• Agarwal R, Aloupis M, Compher C, Golaszewski A, Hudson L, Kennedy S, Koethe J, Lynch R, Melvin M, Spencer C, Umscheid C, Wernsing D, Williams J. Selection and initiation of specialized nutrition support therapy for the University of Pennsylvania Health System: recommendations of the UPHS Nutrition Task Force. Philadelphia (PA): University of Pennsylvania; 2008 Mar. 142 p. [97 references]

This is the current release of the guideline.

Specialized Nutrition Support (SNS) is defined as forced enteral or parenteral nutrition therapy.

1. The Task Force recommends SNS be initiated as soon as possible (preferably within 24-48 hours) in the following patient populations:
   1. Major trauma/surgery
   2. Severe traumatic brain injury (TBI)
   3. Critically ill - ventilated
2. The Task Force supports the initiation of SNS as soon as possible in the following patient populations:
   1. Any patient anticipated to be nothing by mouth (NPO)>7 days
   2. Malnourished patients anticipated to be NPO>2 days
3. The Task Force recommends enteral nutrition (EN) as the preferred route for feeding when oral intake is precluded. In such situations, they support the following timeline for the placement of an enteral access device:
   1. As soon as possible (preferably within 24-48 hours) for critically ill - ventilated patients
   2. Intra-operative placement of temporary or permanent access for all major surgeries after which oral intake will be precluded for an extended period of time
4. The Task Force supports the following contraindications to EN:
   1. Paralytic ileus
   2. Bowel obstruction
   3. Uncontrolled diarrhea (> 500 mL/day or volume that exceeds EN feeds administered)
   4. High output fistula
   5. Unable to obtain safe enteral access (e.g., uncorrectable coagulopathy, severe thrombocytopenia, severe neutropenia, anatomic defect)
   6. Incomplete resuscitation/hemodynamic instability as defined by the Intensive Care Unit (ICU) attending physician
5. If there are no contraindications to EN, the Task Force recommends a trial of gastric EN in all patients without contraindications to gastric EN.
6. The Task Force supports the following contraindications to gastric EN:
   1. Head of bed (HOB) >30 degrees not possible
   2. Intractable nausea/vomiting
   3. Severe reflux
   4. History of aspiration of gastric EN
   5. Gastroparesis
   6. Foregut surgery (esophagus or gastric reduction surgery)
   7. Relative contraindication – Glasgow Come Scale (GCS)<9
7. If gastric EN is poorly tolerated, the Task Force recommends the use of a promotility agent. The Task Force supports the use of metoclopramide as a first line agent and erythromycin as a second line agent.
8. If gastric EN is contraindicated or fails despite promotility agents, the Task Force supports small bowel EN (i.e., placement of a post-pyloric nasoenteric tube, ideally distal to the Ligament of Treitz) with or without gastric decompression.
9. The Task Force supports the definition of failed gastric EN as:
   1. Failed enteral access or <40-60% goal EN despite the above measures in the following time frame:
      1. >2 days in patients with severe TBI
      2. >2 days in patients with severe malnutrition
      3. >5 days in patients with major trauma
      4. >7 days in all other patients
   2. Two consecutive gastric residuals >250 mL despite the above measures and in the above time frame
   3. Aspiration of EN despite the above measures
10. If EN is contraindicated (as described in recommendation #4) or a trial of EN fails (as described in recommendation #8) the Task Force supports the use of parenteral nutrition (PN) if prolonged nutrition support is anticipated (as described in recommendation #1 and #2).
11. If PN is indicated in the hospital, the Task Force recommends delivery of PN using a dedicated single lumen peripherally inserted central catheter (PICC). Alternatively, PN may be given via a dedicated single lumen centrally placed catheter or a free dedicated lumen in a pre-existing multi-lumen centrally placed catheter. The Task Force supports systemwide line policies that help nurses identify the safest lumens in a multi-lumen catheter to dedicate to PN (i.e., those lumens that have been least handled). The Task Force also supports clinicians' judgment to place a virgin lumen if dedication of the pre-existing lumen to PN is thought to place the patient at undue risk of infection (e.g., the pre-existing lumen was placed emergently). The Task Force supports tunneling subclavian lines, implanted subcutaneous ports or PICC lines for longer-term use (more than 30 days).
12. The Task Force supports the use of standardized processes for PN management (including ordering, labeling and administration), the use of commercial preparations of EN and PN for general patient populations, and the use of customized formulations as appropriate for patients with complex nutrition requirements.
13. The Task Force recommends PN be withdrawn once adequate oral or EN is tolerated and nutritional status is stable.
14. The Task Force recommends that each University of Pennsylvania Health System (UPHS) hospital monitor the use of SNS, the placement of catheters for SNS, and adverse events associated with SNS or catheter use. Specific data to be collected may include the use of PN by service, the duration of PN use, contraindication to EN or reason EN trial failed, type of catheter used to administer PN (PICC, position of centrally placed lines, number of lumens), the number and type of catheter(s) in place at the time of catheter placement for PN, and adverse events like aspiration pneumonias in those on EN, and blood stream infections and line removals secondary to complications in those on PN.
15. The Task Force recommends randomized controlled studies examining the efficacy and safety of trophic feeds and/or PN in patients who cannot tolerate goal enteral feeds. They also recommend studies examining the safety of virgin lines versus dedicated lines for the administration of PN.

Algorithms are provided in the original guideline document for University of Pennsylvania Health System (UPHS) Specialized Nutrition Support Guidelines.

The type of evidence supporting each recommendation was not specifically stated.

• Agarwal R, Aloupis M, Compher C, Golaszewski A, Hudson L, Kennedy S, Koethe J, Lynch R, Melvin M, Spencer C, Umscheid C, Wernsing D, Williams J. Selection and initiation of specialized nutrition support therapy for the University of Pennsylvania Health System: recommendations of the UPHS Nutrition Task Force. Philadelphia (PA): University of Pennsylvania; 2008 Mar. 142 p. [97 references]

Not applicable: The guideline was not adapted from another source.

2008 Mar

University of Pennsylvania Health System - Academic Institution

University of Pennsylvania Health System

University of Pennsylvania Health System (UPHS) Nutrition Task Force

Task Force Members: Rajender Agarwal; Marianne Aloupis; Charlene Compher; Ame Golaszewski; Lauren Hudson; Susan Kennedy; John Koethe; Randy Lynch; Michael Melvin; Carolyn Spencer; Craig Umscheid; David Wernsing; Jennifer Williams

Not stated

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI Institute on January 15, 2009. The information was verified by the guideline developer on February 4, 2009. This summary was updated by ECRI Institute on April 1, 2009 following the FDA advisory on Reglan (metoclopramide).

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.