Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition
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Preoperative carbohydrate-containing clear liquids (usually composed of approximately 12% carbohydrate predominantly in maltodextrin form) have provided benefits for the surgical population and further have been included in the Enhanced Recovery After Surgery (ERAS) Society's recommendations as part of a multimodal approach to reduce surgical patients' length of stay and complication rates. Carbohydrate metabolism is greatly affected by the fed state, which is activated by preoperative carbohydrate fluids given up to 2 hours prior to surgery in contrast to the traditional midnight preoperative fast. Carbohydrate-rich fluids have been proven to enhance patient comfort prior to surgery and have been theorized to reduce insulin resistance, reducing patient catabolism, with a positive impact on perioperative glucose control and muscle preservation. ⋯ Preoperative carbohydrate fluid loading is difficult to prove, as the degree of surgical procedure and postoperative pathways are likely more reflective of patient outcome. The use of carbohydrate-loading protocols warrants further adequately blinded, placebo-controlled studies, including the use of variable surgical techniques, reproduction of the hyperinsulinemic euglycemic technique measurements, investigation of ideal carbohydrate fluid composition, and the use of similar surgeries in comparison. Preoperative carbohydrate loading is just one of the many strategies linked to the success of ERAS protocols.
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There has been increased attention on the importance of identifying and distinguishing the differences between stress-induced hyperglycemia (SH), newly diagnosed hyperglycemia (NDH), and hyperglycemia in persons with established diabetes mellitus (DM). Inpatient blood glucose control is now being recognized as not only a cost issue for hospitals but also a concern for patient safety and care. The reasons for the increased incidence of hyperglycemia in hospitalized patients include preexisting DM, undiagnosed DM or prediabetes, SH, and medication-induced hyperglycemia with resulting transient blood glucose variability. ⋯ What differs is how to incorporate EN into the established insulin management protocols. The risk for hyperglycemia with the addition of EN is even higher in those without a previous diagnosis of DM. This review discusses the incidence of hyperglycemia, the pathogenesis of hyperglycemia, factors contributing to hyperglycemia in the hospitalized patient, glycemic management goals, current glycemic management recommendations, and considerations for EN formula selection, administration, and treatment.
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Malnutrition is known to negatively impact the clinical course of advanced heart failure and is associated with increased mortality following left ventricular assist device (LVAD) implantation. Appropriate assessment of nutrition requirements in these patients is critical in their clinical care, yet there has been little discussion on how to best determine resting energy expenditure (REE) in the hospital setting. We investigated the use of indirect calorimetry in a group of patients with advanced heart failure. ⋯ Indirect calorimetry may be reliably and safely used to determine caloric requirements in patients with advanced heart failure. The use of predictive equations based on demographic and clinical parameters appears to generate inaccurate estimations of REE in these patients. However, equations designed for use in critically ill patients better estimate nutrition requirements than those designed for healthy individuals.