Annals of Clinical Nutrition and Metabolism

중환자 영양지원: 이태의; J Clin Nutr 2007;1(1):1-4. Published online December 31, 2007

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Application of Hazard Analysis Critical Control Points System to Enteral Feed Preparation Using 6-sigma Strategy: Sun-Jung Kim, Hye-Kyung Chung, Song-Mi Lee; J Clin Nutr 2007;1(1):5-12. Published online December 31, 2007; DOI: https://doi.org/10.15747/jcn.2007.1.1.5

Abstract PDF: Purpose
The administration of contaminated diets can contribute to severe infections, negative publicity of the hospital and huge financial loss. This study examined the microbiological quality of enteral feeds in order to help improve the process of the enteral feed preparation, storage, and delivery. Methods: The Hazard Analysis Critical Control Points (HACCP) system was implemented to control the level of microbiological contamination of enteral feeding formulations using a 6-sigma strategy, which was processed using the DMAIC method. The effectiveness of the 6-sigma activity was measured using the defect case, which is over the British standard of 10² CFU/ml in enteral feeds. Results: By performing the 6-sigma activity, the microbiological quality of enteral formulas were improved 2.20? to 6.00? (P=0.009). There were more defect cases in the concentrated enteral feeds than the standard or diluted enteral feeds before implementing the HACCP system. Conclusion: These results showed that the implementation of HACCP can help protect against microbial contamination and will be required in the near future for better quality control of enteral feeds. In addition, these results may be applicable to setting up a standard Korean microbiological control in enteral tube feeding. (JKSPEN 2007;1(1):5-12)

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The Antimicrobial Resistance of Nosocomial Enterococcus faecium Infection in Patients Received Probiotics Containing Enterococcus faecium: Jeong Wook Kim; J Clin Nutr 2007;1(1):13-18. Published online December 31, 2007; DOI: https://doi.org/10.15747/jcn.2007.1.1.13

Abstract PDF: Purpose
Probiotics are live microorganisms that confer a health benefit to the host when administered in adequate amounts. The bacteria used as probiotics in Korea are Lactobacillus, Bifidobacterum, Enterococcus, Bacillus and Clostridium. Enterococci form part of the lactic acid bacteria of importance in foods and are used as human probiotics. However, they are also important nosocomial pathogens e.g. vancomycin-resistant enterococcus in a nosocomial infection. Therefore, this study examined the antimicrobial resistance of Enterococcus faecium (E. faecium) related nosocomial infections in patients who received probiotics containing E. faecium. Methods: This study analyzed 234 patients with an E. faecium infection, who were hospitalized between 2003 and 2005. Results: An infection developed in 171 patients during hospitalization and 22 (12.6%) of these had received probiotics E. faecium prior to the infection. Seventy-one (41.5%) of the 171 patients had an urinary tract infection, 44 (25.7%) had a biliary tract infection, 19 (11.1%) had an infection of the blood, 15 (8.8%) had a wound infection and bedsores, 11 (6.4%) had a hemo-bag infection, 6 (3.5%) had an intravenous hyperalimentation infection, and 3 (1.8%) each had pneumonia, vaginal discharge and spontaneous bacterial peritonitis. There were no differences in the source of infection between the group given probiotics and group without probiotics. The frequency of antimicrobial resistance to ampicillin, chloramphenicol, ciprofloxacin, gentamycin, streptomycin, vancomycin and teicoplanin, and the use of these antibiotics were similar in both groups. Conclusion: Probiotics containing E. faecium do not increase the antimicrobial resistance of nosocomial infections by E. faecium. (JKSPEN 2007;1(1):13-18)

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P Wave Change Ratio; A Technique for the Central Venous Catheterization: Do Sang Lee; J Clin Nutr 2007;1(1):19-22. Published online December 31, 2007; DOI: https://doi.org/10.15747/jcn.2007.1.1.19

Abstract PDF: Purpose
This study examined the value of an electrocardiogram (ECG) in central venous catheterization (CVC) for nutrition support. Methods: The rates of change in the P wave and the QRS wave at limb lead II before and after catheter insertion were evaluated in 442 patients who underwent CVC with an ECG. After insertion, a plain chest X-ray was checked to confirm the location of catheter tip. Results: After catheterization, the P wave and the QRS wave increased together at 97%but the P wave (change rate: 0.5∼21.0) was more sensitive than the QRS wave (change rate: 0.5∼5.8). For an abnormal location (3%), the rate of change in the P wave and the QRS wave was ＜2.0 and ＜1.4, respectively. The sensitivity and the specificity of the P wave ＞2.0 were 95% and 100%, respectively. The sensitivity and the specificity of the QRS wave ＞1.4 were 90% and 100%, respectively. Conclusion: In central venous catheterization, ECG can be a useful method, and the normal position of the catheter tip can be estimated using the rate of change in the P wave ＞2.0 or the rate of change in the QRS wave ＞1.4. (JKSPEN 2007;1(1):19-22)

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Prevalence of Patients at Nutritional Risk among Those who Underwent Gastrointestinal Surgery for Cancer: Hosun Lee, Choong Bai Kim; J Clin Nutr 2007;1(1):23-27. Published online December 31, 2007; DOI: https://doi.org/10.15747/jcn.2007.1.1.23

Abstract PDF: Background
Undernutrition is associated with increased morbidity and mortality, and is common encountered in patients admitted to hospital for gastrointestinal (GI) surgery. This study examined the prevalence of nutritional risk among those who had undergone GI surgery, and whether nutritional support was provided for patients at nutritional risk after surgery. Methods: This study prospectively studied 100 patients admitted to the Severance Hospital, Yonsei University Health System for elective GI surgery from September, 2006 to February, 2007. The NRS-2002 was used to evaluate the nutritional risk. The patients were characterized by scoring the components 'undernutrition' and 'severity of disease' into 4 categories (absent, mild, moderate or severe). The patient could have a score of 0∼3 for each component (undernutrition and severity of disease), and any patient with a total score ≥ 3 was considered to be at nutritional risk. Undernutrition was evaluated by 3 variables (BMI, recent weight loss, recent food intake). The primary physicians' order of nutrition support after surgery was recorded. Results: The mean age of the patients was 57.4±11.8 years. Sixty five cases were male and 30 were female. Of the 95 patients who underwent gastric or colon surgery, 47.4% were at nutritional risk. There was no significant difference between the 2 groups according to the site of surgery (46.8% of 62 gastric surgery patients vs. 48.5% of 33 colon surgery patients, P=0.67). Although 42.3% of patients at nutritional risk were not provided nu-trition support, 58.0% of patients not at nutritional risk were provided parenteral nutrition support after surgery. Conclusion: The introduction of a screening system for nutritional risk appears to be necessary for improving the nutritional status of GI surgical patient through a cost-effective nutrition therapy protocol. (JKSPEN 2007;1(1): 23-27)

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The Development of a Computerized Nutrition Support Program for Inpatients: Mi Jin Jeong, Soo Taik Lee, Dong Chan Kim, Hee Chul Yu, Won Kim, Haeng Sun Kim, Ju Sin Kim, Seon Hyeong Kim, Min Woo Kang, Guang Yu Jin, Baik Hwan Cho; J Clin Nutr 2007;1(1):28-37. Published online December 31, 2007; DOI: https://doi.org/10.15747/jcn.2007.1.1.28

Abstract PDF: Purpose
The importance of detecting malnourished patients or those at risk of becoming malnourished early has been emphasized recently. However, it is difficult with limited resources to rapidly identify patients requiring nutrition management. Therefore, the Nutrition Support Team (NST) at our hospital wanted to use the adult nursing admission questionnaire, which is documented by a nurse at admission, for nutrition screening with various parameters of the SGA. The aim of this study was to develop a computerized program that includes nutrition screening using the adult nursing admission questionnaire, a nutrition assessment, a care plan, monitoring and reevaluation for more effective and earlier nutrition management with limited staff. Methods: The task force team within the NST is composed of a physician, nurse, pharmacist and dietitian, whose aim is to develop a practical and fast screening program. The reports express a score that is dependent on the impact of the symptoms and the nutritional status of the patient derived from the adult nursing admission questionnaire. The scores are added to give a total. A score of 0∼5 is deemed adequate nutrition, 6∼10 denotes moderate or suspected malnutrition; 11 or more indicates severe malnutrition. The score uses the ordered diet, percent IBW, albumin and TLC according to the objective index. Malnutrition was defined as two items out of four being abnormal. Results: This program consists of whole procedures in the following order: nutrition screening, malnutrition, assessment and monitoring. The computerized system is as follows: nutrition screening, consultation, assessment and care plan, reply, monitoring, reevaluation and the end. Conclusion: It is expected that this program will facilitate nutrition screening using the adult nursing admission questionnaire, and provide early nutrition management through cooperation with various occupations. However, further study will be needed to assess the validity of identifying malnourished patients using the adult nursing admission questionnaire. (JKSPEN 2007;1(1):28-37)

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Heparin-Induced Thrombocytopenia among Patients Given High Nutritive Fluid: Soo An Choi, Hyoung Uk Namgung, Eun Sook Lee, Do Joong Park, Ho Seoung Han, Whan Gyoon Shin; J Clin Nutr 2007;1(1):38-41. Published online December 31, 2007; DOI: https://doi.org/10.15747/jcn.2007.1.1.38

Abstract PDF: Thrombocytopenia is common in hospitalized patients receiving unfractionated heparin. However, only a minority have heparin-induced thrombocytopenia (HIT). HIT is a serious complication after heparin therapy that can cause serious morbidity and mortality. One or three percent of patients given therapeutic intravenous doses of heparin develop this complication. Although much smaller doses of heparin are also known to cause thrombocytopenia, only a limited number of cases have been reported in the literature and the true incidence is unknown. A recent study reported that 12 out of 19 critically ill surgical patients diagnosed with HIT had been exposed to only 120 to 240 units/day of heparin through a flushs catheter. However, in a clinical environment, the heparin used for flushing vascular access devices, or as components of total parenteral nutrition (TPN) can be overlooked. Even if these cases are rare, the widespread use of TPN suggests that clinicians are likely to encounter this problem. Furthermore, the appearance of thrombosis or thrombocytopenia may not seem surprising because patients receiving TPN usually have serious medical conditions, the appearance of thrombosis or thrombocytopenia may not seem surprising. We encountered three patients with clinical evidence of HIT secondary to daily TPN supplementation. The case studies presented in this study introduce the experience of Nutrition Support Committee (NSC) of Seoul National University Bundang Hospital, which may help readers evaluate and recognize this complicated syndrome. When thrombocytopenia occurs, heparin as a TPN component may either not be initially suspected as a cause of thrombocytopenia or go unnoticed. This oversight may result in delayed treatment for HIT, which can cause serious morbidity and mortality. NSC should consider the occurrence of HIT in patients who experience a decrease in platelet count while receiving TPN. Heparin as a component of TPN should be discontinued if HIT is suspected, regardless of whether there is evidence of thrombosis, and alternative anticoagulation therapy should be started. (JKSPEN 2007;1(1):38-41)

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