Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition
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Placement of a nasogastric enteral access device (NG-EAD), often referred to as a nasogastric tube, is a common practice and largely in the domain of nursing care. Most often an NG-EAD is placed at the bedside without radiographic assistance. Correct initial placement and ongoing location verification are the primary challenges surrounding NG-EAD use and have implications for patient safety. ⋯ Its mission is to identify and promote best practices with the potential of technology development that will enable accurate determination of NG-EAD placement for both the inpatient and outpatient pediatric populations. This article presents the challenges of bedside NG-EAD placement and ongoing location verification in children through an overview of the current state of the science. It is important for all healthcare professionals to be knowledgeable about the current literature, to be vigilant for possible complications, and to avoid complacency with NG-EAD placement and ongoing verification of tube location.
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Delivery of adequate nutrients during illness to counteract the metabolic stress response and facilitate healing and tissue repair is an important goal in the care of critically ill children. With recent advances in technology, accurate minute-to-minute gas exchange and energy expenditure measurements are now available in intensive care units. The bedside availability of these devices may allow a titrated approach to energy delivery for patients, ushering in a new era of individualized nutrition therapy. Basic concepts, available monitoring devices, indications, pitfalls, and bedside application of metabolic monitoring are discussed in this article.
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The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and the Society of Critical Care Medicine (SCCM) published guidelines in 2009 recommending against the use of intravenous lipids for parenteral nutrition (PN) within the first week of hospitalization in critically ill patients. This grade D recommendation is controversial as it is based on the results of 2 studies that evaluated approximately 100 patients and did not evaluate glycemic control. The purpose of this study was to evaluate outcomes associated with the receipt of lipids within the first week in the intensive care unit (ICU) compared with withholding lipids. ⋯ Withholding lipids within the first 7 days of hospitalization in the ICU was not associated with a significant reduction in infections, ICU or total LOS, or mortality. A multicenter, randomized, controlled trial is needed to further evaluate the effects of lipid administration in the critically ill.
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Extracorporeal membrane oxygenation (ECMO) is used to treat patients with severe acute respiratory distress syndrome or severe cardiac and/or respiratory failure that is unresponsive to conventional ventilator therapy. Provision of adequate nutrition support can be challenging due to hemodynamic alterations encountered in these critically ill patients. ⋯ Review of published reports and personal experience indicates that early enteral nutrition support can be well tolerated by transplant patients receiving either venovenous or venoarterial ECMO, if care is taken to adequately assess potential barriers to optimal nutrition support. Until specific guidelines are developed for patients receiving ECMO, it appears that the guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient provide the best guidance for the nutrition support clinician who is caring for the patient receiving ECMO support.
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Despite the abundance of evidence to the contrary, 6-8 hours of total preoperative fasting is still considered essential by many surgeons and anesthesiologists, based on the strength of old concepts. Patients frequently end up fasting for 12 hours or more because of delays and changes in operating room schedules. ⋯ In fact, there has not been any evidence indicating that a shorter fast of 2-3 hours, which includes oral clear or carbohydrate (CHO)-rich (12.5% carbohydrates, 50 kcal/100 mL) fluids, results in an increased risk of aspiration, regurgitation, or related morbidity compared with the standard policy of "nil by mouth after midnight." In addition, preoperative treatment with CHO-rich fluids may reduce postoperative discomfort and, for patients undergoing major abdominal surgery, may decrease the duration of postoperative hospitalization. New formulas for preoperative oral fluids containing amino acid or protein such as glutamine or whey protein are also potential candidates for early preoperative treatment and merit further study.