Current opinion in clinical nutrition and metabolic care
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Curr Opin Clin Nutr Metab Care · Sep 2003
ReviewThe gastrointestinal tract in critical illness: nutritional implications.
Recognition that the gastrointestinal tract is a key element of the immune system has led to a greater interest in understanding its role as a central figure in host defenses. Biologic systems that are perturbed by any destabilizing stimulus are known to respond by adaptive strategies in an attempt to maintain or return to global homeostasis. In critically ill patients, the gut has previously been described as a promoter of progression to sepsis and multi-organ failure. However, with better understanding of gastrointestinal tract mucosal immunity, we are now provided with a new arsenal to combat nosocomial infection and significantly impact return to health. ⋯ Ongoing research in nutritional support in both normal and pathologic gastrointestinal function and response to injury has opened the door to several new opportunities for enhancing rapid recovery in critical care.
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The bioelectrical impedance analysis method is a non-invasive, rapid accurate and practical method for assessing body composition. During last decade evidence has been gathered that supports the use of this method to monitor hydration status. This review critically examines different approaches and applications of segmental bioelectrical impedance analysis in the healthy and clinical situations. ⋯ This is a review of segmental bioelectrical impedance. The preponderance of the published applications of bioelectrical impedance analysis focused on applications in a healthy population and in the field indicate the validity of the methods. A short description of the set-up of the segmental method is also given. This review discusses the application of segmental bioelectrical impedance analysis in children in different ethnic populations, in clinical situations. We also examine the application of the method to assessing body composition, and monitoring rapid changes in internal fluid balance in the field of haemodialysis and during surgery.
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Curr Opin Clin Nutr Metab Care · Sep 2003
ReviewNew developments facilitating nutritional intake after gastrointestinal surgery.
Conventional perioperative care includes a period of semistarvation before bowel function returns and adequate oral intake is allowed. It has been clearly shown that there is no need for restriction in oral intake after, at least lower, gastrointestinal surgery, and that early oral feeding does not increase the risk for dehiscense of the anastomosis. In contrast, early feeding reduces postoperative complications. Even if early oral intake is allowed, however, it is common that side effects such as nausea and vomiting prevent patients from reaching the target energy intakes. Thus, developing routines and treatments that promote sufficient early oral intake after surgery and maintain adequate energy intake in the postoperative period are probably of great importance for the outcome from surgery. ⋯ In general, there is a great need for randomized controlled trials examining factors important for the regulation of oral intake after surgery and also the effects of early oral intake after upper gastrointestinal surgery. Future areas of research may also include regulation of appetite and use of peripherally acting opioid antagonists.
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Curr Opin Clin Nutr Metab Care · May 2003
Review Comparative StudyEnteral nutrition delivery technique.
Ingestion and absorption of a nutritionally adequate diet is necessary to maintain normal body composition and organ function. Patients with all kinds of diseases are at increased risk of developing nutritional abnormalities from anorexia, dietary restriction, malabsorption, increased intestinal losses or altered nutrient requirements. Therefore, it is important for doctors to understand the general principles of clinical nutrition for optimal management of patients with various disorders. The purpose of this review is to highlight an important aspect of nutrition: methods for enteral nutrient delivery. Enteral feeding is the preferred method to provide nutritional support in patients who cannot or will not eat but who have a functional gastrointestinal tract. The placement of a small-diameter nasogastric or nasoduodenal tube is the simplest technique for feeding patients who are unlikely to require tube feeding for more than 6 weeks. Gastrostomy, gastrojejunostomy and jejunostomy tubes placed by using endoscopic, radiologic, or surgical techniques should be considered in patients who require long-term feeding. With newer endoscopic feeding techniques replacing more conventional surgical techniques, this review proposes to discuss the newer developments in techniques of enteral feeding. ⋯ Percutaneous endoscopic gastrostomy placement is an appropriate method for providing nutrition in ill patients if no contraindication to enteral feeding exists. In certain situations, percutaneous endoscopic gastrostomy placement may even be used to make the life of a terminally ill patient comfortable.
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Products of infection, ischemia, and injury stimulate the innate immune system to release proinflammatory cytokines, which act locally to activate specific cellular immune responses and initiate recovery. In pathological cases, however, cytokines are released systemically, resulting in progressive tissue injury, hypotension, organ dysfunction, or death. Observations that animals frequently succumb to systemic inflammation long after the peak activity of tumor necrosis factor and interleukin-1beta suggest that later-acting, downstream inflammatory factors can mediate the pathological sequelae of lethal systemic inflammation. Here, the authors review evidence that the chromosomal protein high mobility group box 1 is a late-acting, downstream mediator of pathological inflammation. ⋯ Several high mobility group box 1 antagonists have recently been identified. These inhibitors may prove effective in a significantly wider therapeutic window than has been available for previous anti-cytokine strategies, because high mobility group box 1 appears in serum with a significantly delayed kinetics as compared with other cytokines.