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Nutrition Therapy in the Adult Hospitalized Patient
Overview of enteral and parenteral feeding access techniques: How should adequacy and tolerance of EN be assessed in the hospitalized patient? Incidence of nutritional risk and causes of inadequate nutritional care in hospitals. Volume-based feeding in the critically ill patient. Caloric requirements in total parenteral nutrition. Confirmatory factor analyses on the appetite questionnaires were conducted to probe fitting to the model. However, respondents are often limited to their working memory:

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WIC determines income based on gross income. WIC counts all of the members of a household, related or unrelated. WIC counts an unborn baby as a household member. Be at nutritional risk. WIC clients receive an initial health and diet screening at a WIC clinic to determine nutritional risk.

WIC uses two main categories of nutritional risk: Clients will be counseled at WIC about these risks and the outcome influenced by nutrition education and nutritious foods provided by WIC. WIC clients usually receive services in the county where they live. Clients must apply in person except in certain limited cases. Are you a pregnant woman, breastfeeding a baby less than one year of age, a postpartum woman one who had a baby within the last six months , or have an infant or a child who is less than 5 years old?

Call or go by the clinic to make an appointment for a pregnant woman, breastfeeding woman, postpartum woman, infant, or child less than 5 years of age. At the time of your appointment, bring documentation of your household's source of income or wages.

This applies to all members of the household. Some examples of documentation include a paycheck stub, a current tax return, a letter from an employer, a Social Security check, a child-support check, or self-employed accounting records.

Applicants and certain family members who receive Medicaid, Temporary Assistance to Needy Families, or SNAP automatically meet income eligibility by bringing acceptable proof of their participation in one of these programs—they do not have to bring other income documents. At the time of your appointment, bring documentation of where you live with your current physical address, such as a utility or credit-card bill, rent receipt, or business letter.

At the time of your appointment, bring one document of identification for each person applying for WIC benefits and the adult responsible for the benefits. Examples of acceptable identification documents are a birth certificate, a driver's license, an immunization card, an employee or school identification card with picture, a Social Security card, or hospital records.

During the appointment the applicant will undergo a simple health screen including height and weight measurement, a finger stick to screen for low iron, a medical and health history and a diet recall and history to determine nutritional risk. At the end of his or her appointment, an applicant will receive counseling and referral to appropriate health and human services, if applicable.

WIC Program eligibility will also be determined. Food benefits will be provided to those eligible. They also learn from you. As they learn, they may also be at risk for an injury. This site is designed to guide you through the many ways to create a safer home for your child months of age. Learn about your child's risks for injuries and tips on how to prevent them. Sign-up here to receive regular free safety tips right to your inbox!

This is an easy way to learn how to prevent your child from being injured and allow your child to have fun while being safe. When your child is playing, look for places they can explore, what they can reach and what they can get into that may hurt them. Think about how they can fall, be burned or poisoned. Many conditions that were previously considered to be contraindications to enteral feeding may be situations where it is appropriate to provide EN with caution in order to improve outcome.

Such conditions include ileus, open abdomen, recent gut anastomoses, GI bleeding, bowel-wall edema, and a stable patient on vasopressor therapy to maintain adequate mean arterial blood pressure How should the hospitalized patient be assessed prior to initiation of specialized nutrition therapy, and how are energy and protein requirements determined?

Previous nutritional assessment tools have tended to focus only on evaluation of nutritional status. These assessment tools, although appropriate for a non-ICU patient, have not been validated for use in critical care and the ICU setting.

They also fail to recognize the importance of disease severity and the contribution of inflammation and oxidative stress in causing deterioration of nutritional status and alteration in utilization of feeding substrates The concept of nutritional risk, however, incorporates both nutritional status and disease severity, as both contribute to poor outcome and the need for nutrition therapy.

Nutritional risk is more easily defined than malnutrition, as objective parameters are used to determine both components of risk. Patients with high nutritional risk NUTRIC scores 6—10 showed a significant decrease in mortality the closer the receipt volume of nutrition therapy was to goal feeding. In those patients at low nutritional risk NUTRIC scores 0—5 , there was no association between the amount of nutrition therapy received and mortality. Additional assessment prior to initiation of nutrition therapy should include an evaluation of comorbid conditions, function of the GI tract, and risk of aspiration.

Serum albumin, pre-albumin, and transferrin should not be used as markers of nutritional status but instead should be considered surrogate markers of risk and level of inflammation Serum albumin levels alone at the time of admission may provide valuable prognostic information prior to a surgical procedure Neither albumin nor pre-albumin should be used as a marker for adequacy of nutrition therapy, as their levels will only rise once the inflammation and degree of oxidative stress abates.

C-reactive protein alone or in combination with pre-albumin may provide some useful information to the clinician with regard to changes in the level of inflammation and resolution of the systemic inflammatory response syndrome.

Aside from basic measures of height, weight, and BMI, anthropometric measures such as mid-arm muscle circumference, creatinine-height index, and skin fold thickness are inaccurate, poorly reproducible, and provide little accurate information with regard to overall nutritional status for the hospitalized patient For clinicians, IC is the gold standard, as results correlate well with direct whole-chamber calorimetry If IC is not available or easily accessible, a weight-based equation e.

Furthermore, a number of predictive equations e. Equations derived from measurements on hospitalized patients Ireton—Jones, American College of Chest Physicians, Penn State, Swinamer are no more accurate than equations derived in research labs by measuring ambulatory healthy volunteers Harris—Benedict, Mifflin-St Jeor These predictive equations should be used with caution, with an understanding of the potential errors in estimates for specific groups such as patients with extreme obesity In the past, providing 1.

Protein needs may be even higher in patients with trauma or large wounds Besides the weight-based equation above, protein requirements may be determined by calculating the nitrogen balance using a h urine collection to measure urine urea nitrogen UUN with the following calculation: How should enteral access be achieved, and at what level of the GI tract should EN be infused? Gastric feeding is successful in the vast majority of patients requiring nasoenteric feeding in the hospital Greater disease severity, however, is associated with a worsening degree of ileus and GI dysmotility, and, in those circumstances, there may be more of a need for small bowel feeding Radiologic confirmation of placement of a nasoenteric or an oroenteric tube in the stomach or small bowel is required Alternative methods to confirm the location of the tube tip in the GI tract below the diaphragm, such as auscultation, detection of CO 2 , and measurement of pH are not accurate enough to confirm placement New optical guidance feeding tubes have recently been approved by the Federal Drug Administration but will require further validation studies before radiologic confirmation can be avoided The incidence of reflux, regurgitation, and aspiration all decrease significantly as the level of infusion of formula is diverted lower in the GI tract, from the stomach to the proximal jejunum A meta-analysis of 12 RCTs showed a reduction in ventilator-associated pneumonia with small bowel compared with gastric feeding; yet, duration of mechanical ventilation, hospital length of stay, and mortality did not change These findings suggest that the appearance of an infiltrate on chest X-ray in a patient on enteral tube feeding may have minimal consequences.

Placement of a feeding tube in the small bowel requires greater expertise, which may lead to delays in initiation of feeding For these reasons, it is best to start with gastric feeds, take additional steps to promote tolerance, and to monitor closely while awaiting expertise for small bowel placement if subsequently required. Long-term jejunal access is best achieved by the use of a jejunostomy tube placed endoscopically, radiologically, or surgically, depending upon available expertise.

Because of frequent displacement of the jejunal extension tube back into the stomach with a GJ device, this is generally not a good long-term option. Recent changes in the design of tubes such as the use of a stiffer double pigtail catheter with a spring in the jejunal portion of the tube , however, seem to result in less displacement. Given the greater ease of placement compared with a direct jejunostomy, reconsideration of the use of such GJ tubes may be warranted.

If the duration of provision of EN is anticipated to exceed 4 weeks, then a percutaneous enteral access device is generally indicated. The 4-week cutoff, although arbitrary, is based on the potential morbidity of a nasoenteric tube, which includes erosion of the nares, an increase in aspiration pneumonia, sinusitis, and esophageal ulceration or stricture Certain institutional practices may dictate early placement of a tracheostomy and percutaneous gastrostomy tube in trauma patients.

Early gastrostomy tube placement in stroke patients may be needed to facilitate transfer to a rehabilitation center.

Placement prior to this time point has been shown to extend survival of the amyotrophic lateral sclerosis patient Most importantly, if the patient demonstrates intolerance and evidence of gastroparesis in the days following gastrostomy tube placement, the access device is better positioned to be converted to a GJ tube Reluctance to positioning percutaneous gastrostomy tubes in the gastric antrum in the past related, in part, to concern for interference with the antral grinding mechanism, bleeding from passage through the falciform ligament, and potential obstruction of the pylorus.

Extensive clinical experience does not support any of these concerns. When feasible, we suggest that all percutaneous gastrostomy tubes be placed to the right of the midline, close to the level of the umbilicus.

A variety of measures can help secure the enteral access device at the time of placement A nasal bridle fashioned from a 5-French neonatal feeding tube or a commercial device with magnetic-tipped flexible rods and surgical ribbon may be used to secure a nasoenteric tube placed through the nose. A recent meta-analysis showed that the use of a nasal bridle nearly eliminates displacement Although an abdominal binder is helpful in protecting the percutaneous gastrostomy tube, it should be loose enough to avoid crushing the access device and positioned with support at the level of the skin to prevent excess side torsion to the gastrostomy tract Ultimately, whenever possible, the reason s for inadvertent removal of the tube e.

How soon, at what dose, and with which formula should enteral nutrition be initiated in the hospitalized patient? The timing of initiation of EN in the hospitalized patient especially critically ill patients in an ICU setting is based on two categories of studies in the literature, early vs. In meta-analyses by Marik and Doig comparing early vs. Tolerance determines how quickly and how aggressively to increase EN delivery. Trophic feeding may not be appropriate in patients who are at extremes of age, BMI, or disease severity Such a regimen should maintain lean body mass while depleting the fat mass, with no increase in adverse outcomes Such a regimen was shown to be associated with significant reductions in infection and hospital LOS compared with full caloric feeding Indications for use of specialized formulae are limited, and their use should be reserved for certain subsets of hospitalized patient populations.

The vast majority of hospitalized patients requiring EN will tolerate a standard polymeric formula with or without fiber. Pre-operative patients awaiting major elective surgery and critically ill patients admitted to a surgical ICU may benefit from an arginine-containing immune-modulating formula also containing fish oil, glutamine, and antioxidants.

How should adequacy and tolerance of EN be assessed in the hospitalized patient? Patients on EN should be monitored daily by physical exam to detect the presence of bowel sounds, passage of stool and gas, abdominal distention, and volume status Caloric and protein target goals should be clearly identified and intake and output should be followed to determine the percent of goal calories delivered. Increased delivery of calories to reduce the deficit is associated with improved outcome.

Such patients should be monitored closely for up to 5 days for electrolyte abnormalities hypokalemia, hypophosphatemia, and hypomagnesemia , and volume status after feeding is initiated It is not clear whether risk of refeeding syndrome is more common with EN or PN The use of feeding protocols with nursing directives is an important strategy for improving the timeliness, adequacy, and safety of delivering EN Important elements of nurse-driven protocols include the use of universal EN connectors, monitoring by focused physical exam, consideration of fluid volumes, management of GRVs, rates for advancement of EN based on tolerance, and measures to reduce risk of aspiration.

A volume-based feeding strategy identifies the volume to be delivered over a 24 h period and empowers the nurse to increase the rate to make up for interruptions in delivery A multi-strategy top-down protocol has been described for use in critically ill patients based on the presumption that these patients are at increased risk of feeding intolerance and that multiple strategies can be used with the initiation of EN to promote better tolerance including the use of volume-based feeding, elevation of the head of the bed, chlorhexidine mouth washes, small bowel feeding, and the use of prokinetic medications Multiple strategies are utilized together with the initiation of EN and then individually removed as tolerance is achieved.

Furthermore, the practice of checking GRV is not well standardized, the values are difficult to interpret, and expense involved with allocation of health-care resources nursing time is substantial The use of GRVs as a monitor increases the likelihood of tube clogging tenfold Lowering the cutoff value does not protect the patient from aspiration but instead simply turns off the delivery of EN.

Bundling individual strategies may be more effective in changing outcome Differences in definition mostly account for the wide range of incidence. Much of what is referred to as diarrhea in hospitalized patients on EN actually represents low-volume fecal incontinence. Although most cases are mild and self-limited, diarrhea in the hospitalized patient on EN may result in electrolyte imbalance, dehydration, perianal skin breakdown, and wound contamination Although factors associated with the formula e.

There is abundant data to recommend stopping prokinetics in individuals who develop non- C. When an underlying cause cannot be identified and diarrhea persists, the addition of a fermentable soluble fiber supplement e. The prebiotic effect of the soluble fiber helps foster a more balanced and biodiverse gut microbiome How should complications of enteral feeding in the hospitalized patient be assessed and treated? Daily cleaning with mild soap and water is important to avoid the drying desiccating effects on the skin from hydrogen peroxide or scented alcohol-based soaps For the first 4 days following tube placement, the external bolster, if present, should be positioned up against the anterior wall with a single layer of gauze underneath against the skin.

If unsuccessful, a nonenteric-coated pancreatic enzyme tablet e. Use of a carbonated soft drink is an acceptable alternative, but the use of papain meat tenderizer should be avoided If still not corrected, a small-bore tube such as an ERCP catheter may be placed down through the feeding tube to the level of the clot and flushing attempts repeated.

If still unsuccessful, before replacing the tube, mechanical de-clogging with a commercial corkscrew de-clogging device, a cytology brush, or a wire stylet should be considered albeit used with caution to prevent penetration of the sidewall of the tube and puncture of the intestinal wall Deterioration, breakdown, and increased drainage at the percutaneous access site should be evaluated carefully to rule out buried bumper syndrome, side torsion on the tract, absence of an external bolster, granulation tissue, or a tube site infection Hypergranulation tissue at the stomal-site should be treated with a topical high potency steroid ointment e.

We suggest treating tube site infections empirically using a broad-spectrum antibiotic administered either orally or through the tube rarely is a parenteral antibiotic needed Because of the high risk of contamination with skin organisms, culture of the tract or tissue is not recommended in routine situations. Although most stomal-site infections are minor, severe infections including necrotizing fasciitis can occur and require rapid recognition to optimize management.

Rarely does the tube need to be removed. For the patient with increased leakage to the point of severe skin injury, we suggest high-dose acid suppression, diverting the level of infusion of formula lower in the GI tract, simultaneous jejunal feeding with gastric aspiration, and involvement of a wound-care expert Occasionally, the tube will need to be removed and the tract allowed to close prior to placing a new tube in the same or different location.

When and how should PN be utilized in the hospitalized patient? The clinical benefit of PN in hospitalized patients other than those with PN-dependent intestinal failure, such as short bowel syndrome, chronic intestinal pseudo-obstruction, high-output enterocutaneous fistula has been difficult to demonstrate.

Three recent trials looked at the use of exclusive PN in the hospitalized patient. The Early Parenteral Nutrition in Insufficient Enteral Feeding EPaNIC trial showed that early provision of PN on the third day of hospitalization in a subset of patients in which there was a contraindication to enteral feeding because bowel was in discontinuity led to an increase in infectious morbidity and a reduced likelihood of being discharged alive from the ICU compared with controls in which PN was started on the eighth day The patients randomized to early PN showed only a 0.

All other outcome parameters ranging from infection and organ failure to hospital length of stay and mortality were no different between the two groups. In a multi-centered ICU trial of nearly 2, patients comparing EN with exclusive PN, there was no difference between the groups in clinical outcome In a well-nourished patient, particularly in the first week of hospitalization, the use of PN appears to provide no benefit over standard therapy and may actually cause net harm 4.

At some point in the patient at low nutritional risk, failure to provide nutrition therapy will lead to deterioration of nutritional status and adverse outcome.

In an older study, Sandstrom showed increased mortality and hospital length of stay if standard therapy was continued beyond the first 2 weeks of hospitalization compared with receipt of PN Most societal recommendations indicate a reluctance to extend standard therapy beyond the first week of hospitalization, suggesting instead initiating PN in the patient at low nutritional risk beginning the second week of hospitalization In the patient at high nutritional risk with increased disease severity and evidence for deterioration of nutritional status, priorities of therapy change.

If EN is not feasible, PN is more likely to benefit these patients than standard therapy. Thus, in patients with high nutritional risk for whom EN is not feasible, PN should be initiated as soon as possible following admission. In patients with a diagnosis indicating PN dependence short bowel syndrome, chronic intestinal pseudo-obstruction , PN should be initiated immediately after admission unless there is evidence for ongoing bacteremia.

The addition of supplemental PN during the first week of therapy to patients already receiving EN, where the enteral feeding is not meeting caloric goals, appears to provide little benefit and may cause net harm Results showed that for study patients, PN added on the third day of hospitalization was associated with worse outcome with respect to virtually every clinical parameter except mortality compared with controls where PN was added beginning on the eighth day Specifically, significant increases in infection, organ failure, hospital and ICU length of stay, cost, and likelihood of being discharged alive were all worse with receipt of early supplemental PN Such strategy may result in some weight loss, but leads to better insulin sensitivity, avoids the effects of overfeeding, and may improve outcome.

In a meta-analysis of five RCTs involving patients with trauma, pancreatitis, and major abdominal surgery, the use of hypocaloric PN was associated with reduced infection and hospital length of stay compared with PN provided at goal feeds 20 vs. As a result, the use of PPN is associated with increased use of IV lipid emulsions to decrease the osmolarity, decreased delivery of overall calories and protein, and increased likelihood for venous sclerosis Routine use of PPN is associated with increasing loss of venous access sites and abuses derived from inappropriate short-term PN.

In a patient receiving both EN and PN, careful transition feeding is necessary to avoid overfeeding as EN tolerance improves and the need for PN is decreased. Should specialized nutrition therapy be provided to a hospitalized patient at end-of-life? However, nutrition therapy is likely to improve a cancer patient managed surgically who is cured from the malignancy but has altered GI anatomy or function post-operatively.

The use of PN in the non-operative management of malignancy should be avoided, as it may lead to worse outcomes compared with standard therapy with no nutrition support 4. Provision of hydration and nutrition therapy is no different than provision of any other medical therapy, including mechanical ventilation, dialysis, and supplemental oxygen There is no difference between non-invasive and invasive therapy, and the distinction between ordinary and extraordinary therapy is meaningless.

Evidence suggests that, even though nutrition therapy may not be provided, the subsequent development of dehydration and starvation does not add to suffering as only a third of patients will sense any degree of hunger or thirst In those situations, minimal therapy with oral mouth care, rinses, candies, or throat lozenges will ameliorate symptoms. Subtle goals and outcome benefits may be achieved by gastrostomy placement in certain end-of-life situations Quality of life for the family of the patient may improve with placement of a percutaneous gastrostomy, as the ease of providing medications, hydration, and nutrition is facilitated and frustration with anorexia and poor oral intake is reduced.

Percutaneous gastrostomy placement may allow transfer out of the hospital setting to a nursing home or skilled nursing facility closer to home A patient with malignant obstruction of the GI tract may benefit from gastrostomy placement through palliative decompression to reduce nausea and vomiting Gastroenterologists are trained to recognize indications and contraindications for a procedure.

Placing a percutaneous gastrostomy in a patient with poor prognosis at high risk for mortality seems like an exercise in futility to the clinician, especially when allocation of health-care resources is limited Ethicists would argue that refusal to place a percutaneous endoscopic gastrostomy in this situation violates the ethical principles of futility and justice. With regard to futility, refusal to place a percutaneous endoscopic gastrostomy generates a clash of values between the family and the caregiver.

With regard to justice, patients should never become aware that their low socio-economic status, lack of insurance, or low points on a survival scoring system has ultimately led to the denial of the procedure by health-care providers The most important ethical principle that drives management is patient autonomy, as the patient is the final arbiter of their own destiny Decisions on gastrostomy placement and provision of nutrition therapy at end-of-life often have little to do with scientific data or medical evidence derived from RCTs Decision making in end-of-life situations is often influenced by both the health-care literacy and the spiritual literacy of the patient and their families If at any time in this process, the clinician becomes uncomfortable or conflicted with the management decisions, he or she may excuse themselves from the care of a particular patient.

This can only be done if they are able to transfer the care to an equally qualified and willing practitioner. At no time should a patient or their families feel abandoned by the health-care process. This guideline was produced in collaboration with the Practice Parameters Committee of the American College of Gastroenterology.

The Committee gives special thanks to Brian P. Bosworth, who served as guideline monitor for this document. McClave is a speaker and an advisor for Nestle, Abbott, Covidien, and Kimberly Clark, a speaker for Nutricia, and has received research support from Nestle. Martindale is a advisor for Nestle, Covidien, and Fresenius Kabi.

DiBaise has received research support from GI Dynamics. Mullin has no potential competing interests. Significance of the four levels of evidence 25 High We are very confident that the true effect lies close to that of the estimate of effect Moderate We are moderately confident in the effect estimate: Indications for nutritional therapy Question: Specialized nutrition therapy in the form of EN should be initiated promptly in the hospitalized patient who is at high nutritional risk and is unable to maintain volitional oral intake conditional recommendation, low level of evidence.

EN should be used preferentially over PN in hospitalized patients who require non-volitional specialized nutrition therapy and do not have a contraindication to the delivery of luminal nutrients conditional recommendation, low level of evidence. Specialized nutrition therapy EN or PN is not required for hospitalized patients who are at low nutritional risk, appear well nourished, and are expected to resume volitional intake within 5 to 7 days following admission conditional recommendation, very low level of evidence.

PN should be reserved for the hospitalized patient under specific circumstances, when EN is not feasible or sufficient enough to provide energy and protein goals conditional recommendation, very low level of evidence. Prior to initiation of specialized nutrition therapy either EN or PN , a determination of nutritional risk should be performed using a validated scoring system such as the Nutritional Risk Score NRS or the NUTRIC Score on all patients admitted to the hospital for whom volitional intake is anticipated to be insufficient conditional recommendation, very low level of evidence.

An additional assessment should be performed prior to initiation of nutrition therapy of factors that may impact the design and delivery of the nutrition regimen conditional recommendation, very low level of evidence.

Surrogate markers of infection or inflammation should not be used for nutritional assessment conditional recommendation, very low level of evidence. Caloric requirements should be determined and then be used to set the goal for delivery of nutrition therapy conditional recommendation, very low level of evidence.

One of the three strategies should be used to determine caloric requirements: Protein requirements should be determined independently of caloric needs, and an ongoing assessment of protein provision should be performed conditional recommendation, very low level of evidence.

Nutrition assessment scoring systems used to determine nutrition risk NRS A nasogastric or orogastric feeding tube should be used as the initial access device for starting EN in a hospitalized patient conditional recommendation, very low level of evidence. Radiologic confirmation of placement in the stomach should be carried out prior to feeding except with the use of electromagnetic transmitter-guided feeding tubes.

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