Evolution of the nutritional support pattern in Pediatric Intensive Care

E v o lu tio n o f th e n u tr itio n a l s u p p o r t

p a tte r n in p e d ia tr ic in te n s iv e c a r e

Pediatric Intensive Care Unit of Department

of Pediatrics, Escola Paulista de Medicina,

Universidade Federal de Siio Paulo - Siio Paulo, Brazil

O b je c tiv e s : to e v a lu a te p a tte rn s o f u s a g e a n d m o n ito rin g o f n u tritio n a l s u p p o rt in a P e d ia tric IC U o f a te a c h in g h o s p ita l a n d th e ro le o f a n e d u c a tio n p ro g ra m in n u tritio n a l s u p p o rt g iv e n th ro u g h o u t th e re s id e n t p h y s ic ia n tra in in g . D e s ig n : in a h is to ric a l c o h o rt s tu d y , re c o rd s fro m c h ild re n w h o re c e iv e d n u tritio n a l s u p p o rt d u rin g th e y e a r 1 9 9 2 w e re a n a ly z e d . T h e re a fte r a c o n tin u in g e d u c a tio n p ro g ra m in N u tritio n a l S u p p o rt w a s c o n v e y e d to th e re s id e n ts . In a s e c o n d p h a s e o f th e s tu d y , th e s a m e p a ra m e te rs w e re re e v a lu a te d in c h ild re n w h o re c e iv e d n u tritio n a l s u p p o rt th ro u g h o u t th e y e a r 1 9 9 5 . S e ttin g : P e d ia tric In te n s iv e C a re U n it o f D e p a rtm e n t o f P e d ia tric s , E s c o la P a u lis ta d e M e d ic in a . P a tie n ts : a ll th e c h ild re n w h o w e re g iv e n n u tritio n a l s u p p o rt d u rin g a p e rio d o f fiv e d a y s o r m o re . B a s e d o n th is c rite ria 3 7 c h ild re n w e re s e le c te d fo r th e firs t p h a s e o f th is s tu d y , a n d 3 5 fo r th e s e c o n d o n e . In te rv e n tio n : th e e d u c a tio n p ro g ra m in c lu d e d th e o re tic a l le c tu re s a b o u t b a s ic th e m e s o f n u tritio n a l s u p p o rt a n d jo u rn a l a rtic le re a d in g s e s s io n s . It w a s g iv e n to s u c c e s s iv e g ro u p s o f re s id e n ts o n a w e e k ly s c h e d u le . M e a s u re m e n ts : D a ily re c o rd s o f flu id , p ro te in , c a lo ric a n d m ic ro n u trie n t s u p p ly , n u tritio n a l a s s e s s m e n t a n d m e ta b o lic m o n ito rin g . R e s u lts : In th e firs t p h a s e o f th e s tu d y , a n e x c lu s iv e ly p a re n te ra l ro u te w a s u tiliz e d fo r 8 0 .5 % , a n d a d ig e s tiv e ro u te 1 9 .5 % o f th e tim e p e rio d . N u tritio n a l a s s e s s m e n t w a s p e rfo rm e d o n 3 c h ild re n ; n o p a tie n t h a d th e n u tritio n a l g o a ls s e t. T h e n itro g e n to n o n p ro te in c a lo rie s ra tio a n d th e v ita m in s u p p ly w e re in a d e q u a te , w h ils t th e s u p p ly o f tra c e e le m e n ts w a s a d e q u a te e x c e p t fo r z in c . N u tritio n a l m o n ito rin g w a s p e rfo rm e d o n a lm o s t a ll p a tie n ts b u t w ith o u t u n ifo rm ity . \n th e s e c o n d p h a s e , th e e x c lu s iv e p a re n te ra l ro u te w a s u s e d fo r 6 9 .7 % a n d th e d ig e s tiv e ro u te fo r 3 0 .3 % o f th e tim e p e rio d ; n o s ig n ific a n t in c re a s e in th e u s e o f th e d ig e s tiv e ro u te w a s d e te c te d . T h e n o n p ro te in c a lo rie s to n itro g e n ra tio a n d m ic ro n u trie n t s u p p ly w e re a d e q u a te . T h e fre q u e n c y o f n u tritio n a l a s s e s s m e n t in c re a s e d , b u t d e fic ie n c y in n u tritio n a l m o n ito rin g a n d in fre q u e n t e n te ra l fe e d in g w e re s till d e te c te d . C o n c lu s io n : T h e re w e re d e fic ie n c ie s in th e im p le m e n ta tio n o f n u tritio n a l s u p p o rt, w h ic h w e re p a rtia lly c o rre c te d in th e s e c o n d p h a s e o f th e s tu d y b y th e tra in in g o f th e re s id e n ts . R e in fo rc e m e n t o f th e e d u c a tio n p ro g ra m , w h ic h s h o u ld b e a p p lie d to th e w h o le m e d ic a l s ta ff, a n d th e o rg a n iz a tio n o f a m u ltid is c ip lin a ry te a m in c h a rg e o f c o o rd in a tin g th e p ro v is io n o f n u tritio n a l s u p p o rt a re s u g g e s te d .

U N IT E R M S : N u tritio n a l s u p p o rt. In tra v e n o u s H y p e ra lim e n ta tio n . E n te ra l F e e d in g . N u tritio n a l a s s e s s m e n t.

IN T R O D U C T IO N

N

i m p o r t a n c eu t r i t i o n a l s u p p o r ti n t r e a t m e n th a sa n d p r o g n o s i si n c r e a s i n g l y o f p a t i e n t sg a i n e d a d m i t t e d i n t o h o s p i t a l d u e t o s e v e r e i l l n e s s ( I) .

A d d r e s s fo r c o r r e s p o n d e n c e : H e ito r P o n s L e ite

R u a A r tu r F ig u e ir e d o , 1 1

S a o P a u lo /S P - B r a s il-

CEP

0 4 0 1 2 - 1 5 0

T h e d e v e l o p m e n t o f n e w p a r e n t e r a l a n d e n t e r a l n u t r i t i o n t e c h n i q u e s h a s i m p r o v e d p e r s p e c t i v e s o f t h e s e p a t i e n t s b y r e d u c i n g i ~ - h o s p i t a l m o r b i d i t y . S i n c e i t i s a r e l a t i v e l y r e c e n t t r e a t m e n t , m o s t h o s p i t a l s d o n o t h a v e a t e a m o r g a n i z e d e x c l u s i v e l y f o r t h i s p u r p o s e . C o n s i d e r i n g t h e h i g h p r e v a l e n c e o f m a l n u t r i t i o n i n c h i l d r e n a d m i t t e d i n t o P e d i a t r i c I C U ( 2 ) a n d t h e r i s k o f a g g r a v a t i n g t h e p i c t u r e b y h y p e r c a t a b o l i s m c a u s e d b y i l l n e s s , i t i s e x t r e m e l y r e l e v a n t t o i m p l e m e n t a p p r o p r i a t e n u t r i t i o n a l s u p p o r t f o r t h e s e p a t i e n t s . F e w s t u d i e s i n t h e l i t e r a t u r e h a v e c o n d u c t e d

a critical ap p ro ach to th is su b ject (3 ,4 ,5 ,6 ). A lth o u g h p resen tin g

d ifferen t casu istry , all stu d ies rep o rted im p o rtan t p ro b lem s

in im p lem en tin g n u tritio n al su p p o rt. T h is stu d y w as

d esig n ed to ev alu ate p attern s. o f u sag e an d m o n ito rin g o f

n u tritio n al su p p o rt in a P ed iatric In ten siv e C are U n it an d

th e ro le o f a p ro g ram fo r co n tin u o u s ed u catio n in n u tritio n al

su p p o rt g iv en to resid en ts o f th e IC U .

P A T IE N T S A N D M E T H O D S

In a h isto rical co h o rt stu d y , ch ild ren ad m itted in to

th e P ed iatric In ten siv e C are U n it o f S ao P au lo H o sp ital,

E sco la P au lista d e M ed icin a, w h o receiv ed n u tritio n al

su p p o rt d u rin g th e y ear 1 9 9 3 w ere .an aly zed . A fter th e

first p h ase o f th is stu d y a co u rse o f co n tin u o u s ed u catio n

in n u tritio n al su p p o rt w as g iv en to su ccessiv e g ro u p s o f

resid en ts o f th e th ird y ear. T h e co u rse w as g iv en w eek ly

an d each sessio n lasted ab o u t six ty m in u tes. It at first

in clu d ed th eo retical lectu res ab o u t b asic th em es o f

n u tritio n al su p p o rt an d th ro u g h o u t th e sch o o l y ear it

in clu d ed jo u rn al article read in g sessio n s w h ere recen t an d

o rig in al p ap ers ab o u t n u tritio n al su p p o rt in critically ill

p atien ts w ere p resen ted . In a seco n d p h ase o f th e stu d y

w h ich w as carried o u t in 1 9 9 6 , th e sam e p aram eters w ere

reev alu ated in ch ild ren w h o receiv ed n u tritio n al su p p o rt

th ro u g h o u t th e y ear 1 9 9 5 .

T a b le 1

P a tie n ts a c c o rd in g to th e d ia g n o s is in th e tw o p h a s e s o f th e s tu d y

D ia g n o s is P h a s e I P h a s e II T o ta l (% )

C a rd ia c S u rg e ry 1 1 1 3 2 4 (3 3 .3 % )

S e p s is 8 9 1 7 (2 3 .6 % )

P n e u m o n ia 8 2 1 0 (1 3 .9 % )

N e u ro s u rg e ry 4 3 7 ( 9 .7 % )

E p ile p tic 2 2 4 ( 5 .5 % )

R e n a l F a ilu re 1 3 4 ( 5 .5 % )

E n c e p h a litis 1 1 2 ( 2 .8 % )

M is c e lla n e o u s 2 2 4 ( 5 .5 % )

T o ta l 3 7 3 5 7 2

P A T IE N T S

T h e criteria ad o p ted fo r th e in clu sio n o f p atien ts in

th e stu d y w as n u tritio n al su p p o rt ad m in istratio n d u rin g a

p erio d o f fiv e d ay s o r m o re. B ased o n th is criteria th irty

-sev en ch ild ren w ere selected fo r th e first p h ase o f th is

stu d y , an d th irty -fiv e fo r th e seco n d o n e. T h ere w as n o

sig n ifican t d ifferen ce in th e ag e g ro u p o f th e p atien ts

b etw een th e tw o p h ases o f th e stu d y , w ith m ed ian v alu es

o f 1 0 m o n th s (1 to 1 2 0 ) in th e first p h ase, an d 9 m o n th s

(1 to 1 4 4 m o n th s) in th e seco n d p h ase. T ab le 1 sh o w s th e

m ain d iag n o sis o f th e p atien ts w h en ' ad m itted in to IC U ,

in b o th p h ases o f th e stu d y .

N U T R IT IO N A L S U P P O R T

N u tritio n al su p p o rt is g iv en to ev ery ch ild ad m itted

in to th e u n it, as o f th e m o m en t th ey are h y d rated an d are

in h em o d y n am ic stab ility , in itially g iv en b y th e p aren teral

ro u te. P aren teral n u tritio n is ad m in istered w h en en teral

access can n o t b e o b tain ed , w h en en teral n u tritio n su p p o rt

fails to m eet n u tritio n al req u irem en ts, an d w h en feed in g

in to th e g astro in testin al tract is co n train d icated . In th is

u n it it is m ain ly u sed fo r acu te illn ess lead in g to m etab o lic

stress an d as n u tritio n al su p p o rt in p o st-o p erativ e care.

S o lu tio n s w ith g lu co se co n cen tratio n u p to 1 2 .5 % are

ad m in istered b y p erip h eral v ein , an d th o se w h ich co n tain

h ig h er co n cen tratio n s are in fu sed v ia cen tral v ein .

S o lu tio n s are ad m in istered w ith lip id em u lsio n s m ix ed in

th e sam e v ial. W h en th e d ig estiv e ro u te can n o t b e u sed

(p resen ce o f ileu m , d ig estiv e h em o rrh ag e o r ab d o m in al

d isten tio n ) th e n aso d u o d en al ro u te is asso ciated to th e

p aren teral. A b len d er d iet is u sed , p rep ared b y th e H o sp ital

D ietetic an d N u tritio n al S erv ice, w ith a m o d ified fo rm u la

w ith n o lacto se an d en rich ed w ith casein an d d ex trin

-m alto se, calo ric co n ten ts 1 k cal/m l, n itro g en to n o n p ro tein

calo rics ratio 1 : 1 0 0 , an d o sm o larity 2 8 9 m O sm /L . W e u se

p o ly u reth an e tu b es an d ad m in ister d iet co n tin u o u sly b y

in fu sio n p u m p s. P o st-p y lo ric tu b e p lacem en t is co n firm ed

b y ab d o m in al x -ray an d is m o n ito red d aily b y p H d o sag e

o f w ith d raw n flu id . T h e o ral ro u te is u sed in ch ild ren w ith

n o n eed fo r resp irato ry su p p o rt, an d b len d er d iet o r

m o d ified m ilk is in tro d u ced .

L E IT E , H .P .; IG L E S IA S , S .B .O .; F A R IA , C .M .S .; IK E D A , A .M .; A L B U Q U E R Q U E , M .P .; C A R V A L H O , W .B . - E v o lu tio n o f th e n u tritio n a l

~IJ n n n rt n ;:lttA rn in ~ o e d ia tric in te n s iv e c a re u n it

M E T H O D S

D a ily r e c o r d s o f f lu id , p r o te in , c a lo r ic a n d

m ic r o n u tr ie n ts s u p p ly , in itia l n u tr itio n a l a s s e s s m e n t a n d

m o n ito r in g w e r e e v a lu a te d d u r in g tr e a tm e n t. T o a s s e s s

c a lo r ic s u p p ly r e c e iv e d b y p a tie n ts , th e r u le o f H o llid a y

& S e g a r ( 7 ) w a s ta k e n in to c o n s id e r a tio n . A s f o r p r o te in

s u p p ly , n itr o g e n to n o n p r o te in c a lo r ie s r a tio e q u a l to o r

g r e a te r th a n 1 : 1 0 0 w a s c o n s id e r e d a p p r o p r ia te ( 8 ) . V ita m in

a n d tr a c e e le m e n t s u p p ly b y th e p a r e n te r a l r o u te w a s

c o m p a r e d w ith th e r e c o m m e n d a tio n s o f th e A m e r ic a n

S o c ie ty f o r C lin ic a l N u tr itio n (~ ».I n o r d e r to c h a r a c te r iz e

th e n u tr itio n a l s u p p o r t m o n ito r in g , th e f o llo w in g

p a r a m e te r s w e r e c o n s id e r e d : r e c o r d o f p r o te in - c a lo r ic

s u p p ly , f lu id b a la n c e , w e ig h t, a n d la b o r a to r y te s ts :

h e m o g r a m , g a s o m e tr y , s e r u m u r e a , g ly c e m ia , s o d iu m ,

p o ta s s iu m , c a lc iu m , a lb u m in a n d . tr ig ly c e r id e s .

A s s e s s m e n t o f n u tr itio n a l s ta tu s w a s c o n s id e r e d w h e n e v e r

th e r e w a s r e f e r e n c e to n u tr itio n a l s ta tu s in th e c a s e n o te s .

S T A T IS T IC A L A N A L Y S IS

S ta tis tic a l a n a ly s is w a s p e r f o r m e d u s in g th e M a n n

-W h itn e y te s t to c o m p a r e th e d if f e r e n c e s in tim e p e r io d

f o r th e u s e o f n u tr itio n a l s u p p o r t, a s w e ll a s tim e p e r io d s

f o r e n te r a l n u tr itio n a n d a g e s o f p a tie n ts , in b o th p h a s e s

o f th e s tu d y . F is h e r 's e x a c t te s t w a s u s e d to c o m p a r e th e

e x c lu s iv e p a r e n te r a l r o u te a n d d ig e s tiv e r o u te in r e la tio n

to f u ll s u p p ly o f th e e s tim a te d c a lo r ic n e e d s . I n a ll te s ts

th e le v e l f o r r e je c tio n o f th e e q u a lity h y p o th e s is w a s

e s ta b lis h e d 'a t 0 .0 5 o r 5 % .

R E S U L T S

d ig e s tiv e r o u te in th e s e c o n d p h a s e ( z

=

1 .8 4 ) . I n th e f ir s t p h a s e , 2 9 .7 % o f th e p a tie n ts h a d th e ir c a lo r ic n e e d

s u p p lie d a n d th e n itr o g e n to n o n p r o te in c a lo r ie r a tio

r a n g e d f r o m 1 :2 5 0 to 1 :8 0 . I n th e s e c o n d p h a s e , 2 8 .6 % o f

th e p a tie n ts h a d th e ir c a lo r ic n e e d s s u p p lie d a n d th e

n itr o g e n to n o n p r o te in c a lo r ie r a tio r a n g e d f r o m 1 : 1 5 0 to

1 :1 0 0 . T a b le 2 s h o w s c o m p a r a tiv e d a ta o f a d e q u a c y o f

n u tr itio n a l s u p p o r t o b s e r v e d in th e tw o p h a s e s o f th e s tu d y .

T h e f u ll e s tim a te d c a lo r ic n e e d s u p p ly w a s a c h ie v e d o n ly

in c h ild r e n w h o ' r e c e iv e d n u tr itio n b y th e d ig e s tiv e r o u te

- a s ig n if ic a n t a s s o c ia tio n b e tw e e n u s e o f e n te r a l r o u te

a n d th e f u ll e s tim a te d c a lo r ic n e e d s u p p ly w a s o b s e r v e d

in th e tw o p h a s e s o f th e s tu d y ( p

=

0 .0 1 6 0 a n d p

=

0 .0 0 8 6 ,

r e s p e c tiv e ly ) . T a b le s 3 a n d 4 , r e s p e c tiv e ly , s h o w p a tie n ts

in p h a s e s I a n d I I a c c o r d in g to th e c a lo r ic s u p p ly a n d

a d m in is tr a tio n r o u te f o r n u tr itio n a l s u p p o r t.

N u tr itio n a l m o n ito r in g in c lu d e d w e ig h t, s e r u m

a lb u m in a n d tr ig ly c e r id e s a n d w a s p e r f o r m e d in m o s t

p a tie n ts , a lth o u g h w ith n o u n if o r m ity . T a b le 5 s h o w s

T a b le 2

P a tie n ts a c c o rd in g to th e n u trie n t s u p p ly in th e tw o

p h a s e s o f th e s tu d y

P h a s e I P h a s e II

E n e rg y s u p p ly 1 1 (2 9 .7 % ) 1 0 (2 8 .6 % )

1 0 0 k c a l/k g /d

N

2:n o n 1 0 (2 7 0 /0 ) 3 5 (1 0 0 % )

p ro te in c a lo rie s

T ra c e e le m e n ts In a d e q u a te fo r z in c A d e q u a te

V ita m in s L a c k in g in b io tin , fo la te ,

••

B 1 2 , in a d e q u a te fo r A , D A d e q u a te

T a b le 3

P h a s e I p a tie n ts a c c o rd in g to th e e n e rg y s u p p ly a n d

th e ro u te o f n u tritio n s u p p o rt a d m in is tra tio n

* F is h e r E x a c t T e s t - P

=

0 .0 1 6 I n b o th p h a s e s o f th e s tu d y , th e n u tr itio n a l s u p p o r t

w a s in itia te d w ith in 4 8 h o u r s o f a d m is s io n . I n th e f ir s t

p h a s e , f r o m a to ta l o f 4 2 5 d a y s o f n u .tr itio n a l s u p p o r t, th e e x c lu s iv e p a r e n te r a l r o u te w a s u s e d f o r 3 4 2 d a y s ( 8 0 .5 % o f th e to ta l n u tr itio n a l s u p p o r t p e r io d ) a n d th e d ig e s tiv e

r o u te ( tu b e f e e d in g o r o r a l r o u te ) f o r 8 3 d a y s ( 1 9 .5 % ) . I n th e s e c o n d p h a s e , f r o m a tp ta l o f 4 0 3 d a y s o f n u tr itio n a l s u p p o r t th e 'e x c lu s iv e p a r e n te r a l r o u te w a s u s e d f o r 2 8 1

d a y s ( 6 9 .7 % ) a n d th e d ig e s tiv e r o u te f o r 1 2 2 d a y s ( 3 0 .3 % ) . T h e r e w a s n o d if f e r e n c e .in th e tim e p e r io d s o f n u tr itio n a l s u p p o r t in th e tw o p h a s e s o f th e s tu d y ( z

=

0 .2 3 ) a n d th e r e w a s n o s ig n if ic a n t in c r e a s e in u s e o f th e

E n e rg y G o a l

A c h ie v e d

Y e s

N o

T o ta l

E x c lu s iv e

P a re n te ra l

o

1 6

1 6

E n te ra l

A s s o c ia te d

1 0 *

2 1

3 1

S a o P a u lo M e d ic a l J o u rn a l/R P M 1 1 6 (1 ): 1 6 0 6 -1 6 1 2 , 1 9 9 8 L E IT E , H .P .; IG L E S IA S , S .B .O .; F A R IA , C .M .S .; IK E D A , A .M .; A L B U Q U E R Q U E , M .P .; C A R V A L H O , W .B . - E v o lu tio n o f th e n u tritio n a l

T a b le 4

P h a s e II p a tie n ts a c c o rd in g to th e e n e rg y s u p p ly a n d

th e ro u te o f n u tritio n s u p p o rt a d m in is tra tio n

E n e rg y G o a l E x c lu s iv e E n te ra l

A c h ie v e d P a re n te ra l A s s o c ia te d

Y e s 0 9 *

N o 1 2 . 1 4

T o ta l 1 2 2 3

* F is h e r E x a c t T e s t - P

=

0 .0 0 8 6

c o m p a ra tiv e d a ta fo r n u tritio n a l s u p p o rt m o n ito rin g in th is

a n d o th e r s tu d ie s in th e lite ra tu re .

D IS C U S S IO N

T h e n u tritio n a l a n d m e ta b o lic p ro file o f c ritic a lly ill

p a tie n ts is d iffe re n t fro m th a t o b s e rv e d in p a tie n ts in

n u tritio n a l d e p riv a tio n . T h is h a s le d to th e d e v e lo p m e n t

o f a n e w tre a tm e n t a p p ro a c h c a lle d m e ta b o lic s u p p o rt (X ),

w h ic h a im s a t m a in te n a n c e o f o rg a n ic s tru c tu re a n d o f

o p tim a l c o n d itio n s fo r re c o v e ry o f in ju re d tis s u e s a n d fo r

im m u n o lo g ic d e fe n s e . T h is a p p ro a c h d iffe rs fro m th e

tra d itio n a l, s in c e it is a im e d a t c ritic a lly ill p a tie n ts w ith

in c re a s e d n u trie n t n e e d s , b u t w h o , o n th e o th e r h a n d ,

p re s e n t lim ita tio n s in th e a c u te p h a s e o f th e p ro c e s s

re g a rd in g m a n ip u la tio n o f s u b s tra te s a n d flu id v o lu m e .

C u rre n t g u id e lin e s fo r n u tritio n a l s u p p o rt in c lu d in g

p ra c tic e s ta n d a rd s fo r th e c ritic a lly ill c h ild h a v e re c e n tly

b e e n p u b lis h e d (1 0 ).

In o u r s tu d y , le s s th a n a th ird o f th e p a tie n ts re c e iv e d

a ll e s tim a te d c a lo ric n e e d s a n d th e m a jo rity o f th e p a tie n ts

d id n o t re c e iv e e v e n h a lf o f th e m . T h e fa c to rs th a t m a y

lim it th e a d m in is tra tio n o f c a lo ric s u p p ly a re : n e e d fo r

flu id re s tric tio n , w h ic h is o fte n re q u ire d in c ritic a lly ill

p a tie n ts , a n d in fre q u e n t u s e o f th e e n te ra l ro u te . In fa c t,

in b o th p h a s e s o f th e s tu d y , th e p a tie n ts w h o c o u ld re c e iv e

a ll e s tim a te d c a lo ric n e e d s w e re th o s e fo r w h o m th e

d ig e s tiv e ro u te w a s u s e d , in d ic a tin g th e n e e d fo r u s e

to g e th e r w ith e n te ra l n u tritio n in o rd e r to a tta in a n

a d e q u a te c a lo ric s u p p ly , o r to p ro v id e a g re a te r c a lo ric

s u p p ly to p a tie n ts in p a re n te ra l n u tritio n b y p e rip h e ra l

v e in s (1 1 ).

A n im p o rta n t a d v a n c e in u n d e rs ta n d in g th e ro le o f

e n te ra l n u tritio n in c ritic a lly ill p a tie n ts h a s ta k e n p la c e .

T h e a b s e n c e o f n u trie n ts in th e d ig e s tiv e tu b e m a y b e

h a rm fu l s in c e it n e e d s lo w -le v e l n u trie n t e x p o s u re to

m a in ta in its tro p h is m a n d b a s e lin e fu n c tio n a l s ta tu s .

E x p e rie n c e h a s s h o w n th a t e n te ra l n u tritio n in itia te d

e a rlie r, a n d a d m in is te re d w ith c o rre c t te c h n iq u e s a n d

a p p ro p ria te d ie ts , is a s a fe a n d e ffe c tiv e m e th o d fo r

a d m in is te rin g n u tritio n a l s u p p o rt (1 1 ). H o w e v e r, it is

im p o rta n t to m e n tio n th a t s u c c e s s in e n te ra l n u tritio n is

d ire c tly re la te d to a w a re n e s s a n d m o tiv a tio n o f p h y s ic ia n s

a n d to c o n tin u o u s m o n ito rin g a n d c a re b y n u rs in g s ta ff.

A lth o u g h lim ite d in s e v e ra l c lin ic a l c o n d itio n s , th e u s e o f

th e o ra l ro u te fo r n u tritio n a l s u p p o rt is m o re p h y s io lo g ic a l,

le s s e x p e n s iv e a n d re s u lts in fe w e r c o m p lic a tio n s , a n d it

s h o u ld b e a lw a y s c o n s id e re d w h e n th e p a tie n t is c o n s c io u s

a n d h is g a s tro in te s tin a l tra c t is in g o o d c o n d itio n (1 2 ,1 3 ).

P la n a s ( 6 \ in a s tu d y o f n u tritio n a l s u p p o rt p a tte rn s in 2 7 In te n s iv e C a re U n its , o b s e rv e d th a t e n te ra l n u tritio n

w a s u s e d in 5 9 .7 % o f th e p a tie n ts (a d u lts ) w h o re c e iv e d

n u tritio n a l s u p p o rt. Io a n n id e s e t a l. ( 3 \ th ro u g h a n a u d it c a rrie d o u t in a te a c h in g h o s p ita l in A u s tra lia , o b s e rv e d

th a t p a re n te ra l n u tritio n w a s p re s c rib e d to p a tie n ts w ith

th e g a s tro in te s tin a l tra c t in g o o d c o n d itio n a n d re c e iv in g

fo o d b y m o u th . D e s p ite th e a d v a n ta g e s o f th e u s e o f e n te ra l

n u tritio n , p a re n te ra l n u tritio n h a s b e e n g e n e ra lly b e e n

a d o p te d a s th e n u tritio n a l tre a tm e n t fo r c ritic a lly ill p a tie n ts ,

p a rtic u la rly c h ild re n . In p ra c tic e , te c h n ic a l a n d m a te ria l

T a b le 5

N u tritio n s u p p o rt m o n ito rin g - C o m p a ra tiv e d a ta

N QP a tie n ts R o u te

N u tritio n a l A s s e s s m e n t T rig ly c e rid e s M o n ito rin g

M c F a rla n e et

a/.

lo a n n id e s et

a/.

L e ite et

ale

L e ite et

ale

(1 9 9 1 ) (1 9 9 5 ) P h a s e I P h a s e II

2 0 C h ild re n 1 6 8 A d u lts 3 7 C h ild re n 3 5 C h ild re n

P a re n te ra l P a re n te ra l P a re n te ra l/ E n te ra l P a re n te ra l/ E n te ra l

3 (1 5 % ) 1 6 8 (1 0 0 % ) 3 (8 % ) 1 3 (3 7 .1 % )

9 (4 5 % ) 1 2 0 (6 9 % ) 1 9 (5 3 % ) 10 (2 9 .4 % )

L E IT E , H .P .; IG L E S IA S , S .B .O .; F A R IA , C .M .S .; IK E D A , A .M .; A L B U Q U E R Q U E , M .P .; C A R V A L H O , W .B . - E v o lu tio n o f th e n u tritio n a l

. ' 1 '_ '_ 1 I _

d iffic u ltie s a n d p re se n c e o f c o m p lic a tio n s su c h a s ile u m

a n d d ig e stiv e h e m o rrh a g e m a y d e la y o r p re v e n t th e u se o f

e n te ra l n u tritio n . T h e se fa c to rs, a sso c ia te d w ith th e fa c t

th a t p h y sic ia n s a re n o t a w a re o f th e a d v a n ta g e s o f th e u se

o f th e d ig e stiv e ro u te , m a y a c c o u n t fo r th e lo w u se o f

e n te ra l n u tritio n . In o u r stu d y , th e in c re a se in u se o f th e

d ig e stiv e ro u te w a s n o t sig n ific a n t in th e se c o n d p h a se ,

in d ic a tin g th a t e n te ra l n u tritio n c o n tin u e s to b e little u se d .

T h e a n a ly sis o f th e re su lts o f th is stu d y p o in ts to th e

u rg e n t n e e d fo r re v isio n o f th e e v a lu a tio n o f fu n c tio n a n d

u se o f th e g a stro in te stin a l tra c t in c ritic a lly ill p a tie n ts, a s

w e ll a s th e e v a lu a tio n o f p ra c tic a l m e th o d s o f tu b e

p o sitio n in g in th e d u o d e n u m a n d je ju n u m .

In h y p e rc a ta b o lic c h ild re n , p ro te in ~ u p p ly b a sic a lly

a im s a t m in im iz in g th e e ffe c ts o f lo ss o f n itro g e n , p a rtia lly

c o m p e n sa tin g h y p e rc a ta b o lism . In th is situ a tio n th e m a in

p u rp o se o f n u trie n t su p p ly is n o t g ro w th , b u t m a in te n a n c e

o f c o rp o re a l m a ss a n d o rg a n ic fu n c tio n in o rd e r to p ro v id e

th e c o n d itio n s fo r th e p a tie n t to su rv iv e . F o r th is p u rp o se ,

a n in c re a se in a m in o a c id su p p ly is re c o m m e n d e d , u sin g

a n i tro g e n to n o n -p ro te in c a lo rie ra tio fro m 1 : 1 5 0 to 1 : 1 0 0

(8 ,1 4 ,1 5 \ g re a te r th a n th a t c o m m o n ly u se d fo r c h ild re n w ith

n o m e ta b o lic stre ss. In th e first p h a se o f th e stu d y , a n d

c o n sid e rin g th a t v irtu a lly a ll th e p a tie n ts w e re

h y p e rc a ta b o lic , th is ra tio w a s a p p ro p ria te in o n ly 2 7 % o f

th e c a se s, risin g to 1 0 0 % d u rin g th e se c o n d p h a se .

T h e p re sc rip tio n o f in su ffic ie n t d o se s o f v ita m in s

a n d tra c e e le m e n ts in so lu tio n s fo r p a re n te ra l n u tritio n

o b se rv e d d u rin g th e first p h a se o f th is stu d y w a s a lso

re p o rt~ d b y M c F a rla n e e t a l. (4 ) in th e ir stu d y . In th e first

p h a se o f o u r stu d y , z in c su p p ly b y th e p a re n te ra l ro u te

w a s in a d e q u a te b e c a u se it w a s b a se d o n ly o n c o rp o re a l

w e ig h t, n o t ta k in g in to a c c o u n t a g e g ro u p . Id e a lly , th e

re c o m m e n d a tio n s fro m th e A m e ric a n S o c ie ty fo r C lin ic a l

N u tritio n (9 ) sh o u ld b e a d o p te d , c la ssify in g th e n e e d fo r

z in c a c c o rd in g to a g e g ro u p a n d g e sta tio n a l a g e ". T h e n e e d

fo r v ita m in s a n d tra c e e le m e n ts sh o u ld b e e n h a n c e d , sin c e

th e re is a g re a te r p ro b a b ility o f d e fic ie n c y d u e to in c re a se

in u se a n d lo sse s th a t o c c u r in h y p e rc a ta b o lism . In th is

situ a tio n , th e n e e d s a re g re a te r b u t h a v e n o t y e t b e e n

d e te rm in e d . If th e re a re p re v io u s d e fic ie n c ie s o r g re a te r

,lo sse s, th e e a rly u se o f tra c e e le m e n t so lu tio n is d e sira b le .

In th e p re se n c e o f c h o le sta sis, c o p p e r a n d m a n g a n e se

m u st n o t b e a d m in iste re d , b e c a u se th e y p re se n t h e p a tic

e x c re tio n (9 ). V ita m in B 1 2 , fo la te a n d z in c a re im p e ra tiv e

fo r th e n o rm a l m e ta b o lism o f n u c le ic a c id s. Z in c

d e fic ie n c y a ffe c ts w o u n d h e a lin g , p ro te in sy n th e sis in th e

a c u te p h a se re sp o n se a n d im m u n o lo g ic a l fu n c tio n . S in c e

z in c is m o re u se d a n d m o re e x c re te d in h y p e rc a ta b o lism ,

a n d its su p p ly is m o re fle x ib le th a n th a t o f o th e r tra c e

e le m e n ts, it is re c o m m e n d e d th a t it is a d m in iste re d in

se p a ra te so lu tio n s. F o r a d e q u a te su p p ly , v ita m in s m u st

b e a d m in iste re d in sp e c ific fo rm u la e fo r p e d ia tric u se .

D a ily su p p ly m o n ito rin g a n d p e rio d ic e v a lu a tio n o f

n u tritio n a l a n d m e ta b o lic sta tu s a re n e c e ssa ry fo r a d e q u a te

su p p ly o f n u tritio n a l su p p o rt. D a ta m u st b e re g iste re d

re g u la rly o n th e d a ily e v o lu tio n sh e e t, in o rd e r to e n a b le

c o rre c t a sse ssm e n t a n d in tro d u c tio n o f n e c e ssa ry c h a n g e s.

In th e c u rre n t stu d y a n d in th a t o f M c F a rla n e e t a l.

(4 ), th e in itia l e v a lu a tio n o f n u tritio n a l sta tu s w a s c a rrie d

o u t w ith a v e ry sm a ll n u m b e r o f p a tie n ts. In th e stu d y b y

Io a n n id e s e t a l.(3 ), c o n d u c te d w ith a d u lts, a ll p a tie n ts w e re

su b m itte d to a p re v io u s n u tritio n a l e v a lu a tio n , sin c e th is

p ro c e d u re w a s p a rt o f th e a u d it p e rfo rm e d b y th e

n u tritio n a l su p p o rt m u ltid isc ip lin a ry te a m . C h e c k in g

p a tie n ts' w e ig h t, a s is n o rm a lly d o n e , d o e s n o t m e a n

n u tritio n a l e v a lu a tio n ; to th is e n d , it is n e c e ssa ry to u se a

re fe re n c e sta n d a rd su c h a s th a t o f th e W o rld H e a lth

O rg a n iz a tio n (1 6 ). T h e p a ra m e te r e x p e c te d w e ig h t fo r a g e

is u se fu l u p to th e a g e o f 2 , b u t fro m th e n o n , it is o n ly

v a lid a s a sc re e n in g fo r e v a lu a tio n o f n u tritio n a l sta tu s.

H e ig h t m u st a lso b e ta k e n in to a c c o u n t, b e c a u se fro m ,

ra tio s o f e x p e c te d h e ig h t fo r a g e a n d e x p e c te d w e ig h t fo r

h e ig h t, it is p o ssib le to e v a lu a te th e d u ra tio n o f a

m a ln u tritio n p ro c e ss (1 7 ). It is im p o rta n t to h ig h lig h t th a t

a ll p a ra m e te rs u se d fo r n u tritio n a l e v a lu a tio n a re

in flu e n c e d b y n o n -n u tritio n a l fa c to rs su c h a s c h a n g e s in

b o d y flu id s, in fla m m a tio n a n d in fe c tio n (I,1 8 ). T h e se

p a ra m e te rs h a v e v e ry little v a lu e w h e n u se d se p a ra te ly ,

a n d sh o u ld b e se q u e n tia lly e v a lu a te d , h a v in g th e p a tie n t

~ s h is o w n c o n tro l. N u tritio n a l re a sse ssm e n t a t re g u la r

in te rv a ls a llo w s th e e ffic ie n c y o f m e ta b o lic su p p o rt a n d

in to le ra n c e to a d m in istra tio n o f n u trie n ts to b e c h e c k e d ,

a n d m a k e s c h a n g e s in n u tritio n a l su p p o rt p o ssib le

a c c o rd in g to th e e v o lu tio n o f th e p a tie n t. Irre g u la r

la b o ra to ry m o n ito rin g w a s a lso o b se rv e d b y M c F a rla n e

e t a l. (4 ). In h is re a so n in g , a lth o u g h a ll c h ild re n re c e iv e d

in tra v e n o u s lip id e m u lsio n s, le ss th a n h a lf o f th e m h a d

se r~ m trig ly c e rid e m e a su re d a t le a st o n c e , a re su lt sim ila r

to th a t fo u n d in th e p re se n t stu d y . It is im p o rta n t to m o n ito r

se ru m trig ly c e rid e in c ritic a lly ill c h ild re n re c e iv in g

in tra v e n o u s lip id e m u lsio n s, b e c a u se in th is situ a tio n , th e re

m a y b e a d e c re a se in lip id c le a ra n c e , le a d in g to d e p o sits

in th e v a sc u la r e n d o th e liu m a n d re tic u lo e n d o th e lia l

sy ste m . M o n ito rin g m u st b e p e rfo rm e d b e fo re b e g in n in g

in fu sio n , a n d w h e n e v e r th e re is a n in c re a se in lip id su p p ly ,

m a in ta in in g le v e ls u n d e r 1 5 0 m g /d l. S e ru m a lb u m in a lo n e

is n o t a g o o d p a ra m e te r fo r a sse ssin g n u tritio n a l sta tu s o r

n u tritio n a l su p p o rt in a P e d ia tric In te n siv e C a re U n it, sin c e

it m a y v a ry a c c o rd in g to in fla m m a to ry re sp o n se , p re se n c e

o f in fe c tio n a n d c h a n g e s in th e c o rp o re a l flu id s.

N e v e rth e le ss, it is a g o o d e v o lu tio n p a ra m e te r, b e in g

u se fu l in p re d ic tin g m o rb id ity a n d m o rta lity in c ritic a lly

ill p a tie n ts (19).

In o u r stu d y , flu id b a la n c e a n d c a lo ric su p p ly re c o rd

w e re p e rfo rm e d d a ily fo r a ll c h ild re n . H e m o g ra m s a n d

b lo o d g a s a n a ly sis w e re c o n d u c te d fo r a ll p a tie n ts, a s w e ll

a s se ru m g lu c o se , u re a a n d e le c tro ly te s. F lu id b a la n c e ,

w e ig h t a n d a c c u ra te q u a n tify in g o f n u trie n t a d m in istra tio n

a re e sse n tia l c lin ic a l p a ra m e te rs, p rin c ip a lly fo r p a tie n ts

re c e iv in g p a re n te ra l n u tritio n . C h e c k in g o f c o rp o re a l

w e ig h t a n d a lb u m in a n d trig ly c e rid e s d o sa g e s w a s c a rrie d

o u t o n th e m a jo rity o f p a tie n ts w h ile a d m itte d in to h o sp ita l,

a lth o u g h th e p ro c e d u re s w e re n o t u n ifo rm .

In th e tw o p h a se s o f th is stu d y n u tritio n a l su p p o rt w a s

in itia te d e a rly . T h is re fle c ts p e rc e p tio n o f th e in c re a se in

m e ta b o lic n e e d s o f p a tie n ts b y th e IC U - p h y sic ia n . E a rly

b e g in n in g o f n u tritio n a l su p p o rt is a n im p o rta n t issu e in

th e tre a tm e n t o f c ritic a lly ill c h ild re n . P a tie n ts w ith se v e re

illn e ss, a n d w h o w e re h e a lth y b e fo re , m a y to le ra te

h y p e rc a ta b o lism d u rin g a fe w d a y s w ith n o g re a t a d v e rse

e ffe c ts. T h e m e ta b o lic d e m a n d s a re g re a te r in th o se w h o ,

in a d d itio n to th e a c u te p ro c e ss, su ffe r fro m c h ro n ic d ise a se ,

a re in a fa st sta g e o f g ro w th o r su ffe r fro m m a ln u tritio n .

C O N C L U S I O N

N u tritio n a l su p p o rt p re se n te d fa ilu re s d u rin g its

im p le m e n ta tio n th a t w e re p a rtia lly c o rre c te d d u rin g th e

se c o n d p h a se o f th e stu d y . T h e g u id a n c e w o rk in c re a se d

a w a re n e ss o f th e u se o f n u tritio n a l su p p o rt, b u t d id n o t

fo ste r e ffe c tiv e c h a n g e s in p ra c tic a l p ro c e d u re s p e rfo rm e d

b y re sid e n ts. B a se d o n th e re su lts o f th is stu d y , th e a u th o rs

re c o m m e n d :

1 ) R e v ie w o f th e e d u c a tio n p ro g ra m . A b a sic

a p p ro a c h , d e sig n e d fo r p ra c tic a l p ro b le m s in

n u tritio n a l su p p o rt a n d o rie n te d to c o rre c t

d e fic ie n c ie s o b se rv e d , m a y b e a b le to c o rre c t

th e se d e fic ie n c ie s a n d c o n trib u te b e tte r to th e

tra in in g o f IC U p e d ia tric ia n s re g a rd in g th is

a sp e c t. T h e p ro g ra m sh o u ld b e a p p lie d to th e

w h o le m e d ic a l sta ff.

2 ) C re a tio n o f a m u ltid isc ip lin a ry te a m in c h a rg e

o f c o o rd in a tin g su p p ly o f n u tritio n a l su p p o rt.

S tu d ie s o f th e lite ra tu re h a v e d e m o n stra te d th a t

th e p e rfo rm a n c e o f a m u ltid isc ip lin a ry te a m m a y

p ro m o te su b sta n tia l im p ro v e m e n t in q u a lity o f

n u tritio n a l su p p o rt (2 (» . T h e te a m w ill b e

re sp o n sib le fo r q u a lity a n d fo r a d ju stm e n t o f

n u tritio n a l su p p o rt, a n d m u st e sta b lish p ro c e d u re

g u id e lin e s th a t a re p e rio d ic a lly re v ise d a n d

u p d a te d . T h e se a c tio n s m a y ra tio n a liz e th e su p p ly

o f n u tritio n a l a n d m e ta b o lic su p p o rt, a d ju stin g it

to th e n e e d s o f th e p a tie n t a n d e n h a n c in g th e

q u a lity o f c a re re n d e re d to c h ild re n .

L E I T E , H . P . ; I G L E S I A S , S . B . O . ; F A R I A , C . M . S . ; I K E D A , A . M . ; A L B U Q U E R Q U E , M . P . ; C A R V A L H O , W . B . - E v o l u t i o n o f t h e n u t r i t i o n a l

REFERENCES

1 . C h w a ls W J . M e ta b o lis m a n d n u tr itio n a l f r o n tie r s in

P e d ia tr ic s u r g ic a l p a tie n ts . S u r g C lin N o r th A m 1 9 9 2 ;

7 2 ( 6 ) : 1 2 3 7 - 1 2 6 6 .

2 . L e ite H P , I s a tu g o M K I , S a w a k i L , F is b e r g M .

A n th r o p o m e tr ic N u tr itio n a l A s s e s s m e n t o f C r itic a lly

I I I H o s p ita liz e d C h ild r e n . R e v P a u l M e d 1 9 9 3 ;

1 1 1 ( 1 ) :3 0 9 - 1 3 .

3 . lo a n n id e s - D e m o s L L , L io lio s L , T o p lis s D J , M c le a n A : A

p r o s p e c tiv e a u d it o f to ta l p a r e n te r a l n u tr itio n a t a m a jo r

te a c h in g h o s p ita l. M e d J A u tr a lia 1 9 9 5 ;1 6 3 :2 3 3 - 3 7 .

4 . M c F a r la n e K , B u llo c k L , F itz g e r a ld J F . A U s a g e E v a lu a tio n

o f T o ta l P a r e n te r a l N u tr itio n in P e d ia tr ic P a tie n ts . J P E N

1 9 9 1 ; 1 5 ( 1 ) :8 5 - 8 8 .

5 . P a y n e - J a m e s J J , d e G a r a C J , G r im b le G K , B r a y M J , R a n a

S K , K a p a d ia S , S ilk D B A . A r tif ic ia l n u tr itio n s u p p o r t in

h o s p ita ls in th e U n ite d K in g d o m - 1 9 9 1 : S e c o n d n a tio n a l

s u r v e y . C lin N u tr 1 9 9 1 ; 1 1 : 1 8 7 - 1 9 2 .

6 . P la n a s M . A r tif ic ia l n u tr itio n s u p p o r t in in te n s iv e c a r e u n its

in S p a in . I n t C a r e M e d 1 9 9 5 ;2 1 :8 4 2 - 4 6 .

7 . H o llid a y M A , S e g a r W E . T h e m a in te n a n c e n e e d f o r w a te r

in p a r e n te r a l f lu id th e r a p y . P e d ia tr ic s 1 9 5 7 ; 1 9 :8 2 3 - 8 3 2 .

8 . C e r r a F B . H y p e r m e ta b o lis m , o r g a n f a ilu r e a n d m e ta b o lic

s u p p o r t. S u r g e r y 1 9 8 7 ; 1 0 1 ( 1 ) : 1 - 1 3 .

9 . G r e e n e H L , H a m b id g e K , S c h a n le r R , T s a n g R C . G u id e lin e s

f o r th e u s e o f v ita m in s , tr a c e e le m e n ts , c a lc iu m , m a g n e s iu m

a n d p h o s p h o r u s in in f a n ts a n d c h ild r e n r e c e iv in g to ta l

p a r e n te r a l n u tr itio n : R e p o r t o f th e S u b c o m m itte e o n

C lin ic a l P r a c tic e I s s u e s o f th e A m e r ic a n S o c ie ty f o r C lin ic a l

N u tr itio n . A m J C lin N u tr 1 9 8 8 ;4 8 :1 3 2 4 - 4 2 .

1 0 . A .S .P .E .N . B o a r d o f D ir e c to r s . G u id e lin e s f o r th e u s e o f

P a r e n te r a l a n d E n te r a l N u tr itio n in A d u lt a n d P e d ia tr ic

P a tie n ts . J P E N 1 9 9 3 ;1 7 ( 4 ) :I S A - 5 2 S A .

1 1 . L e ite H P , C a r v a lh o W B , G r a n d in i S . N a s o d u o d e n a l f e e d in g

o f th e c r itic a lly ill c h ild . R e v P a u l M e d 1 9 9 2 ; 1 0 ( 3 ) : 1 2 4 - 3 0 .

1 2 . H E S S O V I . O r a l d ie t a d m in is tr a tio n a n d s u p p le m e n ta tio n .

I n : A r tif ic ia l N u tr itio n S u p p o r t in C lin ic a l P { a c tic e . P a y n e

-J a m e s J , G r im b le G , S ilk G . ( e d s ) E d w a r d A r n o ld , L o n d o n ,

1 9 9 5 ;5 7 3 .

1 3 . T e lle s J R M , T a n n u r i U . S u p o r te N tI tr ic io n a l e m P e d ia tr ia .

A th e n e u , S .P ., 1 9 9 4 ;3 1 5 .

1 4 . D ia m a n d R J . N u tr itio n a l s u p p o r t o f th e c r itic a lly ill it:lf a n t

a n d c h ild . I n : P e d ia tr ic R e v ie w S e r ie s - . P a r t 2 . S tid h a m

G L , W e ig le C G M . ( e d ) S o c ie ty o f C r itic a l C a r e M e d ic in e ,

A n a h e im , C A , 1 9 9 3 ; 1 7 2 .

1 5 . M a te o s A G L , C u le b r a s J M . N u tr itio n a l a n d m e ta b o lic

s u p p o r t: C o n v e r g in g c o n c e p ts . N u tr itio n 1 9 9 1 ;7 : 1 6 3 - 1 6 7 .

1 6 . O r g a n iz a c io n M u n d ia l D e L a S a lu d - M e d ic i6 n d e l C a m b io

d e l E s ta d o N u tr ic io n a l. G in e b r a , O M S , 1 9 8 3 ; 1 0 5 .

1 7 . W a te r lo w J C . C la s s if ic a tio n a n d d e f in itio n o f

p r o te in - c a lo r ie m a ln u tr itio n . B r M e d J 1 9 7 2 ;3 :5 6 6 - 6 ?

1 8 . L e ite H P . A v a lia ~ a o d o e s ta d o n u tr ic io n a l e in d ic a d o r e s d e

r is c o c ir u r g ic o e m c r ia n ~ a s s u b m e tid a s

a

c ir u r g ia c a r d f a c a .

S a o P a u lo , 1 9 9 2 . [ M a s te r 's T h e s is - E s c o la P a u lis ta d e

M e d ic in a ] .

1 9 . A p e lg r e n K N , R o m b e a u J L , T w o m e y P L , M ille r R A .

C o m p a r is o n o f n u tr itio n a l in d ic e s a n d o u tc o m e in c r itic a lly

ill p a tie n ts . C r it C a r e M e d 1 9 8 2 ; 1 0 ( 5 ) :3 0 5 - 3 0 7 .

2 0 . B u r n h a m W R . T h e r o le o f a n u tr itio n s u p p o r t te a m . I n :

A r tif ic ia l N u tr itio n S u p p o r t in C lin ic a l P r a c tic e . P a y n e

-J a m e s J , G r im b le G , S ilk G . ( e d s ) E d w a r d A r n o ld , L o n d o n ,

1 9 9 5 ;5 7 3 .