Customized nutrition intervention and personalized counseling helps achieve nutrition targets in perioperative liver transplant patients.

BACKGROUND AND AIM: Nutritional therapy is an integral part of care in all phases of liver transplantation (LTx). However, there are several factors that make it a challenge to manage malnutrition in these patients including, but not limited to, loss of appetite, dietary restrictions and dietary habits. Dietary habits are guided by personal choice, social, cultural and regional background with diversity ranging from veganism to vegetarianism with the latter predominant in Indian population. Therefore, it is difficult to improve nutritional intake of patients with standard dietary recommendations. We evaluated the effects of implementing personalized dietary counseling and a customized nutrition plan on its ability to enhance oral intake and, thereby improve nutritional status of patients with end stage liver disease (ESLD) being evaluated for LTx. We compared the outcomes with a matched group of patients who were prescribed standard dietary recommendations from a historic database. Primary outcome was measured by number of patients achieving ≥75% of recommended energy and protein requirements during hospitalization for LTx. Secondary outcomes included mean energy and protein intake, hours of ventilation, length of stay in Intensive Care Unit (ICU) and hospital, mortality and readmission rate in the acute phase (3months) after LTx. METHODS: This was a prospective observational study, performed at a single LTx centre. All patients >18years who enrolled for LTx and consented for the study were included. The study was conducted after obtaining institutional ethics committee approval. A protocol based nutrition planning was implemented from April'14. According to this protocol, all patients being evaluated for LTx underwent a detailed nutritional assessment by a qualified Clinical Dietitian (CD) and regularly followed up with until LTx. Nutritional intervention, including a customized nutrition care plan and personalized dietary counseling, was provided based on the severity of malnutrition. To evaluate the efficacy of this protocol, we compared the nutritional adequacy (calorie and protein intake) of 65 consecutive patients who underwent LTx between August'14-October'15 (group 1) with a historic database of 65 patients who underwent LTx between January'13 and April'14 (group 2). Patients' demographics, disease severity score, baseline markers of nutritional status (subjective global assessment (SGA), and body mass index (BMI)), were recorded. First, assessment of individual patient's oral energy and protein intake was determined by the daily calorie count during hospitalization. Then the nutritional intervention (oral nutrition supplement (ONS)/enteral nutrition (EN)/parenteral nutrition (PN)) plan was customized according to their spontaneous oral intake. As part of the protocol, health related quality of life was also assessed using short form 8 (SF-8) in group 1. Statistical analyses using Pearson's correlation, Chi-Square test were applied with SPSS version 20.0. RESULTS: The mean age of group 1 and 2 were 52.6 ± 9.8, 51.9 ± 10.5 (range 25-70years) with BMI of 26.8 ± 6.0, 26.5 ± 5.4 respectively. According to SGA, there was significant improvement in the nutritional status of group 1 patients compared to group 2 on admission for LTx. It was indicated that 88% of group 1 individuals in comparison to 98% in group 2 were malnourished. The calorie intake of group 1 (1740.2 ± 254.8) was significantly higher than group 2 (1568.5 ± 321.6) (p = 0.005). The marked improvement in protein intake in group 1 (63.1 ± 12.1) when compared with group 2 (53.1 ± 13.4) was statistically significant (p = 0.008). A subset analysis showed that non-vegetarians (consuming meat and dairy products) between the groups showed that group 1 had a significantly higher calorie (p = 0.004) and protein (p = 0.0001) intake compared to individuals in group 2. Following implementation of study's protocol, the goal of achieving ≥75% of the prescribed calories (p = 0.013) and protein (p = 0.0001) was significantly higher in group 1. CONCLUSION: When compared to the standard prescription, an individualized protocol to diagnose, stratify the severity of malnutrition early, and follow up by customized nutrition planning for patients helped to achieve nutritional targets more effectively. Inspite of patients' diversity in nutritional habits and reluctance to accept change, it is clear that a qualified and dedicated transplant nutrition team can successfully implement perioperative nutrition protocol to achieve better nutritional targets.

Parenteral nutrition support: Beyond gut feeling? Quality control study of parenteral nutrition practices in a Tertiary Care Hospital.

BACKGROUND: Enteral nutrition (EN) is preferred over parenteral nutrition (PN) in hospitalized patients based on International consensus guidelines. Practice patterns of PN in developing countries have not been documented. OBJECTIVES: To assess practice pattern and quality of PN support in a tertiary hospital setting in Chennai, India. METHODS: Retrospective record review of patients admitted between February 2010 and February 2012. RESULTS: About 351,008 patients were admitted to the hospital in the study period of whom 29,484 (8.4%) required nutritional support. About 70 patients (0.24%) received PN, of whom 54 (0.18%) received PN for at least three days. Common indications for PN were major gastrointestinal surgery (55.6%), intolerance to EN (25.9%), pancreatitis (5.6%), and gastrointestinal obstruction (3.7%). CONCLUSIONS: The proportion of patients receiving PN was very low. Quality issues were identified relating to appropriateness of indication and calories and proteins delivered. This study helps to introspect and improve the quality of nutrition support.

Feasibility, safety, and outcome of very early enteral nutrition in critically ill patients: Results of an observational study.

BACKGROUND: In critically ill patients, early enteral nutrition (EN) within 24 to 72 hours is recommended. Although vasopressor-dependent shock after resuscitation is not a contraindication for EN initiation, feasibility and safety of very early (within 6 hours) EN initiation soon after resuscitation are unknown. OBJECTIVE: To evaluate the feasibility, safety, tolerance, and adequacy of very EN delivery in critically ill patients within 6 hours of intensive care unit (ICU) admission. MATERIAL AND METHODS: Prospectively collected data from a total of 308 medical and surgical patients admitted to the ICU for at least 3 days were analyzed. The patients in whom EN was initiated within 6 hours of ICU admission (n = 166) were compared with those in whom EN was initiated after 6 hours (n = 142). Comparisons were made between groups in the percentage of target calories and proteins delivered on day 3, percentages of patients achieving target calories and proteins on day 3, incidence of feed intolerance, ICU length of stay (LOS), hospital LOS, ICU/hospital discharge, and mortality. RESULTS: No significant differences were seen in percentage of calories (71.62% vs 71.83%; P = .09) and proteins (71.85% vs 68.89%; P = .2) delivered on day 3 between patients receiving EN within 6 hours and after 6 hours of admission. Similar number of patients achieved target calories (66.3% vs 67.6%; P = .8) and target proteins (66.9% vs 62.7%; P = .5) on day 3 in both groups. There were no significant differences between the groups for ICU LOS (11.41 days vs 11.72 days; P = .7) and hospital LOS (20.7 days vs 17.96 days; P = .1). A total of 77.1% patients were discharged in the group in whom EN was initiated within 6 hours and 67.6% patients were discharged in the group where EN was initiated after 6 hours (P = .07). The mortality rate was 22.9% and 32.4%, respectively (P = .07), in these groups. Overall incidence of EN interruption was 20.13% without significant difference between the 2 groups (<6 hours, 16.2%; >6 hours, 24.7%; P = .087). CONCLUSION: Initiation of EN within 6 hours of ICU admission is feasible and safe and can be implemented routinely in all ICU patients.

Critical care 24 × 7: But, why is critical nutrition interrupted?

BACKGROUND AND AIMS: Adequate nutritional support is crucial in prevention and treatment of malnutrition in critically ill-patients. Despite the intention to provide appropriate enteral nutrition (EN), meeting the full nutritional requirements can be a challenge due to interruptions. This study was undertaken to determine the cause and duration of interruptions in EN. MATERIALS AND METHODS: Patients admitted to a multidisciplinary critical care unit (CCU) of a tertiary care hospital from September 2010 to January 2011 and who received EN for a period >24 h were included in this observational, prospective study. A total of 327 patients were included, for a total of 857 patient-days. Reasons and duration of EN interruptions were recorded and categorized under four groups-procedures inside CCU, procedures outside CCU, gastrointestinal (GI) symptoms and others. RESULTS: Procedure inside CCU accounted for 55.9% of the interruptions while GI symptoms for 24.2%. Although it is commonly perceived that procedures outside CCU are the most common reason for interruption, this contributed only to 18.4% individually; ventilation-related procedures were the most frequent cause (40.25%), followed by nasogastric tube aspirations (15.28%). Although GI bleed is often considered a reason to hold enteral feed, it was one of the least common reasons (1%) in our study. Interruption of 2-6 h was more frequent (43%) and most of this (67.1%) was related to "procedures inside CCU". CONCLUSION: Awareness of reasons for EN interruptions will aid to modify protocol and minimize interruptions during procedures in CCU to reach nutrition goals.