Annals of Clinical Nutrition and Metabolism

Letter from Editor: J Clin Nutr 2018;10(1):1-1. Published online June 30, 2018; DOI: https://doi.org/10.15747/jcn.2018.10.1.1

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Clinical Outcomes of Nutritional Supply in Critically Ill Patients in the Prone Position: Yeonju Lee, Hyung-Sook Kim, Hyungwook Namgung, Eun Sook Lee, Euni Lee, Young-Jae Cho, Yeon Joo Lee; J Clin Nutr 2018;10(1):2-8. Published online June 30, 2018; DOI: https://doi.org/10.15747/jcn.2018.10.1.2

Abstract PDF ePub: Purpose:
Enteral nutrition is recommended in critically ill patients. On the other hand, the recommendation of nutritional support is limited and often controversial in critically ill patients in the prone position. Therefore, this study evaluated the clinical outcomes of nutritional support in critically ill patients in the prone position.
Methods:
A retrospective evaluation of the electronic medical records was conducted, including adult patients who were in the medical intensive care unit (ICU) in the prone position in Seoul National University Bundang Hospital from May 1, 2015 to June 30, 2017. The patients’ characteristics, nutritional support status while they were in the prone position, mortality in ICU and during hospitalization, ICU length of stay, mechanical ventilation days, and complications, such as ventilator associated pneumonia (VAP) and vomiting were collected.
Results:
In total, 100 patients were included. Of these, 12 received enteral nutrition and parenteral nutrition and 88 received only parenteral nutrition. The groups were similar in terms of age, sex, number of comorbidity, weight, PaO₂/FiO₂, hours of prone position, Simplified Acute Physiology Score II (SAPS II), Acute Physiologic and Chronic Health Evaluation II (APACHE II) score, and Sequential Organ Failure Assessment (SOFA) score. No differences were observed in ICU mortality (75.0% vs. 46.6%; P=0.065), hospital mortality (83.3% vs. 58.0%; P=0.081), ICU length of stay (22.2±14.6 vs. 18.2±21.2; P=0.128) and mechanical ventilation days (19.3±14.8 vs. 14.5±19.1; P=0.098). In addition, there were no differences in the possible complications of the prone position, such as VAP (8.3% vs. 4.5%; P=0.480) and vomiting (8.3% vs. 1.1%; P=0.227).
Conclusion:
No significant differences in the clinical outcomes were observed. Further studies will be needed to confirm the way of nutrition support while in the prone position.

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Effects of Parenteral Nutrition in Pediatric Patients with Hematopoietic Stem Cell Transplantation: Soo Young Lim, Min Jae Jung, Ji Eun Park, Jae Song Kim, Soo Hyun Kim, Chuhl Joo Lyu, Eun Sun Son; J Clin Nutr 2018;10(1):9-19. Published online June 30, 2018; DOI: https://doi.org/10.15747/jcn.2018.10.1.9

Abstract PDF ePub: Purpose:
This study examined the effects of parenteral nutrition (PN) on the nutritional status, clinical improvement, and PN-related complications in pediatric patients who had undergone hematopoietic stem cell transplantation (HSCT).
Methods:
A retrospective audit of 110 pediatric patients (age≤18), who underwent HSCT from March 2015 to February 2017 was undertaken. The patients were divided into 3 groups based on the ratio of daily calorie supplementation to the daily calorie requirement (ROCS). The clinical factors related to the nutritional status, such as difference in body weight (BW), body mass index (BMI), percent ideal body weight (PIBW), total protein (T.protein), and albumin; the early clinical outcome, such as PN-duration, length of hospitaliaztion (LOH), engraftment day (ED), graft-versus-host disease, sepsis, pneumonia and mucositis; and PN-related complications, including elevation of total bilirubin (T.bil), direct bilirubin (D.bil), aspartate aminotransferase, alanine aminotransferase, glucose and cholesterol levels, and hepatic veno-occlusive disease were analyzed using the electronic medical records. Additional analysis subject to auto-HSCT and allo-HSCT patients was also performed.
Results:
The very-low-ROCS, low-ROCS, and satisfied-ROCS group were 30 (27.3%), 47 (42.7%), and 33 (30.0%) patients, respectively. The PN-duration (P=0.005, z=–2.271), LOH (P=0.023, z=–2.840), ED (P<0.001, z=–3.695), T.bil elevation (P<0.001, z=–3.660), and D.bil elevation (P=0.002, z=–3.064) tended to decrease with increasing ROCS. The difference in the PN-duration (P=0.017), ED (P=0.001), T.bil elevation (P=0.001), and D.bil elevation (P=0.011) in the 3 groups was statistically significant. In the auto-HSCT patients, the change in BW (P=0.031, z=+2.154), PIBW (P=0.029, z=+2.187), and BMI (P=0.021, z=+2.306) tended to increase. In the allo-HSCT patients, the change in T.protein (P=0.022, z=+2.286) increased but the ED (P=0.021, z=–2.304) decreased.
Conclusion:
Aggressive PN supplementation has an effect on maintaining the nutritional status and achieving better early outcomes in pediatric HSCT patients, whereas it has no effect on increasing the PN-related complications.

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Quality Improvement Activities to Facilitate the Filing of Complexity Payment Claims for Patients with Malnutrition: Kuk Hwan Kwon, Hyung Soon Lee, Jee Hyoung Yoo, Soo Na Chi, Hyun Hee Park, So Won Kim, Kyung Ran Kim, Nan Hee Yun, Kyoung Taek Ra, Hyun Jung Song; J Clin Nutr 2018;10(1):20-24. Published online June 30, 2018; DOI: https://doi.org/10.15747/jcn.2018.10.1.20

Abstract PDF ePub: Purpose:
The grade of complexity in the diagnosis related group (DRG) payment system is influenced by the secondary diagnosis of specific complication and comorbidity level, in which moderate or severe malnutrition is included. This study examined an existing proportion of patients with malnutrition who were supposed to be qualified for the complexity level and devised quality improvement measures to increase the proportion of qualifying complexity payments.
Methods:
The goal of the activities was to increase the rate of complexity payment claims for patients with malnutrition (%). Cases ineligible for the DRG payment system and cases with no diagnosis of malnutrition were excluded. We established a collaborative system between the nutrition support team and departments related to each improvement factor (i.e., patient care, medical records, insurance review, and medical information).
Results:
Before implementing the activities, this study investigated the current level of complexity payment claims for malnutrition patients who were discharged within a specific period (June 1, 2015∼August 31, 2015). The results showed that complexity payment claims were filed in 10.00% (2 of the 20 malnutrition cases). After the activities, the rate of complexity payment claims for the patients with malnutrition within the study period (June 1, 2016∼August 31, 2016) was 46.43% (26 out of 56), showing an approximately 364% increase from the pre activity rate. This change was statistically significant according to the chi-square test on Microsoft Excel 2010 (P<0.01).
Conclusion:
Collaborative efforts by the related departments enabled the smooth implementation of each activity. In addition, moderate or severe malnutrition was revealed to be a variable in the complexity-specific payment system. In the future, hospital-wide awareness and effort are crucial to promot the steady practice of these activities and expand their implementation.

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Esophageal Obstruction Caused by the Solidification of Residue of an Enteral Feeding Formula: Hancheol Jo, Ye Rim Chang, So Mi Kim, Dong Wook Kim, Ye Seob Jee; J Clin Nutr 2018;10(1):25-30. Published online June 30, 2018; DOI: https://doi.org/10.15747/jcn.2018.10.1.25

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The nutritional support of acutely ill patients is very important and early enteral nutrition is recommended. Feeding via the nasogastric route is used widely for its ease of access if the patient cannot maintain volitional food intake. If the position of the tip or side holes of the nasogastric tube (NGT) is above the gastroesophageal junction, there is the possibility of retention and solidification of the administered enteral feeding formula in the esophagus. Therefore, the tip of the NGT should be checked carefully; a chest radiograph to confirm its position can be considered, especially in patients with a higher risk of aspiration and gastroesophageal reflux. In addition, careful consideration of the risk factors that can trigger esophageal obstruction is required when feeding patients in the intensive care unit. This paper describes two unusual cases of esophageal obstruction caused by the solidification of residue of an enteral feeding formula.

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