The primary indication for an esophagectomy is esophageal cancer or Barrett's esophagus with high-grade dysplasia. Patients undergoing esophagectomy often present with dysphagia, side effects from chemotherapy, decreased appetite, and weight loss. Esophagectomy is a major surgery involving the abdomen, neck, and/or chest requiring 5 to 7 days of NPO status to allow healing of the anastomosis between the upper esophagus and new esophageal conduit (usually the stomach). Placement of a feeding jejunostomy preoperatively or at time of surgery provides enteral access for patients who will experience eating challenges and a slow transition back to a normal diet, challenges that often lead to weight loss in the postoperative period. Supplemental tube feeding given nocturnally can provide a consistent intake while appetite, swallowing, and diet advancements improve during the convalescent period. The postesophagectomy diet advances from liquids to soft solids with restrictions to reduce discomfort and aid swallowing and digestion. The esophagectomy patient will experience physical, dietary, and social adaptation for several months postoperatively. Attention to nutrition throughout the process of diagnosis, treatment, and postoperative care is essential for optimal care of the esophagectomy patient.

Continuous renal replacement therapy (CRRT) is a common treatment modality in the intensive care unit for patients with acute kidney injury requiring renal replacement therapy. It offers hemodynamic stability while maintaining excellent control of solute and extracellular fluid. To those outside of nephrology, continuous dialysis is often a confusing and poorly understood form of renal replacement therapy. This review aims to provide an overview of CRRT as well as address some of the nutrition concerns surrounding this complex group of patients.

Background Loss of protein mass and lower fat-free mass index (FFMI) are associated with longer length of stay, post-surgical complications and other poor outcomes in hospitalized patients Normative data for FFMI of U.S. populations does not exist. This work aims to create a stratified FFMI percentile table for the U.S. population using the large bioelectric impedance analysis data obtained from National Health and Nutrition Examination Surveys (NHANES). Methods Fat-free mass (FFM) was calculated from the NHANES III bioelectric impedance analysis and anthropometric data for males and females ages 12 to over 90 years for three race-ethnicities (non-Hispanic white, non-Hispanic black, and Mexican-American). FFM was normalized by subject height to create a FFMI distribution table for the U.S. population. Selected percentiles were obtained by age, sex, and race-ethnicity. Data was collapsed by race-ethnicity before and after removing obese and underweight subjects to create a FFMI decile table for males and females aged 12 and over for the healthy weight U.S. population. Results FFMI increased during adolescent growth but stabilized in the early 20s. The FFMI deciles were similar by race-ethnicity and age group remaining relatively stable between ages of 22 and 80 years. The FFMI deciles for males and females were significantly different. Conclusions After eliminating the obese and extremely thin, FFMI percentiles remain stable during adult years allowing creation of age- and race/ethnicity-independent decile tables for males and females. These tables allow stratification of individuals for nutrition intervention trials to depict changing nutrition status during medical, surgical and nutritional interventions.

Background Critically ill patients with acute kidney injury may require parenteral nutrition (PN) and continuous renal replacement therapy (CRRT). Introduction of a phosphate-free premixed renal replacement fluid without system-wide education in May 2011 resulted in increased incidence of hypophosphatemia, necessitating change in practice. Changes included: 1) maximizing phosphate in PN, 2) modifying the CRRT order set, and 3) developing a CRRT competency evaluation for Nutrition Support Team members. This study evaluates the effect of these changes on incidence of hypophosphatemia. Methods Phosphate levels and predicated probability of hypophosphatemia were evaluated for patients receiving PN and CRRT over three time periods: prior to implementing the changes (pre-implementation), during change implementation (intermediate), and following implementation (post-implementation). Hypophosphatemia was defined as a serum phosphate level <2.5 mg/dL. Generalized linear mixed models were applied for statistical analysis. Results The retrospective study includes 336 measures from 49 patients. Patients in the intermediate and post-implementation periods were not significantly different from each other and had significantly higher mean phosphate levels than patients in the pre-implementation period (p<0.0001). They were also less likely to develop hypophosphatemia compared to pre-implementation patients [intermediate: OR 0.07, 95% CI (0.03, 0.18), p<0.0001; post-implementation: OR 0.09, 95% CI (0.03, 0.27), p<0.0001]. Conclusions Modifications in phosphate dosing together with CRRT education reduced the incidence of hypophosphatemia in PN patients receiving CRRT. Communication of significant changes in clinical care should be shared with all services prior to implementation. Communication and planning between services caring for complex patients is necessary to prevent systems-based problems.