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Harris TD, Farrar JE, Byerly S, Filiberto DM, Dickerson RN. Evaluation of a Novel Enteral Phosphorus Therapy with Enteral Nutrition during a National Intravenous Sodium Phosphate Shortage. Nutrients 2024; 16:1394. [PMID: 38732640 PMCID: PMC11085910 DOI: 10.3390/nu16091394] [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: 04/11/2024] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 05/13/2024] Open
Abstract
The purpose of this study was to evaluate the efficacy and safety of intragastric administration of small volumes of sodium enema solution containing phosphorus as phosphorus replacement therapy in critically ill patients with traumatic injuries who required continuous enteral nutrition. Adult patients (>17 years of age) who had a serum phosphorus concentration <3 mg/dL (0.97 mmol/L) were evaluated. Patients with a serum creatinine concentration >1.4 mg/dL (124 µmol/L) were excluded. Patients were given 20 mL of saline enema solution intragastrically, containing 34 mmol of phosphorus and mixed in 240 mL water. A total of 55% and 73% of patients who received one (n = 22) or two doses (n = 11) had an improvement in the serum phosphorus concentration, respectively. The serum phosphorus concentration increased from 2.5 [2.1, 2.8] mg/dL (0.81 [0.69, 0.90] mmol/L) to 2.9 [2.2, 3.0] mg/dL (0.94 [0.71, 0.97 mmol/L) for those who received two doses (p = 0.222). Excluding two patients with a marked decline in serum phosphorus by 1.3 mg/dL (0.32 mmol/L) resulted in an increase in the serum phosphorus concentration from 2.3 [2.0, 2.8] mg/dL (0.74 [0.65, 0.90] mmol/L) to 2.9 [2.5, 3.2] mg/dL (0.94 [0.81, 1.03] mmol/L; n = 9; p = 0.012). No significant adverse effects were noted. Our data indicated that intragastric phosphate administration using a small volume of saline enema solution improved the serum phosphorus concentrations in most patients.
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Affiliation(s)
- Tinia D. Harris
- Department of Pharmacy, Regional One Health, Memphis, TN 38103, USA
| | - Julie E. Farrar
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Dina M. Filiberto
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Roland N. Dickerson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN 38163, USA
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Dickerson RN, Farrar JE, Byerly S, Filiberto DM. Enteral feeding tolerance during pharmacologic neuromuscular blockade. Nutr Clin Pract 2023; 38:1236-1246. [PMID: 37475530 DOI: 10.1002/ncp.11045] [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: 03/29/2023] [Revised: 06/13/2023] [Accepted: 06/27/2023] [Indexed: 07/22/2023] Open
Abstract
A common misperception is that critically ill patients who receive paralytic therapy will not tolerate enteral nutrition. As a result, some clinicians empirically withhold enteral feedings for critically ill patients who receive neuromuscular blocker pharmacotherapy (NMB). The intent of this review is to examine the evidence regarding enteral feeding tolerance for critically ill patients given NMB. Studies evaluating enteral feeding during paralytic therapy are provided and critiqued. Evidence examining enteral feeding tolerance during NMB is limited. Enteral feeding intolerance is more likely attributable to the underlying illnesses and concurrent opioid analgesia, sedation, and vasopressor therapies. Most critically ill patients can be successfully fed during NMB. Prokinetic pharmacotherapy may be warranted in some patients.
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Affiliation(s)
- Roland N Dickerson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Julie E Farrar
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Dina M Filiberto
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Dickerson RN, Bingham AL, Canada TW, Neander Chan L, Petrea Cober M, Cogle SV, Tucker AM, Kumpf VJ. Significant Published Articles in 2022 for Pharmacy Nutrition Support Practice. Hosp Pharm 2023; 58:504-510. [PMID: 37711416 PMCID: PMC10498963 DOI: 10.1177/00185787231161515] [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: 09/16/2023]
Abstract
Purpose: The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2022 considered important to their clinical practice. The citation list was compiled into a spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby at least 5 out of the 8 author participants considered the article to be important. Guideline and consensus papers, important to practice but not ranked, were also included. Results: A total of 162 articles were identified; 8 from the primary literature were voted by the group to be of high importance. An additional 10 guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were summarized and a narrative regarding its implications to pharmacy nutrition support practice were provided. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.
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Affiliation(s)
| | | | - Todd W. Canada
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Sarah V. Cogle
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anne M. Tucker
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
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4
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Dickerson RN. Clinical pharmacists in nutrition support: Don't throw the baby out with the bath water! Nutr Clin Pract 2023; 38:932-933. [PMID: 37138443 DOI: 10.1002/ncp.11005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 04/16/2023] [Indexed: 05/05/2023] Open
Affiliation(s)
- Roland N Dickerson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Dickerson RN, Andromalos L, Brown JC, Correia MITD, Pritts W, Ridley EJ, Robinson KN, Rosenthal MD, van Zanten ARH. Correction: Obesity and critical care nutrition: current practice gaps and directions for future research. Crit Care 2023; 27:177. [PMID: 37158947 PMCID: PMC10169449 DOI: 10.1186/s13054-023-04456-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Affiliation(s)
- Roland N Dickerson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, 881 Madison Avenue, Suite 345, Memphis, TN, 38163, USA.
| | | | - J Christian Brown
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Wanda Pritts
- Placenta-Linda Hospital, 1301 Rose Dr, Placentia, CA, USA
| | - Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Katie N Robinson
- Scientific and Medical Affairs, Abbott Nutrition, 2900 Easton Square Pl, Columbus, OH, USA
| | - Martin D Rosenthal
- Acute Care Surgery Team, University of Florida College of Medicine, Gainesville, FL, USA
| | - Arthur R H van Zanten
- Chair, Department of Intensive Care Medicine & Research, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP, Ede, The Netherlands
- Division of Human Nutrition and Health, Chair Group Nutritional Biology, Wageningen University & Research, HELIX (Building 124), Stippeneng 4, 6708 WE, Wageningen, The Netherlands
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Dickerson RN, Corley CE, Holmes WL, Byerly S, Filiberto DM, Fischer PE. Gastric feeding intolerance in critically ill patients during sustained pharmacologic neuromuscular blockade. Nutr Clin Pract 2023; 38:350-359. [PMID: 36156827 DOI: 10.1002/ncp.10911] [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: 06/07/2022] [Revised: 07/23/2022] [Accepted: 08/28/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The purpose of this study was to assess gastric feeding intolerance for critically ill patients who received sustained neuromuscular blocker (NMB) pharmacotherapy. METHODS Adult patients (>17 years of age) admitted to the trauma intensive care unit who received continuous intravenous NMB pharmacotherapy (rocuronium, cisatracurium, vecuronium, or pancuronium) for ≥48 h during continuous intragastric enteral nutrition (EN) were retrospectively evaluated. Gastric feeding intolerance was defined by initiation of a prokinetic agent (metoclopramide, erythromycin, or both) for an elevated gastric residual volume (GRV) >300 ml and with distention of the abdomen by physical examination, observation of regurgitation or emesis, temporary discontinuation of EN with low intermittent gastric suctioning, or initiation of parenteral nutrition (PN). Patients were evaluated for gastric feeding intolerance for the first 3 days of combined EN and NMB pharmacotherapy. A P value < 0.05 was considered statistically significant. RESULTS Ten patients of the 47 patients (21%) were intolerant to EN during NMB pharmacotherapy. No statistically or clinically relevant differences in patient characteristics were found between patients who tolerated EN vs those who experienced gastric feeding intolerance, except for a higher median maximum GRV of 125 ml (28, 200) vs 300 (250, 400) ml, respectively (P < 0.001). Five patients responded to prokinetic therapy and five required PN. CONCLUSION Most patients tolerated intragastric EN during sustained NMB pharmacotherapy. Presence of NMB pharmacotherapy is not an absolute contraindication for EN.
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Affiliation(s)
- Roland N Dickerson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Whitney L Holmes
- Department of Pharmacy, Regional One Health, Memphis, Tennessee, USA
| | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Dina M Filiberto
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Peter E Fischer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Dickerson RN, Bingham AL, Canada TW, Chan LN, Cober MP, Cogle SV, Tucker AM, Kumpf VJ. Significant Published Articles in 2021 for Pharmacy Nutrition Support Practice. Hosp Pharm 2022; 57:673-680. [PMID: 36081538 PMCID: PMC9445547 DOI: 10.1177/00185787221095765] [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: 10/03/2023]
Abstract
Purpose: The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2021 considered important to their clinical practice. The citation list was compiled into a single spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby at least 5 out of the 8 author participants considered the paper to be important. Guideline and consensus papers from professional organizations, important to practice but not ranked, were also included. Results: A total of 211 articles were identified; 8 from the primary literature were voted by the group to be of high importance. An additional 18 guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were summarized and a narrative regarding its implications to pharmacy nutrition support practice were provided. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.
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Affiliation(s)
- Roland N. Dickerson
- University of Tennessee Health Science Center, College of Pharmacy, Memphis, TN, USA
| | | | - Todd W. Canada
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Sarah V. Cogle
- Auburn University – Harrison School of Pharmacy, Auburn, AL, USA
| | - Anne M. Tucker
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Dickerson RN, Andromalos L, Brown JC, Correia MITD, Pritts W, Ridley EJ, Robinson KN, Rosenthal MD, van Zanten ARH. Obesity and critical care nutrition: current practice gaps and directions for future research. Crit Care 2022; 26:283. [PMID: 36127715 PMCID: PMC9486775 DOI: 10.1186/s13054-022-04148-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 08/25/2022] [Indexed: 11/25/2022] Open
Abstract
Background This review has been developed following a panel discussion with an international group of experts in the care of patients with obesity in the critical care setting and focuses on current best practices in malnutrition screening and assessment, estimation of energy needs for patients with obesity, the risks and management of sarcopenic obesity, the value of tailored nutrition recommendations, and the emerging role of immunonutrition. Patients admitted to the intensive care unit (ICU) increasingly present with overweight and obesity that require individualized nutrition considerations due to underlying comorbidities, immunological factors such as inflammation, and changes in energy expenditure and other aspects of metabolism. While research continues to accumulate, important knowledge gaps persist in recognizing and managing the complex nutritional needs in ICU patients with obesity. Available malnutrition screening and assessment tools are limited in patients with obesity due to a lack of validation and heterogeneous factors impacting nutrition status in this population. Estimations of energy and protein demands are also complex in patients with obesity and may include estimations based upon ideal, actual, or adjusted body weight. Evidence is still sparse on the role of immunonutrition in patients with obesity, but the presence of inflammation that impacts immune function may suggest a role for these nutrients in hemodynamically stable ICU patients. Educational efforts are needed for all clinicians who care for complex cases of critically ill patients with obesity, with a focus on strategies for optimal nutrition and the consideration of issues such as weight stigma and bias impacting the delivery of care. Conclusions Current nutritional strategies for these patients should be undertaken with a focus on individualized care that considers the whole person, including the possibility of preexisting comorbidities, altered metabolism, and chronic stigma, which may impact the provision of nutritional care. Additional research should focus on the applicability of current guidelines and evidence for nutrition therapy in populations with obesity, especially in the setting of critical illness.
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Dickerson RN, Turner SC, Holmes WL, Van Matre ET, Swanson JM, Byerly S, Filiberto DM, Fischer PE. Reduction in Hypercalcemia Following Readjustment of Target Serum 25-Hydroxy Vitamin D Concentration during Cholecalciferol Therapy in Vitamin D-Deficient Critically Ill Patients. Nutrients 2022; 14:nu14081650. [PMID: 35458212 PMCID: PMC9032836 DOI: 10.3390/nu14081650] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/07/2022] [Accepted: 04/13/2022] [Indexed: 11/23/2022] Open
Abstract
The intent of this study was an evaluation of our effort to reduce the incidence of hypercalcemia in critically ill vitamin D-deficient patients with multiple traumatic injuries given cholecalciferol. Vitamin D deficiency was defined as a serum 25-hydroxy vitamin D concentration (25-OH vit D) of <20 ng/mL. Adult patients (>17 years of age) were given 10,000 IU of cholecalciferol daily with an intended target 25-OH vit D of >19.9 ng/mL. These patients were compared to a historical control group that underwent therapy with a higher target of >29.9 ng/mL. Patients received cholecalciferol via the feeding tube along with enteral nutrition (EN) until the target 25-OH vit D was achieved, EN discontinued, the nutrition support service signed off the patient, or the patient was discharged from the TICU. Patients were included if two consecutive weekly 25-OH vit D were measured. One hundred and three critically ill trauma patients were retrospectively studied. Fifty were given cholecalciferol therapy with the new lower target 25-OH vit D, and 53 were from a historical cohort aiming for the higher target. Hypercalcemia (serum ionized calcium concentration > 1.32 mmol/L) was reduced from 40% (21 out of 53 patients) to 4% (2 out of 50 patients; p < 0.001). None of the hypercalcemic patients were symptomatic. Readjustment of target 25-OH vit D concentration resulted in a ten-fold decrease in the rate of hypercalcemia and improved the safety of cholecalciferol therapy for critically ill patients with traumatic injuries.
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Affiliation(s)
- Roland N. Dickerson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee College of Pharmacy, Memphis, TN 38163, USA; (E.T.V.M.); (J.M.S.)
- Correspondence:
| | | | - Whitney L. Holmes
- Department of Pharmacy, Regional One Health, Memphis, TN 38103, USA;
| | - Edward T. Van Matre
- Department of Clinical Pharmacy and Translational Science, University of Tennessee College of Pharmacy, Memphis, TN 38163, USA; (E.T.V.M.); (J.M.S.)
| | - Joseph M. Swanson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee College of Pharmacy, Memphis, TN 38163, USA; (E.T.V.M.); (J.M.S.)
| | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (S.B.); (D.M.F.); (P.E.F.)
| | - Dina M. Filiberto
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (S.B.); (D.M.F.); (P.E.F.)
| | - Peter E. Fischer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (S.B.); (D.M.F.); (P.E.F.)
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Dickerson RN, Bingham AL, Canada TW, Chan LN, Cober MP, Cogle SV, Tucker AM, Kumpf VJ. Significant Published Articles in 2020 for Pharmacy Nutrition Support Practice. Hosp Pharm 2021; 56:466-473. [PMID: 34720147 DOI: 10.1177/00185787211016363] [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: 11/15/2022]
Abstract
Purpose: The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2020 considered important to their clinical practice. The citation list was compiled into a single spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby at least 5 out of the 8 author participants considered the paper to be important. Guideline and consensus papers from professional organizations, important to practice but not ranked, were also included. Results: A total of 169 articles were identified; 5 from the primary literature were voted by the group to be of high importance. An additional 17 guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were summarized and a narrative regarding its implications to pharmacy nutrition support practice were provided. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.
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Affiliation(s)
- Roland N Dickerson
- University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA
| | - Angela L Bingham
- University of the Sciences in Philadelphia, Philadelphia, PA, USA
| | - Todd W Canada
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Sarah V Cogle
- Auburn University - Harrison School of Pharmacy, Auburn, AL, USA
| | - Anne M Tucker
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Buckley CT, Prasanna N, Mays AL, Tinsley JM, Dickerson RN. Protein requirements for critically ill ventilator-dependent patients with COVID-19. Nutr Clin Pract 2021; 36:984-992. [PMID: 34468046 PMCID: PMC8662189 DOI: 10.1002/ncp.10763] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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] [Indexed: 12/15/2022] Open
Abstract
Background Recent studies indicate critically ill patients with coronavirus disease 2019 (COVID‐19) are hypermetabolic; however, protein requirements in critically ill COVID‐19 patients are unknown. Our intent was to evaluate the nitrogen accretion response to varying protein intakes for critically ill ventilator‐dependent patients with COVID‐19. Methods Adult patients (age ≥ 18 years) with COVID‐19, admitted to the intensive care unit (ICU) and who required mechanical ventilation were retrospectively evaluated. Patients received continuous enteral nutrition (EN), including supplemental protein boluses, and had a 24‐h urine collection for determination of nitrogen balance (NBAL). Data are expressed as mean ± SD with a P‐value < .05 as significant. Results Twenty‐two patients provided 29 NBAL determinations. Protein intake from EN and protein supplements was 0.9 ± 0.7 g/kg/day at the time of the NBAL with an NBAL of –12.1 ± 10.9 g/day at 7 ± 4 days in the ICU. Combined caloric intake from EN and propofol at the time of the NBAL was 12 ± 8 kcal/kg/day. Nitrogen equilibrium (NBAL of –4 g/day or better) occurred in five patients. Patients achieving nitrogen equilibrium received more protein than those with a negative NBAL (1.2 ± 0.4 g/kg/day vs 0.8 ± 0.8 g/kg/day, P = .046). The linear regression for NBAL in response to graded increases in protein intake was as follows: NBAL = 8.5 × protein intake (g/kg/day) – 18.8 (r = 0.450, P < .001). Conclusion Critically ill ventilator‐dependent patients with COVID‐19 exhibit significant variability in nitrogen accretion response to increases in protein intake and often have a markedly negative NBAL.
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Affiliation(s)
- Christopher T Buckley
- Department of Pharmacy Practice, Union University, College of Pharmacy, Jackson, Tennessee, USA
| | - Nivedita Prasanna
- Department of Critical Care Medicine, Jackson-Madison County General Hospital, Jackson, Tennessee, USA
| | - Abby L Mays
- Department of Nutrition, Jackson-Madison County General Hospital, Jackson, Tennessee, USA
| | - Jeanette M Tinsley
- Department of Nutrition, Jackson-Madison County General Hospital, Jackson, Tennessee, USA
| | - Roland N Dickerson
- Department of Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Mechanick JI, Carbone S, Dickerson RN, Hernandez BJD, Hurt RT, Irving SY, Li DY, McCarthy MS, Mogensen KM, Gautier JBO, Patel JJ, Prewitt TE, Rosenthal M, Warren M, Winkler MF, McKeever L. Clinical Nutrition Research and the COVID-19 Pandemic: A Scoping Review of the ASPEN COVID-19 Task Force on Nutrition Research. JPEN J Parenter Enteral Nutr 2020; 45:13-31. [PMID: 33094848 DOI: 10.1002/jpen.2036] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [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: 09/12/2020] [Accepted: 10/16/2020] [Indexed: 12/13/2022]
Abstract
The purpose of this scoping review by the American Society for Parenteral and Enteral Nutrition (ASPEN) Coronavirus Disease 2019 (COVID-19) Nutrition Task Force was to examine nutrition research applicable to the COVID-19 pandemic. The rapid pace of emerging scientific information has prompted this activity to discover research/knowledge gaps. This methodology adhered with recommendations from the Joanna Briggs Institute. There were 2301 citations imported. Of these, there were 439 articles fully abstracted, with 23 main topic areas identified across 24 article types and sourced across 61 countries and 51 specialties in 8 settings and among 14 populations. Epidemiological/mechanistic relationships between nutrition and COVID-19 were reviewed and results mapped to the Population, Intervention, Comparator, Outcome, and Time (PICO-T) questions. The aggregated data were analyzed by clinical stage: pre-COVID-19, acute COVID-19, and chronic/post-COVID-19. Research gaps were discovered for all PICO-T questions. Nutrition topics meriting urgent research included food insecurity/societal infrastructure and transcultural factors (pre-COVID-19); cardiometabolic-based chronic disease, pediatrics, nutrition support, and hospital infrastructure (acute COVID-19); registered dietitian nutritionist counseling (chronic/post-COVID-19); and malnutrition and management (all stages). The paucity of randomized controlled trials (RCTs) was particularly glaring. Knowledge gaps were discovered for PICO-T questions on pediatrics, micronutrients, bariatric surgery, and transcultural factors (pre-COVID-19); enteral nutrition, protein-energy requirements, and glycemic control with nutrition (acute COVID-19); and home enteral and parenteral nutrition support (chronic/post-COVID-19). In conclusion, multiple critical areas for urgent nutrition research were identified, particularly using RCT design, to improve nutrition care for patients before, during, and after COVID-19.
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Affiliation(s)
- Jeffrey I Mechanick
- Marie-Josée and Henry R. Kravis Center for Cardiovascular Health at Mount Sinai Heart, and, Metabolic Support, Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Salvatore Carbone
- Department of Kinesiology & Health Sciences, College of Humanities & Sciences, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Roland N Dickerson
- Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Clinical Coordinator and Clinical Pharmacy Specialist, Nutrition Support Service, Regional One Health, Memphis, Tennessee, USA
| | | | - Ryan T Hurt
- Divisions of Gastroenterology and Hepatology, and Endocrinology, Diabetes, Metabolism, Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Sharon Y Irving
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Ding-You Li
- Gastroenterology and Nutrition, University of Missouri, Kansas City School of Medicine, Kansas City, Missouri, USA
| | | | - Kris M Mogensen
- Department of Nutrition, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | | | - Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - T Elaine Prewitt
- Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Martin Rosenthal
- Acute Care Surgery Team, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Malissa Warren
- VA Portland HealthCare System, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Marion F Winkler
- Department of Surgery and Nutritional Support Service, Rhode Island Hospital, Brown Medical School, Providence, Rhode Island, USA
| | - Liam McKeever
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Dickerson RN. Protein Requirements during Hypocaloric Nutrition for the Older Patient With Critical Illness and Obesity: An Approach to Clinical Practice. Nutr Clin Pract 2020; 35:617-626. [PMID: 32588488 DOI: 10.1002/ncp.10501] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Current guidelines recommend a hypocaloric, high protein nutrition regimen for patients with obesity and critical illness. The impact of advancing age presents with unique challenges in which a greater protein intake is required to overcome the anabolic resistance associated with aging in the face of presumed decreased renal function. The primary objective of this review is to provide an overview of the impact of obesity and advancing age on protein requirements for patients with critical illness and review the scientific evidence supporting the rationale for hypocaloric, high protein nutrition for this subpopulation, as well as provide some practical suggestions for their clinical management.
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Affiliation(s)
- Roland N Dickerson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, Tennessee, USA
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Buckley CT, Van Matre ET, Fischer PE, Minard G, Dickerson RN. Improvement in Protein Delivery for Critically Ill Patients Requiring High-Dose Propofol Therapy and Enteral Nutrition. Nutr Clin Pract 2020; 36:212-218. [PMID: 32589810 DOI: 10.1002/ncp.10546] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Patients with traumatic brain (TBI) injury often require a high dosage of propofol, which can provide an excessive caloric intake. We evaluated our strategy of using liquid protein supplement boluses concurrently with high protein-containing enteral nutrition (EN) formulas and formula rate reduction to avoid caloric overfeeding and inadequate protein intake. METHODS Adult patients (aged >17 years) with TBI admitted to the trauma intensive care unit (TICU) who received concurrent propofol and EN were retrospectively reviewed. Caloric intakes from propofol and EN were obtained. Actual protein intake was compared with projected protein intakes from high protein content and standard protein content enteral formulas when given at an isocaloric intake. RESULTS Fifty-one patients were enrolled. Average caloric intake from propofol was 356 ± 243 kcal/d or 5 ± 3 kcal/kg/d (range, <1-15 kcal/kg/d). Daily EN caloric intake ranged from 7 ± 4 kcal/kg/d (day 2) to 16 ± 9 kcal/kg/d (day 5; P < .001). Average protein intake ranged from 0.6 ± 0.4 g/kg/d (day 2) to 1.5 ± 0.7 g/kg/d (day 5; P < .001). The modified EN strategy resulted in daily delivery of 24%-38% more protein than an isocaloric regimen with a high protein-content formula and twice as much protein than the standard protein-content formula (P < .001). CONCLUSION The strategy of providing an EN regimen comprised liquid protein boluses, and high and very high protein-containing EN formulas at a reduced rate improved protein delivery without caloric overfeeding.
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Affiliation(s)
- Christopher T Buckley
- Department of Pharmacy Practice, Union University, College of Pharmacy, Jackson, Tennessee, USA
| | - Edward T Van Matre
- Department of Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Peter E Fischer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Gayle Minard
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Roland N Dickerson
- Department of Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Dickerson RN, Bingham AL, Canada TW, N Chan L, Cober MP, V Cogle S, Tucker AM, Kumpf VJ. Significant Published Articles for Pharmacy Nutrition Support Practice in 2019. Hosp Pharm 2020; 55:373-381. [PMID: 33245726 DOI: 10.1177/0018578720928264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2019 considered important to their clinical practice. The citation list was compiled into a single spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby at least 5 out of the 8 author participants considered the paper to be important. Guideline and consensus papers from professional organizations, important to practice but not ranked, were also included. Results: A total of 111 articles were identified; 6 from the primary literature were voted by the group to be of high importance. An additional 9 organizational guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were summarized and a narrative regarding its implications to pharmacy nutrition support practice were provided. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.
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Affiliation(s)
| | - Angela L Bingham
- University of the Sciences in Philadelphia, Philadelphia, PA, USA
| | - Todd W Canada
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | | | - Anne M Tucker
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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16
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Affiliation(s)
| | - Roland N Dickerson
- The University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA
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17
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Holmes WL, Maish GO, Minard G, Croce MA, Dickerson RN. Hypercalcemia Without Hypervitaminosis D During Cholecalciferol Supplementation in Critically Ill Patients. Nutr Clin Pract 2019; 35:933-941. [PMID: 31605425 DOI: 10.1002/ncp.10407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 12/21/2022] Open
Abstract
BACKGROUND Vitamin D deficiency during critical illness has been associated with worsened outcomes. Because most critically ill patients with severe traumatic injuries are vitamin D deficient, we investigated the efficacy and safety of cholecalciferol therapy for these patients. METHODS Fifty-three patients (>17 years of age) admitted to the trauma intensive care unit who had a serum 25-hydroxy vitamin D (25-OH vit D) concentration <20 ng/mL were given 10,000 IU of cholecalciferol daily. Efficacy was defined as achievement of a 25-OH vit D of 30-79.9 ng/mL. Safety was evaluated by the presence of hypercalcemia (serum ionized calcium [iCa] >1.32 mmol/L) or hypervitaminosis D (25-OH vit D >79.9 nmol/L). Patients were monitored for 2 weeks during cholecalciferol therapy. RESULTS Twenty-four patients (45%) achieved target 25-OH vit D. No patients experienced hypervitaminosis D. Hypercalcemia occurred in 40% (n = 21) of patients; 2 patients experienced an iCa >1.49 nmol/L. 25-OH vit D was significantly greater for those who developed hypercalcemia (37.2 + 11.2 vs 28.4 + 5.6 ng/mL, respectively, P < 0.001) by the second week of cholecalciferol. Of 24 patients who achieved target 25-OH vit D, 14 (58%) experienced hypercalcemia in contrast to 24% of patients (7 out of 29) who did not achieve target 25-OH vit D (P = 0.024). CONCLUSIONS Cholecalciferol normalized serum 25-OH vit D concentrations in less than half of patients yet was associated with a substantial proportion of patients with hypercalcemia without hypervitaminosis D.
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Affiliation(s)
- Whitney L Holmes
- Department of Pharmacy, Regional One Health, Memphis, Tennessee, USA
| | - George O Maish
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Gayle Minard
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Martin A Croce
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Roland N Dickerson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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18
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Dickerson RN, Kumpf VJ, Bingham AL, Blackmer AB, Canada TW, Chan LN, Cogle SV, Tucker AM. Significant Published Articles for Pharmacy Nutrition Support Practice in 2018. Hosp Pharm 2019; 54:285-293. [PMID: 31555003 DOI: 10.1177/0018578719851727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 12/22/2022]
Abstract
Purpose: The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2018 considered important to their clinical practice. The citation list was compiled into a single spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby the majority of author participants (at least 5 of 8) considered the paper to be important. Guideline and consensus papers from professional organizations, important to practice but not scored, were also included. Results: A total of 117 articles were identified; 8 from the primary literature were voted by the group to be of high importance. An additional 13 organizational guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were reviewed. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.
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Affiliation(s)
| | | | | | - Allison B Blackmer
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Todd W Canada
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Sarah V Cogle
- Auburn University Harrison School of Pharmacy, Auburn, AL, USA
| | - Anne M Tucker
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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19
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Abstract
Purpose: We report a case of a patient with gastrointestinal dysmotility and substantial drainage losses who required parenteral nutrition (PN) and developed a non-anion gap metabolic acidosis secondary to a shortage of concurrent potassium acetate and sodium acetate PN additives. We describe how severe PN-associated metabolic consequences were averted during this acetate shortage. Summary: The patient with inability to swallow and significant weight loss was admitted to the hospital and given PN after failure to tolerate either gastric or jejunal feeding due to dysmotility and severe abdominal distension and discomfort. PN was initiated and the nasogastric and jejunal tubes were left to low intermittent suction or gravity drainage (average losses of 800 mL and 1600 mL daily, respectively) to reduce abdominal distension. The patient had been stable on PN for approximately 2 months prior to when a shortage in potassium acetate and sodium acetate occurred. As a result, potassium and sodium requirements had to be met with chloride and phosphate salts. The patient developed a non-anion gap metabolic acidosis after 11 days of acetate-free PN. Progression to severe acidemia was avoided by administration of sodium bicarbonate daily for 3 days and replacement of 0.9% sodium chloride supplemental intravenous fluid with lactated ringers solution. Conclusion: This case report illustrates that PN component shortages require clinicians to closely monitor patients who require PN. In addition, clinicians may need to use creative therapeutic strategies to avoid potential serious patient harm during PN component shortages.
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Affiliation(s)
- Eric W Brown
- UCHealth Memorial Hospital Central, Colorado Springs, CO, USA
| | | | - Gayle Minard
- The University of Tennessee Health Science Center, Memphis, TN, USA
| | - George O Maish
- The University of Tennessee Health Science Center, Memphis, TN, USA
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20
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Dickerson RN, Kumpf VJ, Bingham AL, Blackmer AB, Canada TW, Chan LN, Cogle SV, Tucker AM. Significant Published Articles for Pharmacy Nutrition Support Practice in 2017. Hosp Pharm 2018; 53:239-246. [PMID: 30038443 PMCID: PMC6050880 DOI: 10.1177/0018578718779006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 12/17/2022]
Abstract
Purpose: The purpose of the article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2017 considered important to their clinical practice. The citation list was compiled into a spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby the majority (at least 5 out of 8 authors) considered the article to be of significance. Guideline and consensus articles from professional organizations, important to practice but not scored, were also included. Results: A total of 95 articles were identified; six from the primary literature were voted by the group to be of high importance. An additional 13 organizational guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were reviewed. Conclusion: It is recommended that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.
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Affiliation(s)
| | | | | | | | - Todd W. Canada
- University of Texas MD Anderson Cancer
Center, Houston, USA
| | | | | | - Anne M. Tucker
- University of Texas MD Anderson Cancer
Center, Houston, USA
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21
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Abstract
Adiposity-based chronic disease, critical illness, and nutrition therapy increase the risk for overfeeding and worsened nutritional and clinical outcomes. Hypocaloric, high-protein nutrition therapy provides critically ill obese patients the opportunity to achieve net protein anabolism with a reduced risk for overfeeding-related complications. The intent of this review is to discuss the impact of obesity on clinical outcomes, describe the consequences of obesity that increase complications associated with nutrition therapy, provide the framework to develop a hypocaloric, high-protein regimen, review the scientific evidence to support this mode of therapy, and discuss its limitations. Practical suggestions for patient monitoring are also provided.
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Affiliation(s)
- Roland N Dickerson
- College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee.
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22
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Dickerson RN, Kumpf VJ, Bingham AL, Cogle SV, Blackmer AB, Tucker AM, Chan LN, Canada TW. Significant Published Articles for Pharmacy Nutrition Support Practice in 2016. Hosp Pharm 2017; 52:412-421. [PMID: 29276265 DOI: 10.1177/0018578717720313] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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: 01/10/2023]
Abstract
Purpose: To assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2016 considered important to their clinical practice. The citation list was compiled into a single spreadsheet where the author participants were asked to assess whether the paper was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby the majority of author participants (at least 5 out of 8) considered the paper to be important. Guideline and consensus papers from professional organizations, important to practice but not scored, were also included. Results: A total of 103 articles were identified; 10 from the primary literature were voted by the group to be of high importance. An additional 11 organizational guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were reviewed. Conclusion: It is recommended that pharmacists, engaged in nutrition support therapy, be familiar with the majority of these articles as it pertains to their practice.
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Affiliation(s)
| | | | | | | | | | - Anne M Tucker
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Todd W Canada
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
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23
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Abstract
Nutritional Support Consultant features issues pertinent to the clinical aspects of pharmacy nutrition support practice. The column is edited by Dr. Roland Dickerson, Associate Professor of Pharmacy, University of Tennessee Health Sciences Center, Memphis, TN.
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Affiliation(s)
- Roland N. Dickerson
- University of Tennessee Health Sciences Center, 26, South Dunlap Street, Memphis, TN 38163
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24
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Abstract
Nutrition Support Consultant features issues pertinent to the clinical aspects of pharmacy nutritional support practice.
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25
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26
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Affiliation(s)
- Roland N. Dickerson
- University of Tennessee Health Science Center, 26 South Dunlap St., Rm 210, Memphis, TN 38163
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27
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Hurt RT, McClave SA, Martindale RG, Ochoa Gautier JB, Coss-Bu JA, Dickerson RN, Heyland DK, Hoffer LJ, Moore FA, Morris CR, Paddon-Jones D, Patel JJ, Phillips SM, Rugeles SJ, Sarav, MD M, Weijs PJM, Wernerman J, Hamilton-Reeves J, McClain CJ, Taylor B. Summary Points and Consensus Recommendations From the International Protein Summit. Nutr Clin Pract 2017; 32:142S-151S. [DOI: 10.1177/0884533617693610] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Ryan T. Hurt
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Stephen A. McClave
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Robert G. Martindale
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Juan B. Ochoa Gautier
- Nestlé HealthCare Nutrition, Inc, Florham Park, New Jersey, USA, and the Department of Critical Care Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Jorge A. Coss-Bu
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Roland N. Dickerson
- Department of Clinical Pharmacology, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Daren K. Heyland
- Department of Critical Care Medicine, Queens University, Kingston, Ontario, Canada
| | - L. John Hoffer
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | | | - Claudia R. Morris
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Douglas Paddon-Jones
- School of Health Professions, University of Texas Medical Branch, Galveston, Texas, USA
| | - Jayshil J. Patel
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Stuart M. Phillips
- Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Saúl J. Rugeles
- Department of Surgery, Pontificia Universidad Javeriana Medical School, Hospital Universitario San Ignacio, Bogota, Colombia
| | - Menaka Sarav, MD
- Department of Medicine, Northshore University Health System, Evanston, Illinois, USA
| | - Peter J. M. Weijs
- Department of Medicine, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
| | - Jan Wernerman
- Department of Clinical Science, Karolinska University, Stockholm, Sweden
| | - Jill Hamilton-Reeves
- Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Craig J. McClain
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Beth Taylor
- Department of Food and Nutrition, Barnes-Jewish Hospital, St Louis, Missouri, USA
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28
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Hoffer LJ, Dickerson RN, Martindale RG, McClave SA, Ochoa Gautier JB. Will We Ever Agree on Protein Requirements in the Intensive Care Unit? Nutr Clin Pract 2017; 32:94S-100S. [PMID: 28388370 DOI: 10.1177/0884533617694613] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The precise value of the normal adult protein requirement has long been debated. For many reasons-one of them being the difficulty of carrying out long-term nutrition experiments in free-living people-uncertainty is likely to persist indefinitely. By contrast, the controlled environment of the intensive care unit and relatively short trajectory of many critical illnesses make it feasible to use hard clinical outcome trials to determine protein requirements for critically ill patients in well-defined clinical situations. This article suggests how the physiological principles that underlie our understanding of normal protein requirements can be incorporated into the design of such clinical trials. The main focus is on 3 principles: (1) the rate of body nitrogen loss roughly predicts an individual's minimum protein requirement and is thus essential to measure to identify individual patients and clinical situations in which the minimum protein requirement is importantly increased, (2) existing muscle mass sets an upper limit on the rate at which amino acids can be mobilized from muscle for transfer to central proteins and sites of injury and is thus important to monitor to identify patients who are at greatest risk of protein deficiency-related adverse outcomes, and (3) negative energy balance increases the dietary protein requirement, so calorie-deprived patients-whether obese or not-should be enrolled in hard clinical outcome trials that compare the current practice of "permissive underfeeding" (underprovision of all nutrients, including protein) with hypocaloric nutrition supplemented by a suitably generous amount of protein.
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Affiliation(s)
- L John Hoffer
- 1 Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Roland N Dickerson
- 2 University of Tennessee Health Science Center, Department of Clinical Pharmacy, Memphis, Tennessee, USA
| | - Robert G Martindale
- 3 Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Stephen A McClave
- 4 Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Juan B Ochoa Gautier
- 5 Nestlé HealthCare Nutrition, Inc, Florham Park, New Jersey, USA.,6 Associate Department of Critical Care Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
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29
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Rugeles SJ, Ochoa Gautier JB, Dickerson RN, Coss-Bu JA, Wernerman J, Paddon-Jones D. How Many Nonprotein Calories Does a Critically Ill Patient Require? A Case for Hypocaloric Nutrition in the Critically Ill Patient. Nutr Clin Pract 2017; 32:72S-76S. [DOI: 10.1177/0884533617693608] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Saúl J. Rugeles
- Pontificia Universidad Javeriana School of Medicine, Hospital Universitario San Ignacio, Bogota, Colombia
| | | | | | - Jorge A. Coss-Bu
- Director of Research, Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Intensive Care Service, Texas Children’s Hospital, Houston Texas, USA
| | - Jan Wernerman
- Department of Clinical Science Interventional Technology, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Douglas Paddon-Jones
- Department of Nutrition and Metabolism, The University of Texas Medical Branch, Galveston, Texas, USA
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30
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Abstract
Obesity compounds the metabolic response to critical illness and increases the risk for overfeeding complications due to its comorbidities. Hypocaloric, high-protein nutrition therapy affords the hospitalized patient with obesity the opportunity to achieve net protein anabolism with a reduced risk of overfeeding complications. The intent of this review is to provide the theoretical framework for development of a hypocaloric high-protein regimen, scientific evidence to support this mode of therapy, and unique considerations for its use in specialized subpopulations. Macronutrient goals and practical suggestions for patient monitoring are given.
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Affiliation(s)
- Roland N Dickerson
- 1 Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Memphis, Tennessee, USA
| | - Jayshil J Patel
- 2 Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Craig J McClain
- 3 Departments of Medicine and Pharmacology & Toxicology, University of Louisville School of Medicine, Louisville, Kentucky, USA
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Weijs PJM, Dickerson RN, Heyland DK, Moore FA, Rugeles SJ, McClave SA. Experimental and Outcome-Based Approaches to Protein Requirements in the Intensive Care Unit. Nutr Clin Pract 2017; 32:77S-85S. [PMID: 28388371 DOI: 10.1177/0884533617692774] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 01/28/2023] Open
Abstract
Insight into protein requirements of intensive care unit (ICU) patients is urgently needed, but at present, it is unrealistic to define protein requirements for different diagnostic groups of critical illness or at different stages of illness. No large randomized controlled trials have randomized protein delivery, adequately addressed energy intake, and evaluated relevant clinical outcomes. As a pragmatic approach, experimental studies have focused on protein requirements of heterogeneous ICU patients. Data are scarce and the absolute value of protein requirements therefore is an approximation. Experimental studies indicate a protein requirement of >1.2 g/kg protein, which is supported by several outcome-based observational studies. Protein intake levels of up to 2.0-2.5 g/kg appear to be safe. A higher level of personalized treatment, within 1.2 and 2.5 g/kg, must involve identification of patients with low muscle protein mass that might benefit most from adequate protein nutrition in the ICU.
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Affiliation(s)
- Peter J M Weijs
- 1 Nutrition and Dietetics, Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands.,2 Nutrition and Dietetics, Faculty of Sports and Nutrition, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands.,3 Department of Intensive Care Medicine, VU University Medical Center, Amsterdam, the Netherlands.,4 Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, the Netherlands
| | - Roland N Dickerson
- 5 Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Memphis, Tennessee, USA
| | - Daren K Heyland
- 6 Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada.,7 Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Frederick A Moore
- 8 Department of Surgery, Division of Acute Care Surgery, and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Saúl J Rugeles
- 9 Department of Surgery, Pontificia Universidad Javeriana, Medical School, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Stephen A McClave
- 10 Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
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32
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Phillips SM, Dickerson RN, Moore FA, Paddon-Jones D, Weijs PJM. Protein Turnover and Metabolism in the Elderly Intensive Care Unit Patient. Nutr Clin Pract 2017; 32:112S-120S. [PMID: 28388378 DOI: 10.1177/0884533616686719] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Many intensive care unit (ICU) patients do not achieve target protein intakes particularly in the early days following admittance. This period of iatrogenic protein undernutrition contributes to a rapid loss of lean, in particular muscle, mass in the ICU. The loss of muscle in older (aged >60 years) patients in the ICU may be particularly rapid due to a perfect storm of increased catabolic factors, including systemic inflammation, disuse, protein malnutrition, and reduced anabolic stimuli. This loss of muscle mass has marked consequences. It is likely that the older patient is already experiencing muscle loss due to sarcopenia; however, the period of stay in the ICU represents a greatly accelerated period of muscle loss. Thus, on discharge, the older ICU patient is now on a steeper downward trajectory of muscle loss, more likely to have ICU-acquired muscle weakness, and at risk of becoming sarcopenic and/or frail. One practice that has been shown to have benefit during ICU stays is early ambulation and physical therapy (PT), and it is likely that both are potent stimuli to induce a sensitivity of protein anabolism. Thus, recommendations for the older ICU patient would be provision of at least 1.2-1.5 g protein/kg usual body weight/d, regular and early utilization of ambulation (if possible) and/or PT, and follow-up rehabilitation for the older discharged ICU patient that includes rehabilitation, physical activity, and higher habitual dietary protein to change the trajectory of ICU-mediated muscle mass loss and weakness.
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Affiliation(s)
- Stuart M Phillips
- 1 McMaster University, Department of Kinesiology, Hamilton, Ontario, Canada
| | - Roland N Dickerson
- 2 Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Frederick A Moore
- 3 Department of Surgery, Division of Acute Care Surgery, and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Douglas Paddon-Jones
- 4 Nutrition and Metabolism, University of Texas Medical Branch, Galveston, Texas, USA
| | - Peter J M Weijs
- 5 Nutrition and Dietetics, Department of Internal Medicine, Department of Intensive Care Medicine, and Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands.,6 Nutrition and Dietetics, Faculty of Sports and Nutrition, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
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Abstract
Dehydration is a serious risk for the long-term tube-fed patient who is not allowed oral intake, has an altered mental status, is unable to communicate, is elderly or fluid-restricted, or has thirst impairment. The intent of this review is to provide a case-based discussion regarding the evaluation, treatment, and prevention of dehydration in these types of patients. Identification of risk factors, along with evaluation of subjective, objective, and laboratory parameters, provides the basis for clinical evaluation. "Hidden" sources of fluid intake such as the water content of solid foods and water generated from nutrient oxidation and "hidden" sources of fluid output such as evaporative losses should be considered in waterbalance calculations. The method for treatment and prevention of dehydration depends on the presence or absence of hypovolemia, type of body fluid losses, and whether the patient demonstrates hypernatremia, normonatremia, or hyponatremia.
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Affiliation(s)
- Roland N Dickerson
- Department of Pharmacy, University of Tennessee Health Science Center, Memphis, TN 38163, USA
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34
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Dickerson RN, Mason DL, Croce MA, Minard G, Brown RO. Evaluation of an Artificial Neural Network to Predict Urea Nitrogen Appearance for Critically Ill Multiple-Trauma Patients. JPEN J Parenter Enteral Nutr 2017; 29:429-35. [PMID: 16224036 DOI: 10.1177/0148607105029006429] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Computer-based simulated biologic neural network models have made significant strides in clinical medicine. METHODS To determine the predictive performance of a conventional regression model and an artificial neural network for estimating urea nitrogen appearance (UNA) during critical illness, 125 adult patients admitted to the trauma intensive care unit who required specialized nutrition support were studied. The first 100 consecutive patients were used to develop the 2 models. The first model used stepwise multivariate regression analysis. The second model entailed the use of a feeding-forward, back-propagation, supervised neural network. Bias and precision of both methods were evaluated in 25 separate patients. RESULTS Multivariate regression analysis revealed a significant highly correlative relationship (r(2) = .918, p < or = .01): Predicted UNA (g/d) = (0.29 x WT) + (1.20 x WBC) + (0.44 x SUN) with WT as current body weight in kg, WBC as white blood cell count in cells/mm(3), and SUN as serum urea nitrogen concentration (mg/dL). The regression method was biased toward overestimating measured UNA, whereas the neural network was unbiased. Precision (95% confidence interval) of the neural network was significantly better than the regression (3.3-7.2 g vs 7.3-11.6 g, respectively, p < .01). Regression analysis successfully predicted UNA within 3 g of measured UNA in 16% (4 of 25) of patients, whereas the neural network successfully predicted UNA in 44% (11 out of 25) of patients (p < .06). CONCLUSIONS These preliminary data indicate that use of an artificial neural network may be superior to conventional regression modeling techniques for estimating UNA in critically ill adult multiple-trauma patients receiving specialized nutrition support.
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Affiliation(s)
- Roland N Dickerson
- Department of Pharmacy, University of Tennessee Health Science Center, Memphis, 38163, USA.
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Brown KA, Dickerson RN, Morgan LM, Alexander KH, Minard G, Brown RO. A New Graduated Dosing Regimen for Phosphorus Replacement in Patients Receiving Nutrition Support. JPEN J Parenter Enteral Nutr 2017; 30:209-14. [PMID: 16639067 DOI: 10.1177/0148607106030003209] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hypophosphatemia is a common metabolic complication in patients receiving specialized nutrition support. We changed our previously reported dosing algorithm because the low dose no longer appeared to be effective at increasing serum phosphorus concentrations. The purpose of this study was to evaluate the safety and efficacy of a revised weight-based phosphorus-dosing algorithm in critically ill trauma patients receiving specialized nutrition support. METHODS Seventy-nine adult trauma patients with hypophosphatemia (serum phosphorus concentration < or = 0.96 mmol/L) receiving nutrition support received an IV dose of phosphorus on day 1 according to the serum concentration of phosphorus: 0.73-0.96 mmol/L (0.32 mmol/kg, low dose), 0.51-0.72 mmol/L (0.64 mmol/kg, moderate dose), and < or = 0.5 mmol/L (1 mmol/kg, high dose). The IV phosphorus bolus dose was administered at 7.5 mmol/hour. Generally, patients with a serum potassium concentration <4 mmol/L received potassium phosphate and patients with a serum potassium concentration > or = 4 mmol/L received sodium phosphate. Patients who still had hypophosphatemia on day 2 were dosed using the new dosing algorithm by the nutrition support service according to that day's serum concentration of phosphorus, or empirically by the trauma service. RESULTS Of the 79 patients studied, 57 were male and 22 were female with a mean age of 44.8 +/- 20.6 years. Mean Injury Severity Scores and APACHE-II scores were 27.1 +/- 11.6 and 15.2 +/- 6.8, respectively. There was no difference in baseline characteristics among the 3 dosing groups. Of the 79 patients, 34 received the low dose, 30 received the moderate dose, and 15 received the high dose of phosphorous. Mean serum phosphorous concentrations on day 2 were significantly increased in the moderate-dosed group (0.64 +/- 0.06 to 0.77 +/- 0.22 mmol/L, p < .05) and high-dosed group (0.38 +/- 0.06 to 0.93 +/- 0.32 mmol/L, p < .01), respectively, when compared with day 1. Mean serum phosphorus concentrations were normal in all 3 groups on day 3. Serum concentrations of magnesium, sodium, and potassium, as well as arterial pH, were stable across the study. Mean concentrations of ionized calcium were not significantly different in any of the 3 dosing groups across the study period. CONCLUSIONS This weight-based phosphorus-dosing algorithm is safe for use in critically ill patients receiving nutrition support. The moderate and severe-dose regimens effectively increase serum phosphorus concentrations.
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Affiliation(s)
- Kaleb A Brown
- Department of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA
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Dickerson RN, Van Cleve JR, Swanson JM, Maish GO, Minard G, Croce MA, Brown RO. Vitamin D deficiency in critically ill patients with traumatic injuries. Burns Trauma 2016; 4:28. [PMID: 27833924 PMCID: PMC5066285 DOI: 10.1186/s41038-016-0054-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 06/30/2016] [Indexed: 11/10/2022]
Abstract
Background Vitamin D depletion has been associated with increased rate of infections, lengthened hospital stay, and worsened mortality for critically ill patients. The purpose of this study was to evaluate the prevalence and variables associated with vitamin D deficiency in critically ill patients with severe traumatic injuries. Methods Critically ill adult patients admitted to the trauma intensive care unit (ICU) between June 2013 and June 2014, referred to the nutrition support service for enteral or parenteral nutrition, and had a serum 25-hydroxyvitamin D (25-OH vitamin D) concentration determination were retrospectively evaluated. Patients were stratified as vitamin D sufficient, insufficient, deficient, or severely deficient based on a 25-OH vitamin D concentration of 30–80, 20–29.9, 13.1–19.9, and ≤13 ng/mL, respectively. Results One hundred and twenty-one patients out of 158 (76 %) patients were vitamin D deficient or severely deficient. Thirty-one patients (20 %) were insufficient and 6 (4 %) had a normal 25-OH vitamin D concentration. 25-OH vitamin D was determined 7.5 ± 5.1 days after ICU admission. African-Americans had a greater proportion of patients with deficiency or severe deficiency compared to other races (91 versus 64 %, P = 0.02). Penetrating gunshot or knife stab injury, African-American race, and obesity (elevated body mass index) were significantly associated with vitamin D deficiency or severe deficiency: OR 9.23 (1.13, 75.40), 4.0 (1.4, 11.58), and 1.12 (1.03, 1.23), P < 0.05, respectively. Conclusions The majority of critically ill patients with traumatic injuries exhibit vitamin D deficiency or severe deficiency. Penetrating injuries, African-American race, and obesity are significant risk factors for deficiency. Severity of injury, extent of inflammation (elevated C-reactive protein concentration), or hospital admission during the winter season did not significantly influence the prevalence of vitamin D deficiency.
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Affiliation(s)
- Roland N Dickerson
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, 881 Madison Avenue, Suite 345, Memphis, 38163 TN USA
| | - Jonathan R Van Cleve
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, 881 Madison Avenue, Suite 345, Memphis, 38163 TN USA
| | - Joseph M Swanson
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, 881 Madison Avenue, Suite 345, Memphis, 38163 TN USA
| | - George O Maish
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, 2nd Floor, Memphis, 38163 TN USA
| | - Gayle Minard
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, 2nd Floor, Memphis, 38163 TN USA
| | - Martin A Croce
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, 2nd Floor, Memphis, 38163 TN USA
| | - Rex O Brown
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, 881 Madison Avenue, Suite 345, Memphis, 38163 TN USA
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Dickerson RN, Kumpf VJ, Blackmer AB, Bingham AL, Tucker AM, Ybarra JV, Kraft MD, Canada TW. Significant Published Articles for Pharmacy Nutrition Support Practice in 2014 and 2015. Hosp Pharm 2016; 51:539-52. [PMID: 27559187 DOI: 10.1310/hpj5107-539] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To assist the pharmacy clinician engaged in nutrition support in staying current with the most pertinent literature. METHODS Several experienced board-certified clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2014 and 2015 that they considered to be important to their practice. Only those articles available in print format were considered for potential inclusion. Articles available only in preprint electronic format were not evaluated. The citation list was compiled into a single spreadsheet where the author participants were asked to ascertain whether they considered the paper important to nutrition support pharmacy practice. A culled list of publications was then identified whereby the majority of author participants (at least 5 out of 8) considered the paper to be important. RESULTS A total of 108 articles were identified; 36 of which were considered to be of high importance. An important guideline article published in early 2016, but not ranked, was also included. The top-ranked articles from the primary literature were reviewed. CONCLUSION It is recommended that the informed pharmacist, who is engaged in nutrition support therapy, be familiar with the majority of these articles.
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Gervasio JM, Dickerson RN, Brown RO, Matthews JB. Chronic Hypothermia and Energy Expenditure in a Neurodevelopmentally Disabled Patient: A Case Study. Nutr Clin Pract 2016. [DOI: 10.1177/088453369701200503] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
Numerous complications can arise when administering medications to patients receiving continuous enteral feeding. We report a case of a patient who could not be fed by mouth and was receiving continuous jejunal enteral feeding who had an adverse event associated with inappropriate administration of a medication via his jejunostomy tube. He had taken an extended-release niacin product before hospitalization for type IIb hyperlipidemia. The patient was inappropriately given a single dose of 750 mg of niacin as the short-acting tablets that were crushed and administered via the jejunostomy tube. He experienced severe cutaneous flushing, a feeling of warmth, itching, nausea, and emesis. He was noted to have "prickly heat" to the forehead, according to the nursing notes. A discussion of problems and guidelines for medication administration in adult patients receiving continuous tube feeding is provided.
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Affiliation(s)
- Roland N Dickerson
- Department of Pharmacy, University of Tennessee Health Science Center, 26 South Dunlap Street, Memphis, TN 38163, USA
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Abstract
The rising prevalence of obesity in the United States has resulted in concerns regarding the implementation of safe and effective specialized nutrition support in hospitalized obese patients. This review discusses complications associated with the provision of specialized nutrition support for obese patients and emphasizes the scientific basis for and against the provision of hypocaloric, high-protein parenteral and enteral nutrition support. Because there is a paucity of data concerning enteral nutrition support, some practical aspects of implementing hypocaloric high-protein enteral nutrition are also given.
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Affiliation(s)
- Roland N Dickerson
- Department of Pharmacy, University of Tennessee Health Sciences Center, 26 South Dunlap St., Room 210, Memphis, TN 38163, USA
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Dickerson RN, Voss JR, Schroeppel TJ, Maish GO, Magnotti LJ, Minard G, Croce MA. Feasibility of jejunal enteral nutrition for patients with severe duodenal injuries. Nutrition 2015; 32:309-14. [PMID: 26704967 DOI: 10.1016/j.nut.2015.08.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 06/19/2015] [Revised: 08/26/2015] [Accepted: 08/26/2015] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the feasibility of enteral nutrition (EN) for critically ill trauma patients with severe traumatic duodenal injuries who received placement of concurrent decompressing and feeding jejunostomies. METHODS Adult patients admitted to the trauma intensive care unit from January 2010 to December 2013, given concurrent afferent decompressing and efferent feeding jejunostomies for severe duodenal injury and provided EN or parenteral nutrition (PN), were retrospectively evaluated. Enteral feeding intolerance was defined as an increase in the decompressing jejunostomy drainage volume output, worsening abdominal distension, or cramping/pain unrelated to surgical incisions. Patients who failed initial EN were transitioned to PN. RESULTS Twenty-six patients were enrolled. Of the 24 patients given EN within the first 2 wk posthospitalization, 18 (75%) failed EN within 2 ± 2 d of initiating EN. EN was discontinued when increases were seen in decompressing jejunostomy drainage volume output (n = 11) and output with abdominal pain and/or distension (n = 6), or abdominal pain/distension was seen without an increase in output (n = 1). Jejunostomy drainage volume output increased from 474 ± 425 mL/d to 1168 ± 725 mL/d (P < 0.001) during EN intolerance. More patients with blunt intestinal injury than those with penetrating injuries (75% versus 15%, respectively; P = 0.035) tolerated EN. Patients initially given PN (n = 13) received more calories (P < 0.005) and protein (P < 0.001) than those given initial EN (n = 13). CONCLUSION The majority of patients with severe duodenal injuries and concurrent decompressing/feeding tube jejunostomies failed initial EN therapy.
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Affiliation(s)
- Roland N Dickerson
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN.
| | - Johnathan R Voss
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN
| | - Thomas J Schroeppel
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - George O Maish
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Louis J Magnotti
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Gayle Minard
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Martin A Croce
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
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Johnston CT, Maish GO, Minard G, Croce MA, Dickerson RN. Evaluation of an Intravenous Potassium Dosing Algorithm for Hypokalemic Critically Ill Patients. JPEN J Parenter Enteral Nutr 2015; 41:796-804. [PMID: 26304602 DOI: 10.1177/0148607115602885] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 11/17/2022]
Abstract
PURPOSE The intent of this study was to evaluate the safety and efficacy of an intravenous (IV) potassium (K) dosing algorithm for hypokalemic critically ill trauma patients. METHODS Adult patients, admitted to the trauma intensive care unit from June 2010 to October 2012 and who received IV K therapy according to a standardized dosing algorithm, were retrospectively evaluated. Patients who received IV K during resuscitation or following initiation of nutrition therapy, IV fluids containing >20 mEq/L of potassium, or medications known to alter K homeostasis or those with an arterial pH change >0.1, diarrhea, hypomagnesemia, renal impairment, or morbid obesity were excluded. RESULTS In total, 715 patients were reviewed to obtain 100 evaluable patients. Serum K for patients with mild depletion (serum K, 3.5-3.9 mEq/L, n = 74) remained unchanged at 0.0 ± 0.3 mEq/L ( P = ns) following 46 ± 8 mEq. Serum K increased by 0.4 ± 0.3 mEq/L ( P = .001) following 78 ± 18 mEq during moderate depletion (serum K, 3-3.4 mEq/L). None of the patients experienced hyperkalemia (serum K, >5.2 mEq/L) postinfusion. The presence of traumatic brain injury (TBI) blunted the response to IV K for mild K depletion as only 26% had an increase in serum K compared with 55% of patients without TBI ( P = .025). CONCLUSIONS The Nutrition Support Service-guided IV K dosing algorithm was safe for patients with mild and moderate hypokalemia and efficacious for those with moderate hypokalemia. Further study in patients with severe hypokalemia (serum K, <3 mEq/L) is warranted.
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Affiliation(s)
- Corry T Johnston
- 1 Department of Pharmacy, University of Maryland Baltimore Washington Medical Center, Baltimore, Maryland, USA
| | - George O Maish
- 2 Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Gayle Minard
- 2 Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Martin A Croce
- 2 Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Roland N Dickerson
- 3 Department of Clinical Pharmacy, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
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Dickerson RN, Berry SC, Ziebarth JD, Swanson JM, Maish GO, Minard G, Brown RO. Dose-response effect of ergocalciferol therapy on serum 25-hydroxyvitamin D concentration during critical illness. Nutrition 2015. [PMID: 26213135 DOI: 10.1016/j.nut.2015.03.008] [Citation(s) in RCA: 13] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the dose-response relationship between ergocalciferol therapy and serum 25-hydroxyvitamin D concentrations in enterally fed, critically ill patients with traumatic injuries. METHODS A retrospective cohort of critically ill patients with traumatic injuries and vitamin D deficiency (25-OH vitamin D <50 nmol/L) were given either 50 000 IU of liquid ergocalciferol weekly, twice weekly, or three times weekly while in the intensive care unit (ICU). Serum 25-OH vitamin D and ionized calcium concentrations were monitored weekly. Ergocalciferol therapy was stopped when the serum 25-OH vitamin D was >75 nmol/L, if the patient experienced hypercalcemia (ionized calcium >1.34 mmol/L), when the patient was discharged from the ICU, or if enteral nutrition was discontinued. RESULTS Sixty-five patients (16, 18, and 31 per dosage group) were examined. One (6%), two (11%), and eight (26%) patients achieved normal 25-OH vitamin D concentrations after 2 to 4 wk of ergocalciferol therapy for each dosage group, respectively (P < 0.001). Serum 25-OH vitamin D concentrations improved from 36 ± 6, 40 ± 7, and 37 ± 6 nmol/L to 50 ± 15, 54 ± 21, and 62 ± 17 nmol/L, respectively, after 2 wk of ergocalciferol therapy (P < 0.001) Two (13%), one (6%), and seven (23%) patients developed hypercalcemia for each dosage group, respectively (P = NS). CONCLUSIONS Ergocalciferol therapy improved baseline serum 25-OH vitamin D concentrations but was inadequate for consistently achieving normal serum concentrations of 25-OH vitamin D during critical illness. The trend in increasing appearance of mild hypercalcemia for the highest dosage group is concerning.
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Affiliation(s)
- Roland N Dickerson
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Scott C Berry
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jamie D Ziebarth
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joseph M Swanson
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - George O Maish
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Gayle Minard
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Rex O Brown
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
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Dickerson RN, Kumpf VJ, Rollins CJ, Frankel EH, Kraft MD, Canada TW, Crill CM. Significant publications for pharmacy nutrition support practice in 2013. Hosp Pharm 2014; 49:717-30. [PMID: 25477597 DOI: 10.1310/hpj4908-717] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [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: 12/17/2022]
Abstract
PURPOSE To assist the pharmacy clinician engaged in nutrition support in staying current with the most pertinent literature. METHODS Several experienced board-certified clinical pharmacists in nutrition support compiled a list of publications published in 2013 that they considered to be important to their practice. The citation list was compiled into a Web-based survey whereby pharmacist members of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), GI-Liver-Nutrition Practice Research Network of the American College of Clinical Pharmacy, and the Pharmacy and Pharmacology Section of the Society of Critical Care Medicine were asked to rank each article according to level of importance in their practice. RESULTS A total of 30 articles were identified by the author group. Thirty-six participants responded to the survey. The top-ranked papers by participants from the Web-based survey were reviewed by the authors. Due to its high level of importance, the parenteral nutrition safety consensus recommendations article, to be published in 2014 by A.S.P.E.N., was also reviewed. CONCLUSION It is recommended that the informed pharmacist, who is engaged in nutrition support therapy, be familiar with the majority of these publications.
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Affiliation(s)
- Roland N Dickerson
- Professor of Clinical Pharmacy, University of Tennessee College of Pharmacy , Memphis, Tennessee
| | - Vanessa J Kumpf
- Clinical Specialist, Nutrition Support, Center for Human Nutrition, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Carol J Rollins
- Clinical Coordinator, Nutrition Support Team, The University of Arizona Medical Center , Tucson, Arizona
| | - Eric H Frankel
- Neonatal Clinical Lead & Metabolic Support Service Clinical Pharmacist, Truman Medical Center Hospital Hill , Kansas City, Missouri
| | - Michael D Kraft
- Assistant Director, Education and Research, Department of Pharmacy Services, University of Michigan Hospitals and Health Centers , Ann Arbor, Michigan
| | - Todd W Canada
- Clinical Pharmacy Services Manager, University of Texas, MD Anderson Cancer Center , Houston, Texas
| | - Catherine M Crill
- Associate Professor of Clinical Pharmacy and Pediatrics, University of Tennessee College of Pharmacy and Medicine , Memphis, Tennessee
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Abstract
We published the first article that addressed hypocaloric, high-protein enteral nutrition therapy for critically ill patients with obesity more than 10 years ago. This study demonstrated that it was possible to successfully achieve this mode of therapy with a commercially available high-protein enteral formula and concurrent use of protein supplements. This study was also the first to demonstrate improved clinical outcomes with the use of hypocaloric, high-protein nutrition therapy. The results of this study, its unique findings, and shortcomings are discussed. Subsequent studies have added clarity to the effective use of this therapy, including its use in home parenteral nutrition patients, patients with class III obesity, and older patients with obesity.
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Dickerson RN, Maish GO, Minard G, Brown RO. Nutrition Support Team-Led Glycemic Control Program for Critically Ill Patients. Nutr Clin Pract 2014; 29:534-541. [DOI: 10.1177/0884533614530763] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
| | - George O. Maish
- Department of Surgery, University of Tennessee College of Medicine, Memphis
| | - Gayle Minard
- Department of Surgery, University of Tennessee College of Medicine, Memphis
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