Gastrointestinal Manifestations, Malnutrition, and Role of Enteral and Parenteral Nutrition in Patients With Scleroderma.

Scleroderma (systemic sclerosis) is an autoimmune disease that can affect multiple organ systems. Gastrointestinal (GI) involvement is the most common organ system involved in scleroderma. Complications of GI involvement including gastroesophageal reflux disease, small intestinal bacterial overgrowth, and chronic intestinal pseudoobstruction secondary to extensive fibrosis may lead to nutritional deficiencies in these patients. Here, we discuss pathophysiology, progression of GI manifestations, and malnutrition secondary to scleroderma, and the use of enteral and parenteral nutrition to reverse severe nutritional deficiencies. Increased mortality in patients with concurrent malnutrition in systemic sclerosis, as well as the refractory nature of this malnutrition to pharmacologic therapies compels clinicians to provide novel and more invasive interventions in reversing these nutritional deficiencies. Enteral and parenteral nutrition have important implications for patients who are severely malnourished or have compromised GI function as they are relatively safe and have substantial retrospective evidence of success. Increased awareness of these therapeutic options is important when treating scleroderma-associated malnutrition.

Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Revised 2021 standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in nutrition support.

Nutrition support is a therapy that crosses all ages, diseases, and conditions as health care practitioners strive to meet the nutrition requirements of individuals who are unable to meet nutrition and/or hydration needs with oral intake alone. Registered dietitian nutritionists (RDNs), as integral members of the nutrition support team provide needed information, such as identification of malnutrition risk, macro- and micronutrient requirements, and type of nutrition support therapy (eg, enteral or parenteral), including the route (eg, nasogastric vs nasojejunal or tunneled catheter vs port). The Dietitians in Nutrition Support Dietetic Practice Group, American Society for Parenteral and Enteral Nutrition, along with the Academy of Nutrition and Dietetics Quality Management Committee, have updated the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs working in nutrition support. The SOP and SOPP for RDNs in Nutrition Support provide indicators that describe the following 3 levels of practice: competent, proficient, and expert. The SOP uses the Nutrition Care Process and clinical workflow elements for delivering patient/client care. The SOPP describes the 6 domains that focus on professional performance. Specific indicators outlined in the SOP and SOPP depict how these standards apply to practice. The SOP and SOPP are complementary resources for RDNs and are intended to be used as a self-evaluation tool for assuring competent practice in nutrition support and for determining potential education and training needs for advancement to a higher practice level in a variety of settings.

Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Revised 2021 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nutrition Support.

Nutrition support is a therapy that crosses all ages, diseases, and conditions as health care practitioners strive to meet the nutritional requirements of individuals who are unable to meet nutritional and/or hydration needs with oral intake alone. Registered dietitian nutritionists (RDNs), as integral members of the nutrition support team provide needed information, such as identification of malnutrition risk, macro- and micronutrient requirements, and type of nutrition support therapy (eg, enteral or parenteral), including the route (eg, nasogastric vs nasojejunal or tunneled catheter vs port). The Dietitians in Nutrition Support Dietetic Practice Group, American Society for Parenteral and Enteral Nutrition, along with the Academy of Nutrition and Dietetics Quality Management Committee, have updated the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs working in nutrition support. The SOP and SOPP for RDNs in Nutrition Support provide indicators that describe the following 3 levels of practice: competent, proficient, and expert. The SOP uses the Nutrition Care Process and clinical workflow elements for delivering patient/client care. The SOPP describes the 6 domains that focus on professional performance. Specific indicators outlined in the SOP and SOPP depict how these standards apply to practice. The SOP and SOPP are complementary resources for RDNs and are intended to be used as a self-evaluation tool for assuring competent practice in nutrition support and for determining potential education and training needs for advancement to a higher practice level in a variety of settings.

Nutritional Interventions in Chronic Intestinal Pseudoobstruction.

Although chronic intestinal pseudo-obstruction (CIPO) is a rare disorder, it presents a wide spectrum of severity that ranges from abdominal bloating to severe gastrointestinal dysfunction. In the worst cases, patients may become dependent upon artificial nutrition via parenteral nutrition or choose to have an intestinal transplant. However, whatever the severity, a patient's quality of life can be seriously compromised. This article defines the disorder and discusses the spectrum of disease and challenges to providing adequate nutrition to help improve a patient's quality of life.

Overview of Home Parenteral Nutrition: An Update.

The trend in modern medicine is to transition care from the hospital to home or other nonacute settings as soon as possible. Increasingly, nutrition support professionals are being asked to help facilitate discharge and/or manage patients who require prolonged intravenous fluid and/or nutrition after having been stabilized during a hospitalization. This updated tutorial reviews many of the concepts and challenges that must be considered for successful care that helps to focus on the patients and their quality of life.

Expediting Transition to Home Parenteral Nutrition With Fast-Track Cycling.

BACKGROUND: Delivery of home parenteral nutrition (PN) is typically cycled over 12 hours. Discharge to home on PN is often delayed due to potential adverse events (AEs) associated with cycling PN. The purpose was to determine whether patients requiring long-term PN can be cycled from 24 hours to 12 hours in 1 day instead of 2 days without increasing the risk of PN-related AEs. METHODS: Hospitalized patients receiving PN at goal calories infused over 24 hours without severe electrolyte or blood glucose abnormalities were eligible. Patients were randomly assigned to a 1-step "fast-track" protocol or 2-step "standard" protocol. AEs were defined as hypoglycemia or hyperglycemia, new-onset or worsening dyspnea, tachycardia, tachypnea, lower extremity or sacral edema, pulmonary edema, or abdominal ascites and were graded as minor or major. RESULTS: In the 63 patients studied, the most prevalent PN-related AE was hyperglycemia, occurring in 24.2% and 30.0% of patients in the fast-track and standard groups, respectively. Overall, there was no significant difference in the prevalence of PN-related minor AEs between fast-track and standard groups (33.3% and 53.3%, P = .5). No major PN-related AEs occurred in the fast-track group, while 1 major PN-related AE (pulmonary edema) occurred in the standard group. CONCLUSIONS: Fast-track cycling is as safe as standard cycling in patients without diabetes mellitus or major organ dysfunction requiring long-term PN. Fast-track cycling could potentially expedite hospital discharge, resulting in decreased healthcare costs and improved patient satisfaction.

Treating Dehydration at Home Avoids Healthcare Costs Associated With Emergency Department Visits and Hospital Readmissions for Adult Patients Receiving Home Parenteral Support.

BACKGROUND: Administration of home parenteral support (HPS) has proven to be cost-effective over hospital care. Avoiding hospital readmissions became more of a focus for healthcare institutions in 2012 with the implementation of the Affordable Care Act. In 2010, our service developed a protocol to treat dehydration at home for HPS patients by ordering additional intravenous fluids to be kept on hand and to focus patient education on the symptoms of dehydration. METHODS: A retrospective analysis was completed through a clinical management database to identify HPS patients with dehydration. The hospital finance department and homecare pharmacy were utilized to determine potential cost avoidance. RESULTS: In 2009, 64 episodes (77%) of dehydration were successfully treated at home versus 6 emergency department (ED) visits (7.5%) and 13 readmissions (15.5%). In 2010, we successfully treated 170 episodes (84.5%) at home, with 9 episodes (4.5%) requiring ED visits and 22 hospital readmissions (11%). The number of dehydration episodes per patient was significantly higher in 2010 ( P < .001) and may be attributed to a shift in the patient population, with more patients having malabsorption as the indication for therapy in 2010 ( P = .003). CONCLUSION: There were more than twice as many episodes of dehydration identified and treated at home in 2010 versus 2009. Our protocol helped educate and provide the resources required to resolve dehydration at home when early signs were recognized. By reducing ED visits and hospital readmissions, healthcare costs were avoided by a factor of 29 when home treatment was successful.

Resources for the Provision of Nutrition Support to Children in Educational Environments.

The use of nutrition support outside of institutional settings has contributed to maintaining the health, well-being, and nutrition status of many medically complex children. As these children grow and enter educational settings, there is a need for awareness of the care that these children require for nutrition support therapy. This document is designed to raise awareness to these needs, provide best practice educational resources for those involved in the supervision or provision of nutrition support to children in an educational environment, and promote safe and effective care. Care of children requiring nutrition support is an ongoing and shared partnership among the educational team, medical team, homecare team, and parents/caregivers. Care is individualized to the specific child and may include provision of nutrition support therapy while in the school setting, maintenance of a nutrition access device, and monitoring to safely prevent or act on signs of potential complications. Suggested roles and responsibilities of those involved with nutrition support care are discussed; however, all interventions and routine care must be in accordance with physician's orders, school nurse privileges and competencies, and state and local regulations.

Central venous catheter infections in home parenteral nutrition patients: Outcomes from Sustain: American Society for Parenteral and Enteral Nutrition's National Patient Registry for Nutrition Care.

BACKGROUND: Home parenteral nutrition (HPN) is a high-cost, complex nutrition support therapy that requires the use of central venous catheters. Central line-associated bloodstream infections (CLABSIs) are among the most serious risks of this therapy. Sustain: American Society for Parenteral and Enteral Nutrition's National Patient Registry for Nutrition Care (Sustain registry) provides the most current and comprehensive data for studying CLABSI among a national cohort of HPN patients in the United States. This is the first Sustain registry report detailing longitudinal data on CLABSI among HPN patients. OBJECTIVE: To describe CLABSI rates for HPN patients followed in the Sustain registry from 2011-2014. METHODS: Descriptive, χ2, and t tests were used to analyze data from the Sustain registry. RESULTS: Of the 1,046 HPN patients from 29 sites across the United States, 112 (10.7%) experienced 194 CLABSI events during 223,493 days of HPN exposure, for an overall CLABSI rate of 0.87 episodes/1,000 parenteral nutrition-days. Although the majority of patients were female (59%), adult (87%), white (75%), and with private insurance or Medicare (69%), CLABSI episodes per 1,000 parenteral nutrition-days were higher for men (0.69 vs 0.38), children (1.17 vs 0.35), blacks (0.91 vs 0.41), and Medicaid recipients (1.0 vs 0.38 or 0.39). Patients with implanted ports or double-lumen catheters also had more CLABSIs than those with peripherally inserted or central catheters or single-lumen catheters. Staphylococci were the most commonly reported pathogens. These data support findings of smaller studies about CLABSI risk for children and by catheter type and identify new potential risk factors, including gender, race, and insurance type. CONCLUSIONS: Additional studies are needed to determine effective interventions that will reduce HPN-associated CLABSI.

Bariatric surgery complications leading to small bowel transplant: a report of 4 cases.

Obesity is a major chronic disease affecting the U.S. population. Bariatric surgery has consistently shown greater weight loss and improved outcomes compared with conservative therapy. However, complications after bariatric surgery can be catastrophic, resulting in short bowel syndrome with a potential risk of intestinal failure, ultimately resulting in the need for a small bowel transplant. A total of 6 patients became dependent on home parenteral nutrition (HPN) after undergoing bariatric surgery at an outside facility. Four of the 6 patients required evaluation for small bowel transplant; 2 of the 6 patients were successfully managed with parenteral nutrition and did not require further small bowel transplant evaluation. Catheter-related bloodstream infection, a serious complication of HPN, occurred in 3 patients despite extensive patient education on catheter care and use of ethanol lock. Two patients underwent successful small bowel transplantation, 1 died before transplant could be performed, and 1 was listed for a multivisceral transplantation. Surgical procedures to treat morbid obesity are common and growing in popularity but are not without risk of serious complications, including intestinal failure and HPN dependency. Despite methods to prevent complications, failure of HPN may lead to the need for transplant evaluation. In selected cases, the best therapeutic treatment may be a small bowel transplant to resolve irreversible, post-bariatric surgery intestinal failure.

A.S.P.E.N. Standards for Nutrition Support: Home and Alternate Site Care.

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is a professional society of physicians, nurses, dietitians, pharmacists, nurse practitioners, physician assistants, other allied health professionals, and researchers. A.S.P.E.N. envisions an environment in which every patient receives safe, efficacious, and high-quality nutrition care. A.S.P.E.N.'s mission is to improve patient care by advancing the science and practice of clinical nutrition and metabolism. These combined Standards for Nutrition Support: Home Care and Alternate Site Care are an update of the 2005 and 2006 standards.

Prevalence and predictors of vitamin D deficiency and response to oral supplementation in patients receiving long-term home parenteral nutrition.

UNLABELLED: Previous studies have suggested a high prevalence of vitamin D deficiency in patients receiving long-term home parenteral nutrition (HPN). The aim of this study was to determine the prevalence and predictors of vitamin D deficiency in long-term HPN patients. METHODS: A retrospective, institutional review board-approved study was performed on all adult patients followed by the Cleveland Clinic HPN program receiving HPN therapy >6 months between 1989 and 2013 with a 25-(OH) D3 level reported. Patients were categorized by serum vitamin D status as follows: sufficient, insufficient, and deficient with respective 25-(OH) D3 levels of ≥30 ng/mL, 20-30 ng/mL, and <20 ng/mL. RESULTS: Seventy-nine patients were categorized based on serum vitamin D status as follows: 35 (44.3%) deficient, 24 (30.4%) insufficient, and 20 (25.3%) sufficient. The mean age of the cohort at the initiation of HPN was 52.0 ± 12.7 years, and 26 (32.9%) were male. The median HPN duration was 39 months, and the most common indication was inflammatory bowel disease (36.7%). Most (82.3%) patients had at least 1 prescription of oral vitamin D supplement (50,000 International Units) during this time. History of jejunal resection (odds ratio [OR], 5.3; 95% confidence interval [CI], 1.9-15.1; P = .002) and lack of oral vitamin D supplementation (OR, 0.7; 95% CI, 0.52-0.93; P = .038) were the strongest predictors of vitamin D deficiency. CONCLUSION: Vitamin D deficiency is common among patients receiving long-term HPN despite oral supplementation.

Navigating reimbursement for home parenteral nutrition.

Reimbursement for home parenteral nutrition (HPN) is important for nutrition support clinicians to understand. This intent of this review is to provide nutrition support clinicians knowledge on navigating through the structured requirements of diagnosis driven billing to receive reimbursement for services related to HPN, provide information on coding, provide practical tips for surviving a Medicare billing audit, and discuss challenges of Medicare guidelines seen in clinical practice.

Hospital readmissions for catheter-related bloodstream infection and use of ethanol lock therapy: comparison of patients receiving parenteral nutrition or intravenous fluids in the home vs a skilled nursing facility.

BACKGROUND: Catheter-related bloodstream infection (CRBSI) is the most serious long-term infectious complication of long-term home parenteral nutrition (PN). Ethanol is being used more commonly as a catheter locking solution in the home PN setting for prevention of CRBSI; however, no current literature reports the use of ethanol lock (ETL) in skilled nursing facility (SNF) patients. METHODS: The authors evaluated the number of hospital readmissions for CRBSI and length of stay between SNF (not receiving ETL) and home patients (receiving or not receiving ETL) receiving PN or intravenous fluid therapy. RESULTS: SNF patients had a significantly longer length of stay (LOS) for CRBSI hospital admissions compared with patients receiving PN at home with or without ETL (P < .001; 16 vs 8 vs 8 days). There was no LOS difference for CRBSI between home patients with or without ETL. Home PN patients not receiving ETL were more likely to have a CRBSI from Staphylococcus sp (48% vs 27%; P = .015), whereas SNF PN patients not receiving ETL were more likely to have a CRBSI from Enterococcus sp (16% vs 3%; P = .004). CONCLUSION: Despite different causative organisms and medical acuity likely affecting the differences observed in LOS, the SNF population is another setting ETL can be used to prevent CRBSI.

Identification and early treatment of dehydration in home parenteral nutrition and home intravenous fluid patients prevents hospital admissions.

BACKGROUND: Early identification and treatment of dehydration is prudent in patients requiring home parenteral nutrition (HPN) or home intravenous fluids (HIVF) to prevent hospital admissions for dehydration. Our home nutrition support service (HNS) developed a protocol in 2010 to provide additional bags of HIVF to be kept on hand for immediate use in patients identified at risk of developing dehydration. METHODS: A retrospective review was performed on all HPN and HIVF patients from a clinical database who received additional HIVF during 2010. Standard treatment for dehydration was 1 L HIVF daily for 3 days in addition to prescribed infusions. RESULTS: Of 308 HNS patients in 2010, additional HIVF were ordered in 161 patients with malabsorption, fistula, or obstruction. Of the 161 patients, 63% (n = 102) required additional HIVF and had 201 episodes of dehydration recorded. Increased enterostomy output (P = .021), negative intake and output (I/O data) (P = .014), and age (P = .021) were predictors of multiple dehydration episodes. I/O data were consistent with signs and symptoms of dehydration 80% of the time. One hundred seventy episodes (84.5%) of dehydration were successfully treated at home compared with 9 emergency room (ER) admissions (4.5%) and 22 hospital admissions (11%) for dehydration. CONCLUSION: We demonstrate 84.5% of episodes of dehydration successfully treated in the home in patients initially identified at risk by our protocol. Education of patients at risk of dehydration prior to discharge and providing additional HIVF on hand for immediate use may avoid ER treatment or hospitalization and potentially save healthcare costs.

Home parenteral nutrition tutorial.

The nutrition support practitioner may be called upon to help coordinate care at home for a patient who requires prolonged intravenous nutrition after he or she becomes stable enough to leave the hospital. This tutorial reviews the many concepts that must be considered to manage this type of care successfully.

Nutrition in the stroke patient.

Malnutrition is common both before and after stroke, with dysphagia adding to nutrition risk. Many patients require specialized nutrition support in the acute phase and beyond when swallowing function does not improve or return to allow for nutrition autonomy. When neurologic deficits improve, assessment of the swallowing function, introduction of dysphagia diets, and specialized swallowing techniques are used to transition away from enteral feeding tubes to oral diets. This article reviews the evaluation and treatment of dysphagia, use of specialized nutrition support, strategies for weaning enteral tube feedings, and the impact of nutrition on quality of life in the stroke patient population.