Current opinion in critical care
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Curr Opin Crit Care · Apr 2012
ReviewParenteral nutrition and calorie delivery in the ICU: controversy, clarity, or call to action?
This review will highlight recent data evaluating the role of parenteral nutrition and calorie delivery in the intensive care setting. Specific focus will be placed on recent trials of early and/or supplemental parenteral nutrition (SPN) and optimization of calorie delivery in ICU patients on the basis of nutrition risk and acuity of illness. The potential key role of protein delivery in outcome will also be discussed. ⋯ The conflicting results of recent RCTs of SPN have provided clarity into the factors defining which patients may benefit from additional calories/protein and which may not. These data, combined with key, large observational studies elicit a clear call to action for trials examining the benefit of optimal calorie/protein delivery in high mortality risk, high preillness nutrition risk patients.
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Curr Opin Crit Care · Apr 2012
ReviewProbiotic, prebiotic, and synbiotic use in critically ill patients.
To summarize the existing data regarding the use of probiotics, prebiotics, and synbiotics in select disorders encountered in the intensive care unit setting. ⋯ Probiotics are living microorganisms which, when ingested in adequate amounts, provide health benefits to the host. The mechanisms of these benefits include improved gastrointestinal barrier function, modification of the gut flora by inducing host cell antimicrobial peptides, releasing probiotic antimicrobial factors, competing for epithelial adherence, and immunomodulation to the advantage of the host. In the intensive care unit, probiotics appear to provide benefits in antibiotic-associated diarrhea, ventilator-associated pneumonia, and necrotizing enterocolitis. With increasing rates of antibiotic resistance among common nosocomial pathogens and fewer new antibiotics in the research pipeline, increasing attention has been placed on nonantibiotic approaches to the prevention and treatment of nosocomial infections. Existing studies of probiotics in critically ill patients are limited by heterogeneity in probiotic strains, dosages, duration of administration, and small sample sizes. Although probiotics are generally well tolerated and adverse events are very rare, the results of the PROPATRIA (Probiotics Prophylaxis in Patients with Predicted Severe Acute Pancreatitis) trial highlight the need for meticulous attention to safety monitoring. Better identification of the ideal characteristics of effective probiotics coupled with improved understanding of mechanisms of action will help to delineate the true beneficial effects of probiotics in various disorders.
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Recovery and rehabilitation after critical illness is a vital part of intensive care management. The role of feeding and nutritional intervention is the subject of many recent studies. The gastric hormone ghrelin has effects on appetite and food intake and on immunomodulatory functions. Here we review the interactions between critical illness, appetite regulation, nutrition and ghrelin. ⋯ Enhancing recovery from critical illness will improve both short-term and long-term outcomes. Ghrelin may offer an important means of improving appetite, muscle mass and rehabilitation in the period after critical illness, although studies are needed to see whether this potential is realized.
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Cerebral vasospasm (CVS) after aneurysmal subarachnoid hemorrhage remains a considerable challenge in neurocritical care medicine. This review aims to cover the recent novel aspects and results in CVS treatment. ⋯ Reviewing the recent literature, there have been some updates on recommendations and newer treatment modalities are under evaluation. However, a novel treatment with convincing evidence has not been reported so far.
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An important goal of neurocritical care is the management of secondary brain injury (SBI), that is pathological events occurring after primary insult that add further burden to outcome. Brain oedema, cerebral ischemia, energy dysfunction, seizures and systemic insults are the main components of SBI. We here review recent data showing the clinical utility of brain multimodality monitoring (BMM) for the management of SBI. ⋯ BMM offers an on-line comprehensive scrutiny of the injured brain and is increasingly used for the management of SBI. Integration of monitored data using new informatics tools may help optimize therapy of brain-injured patients and quality of care.