The Role of a Nutrition Support Team in the Management of Intestinal Failure Patients
Abstract
:1. Introduction
2. General Management of Intestinal Failure Patients
3. The Composition of a Nutrition Support Team
4. Improved Outcomes with Nutrition Support Teams
4.1. Complications in Adults Receiving Parenteral Nutrition
4.2. Complications in Children Receiving Parenteral Nutrition
4.3. Prescription of Parenteral Nutrition
4.4. Discussion
5. Experience of Two Dutch Intestinal Failure Nutrition Support Teams
6. Conclusions
Author Contributions
Funding
Conflicts of Interest
References
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Adults | Children | ||
---|---|---|---|
Cause | Underlying Diseases | Cause | Underlying Diseases |
Short bowel syndrome (extensive bowel resection) |
| Short bowel syndrome (extensive bowel resection or congenital) |
|
Intestinal motility disorder |
| Intestinal motility disorder |
|
Congenital enteropathy |
| Congenital enteropathy |
|
Intestinal fistula |
| ||
Mechanical obstruction |
|
Component | Description |
---|---|
Dietary history and fluid balance | Detailed information about previously tried diets including route, amount, and type of nutrition/formula with reasons for lack of success, and measurement of current fluid balance is required for designing a new individualized feeding regimen. |
Anatomy of intestine | It is important to document the anatomy and function of the intestine or remaining intestine. Most nutrients are absorbed in the first part of the jejunum. In case of jejunum resection, the residual ileum is able to adapt and to partly take over the role of the jejunum in nutrient absorption. However, when the terminal ileum is resected, the reabsorption of vitamin B12 and bile salts cannot be replaced by jejunal cells. Resection of the ileocecal valve decreases intestinal transit time and supposedly predisposes to reflux of colonic content (including higher bacterial counts) back into the small intestine. Dysmotility and/or dilated loops cause intestinal stasis leading to SIBO, which negatively impacts the digestion and absorption of nutrients. [14]. High-output stomas may cause water, sodium, and magnesium depletion [15]. |
Energy requirements, anthropometrics, sex and age | Energy requirements are preferably measured by indirect calorimetry. If this is not possible, these requirements should be calculated based on body weight, height, sex, and age, and adjusted accordingly by patient response (i.e., when not gaining weight as expected). To measure the effect of a nutritional intervention, anthropometrics should be monitored with growth charts in pediatric patients. Next to weight and height, it is also recommended to assess and monitor body composition (with for example air-displacement plethysmography) and muscle function (with for example handgrip strength). In a recent study in pediatric IF patients receiving long-term PN, Neelis et al. reported that these children had higher fat mass and lower fat-free mass (i.e., muscle, water, bone, and internal organs), compared with healthy peers [16]. In another study, involving adult IF patients, it was shown that 73% had sarcopenia (i.e., loss of muscle mass and function) [17]. |
Biochemistry: electrolytes and micronutrients | Micronutrient deficiencies are common in IF patients [18,19]. Electrolytes such as sodium and magnesium may be low due to excessive gastrointestinal losses, whereas calcium, phosphate and potassium can be elevated as a consequence of dehydration [20]. Screening of electrolytes, vitamins, and trace elements should be performed at baseline and monitored thereafter. Electrolytes should be monitored every 1–3 months or more frequently when indicated (e.g., in the case of recent PN composition change or increased gastro-intestinal losses); vitamins and trace elements should be monitored every 6–12 months [21,22]. |
Medication | Some medication may increase intestinal losses (e.g., non-steroidal anti-inflammatory drugs, proton pump inhibitors, antibiotics) [23]. Proton pump inhibitors are frequently used to reduce gastric PH and gastric fluid production which is most markedly increased in the hypersecretory acute phase of IF [24]. Also, because of the decreased enteral absorption of nutrients and fluids by the small intestine, medication dosages may have to be adjusted or converted to intravenous supplementation. If it is uncertain whether the medication will be enterally absorbed, the intravenous route is the preferred one [25]. |
Core Members | Roles |
Supervising physician * | Supervision and overall responsibility of care provided by the team Understands underlying diseases and prognosis Prescribes PN solutions and medication |
Gastroenterologist * | Understands and treats underlying diseases (Aids in) operative insertion of gastrostomies/jejunostomies |
Surgeon * | Operative insertion of CVCs and gastrostomies/jejunostomies Surgical management of IF (e.g., restoration of bowel continuity, surgical lengthening procedures, and management of anastomotic strictures) Is responsible for postsurgical care |
Interventional radiologist */Anesthesiologist * | Assists in challenging pediatric cases of central venous access. In adults, interventional radiologists are the primary consultant regarding CVC placement. |
Nurse specialist * | Teaches and trains patients and/or caregivers in care of tubes, stomas, and CVCs and in home PN administration when applicable Recognizes and manages complications of CVCs etc. Is case manager for patients and their caregivers |
Dietitian * | Conducts nutritional screening and assessment Designs and implements feeding regimens based on measurement or calculation of individual requirements Monitors patient’s response with nutritional, laboratory, and fluid status Is case manager for patients and their caregivers |
Pharmacist * | Is responsible for providing enteral formulations and PN solutions and for composition optimization Advises on compatibility and stability issues and drug/nutrient interactions |
Additional Members | Roles |
Endocrinologist * | Advises on preventing and treating complications of PN (and malnutrition) such as growth problems in children, metabolic bone disease, osteoporosis, and diabetes mellitus |
Hematologist * | Advises on prevention and treatment of catheter-related thrombosis |
Psychologist * | Provides psychological support and therapy for patients (and caregivers) |
Speech therapist * | Advises on oral feeding in case of oral aversion or swallowing difficulties |
Social worker * | Provides emotional support for patients (and caregivers) |
Physiotherapist * | Assesses motor development in pediatric patients Provides training programs focused on weight-bearing exercise |
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Vlug, L.E.; Nagelkerke, S.C.J.; Jonkers-Schuitema, C.F.; Rings, E.H.H.M.; Tabbers, M.M. The Role of a Nutrition Support Team in the Management of Intestinal Failure Patients. Nutrients 2020, 12, 172. https://doi.org/10.3390/nu12010172
Vlug LE, Nagelkerke SCJ, Jonkers-Schuitema CF, Rings EHHM, Tabbers MM. The Role of a Nutrition Support Team in the Management of Intestinal Failure Patients. Nutrients. 2020; 12(1):172. https://doi.org/10.3390/nu12010172
Chicago/Turabian StyleVlug, Lotte E., Sjoerd C. J. Nagelkerke, Cora F. Jonkers-Schuitema, Edmond H. H. M. Rings, and Merit M. Tabbers. 2020. "The Role of a Nutrition Support Team in the Management of Intestinal Failure Patients" Nutrients 12, no. 1: 172. https://doi.org/10.3390/nu12010172