Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition
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Initiating enteral nutrition in the postoperative patient can be challenging. Postoperative ileus and bowel edema, bowel anastomosis, and intra-abdominal pathology contribute to the reluctance and inability to achieve adequate nutrition in this patient population. The addition of vasopressors confounds the difficulties. ⋯ Consideration of the vasopressor agent being utilized and its dose is imperative, as are individual patient characteristics. Temporal changes in the dosage should be closely monitored, as increasing doses may reflect worsening clinical status that can be due to intestinal ischemia. Well-designed prospective trials are clearly necessary to address this controversial topic.
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Type 2 diabetes mellitus (T2DM) and obesity represent two of the biggest global health challenges of this century and are associated with significant comorbidities and healthcare costs. Although multiple factors undoubtedly contribute to the development and progression of DM and obesity, research over the last decade has demonstrated that the microbes that colonize the human gut may play key contributory roles. Gut microbes are now known to codevelop with the human host and are strongly influenced by mode of birth and early diet and nutrition, as well as environmental and other factors including antibiotic exposure. ⋯ In addition, it has been shown that the methanogenic Archaea may contribute to altered metabolism and weight gain in the host. However, the majority of studies are performed with stool or colonic samples and may not be representative of the metabolically active small intestine. Studies predominantly in rodent models are beginning to elucidate the mechanisms by which gut microbes contribute to DM and obesity, but much remains to be learned before we can begin to approach targeted treatments.
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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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Bariatric surgery, an effective treatment for morbid obesity, may result in complications that require nutrition support. Common goals for nutrition support in post-bariatric surgery patients include nutrition repletion, avoiding overfeeding, preserving lean body mass, and promoting wound healing. It is often questioned if continued weight loss can be part of the nutrition goals and if weight loss is safe for patients who become critically ill following bariatric surgery. ⋯ Two small studies in complicated post-bariatric surgery patients requiring nutrition support have shown that the strategy of hypocaloric, high-protein feedings can result in positive outcomes, including positive nitrogen balance, wound healing, weight loss, and successful transition to oral diets. Additional research, including large, randomized studies, is still needed to validate these findings. However, based on a review of available clinical practice guidelines, predictive equations, indirect calorimetry, case studies, and systematic reviews, hypocaloric, high-protein nutrition support appears to at least be equal to eucaloric feedings and may be a useful tool for clinicians to achieve continued weight loss in complicated bariatric surgery patients requiring nutrition support.