Nutrition of critically ill people

Nutritional awareness of critically ill surgical high-dependency patients

It has been recognized that malnutrition in hospital is a serious problem that may go undetected. There is growing evidence that early nutritional support in high-risk patients helps reduce postoperative complications; however, malnutrition is often diagnosed only once it is well established. This study showed that, both retrospectively and prospectively; there were no formal nutritional assessments of patients in a high-dependency unit (HDU), that time to feeding was generally within the recommended 5-7 day postoperative period, and that the most common form of supplementary feeding was total parenteral nutrition (TPN). Prospectively, the choice of supplementary feeding was dependent on the type of surgery and the individual patient's condition. Since this study was completed, a dietician has been allocated to the HDU and carries out formal nutritional assessments on a daily basis. Further research is required to assess the impact of the dietician on patient nutrition.

Malnutrition in critically ill patients in intensive care units

The provision of artificial nutrition for critically ill patients is of great importance as many are unable to maintain their own nutritional needs. The administration of total parenteral nutrition (TPN) and enteral nutrition (EN) has become a daily practice in intensive care units. Despite this, many patients remain undernourished or even malnourished and it is estimated that the incidence of malnutrition in intensive care patients could be as high as 50% (McCain, 1993). The reasons by which patients become or remain undernourished are multifactorial and range from physiological to iatrogenic. In order to lessen the catabolic state which results from the hypermetabolism associated with critical illness, prompt and adequate nutritional support must be delivered. It is essential that members of the multidisciplinary team caring for critically ill patients are aware of the importance of nutrition and the deleterious effects of malnutrition to achieve the best possible outcome for patients.

Physiological changes occurring with positive pressure ventilation: Part Two

Although the physiological effects of positive pressure ventilation are numerous, sometimes undesirable and have varying degrees of significance, positive pressure ventilation still plays a major role in the resuscitation and treatment of critically ill patients. Advances in the various methods of delivering positive pressure, especially when incorporating spontaneous breathing, have reduced the severity of complications. Despite serious complications, mechanical ventilation has advantages. When it is instituted for ventilatory and hypoxaemic respiratory failure, the benefits can be viewed in the context of the work of breathing. Spontaneous breathing normally requires 5% of total oxygen delivery to meet its demands. In lung disease, the ratio of oxygen consumption by the respiratory muscles to whole body oxygen consumption can increase to 25-30% (Henning 1986, Pinksy 1990). Mechanical ventilation reduces the energy demand of respiratory muscles and increases the oxygen delivery to other vital organs. When mechanical ventilation improves hypoxaemia and/or hypercarbia, or significantly decreases the work of breathing, it may also normalize associated changes in heart rate (Perel & Pizov 1991 p53). When cardiac output is increased in response to the increased work of breathing and associated stress, the institution of mechanical ventilation may beneficially lower the cardiac output simply due to the decrease in oxygen demand; thus the physiological reduction in cardiac output may not necessarily be regarded as a complication. The effects of raised intrathoracic pressure during mechanical ventilation may be beneficial when used to prevent or reduce pulmonary oedema, though problematic in some other situations. Mechanical ventilation is a life-saving treatment which has many associated complications; nurses have to accept the unavoidable hazards and adapt their nursing care to minimize their effects.

Nutrition and its importance to intensive care patients

The purpose in this paper is to consider the importance of early nutrition for critically ill patients, briefly reviewing the effects of malnutrition, and the metabolic response to starvation and sepsis. Discussion includes assessment of nutritional status and nutritional requirements, with a suggested enteral feeding regime; and also the combined effect of enteral nutrition and glutamine on gut integrity and its relevance to nosocomial pneumonia, and the ability of the gut to accept food during critical illness.

Preventing the ITU syndrome or how not to torture an ITU patient! Part 2

Admission to an intensive therapy unit (ITU) has been described as a 'necessary evil' (Barrie-Shevlin 1987), and some of the 'tortures' described in Part I of this article (Dyer 1995) may be an inevitable result of ITU care. This does not mean that the development of the ITU syndrome should be regarded as inevitable. Many potential causes of the syndrome can be avoided or at least ameliorated. Some suggested means of preventing the syndrome include designing ITUs with windows (Keep et al 1980), use of noise reducing materials when building ITUs (Hopkinson 1994, Topf & Davis 1993), using noise level as a criterion when purchasing equipment (Dracup 1988) or using remote telemetry for monitoring (Fisher & Moxham 1984). These would undoubtedly be beneficial but they are not practical propositions for nurses who wish to improve psychological care in the short term. For this reason, this article, concentrates mainly on immediately applicable, relatively cost-free interventions. Methods of preventing the syndrome should begin, whenever possible, before admission and should continue throughout the patients' stay. The main emphasis should be placed on prevention, but early detection and treatment of problems should also be given high priority. If a patient exhibits symptoms of psychological disturbance physical causes should be considered, but at the same time the ITU syndrome should be suspected and attempts made to alleviate possible causes of this. Nurses play a vital role in any attempts to alleviate problems and in 'humanising' the technical ITU environment (Ashworth 1987, Mackellaig 1990).(ABSTRACT TRUNCATED AT 250 WORDS)

Preventing the ITU syndrome or how not to torture an ITU patient! Part I

Staff working in intensive therapy units (ITUs) have known about the 'ITU syndrome' for many years. In spite of this the syndrome continues to occur. It is suggested that one of the reasons for this continued occurrence is that ITU staff place a lower priority on psychological care than they do on physical care. In this paper the potential seriousness of the ITU syndrome is emphasised by describing it as a form of torture. Publications from Amnesty International which describe methods of psychological torture are provided to support this suggestion. The analogies between psychological torture and ITU care are explored, and this is followed by consideration of ways of reducing the incidence of the syndrome and a suggested method of auditing an ITU in order to identify potential problem areas.