Current opinion in clinical nutrition and metabolic care
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Curr Opin Clin Nutr Metab Care · Mar 2013
ReviewCritical care nutrition support research: lessons learned from recent trials.
In the past year, there have been a few large-scale trials of nutrition support in the critical care setting that have produced negative results and have challenged certain assumptions. The purpose of this study is to review those current trials and illustrate key methodological points that should help with the interpretation of these trials, and inform the design of critical care nutrition trials of artificial nutrition in the future. ⋯ Future trials of nutrition support in the ICU, such as the TOP UP study, should include only 'high-risk' patients and should evaluate a broader range of outcomes than traditional ICU outcomes (28-day mortality, ventilator-free days, organ failure-free days, etc.). In the meantime, efforts to improve delivery of energy and protein to critically ill patients, such as with the enhanced protein-energy provision via the enteral route feeding protocol, are warranted.
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Curr Opin Clin Nutr Metab Care · Mar 2013
ReviewReconciling divergent results of the latest parenteral nutrition studies in the ICU.
Recent studies on the optimal modalities to feed patients during the ICU stay show divergent results. The level and the timing of energy provision is a critical issue, associated with the clinical outcome. These results questioned the clinical relevance of the recent guidelines issued by American, Canadian and European academic societies. ⋯ The critical analysis of recent prospective studies comparing various levels of calorie administration, enteral versus parenteral nutrition and enteral versus SPN confirms the recommendations to avoid underfeeding and overfeeding. Parenteral nutrition, required if enteral feeding is failing, and if adjusted up to a measured optimal level, may improve outcome. More studies on the optimal level of energy and protein administration to optimize the clinical outcome are required to fine tune current guidelines.
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Curr Opin Clin Nutr Metab Care · Mar 2013
ReviewThe use of indirect calorimetry in the intensive care unit.
This review evaluates whether improvements have occurred in the value of predictive equations for use in designing nutritional therapeutic regimens in the ICU. The report also seeks to determine whether emerging strategies for nutrition therapy in the ICU change the need for an accurate measurement of energy requirements by indirect calorimetry. ⋯ The role of indirect calorimetry in the ICU should be expected to increase in the near future, as predictive equations may be too inaccurate to identify the appropriate goals of nutrition therapy.
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Curr Opin Clin Nutr Metab Care · Mar 2013
ReviewSpecialized nutritional support interventions in critically ill patients on renal replacement therapy.
Optimal nutritional requirements and nutrient intake composition for patients with acute kidney injury remain a partially unresolved issue. Targeting nutritional support to the actual protein and energy needs improves the clinical outcome of critically ill patients, yet very few data are currently available on this topic in acute kidney injury. In this specific clinical condition the risk for underfeeding and overfeeding may be increased by factors interfering on nutrient need estimation, such as rapidly changing body weight due to fluid balance variations, nutrient losses and hidden calorie sources from renal replacement therapy. Moreover, as acute kidney injury is now considered a kidney-centered inflammatory syndrome, the renoprotective role of specific pharmaconutrients with anti-inflammatory properties remains to be fully defined. This review is aimed at discussing recently published results concerning quantitative and qualitative aspects of the nutritional approach to acute kidney injury in critically ill patients. ⋯ Acute kidney injury includes a highly heterogeneous group of patients with widely varying nutrient needs and intakes. Nutritional requirements, in their quantitative and qualitative aspects, should be frequently assessed, individualized, and carefully integrated with renal replacement therapy, in order to avoid both underfeeding and overfeeding, as well as to exploit possible positive pharmacologic effects of specific nutrients.
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The pleotropic effects of vitamin D on chronic diseases have received significant attention; however, its role in acute illness is less understood. The purpose of this review is to summarize the current evidence regarding the role of vitamin D in acute stress and critical illness. ⋯ Single-point assessments of 25-hydroxyvitamin D following acute stress may provide an inaccurate assessment of vitamin D status. In such cases, measurement of binding proteins and free vitamin D metabolites may be essential to create a more realistic approximation of vitamin D status. Variations in patient responses to acute stress and critical illness may depend not only on the degree of systemic vitamin D insufficiency, but also on the individual tissue requirements.