Nutrition in Clinical Practice

Malnutrition in hemodialysis patients is common and may affect as much as 40% of this population of patients. There are many causes of malnutrition and all must be considered before utilizing nutrition support to reverse the malnutrition. Intradialytic parenteral nutrition (IDPN) is a therapy that has become popular among US nephrologists despite the fact that there are no clear data that support its use or efficacy. A thorough review of published articles suggests a relationship between the use of IDPN and improved patient outcome measured by hospitalization rate and a decrease in mortality in certain subgroups. However, these studies have many confounding factors that prevent a definitive conclusion concerning the true efficacy of IDPN. This is very problematic since reimbursement changes for parenteral and enteral nutrition have been proposed by HCFA. The best recommendation that can be made for IDPN is that it may represent a useful form of nutrition support in the malnourished hemodialysis patient who has no other active disease processes, cannot ingest adequate nutrition by mouth, and has a contraindication to or a serious complication from enteral feeding. It is clearly not a therapy to be considered as the first line of nutrition support in these patients.

Malnutrition is frequently observed in the hemodialysis patient population. It may be associated with increased morbidity and mortality as well as affect overall quality of life, which may already be compromised from dialytic physical and psychological demands. In the past, intradialytic parenteral nutrition (IDPN) has been available to hemodialysis patients as an adjunct to their dietary intake. In this time of cost containment and the increasing need to scientifically justify the benefit of such therapies to have them paid for by third party reimbursers, IDPN is coming under much scrutiny. This report describes a case of inadequate enteral nutrient absorption in a malnourished hemodialysis patient. This is a case in which IDPN was beneficial and without which other alternatives would have proven more costly physically, emotionally, and economically to the patient.

With growing concerns over cost containment, hospitals are using clinical pathways to standardize health care and reduce costs. Clinical pathways designate the actions and services that patients should receive at specified time intervals throughout the hospital stay. Although most clinical pathways have been created for specific diseases or diagnoses, the nutrition support team at Tallahassee Memorial Regional Medical Center has developed clinical pathways for enteral and parenteral therapies. These pathways allow the team to track patient outcomes related to nutrition and to document variances when provisions fall outside the pathways. Variances are tallied on a quarterly basis and reported to the hospital Nutrition Support Committee. As data collection continues, trends emerge that guide the team to take appropriate corrective actions. Patient care is continuously improved by incorporating these corrective actions into the pathways.

Nutrition Support Nurse Clinicians at a Central Texas tertiary care facility have developed a research-based nasoenteric feeding tube insertion procedure that minimizes the potential for inadvertent passage of a feeding tube containing a stylet into the respiratory tract and maximizes placement of the feeding tube in the desired gastric or duodenal location. The first 79 staff nurses to be certified to use the technique had a 90% duodenal placement success rate under supervision. No bedside feeding tube insertion complications have been noted since the initiation of the certification program 6 years ago. This article describes the feeding tube insertion technique used in the certification process and the research on which it is based.