PMID: 10871237

Issn Print: 1363-1950

Publication Date: 2000/05/01


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Specialized feeding in hospital and home: computers, regulations and reimbursement issues

Antonio Carlos Campos; Gil Hardy

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Author Information: Division of Digestive Surgery, Federal University of Parana, Curitiba, Brazil, and

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Excerpt

The level of scientific investigation in nutrition achieved in developed countries is remarkable and has contributed to the establishment of clinical nutrition as a science. It is interesting to note, however, that in the clinical setting the doubts and challenges faced every day by the practitioner are quite similar in different countries and continents. The nutrition team members, in their clinical rounds, still debate whether a catheter should or should not be removed in a febrile patient, whether a gastrostomy should be performed instead of insertion of a nasogastric tube, and whether an in-line filter should be used or whether a renal or hepatic formula should be chosen. Even the amount, route and source of calories that should be administered to a hypermetabolic patient is still a matter of controversy at bedside.
Some of these topics were included last year in Current Opinion in Clinical Nutrition and Metabolic Care, in the ‘Technical aspects of nutritional support’ section that we edited. As we observed in our previous editorial, by publishing only technical problems there is a danger that an erroneous impression is created that provision of nutritional support is dogged with dangers and practical difficulties [1]. Indeed, numerous serious and life-threatening complications associated with nutritional therapy have been published in the literature. Because of the dramatic nature and the notoriety that they attract, many of these incidents have appeared as single case reports. We have also pointed out [2] that, although occurring infrequently, the morbidity and mortality of such incidents may be extremely high. In contrast, the main problems associated with nutrition therapy are probably not the dramatic ones, but those that are related to ordinary daily problems. Because of their low mortality they command little attention, but they are important because of their high frequency. It is therefore of great importance to determine how best to prevent and treat them.
In this issue, Chowdhary and Parashar (pp. 217-219) describe central venous access in neonates through the peripheral route, as a way to avoid the potential risks of serious complications associated with the percutaneous puncture of the internal or subclavian vein. The technique is described in detail. It is interesting to note that the peripheral lines are usually introduced in the ward, under sedation with oral chloral hydrate only. By percutaneous puncture of the cephalic, basilic, superficial temporal, saphenous or external jugular veins, the catheter is introduced to a premeasured distance, and the position of the line tip in the right atrium or superior vena cava is confirmed by radiography. The most common problems reported by the authors are catheter displacement, occlusion and sepsis. Therefore, satisfactory positioning, adequate fixation, continuous infusion, staff training and usage of in-line filters are considered the key points for success. Curiously, there is little recent literature on this topic.
In their excellent review, Thomas and Akobeng (pp. 221-225) describe the most common feeding problems that are encountered in children with neurological impairment. They carefully describe the reasons why eating may be a distressing and time-consuming experience to many disabled children and their carers. In particular, they reviewed the causes, diagnostic methods, treatment and prevention of aspiration of food into the airways or lungs, which may result in recurrent chest infection. Chronic aspiration is usually secondary to uncoordinated swallowing or due to gastroesophageal reflux. Whereas esophagitis is best demonstrated by endoscopy, 24-hour pH monitoring is considered the most sensitive indicator of gastroesophageal reflux. Videofluoroscopy may help in the diagnosis and in determining the optimal consistency of foods. Clinical treatment consists of changes in positioning, use of feeding devices and changes in food texture.
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