Good Stuff Happens in 1:1 Meetings: Why you need them and how to do them well
Nutr Clin Pract-2010--92-100
1. http://ncp.sagepub.com/ Nutrition in Clinical Practice
Clinical Nutrition Week 2010 Nutrition Practice Abstracts
Nutr Clin Pract 2010 25: 92
DOI: 10.1177/0884533609358996
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3. CNW 2010 Nutrition Practice Abstracts 93
Abstract of Distinction
P2 - The Use of Prealbumin and C-Reactive Protein for
Monitoring Nutrition Support in Adult Patients Receiving
Enteral Nutrition in an Urban Medical Center
Cassie Davis, MS RD; Diane Sowa, MBA RD; Kathryn Keim,
PhD RD; Kelly Kinnare, MS RD CNSD
Food and Nutrition, Rush University Medical Center, Chicago,
IL.
Introduction: Prealbumin (PAB) is commonly used as a marker to
assess protein status and is therefore also used to monitor a patient’s
response to nutrition support. The ability of PAB to adequately assess
protein status may be influenced by the presence and severity of the
inflammatory response because the liver preferentially synthesizes acute
phase proteins such as C-reactive protein (CRP) at the expense of PAB
in the presence of inflammation. The purpose of this study was to deter-mine
whether changes in PAB are reflective of the delivery of adequate
calories and protein or of changes in inflammatory status in hospitalized
adults, greater than 18 years of age, receiving enteral nutrition (EN)
on all patient care units, except Maternity and Psychiatric units.
Methods: A retrospective review was conducted on 154 adult patients
who received EN for more than three days and had at least two measures
of PAB. Calorie requirements were calculated (30-35 kcal/kg) based on
actual or adjusted body weight and individualized to patients’ needs.
Protein requirements were calculated (0.9 - 2.5 g/kg) based on body
weight and clinical condition. Calorie and protein intake was compared
to changes in PAB, assessed at baseline and twice a week for up to
30 days. C-reactive protein was assessed when PAB was less than 18 mg/
dL. Approval for the study was obtained from the Institutional Review
Board for Human Subjects. SPSS for Windows (version 15.0, 2006,
SPSS Inc, Chicago, IL) was used for statistical analysis. Results: Mean
calorie and protein requirements were 1966 +/- 353 kcal/day and
109.8 +/- 31.4 g protein/day, respectively. Fifty-seven percent of calorie
needs and 56% of protein needs were delivered. Subjects were divided
into tertiles based on percent calories and protein delivered. Percent of
calorie requirements delivered for the first tertile (n=52) was 4-50%,
second tertile (n=54) was 51-68%, and third tertile (n=48) was
69-114%. Percent of protein requirements delivered for the first tertile
(n=54) was 4-48%, the second tertile (n=52) was 49-65%, and the third
tertile (n=48) was 66-143%. One-way ANOVA were conducted for both
calories and protein based on tertiles of percent calories and protein
delivered. There was no significant difference in change in PAB among
the three tertiles for either percent calories delivered: F (2, 151)=1.005,
p=0.37 or protein delivered: F (2, 151)=1.906, p=0.15. C-reactive pro-tein
was analyzed to account for the presence or absence of inflam-mation.
Change in CRP was negatively correlated with change in PAB
(r =-0.544, p<0.001). Two multiple linear regression models were fit
to assess the ability of either percent calories delivered or percent pro-tein
delivered to predict changes in PAB while adjusting for CRP. Only
change in CRP was able to significantly predict change in PAB levels,
explaining 29.6% of the variance (R2=0.296) in change in PAB consis-tently,
adjusting for either percent calories delivered (B=-0.051, p<0.001)
or percent protein delivered (B=-0.051, p<0.001). Conclusions: These
results indicate that PAB is not a sensitive marker for evaluating the
adequacy of nutrition support. Change in CRP was the only variable
that was able to significantly predict changes in PAB levels, suggesting
that a change in inflammatory status, rather than nutrient intake, was
responsible for the increases seen in PAB levels.
Abstract of Distinction. Also appeared in Symposium W20:
Glucose Control in Adult and Pediatric Critical Care
Patients:
P3 - A Comparison of Two Methods of Insulin Administration
in Critically Ill Patients Receiving Parenteral Nutrition
Yimin Chen, MS, RD, CNSD1; Jenny Lewandowski, MS, RD2;
Matthew Sperry, MD3; Kathryn Keim, PhD, RD1; Diane Sowa,
MBA, RD1; Sarah Peterson, MS, RD, CNSC1
1Food and Nutrition, Rush University Medical Center, Chicago, IL;
2Radiant Research, Chicago, IL; 3Intermountain Medical Group,
Provo, UT.
Introduction: While hyperglycemia may be a normal response to stress,
it is associated with adverse patient outcomes including increased noso-comial
bloodstream infections, length of stay, need for renal replacement
therapy, need for mechanical ventilation, and mortality. Although the
benefits of tight glycemic control in critically ill patients have been con-firmed
in the literature, hypoglycemia is a detrimental complication with
intensive glucose control that has also been observed by investigators.
Research has yet to be conducted to explore which method of insulin
administration results in optimal glycemic control in patients receiving
parenteral nutrition (PN). The objective of this study was to compare
glycemic control between two methods of intravenous insulin adminis-tration
in critically ill patients receiving PN: 1) continuous insulin infu-sion
(CII); 2) addition of insulin to the parenteral nutrition (IPN).
Methods: Thirty-seven surgical (n = 31) and medical (n = 6) intensive
care unit patients in a tertiary care urban academic medical center
receiving PN were prospectively identified and randomized to either CII
(n = 21) or IPN (n = 16) group with a goal glycemic control of 80 - 120
mg/dL. Blood glucose was monitored via morning blood draw and four
point-of-care regimen per day for both groups. Hypoglycemic events
were defined as <60 mg/dL; hyperglycemic events were defined as >200
mg/dL. Mann-Whitney U was performed to assess the glycemic control
between study groups. Chi-square tests were conducted to determine the
association of hypo- and hyperglycemic events between study groups.
Results: Baseline morning blood glucose was similar between the CII
and IPN groups (120 vs. 122 mg/dL, respectively; p = NS), and increased
in both groups on day 1 after PN was initiated (136 and 154 mg/dL,
respectively; p = NS). The median morning blood glucose was signifi-cantly
higher in the IPN group when compared with the CII group on
day 2 (149 vs. 107 mg/dL, respectively; p = 0.003), day 3 (140 vs. 102
mg/dL, respectively; p < 0.0001), and day 4 (123 vs. 98 mg/dL, respec-tively;
p < 0.05) of PN infusion (Figure 1). The median combined blood
glucose (morning and point-of-care blood glucose levels) was also sig-nificantly
higher in the IPN group when compared with the CII group on
day 2 (154 vs. 115 mg/dL, respectively; p = 0.006) and day 3 (141 vs. 109
mg/dL, respectively; p < 0.0001) of PN infusion. Blood glucose control
for all subsequent PN days (days 4 - 7) was not significantly different
Figure 1. Contributors of Hypoglycemic Events < 60 mg/dL
While Receiving Parenteral Nutrition (PN)
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4. 94 Nutrition in Clinical Practice / Vol. 25, No. 1, February 2010
between the two groups (Figure 2). There was a trend towards more
hypoglycemic events in the CII group when compared with the IPN
group (8 vs. 2, respectively; p = 0.08), as well as hyperglycemic events
(11 vs. 6, respectively; p = NS). Conclusions: Based on the results of this
study, the CII method reached goal glycemic control sooner than the IPN
method; however, investigators from recent literature suggest increasing
goal glycemic control to 150 mg/dL. Liberalizing blood glucose goals may
allow adequate glycemic control with the addition of insulin in PN. More
research is necessary to determine which method of insulin administra-tion
is best to achieve new goal glycemic control, while minimizing hypo-and
hyperglycemic events that may result in detrimental outcomes in a
larger sample size.
Comparison of Average Morning Blood Glucose Levels Between Continuous Insulin Infusion versus Parenteral Nutrition Insulin Groups
Comparison of Combined Glucose Levels (Morning Blood Glucose Levels and Point-of-Care Levels) Between the Continuous Insulin Infusion and
Parenteral Nutrition Insulin Groups
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5. CNW 2010 Nutrition Practice Abstracts 95
Abstract of Distinction
P4 - Pediatric Nutrition Risk Screening: Association With
Length of Stay
Catherine M. McDonald, PhD, RD, CNSD; Sarah Gunnell,
MS, RD, CNSD
Dietitians, Primary Children’s Medical Center, Salt Lake City, UT.
Introduction: Nutrition risk screening (NRS) identifies patients who
are, or are at risk of, becoming malnourished. An NRS procedure must
correctly separate patients who would benefit from medical nutrition
therapy from those who would not according to the presence of factors
associated with nutrition risk. A valid NRS procedure is based upon fac-tors
most strongly linked to nutrition risk. The potential for malnutrition
and nutrition-related complications is increased for patients who experi-ence
longer hospitalizations. The identification of patients with poten-tially
longer length of stay (LOS) enables the registered dietitian (RD) to
intervene early with preventive medical nutrition therapy. The aim of this
study was to determine any association of inpatient LOS with nutrition
risk scores assigned using a standardized NRS procedure. Methods: An
NRS procedure was developed with IRB approval by RDs at a pediatric
tertiary care facility. Scoring of nutrition risk occurred within 24 hours
of inpatient admission. The NRS score was determined with a standard-ized
tool by evaluating nutrition risk in four categories: anthopometric,
breathing (ventilated or not), clinical (admitting diagnosis), and diet.
Zero to 3 risk points were assigned per category with a maximum total
score of 12. Face validity and reliability for the NRS procedure were
tested and found to be acceptable. A retrospective review of 1299 elec-tronic
medical records was conducted for inpatient admissions during
June -August 2009. Inclusion criteria were inpatient status, LOS > 24
hours, and age < 21 years. Exclusions were admission to newborn inten-sive
care, organ donor status, and age ≥ 21 years. Admissions for new
onset diabetes (n = 69) were excluded because of a relatively short inpa-tient
stay with intensive nutrition intervention that is atypical of other
diagnoses. Records without documented NSR scores (n = 44) were
excluded. Results: Final analysis included 1185 records (male = 651,
female = 534). Mean age = 58.7 months ± 68.2 months, median = 22
months, range 0-236 months (19.7 years). LOS mean = 5.5 ± 6.5 days,
median = 3 days, range 1-75 days. The mean NRS score assigned = 2.1
± 2.1, median = 2.0, range 0-12. A linear regression for the association
between LOS and the NRS score was significant (t = 9.72, B = 0.11, p <
0.001). Conclusions: The NRS procedure was developed to screen for
nutrition risk in pediatric inpatients. The significant association suggests
NRS can be used to predict LOS in the context of screening for nutrition
risk. Although nutrition risk does not depend solely on LOS, longer inpa-tient
stays have been documented to contribute to increased nutrition-related
complications. According to the linear regression, each risk point
assigned using the NRS procedure was associated with an 11.74%
increase in LOS. Because patients with higher NRS scores are likely to
remain hospitalized for longer periods of time, the RD is able to triage
those patients to remediate or prevent nutrition-related complications.
Therefore, these results strengthen the validity of the NRS procedure for
determining within 24 hours of admission which pediatric patients could
benefit from medical nutrition therapy interventions.
Abstract of Distinction
P5 - Parenteral Nutrition Utilization in Patients Receiving
Hematopoietic Stem Cell Transplant
Cheryl Sullivan, MS,RD,CNSD; Sarah Peterson, MS,RD,CNSC;
Yimin Chen, MS,RD,CNSD; Kelly Kinnare, MS,RD,CNSD;
Diane Sowa, MBA,RD
Rush University Medical Center, Chicago, IL.
Introduction: Patients undergoing hematopoietic stem cell transplant
(HSCT) often receive parenteral nutrition (PN) during their hospitaliza-tion
due to inadequate oral intake and gastrointestinal complications.
Increased incidence of hyperglycemia, infection, increased hospital length
of stay (LOS), greater requirements for red blood cell/platelet transfusion
and delayed engraftment has been observed in HSCT patients who
received PN. Current guidelines from the American Society for Parenteral
and Enteral Nutrition recommend that PN be used in HSCT patients
who are malnourished and expected to be unable to absorb adequate
nutrients for 7-14 days. The objective of the current study was to deter-mine
the risks associated with PN utilization among patients admitted for
a HSCT. Methods: A retrospective chart review was completed for
337 patients who underwent a HSCT from 2003-2008 in a tertiary care
urban academic medical center. Patients were categorized as having
received PN or not during their hospitalization. Patients were further
categorized to compare before dietitian PN order-writing privileges
(1/1/03 to 12/31/05), to after dietitian PN order-writing privileges (1/1/06
to 12/31/08). Statistical analysis was completed with Chi-square tests and
Independent t-tests. Results: Of the 337 patients who received a HSCT,
104 patients (31%) were started on PN. There were no significant differ-ences
in sex (PN group: 55/104 [53%] male vs. non-PN group: 130/233
[56%] male), age (PN group: 47.2 ± 12.9 years vs. non-PN group: 49.9 ±
13.5 years) or BMI (PN group: 27.7 ± 6.0 vs. non-PN group: 28.1 ± 6.1).
A higher percentage of allogeneic HSCT patients received PN compared
to autologous HSCT patients (46/85 [54%] vs. 58/252 [23%], respec-tively;
p<0.0001). A significantly higher percent of patients with a diagno-sis
of acute myeloid leukemia or acute lymphocytic leukemia received PN
(18/38 [47%] vs. 86/299 [29%]; p=0.019) compared to patients requiring
PN with all other diagnoses. Patients who received PN had a significantly
higher mortality (9/104 [8.6%] vs. 3/233 [1.3%]; p=0.002), longer hospital
LOS (28.8 days ± 16.2 vs. 19.5 days ± 5.9; p<0.0001) and more admits
to the ICU (23/104 [22%] vs. 15/233 [6%]; p<0.0001) compared to
patients who did not receive PN. There were no significant differences in
ICU LOS or infectious complications between groups. Additionally, when
comparing before to after dietitian PN order-writing privileges, signifi-cantly
fewer patients were started on PN (63/133 [47%] vs. 41/204 [20%],
respectively; p<0.0001). There were no significant differences in sex
(before PN order-writing privileges: 51% male vs. after PN order-writing
privileges: 56% male) and age (before PN order-writing privileges: 47.6 ±
11.9 years vs. after PN order-writing privileges: 46.6 ± 14.4 years). There
was a statistically significant, but clinically irrelevant difference in BMI
between the two groups (before PN order-writing privileges 28.9 ± 6.3 vs.
after PN order-writing privileges: 25.7 ± 5.1; p=0.009). Conclusions:
Additional efforts are needed to further reduce total PN utilization in this
highly vulnerable patient population as PN use has been associated with
negative outcomes. In the current project, there was a significant
decrease in PN utilization after dietitians obtained PN order-writing
privileges. Additional research is needed to identify objective criteria
(such as a severity of illness score or severity and duration of GI complica-tions)
for patients undergoing HSCT to determine which patients may
benefit from PN.
Abstract of Distinction. Also appeared in Symposium H40
Your Responsibility in Parenteral Nutrition Safety:
P6 - Effects of Converting Macronutrients Protein and
Lipids from Percentage to Grams/Kilogram Following CPOE
Implementation in Pediatric PN Population
Carl W. Naessig, RPh.1; Ann Searfoss, Pharmacy Student2
1System Therapeutics, Geisinger Medical Center, Danville, PA;
2Nesbitt School of Pharmacy, Wilkes University, Wilkes-Barre, PA.
Introduction: The full benefit of protein administration is realized when
adequate calories are provided. At Geisinger Medical Center (GMC),
prior to CPOE, pediatric PN macronutrients were ordered as a percent-age
of the final volume. The amount of macronutrients a patient received
varied based on the total volume of PN ordered. Consequently, the
patient’s daily nutrition was variable. Safe Practices for Parenteral
Nutrition (2004) recommends that when ordering PN, the macronutri-ents
should be ordered as grams per kilogram, not as percentages. With
the implementation of computerized physician order entry (CPOE), we
saw this as an opportunity to accomplish the following goals; 1) to
modify ordering practices to be compliant with safe practices guidelines,
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6. 96 Nutrition in Clinical Practice / Vol. 25, No. 1, February 2010
2) to utilized the order as an educational tool to provide guidance for the
physician, 3) to provide a universal, easy to use order that could be uti-lized
for all pediatric patients regardless of age, weight, and administra-tion
site (peripheral and central), 4) to meet the nutrition goals of the
pediatric patient population in the absence of a pediatric NSS. A multi-disciplinary
team including a physician, clinical dietician, and pharma-cist
developed new guidelines and standard recommendation for the new
PN order set to be implemented with CPOE. This was a retrospective
analysis to determine if converting the order for protein and lipids from
percentage to gm/kg and providing standard nutrition recommendations
on the CPOE PN order set would have a beneficial effect in meeting
protein and calorie needs in the hospitalized pediatric population receiv-ing
PN. Methods: All pediatric patients who received PN three months
pre- and post- CPOE implementation were reviewed. Patients were
excluded from this study if they were neonates, patients with incomplete
charts, and patients with inadequate information provided by dietician
consult. All remaining pediatric patients were reviewed and evaluated to
determine what percentage of the protein and calorie needs, as deter-mined
by the clinical dietician, were being provided in each bag of PN.
Averages of these percentages were then determined for all PN bags in
each of the following groups; pre-CPOE TPN, pre-CPOE PPN, post-
CPOE TPN, and post CPOE PPN. Results: The pre-CPOE TPN group
had 84.5% of the protein needs and 78.8% of the calorie needs provided
by TPN. The pre-CPOE PPN group had 71% of the protein needs and
60.4% of the calorie needs provided by PPN. Post-CPOE implementa-tion
TPN group had 100 % of the protein needs and 91.2% of the calorie
needs provided by TPN. Post-CPOE PPN group had 100 % of the pro-tein
needs and 67.4% of the calorie needs provided by PPN. Conclusions:
The conversion from a pediatric PN order form that utilized percentages
of macronutrients to a system that utilized gram per kilogram for protein
and lipids resulted in a significant improvement in the amount of protein
and calories provided in both TPN and PPN. CPOE order sets are a use-ful
tool for standardizing ordering of PN in pediatric patients in order to
more accurately provided recommended nutrition.
Abstract of Distinction
P7 - The Danger of Treating a Number: A Case of Copper
Overload in a Long Term Home PN Patient with Short Bowel
Syndrome
Elizabeth Wall, MS, RD, CNSC1; Kalyani Meduri, MD, MS2;
Gilbert Cusson, RPh, BCNSP1; Carol Semrad, MD1
1The University of Chicago Medical Center, Chicago, IL;
2Private Practice, North Liberty, IA.
Introduction: Patients with short bowel syndrome can live for decades
with parenteral nutrition (PN); however clinicians lack simple methods
to measure physiologic stores of trace minerals (TM). Plasma levels of
TM may not accurately reflect body stores of the nutrients. Infusion of
PN, relative to blood sampling, can artificially increase plasma mineral
levels while true tissue stores are low. The opposite can also occur in
which low plasma levels are measured despite excess deposits of TM
throughout the body. Nutrition support clinicians often assess Cu nour-ishment
in long term PN patients with plasma levels although they are
not equivalent to physiologic stores. Ninety percent of circulating Cu is
bound to ceruloplasmin, but the majority of the body’s Cu is found in
the liver bound to metalloenzymes. Oral Cu is absorbed in the proximal
small bowel and excreted mainly in bile and to a lesser extent in urine.
Patients with diarrhea or high ostomy effluent are known to have greater
intestinal Cu losses compared to normal controls. Patients receiving Cu
in PN have higher urinary losses due to free or amino acid-bound Cu
filtration through the kidneys before arriving at the liver. Methods: LH
is a 53 yo man with a history of Crohn’s disease and hepatitis C status
post multiple small bowel resections with 3 feet of jejunum remaining
to an end jejunostomy. He has been maintained on home PN since
2001, though with bowel adaptation he requires minimal macronutri-ents
in 1.7 L fluid, 90 g dextrose, 30 g amino acids, 20 g fat emulsion,
electrolytes, vitamins, and TM. Liver biopsies in 1998 and 2007 demon-strated
mildly active chronic hepatitis. His PN contained standard cop-per
(Cu) supplementation of 1 mg daily until 2004 when LH was found
to have low plasma Cu. From 2005 until 2008 the PN Cu supplementa-tion
was gradually increased to maintain normal plasma Cu concentra-tions
(see Table). In June 2008 LH had low plasma Cu levels despite 7 mg
Cu daily in the PN. Results: LH’s low plasma Cu was initially thought
to be real given his intestinal losses of > 2L ostomy effluent daily.
However, when incremental increases of parenteral Cu failed to sustain
normal plasma Cu concentration, laboratory tests were performed to
determine his Cu balance. Plasma Cu 50 mcg/dL (75 - 155 mcg/dL),
ceruloplasmin 11 mg/dL (18-36 mg/dL), and 24 hr urine Cu 111
mcg/24 hr (15 - 50 mcg/24hr) were obtained. These tests revealed a Cu
profile suggestive of Wilson’s disease. Therefore the PN Cu was discon-tinued;
liver tissue from his 2007 biopsy while on supplemental Cu was
stained for Cu deposition, and genetic testing for Wilson’s disease was
obtained. The liver biopsy demonstrated significantly elevated Cu depo-sition
of 692 mcg/g dry wt (0-35 mcg/g). Genetic testing for Wilson’s
disease and ophthalmic exam (Kayser-Fliescher rings) were negative. He
has since been maintained on Cu-free PN with plans to monitor his
plasma and urine Cu levels as well as for clinical manifestations of Cu
deficiency. Conclusions: Clinical Cu deficiency in patients receiving
PN with the standard dose of 1.0 mg Cu/day is undocumented. Caution
should be taken in altering PN Cu supplementation without physiologic
or clinical findings of deficiency.
Number of Patients and PN bags Sampled
Pre-CPOE Post-CPOE
TPN patients 27 28
TPN bags 206 267
PPN patients 20 21
PPN bags 69 42
Percentage of Protein and Calorie Rquirements Pre- and Post-CPOE
Percentage of Daily
Requirements
Provided by PN
Pre-CPOE Post-CPOE P Value
TPN daily protein requirements 84.5% 100% <0.05
TPN daily calorie requirements 78.8% 91.2% <0.05
PPN daily protein requirements 71% 100% <0.05
PPN daily calorie requirements 60.4% 67.4% <0.05
LH’s Copper Trends 2005-2009
Apr 05 Aug 05 Dec 05 Jun 06 Feb 07 Jun 07 Jan 08 Jun 08 Apr 09 Aug 09
Plasma Cu (75-155 mcg/dL) 69 75 71 65 50 52 63 50 49 54
Ceruloplasmin (14-21.9 mg/dL) 11.0 11.3 13.9
Albumin (3.5-5g/dL) 4.3 4.7 4.5 4.3 4.4 4.0 4.0 4.4 4.3
Urine Cu (15-50 mcg/24hr) 111 93 16
PN Cu (mg) 1 1.4 2 3.5 4 5 6.5 7 7 0
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7. CNW 2010 Nutrition Practice Abstracts 97
Abstract of Distinction
P8 - Investigation of Compliance with the Renal Diet, Biochem-ical
Parameters and Adequacy of Nutrient Intakes in a Group
of Patients with Chronic Kidney Disease (Stages 4 and 5).
Laura Brennan, BSc (Human Nutrition), Senior Clinical
Nutritionist1; Tracey Waldron, BSc (Human Nutrition), Senior
Clinical Nutritionist1; George J. Mellotte, MB, FRCPI, MSc.,
Consultant Nephrologist and Senior Lecturer in Medicine2,3
1Clinical Nutrition, St. James’s Hospital, Dublin, Ireland;
2St. James’s Hospital, Dublin, Ireland; 3The Adelaide and
Meath Hospital, Dublin, Ireland.
Introduction: Patients with C.K.D. must follow a complex diet, which
can restrict protein, sodium, potassium and phosphorus. Compliance
with the renal diet can reduce complications such as hyperkalaemia and
renal bone disease, can slow progression of renal dysfunction and delay
need for dialysis. However, the multiple dietary restrictions can make it
difficult to adhere to the diet while maintaining adequate nutritional
intake. The purpose of this investigation was to assess compliance with
renal dietary restrictions, acceptability of biochemical parameters and
adequacy of dietary intakes. Methods: Forty-six patients with C.K.D.
were recruited. All patients had been previously educated and established
on a renal diet and were not receiving dialysis. The participants completed
a food diary documenting all foods and drinks consumed over a 72-hour
period. Diaries were analysed using Microdiet for Windows™ (Version 2).
Dietary compliance and biochemical indices were compared to K./D.O.Q.I.
(Kidney Disease Outcomes Quality Initiative) Clinical Practice Guidelines.
Statistical analysis was conducted using S.P.S.S.® for Windows™ (Version
14.0). Results: Compliance with renal dietary restrictions is summarised
in Table 1. Compliance was higher with sodium and potassium restric-tions
than with protein and phosphate restrictions. Compliance with
protein and phosphate restrictions was similar, which is not surprising
given their common dietary sources. Some patients (9%) reported protein
intakes below that recommended, which is of concern. Table 2 compares
biochemical parameters to current recommendations. Patients who
adhered to all restrictions had serum potassium and phosphate levels
within target range. However, serum potassium and phosphate levels were
acceptable regardless of compliance, particularly so in those with stage 4
C.K.D. This raises the question as to whether dietary restrictions may be
too strict for patients with less advanced disease. Although 83% of
patients were not meeting calculated energy requirements, only 11%
(n=4) of these had a BMI<20kg/m2 whereas 61% (n=23) had a BMI>25kg/
m2. Fibre (NSP) intake was insufficient in 65% (n=30) of patients and in
62% (n=8) of diabetics. Compliance with potassium and phosphate
restrictions had a significant adverse affect on fibre intake (P=0.001 and
0.038 respectively) and also affected the adequacy of B vitamins, folate,
iron, calcium and zinc. Conclusions: For the majority of patients, bio-chemical
parameters were within acceptable limits. However, some
patients reported dietary intakes of a number of nutrients that were below
the recommended intakes, leaving them at risk for malnutrition. Intensive
dietetic intervention is paramount to promote adherence to renal dietary
restrictions but also to prevent nutrient deficiencies. Therefore, we advo-cate
a more liberal and individualised approach to restriction when bio-chemical
parameters are acceptable or patients are at nutritional risk.
Abstract of Distinction
P9 - Evaluation of Enteral Feeding Success in Head Injured
Patients Placed in Pentobarbital Induced Comas
Jane Gervasio, Pharm.D., BCNSP1; Jonathan Egel, Pharm.D.1;
Joshua McGehee, Pharm.D.1; Gabriel Drew Stillabower,
Pharm.D.1; Nicole Ponton, Pharm.D.1; Lawrence Bortenschlager,
M.D.2; Timothy Pohlman, M.D.2
1Pharmacy Practice, Butler University College of Pharmacy and
Health Sciences, Indianapolis, IN; 2Clarian Health Partners at
Methodist Hospital, Indianapolis, IN.
Introduction: Nutrition plays a critical role in the recovery of a trau-matic
brain injury. Increased caloric needs, gastric intolerance and
access problems often undermine efforts to provide adequate nutrition
in this population. Additionally, patients with increased intracranial
pressure placed in a pentobarbital comas further challenge the admin-istration
of nutrition. Enteral nutrition (EN) is recommended for head
trauma patients however controversy exists regarding the patients in
pentobarbital induced comas ability to tolerate EN. At our institution,
standard of practice is verified placement using bedside imaging of a
transpyloric small bowel feeding tube for the administration of EN. The
objective of this study was to evaluate the success of small bowel
enteral feeding in head injured patients placed into pentobarbital
induced comas receiving EN. Methods: This study was a retrospective
charts review. Adult patients placed in a pentobarbital induced coma
and initiated on EN were included. Demographic information, EN
tolerance and feeding complications were recorded. Feeding complica-tions
included watery diarrhea, a distended abdomen, severe cramping,
and small bowel necrosis. Gastric residual volumes were also recorded
to identify tube misplacement or migration. Residual volumes greater
than 200 mls for 2 consecutive measurements were considered a feed-ing
complication and placement was reassessed. Patient outcomes were
also collected and included intensive care unit (ICU) and hospital
length of stay (LOS) and patient survival. Descriptive statistics were
utilized to define the characteristics of the study population. A p-value
less than 0.05 was considered statistically significant. All the statistical
analyses were conducted using Statistical Package for Social Sciences
version 16.0. Results: Fifty-three patients were included in the study,
with the majority (60.4%) being males. Data are reported as mean ±
standard deviation. Patient age was 40 ± 14.7 years, weight was 82.8 ±
22.2 kg and admission Glasgow Coma Score was 6.4± 3.7. Subarachnoid
and subdural hemorrhage was the primary and secondary cause of
injury, occurring in 50.9% and 20.8% of the patients, respectively.
Pentobarbital initiation was started within 87.6 ± 72.7 hours with a
length of infusion time of 154.8 ± 113.1 hours. Total pentobarbital
bolus doses were 457.9 ± 775.4 mg and daily pentobarbital doses
(excluding boluses) were 1941 ± 2655 mg. EN was initiated within
Table 1
Compliance with renal dietary restrictions
Restriction Recommended Intake Compliant Non-compliant
Protein 0.8-1g/kg I.B.W./day 37% (n=17)* 63% (n=29)
Sodium <80-100mmol/day 65% (n=30) 35% (n=16)
Potassium <1mmol/kg/day 70% (n=32) 30% (n=14)
Phosphate <15mg/g dietary protein/day 39% (n=18) 61% (n=28)
protein/day
All restrictions 17% (n=8) 83% (n=38)
*includes n=4 with protein intake less than 0.8g/kg I.B.W./day
Table 2
Serum biochemical parameters compared to KDOQI guidelines
Serum Stage 4 C.K.D. Stage 5 C.K.D.
Parameter patients (n=31) patients (n=15)
Potassium Within 3.5-5.0 = 94% Within 3.5-5.0 = 80%
(mmol/l) (n=29) (n=12)
Phosphate Within 0.87-1.49 = 90% Within 1.13-1.78 = 73%
(mmol/l) (n=28) (n=11)
Corrected Within 2.2-2.7 = 90% Within 2.1-2.37 = 67%
Calcium (n=28) (n=10)
(mmol/l)
Calcium Within guide < 55 = Within guide < 55 =
Phosphate 100% (n=31) 93% (n=14)
product
(mg2/dL2)
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8. 98 Nutrition in Clinical Practice / Vol. 25, No. 1, February 2010
53.4 ± 59.5 hours and administered for 555.8 ± 481.3 hours. EN
therapy was tolerated in 46 (86.8%) of the patients. Feeding complica-tions
reported included gastric residuals, 15.1% (n=8) and watery diar-rhea,
22.6% (n=12). A total of 7.5% of patients (n=4) had a distended
abdomen that influenced feeding volumes. Small bowel necrosis was
reported in 2 patients. In only one patient was EN discontinued and
parenteral nutrition initiated. Fourteen patients (26.4%) were able to
advance to an oral diet and 19 (35.8%) patients were discharged from
the hospital to home or a rehabilitation center on EN. ICU LOS was
22.7 ± 18.9 days and hospital LOS was 27.2 ± 22.8 days. Death
occurred in 35.8% of patients. Conclusions: Patients placed in a pen-tobarbital
coma for a traumatic brain injury are able to receive and
tolerate EN infused into the small bowel.
Abstract of Distinction
P10 - Multi-Trace Element Combinations: One Size Does
Not Fit All! Abnormal Levels Drive Need for Individualization
in 60% of Longer Term HPN Patients
Penny L. Allen, RD, LD, CNSC; Barbara Corey, RD, LDN,
CNSC; Jana Wayne, RD, CD, CNSC; Roberta Hurley, Ph.D, RD,
LD; Karen Ackerman, RD, MS, LDN, CNSD; Kara Helzer, RD,
LD, CNSD; Cindi Rafoth, RD, LD; Susan Mandel, MS, RD; Nancy
L. Sceery, RD, LDN, CNSD
Nutrition Support, Critical Care Systems, Nashua, NH.
Introduction: The challenge of providing appropriate doses of micro-nutrients,
particularly trace elements (TE) for TPN patients has
received more attention in the last few years. The adequacy of multi-trace
element (MTE) combinations has been called into question,
most frequently with manganese and the potential for neurotoxicity in
longer term PN patients. It is difficult to accurately assess TE status
since plasma or serum levels often do not reflect actual body stores.
Often the specimen collection for these tests require special handling
in order to insure integrity of the results. These protocols can prove
especially challenging outside of the hospital or clinic setting. TE levels
can also be skewed by infection and acute phase responses. All of these
variables raise significant concerns for the HPN patient reliant on daily
TE infusions. Methods: Trace element assays were reviewed for 69
HPN patients with a total of 120 blood draws between 2008-2009.
Length of stay on HPN ranged from 5 months to 24 years with patients
residing in 10 different geographic markets. Serum zinc, selenium,
copper, chromium and whole blood manganese levels were drawn
according to individual lab requirements. Abnormal results were col-lected
retrospectively by branch via medical records including lab
reports specifying normal ranges for individual laboratories. Need for
individualized TE dosing after the draw was also documented. Results:
Sixty one (61) percent of patients required individualization of trace
elements after abnormal levels were detected in a routine blood draw
after 6 months on PN, and/or subsequent 6 month or yearly intervals.
Of the 120 individual draws, manganese was elevated in 35% of the
assays, followed by chromium elevated at 28%. Zinc was below normal
18% of the time followed by copper elevated 14% of the draws.
Selenium followed with lower than normal levels in 10% of the panels.
Conclusions: This retrospective snapshot of TE levels in a HPN popu-lation
supports the argument for reformulation of the MTE prepara-tions
currently available. The high percentage of abnormal levels
observed, particularly of manganese and chromium, has prompted a
change in our standard of practice, recommending a panel at 3 months
rather than 6 months after initiation of PN. A new Trace Element Lab
Order Request form was developed with very specific instructions for
the blood draw--types of tubes, powder-free gloves, spin down time-frames,
etc. since many agencies in the alternate site setting are unfa-miliar
with correct procedures. It remains a challenge to accurately
assess trace element status and assure adequacy of supplementation
in the PN patient. Individualization of doses and monitoring earlier
appears to be the only solution currently available considering the
number of factors possibly affecting results. Better, more accurate
assessment methods, as well as a reformulated MTE product line--perhaps
eliminating manganese, would allow clinicians to more readily meet
the HPN patient’s needs without exposing them to risk of neurotoxicity.
The complete listing of abstracts is available online at http://ncp.sagepub
.com/content/vol25/issue1/, under the title CNW 2010 Nutrition Practice
Abstracts
CNW 2010 Nutrition Practice
Abstracts Author Index
Ackerman K - P10
Alberda C - P25
Aljarallah B - P85
Allard J - P17, P35, P36, P75, P76, P85
Allen P - P10, P16, P37
Alvarado L - P94
Alvarez K - P41
Ames H - P75, P85
Amirkalali B - P56
Andersen D - P58
Andersen J - P97
Andrews L - P49
Angkatavanich J - P14
Armstrong D - P85
Ataie-Jafari A - P56
Austin T - P44
Authur C - P65
Banks M - P21, P22
Baun M - P17, P75, P76, P85
Belcher D - P103
Benser M - P97
Bentley C P60
Berry A - P24
Bertollo D - P73, P74
Beshgetoor D - P69
Binda K - P69,P90
Bing C - P16
Blandin M - P52
Blau H - P59
Blinman T - P96
Blum I - P87
Bortenschlager L - P9
Brand S - P33
Brennan L - P8
Brinderjit K - P75
Bristol S - P52
Brody R - P31
Brogan A - P42
Burgos A - P94
Bustamante E - P52
Callahan E - P78
Carbajal E - P94
Carney L - P100
Carrillo M - P97
Carter B - P99
Celi M - P23
Chalela J - P24
Chan L - P11
Charney P - P11
Charoenwong B - P14
Chelucci M - P23
Chen Y - P3, P5
Chew M - P27
Chung C - P66
Collier B - P86
Condon S - P94
Cook R - P96
Cooley K - P79
Cooper J -P21, P22
Corey B - P10
Coronado M - P94
Creasey L - P54
Cristy D - P67
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9. CNW 2010 Nutrition Practice Abstracts 99
Curtis C - P71, P77
Cusson G - P7
Cywiak S - P91
Dameron K - P64
Davies A - P21, P22
Davis C - P2
Davis M - P64
Davis R - P83
DeLegge M - P39, P60
Derenski K - P64
Di Biase P - P23
Di Brino A - P23
Di Iorio G - P23
Diamantidis T - P18, P19
Ding L - P90
Drake S - P103
Dreesen E - P83
Drill A - P96
Duda M - P45, P46
Duerksen D - P85
Durett K - P79
Eck D - P79
Egel J - P9
Einfrank M - P52
Engelbert J - P69, P90
Estanque R - P94
Evans S - P15
Faintuch J - P73, P74
Fairholm L - P17, P75, P76, P85
Fanning M - P48
Fernandes G - P17, P35, P36, P75, P76, P85
Ferreyra M - P20
Fink C - P40
Flocco R - P23
Freeman K - P88
Friedberg M - P72
Gately T - P32
Gates J - P79
Gervasio J - P9, P51
Gibson D - P94
Gilbert K - P80
Glanville T - P87
Golaszewski A - P26
Gonzalians T - P32
Good L - P63
Gramlich L - P25, P75, P85
Guerrero L - P20
Gunnell S - P4, P98
Hall K - P64
Hamilton C - P84
Hardy G - P21, P22
Harriman S - P70
Hartney C - P55
Harvey-Banchik L - P60
Hau L - P90
Haubenstricker J - P69
Hayes P - P70
Heavey J - P50
Helzer K - P10
Hertig J - P92
Heshmat R - P56
Hiett J - P49
Holcombe B - P83
Holdy K - P29, P69, P90
Hosseini S - P56
Hujcs M - P26
Hurley R - P10
Irastorza I - P81, P82
Ireton Jones C - P39, P60, P61
Jackson L - P34
Jansson L - P3
Jawa H - P85
Jeejeebhoy K - P75, P76, P85
Jirka A - P47
Johnson S - P38
Kaido T - P102
Kaila B - P76
Kalsekar I - P51
Katada F - P53
Keim K - P2, P3, P55
Kenney L - P79
Kestler M - P41
Kim D - P12, P89
King K - P99
Kinnare K - P1, P2, P5
Kirby D - P84
Klein C - P68
Knowles S - P33
Koruda M - P83
Kozjek N - P95
Krishnamurthy B - P81, P82
Kroeplin G - P96
Kudsk K - P71
Kumpf V - P86
Kusenda C - P68
Lancaster R - P64
Landau E - P59
Landes R - P72
Leal A - P73, P74
Lebenthal Y - P59
Leong D - P65
Lewandowski J - P3
Lim L - P66
Lim S - P66
Lima J - P32
Linford L - P15
Llido L - P67
Londo C - P90
Lopez R - P35
Lorchick A - P52
MacDonald G - P25
Magill D - P38
Mandel S - P10
Manzyuk L - P13
Martin K - P34
Mathern B - P54
McClees E - P69
McDonald C - P4, P98
McDonald C - P98
McDowell L - P62
McGehee J - P9
McIlroy K - P21, P22
McKinney M - P51
Meduri K - P7
Meechan C - P75, P76, P85
Mehta S - P99
Mellotte G - P8
Milicevic L - P91
Millager A - P83
Miller C - P78, P79
Mirtallo J - P92, P93
Mitchell P - P94
Miyakoshi K - P53
Mizumoto M - P102
Mockaitis J - P103
Morais A - P73, P74
Morais R - P73, P74
Mori A - P102
Morrison S - P21, P22
Moscoe S - P58
Moser M - P70
Moss G - P30
Mulvaney M - P11
Naessig C - P6
Nagel R - P63
Najafi M - P56
Nevens R - P24
Nicolo M - P26
Nishikawa R - P18, P19
Noble D - P42
Noe J - P73, P74
Nowobilski-Vasilios A - P45, P46
Ocaña M - P20
O’Day B - P69,P90
O’Flaherty T - P101
Ogura Y - P102
Oike F - P102
Okamoto R - P18, P19
Olafsson S - P94
Olsen P - P50
Opilla M - P18, P19
Ostendorf J - P86
Pacis S - P32
Parrish R - P68
Pastò S - P23
Patel K - P16
Payne B - P93
Peleg-Weiss L - P59
Pentiuk S - P101
Peterson J - P43
Peterson S - P1, P3, P5
Petrica L - P95
Pfister D - P41, P42
Phillips S - P99
Phromwong S - P14
Piazza-Barnett R - P94
Picard M - P50
Pohlman T - P9
Ponton N - P9
Poole S - P45, P46
Poraz I - P59
Pratt J - P50
Rafoth C - P10
Raman M - P76
Resler R - P83
Revenis M - P68
Richardson D - P64
Ridley E - P21, P22
Rodych N - P70
Rojas S - P94
Rose W - P77
Ross K - P16
Runyan L - P37
Sacks G - P77
Saggi B - P60
Sahamitrmongkol A - P14
Salcedu C - P94
Saltanov A - P13
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10. 100 Nutrition in Clinical Practice / Vol. 25, No. 1, February 2010
Sanborn J - P29, P69
Sanfield J - P62
Sanner N -P100
Sano W - P57
Santhe M - P97
Santoro K - P102
Saqui O - P17, P35, P36, P75, P76, P85
Sato-Sen M - P52
Savarese P - P23
Scavo L - P68
Sceery N -P10, P50
Schallert M - P88
Schaning S - P52
Schechter L - P80
Searfoss A - P6
Seidner D - P86
Seipler J - P18, P19
Selchuk V - P13
Semrad C - P7
Sendelback S - P58
Seres D - P12, P89
Sexton-Hamilton K - P39, P40
Sharafetdinov K - P28
Sharp J - P15
Shaw A - P75, P76, P85
Short P - P94
Shu L - P27
Siangprasert T - P14
Snegovoy A - P13
Soto R - P20
Sowa D -P1, P2, P3, P5, P55
Speerhas R - P84
Sperry M - P3
Srisukh V - P14
Steiger E - P60, P84
Stillabower G - P9
Stout A - P78
Sullivan C - P5
Svanda J - P47
Szabo C - P54
Szeszycki E - P51
Temes R - P55
Teoh S - P66
Tesinsky P - P47
Thompson C - P87
Thomson A - P21, P22
Thongthai K - P35, P36
Tran N - P54
Truver K - P99
Tungrugsasut W - P14
Twilla J - P88
Tyler R - P65
Uemoto S - P102
Ukleja A - P91
Valenzuela A - P52
Vogt E - P31
Voravud N - P14
Waldron T - P8
Walker F - P83
Wall E - P7
Wall J - P43
Ward-Welisevich M - P45
Wayne J - P10, P37
Weaver A - P46
Weaver L - P15
Weiss A - P64
White R - P83
White T - P15
Whitmill M - P93
Whittaker J - P85
Wile H - P87
Williams A - P94
Willon J - P69
Worthington P - P80
Xu Y - P90
Yang R - P67
Yates S - P69
Ybarra J - P77
Yeung M - P17
Yoshizawa A - P102
Zhang B - P50
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