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«  Апрель 2008  »

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Главная » 2008 » Апрель » 12 » Есть или не есть?

Есть или не есть?

Should patients on hemodialysis be allowed or encouraged to eat during a dialysis treatment? As with any debate, there are always at least two opposing views and this argument is one that continues to have clinicians on the “pro” and also on the “con” sides.

One point made by the pro-side is that many of our patients have diabetes. Consistency with diet, exercise, and insulin regime is important to maintaining control of blood glucose levels. Regularly missing or skipping meals is not encouraged for anyone trying to maintain a healthy lifestyle and, in particular, it is not a good practice for the population with diabetes. Skipping meals can disrupt the balance of insulin control and can lead to life-threatening hypoglycemic complications.

In general, those supporting eating during hemodialysis advocate for allowing patients to consume small meals or snacks during their treatments in order to improve their overall nutritional status. Improving or at least maintaining the nutritional status of patients on hemodialysis is just one of the many challenges faced by health care teams; and, by improving the nutritional status of our patients, we will undoubtedly increase the odds for positive outcomes.
Because treatments last 3 to 4 hours, patients on hemodialysis are often receiving a treatment through a meal period on treatment days. Treatments are routinely scheduled for 3 days per week, potentially resulting in 156 lost meals per year. This would mean that patients on hemodialysis are missing or are prevented from eating one meal on more than 40% of the days in a given year on dialysis. If patients are not allowed to eat during dialysis, they are at jeopardy for missing meals; this equates to a lost opportunity to improve their nutritional outcomes. Even the Centers for Disease Control (CDC) suggests it is appropriate for patients to eat food brought from home to be consumed while the patients are undergoing dialysis treatment (CDC, 2001).

Those advocating for meals during dialysis see this meal and treatment time as a good opportunity to supplement and improve the patients’ dietary intake by allowing patients to eat during their treatments. Both sides seem to agree that treatment time is a fortuitous time to discuss and review dietary intake, lab results, and general teaching. Because of the potential distractions, however, those arguing against eating during treatment do not see this time as appropriate for consuming any foods. There is evidence that food intake should be limited an hour or more before all hemodialysis treatments to avoid medical problems during dialysis.

If a patient’s blood glucose drops during hemodialysis, those against eating during dialysis can argue that glucose testing is easily attainable while the patient is on dialysis. The dialysate electrolyte concentration is a dextrose based solution of 200 mg/dl, but despite this, some patients will experience hypoglycemia. If blood sugars do decline, juice is available in most units and may be effective in reversing the low blood sugar levels. Since treatments are routinely scheduled, patients can be encouraged to adjust meal times around dialysis treatments. In units that do not allow eating during treatment, patients usually bring in juice, a high protein/caloric nutrition drink (or other supplements), and snack meals for after treatment.

Nurses who do not support eating during dialysis have some very persuasive arguments for their position. One point often made concerns the issue of postprandial hypotension. When food is consumed, blood is shunted to the gastrointestinal track to aid digestion. Blood flow in the splanchnic and hepatic circulation is elevated. This shunting of blood reduces systemic circulating blood volume that may result in a decrease in systemic blood pressure (Kinnel, 2005). Patients who eat during dialysis have often reported experiencing nausea and vomiting, or some may have episodes of diarrhea. These types of complaints may lead patients to request to discontinue their treatments prematurely. When treatment duration is shortened, adequate solute clearances, dialysis adequacy, and outcomes are affected.
A serious blood pressure drop can occur when the shunting of blood to aid digestion is coupled with the treatment’s fluid removal goal. In response to hypovolemia, the body may respond with an increased heart rate and vasoconstriction to improve venous return. Cramping may occur, and, if vomiting occurs, it may increase the risk of aspiration. Drops in systemic blood pressure may jeopardize the efficacy and/or duration of the dialysis treatment as well as adequate organ and tissue perfusion.

A point that may be made by individuals on the con-side is that eating during dialysis may lead to less-than- desired Kt/V results. They hypothesize that, when blood is shunted to the digestive organs and away from the systemic large vessels, clearances are affected. This implies that the circulating blood in the digestive organs reduces the amount of available blood to be circulated through the dialyzer, and therefore diminishes clearances.
Yet another point for not allowing food consumption during hemodiaysis focuses on the question of liability. Nonsupporters contend that when patients are allowed to consume food during their dialysis treatments, there is the possibility for litigation to occur. This now becomes a question of safety. Hypotension is the number one complication that occurs with hemodialysis, and allowing situations that may induce or exacerbate a known risk factor creates a potential for liability. This particular issue has been raised in website chat rooms, such as  AllNurses.com (2003) and AllExperts.com (2005). The suggestion is that physicians and nurses may be liable if they permit patients to actively engage in a behavior that we know has the potential of causing harm.

Bringing food into the unit may require preparation, for example, heated by microwave or arranged for the patient’s convenience. This assistance takes time away from the dialysis staff during an already busy schedule to stop and “play waiter or waitress.” Nurses employed in units that do not permit food to be eaten during the dialysis treatment time have pointed out the burden of potential trash that staff has to clean up related to drink spills, food wrappers, and emesis.

The question of whether patients should eat during or just before a hemodialysis treatment is one with many facets and warrants more research. Patients who miss meals regularly may jeopardize their nutritional health status. Allowing eating during hemodialysis may pose immediate safety and infection control concerns as well as long-term treatment outcomes. The legal implications indicate that facilities need to establish policies for their patients concerning food intake during hemodialysis. Research studies have not directly answered the questions related to patients eating during hemodialysis except the risk of hypotension and related physiological responses. Until that occurs, facilities will need to develop policies, inform patients of the risks and rationales, and ensure that those policies are being followed.

AllExperts.com. (2005). Eating on dialysis. Retrieved February 1, 2008, from http://en.allexperts.com/q/Nephrology-975/Eating-dialysis.htm

AllNurses.com. (2003). Eating on dialysis. Retrieved February 1, 2008, from http://allnurses.com/forums/f48/eating-dialysis-33787.html#post411278

Centers for Disease Control and Prevention (CDC). (2001). Recommendations for preventing transmission of infections amongst chronic hemodialysis patients. Morbidity and Mortality Weekly Report, 50(RR-5), 1-43. Retrieved February 1, 2008, from http://www.cdc.gov/MMWR/ PDF/rr/rr5005.pdf

Kinnel, K. (2005). Should patients eat during hemodialysis treatments? Nephrology Nursing Journal, 32(5), 513-515, 568.
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