Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition
-
Sepsis, shock, multiple trauma, and burns are often associated with altered metabolism characterized by severe catabolism, wasting of the lean body mass, immune dysfunction, and compromised wound healing. Nutrition support is one of the mainstays in the management of these critically ill patients and is aimed at minimizing these complications. The purpose of this article is to compare stress hypermetabolism and starvation metabolism, to review current recommendations for the provision of energy and substrate to the critically ill patient, and to review pertinent literature regarding enteral vs parenteral nutrition. Finally, this article will provide a brief overview of new and future therapies with emphasis on specific substrates and growth factors and the potential for their use in the critically ill patient.
-
The increasing size and longevity of the geriatric patient population dictates that all health care practitioners become more cognizant of the unique requirements for nutritional assessment and support of the elderly. This review summarizes recent advances in the understanding of the nutrition support needs of the old and oldest-old patients requiring enteral or parenteral feeding. ⋯ Indications for choosing enteral or parenteral feeding are considered excessively invasive by some and necessarily "heroic" by others. The patient and his or her family should be part of the decision-making process.
-
Anorexia and involuntary weight loss are prevalent problems in oncology and AIDS patients. Cytokines are suspected but not proven causes of cachexia. Megestrol acetate has been found to increase appetite, food intake, and weight in randomized, placebo-controlled trials in patients with advanced malignancies and in patients with AIDS. ⋯ No significant effect on survival has been demonstrated in these trials. The optimal dose for appetite enhancement is unknown; we have chosen 320 mg/d as our initial dose. Megestrol acetate is usually well tolerated, and it may be helpful in the symptomatic and palliative therapy of patients with anorexia and weight loss.
-
A pilot study to evaluate a technique for the bedside placement of small-bore, weighted feeding tubes past the pylorus in critically ill patients is described. The technique involves the use of a #8 or #10 French small-bore, tungsten-weighted feeding tube, specific patient positioning, and defined insertion techniques, including gastric distention with air. ⋯ Approximate time for successful insertion was 30 minutes. A follow-up study to define factors influencing success or failure of this technique is planned.
-
In two recent clinical trials in surgical patients, supplementation of total parenteral nutrition with daily doses of 12 or 20 g of glutamine resulted in a diminished loss of free glutamine in skeletal muscle tissue. Studies in animals exploring the use of both enteral and parenteral glutamine supplementation suggest that glutamine may be an essential nutrient in the maintenance of gut structure and function during critical illness. ⋯ The average amount of glutamine in selected, whole-protein formulas ranges from a minimum of 3.55 g/4200 kJ to a maximum of 5.15 g/4200 kJ. Although it is still too early to define the safest and most effective dose of glutamine, there are two points regarding glutamine supplementation that clearly merit further investigation: no clinical trials have been conducted to assess the potential benefits of glutamine supplementation of an enteral diet or to assess the effects of using diets containing protein-bound glutamine rather than free glutamine.