Caran Graves

A guide to drug therapy in patients with enteral feeding tubes: Dosage form selection and administration methods

Drug therapy may be complicated in hospitalized patients receiving nutrition via enteral feeding tubes. Dosage form selection and appropriate administration methods are crucial in patients with feeding tubes. Although hospitalized patients receive nutritional support through various routes, oral nutrition is preferred. Enteral or parenteral nutrition may be used if oral intake is inadequate or inadvisable. Patients with functional gastrointestinal tracts usually receive enteral nutrition. Administering oral medications through the enteral feeding tube can lead to complications like tube clogging or decreased drug activity. However, drug therapy need not be compromised in patients receiving enteral nutrition. Careful selection and preparation of dosage forms reduces the complications of medication administration. Flushing the feeding tube and screening for drug incompatibilities decreases the incidence of tube clogging and replacement.

Actual burn nutrition care practices: an update.

In 1989, Williamson published a survey of nutrition care practices in burn centers. Nutrition practices have evolved since then; we conducted a study to determine the current scope of nutrition care in burn centers. With IRB approval, a 64 question survey was emailed to 103 burn centers listed in the Burn Care Resources in North America. Follow-up emails were sent to those who did not respond within 2 weeks. Sixty-five centers (63%) responded and included 66% of currently verified burn centers. Due to incomplete surveys, most questions had 45 to 50 responses. The centers averaged 246 annual admissions and all admitted non-burn patients. Eighty percent of dietitians had >5 years burn experience (vs 17% in 1989) and 90% also worked in other intensive care settings. Most dietitians reported advanced training or education (83%). Nutrition assessment, support and monitoring methods have changed though most centers continue to use serum proteins for assessment. Indirect calorimetry use has increased with most centers (78%) adding a ‘stress factor’ of 10 to 30% above measured energy needs. More centers provided specialized formulas including high-protein (82 vs 8.8%) and immune-enhancing (53 vs 12.3%) than in 1989. All gave a variety of vitamin and mineral supplements. Anabolic steroid and glutamine use was common (92 and 69%). Eighty percent of centers used glucose protocols with 54% having a goal of ≤120 mg/dl; another 42% used 121 to 150 mg/dl as a target. Burn dietitians reported more experience than previously documented but continued to work in other intensive care unit areas. The use of calorimetry and glucose control protocols increased in the past 20 years as did the use of anabolic steroids and supplements. Variability continued in assessment (particularly calorie estimates) and monitoring methods.

Comparison of Urine Urea Nitrogen Collection Times in Critically Ill Patients

Twenty-four-hour urine urea nitrogen (UUN) collections are used to assess nitrogen loss in critically ill patients but are often difficult to obtain accurately. This prospective study compared 6- and 12-hour UUN collections with 24-hour UUN collections in critically ill patients receiving continuous nutrition support. ICU patients admitted from September 1999 through January 2003 who had UUN collections as part of routine care were recruited into the study. Patients were not receiving oral diets, were receiving continuous parenteral or enteral nutrition, and had indwelling urinary catheters. We excluded patients with hepatic or renal failure. Urine samples were collected every 6 hours starting at 6:00 am and kept refrigerated until the 24-hour collection was complete. Samples were analyzed using an automated urease enzymatic reaction. Samples were multiplied by a factor of 4 (6-hour samples) or 2 (12-hour samples) to estimate 24-hour totals and then compared with actual 24-hour totals. Twenty-four patients (18 men) completed the study; 21 patients had 6-hour samples (84 samples), and 24 patients had 12-hour samples (24 samples). Estimated 24-hour UUN from 6-hour (14.7-15.7 g/d) and 12-hour (15.2 g/d) samples did not differ significantly (p > .5) from actual 24-hour totals (15.1 g/d). Shortened UUN collection times may be used to estimate 24-hour nitrogen losses in critically ill patients receiving continuous nutrition support.

Compliance with nutrition support guidelines in acutely burned patients.

BACKGROUND Adequate and timely provision of nutritional support is a crucial component of care of the critically ill burn patient. The goal of this study was to assess a single centers consistency with Society of Critical Care Medicine/American Society for Parenteral and Enteral Nutrition (SCCM/ASPEN) guidelines for nutritional support in critically ill patients. METHODS Acutely burned patients >45kg in weight admitted to a regional burn center during a two-year period and who required 5 or more days of full enteral nutritional support were eligible for inclusion in this retrospective review. Specific outcomes evaluated include time from admission to feeding tube placement and enteral feeding initiation and percent of nutritional goal received within the first week of hospital stay. Descriptive statistics were used for all analyses. IRB approval was obtained. RESULTS Thirty-seven patients were included in this retrospective review. Median age of patients was 44.9 years (IQR: 24.2-55.1), and median burn injury size was 30% (IQR: 19-47). Median time to feeding tube placement was 31.1h post admission (IQR: 23.6-50.2h), while median time to initiation of EN was 47.9h post admission (IQR: 32.4-59.9h). The median time required for patients to reach 60% of caloric goal was 3 days post-admission (IQR: 3-4.5). CONCLUSION The median time for initiation of enteral nutrition was within the SCCM/ASPEN guidelines for initial nutrition in the critically ill patient. This project identified a 16h time lag between placement of enteral access and initiation of enteral nutrition. Development of a protocol for feeding tube placement and enteral nutrition management may optimize early nutritional support in the acutely injured burn patient.

Guideline for Burn Care Under Austere Conditions: Special Care Topics.

Introduction Management of pain after a catastrophe that generates a large number of casualties that may have burns, traumatic brain injury, fractures, amputations, and significant soft tissue injuries will be problematic. In an environment of logistical uncertainty with limited to no resupply, it will be much worse. Supply may be rapidly outstripped by demand. What will be available to treat our patients? In this scenario, drastic changes in pain management philosophy and algorithms will be necessary. Burn mass casualty events (BMCI) will alter what aspects of pain will be treated, and most troubling, the level at which pain is treated. The purpose of this paper is to outline the philosophy of pain management in austere environments and outline practical applications when resources are limited.

Utility of screening for diabetes in a burn center: hemoglobin A1c, Diabetes Risk Test, or simple history?

OBJECTIVE Rates of diabetes mellitus (DM) are increasing. Early identification and treatment of hyperglycemia in the critical care setting can decrease morbidity and mortality. Many burn centers measure hemoglobin A1c (A1c). This study evaluates the prevalence of pre-existing DM and the utility of using A1c for identifying DM compared with a non-invasive risk assessment. METHODS Adult patients admitted to our regional ABA-verified burn center from July 2008 to July 2009 had A1c levels evaluated and were asked to complete the American Diabetes Association Diabetes Risk Test (DRT). RESULTS Forty-one patients consented to participate: 24 patients with burn (19 male) and 17 patients with non-burns (10 male). Non-burn patients had greater BMIs (BMI 32 vs. 28, p=0.093) and had a higher rate of DM prior to admission (35% vs. 17%, p=0.159) than the burn patients. These differences were not statistically significant. Most patients (23/41) were at high risk for developing DM based on the DRT. Patients with pre-existing DM were significantly more likely to have elevated A1c levels (>6.5%) compared with those without pre-existing DM (60% vs. 0%, p<0.001). Compared with history of DM, DRT had a poor positive predictive value of 36% and 50% (burn and non-burn respectively) but a 100% negative predictive value for DM for both groups. CONCLUSION DM and obesity were more common in non-burn patients than in burn patients. A history of DM provides a simple, accurate method for identifying patients with DM. Use of A1c in the ICU provides little additional data for diagnosis of DM and does not impact patient management.

Nutrition support for the burn patient

Nutrition support represents a critical component in the care of the acutely burned patient. Management of nutritional demands mandates attention to the unique hypermetabolic state that results from major burn injury; this pathophysiology results in loss of lean body mass, increased fat accretion and protein wasting, and impaired wound healing. Historically, failure to address these problems in victims of major burn injury often resulted in a fatal degree of inanition and death from infection and heart failure within a few weeks of injury [1, 2]. Current understanding and appreciation of burn hypermetabolism is still imperfect, but methods exist to support the patient throughout the critical period of muscle wasting and metabolic demand while healing occurs. Thus, the goal of nutrition support in the burn patient is to ameliorate- and hopefully optimize- the deranged metabolism resulting from burn injury and permit successful closure of the burn wound and resolution of the hypermetabolic state.

Nutrition in Toxic Epidermal Necrolysis A Multicenter Review

BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe exfoliative diseases treated in burn centers due to large skin losses. Literature on SJS/TEN refers to parenteral nutrition (PN) as the preferred route of nutrition support. This study describes nutrition support interventions in SJS/TEN patients admitted to burn centers. MATERIALS AND METHODS Seven burn centers participated in this Institutional Review Board-exempted retrospective chart review of adults with SJS/TEN admitted from 2000-2012. RESULTS This analysis included 171 patients with SJS/TEN. Median total body surface area involvement was 35% (n = 145; interquartile range [IQR], 16%-62%). The majority required mechanical ventilation (n = 105). Based on indirect calorimetry, measured energy needs were 24.2 kcal/kg of admit weight (n = 58; IQR, 19.4-29.9). Thirty-one patients did not require enteral nutrition (EN) and started oral intake on hospital day 1 (IQR, 1-2), and 81% required EN support due to inadequate oral intake and remained on EN until day 16 (median hospital day, 16; IQR, 9-25). High-protein enteral formulas predominated. PN was rarely used (n = 12, 7%). Most patients were discharged home (57%), with 14% still requiring EN. CONCLUSIONS Nutrition support should be considered in patients with SJS/TEN due to increased metabolic needs and an inability to meet these needs orally. Most SJS/TEN patients continued on EN and did not require escalation to PN.