Nutrition des patients en insuffisance respiratoire aiguë

The nutritional guidelines in patients suffering from acute respiratory insufficiency are close to these recommended in the critically ill patients. But in acute respiratory failure, the constancy of an oxygen debt and the frequent high carbon dioxide levels, are particular elements to consider at the time of the choice of the nutrition support. Lipid emulsions used in parenteral nutrition have been associated with different pulmonary function changes. In general, caloric intakes should not exceed the total energy expenditure because of the risk of hypercapnia, mainly in patients with reduced ventilatory capacities, carbohydrates ensuring 65 to 70% of the energy. Parenteral fat emulsions, in particular those containing soybean oil, may induce pulmonary gas exchange disturbances in patients with underlying abnormalities of the ventilation-perfusion ratio, but only with fast infusion rates or if the amounts of linoleic acid are too high. Some pharmaconutrients, in particular glutamine, n-3 serie long chains polyunsaturated fatty acids (DHA and EPA), gamma-linoleic acid and trace elements, represent important ways of progress in the population of ARDS patients. By modulating pulmonary inflammation, immunity, bronchial reactivity and by improving the nutritional status, they open new and promising prospects in the prevention and the treatment of ARDS, whose prognosis remains poor.     

Prevalence and Contents of Advance Directives in Patients Receiving Home Parenteral Nutrition

Background: Ethical issues may arise with patients who receive home parenteral nutrition (HPN) and have a change in their overall health status. We sought to determine the extent of advance care planning and the use of advance directives (ADs) by patients receiving HPN. Materials and Methods: Retrospective review of the medical records of adult patients newly started on HPN at the Mayo Clinic, Rochester, Minnesota, between January 1, 2003, and December 31, 2012, to determine the prevalence and contents of their ADs. Results: A total of 537 patients met the inclusion criteria. Mean (SD) age at commencement of HPN was 52.8 (15.2) years, and 39% (n = 210) were men. Overall, 159 patients (30%) had ADs. Many mentioned specific life‐prolonging treatments: cardiopulmonary resuscitation (44 [28%]), mechanical ventilation (43 [27%]), and hemodialysis (19 [12%]). Almost half mentioned pain control (78 [49%]), comfort measures (65 [41%]), and end‐of‐life management of HPN (76 [48%]). Many also contained general statements about end‐of‐life care (no “heroic measures”). The proportion specifically addressing end‐of‐life management of HPN (48%) was much higher than that previously reported in other populations with other life‐supporting care such as cardiac devices. The primary diagnosis or the indication for HPN was not correlated with whether or not the patient had an AD (P = .07 and .46, respectively). Conclusion: Although almost one‐third of the patients had an AD, less than half specifically mentioned HPN in it, which suggests that such patients should be encouraged to execute an AD that specifically addresses end‐of‐life management of HPN.     

Réhabilitation respiratoire et prise en charge nutritionnelle dans la bronchopneumopathie chronique obstructive

Pulmonary rehabilitation is an effective therapeutic approach in chronic obstructive pulmonary disease (COPD) in term of improvement of the quality of life, dyspnea and exercice performance. It also has economical implications by reducing exacerbations, the number and the duration of the hospitalizations. Pulmonary rehabilitation is currently recommended among COPD patients presenting dyspnea, an impaired exercice performance or a reduction in their daily activity in connection with their disease inspite of an optimal treatment based on nicotinic weaning, bronchodilatators, and prevention of the infections. Pulmonary rehabilitation program may include cycle ergometry and inspiratory muscle training associated with an educational program concerning the disease and the nutritional aspects. It is recommended to carry out a precise nutritional evaluation comprising in addition to the recent weight history, a body mass index measurement (BMI) and a fat-free mass determination by impedancemetry if the BMI is between 21 and 26 kg/m². Smoking cessation, treatment of the bronchial infection and fractionned hypercaloric dietary intake are recommanded during the rehabilitation program. An oral supplementation near to 500 kcal/j, privileging the carbohydrates, is proposed in COPD patients during the rehabilitation program in case of BMI < 21 kg/m². In the litterature, this oral supplementation associated with the rehabilitation is likely to improve the outcome of training and the pronostic of the disease. In combinaison with the exercice training, anabolic steroids may have positive effects on body weight and fat-free mass by improvements in inspiratory muscle strength or exercice capacity. Nevertheless, further research is needed to confirm the effects of this anabolic intervention in term of efficacity and safety.     

Évaluation de l’état nutritionnel péri-opératoire

In surgical patients, malnutrition is associated with an increase in morbidity, mortality, length of stay and health care costs, and has an impact on quality of life. Before surgery, the risk of malnutrition is depending on patient-related factors (age, associated diseases, on-going symptoms, duration of pre-operative hospital stay), surgical procedure, and medical treatment (radiotherapy, chemotherapy, corticoid treatment). The early screening and management of malnutrition are mandatory during the peri-operative period, with the aim to improve post-operative prognosis and clinical outcome. The nutritional assessment is based on the research of weight loss, the calculation of body mass index and the research of an hypoalbuminemia, all of them having a negative impact on postoperative prognosis. The Nutritional Risk Index (NRI) is also of strong prognostic value. We propose a stratification of the nutritional risk indicating several levels of surgical risk. The organization, the planning and the traceability in the medical record of the nutritional assessment should allow optimizing the management and the clinical outcome of surgical patients. The pre-operative consultation of anaesthesia could be the privileged time to perform the screening of malnutrition and to plan its management, if they were not previously performed by the medico-surgical team.     

Métabolisme des nutriments au cours de l'insuffisance respiratoire chronique

The effect of oxygen in modulating metabolism has been largely investigated in vitro and in animal studies, but very little in humans. This paper focuses on recent literature regarding pathological and physiological situations characterized by chronic exposure to hypoxia, particularly in patients with chronic respiratory insufficiency and in healthy subjects staying at high altitude. The latest allow for very interesting comparison because they do not experience comorbidities observed in patients with chronic respiratory insufficiency and therefore provide a unique model to assess the specific effect of hypoxia on human body and metabolism.     

The Association Between Home Parenteral Nutrition and Patients With FAP‐Associated Intra‐Abdominal Desmoids

Background: Intra‐abdominal desmoid tumors (IADTs) are a common complication of familial adenomatous polyposis (FAP). Treatment is not standardized for advanced disease. Medical and surgical treatments may be ineffective in preventing complications, which can cause intestinal failure. Home parenteral nutrition (HPN) can be a life‐saving treatment in these patients. The aim of this study was to investigate the association with HPN in FAP‐IADTs. Methods: A retrospective review of FAP patients with IADTs at the Cleveland Clinic (CC) between 1980 and 2009 was performed. Patients and tumor characteristics were retrieved from the CC Jagelman Registry for Inherited Neoplasms and CC HPN database. Inclusion criteria were FAP‐IADTs and 6‐month follow up at CC. Exclusion criteria were <6‐month follow‐up, lack of 3‐dimensional lesion or sheet desmoid, and/or incomplete medical records. Kaplan‐Meier curves were analyzed for HPN and non‐HPN groups. Results: One hundred fifty‐four patients were included and divided into 2 groups: HPN (n = 41, 26.6%) and non‐HPN (n = 113, 73.4%). The HPN group was more likely to have advanced‐stage disease and significantly higher incidence of chronic abdominal pain, narcotic dependency, bowel obstruction, ureteral obstruction, deep vein thrombosis, pulmonary embolism, fistulae, and sepsis (P < .05). The need for HPN represented a strong predictor of mortality (5‐year survival HPN = 72% vs non‐HPN = 95%), but duration of HPN did not affect mortality. Conclusion: HPN, although a life‐saving treatment, is an independent poor prognostic factor associated with high morbidity and mortality.     

Psychosocial complaints are associated with venous access-device related complications in patients on home parenteral nutrition

Background: Complications related to venous access devices (VADs) remain the major drawback of home parenteral nutrition (HPN) support. In addition to technical issues, patients also experience psychosocial problems. The aim of this study is to present an overview of VAD‐related complications in patients on long‐term HPN and to assess whether these adversities are related to experienced psychosocial problems and quality of life (QOL). Methods: Information on VAD‐related complications was collected from the medical charts of 110 adult HPN patients who were followed by the 2 major referral centers in the Netherlands. In addition, a survey was conducted in this group to characterize psychosocial problems and assess their association with technique‐related complications; 75 patients (68%) responded. Results: At the time of survey, the majority of patients (76%) had developed 1 or more episodes of catheter‐related sepsis at some point during their HPN treatment. The overall incidence of VAD‐related blood stream infections (BSIs) was 3 per 1,000 venous access days. The incidence of VAD occlusions was 0.8 per 1,000 venous access days. During the observation period, there was a highly significant association between the incidence of VAD‐related complications and the occurrence of psychosocial complaints (eg, depression, fatigue, social impairment, and decreased QOL). Conclusions: Psychosocial complaints are associated with previously experienced VAD‐related complications in patients on HPN therapy. Although only an association, and not a causal relationship is demonstrated by these findings, our results underscore the need for preventive and therapeutic measures regarding both types of problems in these patients.     

National clinical guidelines and home parenteral nutrition

Research-based guidelines provide the best evidence and are the cornerstones of achieving quality outcomes for home parenteral nutrition (HPN) patients and their families. However, evidence about the implementation of HPN guideline recommendations is rarely reported. The purpose of this clinical practice project was to compare HPN clinical guidelines with baseline data reported by HPN patients from 1990-2010 and to explore possible facilitators or barriers to the implementation of guidelines in clinical practice. Methods included PubMed literature searches for HPN clinical guidelines and comparison of the retrieved guidelines with HPN clinical data reported by HPN patients from 3 separate studies conducted in the United States from 1990-2010. Results of reviewing published HPN guidelines found recommendations based primarily on expert opinion and included the appropriate use of HPN, coordination of care by teams of experts, use of dedicated ports, salvaging catheters when possible, and bowel transplantation. Comparison of baseline data over the 2 decades indicated that guidelines for the appropriate use and types of central venous catheters were being implemented, but there was little evidence that most HPN patients had their care coordinated by multidisciplinary teams. Conclusions are that most HPN guideline recommendations were being implemented in practice except for the care delivered by multidisciplinary experts. To ensure quality HPN outcomes, multidisciplinary teams of HPN experts are needed as are large data sets that will provide indicators of guideline use and outcomes. Furthermore, research is needed so that recommendations are not based totally on expert consensus.     

Telehealth videoconferencing: improving home parenteral nutrition patient care to rural areas of Ontario, Canada

BACKGROUND: Telehealth videoconferencing is a medium for health care professionals to communicate and care for patients living in remote areas. The aim of this study was to provide a survey to examine management outcome of home parenteral nutrition (HPN) patients when followed by telehealth as an alternative modality of care. METHODS: Twenty-six individuals who were identified to benefit from tele-health were invited to participate in a satisfaction survey. The survey was sent to patients by postal mail. The survey also documented the incidence of line sepsis and other medical HPN complications. A cost analysis was also performed according to technology, human resources, and infrastructure. RESULTS: Eighty-one telehealth videoconference sessions have been held since the inception of telehealth in 2002. Of the current telehealth patients, 13 were eligible for the survey. The satisfaction survey response rate was 11/13 (84.6%). The average line sepsis rate for the 13 patients was 0.89/1000 catheter-days. All patients were generally satisfied with videoconferencing as an alternative method of communication and care for new consultation, patient and family education, and follow-up. Travel time and costs to the patients, their families, and the health care system were significantly less. For example, a patient who resides 611 km from Toronto would cost CDN (Canadian) 724.00 dollars for flight and accommodation to meet with the team at the HPN clinic in Toronto. Conclusion: Telehealth incorporated the cost-saving ability for HPN patients to maintain proper medical care, support, and collaboration of specialists inaccessible to their local community. Thus, its strongly positive role in HPN care deserves further consideration for a national application.     

AuSPEN clinical practice guideline for home parenteral nutrition patients in Australia and New Zealand

OBJECTIVE: Evidence based guidelines for home parenteral nutrition (HPN) were commissioned by the Australasian Society of Parenteral and Enteral Nutrition (AuSPEN) and developed by a multidisciplinary group. The guidelines make recommendations in four domains: patient selection, patient training, formulation and monitoring regimens, and preventing and managing complications. METHODS: The Appraisal of Guidelines Research and Evaluation guideline process was used to focus questions and identify evidence by systematic literature reviews of meta-analyses and randomized control trials in the Cochrane Library, Medline, Embase, and Cinahl to mid-2007. Where no randomized control trial evidence was found, the search was broadened to observational studies and expert opinion from related national and international guidelines as assessed by a validated appraisal process. RESULTS: Selection of patients must assess individual risk/benefit and medical ethics. Patient training should be undertaken within a structured framework. Access devices should be selected for lowest risk of complications, including occlusion, sepsis, and breakage and be managed by early diagnosis and treatment. HPN should be formulated according to individual patient requirements by professionals with relevant skills and training. Pumps and ancillary products should conform to quality standards. Other intravenous medications may be prescribed provided these are reviewed for compatibility and effects on metabolic status. CONCLUSION: Overall there is a lack of randomized control trials to provide high-quality evidence-based guidance but graded recommendations can be made. Multidisciplinary teams in centers with HPN management expertise are required for optimal care. This guideline should improve outcomes and quality of life for HPN patients in Australia and New Zealand.     

Home parenteral nutrition: effect of patients' lifestyle

The effect of home parenteral nutrition (HPN) on the lifestyle and employment of 30 patients was assessed by a standard questionnaire. Details of the parenteral nutrition and infusion routines, general health, involvement in treatment and the role of the HPN clinic were also investigated. HPN was found to have a major effect on employment prospects and leisure activities. All patients wanted to know more about their nutritional requirements, their assessment and their needs.     

Options available for the infusion of lipid emulsion in home parenteral nutrition (HPN): a questionnaire survey for hospitals in Japan where HPN is practiced

OBJECTIVE: To understand the status of total parenteral nutritional (TPN) composition and the TPN line used for home parenteral nutrition (HPN) in Japan and to investigate how adequate nutritional support should be in HPN, we conducted a questionnaire survey. METHODS: From February to March 2004, questionnaires were sent by mail to the members of the Japan Society for Home Therapy Research. With the content of the questionnaire, we surveyed 1) the types of medical staff who are involved in HPN, 2) the status of the preparation of TPN fluid and its place of preparation, 3) use of the TPN line and final filter, and 4) administration of lipid emulsion and All-in-One. RESULTS: The major survey results from 66 respondents were that the 50% of the medical staff who are involved in HPN have more than 10 y of experience; however, the number of patients who used HPN and were treated by 78% of the medical staff was fewer than 50. With regard to TPN fluid, 50% was prepared in-house and 12% was prepared by home care service providers. In addition, 58% of institutions were infusing lipid emulsion from the side port of the TPN line or through a peripheral route because they used a final filter and closed system infusion line. CONCLUSIONS: Because the final filter and closed system infusion line for HPN management is standard practice, lipid emulsion is not adequately used in Japan. Therefore, the All-in-One system including lipid emulsion is not used.     

内蒙古某三甲医院临床试验医疗器械使用安全现状分析

目的 了解临床试验医疗器械使用安全现状,分析其影响因素,提出建议,为提高临床试验医疗器械管理水平提供参考。方法 收集内蒙古某三甲医院2018年1月1日-2021年12月31日上报的31项医疗器械临床试验项目中与患者安全相关的186份研究报告,对相关数据进行描述性分析。结果 不良事件报告占28.5%,严重不良事件报告占47.8%,器械缺陷报告占0.6%,方案偏离报告占23.1%;患者主要年龄段为>50岁～70岁(57.0%);心内科项目数量占比(51.6%)和报告数量占比(50.5%)均最大;患者安全事件与试验器械有关的报告有52份(28.0%);有合并症和并发症的患者有119人(63.9%)。结论 临床试验医疗器械使用安全与器械本身、研究者能力、方案执行程度、患者自身等因素有关。应加强临床试验项目质量管理医疗器械规范化管理、使用安全管理以及患者自身管理。     

Évaluation de l'état nutritionnel du patient BPCO

Chronic obstructive pulmonary disease (COPD) is associated with a high prevalence of malnutrition. Malnutrition is a predictive factor of overall mortality in COPD, independently of respiratory function. Although a low body mass index is associated with a high mortality rate, population-based studies have shown that the strongest predictive factor of survival in COPD was the fat-free mass. The determination of body composition therefore constitutes a pivotal step in the clinical assessment of COPD patients. Single-frequency bioelectrical impedance analysis appears to be the most convenient tool for the assessment of body composition, because it is an easy, inexpensive, and highly reproducible method. Nevertheless it has been suggested that dual energy X-ray absorptiometry (DEXA) and computed tomography could be useful methods for the assessment of muscle mass in COPD. Despite the associated pitfalls, determination of weight, body mass index and anthropometric measurements remain essential parameters of nutritional assessment of patients with COPD.     

Assessing risk by analogy: a case study of us medical device risk management policy

Medical devices occupy an increasingly important place in global medical care, and yet the risk management systems that govern them are largely overlooked in academic literatures. In the US, home to the largest medical devices market, Food and Drug Administration (FDA) regulation allows most medical devices to enter the market based on analogy, or substantial equivalence, with previously marketed devices. Thus, risk assessment is administered without premarket clinical trials for safety and efficacy. This system represents a permissive regulatory regime based in neoliberal tenets, where risk, in the form of adverse events, is inherently tolerated within governance structures, evidencing risk colonisation. This paper employs a case study approach, examining market clearances of vaginal mesh surgical devices, which have been the subject of US multi-district litigation. We identified 266 devices cleared before 31 December 2017 and analysed the complicated web of device ‘ancestry’ whereby devices as disparate as cardiac patches and hernia mesh allowed clearance of surgical devices for urogynecology. Perhaps of greatest concern, 10 recalled or withdrawn devices influenced new device clearances for up to 17 years after their market-removal. While the FDA must balance its dual mandate to safeguard patients and promote innovation, we find that medical device regulation structurally favours innovation over safety. ‘Light touch’ risk assessment is not counterbalanced with postmarket mechanisms to safeguard against residual and developmental risks that are associated with medical devices, particularly permanent implants. The proportionality principle associated with a precautionary approach should inform medical device risk management.     

Central venous access in the home parenteral nutrition population-you PICC

BACKGROUND: Central venous access is imperative for the delivery of home parenteral nutrition (HPN). Peripherally inserted central catheters (PICC) are being used more frequently for the delivery of HPN. There is an abundance of short-term information on the use of PICC in the hospitalized patient. However, there are no data comparing the use of PICC to other central venous access devices (OCVAD; Hickman, port) for the delivery of HPN. Catheter-related infections (CRI) are the most common cause of hospital readmission for the HPN patients. METHODS: A retrospective analysis was performed from the Digestive Disease Center HPN database at the Medical University of South Carolina and the open architecture clinical information system (OACIS) hospital and clinic reporting system. All CRI were analyzed and compared between patients with PICC and OCVAD. The PICC group and the OCVAD group were further broken down into diabetic patients and nondiabetic patients, and the incidence of CRI was compared within those groups. RESULTS: HPN patients with PICC had a statistically significant increase (p < .01) of CRI as compared with OCVAD within our HPN patients. There was no statistically significant increase in CRI between diabetic and nondiabetic patients. CONCLUSIONS: The use of PICC for HPN may be associated with an increase in CRI. A prospective, randomized trial in the HPN population between PICC and OCVAD must be performed.     

Catheter Salvage After Catheter‐Related Bloodstream Infection During Home Parenteral Nutrition

Background: Catheter‐related bloodstream infection (CRBSI) is a common complication in patients receiving home parenteral nutrition (HPN). Data regarding catheter salvage after a CRBSI episode are limited. We aimed to determine the incidence of CRBSI and rates of catheter salvage in adult patients receiving HPN. Materials and Methods: We retrospectively searched our prospectively maintained HPN database for the records of all adult patients receiving HPN from January 1, 1990, to December 31, 2013, at our tertiary referral center. Data abstracted from the medical records included demographics, diseases, treatments, and outcomes. The incidence of CRBSI and rates of catheter salvage were determined. Results: Of 1040 patients identified, 620 (59.6%) were men. The median total duration on HPN was 124.5 days (interquartile range, 49.0–345.5 days). Mean (SD) age at HPN initiation was 53.3 (15.3) years. During the study period, 465 CRBSIs developed in 187 patients (18%). The rate of CRBSI was 0.64/1000 catheter days. Overall, 70% of catheters were salvaged (retained despite CRBSI) during the study period: 78% of infections with coagulase‐negative staphylococci, 87% with methicillin‐sensitive Staphylococcus aureus, and 27% with methicillin‐resistant S aureus. The percentage of catheters salvaged was 63% from 1990 to 1994, 63% from 1995 to 1999, 61% from 2000 to 2004, 72% from 2005 to 2009, and 76% from 2010 to 2013. Conclusion: Catheter salvage is possible after a CRBSI episode. Since most episodes of CRBSI are caused by skin commensals, effective treatment without removal of the central venous catheter is possible in most cases.