Global PN Fellowship

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The ASPEN Global PN Fellowship is designed to introduce early-career physicians with an interest in nutrition support to ASPEN, so they can discover the important role ASPEN, education, and mentorship may have in their career development. 

This year, we asked the fellows to review select key abstracts from the ASPEN23 conference and share their thoughts on the impact of the research on clinical practice and the future of nutrition. 

Jaclyn Strauss, MD, PhDJaclyn Strauss, MD, PhD
Department of Pediatrics, University of Calgary & Alberta Children’s Hospital
Calgary, Alberta, Canada

Abstract Reviewed: The Use of Peptide-Based Diet in Enteral Nutrition Therapy: A Retrospective Cost Analysis (Elfadil O, et al.)

“The aim of the study was to evaluate the economic impact of using peptide-based diet (PBD) formulas for enteral feeding intolerance (EFI) in home enteral nutrition (HEN) patients. This retrospective study evaluated the total cost (TC) of care of 60 adults on HEN between October 2018 and August 2020, including emergency department visits, inpatient and outpatient care. Indications for HEN included cancer (43.3%), hepatobiliary/pancreatic conditions (15%), dysphagia/odynophagia (36.7%) and malnutrition (30%). The prevalence of EFI decreased from 43.3% to 21.6% after transition to PBD. There was a trend of increasing TC of care per patient in the 4 weeks preceding the change to PBD, with an average per patient cost of $38,774. Despite an increase in total HEN related encounters with the health system in the immediate 4 weeks after transition to PBD, TC decreased to $33,944. This was followed by a further reduction in HEN encounters and TC to $21,129 in the second 4 weeks after transition to PBD.

Enteral feeding intolerance (EFI) is a frequent challenge for HEN patients which may be improved using specialized formulas, such as PBD. However, the increased cost of these formulas over standard formulas is often a barrier to their use. The results of this study highlight the importance of considering the total economic impact of EFI on patients and the health system and should prompt HEN providers to avoid delay in switching to PBD when perceived increase in formula cost is a primary factor in initiating PBD to manage EFI.”  
Benjamin Hall, MD Benjamin Hall, MD
Division of Trauma & Surgical Critical Care, Rhode Island Hospital
Rhode Island, United States

Abstract Reviewed: The Use of Enteral Naloxone and Achieving Energy Goals in Patients With Severe Burns (Richardson D, et al.)

Enhanced Recovery After Surgery (ERAS) has been a hot topic for some time now, showing great outcomes. One of the pharmaceutical interventions has been to preoperatively block gastrointestinal opioid receptors, reducing the rates of ileus and getting nutrition into patients sooner. Like a number of other ERAS measures, in emergency settings, it is not possible to get an agent like alvimopan into patients before they receive opioids.

Another approach studied here by the Brooke Army Medical Center is giving naloxone enterally for their burn patients prophylactically. They adopted this into their standard practice in 2017 and present here their retrospective review. These patients were all major burns, at least 20% TBSA and mechanically ventilated within 2 days, who had at least two weeks of nutritional intake data. In this cohort burn size was substantial, with a mean of 44%, mean age was 43 years, and 84% were men. On average, the energy goal was 4180 kcal/day with patients achieving 71% of this over the first two weeks. The use of enteral naloxone was associated with a 7% increase in goal achievement, adjusted for gender and burn size. They plan to continue this practice, and given its safety profile, is worth considering for other institutions.

Chanita Unhapipatpong, MDChanita Unhapipatpong, MD, FRCP(T) 
Khon Kaen Hospital, Ministry of Public Health
Khon Kaen, Thailand

Abstract Reviewed: Incidence of Micronutrient Deficiencies in Inflammatory Bowel Disease (Kamel A, et al.)

Micronutrient deficiencies are common in patients with inflammatory bowel disease (IBD), which can cause many complications. The objective was to investigate the incidence of micronutrient deficiencies in patients with IBD. A cross-sectional study was conducted, and 219 IBD patients were selected from an ICD‐9/10 code diagnosis to retrospectively have a serum/whole blood micronutrient examination including vitamin A, E, K, B9, and copper. The study found that overall, around one-third of the patients showed micronutrient deficiencies. However, the percentages of micronutrient deficiency varied according to the type of IBD.

However, the study had some limitations, such as the possibility of underestimating the number of patients with micronutrient deficiencies due to the lack of information on medication or supplementation. Additionally, a 2022 ESPEN guideline suggested the possibility of micronutrient deficiency in IBD, including vitamin B1, B6, B12, A, D, E, K, Fe, Se, and Zn. Other reports indicate that more than half of patients with IBD have micronutrient deficiencies, which differ depending on the stage of the disease and type of IBD. Furthermore, background diet may impact vitamin levels, such as the fortification program in diet with folic acid in the United States.

If the study can evaluate the full panel of micronutrients and analyze the data according to the stage of the disease, part of bowel involvement, background diet, and type of IBD, it may guide clinical practice not only for those who will benefit from closed monitoring of micronutrient levels, but also for those who should take upfront micronutrient supplementation.

Trevor Tabone, MDTrevor Tabone, MD, MRCP (UK), ESEGH
Mater Dei Hospital
Msida, Malta

Abstract Reviewed: Evaluation of Parenteral Nutrition Order Safety Upon Transitions of Care (Mulherin D, et al.)

Given the complex nature of parenteral nutrition (PN) therapy, there is a considerable risk for potential errors in PN orders. The risk is further compounded when patients transition between healthcare settings, lack of nutrition support teams and existing knowledge gaps across disciplines.

The findings of this study bring to light the current shortcomings in safe PN practice. The authors revealed that almost 90% of PN orders reviewed over a 14-month period contained at least one PN safety violation. The latter was defined by a multi-disciplinary NST as a suboptimal PN order in line with ASPEN safety recommendations. Micronutrient and micronutrient dosing were the most common safety violations, followed by order clarity and PN volume. 18% of these safety violations resulted in adverse events such as malnutrition, kidney injury, volume overload, electrolyte disturbance, poor glycemic control, and deranged liver function tests.

Optimizing safety for patients receiving PN therapy requires the implementation of multiple risk-avoidance strategies. There is an increased need to standardize management of PN therapy across all practice settings in accordance with ASPEN safety recommendations. Improving training in nutrition support and having access to a multidisciplinary NST can help reduce the risks highlighted in this study to improve health outcomes for patients whilst also being cost-effective. The inherent risks of transitioning patients between healthcare settings may be mitigated by the utilization of transition checklists and automation of PN orders. Future studies should be directed towards evaluating the effectiveness of such strategies.

Jeremiah Torrico, RND, MD, DPPSJeremiah Torrico, RND, MD, DPPS
Division of Pediatric GI, University of Philippines, Philippine General Hospital
Manila, Philippines

Abstract Reviewed: Development of the Pediatric Integrated Nutrition Pathway for Acute Care (P‐INPAC) Using a Modified Delphi Technique (Hulst J, et al.)

A pediatric inpatient nutritional care pathway is necessary in identifying children who are at risk for nutritional deterioration and are in need of standardized approaches for malnutrition detection. This study looked into the development of a pediatric malnutrition pathway by the pediatric working group of the Canadian Malnutrition Taskforce, a group composed of 14 professionals with a special interest/expertise in pediatric malnutrition. The taskforce undertook four meetings to draft the pathway based on existing literature, followed by three online surveys and three rounds of online Delphi consensus meetings, including a total of 51 questions where in consensus was defined as any question/issue in which at least 80% agreed. Nutritional risk assessment using Subjective Global Nutrition Assessment (SGNA) and components of the nutrition care plans were established. The final modified Delphi survey round included participation from 71% of members and consensus was reached on all pathway elements. The finalized pathway was the Pediatric Integrated Nutrition Pathway for Acute Care (P‐INPAC) which incorporates screening, assessment, prevention, and treatment of malnutrition, with malnutrition screening using validated pediatric nutritional screening tools and measurement of standard anthropometric parameters; performance of SGNA to diagnose malnutrition when children screen at nutrition risk, and nutritional care plans that can be triaged for the level of malnutrition identified. Being developed through evidence-informed and consensus-based modified Delphi process, this pathway has great implementation potential. Nevertheless, further research is necessary to assess the feasibility of its implementation and its overall effects on improving health and nutrition outcomes.

The development of the Pediatric Integrated Nutrition Pathway for Acute Care (P‐INPAC) based on modified Delphi process is an example of the use of evidence and professional consensus in coming up with a systematic means of addressing nutritional problems in pediatric inpatients. The integration of screening, assessment, and treatment of malnutrition using this pathway may improve health and nutrition outcomes. Further studies on its implementation and how it affects health and nutrition outcomes may be necessary to further evaluate and support its use.

Maged Ossama Aly, PhD, IOC Dip, MPH, MBChBMaged Ossama Aly, PhD, IOC Dip, MPH, MBChB
High Institute of Public Health
Alexandria, Egypt

Abstract Reviewed: In Good Hands: Application of the Nutrition‐Focused Physical Exam in Hospitalized Adult Patients (Long J, et al.)

The abstract discusses the practical application of the Nutrition-Focused Physical Exam (NFPE) as a valuable nutrition assessment tool for hospitalized adult patients. The authors note that while the NFPE is a useful tool, its practical application with hospitalized patients has not been well-documented. The study aimed to evaluate the use of NFPE in hospitalized adult patients and its support to malnutrition diagnosis based on the Academy/ASPEN Indicators to Diagnose Malnutrition (AAIM) criteria. The authors conclude that NFPE can be effectively used as a malnutrition assessment tool in hospitalized adult patients.

The abstract suggests that incorporating the NFPE into routine clinical practice could improve patient care and outcomes. Subcutaneous fat, muscle mass, fluid accumulation, or micronutrient exams should be assessed. In case of the full NFPE is not feasible, the indicators “loss of subcutaneous fat” and “loss of muscle mass” should be prioritized.

This fellowship is supported by