Nutrition in Clinical Practice

Herbal and related remedies are becoming increasingly popular in the United States. Although some of these products have been promoted as panaceas with little scientific data to support their use, clinical data are starting to accumulate showing the benefit of specific products. For the herbal products, English translation of the German Commission E monographs greatly increases the availability of credible information. Under the 1994 Dietary Health Supplement and Education Act, these products are considered as dietary supplements rather than drugs; regulation by the Food and Drug Administration is therefore limited. This lack of regulation has contributed to drug misadventures; such adverse events should be reported to the MedWatch program of the Food and Drug Administration. One suggestion to improve the status of these products in the United States would be to adopt the German philosophy that the products be approved as drugs based on absolute proof of safety and reasonable proof of efficacy.

Clinical pathways illustrate, sequentially, the most efficient interventions for reaching desired outcomes for various disease states or treatment modalities. With the increasing demand for high-quality, costeffective nutrition care, the Enteral Nutrition Service developed a clinical pathway for enteral feedings. The purpose was to coordinate multidisciplinary efforts to ensure comprehensive, goal-oriented nutrition care. The pathway has two phases. Phase one focuses on initiating and optimizing inpatient enteral nutrition support. Phase two addresses the transition to oral diet and discharge planning. This pathway was designed to augment disease specific pathways already in place. In the model developed at William Beaumont Hospital, the Registered Dietitian is designated as the case manager to monitor compliance and record variances. Corresponding continuous quality improvement indicators include nutritional adequacy, complications, compliance to hospital policies, and trial of the proposed home regimen before discharge. The variances and outcomes are presented routinely to the Hospital Nutrition Committee for review and adaptation of the pathway. From both a legal and quality perspective, clinical pathways allow a proactive, multidisciplinary approach to designing the optimal treatment course.

Nutritional requirements of mechanically ventilated, critically ill trauma patients are to estimate because of the variety of injuries and many variables that must be considered in making an accurate nutrition assessment. The Harris-Benedict predictive equation is often cited in the literature as an overestimation of caloric requirements in the critically ill when compared with indirect calorimetry, and, additionally, studies examining critically ill populations are inconsistent with the application of two important variables: physical activity and fasting. For this study, measurements of resting energy expenditure were compared with the predicted basal energy expenditure (BEE) using the Harris-Benedict equation with the addition of a selected injury correction factor (ICF), and potential relationships were evaluated for their agreement. When the elements of routine intensive care unit physical activity (which increases energy expenditure by approximately 10%) and the patient's fasting state (the specific dynamic action of food which increased energy expenditure by 10%) are accounted for by the addition of 20% to the measured resting energy expenditure (MREE), the predicted BEE with ICF was in moderate significant agreement with MREE.

Despite a large body of literature documenting micronutrient requirements, vitamin and mineral imbalance remains an unappreciated player in altered body composition and functional integrity. The absence of routine biochemical determination of nutrient status contributes in part to the inability of the clinical staff to validate recognizable signs and symptoms of deficiency or toxicity. Disciplined use of Nutrition Physical Examination (NPE) procedures enables assessment of tissues known to reflect nutrient imbalance in a cost-effective way, which can assist clinical history taking and direct nutrition intervention. Macrophotography documenting lesions observed at baseline and after nutrient supplementation, along with laboratory monitoring, can ensure objective, advanced level, outcome-based nutrition therapy. This case illustrates use of the NPE and nutrition diagnostic reasoning in a relational manner to B₆ and zinc imbalance evidenced by (1) mild lip desquamation with ecchymotic-like lesions; (2) angular stomatitis; (3) seborrheic-like dermatitis of the scalp and eyebrows; (4) dry, flaky skin with sparse, wiry hair and scattered corkscrew and swan-neck hairs; and (5) somatic wasting with peripheral neuropathy.

Enteral feeding is used commonly among critically ill patients. An unusual complication related to a weighted nasoenteric feeding tube is described. The hospital course of a critically ill patient with a disrupted weighted tip from a nasoenteral feeding tube was reviewed. All identified references with relevance to similar complications of nasoenteral tubes were reviewed. A 79-year-old woman with intracranial hemorrhage required postoperative mechanical ventilation and enteral feedings using a 12F nasoenteric feeding tube. The weighted tip on the feeding tube became detached during placement and the tungsten discs from this tip were scattered throughout the bowel. The patient passed these discs in her stool by the 12th postoperative day and had no further complications. All nasoenteral tubes should be inspected closely for possible defects before placement. Radiographic confirmation of tube placement should be obtained, and after removal the tip should be examined for any defects.