20. “ systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” U.S. Institute of Medicine “ EBM - the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” Sackett DL et al. BMJ 1996
21.
22. Organisation of Nutrition Support 3. NICE Guidelines for Nutrition Support in Adults 2006 Screen Recognise Treat Oral Enteral Parenteral Monitor & Review
23.
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25. Step 3 Treat: Enteral use the most appropriate route of access and mode of delivery has a functional and accessible gastrointestinal tract if patient malnourished/at risk of malnutrition despite the use of oral interventions and 3. NICE Guidelines for Nutrition Support in Adults 2006
26. Step 3 Treat: PN and has either introduce progressively and monitor closely if patient malnourished/at risk of malnutrition a non-functional, inaccessible or perforated gastrointestinal tract inadequate or unsafe oral or enteral nutritional intake use the most appropriate route of access and mode of delivery 3. NICE Guidelines for Nutrition Support in Adults 2006
44. THE ICU GAMBLE How to tip the scales? Inflammation, organ failure Inflammation and resolution DEATH LIFE DISABILITY
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49. Potential Beneficial Effects of Glutamine GLN pool Wischmeyer PE, Curr Opin Clin Nutr Metab Care 6: 217-222, 2003 Fuel for Enterocytes Fuel for Lymphocytes Nuclotide Synthesis Maintenance of Intestinal Mucosal Barrier Maintenance of Lymphocyte Function Preservation of TCA Function Decreased Free Radical availability (Anti-inflammatory action) Glutathione Synthesis Glutamine Therapy Enhanced Heat Shock Protein Anti-catabolic effect Preservation of Muscle mass Reduced Translocation Enteric Bacteria or Endotoxins Reduction of Infectious complications Inflammatory Cytokine Attenuation NF-kB ? Preserved Cellular Energetics- ATP content GLN Pool Critical Illness Enhanced insulin sensitivity
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60. Borage Oil DGLA PGE 1 and fewer Inflammatory Eicosanoids Substitution of AA By DGLA resulting in: Fish Oil Fewer Inflammatory Eicosanoids (TXA 3 , PGE 3 , LTB 5 ) Substitution of AA By EPA Resulting in: Arachidonic Acid Cyclooxygenase Lipoxygenase Pro-Inflammatory Eicosanoids (LTB 4 , TXA 2 , PGE 2 ) Decrease in X Mechanisms of Action GLA EPA
61.
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65. ACUTE INSULT Exacerbation of cell and tissue injury Inflammatory mediators ROS/RNOS Healing/repair/defence
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67. Which Nutrient for Which Population? Canadian Clinical Practice Guidelines JPEN 2003;27:355 Recom-mend … … … … … Omega 3 FFA … … … … Consider … Anti-oxidants … EN Possibly Beneficial: Consider EN Possibly Beneficial: Consider … PN Beneficial Recom-mend Possible Benefit Glutamine No benefit No benefit (Possible benefit) Harm(?) No benefit Benefit Arginine Acute Lung Injury Burns Trauma Septic General Elective Surgery Critically Ill
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Editor's Notes
NOTES FOR PRESENTERS For the purposes of this guideline, enteral tube feeding refers to the delivery of a nutritionally complete feed (containing protein or amino acids, carbohydrate with or without fibre, fat, water, minerals and vitamins) directly into the gut via a tube. The tube is usually placed into the stomach, duodenum or jejunum via either the nose, mouth or the direct percutaneous route. Enteral tube feeding is not exclusive and can be used in combination with oral and/or parenteral nutrition. Patients receiving enteral tube feeding should be reviewed regularly to enable re-instigation of oral nutrition when appropriate. Most enteral feeding tubes are introduced at the bedside but some are placed surgically, at endoscopy or using radiological techniques, and some are inserted in the community. Enteral tube feeding should be considered for patients who are malnourished or at risk of malnourishment, who can’t be fed orally and who have a working and accessible gut. Whenever possible the patient should be aware of why this form of nutrition support is necessary, how it will be given, for how long, and the potential risks involved. There may be considerable ethical difficulties in deciding if it is in a patient’s best interests to start a tube feed.
NOTES FOR PRESENTERS Parenteral nutrition refers to the administration of nutrients by the intravenous route. It is usually administered via a dedicated central or peripheral placed line. Parenteral feeding should be considered in patients for whom oral or enteral feeding isn’t appropriate or they have an inaccessible or perforated gut. Parenteral nutrition is an invasive and relatively expensive form of nutrition support (equivalent to most ‘new generation’ IV antibiotics daily) and in inexperienced hands, can be associated with risks from line placement, line infections, thrombosis and metabolic disturbance. Careful consideration is therefore needed when deciding to who, when and how this form of nutrition support should be given. Whenever possible, patients should be aware of why this form of nutrition support is needed and its potential risks and benefits. The feed should be given progressively, and monitored closely. Parenteral feeding should be stopped when the patient is established on feeding from the oral or enteral route. Whichever method of feeding is chosen, the patient should be monitored, and any adjustments needed made accordingly.
NOTES FOR PRESENTERS Please refer to the NICE Quick Reference Guide – page 19
