Specialized nutrition support

Maintaining adequate nutritional status, especially during periods of illness and metabolic stress, is an important part of patient care. Malnutrition in hospitalized patients is associated with significant complications, including increased infection risk, poor wound healing, prolonged hospital stay, and increased mortality, especially in surgical and critically ill patients.1 Specialized nutrition support refers to the administration of nutrients via the oral, enteral, or parenteral route for therapeutic purposes.1 Parenteral nutrition (PN), also... 

The first step before delivering specialized nutrition support is to perform a nutritional assessment and determine nutrient requirements based on the patient s nutritional status and clinical conditions. Collect subjective and objective data to determine a patient s level of nutrition, to identify patients with malnutrition or at risk for malnutrition, and to identify risk factors that may put a patient at risk for nutrition-related problems.1 A nutrition assessment should include 1,19... 

After performing a nutrition assessment and estimating nutritional requirements, determine the optimal route to provide specialized nutrition support (e.g., oral, enteral, or parenteral). If PN is deemed necessary, venous access (i.e., peripheral or central see below) for PN infusion must be obtained. Finally, formulate a PN prescription, and administer PN according to proper safety guidelines. 

It might be expected that EN via tubes would have been used widely before the development of parenteral nutrition (PN) however, this was not actually the case. EN via tubes inserted down the mouth or nose into the stomach and also via rectal tubes was used occasionally in the decades before the development of PN in the 1960s.1 However, modern techniques for enteral access, both the placement of the tubes themselves and the materials for making pliable, comfortable tubes, had not yet been developed. Before the PN era, the formulas delivered by the tube route often were blenderized foods. The National Aeronautics and Space Administration effort in the United States in the 1960s led to the development of low-residue (monomeric) diets for astronauts. These diets were adapted for use in sick patients requiring EN. Nonvolitional feedings in patients who cannot meet nutritional requirements by oral intake thus include EN and PN these techniques are collectively known as specialized nutrition support (SNS). 

EN has replaced parenteral nutrition (PN) (see Chap. 60) as the preferred method for the feeding of critically ill patients requiring specialized nutrition support. Advantages of EN over PN include maintaining GI tract structure and function fewer metabolic, infectious, and technical complications and lower costs. 

Improved gastrointestinal function Short bowel syndrome in patients who are also receiving specialized nutritional support... 

From ASPEN Board of Directors and the Qinical Guidelines Taskforce. Administration of specialized nutrition support JPENJ Parenter Enteral Nutr 2002 26 l8SA-2 ISA and ASPEN Board of Directors and the Clinical Guidelines Taskforce. Specific guidelines for disease-Adults. JPEN J Parenter Enteral Nutr 2002 26 61SA-96SA. 

Clark CL, Sacks GS, Dickerson RN, et al. Treatment of hypophosphatemia in patients receiving specialized nutrition support using a graduated dosing scheme Results from a prospective clinical trial. Crit Care Med 1995 23 1504-1511. 

Define goals and objectives of specialized nutrition support therapy. 

Evaluate laboratory data to determine the patient s clinical, nutritional, and metabolic responses to specialized nutrition support. 

Evaluate continued need for specialized nutrition support. 

Participate in development of policy and procedures for patient care and operational aspects of specialized nutrition support. 

Schwenk WE. Specialized nutrition support The pediatric perspective. JPEN J Parenter Enter Nutt 2003 27 160-167. 

Critical reviews of available randomized controlled trials comparing EN to PN in the critically ill adult patient with an intact GI tract suggest a significant reduction in infectious complications associated with EN. Decreased infectious complications have been documented in patients with abdominal trauma, burns, or severe head injury given EN compared to PN. The use of EN has been recommended over PN as the preferred route of feeding in the critically ill patient requiring specialized nutrition support. ... 

Hypokalemia is common in the patient with liver failure who has normal renal function. Poor nutritional intake and vomiting may initiate this disorder. Severe vomiting may lead to volume contraction metabolic alkalosis, with increased renal excretion of potassium. Secondary hyperaldosteronism, seen in the liver failure patient with intravascular depletion, also increases renal excretion of potassium. Loop diuretic therapy causes increased renal excretion of potassium, whereas diarrhea from lactulose therapy increases fecal excretion of potassium. All these conditions can lead to profound hypokalemia. Therefore, potassium requirements in the liver failure patient receiving specialized nutritional support often are increased substantially. 

Adequate nutritional support in the ICU is very important and guidelines for these nutritional interventions have been published (47,48). The interdisciplinary team formulates the nutritional care plan to include monitoring, the most appropriate route of administration, the method of nutritional access, the duration of therapy, and educational objectives. Figure 1 shows the algorithm for the decision to initiate specialized nutritional support. A variety of delivery routes and nutritional formulation components are available. 

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