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© The Board of Management and Trustees of the British Journal of Anaesthesia [2007]. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Nutritional support in critical care: an update
Consultant in Anaesthesia and Intensive Care Wrexham Maelor Hospital
Croesnewydd Road Wrexham LL13 7TD
UK
Tel: +44 0 1978 725955 Fax: +44 0 1978 725932E-mail: campbell.edmondson@new-tr.wales.nhs.uk
Key Words: Enteral nutrition is to be preferred to parenteral whenever access to a working small intestine is available. • Post pyloric feeding may reduce the risk of aspiration but is associated with a higher risk of tube blockage and displacement. • Relative underfeeding is associated with improved mortality no matter which route is used and it is particularly important when parenteral nutrition is being established. • The benefits of immunonutrition are yet to be convincingly demonstrated, particularly when combinations of substances are used. • Whilst glutamine has accumulated the most evidence for improved outcomes in the critically ill, arginine may actually cause harm. • There is some evidence that administration of anti-oxidants (e.g. selenium) might reduce ICU mortality.
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The role of nutrition in the critically ill patient continues to develop. Controversy exists over optimal route, quantity, and components, all of which will be reviewed in this article.
The heterogeneous case-mix of patients in many UK Critical Care Units provides different challenges when trying to establish nutritional support. Choice of nutritional components and delivery depends on patient factors and their disease.
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Early vs late support |
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It is established practice to start enteral nutrition soon after admission, and a number of studies would support that strategy. However, the benefit of delivering nutrition to the sick patient during the resuscitation phase of their admission is questionable. During this time, nutrients (particularly macronutrients) may not be utilized efficiently. However, the administration of vitamins and micronutrients may be beneficial. Their action on cellular enzyme systems may result in enhanced anti-oxidant activity, but this is controversial.
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Route of administration |
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All methods of delivering artificial nutrition carry risks and these must be
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Quantity of support |
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Modification of content |
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Immuno-nutrition: the role of nutraceuticals
Glutamine
Arginine
Fish oils
Anti-oxidants
Fibre