Arginine is hypothesized to have a role in the intermediary metabolism of critically ill patients. Does it have an immune-modulating effect? Robert G. Martindale, MD, PhD and Juan B. Ochoa, MD debate the conflicting critical care literature on arginine use.
Click here for the argument supporting use of arginine "Use of Arginine in Critical Illness - Panacea or Poison" presented by Dr. Robert Martindale.
Click here for the argument opposing increased use of arginine "Arginine Deficiency Syndrome" presented by Dr. Juan B. Ochoa.
KEY NUTRIENTS AND THEIR ROLE IN THE NUTRITION CARE PROCESS
Several substances have growing roles in nutrition therapy. Each has the significant potential to benefit critically ill patients. These discussions blend science and practice as links between nutrition and selected elements are examined. Each presentation increases one’s understanding of how and when a particular nutrient can enhance patient outcomes.
Glutamine may act at multiple levels to assuage GI tract injury and may potentiate the subsequent gut-derived systemic inflammatory response. There is growing literature that examines the clinical utility of glutamine. Paul Wischmeyer, MD and Jan Wernerman, MD, PhD discuss relevant new data regarding the action and utility of glutamine.
Click here for the discussion of the cellular effects of glutamine “Glutamine in Critical Illness – Pharmacology and Mechanism of Action” presented by Dr. Paul Wischmeyer.
Click here for discussion of glutamine administration “Glutamine Supplementation in the ICU” presented by Dr. Jan Wernerman.
Prebiotics/Probiotics may significantly alter patient response to critical illness. Robert G. Martindale, MD, PhD discusses the role of bacterial flora in the critically ill as various clinical interventions alter bacterial interrelationships.
Click here for the discussion of relevant literature “Prebiotics, Probiotics and Synbiotics: Food Fad or "'Bacterial Therapy’” presented by Dr. Robert G. Martindale.
Gut Immunity has an increasingly important role as an immune response modulator. Kenneth A. Kudsk, MD, FCCM examines the relationship between nutrition and mucosal immunity, including a discussion of the common mucosal immune hypothesis.
Click here for a review of the “gut driven inflammatory response” “Nutrition and Mucosal Immunity” presented by Dr. Kenneth A. Kudsk.
Antioxidants and Trace Elements are common components of nutrition therapy. Jean-Charles Preiser, MD, PhD reviews cellular response to acute injury and discusses redox regulation and efficacy of strategies to reduce oxidative stress and dysregulation.
Click here for the discussion of antioxidant role in nutrition management of critically ill patients “Anti-oxidants and Trace Elements: State of the Art” presented by Dr. Jean-Charles Preiser.
STRATEGIES TO MAXIMIZE BENEFIT
Numerous controversies exist within the domain of nutrition therapy. Questions regarding quantity, frequency, strength and patient selection abound. These international experts selected several current controversies and explored them with the intent to promote maximum patient benefit.
Glycemic Control remains a major discussion topic within the critical care team. Evolving evidence and expert opinion work to answer the question: Should the target of glycemic control be euglycemia? Judith Jacobi, PharmD, FCCM and Jean-Charles Preiser, MD, PhD debate this topic. Each shares relevant data supportive of their position.
Click here for the argument in support of intensive insulin therapy “Normoglycemia is the Optimal Target in the ICU” presented by Dr. Judith Jacobi.
Click here for an examination of data in opposition to the need for tight control “Glycemic Control: Target of Tight Glucose Should NOT be Normoglycemia” presented by Dr. Jean-Charles Preiser.
Permissive Underfeeding research indicates that hypocaloric nutrition has the potential to provide nutrition support without exacerbating the stress response that was often intensified during traditional nutrition support of the critically ill. Daren K. Heyland, MD and Jan Wernerman, MD, PhD discuss positive and negative outcomes related to permissive underfeeding.
Click here for the discussion of research evaluating hypocaloric nutrition “Permissive Underfeeding of the Critically Ill????” presented by Dr. Jan Wernerman.
Click here for a discussion of the rationale for limiting exogenous carbohydrates “Providing Exogenous Carbohydrates to Critically Ill Patients” presented by Dr. Daren K. Heyland.
MAXIMIZING BENEFITS AND MINIMIZING RISKS IN NUTRITIONAL THERAPY
Within the group of patients requiring nutrition support, interventions have accompanying risk. Expert faculty explore selected considerations when administering enteral or parenteral nutrition support.
Aspiration/Gastric Residual Volume literature reveals there is great variability in defining gastric residual volume. Norma Matheny, RN, PhD, FAAN discusses the evidence answering the question “How can we find how much is really ‘too much’”?
Click here for a discussion of best practice strategies “Aspiration/Gastric Residual Volume” presented by Dr. Norma Matheny
Gastric vs. Small Bowel Feeding is a nutritional consideration as critically ill patients often receive various interventions that lead to impaired gastric emptying. Beth Taylor, MS, RD, CNSD, FCCM examines differences among ICU patients as you consider enteral feeding routes.
Click here for a discussion of risk/benefits associated with enteral nutrition routes “Gastric vs. Small Bowel Feeding in the ICU” presented by BethTaylor, MS, RD, CNSD.
Efficacy from Parenteral Nutrition. A critical challenge is to improve parenteral nutrition efficacy while reducing inherent risk. Stephen A. McClave, MD focuses on parenteral nutrition within the controversial first week of ICU stay.
Click here for a discussion of strategies to optimize parenteral nutrition outcomes “Optimizing Efficacy from PN” presented by Dr. Stephen A. McClave.
IMPROVING PRACTICE
Practice guidelines are tools to improve the quality of care. They result from objective analysis and grading of gathered evidence and outcomes.
Guideline Development Process. Daren K. Heyland, MD answers the question “What is a GOOD guideline?” He explores the process of guideline development including discussions of levels of evidence and criteria for high quality clinical practice guidelines.
Click here for a discussion of the guideline development process “Guideline Development Process” presented by Dr. Daren K. Heyland.
Available Nutrition Guidelines: Similarities and Differences. Robert G. Martindale, MD, PhD discusses the benefits of guideline use. He identifies nutrients addressed between and among nutrition guidelines prepared by leading groups. He also suggests strategies to help implement guidelines.
Click here for a comparison of selected international nutrition guidelines “ICU Nutrition Guidelines: Similarities and Differences” presented by Dr. Robert G. Martindale.
From Evidence to Practice. Pamela R. Roberts, MD, FCCM outlines strategies for using evidence to drive nutrition therapy practice. She frames her discussion within the Donabedian model of structure, process and outcome.
Click here for a discussion of using evidence to raise the bar for nutrition therapy “From Evidence to Practice: How to Improve Quality of Nutritional Care in the ICU” presented by Dr. Pamela R. Roberts.
DOING IT RIGHT
Substantive strategies for practice improvement are helpful. Expert faculty share their clinical successes with the challenges of glucose control, access routes for nutrition therapy, determination of caloric requirements and timing of nutrition intervention. Implementation strategies are included.
Glucose management
Click here for suggestions for implementing a glycemic control team, “Best Practices – Glycemic Control” presented by Dr. Judith Jacobi.
Issues of access
Click here for a discussion of parameters of concern when selecting the most appropriate enteral and parenteral access route in “A Question of Access” presented by Beth Taylor, MS, RD, CNSD.
Indirect calorimetry
Click here for the discussion of the present and emerging benefits of indirect calorimetry “Indirect Calorimetry: Research versus Clinical Practice" presented by Dr. Pierre Singer.
Nutrition within the first 24 hours of critical illness
Click here for the discussion of strategies for determining early nutrition therapy “Nutrition Within the First 24 Hours of Critical Illness” presented by Dr. Rene L. Chiolero.
Where Do We Go From Here?
Robert G. Martindale, MD, PhD summarizes the key elements of this conference and issues a challenge to advance nutrition therapy to the next level.
Click here for the summary message “Where Do We Go From Here?” presented by Dr. Robert G. Martindale.