Current gastroenterology reports
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Curr Gastroenterol Rep · Aug 2007
ReviewGastric versus post-pyloric feeding: relationship to tolerance, pneumonia risk, and successful delivery of enteral nutrition.
Enteral nutrition has been shown to have clinical advantages over parenteral nutrition in critically ill patients. However, delivery of enteral nutrition can be challenging because of intolerance and potential adverse effects. Gastric feeding is more physiologic than post-pyloric feeding, but its use may be limited by intolerance due to gastric dysfunction and by inappropriately low gastric residual volumes. ⋯ The selection of site for enteral feeding should be based on risks, patient tolerance, and availability of local expertise. Predetermined feeding protocols may help to optimize the delivery of enteral nutrition. Only sufficient and safe delivery of enteral nutrition will have a positive impact on patient outcome.
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Curr Gastroenterol Rep · Aug 2007
ReviewPermissive underfeeding: its appropriateness in patients with obesity, patients on parenteral nutrition, and non-obese patients receiving enteral nutrition.
The concept of permissive underfeeding is based on the rationale that higher nutrient intake is detrimental from a metabolic and functional perspective. Animal studies have demonstrated improved morbidity and mortality with energy restriction. Studies with obese patients have demonstrated that a hypocaloric feeding regimen can promote nitrogen equilibrium and minimize negative nitrogen balance without causing weight loss. ⋯ In enterally fed patients, more research exists but the data are not generated from prospective controlled trials. Studies of enterally supported patients demonstrate an association between higher caloric intake and decreased morbidity and mortality. Despite limited research, provision of reduced energy intake in critically ill patients and obese patients may result in improved metabolic control, reduce the detrimental effects of overfeeding, and promote improved patient outcomes.
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Curr Gastroenterol Rep · Aug 2007
ReviewMaximizing efficacy from parenteral nutrition in critical care: appropriate patient populations, supplemental parenteral nutrition, glucose control, parenteral glutamine, and alternative fat sources.
The gastrointestinal tract is the preferred route for nutritional support in hospitalized patients. Patients with a functioning gastrointestinal tract, including those with pancreatitis or inflammatory bowel disease and those receiving chemotherapy, should be fed enterally. Parenteral nutrition (PN) should be limited to patients with gastrointestinal failure, including those with short gut syndrome, high-output fistula, prolonged ileus, or bowel obstruction. ⋯ Safety may be improved with a low-calorie formula and ensuring tight glycemic control with an insulin protocol. A lipid emulsion containing fish oil, olive oil, or both should replace soybean-containing emulsions. Supplemental glutamine, 0.2 g/kg/d to 0.5 g/kg/d, has been shown to reduce the risk of infection and to improve glycemic control.
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Acute liver failure (ALF) is an uncommon disorder that leads to jaundice, coagulopathy, and multisystem organ failure. Its definition is based on the timing from onset of jaundice to encephalopathy. In 2005, ALF accounted for 6% of liver-related deaths and 7% of orthotopic liver transplants (OLT) in the United States. ⋯ Improved surgical techniques, immunosuppression, and comprehensive care have led to an overall survival rate of approximately 65% with OLT. N-acetylcysteine is effective in ALF caused by acetaminophen overdose, with results strongly related to how soon it is given rather than the route of administration. Liver support systems show potential for the treatment of ALF, but their role needs validation in large multicenter randomized trials.
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Alcoholic hepatitis is a disease with a wide range of severity. Patients with severe disease have short-term mortality rates above 35%. In these high-risk patients, pharmacologic therapy is an important adjunct to supportive medical care and has been proved to improve survival. ⋯ Adequate nutrition is also critical and should be provided by tube feeding if necessary. A prompt decline in serum bilirubin indicates a favorable response to therapy. Patients who do not exhibit a reduction in serum bilirubin within 1 week are considered nonresponders and have a 6-month mortality rate of 50% or higher.