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ENTERALANDTUBEFEEDING ISBN0-7216-0379-3
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Previouseditionscopyrighted 1997,1990,1984
Clinicalnutrition:enteralandtube feeding/editor-in-chief,RolandoH.Rolandelli;
associateeditors,Robin Bankhead,Joseph1.Boullata, CharleneW.Compher.-4thed.
p.;cm.
Includesbibliographicalreferencesandindex.
ISBN0-7216-0379-3
1.Enteralfeeding. 2.Tubefeeding. 1.Rolandelli,Rolando.
[DNLM: 1.EnteralNutrition. 2.Food,Formulated. 3.Intubation,Gastrointestinal. 4.Nutrition.
WB410C64152004)
RM225.C5652005
615.8'55-dc22
2004049197
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DEDICATION
Thisbook isdedicated to mywife Mercedesand my children Patrick, Florencia,
andVictoria fortheircontinued love andsupport.
Contributors
Satoshi Aiko. MD. PhD Stig Bengmark. MD. PhD
ProfessorofSurgery Emeritus ProfessorofSurgery
DepartmentofSurgeryII LundUniversity, Sweden
National Defense Medical College HonoraryVisiting Professor
Tokorozawa, Japan DepartmentsofHepatologyand Surgery
UniversityCollege, London
jorge Albina. MD
LondonMedicalSchool
ProfessorofSurgery, Brown Medical School
London,England
DirectorofSurgical Research
DepartmentofSurgery, RhodeIslandHospital Mette M. Berger. MD. PhD
DirectorofNutritionalSupportService Medecinadjoint(staffphysician)
DepartmentofSurgery, RhodeIslandHospital Servicede SoinsIntensifsChirurgicaux&Centredes
Providence, RhodeIsland Bniles
Lausanne,France
Abhinandana Anantharaju. MD
Fellow inGastroenterology Carolyn D. Berdanier. PhD
Loyola University ProfessorEmerita
Maywood, Illinois Nutrition and CellBiology
UniversityofGeorgia
Olga Antonopoulos. MS. RD
Athens, Georgia
Clinical Dietitian
Clinical Nutrition SupportService
Michele Bishop. MD
UniversityofPennsylvania Medical Center
Assistant ProfessorofMedicine
Philadelphia,Pennsylvania
DirectorofPancreasInterestGroup
Division ofGastroenterologyand Hepatology
Vincent Arment], MD. PhD
Mayo Clinic
ProfessorofSurgery
Jacksonville, Florida
Department KidneyTransplantation
Abdominal OrganTransplantSurgery
joseph I. Boullata. PharmD. BCNSP
TempleUniversityHospital
ProfessorofPharmacyPractice
Philadelphia,Pennsylvania
Nutrition Supportand Critical Care
juan Pablo Arnoletti. MD TempleUniversitySchoolofPharmacy
AssistantProfessor Philadelphia,Pennsylvania
Surgery
Todd W. Canada. PharmD. BCNSP
UniversityofAlabamaatBirmingham
Critical Care/NutritionSupportPharmacist
Birmingham, Alabama
TheUniversityofTexasM.D. AndersonCancerCenter
Robin Bankhead. CRNP.MS.CNSN Division ofPharmacy
Coordinator, NutritionSupportService Houston,Texas
Clinical NurseSpecialist ClinicalAssistant Professor
TempleUniversity TheUniversityofTexasAtAustin CollegeofPharmacy
Philadelphia,Pennsylvania Austin,Texas
Adrian Barbul. MD Pamela Charney. MS. RD/LD. CNSD
Chairman, DepartmentofSurgery PhDStudent
Sinai Hospital ofBaltimore SchoolofHealthRelatedProfessional
Professor,Johns Hopkins Medical Institutions UniversityofMedicineand Dentistry
Baltimore, Maryland Dayton, Ohio
vii
viii Contributors
Connie Brewer, RPh, BCNSP Mark DeLegge, MD
NutritionSupportPharmacist Associate ProfessorofMedicine
Pharmacy Director, Section of Nutrition
Mount Carmel Medical Center Digestive Disease Center
Columbus, Ohio Medical University ofSouth Carolina
Charleston, South Carolina
Rene L. Chiolero, MD
Head Surgical ICU& BurnCenter
Clifford S. Deutschman, MS, MD, FCCM
UniversityHospital (CHUV)
ProfessorofAnesthesiaand Surgery
Lausanne, Switzerland
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania
David Ciccolella, MD
Associate Professorof Medicine
Rupinder Dhaliwal, RD
Director, Asthma Center
Nutrition Research Associate
Medical Director, RespiratoryTherapy
DepartentofMedicine
Associate Director, AirwaysDisease Center
QueensUniversity
Pulmonaryand Critical Care Division
Kingston, Canada
TempleUniversitySchool ofMedicine
Philadelphia, Pennsylvania
Wilfred Druml, MD
Greg van Citters, PhD Professorof Nephrology
Research Fellow University ofVienna
Gonda Diabetes Research Center ViennaGeneral Hospital
DepartmentofGene Regulation& Vienna, Austria
DrugDiscovery
DivisionofMolecularMedicine Nancy Evans-Stoner, MSN, RN
CityofHope National Medical Center/Beckman Clinical Nurse Specialist
Research Institute Clinical Nutrition SupportService
Duarte, California University of Pennsylvania Medical
Center
Melanie Berg, MS, RD Philadelphia, Pennsylvania
Directory ofNutritional Services
Hazelwood Center Ivone M. Ferreira, MD, MSc, PhD
Louisville,Kentucky International Specialist Physician
University ofTorontoand University
Sheila Clohessy, RD, LD, CNSD
ofWestern Ontario
Clinical Dietitian
Ontario, Canada
LoyolaUniversityMedical Center
Maywood, Illinois Lisa Freeman, PhD, DVM
Associate Professor, Department
Charlene Compher, PhD, RD, CNSD
ofClinical Sciences
Assistant Professorin Nutrition Science
TuftsUniversitySchool of Veterinary
Universityof PennsylvaniaSchool of Nursing
Medicine
Philadelphia, Pennsylvania
North Grafton, Massachusetts
Tracy Crane, RD
Jan Willem M. Greve, MD, PhD
Research SpecialistSenior
ProfessorofSurgery
UniversityofArizona
University Hospital Maastricht
Department of Nutritional Sciences
Maastricht, The Netherlands
Tucson, Arizona
Edwin Deitch, MD Peggi Guenter, PhD, RN, CNSN
Chairman and ProfessorofSurgery Managing Editor forSpecial Projects
DepartmentofSurgery AmericanSocietyforParenteral and
Universityof Medicineand Dentistry of Enteral Nutrition
NewJersey Havertown, Pennsylvania
Newark, NewJersey
Dipin Gupta, MD
Cornelis H.C. Dejong, MD, PhD Research Fellow
ConsultantSurgeon Cardiac andThoracicSurgery
Academic Hospital Maastricht Temple UniversitySchool ofMedicine
Maastricht, The Netherlands Philadelphia, Pennsylvania
Contributors ix
Myeongsik Han, MD, PhD Debra S. Kovacevich, RN, MPH
Associate Professor CoordinatorofNursing, Nutrition & PatientCare
DepartmentofSurgery Services
UniversityofUlsan College ofMedicine HomeMed
Seoul,Korea UniversityofMichigan Hospitalsand
HealthCenters
Theresa Han-Markey, MS, RD ClinicalAssistantProfessor, Collegeof
Didactic ProgramDirector, AdjunctLecturer Pharmacy
UniversityofMichiganSchoolofPublicHealth UniversityofMichigan
Program inHumanNutrition AnnArbor, Michigan
AnnArbor, Michigan
Lori Kowalski, MS, RD, CNSD
jeanette Hasse, PhD, RD Clinical Dietitian
TransplantNutrition Specialist Clinical Nutrition/Nutrition Support
BaylorRegionalTransplantInstitute Children'sHospitalofPittsburgh
BaylorUniversityMedical Center Pittsburgh, Pennsylvania
Dallas,Texas
Polly Lenssen, MS, RD, CD, FADA
jimmi Hatton, PharmD, BCNSP Manager
Associate Professor Clinical Nutrition
Pharmacyand Neurosurgery Children'sHospitaland Regional
UniversityofKentuckyCollege ofPharmacy MedicalCenter
Lexington, Kentucky Dietitian
SeattleCancerCareAlliance
Daren Keith Heyland, MD, FRCPC, MSC
Seattle,Washington
Associate Professor
DepartmentofMedicine Henry Lin, MD
QueensUniversity AssociateProfessorofMedicine
Kingston, Canada Division ofGastrointestinal and
LiverDiseases
Mary Hise, PhD, RD
KeckSchoolofMedicine
Assistant Professor, Dieteticsand Nutrition
UniversityofSouthernCalifornia
UniversityofKansas Medical Center
LosAngeles, California
Kansas City, Kansas
Linda Lord, NP, MSN
Daniel L. Hurley, MD, FACE
Nurse Practitioner
Assistant ProfessorofMedicine
Nutrition SupportService
Mayo MedicalSchool
UniversityofRochesterMedicalCenter
Consultant
Rochester,NewYork
Division ofEndocrinology, Diabetes, Metabolism,
Nutrition, and InternalMedicine Louis j. Magnotti, MD
Mayo Clinic and Mayo Foundation Assistant ProfessorofSurgery
Rochester, Minnesota DepartmentofTrauma
UniversityofMedicineand Dentistryof
Gabriel lonescu, MD
NewJersey
FirstYearFellow
Newark, NewJersey
St. Luke's-Roosevelt Hospital Center
NewYork, NewYork Ainsley Malone, MS, RD
NutritionSupportDietitian
Gordon jensen, MD, PhD
Pharmacy
DirectorofVanderbiltCenterfor
MountCarmelWestHospital
HumanNutrition
Columbus,Ohio
Vanderbilt Medical Center
Nashville,Tennessee Paul E. Marik, MD, FCCM, FCCP
ProfessorCritical CareMedicine
Donald Kotler, MD
DepartmentofCritical CareMedicine
Chief, Division ofGastroenterology
UniversityofPittsburgh
St. Luke's-Roosevelt Hospital Center
Pittsburgh, Pennsylvania
ProfessorofMedicine
ColumbiaUniversityCollege ofPhysiciansand Karen McDoniel, RD, LD, CNSD
Surgeons NutritionSupportSpecialist
New York, NewYork Barnes-Jewish Hospital, St.Louis, MO
x Contributors
M. Molly McMahon, MD, FACE Kathy Prelack, PhD, RD
Associate ProfessorofMedicine Clinical Nutrition Manager
MayoMedical School Nutrition Support Service
Consultant Shriners Hospital forChildren
DivisionofEndocrinology, Diabetes, Metabolism, Boston, Massachusetts
Nutrition, and Internal Medicine
Massimo Raimondo, MD
MayoClinicand MayoFoundation
Rochester, Minnesota Assistant ProfessorofMedicine
DivisionofGastroenterology& Hepatology
Margaret M. McQuiggan, MS, RD, CNSD MayoClinic
Clinical Dietitian Specialist Jacksonville, Florida
Herman Hospital
jorge Reyes, MD
Houston,Texas
ProfessorofSurgery
University of Pittsburgh
Kathryn Michel, DVM, MS, DACVN
Children'sHospital ofPittsburgh
AssistantProfessorof Nutrition
Pittsburgh, Pennsylvania
School ofVeterinary Medicine
Universityof Pennsylvania Carol Rollins, MS,RD, CNSD,PharmD, BCNSP
Philadelphia, Pennsylvania Clinical Associate Professor
PharmacyPractice andScience
William E. Mitch, M.D.
College of Pharmacy,The University
President, American Society of Nephrology
ofArizona
Edward Randall ProfessorofMedicine
Tucson, Arizona
Chairman, Department ofMedicine
Clinical Specialist, Nutrition Support
UniversityofTexas Medical Branch
Pharmacy
Galveston, Texas
UniversityMedical Center
Tucson, Arizona
Sohrab Mobarhan, MD
Professor ofMedicine john Rombeau, MD
LoyolaUniversity ProfessorofSurgery
Maywood, Illinois Universityof Pennsylvania
Philadelphia, Pennsylvania
Frederick A. Moore, MD
M. Bonnie Rosbolt, PharmD
Medical Director, TraumaServices
Professor and ViceChairman Clinical Assistant Professor
UniversityofTexas Medical School College ofPharmacy
Department ofSurgery Universityof Kentucky
Houston, Texas Lexington, Kentucky
Trish Fuhrman, MS, RD, FADA, CNSD
Patrick Neligan, MA, MB, BcH,FCARCSI
Area Clinical Nutrition Marketing Manager
AssistantProfessor ofAnesthesia
Coram Healthcare
Hospital ofthe UniversityofPennsylvania
St.Louis, Missouri
Philadelphia, Pennsylvania
julie L. Roth, MD
Anita Nucci, PhD, RD Assistant ProfessorofMedicine
Manager, Clinical Nutrition/Nutrition Support& FeinbergSchool ofMedicine
Intestinal Care Center Northwestern Memorial Hospital
Clinical Nutrition Wellness Institute
Children's Hospital ofPittsburgh Chicago, Illinois
Pittsburgh, Pennsylvania
Heather Rowe, RD, CNSD
Mark Nunnally, MD Clinical Dietitian
Assistant Professor HomeMed
Department ofAnesthesiaand University of Michigan Hospitals and
CriticalCare Health Centers
UniversityofChicago Ann Arbor, Michigan
Chicago, Illinois
Cesar Ruiz, MA, CCC/SLP
julie E. Park, MD Assistant ProfessorinSpeech, Language, and Hearing
Resident, Department ofSurgery Science Program
Johns Hopkins Medical Institutions laSalle University
Baltimore, Maryland Philadelphia, Pennsylvania
Contributors xi
Mary Russell, MS, RD/LD, CNSD Jeremy Z. Williams, MD
Director, NutritionServices Resident, Division of Plastic Surgery
DukeUniversityHospital JohnsHopkinsMedical Institutions
Durham, North Carolina Baltimore,Maryland
Robert Schaffner, NP, DPh, MBA,CNSN, CD·N Marion Winkler, MS, RD
NursePractitioner Surgical NutritionSpecialist
NutritionSupport Service Rhode Island Hospital
Universityof RochesterMedical Center BrownUniversitySchool of Medicine
Rochester,New York Providence, Rhode Island
Phyllis Schiavone-Gatto, MSN, RN, C, CRNP Steven E. Wolf, MD
Advanced Practice Nurse Associate Professor
Department of Clinical NutritionSupport Services Department of Surgery
Hospital of the Universityof Pennsylvania Universityof TexasMedical Branch
Philadelphia, Pennsylvania Director, BlockerBurn Unit
AssistantChief of StaffShriners Hospital for Children
P.B. Soeters, MD, PhD
Galveston,Texas
Professorof GastrointenstinalSurgery
Department of Surgery Rosemary A. Kozar, MD, PhD
University Hospital Maastricht Associate Professorof Surgery
Maastricht, The Netherlands UniversityofTexasMedical School
Departmentof Surgery
Ulrich Suchner, MD
Houston, Texas
Clinic of Anesthesiology
GrosshadernUniversityHospital Kenneth J. Woodside, MD
Ludwig MaximiliansUniversity Resident in General Surgery
Munich, Germany Departmentof Surgery
UniversityofTexasMedical Branch
james S.Scolapio, MD
Galveston,Texas
AssociateProfessorof Medicine
Directorof Nutrition Donna Zimmaro Bliss, PhD, RN, FAAN
Division of Gastroenterology&Hepatology Associate Professor
MayoClinic Professorin Long Term Careof Elders
Jacksonville, Florida Universityof MinnesotaSchool of Nursing
Minneapolis, Minnesota
Cynthia Thomson, PhD, RD
AssistantProfessor Hans10achimG.jung, PhD
Departmentof NutritionalSciences ResearchDairy Scientist
Arizona Cancer Center USDept of Agriculture
UniversityofArizona Agricultural ResearchService
Tucson, Arizona AdjunctProfessor,Departmentof Agronomy
Universityof Minnesota
Clarivet Torres, MD
St.Paul,Minnesota
AssistantProfessorof Pediatrics
Section of Pediatric Gastroenterologyand Nutrition
University of NebraskaMedical Center
Omaha,Nebraska
jon A. Vanderhoof, MD
Professorof Pediatrics and Internal Medicine
Director,JointSection of Pediatric Gastroenterology
and Nutrition
University of NebraskaMedical Center
Omaha, Nebraska
Foreword
Extensive changes have occurred in the delivery of enteral nutritional care since
publication of the last edition of this book in 1997.Perhaps the greatest of these
changes is the need to continue to provide the highest quality care with fewer
resources, and to render this care more efficientlyand expeditiously. A continuing
trend inenteral feeding isitsincreased provision at home ratherthan inthe hospital.
Thisshiftinvenue hascreated new challengesforboth patientand health care prac
titioner. The relevance of these changes and their appropriate resolutions are well
expressed within the contentsofthisedition.
The indications forenteral feeding continue to be refined. Insome conditions
there isgood "evidence-based" rationaletojustifythe use ofenteral feeding whereas
inotherinstancesthere iswoefullylittledatatosupportitsclinical utility.Regardless
of the availability or quality of evidence-based support, the clinician is still
confrontedwiththe dilemmaofwhen and how to feed hisor her patient. Moreover,
the morally and ethically vexing alternative of permitting continued starvation
frequently confoundsthese decisions.
Thisedition remains true to the "raison d'etre" of the three previous editions,
namely to communicate the highest quality ofenteral nutritional science to enable
the practitioner to feed patients safely and efficaciously. This information is well
described inthe sectionsentitled Physiologyofthe Gutand Nutrient Metabolism.
Perhapsthe fastestgrowingcomponentofnutritional caredelivery isitstechno
logy.Thesection Principles ofEnteral Nutrition integratesthe technologic advances
within the context of feasibility, relevance, and cost effectiveness. This theme is
underscored in the chapters on reimbursement and pharmacotherapeutics, which
are integral to providing carewithin the contextoftoday'sfiscalrealities.
Perhaps the newest content of this edition is contained in the Disease Specific
Section.Seventeen chaptersaredevoted tothe intricaciesandspecificsofenteral feed
ingfordiseases rangingfromcentral nervoussystemtraumato immunodeficiencies.
Cancercontinues to be one ofthe most important indications forenteral feed
ingasexemplified inthe fivechaptersdevotedtothistopic. Thesacrosanctprinciple
ofimproving quality oflifeand not prolongingsuffering ofcancerpatients isunder
scored inthiscontent.
Finally,a majorstrength ofthisbook isreflected in the extensive experience of
itsEditorand co-contributors. Dr.Rolando Rolandelli isaworld renowned expert in
enteral feeding and has contributed extensively to past editions of this book. He
remains dedicatedtoproviding both highqualityscienceandthe best availableclin
ical information. Dr. Rolandelli has included a group of outstanding international
contributorsfroma multitudeofdisciplineswho sharehiscommitmenttoacademic
excellence.
Insummary, enteral feeding continuesto be an integral componentofthe care
ofmany hospitalized and home patients. The science and application ofthis impor
tant therapy are well expressed in this book in a scholarly and clinically relevant
manner.
JohnL.Rambeau, MD
Professor ofSurgery
Universityof Pennsylvania
xiii
•
The Multidisciplinary
Approach to Enteral Nutrition
Peggi Guenter, PhD, RN, CNSN
CHAPTER OUTLINE with the founding of the American Dietetic Association
in 1917.2
Introduction Formal nutrition support teams were not established
untilthe developmentofparenteral nutrition inthe early
Traditional Multidisciplinary Nutrition
19705,beginningwithlargemedicalcenters. Theseteams
Support Teams
had amultidisciplinarypatternand weregenerallymade
Traditional Roles of Team Members up ofa physician, nurse, dietitian, and pharmacist. The
Physician's Role number of these teams grew throughout the 1970sand
Nurse's Role 1980s.1n1985,Dr.John Wesleywrote, "Itisapparentthat
Dietitian's Role any well-organized multidisciplinary approach to nutri
Pharmacist's Role tion support can be clinically and economically advan
Contemporary Definition tageous, whether or not it embodies a formal nutrition
Evolution of the Nutrition Support Service supportteam."?Asthe prospective paymentsystem and
capitated health care plans took hold and began
Impact of Nutrition Support Teams on
to drive financing of hospitals, these teams began to
Patient Outcome
disband, decentralize, or disperse.
Conclusion
Despiteadecreaseinthe useofformalnutritionsupport
Editors' Note teams and insufficient administrative support in health
care systems, the multidisciplinary group of health care
professionalsspecializing in nutritionalsupportand car
ing for the patient receiving enteral nutrition isvital. In
INTRODUCTION the absenceofthe multidisciplinarygroupofspecialists,
despite well-intentioned policies and procedures, patient
Since the introduction of enteral nutrition therapy by carecan suffer.Inthischapterthe history,evolution, and
John Hunter in 1790, a varietyofhealth care profession impact of the multidisciplinary approach on the overall
als have been involved inthis process.1Health care has delivery ofenteral nutrition willbe presented.
been multidisciplinary as far back as Greek civilization
and possiblyearlier.Thefirstmedical textwasa pharma
ceutical compendium containing nutritional therapies TRADITIONAL MULTIDISCIPLINARY
fromMesopotamia circa 2100Be. Three Greek gods per NUTRITION SUPPORT TEAMS
sonified the multidisciplinary concept: Asklepios, god
of medicine; Hygieia, goddess of health maintenance Withthe developmentofnutritionsupportservices (NSS)
(nursing); and Panacea, goddess of medication (phar inthe early 1970s,whichwere formed initiallytocarefor
macy). Hippocrates was born during this time and con patientsreceiving parenteralnutrition, camethe reawak
tributed greatly to the fields of medicine and nursing." ening ofinterestinthe patient'snutritionalstatus andthe
During the mid-1850s Florence Nightingale, founder of use ofenteral nutrition. Advances inthe composition of
modern nursing, was very concerned about nutrition.' liquid diets resulted from the aerospace program,
Withthe advent ofnursing schools in the United States, because ofthe need to nourish astronauts on the much
student nurses were taught about "invalidcookery" and anticipatedtriptoand fromthe moon. Research into the
provided therapeutic diets to hospitalized patients. As development of more comfortable feeding tubes and
providing nutrition became a more specialized role, enteral feeding pumps led to the expansion of NSS into
the discipline of dietetics emerged in the early 1900s care fortube-fed patientsaswell.'
3
4 1• TheMultidisciplinaryApproach to EnteralNutrition
The American Society for Parenteral and Enteral finance, and quality improvement issues pertaining to
Nutrition (AS.P.E.N.) was founded in 1976to serve as a nutritionalsupport.'?
forum for nutrition support clinicians and researchers
from all disciplines to exchange information about the
care ofpatientswith nutritional needs. The firstpurpose Nurse's Role
ofA.S.P.E.N. isto promote professional communication
amongdisciplines inthe broad fieldofclinical nutrition The nurse's contribution comes from direct observation
including parenteral and enteral nutrition. The second of enteral feeding delivery and patient response in all
purpose is to promote the application of clinical and settings. The nurse on the nutrition service team com
researchexperienceinthe practiceofnutritionallysound municates directly with the primary care nurses and
medicine (see www.nutritioncare.org/bylaws.html). otherhealthcareprovidersandservesasthe liaison with
The rapid growth in the numbers of nutrition support other team members," The nurse's scope of practice
teams during the 1970sand early 1980shas been well includes direct patient care; consultation with other
documented.Ylna 1991survey conductedbyAS.P.E.N., nurses and health care professionals; education of
29% ofhospitals with greater than 150beds had a nutri patients, caregivers, students, colleagues, and the pub
tion support team, suggesting that the growth of new lic;and participation in research activities and adminis
teams had tapered off and many institutions did not trative functions.J1
perceivea need fora nutritionsupportteam." However,
The AS.P.E.N.Standards forAdult Hospitalized Patients
have recentlystatedthat ifan institutiondoesnot havea Dietitian's Role
defined nutrition support service or team, an interdisci
plinary group of clinicians should provide specialized Thedietitianprovidesnutritionscreeningandassessment,
nutritional support," developsand implementsaspecialized nutritionsupport
Thepurposeofthe nutritionsupportteam istoprovide care plan, monitors the nutritional effectiveness of ther
quality nutritional care. This is accomplished through apy, and develops the transitional feeding care plan."
identification of patients who are at risk nutritionally, The dietitian's role also includes education and training
performanceofa comprehensivenutritional assessment of patients, caregivers, and health care professionals's;
that guides nutritionaltherapy,and provision ofsafe and management of patients receiving home enteral and
effectivenutritional support," To accomplish these goals, parenteral nutrition, and research.
nutrition support teams have developed services that
include inpatient consultations, staff educational pro
grams, quality assurance protocols, research programs, Pharmacist's Role
and home nutrition support services. The overall goals
of the nutrition support team include recognition and The role of the pharmacist in the care of the patient
treatmentofmalnutritionand reductionofcomplications, receivingenteral nutrition isderived from knowledge of
morbidity, and mortality ina cost-effective manner."The pharmacokinetics, drug metabolism, and drug-drug and
quantitative impact of these teams on the delivery of drug-nutrient interactions." The pharmacist's scope of
enteral nutrition willbe presented later inthis chapter. practice in the nutrition support team includes direct
patient care; administrative management of the special
ized nutrition support program; quality improvement;
TRADITIONAL ROLESOF education of health care professionals, patients, and
TEAM MEMBERS caregivers; and research." A recent study of this role
confirmed that pharmacists continue to intervene with
An organized nutrition support service or team should patientsreceivingenteral nutrition inthe clinical setting
include a physician, nurse, dietitian, and pharmacist," to ensure positive effects on patientcare."
Althoughthestructureandfunction ofNSSvaryfromone
healthcaresetting to the next based on needsandavail
able personnel,sometraditional rolesare reviewed here. Contemporary Definition
Amorecontemporarydefinition ofthe nutritionsupport
Physician's Role team includessome ofthe discipline-specific role delin
eation described in the preceding paragraphs and else
The nutrition support physician needs to be familiar where but also includes the recognition that clinicians,
withallaspectsofenteralnutrition careincludingpatient who are board-eertifiedin nutritional supportare capable
screening andassessment, developmentand implemen ofaddressingallofthe nutritionsupportneedsofpatients
tation of an enteral care plan, and termination of ther in acute care, extended care, or home care settings. In
apy. Adistinctive role ofthe nutrition support physician addition, a board-eertified nutrition support team mem
istoselectthe appropriatefeeding access, and, depend ber, regardlessofdiscipline, isresponsible fora patients'
ingon hisor hermedicalspecialty,the actual placement nutritional assessment, plan of care, monitoring, dis
ofthe feeding access.The physician must be capableof charge planning, and follow-up. Much of the nutritional
managing the policy, procedure, personnel, education, careisbased on sharedknowledge,with team members
