Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition
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Despite considerable efforts to define energy requirements for critically ill patients, no single method has been found to be precise and unbiased for all patients. As a result, clinicians have used various methods that may overestimate energy requirements for some patients. Provision of target caloric intake without regard to the complications of overfeeding, such as hyperglycemia, hypercapnia, or gastric feeding intolerance, could result in overall detrimental clinical outcome. ⋯ A pivotal paper by Krishnan and colleagues published in 2003 brought these issues to the forefront of clinical practice. Key papers that support or refute the practice of "permissive underfeeding" are reviewed. Further research is necessary to determine the minimum amount of nutrition required to achieve a therapeutic benefit as well as to ascertain at what amount of additional nutrition intake offers no further improvement in clinical outcome.
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Traditionally, enteral nutrition (EN) goal rates have been calculated based on an intended continuous 24-hour infusion rate. Many factors in the care of critically ill patients result in interruption of EN infusions, often for several hours daily, which may lead to significant underfeeding. The objective of this study was to evaluate the difference of daily EN volume deficits between a traditionally calculated infusion rate and a compensatory, higher calculated infusion rate in which the 24-hour volume was delivered over a 20-hour infusion period. ⋯ Calculating and prescribing higher EN infusion rates, assuming 20 hours of actual infusion daily, promoted delivery of optimal nutrient provisions and avoidance of unintended malnutrition by significantly reducing caloric deficit from frequent EN holding.
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Inadvertent rapid infusion of parenteral lipid emulsion is an inherent risk when fats are infused separately from the dextrose-amino acid solution. Patients may experience hypertriglyceridemia that resolves upon discontinuation of the infusion; in other cases, complications such as fat overload syndrome can occur. Since 2004, fish oil-based emulsions have been used investigationally for the treatment of parenteral nutrition-associated liver disease. Anecdotal reports suggest that patients who receive rapid infusions of this emulsion do not develop symptoms consistent with fat overload syndrome. The aim of this investigation was to determine whether infants receiving a rapid infusion of a fish oil lipid emulsion exhibited symptoms consistent with fat overload syndrome. ⋯ Rapid infusion of a fish oil-based emulsion in 6 infants were well tolerated. No patients developed signs or symptoms of fat overload syndrome.
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This study was conducted to identify current practice in provision of enteral nutrition (EN) and to determine effects of early enteral nutrition (EEN) on length of stay in the medical intensive care unit (ICU). In this prospective, observational study, medical ICU patients were evaluated to determine their candidacy for EEN. If patients were candidates for EN and expected to remain nothing-by-mouth for 48 hours, they were classified as receiving EEN (within 24 hours of admission) or delayed EN. ⋯ The incidence of new pneumonia was lower in the EEN group (5.5% vs 44%), but no difference was found in the incidence of bacteremia. Hospital mortality was lower in the EEN group (1 vs 7 deaths). Given its association with numerous benefits, EEN within 24 hours of admission should be encouraged and implemented by clinicians in medical ICU patients, but additional research is needed.
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Intestinal failure is a complex disease state for which extensive therapy is often required. Parenteral nutrition is one of these therapies, but with its long-term use, life-threatening complications may develop. ⋯ For patients who develop complications from parenteral nutrition and fail intestinal rehabilitation interventions, intestinal transplantation may be the best option. In this review, therapies available for intestinal failure and the use of a multidisciplinary approach to the patient with intestinal failure will be reviewed.