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Alhazzani W, Guyatt G, Marshall JC, Hall R, Muscedere J, Lauzier F, Thabane L, Alshahrani M, English SW, Arabi YM, Deane AM, Karachi T, Rochwerg B, Finfer S, Daneman N, Zytaruk N, Heel-Ansdell D, Cook D, Of OB. Re-evaluating the Inhibition of Stress Erosions (REVISE): a protocol for pilot randomized controlled trial. Ann Saudi Med 2016; 36:427-433. [PMID: 27920416 PMCID: PMC6074211 DOI: 10.5144/0256-4947.2016.427] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Clinicians routinely administer stress ulcer prophylaxis to mechanically ventilated patients in the intensive care unit (ICU), most commonly prescribing proton pump inhibitors (PPIs). However, the incidence of gastrointestinal (GI) bleeding from stress ulceration is low and recent observational studies suggest these agents may increase infections. Therefore, a large randomized clinical trial (RCT) is needed to inform modern practice. The aim of this multicenter pilot trial is to determine the feasibility of performing a large RCT to investigate the efficacy and safety of withholding intravenous pantoprazole. METHODS AND ANALYSIS We will include adult critically ill patients who have an anticipated duration of ventilation of >=48 hours. We will exclude patients with acute or recent GI bleeding, pregnancy, dual antiplatelet therapy, poor prognosis or intent to withdraw life support, or previous enrolment in this or a confounding trial. Following informed consent, patients will be randomized to receive the intervention of placebo (0.9% NaCl) or intravenous pantoprazole 40 mg daily. Patients, families, clinicians, data collectors, adjudicators of outcome and statisticians will be blind to allocation. The three primary feasibility outcomes are the informed consent rate, recruitment rate, and protocol adherence. Clinical outcomes include clinically important upper GI bleeding, ventilator-associated pneumonia (VAP), Clostridium difficile infection, length of stay and mortality in ICU and hospital. ETHICS AND APPROVAL This study has been approved by Health Canada, and research ethics board (REB) at each of the participating centers. TRIAL REGISTRATION NUMBER This trial was registered on 31 October 2014. The trial registration number is NCT02290327. FUNDING REVISE Pilot Trial is funded by Research Grant awarded by Physicians Services Incorporated, Dammam University Research Funds, Capital Health Authority Research Award Halifax, and Royal Adelaide Hospital Project Committee Grant.
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Affiliation(s)
- Waleed Alhazzani
- Dr. Waleed Alhazzani, Critical Care Medicine, McMaster University,, 50 Charlton Avenue East,, Hamilton, Ontario,, L8N 4A6, Canada, T: +1905-522-1155 ext 32800, F: +1905-521-6068 , ORCID: http://orcid.org/0000-0001-8076-9626
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Nutritional controversies in critical care: revisiting enteral glutamine during critical illness and injury. Curr Opin Crit Care 2016; 21:527-30. [PMID: 26539926 DOI: 10.1097/mcc.0000000000000260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW This article examines some of the articles that inspired recent changes to critical care guidelines related to glutamine in enteral nutrition. RECENT FINDINGS Two recent multicenter randomized controlled trials involving enteral glutamine have reported increased mortality rates in groups of mechanically ventilated adult patients, while demonstrating no additional benefits to other outcomes, such as nosocomial infections. SUMMARY Recent studies suggest that enteral glutamine supplementation may not provide significant clinical benefits to adult patients on mechanical ventilation with multiple organ failure, but more information is still needed when attempting to apply these results to other groups of critical care patients.
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Dickerson RN, Kumpf VJ, Blackmer AB, Bingham AL, Tucker AM, Ybarra JV, Kraft MD, Canada TW. Significant Published Articles for Pharmacy Nutrition Support Practice in 2014 and 2015. Hosp Pharm 2016; 51:539-52. [PMID: 27559187 DOI: 10.1310/hpj5107-539] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To assist the pharmacy clinician engaged in nutrition support in staying current with the most pertinent literature. METHODS Several experienced board-certified clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2014 and 2015 that they considered to be important to their practice. Only those articles available in print format were considered for potential inclusion. Articles available only in preprint electronic format were not evaluated. The citation list was compiled into a single spreadsheet where the author participants were asked to ascertain whether they considered the paper important to nutrition support pharmacy practice. A culled list of publications was then identified whereby the majority of author participants (at least 5 out of 8) considered the paper to be important. RESULTS A total of 108 articles were identified; 36 of which were considered to be of high importance. An important guideline article published in early 2016, but not ranked, was also included. The top-ranked articles from the primary literature were reviewed. CONCLUSION It is recommended that the informed pharmacist, who is engaged in nutrition support therapy, be familiar with the majority of these articles.
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Akers AS, Pinsky M. Placement of a Magnetic Small Bowel Feeding Tube at the Bedside. JPEN J Parenter Enteral Nutr 2016; 41:496-499. [PMID: 26129896 DOI: 10.1177/0148607115594235] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Current methods of achieving postpyloric enteral access for feeding are fraught with difficulties, which can markedly delay enteral feeding and cause complications. Bedside tube placement has a low success rate, often requires several radiographs to confirm position, and delays feeding by many hours. Although postpyloric enteral tubes can reliably be placed in interventional radiology (IR), this involves greater resource utilization, delays, cost, and inconvenience. We assessed the utility of bedside enteral tube placement using a magnetic feeding tube (Syncro-BlueTube; Syncro Medical Innovations, Macon, GA, USA) as a means to facilitate initial tube placement. METHODS We recorded the time to insertion, location of tube, success rate, and need for radiographs in a series of patients given magnetic feeding tubes (n = 46) inserted by our hospitalist service over an 8-month interval. RESULTS Of the 46 attempted magnetic tube placements, 76% were successfully placed in the postpyloric position, 13% were in the stomach, and 11% could not be placed. In 83% of the magnetic tubes, only 1 radiograph was needed for confirmation. The median time to placement was 12 minutes (range, 4-120 minutes). CONCLUSION The use of a magnetic feeding tube can increase the success rate of bedside postpyloric placement, decrease the time to successful placement, and decrease the need for supplemental radiographs and IR.
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Affiliation(s)
- Adam S Akers
- 1 Sidra Medical and Research Center, Doha, Qatar
| | - Michael Pinsky
- 2 Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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105
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Merchan C, Altshuler D, Aberle C, Papadopoulos J, Schwartz D. Tolerability of Enteral Nutrition in Mechanically Ventilated Patients With Septic Shock Who Require Vasopressors. J Intensive Care Med 2016; 32:540-546. [DOI: 10.1177/0885066616656799] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose: Enteral nutrition (EN) is often held in patients receiving vasopressor support for septic shock. The rationale for this practice is to avoid mesenteric ischemia. The objective of this study is to evaluate the tolerability of EN in patients with septic shock who require vasopressor support and determine factors associated with tolerance of EN. Materials and Methods: This was a single-center retrospective review of adult patients admitted to the intensive care unit with a diagnosis of septic shock and an order for EN. The primary outcome was EN tolerance. Secondary outcomes included time to initiation of EN from the start of vasopressor(s), length of stay, and mortality. Results: A total of 120 patients were included. Sixty-two percent of patients tolerated EN. The most common reason for intolerance of EN was gastric residuals > 250 mL (74%). No reports of mesenteric ischemia were observed. A multivariate analysis demonstrated that patients with septic shock initiating EN within 48 hours and receiving norepinephrine-equivalent doses of 0.14 μg/kg/min or less were more likely to tolerate EN. Conclusion: Based on our observation, early EN may be tolerated and safely administered in patients with septic shock who are adequately fluid resuscitated and receive doses of < 0.14 μg/kg/min of norepinephrine equivalents.
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Affiliation(s)
- Cristian Merchan
- Department of Pharmacy, New York University Langone Medical Center, New York, NY, USA
| | - Diana Altshuler
- Department of Pharmacy, New York University Langone Medical Center, New York, NY, USA
| | - Caitlin Aberle
- Department of Pharmacy, New York University Langone Medical Center, New York, NY, USA
| | - John Papadopoulos
- Department of Pharmacy, New York University Langone Medical Center, New York, NY, USA
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - David Schwartz
- Department of Medicine, New York University School of Medicine, New York, NY, USA
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Oshima T, Heidegger CP, Pichard C. Supplemental Parenteral Nutrition Is the Key to Prevent Energy Deficits in Critically Ill Patients. Nutr Clin Pract 2016; 31:432-7. [PMID: 27256992 DOI: 10.1177/0884533616651754] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
This review emphasizes the role of a timely supplemental parenteral nutrition (PN) for critically ill patients. It contradicts the recommendations of current guidelines to avoid the use of PN, as it is associated with risk. Critical illness results in severe metabolic stress. During the early phase, inflammatory cytokines and mediators induce catabolism to meet the increased body energy demands by endogenous sources. This response is not suppressed by exogenous energy administration, and the early use of PN to reach the energy target leads to overfeeding. On the other hand, early and progressive enteral nutrition (EN) is less likely to cause overfeeding because of variable gastrointestinal tolerance, a factor frequently associated with significant energy deficit. Recent studies demonstrate that adequate feeding is beneficial during and after the intensive care unit (ICU) stay. Supplemental PN allows for timely adequate feeding, if sufficient precautions are taken to avoid overfeeding. Indirect calorimetry can precisely define the adequate energy prescription. Our pragmatic approach is to start early EN to progressively test the gut tolerance and add supplemental PN on day 3 or 4 after ICU admission, only if EN does not meet the measured energy target. We believe that supplemental PN plays a pivotal role in the achievement of adequate feeding in critically ill patients with intolerance to EN and does not cause harm if overfeeding is avoided by careful prescription, ideally based on energy expenditure measured by indirect calorimetry.
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Affiliation(s)
- Taku Oshima
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | | | - Claude Pichard
- Nutrition Unit, Geneva University Hospital, Geneva, Switzerland
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107
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Du Toit A. SASPEN Case Study: Nutritional management of a patient with an open abdomen. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2016. [DOI: 10.1080/16070658.2014.11734502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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108
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Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Crit Care Med 2016; 44:390-438. [PMID: 26771786 DOI: 10.1097/ccm.0000000000001525] [Citation(s) in RCA: 383] [Impact Index Per Article: 47.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Elke G, van Zanten ARH, Lemieux M, McCall M, Jeejeebhoy KN, Kott M, Jiang X, Day AG, Heyland DK. Enteral versus parenteral nutrition in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials. Crit Care 2016; 20:117. [PMID: 27129307 PMCID: PMC4851818 DOI: 10.1186/s13054-016-1298-1] [Citation(s) in RCA: 194] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 04/14/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Enteral nutrition (EN) is recommended as the preferred route for early nutrition therapy in critically ill adults over parenteral nutrition (PN). A recent large randomized controlled trial (RCT) showed no outcome differences between the two routes. The objective of this systematic review was to evaluate the effect of the route of nutrition (EN versus PN) on clinical outcomes of critically ill patients. METHODS An electronic search from 1980 to 2016 was performed identifying relevant RCTs. Individual trial data were abstracted and methodological quality of included trials scored independently by two reviewers. The primary outcome was overall mortality and secondary outcomes included infectious complications, length of stay (LOS) and mechanical ventilation. Subgroup analyses were performed to examine the treatment effect by dissimilar caloric intakes, year of publication and trial methodology. We performed a test of asymmetry to assess for the presence of publication bias. RESULTS A total of 18 RCTs studying 3347 patients met inclusion criteria. Median methodological score was 7 (range, 2-12). No effect on overall mortality was found (1.04, 95 % CI 0.82, 1.33, P = 0.75, heterogeneity I(2) = 11 %). EN compared to PN was associated with a significant reduction in infectious complications (RR 0.64, 95 % CI 0.48, 0.87, P = 0.004, I(2) = 47 %). This was more pronounced in the subgroup of RCTs where the PN group received significantly more calories (RR 0.55, 95 % CI 0.37, 0.82, P = 0.003, I(2) = 0 %), while no effect was seen in trials where EN and PN groups had a similar caloric intake (RR 0.94, 95 % CI 0.80, 1.10, P = 0.44, I(2) = 0 %; test for subgroup differences, P = 0.003). Year of publication and methodological quality did not influence these findings; however, a publication bias may be present as the test of asymmetry was significant (P = 0.003). EN was associated with significant reduction in ICU LOS (weighted mean difference [WMD] -0.80, 95 % CI -1.23, -0.37, P = 0.0003, I(2) = 0 %) while no significant differences in hospital LOS and mechanical ventilation were observed. CONCLUSIONS In critically ill patients, the use of EN as compared to PN has no effect on overall mortality but decreases infectious complications and ICU LOS. This may be explained by the benefit of reduced macronutrient intake rather than the enteral route itself.
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Affiliation(s)
- Gunnar Elke
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3 Haus 12, 24105, Kiel, Germany
| | - Arthur R H van Zanten
- Department of Intensive Care, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716, RP, Ede, The Netherlands
| | - Margot Lemieux
- Department of Critical Care Medicine, Queen's University and Clinical Evaluation Research Unit, Kingston General Hospital, Angada 4, K7L 2V7, Kingston, ON, Canada
| | - Michele McCall
- Medical/Surgical ICU, Specialized Complex Care, St Michael's Hospital, 30 Bond Street, Toronto, ON, Canada
| | - Khursheed N Jeejeebhoy
- Department of Nutritional Sciences, St Michael's Hospital, 30 Bond Street, Toronto, ON, Canada
| | - Matthias Kott
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3 Haus 12, 24105, Kiel, Germany
| | - Xuran Jiang
- Department of Critical Care Medicine, Queen's University and Clinical Evaluation Research Unit, Kingston General Hospital, Angada 4, K7L 2V7, Kingston, ON, Canada
| | - Andrew G Day
- Department of Critical Care Medicine, Queen's University and Clinical Evaluation Research Unit, Kingston General Hospital, Angada 4, K7L 2V7, Kingston, ON, Canada
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University and Clinical Evaluation Research Unit, Kingston General Hospital, Angada 4, K7L 2V7, Kingston, ON, Canada.
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111
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Klek S. Omega-3 Fatty Acids in Modern Parenteral Nutrition: A Review of the Current Evidence. J Clin Med 2016; 5:E34. [PMID: 26959070 PMCID: PMC4810105 DOI: 10.3390/jcm5030034] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 02/10/2016] [Accepted: 03/01/2016] [Indexed: 12/21/2022] Open
Abstract
Intravenous lipid emulsions are an essential component of parenteral nutrition regimens. Originally employed as an efficient non-glucose energy source to reduce the adverse effects of high glucose intake and provide essential fatty acids, lipid emulsions have assumed a larger therapeutic role due to research demonstrating the effects of omega-3 and omega-6 polyunsaturated fatty acids (PUFA) on key metabolic functions, including inflammatory and immune response, coagulation, and cell signaling. Indeed, emerging evidence suggests that the effects of omega-3 PUFA on inflammation and immune response result in meaningful therapeutic benefits in surgical, cancer, and critically ill patients as well as patients requiring long-term parenteral nutrition. The present review provides an overview of the mechanisms of action through which omega-3 and omega-6 PUFA modulate the immune-inflammatory response and summarizes the current body of evidence regarding the clinical and pharmacoeconomic benefits of intravenous n-3 fatty acid-containing lipid emulsions in patients requiring parenteral nutrition.
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Affiliation(s)
- Stanislaw Klek
- Stanley Dudrick's Memorial Hospital, General Surgery Unit, Skawina 32-050, Poland.
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112
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Must Our Malnourished Patients Eat Right or Die? Crit Care Med 2016; 43:2689-91. [PMID: 26575662 DOI: 10.1097/ccm.0000000000001338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Oshima T, Hiesmayr M, Pichard C. Parenteral nutrition in the ICU setting: need for a shift in utilization. Curr Opin Clin Nutr Metab Care 2016; 19:144-50. [PMID: 26828579 DOI: 10.1097/mco.0000000000000257] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW The difficulties to feed the patients adequately with enteral nutrition alone have drawn the attention of the clinicians toward the use of parenteral nutrition, although recommendations by the recent guidelines are conflicting. This review focuses on the intrinsic role of parenteral nutrition, its new indication, and modalities of use for the critically ill patients. RECENT FINDINGS A recent trial demonstrated that selecting either parenteral nutrition or enteral nutrition for early nutrition has no impact on clinical outcomes. However, it must be acknowledged that the risk of relative overfeeding is greater when using parenteral nutrition and the risk of underfeeding is greater when using enteral nutrition because of gastrointestinal intolerance. Both overfeeding and underfeeding in the critically ill patients are associated with deleterious outcomes. Thus, early and adequate feeding according to the specific energy needs can be recommended as the optimal feeding strategy. SUMMARY Parenteral nutrition can be used to substitute or supplement enteral nutrition, if adequately prescribed. Testing for enteral nutrition tolerance during 2-3 days after ICU admission provides the perfect timing to start parenteral nutrition, if needed. In case of absolute contraindication for enteral nutrition, consider starting parenteral nutrition carefully to avoid overfeeding.
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Affiliation(s)
- Taku Oshima
- aDepartment of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuou-ku, Chiba City, Chiba, Japan bDepartment of Anaesthesiology, General Intensive Care and Pain Control, Division of Cardiac, Thoracic, Vascular Anaesthesia and Intensive Care, Medical University Vienna, Vienna, Austria cNutrition Unit, Geneva University Hospital, Geneva, Switzerland
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McClave SA, DiBaise JK, Mullin GE, Martindale RG. ACG Clinical Guideline: Nutrition Therapy in the Adult Hospitalized Patient. Am J Gastroenterol 2016; 111:315-34; quiz 335. [PMID: 26952578 DOI: 10.1038/ajg.2016.28] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The value of nutrition therapy for the adult hospitalized patient is derived from the outcome benefits achieved by the delivery of early enteral feeding. Nutritional assessment should identify those patients at high nutritional risk, determined by both disease severity and nutritional status. For such patients if they are unable to maintain volitional intake, enteral access should be attained and enteral nutrition (EN) initiated within 24-48 h of admission. Orogastric or nasogastric feeding is most appropriate when starting EN, switching to post-pyloric or deep jejunal feeding only in those patients who are intolerant of gastric feeds or at high risk for aspiration. Percutaneous access should be used for those patients anticipated to require EN for >4 weeks. Patients receiving EN should be monitored for risk of aspiration, tolerance, and adequacy of feeding (determined by percent of goal calories and protein delivered). Intentional permissive underfeeding (and even trophic feeding) is appropriate temporarily for certain subsets of hospitalized patients. Although a standard polymeric formula should be used routinely in most patients, an immune-modulating formula (with arginine and fish oil) should be reserved for patients who have had major surgery in a surgical ICU setting. Adequacy of nutrition therapy is enhanced by establishing nurse-driven enteral feeding protocols, increasing delivery by volume-based or top-down feeding strategies, minimizing interruptions, and eliminating the practice of gastric residual volumes. Parenteral nutrition should be used in patients at high nutritional risk when EN is not feasible or after the first week of hospitalization if EN is not sufficient. Because of their knowledge base and skill set, the gastroenterologist endoscopist is an asset to the Nutrition Support Team and should participate in providing optimal nutrition therapy to the hospitalized adult patient.
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Affiliation(s)
- Stephen A McClave
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - John K DiBaise
- Department of Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Gerard E Mullin
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Robert G Martindale
- Department of Surgery, Oregon Health Sciences University, Portland, Oregon, USA
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Ginguay A, De Bandt JP, Cynober L. Indications and contraindications for infusing specific amino acids (leucine, glutamine, arginine, citrulline, and taurine) in critical illness. Curr Opin Clin Nutr Metab Care 2016; 19:161-9. [PMID: 26828584 DOI: 10.1097/mco.0000000000000255] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW The review assesses the utility of supplementing parenteral or enteral nutrition of ICU patients with each of five specific amino acids that display pharmacological properties. Specifying indications implies also stating contraindications.Combined supplementation of amino acids with ω3-fatty acids and/or trace elements (immune-enhancing diets) will not be considered in this review because these mixtures do not allow the role of amino acids in the effect (positive or negative) of the mixture to be isolated, and so cannot show whether or not supplementation of a given amino acid is indicated. RECENT FINDINGS After decades of unbridled use of glutamine (GLN) supplementation in critically ill patients, recent large trials have brought a note of caution, indicating for example that GLN should not be used in patients with multiple organ failure. Yet these large trials do not change the conclusions of recent meta-analyses. Arginine (ARG), as a single dietary supplement, is probably not harmful in critical illness, in particular in a situation of ARG deficiency syndrome with low nitric oxide production. Citrulline supplementation strongly improves microcirculation in animal models with gut injury, but clinical studies are lacking. Taurine has a potent protective effect against ischemic reperfusion injury. SUMMARY Amino acid-based pharmaconutrition has displayed familiar 'big project' stages: enthusiasm (citrulline and taurine), doubt (GLN), hunt for the guilty (ARG), and backpedalling (leucine). Progress in this field is very slow, and sometimes gives way to retreat, as demonstrated by recent large trials on GLN supplementation.
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Affiliation(s)
- Antonin Ginguay
- aService de Biochimie Générale et Spécialisée, Hôpitaux Cochin et Hôtel-Dieu, Groupement Hospitalier Hôpitaux Universitaires Paris-Centre (GH HUPC), AP-HP bLaboratoire de Biologie de la Nutrition, EA 4466 PRETRAM, Faculté de Pharmacie, Université Paris Descartes, Paris, France
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Abstract
Critically ill patients often require enteral feedings as a primary supply of nutrition. Whether enteral nutrition (EN) should be delivered as a gastric versus small bowel feeding in the critically ill patient population remains a contentious topic. The Society of Critical Care Medicine (SCCM)/American Society for Parenteral and Enteral Nutrition (ASPEN), the European Society for Parenteral and Enteral Nutrition (ESPEN), and the Canadian Clinical Practice Guidelines (CCPG) are not in consensus on this topic. No research to date demonstrates a significant difference between the two feeding routes in terms of patient mortality, ventilator days, or length of stay in the intensive care unit (ICU); however, studies provide some evidence that there may be other benefits to using a small bowel feeding route in critically ill patients. The purpose of this paper is to examine both sides of this debate and review advantages and disadvantages of both small bowel and gastric routes of EN. Practical issues and challenges to small bowel feeding tube placement are also addressed. Finally, recommendations are provided to help guide the clinician when selecting a feeding route, and suggestions are made for future research.
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Declercq B, Deane AM, Wang M, Chapman MJ, Heyland DK. Enhanced Protein-Energy Provision via the Enteral Route Feeding (PEPuP) protocol in critically ill surgical patients: a multicentre prospective evaluation. Anaesth Intensive Care 2016; 44:93-8. [PMID: 26673594 DOI: 10.1177/0310057x1604400114] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Suboptimal levels of feeding in critically ill patients are associated with poor clinical outcomes. The Enhanced Protein-Energy Provision via the Enteral Route Feeding (PEPuP) protocol was developed to improve nutritional delivery in the critically ill and has been studied in several hospitals. However, the experience with this protocol in surgical patients is limited to date. The objective of this analysis was to describe the experience with this protocol in surgical patients. We analysed observational patient data obtained from the 2013 International Nutrition Survey. We compared nutritional practices and outcomes of patients admitted for surgical and medical reasons to ICUs in sites that implemented the PEPuP protocol. We used surgical ICU patients in non-PEPuP sites as a concurrent control group. In sites that implemented the PEPuP protocol, surgical patients received a smaller proportion of prescribed calories (43% versus 61%, P=0.004) and protein (38% versus 57%, P=0.002) compared to medical patients. When compared to the cohort of surgical patients from control sites, the surgical patients from PEPuP sites received similar amounts of calories and protein. Although surgical PEPuP patients were more likely to receive trophic and volume-based feeds compared to surgical patients in control sites, other aspects of the PEPuP protocol were not adequately implemented. We conclude that nutritional delivery to surgical patients remains inadequate and the PEPuP protocol seems ineffective in improving nutritional intake in this population. Further research to determine methods of optimising PEPuP protocol implementation and adherence in surgery patients is needed.
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Affiliation(s)
- B Declercq
- Royal Adelaide Hospital, North Terrace, Adelaide, South Australia
| | - A M Deane
- Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia
| | - M Wang
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - M J Chapman
- Intensive Care Unit, Royal Adelaide Hospital, and Discipline of Acute Care Medicine, North Terrace, Adelaide, South Australia
| | - D K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
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Evaluation of the effect on patient parameters of not monitoring gastric residual volume in intensive care patients on a mechanical ventilator receiving enteral feeding: A randomized clinical trial. J Crit Care 2016; 33:137-44. [PMID: 26948254 DOI: 10.1016/j.jcrc.2016.01.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 12/13/2015] [Accepted: 01/31/2016] [Indexed: 01/15/2023]
Abstract
PURPOSE This study aimed to evaluate the effects of not measuring gastric residual volume (GRV) in intensive care patients on a mechanical ventilator and receiving enteral feeding on the feeding intolerance, gastroesophageal reflux (GER) risk, and nutritional adequacy. METHODS This randomized clinical study was performed in 2 medical intensive care units of 2 university hospitals in Ankara, Turkey. The patients were randomized into 2 groups. In the group with GRV monitoring, GRV was measured 3 times a day, and the GRV threshold was accepted as 250 mL. In addition, 24-hour pH monitoring was used in this group to assess the risk of GER. In the group without GRV monitoring, GRV was not measured. The patients were followed-up for 5 days. RESULTS The feeding targets were reached more quickly in the group without GRV monitoring (n = 26) with no increase in the complication rate (P < .05). No significant relationship was found between GRV and GER in the group with GRV monitoring (n = 25) (P > .05). CONCLUSION The discrepancies in GRV measurement make it unreliable for monitoring feeding intolerance and GER. The use of GRV measurements may therefore be discontinued as part of the standard care protocol in medical intensive care units.
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McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN J Parenter Enteral Nutr 2016. [DOI: 10.1177/0148607115621863 order by 1-- #] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
| | - Beth E. Taylor
- Nutrition Support Specialist, Barnes Jewish Hospital, St Louis, Missouri
| | - Robert G. Martindale
- Chief Division of General Surgery, Oregon Health and Science University, Portland, Oregon
| | - Malissa M. Warren
- Critical Care Dietitian, Portland VA Medical Center, Portland, Oregon
| | - Debbie R. Johnson
- Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Carol Braunschweig
- Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois
| | - Mary S. McCarthy
- Senior Nurse Scientist, Center for Nursing Science and Clinical Inquiry, Madigan Healthcare System, Tacoma, Washington
| | - Evangelia Davanos
- Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, New York
| | - Todd W. Rice
- Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gail A. Cresci
- Project Research Staff, Digestive Disease Institute, Gastroenterology and Pathobiology, Cleveland, Ohio
| | - Jane M. Gervasio
- Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Gordon S. Sacks
- Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Pamela R. Roberts
- Professor and Vice Chair, Division Chief of Critical Care Medicine, Director of Research John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, Oklahoma
| | - Charlene Compher
- Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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121
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McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN J Parenter Enteral Nutr 2016. [DOI: 10.1177/0148607115621863 and 1880=1880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
| | - Beth E. Taylor
- Nutrition Support Specialist, Barnes Jewish Hospital, St Louis, Missouri
| | - Robert G. Martindale
- Chief Division of General Surgery, Oregon Health and Science University, Portland, Oregon
| | - Malissa M. Warren
- Critical Care Dietitian, Portland VA Medical Center, Portland, Oregon
| | - Debbie R. Johnson
- Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Carol Braunschweig
- Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois
| | - Mary S. McCarthy
- Senior Nurse Scientist, Center for Nursing Science and Clinical Inquiry, Madigan Healthcare System, Tacoma, Washington
| | - Evangelia Davanos
- Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, New York
| | - Todd W. Rice
- Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gail A. Cresci
- Project Research Staff, Digestive Disease Institute, Gastroenterology and Pathobiology, Cleveland, Ohio
| | - Jane M. Gervasio
- Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Gordon S. Sacks
- Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Pamela R. Roberts
- Professor and Vice Chair, Division Chief of Critical Care Medicine, Director of Research John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, Oklahoma
| | - Charlene Compher
- Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2016; 40:159-211. [PMID: 26773077 DOI: 10.1177/0148607115621863] [Citation(s) in RCA: 1667] [Impact Index Per Article: 208.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Stephen A McClave
- Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Beth E Taylor
- Nutrition Support Specialist, Barnes Jewish Hospital, St Louis, Missouri
| | - Robert G Martindale
- Chief Division of General Surgery, Oregon Health and Science University, Portland, Oregon
| | - Malissa M Warren
- Critical Care Dietitian, Portland VA Medical Center, Portland, Oregon
| | - Debbie R Johnson
- Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Carol Braunschweig
- Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois
| | - Mary S McCarthy
- Senior Nurse Scientist, Center for Nursing Science and Clinical Inquiry, Madigan Healthcare System, Tacoma, Washington
| | - Evangelia Davanos
- Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, New York
| | - Todd W Rice
- Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gail A Cresci
- Project Research Staff, Digestive Disease Institute, Gastroenterology and Pathobiology, Cleveland, Ohio
| | - Jane M Gervasio
- Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Gordon S Sacks
- Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Pamela R Roberts
- Professor and Vice Chair, Division Chief of Critical Care Medicine, Director of Research John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, Oklahoma
| | - Charlene Compher
- Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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123
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McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN J Parenter Enteral Nutr 2016. [DOI: 10.1177/0148607115621863 order by 8029-- -] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
| | - Beth E. Taylor
- Nutrition Support Specialist, Barnes Jewish Hospital, St Louis, Missouri
| | - Robert G. Martindale
- Chief Division of General Surgery, Oregon Health and Science University, Portland, Oregon
| | - Malissa M. Warren
- Critical Care Dietitian, Portland VA Medical Center, Portland, Oregon
| | - Debbie R. Johnson
- Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Carol Braunschweig
- Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois
| | - Mary S. McCarthy
- Senior Nurse Scientist, Center for Nursing Science and Clinical Inquiry, Madigan Healthcare System, Tacoma, Washington
| | - Evangelia Davanos
- Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, New York
| | - Todd W. Rice
- Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gail A. Cresci
- Project Research Staff, Digestive Disease Institute, Gastroenterology and Pathobiology, Cleveland, Ohio
| | - Jane M. Gervasio
- Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Gordon S. Sacks
- Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Pamela R. Roberts
- Professor and Vice Chair, Division Chief of Critical Care Medicine, Director of Research John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, Oklahoma
| | - Charlene Compher
- Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN J Parenter Enteral Nutr 2016. [DOI: 10.1177/0148607115621863 order by 1-- gadu] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
| | - Beth E. Taylor
- Nutrition Support Specialist, Barnes Jewish Hospital, St Louis, Missouri
| | - Robert G. Martindale
- Chief Division of General Surgery, Oregon Health and Science University, Portland, Oregon
| | - Malissa M. Warren
- Critical Care Dietitian, Portland VA Medical Center, Portland, Oregon
| | - Debbie R. Johnson
- Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Carol Braunschweig
- Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois
| | - Mary S. McCarthy
- Senior Nurse Scientist, Center for Nursing Science and Clinical Inquiry, Madigan Healthcare System, Tacoma, Washington
| | - Evangelia Davanos
- Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, New York
| | - Todd W. Rice
- Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gail A. Cresci
- Project Research Staff, Digestive Disease Institute, Gastroenterology and Pathobiology, Cleveland, Ohio
| | - Jane M. Gervasio
- Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Gordon S. Sacks
- Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Pamela R. Roberts
- Professor and Vice Chair, Division Chief of Critical Care Medicine, Director of Research John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, Oklahoma
| | - Charlene Compher
- Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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125
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McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN J Parenter Enteral Nutr 2016. [DOI: 10.1177/0148607115621863 order by 8029-- #] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
| | - Beth E. Taylor
- Nutrition Support Specialist, Barnes Jewish Hospital, St Louis, Missouri
| | - Robert G. Martindale
- Chief Division of General Surgery, Oregon Health and Science University, Portland, Oregon
| | - Malissa M. Warren
- Critical Care Dietitian, Portland VA Medical Center, Portland, Oregon
| | - Debbie R. Johnson
- Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Carol Braunschweig
- Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois
| | - Mary S. McCarthy
- Senior Nurse Scientist, Center for Nursing Science and Clinical Inquiry, Madigan Healthcare System, Tacoma, Washington
| | - Evangelia Davanos
- Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, New York
| | - Todd W. Rice
- Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gail A. Cresci
- Project Research Staff, Digestive Disease Institute, Gastroenterology and Pathobiology, Cleveland, Ohio
| | - Jane M. Gervasio
- Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Gordon S. Sacks
- Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Pamela R. Roberts
- Professor and Vice Chair, Division Chief of Critical Care Medicine, Director of Research John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, Oklahoma
| | - Charlene Compher
- Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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126
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McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN J Parenter Enteral Nutr 2016. [DOI: 10.1177/0148607115621863 order by 1-- -] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
| | - Beth E. Taylor
- Nutrition Support Specialist, Barnes Jewish Hospital, St Louis, Missouri
| | - Robert G. Martindale
- Chief Division of General Surgery, Oregon Health and Science University, Portland, Oregon
| | - Malissa M. Warren
- Critical Care Dietitian, Portland VA Medical Center, Portland, Oregon
| | - Debbie R. Johnson
- Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Carol Braunschweig
- Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois
| | - Mary S. McCarthy
- Senior Nurse Scientist, Center for Nursing Science and Clinical Inquiry, Madigan Healthcare System, Tacoma, Washington
| | - Evangelia Davanos
- Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, New York
| | - Todd W. Rice
- Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gail A. Cresci
- Project Research Staff, Digestive Disease Institute, Gastroenterology and Pathobiology, Cleveland, Ohio
| | - Jane M. Gervasio
- Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Gordon S. Sacks
- Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Pamela R. Roberts
- Professor and Vice Chair, Division Chief of Critical Care Medicine, Director of Research John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, Oklahoma
| | - Charlene Compher
- Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN J Parenter Enteral Nutr 2016. [DOI: 10.1177/0148607115621863 order by 8029-- awyx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
| | - Beth E. Taylor
- Nutrition Support Specialist, Barnes Jewish Hospital, St Louis, Missouri
| | - Robert G. Martindale
- Chief Division of General Surgery, Oregon Health and Science University, Portland, Oregon
| | - Malissa M. Warren
- Critical Care Dietitian, Portland VA Medical Center, Portland, Oregon
| | - Debbie R. Johnson
- Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Carol Braunschweig
- Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois
| | - Mary S. McCarthy
- Senior Nurse Scientist, Center for Nursing Science and Clinical Inquiry, Madigan Healthcare System, Tacoma, Washington
| | - Evangelia Davanos
- Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, New York
| | - Todd W. Rice
- Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gail A. Cresci
- Project Research Staff, Digestive Disease Institute, Gastroenterology and Pathobiology, Cleveland, Ohio
| | - Jane M. Gervasio
- Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Gordon S. Sacks
- Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Pamela R. Roberts
- Professor and Vice Chair, Division Chief of Critical Care Medicine, Director of Research John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, Oklahoma
| | - Charlene Compher
- Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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128
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Japanese Guidelines for Nutrition Support Therapy in the Adult and Pediatric Critically Ill Patients. ACTA ACUST UNITED AC 2016. [DOI: 10.3918/jsicm.23.185] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Guo YN, Li H, Zhang PH. WITHDRAWN: Early enteral nutrition versus late enteral nutrition for burns patients: A systematic review and meta-analysis. Burns 2015:S0305-4179(15)00317-4. [PMID: 26708272 DOI: 10.1016/j.burns.2015.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 09/04/2015] [Accepted: 10/06/2015] [Indexed: 11/28/2022]
Abstract
This article has been withdrawn at the request of the authors. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
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Affiliation(s)
- Yi-Nan Guo
- Department of Burns & Plastic Surgery, Xiangya Hospital, Central South University, No. 87, Xiangya road, Changsha 410008, Hunan, China
| | - Hui Li
- Department of Burns & Plastic Surgery, Xiangya Hospital, Central South University, No. 87, Xiangya road, Changsha 410008, Hunan, China
| | - Pi-Hong Zhang
- Department of Burns & Plastic Surgery, Xiangya Hospital, Central South University, No. 87, Xiangya road, Changsha 410008, Hunan, China.
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130
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Oshima T, Pichard C. Parenteral nutrition: never say never. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19 Suppl 3:S5. [PMID: 26728859 PMCID: PMC4698923 DOI: 10.1186/cc14723] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
This review emphasizes the benefits of parenteral nutrition (PN) in critically ill patients, when prescribed for relevant indications, in adequate quantities, and in due time. Critically ill patients are at risk of energy deficit during their ICU stay, a condition which leads to unfavorable outcomes, due to hypercatabolism secondary to the stress response and the difficulty to optimize feeding. Indirect calorimetry is recommended to define the energy target, since no single predictive equation accurately estimates energy expenditure. Energy metabolism is intimately associated with protein metabolism. Recent evidence calls for adequate protein provision, but there is no accurate method to estimate the protein requirements, and recommendations are probably suboptimal. Enteral nutrition (EN) is the preferred route of feeding, but gastrointestinal intolerance limits its efficacy and PN allows for full coverage of energy needs. Seven recent articles concerning PN for critically ill patients were identified and carefully reviewed for the clinical and scientific relevance of their conclusions. One article addressed the unfavorable effects of early PN, although this result should be more correctly regarded as a consequence of glucose load and hypercaloric feeding. The six other articles were either in favor of PN or concluded that there was no difference in the outcome compared with EN. Hypercaloric feeding was not observed in these studies. Hypocaloric feeding led to unfavorable outcomes. This further demonstrates the beneficial effects of an early and adequate feeding with full EN, or in case of failure of EN with exclusive or supplemental PN. EN is the first choice for critically ill patients, but difficulties providing optimal nutrition through exclusive EN are frequently encountered. In cases of insufficient EN, individualized supplemental PN should be administered to reduce the infection rate and the duration of mechanical ventilation. PN is a safe therapeutic option as long as sufficient attention is given to avoid hypercaloric feeding.
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131
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Puiggròs C, Molinos R, Ortiz MD, Ribas M, Romero C, Vázquez C, Segurola H, Burgos R. Experience in Bedside Placement, Clinical Validity, and Cost-Efficacy of a Self-Propelled Nasojejunal Feeding Tube. Nutr Clin Pract 2015; 30:815-23. [PMID: 26214512 PMCID: PMC4708005 DOI: 10.1177/0884533615592954] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The procedures needed to insert nasojejunal tubes (NJTs) are often invasive or uncomfortable for the patient and require hospital resources. The objectives of this study were to describe our experience in inserting a self-propelling NJT with distal pigtail end and evaluate clinical validity and cost efficacy of this enteral nutrition (EN) approach compared with parenteral nutrition (PN). MATERIALS AND METHODS Prospective study from July 2009 to December 2010, including hospitalized noncritical patients who required short-term jejunal EN. The tubes were inserted at bedside, using intravenous erythromycin as a prokinetic drug. Positioning was considered correct when the distal end was beyond the ligament of Treitz. Migration failure was considered when the tube was not positioned into the jejunum within 48 hours postinsertion. RESULTS Fifty-six insertions were recorded in 47 patients, most frequently in severe acute pancreatitis (69.6%). The migration rates at 18 and 48 hours postinsertion were 73.2% and 82.1%, respectively. There was migration failure in 8.9% of cases, and 8.9% were classified null (the tube was no longer in the gastrointestinal tract at 18 hours). There were no reported or observed complications. The mean duration of the EN was 12 ± 10.8 days. Five different types of EN formula were used. The total study cost was 53.9% lower compared with using PN in all patients. CONCLUSIONS Our study demonstrated that bedside insertion of a self-propelling NJT is a safe, cost-effective, and successful technique for postpyloric enteral feeding in at least 73% of the patients, and only 18% of patients could eventually need other placement techniques. It can avoid the need for more aggressive or expensive placement techniques or even PN if we cannot achieve enteral access.
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Affiliation(s)
- Carolina Puiggròs
- Nutritional Support Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Rosa Molinos
- Nutritional Support Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - M Dolors Ortiz
- Nutritional Support Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Montserrat Ribas
- Nutritional Support Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Carlos Romero
- Nutritional Support Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Concepcion Vázquez
- Nutritional Support Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Hegoi Segurola
- Nutritional Support Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Rosa Burgos
- Nutritional Support Unit, Vall d'Hebron University Hospital, Barcelona, Spain
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Abstract
PURPOSE OF REVIEW Acute critical illness increases the risk of malnutrition, are more obese, and have multiple comorbidities and frequent pre-existing nutritional deficits. There is a vast amount of research and literature being written on nutritional practices in the critically ill. We review and discuss herein the important nutrition literature over the past 12 months. RECENT FINDINGS Sarcopenia, defined as loss of skeletal mass and strength, is associated with increased mortality and morbidity, particularly in elderly patients with trauma. Ultrasound is emerging as a noninvasive and promising method of measuring muscularity. Measuring gastric residuals and postpyloric feeding may not decrease rates of pneumonia in critically ill patients. Trophic and full feeding lead to similar long-term functional and cognitive outcomes in patients with acute respiratory distress syndrome. SUMMARY Nutrition and metabolic support of critically ill patients is a complex and diverse topic. Nutritional measurements, requirements, and modes and routes of delivery are currently being studied to determine the best way to treat these complicated patients. We present just a few of the current controversial topics in this fascinating arena.
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133
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Abstract
Background The physiological stress following major trauma in critical illness leads to rapid malnutrition and provision of optimal nutritional support in these circumstances can be challenging. Case report We present a complex trauma case where relatively aggressive nutritional support failed to minimise weight loss. Conclusion Nutritional support plays an integral role in the care of critically ill major trauma patients and needs to be continuously monitored in the subacute and rehabilitation phase.
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Affiliation(s)
- Emma Service
- Department of Dietetics, Addenbrooke’s Hospital, Cambridge, UK
| | - Fahim Anwar
- Department of Trauma Rehabilitation, Addenbrooke’s Hospital, Cambridge, UK
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134
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Kalaldeh MA, Shahin M. Implementing evidence-based enteral nutrition guidelines in intensive care units: a prospective observational study. ACTA ACUST UNITED AC 2015. [DOI: 10.12968/gasn.2015.13.9.31] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
| | - Mahmoud Shahin
- Assistant Professor, Faculty of Nursing, Al-Isra University, Jordan
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135
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Samra T, Banerjee N, Gupta A. Use of metabolic monitors in a multidisciplinary Intensive Care Unit: A prospective pilot study of 20 patients. Indian J Crit Care Med 2015; 19:531-6. [PMID: 26430340 PMCID: PMC4578198 DOI: 10.4103/0972-5229.164804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction: Caloric intake of critically ill patients are usually calculated using predictive equations. Recent advances in gas exchange measurements have the potential to estimate energy expenditure at the bedside and at different time periods. Materials and Methods: Energy needs of critically ill patients were estimated over a period of 3 months using simplistic formula of 25 kcal/kg/day estimated energy expenditure (EEE), Harris–Benedict equation (HBE) (Basal energy expenditure [BEE]) and M-COVX™ metabolic monitor resting energy expenditure (REE) on day 4 of Intensive Care Unit (ICU) admission. Calculations based on HBE were taken as standard, and percentage errors (PE) were calculated for each patient for values derived from simplistic formula and metabolic monitor. Adequacy of nutritional intake in ICU was also assessed. Results: Metabolic monitor could be used in only 20/70 patients. The mean age of patients was 40 years, 65% were males, and average body mass index was 23.69 kg/m2. Intermittent intolerance to feeds was reported in 50%. Values of REE and EEE were greater than BEE in 70% of patients. A significant difference was reported in values of PE of ≤20% and ≥30%; P = 0.0003 and 0.0001, respectively estimated using REE and EEE. Conclusions: It is not feasible to use metabolic monitors in all patients. Variability in readings is large and further studies are needed to establish the validity of its measurements. Calculations using simplistic formulas are much closer to values obtained using HBE.
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Affiliation(s)
- Tanvir Samra
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Neerja Banerjee
- Department of Anaesthesia and Intensive Care, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Arushi Gupta
- Department of Anaesthesia and Critical Care, Dr. Ram Manohar Lohia Hospital, New Delhi, India
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Braunschweig C, Sheean P, Peterson SJ, Perez SG, Freels S, Lateef O, Gurka D, Fantuzzi G. Response to Berger and Pichard and Heyland et al. JPEN J Parenter Enteral Nutr 2015; 39:144-5. [PMID: 25632059 DOI: 10.1177/0148607114542832] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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137
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Dickerson RN, Voss JR, Schroeppel TJ, Maish GO, Magnotti LJ, Minard G, Croce MA. Feasibility of jejunal enteral nutrition for patients with severe duodenal injuries. Nutrition 2015; 32:309-14. [PMID: 26704967 DOI: 10.1016/j.nut.2015.08.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/26/2015] [Accepted: 08/26/2015] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the feasibility of enteral nutrition (EN) for critically ill trauma patients with severe traumatic duodenal injuries who received placement of concurrent decompressing and feeding jejunostomies. METHODS Adult patients admitted to the trauma intensive care unit from January 2010 to December 2013, given concurrent afferent decompressing and efferent feeding jejunostomies for severe duodenal injury and provided EN or parenteral nutrition (PN), were retrospectively evaluated. Enteral feeding intolerance was defined as an increase in the decompressing jejunostomy drainage volume output, worsening abdominal distension, or cramping/pain unrelated to surgical incisions. Patients who failed initial EN were transitioned to PN. RESULTS Twenty-six patients were enrolled. Of the 24 patients given EN within the first 2 wk posthospitalization, 18 (75%) failed EN within 2 ± 2 d of initiating EN. EN was discontinued when increases were seen in decompressing jejunostomy drainage volume output (n = 11) and output with abdominal pain and/or distension (n = 6), or abdominal pain/distension was seen without an increase in output (n = 1). Jejunostomy drainage volume output increased from 474 ± 425 mL/d to 1168 ± 725 mL/d (P < 0.001) during EN intolerance. More patients with blunt intestinal injury than those with penetrating injuries (75% versus 15%, respectively; P = 0.035) tolerated EN. Patients initially given PN (n = 13) received more calories (P < 0.005) and protein (P < 0.001) than those given initial EN (n = 13). CONCLUSION The majority of patients with severe duodenal injuries and concurrent decompressing/feeding tube jejunostomies failed initial EN therapy.
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Affiliation(s)
- Roland N Dickerson
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN.
| | - Johnathan R Voss
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN
| | - Thomas J Schroeppel
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - George O Maish
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Louis J Magnotti
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Gayle Minard
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Martin A Croce
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
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138
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Lee ZY, Barakatun-Nisak MY, Noor Airini I, Heyland DK. Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients (PEP uP Protocol): A Review of Evidence. Nutr Clin Pract 2015; 31:68-79. [PMID: 26385874 DOI: 10.1177/0884533615601638] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Nutrition support is an integral part of care among critically ill patients. However, critically ill patients are commonly underfed, leading to consequences such as increased length of hospital and intensive care unit stay, time on mechanical ventilation, infectious complications, and mortality. Nevertheless, the prevalence of underfeeding has not resolved since the first description of this problem more than 15 years ago. This may be due to the traditional conservative feeding approaches. A novel feeding protocol (the Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients [PEP uP] protocol) was proposed and proven to improve feeding adequacy significantly. However, some of the components in the protocol are controversial and subject to debate. This article is a review of the supporting evidences and some of the controversy associated with each component of the PEP uP protocol.
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Affiliation(s)
- Zheng Yii Lee
- Department of Nutrition and Dietetic, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Mohd Yusof Barakatun-Nisak
- Department of Nutrition and Dietetic, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Ibrahim Noor Airini
- Anaesthesiology Unit, Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
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139
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Qiu C, Chen C, Zhang W, Kou Q, Wu S, Zhou L, Liu J, Ma G, Chen J, Chen M, Luo H, Zhang X, Lai J, Yu Z, Yu X, Liao W, Guan X, Ouyang B. Fat-Modified Enteral Formula Improves Feeding Tolerance in Critically Ill Patients: A Multicenter, Single-Blind, Randomized Controlled Trial. JPEN J Parenter Enteral Nutr 2015; 41:785-795. [PMID: 26350918 DOI: 10.1177/0148607115601858] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Improvement of fat digestion and absorption was supposed to relieve feeding intolerance. This trial aimed to evaluate the effect of a fat-modified enteral formula on feeding tolerance in critically ill patients. MATERIALS AND METHODS This trial was conducted in 7 hospitals in China. In total, 144 intensive care unit (ICU) patients with estimated need of enteral nutrition (EN) for at least 5 days were randomly given fat-modified enteral formula containing medium-chain triglycerides (MCT), carnitine, and taurine (interventional feed group, n = 71) or standard enteral formula (control feed group, n = 73). EN intake, feeding intolerance (diarrhea, vomiting, gastric retention, and abdominal distension) and outcomes (mechanical ventilator-free days of 28 days, length of ICU stay, length of hospital stay, and in-hospital mortality) were collected. RESULTS Daily calories and protein intake were increased in the interventional feed group compared with the control feed group ( P < .01). Total incidence of feeding intolerance was 42.3% in the interventional feed group and 65.7% in the control feed group ( P < .001). Daily incidence of feeding intolerance was 11.3%, 18.3%, 14.1%, 25.4%, and 26.1% in the interventional feed group and 31.5%, 32.9%, 34.2%, 34.2%, and 30.4% in the control feed group from study days 1-5 ( P = .0083). Incidence of feeding intolerance without abdominal distention was 32.9% in the interventional feed group and 49.3% in the control feed group ( P = .047), while the incidence of abdominal distension was 26.8% in the interventional feed group and 43.8% in the control feed group ( P = .03). No significant differences existed in outcomes between the 2 groups. CONCLUSIONS The fat-modified enteral formula containing MCT, carnitine, and taurine may improve feeding tolerance in critically ill patients.
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Affiliation(s)
- Chunfang Qiu
- 1 Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Chuanxi Chen
- 1 Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Weixing Zhang
- 2 Department of Intensive Care Unit, Peking University Shenzhen Hospital, Shenzhen, P.R. China
| | - Qiuye Kou
- 3 Department of Intensive Care Unit, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Shengnan Wu
- 4 Department of Gastrointestinal Surgery, Peking University Shenzhen Hospital, Shenzhen, P.R. China
| | - Lixin Zhou
- 5 Department of Intensive Care Unit, The First People's Hospital of Foshan, Foshan, P.R. China
| | - Jiyun Liu
- 6 Department of Intensive Care Unit, The First People's Hospital of Guangzhou, Guangzhou, P.R. China
| | - Gang Ma
- 7 Department of Intensive Care Unit, University Cancer Center, Guangzhou, P.R. China
| | - Juan Chen
- 1 Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Minying Chen
- 1 Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Hua Luo
- 2 Department of Intensive Care Unit, Peking University Shenzhen Hospital, Shenzhen, P.R. China
| | - Xiaofei Zhang
- 3 Department of Intensive Care Unit, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Jianbo Lai
- 4 Department of Gastrointestinal Surgery, Peking University Shenzhen Hospital, Shenzhen, P.R. China
| | - Zhihui Yu
- 5 Department of Intensive Care Unit, The First People's Hospital of Foshan, Foshan, P.R. China
| | - Xiaochun Yu
- 6 Department of Intensive Care Unit, The First People's Hospital of Guangzhou, Guangzhou, P.R. China
| | - Wei Liao
- 7 Department of Intensive Care Unit, University Cancer Center, Guangzhou, P.R. China
| | - Xiangdong Guan
- 1 Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Bin Ouyang
- 1 Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
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140
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Hooper MH, Marik PE. Controversies and Misconceptions in Intensive Care Unit Nutrition. Clin Chest Med 2015; 36:409-18. [DOI: 10.1016/j.ccm.2015.05.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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141
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Brown AM, Carpenter D, Keller G, Morgan S, Irving SY. Enteral Nutrition in the PICU: Current Status and Ongoing Challenges. J Pediatr Intensive Care 2015; 4:111-120. [PMID: 31110860 DOI: 10.1055/s-0035-1559806] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Malnutrition in the critically ill or injured child is associated with increased morbidities and mortality in the pediatric intensive care unit (PICU), whether present upon admission or acquired during the PICU stay. Particular subpopulations such as those with congenital heart disease or severe thermal injury are at highest risk for malnutrition which can worsen with illness progression. A growing body of evidence suggests the presence of a positive association between nutrition support during critical illness and patient outcomes. Enteral nutrition (EN), the preferred route of nutrient delivery, may be a crucial component of care provided in the PICU which modifies the response to critical illness or injury, resulting in improved outcomes. Numerous challenges exist in the delivery of the EN goal in critically ill children. These include accurate assessment of nutrient requirements, hemodynamic instability, feeding intolerance, feeding interruptions, and the lack of a standardized approach to nutrition support. This article describes the current state of the science and challenges related to EN prescription and delivery in the critically ill child. Suggestions for improving EN practice are then presented, in addition to a platform for further research inquiry.
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Affiliation(s)
- Ann-Marie Brown
- School of Nursing, The University of Akron, Akron, Ohio, United States.,Division of Critical Care, Akron Children's Hospital, Akron, Ohio, United States
| | - Debbie Carpenter
- Department of Food Service and Nutrition, Akron Children's Hospital, Akron, Ohio, United States
| | - Gerri Keller
- Department of Food Service and Nutrition, Akron Children's Hospital, Akron, Ohio, United States
| | - Sherry Morgan
- Biomedical Library, The University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Sharon Y Irving
- Department of Nursing, Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.,School of Nursing, The University of Pennsylvania, Philadelphia, Pennsylvania, United States
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142
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Li Z, Qi J, Zhao X, Lin Y, Zhao S, Zhang Z, Li X, Kissoon N. Risk-Benefit Profile of Gastric vs Transpyloric Feeding in Mechanically Ventilated Patients. Nutr Clin Pract 2015; 31:91-8. [PMID: 26260278 DOI: 10.1177/0884533615595593] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Zhuo Li
- Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Jirong Qi
- Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Xiaoke Zhao
- Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Yiqun Lin
- University of Calgary, Calgary, Alberta, Canada
| | - Shaodong Zhao
- Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Zendi Zhang
- Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Xiaonan Li
- Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Niranjan Kissoon
- The University of British Columbia and BC Children’s Hospital, Vancouver, British Columbia, Canada
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143
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Perry J, Stankorb SM, Salgueiro M. Author's Response to "Microbial Contamination of Enteral Nutrition Mixtures in a Hyperthermal Environment: A Follow-Up Investigation". Nutr Clin Pract 2015. [PMID: 26206954 DOI: 10.1177/0884533615586204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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145
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[Enteral nutrition therapy in critical care : Current knowledge, controversies, and practical implementation]. Med Klin Intensivmed Notfmed 2015; 111:330-40. [PMID: 26091922 DOI: 10.1007/s00063-015-0048-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 04/28/2015] [Accepted: 04/30/2015] [Indexed: 01/05/2023]
Abstract
Nutrition therapy is a cornerstone in critical care. Early enteral feeding in patients who are unable to meet caloric requirements from oral intake is associated with better clinical outcomes. However, there are still uncertainties about optimal timing, dose, and formula selection of enteral nutrition in critically ill patients. In the present article, an overview of current knowledge and practical strategies for successful implementation of enteral nutrition in intensive care patients is given.
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146
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Streefkerk JO, Beishuizen A, Groeneveld ABJ. Gastric feeding intolerance is not caused by mucosal ischemia measured by intragastric air tonometry in the critically ill. Clin Nutr 2015; 35:731-4. [PMID: 26082336 DOI: 10.1016/j.clnu.2015.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 05/09/2015] [Accepted: 05/22/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Gastric mucosal ischemia may be a risk factor for gastrointestinal intolerance to early feeding in the critically ill. AIMS To study intragastric PCO2 air tonometry and gastric residual volumes (GRV) before and after the start of gastric feeding. METHODS This is a two-center study in intensive care units of a university and teaching hospital. Twenty-nine critically ill, consecutive and consenting patients scheduled to start gastric feeding were studied after insertion of a gastric tonometry catheter and prior to and after start of gastric feeding (500 ml over 1 h), when clinically indicated. RESULTS Blood gasometry and intragastric tonometry were performed prior to and 2 h after gastric feeding. The intragastric to arterial PCO2 gap (normal <8 mm Hg) was elevated in 41% of patients prior to feeding and measured (mean ± standard deviation) 13 ± 20 and 16 ± 23 mm Hg in patients with normal (<100 ml, 42 ± 34 ml, n = 19) and elevated GRV (250 ± 141 ml, n = 10, P = 0.75), respectively. After feeding, the gradient did not increase and measured 27 ± 25 and 23 ± 34 mm Hg, respectively (P = 0.80). CONCLUSION Gastric mucosal ischemia is not a major risk factor for intolerance to early gastric feeding in the critically ill.
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Affiliation(s)
- Jörn O Streefkerk
- Department of Intensive Care Medisch Centrum Haaglanden and Bronovo Ziekenhuis, Den Haag, Rotterdam, The Netherlands
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147
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Lázaro-Martín NI, Catalán-González M, García-Fuentes C, Terceros-Almanza L, Montejo-González JC. Analysis of the nutritional management practices in intensive care: Identification of needs for improvement. Med Intensiva 2015; 39:530-6. [PMID: 26048410 DOI: 10.1016/j.medin.2015.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/27/2015] [Accepted: 04/27/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To analyze the nutritional management practices in Intensive Care (ICU) to detect the need for improvement actions. Re-evaluate the process after implementation of improvement actions. DESIGN Prospective observational study in 3 phases: 1) observation; 2) analysis, proposal development and dissemination; 3) analysis of the implementation. SETTING ICU of a hospital of high complexity. PARTICIPANTS Adult ICU forecast more than 48h of artificial nutrition. PRIMARY ENDPOINTS Parenteral nutrition (PN), enteral nutrition (EN) (type, average effective volume, complications) and average nutritional ratio. RESULTS A total of 229 patients (phase 1: 110, phase 3: 119). After analyzing the initial results, were proposed: increased use and precocity of EN, increased protein intake, nutritional monitoring effectiveness and increased supplementary indication NP. The measures were broadcast at specific meetings. During phase 3 more patients received EN (55.5 vs. 78.2%, P=.001), with no significant difference in the start time (1.66 vs. 2.33 days), duration (6.82 vs. 10,12 days) or complications (37,7 vs. 47,3%).Use of hyperproteic diets was higher in phase 3 (0 vs. 13.01%, P<.05). The use of NP was similar (48.2 vs. 48,7%) with a tendency to a later onset in phase 3 (1.25±1.25 vs. 2.45±3.22 days). There were no significant differences in the average nutritional ratio (0.56±0.28 vs. 0.61±0.27, P=.56). CONCLUSIONS The use of EN and the protein intake increased, without appreciating effects on other improvement measures. Other methods appear to be necessary for the proper implementation of improvement measures.
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Affiliation(s)
- N I Lázaro-Martín
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España.
| | - M Catalán-González
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
| | - C García-Fuentes
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
| | - L Terceros-Almanza
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
| | - J C Montejo-González
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
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148
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Affiliation(s)
- Suk-Kyung Hong
- Department of Surgery, University of Ulsan College of Medicine
- Division of Trauma and Surgical Critical Care, Department of Surgery, Asan Medical Center, Seoul, Korea
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149
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Tian F, Wang X, Gao X, Wan X, Wu C, Zhang L, Li N, Li J. Effect of initial calorie intake via enteral nutrition in critical illness: a meta-analysis of randomised controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:180. [PMID: 25927829 PMCID: PMC4434568 DOI: 10.1186/s13054-015-0902-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 03/30/2015] [Indexed: 01/07/2023]
Abstract
Introduction Guidelines support the use of enteral nutrition to improve clinical outcomes in critical illness; however, the optimal calorie and protein intake remains unclear. The purpose of this meta-analysis was to quantitatively analyze randomised controlled trials with regard to clinical outcomes related to varying calorie and protein administration in critically ill adult patients. Method We searched Medline, EMBASE, and Cochrane databases to identify randomised controlled trials that compared the effects of initially different calorie and protein intake in critical illness. The risk ratio (RR) and weighted mean difference with 95% confidence intervals (CI) were calculated using random-effects models. The primary endpoint was mortality; secondary endpoints included infection, pneumonia, gastrointestinal intolerance, hospital and intensive care unit lengths of stay, and mechanical ventilation days. Results In the eight randomised controlled trials that enrolled 1,895 patients there was no statistical difference between the low-energy and high-energy groups in mortality (RR, 0.90; 95% CI, 0.71 to 1.15; P = 0.40), infection (RR, 1.09; 95% CI, 0.92 to 1.29; P = 0.32), or the risk of gastrointestinal intolerance (RR, 0.84; 95% CI, 0.59 to 1.19; P = 0.33). In subgroup analysis, the low-energy subgroup, fed 33.3 to 66.6% of goal energy, showed a lower mortality than the high-energy group (RR, 0.68; 95% CI, 0.51 to 0.92; P = 0.01). The improvements in mortality and gastrointestinal intolerance were absent when calorie intake was >66.6% of goal energy in the low-energy group. High-energy intake combined with high-protein intake reduced the infections (RR, 1.25; 95% CI, 1.04 to 1.52; P = 0.02); however, when the daily protein intake was similar in both groups, a high-energy intake did not decrease the infections. No statistical differences were observed in other secondary outcomes. Conclusion This meta-analysis indicates that high-energy intake does not improve outcomes and may increase complications in critically ill patients who are not malnourished. Initial moderate nutrient intake (33.3 to 66.6% of goal energy), compared to high energy, may reduce mortality, and a higher protein intake combined with high energy (≥0.85 g/kg per day) may decrease the infection rate. However, the contribution of energy versus protein intake to outcomes remains unknown. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0902-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Feng Tian
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
| | - Xinying Wang
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
| | - Xuejin Gao
- Department of General Surgery, Jinling Hospital, South Medical University, Guangdong, China.
| | - Xiao Wan
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
| | - Chao Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
| | - Li Zhang
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
| | - Ning Li
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
| | - Jieshou Li
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
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150
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McDougall M. Nutritional support in the critically ill. ANAESTHESIA AND INTENSIVE CARE MEDICINE 2015. [DOI: 10.1016/j.mpaic.2015.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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