Answers to Self-Assessment Questions - ACCP

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in this patient population because there is no evidence that they improve outcomes. 1. Garrel D, Patenaude J, Nedelec B, Samson L, Dorais J, Champoux J, et al. Decreased mortality and infectious morbidity in adult burn patients given enteral glutamine supplements: a prospective, controlled, randomized clinical trial. Crit Care Med 2003;31:2444–9. 2. Prelack K, Dylewski M, Sheridan RL. Practical guidelines for nutritional management of burn injury and recovery. Burns 2007;33:14–24. 47. Answer: D The medical resident would like to discuss changing R.R. to an immune-enhancing EN formulation with omega-3 PUFAs and antioxidants. The correct response to this suggestion would highlight that immune-enhancing EN formulations shown to be beneficial in a specific patient population may not be associated with the same improvements in outcomes in other patient populations. The correct response is that the suggested change should not be made because an immune-enhancing EN formulation with omega-3 PUFAs 8.6 g/L and antioxidants is associated with increased survival in patients with sepsis and ARDS but has not been evaluated in patients with burns (Answer D). An immune-enhancing EN formulation with omega-3 PUFAs 8.6 g/L and antioxidants has not been shown to alter oxygenation in patients with burns (Answer B) or to increase survival in a nonseptic mixed medical ICU population (Answer C). Because an immune-enhancing EN formulation has not been evaluated in patients with burns, switching to an immune-enhancing product (Answer A) is incorrect. 1. Garrel D, Patenaude J, Nedelec B, Samson L, Dorais J, Champoux J, et al. Decreased mortality and infectious morbidity in adult burn patients given enteral glutamine supplements: a prospective, controlled, randomized clinical trial. Crit Care Med 2003;31:2444–9. 2. Prelack K, Dylewski M, Sheridan RL. Practical guidelines for nutritional management of burn injury and recovery. Burns 2007;33:14–24. 48. Answer: D The length of time that RR receives immunonutrition should be evidence-based. In one study that evaluated immunonutrition in patients with burns and demonstrated improved patient survival with enteral glutamine supplementation, immunonutrition was continued until complete wound healing was achieved (Answer D), making Answer D the correct answer. The other durations, until extubation (Answer C), 96 hours (Answer B), or 48 hours (Answer A), have been used as minimum therapy goals in other trials of immune-enhancing nutrients. However, in patients with burns, extending the duration of therapy until complete would healing occurs is more likely to result in additional benefit. 1. Garrel D, Patenaude J, Nedelec B, Samson L, Dorais J, Champoux J, et al. Decreased mortality and infectious morbidity in adult burn patients given enteral glutamine supplements: a prospective, controlled, randomized clinical trial. Crit Care Med 2003;31:2444–9. 2. Prelack K, Dylewski M, Sheridan RL. Practical guidelines for nutritional management of burn injury and recovery. Burns 2007;33:14–24. 49. Answer: C Clinicians should be aware that harm might result from the use of immune-enhancing EN formulations in certain patient populations. Some evidence indicates that argininecontaining immune-enhancing diets may be harmful in critically ill patients with severe sepsis. Therefore, the 62-year-old man with severe sepsis and an APACHE II score of 26 (Answer C) may be harmed by an arginine-containing immune-enhancing EN formulation, making Answer C the best answer. The 32-year-old patient with a urinary tract infection after severe trauma (Answer A) is likely to benefit from an arginine-containing immune-enhancing diet, as is the 59-year-old man with gastrointestinal (GI) cancer after colonic resection (Answer B); thus Answer A and Answer B are incorrect. The 48-year-old man in the medical ICU with an APACHE II score of 12 (Answer D) is less likely to benefit from an immune-enhancing diet, but he is not in a patient population in which additional harm has been suggested. 1. Bertolini G, Iapichino G, Radrizzani D, Facchini R, Simini B, Bruzzone P, et al. Early enteral immunonutrition in patients with severe sepsis: results of an interim analysis of a randomized multicentre clinical trial. Intensive Care Med 2003;29:834–40. 2. Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet P, Kazandjiev G, et al. ESPEN guidelines on enteral nutrition: intensive care. Clin Nutr 2006;25:210–23. 50. Answer: C Glutamine is a major energy source for enterocytes and is associated with enhanced luminal barrier function (Answer A), but this effect is not a potential advantage of parenteral glutamine compared with enteral glutamine because this effect should occur regardless of the route of administration, so Answer A is incorrect. Arginine, not glutamine, increases the production of inducible nitric oxide (NO) (Answer B); thus, neither route of glutamine administration would be expected to produce this effect, and Answer B is incorrect. Increasing the production of heat shock proteins (Answer C) is an advantage of parenteral compared with enteral glutamine administration because this effect has been more strongly associated with parenteral supplementation than enteral supplementation, making Answer C correct. Glutamine by either route would be expected to increase T-helper lymphocytes, rather than decrease them as stated in Answer D; thus, Answer D is incorrect. 1. Tjader I, Berg A, Wernerman J. Exogenous glutamine— compensating a shortage? Crit Care Med 2007;35(suppl):S553– S556. 2. Suchner U, Kuhn KS, Furst P. The scientific basis of immunonutrition. Proc Nutr Soc 2000;59:553–63. 51. Answer: D The use of PN is often necessary because of GI intolerance or other complications of EN or because of the presence of a contraindication to EN. The use of immuneenhancing EN is often limited by the ability of the patient to tolerate an adequate volume enterally, so feeding intolerance Gastroenterology and Nutrition Answers 46 Pharmacotherapy Self-Assessment Program, 6th Edition
(Answer D) occurs more often in patients receiving immunonutrition than those receiving PN, making Answer D the correct answer. Hyperglycemia (Answer A) and hypertriglyceridemia (Answer B) are both more common in patients receiving PN than in those receiving any form of EN, making Answer A and Answer B incorrect. Because of interruptions in the delivery of EN caused by GI intolerance, the ability to deliver enough calories to overfeed a patient (Answer C) is also more likely in patients fed parenterally than enterally, making Answer C incorrect. 1. Adam S, Batson S. A study of problems associated with the delivery of enteral feed in critically ill patients in five ICUs in the UK. Intensive Care Med 1997;23:261–6. 2. Radrizzani D, Bertolini G, Facchini R, Simini B, Bruzzone P, Zanforlin G, et al. Early enteral immunonutrition vs. parenteral nutrition in critically ill patients without severe sepsis: a randomized clinical trial. Intensive Care Med 2006;32:1191–8. 52. Answer: B The EN formulation suggested by the physician contains arginine 2 g/L, omega-3 PUFAs 5 g/L, and antioxidants but does not supplement nucleotides; therefore, it is not the best choice for P.K.’s EN formulation, and Answer A (begin the physician’s suggested formula by nasojejunal tube) is incorrect. The best option for P.K. is an immune-enhancing EN formulation with a higher concentration of arginine and nucleotides (Answer B) because this formulation is most similar to formulations that have been shown to improve outcomes in patients with traumatic injuries; thus Answer B is correct. The use of immune-enhancing diets is appropriate in trauma patients, and those with severe injuries like P.K. (ISS 22) are more likely to benefit; thus, suggesting a standard EN formulation (Answer C) for P.K. is not the best choice, and Answer C is incorrect. No evidence exists that assesses outcomes with the use of immune-enhancing EN formulations supplemented only with omega-3 PUFAs and antioxidants in trauma patients, so Answer D (suggest an immune-enhancing EN formulation with no arginine but more omega-3 PUFAs) is also incorrect. 1. Consensus recommendations from the U.S. Summit on immune-enhancing enteral therapy. JPEN J Parenter Enteral Nutr 2001;25:S61–S63. 2. Kudsk KA, Minard G, Croce MA, Brown RO, Lowrey TS, Pritchard FE, et al. A randomized trial of isonitrogenous enteral diets after severe trauma. An immune-enhancing diet reduces septic complications. Ann Surg 1996;224:531–40; discussion 540–3. 53. Answer: D P.K. is receiving an immune-enhancing EN formulation containing arginine 18.7 g/L, nucleotides 1.8 g/L, and omega-3 PUFAs 2.6 g/L. Clinically significant GI hemorrhage is generally viewed as a complication that can compromise GI perfusion, requiring at least temporary discontinuation of EN, including immune-enhancing diets. Therefore, Answer D (discontinue his immune-enhancing formulation) is the correct action and will decrease the likelihood of further GI-related complications. There is no evidence that indicates P.K.’s outcome will be improved by continuing his current immune-enhancing EN formulation (Answer C), providing enteral glutamine supplementation (Answer B), or switching to a standard EN formulation (Answer A); thus Answer A, Answer B, and Answer C are incorrect. 1. Consensus recommendations from the U.S. Summit on immune-enhancing enteral therapy. JPEN J Parenter Enteral Nutr 2001;25:S61–S63. 2. ASPEN Board of Directors. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr 2002;26:1SA–138SA. 54. Answer: A Clinical studies of the use of immune-enhancing EN formulations containing arginine 12.5 g/L, nucleotides 1.2 g/L, and omega-3 PUFAs 1.7 g/L in patients after trauma show decreased infectious complications (Answer A), making Answer A the best response to a physician asking for justification of the use of the more expensive immuneenhancing EN formulation. There is no evidence, however, indicating that this immune-enhancing EN formulation results in improved survival (Answer B) or better rates of functional recovery (Answer C), making Answer B and Answer C incorrect. Immune-enhancing EN formulations have not been associated with a decreased incidence of hyperglycemia (Answer D) compared with standard EN formulations; thus, Answer D is also incorrect. 1. Kudsk KA, Minard G, Croce MA, Brown RO, Lowrey TS, Pritchard FE, et al. A randomized trial of isonitrogenous enteral diets after severe trauma. An immune-enhancing diet reduces septic complications. Ann Surg 1996;224:531–40; discussion 540–3. 2. Jacobs DG, Jacobs DO, Kudsk KA, Moore FA, Oswanski MF, Poole GV, et al; EAST Practice Management Guidelines Work Group. Practice management guidelines for nutritional support of the trauma patient. J Trauma 2004;57:660–78; discussion 679. 55. Answer: D The use of immune-enhancing diets in surgical patients appears to have the greatest impact in preoperative patients with preexisting malnutrition. The 58-year-old man with a 12% weight loss in the past 6 months (Answer D) best meets these criteria, making Answer D correct. The 56-year-old man with a BMI of 28 kg/m 2 (Answer A) does not appear to be malnourished. The 36-year-old woman with a 4% weight loss in the past 6 months (Answer B) has lost weight but not enough to be considered at risk of malnutrition-related adverse outcomes. The 52-year-old woman with a normal serum albumin concentration (Answer C) does not have evidence of significant malnutrition. Therefore, the patients in Answer A, Answer B, and Answer C are less likely to benefit from an immune-enhancing diet, and these answers are incorrect. 1. Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, Soeters P, et al. ESPEN guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr 2006;25:224–44. 2. Gianotti L, Braga M, Nespoli L, Radaelli G, Beneduce A, Di Carlo V. A randomized controlled trial of preoperative oral supplementation with a specialized diet in patients with gastrointestinal cancer. Gastroenterology 2002;122:1763–70. Pharmacotherapy Self-Assessment Program, 6th Edition 47 Gastroenterology and Nutrition Answers
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