Impact of the clinical nutritionist on tube feeding administration.

An analysis was conducted to evaluate the effect of nutrition assessment by a registered dietitian on tube feeding (TF) tolerance and the length of time required to meet patients' nutritional requirements via those TFs. All adult patients (no. = 87) receiving TFs at the University of Michigan Medical Center over a 3-month period were studied. Their charts were examined for a nutrition assessment with recommendations for TF delivery rate and formula selection, physician's compliance with those recommendations, and TF tolerance. TF tolerance was defined as the absence of diarrhea, gastric distention, elevated TF residuals, nausea, or vomiting. Patients whose physician followed the recommendation in the registered dietitian's assessment showed a statistically significant benefit in tolerance of the TF in comparison with those patients who received no assessment or those whose physician ignored the recommendation (p less than .05, chi-square test). Average time to meet nutritional requirements via TF was 4 days in patients with nutrition recommendations incorporated into their care vs. 7 in those patients without nutrition assessments. Our results suggest the importance of TF recommendations by the registered dietitian and the practical benefit to the patients when these suggestions are implemented.

Association of parenteral nutrition catheter sepsis with urinary tract infections.

The infection rate (IR) of central venous catheters (CVCs) used for parenteral nutrition (PN) was prospectively evaluated over a 12-month period, with emphasis on the relationship between CVC sepsis and preexisting sites of infection. Sepsis was presumed if the CVC tip or blood culture was positive, or if defervescence followed CVC removal. Four hundred seventy-three CVCs were placed for PN for a total of 5,422 patient days, with a mean length of stay of 11.5 days. Twenty two CVCs led to sepsis for an IR of 4.65% or 4.06 infections per 1000 patient days. Twenty of the 22 septic CVCs were in patients with other sites of infection. The IR was 12.0% (20/166) when other sites of infection were present and 0.65% (2/307) in the absence of a second site. The mean length of stay was 13.2 days for CVCs with other sites of infection and 10.3 days for CVCs with no other site of infection. Fifty nine percent of septic CVCs had secondary sites of infection that included urinary tract infections (UTI). Of all septic CVCs, 22.7% had no site of infection other than UTI. The presence of UTI appears to present a high risk of CVC sepsis. Appropriate identification and treatment of UTI prior to CVC insertion is recommended.

Nutrition risk classification: a reproducible and valid tool for nurses.

BACKGROUND: Incorporating the nursing staff to assist with the screening process on admission will allow patients who are at nutritional risk to be assessed by registered dietitians earlier in their hospital stay. The goal of this study was to develop an objective, valid, reproducible nutrition screen for use by registered nurses (RNs) to allow for nutrition classifications of hospitalized patients. METHODS: The current nursing admission assessment form was modified to contain questions on weight loss history, percentage of ideal body weight, and alterations in dietary intake and gastrointestinal function. Assessments were completed within 48 hours of admission. On the basis of the answers to these questions, patients were classified as "at nutritional risk" or "low nutritional risk." In phase 1, to assess reproducibility of the form, a prospective study between staff RNs and a nutritionist was undertaken on 186 consecutive adult admissions. Nutrition screening and classification was done independently by both practitioners. In phase 2 of the study, prospective validation of the form contrasting prealbumin (PAB) levels with RN nutritional risk classification (n = 56) was investigated. RESULTS: Interobserver agreement of nutrition classification between RN and nutritionist was 97.3% (p = .95). Twenty-nine patients were classified at low nutritional risk (27 normal PAB and 2 low PAB); 27 patients were classified as at nutritional risk (16 normal PAB and 11 low PAB) (chi 2 = 8.9, p < .003, power 0.8). The sensitivity of the tool was 84.6%. CONCLUSION: To our knowledge, this is the first nutrition screening tool designed for staff RNs that has been tested for both validity and reproducibility.

Parenteral zinc supplementation in adult humans during the acute phase response increases the febrile response.

The acute phase response (APR) that follows injury or infection is characterized by a decrease in serum zinc concentrations, which we hypothesized benefits the host. Additionally, we proposed that preventing this decline by supplementing zinc would result in an exaggerated APR as indicated by elevated temperatures, increased serum cytokine concentrations, interleukin 6 and the acute phase protein (ceruloplasmin). A prospective, randomized, double-blinded, clinical trial was conducted. Patients on home parenteral nutrition with a diagnosis of catheter sepsis and patients with a diagnosis of pancreatitis, also on total parenteral nutrition (TPN), were recruited for the study. Following enrollment, block randomization was used to assign patients to receive 0 mg (n = 23) or 30 mg (n = 21) of zinc per day for the first 3 d of TPN. Blood samples for measurement of serum zinc, copper, ceruloplasmin and interleukin-6 were obtained upon enrollment and on d 1 through 3 of TPN. The highest temperatures reported on these days in the medical record were also recorded. Repeated measures ANOVA was used to determine differences in the primary outcome variables over time. No significant differences between groups were observed in serum interleukin-6 or ceruloplasmin concentrations. A significantly higher (P = 0.035) temperature was observed in the zinc-supplemented group compared with the control group on d 3 of parenteral nutrition. We conclude that parenteral zinc supplementation in patients experiencing a mild APR resulted in an exaggerated APR as evidenced by a significantly higher febrile response.