Current opinion in critical care
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This review describes considerations preintensive care unit (ICU), within ICU and in the post-ICU period regarding nutrition management and the current state of the literature base informing clinical care. ⋯ Nutrition for the critically ill patient should not be viewed in isolated time periods; what happens before, during and after ICU is likely important to the overall recovery trajectory. It is critical that the impact of nutrition on clinical and functional outcomes across hospitalisation is investigated in specific groups and using interventions in ways that are biologically plausible to impact. Areas that show promise for the future of critical care nutrition include interventions delivered for a longer duration and inclusion of oral nutrition support, individualised nutrition regimes, and use of emerging bedside body composition techniques to identify patients at nutritional risk.
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Curr Opin Crit Care · Aug 2022
ReviewChallenges and advances in nutrition for the critically ill child.
Malnutrition remains prevalent in critically ill children and is associated with worse clinical outcomes. Conversely, nutrition provision has been associated with improved survival. Nutritional challenges must be addressed to guide best nutrition practices for the critically ill child. In this narrative review, we summarize findings from research published between July 2020 and January 2022 on nutrition in critically ill children. Findings from these articles build on previous work to guide next steps in both research and clinical practice in this cohort. ⋯ Research continues to support early initiation and advancement of enteral nutrition. Achieving nutritional adequacy is challenging, but research associated with the timing and dosing of enteral nutrition, alternative methods of enteral nutrition delivery and the use of adjuncts are expanding our understanding of best practices for this cohort. Areas for further research continue to be the use of measured energy requirements, protein dosing and inclusion of functional outcomes to assess the benefit of nutritional interventions.
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Curr Opin Crit Care · Aug 2022
ReviewIntermittent feeding and circadian rhythm in critical illness.
Circadian rhythms, i.e., periodic oscillations in internal biological processes, modulate metabolic processes such as hormonal signalling, nutrient absorption, and xenobiotic detoxification. Meal timing is a strong entraining cue for peripheral clocks in various organs, and eating out of circadian phases can impair glucose, gastrointestinal, and muscle metabolism. Sleep/wake cycles and circadian rhythms are extremely disrupted during critical illness. Timing of nutritional support may help preserve circadian rhythms and improve post-Intensive Care Unit (ICU) recovery. This review summarises circadian disruptors during ICU admission and evaluates the potential benefits of intermittent feeding on metabolism and circadian rhythms. ⋯ Aligning timing of nutritional intake, physical activity, and/or medication with circadian rhythms are potential strategies to reset peripheral circadian rhythms and may enhance ICU recovery but is not proven beneficial yet. Therefore, selecting intermittent feeding over continuous feeding must be balanced against the pros and cons of clinical practice.
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Curr Opin Crit Care · Aug 2022
ReviewMechanical circulatory support in the treatment of cardiogenic shock.
Cardiogenic shock is a condition that is characterized by end-organ hypoperfusion secondary to reduced cardiac output, and is associated with substantial mortality. The mainstay of therapy for cardiogenic shock is reversal of the underlying cause, and concomitant supportive care with vasoactive medications (vasopressors and inotropes). Patients who continue to deteriorate despite these measures may require mechanical circulatory support (MCS). Here, we review the devices available for MCS, and their associated benefits and risks. ⋯ Various devices for MCS in cardiogenic shock are available, but routine use is not supported by high-quality randomized evidence. Given the resources required for initiation of MCS, use of these treatments should be limited to centers experienced in advanced cardiac care, and future research should focus on what role (if any) these devices have in clinical practice.
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Curr Opin Crit Care · Aug 2022
ReviewInotrope and vasopressor use in cardiogenic shock: what, when and why?
Despite increasing interest in the management of cardiogenic shock (CS), mortality rates remain unacceptably high. The mainstay of supportive treatment includes vasopressors and inotropes. These medications are recommended in international guidelines and are widely used despite limited evidence supporting safety and efficacy in CS. ⋯ Review of the current literature fails to show significant mortality benefit with any specific vasopressor or inotropic in CS patients. The upcoming DOREMI 2 and levosimendan versus placebo trials will further tackle the question of inotrope necessity in CS. At this time, inotrope selection should be guided by physician experience, availability, cost, and most importantly, individual patients' response to therapy.