Download Scientific Posters Presented at Clinical Nutrition Week 2009

Scientific Posters Presented at Clinical Nutrition Week 2009
CANCER / LUPUS
SP-1 - THE EFFECT OF n-3-FATTY ACIDS ON QUALITY OF LIFE IN PATIENTS WITH
LUNG CANCER
Grith M. Poulsen, Dietician3; Michael Nørgaard, MSc1,3; Stina Dannerfjord, MSc1,3; Lotte Lauritzen,
MSc, PhD1; Jens B. Sørensen, MD, Dr Med Sci2; Poul Lange, MD2; Nikolaj . Jensen, MD2; Lotte W.
Boisen, MD2; Ramon G. Jensen, MD2; Mads Andersen, MD2; Jens R. Andersen, MD1,3
1
Dept Human Nutrition, University of Copenhagen, Copenhagen, Denmark; 2Dept Oncology 5071,
Rigshospitalet, Copenhagen, Denmark; 3Nutrition Unit 5711, Rigshospitalet, Copenhagen, Denmark.
Introduction: The purpose of the project was to examine the effects of a daily food supplement
consisting of fish oil on the quality of life of lung cancer patients. Previous studies of patients with
pancreatic cancer have reported that fish oil had positive effects in the palliative phase. We wanted to
evaluate the effects of n-3 fatty acids when administered in the early phase of disease during simultaneous
treatment with cytostatic drugs.
Methods: A randomized, controlled trial with 44 lung cancer patients. Patients were given a daily
supplement consisting of 20 ml of fish oil (FO) or rapeseed oil (RO). The fish oil supplied 2 g/d of
eicosapentaenoic acid (EPA), whereas the rapeseed oil supplied 1.6 g/d of α-linolenic acid (ALA). Before
and after the treatment we conducted blood tests, diet registrations, and quality of life using EORTC
QLQ-C30 and QLQ-LC13 questionnaires (altogether 25 scales describing different aspects of quality of
life). The erythrocyte n-3 fatty acids content was determined by gas chromatography. Twenty-four of the
44 patients completed the study. The statistical analyses evaluate the relationships between intake of n-3
fatty acids and quality of life variables. In addition it was analyzed whether the patients’ weight, appetite
and diet composition was influenced by the oil-supplement. Statistical analyses: the Spearman rank
correlation test and the Mann-Whitney rank-sum test.
Results: 1) There was a significant (p<0.05) direct correlation between the presence of nausea, vomiting
and fatigue and the increase in both erythrocyte EPA and DHA-content, but not the total n-3 fatty acidcontent. 2) The scores for nausea and vomiting were significantly higher at baseline in the RO- compared
to the FO-group (p<0.05). However, these scores tended to develop favourably for the patient during the
trial in the rapeseed group, whereas the scores in the fish-oil group developed unfavourably, although not
significantly so. 3) Among quality of life variables only scores related to side effects were significantly
different between the oil groups. 4) No significant differences were found between the groups regarding
weight, appetite and diet composition. 5) The patients reported compliance in ml oil ingested of 85%-FO
and 80%-RO. 6) The reported compliance correlated poorly with the increase in membrane content of n-3
fatty acids in erythrocytes.
Conclusions: Supplements with fish oil did not benefit lung cancer patients in the early stage of their
disease, and did not improve their quality of life. The results indicated that a supplement of fish oil had a
negative effect on nausea, vomiting and fatigue compared to rapeseed oil. These conclusions are,
however, uncertain as the number of participants was small, and because of the poor compliance.
SP-2 - Nutritional screening in cancer outpatients
Talita Mayra R. Ferreira, RD1; Kelly Araújo, RD1; Patrícia Brito, RD1; Isabel Correia, MD, PhD2,1
1
Associação Mário Penna, Belo Horizonte, Brazil; 2Surgical Department, Federal University of Minas
Gerais, Belo Horizonte, Brazil.
Introduction: Malnutrition has been frequently reported among hospitalized patients with malignancies.
Weight loss is related to impaired response and tolerance to treatment, and can reduce performance status.
It is also related to longer hospital stay and higher mortality. Therefore, identifying the nutritional risk of
these patients, especially when still in ambulatory care, allows early indication of nutritional therapy and
helps maintain or increase body weight, improve immunological function and treatment tolerance as well
as promotes patient’s quality of life.
The aim of this study was to assess nutritional risk in outpatients with malignancies, before radiotherapy
and/or chemotherapy treatment.
Methods: This study was carried out in a general hospital in Belo Horizonte (Brazil), from August 2006
to June 2007. Outpatients previously untreated, or who had undergone surgery, radiation or chemotherapy
three months or more before the current screening, were included. Patients with metabolic, infectious and
degenerative diseases were excluded. The patients were assessed by means of Nutritional Risk Screening
(NRS-2002), and performance status was established according to the Eastern Cooperative Oncology
Group-ECOG scale. Statistical analysis using chi-square test was performed with SPSS software.
Results: Two-hundred and forty-four outpatients were screened. The mean age was 57.5 ± 14.1 years,
29.1% were 65 years old or older, and 50.8% were female. There was no difference between genders
concerning age (p>0.05). Among the patients, 56.6% had never been treated before. Low performance
status was found in 5.3% of the patients who presented with ECOG more than two. Malignant tumors of
the digestive tract were found in 25.5% of patients. The risk of malnutrition was found in 17.8% of
patients. The risk was higher in patients with ECOG more than two (18.6%), in those with malignant
tumors of the digestive tract (48.8%), in untreated patients (72.1%), and in patients older than 65 years
(43.6%) (p<0.05).
Conclusions: Nutritional screening should routinely be performed in outpatients with malignant tumors
of the digestive tract, older than 65 years, previously untreated, and with lower performance status.
SP-3 - FUNCTIONAL AND METABOLIC RECOVERY AFTER
PANCREATODUODENECTOMY: A LONG WAY HOME
Aldo A. Beneduce, MD; Simona I. Rocchetti, MD; Massimiliano Bissolati, MD; Nicolò Pecorelli, MD;
Marco Braga, Professor of Surgery
Surgery, IRCCS San Raffaele Hospital, Milan, Italy.
Introduction: Despite newest approaches in the optimization of perioperative care for elective surgical
patients, few data exist on medium period rehabilitation after major pancreatic surgery in terms of
nutritional profile and muscular functions. In fact severe stress, as a result of trauma or surgery is
characterized by major changes in metabolism, with subsequent alterations in food intake, body
composition, fatigue, and reduced quality of life.
Objective of this study was to evaluate the impact of pancreatoduodenectomy (PD) on micronutrients
plasmatic levels and functional/nutritional recovery in patients undergoing surgical procedure.
Methods: In our hospital we observed 28 consecutive patients undergoing PD for malignancy. In all
patients C and E vitamins, selenium and zinc plasmatic levels were registered baseline and on
postoperative day (POD) 1, 3, 7 and 30. Moreover, body weight with its variations and muscular strength
were measured. According to recent concept of early postoperative oral intake, patients were allowed to
assume oral solid food intake from POD 3, when tolerated. Muscular strength was measured in Kg by a
hand-grip dynamometer. Postoperative food intake, postoperative mobilization, length of hospital stay
and postoperative complications were also registered.
Results: 12 of 28 patients (43 %) had a preoperative weight loss. Mean preoperative weight loss was 7.7
kg, (11,1%), with a BMI assessed near the normal range (mean 25). Mean first oral postoperative food
intake occurred after 3,7 days. C and E vitamins, selenium and zinc plasmatic levels significantly dropped
after surgery. In particular we registered C vitamin , zinc and selenium levels assessed strongly below
normal lower levels. One month after surgery all the patients showed a 4,3 Kg average decrease in body
weight (p= 0,05 versus preoperative weight). No difference in weight loss was observed in complicated
patients compared to patients with an uneventful course. Mean preoperative muscular strength was
strongly lower than normal values in all patients (mean handgrip 36,5 Kg) considering the lower normal
level of 40 Kg. A further decrease was found on POD 1 (mean 30.5 Kg), POD 3 (mean 32 Kg), POD 7
(mean 34.5) and POD 30 (mean 34 Kg).Most of patients were able to stand in bed from postoperative day
1.
Conclusions: Near all patients undergoing pancreatoduodenectomy, regardless of their nutritional status
at the time of surgery, have a postoperative significant weight loss and micronutrients consumption, even
if they start eating food few days after the operation. This nutritional evidence is associated to the poor
functional outcome found in hand grip strength values
SP-4 - Weight-Loss Is Correlated to Side-Effects During Radiation-Treatment in Head-and Neck
Cancer
Gry B. Petersen1,2; Jørgen Johansen2; Jens R. Andersen1,3
1
Dept Human Nutrition, University of Copenhagen, Copenhagen, Denmark; 2Dept Oncology, Odense
University Hospital, Odense, Denmark; 3Nutrition Unit 5711, Rigshospitalet, Copenhagen, Denmark.
Introduction: It is well-known that cancer patients are in high risk of loosing weight during treatment
partly due to the disease, partly due to side-effects, and partly due to psychological factors. Head and neck
cancer patients often have severe weight loss before diagnoses and may have side-effects that influence
nutrition years after treatment.
We wanted to investigate if weight loss was correlated to complications during radiation treatment in
patients with cancer in the head and neck regions. Furthermore, to isolate subgroups with very high risks
of negative development in nutritional from anamnesis, objective clinical and biochemical factors
previous to radiation treatment.
Methods: Consecutive patients enter the DAHANCA database with longitudinal, standardized
registration of data related to a long row of clinical factors among those nutritional status in patients with
head and neck cancer. Data consist of to dataset data from time of diagnoses and data from radiation
follow-up. At present the database contains information about 672 patients in radiation therapy.
Negative nutritional development is defines as a weight-loss ≥ 5% per month and/or necessity for feeding
tube.
Results: Weight loss ≥ 5% per month was observed in 43% of the patients.
Cancer in the oropharynx (supraglottis) including the basis of the tongue, cancer spread, and frequent
radiation therapy (6 times a week, > 60 Gy/week) was predictive for negative development of nutritional
status.
Patients with loss of weight ≥ 5%/month had significantly more severe side-effects (dysphagia, mucosal
oedema, mucositis). The frequency of tube feeding was related to the degree of weight loss, and was done
in 33% of patients.
Conclusions: The treatment modulation is crucial for negative nutritional development. The severity of
the related morbidities is associated with weight loss. These results invites a randomized study of the
effect of early (prophylactic) tube feeding or intensive nutritional guidance, especially in patients with
cancer in the oropharynx, supraglottis, local cancer spread and frequent radiation therapy.
SP-5 - Body Composition Changes for Weight Loss Associated with Chemo-radiation for
Esophageal Carcinoma
Caitlin Curtis, PharmD1; Cassandra Kight, PhD, RD2; Tracey Weigel, MD3; Kenneth A. Kudsk, MD3
1
Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI; 2Nutrition, University of
Wisconsin Hospital and Clinics, Madison, WI; 3Surgery, University of Wisconsin-Madison, Madison,
WI.
Introduction: Chemo-radiation therapy for esophageal carcinoma affects body mass, especially fat free
mass (FFM, i.e. lean mass), which is difficult to quantify. Bioelectric impedance analysis (BIA) allows
FFM quantification. Index of FFM by height (FFMI) allows inter- and intra-patient comparisons over
time. Recently we showed that between ages 25-70, percentile values of FFMI in the US population are
stable in patients with a BMI between 18.5 and 30.
Objectives: To define and stratify body composition changes during chemo-radiation for esophageal
cancer using BIA and define percentile FFMI changes vs. the US population.
Methods: Methods:Ten patients scheduled to receive chemo-radiation therapy for esophageal cancer
were consented and prospectively studied. Exclusion criteria included contraindications to BIA, such as
metal implants or missing limbs. Measurements included height, weight, albumin, pre-albumin, Creactive protein and body composition using BIA (Impedimed) at two time points: once before and once
after completion of chemo-radiation. Age, gender, chemotherapy/radiation regimen and time between pre
& post BIA were recorded. Pre and post comparisons were analyzed using Student’s paired t-test with
significance at p<0.05.
Results: Seven of 10 patients (6/7 males with mean age 67: range 50-86) completed the study (2 chose
palliative care & 1 refused final BIA). Mean time between pre-and post-BIA was 9.7 (range 7-13.4)
weeks. Five patients lost weight (mean age 71 with range of 50-86; mean time between measurements of
9.6 weeks range of 7-13.4) and are the focus of this work.
When compared to US population data, the decrease in FFMI with treatment represented an 18.9 (range
3.7 to 33.5) percentile (Pre: 74.6+ 20.5 vs Post: 55.7+ 32.9; p= 0.0301) decrease in lean mass by BIA due
to the chemo/radiation protocol.
Conclusions: Chemo-radiation treatment results in both fat and lean body mass losses in most patients
with simultaneous decreases in serum constitutive proteins. While the absolute values for lean tissue loss
are notable, the decreases become more comprehendible to the clinician when interpreted in the context of
US population data.
Mean values n=5
Pre measurements
Post measurements
P values
Weight (kg)
88.5 ± 10.4
82.4 ± 14.1
0.024
BMI
30.1 ± 2.0
27.8 ± 2.6
0.025
FFM
58.8 ± 11.2
55.6 ± 11.5
0.012
FFMI
19.8 ± 1.1
18.7 ± 1.4
0.014
FM
29.6 ± 5.4
26.7 ± 6.2
0.085
Albumin
4.1 ± 0.2
3.8 ± 0.2
0.078
Pre-albumin
25.1 ± 2.9
21.5 ± 2.0
0.045
C-reactive protein
1.0 ± 1.7
3.2 ± 4.1
0.324
SP-6 - The Use of Micronutrient Supplements Among Patients With Systemic Lupus
Erythematosus
Ellie Aghdassi1; Jiandong Su1; Jaime O. Claudio1; Stacey Morrison1; Anne Cymet1; Carolyn Neville2;
CaNIOS Investigators1; Deborah Da Costa2; Paul R. Fortin1
1
Canadian Network for Improved Outcomes in SLE (CaNIOS), UHN-Toronto Western Hospital, Toronto,
ON, Canada; 2Medicine, McGill University, Montreal, ON, Canada.
Introduction: The use of micronutrient supplements has been steadily increasing among Canadians,
particularly among those with chronic diseases. Objectives: To assess: 1) the prevalence of micronutrient
supplement use among patients with Systemic Lupus Erythematosus (SLE); and 2) potential associations
between the use of micronutrient supplements and disease activity, perceived health status and health care
resource utilization.
Methods: The sample comprised of 202 patients with SLE (193 women & 9 men) from 4 institutions
across Canada. The diagnosis of SLE was made based on the presence of at least 4 out of 11 diagnostic
criteria established by the American College of Rheumatology. Disease activity was determined
according to the SLAM (Systemic Lupus Activity Measure, range 0-86) with scores on the SLAM > 8
considered clinically active. Subjects were classified as micronutrient supplement users (MSU) if they
took multivitamin/mineral or any single vitamin or mineral supplement at the time of enrolment. The
Medical Outcomes Study 36-item Short Form (SF-36), a measure of general health and quality of life,
was used to assess general, physical and mental health. MSU and non-MSU were compared using Unpaired student t-test or Chi square test using SPSS statistical package.
Results: Age at the time of diagnosis was between 9 to 68 years and disease duration was between 3.1 to
58.9 years. 54.2% of the sample was employed, 88.5% were in clinical remission and 11.5% had an active
disease at the time of enrolment. Vitamin/mineral supplements were used by 56.4% of participants.
Among MSU, 82.6% had post-secondary education and 37.7% were smokers. These values were 78%
and 42.7% in non-MSU respectively with no statistical significance between the two groups. Disease
activity scores were similar between MSU (4.76±0.35) and non-MSU (4.95±0.367). Perceived self-rated
health status was considered fair/poor in 33.6% of MSU and 25% of non-MSU (p=0.058). The mean
general health score (scale of 1-5; 1=excellent and 5=poor) was significantly worse in MSU (3.21±0.08)
than non-MSU (2.94±0.11; p =0.04). However, the physical (MSU: 38.5±1.12; non-MSU: 40.5±1.31) and
mental (MSU: 46.0±1.07; 47.5±1.24) component score of SF-36 were similar between the two groups.
MSU were more likely to visit health care professionals (85.2% of participants) than non-MSU (74.2%,
p=0.048). In addition, the use of diagnostic tests were more prevalent among MSU (80.5%) than nonMSU (59.1%; p=0.001).
Conclusions: Micronutrient supplements are frequently used by patients with SLE with no clear benefit
on disease activity or self-reported health status. Considering that many options are available, but with
limited research demonstrating benefits in SLE, patients need to be more educated about the use/choice of
nutritional supplements. In addition, under current regulations, vitamins, supplements and herbs do not
have to be evaluated by any regulatory agency, like the Food and Drug Administration (FDA), prior to
their sale. This leaves the consumer with little or no meaningful information about their benefits or side
effects.
SP-7 - A RANDOMIZED MULTICENTRE TRIAL ON PERI-OPERATIVE PARENTERAL
GLUTAMINE IN ONCOLOGIC WELLNOURISHED GASTROINTESTINAL SURGICAL
PATIENTS
Luca Gianotti1; Marco Braga2; Roberto Biffi3; Federico Bozzetti4; Sinpe Sinpe5
1
Surgery, Milano-Bicocca University, Monza, Italy; 2Surgery, San Raffaele University, Milano, Italy;
3
Abdomino-Pelvic Surgery, European Institute of Oncology, Milano, Italy; 4Surgery, General Hospital,
Prato, Italy; 5Italian Society of Artificial Nutrition and Metabolism, Firenze, Italy.
Introduction: Peri-operative administration of nutrients with immunomodulatory properties is still
debated. Recent meta-analyses showed that intravenous glutamine administration may reduce surgical
morbidity. Nevertheless, only underpowered trials and heterogeneous populations were included. This
trial was designed to investigate whether peri-operative intravenous glutamine supplementation may
affect outcome in major gastrointestinal (GI) operations.
Methods: A randomized, multicentre trial was carried out in 429 subjects candidate to elective major
gastrointestinal (GI) operation. Inclusion criteria were: documented neoplasm of the GI tract, weight loss
(WL) < 10% in previous 6 months, and age > 18 years. Exclusion criteria were: severe organ
insifficiency, ASA score > 3, ongoing infections, emergency operations. Patients received either a
continuous i.v. infusion of Alanine-Glutamine dipeptide (0.40 g/kg/day, equal to 0.25 g of free glutamine)
(G group, n=214), or no supplementation (control group, n=215). Either treatments begun the day before
operation and continued postoperatively for at least six days. No postoperative artificial nutrition (AN)
was allowed unless patients could not eat by day 7 or had major complications (transfer to ICU or
reintervention) or severe catabolism. Postoperative morbidity was assessed by independent observers.
Results: Patients were homogenous for baseline and surgical characteristics (type and duration of
operation, blood loss, transfusion rate). Mean percent of weight loss was 1.2±2.5 in controls and 1.3±2.4
in G group (p=0.67). Postoperative plasma glutamine levels remained stable in control patients, whereas a
constant increase was observed in G group on day +1 and +3 ( p< 0.05) as shown in the graph. Overall
postoperative complication rate was 34.5% (74/214) in G and 33.0% (71/215) in control group (p=0.82).
Infectious morbidity was 18.7% (40/214) in G group and 17.2% in controls (37/215) (p=0.78). The rate of
major complications was 9.3% in the G group and 8.8% in controls (p=0.97). Length of hospitalisation
was 10.3±4.9 days in G group vs. 9.7±3.6 days in controls (p=0.15). The rate of patients requiring
postoperative AN was 12.7% in G group and 11.6% in controls (p=0.85).
Conclusions: Glutamine supplementation does not affect outcome in this type of surgical patients. It
might be useful to test this treatment in undernourished subjects
CRITICAL CARE / SURGERY / TRAUMA
SP-8 - Feeding Critically Ill Patients: What is Happening in American ICUs?
Naomi E. Jones, RD, MSc1,2; Rupinder Dhaliwal, RD1; Miao Wang, MSc1; Xuran Jiang, MSc1; Daren
Heyland, MD, MSc1,3
1
Clinical Evaluation Research Unit, Queen's University, Kingston, ON, Canada; 2Department of
Epidemiology, Queen's University, Kingston, ON, Canada; 3Department of Medicine, Queen's University,
Kingston, ON, Canada.
Introduction: Considerable variation exists in nutrition practices in the critical care setting. Systematic
approaches to patient care, such as clinical practice guidelines (CPGs), can decrease variations in practice
and potentially improve clinical outcomes.
The Canadian Critical Care Nutrition CPGs, published in 2003 and updated in 2007, were developed to
assists critical care practitioners in making more appropriate decisions about feeding their critically-ill
patients, thus improving nutrition practices in Intensive Care Units (ICU) and potentially reducing
morbidity and mortality.The purpose of this study was to describe current nutrition practices in Intensive
Care Units (ICUs) in the United States of America (USA) and compare practices to the Canadian Critical
Care Nutrition Clinical Practice Guidelines (CPGs) and to other ICUs across the world.
Methods: We conducted an international, prospective, observational, cohort study. In January 2007, each
ICU recorded information on nutrition practices on a consecutive cohort of 20 mechanically ventilated
adult patients that stayed in the ICU for at least 72 hours. Data was collected from time of admission to
ICU for a maximum of 12 days. We aggregated the patient data at each ICU and then describe nutrition
practices across sites using means with ranges for continuous variables and counts with percentages for
categorical variables.
Results: Of the 158 participating ICUs, 39 were American sites. A total of 730 patients were enrolled,
with data recorded for 6907 patient days. Of all patients, 69.1% received enteral nutrition (EN) alone,
7.1% received parenteral nutrition (PN) alone, 10.4% received EN and PN combined, and 13.3% received
no artificial nutrition during the first 12 days of their ICU stay. The mean time to start of EN was 59.6
hours (28.6-149.1 hrs) after admission to ICU, with feeding not being initiated within 48 hours in 262
(46.8%) of patients. A total of 20 (51.3%) ICUs used a feeding protocol. Of all patients on EN with high
gastric residuals, 37.6% received motility agents and 16.8% had small bowel feeds. The mean head of bed
elevation was 29.4 degrees (15.0-38.5 degrees). In patients receiving PN, lipids were withheld on 32%
patient days. Supplemental glutamine (via enteral or IV route) was used in 5.9% patients. Enteral
formulas enriched with fish oils, borage oils and antioxidants was used in 2.1% (0-20%) patients on EN,
and arginine enriched enteral formulas were used in 13.5% (0-92.3%). The mean morning blood glucose
was 131.4 mg/dl (75.6-810 mg/dl), with 89.7% of patient days with blood glucose less than 180 mg/dl.
The overall nutritional adequacy was 54.0% (24.8-77.6%) for energy and 39.3% (14.1-77.4%) for protein.
Of the 7 participating geographic regions, the USA ranked lowest for nutritional adequacy.
Conclusions: Nutrition practices are sub-optimal in American ICUs and consequently overall nutritional
adequacy is poor. When compared to the Canadian Critical Care Nutrition CPGs, recommendations such
as small bowel feeding, use of early EN, withholding parenteral lipids (soy-bean oil emulsions), and use
of glutamine are not being followed. Future quality improvement initiatives should focus on these key
areas.
SP-9 - Injury Induced Alterations in Human and Murine Airway Cytokines
Joshua Hermsen, Resident in Surgery; Yoshifumi Sano, Fellow; F. E. Gomez, Fellow; Kenneth A. Kudsk,
Surgery Staff/ Senior author
Surgery, University of Wisconsin-Madison, Madison, WI.
Introduction: IgA is the lung’s specific anti-bacterial mucosal immune defense. Injury induces an innate
airway IgA increase in humans and mice that protects airways. Parenteral nutrition reduces basal airway
IgA levels, destroys antibacterial IgA defenses, and eliminates this injury response in mice. In vitro work
implicates TNFα, IL-6 & IL-1β in this injury response; also, blockade of TNFα & to some extent, IL-1β,
eliminates the murine IgA increase. This work compares human & (chow fed) mouse airway cytokine
injury levels to uninjured levels.
Methods: IgA, IL-6, TNFα, & IL-1β levels in proximal (trachea) and distal (R+L lung) airway lavages
(BAL) were obtained within 30 hr of injury from 11 severely injured, intubated (expected for > 5 d)
patients and compared to levels in 8 elective surgical patients. Male mice received no injury (n=7) or
injury (n=8) with abdominal + neck incisions with sacrifice at 8 hrs. for BAL (shown as concentrations in
BAL epithelial lining fluid) & serum cytokines.
Results: Injury significantly increased airway cytokines & IgA (table 1: nd=not detectable; Students ttest)
Conclusions: Injury significantly increases human & murine airway IgA with TNFα, IL-1β, and IL-6
levels acutely after injury. The data implicate a local rather than systemic-driven lung stress response
since cytokine levels are higher in airways than serum. Studies designed to study the loss of this IgA
injury response with parenteral nutrition should focus on lung cytokine alterations following injury
Table 1. Injury Induced Airway Cytokine Changes After Injury in Humans and Mice
IgA
TNFa
IL-1b
Human proximal
Injured
Control
Injured
Control
94±62
7.2±2.8
96±161
nd
p-value
Human distal
0.19
39±54
0.11
10±14
60±84
Injured
Control
IL-6
Injured
515±598 .48±1.37 874±773
0.027
0.45±1.7 446±721
1.3±2.8
Control
22±41
0.018
557±504
71±153
p-value
Mouse Airway
p-value
Mouse serum
p-value
<0.05
151±30
86±15
<0.05
<0.01
104±45
30±19
0.02
261±110
<0.01
Not done Not done 7.8±7.2
1.8±1.1
0.09
0.01
85±45
<0.01
nd
145±71
43±22
<0.01
nd
738±439 004±0.01
<0.01
SP-10 - Illness marker as a prognostic tool in intensive care unit: a prospective study
Maria Cristina Gonzalez, MD, PhD1; Jaqueline Maslonek, Medical student1; Gustavo L. Uliano, MD1;
Marina M. Munareto, Medical Student1; Luciano O. Teixeira, MD2
1
Universidade Católica de Pelotas, Pelotas, Brazil; 2Intensive Care Unit, Hospital Universitário São
Francisco de Paula, Pelotas, Brazil.
Introduction: Illness marker (IM) is a measurement obtained from multifrequencial bioelectrical
impedance analysis (MBIA). It seems to stand for a general indicator of sickness as a functional marker of
cell membrane. It's not very known if it plays any role as mortality marker in several clinical conditions
like Intensive Care Unite (ICU) patients. The objective of this study is to evaluate the usefulness of IM
measurement as a prognostic tool in an ICU population in a prospective study.
Methods: Eighty five patients (57.7% male, aged 59.9 ± 20.2 years) were evaluated in a longitudinal
way, when admitted to the ICU in an Universitary Hospital. Multifrequncy bioelectrical impedance
analysis (MBIA) was performed (QUADSCAN®, Bodystat) in every morning, at the same time, in all
patients, until discharge or death. Illness marker was obtained from the ratio between 200 kHz and 5 kHz
impedances. Apache score was obtained in the first 24 hours in ICU. The final patients' outcome
(discharge from the hospital or death) was also evaluated. IM values were compared between survivors
and patients who died during ICU or hospital stay. ROC curves were used to compare the prognostic
value of IM and APACHE to predict the death during ICU or hospital stay. All the analyses were
performed using STATA 9.2.
Results: Most of the patients were clinical (64.7%), and 15.4% had cancer. The median ICU and hospital
were 5 and 19.5 days, respectively. The mortality during ICU stay was 28.2% (24 patients). It was found
a weak (r = 0.24) but significant correlation (p = 0.03) between initial IM and APACHE score. Initial IM
and APACHE were significantly higher in patients who died than patients who were discharged from ICU
(0.85 X 0.82, 24.6 X 15.2, repectively). The final IM was also significantly higher in patients who died
(0.88) than in those who were discharged (0.80) from ICU. ROC curves showed that both APACHE and
initial IM have a similar performance to predict death during ICU stay (AUC = 0.79 X 0.67, p = 0.12) or
hospital stay (AUC = 0.74 X 0.71, p = 0.64).
Conclusions: The performance of IM from MBIA as a prognostic tool was comparable to APACHE in
this sample of UCI patients. Futures studies may determine the best IM cut-off value to be used in this
population.
SP-11 - Assessing the Prognostic Value of Plasma Vitamin C Status of Medical Intensive Care Unit
Patients
Erin Hoge, MS Canidate2; Lingtak-Neander Chan, PharmD, BCNSP1,2; Pamela Charney, PhD, RD2,1;
LeighAnn Mike, PharmD4,1; Poonam Sethi, RPh4,1; Dominic F. Reilly, MD3; Joanie Lee, RD, CNSD4;
Katie Farver, RD, CD, CNSD4
1
School of Pharmacy, University of Washington, Seattle, WA; 2Graduate Program in Nutritional
Sciences, University of Washington, Seattle, WA; 3School of Medicine, University of Washington,
Seattle, WA; 4Harborview Medical Center, Seattle, WA.
Introduction: Hypovitaminosis C has been reported in critically ill surgical, trauma and burn patients and
may negatively impact survival. Reduction of intensive care unit (ICU)-related morbidities in these
patients has been observed with vitamin C supplementation. Improved survival in trauma patients was
recently demonstrated using a vitamin C-containing antioxidant cocktail. Similar research in non-surgical
critically ill patients has not been conducted. Data on assessing vitamin C status in medical ICU (MICU)
are limited. The objective of this study is to assess the prognostic value of plasma vitamin C
concentrations in MICU patients.
Methods: This study was approved by the Institutional Review Board. Medical records of all patients
admitted to the MICU over an 8-month period with plasma vitamin C concentrations available were
reviewed. Patients were stratified into two groups (normal, defined as ≥ 0.46 mg/dL, vs. low according to
laboratory reference value) based on the initial plasma vitamin C concentration measured after MICU
admission. Data collected included demographic information, plasma vitamin C concentrations, serum
concentrations of creatinine, albumin, transthyretin, total white blood cell counts and C-reactive protein
(CRP), APACHE II scores, hospital and ICU length-of-stay, survival, and incidence of end-organ failure.
Plasma vitamin C was measured spectrophotometrically in our hospital laboratory. Unpaired Student’s ttest and chi-squared were used where appropriate. A p-value of 0.05 is considered statistically significant.
Least squares linear regression analysis was used to investigate associations within the low vitamin C
group.
Results: Seventy-six patients were included in final analysis. Hypovitaminosis C was observed in 51% of
patients. The normal and low vitamin C groups had similar demographic characteristics and median
APACHE II scores (29.0 and 28.5, respectively). The mean plasma vitamin C concentration was
significantly lower in the low vitamin C group than in the normal vitamin C group (0.24±0.12 mg/dL vs.
1.17±0.69 mg/dL, p < 0.001). No differences in mortality and length-of-stay were observed between
groups. Incidences of organ failure were similar. The only laboratory test with notable difference between
groups was a significantly higher CRP concentrations in the low vitamin C group (127.5±96.4 mg/L vs.
73.4±67.0 mg/L, p = 0.010; Table1). However, further analysis of the correlation between CRP and
vitamin C using linear regression analysis suggested an absence of association (Fig.1). To investigate the
effects of severely low vitamin C, patients in the lowest quintile of the low vitamin C group (n=8; mean
vitamin C concentration 0.06±0.04 mg/dL) were compared to the normal vitamin C group. Again, no
significant differences in clinical outcomes or measured laboratory values between the two groups were
detected.
Conclusions: Our data suggest that hypovitaminosis C is not associated with worse prognosis in this
patient population. Future clinical trials should focus on dose-response relationship between vitamin C
and body antioxidant status, and whether normalization of plasma vitamin C concentrations improves
outcomes in MICU patients.
SP-12 - Relationship between hyperglycemia, APACHE II and early enteral nutrition in critically
ill patients
João Nóbrega, Nut. João Flávio Nóbrega; Valéria Abrahão, Dra Valéria Abrahão
Hospital Ipanema Plus, Rio de Janeiro, Brazil.
Introduction: The purpose of this study is to assess the incidence of hyperglycemia in critically ill
patients, according to the APACHE II, correlating with beginning of nutritional therapy, presence of
diabetes and exogenous insulin infusion. 48 critically ill patients in three hospitals were enrolled in the
study.
Methods: . Patients were followed for 7 days. The beginning of TNE was classified as early (< 48 hours)
and late (> 48 hours) after admission to the ICU. The volume of enteral nutrition requirements and
volume of enteral infused were recorded trying to reach the target of 90% infusion in 72 hours at the start
of nutritional therapy. This study also evaluated the relation between infused calories and nutritional
needs, considered as satisfactory results > 75% of the daily requirement. Average blood glucose
maximum and minimum were recorded, as well as daily infusion of insulin, during the first seven days of
hospitalization. Patients were classified according to their nutritional status by Subjective Global
Assessment (SGA). The data were collected and analyzed statistically with Excel program.
Results: . Of the total patients, 24 patients (50%) were male and 24 patients (50%) were females. The
mean age was 70.46 ± 19.21 years (19-96 years). The most frequent diagnosis were pneumonia (12
patients), hypertension (11 patients), and stroke (8 patients). Nasogastric tube feeding were used in 25
patients (52.1%). The mean total energy expenditure calculated by Harris Benedict corrected by an injury
factor according to disease was 1415.3 ± 284.5 Kcal, and the mean average observed infusion were 76.15
± 22.73%. The highest average blood glucose was 178.2 ± 86.71 mg/dL. The average blood glucose
values, except in situations hypo and/or hyperglycemia, was 157.88 ± 79.76 mg / dL. The minimum blood
glucose of patients had an average of 137.42 ± 80.15 mg/dL. The SGA classified the patients in C 24
patients (50%), B in 12 patients (25%) and A in 12 patients (25%). 43 patients (89.6%) had some episode
of hyperglycemia, with similar profile of the genre. The mean APACHE II scores characterized the
population as critical, with an average of 20.15 ± 4, 55. Of the patients who had hyperglycemia (43), 27
patients (62.8%) were on early enteral nutrition, while 16 patients (37.2%) were on late enteral nutrition.
Regarding insulin requirements: 32 patients (62.7%) received continuous infusion of insulin and 16
patients (37.3%) had conventional therapy. Of the 32 patients who received insulin (62.7%), 12 patients
had diabetes (25%). It was concluded that in this 48 elderly and critically ill patients studied, a significant
group (89.6%) presented some episode of hyperglycemia, unrelated to diabetes mellitus (70%).
Conclusions: APACHE II confirmed that the population were critical and noted that the hyperglycemic
patients, most (48.84%) had already risk of mortality between 25% and 50%.
SP-13 - The Clinical Value of Standard and Immunomodulating Enteral Nutrition in Patients after
Extended Gastrointestinal Surgery - A Prospective, Randomized, Controlled Clinical Trial
Stanislaw Klek, Study designer; Jan Kulig, Chief of the Department; Marek Sierzega, Investigator; Piotr
Szybinski, Investigator
1st Department of General Surgery, Jagiellonian University, Krakow, Poland.
Introduction: Immunomodulating enteral diets were supposed to reduce the incidence of postoperative
complications in surgical patients. However, results obtained from recently published studies are
inconsistent. The aim of the study was to assess the clinical effect of immunomodulating enteral diets in
surgical patients after extensive gastrointestinal resections.
Methods: Between June 2004 and January 2008 201 well-nourished patients undergoing resection for
pancreatic and gastric cancer were randomized in a double-blind manner to receive postoperative enteral
nutrition with an immunostimulating diet (IMEN group) or standard oligopeptide diet (SEN group). The
outcome measures were: the number and type of complications, length of hospital stay, mortality,
treatment tolerance, liver and kidney function.
Results: 201 patients were initially enrolled, finally185 patients (92 SEN, 93 IMEN group; 69 F, 114 M,
m. age 61.2) were analyzed. The median postoperative hospital stay was 12.4 days (SD 5.9) in SEN and
12.9 days (SD 8.0) in the IMEN group (p=0.42). Complications were observed in 21 patients (23.1%) in
the SEN and 23 (25.2%) in the IMEN group (p>0.05). 4 (4.4%) patients in the SEN group and 4 (4.4%) in
the IMEN had surgical complications (p>0.05). There were no differences in liver and kidney function,
visceral protein turnover and treatment tolerance.
Conclusions: Results of our study showed no benefit of an immunomodulating enteral nutrition over
standard enteral nutrition in well-nourished patients after major gastrointestinal surgery.
SP-14 - BURN HYPERMETABOLISM AND DETERMINATION OF RESTING ENERGY
EXPENDITURE IN THE ERA OF EARLY EXCISION AND GRAFTING
Kevin A. Doty2; Beth Shields2; John J. Jones1; Charles E. Wade1; Steven E. Wolf1
1
Institute of Surgical Research, Brooke Army Medical Center, Ft Sam Houston, TX; 2Nutrition Care
Division, Brooke Army Medical Center, Ft Sam Houston, TX.
Introduction: Accuracy of equations to estimate caloric needs are not as reliable as indirect calorimetry
(IC), however, expense, time, and personnel required limit the practicality of IC. This study aims to
evaluate ten commonly used formulas for calculating energy needs in severely burned adult patients
undergoing modern burn care techniques compared to IC.
Methods: Subjects 18 years of age or older with at least 20% full thickness TBSA burn were enrolled
from October 2007 until May 2008. Calculated resting energy expenditure (REE) and measured resting
energy expenditure (MEE) were collected throughout hospitalization, and evaluated with descriptive and
comparative statistics. Linear regression was performed to assess strength of relationship. Bland &
Altman Plots were performed to determine bias based on a 95% confidence interval. Further evaluation
was performed on the studies with the highest correlation to determine appropriate time periods for use of
each equation.
Results: Six methods of estimating REE including 1972 Curreri, Harris Benedict × injury factors of 1.1
and 1.2, Xie, 30 kcal/kg, and 40 kcal/kg were significantly different from MEE; formulas by Carlson,
Milner, Zawacki, and the rate 35 kcal/kg were not. Carlson’s equation had the highest correlation (r2=
0.69) with a bias of -825 to +807 kcal per day followed by Milner’s (r2= 0.66) with a bias of -884 to +912
kcal per day. When the Carlson equation was used on or before 30 days from injury, the association
improved (r2= 0.91); when the Milner equation was used after 30 days from injury, the association
improved (r2= 0.97).
Conclusions: These findings support the use of the Carlson equation up to 30 days from injury, and the
Milner equation beyond 30 days to estimate REE in the severely burned.
EATING DISORDERS / OBESITY
SP-15 - The evaluation of our Eating Disorders-Nutritional Education Program
Carmen G. Candela, MD1; Viviana Loria, MD1; Carolina Dassen, MD1; Thais Lourenço, MD1; Teresa
Lajo, MD1; Blanca Amador, MD2; Belen Bardon, MD2; V ED Multidisciplinary Team, MD2
1
Departament Nutrition, Hospital U La Paz, Madrid, Spain; 2Psychiatry Deparment, Hospital U. La Paz,
Madrid, Spain.
Introduction: As eating disorders comprise both psychological and physiological components, an
appropriate management of these disorders requires input from a number of disciplines, working together
in a co-ordinated manner according to our Practice Guideline. OBJETIVES: The Eating DisordersNutritional Education Program has the purpose to achieve healthier habits and modifying the eating
behavior; carried out by an expertise Nutrition Department Dietician and according to our clinical
protocol.
Methods: We included 89 patients (4 men) that received individual Nutritional Education with
weekly/fortnightly appointments along 6 months. Mean age 24±8 years, mean evolution time from the
diagnosis was 5±5 years and diagnosis were: Anorexia Nervosa (AN, Restrictive or Purgative) 58%,
Bulimia Nervosa (BN) 18%, Eating Disorder Not Otherwise Specified (EDNOS) 22% and Binge Eating
Disorder (BED) 2%. The evaluation anthropometric assessment, oral intake and Eating Attitudes Test
(EAT) 26 questionnaires in the first appointment and at the end of the program.
Results: After 6 months we found a reduction in vomiting episodes (from 3.4±7 to 0.9 ±2 /week, p=0.00)
and binge episodes in binge-purging AN and BN (from 2.2±5 to 0.7±2, p= 0.00). There was a significant
improvement in the intake of dairy food, vegetables, fruits, cereals and oil (p<0.05). At the beginning, 34
% consumed at least 3 of the 6 food groups within the recommended range, but at the end 70% did it
(p=0.002). The percentage of subjects that ate less than 4 meals per day was reduced from 70% to 19%
(p=0.000). After this Education Program 67% spent an adequate time to eat (25-45 minutes) and 54%
began to consume a healthier menu according to Spanish culture (first and second dishes, bread and
dessert).
ANR patients increased total calorie intake from 1043±500 to 1419±447 (p=0.04) and carbohydrates from
136±68 to 182±60 g (p=0.00). Furthermore, the intake of Ca, vitamin K, B2 and Folic Acid improved
significantly (p<0,005).
After treatment we found an increase of all anthropometric parameters in ANR group with a mean weight
increase from 46±7 to 49±7 kg (p=0.00). Patients with ANP and EDNOS maintained it between normal
ranges and BN y BED showed a clear tendency to normalization. The EAT26 questionnaire decreased
from was 32 to 25 points (p=0.001).
Conclusions: Our results have shown that our Eating Disorders Program and Nutritional Education
Program, induced very positive results in order to achieve a better nutritional status, healthier nutritional
habits and better illness evolution .Expertise Dieticians in Eating Disorders treatment have an essential
role within multidisciplinary teams as an adjunct to other treatments according to our Practice Guideline.
SP-16 - Relationship of Food Record Use and Weight Loss in the Veteran Population of Northeast
Ohio
Erin E. Jenks, MS, RD, LD1; Elizabeth C. Guzzo, MS, RD, LD2
1
Nutrition, Case Western Reserve University, Cleveland, OH; 2Nutrition, Louis Stokes Cleveland
Veterans Affairs Medical Center, Cleveland, OH.
Introduction: Obesity is a leading health issue associated with the development of co-morbidities and
increased health care costs. However, the effectiveness of noninvasive treatments including use of food
records in nutrition counseling is still debated.
The purpose of this research is to determine the relationship of food record use in nutrition counseling and
weight loss in the veteran population of Northeast Ohio.
Methods: Retrospective chart review of subjects enrolled in the MOVE! Weight Management Program
prior to Jaunary, 2008 at Northeast Ohio Veterans Medical Affairs Centers. Data collection included pre
and post-MOVE! weight, height, gender, age, ethnicity, number of sessions attended, and diagnosed comorbidities. Data were analyzed in August, 2008 using SPSS 15.0.
Results: Sixty-eight subjects (34 with food record use, 34 without) were included in this study. Ninety
percent of subjects were male with a mean age of 62 ± 10.5. Co-morbidities included 82.4% with
hypertension, 50% with diabetes, and 22% with sleep apnea. Weight loss between groups, food record vs.
no record (mean±SD) 9.4 ± 15.2 pounds vs. 4.2 ± 7.8 pounds (p=0.078) was approaching significance.
There was a significant weight change between males and females (5.7 ±10 pounds lost vs. 16.6 ± 23.9
pounds lost, p=0.025). When food records were used, the BMI change of women vs. men (3.0 ± 4.5 vs.
0.82 ± 1.4, p=0.05) was significant. A positive correlation was also found between number of sessions
attended and amount of weight lost (r=0.25, p=0.04).
Conclusions: The non-invasive treatment of obesity through nutrition counseling can effectively lead to
significant weight loss for overweight and obese individuals.
ENTERAL NUTRITION
SP-17 - NEW INTRODUCER METHOD FOR PERCUTANEOUS GASTROSTOMY IN A
PORCINE MODEL
John Fang, M.D.1; Christopher Maxwell, M.D.1; James G. Carlisle, M.D.1; Robert E. Glasgow, M.D.1;
Kristen Hilden, M.S.1; Jeremy Ollerenshaw, Ph.D.2
1
Gastroenterology, University of Utah HSC, Salt Lake City, UT; 2Research & Technology, KimberlyClark Health Care, Roswell, GA.
Introduction: Percutaneous gastrostomies (PG) may be placed endoscopically or fluorscopically with the
use of T-bar fasteners commonly used to affix the stomach to the anterior abdominal wall. To prevent
complications such as gastric perforation, infection, and upper GI bleeding, standard T-fasteners must be
released following adequate formation of adhesions. We examined the use of an innovative T-fastener
and introducer system yielding easier deployment of an efficient anchoring mechanism coupled with the
use of resorbable suture to allow for timed release of T-bars for safety during and after PG placement.
Methods: Sixteen juvenile farm pigs underwent PG placement using the introducer kit to place 3 Tfasteners in a triangular arrangement around a tentative abdominal stoma site using resorbable suture and
the Russell method of placement. Three differing visualization procedures were used, endoscopic,
laparoscopic and radiologic. With endoscopic placement of a second PG using the Ponsky pull method,
each animal served as its own control. Ease of use and functionality of the new T-bar fastener, and
subsequent gross and histopathological integrity of gastropexy stoma formation was assessed over 1 to 3weeks following PG tube placement.
Results: The test kit facilitated successful PG placement in all animals. Kit convenience scores were high
and were registered at 70%-100% of the scoring range. There were no complications of PG placement
using test or control devices. One study animal died immediately following the PG procedure due to
complications of anesthesia. At sacrifice all PG were intact and there was no evidence of infection,
disruption or significant leakage. Analysis of the probability of retaining all 3, or 1 or more of the kit Tbar fastener devices was 38% and 94% at 1 week (n=5), 0% and 51% at 2 weeks (n=8) and 0 and 10% at
3 weeks (n=2) respectively. Histopathological indices of inflammation were similar with a slight decrease
in fibrosis in test compared to control sites (p=0.02, n=15) and diameters of stoma tracts of all test and
control sites were similarly grossly robust and histologically mature (mean+sem: control 13.1+0.7mm,
test 12.1+0.4mm: p=0.2, n=15).
Conclusions: Placement and performance of PG using the new introducer method with novel T-fasteners
is similar to that of standard endoscopic PG placement in both ease of use and effective gastric anchoring,
with the absence of complications. Because the retention sutures used in conjunction with the new PG
placement kit are resorbed following placement, follow-up procedures to release T-fasteners and the
potential associated complications are obviated.
SP-18 - Use of Refractometry to Determine Volume of Formula Remaining in the Stomach
Improves Interpretation of Gastric Residual Volume and Facilitates Delivery of Enteral Nutrition
Stephen A. McClave, M.D, University of Louisville1; Wei-Kuo Chang, M.D, Tri-Service General
Hospital,Taipei, Taiwan2; Diklar Diklar Mikola, M.D, Miamisburg, OH4; Naomi E. Jones, Kingston
General Hospital3; Karen Beatty, University of Louisville1
1
Division of Gastroenterology, University of Louisville, Louisville, KY; 2Division of Gastroenterology,
Tri-Service General Hospital, Taipei, Taiwan; 3Community Health and Epidemiology, Queen's
University, Kingston, ON, Canada; 4Gastroenterology, Gastroenterology Private Practice, Miamisburg,
OH.
Introduction: The practice of monitoring gastric residual volume (GRV) through bedside aspiration is an
inaccurate measure of gastric emptying and a poor marker for tolerance of enteral nutrition (EN). As a
consequence, enteral feeding is often inappropriately reduced or interrupted; limiting the delivery of
optimal nutrition therapy. Alternative methods of monitoring gastric emptying are required. We designed
this prospective study to determine whether use of refractometry to calculate volume of formula
remaining would improve interpretation of GRV and change physician assessment of tolerance of EN.
Methods: Patients in a long-term acute care facility on EN requiring upper endoscopy to modify enteral
access (NG to PEG, PEG to PEGJ) were included in the study. After an overnight fast and 30 min gastric
aspiration, an Infused Volume of 200 mL or 300 mL of formula (Nutrin 1.0, Nestle, Glendale, CA) was
given randomly by bolus method. Beginning immediately after infusion and repeated at 15 min intervals
over a period of one hour, refractometry Brix Value (BV) measurements were made (before and after a 50
mL water flush). Total GRV was calculated each time by traditional bedside aspiration and by the Chang
Water Dilution technique. Formula Volume was calculated by multiplying the Total GRV from either
method by the quotient (BVinitial / BVfullformula). After final measure, patients underwent endoscopy
and aspiration of all remaining gastric contents (Total GRV) was done under direct visualization (and
Formula Volume calculated from this). A total of 18 physicians were asked to respond to a series of
questions on their interpretation of separate graphs derived from the measurements of Total GRV, and
Formula Volume for each patient (blinded and randomized). Descriptive statistics were used for patient
demographics, Total GRV and Formula Volume. Physician interpretations of the Total GRV, and
Formula Volume graphs were compared using Chi-square tests.
Results: A total of 16 patients (mean age 63.5 yrs, range 48-89; 62.5% male) were entered in the study.
Using Total GRV, a mean 93.6 +/- 14.8% of initial Infused Volume (or 46.7 +/- 5.4% of initial Infused
Volume plus water flushes) remained in the stomach at an average of 69.2 +/- 3.5 min post infusion.
Using final Formula Volume per refractometry, a mean of only 29.7 +/- 8.0% of initial Infused Volume
remained over same time period. The table shows that physician responses based on interpretation of
graphs for each patient were significantly different for graphs of Total GRV compared to graphs for
Formula Volume.
Conclusions: Use of Total GRV by traditional practice is difficult to interpret and underestimates gastric
emptying of infused enteral formula. Alternatively, use of Formula Volume (derived from Total GRV via
refractometry) provides a more relevant clinical monitor of tolerance of EN, allows more accurate
determination of gastric emptying, and better facilitates delivery of EN.
Physician Responses to Interpretation of Total GRV and Formula Volume Graphs.
Interpretation (18 responses per
Total GRV Graphs
Formula Volume Graphs
graph)
(n=16)
(n=16)
Pvalue
Gastric emptying is slow
52% (150/288)
13% (37/288)
<0.001
Gastric emptying is normal or rapid
33% (95/288)
84% (244/288)
<0.001
Patient is tolerating EN
36% (104/288)
85% (245/288)
<0.001
Would continue EN infusion
34% (98/288)
80% (230/288)
<0.001
Would stop EN
23% (66/288)
2% (6/288)
<0.001
Graphs are easy to interpret
53% (153/288)
85% (245/288)
<0.001
Interpretation of tolerance confusing
35% (101/288)
11% (32/288)
<0.001
SP-19 - Optimizing Nutrition While Avoiding Feeding Intolerance
Gerald Moss, MD, PhD, American Board of Surgery, American College of Nutrition, American College
of Critical Care Medicine
Biomedical Engineering Department, Rensselaer Polytechnic Institute, White Plains, NY.
Introduction: Our objective is to determine if postoperative paralytic ileus (“feeding intolerance”) is
triggered by localized distention at the enteral feeding site, and could be avoided by removing feedings
that exceed peristaltic outflow from that location.
Traumatized patients benefit from nutritional support, but have been restricted by gut malfunction
(“paralytic ileus”). Tube feedings are started slowly and increased gradually, delaying optimum nutrition.
Yet frequently we still “overfeed,” inhibiting recovery by causing abdominal distention, nausea, vomiting,
and secondary respiratory embarrassment (“feeding intolerance”).
A prospective study of 797 severe head injuries was recently reported in the Journal of Neurosurgery.
"The amount of nutrition in the first 5 days was related to death; every 10-kcal/kg decrease in caloric
intake was associated with a 30-40% increase in mortality rates."
The impaired immune competence of scalded rats was ameliorated by increasing enteral nutrition.
For fed versus unfed beagles after bowel resection, immune globulin synthesis was doubled. Anastomoses
had doubled the wound strength and collagen content by the fourth day.
The more vulnerable human G-I tract needs protection to tolerate “enteral hyperalimentation” capable of
meeting the hypermetabolic nutritional demands associated with such trauma (surgical, thermal,
neurological, etc.).
The peristaltic gradient increases from the stomach caudad. Localized dilatation at the feeding site could
trigger gastrointestinal vagal reflexes, further slowing the already sluggish gut. A “downhill spiral” of
generalized abdominal distention would result, with respiration secondarily impaired. Similarly induced
vagal cardiovascular reflexes in susceptible subjects could account for the 1:1,000 incidence of
unexplained bowel necrosis associated with jejunal feeding.
Methods: Thirty-one colectomy and 160 consecutive cholecystectomy patients were fed elemental diet at
>100 kcal/hr into the duodenum immediately postoperatively. Duodenal suction was applied 7 cm
proximal to the feeding site, to efficiently aspirate all swallowed air, secretions, and excess feedings that
refluxed. The degassed aspirate was filtered and re-introduced manually via the feeding channel.
Hourly assays were performed for nitrogen balance, serum amino acids, and presence of removed
feedings (carbohydrate) in the aspirate. The colectomy patients had X-ray motility studies initiated 5 - 17
hours after surgery.
Results: Clinically normal motility and absorption resumed within two hours of colectomy. Fed contrast
traversed a secure and functional anastomosis, to ouline the rectum and exit in a bowel movements within
24-48 hours after colectomy. All patients achieved positive protein balance within 2 - 24 hours. Their
serum amino acids were elevated above basal within 2-12 hours after surgery.
The median time to discharge was 48 hours following colectomy. All 160:160 cholecystectomy patients
were discharged within 26 hours of surgery.
A single infection became apparent following cholecystectomy for acute cholecystitis. It resolved after readmission and drainage.
Conclusions: Limiting inflow to match peristaltic outflow from the feeding site consistently prevents
"feeding intolerance," with the most rapid resolution of postoperative paralytic ileus to date. Immediate
nutrition leads to earlier positive protein balance, with beneficial effects on immune competence and
wound healing.
SP-20 - Discrepancy between prescription and delivery of enteral nutrition in a general hospital in
Brazil
Juliana R. Martins, MD1; Dan Waitzberg, MD, PhD2,3; Glaucia M. Shiroma, RD1; Lilian M. Horie, RD,
MsD1,2; Luciana Logullo, RD1; Maria C. Ortolani, RD1; Viviane B. Hafez, RD, PhD1
1
GANEP, Sao Paulo, Brazil; 2Gastroenterology, School of Medicine of the Universidade de Sao Paulo
(USP), Sao Paulo, Brazil; 3LIM 35, School of Medicine of the Universidade de Sao Paulo (USP), Sao
Paulo, Brazil.
Introduction: Delivery of enteral nutrition (EN) in hospitalized patients is often inadequate.
Discrepancies between the optimal and the actually delivered calorie/protein intake have been reported,
but the reasons for that have yet to be thoroughly examined. This prospective observational study
addresses the dynamics of enteral feeding and the discrepancy between what is prescribed and what is
actually delivered to ward and critically ill, surgical and medical patients. Furthermore, the causes for
those discrepancies are identified and analyzed.
Methods: Ward and ICU patients receiving exclusively EN were followed for up to 21 days, over a
period of two months. The caloric target was estimated by the Harris-Benedict equation. Only physicians
that are certified specialists in enteral and parenteral nutrition made the prescriptions. All patients
received industrialized, open-system enteral formulae. The causes for not receiving full amount of tube
feed were non-mutually excluding. Bayesian statistical analysis was performed, with a P Value
(significance) of 5%.
Results: Seventy-two patients were enrolled (17 in wards, 55 in ICUs), in a total of 795 feeding days.
Fifty-one patients required EN for at least 7 days; in this group, there were statistical significant
differences between prescription and delivery of EN. The medium daily administered volume was 81,8%
[standard deviation (SD)=0,7%] of the prescribed. The targeted maximum feed volume was achieved on
day 5 in 73,1% of the patients; in average, patients achieved targeted maximum feed volume in 4,41 days
(SD=0,32). High gastric residue (18,1% of total patients, P<0,0001), obstruction of feeding tube (8,3%,
P<0,0004), accidental loss of feeding tube (23,6%, P<0,0001), patient refusal to treatment (4,2%,
P=0,0025), external physician’s interference (13,9%, P=0,0003), logistics (86,1%, P<0,0001) and nonjustifiable causes (22,2%, P<0001) increased patient’s chances of not receiving full diet prescription.
Conclusions: We observed inadequate delivery of EN and a long delay in achieving the targeted
maximum feed volume in this study. Amongst the causes of that, the most frequent were logistics,
accidental loss of feeding tube and non-justifiable causes. Even though there’s great concern about the
matter and a team of specialists handling these patients in our hospital, efforts should be made in order to
minimize such discrepancies and to reduce delayed target time. The results of this study shall contribute
for the improvement of patient’s care in this hospital.
SP-21 - Corpak with Cortrak
Periwinkle MacKay, RN, BSN, CCRN1; Yuri Villaran, MD1; Debbie Hampton, PhD2
1
CTVU, Saint Joseph Health Care, Lexington, KY; 2College of Nursing, University of Kentucky,
Lexington, KY.
Introduction: Background: Enteral tube feeding was not being started as promptly as desired due to the
length of time necessary to insert Corpak tubes and validate the correct tube placement. This study was
carried out as an initiative to improve patient safety and overall patient outcomes by reducing the length
of time needed to properly place Small Bowel Feeding Tubes (SBFT) and thus begin enteral nutrition
earlier for critically ill patients.
Objective:
To evaluate and validate the effectiveness of the Cortrak, a noninvasive device which aides in the bedside
placement of small-bore feeding tubes into the small bowel. The researchers evaluated the time period
between physician order and the initiation of enteral feeding, successful placement of the tube into the
duodenum on the first placement attempt, cost savings and complications related to both methods of tube
placement.
Methods: The researchers recruited 37 subjects from a convenience sample of patients in two separate
ICU’s. The Cortrak tube placement was done in conjunction with standard hospital protocol for small
bowel feeding tube placement. Abdominal x-rays were used to confirm the placement of the tubes. Data
was collected prospectively on 18 SBFT placements in ICU, where tubes were placed using standard
protocol (control group) and on 19 SBFT placements in a different ICU where the Cortrak was used for
tube placement (study group). The following variables were measured: (a) success rate of placement of
the small bowel feeding tubes into the small bowel on the first attempt, (b) number of x-rays needed to
confirm placement in the duodenum, (c) number of patients requiring fluoroscopy, (d) complications
related to SBFT placement, and (e) the time from physician order to initiation of enteral feedings.
Results: Data reveals that 36% more x-rays were done in the control group. Fluoroscopy procedures were
required in 44% of the patients in the control group in order to place the feeding tubes into the small
bowel, only 5%of those in the intervention group required fluoroscopy. The patients in the intervention
group were fed on average 9 hours and 36 minutes earlier than those patients in the control group.
Conclusions: This study validates that the use of the Cortrak device for placing small bowel feeding
tubes improves the efficiency and lessens the discomfort of the insertion procedure. The Cortrak device
helped reduce the time from physician order for tube insertion to the initiation of feeding. The total
overall cost of tube placement was also reduced.
Standard Placement, n =
18
Cortrak Placement, n =
19
Time interval from MD order to initiation of
feeding
29.0 hours
19.4 hours
Duodenal placement on first attempt
6
12
Average number of X-rays needed per patient
1.67
1.35
Complications
0
0
Average cost per patient
\$596
\$245
SP-22 - Assessment of feeding tube position and stylet reinsertion study utilizing an electromagnetic
guided placement device
Jan Powers, PhD,RN,CCRN,CCNS,CNRN,CWCN,FCCM
St. Vincent Hospital, Indianapolis, IN.
Introduction: Introduction: A new electromagnetic guided placement device can be used to assist with
placement of nasoenteric feeding tube placement. The tip of the stylet used with this device has an
electromagnetic transmitter; a receiver unit acquires the signal from the stylet as it moves through the
patient during the placement procedure.
The purpose of this study was to assess daily position of small bowel feeding tubes placed using an
electromagnetic placement device. The secondary goal of this study was to assess for any complications
occurring during reinsertion of the feeding tube stylet.
Methods: This descriptive, prospective study was undertaken to assess daily feeding tube position and
safety of stylet reinsertion. Patients with a feeding tube placed into the small bowel utilizing the
electromagnetic guided placement device were included in this study. Patients were included in the study
within 24 hours of feeding tube placement. Informed consent was obtained on all patients prior to
enrolling the patient in the study. After tube removal, tubes were assessed for punctures, tears or other
alterations of integrity of feeding tube and stylet. This was completed by visual inspection of the feeding
tube and the stylet, then submersing the tube in water with the tip of the tube clamped while injecting air
to assess for any alterations in the integrity of the feeding tube.
Results: The final sample consisted of 50 subjects. Minimal migration of the feeding tube was noted. The
feeding tube was in place an average of 7.9 (1-30) days. Stylets were re-inserted daily for the length of
time the tube was in place, no complications were noted during stylet re-insertion. Twenty-nine tubes
were retrieved for examination after removal. No loss of integrity of the feeding tubes was noted. Of the
tubes retrieved, one had been in place for 30 days and 10 of them were in greater than 10 days.
Conclusions: Minimal forward migration of feeding tubes was found in this study. This study also
demonstrates that the stylet used with the electromagnetic guided placement device system can be safely
reinserted into the feeding tube to assess for daily placement if desired. This will be beneficial for feeding
tubes that may inadvertently get pulled out. By reinserting the stylet, the location of the feeding tube can
be assessed and the tube can be advanced without placing the patient at undue risk and pain of a new tube
placement.
SP-23 - Should Bedside Feeding Tube Placement be a New Role for Nutrition Support Dietitians? A
Decision Analysis
Amy Peppard, MHA, RD, LD
Nutrition Services, University of Kentucky Hospital, Lexington, KY.
Introduction: Nutrition management in the intensive care unit (ICU) is an essential part of the treatment
of critically ill patients. Patients in the ICU are frequently unable to consume food orally, so a feeding
tube is often placed as an alternative route to provide these patients with required nutrition. Usually
feeding tube placement is the responsibility of the physician or nurse; however, other patient care
responsibilities often take priority for these clinicians, which makes feeding tube placement difficult to
perform in a timely manner. The purpose of this study was to determine if initiation of enteral nutrition is
more timely if nutrition support dietitians place feeding tubes instead of nurses.
Methods: This study took place at the University of Kentucky (UK) Hospital, which is a large Level I
trauma facility and academic medical center. Data was collected on 25 ICU patients who received a
feeding tube placed per nursing. The date and time a physician ordered a feeding tube placement was
collected. This time was then compared to the time that the feeding tube was cleared for use by the
physician, following the completion of x-ray verification. The time the tube feeding product was ordered
was also collected and compared to the time that feeding tube placement was ordered, in order to
determine the average time to place a feeding tube and initiate enteral nutrition.
Results: The average time to establish enteral access and have the tube cleared for use was 16 hours 26
minutes, with a minimum time of 3 hours 12 minutes and a maximum time of 37 hours 49 minutes. It was
determined that once the tube was approved for safe use the average time to begin the feeding regimen
was 8 hours 1 minute. The maximum time to begin feeding was 53 hours 1 minute and the minimum time
was zero minutes. The study found that 17 of 25 patients (68%) were ordered a tube feeding regimen
within 15 minutes of the feeding tube being cleared for use. The overall average time to establish enteral
access and begin the feeding regimen was 24 hours 27 minutes.
Conclusions: Enteral nutrition is often initiated in a timely manner in critically ill patients at UK Hospital
once the feeding tube is safely in place. Establishing the feeding access appears to be a main cause of the
overall delay in providing these patients with enteral nutrition. It is recommended that UK Hospital
consider initiating the practice of nutrition support dietitians placing feeding tubes, in order to provide the
patients with a higher quality of care, while possibly reducing the cost of care. The Gustafson Change
Model was utilized to provide UK Hospital with recommendations for implementing this new process.
The findings support four specific recommendations: 1.) Implement a training program; 2.) Develop a
pilot program; 3.) Hire an additional member to the nutrition support team; and 4.) Provide an in-service
to critical care physicians regarding the change and its significance.
GASTROINTESTINAL / LIVER
SP-24 - INADEQUATE NUTRITION COUNSELING AND POOR DIET INTAKE IN PATIENTS
ON THE WAITING LIST FOR LIVER TRANSPLANTATION
Lívia G. Ferreira, RD, MsC1; Lucilene R. Anastácio, RD1; Agnaldo S. Lima, MD, PhD2,3; Isabel Correia,
MD, PhD2,3
1
Food Science, Federal University of Minas Gerais, Belo Horizonte, Brazil; 2Surgery, Federal University
of Minas Gerais, Belo Horizonte, Brazil; 3Hospital das Clínicas, Federal University of Minas Gerais, Belo
Horizonte, Brazil.
Introduction: Malnutrition is highly prevalent in patients on the waiting list for liver transplantation.
Thus, dietary counseling and assessment of food intake should be part of the routine follow up. The
objective of the current study was to asses the type of nutritional counseling received by patients on the
waiting list for liver transplantation as well as to assess their diet intake.
Methods: Between 2006 and 2007, patients were assessed on the type of nutritional counseling that they
had previously received. Diet intake was assessed by using the 24 hour recall instrument as well as the
three day food record. Daily requirements were based on 35kcal/kg for energy and 1.2g/kg for protein.
Usual weight was considered for those patients without edema or ascites and a normal body mass index
(BMI). For those with edema, ascites or a BMI>25kg/m2 the calculations were based on the average BMI
of 21.7 kg/m2. The software Diet Pro4 was used to calculate diet intake. Paired t test was performed and
p<0.05 was considered significant.
Results: Hundred and fifty eight patients were assessed, mean age of 50 + 10.6 years old; there were
71.1% of men. Physical examination showed that 75.5% had edema and/or ascites. The majority of
patients (71.7%) reported that they had previously received some type of nutritional counseling. Most of
these (85.1%) were to avoid some food or nutrient in their diets (salt - 67.0%; fat - 57.7%; dairy products,
fish and eggs - 16.5% and red meat - 22.7%). Other patients (32,1%) were forbiden to eat salt (55.0%),
overall animal protein (37.5%) and red meat (25.0%); whereas only 15.1% patients reported to have
received other types of counseling (increasing fruits and vegetables for example) and one patient reported
to have been oriented to eat more frequently smaller meals. Daily requirements and intake (energy and
protein) are presented in table 1. Calorie intake was 21.3 ± 8.8kcal/kg and protein intake was 0.8 ±
0.4g/kg. There was no significant difference in the analysis of food intake, when comparing the 24 hour
recall instrument and the three day food register.
Conclusions: Nutritional counseling given to patients on the waiting list for liver transplantation is
inadequate. This might contribute to inadequate food intake which worsens their nutritional status.
Strategies to individualize nutritional treatment should be considered on the follow up of these individuals
in order to improve food intake.
Nutrition intake versus nutrition requirements and percentage of patients who do not reach nutrition
requirements
Intake*
Mean±SD
% patients with intake below the requirements
Requirements**
Energy
Protein
1490.9Kcal±580.7*
2146.59Kcal±274.74**
56.0g±25.1*
73.6g±9.41**
82.1%
73.1%
SP-25 - Studying Colonic Fermentation of Lactose in Humans With Stable Isotopes Delivered Via a
Catheter
Tao He1,2; Steven Vanhoutvin1,3; Freddy J. Troost1,3; Koen Venema1,4; Hongwei Wang2; Ger H. Koek3;
Rober-Jan M. Brummer1,3; Roel J. Vonk2
1
TI Food and Nutrition, Wageningen, Netherlands; 2University Medical Center Groningen, Groningen,
Netherlands; 3Maastricht University Medical Center, Maastricht, Netherlands; 4TNO Quality of Life,
Zeist, Netherlands.
Introduction: When incubated with lactose in vitro, the fecal microbiota from symptomatic lactosemaldigesters produced more short-chain fatty acids (SCFA) at a faster rate than that from asymptomatic
maldigesters. In vivo studies are needed to verify the role of colonic fermentation in lactose intolerance.
The objective of the present study was to develop methods to study colonic fermentation of lactose in
vivo.
Methods: A multilumen feeding catheter was introduced in two healthy adults (male, Caucasian).
Progression of the catheter was aided by inflating the distal balloon and monitored by fluoroscopy. When
the catheter was located in the terminal ileum, an isotonic solution containing 500 mg of U-13C-lactose,
19.5 g of unlabelled lactose and 200 mg of 2H3-acetate was infused through the catheter at a rate of 4.5
ml/min for 45 min. Breath and peripheral blood samples were collected at a 15-min interval for 4 h.
Plasma 13C-acetate and 13C-glucose, and breath 13C-CO2 were analyzed with Gas Chromatography (GC)Combustion-Isotope Ratio Mass Spectrometry (MS), plasma 2H3-acetate with GC/ MS, and breath
hydrogen with GC. The ratios of 13C/2H3-acetate in plasma were calculated as reflections of acetate
production from colonic fermentation of lactose.
Results: Breath hydrogen and 13C-CO2 and plasma 13C/2H3-acetate increased synchronously, and plasma
13
C-glucose increased slightly in subject A. These indicate that the infused lactose was fermented in the
colon. In subject B, the increase in breath hydrogen lagged behind that in breath 13C-CO2. Plasma 13C-
glucose increased sharply. Increases in breath hydrogen and plasma 13C/2H3-acetate were lower in subject
B than in subject A. These suggest that in subject B, the infused lactose was partially digested in the small
intestine and partially fermented in the colon.
Conclusions: The applied approach provides a promising methodology to study colonic fermentation of
lactose and other carbohydrates in humans. Further development of the methodology include, e.g.
inclusion of electromagnetic imaging devices to improve monitoring of progression of the catheter, and
sampling from the intestine via the catheter.
SP-26 - Nutrition Counseling Can Modulate Habitual Dietary Pattern, Reduce Body Fat Percent
and Improve Liver Injury in Nonalcoholic Steatohepatitis.
Puneet Puri, M.B.B.S., M.D.; Sakita N. Sistrun, Clinical Research Nutrition Manager; Carol C. Sargeant,
R.N.; Varun Sharma, M.D.; Polly Tucker, R.N.; Ashutosh Naniwadekar, M.B.B.S., M.D.; Arun J. Sanyal,
M.B.B.S., M.D.
Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, VA.
Introduction: Nonalcoholic fatty liver disease (NAFLD) affects one out of every three Americans. It is
strongly associated with obesity and other components of the metabolic syndrome (MetS). Nonalcoholic
steatohepatitis (NASH) is a severe form of NAFLD, which can progress to cirrhosis and hepatocellular
carcinoma. Diet is integrally linked to the pathophysiology and management of the MetS and NAFLD.
However, dietary patterns in patients with NASH are not well characterized.
Objective: To identify the habitual dietary patterns in adult NASH patients with a potential for targeted
nutrition interventions.
Methods: Consecutive subjects with biopsy proven NASH who consented to provide dietary details in
food frequency questionnaire were selected. Clinical and biochemical data were obtained. Each individual
provided a three-day dietary history at baseline, six and twelve month follow-up intervals.
Anthropometric data were recorded; body fat percent was calculated, and the dietician counseled patients
during these visits. A comprehensive dietary analysis was performed using the Nutrition Data System for
Research (Nutrition Coordinating Center, University of Minnesota, Minneapolis, MN). Statistical analysis
was performed using paired t-test.
Results: A total of 27 subjects (59% females) with a mean (± SEM) age of 53.2 ± 1.9 years were studied.
All subjects were obese with mean body mass index (BMI) of 33.7 ± 1.3 kg/m2 and had mean body fat
percent of 40.6 ± 1.4. The mean aspartate (AST) and alanine (ALT) aminotransferases were 70.6 ± 16
IU/L and 87.9 ± 29.3 respectively. The habitual dietary pattern of subjects with NASH reflected average
intake of ~ 2000 Kcal/day with 57% carbohydrates, 29% fats and 14% proteins. Fructose, starch and
dietary fiber mainly contributed to carbohydrate intake. Interestingly, saturated fat consumption was ~
34%. The impact of nutrition counseling at initial (baseline) and follow up (6 month) visits was then
sought. The key findings are summarized in Table 1. Of note, there was no significant difference in mean
BMI at 6 and 12 months interval compared to the baseline. However, there was a significant decrease in
the intake of stearic, palmitoleic and oleic acids at 6 months, and this effect disappeared at the end of one
year. Also, there was a trend for decrease in fructose consumption at 6 months with reversal to near
baseline at one year. Glycated hemoglobin (HbA1c) did not differ significantly throughout the study
period.
Conclusions: NASH subjects consume significantly more saturated fats than recommended. Nutrition
counseling is a promising intervention strategy that reduced body fat content and improved
aminotransferases suggesting improvement in liver injury. However, it needs to be reinforced to maintain
sustainable dietary modification.
SP-27 - Pancrelipase Delayed-Release Capsules (CREON®) Zero-Overfill Formulation (To-BeMarketed) is Pharmaceutically Comparable to the Current Formulation.
George Shlieout, PhD; Andreas Koerner, PhD; Frithjof Sczesny, PhD; Bernd Thumbeck, PhD; Jens
Onken, PhD; Claus-Jürgen Koelln, PhD
Solvay Pharmaceuticals GmbH, Hannover, Germany.
Introduction: Pancreatic enzyme replacement therapy is essential to treat maldigestion and maintain
adequate nutrition in patients with pancreatic exocrine insufficiency (PEI) due to diseases such as cystic
fibrosis (CF) and chronic pancreatitis (CP). Pancrelipase delayed-release capsules, USP (CREON®) have
been used to treat PEI in the United States for over 20 years. A zero-overfill formulation (to-be-marketed)
of pancrelipase delayed-release capsules, 6,000, 12,000, or 24,000 units lipase, developed to comply with
FDA and European Union directives, is intended to be pharmaceutically comparable to currently
marketed CREON® 5, 10, and 20 (5,000, 10,000, and 20,000 units lipase) and to contain comparable
lipase activity. This investigational product will be labeled to comply with an FDA mandate, applicable to
all pancreatic enzyme replacement therapies, for zero-overfill of lipase units. The objective of this study
was to evaluate the lipase activity of both formulations and to demonstrate the pharmaceutical
comparability of the zero-overfill and current formulations of pancrelipase delayed-release capsules.
Methods: Actual enzyme activity was determined by estimating the enzyme activities of current
formulation CREON® 10,000 and 20,000 administered to patients with CF, CP, and post-pancreatic
surgery in six pivotal and supportive clinical studies. Enzyme degradation data from stability studies with
batches having similar packaging material were applied to the batches used in the clinical studies. At the
start and stop dates of treatment, the enzyme activities per capsule were estimated based on the enzyme
activities at time of manufacture and their stability behavior. In vitro gastric acid resistance and pH
dissolution profiles under discriminating conditions (rotation speeds 50, 75, and 100 rpm) were assessed.
Dissolution profiles were compared by calculating the similarity factor, f2, according to FDA guidance
(Guidance for Industry. Scale Up and Post-Approval Changes-MR: Modified Release Solid Oral Dosage
Forms, September 1997), with values of 50-100 suggesting similarity.
Results: The estimated lipase activity ranges for CREON® 10,000 and 20,000 at the time of
administration in the clinical trials were 11,299-12,569 and 25,341-27,522 units per capsule, respectively.
Based on these data from the current formulation, we derived the zero-overfill formulation label for lipase
activity of 6,000, 12,000, and 24,000 units per capsule. Both formulations showed comparable
performance, release kinetics and lipase, amylase, and free protease activities. Gastric resistance was
similar for both formulations; dissolution profiles were within the pre-specified similarity range at the
three rotation speeds (f2 values were >50).
Conclusions: The labeling of zero-overfill pancrelipase delayed-release capsules reflects the actual lipase
activity of both this and the current (with overfill) formulation, ie, one zero-overfill pancrelipase delayedrelease 12,000 capsule is equivalent to one current CREON® 10,000 capsule. The zero-overfill
formulation is also pharmaceutically comparable to the current formulation. These data suggest that
patients taking stable doses of the current formulation can transfer to the zero-overfill formulation without
dose titration or regimen modification.
SP-28 - Efficiency and safety of Early Enteral Nutrition after liver transplantation surgery
Sung Il Jung, M.D.; Seung-Hwan Chang, M.D.,Ph.D; Hae Won Lee, M.D.; Ik Jin Yun, M.D.Ph.D
Surgery, Konkuk University Hospital, Seoul, South Korea.
Introduction: Many surgeons think that nutritional support after liver transplantation surgery is
unnecessary due to the early beginning of oral feeding and nutritional improving effect of transplantation
itself. However, malnutrition more severe than moderate degree before transplantation is common and
many damages related to transplantation surgery easily deteriorate the graft function, so nutritional
therapy should be considered seriously in many cases. Even enteral feeding (EN) is more physiologic and
effective method, many regard ‘nil to mouth’ until gas-out is common sense and early application of EN
before ‘gas out’ is not secure and safe.
Methods: From June 2006 to July 2008, total 19 patients received liver transplantation in Konkkuk
University Hospital. Early EN is applied to all the transplants. Naso-intestinal tube is inserted during
operation and EN is started from first postoperative day. L-tube is removed at first postoperative day.
Feeding method is continuous infusion with 20 hour per day and beginning with water and increasing
concentration and amount. With oral diet, EN is ceased when the 80% purpose calorie is reached by oral
diet.
Results: EN can be started 15 hours after extubation. On the third day of post-operation, EN feeding
reaches to needed calories. Oral diet is beginning 4 days after transplantation. There is no complication
including wound problems and postoperative infection. Antibiotics is used until 1~2 days after operation.
No GI motility problem is provoked and all the scheduled EN can be performed successfully. Average
stay in ICU is 9.37 days and for average postoperative hospital stay, 39.6 days. No postoperative
mortality is occurred.
Conclusions: Early EN after liver transplantation surgery is safe and effective. All the patients are
tolerable to the early EN. No delayed wound healing and severe infectious complications are occurred
even for the more than moderate malnourished patients. Good outcomes may be closed related to the
proper nutritional therapy. Early EN after liver transplantation seem to be the safe and effective
nutritional therapy and recommended to all the liver transplantation patients.
SP-29 - Low Vitamin B12 and Vitamin D levels: association with lower bone density in Crohn’s
disease population
Mazen Issa, MD, CNSP; Amar Naik, MD; Kathryn Johnson, PA; Yelena Zadvornova, MD
Medical college of Wisconsin, Milwaukee, WI.
Introduction: it is estimated that 30-60% of patients (pts) with Crohn’s disease (CD) have lower-thanaverage bone mineral density, especially Crohn’s disease. However, the underlying mechanism has not
been clearly understood. Proposed etiologies are: vitamin D deficiency, corticosteroid therapy, smoking,
active inflammatory cytokine action on osteoclast and osteoblast activity. Recent studies have suggested
an association of low plasma vitamin B12 level with lower BMD. We sought to assess rate of vitamin D
and B12 deficiencies in our CD patients who have abnormal BMD. We hypothesized a potential
association and maybe cumulative negative effect of these two vitamin deficiencies on BMD in our
Crohn’s population
Methods: This was a retrospective cohort study evaluating all CD pts followed in our tertiary referral
center and had BMD assessed by DEXA. We included patients who had both 25-OH Vitamin D (25OHD) and Vitamin B12 levels drawn. Osteopenia and osteoporosis were defined based on the world
Health organization criteria as a T score between -1 and -2.5, and as a T-score less than -2.5,respectively.
We collected demographic information, disease location and behavior, smoking status and body mass
index (BMI). We classified the patients based on the BMD status into 3 groups: (A) Normal, (B)
osteopenia and (C) osteoporosis.
Results: There were 79 CD patients who had at least one BMD scan done. 76 pts of them (26 males and
53 females) had vitamin B12 and 25-OHD serum levels measured. 58 pts had normal BMD, 17 pts had
osteopenia and 4 pts found to have osteoporosis. Mean BMI was 28.6 + 7 in (A), 26 + 6 in (B) and 21 + 1
in (C). Average age at diagnosis was 30 + 14.4 in (A), 35 + 19 in (B) and 37 + 21 in (C). Mean disease
duration was 15.7 + 11.5 in (A), 16 + 13.5 in (B) and 23.3 + 18 in (C). The anatomic involvement with
Crohn’s was small bowel in 3 out of 4pts with osteoporosis. 49% of pts with abnormal BMD were
smokers. The mean 25-OHD in our cohort was 18.1+ 8.8 in (A), 15.6 + 7.4 in (B) and 14.4 ng/dl + 8.9 in
(C). Mean vitamin B12 was 448 + 359 in (A), 494 + 438 in (B) and 313 pg/ml + 101 in (C).
Conclusions: CD pts with osteoporosis have lower serum vitamin B12 compared with both osteoporosis
and normal BMD groups. There is a trend toward lower BMI and lower mean 25-OHD in pts with lower
BMD. Study results are limited due to small sample size.
SP-30 - DIETARY NUCLEOTIDES AMELIORATE GUT ISCHEMIA/REPERFUSION INJURY
IN A SUPERIOR MESENTERIC ARTERY OCCLUSION MODEL IN MICE
Annie Luo1; R. J. Zhang1; J. Felix2; A. Nguyen2; Koji Wakame3; Anil Kulkarni2,1
1
Pathology and Laboratory Medicine, The University of Texas HSC and Medical School, Houston, TX;
2
Surgery, University of Texas HSC and Medical School, Houston, TX; 3Reasearch & Development,
Amino Up Chemical Company, Sapporo, Japan.
Introduction: Tissues with a rapid turnover, such as the intestinal epithelium and immunocytes use
dietary nucleotides (0.25% RNA) as conditionally essential nutrients. T cells are dependant on
supplemental RNA for their function and maturation. RNA also restore immune function in protein
depravation and malnutrition. It is the objective of this presentation that the RNA will be beneficial in
intestinal growth and repair in a gut ischemia/perfusion model
Methods: Male ICR mice were fed either basal control chow or chow supplemented with RNA for two
weeks. Then mice were randomly divided into five groups: 1) SHAM group, 2) SMAO with control diet
with 30minutes reperfusion, 3) SMAO with control diet with 6 hours reperfusion, 4) SMAO with RNA
diet with 30 minutes reperfusion, and 5) SMAO with RNA diet with 6 hours reperfusion. Ileum, jejunum,
lung, and liver tissues were harvested for histological examination by H & E staining and for apoptotic
assays by tunnel staining. Tissue wet/dry ratio was measured to assess tissue edema.
Results: With control diet, SMAO caused severe mucosal injury (disintegration of lamina propia,
hemorrhage and ulceration) in ileum on 30 minutes reperfusion (Chiu score 4.0±0.51) and in jejunum
6hrs minutes reperfusion (Chiu score 4.0±0.43). RNA diet maintained the mucosal architecture and
significantly decreased the SMAO induced mucosal injury in ileum on 6 hours reperfusion, jejunum Chiu
score 4.0±0.43 with control diet, Chiu score 2.±0.37 with RNA. P=0.0008. RNA diet decrease ileum
edema on 30 minutes reperfusion. Ileum wet/dry ratio 3.3±0.6 with control diet, wet/dry ratio 3.11±0.22
with RNA diet. p=0.002. Lung biopsies had less end-organ injury and neutrophil infiltration in RNA diet
group than that in control group. Tunnel assays showed similar improvements in apoptotic events in
tissues.
Conclusions: Dietary RNA provides significant protective effects against mucosal I/R injury, and
SMAO-induced remote organ injury. Our results suggest a new application to inhibit I/R organ injury in
trauma patients at high risk for MOF. It is possible that gut protection may be one of the beneficial
mechanisms for the overall effects of dietary RNA. Further studies will clarify the mechanism
SP-31 - A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED PILOT STUDY OF
LACTOBACILLUS REUTERI FOR THE PREVENTION OF ANTIBIOTIC-ASSOCIATED
DIARRHEA IN HOSPITALIZED ADULTS
Lisa Cimperman1; Kathleen Best1; Melanie Oster1; Beth Mordarski1; Meghann Smith1; Autumn
Diligente1; Gina Bayless1; Julie Calmes1; Dawn Wiese2; Alison Steiber2; Jeffry Katz1,2
1
University Hospitals Case Medical Center, Cleveland, OH; 2Case Western Reserve University,
Cleveland, OH.
Introduction: Antibiotic-associated diarrhea is a significant problem in hospitalized adults, contributing
to increased length of stay, cost, and mortality. Probiotics have been proposed as a means to prevent
antibiotic-associated diarrhea. Lactobacillus reuteri has been shown to decrease acute infectious diarrhea
in children; however, L. reuteri has never been evaluated for the prevention of antibiotic-associated
diarrhea. Objectives: The purpose of the study was to evaluate L. reuteri for the prevention of antibioticassociated diarrhea in hospitalized adults.
Methods: In a randomized, double-blind, placebo-controlled pilot study, patients receiving antibiotics
were given L. reuteri 1 x 108 CFU b.i.d. or an identical placebo for 4 weeks. Stool frequency,
consistency, and gastrointestinal symptoms were monitored during the 4 week treatment period and for 2
weeks after therapy was discontinued.
Results: A total of 31 patients were enrolled in the study. Eight patients were excluded from the data
analysis due to inadequate length of study participation. Mean age was 51 years +/- 18 yrs, 63% were
female, 37% male. The most common diagnoses were pneumonia (20%), abscess (10%), COPD (6.7%),
and bronchitis (6.7%). The most frequently prescribed antibiotics were azithromycin (30%) and
vancomycin (16.7%). Thirteen patients received L. reuteri and 10 received placebo treatment. All
analyzed patients completed 4 weeks of either L. reuteri or placebo treatment. Patients treated with L.
reuteri had a significantly lower incidence of diarrhea compared to patients receiving placebo (incidence
of diarrhea was 50% in the placebo group vs. 7.7% in the probiotic group, p=0.02). There were no
differences in the incidence or severity of nausea, vomiting, abdominal cramping, bloating, gas,
constipation, and reflux.
Conclusions: In this placebo-controlled, pilot study, L. reuteri twice daily for 4 weeks significantly
decreased antibiotic-associated diarrhea among hospitalized adults. L. reuteri was safe and well-tolerated.
Larger, randomized studies of L. reuteri for the prevention of antibiotic-associated diarrhea are indicated.
HOME CARE
SP-32 - Complications in Crohn's Disease Patients Reqiring Home Parenteral Nutrition
Rene Rivera1; Dawn Wiese4; Douglas Seidner2; Cindy Hamilton1; Rocio Lopez3; Rezvi Razack5
1
Digestive Disease Institute, Cleveland Clinic, Cleveland, OH; 2Vanderbilt Center for Human Nutrition,
Vanderbilt University Medical Center, Nashville, TN; 3Quantitative Health Services, Cleveland Clinic,
Cleveland, OH; 4Lerner College of Medicine, Cleveland Clinic, Cleveland, OH; 5University of Medicine
and Dentistry of New Jersey, UMDNJ, Neward, NJ.
Introduction: Home parenteral nutrition (HPN) allows patients with acute or chronic intestinal failure to
maintain their nutritional status. Despite its advancements, this therapy can be associated with significant
morbidity. This report describes the complications associated with HPN in patients with Crohn’s disease
followed by the Cleveland Clinic HPN program from the years of 1986-2006
Methods: Using Microsoft Access a Crohn’s-HPN database was created by merging data from the
Cleveland Clinic’s prospectively maintained electronic HPN and colorectal surgery databases with
information from the medical charts of our patients. Subjects were included if they had Crohn’s disease
and at least 1 episode of HPN through the Cleveland Clinic. Patients were followed until the end of their
HPN episode or until death occurred. Complications leading to re-hospitalization were tabulated and
designated as mechanical, metabolic, or infectious. Chi-square and Wilcoxon rank sum tests were used to
analyze the data
Results: A total of 112 Crohn’s disease patients with 142 HPN episodes were included in this study. A
total of 222 complications occurred during the study period (1.9 complications/1000 HPN days). Patients
had between 0 and 23 complication with a median value of 1 and a median duration of 43.5 days to the
first complication. Infectious was the most common type of complication with the majority being
classified as sepsis. No significant association was found between infectious complications and age, HPN
composition, disease classification, small bowel or colon lengths, remaining functioning anatomy or type
of catheters used.
Conclusions: To our knowledge this is one of the largest and longest reports of HPN use in Crohn’s
disease patients. Our experience shows that septic complications continue to be the major co-morbidity
associated with HPN with catheter related sepsis accounting for the majority of these cases. These results
support the need for more research and interventions to reduce infectious complications associated with
HPN.
SP-33 - Development of a Home Total Parenteral Nutrition Quality of Life Instrument
Maitreyi Raman, MD, MSc1; Olivia Saqui, RN3; Mone Palacios, MSc1; Sari Czink, RD1; Leah Gramlich,
MD4; David Armstrong, MD, MSc2; Johane Allard, MD3; Claudio Violato, PhD1
1
University of Calgary, Calgary, AB, Canada; 2MacMaster University, Hamilton, ON, Canada;
3
University of Toronto, Toronto, ON, Canada; 4University of alberta, Edmonton, AB, Canada.
Introduction: Instruments that have traditionally been used to assess quality of life (QOL) in recipients
of Home Total Parenteral Nutrition (HTPN) have been well validated in patients with chronic disease, but
not for HTPN patients. Although there is a substantial amount of research published on QOL in HTPN
recipients, use of different unvalidated QOL instruments, scales, and aspects of QOL evaluated have
limited the reliability and generalizability of the true QOL in this patient population. Objectives: To
construct and psychometrically evaluate quality of life instrument (QOLI) specific to long term recipients
of HTPN.
Methods: An HTPN QOLI was developed by clinical nutrition experts at the University of Calgary based
on data obtained from an extensive review of the literature. The initial version of the QOL instrument
consisting of 37 items was circulated to a group of multidisciplinary experts involved in the routine
administration of HTPN comprised of 5 physicians, 7 registered dietitians and 5 registered nurses
nationally. Experts were asked to rate each item on a Likert scale ranging from 1-5; 1 = “not at all
important in assessing QOL” and 5 = “extremely important in assessing QOL”. Using a modified Delphi
process, the 37 items were reduced to 25 items based on agreement by experts that the item under
consideration was considered either very or extremely important in assessing QOL. A second version of
the QOLI was developed and circulated to national multidisciplinary experts using these items plus
additional items identified to be important. These items were then reduced to the final QOLI consisting of
22 items based on item importance among experts. The final QOLI was distributed to HTPN patients
across Canada to adduce evidence of construct and concurrent validity of the QOLI. Patients concurrently
completed the general health Short Form-36 (SF-36) QOL survey.We are in the recruitment phase of data
collection to establish concurrent and construct validity. Preliminary data were analyzed using SPSS
statistical software package and results are reported as mean + standard deviation.
Results: Twenty-two patients completed the HTPN QOLI (age=53.6 + 11.3l; females=15 (65.2%); years
receiving HTPN=9.1 + 7.2; days per week receiving HTPN=5.5 + 1.9). The main indication for HTPN
was short bowel syndrome n=16 (69.6%). Mean QOL score (%) on the new QOL HTPN instrument and
the SF-36 (%) respectively was 65.1 + 12.7 vs. 69.0 + 14.5. The HTPN QOL instrument had a Guttman
split-half reliability coefficient of 0.80. Pearson product moment correlations were significant between
scores obtained from the HTPN QOL instrument and SF-36 (r=0.62, p<0.003) providing evidence of
concurrent validity. A factor analysis was performed to establish construct validity using principal
component analysis (eigenvalues > 1) and varimax rotation. Four factors emerged: (1) Physical Ability,
(2) Psychological Outlook, (3) Sexual and Partner Relationships, and (4) Family Support. These are
theoretically meaningful constructs in addressing QOL issues in patients receiving HTPN.
Conclusions: Preliminary data suggest the newly-developed QOLI for patients receiving HTPN is
reliable, with evidence of content, concurrent and construct validity. This QOLI is specific to patients
receiving HTPN and potentially may identify barriers and therefore solutions to improving QOL in this
population.
SP-34 - Relationships Among Home Parenteral Nutrition, Food and Eating, and Quality of Life
Marion F. Winkler, PhD, RD1,4; Terrie Wetle, PhD2; Carol Smith, RN, PhD3; Julie O'Sullivan Maillet,
PhD, RD4; Riva Touger-Decker, PhD, RD4
1
Surgery/Nutritional Support Service, Rhode Island Hospital, Providence, RI; 2Community Health, Brown
Medical School, Providence, RI; 3School of Nursing, University of Kansas, Kansas City, KS; 4Nutritional
Sciences, University of Medicine and Dentistry of New Jersey, School of Health Related Professions,
Newark, NJ.
Introduction: The value of food and eating on social patterns, self-esteem, pleasure, and nutritional
status is not considered in most generic quality of life (QOL) tools. Similarly, none of the QOL
instruments used in prior studies of home parenteral nutrition (HPN) specifically address the importance
of food and eating. While HPN provides the basic need for nutrients, its impact on other human needs
associated with food requires further investigation. The aim of this research was to explore the meaning
of food and eating from the perspective of adults receiving HPN as their primary form of nourishment and
to describe how living with HPN and the ability to eat influences QOL.
Methods: The research design was qualitative using content and interpretative phenomenological
analysis. A purposeful sampling strategy was used to enroll adults with intestinal failure and HPN
dependency. Sampling continued until data saturation was achieved. Semi-structured interviews were
conducted by telephone, transcribed verbatim, and uploaded into a computerized assisted program
(NVIVO). A subsample of narratives were coded by a second reviewer. Intercoder agreement was >80%.
Results: The sample included 24 adults with short bowel syndrome (96%) and pseudo-obstruction (4%).
The length of remnant small bowel was 56.6+/-40.3 cm. The length of HPN dependency was 8.1+/-8.2
years. HPN was viewed as a lifeline and nutritional safety net. Most participants experienced reduced
pressure to eat once beginning HPN and expressed relief knowing HPN was meeting their nutrition and
hydration needs. Participants defined good quality as "being able to eat what I want, when I want". All
participants were able to eat. Factors interfering with eating and food enjoyment included pain, intractable
diarrhea, physician orders not to eat, restrictive diets, a perception of wasting money, and poor health.
Participants described being thirsty as far worse than being hungry. Three themes emerged from the data
analysis: (1) eating for survival, (2) eating for health benefits, and (3) eating for socialization. Participants
described how eating prior to HPN was a desperate and futile attempt to sustain themselves with oral food
and fluid resulting in weight loss and poor QOL. While receiving HPN, participants chose healthy foods
with an expectation of receiving immune benefits, promoting intestinal adaptation, and sustaining hope
and optimism that HPN could eventually be discontinued. Participants described strategies for restaurant
eating and creating positive social experiences with family and friends whether they were eating or not.
Conclusions: Being able to eat and enjoy food was an important component of good QOL. HPN helped
participants maintain weight and strength without the pressure of having to eat to survive. Eating
strategies were employed to minimize gastrointestinal pain and diarrhea. A healthier orientation around
food was adopted. Satisfaction was achieved from cooking, providing food for others, and participating in
family events. Social isolation was not evident as participants recognized the importance of being
together regardless of whether or not they ate a "normal" meal. Nutritional counseling should include not
only the nutrient content of food and management of diarrhea, but the social and emotional aspects of
food and eating.
SP-35 - Hyperbilirubinemia is More Common in Chronic Home Parenteral Nutrition Patients With
Catheter Related Bloodstream Infections *
John Siepler; Marianne Opilla; Reid A. Nishikawa; Tom Diamantidis; Rod Okamoto.
Nutrishare, Inc, Elk Grove, CA.
* Encore Presentation: originally presented at ESPEN 2008 Conference, Florence, Italy
Introduction: The cause of liver disease in chronic home parenteral nutrition patients (HPN) is thought
to be multi-factorial. Potential causes are excessive calorie delivery, deficiency of nutrients such as
choline, and infectious processes. Catheter bloodstream infections(CRBSI) and exit site infections(EI) are
common in HPN patients. We evaluated a large number of HPN patients to determine if abnormal
bilirubin (BILI) were associated with CRBSI and EI.
Methods: We examined the records of all HPN patients from one home care provider for 2006 and 2007.
We collected patient demographics and all BILI results as well as all CRBSI and EI. The patients were
divided into two groups; those who had a CRBSI and/or EI(Group 1), and those who did not(Group 2).
Mean maximum BILI and those who had BILI >1.5, >2, >3, and >5 were recorded in the two groups.
Statistics were done using a t test and Chi square with p< 0.05 being considered significant.
Results: There were 136 patients who qualified. Of those, there were 66(48%) wre in Group 1. Patient
demographics were not different in the two groups. Mean max BILI was significantly higher in Group
1(1.89±2.5 vs.1.14±1.4, p=0.02). Nineteen patients(29%) in group 1 and 10(14%) in group 2 had a
BILI>1.5(p=0.04). Eighteen(27%) in group 1 and 7(10%) in group 2 had a BILI>2(p=0.004). Ten(15%)
in group 1 and 3(4%) in group 2 had a BILI>3(p=0.02). Seven(11%) in group 1 and 2(3%) in Group 2
had a BILI>5(p=0.07). Using binary logistic regression group 1 was more likely to have an abnormal
BILI (OR1.5; 95%CI-1.01-2.1 p=0.047).
Conclusions: We examined BILI in 136 HPN patients for two years finding that abnormal BILI were
more common in patients who had CRBSI and/or EI. Mean max BILI and number of patients who had
BILI >1.5, 2, and 3 were more frequent in those who had CRBSI and/or EI. The causes of BILI elevations
in HPN patients are multi-factorial, but age, gender, duration of HPN, AA, CHO, and Fat provisions were
similar in the two groups. These results need to be confirmed in larger studies.
NUTRITON ASSESSMENT
SP-36 - Nutritional assessment in hospitalized patients: Impact of prealbumin in the diagnosis and
follow-up of malnutrition
Bulent Saka1; Gulistan B. Ozturk1; Sami Uzun1; Nilgun Erten1; Sema Genc2; Mehmet A. Karan1; Cemil
Tascioglu1; Abdulkadir Kaysi1
1
Internal Medicine, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey; 2Biochemistry,
Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey.
Introduction: High prevalance of malnutrition (20-60%) has been reported among hospitalized patients
in the past. Although poor recognition and monitoring of nutritional status is one of the main causes of
malnutrition in these patients, nutritional assessment is still not performed on a routine basis in many
hospitals. In this study, our aim was to assess the nutritional status of our patients during and after the
hospital admission and compare the results with their serum prealbumin (PAB) levels.
Methods: We enrolled 97 consecutive hospitalized patients into the study. Malnutrition risk was assessed
according to anthropometric data, Subjective Global Assessment (SGA) and Nutrition Risk Screening
2002 (NRS-2002) test results. Nutritional status of the patients were compared with their age, gender,
body mass index (BMI), medical history, weight loss, routine biochemical analysis including prealbumin
and hospital length of stay (LOS).
Results: According to NRS-2002 test, 57% of our patients had malnutrition or malnutrition risk, that was
well correlated with SGA (p<0.001, r=0.700). Multivariate analysis showed positive correlation between
malnutrition and age, weight loss, malignancy and serum CRP (p=0.046, p=0.001, p=0.04 and p=0.002).
NRS-2002 score ≥3 was found associated with prolonged hospital LOS (p=0.001). Nutritional status of
the patients were found associated with serum PAB levels (Pearson Chi-square: p=0.001, x2: 18.186)
(Table 1). Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic value
of PAB in the assessment of malnutrition risk were 94%, 32%, 0.67, 0.78 and 69 respectively. After 7
days of nutritional support, 12% malnutrition risk reduction was achieved (p<0.001) together with 20%
increase in serum PAB levels (p=0.003) (Fig 1).
Conclusions: Instead of reflecting overall nutritional status, low serum PAB may be considered as a sign
of increased malnutrition risk which requires further nutritional assessment. It can be used in the
monitoring of patients those are under nutritional supplementation.
Table 1: Serum prealbumin levels were compared with nutritional status of the patients
Serum Prealbumin
NRS-2002 Score <3
NRS-2002 Score 3-4
NRS-2002 Score >4
>0.17 g/l
13
1
3
0.10 - 0.17 g/l
15
10
8
<0.10 g/l
13
9
25
p = 0.001, x2: 18.186
Mean serum prealbumin level of the patients before and after nutritional supplementation.
SP-37 - A Multicenter Prospective Study in Brazil to Evaluate Malnutrition and Its Impact on
Outcome
Valeria G. Alves; Mônica H. Silva; Eduardo E. Rocha; Armando Porto-Carreiro; Flavia A. Netto; Sofia
M. Portugal
Rio de Janeiro's Chapter, Brazilian Society for Parenteral and Enteral Nutrition, Rio de Janeiro, Brazil.
Introduction: Malnutrition is frequent in hospitalized patients. Enteral and parenteral nutrition might
prevent complications and reduce length of stay.
Methods: A multicenter observational study in 12 private hospitals in Rio de Janeiro. The data included
patients randomized through a sort out method. Written informed consent was obtained from the patient
or family member. Subjective global assessment was performed by dietitians of each institution. Patients
were A when well nourished, B when moderately malnourished and C when severely malnourished.
Outcome was registered, as well as the use of enteral and parenteral nutrition. Statistical analysis was
done by student-t, qui-square, Kruskal-Wallis and Bonferroni tests.
Results: A total of 1492 patients were included, 775 females (51,9%) and 717 males (48,1%), with age
65±19 years. Of the whole population 893 (60%) were A; 511 (34%) were B and 88 (6%) were C.
Patients in groups B and C where older (p<0.001). Six hundred and eighty eight patients (46%) were
admitted due to medical problems, 415 (28%) due to surgical problems and 389 (26%) were in the
Intensive Care Unit. Surgical patients were less malnourished than the other groups (p<0.0001).
Comorbidities (neoplasia, neuropathy and diabetes) were prevalent in the malnourished (p<0.001).
Enteral or parenteral nutrition was offered to 28% of all patients, but only 53% of groups B and C
received it. Enteral nutrition was used in 255 (61%), oral supplements in 132 (32%) and parenteral
nutrition in 28 (7%) of the patients. Length of stay and mortality were significantly higher in groups B
and C, comparing to group A (graphic). Results are the same even excluding the 192 (12,9%) neoplasia
patients. Nutrition support did not influence outcome. Mortality and length of stay were higher in the
malnourished patients that received it, comparing to those that did not (p<0.001).
Conclusions: Malnutrition is prevalent in private hospitals in Rio de Janeiro and corresponds to a higher
mortality and length of stay. Only half of the malnourished patients receive nutritional support, although
75% of the severely malnourished did receive it. Nutrition support did not influence outcome in the
malnourished patients in this observational study.
SP-38 - Continuous Nutrition Risk Assessment Monitoring Correlates with Clinical Outcomes
James V. Sitzmann, Professor Surgery Indiana University; Cynthia Harmon, Roudebush VAMC; Kelli
Vaught, Roudebush VAMC; Imtiaz Munshi, Associate Professor Surgery, IU,Director Critical Care
Roudebush VAMC
Surgery, IU school of medicine, Indianapolis, IN.
Introduction: Objective: The aim was to continuously monitor the nutrition risk status of all patients
admitted to the surgical critical care unit and to determine if a correlation with clinical outcome exists.
Methods: Methods: Retrospective study of 100% of patients admitted over 9 months to the regional VAH
SICU. Subjective Global Assessment (SGA) and nutrition risk index (NRI) scores were obtained every 3
days and correlated with clinical results: morbidity and mortality.
Results: Results: The nutrition screening assessment was applied to 416 consecutive surgical specialty
patients admitted to SICU: age: 63.47 (mean), gender: 99% male; 1% female. SGA and NRI dual
assessments stratified patients’ malnutrition risk: 80% high risk, 10% moderate risk, 5% low risk, 5%
well nourished. The SGA and NRI high risk scores directly correlated with clinical outcome: 99.8 %
(r=0.98.9, p<0.0001). After admission, mortality correlated with a decrease in SGA or NRI score (change
avg:-5%, p<0.001). An improvement in SGA or NRI correlated with survival and reduced length of stay
(LOS) (p<0.05).
Conclusions: Conclusions: If widely applied, continuous nutrition risk monitoring may significantly
impact critical care patient management by identifying patients at high risk of poor outcomes related to
degree of malnutrition. This retrospective study strongly supports continuous SGA or NRI assessments as
a monitoring tool which could be applied to patients admitted to the SICU.
SP-39 - Trends And Organisational Determinants Of Malnutrition Prevalence Rates: A Logistic
Multi-Level Analysis
Judith M. Meijers1; Math Candel2; Jos Schols3; Marian van Bokhorst- de van der Schueren4; Ruud
Halfens1
1
Department of Health Care and Nursing Science, University of Maastricht, Maastricht, Netherlands;
2
Department of statistics, University of Maastricht, Maastricht, Netherlands; 3Department of General
Practice and department Tranzo, University of Maastricht and University of Tilburg, Maastricht,
Netherlands; 4Department of Nutrition and Dietetics, VU University Medical Centre, Amsterdam,
Netherlands.
Introduction: So far it is unknown which organizational determinants are influencing malnutrition
prevalence rates. The aim of this study was first to analyse the trends of the malnutrition prevalence, and
second to analyze the effect of (1)organizational determinants (like nutritional guidelines, dieticians
working, education, trained specialist, multidisciplinary meetings, ambiance, and weighing, and screening
at admission),(2) previous annual malnutrition measurements with the Dutch National Prevalence
Measurement of Care Problems (LPZ) and (3) the involvement in national improvements programs on the
malnutrition prevalence rates.
Methods: Measurements of, amongst others, prevalence were obtained annually in a multi-centre study in
hospitals, nursing homes and home care organisations. From 2004 until 2007 a standardized questionnaire
was administered, which involved measurements at three levels: institutions, wards and patients. The data
were analyzed by logistic multilevel analysis.
Results: Overall 80 hospitals, 141 nursing homes, and 48 home care organisations were included (total
patient N= 74496). The prevalence of malnutrition showed a significantly decreasing trend in hospitals
and home care. In nursing homes prevalence rates were stable. No effect was detected for the
organizational determinants. However, the more often hospitals and home care organizations participated
in the LPZ measurement the higher the decline of the prevalence of malnutrition over years (P < 0.001 ).
Also, the involvement in national improvement programs led to lower prevalence rates (P = 0.0271).
Conclusions: Malnutrition prevalence trends have decreased over years in hospitals and home care.
Participating in LPZ and involvements in national improvement programmes influenced prevalence rates
of malnutrition, indicating that awareness of the problem is a very important factor in changing
prevalence rates of malnutrition.
SP-40 - PROGNOSIS OF ELDERLY PATIENTS RELATED TO THE NUTRITIONAL STATUS
THROUGH THE SUBJECTIVE GLOBAL ASSESSMENT (SGA)
João Nóbrega, Nut João Nóbrega2; Valéria Abrahão, Dra Valéria Abrahão1; Tielle Direito, Nut Tielle
Direito1; Ana Paula Barreto, Mrs Ana Barreto2; Silvio Guimarâes, Nut Silvio Guimarães2
1
Hospital Ipanema Plus, Rio de Janeiro, Brazil; 2Curso de Nutrição, Universidade Estácio de Sá, Rio de
Janeiro, Brazil.
Introduction: Currently, due to the increase in life expectancy worldwide, an increase of the presence of
patients aged over 75 years interned in hospitals, whose nutritional status can be considered critical.
Differentiating the changes of natural aging of clinical signs of malnutrition, as early as possible, it is
essential to avoid prolonged malnutrition. The objective of this study is evaluate the correlation between
nutritional status assessed by the Subjective Global Assessment (GSA) with the clinical prognosis in
elderly patients (> 75 years and correlate the nutritional status of hospital admission in patients over the
age of 75 years with a worse prognosis and length of hospital stay.
Methods: : We included 139 patients in the study of both sexes, aged over 75 years, hospitalized in ICU
of two hospitals in Rio de Janeiro. All patients underwent the Subjective Global Assessment, and
therefore classified as A well-nourished, B moderate malnutrition and C severe malnutrition.
Results: The average age of patients was 83.80 ± 6.44 years. Pulmonary diseases and cancer were the
most common admission diagnosis. AGS graded the patients at the time of admission, in A-20%, B 40%
and C 40%. Mortality rates were 39,29% in the well nourished group (SGA A), 36,36% in the group with
moderate malnutrition (SGA B) and 53,57% in the severely undernourished group (SGA C). Length of
hospital stay were 36.50 ± 29 days in the severely undernourished (SGA C), 31.75 ± 24.76 days in the
group with SGA B and 25.61 ± 18.67 days in the group with SGA A. The length of stay in the intensive
care unit were 27.86 ± 3.33 days in the group with SGA C, 27.34 ± 24.74 days in the group with SGA B
and 20.84 ± 15.84 days in the group with SGA A. Mortality rate in postoperative period was 50% (n = 8)
in the severely undernourished patients classified as C, 37.50% (n = 6) in the group with SGA B and
36.36% (n = 4) in the group with SGA A.
Conclusions: Malnutrition is frequent in the elderly critically ill population and affects the prognosis,
regarding to mortality, length of hospital stay, length of stay in the intensive care and mortality in the
postoperative period .
SP-41 - Assessment of Resting Energy Expenditure Using the Harris-Benedict Equation and the
Sensewear Armband: A Comparative Study
Vassilios A. Alivizatos; Apollon Zygomalas; Maria Manousi; Efi Karampali; Mathiew Souchlakis;
Panagiotis Terzakis
Surgery, Nutrition Unit, "St. Andrew" General Hospital, Patra, Greece.
Introduction: Indirect calorimetry represents the most accurate method for resting energy expenditure
(REE) assessment, but it is difficult to perform in clinical setting. In daily clinical practice, some simple
equations such as the Harris-Benedict equation are widely used for calculating with relative accuracy the
REE, whereas, more recently, portable devices like the Sensewear Armband are used to estimate REE.
The aim of this study was to evaluate the agreement between REE estimated by the Sensewear Armband
and the Harris-Benedict equation.
Methods: Ten surgical patients (5 men, 5 women) with an age of 67.2 years ± SD 11.7 and a body mass
index of 24.4 kg/m2 ± SD 2.9, admitted for elective surgery, were prospectively studied. One day before
the scheduled operation, REE was estimated in every patient simoultaneously with 2 techniques: a
portable armband (Sensewear Armband) and the Harris-Benedict equation (considering stress, activity
and thermal factors). The same procedure was repeated for each patient on the 1st postoperative day. The
Limits of Agreements (LOA) and the correlation coefficient (CC) were used to evaluate the
interchangeability of the methods.
Results: The mean value of preoperative REE calculated by the Harris-Benedict equation was 1710.4
kcal/day ± SD 188.4, whereas with the Sensewear Armband was 1804.8 kcal/day ± SD 342.6;
postoperatively, REE was 1724.8 ± SD 218.3 and 1695.5 ± SD 210.1 respectively. The LOA were wide
(363 to -551.8 kcal/day preoperatively, and 288.7 to -230 kcal/day postoperatively) and CC was low
either preoperatively (0.76, p=0.001) or postoperatively (0.81, p=0.004).
Conclusions: The results of this study suggest that poor agreement exists between the Sensewear
Armband and the Harris-Benedict equation in the assessment of REE in normal-weight surgical patients;
consenquently, these two methods are not interchangeable for REE estimation.
SP-42 - The value of the thickness of the adductor pollicis muscle as an anthropometric parameter
for nutritional assessment in critically ill patients
Fernanda S. Caporossi, RD2; Rosalia Bragagnolo, RD1; Jose E. Aguilar-Nascimento, MD, PhD1; Diana
Dock-Nascimento, RD, MSc2
1
Surgery, University of Mato Grosso, Cuiaba, Brazil; 2Food and Nutrition, Federal University of Mato
Grosso, Cuiaba, Brazil.
Introduction: Malnutrition in hospitalized patients is a major problem and often is underdiagnosed. Early
recognition of malnutrition is important for nutritional support to be effective. Muscle dysfunction is a
common finding in malnourished patients and is associated with poor outcome. The thickness of adductor
pollicis muscle (APM) is a new anthropometric parameter. Few studies investigated the APM thickness as
an anthropometric parameter in critically ill patients. The aim of this study was to evaluate the useful of
the thickness of APM to assess malnutrition in an intensive care unit (ICU) of a tertiary hospital.
Methods: We prospectively examined 95 critically ill patients under either medical (n=78; 83%) or
surgical (n= 16; 17%) treatments. The median (variation) age was 65 [19-92] years. Male/Female ratio
was 55/40. Subjective global assessment (SGA) was recorded in all patients and defined as the gold
standard method to evaluate the nutritional status. The thickness of APM in both dominant and
nondominant hand, and various classical anthropometric parameter (total arm circumference [TAC] and
arm muscle circumference [AMC]) were measured. Patients presenting less than 12 mm for the thickness
of APM were considered as malnourished.
Results: Twenty-three (24.2%) patients were considered as nourished (SGA-A), and 72 (75.8%) as
malnourished (49 as moderate [SGA-B] and 23 as severe malnourished [SGA-C]). APM thickness of both
dominant and nondominant hand significantly correlated (p<0.01) with SGA for malnutrition.
There was also a significant correlation of all classical anthropometric parameters with the thickness of
APM for both hands (TCA: R= 0.36, p<0,001; AMC: R= 0.29 , p< 0,01).
Conclusions: APM thickness is a reliable method to assess nutritional status in ICU patients.
PARENTERAL NUTRITION
SP-43 - Effect of medium chain triglyceride/soybean oil based-emulsion on human lymphocyte and
neutrophil death
Maria F. Cury-Boaventura1; Renata Gorjão2; Thais M. de Lima2; Andre Borella P. Godoy2; Jarlei
Fiamoncini2; Franscisco C. Deschamps4; Francisco G. Soriano3; Rui Curi2
1
Institute of Physical Activity Sciences and Sport, University of Cruzeiro do Sul, São Paulo, Brazil;
2
Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo, Brazil; 3Division of Clinical
Emergency, University of Sao Paulo, Sao Paulo, Brazil; 4Universidade do Vale do Itajaí, Sao Paulo,
Brazil.
Introduction: The incorporation of lipid into nutritional therapy seems to optimize the provision of
energy requirements, essential fatty acids and may prevent many of metabolic disturbances associated
with intravenous feeding amino acids and glucose alone. For different parenteral fat emulsions, a
significant impact on immune system has been shown. The increase of susceptibility to infection on
parenteral nutrition has been associated to immunossupressor effects of fat emulsions. Intravenous fat
emulsions showed a varying immunomodulatory effect in dependence of the fatty acid composition. The
most frequently used intravenous lipid emulsions (LE) are rich in n-6 polyunsaturated fatty acids (PUFA)
triacylglycerols from soybean oil, however, these LE promote lymphocyte and neutrophil death (CuryBoaventura et al., JPEN, 30:115-123, 2006). A new emulsion containing 50% soybean oil and 50%
medium chain triglyceride (MCT) has been recommended as to prevent the e impairment in immune
function. In this study, the toxicity of a medium chain triglyceride/soybean oil-based emulsion
(MCT/SOE) on lymphocytes and neutrophils from healthy volunteers was investigated.
Methods: Seven volunteers were recruited and infusion of MCT/SOE was performed for 6 h. Blood
samples were collected before, immediately afterwards, and 18 hours after infusion. Lymphocytes and
neutrophils were isolated by gradient density using Histopaque-1077. The cells were studied immediately
after isolation, and after 24 h or 48 h in culture. The following determinations were carried out: plasma
triacylglycerol levels and fatty acid composition and levels, lymphocyte proliferation, production of
reactive oxygen species and parameters of lymphocyte and neutrophil death (viability, DNA
fragmentation, phosphatidylserine externalization, mitochondrial depolarization and neutral lipid
accumulation).
Results: MCT/SOE decreased the viability of lymphocytes and neutrophils by 17% and 15%,
respectively. Moreover, MCT/SOE increased lymphocyte DNA fragmentation from 2% to approximately
20 % and neutrophil DNA fragmentation from 20 % to approximately 50 %.
Conclusions: MCT/SOE given as a single infusion of 500 mL was toxic to lymphocytes and neutrophils
from healthy volunteers predominantly throught apoptosis.
SP-44 - PARENTERAL NUTRITION PRESCRIBING PATTERNS: WHAT'S IN YOUR BAG?
Ainsley Malone, MS, RD, LD, CNSD1; Mary Hise, PhD, RD2; Gordon Sacks, PharmD, BCNSP5; Steve
McClave, MD3; Mark DeLegge, MD4; LieLing Wu, MS2; Gary Zaloga, MD2
1
Pharmacy Department, Mt. Carmel West Hospital, Columbus, OH; 2Baxter Healthcare, Chicago, IL;
3
Division of Gastroenterology/Hepatology, University of Louisville School of Medicine, Louisville, KY;
4
Digestive Disease Center, Medical University of South Carolina, Charleston, SC; 5School of Pharmacy,
University of Wisconsin, Madison, WI.
Introduction: Despite published guidelines for the delivery of parenteral nutrition (PN), the
combinations of macro and micronutrients in the design of PN regimens are umlimited, poorly
standardized, and in practice previously undocumented. Objective: To describe PN prescription practices
by patient subtype, institution size, and adherence to A.S.P.E.N. Clinical Guidelines.
Methods: A prospective, observational study of PN prescribing was conducted in 24 university and
community based hospitals within the United States. The study included small (n=6, < 150 beds), medium
(n=10), and large (n=8, ≥350 beds) hospitals. All subjects were prescribed PN according to the standard
of care at each institution. Data were collected from initiation to cessation of PN use or 14 days. Day 3 of
PN was used as the goal (A.S.P.E.N. Recommendation: 25-35 kcal/kg/day, 0.8-2.0 grams protein/kg/day)
prescription day for statistical evaluation.
Results: A total of 233 subjects (46 % male, mean age 58.6 ± 17.1 year, BMI 26.6 ± 8.6, 52 from small,
108 from medium and 73 from large hospitals). Fifty- three patients were enrolled from the ICU. Twentyfour subjects (10.3%)
received enteral nutrition in combination with PN.
Eighteen patients received peripheral PN. The mean volume of PN prescribed was 1.79 ± 0.46 L/day.
Mean kcals/kg/day was 22.7 kcal/kg/day (range: 5.62 - 49.57; SD ± 7.82). The average amount of protein
prescribed was 1.19 ± 0.36 gram/kg/day (range: 0.31-2.77 gram/kg/day). When compared to A.S.P.E.N.
clinical guidelines, only 31% of patients on day 3 of PN met energy goals (62% < 25 kcal/kg/day, 7 % >
35 kcal/kg/day), whereas 84.5% fell within protein ranges (15% < 0.8 g/kg/day, 1% > 2.0 g/kg/day). The
mean lipid prescription was 0.6 grams/kg/day (range: 0-1.61 grams/kg/day). No patient exceeded
A.S.P.E.N. lipid recommendations. The mean energy and protein intakes for the ICU patients were lower
than ward patients at 20.6 ± 6.7 kcal/kg/day and 1.13 ± 0.3 gram/kg/day, respectively. By primary
medical condition, cancer patients received the most calories at 23.6 kcals/kg/day with 1.22 grams/kg/day
of protein. There were no significant differences in energy, macronutrients, or volume of PN delivered
among small, medium and large hospitals or among primary medical conditions. The following graph
depicts protein and calories provided to each patient on day 3; the box encloses the ranges of protein and
calorie recommendations from A.S.P.E.N. Guidelines. There were wide variations in electrolyte intakes
with many patients receiving intakes outside of A.S.P.E.N. guidelines.
Conclusions: Wide variations in PN prescribing patterns exist. Overfeeding of energy or protein by PN is
uncommon. Yet over 70% of patients receive insufficient calories and/or protein. Variation in pattern of
electrolytes prescribed appears to be less (except for Na+). Efforts to standardize PN prescriptions to
avoid extremes of protein and energy provision should be considered.
Electrolyte Intakes
Electrolyte
Mean ± SD
Range
A.S.P.E.N. Recommendations
Sodium (mEq/kg/day)
1.7 ±1.2
0-10.5
1-2 mEq/kg/day
Potassium (mEq/kg/day)
1.1 ± 1.2
0-3.9
1-2 mEq/kg/day
Magnesium (mEq/day)
12.4 ± 8.8
0-80
8-20 mEq/day
Calcium (mEq/day)
9.7 ± 6.9
0-60
10-15 mEq/day
Phosphorus (mmol/day)
22.2 ± 15.8
0-90
20-40 mmol/day
SP-45 - Parenteral Nutrition Prescriptions Over Time: A Report from the Prescribing Patterns of
Parenteral Nutrition Study Group
Mark DeLegge, MD1; Mary Hise, PhD, RD, CNSD2; Stephen A. McClave, MD3; Gordon Sacks, PharmD,
BCNSP4; Ainsley Malone, MS, RD, CNSD5; LieLing Wu, MS6; Gary Zaloga, MD7
1
Digestive Disease Center, Medical University of South Carolina, Charleston, SC; 2IV Therapy, Nutrition,
Baxter Healthcare, Deerfield, IL; 3Division of Gastroenterology/Hepatology, University of Louisville
School of Medicine, Louisville, KY; 4School of Pharmacy, University of Wisconsin, Madison, WI;
5
Department of Pharmacy, Mount Carmel West Hospital, New Albany, OH; 6Statistics, Epidemiology &
Surveillance, Baxter Healthcare, Round Lake, IL; 7IV Therapy, Nutrition, Baxter Healthcare, Deerfield,
IL.
Introduction: Parenteral nutrition (PN) allows for manipulation of macronutrients and micronutrients on
a daily basis. There are a paucity of studies that examine the frequency and magnitude of changes made to
PN solutions over time.
Objective: To examine the initial design and subsequent alterations in the pattern of PN prescriptions
made during usual patient care over the course of hospitalization.
Methods: A prospective, observational study of PN prescribing was conducted in 24 university and
community-based hospitals within the United States. The study included small (n=6, <150 beds), medium
(n=10), and large (n=8, ≥350 beds) hospitals. All subjects were prescribed PN according to the standard
of care at each institution. Data were collected from initiation to cessation of PN use or for 14 days.
Percent change from the mean for energy, macronutrient and electrolyte content was calculated for the
study patients. Changes in magnitude of >20% were considered clinically relevant. Percent changes were
calculated over PN days from the patient mean. Changes >20% were considered to be clinically relevant.
Results: A total of 233 subjects (46% male, mean age 58.6 ± 17.1 year) were studied for 1606 PN days
(21% of days from small, 45% from medium and 36% from large hospitals). Forty-three percent of
patients received PN for 1-5 days, 36% received PN for 6 -10 days and 20% received PN for 11-14 days.
Over the first 7 days of PN delivery, mean calories increased by 19% and mean protein increased by 15%
(See Table 1). However, a substantial number of subjects had no changes in PN prescription over time for
energy (31.4%), lipid (55%), protein (45%), and dextrose (37.6%) (See Table 2). Potassium and
phosphorus were the most frequent electrolytes altered during PN, with approximately half of the subjects
receiving >30% change to their PN therapy. Calcium had the fewest adjustments with half of subjects
never changing from the initial prescription (See Table 3).
Conclusions: Clinically relevant changes in PN energy and macronutrient intakes were uncommon. In
comparison, changes in electrolyte prescription were more frequent but overall the changes were modest.
A large number of PN prescriptions remained unchanged during the course of hospitalization.
Table 1. Mean Calories and Protein Delivered by PN Day
PN Day
# of Subjects
Total calories (Kcal/kg/day)
Total Protein (g/kg/day)
1
233
19.6 ± 7.2
1.1 ± 0.4
2
225
22.1 ± 7.5
1.2 ± 0.4
3
211
22.9 ± 7.8
1.2 ± 0.4
4
181
23.4 ± 7.8
1.2 ± 0.4
5
155
24.1 ± 7.9
1.3 ± 0.4
6
128
24.1 ± 7.7
1.3 ± 0.3
7
105
24.2 ± 8.1
1.3 ± 0.4
8
93
24.3 ± 7.7
1.3 ± 0.4
9
62
25.1 ± 7.9
1.3 ± 0.4
10
55
26.4 ± 8.9
1.3 ± 0.5
11
46
27.2 ± 8.9
1.3 ± 0.5
12
39
27.5 ± 11.2
1.4 ± 0.6
13
30
27.0 ± 8.8
1.4 ± 0.4
14
18
28.1 ± 9.2
1.4 ± 0.4
Table 3. Changes in Electrolytes over PN Days
Max %
Potassium
Magnesium
Change
(n=225)
(n=226)
Calcium
(n=223)
Phosphorus
(n=216)
Sodium
(n=229)
Subject n, (%)
None
42 (18.7)
82 (36.6)
113 (50.8)
58 (26.9)
56 (24.5)
<10%
12 (5.3)
11 (4.9)
11 (4.9)
9 (4.2)
25 (10.9)
10-20%
30 (13.3)
26 (11.5)
23 (10.3)
28 (12.3)
35 (15.3)
21-30%
26 (11.6)
20 (8.9)
16 (7.2)
17 (7.9)
28 (12.2)
> 30%
115 (51.1)
87 (38.5)
60 (26.9)
104 (48.5)
85 (31.1)
Table 2. Changes (%) in Calorie and Macronutrients over PN Days
Max % Change
Energy (n=232)
Lipid (n=211)
Protein (n=229)
Dextrose (n=229)
Subject n, (%)
None
73 (31.5)
116 (55.0)
103 (45)
86 (37.6)
<10%
21 (9.0)
7 (3.3)
22 (9.6)
17 (7.4)
10-20%
45 (19.4)
26 (12.3)
34 (14.9)
31 (13.5)
21-30%
27 (11.6)
12 (5.7)
18 (7.9)
23 (10.0)
>30%
66 (28.4)
116 (55.0)
52 (22.7)
72 (31.4)
SP-46 - Blood Glucose Control in Patients Receiving Glargine Insulin and Parenteral Nutrition
Caitlin Curtis, PharmD1; Gordon S. Sacks, PharmD2; Kenneth A. Kudsk, MD3
1
Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI; 2Pharmacy Practice, University
of Wisconsin-Madison, Madison, WI; 3Surgery, University of Wisconsin-Madison, Madison, WI.
Introduction: It is often difficult to anticipate supplemental insulin needs in diabetic patients when
parenteral nutrition (PN) is initiated, especially in the setting of acute stress response (surgery, severe
pancreatitis, infection) and NPO status. In treating these patients, the standard of care at our institution is
to continue the patient’s current dose of glargine insulin while starting PN with regular insulin added to
the parenteral nutrition at the dose of 0.1 units per gram of dextrose. It is also standard of care at our
institution begin PN at a rate of 25ml/hour, and increasing rate by 25ml/hour every 6 hours until at goal
rate. However, in patients whose blood glucose was controlled (average BG <150mg/dl) with glargine
insulin before the start of PN, investigators noticed that this regimen often resulted in episodes of
hypoglycemia (BG <70mg/dl) during the first 24 hours of nutrition support.
The objective of the study was to manipulate the PN regimen in order to avoid episodes of hypoglycemia.
The investigators hypothesized that by initiating the PN at goal rate, the episodes of hypoglycemia would
be avoided.
Methods: Patients included were those requiring PN while receiving glargine insulin. Retrospective
information was gathered for patients who received the standard of care PN formula with 0.1 units of
insulin per gram of dextrose started on the titration regimen as described above. Prospective information
was gathered for patients with the same inclusion criteria, but whose PN formula was started at goal rate.
Capillary glucose levels were gathered for 24 hours after the start of PN. Hypoglycemia was defined as
blood glucose <70 and hyperglycemia was defined as blood glucose >150.
Results: Twelve patients received the standard of care protocol and 5 patients received the new protocol,
with a total of 113 capillary blood glucose levels (88 in the standard-of-care patients, 25 in the newprotocol patients). Of the 12 standard-of-care patients, 6 patients (50%) had one or more episodes of
hypoglycemia, and 7 patients (58%) had one or more episodes of hyperglycemia. Of the 5 patients who
received the new protocol, no patient (0%) had an episode of hypoglycemia. However, 4 of 5 of these
patients (80%) had one or more episodes of hyperglycemia.
Conclusions: The new protocol eliminated hypoglycemic episodes. Further adjustments can be made to
avoid hyperglycemic episodes.
SP-47 - The Role of Closely Monitoring Glycemic Control Among Non-Critically Ill Inpatients on
Total Parenteral Nutrition: Does it Work?
Sofia Sarkisian, RD2; Tanis R. Fenton, PhD, RD2; Abdel Aziz Shaheen, MD, MPH1; Maitreyi Raman,
MD, MSc1
1
University of Calgary, Calgary, AB, Canada; 2Clinical Nutrition, University of Calgary, Calgary, AB,
Canada.
Introduction: Hyperglycemia is associated with considerable morbidity and mortality among inpatients.
Recent studies have associated hyperglycemia with poor outcomes among critically ill as well as noncritically ill inpatients receiving total parenteral nutrition (TPN). The current policy for blood glucose
monitoring on the medical and surgical units at many medical centers including ours, is to measure blood
glucose levels every four hours for duration of 48 hours once TPN is initiated. However it is unclear
whether these recommendations are actually instituted and effective in clinical practice.Therefore, our
primary objectives were to determine the current standards of care for glucose monitoring at our teaching
center for non-critically ill patients receiving parenteral nutrition, and to assess the subsequent effect of
glycemic control on morbidity and mortality.
Methods: This ongoing chart review has a retrospective study design. Health records of inpatients who
received TPN for a minimum of 7-days between September 2006-August 2007. Detailed demographic,
clinical and laboratory related to our study were measured (glucose levels measurements, frequency of
glucose monitoring, indication for TPN, comorbidities, among others). Outcome variables were: hospital
length of stay (LOS), renal failure, acute coronary disease, admission to ICU and mortality. As per recent
recommendations, we classified hyperglycemia into four groups: Group 1 (<6.3 mmol/L), group 2 (6.47.5 mmol/L), group 3 (7.6-9.9 mmol/L) and group 4 (> 10 mmol/L). Associations among categorical data
were tested with Fisher exact test and data presented as numbers (percent). Continuous variables were
tested with Wilcoxon rank sum test and data reported as median (Inter Quartile Range); p<0.05 is
considered statistically significant.
Results: Fifty-one patients have been recruited to date. Median age of 66 years (53-76), 25 (49.0%) were
female, and 11 patients (21.6%) were diabetics. Major indications for TPN were for gastrointestinal
diseases (54%), and small bowel obstruction (32%). Median LOS was 30 days (23-51); 21 patients
(41.2%) had infection, 9 (17.7%) had renal failure, 3 (5.9%) had acute coronary disease, 5 (9.8%)
required admission to ICU, and 3 patients (5.9%) died. Blood glucose monitoring within the first 48 hours
of TPN initiation was performed significantly less frequently in non-diabetics compared with diabetics (#
of blood glucose readings: 3 (2-4) vs. 11 (8-11), p<0.001). Comparing hyperglycemia group 4 (6 patients)
vs. other groups (45 patients), group 4 had longer LOS than other groups (median LOS, days: 82 vs. 27,
p= 0.016). However, there was no significant difference between groups regarding infection rates, renal
failure, acute coronary syndrome, admission to ICU and mortality.
Conclusions: Our preliminary results show hyperglycemia in TPN recipients is associated with a longer
hospital LOS. In our center, non-diabetics receiving TPN do not have their blood glucose monitored per
local protocol, however, health outcomes did not appear to be significantly different in patients with
hyperglycemia compared to those with adequate glycemic control.
PEDIATRICS
SP-48 - ADMISSION ANTHROPOMETRIC MEASURES AND OUTCOMES IN THE
PEDIATRIC INTENSIVE CARE UNIT (PICU)
Praveen S. Goday, MBBS, CNSP1; Sarah Vermilyea, RD, CNSD, CSP2; Evelyn M. Kuhn, PhD3;
Maureen M. Otto, MS, RD3; Theresa A. Mikhailov, MD1
1
Pediatrics, Medical College of Wisconsin, Milwaukee, WI; 2Clinical Nutrition, Children's Hospital of
Wisconsin, Milwaukee, WI; 3Outcomes, Children's Hospital of Wisconsin, Milwaukee, WI.
Introduction: We have previously shown that underweight is associated with increased mortality and
longer length of stay in the PICU (PLOS). We aimed to study if overweight and other anthropometric
measures of undernutrition at the time of PICU admission correlate with mortality, PLOS and hospital
length of stay (HLOS).
We aimed to investigate the association of admission weight, height/length, weight-for-length and BMI
with mortality and lengths of stay.
Methods: We obtained data on all children admitted to the Children’s Hospital of Wisconsin PICU
between 2005 and 2007. Admission data included age, gender, Pediatric Index of Mortality 2 (PIM2)
score, weight and height/length. We also obtained mortality, PLOS and HLOS(in days) data.
We evaluated the association of PICU admission weight, height/length, weight-for-length (≤2 years) or
BMI (>2 years) with mortality by logistic regression analysis. We adjusted for gender and PIM2 score.
We computed unadjusted and adjusted odds ratios (ORs) and their corresponding 95% confidence
intervals from the logistic regression models. Trend tests were used to evaluate the association between
admission anthropometric measurement z-score (overweight = +1.5 to +2, obese = +2 to +3 and severely
obese > +3, normal = -2 to +1.5, mild underweight = -2 to -3, severe underweight ≤ -3) and mortality
controlling for gender and PIM2 score. We evaluated the correlation of admission anthropometric
measures with LOS using the Spearman rank correlations test. A 2-tailed p value of 0.05 was considered
significant for all analyses.
Results: 4396 admissions were available for analysis between 1 month and 18 years of age.10.1% were
mildly underweight, 7.8% were severely underweight, 4.5% were overweight, 4.3% were obese and 1.2%
were severely obese.
Mortality was 2.9% in normals, 4.0% in mildly underweight and 3.8% in severely underweight children,
5.1% in overweight, 3.7% in obese and 7.8% in severely obese patients.
Compared to normals and adjusting for gender and PIM2 score, those who had a lower height-for-age (z
score = -2 to -3) were more likely to die [OR=3.68 (1.50-9.02) p<0.05]. Children ≤2 years with a higher
weight-for-length (z score > +3) were also more likely to die [OR=6.55 (1.71-24.95) p<0.05].
A low weight-for-age is correlated with longer PLOS (r = -0.08) and longer HLOS (r= -0.12). A low
height-for-age in children ≤2 years is correlated with longer PLOS (r = - 0.1) and longer HLOS (r= 0.18). All p-values <0.005.
A high weight-for-age is correlated with increased mortality (r = 0.04) and a shorter PLOS (r = - 0.04)
(both p<0.05). A high weight-for-length in children ≤ 2 years is correlated with longer HLOS (r=0.06,
p=0.03).
Conclusions: Mortality rates are higher among overweight and underweight children than among normal
children admitted to the PICU. PLOS and HLOS are prolonged in children with a low weight-for-age and
in children ≤2 years with a low height-for-age. The reasons for a shorter PLOS in children with a high
weight-for-age are unclear and this group needs further study.
SP-49 - Efficacy and tolerance of an infant formula with lactose as sole carbohydrate. A
randomised and controlled trial
Louis Dominique Van Egroo, Doctor of Medicine2,1; Emmanuelle Lachambre, P Eng in agronomy1;
Thierry Chautard, PhD in Biology1; Constance Ferry, P Eng in biochemistry1; Laurence Beck, P Eng in
biochemistry1; Christian Kempf, PhD in statistics3; Jean-Philippe Girardet, Professor of Medicine4
1
Direction médicale nutrition Infantile, Nestle France, Marne la Vallée, France; 2Pédiatrie, Hôpital
Ambroise Paré, Boulogne Billancourt, France; 3Statistics, ICD, Strasbourg, France; 4Gastroentérologie et
Nutrition Pédiatriques, Hôpital Armand Trousseau, Paris, France.
Introduction: Most of the infant formulas have a mixed glucidic fraction with lactose and maltodextrines. Several studies have enlightened the positive role of the lactose on the colic flora and the
absorption of several micronutriments.
We evaluated the efficacy and tolerance of a new infant formula with a glucidic fraction of 100% lactose.
Methods: On term, healthy, non breastfed new-borns less than 7 days old were included in this
multicenter clinical trial. At the inclusion date (J0), new born were randomized to receive until the end of
the 4th month(M4) exclusively, the studied formula (Group L ): with 100% lactose (7,5 g/100 ml), or a
formula already commercialised (Nidal Novaïa 1®, Group N) with a mixed carbohydrates fraction
(6,4g/100ml lactose and 1,1g/100ml maltodextrin). Both formulas are otherwise strictly identical notably
with 1,2 g/100ml protein. Formula L’s non inferiority was evaluated with the average daily weight
variation between J0 and M4 by an ANCOVA analysis of the Per Protocol (PP) population. Tolerance
was assessed as secondary criteria on the Intention To Treat population (ITT).
Results: Were included 184 newborns. ITT population was 178 infants and PP population 137 infants.
Both group characteristics were identical at the inclusion date. The difference in the average daily weight
variation between J0 and M4 was within the non inferiority range (+/-2.5g/d). The daily intake in ml/kg
was significantly lower in the group L in the ITT population (Average difference :ITT =-5.28ml/d/kg;
p<0.007; PP=-4.48ml/d/kg; p=0.056). Frequency of undesirable events including transit disorders and
gluteal erythemas were similar in the two groups.
Conclusions: The use of the 100% lactose formula led to a growth and tolerance equivalent with the
control formula. Colic, constipations and abdominal distensions prevalence were strictly identical
between formulas.
This study shows that an infant formula should be seen in its globality. A 100% lactose formula doesn’t
accelerate the transit. The association between 1.2g/100ml proteines and a specific aminogram leads here
to an improvement of the formula. The lower formula intake in group L with an identical growth suppose
a better proteino-energetic use of the new formula which may be due to a lactose’s flora effect. An
analogue decrease of the formula intake was seen in the previous formula improvement.(Turck et al.
JPGN 2006, 43 :364-371). These results justify the recommendations to test the evolutions of infant
formula with clinical trials (ESPGHAN, JPGN 2001, 32 :256-258).
SP-50 - Targeted indirect calorimetry improves accuracy of nutritional intervention in critically ill
children
Nilesh Mehta, MD,MRCPCH2; Lori J. Bechard, MEd,RD,LDN1; Kristen Leavitt, RD,LDN1; Debora
Duro, MD,MS1; Christopher Duggan, MD,MPH1
1
GI/Nutrition, Children's Hospital Boston, Boston, MA; 2Critical Care Medicine, Children's Hospital
Boston, Boston, MA.
Introduction: Underfeeding and overfeeding are prevalent in critically ill patients. We have recently
described a model for selecting critically ill children at high risk of metabolic derangements who may
benefit from measured energy expenditure (MEE) using indirect calorimetry (IC). We hypothesized that
targeted IC would influence nutrition intervention in high-risk children in the pediatric intensive care unit
(PICU).
Methods: Patients admitted to a tertiary care PICU were selected for IC based on the following criteria:
a) known nutritional deficits, e.g. under- or overweight, b) unexpected weight loss or gain, c) clinical
suspicion for underfeeding or overfeeding, d) persistent inflammatory state, e) any known condition
associated with altered metabolism, f) PICU length of stay more than 4 weeks, or g) unexplained failure
to wean or unexpected escalation of respiratory support. For each subject, a pre-test estimate of the
metabolic state by the PICU staff, and the estimated energy expenditure (EEE), as calculated by Schofield
or WHO equations, were recorded. Subjects were classified as hypermetabolic (MEE:EEE >110%) or
hypometabolic (MEE:EEE <90%). Pre-test actual energy intake for each subject was classified as
overfeeding (pre-IC intake:MEE >110%) or underfeeding (pre-IC intake:MEE <90%).
Results: Fifteen IC measurements were performed in 12 children, with median age 2.3 years (range 0 17.8), and median weight 12.3 kg (range 3.8-80). Three subjects (25%) were mildly stunted, 3 (25%)
were overweight or obese; none were underweight. Eleven IC (73%) measurements showed either
hypometabolism (n = 4) or hypermetabolism (n = 7) with an average MEE:EEE ratio of 113% (range 61189%). The pre-test estimate of metabolic state was incorrect in 11 (73%) cases. Average pre-IC energy
intake:MEE ratio was 137% (range 86-200%). We recorded both underfeeding (n=1) and overfeeding
(n=11) prior to IC in this cohort. Nutritional management was modified in 12 cases (80%) following IC
testing. The median change in energy intake was a reduction of 5% compared to pre-IC intake, with a
range of -25% to +32%.
Conclusions: Energy requirements of PICU patients are variable and healthcare providers are frequently
unable to accurately estimate energy requirements in a select group of patients. We noted a wide range of
metabolic status with a predominance of hypermetabolism in our cohort, and a tendency towards
overfeeding prior to IC. Targeted IC allows optimization of nutrition support for high risk patients in the
PICU.
SP-51 - CORRELATION OF 'NUTRITION LABS' WITH ANTHROPOMETRIC
MEASUREMENTS IN THE PEDIATRIC INTENSIVE CARE UNIT (PICU)
Sarah Vermilyea, RD, CNSD, CSP2; Evelyn M. Kuhn, PhD3; Maureen M. Otto, MS, RD3; Theresa A.
Mikhailov, MD1; Praveen S. Goday, MBBS, CNSP1
1
Pediatrics, Medical College of Wisconsin, Milwaukee, WI; 2Clinical Nutrition, Children's Hospital of
Wisconsin, Milwaukee, WI; 3Outcomes, Children's Hospital of Wisconsin, Milwaukee, WI.
Introduction: We hypothesized that standard ‘nutrition labs’ correlate with measures of inflammation but
not with undernutrition in PICU patients.
We aimed to determine whether serum albumin concentration (Alb), absolute lymphocyte count (ALC),
hemoglobin (Hb), hematocrit (Hct), and total white blood cell count (WBC) in children at PICU
admission correlate with anthropometric measures of undernutrition or measures of inflammation.
Methods: We obtained available admission laboratory data for all 4767 children (between 1 month and
18 years of age) admitted to the Children’s Hospital of Wisconsin PICU between 2004 and 2007.
We obtained laboratory data when possible prior to admission but within 6 hours of and closest to the
time of admission otherwise the earliest available data within 24 hours after PICU admission were used.
We obtained Alb, ALC, Hb, Hct, WBC and measures of inflammation - erythrocyte sedimentation rate
(ESR) and C-reactive protein (CRP) values. We also obtained PICU admission weight and height/length.
We calculated z scores for weight-for-age, height-for-age and weight-for-length (for children ≤ 2years)
and BMI (for children > 2years). Based on standard references, each laboratory test was assigned a
normal, borderline or abnormal designation. A z score between -2 and +1.5 was considered normal,
between -2 and -3 borderline and less than -3 abnormal for each of the anthropometric measures. We
evaluated the correlations between the three designations for each laboratory test and the three categories
for each anthropometric measure using the Jonckheere-Terpstra test (J-T). We evaluated the correlations
between the laboratory values and measures of inflammation using the Pearson correlations test. A 2tailed p value of 0.05 was considered significant for all analyses.
Results: We obtained 1408 Alb, 3880 Hb, 3879 Hct, 3882 WBC, 3822 ALC, 183 ESR and 261 CRP
values.
There was a negative correlation between CRP and Alb(r= - 0.431), ALC (r= - 0.207), Hb (r= - 0.28), and
Hct (r= - 0.287) all with p-values ≤0.001. There was a negative correlation between ESR and Alb (r= 0.313), Hb(r= - 0.569) and Hct(r= - 0.557) all with p-values =0.001.
The p-values of the correlations of the anthropometric z-score categories with the three laboratory value
designations are shown in the table.
Conclusions: In children admitted to the PICU, Alb, ALC, Hb, and Hct values decline with increasing
inflammation. Alb, Hb, and Hct increase with measures of decreased weight and may reflect dehydration.
Potential inaccuracy of height measurements obtained may serve as a confounder. ALC and WBC can
serve to differentiate borderline undernourished and undernourished children in the PICU from normals
and can serve as markers of validity when evaluating nutritional screens or as markers of nutritional risk,
but ALC appears superior.
Jonckheere-Terpstra test p-values (correlations between anthropometric z score categories and laboratory
value designations)
Alb
ALC
Hb
Hct
WBC
Weight z scores
NS
<0.0001
NS
Height z scores
NS
0.0025
NS
NS
0.0123
Weight-for-length z scores (age ≤ 2years)
NS
NS
NS
NS
0.031*
BMI z scores (age > 2years)
NS
NS
NS
0.0002*
NS
BMI and weight-for-length z scores (all children)
0.0082*
0.0011
0.0004* 0.0004*
NS
0.0128* 0.0153
*reflects a negative correlation; NS= not significant
SP-52 - Unstable and Inappropriate PN Use in Hospitalized Pediatric Patients at an Academic
Teaching Hospital
Rebekka Dow, Pharm.D.2; Caitlin S. Curtis, Pharm.D.2; Kenneth A. Kudsk, MD3; Gordon S. Sacks,
Pharm.D.1,2
1
Pharmacy Practice, University of Wisconsin-Madison, Madison, WI; 2Pharmacy, University of
Wisconsin Hospital and Clinics, Madison, WI; 3Surgery, University of Wisconsin-Madison, Madison,
WI.
Introduction: A.S.P.E.N. Guidelines recommend the use of EN over PN in hospitalized pediatric
patients. PN use is reserved for severe GI dysfunction, inaccessibility, or when nutrient needs exceed
those which can be met solely through the GI tract. Furthermore, 2-in-1 PN formulations with separate
infusion of intravenous fat emulsions (IVFE) is preferred over total nutrient admixtures (TNAs) in
neonatal and infant patients due to emulsion instability and risks associated with emulsion coalescence at
low final concentrations. Pediatric PN at our institution is prescribed by individual physicians rather than
an Interdisciplinary Pediatric Nutrition Support Team. We suspected that PN therapy often failed to
comply with published guidelines. The objectives of the current study were to compare use and stability
of pediatric PN prescribed by individual physicians to evidence-based guidelines in an academic teaching
hospital.
Methods: Records of consecutive hospitalized pediatric patients receiving PN between January 1 to July
1, 2007 were retrospectively reviewed and analyzed for demographic data, indications for PN, days of
PN, trial of EN, and PN formulation components to determine stability. Indications for PN were based
upon published A.S.P.E.N. Guidelines. An unstable TNA was defined as final concentrations of amino
acids < 4%, dextrose < 10%, or IVFE < 2%, as per published research by Driscoll DF, NCP, 2006.
Results: A total of 59 patients (31F/28M) were identified as receiving PN during the study period.
Demographic data included patient mean age = 8.1 yr (range, 1 day-18 yr), height = 115.1 cm (range, 53179 cm), weight 33.4 kg (range, 2.5-197.9 kg). PN was administered for 693 days with a mean duration
of 11.7 days (range 1-74 days). Twenty-three patients (39%) received < 5 days of PN, while 18 patients
(31%) received > 10 days of PN. Twenty patients (34%) failed a trial of EN, but 20 patients (34%) were
also found to have a functional GI tract prior to starting PN. PN was not clearly indicated in 17 patients
(29%), representing 188 days of potentially avoidable PN. The most common indications for the 42
patients who did have a clear indication for PN were inaccessible GI tract (n=8), paralytic ileus (n=8), and
intractable vomiting (n=7). IVFE was included in the PN for 610 of the total 693 days PN was provided.
These days were analyzed to determine if stability requirements were met. Physicians prescribed unstable
formulations for 431/610 (71%) of TNA days. The mean final concentrations for fat, protein, and dextrose
were 2.9% (range, 0.06-7.1%), 3.4% (range, 1.1-12.5%), 19.7% (range, 1.8-60.1%), respectively. The
percent of days that IVFE, protein, and dextrose fell below stability limits were 27%, 55%, and 6%,
respectively.
Conclusions: PN was inappropriately prescribed by individual physicians in 1/3 of pediatric patients.
TNA formulations failed to meet established stability requirements in over 2/3 of PN days. These results
emphasize the need for implementing a multidisciplinary Nutrition Support Team for management of PN
and EN in pediatric hospitalized patients.
SP-53 - HYPERGLYCEMIA IS A RISK FACTOR FOR RETINOPATHY OF PREMATURITY
(ROP) IN VERY LOW BIRTH WEIGHT (VLBW) NEONATES.EXPERENCE AT
N.Y.METHODIST HOSPITAL
Khaja Raziuddin
Pediatrics & Nutrition, Ny Methodist Hosp., Brooklyn, NY.
Introduction: Retinopathy of Prematurity (ROP) is a proliferative disorder of the developing retinal
vasculature in preterm infants. It remains a leading cause of morbidity in the very low birth weight
(VLBW) infants. Hyperglycemia (defined as plasma glucose values >120 mg/dL) is common occurrence
in the VLBW infants. In total 45% of all infants less than 1000 g and 80% of those less than 750 g will
develop hyperglycemia. The risk of developing hyperglycemia is 18 times greater in infants weighing less
than 1000 g than in those weighing more than 2000 g. The purpose of this study was to assess the
relationship of gestational age, birth weight, blood glucose and the need for ventilation to the risk of
developing ROP.
Methods: A retrospective study of 298 neonates with BW of <1250 g born between 1990 - 2004 at NY
Methodist Hospital was performed. Daily glucose intake was adjusted to maintain glucose levels of <120
mg/dL to a maximum of 23.9 g/kg/day. A minimum and maximum level for each day during 28 postnatal
days was recorded and the mean maximum for each neonate computed. The results of cranial ultrasound
and ophthalmologic exams were recorded.
Results: Thirty nine (13.08%) developed ROP. They had lower GA (p=0.003) and BW (p<0.001) than
neonates without ROP. The proportion of neonates with persistent hyperglycemia was higher in the ROP
group (p<0.0001). Average maximum glucose levels during 28 postnatal days were higher in neonates
with ROP (p<0.0001). Supplemental oxygen was discontinued later in the neonates with ROP and they
required it longer. IVH was present in 14.5% of ROP group compared to 8.5% in non ROP group.
Conclusions: In addition to lower GA and BW, prolonged oxygen supplementation and the presence of
IVH, hyperglycemia plays a major role in pathogenesis of ROP.