Current opinion in clinical nutrition and metabolic care
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Clinical anaesthesia and analgesia address a growing number of elderly surgical patients. Ageing modifies physiology, pharmacokinetics and pharmacodynamics, and comorbidity is a common occurrence in the elderly. Therefore, based on recent information regarding perioperative outcome, indications and techniques should be individualized. ⋯ Postoperative cognitive dysfunction (POCD) is quite frequent. If late POCD seemed not related to the type of anaesthesia and analgesia provided, early POCD (interval delirium) was found to be related to perioperative haematocrit and transfusion requirement and to postoperative pain. Epidural analgesia using local anaesthetics and/or opioids was found to be probably better than parenteral opioids for the control of postoperative pain and the prevention of postoperative morbidity and mortality. However, well implemented protocols of parenteral analgesics could be nearly as efficient.
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Curr Opin Clin Nutr Metab Care · Jan 2005
ReviewNutrition and the chronically critically ill patient.
It has been recently recognized that patients of chronic critical illness (CCI) - those who have stabilized after an acute critical illness but remain dependent on life-support - manifest a distinct set of clinical attributes. This unique patient population is often dismissed as hopeless, with aggressive medical therapies considered futile. In fact, with meticulous care, many CCI patients can be liberated from mechanical ventilation and graduated to a rehabilitation program. The nutritional approach to CCI patients is presented here as part of a comprehensive metabolic program to increase their survival and quality of life. ⋯ Nutritional assessment and support of the CCI patient must be implemented upon admission to the respiratory care unit (RCU). Enteral nutrition (EN) with semi-elemental formulas is preferred. Parenteral nutrition is used to supplement EN when necessary. Overfeeding is avoided and tight glycemic control maintained. Diarrhea is aggressively managed. By correcting proximal etiologic events (infection, inflammatory, injuries), avoiding iatrogenic complications and devoting careful attention to nutritional status, CCI patients can potentially overcome their pulmonary compromise and debilitated state, to fully recover.
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Curr Opin Clin Nutr Metab Care · Jan 2005
ReviewOptimizing functional exercise capacity in the elderly surgical population.
There are several studies on the effect of exercise post surgery (rehabilitation), but few studies have looked at augmenting functional capacity prior to surgical admission (prehabilitation). A programme of prehabilitation is proposed in order to enhance functional exercise capacity in elderly patients with the intent to minimize the postoperative morbidity and accelerate postsurgical recovery. ⋯ A concentrated 3-month progressive exercise prehabilitation programme consisting of aerobic training at 45-65% of maximal heart rate reserve (%HRR) along with periodic high-intensity interval training ( approximately 90% HRR) four times per week, 30-50 minutes per session, is recommended for improving cardiovascular functioning. A strength training programme of about 10 different exercises focused on large, multi-jointed muscle groups should also be implemented twice per week at a mean training intensity of 80% of one-repetition maximum. Finally, a minimum of 140 g ( approximately 560 kcal) of carbohydrate (CHO) should be taken 3 h before training to increase liver and muscle glycogen stores and a minimum of about 200 kcal of mixed protein-CHO should be ingested within 30 min following training to enhance muscle hypertrophy.