We do not run the NS traineeship in
December, but we did host a Nutrition Support Forum this month.
The nutrition support forum is a small group of nutrition support
professionals from a number of area hospitals who meet for half a day
to critique a couple journal articles, discuss case studies and share
clinical ideas in an informal setting. Gary Ecelbarger MS, RD,
from Fairfax Hospital, started and continues to moderate our
forum. His wealth of knowledge, experience and sense of humor
makes our forum great to attend ! This month we reviewed two
Bullock TK, Waltrip TJ, Price SA, et al. A
retrospective study of nosocomial pneumonia in postoperative patients
shows a higher mortality rate in patients receiving nasogastric tube
feeding. Am Surg 2004;70(9):822-826.
The first study that we reviewed, on nosocomial pneumonia in
postoperative patients, was published in the September 2004 issue of
The American Surgeon.
The authors of this retrospective review look at he records of
1969 patients who had elective general, cardiac, and thoracic
procedures over a 6-month period. They reported on 77 patients
who met the criteria for pneumonia, and recorded data on:
Preexisting comorbid conditions
The number of days and type of antibiotic used
Type of microbial flora
Number of ventilator days, and
Use of enteral nutrition.
In the 77 patients who developed pneumonia, 41 received no enteral
feeding, and 33 received enteral feeding. In the small cohort of
patients with pneumonia, the authors report that the mortality was
significantly higher in those patients who were receiving enteral
feeding (11 of 33 patients [30%]), than in those patients who did not
receive enteral feeding (= 7 of 41 patients [17%]).
This is a retrospective survey with an unavoidable potential
for selection bias; some factor may have influenced the decision to
begin enteral feeding, which also affects outcome. The groups
(enteral vs. non-enteral) are similar in a number of factors, but there
is no way to control for all possible variables in a
retrospective trial. The authors suggest that enteral
feeding may have been responsible for the increased mortality in this
sub-population. However, the authors also reported that there
were significantly more patients with a history of smoking in the
non-enteral feeding group. Does this mean that a history of
smoking reduces the mortality from nosocomial pneumonia? It
simply illustrates that these two groups were different in more factors
than just enteral feeding.
Take home message:
Associations found in retrospective trials do not imply
causation, and should not be used as “evidence” for, or against, modes
of therapy or feeding. Associations from retrospective surveys
should be used to justify prospective studies. We agree with the
authors final conclusions that prospective trials are necessary to
address possible harmful effects of enteral feeding, and to weigh that
against possible harmful effects of not providing adequate
Mesejo A, Acosta JA, Ortega C. et al. Comparison of a
high-protein disease-specific enteral formula with a high-protein
enteral formula in hyperglycemic critically ill patients. Clin
The second study that we discussed was from the October 2003
This study was a prospective, randomized single-blind study of
a tube feeding marketed for enhanced glucose control, compared with a
standard fiber-free tube feeding. The experimental formula’s
calorie breakdown was 40% CHO, 20% protein, 40% fat. The control
formula was 49% CHO, 22% protein, 29% fat.
The study was conducted in 2 ICUs; inclusion criteria included adult
patients with a history of DM or stress-induced hyperglycemia, who
required enteral nutrition for 5 or more days. All patients
received 24-hour feedings with of calorie goal of 1.2 X REE
(Harris-Benedict), and had glucose controlled between 100-200
mg/dl with an insulin-drip. The primary endpoints were
glycemic control (glucose between 100-200mg/dl) and insulin
requirements/day. The authors reported that the mean glucose
level, AND the mean insulin requirements were significantly higher in
the 24 patients that received the standard tube feeding, compared to
the 26 patients who received the experimental formula. The
standard feeding group received an average of 30 units of insulin per
day (range 21.5-57.1), with a mean capillary glucose of 216 +/- 56.7
mg/dl, while the experimental group received an average of 8.7 units of
insulin/day (range 2.3-27.5), with a mean capillary glucose of 163 +/-
45.6 mg/dl. There was no significant difference in outcomes
between the two groups in terms of mortality, acquired infections, ICU
length of stay, or days of mechanical ventilation.
This was a prospective, randomized study, but it was not
double-blind. While a double-blind study is clearly desirable,
this study did have the advantage that the primary outcomes were
objective (serum glucose and units of insulin). The groups were
well matched, with no significant difference in terms of calories
provided, severity of illness, corticosteroid treatment, or history of
diabetes. However, one drawback of this study is the relatively
small group size. With small group size it is difficult to rule
out all random chance effects. For instance, if one group had
several patients who had a greater degree of insulin resistance, or
insulin requirement prior to admission, this could alter the
results. In a larger trial, the random allocation of patients
makes an unequal distribution of patients unlikely. Another
factor that may have influenced the results was the protocol for
capillary glucose checks every 6 hours. In our
intensive care units, where glucose is checked hourly
and insulin-drips are adjusted accordingly, it is unlikely that a
formula change would affect the overall glucose control.
Take home message:
This is a solid study, with interesting results. The group
decided that it would be important to have it repeated with larger
numbers, in a double-blind study, and see a cost-effectiveness
evaluation before we could recommend routine use of a more
University of Virginia Health
System Proposed Propofol Protocol (by Sherrie Walker
Patients with a history of
dyslipidemia will have Triglyceride (TG) levels checked 24 hours after
initiation of Propofol if delivery exceeds 500 mL /day (= approx.
20mL/hour). If TG > 400mg/dl, and high dose continues, levels
to be rechecked again in 24 hours.
Patients without a history of
dyslipidemia will have TG levels checked 48 hours after initiation of
Propofol if delivery exceeds 500 mL/day, or if delivery exceeds 50% of
estimated Kcal needs for > 48 hours.
If followed by one of the
nutrition support teams (NST) and the TG level exceeds 400 mg/dl, the
NST will discuss with the primary team. TG levels will continue
to be monitored every 48 hours if infusion continues.
Used with permission from the University of Virginia Health System
Nutrition Support Traineeship Syllabus
The following was sent to us as “The Dali Lama’s
Instructions for Life”… like all e-mail and internet sources you have
to take that with a grain of salt (non peer-reviewed and such) but we
liked it nonetheless…
Take into account that great love and great achievements
involve great risk.
When you lose, don't lose the lesson.
Follow the three Rs:
Ø Respect for
Ø Respect for
Responsibility for all your actions.
Remember that not getting what you want is sometimes a
wonderful stroke of luck.
Don't let a little dispute injure a great
When you realize you've made a mistake, take immediate
steps to correct it.
Spend some time alone every day.
Open your arms to change, but don't let go of your
Remember that silence is sometimes the best
Live a good, honorable life. Then when you get older
and think back, you'll be able to enjoy it a second time
A loving atmosphere in your home is the foundation for
In disagreements with loved ones, deal only with the
current situation. Don't bring up the past.
Share your knowledge. It's a way to achieve
Be gentle with the earth.
Once a year, go someplace you've never been
Remember that the best relationship is one in which your
love for each other exceeds your need for each other.
Judge your success by what you had to give up in order to
Approach love and cooking with reckless
Peace, and Happy Holidays !!!!
From our teams to yours - Good Nutrition For All and to all a good
PS – Please feel free to send this on to friends and colleagues.