Journal of the Academy of Nutrition and Dietetics, Sep 1, 2019
The purpose of this study is to determine the effectiveness of the recent intervention on documen... more The purpose of this study is to determine the effectiveness of the recent intervention on documentation of malnutrition, and, secondarily, to describe some characteristics of the patients identified as malnourished.
Management of patients with ostomies can be challenging to say the least; the management of those... more Management of patients with ostomies can be challenging to say the least; the management of those with fistulas is even more so. Dietary management of patients with fistulas can often make the difference between healing versus a prolonged illness. In the past, 40%-65% of people with enterocutaneous fistulas died from associated complications, including malnutrition, however, mortality is now down to 5%-20%. Dietary restrictions for patients with ostomies are based on patient surveys and anecdotal evidence. The purpose of this article is to discuss nutritional therapy and skin care of patients with ostomies and fistulas.
Up to 450 000 people in the United States have ostomies, and 120 000 new ostomies are formed each... more Up to 450 000 people in the United States have ostomies, and 120 000 new ostomies are formed each year. The majority of these are fecal diversions. Determining the amount of healthy bowel proximal to the stoma is essential for short-term and lifelong diet and nutrition planning. People with colostomies and distal ileostomies usually require minimal, if any, diet modifications. On the contrary, more proximal ileostomies are likely to result in significant nutritional losses. These stomas and any high-output stomas require a coordinated approach to management of medications, diet and nutrition, and/or oral rehydration solution.
Dento-alveolar surgeries can have short-term impacts on oral function and ability to eat and drin... more Dento-alveolar surgeries can have short-term impacts on oral function and ability to eat and drink depending on the location and extent of surgery Maxillofacial trauma results in increased energy and nutrient needs for wound healing; depending on the location and extent of trauma, nutrition support may be needed Treatment following orthognathic surgery typically requires diet consistency modification and additional calories and nutrients for wound healing Patients with cleft lip and palate require modified feeding strategies preoperatively and initially postoperatively Nutrition support following oral surgery is typically achieved using oral liquid nutrition supplements or an enteral tube feeding
Optimal energy goals for adult, obese critically ill surgical patients are unclear. To date, ther... more Optimal energy goals for adult, obese critically ill surgical patients are unclear. To date, there has been little data comparing feeding regimens for obese and non-obese critically ill surgical patients and the effect on outcomes. The objective was to compare the effect of hypoenergetic and euenergetic feeding goals in critically ill obese patients on outcomes, including infection, intensive care unit length of stay, and mortality. We hypothesized that hypoenergetic feeding of patients with premorbid obesity (body mass index ≥ 30 kg•m-2) during critical illness does not affect clinical outcomes. Post hoc analyses were performed on critically ill surgical patients enrolled in a randomized controlled trial. Patients were randomized to receive 25-30 kcal•kg-1•d-1 (105-126 kJ.kg-1•d-1, euenergetic) or 12.5-15 kcal•kg-1•d-1 (52-63 kJ.kg-1 •d-1, hypoenergetic), with equal protein allocation (1.5 g•kg-1•d-1). The effect of feeding regimen on outcomes in obese and nonobese patients were assessed. Of the 83 patients, 30 (36.1%) were obese (body mass index ≥ 30 kg•m-2). Average energy intake differed based on feeding regimen (hypoenergetic: 982±61 vs euenergetic: 1338±92 kcal•d-1, P = .02). Comparing obese and nonobese patients, there was no difference in the percentage acquiring an infection (66.7% [20/30] vs 77.4% [41/53], P = .29), intensive care unit length of stay (16.4±3.7 vs 14.3±0.9 days, P = .39), or mortality (10% [3/30] vs 7.6% [4/53], P = .7). Within the subset of obese patients, the percentage acquiring an infection (hypoenergetic: 78.9% [15/19] vs euenergetic: 45.5% [5/11], P = .11) was not affected by the feeding regimen. Within the subset of nonobese patients, there was a trend toward more infections in the euenergetic group (hypoenergetic: 63.6% [14/22] vs euenergetic: 87.1% [27/31], P = .05). Hypoenergetic feeding does not appear to affect clinical outcomes positively or negatively in critically ill patients with premorbid obesity.
Background: We assessed the differences in postoperative feeding outcomes when comparing early an... more Background: We assessed the differences in postoperative feeding outcomes when comparing early and traditional diet advancement in patients who had an ostomy creation. Methods: At a U.S. tertiary care hospital, data from patients who underwent an ileostomy or colostomy creation from June 1, 2013, to April 30, 2017 were extracted from an institutional database. Patients who received early diet advancement (postoperative days 0 and 1) were compared with traditional diet advancement (postoperative day 2 and later) for demographics, preoperative risk factors, and operative features. The postoperative feeding outcomes included time to first flatus and ostomy output. Mann-Whitney U tests determined bivariate differences in postoperative feeding outcomes between groups. Poisson regression was used to adjust for unequal baseline characteristics. Results: Data from 255 patients were included; 204 (80.0%) received early diet advancement, and 51 (20.0%) had traditional diet advancement. Time to first flatus and time to first ostomy output were significantly shorter in the early compared with traditional diet advancement group (median difference of 1 day for both flatus and ostomy output, P < 0.001). Adjusting for baseline group differences (American Society for Anesthesiology Physical Status Classification System, surgical approach, resection and ostomy type) maintained the significant findings for both time to first flatus (β = 1.32, P = 0.01) and time to first ostomy output (β = 1.41, P < 0.001). Conclusions: Early diet advancement is associated with earlier return of flatus and first ostomy output compared with traditional diet advancement after the creation of an ileostomy or colostomy.
Although some studies have demonstrated lower infectious morbidity in patients receiving suppleme... more Although some studies have demonstrated lower infectious morbidity in patients receiving supplemental glutamine, there remains no consensus on the utility of such treatment. This study was designed to investigate the effects of supplemental enteral glutamine on the rate and outcomes of infection in critically ill surgical patients. All 185 surgical and trauma patients admitted to a single university surgical trauma intensive care unit (STICU) over an approximately three-year period who were to receive enteral nutrition support were assigned sequentially to one of three diets: standard 1-kCal/mL feedings with added protein (Group 1), standard feedings with glutamine 0.6 g/kg per day (Group 2), or immune-modulated feedings with a similar amount of glutamine (Group 3). Group compositions and patient characteristics were similar at baseline. Data were collected prospectively on infections acquired during hospitalization. A total of 119 patients had at least one infection: 59% of the patients in Group 1, 64% of Group 2, and 69% of Group 3 (p = NS). There were no differences among the groups in the mean number of infections. The most common sites in all groups were the lungs, blood, and urine; and the frequencies of these infections did not differ between groups. Minor differences were found between groups in the organisms isolated. Antibiotic usage did not differ. Supplemental enteral glutamine in the dose studied does not appear to influence the acquisition or characteristics of infection in patients admitted to a mixed STICU.
Objective: To compare the effects of early oral feeding to traditional (or late) timing of oral f... more Objective: To compare the effects of early oral feeding to traditional (or late) timing of oral feeding after upper gastrointestinal surgery on clinical outcomes. Background: Early postoperative oral feeding is becoming more common, particularly as part of multimodal or fast-track protocols. However, concerns remain about the safety of early oral feeding after upper gastrointestinal surgery. Methods: Comprehensive literature searches were conducted across 5 databases from January 1980 until June 2015 without language restriction. Risk of bias of included studies was appraised and random-effects model metaanalyses were performed to synthesize outcomes of anastomotic leaks, pneumonia, nasogastric tube reinsertion, reoperation, readmissions, and mortality. Results: Fifteen studies comprising 2112 adult patients met all the inclusion criteria. Mean hospital stay was significantly shorter in the early-fed group than in the late-fed group [weighted mean difference ¼ À1.72 d, 95% confidence interval (CI) À1.25 to À2.20, P < 0.01). Postoperative length of stay was also significantly shorter (weighted mean difference ¼ À1.44 d, 95% CI À0.68 to À2.20, P < 0.01). There was no significant difference in risk of anastomotic leak, pneumonia, nasogastric tube reinsertion, reoperation, readmission, or mortality in the randomized controlled trials (RCTs). The pooled RCT and non-RCT results, however, showed a significantly lower risk of pneumonia in early-fed as compared with late-fed group (odds ratio ¼ 0.6, 95% CI 0.41-0.89, P ¼ 0.01). Conclusions: Early postoperative oral feeding as compared with traditional (or late) timing is associated with shorter hospital length of stay and is not associated with an increase in clinically relevant complications.
Journal of the Academy of Nutrition and Dietetics, Sep 1, 2013
Methods: A convenience sample of adults was surveyed utilizing an online learning management syst... more Methods: A convenience sample of adults was surveyed utilizing an online learning management system. The Motivation for Eating Scale (MFES), a validated 42-item survey, was used to evaluate the primary motivation influencing eating behavior with three subscales classified as emotional, environmental and physical. Additionally, anthropometrics and six 24-hour dietary recalls were collected utilizing a web-based automated self-administered 24-hour dietary recall (National Cancer Institute's ASA24) method over 15 weeks.
Journal of the Academy of Nutrition and Dietetics, Sep 1, 2014
Learning Outcome: Identify symptoms associated with IBS. Irritable Bowel Syndrome (IBS), with sym... more Learning Outcome: Identify symptoms associated with IBS. Irritable Bowel Syndrome (IBS), with symptoms including gas, bloating, diarrhea, constipation and abdominal pain, can be managed using a FODMAP (fructooligosaccharides, disaccharides, monosaccharides and polyols) elimination diet. High FODMAP foods are limited or eliminated initially and after 2-4 weeks, higher FODMAPs foods are reintroduced , systematically, as tolerated. While studies have demonstrated the effectiveness of the FOD-MAPs elimination diet, the Registered Dietitian Nutritionist needs an objective measure of symptom changes to assess outcomes of diet interventions.
Acute kidney injury (AKI) is common among critically ill patients. There are a number of nutritio... more Acute kidney injury (AKI) is common among critically ill patients. There are a number of nutrition considerations in the management of AKI, including fluid balance, electrolyte and acid-base disturbances, protein provision, and management of comorbid conditions. The optimal amount of protein provision for patients with AKI who are not on renal replacement therapy (RRT) has been a topic of debate for years. Excessive protein provision may contribute to azotemia in these patients, but inadequate protein intake may harm nutrition status and result in poorer clinical outcomes. This review discusses a patient case of AKI masked by malnutrition and muscle loss and reviews the current literature on optimal protein intake in AKI (not on RRT). Based on a structured search strategy, 4 articles were reviewed. We conclude that the available evidence suggests that significant restrictions in protein intake are not necessary for those critically ill patients with AKI. However, the studies reviewed here showed significant heterogeneity in protein dose and delivery, estimation of protein needs, patient population, and definition of AKI, and thus further research is needed to systematically determine the optimal dose of protein for critically ill adults with AKI.
Surgical Endoscopy and Other Interventional Techniques, Feb 26, 2019
Background Percutaneous endoscopically placed gastrostomy (PEG) tubes are useful for long-term en... more Background Percutaneous endoscopically placed gastrostomy (PEG) tubes are useful for long-term enteral nutrition; however, they are associated with lack of benefit for patients with advanced dementia, at end of life, and for some stroke patients with early regain of swallowing function. We surveyed physician opinions on decision making with the aim to identify factors that can lead to inappropriate PEG placement, as a first step of a quality improvement initiative to prevent inappropriate PEG placements at our facility. Methods A survey was distributed to 231 physicians, with questions about discussion topics, contraindications, responsibilities, and practices in decision making for PEG placement. Five-point Likert scales were used for most responses. Results Of 62 respondents, the majority were general surgeons (51.6%) and neurologists (30.6%). Levels of agreement were very low that PEG placement is contraindicated in advanced dementia (> 56% disagreed) and at end of life (55% disagreed) with scores of 2.4 and 2.5 (out of 5), respectively. Agreement level was low (score of 2.85) for delaying PEG for stroke patients by at least 2 weeks. Agreement was high for the discussion topics, for allowing 1-7 days for processing information, and for consulting the nutrition service. Over 98% of respondents chose primary team and 58% chose both primary and endoscopy teams as being responsible for discussions with patients and care partners in the decision-making process. Conclusions Greater awareness is needed of the lack of benefit of PEG feeding in advanced dementia, at end of life, and for some stroke patients with early regain of swallow function. Disagreement exists as to whether the primary team and endoscopist share in the responsibility for discussions in decision making for PEG placement.
Journal of Wound Ostomy and Continence Nursing, Sep 1, 2015
Enteric fistulas can be classified as enterocutaneous and/or enteroatmospheric. Both are devastat... more Enteric fistulas can be classified as enterocutaneous and/or enteroatmospheric. Both are devastating complications of bowel disease, abdominal surgery, and/or open abdomen. Enteric fistulas are associated with a mortality rate varying from 1% to 33%; the main cause of death is sepsis. Coordinated and skillful efforts of an interprofessional team are required in customizing successful treatment regimens appropriate to each patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s unique clinical scenario. A 65-year-old white woman experienced an enteroatmospheric fistula patient after ventral hernia repair. Care of this patient was based on the complementary relationship between professionals from 2 disciplines: the wound and ostomy continence nurse (WOC nurse) and the nutrition support registered dietitian/nutritionist. Working together, they developed a comprehensive wound, ostomy, and nutritional plan. Initially, the patient received parenteral nutrition exclusively. After the fistula tract was clearly defined, a feeding tube was placed into the distal limb of the fistula, and she received nourishment via a fistuloclysis (ie, enteral feedings administered via the fistula). A special wound management system was created to contain fistula output while allowing feeding through the distal limb of the fistula. Enterocutaneous and enteroatmospheric fistulas originating from the small bowel present a management challenge to the entire healthcare team. WOC nurses are often called upon to meet the challenge of maintaining skin health while promoting dignity and function. Nutrition support via registered dietitian/nutritionists play a critical role in managing the nutrition regimen for these patients. In this case, the use of fistuloclysis met the patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s nutritional needs while avoiding the risks associated with parenteral nutrition.
Studies have failed to consistently demonstrate improved survival in intensive care unit (ICU) pa... more Studies have failed to consistently demonstrate improved survival in intensive care unit (ICU) patients receiving immune-modulating nutrient-enhanced enteral feeds when compared with standard enteral feeds. The objective was to study in a prospective fashion the effects of adding glutamine to standard or immune-modulated (supplemented with omega-3 fatty acids, -carotene, and amino acids such as glutamine and arginine) tube feeds. Design: Prospective, unblinded study using sequential allocation. Setting: A university surgical trauma ICU. Patients: All surgical and trauma patients admitted to the surgical trauma ICU at a university hospital over a 3-yr period who were to receive enteral feeds (n ؍ 185). Interventions: Sequential assignment to three isocaloric, isonitrogenous diets was performed as follows: standard 1-kcal/mL feeds with added protein (group 1), standard feeds with the addition of 20-40 g/day (0.6 g/kg/day) glutamine (group 2), or an immune-modulated formula with similar addition of glutamine (group 3). The goal for all patients was 25-30 kcal/kg/day and 2 g/kg/day protein. Measurements and Main Results: Patients were followed until discharge from the hospital. The primary end point was inhospital mortality, and multiple secondary end points were recorded. In-hospital mortality for group 1 was 6.3% (four of 64) vs. 16.9% (ten of 59, p ؍ .09) for group 2 and 16.1% (ten of 62, p ؍ .09) for group 3. After controlling for age and severity of illness, the difference in mortality between patients receiving standard tube feeds and all patients receiving glutamine was not significant (p < .11). There were no statistically significant differences between the groups for secondary end points. Conclusions: The addition of glutamine to standard enteral feeds or to an immunomodulatory formula did not improve outcomes. These findings suggest that enteral glutamine should not be routinely administered to patients with surgical critical illness.
The American Journal of Clinical Nutrition, Nov 1, 2014
Background: Proper caloric intake goals in critically ill surgical patients are unclear. It is po... more Background: Proper caloric intake goals in critically ill surgical patients are unclear. It is possible that overnutrition can lead to hyperglycemia and an increased risk of infection. Objective: This study was conducted to determine whether surgical infection outcomes in the intensive care unit (ICU) could be improved with the use of hypocaloric nutritional support. Design: Eighty-three critically ill patients were randomly allocated to receive either the standard calculated daily caloric requirement of 25-30 kcal $ kg-1 $ d-1 (eucaloric) or 50% of that value (hypocaloric) via enteral tube feeds or parenteral nutrition, with an equal protein allocation in each group (1.5 g $ kg-1 $ d-1). Results: There were 82 infections in the hypocaloric group and 66 in the eucaloric group, with no significant difference in the mean (6SE) number of infections per patient (2.0 6 0.6 and 1.6 6 0.2, respectively; P = 0.50), percentage of patients acquiring infection [70.7% (29 of 41) and 76.2% (32 of 42), respectively; P = 0.57], mean ICU length of stay (16.7 6 2.7 and 13.5 6 1.1 d, respectively; P = 0.28), mean hospital length of stay (35.2 6 4.9 and 31.0 6 2.5 d, respectively; P = 0.45), mean 0600 glucose concentration (132 6 2.9 and 135 6 3.1 mg/dL, respectively; P = 0.63), or number of mortalities [3 (7.3%) and 4 (9.5%), respectively; P = 0.72]. Further analyses revealed no differences when analyzed by sex, admission diagnosis, site of infection, or causative organism. Conclusions: Among critically ill surgical patients, caloric provision across a wide acceptable range does not appear to be associated with major outcomes, including infectious complications. The optimum target for caloric provision remains elusive.
Journal of the Academy of Nutrition and Dietetics, Sep 1, 2019
The purpose of this study is to determine the effectiveness of the recent intervention on documen... more The purpose of this study is to determine the effectiveness of the recent intervention on documentation of malnutrition, and, secondarily, to describe some characteristics of the patients identified as malnourished.
Management of patients with ostomies can be challenging to say the least; the management of those... more Management of patients with ostomies can be challenging to say the least; the management of those with fistulas is even more so. Dietary management of patients with fistulas can often make the difference between healing versus a prolonged illness. In the past, 40%-65% of people with enterocutaneous fistulas died from associated complications, including malnutrition, however, mortality is now down to 5%-20%. Dietary restrictions for patients with ostomies are based on patient surveys and anecdotal evidence. The purpose of this article is to discuss nutritional therapy and skin care of patients with ostomies and fistulas.
Up to 450 000 people in the United States have ostomies, and 120 000 new ostomies are formed each... more Up to 450 000 people in the United States have ostomies, and 120 000 new ostomies are formed each year. The majority of these are fecal diversions. Determining the amount of healthy bowel proximal to the stoma is essential for short-term and lifelong diet and nutrition planning. People with colostomies and distal ileostomies usually require minimal, if any, diet modifications. On the contrary, more proximal ileostomies are likely to result in significant nutritional losses. These stomas and any high-output stomas require a coordinated approach to management of medications, diet and nutrition, and/or oral rehydration solution.
Dento-alveolar surgeries can have short-term impacts on oral function and ability to eat and drin... more Dento-alveolar surgeries can have short-term impacts on oral function and ability to eat and drink depending on the location and extent of surgery Maxillofacial trauma results in increased energy and nutrient needs for wound healing; depending on the location and extent of trauma, nutrition support may be needed Treatment following orthognathic surgery typically requires diet consistency modification and additional calories and nutrients for wound healing Patients with cleft lip and palate require modified feeding strategies preoperatively and initially postoperatively Nutrition support following oral surgery is typically achieved using oral liquid nutrition supplements or an enteral tube feeding
Optimal energy goals for adult, obese critically ill surgical patients are unclear. To date, ther... more Optimal energy goals for adult, obese critically ill surgical patients are unclear. To date, there has been little data comparing feeding regimens for obese and non-obese critically ill surgical patients and the effect on outcomes. The objective was to compare the effect of hypoenergetic and euenergetic feeding goals in critically ill obese patients on outcomes, including infection, intensive care unit length of stay, and mortality. We hypothesized that hypoenergetic feeding of patients with premorbid obesity (body mass index ≥ 30 kg•m-2) during critical illness does not affect clinical outcomes. Post hoc analyses were performed on critically ill surgical patients enrolled in a randomized controlled trial. Patients were randomized to receive 25-30 kcal•kg-1•d-1 (105-126 kJ.kg-1•d-1, euenergetic) or 12.5-15 kcal•kg-1•d-1 (52-63 kJ.kg-1 •d-1, hypoenergetic), with equal protein allocation (1.5 g•kg-1•d-1). The effect of feeding regimen on outcomes in obese and nonobese patients were assessed. Of the 83 patients, 30 (36.1%) were obese (body mass index ≥ 30 kg•m-2). Average energy intake differed based on feeding regimen (hypoenergetic: 982±61 vs euenergetic: 1338±92 kcal•d-1, P = .02). Comparing obese and nonobese patients, there was no difference in the percentage acquiring an infection (66.7% [20/30] vs 77.4% [41/53], P = .29), intensive care unit length of stay (16.4±3.7 vs 14.3±0.9 days, P = .39), or mortality (10% [3/30] vs 7.6% [4/53], P = .7). Within the subset of obese patients, the percentage acquiring an infection (hypoenergetic: 78.9% [15/19] vs euenergetic: 45.5% [5/11], P = .11) was not affected by the feeding regimen. Within the subset of nonobese patients, there was a trend toward more infections in the euenergetic group (hypoenergetic: 63.6% [14/22] vs euenergetic: 87.1% [27/31], P = .05). Hypoenergetic feeding does not appear to affect clinical outcomes positively or negatively in critically ill patients with premorbid obesity.
Background: We assessed the differences in postoperative feeding outcomes when comparing early an... more Background: We assessed the differences in postoperative feeding outcomes when comparing early and traditional diet advancement in patients who had an ostomy creation. Methods: At a U.S. tertiary care hospital, data from patients who underwent an ileostomy or colostomy creation from June 1, 2013, to April 30, 2017 were extracted from an institutional database. Patients who received early diet advancement (postoperative days 0 and 1) were compared with traditional diet advancement (postoperative day 2 and later) for demographics, preoperative risk factors, and operative features. The postoperative feeding outcomes included time to first flatus and ostomy output. Mann-Whitney U tests determined bivariate differences in postoperative feeding outcomes between groups. Poisson regression was used to adjust for unequal baseline characteristics. Results: Data from 255 patients were included; 204 (80.0%) received early diet advancement, and 51 (20.0%) had traditional diet advancement. Time to first flatus and time to first ostomy output were significantly shorter in the early compared with traditional diet advancement group (median difference of 1 day for both flatus and ostomy output, P < 0.001). Adjusting for baseline group differences (American Society for Anesthesiology Physical Status Classification System, surgical approach, resection and ostomy type) maintained the significant findings for both time to first flatus (β = 1.32, P = 0.01) and time to first ostomy output (β = 1.41, P < 0.001). Conclusions: Early diet advancement is associated with earlier return of flatus and first ostomy output compared with traditional diet advancement after the creation of an ileostomy or colostomy.
Although some studies have demonstrated lower infectious morbidity in patients receiving suppleme... more Although some studies have demonstrated lower infectious morbidity in patients receiving supplemental glutamine, there remains no consensus on the utility of such treatment. This study was designed to investigate the effects of supplemental enteral glutamine on the rate and outcomes of infection in critically ill surgical patients. All 185 surgical and trauma patients admitted to a single university surgical trauma intensive care unit (STICU) over an approximately three-year period who were to receive enteral nutrition support were assigned sequentially to one of three diets: standard 1-kCal/mL feedings with added protein (Group 1), standard feedings with glutamine 0.6 g/kg per day (Group 2), or immune-modulated feedings with a similar amount of glutamine (Group 3). Group compositions and patient characteristics were similar at baseline. Data were collected prospectively on infections acquired during hospitalization. A total of 119 patients had at least one infection: 59% of the patients in Group 1, 64% of Group 2, and 69% of Group 3 (p = NS). There were no differences among the groups in the mean number of infections. The most common sites in all groups were the lungs, blood, and urine; and the frequencies of these infections did not differ between groups. Minor differences were found between groups in the organisms isolated. Antibiotic usage did not differ. Supplemental enteral glutamine in the dose studied does not appear to influence the acquisition or characteristics of infection in patients admitted to a mixed STICU.
Objective: To compare the effects of early oral feeding to traditional (or late) timing of oral f... more Objective: To compare the effects of early oral feeding to traditional (or late) timing of oral feeding after upper gastrointestinal surgery on clinical outcomes. Background: Early postoperative oral feeding is becoming more common, particularly as part of multimodal or fast-track protocols. However, concerns remain about the safety of early oral feeding after upper gastrointestinal surgery. Methods: Comprehensive literature searches were conducted across 5 databases from January 1980 until June 2015 without language restriction. Risk of bias of included studies was appraised and random-effects model metaanalyses were performed to synthesize outcomes of anastomotic leaks, pneumonia, nasogastric tube reinsertion, reoperation, readmissions, and mortality. Results: Fifteen studies comprising 2112 adult patients met all the inclusion criteria. Mean hospital stay was significantly shorter in the early-fed group than in the late-fed group [weighted mean difference ¼ À1.72 d, 95% confidence interval (CI) À1.25 to À2.20, P < 0.01). Postoperative length of stay was also significantly shorter (weighted mean difference ¼ À1.44 d, 95% CI À0.68 to À2.20, P < 0.01). There was no significant difference in risk of anastomotic leak, pneumonia, nasogastric tube reinsertion, reoperation, readmission, or mortality in the randomized controlled trials (RCTs). The pooled RCT and non-RCT results, however, showed a significantly lower risk of pneumonia in early-fed as compared with late-fed group (odds ratio ¼ 0.6, 95% CI 0.41-0.89, P ¼ 0.01). Conclusions: Early postoperative oral feeding as compared with traditional (or late) timing is associated with shorter hospital length of stay and is not associated with an increase in clinically relevant complications.
Journal of the Academy of Nutrition and Dietetics, Sep 1, 2013
Methods: A convenience sample of adults was surveyed utilizing an online learning management syst... more Methods: A convenience sample of adults was surveyed utilizing an online learning management system. The Motivation for Eating Scale (MFES), a validated 42-item survey, was used to evaluate the primary motivation influencing eating behavior with three subscales classified as emotional, environmental and physical. Additionally, anthropometrics and six 24-hour dietary recalls were collected utilizing a web-based automated self-administered 24-hour dietary recall (National Cancer Institute's ASA24) method over 15 weeks.
Journal of the Academy of Nutrition and Dietetics, Sep 1, 2014
Learning Outcome: Identify symptoms associated with IBS. Irritable Bowel Syndrome (IBS), with sym... more Learning Outcome: Identify symptoms associated with IBS. Irritable Bowel Syndrome (IBS), with symptoms including gas, bloating, diarrhea, constipation and abdominal pain, can be managed using a FODMAP (fructooligosaccharides, disaccharides, monosaccharides and polyols) elimination diet. High FODMAP foods are limited or eliminated initially and after 2-4 weeks, higher FODMAPs foods are reintroduced , systematically, as tolerated. While studies have demonstrated the effectiveness of the FOD-MAPs elimination diet, the Registered Dietitian Nutritionist needs an objective measure of symptom changes to assess outcomes of diet interventions.
Acute kidney injury (AKI) is common among critically ill patients. There are a number of nutritio... more Acute kidney injury (AKI) is common among critically ill patients. There are a number of nutrition considerations in the management of AKI, including fluid balance, electrolyte and acid-base disturbances, protein provision, and management of comorbid conditions. The optimal amount of protein provision for patients with AKI who are not on renal replacement therapy (RRT) has been a topic of debate for years. Excessive protein provision may contribute to azotemia in these patients, but inadequate protein intake may harm nutrition status and result in poorer clinical outcomes. This review discusses a patient case of AKI masked by malnutrition and muscle loss and reviews the current literature on optimal protein intake in AKI (not on RRT). Based on a structured search strategy, 4 articles were reviewed. We conclude that the available evidence suggests that significant restrictions in protein intake are not necessary for those critically ill patients with AKI. However, the studies reviewed here showed significant heterogeneity in protein dose and delivery, estimation of protein needs, patient population, and definition of AKI, and thus further research is needed to systematically determine the optimal dose of protein for critically ill adults with AKI.
Surgical Endoscopy and Other Interventional Techniques, Feb 26, 2019
Background Percutaneous endoscopically placed gastrostomy (PEG) tubes are useful for long-term en... more Background Percutaneous endoscopically placed gastrostomy (PEG) tubes are useful for long-term enteral nutrition; however, they are associated with lack of benefit for patients with advanced dementia, at end of life, and for some stroke patients with early regain of swallowing function. We surveyed physician opinions on decision making with the aim to identify factors that can lead to inappropriate PEG placement, as a first step of a quality improvement initiative to prevent inappropriate PEG placements at our facility. Methods A survey was distributed to 231 physicians, with questions about discussion topics, contraindications, responsibilities, and practices in decision making for PEG placement. Five-point Likert scales were used for most responses. Results Of 62 respondents, the majority were general surgeons (51.6%) and neurologists (30.6%). Levels of agreement were very low that PEG placement is contraindicated in advanced dementia (> 56% disagreed) and at end of life (55% disagreed) with scores of 2.4 and 2.5 (out of 5), respectively. Agreement level was low (score of 2.85) for delaying PEG for stroke patients by at least 2 weeks. Agreement was high for the discussion topics, for allowing 1-7 days for processing information, and for consulting the nutrition service. Over 98% of respondents chose primary team and 58% chose both primary and endoscopy teams as being responsible for discussions with patients and care partners in the decision-making process. Conclusions Greater awareness is needed of the lack of benefit of PEG feeding in advanced dementia, at end of life, and for some stroke patients with early regain of swallow function. Disagreement exists as to whether the primary team and endoscopist share in the responsibility for discussions in decision making for PEG placement.
Journal of Wound Ostomy and Continence Nursing, Sep 1, 2015
Enteric fistulas can be classified as enterocutaneous and/or enteroatmospheric. Both are devastat... more Enteric fistulas can be classified as enterocutaneous and/or enteroatmospheric. Both are devastating complications of bowel disease, abdominal surgery, and/or open abdomen. Enteric fistulas are associated with a mortality rate varying from 1% to 33%; the main cause of death is sepsis. Coordinated and skillful efforts of an interprofessional team are required in customizing successful treatment regimens appropriate to each patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s unique clinical scenario. A 65-year-old white woman experienced an enteroatmospheric fistula patient after ventral hernia repair. Care of this patient was based on the complementary relationship between professionals from 2 disciplines: the wound and ostomy continence nurse (WOC nurse) and the nutrition support registered dietitian/nutritionist. Working together, they developed a comprehensive wound, ostomy, and nutritional plan. Initially, the patient received parenteral nutrition exclusively. After the fistula tract was clearly defined, a feeding tube was placed into the distal limb of the fistula, and she received nourishment via a fistuloclysis (ie, enteral feedings administered via the fistula). A special wound management system was created to contain fistula output while allowing feeding through the distal limb of the fistula. Enterocutaneous and enteroatmospheric fistulas originating from the small bowel present a management challenge to the entire healthcare team. WOC nurses are often called upon to meet the challenge of maintaining skin health while promoting dignity and function. Nutrition support via registered dietitian/nutritionists play a critical role in managing the nutrition regimen for these patients. In this case, the use of fistuloclysis met the patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s nutritional needs while avoiding the risks associated with parenteral nutrition.
Studies have failed to consistently demonstrate improved survival in intensive care unit (ICU) pa... more Studies have failed to consistently demonstrate improved survival in intensive care unit (ICU) patients receiving immune-modulating nutrient-enhanced enteral feeds when compared with standard enteral feeds. The objective was to study in a prospective fashion the effects of adding glutamine to standard or immune-modulated (supplemented with omega-3 fatty acids, -carotene, and amino acids such as glutamine and arginine) tube feeds. Design: Prospective, unblinded study using sequential allocation. Setting: A university surgical trauma ICU. Patients: All surgical and trauma patients admitted to the surgical trauma ICU at a university hospital over a 3-yr period who were to receive enteral feeds (n ؍ 185). Interventions: Sequential assignment to three isocaloric, isonitrogenous diets was performed as follows: standard 1-kcal/mL feeds with added protein (group 1), standard feeds with the addition of 20-40 g/day (0.6 g/kg/day) glutamine (group 2), or an immune-modulated formula with similar addition of glutamine (group 3). The goal for all patients was 25-30 kcal/kg/day and 2 g/kg/day protein. Measurements and Main Results: Patients were followed until discharge from the hospital. The primary end point was inhospital mortality, and multiple secondary end points were recorded. In-hospital mortality for group 1 was 6.3% (four of 64) vs. 16.9% (ten of 59, p ؍ .09) for group 2 and 16.1% (ten of 62, p ؍ .09) for group 3. After controlling for age and severity of illness, the difference in mortality between patients receiving standard tube feeds and all patients receiving glutamine was not significant (p < .11). There were no statistically significant differences between the groups for secondary end points. Conclusions: The addition of glutamine to standard enteral feeds or to an immunomodulatory formula did not improve outcomes. These findings suggest that enteral glutamine should not be routinely administered to patients with surgical critical illness.
The American Journal of Clinical Nutrition, Nov 1, 2014
Background: Proper caloric intake goals in critically ill surgical patients are unclear. It is po... more Background: Proper caloric intake goals in critically ill surgical patients are unclear. It is possible that overnutrition can lead to hyperglycemia and an increased risk of infection. Objective: This study was conducted to determine whether surgical infection outcomes in the intensive care unit (ICU) could be improved with the use of hypocaloric nutritional support. Design: Eighty-three critically ill patients were randomly allocated to receive either the standard calculated daily caloric requirement of 25-30 kcal $ kg-1 $ d-1 (eucaloric) or 50% of that value (hypocaloric) via enteral tube feeds or parenteral nutrition, with an equal protein allocation in each group (1.5 g $ kg-1 $ d-1). Results: There were 82 infections in the hypocaloric group and 66 in the eucaloric group, with no significant difference in the mean (6SE) number of infections per patient (2.0 6 0.6 and 1.6 6 0.2, respectively; P = 0.50), percentage of patients acquiring infection [70.7% (29 of 41) and 76.2% (32 of 42), respectively; P = 0.57], mean ICU length of stay (16.7 6 2.7 and 13.5 6 1.1 d, respectively; P = 0.28), mean hospital length of stay (35.2 6 4.9 and 31.0 6 2.5 d, respectively; P = 0.45), mean 0600 glucose concentration (132 6 2.9 and 135 6 3.1 mg/dL, respectively; P = 0.63), or number of mortalities [3 (7.3%) and 4 (9.5%), respectively; P = 0.72]. Further analyses revealed no differences when analyzed by sex, admission diagnosis, site of infection, or causative organism. Conclusions: Among critically ill surgical patients, caloric provision across a wide acceptable range does not appear to be associated with major outcomes, including infectious complications. The optimum target for caloric provision remains elusive.
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