Recommendations For Nutritional Support Research Articles

Caloric requirement targets for nutritional support in adult autoimmune encephalitis: a retrospective cohort study.

Autoimmune encephalitis (AE) is a severe neurological disease often accompanied by consciousness disturbances, severe swallowing difficulties, and gastrointestinal dysfunction, increasing the risk of malnutrition. However, the optimal caloric intake target during the acute phase of AE remains unclear. This study aims to evaluate the impact of caloric intake on short-term clinical outcomes in AE patients, specifically focusing on the improvement in Clinical Assessment Scale for Autoimmune Encephalitis (CASE) scores, to provide recommendations for nutritional support during the acute phase. A retrospective study analyzed clinical data from 128 adult AE patients requiring nutritional support, admitted to West China Hospital, Sichuan University, from January 2020 to January 2024. Patients were categorized into low-calorie intake (below 70% of requirements), standard-calorie intake (70-100% of requirements), and high-calorie intake (above 100% of requirements) groups. Multivariate linear and logistic regression models were used to quantify the associations. Higher caloric intake was significantly associated with improved CASE scores (β = 8.58, SE = 3.75, 95% CI = 1.14 to 16.03, p = 0.02). Low caloric intake negatively impacted the improvement of CASE scores (p = 0.049), particularly in seizures and speech problems. The low-calorie intake group had significantly longer hospital stays and nutrition therapy durations (45.79 ± 30.98 days, p < 0.01; 40.39 ± 31.92 days, p = 0.02). Adequate caloric intake has a significant positive impact on the short-term clinical outcomes of AE patients, suggesting that meeting or exceeding caloric requirements may promote neurological recovery in AE patients. Future prospective studies are needed to validate these findings and further optimize nutritional support strategies.

Research progress on nutritional support in the neonatal and pediatric populations receiving extracorporeal membrane oxygenation.

Nutritional support is crucial for the prognosis of children supported by extracorporeal membrane oxygenation (ECMO). This article discusses the latest research progress and guideline recommendations for nutritional support during ECMO. We summarize the nutritional status and evaluation of ECMO patients, nutritional support methods and timing, trace elements, the impact of continuous renal replacement therapy (CRRT), and energy requirements and algorithms. The article shows that malnutrition is high in ECMO patients compared to other critically ill patients, with nearly one-third of patients experiencing a decrease in nutritional indicators. The timing of the initiation of nutrition is very important for the nutritional status of the child. Early enteral nutrition can improve patient prognosis, which is the most commonly used, with parenteral nutrition as a supplement. However, the proportion of enteral nutrition is relatively low, and a stepwise nutrition algorithm can determine when to initiate early enteral nutrition and parenteral nutrition. Malnourishment during critical illness have been associated with increased morbidity as well as increased mortality. Nutritional status should be evaluated at admission by screening tools. In addition, changes in the levels of several metabolites in vivo, such as blood lipids, carnitine, and thiamine, can also reflect the degree of nutritional deficiency in critically ill children. This article provides a reference for the implementation of nutrition of pediatric ECMO patients and further research on nutritional support.

Evaluation of effectiveness of the diets developed for children with allergical pathology living in conditions of adverse environmental exposures

Introduction. Nutrition is one of the important preventive measures aimed at enhancing body resistance to adverse effects of environmental factors. Nutrition modelling taking into account its basic quality and environmental exposures is of particular importance for effective management of risks for the disease.&#x0D; Our objective was to assess the effectiveness of the diets specially developed for children with allergies environmentally exposed to industrial pollutants.&#x0D; Materials and methods. We examined cytomorphological features, nutritional status, general health status, and skin manifestations in eighty 3 to 6-year children suffering from allergies and sensitized to food products.&#x0D; Results. A hypoallergenic elimination and detoxification diet specially developed with account for food intolerance, immune status, protein, energy and micronutrient sufficiency, genomic status, mental and physical health of the preschoolers with allergies led to a 1.5-fold decrease in the number of underweight children and &#x0D; a threefold average drop in blood levels of lead, aluminum, arsenic, copper, and cadmium. The mean number of children with clinical manifestations of food intolerance demonstrated the 1.6-fold decline, the level of sIgA increased, while cytogenetic abnormalities in buccal epithelium decreased by 2.1 times.&#x0D; Limitations. A limitation of the study was the lack of compliance of parents with recommendations for nutritional support.&#x0D; Conclusions. The applied method of modelling the diet using dietary techniques based on basic nutrition data, toxic exposures, genetics, anthropometric, clinical, and immunological indicators has had a beneficial effect on all assessed health parameters in children with allergies living in a large industrial city.

Review of ESPEN-2021 Practice Guidelines for Patients with Cancer. Part 2: Interventions Relevant to Specific Patient Categories

This study further discussed the 2021 ESPEN practical recommendations for nutritional support in oncology. The updated version of the 2021 ESPEN practice guidelines differs slightly from the 2017 version and contains flowcharts to facilitate the use of the guidelines in clinical practice, which is also relevant for domestic healthcare. ESPEN-2021 Clinical Guidelines, which offer practical solutions in all areas of oncology, are significant to both oncologists and allied specialists working in oncology. The second part of the review discusses particular issues of nutritional support for patients with cancer and analyzes the domestic experience of their use. The review provides the main protocols for artificial nutrition in surgery, during irradiation, and in drug therapy in patients in remission and at the palliative stage and proves the need to maintain physical activity in patients with cancer. The presented practical guidance allows organizing an adequate supply of nutrient substrates to patients with cancer receiving various types of anticancer treatment, in remission, and at the stage of palliative care.

Review of ESPEN-2021 Practice Guidelines for Cancer Patients: Part 1

This study discusses the 2021 ESPEN Practical Guidelines for Nutritional Support in Oncology. The updated version of the 2021 ESPEN practice guidelines differs slightly from the 2017 version and contains flowcharts to facilitate the use of the guidelines in clinical practice, which is also relevant for domestic healthcare. ESPEN-2021 Clinical Guidelines, which offer practical solutions in all areas of oncology, are of particular interest to both oncologists and allied specialists working in oncology. The first part of the review discusses general recommendations for nutritional support for patients with cancer and the possibility of their use in our country: screening of nutritional status at the initial visit, indications for prescribing additional nutrition, benefits of one or another type of nutritional support in various situations, norms for providing macronutrients, vitamins, and minerals, and need for physical activity. This practical guide forms an algorithm of actions to ensure optimal nutrition for patients with cancer. The general principles of nutritional therapy for all patients with cancer are based on timely screening for nutritional deficiencies and adherence to appropriate nutritional support of patients, which can be achieved by modifying the diet or prescribing additional nutrition, mainly enteral nutrition.

Children's Oxygen Administration Strategies And Nutrition Trial (COAST-Nutrition): a protocol for a phase II randomised controlled trial.

Background: To prevent poor long-term outcomes (deaths and readmissions) the integrated global action plan for pneumonia and diarrhoea recommends under the 'Treat' element of Protect, Prevent and Treat interventions the importance of continued feeding but gives no specific recommendations for nutritional support. Early nutritional support has been practiced in a wide variety of critically ill patients to provide vital cell substrates, antioxidants, vitamins, and minerals essential for normal cell function and decreasing hypermetabolism. We hypothesise that the excess post-discharge mortality associated with pneumonia may relate to the catabolic response and muscle wasting induced by severe infection and inadequacy of the diet to aid recovery. We suggest that providing additional energy-rich, protein, fat and micronutrient ready-to-use therapeutic feeds (RUTF) to help meet additional nutritional requirements may improve outcome. Methods: COAST-Nutrition is an open, multicentre, Phase II randomised controlled trial in children aged 6 months to 12 years hospitalised with suspected severe pneumonia (and hypoxaemia, SpO 2 <92%) to establish whether supplementary feeds with RUTF given in addition to usual diet for 56-days (experimental) improves outcomes at 90-days compared to usual diet alone (control). Primary endpoint is change in mid-upper arm circumference (MUAC) at 90 days and/or as a composite with 90-day mortality. Secondary outcomes include anthropometric status, mortality, readmission at days 28 and 180. The trial will be conducted in four sites in two countries (Uganda and Kenya) enrolling 840 children followed up to 180 days. Ancillary studies include cost-economic analysis, molecular characterisation of bacterial and viral pathogens, evaluation of putative biomarkers of pneumonia, assessment of muscle and fat mass and host genetic studies. Discussion: This study is the first step in providing an option for nutritional support following severe pneumonia and will help in the design of a large Phase III trial. Registration: ISRCTN10829073 (6 th June 2018) PACTR202106635355751 (2 nd June 2021).

Children’s Oxygen Administration Strategies And Nutrition Trial (COAST-Nutrition): a protocol for a phase II randomised controlled trial

Background: To prevent poor long-term outcomes (deaths and readmissions) the integrated global action plan for pneumonia and diarrhoea recommends under the ‘Treat’ element of Protect, Prevent and Treat interventions the importance of continued feeding but gives no specific recommendations for nutritional support. Early nutritional support has been practiced in a wide variety of critically ill patients to provide vital cell substrates, antioxidants, vitamins, and minerals essential for normal cell function and decreasing hypermetabolism. We hypothesise that the excess post-discharge mortality associated with pneumonia may relate to the catabolic response and muscle wasting induced by severe infection and inadequacy of the diet to aid recovery. We suggest that providing additional energy-rich, protein, fat and micronutrient ready-to-use therapeutic feeds (RUTF) to help meet additional nutritional requirements may improve outcome. Methods: COAST-Nutrition is an open, multicentre, Phase II randomised controlled trial in children aged 6 months to 12 years hospitalised with suspected severe pneumonia (and hypoxaemia, SpO 2 <92%) to establish whether supplementary feeds with RUTF given in addition to usual diet for 56-days (experimental) improves outcomes at 90-days compared to usual diet alone (control). Primary endpoint is change in mid-upper arm circumference (MUAC) at 90 days and/or as a composite with 90-day mortality. Secondary outcomes include anthropometric status, mortality, readmission at days 28 and 180. The trial will be conducted in four sites in two countries (Uganda and Kenya) enrolling 840 children followed up to 180 days. Ancillary studies include cost-economic analysis, molecular characterisation of bacterial and viral pathogens, evaluation of putative biomarkers of pneumonia, assessment of muscle and fat mass and host genetic studies. Discussion: This study is the first step in providing an option for nutritional support following severe pneumonia and will help in the design of a large Phase III trial. Registration: ISRCTN10829073 (6 th June 2018) PACTR202106635355751 (2 nd June 2021)

Children’s Oxygen Administration Strategies And Nutrition Trial (COAST-Nutrition): a protocol for a phase II randomised controlled trial

Background: To prevent poor long-term outcomes (deaths and readmissions) the integrated global action plan for pneumonia and diarrhoea recommends under the ‘Treat’ element of Protect, Prevent and Treat interventions the importance of continued feeding but gives no specific recommendations for nutritional support. Early nutritional support has been practiced in a wide variety of critically ill patients to provide vital cell substrates, antioxidants, vitamins, and minerals essential for normal cell function and decreasing hypermetabolism. We hypothesise that the excess post-discharge mortality associated with pneumonia may relate to the catabolic response and muscle wasting induced by severe infection and inadequacy of the diet to aid recovery. We suggest that providing additional energy-rich, protein, fat and micronutrient ready-to-use therapeutic feeds (RUTF) to help meet additional nutritional requirements may improve outcome. Methods: COAST-Nutrition is an open, multicentre, Phase II randomised controlled trial in children aged 6 months to 12 years hospitalised with suspected severe pneumonia (and hypoxaemia, SpO2 &lt;92%) to establish whether supplementary feeds with RUTF given in addition to usual diet for 56-days (experimental) improves outcomes at 90-days compared to usual diet alone (control). Primary endpoint is change in mid-upper arm circumference (MUAC) at 90 days and/or as a composite with 90-day mortality. Secondary outcomes include anthropometric status, mortality, readmission at days 28 and 180. The trial will be conducted in four sites in two countries (Uganda and Kenya) enrolling 840 children followed up to 180 days. Ancillary studies include cost-economic analysis, molecular characterisation of bacterial and viral pathogens, evaluation of putative biomarkers of pneumonia, assessment of muscle and fat mass and host genetic studies. Discussion: This study is the first step in providing an option for nutritional support following severe pneumonia and will help in the design of a large Phase III trial. Registration: ISRCTN10829073 (6th June 2018) PACTR202106635355751 (2nd June 2021)

Nutritional Management of the Critically Ill Neonate: A Position Paper of the ESPGHAN Committee on Nutrition.

The nutritional management of critically ill term neonates and preterm infants varies widely, and controversies exist in regard to when to initiate nutrition, mode of feeding, energy requirements, and composition of enteral and parenteral feeds. Recommendations for nutritional support in critical illness are needed. The ESPGHAN Committee on Nutrition (ESPGHAN-CoN) conducted a systematic literature search on nutritional support in critically ill neonates, including studies on basic metabolism. The Medline database and the Cochrane Library were used in the search for relevant publications. The quality of evidence was reviewed and discussed before voting on recommendations, and a consensus of 90% or more was required for the final approval. Important research gaps were also identified. This position paper provides clinical recommendations on nutritional support during different phases of critical illness in preterm and term neonates based on available literature and expert opinion. Basic research along with adequately powered trials are urgently needed to resolve key uncertainties on metabolism and nutrient requirements in this heterogeneous patient population.

A Review of Nutrition Support Guidelines for Individuals with or Recovering from COVID-19 in the Community.

COVID-19 negatively impacts nutritional status and as such identification of nutritional risk and consideration of the need for nutrition support should be fundamental in this patient group. In recent months, clinical nutrition professional organisations across the world have published nutrition support recommendations for health care professionals. This review summarises key themes of those publications linked to nutrition support of adults with or recovering from COVID-19 outside of hospital. Using our search criteria, 15 publications were identified from electronic databases and websites of clinical nutrition professional organisations, worldwide up to 19th June 2020. The key themes across these publications included the importance in the community setting of: (i) screening for malnutrition, which can be achieved by remote consultation; (ii) care plans with appropriate nutrition support, which may include food based strategies, oral nutritional supplements and referral to a dietitian; (iii) continuity of nutritional care between settings including rapid communication at discharge of malnutrition risk and requirements for ongoing nutrition support. These themes, and indeed the importance of nutritional care, are fundamental and should be integrated into pathways for the rehabilitation of patients recovering from COVID-19.

Considerations for nutrition support in critically ill children with COVID-19 and paediatric inflammatory multisystem syndrome temporally associated with COVID-19

There are reports of children COVID-19 or COVID-19 like symptoms with hyperinflammatory multisystem syndrome, ARDS, gastrointestinal and atypical Kawasaki disease presenting to PICU worldwide temporally associated with COVID-19, for which there are important nutrition support considerations. As a result, the European Society of Pediatric and Neonatal Intensive Care – Metabolism, Endocrine and Nutrition group (ESPNIC-MEN) and paediatric nutritionists working in PICUs are being consulted regarding nutrition management of critically ill children with COVID-19 or COVID-19 like symptoms. Therefore, the aim of this short report is to provide a summary of nutrition support recommendations for critically ill children with COVID-19. They are based on the ESPNIC-MEN section recommendations published in January 2020 and surviving sepsis recommendations from February 2020.

Nutritional support in sepsis: when less may be more

Despite sound basis to suspect that aggressive and early administration of nutritional support may hold therapeutic benefits during sepsis, recommendations for nutritional support have been somewhat underwhelming. Current guidelines (ESPEN and ASPEN) recognise a lack of clear evidence demonstrating the beneficial effect of nutritional support during sepsis, raising the question: why, given the perceived low efficacy of nutritionals support, are there no high-quality clinical trials on the efficacy of permissive underfeeding in sepsis? Here, we review clinically relevant beneficial effects of permissive underfeeding, motivating the urgent need to investigate the clinical benefits of delaying nutritional support during sepsis.

Nutritional Care for Patients with Ebola Virus Disease in Ebola Treatment Units – Past and Current Experiences from Practitioners

Background In November 2014, the World health Organization (WHO), in collaboration with United Nations Children's Fund (UNICEF), and the World Food Programme, produced interim guidelines (iGL) on providing nutritional support to patients in Ebola treatment units (ETUs). They have been translated into French and issued by the Ministry of Health, UNICEF and WHO in adapted versions to be used in the current outbreak in the Democratic Republic of the Congo (DRC). This paper evaluates the use and usefulness of the 2014 iGL in the West Africa and current DRC Ebola virus disease (EVD) outbreaks and identifies experiences and lessons learned from practitioners on the operational aspects of nutritional care and support in ETUs. Methods Key-informants (n=26), from 12 organizations (Non-Governmental Organizations, United Nations, Red Cross Red Crescent Movement) were interviewed who were actively engaged in the nutritional and/or clinical care of EVD patients. Results There was a consensus among key informants that the 2014 iGL initially served a guiding purpose. However, the vast amount of learning from the 2014-2016 and current EVD outbreaks indicates that the interim guidelines need to be revised. Practitioners struggled to find operational solutions for nutritional care, and the challenges were plentiful, especially regarding 1) the different perceptions of the importance of nutritional care among ETU staff; 2) the difficulties around food preparation and distribution for EVD patients; 3) how to take into account the patients’ dietary preferences; 4) the nutritional care needed in relation to specific EVD symptoms; 5) who assumed roles in nutritional care in ETUs; 6) if and how feeding support was organized; 7) whether malnutrition needed to be addressed and how; and 8) whether the intake of specific nutrients could contribute to improved treatment outcomes. Information from the key-informants interviews resulted in numerous lessons learned and recommendations for nutritional support during current and future outbreaks. Conclusions This investigation underscored the importance of documenting experiences of practitioners on nutritional care in emerging infectious diseases for which limited scientific evidence exists and for which interim guidelines are produced to fill in knowledge gaps. It also emphasized the importance of nutritional care in ETUs during treatment.

Nutrition Support for Critically Ill Patients With Cancer.

Oncology patients often experience the classic signs of malnutrition-weight loss as well as fat and muscle wasting, which have been associated with poor tolerance to treatment and increased morbidity and mortality. Nutrition status may be an important factor in determining tolerance to treatment and outcomes associated with it. Thus, identification of those with preexisting malnutrition or who are at risk for developing malnutrition is crucial not only at time of cancer diagnosis but also throughout the treatment course so that nutrition interventions may be implemented to prevent development or worsening of malnutrition in this high-risk population. These patients often have extremely complicated hospital courses due to the aggressive nature of the disease and treatment, leading to intensive care unit admission and periods of critical illness. Critical illness is associated with catabolism, extreme stress on the body, and a state of systemic inflammation. During critical illness, it is important to provide adequate nutrition to prevent further break down of lean muscle mass and oxidative cellular injury and to regulate favorable immune responses. The purpose of this review is to discuss the importance of nutrition screening and assessment for the critically ill patient with cancer; to appropriately identify those at risk for, or who have developed, malnutrition; and to provide appropriate interventions to optimize nutrition status. This review also discusses the complications and difficulties associated with feeding this patient population and offers nutrition support recommendations.

Nutrition Support for Persistent Inflammation, Immunosuppression, and Catabolism Syndrome.

Despite tremendous advances in critical care, multiple-organ failure continues to be a significant problem. However, in recent years, far fewer patients with multiple-organ failure die early, but many experience ongoing immune dysregulation and are developing persistent inflammation, immunosuppression, and catabolism syndrome (PICS). Most PICS patients are discharged to nonhome destinations, fail to rehabilitate, and succumb to indolent death. From a nutrition perspective, patients with PICS experience persistent inflammation-induced cachexia despite evidenced-based recommended intensive care unit nutrition support. Recent basic and translational research indicates that prolonged expansion of myeloid-derived suppressor cells plays a central role in the pathogenesis of PICS. Myeloid-derived suppressor cells express arginase 1, which depletes arginine, causing immunosuppression and impaired wound healing. This is the rationale for arginine supplementation in PICS. Other nutrition support recommendations for PICS are based on inferences made from other patient populations who experience similar persistent inflammation-induced cachexia. These include patients with established cancers, major burns, and sarcopenia. These patients experience anabolic resistance, but studies show that this can be overcome by providing higher levels of protein and certain specific amino acids. Nutrition support guidelines recommend provision of >1.5 g/kg/d of protein and indicate that higher levels may be needed. Protein composition is also important. There is good evidence that leucine can promote anabolism in patients with cancer and sarcopenia. Finally, anabolic interventions-including intensive insulin, oxandrolone, propranolol, and resistance exercise-have proven to be effective in patients with major burns and are likely relevant in combating PICS cachexia.

PTU-094 The Assessment of Resting Energy Expenditure in Patients with Cirrhosis Remains Problematic

Introduction Patients with cirrhosis are frequently malnourished and this has a detrimental effect on outcome. Accurate assessment of resting energy expenditure (REE) would facilitate management by providing an objective measure on which to base individualised recommendations for nutritional support. REE can be accurately measured using indirect calorimetry but this technique cannot be used easily in the clinical setting. A number of portable bedside techniques for estimating REE have now been developed although they have not, to date, been validated in this patient population. The aim of the present study was to validate the use of alternative methods for assessing REE against the ‘gold standard’ of indirect calorimetry. Methods The study population comprised 19 patients (12 men: seven women; mean [range] age, 60.3 [31–83] yr) with cirrhosis; 11 (57.9%) were adequately nourished, three (15.8%) moderately malnourished and five (26.3%) severely malnourished. REE was measured, under standardised conditions, using a precision, indirect calorimeter (Cortex Metamax 3 B). Additional REE measurements were undertaken, at the same sitting, using: (i) the Medgem Handheld indirect calorimeter; (ii) the Sensewear Pro 3 armband direct calorimeter; and, (iii) the Bodystat Quadscan 4000 bioelectric impedance analyzer. REE was also predicted using the generic Harris-Benedict, Schofield, Mifflin, and Cunningham equations and the disease-specific Muller and Morgan & Madden equations. 1 Results The mean (±1 SD) REE measured using the Metamax indirect calorimeter was 1368±456.4 Kcal/24 hr. REE measurments provided by the alternative methods ranged from 1188.1 kcal/24 hr less to 722.6 Kcal/24 hr more than the Metamax values. The Medgem provided the ‘least inaccurate’ REE measurements but values still differed by approximately ±700 Kcal/24 hr. The differences in measurement values between the portable devices and the ‘gold standard’ were inconsistent and bidirectional. Likewise, REE values obtained using the prediction equations ranged from 1018.6 kcal/24 hr less to 1468.3 Kcal/24vhr more than the Metamax values. The generic Mifflin equation provided the ‘least inaccurate’ REE estimates but values still ranged from 887.7 Kcal less to 558.4 Kcal/24 hr more than the Metamax values. Conclusion Measurements of REE provided using these bedside techniques and estimated using the predication equations were not sufficiently accurate to be of value, in the clinical setting, either for the assessment of nutritional requirements nor for monitoring over time to assess disease progression or responses to nutritional therapy. Reference 1 Madden AM, Morgan MY. Resting energy expenditure should be measured in patients with cirrhosis, not predicted. Hepatology 1999; 30 :655–664. Disclosure of Interest None Declared

Early Enteral Nutrition in Trauma: Is There Still Any Doubt?

Early enteral nutrition support has been standard in the care of the injured patient for nearly three decades. The Eastern Association for the Surgery of Trauma (EAST) provided the most recent management recommendations for nutritional support of trauma patients in 2004. Simply stated, the recommendation provided by the authors described the superiority of support via the enteral route within the first 72 h of injury when feasible. This statement implied that both the timing of initiation and route of support had potential to impact patient outcomes. The American Society of Parenteral and Enteral Nutrition (ASPEN) in conjunction with the Society of Critical Care Medicine (SCCM) published a broader set of guidelines in 2009 and 2016 that generally agreed with the EAST recommendations and were applicable to critically ill patients. The superiority of the enteral route for delivery of nutritional support has been theorized to be associated with the non-nutritional benefits of substrate provision at the level of the gastrointestinal tract within a 72-h therapeutic window. These concepts, at least in part, were the product of trials performed by surgeons in the setting of severe trauma and are now applied broadly to critically ill patients. However, as is clearly stated in the above guidelines, there are significant limitations inherent in the available literature. The breadth of literature in clinical nutrition has been plagued with issues including small trial size, the presence of multiple confounding variables, diverse control groups, and heterogeneous patient populations. Trials examining the role of early enteral nutrition support in injured patients have similar limitations. Over the last decade several significant trials have been conducted examining questions regarding nutrition support in the ICU, many of which conflict with historical findings. As a result of these trials, the practice of clinical nutrition is evolving rapidly. The objectives of this review include the following: discussion of the historical perspective on nutrition support in the setting of trauma, brief summary of existing data and more recent trials of importance, and how these trials may impact longstanding dogma.

Nutrition and metabolic support recommendations for the bariatric patient.

Managing the metabolic needs of the patient with obesity is a challenge unto itself without the added demands of accounting for an altered gastrointestinal tract. Nevertheless, with about 200,000 bariatric procedures being performed annually in the United States, clinicians must be prepared to manage the critically ill bariatric surgery patient. This article reviews the recent literature relating to nutrient needs and metabolic support for the bariatric patient. Bariatric patients are at risk for several micronutrient deficiencies, including vitamins D and B₁₂, calcium, and iron; some bariatric procedures affect macronutrient needs as well. Literature on nutrition support guidelines for the bariatric population is limited. However, with an understanding of the anatomical and physiological effects of bariatric surgery, recent guidelines for critically ill patients with obesity can be applied to the bariatric surgery population. The unique needs of the bariatric population, such as susceptibility to micronutrient deficiencies and specialized access routes, must be considered to provide safe and efficacious nutrition support. Further research is necessary to develop specific nutrition support recommendations for the bariatric population.

The Impact of Various Ways the Dietitian Makes Recommendations in a Medical Intensive and a Neuroscience Intensive Care Unit for Mechanically Ventilated Patients Requiring Nutrition Support

The participant will be able to determine the most effective method to communicate nutrition support recommendations to the physician.

Nutritional assessment and support in acute kidney injury

Acute kidney injury (AKI) in the ICU is associated with an increased risk of protein-energy wasting (PEW), a major negative prognostic factor. This review illustrates recently published data and guidelines concerning nutritional problems in AKI, pointing out complexities and peculiarities of the syndrome. The main goals of nutritional support in AKI on renal replacement therapy (RRT) are to ensure the provision of adequate amounts of nutrients, to prevent PEW, to promote tissue reparation, to support the immune system, and possibly to reduce mortality. The enteral route should be preferred, even though parenteral nutrition is often required to target nutritional needs. Special attention should be paid both to the impact of RRT on macronutrient and micronutrient losses, and to the risk of complications. In fact, due to both the acute loss of the kidneys' homeostatic function, and the frequent need of RRT, patients with AKI are especially prone to hypoglycemia and hyperglycemia, hypertriglyceridemia, fluid balance alterations, electrolyte and acid-base derangements. This review highlights the most recent concepts and recommendations for nutritional support in AKI, stressing the need for a close integration between adequate nutrition and RRT in this clinical condition, with the aim of carefully tailoring both therapies on patients' changing needs. Recent findings about the renoprotective role of some nutrients (glutamine, omega-3 fatty acids) are also discussed.