Critical care clinics
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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.
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Critical care clinics · Jul 2010
Parenteral nutrition in critical illness: can it safely improve outcomes?
Total parenteral nutrition was developed in the 1960s and has since been implemented commonly in the intensive care unit (ICU). Studies published in the 1980s and early 1990s indicate that the use of total parenteral nutrition is associated with increased mortality and infectious morbidity. These detrimental effects were related to hyperglycemia and overnutrition at a period when parenteral nutrition was not administered according to the all-in-one principle. ⋯ Thus, the time has come to reconsider the use of parenteral nutrition in the ICU. Supplemental parenteral nutrition could prevent onset of nutritional deficiencies when enteral nutrition is insufficient in meeting energy requirements. Clinical studies are warranted to show that the combination of parenteral and enteral nutrition could improve the clinical outcome of patients in the ICU.
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Critical care clinics · Jul 2010
Gastric residual volumes in critical illness: what do they really mean?
The practice of measuring gastric residual volumes (GRVs) has become a routine part of enteral feeding protocols in the critical care setting. However, little scientific evidence indicates that their use improves patient outcomes. The use of GRVs is more of a tradition, which unfortunately guides the delivery of enteral nutrition (EN). ⋯ This article reviews studies showing the fallacies of these assumptions. Although clinicians are unlikely to stop using GRVs, interpretation of these must be modified so as not to interrupt the delivery of EN. Using a protocol that directs appropriate responses to elevated GRVs should promote the delivery of EN and improve patient outcome.