NOCSPEN Newsletter: July 2019

CNSC Tidbit

The Clinician’s Compendium is useful if you need further review of nutrition support, and it includes sample test questions. It is free to ASPEN members and is being retired from their website on September 30, 2019. If you are planning to take the exam this September/October don’t miss out on this resource and many more on the ASPEN website for exam certification!

Article: Lipid Injectable Emulsions in Critical Care

Lipid Injectable Emulsions: Critical Care Recommendations and New Evidence
— By Meredith Hart, MBA, MS, RD, CNSC 
Medical Science Liaison, Fresenius Kabi USA
Meredith.Hart@fresenius-kabi.com 

Lipid injectable emulsions (ILEs) are an important component of parenteral nutrition (PN) prescriptions, providing a source of fat to PN-dependent patients. Fat is a dense source of energy, though lipids can contribute additional functions beyond the provision of kcals. They provide essential fatty acids (α-linolenic acid [ALA] and linoleic acid [LA]), carry lipid-soluble vitamins (vitamins A, D, E, and K), protect organs, and provide structure to cell membranes. Furthermore, certain conditionally-essential fatty acids, namely arachidonic acid (AA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA), actively contribute to the production of inflammatory mediators (i.e. prostaglandins, leukotrienes, thromboxanes), specialized pro-resolving mediators (i.e. resolvins, maresins, lipoxins), gene regulators, hormones, and enzymes.1 
 

Because lipids contribute to a broad range of important structural, metabolic, and immunologic functions, daily provision is recommended. For the critically ill patient requiring PN, 2016 Nutrition Support Guidelines jointly published by ASPEN and the Society for Critical Care Medicine (SCCM) recommend providing <1 gram/kg/day of ILE.2 These guidelines further suggest withholding soybean oil (SO)-based ILEs for the first week following PN initiation unless there is concern for essential fatty acid deficiency, in which case a maximum of 100 grams/week (divided into two doses) can be provided. The quality of evidence for this recommendation is designated as “very low,” and it is the only recommendation in the guidelines to receive <70% consensus from the authors.2 The recommendation is based on two small clinical trials (<60 patients in each study) evaluating hypocaloric, lipid-free PN versus PN with SO ILE. While the 2000 McCowen et al. study did not find differences in infection rate between groups, the 1997 Battistella et al. study found decreased days of mechanical ventilation and ICU and hospital length of stay (LOS), and a lower number of infections, in the hypocaloric, lipid-free PN group.3,4 

The 2016 ASPEN/SCCM Guidelines go on to address alternative lipid emulsions, which are ILEs containing less than 100% SO plus one or more of the following oils: medium-chain triglycerides (MCT), olive oil (OO), and fish oil (FO). The ASPEN/SCCM recommendation for alternative ILEs states that, based on expert opinion and once available, alternative ILEs be considered for use in the critically ill patient who is an appropriate candidate for PN.
2 Since 2016, the European Society for Parenteral and Enteral Nutrition (ESPEN) has published Expert Recommendations for Lipids in the ICU, Guidelines on Clinical Nutrition in the Intensive Care Unit, and Guidelines for Clinical Nutrition in Surgery.5-7 Collectively, these recommendations state that ILEs enriched with EPA and DHA (FO dose of 0.1-0.2 gram/kg/day) can be provided to patients requiring PN.7 Furthermore, FO-containing ILEs may provide clinical benefits to non-surgical ICU patients compared to SO or SO/MCT ILEs, and that MCT- or OO-containing ILEs can be used post-operatively in surgical ICU patients, though PN for these patients should probably include supplemental omega-3 fatty acids found in FO. FO-containing ILEs, also known as 4th generation ILEs, are recommended for patients with surgical complications.5,6 

Since the first commercially-available and Food and Drug Administration-approved alternative ILE was released in the U.S. in 2016, ASPEN has not provided additional guidance on their use in critical care populations.
8 However, new data on their use continue to emerge in the published literature. The newest meta-analysis assessing alternative ILEs in critical care was e-published ahead of print in the Journal of Parenteral and Enteral Nutrition last month.9 Pradelli et al. evaluated omega-3 enriched PN in hospitalized (ICU and surgical) patients through analysis of 49 randomized controlled trials, including a total of 3641 patients. Results of this meta-analysis found FO-containing ILEs, compared to standard ILEs, significantly reduced infection rate by 40%, risk of sepsis by 56%, length of ICU stay by 1.95 days, and length of hospital stay by 2.14 days. Significant outcomes pertaining to non-clinical laboratory markers were also reported.9

With the release of new ILE-focused evidence, it is important to continuously re-evaluate approaches to PN management in critical care, including type, dose, initiation, and duration of ILE provision. ILEs provide energy, yet their contributions to functional, metabolic, and immunologic processes are worthy of consideration for the critically ill patient.

References:

  1. The ASPEN Adult Nutrition Support Core Curriculum. 3rd ed. United States: American Society for Parenteral and Enteral Nutrition; 2017.

  2. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40(2):159-211.

  3. McCowen KC, Friel C, Sternberg J, et al. Hypocaloric total parenteral nutrition: effectiveness in prevention of hyperglycemia and infectious complications--a randomized clinical trial. Crit Care Med. 2000;28(11):3606-3611.

  4.  Battistella FD, Widergren JT, Anderson JT, Siepler JK, Weber JC, MacColl K. A prospective, randomized trial of intravenous fat emulsion administration in trauma victims requiring total parenteral nutrition. J Trauma. 1997;43(1):52-58; discussion 58-60.

  5. Calder PC, Adolph M, Deutz NE, et al. Lipids in the intensive care unit: Recommendations from the ESPEN Expert Group. Clin Nutr. 2018;37(1):1-18.

  6. Weimann A, Braga M, Carli F, et al. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr. 2017;36(3):623-650.

  7. Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48-79.

  8. Fresenius Kabi LLC USA. Smoflipid Prescribing Information. Lake Zurich, Illinois. 2016.

  9. Pradelli L, Mayer K, Klek S, et al. omega-3 Fatty-Acid Enriched Parenteral Nutrition in Hospitalized Patients: Systematic Review With Meta-Analysis and Trial Sequential Analysis. JPEN J Parenter Enteral Nutr. 2019.

Latest In the News

FDA Approves First Tube Feeding Delivery System Available Over the Counter

In early June, U Deliver Medical, LLC received regulatory clearance from the Food and Drug Administration for the bFed™ System tube feeding delivery products (Bolink™ tubing). The first tube feeding system available to consumers without a prescription, the innovative bFed System makes it easier for home tube feeders to deliver any form of nutrition they choose.

ASPEN Collaborates with ASHP to Develop Nutrition Support Certificate Program

A new continuing education program—designed for pharmacists, physicians, and nurses—teaches the fundamental concepts related to nutrition support care for adult patients. The Nutrition Support Certificate Program offers 19.25 credit hours and consists of 11 educational modules that review best practices for the ordering, access, preparation, and administration of nutrition support. The course also covers potential complications that could result from enteral or parenteral nutrition malnutrition, nutritional requirements for adults receiving nutrition support, and monitoring and error reporting. ASPEN members receive a $100 discount.

2019 Malnutrition Awareness Week

ASPEN Malnutrition Awareness Week (MAW) will be September 23-27, 2019. In addition to educational CE webinars, there will be on-demand videos and other support resources. You can also become an ASPEN Malnutrition Awareness Week Ambassador and help us raise awareness of malnutrition and educate healthcare professionals on early intervention. Ambassadors get free access to our 2019 MAW webinars. Learn more at nutritioncare.org/MAWpartners.

 

Have an interesting article or news to share? Please send it to us at 

NOCSPENnewsletter@gmail.com

Member Spotlight

Dan Furtado, MPA, PharmD

Vice President

I graduated from the UCSF School of Pharmacy. I then went on active duty in the US Army for two years as a pharmacist and was assigned to the Army’s Medical Field Service School, where I taught physiology and pharmacology and served as section chief. Subsequently, I worked for several years at the Palo Alto VA Hospital as a clinical pharmacy and residency coordinator. While working with the pharmacy residents and staff there, we established the TPN Program, in which I served as the Team Leader. In that early time of medical nutrition, there were no IV trace elements available; so as a team, we worked to develop our own trace element solution. I was present at the meeting of the incorporation of ASPEN in Chicago, and was recognized as a Charter Member and Founding Pharmacist Leader of ASPEN. I served the bulk of my career at Stanford as the Associate Director of the PA/NP Program and instructor in pharmacology. For recreation, I like to run, and I compete in several races every year. My family has been in Santa Clara County since the late 1800’s.

Ashlie Clay, RD, CNSC

Treasurer

After completing my internship at UCSF, I was fortunate to be hired on at Kaiser Permanente, where I’ve been practicing for over 7 years. I am the inpatient oncology dietitian at KP Oakland Medical Center, treating heme/onc patients admitted for chemotherapy and GI cancer post-op patients. I participate in Kaiser’s oncology nutrition, malnutrition and clinical nutrition subcommittees. I am currently fascinated by the ketogenic/low carb high fat diet and its therapeutic benefits in metabolic health. In January I attended the Metabolic Health Summit in Long Beach, CA and I’m studying for the Certified Ketogenic Nutrition Specialist certification. NOCSPEN is a great opportunity to advocate for the best clinical nutrition care for my oncology patients. When I’m not working, you’ll find me riding my road bike around the East Bay.

Yishan Huang, RD

Secretary

I am an inpatient Registered Dietitian at Chinese Hospital and UCSF Medical Center. I received my bachelor degree in Nutritional Science-Dietetics at UC Berkeley in 2017. As a Chinese immigrant, I have been serving the local Chinese community since 2015. I helped multiple community nutrition programs, and teach nutrition classes at local churches. I am so happy to be a member of NOCSPEN. To a new RD like me,NOCSPEN is a great place to meet with different providers and continue to advance my profession and patient care skills. 

Get Involved with NOCSPEN

If you have general inquiries, questions or feedback for our chapter, or you would like to join the board or attend a board meeting, please let us know at NOCSPENchapter@gmail.com.

This year, we are looking for 
Student Coordinators / Representatives from Dietetic Internships/ Universities (1 year term). 

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In This Issue

  • Upcoming Events

  • CNSC Tidbit

  • Article - Lipids in Critical Care

  • Latest in the News

  • Member Spotlight

  • Get Involved with NOCSPEN

Upcoming Events

Do you know an individual that you wish to spotlight their achievements? We will spotlight two individuals each newsletter. Contact us if you know of an individual, whether it is a dietitian, a nurse, a pharmacist or a physician.


For now, we are going to spotlight our NOCSPEN Board Members! 

 
 
 
 
 
 

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© 2019 by Northern California Society for Parenteral and Enteral Nutrition.