Current opinion in critical care
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Curr Opin Crit Care · Apr 2012
ReviewA new approach to defining and diagnosing malnutrition in adult critical illness.
This review will highlight a new approach to defining malnutrition syndromes for critically ill adults that incorporates a modern understanding of the contributions of inflammatory response. A systematic approach to nutrition assessment is described to help support diagnosis. ⋯ Inflammation and malnutrition have an intimate interplay; the presence of inflammation contributes to the development of malnutrition and often limits the effectiveness of nutritional interventions. In turn, the associated malnutrition may blunt the effectiveness of medical therapies. A new approach to defining and diagnosing malnutrition syndromes can help to guide intervention and expected outcomes.
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Curr Opin Crit Care · Apr 2012
ReviewBlood pressure control for acute ischemic and hemorrhagic stroke.
Acute stroke, including the subtypes of ischemic stroke, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH), typically involves significant fluctuations in blood pressure (BP). Treatment of BP after all stroke types is controversial. In each case, there are theoretical dangers to leaving BP alone as well as altering it artificially. In this article, we review the role of BP in each stroke subtype and the existing evidence for BP optimization. ⋯ Evidence for BP management in acute stroke is limited, although large randomized trials are currently in progress for both ischemic stroke and ICH. BP management in SAH remains woefully understudied.
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Curr Opin Crit Care · Apr 2012
ReviewDetermining energy needs in critically ill patients: equations or indirect calorimeters.
The review focuses on current methodology for the most accurate way to determine resting metabolic rate in critically ill patients and to evaluate whether application of any particular method improves clinical outcome. ⋯ Indirect calorimetry is the most accurate way to determine calorie needs in critically ill patients. Compared to indirect calorimetry, metabolic rate equations are accurate about 75% of the time. No study has been performed to determine whether the measurement or estimation method improves clinical outcome.
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Malnutrition and obesity are prevalent in children admitted to the pediatric intensive care unit. Nutritional deterioration secondary to suboptimal nutrient delivery can adversely affect outcomes during pediatric critical illness. This review highlights the recent investigations of nutrition assessment, energy balance, indirect calorimetry, nutrition therapy, barriers to nutrient delivery, monitoring during enteral feeding, and the role of nutrition guidelines in critically ill children. ⋯ Timely and adequate nutrition therapy is essential to improve nutrition outcomes in critically ill children. Further research is required to determine clinical outcome benefits with indirect calorimetry and enteral nutrition guidelines, and to identify optimal glucose targets.
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Curr Opin Crit Care · Apr 2012
ReviewHypoxia signaling during intestinal ischemia and inflammation.
During critical illness, alterations of intestinal blood supply and inflammatory activation can result in severe intestinal hypoxia (limited oxygen availability). Conditions of hypoxia lead to the activation of a transcriptional program that is under the control of the transcription factor hypoxia-inducible factor (HIF). In many instances, HIF-dependent alterations of gene expression represent endogenous adaptive responses that dampen pathologic inflammation and could be targeted to treat intestinal injury. ⋯ The present review focuses on HIF-elicited anti-inflammatory pathways that result in intestinal protection during critical illness. Many of these pathways represent novel therapeutic targets for attenuating multiorgan failure and critical illness. Whereas these therapeutic approaches are currently being investigated in cell culture models or in genetic mouse models, we are optimistic that at least some of these novel targets can be translated from bench to bedside in the near future.