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Volume 32 Number 3

June 2010

TABLE OF CONTENTS
2	Guest Editor's Perspective Susan Brantley, MS, RD, LDN, CNSD In all my years of practicing nutrition support in the adult patient population, one issue that seems to surface again and again relates to medication administration via feeding tubes. Questions arise continually about problems with medication absorption, including optimal dosage forms, timing of administration, and potential treatment failures. Working closely with pharmacists has given me a better understanding of these issues, but it also has revealed a real deficiency of evidence-based practice in this area of nutrition support. This issue of Support Line is the result of a direct inquiry I recently received from a colleague.
3	Chair's Column Mary Hise, PhD, RD, CNSD I believe that the members of Dietitians in Nutrition Support (DNS) are the most knowledgeable and hardworking members of any practice group. It is an honor for me to represent you as the Chair of DNS for 2010-2011. Let me introduce myself. I have worked in the area of nutrition support for the last 23 years in clinical, academic, and, most recently, industrial settings. My first job was as a clinical dietitian in Lubbock, Texas, where I learned to love the science and practice of nutrition support. I progressed in my career, became a nutrition support dietitian, and expanded into research and teaching, with my primary focus still in enteral and parenteral nutrition therapy. I currently work in the global medical affairs group for Baxter Healthcare, and nutrition support is as fascinating for me today as it was 23 years ago in West Texas.
4	Warfarin and Continuous Enteral Nutrition Ronelle Mitchell, MA, RD, CNSC, Joyce Dunn, RPh Warfarin is an anticoagulant that has been reported to interact with many medications and enteral products. This article reviews the literature about enteral nutrition (EN)- related interactions, including 11 case studies and one single study involving six patients. EN products appear to reduce the anticoagulant effect of warfarin, but the actual cause for the interaction remains unknown. Strategies for maintaining the anticoagulant effect of warfarin include adjusting the dosage or holding the feeding around the drug administration time.
8	Levothyroxine and Enteral Nutrition Ali Ballard, RD, LD, CNSC, Kristen Kemmerer, RD, LD, CNSC Levothyroxine (LT4) is a common oral medication used to treat hypothyroidism. Although the factors that affect its absorption are not fully elucidated, it is commonly accepted that absorption of LT4 is increased in the fasting state (1). For this reason, it is recommended that patients ingesting an oral diet take the drug on an empty stomach, 30 to 60 minutes before breakfast (2). It has been inferred in clinical practice that patients receiving enteral nutrition (EN) and LT4 should have their feedings held for a period of time around the administration of the drug to induce a "fasting" state. Because research on the effect of EN on LT4 absorption is minimal, the currently accepted practice is to hold EN 1 hour before and after administration of LT4. Additional research is needed to determine the relationship between EN and absorption of LT4 before further recommendations can be made.
10	Enteral Nutrition Practice: The Water Issue Joseph I. Boullata, PharmD, RPh, BCNSP Of the many practical issues in enteral nutrition addressed by the recent American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines, the role of water has engendered much discussion. Based on the available data, water is the preferred fluid for flushing feeding tubes, reconstituting or diluting enteral feeding formulas, and diluting medications for enteral administration. A variety of beverages have been used over the years for flushing feeding tubes, but water is as good as, if not better, than other fluids at maintaining tube patency. For practical reasons, water is the appropriate fluid for reconstituting enteral feeding formulas and medication. Perhaps more importantly, the optimal source of the water depends on its intended use. For hydration and flushing of the tube, drinking water may be adequate for the immunocompetent patient, but it may not be appropriate for the critically ill or immunocompromised patient. Reconstituting enteral feeding formulas requires the use of sterile water due to infection control issues. Purified water also is required for the preparation of drug dosage forms. Purified water is the only source free of microbial or chemical contaminants that otherwise would present a risk for infection or have the potential to interact with medication.
18	The Use of Parenteral Nutrition in Staged Spinal Surgery Kate Willcutts, MS, RD, CNSD, Rebecca Brody, MS, RD, CNSC Staged spinal surgeries are complex procedures that involve an anterior surgical approach followed by a posterior surgical approach, usually separated by 5 to 7 days. The procedures are long and complicated and are performed for scoliosis, kyphosis, spinal tumors, and spinal trauma when a high degree of stability is needed (1). Based on communications with neurosurgeons and our experiences at a tertiary care university hospital, there is an unwritten standard of care among some neurosurgeons for patients to receive parenteral nutrition (PN) between the procedures and until oral diet is tolerated after the second surgery. The dietitian is faced with the challenge of reconciling this practice with the indications for PN from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). This article reviews the published articles related to nutrition in patients undergoing staged spinal surgery as well as other types of spinal surgery. Ideas for randomized, controlled trials for further study of nutrition in this patient population are addressed.
22	Nutrition, Physical Assessment, and Wound Healing Megan Tempest, RD, LDN, Erika Siesennop, RD, LDN, Kristin Howard, RD, LDN, Katherine Hartoin, RD, LDN The relationship between nutrition and pressure ulcer healing has been a focus of ongoing research and discussion. Commonly implemented nutrition interventions for wound healing include protein and micronutrient supplementation. A variety of biochemical and clinical monitoring tools may be useful in predicting risk for skin breakdown and evaluating the efficacy of nutrition interventions intended to accelerate healing. This article reviews the rationale for routine nutrient supplementation to encourage wound healing, research that substantiates such use, and biochemical monitoring tools that may assist the dietitian in supporting pressure ulcer healing. In addition to traditional elements of a nutrition assessment, the dietitian should consider physical assessment of the pressure ulcer. This article provides the clinician with the basic terminology and characteristics typically used to describe pressure wound condition and healing. Nutrition-focused physical assessment allows the clinician to determine wound condition more accurately, address the wound proactively, identify non-nutritional factors that may influence healing, and implement realistic nutrition interventions.

All material appearing in SUPPORT LINE is covered by copyright and may be photocopied or otherwise reproduced for noncommercial scientific or educational purposes only, provided the source is acknowledged. Written consent from the managing editor is required for any other purpose.

Viewpoints and statements in these materials do not necessarily reflect the policies and/or official positions of The American Dietetic Association or DNS.

SUPPORT LINE (ISSN 1067-3768) is published bi-monthly. $60 for individual non-member subscriptions, $120 for institutions per year (plus postage surcharges for international subscriptions). Newsletter subscriptions are available to interested parties who are ineligible for ADA membership. Published by Dietitians in Nutrition Support, a dietetic practice group of The American Dietetic Association (ADA), 120 S. Riverside Plaza, Suite 2000, Chicago, IL 60606. Send requests for subscriptions to Jamie Diamond, MS, RD, CNSD, 3850 Galt Ocean Drive, Apt. 2009, Fort Lauderdale, FL 33308. For address changes: Please submit name and address changes directly to the Membership Team of the American Dietetic Association using the address change card in the Journal of the American Dietetic Association. SUPPORT LINE is indexed in the Cumulative Index to Nursing and Allied Health Literature.

FOR THIS ISSUE:

Editor

Susan Roberts, MS, RD, LD, CNSD
3911 Kramar Court
Arlington, TX 76016
214/820-6751

Managing Editor

Deborah K. Kuhlman
921 N. Western Avenue
Park Ridge, IL 60068
847/692-3407

Associate Editors

Therese Austin, MS, RD, CNSD

Kathy Logan,, MS, RD, CNSD

Associate Editor, Continuing Education:

Neha Parekh, MS, RD, CNSD

Associate Editor, Writer's Mentoring:

Marcia Kalista-Richards, MPH, RD, CNSD

Contributing Editor, Inquire Here:

Gail Cresci, PhD, RD, CNSD

Membership/Subscriptions:

Jamie Diamond, MMS, PA-C, RD

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