الفهرس 
arabic summaryOnly 14 pages are availabe for public view
 |  | from | 114 |  |  |
| | | from | 114 | | |
Abstract
Nutrition management is a vital part of the care of critically ill patients. The changes in metabolic state that occur to patients in the ICU put them at risk for morbidity and mortality. The ICU team should focus on appropriate nutritional assessment, accurate estimation of needs, and reevaluation and adjustment based on reasonable monitoring parameters. The enteral route of nutrition support should be used whenever possible, and feeding should typically begin within the first 24–48 hours after resuscitation after hemodynamic stability is achieved. Those in whom parenteral nutrition is necessary should be fed conservatively initially to ensure metabolic tolerance and prevent hyperglycemia. The ICU team should seek to minimize complications associated with nutritional intervention, and should keep in mind that the primary goal of nutrition support is to improve the clinical outcome of the patient.
Present evidence strongly suggests that, in ICU patients, EN should be preferred to parenteral nutrition whenever possible, due to its favorable trophic effects on the intestinal mucosa, lower rate of complications, and lower costs. Simple guidelines can be set up for assessing the patient’s nutritional state, the timing of nutritional support, choice of feeding route and formula, and protein-calorie requirements. Data are slowly accumulating that in some patients a reduced rate of complications and length of hospital stay can result from the use of immunomodulating enteral formulas, but further studies into this promising development should be performed before their widespread use can be recommended.
A number of simple nutrition rules are clear. ICU patients staying more than a few days will need nutrition support and if malnourished they may need it sooner. Enteral feeding should be encouraged using simple feeding protocols and started early if safe to do so. However, it should not be forced if gastrointestinal intolerance is evident. We should use PN cautiously and follow guidelines of best practice. It is too easy to overfeed. It is reserved for those with verified gastrointestinal intolerance that is, either in the context of gastrointestinal failure for total PN or gastrointestinal intolerance for supplemental PN. There is at present no evidence for ”early” PN. We should ensure tight glycaemic control with insulin and use glutamine containing PN formulations in all-in-one mixtures.
The role of enteral nutrition has expanded throughout the past decade, although the indication for enteral nutrition has remained the same. Enteral nutrition is indicated in patients who have a functional GI tract but are unable or unwilling to take adequate nutrition orally to meet their requirements. It is now recognized that many patients who previously would have received full nutritional support by the parenteral route do have a functional GI tract and can receive at least partial support by the enteral route. In addition, significant changes in tube placement techniques allow access to the GI tract for enteral nutrition in patients where access was not possible in the past. Safety and convenience have driven changes in enteral equipment and supplies. Components of enteral formulas have changed to better reflect guidelines for healthy people, although many formulas have retained their previous name. Numerous specialized formulas have been developed and now compete for their niche in the enteral formula market. In general, minimal evidence is available to suggest a better clinical outcome with most specialized formulas, and they are costly. Patient outcome may be compromised by specialized formulas in some cases. The practitioner faces the task of selecting an enteral nutrition regimen that meets the individual patient’s nutritional goals in an efficacious, cost-effective manner when data to support specific selections are often not the highest quality or based on a consensus of opinion.