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Okawa Y. The Impact of Nutritional Therapy on Gastrointestinal Motility in Older Adults. Healthcare (Basel) 2023; 11:2829. [PMID: 37957974 PMCID: PMC10647505 DOI: 10.3390/healthcare11212829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Japan is becoming a superaged society, and nutrition therapy for the elderly population is very important. Elderly individuals often have multiple diseases and are prone to malnutrition. Furthermore, functional constipation, diarrhoea, faecal incontinence, etc., may occur despite no organic abnormality of digestive tract function. Due to these disabilities, the resulting malnutrition, and the slow recovery, it is often difficult for elderly individuals to reintegrate into society. Secondary or incorrect nutritional management increases complications, decreases physical function and worsens the prognosis. Previous statistical research suggests that in-hospital mortality is significantly higher among hospitalised patients aged ≥65 years who ingest less than half of their caloric needs. Therefore, appropriate nutritional management from an early stage is essential for elderly individuals. Moreover, functional excretion disorders, dementia, and sarcopenia (muscle-wasting disease) are attracting attention as pathological conditions unique to elderly individuals, and it is essential to undergo rehabilitation early with nutritional management. Being elderly does not preclude nutritional management, and it is necessary to reconsider appropriate nutritional therapy even in the terminal stage and in advanced physical and mental illnesses. This review explores the relationship between dietary intake and FGIDs, with a focus on elderly adults.
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Affiliation(s)
- Yohei Okawa
- Department of Psychosomatic Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-Machi, Aoba-Ku, Sendai 980-8575, Miyagi, Japan
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2
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Bechtold ML, Brown PM, Escuro A, Grenda B, Johnston T, Kozeniecki M, Limketkai BN, Nelson KK, Powers J, Ronan A, Schober N, Strang BJ, Swartz C, Turner J, Tweel L, Walker R, Epp L, Malone A. When is enteral nutrition indicated? JPEN J Parenter Enteral Nutr 2022; 46:1470-1496. [PMID: 35838308 DOI: 10.1002/jpen.2364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/07/2022]
Abstract
Enteral nutrition (EN) is a vital component of nutrition around the world. EN allows for delivery of nutrients to those who cannot maintain adequate nutrition by oral intake alone. Common questions regarding EN are when to initiate and in what scenarios it is safe. The answers to these questions are often complex and require an evidence-based approach. The Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) established an Enteral Nutrition Committtee to address the important questions surrounding the indications for EN. Consensus recommendations were established based on eight extremely clinically relevant questions regarding EN indications as deemed by the Enteral Nutrition Committee. These consensus recommendations may act as a guide for clinicians and stakeholders on difficult questions pertaining to indications for EN. This paper was approved by the ASPEN Board of Directors.
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Affiliation(s)
| | | | | | - Brandee Grenda
- Morrison Healthcare at Atrium Health Navicant, Charlotte, North Carolina, USA
| | - Theresa Johnston
- Nutrition Support Team, Christiana Care Health System, Newark, Delaware, USA
| | | | | | | | - Jan Powers
- Nursing Research and Professional Practice, Parkview Health System, Fort Wayne, Indiana, USA
| | - Andrea Ronan
- Fanconi Anemia Research Fund, Eugene, Oregon, USA
| | - Nathan Schober
- Cancer Treatment Centers of America - Atlanta, Newnan, Georgia, USA
| | | | - Cristina Swartz
- Northwestern Medicine Delnor Cancer Center, Chicago, Illinois, USA
| | - Justine Turner
- Department of Pediatrics, Division of Gastroenterology and Nutrition, University of Alberta, Edmonton, Canada
| | | | - Renee Walker
- Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, USA
| | - Lisa Epp
- Mayo Clinic, Rochester, Minnesota, USA
| | - Ainsley Malone
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
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3
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Pham CH, Fang M, Vrouwe SQ, Kuza CM, Yenikomshian HA, Gillenwater J. Evaluating the Safety and Efficacy of Intraoperative Enteral Nutrition in Critically Ill Burn Patients: A Systematic Review and Meta-analysis. J Burn Care Res 2020; 41:841-848. [PMID: 32147686 DOI: 10.1093/jbcr/iraa036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Major burn injuries incite a hypermetabolic response, and the initiation of early enteral nutrition is the standard of care in patients with large burns and contributes to improved outcomes. Perioperative fasting is a common cause of caloric deficits in burn patients and can be obviated with intraoperative enteral nutrition. However, the risks and benefits of this practice are unknown, and there is a concern for aspiration. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of intraoperative enteral nutrition. We performed a systematic literature search using PubMed, Scopus, and OvidSP MEDLINE databases. We identified studies that evaluated the effects of intraoperative enteral nutrition in adult burn patients compared to those undergoing routine perioperative fasting. We performed a meta-analysis on the incidence of mortality, pneumonia, wound infections, and aspiration in burn patients receiving intraoperative enteral nutrition. We identified seven articles for qualitative review and four for quantitative review (N = 83 patients). There were no statistically significant increases in the risk of mortality (odds ratio [OR] = 1.28, 95% confidence interval [CI]: 0.49, 3.31), wound infections (OR = 0.71, 95% CI: 0.16, 3.24), pneumonia (OR = 2.1, 95% CI: 0.7, 6.1), and aspiration (OR = 1.14, 95% CI: 0.07, 18.75) in patients receiving intraoperative enteral nutrition. Within individual studies, intraoperative enteral nutrition patients received significantly more calories than standard fasting patients. Intraoperative enteral nutrition may increase nutritional intake in burn patients without an increase in complications; however, this is based on limited studies. Randomized controlled trials are needed before recommendations on intraoperative enteral nutrition practice can be made.
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Affiliation(s)
- Christopher H Pham
- Division of Plastic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Mike Fang
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Sebastian Q Vrouwe
- Division of Plastic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Catherine M Kuza
- Department of Anesthesiology and Critical Care, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Haig A Yenikomshian
- Division of Plastic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Justin Gillenwater
- Division of Plastic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Wise AK, Hromatka KA, Miller KR. Energy Expenditure and Protein Requirements Following Burn Injury. Nutr Clin Pract 2019; 34:673-680. [PMID: 31418486 DOI: 10.1002/ncp.10390] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Severe burn injuries have long been known to have a profound effect on metabolic equilibrium that can persist after resolution of the cutaneous injuries. Following burn injury, metabolism is a dynamic state resulting in the need for frequent interval reassessment over the course of the care continuum. The acute phase of injury transitions to chronic alterations in macronutrient utilization characterized by futile energy cycling and disproportionate catabolism of skeletal muscle. Protein supplementation appears to be preferentially distributed to the burn wound rather than the skeletal muscle pool. Accurate assessment of caloric and protein requirements is extremely difficult in these patients but is an essential step in efforts to attenuate functional impairment. Indirect calorimetry should be utilized to determine caloric requirements, but trophic feeding strategies are preferred in the initial resuscitative phase to prevent overfeeding while maintaining enteric and immune function. Controversy persists regarding optimal protein targets, and weight-based estimates remain the norm. Exogenous protein and caloric provision performed in isolation is insufficient to optimize outcomes and should be incorporated within a multidisciplinary approach to include muscle loading and pharmaceutical adjuncts.
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Affiliation(s)
- Amy K Wise
- Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | | | - Keith R Miller
- Department of Surgery, University of Louisville, Louisville, Kentucky, USA
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Tseng YC, Chen BC, Chen CT, Chou YC, Dai NT, Chen PJ, Huang TY, Shih YL, Chang WK, Hsieh TY, Lin JC. Early Initiation of Post-Pyloric Feeding in Patients with Major Burns: Experience in Taiwan Formosa Water Park Dust Explosion Disaster. TOHOKU J EXP MED 2019; 247:111-118. [PMID: 30787234 DOI: 10.1620/tjem.247.111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Early initiation of enteral nutrition improves clinical outcomes in critical patients with serious burns. Post-pyloric tube feeding is a valuable therapeutic option for severely burned patients with poor gastric emptying. How early post-pyloric feeding can be initiated to provide more benefits to patients has not yet been examined. A fire erupted at a recreational water park in New Taipei City, Taiwan, on June 27, 2015. The results of early initiation versus delayed post-pyloric feeding in severely burned patients in this mass-casualty incident were compared. Door-to-post-pyloric feeding time ≤ 24 h was considered as early post-pyloric feeding (EPF) and that > 24 h was considered as delayed post-pyloric feeding (DPF). Thirteen patients with severe burn injuries (> 40% of the total body surface area) were assigned to undergo either EPF (five patients) or DPF (eight patients). This study is a "fortuitously controlled" study, and the authors were able to formulate and test whether EPF is better than DPF by comparing the two groups. In patients in the EPF, the intake of calories increased rapidly and was maintained throughout the study period. In addition, rapid restoration of plasma magnesium concentrations as well as pronounced recovery of platelet count in the EPF group was observed. In conclusion, our findings indicate that the time from injury to the onset of post-pyloric feeding is crucial, and EPF allows for the administration of calculated caloric needs. Therefore, EPF can be successfully initiated with beneficial outcomes of nutritional reconstruction in severely burned patients.
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Affiliation(s)
- Yu-Chen Tseng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center
| | - Bao-Chung Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center
| | - Chun-Ting Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center
| | - Yu-Ching Chou
- School of Public Health, National Defense Medical Center
| | - Niann-Tzyy Dai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center
| | - Peng-Jen Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center
| | - Tien-Yu Huang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center
| | - Yu-Lueng Shih
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center
| | - Wei-Kuo Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center
| | - Tsai-Yuan Hsieh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center
| | - Jung-Chun Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center
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Pham CH, Collier ZJ, Garner WL, Kuza CM, Gillenwater TJ. Measuring gastric residual volumes in critically ill burn patients - A systematic review. Burns 2018; 45:509-525. [PMID: 29914737 DOI: 10.1016/j.burns.2018.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 03/22/2018] [Accepted: 05/17/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE Measuring gastric residual volumes (GRV) is common in intensive care units (ICU) in patients receiving enteral nutrition (EN) and are a common source of feeding interruptions. Interruptions in EN yield adverse outcomes and are an area of improvement in burn care. The objectives of this study are to summarize the literature's ICU GRV practices and offer practical suggestions to GRV management in the burn patient. METHODS PubMed, SCOPUS, and OvidSP Medline were systematically reviewed using the keywords: burns; thermal injury; gastric residual volume; enteral feeding; tube feeding; enteral nutrition; gastric intolerance; ICU; critical illness. Reviews, case reports, and consensus and opinion papers were excluded. RESULTS 26 articles were identified. Six burn-specific studies were identified. GRV practices vary widely and are a common cause of EN interruption. Elevated GRVs do not equate to gastrointestinal intolerance and do not always reflect aspiration risk. CONCLUSIONS We advocate a GRV threshold of 500mL should be used to optimize the benefits of EN in burn ICUs. A single incident of elevated GRVs should not mandate immediate EN rate reduction or cessation but should prompt a thoughtful examination of secondary causes of gastrointestinal intolerance. Randomized controlled trials are needed to define the ideal GRV threshold and re-evaluate its role in burn care.
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Affiliation(s)
- C H Pham
- Keck School of Medicine, University of Southern California, 1975 Zonal Avenue, Los Angeles, CA 90033, United States
| | - Z J Collier
- Division of Plastic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Suite 415, Los Angeles, CA 90033, United States
| | - W L Garner
- Keck School of Medicine, University of Southern California, 1975 Zonal Avenue, Los Angeles, CA 90033, United States; Division of Plastic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Suite 415, Los Angeles, CA 90033, United States
| | - C M Kuza
- Keck School of Medicine, University of Southern California, 1975 Zonal Avenue, Los Angeles, CA 90033, United States; Department of Anesthesiology and Critical Care, Keck School of Medicine, University of Southern California, 1520 San Pablo St, Suite 3451, Los Angeles, CA 90033, United States
| | - T J Gillenwater
- Keck School of Medicine, University of Southern California, 1975 Zonal Avenue, Los Angeles, CA 90033, United States; Division of Plastic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Suite 415, Los Angeles, CA 90033, United States.
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7
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Abstract
Most doctors in Britain receive some training in the care of the burned patient, if not as an undergraduate then as part of training in accident and emergency medicine or in the Advanced Trauma Life Support (ATLS®) course. Because major burn injury presents infrequently to the average district hospital, most of this training is rusty by the time it is needed. Further, most have little opportunity to catch up with developments in this very specialized area of trauma medicine. This paper aims to address some of these shortcomings by describing recent advances in burn care and highlighting areas of current debate. The fluids used for resuscitation, improved options for treatment, the status of ongoing discussions about treatment facilities and the state of the art in managing smoke inhalation are reviewed. Some pointers to the future and to avenues for research are suggested.
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Affiliation(s)
- Keith Judkins
- Pinderfields Burn Centre, Pinderfields and Pontefract Hospitals NHS Trust, Wakefield, UK, ,
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8
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Abstract
Malnutrition in hospitalised patients has a significant and disadvantageous impact on treatment outcome. If possible, enteral nutrition with an energy/protein-balanced nutrient should be preferred depending on the patient's condition, type of illness and risk factors. The aim of the nutrition therapy is to increase the efficacy of treatment and shorten the length of hospital stay in order to ensure rapid rehabilitation. In the present review the authors summarize the most important clinical and practical aspects of enteral nutrition therapy.
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Affiliation(s)
- Judit Hallay
- Debreceni Egyetem, Általános Orvostudományi Kar Aneszteziológiai és Intenzív Terápiás Tanszék Debrecen
| | - Dániel Nagy
- Debreceni Egyetem, Általános Orvostudományi Kar Aneszteziológiai és Intenzív Terápiás Tanszék Debrecen
| | - Béla Fülesdi
- Debreceni Egyetem, Általános Orvostudományi Kar Aneszteziológiai és Intenzív Terápiás Tanszék Debrecen
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Askegard-Giesmann JR, Kenney BD. Controversies in nutritional support for critically ill children. Semin Pediatr Surg 2015; 24:20-4. [PMID: 25639806 DOI: 10.1053/j.sempedsurg.2014.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Nutritional support for critically ill infants and children is of paramount importance and can greatly affect the outcome of these patients. The energy requirement of children is unique to their size, gestational age, and physiologic stress, and the treatment algorithms developed in adult intensive care units cannot easily be applied to pediatric patients. This article reviews some of the ongoing controversial topics of fluid, electrolyte, and nutritional support for critically ill pediatric patients focusing on glycemic control and dysnatremia. The use of enteral and parenteral nutrition as well as parenteral nutritional-associated cholestasis will also be discussed.
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Affiliation(s)
- Johanna R Askegard-Giesmann
- Division of Pediatric Surgery, Riley Hospital for Children, Indiana University, 705 Riley Hospital Dr, Room 2500, Indianapolis, Indiana 46202.
| | - Brian D Kenney
- Division of Pediatric Surgery, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio
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10
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Shields BA, Brown JN, Aden JK, Salgueiro M, Mann-Salinas EA, Chung KK. A pilot review of gradual versus goal re-initiation of enteral nutrition after burn surgery in the hemodynamically stable patient. Burns 2014; 40:1587-92. [DOI: 10.1016/j.burns.2014.02.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 02/14/2014] [Accepted: 02/16/2014] [Indexed: 11/17/2022]
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11
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Yang S, Wu X, Yu W, Li J. Early enteral nutrition in critically ill patients with hemodynamic instability: an evidence-based review and practical advice. Nutr Clin Pract 2014; 29:90-6. [PMID: 24449685 DOI: 10.1177/0884533613516167] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Early enteral nutrition (EEN) in critically ill patients is associated with significant benefit as well as elevated risk of complications. Concomitant use of EEN with vasopressors has been associated with nonocclusive bowel necrosis in critically ill patients with hemodynamic instability. The decision when to initiate enteral nutrition in hemodynamically unstable patients that require vasoactive substances remains a clinical dilemma. This review summarizes the effect of EEN and vasoactive agents on gastrointestinal blood flow and perfusion in critically ill patients, based on current evidence. Animal and clinical data involving simultaneous administration of EEN and vasoactive agents for hemodynamic instability are reviewed, and the factors related to the safety and effectiveness of EEN support in this patient population are analyzed. Moreover, practical recommendations are provided. Additional randomized clinical trials are warranted to provide cutting-edge evidence-based guidance about this issue for practitioners of critical care.
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Affiliation(s)
- Shuofei Yang
- Wenkui Yu, Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing 210002, Jiangsu Province, People's Republic of China, Nanjing, 210002, China.
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12
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Berger MM, Que YA. A protocol guided by transpulmonary thermodilution and lactate levels for resuscitation of patients with severe burns. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:195. [PMID: 24229466 PMCID: PMC4059376 DOI: 10.1186/cc13101] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Over-resuscitation is deleterious in many critically ill conditions, including major burns. For more than 15 years, several strategies to reduce fluid administration in burns during the initial resuscitation phase have been proposed, but no single or simple parameter has shown superiority. Fluid administration guided by invasive hemodynamic parameters usually resulted in over-resuscitation. As reported in the previous issue of Critical Care, Sánchez-Sánchez and colleagues analyzed the performance of a 'permissive hypovolemia' protocol guided by invasive hemodynamic parameters (PiCCO, Pulsion Medical Systems, Munich, Germany) and vital signs in a prospective cohort over a 3-year period. The authors' results confirm that resuscitation can be achieved with below-normal levels of preload but at the price of a fluid administration greater than predicted by the Parkland formula (2 to 4 mL/kg per% burn). The classic approach based on an adapted Parkland equation may still be the simplest until further studies identify the optimal bundle of resuscitation goals.
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13
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Rodriguez NA, Jeschke MG, Williams FN, Kamolz LP, Herndon DN. Nutrition in burns: Galveston contributions. JPEN J Parenter Enteral Nutr 2011; 35:704-14. [PMID: 21975669 PMCID: PMC3778650 DOI: 10.1177/0148607111417446] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Aggressive nutrition support is recommended following severe burn injury. Initially, such injury results in a prolonged and persistent hypermetabolic response mediated by a 10- to 20-fold elevation in plasma catecholamines, cortisol, and inflammatory mediators. This response leads to twice-normal metabolic rates, whole-body catabolism, muscle wasting, and severe cachexia. Thus, it is relevant to review the literature on nutrition in burns to adjust/update treatment. Failure to meet the increased substrate requirements may result in impaired wound healing, multiorgan dysfunction, increased susceptibility to infection, and death. Therefore, aggressive nutrition support is essential to ensure adequate burn care, attenuate the hypermetabolic response, optimize wound healing, minimize devastating catabolism, and reduce morbidity and mortality. Here, the authors provide nutrition recommendations gained from prospective trials, retrospective analyses, and expert opinions based on the authors' practices in Galveston, Texas, and Vienna, Austria.
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Affiliation(s)
- Noe A. Rodriguez
- Department of Surgery, The University of Texas Medical Branch and Shriners Hospitals for Children–Galveston, Galveston, Texas
| | - Marc G. Jeschke
- Department of Surgery, The University of Texas Medical Branch and Shriners Hospitals for Children–Galveston, Galveston, Texas
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Felicia N. Williams
- Department of Surgery, The University of Texas Medical Branch and Shriners Hospitals for Children–Galveston, Galveston, Texas
| | - Lars-Peter Kamolz
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - David N. Herndon
- Department of Surgery, The University of Texas Medical Branch and Shriners Hospitals for Children–Galveston, Galveston, Texas
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14
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Gupta P, Tobias JD, Goyal S, Kuperstock JE, Hashmi SF, Shin J, Hartnick CJ, Noviski N. Perioperative care following complex laryngotracheal reconstruction in infants and children. Saudi J Anaesth 2011; 4:186-96. [PMID: 21189858 PMCID: PMC2980667 DOI: 10.4103/1658-354x.71577] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Laryngotracheal reconstruction (LTR) involves surgical correction of a stenotic airway with cartilage interpositional grafting, followed by either placement of a tracheostomy and an intraluminal stent (two-stage LTR) or placement of an endotracheal tube with postoperative sedation and mechanical ventilation for an extended period of time (singlestage LTR). With single-stage repair, there may be several perioperative challenges including the provision of adequate sedation, avoidance of the development of tolerance to sedative and analgesia agents, the need to use neuromuscular blocking agents, the maintenance of adequate pulmonary toilet to avoid perioperative nosocomial infections, and optimization of postoperative respiratory function to facilitate successful tracheal extubation. We review the perioperative management of these patients, discuss the challenges during the postoperative period, and propose recommendations for the prevention of reversible causes of extubation failure in this article. Optimization to ensure a timely tracheal extubation and successful weaning of mechanical ventilator, remains the primary key to success in these surgeries as extubation failure or the need for prolonged postoperative mechanical ventilation can lead to failure of the graft site, the need for prolonged Pediatric Intensive Care Unit care, and in some cases, the need for a tracheostomy to maintain an adequate airway.
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Affiliation(s)
- Punkaj Gupta
- Division of Pediatric Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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15
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Lu G, Huang J, Yu J, Zhu Y, Cai L, Gu Z, Su Q. Influence of early post-burn enteral nutrition on clinical outcomes of patients with extensive burns. J Clin Biochem Nutr 2011; 48:222-5. [PMID: 21562642 PMCID: PMC3082077 DOI: 10.3164/jcbn.10-91] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Accepted: 09/04/2010] [Indexed: 01/15/2023] Open
Abstract
Sepsis commonly occurs in severe post-burn patients, often resulting in death. We aimed to evaluate the influence of early enteral feeding on outcomes in patients with extensive burns, including infection incidence, healing and mortality. We retrospectively reviewed 60 patients with extensive burns, 35 who had received early enteral nutrition and 25 who had received parenteral nutrition. Average healing time, infection incidence and mortality were clinically observed. Hemoglobin and serum albumin were monitored weekly in both groups during treatment. Causative organisms were identified in patients with sepsis. Infection incidence was significantly less in the enteral nutrition group than the parenteral nutrition group (17.1% vs 44.0%; p = 0.023); and latency duration was longer in the enteral nutrition group than in the parenteral nutrition group (30.5 ± 4.7 days vs 14.5 ± 2.3 days; p<0.001). Duration of antibiotic therapy of the enteral nutrition group was significantly shorter than that of the parenteral nutrition group (12.5 ± 3.0 days vs 19.8 ± 3.6 days; p<0.001). Mean hemoglobin results (10.1 ± 1.3 g/L vs 8.3 ± 1.5 g/L; p<0.001) and serum albumin results (44.7 ± 5.7 g/L vs 36.2 ± 6.9 g/L; p<0.001) of enteral nutrition and parenteral nutrition groups, respectively, provided an overview of systemic nutrition and protein metabolism, suggesting higher systemic nutrition and protein synthesis in enteral nutrition group than in parenteral nutrition group. Risk of post-burn infection is reduced in burn patients who are supported by earliest possible enteral nutrition.
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Affiliation(s)
- Guozhong Lu
- Department of Burn and Plastic Surgery, The Third People’s Hospital Affiliated, School of Medicine, Nantong University, Wuxi, Jiangsu 214041, China
| | - Jiren Huang
- Department of Burn and Plastic Surgery, The Third People’s Hospital Affiliated, School of Medicine, Nantong University, Wuxi, Jiangsu 214041, China
| | - Junjie Yu
- Department of Burn and Plastic Surgery, The Third People’s Hospital Affiliated, School of Medicine, Nantong University, Wuxi, Jiangsu 214041, China
| | - Yugang Zhu
- Department of Burn and Plastic Surgery, The Third People’s Hospital Affiliated, School of Medicine, Nantong University, Wuxi, Jiangsu 214041, China
| | - Liangliang Cai
- Department of Burn and Plastic Surgery, The Third People’s Hospital Affiliated, School of Medicine, Nantong University, Wuxi, Jiangsu 214041, China
| | - Zaiqiu Gu
- Department of Burn and Plastic Surgery, The Third People’s Hospital Affiliated, School of Medicine, Nantong University, Wuxi, Jiangsu 214041, China
| | - Qinghe Su
- Department of Burn and Plastic Surgery, The Third People’s Hospital Affiliated, School of Medicine, Nantong University, Wuxi, Jiangsu 214041, China
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16
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[Estimation of substitution volume after burn trauma. Systematic review of published formulae]. Anaesthesist 2011; 60:303-11. [PMID: 21448736 DOI: 10.1007/s00101-011-1849-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Revised: 12/28/2010] [Accepted: 01/03/2011] [Indexed: 12/26/2022]
Abstract
BACKGROUND Fluid resuscitation after severe burns remains a challenging task particularly in the preclinical and early clinical phases. To facilitate volume substitution after burn trauma several formulae have been published and evaluated, nevertheless, the optimal formula has not yet been identified. METHODS A systematic PubMed search was performed to identify published formulae for fluid resuscitation after severe burns. The search terms "burn", "thermal", "treatment", "therapy" or "resuscitation", "fluid", "formula" and "adult", "pediatric" or "paediatric" were used in various combinations. Analysis was limited to the period from 01.01.1950 to 30.06.2010 and database entries in PubMed (http://www.pubmed.com). Additionally, references cited in the papers were analyzed and relevant publications were also included. Publications and formulae were assessed and classified by two independent investigators. RESULTS Within the specified time frame eight publications (five original contributions and three book chapters) were identified of which three formulae recommended colloid solutions, four recommended electrolyte solutions and one suggested hypertonic solutions within the first 24 h for fluid resuscitation. Only one formula specifically dealt with fluid resuscitation in infants. CONCLUSION The identified formulae led to sometimes strikingly diverse calculations of resuscitation fluid volumes. Therefore their use should be monitored closely and clinical values included. Urine output is a well established individual parameter. Use of colloid and hypertonic solutions leads to a reduced total fluid volume but is still controversially discussed.
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Gatt M, MacFie J. Randomized clinical trial of gut-specific nutrients in critically ill surgical patients. Br J Surg 2010; 97:1629-36. [DOI: 10.1002/bjs.7155] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Inadequate gut function is common and may adversely affect prognosis. However, it is difficult to measure and treatment options are limited. This study evaluated whether gut-specific nutrients (GSNs) could stimulate the return of gut function in critically ill patients, and assessed what effect, if any, this would have on patient outcomes.
Methods
Consecutive critically ill patients intolerant to enteral feeding were randomized to receive a cocktail of GSNs or placebo. Administration was for 1 month and patients were followed for 3 months. The primary endpoint was the time to return of normal gut function.
Results
Twenty-five patients were randomized to each group. GSN administration was associated with a quicker return of normal gut function (median 164 versus 214 h; P = 0·016), attenuation of the acute-phase response and a lower incidence of sepsis (4 versus 13 patients, P = 0·015) compared with placebo. There were fewer deaths by 3 months in the GSN group but this did not achieve significance (2 versus 7 deaths; P = 0·138).
Conclusion
GSNs expedite the return of gut function in the critically ill and improve outcomes. Inadequate gut function may be associated with poor prognosis similar to that of other single organ failures. Registration number: ISRCTN61157513 (http://www.controlled-trials.com).
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Affiliation(s)
- M Gatt
- Combined Gastroenterology Research Unit, Scarborough Hospital, Scarborough, UK
| | - J MacFie
- Combined Gastroenterology Research Unit, Scarborough Hospital, Scarborough, UK
- Postgraduate Medical Institute, University of Hull, Hull, UK
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Mehta NM, McAleer D, Hamilton S, Naples E, Leavitt K, Mitchell P, Duggan C. Challenges to optimal enteral nutrition in a multidisciplinary pediatric intensive care unit. JPEN J Parenter Enteral Nutr 2009; 34:38-45. [PMID: 19903872 DOI: 10.1177/0148607109348065] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To describe nutrient intake in critically ill children, identify risk factors associated with avoidable interruptions to enteral nutrition (EN), and highlight opportunities to improve enteral nutrient delivery in a busy tertiary pediatric intensive care unit (PICU). Design, Setting, and Measurements: Daily nutrient intake and factors responsible for avoidable interruptions to EN were recorded in patients admitted to a 29-bed medical and surgical PICU over 4 weeks. Clinical characteristics, time to reach caloric goal, and parenteral nutrition (PN) use were compared between patients with and without avoidable interruptions to EN. RESULTS Daily record of nutrient intake was obtained in 117 consecutive patients (median age, 7 years). Eighty (68%) patients received EN (20% postpyloric) for a total of 381 EN days (median, 2 days). Median time to EN initiation was less than 1 day. However, EN was subsequently interrupted in 24 (30%) patients at an average of 3.7 +/- 3.1 times per patient (range, 1-13), for a total of 88 episodes accounting for 1,483 hours of EN deprivation in this cohort. Of the 88 episodes of EN interruption, 51 (58%) were deemed as avoidable. Mechanically ventilated subjects were at the highest risk of EN interruptions. Avoidable EN interruption was associated with increased reliance on PN and impaired ability to reach caloric goal. CONCLUSIONS EN interruption is common and frequently avoidable in critically ill children. Knowledge of existing barriers to EN such as those identified in this study will allow appropriate interventions to optimize nutrition provision in the PICU.
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Affiliation(s)
- Nilesh M Mehta
- Division of Critical Care, Department of Anesthesia, Department of Nursing, Division of Gastroenterology, and Nutrition and Clinical Research Program, Biostatistics Core, at Children's Hospital Boston, Boston, Massachusetts 02115, USA.
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Affiliation(s)
- Nilesh M. Mehta
- From the Division of Critical Care Medicine, Children's Hospital, Boston, Massachusetts
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Duff S, Price S, Gray J. The Role of Nutrition in Injured Military Personnel at Role 4: Current Practice. J ROY ARMY MED CORPS 2008; 154:284-91. [DOI: 10.1136/jramc-154-04-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Deane A, Chapman MJ, Fraser RJ, Bryant LK, Burgstad C, Nguyen NQ. Mechanisms underlying feed intolerance in the critically ill: Implications for treatment. World J Gastroenterol 2007; 13:3909-17. [PMID: 17663503 PMCID: PMC4171161 DOI: 10.3748/wjg.v13.i29.3909] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Malnutrition is associated with poor outcomes in critically ill patients. Although nutritional support is yet to be proven to improve mortality in non-malnourished critically ill patients, early enteral feeding is considered best practice. However, enteral feeding is often limited by delayed gastric emptying. The best method to clinically identify delayed gastric emptying and feed intolerance is unclear. Gastric residual volume (GRV) measured at the bedside is widely used as a surrogate marker for gastric emptying, but the value of GRV measurement has recently been disputed. While the mechanisms underlying delayed gastric emptying require further investigation, recent research has given a better appreciation of the pathophysiology. A number of pharmacological strategies are available to improve the success of feeding. Recent data suggest a combination of intravenous metoclopramide and erythromycin to be the most successful treatment, but novel drug therapies should be explored. Simpler methods to access the duodenum and more distal small bowel for feed delivery are also under investigation. This review summarises current understanding of the factors responsible for, and mechanisms underlying feed intolerance in critical illness, together with the evidence for current practices. Areas requiring further research are also highlighted.
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Eatock FC, Chong P, Menezes N, Murray L, McKay CJ, Carter CR, Imrie CW. A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis. Am J Gastroenterol 2005; 100:432-9. [PMID: 15667504 DOI: 10.1111/j.1572-0241.2005.40587.x] [Citation(s) in RCA: 245] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND After 50 yr in which nasoenteric feeding was considered contraindicated in acute pancreatitis (AP), several clinical studies have shown that early nasojejunal (NJ) feeding can be achieved in most patients. A pilot study of early nasogastric (NG) feeding in patients with objectively graded severe AP proved that this approach was also feasible. A randomized study comparing NG versus NJ feeding has been performed. METHODS A total of 50 consecutive patients with objectively graded severe AP were randomized to receive either NG or NJ feeding via a fine bore feeding tube. The end points were markers of the acute phase response APACHE II scores and C-reactive protein (CRP) measurements, and pain patterns by visual analogue score (VAS) and analgesic requirements. Complications were monitored and comparisons made of both total hospital and intensive-care stays. RESULTS A total of 27 patients were randomized to NG feeding and 23 to NJ. One of those in the NJ group had a false diagnosis, thereby reducing the number to 22. Demographics were similar between the groups and no significant differences were found between the groups in APACHE II score, CRP measurement, VAS, or analgesic requirement. Clinical differences between the two groups were not significant. Overall mortality was 24.5% with five deaths in the NG group and seven in the NJ group. CONCLUSIONS The simpler, cheaper, and more easily used NG feeding is as good as NJ feeding in patients with objectively graded severe AP. This appears to be a useful and practical therapeutic approach to enteral feeding in the early management of patients with severe AP.
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Affiliation(s)
- F C Eatock
- Lister Department of Surgery and Department of Nutrition and Dietetics, Glasgow Royal Infirmary, Alexandra Parade, Glasgow G31 2ER, Scotland
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Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr 2002. [PMID: 11841046 DOI: 10.1177/0148607102026001011] [Citation(s) in RCA: 365] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Early Enteral Nutrition in the Intensive Care Unit. Intensive Care Med 2002. [DOI: 10.1007/978-1-4757-5551-0_44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Kudsk KA, Jacobs DO. Nutrition. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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MacFie J. Enteral versus parenteral nutrition: the significance of bacterial translocation and gut-barrier function. Nutrition 2000; 16:606-11. [PMID: 10906570 DOI: 10.1016/s0899-9007(00)00249-5] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- J MacFie
- Combined Gastroenterology Unit, Scarborough Hospital, North Yorkshire, UK.
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Taylor SJ. Early enhanced enteral nutrition in burned patients is associated with fewer infective complications and shorter hospital stay. J Hum Nutr Diet 1999. [DOI: 10.1046/j.1365-277x.1999.00147.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Carl P, Reich H. Burns. Curr Opin Anaesthesiol 1998; 11:181-4. [PMID: 17013217 DOI: 10.1097/00001503-199804000-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Inhalation injuries still significantly increase the morbidity and mortality of burn patients. Advances in ventilatory support appear to decrease the frequency of pneumonia and improve the survival of patients. It is now well accepted that early enteral feeding of patients with burn injuries is very important. The addition of anabolic agents in burn care and nutrition may be of importance. Patients receiving pre-storage filtered blood components have fewer blood transfusion-induced side effects and the requirement for transfusion is reduced. Current research on the cellular response to burn injury holds promise for further improvement in burn care.
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Affiliation(s)
- P Carl
- Department of Anaesthesiology and Intensive Care, Hvidovre University Hospital, Hvidovre, Denmark
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