Journal of Medical Nutrition and Nutraceuticals

REVIEW ARTICLE
Year
: 2014  |  Volume : 3  |  Issue : 1  |  Page : 6--10

Nutritional facts in critically ill patients: The past, present and the future


Sukhminder Jit Singh Bajwa 
 Department of Anesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India

Correspondence Address:
Sukhminder Jit Singh Bajwa
Department of Anesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, House No-27-A, Ratan Nagar, Tripuri, Patiala, Punjab
India

Abstract

Nutrition in critically ill patients has traversed a long journey ever since its introduction in the pre-historic times. The nineteenth and the twentieth century have seen a flurry of advancements in enteral and parenteral nutritional practices which have given birth to modern day critical nutrition. The transition has been gradual which has led to evidence based nutritional practices leading to improved outcome in critically ill patients. The advancements have also enabled the answering of many controversial aspects related to nutrition in intensive care unit patients. The future of nutritional supplementation in critically ill patients holds well as many vital areas are being worked upon in numerous randomized clinical controlled trials throughout the globe. The current review describes a long journey of various facts related to critical care nutrition from the past to present and possible clinical status in future.



How to cite this article:
Bajwa SS. Nutritional facts in critically ill patients: The past, present and the future.J Med Nutr Nutraceut 2014;3:6-10


How to cite this URL:
Bajwa SS. Nutritional facts in critically ill patients: The past, present and the future. J Med Nutr Nutraceut [serial online] 2014 [cited 2020 Dec 5 ];3:6-10
Available from: https://www.jmnn.org/text.asp?2014/3/1/6/123429


Full Text

 Introduction



Nutritional therapeutics in critically ill patients has gone a sea of change over the last 4-5 decades. Ever since the birth of intensive care, the nutritional interventions have undergone the evolutionary changes with the advent of new therapeutic nutritional supplements. Evidence based medicine has further given the impetus to nutritional interventions and their decisive significance in morbidity and mortality of critically ill patients. Nutritional therapy has emerged as a specialized disciple in modern day critical care practice.

 Historical Aspects of Enteral Feeding



In the pre-historic times, animal bladders, silver and lead tubes were used to instill nutritional products into human bodies through rectum which were practiced widely till later part of nineteenth century with modified rectal tubes. [1] By the end of nineteenth century and at the turn of 20 th century, more innovative measures led to total discarding of rectal feeding especially when the first citizen of United States, the president James Garfield was fed for almost 3 months through rectal tube causing immense rectal irritation. [2] During sixteenth century, this methodology of delivering nutrients in critically ill tetanus and nearly drowned patients was applied through esophagus and achievement of some reduction in mortality further encouraged the physicians to make advancements in nutritional sciences by developing leather and flexible tubes. [3],[4] John Hunter devised a novel device by drawing eel skin over flexible whalebone in 1790 which was introduced into stomach through esophagus and proved to be a life savior for a patient with neurological deficit. [4] During a short period of two decades from 1803 to 1823, remarkable innovations led to use of stomach tubes and gastric pumps for simultaneous feeding and aspiration of gastric contents in European countries and United States. [5]

Significant transition

Looking at the initial days of critical care nutrition, morbidity was significantly higher as anabolic sciences were in primal stages. During World War-II, wounded soldiers with penetrating abdominal injuries were fed through trocars introduced into stomach. [6] Though the concept of "hyperalimentation" was introduced in 1940's, it was the midst of the 20 th century which saw the application of scientific methods in bringing a revolution in the administration of enteral and parenteral nutrition in critical care practices. [7] Assessment of nutritional requirement and exact calculation of requisite nutritional ingredients marked the beginning of the modern era of critical care nutrition. [7],[8]

The most dramatic turn in enteral feeding occurred during 1918 when striking inroads were made into post-operative feeding though jejunostomy Rehfuss tube devised by Andresen which paved the way for modern day Ryle's tube enteral feeding. [9] From two tubes devised by Stengel and Ravdin, one for stomach and other for jejunum, to a double Lumen tube devised by Abbott and Rawson termed as "medical ileostomy" and subsequent commercial availability of enteral nutrients provided the basis of modern critical care enteral nutrition. [10]

However, birth of modern day Ryle's tube feeding is indebted hugely to a landmark accomplishment of Barron in 1959 when they fed hundreds of patients through mercury-filled ballon tied to the tip of a polyethylene tube. [11] Besides making a major inroad into enteral nutritional practices, work of Barron also proved to be a prototype of parenteral nutrition models. [11] These innovations further encouraged the modifications and development of newer parenteral nutritional techniques. [10] The practices of enteral nutrition were taken to newer heights by a major work carried out by Ponsky in 1980 and by Shike, et al., in 1989 when they introduced the concept of percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy feeding respectively. [12],[13]

The quality of nutrition was further improved with the food and drug administration (FDA) intervention in 1995 when it was clearly recommended that food additive which is the part of nutritional therapy and is meant to diagnose, cure, treat or prevent a disease, should be treated as a therapeutic agent and not as food. [14]

Modern critical care nutritional practices

In the present day clinical scenario, it has been well established that patients after discharge from intensive care unit (ICU) shows higher morbidity and mortality if they are not given adequate nutritional supplementation during prolonged ICU stay. [15] Most of these morbidity statistics can be attributed to pulmonary complications resulting from loss of lean body mass and a higher catabolic rate after discharge from ICU besides limited therapeutic mobility and an equal debilitating inability to walk. [16],[17] Moreover, it has also been observed that more than 50% of the hospitalized patients suffer from some degree of malnutrition. [18],[19] The incidence of malnutrition in critically ill is not known exactly but more likely will be higher than that of general hospitalized population.

Scientific and evidence based recommendations of modern nutritional practices

The present day nutritional therapeutics in critical care units are guided by various recommendations and guidelines set by international organizations and societies such as European society for clinical nutrition and metabolism (ESPEN). [20] ALLIANCE is one such organization which is working very hard to achieve the nutritional goals and therapy at international level in general and in the Indian population in particular.

Never dying controversies of enteral and parenteral nutrition

Enteral and parenteral nutrition have been surrounded by various controversies some which have been answered with the passing time as more and more of evidence has become available. Nutritional supplementation is administered based on the degree of malnutrition and total energy expenditure during acute and recovery phase of the critical illness. [21],[22] Though, both enteral and parenteral route have specific indications whenever possible, enteral nutrition is preferred over parenteral nutrition. [23]

Enteral nutrition is considered to be more physiological, economical, restore gastro-intestinal functions early, reduces total stay in hospital and reduces the risk of infectious complications as compared to parenteral nutrition in critically ill patients. [23],[24] However, enteral nutrition is very challenging to administer as it is frequently interrupted by various difficulties such as invasive procedures like tracheostomy, endoscopies, radiologic procedures, surgeries, diarrhea, abdominal distension and many a times very subjectively in lieu of a larger aspirate. [25] These practices can often lead to a mismatch between calorie intake and actual calorie requirement. [26]

In contrast, parenteral nutrition also has some theoretical complications such as increased incidence of infections resulting from the enhanced translocation of bacteria from the gut to systemic circulation. [27] Besides, the concern of 'overfeeding' is always there if proper calorie intake is not precisely calculated. Though controversial, fewer studies and meta-analysis have observed a decreased morbidity and mortality with parenteral nutrition as compared to enteral nutrition. [27],[28] As per the guidelines of ESPEN, a daily intake of 25-30 kcal/kg is mandatory during the acute phase of any critical illness. If such requirements are difficult to fulfill with enteral nutrition, parenteral nutrition should definitely be supplemented with enteral nutrition. [20]

The combined approach of enteral and parenteral nutrition not only helpful in achieving a higher calorie intake but was also associated with improved serum protein levels. [29] The definite timing of parenteral nutrition initiation is proposed if enteral nutrition fails to provide at least 2/3 rd of the required calorie requirements during the first three days of hospital admission. [30] Maintenance of euglycemia, euelectrolytemia, and euvolemia is of prime significance during administration of such nutritional regimens. [30],[31],[32]

Recently, nutritional supplementation with immunonutrients such as arginine, glutamine, γ-linolenic acid, polyphenols and others has gained widespread acceptance in critically ill patients. [33] However, the biggest obstacle to such nutritional practices has been the limited availability of universal recommendations and guidelines which is responsible for the lack of awareness among the intensivists about the critical aspects of micronutrient supplementation in critically ill patients. [34]

Post-ICU scenario

The transition of nutritional needs from critically ill status to post-discharge ICU needs careful evaluation as the available literary evidence points towards high morbidity and mortality after discharge. [15] The major contributory factors leading to these higher mortality statistics may include but are not limited to high catabolism, minimal physical activity, pulmonary infections, gastro-intestinal disorders, loss of lean body mass, muscle weakness and above all poor follow-up of advice related to nutritional supplementation. [16],[17] A need is also felt to modify the nutritional supplementation by lowering catabolic damage during acute phase of critical illness as the harmful effects possible spreads to the post-discharge period.

Future directions and way to go

In future, nutrition in critical illness is going to have a wider scope for research as most of the patients have variable pathophysiologies and clinical presentations. Invariably such patients have one or more co-morbidities as the incidence of various non-communicable diseases has been on the rise evident from the 2010 report of "Global burden of disease" published in the Lancet. [35] The science of pharmaco-nutrition is growing fast and has laid emphasis on individualizing the nutritional needs of a critically ill patient. [36],[37] This sub-specialty of nutritional sciences is focused on elaborating an individual nutrient's role in specific illness and injury states. A lot of studies have been carried out highlighting the potential protective role of arginine, glutamine and omega-3 fatty acids during critical illness and many more studies related to other pharmaco-nutrients are in the pipeline. [38],[39] These studies have also observed that the requirements of a particular pharmaco-nutrient in specific disease and critical illness have to carefully evaluated and targeted. [40],[41] These pharmaco-nutrients exert their actions by various mechanisms including anti-inflammatory, immuno-stimulatory and immuno-modulation.

The present nutritional scenario in ICU seems to be passing from a transitory phase. With more of the research data getting available in the future, the nutritional aspects in critically ill are definitely going to see a period renascence. Evidence based medicine is providing a well-designed scientific platform on which the future of nutritional pharmacology is going to get improvised. The endoscopic placement of various jejunostomy and gastrostomy feeding tubes are revolutionizing the enteral feeding practices in critically ill patients. The post-operative and patients with pancreatitis, hepatic disease, renal disease, acquired immune deficiency syndrome, morbid obesity, respiratory disease and many other systemic and immune disorders have benefitted immensely from these advanced nutritional practices. [42],[43],[44],[45],[46],[47] Search and availability of new bio-markers of illness will definitely help tremendously in guiding nutritional therapy and will also enhance our molecular understanding of the various complicated disease pathologies in critically ill patients. [42] Advancements in pharmaco-genomics have clearly established the increasing role of nutrition in gene expression. Increasing availability of newer monitoring tools, re-defining of the nutritional standards based on individual needs, evaluation of organ functions with newer technology, more and more of available data on critical illness and a better co-ordination between various medical specialties will definitely help in optimizing the delivery of nutritional care. Few vital areas to be covered comprehensively in the future should include immune-nutrition, pharmaco-nutrition, and tight glycemic control, nutrition in post-surgical patients and appropriate rationale and thinking related to various controversial aspects of enteral and parenteral nutrition.

 Conclusion



The past of critical care nutrition has been studded with various interesting advancements and innovations which have paved the way for evidence based current nutritional practices in critically ill patients. At present, various randomized clinical trials and studies are being carried out throughout the globe which is aiming at improving the nutritional practices in ICU. The goal of such therapeutic trials is mainly to decrease the morbidity and mortality associated with various nutritional regimens based on literary evidence. The future holds good as numerous controversial topics are being dealt and answered and critical areas such as tight glycaemic control, immuno-nutrition and many others are being researched extensively.

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