Proceedings of the 12th Congress of the Parenteral and Enteral Nutrition Society for Asia (PENSA), Metro-Manila, Philippines, yr 2007

Home (Includes Pictures from Day 1 to Day 3) / Day 3: October 20, 2007

Breakfast Symposium Day 1
Symposium 5 Day 2
Symposium 6 Abstracts
Specialty Session 3 Oral Presentation
Lunch Symposium 3
Symposium 7

 

SYMPOSIA

0700 - 0830 BREAKFAST SYMPOSIUM (Abbott sponsored) (top)

Pediatric nutrition support: a wave of the future: Felizardo Gatcheco (Philippines) / view abstract

0830 - 1000 SYMPOSIUM 5: Specific clinical conditions 2 (top)

Chair: Andrew Davies (Australia)

Co-Chair: Carla Sibulo (Philippines)

 

5.1 Liver Disease: Diana Payawal (Philippines)

5.2 Renal Disease: Preyanuj Yamwong (Thailand) / view abstract / view lecture in pdf format

5.3 Pulmonary Disease: Noel Bautista (Philippines)

 

0830 - 0930 SYMPOSIUM 6: Nutrition support beyond the hospital (top)

Chair: Eduardo Poblete (Philippines)

6.1 Home nutrition support: Luciana Sutanto (Indonesia) / view abstract

6.2 Nutrition issues in end of life care: Miguel Ramos (Philippines)

 

1000 - 1200 SPECIALTY SESSION 3: Enteral Nutrition Workshop (top)

Chair: Thanyadej Nimanwudipong (Thailand)

Co-Chair: Higinio Mappala

SS3.1 Issues on enteral access: Thanyadej Nimmanwudipong (Thailand)

SS3.2 Video Presentation: EN access in UGI obstruction: Ryoji Fukushima (Japan) / view abstract

SS3.3 EN delivery and tube care: Satiapoorany Subramaniam (Malaysia)

 

1200 - 1330 LUNCH SYMPOSIUM 3 (sponsored by Tyco Healthcare) (top)

The evolution of how we feed the patients: Thanyadej Nimmanwudipong (Thailand)

 

1330 - 1530 SYMPOSIUM 7: NST DEVELOPMENT AND EDUCATION (top)

Chair: Renato Reyes (Philippines)

Co-Chair: Marianna Sioson (Philippines)

7.1 NST development in developing countries: Krishnan Sriram (USA) / view abstract / view lecture in PDF format

7.2 Nutrition support education and computerization: Luisito Llido (Philippines) / view abstract / view lecture in PDF format

7.3 The experience in Australia and New Zealand: Andrew Davies (Australia) / view abstract

 

 

ABSTRACTS (top)

 

ENTERAL NUTRITION IN PEDIATRICS (top)
Felizardo N. Gatcheco MD, MSc
Pediatric Gastroenterologist/Clinical Epidemiologist

Malnutrition is a very prevalent problem not only among the general pediatric population but more so among hospitalized infants and children, especially those with chronic illnesses or who are critically ill or those with pre-morbid malnutrition states. Seldom do physicians give equal emphasis on the nutritional rehabilitation of these pediatric patients , which if appropriately instituted may even favorably affect the fi nal clinical outcomes of these patients.

The purpose of this presentation is to review the current medical literature on some of the more important aspects in the administration of enteral nutrition in pediatrics. Specifi cally, meta-analytic reviews culled from the Cochrane Review database will be summarized to give credence to whatever the members nutrition team do the patients ( examples, use of immunemodulating additives, care and administration of enteral tubes, etc)

NUTRITION SUPPORT IN ACUTE RENAL FAILURE (top)
Preyanuj Yamwong
Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, THAILAND

Acute renal failure (ARF) is often a complication of underlying conditions such as sepsis, trauma, and multiple-organ failure in critically ill patients. It is an independent risk factor contributing to increased hospital mortality and can be superimposed by poor nutritional status. Malnutrition in ARF patients is caused by hypercatabolism and hypermetabolism that parallel the severity of illness as well as inability to provide adequate nutrients to the patients. Due to underlying hypercatabolic condition, the patients usually require 35-40 kcal/kg/day and 1.5 to 1.8 g of protein/kg/day as a balanced mixture of both essential and nonessential amino acids. However, the regimen should be tailored towards the needs and limitation of each individual patient. Enteral feeding is the preferred route and should be started as early as possible. Parenteral nutrition can be used in cases whose gastrointestinal tract cannot be used. Due to limitation of volume allowed, high concentration of nutrients should be used through central line. In cases with many limitations, renal replacement therapy may be needed early to enable adequate nutrition support. Continuous renal replacement therapy is now widely used in the intensive care unit to manage patients with ARF, because it is better tolerated than intermittent hemodialysis by patients who are hemodynamically unstable. In either case, protein requirement might be higher to substitute the loss of amino acids or protein losses during the dialysis. Minerals replacement should be closely monitored to fi t the condition of each patient.

 

HOME NUTRITIONAL SUPPORT (top)
Luciana B Sutanto
Department of Clinical Nutrition, Medical Faculty, Indonesia University, Jakarta, Indonesia.

Home Nutritional Support (HNS) is indicated for patients with predicted necessary long-term nutritional therapy. This may either be home enteral nutrition (HEN) or home parenteral nutrition (HPN). The patient’s medical condition must be stable before any form of HNS can be implemented. Aside from this, there must be adequate cooperation and understanding, not only from the patients themselves but also from their family members.

One of the benefi ts of HNS is cost-savings of up to 50% for HPN and 70% for HEN. HNS may also increase survival and general wellbeing. Among pediatric patients with intestinal failure, HPN provides a successful bridge from hospital nutrition to HEN.

Managing home nutritional support requires careful assessment of nutrition, planning, monitoring and follow up. Interdisciplinary team is necessary for providing good management. Nutrition care plan in HNS includes access, formula selection, administration technique, reimbursement, preparing patient & family in education, supplies, monitoring & complication identifi cation and management.

Home nutritional support will likely increase as the paradigm shifts to more shortened length of stay in hospital. The skilled nutrition support clinicians will contribute positively to the outcome of the health and the quality of life of patients.

 

ENTERAL ACCESS IN GASTROINTESTINAL OBSTRUCTION (top)
Ryoji Fukushima MD
Department of Surgery, Teikyo University School of Medicine, Tokyo Japan

Malnutrition is a common and signifi cant problem in patients with upper gastrointestinal cancer and some other diseases. Enteral nutritional support is an important therapy and is preferred over parenteral nutrition in the setting of a functioning gastrointestinal tract. Placement of feeding tubes into the esophagus, stomach or small intestine can overcome some of the most common causes of impaired caloric intake. For example, gastrostomy tube placement can bypass proximal obstructions caused by esophageal cancer. Percutaneous endoscopic gastrostomy tube placement (PEG) is now the most common method for enteral route access in such patients, however, there is diffi culty in placement of PEG by usual “pull methods” in the presence of severe stenosis. Also there is a possibility of tumor implantation at the insertion site. Newly developed “seldinger method” may overcome these problems and concerns. By using thin scope and gastric wall lifting device, we may be able to make PEG without the tube getting through the stenotic tumor-bearing esophagus.

For gastrectomized patients in whom PEG placement is not possible, percutaneous transesophageal gastro-tubing (PTEG) is a useful method in placing of feeding tubes. The technique was developed in Japan by Oishi et al. Ultrasonography, fl uoroscopy, and a rupture-free balloon is needed for the placement. These tubes can be effectively used for chronic decompression of bowel obstruction such as peritoneal cancer dissemination.

 

NUTRITION SUPPORT TEAM DEVELOPMENT (top)
Krishnan Sriram
Stroger Hospital of Cook County & Rush University, Chicago, USA

This presentation will highlight the growth & decline of Nutrition Support Teams (NST) in the USA. Benefi ts of NSTs, reasons for current decline, and suggestions for Asian countries will be presented. Nutritional support (NS), like critical care medicine, is a multi disciplinary specialty, requiring expertise from dieticians, nutritionists, physicians, pharmacists, nurses & hospital administrators. NSTs were fi rst organized in the USA in the mid 1970s when the importance of specialized nutritional support was recognized & confi rmed. Length of hospitalization, infectious complications especially catheter related, metabolic complications, utilization of resources, & total cost of care, were favorably improved with NST participation.

Dieticians play a key role in nutritional assessment, monitoring, and discharge planning/home care. Nurses assist in maintenance of feeding tubes & venous access devices. Pharmacists are responsible for parenteral nutrition compounding, and monitoring for drug -nutrient interactions and electrolyte/acid base issues. Physicians remain key leaders with overall responsibility, but fi nding physicians with a specifi c interest in NS has been diffi cult.

In recent years, in USA, a gradual decline in NSTs has occurred. Administrators & third-party insurance payers have not accepted supporting literature. Health care statistics can be manipulated by fi nancial offi cers making it diffi cult to fi ght the system. This has resulted in an increase in dieticians well trained in all aspects of NS, including parenteral nutrition, most of whom have higher degrees. These lessons learnt must be used to the benefi t Asian countries, where a large proportion of care is delivered in public hospitals. Hospital administrators need to be provided regional data to support NSTs and to restrict the role of clinical dieticians to non-kitchen based responsibilities. The future of NSTs depends on dieticians & nutritionists.

 

NUTRITION SUPPORT EDUCATION AND COMPUTERIZATION (top)
Dr. Luisito Llido
Chairman, Nutrition Support Service, St. Lukes Medical Center, Philippines

Nutrition support has been recognized to be one of the components of the highest standard of care to the patient as shown by studies on patient care for the past fi fteen to twenty years (1,2). Its development runs parallel to the recognition that malnutrition is an ever present problem in the hospital setting (3,4). With the increasing awareness of this problem there was an increase in the development and implementation of nutrition programs and teams in Europe, the US, the Americas, and fi nally Asia. Currently nutrition support has become a requirement for critical care management in all age groups and in all situations (5,6). It has made the study of body composition, enteral and parenteral nutrition, and understanding of the pathophysiology as well as cellular and subcelluar changes of disease and nutrition interaction an indispensable part of providing total patient care (7).

Nutrition support practice is still to be fully developed in most of the Asian countries (8) and in the Philippines the situation is as poignant as the rest of its Asian neighbors. The Philippine Society of Parenteral and Enteral Nutrition was founded in 1995, but it was only in 2004 that it was able to have its fi rst national convention – a full 9 years of hibernation. The key to this breakthrough was the development of a nutrition support program, organization of a nutrition support team, and initiation of a training program in nutrition support in one of the key medical centers of the country. It took four years after the nutrition support program and team was initiated when the clinical dietitian was recognized to be an active part of the nutrition support process. Regular orientation, post graduate courses on nutrition, and mini-workshops in nutrition support (nutrition screening and assessment, enteral and parenteral nutrition) were held within the hospital. When the prevalence of malnutrition in the hospital was reported in 1995 it took four years for the hospital administration to realize and order that all nutrition support personnel see all critical care patients. While these slow developments were going on workshops and attempts by the medical nutrition industry to develop nutrition support teams in the different parts of the country were initiated and eventually failed.

The initiation of a nutrition workshop partnered by a medical nutrition company and this institution through its nutrition support team in 1999 and 2000 sparked the resurgence of interest in the rest of the country. Its key impact was the development of a nutrition support fellowship training program in 2001, which now produced both faculty and students in clinical nutrition. One year before this development, the initiation of a computerized system of nutrition surveillance was implemented by the nutrition support team in this institution which enabled identifi cation of the nutritionally at risk patient. It further made the nutrition care of the patient more focused. After three years of implementation the compliance of standards of patient care was improved from 2% to almost a 98 % (9). Height and weight were diligently taken, critical care patients’ nutrition care plan were implemented with an increase in the number of patients seen and adequacy of intake assessed and corrected (10). Referrals to the nutrition support team increased and were sustained. A weight management center was also set up with experience in bariatric surgery reported (11).

These were the results of the establishment of a nutrition support fellowship training program:
a) Follow up of patients identifi ed by the computerized nutrition surveillance system was better organized with scheduled visits done on a regular basis due to the presence of more personnel.
b) Communication of nutrition needs of both patients and physicians of other disciplines were increased and more in-depth in character. Awareness of the value of nutrition support was increased.
c) Increase in the number of personnel who provided the manpower in the organization and holding of the fi rst congress in parenteral and enteral nutrition in 2004 and successive ones.
d) Initiation and publication of research in clinical nutrition focusing on outcome and quality of patient care
e) Provision of consultants and resource persons who organized workshops in clinical nutrition all throughout the country and are now members of several nutrition committees in major health societies/organizations in the country
f) Provision of consultants who now organize nutrition support programs and teams in other hospitals either through lectures, workshops, or as advisers.

Currently fi ve major hospitals in the Philippines are benefi ting from this program (three with computerized nutrition surveillance and fi ve with specialists in clinical nutrition). It is the hope of the society (PHILSPEN) to further develop similar programs in the country. It further aims to strengthen the membership by establishing a certifying board in clinical nutrition for the nutrition support team members (physician, dietitian, nurse, and pharmacist) after they have completed the training program in nutrition support.

A new development was the development of a master of science in clinical nutrition which is focused on hospital practice and designed for physicians, dietitians, nurses, and pharmacists. This program was set up in 2005 and aimed to develop more practitioners in nutrition support who will deliver nutrition care to most of the institutions of the country. A partnership with the neighboring countries in Asia in developing a clinical education program that fosters rotation and sharing of experience either through exchange programs or out-of-country rotation would provide a lot of mileage in achieving the goal of increasing the number of clinical nutrition specialists not only in the Philippines, but in Asia (8).

Three key ingredients for the success of nutrition support implementation were identifi ed:
a) the presence of dedicated person(s) who either perform the nutrition support process or continuously monitor and improve the established programs – in other words: leaders!, b) supportive administration, and c) an active, ongoing training program in clinical nutrition which is attractive to all interested practitioners in clinical nutrition (12).

References:
1. Merritt R. Integration of nutrition support into patient care. In A.S.P.E.N. Nutrition Support Practice Manual, 2nd ed. Merritt R. (editor in chief); xviii (2005)
2. Coats K.G., Morgan, S.L., Bartolucci, A.A., & Weinsier, R.L. Hospital associated malnutrition: a reevaluation 12 years later. Journal of the American Dietetic Association, 93, 27-33 (1993).
3. Butterworth CE Jr. The skeleton in the hospital closet. Nutrition 10, 42 (1994).
4. A.S.P.E.N. Board of Directors and Task Force on Standards for Specialized Nutrition Support for Hospitalized Adult Patients. Standards for specialized nutrition support: Adult hospitalized patients. Nutr Clin Pract; 17:384-391 (2002).
5. JCAHO. 2004 Comprehensive Accreditation Manual for Hospitals: The Offi cial Handbook (CAMH). Oakbrook Terrace, IL, (2004).
6. JCAHO. 2004 Comprehensive Accreditation Manual for Long Term Care (CAMLTC). Oakbrook Terrace, IL: Joint Commission Resources, (2004).
7. Laviano A. Research in nutritional science: providing evidence to the clinical relevance of nutrition. Plenary lecture, 11th PENSA Congress, Seoul, Korea, (2005).
8. Saito H. What is the state of PEN in Asia? Plenary lecture, 11th PENSA Congress, Seoul, Korea.
9. Llido LO. The impact of computerization of the nutrition support process on the nutrition support program in a tertiary care hospital in the Philippines: report for the years 2000- 2003. Clin Nutr; 25 (1): 91-101 (2006).
10. Umali MN, Llido LO, Francisco EM, et al. Recommended and actual calorie intake of intensive care unit patients in a private tertiary care hospital in the Philippines. Nutrition; 22 (4): 345-9 (2006).
11. Dineros H, Sinamban R, Siozon M, et al. Obesity surgery in the Philippines: experience in a private tertiary care hospital for years 2002 to 2004. Obes Surg; 17 (1):82-7 (2007).
12. Howard P. Organizational aspects of starting and running an effective nutritional support service. Clin Nutr;20 (4):367-74 (2001).
13. Howard JP, Bruce J, and Powell-Tuck J. Nutritional support: a course for developing multidisciplinary clinical teams. Education Committee, British Association for Parenteral and Enteral Nutrition. J R Soc Med; 90 (12):675-8 (1997).

 

THE EXPERIENCE IN AUSTRALIA & NEW ZEALAND (top)
Dr Andrew Davies
President AuSPEN, Alfred Hospital, Melbourne, Australia

Using nutritional support (NS) to achieve best outcomes for our critically ill patients is important in all countries. The Australian and New Zealand healthcare systems place strong emphasis on the education and clinical practice of high quality critical care nutrition. A recent international survey has demonstrated that Australasians administer a high proportion of enteral nutrition (EN), which is commenced early after admission. There is very common use of evidence-based feeding protocols which place emphasis on the use of promotility drugs and small bowel feeding when gastric intolerance occurs. Parenteral nutrition (PN) is uncommonly administered unless there is major gastrointestinal pathology and the combination of EN and PN is rare. Arginine-containing EN is used very rarely and glutamine is only infrequently supplemented. Unfortunately, despite the recent supportive evidence, EN with fi sh oil, borage oil and antioxidants is not commercially available in our countries. Nevertheless when PN is used, newer style lipids (such as olive oil) appear to be taking over from soybean oils. The Australian and New Zealand Intensive Care Society Clinical Trials Group has a strong focus on critical care nutrition with 3 important multi-centre research trials underway. These are testing the interventions of early nasojejunal feeding, early parenteral nutrition and intensive insulin therapy with results eagerly awaited.