Protocoles d’assistance nutritionnelle en réanimation

Providing nutritional support is a standard component of managing critically ill patients. Guidelines for provision and assessment of nutrition support therapy have been shown as beneficial to the patient and able to reduce healthcare expenditures. Nevertheless, routine practice of these guidelines is not widespread and their objectives are often difficult to follow in practice. This article reviews the literature, examining the different nutrition support protocols available for the critically ill patient. A nutrition support protocol recently implemented in our intensive care unit is presented.     

The metabolic response to stress: a case of complex nutrition support management

The ICU patient with burns, neurotrauma, sepsis, or major surgery typifies the classic hypermetabolic patient. These patients have increased energy and nutrient needs as a result of their injuries and require early nutrition support. Although these patients are likely to benefit from nutritional intervention, the complexity of the stress response to injury and subsequent changes in nutrient metabolism make the design and implementation of nutrition care challenging. This article reviews the pathophysiology of common hypermetabolic conditions and provides strategies to manage the complications associated with nutrition support.     

重症急性胰腺炎合并多个肠瘘患者营养支持结合功能锻炼的护理

报告了1例重症急性胰腺炎并发多个肠瘘(8个瘘口)的护理过程。根据患者并发多个肠瘘的特点,与营养专职护士共同制订详细的营养支持方案与个体化功能锻炼计划,注重功能锻炼,通过早期完全胃肠外营养支持逐步过渡到多途径肠内营养+消化液回输,采取有针对性的护理措施,有效地促进了营养液吸收,增加了体重,使患者一次性肠瘘修补成功治愈。     

危重病救治中肠内和肠外营养支持的研究

目的研究重症监护病房(ICU)危重病人肠内和肠外营养支持效果。方法对我院ICU中56例危重病人的营养支持情况进行对比分析,其中肠内营养支持组32例,肠外营养支持组24例。结果本组病人52例康复,4例死于原发病。经肠内营养支持后,血清前蛋白明显升高(P<0.01),血清白蛋白和血红蛋白亦有升高(P<0.05);而肠外营养支持后,各指标差异无显著性意义。两组对比,肠内营养支持组病人血清前蛋白和白蛋白均高于肠外营养支持组(P<0.05),上臂肌围和肱三头肌皮皱厚度无显著差异。结论ICU危重病人救治中,应根据疾病的不同情况,选择合适的营养支持方式,肠内营养有更好的代谢效应及营养效果。     

Nutrition support in cancer

OBJECTIVES: To describe nutrition intervention strategies frequently used to support cancer patients experiencing malnutrition. DATA SOURCES: Textbook chapters, database reports, and current related literature. CONCLUSIONS: Clinicians have many options for providing nutrition support interventions for the cancer patient at risk for malnutrition. The most appropriate strategy for a patient should be based on a careful assessment of contributing factors with input from a multidisciplinary team. IMPLICATIONS FOR NURSING PRACTICE: It is important for nurses to be knowledgeable about nutrition intervention options available to patients at various points along the cancer trajectory. Oncology nurses are in a key position to provide support to patients and families with regard to nutrition issues. Of paramount importance is their contribution to ongoing assessment of nutritional status and early and aggressive intervention to meet nutritional needs.     

The complex gastrointestinal patient and Jean Watson's Theory of Caring in nutrition support.

The care of the patient with gastrointestinal disease is complex and challenging. The reasons for the complexity are varied and different for each patient. Any of these variables can affect the nutritional health of the patient, an essential element of care that supports healing, recovery, and improved quality of life. A nutritional assessment, an evaluation of the patient's nutritional status, can be used to establish the patient's weight history, dietary habits, tolerances, and likes and dislikes. Intake and output values from this assessment provide information relating to the patient's ability to meet his or her nutritional requirements orally or whether alternate methods for nutrition support need be considered, such as a feeding tube or a central intravenous catheter.Parenteral nutrition is the intravenous nutrition supplementation required when the oral or enteral route for nutrition support is unavailable or impossible. In this article, a clinical case scenario for a 34-year-old man with a history of cancer and an extensive bowel resection will be presented to better explore the decision-making process for determining appropriate nutrition support. In addition, various issues the health practitioner needs to consider when managing the nutritional health of the complex gastrointestinal patient will be explored, relative to Jean Watson's Theory of Caring.     

Parenteral nutrition in the malnourished: dialysis, cancer, obese, and hyperemesis gravidarum patients

Malnutrition is a complication of many disease processes and can have deleterious effects on patient care outcomes. Providing adequate nutritional support requires a plan that is tailored to the individual needs of the patient and occasionally requires the use of parenteral nutrition. The varied nutritional needs of malnourished dialysis, cancer, obese, and hyperemesis gravidarum patients will be discussed. The infusion nurse specialist is a vital member of the nutrition support team in the care and recovery of the malnourished patient who requires parenteral nutrition.     

Perioperative nutrition support: who and how

Perioperative nutrition support can reduce postoperative complications in some malnourished patients, but there are risks, such as a greater risk of infection. The decision to use nutrition support--either total parenteral nutrition or enteral feedings--before and after surgery depends on how severely the patient is malnourished, the type of surgical procedure, and whether the surgery is elective.     

Specialized nutrition support

Specialized nutrition support should be offered to patients who are malnourished or at risk of becoming malnourished when it would benefit patient outcomes or quality of life. Improving the nutritional value of ingested food and tailoring intake to the patient's preferences, abilities, and schedule should be the first measures in addressing nutritional needs. When these interventions alone are insufficient to meet nutritional requirements, oral nutritional supplements should be considered. Nutritional status should be evaluated in patients before specialized nutrition sup- port is considered. Enteral nutrition is used when patients have a functional gastrointestinal tract but are unable to safely swallow. Although a variety of enteral formulas are available, evidence for choosing a specific formula is often lacking. Parenteral nutrition should be used only when enteral nutrition is not feasible. There are no known benefits of parenteral nutrition over the enteral route, and the risk of serious complications is much greater with parenteral nutrition. Even when the parenteral route is necessary, some enteral nutrition is beneficial when possible. Specialized nutrition support can provide an effective bridge until patients are able to return to normal food and, in rare cases, may be continued as long-term home enteral or parenteral nutrition. Specialized nutrition support is not obligatory and can be harmful in cases of futile care and at the end of life.     

New paradigm in nutrition support: using evidence to drive practice

Adequate nutrition support is a key component in achieving favorable outcomes for the critically ill patient. Significant evidence supports starting enteral nutrition rather than parenteral nutrition as early as possible after injury to promote positive outcomes. Evidence shows that enteral nutrition improves patient outcomes and decreases intensive care unit length of stay by improving splanchnic blood flow, moderating the metabolic response, sustaining gut integrity, and preventing bacterial translocation from the gut to the bloodstream. Implementing early enteral nutrition can be challenging. This article describes the rationale for early enteral nutrition, the evidence that favors enteral nutrition over parenteral nutrition, barriers to delivery of full enteral nutrition, and an evidence-based protocol developed at Harborview Medical Center to promote appropriate support. The role of the registered dietitian on the health care team in facilitating appropriate feeding is discussed. In addition, we will describe emerging nutrition therapies including the use of antioxidants, addition of the amino acid glutamine, use of immune-enhancing enteral formulas, and the potential role of probiotics that show promise in improving patient outcome.     

Nutrition integration across the nursing curriculum: A novel teaching model within a pre-licensure program

Across the healthcare spectrum, the provision of evidence-based nutrition education is critical in supporting optimal patient care and health outcomes. Nurses are uniquely positioned to deliver nutrition-focused patient education related to health promotion and disease management; yet widespread evidence of sufficient nutrition instruction in nursing curricula is not available. Although lifestyle and nutrition recommendations have historically been the domain of registered dietitians, interprofessional collaboration requires that nurses are prepared to reinforce and support the dissemination of accurate nutrition education. Interdisciplinary teaching approaches are therefore imperative for consistent communication and execution of nutrition guidance. At a private nursing college, an innovative model for nutrition integration across a nursing curriculum has been developed and implemented. This model features an ongoing instructional partnership between registered dietitian faculty and nurse educators. This integrative model enhances nutrition-related nursing competencies demonstrated by undergraduate nursing students and aims to produce graduates who are confident in the delivery of nutrition-related nursing care.     

一例新冠疫情期间胰腺癌术后并发粘连性肠梗阻的营养支持护理

总结一例胰腺癌术后并发粘连性肠梗阻的营养支持护理经验。护理要点包括：肠外营养与肠内营养支持护理、新冠疫情期间功能锻炼、心理护理。经过积极治疗与精心护理,现患者顺利康复出院。     

Clinical skills: importance of nutrition for acutely ill hospital patients

Providing good nutrition to patients in hospital has become a primary focus in many NHS trusts. Whether it is provided by hospital food or nutrition support, the impact of adequate food on patient outcome is now well documented. However, the physiological, social and economic consequences of malnutrition in hospitals must be acknowledged. This article provides an overview of the metabolic changes that occur during starvation in health and in illness. The methods used by different healthcare professionals to assess nutrition are summarized. A review of the range of nutrition support options available and indications for their use is provided. Hospital nutrition is considered in the context of recent national and international recommendations.     

空肠造瘘用于肠内营养在危重症患者的护理进展华东医院 孙滨海 陈贞

临床营养支持根据输入途径的分为肠内营养和场外营养。其中肠内营养液输注是危重病患者营养支持中的重要途径。选择恰当的输入途径和输注方式是保证肠内营养顺利进行的重要条件。肠内营养分口服和管饲两种途径,后者包括鼻胃管、双腔胃-空肠管、空肠造瘘管、胃造瘘管、鼻十二指肠及鼻空肠管。由于鼻胃管的适用范围存在一定的局限性,因此不适于鼻胃管的患者在术中可置空肠造瘘管,以利于术后进行早期的肠内营养支持。现将空肠造瘘用于危重症患者肠内营养的国内外护理进展报告如下。     

Nutrition

The use of nutrition for the medical patient, in the inpatient setting and at home, will likely continue to increase in the future. Each patient should be evaluated in an individualized but systematic fashion. Each patient in whom malnourishment is suspected should undergo a thorough assessment for the presence and degree of malnutrition with an accurate calculation of nutritional requirements. It is important to choose the correct method of delivery of nutrition, to monitor and recognize any complications or problems that may arise, and to tailor the nutritional therapy to the unique diseases that are encountered in medicine. Although increasingly new advances and changes are occurring in the field of nutrition, nutritional support and therapy are best delivered and supplied to the patient with a network of health care workers, including the physician, the nurse, the dietitian, the social worker, and pharmacist.     

Nutrition and infection in the intensive care unit: what does the evidence show?

PURPOSE OF REVIEW: Nutrition support when applied appropriately, can improve clinical outcomes, particularly the incidence of infections. The Canadian Clinical Practice Guidelines for Nutrition Support, published in October 2003, summarized the evidence on nutrition support in the critically ill patient and provided recommendations aimed at maximizing the benefits of nutrition support while minimizing the risks. The purpose of this review is to highlight recent advances in nutrition research in critically ill adult patients, particularly with respect to minimizing infection. The newly published data will be used to update the Canadian Clinical Practice Guidelines. RECENT FINDINGS: Recent studies have confirmed that the use of enteral nutrition versus parenteral nutrition, early initiation of enteral nutrition, use of enteral and parenteral glutamine and intensive insulin therapy are all associated with reduced infectious morbidity in critically ill patients. A recent meta-analysis suggests that antioxidant supplementation is associated with no improvement in infectious complications, but an increase in survival. The recommendations from the Canadian Clinical Practice Guidelines for Nutrition Support have been updated based on the data from these recent trials. SUMMARY: This review provides insights into the results of recent randomized trials on nutrition support in critically ill patients. The Canadian Clinical Practice Guidelines for nutrition support help intensive care unit clinicians to keep abreast of emerging evidence and the impact of nutrition support practices on outcomes such as infections.     

Nutrition support. Making the difficult decisions

Weight loss and cachexia are common characteristics associated with the cancer patient. Although the wasted appearance seems the same in each person, the causes are varied. Studying a patient's history and identifying surgical causes to weight loss or weight loss as a result of treatment complications assists in the consideration of nutritional support. Nutritional parameters combined with the oncology nurse's knowledge of the patient, disease process, and treatment side effects place the nurse in the position to help identify options for nutritional support. The oncology nurse's expertise assists in the decision making process, since it is often not appropriate to institute nutritional support in the inpatient setting nor extend it to the home situation. Objective assessment parameters for home parenteral nutrition assist the nurse in making some of these decisions. The conflicts that arise within the decision making process are usually not clearcut nor easily resolvable. Home parenteral nutrition brings to the forefront requirements and variables that are often not consciously addressed when hyperalimentation is instituted in the inpatient setting.     

Is it now time to promote mixed enteral and parenteral nutrition for the critically ill patient?

Background Intensive care outcome measured by morbidity and mortality is altered in the severely malnourished ICU patient, and nutritional support of the critically ill is accepted as a standard of care. Current recommendations suggest starting enteral feeding as soon as possible whenever the gastrointestinal tract is functioning. The disadvantage of enteral support is that inadequate energy and protein intake can occur. The present commentary focuses on some recent findings regarding the nutritional support of critically ill patients and proposes to promote mixed nutrition support by enteral nutrition (EN), and by parenteral nutrition (PN) whenever EN is insufficient. Recent findings An increasing nutrition deficit during a long ICU stay is associated with increased morbidity (increased infection rate or impaired wound healing). Evidence shows that EN can result in underfeeding and that nutrition goals are reached only after 5–7 days. Contrary to former beliefs, recent meta-analyses of studies in the ICU showed that PN is not related to excess mortality but may even be associated with improved survival. Conclusions Optimising the increased substrate requirement for the critically ill by initiating timely nutrition support and ensuring tight glycaemic control with insulin is now considered central for improved intensive care outcomes. Supplemental PN combined with EN could be an effective alternative to achieve 100% of energy and protein targets at day 4, when EN alone fails to achieve goals greater than 60% by day 3. Whether such combined nutrition support provides additional benefit on overall outcome has to be ascertained in further studies.     

Factors predicting adherence to the Canadian Clinical Practice Guidelines for nutrition support in mechanically ventilated, critically ill adult patients

Purpose

The aim of this study was to determine factors that are associated with adherence to the Canadian nutrition support clinical practice guidelines (CPGs).

Materials and Methods

We conducted a secondary analysis of data from a prospective observational cohort study of nutrition support practices in 58 intensive care units (ICUs) across Canada, grouped into 50 clusters. Adequacy of enteral nutrition (EN) (energy received from EN ÷ energy prescribed by the dietitian × 100), was used as a marker of adherence to the guidelines. We applied hierarchical modeling techniques to examine the impact of various hospital, ICU, and patient factors on EN adequacy.

Results

The overall average EN adequacy was 51.3% (SE, 1.8%). In a multiple regression analysis, after adjusting for varying days of observation, hospital type (academic 54.3% vs community 45.2%, P < .001), admission category of the patient (medical 60.2% vs surgical 39.2%, P < .001), and sex of the patient (male 46.5% vs female 52.8%, P < .001) were found to be significant predictors of EN adequacy and adherence to the Canadian nutrition support CPGs.

Conclusions

Specific hospital, ICU, and patient characteristics influence adherence to the Canadian nutrition support CPGs. Further research is required to illuminate the mechanisms by which female and surgical patients and community hospitals lead to lower guideline adherence.     

住院恶性肿瘤患者与家属营养支持治疗认知度的调查

目的 探讨恶性肿瘤患者与家属对营养支持治疗的认知程度.方法 采用问卷调查法汇总住院的369例恶性肿瘤患者及366例家属进行关于营养支持治疗的认知度.并对数据进行统计分析.结果 同等教育程度的住院肿瘤患者及家属对营养支持治疗认知情况的比较差异无统计学意义（P＞0.05）;其认知情况与文化程度呈正相关（P＜0.05）.文化程度对认知度的影响从高到低依次是研究生、专、本科学历、高中学历、初、小学历、无文化程度.结论 住院肿瘤患者及家属对营养支持治疗认知度总体较低,但二者在同等文化程度下无差别;文化程度与营养支持治疗认知度呈正相关.因此,医护人员进行营养学教育时,家属与患者同样重要,讲解力度应随知识结构的下降而相应加强.