Nutrition in Critical Illness, An Issue of Critical Nursing Clinics (eBook)

Miranda Kelly (Autor)

eBook Download: PDF | EPUB

2014 | 1. Auflage
129 Seiten
Elsevier Health Sciences (Verlag)
978-0-323-29936-7 (ISBN)

Infos

Nutrition in Critical Illness, An Issue of Critical Nursing Clinics,

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Nutrition is an important aspect of care for any patient entering the hospital, but the patient admitted to the intensive care unit (ICU) is at an even higher risk for nutritional compromise. Nutrition affects all ages, from the neonate to the geriatric patient, and all patient populations. Evidence-based practice guidelines regarding appropriate nutritional support within the critical care setting are published. Yet, researchers continue to identify that despite published evidence, countless ICU patients continue to lack adequate and timely nutritional support on admission. Each of the authors in this issue promotes nutrition in their careers and individual practice areas, which brings knowledge from many different arenas throughout the nation. This issue discusses nutrition throughout the lifespan, special patient populations, implementation of guidelines, and how nutrition is being utilized as medical therapy.

Inhalt

Front Cover 1
Nutrition in Critical 
2 
copyright 
3 
Contributors 4
Critical Care Nursing 
 
8 
Preface 
10 
References 11
Nutritional Support for Premature Infants in the Neonatal Intensive Care Unit 14
Key points 14
Introduction 14
Effect of Early Nutritional Support for Premature Infants 15
Growth Restriction and Neurodevelopment 15
Premature infants: classifications and definitions 15
Premature Infant Categories by Birth Weight and Gestational Age 15
Differentiation Between Gestational and Postnatal Maturation 16
Development of anatomy and physiologic function, and effect of premature delivery 16
Gastrointestinal Tract and Digestive System 16
Development of the gastrointestinal tract and digestive system 16
Enteric Nervous System 16
Gastric emptying 17
Feeding intolerance 17
Necrotizing enterocolitis 17
Causes of NEC 17
Clinical presentation of NEC 18
Short bowel syndrome 18
Renal System 18
Development of the renal system 18
Primary functions of the renal system 19
Challenges of providing optimal nutrition in the NICU and evidence-based strategies 19
Nutritional Needs of Premature Infants 19
PN 19
PN-related Cholestasis 20
Enteral Nutrition 20
Trophic feeds 20
Enteric feeds after NEC 23
Human Breast Milk 23
Donor Breast Milk 23
Breast Milk Fortifiers and Premature Infant Formulas 24
Assessment of Growth in Response to Nutritional Support 25
Weight, head circumference, and length 25
Growth charts 25
Body composition measurements 25
Effect of Nutrition During Initial Hospitalization of Premature Infants on Later Adulthood 25
Summary 26
References 26
Nutrition in the Pediatric Population in the Intensive Care Unit 32
Key points 32
Introduction 32
Determining nutritional needs 33
Energy Needs 35
Macronutrient Needs 36
Electrolyte and Micronutrient Needs 37
Enteral nutrition 37
Human Milk 37
Commercial Enteral Formulas 38
Fiber 38
Enteral Nutrition Delivery 38
Timing 39
Gaps in Prescription and Delivery 39
Enteral Complications and Limitations 40
Parenteral nutrition 40
Summary 42
References 42
Nutrition in the Chronically Ill Critical Care Patient 50
Key points 50
Introduction 50
ASPEN guidelines 50
Implementing risk assessment into practice 51
Evidence for use of enteral nutrition 52
Evidence for monitoring of gastric residual volume 53
Evidence of recommendations for enteral nutrition in critically ill 54
Chronic disease considerations 54
Nutrition support team and special considerations 55
Summary 58
References 58
Malnutrition in the ICU Patient Population 60
Key points 60
Introduction 60
Critical illness and malnutrition 60
Malnutrition defined 61
Screening and assessment 62
Nutrition therapy 63
Estimating Energy Needs 63
Delivery of Nutritional Support 64
Parenteral Nutrition 66
Adjunctive therapies 67
Common complications of specialized nutrition therapies 67
Nursing considerations 69
Monitoring Tolerance of Enteral Feedings and Gastric Residual Volumes 70
Flushing Feeding Tubes 71
Summary 71
References 71
Nutrition and Care Considerations in the Overweight and Obese Population Within the Critical Care Setting 76
Key points 76
Introduction 76
Obesity defined 76
Obesity prevalence 77
Care considerations 78
Nutritional support 82
Summary 84
Acknowledgments 84
References 84
Nutritional Requirements After Bariatric Surgery 88
Key points 88
Introduction 88
Management goals 88
Diet Stages and Progression 89
Dumping syndrome 90
Nutrients 90
Protein 91
Carbohydrates 91
Hydration 91
Micronutrients 92
Nutrition support 93
Achieving success 94
Summary 94
References 94
Bedside Caregivers as Change Agents 96
Key points 96
Introduction 96
Model for change 97
Assess the need for change in practice 97
Development of a Team and Identification of the Clinical Problem 97
Best Practice and Benchmarks for EN 98
Locating the best evidence 101
Critical analysis of the evidence 101
Risks 102
Feasibility 102
Benefits 102
Design of EN practice change 103
Outcomes 103
Implementation and evaluation 104
Integration and maintenance 105
Summary and discussion 106
References 106
Nutrition as Medical Therapy 110
Key points 110
Introduction 110
Selenium for sepsis 111
Lipid rescue therapy 112
Insulin as an antidote 113
l-carnitine for valproic acid toxicity 115
Summary 117
References 117
Index 122

Textauszug

Nutrition in the Pediatric Population in the Intensive Care Unit

Judy Verger, RN, PhD, CRNP, CCRNabc∗[e-mail],     aPediatric Acute Care Nurse Practitioner Program, Critical Care Department, School of Nursing, Children’s Hospital of Philadelphia, University of Pennsylvania, 17 Ridings Way, Chadds Ford, PA 19317, USA; bPediatric Clinical Nurse Specialist Program, Critical Care Department, School of Nursing, Children’s Hospital of Philadelphia, University of Pennsylvania, 17 Ridings Way, Chadds Ford, PA 19317, USA; cNeonatal Clinical Nurse Specialist Program, Critical Care Department, School of Nursing, Children’s Hospital of Philadelphia, University of Pennsylvania, 17 Ridings Way, Chadds Ford, PA 19317, USA

∗17 Ridings Way, Chadds Ford, PA 19317.

Nutrition is an essential component of patient management in the pediatric intensive care unit (PICU). Poor nutrition status accompanies many childhood chronic illnesses. A thorough assessment of the critically ill child is required to inform the plan for nutrition support. Accurate and clinically relevant nutritional assessment, including growth measurements, provides important guidance. Indirect calorimetry provides the most accurate measurement of resting energy expenditure, but is too often unavailable in the PICU. To prevent inappropriate caloric intake, reassessment of the child’s nutrition status is imperative. Enteral nutrition is the recommended route of intake. Human milk is preferred for infants.

Keywords

Nutrition

Critically ill child

Nutritional disorders

Child

Intensive care unit

Key points

• Critically ill infants and children have an increase in metabolic needs and lower macronutrient stores.

• For any hospitalized child, growth assessment is vitally important, and documenting baseline nutrition parameters including body weight, length/height, and body mass index provides guidance for nutritional support.

• The energy requirements for the critically ill child are highly individualized and may vary widely.

• The immunoglobulins available in human milk support a wide range of bacteriostatic and bactericidal activity.

• Although brief nutritional inadequacies may have limited consequences, if adequate oral intake is not expected within 24 to 48 hours of admission, alternative methods should be sought.

• Parenteral nutrition is used in the pediatric intensive care unit when the enteral route cannot be used or is unable to provide sufficient calories.

Introduction

Nutrition is an essential component of patient management in the pediatric intensive care unit (PICU). Critically ill infants and children have an increase in metabolic needs and lower macronutrient stores inherent in infancy and childhood. In addition, the added nutritional complexities of critical illness make providing adequate nutrition particularly difficult. Undernourished states are a common consequence of disease and its treatment. Although a few recent studies challenge assumptions, the significance of nutrition support for hospitalized patients has been well documented.1–7 Delivery of acceptable nutrient amounts is linked with enhanced clinical outcomes, including improved wound healing and tissue integrity.7–15 Higher calorie and protein intake is associated with positive protein balance in children who are ventilated mechanically.8,16–18 In addition, increased delivery of nutrition is linked to reduced infection rates, length of hospital stay, and mortality, especially when nutrition protocols are in place.1,8,13,15,19

Malnutrition has been reported at admission and during hospitalization in critically ill children since the 1980s.20–27 Two of the first widely disseminated studies were completed by Pollack and colleagues.25,26 These investigators noted a 20% occurrence of chronic and acute malnutrition. A recent study confirmed that rates for suboptimal nutrition remain high in PICUs worldwide.28 This international point prevalence study included 31 intensive care units (ICUs), and found that 30% of all PICU patients demonstrate signs of malnutrition.

The trajectory of critical illness varies and is a multifactorial, heterogeneous disease process. Hypermetabolism leads to a shortfall in energy, and simultaneous changes in micronutrient and macronutrient needs. Body storage sites, especially muscles, are depleted for energy to support the immune system and other key body functions. Despite this catabolism, the contraction of muscle fibers associated with mechanical work is an energy-demanding process. With muscle wasting, respiratory insufficiency may lead to delayed weaning from mechanical ventilation.29 Gastrointestinal (GI) dysfunction is commonly reported in critically ill patients.30,31 The motility of the GI tract diminishes almost immediately, triggered by sympathetic stimulation and the inflammatory response connected to injury.32 Alterations in the GI tract place the patient at risk for systemic infections by translocation of the GI flora into the systemic circulation. Acute lower respiratory infections have been associated with undernutrition and zinc deficiency.33 Malnourished patients often have prolonged hospitalizations and increased hospital costs.22,24,34,35

Poor nutrition status accompanies many chronic childhood diseases. Conditions such as congenital heart disease (CHD), oncologic disorders, significant neurologic dysfunction, and other common chronic conditions contribute to the risk of undernutrition. Infants with CHD have demonstrated the presence of growth failure in all age groups and in all stages of repair.20,36 Patients with CHD have a 3.6 times higher chance of not reaching satisfactory caloric intake when matched against subjects without CHD.20 Factors leading to energy deficiency in children with cancer include insufficient intake, increased metabolic rate, altered physical activity, and inflammation.37 Those children with conditions that include severe motor disability are at higher risk of undernutrition.38 In addition, infants with brainstem injury often have feeding difficulties.39

An imbalance of energy and nutrient equation leads to nutrition related consequences. Children with injury or sepsis or those who are admitted to the ICU in a malnourished state are particularly at risk and require the highest priority. Although the metabolic response in critical illness is unavoidable, provision of adequate calories and protein based on patient size and metabolic needs is crucial.40

Determining nutritional needs

A thorough assessment of the critically ill child is required to inform the plan for nutritional support. The American Society of Parenteral and Enteral Nutrition (ASPEN) nutritional support guidelines for critically ill children recommend that children undergo nutrition screening to identify those with existing malnutrition and those nutritionally at risk.13 The Joint Commission requires assessment of nutritional risk within 24 hours of hospital admission.41 Those not at risk on admission should be regularly rescreened, as significant protein and energy depletion in patients hospitalized for longer than 7 to 10 days has been demonstrated.42 Added risk is also related to the longer duration the patient has been without adequate nutrition. When screening measures identify risk of malnutrition, a formal assessment is warranted.

No sole assessment measure is adequate to provide a complete picture of the nutritional status of sick infants and children. A systematic appraisal of the child’s physical examination findings, a review of relevant diagnostics, and an awareness of the metabolic consequences of the child disease are essential. Clinical and biochemical assessment strategies provide specific information to support nutritional prescription. In addition, an evaluation of energy expenditure can be an important asset in guiding the nutrition plan.

The first step in nutritional risk assessment is a careful history. Accurate and clinically relevant nutritional assessment provides important guidance.32 Historical growth data, hospitalizations, surgical procedures, and acute and chronic conditions, especially those that have GI sequelae and feeding difficulties, are important to note. Because of their effect on intake, identifying prior sensory and fine motor dysfunction and chewing and swallowing difficulties is important. In addition, any recent weight loss or decreases in nutrient intake are key indicators of nutrition risk.

The physical examination is useful in establishing nutrition status. Some of the first visual signs of protein malnutrition are seen in rapidly growing tissues.42,43 Skin is thin, dull, and dry in appearance. Hair is brittle and falls out easily. The abdomen may appear...

Produkt-Details

• Erscheint lt. Verlag: 9.8.2014
• Sprache: englisch
• Themenwelt: Pflege ► Fachpflege ► Anästhesie / Intensivmedizin
• ISBN-10: 0-323-29936-9 / 0323299369
• ISBN-13: 978-0-323-29936-7 / 9780323299367