ASPEN 2018 Nutrition Science & Practice …...ASPEN 2018 Nutrition Science & Practice Conference 9 Purpose: Patients undergoing hematopoietic stem cell transplantation (HSCT) are at

ASPEN 2018 Nutrition Science & Practice Conference 1

Poster Presentations

Session Title Poster Number Page

Parenteral Nutrition T1-T33 1

Critical Care and Other Critical Health Issues

T34-T63 52

Pediatric and Neonatal

T64-T91 100

Parenteral Nutrition POSTER OF DISTINCTION T1 - Pediatric HPN Patient Passive Disinfection Cap Use and Safety David Keeler, BSN, RN2; Susan McElroy, PhD, RN 2; Susan Abdel-Rahman, PharmD2; Uttam Garg, PhD1; Marty Snyder, BSN, RN2; Molly Hufferd, BSN, RN2; Beth Lyman, MSN, RN, CNSC2

1Pathology and Laboratory Medicine, Children's Mercy Hospital, Kansas City, MO; 2Children's Mercy Hospital, Kansas City, MO

Purpose: Innovations in technology designed to promote patient safety may have untoward effects that present in post marketing use. Passive disinfection caps (PDC) are isopropyl alcohol (IPA) containing caps that attach to the end of intravenous (IV) access points to disinfect and protect from pathogens. A recent in vitro study reported safety concerns in the use of PDCs for IV infusion tubing in neonatal patients. It is not known if inadvertent IPA exposure could be happening with Home Parenteral Nutrition (HPN) patients who have PDCs in place for many hours of the day while cycled off TPN. This study further examined the safety of PDC use in the pediatric HPN patients. Methods: An in vitro three-phase study was conducted to assess whether PDCs introduce unsafe quantities of isopropanol to IV fluid. The first phase evaluated the highest concentration of IPA in two commercially-available PDC products. Two different lots of each brand of PDC were placed in a test tube with 10 mL of sterile water and agitated for 15 minutes and the IPA concentration was analyzed with gas-chromatography (GC). The PDC brand with the highest mean concentration in the first phase was used in the second and third phase to emulate a worst case scenario. The second phase assessed whether IPA is inadvertently introduced into a needleless adapter (NA) connected to a central venous catheter (CVC) and is released over time into IV fluid. An IV infusion setup was created to mimic a typical HPN administration setup. A 6.6 French single lumen silicone CVC with an NA was prepared by priming with normal saline and then placing a PDC. After 24 hours, the PDC was removed and the CVC setup was immediately connected to an IV infusion of 0.9% saline infusing at 21 mL/hr. Samples were collected from


the end of the CVC catheter every 3 minutes for 30 minutes and analyzed with GC. The third phase assessed whether IPA concentrations would be greater after 7 days of repeated PDC use in a CVC + NA setup. The results of each phase were extrapolated to assess the effect of IPA levels on various indexed pediatric patients by body weight with systemic IPA. Qualitative assessment of NA appearance and function in each setup was conducted in phase II and III. Results: In the method used to quantify the isopropanol content of the brands of PDCs in phase I, ICU Medical© SwabCaps® were found to have significantly greater average absolute dose of IPA compared to 3M™Curos™ (61 mg vs 19.55 mg, respectively) . In phase II, IPA was detected in the 0-3 minute and the 3-6 minute collections of each trial, but no isopropanol was detected from 6 minutes on. The average isopropanol dose detected was 4.96 mg. In phase III, the average dose of isopropanol was 2.15 mg. No abnormalities were seen in function or appearance of the NA during Phase II and III. Conclusions: Inadvertent parenteral introduction of isopropanol into pediatric HPN patients represents a major safety concern, especially those with low body weight. Using a toxic threshold of 25mg/dL, the use of a single PDC per day in pediatric HPN patients with a body weight of 1 kg or greater in a manner consistent with this study appears to be safe.[KDM1] It is unclear why the quantity of isopropanol detected in phase II is greater than phase III. The use of PDCs did not appear to negatively affect the function or appearance of NAs over 24 hours of use in phase II or 7 days of use in III. Further investigation of other IV circuit products and setups could yield further evidence of safe practice.

Financial Support received from: Patient Care Services Research, Children's Mercy Kansas City



POSTER OF DISTINCTION T2 - Provider Education and Implementation of Multidisciplinary Nutrition Support Team to Reduce Inappropriate Parenteral Nutrition. Ann M. Richards, RD, CNSC1; Tanya K. Campbell, RD, CNSC1; David Podkameni, M.D. F.A.C.S.2 1Nutrition, Banner Gateway Medical Center, Gilbert, AZ; 2Bariatric Surgery, Banner Gateway Medical Center, Gilbert, AZ

Purpose: To reduce inappropriate parenteral nutrition (PN) and encourage use of the enteral route in patients with functional GI tracts through targeted provider education and implementation of a multidisciplinary nutrition support team (NST). Methods: An assessment tool based on American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines was created to evaluate the appropriateness of PN use. Baseline data was collected for ten months on percentage of inappropriate PN consults in relation to total consults received when compared to the assessment tool. After baseline data collection, targeted provider education was provided at department meetings regarding ASPEN guidelines on PN use, the assessment tool, and how it will be used by the registered dietitian (RD) to screen PN consults. Data collection continued after provider education to determine if the percentage of inappropriate PN consults changed. Once a PN consult was received, the RD evaluated the appropriate route of nutrition support therapy utilizing the assessment tool. The ordering provider was contacted by the RD if enteral nutrition was recommended. After five months of data collection post provider education, a NST was created including a physician champion, RDs, pharmacists, and line team members. Providers were notified about the implementation of the NST and reminded of the assessment tool through email. Data collection continued after the implementation of the NST for an additional five months. The RDs continued to screen all PN consults using the assessment tool and notify the provider if enteral nutrition was recommended. If the provider disagreed with the RD recommendation, the PN consult was elevated to the physician champion for further resolution. As part of the NST protocol, central line placement orders were held pending completion of the review process. Results: In the 10 month period prior to intervention, the data showed that 37% (N= 23/62) of PN consults received were inappropriate. The first intervention was to deliver targeted provider education regarding appropriate PN use. In the 5 months following education, inappropriate consults decreased to 32% (N= 11/34) of total PN consults. The second intervention included implementation of a NST including a physician champion with the goal to further reduce inappropriate PN use. Within 5 months of implementation of this team, inappropriate consults dropped to 24% (N= 6/25) of total PN consults. When tested for trend through time over all three time periods, p = 0.246. Although no statistical significance was seen, a clinical significance was seen with a 35% reduction of inappropriate consults. Conclusions: Although targeted education encouraged a small decrease in inappropriate PN use, it was the implementation of a formal NST including a physician champion that produced the greatest reduction of inappropriate PN use. The initiation of this team allowed for a more open dialogue between physicians


and RDs regarding nutrition support therapy and best practice. Whereas previously a PN consult was an order to start PN, post interventions, RDs were consulted to assess the appropriateness of PN in each case.

Financial Support received from: N/A

Parenteral Nutrition Consults Before and after Interventions

Inappropriate Consults Total Consults

Before Interventions 23 62

After Provider Education 11 34

After Implementation of Nutrition Support Team 6 25



T3 - A quality assurance program approach to reduction of Central Line Associated Blood Stream Infections (CLABSI) in Parentral Nutrition (PN) dependent children Kathleen Palas, RN, BSN, CPN1; Russell Merritt, MD, PhD Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles and Department of Pediatrics and the Keck School of Medicine, University of Southern California2 16 west, Children's Hospital Los Angeles, Los Angeles, CA; 2Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, Los Angeles, CA

Purpose: We developed a quality assurance program on a nursing unit within a major Children's Hospital to reduce CLABSI. The nursing unit provides care to many patients with central venous catheters (CVC's) used for parenteral nutrition. The nursing staff had varying degrees of experience in caring for such patients. In the 6 months prior to the interventions, there was a mean (SD) CLABSI /1000 line days of 2.81 (2.53). Methods: Initial data were collected for 100 line days of high risk patients to determine compliance with 7 important infection prevention techniques as seen in (Table 1). Compliance with these desired behaviors ranged from 41-100%. A multifaceted education effort was undertaken with the nursing staff. Interventions included a slide presentation at RN yearly updates class, staff meetings (including nursing assistants) and pointers in pre shift huddles. A checklist was developed and placed at the bedside of the children on PN for the nurses to fill out each shift, to gauge compliance with the 7 targeted behaviors. Results: 100 line days of post intervention data were then collected from the nurses completed checklist. Compliance with the infection prevention techniques had improved and ranged from 84-100% for the 7 targeted behaviors. During this time and after data collection was completed, there was a decrease in CLABSI on this unit. In the 6 months post intervention, there was a mean (SD) CLABSI /1000 line days of 0.64 (1.59). This statistically significant relationship (p <0.0001) suggests a 77% reduction in CLABSI from before interventions (Graph 1). Conclusions: We believe these interventions, focused on 7 targeted techniques related to CVC care and maintenance, helped to decrease the rate of infections on the nursing unit.

Financial Support received from: None


T4 - Effect of Intravenous Fat Emulsion containing Fish Oil with Parenteral Nutrition in Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation. Ji Hyeong Choe, B3; Young Joo Lee, B3; Hye Jung Bae, MS 3; Sun hoi Jung, phD1; Hyeon Joo Hahn, MS 3; Yungil Koh, MD, phD2; Sung Yun Suh, MS 3; Yoon Sook Cho, MS 3 1Pharmacy, Seoul National University Boramae Medical Center, Seoul, Korea (the Republic of); 2Internal Medicine, Seoul National University Hospital, Seoul, Korea (the Republic of); 3Pharmacy, Seoul National University Hospital, Seoul, Korea (the Republic of)


Purpose: Patients undergoing hematopoietic stem cell transplantation (HSCT) are at nutrition risk due to their underlying disease, high-dose conditioning, and other treatment-related toxicity. The gastrointestinal (GI) toxicity secondary to HSCT can cause inadequate food intake and patients with GI complication may need parenteral nutrition (PN). Omega-3 fatty acid is known for Immunonutrition that has anti-inflammatory properties and improves patients’ immune function, and several studies have shown that the supply of omega-3 fatty acid, orally or enterally, in cancer patients may have potential benefits. The aim of this study was to determine the effect of intravenous fat emulsion (IVFE) containing fish oil for adult patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT). Methods: This was a retrospective study on 90 adult of allogeneic HSCT patients from July 2011 to June 2015. Patients were divided into two groups according to the lipid type provided; fish oil group (FO group, n=55) and non-fish oil group (NFO group, n=35). The demographics including diagnosis, transplantation source, donor HLA typing, and disease status were collected. In addition, PN and lipid emulsion duration, length of hospital stay (LOS), weight change, 30 day mortality, survival period, incidence of acute graft-versus-host disease (aGVHD), neutropenic fever, sepsis, and re-hospitalization were reviewed from the electronic medical records. Results: The patients’ characteristics including age, sex, body mass index, and underlying disease were similar in the two groups. The median duration of PN was significantly longer in FO group (FO vs NFO = 23days (3~144) vs 17days (3~68), P=0.010) and median duration of fish oil based IVFE has no difference. The incidence of aGVHD and infectious complications, mortality, LOS, re-hospitalization were also similar. The FO group showed weight gains, whereas the NFO group showed weight loss (FO vs. NFO=0.34% vs. −1.08%, P=0.245). Conclusions: The clinical outcomes were similar in the two groups but there was a tendency for gain weight in the FO group. A large, well designed study, and a dosing study will also be needed to determine the optimal dose range for HSCT patients.


Patients' characteristics (n=90)

Characteristic Fish oil group (n=55) Non-fish oil group (n=35) p-value

Age (y) 46 (21~64) 42 (22~62) 0.266

Sex (male/female) 34/21 (61.8/38.2) 22/13 (62.9/37.1) 0.921

Height (cm) 165.59±8.08 168.96±7.10 0.046

Weight (kg) 62.71±12.98 67.56±12.88 0.087

Body mass index (kg/m2) 22.80±4.10 23.51±3.29 0.390

Disease 0.125

Acute lymphocytic leukemia 12 (21.8) 15 (42.9)

Acute myeloblastic leukemia 31 (56.4) 14 (40.0)

Hodgkin lymphoma 1 (1.8) 2 (5.7)

Myelo-dysplastic syndrome 8 (14.5) 2 (5.7)

Severe aplastic anemia 3 (5.5) 2 (5.7)

Transplantation source 0.389

Peripheral blood 55 (100.0) 34 (97.1)

Bone marrow 0 1 (2.9)

Donor HLA typing 0.191

Full match 38 (69.1) 20 (57.1)


1 locus mismatch 13 (23.6) 8 (22.9)

2 loci mismatch 4 (7.3) 7 (20.0)

Disease status (n=75) 0.171

CR1 26 (59.1) 21 (67.7)

CR2 9 (20.5) 5 (16.1)

Partial remission 0 2 (6.5)

Persist 8 (18.2) 2 (6.5)

Progressive disease 0 1 (3.2)

Relapse 1 (2.3) 0

Values are presented as median (range), number (%), or mean±standard deviation. CR = complete remission. Clinical outcomes (n=90)

Fish oil group (n=55) Non-fish oil group (n=35) p-value

Acute graft-versus-host disease 26 (47.3) 19 (54.3) 0.517

Neutropenic fever 35 (63.6) 23 (65.7) 0.841

Sepsis (culture) 22 (40.0) 9 (25.7) 0.164

30 days mortality 2 (3.6) 1 (2.9) 1.000

Length of stay 44 (24~323) 43 (23~107) 0.474

Re-hospitalization (n=71) 14/40 (35.0) 12/31 (38.7) 0.748

Weight change (%) ＋0.34±5.61 −1.08±5.57 0.245

Values are presented as median (range), number (%), or mean±standard deviation.

T5 - The impact of two intravenous protein infusion strategies on muscle mass and functionality Silvia M. Piovacari, Silvia Piovacari; Diogo O. Toledo, Diogo Toledo; Ana L. Potenza, Ana Potenza; Thaisa Assis, Thaisa Assis; Mirna M. Silva, Mirna Silva; Patricia a. Silva, Patricia Silva; Evandro J. Figueiredo, Evandro Figueiredo; João Silva Jr, João Silva Jr Hospital Israelita Albert Einstein, São Paulo, Brazil

Purpose: In several clinical situations parenteral nutrition becomes necessary to prevent or recover malnutrition. In this process, the recovery of sarcopenia is essential as the skeletal muscles mass and function loss also leads to a loss of quality of life and an increase morbidity and mortality. The evaluation of skeletal muscle, therefore, becomes increasingly important to monitoring nutritional rehabilitation. Studies evaluating the time course of stimulation of muscle protein synthesis during a continuous intravenous infusion of amino acid in healthy humans, showed an increase in muscle protein synthesis rate within the first 30 min, reaching a maximum stimulation after 2 hours; thereafter, protein synthesis rapidly declined returning to basal levels at the 4th hour, despite of a continuous amino acid availability. This saturable kinetic of amino acid mediated stimulation of muscle protein synthesis is defined as “muscle full” effect. The objective of this study was to assess the evolution on muscle mass and functionality of two intravenous protein supply strategies: continuous versus continuous associated with intermittent. Methods: The continuous protein infusion (CPI) strategy were evaluated for 28 days and upon the continuous associated with an intermittent protein infusion (CAIPI) were evaluated for more 28 days, both applied in a malnourished 14-year-old patient with ultra-short bowel syndrome weighing initially 31.5 kg. The CPI strategy was characterized by the continuous protein supply in Parenteral Nutrition (PN), and,


the CAIPI by supplying part of the daily protein in intermittent infusion, 125 ml solution (10% amino acids) in 3 hours infusion, once daily after physiotherapeutic rehabilitation, maintaining the rest of the protein supply by continuous infusion in the PN. The caloric requirements were assessed by indirect calorimetry and the protein supply was modified to maintain 2.5 g protein/kg/day. The variables weight, mid-thigh circumference, ultrasound measurement of quadriceps muscle layer thickness (QMLT), Medical Research Council (MRC) scale, handgrip strength and nitrogen balance were monitored weekly during the whole period. Results: Comparing the CIP and CAIPI strategies, we found a median weight (Kg) of 31.6 (30.8 to 32.65) vs 36.5 (34.5 to 39.3) p=0.04, for CIP and CAIPI, respectively. There was also an increase in median mid-thigh circumference 31 cm (30 to 32) vs 36.3 cm (33 to 39) p=0.04; QMLT 1.33 cm (1.1 to 1.73) vs 2.63 cm (2.14 to 3.33) p=0.04; MRC scale 36 (36 to 46) vs 48 (47 to 50) p=0.04; and handgrip strength 18 Kg (8 to 19) vs 21 Kg (19 to 23) p=0.04 for CPI and CAIPI, respectively. In addition, nitrogen balance median found in the CPI was -0.02 (-5.0 to 0.33) and in the CAIPI was 4.74 (1.26 to 9.58), p=0.02. Conclusions: The intervention with the CAIPI strategy showed significant difference in all parameters contributing to the positive outcome and quality of life of the patient. Therefore, data suggest that intravenous intermittent protein infusion post rehabilitation may increase muscle gain and functionality. New clinical studies are important since studies comparing the effects on protein metabolism of a continuous or intermittent infusion are limited.


Data comparing the CIP and CAIPI strategies.

Variables CPI strategy CAIPI strategy p-value

Weight (Kg) 31,6 (30,8 – 32,65) 36,5 (34,5 – 39,3) 0,04

Mid-thigh circumference (cm) 31 (30 – 32) 36,3 (33 – 39) 0,04

QMLT (cm) 1,33 (1,1 – 1,73) 2,63 (2,14 – 3,33) 0,04

MRC scale 36 (36 – 46) 48 (47 – 50) 0,04

Handgrip strength (Kg) 18 (8 – 19) 21 (19 – 23) 0,04

Nitrogen balance -0,02 (-5,0 – 0,33) 4,74 (1,26 – 9,58) 0,02

Data expressed as medians (min – max). Wilcoxon test p-value <0,05. CPI strategy: continuous protein infusion for 28 days. CAIPI strategy: continuous and intermittent protein infusion. QMLT: Ultrasound

measurement of quadriceps muscle layer thickness. MRC scale: Medical Research Council scale. T6 - Alternative Lipid Emulsion Utilization in the HPN population: Patient Characteristics and Clinical Observations Hannah Heredia, MS, RD, CNSC; Paul Choi, PharmD, BCNSP; Angelina Mason, RD, LDN, CNSC; Kristin Kovanis, RD, CDE, CNSC; Shirley Au, RD, CNSC; Penny L. Allen, RD, LDN, CNSC Parenteral Nutrition, BriovaRx Infusion, Chandler, AZ

Purpose: Soybean oil based intravenous lipid has been the only product available for fat-based calories in parenteral nutrition (PN) until Smoflipid, a four-oil lipid emulsion, was FDA approved for use in adults in August 2016. Smoflipid was first launched in 2004, has been available in many markets worldwide and contains soybean oil, medium-chain triglycerides, olive oil, and fish oil. Potential benefits may include: potential anti-inflammatory effects, reduction in PN associated liver diseases, and a reduction or improvement in liver function tests (LFTs). The aim of this review is to evaluate changes observed in a home PN (HPN) population of patients transitioned to this new four oil lipid emulsion over a twelve-month period. Methods: Medical records of patients on service with a national HPN provider from August 2016 to


August 2017 were reviewed. All patients transitioned from 100% soybean oil based lipid to the four oil lipid emulsion received HPN therapy for greater than 90 days prior. Patients excluded: those with incomplete lab work; no indication for lipid change; or those transitioned to hospice care or had expired during the time of the study. Data collected for 56 patients included: indication for PN; rationale for lipid change; initiator of change; lipid dose before product change; baseline LFTs and LFT results at 30-day intervals post-change from 30 days to 150 days. Associations between therapy and clinical outcomes were examined. Results: Of 56 total patients included in the review, 27% were pediatric, 73% adult with 38% male and 63% female. Forty five percent of patients received PN for >90days; 55% received PN for >1 year. Physician prescribers initiated lipid change in 50% of cases; 48% were initiated by homecare clinician; 2% were patient request. *Primary reason for change: Abnormal LFTs 41%, multiple reasons 18%, known PNALD 9% *Indication for PN: 25% short bowel syndrome, 18% fistula(s), 13% Crohn’s disease *Prior to change of lipid brand: a. Soybean oil lipid dose was >1g/kg in 23% of patients and <1g/kg for 57% patients b. 11% were not receiving any lipid, 9% were prescribed Smoflipid at start of care *Smoflipid dose prescribed was >1g/kg for 32% of patients and <1g/kg for 68% of patients *Eighty percent of patients converted showed improvement in LFT’s Data in the figures represents the mean ± SE lab values for patients with baseline elevations prior to initiating the four oil lipid emulsion. Measurements were taken baseline and at 30 day intervals thereafter. Mean reductions for AST, ALT, alkaline phosphatase, and total bilirubin were 50%, 44%, 22%, and 69%, respectively. The respective percentage of patients whose labs showed improvement from baseline were 84%, 76%, 59%, and 86%. Conclusions: Smoflipid is the first four oil lipid emulsion available in the US. Ongoing research may help determine potential benefits of more anti-inflammatory lipid blends as they become available. In this HPN population, reductions in LFTs were noted early on post-conversion, with 80% of patients experiencing a decrease in elevated LFTs. Of significance, 68% of the patients converted were prescribed for less than the generally recommended dose of 1 gm/kg/day for adults. Future research and ongoing education should examine the effects of appropriate dosing since practice patterns in the US may still be based on previous lipid shortage situations or lipid minimization tactics prior to the advent of alternative lipid emulsion availability.




POSTER OF DISTINCTION T7 - The Use of Enhanced Patient Education Tools to Prevent Venting Gastrostomy Tube Associated Dehydration in Home Parenteral Nutrition Patients. Chanelle Hager, RN; Darcie Moehnke, RN; Susan Olson, RN


Home Parenteral Nutrition Team, Mayo Clinic, Rochester, MN

Purpose: Home parenteral nutrition team (HPN) registered nurse (RN) triage calls at our tertiary medical center identified increased reports of dehydration. Chart review identified that patients experiencing these symptoms frequently had a venting gastrostomy tube. Opportunities for enhancement of education on management of venting gastrostomy tubes were found to be a direct link to the patient’s dehydration. The purpose of this study was to evaluate the role of venting gastrostomy tube education on dehydration in HPN patients. Methods: A retrospective analysis of 10 HPN patients from October 2016-January 2017 (control group) included identifying documentation of diet education, G-tube care, and if home going instructions were completed prior to hospital discharge. Inconsistences present in the control group electronic medical record (EMR) lead to the development of tools and communication pathways to achieve and sustain delivery of education and subsequently improved outcomes. Tools were used by the multidisciplinary teams and the patient. The goal of enhanced patient education tools was to teach patients how to prevent dehydration from the venting G-tube. Following development of these communication tools an additional 10 patients (intervention group) were included during the months of March 2017-August 2017. The intervention group received targeted education tools prior to discharge. Three months post discharge the control and intervention group were followed to evaluate tool effectiveness. Results: A total of 30% of the control group received diet education. A care plan that included education and directions for use of the G-tube at home was not found on all control patients in the EMR. The first month post discharge the control group had 10 episodes (6 of 10 patients) of dehydration that required use of IV fluids and additional lab work, compared to the intervention groups having 3 episodes (1 of 10 patients). Additionally, one control patient was readmitted. Month two, the control group had 6 episodes (2 of 10 patients) of dehydration that required IV fluids and one readmission for hydration management, compared to only 3 episodes (2 of 10 patients) in the intervention group. Month three after hospital discharge the control group had 6 episodes (2 of 10 patients) of dehydration that required intervention and zero re-admissions, compared to 1 episode of dehydration and zero readmissions in the intervention group. Overall 60% of the intervention group had both venting tube care and venting diet instruction documented in the EMR. Furthermore, 40% were given take home educational materials for self-reference and 50% had directions for clamping or gravity drainage of their venting tube in their hospital dismissal instructions. Conclusions: HPN patients, who require a venting gastrostomy tube, require additional education on how to effectively manage their gastrostomy tube output prior to discharge from the hospital. We have demonstrated that additional targeted education for venting gastrostomy use can lead to decreased rates of dehydration. The HPN RN collaborates with the hospital team to assure the right person, right role, and appropriate educational resources are used prior to discharge. This intervention allowed the patient to experience a smooth transition from hospital to home.


T8 - Effect of Computerized Prescriber Order Entry Implementation on Parenteral Nutrition Safety Sara E. Bliss, PharmD, BCPS, BCNSP, BCCCP2; JOY Jaco, PharmD1 1pharmacy, WFUBMC, Winston Salem, NC; 2Pharmacy, Wake Forest Baptist Medical Center, Lewisville, NC

Purpose: The purpose of this quality improvement project was to assess the effect of implementation of computerized prescriber order entry (CPOE) on patient safety associated with the parenteral nutrition (PN) use process in the adult population at a large academic medical center with a focus on prescribing and order verification. Methods: The institution’s PN use process was evaluated for deficiencies as compared A.S.P.E.N.


Safety Consensus Recommendations published in March 2014. Significant opportunities for improvement were identified in the categories of prescribing and order review and verification. Changes to the PN use process were made in a step-wise fashion over the course of a three-year period. Effects on safety were evaluated using a report generated from the institution’s voluntary patient safety reporting software for one year prior to and one year following the implementation of CPOE. Differences in rates of error types were analyzed using the Fisher’s Exact test. Results: Prior to publication of the updated safety consensus recommendations, the institution was compliant with 23 of 49 (46.9%) recommendations regarding prescribing practices and 35 of 53 (66%) recommendations regarding order review and verification practices. Significant changes to the PN process include implementation of an electronically editable paper order form which later served as a template for converting paper orders to computerized prescriber order entry (CPOE); inclusion of clinical decision support warnings; formalized training requirements for pharmacists involved in the prescribing process; and transition to a quiet work environment for performing parenteral nutrition review during the compounding process. During a three-year period of changes to the PN use process, compliance with safety recommendations increased by 20 of 49 (40.8%) for an overall compliance rate of 43 of 49 (87.7%) as well as partial compliance with an additional 3 of 49 (6.1%) recommendations for prescribing practices. Compliance was achieved for an additional 8 of 53 (15.1%) of recommendations regarding order review and verification compliance as well as partial compliance with 1 of 53 (1.9%). Approximately 2500 adult PN are processed annually at this institution. Overall, error reporting was very low during both pre- and post-intervention periods, 0.9% and 0.5% respectively. In the year prior to CPOE implementation, there were 21 errors reported in the adult population which were related to the parenteral nutrition use process: 2 prescribing and 6 order review and verification. In the year following the implementation of CPOE, 14 errors were reported: 1 prescribing, 3 order review and verification. The majority of errors which occurred during the order verification process were determined to be transcription errors. Although the number of errors of each type decreased in the post-intervention phase, the difference was not statistically significant for either prescribing or order review and verification. Conclusions: The low reporting rate likely contributed to the inability to show a difference in the impact that the change to CPOE made on safety. At this time, a transcription step is still required to enter the order into the automated compounding device (ACD) which contributes to the high number of transcription errors during the order review and verification steps of the PN use process. Future areas of research include working with the information technology team to enhance warning capabilities in the electronic medical record to allow direct communication of CPOE to the ACD.


Table 1: A.S.P.E.N. Safety Recommendation Compliance

Prescribing

n (%) N = 49

Order Review and Verification n (%)

N = 53

Compliant Prior to Publication 23 (46.9%) 35 (66%)

Compliance Achieved 20 (40.8%) 8 (15.1%)

Partial Compliance Achieved 3 (6.1%) 1 (1.9%)

Compliance Not Achieved 1 (2%) 4 (7.5%)

Not Applicable 2 (4.1%) 5 (9.4%)

Table 2: Adult PN-Related Errors

Pre-CPOE

Errors N = 2441

Post-CPOE Errors

N = 2667 p-value

Prescribing 2 1 0.61


Order Review and Verification 6 3 0.33

T9 - Results of Clinical Pharmacist Review on Pediatric and Neonatal Parenteral Nutrition Order Process Sara E. Bliss, PharmD, BCPS, BCNSP, BCCCP; JOY Jaco, PharmD Pharmacy, Wake Forest Baptist Medical Center, Lewisville, NC

Purpose: The purpose of this quality improvement project was to assess the effect of clinical pharmacist review on the parenteral nutrition (PN) use process in the neonatal and pediatric populations at a large academic medical center with a focus on interventions made during order review and verification. Methods: During an external mediation management review of the department of pharmacy, it was noted that neonatal and pediatric PN orders did not undergo a clinical review. Orders were evaluated strictly based on limits and warnings built into the automated compounding device (ACD) software. The institution’s PN order review process was modified to include review by clinical pharmacists for both neonatal and pediatric orders beginning October of 2015. The success of the process modification was evaluated by intervention documentation in the electronic medical record as well as compliance with A.S.P.E.N. Safety Consensus Recommendations published in March 2014. Results: Clinical pharmacist review of PN orders in this population began in October of 2015. The impact of this process modification was assessed through clinical intervention reporting within the electronic medical record. During this time period, a total of 692 interventions which resulted in a change to the PN formula were documented on the 3064 orders processed (22.6%) for the combined populations. There was no baseline intervention data for comparison as this was a new process. However, this new process did result in increased compliance with published A.S.P.E.N. Safety Consensus Recommendations by 5.7% in both neonatal and pediatric patients. Conclusions: Clinical pharmacist review of PN orders in this population began in October of 2015. Although there is no baseline data for comparison, 692 of 3064 PN orders were impacted by this intervention for a 22.6% intervention rate. This new process also resulted in an increased compliance with order review and verification safety recommendations as per the March 2014 A.S.P.E.N. Safety Consensus Recommendations.


Table 1: A.S.P.E.N. Safety Recommendation Compliance with Order Review and Verification

Neonates

n (%) N = 53

Pediatrics n (%)

N = 53

Compliant Prior to Publication 36 (67.9%) 35 (66%)

Compliance Achieved 3 (5.7%) 3 (5.7%)

Partial Compliance Achieved 3 (5.7%) 3 (5.7%)

Compliance Not Achieved 6 (11.3%) 7 (13.2%)

Not Applicable 5 (9.4%) 5 (9.4%)

T10 - Refeeding Hypophosphatemia Is Uncommon With Inpatient Initiation of Parenteral Nutrition And Unrelated to Caloric Delivery Bin Zhang, PhD, RPh, BCNSP1; Robert M. Dunn, BS 2; Alexandra Regalado, BS 2; Felicia N. Stewart, BA2; Martin Rosenthal, MD3; Sareh Parangi, MD3; D. D. Yeh, MD4


1Pharmacy, Massachusetts General Hospital, Winchester, MA; 2Clinical Nutrition, Massachusetts General Hospital, Boston, MA; 3Surgery, Massachusetts General Hospital, Boston, MA; 4The DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center / Jackson Memorial Hospital, Miami, FL

Purpose: Refeeding syndrome may be a life-threatening complication of aggressive initiation of parenteral nutrition (PN) after prolonged starvation. Historically, it has been described after starting PN given in very high doses. In the current era, caloric prescription is more moderate and the conservative practice of starting low and increasingly slowly to prevent refeeding syndrome may be inadvertently harming patients by iatrogenically underfeeding them. Our aim is to evaluate the incidence of refeeding syndrome and refeeding hypophosphatemia (RH) in adult hospitalized patients initiating PN, as well as repletion strategies when this occurs. Methods: We performed a retrospective review of 402 inpatients initiating PN therapy between May and December 2016. Data collected included demographics, hospital length of stay (LOS), PN indication, initial PN type, duration of PN, calorie/protein goals and delivery, daily serum phosphate levels, and daily phosphorus replacement. Energy (KCals) and protein per kilogram (kg) were prescribed per A.S.P.E.N. guidelines. Low serum phosphorus was defined as ≤ 2.5 mg/dL, and refeeding hypophosphatemia was defined as ≤ 1.5 mg/dL during the first 7 days of PN. Patients with refeeding hypophosphatemia were further evaluated by chart review for refeeding syndrome, defined as neurologic, cardiac, pulmonary, hematologic, or neuromuscular dysfunction not explained by other causes. Descriptive statistics were performed: Student’s t-est (two-tailed) was used to compare means, Wilcoxon rank-sum test to compare medians, and chi-quare test to compare frequencies. To test the association of low serum phosphorus prior to PN initiation with RH, we performed logistic regression analysis controlling for weight, body mass index (BMI), and days from hospital admission to PN initiation. Results: There were 22 patients (5%) identified with refeeding hypophosphatemia and the majority (13 of 22) experienced RH on PN day 1. Demographics, nutrition prescription, and nutrition receipt are displayed in Table 1. There was no significant difference in daily calorie/protein received during the first 7 days between groups (Table 2). Patients with RH had significantly lower serum phosphate levels prior to PN start (2.3 ±0.9 vs 3.1 ±1.0 mg/dL, p= <0.001), and on every subsequent PN day. While there were no significant differences between groups in the amount of kcal/kg and grams of protein/kg delivered, the RH group received significantly more supplemental phosphorus on the first two days of PN. On multiple logistic regression analysis, only a low serum phosphorus (OR 6.3, 95% CI 2.19 – 19.3, p=0.001) was predictive of RH. None of the 22 patients with refeeding hypophosphatemia demonstrated clinical signs of refeeding syndrome. Conclusions: With modern A.S.P.E.N.-recommended calorie prescription and careful phosphorus monitoring/replacement, refeeding hypophosphatemia occurs uncommonly after inpatient PN initiation. RH does not appear to be related to weight, BMI, or amount of calories received. Low serum phosphorus prior to PN initiation is predictive of RH. Refeeding syndrome did not occur in any patients.




T11 - Evaluation of Potential Complications associated with the Use of a Fourth Generation ILE used in the Provision of Parenteral Nutrition Therapy in a Community Hospital Setting. Jonathan T. Burdick, PharmD. Candidate1; Christopher Miller, PharmD., MS, MBA, BCNSP1,2 1University of Kentucky, Louisville, KY; 2Pharmacy, Norton Healthcare, Louisville, KY

Purpose: Lipid injectable emulsions (ILEs) are an essential part of a balanced macronutrient regimen in patients requiring parenteral nutrition (PN) therapy. ILEs represent a concentrated source of calories and


essential fatty acids (FAs) in patients who are unable to obtain adequate nutrition via the oral or enteral route. First generation ILEs (100% soybean oil) have been the mainstay of lipid macronutrient dosing in the U.S. for patients requiring PN therapy. They contain an excessive amount of pro-inflammatory ω-6 FAs. A novel ILE recently approved by the U.S. FDA is an alternative to the pure soybean oil ILEs and has potential advantages based on the FA lipid profile. This ILE contains a combination of four oils (30% soybean oil, 30% medium chain triglycerides, 25% olive oil and 15% fish oil). This formulation consists of a lower concentration ω-6 FAs, and supplemented with an increased amount of anti-inflammatory ω-3 FAs. This ILE is classified as a fourth generation IVFE based on the fish oil content and has been available in Europe for some time. The Pharmacy and Therapeutics committee at this institution approved it for use as the primary ILE in the adult patient population receiving parenteral nutrition therapy. The primary purpose of this study was to assess the safety of this product with regard to triglyceride and liver complications. Methods: This retrospective cohort study was approved by the IRB under exempt status. The study sample consisted of 30 patients with an age range of 18-89. The data was collected over a five week time frame using the electronic data records at the institution. The study subjects were all initiated on ILE as part of their PN regimen at a dose of 250 mL (50 g) given via y-site and assessed over a maximum 10-day period. The laboratory values were recorded at baseline and throughout the study, specifically targeting triglycerides, total bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (AP). These labs were drawn according to hospital protocol. A paired-t test was used for the statistical analysis on each laboratory parameter to provide a comparison of the study data collected at baseline and the last value collected over the 10 days of PN therapy. Results: The average dose of ILE provided to the study subjects was 0.75 g/kg/day. The statistical analysis of the paired-t analysis revealed the following: Triglycerides (106 /134; P=0.058), total bilirubin (0.88/0.64; P=0.03), AST (69 /59; P=0.23), ALT (73/85; P=0.22), AP (98/112; P=0.11). Total bilirubin was the only lab parameter that was significantly lower at the end of study compared to baseline. Additionally, two patients were switched to ILE administration every other day, due to hypertriglyceridemia during the course of therapy. Conclusions: The ILE evaluated in this study is gaining wider spread use and is expected to offer advantages over the older ILEs. This ILE provides a unique FA profile containing EPA, DHA, α-tocopherol and essential FAs without providing excess ω-6 FAs. Therefore, it has the potential of offering advantages in terms of reduced oxidative stress and mitigating inherent risks associated with PN such as risk of infection, hypertriglyceridemia, hyperbilirubinemia, and PN associated cholestasis and liver complications. This small pilot study, although limited in nature, did not reveal any significant safety concerns for the patient based on the laboratory parameters monitored. A larger scale study is warranted to validate these results and evaluate any other potential risks associated with the use of this ILE.


T12 - A Case for Parenteral Nutrition Before Surgical Repair of Giant Omphalocele in Delayed Closure Patients. Audrey A. Foster, MS RD LDN Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA

Purpose: Introduction: Children with giant omphalocele (GO) typically exhibit feeding challenges such as oral aversions, gastroesophageal reflux, poor motility, and elevated calorie needs due to hypoplastic lungs. These feeding complications may become intensified after surgical repair of GO. These children often experience difficulty resuming enteral nutrition and are at greater risk for malnutrition. Presented here are three cases illustrating these challenges. Case 1: Nine year old male with history of GO and failed closure during infancy. At time of surgery patient did not have malnutrition, was eating by mouth for pleasure and receiving 100% of nutrition via NGT. Central access was obtained for PN on post-operative day (POD) 3. A fluid limit was in place and it was not until POD 9 that patient received full nutrition needs via PN. Enteral nutrition was started on POD 13,


but limited by abdominal pain. Patient was discharged without parenteral nutrition and prior to achieving full enteral feeds. One month after surgery the patient was eating 50% of usual amount and tolerating 90% of tube feed goal but now had moderate malnutrition having lost 8.7% of his body weight. Case 2: Six year old female with history of GO, failed closure attempt during infancy, tracheostomy and vent dependence. At time of surgery patient did not have malnutrition and 100% of her nutrition came from NGT feedings. After surgery the patient went 7 days without nutrition with peripheral PN started on POD 7. Enteral feeds were started on POD 8 at 1/3 goal volume, but paused frequently due to abdominal pain. By POD 23 she had received an average of 45% of nutrition needs through the course of her hospitalization and had lost 14.7% of her body weight, indicative of severe malnutrition. Central access was obtained in order to provide 100% of nutrition needs via PN. The patient was discharged on PN and weaned off after 3 months once tolerating full enteral nutrition and no longer meeting the criteria for malnutrition. Case 3: Four year old male with history of GO and NGT dependence until two years prior to surgery. On admission patient met criteria for mild-malnutrition based on BMI and mid-upper arm circumference with patient receiving 100% of calories by mouth. Central access was obtained and PN given for one week prior to scheduled GO repair. Patient returned to the OR emergently on POD 2 for decompressive laparotomy and application of abdominal VAC dressing. He remained on parenteral nutrition for 37 days until tolerating full enteral nutrition. At follow up one week after discharge, patient was receiving 100% of nutrition via ng-tube, eating small amounts PO, and met criteria for mild-malnutrition based on BMI z-score. Discussion: Following the experience of patients one and two, it was decided to obtain central access for pre-operative provision of parenteral nutrition. Though patient three required a second surgery and had the longest hospital stay he was able to maintain his weight and malnutrition did not worsen throughout the course of his admission. The patients described in this case series were identified as children who underwent delayed closure of their GO who were also at risk for malnutrition based on pre-operative feeding difficulties. After closure the risk for malnutrition becomes greater due to cardiorespiratory compromise, fluid restrictions, and inability to tolerate enteral nutrition. Conclusion: Obtaining central access for TPN prior to GO repair may be indicated for patients at risk for malnutrition who require delayed closure. Having a central line before surgery facilitates prompt administration of PN in immediate post-operative period. Methods: N/A Results: N/A Conclusions: N/A


T13 - Survival of Home Parenteral Nutrition Patients with a Malignant Bowel Obstruction. Bradley Salonen, MD1; Sara Bonnes, MD1; Ryan Hurt, MD, PhD1; Manpreet Mundi, MD2; Elizabeth Bauer, NA1 1Mayo Clinic, Rochester, MN; 2Division of Endocrinology, Mayo Clinic, Rochester, MN

Purpose: With a malignant bowel obstruction (MBO), cancer patients are faced with the challenging situation of how to obtain sufficient nutrition in order to sustain life. Parenteral nutrition allows these patients an alternative route for administration of their nutrition. Home parenteral nutrition (HPN) takes this a step further and allows the cancer patient with an MBO to return home. The purpose of this study was to perform a retrospective analysis of our HPN database to assess survival with a MBO in HPN cancer patients. Methods: This study was retrospective analysis of all cancer patients with a MBO in our HPN database approved by our institution's IRB. The medical records were reviewed in order to gather information regarding length of survival, which was measured as HPN initiation until death for those deceased


patients or as HPN initiation until date of last follow-up (7/31/2017) for those patients who were still alive at study conclusion. Patients were divided into two groups 1) those that died on HPN or within 7 days of stopping HPN, 2) those that are either still on HPN or those that lived greater than 7 days after stopping HPN (minimum of 30 days on HPN). Results: A total of 114 patients with a MBO were included in the survival analysis. The patients were divided into three main cancer categories: gastrointestinal (n=52), genitourinary (n=38), and other (n=24). For the first cohort that either died on HPN or within 7 days of stopping, the combined, GI, GU, and other median survival times were 82.5, 58, 112, and 130 days. The 3, 6, and 12 month survival rates were 39.2%, 32.1%, and 14.2% for GI cancers; 50.0%, 38.9%, and 22.2% for GU cancers; and 60.0%, 30.0%, and 10.0% for other cancers (figure 1). For the second cohort that are either still on HPN or those that lived greater than 7 days after stopping HPN, the combined, GI, GU, and other median survival times were 889, 566, 2772, and 3430 days. The 3, 6, and 12 month survival rates were 91.5%, 73.2%, and 63.4% for GI cancers; 89.7%, 79.1%, and 58.1% for GU cancers; and 85.7%, 71.4%, and 57.1% for other cancers (figure 2). Conclusions: This study shows that the length of survival on HPN for cancer patients with a MBO can vary greatly. Even within this relatively limited patient population, there remains a great deal of variation from patient to patient where some used it temporarily to circumvent a temporary bowel obstruction, whereas others had chronic obstruction and needed it for the remainder of their lifetime. This study adds insight to the complicated question of the survival prognosis of cancer patients with bowel obstructions who receive HPN, but clearly more research is warranted.


Figure 1. Survival of HPN cancer patient with a MBO that died on HPN or within 7 days of stopping HPN


Figure 2. Survival of HPN cancer patients with a MBO that are either still on HPN or those that lived greater than 7 days after stopping HPN (minimum of 30 days on HPN). T14 - Effectiveness of Oral Zinc Supplementation in Home Parenteral Nutrition Patients with Malabsorption During an Intravenous Zinc Shortage: A Case Series. Ronelle Mitchell, MA, RD, CNSC; Sandra I. Austhof, MS, RD, CNSC; Denise M. Konrad , RD, CNSC; Jamie Davila, RD, CNSC; Mandy L. Corrigan, MPH, RD, CNSC, FAND Center for Human Nutrition, Cleveland Clinic, Avon, OH

Purpose: In 2013, multiple parenteral nutrition (PN) shortages occurred, including multivitamins, electrolytes, lipids and individual trace elements. Our protocol during shortages for home parenteral nutrition (HPN) patients was to instruct patients to use chewable supplements or crush the supplement. Since zinc is absorbed primarily in the distal duodenum and proximal jejunum, patients with this portion of bowel intact should theoretically absorb zinc. The aim of this study was to identify how patients with malabsorptive conditions responded to oral zinc supplementation during an IV zinc shortage. Our hypothesis was that patients with malabsorptive conditions would not be able to maintain their serum zinc levels within the normal range with the use of oral zinc. Methods: A retrospective chart review of malabsorptive patients who were on HPN for ≥5 days per week and receiving HPN for a minimum of 1 month during PN zinc shortages. Laboratory results for serum zinc both pre- IV zinc shortage and during oral supplementation were analyzed. Results: Of 675 patients reviewed, 6 patients met the inclusion criteria. The content of zinc in the PN prior to zinc shortage ranged from 4-7 mg. Two patients had deficient serum zinc levels prior to the shortage, which increased to within normal range while on oral zinc. Patient 1, had <90 cm of small bowel and took 50 mg elemental zinc orally TID, over a period of 29 days. Patient 2, had 90-149 cm small bowel, crushed 50 mg zinc once a day for 67 days. Serum zinc increased 63% and 64% respectively. Patients 3 and 4 (>200 cm small bowel and unknown amount of small bowel, respectively) chewed a supplement, which contained 11 mg zinc once daily. Serum zinc decreased 34% in patient 3 and 15% for patient 4. Patient 5 (>200 cm small bowel) swallowed one 50 mg tablet whole per day, and serum zinc level decreased 13%. These three patients, (3-5), received oral zinc an average of 311 days (range: 179-


546 days) and although serum zinc levels decreased, they remained within the normal range. Finally, patient 6, (<90 cm small bowel) had minimal change in the serum zinc level with the use of 11 mg of oral zinc taken twice daily over a period of 284 days. No signs or symptoms of zinc deficiency were documented. Conclusions: While the sample size was too small to draw any general conclusions, we find our alternative protocol was effective in mitigating zinc deficiency during time of IV zinc shortage in malabsorptive HPN patients. Patients with the shortest known length of small bowel exhibited increased or stable zinc levels. Except for one patient, all patients’ serum zinc values remained within the normal range for an extended time period regardless of whether the supplement was swallowed whole or crushed. Additional research is warranted to determine the efficacy of oral zinc supplementation on long-term effects as well as optimal administration method in patients with altered small bowel anatomy when IV zinc is unavailable.


T15 - Do Patients Receiving First Dose of an Alternative Intravenous Lipid Emulsion Require Nursing Observation Carol M. Cheney, RN, CNSC2; Deborah Pfister, MS, RD, CNSC1 1ThriveRx, Littleton, MA; 2ThriveRx, Hopkinton, MA

Purpose: Many medications carry the risk of anaphylaxis due to an allergic response which often requires test dose administration in a clinic setting or nursing observation during infusion in the home. Intravenous lipid emulsions (ILE) were first released in the late 1950s but were taken off the market due to side-effects. After FDA approval of a soy-based ILE in 1972, test dosing in a hospital setting was common. With documented tolerance, first dose infusion of ILE in the home became acceptable practice. Protocols for this included: exclusion of patients with known soy allergies or other complex allergy history and dispensing ephinephrine with patient education regarding its use for possible reaction. Recent FDA approval of an alternative ILE composed of fish, olive, soy and MCT oils prompted our creation of an administration policy to include test dose requirement due to lack of US experience with potential anaphylaxis. The purpose of this retrospective review was to evaluate the incidence of anaphylaxis associated with an alternative ILE infused in the home setting. Methods: An administration policy was created which required an allergy history. Any patients with a suspected allergy to fish, egg, soybean or peanut protein were determined to be clinically inappropriate for initiation in the home. Patients who were free of these allergies, were determined to be appropriate for home initiation. The protocol required that a registered nurse (RN) administer the ILE over one hour with observation for possible adverse events. Epinephrine was dispensed and available for treatment if needed and documentation of response to first dose infusion was completed. Records for all patients receiving the alternative ILE between August 2016 and July 2017 were reviewed for possible response. Results: A total of 62 patients received an alternative ILE during the study period. Forty patients received the test dose in an inpatient or outpatient setting. Reasons for controlled setting administration included initiation concurrent with an inpatient stay, institution policy on first dose medication administration and lack of home health nursing to assist. One patient had a documented peanut allergy and was admitted for an overnight stay. Tweny-two patients received the test dose of the alternative ILE in the home setting with RN observation during the fist hour of infusion with an anaphylaxis kit available. Ten of these patients were pediatric and 12 were adult. Of the 22 patients who received test dosing in the home setting, none demonstrated any adverse events requiring nursing intervention during the first hour of infusion or noted symptoms of concern during the infusion. One patient complained of nausea 4 hours into infusion, requiring discontinuation of the ILE. Conclusions: Based on the absence of any adverse response to an alternative ILE infusion, recommendation was made to modify the policy to exclude RN observation during the first hour of infusion. Epinephrine dispense and administration education was continued as a part of the protocol.



T16 - What is the optimal nutritional index during the early perioperative period after pylorus preserving pancreaticoduodenectomy? Kyung Sik Kim, M.D1; Sung Hwan Cha, M.D1; Song Hee Baek, M.D2 1Surgery, Yonsei University College of Medicine, Seoul, Korea (the Republic of); 2Radiology, Yonsei University College of Medicine, Seoul, Korea (the Republic of)

Purpose: Malnutrition leads to adverse effects on the short term and long term prognosis in patients with periampullary diseases who underwent surgery. Nutritional risk indicator based on albumin and body weight has been developed for the evaluation of the nutritional status and the efficacy of nutritional therapy. But there is no single gold standard objective measurement for the evaluation of nutritional status in the early period after pancreaticoduodenectomy(PD). Methods: We analyzed the 28 patients with periampullary diseases(CBD cancer : 13 , Ampulla vater cancer : 9, Pancreas head cancer : 2, Neuroendocrine tumor : 2, Chronic pancreatitis 2) who underwent PD from Jan. 1, 2012 through Dec. 31, 2016, retrospectively. The TPN was started routinely at POD#1 with 25Kcal/kg Bwt. We measured various nutritional indicators(BMI, NRI, Protein, Albumin, prealbumin and CRP). Skeletal muscle area, muscle density with HU, visceral and SQ fat area were assessed using two times of CT scans, preop and POD #7 at L3 level. Results: Patients consist of 18 males and 10 females and average age is 63.5±9.7 years old. Although there is no difference in BMI between preop and POD #7, protein, albumin and prealbumin were decreased(p<0.001) and CRP was increased(P <0.001) at POD#7. Prealbumin and CRP showed negative correlation(R=-0.682, p<0.01). Although there is no difference in muscle density and amount of subcutaneous fat between preop and POD #7, amount of muscle mass was increased(p=0.02) and amount of visceral fat decreased(p=0.00) at POD#7. According to the amount of CRP, muscle density, amount of muscle, visceral and subcuatneous fat did not changes before and after PD. Conclusions: In order to accurately evaluate the nutrition scale after the PD, we suggest a method using CT scan of nutritional evaluation that can adjust the degree of inflammation during early postoperative period.


T17 - A Quality Improvement Initiative Using a Risk Factor Based Insulin Protocol in Hospitalized Total Parenteral Nutrition Patients Decreases Hyperglycemia and Insulin Use. Arielle Lehman, MS ; Venkata R. Konjeti, MD; Navid Hejazifar, MD; Linda Creasey, RD CNSC; Puneet Puri, MD Division of Gastroenterology, Hepatology and Nutrition, McGuire VA Medical Center, Virginia Commonwealth University, Richmond, VA

Purpose: Hospitalized patients receiving total parenteral nutrition (TPN) are at a higher risk of developing hyperglycemia (>180 mg/dL) and hypoglycemia (<60 mg/dL), which are associated with significant morbidity and mortality. Current TPN guidelines lack recommendations regarding the type and method of insulin administration. In this quality improvement initiative at the Virginia Commonwealth University (VCU), we aimed to assess the prevalence of hyper- or hypo-glycemia following implementation of a risk factor based insulin use protocol designed to maintain euglycemia in TPN patients. Methods: Risk factors for hyper- and hypo-glycemia were defined as steroid use, acute kidney failure, or infection. A risk factor based protocol was established and patients receiving TPN were analyzed pre- (n = 40) and post- (n = 44) implementation. Additionally, diabetic patients in pre- and post-implementation groups were further categorized into: (i) no risk factors [pre (n = 4) and post (n = 1)], (ii) with risk factors


at any time point on TPN [pre (n = 0) and post (n = 1)], and (iii) with risk factors throughout TPN [pre (n = 8) and post (n = 8)]. Daily blood glucose levels, dextrose infusion, insulin administration and dosage, and medical history were recorded for all patients. Insulin to carbohydrate ratios (1 unit to 10 grams) were used to calculate if insulin in the TPN bags were used to solely balance carbohydrate administration (ratio ≤ 0.1) or to also account for increased glucose levels due to risk factors (ratio > 0.1). Descriptive statistics, t-test, or Chi-square tests, as appropriate, were used for analysis of data. Results: Hyperglycemia (glucose >180 mg/dL): Twenty-four of 40 patients (60%) in the pre-implementation versus 26/44 patients (59%) in the post-implementation group experienced hyperglycemic events. Among the diabetics, hyperglycemic events were observed in 11/12 (92%) and 8/10 (80%) pre- and post-implementation groups, respectively (see table). Of note, patients with diabetes and hyperglycemic risk factors were 34% more likely to experience a hyperglycemic event than patients with diabetes lacking risk factors. Insulin use: Among the diabetics, 6/40 patients in the pre-implementation group received insulin in the TPN bag compared to 4/44 patients in the post-implementation group, accounting for a 6% decrease. Hypoglycemia (<60 mg/dL): There was a 7.7% decrease in the number of hypoglycemic occurrences following implementation of the protocol, with a 50% decrease in diabetic groups. Insulin to carbohydrate ratio: Among the diabetics, 66.7% of pre-implementation group patients who had insulin in their TPN bag had a ratio exceeding 0.1 contrasted to 50% in the post-implementation patient group. All of these changes showed trends, but did not achieve statistical significance. Conclusions: A quality improvement initiative at VCU demonstrated promising improvements in decreasing (a) both hyperglycemic and hypoglycemic episodes, (b) insulin use in 1 out of every 20 patients, and (c) insulin to carbohydrate ratio by 16%. Thus, insulin in the TPN bag was less frequently used to compensate for basal insulin, demonstrating protocol adherence. Small sample size may be related to lack of statistical significance. These findings are, however, very encouraging and merit large prospective evaluation that will assist in the development of evidence-based guidelines regarding the use of insulin in TPN patients.



Table 1. Main results of diabetic patients on TPN.


T18 - Effect of Non-soybean Oil Based Intravenous Lipid Emulsion Compared to a Soybean Oil Based Intravenous Lipid Emulsion on Hyperkeratosis and Fatty Acid Status: A Case Study Carol Ireton-Jones, PhD, RDN, CNSC, FASPEN2; Reid Nishikawa, Pharm D, BCNSP1; Rodney Okamoto, RPh3 1Nutrishare, Inc., Elk Grove, CA; 2Nutrishare, Inc, Elk Grove , CA

Purpose: Intravenous lipid emulsion (ILE) is used to provide sufficient quantities of linoleic and alpha-linolenic acid to prevent essential fatty acid deficiency (EFAD) and as a caloric source. Until recently, only 100% soybean oil (omega 6 fatty acids) ILE was available in the US. Varying soybean oil content of ILE is available outside the US. Clinolipid® (OO-SO ILE) contains 80% olive oil and 20% soybean oil. Although OO-SO ILE has received FDA approval, it is not available in the US. An alternative, Smoflipid containing soybean oil (30%), MCT oil (30%), olive oil (25%) and fish oil (15%) was approved by the FDA (July 2016) and made available in the US. This is a case study of a 62-year-old female requiring home parenteral nutrition (HPN) for 29 years secondary to a midgut volvulus resulting in loss of her small bowel as well as the proximal third of colon. She has a significant dermatologic condition, hyperkeratosis, which causes viral warts primarily on her legs and has been followed by a dermatologist for treatment using PDT (phototherapy) without much success. Because of the pro-inflammatory effect of 100% soybean oil, an alternate ILE with decreased amounts of soybean oil was used in her HPN in place of the SO-ILE to determine if there would be an improvement in her hyperkeratosis and viral warts. Methods: A compassionate use trial of OO-SO ILE was approved for this patient and implemented to replace the SO-ILE in an isocaloric dose (40 grams, 3 times per week). When the alternative, Smoflipid, was made available in the US, the ILE in the HPN was changed from OO-SO ILE to Smoflipid in an isocaloric dose (40 grams, 3 times per week). Data collected included assessment of the viral warts on her legs, weights, nutritional composition, serum albumin, complete blood count, and liver enzymes. Results: The patient is 170.18 cm tall and weighs 51.8 - 53.2 kg which has been stable for many years. She receives HPN daily providing 1431 kcal (27 kcal/kg) with 60 gm protein (1.2 gm/kg) and consumes a small amount of food daily. For 26 years she received SO-ILE at 40 grams, 3 times per week. After receiving OO-SO ILE for ~6 months, the viral warts and inflammation on her legs improved. When Smoflipid became available, it was administered in place of the OO-SO ILE. She has now received Smoflipid for 8 months. Her dermatologist stated that her skin was markedly improved compared to the period when she was receiving OO-SO ILE. The patient noted a significant improvement in the skin on her legs. The only difference in her therapy was a change in the ILE from OO-SO ILE to Smoflipid. Her weight remains unchanged (51.8kg) using either ILE and there were no significant differences in liver enzymes or serum albumin with either ILE. The Triene:Tetraene ratio was normal during SO-ILE, OO-SO ILE, and Smoflipid administration. The EFA panel composition changed due to the change in fatty acid content of the ILE. While total alpha-linoleic and linolenic acid decreased, EPA, DHA and AA were in normal range when receiving Smoflipid. Conclusions: The availability of an alternative ILE which is FDA approved allowed this patient to receive a lipid composition that resulted in a significant improvement in her hyperkeratosis and viral warts. As she is dependent on home PN, this ILE composition decreased omega 6 intake while increasing omega 3 intake. The use of Smoflipid has been shown to be safe as there were no changes in her liver enzymes or CBC. It was efficacious as her weight, normal fatty acid profile, and serum albumin were maintained. There was clinical evidence of decreased inflammation which translated to improvement in her skin condition.

Financial Support received from: Baxter Heatlhcare provided Clinolipid under compassionate use for this patient

T19 - The Positive Impact of Dietitian Intervention on Clinical Outcomes in Home Parenteral Nutrition Patients


Allison Thompson, RD, LDN, CNSC; Kathleen Martinez, RD, LDN, CNSC; Patricia R. Skiendziel, MBA, RD, LD, CNSC Nutrition, Bioscrip, Inc, Mt. Pleasant, SC

Purpose: To be successful in today’s healthcare environment, providers in the post-acute space must be able to quantify the quality of care they deliver, with much of the focus on optimizing clinical outcomes, reducing hospital readmissions and improving patient satisfaction. Based on clinical complexity and cost, home infusion providers monitor these metrics closely in their parenteral nutrition (HPN) patient population. Evaluation of the data is complicated by variability in clinical management among providers and even within a single organization – especially as it relates to the role of dietitians on the care team. This study looks specifically at the positive impact of having a nutrition support dietitian actively engaged in the management of HPN patients. Methods: The electronic medical records for 329 HPN patients cared for by a large national home infusion company were accessed. For the month of July 2017 these patients had a total of 711 nutrition assessments completed by Company registered dietitians. Assessments were reviewed and data collected on type of RD recommendation, patient response to RD intervention, goals of therapy, hospital readmission rates and patient satisfaction. The data sample included assessments from 53 pharmacy locations across the country and 57 patients who were started on PN without a hospital admission. Results: Results: The most common goals of parenteral nutrition therapy were to achieve/maintain nutrition status, improve quality of life and reverse signs and symptoms of malnutrition. Dietitian recommendations for nutrition therapy varied but most frequently included changes to the PN formulation, recommendations for additional lab testing and adjustments/education on oral diet. 87% of the time, patients responded favorably when dietitian recommendations were implemented. The HPN patients included in this data review had an overall patient satisfaction rate of 100%. Their 30 day hospital readmission rate was 1.8%, or 93% below the findings of Vallabh et al, 2016. Conclusions: Reimbursement for dietitian services in home infusion is uncommon and including dietitians on the clinical team is not a regulatory or licensing requirement. As a result, establishing a consistent role for dietitians in this space is challenging. Providers have different resources and may have different views of the benefit to including dietitians on their teams. As healthcare moves away from the traditional fee for service model of reimbursement and there is increasing demand to report on quality of care metrics, there is an opportunity for home nutrition support dietitians to quantify their value. Improving outcomes, increasing patient satisfaction, reducing readmission rates, preventing emergency room visits and minimizing and/or eliminating the need for parenteral nutrition all reduce the cost burden on the healthcare system. In addition these are all areas where the expertise of a home nutrition support dietitian can have a positive impact. Further research is needed to clearly tie dietitian intervention to cost savings across the healthcare continuum.


T20 - Adverse reaction to parenteral amino acids (AA) in a patient with Mast Cell Activation Syndrome (MCAS) – a case report Angelina Mason, RD LDN CNSC1,2 1AxelaCare, Columbia, MD; 2BriovaRx Infusion Services, Columbia, MD

Purpose: Background: Mast cells are a part of IgE mediated inflammation. They are found throughout the body, in particular in mucosal membranes, lungs, skin, and the GI tract. Mast cells contain histamine, and are effectors in anaphylactic reactions. MCAS is a condition where mast cells can have an abnormal release of inflammatory mediators, leading to a constellation of systemic reactions, including anaphylaxis. Treatment frequently involves the administration of antihistamines and avoiding triggers. Dietary recommendations


include avoiding foods with high levels of histadine (His), the AA precursor of histamine. Methods: KW is a 17 year old female diagnosed with MCAS in 2017. KW was referred to a national home infusion company for initiation of home parenteral nutrition (PN) in 2016 related to weight loss, poor oral intake, delayed intestinal transit time and poor motility. She presented at 51.4kg, 165cm, which was 73% of her usual body weight (UBW). KW was started on a lipid free PN formula of 200 gm of dextrose, 50 gm of AA (Travasol®), electrolytes, MTE concentrate and MVI in 1500 ml, starting on a 24 hour infusion with plans to cycle and advance macronutrients to meet nutritional needs. After three weeks of PN, KW experienced urinary retention, abdominal pain, and edema with PN infusions. MVI was held, but symptoms persisted. PN was discontinued after 5 weeks of therapy since symptoms continued to worsen. She was then maintained on dextrose-based hydration. KW restarted HPN in 2017 due to weight loss after a vascular procedure, with weight down to 48.6 kg. The physician requested a “high protein” formula. Lipid free PN was initiated at 1000 ml, 200 gm of dextrose, 80 gm of AA (Prosol®) over 24 hours with electrolytes, MVI and MTE concentrate. Eight hours into the infusion, patient started complaining of headache, flushing, tachycardia, shortness of breath, and feeling tightness in her throat. PN infusion was stopped, and antihistamines administered. Symptoms subsided for several hours. Antihistamines were administered again after about 6 hours. PN was held, and symptoms resolved. Patient has been maintained on dextrose containing hydration with MVI since. Discussion: All parenteral AA solutions contain His, a non-essential AA in varying concentrations. (Table 1.) Histadine converts to histamine in a one-step decarboxylation reaction. (Figure 1.) KW had received parenteral infusions with dextrose and MVI without any adverse reactions. It was only with the addition of AA that symptoms of intolerance arose. When KW received PN in 2016, she did not yet have a diagnosis of MCAS, but her symptoms were consistent with the syndrome. Given this diagnosis, it is possible that adverse reactions to AA could be related to the dose of His in the PN, especially considering the milder reaction occurred with a dose of 2400 mg, and a severe reaction in 2017 occurred with a 4720 gm dose. Conclusion: PN is a complex therapy that may contain up to 30-40 different ingredients. Reactions to individual components in PN are rare and typically are associated with IV lipid emulsions, and less frequently parenteral MVI. Reactions to parenteral AA are infrequent, but can occur in patients with inborn errors of metabolism, or other conditions that affect amino acid metabolism. Careful initiation and monitoring for adverse reactions to PN is an essential responsibility of the nutrition support team. Methods: n/a Results: n/a Conclusions: n/a

Financial Support received from: n/a


Table 1.

Figure 1. T21 - Utilization of Cutaneous Safflower Oil in Chronic Total Parenteral Nutrition Patient with Essential Fatty Acid Deficiency. Gina M. Catalano, RD, LDN, CNSC; Rena Zelig, DCN, RDN, CDE, CSG; Michelle Stelling, MS, RD, LDN, CNSC; Sharon Lockwood, MS, RD, CNSC; Heather Stanner, RD, LDN, CNSC School of Health Professions, Rutgers University, Harleysville, PA


Purpose: An essential fatty acid deficiency (EFAD) occurs when the oral, enteral, or parenteral provision of linoleic and α-linolenic acid is insufficient, defined as less than 3-4% of total calorie intake from linoleic acid and 0.2-0.5% from α-linolenic acid. The diagnosis of EFAD includes the biochemical marker, triene to tetraene ratio (T:T; normal range: 0.010 to 0.038) and physical findings such as alopecia, poor skin integrity, and scaly dermatitis. Patients receiving essential fatty acids (EFAs) via injectable lipid emulsions (ILE), as a component of parenteral nutrition (PN), may experience the issue of critical hypertriglyceridemia, defined as a triglyceride (TG) level of at least > 400 mg/dL. In order to reduce the risk of adverse effects associated with hypertriglyceridemia, is it recommended that the frequency and concentration of ILE be reduced, or withheld altogether. The cutaneous application of safflower oil has been suggested as an alternative source of EFAs to prevent EFAD. The patient in this case presents with a primary diagnosis of severe gastroparesis and chronic obstructive enteropathy. Past medical and surgical history includes chronic abdominal pain, narcotic dependence, approximately 30 abdominal procedures, jejunostomy tube placement with subsequent removal, and a current ileostomy. The patient began home PN therapy in June of 2013 as a primary source of nutrition, along with scant oral intake. Methods: As of mid-year 2016, TG levels were reported as >400 mg/dL, and therefore IVFE were discontinued. In January 2017, after 6 months without ILE, TG levels decreased to 247 mg/dL. As the patient was monitored by a home care dietitian, physical signs of EFAD were determined through weekly conversations with the patient’s care-taker. In February of 2017, physical signs of EFAD, including alopecia and mild dermatitis, were reported. The following statement is used to describe the patient's nutrition diagnosis: Inadequate essential fatty acid intake (NI-5.5.1) related to parenteral nutrition without injectable lipid emulsions as primary source of nutrition as evidence by elevated serum triene:tetraene ratio of 0.112 and physical signs of alopecia and scaly dermatitis. In response to the absence of ILE in the PN regimen and the physical symptoms of EFAD, the home infusion dietitian recommended cutaneous administration of 2 tablespoons of safflower oil to the thighs, once daily as a source of EFAs. Results: As of July 24th 2017, the patient’s caretaker reported that hair growth was improving and there were no signs of dermatitis or skin abnormalities. The patient’s T:T ratio was first measured at 0.112 in March 2017, 1 month after starting the cutaneous safflower oil (Figure 1). In June 2017, the serum T:T ratio decreased to 0.076 (Figure 1). It can be determined that administration of subcutaneous safflower oil at a dosage of 2 tablespoons, daily, for 5 months, led to a decrease in physical signs of EFAD and an improvement in biochemical markers associated with EFAD. The physical signs of EFAD will continue to be discussed with the caregiver and monitored weekly by the home infusion dietitian and T:T ratio will continue to be measured every 3 months. Conclusions: Cutaneous safflower oil application was utilized effectively as an alternate to ILE to prevent EFAD in this case. Healthcare providers should monitor for signs and symptoms of EFAD in patients on PN not receiving ILE for at most 3 months. This includes measuring T:T ratio and utilizing physical examination to observe for hair loss, dermatitis and poor skin integrity as part of a comprehensive assessment.



T22 - Pediatric intestinal failure patients transitioning to a mixed lipid emulsion: a series of cases Mary Beth Harris, MPH, RDN, CSP, CNSC2; Meghan A. Arnold, MD, FACS4; Maria L. Partipilo, PharmD, BCNSP3; Dana B. Steien, MD1; Lola Rosewig, MPH, RDN, CNSC2 1Pediatric Gastroenterology, Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, MI; 2Patient Food and Nutrition Services, Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, MI; 3Michigan Medicine, Ann Arbor, MI; 4Pediatric Surgery, Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, MI

Purpose: Smoflipid, an lipid injectable emulsion (ILE) commonly used in pediatric parenteral nutrition (PN) admixtures in other countries, was recently approved for use in the United States. Smoflipid combines soybean, olive, and fish oils with medium chain triglycerides which differs from soybean oil lipid injectable emulsion (SO ILE) alone. SO ILE has been associated with PN-induced cholestasis.1 Our current practice in long-term PN dependent pediatric patients who develop cholestasis is lipid restriction2 which has been shown to reduce bilirubin levels however puts patients at risk for essential fatty acid (EFA) deficiency. This is detrimental for pediatric patients who require adequate fat for growth and development. Our institution has initiated the use of Smoflipid on select patients since its approval. Our aim is to describe the changes noted in 3 patients after their ILE was changed from SO ILE to Smoflipid. We completed retrospective chart reviews of these patients who are completely PN dependent and their lab trends are described. Case 1: 3 yo male with a history of microvillus inclusion disease. On PN since birth without enteral feedings. At 2 years old he developed cholestasis with a direct bilirubin of 3.6 mg/dL so his SO ILE was restricted to 0.58 g/kg/day. After 6 months his direct bilirubin decreased but remained elevated (>2.0 mg/dL). His EFA profile showed a low linoleic acid (LA) and increasing triene to tetraene (T:T) ratio. Smoflipid was then started at 2.2 g/kg/day. After only 1 week his direct bilirubin lowered to 1.2 mg/dL, and to 0.6 mg/dL after 6 weeks. His EFA profile showed minimal improvement in LA. Smoflipid dose was then increased to 3 g/kg/day. Case 2: 5 yo female with chronic intestinal malabsorption and congenital secretory diarrhea secondary to MYO5B mutation (found in microvillus inclusion disease). On PN since shortly after birth without enteral feedings. At 4 years old her direct bilirubin reached 12.2 mg/dL so SO ILE was restricted to 0.42 g/kg/day. After lipid restriction for 10 months her direct bilirubin decreased to 0.8 mg/dL. During lipid restriction her T:T ratio increased, mead acid (MA) elevated, and alpha linoleic acid (ALA) and LA decreased. Smoflipid was initiated at 1.24 g/kg/day. Total bilirubin then decreased from 1.3 mg/dL to 0.6 mg/dL. EFA profile


showed a decrease in ALA, low LA, and normal MA. Smoflipid dose was then increased to 1.91 g/kg/day. Case 3: 3 yo female with megacystis microcolon intestinal hypoperistalsis syndrome. On PN since birth with no enteral feeds. Total and direct bilirubin were 2.1 mg/dL and 1.9 mg/dL so SO ILE was restricted to 0.79 g/kg. Direct bilirubin increased to 2.9 mg/dL. Smoflipid was started at 1.95 g/kg/day. She developed cholelithiasis within 2 weeks and underwent cholecystectomy. Direct bilirubin eventually decreased to 1.2 mg/dL. Followup EFA profile showed a low LA and normal T:T ratio, ALA, and MA. SMOFlipid® dose was then increased to 2.28 g/kg/day. The use of SO ILE in children completely dependent on PN is associated with the development of cholestasis. Our practice had been to initiate lipid restriction despite the risk of developing EFA deficiency. With the recent approval of Smoflipid, however, we have transitioned several completely PN-dependent patients to this new IVFE. In all patients we have seen decreases in their direct hyperbilirubinemia but their EFA profiles have remained abnormal thus highlighting the need to continue aggressive EFA monitoring while on Smoflipid. Methods: n/a Results: n/a Conclusions: n/a



T23 - Trends in Parenteral Nutrition Home Start Patient Demographics Danielle Richardson, RD, CNSC Soleo Health , Sharon Hill , PA

Purpose: Home parenteral nutrition (HPN) in and of itself, is complex therapy requiring careful management to prevent therapy-related complications. When parenteral nutrition (PN) is initiated in the home setting, it can present further safety risk as progression towards goal formulation is prolonged and the monitoring of the patient is reduced in frequency when compared to the hospital setting. Currently there are no established clinical guidelines that detail how PN is to be initiated in the home, but there is attention given to who may or may not be an acceptable candidate. Standard 7.4 of the American Society for Parenteral and Enteral Nutrition’s (A.S.P.E.N.) practice standards for the provision of HPN therapy states “initiation of PN in the home setting shall only be considered in patients who are clinically stable, have an appropriate indication for PN, are able to be evaluated in the home, and are capable of safe administration of the therapy. Initiating therapy at home shall be considered only when assessment confirms that benefits greatly outweigh the risks.”1 With the identification of patient populations that are most appropriate and successful with home initiated PN therapy, it is possible for efforts of cost savings in the medical setting to be combined with safe initiation and delivery of HPN. The purpose of this review was to summarize trends of home initiated PN through this provider’s specialty PN program. Successful home initiated PN patients are defined as those who received their initial dose of PN in the home setting and were able to avoid hospitalization as goal rate, volume and caloric recommendations were achieved. Methods: A retrospective chart review of clinical documentation through the proprietary clinical outcomes


program, SoleMetrics™ was conducted. Patients receiving HPN from this national specialty home infusion provider were identified and reviewed by a Certified Nutrition Support Clinician (CNSC), and the following data was gathered: 1. Number of HPN patients successfully initiated on therapy in the home 2. Primary diagnosis for each HPN patient successfully initiated on therapy 3. Age and gender of each HPN patient successfully initiated on therapy Results: A total of 247 HPN patient records were reviewed and thirty-five (14.2%) of these patients were successfully initiated on PN therapy in the home. Of these 35 patients 2.8% had a primary diagnosis of pancreatitis, 2.8% ulcerative colitis, 8.5% Crohn’s disease, 11.4% gastroparesis, 11.4% malabsorption, 11.4% fistula and 51.4% malnutrition. Those with a primary diagnosis of malnutrition were further categorized into primary cause of malnutrition as either cancer (31.4%) or unspecified (20%). Twenty-eight (80%) patients were females, and seven (20%) were male. The average age for these home initiated PN patients was 59 years old, with zero pediatric patients. Conclusions: This national specialty home infusion provider sees a variety of patient diagnoses which qualify for initiation of PN in the home as shown. The majority are middle age, female patients diagnosed primarily with malnutrition related to cancer. With the oncology population, there is indeed a benefit to home initiated PN, as this population tends to be immunosuppressed or compromised related to disease progression or the treatment itself. Avoidance of hospitalization for the oncology patient to begin PN therapy reduces the risk for nosocomial infections, treatment and progression set-backs and additional medical costs.



T24 - Inadequate Calcium Delivery – A Consequence of Transition to an External Compounding Parenteral Nutrition Pharmacy Kristen Nowak, MS, RD, CNSC, LDN; Kelly Roehl, MS, RD, CNSC, LDN Rush University Medical Center, Chicago, IL

Purpose: Our institution recently transitioned from in-house parenteral nutrition (PN) compounding, to off-site PN compounding with an external company. As a result, calcium-phosphorus precipitate curves were lowered, potentially resulting in inadequate calcium delivery to PN-dependent patients. The objective of this quality improvement (QI) project was to determine differences in calcium delivery pre- and post-transition to an external compounding facility. Methods: Data were extracted from an ongoing PN QI database at a large academic medical center. Patients aged >18 years, admitted to an adult inpatient care unit, and started on PN between June 15, 2016 through June 19, 2017 were included. The following variables were collected: days on PN (days), PN volume (liters), mean, minimum, and maximum PN phosphorus given (mmol), mean, minimum, and maximum corrected serum calcium levels (mg/dL), and days received PN calcium (%, defined as days when serum calcium was low or within goal range). Data were separated into two groups as the six months of in-house compounding and six months of off-site compounding after the transition. Independent t-tests were used to determine difference between all variables. Results: A total of 195 patients were started on PN between June 15, 2016 and June 19, 2017. Mean PN days were longer for those during the in-house compounding period versus off-site compounding period (11.2+11.9 vs 8.9+6.8 days; P=0.002); Table 1. There were no differences between mean PN volume, mean, minimum, and maximum PN phosphorus doses, or mean, minimum, and maximum corrected serum calcium concentrations between groups. Compared to the in-house compounding period, mean percent of days with PN calcium given was significantly lower during the off-site compounding period (78+32% vs 61+38%; P=0.001). No incidences of calcium phosphate precipitation were identified during either time period. Conclusions: Transition to an off-site PN compounding pharmacy significantly reduced calcium delivery for patients receiving PN at a large academic medical center. As there were no known calcium-phosphate precipitation incidences during either time period, liberalizing solubility curves at the off-site compounding pharmacy may be warranted. Clinicians should be cognizant of the adequacy of calcium delivery among patients receiving PN support to reduce the risk of calcium resorption from the bones to maintain serum concentrations.



Differences in Parenteral Nutrition (PN) Related Components Before and After Transition to Off-site PN Compounding

Total

Sample n=195

In-House Compounding

n=106

Off-Site Compounding

n=89

P-value

Mean PN days (days) 10.3±10.2 11.2±11.9 8.9±6.8 0.002

Mean PN volume (Liters) 1.6±0.3 1.6±0.3 1.6±0.3 0.692

Mean PN Phosphorus given (mmol) 37±23 34±18 41±21 0.242

Minimum PN Phosphorus given (mmol)

20±18 19±18 22±19 0.263

Maximum PN Phosphorus given (mmol)

55±23 52±21 60±25 0.394

Mean serum Calcium1(mg/dL) 9.8±0.7 9.9±0.6 9.6±0.7 0.877

Minimum serum Calcium1(mg/dL) 9.2±0.7 9.3±0.7 9.1±0.7 0.569

Maximum serum Calcium1(mg/dL) 10.3±0.8 10.3±0.8 10.1±0.8 0.967

Mean % days with PN Calcium2(%) 71±36 78±32 61±38 0.001

1corrected calcium; 2defined as days when serum calcium was low or within goal range

ENCORE ABSTRACT Presented at the 39th ESPEN Conference, Sep. 2017 in The Hague, Netherlands. Previously unpublished. T25 - Long Term use of Mixed Oil Lipid Emulsion in Adult Home Parenteral Nutrition Patients: a case series. Manpreet Mundi, MD1; Megan McMahon, PA-C2; Jennifer Carnell, PharmD2; Ryan Hurt, MD2 1Division of Endocrinology, Mayo Clinic, Rochester, MN; 2Mayo Clinic, Rochester, MN

T26 - The Role of the Dietitian in the Design of the Electrolyte Composition of Parenteral Nutrition and Educational Implications. Jan Greenwood, RD1; Elena Tejedor, RD2; Meena Karsanji, MS, RD 4; Linda Brooks, RD, CNSC3; Patti Wahl, RD, CNSC2 1Nutrition Support Consultant, Vancouver, Canada; 2Vancouver Coastal Health - Vancouver Hospital, Vancouver, Canada; 3Fraser Health - Surrey Hospital, Surrey, Canada; 4Vancouver Coastal Health - Richmond Hospital , Richmond, Canada

Purpose: In the province of British Columbia, provincial legislation designates the design of parenteral nutrition (PN) as a Restricted Activity, a designation given to higher risk activities and restricted to qualified providers. The College of Dietitians of British Columbia (CDBC) requires dietitians to provide proof of competence to design PN through completion of an educational program or demonstration of competency verified by a qualified colleague. Additionally, CDBC mandates that dietitians must be practice ready when participating in PN design. Practice readiness is defined as confidence in the dietitian's ability to independently fulfill the duties and responsibilities required in any area of dietetic practice. The role of the dietitian in the design of the PN electrolyte composition varies between institutions and within practice areas. To help identify the various role expectations of dietitians in the design of the electrolyte composition of the PN prescription, a province-wide survey of dietitians qualified with the PN Restricted Activity was conducted. Methods: A letter of invitation to participate in an anonymous online survey was distributed to dietitians through a dietitian-managed, electronic, province-wide communications network. To participate, dietitians were required to be qualified with the PN Restricted Activity. Participants were asked to select, from a list


of eight possible scenarios, the option that best described their role in the design of the electrolyte composition of the PN prescription. Results: According to the 2017 year-end CDBC Registry, 337 dietitians were registered with the PN Restricted Activity. A total of 94 dietitians (28%) completed the survey. Sixty-two percent and 38% of respondents were employed in teaching hospitals and community hospitals, respectively. Forty-six percent had less than or equal to 5 years, 32% had 6 - 10 years, and 22% greater than 10 years experience in PN design. Participants were frequently responsible for more than one practice area with 70% identifying surgery, 62% medicine, 51% critical care, 12% pediatrics and 6% 'Other' as their clinical practice area(s). The majority of dietitians (85%) participated in the design of the electrolyte composition of the PN prescription, 46% as a collaborative activity. The collaboration was with a physician or surgeon (20%), a physician or surgeon and a pharmacist (15%), or a pharmacist (11%). Thirty-nine percent of the survey participants reported that the design of the electrolyte composition of the PN prescription was the responsibility of the dietitian as a non-collaborative activity. Conclusions: The majority of dietitians participated in the design of the electrolyte composition of the PN prescription, either alone or in collaboration with other healthcare team members. These results emphasize the need to ensure that dietitians have access to educational opportunities that promote competence and confidence in PN electrolyte design and management.


T27 - Total Parenteral Nutrition Using Fish Oil-containing Combination Intravenous Lipid Emulsion in a Patient with High Inflammatory Burden. Joseph E. Cruz, PharmD, BCPS2; GaEun Joung, PharmD, BCPS2; Emily Kim, MS, RD, CNSC1 1Food and Nutrition, Englewood Hospital and Medical Center, Englewood, NJ; 2Pharmacy, Englewood Hospital and Medical Center, Englewood, NJ

Purpose: Introduction: A fish oil-containing combination intravenous lipid emulsion was approved by the FDA and made available for use during July 2016 in the United States. This product, smoflipid, contains 30% soybean oil (ω-6), 30% medium-chain triglycerides, 25% olive oil (ω-9), and 15% fish oil (ω-3), and is currently the only available FDA-approved alternative to the soy-based 18-carbon ω-6 intravenous lipid emulsion, (SO ILE). Meta-analysis and clinical studies have shown significant decreases in length of stay (LOS), lower rates of infection, improved fatty acid profiles, reduced inflammatory makers, and relative cost effectiveness when combination intravenous lipid emulsions are used in select patient populations. Description: A 55-year old patient with endoscopic retrograde cholangiopancreatography (ERCP)-induced pancreatitis, was re-admitted to our institution approximately one month following their procedure due to an elevation in white blood cell count and extensive peripancreatic phelgmonous inflammation and collections. The patient underwent laparotomy, cholecystectomy, and debridements for necrotic collections. Due to the extensiveness of the disease, the patient required two subsequent procedures and was intubated for several days. The patient also required placement of multiple drains due to presence of intra-abdominal collections and was treated with broad-spectrum intravenous antibiotics. A 2-in-1 total parenteral nutrition (TPN) therapy was started via peripherally inserted central catheter, using smoflipid, on Day 5 of hospital admission. The choice to utilize smoflipid in place of the more commonly used SO ILE was based on the patient’s theoretical high inflammatory state due to her post-ERCP pancreatitis with necrotic collections. Results: The patient’s total LOS was 57 days, of which, 24 days were spent in the intensive care unit. After 46 total days of TPN (Day 5 through Day 50), the patient was transitioned to tube feeds, and eventually, food alone. The patient received an average of 0.54 g/kg/day of smoflipid during their treatment course. The total duration of therapy with smoflipid was 45 days (lipids from TPN were held on Day 22 while a propofol continuous infusion was used for sedation in the intensive care unit). Hepatic panel, triglycerides, and prealbumin were collected throughout the hospital course to monitor for the effects of smoflipid (See


Table 1). Prealbumin levels increased following TPN therapy indicating improvement in nutritional status and reduced inflammation. Liver enzyme measurements remained consistent throughout the hospital stay, with AST/ALT and total bilirubin levels within normal limits at all times, and mild elevations in alkaline phosphatase that began prior to TPN therapy and persisted beyond transition to enteral nutrition. Glycemic control was well maintained with all but one point of care glucose readings ≤ 150 mg/dL and a hemoglobin A1C of 5% noted prior to discharge. Conclusions: We report a case report of a complicated patient with a high-inflammatory burden who had their nutritional needs successfully managed with TPN using smoflipid for 45 days. The patient had notable triglyceride tolerance, stable liver function tests, and was able to eventually transition to a regular diet after making a clinical recovery. It is theorized that smoflipid may confer anti-inflammatory benefits due to the inclusion of ω-3 fatty acids as a portion of the delivered energy source. Further studies in patients with high inflammatory burdens will be required to determine if any additional clinical impact can be derived from this unique fatty acid composition, but smoflipid remains a viable therapeutic option in patients who need nutritional supplementation with lipid emulsion while receiving TPN. Methods: N/A Results: N/A Conclusions: N/A


Table 1. Laboratory Values During Hospital Stay/TPN Therapy

Day

0 Day

2 Day

4 Day

6 Day 10

Day 17

Day 21

Day 22

Day 26

Day 33

Day 40

Day 41

Day 49

Day 51

Day 53

Pre-albumin (mg/dL)

5.8 8.4 8.3 7.0 6.6 6.7 7.2 14.1 14.7

Albumin (g/dL) 2.6 2.3 2.0 2.0 1.7 1.8 2.3 2.1 2.3 2.2 2.4

Total Protein (g/dL)

6.1 5.3 5.1 5.1 4.2 3.7 4.6 4.9 5.6 5.4 5.8

Alkaline Phosphatase

(Units/L) 138 101 174 114 78 49 77 154 208 190 192

AST (Units/L) 40 24 30 26 34 16 15 23 19 21 17

ALT (Units/L) 40 37 40 46 44 31 23 36 30 31 27

Bilirubin, Total (mg/dL)

0.5 0.3 0.3 0.2 0.6 0.6 0.4 0.4 0.2 0.2 0.2

Triglyceride (mg/dL)

151 150 213 159 192 143 207 156

T28 - Analysis of macronutrients in adult parenteral nutrition (PN) orders compared to published guidelines in an acute care hospital Tugba Bayrak, Graduate Student2; Heidi Kiehl, MS, RDN, CNSD3; Colette LaSalle, RD, PhD1 1Nutrition, Food Science & Packaging, San Jose State University, San Jose, CA; 2Nutrition, Food Science and Packaging, San Jose State University, San Jose, CA; 3Clinical Nutrition Services, Santa Clara Valley Medical Center, Santa Clara, CA

Purpose: The purpose of this study is to assess any discrepancy of macronutrients in an adult PN prescription written by a medical doctor (MD) and recommendations written by a registered dietitian (RD)


from the current A.S.P.E.N. guidelines and to compare some of serum markers before and after PN initiation. Methods: Retrospectively, this study uses data from electronic health records of patients receiving PN from October 2015 to October 2016. The amounts of dextrose, amino acid, IVFE, percentage of non-protein calories (NPC) and total volume in MD order and RD recommendations are compared with each other and the current guidelines of A.S.P.E.N. Also, blood glucose, serum potassium, serum phosphorous serum magnesium and BUN are compared before and after PN initiation. Results: Sixty-four patients’ PN orders and RD recommendations are analyzed (Average age=58 years old, average PN duration=15 days). 55.6% of patients are admitted to surgical unit. 75% of the patients have received only PN. The prescribed amount of dextrose (g/kg & mg/kg/min), and NPC (%) are significantly higher in MD order (P= .000, .000, and .000, respectively). Contrarily, the given amount of amino acid, IVFE and total volume are not significantly different in MD order vs. RD recommendations (P= .766 & .658). Similarly, RD recommendations follow the guidelines closer than the MD orders in terms of dextrose (g/kg & mg/kg/min), amino acids, and percentage of non-protein calories (P= .001, .004, .045, and .000, respectively). Furthermore, the mean value of blood glucose is significantly higher while the mean values of serum potassium and serum phosphorous are significantly lower after PN initiation (P=.000, .019, and .000). However, the mean values of BUN and serum magnesium have not changed significantly after PN (P= .629 and .150). Conclusions: Macronutrients in adult PN orders written by MD are less likely close to the guidelines while macronutrients in adult PN recommendations by RDs are more likely to follow the guidelines in an acute care hospital.


T29 - Octreotide treatment in parenteral nutrition (PN) for a hospitalized pediatric patient with uncontrolled secretory diarrhea Khang Tran, M43; Kyle J. Hampson, Pharm.D., CNSC2; Joel Lim, MD1 1Department of Gastroenterology, Hepatology, and Nutrition, Childrens Mercy Kansas City, Kansas City, MO; 2Department of Pharmacy, Children's Mercy Kansas City, Kansas City, MO; 3Kansas City University of Medicine and Biosciences, Kansas City, MO

Purpose: Secretory diarrhea occurs secondary to infection or an inflammatory process and is characterized by large stool or ostomy losses. The large stool volume is due to the presence of a stimulating substance (secretin, bacterial toxins, or unabsorbed dietary fat) in the gastrointestinal tract. Besides adequate rehydration, controlling output from diarrhea is imperative to maintaining appropriate fluid and nutrition status. Methods: Traditional agents used to treat diarrhea include loperamide and cholestyramine. Adverse effects of these medications, like toxic megacolon secondary to reduced motility in the setting of infection and bowel obstruction limit the use of these medications in inflammatory diseases of the bowel. Here we present a case where Octreotide was incorporated in the parenteral nutrition regimen to control diarrhea. Results: Our patient is a 3-year-old PN-dependent male who presented with ongoing diarrhea/increased ostomy output. He has a complicated past medical history with suspected underlying inflammatory process within the gastrointestinal tract and immunodeficiency with multiple recurrent infections including histoplasmosis, candidemia, and haemophilus influenzae. He had a colonic perforation status post repair with ileostomy. He was also hospitalized previously for dehydration from increased ostomy output. Upon presentation, his output was above 60mL/kg. Interventions to control ostomy output with steroids, metronidazole, and nil per os status (NPO) had proven ineffective. However, his condition improved significantly with octreotide (fig 1.) with a decreased and stabilized ostomy output (goal ostomy output is below 40 mL/kg/day). We provided the patient with a 1mcg/kg octreotide bolus, which was followed by administration of 24mcg/kg/day of octreotide as an additive in continuous parenteral nutrition and lipid solution.


Octreotide, a somatostatin analog, works to reduce the production of gastrointestinal hormones that promote gastrointestinal secretions and motility, like secretin, gastrin, motilin, and vasoactive-intestinal peptide (VIP). By reducing these hormones, octreotide can help control secretory diarrhea. The addition of octreotide in parenteral nutrition/lipid solutions remains controversial, especially in the pediatric population, due to its compatibility and difficulty with dose titration. Octreotide has a narrow therapeutic index and requires close monitoring for optimal effect. Therefore, although octreotide can have a favorable effect on controlling secretory diarrhea, its compatibility profile and complex dosing limit its use clinically. Conclusions: Persistent secretory diarrhea is a challenging clinical scenario in the setting of inflammatory intestinal disease. Octreotide may be a useful therapeutic option for this pathology and can be safely administered to pediatric patients in their parenteral nutrition regimen.




T30 - A Potential Role for an Alternative Intravenous Lipid Emulsion for Nausea Management in the Home Nutrition Support Consumer: An Expanded Case Study. Jill W. Taliaferro, RD, CNSC.; Karen Ackerman, MS, RD, CNSC.; Deborah Pfister, MS, RD, CNSC, ThriveRx, Attleboro, MA

Purpose: Introduction: During patient interviews, a subset of our home parenteral nutrition (HPN) consumers reported a direct correlation between increased nausea and administration of a soy based intravenous lipid emulsion (ILE). The severity of these symptoms appeared to further reduce oral tolerance requiring a reduction in lipid volume, which resulted in weight loss and essential fatty acid deficiency. With the availability of an alternative ILE composed of fish, soy, olive and MCT oils, a trial was initiated to evaluate whether use of this ILE with a lower soy concentration would reduce nausea in these HPN consumers. S.T. has been on HPN for four and a half years due to GI dysmotility with gastroparesis. Historically, she reported reduced oral intake following her infusion of a soy-based ILE at a dose of 1g/kg administered twice weekly as a part of a 3:1 nutrient admixture infused over twelve hours. In an attempt to minimize GI symptoms, S.T. was initiated on a 1.5 g/kg dose of the alternative ILE, according to product dosing recommendation. No reduction in her earlier reported symptoms of nausea and GI fullness were reported. All ILE was held for four months and then the alternative ILE was then instituted at a lower dose of 1g/kg. At this dose, S.T. reported a moderate improvement in GI symptoms and she was again able to meet her calculated essential fatty acid requirements from a combination of diet and alternative source ILE. Based on this observation, three additional consumers with diagnoses of GI dysmotility were trialed on a 1 g/kg dose of the alternative ILE. All three consumers reported decreased nausea as compared to the same dose of a soy-based ILE. Methods: N/A Results: N/A Conclusions: Although this observation represents only very small population, it suggests that a low dose alternative intravenous lipid emulsion with a balanced lipid profile, may be helpful for those who experience nausea with the traditional soy based ILE.


T31 - Collaboration Between Digestive Disease Center and Home Nutrition<br /> Support Team: Model to Optimize Patient Outcomes Gabriela Gardner, RDN-AP, LD, CNSC2; Karen A. Martin, MA,RDN,LD,FAND4,1 1Neurology, UT Health, San Antonio, TX; 2Clinical Nutrition, Memorial Hermann Hospital - TMC, Houston, TX; 4Amerita Specialty Infusion, San Antonio, TX

Purpose: Demonstrate the value of collaboration amongst health care providers (HCP) and nutrition support team (NST) to optimize patient outcomes with parenteral nutrition (PN) therapy. Enhance efforts/strategies to identify risk and minimize complications, such as refeeding syndrome, and maximize participation in activities of daily living (ADL’s.) Methods: Our paper describes a model of proactive collaboration between HCP at a Digestive Disease Center (DDC) and the NST at an infusion company. HPN therapy patients are referred to infusion company by HCP. NST at infusion company assists with home health services, provision of HPN, intravenous (IV) medications, additives, and other HPN supplies.


The dietitian at the DDC, discusses care with prescribing physician, facilitates orders, monitors labs, and performs nutrition evaluation during clinic visits. Collaboration includes discussion of anthropometric and laboratory data, course of care, management of IV access, macro and micronutrient interventions, and other medications. Results: PATIENT A: acid/base imbalances, lack of adequate home health Prior to collaboration model: patient was experiencing chronic metabolic acidosis, lacked home health services leading to emergency room visits, and frequent antibiotic use due to frequent line infections. Using the NST and HCP model; blood work monitoring allowed normalization of acid/base balance by adding of oral sodium citrate, switching to a tunneled central venous catheter (CVC), initiation of iron therapy, as well as thorough line care education to patient & caretaker resulting in reduction of central line infections. PATIENT B: optimized parenteral nutrition (PN) formulation by using mixed lipid injectable emulsion (ILE) Prior to collaboration model: Patient on same HPN formulation, underweight status, chronic kidney disease, abnormal LFTs and hypertriglyceridemia with poor tolerance to soybean oil lipid emulsion. Using the NST and HCP model: PN was optimized and switched to mixed ILE (soybean, medium-chain triglycerides, olive oil, and fish oil), which allowed increased caloric provision resulting in improved nutritional status. PATIENT C: Safe home start with refeeding syndrome risk 36 year old woman with chronic malnutrition, Crohn’s disease, and history of line infections, who required PN for pre-surgical nutrition optimization. Using the NST and HCP model: patient was safely started on HPN without any metabolic complications. PN was progressed slowly with frequent monitoring of labs. Glucose testing supplies were provided by the infusion provider to better monitor glycemic response. A tunneled catheter was recommended due to history of line infections. Use of a mixed ILE to minimize inflammatory response. Conclusions: Our model demonstrates that collaboration between HCP and a NST helps to improve clinical outcomes and promote patient safety. Variability of involvement by infusion companies does a disservice to patients and does not facilitate optimal nutrition, with the preference always being for the least invasive therapeutic option. Lack of collaboration when managing HPN patients can impact quality of care and compromise patient safety.




T32 - Effect of total parenteral nutrition therapy in palliative gastrojejunostomy status patients Myoung Won Son, MD PhD2; Young Gil Kim, MD3; Dong Hee Jo, MD5; Dong Hyun Kang, MD2; Geum Jong Song, MD2; Moo-Jun Baek, MD PhD1; Moon Soo Lee, MD PhD4 1Surgery, Soonchunhyang University Hospital, Cheonan, Korea (the Republic of); 2Soonchunhyang University Cheonan Hospital, Cheonan, Korea , Cheonan, Korea (the Republic of)

Purpose: Gastric outlet obstruction (GOO) is a common problem associated with advanced malignancies of the upper gastrointestinal tract. Adverse events such as malnutrition can affect quality of life, and gastrojejunostomy can be performed for palliative care. This study evaluated effect of total parenteral nutrition (TPN) therapy in post-operation state patients underwent palliative gastrojejunostomy (PGJ). Methods: Between January 2011 and June 2015, a total of 65 patients underwent PGJ at Soonchunhyang University Cheonan Hospital and all consecutive patients were included in this retrospective study. All patients were divided into preoperative TPN group and non-TPN group. Nutritional status assessment included body weight (BW), body mass index (BMI), CRP level, serum albumin, serum total protein, hemoglobin, and total lymphocyte count (TLC). Results: Thirty-one patients did not receive TPN treatment, and 34 patients received TPN treatment before surgery. There was a significant difference between preoperative and postoperative BW, BMI, CRP level, serum albumin, serum total protein, hemoglobin, and TLC in non-TPN group. But, we found that there was no significant difference between preoperative BW, BMI, TLC and postoperative BW, BMI, TLC in the TPN group (p=0.914, p=0.873, p=0.319). Conclusions: Our study results suggested that preoperative TPN therapy has an effect of improving nutritional status inpatients underwent PGJ.


T33 - Safety First! Improving TPN Stability and Safety at Home. Lindsey Haffke, MS, RD, LMNT, LD, CNSC; Candace Embree, PharmD; Erin Henrickson, PharmD; Sarah Thompson, PharmD; Krista Miller, RN, CRNI CHI , Papillion, NE


Purpose: There is limited data to support the use of 3-in-1 formulations as the standard TPN formulation used in adults. A.S.P.E.N.’s Clinical Guidelines have noted that 3-in-1 formulas have less risk of contamination during administration, potential cost savings, and compounding efficiency but are at higher risk for destabilization and medication incompatibility, particularly in home TPN patients. In an effort to maximize the safety of home TPN and educate patients on TPN stability, a handout was created, mailed to, and discussed with each home TPN patient. A team of pharmacists, a nutrition support dietitian, and a regional clinical manager determined a company-wide need to educate home TPN patients on safety and stability of TPN. Commonly asked questions by patients and families were included in the handout. Answers were based on current research, including A.S.P.E.N.’s clinical guidelines and safety recommendations. Four different TPN images from RxKinetics© illustrating stability concerns of cracking, creaming, aggregation, and coalescence were included in the handout after being granted permission to use the images for educational purposes. Image 1 represents the commonly asked questions. Image 2 represents the TPN stability images to alert patients of any potential TPN stability issues prior to infusing at home. Each home TPN patient was mailed this TPN Fact Sheet handout. Pharmacists reviewed stability and counseled patients about changes in TPN consistency and referred to the images in the handout. After ten months, from September 2016 through July 2017, no reported issues occurred with TPN stability based on weekly assessments completed by pharmacists with each home TPN patient. In addition, a progress note was developed by a Director of Operations and a nutrition support dietitian outlining the stability of the TPN and if any changes were needed or made to improve stability. This progress note was documented in each patient’s chart and updated each time a change was made to the TPN with potential to affect stability. There are several factors that contribute to TPN stability, including nutrient concentration, storage conditions, light exposure, and refrigeration. Home infusion providers of TPN must guarantee electrolytes and macronutrients are stable. Research has noted formulations may not be stable for more than 30 hours at room temperature and coalescence is not immediate, which makes the beyond-use dating and refrigeration even more imperative for home infusion. A potential solution to stability is using multi-chamber bags, which may reduce the risk for unstable TPN formulations. In the home care setting, patients and caregivers require extensive training on proper mixing of the multi-chamber bags. This company has decided to continue providing 3-in-1 formulations. Further educational resources and data needs to be collected and published to increase the safety and stability of home TPN formulations. Methods: N/A. Results: N/A. Conclusions: N/A.





Critical Care and Other Critical Health Issues T34 - Obesity attenuates serum 25-OH vitamin D response to cholecalciferol therapy in critically ill patients. Whitney L. Holmes, PharmD1; Malcolm D. Earle, PharmD student2; George O. Maish, MD3; Gayle Minard, MD4; Martin A. Croce, MD5; Roland N. Dickerson, PharmD2 1Regional One Health, Memphis, TN; 2Clinical Pharmacy and Translational Research, University of Tennessee, Memphis, TN; 3Surgery, University of Tennessee, Memphis, TN

Purpose: Vitamin D deficiency has been associated with worsened clinical outcomes in critically ill patients. The presence of obesity may confound dosing due to potential fat depot sequestration and decreased bioavailability. The purpose of this study was to evaluate the efficacy and safety of a fixed cholecalciferol dosage in vitamin D deficient critically ill trauma patients with and without obesity. Methods: Adult patients (>17 y of age), admitted to the trauma intensive care unit (ICU) and referred to the Nutrition Support Service (NSS) for enteral nutrition (EN) were retrospectively evaluated. A serum 25-OH vitamin D concentration (25-OH vit D) and ionized calcium concentration (iCa) was obtained initially and then weekly. Measurement of 25-OH vit D was conducted via automated chemiluminescent microparticle immunoassay (detection limit of 8 ng/mL and inter-assay CV of 4.8%). Patients who had a 25-OH vit D < 20 ng/mL were prescribed cholecalciferol liquid 10,000 IU per tube daily. Cholecalciferol therapy was discontinued when: a normal 25-OH vit D (30 to 80 ng/mL) was achieved, the patient was discharged from the ICU, EN was discontinued, the iCa was > 1.32 mmol/L, or when NSS signed off the patient case. Patients who had < 2 serial 25-OH vit D measurements, or received parenteral nutrition (PN) > 10 days were excluded from study entry. Efficacy of cholecalciferol therapy was defined as achievement of a normal 25-OH vit D (30 to 80 ng/mL). Safety of cholecalciferol was evaluated by the presence of hypercalcemia (iCa > 1.32 mmol/L), severe hypercalcemia (iCa > 1.49 mmol/L), or a 25-OH vit D > 80 ng/mL. Continuous data were expressed as mean ± SD. Differences between groups were assessed using the student t-test or Mann Whitney U test. Nominal data were analyzed using χ2 or Fisher Exact test. Two-way ANOVA was used for comparing serial 25-OH vit D determinations over time between groups. Results: Fifty-three (18 obese, 35 non-obese) patients were identified for study. Patient characteristics were similar between groups (Table 1). Despite a similar baseline 25-OH vit D, 25-OH vit D response was significantly attenuated for those with obesity when compared to those without obesity (Figure 1, P < 0.001). Patients with obesity were less likely to achieve target 25-OH vit D concentrations compared to those without obesity (Table 2; 28% vs 57%, respectively, P = 0.082). Patients with obesity tended to experience less hypercalcemia (22% vs. 49% of patients, P = 0.119) and severe hypercalcemia (0% vs. 11% of patients, P = 0.543). No patients developed hypervitaminosis D (25-OH vit D > 80 ng/mL). Conclusions: Obese patients exhibited an attenuated serum 25-OH vitamin D response to cholecalciferol therapy when compared to non-obese patients. Hypercalcemia was twice as prevalent in non-obese patients compared to those with obesity. Obesity alters the pharmacokinetic and pharmacodynamic response to cholecalciferol therapy in vitamin D deficient, critically ill trauma patients.


Table 1. Patient demographics

Variable Obese

(BMI ≥ 30) Non-obese (BMI < 30)

P ≤

N 18 35 -

Sex, Male/Female, n/n 12/6 24/11 0.865


Race African American, n

Caucasian, n Hispanic/other, n

8 9 1

15 18 2

0.994

Age, y 44 ± 15 41 ± 14 0.433

Traumatic brain injury, n 9 (50%) 22 (63%) 0.545

BMI, kg/m2 37.4 ± 7.0 24.3 ± 2.9 0.001

Weight, kg 111 ± 17 76 ± 11 0.001

ETOH history, n 5 (28%) 6 (17%) 0.478

Sepsis, n 10 (56%) 21 (60%) 0.987

WBC, cells/mm3 17.5 ± 5.2 17.6 ± 8.9 0.599

Tmax (oC) 38.4 ± 0.7 37.7 ± 1.2 0.024

Serum C-reactive protein, mg/dL 26.8 ± 4.1 22.3 ± 11.3 0.240

Serum prealbumin, mg/dL 7.1 ± 3.6 8.2 ± 4.2 0.293

Serum albumin, g/dL 2.4 ± 0.2 2.4 ± 0.3 0.517

Serum phosphorus, mg/dL 3.7 ± 1.0 3.5 ± 0.8 0.454

Serum magnesium, mg/dL 2.1 ± 0.2 2.1 ± 0.3 0.290

Serum creatinine, mg/dL 0.9 ± 0.2 0.8 ± 0.2 0.006

Serum urea nitrogen, mg/dL 15 ± 6 13 ± 5 0.584

Hospital mortality, n 2 (11%) 2 (6%) 0.598

BMI, body mass index; d, days; GSW, gunshot wound; KSW, knife stab wound; EN, enteral nutrition; EtOH, ethanol; MVC, motor vehicle crash; n, number of patients; PN, parenteral nutrition; Tmax, maximum temperature WBC, white blood cell count Table 2. Vitamin D and calcium response

N Obese

(BMI ≥ 30)

Non-Obese

(BMI < 30) P ≤

N 18 35 -

EN/EN+PN, n/n 13/5 33/2 0.030

Hospital day EN or PN started, d 3 ± 2 3 ± 2 0.640

Hospital day cholecalciferol started, d 6 ± 2 7 ± 5 0.864

Cholecalciferol duration, d 15 ± 5 12 ± 5 0.046

Patients who achieved normal serum 25-OH vit D within 2 weeks of observation, n

5 (28%) 20 (57%) 0.082

Initial serum iCa, mmol/L 1.17 ± 0.05

1.19 ± 0.06

0.350

Maximum iCa, mmol/L 1.28 ± 0.09

1.31 ± 0.09

0.270

Hospital day of maximum iCa, d 18 ± 8 16 ± 6 0.317

25-OH vit D, 25-hydroxy vitamin D; d, days; EN, enteral nutrition; iCa, ionized calcium concentration; n,


number; PN, parenteral nutrition

Figure 1. Impact of obesity upon serial serum 25-OH vitamin D concentrations during cholecalciferol therapy (p < 0.001). *P < 0.01 between groups. T35 - Evaluation of daily cholecalciferol therapy for critically ill patients with vitamin D deficiency. Whitney L. Holmes, PharmD1; Malcolm D. Earle, PharmD student2; George O. Maish, MD3; Gayle Minard, MD3; Martin A. Croce, MD3; Roland N. Dickerson, PharmD2 1Regional One Health, Memphis, TN; 2Clinical Pharmacy and Translational Research, University of Tennessee, Memphis, TN; 3Surgery, University of Tennessee, Memphis, TN

Purpose: Vitamin D deficiency has been associated with worsened clinical outcomes. One study indicated that mortality was improved without hypercalcemia when a 540,000 IU dose of cholecalciferol was given to severely vitamin D depleted critically ill patients. The purpose of this study was to evaluate the efficacy and safety of smaller daily cholecalciferol doses in critically ill, vitamin D deficient trauma patients. Methods: Adult patients (>17 y of age), admitted to the trauma intensive care unit (ICU) and referred to the Nutrition Support Service (NSS) for continuous enteral nutrition (EN) were retrospectively evaluated. A serum 25-OH vitamin D concentration (25-OH vit D) and ionized calcium concentration (iCa) was obtained initially and then weekly. Measurement of 25-OH vit D was conducted via automated chemiluminescent microparticle immunoassay (detection limit of 8 ng/mL and inter-assay CV of 4.8%). Patients who had a 25-OH vit D < 20 ng/mL but > 13 ng/mL were identified as experiencing deficiency; those with a 25-OH vit D < 13 ng/mL were categorized as severely deficient. Vitamin D deficient patients


were prescribed cholecalciferol liquid 10,000 IU per tube daily. Cholecalciferol was discontinued when: a normal 25-OH vit D (30 to 80 ng/mL) was achieved, the patient was discharged from the ICU, EN was discontinued, the iCa was > 1.32 mmol/L, or when NSS signed off the patient case. Patients who had < 2 serial 25-OH vit D measurements or received parenteral nutrition (PN) > 10 days were excluded from study entry. Efficacy was defined as achievement of a normal 25-OH vit D (30 to 80 ng/mL). Safety was evaluated by the presence of hypercalcemia (iCa > 1.32 mmol/L), severe hypercalcemia (iCa > 1.49 mmol/L), or hypervitaminosis D (a 25-OH vit D > 80 ng/mL). Continuous data were expressed as mean ± SD. Differences between groups were assessed using the student t-test or Mann Whitney U test. Nominal data were analyzed using χ2 or Fisher Exact test. Two-way ANOVA was used for comparing serial 25-OH vit D determinations over time between groups. Results: Fifty-three patients (29 severely deficient, 24 deficient) were identified (Table 1). A significant increase in 25-OH vit D was observed; however, only 25 patients (47%) achieved a normal serum 25-OH vit D (Figure 1) after two weeks of therapy. No patients developed hypervitaminosis D. Twenty-one patients (40%) experienced hypercalcemia and 2 patients (4%) exhibited severe hypercalcemia. Both deficiency groups paralleled each other in serum 25-OH vit D response with lower concentrations overall for those with severe deficiency (P < 0.001; Figure 2). Prevalence of hypercalcemia was similar between severe and non-severe deficiency groups (45% vs. 33%, respectively, P = 0.569; Table 2). Conclusions: A normal 25-OH vit D was achieved in half of the patients after two weeks of cholecalciferol therapy. However, hypercalcemia occurred in 40% of patients with similar rates observed between deficiency severity groups. The high incidence of hypercalcemia warrants caution for routine use of 10,000 IU of cholecalciferol daily in vitamin D deficient trauma patients receiving nutrition support therapy.


Table 1. Patient demographics

Variable Severely Deficient Deficient P ≤

N 29 24 -

Sex, Male/Female, n/n 18/11 18/6 0.479

Race African American, n

Caucasian, n Hispanic/Other, n

17 10 2

6 17 1

0.030

Age, y 46 ± 15 38 ± 13 0.051

Admission diagnosis MVC, n

GSW/KSW, n Fall/Assault/Other, n

23 4 2

16 2 6

0.175

Traumatic brain injury, n (%) 14 (48%) 17 (71%) 0.168

BMI, kg/m2 29.5 ± 8.5 27.9 ± 7.0 0.491

Weight, kg 87 ± 21 88 ± 23 0.865

EtOH history, n(%) 10 (34%) 1 (4%) 0.008

Hospital mortality, n (%) 1 (3%) 3 (13%) 0.318

Sepsis, n (%) 17 (59%) 14 (58%) 0.796

WBC, cells/mm3 17.0 ± 6.8 18.3 ± 9.0 0.950

Tmax, oC 37.9 ± 0.7 37.9 ± 1.5 0.416

Serum C-reactive protein, mg/dL 22.3 ± 9.6 25.5 ± 9.7 0.239

Serum prealbumin, mg/dL 6.8 ± 3.2 9.1 ± 4.7 0.055


Serum albumin, g/dL 2.4 ± 0.3 2.5 ± 0.3 0.875

Serum phosphorus, mg/dL 3.7 ± 0.8 3.4 ± 1.0 0.252

Serum magnesium, mg/dL 2.1 ± 0.3 2.1 ± 0.2 0.848

Serum creatinine, mg/dL 0.8 ± 0.2 0.8 ± 0.2 0.596

Serum urea nitrogen, mg/dL 14 ± 6 15 ± 2 0.429

BMI, body mass index; d, days; GSW, gunshot wound; KSW, knife stab wound; EN, enteral nutrition; EtOH, ethanol; MVC, motor vehicle crash; n, number of patients; PN, parenteral nutrition; Tmax, maximum temperature WBC, white blood cell count Table 2. Vitamin D, nutrition, and calcium response

Variable Severely Deficient

Deficient P ≤

N 29 24 -

EN/EN+PN, n/n 26/3 20/4 0.688

Hospital day EN/PN started, d 3 ± 1 3 ± 2 0.941

Hospital day cholecalciferol started, d 7 ± 4 7 ± 4 0.950

Cholecalciferol duration, d 13 ± 5 12 ± 5 0.465

Patients who achieved normal serum 25-OH vit D within the 2 week observation, n (%)

12 (41%) 13 (54%) 0.514

Initial serum iCa, mmol/L 1.19 ± 0.06 1.23 ± 0.24

0.699

Maximum iCa, mmol/L 1.34 ± 0.09 1.30 ± 0.09

0.830

Hospital day of maximum iCa, d 18 ± 7 16 ± 7 0.319

25-OH vit D, 25-hydroxy vitamin D; d, days; EN, enteral nutrition; iCa, ionized calcium concentration; n, number; PN, parenteral nutrition


Figure 1. Serum 25-OH vitamin D response to cholecalciferol in all patients (n = 53; P < 0.001). Each time observation is significantly different from each other (P < 0.001).


Figure 2. Comparison of serum 25-OH vitamin D response to cholecalciferol in severely vitamin D deficient (25-OH vitamin D concentration < 13 ng/mL) and deficient (25-OH vitamin D concentration < 20 ng/mL and > 13 ng/mL) patients (P < 0.001). *indicates P < 0.05 between deficiency groups. T36 - Improving Nutritional Delivery in Trauma Patients Through Elimination of Gastric Residual Assessments Phillip Prest, DO, FACOS2; Jessica A. Justice, RD, LD, CNSC1; Aaron Moore, MD1; Mona Rabieh, RN, BSN1; Mark Jones, MD, FACS3; Christopher M. Watson, MD, FACS4; Raymond Bynoe, MD, FACS1 1Division of Trauma, Palmetto Health USC Medical Group, Columbia , SC; 2Division of Trauma, Palmetto Health USC Medical Group, Columbia, SC

Purpose: Study the effect of elimination of routine gastric residual volume (GRV) assessments in critically ill trauma patients on nutrient delivery, morbidity, and mortality. Methods: We retrospectively reviewed trauma patients in an ICU at a Level 1 trauma center comparing cohorts before and after implementation of a revised policy for GRV assessments. The new policy eliminated GRV assessments unless intolerance of enteral feeds was noted. The primary endpoint was achieving 80% of prescribed nutrient goals. The secondary endpoints were hospital acquired infection, hospital length of stay, ICU length of stay, all-cause in-hospital mortality, length of mechanical ventilation, and gastric residual volumes and interruptions. We analyzed the groups utilizing Fischer Exact test and Wilcoxon-Rank sum test. Demographics and Injury Severity Score (ISS) were assessed using T-test and Chi-square. Results: A total of 326 patients were included. There was no statistical difference in regards to age or gender between the cohorts; there was statistical significance between ISS scores (p=0.003). The post-


implementation (n=164) patients maintained 80% of caloric and protein needs more often (54.3 vs 40.7%, p=0.05), had feeds held for less time (1.5 vs 3.7h/day, p =0.012), had decreased STICU LOS (13 vs 16d, p=0.02), shorter mechanical ventilation days (11 vs 16d, p<0.001), and trended towards less hospital-acquired infections (36.6 vs 46.9%, p=0.072), compared with the pre-implementation group (n=162). Conclusions: The elimination of GRV assessments appears to improve nutrition delivery, and trends towards improved hospital infections and shorter mechanical ventilation days.


Table 1

GRV Checks No GRV Checks p value

Age (mean years) 46 48 p = 0.224

Male/Female (%) 74 / 26 71 / 29 p = 0.583

ISS (mean) 20 24 p = 0.0025

Table 1 includes the demographics between the cohorts. A t-test was used for age and ISS with statistical significance noted at p = 0.05. A chi-square test was used for gender with statistical significance at p = 0.05. Table 2

GRV

Checks No GRV Checks

p-value

Calories Provided (80% mean) 40.7 54.3 0.015

Protein Provided (% of patients that maintained 80% of prescribed protein throughout ICU stay)

40.7 53.7 0.02

Met 80% of prescribed nutrient needs by 48 hours of ICU admission 63 69.5 0.0242

Highest Gastric Residual (mean, cc) 171.8 163.5 0.017

Enteral nutrition holds (mean, h/day) 3.69 1.46 0.012

Inappropriate holds of enteral nutrition (mean, %) 18.5 9.1 0.016

Hospital-acquired infections (mean, %) 46.9 36.6 0.072

Hospital LOS (mean, d) 37.7 35.2 0.12

STICU LOS (mean, d) 16.3 13.4 0.02

Mechanical Ventilation (mean, d) 16.2 11.9 <0.001

All-cause in-hospital mortality (%) 9.3 18.9 0.016

Table 2 demonstrates the nutrition outcomes, gastric residuals, and hospital outcomes between the non-routine GRV checks and the routine GRV checks. The Fisher's exact test was used in the analysis of contingency tables for nutrition outcomes (p=0.05). The average highest GRV and the average time nutrition was held were analyzed with the Wilcoxon Rank-Sum test (p<0.001). The percentage of inappropriate holds on enteral nutrition due to residual amounts was analyzed with the Fisher's exact test. Hospital acquired infections and all-cause in-hospital mortality were analyzed with the Fisher's exact test. Average hospital length, average STICU length of stay, and days of mechanical ventilation were analyzed with the Wilcoxon Rank-Sum test. T37 - Clinical Factors Impacting Admission Rates During Radiation Treatment for Head and Neck Cancer Patients. Marisa Mozer, MS, RD, CSO, CNSC 2; Sarah Peterson, PhD, RD, CNSC1; Diane Sowa, MBA, RD3


1Clinical Nutrition, Rush University Medical Center, Chicago , IL; 2Food and Nutrition Services, Rush University Medical Center, Chicago, IL

Purpose: Malnutrition is common in head and neck cancer (HNC) patients due to tumor burden and treatment-related side effects; poor nutritional status impacts up to 40% of patients prior to treatment. Malnutrition is independently associated with treatment delays, cancer recurrence, readmission rates, and mortality. The objective of this quality improvement study was to determine the association between nutritional status and clinical variables with admission rates during radiation treatment for HNC patients. Methods: All HNC patients who received radiation treatment from 2015-2017 and had completed treatment three months prior to data collection were included (n=151). Demographic (age, gender), nutritional status (BMI, weight loss prior and during treatment, type of feeding tube [FT, defined as prophylactic: placed prior to/within two weeks of starting treatment, or reactive: placed during treatment due to clinical worsening associated with lack of oral intake, weight loss, and dysphagia]) and clinical variables (site of cancer, staging [categorized as T1/T2 versus T3/T4 tumor size], and regional lymph node involvement [categorized as N0/N1 versus N2/N3], treatment modality [defined as radiation with surgery versus chemotherapy or a combination of treatments]) were collected. Admission rate was defined as any admission encounter during their treatment course; admission for a planned FT was not included as this was an anticipated admission. Admission was categorized into a dichotomous variable (one or more admits versus none). Chi square analysis and logistic regression were used to identify clinical variables that predicted admissions during radiation treatment. Results: Patients were 61 + 12 years old, mostly overweight/obese (72%, average BMI of 28 + 7), and male (68%). Patients lost an average of 6% of usual body weight during the 6-7 week treatment. The type of tube placed varied: 15% received a prophylactic tube, 16% reactive tube, and 69% did not have a tube placed during treatment. A total of 38 patients were admitted during treatment. Admission was associated with >6% weight loss (27 [71.1%] vs 11 [28.9%], p=0.01), larger tumor size (29 [76.3%] vs 9 [23.7%], p<0.01), regional lymph node involvement (25 [60.5%] vs. 15 [39.5%], p=0.04), and receiving both chemotherapy/radiation (37 [97.4%] vs 1 [2.6%], p<0.01). Additionally, patients who received a reactive FT were more likely to be admitted (reactive FT 47% vs prophylactic FT 26% vs no FT 26%, p<0.01). A logistic regression identified that patients who had a large tumor size (T3/T4) (OR 7.7 95% CI 2.9-20.4, p<0.01) and a reactive feeding tube (OR 12.4 95% CI 4.1-37.7 p<0.01) were more likely to be admitted during radiation treatment. Conclusions: Based on these predictive factors, HNC clinicians can better identify who will likely be admitted during treatment and take proactive measures to prevent undernutrition.


T38 - MALNUTRITION IS STILL A BIG PROBLEM IN ONCOLOGY CLINICS: RESULTS FROM 1000 PATIENTS Derya Hopanci Bicakli, PhD, RD1; Ahmet Ozveren, MD1; Ozge Kucukerdonmez, PhD, RD2; Kubilay Demirag, MD3; Ruchan Uslu, MD1; Erdem Goker, MD1 1Medical Oncology, Ege University School of Medicine, Izmir, Turkey; 2Nutrition and Dietetics, Ege University School of Medical Sciences, Izmir, Turkey; 3Department of Anesthesia and Critical Care, Ege University School of Medicine, Izmir, Turkey

Purpose: Although the importance of the nutritional screening and assessment of cancer patients has been well established, the nutritional status of those patients is not sufficiently evaluated in the routine oncology practice. The primary aim of this study is to investigate the prevalence of malnutrition among cancer patients admitted to the oncology outpatient clinic. The secondary aim is to determine the association of the nutritional condition of the patients with their performance status and presence of symptoms. Methods: A total of 1000 consecutive patients who admitted to the medical oncology outpatient clinic for


chemotherapy or follow-up were included in this prospective study. The nutritional assessments of those patients were performed by patient generated-subjective global assessment (PG-SGA) scale. Eastern Cooperative Oncology Group Performance Status (ECOG) score of those patients was also been evaluated prospectively. The association between the presence of two or more symptoms, which can affect nutrition of the patients, and malnutrition status has been analyzed. Results: Of the patients, 651 (65.1%) were female and 349 (34.9%) were male; with median ages of 55 (min:20-max:87) and 60 (min:18-max:83) years, respectively. The diagnoses of the patients were breast cancer (n=358), colorectal cancer (n=140), gynecological cancer (n=92), hepatopancreatobiliary cancer (n=80), esophageal-gastric cancer (n=75), lung cancer (n=42), melanoma (n=36), sarcoma (n=31), head-neck cancers (n=30), bladder cancer (n=22), prostate cancer (n=21) and other (n=73). PG-SGA nutritional assessment categories were 0-1 points, 2-3 points, 4-8 points and ≥9 points in 134 (13.4%), 333 (33.3%), 323 (32.3%) and 210 (21%) patients, respectively. Malnutrition was most commonly detected among patients with head-neck (86.7%), hepatopancreatobiliary (77.6%) and esophageal-gastric cancer (76%). The ECOG scores of the patients with malnutrition were significantly lower (p<0.01).There was a positive correlation between having 2 or more symptoms and malnutrition status (p<0.01). Conclusions: The frequency of malnutrition among oncology patients was found to be high based on PG-SGA. The ECOG performance status was impaired with the deterioration of the nutritional status. The presence of 2 or more symptoms had a detrimental effect on the nutritional status. Patients who have a high risk of malnutrition should be monitored closely and nutritional interventions should be performed on time when needed.


Table 1. The distribution of the patients according to demographic and cancer related characteristics

n %

Gender

Female 651 65,1

Male 349 34,9

Primary tumor

Breast 358 35,8

Colorectal 140 14

Gynecological 92 9,2

Hepatopancreatobiliary 80 8

Esophagogastric 75 7,5

Lung 42 4,2

Melanoma 36 3,6

Sarcoma 31 3,1

Head-neck 30 3

Bladder 22 2,2

Prostate 21 2,1

Others 73 7,3

Presence of at least 1 concomitant chronic disease

Yes 444 44,4

No 556 55,6

Previous surgery


Present 785 78,5

Absent 215 21,5

Chemotherapy

Receiving 697 69,7

Not receiving 303 30,3

Chemotherapy line count (n=697)

Neo-adjuvant/adjuvant 181 26

1st line 220 31,6

2nd or up 296 42,4

Table 2. The distribution of the patients according to their PG-SGA categories

PGSGA 0-1

%(n) PGSGA 2-3

%(n) PGSGA 4-8

%(n) PGSGA ≥9

%(n) Total %(n)

Head-neck 0 (0) 13,3 (4) 30 (9) 56,7 (17) 100 (30)

Esophageal-gastric 5,3 (4) 18,7 (14) 26,7 (20) 49,3 (37) 100 (75)

Hepatopancreatobiliary 5 (4) 17,5 (14) 38,8 (31) 38,8 (31) 100 (80)

Prostate 9,5 (2) 33,3 (7) 28,6 (6) 28,6 (6) 100 (21)

Lung 19 (8) 16,7 (7) 40,5 (17) 23,8 (10) 100 (42)

Urinary bladder 0 (0) 31,8 (7) 45,5 (10) 22,7 (5) 100 (22)

Colorectal 13,6 (19) 34,3 (48) 32,1 (45) 20 (28) 100 (140)

Melanoma 11,1 (4) 33,3 (12) 36,1 (13) 19,4 (7) 100 (36)

Gynecological 17,4 (16) 32,6 (30) 33,7 (31) 16,3 (15) 100 (92)

Sarcoma 12,9 (4) 38,7 (12) 32,3 (10) 16,1 (5) 100 (31)

Breast 17,6 (63) 43,3 (155) 29,6 (106) 9,5 (34) 100 (358)

Others 13,7 (10) 31,5 (23) 34,2 (25) 20,5 (15) 100 (73)

Total 13,4 (134) 33,3 (333) 32,3 (323) 21 (210) 100 (100)

p<0.01


T39 - Beneficial effects of early initiation of enteral nutrition on clinical outcomes in critically ill patients Takae Tsujimoto, RPh, PhD1; Ryosuke Kai, BS 1; Mai Ikemura, PhD1; Ryutaro Seo, MD2; Koichi Ariyoshi, MD, PhD2; Toru Hashida, PhD3; Noriaki Kume, MD, PhD1 1Kobe Gakuin University, Kobe, Japan; 2Emergency Department, Kobe City Medical Center General Hospital, Kobe, Japan; 3Department of Pharmacy, Kobe City Medical Center General Hospital, Kobe, Japan

Purpose: Early nutrition is recommended for critically ill patients. The 2016 Critical Care Guidelines published by ASPEN recommended initiation of enteral nutrition (EN), rather than parenteral nutrition(PN), within 24−48 hours following the onset of critical illness and admission to the ICU. In addition, the guidelines also recommend to make efforts to provide more than 80% of estimated or calculated goal energy and protein within 48–72 hours in order to achieve the clinical benefit of EN over the first week of hospitalization. However, according to the International Nutrition Survey (INS) in 2014, the average time of the EN support initiation was 52 hours in Japan. Some ICUs still have difficulties in the early initiation of EN support, and the required calorie intake goal achievement rate was as low as 50% at 6 days after hospitalization. The purpose of this study, therefore, is to confirm the beneficial impacts of early initiation of EN on clinical outcomes in critically ill patients in Japan. Methods: We retrospectively reviewed the medical records of adult patients who were admitted to the Traumatology and Acute Critical Care Center of Kobe City Medical Center General Hospital between January 1st and December 31st in 2015. One hundred sixty one patients, who met the inclusion criteria, were enrolled in this study. The patients were divided into two groups: those who underwent EN within 48 hours after the admission to the EICU (Group A), and those in whom EN were initiated at more than 48 hours after the admission to the EICU (Group B). The primary end point was 30 day mortality. We also assessed the duration of hospital stay, new onset of infectious diseases, and percent fulfilment of the required calorie intake. Results: One hundred sixty one patients (median age: 71 years, range: 20-90 years, male/female: 93 [57.9%]/68 [42.2%]) were enrolled, and the average APACHE II score was 21.7±7.4. There was no significant difference in 30 day mortality (17.8% versus 16.7%) or incidence of the new onset of infectious diseases (47.5% versus 48.3%) between the groups A and B, respectively. However, the duration of


hospital stay in group A (38.3 ± 25.0 days) was significantly (p = 0.047) shorter than that in group B (46.0 ± 28.0 days). The time from EICU admission to initiation of EN was positively and significantly correlated to the duration of hospital stay (R = 0.156, p = 0.049) and ICU stay (R = 0.162, p = 0.040). Furthermore, percentage fulfilment of the required calorie intake at 6 days after admission was significantly (p = 0.018) higher in group A (87.1 ± 0.9%) than in group B (54.2 ± 0.5%). Conclusions: The early initiation of EN within 48 hours after the admission improves clinical outcomes, such as duration of the hospital stay and the nutritional status, in critically ill patients.


T40 - The Relationship Between Vasoactive and Inotropic Support, Tube Feeding, and Ischemic Gut Complications in Postop Cardiac Surgery Patients. Patricia Brown, RD-AP, CNSC1; Chin S. Ong, MBBS1; Pooja Yesantharao, MS 1; Xun Zhou, MD1; Joseph K. Canner, MHS2; Munirih Quinlan, RD, LDN, CNSC1; Evan Brown, BS 1; Marc Sussman, MD1; Glenn J. Whitman, MD1 1Division of Cardiac Surgery, Johns Hopkins Hospital , Baltimore, MD; 2Division of Surgery, Johns Hopkins Hospital , Baltimore, MD

Purpose: Metabolic stress induced by tube feeding (TF) may be associated with ischemic gut complications. Vasoactive and inotropic support (VIS) may further exacerbate malperfusion. To better understand this relationship in postop cardiac surgery patients (CSP) requiring TF, we sought to describe


a) the effect of VIS on the manner in which we deliver TF, and b) to determine its relationship with ischemic gut complications. Methods: We reviewed CSP (n=3125) at a single institution, from December 2014 to June 2017, and a) examined the manner TF was administered as it related to VIS (defined as: 0 = No support, Low = epinephrine in mcg/kg/min, or its equivalent < 0.05, Moderate = 0.05 to < 0.1, and High ≥ 0.1), b) evaluated CSP for ischemic gut complications (IGCx), and c) related diffuse IGCx with TF. Results: Of all CSP, a total of 249 patients (8%) required TF, allowing an evaluation of 1548 total TF-days (Table 1). With increasing VIS, there was decreased rates of TF administered per day, increased numbers of hours TF held, decreased rates of TF when administered, and a decreased percentage of calorie goal met (p < 0.0001). VIS was associated with decreased intact formula use, but not TF location, gastric vs post-pyloric (see Table 1). There were 11 of 3125 CSP with IGCx (0.4%), with a mortality of 72% (see Table 2). Of the 3 receiving TF, two IGCx were focal, consistent with acute embolus, while one IGCx was diffuse, on maximal VIS with an intra-aortic balloon pump. 1 of 249 (0.4% TF) vs 3 of 2876 (0.1% non-TF) had diffuse IGCx, inconsistent with embolus (p=0.28). Conclusions: In postop cardiac surgery patients, 8% required nutrition support with TF. In this series, increasing VIS led to a) decreased TF rate, b) decreased intact formula use, and c) lower percent calorie goal met. Location of delivery was unaffected by VIS. Despite 32% of TF-days on moderate to high VIS, IGCx incidence was not increased compared to the non-TF patients. As performed in this study, nutrition support requiring tube feeds in postop cardiac surgery patients, even those requiring moderate to high vasoactive and inotropic support, was not associated with an increased rate of ischemic gut complications.

Financial Support received from: Abbott Nutrition

T41 - Correlation between energy-protein adequacy and clinical outcome in critically ill patients


Mayumi Shima, RD; Silvia M. Piovacari, RD; Giovanna Lopes, RD; Ana Carolina V. Alvarenga, MD; Evandro J. Figueiredo, MD; Andreia Pardini, MS ; João Silva Jr, MD; Diogo O. Toledo, MD Hospital Israelita Albert Einstein, São Paulo, Brazil

Purpose: Energy-protein adequacy in the first 72 hours of hospitalization is a difficult task. Patients may be underfeeding in relation to their energy and protein requirements and to provoke a negative nitrogen balance, loss of muscle mass and worse prognosis. Therefore, the purpose of this study was to correlate nutritional adequacy on the third day of nutrition therapy in the intensive care unit (ICU) with the clinical outcome. Methods: We performed a retrospective, observational study in the ICU of a tertiary hospital. Patients admitted from April to July 2017 were included, age > 18 years old, with enteral nutrition (EN) or parenteral nutrition and received at least 72 hours of nutrition in the ICU. Demographic data collected were: age, sex, weight, body mass index (BMI), simplified acute physiology score 3 (SAPS 3), energy-protein adequacy and clinical outcome (hospital discharge and death). We compared patients who received 100% of energy and protein goal versus who were unable to receive within 72 hours (100% of goal target of 25 kcal/Kg/day and 1.2 g/Kg/day of protein). Results: A total of 71 patients were included, mostly female (52.1%), age of 74.0 years (± 17.5) and BMI of 24.7kg / m2(± 5.2), and SAPS 3 of 58.7 (±13.3). Of these, 58 patients (81.7%) were hospital discharge and 13 (18.3%) died, 22 (31%) had energy-protein adequacy, 32 (45%) had only protein adequacy, 28 (39.4%) had only energy adequacy. The average of calories received was 22.5 Kcal/Kg/day (± 7.5) and 1.13g protein/Kg/day (± 0.4), and regarding the energy and protein adequacy, it was noted that the nonsurvivors patients received lower goal protein (1.06 ± 0.54 versus 1.15 ± 0.39g/kg/day) and lower goal caloric (21.5 ± 9.2 versus 22.7 ± 7.2 kcal /Kg/day). Patients who received 100% of energy-protein adequacy had lower mortality than patients who did not (13.6% versus 20.4%). The same was observed in patients that received only 100% of protein target (12.5% versus 23.1% of mortality) and those that received only 100% of the energy target (14.3% versus 20.9% of mortality). There were no differences between patients who received adequate nutritional goal or not in relation to SAPS 3, age and BMI. Conclusions: Nutritional goal was observed in 31% of the patients. Those patients were too much high risk because high value of SAPS 3. Mortality was higher in patients who did not reach the adequate energy-protein goal target.


Table 1: General characteristics by group.

Variables Survivors (n=58) Nonsurvivors n=(13)

SAPS 3, mean (SD) 58,2 (±12,1) 60,6 (±18)

Age (years),mean (SD) 73 (±18) 81 (±18)

BMI (Kg/ m2) ,mean (SD) 25,00(±5,57) 23,62(±3,42)

Calories received (Kcal/Kg/d), mean (SD) 22,7 (±7,2) 21,5 (±9,2)

Protein received (g/Kg/d), mean (SD) 1,15 (±0,39) 1,06 (±0,54)

<100% energy-protein adequacy, n (%) 41 (70,69) 10 (76,92)

>100% energy-protein adequacy, n(%) 17 (29,31) 3 (23,08)

SD: standard deviation T42 - High Prevalence of Malnutrition and Sarcopenia in Newly Diagnosed Cancer Patients in Turkey: Multicenter, Cross-Sectional Study


Cafer BALCI, MD1; Gülnihal Tufan, MD2; Nuriye Ozdemir, MD, Assoc. Prof.3; Sercan Aksoy, MD, Prof.4; Omur Berna Oksuzoglu, MD, Prof.2; Nurullah Zengin, MD, Prof.3; Ayse Kars, MD, Prof.4; Meltem Halil, MD, Prof.1 1Internal Medicine Division of Geriatrics, HACETTEPE UNIVERSITY, Ankara, Turkey; 2Oncology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey; 3Oncology, Ankara Numune Training and Research Hospital, Ankara, Turkey; 4Internal Medicine Division of Oncology, HACETTEPE UNIVERSITY, Ankara, Turkey

Purpose: Clinical care of the cancer patients mostly focuses on the medical management with less attention on disease related malnutrition and sarcopenia that even exist at the time of the diagnosis. Both sarcopenia and malnutrition are frequent in cancer patients and are associated with treatment related toxicity, decline in quality of life and reduced survival. The aim of this study was to examine the prevalence of sarcopenia and malnutrition in patients with newly diagnosed cancer. Methods: A total of 115 patients with newly diagnosed cancer who were admitted to oncology outpatient clinics in three different tertiary hospital were enrolled. Patients were diagnosed with one of the following 22 different types of malignant tumors: lung cancer, gastric cancer, colorectal cancer, liver cancer, pancreatic cancer, esophageal cancer, breast cancer, cervical cancer, endometrial cancer, nasopharyngeal carcinoma, malignant lymphoma, ovarian cancer, prostate cancer, bladder cancer, brain tumor, laryngeal cancer, malignant melanoma, renal cell carcinoma, thyroid cancer, synovial cell carcinoma, biliary tract malignant tumors and gastric stromal tumors. Nutritional status of the patients was assessed using Patient-Generated Subjective Global Assessment (PG-SGA) and Malnutrition Universal Screening Tool (MUST) tool. Demographics, clinical characteristics, anthropometric and biochemical parameters were recorded. Body composition was evaluated by bioelectrical impedance (BIA), strength was assessed by hand grip dynamometer and the physical performance was determined by the 6-meter walking speed. Sarcopenia was defined as low muscle mass, with either the presence of low grip strength or low physical performance. Results: Our study consists of 67 male patients (58.3%) and 48 female (41.7%) with mean age of 59.5 ± 11.4 years and average BMI of 26.7 ± 5.2 kg/m2 . Although the mean BMI values of the participants were not low, 28 (24.3%) of 115 patients had low muscle mass, 47 (40.9%) of 115 patients had low hand grip strength and 81 (70.4%) of 115 patients had low gait speed. Other characteristics of the participants were shown in Table 1. According to the PG-SGA and MUST 31.3% and 44.3% of the participants were classified as severely malnourished while 28.7% and 18.3% were classified as moderately malnourished, respectively. Total scores of the both screening tools were statistically different between normal and malnourished patients. Sarcopenia was observed in 20% (n=23) of the participants. Conclusions: Malnutrition and sarcopenia in cancer patients are a big concern. According to our results one-fifth of patients had sarcopenia and more than half of the patients were malnourished at the time of cancer diagnosis. In our study we demonstrate that despite the normal BMI value, malnutrition and sarcopenia are relatively high in cancer patients. It is known that, timely nutrition interventions prior to the initiation and during cancer therapy is beneficial to reduce the cytotoxic effects and associated complications. Incorporating early nutritional screening to oncology routine clinical practice to identify the malnourished patients with cancer prior to the initiation of cancer treatment is essential.



T43 - Evaluation of fluid retention during acute postoperative period using multi-frequency bioimpedance analysis. Ryoji Fukushima, MD, PhD; Tsuyoshi Inaba, MD, PhD Surgery, Teikyo University School of Medicine, Tokyo, Japan

Purpose: Measurement of body water is beneficial for postoperative fluid management however standard measurement technique of body water after surgery has not been established. Multi-frequency bioimpedance analysis (MF-BIA) is an inexpensive, noninvasive, easy to use, and portable technique to measure body water, and may be suitable for postoperative use. However, the reliability of MF-BIA during the acute postoperative period has not been established. The purpose of this study was to validate MF-BIA for measurement of body water during the acute postoperative period. Methods: Study 1: Total body water (TBW) was measured in ten patients who underwent upper GI surgery using both MF-BIA (MLT-100, Sekisui Chemical Co., Tokyo) and deuterium oxide (D2O) dilution method on postoperative day (POD) 1 and 3. Study 2: Postoperative TBW, extracellular fluid (ECF), intracellular fluid (ICF) and fat free mass (FFM) was determined by MF-BIA in various types of upper GI surgery in 96 patients and comparison among the surgical procedures was performed. The surgical procedures were esophagectomy (Group-E), total gastrectomy (Group-T), distal gastrectomy (Group-D), segmental gastrectomy (Group-S), proximal gastrectomy (Group-P) and laparoscopic distal gastrectomy (Group-L). Results:


Study 1: TBW determined by isotope dilution and MF-BIA was 36.60±1.55kg and 36.16±1.58kg, respectively. The difference between the two methods was small and the results of the two methods strongly correlated (p<0.001, r=0.966)(Fig 1). Study 2: Overall TBW/FFM was increased on POD 1 from the preoperative level; however, it had decreased again to the preoperative level on POD 3. ECF/FFM was also increased on POD 1. ECF/FFM was still high on POD 3; however, it had decreased again to the preoperative level on POD 5 (Fig 2). ICF/FFM was decreased on POD 1 but had increased again on POD 3. The increase in ECF from preoperative day to POD 1 positively correlated with intraoperative blood loss, operative time and the amount of infusion. TBW and ECF retentions measured by MF-BIA after surgery were greater after major invasive surgical procedures than after mild surgical stress (Fig 3). Conclusions: MF-BIA measurement is a simple and reliable method to determine the postoperative body water. Utilization of MF-BIA for postoperative fluid management seems to be promising.




ECF/FFM in Group-E, Group-T, and Group-P on POD 1 was significantly higher than that in Group-D, Group-S, and Group-L ($ p=0.0183 vs. Group-D, p=0.0040 vs. Group-S, and p=0.0052 vs. Group-L, $$ p=0.0416 vs. Group-D, p=0.0082 vs. Group-S, and p=0.0106 vs. Group-L, $$$ p=0.0361 vs. Group-D, p=0.0069 vs. Group-S, and p=0.0079 vs. Group-L). T44 - Teduglutide, a new tool in the pediatric intestinal rehabilitation repertoire. Report of the first case in Latin-America. Maria I. Martinez, MD; Adriana Fernandez, MD; Gabriel Gondolesi, MD; Carolina Rumbo, MD Intestinal Rehabilitation and Intestinal Transplant Unit, Hospital Universitario Fundacion Favaloro, Buenos Aires, Argentina

Purpose: BACKGROUND: Intestinal adaptation is the natural process that occurs in the early period after an intestinal resection. It implies the interaction of endocrine, anatomical and motility processes with the common aim of enhancing the intestinal absorption. When the intestinal length is too short or the intestinal anatomy is not favourable, the patient remains dependent on parenteral nutrition (PN). Surgical and medical rehabilitation techniques aid to potentate the natural adaptation process. Glucagon-like peptide-2 is an intestinal hormone naturally produced by the intestinal endocrine L cells that has specific trophic effects on the small and large intestine. Teduglutide, an analogue of glucagon-like peptide 2, has been recently incorporated as part of the medical armament to improve the intestinal adaptation process. AIM: To present the first case in Latin-America of a pediatric patient with short bowel syndrome and intestinal failure treated with Teduglutide. CASE: This a boy full term delivered with intestinal atresia type IIIa. He had intestinal surgery on the second day of life; the remnant intestine was composed of 20 cm of jejunum anastomosed to 3 cm of ileum with ileocecal valve and the whole colon. He underwent three other surgeries due to intestinal


obstruction and suffered from several catheter-related bloodstream infections. At 10 months of age a STEP procedure was performed reaching 86 cm of small bowel. At 11 months of age, he was sent home on parenteral and enteral nutrition, no oral foods due to oral aversion. He was readmitted several times due to line sepsis and required several catheter replacements complicated with central veins thromboses. When he was 3 years of age, he was referred to this Center. Due to small bowel dilation, recurrent Gram-negative bacteria sepsis and failure to advance enteral feeds, a re-STEP procedure was performed reaching a small bowel length of 133 cm. With intense medical management, PN was progressively tapered to 3 days/week in two opportunities, but the patient didn’t tolerated it evidencing weight loss and electrolyte disturbances. He was placed on PN 6 days/week. He developed central vein thrombosis, with further loss of accesses and was placed on the intestinal transplant waiting list with a femoral catheter as the last conventional central access available. BMI/A was -0.69, and H/A – 2.42. At that point Teduglutide was approved in Europe to be used in pediatric patients and offered to this patient in Argentina as an orphan drug. When this treatment was started, the patient was 6 years old, BMI/A was 0.27 and H/A -3.19. The protocol consisted of a daily dose of 0.05 mg/kg subcutaneously. No adverse effects, local or systemic reactions occurred. Enteral tolerance and diarrhea progressively improved. Enteral feedings were increased and PN progressively decreased paired with weight and height progression. PN was discontinued 25 weeks after starting treatment. BMI/A was 0.94 y H/A -2.68. The central catheter was electively removed 8 weeks after discontinuing PN. The patient has maintained his nutritional status (BMI/A 0.81; H/A -2.55) and the laboratory values are within the normal range. He currently continues on daily treatment with Teduglutide, week 34. Conclusion: From our perspective Teduglutide is a treatment option that can be offered to selected intestinal failure patients that could not achieve intestinal adaptation using other medical and surgical strategies. Larger groups of patients are needed to better define the timing of the Teduglutide indication and its long-term effects on pediatric patients. Methods: N/A Results: N/A Conclusions: N/A


ENCORE ABSTRACT Pending acceptance to the American Society of Transplant Surgeons Winter Symposium, Jan. 11-14, 2018. Jane Lee, MD, PhD; Mignote Yilma, MS; Douglas Farmer, MD. Barriers to Adequate Nutritional Support in Critically Ill End Stage Liver Disease Candidates and Recipients: A Single Institution Experience. Am J Transplant. 2018; 18 (suppl 2) T45 - Barriers to Adequate Nutritional Support in Critically Ill End Stage Liver Disease Candidates and Recipients: A Single Institution Experience. Jane Lee, MD., PhD; Mignote Yilma, MS ; Douglas Farmer, MD Surgery, David Geffen School of Medicine, UCLA, Los Angeles, CA

Purpose: Malnutrition is present in 22-43% of all hospitalized patients. The risk of malnutrition is higher in critically ill patients in the intensive care unit (ICU). Furthermore, malnutrition is inherent in ESLD/cirrhotic patients as the liver is the largest metabolically active organ in the body and its derangement involves abnormalities in energy storage and regulation via various endogenous and exogenous biochemical processes. (O'Brian & Williams, 2008). The combination of critically ill ICU patients with ESLD presents a major nutritional challenge, which is under-studied and poorly understood. Methods: A retrospective chart review identified 82 critically ill patients with ESLD in a tertiary care ICU dedicated to the care of pre- and post-liver transplant (LT) patients (LICU) staying for greater than 14 days between January and June of 2018. Data collection included type and route of nutritional support, liver transplant status (pre- or post-LT), MELD score, SOFA score, calorie intake, and total number and type of nutrition interruption (NI). This study categorized NI as undetermined, GI, intra-ICU, extra-ICU, and airway (intubation, extubation). Statistical analysis included ANOVA and chi square test as appropriate using Statistical Package for the Social Science Software.


Results: Out of 82 patients, 47 were on oral (PO) diets and 35 patients were on either EN (enteral nutrition) or TPN (total parenteral nutrition) diet. In the PO GROUP: 28 (43.1%) were pre-LT and 19 (29.2%) were post-LT. The mean length of time to initiate PO diet was 47 hours (SD 26.05) in pre-LT and 96.2 hours (SD 37.74) in post-LT. Calorie counts were largely incomplete and inaccurate, and overall there is insufficient data for analysis. In the EN/TPN GROUP: 19 (54.3%) were pre-LT and 16 (45.7%) were post-LT. The mean length of time to initiate EN/TPN in pre-LT patients is 50.67 hours (SD 31.41) vs 96.92 hours (SD 40.45) in post-LT patients. The average daily calorie intake during Week 1 is 796.42 kcal/day (SD = 562.2 (<10% recommended calories)) while it was 1474.5 kcal/day (SD 472.6 (50% recommended calories)) for Week 2. During Week 1, 34.3% were on TPN, 45.7% on EN, and 20% on a combination of both. 54.3% experienced NI (34.3% undetermined, 8.6% GI events, 5.7% intra-ICU procedures, and 2.9% extra-ICU procedures). Only 5.7% of patients met their caloric goal by the end of Week 1. During Week 2, 28.6% were on TPN, 54.3% on EN, and 17.1% on a combination of both. 85.7% experienced NI (37.1% undetermined, 17.1% GI events, 11.4% intra-ICU procedures, and 5.7% airway manipulation). Only 20% of patients met their caloric goal by the end of Week 2. The mean SOFA score on Day 0 was 12.14 (SD = 6.24) and there was no correlation between daily calorie intake and SOFA score. A positive statistical correlation was found between the time delay to start nutrition and the number of NI in Week 1 (p = 0.008); however, no similar correlation was seen Week 2. Conclusions: Based on this retrospective chart review of patients on EN/TPN in the LICU, we conclude that the majority of patients in this population: are underfed, have frequent NI, and have a delay in nutrition initiation. However, despite NIs, caloric support increased from week 1 to 2 but the majority of patients failed to meet nutritional goals. While poor nutritional support did not affect obviously early outcome, we remain concerned over the long-term impact of inadequate nutritional support. Overall, there was no statistically significant single barrier to nutrition identified in this evaluation. This study highlights the shortcomings in nutritional support that can occur in the LICU setting and represents a mechanism to begin process improvements.


Liver Disease Etiology

Type of Disease Patient Number Percentage

NASH 9 24.3

Alcohol 6 16.2

Hepatitis C 5 13.5

Hepatitis B 3 8.1

Cryptogenic 3 8.1

Fulminant 2 5.4

Autoimmune 2 5.4

NASH + Autoimmune 1 2.7

HepC + Alcohol 1 2.7

Small Bowel Ca 1 2.7

Esophageal Ca 1 2.7

Hemochromatosis 1 2.7

HepC + Liver Ca 1 2.7

Polycystic Liver Disease 1 2.7

Total 37 100

Liver etiology demographic data presented above correlates with the current prevalence of indications for liver transplant in the United States. NASH being the most common, followed by alcoholic liver disease


and hepatitis C virus related liver disease. Causes of Nutritional Interruptions (NI)

Categories Description of NI Week 1 (%) Week 2 (%)

Not Specified not well documented 34.3 37.1

GI abnormal NGT outputs, NGT displacements 8.6 17.1

Intra-ICU central line placement and removal 5.7 11.4

Extra-ICU radiological and surgical procedures 2.7 0

Airway intubations, extubations, repositioning of ETTs 0 12.1

Uninterrupted no documented NI 48.5 22.3

Many nutritional interruptions occur which are not well documented; however, of the documented causes of NI, GI events largely related to NGT issues is the most common but not statistically significant in both Week 1 and Week 2.


Graph A shows the percentage of TPN/EN patients in detail for Week 1 and Graph B for Week 2. Graph C shows percentage of patients meeting goal recommended calories for Week 1 and Graph D for Week 2. Only 5.7% meet goal calories in Week 1 and 20% in Week 2.


There is no correlation between clinical status as indicated by SOFA score and average daily calories in Week 2 suggesting that nutrition does not effect early outcomes. T46 - ELDERLY PATIENTS UNDERGONE HEMATOPOIETIC STEM CELL TRANSPLANTATION: BODY COMPOSITION AND ENGRAFTMENT Andrea Z. Pereira, MD, PhD1; Ludmila O. Koch, MD1; Polianna M. Souza, MD1; Andreza F. Ribeiro, MD, PhD1; Nelson Hamerschlak, MD, PhD2 1Oncology and Hematology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil; 2Onco Hematoloty , Hospital Israelita Albert Einstein, Sao Paulo, Brazil

Purpose: Hematopoietic Stem Cell Transplantation (HSCT) in elderly is a brand-new issue. Changes in body composition after HSCT have been the subject of previous studies, however there aren`t many studies in elderly people. Objectives: To evaluate muscle thickness and visceral fat by US; % muscle mass, % fat mass and phase angle by BIA. To correlate body composition with engraftment(EN). Methods: In this prospective study, we evaluated 16 HSCT patients (≥60years) at Hospital Israelita Albert Einstein, São Paulo, Brazil, on their first day of hospitalization, before HSCT and after the EN. The thickness of the right femoral quadriceps muscle (RFQ), measured at 6 cm from the top edge of the patella was measured using ultrasound (US) in B-mode, transversal plane. The visceral fat(VF) was measured in the abdominal region, by the thickness of the fat layer between the linea alba and the anterior wall of the aorta. The % muscle mass (MM), % fat mass(FM) and phase angle(PA) were evaluated by Bioimpedanciometry(BIA). Results: Most patients were men (75%) with a mean age of 64(±5,0 years). We had 50% of autologous


HSCT and 50% allogenic HSCT. The mean time EN was 13(± 4 days). In the baseline, weight was 80(±17 kg), RFQ was 1.8(±0.3 cm) and the VF was 5,5(± 2,0 cm); %MM was 68,5(±11); %FM was 27,5(±7,5); PA was 5,3((±0,7). After EN, weight was 73(±13kg). RFQ was 1.5(±0.3cm) and the VF was 5,0(±2.2cm); %MM was 55,5(±20,5); %FM was 25(±7,0); PA was 7,4(±0,8). There wasn`t significant difference between baseline and after engraftment, although all measurements had reduced in all patients, exception for PA and VF had increased. We found the negative correlation between engraftment and RFQ(rp: -0,6), independently of HSCT type by regression. (rp: -0,6) Conclusions: In this cohort of patients, muscle thickness and mass was reduced, and visceral fat and phase angle was increased after engraftment. The higher muscle thickness correlated faster engraftment.


T47 - ULTRASOUND: A NEW STRATEGY TO EVALUATE BODY COMPOSITION IN CROHN’S PATIENTS UNDERGOING HEMATOPOIETIC STEM CELL TRANSPLANTATION(HSCT) Andrea Z. Pereira, MD, PhD2; Sandra E. Gonçalves, MD2; Bianca L. de Sá, DR3; Marister N. Cocco, PD2; Andreza F. Ribeiro, MD, PhD2; Nelson Hamerschlak, MD, PhD1 1Onco Hematoloty , Hospital Israelita Albert Einstein, Sao Paulo, Brazil; 2Oncology and Hematology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil; 3Nutrition, Hospital Israelita Albert Einstein, S.Paulo, Brazil

Purpose: Crohn disease is a chronic inflammatory disorder of the gastrointestinal tract with a strong polygenic immune component. In refractory cases, autologous HSCT can decrease disease activity and mucosal healing and improve quality of life. Reduced muscular mass and excess visceral fat in patients undergoing HSCT are associated with higher mortality, longer hospitalization, longer use of immunosuppressive drugs, graft-versus-host disease, shorter disease-free interval after the HSCT and comorbidities leading to shorter survival time. Objectives: To evaluate muscle thickness and visceral fat by US. Methods: We evaluated 5 HSCT patients (≥18years) at Hospital Israelita Albert Einstein, São Paulo, Brazil, on their first day of hospitalization, before HSCT and after the engraftment. The thickness of the right femoral quadriceps muscle (RFQ), measured at 6 cm from the top edge of the patella was measured using US in B-mode. The VF was measured in the abdominal region, by the thickness of the fat layer between the linea alba and the anterior wall of the aorta. Results: Most patients were men (75%) with a mean age of 35 years (± 14 years). Most patients were undernutrition, with body mass index (BMI) of 21 kg \ m2 (± 2,5 kg \ m2). The average time EN was 11 days (± 1 days). In the baseline, RFQ was 1.5 cm (± 0.2 cm) and the VF was 4,2 cm (± 1.3 cm). After engrafment, RFQ was 1.3 cm (± 0.2 cm) and the VF was 4,2 cm (± 1.2 cm). There wasn`t significant difference between baseline and after engraftment, although RFQ had reduced in all patients. Conclusions: In this cohort of patients we found reduced muscle thickness after engraftment and VF didn`t have any alterations. The US was a practical, economical and effective method to evaluate these patients.


T48 - The views and practice of oncologists on assessment of nutritional status and provision of nutritional care among cancer patients: A questionnaire-based survey. Mahmut Gumus, Prof. MD1; Turkkan Evrensel, Prof. MD2; Erdem Goker, Prof MD3; Nil Mandel, Prof MD4; Omur Berna C. Oksuzoglu, Prof. MD5; Feyyaz Ozdemir, Prof. MD6; Berksoy Sahin, Prof MD7; Suayib Yalcin, Prof. MD8; Aysugul A. Sarioglu, MD9 1Department of Medical Oncology, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey; 2Deparment of Medical Oncology, Uludag University Faculty of Medicine, Bursa, Turkey; 3Department of Medical Oncology, Ege University Faculty of Medicine, Izmir,


Turkey; 4 Clinic of Medical Oncology, Istanbul Private American Hospital, Istanbul, Turkey; 5Clinic of Medical Oncology, Ankara Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, Ankara, Turkey; 6Department of Medical Oncology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey; 7Department of Medical Oncology, Cukurova University Faculty of Medicine, Adana, Turkey; 8Department of Medical Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey; 9Abbott Nutrition International, Istanbul, Turkey

Purpose: High prevalence and poor prognostic role of malnutrition in cancer patients emphasize the timely recognition and appropriate management of the condition in the oncology setting. This cross-sectional questionnaire-survey was therefore designed to evaluate views and practice of oncologists on assessment of nutritional status and provision of nutritional care among cancer patients. Methods: A total of 107 medical oncology specialists from Turkey were included in this cross-sectional questionnaire survey based on their voluntary participation. A 10-item questionnaire form was applied via face-to-face interview method which elicited data on views of oncologists about the likelihood of nutrition-related problems and potential benefit of nutritional support on treatment outcomes in cancer patients and provision of clinical nutrition as well as their current practice regarding assessment of nutritional status and necessity, timing and indications of prescribing oral nutritional supplements (ONS) in cancer patients. Results: Majority of oncologists confirmed the likelihood of nutritional problems in cancer patients (99.1%) and contribution of nutritional support to better patient outcomes (89.7%). Medical oncologists by 27.5% of participants and dieticians by 11.8% were considered to have a central role per se in provision and monitoring of nutritional care among cancer patients, while 58.8% of oncologists identified necessity of a multidisciplinary team approach involving oncologists with consultation from clinical nutrition specialists. Overall, 76.6% and 83.2% of physicians identified that they perform routine assessment of nutritional status and body weight, respectively. Most of oncologists (82.2%) identified that they prefer to prescribe ONS, via planning the nutritional therapy simultaneously with the initial diagnosis of cancer (46.0%), only in patients with noticeable weight loss (28.0%) or in patients with poor oral intake (23.0%). Body mass index (73.8%), unintentional weight loss (59.8%), noticeable/significant weight loss (58.9%) and blood analysis or tests for markers (pre-albumin, albumin) (43.0%) were the most common diagnostic tools used to assess nutritional status of cancer patients, while use of evidence-based screening tools was identified by 14.0% of oncologists. Reasons for not prescribing ONS (17.8%) were identified as the lack of a role of ONS in cancer treatment (33.3%), ineffective brand reminder activities of pharmaceutical companies (33.3%) and lack of scientific evidence or guidelines in use of ONS in cancer (28.6%). Conclusions: In conclusion, our findings revealed that oncologists acknowledge the prevalence of nutrition related problems and a need for routine assessment of nutritional status in cancer patients as well as the potential contribution of providing adequate nutritional support to better outcome. However, the diagnosis and practice patterns needs to be improved in terms of use of evidence-based malnutrition screening tools, consulting with clinical nutrition specialists in provision and monitoring of nutritional support and appropriate prescribing of ONS. Our findings emphasize the likelihood of continuing effective education for oncologists and developing evidence-based guidelines for optimal nutritional management to increase timely recognition and more effective and extensive management of poor nutritional status among cancer patients.


T49 - Sarcopenia as a predictor of prognosis in patients undergoing pulmonary resection for lung cancer Ryota Nakamura, MD; Satoshi Yoneyama, MD, PhD; Kenji Yuzawa, MD, PhD; Yoshinobu Kobayashi, MD, PhD; Ryo Muto, MD, PhD; Akiho Okada, MD, PhD; Takehito Kato, MD, PhD; Yoshihisa Inage, MD, PhD; Koichi Kozaki, MD, PhD; Toru Terashima, MD, PhD Surgery, National Hospital Organization Mito Medical Center, Ibaraki, Japan


Purpose: Recently, skeletal muscle depletion, referred to as sarcopenia, was identified as a poor outcomes in patients with various malignancies. However, sarcopenia in patients with lung cancer following surgery has not been adequately determined the prognostic significance. This study investigated the impact of sarcopenia in patients undergoing pulmonary resection for lung cancer. Methods: This retrospective study consisted of a total 328 patients with pathological confirmed non-small cell lung cancer who underwent curative intent lung resection between January 2005 and April 2017. Preoperative computed tomography (CT) imaging at the third lumbar vertebrae level was assessed to measure the psoas muscle mass index (PMI, cm2/m2). Sarcopenia was defined as a cutoff value of PMI less than 6.36 cm2/m2 for male and 3.92 cm2/m2 for female, whose cutoff value of PMI were recommended for Asian population. Clinicopathological, surgical outcomes and overall survival were analyzed with or without sarcopenia. Results: Median patient age was 71 years and 59% were male. Sarcopenia was present in 183(55.8%) and significantly related with over age(P<0.001), male(P<0.001), smoking habit(P<0.001), lower body mass index(P<0.001) and postoperative major complication(Clavien Dindo grade ≥3, P<0.001). The 5-year overall survival rate were 61.0% with sarcopenia and 91.0% without sarcopenia. Multivariate analysis revealed that sarcopenia was an independent prognostic factor of poor outcomes(P=0.032). Conclusions: Sarcopenia as determined preoperative CT could be used to predict postoperative major complication and prognosis in patients with surgically resected lung cancer. Further study will clarify to investigate how such therapeutic interventions reverse muscle wasting and improve outcomes.


T50 - Intermittent Gastric Feeds Lower Insulin Requirements in the Critically Ill without Worsening Dysglycemia Tyson J. Sjulin, D.O.1; Richard Strilka, M.D.2 1Pulmonary/Critical Care, San Antonio Miltary Medical Center, San Antonio, TX; 2Trauma, Critical Care, and Acute Care Surgery, University of Cincinnati, Cincinnati, OH

Purpose: Healthy adults have a lower mean glucose concentration (MGC) following intermittent gastric feeds (IGF) when compared to continuous gastric feeds (CGF). Also, a numerical simulation of a small virtual crossover study of critically ill diabetic patients showed that MGC decreased in the IGF arm. We hypothesized that critically ill medical patients treated with an insulin infusion to a glucose goal of 140-180 mg/dl would experience a decrease in insulin requirements, but an increase in maximum glucose and glucose variability (GV), when fed with IGF. Methods: Twenty-one patients treated with an insulin infusion to a glucose goal of 140–180 mg/dl were randomized to receive either IGF or CGF first; IGF was defined as a feed bolus given over one hour. After the enteral feeds were advanced to the goal rate, the patients entered a pre-crossover four-hour data collection period. Next, the types of enteric feeds were switched, and the goal feeds were repeated over another four-hour interval; no data was collected during this time to mitigate “data coupling” between the two crossover arms. Finally, goal enteric feeds were given for a second post-crossover four-hour data collection period. The primary endpoints included the total amount of insulin infused, MGC, the standard deviation of glucose, MGC, hypoglycemic events, and the time-within-range of the glucose. Glucose concentration data were gathered hourly and with a continuous glucose monitor (CGM). Results: Sixteen of the 21 patients successfully completed the protocol, 8 of which had complete glucose data gathered by a CGM. Glucose variability, measured via standard deviation, was similar between the two study arms: p=0.33 from the hourly data and p=0.98 from the CGM data. MGCs were also similar between the arms: p=0.07 from the hourly data and p=0.17 from the CGM data. The total amount of


insulin infused was significantly lower in the IGF arm (p=0.032), while the MGCs were similar: p=0.070 for the hourly glucose data and p=0.37 for the CGM data. Hypoglycemia rates were comparable: one event in the IGF arm and two events in the CGF arm. Finally, the time-within-range for the glucose measurements were also similar (p=0.286 for the hourly glucose data). Of note, there were no complications in the IGF arm. Conclusions: Critically ill medical patients maintained with an insulin infusion to a glucose goal of 140–180 (mg/dl) have a decreased insulin requirement when IGF is used instead of CGF. At the same time, contrary to our hypothesis, dysglcyemia – as measured by MGC, GV, the time-within-range of the glucose, and hypoglycemic events – did not worsen. A larger clinical trial is warranted to confirm these findings.


T51 - Nutritional Adequacy and Outcomes in Critically Ill Cardiac Surgical Patients. Joanne MacNeill, MS, RD 1,3; Etienne Archambault, MD Candidate 2019 University of Ottawa1; Bernard J. McDonald, MD, PhD2; Diem Tran, MD2 1Cardiac Surgical Intensive Care, University of Ottawa Heart Institute, Ottawa, Canada; 2Cardiac Surgical Intensive Care, Division of Cardiac Anesthesia and Critical Care Medicine, University of Ottawa Heart Institute, Ottawa, Canada; 3Nutrition, University of Ottawa Heart Institute, Ottawa, Canada

Purpose: Optimal calorie and protein intake in critical illness and their effect on outcome remains controversial1. Beyond recent observations indicating that cardiac surgical patients are especially at risk for iatrogenic malnutrition2, little is known regarding nutritional adequacy in critically ill cardiac surgical patients. The objective of this study was to examine the relationship between calorie and protein intake on in-hospital outcomes in critically ill cardiac surgery patients, a severely ill group with unique pathophysiologies and therapies. Methods: Following local REB approval, a retrospective chart review was undertaken. All consecutive adult patients who underwent major cardiac surgical procedures at a single centre between July 1, 2012 and December 31, 2015 and who remained alive in the ICU and had not progressed to oral diet by POD 10 were included in the study. We calculated energy delivery over the first 10 ICU days as total delivered from enteral and/or parenteral feeds and from non-nutritional sources and lipids delivered with sedatives. We calculated energy target for patients with BMI < 30 kg/m2 as 25 kcal/kg/d. For obese patients with a BMI >30 kg/m2, the calculated energy target was 23.5 kcal/kg of ideal body weight. Similarly, the protein targets were calculated as follows: BMI < 30 kg/m2 = 1.35 g/kg, BMI 30-40 kg/m2 = 2 g/kg ideal body weight, BMI > 40 kg/m2 = 2.5 g/kg ideal body weight. Logistic regression analyses were then performed to assess the association of 10 day cumulative caloric or protein deficit on in-hospital mortality, our primary outcome. Regression modeling included baseline demographic and surgical predictors as well as physiologic severity of illness score on ICU admission. Results: Over the study period there were 5054 cardiac surgical cases and 206 patients met our inclusion criteria. There were 201 patients who received enteral nutrition and/or 24 patients who received parenteral nutrition. Over the first 10 postoperative days, the mean daily energy intake was 1181 +/- 387 Kcal and average of % caloric goal achieved was 66.5% +/- 21.2%. The mean daily protein intake was 55.6 +/- 20.2 g and average of % protein goal achieved over first 10 days was 49.7% +/- 8.0%. In hospital mortality was 18.4 %, however neither cumulative 10 day caloric or protein deficit was an independent factor for mortality. Conclusions: Post-operative cardiac surgery patients who require prolonged nutritional support in the ICU are severely ill yet at high risk for inadequate nutritional therapy during the initial phase of their critical illness. Nutritional inadequacy was worse for protein versus caloric intake and is a good target for practice improvement. However, nutritional inadequacy was not associated with hospital mortality. Further work needs to be done to identify cardiac surgery patients most likely to benefit from nutritional intervention.



Demographics and Surgical

Age yrs mean(sd) 67.2 (+/-12.7)

Female n(%) 80 (38.8)

BMI median [IQR] 28.2 (24.7,31.8)

Euroscore II median 11.2 [4.8,26.4]

Surgery Type N (%)

CABG 49 (23.8)

CABG &Valve 48 (23.3)

Isolated Valve 24 (11.7)

Multi-Valve 23 (11.2)

Thoracic Aorta 17 (8.3)

LVAD/Transplant 27 (13.1)

Other 18 (8.7)

CASUS POD2 median 13 [10,16]

Clinical Outcomes

In Hospital Mortality n (%) 38 (18.4)

Ventilation hrs median [IQR] 280[187, 559]

ICU stay days median [IQR] 22 [14,38]

Hospital stay days median 41 [28,64]

Renal Replacement Tx n (%) 117 (56.8)

Reintubation n (%) 87 (48.2)

Tracheostomy n (%) 61 (29.8)


Survival Analysis

Survival Analysis


T52 - Phosphate Monitoring and Supplementation during Treatment of Severe Diabetic Ketoacidosis Pavel Tesinsky, MD; Adam Haken, student; Jan Gojda, MD,PhD 3rd Faculty of Medicine, Charles University, Prague, Czechia

Purpose: Hypophosphataemia is a common complication in severe diabetic ketoacidosis (DKA).Clinical manifestations may remain unestimated and include weakness, changes of state of consciousness, and muscle fatigue. The aim of this prospective observational study was to identify the presence of hypophosphataemia in severe diabetic ketoacidosis and to compare the metabolic and clinical state of the patients. Methods: Patients with DKA were monitored within a period of 48 hours after admission. Following parameters were monitored at times 0, 12, 24, and 48 hours: pH, bicarbonate, glycaemia, potassium (K), phosphate (P), CRP, and urinary ketones. Simultaneously, cumulative doses of insulin, energy, fluids, K, and P during treatment were calculated. Results: 113 patients had a diagnosis of DKA out of 3595 patients admitted to the medical ICU between January 1, 2012, and December 31, 2016 (3.14% of all admissions). Out of them, 62 patients with DKA (49 %) had severe hypophosphataemia (less than 0.35 mmol/L), 41 patients (43 %) had mild hypophosphataemia (0.36 – 0.65 mmol/L), and 10 patients (8 %) were normophosphataemic during the treatment. 10 patients required temporary ventilatory support. Mean pH on admission was 7.116 in the whole group, and 7.070 in patiens with severe hypophosphataemia. The lowes pH level was 6.79. The total dose of insulin was 223 IU on average in the severe DKA group in comparison to the mean value of the whole group (189 IU). Fluid delivery war equal in both groups (4750 ml vs. 4719 ml). The total phosphate substitution was 127 mmol vs. 103 mmol. The clinical symptomatology resumed completely in all patients within next 24 hours with suplementation of fluid, energy, K, and P, and compensation of the clinical symptomatology. Conclusions: Despite of the fact that supplementation of phosphate is not routinely recommended during treatment of diabetic ketoacidosis in most current guidelines, we should be aware of the risk of potential hypophosphataemia. The risk appears to be higher with severity of acidosis on admission. Thus, monitoring of serum phosphate level and its supplementation if necessary should be considered.

Financial Support received from: Charles University Institutional Support PROGRES Q36

T53 - Improving Surgical Outcomes in Patients Undergoing Major Gastrointestinal and Gynecologic Surgery with Aggressive Perioperative Immunonutrition Ami Desai, RDN, CNSC, LDN; Garry H. Schwartz, MD; candace Bashaw, RN, OCN, BSN Levine Cancer Institute, Carolinas healthcare system, Mooresville, NC

Purpose: Early recognition of malnutrition and preoperative nutritional status is paramount in improving surgical outcomes. Poor nutrition can be an independent risk factor for postoperative morbidity. Perioperative immunonutrition can modulate favorable immune and inflammatory responses in patients undergoing oncologic surgery. Amino acids, dietary nucleotides, and lipids play a critical role in controlling immune function resulting in decreased surgical site infections, shorter hospital length of stay (LOS) and fewer overall complications. Our purpose was to institutionalize these best practices using a standard protocol for at risk malnourished gastrointestinal (GI)/gynecologic (GYN) cancer surgery patients using an immunonutrient blend product(IBP) to decrease their hospital LOS, post-operative complications and readmission rates. Methods: The population was limited to patients with a new diagnosis of upper/lower GI and GYN malignancies. To deliver a consistent nutritional formula, an immunonutrient blend product (IBP) containing arginine, fish oil, nucleotides and antioxidants was purchased through a hospital research grant. Patients were screened using a standard screen adapted from AND /ASPEN malnutrition


guidelines. If patient met >/= 2 criteria, they received IBP – 500 – 1000 ml per day for 5 days before and 5 days after surgery. Outcome measures were hospital LOS, post-operative complications and readmission rates. Results: Fifty-one patients were screened for malnutrition based on parameters for Ascites (Moderate vs Severe), Edema (+2 vs >/=3), Weight loss (> 5% in 1 m vs >/= 5-10% in 1-3 m), Oral intake (~ 50 % vs <50 %), Facial fat loss/muscle wasting (moderate vs severe) and skin integrity (superficial breakdown vs skin loss). 68 % (N=35) met criteria with >=2 parameters for receiving IBP while 32% did not. Per benchmark data for GYN and GI cancer surgical patients, median LOS is 8.5 days, the average post op complication rate is 27.27% and readmission rate is 14.77 %. In IBP study patients, the median hospital LOS was 5 days, post op complication rate was 26% and readmission rate 8.5%. Of the 32% of patients not receiving IBP and had surgery, median LOS was 6 days, 40% post op complication and 20% readmit rate despite not at risk of malnutrition per screening. The LOS cost analysis based on NIS – HCUP data (2008) for GI surgery reflected an average cost saving of $100,136.48 after including the cost of IBP. The cost analysis was based on the decreased LOS of 1 day in 68 % patients (N=35) with IBP as compared to the remaining 32% not on IBP (median of 5 days’ vs 6 days) using national average of per day hospital cost of $2,948 dollars. Conclusions: Recognizing and treating patients with an immunonutrient blend product who meet criteria for malnutrition can result in reduced hospital length of stay, postoperative complication rates and readmission rates. Utilizing this approach resulted in better patient outcomes and significant cost savings and should serve as the standard of care in the GI/GYN malignancy pre/postoperative setting.

Financial Support received from: Northeast Foundation - Carolinas Health Care System - Concord





T54 - A Systematic Literature Review of Adjuvant Vitamin C in Sepsis. Amber Verdell, PharmD, BCPS, BCNSP, CNSC; Ross Pineda, PharmD candidate; Su Lee, PharmD, MS, BCPS-AQID; Kenneth Lin, PharmD West Coast University - School of Pharmacy, Los Angeles, CA

Purpose: Sepsis is defined as a clinical syndrome causing fatal organ dysfunction as a result of a dysregulated host response to infection, the prevalence of which has increased in the last few decades. Several vitamins and nutrients have been investigated for use in critically ill patients with sepsis. Recently, vitamin C has gained attention as adjuvant therapy for the management of sepsis. We systematically reviewed published literature to evaluate effects, safety, and limitations of vitamin C therapy in sepsis. Methods: A MEDLINE and PubMed search of the English language literature was completed using search terms including any combination of “vitamin C”, “ascorbic acid”, or “ascorbate” alongside “sepsis”


or “septic shock” through July 2017. Studies were included if they evaluated vitamin C, alone or in combination, in patients with sepsis or septic shock and included a control group. Studies that included patients without sepsis were excluded. References from relevant articles were reviewed to locate additional citations. Data extraction was performed by one author and checked by another. Results: Five published articles were found that investigated vitamin C in patients with sepsis. Three of the five utilized other nutrients or drugs as part of the study protocol. All five studies had small patients numbers (range: 24-94 patients). Doses of vitamin C utilized in these studies ranged from 450 milligrams to 6 grams daily. Each of the five studies evaluated different primary outcomes; only one evaluated in-hospital mortality as a primary outcome. Positive effects attributed to vitamin C treatment reported by these studies includes decreased IL-6 concentrations, improved hemodynamic parameters (heart rate, cardiac index, systemic vascular resistance index), decreased vasopressor duration, improved SOFA score, and decreased in-hospital and 28-day mortality. There were no treatment-related adverse events reported in any of the five included studies. There is high heterogeneity in the data reporting and study design of the available literature. Conclusions: The number of studies included in this review show the paucity of published controlled studies of vitamin C in the treatment of sepsis. Caution should be used in interpreting this data until larger randomized controlled trials are published.


T55 - Identification of the patients at risk of refeeding syndrome in surgical ICU Chi-Min Park, MD, PhD3,1; Yeonkyoung Kim, RD2; Jeong-Meen Seo, MD, PhD1; Gee Young Suh, MD, PhD3,4; Miyong Rha, RD2; YoungYun Cho, RD2 1Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (the Republic of); 2Department of Dietetics, Samsung Medical Center, Seoul, Korea (the Republic of); 3Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (the Republic of); 4Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (the Republic of)

Purpose: Refeeding syndrome is a syndrome consisting of metabolic disturbances that can occur when nutrition support is started to patient who are starved or severely malnourished. This syndrome could cause serious complications, however clinicians are often not aware of the problem. The purpose of this study was to analyze the frequency of the patients at risk of developing refeeding syndrome and distribution of the risk factors in the patients admitted to surgical intensive care unit (ICU). Methods: From January to July 2016, 47 patients who were referred to the NST consultation were analyzed at Samsung Medical Center, Seoul, South Korea. The patients at risk of refeeding syndrome were identified based on the criteria from 2006 NICE guideline. The risk factors from guideline were body mass index (BMI), unintentional weight loss in the past 3-6 months, little or no nutritional intake, history of alcohol misuse or drugs, and low levels of potassium, phosphate, or magnesium. We analyzed these risk factors of patients in each high or low risk group. Results: Of the 47 patients, 30 were men (63.8%) and 17 were women (36.2%). The mean age was 63.8 ± 16.1 years. The mean BMI was 23.22 ± 4.22 kg/m2. 17 patients had weight loss and average weight loss was 10.8%. When evaluated according to criteria, 24 patients (51.1%) were at risk of refeeding syndrome. Of these, 5 (10.6%) were low-risk patients and 19 (40.4%) were high-risk patients. Three out of five low-risk patients were accompanied by weight loss and inadequate nutrition for more than 5 days. Seven of the 19 high-risk patients had electrolyte imbalance, 12 had low BMI, or had inadequate nutrition for more than 10 days. Conclusions: In the patients admitted to the surgical ICU, 51% were at risk of developing refeeding


syndrome. For these patients, careful attention should be paid to the initiation of nutritional support through precise risk assessment.


ENCORE ABSTRACT Presented at NALTH Spring Conference, April 20, 2017 in San Antonio, Texas. Accepted for presentation at the AARRC Conference in Indianapolis, IN in Oct. 2017. Previously Unpublished. T56 - Nutrition Administration and Ventilator Weaning in Long-term Acute Care. Anne E. Woodbury, RDN, CD1; Jill Marshall, RDN, CD2 1Dietary, Utah Valley Specialty Hospital, SLC, UT; 2Northern Idaho Advanced Care Hospital, Post Falls, ID

Purpose: Patients on mechanical ventilation in long-term acute care hospitals (LTACHs) are at high risk for malnutrition. This malnutrition can in turn impact ventilator weaning success. Our goal was to search for trends and correlations between nutrition provision and successful ventilator weaning. Methods: After an extensive literature review, we utilized best-practice guidelines and the ADA’s CCI Toolkit Outcomes Monitoring Form to create our own nutrition tracking form. Nutrition data was collected by a registered dietitian bi-weekly on the tracking form for each individual patient who was on a ventilator. We compiled data for 204 acute long-term ventilator patients from LTACHs in Utah, Colorado, Idaho, and Montana. We assessed the effects of blood glucose (BG) control of less than 180mg/d.; the amount protein administration (gm/kg) delivered and diarrhea with acute long term ventilator patients during ventilator weaning. Results: BG Control: Data show that when a patient’s BG is less than 180gm/dL, the patient is between 11.7% and 37.3% more likely to wean from the ventilator (p-value = 0.0002) (see figure 1). Protein Provision: General protein recommendations from ASPEN critical care guidelines suggest providing 1.2-2.0gm/kg of protein/day. We were interested to know if there was any correlation between the average gm/kg/protein/day provided and ventilator weaning success. Though not statistically significant (p-value 0.08), there seems to be a positive trend between gm/kg of protein provided and ventilator weaning success (figure 2). Diarrhea: Data showed that if a patient had acute diarrhea during the ventilator weaning process, the patient was less likely to wean from the ventilator (p-value 0.04). Conclusions: BG Control: Dietitians can evaluate patients for potential causes for poor BG control, including steroid use, sepsis, inflammatory stress response, and a history of poorly controlled diabetes. Possible interventions include changing to a lower carbohydrate tube feeding formula or adding/adjusting hypoglycemic medications. The dietitian can also closely evaluate the patient for possible over-feeding as this can be associated with both hyperglycemia and hypercapnia. It is imperative for the dietitian to communicate about BG control with the whole care team so an appropriate plan of care can be put into action. Protein Provision: An important part of our data collection featured calculating the actual amount of protein provided during ventilator weaning. It is important for the dietitian to monitor the actual amount of nutrition provided and to make necessary adjustments if the tube feedings are consistently meeting less than the patient’s estimated needs. Aiming to provide closer to 2.0gm/kg of protein/day rather than 1.2gm/kg may be more desirable for this patient population. Diarrhea: When tube feedings are frequently turned off due to diarrhea, patients may not receive adequate nutrition. Nutrition interventions include changing fluid administration, utilizing a semi-elemental formula, increasing or decreasing fiber, adding anti-diarrheal medications, and/or probiotics. The patient


could possibly engage in less therapy due to bowel incontinence, and therefore have less time in an upright position. If the patient feels ill, depressed, or embarrassed by loose bowel movements, this could impede their motivation to work with respiratory and physical therapists. Nutrition does have an impact on the prolonged ventilator patient. Dietitians are an integral part of the interdisciplinary team for ventilator management and should monitor actual protein provision, blood glucose control, and bowel movements during ventilator weaning. The dietitian can then make nutrition interventions to improve ventilator weaning outcomes.


T57 - The Need to Feed: Evaluation of Nutrition Practices in a Surgical Intensive Care Unit Sandra W. Citty, PhD, ARNP-BC, CNE-BC1; Jordan Hardy, RN, BSN, CCRN1,3; Whitney Jacob, BA, BSN, RN, CCRN 1,3; Karah Sickler, DNP, AGACNP-BC1,3; Amir Y. Kamel, PharmD2; Lee Marlowe, RD3; Tonja Hartjes, DNP, ACNP-BC, CCRN, FAANP 1 1College of Nursing, University of Florida, Newberry, FL; 2Pharnacy, University of Florida, Gainesville, FL; 3University of Florida Health, Gainesville, FL

Purpose: Background: Nutrition support (NS) is a vital component in improving clinical outcomes and reducing complications in the critically ill. Purpose: To evaluate adherence ASPEN/SCCM guidelines in the SICU and make recommendations based on a review of current evidence to improve nutritional indices after surgery. Methods: Methods: A random 35 patient convenience sample was obtained over a two-week period in


the SICU of patients who had undergone surgery 48 hours prior were included. Demographics data were collected and descriptive statistics were utilized. Primary endpoints included initiation timing of nutrition orders, presence of nutritional consult for patients at high risk for and/or having clinical evidence of malnutrition, and provider adherence to Registered Dietitian (RD) and current guideline recommendations. Results: Results: Of the 35 patients included in the study, 27 (77.1%) were initiated on NS within 48 hours of admission to the SICU (Table 1). Fifty percent of at risk of malnutrition did not have nutrition initiated within 48 hours. Nutrition consults were ordered in nine patients (25.7%). Eight patients were at risk for malnutrition based on an MST score ≥ 2, and they were consulted on by nursing staff and seen by RD. Twelve (34.3%) patients had a coded diagnosis (ICD-10) for malnutrition; however only 8out of 12 (66.7%) patients received nutrition consults. Twenty-two (62.9%) patients were seen by a RD who completed a Nutrition Risk in the Critically Ill (NUTRIC) score for 6 (27.3%) out of the 22 patients seen. Of the 6 patients screened with the NUTRIC score, 5 (83.3%) were identified to be at high nutrition risk (NUTRIC score ≥ 5). Providers followed recommendations provided by the RD or current guidelines-based unit protocol for 19 (86.4%) of the 22 patients. Limitation: Small sample size and retrospective design. Conclusions: Conclusions: Overall, providers followed ASPEN/ SCCM guideline recommendations for initiation of nutrition support within 48 hours of ICU admission but the utilization of provider ordered nutrition consult was low in this study despite a significant risk or diagnosis of malnutrition. Moving forward, the team will provide additional education on nutrition assessment, where to locate nursing and RD nutrition assessments (in electronic chart?) and when to order nutrition consultations. Despite the low utilization of nutrition consult orders, nurse driven RD consults were significantly higher, suggesting that a nurse driven nutritional assessment and protocol as well as additional triggers for RD consultation should be explored. Next, the utilization of NUTRIC scores, completed upon RD assessment, is also low despite its validation as a tool to utilize within the critical ill. Increased utilization of the NUTRIC score would likely be beneficial for identifying those at risk for malnutrition and who would benefit most from early nutrition support therapy. Finally, inclusion of the nutrition assessment and plan of care discussions should occur daily during interdisciplinary rounds and in progress notes.



T58 - Comparison of nutritional parameters between open and laparoscopic subtotal gastrectomy with Billoth II anastomosis in early gastric cancer patients Jae-Moon Bae, MD., PhD1; Man Ho Ha, MD2; Ji Yeong An, MD,PhD1; Min-Gew Choi, MD,PhD1; Jun-Ho Lee, MD, PhD1; Tae Sung Sohn, MD, PhD1; Sung Kim, MD,PhD1 1Surgery, Samung Medical Center, Sungkyunkwan Univ. , Seoul, Korea (the Republic of); 2Surgery, International ST. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea (the Republic of)

Purpose: This study was conducted to investigate the comparison of changes in pre and post-operative nutritional parameters between open and laparoscopy/robot-assisted surgery among patients who underwent subtotal gastrectomy with Billoth II anastomosis in early gastric cancer. Methods: From June 2012 to December 2016, patients with early gastric cancer who underwent subtotal gastrectomy with Billoth II anastomosis were included. A case control study using matching technique for age and sex was performed to compare laparoscopy (n=30 cases) and open groups (n=30 controls). Body mass index (BMI), protein, albumin, cholesterol, hemoglobin, white blood cells(WBC), absolute lymphocyte count (ALC), and prognostic nutrition index (PNI) were measured before and 3 months after surgery. The repeated measures ANOVA was used to compare the changes in the two groups. Results: As a result of characteristics comparison between the two groups, BMI was significantly higher


in the open group. Repeated measures ANOVA showed a significant decrease in BMI in the open group

after 3 months(p〈0.001). Other parameters were not significantly different between the two groups.

Conclusions: There was no significant difference in nutritional parameters except for BMI between open and laparoscopy assisted gastrectomy with Billroth II anastomosis in early gastric cancer patients. It is suggested that the difference of BMI was derived from total omentectomy in open gastrectomy.

Financial Support received from: none

T59 - Assessing Adequacy of Enteral Nutrition in Intensive Care Unit Patients with High NUTRIC Scores Rebecca Wehner, RD, LD, CNSC2; Allison M. Krall, RDN, LD, CNSC1,3; Kellsey O'Donnell, MS, RDN, LD3; Polina Zhuzhina, MS, RDN, LD3; Cara Chase, RDN, LD3; Julie Kennel, PhD, RDN, LD3 1Nutrition Services, The Ohio State University Medical Center, Lewis Center, OH; 2Nutrition Services Department, The Ohio State Wexner Medical Center, Columbus, OH; 3Department of Human Sciences, The Ohio State University, Columbus, OH

Purpose: Patients at high nutrition risk are more likely to benefit from aggressive nutrition therapy compared to patients without high nutrition risk. The NUTRIC Score is a validated tool to identify high nutrition risk patients in the intensive care unit (ICU) setting. Patients with high NUTRIC Scores receiving adequate enteral nutrition (EN) are more likely to survive compared to those who do not receive adequate EN. The purpose of this study was to assess EN delivery in high nutrition risk patients in the medical ICU of our tertiary academic medical center. Methods: The design was a retrospective observational study of 100 ICU patients selected from a previous study. Inclusion criteria were admission to ICU, ≥ 3 days of enteral nutrition, and high nutrition risk (modified NUTRIC Score ≥5). Descriptive statistical analyses were made with respect to time taken to initiate EN and quantification of EN attainment (% received/goal) on days 3, 7, and 14 length of stay. The goal EN regimen was determined and documented by the RDN alongside the clinician. The amount of EN received was captured from nursing daily intake records. Data were compared to ASPEN/SCCM Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient (2016) benchmarks of achieving >80% of estimated/calculated goal energy requirements and EN initiation within 24-48 hours of the patient’s inability to maintain volitional intake. Results: Eighty high risk patients met inclusion criteria for this secondary analysis. After 3 days of ICU stay 0% of percent of patients achieved the benchmark goal volume. After 7 days of ICU stay, 2% percent of patients achieved benchmark goal volume. Finally after 14 days of ICU stay, 8% percent of patients achieved benchmark goal volume. Average EN delivery across the board was 24%, 47% and 57% at days 3, 7 and 14, respectively. Average time to initiate EN was 32 hours. Most patients (78%) were started on EN within the 48 hour initiation recommendation. Conclusions: Suboptimal delivery of EN in critically ill high nutrition risk patients during the first two weeks of stay was a pervasive issue. Our findings are consistent with those found in the published literature. Although EN initiation rates were closer to the target standard there is room for improvement. Determining root causes for failing to reach or sustain >80% EN attainment is imperative for targeting next steps to improve protein-energy provision via enteral route, and thus, ICU patient outcomes. Future studies may explore protocols to sustain EN delivery in high nutritional risk patients such as a customized algorithm or PEP uP protocol.


T60 - Impact of Skeletal Muscle Depletion on Survival in Patients with Colorectal Perforation


Satoshi Yoneyama, MD, PhD; Ryota Nakamura, MD; Kenji Yuzawa, MD, PhD; Yoshinobu Kobayashi, MD, PhD; Ryo Muto, MD, PhD; Akiho Okada, MD, PhD; Takehito Kato, MD, PhD; Yoshihisa Inage, MD, PhD; Koichi Kozaki, MD, PhD; Toru Terashima, MD, PhD Surgery, National Hospital Organization Mito Medical Center, Ibaraki, Japan

Purpose: Skeletal muscle depletion predicts morbidity and mortality in patients undergoing digestive surgery, such as colorectal cancer resection or liver transplantation. However, the impact on septic condition is unclear. We investigated the impact of skeletal muscle depletion on patients underwent surgery for colorectal perforation. Methods: Cross-sectional areas of psoas muscle at L3 level were assessed by computerized tomography scan in 63 adult patients underwent surgery for colorectal perforation between January 2013 and December 2016. To normalize for body habitus, the cross-sectional area of the L3 vertebral body was also recorded. The lower tertile of the psoas:vertebral ratio value was determined for each male and female, and patients were grouped into low and high categories. The correlation of skeletal muscle depletion with other patient factors and the survival after surgery were analyzed. Results: 21 patients were classified into lower psoas:vertebral ratio group and 42 patients were classified into higher psoas:vertebral ratio group. Mean age was not significantly different in both groups (74 years in lower group versus 70 years in higher group). Preoperative Sequential Organ Failure Assessment (SOFA) score, comorbidity rate for malignant tumor and intraoperative bleeding were not significantly different between two groups. 30-day morality and 90-day mortality were higher in lower psoas:vertebral ratio group (30days mortality were 6/21 versus 2/42, and 90 days mortality were 7/21 versus 2/42, respectively). Length of hospital stay in survived patients was not significantly different in both groups. In univariate analysis, aging, SOFA score and skeletal muscle depletion were identified as risk factors for 30-day mortality. In multivariate analysis, SOFA score and skeletal muscle depletion were identified as risk factors for 30-day mortality. Conclusions: Skeletal muscle depletion was related with postoperative mortality in patients with colorectal perforation. Cross sectional area of psoas muscle may help to identify patients at increased risk of mortality.


T61 - The characteristic of oxygen supply-demand balance for elderly people under the critical ill situation. TAKESHI EBIHARA, MD; KENTARO SHIMIZU, MD, PhD; HIROMI MITSUYAMA, MD; MITSUO ONISHI, MD, PhD; HIROSHI OGURA, MD, PhD; TAKESHI SHIMAZU, MD, PhD Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, SUITA, Japan

Purpose: The relationship between age and oxygen supply-demand balance under the critical ill situation was unclear. In this study, oxygen consumption(VO2), oxygen delivery(DO2) and oxygen extraction ratio(VO2/DO2) were measured. We evaluated the characteristic of oxygen supply-demand balance for elderly people. Methods: This study was performed in adult patients with sepsis, trauma and post cardiac arrest. Sixty measurements of VO2 and VCO2 by indirect calorimetry (AMIS2000) and cardiac index (CI) by FloTracTM were performed simultaneously by day 7. DO2 was calculated with CI and arterial blood gas data. We evaluated relationship between age, DO2 and VCO2. The patients were divided into two groups, one was over 65 (Elderly Group), and the other was under 64 (Control). DO2, VO2/DO2, and mortality between two groups were compared. Results: Forty-seven patients (median age was 69) included 23 sepsis, 13 trauma and 14 post cardiac arrest. Mortality was 27.6%. The age showed a strong negative correlation with VO2 (p<0.01). Elderly Group was higher extraction ratio than the others (p=0.02). (DO2 and VO2/DO2 had significant difference between the groups respectively. (DO2: 527.0±33.7 vs. 333.7±25.3, VO2/DO2: 28.1±3.9 vs.


39.9±3.0(Elderly vs. Control)). The number of patients whose DO2 was lower than 420ml/min/m2 and VO2/DO2 was higher than 50% (which based on partition statistics), had higher mortality in Elderly Group compared with Control (4/10vs. 0/0 (Elderly vs. Control)). Conclusions: Elevation of DO2 was needed to match the increasing energy consumption under the critical ill situation. Because DO2 was decreased by the age, elevation of oxygen extraction was needed for elderly people. The characteristic of oxygen supply- demand balance for elderly people demonstrated that low DO2 and extremely high VO2/DO2 lead to high mortality.


The age showed a strong negative correlation with VO2 (p<0.01)


The number of patient whose DO2 was lower than 420ml/min/m2 and VO2/DO2 was higher than 50% had higher mortality in Elderly Group compared with Control (4/10 vs. 0/0) T62 - Enteral Feeding During Therapeutic Hypothermia: A Case Series Paul J. McCarthy, MD, CNSC1; Avnee Kumar, MD1; Gabrielle Judd, RD, CNSC, LDN2 1Depatment of Medicine, University of Maryland Medical Center, Baltimore, MD; 2Department of Clinical Nutrition, University of Maryland Medical Center, Baltimore, MD

Purpose: Enteral nutrition preferred is critically ill patients that will tolerate the therapy and do not have a contraindication. Targeted temperature management and therapeutic hypothermia are being used with increasing frequency in critically ill neurologic patients for neuroprotection and/or as a therapeutic intervention. The data on enteral nutrition is in this patient population is limited with many centers not initiating enteral nutrition while a patient is undergoing targeted temperature management. The neurocritical care service at our institution as part of standard care starts enteral nutrition within 24 hours on most patients undergoing therapeutic hypothermia. We have reviewed a series of these patients. Methods: This is a retrospective chart review of fifteen patients undergoing therapeutic hypothermia with targeted temperatures of less than 35 degrees Celsius and having enteral nutrition started with 24 hours of admission over period of December 2015 through December 2016 in a dedicated neurologic intensive care unit at a single academic referral center. Results: A total of fifteen patients were managed with therapeutic hypothermia for at least 24 hours and had enteral nutrition started within the first 24 hours of admission. There was a variation in observed practice ranging from maintaining trophic feeds to titrating enteral feeds to staring enteral nutrition at goal.


Ten patients were male, the average duration of hypothermia was 72 hours, two patients had post-pyloric access with the remainder gastric. The average rate of delivery of enteral nutrition was 28 ml/hour and the average calories delivered was 1028 per day. Two patients in this series developed an ileus, one patient had several episodes of emesis, one patient has one episode of emesis and one patient had feeds held for residuals over 500 ml. Two patients developed pneumonia and one patient had a urinary tract infection. Four patients in this series did die. These clinical results are not unexpected in this critically ill patient population. Conclusions: This case series shows that early enteral nutrition in patients undergoing therapeutic hypothermia is feasible. Complications and outcomes in this series were not inconsistent with clinicians’ expectations. Potential areas for future studies should include indirect calorimetry, post-pyloric access and volumetric feeding.


T63 - Step-by-Step Development of a Pilot Neurosurgical Enhanced Recovery After Surgery (ERAS) Protocol. Martina Cartwright, PhD, RD Nutritional Sciences, University of Arizona, Scottsdale, AZ

Purpose: Enhanced Recovery After Surgery (ERAS) is a multimodal, multidisciplinary protocol that improves patient outcomes by reducing surgical stress and maintaining homeostasis. Research suggests ERAS neurosurgery protocols may improve patient outcomes, accelerate functional recovery, decrease length of stay (LOS) and reduce cost and complications. Key components unique to neurosurgical ERAS protocols are scalp blocks, minimal access surgery and control of post-operative nausea and vomiting. Integral to these protocols is the inclusion of pre and post surgical nutrition. Herein an ERAS neurosurgical care protocol that includes continuous nutrition therapy and addresses challenges of creating a protocol is described. Methods: A neurosurgeon and dietitian champion spearheaded a multidisciplinary effort to discuss key ERAS elements within preoperative, intraoperative and postoperative domains. A “four tier process” for creating a protocol was utilized: 1. Identify Who, Where, Why: Organizational or unit consensus that nutrition therapy throughout a patient’s stay is paramount to addressing surgical outcomes. Recognize that consistency in nutrition therapy that begins before surgery and continues beyond hospital discharge; 2. What: Need to standardize. Application of ERAS—create protocols based on guidelines; 3. How: Audit practices; Agree on standards; Identify barriers; Improve ERAS knowledge; Be or assign an ERAS champion; 4: Modify: Measure and Evaluate. Determine if the protocol is successful and where improvements can be made. Utilize questionnaires. Results: The standardized approach to creating a pilot ERAS protocol was well received by the multidisciplinary team based on input and participation. Approximatley 10 drafts were created before a two page final protocol was developed and presented for final internal review. It was discovered that some elements of other surgical ERAS protocols do not fit within the neurosurgery specialty, however, there was one element unique to neurosurgery: scalp blocks and short acting anesthesia. Conclusions: ERAS protocols have been developed for a number of co-morbidities resulting in a reduction in LOS and complications. Key elements include screening and assessing peri-operative nutritional status and addressing nutrition therapy before, during and after surgery. Neurosurgical patients pose a unique challenge as they are often predisposed to pain, nausea, and vomiting with limited pre-surgical lead times. However, a tailored ERAS protocol that is easy to use and transferable, that includes a multidisciplinary team, and is automated to include a dietitian consult and attention to diet advancement, was developed. It is predicted that widespread initiation of this protocol will improve patient quality of life and reduce costs and complications, however more data is needed to confirm this hypothesis.



The 4 Tier Process for Creating an ERAS Protocol


Elements of a Neurosurgical ERAS Protocol

Pediatric and Neonatal BEST OF ASPEN-PEDIATRIC AND NEONATAL TOPICS ENCORE ABSTRACT Published: Transplantation, Vol. 101, June 2017, S1-S162. Presented: Congress of the International Intestinal Rehabilitation and Transplant Association Conference, Aug 18-23, 2016, Hong Kong, China. T64 - An observational Study of a Composite Lipid Emulsion versus Soy-based Lipid Emulsion on the evolution of parenteral nutrition associated liver disease in neonates with intestinal failure Christina Belza, NP, RN2; John C. Wales, NA1; Glenda Courtney-Martin, PhD, RD2; Nicole de Silva, NP, RN3; Yaron Avitzur, MD2; Paul W. Wales, MD1 1Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada; 2Transplant Centre, The Hospital for Sick Children, Toronto, Canada; 3Hospital for Sick Children, Toronto, Canada

TRAINEE AWARD POSTER OF DISTINCTION T65 - Neonatal Cholesterol Provided by Breastmilk and the Gap in Nutrition Support Solutions. Margaret Cinibulk, BS 1; Amy Stucky, PhD2; Emily A. DeFranco, DO, MS3; Ardythe L. Morrow, PhD1; Christina Valentine, MD, RD4,2 1University of Cincinnati College of Medicine, Norwood, OH; 2Mead Johnson Nutrition, Chicago, IL; 3University of Cincinnati College of Medicine, Cincinnati, OH

Purpose: Neonatal parenteral nutrition (PN) and enteral nutrition (EN) research has recently focused on improving fatty acid composition without attention to cholesterol. Infants on exclusive PN have been shown to have a different cholesterol lipid protein profile in their blood as compared to healthy infants because of the phytosterol composition. In addition, it is well known that developmental scores are decreased in infants on long term PN as well as infants with illnesses requiring long term EN. Cholesterol is vital in development of the nervous system, synthesis of vitamins, bile acids, lipoproteins, and hormones, and has potential long term cardioprotective effects. Measurement of human breastmilk cholesterol concentration has consisted of small individual samples, finding concentrations more robust than that provided by infant EN or PN. Re-examining a large global cohort is the first step in targeting cholesterol in nutrition support solutions. Methods: In a large (n=360 mothers; 120 mothers per site) prospective, longitudinal –Global Exploration of Human Milk (GEHM) cohort study we examined the cholesterol concentrations of human milk from three distinct urban populations in Shanghai, China, Mexico City, Mexico and Cincinnati, USA. Enrollment was limited to healthy mothers of term, singleton infants. Sample collection was standardized as a full breast expression during a 4 hour window (9am-1pm) at 4 weeks of infant age. Milk was saponfied in alcoholic KOH, sterol extracted, and mass of cholesterol measured by gas liquid chromatography GC using stigmastanol as an internal standard. Results: Breastmilk cholesterol concentration (mg/100mL) differed significantly between all sites with the highest levels in Cincinnati followed by Mexico City and Shanghai (median; IQR): 14.2; 6.2, 10.3; 5.6, 9.5; 4.8, respectively (p<0.001). Among the sample as a whole, breastmilk cholesterol levels were significantly different between BMI classes, with higher classes having higher cholesterol levels (P=0.001). Both pre-pregnancy BMI and delivery BMI were positively correlated with breastmilk cholesterol levels (P <0.001 R2 = 0.04, P <0.001 R2 = 0.03). The median concentration of cholesterol from normal weight mothers (BMI 18.5-24.9) in the large cohort was 10.75 mg/100mL, which is significantly higher than EN (1.7-3.8 mg/100 mL) and PN (0 mg/100mL). In fact a cummulative deficit of about 1500 mg cholesterol in a formula or parenteral fed infant would be realized as compared to a healthy nursing infant over four weeks.


Conclusions: Human milk cholesterol levels, provided via a milk fat globule membrane (MFGM), are significantly greater than that provided by PN or EN and result in a gap of intake in the non-nursing infant. Future studies are imperative to determine appropriate infant PN and EN modifcation to include cholesterol.


POSTER OF DISTINCTION T66 - Factors associated with mid-upper arm circumference and thigh circumference deterioration in critically ill children. Julia C. Ventura, RD, MSc1; Mayara D. Martins, None2; Daniela B. Hauschild, RD, MSc1; Eliana Barbosa, RD, MSc3; Nilzete L. Bresolin, MD, MSc4; Yara M. Moreno, RD, PhD1 1Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil; 2Undergraduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil; 3Nutrition, Joana de Gusmão Children’s Hospital, Florianópolis, Brazil; 4Pediatric Intensive Care Unit, Joana de Gusmão Children’s Hospital, Florianópolis, Brazil

Purpose: Critically ill children can experience muscle mass depletion during Pediatric Intensive Care Unit (PICU) stay, and it is associated with worse clinical outcomes. Mid-upper arm circumference (MUAC) and thigh circumference (TC) are considered simple measures and easy-to-perform, and allow to evaluate the subcutaneous fat and muscle mass. Thus, to prevent the nutritional status deterioration and its complications, it is essential the early identification of the factors associated with nutritional depletion. We aimed to evaluate the association between anthropometric, inflammatory-nutritional, nutrition therapy (NT) and clinical parameters with MUAC and TC deterioration in critically ill children on mechanical ventilation (MV). Methods: Prospective cohort study conducted in a PICU of a tertiary hospital in south of Brazil, between July 2013 and February 2016, with critically ill children on MV, aged between 1 month and 15 years. Nutritional status at PICU admission was evaluated by body mass index-for-age (BMI/A). MUAC and TC were performed at PICU admission and before PICU discharge, and delta (Δ) was calculated (Δ = PICU discharge minus PICU admission). Inflammatory-nutritional evaluation was composed of serum albumin, C-reactive protein (CRP) and CRP/albumin ratio. NT was evaluated by prior NT, early NT, route of administration, energy and protein adequacy, and cumulative energy and protein balance (calculated as the sum of daily energy and protein intake up to day 7 minus energy and protein goals). Pediatric Index of Mortality 2 (PIM2), diagnostic category, Complex Chronic Conditions and fluid overload were evaluated. MUAC and TC deterioration was defined as a reduction of at least 2% during PICU stay. Logistic regression adjusted for sex, age and PIM2 (Adjustment 1) and for sex, age and fluid overload (Adjustment 2) was applied. P-value <0.05 was considered significant. Results: There were included 69 patients, 59% male with a median age of 15.6 (interquartile range 3.7; 92.8) months. The prevalence of undernutrition at PICU admission was 17.6% according BMI/A. MUAC deterioration was observed in 61% and TC deterioration in 67% of the patients. The patients presented a median ΔMUAC of -3.87% and a median ΔTC of -6.14%. Cumulative negative energy (OR 0.99; p=0.006) and protein (OR 0.85; p=0.032) balances were associated with MUAC deterioration in crude analysis (Table 1). In adjustment 1, higher CRP/albumin ratio (OR 5.00; p=0.047) and cumulative negative energy balance (OR 0.99; p=0.016) were associated with MUAC deterioration (Table 1). In adjustment 2, early NT (OR 0.27; p=0.040) and cumulative negative energy balance (OR 0.99; p=0.017) were associated with MUAC deterioration (Table 1). There were no association between anthropometric, inflammatory-nutritional, clinical or NT parameters with TC deterioration in the crude and adjusted analysis (Table 2). Conclusions: Inflammatory-nutritional and NT parameters were associated with MUAC deterioration during PICU stay. The evaluation of MUAC and CRP/albumin ratio could be included in the nutritional status assessment of critically ill children, and the use of NT protocols to ensure the adequacy of NT should be incorporated in the PICU routine. Further studies investigating the association of clinical and nutritional parameters with TC are necessary.


Financial Support received from: Financial Support received from: A doctorate scholarship to Ventura JC and to Hauschild DB were awarded by the Coordination for the Improvement of Higher Education Personnel (CAPES).

Table 1 - Logistic Regression of factors associated with mid-upper arm circumference deterioration in critically ill children on mechanical ventilation in a Pediatric Intensive Care Unit, between July 2013 and February 2016.

Variables

Mid-upper Arm Circumference deterioration (n=39)

Crude Adjustment 1+ Adjustment 2++

OR (95% CI) p-value OR (95% CI) p-value OR (95% CI) p-value

Diagnostic (Surgical) 1.15 (0.30; 4.41) 0.840 1.14 (0.28; 4.65) 0.857 1.23 (0.29; 5.16) 0.778

CCC 1.08 (0.23; 4.97) 0.923 1.03 (0.21; 5.12) 0.968 1.05 (0.21; 5.40) 0.950

Albumin (g/dL) 1.04 (0.70; 1.54) 0.845 1.04 (0.70; 1.56) 0.833 1.07 (0.71; 1.61) 0.730

Hypoalbuminemia (< 3.0 g/dL)

1.73 (0.61; 4.86) 0.299 1.69 (0.57; 5.05) 0.344 1.59 (0.52; 4.82) 0.411

CRP (mg/dL) 1.00 (0.99; 1.01) 0.385 1.00 (0.99; 1.01) 0.334 1.00 (0.99; 1.01) 0.474

CRP/Albumin ratio (mg/dL:g/dL)

1st tertile 1.00 1.00 1.00

2nd tertile 2.25 (0.60; 8.38) 0.227 3.14 (0.69; 14.31) 0.138 2.29 (0.56; 9.29) 0.245

3rd tertile 2.81 (0.73; 10.77) 0.131 5.00 (1.02; 24.56) 0.047 2.50 (0.63; 9.90) 0.192

Nutritional status *

Eutrophic 1.00 1.00 1.00

Nutritional risk/ undernutrition(<-1)

0.73 (0.23; 2.28) 0.587 0.88 (0.26; 2.99) 0.844 0.84 (0.24; 2.87) 0.777

Overweight 0.78 (0.15; 3.99) 0.763 0.93 (0.17; 5.21) 0.934 0.76 (0.13; 4.29) 0.755

Prior NT 0.75 (0.27; 2.05) 0.570 0.81 (0.26; 2.51) 0.720 0.75 (0.24; 2.35) 0.627

Early NT (24 hours) 0.32 (0.10; 1.04) 0.058 0.34 (0.10; 1.14) 0.082 0.27 (0.08; 0.94) 0.040

Route of NT (parenteral)

1.69 (0.30; 9.47) 0.550 1.34 (0.21; 8.47) 0.757 1.55 (0.26; 9.19) 0.628

Energy adequacy (<66.7%)**

2.94 (0.84; 10.30) 0.092 2.38 (0.62; 9.17) 0.208 2.44 (0.66; 8.94) 0.180

Protein adequacy (<60%)**

3.09 (0.96; 9.92) 0.058 2.66 (0.80; 8.83) 0.109 2.72 (0.81; 9.10) 0.104

Cumulative energy balance (kcal/kg/day)**

0.99 (0.99; 1.00) 0.006 0.99 (0.99; 1.00) 0.016 0.99 (0.99; 1.00) 0.017

Cumulative protein balance (0.1g/kg)**

0.85 (0.74 ; 0.99) 0.032 0.87 (0.75; 1.01) 0.062 0.87 (0.75; 1.01) 0.064

OR: Odds Ratio; CI: Confidence Interval; CCC: Chronic Complex Condition; CRP: C-reactive protein; NT: Nutritional Therapy * assessed at PICU admission, by body mass index-for-age; ** average percentage of first 7 days +Adjustment 1: sex, age and PIM 2; ++Adjustment 2: sex, age and fluid overload Table 2 - Logistic Regression of factors associated with thigh circumference deterioration in critically ill


children on mechanical ventilation in a Pediatric Intensive Care Unit, between July 2013 and February 2016.

Variables

Thigh Circumference deterioration (n=41)

Crude Adjustment 1+ Adjustment 2++

OR (95% CI) p-

value OR (95% CI)

p-value

OR (95% CI) p-

value

Diagnostic (Surgical) 1.25 (0.22; 7.08) 0.801 0.85 (0.11; 6.56) 0.880 0.88 (0.10; 7.49) 0.905

CCC 0.97 (0.16; 5.82) 0.976 1.35 (0.17;

10.50) 0.773 1.20 (0.16; 9.06) 0.858

Albumin (g/dL) 1.18 (0.65; 2.15) 0.577 1.18 (0.65; 2.16) 0.584 1.16 (0.62; 2.16) 0.636

Hypoalbuminemia (< 3.0 g/dL)

1.11 (0.36; 3.46) 0.853 1.15 (0.31; 4.24) 0.835 1.22 (0.33; 4.52) 0.763

CRP (mg/dL) 1.00 (0.99; 1.01) 0.338 1.00 (0.99; 1.01) 0.971 1.00 (0.99; 1.01) 0.893

CRP/Albumin ratio (mg/dL:g/dL)

1st tertile 1.00 1.00 1.00

2nd tertile 1.42 (0.34; 5.94) 0.633 1.65 (0.31; 8.93) 0.559 1.81 (0.35; 9.48) 0.479

3rd tertile 1.17 (0.31; 4.46) 0.819 0.70 (0.14; 3.60) 0.672 1.00 (0.22; 4.55) 0.999

Nutritional status *

Eutrophic 1.00 1.00 1.00

Nutritional risk/ undernutrition (<-1)

0.43 (0.13; 1.43) 0.171 0.80 (0.20; 3.11) 0.742 0.81 (0.21; 3.19) 0.764

Overweight 1.15 (0.20; 6.70) 0.873 1.54 (0.22;

10.76) 0.666

1.58 (0.23; 10.60)

0.638

Prior NT 0.86 (0.29; 2.51) 0.781 1.75 (0.48; 6.36) 0.393 2.06 (0.55; 7.75) 0.284

Early NT (24 hours) 1.98 (0.65; 5.99) 0.228 2.28 (0.64; 8.12) 0.204 2.42 (0.67; 8.72) 0.178

Route of NT (parenteral)

2.64 (0.29; 24.24)

0.391 2.68 (0.13;

53.70) 0.519

1.91 (0.14; 25.57)

0.624

Energy adequacy (<66.7%)**

2.63 (0.65; 10.59)

0.173 1.78 (0.36; 8.17) 0.477 1.88 (0.36; 9.37) 0.443

Protein adequacy (<60%)**

1.73 (0.52; 5.72) 0.368 1.05 (0.27; 4.07) 0.948 1.11 (0.28; 4.43) 0.880

Cumulative energy balance

(kcal/kg/day)** 1.00 (0.99; 1.00) 0.257 1.00 (0.99; 1.00) 0.862 1.00 (0.99; 1.00) 0.794

Cumulative protein balance (0.1g/kg)**

0.92 (0.80; 1.06) 0.238 0.96 (0.83; 1.12) 0.643 0.96 (0.82 ; 1.12) 0.600

OR: Odds Ratio; CI: Confidence Interval; CCC: Chronic Complex Condition; CRP: C-reactive protein; NT: Nutritional Therapy * assessed at PICU admission, by body mass index-for-age; ** average percentage of first 7 days +Adjustment 1: sex, age and PIM 2; ++Adjustment 2: sex, age and fluid overload

POSTER OF INTERNATIONAL DISTINCTION T67 - Development of a Weekly Nutrition Rescreening Tool for Long Stay Pediatric Inpatients Melinda White, PhD1,2; Annabel Doolan, BHScNutr&Diet1; Shang Qian Song, BNutr&Diet3; Caitriona O'Shea, BHScHonsDiet1; Melinda Thomas, BNutr&Diet1


1Dietetics and Food Services, Lady Cilento Children's Hospital , Brisbane, Australia; 2Faculty of Medicine, University of Queensland, Brisbane, Australia; 3Queensland Univeristy of Technology, Brisbane, Australia

Purpose: Since publication in the Journal of Parenteral and Enteral Nutrition the Pediatric Nutrition Screening Tool (PNST) has been implemented in hospitals internationally including America and Australia. The PNST is designed for nutrition screening on admission. Children who have extended hospital stays are at risk of nutritional deterioration making nutrition rescreening an integral part of the care pathway. The purpose of our study was to design a simple, quick and universal weekly nutrition rescreening tool to identify nutritional deterioration in pediatric inpatients. Methods: The test questions were developed in consultation with pediatric nurses, directors of pediatric dietetic departments and information technologists to ensure the tool can be incorporated into electronic systems. The questions were trialled for usability and practicality with paediatric inpatients. A cross sectional sample of children aged term to 16 years admitted to the Lady Cilento Children’s hospital, Australia who stayed for seven days or more were included in the rescreening study. The tool needed to have universal application therefore no sections of the hospital were excluded from the study, including the intensive care unit. Nutritional deterioration measures were performed every seven days and compared to the rescreening questions. The rescreening questions were asked by a second investigator blinded to the nutritional deterioration measures. Nutritional deterioration measures included changes in weight (kg), mid upper arm circumference (MUAC), energy intake (kcal/day) and protein intake (g/day) over a seven day period. Agreement between the answers to the rescreening questions and nutritional deterioration markers was analysed. Results: Following consultation and inpatient trials, two rescreening questions were produced 1. Has the child had reduced nutritional intake in the last 7 days? 2. Has the child lost weight or had poor weight gain in the last 7 days? Twenty-four children were included in the study, 15 male and 9 female. At the first measurement the average (SD) age and BMI z score was 5.5 (6.25) years and -0.6 (1.3). Twenty-six nutritional intake changes were recorded, 27% of children had reduced energy intake and 19% had reduced protein intake over a 7 day period of admission. Eight-eight percent and 73% of responses to the question ‘Has the child had reduced nutritional intake in the last 7 days?’ were correct when compared with measures of energy and protein intake respectively. Twenty-two weight changes were recorded, 14% of children had lost weight or had poor weight gain. Eighty-six percent of responses to the question ‘Has the child lost weight or had poor weight gain in the last 7 days?’ were correct when compared to changes in weight. Twenty changes in MUAC were measured, 45% of children had a reduction in MUAC. Only Forty-five percent of responses to the weight loss question identified a reduction in MUAC. Conclusions: The proposed weekly nutrition rescreening questions had good agreement with markers of nutritional deterioration and show potential to provide a quick and simple tool for nutrition rescreening of long stay paediatric patients. The findings of this study indicated that the rescreening questions can progress to full validation methodology of sensitivity, specificity and reliability.

Financial Support received from: Nestle Australia T68 - Body Composition in Children on the Ketogenic Diet for Management of Epilepsy Melinda White, PhD1; Katie Barwick, MastN&D1; Bree Whiteoak, MastN&D2; Sophie Calvert, BMBS, FRACP3,5; Honey Heussler, BMBs, FRACP4,5 1Dietetics and Food Services, Lady Cilento Children's Hospital , Brisbane, Australia; 2University of Queensland, Brisbane, Australia; 3Neurosciences, Lady Cilento Children's Hospital, Brisbance, Australia; 4Centre for Clinical Trials in Rare Neuro Developmental Disorders, Children’s Health Queensland, Brisbane, Australia; 5Mater Research Institute, University of Queensland, Brisbane, Australia


Purpose: The ketogenic diet (KD) is a high fat, protein restricted diet low in micronutrients, with side effects including poor growth and potential effects on bone health. In addition a large proportion of this population of patients are disabled with limited mobility. While the KD has shown to be an effective treatment for intractable childhood epilepsy, there is limited evidence for how this diet therapy affects body composition and resting energy expenditure (REE). This study aimed to 1) Compare body size and composition of children on KD to the healthy population; 2) Determine the relationship between anthropometric and body composition measures. Methods: Children on the ketogenic diet aged 5 years or older were recruited from the Ketogenic Diet Service at Lady Cilento Children’s Hospital in Brisbane, Australia. The cross-sectional study measured anthropometry (height, weight, body mass index (BMI), mid-upper arm circumference, triceps skinfolds, upper-arm fat area, upper-arm muscle area); body cell mass (BCM) from total body potassium; percentage body fat, fat mass (FM), fat-free mass (FFM) and bone mineral density (BMD) by dual X-ray absorptiometry (DXA); resting energy expenditure (REE) using a metabolic cart. Variables were transformed into Z-scores using age- and sex-matched reference data, and cut-offs were used to identify abnormalities. Results: Eight subjects were recruited age range 6.3-14.3 years. Compared to the healthy population all subjects were well nourished according to BMI and arm anthropometry z-scores. Fifty percent of the subjects were stunted and 25% were underweight for age. Eighty-eight percent were overfat or obese based on percentage body fat compared to the healthy population. Sixty-three percent had a low BCM, indicating malnutrition and 50% had low BMD. There was a relationship between BCMI Z-score and BMI Z-score, although not significant (p=0.06). Percentage body fat was not correlated with any anthropometric measures. REE was correlated with predicted basal metabolic rate and FFM. Conclusions: These results suggest that children on the ketogenic diet have altered body composition and poor bone health, which may not be detected via simple nutritional measures. Detection of changes in body composition or bone health enables a ketogenic diet service to target nutrition care and support families to increase protein intake, ensure appropriate supplementation of calcium and vitamin D or exercise to improve fat-free mass. Further research with a larger sample is necessary to confirm these findings.


T69 - Human milk with a cherry on top: Achieving Adequate Growth for Infants with Congenital Diaphragmatic Hernia Utilizing Human Milk Dana Bartholomew, RD, LDN, CSP, CNSC3; Taryn Edwards, MSN, CRNP, NNP-BC2; Katherine Wild, MD3; Cynthia Villasis, MD1; Elizabeth Froh, PhD, RN 3,4; Diane Spatz, PhD, RN-BC, FAAN 4,3; Ursula S. Nawab, MD1,5 1Pediatrics Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA; 2Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA; 3The Children's Hospital of Philadelphia, Philadelphia, PA; 4Univeristy of Pennsylvania School of Nursing, Philadelphia, PA; 5Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA

Purpose: The purpose of this retrospective case series is to describe the enteral feeding requirements , including caloric provisions, of infants with congenital diaphragmatic hernia (CDH) from admission to discharge in relation to growth patterns. Prior evidence has shown that infants with CDH are at increased risk for malnutrition and require higher than standard caloric density feedings to achieve optimal growth velocity. Since human milk is the optimal diet for infants, this review specifically evaluates the need for earlier fortification to prevent malnutrition. Methods: Infants admitted to the N/IICU with a diagnosis of CDH between August 1, 2012 and March 31, 2017 were included in this retrospective case review. Infants with CDH who died or were withdrawn from


care prior to initiating feeds were excluded. Medical records were reviewed to determine feeding choice, caloric provision, and growth patterns. Data points evaluated were weight, length, and head circumference at the time of discharge. Z-scores were then evaluated utilizing peditools.org and the World Health Organization (WHO) recommendations, including the weight for length. Results: 93 infants born with CDH admitted to the CHOP N/IICU were evaluated. The majority were full term (38 weeks ± 1.9) and male (59%). Average duration of TPN was 32 days ± 26 d and length of stay 64 days ± 58. (Table 1) Maternal human milk was initiated in 77 babies as their first feed. 41 required fortification to achieve appropriate growth while 14 received additives for increased calories. Microlipid was the most common (13/14). For babies with a length of stay >30 days, the average enteral caloric intake was 108 Kcal per kilogram (n = 59) ranging from 76 to 128 kcal/k/day. These babies demonstrated an average daily weight gain of 25 g/d ± 9.7g on enteral feeds. 30% of babies required fortification up to 24 Kcal/oz for adequate growth. However, 60% required additional calories either via fortification or additives. See Fig. 1 The average daily weight gain prior to discharge was 23 g/d. The average weight for length z-score was -0.946 ± 1.4. Thirty-seven babies continued to require fortification with an average caloric density of 22 Kcal/oz to receive approximately 110 Kcal/k/day. Of the 93 infants, 69 infants were feeding human milk at the time of discharge. Thirty were discharged feeding unfortified human milk (4 required hind milk feeds). These infants had an average daily weight gain of 21 g/d prior to discharge. Weight for length z-scores were -0.6 ± 1.5. 12/30 babies were feeding ad libitum. Babies requiring tube feeds were receiving 95 Kcal/k/day at discharge. Conclusions: Provision of human milk is important for the myriad of benefits, both short-term and long-term in infants. Critically ill infants are less likely to receive human milk; however, they may derive greatest benefits. While high rates of human milk feeds can be achieved in babies with CDH, nearly 60% require additional calories in the way of fortification or additives for adequate growth. Prompt recognition of malnutrition and growth failure with aggressive supplementation may improve the overall growth of infants with CDH while in the intensive care unit. These data will help to establish standards for initial caloric goals and higher calorie feeding regimes to improve growth velocity in these patients at high risk for malnutrition.


Demographic Data

n = 93

Gestational Age (weeks): 38±1.9

Male (n) 55

Birth Weight (kilograms) 3.133 ± 0.53

Day of life of admission (d) 1.7

Required ECMO (n) 22

TPN Days (d) 32 ± 26

Duration of ventilation (d) 25 ± 25

Length of Stay (d) 64 ± 58


ENCORE ABSTRACT Previously presented at the 2017 ASHP Midyear Clinical Meeting, December 3-7, 2017, Orlando, FL. Previously unpublished. T70 - Compatibility of Magnesium with Calcium & Phosphate in Parenteral Nutrient Solutions containing TrophAmine Hansel Fernandes, Honors PharmD Student Class of 20181; Kathleen M. Gura, PharmD, BCNSP2,3; Paul Kiritsy, MS, Pharm.D, RPh 1 1MCPHS University, Chelmsford, MA; 2Pharmacy, Boston Children's Hospital, Boston, MA; 3Harvard Medical School, Boston, MA

Purpose: The knowledge about calcium and phosphate compatibility in parenteral nutrient solutions has been well established through the utilization of solubility curves. The concentration of calcium and phosphate is one of a number of factors that can cause precipitation; among others are pH, the type of amino acid, the mixing order of ingredients, and temperature. What hasn’t been established is the effect that magnesium has on the solubility of calcium and phosphate in parenteral nutrient solutions. Both calcium and magnesium have two valence electrons and form ions with the same charge (+2) and could therefore potentally affect the solubility of calcium and phosphate in total parenteral nutrient solutions. This experiment aims to establish the effect of magnesium on calcium and phosphate solubility in parenteral nutrient solutions containing TrophAmine. Methods: A total of 180 20-ml samples were withdrawn from a 2 liter bag of TrophAmine 1% and transferred to individual test tubes using calibrated pipettors. The pH of each solution was determined after preparation of the solution and at various points throughout the experiement. Phosphate was added first as mono, or dibasic potassium phosphate in concentrations ranging from 5-30 mmol/L. Magensium was then added as magnesium sulfate in concetrations ranging from 0-40 mEq/L. Calcium was added last as 10% calcium gluconate in concentrations ranging from 2.5-25 mEq/L. All test tubes were capped and vigorously mixed with a vortex mixer to eliminate local concentrations of calcium, magnesium, and phosphate. All samples were allowed to sit undisturbed at room temperature for approximately 24 hours,


after which the samples would then be placed in a water bath maintained at a temperature of 37 ± 1 degrees Celsius for 30 minutes. Each sample was then visually and spectrophotometrically inspected for signs preipitation. The procedure was then repeated two more times, after which solubility curves were prepared for each magnesium concentration by plotting the concentrations of calcium and phosphate, where precipitation occurred at any point in the experiment. Results: Calcium and phosphate solubility was found to be greater in samples that had higher concentrations of magnesium. As the concentration of magnesium increased there was greater compatibility between calcium and phosphate. The pH of the solution did not drastically change upon administration of the ingredients nor did it change over the 24 hour waiting period. Figure 1 shows the solubility curves shifting to the right and increasing the compatibility zone as the concentration of magnesium increases. Conclusions: The use of magnesium may in fact help the solubility of calcium and phosphate in parenteral nutrient solutions. Use of these precipition curves should be a foundation for future studies to examine the reason magnesium plays a protective role in increasing the compatibilty of calcium and phosphate. Additional studies should be conducted, especially with different brands and concentrations of amino acids to see if this trend continues to show. The effect of these results, with attention to its limitations, should aid in the safe administration of calcium, phosphate, and magnesium in parenteral nutrient solutions.

Financial Support received from: MCPHS University-Boston

Figure 1 T71 - Low body mass index does not correlate with lean mass in children with Cystic Fibrosis, and is associated with worse pulmonary function BOUTAINA ZEMRANI, MD; Andreas Nydegger, MD GASTROENTEROLOGY AND NUTRITION, University Hospital Lausanne, Lausanne, Switzerland


Purpose: Malnutrition is frequent in children with cystic fibrosis (CF). Nutritional status is strongly associated with pulmonary function and survival in these children. Lean mass (LM) is a sensitive indicator of nutritional deficiency and could more accurately predict poor lung function in children with CF. We assessed the relationship between body mass index (BMI) and LM in children with CF at the University Hospital Lausanne in Switzerland, and evaluated the relationship between BMI, LM, fat mass (FM) and lung function of these children. Methods: We conducted a retrospective cross-sectional study that included all children with CF followed up at the University Hospital Lausanne, Switzerland. The following parameters were collected in 2016: weight, height, BMI, body composition determined by anthropometrics (mid-upper arm circumference) by the same dietitian, and pulmonary function determined by forced expiratory volume (FEV1) and lung clearance index (LCI). Malnutrition was defined as a BMI <10th percentile (P). A low LM was defined as <5th P. Statistics were done using linear regression for comparison of nutritional and pulmonary parameters. Results: A total of 54 children were followed up at the CF clinic. They were aged between 6 months and 17 years old with a mean age of 9 years. Of all children, 14% were malnourished (BMI <10thP) and two thirds had a BMI below the 50thP recommended by European and American nutrition societies. All patients aged 5 years and older had an assessment of their body composition, i.e. 26 children. Only 8 % of children had a low LM (<5thP). All children with low LM had a BMI above the 10th P. Surprisingly, all malnourished children had a LM above the 5th P. All children with a LM > 5th P had a BMI >50th P, and all children with a BMI >50th P had a normal LM. A significant correlation (p = 0.001) was found between BMI and lung function, both for FEV1%-predicted and LCI. There was a trend towards a better lung function with increased lean mass, although non-significant: FEV1%-predicted (p = 0.19), LCI (p = 0.59). A non-significant trend was also noted between the increase in FM and the worsening of LCI (p = 0.3). Conclusions: At lower BMI percentiles, BMI does not accurately depict LM in children with CF, whereas a BMI > 50thP is generally associated with a normal LM. These results reinforce the importance of the 50thP as a cut-off for a good nutritional state in children with CF, and support the importance of body composition measurement. Anthropometrics is an easy and reproducible technique for assessing body composition during long-term follow-up of children with CF. Our study also confirmed a trend toward a better lung function with better BMI, better lean mass and low fat mass. We suggest that body composition thresholds should be included in the future nutritional criteria for children with CF.


T72 - Increased Needs for Copper in Parenteral Nutrition for Children in the Neonatal Intensive Care Unit with an Ostomy. Andrea Adler, RD, CSP, LD1; Kadakkal Radhakrishnan, MBBS, MD (Peds), DCH, MRCP (UK), MRCPCH, FAAP2; Sarah Worley, MS 3 1Pediatric Nutrition Support, Pediatrics, Cleveland, OH; 2Pediatric Gastroenterology, Pediatrics, Cleveland, OH; 3Quantitative Health Sciences, Lerner Research Institute, Cleveland, OH

Purpose: To assess the adequacy of the current A.S.P.E.N. recommendations for copper (Cu) dosing in parenteral nutrition (PN) in preventing deficiency in neonates with end-ostomies. Methods: A retrospective electronic medical record review of patients born between January 1, 2015 and December 31, 2016 who were admitted to the Cleveland Clinic Main Campus Neonatal ICU (NICU) for surgical intervention resulting in an ostomy (ileal or jejunal). Standard PN Cu supplementation in this population is 20mcg/kg, and depending on the location of the ostomy site, 400-600mcg Zinc (Zn)/kg. Daily intakes of Cu and Zn were tracked from PN, enteral, and supplemental sources from Epic documentation, along with daily ostomy output. Supplemental Cu was provided with additional Cu in the PN or by providing the IV form of Cu enterally. Serum Cu and Zn levels were obtained 2 months’ post-surgical intervention and if they were suboptimal, per standard protocol, adjustments were made in the nutrition support regimen and values were reassessed monthly until serum levels normalized. The number of serum Cu levels obtained ranged from 1 to 4 depending on their length of stay and the


patient’s levels. Data are described using medians and ranges for continuous variables and counts and percentages for categorical variables. Fisher’s exact test was used to assess the association of low serum Cu levels with low serum Hematocrit (Hct) levels. All analyses were performed on a complete-case basis. Results: Eight patients were admitted who qualified for enrollment; 1 patient was transferred to another facility closer to home. Therefore 7 patient’s data were analyzed for intake compared to serum levels to assess for deficiencies. Low serum Cu level was identified in 71% of the patient’s and low serum Zn was identified in 0% of the patients during the first lab assessment, while 43% of the patients had low serum Hct levels. There was no statistically significant association between low serum Cu and low serum Hct levels (p=0.99). Copper intake (parenteral, enteral, supplemental, or combined) averaged 27.4mcg/kg and Zinc intake (parenteral, enteral, or combined) averaged 521mcg/kg from surgical intervention to 2 months’ post-surgery. Weekly average ostomy output ranged from 3 to 25ml/kg with an average of 15.6ml/kg from surgical intervention to 2 month’s post-surgery. Conclusions: Copper intake in PN support following A.S.P.E.N. standard dosage of 20mcg/kg for patient with an ileal or jejunal ostomy may not be sufficient and potentially lead to a deficiency. More studies are warranted in the neonatal population to determine optimal recommendations and guidelines for PN Cu dosing in this patient population.


T73 - Growth of Very-Low-Birth-Weight Infants: Relationships with Proportion of Diet as Human Milk and Preterm Infant Formula. Hunter L. Pepin, MS, RDN, LDN, CNSC1,8; Deirdre M. Ellard, MS, RDN, LDN1; Katherine A. Bell, MD2,3; Tina Steele, RN, IBCLC2,9; Nneka Nzegwu, DO2,3; Carolyn W. Finch, MS, RDN, LD5,4; Diane M. DellaValle, PhD, RDN, LDN6,7; Mandy B. Belfort, MD, MPH2,3 1Department of Nutrition, Brigham and Women's Hospital, Boston, MA; 2Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA; 3Pediatrics, Harvard Medical School, Boston, MA; 4Director, Advanced Practice Residency: Nutritional Care of the High Risk Infant, Charleston, SC; 5Department of Pediatrics, Medical University of South Carolina, Charleston, SC; 6Department of Nutrition, Athletic Training and Exercise Science, Marywood University, Scranton, PA; 7Faculty, Advanced Practice Residency: Nutritional Care of the High-Risk Infant, Charleston, MA; 8Resident, Advanced Practice Residency: Nutritional Care of the High Risk Infant, Charleston, SC; 9Department of Nursing, Brigham and Women's Hospital, Boston, MA

Purpose: Human milk (HM) exposure and improved growth during the neonatal intensive care unit (NICU) hospitalization are both associated with improved neurodevelopmental outcomes among very-low-birth-weight (VLBW, <1500g) infants. However, the extent to which an HM-only diet, rather than a diet including preterm infant formula, optimally supports growth remains unclear. Our objectives were to (1) determine the extent of differences in growth in relation to NICU diet; and (2) compare the odds of meeting target weight gain (0.8 or less z-score below birth weight z-score) according to diet. We hypothesized that a diet proportionally greater in HM compared with preterm infant formula would be associated with slower growth in all parameters, but that most infants would meet this target regardless of diet. Methods: Retrospective cohort study of 149 VLBW infants born between June 1, 2015 and March 31, 2017. We included all infants with a length of stay ≥28 days and discharge ≥35 weeks’ post-menstrual age (PMA). Exclusion criteria included necrotizing enterocolitis or congenital anomalies known to affect growth. HM was fortified with bovine human milk fortifier until ≥35-36 weeks PMA and enriched with infant formula prior to discharge. The percentage of enteral intake as an HM-based feed was abstracted from the electronic health record every 7 days from birth until discharge or 105 days of life; %HM intake indicates the mean percentage of HM intake. Infants were grouped based on %HM intake as follows: >99% (HM-only), 50-99% (Moderate HM), 0-49% (Low HM). The primary outcome was weight z-score change from birth to discharge (Z-change). Secondary outcomes were Z-change in length, head circumference and body mass index (BMI). We used linear regression to estimate associations of %HM


with Z-change of all growth parameters, adjusting for gestational age, sex and birthweight z-score. We estimated odds ratios for meeting target weight gain for infants fed Moderate and Low as compared to an HM-only diet; and any diet including preterm infant formula as compared with an HM-only diet, adjusting for birth weight z-score in logistic regression. Results: Mean gestational age was 29.3±2.5 weeks, birth weight 1089±282 grams, and z-score -0.89±1.12. Mean %HM intake was 72±32% and 86% of infants met the weight gain target. Higher %HM during NICU stay was associated with slower growth in weight and length but not head circumference or BMI (Table 1). Seventy-nine percent of infants in HM-only group met weight gain target, as compared with 91% of infants fed diets containing preterm infant formula (p=0.056) (Table 2). The odds of meeting weight gain target appeared higher for infants who received diets containing preterm infant formula as compared with an HM-only diet. Conclusions: An HM-only diet, as compared with a diet containing preterm infant formula, was associated with slower weight and linear growth, but not with differences in BMI or head growth. While the majority of infants met target weight Z-change, infants fed some formula appeared more likely to meet weight gain target than infants receiving a diet consisting of HM only. The long term neurodevelopmental and metabolic implications of these differences in growth are unknown.


Table 1. Associations of HM intake with growth during the NICU hospitalization

β (95% CI)

Indicates Z-change per additional 10% of HM during NICU stay

Model 1

(unadjusted) Model 2

(adjusted)

Weight Z-change -0.04 (-0.07, -0.00) -0.03 (-0.06, -0.01)

Length Z-schange -0.06 (-0.09, -0.02) -0.05 (-0.08, -0.01)

Head circumference Z-change -0.03 (-0.07, +0.01) -0.03 (-0.07, +0.01)

Body Mass Index (BMI) Z-change +0.02 (-0.03, +0.07) +0.01 (-0.03, +0.06)

Z-change is change in z-score from birth to discharge. Model 2 adjusted for gestational age, sex and birth weight z-score in linear regression. Table 2. Meeting Weight Gain Target by Diet Group

Diet Group

HM-only

(>99% HM) n=62

Moderate HM (50-99% HM)

n=45

Low HM (0-49% HM)

n=42

Moderate + Low HM

(any formula) n=87

Mean (range) %HM 100% (99.6-

100%) 74% (50-

98%) 26% (0-48%) 51% (0-98%)

Mean (±SD) weight Z-change -0.41 (±0.58) -0.23 (±0.56) -0.02 (±0.65) -0.13 (±0.67)

n (%) met target weight Z-change

49 (79%) 40 (90%) 39 (93%) 79 (91%)

Odds Ratios (95% CI) for Meeting Target Weight Z-change

Model 1 (unadjusted) (Reference) 2.1 (0.7, 6.5) 3.5 (0.9,

13.0) 2.6 (1.0, 6.8)

Model 2 (adjusted) (Reference) 2.6 (0.7, 9.1) 3.1 (0.7,

13.0) 2.8 (1.0, 8.1)


HM = Human Milk (fortified with bovine human milk fortifier until ≥35 weeks PMA and enriched with infant formula prior to discharge.) %HM is mean percentage of enteral intake as an HM-based feed. Weight Z-change is change in z-score from birth to discharge; target weight gain is Z-change ≥-0.8. Infants fed any formula were more likely to meet target weight gain and infants fed low HM were more likely than moderate HM to meet target. Model 2 adjusted for birth weight z-score in logistic regression. T74 - Exploring Potential Factors Contributing to Delayed Enteral Feeding in Children with Moderate and Severe TBI. Stephanie M. Lakinger, MS, RD, CSP1; Heather E. Skillman, MS, RD, CSP, CNSC1; John Recicar, MBA, MHA, RN2; Kimberly Statler-Bennett, MD, MPH3 1Clinical Nutrition, Children's Hospital Colorado, Denver, CO; 2Surgery, Children's Hospital Colorado, Aurora, CO; 3PICU, Children's Hospital Colorado, Aurora, CO

Purpose: Unintentional injuries are the leading cause of death in people aged 1-44 years, and about half of those are traumatic brain injuries (TBI). Critically ill children with TBI are vulnerable to delayed feeding. Enteral nutrition (EN) initiated within 48 hours of admission (early EN), and intake greater than 67% of goal calories and protein (adequate intake) are associated with improved outcomes in critically ill children. However, at our institution, children critically ill with moderate and severe TBI have a later average time to initiation of feeds and meet less of their goal calorie and protein requirements when compared to our whole PICU population. We sought to identify barriers to early EN and adequate intake among PICU patients with TBI. Awareness of these barriers is a first step toward development of quality improvement efforts to improve early and adequate EN for this vulnerable subset of PICU patients. Methods: A retrospective chart review of PICU patients from June 2015-June 2017 was performed. Inclusion criteria included PICU length of stay >2 days, head AIS Score >3, and administration of EN. Parenteral nutrition patients were excluded. Data collected included anthropometrics, mechanism of injury, nutrition intake data, feeding tube route and placement time, medication exposure, clinical outcomes, and surgical procedures. Results: 76 patients met criteria (Table 1). The average time to start EN was 40.5 hours (SD+22.5) from PICU admission. Time to meet goal intake was 62.3 hours (SD+31.9). TBI patients received adequate enteral calorie and protein intake, 77.3% (SD+23.4%) and 74.9% (SD+23.8%), respectively. Compared to our whole PICU population, TBI patients started feeding later (40.5h vs 24.4h), achieved adequate intake later (62.3h vs 34.7h) and received lower percentages of both goal calorie intake (77.3% vs 80 %) and goal protein intake (74.5% vs 85%) (Table 2). TBI patients taken to the operating room had delayed feeds by 4.1 hours on average and delayed goal by 8.6 hours on average when compared to those that did not go to the operating room (Figure 1). They also received lower percentages of both calorie and protein intake (Figure 2). Concurrent facial injuries delayed feeding tube placement by 18.4 hours (57.1h vs 38.7h) but started and reached goal feeds in similar time compared to patients without facial injuries (Table 2). Among TBI patients exposed to vasoactive medications, neuromuscular blockade, pentobarbital administration; concurrent abdominal injury, facial injuries, and ICP monitoring were not associated with significant differences in enteral initiation and adequacy of intake. Conclusions: This study observed trips to the operative room delayed feeding initiation and meeting goals and lowered calorie/protein intake. Delayed feeding tube access in patients with facial fractures may suggest temporary orogastric or salem sump gastric tubes can be used until a stable feeding tube can be placed. Future efforts will identify strategies to improve intake of enteral feedings of TBI patients with multiple operative procedures. TBI patients are complex and multifactorial, therefore further exploration is needed to identify consistent correlations associated with delayed feeding or inadequate intake.





T75 - Mixed Oil Fat Emulsion Use in a Level IV Neonatal Unit: Review and Observations. Laura J. Szekely, MS, RD, LD1; Mary Petrea Cober, PharmD, BCNSP, BCPPS2,3 1Nutrition Services, Akron Children's Hospital, Akron, OH; 2Pharmacy, Akron Children's Hospital, Akron, OH; 3Pharmacy Practice, Northeast Ohio Medical University, College of Pharmacy, Rootstown, OH

Purpose: In premature and critically ill neonates, parenteral nutrition (PN) is often the primary source of nutrition support. Given volume limitations, lipid injectable emulsions (ILEs) provide the benefit of increased caloric density and delivery of essential fatty acids (EFAs). Various ILEs are available, but soy oil-based fat emulsions (SOFEs) have been the primary source in the US. SOFEs contain needed EFAs but concerning pro-inflammatory ω6 fatty acids and phytosterols. Alternatively, fish oil-based fat emulsions (FOFEs) contain anti-inflammatory ω3 fatty acids but limited EFAs. Development of a mixed oil fat emulsion (MOFE) may provide benefits from both oil sources in the hope of reducing the incidence of parenteral nutrition associated liver disease (PNALD) and maintain the nutritional benefits of ILEs. While implementation of other strategies, i.e. SOFE lipid minimization and FOFE monotherapy, may impact the development and outcomes of PNALD, alternate use of a MOFE may provide optimal nutrition while minimizing adverse effects on bile acid metabolism. Although not currently FDA approved for use in neonates, use of MOFEs in the neonatal population shows promise. Consequently, a MOFE product was introduced as the primary ILE in Akron Children's Hospital 75 bed Level IV Neonatal Intensive Care Unit (NICU) in January 2017. Our intent is to report the use of a MOFE in the neonatal population and the observed impact on PNALD and growth. Methods: This study was approved by the Institutional Review Board. A retrospective chart review of all NICU patients who received the MOFE between January and August 2017 was conducted to describe the impact on PNALD and growth. The data obtained included gestational age (GA), anthropometric measurements, PN days, medical/surgical presentation, laboratory findings and malnutrition indicators. Results: Fifty eight patients between 22 and 41 weeks GA received the MOFE. PNALD, defined as a direct bilirubin greater than 2 mg/dL was the primary outcome observed. Of the 58 patients, 17% developed PNALD. Of the 17%, 70% underwent extensive abdominal surgical interventions secondary to necrotizing enterocolitis (NEC), midgut volvulus or chronic intestinal obstruction. The remaining 30% developed gastrointestinal dysmotility, sepsis or coagulopathy concerns prior to developing PNALD. 60% of PNALD affected patients were born at less than 28 weeks GA. Despite optimal MOFE dosing of 3


g/kg/day, patients on PN greater than 14 days demonstrated declining anthropometric Z scores. In some instances, changing clinical status and medication co-administration impacted MOFE product administration. Resolution of PNALD, where achieved, was achieved by transition to enteral feeding. Conclusions: Results of this retrospective review indicate surgical presentation resulting from intestinal perforation, obstruction, necrosis, stage III NEC or overwhelming sepsis may possibly be primary predictors for the development of PNALD despite use of a MOFE. Additionally, growth is negatively impacted despite optimal nutrient provision. More studies are needed to learn about MOFE use in the neonatal population, the predictive factors leading to development of PNALD, and the impact of nutrition support.


T76 - Malnutrition Risk Assessment of Chronically Ill Pediatric Patients in the Outpatient Setting. Jurate Lukosaityte, BSc; Peggy R. Borum, PhD Food Science and Human Nutrition, University of Florida, Gainesville, FL

Purpose: The release of the American Society for Parenteral and Enteral Nutrition and American Academy of Nutrition and Dietetics (ASPEN/AND) clinical guidelines for pediatric malnutrition assessment is an important step for improving identification of undernutrition among hospitalized patients. However, studies have also shown that chronically ill patients, who are not acutely ill or hospitalized, may also be at increased risk for undernutrition. The objective of this study was to evaluate nutritional status in a pediatric population with a refractory epilepsy diagnosis in the outpatient setting. The nutritional status of patients with refractory epilepsy was compared to patients with epilepsy and to a general pediatric care population, both reflective of environmental influence. Methods: This was a retrospective analysis of three pediatric populations (1-20 years) who received routine care in an outpatient clinic within the University of Florida (UF) Health consortium: refractory epilepsy, epilepsy, and general pediatric care. Data for height, weight, sex, and age were collected between June 2011 and October 2016 and were obtained from the UF Integrated Data Repository. Height, weight, and body mass index (BMI) zscores were calculated using age appropriate references from the World Health Organization and Centers for Disease Control and Prevention. The ASPEN/AND clinical guidelines for pediatric malnutrition assessment were used to evaluate risk for undernutrition, and guidelines were extended to include overnutrition. The percentage (%) of clinical encounters for each nutritional status classification was calculated for each population and was compared to expected % in a reference population. Statistical analysis was conducted using the Mann-Whitney test to compare height, weight, and BMI z scores among the refractory epilepsy, epilepsy, and general pediatric care populations. Results: Data from 87,593 clinical encounters, representative of 26,853 patients, were available for analysis. Table 1 lists the % of clinical encounters that were categorized at each nutritional status classification. Compared to the reference and general pediatric care populations, 11% of clinical encounters in with refractory epilepsy population represented height z scores ≤-2, indicating moderate-severe risk for undernutrition (figure 1). Compared to the general pediatric population, a similar % of clinical encounters from patients with refractory epilepsy and epilepsy represented weight and BMI z scores ≥2, indicating moderate-severe risk for overnutrition. Table 2 lists the median and interquartile range (IQR) of height, weight, and BMI z scores for each population. Compared to the general pediatric care population, height z score was significantly lower and BMI z score was significantly higher for both the epilepsy and refractory epilepsy populations (p<.005). Conclusions: Compared to the general pediatric care population, patients with chronic disease are at similar risk for overnutrition, likely related the obesogenic environment of the southeast. However, a subgroup of patients with chronic disease is at increased risk for undernutrition, as indicated by low height z scores. These data suggest chronic malnutrition is an issue among this patient population. These results present a need for earlier identification and prevention of undernutrition among chronically ill pediatric patients in the outpatient setting.





T77 - Determination of Energy Expenditure (EE) in pediatric patients on Extracorporeal Membrane Oxygenation (ECMO). George Mitri, BS, RRT1; Katherine M. Pelletier, MPH, RD, CSP, CNSC 2; Jeffery Cain, RRT4; Ronald E. Dechert, MPH3 1Respiratory, Michigan Medicine, Howell, MI; 2Patient Food and Nutrition Services, University of Michigan Mott Children's Hospital, Ann Arbor, MI; 3Michigan Medicine, Ann Arbor, MI; 4Respiratory Care, Michigan Medicine, Ann Arbor, MI

Purpose: Current clinical practice involves the use of numerous formulas and/or indirect calorimetry for determination of energy expenditure in intensive care patients. Although many equations exist their accuracy may be limited in the most severe patient population. Patients requiring Extracorporeal membrane oxygenation (ECMO) representing some of the most severe and challenging cohort for determination of EE. The purpose of this study is to describe our method of determining EE which accounts for gas exchange (oxygen, carbon dioxide) through both the patient’s native and the artificial lung (ECMO circuit). By accounting for both methods of gas exchange, we believe provides a more accurate assessment of oxygen consumption (VO2) and calculation of energy expenditure in this severe ICU population. Methods: To obtain EE measurements from the artificial lung (ECMO) requires obtaining pre- and post-oxygenator blood gases and the ECMO circuit blood flow (pump flow rate). The ECMO pump flow can be used as a surrogate for cardiac output for the artificial circuit. Application of the Fick principle allows calculation of VO2 as shown below. The respiratory quotient can be assumed as a constant of 0.7-0.8 depending on the feeding status of the patient. Once VO2 and VCO2, EE can be calculated 1. Oxygen consumption (VO2) using the Fick method VO2 = pump flow X (CaO2-CvO2) where CaO2-CvO2 represents the oxygen content difference between arterial and venous blood 2. Carbon dioxide elimination (VCO2) = assumed Respiratory Quotient X oxygen consumption 3. Caloric requirements using the Weir formula (metabolic rate) = 1.44 (3.94 VO2 + 1.11 VCO2) kcals/24 hours If the patient is attached to a mechanical ventilator while on ECMO we obtain REE of native lung using indirect calorimetry (Vmax) and combine both measurements of native and artificial lung for total patient energy expenditure. Results: We performed 32 test on 10 patients on ECMO. Of the patients enrolled 60% (n=6) male with age range from 8 months to 17 years, and weights 4.6 – 109 kg. Malnutrition was identified in 40% (n=4).


twenty-one of 32 test (65%) fell within +/- 10% of the RDN estimated energy expenditure(EEE). Twenty-three of 32 (70%) of the MREE’s were recorded in the RDN documentation (assessment, re-assessment or brief note) 10 of feeding regimens were modified based on MREE if EEE differed within +/- 10% of MREE. Conclusions: The procedure we described above allows determination of gas exchange in both native and artificial lungs (circuit) which can be used to determine EE during periods of ECMO. From our analysis we conclude that 35% of tests conducted showed 10% over/under estimation of caloric needs using conventional assessment. Although these finding are limited with the small sample size, we propose conducting a larger study to better validate our process in order to better assess caloric needs for patients on ECMO.


T78 - Higher calcium and phosphate compatibility curves in parenteral nutrition solutions of two amino acids products. Christina Nguyen, B.Pharm, M.Sc1,2; Valérie Clermont, B.Sc2; Charles Magnan, B.Sc2; Caroline Pellerin, B.Sc2; Ina Puscas, B.Sc2; Brigitte Zoé Martin, B.Pharm, M.Sc1,2; Jean-Marc Forest, B.Pharm, D.P.H., M.Sc1,2; Grégoire Leclair, B.Pharm, PhD2 1Department of Pharmacy, CHU Sainte-Justine, Montreal, Canada; 2Faculty of Pharmacy, University of Montreal, Montreal, Canada

Purpose: Providing adequate amounts of calcium and phosphorus in parenteral nutrition (PN) to pediatric and neonatal populations is often limited by the salts’ compatibility. The aim of this study was to evaluate the presence of precipitation in pediatric and neonatal PN solutions containing various concentrations of two amino acids (AA) products, calcium gluconate and potassium phosphate provided as monobasic (henceforth “monobasic regimen”) or monobasic and dibasic salts (henceforth “dibasic regimen”). Methods: PN solutions were prepared in ethylene vinyl acetate bags according to standard clinical practice, under a laminar airflow hood with an automated compounder at room temperature. The solutions contained standard quantities of ingredients (Table 1) with varying concentrations of calcium gluconate (0-93 mEq/L), potassium phosphate as the monobasic or dibasic regimen (0-65 mmol/L) and AA as Primene® or Travasol blend C® (1, 2, 3 or 4%). Each triplicated preparation was stored under minimal or no lighting at room temperature (20±2°C) for 48h, and then heated for 3h at 37±2°C to simulate passage through an incubator. Precipitation was assessed by visual inspection (t= 0, 4, 24, 48h or 48+3h) and by particle count using light obscuration (t = 0, 48h or 48+3h). A solution was considered compatible in the absence of any visible particle and according to USP <788> standards (no more than 25 particles larger than 10mcm/mL and 3 particles larger than 25mcm/mL). When a single test failed, an additional set of triplicates was compounded and retested. In that case, the combination was considered compatible only if all three solutions from the second set passed the tests. pH was measured at t= 0h for bags containing 20 mEq/L of calcium and 12,9 mmol/L of phosphorus. Results: Eight calcium and phosphate compatibility curves were drafted for each of the AA products (Figures 1 and 2). The monobasic regimen of potassium phosphate yielded higher compatibility for both AA types at all studied percentages. Temperature significantly impacted the compatibility curves for one type of AA, but since it is not used in the neonatal wards of our institution only results at t=48h are presented. Solutions containing the dibasic regimen had consistently higher pH than the monobasic regimen (Table 2), although potassium phosphate accounted for less than 1% of the total bag volume. Conclusions: These solubility curves will be useful for clinicians to safely optimize calcium and phosphorus intake in neonatal and pediatric patients receiving specifically these studied AA blends. Where organic phosphates are unavailable, monobasic potassium phosphate should be favored over monobasic and dibasic potassium phosphate. Additional research is needed to study the compatibility of calcium gluconate with monobasic and dibasic sodium phosphate to safely provide these electrolytes for patients at risk of hyperkalemia.


Financial Support received from: CHU Sainte-Justine pharmacy department and University of Montreal faculty of pharmacy.

Composition of PN solutions

Components Products Concentrations1

Amino acids Primene® 10%

Travasol blend C® (Baxter Corporate, Mississauga, ON, CA)

1 – 4%

Dextrose Dextrose 70%

(Baxter Corporate, Mississauga, ON, CA) 10%

Sodium Sodium acetate Sodium chloride

(PPC®2,Richmond Hill, ON, CA) 30 mMol/L

Potassium3

Monobasic potassium phosphate (Sandoz®, Boucherville, QC, CA)

Potassium Acetate (Hospira®, Lake Forest, IL, USA)

20 – 64,5mMol/L

Calcium4 Calcium gluconate 10%

(Fresenius Kabi®, Richmond Hill, ON, CA) 0 – 93 mEq/L

Phosphate Monobasic potassium phosphate

Monobasic and dibasic potassium phosphate4 (Sandoz®, Boucherville, QC, CA)

0 – 65 mmol/L

Magnesium Magnesium sulfate

(Sandoz®,Boucherville, QC, CA) 5 mmol/L

Zinc Zinc sulfate

(Sandoz®,Boucherville, QC, CA) 3750 mcg/L

Copper5 (Sandoz®, Boucherville, QC, CA) 200 mcg/L

Selenium6 (Sandoz®, Boucherville, QC,CA) 20 mcg/L

Iodine (Sandoz®, Boucherville, QC, CA) 60 mcg/L

Heparin (B.Braun®, Irvine, CA, USA) 1000 units/L

Pediatric vitamins MVI pediatric

(Sandoz®,Boucherville, QC, CA) 35 mL/L

Sterile Water (Baxter®, Deerfield, IL, USA) QS AD

1. For Travasol® with monobasic potassium phosphate, all ingredients excluding calcium and phosphate might have been diluted up to 16%. Solutions prepared for pH testing did not undergo this dilution and concentrations are as presented in this table. 2. PPC® 3. Adjusted to make sure that only one type of phosphate was present. 4. Injected manually. 5. Copper was not added to Primene® solutions to avoid copper cysteinate precipitate. 6. Selenium was not added to Travasol® solutions containing monobasic potassium phosphate due to a backorder at the time of the study. PN solutions’ pH

Amino acids type

Amino acids concentration (%)

Monobasic regimen pH

Dibasic regimen pH

Difference in pH

Primene® 0 5,56 6,32 0,76

1 5,36 5,9 0,54


2 5,29 5,7 0,41

3 5,21 5,55 0,34

4 5,19 5,43 0,24

Travasol®

0 5,56 6,32 0,76

1 5,61 6,2 0,59

2 5,66 6,12 0,46

3 5,68 6,07 0,39

4 5,7 6,32 0,62



T79 - Failure Mode, Effect and Criticality Analysis of the Parenteral Nutrition Process in a Mother-Child Hospital : The AMELIORE Study. Christina Nguyen, B Pharm, MSc; Sophie Lachapelle, PharmD, MSc candidate; Marianne Boulé, PharmD, MSc candidate; Émile Demers, PharmD, MSc candidate; Laurence Collin-Lévesque, PharmD, MSc candidate; Marylou Fournier-Tondreau, PharmD, MSc; Maxime Thibault, B Pharm, MSc; Denis Lebel, B Pharm, MSc, FSCHP; Jean-Françcois Bussières, B Pharm, MSc, MBA, FSCHP, FOPQ Pharmacy department, Centre hospitalier universitaire Sainte-Justine, Canada, Canada

Purpose: The parenteral nutrition (PN) process is complex and involves multiple steps and substeps. Given the particular needs of pediatric and neonatology patients, risks of medication accidents and incidents such as adverse events (AEs) are increased. The objective of this study was to perform a critical analysis of the PN process at the Centre hospitalier universitaire Sainte-Justine (CHUSJ) in order to determine which potential AEs are related to this process and which AEs should be prioritized when implementing corrective measures. Methods: This is a Failure Mode, Effect and Criticality Analysis (FMECA) study. FMECA is a systematic and prospective analysis that proactively identifies the failure modes associated with a process, while attempting to quantify their effects and consequences. A multidisciplinary team assessed each step of the PN process and identified associated failure modes. Adapted rating scales were used to determine failure modes’ severity, frequency and detectability. Ratings were established through multidisciplinary consensus and a criticality index (CI) was calculated for each failure mode. Results: The FMECA was conducted from November 2016 to August 2017. The multidisciplinary team consisted of nurses, nurse practitioners, physicians, pharmacists, pharmacy risk manager and pharmacy technicians. Fourteen multidisciplinary meetings for a total of 13 hours of group discussion and brainstorming were required excluding individual meetings. From 8 to 12 professionals participated actively in each meeting for a total of 34 participants. The five identified steps of the CHUSJ PN process were prescription writing, prescription transcription and validation, compounding and verification, transport to patient care units and administration to patient. A total of 265 failure modes were identified. The step with the highest cumulative CIs was administration to patients with a CI sum of 7,691 (Table 1). The


failure mode with the highest CI was the inscription of an inaccurate weight at prescription with a CI of 800 (Table 2). The most frequent failure modes were identified during the prescription writing step. The AMELIORE study results are similar to those found in the literature, although there are undeniable differences among specific processes at each healthcare facility. General and specific recommendations aimed at minimizing the risks were made according to the 10 most critical and frequent failure modes. Conclusions: The FMECA AMELIORE identified the main steps and sub-steps of the CHUSJ PN process and its failure modes. Several recommendations of potential interventions were made to improve the process. Additional interventions are expected to derive from this project as data will be presented throughout the involved departments. The AMELIORE study is a successful example for other hospitals interested in carrying out the same kind of healthcare improvement initiative.


Table 1: Profile of the number of failure modes and the criticality index sums of each step of the parenteral nutrition process

Steps Number of failure modes Criticality index sums

Prescription writing 33 4216

Prescription transcription and validation 77 5291

Compounding and verification 72 4364

Transport to patient care units 16 1601

Administration to patient 67 7691

Global parenteral nutrition process 265 23163

Table 2: Failure modes profile in descending order of criticality index

Step Sub-step Failure mode Criticality

index

Prescription writing

The prescriber writes the date and/or duration of the prescription, the weight, the infusion time and PN components.

The prescriber writes down a weight other than the right

prescription weight. 800

Compounding and verification

The pharmacy technician removes everything that has remained in place

from the previous day and throws it in the garbage bin (e.g. vials, tubing, bags).

Bags of amino acids and dextrose can be retained for a second day if they are more

than 50% filled.

Inappropriate handling impairs the sterility of the preparation

area. There is a risk of contamination.

648


The prescriber writes the dose of dextrose, the type and doses of amino acids and lipids, and doses of sodium,

potassium, calcium, magnesium, phosphorus and the chlorine percentage.

The pre-printed field of an ingredient required today does

not appear on the re-prescription sheet.

640


The prescriber writes the dose of dextrose, the type and doses of amino acids and lipids, and doses of sodium,

potassium, calcium, magnesium, phosphorus and the chlorine percentage.

The prescriber thinks he is prescribing the optimal dose of

phosphorus by rewriting the dose of the previous day, which is no longer appropriate for this

order.

560


Prescription transcription and

validation

The pharmacist verifies that the transcription is adequate.

Validation is incomplete or inadequate.

500

Administration to patient

The patient's identity is verified when entering the room.

The patient's identity is not confirmed when entering the

room. 500


The assembly of the PN pump and tubing is checked.

Self-check up of the assembly is not carried out or is

incomplete. 500


The prescriber writes down the dose of heparin, copper, iodine, selenium, zinc, multivitamins and the name and dose of other ingredients (e.g., iron, ranitidine,

albumin).

The trace element dose is incorrect because the pre-

printed units change automatically according to

weight (e.g., mcg/kg/day vs. mcg/day).

432


The tubing purge is completed at bedside.

Purge is incomplete. 400


The nurse programs the pump. The nurse does not disable the mode to maintain the veinous

access open on the pump. 400

PN : parenteral nutrition

T80 - Essential fatty acid deficiency in infants on parenteral nutrition with restricted doses of composite intravenous lipid emulsion: A case series. Alexandra N. Carey, MD2,4; Coral Rudie, RD, LDN2; Bram Raphael, MD1,4; Kathleen M. Gura, PharmD, RPh3,4; Mark Puder, MD, PhD5,4 1GI/Nutrition, Boston Children's Hospital, Boston, MA; 2Gastroenterology and Nutrition, Boston Children's Hospital, Boston, MA; 3Pharmacy, Boston Children's Hospital, Boston, MA; 4Harvard Medical School, Boston, MA; 5Department of Surgery and the Vascular Biology Program, Boston Children's Hospital, Boston, MA

Purpose: Introduction: Infants requiring prolonged parenteral nutrition (PN) may receive intravenous (IV) fat emulsion in the form of soybean oil lipid (SOLE), fish oil lipid (FOLE) or composite lipid emulsion (SMOFlipid®). SOLE restriction is a popular method of reducing risk of intestinal failure associated liver disease (IFALD) that may influence dosing strategies of other IV fat emulsions. SMOFlipid® is composed of soybean oil, medium chain triglycerides, olive oil and fish oil with a distinct dosing strategy depending on characteristics such as age, prematurity, enteral intake and diagnosis. Here we present 4 patients on PN with SMOFlipid® as their IV lipid source to examine trends in essential fatty acid (EFA) status, triglycerides (Tg) and dosing. Description: Patient 1 is a 10 month ex-23 week male with short bowel syndrome (SBS) from necrotizing enterocolitis who presented nil per os (NPO) on PN since birth. Due to IFALD and hypertriglyceridemia on SOLE (1-1.5g/kg/day), SMOFlipid® was started at 0.5g/kg/day 3 weeks prior to transfer to our facility. Upon presentation, essential fatty acid (EFA) panel showed EFA deficiency (EFAD) (triene:tetraene (T:T) = 0.325, mead acid 168 nmol/mL; reference range <0.2 and 3-24, respectively). Due to persistent hyperbilirubinemia, SMOFlipid® was stopped and replaced with FOLE (1g/kg/day). T:T ratio and mead acid normalized 15 days after starting FOLE (0.022 and 22 nmol/mL, respectively). Hypertriglyceridemia improved. Patient 2 is a 3 month ex-35 week male with esophageal atresia who presented NPO on PN with SMOFlipid® at 0.86g/kg/day (2g/kg, 3 days/week). Restricted SMOFlipid® was started 2.5 weeks prior to transfer. EFA panel at admission showed EFAD (T:T = 0.464, mead acid 185 nmol/mL). SMOFlipid® increased to 3g/kg/day, jejunal feeds advanced and EFA panel 12 days after dose adjustment showed resolution of EFAD (T:T = 0.017, mead acid 9 nmol/mL). Patient 3 is a 5 month full term male with giant gastroschisis who was NPO since birth. PN with SMOFlipid®


(2g/kg/day) was started. EFA panel 54 days after initiation showed EFAD (T:T = 0.206, mead acid 35 nmol/mL). FOLE was started at 1g/kg/day due to IFALD. EFAD resolved after 13 days on FOLE (T:T = 0.075, mead acid 17 nmol/mL). Patient 4 is a 3 month ex-33 week female with SBS from a meconium pseudocyst. PN with SMOFlipid® (2.5g/kg/day) was started. Enteral feeds advanced. Due to poor growth SMOFlipid® increased to 3g/kg/day. Sixty-one days after SMOFlipid® started and 45 days following dose increase, EFA panel (T:T 0.024, mead acid 7 nmol/mL) and Tg (96 mg/dL) were normal but cholestasis developed. SMOFlipid® was replaced with FOLE (1g/kg/day). Discussion: SMOFlipid® may be a suitable alternative to SOLE in infants on prolonged PN due to the presence of fish oil and α-tocopherol, as well as decreased phytosterol and soybean oil dose. Recommended dose for infants is 2.5-3g/kg/day. To prevent EFAD, a minimum linoleic acid intake of 0.25g/kg/day in preterm infants and 0.1g/kg/day in term infants is recommended. When SMOFlipid® dose is restricted in patients with minimal or no enteral intake, EFAD can occur as noted in patients 1 and 2. Since SMOFlipid® contains only 30% soybean oil, a minimum dose of 2.5g/kg/day may be required to prevent EFAD as noted in patient 3. Patient 4 demonstrated normal EFA status and Tg on recommended doses but developed IFALD. Conclusions: Misapplication of lipid restriction protocols to SMOFlipid® regimens renders patients at risk for EFAD. SMOFlipid® should be dosed within recommended ranges to prevent EFAD. Restricted protocols warrant close monitoring of EFA status in infants on prolonged PN. Hypertriglyceridemia and cholestasis are known adverse effects of SMOFlipid® and require monitoring. Methods: NA Results: NA Conclusions: NA

Financial Support received from: NA

ENCORE ABSTRACT Previously presented at the Mountain States Conference, May 11-12, 2017, Salt Lake City, Utah.

Previously unpublished. T81 - Impact of Sodium Glycerophosphate Solubility on Calcium and Phosphate Prescribing Patterns within Neonatal Parenteral Nutrition Collin Anderson, PharmD; Jared Olson, PharmD; Christian Armstrong, PharmD; Brian Winther, PharmD Primary Children's Hospital, Salt Lake City, UT

Purpose: Premature neonates are at greater risk for metabolic bone disease due to multiple factors, one of which is the ability to provide adequate mineral content within parenteral nutrition due to solubility factors. Well established research has demonstrated the increased solubility of calcium and phosphate within parenteral nutrition containing sodium glycerophosphate versus inorganic phosphate sources. The purpose of this research was to determine if the utilization of glycerophosphate, with its liberal calcium phosphate solubility curves, changed prescribing patterns of calcium and phosphate within parenteral nutrition. Methods: Patients born prior to 33 weeks gestational age, who were prescribed parenteral nutrition for greater than 28 days were included in the review spanning from January 2011 through December 2016. Patients were excluded if they received both sodium glycerophosphate and inorganic phosphate during their hospital stay. The parenteral nutrition prescribing software displayed information to the prescriber informing them of the prescribed solution in relation to known solubility studies for the type of phosphate being utilized. Serum calcium and phosphate levels were analyzed for patients in the sodium glycerophosphate group and compared with patients who received inorganic phosphate. Likewise, the amount of calcium and phosphate prescribed within the PN for both groups were evaluated. Utilization of caffeine, diuretics, steroids, and cholecalciferol were examined between groups. Results: A total of 94 patients met the inclusion criteria with 43 patients in the sodium glycerophosphate group and 51 patients in the control group. Baseline characteristics are listed in Table 1. On average, patients included in the study were 27 weeks gestational age and weighed greater than 1000 grams. The amount of calcium and phosphate prescribed was similar between those receiving sodium


glycerophosphate and those receiving inorganic phosphate within the parenteral nutrition. The sodium glycerophosphate group were prescribed an average 2.97 mEq/kg/day of calcium and 1.38 mmol/kg/day of phosphate compared to the inorganic phosphate group which received 3.08 mEq/kg/day of calcium and 1.34 mmol/kg/day of phosphate, p=0.26 and 0.37 for calcium and phosphate prescribed, respectively. Serum calcium and phosphate levels were 9.99 mg/dL calcium and 5.57 mg/dL phosphate within the sodium glycerophosphate group compared with 9.65 mg/dL calcium and 5.61 mg/dL phosphate for those receiving inorganic phosphate, p=0.02 and 0.67 for calcium and phosphate serum levels, respectively. Conclusions: Although sodium glycerophosphate allows for greater amounts of calcium and phosphate to be prescribed within neonatal parenteral nutrition and the potential to provide amounts closer to those received in utero, there was no difference in the actual prescribing pattern of these two minerals when compared to parenteral nutrition compounded with inorganic phosphate.


T82 - Association of hydration status, assessed by resistance/height and clinical parameters, with clinical outcomes in critically ill children. Luna D. Oliveira, RD1; Daniela B. Hauschild, RD, MSc1; Julia C. Ventura, RD, MSc1; Mirelle S. Farias, RD, PhD3; Nilzete L. Bresolin, MD, MSc2; Yara M. Moreno, RD, PhD1 1Graduate Program in Nutrition, Federal University of Santa Catarina, Florianopolis, Brazil; 2Pediatric Intensive Care Unit, Joana de Gusmão Children’s Hospital, Florianopolis, Brazil; 3Nutrition, Joana de Gusmão Children’s Hospital, Florianopolis, Brazil

Purpose: Changes in hydration status has been associated with increased risk for morbidity and mortality in critically ill children. However, the evaluation of the hydration status is a challenge. Bioelectrical impedance analysis (BIA) is a safe and non-invasive tool that can be performed at the bedside. The resistance, obtained by BIA, reflects the restriction of electric current flowing through the body and is inversely related to the amount of water in the tissues. Thus, this study aimed: to evaluate the association of resistance/height with clinical and biochemical measurements of hydration status and to associate the hydration status with clinical outcomes. Methods: Prospective cohort study conducted in a pediatric intensive care unit (PICU) of a tertiary hospital in south of Brazil, with critically ill children, aged between 1 month and 15 years. Demographic and clinical data, as age, sex, Pediatric Index of Mortality 2 (PIM-2) and use of diuretic, were assessed at admission. Hydration status was assessed within 72 hours of PICU admission and it was evaluated by serum sodium (mmol/L), albumin (g/dL), hemoglobin/hematocrit ratio (g/dL:%), presence of edema, fluid balance (mL/kg/day) in the first 3 days of PICU admission, and resistance/height (Ohms/m). Clinical outcomes of PICU and hospital length of stay (LOS), nosocomial infection, mechanical ventilation and overall mortality were assessed. Mann-Whitney, linear regression and Spearman’s correlation were applied. P-value <0.05 was considered significant. Results: A total of 49 patients were included, 21% male, median age of 51.9 (Interquartile range (IQR) 9.3; 122.4) months and median PIM-2 of 1.9% (IQR 0.9; 4.1). The median PICU LOS was 3 (IQR 2.0; 7.5) days and presence of edema was observed in 10 (20.4%) patients. The median value of resistance/height was 692.4 [401.4; 814.3] Ohms/m (Table 1). There was no association between resistance/height with edema, fluid overload, serum sodium and hemoglobin/hematocrit ratio. There was a directly association between resistance/height with albumin, and inversely association with fluid balance at day 1 and at day 3 (Table 2). Hospital LOS was higher in patients with presence of edema (21 vs. 13 days; p=0.049). Hospital LOS was also correlated with hemoglobin/hematocrit ratio (r=0.31; p=0.039). There was no association between resistance/height and other hydration status parameters with clinical outcomes. Conclusions: In summary, resistance/height was associated with serum albumin and fluid balance, but there was no association with edema, fluid overload, sodium and hemoglobin/hematocrit ratio. Hydration status evaluated by edema and hemoglobin/hematocrit ratio was associated with hospital LOS. More studies with larger sample are necessary to evaluate the use of resistance/height as a parameter of hydration status.


Financial Support received from: A scholarship to Oliveira LDA, Hauschild DB and to Ventura JC were awarded by the Coordination for the Improvement of Higher Education Personnel (CAPES).

Table 1 - Characterization of critically ill children in a Pediatric Intensive Care Unit (n = 49).

Variables Median [IQR]/ n (%)

Sex (male) 21 (42.9)

Age (months) 51.9 [9.3;122.4]

Diagnostic category

Medical 28 (57.1)

Surgical 21 (42.9)

PIM-2 (%) 1.9 [0.9;4.1]

Hydration status

Resistance/height (Ohms/m) 692.4 [401.4;814.3]

Edema 10 (20.4)

Albumin (g/dL) (n=44) 3.3 [3.1;3.6]

Sodium (mmol/L) 139 [136;141]

Hemoglobin/hematocrit (g/dL:%) 0.33 [0.32;0.33]

Fluid balance (mL/kg) day 1 (n=48) 13.8 [5.0;24.2]

Fluid balance (mL/kg) day 2 (n=39) 16.4 [-1.4;36.6]

Fluid balance (mL/kg) day 3 (n=23) 7.6 [-16.2;25.4]

Clinical outcomes

Nosocomial infection (n=48) 4 (8.3)

PICU LOS (days) 3 [2.0;7.5]

Hospital LOS (days) (n=42) 15 [8.0;23.0]

MV 18 (36.7)

Duration of MV (days) (n=18) 4 [1.0;8.0]

Overall mortality (n=42) 3 (7.1)

IQR: interquartile range; LOS: length of stay; MV: mechanical ventilation; PICU: pediatric intensive care unit; PIM-2: Pediatric Index of Mortality 2. Table 2 - Association between clinical parameters with resistance/height at PICU admission.

Variables log Resistance/Height (Ohms/m)1

r β(CI95%)1 p-value

Edema - -0.11 (-0.45; 0.23) 0.518

Albumin (g/dL) 0.38* 0.40 (0.14;0.166) 0.004

Sodium (mmol/L) 0.10 0.02 (-0.01; 0.05) 0.205

Hemoglobin/hematocrit (g/dL:%) -0.07 -0.13 (-0.62;9.36) 0.978

Fluid overload (%) 0.10 0.01 (-0.02; 0.04) 0.646

Fluid balance (mL/kg) day 1 -0.60* -0.00 (-0.00; -0.00) <0.001

Fluid balance (mL/kg) day 2 -0.11 -0.00 (-0.00; -0.00) 0.115


Fluid balance (mL/kg) day 3 0.25 -0.00 (-0.00; -0.00) 0.035

CI: Confidence Interval. 1Logarithm – Ohms. *Spearman correlation p<0.05. T83 - Comparison of Fecal Calrprotectin levels according to feeding kinds in very preterm infants Seung-Wan Ryu, MD.PhD Surgery, Keimyung University, Daegu, Korea (the Republic of)

Purpose: Functional and biochemical maturation of the gastrointestinal tract are established over the last trimester of gestation, which affects the digestive absorptive function of very preterm infants. Fecal calprotectin (FCP) indicates neutrophil migration to the gastrointestinal mucosa and can suggest the severity of mucosal inflammation. We investigated the fecal calprotectin level according to feeding kinds in very preterm infants with or without feeding intolerance (FI) Methods: We prospectively investigated 68 very preterm infants born at 28-31 weeks’ gestation in Keimyung Universitiy Dongsan Medical Center between July 2016 and April 2017. All enrolled infants was fed within 3 hours of life using preterm formula, who achieved full enteral feeding (>100cc/kg/day) within 7days of life. Fecal calprotectin levels were routinely investigated at 7days and 28days of life in fully enteral-fed very preterm infants without parenteral nutrition. FI was defined as gastric residual volume ≥ 50% of previous feeding volume, abdominal distention or emesis, and the disruption of the patient’s feeding plan. The infants with FI were temporarily fed with amino-acid based formula (AAF, Neocate®) after investigation with FCP. Infants with necrotizing enterocolitis, bacterial sepsis, and perinatal asphyxia during hospitalization were not included. FCP were measured by using a commercial quantitative enzyme-linked immunosorbent assay on the Alegria system (ORGENTEC Diagnostika, Mainz, Germany). Results: Median gestational age was 30.1 weeks, and median birth weight was 1488 g. The median age to achieve full enteral feeding was 3.8 days. In sixteen infants with FI, which was developed at median 3.3 days of life (range: 2-6 days of life), FCP levels in formula-fed or breast-fed infants (905±133 μg/g) was significantly higher than that in infants fed amino acid based-formula (217±232 μg/g) (p<0.01). FCP level in formula-fed or breast-fed infants with FI (905±133 μg/g) was significantly higher than that without FI (405±267 μg/g) (p<0.01). In infants without FI, FCP level in formula-fed infants (360±283 μg/g) was not significantly different with that in breast-fed infants (477±234 μg/g) (p>0.05) Conclusions: FCP might be sensitive according to feeding kinds in very preterm infants with feeding intolerance


T84 - Comparison of Estimated Resting Energy Expenditure versus Measured Energy Expenditure in Pediatric ECMO Patients. Katherine M. Pelletier, MPH, RDN, CSP, CNSC2; George Mitri, RT1; Jeffery Cain, RT1 1Respiratory, Michigan Medicine, Howell, MI; 2Patient Food and Nutrition Services, Michigan Medicine Mott Children's Hospital, Ann Arbor, MI

Purpose: Extracorporeal membrane oxygenation (ECMO) is used to support critically ill pediatric patients with severe cardiac and/or respiratory failure. While clinical guidelines exist for neonatal patients supported on ECMO (J.P.E.N 2010), to date, minimal data exists regarding provision of nutrition support to pediatric patients supported by ECMO. Previous research has demonstrated that indirect calorimetry (IC) is the gold standard when determining energy requirements in the critically ill pediatric population as predictive energy equations have been shown to be inaccurate. In the pediatric intensive care unit (PICU), the Registered Dietitian Nutritionist(RDN) uses predictive equations on initial nutrition assessment to help guide energy and protein provision during critical illness until the measured resting energy expenditure (MREE) is available. This study aims to investigate the difference between the estimated


resting energy expenditure (EREE) using predictive equations and the MREE in pediatric patients supported by ECMO. Results of this comparison will be used to identify areas in which we can improve energy provision in pediatric ECMO patients to help optimize nutrition support regimens and improve clinical outcomes. Methods: A retrospective chart review was conducted from the existing electronic medical record (EMR) database on N = 10 pediatric patients receiving ECMO support. Of the 10 patient encounters that were reviewed, there were 32 measured REEs completed by the respiratory therapist (RT). RDN estimation of needs by predictive equation was documented on initial assessment/admission to the PICU and energy needs were monitored and adjusted accordingly based on MREE results when available. Results: Of the 10 patients reviewed for the study, N = 6 were male and N=4 were female ranging in age from 8 months to 17 years. Mortality was 50% where N= 5 survived to discharge and N= 5 were deceased. Malnutrition was diagnosed using Michigan Medicine’s MTool in 40% of the patients (N=4). When split into severity, 20% were diagnosed with moderate malnutrition and 20% (N=2) with severe malnutrition. The predictive equations utilized for comparison of the 32 MREE’s were the World Health Organization (WHO), Schofield Equation, and kcal/kg with N = 13 (41%), N= 18 (56%), and N= 1 (3%) respectively. Moreover, 65% (N=21) of the MEE’s fell within +/- 10% of the RDN EREE. When further broken down between predictive equations, N = 10 (77%) of the MREE compared to WHO fell within estimated range, N=11 (61%) of the MREE compared to Schofield fell within estimated range and N = 0 (0%) of the MREE compared to kcal/kg fell within estimated range. Finally, 70% (N=23) of the MREE’s were recorded in the RDN documentation (assessment, re-assessment or brief note), and 31% (N=10) of feeding regimens were modified based on MREE if the EREE differed within +/- 10% of the MREE. Conclusions: Due to the highly specialized practice of pediatric ECMO support, minimal data exists regarding the use of MREE to optimize nutrition support in pediatric ECMO patients. Our data indicate that the use of the ECMO MREE is extremely valuable to the RDN as ~30 percent of feeding regimens were adjusted following the availability of measured data. As the practice of obtaining MREE in ECMO patients becomes more widely available there is potential for a substantial impact on the prevention or mitigation of malnutrition in this high risk population.


T85 - Enteral protein supplementation in critically ill children: a randomized controlled pilot and feasibility study Daniela B. Hauschild, RD, MSc2; Luna D. Oliveira, RD2; Mirelle S. Farias, RD, PhD3; Eliana Barbosa, RD, MSc3; Nilzete L. Bresolin, MD, MSc4; Nilesh M. Mehta, MD1; Yara M. Moreno, RD, PhD2 1Critical Care Medicine, Dept. of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA; 2Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil; 3Nutrition, Joana de Gusmão Children's Hospital, Florianopolis, Brazil; 4Pediatric Intensive Care Unit, Joana de Gusmão Children's Hospital, Florianópolis, Brazil

Purpose: Loss of muscle mass due to the metabolic stress in critically ill children can negatively impact outcomes. Therefore, protein requirements in this population are higher than for healthy children. However, the exact dose of protein intake associated with improved clinical outcomes in this population is unclear The aim of this study was to examine the effect of protein supplementation on clinical outcomes and nutritional status in critically ill children on enteral nutrition, and to assess the feasibility of a protein supplementation trial in the pediatric intensive care unit (PICU). Methods: Three-arm parallel randomized controlled trial (RCT) in critically ill children on enteral nutrition therapy admitted to an academic center PICU. Patients were randomized to 2 intervention groups, i) polymeric or ii) oligomeric protein modules added within 72 hours of admission, in addition to the nutrition therapy prescribed by the staff. The aim was to reach the protein delivery goal by 4 days. The control group received routine nutritional therapy prescribed by the local dietitian. Demographic and clinical characteristics, nutritional status and daily nutritional intake variables were recorded. Nosocomial infection, PICU and hospital length of stay and duration of mechanical ventilation, and mortality were the


primary outcomes. The secondary outcomes included nitrogen balance, nutritional status parameters (body mass index (BMI) for age and weight for age, mid upper arm circumference (MUAC), triceps skinfold thickness and bioelectrical impedance, serum albumin, prealbumin, and C-reactive protein), and signs of intolerance to nutritional therapy. Results: Over 10 months, we screened 260 patients for eligibility and 20 eligible patients were randomized. One patient was lost to follow-up. At baseline, all patients had BMI values, but after the intervention, MUAC was the most feasible variable (BMI N=14; MUAC N=16). Albumin was obtained from 19 patients at baseline (95%) and from 13 patients (65%) after the intervention. Fourteen patients (70%) had prealbumin at baseline and only 9 (45%) after the intervention. Nitrogen balance was available in 13 patients. The intervention groups, compared to control group, achieved higher protein prescription (p=0.011), actual protein intake (p=0.010) and protein adequacy (p=0.030) in the first 5 days after admission. Enteral nutrition was introduced early and advanced in a stepwise fashion according to the PICU protocol. Approximately 78.5% (11/14) of the patients in the intervention groups used protein supplement in the first 5 days of admission, while none of the control group used the protein supplement. There was no difference between the groups in the rate of predefined adverse effects between 5 and 7 days of admission. Conclusions: Our preliminary results suggest that a larger RCT designed to assess the effect of protein supplementation on clinical outcomes and nutritional status parameters in critically ill children on enteral nutritional therapy is potentially feasible. Early EN and use of protein supplementation allows protein intake goals to be achieved during acute illness.

Financial Support received from: Scholarships to Hauschild DB and Oliveira LDA were awarded by the Coordination for the Improvement of Higher Education Personnel (CAPES).

Table 1 – Adverse effects and clinical outcomes in included patients

Variables Polymeric

N=6 Oligomeric

N=8 Control

N=6 p-value

Adverse effects

After 5 days of admission

Hydric balance (mL/kg/day)

17.8 (3.5; 25.5)

23.9 (20.5; 32.7)

24.5 (18.3; 31.0)

0.418 1

EN interruption - n (%) 5 (83.3) 4 (50.0) 4 (66.7) 0.447 2

Abdominal distension - n (%)

0 (0.0) 0 (0.0) 2 (33.3) -

≥ 3 defecations/day - n (%)

1 (16.7) 1 (12.5) 1 (16.7) 1.000 2

After 7 days of admission

Hydric balance (mL/kg/day)

18.2 (10.6; 23.6)

24.8 (18.3; 27.9)

19.2 (17.9; 34.7)

0.601 1

EN interruption - n (%) 5 (83.3) 5 (62.5) 4 (66.7) 0.837 2

Abdominal distension - n (%)

0 (0.0) 1 (12.5) 2 (33.3) -

≥ 3 defecations/day - n (%)

2 (33.3) 1 (12.5) 0 (0.0) -

Clinical Outcomes

At discharge


Nosocomial infection - n (%)

2 (40.0) 2 (25.0) 2 (33.3) 1.000<sup2<

sup=""></sup2<>

Duration of MV (days) 4.0 (4.0;7.0) 9.5 (4.0; 13.5) 8.5 (4.0; 15.0) 0.687 1

Hospital LOS (days) 13.0 (11.0;

23.0) 26.0 (13.0;

36.0) 29.5 (15.0;

32.0) 0.304 1

PICU LOS (days) 7.0 (6.0; 15.0) 13.5 (8.0; 26.0) 10.5 (8.0;

21.0) 0.455 1

1 Kruskal-Wallis; 1 Fisher's test; EN: enteral nutrition; MV: mechanical ventilation; LOS: length of stay; PICU: Pediatric Intensive Care Unit

Figure 1 – Median of protein intake (g/kg/day) by enteral nutrition, stratified by intervention groups.


Figure 2 – Median of energy intake (kcal/kg/day) by enteral nutrition, stratified by intervention groups.

Figure 3 – Median of volume intake (mL/kg/day) by enteral nutrition, stratified by intervention groups. T86 - Nutritional Management of Recurrent D-Lactic Acidosis in a Child with Short Bowel Syndrome: A Case Report. Megan Gray, RD, LDN1,2; Christopher P. Duggan, MD, MPH3,2; Alexandra N. Carey, MD1,2 1Center for Nutrition, Boston Children's Hospital, Boston, MA; 2Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA


Purpose: Introduction: D-lactic acidosis is a recognized complication of short bowel syndrome (SBS). Acid-base abnormalities can occur when excessive D-lactate is produced by fermentation by intestinal bacteria and absorbed systemically.1 D-lactic acidosis can present as ataxia, slurred speech, and lethargy.2 Although enteral antibiotics are typically used, nutritional management remains crucial in treatment of recurrent D-lactic acidosis. We present a patient with SBS and life threatening recurrent D-lactic acidosis managed in part by nutritional manipulation and antibiotic therapy. Description: A 2-year-old male with SBS secondary to malrotation and volvulus with 20cm of small bowel in continuity with full colon, absent terminal ileum and ileocecal valve, presented to the emergency department (ED) with lethargy and weakness. Laboratory data showed high anion gap metabolic acidosis with elevated serum D-lactate (7.97mmol/L; reference range 0.0-0.25), low CO2 (11mmol/L; reference range: 22-30) and high anion gap (19mmol/L; reference range 7-14). Nutritional intake consisted of an unrestricted oral diet, overnight elemental gastrostomy tube feedings, and intravenous (IV) hydration. In the ED, he received lactated ringer and normal saline boluses. Upon admission, he started on acetate-containing IV fluids and enteral ciprofloxacin to reduce GI tract bacteria. Symptoms and metabolic acidosis resolved. He resumed his previous diet and was discharged. One week later, he presented to the ED with high anion gap metabolic acidosis and lethargy. D-lactate was 11.75mmol/L. Upper GI endoscopy was performed and duodenal cultures sent to evaluate bacterial overgrowth of the small intestine. Due to concern that his carbohydrate-rich oral diet was contributing to D-lactic acidosis, he was made nil per os and a modular enteral formula was initiated; carbohydrates restricted to 25% total calories. Laboratory values normalized and symptoms resolved. He was discharged on acetate-containing IV fluids, enteral sodium bicarbonate, continuous enteral vancomycin coverage, modular enteral formula, and a carbohydrate-free oral diet. Two weeks later, repeat laboratory indices were reassuring. Carbohydrate intake was increased to provide 32% total calories. Oral carbohydrate allowance was liberalized to 45g per day. Continuous enteral vancomycin was weaned to alternating weeks per month. Upon follow up, repeat indices were reassuring. The modular formula was discontinued and elemental formula restarted. Two weeks later, he represented to the ED with high anion gap metabolic acidosis. He transitioned back to the modular formula and continuous enteral antibiotics. Laboratory values normalized. The oral carbohydrate restriction was lifted several weeks later with continuation of the modular formula, enteral sodium bicarbonate and enteral antibiotic coverage with stable follow up serum D-lactate and CO2 levels. Conclusions: D-lactic acidosis can present as a rare but life-threatening complication of SBS. Laboratory evaluation may show high anion-gap metabolic acidosis and elevated D-lactate. Alteration of normal intestinal flora, exogenous sources of D-lactate or reduced metabolism of D-lactate can lead to recurrent D-lactic acidosis in SBS patients. Modular formulas can prevent buildup of D-lactate by decreasing carbohydrate load and excessive malabsorption. Enteral antibiotics can limit bacterial overgrowth and be tailored based on results of endoscopic duodenal aspirates. Special attention should be focused on the etiology of recurrent D-lactic acidosis so that therapy can be prescribed accordingly. Methods: N/A Results: N/A Conclusions: N/A


T87 - Effects of Cyclic Parenteral Nutrition on Parenteral Nutrition-Associated Cholestasis in Newborns Hye Jung Bae, RPh, BCNSP, MS Pharm1,2; Seung Han Shin, MD, PhD3; Ee-Kyung Kim, MD, PhD3; Han-Suk Kim, MD, PhD3; Hye Sun Gwak, PharmD, PhD2; Sung Yun Suh, RPh, MS Pharm1; Yoon Sook Cho, RPh, MS Pharm1 1Department of Pharmacy, Seoul National University Hospital, Seoul, Korea (the Republic of); 2College of Pharmacy and Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul, Korea (the Republic of); 3Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of)


Purpose: Parenteral nutrition (PN) is among the main nutritional methods used in newborns. However, long-term PN induces PN-associated cholestasis (PNAC). Thus, this study aims to evaluate the effect of cyclic PN in the prevention and improvement of PNAC in newborns requiring long-term PN. Methods: A retrospective cohort study was conducted on patients admitted at the Seoul National University Children’s Hospital neonatal intensive care unit between October 2010 and September 2015. They were referred to a nutrition support team and received total parenteral nutrition (TPN) for more than 14 days. No cholestasis was initially observed, but direct bilirubin (DB) levels were measured during the PN period. The incidence of PNAC and hypoglycemia, changes in DB levels, and length of hospital stay were investigated. Results: The subjects comprised 124 patients. Among these, 100 patients received continuous PN, whereas 24 patients received both continuous and cyclic PN. PNAC occurred in 31.5% (39/124) of the total patients. However, it occurred in 87.2% (34/39) of patients under continuous PN. Cyclic PN was an independent factor that significantly decreased PNAC incidence (odds ratio [OR] = .154; 95% confidence interval [CI], .045-.529, p =.003). DB levels significantly reduced (p = .049) with therapeutic cyclic PN, but remained normal with prophylactic cyclic PN. No significant difference in hypoglycemia incidence and length of hospital stay was observed in both continuous PN and continuous to cyclic PN groups. Conclusions: Cyclic PN could be effective in the prevention and improvement of PNAC and safe even in newborns in terms of rate of hypoglycemia.


T88 - Alternative Lipid Emulsion Use in a Pediatric Patient with Cholestasis: A Case Report Kristin Kovanis, RD, CDN, CNSC; Lucia Fox, PharmD; Penny L. Allen, RD, LDN, CNSC Parenteral Nutrition, BriovaRx Infusion, Lenexa, KS

Purpose: While parenteral nutrition (PN) has been a life sustaining therapy for infants with intestinal failure, long term use carries the risk of progressive liver disease. Hepatic dysfunction such as cholestasis and steatosis has been associated with 100% soybean oil lipid. Alternative lipid emulsions were not available in the US until August 2016 when Smoflipid was approved for use in the adult population. This four oil lipid emulsion is a blend of soybean oil, medium-chain triglycerides, olive oil and fish oil with studies suggesting improvement in liver function tests (LFTs), reduction in PN associated liver disease (PNALD), and anti-inflammatory benefits. Currently this product is not approved for pediatric use in the US. Diagnosed with microvillous inclusion disease at birth, GC has since been fully dependent on PN. At 29 months old, PN therapy was transitioned from her original home infusion company to a new PN provider. She presented at 79 cm and 13.4 kg, with cholestasis and cholelithiasis, and medication list included ursodiol. PN was prescribed for 20 hours/day and included 15 mg/kg carnitine, electrolytes, MVI, trace elements, 195g dextrose, 37g amino acid, 13.4g soybean oil based lipid to provide 947 kcal (71kcal/kg). Labs on admission included TG 319 (H), ALT 60 (H), AST 65 (H), ALP 58, total bilirubin 5.9 (H), conjugated bilirubin 3.7(H). Within six months, weight increased to 15.2kg and LFTs worsened: ALP 1269(H), ALT 120 (H), AST 79(H). Due to weight gain and LFTs, lipid was decreased to 3 days/week and infusion time reduced to 15 hours. Over the next two years LFTs declined and weight maintained at 15-16kg. By age 5, LFTs had improved to WNL although GC’s weight had declined to the 3rd percentile (weight-for-age). Increased calories promoted adequate weight gain, but concurrently LFTs increased with ALP 434 (H), AST 45, ALT 47 (H) as of December 2016. Despite temporary dextrose and lipid minimization strategies including a 2 week PN omission, LFTs remained elevated. Methods: Smoflipid had been approved for use in adults four months earlier. Although not approved for


pediatric use in the US, the home infusion nutrition support team facilitated physician and parent approval of a trial, noting the global usage of Smoflipid in the pediatric population. In December 2016, lipid brands were changed in GC’s PN formula. Dosing of the four oil lipid emulsion was prescribed at the previously restricted dose of 20g (1g/kg) three times weekly, less than the manufacturer recommended dose of approximately 28g daily. After 60 days, ALP had improved to WNL and continued to decline past 150 days. After 150 days, total bilirubin remained WNL while AST and ALT had no significant change. Results: Home nutrition support teams are often challenged with meeting a child’s increased calorie needs to support adequate growth, while mitigating hepatic dysfunction with lipid minimization since there are currently no alternative lipid emulsions approved for pediatric use. Despite this strategy, GC’s LFTs continued to rise until the lipid brand was changed, which led to a decline in her ALP. Her AST and ALT levels had no significant change after 150 days which could possibly be related to not receiving the manufacturer’s recommended dosage of at least 143 ml of Smoflipid/day (or approximately 1.5 gm/kg/day). Conclusions: GC’s home PN team continues to work with the physician to increase GC’s Smoflipid dose to assess possible effects on AST and ALT levels. Alternative lipid emulsions may help improve long-term outcomes for children with PNALD; however, prescribers should be aware of recommended dosing in order to maximize hepatic benefits and prevent essential fatty acid deficiency, in particular when transitioning from a restricted dose of soy based lipid.



GC's Liver Function Tests


T89 - Which is the best vascular access in PICU ? : Prospective survey of complications compared with peripheral inserted central catheter(PICC) and central venous catheter(CVC) in pediatric intensive care unit. Yoshiyuki Shimizu, MD1; Hiromi Miyoshi, MD1; Takeshi Hatachi, MD2; Yu Inata, MD3; Kazue Moon, MD4; Jun Takeshita, MD1; Muneyuki Takeuchi, MD5 1Intensive Care Medicine, Osaka Women's and Children's Hospital, Izumi, Japan; 4Intensive Care Medicine, Osaka Women's and Children's Hospital, Izumi, Japan

Purpose: Placement of vascular access is essential and important in pediatric ward, particularly in PICU. Peripheral inserted central catheter(PICC) are useful outside of PICU, however its value (safety in placement, low complication rate in its use and infection, etc) in PICU has not been reported. To assess the optimal use of PICC and CVC in PICU, we conducted the prospective survey of all central venous catheters including PICCs and CVCs from their placement to removal. And, we compared their complications related to their placement, their use, and the reasons of their removal. Methods: Study design: single center, prospective study. All PICCs (Group: P) and CVCs (Group: C) which were placed in our PICU from April 2016 to May 2017 were eligible in this study. All catheters were placed under maximal barrier precaution. We collected 1) patients clinical data (age, weight, height, clinical diagnosis, reasons for PICC or CVC placement), 2) procedural details (puncture site, complications related to catheter placement [mislodging, arterial puncture, pneumothorax]), and 3) clinical course of each PICC (catheter dwell time (days), reasons for catheter removal, 4) complications of the catheter use(catheter-related infection, occlusion, irregularity of fluid infusion, thrombosis, phlebitis, malposition of catheter tip, and the other complication), and we


compared in two groups. Results: In this study period, 175 PICCs and 275 CVCs were placed. Complication rate related to placement were higher in Group P (24 cases [13.7%]) compared to Group C (5 cases [1.8%]) (p<0.01). No fatal complication was recorded in two groups, and most frequent complications in Group P was mislodging (23 cases). Dwell time were longer in Group P (Group P: 15.1±14.5 days [mean ± SD], Group C: 5.05±7.08 days, p<0.01). The rate of removal due to complications in Group P was higher than Group

C (Group P: 47 cases[26.8%], Group C 29 cases[10.5％], p<0.01).

Of accidental removals, the cases of suspicion of catheter related blood stream infection were 28 cases (16%) in Group P and 11 cases (4%) in Group C. Conclusions: There is no lethal complication related to its placement, this showed the safety of PICCs and CVCs in pediatric patients requiring intensive treatment. Some studies showed the advantage of PICCs, however this study pointed out that minor complications were frequent in PICC use than conventional CVC. And, maybe, because of dwell time, there were more accidental removals in PICCs.


T90 - Use of an alternate IV lipid emulsion in a home parenteral nutrition (HPN) patient with Hyperemesis Gravidarum (HG) – a case report Angelina Mason, RD LDN CNSC BriovaRx Infusion Services, Columbia, MD

Purpose: Background: Malnutrition in pregnancy is correlated with low birth weights in infants, neonatal death, and the potential for long-term medical and developmental problems. HG is associated with pre-term birth, pregnancy related hypertension, maternal depression, and increased length of hospital stays for both mothers and infants. Nausea and vomiting of pregnancy (NVP) may occur in 50-80% of all pregnancies, with 0.3 to 3.0% of pregnant women experiencing the extreme NVP of HG. This is typically treated with anti-emetic medications, diet modifications, and IV fluids as needed. In some cases, patients with HG may require PN to maintain nutrition and hydration for the mother and fetus until the NVP resolves, or, in exceptional cases, throughout the pregnancy. Methods: HA is a 28 year old female referred to a national home infusion company for HPN relative to HG symptoms. At the time of referral, patient was 9 weeks pregnant, G1 P0 with no significant PMH. She had several ED admissions for nausea, vomiting and dehydration and failed conservative management of HG symptoms, subsequently losing 7.3 % of her pre-gravida weight. Patient discharged home on PN, hydration, and IV antiemetic medication. She was also noted to have elevated LFT’s and lipase of unclear etiology while in the hospital. Anthropometrics at the start of HPN were 64”, 113lb, UBW 122lb. PN formula at the time of discharge was: 2400ml, 100gm amino acid (AA), 250gm of dextrose and 50gm of soy based lipid, which provided 34kcal/kg and 1.9gm of protein/kg. Hydration in the form of 1000ml LR (PRN) was added to prevent further readmissions for dehydration. After 4 weeks of HPN, HA had not gained any weight and was still unable to tolerate oral intake. AST and ALT remained elevated. PN was reformulated to 2400ml 300gm dextrose, 100gm AA, 60gm of an intravenous blend of soy, MCT, olive oil, and fish oil (Smoflipid®) to provide 39kcal/kg, 1.9gm protein/kg. Supplemental IV folic acid (1 mg) was added to PN. Fetal growth and development was monitored via routine ultrasound. Results: HA started to gain weight once caloric, lipid and micronutrient changes were implemented. (Table 1.) AST and ALT normalized and remained within normal limits after 8 weeks of the new four oil IV lipid blend. Triglycerides and alkaline phosphatase were normal throughout. (Figure 1.) HA tolerated IV therapy (PN, hydration and antiemetics) and had no adverse events related to the infusions. Fetal growth was at about the 50th percentile, and development appeared normal as per serial ultrasounds throughout the pregnancy. Discussion:


Some obstetric practitioners are not as fluent or comfortable with the use of HPN in HG. When there is no other alternative to feed a patient with severe symptoms of nausea and vomiting; HPN along with ongoing nutritional assessment by an interdisciplinary PN team, regular maternal and fetal monitoring, nursing care and education regarding central access and appropriate interventions in care utilizing state of the art products available, can offer mothers and infants positive outcomes. Pregnancy changes macro and micronutrient requirements, as well as metabolism. The use of an alternative blend of lipid emulsions as compared to a 100% soy based lipid may constitute a benefit with the provision of increased DHA and EPA, shown to be beneficial for fetal neurological development. Alternative lipid emulsion blends may also minimize the elevation of LFTs and triglyceride levels that can be seen in pregnancy. More research is indicated to determine potential benefits to this unique population of HPN patients. Methods: n/a Results: n/a Conclusions: n/a


Table 1.


Graph 1. T91 - Recurrent Central Venous Catheter Occlusion Attributed to Calcium Phosphorus Precipitate in a Pediatric Home Parenteral Nutrition Solution Identified During a Transition of Care: a Case Report. Margaret K. Murphy, Pharm D, BCNSP1; Kathleen M. Gura, Pharm D, BCNSP, FASPEN1,2; Jennifer McClelland, MS, FNP-BC2; Carolyn Rosa, NP2; Mary Gallotto, BSN, RN2; Megan Gray, RD, LDN2; Alexandra N. Carey, MD2,3; Bram Raphael, MD2,3 1Pharmacy, Boston Children's Hospital, Brookline, MA; 2Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA; 3Harvard Medical School, Boston, MA

Purpose: Introduction: Calcium(Ca) and phosphorus(P) in parenteral nutrition(PN) solution can precipitate and cause central venous catheter(CVC) occlusions. Solubility of Ca and P in PN is complex and depends on many factors including formulation of amino acids(AA) and beyond use dating(BUD), with inpatient pharmacies using a BUD of 30 hours while home infusion pharmacies must ensure 9 day BUD stability. Here we report a case of a pediatric home parenteral nutrition(HPN) patient with recurrent CVC patency issues likely caused by a Ca/P precipitate which occurred during a transition of care. Description: A 12 year old PN dependent male was admitted to our facility 13 times from January to July 2017, with 62% of admissions due to CVC occlusions. The inpatient pharmacy compounded PN to match the patient’s current HPN. Both HPN and PN were 2-in-1 solutions, with lipids infused via a Y-site. HPN was compounded with AA brand A, while inpatient PN was made with brand B. CVC patency issues were observed only during HPN infusion. Since February 2017, the Ca and P doses in the PN /HPN had been increased due to hypocalcemia/hypophosphatemia(Table 1). Due to a national shortage of brand B, inpatient PN was made with brand A or brand C after 6/6/17. During admission on 6/11/17, the pharmacy was unable to compound the PN with brand A due to a compounding software warning that the Ca/P would precipitate. An inpatient pharmacist noted that the HPN had been made with brand A and these same Ca/P amounts since 2/7/17. Investigation revealed that interpretation of brand A solubility curves differed between the inpatient and home infusion pharmacists. The CVC through which HPN had been infusing was removed and analyzed and a Ca precipitate was identified. The Ca in the PN was gradually reduced due to hypercalcemia. To date, the patient has had no further issues with line patency. Discussion: The nature of Ca/P compatibility in PN solution is complex. Multiple AA brands


exist, each with unique Ca/P solubility parameters. Limited AA brand-specific solubility curves exist to provide guidance, but pharmacists must use clinical judgment when determining maximum allowable Ca/P doses. Based on available curves, the HPN made with brand A was judged to be stable by the home infusion pharmacist, whereas the inpatient pharmacist judged that the same solution would precipitate. When the identical solution was compounded with brand B or C, it was judged to be stable. Recent national shortages of AA often necessitate brand substitutions. It is important for clinicians to be aware of the Ca/P solubility differences among AA brands. Any brand substitution should be considered carefully and pharmacists should recommend changes when precipitation is likely. Solubility differences may also exist between PN compounded for same day use and HPN compounded days prior to infusion. In this case, precipitation seems to have occurred during the transition to outpatient care, when the HPN was made with brand A and stored for weekly use rather than when the PN was made with brand B or C and infused the same day. Conclusion: In cases of recurrent CVC patency issues Ca/P precipitation should be considered. Precipitation of Ca and P in PN is complex and depends on many variables, including AA brand and BUD. Pharmacists must consider the entire PN composition carefully to determine maximum allowable amounts of Ca and P. Vigilance may be especially important during transitions of care and during times of product shortages. Home infusion pharmacies cannot assume an inpatient PN stable for 30 hours is stable for 9 days. AA brand substitutions should be communicated to the prescriber. The ASPEN Safe Practices should always be followed regardless of practice setting. Methods: N/A Results: N/A Conclusions: N/A


Table 1. Formulation changes of the patient's HPN and Inpatient PN solution by date

Date Ca conc. (mEq/L)

P conc. (mmol/L)

AA conc. (g/L)

AA brand

Dextrose conc. (g/L)

Inpatient or HPN

10/31/16 11 12 12 A 50 HPN

2/7/17 15 12 12 A 50 HPN

2/18/17 15 12 12 B 50 Inpatient

2/24/17 15 12 12 A 50 HPN

4/13/17 15 15 12 B 50 Inpatient

4/14/17 15 12 12 A 50 HPN

4/30/17 10 17 12 B 50 Inpatient

5/10/17 15 12 12 A 50 HPN

6/11/17 15 12 12 C 50 Inpatient

6/14/17 10 12 12 C 50 Inpatient

6/17/17 5 12 12 A 50 Inpatient

6/18/17 3 12 12 A 50 Inpatient

6/21/17 3 12 12 A 50 HPN

HPN – home parenteral nutrition; PN - parenteral nutrition; Abbreviations: Ca-calcium; conc. – concentration; mEq- milliequivalent; L-liter; P-phosphorus; mmol-millimole; AA-amino acids; g-grams;mg-milligram

Documents

ASPEN 2018 Nutrition Science & Practice …...ASPEN 2018 Nutrition Science & Practice Conference 9 Purpose: Patients undergoing hematopoietic stem cell transplantation (HSCT) are at