A CREATIVE AGE PUBLICATION
`
`, • • 70,
`
`VOLUME 5, NUMBER 8, AUGUST 1985
`
`Nutritional
`port
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`CORPAK Ex 1010, Page 1
`
`

`
`N~
`
`The Journal of Practical Appllcallon In Clinical Nutrition
`
`Nutritional Support Services
`Articles
`
`VOLUME 5, NUMBER 8, AUGUST 1985
`
`8
`
`NUTRITIONAL SUPPORT IN ADVANCED LIVER DISEASE
`Benj amin KrevskY, MD, MPH; Joanne GodleY, MD, MPH
`
`16
`
`SELF-TEST
`Advanced Liver Disease
`
`18
`
`25
`
`28
`
`NUTRITION ASSESSMENT IN CHRONIC RENAL FAILURE
`Charlene W Compher, MS, RD
`
`INDICATIONS FOR TPN IN THE SURGICAL PATIENT IN THE
`COMMUNITY HOSPITAL
`Mervyn Deitel, MD, FRCS(C), FAGS; Surinder S. Basi, MB BS
`
`COMPUTER SOFTWARE DIRECTORY
`
`Features
`
`Cover
`
`28
`28
`30
`30
`
`33
`39
`
`40
`
`42
`
`CALENDAR
`
`CLASSIFIED ADVERTISING
`NEW PRODUCTS
`
`BOOK REVIEW
`Nutrition and Metabolism in the
`Surgical Patient
`Editor, John R. Kirkpatrick, MD
`
`NSS TODAY
`
`NURSING STATION
`Training the Patient With a Leaming
`Disability
`Susan C. Hushen, RN
`
`PHYSICIAN EXCHANGE
`Feeding Tube Anchor
`Robin Levenson, RN, BSN
`Anne Dyson, RN, BSN
`William W Turner, Jr., MD
`
`ADVERTISERS' INDEX
`
`The cover by Los
`Angeles
`illustrator
`Howard Goldstein
`depicts a musician
`so immersed In his
`art that he has be(cid:173)
`come fused with his
`instrument. Just as
`artists fully involve
`themselves in their
`crafts, so do physi·
`cians, nurses, and
`other health care
`professionals devote themselves to caring for
`patients, often to the point where the patients'
`concerns become their own concerns. This is(cid:173)
`sue of NSS examines the unique nutritional
`needs of two groups of patients requiri ng spe(cid:173)
`cial attention-those with liver disease or
`chronic renal failure. Also included is a feature
`new to NSS: a self-test (page 16) based on the
`article "'Nutritional Support in Advanced Liver
`Disease" (beginning on page 8).
`
`NUTRITIONAL SUPPORT SERVICES(ISSN 0279-9480) is published monthly plus an annual Buyers Guide in December by
`Nutritional Support Services, Inc., 7628 Densmore Ave., Van Nuys, CA 91406-2088. SUBSCRIPTIONS for U.S., its territories and
`possessions: One year, $35; two years, $65; three years, $90. Canada and foreign countries: One year, $60; two years, $115;
`three years; $165. Foreign airmail: add $45 per year. Single copy prices: Domestic $4.00, foreign $6.00, Buyers Guide $10.
`Claims concerning non-receipt of journals must be made within four months of issue mailing date. POSTMASTER: Send ad·
`dress changes to NUTRITIONAL SUPPORT SERVICES, 7628 Densmore Ave., Van Nuys, CA 91406-2088. CHANGE OF AD·
`DRESS notices should be sent promptly. Provide old mailing label as well as new address; please Include ZIP code. Allow two
`months for change to take effect.
`PUBLICATION OFFICES: Address all communications to NUTRITIONAL SUPPORT SERVICES, 7628 Densmore Ave., Van
`Nuys, CA 91406-2088. Telephone 818/782-7328. The views and opinions in the articles herein are not to be taken as offlclal ex(cid:173)
`pressions of the publishers, unless so stated. The publishers do not warrant, either expressly or by implication, the factual
`accuracy of the articles herein, nor do they so warrant any views or opinions offered by 1he authors of said articles. ®. Copy(cid:173)
`right 1985 by Nutritional Support Services, Inc. All rights reserved. This Journal Is protected by copyright. No part of this Jour(cid:173)
`nal may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and re(cid:173)
`trieval sys1em without written permission from Nutritional Suppprt Services, Inc. Second class postage paid at Van Nuys,
`California, and additional malting offices.
`PAPERS APPEARING IN NUTRITIONAL SUPPORT SERVICES ARE CITED IN
`THE CUMULATIVE INOfX TO NURSING ANO ALLIED HEALTH LITERATURE.
`
`NUTRITIONAL SUPPORT SERVICES
`
`NSS article reprints
`are excellent for:
`
`• In-house training aids
`• Supplemental classroom
`reading
`• Literature for patient and
`PR packets
`• Handouts at
`seminars/conferences
`
`2 page articles
`100 Copies
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`4 page articles
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`NUTRITIONAL
`SUPPORT SERVICES
`7628 Densmore Ave.
`Van Nuys, CA 91406-2088
`818/782-7328
`A Creative Age Publication
`
`CORPAK Ex 1010, Page 2
`
`

`
`clamp and a new cap. Turn off the tape
`recorder. When you have the heparin,
`syringe, alcohol and iodine wipe, clamp,
`and cap, tum the tape recorder back on
`and go to the next step."
`All aspects of his care were presented
`to him as clearly and simply as possible.
`Oddly enough, at no time during the
`teaching sessions, including those before
`the tape was utilized, did Mr. F. have dif(cid:173)
`ficulty changing his catheter dressings.
`This procedure was facilitated by the use
`of a prepackaged TPN dressing kit in(cid:173)
`stead of a combination of individual
`components.
`It should be noted that throughout the
`training period Mr. F. sincerely wanted
`to go home, and he expressed this desire
`several times to doctors and nurses. And,
`with the shoe boxes and the new tape,
`
`he began to learn th(;'. procedures at a
`much faster rate. However, it became ap(cid:173)
`parent that Mr. F. would never master
`the type of volumetric pump we were
`using. The doctors wanted to let him
`gravity infuse during the day, which
`would eliminate the need for any infu(cid:173)
`sion device, but we asked permission to
`first try another simpler pump. The tape
`was remade, with instructions for a peri(cid:173)
`staltic infusion pump. Mr. F. was even(cid:173)
`tually able to master this new pump.
`When the discharge date arrived the
`patient was calm, but the nurses, usually
`reassuring and at ease, were anxious. We
`met Mr. F. at his home that day, and
`spent the usual time organizing his sup(cid:173)
`plies and reviewing paperwork and pro(cid:173)
`cedures. Then, offering sideline encour(cid:173)
`agement, we watched Mr. F. go through
`
`__ Ph_ys_ici_an_Ex_ch_an_ue __ 4J
`
`Feeding Tube Anchor
`
`Presented at the Nu trition Practice Poster Session, Ninth Clinical Congress,
`American Society for Parenteral and Enteral Nutrition, l',liami Beach, Florida, January 21 - 24, 1985.
`
`Robin Levenson, RN, BSN
`Anne D yson, RN , BSN
`N utritional Support Team
`Parkland Hospital
`William W. Turner, Jr., M D
`Associate Professor
`The University of Texas Health Science Center
`at Dallas
`Dallas, Texas
`
`Introduction. Feeding tube dislodg(cid:173)
`ment by disoriented or uncooperative
`patients frequently compromises naso(cid:173)
`enteral alimentation. Repeated and/or
`prolonged interruptions of tube feeding
`infusions lead to suboptimal nutritional
`support. Frequent reinsertions of dis(cid:173)
`placed feeding tubes are expensive, trau(cid:173)
`matic, and time-consuming. The use of
`a nasopharyngeal bridle' may decrease
`
`but not eliminate feeding tube dislodg(cid:173)
`ment. We investigated the effectiveness
`of a feeding tube anchoring attachment,
`used along with a nasopharyngeal bridle,
`in decreasing the incidence of tube dis(cid:173)
`lodgment and in prolonging the length
`of time that feeding tubes remained in
`place.
`Methods. Patients requiring nasopha(cid:173)
`ryngeal bridles in order to secure feed(cid:173)
`ing tubes were randomized into two
`groups. Group I patients had an 0.5 cm
`segment of 14 French Silastic tubing
`bonded to an 8 French Entriflex* feed(cid:173)
`ing tube using Silastic cement (Figures
`1 and 2). Nasopharyngeal bridles were
`inserted 1 using the following materials:
`
`*Biosearch Medical Products, Inc., Somerville, NJ.
`
`the steps that were to become his daily
`routine. With a little help from us, such
`as turning on and off the tape recorder
`and locating Box #1, he slowly but surely
`completed each step successfully.
`We visited Mr. F. every day that first
`week, observing each procedure. E very
`day the steps went a little quicker and
`more smoothly. By the end of the week
`we were convinced that he was going to
`make it as a home TPN patient. In addi(cid:173)
`tion, it was arranged that a homemaker
`would come in each morning and keep
`track of his inventory of supplies.
`What had started out as a frustrating
`situation turned out to be a very reward(cid:173)
`ing experience for all involved. The train(cid:173)
`ing also proves that the old adage,
`"Where there is a will, there is a way"
`NIB
`still holds true.
`
`• Two 8 French polyethylene tubes,
`• One pair Magill forceps,
`• One tongue blade,
`~ Flashlight,
`• 2-0 silk suture on a straight needle,
`• Scissors.
`The 8 French polyethylene tubes
`were inserted into each naris. These
`were grasped in the posterior nasophar(cid:173)
`ynx with the Magill forceps and brought
`out through the mouth. The tips of
`these tubes were sutured, and the bri(cid:173)
`dle was withdrawn from the nares in
`such a way as to leave one of the 8
`French polyethylene tubes extending
`around the internasal septum with ends
`protruding through both nares. The ex(cid:173)
`ternal ends of the bridle were sutured
`and trimmed.
`The "anchored" feeding tubes were
`then secured to the nasopharyngeal bri(cid:173)
`dles within the patient's nares with 2-0
`silk sutures tied on both sides of the an(cid:173)
`chors (Figure 3). Group II patients had 8
`French Entriflex feeding tubes without
`anchors inserted. In these patients, the
`feeding tubes were attached to nasopha(cid:173)
`ryngeal bridles within the patients' noses
`using 2-0 silk sutures.
`Patients were followed for a minimum
`
`Figure 1: An 0.5 cm segment of 14 French Sllastlc tubing Is bonded to an & French Entrl(cid:173)
`flex feeding tube using Sllastlc cement and a blunt needle.
`
`Figure 2: An anchoring attachment bonded
`to a feeding tube.
`
`40
`
`NUTRITIONAL SUPPORT SERVICES
`
`CORPAK Ex 1010, Page 3
`
`

`
`Ta·ke the Easy Way On.
`BIOCLUSIVE* Transparent Dressing
`
`edges curling. Protects healing tissue BIOCLUSIVE Trans(cid:173)
`parent Dressing adheres to clean, dry skin but not to moist
`wound surfaces. It provides an effective, waterproof barrier to
`bacteria, yet al lows the
`skin to breathe while main(cid:173)
`tainin g a moist environ(cid:173)
`ment conducive to healing.
`
`Improved - goes on fast New BIOCLUSIVE Transparent
`Dressing allows quick and easy placement ... perfect every
`time. The transparent center panel lets you accurately posi(cid:173)
`tion and place the dress- .----- - - - (cid:173)
`ing over the wound or IV
`site. Side tabs help insure
`secure placement on the
`patient's skin -
`not yours.
`Imp roved -
`stays fast
`Improved adhesion keeps
`the dressing securely
`in place. BIOCLUSIVE
`Transparent Dressing is
`designed to stay where Removecentertab andplacetransparent
`you want it, without the panelonwoundorlVsite.
`
`Peel off side tabs to secure dressing to
`patient's skin.
`
`To request fu rther
`product informa(cid:173)
`tion -
`in the Con-
`t inent al U.S., call tol l
`free 800-526-2459 (except
`in New Jersey, call 800-
`'
`352-4845).
`
`"Trademark of Johnson & Johnson
`
`© J & J Pl. 1984 All rights reserved.
`
`For More Information Circle 23 on Reader Service Card ~AA~ .... ~AA~
`
`~"' r ";:~~J~£1 ~~~ r ro"' r"
`a~~ company
`
`CORPAK Ex 1010, Page 4
`
`

`
`NH+J ~ V NeN
`
`HARVARD
`MEDICAL
`SCHOOL
`
`England
`Deaconess
`Hospital
`
`ADVANCES IN
`HYPERALIMENTATION:
`A PRACTICAL APPROACH
`
`SEPTEMBER 18-20. 1985
`NEW ENGLAND
`DEACONESS HOSPITAL
`BOSTON. MASSACH USETIS
`
`Under the Direction of
`George L. Blackburn, MD, PhD
`Albert Bothe, Jr., MD
`Bruce R. Bistrian, MD, PhD
`
`This course will present
`the logistical, technical,
`and metabolic
`considerations in
`designing optimal
`nutrition support.
`Emphasis will be placed
`on aspects of catheters
`for venous access,
`enterostomies, pumps,
`tubing and bags,
`pharmaceutical
`compounding of
`solutions, and infection
`and anticoagulation
`control.
`
`Registration Fee: $325
`For information, contact:
`Harvard Medical School, Dept. of
`Continuing Education, Boston, MA
`02115, or call Mon. -Fri.
`(617) 732-1525
`
`Circle 24 on Reader Service Card
`
`42
`
`Figure 3: A feeding tube with an anchoring attachment secured to a nasopharyngeal bridle
`(simulation).
`
`of seven days after feeding tube and bri(cid:173)
`dle insertions, unless the feeding tubes
`were dislodged earlier. If a patient ex(cid:173)
`pired, was discharged from the hospital,
`or had the feeding tube voluntarily dis(cid:173)
`continued earlier than seven days follow(cid:173)
`ing insertion, the patient was replaced
`in the study randomization using the
`same type of anchored or nonanchored
`tube originally inserted. If a feeding tube
`became unusable (occluded or ruptured),
`it was replaced with an anchored or non(cid:173)
`anchored tube of the same type as orig(cid:173)
`inally inserted. Patients with function(cid:173)
`ing feeding tubes were followed for as
`long as they remained hospitalized.
`The incidence of feeding tube dis(cid:173)
`lodgment, the length of time to dislodg(cid:173)
`ment, and any complications related to
`the anchor, the nasopharyngeal bridle,
`and the feeding tube were compared in
`the two study groups.
`Results. Feeding tubes were inserted
`into 67 patients. Of these, 53 patients
`(79%) completed the study protocol. Pa(cid:173)
`tients ranged in age from 22-102 years.
`There were 37 males and 30 females-
`29 Group I patients and 24 Group II pa(cid:173)
`tients. Anchored feeding tubes (Group
`I) were dislodged in two patients (7% ),
`
`while nonanchored feeding tubes (Group
`II) were dislodged in eight patients
`(3 3 % ). This difference was significant
`(P=0.031, Fischer's exact test). Anchored
`feeding tubes became dislodged an av(cid:173)
`erage of 15 days following insertions,
`while nonanchored tubes became dis(cid:173)
`lodged an average of four days after in(cid:173)
`sertions (P=0.022, Mann-Whitney U ·
`test).
`There were no nasal erosions or in(cid:173)
`stances of nasopharyngeal bleeding not(cid:173)
`ed in any of the patients.
`Summary. Enteral alimentation is a
`safe, economical, and physiological meth(cid:173)
`od of specialized nutritional support.
`Feeding tube dislodgment, especially in
`uncooperative patients, often precludes
`effective enteral alimentation. We report
`a safe and effective method of signifi(cid:173)
`cantly improving long-term enteral ac(cid:173)
`cess. T he technique has important im(cid:173)
`plications, including cost containment,
`improved nursing productivity, mainte(cid:173)
`nance of adequate nutritional support,
`and improved patient comfort.
`REFERENCE---- -- - - -
`0 I. Barrocas A. The bridle: Increasing the use
`of nasoenteric feedings. Nutr Supp Serv 2(8):8-
`10, 19s2.
`
`as
`
`Advertisers' Index
`
`Abbott HomeCare .(RS #17) . : ... . ... . 29
`American ContinueCare
`(RS #27) . ........ . ...... Back Cover
`American Mc;:Gaw (RS #4) ........ . 9, 10
`American Medical Instruments, Inc.
`(RS #16) ... . . . ... .. ....... ... ... 26
`Antigen Supply House (RS #22) .. , ... 39
`AVI, Inc. (RS #19) ..... . .. . . . ....... 35
`B & G Enterprizes (RS #7) .......... 15
`Clinipad Corp. (RS #2) .......... .. ... 4
`Corpak Co. (RS #1) ............... 2, 3
`Creative Care Systems, Inc.
`(RS #9) . .. .... . _ ... . ....... ..... 17
`Data Med, Inc. (RS #13) . .. . ..... .. .. 20
`
`HMSS (RS #14) .................... 24
`Home Health Care of America
`(RS #25) ... ........ ..... . . . .. 22, 23
`IMED Corp. (RS #21) ......... . . ... 38
`IV League Products Inc.
`(RS #5) ... ........ . ..... ... .... . 11
`Johnson & Johnson Products Inc.
`(RS#23) ......... . . .. . . ...... . .. 41
`Medical Innovations Corp.
`(RS #18) . . ............. .... ..... 30
`New England Deaconess Hospital
`(RS #24) .......... . , .. . ... . .. . .. 42
`Quinton Instrument Co.
`(RS #26) ........... Inside Back Cover
`Sandoz Nutrition .. .. ........ 15, 17, 19
`Sheridan Catheter Corp.
`(RS #6) .............. . .......... 12
`Superior (RS #20) . ......... .. ...... 37
`Travenol Home N utrition and
`IV Therapy (RS #3) ........ ... .. . .. 7
`RS - Reader Service Card
`
`NUTRITIONAL SUPPORT SERVICES
`
`CORPAK Ex 1010, Page 5