This document summarizes the A.S.P.E.N. Clinical Guidelines for nutrition support of critically ill children. It discusses the high prevalence of malnutrition among critically ill patients and how failure to provide optimal nutrition support can exacerbate deficiencies and affect outcomes. The guidelines were developed by the American Society for Parenteral and Enteral Nutrition to standardize and improve nutrition care for critically ill children. They review current evidence and best practices for assessing energy needs and providing appropriate enteral or parenteral nutrition support. However, more research is still needed in this area, especially randomized controlled trials in pediatric intensive care units.
This document provides a summary of the American Dietetic Association's position on weight management. It endorses lifelong commitment to healthful lifestyle behaviors through sustainable eating and daily physical activity for successful weight management. It discusses goals of weight management, which go beyond numbers to also include prevention of weight gain and improvements in health. It also covers assessment of obesity, which involves measuring BMI, waist circumference, medical history, psychological factors, and nutrition intake to develop a care plan.
This document provides clinical guidelines from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) regarding nutrition support of neonatal patients at risk for necrotizing enterocolitis (NEC). It addresses questions about when and how to start enteral feeds, the impact of mother's milk versus formula, use of probiotics, effects of certain nutrients, and when to reintroduce feeds after NEC. For each question, the guidelines provide a recommendation based on the available evidence and research.
Pamela Aye Simon has over 30 years of experience as a clinical dietitian, teacher, author, and researcher. She has worked in various clinical settings including renal, weight control, oncology, and diabetes. She has taught at the college level and coordinated clinical experiences for dietetic interns. Simon has also managed several research studies and published two books.
This document provides guidelines from the European Society for Clinical Nutrition and Metabolism (ESPEN) on clinical nutrition for patients in the intensive care unit (ICU). It defines who is at nutritional risk, how to assess a patient's nutritional status, how to determine energy needs, and the appropriate route (enteral vs parenteral) and progression of nutrition support. Recommendations are given for the amount and composition of macronutrients (carbohydrates, fat, protein) to provide. Special clinical situations like dysphagia, trauma, sepsis, and obesity are also addressed. The guidelines aim to guide practitioners in providing optimal evidence-based medical nutrition therapy to critically ill patients.
Medical residents were surveyed about their knowledge, attitudes, and practices regarding enteral nutrition in critical care settings. The survey found that while most residents agreed nutrition is important, over half felt other aspects of care took higher priority. Residents also reported inadequacies in their nutrition knowledge and training. There were discrepancies between residents' positive attitudes about enteral nutrition and their actual reported practices and knowledge. Most residents agreed a standardized enteral nutrition protocol should be used.
American Society of Anesthesiologists, 2002-2004.
Scientific and Educational Exhibitor: American Society of Anesthesiologists, Orlando, Florida,
October 2003.
Scientific and Educational Exhibitor: American Society of Anesthesiologists, San Francisco,
California, October 2002.
Scientific and Educational Exhibitor: American Society of Anesthesiologists, New Orleans,
Louisiana, October 2001.
Scientific and Educational Exhibitor: American Society of Anesthesiologists, San Francisco,
California, October 2000.
Scientific and Educational Exhibitor: American Society of Anesthesiologists, Atlanta, Georgia,
October 1999.
Scientific
This document discusses several studies that evaluated nurse-driven enteral feeding protocols in the ICU. Standard enteral feeding protocols often fail to adequately nourish critically ill patients. The studies found that nurse-driven protocols that set caloric intake targets and required starting feeds within 48 hours led to earlier initiation of feeds and higher caloric intake compared to standard protocols. One study found the percentage of patients reaching 80% of caloric needs increased from 44% to 90% with a nurse-driven protocol. The proposed intervention would implement a similar nurse-driven protocol in a randomized ICU to determine if it improves patient nourishment compared to the standard protocol.
This document provides a summary of the American Dietetic Association's position on weight management. It endorses lifelong commitment to healthful lifestyle behaviors through sustainable eating and daily physical activity for successful weight management. It discusses goals of weight management, which go beyond numbers to also include prevention of weight gain and improvements in health. It also covers assessment of obesity, which involves measuring BMI, waist circumference, medical history, psychological factors, and nutrition intake to develop a care plan.
This document provides clinical guidelines from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) regarding nutrition support of neonatal patients at risk for necrotizing enterocolitis (NEC). It addresses questions about when and how to start enteral feeds, the impact of mother's milk versus formula, use of probiotics, effects of certain nutrients, and when to reintroduce feeds after NEC. For each question, the guidelines provide a recommendation based on the available evidence and research.
Pamela Aye Simon has over 30 years of experience as a clinical dietitian, teacher, author, and researcher. She has worked in various clinical settings including renal, weight control, oncology, and diabetes. She has taught at the college level and coordinated clinical experiences for dietetic interns. Simon has also managed several research studies and published two books.
This document provides guidelines from the European Society for Clinical Nutrition and Metabolism (ESPEN) on clinical nutrition for patients in the intensive care unit (ICU). It defines who is at nutritional risk, how to assess a patient's nutritional status, how to determine energy needs, and the appropriate route (enteral vs parenteral) and progression of nutrition support. Recommendations are given for the amount and composition of macronutrients (carbohydrates, fat, protein) to provide. Special clinical situations like dysphagia, trauma, sepsis, and obesity are also addressed. The guidelines aim to guide practitioners in providing optimal evidence-based medical nutrition therapy to critically ill patients.
Medical residents were surveyed about their knowledge, attitudes, and practices regarding enteral nutrition in critical care settings. The survey found that while most residents agreed nutrition is important, over half felt other aspects of care took higher priority. Residents also reported inadequacies in their nutrition knowledge and training. There were discrepancies between residents' positive attitudes about enteral nutrition and their actual reported practices and knowledge. Most residents agreed a standardized enteral nutrition protocol should be used.
American Society of Anesthesiologists, 2002-2004.
Scientific and Educational Exhibitor: American Society of Anesthesiologists, Orlando, Florida,
October 2003.
Scientific and Educational Exhibitor: American Society of Anesthesiologists, San Francisco,
California, October 2002.
Scientific and Educational Exhibitor: American Society of Anesthesiologists, New Orleans,
Louisiana, October 2001.
Scientific and Educational Exhibitor: American Society of Anesthesiologists, San Francisco,
California, October 2000.
Scientific and Educational Exhibitor: American Society of Anesthesiologists, Atlanta, Georgia,
October 1999.
Scientific
This document discusses several studies that evaluated nurse-driven enteral feeding protocols in the ICU. Standard enteral feeding protocols often fail to adequately nourish critically ill patients. The studies found that nurse-driven protocols that set caloric intake targets and required starting feeds within 48 hours led to earlier initiation of feeds and higher caloric intake compared to standard protocols. One study found the percentage of patients reaching 80% of caloric needs increased from 44% to 90% with a nurse-driven protocol. The proposed intervention would implement a similar nurse-driven protocol in a randomized ICU to determine if it improves patient nourishment compared to the standard protocol.
This document summarizes a presentation on enteral nutrition for pediatric patients with gastrointestinal impairment. It discusses various conditions that can cause GI impairment including short bowel syndrome, cystic fibrosis, and Crohn's disease. It reviews the available research on different formula types for these conditions, including elemental, semi-elemental, and polymeric formulas. Guidelines are provided on selecting the appropriate formula based on a patient's age, diagnosis and degree of GI impairment. Breast milk, hydrolyzed formulas, and elemental formulas are also discussed as options for infants and children with severe GI issues.
1) PEG tubes are commonly placed in patients with advanced dementia to provide nutrition, though evidence supporting their effectiveness is lacking.
2) Multiple studies have shown that PEG tubes seldom improve nutrition, maintain skin integrity, prevent pneumonia, reduce suffering, improve function, or extend life for patients with advanced dementia.
3) The decision to place a PEG tube is complex and involves considering a patient's directives, ethics, legal issues, emotions, culture, religion, and family input.
The document provides 10 tips for enteral nutrition in intensive care units based on recent American and European guidelines and expert consensus:
1) Low-dose enteral nutrition can be started within 48 hours of admission, even during treatment with small or moderate doses of vasopressor agents.
2) A percutaneous enteral access should be used when enteral nutrition is anticipated for 4 weeks or longer.
3) Energy delivery should not be calculated to match energy expenditure before day 4-7, and use of energy-dense formulas can be restricted to cases where full-volume isocaloric enteral nutrition is not tolerated or fluid restriction is needed.
4) The occurrence of refeeding syndrome should be assessed
Nearly 1.4 million individuals suffer from traumatic brain injury (TBI) each year, leaving many survivors with significant deficits. Early and adequate nutrition support is challenging but may improve outcomes for TBI patients. The document discusses the metabolic and immune alterations caused by TBI and recommends enteral nutrition over parenteral nutrition when possible. It emphasizes starting nutrition within 48 hours and achieving full caloric needs by day 7 to prevent protein breakdown and support recovery. Barriers to providing nutrition like feeding intolerance are also reviewed.
As a newly emphasized modality to treat infectious complications and also to folloew non-antibiotic regimens against infection, Probiotics has recieved more and more attention now a days.
Campbell University Medical School partners with Southeastern HealthRepDavidRLewis
Campbell University and Southeastern Health in Lumberton, North Carolina staged a major partnership announcement on Tuesday, Feb. 19 in Southeastern Health's flagship hospital, Southeastern Regional Medical Center.
More than 150 friends of Southeastern Health and Campbell University attended, including many local leaders in Robeson County, Campbell University trustees, and Southeastern Health trustees.
The Campbell University School of Osteopathic Medicine and Southeastern Health look forward to bringing up to 50 Campbell medical students to Robeson County and the surrounding community each year. It's a tremendous opportunity to bring these young medical professionals to one of the most medically under served regions in North Carolina (and indeed the entire country).
This literature review investigated restrictions on oral intake during labour. It found no evidence that restricting intake improves maternal or neonatal outcomes when the mother is low risk. While earlier concerns about aspiration prompted restrictions, modern techniques have made aspiration extremely rare. The evidence suggests low-risk women who wish to eat or drink lightly in labour should not be prevented from doing so.
In this Australian randomized trial, continued avoidance of gluten was associated with fewer and less severe symptoms among patients with irritable bowel syndrome
This document provides a nutrition assessment and medical nutrition therapy plan for a 63-year-old male patient who underwent a laryngectomy, pharyngectomy, esophagectomy with gastric pull-up followed by radiation for squamous cell carcinoma. The registered dietitian found the patient to be at high nutritional risk due to a 23 pound unintended weight loss over the past year and being 79% of his ideal body weight at the time of surgery. The initial plan was to start enteral nutrition via tube feeding post-operatively. Follow-up notes document the patient tolerating the tube feeding well with some loose stools. The plan was adjusted to a fiber-containing formula and supplements to address this. The registered diet
Feasting or fasting in ICU? by Professor Marianne ChapmanSMACC Conference
This document summarizes the current evidence and ongoing research regarding optimal calorie delivery for critically ill patients in the ICU. It discusses previous studies that have shown conflicting results regarding whether aiming for full calorie delivery leads to better outcomes compared to permissive underfeeding or usual care. The document concludes that high-quality evidence is still needed to guide practice and describes the ongoing TARGET trial, a large multicenter randomized controlled trial aiming to determine if full calorie delivery improves survival in critically ill patients.
Nutrition in icu closed system nutrition benefitsSubha Deep
This document discusses the importance of ready-to-hang enteral feeding systems for critically ill patients. It notes that gastrointestinal dysfunction is common in ICU patients and can lead to malnutrition if adequate nutrition is not provided. Ready-to-hang systems have advantages over open systems like less risk of contamination, better maintenance of nutritional adequacy, and reduced nursing time. Guidelines recommend ready-to-hang formulations for critically ill patients. Clinical evidence shows benefits of ready-to-hang systems like lower rates of infection, better nutritional outcomes, and more cost-effective care.
Enteral and parenteral nutrition are important for critically ill children to prevent further deterioration. Enteral nutrition is preferred when possible due to gut trophic effects. Nutritional requirements vary based on factors like age, illness severity, and metabolic stress. Careful monitoring is needed to avoid overfeeding and associated complications while meeting caloric and protein goals tailored for each patient.
The document discusses how hospitalization can disrupt the normal parent-child attachment process. It provides details on Bowlby's attachment theory and the importance of physical and emotional closeness between caregiver and infant. The theory guides nursing interventions to promote attachment when a child is hospitalized, such as encouraging parents to hold their infant skin-to-skin and be involved in their care. The utility of the theory is that it explains the importance of the parent-child bond and informs best practices to support attachment formation during hospitalization.
The document discusses how hospitalization can disrupt the normal parental attachment process in neonates, infants, and young children. It describes the mechanisms through which attachment normally develops, such as skin-to-skin contact, breastfeeding, and responding to infant cues. However, the physical barriers and emotional stress of hospitalization can interrupt these attachment behaviors. The document recommends nursing interventions to promote attachment during hospitalization, such as encouraging parental involvement in care, holding, and visitation. Bowlby's Attachment Theory provides a useful framework for understanding the importance of the parent-child bond and for guiding practices to support attachment development even in stressful situations like hospitalization.
Total enteral nutrition and total parenteral nutrition in critically ill pat...Prof. Mridul Panditrao
This document discusses total enteral and parenteral nutrition in critically ill patients. It begins by outlining normal energy and protein requirements, then discusses the prevalence and consequences of malnutrition in hospitalized patients. It describes the metabolic response to critical illness and trauma as having an "ebb phase" and "flow phase". The document advocates for early initiation of nutritional support via the enteral route when possible using techniques like post-pyloric feeding tubes, but notes total parenteral nutrition may be needed if enteral nutrition is not tolerated. It provides guidelines on calculating protein and calorie needs and discusses considerations, benefits, risks and protocols for both enteral and parenteral nutrition.
The document discusses the history and development of parenteral nutrition, which began in the 1960s with lipid infusions and the development of parenteral nutrition for patients who had lost their small bowel. It then covers key aspects of parenteral nutrition including formulations, administration routes, indications, and complications. Total parenteral nutrition provides complete nutritional support through intravenous infusion and is indicated when enteral nutrition is not feasible or sufficient, such as in cases of severe gastrointestinal dysfunction.
Artificial intelligence (AI) is everywhere, promising self-driving cars, medical breakthroughs, and new ways of working. But how do you separate hype from reality? How can your company apply AI to solve real business problems?
Here’s what AI learnings your business should keep in mind for 2017.
Study: The Future of VR, AR and Self-Driving CarsLinkedIn
We asked LinkedIn members worldwide about their levels of interest in the latest wave of technology: whether they’re using wearables, and whether they intend to buy self-driving cars and VR headsets as they become available. We asked them too about their attitudes to technology and to the growing role of Artificial Intelligence (AI) in the devices that they use. The answers were fascinating – and in many cases, surprising.
This SlideShare explores the full results of this study, including detailed market-by-market breakdowns of intention levels for each technology – and how attitudes change with age, location and seniority level. If you’re marketing a tech brand – or planning to use VR and wearables to reach a professional audience – then these are insights you won’t want to miss.
NUTRITIONAL THERAPY IN CRITICAL ILL PATIENTS
However, significant barriers can impede the enteral administration of nutrients, including gastroduodenal dysfunction reflected by high gastric residual volumes, and diarrhoea and constipation.
Possible solutions are suggested. In case of contraindication or failure of enteral nutrition, parenteral nutrition is indicated -----as a replacement or a supplement to failing enteral feeding.
The perfect timing of supplemental parenteral nutrition (early or late) remains uncertain, and parenteral nutrition should be carefully monitored
Comparison of the effects of different intravenous fat emulsions in patients ...johnregar
This study compared the effects of two different intravenous fat emulsions, a medium- and long-chain triglyceride emulsion (MCT/LCT) and a fish oil-based emulsion, in patients with systemic inflammatory response syndrome (SIRS) and sepsis. Forty patients were divided into four groups receiving one of the emulsions. The study found that sepsis patients receiving the MCT/LCT emulsion had higher grades of liver steatosis on ultrasound on days 7 and 10 compared to those receiving the fish oil emulsion. Inflammatory markers like TNF-α and IL-6 were also higher in the MCT/LCT sepsis group on day 7. The fish oil emulsion appeared to have anti-inflammatory and hepat
This document summarizes a presentation on enteral nutrition for pediatric patients with gastrointestinal impairment. It discusses various conditions that can cause GI impairment including short bowel syndrome, cystic fibrosis, and Crohn's disease. It reviews the available research on different formula types for these conditions, including elemental, semi-elemental, and polymeric formulas. Guidelines are provided on selecting the appropriate formula based on a patient's age, diagnosis and degree of GI impairment. Breast milk, hydrolyzed formulas, and elemental formulas are also discussed as options for infants and children with severe GI issues.
1) PEG tubes are commonly placed in patients with advanced dementia to provide nutrition, though evidence supporting their effectiveness is lacking.
2) Multiple studies have shown that PEG tubes seldom improve nutrition, maintain skin integrity, prevent pneumonia, reduce suffering, improve function, or extend life for patients with advanced dementia.
3) The decision to place a PEG tube is complex and involves considering a patient's directives, ethics, legal issues, emotions, culture, religion, and family input.
The document provides 10 tips for enteral nutrition in intensive care units based on recent American and European guidelines and expert consensus:
1) Low-dose enteral nutrition can be started within 48 hours of admission, even during treatment with small or moderate doses of vasopressor agents.
2) A percutaneous enteral access should be used when enteral nutrition is anticipated for 4 weeks or longer.
3) Energy delivery should not be calculated to match energy expenditure before day 4-7, and use of energy-dense formulas can be restricted to cases where full-volume isocaloric enteral nutrition is not tolerated or fluid restriction is needed.
4) The occurrence of refeeding syndrome should be assessed
Nearly 1.4 million individuals suffer from traumatic brain injury (TBI) each year, leaving many survivors with significant deficits. Early and adequate nutrition support is challenging but may improve outcomes for TBI patients. The document discusses the metabolic and immune alterations caused by TBI and recommends enteral nutrition over parenteral nutrition when possible. It emphasizes starting nutrition within 48 hours and achieving full caloric needs by day 7 to prevent protein breakdown and support recovery. Barriers to providing nutrition like feeding intolerance are also reviewed.
As a newly emphasized modality to treat infectious complications and also to folloew non-antibiotic regimens against infection, Probiotics has recieved more and more attention now a days.
Campbell University Medical School partners with Southeastern HealthRepDavidRLewis
Campbell University and Southeastern Health in Lumberton, North Carolina staged a major partnership announcement on Tuesday, Feb. 19 in Southeastern Health's flagship hospital, Southeastern Regional Medical Center.
More than 150 friends of Southeastern Health and Campbell University attended, including many local leaders in Robeson County, Campbell University trustees, and Southeastern Health trustees.
The Campbell University School of Osteopathic Medicine and Southeastern Health look forward to bringing up to 50 Campbell medical students to Robeson County and the surrounding community each year. It's a tremendous opportunity to bring these young medical professionals to one of the most medically under served regions in North Carolina (and indeed the entire country).
This literature review investigated restrictions on oral intake during labour. It found no evidence that restricting intake improves maternal or neonatal outcomes when the mother is low risk. While earlier concerns about aspiration prompted restrictions, modern techniques have made aspiration extremely rare. The evidence suggests low-risk women who wish to eat or drink lightly in labour should not be prevented from doing so.
In this Australian randomized trial, continued avoidance of gluten was associated with fewer and less severe symptoms among patients with irritable bowel syndrome
This document provides a nutrition assessment and medical nutrition therapy plan for a 63-year-old male patient who underwent a laryngectomy, pharyngectomy, esophagectomy with gastric pull-up followed by radiation for squamous cell carcinoma. The registered dietitian found the patient to be at high nutritional risk due to a 23 pound unintended weight loss over the past year and being 79% of his ideal body weight at the time of surgery. The initial plan was to start enteral nutrition via tube feeding post-operatively. Follow-up notes document the patient tolerating the tube feeding well with some loose stools. The plan was adjusted to a fiber-containing formula and supplements to address this. The registered diet
Feasting or fasting in ICU? by Professor Marianne ChapmanSMACC Conference
This document summarizes the current evidence and ongoing research regarding optimal calorie delivery for critically ill patients in the ICU. It discusses previous studies that have shown conflicting results regarding whether aiming for full calorie delivery leads to better outcomes compared to permissive underfeeding or usual care. The document concludes that high-quality evidence is still needed to guide practice and describes the ongoing TARGET trial, a large multicenter randomized controlled trial aiming to determine if full calorie delivery improves survival in critically ill patients.
Nutrition in icu closed system nutrition benefitsSubha Deep
This document discusses the importance of ready-to-hang enteral feeding systems for critically ill patients. It notes that gastrointestinal dysfunction is common in ICU patients and can lead to malnutrition if adequate nutrition is not provided. Ready-to-hang systems have advantages over open systems like less risk of contamination, better maintenance of nutritional adequacy, and reduced nursing time. Guidelines recommend ready-to-hang formulations for critically ill patients. Clinical evidence shows benefits of ready-to-hang systems like lower rates of infection, better nutritional outcomes, and more cost-effective care.
Enteral and parenteral nutrition are important for critically ill children to prevent further deterioration. Enteral nutrition is preferred when possible due to gut trophic effects. Nutritional requirements vary based on factors like age, illness severity, and metabolic stress. Careful monitoring is needed to avoid overfeeding and associated complications while meeting caloric and protein goals tailored for each patient.
The document discusses how hospitalization can disrupt the normal parent-child attachment process. It provides details on Bowlby's attachment theory and the importance of physical and emotional closeness between caregiver and infant. The theory guides nursing interventions to promote attachment when a child is hospitalized, such as encouraging parents to hold their infant skin-to-skin and be involved in their care. The utility of the theory is that it explains the importance of the parent-child bond and informs best practices to support attachment formation during hospitalization.
The document discusses how hospitalization can disrupt the normal parental attachment process in neonates, infants, and young children. It describes the mechanisms through which attachment normally develops, such as skin-to-skin contact, breastfeeding, and responding to infant cues. However, the physical barriers and emotional stress of hospitalization can interrupt these attachment behaviors. The document recommends nursing interventions to promote attachment during hospitalization, such as encouraging parental involvement in care, holding, and visitation. Bowlby's Attachment Theory provides a useful framework for understanding the importance of the parent-child bond and for guiding practices to support attachment development even in stressful situations like hospitalization.
Total enteral nutrition and total parenteral nutrition in critically ill pat...Prof. Mridul Panditrao
This document discusses total enteral and parenteral nutrition in critically ill patients. It begins by outlining normal energy and protein requirements, then discusses the prevalence and consequences of malnutrition in hospitalized patients. It describes the metabolic response to critical illness and trauma as having an "ebb phase" and "flow phase". The document advocates for early initiation of nutritional support via the enteral route when possible using techniques like post-pyloric feeding tubes, but notes total parenteral nutrition may be needed if enteral nutrition is not tolerated. It provides guidelines on calculating protein and calorie needs and discusses considerations, benefits, risks and protocols for both enteral and parenteral nutrition.
The document discusses the history and development of parenteral nutrition, which began in the 1960s with lipid infusions and the development of parenteral nutrition for patients who had lost their small bowel. It then covers key aspects of parenteral nutrition including formulations, administration routes, indications, and complications. Total parenteral nutrition provides complete nutritional support through intravenous infusion and is indicated when enteral nutrition is not feasible or sufficient, such as in cases of severe gastrointestinal dysfunction.
Artificial intelligence (AI) is everywhere, promising self-driving cars, medical breakthroughs, and new ways of working. But how do you separate hype from reality? How can your company apply AI to solve real business problems?
Here’s what AI learnings your business should keep in mind for 2017.
Study: The Future of VR, AR and Self-Driving CarsLinkedIn
We asked LinkedIn members worldwide about their levels of interest in the latest wave of technology: whether they’re using wearables, and whether they intend to buy self-driving cars and VR headsets as they become available. We asked them too about their attitudes to technology and to the growing role of Artificial Intelligence (AI) in the devices that they use. The answers were fascinating – and in many cases, surprising.
This SlideShare explores the full results of this study, including detailed market-by-market breakdowns of intention levels for each technology – and how attitudes change with age, location and seniority level. If you’re marketing a tech brand – or planning to use VR and wearables to reach a professional audience – then these are insights you won’t want to miss.
NUTRITIONAL THERAPY IN CRITICAL ILL PATIENTS
However, significant barriers can impede the enteral administration of nutrients, including gastroduodenal dysfunction reflected by high gastric residual volumes, and diarrhoea and constipation.
Possible solutions are suggested. In case of contraindication or failure of enteral nutrition, parenteral nutrition is indicated -----as a replacement or a supplement to failing enteral feeding.
The perfect timing of supplemental parenteral nutrition (early or late) remains uncertain, and parenteral nutrition should be carefully monitored
Comparison of the effects of different intravenous fat emulsions in patients ...johnregar
This study compared the effects of two different intravenous fat emulsions, a medium- and long-chain triglyceride emulsion (MCT/LCT) and a fish oil-based emulsion, in patients with systemic inflammatory response syndrome (SIRS) and sepsis. Forty patients were divided into four groups receiving one of the emulsions. The study found that sepsis patients receiving the MCT/LCT emulsion had higher grades of liver steatosis on ultrasound on days 7 and 10 compared to those receiving the fish oil emulsion. Inflammatory markers like TNF-α and IL-6 were also higher in the MCT/LCT sepsis group on day 7. The fish oil emulsion appeared to have anti-inflammatory and hepat
1) Enteral nutrition involves providing calories, protein, electrolytes, vitamins, and minerals through the gastrointestinal tract and is the preferred method of nutrition for critically ill patients who can tolerate it.
2) Early initiation of enteral nutrition within 48 hours for critically ill patients is recommended to provide clinical benefits over parenteral nutrition or no nutrition support.
3) Factors such as underlying disease state, severity of illness, nutritional status, and ability to be fed enterally must be considered when determining a patient's eligibility for and initiation of enteral nutrition.
Characteristics Of Breastfeeding Practices Among Us MothersBiblioteca Virtual
1) More than half of breastfeeding mothers exclusively breastfed (breast milk only) until 4 months of age, after which exclusive breastfeeding declined sharply. Formula supplementation peaked at 42% at 1 month and declined to 15% at 1 year.
2) Around 6% of mothers reported exclusively pumping breast milk rather than directly breastfeeding.
3) Maternal reports showed considerable variation in behaviors related to common breastfeeding advice on frequency, duration, and intervals of feedings over the infant's first year.
This document provides guidelines for clinical nutrition in the intensive care unit (ICU) developed by an expert panel. It defines key aspects of nutritional support for critically ill patients such as assessing nutritional status, determining energy needs, choosing the route of nutrition (enteral vs parenteral), and adapting support for various clinical conditions. Special conditions like trauma, surgery, and sepsis are also addressed. The guidelines aim to provide evidence-based recommendations to optimize nutritional therapy and identify gaps in knowledge to guide future research.
This document provides guidelines for clinical nutrition in the intensive care unit (ICU) developed by an expert panel. It defines key aspects of nutritional support for critically ill patients such as assessing nutritional status, determining calorie and protein needs, choosing an enteral or parenteral route, and adapting support for various clinical conditions. Special conditions like trauma, surgery, and sepsis are also addressed. The guidelines aim to provide best practices for nutritional therapy and identify gaps in knowledge to help guide future research.
This document provides guidelines for clinical nutrition in the intensive care unit (ICU) developed by an expert panel. It defines key aspects of nutritional support for critically ill patients such as assessing nutritional status, determining calorie and protein needs, choosing an enteral or parenteral route, and adapting support for various clinical conditions. Special conditions like trauma, surgery, and sepsis are also addressed. The guidelines aim to provide evidence-based recommendations to optimize nutritional therapy and identify gaps requiring further research.
The Journal of the Academy of Nutritionand Dietetics, Journa.docxrhetttrevannion
The Journal of the Academy of Nutrition
and Dietetics, Journal of Parenteral and
Enteral Nutrition, and MEDSURG Nursing
Journal have arranged to publish this
article simultaneously in their publica-
tions. Minor differences in style may
appear in each publication, but the article
is substantially the same in each journal.
Copyright ª 2013 by the Academy of
Nutrition and Dietetics, American Society
for Parenteral and Enteral Nutrition, and
Academy of Medical-Surgical Nurses.
2212-2672/$36.00
doi:10.1016/j.jand.2013.05.015
Available online 17 July 2013
JO
FROM THE ACADEMY
Critical Role of Nutrition in Improving Quality of Care:
An Interdisciplinary Call to Action to Address Adult
Hospital Malnutrition
Kelly A. Tappenden, PhD, RD, FASPEN; Beth Quatrara, DNP, RN, CMSRN; Melissa L. Parkhurst, MD; Ainsley M. Malone, MS, RD;
Gary Fanjiang, MD; Thomas R. Ziegler, MD
ABSTRACT
The current era of health care delivery, with its focus on providing high-quality, affordable care, presents many challenges to hospital-
based health professionals. The prevention and treatment of hospital malnutrition offers a tremendous opportunity to optimize the
overall quality of patient care, improve clinical outcomes, and reduce costs. Unfortunately, malnutrition continues to go unrecognized
and untreated in many hospitalized patients. This article represents a call to action from the interdisciplinary Alliance to Advance Patient
Nutrition to highlight the critical role of nutrition intervention in clinical care and to suggest practical ways to promptly diagnose and
treat malnourished patients and those at risk for malnutrition. We underscore the importance of an interdisciplinary approach to
addressing malnutrition both in the hospital and in the acute post-hospital phase. It is well recognized that malnutrition is associated
with adverse clinical outcomes. Although data vary across studies, available evidence shows that early nutrition intervention can reduce
complication rates, length of hospital stay, readmission rates, mortality, and cost of care. The key is to systematically identify patients
who are malnourished or at risk and to promptly intervene. We present a novel care model to drive improvement, emphasizing the
following six principles: (1) create an institutional culture where all stakeholders value nutrition; (2) redefine clinicians’ roles to include
nutrition care; (3) recognize and diagnose all malnourished patients and those at risk; (4) rapidly implement comprehensive nutrition
interventions and continued monitoring; (5) communicate nutrition care plans; and (6) develop a comprehensive discharge nutrition
care and education plan.
J Acad Nutr Diet. 2013;113:1219-1237.
T
HE UNITED STATES IS
entering a new era of health
care delivery in which changes
in health care policy are driving
an increased focus on costs, quality,
and transparency of care. This new
focus on improving the quality and ef-
ficiency of hospital care highlights an
urgent need to revis.
This document provides guidelines for training in pediatric gastroenterology fellowship programs. It summarizes the key changes and considerations in the field that necessitated updating training guidelines, including advances in medical knowledge, emphasis on competencies and outcomes-based education, lifestyle and duty hour changes, and the evolving healthcare system. The document reviews existing guidelines that were consulted in developing the new NASPGHAN guidelines. It describes the unique characteristics of pediatric gastroenterology and outlines the core competencies that fellowship training must address according to accrediting bodies like ACGME and RCPSC.
This essay is based on a patient who was admitted to Gondar university Hospital in the
paediatric ward with a diagnosis of sever acute malnutrition (SAM). The essay will discuss
the assessment and management of a patient by using the holistic care approach that
focuses the rehabilitation issues. After analysing the patient’s assessment and
rehabilitation aspects will be discuss with its rational supported by literature, guidelines
and standards. Finally recommendation will be given based on the evaluation of the care
to improve the quality of nursing practice to nurses in the Hospital based on its rule and
regulations
Opinions And Practices Of Clinicians Associated With Continuation Of Exclusiv...Biblioteca Virtual
This study examined how clinician opinions and practices are associated with continuation of exclusive breastfeeding. The study prospectively followed 288 low-risk mother-newborn pairs who were breastfeeding at 4 weeks. Mothers completed interviews at 4 and 12 weeks, and their obstetric and pediatric clinicians completed surveys. The primary outcome was exclusive breastfeeding at 12 weeks. The study found that clinicians who recommended formula supplementation if an infant was not gaining weight or who felt their breastfeeding advice was not important were associated with early discontinuation of exclusive breastfeeding. Continued exclusive breastfeeding support from clinicians may help improve breastfeeding rates at 6 months.
This document summarizes a conference on maternal nutrition and infant feeding practices. The conference was organized to address gaps in understanding how maternal nutrition affects fetal growth, birth outcomes, and infant feeding practices. It covered 3 topics: 1) the effect of maternal nutrition and the placenta on fetal development and birth outcomes, 2) feeding preterm infants, and 3) feeding full-term infants. For topic 1, presentations showed the placenta's role in nutrient transport affects fetal growth and discussed the importance of nutrients like folate and calcium. Research priorities identified included studying nutrient interactions and their effects on different populations. Topic 2 noted a lack of evidence on best practices for preterm infant nutrition. Topic 3 discussed ensuring evidence on human milk
Bone marrow transplant (BMT) recipients often require parenteral nutrition (PN) to meet their nutrient needs. While general guidelines for the provision of PN support by nutrition support teams (NSTs) have been shown to decrease inappropriate PN use, recommendations for nutrition in BMT recipients are lacking. We reviewed the charts of patients status post BMT on PN to determine whether institutional guidelines for PN initiation and continuous supervision of NSTs could be applied in this population. With the Institutional Review Board (IRB) approval, charts of adult BMT recipients on PN between June 14, 2006 and June 30, 2007 were examined. Sixty-nine charts were reviewed. Indications for initiation of PN included severe mucositis, graft versus host disease (GVHD), and other transplant related side effects resulting in poor oral intake. Among 69 patients, 37 (54%) had severe mucositis, 12 (17%) had GVHD, 2 (3%) had both mucositis and GVHD, and 18 (26%) had other side effects. It was determined that all patients met the criteria for initiation of PN support, as outlined in the guidelines form. Comprehensive guidelines for initiating PN support, developed by NSTs can also be used for BMT recipients in order to optimize their nutritional status.
Clinician Support And Psychosocial Risk Factors Associated With BreastfeedingBiblioteca Virtual
This study examined factors associated with breastfeeding discontinuation at 2 and 12 weeks postpartum in a cohort of 1007 low-risk mothers who initiated breastfeeding. The study found that breastfeeding rates declined over time, with 13% discontinuing by 2 weeks and 45% discontinuing by 12 weeks. Factors associated with earlier discontinuation included lack of breastfeeding confidence, early breastfeeding problems, Asian race, lower education, and depressive symptoms. Receiving encouragement from clinicians was associated with lower risk of discontinuing by 12 weeks, as was not returning to work or school by 12 weeks. The results suggest clinician support and addressing maternal mental health could help promote longer breastfeeding duration.
medical nutrition products - rol van medische voedingtcnn
De rol van medische voeding
Nutricia Advanced Medical Nutrition heeft als missie: "Herstel en welzijn begint voor iedere patiënt die het nodig heeft met Nutricia Advanced Medical Nutrition" Dat betekent voor Nutricia dat medische voeding een essentieel onderdeel is van medische behandelingen.
Voor oudere patiënten kan het lastig zijn om voldoende te blijven eten. Terwijl goede voeding voor hen juist extra belangrijk is.
This document discusses obesity, including its definition, classification, causes, health risks, diagnosis, and management. Obesity is defined as excess body fat accumulation that negatively impacts health, and is classified using body mass index (BMI), waist circumference, and waist-to-hip ratio. Causes include genetic, environmental, and behavioral factors. Health risks associated with obesity include increased risk of diabetes, cardiovascular disease, respiratory issues, cancers, and mental health conditions. Treatment involves lifestyle modifications focusing on diet and exercise, as well as potential medication options to help with weight loss.
Infant Feeding And Feeding Transitions During The First Year Of LifeBiblioteca Virtual
This document summarizes infant feeding patterns during the first year of life based on data from the Infant Feeding Practices Study II. Key findings include:
1) While 83% of infants were breastfed in the hospital, 42% of these infants also received formula supplementation. By 3 months, 61% of infants received formula.
2) Solid foods were introduced earlier than recommended, with 40% of infants consuming cereal and 17% consuming fruits/vegetables by 4 months of age.
3) Early introduction of solids was associated with discontinuing breastfeeding earlier and consuming more fatty/sugary foods by 12 months.
Comparison of prolonged low volume milk and routine volume milk onamir mohammad Armanian
This study compared outcomes for very low birth weight neonates who were fed using either a prolonged low volume milk strategy (20 mL/kg/day for 7 days before increasing) or a routine advancing volume strategy (increasing volumes by 20 mL/kg/day). The study found that the incidence of necrotizing enterocolitis was significantly lower in infants fed with the prolonged low volume strategy compared to those fed with advancing volumes. However, infants fed with advancing volumes reached full enteral feeding volumes sooner. Overall hospital stay times and weight gain at 30 days were similar between the two groups. The study suggests prolonged low volume feeding may help reduce NEC risk in very low birth weight neonates.
The study identified 11 factors that contribute to stunting in children under 5 years old in Putrajaya, Malaysia. The strongest associated factor was complications during pregnancy like intrauterine growth restriction. Other significant factors included mid-parental height less than 150cm, low household income, low birth weight, use of pacifiers, lower maternal education, unemployed fathers, anemia in children, bottle feeding, lack of minimum dietary diversity, and care by babysitters. Addressing these maternal, socioeconomic, childcare and nutritional factors through community interventions and policies could help reduce the high prevalence of stunting in Putrajaya.
4-One potential barrier to the success of my projet will be bein.docxtroutmanboris
4-One potential barrier to the success of my projet will be being able to keep children and their parents and caregivers is keeping them engaged long enough to see positive changes. Weight loss and management is a process and keeping with it can be trying. One way to combat this would be to check in periodically to provide encouragement and assess progress. A lack of trust in the process or not fully understanding the EBP can hinder healthcare professionals from continuing to adhere to the practice (Spallek et al., 2010).
References
Spallek, H., Song, M., Polk, D. E., Bekhuis, T., Frantsve-Hawley, J., & Aravamudhan, K. (2010). Barriers to implementing evidence-based clinical guidelines: A survey of early adopters.
J Evid Based Dent Pract.
, 195-206
5-Two potential barriers that might prevent the EBP change proposal from continuing to obtain the same required results are patients’ culture. Many times, nurses take for granted the patients culture and beliefs. For example, in the Hispanic culture, men are considered weak if they asked for assistance; this can increase patient falls rates. An additional barrier will be an Asian postpartum woman, who believes she needs to stay in bed rest for the first 40 days, making her a higher risk for falls, due to muscle weakness as well as prone to blood clots.
Another factor that will impact the EBP change proposal is the staff knowledge toward fall and safety precautions. Safety education has a substantial impact on patients’ and staff safety. Strategies to overcome these barriers would be patient and staff education and identifying patient culture barriers.
6-To continue to impact outcomes over time in ensuring practice change is making sure nursing educators or clinicians should inform the families of the right time and ways to take the drugs, and how to monitor the blood sugar. The family members or patients themselves should be taught how to make detailed record every time after testing blood sugar. For patients that are on long term medications , they should be taught and encouraged to take insulin subcutaneous injections on time, to avoid elevated blood glucose and problems such as ketoacidosis due to belated drug use. Secondly , dietary education is considered for specific and individualized regimen for each patient . The patients with their families are informed of the importance of eating right in the whole process of treatment which will be achieved by following advice of nutritionists and cultivating a good dietetic habit. The concerns or barriers such as not taking drugs timely, healthy diets, keeping exercises, testing and recording the level of blood glucose are barriers that may prevent EBP change proposal. Periodic telephone follow-up should be made during 3 months after discharge from the hospital to explore the effects of family rehabilitation on patients especially children that are impacted by the disease.
.
The document presents a case study and nutrition care plan for a 49-year-old male patient admitted to the ICU with 17% mixed thickness burns. It includes the patient's anthropometric and biochemical data, a nutrition diagnosis of protein losses related to burns, and an enteral nutrition regime designed to provide 2600 kcal and 120g of protein per day using Enercal Plus and Myotein formulas administered through a feeding tube.
Mr. S is a 59-year old man diagnosed with stage 1 COPD who has experienced weight loss from 68kg to 59kg. He was referred to a dietitian for a diet consultation to address his poor appetite and malnutrition. The dietitian assessed his nutrition status and designed a 2,200 calorie diet plan focusing on small, frequent meals high in calories, protein, and antioxidants to support his lung function and delay COPD progression.
Mr. TEC is a 62-year-old Chinese man admitted to the oncology ward due to metastatic adenocarcinoma neck cancer. He has experienced weight loss and dysphagia. A nutritional plan is developed to provide adequate calories and nutrients through enteral nutrition via 6 feedings per day of a specialized formula. The plan will be gradually increased over 4 steps to reach goals of 2442 kcal, 133.2 g protein, and 399.9 g carbs to support weight gain and prevent further malnutrition.
A 16-year-old Indian boy was admitted to the hospital with an acute subdural hematoma following a motor vehicle accident. He underwent a decompressive craniectomy and was referred for enteral tube feeding. A feeding regimen was developed to provide adequate calories and protein to promote recovery, consisting of incremental increases in feeding volume up to 150ml given 8 times per day via Ryle's tube. MCT oil was also prescribed to boost calories without increasing protein. The goal was to preserve lean body mass and improve healing through optimized nutrition support.
1 scoop myotein in 2 times feeding per day
Calories = 6(42kcal) x 6 + 2(30.1) = 1566.2 kcal/day
Protein = 6(1.7g) x 6 + 2(5g) = 72.4 g/day
Total CHO = 6(5.1g) x 6 = 183.6g/day
Total Fat = 6(1.6g) x 6 = 57.6g/day
3. Flush with 30ml of water
Gradually increase feeding amount based on tolerance.
Monitoring and Evaluation
1. Daily monitoring of:
- Intake and output
RK is a 25-year old man who suffered multiple injuries including fractures and head trauma in a motor vehicle accident. He has been unconscious and receiving nutrition via a nasogastric tube. The plan is to insert a PEG tube. A 6-step plan is outlined to gradually increase nutrition from the PEG tube to meet RK's estimated daily energy needs of 3100 calories and protein needs of 128 grams. Education for caregivers is also included on proper PEG tube feeding and hygiene.
This document provides definitions and information about HIV/AIDS including:
- Definitions of HIV and AIDS
- Global and regional statistics on HIV/AIDS prevalence and deaths
- Modes of HIV transmission and risk factors
- Stages of HIV infection from acute to symptomatic disease
- Diagnosis and treatment of HIV/AIDS
- Nutritional complications and the role of dietitians in HIV/AIDS care
The document discusses nutrition support and the conditions that require specialized nutrition through enteral or parenteral means. It covers the indications, contraindications, advantages, and disadvantages of enteral nutrition support through various tube feeding routes and administration methods. The roles and responsibilities of nutrition support dietitians in implementing individualized nutrition care plans are also outlined.
This document summarizes medical nutrition therapy for various pulmonary diseases. It discusses the anatomy and physiology of the respiratory system and mechanics of breathing. It then covers several chronic pulmonary diseases including asthma, bronchopulmonary dysplasia, chronic obstructive pulmonary disease, and cystic fibrosis. For each condition, it describes nutritional implications, recommended nutritional assessments, and medical nutrition therapy goals and strategies.
The document contains 6 case studies presenting patients with various medical conditions requiring nutritional support. RK suffered head injuries and was being fed via NG tube. Dietary plans would focus on meeting calorie and protein needs during NG and after PEG tube insertion. AH had cancer and underwent stomach surgery, requiring TPN then transition to EN. Dietary plans would focus on meeting calorie and protein needs during TPN and after transition to EN. Mr. TEC had neck cancer and lost weight due to dysphagia, requiring an EN regime to meet calorie and protein needs.
The document discusses metabolic stress that occurs in critically ill patients. It describes the ebb and flow phases of the metabolic response to stress or injury. In the ebb phase, metabolic rate decreases as the body shuts down in response to trauma or infection. In the flow phase, metabolism increases as the body enters an acute response with catabolism predominating. This is followed by an adaptive response where anabolism predominates as the body recovers. The document outlines the hormonal and metabolic changes that occur during stress, including increases in energy expenditure, protein breakdown, and impaired fuel utilization. It provides recommendations for nutritional support and assessment of critically ill patients experiencing metabolic stress.
Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Pictorial and detailed description of patellar instability with sign and symptoms and how to diagnose , what investigations you should go with and how to approach with treatment options . I have presented this slide in my 2nd year junior residency in orthopedics at LLRM medical college Meerut and got good reviews for it
After getting it read you will definitely understand the topic.
Summer is a time for fun in the sun, but the heat and humidity can also wreak havoc on your skin. From itchy rashes to unwanted pigmentation, several skin conditions become more prevalent during these warmer months.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7shruti jagirdar
Unit 4: MRA 103T Regulatory affairs
This guideline is directed principally toward new Molecular Entities that are
likely to have significant use in the elderly, either because the disease intended
to be treated is characteristically a disease of aging ( e.g., Alzheimer's disease) or
because the population to be treated is known to include substantial numbers of
geriatric patients (e.g., hypertension).
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
A statistics is a measure which is used to estimate the population parameter
Parameters-It is used to describe the properties of an entire population.
Examples-Measures of central tendency Dispersion, Variance, Standard Deviation (SD), Absolute Error, Mean Absolute Error (MAE), Eigen Value
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)
Aspen children
1. Journal of Parenteral and Enteral
Nutrition http://pen.sagepub.com/
A.S.P.E.N. Clinical Guidelines: Nutrition Support of the Critically Ill Child
Nilesh M. Mehta, Charlene Compher and A.S.P.E.N. Board of Directors
JPEN J Parenter Enteral Nutr 2009 33: 260
DOI: 10.1177/0148607109333114
The online version of this article can be found at:
http://pen.sagepub.com/content/33/3/260
Published by:
http://www.sagepublications.com
On behalf of:
The American Society for Parenteral & Enteral Nutrition
Additional services and information for Journal of Parenteral and Enteral Nutrition can be found at:
Email Alerts: http://pen.sagepub.com/cgi/alerts
Subscriptions: http://pen.sagepub.com/subscriptions
Reprints: http://www.sagepub.com/journalsReprints.nav
Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Apr 27, 2009
What is This?
Downloaded from pen.sagepub.com at International Islamic University Malaysia on February 15, 2012
3. A.S.P.E.N. Clinical Guidelines / Mehta et al 261
an ongoing basis, reviewing about 20% of the chapters Table 1
each year in order to keep them as current as possible. Grading of Guidelines and Levels of Evidence
These clinical guidelines were created in accordance Grading of Guidelines
with Institute of Medicine recommendations as “syste
matically developed statements to assist practitioner and A Supported by at least two level I investigations
patient decisions about appropriate health care for specific B Supported by one level I investigation
clinical circumstances.”9 These clinical guidelines are for C Supported by level II investigations
use by healthcare professionals who provide nutrition D Supported by level III investigations
support services and offer clinical advice for managing E Supported by level IV or V evidence
adult and pediatric (including adolescent) patients in Levels of Evidence
inpatient and outpatient (ambulatory, home, and specia
I Large randomized trials with clear-cut results; low risk of
lized care) settings. The utility of the clinical guidelines is
false-positive (alpha) and/or false-negative (beta) error
attested to by the frequent citation of this document in
II Small, randomized trials with uncertain results;
peer-reviewed publications, and their frequent use by moderate-to-high risk of false-positive (alpha) and/or
A.S.P.E.N. members and other healthcare professionals false-negative (beta) error
in clinical practice, academia, research, and industry. III Nonrandomized cohort with contemporaneous controls
They guide professional clinical activities, they are help IV Nonrandomized cohort with historical controls
ful as educational tools, and they influence institutional V Case series, uncontrolled studies, and expert opinion
practices and resource allocation.10
Reproduced from Dellinger RP, Carlet JM, Masur H. Introduction.
These clinical guidelines are formatted to promote Crit Care Med. 2004;32(11)(suppl):S446 with permission of the
the ability of the end user of the document to understand publisher. Copyright 2004 Society of Critical Care Medicine.
the strength of the literature used to grade each recom
mendation. Each guideline recommendation is presented Systematic reviews are a specialized type of literature
as a clinically applicable definitive statement of care and review that analyzes the results of several RCTs, and may
should help the reader make the best patient care decision. receive a grade level of I or II, depending on the overall
The best available literature was obtained and carefully quality of the reports. Meta-analyses can be used to
reviewed. Chapter author(s) completed a thorough combine the results of studies to further clarify the overall
literature review using Medline, the Cochrane Central outcome of these studies but will not be considered in the
Registry of Controlled Trials, the Cochrane Database of grading of the guideline. A level of III is given to cohort
Systematic Reviews and other appropriate reference studies with contemporaneous controls, while cohort
sources. These results of the literature search and review studies with historic controls will receive a level of IV.
formed the basis of an evidence-based approach to the Case series, uncontrolled studies, and articles based on
clinical guidelines. Chapter editors work with the authors expert opinion alone will receive a level of V.
to ensure compliance with the author’s directives regarding
content and format. The initial draft is then reviewed
internally to ensure consistency with the other A.S.P.E.N. Practice Guidelines and Rationales
Guidelines and Standards and externally reviewed (by
experts in the field within our organization and/or out ide
s Table 2 provides the entire set of guidelines recom-
of our organization) for appropriateness of content. Then mendations for nutrition support in the critically ill child.
the final draft is reviewed and approved by the A.S.P.E.N.
Board of Directors.
The system used to categorize the level of evidence 1. Nutrition Assessment
for each study or article used in the rationale of the guide 1A) Children admitted with critical illnesses
line statement and to grade the guideline recommendation should undergo nutrition screening to identify
is outlined in Table 1.11 those with existing malnutrition or those who
The grade of a guideline is based on the levels of are nutritionally at-risk. Grade D
evidence of the studies used to support the guideline. 1B) Formal nutrition assessment with the devel-
A randomized controlled trial (RCT), especially one that opment of a nutrition care plan should be
is double blind in design, is considered to be the stron est
g required, especially in those children with pre-
level of evidence to support decisions regarding a therapeutic morbid malnutrition. Grade E
intervention in clinical medicine.12 A level of I, the
highest level, will be given to large RCTs where results
Rationale
are clear and the risk of alpha and beta error is low (well-
powered). A level of II will be given to RCTs that include The prevalence of malnutrition in hospitalized children
a relatively low number of patients or are at moderate- has remained unchanged over several years and has impli-
to-high risk for alpha and beta error (under-powered). cations on hospital length of stay (LOS), illness course
Downloaded from pen.sagepub.com at International Islamic University Malaysia on February 15, 2012
4. 262 Journal of Parenteral and Enteral Nutrition / Vol. 33, No. 3, May/June 2009
Table 2
Nutrition Support Guideline Recommendations in the Critically Ill Child
# Guideline Recommendations Grade
1 1A) Children admitted with critical illnesses should undergo nutrition screening to identify those with existing D
malnutrition and those who are nutritionally-at-risk.
1B) A formal nutrition assessment with the development of a nutrition care plan should be required, especially in E
those children with premorbid malnutrition.
2 2A) Energy expenditure should be assessed throughout the course of illness to determine the energy needs of D
critically ill children. Estimates of energy expenditure using available standard equations are often unreliable.
2B) In a subgroup of patients with suspected metabolic alterations or malnutrition, accurate measurement of E
energy expenditure using indirect calorimetry (IC) is desirable. If IC is not feasible or available, initial energy
provision may be based on published formulas or nomograms. Attention to imbalance between energy intake
and expenditure will help to prevent overfeeding and underfeeding in this population.
3 There are insufficient data to make evidence-based recommendations for macronutrient intake in critically ill E
children. After determination of energy needs for the critically ill child, the rational partitioning of the major
substrates should be based upon understanding of protein metabolism and carbohydrate- and lipid-handling
during critical illness.
4 4A) In critically ill children with a functioning gastrointestinal tract, enteral nutrition (EN) should be the C
preferred mode of nutrient provision, if tolerated.
4B) A variety of barriers to EN exist in the pediatric intensive care unit (PICU) Clinicians must identify and D
prevent avoidable interruptions to EN in critically ill children.
4C) There are insufficient data to recommend the appropriate site (gastric vs post-pyloric/transpyloric) for enteral C
feeding in critically ill children. Post-pyloric or transpyloric feeding may improve caloric intake when compared
to gastric feeds. Post-pyloric feeding may be considered in children at high risk of aspiration or those who have
failed a trial of gastric feeding.
5 Based on the available pediatric data, the routine use of immunonutrition or immune-enhancing diets/nutrients D
in critically ill children is not recommended.
6 A specialized nutrition support team in the PICU and aggressive feeding protocols may enhance the overall E
delivery of nutrition, with shorter time to goal nutrition, increased delivery of EN, and decreased use of
parenteral nutrition. The affect of these strategies on patient outcomes has not been demonstrated.
and morbidity.4,5 Children admitted to the PICU are fur- and resting energy expenditure (REE). Albumin, which
ther at risk of longstanding altered nutrition status and has a large pool and much longer half-life (14-20 days), is
anthropometric changes that may be associated with mor- not indicative of the immediate nutrition status. Indepen
bidity.13 Hulst et al observed a correlation between energy dently of nutrition status, serum albumin concentrations
deficits and deterioration in anthropometric parameters may be affected by albumin infusion, dehydration, sepsis,
such as mid-arm circumference and weight in a mixed trauma, and liver disease. Thus, its reliability as a marker
population of critically ill children.13 These anthropo- of visceral protein status is questionable. Prealbumin
metric abnormalities accrued during the PICU admis (also known as transthyretin or thyroxine-binding preal-
sion returned to normal by 6 months after discharge.1 bumin) is a stable circulating glycoprotein synthesized in
Using reproducible anthropometric measures, Leite et al the liver. It binds with retinol binding-protein and is
reported a 65% prevalence of malnutrition on admission involved in the transport of thyroxine as well as retinol.
with increased mortality in this group.5 On follow up, a Prealbumin, so named by its proximity to albumin on an
significant portion of these children had further deterio- electrophoretic strip, has a half-life of 24-48 hours.
ration in nutrition status (Table 3). Nutrition assessment Prealbumin serum concentration is diminished in liver
of children during the course of critical illness is desirable disease and may be falsely elevated in renal failure.
and can be quantitatively assessed by routine anthropo- Prealbumin is readily measured in most hospitals and is a
metric measurements. Routine monitoring of weight is a good marker for the visceral protein pool.14,15 Visceral
valuable index of nutrition status in critically ill children. proteins such as albumin and prealbumin do not accu-
However, weight changes and other anthropometric rately reflect nutrition status and response to nutrition
measurements during the PICU admission should be intervention during inflammation. In children with burn
interpreted in the context of fluid therapy, other causes injury, serum acute-phase protein levels rise within 12–24
of volume overload, and diuresis. Nutrition assessment hours of the stress, because of hepatic reprioritization
can also be achieved by measuring the nitrogen balance of protein synthesis in response to injury.16 The rise is
Downloaded from pen.sagepub.com at International Islamic University Malaysia on February 15, 2012
5. A.S.P.E.N. Clinical Guidelines / Mehta et al 263
proportional to the severity of injury. Many hospitals are Rationale
capable of measuring C-reactive protein (CRP) as an
Acute injury markedly alters energy needs. Acute injury
index of the acute-phase response. When measured seri-
induces a catabolic response that is proportional to the
ally (once a day during the acute response period), serum
magnitude, nature, and duration of the injury. Increa
prealbumin and CRP are inversely related (ie, serum pre-
sed serum counter-regulatory hormone concentrations
albumin concentrations decrease and CRP concentra-
induce insulin and growth hormone resistance, resulting
tions increase with the magnitude proportional to injury
in the catabolism of endogenous stores of protein, carbo-
severity and then return to normal as the acute injury
hydrate, and fat to provide essential substrate interme-
response resolves). In infants after surgery, decreases in
diates and energy necessary to support the ongoing
serum CRP values to levels < 2 mg/dL have been associ-
metabolic stress response.19 In mechanically ventilated
ated with the return of anabolic metabolism and are fol-
children in the PICU, a wide range of metabolic states
lowed by increases in serum prealbumin levels.17
has been reported with an average early tendency
towards hypermetabolism.20 Children with severe burn
Future Research injury demonstrate extreme hypermetabolism in the early
stages of injury whereby standard equations have been
Standard anthropometric measurements may be inaccu-
shown to underestimate the measured REE.21 Failure to
rate in critically ill children with fluid shifts, edema, and
provide adequate energy during this phase may result in
ascites. The prevalence of malnutrition in this group of
loss of critical lean body mass and may worsen existing
patients and the dynamic effects of critical illness on
malnutrition. Stress or activity correction factors have
nutrition status require the ability to accurately measure
been traditionally factored into basal energy requirement
body composition in hospitalized children. Body composi-
estimates to adjust for the nature of illness, its severity
tion measurement in children admitted to the PICU has
and the activity level of hospi alized subjects.22,23 On the
t
been limited due to the absence of reliable bedside tech-
other hand, critically ill children who are sedated and
niques while existing measurement techniques such as
mechanically ventilated may have significant reduction in
the dual energy X-ray absorptiometry (DEXA) scan are
true energy expenditure, due to multiple factors including
impractical in this cohort. Future research related to vali-
decreased activity, decreased insensible fluid losses and
dation of simple, noninvasive bedside body composition
transient absence of growth during the acute illness.8
measurement techniques is desirable and will allow moni-
These patients may be at a risk of overfeeding when esti-
toring of relevant parameters such as lean body mass, total
mates of energy requirements are based on age-appropri-
body water, and fat mass in critically ill children. Further
ate equations developed for healthy children and especially
more, long-term follow up studies in survivors of critical
if stress factors are incorporated. The application of a
illness will provide a better idea of the toll of a PICU
uniform stress correction factor for broad groups of
course on nutrition status of children. For the purpose of
patients in the ICU is simplistic, likely to be inaccurate
such long-term follow up, qualitative markers of lean body
and may increase the risk of overfeeding. IC testing may
mass integrity and function or indicators of return to base-
be considered before incorporating stress factor correc-
line activity are examples of outcome variables relevant to
tion to energy estimates in critically ill children. Therefore,
nutrition in children surviving critical illness.
the application of correction factors for activity, insensi-
ble fluid loss and the energy or caloric allotment for
growth, which is substantial in infancy, must be
2. Energy Requirement in the Critically Ill Child
reviewed.
2A) Energy expenditure should be assessed To account for dynamic alterations in energy meta
throughout the course of illness to determine bolism during the critical illness course, REE values
the energy needs of critically ill children. remain the only true guide for energy intake. It is likely
Estimates of energy expenditure using avail- that resource constraints and lack of available expertise
able standard equations are often unreliable. restricts the regular use of IC in the PICU. Estimating
Grade D energy expenditure needs based on standard equations
2B) In a subgroup of patients with suspected has been shown to be inaccurate and can significantly
metabolic alterations or malnutrition, accu- underestimate or overestimate the REE in critically ill
rate measurement of energy expenditure using children (see Table 4). This exposes the critically ill
indirect calorimetry (IC) is desirable. If IC is child to potential underfeeding or overfeeding during
not feasible or available, initial energy provi- the ICU stay, with significant morbidity associated with
sion may be based on published formulas or each scenario. While the problems with underfeeding
nomograms. Attention to imbalance between have been well documented, overfeeding too has dele
energy intake and expenditure will help to terious consequences.24,25 It increases ventilatory work
prevent overfeeding and underfeeding in this by increasing carbon dioxide production and can poten
population. Grade E tially prolong the need for mechanical ventilation.26
Downloaded from pen.sagepub.com at International Islamic University Malaysia on February 15, 2012
6. 264 Journal of Parenteral and Enteral Nutrition / Vol. 33, No. 3, May/June 2009
Table 3
Anthropometric Changes During Pediatric Critical Illness and Role of Nutrition Assessment
Study Population
Year Intervention Sample Clinical Outcome
Grade Outcome Measured Size Results Comments
Hulst Children in a multidisciplinary N = 261 Mean Energy deficits (over a Mixed population.
et al1,13 ICU maximum of 14 days) were Negative energy and protein
2004 a) Total actual intakes of calories 27 kcal/kg—Preterm neonates balance in this population
Level III and protein were recorded. 20 kcal/kg—Term neonates correlated with decreasing
Balance was calculated by sub- 12 kcal/kg—Older children anthropometric parameters.
tracting actual intake from RDA, Mean Protein deficits: A 14-day period of monitoring
over a maximum of 14 days. 0.6 g/kg/day—Preterm may not be adequate for
Relations between balance and 0.3 g/kg/day—Term Newborns anthropometric changes.
clinical factors and change in 0.2 g/kg/day—Children Energy balance was
anthropometry Cumulative deficits—related to calculated from estimates of
b) Patients were also followed up decrease in weight and arm RDA and not measured by
to 6 months for anthropometric circumference SD-scores. indirect calorimetry.
parameters. Negative correlation with age, At 6 months follow up, almost
length of stay in the ICU and all children had recovered
duration of mechanical their nutrition status.
ventilator support.
Hulst et al18 Children in a multidisciplinary N = 105 Prevalence of hypomagnesemia, Except for uremia, no
2006 PICU hypertriglyceridemia, uremia significant association was
Level III Serum urea, albumin, triglycerides and hypoalbuminemia were found between
and magnesium were measured 20%, 25%, 30% and 52%, abnormalities in
in 105 children (age, 7 days to respectively, with no significant biochemical parameters and
16 years) within the first 24 associations between the changes in SD scores of
hours after admission. different disorders. anthropometric
Association with anthropometric measurements.
outcomes parameters
Leite et al5 PICU N = 46 65% of the patients presented with A significant number of
1993 Anthropometry at admission and indices of malnutrition. Of patients are nutritionally-at-
Level III follow-up these, chronic malnutrition was risk at the time of hospital
predominant. admission, and there is an
Mortality was higher in association between
malnourished individuals (20% nutrition status and hospital
vs 12.5%). course.
36% of patients showed a decrease The anthropometric nutrition
in weight-for-height on follow evaluation is a simple,
up. reproducible and objective
tool for nutrition
assessment of the critically
ill child.
ICU, intensive care unit; PICU, pediatric intensive care unit; RDA, recommended daily allowance; SD, standard deviation.
Overfeeding may also impair liver function by inducing feeding in a select group of chronically ill children at high
steatosis and cholestasis, and increase the risk of infection risk of obesity is currently sporadic. In general, the energy
secondary to hyperglycemia. Hyperglycemia associated goals should be assessed and reviewed regularly in
with caloric overfeeding has been associated with critically ill children.
prolonged mechanical ventilator requirement and PICU Table 4 summarizes studies examining the performance
LOS.27 The use of the respiratory quotient (RQ) as a of estimated energy needs in relation to measured REE in
measure of substrate use in individual children cannot be critically ill children requiring mechanical ventilator
recommended. However, a combination of acute phase support. In general, these small sized, prospective or
proteins (CRP) and RQ may reflect transi ion from the
t retrospective cohort studies demonstrate the variability of
catabolic hypermetabolic to the anabolic state. There are the metabolic state and the uniform failure of estimated
no data in general pediatric populations for the role of energy needs in accurately predicting the measured REE
hypocaloric feeding. The application of hypocaloric in critically ill children. In the absence of REE, some
Downloaded from pen.sagepub.com at International Islamic University Malaysia on February 15, 2012
7. A.S.P.E.N. Clinical Guidelines / Mehta et al 265
Table 4
Estimated Energy Expenditure vs Measured Resting Energy Expenditure (REE)
Study Population
Year Intervention Clinical Outcome
Grade Outcome Measures Sample Size Results Comments
De Klerk Children needing > 24 hours of N = 18 Variability in total daily energy Single measurement
et al28 mechanical ventilator support expenditure appears to accurately
2002 in a PICU (40-64 kcal/kg/d) reflect total daily energy
Level III Serial measured REE CV was < 10% requirement.
Respiratory Quotient (RQ) Positive energy balance in Results of this study do not
Energy balance = actual energy many children (n=8) suggest the need for
intake – total energy [Average RQ in this group was serial REE.
expenditure 0.89] RQ was marginally affected
Negative balance (n=10) by energy balance.
[Average RQ in this group was
0.84]
White et al29 Mechanically ventilated children N = 11 30-minute REE Small numbers. No
1999 in the PICU CV was 7.2% ± 4.5% correlation examined
Level III 24 h indirect calorimetry 30-min vs 24 h: no difference with clinical state.
measurement (P < 0.69) 30-minute REE accurately
30 minute steady state REE No diurnal variation represented the 24-h
compared to 24-h total energy Between-day CV = 21% ± 16% values.
expenditure The authors recommend
Daily CV in measured REE was serial REE measure-
calculated ments based on signi-
ficant between-day CV.
White et al30 Mechanically ventilated children N = 100 A new equation for estimated The authors concluded
2000 in a PICU (derivation) REE was derived, that there is no
Level III Clinical variables N = 25 incorporating age, weight, substitute for measured
REE by indirect calorimetry (validation) temperature, days in the REE.
PICU, and disease. Their derived equation
performed better than
existing standard
equations.
Derumeaux- Obese children N = 471 REE equation using fat-free Special equations may be
Burel BMI z score ≥ 2 (derivation) mass was more accurate than necessary for obese
et al31 Measured REE N = 211 weight-based equations children.
2004 Fat free mass—obtained by (validation) Body composition is an
Level III bioelectric impedance important factor in REE.
assessment Measured REE is ideal.
Predicted equations
Mlcak et al32 Children < 18 years with total N = 100 (40 REE was expressed in 3 Increased REE persisted
2006 body surface area burn > 40%, female) different ways: actual REE in for over 12 months after
Level III and consent to return at 6, 9, kcal per day, percent of burn injury.
and 12 months for post-burn predicted REE, and actual
follow up REE divided by the BMI.
Measured REE vs Harris- Hypermetabolism persisted 12
Benedict equation and months after burn injury.
corrected by BMI Female children exerted a
REE measurements were decreased hypermetabolic
repeated at 6, 9, and 12 response compared with
months post-burn when the male children.
patients returned for
outpatient surgery.
(continued)
Downloaded from pen.sagepub.com at International Islamic University Malaysia on February 15, 2012
8. 266 Journal of Parenteral and Enteral Nutrition / Vol. 33, No. 3, May/June 2009
Table 4 (continued)
Study Population
Year Intervention Clinical Outcome
Grade Outcome Measures Sample Size Results Comments
Framson Children admitted to a PICU. N = 44 (29 In general, equations The hypermetabolic
et al33 Both spontaneously breathing males) performed well. response apparent in
2007 and mechanically ventilated Mean REE for all adults was not evident
Level III patients were included. No measurements was 821 ± in these critically
children with chronic disease. 653 kcal/24 hours. ill children.
The Schofield equation
REE measurement within 24 estimate was 798 ± 595 Authors do not recommend
hours of admission, then 48 kcal/24 h and the White the use of REE
hours after the first equation estimate was 815 ± estimates from equations
measurement, and finally 564 kcal/24 h (P not as a guide for caloric
within 24 hours before significant). intake in critically ill
discharge from the PICU. Only 45% of REE were within children.
Measured REE was compared to 90%–110% of that predicted
estimates from Schofield and by the Schofield equation.
White equations. The White equation was
inaccurate (not within 10%
of REE) in 66 of 94
measurements (70%). The
discrepancy was greatest
(100%) in children with REE
<450 kcal/24 h.
Vazquez Mechanically ventilated children N = 43 (18 Measured REE = 674 ± 384 Children may be
Martinez in a PICU female); 35 kcal/day. hypometabolic in the
et al34 Measured REE was compared to surgical and Patients noted to be first 6 h after PICU
2004 estimates from various 8 medical hypometabolic in the first 6 admission.
Level III equations/formulas such as h after admission to PICU.
Harris-Benedict, Caldwell- Most equations overestimated Equations overestimate
Kennedy, Schofield, FAO/ measured REE in ventilated, energy expenditure.
WHO, Maffeis, Fleisch, critically ill children during Authors do not recommend
Kleiber, Dreyer, and Hunter the early post-injury period. equations for predicting
equations. Measured and predicted energy energy expenditure in
expenditure differed critically ill children.
significantly (P < .05) except
when the Caldwell-Kennedy
and the Fleisch equations
were used.
BMI, body mass index; CV, coefficient of variation; FAO/WHO, Food and Agriculture Organization/World Health Organization;
PICU, pediatric intensive care unit.
investigators recommend that basal energy requirements Future Research
should be provided without correction factors to avoid
the provision of calories and/or nutrition substrates in IC remains sporadically applied in critically ill
excess of the energy required to maintain the metabolic children in the setting of mounting evidence of the
homeostasis of the injury response. Criteria for targeting inaccuracy of estimated basal metabolic rate using
a select group of children in the PICU for IC measurement standard equations. This could potentially subject a sub
of REE may be useful for centers with limited resources group of children in the PICU to the risk of underfeeding
for metabolic testing. Some children in the PICU are or overfeeding. In the era of resource constraints, IC may
likely to be at risk of altered metabolism or malnutrition, be applied or targeted for certain high-risk groups in the
where estimates of energy expenditure using standard PICU. Selective application of IC may allow many units
equations are likely to be inaccurate. If resources are to balance the need for accurate REE measurement and
limited, this subset of the population may benefit from limited resources (Appendix 1). Studies examining the
targeted IC for accurate measurement of REE to guide role of simplified IC technique, its role in optimizing
energy administration. nutrient intake, its ability to prevent overfeeding or
Downloaded from pen.sagepub.com at International Islamic University Malaysia on February 15, 2012
9. A.S.P.E.N. Clinical Guidelines / Mehta et al 267
underfeeding in selected subjects, and the cost-benefit response. This allows for maximal physiologic adaptability
analyses of its application in the PICU are desirable. The at times of injury or illness. Although children with criti-
effect of energy intake on outcomes needs to be examined cal illness have increases in both whole-body protein
in pediatric populations especially in those on the extremes degradation and whole-body protein synthesis, it is the
of body mass index (BMI). former that predominates during the stress response.
Thus, these patients manifest net negative protein and
nitrogen balance characterized by skeletal muscle wast-
Appendix 1
ing, weight loss, and immune dysfunction. The catabo-
Children at high risk for metabolic alterations who lism of muscle protein to generate glucose and
are suggested candidates for targeted measurement of inflammatory response proteins is an excellent short-term
REE in the PICU include the following: adaptation, but it is ultimately limited because of the
reduced protein reserves available in children and neo-
• Underweight (BMI < 5th percentile for age), at risk nates. Unlike during starvation, the provision of dietary
of overweight (BMI > 85th percentile for age) or carbohydrate alone is ineffective in reducing the endoge-
overweight (BMI > 95th percentile for age) nous glucose production via gluconeogenesis in the
• Children with > 10% weight gain or loss during metabolically stressed state.35 Therefore, without elimina-
ICU stay
tion of the inciting stress for catabolism (ie, the critical
• Failure to consistently meet prescribed caloric goals
• Failure to wean, or need to escalate respiratory
illness or injury), the progressive breakdown of muscle
support mass from critical organs results in loss of diaphragmatic
• Need for muscle relaxants for > 7 days and intercostal muscle (leading to respiratory compro-
• Neurologic trauma (traumatic, hypoxic and/or isch- mise), and to the loss of cardiac muscle. The amount of
emic) with evidence of dysautonomia protein required to optimally enhance protein accretion is
• Oncologic diagnoses (including children with stem higher in critically ill than in healthy children. Infants
cell or bone marrow transplant) demonstrate 25% higher protein degradation after surgery
• Children with thermal injury and a 100% increase in urinary nitrogen excretion with
• Children requiring mechanical ventilator support bacterial sepsis.36,37 The provision of dietary protein suf-
for > 7 days ficient to optimize protein synthesis, facilitate wound
• Children suspected to be severely hypermetabolic
healing and the inflammatory response, and preserve
(status epilepticus, hyperthermia, systemic inflam-
matory response syndrome, dysautonomic storms,
skeletal muscle protein mass is the most important nutri-
etc) or hypometabolic (hypothermia, hypothyroid- tion inter ention in critically ill children. The quantities
v
ism, pentobarbital or midazolam coma, etc.) of protein recommended for critically ill neonates and
• Any patient with ICU LOS > 4 weeks may benefit children are based on limited data. Certain severely
from IC to assess adequacy of nutrient intake. stressed states, such as significant burn injury, may
require additional protein supplementation to meet meta-
bolic demands. Excessive protein administration should
3. Macronutrient Intake During Critical Illness be avoided as toxicity has been documented, particularly
There are insufficient data to make evidence- in children with marginal renal and hepatic function.
based recommendations for macronutrient Studies using high protein allotments of 4–6 g/kg/day
intake in critically ill children. After determi- have been associated with adverse effects such as azotemia,
nation of energy needs for the critically ill metabolic acidosis, and neurodevelopmental abnormali-
child, the rational partitioning of the major ties.38 A similar evaluation of the effects of high protein
substrates should be based upon basic under- administration using newer formulas is desirable. Although
standing of protein metabolism and carbohy- the precise amino acid composition to best increase
drate- and lipid-handling during critical illness. whole-body protein balance has yet to be fully deter-
Grade E mined, stable isotope techniques now exist to study this
issue. Estimated protein requirements for injured
children of various age groups are as follows: 0–2 years,
Rationale
2–3 g/kg/day; 2–13 years, 1.5–2 g/kg/day; and 13–18
Critical illness and recovery from trauma or surgery are years, 1.5 g/kg/day.
characterized by increased protein catabolism and turn- Once protein needs have been met, safe caloric provi
over. An advantage of high protein turnover is that a con- sions using carbohydrate and lipid energy sources have
tinuous flow of amino acids is available for synthesis of similar beneficial effects on net protein synthesis and
new proteins. Specifically, this process involves a redistri- overall protein balance in critically ill patients. Glucose is
bution of amino acids from skeletal muscle to the liver, the primary energy used by the brain, erythrocyte, and
wound, and other tissues involved in the inflammatory renal medulla and is useful in the repair of injured tissue.
Downloaded from pen.sagepub.com at International Islamic University Malaysia on February 15, 2012
10. 268 Journal of Parenteral and Enteral Nutrition / Vol. 33, No. 3, May/June 2009
Glycogen stores are limited and quickly depleted in illness generally restricted to a maximum of 30%–40% of total
or injury, resulting in the need for gluconeogenesis. In calories, although this practice has not been validated by
injured and septic adults, a 3-fold increase in glucose clinical trials.
turnover and oxidation has been demonstrated as well as
an elevation in gluconeogenesis. A significant feature of
4. Route of Nutrient Intake (Enteral Nutrition)
the metabolic stress response is that the provision of
dietary glucose does not halt gluconeogenesis. Conse 4A) In critically ill children with a functioning
quently, the catabolism of muscle protein to produce gastrointestinal tract, enteral nutrition (EN)
glucose continues unabated, and attempts to provide should be the preferred mode of nutrient pro-
large carbohydrate intake in critically ill patients have vision, if tolerated. Grade C
been abandoned. 4B) A variety of barriers to EN exist in the PICU.
The Surviving Sepsis Campaign has recommended Clinicians must identify and prevent avoidable
tight glucose control in critically ill adults based on interruptions to EN in critically ill children.
results of a single trial that showed decreased mortality in Grade D
critically ill adults randomized to this strategy. Subsequent 4C) There are insufficient data to recommend
studies examining the role of strict glycemic control in the appropriate site (gastric vs post-pyloric/
adults have yielded conflicting results and the incidence transpyloric) for enteral feeding in critically ill
of hypoglycemia in these studies is concerning.39 children. Post-pyloric or transpyloric feeds
Hyperglycemia is prevalent in critically ill children and may improve caloric intake when compared to
has been associated with poor outcomes in retrospective gastric feeds. Post-pyloric feeding may be con-
studies.27,40,41 The etiology of hyperglycemia during the sidered in children at high risk of aspiration or
stress response is multifactorial. Despite the prevalence those who have failed a trial of gastric feeding.
of hyperglycemia in the pediatric intensive care population, Grade C
no data exist currently evaluating the effects of tight
glycemic control in the pediatric age group. Both
Rationale
hypoglycemia and glucose variability also are associated
with increased LOS and mortality, and hence are Following the determination of energy expenditure and
undesirable in the critically ill child.42 In the absence of requirement in the critically ill child, the next challenge is to
definitive data, aggressive glycemic control cannot be select the appropriate route for delivery of nutrients. In the
recommended as yet in the critically ill child. critically ill child with a functioning gastrointestinal tract,
Lipid turnover is generally accelerated by critical the enteral route is preferable to parenteral nutrition (PN).
illness, surgery, and trauma.43 Recently, it has been EN has been shown to be more cost-effective without the
shown that critically ill children do, indeed, have a added risk of nosocomial infection inherent with PN.47,48
higher rate of fat oxidation.44 Thus, this suggests that However, the optimal route of nutrient delivery has not been
fatty acids are, in fact, the prime source of energy in systematically studied in children and there is no RCT com-
metabolically stressed children. Because of the increased paring the effects of EN vs PN. Current practice in many
demand for lipid use in critical illness coupled with the centers includes the initiation of gastric or post-pyloric
limited fat stores in the pediatric patient, critically ill enteral feeding within 48-72 hours after admission. PN is
children are susceptible to the evolution of biochemically being used to supplement or replace EN in those patients
detected essential fatty acid deficiency if administered a where EN alone is unable to meet the nutrition goal.
fat-free diet.45 Clinically, this syndrome presents as In children fed with EN, there are insufficient data to
dermatitis, alopecia, thrombo ytopenia, and increased
c make recommendations regarding the site of enteral
susceptibility to bacterial infec ion. To avoid essential
t feeding (gastric vs post-pyloric). Meert et al examined the
fatty acid deficiency in critically ill or injured infants, role of small bowel feeding in 74 critically ill children,
the allotment of linoleic and linolenic acid is randomized to receive either gastric or post-pyloric
recommended at concentrations of 4.5% and 0.5% of nutrition.49 The study was not powered to detect
total calories, respectively. The provision of commercially differences in mortality. EN was interrupted in a large
available intravenous fat emulsions (IVFE) to parenterally number of subjects in this study and caloric goals were
fed critically ill children reduces the risk of essential met in a small percentage of the population studied. This
fatty acid deficiency, results in improved protein use, unblinded RCT did not show difference in microaspiration,
and does not significantly increase CO2 production or enteral access device displacement, and feed intolerance
metabolic rate.46 Most centers, therefore, start IVFE between the gastric or post-pyloric fed groups. A higher
supplementation in critically ill children at 1 g/kg/day percentage of subjects in the small bowel group achieved
and advance over a period of days to 2-4 g/kg/day, with their daily caloric goal compared to the gastric fed group.
monitoring of triglyceride levels. IVFE administration is Sanchez et al report better tolerance in critically ill
Downloaded from pen.sagepub.com at International Islamic University Malaysia on February 15, 2012
11. A.S.P.E.N. Clinical Guidelines / Mehta et al 269
children receiving early (< 24 hours after PICU admission) population. Consistently underachieved EN goals are
vs late (started after 24 hrs) post-pyloric nutrition.50 Of thought to be one of the reasons for the absence of
the 526 children in their cohort who were deemed to have beneficial effect in multiple studies and meta-analysis of
intolerance to EN, 202 received early post-pyloric the efficacy of immunonutrition in preventing infection.56
nutrition and had decreased incidence of abdominal Awareness of these factors hindering the achievement of
distension. Despite evidence to suggest that it is reasonably EN goals is essential in order to address preventable
tolerated, the routine use of postpyloric feeding in the interruptions in enteral feeding in critically ill children.
critically ill child cannot be recommended. It may be There is not enough evidence to recommend the use of
prudent to consider this option in patients who do not prokinetic medications or motility agents (for EN
tolerate gastric feeding or those who are at a high risk of intolerance or to facilitate enteral access device
aspiration. Postpyloric or transpyloric feeding may be placement), prebiotics, probiotics, or synbiotics in
limited by the ability to obtain small bowel access, and critically ill children.
the expertise and resources in individual PICUs are likely
to be variable. A standardized approach to optimizing
Future Research
benefits and minimizing risks with EN delivery will help
clinicians identify patients who would benefit from small Future studies may be directed at examining methods to
bowel feeding. ensure optimal prescription and delivery of nutrient
Despite the absence of sound evidence to support the intake at the bedside, identifying and preventing common
superiority of one route of feeding over the other, the reasons for avoidable interruptions in nutrient intake,
enteral route has been successfully used for nutrition selection of children at risk of aspiration in the PICU,
support of the critically ill child.51-53 In another unblinded and the role of EN (gastric vs postpyloric feeds) in this
RCT, Horn et al randomized 45 children admitted to subgroup. The advantages of EN in terms of its role in gut
the PICU to receive gastric tube feeding either continu immunity, prevention of PN related complications and
ously or intermittently every 2 hours. The main outcome the cost benefit analysis when compared to PN require
measure examined in this study was tolerance of enteral further evaluation.
feedings. The small sample size and the short observation
period of < 66 hours makes any meaningful interpretation
5. Immunonutrition in the PICU
difficult. However, the number of daily stools, diarrheal
episodes, or vomiting episodes was similar between the 2 Based on the available pediatric data, the routine
groups. Intolerance to enteral feedings may limit intake use of immunonutrition or immune-enhancing
and supplementation with PN may be required. Prospective diets/nutrients in critically ill children is not
cohort studies and retrospective chart reviews have recommended. Grade D
reported the inability to achieve daily caloric goal in
critically ill children.54,55 The most common reasons for
Rationale
suboptimal enteral nutrient delivery in these studies are
fluid restriction, interruptions to EN for procedures, and The use of specific nutrients aimed at modulating the
EN intolerance due to hemodynamic instability. The inflammatory or immune response has been reported for
percent of estimated energy expenditure actually several years. Despite several RCTs employing immunonu
administered to these subjects was remarkably low. In a trition in critically ill patients, a positive treatment effect
study examining the endocrine and metabolic response of of immunonutrition or the use of immune-enhancing
children with meningococcal sepsis, goal nutrition was diets (IED) has not been demonstrated. These studies
achieved in only 25% of the cases.19 Similar observations are flawed by their poor methodology and small sample
have been made in a group of 95 children in a PICU size. The studies were conducted using a variety of nutri-
where patients received a median of 58.8% (range ents in combination that were administered to heteroge-
0%-277%) of their estimated energy requirements. In this neous patient populations. The studies do not allow
review, EN was interrupted on 264 occasions for clinical meaningful interpretation of the safety or efficacy of indi-
procedures. In another review of nutrition intake in 42 vidual nutrients and fail to detect significant differences
patients in a tertiary-level PICU over 458 ICU days, in relevant clinical outcomes. Arginine, glutamine, amin-
actual energy intake was compared with estimated energy opeptides, w-3 fatty acids and antioxidants are some of
requirement.55 Only 50% of patients were reported to the nutrients studied for their immune modulation effects.
have received full estimated energy requirements after a Systematic reviews of immunonutrition studies in adults
median of 7 days in the ICU. Protocols for feeding use of have cautioned against the use of arginine and other
transpyloric feeding tubes and changing from bolus to nutrients due to potential for harm in septic and critically
continuous EN during brief periods of intolerance are ill patients.59 Fish oils, borage oils, and antioxidants
strategies to achieve estimated energy goals in this may have a role in patients with acute respiratory distress
Downloaded from pen.sagepub.com at International Islamic University Malaysia on February 15, 2012
12. 270 Journal of Parenteral and Enteral Nutrition / Vol. 33, No. 3, May/June 2009
Table 5
Clinical Outcomes Associated With Enteral Feeding
Study Population
Year Intervention Sample Clinical Outcome
Grade Outcome Measures Size Results Comments
Meert et al49 Critically ill children (<18yrs) in N = 74 Daily caloric goal achieved was Small number of patients
2004 a PICU significantly lower (p < 0.01) studied.
Level II RCT comparing gastric vs small in gastric group (30 ± 23%) vs Difficult to blind such a
bowel continuous tube feeds small bowel group (47 ± 22%). study at the bedside (due
Percentage of caloric goals Proportion of patients with to need for radiographic
achieved, pepsin positive microaspiration, tube confirmation of
tracheal secretions, and feed displacement, and EN placement of tip of
tolerance (vomiting, diarrhea intolerance were similar enteral access device).
or abdominal distension) were between the 2 groups. Fairly high number of
the main outcome variables. subjects in the study
experienced EN
interruptions and percent
of caloric goals met was
low in both groups.
Horn et al57 Children < 18y in a PICU with N = 45 Number of stools/d (1.5 vs 1.6), Small number of patients
2003 EN mean episodes of diarrhea/d studied.
Level II RCT comparing gastric EN (0.32 vs 0.64), mean number The duration of study was
administered either of vomiting episodes/person too small to detect
continuously or every 2 h (0.64 vs 0.22) were similar meaningful differences—
Tolerance—number and type of between the continuous and median 64.5 and 66
stools, diarrhea and vomiting intermittent gastric fed group. hours for the 2 groups.
De Oliveira Children in a PICU with N = 55 EN started on day 3 ± 1 and Energy requirements were
Iglesias EN ≥ 2 d maintained for 6 ± 3 d. 71% estimates and not
et al58 Required (estimates) vs received the required calories measured.
2007 prescribed vs. delivered calories (38% of which reached caloric Barriers to EN remain a
Level III were recorded. goal by d 5 of PICU significant challenge to
Variables associated with not admission). Daily average ensuring the delivery of
achieving caloric goals were caloric intake was 60% of prescribed calories to
recorded. required and 85% of patients in the PICU.
prescribed.
Barriers to EN were procedures,
clinical instability, use of
inotropic agents, enteral
access device displacement,
postoperative fasting, and
feeding intolerance
(abdominal distension,
vomiting, and diarrhea).
Sanchez Children over 10 years of age N = 526 Clinical characteristics, nutrients Retrospective cohort
et al50 admitted to a PICU were (202 were delivered and incidence of Children tolerate early
2007 eligible for transpyloric tube fed early) diarrhea were similar in both postpyloric feeds.
Level III placement if they were deemed groups.
to not tolerate enteral feedings Abdominal distension was less
within 24-48 hrs after frequent in early EN group
admission. (3.5%) vs late (7.8%); P < .05.
Tolerance of feeds was compared
between patients started on
transpyloric feeds early (< 24
hours after admission) vs those
started late (> 24 hrs)
Calories delivered, duration of
nutrition, abdominal distension
and diarrhea were recorded.
(continued)
Downloaded from pen.sagepub.com at International Islamic University Malaysia on February 15, 2012
13. A.S.P.E.N. Clinical Guidelines / Mehta et al 271
Table 5 (continued)
Study Population
Year Intervention Sample Clinical Outcome
Grade Outcome Measures Size Results Comments
Rogers Children admitted to a PICU N = 42 Patients received 37.7% (median) of PICU patients, especially
et al55 with length of stay >3 d (18 Cardiac their EER. cardiac surgical patients,
2003 and EN intake surgical) Cardiac surgical patients had lower do not receive their energy
Level III The proportion of patients caloric intake than others. goals. Fluid restriction in
reaching estimated energy Only 52% of the pts received full both groups is the major
requirement goals was energy intake goal at any time reason for inability to meet
recorded. during the PICU stay. Significant energy goals.
weight decrease was noted in Fasting for procedures and
cardiac surgical patients. EN interruptions due to
Major barrier to caloric intake—fluid intolerance were other
restriction barriers to nutrition in
Minor barriers—feed interruption this study.
for procedures and intolerance
Taylor Children admitted to PICU N = 95 59% were fed within 24 hours of Poor % energy intake goal
et al54 with length of stay ≥3 d admission. achieved with EN.
2003 Information on nutrition EN was administered 54% of time. Procedure-related feeding
Level III delivery was recorded. 10% received PN; 9.5% did not interruptions were
receive any nutrition support. significant.
PICU pts received 58.8%, median The study highlights the
(range 0–277%) of their energy need for a proactive
intake goal. approach to bridge the
Energy intake was greater when gap between desirable
supplemented by PN. and achieved nutrient
EN was interrupted 264 times intake.
(mainly for procedures).
For up to 75% of study time,
children had abnormal bowel
patterns. 79% were constipated for
3-21 days. And 43% had diarrhea
of unknown etiology.
EER, energy efficiency ratio; EN, enteral nutrition; PICU, pediatric intensive care unit; RCT, randomized controlled trial.
syndrome (ARDS). Glutamine may have beneficial effects Another small pilot RCT reported improved outcomes
in adults with burn injury and trauma. in children fed with a glutamine-enriched formulation,
The role of immune-enhancing EN in children during although the numbers are too small for meaningful
critical illness has not been extensively studied. Briassoulis conclusions.60 The use of a specialized adult immune
et al reported their results of a blinded RCT in children modulating enteral formula in pediatric burn victims has
admitted to the PICU with expected LOS and need for been associated with improvement in oxygenation and
mechanical ventilation of ≥ 5 d.22 EN was started in these pulmonary compliance in a retrospective review.61
patients within 12 h of admission to PICU. Patients were
randomized to receive either a formulation containing
Future Research
glutamine, arginine, w-3 fatty acids, and antioxidants or
standard age-appropriate formulation. Protocolized increase Future pediatric studies in this field must focus on exam-
in EN ensured that goal feeds were reached by day 4. The ining the effects of single (vs combination of) nutrients,
study did not show any outcome differences in the 25 in large (multicenter) trials, on homogeneous PICU
children in each arm, although authors report a trend populations designed to detect differences in important
toward a decrease in nosocomial infection rates and outcome measures. This approach will ensure that results
positive gastric aspirate culture rates in the treatment arm. allow meaningful inferences to be made about sound
The immunologically active formula used in this study was hypotheses on single immune modulating nutrients and
not specifically tailored for children and transient diarrhea will prevent the current absence of strong conclusions
was noted in children receiving this formula, which had despite a large amount of investment in this area of
a higher osmolarity compared to the control formula. research in adult ICU populations.
Downloaded from pen.sagepub.com at International Islamic University Malaysia on February 15, 2012