Nutrición hospitalaria : organo oficial de la Sociedad Española de Nutrición Parenteral y Enteral
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Existing data about indication and time of onset of nutritional support are not homogeneous. However, the presence of a deterioration of the nutritional status is accompanied by harmful effects so that, broadly speaking, specialized nutritional support onset would be advisable if a fasting period longer than 5-7 days is foreseen. ⋯ Enteral nutrition should be started early on (within the first 36 hours of admission). Although transpyloric nutrients administration may however reduce bronchoaspiration and increase the diet effective volume received by patients, there are no data for recommending routinary usage of the transpyloric route for nutritional support in the critically ill patients.
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Nutritional and metabolic support in patients with liver failure should be able to adequately provide the nutritional requirements and, at the same time, to contribute in patients' recovery by controlling or reverting the metabolic impairments observed. However, in spite of the pathophysiologic basis described by some authors considering amino acids unbalance as a triggering and maintaining factor for encephalopathy, there are no sufficient data to recommend the use of "specific" solutions (branched amino acids-enriched and low on aromatic amino acids) as part of the nutritional support of patients with acute liver failure. Its routinary use is neither recommended for preventing complications in patients submitted to liver transplantation. ⋯ In patients requiring parenteral nutrition, there is no contraindication to the use of lipid infusions. An increase in vitamins and micronutrients intake is recommended. In patients submitted to liver transplantation, nutrients intake should be started early in the postoperative period through a transpyloric route of access.
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Due to the characteristics of critically ill patients, elaborating recommendations on nutritional support for these patients is difficult. Usually the time of onset of nutritional support or its features are not well established, so that its application is based on experts' opinion. ⋯ Several clinical situations have been considered which are developed in the following articles of this publication. The present recommendations aim at providing a guideline for the less experienced clinicians when considering the metabolic and nutritional issues of critically ill patients.
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Nutritional support in critically ill patients that present with acute renal failure has been a matter of change in recent years. This is due to the increasing and earlier use of extrarenal depuration techniques. Modifications in nutritional and metabolic support regimen aimed at preventing renal failure progression, classically recommended, would not have an indication in these situations but in cases not treated with one of these depurative techniques. ⋯ However, the relationship between substrates flow through dialysis membranes and its effect on nutrients demands has not been fully established yet. It is likely that an increase in nutrients intake may be necessary to counteract the obliged loss by depurative techniques. The other way around, the role of these techniques as an appropriate way for nutritional support in critically ill patients remains to be studied.
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The need to strictly control glucose levels, even in nondiabetic patients, has recently emerged following the publication of the results that indicate the possibility of reducing the morbidity and mortality in critically ill patients. Since hyperglycemia is one of the most frequent metabolic impairments in these patients, insulin therapy is a necessity in most of the cases. In order to prevent hyperglycemia and its associated complications, nutritional support must be adjusted to the patient's requirements, avoiding hyponutrition. ⋯ In both cases, the use of low glycemic index carbohydrates is recommended. Protein intake should be adjusted to the patients' metabolic stress level. In diabetic patients with acute disease, an increase in antioxidants intake is recommended.