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Inappropriate Use of Parenteral Nutrition in the Intensive Care Unit
SUNDAY, OCTOBER 26
POSTER SESSION: PROFESSIONAL SKILLS/NUTRITION ASSESSMENT/MEDICAL NUTRITION THERAPY Title: TUBE FEEDING: ASSISTING THE RESIDENT AND FAMILY IN MAKING AN INFORMED DECISION Author(s): G. Graphos; Nutrition & Food Services, Maimonides Geriatric Centre, Montreal, QC, Canada Learning Outcome: The participant will be able to describe the two components developed that improved the current process of decision making regarding tubefeeding and enhanced the quality of care. Text: Maimonides Geriatric Center is a long term care facility whose strategic plan includes serving as a model for care delivery, teaching and research. The centre continuously strives to enhance the quality of care for residents and families by encouraging and supporting their involvement in care and through ongoing education. Core beliefs include an interdisciplinary approach to care and evidence based practice. Being one of three Planetree affiliates in Canada, Maimonides is a leader in resident centered care. Facing the decision of tube feeding is an emotional and difficult choice for residents and families. Providing information and support during this sensitive time becomes crucial. The Chief of Clinical Nutrition recognized a need for improvement in the current process. There appeared to be a lack of consistency across units in the following areas: team communication and involvement, depth of information provided to the resident and family, communication method, and documentation. A comprehensive guide was developed to be provided to residents and families during a meeting. A policy and procedure was also developed to ensure a consistent approach, including a meeting checklist to facilitate documentation and allow for future monitoring. The Chief of Clinical Nutrition closely collaborated with Medicine, Nursing, Occupational Therapy, Social Service, Rabbi, and received input from a family recently faced with this decision. Our User’s Council has expressed thanks for this very positive contribution towards education and support. Through this project, we continue to deliver quality care in a compassionate manner, respecting the individual choices and beliefs of our clientele.
Title: CORRECTING MULTIPLE NUTRITIONAL DEFICIENCIES VIA INTRADIALYTIC PARENTERAL NUTRITION INFUSIONS IN A HEMODIALYSIS PATIENT Author(s): C. J. Martin, J. M. Geisler; NutrePletion Resources, Bensalem, PA Learning Outcome: The dietitian will recognize the benefits of adding nutritional additives to intradialytic parenteral nutrition formula to correct nutritional deficiencies. Text: Many end-stage renal disease (ESRD) patients have protein calorie malnutrition (PCM) resulting in electrolyte imbalances, particularly phosphorus and potassium. Intradialytic Parenteral Nutrition (IDPN) is an effective therapy for patients who require more aggressive approaches to improving nutritional status when diet and oral supplementation are insufficient. A case report is presented of a patient exhibiting PCM and hypophosphatemia repleted with IDPN therapy. An 86-year old female presented with a serum albumin of 3.2 mg/dl. Past medical history included PCM, ESRD, DM type 2, chronic diarrhea, gastroenteritis, CHF, HTN, and CAD. Hypophosphatemia was present for the last 6 months secondary to malnutrition. Oral supplementation was tried for several months prior to the initiation of IDPN. Early satiety and anorexia precluded increasing oral intake. Pertinent medications included Megestrol Acetate 20mg p.o. BID. Initially, serum phosphorus was 2.2 mg/dl. The IDPN formula consisted of 48 grams protein, 55 grams carbohydrates, 35 grams fat, and 728 kcal per treatment. It was administered during dialysis three times per week for five months. Additionally, 20 mEq of Sodium Phosphate and 10 mmol of Potassium Phosphate were added per bag. After one month, phosphorus level normalized at 4.3 mg/dL and was maintained. Albumin increased to 3.4 mg/dL during the 5 month period. Six treatments were missed during this period for hospitalization. The addition of phosphate to IDPN should be considered when hypophosphatemia and PCM are present. This case illustrates that provision of macronutrients and correction of electrolyte imbalances can lead to improved nutritional status in the hemodialysis patient. Funding Disclosure: None
Funding Disclosure: Maimonides Geriatric Centre
Title: COMPARISON OF A FIBER-CONTAINING VERSUS A PREBIOTICS-CONTAINING ENTERAL PRODUCT ON GASTROINTESTINAL TOLERANCE IN CRITICALLY ILL PATIENTS Author(s): A. C. Hummell, M. Tempest; Nutrition Therapy, Cleveland Clinic, Cleveland, OH Learning Outcome: To understand that different types of fiber in enteral products have no impact on gastrointestinal tolerance in critically ill patients. Text: Dietary fiber is known to normalize gastrointestinal function. Prebiotics may beneficially alter the gastrointestinal mucosal barrier, thus promoting improved gastrointestinal function. This study retrospectively compared the effectiveness of 2 fiber-containing products in preventing gastrointestinal intolerance defined as diarrhea and/or constipation in 58 critically ill, enterally-fed patients. Twenty-nine patients were fed a product containing soy fiber and another twentynine patients received a product with prebiotics (insulin and oligofructose). Antibiotics and narcotics usages were noted due to their tendencies to promote diarrhea and constipation, respectively. Average number of days receiving these products was 8 days for the soy fiber group and 7 days for the prebiotics group. Diarrhea and/or constipation occurred in 12 patients receiving soy fiber and in 15 patients getting prebiotics. Eight patients in the soy fiber group and 5 patients in the prebiotics group had diarrhea; this was insignificant, based on chisquare analysis (p⫽0.34). Constipation occurred in 4 patients receiving soy fiber and 10 patients getting prebiotics; this was insignificant, based on chi-square analysis (p⫽0.07). Antibiotics were administered to 15 patients in the soy fiber group and 19 patients getting prebiotics. Narcotics were given to 12 patients in the soy fiber group and 15 patients in the prebiotics group. This study indicated that the type of fiber made no difference in preventing diarrhea and/or constipation in critically ill, enterally-fed patients and those medications known to cause gastrointestinal intolerance had little impact on gastrointestinal function in these patients receiving fiber-containing formulas. Funding Disclosure: None
A-44 / September 2008 Suppl 3—Abstracts Volume 108 Number 9
Title: INAPPROPRIATE USE OF PARENTERAL NUTRITION IN THE INTENSIVE CARE UNIT Author(s): K. Swedberg, S. Moscoe, K. Listerud; Abbott Northwestern Hospital, Minneapolis, MN Learning Outcome: Be able to identify appropriate use of Parenteral Nutrition in the Intensive Care Unit. Text: Inappropriate Parenteral nutrition (PN) use is a challenge in many facilities. In 2006, data were gathered by the dietitians at a large metropolitan hospital to determine the reasons PN was inappropriately ordered in the intensive care units. A hospital-wide policy in place for over one year outlined guidelines for appropriate PN use. All patients that had PN initiated were recorded along with the reasons for initiation. Over the course of the twelve month study, 139 patients in the ICU had PN initiated and thirty-eight times (27%) it was deemed inappropriate by the dietitian. Results indicated inappropriate infusion of PN could be decreased by 37% if interventional radiology (IR) was utilized to place nasogastric/jejunal tubes and patients were appropriately restrained to keep them from pulling out tubes. If the hospital-wide policy had been followed, the remaining 63% of inappropriate PN use would have been eliminated. We presented our findings to the Hospitalists, Intensivists, Pharmacy & Therapuetics Committee, Nutrition Committee, and included our findings in the physician newsletter. Our recommendations included: 1) Utilize IR to place nasogastric/jejunal tubes when a feeding tube is difficult to place at the bedside, 2) Use appropriate methods to restrain or sedate a patient when he/she is agitated, 3) Review the hospital-wide policy on PN use and follow the guidelines. Funding Disclosure: None
POSTER SESSION: PROFESSIONAL SKILLS/NUTRITION ASSESSMENT/MEDICAL NUTRITION THERAPY Title: TUBE FEEDING: ASSISTING THE RESIDENT AND FAMILY IN MAKING AN INFORMED DECISION Author(s): G. Graphos; Nutrition & Food Services, Maimonides Geriatric Centre, Montreal, QC, Canada Learning Outcome: The participant will be able to describe the two components developed that improved the current process of decision making regarding tubefeeding and enhanced the quality of care. Text: Maimonides Geriatric Center is a long term care facility whose strategic plan includes serving as a model for care delivery, teaching and research. The centre continuously strives to enhance the quality of care for residents and families by encouraging and supporting their involvement in care and through ongoing education. Core beliefs include an interdisciplinary approach to care and evidence based practice. Being one of three Planetree affiliates in Canada, Maimonides is a leader in resident centered care. Facing the decision of tube feeding is an emotional and difficult choice for residents and families. Providing information and support during this sensitive time becomes crucial. The Chief of Clinical Nutrition recognized a need for improvement in the current process. There appeared to be a lack of consistency across units in the following areas: team communication and involvement, depth of information provided to the resident and family, communication method, and documentation. A comprehensive guide was developed to be provided to residents and families during a meeting. A policy and procedure was also developed to ensure a consistent approach, including a meeting checklist to facilitate documentation and allow for future monitoring. The Chief of Clinical Nutrition closely collaborated with Medicine, Nursing, Occupational Therapy, Social Service, Rabbi, and received input from a family recently faced with this decision. Our User’s Council has expressed thanks for this very positive contribution towards education and support. Through this project, we continue to deliver quality care in a compassionate manner, respecting the individual choices and beliefs of our clientele.
Title: CORRECTING MULTIPLE NUTRITIONAL DEFICIENCIES VIA INTRADIALYTIC PARENTERAL NUTRITION INFUSIONS IN A HEMODIALYSIS PATIENT Author(s): C. J. Martin, J. M. Geisler; NutrePletion Resources, Bensalem, PA Learning Outcome: The dietitian will recognize the benefits of adding nutritional additives to intradialytic parenteral nutrition formula to correct nutritional deficiencies. Text: Many end-stage renal disease (ESRD) patients have protein calorie malnutrition (PCM) resulting in electrolyte imbalances, particularly phosphorus and potassium. Intradialytic Parenteral Nutrition (IDPN) is an effective therapy for patients who require more aggressive approaches to improving nutritional status when diet and oral supplementation are insufficient. A case report is presented of a patient exhibiting PCM and hypophosphatemia repleted with IDPN therapy. An 86-year old female presented with a serum albumin of 3.2 mg/dl. Past medical history included PCM, ESRD, DM type 2, chronic diarrhea, gastroenteritis, CHF, HTN, and CAD. Hypophosphatemia was present for the last 6 months secondary to malnutrition. Oral supplementation was tried for several months prior to the initiation of IDPN. Early satiety and anorexia precluded increasing oral intake. Pertinent medications included Megestrol Acetate 20mg p.o. BID. Initially, serum phosphorus was 2.2 mg/dl. The IDPN formula consisted of 48 grams protein, 55 grams carbohydrates, 35 grams fat, and 728 kcal per treatment. It was administered during dialysis three times per week for five months. Additionally, 20 mEq of Sodium Phosphate and 10 mmol of Potassium Phosphate were added per bag. After one month, phosphorus level normalized at 4.3 mg/dL and was maintained. Albumin increased to 3.4 mg/dL during the 5 month period. Six treatments were missed during this period for hospitalization. The addition of phosphate to IDPN should be considered when hypophosphatemia and PCM are present. This case illustrates that provision of macronutrients and correction of electrolyte imbalances can lead to improved nutritional status in the hemodialysis patient. Funding Disclosure: None
Funding Disclosure: Maimonides Geriatric Centre
Title: COMPARISON OF A FIBER-CONTAINING VERSUS A PREBIOTICS-CONTAINING ENTERAL PRODUCT ON GASTROINTESTINAL TOLERANCE IN CRITICALLY ILL PATIENTS Author(s): A. C. Hummell, M. Tempest; Nutrition Therapy, Cleveland Clinic, Cleveland, OH Learning Outcome: To understand that different types of fiber in enteral products have no impact on gastrointestinal tolerance in critically ill patients. Text: Dietary fiber is known to normalize gastrointestinal function. Prebiotics may beneficially alter the gastrointestinal mucosal barrier, thus promoting improved gastrointestinal function. This study retrospectively compared the effectiveness of 2 fiber-containing products in preventing gastrointestinal intolerance defined as diarrhea and/or constipation in 58 critically ill, enterally-fed patients. Twenty-nine patients were fed a product containing soy fiber and another twentynine patients received a product with prebiotics (insulin and oligofructose). Antibiotics and narcotics usages were noted due to their tendencies to promote diarrhea and constipation, respectively. Average number of days receiving these products was 8 days for the soy fiber group and 7 days for the prebiotics group. Diarrhea and/or constipation occurred in 12 patients receiving soy fiber and in 15 patients getting prebiotics. Eight patients in the soy fiber group and 5 patients in the prebiotics group had diarrhea; this was insignificant, based on chisquare analysis (p⫽0.34). Constipation occurred in 4 patients receiving soy fiber and 10 patients getting prebiotics; this was insignificant, based on chi-square analysis (p⫽0.07). Antibiotics were administered to 15 patients in the soy fiber group and 19 patients getting prebiotics. Narcotics were given to 12 patients in the soy fiber group and 15 patients in the prebiotics group. This study indicated that the type of fiber made no difference in preventing diarrhea and/or constipation in critically ill, enterally-fed patients and those medications known to cause gastrointestinal intolerance had little impact on gastrointestinal function in these patients receiving fiber-containing formulas. Funding Disclosure: None
A-44 / September 2008 Suppl 3—Abstracts Volume 108 Number 9
Title: INAPPROPRIATE USE OF PARENTERAL NUTRITION IN THE INTENSIVE CARE UNIT Author(s): K. Swedberg, S. Moscoe, K. Listerud; Abbott Northwestern Hospital, Minneapolis, MN Learning Outcome: Be able to identify appropriate use of Parenteral Nutrition in the Intensive Care Unit. Text: Inappropriate Parenteral nutrition (PN) use is a challenge in many facilities. In 2006, data were gathered by the dietitians at a large metropolitan hospital to determine the reasons PN was inappropriately ordered in the intensive care units. A hospital-wide policy in place for over one year outlined guidelines for appropriate PN use. All patients that had PN initiated were recorded along with the reasons for initiation. Over the course of the twelve month study, 139 patients in the ICU had PN initiated and thirty-eight times (27%) it was deemed inappropriate by the dietitian. Results indicated inappropriate infusion of PN could be decreased by 37% if interventional radiology (IR) was utilized to place nasogastric/jejunal tubes and patients were appropriately restrained to keep them from pulling out tubes. If the hospital-wide policy had been followed, the remaining 63% of inappropriate PN use would have been eliminated. We presented our findings to the Hospitalists, Intensivists, Pharmacy & Therapuetics Committee, Nutrition Committee, and included our findings in the physician newsletter. Our recommendations included: 1) Utilize IR to place nasogastric/jejunal tubes when a feeding tube is difficult to place at the bedside, 2) Use appropriate methods to restrain or sedate a patient when he/she is agitated, 3) Review the hospital-wide policy on PN use and follow the guidelines. Funding Disclosure: None