube at a rate of approximately 50 ml/min, and the tube was removed after finishing the supplement infusion.

RESULTS

We found that the IOE method had the following advantages: (i) IOE feeding took approximately 15 min; (ii) potentially reduced a risk of complications such as pneumonia and diarrhea; and (iii) oral tube insertion stimulated the oral cavity and pharynx, which may improve the swallowing function. However, the IOE feeding method should not be used in patients who: (i) could not understand the IOE procedure; (ii) had an esophageal hiatal hernia or incomplete peristalsis of the esophagus, as such patients are at risk of having the supplement reflux into the oral cavity.

CONCLUSION

The IOE feeding method may be one of the alternatives to continuous nasogastric tube feeding in acute stroke patients with severe dysphagia, who are alert.

Parenteral Nutrition in Advanced Cancer: Indications and Clinical Practice Guidelines

Cachexia is a disturbing and disfiguring aspect of many advanced cancers. Parenteral nutrition (PN) is a controversial and expensive treatment for cancer cachexia. Guidelines for the use of PN for these patients have been suggested. These two case reports will highlight some of the issues around the etiology of cancer cachexia, the clinical dilemmas and the use of clinical practice guidelines.

Computer Assisted Total Parenteral Nutrition for Pre-term and Sick Term Neonates

INTRODUCTION

Over the past few years, the use of total parenteral nutrition (TPN) has been established for pre-term and sick term neonates. At 'IASO' Hospital, a series of protocols implemented through the use of a computer programme has been developed to assist in the time consuming task of prescribing and preparing TPN in neonates. The algorithms used for neonates of a different gestational age are based on the protocols created through screening of literature and personal experience. This is important because it heralds a uniformity of the prescription of TPN at IASO and other hospitals where these protocols have been implemented.

OBJECTIVE

The objective is to determine the extent of error occurrence of the manual method as opposed to the new computerized procedure of TPN formulation, and to assess the immediate benefits stemming from the computer programme's use, in terms of personnel time reduction. Furthermore, the usefulness of the automated compounder in the computer driven process of TPN solution formulation was also assessed.

SETTING

Gynaecology Hospital 'IASO'.

METHOD

For a period of 6 months, sick and prematurely born babies were included in the study. Calculations regarding the composition of TPN solutions were conducted both by computer and manually.

MAIN OUTCOME MEASURE

The time needed to complete the procedure and the results' accuracy were measured and compared.

RESULTS

Implementation of the protocols into practice via this computer programme has been found to reduce the time spent by the physician and the pharmacist on TPN solution preparation, but the most important contribution is the virtual elimination (no errors in computerized calculation) of errors in the complex task of prescribing and formulating TPN solutions. For example, the average time taken to prepare the individual TPN solutions was 5.2 min while the computerized procedure took 15.4 min.

CONCLUSION

Use of this system can optimize pharmacists' and physicians' work and help prevent prescription and preparation errors.

Prospective evaluation of nutritional status related to body mass indices and outcomes after modified D2 gastrectomy for carcinoma

AIMS

The aim of this study was to examine the perioperative nutritional status, body mass indices (BMI) and nutritional intakes of patients undergoing a modified D2 gastrectomy (preserving pancreas and spleen) for carcinoma to determine whether a relationship exists between the above and outcomes.

METHODS

Fifty consecutive patients [median age 71 years, 38 male] with gastric adenocarcinoma were studied prospectively.

RESULTS

Seven patients (14%) were obese (BMI > 30 kg/m2), 16 patients (32%) were overweight (BMI > 25 kg/m2), 21 patients (42%) were of normal weight (BMI 20-25 kg/m2), and six patients (12%) were underweight (BMI < 20 kg/m2). Operative morbidity was commoner in underweight patients (33%) when compared with overweight patients (17%, P = 0.391) and patients of normal weight (14%, P = 0.289). Fatal complications, however (two patients, 4%) were confined to overweight patients (P = 0.118). Preoperative serum albumin levels were significantly higher in overweight patients (43 g/dl) compared to underweight patients (34.5 g/dl; P = 0.003), though no correlation was found between patients' serum albumin levels and postoperative morbidity (r = -0.023, P = 0.877). Overweight patients were significantly less likely to achieve their protein requirements postoperatively than underweight patients (P = 0.037). Early enteral feeding contributed to 56% of the median energy requirements and 45% of the median protein requirements on the seventh postoperative day.

CONCLUSION

BMI alone is a poor indicator of outcomes after modified D2 gastrectomy for carcinoma. The role of early enteral nutrition in patients undergoing gastrectomy for cancer deserves further evaluation.

Evaluation of complications and prognostic factors associated with administration of total parenteral nutrition in cats: 75 cases (1994–2001)

OBJECTIVE

To determine frequency and types of complications, prognostic factors, and primary diseases affecting clinical outcome associated with administration of total parenteral nutrition (TPN) in cats.

DESIGN

Retrospective study.

ANIMALS

75 cats that received TPN for > or = 12 hours.

PROCEDURE

Medical records were reviewed, and information was obtained on signalment, history, problems at initial evaluation, physical examination findings, weight and changes in weight while receiving TPN, duration in the hospital before initiation of TPN, the type of TPN catheter used, duration of TPN administration, and final diagnosis. Laboratory results obtained immediately prior to TPN and at 24 and 96 hours following initiation of TPN administration were compared.

RESULTS

Reports of weight loss at initial evaluation, hyperglycemia at 24 hours, or diagnosis of chronic renal failure were significantly associated with increased mortality rate. Greater serum albumin concentrations prior to and at 96 hours following TPN administration were significantly associated with decreased mortality rate. Mechanical and septic complications were infrequent and not associated with increased mortality rate. Most cats had multiple diseases. The overall mortality rate was 52%; among 75 cats, 36 recovered, 23 were euthanatized, and 16 died as a result of their primary illness or complications associated with their illness.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated high mortality rate in cats maintained onTPN that had multiple concurrent diseases associated with a poor prognosis. Indicators of poor prognosis included a history of weight loss, hyperglycemia at 24 hours following TPN administration, hypoalbuminemia, and chronic renal failure.