Journal of Parenteral and Enteral Nutrition RSS feed -- OnlineFirst Articles

The Clinical and Psychometric Validation of a Questionnaire to Assess the Quality of Life of Adult Patients Treated With Long-Term Parenteral Nutrition

Baxter, J. P., Fayers, P. M., McKinlay, A. W. — Tue, 17 Nov 2009 10:33:24 PST

Background: Home parenteral nutrition (HPN) is an established treatment for the management of patients with chronic intestinal failure. No quality-of-life assessment tools have been developed and validated specifically for this patient population, and previous studies have used generic instruments or techniques not validated in HPN. The assessment of quality of life (QOL) should produce clinically relevant data reflecting patients’ issues. The HPN-QOL was designed to assess the QOL of HPN patients. The purpose of this study was to test the hypothesized scale structure of the questionnaire with regard to reliability and validity in a sample of patients. Methods: A provisional questionnaire was prepared following recognized guidelines and then subjected to field testing. The questionnaire was administered to 100 adult patients receiving HPN. Psychometric tests examined the reliability and validity of the questionnaire, and patients’ debriefing comments were analyzed. Results: The provisional questionnaire was adapted using evidence from quantitative and qualitative analysis. Multitrait scaling analysis and face validity refined the questionnaire to 48 items. Compliance rates were high, and the questionnaire was well accepted. Conclusions: A method of objectively assessing the QOL of patients treated with HPN has been developed. The HPN-QOL has been rigorously prepared and demonstrates psychometric and clinical validity to assess the QOL of long-term HPN patients. (JPEN J Parenter Enteral Nutr. XXXX;XX:xx-xx)

After Cardiac Surgery, How Does Nutrition Fit in With Risk Factors?

Kones, R. — Thu, 12 Nov 2009 11:10:03 PST

Challenges to Optimal Enteral Nutrition in a Multidisciplinary Pediatric Intensive Care Unit

Tue, 10 Nov 2009 11:32:23 PST

Objective: To describe nutrient intake in critically ill children, identify risk factors associated with avoidable interruptions to enteral nutrition (EN), and highlight opportunities to improve enteral nutrient delivery in a busy tertiary pediatric intensive care unit (PICU). Design, Setting, and Measurements: Daily nutrient intake and factors responsible for avoidable interruptions to EN were recorded in patients admitted to a 29-bed medical and surgical PICU over 4 weeks. Clinical characteristics, time to reach caloric goal, and parenteral nutrition (PN) use were compared between patients with and without avoidable interruptions to EN. Results: Daily record of nutrient intake was obtained in 117 consecutive patients (median age, 7 years). Eighty (68%) patients received EN (20% postpyloric) for a total of 381 EN days (median, 2 days). Median time to EN initiation was less than 1 day. However, EN was subsequently interrupted in 24 (30%) patients at an average of 3.7 ± 3.1 times per patient (range, 1–13), for a total of 88 episodes accounting for 1,483 hours of EN deprivation in this cohort. Of the 88 episodes of EN interruption, 51 (58%) were deemed as avoidable. Mechanically ventilated subjects were at the highest risk of EN interruptions. Avoidable EN interruption was associated with increased reliance on PN and impaired ability to reach caloric goal. Conclusions: EN interruption is common and frequently avoidable in critically ill children. Knowledge of existing barriers to EN such as those identified in this study will allow appropriate interventions to optimize nutrition provision in the PICU. (JPEN J Parenter Enteral Nutr. XXXX;XX:xx-xx)

Ethical Issues in Artificial Nutrition and Hydration: A Review

Geppert, C. M. A., Andrews, M. R., Druyan, M. E. — Fri, 06 Nov 2009 11:22:41 PST

Healthcare professionals often face clinical and ethical challenges when charged with making decisions related to provision or lack of provision of artificial nutrition and hydration. The intent of this review is to supply a framework of clinical practices, ethical principles, legal precedents, and professional guidelines that will impart information and can assist decision making regarding artificial nutrition and hydration. Comprehensive understanding of the theory and practice of informed consent for competent adults, decisionally incompetent adults, and minors is necessary for making valid clinical judgments and for guiding patients and their families or surrogates in choosing options related to initiating, withholding, or withdrawing artificial nutrition and hydration. The framework offered in this review can serve as a basis for evaluation of appropriateness of artificial nutrition and hydration in 3 common conditions in which decision making is particularly challenging: terminal illness, advanced dementia, and a persistent vegetative state. The framework facilitates guidance for institutional policy makers and individual nutrition support professionals dealing with situations in which personal values often create ethical dilemmas related to artificial nutrition and hydration and its utility. (JPEN J Parenter Enteral Nutr. XXXX;xx:xx-xx)

Relationship Between Energy Balance and Complications After Subarachnoid Hemorrhage

Mon, 02 Nov 2009 09:29:25 PST

Background: Subarachnoid hemorrhage patients are hypermetabolic and at risk for developing medical complications. A relationship was hypothesized between energy balance and complications following subarachnoid hemorrhage. Methods: Fifty-eight consecutive poor-grade subarachnoid hemorrhage patients (mean age, 58; range, 26–86; 66% women) were studied between 2005 and 2007. Caloric intake and energy expenditure were assessed. In-hospital complications over the first 14 days posthemorrhage were defined as renal failure, fever (>38.3°C), any infection, anemia, hyperglycemia (>11 mmol/L), and myocardial infarction. Energy balance was calculated by subtracting energy expenditure from caloric intake. Results: Enteral nutrition was begun 1 day posthemorrhage (range, 0–5 days). Recommended (mean ± SD) caloric intake was 28 ± 3 kcal/kg/d, and the actual was 14 ± 5 kcal/kg/d. Enteral nutrition accounted for 67% of caloric intake; propofol and dextrose infusions accounted for 33% of caloric intake. Cumulative energy balance over the first 7 days was -117 ± 53 kcal/kg. The average energy balance during the first 7 days after subarachnoid hemorrhage significantly correlated with the total number of infectious complications (r = -0.5, P < .001) but not medical complications (r = -0.2, P = .1). After adjustment for Hunt-Hess grade, fever, hyperglycemia, and anemia, negative energy balance during the first 7 days after subarachnoid hemorrhage correlated with the number of infectious complications (P = .01). Conclusions: Infectious complications after subarachnoid hemorrhage are associated with negative energy balance. Studies are needed to better understand the impact of negative energy balance on outcome after subarachnoid hemorrhage. (JPEN J Parenter Enteral Nutr. XXXX;XX:xxx-xxx)

Using Pareteral Fish oil to Modulate Inflammatory Response

Pontes-Arruda, A. — Mon, 02 Nov 2009 09:29:26 PST

Systemic Inflammatory Response Syndrome, the Link Between Subarachnoid Hemorrhage and Caloric Balance

Kutsogiannis, D. J., Alberda, C. — Mon, 02 Nov 2009 09:29:26 PST

Measurement of Body Composition in Burned Children: Is There a Gold Standard?

Mon, 02 Nov 2009 09:29:25 PST

Background: Maintaining lean body mass (LBM) after a severe burn is an essential goal of modern burn treatment. An accurate determination of LBM is necessary for short- and longterm therapeutic decisions. The aim of this study was to compare 2 measurement methods for body composition, wholebody potassium counting (K count) and dual x-ray absorptiometry (DEXA), in a large prospective clinical trial in severely burned pediatric patients. Methods: Two-hundred seventy-nine patients admitted with burns covering 40% of total body surface area (TBSA) were enrolled in the study. Patients enrolled were controls or received long-term treatment with recombinant human growth hormone (rhGH). Near-simultaneous measurements of LBM with DEXA and fat-free mass (FFM) with K count were performed at hospital discharge and at 6, 9, 12, 18, and 24 months post injury. Results were correlated using Pearson’s regression analysis. Agreement between the 2 methods was analyzed with the Bland-Altman method. Results: Age, gender distribution, weight, burn size, and admission time from injury were not significantly different between control and treatment groups. rhGH and control patients at all time points postburn showed a good correlation between LBM and FFM measurements (R² between 0.9 and 0.95). Bland-Altman revealed that the mean bias and 95% limits of agreement depended only on patient weight and not on treatment or time postburn. The 95% limits ranged from 0.1 ± 2.9 kg for LBM or FFM in 7- to 18-kg patients to 16.3 ± 17.8 kg for LBM or FFM in patients >60 kg. Conclusions: DEXA can provide a sufficiently accurate determination of LBM and changes in body composition, but a correction factor must be included for older children and adolescents with more LBM. DEXA scans are easier, cheaper, and less stressful for the patient, and this method should be used rather than the K count. (JPEN J Parenter Enteral Nutr. XXXX;xx:xx-xx)

Role of Vitamin D in Adults Requiring Nutrition Support

Pittas, A. G., Laskowski, U., Kos, L., Saltzman, E. — Thu, 29 Oct 2009 13:57:48 PDT

The major and most well-known function of vitamin D is to maintain calcium and phosphorus homeostasis and promote bone mineralization. However, recent evidence suggests that vitamin D may be important for a variety of nonskeletal outcomes. The review synthesizes the available evidence for the role of vitamin D in skeletal health as well as its novel roles in medical conditions such as muscle function, falls, immunity, glucose homeostasis, and cardiovascular diseases. The article reviews methods for assessing vitamin D status and suggests strategies to restore vitamin D status in patients requiring enteral or parenteral nutrition who are at particularly high risk of hypovitaminosis D. Screening for hypovitaminosis D with plasma total 25-hydroxyvitamin D should be a routine part of the care of the patient requiring enteral or parenteral nutrition. Restoration of optimal vitamin D status with high-dose supplemental vitamin D is required in most cases, whereas exposure to sunlight or an ultraviolet B radiation–emitting device is most effective in patients with severe malabsorption or those requiring longterm parenteral therapy. Given the emerging role of vitamin D for a variety of acute and chronic conditions, the optimal vitamin D status in acutely ill patients as well as in patients requiring longterm nutrition therapy warrants further investigation. (JPEN J Parenter Enteral Nutr. XXXX;xx:xx-xx)

Letter to the Editor

Elia, M., Engfer, M., Green, C., Silk, D. B. A. — Wed, 28 Oct 2009 12:25:06 PDT

Effect of Intravenous Omega-3 Fatty Acids on Clinical Symptoms of Rheumatoid Arthritis

Rollins, C. J. — Tue, 27 Oct 2009 09:31:35 PDT

Impact of Not Measuring Residual Gastric Volume in Mechanically Ventilated Patients Receiving Early Enteral Feeding: A Prospective Before-After Study

Tue, 27 Oct 2009 09:31:35 PDT

Background: Monitoring of residual gastric volume (RGV) to prevent aspiration is standard practice in mechanically ventilated patients receiving early enteral nutrition (EN). No data are available to support a correlation between RGV and adverse event rates. We evaluated whether not measuring RGV affected EN delivery, vomiting, or risk of nosocomial pneumonia. Methods: Two hundred and five eligible patients with nasogastric feeding within 48 hours after intubation were included in a 7-day prospective before–after study. Continuous 24-hour nutrition was started at 25 mL/h then increased by 25 mL/h every 6 hours, to 85 mL/h. In both groups, intolerance was treated with erythromycin (250 mg IV/6 h) and a delivery rate decrease to the previously well-tolerated rate. RGV monitoring was used during the first study period (n = 102), but not during the subsequent intervention period (n = 103). Intolerance was defined as RGV >250 mL/6 h or vomiting in the standard-practice group and as vomiting in the intervention group. Results: Groups were similar for baseline characteristics. Median daily volume of enteral feeding was higher in the intervention group (1489; interquartile range [IQR], 1349–1647) than in the controls (1381; IQR, 1151–1591; P = .002). Intolerance occurred in 47 (46.1%) controls and 27 (26.2%) intervention patients (P = .004). The vomiting rate did not differ between controls and intervention group patients (24.5% vs 26.2%, respectively; P = .34), and neither was a difference found for ventilator-associated pneumonia (19.6% vs 18.4%; P = .86). Conclusion: Early EN without RGV monitoring in mechanically ventilated patients improves the delivery of enteral feeding and may not increase vomiting or ventilator-associated pneumonia. (JPEN J Parenter Enteral Nutr.XXXX;xx:xx-xx)

Vitamin D: Getting to Know You . . . Again

Boullata, J. I. — Tue, 27 Oct 2009 09:31:34 PDT

A.S.P.E.N. Recommendations for Enteral Nutrition: Practice Is the Result of Potential Benefits, Harms, Clinical Judgment, and Ethical Issues

Cereda, E., Pedrolli, C. — Tue, 27 Oct 2009 09:31:33 PDT

Jonathan E. Rhoads Lecture: Mentoring and Nutritional Care

Rombeau, J. L. — Tue, 27 Oct 2009 09:31:34 PDT

Calcium and Phosphate Compatibility in Low-Osmolarity Parenteral Nutrition Admixtures Intended for Peripheral Vein Administration

Wed, 21 Oct 2009 08:59:30 PDT

Background: Precipitation of calcium (Ca) and phosphate (P) salts can lead to potentially lethal outcomes, especially in low-osmolarity parenteral nutrition (LO-PN) formulations. Three concentrations of amino acids (AA) and 2 concentrations of calcium gluconate and sodium phosphate injections on the compatibility of Ca and P in LO-PN admixtures were studied. Methods: Final AA concentrations of 1%, 2%, or 3% (n = 3) and 5% glucose (G) were prepared with either 2.5 or 5 mmol/L (5 or 10 mEq) of Ca (n=2) and 15 or 30mmol/L of P (n=2) for a total of 12 base (3 x 2 x 2) formulations. Triplicate bags of each were analyzed for subvisible micro-precipitates using the light obscuration (or extinction) method for particle counts per milliliter (PC) in the size range of 1.8-50 µm at 7 time intervals over 48 hours stored at 30°C ± 0.2°C. Visual evaluation was performed using a high-intensity lamp against a black background for detection of macro-precipitates. The pH of all 36 admixtures was measured at 0 and 48 hours. Any precipitated material was isolated and characterized by polarized light icroscopy and infrared spectroscopy. Results: Of the 12 base LO-PN formulations tested, those containing 1% and 2% AA with 5 mmol/L of Ca and 30 mmol/L of P showed significant increases in PC, and some resulted in visible dibasic calcium phosphate precipitation. Analyses of variance based on concentrations of AA, Ca, P, and time were highly significant independent variables for increases in the PC of potentially embolic particles, that is, sizes >5 µm (P < .0001). The lowest concentrations of Ca and P, 2.5 and 15 mmol/L, respectively, had significantly lower PC (P < .05) for all sizes compared with the other Ca and P combinations. Conclusions: LO-PN admixtures (AA ≤3%; G = 5%) should not contain more than 2.5 mmol/L of Ca from calcium gluconate injection and no more than 15 mmol/L of P from potassium or sodium phosphates injection. (JPEN J Parenter Enteral Nutr. 2009;xx:xx-xx).

High Rates of Mortality and Morbidity Occur in Infants With Parenteral Nutrition-Associated Cholestasis

Wed, 08 Jul 2009 15:44:34 PDT

Background: Extremely few data are available about the natural history of parenteral nutrition (PN)–associated cholestasis. The authors evaluated a cohort of infants at a large center to determine the outcome of PN-associated cholestasis in infants with some gastrointestinal function. Methods: The authors reviewed the records of all infants admitted to a level 3 neonatal intensive care unit over a 16-month period who had the diagnosis of PN-associated cholestasis. Records were reviewed in these infants for course of cholestasis, laboratory values, outcome, and infection rate. Results: Sixty-six patients were admitted who met the study criteria. There were 10 deaths and 1 referral for liver transplant (Death/TPlant) (17%) in the first year of life. All Death/TPlant infants had at least 1 positive blood culture after the onset of cholestasis. Maximum conjugated bilirubin (MaxCB) in Death/TPlant infants was 15.7 ± 2.2 (SEM) compared to 8.4 ± 1.0 mg/dL in babies who recovered. Of 21 infants with a MaxCB ≥10.0, Death/TPlant occurred in 8/21 (38%). Of 40 babies with positive blood cultures, 11 were in the Death/TPlant group vs no deaths among the 25 without positive blood cultures. Average time to resolution from the MaxCB to a CB <2.0 mg/dL was 66 ± 7 days (n = 49). Conclusions: Infants with PN-associated cholestasis have high rates of mortality despite the presence of some gastrointestinal function. These data support further evaluation and the development of novel forms of therapy for babies with parenteral-associated CB ≥2 mg/dL with emphasis on interventions for infants with a CB >10 mg/dL. (JPEN J Parenter Enteral Nutr. XXXX;XX:xx-xx)

Infant Parenteral Nutrition-Associated Cholestasis: A Severe Iatrogenic Disease

Puder, M. — Thu, 30 Apr 2009 11:10:30 PDT