The Role of Nutrition in Maintaining Health in the Nation's Elderly Evaluating Coverage of Nutrition Services for the Medicare Population (2000) / Chapter Skim
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10 Nutrition Support
10 Nutrition Support
Pages 173-212
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From page 173... ...
Parenteral nutrition is the intravenous administration of nutrients into the bloodstream, by either peripheral or central venous access routes. Nutrition administered by the peripheral route is termed peripheral parenteral nutrition, and by the central route total parenteral nutrition (TPN)
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From page 174... ...
, as well as those with severe oropharyngeal dysfunction or permanent neurological impairment. Enteral and parenteral nutrition support of shorter duration can also prevent and treat protein-energy undernutrition among other selected Medicare beneficiaries in the hospital setting.
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From page 175... ...
Short-bowel syndrome is characterized by severe malabsorption and resulting dehydration, electrolyte losses, metabolic abnormalities, and undernutrition (Purdum and Kirby, 1991~. Since clinical experience has demonstrated the clear efficacy of nutrition support in this setting, prospective randomized trials that include nonintervention arms have not been and are unlikely to be conducted.
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From page 176... ...
The least favorable anatomical alteration is to have combined resections of both the small and the large intestines and resulting decreased function (Gouttebel et al., 1986; Nightingale et al., 1990~. Nonetheless, even in the setting of long-term TPN dependence, it is sometimes possible with aggressive enteral nutritional supplementation and rehydration therapies, in combination with pharmacologic interventions, to modulate gut secretions and transit in order to obviate the need for parenteral support (Cosnes et al., 1985; Lennard-Iones, 1990~.
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From page 177... ...
Patients randomized to bowel rest and TPN had no better outcomes than those assigned to enteral feedings (GonzalezHuix et al., 1993~. Enteral diets using elemental formulas have been suggested to be as effective as glucocorticoid therapy in inducing remission of Crohn's disease, but the majority of randomized prospective trials suffer from small size, heterogeneous participants, variable diet composition and intake, HA liquid formula designed for easy digestion and absorption and leaves minimal residue in the bowel.
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From page 178... ...
The majority of patients with acute pancreatitis have mild or moderate disease. Prospective randomized trials indicate that the provision of enteral or parenteral nutrition does not alter the natural history of pancreatitis in this setting (Sax et al., 1987~.
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From page 179... ...
Some prospective randomized trials have observed improved survival among patients with chronic alcoholic liver diseases who receive enteral or parenteral nutrition (Cerra et al., 1985) , while others have not (Nasrallah and Galambos, 1980; Naveau et al., 1986; Naylor et al., 1989~.
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From page 180... ...
Enteral and parenteral nutrition may improve some laboratory measures of liver function in patients with chronic alcoholic liver diseases. Studies are conflicting with regard to whether there are associated improvements in survival.
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From page 181... ...
The majority of weight gain in these studies was fat, however, as opposed to lean body mass. In a randomized study comparing total parenteral nutrition to dietary counseling in severely malnourished men (loss of more than 10 percent usual body weight and concomitant diarrhea)
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From page 182... ...
There are limited data which indicate that total parenteral nutrition may be more costly and associated with lower quality of life than either oral or enteral nutrition. HIV/AIDS Recommendations · Nutrition therapy to improve caloric intake and weight gain in persons with AIDS is recommended using a multidisciplinary team of nutrition support professionals.
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From page 183... ...
In another trial involving metastatic cancer patients treated with high doses of interleukin-2, a brief course of TPN during treatment corrected calorie and protein undernutrition, improved control of serum electrolytes, and was well tolerated (Samlowski et al., 1998~. A prospective study of nutrition support in patients receiving antineoplastic therapy indicated that parenteral nutrition successfully maintained the body weight of patients who were unable to receive enteral nutrition (Lees, 1997~.
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From page 184... ...
randomized patients to TPN versus an enteral-oral feeding program and found that the nutritional needs of 23 of 30 patients could be met with the enteral feeding program. The safety of enteral feeding in bone marrow transplant patients was also documented in a small group of patients undergoing autologous BMT (Murder et al., 1989~.
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From page 185... ...
The limitations of the available data, however, do not rule out the possible utility of nutrition support in older cancer patients undergoing chemotherapy or radiation therapy. In bone marrow transplantation, enteral nutrition is safe and can be used to meet energy needs.
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From page 186... ...
When clinically indicated, the initiation of acute hemodialysis or ultrafiltration facilitates the provision of adequate amino acids or protein but also promotes nutrient losses (Ikizler et al., 1994; Mehta, 1994; Wolfson et al., 1982~. There have been no prospective randomized trials of enteral nutrition in the setting of acute renal failure.
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From page 187... ...
Unfortunately there are so few studies that directly contrast carefully matched enteral and parenteral nutrition that a meta-analysis comparing these interventions across the spectrum of critical illness is not feasible. Patients with major trauma, including major blunt or penetrating trauma, head injury, or burn, are at high risk of protein-energy undernutrition.
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From page 188... ...
While early studies (Rapp et al., 1983) suggested that parenteral nutrition had more favorable outcomes when head-injured patients received greater parenteral than enteral nutrition, more recent clinical trials have observed equivalent outcomes with enteral or parenteral nutrition when nutrient intakes are comparable (Borzotta et al., 1994; Grahm et al., 1989; Norton et al., 1988~.
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From page 189... ...
Nutrient formulations modified with specific nutrients which may preserve or promote immune or other vital functions have shown promise in preliminary trials with critically ill patients, but studies among older persons are inadequate to draw definitive conclusions for the Medicare population at this time. Critical Illness Recommendations · There is a need for prospective randomized trials of enteral versus parenteral nutrition in well-characterized subgroups of critically ill patients.
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From page 190... ...
In addition, there is current evidence and expert opinion supporting the use of nutritional support in severely malnourished patients undergoing major elective surgery and in surgical patients unable to eat for more than 1 to 2 weeks preand/or postoperatively. Gastrointestinal Surgery Enteral Nutrition A meta-analysis of six randomized, controlled clinical trials of gastrointestinal cancer surgery patients treated postoperatively with enteral supplements enriched with selected nutrients (Heys et al., 1999)
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From page 191... ...
Considering the substantial costs associated with treating infectious complications and of administering TPN, coupled with the costs of longer hospital stays, the use of early enteral nutrition has implications for reducing overall hospital costs. Total Parenteral Nutrition Estimates from a pooled analysis of 13 prospective randomized clinical trials have indicated that TPN given to "malnourished" gastrointestinal cancer patients, as defined by weight loss, plasma proteins, or prognostic indices, for 7 to 10 days before surgery reduced the overall risk of postoperative complications by approximately 10 percent.
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From page 192... ...
who received preoperative parenteral nutrition had fewer postoperative complications, better serum protein and immune parameters, and a lower mortality rate than patients who received a regular diet (Muller et al., 1982~. Similarly, Fan and colleagues (1994)
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From page 193... ...
No differences between supplemented patients and control patients were found in relation to postoperative complications and in-hospital mortality. Perioperative Nutrition Support Summary Consistent data show that enriched enteral nutrition administered in the postoperative period reduces the incidence of infectious complications and length of hospital stay in gastrointestinal cancer surgery patients.
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From page 194... ...
· Postoperative enteral nutrition is recommended for undernourished hip fracture patients. · Further studies are needed to evaluate the safety and benefits of enteral and parenteral nutrition, including the use of early enteral nutrition and modified enteral formulas, in well-characterized groups of older surgical patients.
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From page 195... ...
Some institutions have eliminated nutrition support teams based on the rationale that the work they perform can be done by less specialized staff. However, most of the work performed by the nutrition support team members (assessment of nutritional status, implementation of enteral and parenteral nutrition therapy, monitoring response to therapy, patient education, and quality assurance monitoring)
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From page 196... ...
96 NUTRITION AND HEALTH IN THE NATION'S ELDERLY TABLE 10.1 Hospital Settings: Evaluation of Nutrition Support Interventions Observational Consensus Systematic Some Cli Studiesa Document Review Trial Evi Intervention GPb Elderly GP Elderly GP Elderly GP E1` Gastrointestinal Short bowel Enteral ~ - ~ Parenteral ~ - ~ Fistulas Enteral ~ - ~ Parenteral ~ - ~ Inflammatory bowel disease Enteral ~ - ~ - ~ Parenteral ~ - ~ - ~ Pancreatitis Enteral ~ - ~ - ~ Parenteral ~ - ~ - ~ Liver disease Enteral ~ - ~ - ~ Parenteral ~ - ~ - ~ HIV/AIDS Enteral ~ - - - - Parenteral ~ - - - - Cancer Therapy Chemotherapy Enteral ~ - ~ - ~ Parenteral ~ - ~ - ~ Radiation Therapy Enteral ~ - ~ - ~ Parenteral ~ - ~ - ~ Renal Failure Acute Enteral Parenteral ~ - - - - Chronic Enteral Parenteral Critical Illness Enteral ~ - ~ - - Parenteral ~ - ~ - ~ Perioperative Abdominal Enteral - ~ - - ~ Parenteral ~ ~ - - ~ Hip fracture Enteral - ~ - - - - Parenteral a This category includes case series, case-control studies, cohort studies and nonrandomized trials of nutrition-based therapies including nonhuman studies. b GP = general population.
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From page 197... ...
NUTRITION SUPPORT 197 antic v Elderly Some Clinical Trial Evidence GP Elderly Extensive Clinical Trial Evidence GP Elderly Overall Strength of Evidence Supporting Nutrition Therapy for Elderly Persons Err rrlCaClOUS Efficacious Insufficient data Efficacious Insufficient data Not primary therapy Insufficient data Insufficient data Insufficient data Insufficient data Insufficient data Insufficient data Not supported Not supported Not supported Not supported Insufficient data Insufficient data Insufficient data Not supported Insufficient data Insufficient data Selected efficacy Selected efficacy Efficacious Insufficient data
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From page 198... ...
A discussion of these studies follows. Early studies justified nutrition support teams based on their role in reducing catheter sepsis during parenteral nutrition (Dalton et al., 1984; Faubion et al., 1986; Hickey et al., 1979; lacobs et al., 1984; Nehme, 1980; Sanders and Sheldon, 1976; Traeger et al., 1986~.
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From page 199... ...
A prospective review of 50 patients (average age 63 + 4 years) who received parenteral nutrition identified inappropriate or avoidable days of parenteral nutrition (Maurer et al., 1996~.
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From page 200... ...
For patients not followed by the nutrition support team, 56 percent of the starts were not indicated (p < 0.005~. Avoidable charges were calculated based on a charge of $301 per day for parenteral nutrition.
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From page 201... ...
However, the requirements for nutrition assessment are increasing, and with decreasing hospitalizations, the percentage of malnourished patients would logically remain the same or increase. Therefore, regulatory agencies should be encouraged to ensure that sufficient qualified staff are available to monitor patients receiving enteral and parenteral nutrition.
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From page 202... ...
1997. Chemotherapy and total parenteral nutrition for advanced ovarian cancer with bowel obstruction.
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From page 203... ...
1996. Metabolic complications of total parenteral nutrition: Effects of a nutrition support service.
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From page 204... ...
1983. Total parenteral nutrition with high or low nitrogen intakes in patients with acute renal failure.
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From page 205... ...
1986. Total parenteral nutrition needs in different types of short bowel syndrome.
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From page 206... ...
1998. Total parenteral nutrition in the critically ill patient.
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From page 207... ...
1997. Total parenteral nutrition for patients receiving antineoplastic therapy at a regional oncology unit: A two-year study.
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From page 208... ...
1998. Total parenteral nutrition with glutamine dipeptide after major abdominal surgery: A randomized, double-blind, controlled study.
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From page 209... ...
1998. Clinical and metabolic effects of different parenteral nutrition regimens in patients undergoing allogeneic bone marrow transplantation.
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From page 210... ...
1993. Total parenteral nutrition with glutamine in bone marrow transplantation and other clinical applications (a randomized, double-blind study)
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From page 211... ...
1987. Nutritional support of bone marrow transplant recipients: A prospective, randomized clinical trial comparing total parenteral nutrition to an enteral feeding program.
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From page 212... ...
1992. Clinical and metabolic efficacy of glutaminesupplemented parenteral nutrition after bone marrow transplantation.
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