Mechanically ventilated critically ill patients treated in the intensive care unit (ICU) require enteral feedings to maintain adequate nutrition during critical illness. Delivery of adequate enteral nutrition is also critical to the recovery of critically ill patients. Enteral nutrition has been shown to decrease length of time on the ventilator, decrease length of stay and ICU and decrease mortality. Despite all the evidence regarding the benefits of enteral nutrition, critically ill patients continue to receive less than their prescribed calories and protein. Nurses are in a unique position to influence the delivery of enteral nutrition. Nursing practices that contribute to underfeeding must be identified and corrected to ensure adequate delivery of nutrients is achieved. The purpose of the study was to describe the professional practice of critical care nurses regarding enteral feeding in mechanically ventilated critically ill patients. Several barriers were identified by the participants in the study that contributed to underfeeding including inconsistent practice regarding gastric residual volume, holding feeds when changing patient position and lack of a standardized protocol for enteral feeding. Also identified in the study was the idea that nurses do not see enteral feeding as a life-saving intervention. It is not the “sexy part” of what ICU nurses do. Enteral feeding guidelines need to be developed to include those interventions that are important to nursing practice in order to increase enteral feeding times and improve patient outcomes.

Acute pancreatitis is a disease which can present in a mild or severe form. In the last few years, the incidence of acute pancreatitis has been steadily rising. The treatment of severe cases is complex and nutrition is one of the key treatment factors. Enteral and parenteral nutrition are documented parts of acute phase treatment included in many guidelines. However, there is a controversy about the timing of initiation of peroral nutrition after the acute phase of severe pancreatitis has resolved. This dissertation shows the results of monocentric prospective randomized trial which compares the safety and effectivity of peroral nutrition compared to enteral nutrition in patients with severe acute pancreatitis during hospitalization as well as in long term after hospital discharge. Patients with severe acute pancreatitis were randomized into two groups - enteral nutrition versus peroral nutrition. The randomized nutrition strategy was initiated within the first 14 days of hospitalization. We monitored the length of hospital stay, tolerance of nutrition, complications, body weight and nutrition parameters. The two groups did not differ significantly in the length of hospital stay. The number of complications was similar between the groups, there was no significant difference in the rate of acute...

The purpose of this study was to ascertain the number of registered dietitians in Tennessee who perceive they are practicing at advanced levels versus those making recommendations only. Job satisfaction according to order writing privileges was also assessed. A five question survey was sent to hospitals meeting selection criteria. Thirty-three surveys (89%) were returned. Eighty-nine percent of dietitians with order writing privileges considered themselves to be advanced level practitioners compared to 60% in the group of dietitians who did not have order writing privileges. Dietitians with order writing privileges indicated greater job satisfaction compared to dietitians that did not have that privilege. Greater job satisfaction was reported with advanced level skills which included order writing privileges. This study may show the need for dietitians to pursue advanced level skills in order to be challenged by their work, which may improve job satisfaction, and advancement in the field of nutritional care.

No description available.

No description available.

0BABSTRACT This thesis is focused on enteral nutrition. This issue is an integral part of intensive and resuscitation care, but it is also a part of standard and follow-up care. There are more and more new resources and the products for enteral nutrition are improving. The theoretical part deals with malnutrition, discusses the different components of nutrition. Much of the thesis forms ways of application of nutrition. The issue is a nasogastric tube, a nasojejunal tube, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy, feeding button or sipping. There are further expanded the introductions, nursing care, indications and contraindications of these options. The following chapters analyse the modes of enteral feeding, advantages and disadvantages of enteral nutrition compared to parenteral. The practical part is focused on research using anonymous questionnaires in the area of enteral nutrition. The survey was conducted in four departments of three teaching hospitals in Prague. It was focused on nurses and paramedics in medical intensive metabolic care units. The survey had 73 respondents. The aim was to identify the mode of feeding that nurses prefer and how they apply it, analyze the extent to which the nurses actively involve themselves in this, how they are oriented in...

Introdução: A terapia de nutrição enteral é imprescindível na manutenção e na reabilitação da pessoa acometida por condições crônicas assistida no contexto domiciliar. Para o êxito desta terapêutica, é imperativo assegurar a articulação entre os profissionais e os serviços de saúde e promover a autonomia dos usuários/cuidadores, reconhecendo-os como parceiros. Objetivo geral: Avaliar a prática da terapia de nutrição enteral (TNE) no Programa de Assistência Domiciliária, em um hospital universitário do Município de São Paulo. Método: Pesquisa desenvolvida nas abordagens quantitativa (fase1) e qualitativa (fase 2), exploratório-descritiva, na modalidade de estudo de caso. O cenário foi o Programa de Assistência Domiciliária do Hospital Universitário da Universidade de São Paulo. A coleta de dados ocorreu entre outubro de 2015 e maio de 2016. Na fase 1, quantitativa, os sujeitos corresponderam a 36 usuários, e os dados foram coletados por meio de dois formulários. Para a análise, empregou-se a estatística descritiva e inferencial. Na fase 2, qualitativa, os participantes foram sete profissionais de saúde e 10 cuidadores/familiares. Para a coleta de dados, adotou-se a entrevista semiestruturada que foi transformada em narrativas, submetidas à análise de conteúdo de Bardin, categorizadas e analisadas à luz do referencial teórico proposto por Wagner. Resultados: Na fase 1, constatou-se que 66,7% eram do sexo feminino, 77,8% com idade a 60 anos e 88,9% estavam acamados. Em relação aos cuidadores/familiares, 88,9% pertenciam ao sexo feminino, possuíam vínculo familiar e média de idade de 51,2 anos (dp13). Quanto à via de acesso, predominaram a nasoenteral (52,8%) e a dieta industrializada (47,3%). A incidência de extubação gástrica foi 1,15/100 pacientes-dia; sendo 0,67/100 pacientes-dia para a não planejada, tendo como principal motivo, o rompimento do balão da sonda de gastrostomia. Nos achados da fase 2, as cinco categorias corresponderam: A nutrição enteral em domicílio: o desvelar do cuidado; Os componentes da tríade avaliativa donabediana no contexto institucional; A expressão de sentimentos: passado, presente e futuro; A tessitura do cuidar: o olhar da equipe interprofissional e dos cuidadores/familiares e A articulação dos serviços de saúde na atenção ao usuário em TNED: do ideal ao real. Dessa maneira, a experiência dos participantes foi marcada pela transição e estabelecimento do cuidado no domicílio, pelo compromisso com o aprendizado e pela superação de obstáculos, frente às extubações não planejadas e o processo de aquisição de dieta industrializada. Considerações Finais: Esta pesquisa propiciou descrever a realidade dos usuários em terapia de nutrição enteral domiciliar (TNED) e conhecer a percepção dos profissionais de saúde e cuidadores/familiares acerca da assistência, permeada por questões envolvendo as atividades do cotidiano dos usuários, o trabalho interprofissional e os desafios oriundos da nutrição enteral no contexto domiciliar. Outrossim, permitiu revisitar o processo de educação em saúde para usuários/cuidadores em TNED, oportunizando a reconstrução de material educativo, com vistas a aprimorar a aquisição do conhecimento e o desenvolvimento de habilidades, que fomentem escolhas e decisões assertivas para melhores desfechos em saúde. / Introduction: Enteral nutrition is essential for maintaining and rehabilitating a person affected by chronic conditions assisted in the home context. For the success of this therapy, it is imperative to ensure the articulation between professionals and health care services promoting the autonomy of patient and caregivers, recognizing them as partners. Objective: To evaluate the practice of Enteral Nutrition (EN) therapy in a Home Care Program, in a university hospital in the city of São Paulo. Method: This research was developed in two phases: quantitative (phase 1) and qualitative (phase 2), both in exploratory-descriptive approaches as a case study. The scenario was the Home Care Program of the University Hospital of the University of São Paulo. Data collection was made between October 2015 and May 2016. In the quantitative phase, the subjects corresponded to 36 patients and the data was collected through two forms while descriptive and inferential statistics were used for the analysis. In the qualitative phase, the participants were seven health professionals and 10 caregivers/family members. For the data collection, a semi-structured interview was adopted, which was then converted into narratives and submitted to the Bardin content analysis, categorized and analysis in light of the theoretical framework proposed by Wagner. Results: In stage 1, was found that 66.7% were female, 77.8%, 60 years and 88.9% were bedridden. Regarding the caregivers/family members, 88.9% were female, with a family tie and the mean age was 51.2 years (sd13). Concerning the access routes, the nasoenteral (52.8%) and the industrialized diet (47.3%) were predominant. The incidence of gastric extubation was 1.15/100 patient-days; and 0.67/100 patient-days represented unplanned ones, due mostly to ruptures of the gastrostomy tube. In the findings of phase 2, five categories corresponded to: Home Enteral Nutrition (HEN): the unveiling of care; The components of the Donabedian triad evaluation in the institutional context; The expression of feelings: past, present and future; The structure of care: the look of the interprofessional team and caregivers/family; and The articulation of health services in the care of users in home enteral nutrition therapy: from ideal to reality. This way, the participants\' experience was marked by the transition to and establishment of home care, the commitment to learning and overcoming obstacles due to unplanned extubations, and the process of acquiring an industrialized diet. Conclusion: This research aimed to describe the reality of patients in HEN and to comprehend the perception of health professionals and caregivers/family concerning the care, permeated by issues involving patient\' daily activities, interprofessional work and the challenges of enteral nutrition in the home context. In addition, it allowed revisiting the process of health education for patients, caregivers and family members in HEN, offering a reconstruction of the educational material, with a view to improving the knowledge acquisition and abilities development, which foment choices and assertive decisions for better outcomes in health.

1) Introdução: A subnutrição em pacientes hospitalizados é comum, independente das condições econômicas do país. Os pacientes gravemente doentes são altamente predispostos a desenvolver subnutrição. E a descontinuidade da administração da terapia nutricional (TN) em unidade de terapia intensiva pediátrica (UTIP) está associada a vários fatores como: distúrbios digestórios, interrupções para procedimentos diagnósticos/terapêuticos, bem como pausa para administração de medicamentos. Objetivo: Identificar as possíveis causas da infusão incompleta da terapia nutricional no paciente gravemente doente. Métodos: Estudo prospectivo, realizado entre abril de 2015 a abril de 2017, foi avaliado sequencialmente a oferta de terapia nutricional enteral e/ou terapia nutricional parenteral com ênfase no volume efetivamente não administrado e as possíveis causas de oferta incompleta da TN. Resultados: Foram avaliados 120 pacientes com média de Z-escore para peso/estatura (-0,5) e desvio padrão (4.12) que apresentaram perdas significativas de terapia nutricional enteral (TNE) e/ou parenteral (TNP) no primeiro e terceiro dias de administração. A principal causa de perda foi a interrupção por procedimentos ou complicações do paciente na unidade de terapia intensiva pediátrica (UTIP). Conclusões: 1) Ocorreu administração incompleta de TN no primeiro e terceiro dias de avaliação em crianças gravemente doentes. 2) Procedimentos e complicações digestivas foram causas importantes de administração incompleta de TNE. 3) Pausa para administração de medicamentos repercutiu na administração incompleta da TNP. 4) O estudo enfatizou a necessidade de envolvimento de todos os profissionais no processo para garantir o aporte de macro e micronutrientes durante a administração da TN / Introduction: Undernutrition is common among hospitalized patients regardless of the economic conditions of a given country. Severely ill patients are predisposed to experience undernutrition. And the discontinuity of nutrition therapy (NT) in the pediatric intensive care setting is associated with several factors, such as gastrointestinal disorders, interruptions for diagnostic/therapeutic procedures, and pauses for the administration of medications. Aim: To identify possible causes of incomplete infusion of nutritional therapy (NT) for severely ill patients. Methods: A prospective study, conducted between April 2015 and April 2017, was sequentially evaluated the offer of enteral nutrition therapy (ENT) and/or parenteral nutrition therapy (PNT) with emphasis on the volume not effectively administered and the possible causes of incomplete offer of (TN). Results: One hundred twenty patients with a mean Z-score for weight/height of 0.5 (standard deviation, 4.12) who presented significant losses of ENT and PNT nutrition on the first and third days of administration. The main cause of losses was interruptions due to procedures or complications of the patient in the pediatric intensive care unit (PICU). Conclusion: 1) Incomplete TN administration occurred on the first and third day of evaluation in critically ill children. 2) Digestive procedures and complications were important causes of incomplete administration of TNE. 3) Pause for administration of drugs has repercussions on incomplete administration of NPT. 4) The study emphasized the need to involve all professionals in the process to ensure macro and micronutrient inputs during TN administration

Introdução: Arginina e antioxidantes estão associados à melhora funcional de cicatrização. Formulação enteral suplementada com arginina e antioxidantes tem sido proposta para corrigir déficit nutricional e garantir substratos ideais para uma boa cicatrização. Ainda não existem informações disponíveis sobre os possíveis mecanismos envolvidos. Objetivo: Avaliar o efeito da nutrição enteral suplementada com arginina e antioxidantes sobre o processo de cicatrização de feridas cutâneas em ratos nutridos e previamente desnutridos, em termos de avaliação morfo-estrutural, bioquímica e biologia molecular. Método: Ratos isogênicos, machos, adultos com peso entre 250 a 350 g, foram divididos aleatoriamente em seis grupos. Três grupos foram mantidos nutridos com alimentação com dieta padrão AIN-93M e três grupos foram submetidos ao regime de desnutrição por 14 dias, com perda de peso corpóreo entre 12 e 15% em relação ao peso corpóreo inicial. Após esse período, os grupos de ratos nutridos e os previamente desnutridos, foram submetidos à lesão cutânea dorsal padronizada e gastrostomia. A seguir, os ratos receberam aleatoriamente dieta por via oral, dieta enteral padrão ou dieta enteral suplementada com arginina e antioxidantes por via gastrostomia, durante 14 dias pós-trauma (PT). A área da lesão cutânea no dia do trauma, no 7º e 14º dias PT foram medidas por fotografia digital. No 7º e 14º dias PT, em tecido de granulação cicatricial, por meio de análise histológica, foram avaliadas as variáveis reepitelização, infiltrado inflamatório, recomposição da derme, quantificação do colágeno total e miofibroblastos (imunoistoquímica). Amostras do tecido de granulação, retiradas no 7º dia PT, foram submetidas à análise de expressão gênica de fatores de crescimento (TGF-beta, KGF, PDGF, VEGF) e colágenos (tipo I e III). Resultados: Ratos nutridos apresentaram maior fechamento da lesão cutânea quando comparados aos previamente desnutridos, no 7º e 14º dias PT, independente dos diferentes tipos de dieta administrados por via gastrostomia. No 14º dia PT, ratos nutridos apresentaram maior reepitelização, intensidade de infiltrado inflamatório e recomposição da derme, quando comparados aos ratos previamente desnutridos, independente da oferta de dieta por via oral, dieta enteral padrão e suplementada. Ratos nutridos e previamente desnutridos, no 7º e 14º dias PT, não apresentaram diferença na quantidade de colágeno total e miofibroblastos, independente do tipo de dieta enteral administrada por via gastrostomia. No 7º dia PT, ratos nutridos apresentaram aumento na expressão gênica dos fatores de crescimento TGF-beta e KGF e colágenos I e III, quando comparados aos ratos previamente desnutridos, independente da dieta enteral administrada por via gastrostomia. Conclusões: 1 - Com estado nutricional mantido, a cicatrização ocorre de maneira adequada, independente da dieta oral, enteral padrão ou suplementada. 2- A desnutrição retarda a cicatrização em termos de epitelização, recomposição da derme e contração da ferida cutânea, independente da realimentação com dieta oral, enteral padrão ou suplementada. 3- Após uma semana de trauma cutâneo, a expressão gênica de fatores de crescimento ligados à cicatrização apresentaram-se alterados em virtude da desnutrição prévia, e não foram revertidos independentemente da realimentação com dieta oral, enteral padrão ou suplementada. 4- Após uma semana de trauma cutâneo, a expressão gênica dos colágenos tipo I e III ligados à cicatrização apresentaram-se alterados em virtude da desnutrição prévia, e não foram revertidos independentemente da realimentação com dieta oral, enteral padrão ou suplementada / Introduction: Arginine and antioxidants are associated with functional enhancement of healing. Arginine and antioxidants supplemented enteral formulas have been used to revert nutritional deficits and to guarantee substrates to ideal healing. The possible mechanisms involved have not been totally elucidated. Objective: To examine the effect of enteral nutrition supplemented with arginine and antioxidants on cutaneous wound healing process in nourished and previously malnourished rats in morphological structural, biochemical and molecular analyses. Methods: Isogenic rats, male, adults, weighting 250 to 350 g, were divided in six groups. Three groups were maintained nourished with oral diet AIN-93 and three groups were submitted to malnutrition process for 14 days, with 12 to 15% of body weight loss. Nourished and previously malnourished groups were submitted to dorsal cutaneous wound and gastrostomy. The rats received oral diet, standard enteral diet or enteral diet supplemented with arginine and antioxidants through gastrostomy during 14 days post trauma (PT). The cutaneous wound area on day of trauma, 7th and 14th days post-trauma were calculated. At 7th and 14th day, histological variables (re-epithelization, inflammatory infiltrate, dermal recomposition and total collagen quantification) and myofibroblasts were analyzed at granulation tissue. Growth factors (TGF-beta, KGF, PDGF and VEGF) and collagens (type I and III) gene expression analyses were performed at samples from the granulation tissue. Results: Nourished rats showed higher contraction of cutaneous wound when compared with previously malnourished rats, on 7th and 14th days post trauma (PT) independent of different enteral diet administered through gastrostomy. On 14th day PT, nourished rats showed higher re-epithelization, inflammatory infiltrate intensity and dermal recomposition when compared to previously malnourished rats, independent of physiologic solution, standard enteral diet and supplemented enteral diet with arginine and antioxidants. Total collagen quantification and myofibroblasts semi-quantification, did not show any significant difference, independent of the enteral diet type, administered through gastrostomy in nourished and previously malnourished rats, at 7th and 14th days PT. Nourished rats showed higher levels of TGF-beta, KGF, collagen type I and III gene expression when compared to previously malnourished rats, independent of the enteral diet type administered through gastrostomy at the 7th day PT. Conclusions: 1- Adequate healing process occurs with the maintenance of nutritional status, independent of the feeding of a oral diet, standard enteral diet or supplemented enteral diet with arginine and antioxidants, 2- Previous malnutrition state slower re-epithelization, dermal recomposition and contraction, independent of refeeding with oral diet, standard enteral diet or supplemented enteral diet with arginine and antioxidants refeeding. 3- Previous malnutrition reduce the levels of growth factors gene expression involved on wound healing, independent of refeeding with oral diet, standard enteral diet or supplemented enteral diet with arginine and antioxidants after seven days post-trauma. 4- Previous malnutrition reduce the levels of collagens type I and III gene expression involved on wound healing, independent of refeeding with oral diet, standard enteral diet or supplemented enteral diet with arginine and antioxidants after seven days post-trauma

Introdução: O câncer de cabeça e pescoço (CCP) ocupa mundialmente a sétima posição em incidência. Até dois terços dos pacientes com CCP podem apresentar disfagia já no diagnóstico da doença. A gastrostomia endoscópica percutânea (GEP) é, atualmente, o método de escolha para oferecer suporte nutricional por longo prazo. A técnica de tração é a mais utilizada por sua simplicidade e baixa morbidade. Entretanto, em pacientes com CCP, a presença de estenoses benignas ou malignas pode dificultar ou impedir a realização do procedimento, além de estar associada a maiores taxas de infecção local e implante tumoral para o sítio de punção da gastrostomia, quando comparada à técnica de introdução com gastropexia. Objetivo: Comparar as técnicas de GEP de tração e de introdução com gastropexia em pacientes com CCP. Métodos: Análise retrospectiva de banco de dados coletado prospectivamente, sobre pacientes com câncer de cabeça e pescoço submetidos à gastrostomia endoscópica percutânea. A técnica de tração foi realizada utilizando-se o kit de gastrostomia PEG 24® PULL METHOD (Cook Medical, Bloomington, Estados Unidos), enquanto a técnica de introdução com gastropexia foi realizada utilizando-se o kit de gastrostomia Freka® Pexact 15 (Fresenius-Kabi, BadHomburg, Alemanha). Resultados: 314 pacientes com câncer de cabeça e pescoço foram encaminhados para realização de GEP. O procedimento foi realizado com sucesso em 309 pacientes (98,4%), sendo 172 gastrostomias pela técnica de tração (GT) e 137 pela técnica de introdução (GI). Os dois grupos foram semelhantes em relação à idade, gênero, média dos níveis séricos de albumina e uso de anticoagulantes ou antiagregantes plaquetários. Os pacientes no GI, no entanto, apresentavam menor índice de Karnofsky (p=0,019) e maior presença de traqueostomia (p=0,003) e trismo (p < 0,001). A localização do tumor foi semelhante entre os dois grupos, no entanto, o estadiamento foi diferente. A maioria nos dois grupos apresentavam tumores estadio IV, entretanto alguns pacientes no grupo de tração apresentavam estadio I e II, enquanto no grupo de introdução não. A taxa total de complicações foi de 36,9%, sendo 5,8% maiores e 31,1% menores. As taxas de complicações imediatas e tardias foram de 6,5% e 30,4%, respectivamente. Não houve diferença estatisticamente significativa dessas taxas entre os dois grupos. Em relação às complicações isoladamente, as únicas que apresentaram diferença significativa foram sangramento menor no local da gastrostomia (p=0,006) e disfunção precoce da sonda (p=0,005), sendo ambas mais frequentes no grupo de introdução. Houve apenas um óbito relacionado ao procedimento, no GT. A mortalidade em 30 dias foi de 20,7%, semelhante entre os grupos. Conclusão: As duas técnicas de GEP apresentam altos índices de sucesso técnico em pacientes com CCP, porém com altos índices de complicações menores. A técnica de introdução com gastropexia apresenta risco aumentado de sangramento menor no local da gastrostomia e de disfunção precoce da sonda quando comparada à técnica de tração / Background: Head and neck cancer (HNC) is the seventh most frequent neoplasm in the world. Up to two-thirds of HNC patients present with dysphagia at diagnosis. Gastrostomy is the method of choice to provide long term tube feeding in patients who are unable to swallow. Percutaneous endoscopic gastrostomy (PEG) with the pull technique is the preferred procedure due to its simplicity and low complication rate. However, in HNC patients, severe stenosis or trismus may preclude the passage of the endoscope and there is an increased infection and PEG site metastasis rates, when compared to the introducer technique. Aim: Compare the pull and introducer with gastropexy PEG techniques in patients with HNC. Methods: Retrospective analysis of a prospectively collected database of HNC patients who underwent PEG. The pull technique was performed with the PEG 24® PULL METHOD (Cook Medical, Bloomington, United States) kit, while the introducer with gastropexy technique was done with the Freka® Pexact 15 (Fresenius-Kabi, BadHomburg, Germany) kit. Results: 314 patients with HNC were sent to the endoscopy unit for PEG. The procedure was successful in 309 (98,4%) patients. The pull technique was employed in 172 patients (PG) while the introducer technique with gastropexy was used in 137 patients (IG). Both groups were similar regarding age, gender, albumin level and the use of anticoagulant or antiplatelet drugs. However patients in the IG had a lower Karnofsky status (p=0,019) and presented more frequently tracheostomy (p=0,003) and trismus (p < 0,001). Although the tumor location was similar in both groups, the staging was different. Most patients presented with stage IV disease in both groups, however in the PG there were more patients with stage I or II. Overall complication rate was 36,9%, with 5,8% of major complications and 31,1% of minor complications. Immediate and late complication rates were 6,5% and 30,4%, respectively. These complications rates were similar in both groups. When the complications were analyzed individually, the IG presented higher minor bleeding (p=0,006) and tube dysfunction (p=0,005) rates. There was only one death directly related to the PEG, in the PG. The 30-day mortality was 20,7%, similar in both groups. Conclusion: The two PEG techniques present high technical success rate in patients with head and neck cancer, however with high minor complications rates. The introducer with gastropexy technique presents higher minor bleeding and tube dysfunction rates when compared to the pull technique