Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition
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Critical illness can be viewed as consisting of 4 distinct stages: (1) acute critical illness (ACI), (2) prolonged acute critical illness, (3) chronic critical illness, and (4) recovery. ACI represents the evolutionarily programmed response to a stressor. In ACI, substrate is shunted away from anabolism and toward vital organ support and inflammatory proteins. ⋯ It is at this point that nutrition and metabolic support become integral to the care of the patient. This paper (1) delineates and develops the 4 stages of critical illness using current evidence, clinical experience, and new hypotheses; (2) defines the chronic critical illness syndrome (CCIS); and (3) details an approach to the metabolic and nutrition support of the chronically critically ill patient using the metabolic model of critical illness as a guide. It is our hope that this clinical model can generate testable hypotheses that can improve the outcome of this unique population of patients.
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During critical illness, the stress response causes accelerated gluconeogenesis and lipolysis, leading to hyperglycemia and elevated serum triglyceride levels. The traditional nutrition support strategy of meeting or exceeding calorie requirements may compound the metabolic alterations of the stress response. Hypocaloric nutrition support has the potential to provide nutrition support without exacerbating the stress response. ⋯ Providing adequate dietary protein has emerged as an important factor in efficacy of the hypocaloric regimen. Although it is inconclusive, currently available research suggests that a nutrition support goal of 10-20 kcal/kg of ideal or adjusted weight and 1.5-2 g/kg ideal weight of protein may be beneficial during the acute stress response. Well-designed, randomized, controlled studies with adequate sample size that evaluate relevant clinical outcomes such as mortality, ICU LOS, and infection while controlling for factors such as glycemic control, severity of illness, incorporation of calories from all sources, in addition to feeding regimens, are needed to definitively determine the effects of hypocaloric nutrition support.
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Nutrition supplementation is paramount to the care of severely injured patients. Despite its widespread use in trauma patients, many areas of clinical practice remain controversial. ⋯ Additional controversies confronting clinicians are reviewed, including the use of immune-enhancing agents and the optimal site for enteral nutrition delivery (gastric vs small intestinal). Evidence-based recommendations for clinical practice are presented when available.
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Appropriate fluid management of patients with traumatic brain injury (TBI) presents a challenge for many clinicians. Many of these patients may receive osmotic diuretics for the treatment of increased intracranial pressure or develop sodium disturbances, which act to alter fluid balance. ⋯ Electrolyte derangements are also common after neurologic injury, with many having neurologic manifestations. In addition, the role of electrolyte abnormalities in the secondary neurologic injury cascade is being delineated and may offer a potential future therapeutic intervention.
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Early nutrition intervention, both parenteral and enteral, is becoming a standard of care for the extremely low-birth-weight infant (ELBW; <1,000 g) in many neonatal intensive care units (NICU) across the United States. However, there are no published or widely accepted guidelines regarding nutrition support strategies for this population. Most NICU clinicians have developed their own guidelines, so nutrition practices vary widely. In an effort to standardize our practice, we implemented nutrition support guidelines for ELBW infants, initiating both parenteral nutrition (PN) and minimal enteral feedings (MEFs) within the first 24 hours of life, whenever possible. The purpose of this study was 2-fold: (1) to evaluate the adherence to the nutrition guidelines and (2) to compare pre- and postguideline outcomes such as time to regain birth weight, time to reach full enteral feedings, and average daily weight gains. ⋯ The implementation of early nutrition support guidelines influenced the timeliness of initiating nutrition support in our unit. Early initiation of nutrition support in ELBW infants produces a rapid regain of initial weight loss, improves weight gain, and enhances earlier achievement of full enteral feedings.