What is the role of parenteral nutrition in the management of the patient with severe acute pancreatitis?

Severe acute pancreatitis often presents as a complex critical illness associated with a high rate of infectious morbidity, multiple organ failure, and in-hospital mortality. Breakdown of gut barrier defenses, dysbiosis of intestinal microbiota, and exaggerated immune responses dictate that early enteral nutrition (EN) is preferred over parenteral nutrition (PN) as the primary route of nutrition therapy. EN, however, is not feasible in all cases because of intolerance, risk of complications, or a direct contraindication to enteral feeding.

The challenge of integrating a diagnosis of malnutrition in the practical application of nutrition care in the intensive care unit.

Evidence of poor nutrition status in a patient present on admission to the intensive care unit is associated with worse clinical outcomes than that for a well-nourished patient who becomes critically ill. Diagnosing malnutrition in this setting is fraught with difficulty, though, because elements of nutrition history are hard to obtain, the interpretation of anthropometric parameters is influenced by the disease process and interventions of critical care and the subjectivity of traditional assessment tools lacks precision. Determining the severity of disease drives the initial management and sets priorities in the derivation of the nutrition plan, focusing on strategies that promote survival.

Considerations for medical nutrition therapy management of the critically ill patient with hematological malignancies: A narrative review.

Patients with hematological malignancies (HMs) are more frequently admitted now than in the past to the intensive care unit (ICU) due to more aggressive approaches in primary therapy of HMs and the need for critical care support. Pathophysiological alterations derived from HMs and the different hematological therapies, such as chemotherapy, negatively affect gastrointestinal (GI) function, metabolism, and nutrition status. Further, malnutrition strongly influences outcomes and tolerance of the different hematological therapies.

Enteral nutrition in septic shock: a call for a paradigm shift.

Purpose Of Review: The purpose of this review is to identify contemporary evidence evaluating enteral nutrition in patients with septic shock, outline risk factors for enteral feeding intolerance (EFI), describe the conundrum of initiating enteral nutrition in patients with septic shock, appraise current EFI definitions, and identify bedside monitors for guiding enteral nutrition therapy.

Recent Findings: The NUTRIREA-2 and NUTRIREA-3 trial results have better informed the dose of enteral nutrition in critically ill patients with circulatory shock. In both trials, patients with predominant septic shock randomized to receive early standard-dose nutrition had more gastrointestinal complications.

The importance of providing dietary fiber in medical and surgical critical care.

The early provision of soluble/insoluble fiber to the patient who is critically ill has been controversial in the past. Especially in the setting of hemodynamic instability, dysmotility, or impaired gastrointestinal transit, fear of inspissation of formula with precipitation of nonocclusive mesenteric ischemia (NOMI)/nonocclusive bowel necrosis (NOBN) limited its utilization by medical and surgical intensivists. The incidence of NOMI/NOBN has been estimated at 0.

Browning of white adipose tissue may be an appropriate adaptive response to critical illness.

Both the baseline amount of brown adipose tissue (BAT) and the capacity to stimulate browning of white adipose tissue (WAT) may provide a protective effect to the patient in a critical care setting. Critical illness is associated with reduced mitochondrial volume and function resulting in the increased production of reactive oxygen species, greater demand for adenosine triphosphate, a switch to uncoupled fat metabolism, and hibernation of the organelle, which all contribute to multiple organ failure. Increasing insulin resistance, decreasing fatty acid oxidation, and dependence on carbohydrate metabolism result.

Personalized nutrition therapy in critical care: 10 expert recommendations.

Personalization of ICU nutrition is essential to future of critical care. Recommendations from American/European guidelines and practice suggestions incorporating recent literature are presented. Low-dose enteral nutrition (EN) or parenteral nutrition (PN) can be started within 48 h of admission.

Nutrition dose in the early acute phase of critical illness: Finding the sweet spot and heeding the lessons from the NUTRIREA trials.

The landmark NUTRIREA-2 and NUTRIREA-3 trials compared the route and dose of nutrition, respectively, in critically ill patients with circulatory shock. The results of both trials support a "less-is-more" paradigm shift in the early acute phase of critical illness. In this review, the authors outline and appraise the results of the NUTRIREA-2 and NUTRIREA-3 trials, introduce the concept of identifying the "sweet spot" for nutrition dose based on severity of illness/nutrition risk and nutrition dose, and identify the unintended consequences of delivering full-dose nutrition in sicker critically ill patients during the early acute phase of critical illness.

Immunonutrition vs standard nutrition for patients with cancer.

The prevailing belief in the value of immunonnutrition has been questioned as different patient populations show variable responses ranging from no benefit or even harm to significant improvements in clinical outcomes. The subject of this invited review is a previously published meta-analysis that showed important benefits from the perioperative use of an immunonutrition formula (defined as nutrition therapy that contains specific immune-modulating agents) in a distinct population: adult patients with cancer undergoing an elective major surgical operation. Findings showed that use of an immunonutrition formula was associated with reduced infectious morbidity, anastomotic leakage, hospital length of stay, and postoperative complications compared with standard formulations.

2022 Peggi Guenter Excellence in Clinical Practice Lectureship: Expanding the clinical practice of nutrition-Challenging the known, exposing inconvenient truths, and engaging the young.

To expand the clinical practice of nutrition, the influence of the American Society for Parenteral and Enteral Nutrition (ASPEN) must reach an audience outside the nutrition community, must be relevant and meaningful to clinicians, and must meet the needs of specific patient populations throughout medical and surgical specialties. Individual members of our society need to share their enthusiasm and expertise with youth through conscious, intentional mentorship. Efforts should be made to promote advanced practice, increasing the skill set of the individual nutritionist.

Preparative Fasting Orders for Medical/Surgical Interventions and Imaging Studies: Time to Review and Revise!

Purpose Of The Review: Preparative fasting orders arose out of a purported need to enhance imaging studies, reduce interference of food with intended medical/surgical interventions, and protect the patient from vomiting and aspiration pneumonia. This review discusses the frequency, appropriateness, and efficacy of fasting orders in meeting those needs and whether their use should be modified in the future.

Recent Findings: Nil per os (NPO) orders are overused, as they are often inappropriate, typically excessive, and routinely create barriers which may increase risk for patients.

Optimizing the nutrition support care model: Analysis of survey data.

Background: Malnutrition is underrecognized and underdiagnosed, despite high prevalence rates and associated poor clinical outcomes. The involvement of clinical nutrition experts, especially physicians, in the care of high-risk patients with malnutrition remains low despite evidence demonstrating lower complication rates with nutrition support team (NST) management. To facilitate solutions, a survey was designed to elucidate the nature of NSTs and physician involvement and identify needs for novel nutrition support care models.

Nutrition, defecation, and the lower gastrointestinal tract during critical illness.

Purpose Of Review: The goal of this report is to delineate the correlation between constipation as a manifestation of impaired gastrointestinal transit with adverse clinical outcomes, to identify risk factors, which predispose to this condition, and outline a management scheme for prophylactic treatment.

Recent Findings: Constipation is common in the ICU, affecting upwards of 60-85% of critically ill patients. As suggested by case series and observational studies, constipation may be an independent prognostic factor identifying patients with greater disease severity, higher likelihood of organ dysfunction, longer duration of mechanical ventilation, prolonged hospital length of stay, and possibly reduced survival.

A guide to enteral nutrition in intensive care units: 10 expert tips for the daily practice.

The preferential use of the oral/enteral route in critically ill patients over gut rest is uniformly recommended and applied. This article provides practical guidance on enteral nutrition in compliance with recent American and European guidelines. Low-dose enteral nutrition can be safely started within 48 h after admission, even during treatment with small or moderate doses of vasopressor agents.

Surgical Diagnoses of Pancreatic Adenocarcinoma Not Found on Previous Endoscopic Ultrasound: A Case Series and Review of the Literature.

Introduction: Pancreatic cancer is a leading cause of death in North America and Western Europe with rising rates in the developing world. Endoscopic ultrasound (EUS) with FNA (fine needle aspiration) is a critical component in the evaluation and diagnosis of pancreatic lesions with a high sensitivity and specificity. In this paper, we report patients at our center who eventually developed pancreatic cancer despite an early negative EUS, and identifying factors that may result in a missed diagnosis.

How Differences in the Disease Process of the COVID-19 Pandemic Pose Challenges to the Delivery of Critical Care Nutrition.

Purpose Of Review: The COVID-19 pandemic is a unique disease process that has caused unprecedented challenges for intensive care specialists. The hyperinflammatory hypermetabolic nature of the disease and the complexity of its management create barriers to the delivery of nutritional therapy. This review identifies the key differences which characterize this pandemic from other disease processes in critical illness and discusses alternative strategies to enhance success of nutritional support.

Food Access, Food Insecurity, and Gun Violence: Examining a Complex Relationship.

Purpose Of Review: Food insecurity and gun violence are timely and relevant public health issues impacting many regions within the USA with a potential association. Terminology surrounding food access and food security can be confusing, which is important to understand when examining the relationship between these issues and gun violence.

Recent Findings: Food insecurity is an individual level risk factor that appears to correlate with an increased rate of exposure and future involvement in violence.

Prolonged progressive hypermetabolism during COVID-19 hospitalization undetected by common predictive energy equations.

Background & Aims: Indirect calorimetry (IC) is the gold-standard for determining measured resting energy expenditure (mREE) in critical illness. When IC is not available, predicted resting energy expenditure (pREE) equations are commonly utilized, which often inaccurately predict metabolic demands leading to over- or under-feeding. This study aims to longitudinally assess mREE via IC in critically ill patients with SARS-CoV-2 (COVID-19) infection throughout the entirety of, often prolonged, intensive care unit (ICU) stays and compare mREE to commonly utilized pREE equations.

Barriers to nutrition therapy in the critically ill patient with COVID-19.

Background: Coronavirus disease 2019 (COVID-19) has created challenges for intensivists, as high ventilatory demands and prolonged hypermetabolism make it difficult to sustain nutrition status. The purpose of this survey was to determine current practices in nutrition therapy and identify barriers to its delivery.

Methods: A survey about delivering nutrition therapy to critically ill patients with COVID-19 was sent to clinicians at academic and community hospitals from September to December 2020.

Can feeding strategies alter immune signaling and gut sepsis in critical illness?

The insult necessitating admission to the intensive care unit propels the patient along a course involving increasing oxidative stress, immune dysregulation, and adverse outcomes. As the largest immune organ with the greatest microbial burden, the gastrointestinal (GI) tract may change the speed and direction the patient follows along this pathway. The gut's influence is mediated by a complex process of cross-talk immune signaling between the intestinal epithelium, the liver, and the microbiome.