Annals of Clinical Nutrition and Metabolism

Letter from Editor: Hyuk-Joon Lee; J Clin Nutr 2014;6(3):87-87. Published online December 31, 2014; DOI: https://doi.org/10.15747/jcn.2014.6.3.87

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Drug-induced Gastrointestinal Hypomotility and Current Issues on Safety of Prokinetics in Critically Ill Patients: Hyung-Sook Kim; J Clin Nutr 2014;6(3):88-93. Published online December 31, 2014; DOI: https://doi.org/10.15747/jcn.2014.6.3.88

Abstract PDF: Impaired gastrointestinal (GI) motility is extremely common in the intensive care unit (ICU), affecting up to 50% of mechanically ventilated patients and up to 80% of patients with traumatic brain injury. This includes disturbances in esophageal, gastric, small intestinal, and colonic function; alone or in combination. Impaired upper GI motility can lead to reflux, aspiration, vomiting, high gastric residuals, and interruptions in enteral nutrition. In critically ill patients, prolonged constipation may cause delayed weaning from mechanical ventilation, lengthened ICU stay, and inability to take in enteral nutrition; at least one study has suggested an association between delayed defecation and both increased bacterial infections and mortality. Drugs used for analgesia and sedation are commonly associated with impaired gastric and small intestinal motility in critically ill patients. Drugs frequently impair gastric motility via one or more mechanisms, and the precise mechanisms of drug-induced hypomotility are often unknown. Therefore, measures to prevent drug-induced motility disturbances include correction of fluid and electrolyte imbalances, early enteral feeding, and judicious use of drugs known to alter motility. Prokinetic agents are currently the mainstay of therapy for impaired GI motility in the critically ill. Of the available prokinetic agents, current information, while limited, suggests that erythromycin or metoclopramide (alone or in combination) are effective in management of feeding intolerance for the critically ill in terms of evidence-based practice. Based on the current evidence evaluating the adverse effects of prokinetic agents in critical illnesses and the lack of prokinetic agents with a safer adverse effect profile, the ongoing need for prokinetic drugs in these patients should be reviewed daily in order to minimize avoidable adverse effects.

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The Effect of Combined Enteral and Parenteral Nutrition for Anastomotic Leakage after Gastric Cancer Surgery: Kyung-Goo Lee, Hyuk-Joon Lee, Jun-Young Yang, Seung-Young Oh, Yun-Suhk Suh, Seong-Ho Kong, Han-Kwang Yang; J Clin Nutr 2014;6(3):94-100. Published online December 31, 2014; DOI: https://doi.org/10.15747/jcn.2014.6.3.94

Abstract PDF: Purpose
The effectiveness of enteral nutrition for patients with anastomotic leakage after gastric cancer surgery is controversial. The purpose of this study is to compare effectiveness between combined enteral nutrition with parenteral nutrition (EPN) and total parenteral nutrition (TPN).Methods: Patients who underwent gastric cancer surgery for primary gastric cancer from April 2010 to August 2012 were reviewed. Clinicopathologic characteristics, complication, laboratory tests, and body weight (Bwt) were compared between EPN and PN.Results: Among patients with postoperative leakage within postoperative 1 month (n=43), 13 patients were supported by EPN and 23 patients by TPN. Clinicopathologic characteristics, including preoperative Bwt, body mass index, nutritional status, other complications, and TNM stage were similar. Preoperative serum albumin and Bwt were similar between EPN and TPN. However, after 1 week of nutritional support, albumin at EPN was significantly higher than that of PN (3.52±0.3 and 3.25±0.3; P=0.010). Adjusted by preoperative Bwt, preoperative nutritional status, and difference in Bwt between preoperative and pre-nutritional support period, decrease of Bwt between pre-nutritional support and discharge was significantly less at EPN than at TPN (?4.5±5.4%and ?6.3±4.1%; P=0.001).Conclusion: In terms of the maintenance of serum albumin and Bwt during nutritional support, EPN may be a better supportive option than TPN for patients with anastomotic leakage after gastric cancer surgery.

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Quality Improvement Activities for Establishment of Intestinal Rehabilitation in Intestinal Failure Patients: Hyo-Jung Park, Sang-Hoon Lee, Ji-Hye Yoon, Hyun-Jung Kim, Seul-Hee Hong, Eun-Ju Kim, Ja-Kyung Min, Hyun-Jung Kim, Bo-Kyung Jung, Chae-Yon Oh, Yong-Won In, Young-Mee Lee, Jeong-Meen Seo; J Clin Nutr 2014;6(3):101-107. Published online December 31, 2014; DOI: https://doi.org/10.15747/jcn.2014.6.3.101

Abstract PDF: Purpose
Intestinal failure (IF) is a complex clinical condition requiring a multi-disciplinary team approach. Our objective was to set up the treatment protocols and education documents for IF patients for development of intestinal rehabilitation programs in our hospital.Methods: We compared the number of inpatients, length of hospital stay, mode of nutrition and calorie supply at discharge, and the frequency of blood transfusions before and after quality improvement of multidisciplinary activities, in order to evaluate the indirect effects of new protocols and training materials and for development of the intestinal rehabilitation system.Results: We integrated eleven protocols for treatment and monitoring and seven educational materials for patients and caregivers. We compared indirect effects before and after the quality improvement activities. The number of IF patients hospitalized was reduced from 12 to 9. The mean days of hospital stay was decreased from 322 days to 73 days, the average number of monthly blood transfusions was also reduced from 1.8 to 0.3. In addition, the percentage of patients administered enteral nutrition and calories supplied was increased at discharge.Conclusion: By integrating IF protocols and education materials for IF patients, we found possible indirect effects of intestinal rehabilitation using a multidisciplinary team approach.

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Adequacy of Lipid Emulsion Administration Prescription Rate in a Single Center: Hye Ryun Jung, Myoung On Eun, Eun Sook Bang, Ji Hyun Lee, Mi Hyang Kim, Jeong Hong, Eun Jung Park, Jae Myeong Lee; J Clin Nutr 2014;6(3):108-113. Published online December 31, 2014; DOI: https://doi.org/10.15747/jcn.2014.6.3.108

Abstract PDF: Purpose
IV-lipid emulsion can be a nutritional supplement to provide essential fatty acids and energy for patients who need total parenteral nutrition support. The recommended administration dose of lipid emulsion is less than 2.5 g/kg/d and the rate should not exceed 0.15 g/kg/h for adult patients. The purpose of this study is to evaluate the adequacy of the currently prescribed administration rate of IV-lipid emulsion in a single center. Methods: We analyzed 1,739 lipid emulsion administration prescriptions in 1,095 patients over 18 years old at Ajou University Hospital from January 1, 2014 to March 31. Results: The median prescription rate of total lipid emulsion was 0.134 (0.012∼1.125) g/kg/h, and the exceeding portion of maximum recommended infusion rate was 36.9%. The median administration prescription rate of lipid emulsion was faster in 500 mL emulsions, compared to 250 mL emulsion (0.146 g/kg/h vs. 0.075 g/kg/h; P＜0.001) and at emergency room (ER), compared to general ward (0.154 g/kg/h vs. 0.123; P＜0.001). The exceeding portion of maximum recommended infusion rate of lipid emulsion was also higher in 500 mL emulsion, compared to 250 mL emulsion (52.2% vs. 30.4%; P＜0.001) and at ER, compared to general ward (52.1% vs. 30.4%; P＜0.001). Triglyceride level was higher in exceeding recommended infusion rate compared to less, but not statistically significant (119 mg/dL vs. 261 mg/dL; P=0.202). Conclusion: Administration prescription rate of lipid emulsion exceeded the recommended rate and this feature was dominant in 500 mL emulsion and at ER. Education and monitoring of lipid emulsion prescription is needed for appropriate lipid administration and prevention of fat overload syndrome.

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Kennedy Disease: 3-year Experience of Home Parenteral and Enteral Nutrition: Ja-Kyung Min, Soo-Joung Oh, Hyun-Jung Kim, Hyo-Jung Park, Mi-Young Rha, Dong-Kyung Chang; J Clin Nutr 2014;6(3):114-116. Published online December 31, 2014; DOI: https://doi.org/10.15747/jcn.2014.6.3.114

Abstract PDF: A 69-year-old man was consulted to our Home Health Care department for home parenteral enteral nutrition. He was diagnosed with Kennedy disease. He had swallowing difficulty and bowel ischemia. We provided nutritional support in a variety of ways in order to suit his condition. The role of the home care nurse involves training methods depending on changes in the nutritional support to patient and care giver. However, in the case of Kennedy disease, increasing the target patient’s nutritional requirements as calculated was difficult.

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