risks and benefits of nutritional support during critical illness part ii课件

RISKS AND BENEFITS OF NUTRITIONAL SUPPORT DURING CRITICAL ILLNESS Part II,Present: 謝廣宇 Supervisor: Dr 陳奇祥主任,本檔僅供內部教學使用 檔案內所使用之照片之版權仍屬於原期刊 公開使用時, 須獲得原期刊之同意授權,Is Enteral Nutrition Without Risks?,altered gastric emptying and decreased intestinal motility critical illness ,MV , sedatives, opiates, and catecholamines high gastric residues inadequate nutritional intake, reflux, emesis, and aspiration abdominal distention, diarrhea, constipation, and, rarely, mesenteric ischemia.,Mechanical complications misplacement or dislodgment of feeding tube or luminal blockage both gastric enteral feeding and feeding in supine position, as opposed to semirecumbent position, are independent risk factors for nosocomial pneumonia in MV patients - Drakulovic MB, 1999. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 354:185158,“postpyloric” feeding may result in an improved tolerance of enterally delivered nutrition and concomitant faster achievement of desired calories- Kortbeek JB 1999.Duodenal versus gastric feeding in ventilated blunt trauma patients: a randomized controlled trial. J. Trauma 46:99296; discussion 99698 no trial was able to reduce incidence of nosocomial pneumonia compared with NG feeding- one study in medical ICU even resulted in gastric way is better,feeding tube beyond gastric pylorus -technically difficult, expensive, easy malposition and jejunal feeding is associated with risk of mesenteric ischemia strict attention to patient positioning and vigilant nursing care help to minimize rates of complications with enteral access and more important than location of enteral access,metoclopramide was able to postpone nosocomial pneumonia by one day in ICU setting, its use was unable to decrease the incidence of pneumonia and mortality-Yavagal DR, 2000. Metoclopramide for preventing pneumonia in critically ill patients receiving enteral tube feeding: a randomized controlled trial. Crit. Care Med. 28:140811 promotility drugs have some beneficial effect on GI motility, no evidence affects any aspect of clinical outcome,IV erythromycin not only promoted gastric emptying but also significantly improved chances for successful early enteral feeding- Reignier J, 2002. Erythromycin and early enteral nutrition in mechanically ventilated patients. Crit. Care Med. 30:123741 Diarrhea is a common complication associated with tube feeding consequences include infections , skin care problems, loss of electrolytes, increased costs,soluble partly hydrolyzed guar as a source of fiber successfully incidence of diarrhea (from 32% to 9%) in mechanically ventilated septic patients - Spapen H, 2001. Soluble fiber reduces the incidence of diarrhea in septic patients receiving total enteral nutrition: a prospective, doubleblind, randomized, and controlled trial. Clin. Nutr. 20:3015 upper digestive intolerance to EN is a risk factor for unfavorable outcome pneumonia , longer ICU and hospital stays , an increased risk of death,no difference in incidence of septic morbidity between nonrandomized groups of enterally and parenterally fed patients; but a highly significant increase of non-septic feeding-related complications in the EN group a significant excess in mortality-Woodcock N, 2002. Optimal nutrition support (and the demise of the enteral versus parenteral controversy). Nutrition 18:52324 choice of feeding route by clinical assessment of GI function - Woodcock, 2001. Enteral versus parenteral nutrition: a pragmatic study. Nutrition 17:112,Combined Enteral/Parenteral Nutrition,EN safer option in majority of patients when applied under close supervision but frequently hypocaloric feeding. actually no evidence that use of supplemental PN in ICU, when EN fails to reach adequate amounts of energy delivery, holds risks,recent prospective, double-blind, randomized, placebo-controlled study of 120 critically ill patients demonstrated 7 days of EN supplemented with PN led to a faster recovery of nutritional markers retinol-binding protein and prealbumin and reduced hospital stay by 2.5 days but no difference in terms of morbidity or day 90 mortality-Bauer P. 2000. Parenteral with enteral nutrition in the critically ill. Intensive Care Med. 26:893900,a meta-analysis including five studies with combined EN and PN also did not document an increased mortality or infectious complication rate in comparison with EN alone-Dhaliwal R. 2004. Combination enteral and parenteral nutrition in critically ill patients: harmful or beneficial? A systematic reviewof the evidence. Intensive Care Med. 30:166671 combined nutritional support may provide a protective window necessary for EN to restore intestinal function, earlier assure adequate calories,SPECIALIZED NUTRITIONAL SUPPORT,nutritional support a way to provide energy under the form of carbohydrates (60%80%) and lipids (20%40%), protein (up to 1.5 g/kg/day), and essential micronutrients offset muscle wasting and prevent starvation-induced immune depletion,Alternative Lipid Solutions,containing medium-chain triglycerides (MCTs) or structured triglycerides (STs) have been proposed for PN since they are oxidized more readily as compared with LCTs short-term administration of an ST emulsion results in an amelioration of nitrogen balance in ICU patients but no evidence results in a better clinical outcome,Specialty Solutions,Liver formulas branched-chain amino acids (BCAAs) and amount of aromatic and sulfur-containing amino acids for hepatic encephalopathy-no convincing evidence Specialized pulmonary enteral solutions high fat-to-carbohydrate ratio But avoiding overfeeding is probably more important in decreasing ventilatory load,specialized formulation contains eicosapentaenoic acid, -linolenic acid, and antioxidants no proof for a survival benefit “renal formulas” low protein content BUT deleterious nutritional status and under continuous renal replacement therapy (CRRT) critically ill patients with acute renal failure should receive normal diets Diabetic EN solutions with lower carbohydrate and higher monounsaturated fat- doubted under strict insulin control,Immunonutrition,Glutamine important fuel for rapidly dividing cells in gut and immune system and substrate for synthesis of endogenous antioxidant, glutathione beneficial fornot tolerate EN and dependent on PN for longer periods with glutamine or L-ananyl-L-glutamine improved six-month survival and lowered hospital costsbut A recent meta-analysis concluded no harm but also no benefit (Novak F, 2002. Glutamine supplementation in serious illness: a systematic review of the evidence. Crit. Care Med. 30:2022 29),Arginine precursor of NO, is advocated to enhance immune function and wound healing Omega-3 fatty acids if fed before insult, influence cytokine production and target tissue responsiveness Nucleotides enhance host immune responses,enteral immunonutrition cocktails two largest studies addressed hospital mortality and intention-to-treat analysis divulged a significantly increased mortality in intervention group Until we understand the causes of these risks, generalized use of immune nutrient cocktails cannot be recommended for critically ill Atkinson S, 1998. A prospective, randomized, double-blind, controlled clinical trial of enteral immunonutrition in the critically ill. Guys Hospital Intensive Care Group. Crit. Care Med. 26:116472 Bower RH,. 1995. Early eNteral administration of a formula (Impact) supplemented with arginine, nucleotides, and fish oil in intensive care unit patients: results of a multicenter, prospective, randomized, clinical trial. Crit. Care Med.23:43649,IMPORTANCE OF METABOLIC CONTROL,Hyperglycemia and insulin resistance are common in critically ill patients, EVEN without a history of DM poor outcome after cardiac surgery, myocardial infarction and stroke an impaired leukocyte function contributing to an increased nosocomial infection rate reflection of severity of illness,Leuven study effect of strict maintenance of normoglycemia (blood glucose between 80 and 110 mg/dl) by intensive insulin therapy reduced hospital mortality by 34% a threshold level of 144 mg/dl would suffice ( Finney SJ, 2003. Glucose control and mortality in critically ill patients. JAMA 290:204147),parenterally fed patients required substantially more insulin in order to achieve normoglycemia than did those receiving EN effects of enteral nutrition on incretin-mediated endogenous insulin release potential risks of PN due to its higher hyperglycemic potentialinsulin is titrated to achieve normoglycemia, this risk of PN disappears Van den Berghe G, et al. 2003. Outcome benefit of intensive insulin therapy in the critically ill: insulin dose versus glycemic control. Crit. Care Med. 31:35966,Dyslipidemia in critically ill ( high TG and low LDL, HDL) restored and reversed by intensive-insulin therapya significant part of benefici