This Article Free Full Text (Free PDF) Free Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Saved Citations Download to citation manager Request Permissions Request Reprints Add to My Marked Citations Citing Articles Citing Articles via Google Scholar Citing Articles via Scopus Google Scholar Articles by Steiger, E. Search for Related Content PubMed PubMed Citation Articles by Steiger, E. Pubmed/NCBI databases Medline Plus Health Information Nutritional Support Social Bookmarking                         What's this?

Minding Your Ps and Qs in Specialized Nutrition Support

Cleveland Clinic, General Surgery, Cleveland, Ohio

Correspondence: Correspondence: Ezra Steiger, MD, General Surgery, Deck A-80, 9500 Euclid Avenue, Cleveland, OH 44195. Electronic mail may be sent to STEIGEE{at}ccf.org.

The editors of this issue of Nutrition in Clinical Practice have brought together well-written articles with important information by experts to help readers interested in contributing to, as well as evaluating, research in specialized nutrition support. Topics are presented in a way that prepares readers to design, analyze, submit, present, and publish research findings. The manuscript by August and Serrano¹ is particularly stimulating and challenges us all to answer important questions relating to the daily care and management of our patients. The great difficulty in doing well-designed, prospective, randomized, controlled, double-blind, clinical trials in an environment of constantly improving and evolving patient care makes it very difficult to find significant p values (the Ps) for everything we need to do in caring for our patients. Evidence-based practice² demands that we seek out and apply the best evidence available in managing clinical questions (the Qs), but the answers are not always there.^3,4 Good patient care requires that we still answer the Qs even in the absence of Ps.

Thanks to the pioneering work of Dudrick et al,⁵ the past 4 decades has seen an explosion of information relating to the use of specialized nutrition support in the management of desperately sick patients. Most of the early reports were able to demonstrate 3 things:

1. It was possible to deliver nutrient needs to patients effectively and efficiently using the IV route.
   
2. The patients were able to achieve positive nitrogen balance and an improved nutrition status.
   
3. This therapy provided the time needed for wounds to heal and patients to recover from gastrointestinal tract dysfunction and repeated surgical and medical procedures and therapies.
   The only disease that parenteral nutrition (PN) can possibly cure or prevent is malnutrition while providing time for the application of other medical or surgical therapies in patients who have lost gastrointestinal tract function.
   

As clinicians caring for sick malnourished patients with gastrointestinal tract dysfunction who are recovering from surgery and its complications or are being prepared for surgery or other medical therapies, we are often asked if specialized nutrition support will benefit the patient. As noted above, there is no medical or surgical condition other than malnutrition that specialized nutrition support will cure. But if time is needed to heal and fight infection, and gastrointestinal tract dysfunction is prolonged and precludes adequate enteral nutrition in a malnourished patient, the question answers itself. Finding a P for that Q will be very difficult, if not impossible, today.¹ However, there are a number of topics related to improving the safety and efficacy of specialized nutrition support that can be answered and will improve the art and science of specialized nutrition support. Some of the areas that we can explore using the guidelines provided in this issue of NCP are the prevention of access complications, development of newer techniques for achieving and maintaining vascular and enteral access, assessment of quality-of-life issues, identification and prevention of nutrient deficiencies and excesses, improvement of intestinal absorption, and evaluation of complementary and competing therapies. Research to provide statistically significant improvement in patient care is vital in advancing the clinical field of specialized nutrition support. Questions regarding critical patient care issues demand answers that in the absence of available research must be resolved by good clinical judgment and avoidance of harm to the patient. Proof of harm should make us steer clear of a therapeutic option. However the absence of proof that a therapeutic modality can help should not hinder clinical judgment in deciding to implement therapy to help critically ill malnourished patients. We all have to mind our Ps and Qs, but sometimes good patient care needs answers in the absence of Ps.

1 August DA, Serrano D. Outcomes research in specialized nutrition support. Nutr Clin Pract.2007; 22:602 –608.[Abstract/Free Full Text]

Nutrition in Clinical Practice, Vol. 22, No. 6, 591-592 (2007)
DOI: 10.1177/0115426507022006591


CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter    What's this?

This Article Free Full Text (Free PDF) Free Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Saved Citations Download to citation manager Request Permissions Request Reprints Add to My Marked Citations Citing Articles Citing Articles via Google Scholar Citing Articles via Scopus Google Scholar Articles by Steiger, E. Search for Related Content PubMed PubMed Citation Articles by Steiger, E. Pubmed/NCBI databases Medline Plus Health Information Nutritional Support Social Bookmarking                         What's this?