Early nutrition support in critical care: a European perspective

PURPOSE OF REVIEW: Today, early nutrition support is considered standard care in most ICUs. The recommended method is the enteral route, although there is only minor evidence for this. Often inadequate delivery of energy and a cumulative energy deficit are implied. The purpose of this paper is to evaluate the indication for early enteral nutrition or immunonutrition and to discuss the application of additional parenteral nutrition. RECENT FINDINGS: The indication for early enteral nutrition is also supported by guidelines for enteral nutrition recently published by the European Society for Clinical Nutrition and Metabolism. Some more recent results strengthen the indication for a special formula in acute respiratory distress syndrome and septic patients. A recent metaanalysis has shown that parenteral nutrition is superior to delayed enteral nutrition. Additional parenteral nutrition thus seems to be the way to avoid cumulative energy deficit associated with insufficient or no enteral nutrition. SUMMARY: Early enteral nutrition is recommended for critically ill patients, with special formulas indicated in specific subgroups of patients. If enteral nutrition is insufficient or fails, parenteral nutrition should be instituted, respecting the often reduced demand for exogenous substrates in critically ill patients.     

Home parenteral nutrition: a hospital-based program with commercial logistic support

Since home parenteral nutrition was introduced in the 1970's, a number of medical centers have formed successful home parenteral nutrition programs which have reduced expenses to the patient and third party payers by 50 to 73% over in hospital costs. However, the cost of maintaining these programs for training and follow-up has largely been absorbed by the hospital as a nonreimbursable teaching expense. To offset the costs of our growing program in these times of budget "caps," we have established an agreement between our hospital and commercial home care company which provides for patient instruction and follow-up by the hospital parenteral and enteral nutrition team and logistic support by the home care company. We used the average cost of our first five patients to establish a fee schedule which the commercial company agreed to pay the hospital parenteral and enteral nutrition team for its services. This agreement reduces the number of nurses and pharmacists that the commercial company would otherwise have to hire for teaching and follow-up of home care patients, and supports the concept of regional care in medical centers where parenteral and enteral nutrition teams maintain quality control, continuity of care, and efficient teaching programs for patients requiring home parenteral nutrition.     

Special commentary: a call for intensive metabolic support

PURPOSE OF REVIEW: This special commentary addresses recent clinical reviews regarding appropriate nutrition and metabolic support in the critical care setting. RECENT FINDINGS: There are divergent approaches between North America and Europe for the use of early nutrition support and combined enteral nutrition and parenteral nutrition support possibly due to the commercial availability of specific parenteral nutrients. The advent of intensive insulin therapy has changed the landscape of metabolic support in the intensive care unit, and previous notions about infective risk of parenteral nutrition will need to be re-addressed. Patients with brain failure may benefit from an intensive insulin therapy with a blood glucose target that is higher than that used in patients without brain failure. Patients with heart failure may benefit from the addition of nutritional pharmacology that targets proximate oxidative pathophysiological pathways. Intradialytic parenteral nutrition may be viewed as another form of supplemental parenteral nutrition when enteral nutrition is insufficient in patients on hemodialysis in the intensive care unit. SUMMARY: It is proposed that intensive metabolic support be routinely implemented in the intensive care unit based on the following steps: intensive insulin therapy with an appropriate blood glucose target, nutrition risk assessment, early and if needed combined enteral nutrition and parenteral nutrition to target 20-25 kcal/kg/day and 1.2-1.5 g protein/kg/day, and nutritional and metabolic monitoring.     

Changes in nutrition support services between 1984 and 1986

Reports of the economic impact of diagnosis-related group funding on staffing and patient care in hospitals have varied from optimistic to bleak. The Dietitians in Nutrition Support Practice Group of The American Dietetic Association developed a questionnaire to evaluate changes in nutrition support services provided to inpatients and home patients between 1984 and 1986. The written survey instrument was mailed to clinical nutrition managers at a nationwide random selection of 1,000 hospital members of the American Hospital Association. Two hundred thirty-six responses were received. Respondents reported an increase in the use of enteral nutrition support for inpatients between 1984 and 1986. In 1986, tertiary-care hospitals also reported greater use of parenteral nutrition support and tube feeding for inpatients and home patients than did primary-care hospitals. Tertiary-care hospitals also reported higher staffing in 1986 than did primary-care hospitals in the following areas: clinical, nutrition support, and outpatient dietitians and dietetic technicians. Greater use of enteral and parenteral support for inpatients was noted by large hospitals as well as greater staffing in the following areas: clinical managers; nutrition support, clinical, outpatient, and home care dietitians; and dietetic technicians. However, the ratio of patients to RDs was greater in large than in small hospitals. There was no significant difference in patients:RD ratio between tertiary-care and primary-care hospitals. The only difference between responses from for-profit and nonprofit hospitals was in the number of nutrition support RD positions, which was larger in the nonprofit hospitals. Utilization of nutrition support for inpatients or home patients was not different for hospitals in different profit categories.     

Artificial nutrition support for patients in the Cambridge Health District

This paper describes the results of a one-year prospective survey of patients who received artificial enteral and parenteral nutritional support at home and in the hospitals of the Cambridge Health District. Enteral tube feeding accounted for most of the artificial nutritional support provided both in hospital and in the community. The findings of the study suggest that nutritional support is an important adjunct to the treatment of serious clinical disorders, and that the care of such patients can be improved by the establishment of a multidisciplinary enteral and parenteral nutrition team. Suggestions are made for establishing a structured home nutritional service.     

Home Parenteral and Enteral Nutrition

While the history of nutrition support dates to the ancient world, modern home parenteral and enteral nutrition (HPEN) has been available since the 1960s. Home enteral nutrition is primarily for patients in whom there is a reduction in oral intake below the amount needed to maintain nutrition or hydration (i.e., oral failure), whereas home parenteral nutrition is used for patients when oral-enteral nutrition is temporarily or permanently impossible or absorption insufficient to maintain nutrition or hydration (i.e., intestinal failure). The development of home delivery of these therapies has revolutionized the field of clinical nutrition. The use of HPEN appears to be increasing on a global scale, and because of this, it is important for healthcare providers to understand all that HPEN entails to provide safe, efficacious, and cost-effective support to the HPEN patient. In this article, we provide a comprehensive review of the indications, patient requirements, monitoring, complications, and overall process of managing these therapies at home. Whereas some of the information in this article may be applicable to the pediatric patient, the focus is on the adult population.     

Effect of recombinant human growth hormone and enteral nutrition on short bowel syndrome

BACKGROUND: Studies showed that bowel rehabilitation therapy, including recombinant human growth hormone (rhGH), nutrition support, glutamine, and dietary fiber, promotes intestinal adaptation in patients with short bowel syndrome. The aim of the current study was to determine if enteral nutrition and rhGH are effective in weaning short bowel patients off total parenteral nutrition (TPN). METHODS: Thirty-seven patients with short bowel syndrome received bowel rehabilitation therapy for 4 weeks. Thirty-four patients were treated within 2 years after short bowel syndrome. Treatment included nutrition support from enteral nutrition 500 to 1500 kcal/d, oral glutamine 0.6 g/kg/d, plus a high-carbohydrate and low-fat diet. Once patients were in positive nitrogen balance, rhGH 0.05 mg/kg/d was administered for 3 weeks. RESULTS: All patients completed the treatment; there were no deaths caused by malnutrition. Intestinal absorptive capacity and plasma levels of proteins were significantly improved after treatment (p < .05). Of the 23 patients who have been followed for >2 years after bowel rehabilitation therapy, 21 patients (57%) weaned off parenteral nutrition, among which 18 (49%) patients lived on a high-carbohydrate and low-fat diet supplemented with enteral nutrition, and 3 patients were free of enteral nutrition and relied on high-carbohydrate and low-fat diet alone. The minimal intestinal length for these patients was 15 cm with ileocecal valve and intact colon in adults. CONCLUSIONS: Providing patients with enteral nutrition, glutamine, dietary fiber, and rhGH during howel rehabilitation therapy allows weaning from TPN in a sign;ficant number of patients.     

American Society of Parenteral and Enteral Nutrition Presidential Address: food for thought: it's more than nutrition

Three issues were highlighted in the 30(th) Presidential Address to the society: (1) A.S.P.E.N.'s unique interdisciplinary structure; (2) support of the A.S.P.E.N. Rhoads Research Foundation; and (3) the meaning of food from the perspective of the patient who is receiving life-sustaining home enteral or parenteral nutrition. A.S.P.E.N., founded as a multidisciplinary society in the 1970s has evolved into an interdisciplinary society with an expanded and diverse membership of health care professionals and scientists with overlapping interests in clinical nutrition and metabolism. A.S.P.E.N. envisions an environment in which every patient receives safe, efficacious, and high quality patient care. The society is committed to advancing the science and practice of nutrition support therapy. In support of this direction, the A.S.P.E.N. Rhoads Research Foundation exists to fund research grants, promote evidence-based practice, and foster training and mentorship in nutrition and metabolic research. The scientific advances and technologic innovations that have enabled our profession to provide enteral and parenteral nutrition to patients has caused practitioners to forget that the meaning of food extends beyond nutrient value. Some individuals receiving long term enteral nutrition or home parenteral nutrition have expressed feelings of anger, anxiety, and depression resulting from the inability to eat normally, from losses of independence, and control of body functions. The ritual of eating may be altered when the enteral or intravenous feedings provide nourishment and, for some, the loss of the eating function is a distressing experience, especially given the cultural focus on social gatherings and meals. The emotional meaning attributed to food, and changes in food preferences and eating behaviors, may become a source of conflict for individuals who have substantial dietary restrictions, or for those individuals dependent on enteral or parenteral nutrition therapy. The value of food intake on social patterns, self-esteem, pleasure, and enjoyment, may impact quality of life. While nutrition support can provide the basic need for nutrients, its impact on human needs associated with food requires further investigation.     

Home artificial nutritional support: the value of the British Artificial Nutrition Survey

The British Artificial Nutrition Survey (BANS) was established in 1996 by the British Association for Enteral and Parenteral Nutrition to audit and research nutritional care in hospital and the community, with the overall aim of improving the quality of nutritional support in patients with disease-related malnutrition. In this article the following information emerging from BANS is presented: growth and prevalence of artificial nutrition (enteral tube feeding and parenteral nutrition), clinical outcome of a wide range of diagnoses receiving artificial nutrition in the community, an economic perspective on home artificial nutrition, and some ethical issues. This information is used to illustrate how BANS can be of value in a wide range of health care activities, including health planning, health economics, clinical practice and patient care.     

Home health care: A new worksite for dietitians monitoring nutrition support

Dietitians have been practicing in the home setting for many years. However, monitoring patients receiving home parenteral and enteral nutrition has been performed primarily on an outpatient basis by dietitians affiliated with hospital-based nutrition support teams. Changes in physician familiarity with these specialized therapies and expansion of the home infusion therapy industry have resulted in oppurtunities for dietitians to monitor nutrition support in a patient's home. This article describes the role of the home nutrition support dietitian, the work environment, and the training needed to prepare the practitioner for effective work in this field. Practical concerns of interest to the dietitian monitoring home nutrition support include equipment, resources, and communication tools. Home visits impart several benefits to dietetics practice by enriching the contact between patient and dietitian. A case study describes a dietitian's involvement in and potential cost-effectiveness of treatment of a patient whose parenteral nutrition therapy was initiated and completed without hospitalization. The home is emerging as a worksite for dietitians who monitor nutrition support. As providers of home infusion therapy continue to expand, widespread availability of dietitians' services for patients receiving parenteral and enteral support at home must be ensured.     

Prise en charge nutritionnelle à domicile des malades cancéreuxHome artificial nutrition in cancer patients

Cancer is the first indication for home artificial nutrition in France, with rising figures. Survival of cancer patients on home parenteral nutrition is lower than that of other patients on home parenteral nutrition, due to the evolution of the underlying disease, and cancer is also associated with lower survival figures in home enteral nutrition patients. More than half of cancer patients die within the first year of home artificial nutrition. Home artificial nutrition seems to improve health-related quality of life, and may improve life expectancy in some patients. It is prescribed in patients during treatment (supportive care) or with therapeutic sequels, the indications being comparable to those in the hospital setting. Home artificial nutrition as a palliative care is much more debated, as it has not proved to increase quality of life or survival. It should be banned for patients with a life expectancy lower than three months and a Karnofsky index lower than 50. There is no specific nutrition technique for cancer patients.     

胃癌术后肠内营养与肠外营养的护理分析

目的：探讨胃癌术后肠内营养与肠外营养的护理。方法：研究我院2014年3月至2015年12月期间随机抽取的胃癌术后患者80例,分为对照组与观察组各40例,其中对照组运用肠外营养支持护理,观察组运用肠内营养支持护理,分析两组患者营养支持护理效果差异。结果：在护理前后各蛋白指数上,观察组改善幅度高于对照组,p<0.05;在术后感染率显著并发症发生率上,观察组低于对照组,p<0.05;在肛门排气与住院时长上,观察组短于对照组,p<0.05。结论：胃癌术后通过肠内营养支持护理可以有效的提升患者恢复效果,加快术后恢复,减少术后并发症。     

Adaptations de la prise en charge des patients en nutrition artificielle à domicile au cours de l’épidémie virale COVID-19 en France : avis du Comité de nutrition à domicile de la Société Francophone de Nutrition Clinique et Métabolisme (SFNCM)

Home artificial nutrition, whether enteral or parenteral, is provided to chronic and fragile patients. The current COVID-19 epidemics may compromise their care at several levels: difficulties to access to hospitals mainly focused on treating COVID-19 patients, possible lack of nurses at home, strong reduction of visits by homecare providers, tended flow or lack of hand sanitizers, surgical masks and pumps. The aim of these recommendations put together by the French-speaking Society for Clinical Nutrition and Metabolism (SFNCM)’s Home Artificial Nutrition Committee is to define in terms of healthcare resources the minimum care to provide to these patients. We also aim to help cope with the possible tensions, in order to secure the care we must provide to home artificial nutrition patients during this crisis.     

肝切除患者围手术期营养支持的护理作用

目的 评述肝切除患者围手术期营养支持的护理作用.方法 146例接受肝切除手术的患者人院后进行营养风险筛查,术前给予肠内营养,术后进行肠外和肠内营养支持,围绕术后营养指标变化、临床部分结局指标,就诊治过程中的各种护理方法进行总结.结果 146例患者营养风险筛查评分≥3分者91例,＜3分者55例;接受肠外肠内营养支持者118例,平均肠内营养支持时间9.6 d,平均肠外营养支持时间5.4d;术后平均肛门排气时间(70.7±17.1)h;死亡3例,术后感染15例次,其他并发症13例,中位住院习25.5 d.结论 肝切除患者人院后应进行营养风险筛查,围手术期营养支持以肠内营养为主,术后需要联合肠外营养,强化护理作用是实施营养支持的保障.     

Le patient acteur dans le parcours de soin : à propos de l’assistance nutritionnelle en auto-soin

In severely malnourished patients, or in patients unable to meet their nutritional needs, the continuation of the nutritional support started in the hospital is often required after discharge. However, the management of an enteral or parenteral nutrition at home or in post-hospital facilities requires a specific training and its acceptance can be impaired by several hurdles. For these reasons, standardized therapeutic training programs involving successive steps are necessary. The management of the preparatory phase of home artificial nutrition is coordinated by a multidisciplinary hospital team in charge of (1) checking the feasibility and relevance of long-term nutrition support, (2) the placement of the device required for long-term enteral or parenteral feeding, (3) the education of the patient or his relatives for handling the connection and disconnection and (4) the coordination of the post-hospital follow-up.     

Aspects pratiques de la nutrition parentérale à domicile

For 20 years, the number of patients with home enteral or parenteral nutrition is increasing in France. The improvements in regulatory framework and logistic infrastructure allowed to care more patients at home without altering care quality. Education of patients and their relatives, a reliable relation with home care providers, based on a precise specifications, are essential to maintain quality of home artificial nutrition. The regional expert centres for home nutrition will have to have a major role of coordination, assessment, education of the various partners, under the aegis of the SFNEP.     

Éducation des familles et de l'enfant en nutrition artificielle à domicile

The techniques of artificial nutrition came of age since the seventies (1969 for enteral nutrition and 1973 for parenteral nutrition). Artificial nutrition has considerably modified the outcome of a great number of children with severe digestive tract pathologies or many other disorders making impossible or ineffective oral food administration. There are currently two techniques of artificial nutrition: enteral nutrition (the most physiological using the digestive tract) and parenteral nutrition (by central venous line, more demanding and more complications). Home parenteral and enteral nutrition emerged with new realities: increase in the number of children needing a nutritional assistance, increase in the number of indications and a constant need to make autonomous the child and the family leading to a better quality of life. The best care for these children needs a multidisciplinary approach (physicians, nurses, dieteticians, pharmacists, speech therapist, psychologists…) and a close relation between primary care and hospital. This also requires a significant investment of parents who are sometimes assisted by private nurses. Parents are thus educated with techniques of enteral nutrition and parenteral nutrition: use of the material, training with the care, learning the action to be taken in case of problem. They have thus a role of caregiver: heavy responsibility necessary to the return at home of their child. The educational role of the hospital team thus takes a paramount importance with the aim to provide an optimal home return and the most adequate care by the family.     

Effective contracting of high-tech health care for patients at home

High-technology treatments such as total parenteral nutrition or intravenous antibiotics may increasingly be provided to patients at home. In the past, these services have been funded by the NHS prescribing budget. The aim of the Department of Health's Executive letter EL(95)5, Purchasing High Tech Healthcare for Patients at Home was to ensure that contracts placed by health authority purchasers maintain effective patient services and obtain better value for money by encouraging competition between potential homecare providers. Examines contracting for high-tech health care for patients at home and suggests that efficiency could be improved when contracting with commercial home-care organizations by lead purchasing arrangements. In the long-term, contracting with NHS tertiary centres is most likely to ensure continuity of care and appropriate clinical monitoring of patients.