Current opinion in clinical nutrition and metabolic care
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Curr Opin Clin Nutr Metab Care · Mar 2008
ReviewParadigm of early parenteral nutrition support in combination with insufficient enteral nutrition.
Several observational studies have pointed out the negative effects of an energy deficit in long-staying ICU patients. Morbidity as well as mortality seem to be linked to such an energy deficit, which is often built up during the first week of stay. A combination of enteral and parenteral nutrition may be a strategy to avoid the development of an energy deficit. ⋯ This field of intensive care medicine is clearly lacking prospective randomized trials. The diversity of opinions is broad, ranging from questioning the use of any nonvolutional nutrition to the use of a combination of enteral and parenteral nutrition to obtain full coverage of the energy needed early on during ICU stay. The arguments for the latter view are summarized in this review.
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Curr Opin Clin Nutr Metab Care · Mar 2008
ReviewEarly nutrition support in the intensive care unit: a US perspective.
Early nutrition support, defined as within the first 24-48 h of ICU care, is recommended by clinical practice guidelines. The purpose of this paper is to provide an evidence-based US perspective on early nutrition support in critical illness, explain its mechanism of action, and describe its implementation using combined enteral and parenteral nutrition support. ⋯ Early enteral nutrition should be first-line therapy in the ICU. If a caloric goal of 20-25 kcal/kg/day is not possible, then combined enteral and parenteral nutrition should be started. In the new age of intensive insulin therapy, parenteral nutrition has not been shown to confer significant additional infective risk. There are many unanswered questions, but a proactive posture for metabolic support in the ICU is advocated.
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The aim of this review is to discuss recent advances in the role of n-3 lipids derived from fish oil in clinical nutrition in an intensive care setting. ⋯ Inclusion of fish oil in nutrition may influence the immune response and clinical outcomes by balancing the negative effects of n-6 fatty acids. Application as a part of enteral immunonutrition in surgical or acute respiratory distress syndrome patients and in lipid emulsions in surgical patients has beneficial effects. In septic patients, data on enteral use are highly controversial. Prospective data from randomized trials, however, are lacking.
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A substantial body of evidence supports the use of intensive insulin therapy in general critical care practice, particularly in surgical intensive care unit patients. The impact of intensive insulin therapy on the outcome of critically ill neurological patients, however, is still controversial. While avoidance of hyperglycemia is recommended in neurointensive care, no recommendations exist regarding the optimal target for systemic glucose control after severe brain injury. ⋯ Questions persist regarding the optimal target for glucose control after severe brain injury. Further studies are needed to analyze the impact of intensive insulin therapy on brain glucose metabolism and outcome of critically ill neurological patients. According to the available evidence, a less restrictive target for systemic glucose control (6-10 mmol/l) may be more appropriate.
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Curr Opin Clin Nutr Metab Care · Mar 2008
ReviewThe nutritional and metabolic support of heart failure in the intensive care unit.
Heart failure and cardiovascular disease are common causes of morbidity and mortality, contributing to many ICU admissions. Nutritional deficiencies have been associated with the development and worsening of chronic heart failure. Nutritional and metabolic support may improve outcomes in critically ill patients with heart failure. This review analyzes the role of this support in the acute care setting of the ICU. ⋯ Shifting the metabolic milieu from catabolic to anabolic, reducing free radicals, and quieting inflammation in addition to caloric supplementation may be the key to nutritional support in the heart failure patient. Tight glycemic control with intensive insulin therapy plays an expanding role in the care of the critically ill. Glucose-insulin-potassium therapy probably does not improve the condition of the patient with heart failure or acute myocardial infarction.