Nutrition Therapy in the Adult Hospitalized Patient

B. Nutritional assessment

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For people with diabetes and diabetic kidney disease either micro- or macroalbuminuria , reducing the amount of dietary protein below the usual intake is not recommended because it does not alter glycemic measures, cardiovascular risk measures, or the course of glomerular filtration rate GFR decline. Metabolic control can be considered the cornerstone of diabetes management. The Canadian Trial of Carbohydrates in Diabetes CCD , a 1-y controlled trial of low-glycemic-index dietary carbohydrate in type 2 diabetes: Fatty fish in the diet of patients with type 2 diabetes: Jorde R , Figenschau Y. The DSC approach is seen as a system with three sub-systems that provide the framework for planning, implementation, and evaluation.

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Subtle goals and outcome benefits may be achieved by gastrostomy placement in certain end-of-life situations Quality of life for the family of the patient may improve with placement of a percutaneous gastrostomy, as the ease of providing medications, hydration, and nutrition is facilitated and frustration with anorexia and poor oral intake is reduced.

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

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

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

This can only be done if they are able to transfer the care to an equally qualified and willing practitioner. At no time should a patient or their families feel abandoned by the health-care process. This guideline was produced in collaboration with the Practice Parameters Committee of the American College of Gastroenterology. The Committee gives special thanks to Brian P. Bosworth, who served as guideline monitor for this document.

McClave is a speaker and an advisor for Nestle, Abbott, Covidien, and Kimberly Clark, a speaker for Nutricia, and has received research support from Nestle. Martindale is a advisor for Nestle, Covidien, and Fresenius Kabi.

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

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

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

An additional assessment should be performed prior to initiation of nutrition therapy of factors that may impact the design and delivery of the nutrition regimen conditional recommendation, very low level of evidence. Surrogate markers of infection or inflammation should not be used for nutritional assessment conditional recommendation, very low level of evidence.

Caloric requirements should be determined and then be used to set the goal for delivery of nutrition therapy conditional recommendation, very low level of evidence. One of the three strategies should be used to determine caloric requirements: Protein requirements should be determined independently of caloric needs, and an ongoing assessment of protein provision should be performed conditional recommendation, very low level of evidence. Nutrition assessment scoring systems used to determine nutrition risk NRS A nasogastric or orogastric feeding tube should be used as the initial access device for starting EN in a hospitalized patient conditional recommendation, very low level of evidence.

Radiologic confirmation of placement in the stomach should be carried out prior to feeding except with the use of electromagnetic transmitter-guided feeding tubes. Conversion to a post-pyloric feeding tube should be carried out only when gastric feeding has been shown to be poorly tolerated or the patient is at high risk for aspiration strong recommendation, moderate-to-high level of evidence. When long-term enteral access is needed in a patient with gastroparesis or chronic pancreatitis, a jejunostomy tube should be placed conditional recommendation, very low level of evidence.

A percutaneous gastrostomy should be placed preferentially in the gastric antrum in order to facilitate conversion to a GJ tube in the event that the patient is intolerant to gastric feeding conditional recommendation, very low level of evidence. For the patient at high risk for tube displacement, steps should be taken proactively to secure the access device at the time of placement conditional recommendation, very low level of evidence.

Initiating Enteral Nutrition Question: In the patient at high nutritional risk unable to maintain volitional intake, EN should be initiated within 24—48 h of admission to the hospital conditional recommendation, low level of evidence. Although early EN should be initiated within 24—48 h of admission, the timing by which to advance to goal is unclear.

When tolerated, feeding should be advanced to goal within 48—72 h conditional recommendation, very low level of evidence. With reduced tolerance, feeding should be advanced with caution to goal by 5 to 7 days conditional recommendation, very low level of evidence.

A standard polymeric formula or a high-protein standard formula should be used routinely in the hospitalized patient requiring EN conditional recommendation, very low level of evidence. An immune-modulating formula containing arginine and omega-3 fish oil should be used for patients who have had major surgery and are in a surgical ICU setting conditional recommendation, very low level of evidence.

An immune-modulating formula containing arginine and omega-3 fish oil should not be used routinely in patients in a medical ICU conditional recommendation, very low level of evidence. Monitoring tolerance and adequacy of EN Question: Hospitalized patients on EN should be monitored daily by physical exam conditional recommendation, very low level of evidence.

Patients on EN should be monitored for adequacy of provision of EN as a percent of target goal calories, cumulative caloric deficit, and inappropriate cessation of EN conditional recommendation, very low level of evidence.

In the patient at high risk for refeeding syndrome, feeding should be ramped up slowly to goal over 3 to 4 days, while carefully monitoring electrolytes and volume status conditional recommendation, very low level of evidence. Enteral feeding protocols should be used in hospitalized patients in need of nutrition therapy strong recommendation, moderate-to-high level of evidence.

A validated protocol should be used, such as a volume-based feeding protocol or a multi-strategy bundled top-down protocol conditional recommendation, very low level of evidence. Gastric residual volume GRV should not be used routinely as a monitor in hospitalized patients on EN conditional recommendation, very low level of evidence.

Patients on EN should be assessed for risk of aspiration conditional recommendation, very low level of evidence. For patients determined to be at high risk, the following steps should be taken to proactively reduce that risk: For the patient receiving EN who develops diarrhea, an evaluation should be initiated to identify an etiology and direct management conditional recommendation, very low level of evidence.

The patient receiving EN who develops diarrhea should be managed by one of the three strategies: Complications of enteral access Question: The percutaneous enteral access site should be monitored by cleaning daily with mild soap and water and maintaining correct positioning of the external bolster conditional recommendation, very low level of evidence.

Prevention of tube clogging is important to successful EN and may be achieved by frequent water flushes delivered every shift and each time medications are given conditional recommendation, very low level of evidence. When a clogged tube is encountered and the use of water flushes is unsuccessful at clearing, a de-clogging solution comprising a nonenteric-coated pancreatic enzyme tablet dissolved in a sodium bicarbonate solution should be used conditional recommendation, very low level of evidence.

If still unsuccessful, a mechanical de-clogging device should be considered prior to exchanging the tube for a new one conditional recommendation, very low level of evidence.

In this latter circumstance, radiologic confirmation should be carried out prior to feeding if there is any question of inappropriate location of the tube conditional recommendation, very low level of evidence. Placement of a larger tube should not be used to manage leakage caused by an enlarging stoma around the percutaneous access device conditional recommendation, very low level of evidence.

A percutaneous enteral access device that shows signs of fungal colonization with material deterioration and compromised structural integrity should be replaced in a non-urgent but timely manner conditional recommendation, very low level of evidence. If early EN is not feasible and the patient is at low nutritional risk upon admission, no specialized nutrition therapy should be provided and PN should be withheld for the first week of hospitalization conditional recommendation, very low level of evidence.

If a patient is at high nutritional risk on admission to the hospital and EN is not feasible, PN should be initiated as soon as possible strong recommendation, moderate level of evidence. Initiating supplemental PN prior to this 7—day period in those patients already receiving EN does not improve outcomes and may be detrimental to the patient strong recommendation, moderate level of evidence.

Following this first week if long-term PN is required , energy provision should be increased to meet energy goals conditional recommendation, low level of evidence. Peripheral PN PPN should not be used, as it leads to inappropriate use of PN, has a high risk of phlebitis and loss of venous access sites, and generally provides inadequate nutrition therapy conditional recommendation, very low level of evidence.

Careful transition feeding should be used in the patient on PN, for whom EN is now being initiated. As tolerance to EN improves and volume of delivery increases, PN should be tapered to avoid overfeeding conditional recommendation, very low level of evidence. Nutritional Therapy at End-of-Life Question: The decision to place a gastrostomy tube in an end-of-life situation should be determined by patient autonomy and the wishes of that patient and their family, even though the nutrition therapy may do little to change traditional clinical outcomes conditional recommendation, very low level of evidence.

Percutaneous gastrostomy placement should be considered even if the only benefit is to provide improvement in the quality of life for the family, increased ease of providing nutrition, hydration, and medications, or to facilitate transfer out of the hospital setting to a facility closer to home conditional recommendation, very low level of evidence.

The clinician is not obligated to provide hydration and nutrition therapy in end-of-life situations. The decision to initiate nutrition therapy is no different than the decision to stop therapy once it has started thus, clinicians are not obligated to provide therapy that is unwarranted conditional recommendation, very low level of evidence. If requested, nutrition therapy in end-stage malignancy should be provided by the enteral route conditional recommendation, very low level of evidence.

Use of PN in this setting may cause net harm and should be highly or aggressively discouraged conditional recommendation, very low level of evidence.

The clinician who has ethical concerns of his own in a difficult end-of-life situation should excuse himself from the case, as long as he can transfer care to an equally qualified and willing health-care provider conditional recommendation, very low level of evidence. Summary of Recommendations Indications for nutritional therapy Question: EN should be used preferentially over PN in hospitalized patients who require non-volitional specialized nutrition therapy, and do not have a contraindication to the delivery of luminal nutrients conditional recommendation, low level of evidence.

Prior to initiation of specialized nutrition therapy either EN or PN , a determination of nutritional risk should be performed using a validated scoring system such as the NRS or the NUTRIC Score on all patients admitted to the hospital for whom volitional intake is anticipated to be insufficient conditional recommendation, very low level of evidence.

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

Indirect calorimetry conditional recommendation, very low level of evidence. Simple weight-based equations conditional recommendation, very low level of evidence. Published predictive equations conditional recommendation, very low level of evidence. How should enteral access be achieved, and at what level of the GI tract should enteral nutrition be infused?

Radiologic confirmation of placement in the stomach should be carried out prior to feeding except with use of electromagnetic transmitter-guided feeding tubes. A percutaneous enteral access device should be placed, either via the gastric or jejunal route, if enteral feeding is anticipated to be required for greater than 4 weeks duration conditional recommendation, very low level of evidence. Initiating enteral nutrition Question: Placement on PN over the first week of nutrition therapy conditional recommendation, low level of evidence.

Monitoring tolerance and adequacy of enteral nutrition Question: How should adequacy and tolerance of enteral nutrition be assessed in the hospitalized patient? Gastric residual volume should not be used routinely as a monitor in hospitalized patients on EN conditional recommendation, very low level of evidence. Use a prokinetic agent conditional recommendation, low level of evidence. Divert the level of feeding lower in the GI tract strong recommendation, moderate-to-high level of evidence.

Switch to continuous infusion conditional recommendation, very low level of evidence. Use chlorhexidine mouthwash twice daily conditional recommendation, very low level of evidence.

Use of fermentable soluble fiber as an adjunctive supplement to a standard EN formula conditional recommendation, very low level of evidence. Switching to a commercial mixed fiber soluble and insoluble formula conditional recommendation, low level of evidence. When and how should parenteral nutrition be utilized in the hospitalized patient?

Peripheral PN should not be used, as it leads to inappropriate use of PN, has a high risk of phlebitis and loss of venous access sites, and generally provides inadequate nutrition therapy conditional recommendation, very low level of evidence. Nutritional therapy at end-of-life Question: All authors contributed to the manuscript.

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Goals of nutrition therapy that apply to adults with diabetes