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Eglseer D, Bauer S, Schuettengruber G. Malnutrition management and the application of medical nutrition therapy in hospitalized patients at the end of life. J Nutr Health Aging 2024; 28:100255. [PMID: 38688116 DOI: 10.1016/j.jnha.2024.100255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/16/2024] [Accepted: 04/21/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVES (1) To determine the prevalence of malnutrition risk in hospitalized patients at the end of life (EOL), (2) to evaluate which nutritional interventions are administered in hospitalized end-of-life patients with malnutrition risk and (3) to assess the association of end-of-life care and the administration of medical nutrition therapy in patients with malnutrition risk. DESIGN Cross-sectional multi-center study SETTING: Hospital PARTICIPANTS: Hospitalized adult patients MEASUREMENTS: Based on the valid and reliable questionnaire of the Nursing Quality Measurement 2.0 (LPZ), the parameters of demographic data, medical diagnoses, end-of-life phase, care dependency, malnutrition risk according to the Malnutrition Universal Screening Tool (MUST) and nutritional interventions conducted in patients at risk of malnutrition were assessed. Descriptive statistics and statistical tests were conducted. Logistic regression models were established to identify odds ratios (OR) and confidence intervals (CI) for the association of end-of-life care and the provision of medical nutrition therapy. This was done separately for oral nutritional supplements (ONS), enteral nutrition and parenteral nutrition as the respective dependent variables. RESULTS Of all 12,947 participants, 706 (5.5%) were in an end-of-life phase. The prevalence of malnutrition risk in end-of-life patients was 41.1% compared to 24.7% in other patients (p < 0.001). End-of-life patients with malnutrition risk received more nutritional interventions than other patients with malnutrition risk. The regression models showed that being at the end of life (CI 1.30, 2.63; p < 0.001), being treated by a dietitian (OR 6.02; CI 4.86, 7.45; p < 0.001), suffering from dementia (OR 1.85; CI 1.10, 3.12; p = 0.02) or cancer (OR 1.56; CI 1.25, 1.96; p < 0.001) increased the chance of receiving oral nutritional supplements. For receiving parenteral nutrition, being at the end of life (OR 1.68; CI 1.04, 2.71; p = 0.04), being treated by a dietitian (OR 5.80; CI 4.07, 8.25; p < 0.001), surgery within the previous two weeks (OR 1.58; CI 1.09, 2.30; p = 0.02), younger age (OR 0.99; CI 0.98, 1.00; p = 0.04), care dependency (OR 0.97; CI 0.96, 0.98; p < 0.001), suffering from a disease of the digestive system (OR 2.92; CI 2.07, 4.11; p < 0.001) or cancer (OR 2.44; CI 1.71, 3.49; p < 0.001) were independent predictors. Being at the end of life did not influence the application of enteral nutrition. CONCLUSION This study showed that nutritional interventions are often applied in end-of-life patients admitted to general hospitals. Being at the end of life was positively associated with the application of oral nutritional supplementation and parenteral nutrition. This data does not allow a conclusion about the appropriateness of using medical nutrition therapy in this study sample. Judging the appropriateness of medical nutrition therapy at the end of life is challenging because of the high variability of prognostication as well as the wishes and needs of the specific patients and their relatives that influences the appraisal of adequate interventions. Every decision about nutrition and hydration in end-of-life patients should be a shared decision and be based on advanced care planning principles.
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Affiliation(s)
- Doris Eglseer
- Medical University of Graz, Institute of Nursing Science, Graz, Austria.
| | - Silvia Bauer
- Medical University of Graz, Institute of Nursing Science, Graz, Austria
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Chalopin S, Bel Lassen P, Genser L, Aron-Wisnewsky J, Poitou C, Ciangura C, Torcivia A, Oppert JM, Bedock D, Faucher P. Management of Severe Malnutrition Post-bariatric Surgery Using Artificial Nutrition. Obes Surg 2024; 34:363-370. [PMID: 38123784 DOI: 10.1007/s11695-023-06842-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 09/12/2023] [Accepted: 09/24/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Bariatric surgery (BS) results in major and sustained weight loss and improves comorbidities in patients with obesity but can also lead to malnutrition, especially through severe malabsorption and/or surgical complications. Little is known about the efficacy of artificial nutrition (AN) in this setting. METHODS In this case series, we describe data from consecutive severely malnourished patients after BS (resectional and non-resectional), managed by AN at our hospital unit over a 4-year period. RESULTS Between January 2018 and June 2022, 18 patients (mean ± SD age 42.2 ± 10.4 years, 94% women) required AN following BS complications. At the time of AN initiation, more than half of the patients (53%) had multiple revisional surgeries (up to four). Mean BMI was 49.7 ± 11.3 kg/m2 before BS and 29.6 ± 9.6 kg/m2 when AN was initiated. Most patients (n=16, 90%) received enteral nutrition. AN management resulted in weight regain (+4.7kg ± 8.0, p=0.034), increased serum albumin (+28%, p=0.02), pre-albumin (+88%, p=0.002), and handgrip strength (+38%, p=0.078). No major AN complication nor death was observed. Median total AN duration was 4.5 months [1-12]. During follow-up, the cumulative duration of hospitalization was 33 days [4-88] with a median of 2.5 hospitalizations [1-8] per patient. CONCLUSION Malnutrition can occur after any BS procedure, and AN when required in this setting appears safe and effective on nutritional parameters. It is important to recognize the potential risk factors for malnutrition, which include excessive weight loss resulting from surgical complications, eating disorders, multiple revisional BS, and pregnancy.
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Affiliation(s)
- Sarah Chalopin
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière Hospital, Nutrition Department, Sorbonne University, Institute of Cardiometabolism and Nutrition (ICAN), 47-83 boulevard de l'Hôpital, 75013, Paris, France
| | - Pierre Bel Lassen
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière Hospital, Nutrition Department, Sorbonne University, Institute of Cardiometabolism and Nutrition (ICAN), 47-83 boulevard de l'Hôpital, 75013, Paris, France
- Sorbonne Université, INSERM, Nutrition and obesities; systemic approaches (NutriOmics), Paris, France
| | - Laurent Genser
- Sorbonne Université, INSERM, Nutrition and obesities; systemic approaches (NutriOmics), Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière Hospital, Department of Hepato-Biliary and Pancreatic Surgery, Sorbonne University, Paris, France
| | - Judith Aron-Wisnewsky
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière Hospital, Nutrition Department, Sorbonne University, Institute of Cardiometabolism and Nutrition (ICAN), 47-83 boulevard de l'Hôpital, 75013, Paris, France
- Sorbonne Université, INSERM, Nutrition and obesities; systemic approaches (NutriOmics), Paris, France
| | - Christine Poitou
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière Hospital, Nutrition Department, Sorbonne University, Institute of Cardiometabolism and Nutrition (ICAN), 47-83 boulevard de l'Hôpital, 75013, Paris, France
- Sorbonne Université, INSERM, Nutrition and obesities; systemic approaches (NutriOmics), Paris, France
| | - Cécile Ciangura
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière Hospital, Nutrition Department, Sorbonne University, Institute of Cardiometabolism and Nutrition (ICAN), 47-83 boulevard de l'Hôpital, 75013, Paris, France
| | - Adriana Torcivia
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière Hospital, Department of Hepato-Biliary and Pancreatic Surgery, Sorbonne University, Paris, France
| | - Jean-Michel Oppert
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière Hospital, Nutrition Department, Sorbonne University, Institute of Cardiometabolism and Nutrition (ICAN), 47-83 boulevard de l'Hôpital, 75013, Paris, France
| | - Dorothée Bedock
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière Hospital, Nutrition Department, Sorbonne University, Institute of Cardiometabolism and Nutrition (ICAN), 47-83 boulevard de l'Hôpital, 75013, Paris, France
| | - Pauline Faucher
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière Hospital, Nutrition Department, Sorbonne University, Institute of Cardiometabolism and Nutrition (ICAN), 47-83 boulevard de l'Hôpital, 75013, Paris, France.
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Danielis M, Mattiussi E, Piani T, Iacobucci A, Tullio A, Molfino A, Vetrugno L, Deana C. Diarrhoea and constipation during artificial nutrition in intensive care unit: A prospective observational study. Clin Nutr ESPEN 2023; 57:375-380. [PMID: 37739681 DOI: 10.1016/j.clnesp.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 06/27/2023] [Accepted: 07/06/2023] [Indexed: 09/24/2023]
Abstract
PURPOSE To describe the occurrence of gastrointestinal (GI) complications, specifically diarrhoea and constipation, in artificially (enterally or parenterally) fed critically ill patients within their first seven-day stay in Intensive Care Unit (ICU). METHODS Observational prospective study conducted from September 1st to October 30th, 2019 and from August 1st to October 30th, 2021, in an ICU of a 1000-bed third-level hospital. General characteristics, nutritional variables, and medications administered were recorded and analysed. This study was registered on ClinicalTrials.gov (Identifier: NCT05473546). RESULTS In total, 100 critically ill patients were included. Diarrhoea was present in 44 patients (44.0%), while constipation occurred in 22 (22.0%) patients. Patients with diarrhoea were generally those admitted for respiratory failure, whereas patients without diarrhoea were mostly affected by neurological disorders (22.7% vs 25%, respectively; p = 0.002). Likewise, patients with constipation were primarily those admitted for trauma (36.4%). Trauma patients were almost 24 times more likely to be constipated than patients with respiratory failure (OR 23.99, CI 1.38-418.0) and patients receiving diuretics were over 16 times more likely to have diarrhoea than patients not receiving diuretics (OR 16.25, IC 1.89-139.86). CONCLUSION GI complications of enteral nutrition represent still a very common issue in ICU. The main predictor of constipation was an admission for trauma whereas the main predictor of diarrhoea was the use of diuretics. Clinicians should consider and integrate these findings into more personalized nutritional and management protocols to avoid gastrointestinal complications.
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Affiliation(s)
- Matteo Danielis
- Department of Anesthesia and Intensive Care, Health Integrated Agency Friuli Centrale, Academic Hospital of Udine, Piazzale Santa Maria della Misericordia 15, Udine, Italy; Laboratory of Studies and Evidence Based Nursing, Department of Medicine, University of Padua, Italy
| | - Elisa Mattiussi
- School of Nursing, Department of Medical Sciences, University of Udine, Viale Ungheria 20, 33100, Udine, Italy
| | - Tommaso Piani
- Department of Anesthesia and Intensive Care, Health Integrated Agency Friuli Centrale, Academic Hospital of Udine, Piazzale Santa Maria della Misericordia 15, Udine, Italy
| | - Anna Iacobucci
- Department of Anesthesia and Intensive Care, Health Integrated Agency Friuli Centrale, Academic Hospital of Udine, Piazzale Santa Maria della Misericordia 15, Udine, Italy
| | - Annarita Tullio
- Hygiene and Clinical Epidemiology Unit, Health Integrated Agency Friuli Centrale, Piazzale Santa Maria della Misericordia 15, Udine, Italy
| | - Alessio Molfino
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, 66100 Chieti, Italy; Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, 66100 Chieti, Italy
| | - Cristian Deana
- Department of Anesthesia and Intensive Care, Health Integrated Agency Friuli Centrale, Academic Hospital of Udine, Piazzale Santa Maria della Misericordia 15, Udine, Italy.
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Zametkin E, Guyer D, Tarshish Y, Bash K, Almhanna K. Total parenteral nutrition for patients with gastrointestinal cancers: a clinical practice review. Ann Palliat Med 2023; 12:1072-1080. [PMID: 37691334 DOI: 10.21037/apm-22-1380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 07/27/2023] [Indexed: 09/12/2023]
Abstract
The use of total parenteral nutrition (TPN) in patients with gastrointestinal cancers is a well-established practice, yet there is substantial variability in its use across institutions. Decision-making around the initiation of TPN is complex. An interdisciplinary team can help identify patient factors and clinical situations that influence whether a patient is likely to benefit from parenteral nutrition. We present the case of a woman with a gastrointestinal cancer who benefited from the initiation of TPN as a bridge therapy to further cancer treatment. This case highlights the importance of establishing a plan for nutrition with specific goals in mind, such as optimizing patients for more cancer-directed therapy. Although patients with gastrointestinal cancers may be candidates for TPN, many patient-specific factors, such as functional status and opportunities for future treatments, must be considered prior to the initiation of parenteral nutrition. An interdisciplinary approach should be used to make recommendations based on patient goals, with a focus on patient and cancer characteristics that are associated with positive outcomes after initiation of TPN. These characteristics include functional status, nutritional status, degree of symptom control, and ability to safely administer nutrition. It is important to continually assess whether parenteral nutrition is beneficial in respect to a patient's preferences and prognosis.
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Affiliation(s)
- Emily Zametkin
- Division of Geriatrics and Palliative Care, Department of Medicine, University of Massachusetts-Chan Medical School, Baystate Health, Springfield, MA, USA
| | - Dana Guyer
- Division of Hematology-Oncology, Department of Medicine, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA; Division of Geriatrics and Palliative Medicine, Department of Medicine, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Yael Tarshish
- Division of Geriatrics and Palliative Care, Department of Medicine, University of Massachusetts-Chan Medical School, Baystate Health, Springfield, MA, USA
| | - Kinan Bash
- University of New England Graduate School, Biddeford, ME, USA
| | - Khaldoun Almhanna
- Division of Hematology-Oncology, Department of Medicine, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
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Bower KL, Shilling DM, Bonnes SL, Shah A, Lawson CM, Collier BR, Whitehead PB. Ethical Implications of Nutrition Therapy at the End of Life. Curr Gastroenterol Rep 2023; 25:69-74. [PMID: 36862286 DOI: 10.1007/s11894-023-00862-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 03/03/2023]
Abstract
PURPOSE OF REVIEW Provide an evidence-based resource to inform ethically sound recommendations regarding end of life nutrition therapy. RECENT FINDINGS • Some patients with a reasonable performance status can temporarily benefit from medically administered nutrition and hydration(MANH) at the end of life. • MANH is contraindicated in advanced dementia. • MANH eventually becomes nonbeneficial or harmful in terms of survival, function, and comfort for all patients at end of life. • Shared decision-making is a practice based on relational autonomy, and the ethical gold standard in end of life decisions. A treatment should be offered if there is expectation of benefit, but clinicians are not obligated to offer non-beneficial treatments. A decision to proceed or not should be based on the patient's values and preferences, a discussion of all potential outcomes, prognosis for given outcomes taking into consideration disease trajectory and functional status, and physician guidance provided in the form of a recommendation.
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Affiliation(s)
- Katie L Bower
- Carilion Clinic, Department of Surgery, Virginia Tech Carilion School of Medicine, 1906 Belleview Ave., Roanoke, VA, 24014, USA. .,Carilion Clinic Palliative Medicine, Virginia Tech Carilion School of Medicine, 1906 Belleview Ave, Roanoke, VA, 24014, USA.
| | - Danielle M Shilling
- Mayo Clinic, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Sara L Bonnes
- Mayo Clinic, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Apeksha Shah
- Cooper University Health Care, Cooper Medical School of Rowan University Digestive Health Institute, Camden, NJ, USA
| | - Christy M Lawson
- Division of Trauma and Critical Care Surgery, Univeristy of Tennessee, Knoxville, TN, USA
| | - Bryan R Collier
- Carilion Clinic, Department of Surgery, Virginia Tech Carilion School of Medicine, 1906 Belleview Ave., Roanoke, VA, 24014, USA
| | - Phyllis B Whitehead
- Carilion Clinic Palliative Medicine, Virginia Tech Carilion School of Medicine, 1906 Belleview Ave, Roanoke, VA, 24014, USA
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Abstract
Judaism offers a rich body of traditional beliefs and practices surrounding end-of-life, death, mourning, and the afterlife. A more detailed understanding of these topics might prove helpful to clinicians seeking guidance for how best to care for Jewish patients, to anyone supporting dying individuals, or to anyone interested in learning more about the subject. The objectives of this chapter are to examine Jewish approaches to key bioethical issues surrounding palliative care, to analyze meaning-making rituals following a loss, at a funeral, and throughout mourning, and to explore Jewish beliefs in an afterlife. Research was collected from sacred texts, legal codes, modern rabbinic responsa literature, and secondary sources. Core, guiding principles include human beings' creation "in the image of God," an obligation to save life, an obligation to mitigate pain, a prohibition against self-harm and hastening death, respect for the dead, and ritualized mourning periods ("shiva," "shloshim," and "shanah"), which feature special liturgy ("kaddish") and practices. Judaism is a religion that values thorough questioning, debate, and argumentation. It also encompasses diverse cultural and ethnic backgrounds, and various denominations. Many Jews are also unaffiliated with a movement or rarely engage with traditional law altogether. For all of these reasons, no summary can comprehensively encapsulate the wide range of opinions that exist around any given topic. That said, what follows is a detailed overview of traditional Jewish approaches to artificial nutrition/hydration, extubation, dialysis, euthanasia and more. It also outlines rituals surrounding and following death. Finally, views and beliefs of the afterlife are presented, as they often serve to imbue meaning and comfort in times of grief, uncertainty, and transition.
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Affiliation(s)
- Joshua Jacobs
- B'nai Jeshurun Congregation, 27501 Fairmont Boulevard, OH, 44124, Pepper Pike, USA
| | - Patricia Jacobs
- Lynn Cancer Institute, 701 NW 13th Street, Boca Raton, FL, 33486, USA.
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Ramos A, Joaquin C, Ros M, Martin M, Cachero M, Sospedra M, Martínez E, Sánchez Migallón JM, Sendrós MJ, Soldevila B, Puig-Domingo M. Impact of COVID-19 on nutritional status during the first wave of the pandemic. Clin Nutr 2022; 41:3032-3037. [PMID: 34049748 PMCID: PMC8106234 DOI: 10.1016/j.clnu.2021.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/18/2021] [Accepted: 05/04/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND & AIMS Patients affected by COVID-19 may develop disease related malnutrition (DRM) due to the catabolic situation, symptoms that interfere with intake and prolonged hospital stay. This study aims to know the percentage of patients admitted for COVID-19 who required artificial nutrition (AN), their clinical characteristics, as well as the prevalence of DRM and the risk of sarcopenia at hospital discharge and after 6 months. MATERIAL AND METHODS Observational, prospective study, with successive inclusion of adult patients admitted for COVID-19 in whom institutional nutritional support (NS) care protocol was applied. Those who received AN underwent a nutritional screening by Short Nutritional Assessment Questionnaire (SNAQ) and an assessment by Subjective Global Assessment (SGA) at hospital discharge, as well as a screening for sarcopenia (SARC-F test) and SNAQ re-test 15 days and 6 months after by a phone call. Symptoms related to food intake, anthropometric and analytical data were also collected. RESULTS We evaluated 936 patients with a mean age of 63.7 ± 15.3 years; predominantly male (59.7%), overweight 41%, obesity 40.4%; hypertension 52.9%; diabetes mellitus 26.6% and cancer 10.4%. The stay hospital length was 17.3 ± 13.8 days and 13.6% patients died during hospitalization. The modality of nutritional support was: 86.1% dietary adaptation + oral nutritional supplements (ONS); 12.4% enteral nutrition (EN) by nasogastric (NG) tube; 0.9% parenteral nutrition (PN) and 0.6% EN plus PN. Focusing on patients who received AN, follow-up post discharge was possible in 62 out of 87 who survived. Of these, at the time of hospital discharge, 96.7% presented nutritional risk by SNAQ and 100% malnutrition by SGA (20% B; 80% C). During admission, 82.3% presented intense anorexia and the mean weight loss was 10.9 ± 6 Kg (p < 0.001). Fifteen days after being discharged, 12.9% still had anorexia, while hyperphagia appeared in 85.5% of the patients and risk of sarcopenia by SARC-F was present in 87.1% of them. Six months after discharge, 6.8% still had anorexia and 3.4% hyperphagia, with a global weight gain of 4.03 ± 6.2 Kg (p=<0.0001). Risk of malnutrition was present in only 1.7% of the patients, although risk of sarcopenia persisted in 49.2%. CONCLUSION All patients admitted by COVID-19 for whom EN or PN were indicated following an institutional protocol still presented malnutrition at hospital discharge, and almost all showed risk of sarcopenia, that persisted in almost half of them at 6 months. These findings suggest that nutritional and functional problems persist in these patients after discharge, indicating that they require prolonged nutritional support and monitoring.
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Affiliation(s)
- Analía Ramos
- Endocrinology and Nutrition Service, Hospital Universitari Germans Trias i Pujol, Badalona, Spain,Autonomous University of Barcelona, Barcelona, Spain
| | - Clara Joaquin
- Endocrinology and Nutrition Service, Hospital Universitari Germans Trias i Pujol, Badalona, Spain,Autonomous University of Barcelona, Barcelona, Spain
| | - Mireia Ros
- Endocrinology and Nutrition Service, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Mariona Martin
- Endocrinology and Nutrition Service, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Montserrat Cachero
- Endocrinology and Nutrition Service, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - María Sospedra
- Endocrinology and Nutrition Service, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Eva Martínez
- Endocrinology and Nutrition Service, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | - María-José Sendrós
- Endocrinology and Nutrition Service, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Berta Soldevila
- Endocrinology and Nutrition Service, Hospital Universitari Germans Trias i Pujol, Badalona, Spain,Autonomous University of Barcelona, Barcelona, Spain
| | - Manel Puig-Domingo
- Endocrinology and Nutrition Service, Hospital Universitari Germans Trias i Pujol, Badalona, Spain,Autonomous University of Barcelona, Barcelona, Spain,Corresponding author. Endocrinology and Nutrition Service, Hospital Universitari Germans Trias i Pujol, Ctra. Canyet s / n, 08916, Badalona, Barcelona, Spain
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Dell'Aquila G, Peladic NJ, Nunziata V, Fedecostante M, Salvi F, Carrieri B, Liperoti R, Carfì A, Eusebi P, Onder G, Orlandoni P, Cherubini A. Prevalence and management of dysphagia in nursing home residents in Europe and Israel: the SHELTER Project. BMC Geriatr 2022; 22:719. [PMID: 36042405 PMCID: PMC9429699 DOI: 10.1186/s12877-022-03402-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/30/2022] [Indexed: 11/18/2022] Open
Abstract
Background Dysphagia is a frequent condition in older nursing home residents (NHRs) which may cause malnutrition and death. Nevertheless, its prevalence is still underestimated and there is still debate about the appropriateness and efficacy of artificial nutrition (AN) in subjects with severe dysphagia. The aim is to assess the prevalence of dysphagia in European and Israeli NHRs, its association with mortality, and the relationship of different nutritional interventions, i.e. texture modified diets and AN—with weight loss and mortality. Methods A prospective observational study of 3451 European and Israeli NHRs older than 65 years, participating in the SHELTER study from 2009 to 2011, at baseline and after 12 months. All residents underwent a standardized comprehensive evaluation using the interRAI Long Term Care Facility (LTCF). Cognitive status was assessed using the Cognitive Performance Scale (CPS), functional status using Activities of Daily Living (ADL) Hierarchy scale. Trained staff assessed dysphagia at baseline by clinical observation. Data on weight loss were collected for all participants at baseline and after 12 months. Deaths were registered by NH staff. Results The prevalence of dysphagia was 30.3%. During the one-year follow-up, the mortality rate in subjects with dysphagia was significantly higher compared with that of non-dysphagic subjects (31.3% vs 17.0%,p = 0,001). The multivariate analysis showed that NHRs with dysphagia had 58.0% higher risk of death within 1 year compared with non-dysphagic subjects (OR 1.58, 95% CI, 1.31–1.91). The majority of NHRs with dysphagia were prescribed texture modified diets (90.6%), while AN was used in less than 10% of subjects. No statistically significant difference was found concerning weight loss and mortality after 12 months following the two different nutritional treatments. Conclusions Dysphagia is prevalent among NHRs and it is associated with increased mortality, independent of the nutritional intervention used. Noticeably, after 12 months of nutritional intervention, NHRs treated with AN had similar mortality and weight loss compared to those who were treated with texture modified diets, despite the clinical conditions of patients on AN were more compromised.
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Affiliation(s)
- Giuseppina Dell'Aquila
- Geriatria, Accettazione geriatrica e Centro Di Ricerca Per L'invecchiamento, IRCCS INRCA, Via della Montagnola 81, 60127, Ancona, Italy
| | - Nikolina Jukic Peladic
- Clinical Nutrition Unit, IRCCS INRCA Ancona, Via della Montagnola 81, 60127, Ancona, Italy
| | - Vanessa Nunziata
- Geriatria, Accettazione geriatrica e Centro Di Ricerca Per L'invecchiamento, IRCCS INRCA, Via della Montagnola 81, 60127, Ancona, Italy. .,Geriatrics and Geriatric Emergency Care, Italian National Research Center On Aging (IRCCS-INRCA), Via della Montagnola, 81, 60127, Ancona, Italy.
| | - Massimiliano Fedecostante
- Geriatria, Accettazione geriatrica e Centro Di Ricerca Per L'invecchiamento, IRCCS INRCA, Via della Montagnola 81, 60127, Ancona, Italy
| | - Fabio Salvi
- Geriatria, Accettazione geriatrica e Centro Di Ricerca Per L'invecchiamento, IRCCS INRCA, Via della Montagnola 81, 60127, Ancona, Italy. .,Geriatrics and Geriatric Emergency Care, Italian National Research Center On Aging (IRCCS-INRCA), Via della Montagnola, 81, 60127, Ancona, Italy.
| | - Barbara Carrieri
- Geriatria, Accettazione geriatrica e Centro Di Ricerca Per L'invecchiamento, IRCCS INRCA, Via della Montagnola 81, 60127, Ancona, Italy
| | - Rosa Liperoti
- Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Angelo Carfì
- Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Paolo Eusebi
- Geriatria, Accettazione geriatrica e Centro Di Ricerca Per L'invecchiamento, IRCCS INRCA, Via della Montagnola 81, 60127, Ancona, Italy
| | - Graziano Onder
- Department of Cardiovascular, Endocrine-Metabolic Diseases and Aging, Istituto Superiore Di Sanità, Via Giano della Bella 34, 00161, Rome, Italy
| | - Paolo Orlandoni
- Clinical Nutrition Unit, IRCCS INRCA Ancona, Via della Montagnola 81, 60127, Ancona, Italy
| | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e Centro Di Ricerca Per L'invecchiamento, IRCCS INRCA, Via della Montagnola 81, 60127, Ancona, Italy
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Hägglund P, Gustafsson M, Lövheim H. Oropharyngeal dysphagia and associated factors among individuals living in nursing homes in northern Sweden in 2007 and 2013. BMC Geriatr 2022; 22:421. [PMID: 35562667 PMCID: PMC9107260 DOI: 10.1186/s12877-022-03114-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Swallowing difficulties in the oral cavity or pharynx (i.e., oropharyngeal dysphagia) are a common problem in the aging population, which may result in severe consequences, such as malnutrition, aspiration pneumonia, and mortality. Identifying oropharyngeal dysphagia and its associated factors is essential for establishing better healthcare policies in nursing homes. In this study, we aimed to describe the oropharyngeal dysphagia prevalence among nursing home residents, and to investigate the association between dysphagia and potentially related factors in a large survey of nursing home residents in Sweden, including individuals with various degrees of cognitive impairment. A secondary aim was to compare findings between years on oropharyngeal dysphagia and its associated factors. METHODS This study is based on two cross-sectional surveys performed in 2007 and 2013, including 4,995 individuals living in nursing homes in the Region of Västerbotten, Sweden. Data were collected from caregivers' reports regarding swallowing ability, nutritional status, chewing ability, and other baseline characteristics, such as cognitive function and activity of daily living (ADL). Data were analyzed using logistic regression models to calculate the odds of the association between oropharyngeal dysphagia and associated factors. RESULTS Oropharyngeal dysphagia was reported in 14.9% (95% CI: 13.9-16.0) of the nursing home residents. An adjusted model revealed that oropharyngeal dysphagia was associated by severe cognitive impairment (OR: 1.56, 95% CI: 1.14-2.12) and ADL independence (OR: 0.81 95% CI: 1.82-2.66) among nursing home residents. We also identified the following as independently associated factors of dysphagia: reduced nutritional status (OR: 1.84, 95% CI: 1.49-2.27), artificial nutrition (OR: 6.33, 95% CI: 2.73-14.71), and clinical signs of aspiration (OR: 10.89, 95% CI: 8.40-14.12). CONCLUSIONS Oropharyngeal dysphagia was reported among approximately 15% nursing home residents and was associated with cognitive impairment and ADL capability. Furthermore, reduced nutritional status and artificial nutrition were also associated with oropharyngeal dysphagia. Implementing routine protocols in nursing homes may help detect oropharyngeal dysphagia and manage oropharyngeal dysphagia among residents.
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Affiliation(s)
- Patricia Hägglund
- Department of Clinical Sciences, Speech-Language Pathology, Umeå University, Umeå, Sweden.
| | - Maria Gustafsson
- Department of Integrative Medical Biology, Umeå University, Umeå, Sweden
| | - Hugo Lövheim
- Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden.,Wallenberg Centre for Molecular Medicine, Umeå, Sweden
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Bretault M, Zaharia R, Vigan M, Vychnevskaia K, Raffin-Sanson ML, Crenn P, Hage M. Complications Requiring Intensive Nutritional Care After Bariatric Surgery Result in More Long-Term Weight Loss but Has No Impact on Nutritional Deficiencies and Depression-Anxiety Scores. Obes Surg 2021; 31:4767-4775. [PMID: 34491508 DOI: 10.1007/s11695-021-05623-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/12/2021] [Accepted: 07/20/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Bariatric surgery is associated with significant weight loss and improvement in comorbid conditions but in rare cases can expose to complications requiring intensive nutritional care (INC). INC in this context is poorly described and no data are available concerning long-term impact. MATERIALS AND METHODS We retrospectively reviewed charts of bariatric patients who were hospitalized in our institution between 2013 and 2018. We identified patients with a postoperative complication requiring INC and we described their nutritional management (INC group). These patients were compared with controls matched to age, gender, preoperative BMI, and type of surgery selected from our database (control group). The primary endpoint was the percentage of total weight loss (%TWL) at 2.5 years. Secondary endpoints were improvement of co-morbidities, vitamin deficiencies, and depression/anxiety scores. RESULTS The INC group consisted of 18 patients among which 77.8% had sleeve gastrectomy (SG). Half of these patients underwent revisional surgery. The most common complication was fistula formation (66.7%). Patients in the INC group, compared to the control group, showed a significantly higher %TWL at 2.5 years (33.6% vs 26.1%, P = 0.03). There was no significant difference in either reduction of preoperative comorbidities or depression/anxiety scores between the two groups. The number of patients with more than three nutritional deficiencies was similar in both groups. Thiamine deficiency was only observed in the INC group. CONCLUSION Complications requiring INC after bariatric surgery occur mainly after revisional surgery and may increase long-term %TWL but have no impact on nutritional deficiencies or symptoms of anxiety/depression.
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Affiliation(s)
- Marion Bretault
- Department of Endocrinology-Nutrition, Ambroise Paré Hospital, AP-HP, EA4340 Research Unit, University Paris-Saclay, 92100, Boulogne-Billancourt, France.
| | - Ramona Zaharia
- Department of Endocrinology-Nutrition, Ambroise Paré Hospital, AP-HP, EA4340 Research Unit, University Paris-Saclay, 92100, Boulogne-Billancourt, France
| | - Marie Vigan
- Clinical Research Unit, AP-HP, Paris-Saclay, Hôpital Ambroise Pare, Boulogne-Billancourt, France
| | - Karina Vychnevskaia
- Department of Surgery and Oncology, Ambroise Paré Hospital, AP-HP, Boulogne-Billancourt, France
| | - Marie-Laure Raffin-Sanson
- Department of Endocrinology-Nutrition, Ambroise Paré Hospital, AP-HP, EA4340 Research Unit, University Paris-Saclay, 92100, Boulogne-Billancourt, France
| | - Pascal Crenn
- Department of Gastro-enterology, Ambroise Paré Hospital, AP-HP, Boulogne-Billancourt, France
| | - Mirella Hage
- Department of Endocrinology-Nutrition, Ambroise Paré Hospital, AP-HP, EA4340 Research Unit, University Paris-Saclay, 92100, Boulogne-Billancourt, France
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Saavedra R, Fahy BN. Artificial Nutrition in Patients with Advanced Malignancy. Surg Oncol Clin N Am 2021; 30:505-518. [PMID: 34053665 DOI: 10.1016/j.soc.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Cancer is a progressive disease that can lead to malnutrition and cachexia. Artificial nutrition is a medical therapy used to combat malnutrition in these patients. In this article, the authors discuss factors affecting the decision to use artificial nutrition, including the patient's mental and physical health, technical factors of the procedures used to deliver artificial nutrition, and the oncologic factors affecting treatment. Through this review, the authors provide guidelines on who is and is not likely to benefit from therapy, available routes of administration, and necessary factors to consider for appropriate decision-making for palliative patients and those with advanced cancers."
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Affiliation(s)
- Ramses Saavedra
- Department of Surgery, University of New Mexico, 1 University of New Mexico, MSC 07-4025, Albuquerque, NM 87131, USA
| | - Bridget N Fahy
- Department of Surgery, University of New Mexico, 1 University of New Mexico, MSC 07-4025, Albuquerque, NM 87131, USA; Division of Palliative Medicine, University of New Mexico, Albuquerque, NM, USA.
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12
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Carrillo Lozano E, Osés Zárate V, Campos Del Portillo R. Nutritional management of gastric cancer. ENDOCRINOL DIAB NUTR 2021; 68:428-438. [PMID: 34742476 DOI: 10.1016/j.endien.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 09/17/2020] [Indexed: 06/13/2023]
Abstract
Gastric cancer is the third leading cause of cancer mortality and is frequently associated with nutritional disorders, the detection and proper management of which can contribute to improving quality of life and survival. Being aware of the consequences and of the different treatments for this neoplasm allows us to offer an adequate nutritional approach. In surgical candidates, integration into ERAS-type programs is increasingly frequent, and includes a pre-surgical nutritional approach and the initiation of early oral tolerance. After gastrectomy, the new anatomical and functional state of the digestive tract may lead to the appearance of "post-gastrectomy syndromes", the management of which may require diet modification and medical treatment. Those who receive neoadjuvant or adjuvant antineoplastic therapy benefit from specific dietary recommendations based on intercurrent symptoms and/or artificial nutrition. In palliative patients, the nutritional approach should be carried out while respecting the principle of autonomy and weighing the risks and benefits of the intervention. The objective of this review is to highlight the importance and role of nutrition in patients with gastric cancer and to provide guidelines for nutritional management based on the current evidence.
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Affiliation(s)
- Elena Carrillo Lozano
- Servicio de Endocrinología y Nutrición, Hospital Universitario de La Princesa, Madrid, Spain.
| | | | - Rocío Campos Del Portillo
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
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13
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Mouillot T, Brindisi MC, Chambrier C, Audia S, Brondel L. [Refeeding syndrome]. Rev Med Interne 2021; 42:346-354. [PMID: 33549330 DOI: 10.1016/j.revmed.2020.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 11/22/2020] [Accepted: 12/26/2020] [Indexed: 10/22/2022]
Abstract
Refeeding syndrome (RS) is a rare but severe condition that is poorly understood, often under-diagnosed and can lead to death. It occurs within 5 days after refeeding in patients after prolonged fasting or in a context of undernutrition. As a consequence of the abrupt transition from catabolism to anabolism, RS is defined as a decrease in plasma levels of phosphorus, potassium and/or magnesium, whether or not associated with organ dysfunction resulting from a decrease in one of the electrolytes or a thiamine deficiency, after refeeding. The clinical symptoms are varied and non-specific and are related to hydro electrolyte disorders, sodium-hydroxide retention or failure of one or more organs. Patient management should be appropriate with regular clinical examination and careful biological monitoring, including hydro electrolyte monitoring. The correction of hydroelectrolytic disorders and systematic thiamine supplementation are essential during refeeding, that must be done carefully and very progressively, whatever its form (oral, enteral or parenteral). The severity of the refeeding syndrome indicates that its prevention and screening are the corners of its management in at-risk patients.
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Affiliation(s)
- T Mouillot
- Service d'hépato-gastro-entérologie, CHU F.-Mitterrand, 21000 Dijon, France; AgroSup Dijon, CNRS, Inrae, centre des sciences du goût et de l'alimentation, université Bourgogne Franche-Comté, 21000 Dijon, France.
| | - M-C Brindisi
- AgroSup Dijon, CNRS, Inrae, centre des sciences du goût et de l'alimentation, université Bourgogne Franche-Comté, 21000 Dijon, France; Service d'endocrinologie et diabétologie, CHU F.-Mitterrand, 21000 Dijon, France
| | - C Chambrier
- Service de nutrition clinique intensive, hospices civils de Lyon, hôpital Lyon sud, 69495 Pierre-Bénite, France
| | - S Audia
- Service de médecine interne 1, CHU F.-Mitterrand, 21000 Dijon, France
| | - L Brondel
- Service d'hépato-gastro-entérologie, CHU F.-Mitterrand, 21000 Dijon, France; AgroSup Dijon, CNRS, Inrae, centre des sciences du goût et de l'alimentation, université Bourgogne Franche-Comté, 21000 Dijon, France
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14
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Lenz K, Mittendorfer H, Sterrer H. [Clinical ethic consultations in longterm care in Upper Austria-5 years report of the Landesverband Hospiz Upper Austria]. Wien Med Wochenschr 2021; 172:151-156. [PMID: 33439380 PMCID: PMC9038856 DOI: 10.1007/s10354-020-00801-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/13/2020] [Indexed: 11/28/2022]
Abstract
Die Betreuung pflegebedürftiger alter Menschen in Senioreneinrichtungen und Altenheimen stellt deren Mitarbeiter in ihrer täglichen Arbeit immer wieder vor ethischen Fragen. Der Hospizverband Oberösterreich hat vor 5 Jahren ein klinisches Ethikkomitee eingerichtet, deren Aufgabe es ist, Mitarbeiter von außerklinischen Langzeiteinrichtungen bei ethischen Problemstellungen zu beraten und Hilfe zur Lösung gemeinsam zu erarbeiten. In dieser Zeit wurden 38 ethische Beratungen durchgeführt. Die Anfragen kamen von 24 der 137 in Oberösterreich derzeit bestehenden Langzeiteinrichtungen. Wobei 9 Einrichtungen mehr als eine Anfrage zu einer Beratung in diesem Zeitraum stellten. Teilnehmer an den Beratungen waren einerseits Mitglieder des Behandlungsteams, wobei bei 30 der 38 Beratungen auch die/der behandelnde Ärztin/Arzt anwesend war. Von Seiten des Ethikteams des Hospizverbandes nahmen in der Regel 2 (1–3) Mitglieder teil, wobei ein Mitglied die Moderation leitete, das weitere fertigte das Protokoll an. Die häufigsten Konfliktfelder, die zu einer Beratung führten, waren (bei Mehrfachnennungen) mit über 25 % die Frage nach der Krankenhauseinweisung, gefolgt von Konflikten mit Angehörigen, die Frage der künstlichen Ernährung (einschließlich Setzen bzw. Entfernen einer PEG Sonde) und Einschränkungen der persönlichen Freiheit. Die Hälfte der involvierten Bewohner litten unter einer schweren Demenz, 80 % waren nicht mehr selbstbestimmend. Bei keinem/r der BewohnerInnen lag eine verbindliche Patientenverfügung vor.
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Affiliation(s)
- Kurt Lenz
- Landesverband Hospiz, Pfalzgasse 2, 4055, Pupping, Österreich.
- Medizinische Universität Wien, Wien, Österreich.
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Abstract
For patients undergoing major surgery, perioperative management according to an early recovery after surgery (ERAS) protocol focusing on early oral food intake is the strategy of choice. So-called perioperative nutritional (artificial) support now seems to be very traditional and outdated. Nevertheless, even in an overweight and obese society the prevalence of combined malnutrition and/or sarcopenia should not be underestimated. This results in the necessity for identification of patients at metabolic risk and the indications for nutritional therapy. This article provides a review of the current concepts of perioperative nutritional supplementation and discusses the available evidence and guideline recommendations.
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Affiliation(s)
- Arved Weimann
- Klinik für Allgemein‑, Viszeral- und Onkologische Chirurgie, Klinikum St. Georg gGmbH, Delitzscher Str. 141, 04129, Leipzig, Deutschland.
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16
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Carrillo Lozano E, Osés Zárate V, Campos Del Portillo R. Nutritional management of gastric cancer. ACTA ACUST UNITED AC 2020. [PMID: 33388299 DOI: 10.1016/j.endinu.2020.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Gastric cancer is the third leading cause of cancer mortality and is frequently associated with nutritional disorders, the detection and proper management of which can contribute to improving quality of life and survival. Being aware of the consequences and of the different treatments for this neoplasm allows us to offer an adequate nutritional approach. In surgical candidates, integration into ERAS-type programs (Enhanced Recovery after Surgery) is increasingly frequent, and includes a pre-surgical nutritional approach and the initiation of early oral tolerance. After gastrectomy, the new anatomical and functional state of the digestive tract may lead to the appearance of «post-gastrectomy syndromes», the management of which may require diet modification and medical treatment. Those who receive neoadjuvant or adjuvant antineoplastic therapy benefit from specific dietary recommendations based on intercurrent symptoms and/or artificial nutrition. In palliative patients, the nutritional approach should be carried out while respecting the principle of autonomy and weighing the risks and benefits of the intervention. The objective of this review is to highlight the importance and role of nutrition in patients with gastric cancer and to provide guidelines for nutritional management based on the current evidence.
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Affiliation(s)
- Elena Carrillo Lozano
- Servicio de Endocrinología y Nutrición, Hospital Universitario de La Princesa, Madrid, España.
| | | | - Rocío Campos Del Portillo
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
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17
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Loddo C, Poullenot F, Rivière P, Pupier E, Monsaingeon-Henry M, Gronnier C, Collet D, Gatta-Cherifi B. Malnutrition After Bariatric Surgery Requiring Artificial Nutrition Supplies. Obes Surg 2018; 28:1803-5. [PMID: 29568984 DOI: 10.1007/s11695-018-3207-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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18
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Abstract
BACKGROUND Progress in management has improved hospital mortality of patients admitted to the intensive care units, but also the prevalence of those patients needing weaning from prolonged mechanical ventilation, and of ventilator assisted individuals. The result is a number of difficult clinical and organizational problems for patients, caregivers and health services, as well as high human and financial resources consumption, despite poor long-term outcomes. An effort should be made to improve the management of these patients. This narrative review summarizes the main concepts in this field. MAIN BODY There is great variability in terminology and definitions of prolonged mechanical ventilation.There have been several recent developments in the field of prolonged weaning: ventilatory strategies, use of protocols, early mobilisation and physiotherapy, specialised weaning units.There are few published data on discharge home rates, need of home mechanical ventilation, or long-term survival of these patients.Whether artificial nutritional support improves the outcome for these chronic critically ill patients, is unclear and controversial how these data are reported on the optimal time of initiation of parenteral vs enteral nutrition.There is no consensus on time of tracheostomy or decannulation. Despite several individualized, non-comparative and non-validated decannulation protocols exist, universally accepted protocols are lacking as well as randomised controlled trials on this critical issue. End of life decisions should result from appropriate communication among professionals, patients and surrogates and national legislations should give clear indications. CONCLUSION Present medical training of clinicians and locations like traditional intensive care units do not appear enough to face the dramatic problems posed by these patients. The solutions cannot be reserved to professionals but must involve also families and all other stakeholders. Large multicentric, multinational studies on several aspects of management are needed.
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Affiliation(s)
- Nicolino Ambrosino
- Istituti Clinici Scientifici Maugeri, IRCCS, Istituto Scientifico di Montescano, 27040 Montescano, PV Italy
| | - Michele Vitacca
- Istituti Clinici Scientifici Maugeri, IRCCS, Respiratory Unit, Istituto Scientifico di Lumezzane, Lumezzane, BS Italy
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Molfino A, Alessandri F, Mosillo P, Dell'Utri D, Farcomeni A, Amabile MI, Laviano A. PTEN expression and its association with glucose control and calorie supplementation in critically ill patients. Clin Nutr 2017; 37:2186-2190. [PMID: 29154111 DOI: 10.1016/j.clnu.2017.10.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 08/07/2017] [Accepted: 10/28/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND & AIM Phosphatase and tensin homologue (PTEN) reduces insulin sensitivity. Since critically ill patients present insulin resistance, we aimed at assessing the role of PTEN expression on glucose homeostasis and clinical outcome in patients admitted to an intensive care unit (ICU) and receiving artificial nutrition. METHODS Observational, single-center study conducted in one ICU in Rome, Italy on adult patients hospitalized for trauma. Plasma glucose levels and its variability were recorded in patients receiving artificial nutrition. PTEN expression was measured by western blotting analysis and the associations between PTEN, plasma glucose levels and variability, and calories administered were investigated. Parametric and non-parametric tests were used, as appropriate. RESULTS Twenty consecutive patients (13 men and 7 women, mean age of 37.3 ± 12.7 years) were studied. No correlation between plasma glucose and PTEN was documented (r = -0.15, P = 0.55), neither between glycemic variability and PTEN expression (r = -0.00, P = 0.99). However, total kcal/day administered and PTEN expression significantly correlated (r = 0.56, P = 0.01). Also, patients with PTEN levels below the median received less kcal/day than those with PTEN above the median (P = 0.048). This association was more pronounced when normalized per body weight (P = 0.03) and after adjusting for the average of insulin daily administered (P = 0.02). CONCLUSIONS PTEN expression might significantly contribute to glucose homeostasis and disposal in critically ill patients receiving artificial nutrition. Larger samples are necessary to confirm our observation. CLINICAL TRIAL REGISTRY NUMBER NCT01796847 (www.clinicaltrials.gov) submitted on February 11, 2013.
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Affiliation(s)
- Alessio Molfino
- Department of Clinical Medicine, Sapienza University of Rome, Italy.
| | - Francesco Alessandri
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Italy.
| | - Paola Mosillo
- Department of Physiology and Pharmacology "Vittorio Erspamer", Sapienza University of Rome, Italy.
| | - Donatella Dell'Utri
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Italy.
| | - Alessio Farcomeni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy.
| | - Maria Ida Amabile
- Department of Clinical Medicine, Sapienza University of Rome, Italy.
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Ramos A, Zapata L, Vera P, Betbese AJ, Pérez A. Transition from intravenous insulin to subcutaneous long-acting insulin in critical care patients on enteral or parenteral nutrition. ACTA ACUST UNITED AC 2017; 64:552-556. [PMID: 29179857 DOI: 10.1016/j.endinu.2017.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 06/01/2017] [Accepted: 08/01/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The optimal initial dose of subcutaneous (SC) insulin after intravenous (IV) infusion is controversial, especially in patients receiving continuous enteral nutrition (EN) or total parenteral nutrition (TPN). The aim of this study was to evaluate the strategy used at our hospital intensive care unit (ICU) in patients switched from IV insulin to SC insulin glargine while receiving EN or TPN. DESIGN AND METHODS A retrospective analysis was made of 27 patients on EN and 14 on TPN switched from IV infusion insulin to SC insulin. The initial dose of SC insulin was estimated as 50% of the daily IV insulin requirements, extrapolated from the previous 12h. A corrective dose of short-acting insulin (lispro) was used when necessary. RESULTS Mean blood glucose (BG) level during SC insulin treatment was 136±35mg/dL in the EN group and 157±37mg/dL in the TPN group (p=0.01). In the TPN group, mean BG was >180mg/dL during the first three days after switching, and a 41% increase in the glargine dose was required to achieve the target BG. In the EN group, mean BG remained <180mg/dL throughout the days of transition and the dose of glargine remained unchanged. CONCLUSIONS In the transition from IV to SC insulin therapy, initial insulin glargine dose estimated as 50% of daily IV insulin requirements is adequate for patients on EN, but inadequate in those given TPN.
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Affiliation(s)
- Analía Ramos
- Department of Endocrinology & Nutrition, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Lluis Zapata
- Department of Critical Care Medicine, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Paula Vera
- Department of Critical Care Medicine, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Antoni J Betbese
- Department of Critical Care Medicine, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Antonio Pérez
- Department of Endocrinology & Nutrition, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Spain.
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Abstract
Artificial nutrition (AN) is necessary to meet the nutritional requirements of critically ill patients at nutrition risk because undernutrition determines a poorer prognosis in these patients. There is debate over which route of delivery of AN provides better outcomes and lesser complications. This review describes the management of parenteral nutrition (PN) in critically ill patients. The first aim is to discuss what should be done in order that the PN is safe. The second aim is to dispel “myths” about PN-related complications and show how prevention and monitoring are able to reach the goal of “near zero” PN complications. Finally, in this review is discussed the controversial issue of the route for delivering AN in critically ill patients. The fighting against PN complications should consider: (1) an appropriate blood glucose control; (2) the use of olive oil- and fish oil-based lipid emulsions alternative to soybean oil-based ones; (3) the adoption of insertion and care bundles for central venous access devices; and (4) the implementation of a policy of targeting “near zero” catheter-related bloodstream infections. Adopting all these strategies, the goal of “near zero” PN complications is achievable. If accurately managed, PN can be safely provided for most critically ill patients without expecting a relevant incidence of PN-related complications. Moreover, the use of protocols for the management of nutritional support and the presence of nutrition support teams may decrease PN-related complications. In conclusion, the key messages about the management of PN in critically ill patients are two. First, the dangers of PN-related complications have been exaggerated because complications are uncommon; moreover, infectious complications, as mechanical complications, are more properly catheter-related and not PN-related complications. Second, when enteral nutrition is not feasible or tolerated, PN is as effective and safe as enteral nutrition.
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Abe K, Yamashita R, Kondo K, Takayama K, Yokota O, Sato Y, Kawai M, Ishizu H, Nakashima T, Hayashi H, Nakata K, Asaba H, Kadota K, Tanaka K, Morisada Y, Oshima E, Terada S. Long-Term Survival of Patients Receiving Artificial Nutrition in Japanese Psychiatric Hospitals. Dement Geriatr Cogn Dis Extra 2016; 6:477-485. [PMID: 27843445 PMCID: PMC5091231 DOI: 10.1159/000448242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background/Aims Most patients with dementia suffer from dysphagia in the terminal stage of the disease. In Japan, most elderly patients with dysphagia receive either tube feeding or total parenteral nutrition. Methods In this study, we investigated the factors determining longer survival with artificial nutrition. Various clinical characteristics of 168 inpatients receiving artificial nutrition without oral intake in psychiatric hospitals in Okayama Prefecture, Japan, were evaluated. Results Multiple logistic regression analysis showed that the duration of artificial nutrition was associated with a percutaneous endoscopic gastrostomy (PEG) tube, diagnosis of mental disorder, low MMSE score, and absence of decubitus. Conclusion Patients with mental disorders survived longer than those with dementia diseases on artificial nutrition. A PEG tube and good nutrition seem to be important for long-term survival.
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Affiliation(s)
- Keiichi Abe
- Department of Psychiatry, Mannari Hospital, Okayama, Japan
| | | | - Keiko Kondo
- Department of Psychiatry, Sekizen Hospital, Tsuyama, Japan
| | - Keiko Takayama
- Department of Psychiatry, Kibogaoka Hospital, Tsuyama, Japan
| | - Osamu Yokota
- Department of Psychiatry, Kinoko Espoir Hospital, Kasaoka, Japan
| | - Yoshiki Sato
- Department of Psychiatry, Yura Hospital, Tamano, Japan
| | - Mitsumasa Kawai
- Department of Psychiatry, Setouchi Kinen Hospital, Setouchi, Japan
| | - Hideki Ishizu
- Department of Psychiatry, Zikei Hospital, Okayama, Japan
| | | | - Hideki Hayashi
- Department of Psychiatry, Hayashi Hospital, Okayama, Japan
| | - Kenji Nakata
- Department of Psychiatry, Taiyo Hills Hospital, Takahashi, Japan
| | - Hiroyuki Asaba
- Department of Psychiatry, Kohnan Hospital, Tamano, Japan
| | - Koichi Kadota
- Department of Psychiatry, Kurashiki Jinpu Hospital, Kurashiki, Japan
| | | | - Yumi Morisada
- Department of Psychiatry, Kurashiki Shinkeika Hospital, Kurashiki, Japan
| | - Etsuko Oshima
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Seishi Terada
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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23
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Abstract
The decision of whether or not to use artificial nutrition or hydration is one with which many health care providers, patients, and families struggle. These decisions are particularly challenging in the setting of life-limiting illness, which is often associated with a prolonged decline because of medical advances in these patient populations. A patient-centered and family-centered approach helps to attain high-quality care in this special population.
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Affiliation(s)
- Meghan E Lembeck
- Internal Medicine, PinnacleHealth Primary Care, Annville Family Medicine, 475 North Weaber Street, Annville, PA 17003, USA
| | - Colette R Pameijer
- Penn State College of Medicine, 500 University Drive, Mail Code H149, PO Box 850, Hershey, PA 17033, USA
| | - Amy M Westcott
- Geriatric and Palliative Medicine, Penn State College of Medicine, 500 University Drive, Mail Code H106, PO Box 850, Hershey, PA 17033, USA.
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24
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Abstract
Diabetes and cancer are increasingly common conditions, and the management of cancer patients with diabetes is often challenging. Diabetes in cancer patients poses several complex clinical issues, including which treatment is suitable to control hyperglycemia, how to better counteract glucocorticoid-induced hyperglycemia, and how to manage nutritional problems of cachectic patients and glucose variability linked to artificial nutrition. A key aspect to consider is the patients' position on the trajectory of the oncologic disease, both to establish which level of glycemic control should be pursued and to decide the most suitable antidiabetic treatment to recommend. Endocrinologists are rarely involved in the management of patients with advanced cancer. Furthermore, lack of guidelines results in a "trial-and-error" approach, often with suboptimal disease management. Lastly, cancer survivors represent a frequently underestimated category of patients at higher cardiometabolic risk. A practical solution for these challenges lies in the implementation of care networks based on a close partnership and ongoing communication between oncologists, endocrinologists, and nutritionists, placing the patient at the center of the care process. At the same time, universities and scientific societies should play a key role in promoting research into areas of intersection of oncology and endocrinology, in raising awareness of common possibilities of primary and secondary prevention of metabolic and oncologic diseases, as well as specific challenges of managing diabetes and cancer, and proper training of health workers, while also supporting the shared implementation of effective management strategies.
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Affiliation(s)
- Marco Gallo
- Oncological Endocrinology Unit, Department of Medical Sciences, AOU Città della Salute e della Scienza di Torino, Via Genova 3, 10126, Turin, Italy.
| | - Luigi Gentile
- Endocrinology and Diabetes Unit, Cardinal Massaja Hospital, Asti, Italy
| | | | - Oscar Bertetto
- Head of the Piemonte and Valle d'Aosta Oncology Network, Turin, Italy
| | - Gennaro Clemente
- Institute of Food Science, National Research Council, IRPPS - Institute for Research on Population and Social Policies, Penta di Fisciano, Salerno, Italy
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25
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Matuschek C, Bölke E, Geigis C, Kammers K, Ganswindt U, Scheckenbach K, Gripp S, Simiantonakis J, Hoffmann TK, Greve J, Gerber PA, Orth K, Roeder H, Hautmann MG, Budach W. Influence of dosimetric and clinical criteria on the requirement of artificial nutrition during radiotherapy of head and neck cancer patients. Radiother Oncol 2016; 120:28-35. [PMID: 27296411 DOI: 10.1016/j.radonc.2016.05.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 05/02/2016] [Accepted: 05/10/2016] [Indexed: 01/08/2023]
Abstract
PURPOSE/OBJECTIVE(S) Intensification of radiotherapy and chemotherapy for head-and-neck cancer (HNC) may lead to increased rates of long term dysphagia as a severe side effect. Mucositis and consequent swallowing problems require artificial nutrition in many HNC patients undergoing radiotherapy or chemoradiation. It is unknown, which predict factors for prophylactic PEG tube insertion appear useful. MATERIALS/METHODS From an institutional database, 101 patients (72 male, 29 female, mean age 59.5years) were identified who underwent radiotherapy or chemoradiation for HNC. Primary end point of the investigation was the need for artificial nutrition for more than 4days during radiotherapy. Dose volume parameters of defined normal tissue structures potentially of relevance for swallowing ability as well as clinical factors were used to develop a predictive model using a binary multiple logistic regression model. RESULTS Whereas several dosimetric and clinical factors were significant predictors for the need of artificial nutrition on univariate analysis, on multivariate analysis only three factors remained independently significant: mean dose to the oropharynx+1cm circumferential margin, ECOG performance state (0-1 vs. 2-4), and the use of chemotherapy (yes vs. no). CONCLUSIONS Using a 3 parameter model we could distinguish HNC-patients with different risks for the need of artificial nutrition during radiotherapy. After independent validation, the model could be helpful to decision on prophylactic PEG tube insertion.
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Affiliation(s)
- Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty Heinrich Heine University Hospital Duesseldorf, Germany.
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty Heinrich Heine University Hospital Duesseldorf, Germany
| | - Caroline Geigis
- Department of Radiation Oncology, Medical Faculty Heinrich Heine University Hospital Duesseldorf, Germany
| | - Kai Kammers
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Ute Ganswindt
- Department of Radiation Oncology, Ludwig Maximilians University Hospital, Großhadern and Campus, Germany
| | - Kathrin Scheckenbach
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty Heinrich Heine University Hospital Duesseldorf, Germany
| | - Stephan Gripp
- Department of Radiation Oncology, Medical Faculty Heinrich Heine University Hospital Duesseldorf, Germany
| | - Jannis Simiantonakis
- Department of Radiation Oncology, Medical Faculty Heinrich Heine University Hospital Duesseldorf, Germany
| | - Thomas K Hoffmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Germany
| | - Jens Greve
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Germany
| | - Peter Arne Gerber
- Department of Dermatology, Medical Faculty Heinrich Heine University Duesseldorf, Germany
| | - Klaus Orth
- Department of General, Visceral and Thoracic Surgery, Harzkliniken Goslar, Germany
| | - Henning Roeder
- Department of Radiation Oncology, Medical Faculty Heinrich Heine University Hospital Duesseldorf, Germany
| | | | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty Heinrich Heine University Hospital Duesseldorf, Germany
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26
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Druml C, Ballmer PE, Druml W, Oehmichen F, Shenkin A, Singer P, Soeters P, Weimann A, Bischoff SC. ESPEN guideline on ethical aspects of artificial nutrition and hydration. Clin Nutr 2016; 35:545-56. [PMID: 26923519 DOI: 10.1016/j.clnu.2016.02.006] [Citation(s) in RCA: 156] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 01/28/2016] [Accepted: 02/05/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND The worldwide debate over the use of artificial nutrition and hydration remains controversial although the scientific and medical facts are unequivocal. Artificial nutrition and hydration are a medical intervention, requiring an indication, a therapeutic goal and the will (consent) of the competent patient. METHODS The guideline was developed by an international multidisciplinary working group based on the main aspects of the Guideline on "Ethical and Legal Aspects of Artificial Nutrition" published 2013 by the German Society for Nutritional Medicine (DGEM) after conducting a review of specific current literature. The text was extended and introduced a broader view in particular on the impact of culture and religion. The results were discussed at the ESPEN Congress in Lisbon 2015 and accepted in an online survey among ESPEN members. RESULTS The ESPEN Guideline on Ethical Aspects of Artificial Nutrition and Hydration is focused on the adult patient and provides a critical summary for physicians and caregivers. Special consideration is given to end of life issues and palliative medicine; to dementia and to specific situations like nursing care or the intensive care unit. The respect for autonomy is an important focus of the guideline as well as the careful wording to be used in the communication with patients and families. The other principles of Bioethics like beneficence, non-maleficence and justice are presented in the context of artificial nutrition and hydration. In this respect the withholding and withdrawing of artificial nutrition and/or hydration is discussed. Due to increasingly multicultural societies and the need for awareness of different values and beliefs an elaborated chapter is dedicated to cultural and religious issues and nutrition. Last but not least topics like voluntary refusal of nutrition and fluids, and forced feeding of competent persons (persons on hunger strike) is included in the guideline.
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Affiliation(s)
- Christiane Druml
- UNESCO Chair on Bioethics at the Medical University of Vienna, Collections and History of Medicine - Josephinum, Medical University of Vienna, Waehringerstrasse 25, A-1090 Vienna, Austria.
| | - Peter E Ballmer
- Department of Medicine, Kantonsspital Winterthur, Brauerstrasse 15, Postfach 834, 8401 Winterthur, Switzerland.
| | - Wilfred Druml
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - Frank Oehmichen
- Department of Early Rehabilitation, Klinik Bavaria Kreischa, An der Wolfsschlucht 1-2, 01731 Kreischa, Germany.
| | - Alan Shenkin
- Department of Clinical Chemistry, University of Liverpool, Duncan Building, Daulby Street, Liverpool L69 3GA, UK.
| | - Pierre Singer
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Jean Leven Building, 6th Floor, Tel Aviv, Israel.
| | - Peter Soeters
- Department of Surgery, Academic Hospital Maastricht, Peter Debeyelaan 25, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands.
| | - Arved Weimann
- Department of General Surgery and Surgical Intensive Care, St Georg Hospital, Delitzscher Straße 141, 04129 Leipzig, Germany.
| | - Stephan C Bischoff
- Department of Nutritional Medicine, University of Hohenheim, Fruwirthstr. 12, 70599 Stuttgart, Germany.
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27
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Abstract
Parenteral nutrition may be considered when oral intake and/or enteral nutrition are not sufficient to maintain nutritional status and the patient is likely to die sooner from starvation than from the cancer. A detailed assessment should be made prior to the decision about whether parenteral nutrition should be started. A follow up plan should be documented with objective and patient centred treatment goals as well as specific time points for evaluation.
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28
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van de Vathorst S. Artificial nutrition at the end of life: ethical issues. Best Pract Res Clin Gastroenterol 2014; 28:247-53. [PMID: 24810185 DOI: 10.1016/j.bpg.2014.02.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 02/06/2014] [Accepted: 02/09/2014] [Indexed: 01/31/2023]
Abstract
Artificial nutrition is a medical treatment that first of all needs a sound scientific base before prescribing it. This base is absent for dying patients and patients in the end stage of dementia. Because feeding is a very emotional and symbolical issue, patient and family may request this treatment despite the lack of evidence. These issues should be addressed in good communication with patient and relatives. For comatose patients and patients in a persistent vegetative state artificial nutrition is a necessary support to bridge the time until either recovery is imminent or improbable. At that moment artificial nutrition no longer contributes to the life of the patient and should be ceased. Artificial nutrition has no place in patients that voluntary decide to stop eating and drinking in order to die.
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Affiliation(s)
- Suzanne van de Vathorst
- Department of Ethics and Philosophy, Na 2117, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, The Netherlands; Department of General Practice, J2-123, AMC, PO Box 22660, 1100 DD Amsterdam, The Netherlands.
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29
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Owais AE, Kabir SI, Mcnaught C, Gatt M, MacFie J. A single-blinded randomised clinical trial of permissive underfeeding in patients requiring parenteral nutrition. Clin Nutr 2014; 33:997-1001. [PMID: 24467878 DOI: 10.1016/j.clnu.2014.01.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 01/05/2014] [Accepted: 01/07/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND & AIMS The importance of adequate nutritional support is well established, but characterising what 'adequate nutrition' represents remains contentious. In recent years there has been increasing interest in the concept of 'permissive underfeeding' where patients are intentionally prescribed less nutrition than their calculated requirements. The aim of this study was to evaluate the effect of permissive underfeeding on septic and nutrition related morbidity in patients requiring short term parenteral nutrition (PN). METHODS This was a single-blinded randomised clinical trial of 50 consecutive patients requiring parenteral nutritional support. Patients were randomized to receive either normocaloric or hypocaloric feeding (respectively 100% vs. 60% of estimated requirements). The primary end point was septic complications. Secondary end points included the metabolic, physiological and clinical outcomes to the two feeding protocols. RESULTS Permissive underfeeding was associated with fewer septic complications (3 vs. 12 patients; p = 0.003), and a lower incidence of the systemic inflammatory response syndrome (9 vs. 16 patients; p = 0.017). Permissively underfed patients had fewer feed related complications (2 vs. 9 patients; p = 0.016). CONCLUSION Permissive underfeeding in patients requiring short term PN appears to be safe and may results in reduced septic and feed-related complications. TRIAL REGISTRATION NCT01154179 TRIAL REGISTRY: http://clinicaltrials.gov/ct2/show/NCT01154179.
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