Critical care clinics
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Critical care clinics · Jul 2010
ReviewThe evolutionary role of nutrition and metabolic support in critical illness.
Maintenance of nutritional status is particularly challenging during critical illness. There is a common perception of a race against the clock to adequately feed the patient to prevent or minimize the sometimes catastrophic muscle wasting and general catabolic state that can result in the patient's deterioration. However, the course of critical illness may be separated into 3 phases, each with highly differing metabolic needs. ⋯ Those strong enough to survive this phase enter into a period of recovery during which appetite returns, anabolism recommences, and organ function is restored. Nutrition should perhaps closely follow these nonlinear requirements, so as to avoid deleterious under- or overnutrition during the appropriate phase. This approach fits a teleologic argument that enabled many sick people to survive well before the advent of modern medicine and explains why catabolism still occurs despite adequate feeding.
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Critical care clinics · Jul 2010
ReviewFish oil in critical illness: mechanisms and clinical applications.
Fish oil is rich in omega-3 fatty acids, which have been shown to be beneficial in multiple disease states that involve an inflammatory process. It is now hypothesized that omega-3 fatty acids may decrease the inflammatory response and be beneficial in critical illness. ⋯ The results of this research to date are inconclusive for both enteral and parenteral omega-3 fatty acid administration. More research is required before definitive recommendations can be made on fish oil supplementation in critical illness.
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Critical care clinics · Jul 2010
Enhanced recovery after surgery: the future of improving surgical care.
Enhanced recovery after surgery (ERAS) is a multimodal perioperative care pathway designed to attenuate the stress response during the patients' journey through a surgical procedure to facilitate the maintenance of preoperative bodily compositions and organ function and in doing so achieve early recovery. The key factors that keep patients in hospital after uncomplicated major abdominal surgery include the need for parenteral analgesia, intravenous fluids secondary to persistent gut dysfunction, and bed rest caused by lack of mobility. The elements of the ERAS pathways are aimed to address these issues and the interventions that facilitate early recovery cover all three phases of the perioperative period during the patients' journey. They also provide clear guidance to all members of the clinical team.
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At present, we are in a "revival" period in clinical nutrition in critical care, especially in the area of "pharmaconutrition." Adequate nutrition may hinge not only on how many calories are provided but also on the ability to provide key pharmacologically acting nutrients. Traditionally, nutrition has been viewed as vital for metabolism, growth, and repair. But, it is now known that some nutrients, when given in therapeutic doses, appear to serve as pharmacologic agents to improve clinically relevant outcomes. ⋯ Specific pharmaconutrients can also be administered as separate components, much like a drug is given. Large multicenter trials are planned or are underway to test these hypotheses. The use of basic clinical pharmacology, molecular biology, and clinical research principles in the study of nutritional therapy will lead to answers on how to administer the right nutrients, in the right amounts, at the right time to critically ill patients.
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Glutamine (GLN) has been shown to be a key pharmaconutrient in the body's response to stress and injury. It exerts its protective effects via multiple mechanisms, including direct protection of cells and tissue from injury, attenuation inflammation, and preservation of metabolic function. Data support GLN as an ideal pharmacologic intervention to prevent or treat multiple organ dysfunction syndrome after sepsis or other injuries in the intensive care unit population. A large and growing body of clinical data shows that in well-defined critically ill patient groups GLN can be a life-saving intervention.