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- Volume 3 (1); June 2012
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Review Articles
- A Comparison of Guidelines for Nutritional Support: ASPEN and ESPEN
- Myeong Sik Han
- Surg Metab Nutr 2012;3(1):1-4. Published online June 30, 2012
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Abstract
PDF - Clinical Practice Guidelines have been defined as “systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances” and aim at reducing variations in practice and improving care processes and patient outcomes. ASPEN and ESPEN guidelines are most frequently employed in nutritional support services. However, inconsistencies in the interpretation of the evidentiary basis of these guidelines and differences in the appreciation of their relevant value can lead to different conclusions and recommendations. This paper reviews the differences between these two guidelines, particularly from the perspective of ICU patients. The results indicate that these guidelines may appear to be different but ultimately reflect the same content when detailed situations under the same conditions and limitations are considered, suggesting that care must be taken in interpreting and applying these guidelines by considering specific conditions and limitations. (SMN 2012;3:1-4)
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- Nutrition Support Therapy during Anticancer Treatment
- Young Joon Lee
- Surg Metab Nutr 2012;3(1):5-8. Published online June 30, 2012
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Abstract
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- Nutritional support therapy (NST) was introduced four decades ago to treat cancer patients, and since then, NST has witnessed substantial developments and made important contributions to the improvement of cancer patients’ immune system, enabling safer surgery, chemotherapy, and radiation therapy. In addition, NST has provided terminal cancer patients with opportunities to improve their quality of life. The prevention and early detection of cancer cachexia syndrome (CCS) represent one of the most important factors in the treatment of cancer patients. However, according to the 2009 ASPEN (American Society for Parenteral and Enteral Nutrition) guidelines, NST is not required for all cancer patients and can be considered for patients with moderate to severe malnutrition who are undergoing surgery, chemotherapy, or radiation therapy. TPN is recommended for patients if their food intake or absorption of nutrients is expected to be difficult for more than seven days. The palliative use of NST for terminal cancer patients is rarely indicated, and immune-enhancing enteral formulas reflecting mixtures of arginine, nucleic acids, and essential fatty acids may be beneficial for malnourished cancer patients undergoing major surgery. Clinical trials are needed to assess the impact of nutrition screening on outcomes for cancer patients. (SMN 2012;3:5-8)
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- Nutritional Support for Geriatric Oncology Patients
- Bong-Seog Kim
- Surg Metab Nutr 2012;3(1):9-15. Published online June 30, 2012
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Abstract
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- Nutrition plays a major role in many aspects of cancer development and treatment. Malnutrition is a common problem in cancer patients and has been recognized as an important component of adverse outcomes, including an increase in morbidity or mortality and a decrease in the quality of life. Weight loss has been identified as an important indicator of a poor prognosis for cancer patients. Good nutritional practices can help cancer patients to maintain their weight and store of nutrients, providing them with some relief from nutrition impact symptoms and improving their quality of life. Poor nutritional practices, which can lead to undernutrition, can contribute to the incidence and severity of treatment side effects and increase the risk of infection, thereby reducing chances of survival. Nutrition impact symptoms are those symptoms that impede oral intake. On the other hand, aging is a complex process for all living organisms. During the process of aging, the human body accumulates damage at molecular, cellular, and organ levels, which results in diminished or dysregulated functions and an increased risk of disease and death. These age-related changes are well exemplified in the immune system. The early recognition and detection of various risks associated with malnutrition through nutritional risk screening, followed by comprehensive assessments, has been increasingly recognized as imperative in the development of quality standards for care in oncology practices. A patent’s nutritional status is often jeopardized by the natural progression of some neoplastic disease. Protein-calorie malnutrition (PCM) is the most common secondary diagnosis for cancer patients. PCM in cancer can result from multiple factors most often associated with anorexia, cachexia, and early satiety frequently experienced by cancer patients. In addition, cancer-induced abnormalities in the metabolism of major nutrients can increase the incidence of PCM. Such abnormalities may include glucose intolerance, insulin resistance, increased lipolysis, and increased whole-body protein turnover. If left untreated, PCM can lead to progressive wasting, weakness, and debilitation because the protein synthesis is reduced and the lean body mass is lost, possibly resulting in death. Anorexia can be exacerbated by side effects of chemotherapy and radiation therapy, including changes in taste and smell, nausea, and vomiting. Anorexia can hasten the course of cachexia, a progressive wasting syndrome evidenced by weakness and a marked and progressive loss of body weight, fat, and muscle tissue. Cachexia is estimated to be the immediate cause of death in 20% to 40% of cancer patients. Several theories of the etiology suggest that cachexia is caused by a complex mix of variables, including tumor-produced factors and metabolic abnormalities. Some individuals do respond to nutrition therapy, but most do not see a complete reversal of the syndrome, even with aggressive therapy. Therefore, the most prudent and advantageous approach to cachexia is the prevention of its initiation through nutrition monitoring and intervention. Nutrition plays a critical role in maintaining the immune response of the aged, but there is a need for a more in-depth and holistic approach to determining optimal nutritional strategies that can help maintain a healthy immune system for the aged and promote their resistance to infection and other immune-related diseases. (SMN 2012;3:9-15)
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Original Articles
- Validation of an Electronic Nutritional Risk Screening Tool for Hospital Cancer Patients
- Mi Ran Jung, Young Kyu Park, Eun Young Kim, Soo Jin Jang
- Surg Metab Nutr 2012;3(1):16-22. Published online June 30, 2012
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Abstract
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- Purpose: Although a number of validated nutritional risk screening tools are available, there is no gold standard for cancer patients, and most tools may not be applicable to the Korean population. To address this limitation, the Chonnam National University Hwasun Hospital developed an electronic nutritional risk screening tool for hospital cancer patients called the Chonnam National University Hwasun Hospital?Nutritional Risk Screening Tool (CNUHH-NRST). This study assesses the validity of the CNUHH-NRST by comparing it with Nutritional Risk Screening (NRS 2002) and the Malnutrition Screening Tool (MST).
Materials and Methods: A total of 529 cancer patients admitted in January 2010 were independently rated as not at risk or at risk of malnutrition by using the CNUHH-NRST, NRS 2002, and the MST. The cross-validity of the CNUHH-NRST was established, and secondary validation was conducted based on biochemical nutritional markers and clinical outcomes.
Results: The results indicate that 15.3%, 22.3%, and 16.6% of the patients were classified as at risk of malnutrition by the CNUHH-NRST, NRS 2002, and the MST, respectively. The sensitivity and specificity of the CNUHH-NRST relative to NRS 2002 and the MST were 66.1% and 99.3% and 70.5% and 95.7%, respectively. The kappa values were 0.74 and 0.68 (P<0.001). In comparison with the patients at no risk of malnutrition, those at risk showed lower serum albumin, total lymphocyte counts, and hemoglobin (P<0.05); a longer hospital stay (P<0.001); and higher mortality rates (P<0.001).
Conclusion: The CNUHH-NRST shows acceptable validity in comparison with NRS 2002 and the MST. In addition, the CNUHH-NRST can be used easily and quickly because it is an automated system based on electronic medical records. Further validation using a nutritional risk assessment tool is needed. (SMN 2012;3:16-22)
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- Evaluation of an Insulin Infusion Protocol for Blood Glucose Control in Surgical Intensive Care Units
- Dae-Sang Lee, Chi-Min Park, Yong-Beom Cho, Jae-Moon Bae
- Surg Metab Nutr 2012;3(1):23-28. Published online June 30, 2012
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Abstract
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- Purpose: There are no uniform guidelines for insulin infusion, and therefore hospitals use different insulin infusion protocols to maintain the optimal blood glucose level (BGL). This study evaluates the efficacy of a new insulin infusion protocol (IIP) developed by the Surgical Intensive Care Unit (SICU) at the Samsung Medical Center for surgical ill patients.
Materials and Methods: We considered a total of 246 patients admitted to the SICU at the SMC between August 2010 and January 2012. Over the course of four months, we developed a new IIP for the intensive care unit (ICU) based on a literature review and applied it from July 2011. Before the new IIP, we used a fixed insulin dose according to the checked blood sugar level (BSL), but with the new IIP, we used a flexible insulin infusion rate by considering the variance of the BSL. The BGL ranged from 140 mg/dl to 180 mg/dl. We compared the BGL and clinical outcomes between the old and new IIPs.
Result: There was no difference between participants except for the prevalence of diabetes. The new IIP reduced the average/minimum/maximum BGLs (mg/dl) from 207.9/152.7/268.5 to 181.4/138.7/230.8 (P=0.000/0.005/0.000) as well as the mortality rate, although this decrease was not significant. There was no change in the frequency of hypoglycemia. The results of a subgroup analysis indicate that the new IIP better controlled the BGL regardless of the presence of diabetes.
Conclusion: The new IIP, by considering the variance of the BSL, can control the BGL without increasing the morbidity rate in surgical ICUs. That is, the proposed IIP may be a safe, simple, and effective tool for controlling the BGL in surgical ill patients. (SMN 2012;3:23-28)
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