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Two Chinese studies looked at the implementation of a multifaceted national antibiotic stewardship programme, containing structural changes, antibiotic restriction, education, guidelines, and audit and feedback, in 65 and 15 secondary and tertiary public hospitals respectively. Add extra protein and calories to food. Emphysema is characterized by destruction of the alveolar walls, hyperinflation of the alveoli, and loss of lung elasticity. In those patients at low nutritional risk NUTRIC scores 0—5 , there was no association between the amount of nutrition therapy received and mortality. Eat foods that are easy on your stomach: Monitoring temperature every 2 hours. A gravity drip from a bag or syringe with a slow push can be used to administer the formula.

B. Nutritional assessment

Feeding tube

After the first intervention, no significant changes were reported. The net effect of the intervention bundle remains unclear. A study in a Brazilian cardiology hospital first introduced restriction of certain antibiotics with individual audit and feedback to prescribers by an infectious diseases specialist and subsequently more comprehensive audit and feedback by a pharmacist.

Two Chinese studies looked at the implementation of a multifaceted national antibiotic stewardship programme, containing structural changes, antibiotic restriction, education, guidelines, and audit and feedback, in 65 and 15 secondary and tertiary public hospitals respectively. Both studies reported a significant decrease in antibiotic use after the intervention. In this systematic review the majority of the included studies reported a positive effect of antibiotic stewardship interventions for hospitalized patients.

This is in line with previously published systematic reviews on stewardship interventions in hospitals, which did not focus specifically on low- and middle-income countries.

So, although antibiotic stewardship is taking place and is being studied in low- and middle-income countries, most studies fall short methodologically. The studies we did include were also generally of low quality. For those with a randomized study design, a major risk of bias was contamination, meaning that prescribers could be involved in treatment of both the intervention and control groups. Because it may not be feasible to randomize individual prescribers, wards or hospitals to overcome this bias, interrupted time-series design has been recommended as an alternative.

In interrupted time-series, data are collected continuously, and trends and outcome levels are compared before and after the intervention. To minimize bias and confounding, interrupted-time-series should meet certain requirements: Poor quality of methods is a consistent theme among reviews of antibiotic stewardship in countries of all income levels and this issue needs to be addressed to strengthen the evidence base.

Many of the included studies focused on a quantitative reduction in antibiotic prescribing. However, stewardship is not merely concerned with a reduction in antibiotic use, but in finding the balance between the potency of antibiotics and their potentially hazardous effects. There is an ongoing debate about which parameters should be reported to accurately reflect the above-mentioned outcomes.

This lack of uniformity limits comparison and aggregation of data. Also, for low- and middle-income settings, the measurement of certain clinical or microbiological outcomes, for example infection with Clostridium difficile , may be challenging if not impossible. Defining feasible outcome measures that can be uniformly applied in low- and middle-income countries should be prioritized.

In the meantime, parameters that are easy to assess, such as mortality or hospital length of stay, should be reported by every stewardship study. The majority of studies were performed in tertiary care centres in urban areas in middle-income countries, which limits the generalizability of the results. Large differences exist in terms of resources, organization, prescription practices and financing between countries and between facilities within countries.

Although this intervention showed promising results, it may not be feasible to implement in many health-care settings in low- and middle-income countries. In addition, good quality evidence from non-tertiary or rural hospitals in low-income countries is lacking. Studies focusing on these settings should therefore be prioritized.

The effectiveness of the interventions varied across the studies, even those that implemented similar interventions. This is likely due to differences in the intervention or the implementation strategy, which may have been adapted to fit local circumstances.

A detailed description of the intervention and the implementation strategy is therefore mandatory to interpret the study findings. This behaviour is influenced by social norms, attitudes and beliefs. For this reason, collaboration with behavioural scientists has been recommended. Our review has several limitations. We defined a broad search strategy, allowing different settings, participants, interventions and outcomes to be included. This strategy provides a good overview of what evidence is available, but limits the generalizability of the findings.

Moreover, to ensure the validity of the results, studies had to fulfil high methodological standards to be included. This led to discarding numerous lower quality studies. Also, we did not include studies that only reported cost effectiveness as an outcome, as these require a different analysis model.

Lastly, due to publication bias not reporting negative results and language restrictions we may have missed certain studies. We conclude that, based on the currently available evidence, general recommendations regarding the effectiveness of antibiotic stewardship interventions in low- and middle-income countries cannot be made. As many hospitals in low- and middle-income countries are setting up antibiotic stewardship programmes, what should be the way forward?

On the basis of our findings, we suggest the following actions should be prioritized to strengthen the evidence base: While awaiting the effect of these actions, the current lack of evidence should not prevent health-care workers from engaging in stewardship. Evidence and examples both from high- and low-and middle-income countries can inspire and provide guidance in the meantime. Skip to main content. Bulletin of the World Health Organization.

Antibiotic stewardship interventions in hospitals in low-and middle-income countries: Search strategy for the review of antibiotic stewardship interventions in hospitals in low-and middle-income countries We searched the following databases from inception to 5 December Figure 1 - full screen.

Figure 2 - full screen. Alternative methods to confirm the location of the tube tip in the GI tract below the diaphragm, such as auscultation, detection of CO 2 , and measurement of pH are not accurate enough to confirm placement New optical guidance feeding tubes have recently been approved by the Federal Drug Administration but will require further validation studies before radiologic confirmation can be avoided The incidence of reflux, regurgitation, and aspiration all decrease significantly as the level of infusion of formula is diverted lower in the GI tract, from the stomach to the proximal jejunum A meta-analysis of 12 RCTs showed a reduction in ventilator-associated pneumonia with small bowel compared with gastric feeding; yet, duration of mechanical ventilation, hospital length of stay, and mortality did not change These findings suggest that the appearance of an infiltrate on chest X-ray in a patient on enteral tube feeding may have minimal consequences.

Placement of a feeding tube in the small bowel requires greater expertise, which may lead to delays in initiation of feeding For these reasons, it is best to start with gastric feeds, take additional steps to promote tolerance, and to monitor closely while awaiting expertise for small bowel placement if subsequently required.

Long-term jejunal access is best achieved by the use of a jejunostomy tube placed endoscopically, radiologically, or surgically, depending upon available expertise. Because of frequent displacement of the jejunal extension tube back into the stomach with a GJ device, this is generally not a good long-term option. Recent changes in the design of tubes such as the use of a stiffer double pigtail catheter with a spring in the jejunal portion of the tube , however, seem to result in less displacement.

Given the greater ease of placement compared with a direct jejunostomy, reconsideration of the use of such GJ tubes may be warranted. If the duration of provision of EN is anticipated to exceed 4 weeks, then a percutaneous enteral access device is generally indicated.

The 4-week cutoff, although arbitrary, is based on the potential morbidity of a nasoenteric tube, which includes erosion of the nares, an increase in aspiration pneumonia, sinusitis, and esophageal ulceration or stricture Certain institutional practices may dictate early placement of a tracheostomy and percutaneous gastrostomy tube in trauma patients. Early gastrostomy tube placement in stroke patients may be needed to facilitate transfer to a rehabilitation center.

Placement prior to this time point has been shown to extend survival of the amyotrophic lateral sclerosis patient Most importantly, if the patient demonstrates intolerance and evidence of gastroparesis in the days following gastrostomy tube placement, the access device is better positioned to be converted to a GJ tube Reluctance to positioning percutaneous gastrostomy tubes in the gastric antrum in the past related, in part, to concern for interference with the antral grinding mechanism, bleeding from passage through the falciform ligament, and potential obstruction of the pylorus.

Extensive clinical experience does not support any of these concerns. When feasible, we suggest that all percutaneous gastrostomy tubes be placed to the right of the midline, close to the level of the umbilicus. A variety of measures can help secure the enteral access device at the time of placement A nasal bridle fashioned from a 5-French neonatal feeding tube or a commercial device with magnetic-tipped flexible rods and surgical ribbon may be used to secure a nasoenteric tube placed through the nose.

A recent meta-analysis showed that the use of a nasal bridle nearly eliminates displacement Although an abdominal binder is helpful in protecting the percutaneous gastrostomy tube, it should be loose enough to avoid crushing the access device and positioned with support at the level of the skin to prevent excess side torsion to the gastrostomy tract Ultimately, whenever possible, the reason s for inadvertent removal of the tube e.

How soon, at what dose, and with which formula should enteral nutrition be initiated in the hospitalized patient? The timing of initiation of EN in the hospitalized patient especially critically ill patients in an ICU setting is based on two categories of studies in the literature, early vs. In meta-analyses by Marik and Doig comparing early vs. Tolerance determines how quickly and how aggressively to increase EN delivery. Trophic feeding may not be appropriate in patients who are at extremes of age, BMI, or disease severity Such a regimen should maintain lean body mass while depleting the fat mass, with no increase in adverse outcomes Such a regimen was shown to be associated with significant reductions in infection and hospital LOS compared with full caloric feeding Indications for use of specialized formulae are limited, and their use should be reserved for certain subsets of hospitalized patient populations.

The vast majority of hospitalized patients requiring EN will tolerate a standard polymeric formula with or without fiber. Pre-operative patients awaiting major elective surgery and critically ill patients admitted to a surgical ICU may benefit from an arginine-containing immune-modulating formula also containing fish oil, glutamine, and antioxidants.

How should adequacy and tolerance of EN be assessed in the hospitalized patient? Patients on EN should be monitored daily by physical exam to detect the presence of bowel sounds, passage of stool and gas, abdominal distention, and volume status Caloric and protein target goals should be clearly identified and intake and output should be followed to determine the percent of goal calories delivered. Increased delivery of calories to reduce the deficit is associated with improved outcome.

Such patients should be monitored closely for up to 5 days for electrolyte abnormalities hypokalemia, hypophosphatemia, and hypomagnesemia , and volume status after feeding is initiated It is not clear whether risk of refeeding syndrome is more common with EN or PN The use of feeding protocols with nursing directives is an important strategy for improving the timeliness, adequacy, and safety of delivering EN Important elements of nurse-driven protocols include the use of universal EN connectors, monitoring by focused physical exam, consideration of fluid volumes, management of GRVs, rates for advancement of EN based on tolerance, and measures to reduce risk of aspiration.

A volume-based feeding strategy identifies the volume to be delivered over a 24 h period and empowers the nurse to increase the rate to make up for interruptions in delivery A multi-strategy top-down protocol has been described for use in critically ill patients based on the presumption that these patients are at increased risk of feeding intolerance and that multiple strategies can be used with the initiation of EN to promote better tolerance including the use of volume-based feeding, elevation of the head of the bed, chlorhexidine mouth washes, small bowel feeding, and the use of prokinetic medications Multiple strategies are utilized together with the initiation of EN and then individually removed as tolerance is achieved.

Furthermore, the practice of checking GRV is not well standardized, the values are difficult to interpret, and expense involved with allocation of health-care resources nursing time is substantial The use of GRVs as a monitor increases the likelihood of tube clogging tenfold Lowering the cutoff value does not protect the patient from aspiration but instead simply turns off the delivery of EN.

Bundling individual strategies may be more effective in changing outcome Differences in definition mostly account for the wide range of incidence. Much of what is referred to as diarrhea in hospitalized patients on EN actually represents low-volume fecal incontinence. Although most cases are mild and self-limited, diarrhea in the hospitalized patient on EN may result in electrolyte imbalance, dehydration, perianal skin breakdown, and wound contamination Although factors associated with the formula e.

There is abundant data to recommend stopping prokinetics in individuals who develop non- C. When an underlying cause cannot be identified and diarrhea persists, the addition of a fermentable soluble fiber supplement e. The prebiotic effect of the soluble fiber helps foster a more balanced and biodiverse gut microbiome How should complications of enteral feeding in the hospitalized patient be assessed and treated?

Daily cleaning with mild soap and water is important to avoid the drying desiccating effects on the skin from hydrogen peroxide or scented alcohol-based soaps For the first 4 days following tube placement, the external bolster, if present, should be positioned up against the anterior wall with a single layer of gauze underneath against the skin.

If unsuccessful, a nonenteric-coated pancreatic enzyme tablet e. Use of a carbonated soft drink is an acceptable alternative, but the use of papain meat tenderizer should be avoided If still not corrected, a small-bore tube such as an ERCP catheter may be placed down through the feeding tube to the level of the clot and flushing attempts repeated. If still unsuccessful, before replacing the tube, mechanical de-clogging with a commercial corkscrew de-clogging device, a cytology brush, or a wire stylet should be considered albeit used with caution to prevent penetration of the sidewall of the tube and puncture of the intestinal wall Deterioration, breakdown, and increased drainage at the percutaneous access site should be evaluated carefully to rule out buried bumper syndrome, side torsion on the tract, absence of an external bolster, granulation tissue, or a tube site infection Hypergranulation tissue at the stomal-site should be treated with a topical high potency steroid ointment e.

We suggest treating tube site infections empirically using a broad-spectrum antibiotic administered either orally or through the tube rarely is a parenteral antibiotic needed Because of the high risk of contamination with skin organisms, culture of the tract or tissue is not recommended in routine situations. Although most stomal-site infections are minor, severe infections including necrotizing fasciitis can occur and require rapid recognition to optimize management.

Rarely does the tube need to be removed. For the patient with increased leakage to the point of severe skin injury, we suggest high-dose acid suppression, diverting the level of infusion of formula lower in the GI tract, simultaneous jejunal feeding with gastric aspiration, and involvement of a wound-care expert Occasionally, the tube will need to be removed and the tract allowed to close prior to placing a new tube in the same or different location.

When and how should PN be utilized in the hospitalized patient? The clinical benefit of PN in hospitalized patients other than those with PN-dependent intestinal failure, such as short bowel syndrome, chronic intestinal pseudo-obstruction, high-output enterocutaneous fistula has been difficult to demonstrate. Three recent trials looked at the use of exclusive PN in the hospitalized patient. The Early Parenteral Nutrition in Insufficient Enteral Feeding EPaNIC trial showed that early provision of PN on the third day of hospitalization in a subset of patients in which there was a contraindication to enteral feeding because bowel was in discontinuity led to an increase in infectious morbidity and a reduced likelihood of being discharged alive from the ICU compared with controls in which PN was started on the eighth day The patients randomized to early PN showed only a 0.

All other outcome parameters ranging from infection and organ failure to hospital length of stay and mortality were no different between the two groups. In a multi-centered ICU trial of nearly 2, patients comparing EN with exclusive PN, there was no difference between the groups in clinical outcome In a well-nourished patient, particularly in the first week of hospitalization, the use of PN appears to provide no benefit over standard therapy and may actually cause net harm 4.

At some point in the patient at low nutritional risk, failure to provide nutrition therapy will lead to deterioration of nutritional status and adverse outcome. In an older study, Sandstrom showed increased mortality and hospital length of stay if standard therapy was continued beyond the first 2 weeks of hospitalization compared with receipt of PN Most societal recommendations indicate a reluctance to extend standard therapy beyond the first week of hospitalization, suggesting instead initiating PN in the patient at low nutritional risk beginning the second week of hospitalization In the patient at high nutritional risk with increased disease severity and evidence for deterioration of nutritional status, priorities of therapy change.

If EN is not feasible, PN is more likely to benefit these patients than standard therapy. Thus, in patients with high nutritional risk for whom EN is not feasible, PN should be initiated as soon as possible following admission.

In patients with a diagnosis indicating PN dependence short bowel syndrome, chronic intestinal pseudo-obstruction , PN should be initiated immediately after admission unless there is evidence for ongoing bacteremia.

The addition of supplemental PN during the first week of therapy to patients already receiving EN, where the enteral feeding is not meeting caloric goals, appears to provide little benefit and may cause net harm Results showed that for study patients, PN added on the third day of hospitalization was associated with worse outcome with respect to virtually every clinical parameter except mortality compared with controls where PN was added beginning on the eighth day Specifically, significant increases in infection, organ failure, hospital and ICU length of stay, cost, and likelihood of being discharged alive were all worse with receipt of early supplemental PN Such strategy may result in some weight loss, but leads to better insulin sensitivity, avoids the effects of overfeeding, and may improve outcome.

In a meta-analysis of five RCTs involving patients with trauma, pancreatitis, and major abdominal surgery, the use of hypocaloric PN was associated with reduced infection and hospital length of stay compared with PN provided at goal feeds 20 vs. As a result, the use of PPN is associated with increased use of IV lipid emulsions to decrease the osmolarity, decreased delivery of overall calories and protein, and increased likelihood for venous sclerosis Routine use of PPN is associated with increasing loss of venous access sites and abuses derived from inappropriate short-term PN.

In a patient receiving both EN and PN, careful transition feeding is necessary to avoid overfeeding as EN tolerance improves and the need for PN is decreased. Should specialized nutrition therapy be provided to a hospitalized patient at end-of-life? However, nutrition therapy is likely to improve a cancer patient managed surgically who is cured from the malignancy but has altered GI anatomy or function post-operatively.

The use of PN in the non-operative management of malignancy should be avoided, as it may lead to worse outcomes compared with standard therapy with no nutrition support 4.

Provision of hydration and nutrition therapy is no different than provision of any other medical therapy, including mechanical ventilation, dialysis, and supplemental oxygen There is no difference between non-invasive and invasive therapy, and the distinction between ordinary and extraordinary therapy is meaningless.

Evidence suggests that, even though nutrition therapy may not be provided, the subsequent development of dehydration and starvation does not add to suffering as only a third of patients will sense any degree of hunger or thirst In those situations, minimal therapy with oral mouth care, rinses, candies, or throat lozenges will ameliorate symptoms. Subtle goals and outcome benefits may be achieved by gastrostomy placement in certain end-of-life situations Quality of life for the family of the patient may improve with placement of a percutaneous gastrostomy, as the ease of providing medications, hydration, and nutrition is facilitated and frustration with anorexia and poor oral intake is reduced.

Percutaneous gastrostomy placement may allow transfer out of the hospital setting to a nursing home or skilled nursing facility closer to home A patient with malignant obstruction of the GI tract may benefit from gastrostomy placement through palliative decompression to reduce nausea and vomiting Gastroenterologists are trained to recognize indications and contraindications for a procedure.

Placing a percutaneous gastrostomy in a patient with poor prognosis at high risk for mortality seems like an exercise in futility to the clinician, especially when allocation of health-care resources is limited Ethicists would argue that refusal to place a percutaneous endoscopic gastrostomy in this situation violates the ethical principles of futility and justice.

With regard to futility, refusal to place a percutaneous endoscopic gastrostomy generates a clash of values between the family and the caregiver.

With regard to justice, patients should never become aware that their low socio-economic status, lack of insurance, or low points on a survival scoring system has ultimately led to the denial of the procedure by health-care providers The most important ethical principle that drives management is patient autonomy, as the patient is the final arbiter of their own destiny Decisions on gastrostomy placement and provision of nutrition therapy at end-of-life often have little to do with scientific data or medical evidence derived from RCTs Decision making in end-of-life situations is often influenced by both the health-care literacy and the spiritual literacy of the patient and their families If at any time in this process, the clinician becomes uncomfortable or conflicted with the management decisions, he or she may excuse themselves from the care of a particular patient.

This can only be done if they are able to transfer the care to an equally qualified and willing practitioner. At no time should a patient or their families feel abandoned by the health-care process. This guideline was produced in collaboration with the Practice Parameters Committee of the American College of Gastroenterology. The Committee gives special thanks to Brian P.

Bosworth, who served as guideline monitor for this document. McClave is a speaker and an advisor for Nestle, Abbott, Covidien, and Kimberly Clark, a speaker for Nutricia, and has received research support from Nestle. Martindale is a advisor for Nestle, Covidien, and Fresenius Kabi. DiBaise has received research support from GI Dynamics. Mullin has no potential competing interests.

Significance of the four levels of evidence 25 High We are very confident that the true effect lies close to that of the estimate of effect Moderate We are moderately confident in the effect estimate: Indications for nutritional therapy Question: Specialized nutrition therapy in the form of EN should be initiated promptly in the hospitalized patient who is at high nutritional risk and is unable to maintain volitional oral intake conditional recommendation, low level of evidence.

EN should be used preferentially over PN in hospitalized patients who require non-volitional specialized nutrition therapy and do not have a contraindication to the delivery of luminal nutrients conditional recommendation, low level of evidence. Specialized nutrition therapy EN or PN is not required for hospitalized patients who are at low nutritional risk, appear well nourished, and are expected to resume volitional intake within 5 to 7 days following admission conditional recommendation, very low level of evidence.

PN should be reserved for the hospitalized patient under specific circumstances, when EN is not feasible or sufficient enough to provide energy and protein goals conditional recommendation, very low level of evidence.

Prior to initiation of specialized nutrition therapy either EN or PN , a determination of nutritional risk should be performed using a validated scoring system such as the Nutritional Risk Score NRS or the NUTRIC Score on all patients admitted to the hospital for whom volitional intake is anticipated to be insufficient conditional recommendation, very low level of evidence. An additional assessment should be performed prior to initiation of nutrition therapy of factors that may impact the design and delivery of the nutrition regimen conditional recommendation, very low level of evidence.

Surrogate markers of infection or inflammation should not be used for nutritional assessment conditional recommendation, very low level of evidence. Caloric requirements should be determined and then be used to set the goal for delivery of nutrition therapy conditional recommendation, very low level of evidence.

One of the three strategies should be used to determine caloric requirements: Protein requirements should be determined independently of caloric needs, and an ongoing assessment of protein provision should be performed conditional recommendation, very low level of evidence.

Nutrition assessment scoring systems used to determine nutrition risk NRS A nasogastric or orogastric feeding tube should be used as the initial access device for starting EN in a hospitalized patient conditional recommendation, very low level of evidence.

Radiologic confirmation of placement in the stomach should be carried out prior to feeding except with the use of electromagnetic transmitter-guided feeding tubes. Conversion to a post-pyloric feeding tube should be carried out only when gastric feeding has been shown to be poorly tolerated or the patient is at high risk for aspiration strong recommendation, moderate-to-high level of evidence.

When long-term enteral access is needed in a patient with gastroparesis or chronic pancreatitis, a jejunostomy tube should be placed conditional recommendation, very low level of evidence. A percutaneous gastrostomy should be placed preferentially in the gastric antrum in order to facilitate conversion to a GJ tube in the event that the patient is intolerant to gastric feeding conditional recommendation, very low level of evidence.

For the patient at high risk for tube displacement, steps should be taken proactively to secure the access device at the time of placement conditional recommendation, very low level of evidence.

Initiating Enteral Nutrition Question: In the patient at high nutritional risk unable to maintain volitional intake, EN should be initiated within 24—48 h of admission to the hospital conditional recommendation, low level of evidence. Although early EN should be initiated within 24—48 h of admission, the timing by which to advance to goal is unclear. When tolerated, feeding should be advanced to goal within 48—72 h conditional recommendation, very low level of evidence.

With reduced tolerance, feeding should be advanced with caution to goal by 5 to 7 days conditional recommendation, very low level of evidence. A standard polymeric formula or a high-protein standard formula should be used routinely in the hospitalized patient requiring EN conditional recommendation, very low level of evidence. An immune-modulating formula containing arginine and omega-3 fish oil should be used for patients who have had major surgery and are in a surgical ICU setting conditional recommendation, very low level of evidence.

An immune-modulating formula containing arginine and omega-3 fish oil should not be used routinely in patients in a medical ICU conditional recommendation, very low level of evidence. Monitoring tolerance and adequacy of EN Question: Hospitalized patients on EN should be monitored daily by physical exam conditional recommendation, very low level of evidence.

Patients on EN should be monitored for adequacy of provision of EN as a percent of target goal calories, cumulative caloric deficit, and inappropriate cessation of EN conditional recommendation, very low level of evidence. In the patient at high risk for refeeding syndrome, feeding should be ramped up slowly to goal over 3 to 4 days, while carefully monitoring electrolytes and volume status conditional recommendation, very low level of evidence.

Enteral feeding protocols should be used in hospitalized patients in need of nutrition therapy strong recommendation, moderate-to-high level of evidence. A validated protocol should be used, such as a volume-based feeding protocol or a multi-strategy bundled top-down protocol conditional recommendation, very low level of evidence.

Gastric residual volume GRV should not be used routinely as a monitor in hospitalized patients on EN conditional recommendation, very low level of evidence. Patients on EN should be assessed for risk of aspiration conditional recommendation, very low level of evidence.

For patients determined to be at high risk, the following steps should be taken to proactively reduce that risk: For the patient receiving EN who develops diarrhea, an evaluation should be initiated to identify an etiology and direct management conditional recommendation, very low level of evidence.

The patient receiving EN who develops diarrhea should be managed by one of the three strategies: Complications of enteral access Question: The percutaneous enteral access site should be monitored by cleaning daily with mild soap and water and maintaining correct positioning of the external bolster conditional recommendation, very low level of evidence.

Prevention of tube clogging is important to successful EN and may be achieved by frequent water flushes delivered every shift and each time medications are given conditional recommendation, very low level of evidence.

When a clogged tube is encountered and the use of water flushes is unsuccessful at clearing, a de-clogging solution comprising a nonenteric-coated pancreatic enzyme tablet dissolved in a sodium bicarbonate solution should be used conditional recommendation, very low level of evidence.

If still unsuccessful, a mechanical de-clogging device should be considered prior to exchanging the tube for a new one conditional recommendation, very low level of evidence. In this latter circumstance, radiologic confirmation should be carried out prior to feeding if there is any question of inappropriate location of the tube conditional recommendation, very low level of evidence. Placement of a larger tube should not be used to manage leakage caused by an enlarging stoma around the percutaneous access device conditional recommendation, very low level of evidence.

A percutaneous enteral access device that shows signs of fungal colonization with material deterioration and compromised structural integrity should be replaced in a non-urgent but timely manner conditional recommendation, very low level of evidence.

If early EN is not feasible and the patient is at low nutritional risk upon admission, no specialized nutrition therapy should be provided and PN should be withheld for the first week of hospitalization conditional recommendation, very low level of evidence.

If a patient is at high nutritional risk on admission to the hospital and EN is not feasible, PN should be initiated as soon as possible strong recommendation, moderate level of evidence. Initiating supplemental PN prior to this 7—day period in those patients already receiving EN does not improve outcomes and may be detrimental to the patient strong recommendation, moderate level of evidence. Following this first week if long-term PN is required , energy provision should be increased to meet energy goals conditional recommendation, low level of evidence.

Peripheral PN PPN should not be used, as it leads to inappropriate use of PN, has a high risk of phlebitis and loss of venous access sites, and generally provides inadequate nutrition therapy conditional recommendation, very low level of evidence.

Careful transition feeding should be used in the patient on PN, for whom EN is now being initiated. As tolerance to EN improves and volume of delivery increases, PN should be tapered to avoid overfeeding conditional recommendation, very low level of evidence.

Nutritional Therapy at End-of-Life Question: The decision to place a gastrostomy tube in an end-of-life situation should be determined by patient autonomy and the wishes of that patient and their family, even though the nutrition therapy may do little to change traditional clinical outcomes conditional recommendation, very low level of evidence.

Percutaneous gastrostomy placement should be considered even if the only benefit is to provide improvement in the quality of life for the family, increased ease of providing nutrition, hydration, and medications, or to facilitate transfer out of the hospital setting to a facility closer to home conditional recommendation, very low level of evidence. The clinician is not obligated to provide hydration and nutrition therapy in end-of-life situations.

The decision to initiate nutrition therapy is no different than the decision to stop therapy once it has started thus, clinicians are not obligated to provide therapy that is unwarranted conditional recommendation, very low level of evidence. If requested, nutrition therapy in end-stage malignancy should be provided by the enteral route conditional recommendation, very low level of evidence.

Use of PN in this setting may cause net harm and should be highly or aggressively discouraged conditional recommendation, very low level of evidence. The clinician who has ethical concerns of his own in a difficult end-of-life situation should excuse himself from the case, as long as he can transfer care to an equally qualified and willing health-care provider conditional recommendation, very low level of evidence. Summary of Recommendations Indications for nutritional therapy Question: EN should be used preferentially over PN in hospitalized patients who require non-volitional specialized nutrition therapy, and do not have a contraindication to the delivery of luminal nutrients conditional recommendation, low level of evidence.

Prior to initiation of specialized nutrition therapy either EN or PN , a determination of nutritional risk should be performed using a validated scoring system such as the NRS or the NUTRIC Score on all patients admitted to the hospital for whom volitional intake is anticipated to be insufficient conditional recommendation, very low level of evidence.

An additional assessment should be performed prior to initiation of nutrition therapy of factors, which may impact the design and delivery of the nutrition regimen conditional recommendation, very low level of evidence. Indirect calorimetry conditional recommendation, very low level of evidence.

Simple weight-based equations conditional recommendation, very low level of evidence. Published predictive equations conditional recommendation, very low level of evidence. How should enteral access be achieved, and at what level of the GI tract should enteral nutrition be infused? Radiologic confirmation of placement in the stomach should be carried out prior to feeding except with use of electromagnetic transmitter-guided feeding tubes. A percutaneous enteral access device should be placed, either via the gastric or jejunal route, if enteral feeding is anticipated to be required for greater than 4 weeks duration conditional recommendation, very low level of evidence.

Initiating enteral nutrition Question: Placement on PN over the first week of nutrition therapy conditional recommendation, low level of evidence.

Monitoring tolerance and adequacy of enteral nutrition Question: How should adequacy and tolerance of enteral nutrition be assessed in the hospitalized patient? Gastric residual volume should not be used routinely as a monitor in hospitalized patients on EN conditional recommendation, very low level of evidence. Use a prokinetic agent conditional recommendation, low level of evidence. Divert the level of feeding lower in the GI tract strong recommendation, moderate-to-high level of evidence.

Switch to continuous infusion conditional recommendation, very low level of evidence. Use chlorhexidine mouthwash twice daily conditional recommendation, very low level of evidence. Use of fermentable soluble fiber as an adjunctive supplement to a standard EN formula conditional recommendation, very low level of evidence.

Switching to a commercial mixed fiber soluble and insoluble formula conditional recommendation, low level of evidence. When and how should parenteral nutrition be utilized in the hospitalized patient? Peripheral PN should not be used, as it leads to inappropriate use of PN, has a high risk of phlebitis and loss of venous access sites, and generally provides inadequate nutrition therapy conditional recommendation, very low level of evidence.

Nutritional therapy at end-of-life Question: All authors contributed to the manuscript. History of parenteral nutrition. J Am Coll Nutr ; The skeleton in the hospital closet.

Brief history of enteral and parenteral nutrition in the hospital in the USA. In Elia M, Bistrian B, eds. Vol 12 pp —Nestec Ltd. Enteral compared with parenteral nutrition: Am J Clin Nutr ; Total parenteral nutrition in the critically ill patient: Perioperative total parenteral nutrition in surgical patients. N Engl J Med ; Early enteral feeding, compared with parenteral, reduces postoperative septic complications.

The results of a meta-analysis. Early enteral feeding versus "nil by mouth" after gastrointestinal surgery: Calorie Intake of enteral nutrition and clinical outcomes in acutely critically ill patients: J Parenter Enteral Nutr ; Initial trophic vs full enteral feeding in patients with acute lung injury: Hypocaloric compared with eucaloric nutritional support and its effect on infection rates in a surgical intensive care unit: Trial of the route of early nutritional support in critically ill adults.

Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. The presence and effect of bias in trials of early enteral nutrition in critical care. Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: Intensive Care Med ; Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding: J Gastrointest Surg ; Nutrition support in acute pancreatitis: Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients.

Computerized energy balance and complications in critically ill patients: The relationship between nutritional intake and clinical outcomes in critically ill patients: Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury.

Crit Care Med ; The physiologic response and associated clinical benefits from provision of early enteral nutrition. Nutr Clin Pract ; Feeding the critically ill patient. Rating the quality of evidence. J Clin Epidem ; Grading quality of evidence and strength of recommendations. Percentage of weight loss, a basic indicator of surgical risk in patients.

Recognizing malnutrition in adults: Identifying critically ill patients who benefit the most from nutrition therapy: Incidence of nutritional risk and causes of inadequate nutritional care in hospitals.

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