108 Questions
What is the primary challenge in managing patients with enterocutaneous fistula (ECF)?
Dealing with limited and dated clinical studies
What is the purpose of the clinical guideline for the nutrition care of adult patients with ECF?
To develop recommendations for the nutrition care of adult patients with ECF
What is the preferred route of nutrition therapy for adult patients with ECF?
The route of nutrition therapy is not clearly defined
What is the definition of enterocutaneous fistula (ECF)?
An abnormal connection between the gastrointestinal tract and the skin
Which of the following is NOT a question addressed by the clinical guideline?
What is the role of antioxidants in the management of ECF?
What is the primary goal of the systematic review conducted by the GRADE Working Group?
To answer a series of questions regarding clinical management of adults with ECF
Who approved the clinical guideline recommendations?
Both the ASPEN Board of Directors and FELANPE
What is fistuloclysis?
A type of nutrition therapy specifically designed for patients with ECF
When is further research likely to affect confidence in the estimate of effect and change the effect size?
When the evidence is moderate
What is the minimum percentage of congruence needed to establish consensus in the modified Delphi scheme?
60%
What is the primary reason for making weak recommendations?
When evidence quality is low or important trade-offs are considered
What is the primary component of quality medical care according to the clinical guidelines?
The professional judgment of the attending health professional
How many guideline statements were based on randomized controlled trials?
1
What is the main objective of the ASPEN and FELANPE organizations?
To improve patient care by advancing the science and practice of clinical nutrition and metabolism
What is the primary purpose of periodic nutrition assessment in patients with ECF?
To identify patients at high risk of becoming malnourished
What is the GRADE Working Group responsible for?
Grading of Recommendations, Assessment, Development, and Evaluation
What is the quality of evidence for the recommendation on diagnosing malnutrition in adult patients with ECF?
Very low
What was the time period for the PubMed/MEDLINE database search?
January 1995 to June 2016
What type of studies were included in the search for abstracts?
Randomized clinical trials and observational studies with a control group
What is the role of serum protein concentrations in nutrition therapy?
They are prognostic outcome indicators
What was the language restriction for the abstracts?
English, Spanish, or Portuguese
How many authors participated in the guideline development process?
A multidisciplinary team of volunteers
What was the primary source of citations reviewed for inclusion in the guideline development?
PubMed/MEDLINE
What was the purpose of the final search of the MEDLINE database?
To protect against miscataloged terms in MEDLINE
What was the purpose of the forest plots?
To aggregate the effect size for each intervention and outcome
Why was revision of this guideline not planned?
Because further research is needed to support revision
What was the purpose of the international author task force?
To identify key clinical outcomes
What was the main focus of the clinical guidelines?
The management of nutrition therapy in patients with ECF
Which of the following tools has been specifically validated for use in ECF?
None of the above
What is a common limitation of nutrition assessment tools in ECF patients?
They may fail to diagnose malnutrition in the overweight or obese patient
What is the significance of weight loss in ECF patients?
It is a consequence of the clinical course and management of the disease process
What is a potential limitation of using serum protein levels to diagnose malnutrition?
They lack sensitivity and specificity
What is the significance of increased serum albumin concentration after PN therapy?
It is associated with significantly less fistula drainage and improved rate of spontaneous closure
What is a potential consequence of malnutrition in critically ill obese patients?
They have a higher risk of death
What is the primary goal of documenting body weight and weight change at the time of presenting symptoms and throughout the course of ECF management?
To monitor for malnutrition
What is a characteristic used to diagnose malnutrition according to the consensus criteria published by the Academy of Nutrition and Dietetics and ASPEN?
Localized or generalized fluid accumulation that may mask weight loss
What is a limitation of using SGA to diagnose malnutrition in ECF patients?
It is not validated for use in ECF patients
What is a potential reason for the variability in the inclusion of nutrition parameters among the studies?
Lack of standardization in nutrition assessment tools
What is the primary reason for changing the polymeric formula to a semi-elemental formula in the fistuloclysis group?
In cases of intolerance
What is the effect of oral glutamine on secretory IgA production in the intestinal mucosa?
It enhances the production
What is the primary factor that predicts spontaneous closure of ECF?
Serum transferrin concentration
What is the recommended ECF output for patients receiving PN with improved serum albumin concentrations?
40 kg/m2
What is the recommended route of nutrition therapy for adult patients with ECF?
Not specified in the content
What is the outcome of using oral glutamine in addition to PN in patients with high-output postoperative small bowel ECF?
Lower mortality and shorter hospital stay
In which patients is fistuloclysis recommended for nutrition therapy?
Patients with intact intestinal absorptive capability distal to the infusion site
What is the primary advantage of using semi-elemental (oligomeric) diets in fistuloclysis?
They provide greater nutrient delivery
What is the condition under which glutamine supplementation may be toxic?
In patients with renal or hepatic failure or sepsis
What is the outcome of fistuloclysis in terms of PN usage?
PN is replaced in most patients
What is the effect of somatostatin analogue on high-output ECF?
It reduces the effluent drainage and enhances spontaneous closure
What is the quality of evidence for using somatostatin analogue in adult patients with high-output ECF?
Moderate
What is the recommended initial rate of EN formula infusion in fistuloclysis?
30 mL/h
How many patients received oral glutamine in addition to PN in the retrospective observational study?
9 patients
What is the outcome of fistuloclysis in terms of ECF output?
ECF output may increase or decrease
What is the duration of fistuloclysis before reconstructive surgery in a study?
Median of 155 days
What is the odds ratio for fistula closure rates in patients who received oral glutamine?
13.2
What is the quality of evidence for the use of fistuloclysis in patients with ECF?
Very low
What is the purpose of collecting the output from the proximal stoma in the fistuloclysis group?
To reinfuse the output into the distal fistula
What is the primary advantage of using fistuloclysis compared to PN alone?
Lower cost
What is the primary purpose of the GRADE process in the development of the guidelines?
To categorize the evidence grade based on study design and execution
What is the main reason for strengthening the evidence provided by observational studies?
Strong dose-response relationship and protocolized interventions
What is the primary difference between strong and weak recommendations?
The strength of the evidence supporting the recommendation
What is the primary purpose of the literature search using MEDLINE/PubMed and EMBASE databases?
To identify well-designed RCTs related to nutrition support in critically ill pediatric population
What is the primary limitation of using serum protein concentrations in nutrition therapy?
It is not a reliable indicator of malnutrition
What is the primary reason for separating the body of evidence from the recommendation statements?
To incorporate the weight of the risks versus the benefits of adopting a recommendation
What is the primary purpose of the search strategy using MeSH folders and text-based terms?
To restrict citations to those indexed in MeSH folders for pediatrics
What is the primary difference between the PubMed/MEDLINE and EMBASE database searches?
The publication type searched in the MEDLINE database
What is the primary purpose of the final search of the MEDLINE database?
To restrict citations to those carrying specific terms in their title or abstract
What is the primary reason for the variability in the inclusion of nutrition parameters among the studies?
Due to differences in study design and execution
What is the primary consideration for considering HPN in patients with high-output ECF?
When the patient is medically stable and the fistula output is manageable
What is the purpose of nutrition assessment in patients with ECF?
To detect malnourished patients who are most vulnerable
What is recommended for estimating energy needs in patients with ECF?
All of the above
What is the preferred route of nutrient delivery in patients with ECF?
Enteral nutrition (EN)
What is the target patient population for these guidelines?
Pediatric critically ill patients (>1 month and 2-3 days in a PICU admitting medical, surgical, and cardiac patients)
What is the purpose of the GRADE criteria?
To assess the quality of study design and execution
What is the primary goal of nutrition support therapy in patients with ECF?
To stabilize nutrition and fluid balance
What is the benefit of a delayed approach to supplemental parenteral nutrition?
It appears to be beneficial
What is the purpose of the search for abstracts?
To identify relevant clinical trials and cohort studies
What is the target audience for these guidelines?
Physicians, nurses, dietitians, and pharmacists
What is the primary mechanism by which somatostatin and somatostatin analogues reduce fistula output in patients with ECF?
Prolongation of intestinal transit time
What is the typical duration of treatment with somatostatin or somatostatin analogue in adult patients with ECF?
10-20 days
Which of the following is a potential complication of somatostatin analogue therapy in patients with ECF?
All of the above
What is the recommended approach to determining the appropriate use of somatostatin analogue in patients with ECF?
Selective approach based on fistula output
What is the primary benefit of using somatostatin analogue in patients with ECF?
All of the above
What is the recommended duration of trial use to assess the efficacy of somatostatin analogue in achieving fistula closure?
10-20 days
Which of the following is a potential advantage of using somatostatin analogue in patients with ECF?
Easier management in the home setting
What is the primary reason for the use of somatostatin analogue in patients with ECF?
To reduce fistula output
What is the result of the meta-analysis of 6 RCTs that evaluated the use of somatostatin or somatostatin analogue in patients with ECF?
A significant increase in spontaneous fistula closure
What is a potential drawback of using somatostatin analogue in patients with ECF?
All of the above
What is the primary factor that contributes to the variability in nutrition practices among institutions and providers?
Heterogeneity of patients in the PICU
What is the purpose of generating evidence tables for each question?
To develop practical recommendations for each question using the GRADE methodology
What is the significance of the temporal dimension in prospective or retrospective cohorts?
It allows for the measurement of disease occurrence and its association with an exposure
What is the primary purpose of the recommendations provided in the guideline?
To serve as a starting point for building customized nutrition therapy for individual patients
What is the significance of the publication of the first pediatric critical care nutrition guidelines in 2009?
It led to a substantial increase in research and publications related to nutrition in critical illness
What is the primary limitation of RCTs in the pediatric critical care nutrition literature?
They require tremendous time and resources to complete
What is the significance of the association between malnutrition and adverse clinical outcomes in critically ill children?
It highlights the importance of nutrition assessment in the PICU
What is the primary goal of nutrition support in the PICU?
To individualize nutrition therapy according to the baseline nutrition status and vulnerabilities of patients
What is the significance of the GRADE methodology in the development of practical recommendations?
It is a tool for evaluating the quality of evidence
What is the primary significance of the observation that nutrition status is associated with clinical outcomes in critically ill children?
It highlights the importance of nutrition assessment in the PICU
What is the primary objective of nutrition management in patients with enterocutaneous fistulae?
To provide estimated nutrient requirements
Which of the following is a factor associated with failure to spontaneously close enterocutaneous fistulae?
Intestinal discontinuity
What is the definition of high-output enterocutaneous fistulae?
Output exceeding 500 mL/24 hours
What is the role of somatostatin analogues in the management of patients with enterocutaneous fistulae?
To reduce fistula output and enhance spontaneous closure
What is the primary goal of medical management in patients with enterocutaneous fistulae?
To manage sepsis and wound care
What is the significance of enteroatmospheric fistulae?
They are a subset of enterocutaneous fistulae that will almost never close spontaneously
What is the significance of fistuloclysis in patients with enterocutaneous fistulae?
It is a means of reinfusing fistula output along with infusion of enteral formula via the fistula opening
What is the recommended timing for surgical intervention in patients with enterocutaneous fistulae?
At least 3 months after the initial injury
What is the primary challenge in managing patients with enterocutaneous fistulae?
The management of patients with enterocutaneous fistulae requires an interdisciplinary approach and poses a significant challenge to physicians, wound/stoma care specialists, dietitians, pharmacists, and other nutrition clinicians.
What is the purpose of the clinical guideline for nutrition care of adult patients with enterocutaneous fistulae?
To develop recommendations for the nutrition care of adult patients with enterocutaneous fistulae
Study Notes
Enterocutaneous Fistula (ECF) Management
- ECF is an abnormal connection between the gastrointestinal tract and the skin, which may occur spontaneously or as a complication of gastrointestinal surgery.
- Factors associated with failure to spontaneously close ECF include:
- Intestinal discontinuity
- Adjacent abscess
- Stricture or inflamed bowel
- Radiation therapy
- Foreign bodies
- Distal obstruction
- Small enteric defects (<2 cm) are more likely to close spontaneously.
Nutrition Management in ECF Patients
- Nutrition management goals:
- Provide estimated nutrient requirements
- Maintain fluid and electrolyte balance
- Enhance spontaneous ECF closure whenever feasible
- Somatostatin analogues have been used to reduce fistula output and enhance spontaneous closure.
- Parenteral nutrition (PN) with nil per os (NPO) has been used to provide necessary nutrition while attempting to reduce fistula output and maintain fluid/electrolyte balance.
Fistuloclysis
- Fistuloclysis is defined as the infusion of enteral nutrition formula via the distal stoma of an ECF with or without reinfusion of the output from the proximal fistula opening.
- Indications for fistuloclysis:
- Intact intestinal absorptive capability distal to the infusion site
- ECF not expected to close spontaneously
- Initially, polymeric formulas are used, and if intolerance occurs, semi-elemental (oligomeric) diets are used.
Nutrition Status Assessment in ECF Patients
- Malnutrition should be diagnosed by:
- Nutrition history, including unintentional weight loss and estimation of energy/nutrient intake
- Physical examination
- Serum protein concentrations should be obtained prior to and during nutrition therapy, as they are prognostic outcome indicators.
- Quality of evidence for nutrition status assessment is very low.
Clinical Guidelines Development
- The clinical guideline was developed through a systematic review of the best available evidence.
- A rigorous search of the PubMed/MEDLINE database was performed, and abstracts were reviewed against inclusion criteria.
- The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group concepts were adopted.
- A team of authors drafted each recommendation and rationale, and consensus was established using an anonymous modified Delphi scheme.### Nutrition Support in Pediatric Critical Care
Study Methodology
- A rigorous search of MEDLINE/PubMed and EMBASE databases was performed spanning January 1995 through March 2016
- 2032 citations were scanned for relevance
- 1107 citations for clinical trials and 925 citations for cohort studies were found
- 16 RCTs and 37 cohort studies were included in the guideline development
Target Patient Population and Audience
- Pediatric critically ill patients (>1 month and 2-3 days in a PICU)
- Not intended for neonates or adult patients
- Target audience: healthcare providers involved in nutrition therapy of the critically ill child
Key Questions and Recommendations
- Question 1A: What is the impact of nutrition status on outcomes in critically ill children?
- Recommendation: Malnutrition is associated with adverse clinical outcomes; detailed nutrition assessment should be performed within 48 hours of admission and reevaluated at least weekly throughout hospitalization
- Quality of evidence: Very low
- GRADE recommendation: Strong
- Question 1B: What are the best practices to screen and identify patients with malnutrition or those at risk of nutrition deterioration in the PICU?
- Recommendation: (details not provided)
- Question 5: In adult patients with ECF, are immune-enhancing formulas associated with better outcomes than standard formulas?
- Recommendation: We cannot recommend multicomponent immune-enhancing formulas to improve outcomes of ECF due to lack of evidence
- Quality of evidence: Very low
- Question 6: In adult patients with ECF, does the use of somatostatin or somatostatin analogue provide better outcomes than standard medical therapy?
- Recommendation: We recommend use of somatostatin analogue in adult patients with high-output (>500 mL/d) ECF as a method to reduce effluent drainage and enhance spontaneous closure
- Quality of evidence: Moderate
- Question 7: In adult patients with ECF, when is home parenteral nutrition (HPN) therapy indicated?
- Recommendation: Based on expert consensus, we suggest consideration of HPN when the patient is medically stable and the fistula output is manageable, as well as in patients with high-output ECF (>500 mL/d) when surgical repair is not yet advised
- Quality of evidence: Based on consensus only
Fistuloclysis
- Defined as the reinfusion of the output collected from the proximal fistula into the distal fistula through a feeding tube
- Biochemical parameters such as hepatic function indexes and C-reactive protein levels significantly improved in fistuloclysis patients
- Hospital costs, hospital stay, and hospital mortality were significantly lower, and 1-year survival was significantly higher in the fistuloclysis group
Somatostatin and Somatostatin Analogue
- Used to treat gastrointestinal and pancreatic fistulas due to their ability to inhibit the release and secretory effects of a wide variety of GI hormones and enhance water and electrolyte absorption
- Intended overall effect is to reduce the volume of GI secretions as a method to reduce fistula output and promote spontaneous fistula closure
- Meta-analysis of 3 RCTs showed a significant reduction in fistula output with use of somatostatin or somatostatin analogue compared with control
- Meta-analysis of 6 RCTs showed a greater likelihood of spontaneous closure when somatostatin or somatostatin analogue was added to standard medical care
- Meta-analysis of 4 RCTs showed a reduction in time to achieve fistula closure favoring somatostatin analogues
This quiz covers the interdisciplinary approach to managing patients with enterocutaneous fistula, including guidelines for optimizing nutrition status. It explores specific nutrient requirements, routes of nutrition, and more.
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