Orientador: Silvia Justina Papini / Coorientador: Sérgio Alberto Rupp de Paiva / Coorientador: Miriam Cristina Marques da Silva Paiva / Banca: Marina Nogueira Berbel Bufarah / Banca: Paula Azevedo Gaiola / Resumo: Introdução: O estudo surgiu em razão da necessidade de compreender o desperdício de dieta enteral na unidade de terapia intensiva. Diversos fatores contribuem para o desperdício de dieta enteral, podendo ser intrínsecos (intolerância gastrointestinal) ou extrínsecos ao paciente (exames, cirurgias), desde a prescrição da dieta até o final da sua administração. Duas formas de verificação do desperdício foram comparadas e testadas como hipóteses: a anotação de enfermagem e a medida direta do volume residual do frasco. A utilização da metodologia de Modo de Falhas e Análise de Efeitos na terapia nutricional e o estudo do desperdício da dieta trouxe pioneirismo ao estudo. Metodologia: O desperdício foi verificado por metodologia quantitativa, o volume anotado pela enfermagem e o volume medido no frasco. Foram avaliados também índices de gravidade dos pacientes e comparados com variáveis relacionadas à dieta enteral. As causas do desperdício poderiam ser encontradas em todas as etapas do processo de dieta enteral. Optou-se nesse trabalho, também, pela metodologia da análise do modo de falhas e efeitos (FMEA), mapeando as etapas, identificando os riscos potenciais e avaliando possíveis danos com pontuação acima de oito através da análise de causa raiz. Resultados/ Discussão: Houve diferença significativa em relação aos volumes de dieta desperdiçados segundo a anotação de enfermagem e o volume medido no frasco. O volume anotado pela enfermagem era maior que o medido. Esse fato pode levar a consequências importantes referentes à anotação inadequada por se tratar de um grande volume desperdiçado, segundo a anotação de enfermagem. Quanto aos índices de gravidade do paciente e variáveis referentes à dieta enteral, houve diferença significativa relacionada às variáveis sexo, idade, uso de droga vasoativa e tempo de internação. Assim, o desperdício foi maior entre os homens, não idosos, internados ... / Abstract: Introduction: This study arose from the need to understand the waste of enteral nutrition in the intensive care unit. Several factors contributed to the waste of enteral feeding and may be intrinsic (gastrointestinal intolerance) or extrinsic to the patient (tests, surgeries), since the diet prescription moment until the end of its administration. Two ways of checking the waste were compared and tested as hypotheses: nurse diary and direct measurement of the residual volume of the bottle. The use of Failure Mode and Effects Analysis methodology in nutritional therapy and the study of diet waste brought originality to the work. Methodology: The waste was verified by quantitative methodology, the volume recorded by the nursing staff and the volume measured on the bottle. Severity scores of patients were also evaluated and compared with enteral nutrition-related variables. The causes of waste could be found at all stages of enteral feeding process, and in this study it was decided by the Failure Mode and Effect Analysis (FMEA) methodology, mapping process, identifying potential risks and evaluating probable damage with score above eight through root cause analysis. Results / Discussion: there was a significant difference between volumes of diet waste according to the nurse diaries and the volume measured on the bottle. The volume registered by the nursing staff was higher than the measured one. This fact may lead to important consequences regarding inappropriate notes once it's about a big volume wasted, according to the records of the nursing staff. As for patient severity scores and variables related to enteral feeding, there were meaningful differences related to sex, age, use of vasoactive drugs and hospitalization time. Thus, the waste was higher among men, not elderly, hospitalized for less than a week (waste per day), without the use of vasoactive drugs. Regarding process failures, most occurred in the period of suspension of the ... / Mestre

Orientador: José Ricardo de Arruda Miranda / Banca: Oswaldo Baffa Filho / Banca: José Carlos Rossi / Banca: Carlos Antônio Caramori / Banca: Roberto Morato Fernandez / Resumo: Não disponível. / Abstract: Not available. / Doutor

Orientador: Maria Isabel Pedreira de Freitas Ceribelli / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-04T02:15:21Z (GMT). No. of bitstreams: 1 Malta_MonicaAlexandre_M.pdf: 4654022 bytes, checksum: 38002dea9a94db1b48fc9aef0d3ccd88 (MD5) Previous issue date: 2003 / Resumo: Para se prevenir a desnutrição, provocada pela oferta de nutrientes menor que as necessidades reais do paciente, deve-se iniciar a terapia nutricional enteral precocemente, através de uma sonda, quando há a impossibilidade da reposição dos nutrientes necessários à alimentação do doente. Com intuito de se predizer medidas antropométricas para realizar a sondagem nasogástrica, usou-se neste estudo a esofagogastroduodenoscopia (EGDA) como padrão de uma medida como referência interna, determinante do comprimento necessário para a introdução do tubo de alimentação até o estômago. Medidas externas foram obtidas entre os pontos : ponta do nariz x lobo da orelha x apêndice xifóide x umbigo e altura correlacionadas com a medida padrão. Trata-se de estudo prospectivo, clínico e descritivo constituído por 140 usuários, encaminhados por demanda espontânea, à esofagogastroduodenoscopia diagnóstica. Para a análise dos dados utilizou-se a correlação linear e multivariada. Encontrou-se duas correlações estatisticamente significativas entre a linha zeta, identificada durante a EGDA, acrescida da distância da rima labial à arcada dentária superior, com a distância compreendida entre os pontos anatômicos lóbulo da orelha e apêndice xifóide (r=0.75) e desta linha com a altura ortostática (r= 0.72). Para se inserir a sonda de alimentação em estômago, de maneira a realizar o procedimento com segurança aos pacientes. Os resultados revelam a possibilidade de se usar a distância predita entre os pontos: lobo da orelha x apêndice xifóide x umbigo para servir como referência / Abstract: In order to prevent malnutrition due to a minor demand of the patient¿s real nutrient supplies, the enteral nutrition therapy must be started early through a feeding tube when the spontaneous feeding remain impossible. With the aim of predicting the anthropometric measures to perform the nasogastric probing, it was used, in this study, the esophagusgastroduodenuscopy(EGDA) as a standard to establish a measurement as an internal reference which determines the necessary length in order to perform the insertion of the feeding tube up to the stomach. External reference measurements were obtained through the points nose tip x earlobe x xiphoid appendix x umbilicus and height which were correlationed with the standard measurement. This is a prospective, clinical and descriptive study with 140 patients, referred as spontaneous request to the diagnostic. In order to do the data analysis, it was used a multivariate and linear correlation. Two it was found a significant statistically correlation: between the ¿zeta¿ line, identified during the esophagusgastroduodenuscopy(EGDA) , with the distance measured between the antomic points of the earlobe and xiphoid appendix ( r= 0.75) and from this line with the orthostatic height ( r=0.72). The results revealed the possibility of using the distance as a prediction measurement among the points: earlobe x xiphoid appendix x umbilicus to establish it as a reference measurement to insert the feeding tube into the stomach / Mestrado / Enfermagem e Trabalho / Mestre em Enfermagem

BACKGROUND: Adequate feeding is a significant challenge for premature infants in the neonatal intensive care unit. These patients are often treated with glycerin suppositories to stimulate the passage of meconium and prevent feeding intolerance. Unfortunately, the evidence for this practice is limited and inconclusive. METHODS: We conducted a systematic review on the use of glycerin suppositories and enemas in premature infants. Following this, we conducted a pilot study for a multicenter randomized controlled trial of premature infants randomized to glycerin suppositories or a placebo procedure once daily. Outcomes included rate of recruitment, rate of reaching the primary endpoint of full enteral feeds, treatment-related adverse events, and cost. RESULTS: Twenty-two infants were recruited and randomized active treatment or the placebo procedure. Gestational age was 24-32 weeks and birth weight was 500-1500 grams. During the study period, 61 infants were screened, 46 (75%) were eligible and approached for consent, 25 (54%) consented to participate, 22 (48%) were randomized, and 19 reached the primary endpoint of full enteral feeds. Three infants (14%) experienced rectal bleeding 5 to 43 days after completing study treatments. An anal fissure was also noted in two of these patients (9%). There were no cases of rectal perforation or necrotizing enterocolitis. Protocol violations occurred during 14 of 130 (11%) treatment days. The total cost for running this pilot study was estimated to be $16,000. A revised sample size calculation for the multicenter study indicated that 72 infants would be required to detect a treatment effect of 2 days faster to full enteral feeds. CONCLUSIONS: This external pilot study suggested that conducting a multicenter randomized controlled trial of glycerin suppositories in premature infants is feasible and safe. In the multicenter trial, we recommend tolerating a lower platelet count in the exclusion criteria, using a fixed rather than variable treatment duration, conducting follow-up assessments at predefined time points, and conducting an interim analysis to ensure that treatment is not associated with increased risk of necrotizing enterocolitis. / Thesis / Master of Science (MSc) / Feeding is a significant challenge for premature babies in the neonatal intensive care unit. These infants have immature digestive tracts and may not have normal bowel movements until a week or more after birth. One way to help premature babies is by giving them a medication called glycerin suppositories. This treatment is already used in many hospitals around the world. Unfortunately, previous studies have not shown for sure that this medication is actually helpful. In fact, there are some signs that using glycerin suppositories in premature infants may be harmful. We conducted a small study involving 22 premature infants randomized to either glycerin suppositories or a placebo. We found that it is safe and practical to do a larger study on this treatment involving multiple hospitals and hundreds of premature babies. The larger study will have enough participants to full show the risks and benefits of using glycerin suppositories to treat these infants.

O objetivo geral deste trabalho foi elaborar formulados alternativos, à base de mistura de alimentos convencionais, provenientes da cesta básica distribuída por entidades do município de Piracicaba-SP, entre outros alimentos, com o intuito de suplementar a alimentação enteral de idosos. Os alimentos utilizados para a elaboração dos formulados foram fubá, óleo de soja, arroz, feijão, macarrão, sardinha, leite em pó, amido de milho, ovos, proteína texturizada de soja, couve- manteiga e cenoura. Foram realizadas análises físicas: gotejamento e viscosidade; análises químicas: composição centesimal, digestibilidade de proteína, determinação do mineral ferro, diálise de ferro in vitro, determinação de -caroteno e fatores antinutricionais, assim como fenólicos totais e ácido fítico; análises microbiológicas: Salmonella, Bacillus cereus, Estafilococos coagulase positiva e Coliformes totais; análise de custos dos formulados e elaboração do manual de boas práticas de manipulação. Os resultados obtidos foram submetidos às análises estatísticas, empregando-se o teste de Tukey, utilizando o software SAS (1996) e análises de regressão, pelo programa Microsoft Office Excel (2003). Concluiuse, com esse estudo, que os formulados líquidos apresentaram os melhores resultados nutricionais, físicos, microbiológicos, e a maior viabilidade econômica, sendo, por isso, sugeridos para a suplementação enteral de idosos. Dentre eles, pode-se eleger uma entre duas alternativas, conforme a necessidade clinica do idoso, considerando-se todos os aspectos nutricionais e físicos dos formulados. O formulado F3 destacou-se nas seguintes características: disponibilidade de ferro, quantidades de -caroteno, digestibilidade, viscosidade e gotejamento. Já o formulado F4 teve destaque na distribuição do valor calórico total de macronutrientes, apresentando valores ideais para os idosos, segundo as recomendações internacionais, além do maior valor calórico entre os formulados e boa viscosidade e gotejamento. No que diz respeito ao valor calórico total, os formulados apresentaram de 131 a 216 calorias por 250ml, os tratamentos líquidos apresentaram valor calórico superior ao dos formulados em pó. Pode-se dizer que os formulados contribuem com percentual médio de 20% de adequação, em relação às recomendações de macronutrientes sugeridas pela DRI (2002) para idosos, quando ingeridas duas porções de 250mL/dia de formulados líquidos ou em pó. / The aim of this study was to develop alternative formulas for elderly enteral feeding using conventional foods from food staples distributed in the city of Piracicaba-SP. The foods used in the formulas were: corn meal, soya oil, rice, beans, pasta, sardine, powder milk, corn starch, eggs, texturized soya protein, cabbage, and carrot. Physical analyses (dripping and viscosity), chemical analyses (centesimal composition, protein digestibility, iron determination, iron dialyses in vitro, -carotene determination, anti-nutritional factors - tannins and phytate), microbiological analyses (Salmonella, Bacillus cereus, positive Staphylococcus coagulase and total Coliforms), cost analyses and elaboration of a manual for good manipulation practices were carried out. Results were analyzed statistically using Tukey test, SAS software (1996) and for regression using Microsoft Office Excel (2003). Liquid formulas presented better nutritional, physical and microbiological results as well as economical viability Therefore were suggested for elderly enteral nourishment. According to the elderly clinical needs, two alternatives are suggested among liquid formulas. The F3 formula is noticeable for iron availability, quantity of -carotene, digestibility, dripping and viscosity. The F4 formulas is noticeable for the total calorie distribution of macronutrients as well as for having a higher number of calories and good viscosity and dripping which is ideal for the elderly, according to international recommendations. The formulas presented a range of 131 to 216 calories/250ml. Liquid formulas presented higher number of calories than powder formulas. The formulas contributed with a 20% adequacy regarding to macronutrient recommendations for the elderly from DRI (2002), when two servings of 250mL.day-1 (powder or liquid) were ingested.

Delayed gastric emptying, that manifests clinically as intolerance to enteral feeding, occurs in over 50% of critically ill patients and has a major impact on patient morbidity and mortality. Despite the recognition that the proximal stomach has a major role in gastric emptying of liquids, only the motor activity of the antro-pyloro-duodenal region has been evaluated in detail. In addition, many of the proposed risk factors for the gastric dysmotility, particularly a prior history of diabetes mellitus, have not been evaluated formally but have been extrapolated from data from non-critically ill patients. The currently available prokinetic drugs, erythromycin and metoclopramide, are considered to be the first line treatment for feed intolerance. However, neither data comparing the effectiveness of these agents nor the data on the effects of combination of therapy in the treatment of feed intolerance are available. The aims of this thesis were, therefore, to examine: (i) proximal gastric motor activity and the association between proximal and distal motility; (ii) the relationship between entero-gastric humoral responses to nutrients, gastric emptying and feed intolerance; (iii) the impact of admission diagnoses, choice of sedations, timing of initiation of feeding, and pre-existing history of diabetes mellitus on gastric emptying and feed intolerance; and (iv) the efficacy of erythromycin, metoclopramide and combination of these drugs in treatment of feed intolerance in critically ill patients. The current thesis indicates that motor activity is impaired in multiple regions of the stomach in the critically ill. When compared to healthy humans, proximal gastric relaxation was prolonged and fundic wave activity was educed during small intestinal nutrient infusion in critically ill patients. In addition, simultaneous assessment of proximal and distal gastric motility demonstrated a possible disruption of the motor integration between the proximal and distal stomach. In light of the recent data that suggested a significantly greater proportion of meal distributed proximally in critically ill patients with delayed gastric emptying (Nguyen, et al. 2006), the disruption of the gastric motor integration and the prolonged gastric relaxation in response to duodenal nutrients may play a significant role in the pathogenesis of slow gastric emptying during critical illness, especially as liquid formulae. The entero-gastric hormonal feedback responses were also disturbed during critical illness. Both fasting and duodenal nutrient-stimulated plasma CCK and PYY concentrations were significantly higher in critically ill patients, particularly those who did not tolerated gastric feeds. The rate of gastric emptying of a liquid meal was inversely related to both fasting and postprandial plasma CCK and PYY concentrations, supporting the potential role of plasma CCK and PYY in the pathogenesis of gastric dysmotility in critically ill patients. Admission diagnosis, choice of sedative drug and blood glucose control but not the timing of enteral feeds were important factors for delayed gastric emptying and feed intolerance in these patients. In particular, delaying enteral feeding by 4 days had no impact on the rate of gastric emptying, intra-gastric meal distribution, or plasma CCK and PYY concentrations. Contrary to traditional belief, critically ill patients with a pre-existing diagnosis of type 2 DM have only a minor disturbance to the proximal stomach, a relatively normal gastric emptying and are at no higher risk of feed intolerance than those without DM, suggesting the presence of pre-existing DM 2 in critically ill patients should not influence the standard practice of gastric feeding. Therapeutically, short-term treatment with low dose erythromycin was more effective than metoclopramide, but the effectiveness decreased rapidly overtime at similar rate as observed with metoclopramide. In patients who failed to response to either agent, treatment with both agents was highly effective in re-establishing feeding success. The use of combination therapy as the initial treatment for feed intolerance was also more effective than erythromycin alone and had less tachyphylaxis. Treatment with erythromycin and metoclopramide, either as a single agent or in combination did not associated with major cardiovascular adverse side effects. Although diarrhoea was a common side effect and was highest with combination therapy, it was not associated with Clostridium difficile infection and settled quickly after the cessation of the prokinetic therapy. In summary, the work performed in the current thesis has provided substantial insights into the understanding of the nature, risk factors, pathogenesis and treatment of disturbed gastric motor function in critically ill patients. Not only do these findings stimulate further research into the mechanisms responsible for gastric dysmotility in critical illness, they also lead to the development of new strategies for optimizing the management of feed intolerance. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1320667 / Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2008

Thesis (Ph. D.)--Ohio State University, 2006. / Title from first page of PDF file. Includes bibliographical references (p. 117-124).

This study compared calorie needs, prescription and intake in enterally fed trauma and burn patients. Calorie needs of twenty-eight sequentially admitted patients were assessed by indirect calorimetry or by the Fick method. Caloric prescriptions were calculated from physicians orders. Following attainment of ordered goal rate, three day caloric intake was averaged. Caloric needs were not statistically different from caloric prescription. Caloric intake was significantly lower than caloric needs (p= 0.001). Intolerance and procedures were frequently cited reasons for withholding feedings. Results of this study suggest that trauma and burn patients may not receive the prescribed level of calories during the initial stage of enteral nutrition support. / Department of Family and Consumer Sciences

Delayed gastric emptying, that manifests clinically as intolerance to enteral feeding, occurs in over 50% of critically ill patients and has a major impact on patient morbidity and mortality. Despite the recognition that the proximal stomach has a major role in gastric emptying of liquids, only the motor activity of the antro-pyloro-duodenal region has been evaluated in detail. In addition, many of the proposed risk factors for the gastric dysmotility, particularly a prior history of diabetes mellitus, have not been evaluated formally but have been extrapolated from data from non-critically ill patients. The currently available prokinetic drugs, erythromycin and metoclopramide, are considered to be the first line treatment for feed intolerance. However, neither data comparing the effectiveness of these agents nor the data on the effects of combination of therapy in the treatment of feed intolerance are available. The aims of this thesis were, therefore, to examine: (i) proximal gastric motor activity and the association between proximal and distal motility; (ii) the relationship between entero-gastric humoral responses to nutrients, gastric emptying and feed intolerance; (iii) the impact of admission diagnoses, choice of sedations, timing of initiation of feeding, and pre-existing history of diabetes mellitus on gastric emptying and feed intolerance; and (iv) the efficacy of erythromycin, metoclopramide and combination of these drugs in treatment of feed intolerance in critically ill patients. The current thesis indicates that motor activity is impaired in multiple regions of the stomach in the critically ill. When compared to healthy humans, proximal gastric relaxation was prolonged and fundic wave activity was educed during small intestinal nutrient infusion in critically ill patients. In addition, simultaneous assessment of proximal and distal gastric motility demonstrated a possible disruption of the motor integration between the proximal and distal stomach. In light of the recent data that suggested a significantly greater proportion of meal distributed proximally in critically ill patients with delayed gastric emptying (Nguyen, et al. 2006), the disruption of the gastric motor integration and the prolonged gastric relaxation in response to duodenal nutrients may play a significant role in the pathogenesis of slow gastric emptying during critical illness, especially as liquid formulae. The entero-gastric hormonal feedback responses were also disturbed during critical illness. Both fasting and duodenal nutrient-stimulated plasma CCK and PYY concentrations were significantly higher in critically ill patients, particularly those who did not tolerated gastric feeds. The rate of gastric emptying of a liquid meal was inversely related to both fasting and postprandial plasma CCK and PYY concentrations, supporting the potential role of plasma CCK and PYY in the pathogenesis of gastric dysmotility in critically ill patients. Admission diagnosis, choice of sedative drug and blood glucose control but not the timing of enteral feeds were important factors for delayed gastric emptying and feed intolerance in these patients. In particular, delaying enteral feeding by 4 days had no impact on the rate of gastric emptying, intra-gastric meal distribution, or plasma CCK and PYY concentrations. Contrary to traditional belief, critically ill patients with a pre-existing diagnosis of type 2 DM have only a minor disturbance to the proximal stomach, a relatively normal gastric emptying and are at no higher risk of feed intolerance than those without DM, suggesting the presence of pre-existing DM 2 in critically ill patients should not influence the standard practice of gastric feeding. Therapeutically, short-term treatment with low dose erythromycin was more effective than metoclopramide, but the effectiveness decreased rapidly overtime at similar rate as observed with metoclopramide. In patients who failed to response to either agent, treatment with both agents was highly effective in re-establishing feeding success. The use of combination therapy as the initial treatment for feed intolerance was also more effective than erythromycin alone and had less tachyphylaxis. Treatment with erythromycin and metoclopramide, either as a single agent or in combination did not associated with major cardiovascular adverse side effects. Although diarrhoea was a common side effect and was highest with combination therapy, it was not associated with Clostridium difficile infection and settled quickly after the cessation of the prokinetic therapy. In summary, the work performed in the current thesis has provided substantial insights into the understanding of the nature, risk factors, pathogenesis and treatment of disturbed gastric motor function in critically ill patients. Not only do these findings stimulate further research into the mechanisms responsible for gastric dysmotility in critical illness, they also lead to the development of new strategies for optimizing the management of feed intolerance. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1320667 / Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2008

Sväljsvårigheter uppstår hos individer med avancerad form av demens som en del av sjukdomsprocessen. Det ställer krav på hälso- och sjukvården att bemöta dessa symtom när individen själv saknar den kognitiva förmågan att fullt hävda sin autonomi avseende nutritionsbehandling. Frågan om sondnäring via sond eller PEG är en adekvat behandling för dessa patienter aktualiseras. Även om det rent utav är ett övergrepp och omvårdnaden istället bör ta en palliativ riktning. Sjuksköterskan betraktar ofta sin kunskap inom området som egna personliga preferenser och inte något som kan hänvisas till i ett kliniskt vårdsammanhang. Syftet med denna studie var att utforska sjuksköterskans etiska medvetenhet kring administrering av sondnäring till individer med avancerad form av demens. Studien genomfördes utifrån en kvalitativ design med en empiriskt utformad intervju, en litteraturöversikt samt en etisk analys utifrån sjuksköterskans möjliga handlingsalternativ i beslutandeprocessen. Slutsatser av denna studie består till en del av att sjuksköterskan bör agera som advokat för individens upplevda bästa och önskemål, ej stödja läkares beslut om administrering av sondnäring till dessa patienter samt bidra till en värdig död inom den palliativa domänen för individen med minsta möjliga lidande som resultat. / Swallowing difficulties occur as a part of the disease process in individuals with advanced dementia. Demands is set on the healthcare-staff to meet with these symptoms when the individual due to loss in cognitive function, lack a complete ability to claim autonomy regarding nutritional treatment. The issue arises regarding enteral feeding by PEG or NG-tube as a viable treatment option for these patients. Even if it is an encroachment and that the care instead should be performed from a palliative point of view. Registered nurses view their knowledge within the area as personal preferences that they cannot refer to in a clinical setting. The aim of this study was to explore the nurse´s ethical awareness regarding enteral nutrition to individuals with advanced dementia. The study was conducted from a qualitative approach with an empirical interview, a literature review and an ethical analysis concerning the nurse’s possible actions’ in the decision making-process. Conclusions of this study consists to a part of that the nurse should act as the patient’s advocate regarding from what’s perceived to be the best for the patient and the patient’s wishes. Also, not supporting the doctor’s decision of tube feeding to these patients’ and to contribute to a dignified death within the palliative domain, with least possible suffering as a result.