Global PN Fellowship

Congratulations to the 2024 Global PN Fellows.

ASPEN offers a Global PN Fellowship program designed to introduce early career physicians to ASPEN and help them understand how ASPEN can play an important role in their career development. Each year, the fellowship is awarded to five physicians interested in enhancing their knowledge and expertise in nutrition support. Applications for the 2025 Fellowship will open in the fall of 2024.

The 2024 ASPEN Global PN Fellows share their thoughts on how research from some of the ASPEN24 conference abstracts will impact clinical practice and the future of nutrition.  

 
Liran Rina Barda Liran Rina Barda, MD
Miami, Florida

Abstract Reviewed: Beyond the Baseline: How Accurate is the Mifflin-St Jeor Equation in ICU Nutritional Management? (Beyer M, et al.)

“The applicability of indirect calorimetry (IC) is limited by availability and cost. Many practitioners use predictive equations to further guide their nutrition prescription as the 2022 ASPEN/SCCM guidelines include broad range 12-25 kcal/kg for the first 7-10d of ICU stay; recent data suggest benefit to even lower intake (6 kcal/kg). Underfeeding complications in the surgical population (under-represented in most studies) remains a concern; wound failure and anastomotic leak, are known to increase morbidity. This prospective interventional trial aims to evaluate the predictive capabilities of the Mifflin-St Jeor equation (MSJE) among SICU patients. Forty-six critically ill adults with open abdomens, who were not expected to advance GI intake in 72 hours were initiated on PN. Calorie requirements were determined by IC at multiple time points. The relationship between IC and MSJE estimate was examined. The study group included patients 22-87 y/o (mean 56.3 7±19.77), male predominant (63% vs 37%) with average BMI 27.3±5.8. The acuity level as determined by SOFA score was average (6.89) when compared to ICU literature. Linear regression models were employed for statistical analysis. The authors found moderate, statistically significant, correlation between the MSJE estimate (1512±282) and the actual REE derived from the average initial IC measured throughout the first week (1422±339), p=0.002. Nonetheless, subgroup analysis revealed significant correlation specifically within the emergency general surgery group but not for the trauma group. Trauma patients had higher IC measurements when compared to emergency surgery patients. The authors comment IC measurements usually correlate ASPEN/SCCM kcal/kg range and most helpful in elderly and obese patients. It is concluded that calculated REE can further help guide nutrition prescription for surgical patients, nonetheless, comparing to the kcal/kg recommendations is advisable. Further research in the surgical and trauma population is needed, long-term complications of undernutrition should be taken into consideration, and calorie goals inside and outside the first week of critical illness should be further validated.”  

Valentina Da Prat Valentina Da Prat, MD
Milan, Italy

Abstract Reviewed: Association of Time-Dependent Nutritional Intake and Clinical Outcomes According to the Presence of Malnutrition Diagnosed by the GLIM Criteria in Mechanically Ventilated Critically Ill Patients (Lee A, et al.)

“ASPEN24 confirmed the growing interest of clinicians in nutritional support for ICU patients, with many abstracts presented on this topic. The retrospective study by Lee and colleagues highlighted the importance of considering both the time variable, i.e. defining whether the patient is in the acute or chronic phase, and the nutritional status. Based on thresholds derived from the literature, the authors analyzed the association of mortality with the level of mean daily calorie/protein intake (low/intermediate/high) in three phases (early-acute/late-acute/recovery). A modified GLIM approach was used to diagnose malnutrition, proxying the Clinical Frailty Scale for muscle mass assessment. A significant beneficial effect on mortality was observed only for high calorie (>20 kcal/kg/day) and intermediate protein levels (0.8-1.2 g/kg/day) provided to malnourished patients in the recovery phase; there were no differences related to COVID-19 diagnosis. These results appear to be consistent with recent studies in the literature (e.g. EFFORT trial) and provide further guidance on the clinical aspects to be considered when prescribing nutritional support for ICU patients. However, the limitations associated with the retrospective design of the study (e.g., calorie/protein intake likely to be a function of patient tolerance and clinical status and time grouping based on ICU days rather than clinical parameters/interventions) make prospective trials essential to translate these findings into clinical practice. Future studies should combine the nutritional status with other variables, including timing, organ dysfunction, comorbidities, and type of vital support; in particular, optimal screening/diagnostic methods to assess nutritional status in this setting remain to be defined. Hopefully, a tool/score for ICU patients will be developed in the future to assist clinicians (perhaps with AI?) in selecting the most appropriate nutritional support. The findings in invasively ventilated patients could be extended to other patients, e.g. non-invasively ventilated or on vasopressors – this could become an interesting research project.”  

Tam Lac Tam Lac, MD
Ho Chi Minh City, Vietnam

Abstract Reviewed: Improving the Diagnosis and Management of Refeeding Syndrome in Pediatric Patients (Hachem J, et al.)

“This study investigated 2,127 hospitalized children between January and June 2018 whose ages ranged from 29 days to 18 years. The preliminary retrospective chart illustrated patients who suffered from developed Refeeding Syndrome (RS) (n=10) who were considered at risk for malnutrition and had an assay for electrolytes (n=61). Several significant findings were yielded from this study. 

Firstly, a total of 61 patients (out of 2127 patients, 2,9%) were considered at risk of malnutrition and met inclusion criteria, and 29 (47,5%) were all at high risk for RS. In 10 out of the 29 at-risk patients who developed RS, the mild, moderate, and severe RS patients were 3 (30%), 4(40%), and 3 (30%), respectively. Secondly, the RS incidence was 0.47% (10/2127). RS patients tended to be older (median age 61.2 vs 20 months) and the ratio was significantly higher in males than females (90% vs 51%, p=0.03) compared with malnourished patients without RS (n=51). In addition, RS patients were more likely to be managed in the PICU (20% vs 5.9%, p=0.051) and experienced severe (>10%) weight loss (50% vs 9.8%, p=0.01). Lastly, the study showed no mortality associated with RS but encephalopathy, seizures, and hemodynamic instability were associated with electrolyte abnormalities in severe RS.

The authors were able to evaluate patients at risk for RS with an appropriate approach using the ASPEN guidelines. There was a conclusion that only patients who were at high risk for RS suffered from RS among those at risk for malnutrition. The study aimed to show the stratification of risk. They also were looking at the knowledge gap, but they were evaluating data before the current recommendations were published (2018 and 2020). As a result, it would be interesting to know if things changed or if process implementation occurred after the publication of the ASPEN recommendations.

The research was limited by a modest sample size. In addition, the p-value of 0.051 is higher than 0.05 for RS patients treated in the PICU. It would be nice to know if any patient was prophylactically treated for RS. It would be better if there were larger categories so they could analyze each criterion for risk severity and identify what contributed most to the findings. For the future of the nutrition field, the authors aspire to propose the provision of standardized data to improve not only precise RS diagnosis, and recognition of at-risk patients for prophylaxis but also appropriate management for those at risk or developed RS.

Since ASPEN Consensus Recommendations for RS were published in April 2020, RS is likely to be broadly approached in clinical practice; however, there are limited studies related to the effectiveness of implementing ASPEN recommendations. After reviewing this study, we gained insights into the recognition, identification, stratification, prevention, and management of RS in pediatric patients. If they were given a chance, they could improve their abstract by more clearly stating their aims in the background.
Clinically, there is a lack of guidelines for recommendations of RS in developing countries. Also, there are some barriers to optimizing hypophosphatemia conditions, such as costly phosphorus evaluation and monitoring, and insufficient phosphorus supplements in developing countries. Last but not least, validation of the risk stratification of RS should be considered in future ground-breaking research.”  

Gabriela de Oliveira Lemos Gabriela de Oliveira Lemos, MD
Asa Norte, Brazil

Abstract Reviewed: Metabolic Impact of High-Lipid Low-Dextrose Parenteral Nutrition (Adorno A, et al.)

“In this abstract, the authors explored retrospectively the metabolic impact of providing a high lipid low dextrose (HLLD- ≥1 g/kg) parenteral nutrition (PN) containing a lipid emulsion (SO, MCT, OO, FO-ILE) compared to an adequate lipid high dextrose (ALHD <1 g/kg) containing a 100% soybean oil lipid to 62 patients (31 each group) ≥18 years on PN ≥ 7 days in the acute care setting. Mean dextrose and lipid in PN were 25-30% and fat 40-45% x 55-60% fat 20-25%, respectively for HLLD and ALHD. The group on HLLD PN had decreased glucose levels and insulin requirements, decreased alkaline phosphatase and CRP levels, and increased pre-albumin levels (p < 0.05). There were no statistically significant differences between the groups according to age, gender, race, glycated hemoglobin, and steroid use. However, patients in the HLLD group had decreased body weight and BMI compared to ALHD (70.5 ±20.8 x 88.6 ±23.6, and 28.5±6.9 x 24.2±6.8, p< 0.05). Interestingly, there was a trend for more calories in the HLLD group (26.6±7.4 x 24.1±7.3, p 0.089). These results should be cautiously interpreted since they may be assigned to either the effect of low levels of glucose in TPN or the mixed lipid emulsion. Nonetheless, they show that using HLLD is safe in clinical practice and may be beneficial. Thus, more studies are still needed to evaluate the potential role of implementing HLLD PN use.

More details can be found in: Adorno A, et al. Metabolic impact of high lipid low dextrose parenteral nutrition. Clinical Nutrition ESPEN, 2023.”  

Danial Nadeem Danial Nadeem, MD
Danville, Pennsylvania

Abstract Reviewed: Should We Check Gastric Residual Volumes in the 21st Century? (O'Connor A, et al.)

“This study performed by O’Connor et al. sought to determine the impact of implementing a new guideline that prioritized tube feeding tolerance indicators over routine gastric residual volume (GRV) checks in ICU patients. Historically, GRV has been used to assess feeding intolerance in tube-fed patients, but this approach often leads to unnecessary interruptions in nutrition due to unfounded GRV thresholds. The new guideline emphasizes patient positioning, abdominal examinations, and monitoring for intolerance symptoms, excluding certain patients based on specific criteria and setting a 500 ml GRV threshold for action. Comparing data from before and after the guideline's implementation showed a significant decrease in GRV checks and interruptions in tube feeding, without an increase in vomiting episodes. This change not only improved patient care by ensuring more consistent nutrition but also saved a significant amount of nursing time.

This research highlights a significant shift in critical care nutrition by prioritizing patient assessment over routine gastric residual volume checks for tube feeding tolerance. Implementing the Tube Feeding Tolerance Assessment Guideline improved nutritional delivery by minimizing unnecessary feeding interruptions and enhancing patient safety and comfort. It also increased nursing efficiency, freeing up valuable resources for other patient care areas. These findings encourage the adoption of evidence-based practices in nutrition, promising better patient outcomes and guiding future research. This approach underscores the importance of updating clinical practices based on current evidence and setting a new standard for nutritional support in critical care.

After reviewing the data and speaking to Alice, I hope to improve my own patient care by prioritizing patient assessments over routine GRV checks for tube feeding tolerance, ensuring consistent nutritional delivery and enhancing care efficiency. By adopting evidence-based guidelines, I'll contribute to improved patient outcomes and resource utilization, aligning my practice with the latest research findings for optimal critical care nutrition management.”  

Wilma de Guzman-Bato Wilma de Guzman-Bato, MD
Calabarzon, Philippines 

*Dr. Bato was a Global PN Fellow recipient from 2022, who was unable to attend the ASPEN Conference until 2024.

Abstract Reviewed: Neonatal Malnutrition Criteria: Do Current Indicators Agree in Diagnosis? (Barr S, et al.)

"Preterm infants and neonates are more vulnerable to times of nutrition deficits than any other time in the life cycle. The risk of malnutrition is related to their reduced nutrient stores at birth, immature nutrient absorption and use, organ immaturity, delayed advancement of parenteral and enteral feeds due to cautious advancement, and dependence on health care providers to accurately identify and effectively provide needed nutrients during a period of rapid growth and development.1

The diagnostic criteria for neonatal malnutrition were proposed in 2018 by field experts wherein their goal was to provide a uniform definition of malnutrition for this population using recommended indicators as shown in Table 1. This single-center, retrospective cohort study performed at a level III Neonatal Intensive Care Unit (NICU) assessed the agreement and reliability of both the overall malnutrition tool and individual indicators. However, results showed that proposed neonatal malnutrition definitions have poor agreement overall and limited inter-indicator reliability at the individual indicator level. Utilizing commonly cited generalized weight gain goals may be appropriate due to their strong inter-indicator reliability with weight gain goals determined by maintaining weight-for- age z-score.

Indeed, there is a need for additional validation research to assess applicability of the neonatal malnutrition criteria. Diagnosing malnutrition in this population requires clinical judgement which can influence the indicators. I agree with the recommendation of the authors that what is more important is to establish the value of a malnutrition diagnosis on critical patient outcomes in preterm infants. There are available researches which found a link between poor growth in preterm infants and subsequent neurocognitive development up to age 19 years. Hence, the need to determine degree of malnutrition during neonatal period is important to determine the ones who will need nutrition therapy."                     

1 See Reference Table.  

This fellowship is supported by

Baxter