P11 - Assessment of Current Practice on Micronutrient Management After Bariatric Surgery in the United StatesLingtak-Neander Chan, PharmD, BCNSP1,2; Mark Mulvaney, PharmD1; Pam Charney, PhD, RD1,2
1Pharmacy, University of Washington, Seattle, WA; 2Nutritional Sciences, University of Washington, Seattle, WA. Introduction: Bariatric surgery procedures facilitate and maintain weight loss by decreasing overall food consumption and/or inducing nutrient malabsorption. Clinically significant micronutrient deficiencies may develop in these patients postoperatively if adequate monitoring and supplementation are not provided. Little information is currently avail-able comparing how different institutions and surgery programs approach micronutrient monitoring and supplementation in bariatric surgery patients. OBJECTIVE: The aim of this study is to assess the current practices in micronutrient monitoring and supplementation among major bariatric surgery programs in the United States. Methods: This study was approved by the Institutional Review Board. A web-based sur-vey consisting of 28 questions was created. These questions addressed the following areas: (i) demographic data of the bariatric surgery center; (ii) overall postoperative follow-up protocol; (iii) monitoring and supple-ment plan for each of the following micronutrients- calcium, iron, vita-min D, folate, thiamin, and cobalamin. Differences in care and monitoring between recipients of Roux-en-Y gastric bypass surgery (RYGB) and adjustable gastric banding (AGB) was also examined. Potential participants of the survey were identified by the information available from the American Society of Metabolic and Bariatric Surgery and American College of Clinical Pharmacy. The programs were then contacted either by telephone or electronic mail, where a web link to the survey was provided. Before proceeding to the survey, all participants read the informed consent statement at the beginning of the survey and agreed to participate. Results: The online survey was conducted between March and June, 2009. Sixty-five programs responded to the survey. Percent of respondents according to geographic location were: Midwestern states 36.7%, Northeast 22.7%, South/southeast 22.7%, and Western region 18.2%. The majority of the respondents performed over 150 cases of RYGB and between 50-100 cases of AGB annually. Postoperatively, monitoring of vitamin D, iron, folate, thiamin, and cobalamin was routinely performed after RYGB in 81%, 90%, 76%, 80% and 91% of the respondents respectively. In contrast, after AGB, these nutrients were only monitored in 64%, 68%, 72%, 56% and 49% of the respondents, respectively. Monitoring schedules varied among programs. With regard to the approaches towards micronutrient supplementation, the daily amount of calcium supplements ranged from 1000 to 2000 mg, with 1200 mg being the most common dose. Calcium citrate is recom-mended calcium supplement of choice in 85% of the respondents. The daily amount of vitamin D supplement ranged from 400 to 2000 IU. The dose of iron supplement ranged from 15 to 65 mg of elemental iron daily. The doses for folate, thiamin, and cobalamin varied depending on the
formulation chosen. The most commonly recommended route of cobala-min supplementation is oral (64%), followed by intramuscular injection (18%). Empirical multivitamin supplementation was initiated pre-operatively in 48.8% of the respondents. Additionally, routine supple-mentation of selenium and zinc was also employed in 55% and 64% of the respondents respectively. Conclusions: Substantial differences in micronutrient monitoring and supplementation practices were observed across institutions. Recipients of RYGB are more likely to receive more frequent monitoring of micronutrients over recipients of AGB.
Body Composition
P12 - Comparison of Ideal Body Weight Equations Using HeightDong Wook Kim, Clinical Fellow; David Seres, Asst. Professor of Clinical Medicine, Director of Medical NutritionMedicine - Division of Preventive Medicine & Nutrition, Columbia University Medical Center, New York, NY. Introduction: Ideal Body Weight (IBW) is used to calculate dosage of many medications and measure obesity and malnourishment. There are various equations used to estimate IBW. Many IBW equations have been published since Broca proposed the first IBW equation in 1873. Most of them, Hamwi, Divine, Miller, Robinson, and the Simple Rule, for example, were based on mathematical derivations of the weights in the Metropolitan Life Insurance Company’s Height and Weight Table (MHWT). There is now one equation based on Body Mass Index (BMI), which was introduced in 2005. (Table 1) Methods: The pur-pose of this poster presentation is 1) to compare the accuracy of using the different IBW equations to estimate the MHWT data and 2) to estimate the closeness of the different IBW equations. More specifi-cally, we compare the most commonly used MHWT based Simple Rule and the most recently published but not as well known BMI based equation against the generally accepted Robinson and Miller equations. Differential analysis of the curves generated by the different equations is used to calculate closeness. Weight and height units in the equa-tions were converted to International Systems of Units (SI). Results: 1) Comparison of Different IBW Equations: The Divine equation is a kilogram version of the Simple Rule, so they are almost identical (Figure1, 2). For Men, calculated IBW using these formulae is below the MHWT lower limit when the height is low in all equations except for Miller. For Women, calculated IBW is below the MHWT lower limit only in the Simple Rule when the height is low. Values from all IBW equations otherwise land within the IBW range of MHWT. However, all but Miller for women begin to significantly underestimate the median for MHWT beginning at approximately the midpoint of height ranges evaluated. 2) Estimation of Closeness of IBW Equations: All MHWT based equations are linear equations while the BMI based equation is a quadratic equation. We compared the closeness of the Simple Rule and BMI-based equations by calculating the dimension between the two equations and the Robinson and Miller equations (Table 2). As a result, the BMI based equation is closer to the Robinson
2S Nutrition in Clinical Practice / Vol. 25, No. 1, February 2010
Table 1Ideal body weight equations using height
Reference Published Year Equation
Broca equation 1873 Men:Ideal Body Weight(kg)=[Height (cm)-100]-([Height (cm)-100]x10%) Women: Ideal Body Weight(kg) = [Height(cm)-100]+ ([Height(cm)-100]x15%) Hamwi equation 1960 Men: Ideal Body Weight (kg) = 48kg + 2.7kg for each inch over 5 feet Women: Ideal Body Weight (kg) = 45.5kg + 2.2kg for each inch over 5 feet Divine equation 1974 Men: Ideal Body Weight (kg) = 50 + 2.3kg per inch over 5 feet Women: Ideal Body Weight (kg) = 45.5 + 2.3kg per inch over 5 feet Miller equation 1983 Men: Ideal Body Weight (kg) = 56.2kg + 1.41kg for each inch over 5 feet Women: Ideal Body Weight (kg) = 53.1kg + 1.36kg for each inch over 5 feet Robinson equation 1983 Men: Ideal Body Weight (kg) = 52kg + 1.9kg for each inch over 5 feet Women: Ideal Body Weight (kg) = 49kg + 1.7kg for each inch over 5 feet Simple Rule Unknown Men: Allow 110lbs for the first 5 feet and 5lbs for each additional inch. Women: Allow 100lbs for the first 5 feet and 5lbs for each additional inch BMI base equation 2005 Men and Women: IBW (kg) = [Height(meter)]^2×22
Table 2Comparison BMI based equation and simple rule
Male (Height: Male (Height: Female (Height: Female (Height: 158cm~192cm) 158cm~192cm) 142cm~182cm) 142cm~182cm)
The closer the numbers are to zero, the closeness of the two equations are stronger.
Figure 1. Comparison of ideal body weight equations for MenMHWTMax* Maximum weight in Metropolitan height and weight tableMHWTMin** Minimum weight in Metropolitan height and weight table
Figure2. Comparison of ideal body weight equations for womenMHWTMax* Maximum weight in Metropolitan height and weight tableMHWTMin** Minimum weight in Metropolitan height and weight table
and Miller equations than the Simple rule. Furthermore, the BMI based equation is closest to the Robinson equation for men. Conclusions: Each equation has its limitations in calculating IBW in extreme cases. All methods become further from median MHWT as the height decreases, but do not differ significantly from one another (Figure 1, 2). Therefore, any one of these equations may be used in estimating IBW.
However, when the closeness of BMI based and the Simple equations were mathematically compared the BMI based equation was closer to the generally accepted standard Robinson and Miller equations. Since the BMI based equation is as easy to calculate as the Simple Rule, the BMI based equation appears to be a good alternative for calculating IBW, especially when SI units are used.
CNW 2010 Nutrition Practice Abstracts 3S
Cancer
P13 - Application Nutritional Support (NS) for Treatment Chemotherapy-Induced Intestinal Failure (CIIF)Anton Snegovoy, Medical oncologist1; Liudmila Manzyuk, Head of department research of new anticancer drugs, with out-patients chemotherapy unit1; Alexander Saltanov, Head of department pediatric ICU2; Vladimir Selchuk, Head doctors of NNBRCRC3
1Research of new anticancer drugs, with out-patients chemotherapy unit, N.N.Blokhin Russian Cancer Research Center, RAMS, Moscow, Russia; 2Pediatric ICU, N.N.Blokhin Russian Cancer Research Center, RAMS, Moscow, Russia; 3Head doctors, N.N.Blokhin Russian Cancer Research Center, RAMS, Moscow, Russia. Introduction: Damage of intestinal epithelium is the most common complication observed in cancer patients receiving chemotherapy (CT) and/or radiation therapy. These clinical manifestations are important factors, which let us to conduct treatment in optimal regimen for the following patients. In accordance with the data obtained from various authors: Scully & Epstein 1996; Sonis et al., 2004; frequency of CIIF may be 40%, whereas it could reach up to 67% in high-dose CT (Wardley et al., 2000). Important significance in the treatment of CIIF pertains to NS. NS may be administered as treatment and as well as prophylaxis. Methods: 31 patients (pts) with metastatic tumor process were included in the study. Out of them: gastric cancer - 11 pts, ovarian cancer - 2, B-large cell lymphoma - 1, colorectal cancer - 12, lung can-cer - 1, pancreatic cancer - 2, Peritoneal tumor - 1, renal carcinoma - 1. The pts were from 39 to 63 years old. (Median age - 50 years). Male - 19, Female - 29. All the pts received chemotherapy (CT) in ambulatory set-ting with taxanes, platinum derivatives, topoisomerase I & II inhibitors, pyrimidine antagonists, thymidylate synthatase inhibitors, anthracy-clines, Mitomymin and others. The number of cycles ranged from 2 to 8 (median - 4,8 cycles). The major clinical manifestations of CIIF were, diarrhea (Gr 1-2), dysphagia (Gr 2-3), meteorism, tenesmus, postpran-dial feeling of ‘discomfort’, decrease of appetite (Gr 1-2), weight loss of 1,5-3 kg during the treatment period, fatigue (ECOG 2). Persistent hypoproteinemia, hypoalbunemia (Gr 1) and lymphocytopenia (Gr 1) were observed in blood analyses. Clinical symptoms and laboratory analyses were evaluated in accordance with NCI CTCAE v.3.0. NS included intake of enteral and sometime add parenteral support with mandatory inclusion of glutamine, omega -3 fatty acid, fibers. NS was chosen depending on the severity of enteropathy. Duration of NS depended on the clinical conditions, not less than 14 days with gradual transition to supportive regimen. Supportive regimen included intake of oral liquid enteral mixtures not less than 1-1,5 L, with a density of 1-1,5 kcal/ml. Results: In 80% of pts, administration of NS allowed us to ameliorate the general status by, 1)increase of appetite to Gr 1, 2) mete-orism, tenesmus, postprandial feeling of ‘discomfort’ decreased to Gr 1, whereas in 3% of pts there was total relief of symptoms. All the pts noted increased physical activity, however not more than ECOG 1 score. In 65% of cases diarrhea was controlled, whereas in 35% diarrhea mani-fested an episodic character with loose stool not more than twice a day. Increase in the level of protein and albumin was noted only in pts receiv-ing NS in full doses - 60%, whereas in the rest 40% of cases, stabiliza-tion in levels of hypoproteinemia and hypoalbuminemia up to Gr 1 were observed. The lymphocytes control was similar with fluctuation of albu-min and protein levels. Conclusions: In CIIF, administration of NS allows us to effectively ameliorate the general status of pts and to con-tinue the necessary chemotherapy.
P14 - Multiple Aversions on Food Sensation, Taste, and Smell in Cancer Patients Receiving ChemotherapyJongjit Angkatavanich, BS(Pharmacy),MS(Nutrition), PhD(Biomedical science)1; Narin Voravud, M.D., Diploma(Medical
1Nutrition and Dietetics Program, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand; 2Oncology and Radiotherapy Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; 3Department of Food Chemistry, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand. Introduction: Disturbed sensation in olfactory and gustatory function during chemotherapy could lead to diminished food intake, weight loss, and malnutrition. The patients whose food preference of hot and spicy food like Thais may severely suffer from strong-taste intolerance as a consequence of chemotherapy. The extent and pattern of smell, taste, and food sensation alterations in cancer patients undergoing chemo-therapy need to be well characterized. This is the first report on the multiple occurrence of taste, food sensation, and smell aberrations in these patients. Methods: Questionnaires addressing changes in smell, taste, and food sensation (hot and spicy, fatty and oily) using visual analog scales along with an in-depth interview were undertaken in patients in chemotherapy daycare unit, King Chulalongkorn Memorial Hospital. Results: Taste, sensation, and smell aversions were investi-gated in 130 cancer patients undergoing chemotherapy, 98 females and 32 males, aged 52.82 +/- 10.89 years, body weight 58.78 +/- 10.67 kg. The patients were diagnosed primarily with cancer of the breast (54.5%), and of the lung (12.4%). Premedication with antiemetics and/or corticosteroids was routinely provided. Taste aberrations occurred in 80.8 % whereas smell abnormality in 47.7 % of the patients. Changes in hot and spicy sensation were reported in 71.5% with 54.7% increasing and to much lesser extent, 10.8% of the patients, with decreasing sensa-tion. Aberration in perception of fatty and oily food was found in 53.1% mostly increasing, 43.8%, and much less decreasing, 3.9% of the patients. The four basic tastes, saltiness > sweetness > sourness and bitterness were aberrant in 46.9%, 40.0%, 33.8%, and 33.1% of the patients respectively in a comparable up/down fashion for salty, sweet, and sour tastes. Bitterness, on the other hand, was reported toward more intense sensation, 19.2% vs 7.0% declining trend. Also of concern were reported taste loss in 26.2% and smell loss in 6.9% of the patients. When all three factors were considered, the food sensation change only, occurred in 11.8%, taste change only, 5.9%, odor change only 0.7%, food sensation and taste changes 19.9%, food sensation and odor changes 12.5%, taste and odor changes 2.2%, and concurrent food sen-sation plus taste plus odor changes 27.9%. Some patients, 4.6% to 6.9%, were unable to rate the taste change occurrence. The patients also reported considerable loss of the pleasure of eating. Conclusions: The dramatic aberration in hot and spicy sensation coupled with increasing intolerance to oily and fatty food will be detrimental to the nutrition status of the patients under chemotherapy especially in Thai patients habituated with strong-taste food. Confused by multiple sensation changes simultaneously presented during chemotherapy, the patients’ quality of life may be hampered. Measures to manipulate and increase food intake need to be explored individually as a diverse pattern of sen-sation change was observed. Otherwise, it will hinder tolerance to che-motherapy and clinical outcomes.
Catheters/Care*Encore Presentation: Association for Vascular Access Conference 2009, PosterP15 - Does Catheter Size Matter? A Retrospective Analysis of PICC Associated Symptomatic ThrombosisLorraine Linford, RN, BS, CNSC1; Jamie Sharp, RN, CNSN1; Scott Evans, MS, Ph.D.2; Tom White, MD4,1; Lindell K. Weaver, MD3
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1Nutrition Support Service, Intermountain Medical Center, Murray, UT; 2Information Systems, LDS Hospital, Salt Lake City, UT; 3Hyperbaric Medicine, Intermountain Medical Center, Murray, UT; 4Shock Trauma ICU, Intermountain Medical Center, Murray, UT. Introduction: Deep vein thrombosis (DVT) is one of the most common adverse events reported with peripherally inserted central catheters (PICC) frequently used for TPN administration. The incidence of PICC related symptomatic thrombosis is reported to vary from 3% to 50%. Attempts at data collection to establish the incidence of PICC symptomatic thrombosis at Intermountain Medical Center (a 432 bed, Level I Trauma Center) were extremely difficult. The PICC team was dependent on notification by nursing or the peripheral vascular lab, and intensive manual surveillance of vascular studies to identify DVT rates. Interdisciplinary partnering with PICC team clinicians, physi-cians, and a medical informaticist led to the development of an auto-mated electronic identification tracking tool providing reliable data. Methods: Data gathering and quality monitoring was accomplished through the clinical computer information system and manual data review. Thrombosis risk factors identified were anatomical vein choice, catheter size and patient demographics. After thrombosis prevalence was determined, practice interventions were implemented by the PICC team regarding vein choice and catheter size at time of initial vascular
assessment. Extensive education of PICC nurses, ICU physicians, and ICU nurses resulted in a practice change of verifying clinical need for each catheter lumen over a mind set of ‘need a triple lumen.’ PICC team also implemented vein measurement requiring that the vein be at least 0.5cm for a triple lumen insertion to be considered. Results: PICC symptomatic thrombosis tracking occurred over 3 years (2006-2008) totaling 5519 PICC insertions. **(insert table here)** Statistical significance was established with size of catheter. Logistic regression was performed on a subset of 2007 and 2008 data with thrombosis as the outcome variable (yes vs. no) and size (4, 5, or 6 Fr), arm (left vs. right), age, vein choice (basilic, brachial, or cephalic) and sex as the predictor variables. Size emerged as the only significant predictor; patients who received size 6 Fr were 2.65 times more likely to get a thrombosis than with a 5 Fr (P = .005). Although not statistically sig-nificant, a greater than 1% decrease in thrombosis was noted when choosing the basilic and brachial veins instead of the cephalic vein. This reduction of thrombosis was deemed to be meaningfully signifi-cant which led to a reduction of cephalic vein usage as a PICC team practice change. Conclusions: PICC catheter size does matter in the development of symptomatic thrombosis. <li> Larger catheter size increased thrombosis incidence <li>Cephalic vein selection tended to increase thrombosis <li>Education of clinicians helped to prevent PICC related thrombosis</UL>< p>
PICC Insertions Total Thrombosis Incidence Incidence by Vein Selection
Incidence by Catheter Size (reverse taper design)
2006 n=1688 60 3.6% Tracking by vein and catheter size began in second year of data collection (2007-2008)
2007 n=1836 62 3.4% BasilicBrachialCephalic
3.2%3.6%4.9%
4 Fr5 Fr6 Fr
0%2.7%7.6%
2008 n=1995 60 3.0% BasilicBrachialCephalic
3.4%2.3%3.4%
4 Fr5 Fr6 Fr
0.6%2.9%8.9%
*Encore Presentation: ASHP Midyear Meeting December 2009-Pending
*Encore Presentation: ASHP Midyear Meeting December 2009-Pending
P16 - Complications Associated with Peripherally Inserted Central Catheters in Hyperemesis GravidarumKajal Patel, PharmD.; Caryn Bing, PharmD.; Kevin Ross, RN, BSN; Penny L. Allen, RD, LD, CNSCNutrition Support, Critical Care Systems, Nashua, NH. Introduction: Controversy surrounds the use of peripherally inserted central catheter (PICC) lines in pregnant patients, with several recent publications reporting significantly high rates of complications. Due to a perceived reluctance of many physicians to use PICC lines in pregnant patients, our organization continues to observe cases when hyperemesis gravidarum (HG) patients are not receiving parenteral therapies as needed per the recommendations in the 2004 American College of Obstetricians and Gynmecologists (ACOG) Practice Bulletin on Nausea and Vomiting of Pregnancy. The objective of this project was to evaluate the complication rates associated with PICC lines in HG patients receiv-ing home parenteral therapies from our organization as part of their peripartum care. Methods: This multi-centered retrospective study reviewed the electronic medical records of women with the treatment
diagnosis ICD-9 code 643.0, hyperemesis gravidarum. Patient selection criteria included those receiving home total parenteral nutrition (HPN), intravenous (IV) hydration, and IV anti-emetics requiring PICC (central line) access for safety and continuity of care. We collected and evaluated specific data to assess the types and frequency of PICC complications encountered in this group of patients, and compared this to the larger cohort of all patients with PICC’s receiving IV therapy when our organiza-tion was providing nursing care. The study reviewed available electronic patient records from a national specialty infusion data base of patients who received services between January 1, 2004 and March 31, 2009. Results: Four hundred and eighty three (483) pregnant patients received IV therapy from our organization during this period. One hundred and twenty eight (128) patients met the study criteria which represented 6946 catheter dwell days. One hundred and fifteen (115) or 89.3% of these patients had no reported complications with PICC access, representing 6738 complication-free dwell days. Thirteen, or 10.2% of the patients with 208 dwell days had complications resulting in documented removal of their PICC lines. Only five patients, or 4% were confirmed complica-tions-- with eight patients or 6.2% having unconfirmed complications. Conclusions: These results demonstrate that HG patients who received parenteral therapy via PICC lines from our organization between 2004
CNW 2010 Nutrition Practice Abstracts 5S
and 2009 experienced a dramatically lower rate of complications than in previously published studies, some which reported as high as 66%. This cohort is significantly larger than previously published reports most of which were hospital based. Hospital based line infection rates usually do not correlate to much lower complication rates experienced in the home setting. This data supports the appropriate use of PICC lines in women who are otherwise healthy pregnant females requiring parenteral manage-ment of HG to meet their nutritional and fluid requirements.
*Encore Presentation: Canadian Society for Clinical Nutrtion (CSCN), May, 2009
P17 - Assessment of Inaccurate Parenteral Nutrition BloodworkLydia Fairholm, RD CNSD; Olivia Saqui, RN BScN; Mary Baun, BSc.Phm; Millie Yeung, MSc.Phm; Gail Fernandes, BSc; Johane Allard, MDUniversity Health Network, Toronto General Hospital, Toronto, ON, Canada. Introduction: During parenteral nutrition(PN), regular monitoring of laboratory blood results is essential. At times, blood samples can be contaminated by PN solution if the proper blood drawing technique is not followed. This can lead to incorrect results such as high glucose and potassium together with low sodium concentrations. This may lead to unnecessary medical interventions to correct these levels. Objectives: To determine the incidence of inaccurate bloodwork and whether this is associated with incorrect blood collection technique. Methods: This was a one year prospective study of PN patients hospitalized at the University Health Network in Toronto. Data was collected from October 1, 2007 to September 30, 2008. PN patients who had sudden unex-plained changes in glucose, potassium and sodium were identified. Demographic data for these patients was recorded. In addition, inter-views with nurses responsible for drawing these blood samples were conducted to determine if the policy for blood collection was followed. Any actions performed because of inaccurate blood results were docu-mented. Descriptive statistics were reported on patient demographics, nursing units, nursing techniques, nursing experience, nursing shift, types of venous access and cost. Chi square tests and one sample t test were used to compare nursing technique. SPSS for Windows was used. Results: Among the 201 patients on PN, 34 patients had 63 incidents of inaccurate blood work. The most frequent problem identified was the failure to stop the PN infusion prior to blood collection. The mean (± SEM) time between the discontinuation of the infusion and the blood collection was 1.86±0.75 minutes. There was a higher occurence of inaccurate blood results by nurses with <10 years nursing experience. Cost of incorrect bloodwork and subsequent interventions over 1 year was CAD$3,480.00. This included nursing time, supplies, repeat labo-ratory work and treatments. Physician time was not monitored. Conclusions: Inaccurate blood results were due to contamination of the blood collection by PN solution. This was associated with an incor-rect blood collection technique by the nurses. This suggests that an institution wide nursing re-education program is required to ensure compliance with current blood collection policy. In addition, the policy need to be amended to include wait time between discontinuing PN infusion and blood collection. This will likely lead to enhanced patient safety and reduced health care costs.
P18 - Tunneled Catheter Exit Site Symptoms, Treatment, and Catheter Outcomes in a Home Parenteral Nutrition PopulationMarianne Opilla, RN, CNSC; John Siepler, PharmD, BCNSP, FCCP; Tom Diamantidis, PharmD; Rod Okamoto, RPh; Reid Nishikawa, PharmD, BCNSP, FCSHPNutrishare, Inc., Elk Grove, CA.
Introduction: Tunneled central venous access devices(CVAD) are com-monly used for home parenteral nutrition(HPN). Exit site symptoms (ESS) such as erythema, tenderness, or drainage can represent infec-tious complications that may ultimately lead to CVAD removal.The aim of this study was to examine a group of HPN consumers for ESS, deter-mine which treatment modalities were successful as evidenced by CVAD salvage, and identify possible risk factors that may lead to CVAD removal associated with ESS. Methods: Data were collected for 42 months from January 2006 to June 2009 by medical record review from one home infusion pharmacy. Age and diagnosis were examined, as well as ESS: erythema, tenderness, drainage, swelling, fever, and skin break-down. Treatment modalities included systemic antibiotics, more fre-quent dressing changes, use of antimicrobial ointments or creams, suture removal, antiseptic patch, and no treatment. Primary outcome was defined as resolved or non-resolved as evidenced by catheter salvage vs. removal. Statistical analysis was done using Student’s t-test and Chi-square with p<0.05 considered significant. Results: Forty-two patients with tunneled CVAD’s reported 71 occurrences of ESS. Fifty-seven(80.3%) ESS resolved with CVAD salvage, while 13(16.9%) had CVAD removal. Catheter removal was required for failed systemic anti-biotic treatment(9), skin breakdown(2), and multiple ESS only(2). One patient did not have resolution, but the CVAD was not removed. No CVAD was removed for catheter related bloodstream infection directly related ESS. The average age was 42 years (range of 9-74 years). Five patients reported swelling in combination with other ESS with 4 result-ing in catheter removal(p<0.001). The most frequent symptom was erythema(71.8%) followed by drainage(62.0%), tenderness(40.8%), swelling(7.0%), fever(2.8%), and skin breakdown(2.8%). Two or more ESS occurred in 43(60.5%) of cases. The most common combination of ESS was erythema and drainage (62.7%) followed by erythema and tenderness (51.1%). Multiple symptoms occurred in 9(64.2%) of the non-resolved cases and 34(59.6%) of the resolved cases(ns). Intravenous antibiotic therapy(36.6%) was the most commonly prescribed treatment followed by daily dressing change(29.6%), ointment or cream applica-tion(22.5%), oral antibiotics(19.7%), no treatment(11.3%), suture removal(7.0%), and lastly antiseptic patch application(4.2%). There was no significant difference in age, primary diagnosis, symptoms (other than swelling), and treatment modality between the resolved vs. non-resolved groups. Conclusions: Problematic ESS are seen in HPN patients with tunneled CVAD’s. Our data demonstrates that most ESS in this cohort resolved with catheter salvage using a variety of treatment modalities. We are unable to determine that one modality is superior to others. Swelling with multiple symptoms was a predictor for CVAD removal. A limitation of this study is that data was collected from the patient’s medical record and symptoms were not actually visualized. Strategies for catheter salvage are vital for HPN patients; therefore, more studies are needed to evaluate successful approaches for ESS management.
P19 - Self Care and Blood Drawing Practices May be Predictors for Central Venous Access Device Longevity in a Home Parenteral Nutrition PopulationMarianne Opilla, RN, CNSC; John Siepler, PharmD, BCNSP, FCCP; Tom Diamantidis, PharmD; Rod Okamoto, RPh; Reid Nishikawa, PharmD, BCNSP, FCSHPNutrishare, Inc., Elk Grove, CA. Introduction: A central venous access device(CVAD) is required for home parenteral nutrition(HPN) administration. Commonly used CVADs for HPN are tunneled catheters, infusion ports, and percuta-neously inserted central catheters(PICC). Consumers may require HPN for many years, so CVAD maintenance is a priority. The aim of this survey was to determine CVAD history and if self care and blood drawing practices in an HPN population affect CVAD longevity. Methods: A multiple choice survey was mailed to all HPN consumers
6S Nutrition in Clinical Practice / Vol. 25, No. 1, February 2010
from one home infusion provider. Questions included years of HPN, number and duration of CVADs, caregiver information, and blood drawing practices. Returned surveys were divided into two groups based on CVAD duration. Group 1 retained at least one CVAD for 0 through 5 years and Group 2 for 6 or more years. Groups 1 and 2 were compared by statistical analysis using Student’s t-test and Chi-square with p<0.05 considered significant. Results: Ninety four surveys were returned. Group 1 and Group 2 had 46 and 48 surveys respectively. Females represented in Group 1 (71.7%) and Group 2 (62.5%). The average age in Group 1 vs. Group 2 was 42 years (range 2-78 years) vs. 51 years (range 17-73 years; p=0.03). The average duration of HPN for Group 1 was 9 years (range 0.5-26 years) vs. Group 2 with 21 years (range 5-34 years; p=0.04). Patients in Group 1 maintained a single CVAD for an average of 2.67 years and Group 2 for 10.58 years (p<0.001). Group 1(65.2%) delivered less self care for infusion related tasks (admixing, connect, and disconnect) than Group 2(91.7%; p=0.002). This was also true for CVAD site and dressing care (58.7% vs. 89.6%; p=0.001). Blood was drawn more often by venipuncture in Group 2 vs. Group 1(72.9% vs. 41.3%; p=0.002). Blood draws via the catheter were more frequent in Group 1 vs. Group 2 (60.9% vs.35.4%; p=0.014). Group 1 had more frequent blood draws than Group 2: weekly(15.2% vs. 0%; p=0.003), and monthly(37.0% vs. 12.5%; p=0.006). Group 2 had more blood draw intervals greater than one month than Group 1(29.2% vs. 19.6%; ns). Conclusions: This survey confirms that patients receiving HPN can maintain the same CVAD for many years. Self care limits CVAD exposure to multiple handlers which may contribute to CVAD longevity. Frequent blood draws from a CVAD may increase incidence of CVAD dysfunction leading to removal. Venipuncture rather than catheter blood draws and less fre-quent lab monitoring are associated with longer CVAD life in this cohort of HPN patients. These factors may be predictors for CVAD longevity.
P20 - Femoral Tunneled Central Venous Catheters for Total Parenteral NutritionMario E. Ferreyra, MD,PhD1,2; Luisa A. Guerrero, RN, Ms1,2; María C. Ocaña, RPharm1,3; Roxana C. Soto, RD1,3
1Nutritional Support Unit, E. Rebagliati Hospital, Lima, Peru; 2Surgery, San Martín de Porres University, Lima, Peru; 3Nutritional Support, Nutrimedic, Lima, Peru. Introduction: When it is not possible to obtain safe central venous access to the superior vena cava or it is no advisable, inferior vena cava(IVC) access, through femoral vein, is an alternative, as a last resort for an interdisciplinary Nutritional Support Team to obtain safe venous access for Total Parenteral Nutrition (TPN). We wished to study our experience with a group of these selected patients. Methods: We retro-spectively studied every Femoral Tunneled Central Venous Catheters(FTCVC) placed under general anesthesia in operating the-atres, between July 2006 and August 2009, for TPN, either, for in-patients of for home TPN. A silicone, 6.5F, one-lumen, dacron-cuff catheter was used in all patients. Placement was confirmed by X ray abdominal film. Every effort was made to place the tip of the catheter in the middle third of IVC. A 30-cm tunnel had an exit site at the outer side of the thigh. Results: Eleven FTCVC were placed at the right lower limb in 10 patients. Range of permanency was of 13 to 165 days with a mean of 63.72 ± 46.4 (1SD) days. Seven out of ten patients were dis-charged with a FTCVC. Four out of ten patients were on Home TPN, range of periods on Home TPN was of 32 to 97 with a mean of 64.25 ± 28.58 days. Three out of ten patients had catheters looked after and patent without Home TPN. Two (2/11) catheters were removed because of sepsis suspicion.Conclusions: As a last resort FTCVC may be useful and life saving under the care of an Interdisciplinary Nutritional Support Team.
Critical Care
*Encore Presentation: AuSPEN ASM, Christchurch October 2009P21 - A multi-centre prospective study of the use of enteral and parenteral nutrition in severe acute pancreatitis patients in Australia and New ZealandAndrew Davies, MBBS, FRACP, FJFICM1,2; Emma Ridley, BNutrDietet1,2; Siouxzy Morrison, BNursing, GradDip CritCare, MPH1; Kerry McIlroy, BHSc3; Merrilyn Banks, Bsc, GradDipEd, GradDip NutrDietet, MHSc, PhD4; Jamie Cooper, BMBS, FRACP, FFARACS, FANZCA, FFICANZCA, MD, FJFICM1,2; Gil Hardy, PhD FRSC5; Andrew Thomson, MBBS, MRCP, FRACP6
1Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; 2Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia; 3Department of Nutrition and Dietetics, Auckland and Starship Hospitals, Auckland, New Zealand; 4Department of Nutrition and Dietetics, Royal Brisbane & Women’s Hospital, Brisbane, QLD, Australia; 5Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; 6Gastroenterology and Hepatology Unit, The Canberra Hospital, Canberra, ACT, Australia. Introduction: Nutrition Therapy (NT) is now considered to be an important component of treatment in severe acute pancreatitis (SAP). Despite this, there is significant variation in guidelines in this area and very limited data exists concerning what actually occurs in clinical practice. Our objective was to determine the current NT practices of patients with SAP in Australasia with particular focus on the choice of enteral nutrition (EN) or parenteral nutrition (PN). Methods: A pro-spective observational multi-centre study was performed in 40 sites in Australasia over 6 months during 2008. Patients were enrolled if they were admitted to the ICU or high dependency unit with a provisional diagnosis of acute pancreatitis. Those with chronic pancreatitis were excluded. The primary outcome measure was the proportion of days patients received NT. Statistical analysis was descriptive with normally distributed outcomes reported as means. Results: Of 121 patients enrolled, 117 were analysed. The mean age was 61 years and males were more common (53%). EN was delivered to 58 (50%) and PN to 49 (42%) patients overall. PN (59%) was more commonly used as the ini-tial mode of NT than EN (41%). The most common reason recorded for use of PN was the treating doctor’s preference. EN was delivered on 77% and PN on 41% of the total of 1184 days of NT. The overall pro-portion of target volume received was 75% for patients who received EN and 79% for PN. We observed a trend that those who received PN had a higher hospital mortality rate than those who received EN (28% v 7%, p=0.06).Conclusions: The nutritional management of SAP in Australasia varies considerably and does not conform to the growing evidence favouring EN. EN was used most commonly throughout the study period, however PN was the most common initial mode of NT. Patients who received NT by either route achieved similar targets but those who received PN may have had higher mortality rates. Improved education regarding current clinical practice guidelines for NT in patients with SAP is required.
*Encore Presentation: AuSPEN ASM, Christchurch October 2009
P22 - A multi-centre prospective study of the route and substrate of nutrition therapy in severe acute pancreatitis patients in Australia and New Zealand
1Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; 2Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia; 3Department of Nutrition and Dietetics, Auckland and Starship Hospitals, Melbourne, New Zealand; 4Department of Nutrition and Dietetics, Royal Brisbane & Women’s Hospital, Brisbane, QLD, Australia; 5Faculty of Medical and Health Sciences, University of Auckland, Auckalnd, New Zealand; 6Gastroenterology and Hepatology Unit, The Canberra Hospital, Canberra, ACT, Australia. Introduction: Nutrition Therapy (NT) is now considered to be an important component of treatment in severe acute pancreatitis (SAP). Despite this, there is significant variation in guidelines in this area and very limited data exists concerning what actually occurs in clinical practice. Our objective was to determine the current NT practices of patients with SAP in Australasia. In this report we focus on the route and substrate of NT delivery. Methods: A prospective observational multi-centre study was performed in 40 sites in Australasia over 6 months during 2008. Patients were enrolled if they were admitted to the ICU or high dependency unit with a provisional diagnosis of acute pancreatitis. Those with chronic pancreatitis were excluded. Outcome measures included mode of delivery, substrates administered, and number of days where nutritional support was interrupted. . Statistical analysis was descriptive with normally distributed outcomes reported as means. Results: Of 121 patients enrolled, 117 were analysed. The mean age was 61 years and males were more common (53%). EN was delivered to 58 (50%) patients and in these, gastric and small bowel tubes were present in 78% and 41% respectively. PN was delivered to 49 (42%) patients and it was combined with EN for 28 (57%) of those patients. Combined EN and PN was delivered on 174 (14%) of the of total NT days. The EN product was more frequently polymeric (90%) than semi-elemental (7%) or elemental (3%). No EN or PN products contained supplemental glutamine or selenium. Four (3.4%) patients received probiotics. EN was interrupted on 349 (38%) days most com-monly for tube dislodgment (16%, 51 days) and the requirement for a procedure outside of ICU (16%, 51 days). Conclusions: The nutri-tional management of SAP in Australasia varies considerably with EN being used in only 50% of all patients. A polymeric enteral product delivered by a gastric tube was the most common feeding method. Surprisingly, EN was not uncommonly supplemented with PN and PN was the only form of NT in 42% of cases. There was infrequent use of semi-elemental products, supplemental glutamine, selenium or probi-otics. EN was commonly interrupted because of tube dislodgement and procedures.
P23 - Use of an Armband Device to Assess Energy Expenditure in ICU Patients: New Device or New Bluff?Sergio Pastò, MD, Chief of Dietetics & Clinical Nutrition Unit1; Pasquale Di Biase, MD, Vice Chief of Dietetics & Clinical Nutrition Unit1; Mariangela Chelucci, MD1; Maria Carmela Celi, Dietician1; Anna Maria Di Brino, Dietician1; Pasquale Savarese, Dietician1; Romeo Flocco, MD2; Giovanni Di Iorio, MD, Chief of Anesthesiology & ICU2
1Dietetics and Clinical Nutrition Unit, Regional Hospital A.Cardarelli, Campobasso, Italy; 2Anesthesiology and Intensive Care Unit, Regional Hospital A.Cardarelli, Campobasso, Italy.
Introduction: Estimating energy needs is the first and most important part of a nutritional intervention. Indirect calorimetry represents the most reliable method, but it demands equipment not always available and in any case the measured energy requirement is referred only to a small fraction of time. In order to try to obtain longer measurements in dynamic conditions, various low cost, small and light weight devices have been invented which use a “Holter” method. According to manu-facturer’s statement, one of these armband devices (SenseWear Armband-SWA) collects and memorizes a variety of physiologic data through multiple specific sensors: (1) movements by a 2-axis microelec-tronic mechanical sensor, (2) heat flux by a thermocouple array, (3) skin and near-body ambient temperature by temperature sensor, and (4) galvanic skin response (an indicator of evaporative heat loss) by 2 hypoallergenic stainless steel electrodes. While through the use of a specific software, physiologic body signals are then integrated to accel-erometry data and used, in combination with free-living activity recog-nition patterns, to calculate energy expenditure (EE) according to specific algorithms. In order to evaluate if the SWA measures the actual REE in conditions of inactivity, we tested it in patients with known variable and metabolic instability as those in the ICU. Methods: 20 critically ill pts underwent REE measurements with each of the fol-lowing methods: indirect calorimetry (IC) [CCM Express, Medica Graphics Corporation, St. Paul, MN, USA], armband device (SWA) [SenseWear®, BodyMedia Inc., Pittsburg, PA, USA], and Harris-Benedict equation (HB). Measurements were confronted using statisti-cal analysis (Bland-Altman plots, simple correlation model and Deming regression). All statistical analyses were performed by MedCalc for Windows (Medcalc Software, Mariakerke, Belgium). Results: The Bland-Altman plots revealed significant differences between REE esti-mated by SWA and IC showing a poor correlation (r= -0.53; p= 0.017) with a significant bias (BIAS = -194.9; p-value 0.02868057) with a systematically tendency of SWA values inferior to IC. Similarly, the Bland-Altman plots revealed significant differences between REE esti-mated by HB and IC showing a poor correlation (r= -0.51 p= 0.021) with a strong significant bias (BIAS= -429,05; p-value 0,507931). Comparing SWA with HB, the Bland-Altman plots revealed no signifi-cant differences, with a very high correlation (r=0,9733; P<0,0001) (see fig.1, 2 and 3) and a bias correction factor C (accuracy) = 0,9999. Conclusions: Our data shows that there are no significant differences between SWA and HB, in fact SWA gives values of REE nearly equal to those obtainable with the HB equation, in each patient and in every metabolic conditions. For us, it means that SWA does not use any of the other parameters declared by the manufacturer to measure REE and the “specific algorithms” is only a mere equation. Furthermore, SWA shows a scarce correlation with IC.
Figure 1. Bland and Altman plot
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P24 - Energy Expenditure in Patients with Traumatic and Non-Traumatic Brain Injury Measured by Indirect Calorimetry.Amy Berry, MS, RD, CNSD; Ron Neyens, PharmD, BCPS; Julio Chalela, MDDepartment of Neurosciences, Medical University of South Carolina, Charleston, SC. Introduction: The Brain Trauma Foundation Guidelines state that energy expenditure in brain injury patients can range from 120 - 250% of the BEE. As it is well documented that TBI causes a significant increase in REE, less is known about the effect of non-traumatic inju-ries such as SAH and ICH. All brain injury patients have other variables occurring that affect REE including: extreme sedation and paralysis, escalating intracranial pressures, induced hypothermia, surgeries including craniotomy or craniectomy, among other factors. The objec-tive of our quality improvement measure was to ensure appropriate feeding in our Neurosurgical ICU by changing our standard of care to administering weekly metabolic cart studies in all critically ill traumatic and non-traumatic brain injury patients from the time of admit through the first weeks in the ICU. Methods: All intubated TBI, SAH, or ICH patients admitted under the Neurosurgical ICU service had a metabolic cart weekly. Data pertinent to potential alteration of caloric needs was noted including: craniectomy/craniotomy, clipping, coiling, diprivan/barbiturate use and induced hypothermia. Results: Metabolic carts
were conducted in 20 patients, of which 5 were TBI patients and the remaining were non-traumatic injury patients; 4 with SAH and 11 with ICH. Patients ranged in age from 17-91, with the median age of 59. BMI ranged from 20-61.5, with a median of 25.5. Sixteen of the patients were male and four were female. Week one, in the non-trau-matic injury group, MEE ranged from 1488-4015 kcals/d with a median of 2526 kcals. Calories per kg ranged from 24-40, with a median of 29 kcal/kg. In this group, 10% were post-coiling, 27% were post-craniectomy, 15% had hydrocephalus, and 15% were on diprivan. In the traumatic injury group, MEE ranged from 2288-3259 kcals/d, with a median of 2568 kcals. Calories per kg ranged from 28-47, with a median of 35 kcal/kg. In this group, 60% were post-craniectomy and 40% of patients were on diprivan. Eight patients received a metabolic cart study the second week of admission. Week two, in the non-traumatic injury group, MEE ranged from 2132-3631 kcals/d, with a median of 3079 kcals. Calories per kg ranged from 27-49 kcal/kg, with a median of 34 kcal/kg. In this group, one patient had ongoing sympathetic storming and he expended 34 kcal/kg. Only one TBI patient received a metabolic cart during the second week. Conclusions: Major limitations included that this was a very small quality improvement measure that did not include enough patients to achieve clinical or statistical significance. We noted that the non-traumatic brain injury patients seemed to have equivalent caloric needs compared to the TBI patients, and furthermore, energy expenditure increased in the second week. Future research could include a study investigating the impact of interventions and complica-tions on energy expenditure in the neurosurgical population. It would also be interesting to compare the metabolic cart data to predictive equations to assess if one equation is superior in this specific popula-tion. Lastly, the most pertinent study would investigate whether deliver-ing 100% of energy needs based on metabolic cart studies improves patient outcomes.
P25 - Nurses Perceptions of Nutrition Training and Education for the ICU EnvironmentCathy Alberda, MSc, RD; Gwynne MacDonald, RN, MN; Leah Gramlich, MDRoyal Alexandra Hospital, Edmonton, AB, Canada. Introduction: ICU patients who receive less nutrition are more likely to experience adverse events (increased mortality, increased length of hos-pitalization). Despite evidence-based clinical practice guidelines (CPGs) for nutrition therapy in the ICU, delivery of optimum nutrition provisions remains difficult to achieve. Nursing practices impact success or failure of nutrition therapy in the ICU. Methods: An informal focus group was conducted with eight critical care nurses who had < 1 year to >20 years critical care experience. The goal was to identify barriers, knowledge and practice gaps in nutrition practice of ICU nurses, and ultimately to identify nursing strategies to improve nutrition delivery in the ICU. The 45 minute session was conducted by the ICU dietitian and the clinical nurse specialist. The ICU nurses were asked to discuss the following questions in an open format: 1.)What is your role with respect to nutri-tion in the ICU patient? Identify the knowledge, skills and attitudes an ICU nurse should have for nutrition therapy. 2.)What are your biggest challenges with respect to delivery of nutrition to the ICU patient? 3.)Are there any gaps in your nursing training, with respect to nutrition therapy? Can you think of any strategies to address the gaps? The infor-mation was gathered and analyzed using a framework developed by N.Cahill to understand barriers/challenges in adhering to nutrition clinical practice guidelines. Results: See Table Conclusions: Five strat-egies were identified by the critical care nurses to enhance nutrition practice: 1. engaging formative nursing programs to address knowledge gaps especially around outcomes related to nutrition; 2. developing “clinically credible” nursing resource experts to facilitate ongoing educa-tion in the ICU; 3. more input of critical care nurses to development of
Figure 3. Deming regression
Figure 2. Linear regression
CNW 2010 Nutrition Practice Abstracts 9S
feeding guidelines; 4. addressing topics pertinent to nursing nutritional management issues (i.e. skin breakdown, GRV’s) and 5. improving orga-nizational characteristics of the ICU team to improve interdisciplinary communication.
P26 - Managing an Ornithine Trans-Carbamylase (OTC) Deficiency Crisis in an Adult Patient: A Novel Team Approach
1Clinical Nutrition Support, Hospital of the University of Pennsylvania, Philadelphia, PA; 2Department of Nursing, Hospital of the University of Pennsylvania, Philadelphia, PA. Introduction: A thirty-seven year old woman from a referring facility with a history of OTC deficiency presented with fulminant hepatic encephalopathy associated with a sharp increase in serum ammonia concentration after initiation of intravenous steroids for bronchial asthma. An interdisciplinary approach was necessary for the emergent medical and nutritional management of this complex patient. At our urban academic medical center, team communication, systemic coordi-nation of supplies and resources and expert nutrition support service consultation resulted in the successful management of this rare patient condition. Methods: Neurocritical Care: Traditional therapies designed to reduce intracranial hypertension were implemented in this unique case. Initially, intracranial pressure monitoring (ICP) and intracerebral brain tissue oxygen monitoring (PbtO2) devices were inserted revealing high ICP with normal brain tissue oxygenation. Per protocol, hyperos-molar therapy that included intravenous mannitol and hypertonic saline administration were initiated. In a stepwise progression, multiple medi-cal modalities were implemented to reduce this patient’s intracranial hypertension including intravenous sedation and pain control measures; induced therapeutic hypothermia; and nursing measures including head of bed elevation and body positioning. Ultimately, medical measures to reduce this patient’s ICP were ineffective and the patient underwent a bifrontal craniectomy to definitively reduce the intracranial hyperten-sion. Over the next month, these neurocritical care therapies were continued in order to sustain a reduced ICP and prevent secondary brain injury related to perfusion and pressure. Nutrition Support: Severe hyperammonemia was initially treated with continuous renal replacement therapy (CRRT). Sodium phenylacetate/ sodium benzoate
(Ammonul®) and intervenous arginine were used in conjunction with CRRT to maximize decreasing serum ammonia levels. During this criti-cal therapeutic intervention, special attention was placed on nutrition support to assure the patient did not enter a catabolic state, and thus further increase ammonia levels. An indirect calorimetry study was per-formed to assess true metabolic demand in conjunction with hypother-mia therapy and continuous sedation. Balancing cerebral perfusion and metabolic demand required vital communication across all disciplines to assure the provision of nutrition for this patient. A wide range of nutri-tion therapies, ranging from intravenous lipid and glucose infusions, an enteral formula containing only essential amino acids, to eventually an oral diet with minimal protein, was used during a six month hospital admission. Results: Throughout the hospital course, the critical care management for acute hepatic encephalopathy with intracranial hyper-tension was conjoined with an innovative nutritional management plan; these plans required daily collaboration with physicians, nurses, phar-macists and clinical nutrition support experts for successful implemen-tation and communication. This patient survived this event and was eventually discharged to home, tolerating an oral diet. Conclusions: Successful implementation of a complex nutritional management strat-egy is achievable and necessary when patients require such treatment.
P27 - A Quality Improvement Project for Nutrition Therapy in Critically Ill VeteransLin H. Shu, MS, RD, CNSD; Mary Mancini Chew, MS, RD, CSO, CNSDClinical Nutrition, Phoenix VA Health Care System, Phoenix, AZ. Introduction: The Canadian Nutrition Support Practice Guidelines for Nutrition Support in Mechanically Ventilated Critically Ill Adult Patients (CPGs) were published in 2003 to provide guidance for the improvement of nutrition therapy in Intensive Care Units (ICUs). The Nutrition Support Team at the PVAHCS participated in the Clinical Evaluation Research Unit international nutrition survey in 2008, to compare nutrition therapy in the ICU setting within the U.S. (sister sites) and across the world (all study sites) as compared to the CPGs. Additionally, to identify areas of deficiency and plan for improvement. Methods: Veterans that were mechanically ventilated within 48 hours of ICU admission, and who stayed in the ICU ≥ 72 hours were enrolled in the study. Hospital and ICU demographics, veteran’s baseline infor-mation, nutrition assessment, nutrition delivery and outcomes were
Nursing knowledge and skills with strategies to enhance nutrition practice
Content (knowledge)
General Knowledge -nutrition risk assessment -relationship between nutrition therapy and outcome -timing -route -nutritional deficiency
EN -maximize benefit; start early; achieve target -minimize harm: techniques to prevent aspiration -managing complications: diarrhea, skin breakdown, high GRV’s -disease/patient specific considerations
PN -maximize benefit: optimal nutrition -minimize harm thru glycemic control and central line care -disease/patient specific considerations
Outcome
-integration of nutrition content in ICU nursing training -positive attitudes regarding role of nutrition therapy in ICU -proactive, engaged learners -improved adherence to CPGs
-increased nursing awareness regarding benefit/harm of nutrition -CPGs address key questions and guide nursing decisions
-increased nursing awareness regarding benefit/harm of nutrition -evolution of CPGs to meet nurses needs
Strategies
-nursing resource experts for managing complications of nutrition -develop standard tools for orientation regarding nutrition -understand institutional characteristics that influence CPG adherence -electronic communication/education modalities
-detail EN feeding optimization strategies -refine protocols to meet nursing needs and address management of complications -prioritize and undertake research nursing in areas relevent to nurses
-understanding of protocols based on best-evidence (i.e. optimal glycemic control)
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entered into a secure website and compared with sister sites, all study sites and CPGs. Results: Eighteen overweight male veterans with a medium age of 61 years were enrolled in the PVAHCS. The median prescribed energy and protein for the veterans were similar to that of the sister sites and all study sites (22.2kcal/kg, 1.2gm protein/kg). By the 3rd ICU day, veterans received 15% more total calories, 10% more total protein than those of all study sites, and 8% more Enteral Nutrition (EN) than those of all study sites. During 12 days of ICU, total nutrition (total calories/protein) delivered to veterans were 62% / 53.8% compared to 53.3% / 49.7% at sister sites, and 61.4% / 58% at all study sites. Total nutrition and EN delivery declined on the 7th, 10th and 12th ICU day because of EN intolerance and procedures interrupted EN. The mean full time equivalent (FTE) dietitian per 10 beds in the PVAHCS was 0.5 compared to 0.4 in the sister sites and all study sites. The PVAHCS practice was in line with the CPGs; 72% of nutrition therapy was provided by EN and 60% of EN was delivered via small bowel feeding. Only 50% of veterans received early EN (within 48 hours of ICU admission). The median length of mechanical ventilation was 3.3 days, ICU stay was 8.9 days, hospital stay was 18.1 days, and 60 day mortality was 27.8%. Conclusions: The PVAHCS has a slightly higher dietitian FTE in our ICU and delivered more nutrition to the veterans by the 3rd ICU day. However, the total nutrition delivery was similar to that of all study sites during the 12 ICU days. The primary cause of decreased nutrition delivery was the interruption of EN by EN intolerance and medical procedures. The main reason delaying early EN may be a lack of knowledge by medical residents. The Apache II score was higher among veterans. ICU length of stay, mechanical ven-tilation days and hospital length of stay were shorter than those of all study sites. However, the 60-day mortality rate was similar. The study will be repeated this year.
Diabetes Mellitus
P28 - Evaluation of efficacy of a specialized product for enteral nutrition “Glucerna SR” in patients with type 2 diabetesKhayder K. Sharafetdinov, Institute of Nutrition RAMSDept. of metabolic diseases, Institute of nutrition of RAMS, Moscow, Russia. Introduction: Short-term use of diabetes-specific nutritional supple-ments as an integral component of medical nutrition therapy can sig-nificantly lower postmeal glucose levels and area under the glycemic curve. Methods: Evaluation of dynamics of the postmeal glycemia in patients with type 2 diabetes was carried out in the form of an open-label, double-group, parallel study. Thirty four patients with type 2 diabetes were recruited from our in-patient clinic. In the main group patients, the level of glucose in capillary blood was examined before the meal (fasting) and for 240 min (30, 60, 90, 120, 180 and 240 min) after consumption of 230 ml of the product containing 10.7 g of pro-tein, 7.8 g of fat and 26.0 g of carbohydrates. In patients from the comparison group, the evaluation of the postmeal glycemia was carried out after their consumption of 27 g of wheat bread, 4.5 g of butter and 250 ml of drinking sterilized milk with 1.5% fat content. Results: Consumption of the product was accompanied by a significantly lower increase of glycemic level in 30 min after the beginning of study, as compared with standard meal load (on average, by 20.1% and 27.8% from the baseline, respectively, p<0.05). In 60 and 90 min after con-sumption of this specialized product, increase of blood glucose level was also lower than that after standard meal load.The area under gly-cemic curve upon consumption of the specialist product was signifi-cantly lower than that upon standard meal load (236.5±26.7 mmol/L×min versus 352.7±41.2 mmol/L×min, p< 0.05). Conclusions: Evaluation of the postmeal glycemia and areas under glycemic curves in patients with type 2 diabetes has shown a smaller postmeal glycemic
reaction upon consumption of the product as compared with standard meal load.
Enteral Nutrition
P29 - Enteral Nutrition Usage Data Base: Initial Two Year AnalysisJulie Sanborn, MS, RD, CNSC; Kalman E. Holdy, MD, ABPNSClinical Nutrition, Sharp Memorial Hospital, San Diego, CA. Introduction: Enteral nutrition (EN) is the preferred form of special-ized nutrition support for patients who cannot eat but have a function-ing GI tract. Yet little attention is given to the systematic analysis of EN usage statistics compared to parenteral nutrition. In March 2007 our Nutrition Metabolic Support Service created an EN usage data base. The purpose of this report is to demonstrate the structure of the data-base and to present our initial application of EN statistics. Methods: Using Microsoft Access 2003 a data base was created with an input form, including ordering MD, dates, EN days, initiating RD, unit, dis-charge status, outcome, EN formula, nutrition assessment by subjective global assessment(SGA), acuity, and comments. March-June 2007 was a development period. A single RD was assigned to enter data and main-tain the data base. Data was analyzed using the Access query feature comparing 7/2007-6/2008 to 7/2008-6/2009. Results: The data base currently contains 1854 patients representing 24,129 EN patient days. EN usage increased 53% (Table 1), an increase of 320 patients. Almost half of the increase was in the ICUs. The single unit specific increase was largest in the SICU. EN patients increased from 55 to 80 per month. EN days per patient (average 13 days per patient), the initial EN formula selection (Figure 1), and outcomes (Figure 2) were similar in the two periods. Short term EN (≤ 3 days) accounted for 11% of the patients and of these 1/5 were discharged with an oral diet. About 70% of the short term EN patients were not in the ICUs (Table 2). About 6% of the patients were severely malnourished while about 66% were well nourished (SGA). Conclusions: Tracking EN usage can identify hospi-tal wide trends in EN, facilitate RD staff allocation based on EN usage, and assist with staffing justification. Our increase in SICU EN has sup-ported 8 additional RD hours/week. We were surprised that 10% of the patients received enteral nutrition for ≤ 3 days. Such short term EN may not be beneficial and pose avoidable risk, e.g., avoidable feeding tube placements. We now plan to prospectively analyze the characteristics of short term EN.
Table 1Increase in Enteral Nutrition Patients.
SICU MICU Oncology Rehab Other
Unit 40% 16% 33% 22% 45% BasedHospital 32% 12% 5% 3% 48% Based
Expressed per unit total or per hospital total. “Other” includes multiple units which could not be compared due to our move to a new facility in January 2009.
P30 - Advances in Feeding Tube TechnologyGerald Moss, MD, PhD, FACN, FCCMBiomedical Engineering Department, Rensselaer Polytechnic Institute, White Plains, NY. Introduction: Background: Nasoenteric feeding requires transgastric placement of a catheter, whose o.d. is limited to approximately 19 Fr (6.33 mm) by the anatomy of the nasal passage. Requiring a second channel to aspirate swallowed air and excess liquid would further reduce each lumen’s useful bore size. An all-plastic feeding catheter with a 6 mm i.d. is commercially available. A wall thickness of 0.067” currently is provided to prevent kinking, for an o.d. of 9.3 mm (28 Fr). Liquid flow is proportional to the fourth power of the lumen diameter. The likelihood of mucus or particulate occlusion cannot be so simply defined, but the non-linear relationship to bore size may be of similar or even greater magnitude. Transgastric positioning of the catheter into the intestine requires expensive and time consuming manipulation that may involve X-ray, complex endoscopy, exchanges over guide-wire, etc. Objective: We wanted to design a catheter that would have an FDA approved biocompatible interface with the patient’s mucosa, could fit as a sheath over the currently available 5 mm nasal gastroscopes, yet have an o.d. no larger than approximately 19 Fr and be kink resistant. Methods: We started with the softest available polyurethane tubing to serve as the external surface of the catheter we were constructing. It has a 0.004” wall thickness. Kink resistance was provided by a 0.004” thick coil spring band of stainless steel as an internal “stent.” The total composite wall thickness was only 0.008”. It has an external diameter
of <6.3 mm (<19 French), yet it has an inner diameter of 6 mm. This provides the minimum required clearance for delivery over a 5 mm nasal gastroscope that is 1,100 mm long. It allows safe and rapid inser-tion into the distal duodenum under direct vision, without the need for Seldinger technique exchange over a guide-wire. Our catheter required dual lumens for both feeding and decompression. A 6 mm i.d. re-enforced wall tube was delivered into the duodenum to serve as the aspiration channel. The gastroscope was removed, and a second fine feeding catheter (0.07” i.d.) was easily passed co-axially. This feeding tube extended 5 mm beyond the end of the aspiration tube, into the slightly more distal duodenum. Results: The ultra thin-walled feeding-decompression catheter was utilized without anesthesia in a dozen critically ill patients in need of enteral nutrition. There were no com-plications attributable to the construction of the catheters or its place-ment. There was no occlusion of the “oversized” channels, and the entire placement process averaged about 5 - 10 minutes. Conclusions: The wall thickness of feeding tubes can be reduced without compro-mising function. Kink resistance can be regained by an internal stain-less steel spring “stent.” For all lumen diameters, reducing the overall size will benefit patients by decreasing trauma and discompfort. The patient might be better served if this advance in technology were employed to increase the i.d. of the catheter lumen(s). An apparently small increase in the diameter of the channel leads to, literally, an exponential increase in flow and occlusion resistance. A <19 Fr cathe-ter can have the same size lumen and function as a conventionally constructed 28 Fr catheter. Enteral feeding catheters can safely and quickly be positioned over the currently available nasal gastroscopes under direct vision and without requiring the manipulation of a Seldinger type exchange over a guide-wire.
*Encore Presentation: Support Line. 2009;31(3);3-8.P31 - Nutritional Management of Chyle LeaksEva Annelie M. Vogt, MS, RD, LD, CNSD1,2; Rebecca Brody, MS, RD, CNSD1
1SHRP, University of Medicine and Dentistry of New Jersey, Newark, NJ; 2Pharmacy/Clinical Nutrition, Washington Hospital Center, Washington, DC. Introduction: Chylous leakage due to lymphatic injury is a relatively uncommon condition that can present post cardiothoracic surgeries, head and neck dissections, malignancies, trauma, lymphatic anatomic anomalies, and cirrhosis. Chyle is contained in the lymphatic system with chylomicrons, triglycerides, lymphatic fluid and fat-soluble vita-mins. Approximately 70% of ingested long-chain triglycerides are absorbed via the lymphatic system and 2-3 hours after a fatty meal, lymph flow can increase from 1-200 mL/min. When the lymphatic sys-tem is damaged, a milky fluid can become visible in the area surround-ing the injured vessel and large quantities (up to 2.5 L/day) of long duration (>1 week) can lead to extensive losses of protein, energy, chy-lous fluid, lymphocytes and fat-soluble vitamins; increasing the risk of immunosuppression, pneumonia and sepsis. Resultant metabolic distur-bances can induce hypovolemia, metabolic acidosis, electrolyte imbal-ances and hemodynamic instability. Nutrition management should begin soon after diagnosis and include enteral nutrition with a low-fat or fat-free formula with or without supplemented Medium Chain Triglycerides (MCT’s) or NPO with parenteral nutrition (PN). Controversy surrounds which modality is more effective but the consen-sus is that an elemental low-fat enteral or low-fat oral diet should be attempted before PN. Problematic when deciding on a nutritional inter-vention is that available evidence stems from cohorts and case reports and that a mere association exists between dietary fat and onset of symp-toms. Methods: The objective of this case study is to describe the complications and management of chyle leaks and describe optimal nutritional therapy, including the most favorable route of feeding based
Figure 1. Enteral nutrition formula selection. The types of formula selection were unchanged from 2007 to 2009.
Figure 2. The outcome of enteral nutrition patients. Outcomes were similar from 2007 to 2009. (PO and EN, oral or enteral nutrition at discharge; NH, nursing home discharge).
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on available evidence. Results: A 56 year old male with small cell cancer of the tongue is admitted for procedures relating to his cancer, including an esophagectomy and a right neck dissection. After surgery a Jackson-Pratt drain is placed in the chest cavity and about 20 ml of a creamy fluid is noticed with advancement of diet. The output gradually increases to 100 ml over the next 24 hours and a chyle leak is diagnosed (see table). The patient is started on EN using a high nitrogen low-fat formula via a naso-gastric tube while pressure is applied to the neck area in an attempt to seal the fistula. The RD is consulted and places the patient on a semi-elemental, low-fat formula, described as optimal for chyle leak patients. With the change to the low-fat formula, the chyle output steadily decreases and after 5 days the RD suggests attempting a
low fat oral diet. No increase in output is seen, the diet is advanced to a regular diet and the patient is sent home. Conclusions: The literature on nutritional management of chyle leaks is sparse and lack of evidence-based guidelines forces practitioners to make inconsistent decisions based on case reports and small cohort studies. Because only an asso-ciation exists between increased lipid intake and chyle output, treatment focuses on decreasing the amount of chyle and replacing fluid, electro-lytes and other nutrients. Generally, the more severe the chyle leak, the more conservative treatment is in terms of allotment of fat and modality of feeding. Directions for future study would include a multicenter trial comparing EN and PN to ascertain the most favorable feeding regimen and route.
TableJackson-Pratt Output
Consistency Amount of Medium-Chain Long-Chain Day Amount, mL of drainage Color Fat Ingested (g) Triglycerides (g) Triglycerides (g)
1 100 Creamy and cloudy Pink 49 15 332 95 Creamy and cloudy Pink 58 23 343 40 Less milky, still cloudy Tan 58 23 344 25 Clear Straw-colored 58 23 345 Minimal drainage Clear Serosanguinous N/A (oral diet) N/A (oral diet) N/A (oral diet)
*Encore Presentation: As poster presentation at Association of Rehabilitation Nurses 2008 and as a podium presentation at Magnet 2009P32 - Do We Need to Check Gastric Residuals for the Sub Acute Patient?Terri Gately, RN,BS,MS,CRRN; Jorilynn Lima, RN,BS, CRRN; Tina Gonzalians, BSN; Sylvia Pacis, BSNSub Acute, Providence Holy Cross Medical Center, Mission Hills, CA. Introduction: Enteral tubes for feeding are frequently used to maintain the health of chronically ill patients. Nurses check residual volumes of enteral tube feedings believing they decrease the risk of aspiration that can lead to pneumonia, and to monitor gastric emptying. However, there is a lack of evidence to support that monitoring gastric residuals prevents aspiration pneumonia, and no standardized amount of residual that is considered to put an individual at risk. Research has shown that the frequent checking of enteral tube gastric residual volumes is an unreli-able marker of tolerance to enteral feeding. Some of the potential prob-lems associated with monitoring gastric residuals include introduction of infections at the gastrostomy tube site, disruption of caloric intake, and clogging of the tube. To promote evidence-based practice, a retrospective study was conducted in 2007 on our Sub Acute unit, to determine whether residual volumes leading to aspiration pneumonia are a signifi-cant problem in this population. Methods: This project took place in a Sub Acute unit associated with a 250 bed community hospital. A retro-spective chart review of chronically ill patients who had been receiving enteral tube feedings as a means of nutrition was conducted. A total of 10,950 gastric aspirations for residuals from fifteen individual patients over one year were assessed. Variables examined included occurrence of aspiration pneumonia, residual amounts necessitating holding subse-quent enteral feedings, and site infection or tube clogging requiring enteral tube change. To be included in the group of fifteen patients, all participants must have had continuous enteral tube feedings for a mini-mum of one year. The fifteen patients ranged in age from twenty-six to eighty-eight years of age with a variety of chronic illnesses/disorders receiving four different gastric feeding formulas. Results: Gastric aspira-tions for residuals from fifteen individuals over the period of one year, totaling 10,950 aspirations, were reviewed for residual amounts neces-sitating holding subsequent enteral feedings, occurrence of aspiration
pneumonia and site infection or tube clogging requiring enteral tube change. Out of the 10,950 gastric aspirations for residuals from the fif-teen patients in this study, no cases of aspiration pneumonia were found, and no enteral feedings needed to be withheld due to residuals. There were 5 instances of tube clogging or need for replacement, and two instances of gastric tube insertion site infection. There was adequate evidence for eliminating the practice of routine gastric residual monitor-ing. Conclusions: Residual volumes leading to aspiration pneumonia are not a significant problem in our population. Results coupled with previ-ous similar research results indicated that there is adequate evidence for eliminating the practice of routine gastric residual monitoring.
P33 - Preventing Enteral Misconnections in Home CareLorene K. Jansson, RD, CD, CNSD; Susan M. Brand, RD, CD; Sheryl A. Knowles, RN, CRNIWalgreens-OptionCare, Everett, WA. Introduction: An enteral misconnection is defined by A.S.P.E.N. as “an inadvertent connection between an enteral feeding system and a non-enteral system such as an intravascular catheter, peritoneal dialysis catheter, tracheostomy, medical gas tubing, etc.” Patient harm or even death can occur, and have occurred, when enteral formulas, fluids, or medications are inadvertently placed into a nonenteral route (e.g., enteral formula infused into an IV line). Enteral delivery systems include everything from the enteral formula container to the enteral tube itself. These systems are often compatible with IV delivery systems. IV-compatible enteral systems include leur lok connections, leur slip connections and spike tubing. Safe enteral-only systems include feeding tubes with oral hubs that connect only with oral syringes, tubes that use cath tip syringes, and spike systems that are incompatible with IV spike systems. However, adapters are available to make these otherwise enteral-only connections dangerously compatible with IV systems. Home care patients receiving dual therapies (e.g., enteral and IV thera-pies) face the risk of enteral misconnections. Home care clinicians must ensure that all enteral patients and caregivers receive safe supplies and education on how to avoid misconnections. Even patients receiving a single therapy should be aware of the risks, in case they transition to a dual therapy. Methods: To improve patient safety, one home care team set out to reduce the risk of enteral misconnections. Clinical dietitians researched the topic and conducted a systematic review of
CNW 2010 Nutrition Practice Abstracts 13S
the organization’s existing enteral supplies. After a thorough review, the clinical team analyzed safe enteral system alternatives, began using them in patient care and collected feedback from clinicians, patients and caregivers. Results: The improvement process identified several challenges. For example, some hospitals still use IV-compatible nasogas-tric feeding tubes or send patients home with oral nasogastric tubes fit-ted with IV adapters. In some cases, there is caregiver resistance to introducing enteral-only alternatives once the patient is in home care. Also, many syringe pumps require IV-compatible leur lok syringes. Unfortunately, there is no universal system for color-coding safe enteral-only connections, and the current selection of safe-system enteral con-nections is limited. Home care clinicians must often navigate varied manufacturer offerings and product updates to find safe options. Conclusions: Ensuring against enteral misconnections is an ongoing challenge that requires active collaboration among hospitals, home care organizations, manufacturers, patients and caregivers. Care teams must work to increase patient and caregiver education on how to reduce the risk of enteral misconnections. At the same time, clinicians must become more aware of the risks posed by using convenient but poten-tially unsafe enteral systems. Collaboration between clinicians and manufacturers may also help produce universally coded and more readily available safe enteral-only systems to improve patient safety.
P34 - Management of Enteral Feedings for Respiratory-Compromised Patients on Noninvasive VentilationKaren Martin, MA, RD, LD1,2; Lisa Jackson, RRT2
1Neurology, University of Texas Health Science Center at San Antonio & South TX ALS Association, San Antonio, TX; 2Walgreens, San Antonio, TX. Introduction: Patients with compromised respiratory systems often present unique challenges to the nutrition support team, particularly in regard to enteral feedings. Patients with decreased pulmonary function often require more calories to support the difficult task of breathing. While certain respiratory therapies may decrease metabolic demands, they may also increase air in the GI tract, decreasing a patient’s feeding tolerance and ability to meet nutritional goals. Neuromuscular disease progression increases the need for additional pressure support and the number of hours of prescribed therapy, which might worsen feeding intolerance. In addition, ineffective swallow increases the risk for aspi-ration pneumonia, which is further deleterious to a fragile neuromuscu-lar patient.<p> Some treatment interventions, including physiologic manipulations, motility agents, gastric venting and valve use, can improve tolerance to enteral nutrition. However, collaboration among members of the clinical care team, particularly between dietitians, speech pathol-ogists with swallowing specialization and respiratory therapists, is essen-tial to understanding each patient’s unique respiratory and nutritional needs and how these factors can interact during treatment. Clinical expertise in nutritional and respiratory support is vital to improving treat-ment and outcomes. Methods: Certain respiratory interventions, such as bi-level positive airway pressure (BiPAP) support, along with other factors, such as immobility, weakened GI muscles, patient positioning or concurrent treatments, can compound delayed gastric emptying. The resulting gas and distention can pose treatment and nutritional chal-lenges. In this case study, a patient with amyotrophic lateral sclerosis who was receiving BiPAP therapy developed gastric distention and was not meeting volume goals for feeding. The patient reported satiety prior to initiation of meals or feedings. Results: The clinical team attempted several interventions to address the patient’s feeding intolerance and improve overall treatment. Nocturnal pump feedings and slow boluses were initiated for volume intolerance. Knees-to-belly manipulations and use of a gastric valve bag did not relieve gastric distention. Though the home care nurse provided education on venting the gastrostomy tube, the patient and caregiver may have been overwhelmed and not in a teach-able mode at the beginning of treatment. Re-educating the caregiver regarding this intervention at a later visit helped provide the most relief
for the patient. Based on the case study, appropriate troubleshooting approaches for similar cases may include targeted delivery of enteral feedings, increased use of liquid meals to decrease respiratory effort and education regarding venting the gastrostomy tube at each clinic visit and patient encounter. Conclusions: Collaboration within multidisciplinary clinical care teams can help troubleshoot and manage oral and enteral challenges for respiratory-compromised patients. In addition to increas-ing communication with patients and caregivers to help reinforce self-care, clinicians must work together to understand one therapy’s impact on another to help optimize each patient’s nutrition support and respira-tory status.
Home Care / Long Term Care
P35 - Quality of Life Analysis during Conversion from Stationary to Portable Infusion Pump in HPN Patients: A Canadian ExperienceOlivia Saqui, RN, BScN; Gail Fernandes, BSc; Raquel Lopez, MASc; Kansuda Thongthai, MD; Johane Allard, MDHome TPN Program, Toronto General Hospital, UHN, Toronto, ON, Canada. Introduction: Home Parenteral Nutrition (HPN) may impact on quality of life (QOL) independently from other factors such as underlying dis-ease. This may be due to administration technology, particularly the type of infusion pump used in the HPN program. In another study, we found our patients’ QOL may have been affected by the use of stationary pump. Objective: To determine if QOL in HPN patients will improve by replacing the stationary infusion pump with a portable pump. Methods: Through heuristic evaluation, a portable pump with the best user inter-face design for usability and safety was selected. QOL assessment and pump-specific questionnaire were completed at baseline while on sta-tionary pump study. Those who consented were enrolled in a 2-month prospective crossover open study in which patients were randomized to either 1) the group remaining on the stationary pump or 2) the group switching to the portable pump. After one month, each arm crossed over. Measurements were repeated at 4 and 8 weeks. QOL measuring the eight domains using the internationally validated short-form 36 ver-sion 2 (SF-36v2) were gathered. Results were reported as mean ± SEM out of a possible 100. A pump-specific questionnaire (prepared by the investigators) measured patients’ satisfaction on the pump’s noise level, mobility, home set-up and personal comfort. Each question was scored using five-point Likert scale, with one indicating extreme dissatisfaction and five indicating extreme satisfaction. Results were reported as mean ± SEM and treated as interval-level data. Paired t-test and if normality failed, Wilcoxon signed rank test was applied to compare between sta-tionary and portable pump scores. Results: Out of thirty-two, twenty patients (5 male; 15 female); mean age 52.8 ± 3.3 years consented to participate. The most common reason for HPN was short bowel syn-drome (50 %); average length of time on HPN was 83.3 ± 15.9 months. HPN was infused over 11.2 ± 0.3 hours per day; 4.3 ± 0.4 days per week. The patients were stable during the study. The SF-36v2 health survey showed a trend towards improvement in physical and social func-tioning and vitality when portable pump was used. Although it did not reach significance, patients’ scores showed improvement in performing social and physical activities without limitations due to health. Patients also scored higher in their role-emotional and felt less depressed while on the portable pump. The pump-specific questionnaire showed that on the stationary device there was no significant difference in noise level, mobility, home set-up and personal comfort between baseline and at four weeks. On the other hand, over the 4-week period, patients with the portable pumps reported lower noise level (p<0.001) and increased portability (p<0.001). Only 5.0% were sleep disturbed from the noise of portable pump compared to the 42.1% with the stationary pump. From the social point of view, those who needed to infuse while entertaining found the portable pump significantly more convenient (p=0.008) than
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the stationary one. Overall, patients reported being significantly happier with the portable than the stationary pump (p<0.001). Conclusions: Transition from stationary to portable infusion pump showed improve-ment in HPN patients’ mental health, social and physical functioning. The test/re-test reliability indicates that the pump questionnaire is con-sistent and stable in measuring what is intended to measure. Our study limitation is the small sample size.
P36 - Quality of Life Analysis in Canadian Home Parenteral Nutrition Patients Who are Infusing with Stationary PumpOlivia Saqui, RN BScN; Gail Fernandes, BSc; Kansuda Thongthai, MD; Johane Allard, MDHome TPN Program, Toronto General Hospital, UHN, Toronto, ON, Canada. Introduction: Home Parenteral Nutrition (HPN) is indicated for patients with intestinal failure. HPN improves nutritional status but may decrease quality of life (QOL) because of the technology associated with its administration, particulary the type of infusion pump. Objective: To measure the quality of life in HPN patients using stationary infusion pumps. Methods: Patient demographics such as age, gender, indica-tions and length of time on HPN were collected. QOL measuring the eight domains using the internationally validated short-form 36 version 2 (SF-36v2) were gathered. Results were reported as mean ± SEM out of a possible 100. A pump-specific questionnaire (prepared by the inves-tigators) measured patients’ satisfaction on the stationary pump’s noise level, mobility, home set-up and social structure. Each question was scored using a five-point Likert scale, with 1 indicating extreme dissat-isfaction and 5 indicating extreme satisfaction. Results were reported as mean ± SEM and treated as interval-level data. Results: Thirty-two patients (11 male; 21 female); mean age 53.3 ± 2.5 years participated in the study. The most common reason for HPN was short bowel syndrome (50.0%); average length of time on HPN was 76.7 ± 14.2 months. The patients were stable during the study. For the SF-36v2, patients scored 41.13 ± 5.41 for physical functioning indicating limitations in perform-ing physical activities and 50.00 ± 5.25 for social functioning, indicating limitations in performing social activities. This was lower in our patient cohort than that seen in previous studies on US HPN population. Our patients scored 39.44 ± 5.49 in their role-physical and 34.48 ± 3.79 in their vitality indicating problems with daily activities due to physical health. This was similar to that noted in the US HPN population. Our patients infused HPN at 11.4 ± 0.2 hours per day for 4.7 ± 0.3 days per week. For the pump-specific five-point Likert scale questionnaire, patients were dissatisfied with the loud noise (2.77± 0.28) and 32.3% were sleep disturbed due to pump noise. They reported dissatisfaction with lack of mobility (2.62 ± 0.37) and 40.0% had to make home adjust-ments due to the IV pole used with the pump. Most patients found it inconvenient to infuse while entertaining (2.15 ± 0.27); 51.9% were embarrassed if in public with the pump and 37.3% reported it affected intimacy with partners. In general, patients were somewhat unhappy (3.00 ± 0.25) with the stationary pump. Conclusions: Our patient population had lower scores for physical and social functioning com-pared to other HPN population based on the SF-36v2. One contributing factor may be the stationary pump. Patients were somewhat unhappy with low satisfaction levels for pump noise, mobility and convenience. This supports the need to study the impact of a portable pump.
P37 - The Trouble with Trace Elements: A Case ReportJana Wayne, RD, CD, CNSC2; Laura Runyan, RPh.2; Penny L. Allen, RD, LD, CNSC1
1Nutrition Support, Critical Care Systems, Nashua, NH; 2Nutrition Support, Critical Care Systems, Fort Wayne, IN. Introduction: Periodic monitoring of trace element (TE) levels is rec-ommended for all patients receiving long-term parenteral nutrition (PN) with many long-term PN patients requiring customization of TE at some point during their therapy. There is little consensus regarding frequency
of testing and interpretation of the results. Plasma, serum, or urine levels do not likely reflect tissue stores or bioavailability, nor are testing methodologies sensitive or specific to the particular nutrient. Preanalytic variables can alter TE results. Blood collection equipment (i.e. rubber caps of collection tubes, stainless steel needles, powdered gloves) and PN components contain known metal contaminants. Red blood cells leak metals into the serum and plasma over time. Patients generally receive a standard TE solution, and no fast or “wash out” period is con-sistently applied prior to testing. Many clinicians lack understanding of the special handling requirements of TE samples, yet results are used to make clinical decisions regarding PN composition. Methods: Case Report: A 51 y.o. female with history of Short Bowel Syndrome (SBS) secondary to ischemic bowel, chronic pancreatitis, anemia due to men-orrhagia, obesity, depression, and remote ethanol use was referred to a specialty home infusion provider for PN in February 2007. The patient exhibited symptoms of cholestatic disease: elevated liver function tests (LFTs) along with complaints of postprandial abdominal pain, dyspepsia and gas. Baseline TE levels were obtained in October 2007. Results: In August 2008 the serum manganese level was reported as 95.4 mcg/L (reference range < 2.5 mcg/L). A redraw showed 120.6 mcg/L, and a third sample sent to a different lab was 4.8 mcg/L. A discussion with a toxicologist from the reference laboratory identified several possible confounders. Iron sucrose was infused prior to the first draw, and more than an hour had elapsed between draw time and delivery to the local lab. Subsequent levels in 2009 were 5.1 mcg/L, 4.2 mcg/L, and 52 mcg/L in August 2009. Upon investigation, a new nurse had visited the patient and infused iron sucrose prior to the TE collection. She was aware of the necessary prompt delivery time, but the lab notes indicated the serum may have had prolonged contact with cells. All samples were collected in proper tubes. TE levels were customized for this patient, removing copper and manganese. Total kilocalories were decreased with lipid emulsion intermittently administered, resulting in a 40 pound weight loss. The patient was diagnosed with cholelithiasis in January 2009. She declined the recommended cholecystectomy and hysterec-tomy. Her individualized TE cocktail and other PN alterations resulted in stable LFTs. Conclusions: Many preanalytic variables can account for TE discrepancies. This is especially challenging in the homecare setting, where nursing is charged with a unique procedure for the blood draw within the confines of a multi-task home visit. Laboratories sur-veyed recommend that metal-free (royal blue top) tubes along with powder- free gloves be used for collection, with delivery of specimen to lab within 60 minutes. A new Trace Element Lab Order Request form was developed to provide the home nurse with the correct procedure for obtaining samples and for assisting the physician in ordering the correct assays. We continue to evaluate the effectiveness of the form in reduc-ing preanalytical errors.
P38 - Home Parenteral Nutrition: Descriptive analysis of a populationSophia L. Johnson, PharmD, MPh; Daniel Magill, CPhTFairview Home Infusion, Fairview Pharmacy Services, Minneapolis, MN. Introduction: Home parenteral nutrition (HPN) is a life saving therapy that is expensive and requires a vast number of resources. It is of para-mount importance to describe the populations that receive this therapy as a first step to ensure appropriate utilization and achievement of rel-evant therapeutic goals. In addition, it may also prove instrumental in resource allocation to identify predictive risk factors for protracted lengths of hpn therapy. The objective of this evaluation is to describe the HPN population serviced by an academic health-system based home infusion company in the Upper Midwest, and to begin to investigate factors that predict long lengths of treatment with HPN. Methods: Electronic medical records were analyzed for the time period 1/2002 to 7/2009. Data collected includes: age, gender, ICD-9 codes, nursing care provision and physician discipline. Surrogate markers were used to esti-mate length of therapy (LOT) and patient locality. Chi square tests were
CNW 2010 Nutrition Practice Abstracts 15S
Physician Discipline/RN services/Diagnostic Groups
Physician Discipline Heme/Onc Generalist 370 329 252 SurgeonsRN Service Type Visit RN No RN 832 350 Diagnostic Group Digestive Solid Ca 337 177 126 Malabs
P39 - Trends in Home PN: Are the Demographics Shifting?Karen M. Sexton-Hamilton, MS, RD, LD, CNSD1; Carol Ireton-Jones, PhD, RD, LD, CNSD,1; Mark H. DeLegge, MD2,1
1TPN Center of Excellence, Coram Specialty Infusion, Denver, CO; 2Digestive Disease Center, Medical University of South Carolina, Charleston, SC. Introduction: We have previously published outcomes of patients receiv-ing home parenteral nutrition (HPN) cared for by one national HPN provider and now present data reaching from 1997 to 2005 and 2007- 2008. Methods: The data comes from both long- and short-term HPN patients (<30 days to >30 years) referred from multiple clinical settings, including private practice and tertiary medical centers. The average data and the data for all three sub-groups analyzed represent statistically significant HPN patient populations across the United States and allow for a trended view of demographic changes over time.Results: The aver-age values calculated over the 11 years of data collection indicates a patient mean age of 44 years. Twenty percent of the patients were >65 years old and 16% were <16 years old. Forty-one percent were male and 59% female. The top diagnoses used to indicate the reason for HPN need were: nutritional deficiencies, intestinal malabsorption, pancre-atic disease, regional enteritis, intestinal obstruction, oncology of the digestive system, enteritis/colitis and diseases of the stomach and duo-denum. The average length of therapy (LOT) for this period was 111.7 days when data was annualized. Patients received the following concur-rent infusion therapies: antibiotic 23.7%; enteral therapy 6.3%; and pain management: 4.4%. When we divided the data into three subsets: 1997-2001 (Grp. 1); 2002 - 2005 (Grp. 2); and 2007-2008 (Grp. 3); mean age or range of age of patients was not different among the three groups nor was % of males vs. females. LOT was different with Grp. 1 - 100 days; Grp. 2 - 120.9 days; and Grp. 3 - 131.3 days. The average number of HPN patients receiving concomitant IV antibiotic therapy was 28% for Grp. 1
used to identify associations between patient characteristics and the length of an hpn therapy course. Results: The HPN population con-sisted of 1182 cases, 656 females and 526 males. The mean age was 39.53 years, range (0-106). Mean length of therapy was 131.27 days, with a median of 34 and maximum LOT of 2771 days. Of the cases reviewed, 908 reside in the twin cities metropolitan area. A summary of the largest physician disciplines and diagnostic groups represented as well as nursing care provision are shown in the table below. Analyses of the degree of association between LOT and the other variables was also conducted. Results suggest that women are more likely than men to be longer utilizers (p= 0.045) and that physician type also appeared to be related to LOT (p=.001). Disease state was not predictive (p=0.148) and neither was age (p=0.413), type of nursing care (p= 0.125) or location of residence (p= 0.405). When the association between LOT and physi-cian specialty was analyzed for men and women separately, there con-tinued to be a significant association (women p=.002, men p=.011). Conclusions: The hpn population served is comprised of a large age range, numerous diagnostic groups and types of care/care providers. In the current analyses, gender and physician type separately, and physi-cian type when evaluated by gender, appeared to be correlated to longer HPN lengths of therapy. Targets for further investigation would include further evaluating the current parameters with markers of disease sever-ity. The goal of future work is to develop logical predictive equations of risk factors for protracted HPN use.
and 22.6 % for Grp. 2, 26.7% for Grp. 3. The average number of HPN patients receiving concomitant IV pain therapy was 5.1% Grp. 1, 4.6 % Grp. 2 and 4.4% Grp. 3. The average number of HPN patients receiving enteral therapy was 6.7% Grp. 1, 7.1% Grp. 2 and 8.5% in Grp. 3. In Grp. 1, the top five diagnoses for receiving HPN in order of frequency were nutritional deficiencies, intestinal malabsorption, pancreatic dis-ease, regional enteritis and intestinal obstruction. For Grp. 2, the top five diagnoses were similar with differences in order of frequency, and included intestinal malabsorption, protein calorie malnutrition, intesti-nal obstruction, pancreatic disease, and regional enteritis. For Grp. 3, intestinal malabsorption, oncology of the digestive system, diseases of the intestine and peritoneum, enteritis and colitis and diseases of the stomach and intestine were the top five diagnoses in order of frequency. Conclusions: While the age and distribution of patients has not changed, the data suggests the use of IV antibiotic and enteral concurrent thera-pies with HPN has increased with a decreasing trend in concurrent IV pain therapy. The average length of therapy has increased. A trend toward an increased use of HPN in oncology was also noted. This data provides a detailed sample of HPN patient demographics in the United States with special emphasis on changes over time.
P40 - Patient Satisfaction: An Essential Measure of Parenteral and Enteral Nutrition Therapy QualityKaren M. Sexton-Hamilton, MS, RD, LD, CNSD1; Carl Fink, JD, MBA2
1TPN Center of Excellence, Coram Specialty Infusion, Denver, CO; 2Outcomes & Analytics, Coram Specialty Infusion, Columbia, MD. Introduction: Patient-centered outcomes have been identified as the primary means of measuring the effectiveness of healthcare delivery. It is acknowledged that patients’ reports of their satisfaction with the qual-ity of care and services, are as important as many clinical health measures. Many healthcare organizations use patient satisfaction (PS) informa-tion when making decisions about patient education and program enhancement. Also, as PS data reflects care delivered, this informa-tion is scrutinized by managed care organizations, patients, employers, and accrediting organizations. As more payers move to a “pay-for-performance” model, organizations that do not provide high-quality care and service may receive reduced reimbursement. Methods: Routine measurement of PS for a variety of care indicators is fundamental in the assurance of quality care provision and scrutiny of data validity is essen-tial to accurately reflect the care delivered. This underscores the need for organizations to systematically collect reliable and unbiased PS information from their own patients on an ongoing basis. One large, national home infusion company performs continuous measurement of PS with all key aspects of infusion service to identify service effectiveness and opportunities to enhance satisfaction. Further, PS data is evaluated by therapy line (enteral (EN) and parenteral (PN)) to delineate specific PS and determine the unique satisfaction drivers of Home Parenteral and Enteral Nutrition (HPEN) consumer. EN and PN therapy patients are selected on a random sample basis to receive a mailed satisfaction survey. Patients are eligible to be selected to receive a survey shortly after the start of therapy, during long-term therapy, and following discharge. Survey questions address numerous key aspects of services provided. All questions are scored on a five-point Likert scale. The rate of response is determined to assure a statistically meaningful sample upon which judg-ments about patient satisfaction for multiple variables can be made. Scored survey results are available for continuous review through a web-enabled reporting site. In addition to scored survey results, specific comments written on returned surveys by patients are also available for review. PN and EN patients’ satisfaction is discretely evaluated sepa-rated from all other infusion patients’ satisfaction.For the purposes of this study, a six-month period ending 6/30/09 was evaluated. Results: A company-wide Response Rate of 24.8 percent was achieved. Of the PN patients surveyed, 96.9 percent of patients were satisfied with overall
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services provided. When EN patients’ satisfaction was explicitly evalu-ated, 87.0 percent of patients were satisfied with overall services pro-vided. For both groups, the lowest satisfaction scores focused on the patients’ perception of how well costs for their therapies were explained to them. The highest scores for HPEN patients were noted in the area of equipment use and clinical staff. In addition to evaluating trends quarter over quarter, results are compared with internal benchmarks. These HPEN consumers are generally highly satisfied with care and service overall. Conclusions: Utilization of a systematic survey process and detailed tool provides targeted information that allows specific iden-tification of areas for performance improvement to enhance specific patient satisfaction.
P41 - Use of a Centralized Pharmacy Model to Provide Home Parenteral Nutrition (HPN) NationwideKathleen Alvarez, RPH; Mark Kestler, RPH; Deborah E. Pfister, MS, RD, CNSDThriveRx, Cincinnati, OH. Introduction: In traditional home infusion, HPN is provided via a decentralized pharmacy model, whereby order processing, solution compounding and delivery are completed local to the consumer. Challenges for the decentralized pharmacy include; service duplica-tion, staffing, productivity, continuity of care, and servicing patients outside of the coverage area. To overcome these challenges, we estab-lished a centralized pharmacy to provide HPN to consumers nation-wide. To maximize success, we implemented selection criteria including; patient acuity, therapy needs, timing of lab draws, time zone factors and common carrier accessibility. Methods: Our goal was to measure the success of the established criteria and the impact of the centralized model on clinical and financial oucomes. We reviewed data over a 6-month period relative to: compounding frequency and cost; distribu-tion frequency and timeliness; number of days from lab testing to HPN infusion; HPN stability factors; and overall financial impact. Results: We reviewed data from January 1 through June 30, 2009. During this time, 1,906 bags of HPN were dispensed to consumers in 11 states. Of the dispensed HPN bags, 1,892 were shipped overnight to the con-sumer, according to our protocol. The remaining 14 bags were com-pounded and delivered same day, by a local First Dose Pharmacy. Of these same day deliveries, 100% were related to hospitalization where final orders were not available earlier than the day of discharge. None of the same day deliveries were related to stat order changes. There was no cost difference recognized between the overnight and same day groups. During this same period, we measured planned and unplanned deliveries. There were no unplanned HPN deliveries, reflecting con-sumer stability. To further support the efficacy of the admission criteria, we reviewed patient stability factors. Of the patients serviced, 80% were defined as low acuity suppported by an average lab draw frequency of 21.9 days. On average, patients tolerated a gap time between lab draw and HPN infusion of 3.45 days. To support the clinical quality of care, we measured HPN solution stability and temperature. Test HPN bags were sent to an outside lab on a monthly basis for stability testing via a membrane filtration method. From this testing, Certificate 71 Compliance was granted, indicating 14 day stability thus ensuring safety and allowing shipping and hang time flexibility. Quarterly temperature checks of shipped solutions were also completed with temperatures maintained in the 32 to 37 degree Centigrade range. Additional tem-perature monitoring was conducted in situations of significant distance or during the summer months. Conclusions: Overall, clinical quality of care and positive financial outcomes have been accomplished through implementation of a centralized pharmacy model. The selec-tion criteria and creative intitiatives to overcome obstacles related to distance, weather and hospitalization have helped promote success. Future work will involve assessment of better packaging to minimize costs, and evaluation of extended solution stability.
P42 - Improving the Quality of the Physician Visit for the Home Parenteral and Enteral Nutrition (HPEN) PatientAbigail Brogan, BS; Donna Noble, BA; Deborah E. Pfister, MS, RD, CNSDThriveRx, Cincinnati, OH. Introduction: The lay and professional literature is replete with sugges-tions to maximize patient outcomes and satisfaction with medical appointments. A number of factors influence outcome such as; commu-nication patterns, visit expectations, patient age, education and the type of information discussed. Research has been completed on communica-tion styles and information type, with identification of patterns ranging from closed-ended medical qustions directed by the physician, to pure psychosocial exchange. Patient satisfaction with medical visits is highest in groups who communicate in a psychosocial pattern and, when diagno-sis and prognosis of symptoms are discussed. With the average physician appointment lasting 15 minutes or less, the value of the information shared by patient and medical personnel is important. Medical school education focuses on a three-part visit; the description of the complaint, the physical exam, and the diagnosis and treatment. To determine the most accurate diagnosis and treatment, the patient information shared in the first part of the visit is crucial. Methods: In order to understand how HPEN consumers prepare for medical visits, we developed a consumer survey of five open-ended questions. The survey focused on tools and tips that consumers use to maximize their visit. Survey results were catego-rized by intervention type. Results: The survey return rate was 53% with results categorized by common trends including; preparation and plan-ning, prepared questions, prepared documents, and management of children during the pediatric visit. The majority of consumers prepared questions and either emailed or brought written questions to the visit. Additionally, 88% reported bringing a list of current medications; 56% brought an Intake/Output log or weight and diet records; 31% brought copies of their medical history, recent studies or labs. To improve visit comprehension, 63% reported taking notes during the visit and 38% reported bringing another adult for listening and communication. The parents of pediatric consumers were most likely to report distractions during the visit. In order to manage distraction, 88% brought activities or games, 69% report bringing another adult to assist with the child, 44% report scheduling the appointment for times that were best for the child. To maximize the pediatric visit, 94% of parents reported preparing their child through role play or reviewing visit expectations. Conclusions: Overall, HPEN consumers surveyed had developed methods to maximize their medical appointments including; creating data reporting forms, question lists and other tools for better information sharing. The parents of pediatric consumers were most successful when they brought activi-ties or another adult to assist with childcare. From this survey, we devel-oped a Medical Visit Checklist for HPEN consumers and a USB-driven Medical Data Form for consumer use at the medical visit.
P43 - Alternative Use of an Enteral Feeding DeviceJanelle Peterson, RD, LD, CNSD; Jill Wall, RNPediatric Home Service, Roseville, MN. Introduction: An ACE (Antegrade Continent Enema) procedure is performed under the conditions of severe constipation or incontinence of bowel. Surgeons each have their own methods of performing this procedure; however the ultimate goal is for the patient to be able to self-administer enemas into the bowel to encourage evacuation of bowel contents. After the procedure is completed, a small catheter is passed through the ACE stoma to introduce fluid into the bowel. Within 20 minutes to one hour the bowel contents will usually be cleared. ACE stomas often leak stool at the stoma site and therefore an ileostomy or colostomy bag is used to collect this leakage so it does not irritate the abdominal skin. Methods: A 13 year old female patient had an ACE procedure performed. Ileostomy and Colostomy bags were tried without success to capture the stool leakage. The urologist following this patient
CNW 2010 Nutrition Practice Abstracts 17S
recommended the use of a low profile gastrostomy button to be placed in the stoma site. The low profile button was placed in the stoma and the balloon on the button was filled with distilled water to the appropri-ate amount per the manufacturer. Results: The patient’s caregivers can access the low profile gastrostomy button by placing an extension in the button and give normal saline flushes to help evacuate bowel contents. This has proven to be effective and then the patient will stool within 20 minutes of provision of the normal saline flush. The button has provided sealing of the ACE stoma and a convenient means to provide the bowel flush as the enema. Conclusions: Low profile gastrostomy buttons are designed to be placed in stomas to provide enteral feedings to patients. In patients with ACE stomas, they can also be used to provide sealing of the stoma site and a means to provide bowel flushes to help evacuate bowel contents. In a teenage girl, this also provides some modesty as the ostomy pouch does not have to be seen through clothing or risk the chance that it would come unattached.
P44 - Saving Healthcare Dollars: Safe Home Initiation of Parenteral Nutrition in Patients at Nutrition Risk Prevents Hospital AdmissionsTherese L. Austin, MS, RD, LD, CNSD1; Lily Wu, RD, CNSC2
1Nutrition Services, Coram Specialty Infusion, Cleveland, OH; 2Nutrition Services, Coram Specialty Infusion, Los Angeles, CA. Introduction: Healthcare reform is a major issue in the United States. Hospital admissions and healthcare dollars are being scrutinized. Initiating parenteral nutrition (PN) in the home care setting versus an acute care center in carefully selected, appropriate patients will avoid hospitalization and therefore avoid a costly hospital admission. A “Home PN Initiation Checklist,” used to identify patients who are appropriate for safe home initiation of PN, has been published and was applied in the following case studies to further substantiate the application of this tool. Methods: Retrospective case analysis from one large national homecare company was evaluated at two different locations. Results: Case Report #1: A 57-year-old female was admitted to the hospital for initiation of PN due to persistent diarrhea, dehydration and weight loss over several months. She did not meet criteria for an inpatient hospital admission. A PICC line was placed and the patient was discharged to home to initiate PN after the “Checklist” indicated that she could safely start PN in the home. Baseline labs demonstrated electrolytes were within normal limits (WNL) and PN containing 75g of dextrose and 30g of amino acid without lipid was initiated. Her labs were redrawn in 48 hours and were WNL. She was advanced to her PN goal and remained stable allowing cycling of PN. The PICC line was inadvertently cut two weeks later and not replaced for one month. Diarrhea and weight loss continued and PN was resumed at home after PICC replacement. Transition to an oral diet was initiated using pancreatic enzyme replace-ment therapy after her GI workup demonstrated pancreatic insufficiency. She achieved her goal weight, eventually tolerated an oral diet and PN was discontinued after three months. Case Report #2: A 57-year-old female s/p laparoscopic gastric bypass complicated by post-prandial vomiting, abdominal pain and severe weight loss was referred for home initiation of PN. The “Checklist” was completed and it was determined that the patient met criteria to safely initiate home PN despite a 47 percent weight loss over 10 months and a body mass index (BMI) of 17.7. According to the “Checklist” criteria was met as evidenced by stable electrolytes, no excessive non-urinary fluid losses and a safe home environment. Home PN was started at goal protein, with 10 percent dextrose concentration cycled over 20 hours with an additional 100mg of thiamin. PN was advanced to goal calories and cycled to a 12-hour infusion within one week. The patient did not experience any PN complications during the seven months of therapy until her gastric bypass was revised and she was able to tolerate an oral diet. Conclusions: These cases demonstrate the success of overcoming barriers to safe home initiation of PN in patients who are carefully evaluated using a standardized checklist and advanced
to goal nutrition support. This allows for a savings of healthcare dollars and improves patient quality of life.
P45 - A Methodology for Establishing Smart Pump Parameters for the Home Parenteral Nutrition PopulationAnna Nowobilski-Vasilios, PharmD MBA FASHP CNSC BCNSP1; Susan Poole, BSN MS CRNI CNSN CIC1,2; Marianne Duda, MS RD LD CNSD3; Mary Ward-Welisevich, BA4
1Anovation Care Management Innovation, Chicago, IL; 2Southwest Horizon Health Care Consulting, Peoria, AZ; 3CarePoint Partners, Tampa, FL; 4Smiths Medical ASD, St. Paul, MN. Introduction: As the medical device industry transforms ambulatory infusion pumps into those with smart technology for the hospital set-ting, these same pumps will soon be available to the home infusion care setting, allowing for automated recognition of programming errors. As legacy electronic ambulatory infusion pumps are retired from service, they will be replaced with smart pumps in all patient care settings. This poster provides one possible methodology for implementing a smart pump library appropriate for the home parenteral nutrition patient population, thereby addressing this additional preparatory step for smart pump implementation. Methods: Smart pump libraries are designed to perform a test of reasonableness, defining hard and soft upper and lower infusion limits specific to therapies administered. While this methodol-ogy is very logical, the actual determination of the programming param-eters can be confusing and difficult to interpret. Further, each organization creates a drug library specific to the patient population it serves. In designing a pump library for the home nutrition population, several variables must be considered. These include variables which dif-fer from patient to patient within this population, such as age group, weight group, glucose concentration, TPN volume and catheter type. At the most basic, the hard lower infusion limit can be interpreted as that rate under which the catheter might occlude. The hard upper limit might be the rate over which the patient can not maintain glucose homeostasis. Simply put, the maximum glucose oxidation rate might be substituted for this value. Results: A range of pump protocols are pre-sented that may be used as models when developing an organization’s library for home parenteral nutrition patients. Conclusions: For smart pumps to be effective in the home parenteral nutrition population, their programming must be efficient. While pump programming libraries are traditionally the responsibility of the pharmacy department, a multidis-ciplinary approach is needed to create an effective library for the nutri-tion population. The expertise of infusion nurses and their understanding of catheter dynamics is needed to define the lower hard limit rate for the organization’s TPN pump library, while expertise of nutrition support clinicians and their understanding of nutrition utilization is needed to define upper hard limit. With increased care fragmentation and separa-tion of nursing and pharmacy functions, it may become more important to provide additional safety measures to prevent patient harm from errors in pump programming. Home infusion organizations must learn from their hospital colleagues and be prepared for the challenge of managing this new generation of infusion pumps.
Nutrition Education
P46 - The Role of the Caregiver and the Dietitian in Providing Nutrition Support Instruction within a Home Infusion Elective at a College of PharmacyAnna Nowobilski-Vasilios, PharmD MBA FASHP CNSC BCNSP1,2; Marianne Duda, MS RD LD CNSD3; Ann Weaver, BA4; Susan Poole, BSN MS CRNI CNSN CIC1,5
1Anovation Care Management Innovation, Chicago, IL; 2Midwestern University, Downers Grove, IL; 3Care Point Partners, Tampa, FL; 4The Oley Foundation, Naperville, IL; 5Southwest Horizon Health Care Consulting, Peoria, AZ.
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Introduction: An academic 2 hour 10-week elective was developed at a college of pharmacy as an introduction to the home infusion practice setting for third-year pharmacy students. To provide students with as practical an introduction to this interdisciplinary practice setting, the patient’s and the dietitian’s perspectives were used to present subject matter related to nutrition support. Methods: The caregiver and the dietitian deliver two tandem lectures of the twenty included in the course, providing students with an introduction to parenteral and enteral nutrition in the home care setting. The caregiver candidly shares her experience of being the mother of a son on lifelong nutrition sup-port. She shares photographs, real-life experiences, answers questions, and gives pointers on what the patient expects from their health care team. The dietitian follows the caregiver’s discussion, focusing on the differences and similarities between hospital and home management of the patient on nutrition support, patient evaluation, therapy goals, the nutrition care plan, monitoring, providing psychosocial support, and identifying, troubleshooting, and minimizing complications. Results: Education from instructors with the direct experience of providing and receiving nutrition support services allows for a unique experience within the classroom. The ability to visualize and comprehend the problems that a patient may experience with nutrition support is invaluable and highly rated by students. Interaction with individuals who are members of the health care team, including the parent and the dietitian, will lead to more successful outcomes for patients and create job satisfaction if these future pharmacists choose to work in the infusion therapy arena. Conclusions: While pharmacy student knowledge related to the home nutrition support practice setting is limited and clinical clerkship sites are few, an elective course in home infusion therapy is an excellent way to introduce students to this novel career path. Teaching by a certified nutrition support dietitian introduces the pharmacy student to the dieti-tian’s expertise, and a personal glimpse into twelve years of parenting a child on nutrition support provide the student with an appreciation for the value of an interdisciplinary team, compassion for the home infu-sion patient, and a flavor of this unique and exciting practice setting.
Home Care / Long Term Care
P47 - National Registry of Home Parenteral and Enteral Nutrition in Czech RepublicPavel Tesinsky, associate professor; Adam Jirka, junior lecturer; Jan Svanda, senior lecturerDept of Medicine II, Charles University Hospital, Prague, Czech Republic. Introduction: The National Registry contains the data of patients receiv-ing home parenteral nutrition (HPN), and home enteral nutrition (HEN) in Czech Republic in the past year. The presented results demonstrate the state of the art of home nutritional support in 2008. Methods: The data were acquired by means of electronic questionaires based on the standards of the OASIS organisation and MSM 0021620814. Czech Republic is covered by the network of 60 Nutrition Centres. The Registry summarizes data of 2699 patients enrolled between 1st January, and 31st Decembre, 2008. HPN has been provided by 7 out of 60 centres, mainly related to teaching hospitals. Results: I. The HPN registry enrolled 84 patients: mean age 54 years (29-89), 32 male, 52 female. 65% of them were in economically active age, but only 20% were economically active. 63 patients continued HPN, 14 patients died, and 7 patients were weaned during 2008. The main indications were cancer (44%), post-operative complications (17%), vascular catastrophes (14%), Crohn dis-ease (13%), and other (12%). 61% patiens suffered from short bowel syndrome, 17% from bowel occlusion. The most frequent complication (66%) were catheter related infections (0.3/patient/year), followed by hepatobiliary complications (14%), and catheter occlusion (10%). II. The HEN registry enrolled 2615 patients. Sipping was the main way of deliv-ery in 51%, percutaneous gastrostomy in 29%, and tube feeding in 14% patients. The main diagnoses were cancer (40%), neurological lesions (18%), and Crohn disease (8%). Conclusions: The National Registry
scans the status of HPN/HEN in Czech Republic periodically. The abso-lute number of patients shows a rapid developement of home nutrition support in Czech republic. The HPN is mostly provided to patients with cancer. Tunneled central venous catheters are more used than implant-able ports and have lower incidence of infectious complications.
Malnutrition
P48 - Nutritional Screening in Patients Admitted to Acute Elderly WardsMichelle E. Fanning, BSc. Human Nutrition and Dietetics; Claire Browne, BSc. Human Nutrition and Dietetics, H.Dip.Clinical Nutrition, St. James’s Hospital, Dublin, Ireland. Introduction: Malnutrition is known to be prevalent in hospitalised patients, with 11-40% of all patients admitted to hospital reported to be undernourished. Routine screening of nutritional status is recommended in all patients admitted to hospital to allow early intervention (National Institute of Clinical Excellence (NICE), 2006). The ‘Malnutrition Universal Screening Tool’ (‘MUST’) was developed by the Malnutrition Advisory Group of the British Association of Parenteral and Enteral Nutrition (BAPEN) in 2003 and is a validated evidence-based tool designed to identify adults who are malnourished or at risk of malnutri-tion. In hospital, ‘MUST’ predicts length of hospital stay, discharge des-tination and mortality. The objective of this audit was to establish the nutritional status and the prevalence of malnutrition using ‘MUST’ in patients admitted to acute elderly wards at St. James’s Hospital, Dublin. Methods: A prospective study was carried out on two acute elderly wards between August 2008 and January 2009. A dietetic assistant was trained to complete ‘MUST’ on all patients admitted to these wards. A referral to the Department of Clinical Nutrition was immediately sought on all patients identified at high risk of malnutrition. Low and medium risk patients were monitored through weekly repeat screening. Cross tabula-tion was used to compare differences between groups for categorical variables. Significant differences were tested using Pearson Chi-square analysis. Results: Fifty seven percent (n=211) of all patients admitted to the acute elderly wards were screened. Patients were screened a median of 2.5 days from date of admission to hospital. Patients were categorised by BMI, 12% of patients screened had a BMI <18.5Kg/m2, 43% of patients had a BMI of 18.5-24.9Kg/m2, while 45% of patients fell within the overweight or obese categories having a BMI >24.9kg/m2. Based on ‘MUST’ scores, 23% of patients were at high risk, 15% of patients were at medium risk and 61.4% of patients were at low risk of malnutrition on admission. There was no significant difference between ‘MUST’ scores and age groups (≥ 75 years and < 75 years) or between males and females. The number of referrals to the Department of Clinical Nutrition increased by 31% during this 6-month period as a result of nutritional screening using ‘MUST’. Conclusions: We identified a large number of patients at risk of malnutrition (15% medium risk and 23% high risk) using ‘MUST’, which has predictive validity and predicts clinically rele-vant outcomes. Correct identification of these patients, who are most at need of nutritional intervention, allows appropriate targeting of clinical nutrition expertise and resources, with a view to improving clinical out-come in acute elderly patients at St. James’s Hospital. The findings in this audit support the consensus of recommendations made by national and international bodies that routine screening to identify malnutrition should be carried out. This audit provides information on nutritional risk on admission to hospital and its prevalence highlights the problem of malnutrition among older people in the community.
Micronutrients
P49 - Retrospective review of treatment of vitamin D deficiency in an acute care hospitalLisa Andrews, MEd, RD, LD; Jason Hiett, Pharm DNutrition & Food Services, VA Medical Center, Cincinnati, OH.
CNW 2010 Nutrition Practice Abstracts 19S
Introduction: Vitamin D deficiency has become more prevalent in the US over the past decade. Researchers estimate that up to 75% of Americans do not obtain adequate vitamin D. Some studies have discov-ered that up to 45% of hospitalized patients have vitamin D deficiency. In addition to its role in calcium and phosphorus balance, vitamin D may affect other conditions. Vitamin D deficiency has been implicated in the development of heart disease, glucose intolerance, high blood pressure, asthma, type 2 diabetes, Multiple Sclerosis, and some cancers. Deficiency of vitamin D occurs when the serum level drops below 20 ng/ml, but treatment may begin when levels are under 30 ng/ml. Treatment of deficiency may range from 1000 IU per day to 50,000 IU vitamin D once per week. The objective of this retrospective study was to review the occurrence of vitamin D deficiency in hospitalized adult patients and treatment modality used. Methods: A retrospective review of vita-min D deficient patients was conducted using a computer-generated list over a 6 month period. The list included inpatient medical, surgical and ICU patients with a vitamin D, hydroxy 25 level < 30ng/ml. The number of treated versus untreated patients and method of treatment were evaluated. Number of deaths in deficient patients was also observed. Results: In this study, ages ranged from 48 to 90 with mean age of 69 years. 74 patients had insufficient vitamin D levels (vitamin D25, hydroxy level < 30 ng/ml). There were 72 male and 2 female patients. Of the 74 patients, 68% (n = 50) were deficient in vitamin D (vitamin D, hydroxy level < 20 mg/ml). Of the vitamin D deficient patients, 28% (n = 14) were treated and 72% (n=36) were untreated. In the untreated group, 25% of patients (n = 9) had CKD stage III or IV (dialysis). Of the 14 patients that received vitamin D treatment, 6 patients (43%) received 50,000 IU ergocalciferol once/week, 3 patients (21%) received 1000 units cholecalciferol daily, 2 patients (14%) received 1 calcium/vit D tab daily, 1 patient (7%) received 2.5 mcg doxercalciferol 3 x/week, 1 patient (7%) received 200 IU vitamin D per day and 1 patient (7%) received 400 IU vitamin D daily. Formulations of ergocalciferol varied from liquid for tube fed patients (6.25 ml) to 50,000 IU capsules once/week in those on oral diets. Death accounted for 18% of all patients with low vitamin D levels, but was more common in the untreated group of patients with vitamin D levels below 20 ng/ml (28%, n = 10). Conclusions: Vitamin D deficiency was observed in over 65% of hospitalized patients studied. Several patients with vitamin D deficiency were untreated (68%) includ-ing patients with stage 3 or 4 renal disease. Treatment of vitamin D deficiency was not standardized as multiple types and doses of vitamin D were used. Death in vitamin D deficient patients was observed in 28% of untreated patients. More research on screening and standardization of appropriate treatment of vitamin D deficiency in hospitalized patients is indicated.
P50 - Evidenced Based Findings of Essential Trace Metal Deficiency and/or Excess in Parenteral Nutrition PatientsPatricia Olsen, APRN-BC, CNSN1; Bin Zhang, Ph.D., R.Ph., BCNSP2; Nancy L. Sceery, RD, LD, CNSD1; Janice Heavey, MS, RN, CNSN1; Michelle Picard, BSN, RN, CNSN1; Janey Pratt, MD1
1Surgery, Massachusetts General Hospital, Boston, MA; 2Pharmacy, Massachusetts General Hospital, Boston, MA. Introduction: Standard additives to a parenteral nutrient (PN) formula routinely include the trace element admixture as recommended in accordance with AMA/NAG guidelines. However, these guidelines are applicable to healthy adult population not acutely ill patients. Parenteral patients cited at risk for micronutrient deficiencies include Gastric Bypass patients, Refractory Crohn’s disease, recurrent fistulas, Short Gut and/or any other condition of nutrient malabsorption. Abnormal serum values can occur with inappropriate administration, increased or altered requirements, inflammatory processes, increased losses and any other condition affecting biochemical pathways. True deficiencies and/or toxicity can result in organ dysfunction, impaired wound healing, and altered immune status with deleterious outcome. Recent citations
suggest certain trace elements may be inadequate in the PN mix, and others excessive. In an effort to identify risk of deficiency and/or excess, since 2007 the MGH Nutrition Support Unit (NSU) has begun moni-toring trace elements panel in long term PN patient ( >4-6 weeks) and/or any patient at risk of malabsorption / malnutrition. Methods: From January 2007 to June 2009, trace elements panel (Se, Zn, Cu, Mn, Cr) was monitored in 80 PN patients at risk by clinical criteria. Based on a series of lab data, patients were categorized into normal, below normal and above normal, which were correlated with their primary underlining conditions. Potential for false abnormality based on disease state (i.e. inflammation) was noted in the patients. Results: Among the 80 PN patients monitored, a range of 1 to 3 trace elements labs in 53 patients were below normal (66%): 39 patients lab low in Zn (48.75%), 39 patients’lab low in Se (48.75%) and 15 patients’ lab low in Cu (18.75%). Meanwhile, Cr and/or Mn labs in 41 patients were above normal (51%). When correlating diseases and clinical status with trace element data, our observation revealed the lower than normal trace element level in the following subpopulation of PN patients: 11 out of 14 Crohn’s dis-ease patients, 12 out of 21 recurrent or newly developed fistula patients, 10 out of 11 gastric bypass patients, 5 out of 5 short gut patients, 6 out of 6 prolong diarrhea patients, 3 out of 9 critical ill with prolonged PN patients, 3 out of 9 oncology PN patients, 3 out 3 patients on prolonged PN due to FTT or GI hypo-motility, and 0 out of 2 patients with refrac-tory emesis. Conclusions: Results showed that PN patients with malab-sorption / malnutrition are at increased risk of essential trace elements deficiency (Zn, Se, and/or Cu), while patients with prolonged PN are at increased risk of exposure to excessive trace elements (Mn and/or Cr). Monitoring serum trace panel provides a useful tool for assessment of nutrient abnormalities.
Neonatal
P51 - A Comparison of Efficacy of Heparin 0.5 unit/ml versus Heparin 1 unit/mL in Parenteral Nutrition Administrated in the Neonatal PopulationJane Gervasio, Pharm.D., BCNSP1,2; Meredith McKinney, Pharm.D. Candidate1; Iftekar Kalsekar, PhD1; Elaina Szeszycki, Pharm.D., BCNSP2
1Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, Indianapolis, IN; 2Clarian Health Partners, Indianapolis, IN. Introduction: Heparin is utilized in neonatal parenteral nutrition (PN) to maintain line patency. Adverse effects of heparin have been associated with bleeding and thrombocytopenia. Determining the lowest effective dose of heparin necessary to prevent loss of intravenous access is opti-mal. A retrospective study from our institution reported no differences in efficacy between 0.5 unit/mL and 1 unit/mL of heparin in PN which prompted a prospective investigation. The purpose of this trial was to prospectively compare line patency and safety between neonates receiv-ing PN using heparin dosages at 1 unit/mL and 0.5 unit/mL. Methods: This study was a prospective, observational chart review. Neonates admit-ted to either Riley Children’s Hospital or Methodist Hospital Neonatal Intensive Care Unit (NICU) receiving PN were eligible for enrollment into the study. NICU patients receiving heparin for therapeutic indica-tions were not included. Neonates were followed to determine if a dif-ference in line patency was observed between patients receiving 0.5 units/mL of heparin compared to those receiving 1 unit/mL of heparin in the PN. Demographic information was collected as well as heparin induced complications including thrombocytopenia, bleeding and line hemorrhaging. Data was analyzed on intent to treat basis. Number of complications between 0.5 unit/mL and 1 unit/mL of heparin were assessed using chi square tests. All statistical analyses were conducted using the Statistical Package for Social Sciences. Results: Ninty-one patients were enrolled with an equal distribution observed between males (50.5%) and females (49.5%). As expected, the majority of admissions
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Table 1Outcomes and complications associated with heparin administration.
0.5 unit/mL 1 unit/mL N=65 N=26 p < 0.05
Thrombocytopenia 26.4% 5.5% 0.137 Line changes due to 5.5% 4.4% 0.270 complicationsOcclusion 0% 1.1% 0.286
P52 - A Survey Of Nutrition Support Practices In The Neonatal Intensive Care Unit And Their Impact On Weight Gain Velocity.Elizabeth P. Bustamante, RD1; Miharu A. Sato-Sen, MS,RD,CDE1; Melissa Einfrank, MS,RD,CSP1; Susan Bristol, MS,RD,CNSD1,2; Stephanie Schaning, BS, Dietetic Intern1; Alissa Lorchick, BS, Dietetic Intern1; Margaret C. Blandin, BS, Dietetic Intern1; Andres Valenzuela, BS, Dietetic Intern1
1Nutrition Services, University Medical Center, Tucson, AZ; 2University Medical Center, Aramark Healthcare, Tucson, AZ. Introduction: Infants born prematurely often require adjuvant nutrition support because of their immature gastrointestinal tract and inability to feed orally. A combination of parenteral (PN) and enteral nutrition (EN) is typically required. Initiation time and amounts of PN/EN given to a premature infant in the Neonatal Intensive Care Unit (NICU) have been shown to directly impact weight gain velocity. Current published guide-lines recommend providing at least 110 kcals/kg/day and 3-4 gm protein/kg/day. Satisfactory weight gain is considered to be 15 gm/kg/day. Objective: To identify the links between nutrition provision and growth velocity in the neonatal population at University Medical Center (UMC) in Tucson, AZ. Methods: QI data was collected on premature infants admitted to the NICU over a 24-month period as a retrospective review. Data was collected until discharge from the NICU or until the patient reached >40 weeks corrected gestational age. Due to anticipated weight loss after birth, weight change was not analyzed until the infant reached 2 weeks of age when birth weight is typically regained. Criteria for inclu-sion were infants born at >28 weeks and <33 weeks and infants receiving expressed breast milk (EBM) or formula via gavage or bottle. The caloric value assigned to EBM was 20 kcal/oz. Criteria for exclusion were infants born with pulmonary hypertension, congenital heart disease, renal failure or intestinal defects because these patient populations often have differ-ent nutrient needs. Patients that developed necrotizing enterocolitis dur-ing data collection were excluded. Due to the difficulties in quantifying the volumes taken in by infants who were breastfed, this population was also excluded. The total number of patients reviewed in this investigation was N=52. Weight and nutrient provision from intravenous fluids, PN, EN, and/or a combination of the three were collected. Microsoft Office Excel® and SPSS 17® were used to analyze the data collected. Hypothesis
into the NICU included prematurity (72.5%) and respiratory distress (64.9%). Initial concentrations of 0.5 unit/mL of heparin were adminis-tered in 71.4% of neonatal PN. Outcomes and complications associated with heparin administration are reported on Table 1. Line removal was associated with diagnosed sepsis in 4.4% of the patients. Conclusions: There were no significant differences in line patency between neonatal patients receiving 0.5 unit/mL or 1 unit/mL of heparin in their PN. Smaller dosages of heparin at 0.5 unit/mL appear to maintain line patency and may result in less drug induced adverse outcomes com-pared to the use of higher dosages of heparin. Further investigation is necessary to determine the minimum effective dosage of heparin in PN that will still maintain line patency.
testing and correlation analysis was used to analyze the data. Results: For this QI study, 34% of infants received the recommended calorie and pro-tein provision. There was no significant correlation between caloric provi-sion and weight gain for the study group (p=0.064). Patients receiving >110 kcal/kg/day (N=18) and an average of 3.49 gm protein/kg/day, gained an average of 14.4 gm/kg/day. Patients receiving <110 kcal/kg/day (N=34) and an average of 2.72 gm protein/kg/day, gained an average of 12.32 gm/kg/day. Conclusions: For this QI study, the difference between nutrient provision and weight gain for the two calorie groups was not statistically significant. When plotted, it was noted that the data set had two extreme outliers. The Pearson correlation test was then run excluding these two outliers showing a correlation between calories received and weight gain (P<0.01). Further investigation and a larger sample size are needed to provide more conclusive results.
Neurological Disorders
P53 - Prognostic Factors for Oral Intake Ability in Acute SAH PatientsKoichi Miyakoshi, MD1; Fumiaki Katada, MD, MPH, CNSC2
1Department of Rehabilitation Medicine, Kameda Medical Center, Kamogawa City, Chiba Prefecture, Japan; 2Department of Neurology, Kameda Medical Center, Kamogawa City, Chiba Prefecture, Japan. Introduction: As described in ASPEN’s guideline, physicians must con-sider using tube feeding, when the patients cannot take meals orally for a long period. Therefore, the prediction of their future ability of oral intake is mandatory. But prediction of the oral intake ability in acute stage patients is frequently tricky and unintelligible. Especially on sub-arachnoid hemorrhage (SAH) patients, it is difficult to predict their destined oral intake ability in acute stage, because their symptoms or clinical courses are complicated. In this presentation, we report the relationship between factors in SAH patients on admission and oral intake ability at discharge, as a preliminary study for development of a more precise model of oral intake ability prediction. Methods: The subjects were consecutive acute SAH patients who admitted to our hospital, from January 2004 to December 2008. Exclusion criteria were difficulty of oral intake before SAH attack and death during inpatient period. We picked up the factors described below, from our medical records retrospectively. The prognostic factors were age, Fisher group of CT findings and Hunt and Kosnik grading. The ability to have meals orally to the full extent of their nutritional requirement was chosen as the outcome indicator. The patients who depend on tube feeding par-tially were considered to be those who failed in oral intake. After uni-variate analysis by using chi square test or Student’s t-test, logistic regression analysis was done. To complete these statistical analyses, we used the software package SPSS15.0 Japanese edition, P<0.05 was considered to be statistically significant. Results: The participants were 192 patients (65men and 127 women), the age was 32 to 98 years old (mean 63.0). Length of hospital stay was 10 to 394 days (mean 57.1). Of these, 32 patients cannot consume food orally, or depend partially on tube feeding. All values were statistically significant in univariate analy-sis. According to either of the logistic regression analyses, all factors were statistically significant. The odds ratios of age was 0.922 (95%CI: 0.886-0.959), those of Fisher group was 0.414 (95%CI: 0.187-0.916) and those of Hunt and Kosnik grading was 0.622 (95%CI: 0.403-0.962). Applying our prediction model (equation which derived from logistic regression analysis), the sensitivity was 87.5%, specificity was 62.5%. A receiver operating characteristic curve fitted to this model had an area under the curve of 85.8%. (Figure) Conclusions: The factors which predict the ability of fated oral intake in acute SAH patients were age, Fisher group, Hunt and Kosnik grading. From this analysis, we attempt to create prognostic model of oral intake ability. Using the equation from the logistic regression analysis, the sensitivity was 87.5% and the
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Figure. Receiver operating characteristic curve for logistic regression model of factors predicting outcome on oral intake ability.
P54 - Enteral Nutrition Practice in the Neurosurgical Intensive Care UnitLinda Creasey, RD CNSD; Christina Szabo, RN; Nam Tran, MD; Bruce Mathern, MDVCU Health Systems, Richmond, VA. Introduction: Hypermetabolism in traumatic brain injury patients is well documented in the literature and has resulted in treatment guide-lines by the Brain Trauma Foundation. A prospective review was under-taken to evaluate effectiveness of an evidence based treatment protocol of nursing placed feeding tubes and feeding advancement in head injured patients. Data were collected on when patients had initiation of nutrition support, met caloric goals, and when patients were cleared for oral intake. These results were also analyzed to determine the need for long term feeding access. Methods: Data was collected by the service dieti-tian on patients admitted to the Neuroscience Intensive Care Unit, excluding spinal cord injury, brain tumors, and stroke over a four month period. Patients were followed by the service dietitian once transferred to the floor or rehabilitation unit for date of peg placement and/or oral intake. Results: A total of 102 patients were followed, 29 patients met criteria for enteral nutrition support. A summary of findings are repre-sented in Table 1. Conclusions: Traumatic head injured patients had nutrition support initiated consistent with the Brain Trauma Foundation Guidelines. Patients fed via nasogastric tubes were more likely to achieve goal rate within 7 days than those fed via the intestine. Patients fed gas-trically were more likely to receive a PEG than the nasointestinal feeding group, who were fed until they achieved oral intake. The majority of the patients receiving PEG tubes achieved oral intake over the next month. Education regarding the use and effectiveness of nutrition support pro-tocols is ongoing with intensive care unit staff and physicians.
Table 1
Nasogastric Nasointestinal (N=24) (N=5)
% Mortality 33% (N=8) 20% (N=1) Glasgow Coma Score 3T-14 3T-12 on admissionDays to Initiation 2.7 2.6 Goal calories by day 7 65% 25% Patients on oral intake by day 7 29% (N=7) 20% (N=1) Patients on oral intake day 8-13 38% (N=9) 20% (N=1) Patients on oral intake day 14-30 46% (N=11) 80% (N=4) Patients receiving a PEG 5 0 Patients on oral intake after 3 0 day 30 and PEG placement
*Encore Presentation: Food and Nutrition Conference and Expo, 2009; Neurocritical Care Society, 2009, J Am Diet Assoc Volume 109, Issue 9, Supplement (September 2009) page 134;Neurocritical Care Volume 11, Number 2 (October 2009) Supplement, in press
specificity was 62.5%. To improve the precision of the prediction model, and to make this prognostic model more useful, we intend to incorpo-rate more prognostic values and follow up the long term outcome.
P55 - Differences in Resting Energy Expenditure of Critically Ill Neurology Patients Admitted to a Neuroscience Intensive Care UnitChristine Hartney, MS, RD, CNSC, LDN1; Kathryn Keim, PhD, RD, LDN1; Diane Sowa, MBA, RD, LDN1; Richard Temes, MD, MS2
1Department of Food and Nutrition Services, Rush University Medical Center, Chicago, IL; 2Department of Neurological Sciences, Rush University Medical Center, Chicago, IL. Introduction: Indirect calorimetry measurements are routinely per-formed on patients admitted to an intensive care unit to determine appropriate caloric delivery through nutrition support. Patients admitted to a neuroscience intensive care unit have high metabolic demand as a result of the insult or injury regardless of BMI status, gender and race. Looking at results of indirect calorimetry measurements performed patients admitted to a neuroscience intensive care unit, we sought to determine if differences in energy expenditure and a high metabolic demand was seen in patients admitted to our institution.The objective of this study was to compare differences in resting energy expenditure (REE) results of critically ill neurology patients based on gender, body mass index (BMI) class and race. Methods: This study was a retrospec-tive chart review of patients admitted to the Neurosciences Intensive Care Unit at an urban medical center who were started on enteral nutri-tion support. Results: Forty-six patients (25 male) with average age of 56.3 + 2.3 years (mean + standard deviation) and BMI= 28.2 + 1.2 kg/m2 met inclusion criteria and had at least one metabolic cart measure-ment with a Medgraphics CPX Ultima Metabolic Cart (Medical Graphics Corporation, Minneapolis, MN). Results of the male mean REE was 2213 + 734 kcal and female mean REE was 1992.2 + 597 kcal. There were no significant differences in measured REE based on gender (p=0.289), BMI class (p=0.783), and race (p=0.406). Conclusions: The differences between gender, BMI class and race may not have been detected as a limitation of the sample size. Research is needed to further explore the relationship among gender, BMI class and race and use of established predictive equations for the critically ill neurology patient. The research methods received approval from the Institutional Review Board for Human Studies.
Nutrition Assessment
*Encore Presentation: , Vascular Health and Risk Management 2008:4(5)
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P56 - Under and Over Reporting of Energy Intake in a Group of Candidates for CABG Surgery and its Association with some Anthropometric and Socio-Demographic Factors, Tehran, IranBahareh Amirkalali, MS1; Mehdi Najafi, MD2; Asal Ataie-Jafari, MS1; Saeed Hosseini, MD,PhD1; Ramin Heshmat, MD, PhD1
1nutrition, The Endocrinology and Metabolism Research Centre (EMRC) of Tehran University of Medical Sciences (TUMS) and Tehran Heart Center, Tehran, Iran; 2Tehran Heart Center, Tehran, Iran. Introduction: Numerous studies have documented a high prevalence of underreporting energy intakes from 24-hour food recalls, food records and food-frequency questionnaires. Many of these studies have shown that underreporting is not random, but is related to characteristics such as obesity, smoking, dieting and psychological factors. Most of these studies have been performed on a healthy population but as it is clear accurate evaluation of dietary intake is very important in some diseases like cardiovascular problems which life style especially diet has a great effect on their procedure. So this study examines the prevalence of under and over reporting of energy intake in a group of candidates for Coronary Artery Bypass Graft (CABG) surgery and its association with BMI and some socio-demographic factors. Methods: Dietary assessment (using a food frequency questionnaire) and demographic evaluation of 449 CABG surgery candidates was performed. Weight and height was also measured. McCrory equation was used to identify inaccurate records of energy intake. With this equation, reporting energy intake less than 78% and more than 122% of predicted energy expenditure was considered as under and over reporting respectively. Results: Less than half of the participants reported energy intakes within the plausible limits. There were more over reporters than under reporters in this sample. The only significant association between misreporting and related factors was seen in BMI groups. As BMI increased the number of under reporters increased significantly. Expressed as a percentage of total energy, mean carbohydrate intake was significantly lower and mean fat and protein intake was significantly higher in under reporters compared to over reporters. Conclusions: The high prevalence of misreporting suggests more research to examine the characteristics of misreporters. Calibrating data, with these characteristics can help to improve intake estimates.
P57 - Serum Albumin Levels as Nutritional Index for Patients Having Abdominal Pain in Gastrointestinal DepartmentWataru Sano, Digestive SurgerySurgery, Kamitsuga General hospital, Kanuma, Tochigi, Japan. Introduction: Serum albumin level is valuable as nutritional index, but is influenced by dehydration or inflammation. In gastrointestinal depart-ment, serum albumin levels at the time of hospitalization is especially affected by dehydration (ileus, enteritis), inflammation (acute appendi-citis, cholecystitis). After adequate medical treatment, serum albumin levels return to their usual level which indicates their true nutritional status. So we introduced a form estimating serum albumin value after treatment by calculating several clinical data at the time of hospitaliza-tion. Methods: A total of 181 patients having abdominal pain and taken to hospital in gastrointestinal department were enrolled. Patients with duration of hospitalization more than two weeks or having major surgery were excluded because nutritional status of these patients could change for the worse during hospitalization. In this study, patients got well by medication or had only minor operation. The patients’ level of albumin at the time of hospitalization were measured from May 2005 to July 2009 which were compared with albumin levels after treatment. Multiple regression analysis was made with age, albumin, CRP and specific gravity of urine at the time of hospitalization. Usually we esti-mate level of dehydration by comparing current hemoglobin level with previous hemoglobin level which often could not provided at the time of
hospitalization, so we used gravity of urine for estimation of dehydra-tion. CRP levels stand for grade of inflammation. Results: The average age of these patients were 62 years old. The value of serum albumin in all patients at the time of hospitalization was 4.1±0.5g/dl. But the value of serum albumin after treatment was 3.6±0.5g/dl. Chief disease of these patients were ileus(n=53), appendicitis(n=35), cholecystitis(n=30), enterocolitis(n=18) and inguinal hernia(n=16). A form for estimation of albumin level after treatment was made by multiple regression analysis and completed as follows: Y=3.382-0.06×age+0.002×CRP+0.548×alb-1.629×urine gravity. Estimated value of albumin was 3.6±0.3 g/dl. This estimated albumin level was significantly correlated with albumin level after treatment (p<0.01). Correlation efficient was 0.668. Conclusions: The value of serum albumin is known to be influenced by dehydration or inflammation. By introducing specific gravity of urine which stand for grade of dehydration and CRP levels which stand for grade of inflamma-tion, accurate albumin level as nutritional index at hospitalization could be calculated.
P58 - An Interdisciplinary Approach to the Prevention of Pressure UlcersDenise Andersen, MS RD LD CLC1; Sue Sendelbach, PhD, RN, CCNS, FAHA2; Samantha Moscoe, RD LD1
1Nutrition Services, Abbott Northwestern Hospital, Minneapolis, MN; 2Nursing, Abbott Northwestern, Minneapolis, MN. Introduction: A Skin Integrity Workgroup of a large multi-hospital system in the Midwest was formed with the goal of prevention of pres-sure ulcers. Methods: A review of the literature provided evidenced-based guidelines that included nutritional intervention as one of the key strategies for pressure ulcer prevention. In addition to nursing educa-tion for Skin Inspection, the documentation of the Braden score in the Electronic Medical Record (EMR)will benefit other disciplines includ-ing the Registered Dietitian (RD)to provide nutrition intervention. The Skin Integrity Workgroup developed guidelines for the identification of patients and education of staff for the delivery of these guidelines. Results: The Result included development of Policies and a Nutrition Intervention Protocol which prompts action when a patient’s Braden score is 14 or less and a nutrition subscale score of 2 or less for 3 con-secutive days. Upon the order received from the Licensed Independent Practitioner (LIP) the Nutrition Intervention Protocol (NIP) is docu-mented in the Electronic Medical Record (EMR)with the interventions listed. Conclusions: A magnet designed as an Iceberg will be placed outside the room of the patient. This will be a notification to nursing and other hospital staff the patient is at risk for pressure ulcers. Documentation in the EMR will be followed daily by the Registered Dietitian (RD) and nutrition intervention may occur and include indi-rect calorimetry, oral nutrition supplements, modular diet components, multivitamins, minerals, enteral nutrition, a fiber containing module. The identification of patients that meet specific criteria for developing Pressure Ulcers will initiate interdisciplinary intervention. The Skin Integrity workgroup will conduct ongoing study of patients identified to be at risk for the development of Pressure Ulcers.
Nutrition Education
*Encore Presentation: European CF conference, Brest 2009P59 - A Dietetic and Psychological Behavioral Approach towards Treating Food neophobiaLilach Peleg-Weiss, RD Bsc1,3; Edwina Landau, Clinical Psychologist. Dr2,3; Yael Lebenthal, MD4; Irit Poraz, RD Bsc MA1; Hannah Blau, MD Prof3
1clinical dietetics, schneider children’s medical center of Israel, Petach-Tikva, Israel; 2clinical psychology, schneider children’s medical center of Israel, Petach-Tikva, Israel; 3CF center,
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schneider children’s medical center of Israel, Petach-Tikva, Israel; 4endocrinology, schneider children’s medical center of Israel, Petach-Tikva, Israel. Introduction: Bone disease has emerged as a common complication in long- term survivors of CF. Decreased bone mineralization can lead to pathological fractures and kyphosis earlier than expected. One of the risk factors that can accelerate this process is a low intake of calcium and reduced levels of vitamin D. This can be influenced by individuals who suffer from food neophobia (picky eater) since they have a limited dietary repertoire. Food neophobia is defined as the avoidance and reluctance to taste unfamiliar foods. Methods: not relevant Results: We present a 16 years old girl with atypical CF, pancreatic sufficient, who suffers from severe idiopathic scoliosis. The patient had recurrent ante-rior spinal fusion. On DEXA we found severe osteoporosis (left hip; Z score -2.9, spinal; Z score -4.4). We also found vitamin D deficiency (13ng/ml), despite receiving calcium and vitamin D supplements. In addition the patient had suffered from food neophobia meeting the criteria as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Accordingly, the patient had an extremely limited food repertoire, exhibited marked and unreasonable fear of cer-tain foods, as well as immediate anxiety upon exposure to these foods and avoidance of them. In order to improve her food repertoire and nutritional status we implemented a dietetic psychological behavioral model. The intervention included joint and separate meetings with the psychologist and dietician, biweekly for 8 weeks. The psychologist worked on a variety of techniques including relaxation training, system-atic desensitization and imagery use as well as cognitive shaping and restructuring. Psychological treatment began before actual in vivo food exposure. The dietician was responsible for nutritional counseling and education as well as in vivo exposure to feared foods. This treatment focused on exposure to milk and dairy products. After the intervention, the patient progressed to eating milk and dairy products with less diffi-culty. As a result, her dietary calcium intake significantly improved to 65% of the DRI recommendations and stabilized. Conclusions: This paper presents an atypical CF patient with severe osteoporosis, despite receiving 100% calcium recommendations from additives. Food neopho-bia which is common in infants and toddlers was found in this teenage patient. In view of these findings, nutritional and psychological inter-vention was necessary to improve her dietary intake. We still do not know the long lasting effect on osteoporosis. Joint interventions, using both dietetic and psychological approaches, can be beneficial in treating food neophobia.
P60 - Multimedia Programs Focused on Catheter-related Infection AvoidanceCarol Ireton-Jones, PhD, RD, LD, CNSD1; Ezra Steiger, MD2; Bob Saggi, MD3; Lillian Harvey-Banchik, MD4; Mark H. DeLegge, MD5,1; Carlota Bentley, BS1
1Coram, Denver, TX; 2Cleveland Clinic, Cleveland, OH; 3Memorial Hermann, Houston, TX; 4North Shore Hospital, Great Neck, NY; 5MUSC, Charleston, SC. Introduction: One of the most serious complications of home parenteral nutrition (HPN) is a catheter-related blood stream infection (CRBSI). Earlier this year, a group of physician thought leaders in Home Parenteral and Enteral Nutrition (HPEN) identified CRBSI as an area of concern for practitioners as well as an area where enhanced education could be ben-eficial for both patients and clinicians. Patient care and safety are key concerns as a central line infection or blockage may be life threatening if the line must be removed; resulting in a lack of access for nutrition and potentially a loss of venous access sites. CRBSI and its associated sequel-lae may be decreased or avoided with proper clinician and patient educa-tion. Policies and procedures as well as standards of care on avoidance of CRBSI are not consistent among providers. Visual as well as written instructions have been shown to improve understanding of educational
materials provided. Methods: Taking this information into account, the HPEN physicians worked together to develop a number of new multime-dia resources for patients and clinicians focused directly on the avoidance of catheter-related infections. These were designed to be accessible through a website specifically designed for patients as well as through a live educational webinar series. The online educational series featured videos viewable from a patient focused component of a provider web site; however, these are accessible by any consumer or clinician and are not limited by a password for healthcare practitioners alone. The first two videos in the series focus on how consumers can change their end cap and how to mix a dual chamber bag of PN. These were introduced at the annual Oley Foundation consumer conference in St. Petersburg, Florida in June, 2009 with additional videos to be added Results: Another com-ponent of this education program utilized a live web cast (webinar) series aimed at practicing clinicians and focused on four key topics identified by the HPEN Working Group physicians These four key topics and present-ers were - Identification of Patients At Risk for CRBSI - Dr. Bob Saggi (Houston), Prevention and Treatment of CRBSI - Dr. Ezra Steiger (Cleveland), Central Line Occlusion Prevention and Treatment - Dr. Lillian Harvey-Banchik (New York) and Patient Education - Dr. Mark DeLegge (Charleston, S.C.) These web casts lasted approximately 30 to 45 minutes with a lecture followed by an open period of questions and answers from the audience to the speaker. Dietitians and nurses received one hour of continuing education credit for each webinar attended. More than 1000 clinicians have participated in the live web casts. These are also posted to the website in the clinician/practitioner focused section. Conclusions: Education in the area of prevention and treatment of CRBSI can be accomplished through online video access for patients (consumers) and web cast/recordings for clinicians.
P61 - Oral Rehydration Solutions: Understanding Choices for Improved OutcomesCarol Ireton-Jones, PhD, RD, LD, CNSDCoram, Denver, CO. Introduction: Oral rehydration solutions (ORS) can be useful in an intestinal rehabilitation program as well as an ongoing adjunct in treat-ment for short bowel syndrome (SBS). Most patients who have increased output and require fluid supplementation have SBS or a similar diagnosis that causes increased gastrointestinal (GI) losses. Many depend on home parenteral nutrition (PN). However, advances in drug therapy, medical nutrition therapy and clinical care have led to increased utilization of specialized diet and fluid interventions to reduce dependence on home PN. The key components of an ORS are fluid (usually water or a hypotonic or calorie free fluid), sodium and sucrose. Additional ingredients which can be added are potassium and bicarbonate. Commercial ORS’ are available but are expensive and may be difficult to find. Sports drinks may not have the appropriate electro-lyte and carbohydrate levels for patients with SBS. Low-cost, easy to obtain and palatable recipes are available as well. However, many con-sumers are not aware of the application of ORS to improve health status. Methods: “Hands on” sessions on ORS were held at the Oley Foundation Consumer and Clinician Conference with home PN con-sumers predominately in attendance. An overview of the rationale for the use of an ORS as well as the function of the components was pro-vided. Eight different ORS solutions were mixed by those attending and taste-tested. The solutions included the World Health Organization (WHO) ORS and 6 ORS with a beverage or juice base. The ORS which contained a sugar-free, clear soda mixed with added sucrose and sodium chloride as well as a zero calorie orange flavored drink mix was liked best. The WHO ORS which contains water, potassium chloride, sodium chloride, sodium bicarbonate and sucrose, was second with the comment that it tasted like “soft water”. Juice based ORS’ were favored based on personal preference for the juice and the sports beverage base with added water and sodium chloride was the least preferred; however
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the lower carbohydrate sports beverage with added sodium improved acceptability. All consumers stated that they had enhanced their knowl-edge of the use of an ORS and improved their confidence in being able to make their own solution which could “taste good”. Food choices, taste tests and recipes have been added to enhance the consumers experience and education. One consumer sent a follow up and said that she had never been told how to choose an ORS and after learning about and taste-testing each solution, she began drinking the WHO ORS and successfully increased her urine output. Results: These sessions show that “hands on” taste tests/discussions can be the best method to dem-onstrate the use and palatability of ORS and that compliance to daily intake is achievable. Conclusions: Clinicians who are working with patients with SBS who are on home PN should not only be aware of these ORS “recipes” but should provide an opportunity to mix and taste with their consumers. It is fun and allows consumers and their family to actively participate in their care.
Nutrition Support Teams
P62 - Hardwiring the Nutrition Support Team’s objectives with the Institute of Medicine’s Quality TriangleLisa M. McDowell, MS, RD, CNSD; Jeffrey Sanfield, MDPharmacy Department, St Joseph Mercy Health System, Ann Arbor, MI. Introduction: Registered Dietitians (RD’s) working in an inpatient acute care hospital are uniquely poised to impact patient outcomes. Commercial insurance providers and The Centers for Medicare & Medicaid Services (CMS) offer incentives and superior reimbursement to hospitals that exceed best practice benchmarks. The American Hospital Association (AHA) Quality Center™ provides access to tools that support hospital initiatives for quality improvement. In 2001, the Institute of Medicine (IOM) described six quality aims that provide a foundation for the implementation of the AHA quality and patient safety agenda. These six aims include: patient safety, patient-centeredness, efficiency, effectiveness, timeliness and equity. In collaboration with the medical and surgical initiatives, our objective was to align the nutrition support service with relevant quality objectives within each service line to further advance patient outcomes. Partnering with physician champi-ons allowed for the implementation of hospital-wide policies, proce-dures, protocols, privileges, and computerized order-entry pathways. Hardwiring safety initiatives with quality care components such as departmental order sets provided consistent care delivery and improved patient metrics. Methods: Privileges and scope of care were clearly defined for each RD specific to the applicable service line. Objectives and metrics were planned with respective physician service line leaders and the RD. Data collection was hardwired in the departmental comput-erized pathways. Each RD was evaluated on the respective metrics as part of a pay for performance job appraisal. Results: Improved out-comes and achieved metrics created an essential staffing productivity requirement within each service line, which provided justification for staffing levels. Minimum FTE staffing models were approved to main-tain efficiencies and outcomes realized. The results included major improvements in the six IOM quality aims. Examples of the metric results include <7% minor/major complications with permanent enteral feeding tubes, 98% appropriate parenteral nutrition utilization, improved PICC line placement criteria, 94% compliance for nutrition risk screen-ing, < 48 hour consult response time, NICU breastmilk utilization increase, incidence of catheter-related infections decreased 26%, and <2 day to enteral feeding goal in the ICU. Conclusions: Utilizing the IOM quality standards to align RD objectives resulted in significant quality improvements pertinent to each service line. Other benefits included established credentialing privileges with a clearly defined scope of care for the RD’s, which improved employee engagement scores and job satisfaction in the 99th percentile, thus resulting in no staff turnover in two years.
P63 - Resection, Rehabilitation and Recovery - Against All Odds; the Impact of a Home Nutrition Support Team on Fostering Bowel Adaptation in a Patient with Short Bowel SyndromeRobin A. Nagel, RD1; Larry Good, MD2
1Coram Healthcare, Plainview, NY; 2Gastroenterology, South Nassau Communities Hospital, Oceanside, NY. Introduction: This case is a 44-year-old female who underwent three embolectomies and small bowel resection due to a superior mesenteric infarction leaving her with extensive short bowel syndrome (SBS). Operative reports noted the duodenum was unaffected; however, only 15cm of proximal jejunum and 10cm of terminal ileum were viable. A proximal jejunostomy and a mucous fistula of the terminal ileum were created with the intact colon. Methods: In January 2008 the patient was discharged home on Parenteral Nutrition (PN). She was simultane-ously referred to an Intestinal Transplant Center for evaluation with the expectation of eventual small bowel transplantation. Prior to discharge, the dietitian (RD) at the home infusion provider, conferred with the physician to discuss the optimal home PN formulation. Post discharge, weekly communication occurred between the patient, physician and home care clinicians with continual modification to the home PN regi-men. Modifications included the following: addition of an H2 blocker, compression of home PN hours and reduction in amino acids to prevent hypercalcuria. Despite conservative home PN calories, the patient gained non-fluid weight and it was determined that absorption of oral intake, permitted for comfort, was occurring even with the proximal location of the jejunostomy. Oral rehydration solutions (ORS) were introduced to provide adequate fluid intake while total home PN calo-ries were reduced. Results: After four months the patient underwent reanastomosis of the 40cm of small bowel to her healthy colon remnant with placement of a gastrostomy tube (GT). Trophic enteral nutrition (EN) of a peptide-based formula was ordered by the transplant team at a rate of 5ml/hr over 12 hours, with a goal of 25ml/hr. She was also permitted small amounts of solid food/hyposmolar liquids and was extensively educated on diet for SBS with colon in continuity. From this point, the patient’s gastroenterologist and homecare team assumed pri-mary direction of the bowel rehabilitation process. The patient’s course was complicated by sepsis and acute renal failure related to Cresentic Glomerular Nephritis. Additionally, she developed pneumoperitoneum, without peritonitis, related to steroid use. Throughout these medical challenges the patient continued on EN and PN and maintained her nutritional status. EN was converted to a polymeric formula containing soluble fiber with added glutamine. Despite reduction in steroid dose, limited home PN calories and low dose EN, the patient was gaining weight indicating further improvement in enteral absorption. Home PN was discontinued and an EN regimen of ORS, glutamine and approxi-mately 500 kcals of enteral formula continued in conjunction with an oral diet. The patient reported further weight gain and excellent toler-ance to the oral diet, including foods outside a typical SBS menu. A localized infection at the patient’s GT site necessitated removal, and the patient declined GT replacement. Oral vitamin and mineral supple-ments were prescribed as needed. Conclusions: After 15 months of home EN and PN, the patient was nutritionally independent as she was consuming a predominantly unrestricted diet with supplemental ORS. The patient was discharged from homecare. Today she enjoys working, traveling and spending unencumbered time with family and friends.
P64 - Establishing a Small Bowel Feeding Tube Insertion TeamMarsha Davis, BSN, RN, CNSC; Karrie Derenski, PharmD, BCNSP; Donna Richardson, RD, LD, CNSD; Ann Weiss, RD, LD, CNSD; Karen Dameron, RPh, CNSC; Konni Hall, BSN, RN, CNSC; Rose Lancaster, BS, RNMetabolic Support Services, CoxHealth, Springfield, MO.
CNW 2010 Nutrition Practice Abstracts 25S
Introduction: Enteral nutrition (EN) is a safer, cost effective and physiological sound alternative to parenteral nutrition (PN) for patients who are unable to meet their nutritional needs per an oral diet. Use of EN compared to PN has resulted in decreased infection rates, reduction in intensive care stay, lower cost of nutritional care and perservation of intestinal function by promoting efficient utiliza-tion of nutrients. Providing EN through a gastric feeding tube in the critically ill population poses potential problems; including increased residuals, abdominal distention and increased risk of aspiration. Placement of bedside small bowel feeding tubes (SBFT) has the ability for earlier initiation and less interruption of feeds, less exposure to radiation and significant savings in cost and time. To increase EN suc-cess rate and decrease PN usage, a dedicated team within Metabolic Support Service (MSS) was created to place bedside SBFT using the corkscrew method. Methods: Initially, MSS had a lecturer experienced in placing SBFT provide a talk and assist with training. MSS developed policies and procedures that were approved by the organization. In-services were provided to medical support staff about the new ser-vice. SBFT were initially placed in critical care units using an approved list of inclusion and exclusion placement parameters. Due to the initial success of SBFT placements and the need for 6 day coverage, addi-tional nurses were hired. The preliminary success rate was 97%. However, with the addition of less experienced team members the suc-cess rate declined to 89% with an average placement time of approxi-mately 55 minutes. To improve the success rate and decrease placement time, an electromagnetic tube placement device was acquired. After some changes in hospital policies, a pharmacist member of the MSS team became successful with SBFT placement. Data was collected on the reason for placement, time to place, and results of x-rays. Census data that includes EN and PN usage continued to be collected. Results: Comparing PN usage from January through July 2004 to January through July 2009, the total PN therapy days per month declined significantly by 11%. Monthly average is 65 SBFT placements with a sustained 96% success rate. Placement times average eighteen minutes with one x-ray to confirm SBFT placement. Conclusions: The formation of the SBFT team has had an impact in the reduction of PN therapy days. The 96% success rate with SBFT placement surpasses other published average success rate. Placement of SBFT is a highly technical skill that takes months to acquire, and demands continued placement on a daily basis to maintain proficiency. As the success rate increased so have the responsibilities. The team now places difficult gastric tubes after failed attempts by the bedside nurse to avoid trans-port to radiology for placement. This has drastically reduced the need for fluorscopy placed nasogastric access. The outstanding reputation of the dedicated SBFT placement team has lead to improvement in nutritional care and less exposure to radiation. It has also shown a significant savings in time and resources.
P65 - Appropriateness of Central Parenteral Nutrition in an Academic Hospital SettingChristi Arthur, RD, LDN, CNSD1; Renay D. Tyler, MSN, ACNP, CNSN1; Dana M. Leong, BSN2
1Parenteral Enteral Support Service, The Johns Hopkins Hospital, Baltimore, MD; 2School of Nursing, Johns Hopkins University, Baltimore, MD. Introduction: The Parenteral Enteral Support Service (PESS) at The Johns Hopkins Hospital is a multi-disciplinary team responsible for consultation and management of adult central parenteral nutrition (CPN) support. Appropriate use of CPN was identified as a perfor-mance measure based on a growing concern that providers were pre-scribing CPN without regard to nutritional status, length of therapy or level of gastrointestinal function. Methods: The literature was reviewed and rated with regard to quality and scope. Consensus was reached on
appropriate indicators for CPN and incorporated into a tool for assess-ment and data collection. The tool was piloted for a period of 2 months and revised to better define the subjective portion where “appropriate-ness” was determined. Results: A concurrent review of 61 CPN requests over a 9 week period revealed that PESS agreed appropriate criteria was met for CPN in 48 patients(79%). In the remaining 13 patients (21%), PESS was successful in guiding prescribers to a more appropriate therapy (peripheral parenteral nutrition, enteral or oral) in 7 patients (54%). Additional data will be collected and correlations between inappropriate CPN requests and particular groups of patients explored. Conclusions: The literature review was critical in developing a tool with evidence-based indicators for assessing appropriateness of CPN therapy. Initial results indicate an overall compliance with PESS recommendations for appropriate use of CPN and the ability of a nutri-tion support team to influence prescriber practice and avoid inappro-priate CPN therapy.
P66 - Parenteral Nutrition Support Team in a Singapore Tertiary Hospital - a 6-month Service EvaluationCherie Chung Yan Tong, Senior Dietitian, RD,CNSD1; Siang Nee Teoh, Senior Pharmist2; Su Lin Lim, Chief Dietitian, Senior Manager, RD1; Li Lin Lim, Consultant3
1Dietetics, National University Hospital Singapore, Singapore, Singapore; 2Pharmacy, National University Hospital, Singaproe, Singapore; 3Gastroenterology, National University Hospital, Singaproe, Singapore. Introduction: Parenteral Nutrition (PN) is an expensive specialized nutrition support, its use should to be justified and optimised through appropriate specialist input. Previously, there were no standardized guidelines for prescription and monitoring of such nutritional support in National University Hospital (NUH) in Singapore. Problems and complications may arise through inappropriate use of parenteral nutri-tional therapy. Improper prescription of parenteral nutrition may also lead to serious medical consequences and pose a definite risk of mor-bidity and mortality to the patients, increase their length of hospital stay, worsen the clinical outcomes and negatively impact the hospital expenses. NUH Parenteral Nutrition Support (PaNS) Team is a multi-disciplinary team set up in April 2008 to advise on parenteral nutrition therapy to optimize patient clinical outcome. Objective: To evaluate the PaNS team service in managing parenteral nutrition, and its impact on clinical outcome. Methods: The retrospective study com-pared data collected from patients receiving PN in NUH 3 months before (pre group) and 6 months after PaNS Team service was com-menced (post group). Epidemiology data, clinical outcome, nutritional status, PN administration and biochemistry monitoring were col-lected. Mann-Whitney test was used to compare discrete data whilst Pearson Chi square test was used to compare continuous data. Results: Both groups (pre: 25 subjects, post: 77subjects) had similar epidemiology data and nutritional status before PN was started on those patients. Appropriate use of PN, length and cost of PN were not statistically different. Mortality of post group was 23% lower but not statistically significant. Length of stay, incidence of line sepsis, infec-tion, hyperglycaemia and re-admission rate were similar in both groups. Both groups met 86% of estimated energy requirement. Thirty-one percent more patients in the post group met above 80% of esti-mated protein requirement. (Table 2) PaNS team corrected most electrolyte abnormality. (p<0.01) The rate of refeeding syndrome was significantly lower (33%, p<0.01) in the post group. (Table 1) PN was better tailed off according to enteral nutrition tolerance (p<0.01) via PaNS team management. (Table 2) Conclusions: A 6-month PaNS Team service evaluation demonstrated effectiveness in meeting nutri-tional requirement and preventing metabolic complications of patients receiving PN in the hospital.
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Table 1Corrected Electrolyte Levels & Incidence of Refeeding Syndrome
Table 2Meeting Estimated Nutritional Requirement & Tailing off PN When EN commenced
P67 - Development of a Nutrition Support Team in a Provincial Tertiary Care Hospital in the Philippines
Divina Cristy D. Redondo, MD,RND1; Luisito O. Llido, MD, FPCS,DPBCN2; Reynaldo C. Yang, MD,FPCP1
1Medical Nutrition, Premiere Medical Center, Cabanatuan City, Philippines; 2Clinical Nutrition, St. Luke’s Medical Center, Quezon City, Philippines. Introduction: Although the concept and practice of nutrition support teams (NST) is not new in Europe and in the US, this is relatively new in the Philippines. In a survey conducted by the Philippine Society for Parenteral and Enteral Nutrition (PhilSPEN) in 2008, 22% of hospitals in the Philippines have an NST, but up to this date, no reporting on how things were done in organizing an NST has been done. Objective: This paper reports the experience in starting and running a multi-profes-sional NST in a provincial tertiary care hospital in the Philippines. Methods: NST development had four phases. The initial phase identi-fied the leaders who have an influence within the hospital, who would
be the support of NST and whose primary responsibility was to design the protocols and guidelines for the implementation of the clinical nutrition process. The second phase was the interest generation on nutrition which was done by getting the prevalence of malnutrition. It was made easy through computerized daily nutrition surveillance. An educational program was also launched to spread nutrition awareness. The third phase was getting the active involvement in nutrition strategic planning from the hospital administration, heads of the medical and non-medical staff including the chief nurse, nursing supervisors, head of the dietary department, finance and purchasing officers. The final phase of the NST development was the full implementation of the clinical nutrition process using standard forms devised by PhilsPEN. Results: A Nutrition Steering Committee was set up as the source of influence and support within the hospital organization which helped establish the Nutrition Support Team. The multi-disciplinary NST con-sists of a physician who trained in a Clinical Nutrition Fellowship program and who leads the team, a dietitian, a nurse and a pharmacist. Each team member has specific tasks and the team conducts regular educational
CNW 2010 Nutrition Practice Abstracts 27S
and publicity programs to introduce and implement the clinical nutrition program in the hospital among the consultants and different depart-ments. Consultations and discussions were done weekly with the admin-istration, nursing, and medical staff when faced with difficulties in introducing and implementing the clinical nutrition process. The instal-lation of a computerized nutrition surveillance system made the nutrition screening process easier and “nutritionally-at-risk” patients were easily identified for nutrition assessment and follow-up. The “nutritionally-at-risk” include patients who are underweight, overweight/obese, critically ill, cancer, stroke and geriatric patients. One month nutrition surveil-lance showed nutritional status distribution to be: normal (60%), under-weight (14.7 %), overweight (22.7%), and obese (9.2 %). Two months after the nutrition support team became fully functional, improvement was seen in the entry of height and weight in the patient record from 17% to 50%. Out of 572 patients admitted, 363 (63%) patients were identified to be nutritionally-at-risk, nutrition assessment was done on 139 (38%) of these identified patients, with 27% of the assessed patients referred to NST. Conclusions: The effective establishment and running of the nutrition support service in the hospital was due to the establish-ment of a nutrition support team which is run by a team leader who is formally trained in Clinical Nutrition and fully supported by both administration and medical staff. A computerized nutrition surveillance system further adds to the effectiveness of the program.
P68 - Initiating Compassionate Use of Experimental Products:The Example of Omega-3 Fatty AcidsCatherine J. Klein, PhD, RD1,2; Mary Revenis, MD1,2; Carolyn Kusenda, MS, RD, CNSD1; Richard Parrish, BSPharm, PhD1; Louis Scavo, MD1,2
1Children’s National Medical Center, Washington, DC; 2George Washington University School of Medicine and Health Sciences, Washington, DC. Introduction: When planning to introduce an experimental nutrition product to treat critically ill patients, it is essential to utilize the exper-tise of a team with representatives from pharmacy, medicine, nursing, and dietetics. The multidisciplinary team plays an important role in gaining infrastructure support and in coordinating the new procedures required. Methods: As an example of the process for initiating a com-passionate use protocol, we describe our experience with intravenous (IV) omega-3 fatty acid (O3FA) emulsion to reverse the effect of paren-teral nutrition (PN)-associated cholestasis (AC). Highly-purified fish oil emulsions that are rich in O3FA, when used in place of standard IV soy oil-based lipid, are associated with reversing steatosis and cholestasis and in some cases preventing liver transplantation. The U.S. Food and Drug Administration (FDA) had not approved IV O3FA for general use; however, it has given approval on a case-by-case basis for compassionate use of this product to treat infants with severe PNAC. Results: In the example of O3FA, a retrospective review of medical records confirmed suspicions that neonates who were at risk for PNAC had long lengths of stay [mean±SD: 85±43 days], were dependent on PN for prolonged periods [median (range): 64 (22 - 168) days] and had substantial mortal-ity (21%). Moreover, the retrospective review revealed an estimate of four new PNAC cases monthly, with a male to female ratio of nearly 2:1. Infants were selected for treatment with O3FA based on the resulting criteria: progressive cholestasis, blood direct bilirubin > 3 mg/dL, require-ment for PN for more than three weeks, and the failure of other thera-pies to reverse PNAC. Dosing, monitoring and end points of therapy were based on the team’s review of case studies reported in the litera-ture. Regulatory requirements as determined by the FDA Investigational New Drug and Institutional Review Board approvals were met for prod-uct access and were incorporated into the plan of work. Pharmacy organized the requisition of product, set up processes for storing, pack-aging, and dispensing product, and met regulatory requirements for control of product. A multidisciplinary effort was required to control patient selection, initiate therapy and monitor responses to the new therapy. The
data safety monitoring plan relied on data collected and analyzed for individual patients as well as in aggregate to identify trends in outcomes. The multidisciplinary team gained experience with a promising new therapy through compassionate use protocols but had to remain dedi-cated to the process and persevere to obtain regulatory approval and gain acceptance and commitment from staff. Clinical staff required instruction prior to introducing the experimental product. Conclusions: The process of gaining approval from regulatory and authoritative groups and integrating new products into clinical systems of care, if well planned, can benefit patients as well as provide valuable insight for designing future prospective, randomized controlled trials.
P69 - The Impact of a Multidisciplinary Team in Promoting Early Enteral Nutrition in Critical Care PatientsBrenda O’Day, RD, CNSC1,2; Kristine Binda, RD, CSO, CNSD1; Susan Yates, MPH, RD, CNSC1; Erika McClees, MS, RD1; John Haubenstricker, MS, RD1; Judy Willon, RN1; John Engelbert, Pharm D1; Julie Sanborn, MS, RD, CNSC1; Donna Beshgetoor, PhD2; Kalman E. Holdy, MD, ABPNS1
1Sharp Memorial Hospital, San Diego, CA; 2School of Exercise and Nutritional Sciences, San Diego State University, San Diego, CA. Introduction: Newly published guidelines from the Society of Critical Care Medicine (SCCM) and the American Society for Parenteral and Enteral Nutrition (ASPEN) recommend the initiation of enteral nutri-tion (EN) within 24-48 hours of admission to critical care units. Unfortunately, many barriers exist in critical care practice and result in delayed initiation of EN. The purpose of this project is to improve our standard practice of feeding patients from 72-120 hours of admission with the new promoted practice of implementing EN within 24-48 hours. Methods: This is an ongoing evidence-based practice project comparing EN implementation practices (baseline) to current efforts by a multidisciplinary team to feed patients within 24-48 hours of admis-sion to the intensive care unit (ICU). Data was collected on implemen-tation of EN from June to September of 2008 and compared to post-intervention data on patients admitted during Fall of 2009. Specific barriers to early EN access and initiation were identified and addressed by the multidisciplinary team prior to the 2009 data collection period. These included adjustment to critical care admission order sets, equip-ment needs, and education of ICU staff members on the importance of early enteral feeding. Education is an integral part of our intervention efforts and several committee presentations and in-services were com-pleted. Data on diagnosis, duration of intubation, length of ICU stay, amount of EN provision and total length of hospital stay were also col-lected. A t-test analysis was performed using Excel 2007. Statistical significance was set at p < 0.05. Results: In 47 of our ICU patients, we determined that only 25% received EN within 48 hours of admission. The mean time frame of EN initiation was 77.61, +/- SD = 44.80 hours. Barriers to early EN included delay in obtaining orders, limited EN feed-ing tube placement equipment, and a lack of knowledge with the ICU staff regarding the importance of early EN. Conclusions: Intervention efforts by our multidisciplinary team are expected to provide an effective means of reducing the time needed to initiate EN in our ICU patients.
P70 - A 15-Year Experience of a Nutrition Support Service Team in the Management of Gastrointestinal Fistulas.Suzanne Harriman, B Kinesiology2; Nadia J. Rodych, BSc, RD, CNSD1; Paul Hayes, BSc, MD, FRCSC2; Michael A. Moser, MD, MSc, FRCSC2,1
1Nutrition Support Service, Royal University Hospital, Saskatoon, SK, Canada; 2Department of Surgery, Royal University Hospital, Saskatoon, SK, Canada. Introduction: At our university hospital, all patients requiring paren-teral or intensive enteral nutrition support are referred to our Nutrition
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PICC LINE PLACEMENT PROTOCAL
Obesity
P73 - Anthropometric and metabolic correlations of inflammation in severe obesityAna Adelaide S. Leal, Instituto Dr. João Alípio1; Joao Alipio B. Noe, Instituto Dr. João Alípio1; Diandria M. Bertollo, Instituto Dr. João Alípio1; Rafael C. Morais, EMESCAM - Surgery2; Alvaro C. Morais, EMESCAM - Surgery2; Joel Faintuch, Hospital das Clínicas USP - Gastroenterology3
1Instituto Dr. João Alípio, Vitoria, Brazil; 2Centro de Ensino e Pesquisa, EMESCAM, Vitoria, Brazil; 3Gastroenterology, Hospital das Clínicas USP, Sao Paulo, Brazil. Introduction: Accumulated fat is an accepted trigger of inflammation but clinical associations are still controversial. In a prospective study, multiple variables were analyzed to search for somatic and visceral cor-relations. Methods: Bariatric candidates (n=94) were consecutively investigated. Age was 34.9 ± 10.4 years (68.1% females), and BMI was 40.8 ± 4.6 kg/m2. Methods included anthropometrics, bioimpedance analysis (BIA) and biochemical measurements. C-reactive protein
Support Service (NSS) Team. The purpose of this study is to examine the 15-year experience of our NSS team with regards to patients diag-nosed with gastrointestinal fistulas. Methods: A total of 70 patients with gastrointestinal fistulas were identified from the Royal University Hospital NSS database between July 1994 and June 2009. Additional information was obtained from the hospital charts of these patients. Comparisons were carried out using Wilcoxon’s test for non-parametric data. Results: Seventy patients with a mean age of 59 were included in the study. Albumin levels did not differ significantly over the first three weeks. The average prealbumin values were 118+/-6 for week one, 145+/-7 (p<0.0001 vs. week one) for week two and 162+/-11 mg/L (p=0.008 vs. week 2) for week three. The average output for week one, two and three were 240±49, 170±46 and 215±41 cc/day, respectively. Fifty-four patients were initially managed non-operatively, and 39 (72.2%) closed spontaneously in less than 6 weeks. Of the 15 that did not close with conservative management, 10 had surgical closure, of which 2 of 10 reopened postoperatively. Sixteen patients were treated operatively without a trial of non-operative therapy, and 10 had success-ful closure. Overall, 57 of 70 patients (81.4%) had successful closure. Conclusions: Our results with non-operative management compare favorably to those found in the literature at larger centres. The fact that the prealbumin levels rose from week to week supports the utility of the NSS team. Patients with gastrointestinal fistulas require a multi-disciplinary approach which should include aggressive nutrition support and the monitoring of nutritional status by a NSS Team.
P71 - Converting Nutrition Support Orders to an Electronic Medical Record and Prescriber Order EntryCaitlin Curtis, PharmD, BCNSP1; Kenneth A. Kudsk, MD2
1Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI; 2Surgery, University of Wisconsin-Madison, Madison, WI. Introduction: Computer physician order entry (CPOE) is being imple-mented across the country to increase patient safety and decrease errors in written orders, including nutrition support orders. Methods: CPOE, as a component of a newly adopted electronic medical record (EMR), was implemented in a 450 bed teaching hospital. Information technology (IT) worked with the Nutrition Support Team (NST) pharmacists and dietitians in designing and building nutrition-related orders, including parenteral (PN) and enteral (EN) nutrition as well as documentation of nutrition support activities specific to the EMR. The NST pharmacists reviewed all orders before they “went live.” Results: When CPOE and EMR were implemented, the NST and IT teams were faces with unan-ticipated problems that interrupted daily work flow and increased the potential for prescribing errors including the following: 1) The existing consulting process “disappeared,” requiring construction of a more com-plex system. 2) Ability to view previous PN formulations “disappeared.” 3) Discharge PN orders could not be written for home PN patients. 4) Lab order duplication with primary servic orders resulted in unnecessary blood draws. 5) Cancelling of duplicate orders often resulted in both orders being cancelled. 6) Subsequent “upgrades” to the system resulted in lost function requiring re-entry of every NST order. 7) Discontinuation orders for PN were programmed incorrectly. 8) The CPOE PN order form was error-prone allowing for macro- and micro-nutrient overdosing, particularly in pediatric patients. Conclusions: NST members must be involved in the design and implementation of CPOE to ensure that orders are built correctly. Even with involvement of the NST, initiation of CPOE requires rapid response and novel solutions to unexpected problems. Implementation of CPOE and EMR for nutrition support orders is a challenging and error-prone process.
P72 - PICC Placement Protocol: Avoiding Inappropriate PICC LinesMary C. Friedberg, MS,RD,CNSC; Raymond V. Landes, MD,CNSP,FACSSurgery, William Beaumont Hospital Troy, Troy, MI.
Introduction: Efficiencies in Interventional Radiology may result in placement of a PICC line before a patient has been evaulated for TPN appropriateness by the Nurtition Support Team. Methods: Between April 1, 2008 and March 31, 2009 patients undergoing new PICC line placement were subject to a PICC placement protocol to ensure appro-priateness criteria were met. Results: 208 patients were approved for TPN during this time interval. Concurrently, 1361 patients had PICC lines placed. With our protocol in place, no patient had a PICC line placed for TPN without prior evaluation for TPN appropriateness. Conclusions: PICC Placement Protocol can avoid inappropriate PICC line placement
CNW 2010 Nutrition Practice Abstracts 29S
BIA X BMI Males Females
Resistance -0.351 P=0.048 -0.523 P=0.000Reactance -0.326 P=0.010Body fat 0.847 P=0.000 0.855 P=0.000Body water 0.640 P=0.000 0.566 P=0.000BIA X WC Resistance -0.455 P=0.009 -0.392 P=0.001Reactance -0.348 P=0.049 Body fat 0.687 P=0.000 0.544 P=0.000Body water 0.655 P=0.000 0.480 P=0.000
Parenteral Nutrition
P75 - Canadian Home Total Parenteral Nutrition Registry: 2-year Follow-upGail Fernandes, BSc1; Brinderjit Kaila, MD, FRCPC1; Olivia Saqui, RN, BScN1; Lydia Fairholm, RD, CNSD1; Mary Baun, BScPhm1; Clare Meechan, BA, RN, BScN, CGN(C)2; Holly Ames, Msc, RD3; Andrew Shaw, HTPN registry author and developer4; Khursheed Jeejeebhoy, MBBS, PhD, FRCPC2; Leah Gramlich, MD, FRCP(C)3; Johane Allard, MD, FRCPC1
1Medicine, University Health Network, Toronto, ON, Canada; 2St. Michael’s Hospital, Toronto, ON, Canada; 3Alberta Health Services, Edmonton, AB, Canada; 4Twenty One Ton, Toronto, ON, Canada. Introduction: Currently, 7 large HTPN centers, representing about a third of the HTPN patient population in Canada, collect and enter clinical data. The objective was to assess the 2-year clinical outcomes
(CRP) and white blood cell count (WBC) were the inflammatory mark-ers. Results: CRP correlated with total and HDL-cholesterol and espe-cially alkaline phosphatase (P=0.000) whereas a tendency regarding HbA1c was unveiled (P=0.094), all in males. BMI was relevant (P=0.048) in females, whereas BIA body fat reached significance in the whole population (P=0.049). WBC correlated with serum triglycerides in females (P=0.048). Conclusions: 1) BMI and total fat, but not other anthropometric measurements, were moderately associated with inflam-mation ; 2) Comorbidities (dyslipidemia, diabetes) could be important, as well as liver dysfunction in males; 3) Multiple influences seem to contribute to systemic inflammation in this context.
P74 - Bioimpedance analysis in morbidly obese subjects: Correlations in males and femalesAna Adelaide S. Leal, Nutritionist1; Joao Alipio B. Noe, MD1; Diandria M. Bertollo, MD1; Rafael C. Morais, MD2; Alvaro C. Morais, Prof2; Joel Faintuch, Prof3
1Instituto Dr. Joao Alipio, Vitoria, Brazil; 2Centro de Ensino e Pesquisa, EMESCAM, Vitoria, Brazil; 3Gastroenterology, Hospital das Clinicas USP, Sao Paulo, Brazil. Introduction: Use of bioimpedance analysis (BIA) is questioned in severely obese subjects. Aiming to compare BIA with anthropometry, a prospective study was designed. Methods: Bariatric candidates (n=94) were consecutively enrolled. Age was 34.9 ± 10.4 years (68.1% females), and BMI was 40.8 ± 4.6 kg/m2. Waist circumference (WC) and waist/hip ratio (WHR) were documented along with primitive BIA resistance (Res) and reactance (Reac) along with derived total body fat and water Results: Significant Pearson “r” indices for BIA versus BMI and WC are shown . WHR did not improve results of WC only. (TABLE 1) Conclusions: 1) Various primitive and secondary BIA values strongly correlated with BMI and waist circumference; 2) Moderate gender dif-ferences occurred; 3) Bioimpedance analysis is not worthless in mor-bidly obese subjects.
in this cohort of patients. Methods: Currently, 3 centers have com-pleted their second data entry: University Health Network (UHN), Toronto, St. Michael’s Hospital (SMH), Toronto and Alberta Health Services (AHS), Edmonton. The collected data included: patient char-acteristics, nutrition, labs, quality of life (QOL), vascular access and mortality. Paired t-test and if normality failed, Wilcoxon test was used to assess changes between baseline and follow-up. Survival analysis was performed using the Kaplan-Meier method. Factors impacting survival were evaluated using the Breslow (Generalized Wilcoxon). Results: A total of 83 patient charts (48 patients at UHN, 15 patients at SMH, 20 patients at AHS(Edmonton)) have had a second data entry at mean follow-up (± SEM) of 1.93 ± 0.09 years. The mean (± SEM) age, BMI and TPN duration were 53.4 ± 1.6 years, 21.3 ± 0.4 kg/m2, 87.2 ± 9.1 months. The most common indication for HTPN was short bowel syn-drome (SBS) in 62.7% of patients. Other indications for HTPN included motility disorders (13.3%), mucosal defects (8.4%), oncology (7.2%), surgical complications (2.4%) and pancreatic disease (1.2%). Over the follow-up period, there was a significant reduction in TPN [Calories from 1280.98 ± 71.13 to 1145.42 ± 72.67; p=0.024 and TPN protein from 58.73 ± 2.89 to 52.18 ± 3.11; p=0.007] while BMI remained unchanged suggesting that patients were being weaned from TPN. From the laboratory point of view, there were no changes over time except for lower platelet count (p=0.034) and lower total protein (p=0.033). There was no significant changes in liver enzymes but there was a trend toward an increase in bilirubin from 13.78 ± 2.37 to 30.16 ± 10.23 (p=0.118). Regarding liver disease, there was insufficient data on liver biopsies and imaging. For the QOL, the Karnofsky score also decreased significantly over time (p=0.001). There was insufficient data on vascular access complications. The combined mean survival since initiation of HTPN was 17.77 ± 2.05 years (95% CI 13.76- 21.78) and the probability of survival at 5 and 10 years on HTPN was 82% and 60%, respectively. There was no difference in survival in patients with SBS versus no SBS as an indication for HTPN. However patients with abnormal bilirubin levels had a significantly shorter survival than those with normal levels of bilirubin (p=0.037). There was also a significantly shorter survival in those patients with tumor/cancer (p<0.001). Conclusions: HTPN patients maintain good nutritional status while being weaned from TPN. Although most laboratory values remained stable, the results suggest that there is progressive liver dysfunction which affects survival. Quality of life is progressively reduced possibly related to underlying diagnosis (tumor/cancer and HTPN complica-tions such as liver dysfunction). The lack of data on liver disease and vascular access events could be improved by introducing a patient diary to report on these complications.
P76 - Canadian Home Total Parenteral Nutrition (HTPN) Registry: Validation of Data Entry In a Subset of HTPN PatientsGail Fernandes, BSc1; Brinderjit Kaila, MD, FRCPC1; Olivia Saqui, RN, BScN1; Lydia Fairholm, RD, CNSD1; Mary Baun, BScPhm1; Clare Meechan, BA, RN, BScN, CGN(C)2; Andrew Shaw, HTPN Registry Author & Developer3; Maitreyi Raman, MD, MSc, FRCPC4; Khursheed Jeejeebhoy, MBBS, PhD, FRCPC2; Johane Allard, MD, FRCPC1
1University Health Network, Toronto, ON, Canada; 2St. Michael’s Hospital, Toronto, ON, Canada; 3Twenty One Ton, Toronto, ON, Canada; 4University of Calgary, Calgary, AB, Canada. Introduction: Currently, 7 large HTPN centers, representing about a third of the HTPN patient population in Canada, collect and enter clinical data. The objective was to validate the web-based data entry in a subset of patients from 2 participating centers. Methods: Validation was performed at 2 different centers in Toronto: University Health Network (UHN) and St. Michael’s Hospital (SMH). The baseline data entered into the HTPN registry was recollected from the patients’ charts
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by the blinded members of the HTPN team using similar blank case report forms. The data included patient characteristics, nutrition, blood work, quality of life, vascular access, liver disease and bone mineral density. Paired t-test was used to compare both entries and Intra-class correlation coefficient (ICC) was used to assess correlation and agree-ment between the two entries. Results: A total of 63 patient charts (UHN: 48, SMH: 15) were reviewed. The mean (± SEM) age, BMI and TPN duration were: UHN: 50.8 ± 2.3 years, 21.7 ± 0.6 kg/m2 , 91 ± 14 months; SMH: 54.2 ± 2.9 years, 19.9 ± 0.7 kg/m2, 15 ± 11.2 months. The most common indication for HTPN was short bowel syndrome (SBS) at both sites: 60% of patients at UHN and 67% at SMH. In gen-eral, at both sites, comparison of the data for nutrition assessment (body weight, height, BMI, estimated energy requirements) and TPN pre-scription showed no statistical difference with highly significant correla-tion and agreement (p<0.05). Exceptions were selenium and chromium content in TPN. There was also, in general, significant correlation and agreement between most parameters in the blood work. Exceptions were sodium, chloride, folate, parathyroid hormone (PTH), vitamin D, mean corpuscular volume, white blood cell, calcium and iron levels. For both sites, quality of life assessed by Karnofsky performance scale ratings revealed significant agreement and correlation and as well, bone mineral density showed a highly significant correlation and agreement (p<0.05) for the spine T-score, femoral neck T-score and hip T-score, diagnosis of osteoporosis and osteopenia. However, the numbers of fractures were not recorded. For information on changes in vascular access and line sepsis, the validation was not good. At UHN, only the number of lumens for central catheter (p<0.0001) revealed a statistically significant ICC. Statistics could not be performed for line sepsis due to a lack of data as patients are often diagnosed and treated at peripheral centers. In addi-tion, at both sites, there was poor retrieval of data for liver disease (ultrasound, biopsy, diagnosis) and thus no data comparison could be performed. Conclusions: Based on this study of a subset of patients, the Canadian HTPN registry is a valid clinical tool to assess several clinical parameters, particularly regarding nutritional parameters, laboratory results, functional status and metabolic bone disease. However, data was not entered or not in agreement for parameters regarding changes in vascular access, line sepsis, bone fractures and TPN related liver diseases. This is likely due to the lack of availability of information as patients may have been diagnosed and treated at peripheral centers. These findings have resulted in further modification of the data entry protocol to allow better tracking of these parameters, including a patient diary to chart information regarding line sepsis; fracture or surgery.
*Encore Presentation: Great Lakes Pharmacy Resident Conference, 2009P77 - Sterility of Injectable Lipid Emulsions Repackaged by an Automated Compounding Device for the Pediatric PopulationJoseph Ybarra, PharmD1; Warren Rose, PharmD2; Caitlin Curtis, PharmD, BCNSP3; Gordon Sacks, PharmD, BCNSP, FCCP1
1Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, AL; 2Pharmacy Practice Division, University of Wisconsin-Madison School of Pharmacy, Madison, WI; 3Department of Pharmacy Services, University of Wisconsin Hospital and Clinics, Madison, WI. Introduction: Pediatric patients require low volumes of injectable lipid emulsions (IVLE) to be infused over 12-hour time periods. Extended IVLE infusions longer than the recommended time interval may increase the risk for microbial growth. Repackaging of IVLE into syringes has been used in clinical practice to prevent infusions exceed-ing 12 hours, reduce waste, and improve patient safety. While this novel approach has its theoretical benefits, recent data suggest an increasing risk of contamination when repackaging these preparations manually. The objective of this study is to determine the sterility of using an automated
compounding device (ACD) to repackage IVLE into empty intravenous bags for administration to the pediatric population. Methods: A total of 152 IVLE bags were repackaged with an ACD in an ISO Class 5 envi-ronment. Appropriate aseptic technique was performed with proper garbing and hand washing. Forty commercially-available bags of IVLE obtained direct from the manufacturer served as controls. At 0, 24, 48 and 120 hours after repackaging, IVLE were filtered and placed onto blood agar medium. Filters were observed for growth following 24 and 48 hours of incubation for aerobic and anaerobic microorganisms. Sterility testing was conducted over a total period of 3 consecutive weeks. Results: Microbial growth occurred in 12 of the 152 repackaged preparations compared to 0 of the 40 control bags (7.9 vs. 0%, p < 0.001, Chi Square). Positive cultures consisted of gram-positive cocci (n = 5, 3.3%), gram-positive rods (n = 5, 3.3%), and yeast (n = 2, 1.3%). There was no difference in positive bacterial or yeast growth between weeks 1, 2, and 3, suggesting an absence of outside contamination dur-ing preparation. Conclusions: The positive microbial growth suggests a concerning incidence of contamination of IVLE repackaged with ACD. Additional research is needed to further identify and validate the clinical impact of these preparations.
P78 - Emphasizing Parenteral Nutrition Safety through Education in Homecare PracticeChristopher M. Miller, PharmD,MS,MBA,BCNSP1; Eve Callahan, RD,CNSD,LDN2; Allyson Stout, RD,LD3
1College of Pharmacy, University of Kentucky, Lexington, KY; 2Clinical Nutrition, Vanderbilt Home Care affiliated with Walgreens Infusion and Respiratory Service, Nashville, TN; 3Clinical Nutrition, Walgreens Infusion Pharmacy, Louisville, KY. Introduction: The interpretation of physician orders and avoidance of errors in processing parenteral nutrition (PN) orders is important in ensuring the safety of PN therapy. PN therapy in a homecare setting is often high volume therapy and has a high potential for complications. This abstract describes one company’s approach to ensuring PN safety through targeted education. Methods: To identify gaps in pharmacist knowledge and skill in accurately interpreting and processing PN orders, a PN continuing education (CE) program was designed and imple-mented by a BPS certified nutrition support pharmacist. An educational reference binder was developed and distributed to all pharmacy sites of the company. The educational component included a mandatory adult PN CE program (0.4 CEU). The CE training module is a comprehen-sive exam which includes a sample PN order to be processed using an internally designed spreadsheet tool. This tool incorporates patient spe-cific nutritional assessment, normal dosing ranges, safety and critical compatibility checks. The sample PN order included on the exam must be processed accurately using the spreadsheet tool, thus demonstrating accurate interpretation of the physician order. If errors in processing are identified, the pharmacist must re-enter the PN order accurately using the spreadsheet tool to obtain the continuing education credit. All phar-macists were asked to provide an evaluation of the CE module upon completion. Additionally, a survey was sent to all pharmacists to assess satisfaction with the program. Results: Over fifty pharmacists com-pleted the adult CE module during the initial phase of the program. Fifteen of which had to resubmit the sample PN order demonstrating that order interpretation is an area of concern. This led to the decision that for future phases of the program all company pharmacists are required to complete this exam with a passing score of 70% to be certi-fied to work independently on PN orders. If a pharmacist has not com-pleted the CE module a double sign-off on PN orders by a CE completed pharmacist is now required. Use of the spreadsheet assessment tool, which is continuously updated per ASPEN guidelines, is mandatory for adult PN orders and this requirement is targeted by the quality improve-ment team during site audits. Upon review of the CE evaluations, the vast majority of the pharmacists indicated that this program provided significant enhancement of their knowledge on PN therapy. This was reinforced by a preliminary survey (n=16) indicating that pharmacist
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found both the CE module and the spreadsheet tool valuable in the clinical management of PN patients. On a scale of 1 to 5 (1= minimally valuable to 5= extremely valuable) the mean score was 4 for both the CE module and spreadsheet tool. Conclusions: PN competency assessment is an ongoing program for the company and has been successful in identifying and correcting knowledge gaps. This program has been important for the company in ensuring the appropriateness and safety of the PN formulation and has been instrumental in targeting pharma-cists with gaps in PN knowledge. A more comprehensive follow-up survey is being developed to assess additional needs and overall satisfac-tion with this program.
P79 - Service Enhancement Provides Improvement in Parenteral Nutrition (PN) TherapyChristopher M. Miller, PharmD,MS,MBA,BCNSP1,2; Jacqueline Gates, PharmD1; Kristin Durrett, PharmD1; Leslie Kenney, RPh,BCPS2; Kimberly J. Cooley, MS,RD3; M. Deborah Eck, RD,CNSD3
1College of Pharmacy, University of Kentucky, Lexington, KY; 2Pharmacy Services, Norton Healthcare, Louisville, KY; 3Nutrition Services, Norton Healthcare, Louisville, KY. Introduction: An academic partnership was developed between a 450 bed community hospital and the state’s university college of pharmacy. A faculty member specializing in nutrition support began assisting in the clinical management of PN patients during the summer of 2008.This service enhancement was expected to improve communication between Nutrition Services and the Pharmacy resulting in a positive impact on patient care. The purpose of this research is to demonstrate quality improvement through implementation of this service partnership. Methods: During the implementation phase, Nutrition Services expressed concern that the standard PN formula was potentially over-feeding patients. Evaluation of the standard order suggested that the calories provided were aggressive and phosphate dosing was suboptimal. The standard PN provides 13.6 mM phosphate given as 20 mEq of potas-sium phosphate. The recommended range of phosphate in PN is 20-40mM and is impacted by calories administered. The standard PN provides 2160 total calories, 1300 of which are CHO. To evaluate phos-phate dosing, a retrospective study was conducted on all PN patients admitted to service from April through June of 2008 who received a minimum of seven consecutive days of PN therapy. Patients with renal insufficiency (CrCl < 30mL/min) were excluded, leaving a total of forty-eight (n=48) patients for analysis (27 ICU patients, 21 non-ICU). To evaluate macronutrient dosing, all patients initiated on PN therapy in August and September of 2008 (n=56) were reviewed. Thirty-five of the initial PN orders were written as pharmacy consults. Of the remaining 21 orders, ten were written for the standard PN formula. Results: Only two patients in the phosphate review study received adequate dosing (≥ 20mM) at initiation of therapy indicating that PN order writing for this nutrient is influenced by the standard. Approximately half of the patients required additional phosphate outside the PN during the first seven days of therapy. Seventy-seven percent of the patients in the study experi-enced clinical hypophosphatemia (<3 mg/dl), 62% Non-ICU vs. 89% of the ICU group. Three patients in each group experienced more severe hypophosphatemia (<1.6mg/dl). Based on this investigation, PN phos-phate dosing is being addressed by the service. In the macronutrient dosing study, the average PN initiated provided 1727 Kcal’s which was very close to the average recommendations made by Nutrition Services of 1733 Kcal’s. This study indicates that macronutrient dosing recom-mendations made by the clinical dietitians are being followed and appro-priate interventions are being performed. Of the ten standard orders written by physicians, five were changed through intervention. If the study population (n=56) would have received the standard formula upon initiation of therapy they would have received on average 25% more Kcal’s over the recommendation. Conclusions: Use of the current stan-dard PN order has the potential of placing the patient at risk for over-feeding and may provide insufficient phosphate if interventions are not
made. If the standard PN formula would have been given to all the patients in the macronutrients dosing study, eight would have exceeded the maximum recommended CHO dose of 25Kcal/kg. The phosphate study suggests dosing was influenced by the standard PN order. Based on the results of these studies and in light of the current ASPEN guidelines, recommendations to change the standard PN order have been made.
P80 - Pharmacist-driven Interdisciplinary Computerized Order Entry for Parenteral NutritionLeslie N. Schechter, BS, Pharm.D.1; Patricia Worthington, RN,MSN2; Karen A. Gilbert, RN,MSN,CRNP2
1Pharmacy, Thomas Jefferson University Hospital, Philadelphia, PA; 2Nursing, Thomas Jefferson University Hospital, Philadelphia, PA. Introduction: Although computerized order entry (COE) has been in place for many years in our 700-bed academic medical center, the facil-ity continued to rely on a paper/pen system for parenteral nutrition (PN) orders (18 adult patients daily). The complexity of PN orders and the need for frequent pharmacist intervention impaired efforts to convert PN to COE. Audits revealed that 60% of PN orders required some clarification. For the last quarter of 2008, 477 interventions for PN orders occurred, accounting for 24% of all pharmacist interventions. In rank order of frequency, these interventions included electrolyte changes, insulin adjustments, base formula corrections, handwriting clarification, and modification of orders for cycled PN infusions. In addition, clerical staff sometimes overlooked paper orders, thus delaying nutrition therapy. A Failure Mode Effects Analysis validated many prob-lems inherent to paper orders and underscored the need to revamp our system for ordering PN. Our goals were to enhance safety and efficiency of PN ordering while promoting prescriber education and satisfaction. Methods: We developed an innovative pharmacist-driven COE system that offers decision support and education to clinicians prescribing PN. To activate the system, clinicians submit an electronic “PN Request” requiring documentation of the PN indication and location of vascular access. (Figure 1) The system features an interactive communication tool that allows the Nutrition Support Team (NST) pharmacist to post PN recommendations for review by the prescribing clinician. Recommendations reflect input from all interdisciplinary NST members and include the rationale for changes. Besides the interactive element, the communication screen displays current laboratory values and links to pertinent clinical information. (Figure 2) After the prescribing clini-cian accepts or modifies the PN recommendations, the pharmacist submits an electronic PN order for approval/signature. The NST gath-ered staff feedback about the system using a Likert scale questionnaire. Results: The 162 responses to the questionnaire were positive, with all indicators favoring the new system. In particular, on a 5-point scale, users find the pharmacist-driven system convenient (4.20) and easy to use (4.20). In addition, the system has increased confidence that orders are processed in a timely manner (4.20). Overall, respondents felt that the system has improved patient care (3.68), a finding that was rein-forced by numerous free-text comments on the questionnaire. The new system circumvents the potential for transcription errors and has streamlined the PN ordering process. By proactively recommending both the base formula and micronutrient content, the NST has elimi-nated orders for unstable PN formulations. Verbal orders for PN have been abolished and compliance with baseline laboratory monitoring has improved. The dialogue established by the interactive feature of the system promotes an exchange of pertinent information between the prescriber and the NST while educating clinicians about the intricacies of PN management. Conclusions: We implemented COE for PN order-ing by developing a pharmacist-driven process that enhanced interdisci-plinary collaboration, promoted optimal nutrition therapy, and reduced the potential for PN prescribing errors. Pharmacists, nurses, dietitians, and physicians all expressed high levels of satisfaction with the COE ordering process. Data derived from this program will guide quality improvement initiatives.
32S Nutrition in Clinical Practice / Vol. 25, No. 1, February 2010
Figure 1. PN order request.
Figure 2. PN communication tool.
P81 - Azathioprine and Short-term Steroid Therapy Do Not Affect Growth and Bone Mineralization in Children on Home Parenteral NutritionInaki X. Irastorza, Hospital de Cruces1; Bala Krishnamurthy, Great Ormond Street Hospital2; Susan Hill, Great Ormond Street Hospital2
1Pediatric Gastroenterology, Hospital de Cruces, Barakaldo, Spain; 2Paediatric Gastroenterology, Great Ormond Street Hospital, London, United Kingdom. Introduction: Steroids and azathioprine are used in some home paren-teral nutrition (HPN) dependent children with severe intestinal inflamma-tion to improve intestinal dynamics and enhance intestinal adaptation.
It has been described that both steroid and azathioprine can affect growth and bone mineralization by interfering bone osteoblastic activity. We aimed to evaluate immunosuppressant therapy effect in growth and bone mineral density (BMD) of our HPN dependent children. Methods: 18 children (10 boys) aged 5.5 to 18 years, median 12, who were on HPN for longer than 5 years were included in the study. 13 children had received shot-term therapy with steroids and maintenance therapy with azathioprine (SAT)to treat gut inflammation. Height, weight and BMD were analyzed along with the following variables: sex, age, underlying disease, age at HPN onset, length on HPN, and gut inflammation-SAT. Results: 8 children (44%) had normal height, weight and BMD for age. Having a mucosal enteropathy increased the risk of short stature among children on HPN (p=0.03). No other variables had significant effect on
CNW 2010 Nutrition Practice Abstracts 33S
growth or BMD. 5 of 13 children (38%) receiving SAT had a BMD below -1sd vs. 2 of 5 children (40%) who had not received SAT; mean BMD z-score in children on SAT was - 1.08 ± 1.39 vs. - 0.6 ± 0.82 in children who were not receiving SAT (p=0.67).; 7 of 13 children (54%) receiving SAT had a height below 3rd centile vs. 2 of 5 children (40%) who had not received SAT; mean height z-score in children on SAT was - 1.71 ± 1.32 vs. - 0.77 ± 1.49 in children who had not received SAT (p=0.14); and mean weight z-score in children on SAT was - 0.86 ± 0.85 vs. - 0.4 ± 1.39 in children who had not received SAT (p=0.38). Conclusions: Short-term steroid therapy and azathioprine maintenance therapy does not have adverse effects on BMD and growth of children on HPN. Almost half of children receiving HPN grow normally. Mucosal enter-opathy is the main risk factor for short stature among these children.
P82 - Warfarin Does Not Affect Growth and Bone Mineralization in Children on Home Parenteral NutritionInaki X. Irastorza, Hospital Universitario de Cruces1,2; Bala Krishnamurthy, Great Ormond Street Hospital2; Susan Hill, Great Ormond Street Hospital21Pediatric Gastroenterology, Hospital Universitario de Cruces, Barakaldo, Spain; 2Pediatric Gastroenterology, Great Ormond Street Hospital, London, United Kingdom. Introduction: Warfarin is used in some home parenteral nutrition (HPN) dependent children to prevent embolic events. It has been described that warfarin might affect growth and bone mineralization by interfering with osteocalcin and protein S synthesis. We aimed to evalu-ate warfarin therapy effect in growth and bone mineral density (BMD) of our HPN dependent children Methods: 18 children (10 boys) aged 5.5 to 18 years, median 12, who were on HPN for longer than 5 years were included in the study. 6 children had been receiving warfarin for a median of 9.2 years [2.4 - 13]. Height, weight and BMD were analyzed along with the following variables: sex, age, underlying disease, age at HPN onset, length on HPN, immunosuppressant therapy and warfarin therapy. Results: 8 children (44%) had normal height, weight and BMD for age. Having a mucosal enteropathy increased the risk of short stature among children on HPN (p=.031). No other variables had significant effect on growth or BMD. 3 of 6 children (50%) receiving warfarin had a BMD below -1sd vs. 4 of 12 children (33%) who were not receiving warfarin (p=ns); 3 of 6 children (50%) receiving warfarin had a height below 3rd centile vs. 6 of 12 children (50%) who were not receiving warfarin; mean height z-score in children on warfarin therapy was -1.41±1.79 vs. -1.47±1.24 in children who were not receiving warfarin; mean weight z-score in children on warfarin therapy was -0.83±0.9 vs. -0.69±1.09 in children who were not receiving warfarin; and mean BMD z-score in children on warfarin therapy was -0.8±0.68 vs. -1.03±1.49 in children who were not receiving warfarin. Conclusions: Long-term warfarin therapy does not have adverse effects on BMD and growth of children on HPN. Almost half of children receiving HPN grow normally. Having a mucosal enteropathy is the main risk factor for short stature among these children.
P83 - Development and Implementation of a Computerized Provider Order Entry Pathway for Adult Parenteral NutritionBeverly Holcombe, PharmD, BCNSP1; Rosemary Resler, BSN, RN4; Francine S. Walker, RD, CNSD2; Reid White, MSN, RN3; Ronald Davis, PharmD, BCPS1; Andy Millager, RPh, BCPS1; Elizabeth Dreesen, MD5; Mark Koruda, MD5
1Pharmacy Department, University of North Carolina Health Care, Chapel Hill, NC; 2Nutrition and Food Services, University of North Carolina Health Care, Chapel Hill, NC; 3Information Services, University of North Carolina Health Care, Chapel Hill, NC; 4Faculty, School of Medicine, University of North Carolina, Chapel Hill, NC; 5Surgery Department, School of Medicine, University of North Carolina, Chapel Hill, NC.
Introduction: Computerized provider order entry (CPOE) systems are used to enter orders in the patient’s electronic medical record. The principal benefits of CPOE are improved efficiency and error reduc-tion. Due to the complexity of parenteral nutrition (PN), a CPOE pathway for PN is a challenge to design, develop and implement. Methods: An interdisciplinary team was charged with designing and developing a CPOE pathway for ordering PN formulations for adult inpatients. The team was composed of members of the Adult PN Service; pharmacists experienced with preparing and dispensing PN formula-tions; and an application systems analyst with experience in developing CPOE pathways. The team reviewed the A.S.P.E.N. Safe Practices for PN and identified the mandatory elements of a PN order to incorporate in the pathway. The team then analyzed the PN paper order system. Positive components were identified for inclusion in the CPOE path-way as well as problem areas requiring resolution within the new appli-cation. Current electronic prescribing capabilities were also evaluated for features that would enhance PN prescribing. Results: Information from the analyses of the paper and electronic systems and the Safe Practices for PN were used to develop a CPOE pathway for adult PN. The user interface was designed to be an intuitive experience for pro-viders. The pathway offers 3 options for ordering central PN. Two options are available for patient-specific formulations, which can be prescribed as either daily amounts of calories and protein or daily amounts of amino acids, dextrose and IV fat emulsion. Additionally, there is an option for a “starter” formulation. All orders are converted to a standardized format of daily amounts of amino acids, dextrose and IV fat emulsion. Electrolytes are prescribed as daily amounts of indi-vidual salts. Key features are safety alerts when the prescribed macro- or micronutrients exceed guidelines or institution-specific limits, reorder prompts, a summary of the formulation’s macro- and micronu-trients, a function to replicate and revise orders, a standardized order printout for pharmacy and nursing, a standardized PN label and the capability to administer a deadline for order submission. Links are available to educational resources and hospital policies and procedures. The CPOE pathway was tested by Adult PN service members, selected providers, pharmacists responsible for compounding and dispensing PN formulations and nurses who frequently administer PN. After minor modifications were made, the pathway was approved by the CPOE steering committee and slated for implementation. Education and training was offered to providers, pharmacists, pharmacy techni-cians, nurses, and health unit coordinators prior to implementation. The CPOE pathway for adult PN therapy was successfully implemented in 2007. It is routinely evaluated and revised to improve the application. Conclusions: An interdisciplinary team designed, developed and imple-mented a CPOE pathway for adult PN. The pathway includes features and components essential for a prescribing system that promotes best practices, reduces problematic orders, improves efficiency and enhances patient safety.
P84 - Cleveland Clinic Home Parenteral Nutrition Program 2003-2008Rex A. Speerhas, R.Ph., CDE, BCNSP; Cynthia Hamilton, MS, RD, CNSD; Donald F. Kirby, MD, CNSP; Ezra Steiger, MD, CNSPPharmacy, Cleveland Clinic, Cleveland, OH. Introduction: The Cleveland Clinic discharged its first patient home on parenteral nutrition (HPN) in 1976. Since that time, over 1600 patients have been discharged on HPN. The management of these patients now requires five physicians, two dietitians, three nurses, one pharmacist and a full time secretary. In anticipation of discharge on HPN, a perma-nent venous access device is placed, the PN infusion is cycled (usually over 12 hours) and fluid status and electrolytes are stabilized. All HPN patients have trace element levels drawn prior to discharge. Nurses train patients and/or their caregivers on all catheter and infusion procedures. A case manager establishes the home infusion pharmacy and the home
34S Nutrition in Clinical Practice / Vol. 25, No. 1, February 2010
Cleveland Clinic HPN Census 2003-2008
Home PN Patient Status 2003 2004 2005 2006 2007 2008 Total Average/Year
active patients 116 109 120 116 131 111 703 117 new patients 140 107 143 131 122 131 774 129 patients discontinued 99 91 113 111 109 104 627 104 Reason For PN End * HPN care transfer to another M.D. 14 12 9 4 39 10 Oral Diet 64 69 78 76 276 69 Transfer To Palliative Care 2 3 4 6 15 4 Transition to Tube Feeding 6 6 7 2 21 5 Oral Diet and Tube Feeding 5 1 1 0 7 2 Withdraw Support 2 5 1 2 10 2 Expired 10 15 9 14 48 12 PN patients discharged to Skilled 104 106 107 104 102 126 649 108 Nursing FacilitiesHPN Catheter Episode Days 28126 29623 32740 31381 35988 30206 187704 31284 CRBSI Admits/1000 catheter days 2.3 2.2 2.4 2.2 2.7 1.3 2.2 Patients seen in Out-patient Clinic 161 156 154 120 171 142 904 151
*Reason for PN End data not collected prior to 2005
2003 2004 2005 2006 2007 2008
Year Count Count Count Count Count Count Total Percent
care nursing services for each HPN patient prior to discharge. Patients are seen at regular intervals in the out-patient clinic after discharge. This report describes activities of the HPN service over the past 6 years (2003-2008) including the number of patients started/discontinued on HPN, the reason for HPN discontinuation, number of catheter days, rate of catheter-related blood stream infection (CRBSI) and number of patients seen in our out-patient clinic annually. Cleveland Clinic is a tertiary care center with a large number of patients referred for HPN for a variety of diagnoses. Methods: Data are prospectively collected and reported from the Cleveland Clinic HPN database. This database is registered with the IRB and meets all criteria for reporting patient infor-mation. Results: The HPN Census report (Table 1) shows on average 117 active HPN patients and 129 new patients each year from 2003 to 2008. As of August, 2009 the current program has 148 patients. Most
patients transitioned to an oral diet (37.8 %), died (5.6 %), or transferred care to another MD (4.8 %). The rate of CRBSI has recently dropped to 1.3 /1000 catheter days and on average 151 patients (17.1 %) are seen in the clinic annually. The Diagnosis Summary (Table 2) lists the reason for HPN by diagnosis. The number of patients with each diagnosis and the percent of total are listed. Conclusions: The HPN program at the Cleveland Clinic cares for a large number of patients on HPN with most patients being able to transition to oral diet. The dramatic reduction in CRBSI readmissions may be a result of increased use of ethanol lock therapy in long-term catheters with at least one CRBSI. This is an area for potential future review. Benign post-operative fistulae, Crohn’s dis-ease, high output enterostomy (e.g. ileostomy, jejunostomy) and benign post-operative adhesive obstruction continue to be the most prominent reasons for HPN in the last six years.
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P85 - Canadian Home Total Parenteral Nutrition (HTPN): Practice of Vitamin K Prescription and Bone Mineral DensityBadr Aljarallah, MD,FRCPC1; Gail Fernandes, BSc1; Olivia Saqui, RN, BScN1; Lydia Fairholm, RD, CNSD1; Mary Baun, BScPhm1; Hani Jawa, MD,FRCPC1; Clare Meechan, RN, BScN, CGN2; Holly Ames, Msc,RD3; Andrew Shaw, RN4; Khursheed Jeejeebhoy, MBBS,FRCPC2; Js Whittaker, MD,FRCPC5; David Armstrong, MB BChir,FRCPC, FRCP(UK)6; Donald Duerksen, MD,FRCPC7; Leah Gramlich, MD,FRCPC3; Johane Allard, MD,FRCPC1
1University Of Toronto, Toronto, ON, Canada; 2St. Michael’s Hospital, Toronto, ON, Canada; 3Alberta Health Services, Edmonton, AB, Canada; 4Twenty One Ton, Toronto, ON, Canada; 5BC Home Parenteral Nutrition Program, Vancouver, BC, Canada; 6Hamilton Health Sciences & McMaster University, Hamilton, ON, Canada; 7Manitoba Home Nutrition Program, St. Boniface Hospital, Winnipeg, MB, Canada. Introduction: The lipid emulsion component of HPTN regimens pro-vides 0.05 - 0.7 mcg/ml of vitamin K; as this is sufficient to meet normal daily requirements, additional vitamin K supplements may be unneces-sary. However, vitamin K supplementation improves bone health and its absence may be associated with low bone mineral density (BMD). Objectives: To assess vitamin K supplementation practice and its rela-tionship to bone density in Canadian HTPN patients. Methods: A cross-sectional study of patients enrolled in 7 programs (2005-2009) comprising the Canadian HTPN Registry. Details of patient character-istics, nutritional intake, blood tests, medication and BMD were entered, into a web-based database by HTPN program staff. Statistical analyses (SPSS Inc version 14, USA) compared data from patients receiving (VK+) and not receiving (VK-) vitamin K supplements using the Chi-squared test (categorical variables), independent samples t-test (normally distributed continuous variables) or Mann-Whitney U test (non-normally distributed continuous variables); p<0.05 was considered statistically significant. General linear model (Proc GLM) was used to assess the interaction effect of vitamin K, body mass index (BMI), age and magnesium (Mg) and phosphate (P) supplementation on BMD. Results are presented as mean [SD]. Results: Data were available for 224 patients (mean age:55.5 y/ 41% male), 202 (90.2%) of whom were VK+. The primary indication for HTPN was short bowel syndrome (VK+ 60.5%, VK- 56%). On univariate analysis, VK+ patients received more Mg (10.33 [0.36] vs 6.58 [1.24]; p=0.011) and more P (11.57 [0.81] vs 4.49 [1.60]; p=0.020) than VK- patients; however, there were no other significant differences with respect to HTPN calcium or lipid content, blood tests, age, gender, reason for HTPN, warfarin or bisphosphonate intake. VK+ patients had higher BMI (23.0 [1.16] vs 20.3 [0.42] kg/m2; p=0.045), lumbar spine T-score (=1.49 [0.16] vs -3.43 [0.74]; p=0.028) and hip T-score (-1.56 [0.17] vs -3.08 [0.64]; p=0.047) than VK- patients. However, GLM analysis, adjusted for BMI, age, Mg and P showed trend for better hip T-score (p=0.053)for VK+ patients com-pared to VK- patients Conclusions: Most Canadian HTPN patients enrolled in this registry receive additional vitamin K supplements. However, multivariate analysis suggests trends towards better hip bone mineral density with vitamin K supplementation. Prospective studies, controlling for confounding factors, are required to determine whether or not vitamin K supplementation is beneficial for HPTN patients.
P86 - Identifying Predictive Variables of Patients Receiving Short Term Parenteral NutritionJill N. Ostendorf, RD, MS, CNSC; Bryan R. Collier, DO, CNSP, FACS; Vanessa J. Kumpf, PharmD, BCNSP; Douglas Seidner, MD, FACG, CNSPCenter for Human Nutrition, Vanderbilt Medical Center, Nashville, TN. Introduction: Parenteral nutrition (PN) benefits have been shown in the appropriate patient population. There are numerous risks involved
with this form of nutrition therapy and it should be used judiciously. Providing short term PN (<5 days) may be of greater risk than the ben-efits received. The purpose of this study is to identify clinical variables of patients receiving PN for less than 5 days with the goal of potentially reducing inappropriate PN initiations. Methods: All adult patients who receive PN at Vanderbilt Medical Center are managed by a multi-disciplinary nutrition support team (NST). All patient care data is main-tained in an electronic medical record (EMR) that was queried for this study. The following data was extracted from the EMR over the 4-month period in patients receiving PN for less than 5 days as a quality control audit: primary service and diagnosis, reason for PN, number of days on PN, and nutritional status. This study was approved by the IRB. Results: The NST managed 253 inpatients from February through May 2009. Of these, 32 (12.6%) received PN for less than 5 days. The median days on PN was 3. There were 19 (59%) surgical patients and 13 (41%) medical patients. The most common primary diagnosis was cancer (n=15), of which 9 (60%) were post bone marrow transplant (BMT). There were 10 (31%) patients with GI disorders/surgeries, 5 (16%) trauma/burn, and 2 (6%) with other medical conditions. PN was initiated because of intolerance/difficulty providing enteral feeds (n=12), ileus/ bowel obstruction (n=11), or poor oral intake (n=9). Of the 17 patients who underwent surgery, the median post op day (POD) to start PN was 7 (range 2 to 11). There were 4 (22%) patients who started PN before POD 7, only 1 being severely malnourished. Of the 17 patients with a functioning GI tract, 9 (53%) did not have a trial of enteral feeds. Of those without a trial of enteral feeds, 8 (88%) were on the BMT unit and only 1 was severely malnourished. Conclusions: It is difficult to predict the type of patient who will ultimately require short term PN. Very few surgical patients started PN before POD 7, which follows rec-ommended guidelines. There were a modest number of BMT patients who were mild to moderately malnourished receiving short term PN. Hospital guidelines and education regarding the indication for PN may be of benefit in reducing short term PN use.
P87 - A Comparison of 12-hour vs. 24-hour Intravenous Lipid Emulsion Hangtime on Metabolic Clearance and Infectious Morbidity in Hospitalized Adult Patients Receiving 2-in-1 Parenteral Nutrition SupportCarole Thompson, RD CNSD1; Ilya Blum, Ph.D3; Theresa Glanville, Ph.D RD2; Heather Wile, MA RD4
1Food and Nutrition Services, Capital Health, Halifax, NS, Canada; 2Applied Human Nutrition, Mount Saint Vincent University, Halifax, NS, Canada; 3Mathematics and Computer Science, Mount Saint Vincent University, Halifax, NS, Canada; 4Nestle Nutrition, Halifax, NS, Canada. Introduction: The presence of PEM increases infectious risk, worsen-ing clinical outcome. Impaired GI function requires catheter insertion for TPN, further increasing risk. TPN may decrease immune function, as nutrients bypass GALT. North American IVLE products have a pro-inflammatory (high O6FA; LCFA content) fatty acid profile, and have been found to impair immune response, in a dose-dependent manner. The hangtime of separately infused IVLEs is controversial: An IVLE supports clinically significant microbial growth, within 24h. Packaged under sterile conditions, IVLE can become contaminated when admin-istered. Guidelines from the CDC and ASPEN recommend a 12h hang-time. Clearance is not addressed in the CDC recommendation, and has not been proven when IVLE are infused over 12h. Improved infectious risk is weighed against impaired metabolic clearance. Recommendations for appropriate substrate prescription exist. Prolonged IVLE avoidance causes inadequate energy provision, and EFAD. No published study directly compares 12h versus 24h IVLE hangtimes for infectious and clearance outcomes. Objectives -To compare 12h and 24h hangtimes of a 10% soybean oil-based IVLE for differences in: 30-day all-cause infec-tious morbidity rates, and clearance efficacy, in adult patients treated
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P88 - Retrospective Review of VAMC Patients Receiving Total Parenteral Nutrition After Implmentation of the New Aluminum Labeling Requirements in 2004Jennifer Twilla, Pharm.D.1; Kevin L. Freeman, Pharm.D., BCNSP2; Mary Catherine Schallert, MS,RD,LDN,CNSC3
1Pharmacy, Methodist University Hospital, Memphis, TN; 2Pharmacy (119), VAMC Memphis, Memphis, TN; 3Nutrition and Food Service, VAMC Memphis, Memphis, TN. Introduction: Aluminum contamination of parenteral nutrition solutions has been associated with bone disease and neurologic impairment. Due to increasing reports of toxicity secondary to overexposure to aluminum via PN products, the FDA published new labeling requirements mandat-ing that manufacturers include information regarding aluminum content present in large volume parenterals (LVPs), small volume parenterals (SVPs), and pharmacy bulk packages (PBPs). On January 26, 2004 these regulations became effective. The American Society for Clinical Nutrition and the American Society for Parenteral and Enteral Nutrition (ASPEN) state that a daily dose of 15-30 mcg/kg/day is unsafe and aluminum doses exceeding 60mcg/kg/day are toxic. Generally, the amount of aluminum regarded as safe is 5mcg/kg/day. It is important to determine if our patients at the VAMC Memphis are exceeding the aluminum dose gener-ally recognized as safe and to determine if there is a temporal relationship between aluminum content and adverse effects. This study will provide clinically relevant information that will help determine if the VAMC Memphis patients are receiving potentially toxic amounts of aluminum with TPN administration. Methods: Patients receiving total parenteral nutrition at the Memphis VAMC from 10/05 to 6/08 have been compiled in a personal database by the Clinical Pharmacy Nutrition Specialist. Demographic data, aluminum content, length of therapy, concomitant
Table 1Frequency and Distribution of Infections between Hangtime groups
12h 24h
Patients 14/40 35.0% 26/40 65.0%#pts with infections/group 3/14 21.4% 18/26 69.2%Cases with no infections 11/14 78.6% 8/26 30.8%#New infections/group 5/68 7.4% 63/68 92.6%Range of infections per 0-2 - 0-7 - affected
concurrently with 2-in-1 PN and separately run IVLE. -To investigate whether PEM affects metabolic tolerance. Methods: A retrospective survey of EMRs was completed, of all patients on TPN during a 6-week period. Patients were placed into 12h or 24h groups, based on initial hangtime prescribed. Infections were identified through culture reports, susceptibility reports, and antimicrobial orders. Routinely used clear-ance parameters (BG;TG;ALP;ALT;AST; tbili) were monitored. Average daily substrate provision, and NRI score was calculated. Results: Forty of seventy-six patients met inclusion criteria. There were significant dif-ferences in the number of new infections, developed post TPN initia-tion, in the 24h group. (TABLE 1) Three variables predicted increased infectious risk: length of hangtime, duration of TPN therapy, and NRI score. A model was developed to predict the number of new infections. There were no significant differences in any index of metabolic clear-ance tracked as part of standard care of patients receiving TPN in Capital Health. Nutrition status was not associated with clearance effi-cacy. All data will be presented at the Meetings. Conclusions: A 12h hangtime for separately run IVLE minimizes infectious risk, and allows adequate clearance in acutely ill, severely malnourished adult patients. Lacking products with more favourable fatty acid profiles, available formulations can safely provide necessary energy and essential fatty acids to patients with GI dysfunction, provided appropriate dosing and infusion rates are used.
medications, and appropriate baseline and follow-up laboratory data were reviewed and evaluated. Results: One hundred forty-eight patients were reviewed. The mean aluminum exposure from parenteral nutrition was 4.04 mcg/kg/day with a range of 0.38 mcg/kg/day to 13mcg/kg/day. Thiry-one patients received >5mcg/kg/day. One hundred thirty-four patients received additional aluminum through boluses of calcium gluconate, sodium and potassium phosphate. The average aluminum exposure from boluses of electrolytes was 1453 mcg ranging from 1.8 mcg to 26,508 mcg. Conclusions: The majority of our patients did not receive excessive exposure to aluminum. In our analysis, there was no correlation between aluminum exposure and adverse effects.
P89 - Allergic Skin Reaction Associated With Intravenous Fat Emulsion: Case report and review of the literatureDong Wook Kim, Clinical Fellow; David Seres, Asst. Professor of Clinical Medicine, Director of Medical NutritionMedicine - Division of Preventive Medicine & Nutrition, Columbia University Medical Center, New York, NY. Introduction: Hypersensitivity reactions associated with Total Parenteral Nutrition (TPN) are an uncommon occurrence. All allergic or hypersen-sitivity reactions in the case reports to date are related either to multivi-tamins or intravenous fat emulsion (IVFE). Methods: Case Report Results: A 62 year old woman with past medical history of hepatitis C, hypertension, and latent tuberculosis was admitted with persistent hematuria. Invasive adenocarcinoma of bladder was diagnosed and cys-tectomy with ileal-conduit reconstruction was performed. She did not have any previously known allergies. On post-operative day 15, she developed fascial dehiscence and high output enterocutaneous fistula. Parenteral nutrition (3-in-1 total nutrient admixture) was started with IVFE contributing 20% of total calories. Twelve hours after the initiation of TPN, the patient developed a maculopapular erythematous rash, which was mainly located on her torso. She denied dyspnea or cough. There were no new medications started, except for the TPN, within 48 hours of the development of the rash. Vancomycin and Piperacillin/Tazobactam had been administered for wound infection for 5 days prior to the development of the rash. She did not have any systemic symptoms, an antihistamine was started, and TPN was continued. The rash, how-ever, worsened and spread to her limbs. The IVFE was removed from the TPN approximately 48 hours after the development of the rash. The total amount of calories and fluid were not changed and multivitamins were continued. The antibiotics were continued throughout this period. The skin reaction improved and was completely resolved within 24 hours after discontinuing IVFE. Unfortunately, further IVFE trials or skin tests could not be performed. TPN was discontinued due to devel-opment of fungemia and sepsis 6 days later. Conclusions: Of reported cases of allergic reaction associated with IVFE, anaphylactic reactions to lipids are less frequent. Skin rashes are the most common manifesta-tion of allergic reaction to IVEF. On the other hand, all of the reviewed case reports of allergic reaction associated with multi-vitamins were systemic and/or severe anaphylaxis. In general, TPN should be discon-tinued immediately if a patient develops a systemic hypersensitivity reaction. However, if the allergic reaction is limited, challenge with lipid and/or multi-vitamin free TPN may be considered. If the allergic reac-tion is solely dermal, as occurred in our case, we suggest that discon-tinuing IVEF alone may be sufficient. Allergy to components of IVFE presents an unusual challenge. Long-term fat free TPN may be associated with essential fatty acid deficiency, and an alternative source of long-chain fat is likely to become necessary
P90 - Monitoring Metabolic Stability as a means of Determining Quality when Providing Parenteral NutritionJohn J. Engelbert, Pharm D; Yong Mei Xu, Pharm D; Leola Hau, Pharm D; Lan Ding, Pharm D; Cynthia Londo, Pharm D; Brenda O’Day, RD, CNSC; Kristine Binda, RD, CSO, CNSD; Kalman E. Holdy, MD
CNW 2010 Nutrition Practice Abstracts 37S
Metabolic Index SMH
Benchmark SMH (% in range) (% in range)
Potassium 88 80 Sodium 75 61 Glucose 90 40 Magnesium 80 not reported Phosphate 85 not reported
P91 - Hypersensitivity Reaction to Parenteral Lipid Emulsion. A Case ReportLori Milicevic, Pharm.D., BCNSP1; Susan Cywiak, Pharm.D.1; Andrew Ukleja, M.D.21Pharmacy, Cleveland Clinic Florida, Weston, FL; 2Gastroenterology, Cleveland Clinic Florida, Weston, FL. Introduction: To report a case of hypersensitivity reaction to parenteral lipid emulsion in a patient with no prior history of food or drug allergies. Methods: A 45-year-old female with post-operative complication of anas-tomotic leak required parenteral nutrition (PN) because of anticipated
Nutrition and Metabolic Support Services, Sharp Memorial Hospital, San Diego, CA. Introduction: Metabolic instability during PN and was first reported approximately 30 years ago and remains a common, well recognized complication. Although much attention has recently been given to gly-cemic management during PN, there is a paucity of studies reporting aggregate data for other common metabolic issues. It would seem pru-dent for all institutions to develop quality parameters measuring com-prehensive metabolic control during provision of PN. Development of a complete clinical benchmark seems imperative to insure that any changes in provision of PN. (i.e. the utilization of standard solutions vs. individualized) does not result in less favorable metabolic stability. At Sharp Memorial Hospital (SMH) over 95% of PN is provided by a mul-tidisplinary metabolic support service. Previous efforts at determining quality by the team have been to insure appropriate utilization of PN (2000 to present) and Glycemic control (2002 to present). Our most recent effort is to determine more comprehensive aggregate metabolic review during PN. Methods: Data was collected for PN in the first quar-ter of 2008. Potassium (K), Sodium (Na), Magnesium, Phosphate and Glucose were the metabolic parameters monitored. Only the morning venous sample was reviewed. Data was collected serially for up to ten days of PN. Incidence was reported as a percentage of days within the established hospital normal range. A large teaching hospital (Sanborn,M;presented at American Society of Health Systems Pharmacy, December 4, 2007) had previously reported similar data and was used as a benchmark. Results: A total of 35 patient receiving PN in January to April of 2008 were included in the analysis. This represented a sample of 275 patient days. Metabolic control compared favorably with the chosen benchmark; K 88% vs. 80%, Na 75% vs. 61%, glucose 90% vs. 40%. Several suggestions were made by the MNSS performance improvement team to improve clinical relevance that included the following: 1. In addition to percentage of time in the therapeutic range for normal values a determination of “extreme” low and high values should be monitored. 2. Metabolically stability should be reviewed via time sequence compar-ing comprehensive stability by PN day (i.e. comparison of day one of PN to day three of PN etc.) 3. The incidence and need for corrective solu-tions or aliquots should be monitored. 4. Data should be reported for patients in critical care vs. acute care. 5. Insuring the caloric goals are also met in a timely fashion in addition to metabolic stability. Conclusions: Our initial data compared favorably with those reported at a large teach-ing hospital, however several key elements were felt to be missing. A second analysis will be conducted from October 1st, 2009 to December 2009 that incorporates the suggested additional parameters.
prolonged bowel rest. A peripheral 3 in 1 formulation (86g of protein, 486g of dextrose and 250mL of 20% lipids) was started at a rate of 90mL/h. She developed excruciating “cramp type” back pain (8/10 in severity) with radiation to lower extremities and dyspnea within minutes of the infusion. The infusion was stopped immediately. The patient was hemodynamically stable and she was treated with hydromorphone 1mg IV and diphenhydramine 50mg IV. The pain subsided within 10 minutes after discontinuation of the PPN. On the following day, a PICC line was placed and the same PN formulation was infused via central catheter. The patient developed the same symptoms after rechallenge with only 7mL of infused formula. Allergic-type reaction was suspected to a PN component. This reaction did not reoccur when lipid emulsion was removed from the PN solution and the patient received two weeks of lipid-free PN without complications. Results: Intravenous lipid emul-sion is an important source of essential fatty acids (EFA) as well as a dense source of non-protein calories. Acute reactions to lipid emulsion are rather uncommon, usually mild and transient, and often associated with a higher dosage and/or rapid rate of lipid administration. Symptoms of dyspnea, cyanosis, nausea, vomiting, headache, sweating and back pain have been infrequently described after lipid infusion and they can mimic other medical conditions. Although direct testing was not per-formed in this case, based on rechallenge on day 2 and no recurrence of symptoms after lipid withdrawal, the lipid emulsion was responsible for the patient’s hypersensitivity reaction. Conclusions: Although the occurrence of a hypersensitivity reaction to lipid emulsion is uncom-mon, early recognition and proper formula modification is necessary. Individuals with a prior history of allergy to lipids, egg yolk and soybean oil may be particularly susceptible to this systemic reaction and high index of suspicion is needed.
P92 - Parenteral Nutrition (PN) Education using a Competency ChecklistJay M. Mirtallo, M.S., R.Ph., F.A.S.H.P., B.C.N.S.P.; John Hertig, Pharm.D.Pharmacy, The Ohio State University Medical Center, Columbus, OH. Introduction: Staff training in parenteral nutrition therapy has been a challenge for our department. Formal lectures at the beginning of employment or pharmacy residency have been shown to be insufficient in assuring adequate competence in daily practice. Since a formal rota-tion in PN is not available to everyone who needs training, it was decided to implement a competency checklist for preceptors of staff and residents to use to assess skills as they complete their orientation or residency. Methods: Formal lectures were evauated for content. Since there is diversity in both the didactic and experiential training of pharmacists that come to our organization, it was decided to continue the didactic component of the training, which included a 2-hour lec-ture on the basics of parenteral nutrition and the system, including our Nutrition Support Service (NSS) database used for daily PN manage-ment. It was found from staff and resident feedback that this was insuf-ficient. The content learned in the session was forgotten by the time some had an opportunity to use the knowledge presented. As a result of these findings, a second training session was developed which focused on skills needed to initiate, manage and coordinate discharge on PN. A competency checklist was developed based on the most frequent skills used to manage PN. The training session was case-based using actual patients in the NSS database to provide staff and residents hands on experience with the computer programs used to assess PN patients and then to place orders. Results: The competency checklist focused on computer skills such as updating laboratories in the database and plac-ing PN orders on the computer-assisted order system of the organiza-tion (Figure 1). It also included knowledge of pertinent monitoring issues such as refeeding syndrome and glucose control. Systems issues such as adjusting fluid volumes of PN, cycling PN for home therapy and developing a continuity of care for home PN therapy were also cov-ered. It was decided to use actual patient cases from the NSS database
38S Nutrition in Clinical Practice / Vol. 25, No. 1, February 2010
Requirement
Preceptor Signature/date
Enter laboratory values into the NSS data base Lab Results Table
Remove duplicate laboratory values from the Lab Results Table
Enter accuchecks and insulin administered into the NSS database
Review past consults to determine previous PN formulas
Determine a patient’s risk for re-feeding syndrome
Enter new PN based on the NSS consult into the NSS database
Enter new PN in CAPi/e Results (CPOE)
Enter laboratory values, nursing orders, evaluate maintenance IV fluid rates, and ensure appropriate line placement associated with starting new PN in CAPi/e Results (CPOE)
Re-start PN on a patient previously discontinued
Evaluate laboratory trends and information in the NSS database and patient bed-side chart to modify existing PN formulas
Understand when cycling a patient is appropriate and how to enter a cycle into the NSS database and CAPI/e Results (CPOE)
Manage a patient on PN with poor glucose control (goal of 100-150 mg/dL continuous infusion; <200 mg/dL on a cycle)
Understand when a patient’s condition requires therapy management in addition to PN
Calculate a new rate based on a PN formula change and/or the need to concentrate or dilute the PN
Discontinue PN in the NSS Database and in CAPI/e Results
Complete a continuity of care document in the NSS database and place in the patient chart
Competency Checklist for Parenteral Nutrition
Table 1Patient Demographics
Sex, N(%) 3(50)Male 3(50)Female
Age, y, mean ±SD 47±15Range, y 33-61
Weight,kg, mean ± SD 140±32Range, y 110-196
Ideal Body Weight, kg, mean ±SD 64±13Range y 52-81
Body Mass Index, kg/m2,mean ± SD 48.6±8.9Range, kg/m2 40.4-58.5
in the education session so that the learner could have actual experi-ence with the programs under the tutelage of the Nutriton Support Service specialist. Subsequent to the training, the pharmacy preceptors were educated on the use of the competency checklist and advised to use this to assess staff and resident capablilities in managing PN. Program directors also incorporated the checklist in their quarterly evaluations to assure adequate progress was being made in completing these skills in a timely manner. If not, adjustments in residency rotations or further staff in-service training could be scheduled. Conclusions: A competency checklist was developed to assist with the eduation of staff and residents on PN therapy. It clearly delineated for the educator, students and preceptors those concepts and skills needed to success-fully manage PN therapy.
Competency Checklist for Parenteral Nutrition
P93 - Long-term Hypocaloric Parenteral Nutrition (PN) in Morbidly Obese PatientsJay M. Mirtallo, M.S., R.Ph., F.A.S.H.P., B.C.N.S.P.1; Brett Payne, R.D.L.D.2; Melissa Whitmill, M.D.31Pharmacy, The Ohio State University Medical Center, Columbus, OH; 2Nutrition and Dietetics, The Ohio State University Medical Center, Columbus, OH; 3Surgery, The Ohio State University, Columbus, OH. Introduction: Hypocaloric PN has been used in obese patients for short (< 1 month) courses to achieve weight loss while supporting recovery from major surgery and for metabolic control while achieving positive effects on protein accretion. We have been using this approach for long-term PN patients with morbid obesity but have not seen any data on the success of this practice. Objective. The purpose of this case series is to evaluate nutritional and metabolic outcomes of long-term, hypocaloric PN in mor-bidly obese patients. Methods: Patients receiving hypocaloric PN for >30 d and having a BMI≥40 and normal renal function were included. The PN formula (0.7 Cal/ml) provided 35% of total calories as protein, 29% as fat and consisted of a 7.5% dextrose concentration. Parameters collected were initial and final values of weight, prealbumin, BUN, Cr, triglycer-ides. Glucose values were assessed by quartile analysis and separated into hyperglycemic (required insulin in PN to maintain glucose < 200 mg/dl) and normal groups. Initial vs final values as well as hyperglycmic vs nor-mal glucose values were analyzed using Student’s T test. Results: Six patients having an average age of 47 years and BMI of 48.6 were included in the analysis (Table 1). Four of the 6 patients had diabetes but only 3 of the 6 patients required insulin therapy (Hyperglycemic group). The most frequent (66.7%) indication for PN was an enterocutaneous fistula. PN provided 23 Calories and 2 grams protein/kg IBW/d (Table 2). Each patient lost weight during PN but this was not statistically significant for the group. There was a non significant increase in BUN and triglycerides. At no time were fats removed from PN for elevated triglycerides. Glucose values averaged 130 mg/dl for the entire group. The mean glucose was significantly greater for the hyperglycmic group (Table 2). Glucose values remained within acceptable limits with only 37 (3.5%) of values > 200 mg/dl. PN therapy averaged 130 days and 4 of the 6 (66.7%) patients success-fully transitioned to an enteral diet. Conclusions: Long-term hypocaloric PN was well tolerated in this small series of morbidly obese patients. Nutritional objectives which included weight loss were achieved.
CNW 2010 Nutrition Practice Abstracts 39S
Table 2Results
PN TherapyEntergy, Cal/day, mean ± SD 1515±276
/kg IBW/d 11±1.7/kg Actual BW/d 23±0.6
Protein, Grams/d, mean ± SD 131±24/kg IBW/d 2/kg Actual BW/d 1 ± 0.1
Therapy duration, d, mean ± SD 130±68Range, d 44-230Outcomes Initial Final pValue
Glucose, mg/dl, mean ± SD 130±33Median, mg/dl 124Range, mg/dl 65-339
Hyperglycemic vs Hyperglycemic Normal pValue normal patient glucoseValues, mg/dl, mean ± SD 140 ± 35 110 ± 19 <0.01
Median, mg/dl 135 108Transition to enteral diet, N(%) 4(66.7)
P94 - Impact of Diagnosis, Nutritional Status and Line Sepsis on OutcomesDottie J. Gibson, RD,CNSD; Michael Coronado, PharmD; Snorri Olafsson, MD,PhD; Stanley Condon, MD; Lisa Alvarado, MS,RN; Aurea Burgos, RD; Rebecca Estanque, RN, NP; Emlyn Carbajal, MS, RN; Peng Mitchell, RD,CNSD; Renee Piazza-Barnett, RD, CNSD; Susan Rojas, RN; Cynthia Salcedo, RD, CNSD; Pamela Short, RD, CNSD; Andrea Williams, RD, CNSDPharm, Loma Linda Univ Med Center, Loma Linda, CA. Introduction: In concurrence with the 2009 National Patient Safety Goals (NPSG), the Nutritioal Support Team at Loma Linda Univesity Medical Center (LLUMC) looked at 555 adult parenteral nutrition (PN) patients and categorized them based on diagnosis, nutritional status, type of central line, and rates of line sepsis. Based on analysis of our data and evaluation of our current practices, we identified high risk patients and are proposing several evidence based process changes. Methods: The patients were catagorized into 4 groups based on clinical setting (CS) and/or diagnosis and nutritional status. Group 1: PN for patients with protracted non-functional/ non-available GI tract and/or inability to absorb nutrients. Group 2: PN for patients with protracted inability to adequately and/or safely utlize nutrients via the GI tract Groups 3 and 4: PN for patients thought to be of limited value or probably should not have been utilized. The nutrition evaluation included percent weight change from usual body weight, BMI, and serum albumin, and trans-thyretin. The central line information included type of central line, tip placement, and the presence or absence of PN associated infection. A PN associated line infection as defined as a positive line culture 3 days after initiation of PN. Results: Gender N Percent Male 268 48 Female 287 52 Age Distribution Mean 54.5, range 14-98 PN Start on Hospital Day Mean start 10 days range 1-176 days Clinical Setting/Diagnosis and Length of Stay (LOS) CS N Mean 1 147 31.5 days 2 385 32.1 3 3 15.8 4 19 21.1 LOS Mean 32 days Range 2-232 Mean LOS for pts with 15-20% wt loss 45 days Nutritional Factors, LOS and Malnutrition Frequency Malnutrition Frequency N = 394 Percent 71 LOS and Albumin at admit N = 551 P-value 0.033 LOS and BMI N = 553 P-value
0.081 LOS and % wt changes N 342 P-value 0.045 PN Access Line Type N Percent Peripheral line 67 12 Central line* 488 88 Central line: PICC, subclavian, internal jugular Infection Frequency (+ line cultures LC) Line associated infection N Percent Pts cultured for line infection 139 28 Pts with PN associated infections 21 4.3 Pts with suboptimal central line placement 13 2.6 Conclusions: Out of 555 patients intiti-ated on PN, 473 survived. Three of the 21 patients with + LC expired. Of the 21 patients with documented central line infections, 13 (62%), had suboptimal line placement defined as tip location other than the superior vena cava or cavoatrial junction. PN is associated with an inher-ent risk line infection and high morbidity. This is partially related to type of diagnosis, clinical characteristics and degree of malnutrition. Given the prolonged length of stay for PN and the increased risk of morbidity, the Nutritional Support Team at LLUMC has developed a clinical path-way, algorithm and guidelines for initiation and management of PN in the high risk patient. This algorithm and guidelines include recommen-dations for the line tip placement as well as catheter composition, and a technique for ethanol lock to be used in silicone type central catheters. Implementation of the above algorithm and guidelines along with staff education should help to further reduce incidence of PN associated central line infections and comply with the NPSG.
P95 - Is central venous access port suitable for HPN?Nada Kozjek, MD; Laura Petrica, RNClinical nutrition, Institute of Oncology, Ljubljana, Slovenia. Introduction: Venous access ports (VAPs) are totally implanted devices which are used in patients receiving long parenteral treatments. Regarding recommendations this is not recommended venous acces for home paren-teral nutrition (HPN). Despite some advantages of totally implanted devices, skin tunneled central venous catheters continue to be commonly used for HPN. As the local situation in our hospital was in favor of using VAPs we decided to use this device for our group of patients on HPN. The aim of this retrospective study was to analyse the complications of VAPs use in our patients on HPN. Methods: We analysed the records of all our patients patients on HPN since the beginning of their treatment (clinical diagnosis, underlying conditions, date of VAP, number of days, all signifi-cant events during treatment). Results: From August 2008 till the end of August 2009, 18 VAPs were inserted to 18 patients. 11 of them were/are paliative cancer patients , 8 patients need HPN because of malabsortion or short bowel syndrom. 5 cancer patients died in less than 2 months (14 to 50 days) and they didn’t have any catheter related complications. 2 cancer patients had VAPs inserted 184 and 230 days with no catheter related complications before they died. 4 paliative cancer patient are on HPN 167 to 365 days without any complications regarding VAP. The other 7 patients have VAPs inserted 32-343 days . In this group 1 patient with Chrons disease had once the catheter obstruction and finally, after 297 days, the cather was removed because of catheter infectIon with coagulase-negative staphylococci. The overal rate of complications was 5,5%. Conclusions: Incidence of associated VAP-use complications is extremly low in our hospital. On the basis of data from the present study we will continue to use VAPs as a vascular acces device for HPN.
Pediatrics
P96 - A Multidisciplinary Clinic Improves Surgical and Functional Outcome after Fundoplasty in ChildrenRobin C. Cook, MS, RD, LDN; Thane Blinman, MD; Gina Kroeplin, RN, MSN, CRNP; Antoinette Drill, RN, MSN, CRNPThe Children’s Hospital of Philadelphia, Philadelphia, PA. Introduction: In children, fundoplication is the most effective treatment for gastroesophageal reflux disease (GERD). Because of this effective-ness and the improvement in laparoscopic technique, it has become one of the most common procedures performed by pediatric surgeons in the U.S. Despite this success, complications of surgical control of reflux are common, debilitating, and poorly understood. Feeding “intolerance”
40S Nutrition in Clinical Practice / Vol. 25, No. 1, February 2010
after fundoplication, includes dysphagia, gastric dysfunction, retching, dumping syndrome (early and late), intestinal dysfunction, and gas bloat syndrome. When children exhibit these problems, their parents may come to regard the treatment as worse then the cure. As more children with more complex medical problems undergo fundoplasty, post-fundo-plication feeding intolerance will continue to rise, with more clinicians struggling to ameliorate these problems. We hypothesized that an inten-sive multidisciplinary clinic could offer relief to children with these problems, while providing useful advice to other clinicians. Methods: In February of 2008, a multidisciplinary clinic consisting of a pediatric surgeon, an advanced practice nurse, and a surgical dietitian plus focused consultations from pulmonology, otolaryngology, and radiology was established. The clinic approached managing post-fundoplication from a philosophy that emphasized: 1) feeding strategies that accounted for gastrointestinal biomechanical changes after surgery 2) formula and additives that promoted desired gastrointestinal performance (low osmo-larity and specific biochemical components) and 3) restoration to a “normal” lifestyle with manageable feeds, reduction of medications, and minimization of medical disruptions. Results: Eighty-eight patients were enrolled in the clinic between February 2008 and January 2009. All had undergone fundoplasty and gastrostomy, largely but not exclusively at our institution. Three percent had subsequent conversion of the gastros-tomy to gastro-jejunostomy. The major complaints at the initial clinic visit included retching (69%), diarrhea (24%), post-prandial hypoglyce-mia (7%), and gas bloat (5%). Even in this population of “failed” fundo-plasties, only 6% of the patients required surgical revision. The remainder were empirically treated with both a medical and feeding plan that was specifically designed to fit each child. Intolerance was attributed to osmolarity of medications and formula (35%), inadequate venting (35%), large bolus volumes (34%), overfeeding (25%), secretion handling (24%), other formula problems, (e.g., casein predominance or unnecessary use of an elemental formula (22%)), inadequate venting (22%), untreated infection (including Clostridium difficile, otitis media, and UTI (19%)), and polypharmacy (18%). Ninety one percent of patients had resolution of retching while 75% had resolution of diarrhea and 100% achieved stable glucose control. All patients achieved their growth goals. Conclusions: Retching is not reflux, yet manifestations of intolerance post-fundoplasty are often misdiagnosed as recurrent GERD. This mis-diagnosis leads clinicians to attempt to control intolerance using treatments aimed at reflux, a futile strategy. Instead, successful post-fundoplasty management can be reliably achieved by a multidisciplinary team and a feeding regimen that works with the constraints of the patient’s surgical anatomy, and within the context of the patient’s particular medical his-tory. Most post-fundoplasty intolerance stems from a short list of prob-lems that are treatable with a few straightforward strategies.
P97 - Diagnosis and management of dumping syndrome in children following antireflux surgery: A single center experienceMeghana N. Sathe, MD1; Maria-Paula Carrillo, MS, RD, LD2; Margareta Benser, RD, LD, CSP2; John Andersen, MD1
1Pediatric GI and Nutrition, UTSW/CMC Dallas, Dallas, TX; 2Clinical Nutrition, CMC Dallas, Dallas, TX. Introduction: Dumping syndrome is characterized clinically by retch-ing, gagging, diarrhea, diaphoresis, and decreased alertness post feed caused by rapid emptying of food and consequent hyperglycemia, fol-lowed by reactive hypoglycemia usually within 30-45 minutes after feeding. In addition, radiologic evaluation may confirm rapid gastric emptying. In children, these symptoms may occur following Nissen fundoplication surgery for GERD. Management of symptomatic dump-ing syndrome is based on nutritional modifications that avoid rapid glycemic shifts, either by delaying gastric emptying (high fat diet) or delivering a delayed glucose absorption rate (corn starch or continuous feeds). We reviewed our 15 year experience in the diagnosis and man-agement of 47 children with dumping syndrome. Methods: We reviewed
charts from the UTSW/CMC Dallas gastroenterology clinic diagnosed with dumping syndrome by clinical syndrome or formal laboratory tests. Each chart was evaluated for age at Nissen fundoplication surgery, age at diagnosis of dumping syndrome, whether diagnosis was established based on clinical or laboratory criteria, type of nutritional intervention implemented, whether nutritional intervention resulted in resolution of symptoms, weight at diagnosis and approximately one year out, and age at transition to oral feeds. Results: We identified 47 patients with dumping syndrome secondary to Nissen fundoplication surgery. The majority of patients (72%, 34/47) were diagnosed based on clinical syn-drome, whereas 28% (13/47) were diagnosed based on laboratory find-ings of hyper- and hypoglycemia. Nutritional intervention involved the use of corn starch blenderized tube feedings, high fat blenderized tube feedings, or continuous formula feeds. Most patients were trialed on feeds in this order. Overall 79% (37/47) of patients achieved resolution of their clinical or laboratory symptoms. 71% (24/34) of patients with a clinical diagnosis, achieved resolution of their dumping symptoms. 92% (12/13) patients with a laboratory diagnosis were able to attain an asymptomatic and euglycemic state. Once placed on the modified diet, 53% of patients increased their weight by 15% of baseline. Eventually, 47% (22/47) of patients were able to be weaned off nutritional therapy involving a blenderized or continuous formula to oral feeds. This included 16/34 (47%) of patients with a clinical diagnosis and 6/13 (46%) of patients with a laboratory diagnosis. Conclusions: Dumping syndrome can be diagnosed utilizing subjective clinical symptoms or objective laboratory findings. All patients diagnosed with dumping syn-drome were on tube feedings post Nissen fundoplication, none were orally fed. Successful treatment, characterized by resolution of symp-toms and increased weight from baseline, can be attained in both groups with the use of high fat blenderized tube feedings, corn starch blender-ized tube feedings, or continuous formula feedings. Transition to oral feeds may not be an appropriate measure of success as most pediatric patients requiring antireflux surgery have other complex medical prob-lems preventing this transition. This retrospective review has brought to our attention areas of success and areas in need of improvement in our clinical practice. In the future, we plan to design a prospective study that will evaluate improved methods of diagnosis and nutritional man-agement for our patients with dumping syndrome.
P98 - Pediatric Nutrition Risk Screening: Reliability Of A Standardized ProcedureCatherine M. McDonald, PhD, RD, CNSD; Sarah Gunnell, MS, RD, CNSDDietitians, Intermountain Primary Children’s Medical Center, Salt Lake City, UT. Introduction: Screening hospitalized pediatric patients for nutrition risk is standard of care, but few validated and reliable nutrition risk screening (NRS) procedures exist. After extensive revision and clinical testing, the NRS procedure for a pediatric facility was evaluated for reli-ability among potential users. Inter-rater reliability assesses the agree-ment among users (raters). A reliable NRS procedure should show an acceptable level of agreement by raters in classification over that expected by chance. That is, for each case multiple raters should be able to apply the NRS and arrive at the same score. The aim of this study is to report the inter-rater reliability of an evidence-based, standardized procedure for screening hospitalized pediatric patients for nutrition risk. Methods: The NRS procedure was developed according to ASPEN guidelines and clinical trials with Institutional Review Board approval. The NRS procedure was tested for reliability by two unique groups of dietitians. Group 1 consisted of registered dietitians (RD) with pediatric experience and extensive training on the revised NRS. Group 2 included RDs employed in administrative and adult practice, naïve to the NRS. Group 2 received brief written and verbal instructions on the use of the NRS. Both groups scored a series of case studies using the NRS proce-dure. Each RD in both groups scored up to 5 separate case studies. All
CNW 2010 Nutrition Practice Abstracts 41S
case studies were randomly selected from a pool of 15 de-identified pediatric cases, typical of admissions to this facility. Inter-rater reliability was determined by Fleiss’ Kappa, a statistical measure for assessing the reliability of agreement among a fixed number of raters when assigning categorical scores. Fleiss’ Kappa scores range from 0 (no agreement) to 1 (perfect agreement). Results: Group 1 RDs (n = 12) scored 59 case studies; group 2 RDs (n = 81) scored 382. Fleiss’ Kappa scores were 0.90 (nearly perfect) for Group 1 RDs and 0.80 (substantial agreement) for the group 2 RDs. Conclusions: Substantial agreement among raters is considered an acceptable level. Therefore, the NRS procedure is a reliable tool for producing similar results when scoring nutrition risk for pediatric patients by multiple users. Although a brief instruction on the application of the NRS procedure enabled users to replicate scores with substantial agreement, users who were trained more extensively were able to achieve better agreement.
P99 - Ethanol Lock Protocol Decreases Central Line Infection Frequency in a Challenging Case of Pediatric Intestinal Failure: An Illustrative ReportKristi King, MPH, RD, LD1; Seema Mehta, MD2,1; Sarah Phillips, MS, RD, LD2,1; Krista Truver, RN1; Beth Carter, MD2,1
1Nutrition & GI Clinic, Texas Children’s Hospital, Houston, TX; 2Section of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, TX. Introduction: We describe a challenging case of pediatric intestinal failure, and its multidisciplinary treatment approach, including imple-mentation of a 70% ethanol (EtOH) lock protocol for prevention of central line (CL) infections. The dramatic reduction in the frequency of CL infections and the successful wean off PN after the 70% EtOH lock protocol is highlighted. Patient HS was born Aug 2006 at 34 4/7 weeks with a prenatal diagnosis of “bowel dilation.” On day of life (DOL) #3 she was diagnosed with jejunal atresia type 3B which was repaired surgi-cally. HS was discharged from the NICU on DOL #77 with full feeds by mouth. In March 2008 (1 year 7 months age), HS emergently presented to the ER with large diarrhea output (~20 stools per day) and bilious vomiting. Exploratory surgery revealed gangrenous intestine which was resected. Post-surgically, 57 cm of remnant small bowel remained, with an intact ileocecal valve. Despite multiple attempts, HS was unable to tolerate appreciable enteral feeds (maximum ~6-10 cc/hr) and was placed on full PN. Between Mar 2008 and Nov 2008, she had 7 CL infections (Klebsellia, Enterococcus, Candida Tropicalis, Pseudomonas, Yeast, & Enterobacter) that resulted in 5 pulled CLs. Methods: In Nov 2008, in effort to prevent CL infections and salvage tenuous CL access, the patient was started on a 70% EtOH lock protocol. Specifically, 1.2 ml 70% EtOH was infused into CL and allowed to indwell in CL while HS was off PN/lipid infusions (6-12 hrs/day). Results: While on the EtOH lock protocol, HS had only 1 central line infection (CONS) to which the medical management team was able to “treat through” and save the CL. The reduced frequency of CL infections helped the Intestinal Rehabilitation Team increase enteral feeds, thereby firmly establishing her maximum rate of enteral feed tolerance (peptide-based formula @ 34 cc/hr X 24 hrs = ~1/2 estimated caloric needs). Inability to advance enteral feeds past this rate (outside the setting of recurrent CL infections) in addition to a dilated intestinal segment on upper GI imaging led the team to recommend a surgical bowel lengthening pro-cedure. A Serial Transverse Enteroplasty (STEP) procedure was per-formed on HS in May 2009. Within 112 days post-op, while continuing the 70 % EtOH lock protocol, the peptide-based enteral feeds were advanced to full feeds of 63 cc/hr. HS was trialed of PN/lipids for 2 weeks, and she maintained a 75th percentile weight/length. Her CL was discontinued in mid Sept 2009, at age 3 yrs. Conclusions: In this child with intestinal failure, the implementation of a 70% EtOH lock protocol to the CL dramatically reduced the frequency of CL infections and may have contributed to the favorable clinical outcome. More in-depth research is warranted comparing EtOH locks and other line maintenance
protocols in order to determine which method is best to prevent CL infections, thus reducing potential complications and interruptions in the rehabilitation of the intestines.
P100 - Case Presentation:7 Year Old Female with Childhood-Onset Anorexia NervosaLiesje N. Carney, RD, CNSD, LDN; Nicole Sanner, RD, LDNClinical Nutrition Dept, Children’s Hospital of Philadelphia, Philadelphia, PA. Introduction: Childhood-onset anorexia nervosa (AN) is characterized by the following: preoccupation with weight, distorted body image, and inadequate intake of food. If forced to eat, the child will consume as little as possible and avoid high-calorie items. JK is a 7 year old female who presented to hospital with significant weight loss (38% of UBW in 5 months), bradycardia, constipation and dehydration. JK was admitted for refusal of all food and beverage for 3 days. JK disclosed that her diet and exercise habits changed after a physician advised her and a parent to make dietary changes because JK’s weight-for-age was >95th%tile. JK stated that eating caused severe anxiety and bloating. Methods: This facility’s eating disorder inpatient protocol was implemented. Meals were planned by the RD due to lack of patient cooperation. Once served, JK had 30 minutes to consume a meal. The caloric value of items remaining after 30 minutes were provided as 1 kcal/mL pediatric enteral formula. If this was not consumed within 15 minutes, NGT was placed and formula was administered. Because of high risk for refeeding syndrome, JK’s energy needs were initially assessed at 70% REE. Nutrition support was titrated gradually to goal of 150% REE. Results: On average, JK consumed <25 calories orally daily. NGT feeding was required to meet 100% of JK’s nutrient needs for the duration of admis-sion. Refeeding syndrome did not develop. Bradycardia resolved. Weight and hydration status stabilized. JK was discharged home with NGT feed-ings. Conclusions: Eating disorder protocols are often intended for adolescents. It was challenging to modify the protocol to be effective given JK’s young age. Typically adolescents will drink a supplement to avoid NGT placement, but JK did not view the NGT as a consequence. This type of very early onset AN is extremely difficult to treat and can be severe. Long-term prognosis is poor.
P101 - Use of a Pureed By Gastrostomy Tube (PBGT) Diet as a Medical Therapeutic Approach to Gastrostomy Tube Feeding IntolerancesTherese O’Flaherty, MS,RD,LD,CSP1; Kathy Santoro, MEd,RD,LD,CSP1; Scott Pentiuk, MD2
1Aerodigestive Feeding Team, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 2Gastroenterology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH. Introduction: There are several groups of children who may benefit from receiving pureed foods by gastrostomy tube; children experiencing gagging and retching post Fundoplication, and children with feeding intolerances, such as volume sensitivity, intolerance to large boluses or rapid rates of drip feedings. As many dietitians are unfamiliar with how to design this diet, we receive more requests to implement this diet, and we describe the development of a Pureed By Gastrostomy Tube (PBGT) diet. Methods: To provide a well balanced,nutritionally complete PBGT diet, a Registered Dietitian completes the following: 1.Comprehensive Nutritional Assessment including caloric, protein, vitamin/mineral, and fluid goals, as well as review of financial constraints, educational needs and family commitment to follow diet protocol. 2.Calculation of the PBGT using The Food Processor Program (ESHA Research)with special consideration to percentages of protein, fat, and carbohydrate; total volume and viscosity of mixtue, current oral intake, possible food allergies, additional fluid requirements, and vitamin/mineral supplementation. The diet consists of a mixture of Stage 2 pureed meats, fruits, vegeta-bles, cereals, oils, and/or small amounts of milk, yogurt, or formula. 3.
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Education of caregivers before starting PBGT, to include formula preparation, feeding schedule, vitamin/mineral supplements, and sani-tation and safety requirements 4. Close monitoring of tolerance and advancement with caregivers as they initiate PBGT. Daytime pureed gastrostomy tube boluses are gradually increased as nightime continu-ous drip feeds are discontinued. 5. Follow-up visits to monitor growth parameters and review fluid and nutritional goals. Nutritional labs are obtained to determine the adequacy of the diet. Multiple phone calls may occur, resulting in formula changes and recalculations to assure good tolerance and parental satisfaction. Results: A PBGT diet can be used as a viable alternative to commercially made formulas in children with feeding disorders. A thorough nutritional assessment as well as close follow-up are essential to successful outcomes. Conclusions: The PBGT diet should be considered as a medical therapeutic alternative to improve tube feeding tolerances that occur post fundoplication or in children with volume sensitivity. The diet should be calculated and implemented by a Registered Dietitian to assure nutritional adequacy and safety of feedings.
Transplantation
P102 - Significance of Pretransplant Nutritional Assessment and Support in Patients undergoing Living Donor Liver TransplantationToshimi Kaido, MD, PhD; Fumitaka OIke, MD, PhD; Yasuhiro Ogura, MD, PhD; Atsushi Yoshizawa, MD, PhD; Masaki Mizumoto, MD, PhD; Akira Mori, MD, PhD; Shinji Uemoto, MD, PhDKyoto University School of Medicine, Kyoto, Japan. Introduction: Protein-energy malnutrition is common in patients with end-stage liver disease requiring liver transplantation (LT) and is a risk factor for posttransplant morbidity including sepsis. Especially, infec-tious complications including sepsis often occur after LT and are the most frequent causes of in-hospital death despite recent advances in surgical procedures and perioperative management. Therefore, it is important to accurately estimate preoperative nutritional status and provide adequate perioperative nutritional support in order to improve the results of LT. We examined the efficacy of preoperative nutritional assessment by bioelectric impedance analysis and prognostic factors of posttransplant sepsis in patients undergoing living donor LT (LDLT). Moreover, we investigated the effects of individually tailored preopera-tive aggressive nutritional therapy. Methods: 1) We prospectively mea-sured body cell mass (BCM) using a body composition analyzer and various nutritional parameters including prealbumin, branched-chain amino acids (BCAA)/tyrosine ratio, and zinc as well as common nutri-tional parameters such as albumin, cholinesterase, and total lymphocyte count in 50 consecutive recipients undergoing LDLT between February 2008 and February 2009. Multivariate analysis was performed to deter-mine the prognostic factors of posttransplant sepsis, focusing on nutri-tional parameters. In the present study, we defined conditions fulfilling the diagnostic criteria of systemic inflammatory response syndrome with infection as sepsis. 2) We developed an individually tailored preoperative aggressive nutritional treatment based on the nutritional status of each
patient especially in poorly nourished recipients in April 2009; the treat-ment consists of BCAA-enriched nutrient mixture followed by immuno-nutrition for 7 days prior to surgery and synbiotics. The usefulness of the new nutritional treatment was examined. Results: The incidence of severe perioperative infection and in-hospital death was significantly higher in patients with low BCM than in patients with normal or high BCM. Multivariate analysis showed that preoperative low BCM, absence of preoperative supplementation with BCAA-enriched nutrient mixture, and a Model for End-stage Liver Disease (MELD) score of 20 or above, but not common nutritional parameters, were of prognostic signifi-cance. Surprisingly, BCAA-enriched nutrient mixture and preoperative low BCM had a higher impact on the incidence of posttransplant sepsis than high MELD score. Pretransplant aggressive nutritional treatment significantly reduced the incidence of postoperative sepsis. Conclusions: Pretransplant nutritional assessment with a body composition analyzer could predict the postoperative clinical course. Malnutrition before LT was closely related to the incidence of posttransplant sepsis. Pretransplant aggressive nutritional therapy was useful in preventing postoperative sepsis.
P103 - Weight Change in Cardiac Transplant PatientsJane Mockaitis, BS, RD, LDN1; Donna Belcher, MS, RD, LDN, CDE1; Sarah Drake, BS, RD2
1Clinical Nutrition, Northwestern Memorial Hospital, Chicago, IL; 2Dietetic Internship, Loyola University, Chicago, IL. Introduction: Previous research has shown a mean increase of approx-imately 8 kilograms (kg) at six months post heart transplantation. The objective of this study is to analyze overall weight change and the need for further diet education and weight management for heart transplant patients at Northwestern Memorial Hospital (NMH). Methods: Participants of this study included all NMH heart transplant patients from 2005-2008 who did not receive a Ventricular Assist Device (VAD) and who had all weight and Body Mass Index (BMI) data available. This included 13 females and 20 males ranging in age from 27 to 72 years at the time of transplantation (n=33). Data was collected from electronic medical records up to six months post-transplantation. Nutrition inter-ventions included an initial Registered Dietitian (RD) consultation related to diet education, weight loss, and/or supplementation and sub-sequent weekly visits by the RD for the length of the patient’s hospital stay. Additionally, upon discharge some patients were seen by an outpa-tient RD for weight management. Other interventions included two support group presentations by an RD related to heart healthy diets. Results: Data analysis showed that on average all patients gained 1.52kg and BMI increased from 26.16 initially to 26.41 six months post-transplantation. Weight changes ranged from a loss of 12.3kg to a gain of 31.75kg with a mean gain of 1.46kg (median +0.78kg). The changes were not significantly different using a paired t-test (p 1.7049 for BMI and p 0.3259 for weights) or the Wilcoxon matched-pairs signed rank test (p< / = 0.6335 BMI and p< / = 0.5376 weights). Conclusions: These weight gains did not trend as high as previously reported studies. Based on these findings and findings from previous research, it can be expected that further weight changes can continue for both genders and that follow-up by an outpatient RD would aid in weight management.
