RESUMEN
BACKGROUND: Many methods are available to determine energy requirements, however, all have limitations, particularly when used for the obese. OBJECTIVES: The aim of this survey was to investigate current practice in the estimation of energy requirements in an underweight and obese hospitalised patient in a large cohort of UK dietitians. SUBJECT/METHODS: A cross-sectional anonymous online survey of UK registered dietitians was performed. RESULTS: A total of 672 responses were received. Underweight patient: prediction equations with adjustment for metabolic stress and physical activity were most commonly used (90%). The median estimated energy requirement was 2079 kcals/day. The estimated energy requirement using calorie per kilogram method was significantly lower compared with equations (P<0.001). The median target volume of feed prescribed was 2000 mls/day. A significant reduction in feed prescribed compared with estimated energy requirements was found (P<0.001). Obese patient: prediction equations to estimate the basal metabolic rate alone were most commonly used (51%). Nutrition support dietitians used a lower stress factor compared with non-nutrition support dietitians (P=0.016). Method used to estimate the energy requirements was associated with years in clinical practice and place of work (P<0.001, 0.001). Calorie per kilogram used in the obese case study (median: 25 kcal/kg) was significantly lower than calorie per kilogram used in the underweight case study (median: 30 kcal/kg; P=0.014). CONCLUSIONS: A significant variation in the methods used by dietitians to estimate the energy requirements was found, particularly in the obese patient group. In an age of rapidly increasing rates of obesity a professional consensus of treatment of this patient group is needed.
Asunto(s)
Dietética/métodos , Metabolismo Energético , Hospitalización , Necesidades Nutricionales , Apoyo Nutricional , Obesidad/metabolismo , Delgadez , Metabolismo Basal , Calorimetría Indirecta , Estudios Transversales , Ingestión de Energía , Encuestas de Atención de la Salud , Personal de Salud , Humanos , Matemática , Competencia Profesional , Estrés Fisiológico , Reino UnidoRESUMEN
BACKGROUND: Artificial nutrition support is used in treating hospital patients and has been shown to reduce hospital stays. The NICE (National Collaborating Centre for Acute Care) guidelines are the first national consensus guidelines for dietetic practice in artificial nutrition. The aim of the current survey was to explore the influence of local and national guidelines, and clinical experience on enteral tube feeding practices in a large cohort of UK dietitians. METHODS: A cross-sectional anonymous online survey of UK registered dietitians was performed. RESULTS: A total of 681 responses were received. In all, 85% deemed 'clinical experience' to be of greatest influence when initiating a tube feeding regimen; the influence of 'clinical experience' was significantly associated with the number of years in practice (P=<0.001). A total of 70% of respondents were aware of a department feeding protocol with 67% of protocols using a start rate of 24-49 ml/h; furthermore, 65% of respondents reported most commonly using a feeding start rate of 24-49 ml/h and 75% of them reported that their department had a protocol for preventing refeeding syndrome; 23% had mandatory implementation of NICE guidelines. CONCLUSIONS: Enteral feeding practice varies among practitioners. Clinical experience and published clinical guidelines have a pivotal role when treating adult patients that require enteral tube feeding.
Asunto(s)
Competencia Clínica , Cuidados Críticos/métodos , Dietética , Nutrición Enteral , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina , Protocolos Clínicos , Estudios Transversales , Nutrición Enteral/métodos , Adhesión a Directriz , Encuestas de Atención de la Salud , Hospitales , Humanos , Tiempo de Internación , Síndrome de Realimentación/prevención & control , Reino UnidoRESUMEN
Morphologic studies were undertaken in a sheep model of pulmonary permeability edema (PPE) induced by cecal ligation and perforation. Biopsies taken every 24 hours through 96 hours following induction of sepsis showed, at 24 hours, interstitial edema accompanied by widespread aggregation of polymorphonuclear leukocytes. This was confirmed by electron microscopy, which also demonstrated endothelial cell swelling, platelet aggregation, and fibrin deposition. By 48 hours, a "thromboangiitis" had developed that persisted through 96 hours. In vitro pulmonary angiograms done at 60 and 96 hours showed multiple filling defects; it was possible to demonstrate that these defects corresponded to the "thromboangiitis." These thrombotic lesions, which were not the result of embolization from indwelling lines, closely resembled vascular changes described in the adult respiratory distress syndrome. It is believed that this is the first time that such lesions have been described in a model of PPE resulting from nonpulmonary sepsis.
Asunto(s)
Pulmón/patología , Edema Pulmonar/patología , Sepsis/complicaciones , Animales , Permeabilidad Capilar , Agregación Celular , Modelos Animales de Enfermedad , Hemodinámica , Pulmón/ultraestructura , Microscopía Electrónica , Neutrófilos/patología , Edema Pulmonar/etiología , Edema Pulmonar/fisiopatología , Síndrome de Dificultad Respiratoria/patología , OvinosRESUMEN
To characterize some of the remote effects of systemic sepsis on the lung, we evaluated changes in pulmonary microvascular fluid flux before and during sepsis secondary to a peritoneal focus of inflammation in sheep. We induced peritonitis by cecal ligation, perforation, and devascularization. During a subsequent 72-hour study period, both the mean blood pressure and the pulmonary capillary wedge pressure were unchanged, while the cardiac index increased slightly. The PaO2 fell by 48 hours (98 +/- 8 to 84 +/- 10 mm Hg; p less than 0.05) (mean +/- SD) and subsequently remained low throughout the experiment. Simultaneously, pulmonary lymph flow increased by 24 hours (11.5 +/- 4.9 to 26.7 +/- 13 ml/hr; p less than 0.05) and remained elevated throughout the experiment while [L/P] total protein ratios remained unchanged at 24 hours (baseline: 0.59 +/- 0.15 at 24 hours: 0.65 +/- 0.16). Morphologic examination of the lung showed that this model of peritonitis was characterized by neutrophil emigration into the pulmonary interstitium by 24 hours and interstitial edema by 48 hours. Therefore this model of bacterial peritonitis in sheep demonstrates that one of the remote effects of surgically induced systemic sepsis is an increase in permeability of the pulmonary microvascular membrane.
Asunto(s)
Infecciones Bacterianas/fisiopatología , Pulmón/irrigación sanguínea , Peritonitis/fisiopatología , Síndrome de Dificultad Respiratoria/etiología , Animales , Infecciones Bacterianas/complicaciones , Permeabilidad Capilar , Modelos Animales de Enfermedad , Endotelio/fisiopatología , Hemodinámica , Recuento de Leucocitos , Pulmón/patología , Linfa , Sistema Linfático , Neutrófilos , Respiración , OvinosRESUMEN
To assess the integrated cardiopulmonary response to acute microvascular lung injury, we infused zymosan-activated plasma (ZAP) into mature, awake sheep. ZAP infusion resulted in an immediate increase in the mean pulmonary artery pressure (PAP) from 17.5 +/- 4.5 mm Hg to a maximum of 33.0 +/- 5.4 mm Hg by 5 min (p less than 0.01) of a 90-min infusion. The pulmonary artery hypertension (PAH) was sustained throughout ZAP infusion, and for up to 30 min after infusion was completed (p less than 0.05). Lung lymph flow increased immediately, but lymph to plasma total protein ([L/P]) ratios remained unchanged, suggesting increased pulmonary microvascular permeability. The PaO2 fell to a minimum by 5 min (106.9 +/- 17 to 88.3 +/- 14 mm Hg; p less than 0.01), but recovered toward preinfusion values in the final 60 minutes of ZAP infusion. The cardiac index (CI) and stroke volume index (SVI) also fell significantly for 15 minutes (p less than 0.01), and then recovered to levels not different from baseline by 30 min. In parallel with all of these changes, the polymorphonuclear leukocyte count (PMN) in arterial blood fell immediately [baseline to 5 min, delta 4.9 +/- 2.5 (X 10(3))/mm3; (p less than 0.01)] due to sequestration within the pulmonary microvasculature, since a baseline PMNs were being released from the lung, -6.0 +/- 19%, while by 15 min the PMNs were being sequestered, +58.4 +/- 31% (p less than 0.01). Therefore, ZAP infusion reproduced the clinical picture of acute microvascular lung injury in humans, specifically acute PAH and increased pulmonary microvascular permeability. These two changes were due to a cascade of events associated with the pulmonary microvascular trapping of PMNs.