Download Winter 2017 - American Society for Parenteral and Enteral Nutrition

Letter from the Chair
Winter 2017
Although we all had a great time during
The 2017 award winners are:
the holiday season with family and
 Jessica Stangenes, RD, LD, CNSC
friends, it is now time to focus our
Dietitian Distinguished Service
enthusiasm and energy on the upcoming
Award
Clinical Nutrition Week, February 18-21,
 Cassandra Kight, PhD, RDN, CNSC
2017 in warm and wonderful Orlando,
Dietitian Advanced Practice Award
FL.
 Lauren Probstfeld, MS, RD, CNSC
Mark your calendar to attend the
New Practitioner Award for Dietetics
Dietetics Practice Section Networking
Practice
Community meeting!
 Roaxana Tamijani, MS, RDN, LD,
The Dietetics Practice Section
FAND
meeting will be held on Sunday,
NBNSC Scholarship Award for
February 19 from 5:45 pm – 7:00 pm
Dietetics Practice
in the Crystal D-E rooms. Join your
friends and colleagues for
Please take the time to
this educational and
congratulate our award
networking event. Cindy
recipients whenever you
Hamilton, MS, RD, LD,
get a chance.
FAND, the Director of
Consider making it your
Nutrition at the Center for
New Year’s resolution to
Human Nutrition and the
share your expertise and
Digestive Disease and
time as a volunteer. The
Surgery Institute at the
return on your investment is
Cleveland Clinic in
huge. Pay it Forward by
Cleveland, OH, will inspire
helping to build member
us to communicate and
value for you and your
work effectively with the CTrisha Furhman, MS, RDN, LD,
colleagues in A.S.P.E.N.
FASPEN, FAND
suite of our institutions.
and DPS. Volunteer today!
The meeting is also an
Share your ideas for what
opportunity to recognize and
we can do as a section to better meet
congratulate this year’s DPS award
your needs as a dietetics professional.
recipients.
Feel free to contact us with your
thoughts, suggestions, and willingness to
become active in DPS.
Continued on next page
Dietetics Practice Section Newsletter - Winter 2017
Inside this Edition:
Page
Member Spotlight
2
Membership News
3
CNW16
Summaries:
Physical Exam Lab
4
EN Hot Topics
6
Parenteral Nutrition
Conundrum
7
Transitioning IF to
Adult Programs
8
Dudrick
Symposium
10
Letter from the Chair
continued
I also want to remind you about the plethora of resources available through
A.S.P.E.N. Both A.S.P.E.N. and DPS are here to help you strengthen your
clinical skills and extend your network of colleagues.
Have a safe and joyous 2017. I look forward to seeing you at CNW 2017
and the DPS Networking Community in Orlando!
Trisha Fuhrman, MS, RDN, LD, FAND, FASPEN
[email protected]
Chair of DPS
CNW17 Orlando
Marisa Mozer, MS, RD, LDN, CNSC
Senior Clinical Dietitian
Rush University Medical Center
Why did you become interested in nutrition support?
I became interested in nutrition support because I saw the
impact of nutrition in improving a patient’s tolerance to
their cancer treatment. Nutrition support should be
considered for all cancer patients who are malnourished,
or for those who are receiving treatment
which could potentially impair their
ability to eat and lead to malnutrition. In
my experience, there have been several
cases where nutrition support has been
an integral part of the treatment process
in saving a patient’s life following
aggressive treatment.
What is your favorite aspect of being
a member of A.S.P.E.N.?
My favorite part of being a member of
A.S.P.E.N is the abundant number of
evidenced based resources that are available, and the
ability to connect with other nutrition support clinicians.
A.S.P.E.N. is a great way to interact with other clinicians
in your area of practice, as well as areas you are just
beginning to be exposed to.
Tell us about your career pathway and how you got to
where you are now?
Initially, I thought I wanted to work in childhood obesity.
After completing my inpatient oncology rotation as part of
my internship at Rush University Medical Center in
Chicago, I knew my career path was going to be different.
I quickly realized my love for the oncology population, and
knew that I was making a difference in their lives. These
patients have trust and respect for oncology dietitians
because they know they need the help with symptom
Dietetics Practice Section Newsletter
management and preserving lean body mass. This led
me to a position working as the lead oncology dietitian,
specifically working with the inpatient hematology / bone
marrow transplant and oncology teams, as well as the
outpatient radiation oncology population at Rush.
What is your proudest moment as
a nutrition support dietitian?
My proudest moment as a nutrition
support dietitian is gaining the respect
of the hematology and stem cell
transplant teams, ultimately leading to
approval for routine placements of
nasogastric feeding tubes in
hematology and stem cell transplant
patients – a practice that rarely
occurred at our institution. The team
truly values nutrition in recovery, and
for many patients, nutrition support is crucial to their
treatment and recovery.
What advice do you have for dietitians entering the
field of nutrition support?
Although nutrition support is often overlooked among
cancer patients, being well versed in the evidence
supporting its use will allow the multidisciplinary team to
support you, ultimately leading to improved patient
outcomes.
What do you do to relax?
Exercise – nothing like a good spin class to get the
adrenaline flowing and motivation to keep focused!
2
Call for CNW17 Session Reporters
Volunteers Needed!
Will you be attending CNW 2017 in Orlando, either in person or virtually? Would you be willing to summarize the
content of one or two sessions you attend?
This is YOUR chance to get involved in your section! Reporting on a session you attend provides you the opportunity
to reflect on the content you heard, follow up by reading some of the papers referenced, and summarize your final
thoughts on the information presented. This process helps you retain the information and incorporate it into your own
clinical practice knowledge and skill set. It also provides an informative and quick outline of the topic to share with
fellow clinicians who may have been unable to attend the session.
Writing a summary is an easy way to get more involved in the Dietetics
Practice Section and to share your skills, while enhancing our profession
as a whole. Please consider being a Volunteer Reporter at this year’s
conference.
To volunteer, contact Jessica at [email protected] for
more information and to sign up for your favorite sessions.
Thank you to our excellent reporters who brought us summaries
of 15 sessions from CNW16 over the past year!
Jackie Wessel, MEd, RD, CNSC, CSP, CLE
Neonatal Dietitian
Cincinnati Children’s Hospital Medical Center
Cincinnati, OH
Jessica Stauffer-Engelbrecht, MS, RD, CSR, LD, CNSC
Nutrition and Metabolic Support Team
Inpatient Cancer Treatment Centers of America
Tulsa, OK
Gabriela Gardner, RDN, LD, CNSC
Memorial Hermann Hospital and
Ertan Digestive Disease Center
Houston, Texas
Dietetics Practice Section Newsletter - Winter 2017
Progya Banerjee Aakash, MSc, MS, RD,LDN
Thomas Jefferson University Hospital
Philadelphia, PA
Mara Lee Beebe, MS, RD, LD, CNSC
Kettering Medical Center, Kettering, Ohio
Ashley Peña, RD, LD, CNSC
Nutrition Support Dietitian
Option Care, Irving, TX
Patricia Savino, RD, MBA, CNSD
Nutritional Support Team
Hospital Universitario de la Fundación Santa Fe
Bogotá, Colombia
3
Session Title: Post Graduate Course 3:
Physical Examination and Skills Lab
Date: January 16, 2016
Educational Level: Basic
Submitted by:
Jessica L. Stauffer-Engelbrecht, MS, RD, CSR, LD, CNSC
Cancer Treatment Centers of America
Tulsa, Oklahoma
The physical examination and skills lab post graduate
course provided a great opportunity for CNW attendees to
learn about and practice performing a physical examination with experts present for evaluation and critique.
Current evidence and consensus suggests that performing a physical examination with a focus on body fat, muscle mass, fluid accumulation, and functional performance
is a necessary part of the nutrition assessment and for
determining presence and degree of malnutrition.1 This
post graduate course showcased skills necessary for a
complete nutrition-focused physical examination. The
Dietitians in Nutrition Support DPG Nutrition-Focused
Physical Exam video was shown. The video was a complete head to toe nutrition-focused physical exam performed by an RDN with an actor/patient in a hospital setting.2
Following the general session, attendees were divided
into smaller groups to attend seven breakout training sessions. These break-out trainings provided history, evidence, and an overview of a specific part of the nutritionfocused physical exam. Tools that might be used by the
RDN during the nutrition-focused physical exam were
highlighted and available for hands-on use. Attendees
had an opportunity to practice and ask questions of the
experts about each learning point before moving on to the
next training session.
Understanding Hemodynamics in the ICU and the Relationship to Nutrition
Dr. Oltermann provided a concise review of basic hemodynamics in the intensive care unit to give a better understanding of interpreting findings and be able to better participate in a multidisciplinary team.
Lean Body Mass Assessment
 Interpretations of bedside ultrasound of the quadriceps femoris muscle

Correct performance of ultrasound assessment

Practice with ultrasound device
Abdominal and Extremity Examination
 Understand the components of an abdominal assessment

Describe and interpret types of bowel sounds

Understand and recognize general signs and symptoms of bowel obstruction

Practice assessment using available stethoscope,
percussion, palpation techniques with expert observer

Review and practice reading abdominal radiographs
for better understanding of ileus versus a bowel obstruction and to determine placement of feeding tube
and if safe to feed

Assessment of fluid distribution, fluid balance and fluid
accumulation
Orofacial Region Examination
 Identify and review the steps involved in the nutrition
focused physical exam of the orofacial region.

Practice an orofacial nutrition-focused physical examination
Handgrip Strength Assessment (Dynamometry)
 Correct positioning and use of handgrip strength assessment

Practice with different hand grip strength dynamometer
Dietetics Practice Section Newsletter
Continued on next page
4
Macronutrients: Muscle and Fat Assessment
 Identify areas of the body to assess for subcutaneous
fat loss and muscle loss.
earlier detection of malnutrition, and earlier implementation of nutrition interventions to lessen further muscle
wasting.

Resource used: Nutrition Focused Physical Exam
(Flash Drive, available at dnsdpg.org/store)
Learn to distinguish between normal, mild/moderate
and severe depletion of muscle mass and fat

Practice physical assessment with expert observing
using a case study approach
Micronutrients Assessment
 Identify micronutrient deficiencies and toxicities using
a nutrition-focused physical examination
The nutrition-focused physical examination skills lab presenters and moderators provided expert guidance for
each specific assessment and tool that a RDN may use in
clinical practice. Incorporation of these skills into daily
practice enables clinicians to better assess the patient for
References:
1. White JV, Jensen G, Malone A, et al. Consensus Statement: Academy of Nutrition and Dietetics and American
Society for Parenteral and Enteral Nutrition: Characteristics
recommended for identification and documentation of malnutrition (undernutrition). JPEN. 2012;36:275-283
2. DNS Nutrition-Focused Physical Assessment Video. Dietitians in Nutrition Support Dietetic Practice Group of the
Academy of Nutrition and Dietetics/Cleveland Clinic Foundation. www.dnsdpg.org
Orlando Fun Facts
CNW17 takes place this month in Orlando, FL.
We’ve gathered a few interesting Orlando facts you may not have known:

Orlando has 100 lakes, many of which are the result of sinkholes. Rose Lake, an infamous lake
formed from a sinkhole in Winter Park, was mentioned in HBO’s "The Sopranos" as a good place to
hide bodies. If you’re flying into CNW, you’ll have a birds eye view.

Lake Eola (home of the famous fountain on page 2) is actually a giant sinkhole and reaches 80 feet
deep. Take a stroll around this downtown Orlando lake and visit the over 50 swans in residence.

Orlando is home to a strong local food movement, James Beard winning chefs,
a huge food truck scene, and the first free-standing seed to plate school
nutrition curriculum program in the country!

Orlando City is the Major League Soccer team and will begin this season in a
brand new stadium in downtown Orlando.

Orlando businessman Dr. Philip Phillips once owned 5,000 acres of citrus,
perfected the canned orange juice process and sold his company to
Minute Maid in 1954 for $50 million.

Florida is both the Sunshine State and the Lightning Capital of America.

In 1957, the famous beat writer Jack Kerouac wrote “On the Road” in Orlando.

The largest collection of Tiffany glass in the world can be found at the
Morse Museum of American Art in Winter Park.
Dietetics Practice Section Newsletter - Winter 2017
5
Session Title: Enteral Nutrition - Hot Topics and Hands On Updates
Date: January 18, 2016
Educational Level: Intermediate
Moderators and Presenters:
Peggie Guenter, PhD, RN, FAAN, Senior Director of Clinical Practice, Quality and Advocacy, American Society for Parenteral and Enteral Nutrition, Silver Spring, MD
Carol McGinnis, DNP, RN, CNS, SNCS, Clinical Nurse Specialist, Nutrition Support, Sanford USD Medical Center,
Sioux Falls, SD
Katina Rahe, BSN, RN, CPN, Enteral Access Team Nurse Coordinator, Children’s Mercy Hospital Kansas City, MO
Patricia A. Worthington, MSN, RN, CNSC, Nutrition Support Nurse, Thomas Jefferson University Hospital, Philadelphia,
PA
Joseph Boulata, PharmD, RPH, BSCNSP, FASPEN, Professor of Pharmacology, and Therapeutics, School of Nursing,
University of Pennsylvania: Pharmacy Specialist, Nutrition Support, Hospital of University of Pennsylvania, Philadelphia,
PA
Linda M. Lord, NP, CNSC, ACNP-C, Nutrition Support Nurse Practitioner, Adult Nutrition Support Clinic, University of
Rochester Medical Center, Rochester, NY
Karen Gilbert, RN, MSN, CNSC, CRNP, Nutrition Support Clinical Nurse Specialist, Thomas Jefferson University Hospital, Philadelphia, PA.
Moderator: Renay Tyler, DNP, ACNP, CNSC, Senior Director of Nursing, Ambulatory Services, Johns Hopkins Hospital,
Baltimore, MD.
Submitted by:
Mara Lee Beebe, MS, RD, LD, CNSC, Kettering Medical Center, Kettering, Ohio
This session on “Hot Topics” in enteral nutrition
round table sessions with leading A.S.P.E.N.
began with an update from Peggy Guenter on
experts in enteral nutrition:
adopting new enteral connectors. Peggy ex Carol McGinnis demonstrated a bridle sysplained how the use of universal small-bore
tem to secure nasal feedings tubes to prevent
connectors such as a Luer connector has opaccidental removal or dislodgement. Carol
portunities for enteral misconnections and that
used a small 5Fr pediatric feeding tube as the
these misconnections have led to patient
bridle in her technique but also discussed
deaths. These and other types of misconneccommercially available nasal bridle sets. Carol
tions led to a call for change in all small bore
Mara Lee Beebe, MS, RD, also focused on ways to ensure patient comconnectors (eg, enteral, respiratory, urethral,
LD, CNSC
fort during her presentation.
neuraxial, intravascular) and the creation of ISO
 Karen Gilbert and Patricia Worthington
80368-1 master standard. The new EnFit connectors
discussed the current methods for placing nasoenteric
have a male connector for the feeding tube and a female
feeding tubes and the shortcomings of traditional blind
connector on the administration sets and syringes that will
placement. As an alternative to blind placement, atonly connect with each other. Although many manufacturtendees were able to test the CORTRAK® Enteral
ers are making the connectors purple, color is not part of
Access System. CORTRAK® uses electromagnetic
the ENFit design standard. The rollout of these connectguidance technology to assist clinicians in placing
ors has been delayed due to the need to develop devices
feeding tubes by tracking the relative location of the
that will allow for venting and drainage from new ENFit
tube and providing visual feedback aids. The system
gastric tubes, creation of devices to allow feeding via safacilitates post-pyloric placement of feeding tubes and
lem sump tubes, testing of blenderized diets through new
helps avoid inadvertent intubation of the pulmonary
ENFit tubes and syringes, and the creation of new low
system. Using the system may also reduce the need
dose syringes to prevent over or under dosing of medicafor abdominal x-rays to confirm placement of feeding
tions in infants. Until the new ENFit feeding tubes and
tubes.
syringes are launched, transition sets are being used to
 Katina Rahe discussed proper tube site care and
connect feeding sets to current feeding ports.
The latter portion of the session divided into four hands-on
Continued on next page
Dietetics Practice Section Newsletter
6

some of the most common skin related complications
from feeding tubes (drainage, erythema, breakdown,
granulation, rash, skin erosion, and prolapse). Algorithms for determining the best treatment approach for
each condition were provided, and attendees were
able to touch and feel several different wound care
products.
Joseph Boullata and Linda Lord shared best practices
for preventing feeding tube obstructions and recommended methods for unclogging a feeding tube. Key
recommendations included at least 30ml water flushes every 4 hours during continuous feedings and before and after intermittent feedings and residual volume checks. They emphasized the importance se-
lecting the best formulation of drug and proper drug
preparation before administration. Fruit juices and
carbonated beverages were discouraged and activated pancreatic enzyme solutions were recommended
for unclogging feeding tubes.
In addition to the lecture and hands-on sessions, attendees were able to visit the GEDSA (Global Enteral Device Supplier Association) table and examine the new ENFit connectors, feeding tubes, and syringes. Attendees
were encouraged to visit the Stay Connected website
(http://stayconnected.org) to keep updated on the timeline
for implementation.
Session Title: Parenteral Nutrition Formulation Conundrum
Date: January 19, 2016
Educational Level: Intermediate
Moderators and Presenters:
Amber Verdell, PharmD, BCPS, BCNSP, Assistant Professor, Pharmacy Practice, West Coast University, Pasadena,
CA
Sara Bliss, PharmD, BCPS, BCNSP, Clinical Pharmacist, Surgery/Nutrition Support, Wake Forest University Baptist
Medical Center, Winston-Salem, NC
M. Petrea Cober, PharmD, BCNSP, Clinical Pharmacy Coordinator, Neonatal Intensive Care Unit, Akron Children’s
Hopsital, Akron, OH
Moderator: Carol J. Rollins, MS, RD, PharmD, FASHP, FASPEN, BNSP, Coordinator, Nutrition Support Team, Banner
University Medical Center Tucson; Clinical Professor, Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ
Submitted by:
Ashley Peña, RD, LD, CNSC, Nutrition Support Dietitian, Option Care / Walgreen’s Infusion, Dallas, TX
Amber Verdell, PharmD, reviewed 3-in-1 PN
solutions. Specifically, 2-in-1 solutions are preadmixture stability. Major factors that affect
ferred for patients with high fluid requirements,
stability include: order of adding components
high calcium or magnesium requirements, or
to admixture, final pH, final concentration of
neonates.
macronutrients (AA>4%, dextrose>10%, liSara Bliss, PharmD, reviewed the risks and
pid>2%), electrolyte concentrations, additives,
benefits of using premixed parenteral nutrition
storage conditions, and aging/end use date.
(PN) solutions versus customized PN. Bliss
Verdell then reviewed advantages and disadreviewed the cost of premixed versus custom
vantages of using 3-in-1 PN solutions. She
PN. Busch and colleagues studied the cost of
discussed availability of only 1 retrospective
Ashley Peña, RD, LD,
electrolyte supplementation and found that prestudy evaluating catheter occlusion rates in 3mixed PN was associated with a higher cost versus standin-1 versus 2-in-1 PN, noting increased rates of catheter
ard PN mixtures. She then reviewed Magee and colfailure and replacement in pediatric patients receiving
leagues’ retrospective study of total cost in terms of length
home 3-in-1 solutions. Verdell also discussed specific
of stay which showed hospital length of stay for premixed
populations that would benefit from 3-in-1 PN and which
patient populations would be more appropriate for 2-in-1
Continued on next page
Dietetics Practice Section Newsletter - Winter 2017
7
PN was 9.4 days and 9.65 days for custom PN. The difference was statistically significant, but possibly not clinical significant. Bliss concluded that premixed PN may
offer some advantages over custom PN except in high
risk patient populations.
M. Petrea Cober, PharmD, reviewed the Pros and Cons of
repackaging intravenous fat emulsions (IVFE) specifically
in the neonatal population since NICU’s almost exclusively use 2-in-1 PN solutions due to stability of emulsions
with < 2% lipid, increased neonatal calcium/phosphorus
needs, and limited venous access. Cober noted that commercial IVFE are available in volumes of 100mL in the US
which is significantly greater than a neonate’s need.
Cober also mentioned repackaging IVFE improves utilization of limited resources given recent lipid shortage.
Cober noted common NICU IVFE medication errors, such
as resetting the infusion rate for IVFE, rates of PN and
IVFE being switched, and IVFE being infused too quickly.
Cober then reviewed ASPEN recommendations against
repacking IVFE into syringes, suggesting drawn-down
IVFE units. Ultimately, Cober encouraged discussion with
companies to produce smaller packages of IVFE and reevaluating each facility’s process for administering IVFE.
References:
Erdman, et al. Central line occlusions with three-in-one nutrition
admixtures administered at home. JPEN. 1994;18(2):177-181
Busch RA, et al. Use of piggyback electrolytes of patients receiving individually prescribed vs. premixed parenteral nutrition.
JPEN. 2015;39(5):586-590
Magee G, et al. A Retrospective, observation study of patient
outcomes for critically ill patients receiving parenteral nutrition.
Value in Health. 2014;17:328-333
Session Title: Intestinal Failure Transitions from Childhood to Adulthood
Date: January 21, 2016
Submitted by:
Jackie Wessel, MEd, RD, CNSC, CSP, CLE, Neonatal Dietitian
Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
Deciding When it’s Time to Move Along…
Or not
Laura Beerman, RD, LMNT, CNSC
University of Nebraska Medical Center,
Omaha, Nebraska
This session discussed strategies to provide
for a smooth transition from pediatric to adult
care. This involves placing the majority of
the responsibility on the pediatric provider in
helping the patient learn to be responsible
for their care. In the diabetic population, transitioning from
pediatric to adult care led to a 2.5 times higher HgbA1c.
There are vast differences in pediatric versus adult care
delivery systems. Pediatric systems are family based
care with multi-disciplinary teams, whereas adult care is
patient based rather than family based. Other disciplines
are not necessarily at each clinic visit.
Studies have shown patients have difficulty with the transition. They may not have a good understanding of their
disease state, their prior treatment history and overall
plans, etc. Families have often been over involved in patient care and that transition to the patient taking full responsibility is difficult.
It is recommended to start this transition early. Checklists
Dietetics Practice Section Newsletter
may be helpful as the patient, family, and
medical team move through the transition
process.
The Case for Keeping the Young adult in
a Pediatric Program
Tom Jaksic MD, Professor of Surgery, Harvard Medical School, Surgical Director,
Center for Advanced Intestinal Rehabilitation, Boston Children’s Hospital, Boston, MA.
Highlights from Dr. Jaksic’s discussion:

80% of these patients will eventually adapt

Clinicians need to keep in mind the issues of calorie
needs going down over time - from high calorie per kg
needs as babies to much lower as adults

10% of patients with normal bilirubin have cirrhosis

34% have metabolic bone disease

Adolescents need to assume self care and clinicians
need to educate them to do that.

Impediments - Adult multidisciplinary teams essentialContinued on next page
8
ly do not exist. Many pediatric programs are blossoming, but adult programs have shrunk.

Patients are often resistant to changing their care providers; in fact some adults are asking to be covered
by pediatric teams. There is a no age limit in the clinic,
and in the hospital surgery can be performed on anyone 35 and under.

Each center needs to have their own solutions, depending on the adult resources in their own area.
Making the Case for Transfer to an Adult IF Programmorphed the topic to: Perspectives on Transfer to an
Adult IR Program
Kishore Iyer, MD, Pediatric Surgeon, Mt. Sinai, New York
Dr Iyer acknowledged the help and research of Dr. Rachel
Annunziato who has many articles on this topic. Some
are referenced below along with his main discussion
points:

Dr. Iyer works with both pediatric and adult intestinal
failure patients

Transition is a process where the patient takes over
his care, whereas transfer is just a moment in time.

In other fields such as congenital heart disease, diabetes, and transplant, we have seen a marked loss of
compliance after transferring centers. Tacrolimus levels were much higher after transfer from a pediatric to
adult transplant center, suggesting problems with
compliance, even 2 years later.

Recommended using a transition coordinator and reviewed their job responsibilities.
Attending CNW17 for the first time?
Sign-up for the A.S.P.E.N. buddy
program and you’ll be connected
with a seasoned attendee.
http://www.nutritioncare.org/CNWFirstTime
Dietetics Practice Section Newsletter - Winter 2017
Transfer - a moment in time, patient transferring
from once team or center to the next
Transition - a process of allowing the patient to
learn to take over their care and transition from
the pediatric to the adult model of care

Tacrolimus levels and other markers suggested better
adherence in the group using a transition coordinator.

They have had this system in place since 2007.

Adherence status appears to be coordinated with
global mental health markers using Global Severity
Index.

Reviewed some of the checklists in use by intestinal
failure programs.

Text messaging program may be used to improve
adherence particularly for transplant medications.

Reviewed some of their patients preferred communication methods- email, texts, calls, etc.
References:
Annunziato RA, Baisley MC, Arrato N, et al. Strangers headed to
a strange land? A pilot study of using a transition coordinator to
improve transfer from pediatric to adult services. J Pediatr. 2013;
163:1628-1633.
Annunziato RA, Shemesh E. Tackling the spectrum of transition:
what can be done in pediatric settings. Pediatr Transplant. 2010;
14: 820-822.
Kerkar N, Annunziato. Transitional care in solid organ Transplantation. Semin Pediatr Surg. 2015; 24:83-87.
Use the hashtag #CNW17 on twitter to
follow all the latest updates before and
during Clinical Nutrition Week.
Download the free app →→→
for maps, schedules, and more!
9
Session Title: Dudrick Symposium; Critical Care Nutrition - Lessons Learned and Future Directions
Date: January 18, 2016
Moderator: Nilesh M. Mehta, MD, DCH
Submitted by:
Patricia Savino RD,MBA,CNSD
Nutritional Support Team, Hospital Universitario de la Fundación Santa Fe
Past president of the Asociación Colombiana de Nutrición Clínica and current editor of society Journal
Bogotá , Colombia
Adult Critical Care Nutrition - Looking Back at
Lessons Learned and Planning Future Directions
Daren K. Heyland, MD, RFCPC, MSC
Full Professor of Medicine Department of Medicine
Queens University, Director of Research for the Critical
Care Program and Director of the Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON,
Canada
same BMI of 35, but also chronic obstructive pulmonary
disease and poor baseline functional status. Will nutrition
have the same impact in these two types of patients?
In order to determine which patient will benefit the most, a
conceptual model was developed for nutrition risk assessment in the critically ill patient. The true nutritional state of
a critically ill individual would include their acute and
chronic degree of nourishment and inflammation. The
degree of acute inflammation could be measured by interleukine 6 (IL6), C-reactive protein (CRP),
Dr. Heyland shared that after working for 25
and procalcitonin (PCT). Chronic inflammayears in Critical Care Nutrition, he has found
tion could be reflected by comorbidities.
that ICU patients are not created equal;
Acute starvation could be determined from a
therefore we could not expect that the impact
diet or intake history, and chronic undernourof nutrition therapy can be the same across
ishment might be diagnosed by obtaining a
all patients. Unfortunately, due to the design
weight history (Figure1).
and interpretation of randomized clinical triThe NUTRIC Score may be a tool that can
als, guidelines are generalizations on how we
help the clinician determine nutrition risk in
should manage very different patients. In the
Patricia Savino RD,MBA,CNSD their patient by assessing factors such as
2015 Canadian Clinical Practice Guidelines,
age, APACHE II score, IL6, and comorbidithere were controversies around some of the
ties. An increased NUTRIC Score is associated with morguidelines regarding optimizing enteral nutrition in the crittality and increased duration of mechanical ventilation. In
ically ill patient. A poll asking audience members if trophic
patients with low NUTRIC Scores, increasing nutrition adfeeds were an acceptable practice in the ICU demonstratequacy does not impact 28-day mortality. In patients with
ed the absence of agreement among the audience.
high NUTRIC Scores, increasing nutrition adequacy is
Some of the controversy and confusion come from trials
associated with a reduction in mortality.
such as the PERMIT trial.1 This trial randomized patients
Since ICU patients are not created equal, the impact of
to receive either 40-60% or 70-100% of the prescribed
nutrition therapy is not going to be the same across all
calories for 14 days. After 90 days there were no differpatients. Perhaps patients with sarcopenia and low musences between the two groups in the main patient outcularity will benefit the most from nutrition therapy. But
comes (mortality, mechanical ventilation, ICU length of
how do we best identify these patients? CT images that
stay, and hospital length of stay). As a result, we have to
have been taken for other medical reasons could be used
ask - does nutrition really matter and should we systematito quantify skeletal muscle. Ultrasound could be used to
cally underfeed?
measure quadriceps thickness, and monitor the effect of
The answer may be a better tool to identify patients who
nutrition in patient recovery.
will benefit from nutrition support. For example, a 34Outcomes research has started to turn from survivorship
year-old male athlete with a BMI of 35 involved in a motor
to quality of life and functional status. The EDEN trial2
vehicle accident with a mild head injury and a fractured
right leg is not the same as a 79-year-old woman with the
Continued on next page
Dietetics Practice Section Newsletter
10
Figure 1
was the first RCT that started to systematically look at the
survivorship issues in critically ill patients, such as physical and cognitive assessments after one year. Patients
who were fully fed had better outcomes in their 6 minute
walk distance and 4 minute timed walk, in comparison to
those who were not. Even though the results were not
statistically significant, there was a clinically relevant improvement. This data is comparable to a sub study of the
REDOXS trial, in which patients with nutritional adequacy
during the first eight days of mechanical ventilation in the
ICU were assessed using the Short-Form 36 Health Survey questionnaire at 3 and 6 months post ICU admission.
Table 1
Increased nutritional adequacy in the ICU was associated
with better scores - indicating patients who had received
adequate nutrition had a faster recovery.
As we move forward and think about the survivors’ journey, it is necessary to develop a framework for evaluating
the impact of nutrition and exercise interventions in survivors of critical illness. This will enable us to standardize
across time and studies; beginning with defining a baseline status that could be compared with the same parameters after acute illness. It is necessary to determine the
pathology and impairment of critical illness, the activity
limitations within the hospital, the restriction at the patient’s home environment, and finally assessing quality of
life.3
There has been a lot of research in glutamine in the critical ill context. In a RCT conducted by Heyland et al, glutamine supplementation was given to the sickest patients.4 The result was increased mortality with supplementation. When the plasma glutamine levels were
measured, 1/3 of the patients were deficient, 1/3 were
normal, and 1/3 had super elevated levels of plasma glutamine. Other work has shown that both low and high
levels of glutamine increase mortality. It appears that the
best approach is to know the plasma levels of glutamine
before supplementing.
In conclusion, not all ICU patients are the same; it is necessary to have new approaches to determine which patients or subpopulations will benefit the most from nutrition
therapy. This will have important implications for clinical
practice, design of research trials, and interpretation of
existing studies.
References
1. Arabi YM, Aldawood AS, Haddad SH, et al. Permissive underfeeding or standard enteral feeding in critically ill adults.
N Engl J Med. 2015; 372(25):2398–2408.
2. Rice TW, Wheeler AP, Thompson BT, Steingrub J, Hite RD,
Moss M, Morris A, Dong N, Rock P. Initial trophic vs full
enteral feeding in patients with acute lung injury: the EDEN
randomized trial. JAMA. 2012 Feb 22;307(8):795-803.
3. Heyland D, Stapleton R, Mourtzakis M, Hough C, Morris P,
Deutz N, et al. Combining nutrition and exercise to optimize
survival and recovery from critical illness: Conceptual and
methodological issues. Clin Nutr. 2015 Jul 16.pii:S02615614(15)00177-6.
4. Heyland D, Muscedere J, Wischmeyer PE, Cook D, Jones
G, Albert M, Elke G, Berger MM, Day AG; Canadian Critical
Care Trials Group. A randomized trial of glutamine and antioxidants in critically ill patients. N Engl J Med. 2013 Apr 18;
368(16):1489-97.
Continued on next page
Dietetics Practice Section Newsletter - Winter 2017
11
Energy Balance in Critically Ill Newborns and Children
Tom Jaksic, MD, PhD, FASPEN
Vice-Chairman, Pediatric General Surgery, Surgical Director, Center for Advanced Intestinal Rehabilitation, Boston
Children’s Hospital; W Hardy Hendren Professor of Surgery, Harvard Medical School, Boston, MA.
The truth is that today hypermetabolism is not what is
used to be. The story begins with Sir David Cuthbertson,
in his famous paper1 from 1932 in which he related increased protein catabolism with increased energy expenditure. The next landmark paper was from Calving
Long2 in which he showed that in different kinds of injury
(major and minor burns and major and minor trauma) the
energy expenditure was increased above the resting energy expenditure (REE), meanwhile the curve for starving
patients was below the REE. Bistrian and Blackburn3
used a formula which multiplied the weight in pounds by
10, obtaining the total daily calories required. Hunter3
then compared this formula with the results of indirect calorimetry and the Harris Benedict equation and found fairly
similar results, within 100kcal per day.
As clinicians know, standard estimation equations are frequently inaccurate in today’s ICUs.4 Advances in ICU
care such as synchronous ventilation, infection control,
thermo-neutral environments for burn care, enhanced
pain management, improved anesthesia, and superior
surgical techniques could all be factors that have modified
the energy needs. We now know that standard equations
do not adequately predict individual REE and that actual
measurements are advised for patients at risk.4
The nutritional needs of pediatric patients are different
than adults because pediatric needs must account for
growth. In a study of two different groups of pediatric patients (stable ventilated postoperative parental nutrition
fed term neonates versus parenteral nutrition fed term
neonates on extracorporeal membrane oxygenation), the
measurement of the energy requirements through stable
isotopes had similar mean requirements to age matched
well children. Therefore, after obtaining the REE, the
question is if the provision of excess calories will enhance
the protein sparing effect. Providing excess calories to
neonates may not improve protein balance, paradoxically
it could worsen it, since it accentuates protein breakdown.
The effect of surgery in premature neonatal patients with
narcotic anesthesia does not increase the REE. There is
only a small incremental increase during the first few
hours post-op and needs quickly return to pre-surgical
levels. The best predictor of postoperative REE is preoperative REE; nevertheless there is a paradox because
in the convalescence phase of illness, when neonates are
removed from the ventilator, the difficult work of breathing
Dietetics Practice Section Newsletter
increases the REE.
Does the type of calorie have an effect on protein sparing? The ideal ratio of fat to carbohydrate is unknown in
critically ill children. In general, fat should be limited to
<40% of the caloric needs. Glucose and fat both have
beneficial effects on net protein balance in children. Lipid
turnover is increased and stores are reduced in neonates
(14% in neonates, 17% in children and 19% adults).
When fat is not administered for one week, there can be
biochemical evidence of fatty acid deficiency. Fatty acid
deficiency can be avoided by the administration of 4% of
total calories coming from fat.
Potential advantages of using lipids as a caloric source
include: unlike glucose lipids do not increase carbon dioxide production, lipids are dense in calories so it is possible
to reduce feeding volume, and lipids decrease the need
for glucose which can help reduce risk of hyperglycemia
in the relatively insulin resistant child.
Hyperglycemia is frequently seen in pediatric ICU patients, for example 87% of cardiac surgery patients had
hyperglycemia postoperatively. Taking into consideration
the van den Berghe5 study regarding tight glycemic control in ICU patients, the Boston group did a randomized
prospective trial to see if controlling hyperglycemia would
have beneficial effects in the pediatric patient. Tight glycemic control was achieved with a relatively low hypoglycemia rate after cardiac surgery but it did not significantly
change the infection rate, mortality, length of stay, or
measures of organ failure, as compared with standard
care (180 mg/dl glucose or lower). Muscle protein degradation measured through urinary 3-methylhystidine/
creatinine ratio was also not altered.6,7
In summary, the energy requirements of the critically ill
child are generally similar to age matched healthy children. Measuring, rather than estimating energy expenditure is recommended. It is necessary to regularly obtain
basic anthropometric data and follow growth curves to
determine the adequacy of nutrition support. Throughout
the convalescence phase of illness, “catch up growth”
should occur and careful follow up should be done. Survival is not a good outcome measure for critical ill neonates. The ultimate goal is an adequate neurocognitively
intact individual.
References
1. Cuthbertson D. Observations on disturbance of metabolism
produced by injury to the limbs. Quarterly Journal of Medicine.1932;25:233.
2. Long C. Energy balance and carbohydrate metabolism in
Continued on next page
12
3.
4.
5.
6.
7.
infection and sepsis. Am J Clin Nutr. 1977; 30:1301-1310.
Hunter D, Jaksic T, Lewis D, Benotti P, Blackburn G and
Bistrian B. Resting energy expenditure in the critically ill:
Estimations versus measurement. Br J Surg. 1988; 75: 875878.
Duro D, Mitchell P, Mehta N, Bechard L, Yu Y, Jaksic T et
al. Variability of resting energy expenditure in infants and
young children with intestinal failure- associated liver disease JPGN.2014;58:637-641.
van den Berghe G, Wouters P, Weekers F, et al. Intensive
insulin therapy in critically ill patients. N Engl J Med. 2001;
345:1359-1367.
Agus M, Steil G, Wypij D, Costello J, Laussen P,Langer M,
et al. Tight glycemic control versus standard care after pediatric cardiac surgery. N Engl J Med. 2012; 367:1208-1219.
Fisher JG, Sparks EA, Khan FA, Alexander JL, Asaro LA,
Wypij D, et al. Tight glycemic control with insulin does not
affect skeletal muscle degradation during the early postoperative period following pediatric cardiac surgery. Pediatr
Crit Care Med. 2015;16:515–21.
Protein Catabolism during Pediatric Critical Illness
and Impact of Protein Delivery on Outcomes
Nilesh M. Mehta, MD, DCH, Director, Critical Care Nutrition; Associate Medical Director, MSICU, Boston Children’s Hospital; Associate Professor in Anesthesia, Harvard Medical School, Boston, MA
In this lecture Dr. Mehta discussed protein in critical illness; metabolism, intake, how can we measure protein
metabolism, and what are the next steps in optimizing it.
The history of protein is fascinating. It started in Paris
with Francois Magendie (1816) who said that dogs would
die if they were fed only with CHO and fat. At that time,
protein was only for the rich people and for the soldiers.
Jacob Berzelius (1830), in Sweden named protein based
on the Greek word “protas”, which means of primary importance. Justus von Liebig (1845) from Germany and
Wilbur Olin Atwater from the USA increased the estimated
protein requirements to 115 grams per day for a healthy
young adult working in the field. Then came the tempering effect during the 1920s, when vitamins, micronutrients,
and energy gained importance once again. In 1950, the
appearance of kwashiorkor in Africa brought protein back
to the center of both the global and political stage. The
“World Protein Gap” occured between 1950 and 1970,
when the United Nations declared protein deficiency as
the single most important enemy and declared the importance of adequate protein administration.
The two individuals who brought protein into the ICU were
Sir Dr. Cuthbertson (1942) with his description of the metabolic stress response, and Dr. Dudrick who stabilized,
sterilized, and solubilized amino acids, making it possible
Dietetics Practice Section Newsletter - Winter 2017
to feed ICU patients.
Sir David Cuthbertson summarized his work in Lancet in
1942, with a discussion of the post-shock metabolic response (Figure 2). The human body has a double response to injury whether it is trauma, sepsis, burn, or surgery. Each of these insults drives the cytokine and the
neurohormonal response, which along with the counterregulatory hormones leaves the patient in a state of
insulin resistance. The result is the breakdown of endogenous substrates to release nutrients that can sustain the
individual to recover from the injury. This protein breakdown from the visceral protein or the muscle mass generates amino acids that enter the amino acid pool, which
can then be used for protein synthesis to make acute inflammatory proteins, heal wounds and tissue, and supply
glucose as a fuel for essential organs through the gluconeogenesis pathway.
Nitrogen balance has been the traditional way to measure
protein; nevertheless it misses the profound interaction
that is constantly going on, even in someone with normal
nitrogen balance. There is a tremendous amount of turnover that is happening, which is not measured through the
nitrogen balance.
The window into that world is stable isotopic methods,
which are amino acids labeled with C or N and/or H. C
Leucine or d5 Phenylalanine are injected either as a bolus
or a prime followed by a continuous infusion until steady
state is reached, then blood is sampled to pick up concentrations of these tracers in the plasma pool. Next a series
of equations are applied to reach a reasonable idea of the
protein balance, protein synthesis, and protein breakdown. You can also use the n product enrichment method, using N15Glycine given intravenously or enterally and
then measured to determine how much enrichment is niFigure 2
Continued on next page
13
trogen, urea and ammonia and hence the end product.
A more sophisticated method, used in burned pediatric
patients, is d5 phenylalanine. After sedating the patient,
d5 phenylalanine is infused through femoral arterial and
venous catheterization. After giving a prime dose and 5
hours of constant infusion of the tracer, venous and arterial blood samples are taken, and different formulas are
applied with the objective of obtaining protein balance,
protein synthesis, and protein breakdown. It is interesting
to know that phenylalanine in the peripheral tissue does
not get metabolized, so there is no oxidation going on at
that level; therefore the rate of disappearance from the
pool of this tag phenylalanine gives a good idea of synthesis. In pediatric burn patients, a dramatic increase in protein breakdown is observed, far more than the synthetic
capabilities, and as a result, the nitrogen balance is negative for 6-9 months. After 12 months the protein breakdown severity finally declines to nearly zero. DEXA scans
were also taken during this study and showed that with
negative protein balance the lean body mass was eroded
and muscle mass decreased.1
Deuterium, heavy water, is one of the two stabilizer isotopes of hydrogen that we have on earth. It is present in
very small quantities even in tap water, and it is normally
present in human body in small amounts. Deuterium can
be used to determine body composition. Initially, it is necessary to measure the basal quantity in the body, then
after a dose of deuterium it can be measured again to
quantify the enrichment. Since deuterium is like water, it
goes everywhere that water goes, so the dilution allows
clinicians to calculate total body water and fat free mass
with the use of the isotope ratio mass spectrometer. This
technique was tested in children with short bowel syndrome; even with their poor gut function they could absorb
it. An important advantage is that deuterium can be tested in the urine without needing a femoral artery and a
central venous catheter. The deuterium results of body
composition were compared to the DEXA scan and very
similar results were found.
In critically ill patients, the 15NGlycine method was used
with an oral bolus. In a study of 19 patients with thoracic
surgery with a median age of 13.8 years (SD 12.1-15.1),
anesthesia time of 5.9 hours (SD 4.5-7.3), and surgical
time of 3.7 hours (SD 2.3 - 4.7), the results showed a dramatic increase in synthesis, but also a very high breakdown, much greater than synthesis. Patients were found
to be in a significant negative protein balance of 1g/kg/
day.
The comparison of negative balance with different methods showed very similar results between the 24 urinary
urea nitrogen balance, the N urea enrichment method,
and the mean 15 N end-product enrichment methods.
The problem with the stabilized isotopes studies is that it
is not known how much of the breakdown is contributed
by different areas, and skeletal muscle is the principle area of interest.
Myosin and 3MH-Actin contain histidine residues which
get post translationally modified and when this breaks
down they release 3-methyl-histidine/creatinine. This
compound is unique because it does not go back to the
synthetic pathway, so once it starts coming in, it is always
an indication of breakdown, thus knowing the percentage
of protein losses originating in muscle tissue.
After putting all these studies together, it seems that critically ill, surgical, and septic patients have elevated protein
synthesis compared to healthy children. The protein
breakdown is much more elevated, and they are all in
negative protein balance compared to healthy children.
So how much protein are we feeding our patients? We
need to pay attention to the different steps that need to be
followed: first the requirements, then how it can be translated into recommendations, the prescription, and finally
the delivery.
Beginning with the requirements, one of the most important methods is the Indispensable Amino Acids Oxidation (IAAO). If there is an abundance of protein in the diet, there is going to be less of the given tracer breaking
down to try to create energy. So if the intake goes from
zero to an increased amount of protein intake, the marker
of oxidation of the essential tagged protein starts slowing
down until it reaches a plateau. This is used as the average requirement estimation (EAR), to which is added two
standard deviations to obtain the RDA. Table 2 shows the
differences in the protein requirements estimated by EAR,
the RDA, and the IAAO. The difference between the EAR
and the IAAO is nearly doubled.
In the international study that Dr. Mehta recently completed,2 they looked at over 1,245 mechanically ventilated
patients from 59 pediatric ICUs in 15 countries and observed that a quarter of these patients at admission were
already malnourished. The protein prescription on average was 1.9 g /kg/day; but over a third of these patients
Continued on next page
Dietetics Practice Section Newsletter
14
Table 2
(37%) had significantly lower prescriptions compared to
what the requirements were. Protein delivery was 0.66 g/
kg/day. This came to a 1 g/kg/day deficit compared to
what was required, what was prescribed, and what was
delivered. Worldwide, the percentage of enteral protein
adequacy is ~50% on day seven. As protein adequacy
goes up, the odds of mortality come down. If clinicians
are able of deliver even 50% of what is prescribed, mortality risk significantly drops.
A study of the pediatric congenital heart disease population (J Pediatr Surg 2015 Jan;50(1):74) followed the
weight for age z-scores after patient discharge from the
ICU and then every three months during the first year. By
12 months, patients were doing well and their weight for
age z-scores had returned to baseline. The predictors of
good growth at the end of one year for these patients
were patch repair versus no patch repair, low birth weight,
and intake of at least 2.3 g protein/kg/day. Only those
who met this goal after accounting for the other factors
reached their growth potential.
Optimal protein intake improves outcomes in critically ill
children. Delivery options are changing the relationship
with energy intake in the diet; selecting enteral or parenteral nutrition or both, considering the amino acid composition, and applying bedside best practices.
The protein intake study2 showed that the factors responsible for better outcomes were early initiation of enteral
nutrition, the use of post pyloric feeding, the reduction of
interruption of enteral nutrition; and the most important
factor was the presence of an ICU dietitian.
Boston Children’s PICU uses a stepwise nurse driven
algorithm for enteral nutrition. A follow up of 80 patients
before and 80 after initiating the algorithm showed that in
Dietetics Practice Section Newsletter - Winter 2017
days four and five before the algorithm, 50% of patients
were achieving the goal, but after the implementation of
the algorithm this increased to 80% or even 100% in a
short period of time. Both the dietitian and the algorithm
make a successful combination that improve nutrient delivery.
Botran et al3 studied patients fed enteral nutrition exclusively. The patients were randomized in two groups, regular diet versus diet plus protein supplementation. The
regular diet provided 1.5 g/kg/day (SD1.3-2.1) and the
protein enhanced diet was 3.1g/kg/day (SD 2.6-3.4). The
results showed no side effects including biochemically,
but the nitrogen balance before and after in both groups
improved. The supplemented group improved from -2.3
(SD -3.0 to -1.2) to 0.5 (SD-0.6 to 0.8). Even though
these results are not conclusive it gives the message that
this can be done safely.
The traditional relationship between protein and nonprotein calories and total calories in the enteral formulas
should be rethought. In a systematic review that included
9 trials, nitrogen balance was achieved only with a minimum intake of 57kcal/kg/day and 1.5g protein/kg/day.4
Particularly as we give hypocaloric feeding, we need to
ensure that provision of protein does not suffer. In addition to the provision of protein and calories, another way
to modulate the catabolism after pediatric burn injury is
anabolic agents that could improve muscle protein synthesis, such as propranolol and beta-blockers.
Body composition is the next frontier for us to address in
pediatrics, since it has direct implications in the functionality of the patient.
“Why critically ill patients are deprived: blame rests
squarely on the shoulders of the academic leaders and
clinical investigators who have allowed research on this
crucial question to lapse for decades… we ourselves are
not exempt from this criticism” - Hoffman and Bristian.5
References
1) Hart D, Wolf S, Micak R, Chinkes D, Ramzy P, Obeng M,
Ferrando A, et al. Persistence of muscle catabolism after
severe burn. Surgery. 2000; 128(2):312-9.
2) Mehta N, Bechard L, Zurakowski D, Duggan C, Heyland D.
Adequate enteral protein intake is inversely associated with
60-d mortality in critically ill children: a multicenter, prospective,cohort study. Am J Clin Nutr. 2015;102:199-206.
3) Botrán M, López-Herce J, Mencía S, et al. Enteral nutrition
in the critically ill child: comparison of standard and proteinenriched diets. J Pediatr. 2011;159:27-32.
4) Bechard L, Parrot S, Mehta N. Systematic review of the
influence of energy and protein intake on protein balance in
critically ill children. J Pediatr. 2012;161(2):333-9.
5) Hoffer J, Bristian B. Why critically Ill patients are protein
deprived. J Parenter Enteral Nutr. 2013; 37(3) 300-309.
15
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Dietetics Practice Section meeting:
Sunday, February 19 from 5:45 pm – 7:00 pm
Crystal D-E
2017 DPS LEADERSHIP COUNCIL
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