Home (Includes Pictures from Day 1 to Day 3) / Day 1: October 18, 2007

Keynote Lecture

Main Abstract Topics | Day 2 | Day 3

Abstracts Poster Database |
Summary/statistics

1) Nutrition screening/ assessment

2) Enteral nutrition/ access

3) Enteral/parenteral nutrition

4) Parenteral nutrition /access

5) Special nutrients

6) Critical care/NST

7) Nutrition support / management

8) Obesity / Weight management

9) Pediatric nutrition support

Plenary Sessions

Symposia

1. Critical Care
2. Specialty Session 1
3. Special Nutrients

4. Breakfast Symposium

5. Lunch Symposium

Abstracts of Symposia

Poster Presentations (Statistics)

 

 

 

KEYNOTE LECTURE (Top) :

MYUNG DUK LEE (Korea) (view lecture in PDF format)

 

PLENARY SESSIONS (Top)

1: The future of nutrition research: how we can put principles into practice

Paul Wischmeyer (USA) / View lecture in PDF format part 1a: Putting Principles to Practice / part 1b: Gut Function and the ICU patient / part 2: Parenteral Nutrition / part 3: Inflammatory and Oxidative Stress / part 4: Topics for Research in Clinical Nutrition

Chair: Luisito Llido (Philippines)

 

2: Current trends in nutrition support in critical illness: from bench to bedside

Andrew Davies (Australia) / view abstract

Chair: Tsann Long Hwang (Taiwan)

 

SYMPOSIA (Top)

 

BREAKFAST SYMPOSIUM (Abbott sponsored) / (top)

Advancing nutrition in diabetes management: achieving better outcomes: Editha Dalisay (Philippines)

 

LUNCH SYMPOSIUM (Abbott sponsored) / (top)

The role of eicosapentanoic acid in the management of cancer-induced weight loss: Maurizio Muscaritoli (Italy)

 

SYMPOSIUM 1: CRITICAL CARE (top)

Chair: Sun Sunatrio (Indonesia)

Co-Chair: Jude Erric Cinco (Philippines)

1.1 Impact of immunonutrition on host response: Kazuhiko Fukatsu (Japan) / View abstract

1.2 Strategies to optimize EN in critically ill patients: Patricia Anthony (Switzerland) / view lecture in PDF format

1.3 Modulation of oxidative stress: Tsann Long Hwang (Taiwan)

 

SPECIALTY SESSION 1: Issues in PN implementation (top)

Chair: Harbans Kaur Dhillon (Malaysia)

Co-Chair: Reynaldo Sinamban (Philippines)

SS1.1 Safe effective parenteral nutrition from factory to vein: Pharmacist's role: Patrick Ball (New Zealand) / view abstract

SS1.2 Compounding and protocols in ordering PN: Edmon Gutierrez (Philippines)

SS1.3 Aseptic dispensing techniques / Drug nutrient interactions: Harbans Kaur Dhillon (Malaysia) / view abstract / view lecture in PDF format

SS1.4 Monitoring delivery of PN: Raymundo Resurreccion (Philippines)

 

SYMPOSIUM 2: SPECIAL NUTRIENTS (top)

Chair: Myung Duk Lee (Korea)

Co-Chair: Maria Victoria Manuel (Philippines)

2.1 Impact of micronutrient deficiency on critical illness: Krishnan Sriram (USA) / View abstract / View lecture in PDF format

2.2 Updates on lipid emulsions in clinical nutrition: Hrishikesh Kulkarni (Hongkong) / view abstract / View lecture in PDF format

2.3 Virgin coconut oil: fad or fact?: Maria Rosario Sevilla (Philippines)

 

 

ABSTRACTS (top)

 

CURRENT TRENDS IN NUTRITIONAL SUPPORT IN CRITICAL ILLNESS: FROM BENCH TO BEDSIDE

Dr Andrew Davies President AuSPEN, Alfred Hospital, Melbourne, Australia (top)

Nutritional support (NS) improves clinical outcomes in the critically ill and our understanding of its effects has advanced signifi cantly over the last few years. Several recently published evidence-based guidelines are extremely useful in assisting clinicians to provide NS. The predominant current recommendations for ICU patients are that (1) enteral nutrition (EN) should be preferred to parenteral nutrition (PN) unless there is a major gut condition which will delay commencement of EN; and (2) nasogastric feeding should begin within 24 hours, but if intolerance develops, small bowel feeding or promotility drugs (erythromycin or metoclopramide) should be attempted. Most of the recent trends revolve around the composition of the EN formula leading to the view that the term pharmaconutrition should replace the term nutritional support. EN should not routinely be supplemented with arginine or glutamine, but recent evidence suggests a formula of fi sh oil, borage oil and antioxidants should be used if the patient has acute lung injury or sepsis. PN should be supplemented with glutamine and the PN prescription should be limited in energy to avoid hyperglycaemia. Whether using EN or PN, most patients should receive intravenous selenium and may also need zinc and copper supplementation for their antioxidant effects. (top)

IMPACT OF IMMUNONUTRITION ON HOST RESPONSE (top)
Kazuhiko Fukatsu, MD

Immunonutrition is a new nutritional therapy modulating host immunity and has been reported to reduce morbidity of infectious complications and hospital stay when administered to elective surgery patients. Because components of immunonutrition, immunonutrients, are nutrients contained in foods, their possible adverse effects were not frequently discussed. However, because of their strong effects on host response, some cautions have recently been given. Moreover, use of immunonutrition for severely injured and/or critically ill patients such as severe sepsis patients, is still controversial.

For adequate use of immunonutrition in clinical settings, we should understand how each immunonutrient modulates host response and which timings are appropriate for their administration. In this symposium, our experimental data on impact of immunonutrition on host response will be shown in terms of gut associated lymphoid tissue (GALT), peritoneal host defense, and gut ischemia-reperfusion injury. GALT is a center of both gut and systemic mucosal immunity. Peritoneal leukocytes protect host against contamination of pathogens in peritoneal cavity. Gut ischemia reperfusion is now considered to be an important mechanism underlying severe injury-induced multiple organ failure. I would like to focus on glutamine, arginine and omega-3 fatty acids as immunonutrients.

 

SAFE, EFFECTIVE PARENTERAL NUTRITION FROM THE FACTORY TO THE VEIN, THE ROLE OF THE PHARMACIST (top)
Patrick Ball
Professor of Pharmacy, Charles Sturt University, Wagga Wagga, Australia

In the early days of PN there was great excitement and enthusiasm. Multidisciplinary nutrition support teams (NST) were widespread, and a great deal of time and effort was expended to achieve the best possible outcomes from this expensive (but mostly cost-effective) therapy. Pharmacists have a role to play at every step.

Most patients were receiving individualised therapy, but many of these individual regimens did not have good stability data. There were also clinical incidents resulting from contamination in compounding units prompting moves to centre compounding in larger scale industrial units. These could provide better and more cost effective quality assurance, but were less responsive to patient needs. The ‘standard bag’ emerged and it was suggested that the needs of most patients could be adequately fed from only a small range of formulations.

In Europe and the USA, in the cost conscious 1980’s and 1990’s, many NSTs were disbanded and it has been argued that a ‘dumbing down’ of parenteral nutrition took place. Meanwhile enteral nutrition became more interventional and people seriously talked about the end of parenteral nutrition.

Parenteral nutrition is still life-saving, safe and cost effective, but only when performed to a high standard. Off the shelf standardised formulations are here to stay but they can and must be tailored and adapted to meet individual needs by dosage adjustment and minor customising. However, there will always be individuals who must have special formulae and it will be essential for countries to maintain the skill base and infrastructure to support this.

PN solutions are purchased from licensed manufacturers, but is remains important today to monitor transport cold-chain, in-house storage conditions, and during transport within the hospital to the patient. If additions need to me made (there are no nutritionally complete admixtures currently available), the additions must be made under suitable aseptic precautions and be of known stability and compatibility with the nutrition admixtures in use. The phrase coined by the Welsh Pharmacist, the late Dr Michael Barnett remains true; “no substitution (of products) without validation.”

A stable PN formula also requires safe administration. Concurrent parenteral therapy must be evaluated and safely co-administered. Pharmacists have a great deal to contribute if they take the time to learn and understand infusion equipment and devices. It is important to understand that, for example, if you co-administer antibiotics into a running infusion line, the position in the line at which it is added can make a profound difference to the plasma profi le. For medications such as penicillins, which have only time-dependent killing of micro-organisms this will be of little consequence but for gentamicin which has concentration-dependent killing, the route of administration may make the difference between good effect or therapeutic failure. When multiple agents are co-infused, changing any one may unintentionally affect the delivery profi le of the others. Pharmacists can become very skilled at managing these issues.

The venous access in use must be secured and kept free of infection and line patency maintained. Understanding the difference between the various types of circulatory access available and appropriate attention to the osmolarity of the solution and rate of delivery can prolong the life of an access route, especially if backed up by rigorous protocols for avoiding catheter infections.

Pharmacists understand that a ‘drug’ is actually administered as a formulated medicinal product, which may contain sugars, electrolytes, other excipients and a certain volume of water that may need to be included in calculations of daily fluid and electrolyte requirements. A number of medications also have signifi cant interactions with nutrition.

Safe, effective PN requires attention to detail from start to fi nish, and the pharmacist has a role at all stages. (top)

 

ASEPTIC TECHNIQUES/DRUG-NUTRIENT INTERACTIONS (top)
Harbans Dhillon
President of PENSMA, Kuala Lumpur, Malaysia

Total Parenteral Nutrition (TPN) solutions must be prepared aseptically according to strict aseptic techniques with quality control and assurance fi rmly in place to prevent microbial and particulate contamination. TPN solutions should be prepared aseptically in pharmacy based cleanrooms, where trained and validated personnel have the expertise and resources for strict aseptic compounding of parenteral products.

The stability evaluation of a TPN solution is complex, because such a solution consists of more than 50 chemical components. A lot of physical and chemical reactions can take place in such an environment. A number of precautions must therefore be taken when preparing, storing, and using a TPN solution especially an all-in-one admixture to ensure that it reaches the patient as a safe and stable solution. There are many challenges to doing this. The ingredients must not interact with each other and form new compounds which may be unstable and they must also not degrade over time as could happen during storage.

There are three processes that may make a TPN solution unstable. They are:
• precipitation
• chemical and physical incompatibility
• instability of the fat emulsion

Calcium for example reacts with phosphate and precipitates when the concentrations of the calcium phosphates formed exceed their solubility limits. Reactions between phosphate and trace elements or trace elements and amino acids may also occur and form precipitates.

Chemical incompatibility includes degradation of certain components, which decreases their effi cacy or activity. Amino acids and vitamins are most sensitive to chemical degradation.

Acidity is also another component that affects stability of a TPN solution. Although glucose is a neutral molecule, its sterilized IV solution is acidic, with a pH ranging from 3.5 to 6.5, depending on the concentration and varying among manufacturers and within batches of the same manufacturer. Highly concentrated glucose solutions often have a negative effect on lipid emulsions. In general amino acid solutions have a protective effect on lipid emulsions, since they have a strong buffering capacity for the acidic glucose solutions and they enhance the mechanical barrier of the emulsifying agent.

It is not advisable to add drugs to TPN bags. The drug itself may react with components in the admixture or the container material. This may reduce the efficacy or bioavailability of the drug or change its kinetics. The drug itself or additives in the product may cause precipitation by changing the pH or destroy the fat emulsion by increasing the ionic concentrations, especially ofof di- and trivalent
ions, and by inactivation of the emulsifi er due to solubilizers. In principle no drugs should be added to a nutritional admixture. Even piggy-back infusions should be avoided especially if the compatibility is unknown. (top)

 

IMPACT OF MICRONUTRIENT DEFICIENCY IN CRITICALLY ILLNESS (top)
Krishnan Sriram
Stroger Hospital of Cook County, and Rush University, Chicago, IL, USA

Pre-existing micronutrient (vitamins and trace elements) defi ciencies, especially zinc (Zn), iron (Fe), selenium (Se), vitamins B and C, are often present in critically ill patients. Additional defi ciencies occur due to inadequate or inappropriate administration, increased or altered requirements and increased losses, which can affect various biochemical processes, resulting in organ dysfunction, poor wound healing and altered immune status with deleterious sequelae.

The American Medical Association has established guidelines for the 13 essential vitamins (4 fat soluble and 9 water soluble.) and for trace elements (Cr, Cr, Co, Fe, Fl, I, Mo, Mn, Se, Zn). These recommendations are applicable to healthy adults and not for critically ill patients. Decreased serum levels may indicate actual defi ciencies but also redistribution. Benefi ts of supplementation, which may not result in increased serum levels, are also unclear. Vitamin requirements (specifi cally vitamins B1, B6, C and K) are increased in disease states, but a similar recommendation for trace elements has not been initiated except for Se and Zn.

In practice, a multivitamin preparation (including vitamin K) and a multiple trace element admixture {containing Zn, Se, Cu, Cr, and Mn is added to parenteral nutrition formulations. Most enteral nutrition preparations also contain adequate amounts of vitamins and trace elements, though bioavailability may be an issue. Detailed information about individual micronutrient use specifi cally in critical care practice will be discussed, emphasizing the practical and clinical aspects. Clinical case scenarios will be presented. Recommendations for specifi c disease states, especially renal and hepatic dysfunction will also be discussed. Appropriate references will be provided and more recent information reviewed. (top)

 

UPDATES ON LIPID EMULSIONS IN CLINICAL NUTRITION (top)
Dr. Hrishikesh Kulkarni
Medical Director
Fresenius Kabi Asia Pacific, Hong Kong

All LEs have some components in common. A triglyceride (TG-oil) is present to provide energy and also the essential fatty acids. The oil is emulsifi ed in water with the help of an emulsifi er, which typically is a phospholipid (PL). The emulsion thus formed is quite hypo-osmolar and hence the osmolarity is increased to make the emulsion iso-osmolar with blood. The agent commonly used is glycerol, which is easily metabolized in the Krebs’ cycle. Iso-osmolarity is the main reason due to which LEs can be safely given through a peripheral vein by themselves. Moreover, when they are added to other hyper-osmolar solutions (like amino acid solutions), lipids lower the overall osmolarity and improve tolerability of the nutrient admixture.

The proportion of phospholipids in a LE seems to be of clinical importance. Initially when LEs used to be 10% oil-in-water emulsions, the proportion of PL to TG was 0.12. This was far higher than 0.04-0.08, the PL:TG ratio in chylomicrons, body’s natural LE. High PL:TG ratio is associated with some clinical problems, typically hypercholesterolemia. Subsequently, newer 20% and 30% LEs were developed which had PL:TG ratio similar to that of chylomicrons. The modern LEs, look very much like chylomicrons under microscope and have similar pharmaco-kinetic properties.

Medium chain triglycerides (MCTs) were introduced in parenteral nutrition in order to provide a source of “fast energy”. As MCTs are metabolized relatively faster and partly independent of carnitine, this made sense. Pure MCT emulsions, however are not only devoid of essential fatty acids but also toxic. Hence MCTs are never present in an emulsion by themselves. They are always combined with other emulsions, commonly, LCTs (long chain triglycerides). The MCT-LCT physical mixtures are quite popular and are sometimes believed to be superior to pure LCT mixtures. The evidence supporting this belief however is not extensive.

In the next step of evolution, scientists combined MCTs and LCTs not physically but chemically to create the structured triglycerides (STGs). STGs were shown to overcome many limitations of both LCTs and MCT/LCT physical mixtures while keeping the advantages of both. Like LCTs, STGs provide the essential, polyunsaturated fatty acids (PUFA) and like MCTs, they are metabolized rapidly, resulting in faster clearance and lower serum TG levels in patients. Olive oil, rich in mono-unsaturated fatty acids (MUFA) gained popularity based on the popularity of the “Mediterranean diet”. Olive oil, by itself is defi cient in PUFA and hence soybean oil still stayed as a PUFA source component in the “olive oil” emulsions.

Recently a tremendous interest has been generated in fi sh oil (FO) emulsions. These oils are rich in particularly ω-3 PUFAs namely eicosapentaenoic acid and dochosahexaenoic acid. The oral use of fi sh oils has been famous for prevention of heart diseases as shown in a number of large scale studies. In parenteral form,however, FO emulsions were developed just to provide the ω-3 PUFAs as a part of a total parenteral nutrition regimen, with the thought that soy-bean oil being the main component of conventional LEs, patients were being delivered a relatively lower proportion of ω-3 PUFAs compared to ω-6 PUFAs. FO emulsions are available singly (only as FO emulsion) or as a part of combinations of Soy-MCT-FO (SMF) or Soy-MCT-Olive-FO (SMOF) LEs. The new LEs containing FOs have shown a number of benefi ts in clinical settings including faster clearance of fats , better laboratory safety and even reduced hospital stay. A recent publication showed in a prospective large scale study in German ICUs that the use of FO emulsions was associated with reduction in mortality, length of stay and use of antibiotics in a dose dependent
manner, with the best results being obtained by provision of FO emulsion in a dose between 0.1-0.2 g/kg/d.

Although by regulatory status, FOs are supposed to be used for supplying ω-3 PUFAs to patients on parenteral nutrition, their immunomodulator properties have generated a tremendous interest. FO emulsions have been shown to blunt both the overstimulation and suppression of the immune system in response to a variety of precipitating factors. Their infl uence on eicosanoid generation, interleukine and cytokine responses to infl ammatory and immune suppressing stimuli is at the forefront of current research.

The old belief that LEs suppress immunity is slowly being dissipated for lack of evidence and plethora of evidence on the contrary. In general, however, it is not the LE by itself but hypertriglyceridemia caused by overinfusion or too fast infusion has been associated with deleterious effects on the immune system. Apart from rate of infusion and total dose, other factors such as quality of a LE can infl uence the adverse reaction profi le of an individual LE.

To summarize, among the number of LEs available today, soybean oil LEs are still useful due to their ability to provide PUFAs. MCTs are known as the “fast energy” sources. STG LE was developed to enhance the safety of MCT/LCT combination. Olive oil LEs are distinct by their high MUFA content. Fish oil is currently the “hot topic” in LE related research due to its immunomodulator properties. (top)

 

 

 

 

 

 

 

ORAL / POSTER PRESENTATIONS SUMMARY: (top)

* Oral Presentations: 11 (View oral presentations)

Research areas
Greece
Hongkong
India
Japan
Malaysia
Philippines
SouthKorea
Taiwan
Thailand
Total
Nutrition screenng / assessment
-
-
2
1
1
6
7
-
-
17
Enteral nutrition / access
-
-
-
-
1
2
-
-
-
3
Enteral and parenteral nutrition
-
-
-
-
-
-
1
-
-
1
Parenteral nutrition / access
1
-
-
1
-
-
1
2
1
6
Special nutrients
-
-
-
1
-
-
1
1
-
3
Critical care / NST
-
1
-
1
-
1
1
-
-
4
Nutrition support / mgt
-
-
-
1
-
-
-
1
-
2
Obesity / weight mgt
-
-
-
-
-
1
-
-
-
1
Pediatric nutrition support
-
-
-
-
-
2
1
-
-
3
Total
1
1
2
5
2
12
12
4
1
40