D37881 enteral nutrition

D37881 Enteral Nutrition 23/4/07 11:33 Page 1 Contents
Immunonutrition in septic patients: A
Effect of an enteral diet
philosophical view of the current situation
supplemented with a specific blend
of amino acid on plasma and muscle
protein synthesis in ICU patients

Clinical and biochemical outcomes
after a randomized trial with a high
dose of enteral arginine formula in

Cancer wasting and quality of
postsurgical head and neck cancer patients
life react to early individualized
nutritional counselling!
P Ravasco, I M Grillo and M Camilo
Optimizing the dose of glutamine
Nutritional advice and treatment
dipeptides and antioxidants in critically
by dietitians to patients with
ill patients: A phase I dose-finding study
amyotrophic lateral sclerosis/motor
neurone disease: a survey of current
practice in England, Wales,

Enteral Nutrition in Critically Ill
Northern Ireland and Canada
Children: Are Prescription and Delivery
According to Their Energy Requirements?
S Brasil de Oliveira Iglesias et al.
Energy requirements in frail elderly
people: A review of the literature
Nasojejunal tube placement in
paediatric intensive care
A McDermott, N Tomkins and G Lazonby
Response of albumin synthesis to oral
nutrients in young and elderly subjects
Synbiotics, Prebiotics, Glutamine,
or Peptide in Early Enteral Nutrition:
A Randomized Study in Trauma Patients

Is serum albumin a good marker
for malnutrition in the physically
impaired elderly?

Development of the Infant Intestine:
Implications for Nutrition Support
C E Commare and K A Tappenden
Failure to thrive: the prevalence and
concurrence of anthropometric criteria
Testing nasogastric tube positioning
in a general infant population
in the critically ill: Exploring the evidence
Nutritional status, perceived body
image and eating behaviours in adults
Enteral Nutrition Support of Head
with cystic fibrosis
and Neck Cancer Patients
Update on Enteral Nutrition Support
Early versus late enteral nutritional
for Cystic Fibrosis
support in adults with burn injury:
a systematic review
J Wasiak, H Cleland, and R Jeffery
Effect of exclusive enteral
nutritional treatment on plasma
Comparison of nutritional and
antioxidant concentrations in
inflammatory markers in dialysis
childhood Crohn’s disease
patients with reduced appetite
Nutrition Issues in Pediatric
Effect of nutritional support
Crohn’s Disease
on glucose control
Prevalence of home artificial
nutrition in Italy in 2005: A survey
Reference List
by the Italian Society for Parenteral
and Enteral Nutrition (SINPE)
L Pironi et al.
D37881 Enteral Nutrition 23/4/07 11:33 Page 2 Introduction
Welcome to Fresenius Kabi’s Quarterly Abstract Bulletinfor enteral nutrition. We have reviewed the followingjournals over the past three months, and selected anynutrition support related articles: • American Journal of Clinical Nutrition • Journal of Human Nutrition and Dietetics • Journal of Parenteral and Enteral Nutrition • Current Opinion in Clinical Nutrition and Metabolic Care • European Journal of Clinical Nutrition We do recommend that the original article is used for thefull details and results.
Please note that due to copyright law our ability to
copy and distribute clinical papers is restricted.

This publication and previous editions are also
available online at www.fresenius-kabi.co.uk under
the nutrition service section.

D37881 Enteral Nutrition 23/4/07 11:33 Page 3 quarterly abstract bulletin 5
Effect of an enteral diet supplemented with a specific blend of
amino acid on plasma and muscle protein synthesis in ICU

O Mansoor, D Breuillé, F Béchereau, C Buffière, C Pouyet, B Beaufrère,J Vuichoud, M Van’t-Of and C Obled Clinical Nutrition (2007) 26(1): 30-40
Background & aim:
Polytrauma patients are characterized
day 3 to Df. Results: The contribution of total plasma
by a negative nitrogen balance and muscle wasting.
proteins to whole body protein synthesis was greatly Standard nutrition is relatively inefficient to improve muscle increased, from 11% in healthy volunteers to about 25% in protein turnover. The aim of this study was to investigate polytrauma patients. AA supplementation had no effect on the effect of enteral nutrition (EN) supplemented with nitrogen balance, leucine kinetics or plasma protein specific amino acids on protein metabolism in polytrauma synthesis in patients. In contrast, the urinary excretion of patients. Methods: In a double blind study, 12 polytrauma
3-methyl histidine tended to decrease along the study in patients were randomized to receive EN supplemented with the AA supplemented group compared to an increase in either a mixture of cysteine, threonine, serine and aspartate the Ala group. Muscle protein synthesis tended to be (AA patients) or alanine at isonitrogenous levels (Ala higher in the AA group than in the Ala group (46%, patients). An intravenous infusion of l-[1-13C]-leucine was P=0.065). Conclusion: During injury, an increased supply
performed in the fed state between day 9 and 12 post- of cysteine, threonine, serine and aspartate could be able to injury (Df) in patients and in a group of healthy volunteers better cover the specific amino requirements, thus resulting (n=8) (EN+Ala) to measure whole body leucine kinetics, in improved muscle protein synthesis without impairment plasma and muscle protein synthesis rates. Nitrogen balance, 3-methyl histidine excretion were measured from Cancer wasting and quality of life react to early individualized
nutritional counselling!

Clinical Nutrition (2007) 26(1): 7-15
To devise a meaningful nutritional therapy in cancer, a
prospective randomized controlled trial in head and neck greater understanding of nutritional dimensions as well as cancer patients stratified by stage undergoing patients’ expectations and disease impact is essential. We radiotherapy. Pre-defined outcomes were: nutritional have shown that nutritional deterioration in patients with status and intake, morbidity and QoL, at the end and 3 gastrointestinal and head and neck cancer was months after radiotherapy. Nutritional interventions, only multifactorial and mainly determined by the tumour given during radiotherapy, consisted of three burden and location. In a larger cohort, stage and location randomization arms: (1) individualized nutritional were yet again the major determinants of patients’ quality counselling vs. (2) ad libitum diet+high protein of life (QoL), despite the fact that nutritional deterioration supplements vs. (3) ad libitum diet. Nutritional combined with intake deficits were functionally more interventions 1 and 2 positively influenced outcomes relevant than cancer stage. Based on this framework, the during radiotherapy; however, 3 months after its potential role of integrated oral nutritional support on completion individualized nutritional counselling was the outcomes was investigated. In a pilot study using single method capable of sustaining a significant impact individualized nutritional counselling on a heterogeneous on patients’ outcomes. The early provision of the patient population, the achieved improvement of appropriate mixture of foods and textures using regular nutritional intake was proportional to a better QoL. The foods may modulate outcomes in cancer patients. role of early nutritional support was further analysed in a D37881 Enteral Nutrition 23/4/07 11:33 Page 4 Nutritional advice and treatment by dietitians to patients with
amyotrophic lateral sclerosis/motor neurone disease: a survey of
current practice in England, Wales, Northern Ireland and Canada

Journal of Human Nutrition & Dietetics (2007) 20(1): 3-13
The management of amyotrophic lateral
reported using body weight, percentage weight loss (PWL) sclerosis/motor neurone disease (ALS/MND) has shifted and body mass index (BMI) to assess nutritional status.
from an attitude of nihilism to treatments that prolong Equations used to estimate energy and protein survival and offer hope. Nutrition is an integral component requirements differed. Most frequent dietary advice was of ALS/MND care requiring coordination among acute and high calorie, texture modification and prescription community multi-disciplinary teams (MDT). Evidence- nutritional supplements. Artificial nutrition and hydration based nutrition guidelines exist for this patient group but (ANH) was discussed when patients developed dysphagia, their use among dietitians is unknown. The aim of this energy intake was inadequate, weight loss of 10% or study was to survey the knowledge, practice and guideline forced vital capacity (FVC) was reduced. A percutaneous use of dietitians working in ALS/MND centres/clinics endoscopic gastrostomy (PEG) service was available at all ?across England, Wales, Northern Ireland (EWNI) and clinics/centres. Conclusion:
Canada. Method: Dietetic contact details were obtained
techniques and dietary advice should be standardized.
from the Motor Neurone Disease Association (MNDA) and Dietetic collaboration at national and international level is the ALS Society of Canada (ALSSC) websites. Telephone recommended to reduce professional isolation. Training interviews were conducted with 23 dietitians using a and support in ALS/MND nutrition should be made standardized questionnaire. Results: Multi-disciplinary
available as part of post-dietetic registration. Further team membership was high (78%). Only 22% dietitians dietetic research is required to stimulate nutritional care. had >4-years experience in ALS/MND care. Dietitians Energy requirements in frail elderly people: A review
of the literature

C Gaillard, E Alix, A Sallé, G Berrut and P Ritz Clinical Nutrition (2007) 26(1): 16-24
This review collates studies of healthy, sick, underweight
physical activity level, i.e. the ratio of total energy (BMI<21 kg/m2) and very elderly people (>90 yr), in expenditure to REE, is reduced during disease averaging at whom resting energy expenditure (REE) was measured 1.36, (4) energy intake (EI) being only 1.23xREE is using indirect calorimetry. We have observed the insufficient to cover energy requirements in sick elderly following: (1) REE, when adjusted for differences in both patients, whereas the EI of healthy elderly people appears body weight and fat-free mass (FFM), is similar in healthy sufficient to cover requirements, and finally, (5) gender and in sick elderly people being 20 and 28 kcal/kg of FFM ceases to be a determinant of REE in people aged 60 yr or per day, respectively, (2) their nutritional status influences over, with the Harris & Benedict equation capable of their energy requirements given that weight-adjusted REE accurately predicting mean REE in this population, increases in line with a decrease in BMI, (3) total energy expenditure is lower in sick elderly people given that their D37881 Enteral Nutrition 23/4/07 11:33 Page 5 quarterly abstract bulletin 7
Response of albumin synthesis to oral nutrients in young and
elderly subjects

G Caso, J Feiner, I Mileva, L J Bryan, P Kelly, K Autio,M C Gelato and M A McNurlan American Journal of Clinical Nutrition (2007) 85(2): 446-451
The synthesis of albumin after oral ingestion
synthesized per day), was significantly lower in elderly of nutrients provides a means of storing amino acids, which subjects (108 ± 7 mg · kg body wt–1 · d–1) than in young can be made available during periods of fasting.
subjects (141 ± 7 mg · kg body wt–1 · d–1). In response to Objective: This study was undertaken to see whether the
the complete meal, albumin synthesis was significantly response of albumin synthesis to the oral intake of nutrients increased in both the elderly (144 ± 7 mgkg body wt–1 · d–1) is compromised in elderly subjects. Design: Albumin
and the young (187 ± 11 mg · kg body wt–1 · d–1) subjects.
synthesis was determined from the incorporation of 43 mg The protein component of the meal was sufficient to L-[2H5]phenylalanine/kg body wt. Eight elderly subjects stimulate albumin synthesis in both the elderly (147 ± 14 (aged >60 y) and 8 young subjects (aged 21–35 y) were mg · kg body wt–1 · d–1) and the young (182 ± 6 mg · kg studied on 3 separate occasions: after the intake of water, body wt–1 · d–1) subjects. Conclusions: Elderly subjects have
a liquid meal (with 15% of energy from protein, 30% of lower rates of albumin synthesis than do young subjects energy from fat, and 55% of energy from carbohydrate), or during fasting, but they stimulate albumin synthesis an isonitrogenous but not isocaloric meal containing only proportionately in response to the oral ingestion of protein.
protein. Results: Mean (±SEM) albumin synthesis,
The intakes of additional fat and carbohydrate do not expressed as an absolute rate (ie, the amount of albumin Is serum albumin a good marker for malnutrition in the
physically impaired elderly?

M Kuzuya, S Izawa, H Enoki, K Okada and A Iguchi Clinical Nutrition (2007) 26(1): 84-90
Background and Aims:
Although serum albumin is well
serum albumin levels correlated with various nutritional known as a marker of nutritional status, it has remained parameters including anthropometric measurements and unclear whether impaired physical function affects serum levels of serum total cholesterol as well as the SGA albumin concentrations in older people. We examined evaluation. However, after adjusting for age and gender, whether hypoalbuminemia can be used as a marker of serum albumin levels in participants with a low ADL malnutrition in elderly subjects with various levels of function did not correlate with nutritional parameters.
physical impairment. Methods: A total of 262 elderly
Approximately 80% participants with low ADL function subjects without acute illness were enrolled from various who were evaluated as being well nourished according to geriatric settings. For the nutritional assessment, serum SGA evaluation had serum albumin levels lower than albumin, total cholesterol, anthropometric measurements, 35g/l. Conclusions: The utility of serum albumin and the
and subjective global assessment (SGA) were determined.
traditional cutoff (35g/l) in older people with low ADL Physical function was evaluated by rating score of activity function is questionable even among those without of daily living (ADL). Results: As a whole, participants’
D37881 Enteral Nutrition 23/4/07 11:33 Page 6 Failure to thrive: the prevalence and concurrence of
anthropometric criteria in a general infant population

E M Olsen, J Petersen, A M Skovgaard, B Weile, T Jørgensen and C M Wright Archives of Disease in Childhood (2007) 92(2): 109-114
Failure to thrive (FTT) in early childhood is
2–6 and 6–11 months of life. Results: 27% of infants met
associated with subsequent developmental delay and is one or more criteria in at least one of the two age groups.
recognised to reflect relative undernutrition. Although the The concurrence among the criteria was generally poor, concept of FTT is widely used, no consensus exists with most children identified by only one criterion. Positive regarding a specific definition, and it is unclear to what predictive values of different criteria ranged from 1% to extent different anthropometric definitions concur.
58%. Most single criteria identified either less than half the Objective: To compare the prevalence and concurrence of
cases of significant undernutrition (found in 3%) or different anthropometric criteria for FTT and test the included far too many, thus having a low positive sensitivity and positive predictive values of these in predictive value. Children with low weight for height detecting children with “significant undernutrition”, tended to be relatively tall. Conclusions: No single
defined as the combination of slow conditional weight measurement on its own seems to be adequate for gain and low body mass index (BMI). Methods: Seven
identifying nutritional growth delay. Further longitudinal criteria of FTT, including low weight for age, low BMI, low population studies are needed to investigate the conditional weight gain and Waterlow’s criterion for discriminating power of different criteria in detecting wasting, were applied to a birth cohort of 6090 Danish significant undernutrition and subsequent outcomes. infants. The criteria were compared in two age groups: Nutritional status, perceived body image and eating
behaviours in adults with cystic fibrosis

J Abbott, A M Morton, H Musson, S P Conway, C Etherington,L Gee, J Fitzjohn and A K Webb Clinical Nutrition (2007) 26(1): 91-99
Background & Aims:
Achieving and maintaining an
self-esteem and quality of life (QoL). Results: A minority
ideal nutritional status is the primary aim of the of CF patients reported disordered eating. Those receiving nutritional management of cystic fibrosis (CF). It is unclear nutritional interventions engaged in less dieting how nutritional interventions impact on patients’ behaviour. All CF groups, especially intervention groups, perceptions and behaviours concerning body image and received more pressure from others to eat. For females, eating. This work aimed to provide a psychosocial profile control groups desired to be slimmer whereas and compare CF patients receiving (a) enteral tube intervention groups desired to be heavier. Healthy males feeding, (b) nutritional supplements, (c) no nutritional were content with their body whereas CF males wished to interventions, and (d) healthy controls. Methods: A
be heavier. Patients receiving enteral tube feeding were cross-sectional questionnaire design was employed. Age, less satisfied with their body image, reported lower self- gender, lung function, and body mass index were esteem and poorer QoL. Conclusion: Body image and
recorded. Subjects completed measures of eating eating behaviours are important considerations of attitudes, perceived and desired body shape, body image, nutritional interventions for maintaining QoL. D37881 Enteral Nutrition 23/4/07 11:33 Page 7 quarterly abstract bulletin 9
Update on Enteral Nutrition Support for Cystic Fibrosis
Nutrition in Clinical Practice (2007) 22(2): 223-232
Cystic fibrosis (CF) is an inherited disease affecting the
population) or tube feeding (used in >13% of the CF respiratory, gastrointestinal, hepatobiliary, and reproductive population) is often required for children and adults with systems. Nutrition status in persons with CF is often CF. The purpose of this update is to describe current compromised due to increased energy needs, frequent consensus and evidence for enteral nutrition support infections, pancreatic insufficiency, lung disease, or CF- guidelines, reported complications of enteral feeding in the related diabetes. Maintaining good nutrition status has CF population, evidence of expected outcomes, and to been associated with better pulmonary function, reduced discuss related areas requiring further research. A case hospitalizations, and increased longevity. Nutrition support report is provided to illustrate potential outcomes of as oral supplementation (used in >37% of the CF Effect of exclusive enteral nutritional treatment on plasma
antioxidant concentrations in childhood Crohn’s disease

A K Akobeng, K Richmond, V Miller and A G Thomas Clinical Nutrition (2007) 26(1): 51-56
Background & Aims:
Oxidative stress and depletion of
malondialdehyde (MDA) were measured at baseline and antioxidants may play a role in the pathogenesis of Crohn’s after 4 weeks of exclusive enteral nutritional treatment. disease (CD). The aim of this study was to determine the Results: Mean (95% CI) selenium concentra E {11.3 mg/l
effect of exclusive enteral nutrition, which is increasingly (10.3, 12.4) to 9.4 mg/l (8.7, 10.1), P=0.03}. The being used as primary therapy for CD, on plasma concentrations of vitamin A, urates, glutathione and MDA antioxidant concentrations in children with active CD.
did not change significantly over the study period.
Methods: In a double-blind randomised controlled trial,
Glutamine supplementation did not have any significant 15 children with active CD (mean age, 11.3 years, range effect on plasma antioxidant concentrations. 6.8–15.7) attending a paediatric gastroenterology referral Conclusions:
centre, were assigned to receive either a standard antioxidant concentrations occurred in children with active polymeric diet (Group S, n=8) or a glutamine-enriched CD receiving exclusive enteral nutritional treatment.
polymeric diet (Group G, n=7) as primary therapy for Glutamine supplementation was not beneficial in active CD. Plasma concentrations of selenium, urates, improving plasma antioxidant status.
vitamin A, vitamin E, vitamin C, glutathione, and also D37881 Enteral Nutrition 23/4/07 11:33 Page 8 Nutrition Issues in Pediatric Crohn’s Disease
Nutrition in Clinical Practice (2007) 22(2): 214-222
Twenty-five percent of inflammatory bowel disease (IBD)
nutrition needs of such children and how they may be best diagnoses present in childhood, with Crohn’s disease (CD) met. However, our understanding of the manner in which being the most common type. Many children have poor the disease process affects the energy demands of children nutrition status at presentation of the disease, which may with CD or how poor nutrition, in turn, may affect the worsen during the clinical course, with a significant disease course is limited. This may constrain the efficacy number of children having impaired linear growth. The and effectiveness of standard therapeutic approaches to cause of this poor nutrition status is complex, and care. This review explores the many factors of relevance in contributing factors include inadequate intake, the delivery of nutrition support to children with malabsorption, altered energy demands, and losses inflammatory bowel disease, and explores the role of through stool, particularly in colitis. The principal aim of exclusive enteral nutrition as a corticosteroid-sparing medical management is to induce disease remission, with strategy to induce remission in children with active Crohn’s minimal side effects, thereby enabling normal growth and development. This must include active consideration of the Prevalence of home artificial nutrition in Italy in 2005:
A survey by the Italian Society for Parenteral and
Enteral Nutrition (SINPE)

L Pironi, M Candusso, A Biondo, A Bosco, P Castaldi, F Contaldo, E Finocchiaro,A Giannoni, S Mazzuoli, P Orlandoni, A Palozzo, C Panella, S Pastò, E Ruggeri,G Sandri, E Stella, G Toigo and the Italian Society for Parenteral andEnteral Nutrition (SINPE) Executive Committee Clinical Nutrition (2007) 26(1): 123-132
To determine the prevalence (cases per million
prevalence 152.6 (83.9% HEN, 16.1% HPN); the HAN inhabitants) of home artificial nutrition (HAN), enteral range among the regions was: prevalence 28.1–519.8; (HEN) and parenteral (HPN), in Italy, grouped according to oncological disease 13.8–75.7%, neurological disease administrative regions, patient age and primary disease, 15.5–79.9%, intestinal failure 1.3–14.0%. An HAN and to analyze the impact both of the presence of an HAN regulation was present in 11 regions. A positive regional regulation and of demographic characteristics. association (P=0.012) was found between the number of Methods: In April 2005, the Regional Coordinators of the
years since the regulation was issued and the HAN Italian Society for Parenteral and Enteral Nutrition (SINPE) prevalence, and also between the % neurological patients recorded all the ongoing cases of HAN using a structured and the population density (P=0.130) and the questionnaire and were asked to estimate the % inhabitants 75 years (P=0.040). Conclusions: The
representativeness of the collected sample with respect to need for HAN regards a great number of patients the total expected HAN. Results: A total of 6955 cases of
throughout the country; there are substantial differences HAN (93.5% adults, 6.5% pediatric patients 18 years) were between the regions with respect to both the prevalence recorded in 16 of the 20 Italian regions (80% of the Italian and the use of HAN in various disease categories. A specific population; sample representativeness 78%). HAN regulation may favor the development of HAN.
D37881 Enteral Nutrition 23/4/07 11:33 Page 9 quarterly abstract bulletin 11
Immunonutrition in septic patients: A philosophical view of
the current situation

Clinical Nutrition (2007) 26(1): 25-29
Background & aims:
Two different ways of thinking
immunonutrition in sepsis from the rationalist and the pervaded the history of science: rationalism and empiricist perspectives. Results: The large body of
empiricism. In theory, these two paradigms are not evidence for positive effects of immunonutrients in necessarily in conflict. In practice, there has always been experimental models and the contradictory results from tension between them. The coming of evidence-based clinical trials make the discussion on immunonutrition in medicine put empiricism in a privileged position, but sepsis a typical example where the conflict between empiricism without a rationalistic guide could even be rationalism and empiricism hampered the advancement of usefulness. The aim of this work is to present the tension knowledge and the implementation of new effective between the rational reasons to administer therapies into clinical practice. Conclusions: Future
immunonutrients to patients with sepsis and the research projects involving immunonutrients should be controversial empirical evidence stemming from clinical based on robust knowledge of basic mechanisms of action trials. Methods:
to be properly addressed in clinical trials.
Clinical and biochemical outcomes after a randomized trial
with a high dose of enteral arginine formula in postsurgical
head and neck cancer patients

D A de Luis, O Izaola, L Cuellar, M C Terroba, T Martin and R Aller European Journal of Clinical Nutrition (2007) 61(2): 200–204
Patients with head and neck cancer
significant intergroup differences in the trend of the three undergoing surgery have a high incidence of postoperative plasma proteins (albumin, transferrin, prealbumin) and complications. The aim of our study was to investigate lymphocytes were detected. Episodes of diarrhea rate were whether postoperative nutrition of head and neck cancer equal in both groups (22.8% group I and 21.6% group patients, using a higher dose of arginine-enhanced diet II: NS). The postoperative infections complications were (17 g/day) than previous studies, could improve equal in both groups (5.7% group I and 5.4% group nutritional variables as well as clinical outcomes, when II: NS). Fistula (wound complication) was less frequent in compared with a control enteral diet. Design:
enriched nutrition group (2.8% group I and 18.9% group Randomized clinical trial. Setting: Tertiary care. Subjects:
II: P<0.05), whereas wound infection was similar in both A population of 72 patients with oral and laryngeal cancer groups. The length of postoperative stay was similar in was enrolled. Interventions: At surgery, patients were
both (27.9±21 vs 28.2±12 days; NS). Conclusions: At
randomly allocated to two groups: (a) 35 patients this dose, arginine-enhanced formula improves fistula receiving an arginine-enhanced formula with arginine rates in postoperative head and neck cancer patients (group I) and (b) 37 patients receiving an isocaloric, isonitrogenous enteral formula (group II). Results: No
D37881 Enteral Nutrition 23/4/07 11:33 Page 10 Optimizing the dose of glutamine dipeptides and antioxidants
in critically ill patients: A phase I dose-finding study

D K Heyland, MD, R Dhaliwalm, A Day, J Drover, H Cote and P Wischmeyer Journal of Parenteral and Enteral Nutrition (2007) 31(2): 109-118
Supplementation with glutamine and
were change in sequential organ function assessment antioxidants may be associated with an improvement in (SOFA) score and safety parameters. Secondary outcomes clinical outcomes, but the optimal dose of these substrates included whole blood glutathione (GSH), thiobarbituric is unknown. The purpose of this study was to determine acid reactive substances (TBARS), and blood cellent the safety of high doses of glutamine combined with groups, the slopes straighten out and the p values are no antioxidants in critically ill patients. Methods: We
longer significant, suggesting a greater preservation of conducted a single-center, open-label, dose-escalating GSH levels with escalating doses. In group 2, the slope of clinical trial. Mechanically ventilated adult patients with the line representing TBARS was horizontal. With clinical evidence of hypoperfusion were sequentially subsequent groups, the slopes decrease, and by group 5, enrolled to 1 of 5 groups. Group 1 (n = 30): no this decrease reaches statistical significance (p = .03), supplementation; group 2 (n = 7): 0.35 g/kg/d of suggesting a greater reduction in oxidative stress with the glutamine IV; group 3 (n = 7): same as group 2 plus 15 higher doses in group 5. The difference in slopes across all g/d of glutamine and 150 µg of selenium enterally; group groups describing the mitochondrial RATIO is statistically 4 (n = 7): same as group 2 plus 30 g/d of glutamine and significant (p = .001), again suggesting that, with higher 300 µg of selenium enterally; and group 5 (n = 7): same doses, there is increased mitochondrial function.
as group 4 plus an additional 500 µg of selenium IV. After Conclusions: The doses of glutamine and antioxidants
enrollment, nutrients were started as soon as possible. All tested in this study seem to be safe and may have positive patients were fed enterally according to clinical practice effects on some mechanistic endpoints. A larger trial will guidelines. Results: The primary outcomes for this study
be necessary to confirm their therapeutic effects. Enteral Nutrition in Critically Ill Children: Are Prescription and
Delivery According to Their Energy Requirements?

S Brasil de Oliveira Iglesias, H Pons Leite, J Fernandez Santana e Menesesand W Brunow de Carvalho Nutrition in Clinical Practice (2007) 22(2): 233-239
The purpose of this study was to compare
prescribed and delivered: energy were attributable to the differences between prescribed and delivered energy interruptions in feeding caused by clinical instability, among critically ill children and to identify the factors that airway management, radiologic and surgical procedures, impede the optimal delivery of enteral nutrition in the first and accidental feeding tube removal. The other factors 5 days of nutrition support. Methods: In a prospective
associated with the delivery of less than required energy cohort study, we evaluated 55 critically ill children aged 8.2 were PIM 215%, gastrointestinal complications, dialysis,
± 11.4 months (0–162.3 months), who were fed for 2 and use of ʷ-adrenergic vasoactive drugs. The latter was
days through a gastric or postpyloric tube. The patients the only variable in multivariate analysis that was were followed from admission until day 10 of enteral associated with not ultimately achieving energy goal.
nutrition. Prescribed and delivered energy were recorded Conclusions: The prescription and delivery of energy were
daily and compared with each other and with the not adequate in >50% of enteral nutrition days. The gap estimated basal metabolic rate (BMR). The Paediatric Index between the effective administration and energy of Mortality 2 (PIM 2) was used to estimate illness severity.
requirements can be explained by both underprescription Results: The ratio of delivered:required energy was <90%
and underdelivery. Administration of vasoactive drugs was in 55.7% of the enteral nutrition days. Low prescription the only variable independently associated with a low was the main reason for not achieving the energy goal in the first 5 days of enteral nutrition. Discrepancies between D37881 Enteral Nutrition 23/4/07 11:33 Page 11 quarterly abstract bulletin 13
Nasojejunal tube placement in paediatric intensive care
Paediatric Nursing (2007) 19(2): 26-28
Nasojejunal delivery of enteral feeds is a safe and effective
there has been a reduction in the use of medication and X- alternative to parenteral nutrition in critically ill children in ray to place NJTs. Based on the audit data, 58 per cent of whom intra-gastric feeding is usually poorly tolerated. A the children would have definitely or probably commenced guideline for bedside placement of nasojejunal tubes (NJTs) parenteral nutrition had NJT placement and feeding been was developed by a mulit-disciplinary group. An audit of unsuccessful. The audit also demonstrated that 26 out of practice was carried out following implementation of the 27 nurses and doctors reported they found the guidelines guideline. During the audit period 27 NJTs were easy or very easy to follow. Reducing variations in practice successfully passed in 21 patients. The result of this through the use of guidelines increases the frequency of innovation has been early initiation of nasojejunal feeding jejunal feeding. This benefits critically ill patients by and an increase in bedside placement of NJTs within the improving tolerance of enteral feeding for better PICU. Paediatric radiologists have reported a reduction in requests for NJT placement under X-ray screening and Synbiotics, Prebiotics, Glutamine, or Peptide in Early Enteral
Nutrition: A Randomized Study in Trauma Patients

A Spindler-Vesel, S Bengmark, I Vovk, O Cerovic and L Kompan Journal of Parenteral and Enteral Nutrition (2007) 31(2): 119-126
Since the hepatosplanchnic region plays a
infections, including 38 pneumonia, were observed, with central role in development of multiple-organ failure and only 5 infections and 4 pneumonias in group D, which was infections in critically ill trauma patients, this study focuses significantly less than combined infections (p = .003) and on the influence of glutamine, peptide, and synbiotics on pneumonias (p = .03) in groups A, B, and C. Intestinal intestinal permeability and clinical outcome. Methods:
permeability decreased only in group D, from 0.148 One hundred thirteen multiple injured patients were (0.056–0.240) on day 4 to 0.061 (0.040–0.099) on day 7; prospectively randomized into 4 groups: group A, (p < .05). In group A, the lactulose-mannitol excretion glutamine; B, fermentable fiber; C, peptide diet; and D, ratio increased significantly (p < .02) from 0.050 standard enteral formula with fibers combined with (0.013–0.116) on day 2 to 0.159 (0.088–0.311) on day 7.
Synbiotic 2000 (Synbiotic 2000 Forte; Medifarm, Sweden), The total gastric retention volume in 7 days was 1150 a formula containing live lactobacilli and specific bioactive (785–2395) mL in group D, which was significantly more fibers. Intestinal permeability was evaluated by measuring than the 410 (382–1062) mL in group A (p < .02), and lactulose-mannitol excretion ratio on days 2, 4, and 7.
620 (337–1190) mL in group C (p < .03). Conclusions:
Results: No differences in days of mechanical ventilation,
Patients supplemented with synbiotics did better than the intensive care unit stay, or multiple-organ failure scores others, with lower intestinal permeability and fewer were found between the patient groups. A total of 51 D37881 Enteral Nutrition 23/4/07 11:33 Page 12 Development of the Infant Intestine: Implications
for Nutrition Support

Nutrition in Clinical Practice (2007) 22(2): 159-173
The incidence of preterm births has continued to increase
with a particular emphasis on developmentally immature over the past 25 years, and therefore the optimal feeding functions of the preterm intestine and the resulting of these infants is an important clinical concern. This implications for nutrition therapies used to feed the review focuses on intestinal development and physiology, Testing nasogastric tube positioning in the critically ill:
Exploring the evidence

British Journal of Nursing (2007) 16(7): 414-418
Nutritional support in the critically ill is commonly
critical ill patients whose gastric pH may well be altered delivered via a nasogastric tube. Correct positioning in the due to prophylactic stress ulcer medications and stomach must first be confirmed as inadvertent feeding continuous feeding regimens. There is a lack of quality into the lungs carries a high risk of mortality. The National research testing this method in the critically ill population.
Patient Safety Agency (2005) recommends the method of The theory-practice gap is addressed, and preliminary pH testing nasogastric tube aspirates to verify tube research behind use of thechniques such as capnography position. This article critically analyses the research supporting this method, and questions its reliability in D37881 Enteral Nutrition 23/4/07 11:33 Page 13 quarterly abstract bulletin 15
Enteral Nutrition Support of Head and Neck Cancer Patients
A Raykher, L Russo, M Schattner, L Schwartz, B Scott and M Shike Nutrition in Clinical Practice (2007) 22(1): 68-73
Patients with head and neck cancer are at high risk for
in the home by the patient helps to prevent weight loss, malnutrition due to dysphagia from the tumor and dehydration, nutrient deficiencies, treatment interruptions, treatment. Despite difficulty with oral intake, these and hospitalizations. It also improves quality of life.
patients usually have a normal stomach and lower Successful management of these patients requires orderly gastrointestinal tract. Enteral nutrition support via care and follow-up by a multidisciplinary nutrition team. percutaneous endoscopic gastrostomy (PEG) administered Early versus late enteral nutritional support in adults
with burn injury: a systematic review

Journal of Human Nutrition & Dietetics (2007) 20(2): 75-83
Burn injury increases the body’s metabolic
2006), MEDLINE (from 1950), CINHAL (from 1982) and demands, and therefore nutritional requirements.
EMBASE (from 1980). Results: The trial evidence about
Provision of an adequate supply of nutrients is believed to the benefit of early enteral nutritional support on lower the incidence of metabolic abnormalities, thus standardized clinical outcomes such as length of hospital reducing septic morbidity, and improving survival rates.
stay and mortality remained inconclusive. Similarly, the Enteral nutrition support is the best feeding method in a question of whether early enteral feeding influenced or patient who is unable to achieve an adequate oral intake, decreased metabolic rate, reduced septic and other but optimal timing of its introduction after burn injury (i.e.
complications remained uncertain. Conclusions:
early versus late) needs to be established. The purpose of Promising results suggest early enteral nutrition support this review is to examine evidence for the effectiveness and may blunt the hypermetabolic response to thermal injury, safety of early versus late enteral nutrition support in but it is insufficient to provide clear guidelines for practice.
adults with burn injury. Methods: An examination of
Further research incorporating larger sample sizes and randomized and controlled clinical trials using various rigorous methodology that utilizes valid and reliable medical databases such as The Cochrane Library (Issue 3, D37881 Enteral Nutrition 23/4/07 11:33 Page 14 Comparison of nutritional and inflammatory markers in
dialysis patients with reduced appetite

J J Carrero, A R Qureshi, J Axelsson, C M Avesani, M E Suliman, S Kato, P Bárány,S Snaedal-Jonsdottir, A Alvestrand, O Heimbürger, B Lindholm and P Stenvinkel The American Journal of Clinical Nutrition (2007) 85(3): 695-701
Anorexia is common in chronic kidney
concentrations of insulin-like growth factor I, albumin, disease and worsens as the disease progresses. Sex urea, and creatinine). However, across worsening appetite hormones and inflammatory cytokines may be related to scale, handgrip strength was incrementally lower in men feeding behavior. Objective: We hypothesized that
but not in women (multivariate analysis of variance). In a appetite would be related to inflammation and outcome in multivariate logistic regression analysis (pseudo r2 = 0.19), hemodialysis patients but that sex may account for appetite loss was associated with sex [odds ratio (OR): differences in the symptoms associated with poor 0.41; 95% CI: 0.24, 0.72], insulin-like growth factor I appetite. Design: A cross-sectional study was conducted
(3.58; 2.10, 6.32), and C-reactive protein > 10 mg/L in patients undergoing prevalent hemodialysis (n = 223; (2.39; 1.34, 4.11). Finally, appetite loss was associated 127 M;
– ± SD age: 66 ± 14 y). Anthropometric markers with worse clinical outcome even after adjustment for age, of body composition, handgrip strength, and nutritional sex, inflammation, dialysis vintage, and comorbidity and inflammatory status were measured, and 3 groups (likelihood ratio = 44.3; P < 0.0001). Conclusions: These
according to their self-reported appetite were established.
results show a close association among appetite, Overall mortality was assessed after 19 mo (range: 2–29 malnutrition, inflammation, and outcome in patients mo) of follow-up. Results: Poor appetite was associated
undergoing prevalent hemodialysis. Moreover, our data with a longer vintage time, increased inflammation (higher suggest that uremic men may be more susceptible than serum concentrations of interleukin 6 and C-reactive are women to inflammation-induced anorexia.
protein), and a worse nutritional status (lower serum Effect of nutritional support on glucose control
Current Opinion in Clinical Nutrition & Metabolic Care (2007) 10(2): 210-214
Purpose of review:
There is evidence that maintaining a
(metformin, thazolidinediones), which may be of interest normal glycemia level in critically ill patients has beneficial in the intensive care unit. Besides insulin, plasma glucose effects on outcome. Strategies aimed at lowering glycemia concentrations may be lowered by hypocaloric feeding, or are based on the understanding of mechanisms regulating by feeding ‘diabetic’ formula with low glucose content glucose metabolism. Recent findings: Activation of AMP
and supplemented with fructose. Whether such protein kinase in skeletal muscle and in the liver leads to a approaches lead to beneficial effects comparable to those reduction in glucose production, a stimulation of glucose observed with insulin remains to be established.
uptake, and a lowering of glycemia. These mechanisms Summary: Recent findings regarding the molecular
appear to be activated during exercise, or by the mechanisms underlying glucose transport and metabolism endogenous adipokine adiponectin. Alterations in are summarized, and potential strategies other than adiponectin concentrations during critical illness may thus insulin are outlined which may contribute to lowering play a role in the metabolic stress responses. In addition, glycemia in critically ill patients.
AMP-activated protein kinase is the target for drugs D37881 Enteral Nutrition 23/4/07 11:33 Page 15 quarterly abstract bulletin 17
Reference List
Further references on nutrition support
• Nething J et al. (2007) Establishing the Use of Body published in the last quarter.
Mass Index as an Indicator of Nutrition Risk in Childrenwith Cancer. Journal of Parenteral and Enteral Nutrition • Nazarko L (2007) Swallowing difficulties in stroke patients. Nursing and Residential care 9(2): 494-497 This article aims to determine the usefulness of body This article looks at the fact that many stroke survivors mass index (BMI) for age as a tool to prospectively have swallowing difficulties, which may increase the risk identify pediatric cancer patients at risk of malnutrition of chest infection, malnutrition, dehydration and tissue and to determine the BMI percentile that would be breakdown. It aims to enable care staff to identify the required to identify at-risk patients. signs of dysphagia and provide the individual withappropriate care. • Raurich J M et al. (2007) Resting energy expenditure during mechanical ventilation and Its relationship with • Denny A (2007) Tackling malnutrition among older the type of lesion. Journal of Parenteral and Enteral people in the community. British Journal of Community This article looks at resting energy expenditure (REE) of This article looks at some of the causes of under critically ill patients. The objective of this study was to nutrition, NICE guidelines for its management and the investigate whether or not the type of lesion affects the metabolism level of critically ill patients treated withmechanical ventilation. • Stanner S (2007) Older people with dementia: Eating and drinking healthily. Nursing and residential care 9(1): • Kamimura M A et al. (2007) Resting energy expenditure and its determinants in hemodialysis patients. European This article discusses some of the common eating and Journal of Clinical Nutrition 61(3): 362–367. drinking problems associated with dementia and how This article looks at Chronic kidney disease and aims to evaluate the resting energy expenditure (REE) and itsdeterminants in HD patients. • Colagiovanni L (2007) ‘We have got to change the attitude of nurses towards food and nutrition’. Nursing • St-Onge M et al. (2007) Evaluation of a portable device to measure daily energy expenditure in free-living This article looks at the concerns that people have adults. American Journal of Clinical Nutrition 85(3): about malnutrition in hospitals and how nurse attitudes affect the implementation of guidelines, moreover that This article evaluates a portable armband device for the change must be supported at all levels. measuring daily and physical activity EE in comparisonto the doubly labelled water (DLW) method in free- • Cereda N and Vanotti A (2007) The new Geriatric Nutritional Risk Index is a good predictor of muscledysfunction in institutionalized older patients. Clinical • Nicolien Zijlstra et al. (2007) 24-Hour Indirect Calorimetry in Mechanically Ventilated Critically Ill This article looks at the validity of Geriatric Nutritional Patients. Nutrition in Clinical Practice 22(2): 250-255.
Risk Index (GNRI), in predicting nutrition-related risk of This article looks at energy imbalance in critically ill, complications in the elderly and therefore aims to mechanically ventilated patients and investigates investigate if GNRI might be a reliable detector of whether brief measurements of indirect calorimetry at muscle dysfunction in institutionalised older people. any time of the day would give valid estimates of 24-hour energy expenditure. • Cuerda C et al. (2007) How accurate are predictive formulas calculating energy expenditure in adolescent • Siddiqui R A, Harvey K A and Stillwell W (2007) patients with anorexia nervosa? Clinical Nutrition 26(1): Modulation of Lipid Rafts by Ω-3 Fatty Acids in Inflammation and Cancer: Implications for Use of Lipids This article compares resting energy expenditure, During Nutrition Support. Nutrition in Clinical Practice measured by indirect calorimetry, to values estimated by different predictive formulas in adolescent patients with This article looks in depth at lipid rafts, the important membrane-signaling proteins contained, the modulationof these and their effects on inflammation and cancer innutrition support. D37881 Enteral Nutrition 23/4/07 11:33 Page 16 Reference List
• Lecko C (2007) Patient safety: Pinning down the • Gandy J (2007) Nutrition in neurological conditions.
nutritional issues. Complete Nutrition 7(1): 8-10.
Journal of Human Nutrition and Dietetics 20(1): 1-2.
This article discusses the NPSA’s role, responsibilities This article looks at the role of nutrition and dietitians in and planned projects surrounding nutrition as a patient the care of patients with various neurological

Source: http://www.fresenius-kabi.ie/files/EN_QAB_April_2007.pdf


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