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Nutrition in the critically ill patient

N.R. WEBSTER and H.F. GALLEY


Academic Unit of Anaesthesia and Intensive Care, University of Aberdeen,
ABERDEEN, UK
Critically ill patients are hypermetabolic and have increased nutrient requirements.
Although it is assumed that nutritional support is beneficial in this group of patients
there are no well designed clinical trials to test this hypothesis. The rationale for
nutritional support, therefore, is based upon clinical judgement. Although it is not
known how long a critically ill patient can tolerate what is effectively starvation, the loss
of lean tissue which occurs in catabolic patients (20-40g nitrogen/day) suggests that
depletion to a critical level may occur after 14 days. Total parenteral nutrition given to
malnourished patients with gastrointestinal cancer for 7 to 10 days before surgery has
been shown to decrease complications by about 10%. Wound healing and normal
immune responses are dependent upon adequate nutrient intake, and it seems
reasonable, therefore, to commence feeding as soon as possible. Earlier feeding may
decrease length of stay and complication rates in both critically ill patients and
following surgery. It has been shown in randomised controlled trials of both enteral and
parenteral feeding in the critically ill, that current regimens are sub-optimal. Calorie
intake was shown to be often considerably in excess of metabolic requirements alone,
and variable study design has made comparisons impossible. Despite the lack of
knowledge regarding even the most simple of nutritional requirements in these patients,
the administration of specific micronutrients and specialised supplements has attracted
attention. Again, many of these more recent studies are limited because of poor study
design.
Keywords: Enteral nutrition, glutamine, nutritional antioxidants, parenteral nutrition
J.R.Coll.Surg.Edinb., 45, December 2000, 373-379

INTRODUCTION
Over the past 30 to 40 years advances in enteral feeding techniques, venous access and
enteral and parenteral nutritional formulations have made the provision of nutritional support
possible for most critically ill patients. Specialised formulations and additives providing
either specific micronutrients and other so-called nutritional support agents are now available.
However, although there is widespread use of nutritional therapy and a wealth of medical
literature on this subject, many areas of nutritional support remain controversial. Discussion
on this topic is hampered by the relative lack of well controlled randomised trials and much
of the literature is in the form of case series or meta-analyses.

It is assumed that nutrient depletion is associated with increased morbidity and mortality, and
that correction or prevention of such nutrient depletion can eliminate this excess morbidity
and mortality associated with malnutrition. There are many factors that determine outcome
from critical care and indeed any hospital treatment, and nutritional status clearly has an
effect. However, the interaction between malnutrition and the other factors which influence
outcome, makes it very difficult to isolate the independent contribution of nutritional status.
Consequently, there are few data that conclusively support this generally assumed interaction.
Nutritional support has become a routine part of the care of critically ill patients and it is now
widely accepted for the treatment and prevention of malnutrition and specific nutrient
deficiencies. It is also generally assumed to improve outcome. As with most other forms of
treatment there are, however, concomitant adverse effects.
A number of comprehensive textbooks have been written on the subject of nutritional support
in the critically ill, and this review, therefore, will focus on the current 'state of the art'
relating to nutritional approaches in the critically ill adult. The review will cover most of the
information required for the Diploma examination candidate to demonstrate adequate
knowledge in this topic. In addition, recent and possibly controversial information will be
presented to enable the reader to formulate an opinion on the relative merits of specific
nutrient supplementation and the role of very early enteral nutrition following surgery or
trauma.
MALNUTRITION IN CRITICALLY-ILL PATIENTS
The adaptive changes which occur during starvation and as part of the stress response after
injury are now well known and are directed at conserving body protein and maintaining
normoglycaemia, whilst ensuring that the body is well placed to fight infection and undergo
subsequent necessary healing processes.1 The term 'malnutrition' refers to a generalised
disordering of body composition such that either macro- or micro- nutrient intake is suboptimal. In effect, malnutrition would be better referred to as a nutritional deficit. Severe
deficits can result in organ dysfunction, abnormalities in blood biochemistry and reduced
body mass, and may also be associated with altered outcome following hospital treatment.
Although a clear definition of malnutrition has caused some difficulty, it is thought that most
critically ill patients suffer to some degree, particularly those patients who have been treated
on the intensive care unit (ICU) for more than a few days.
Assessment of the state of nutrition, or more accurately the level of nutritional deficit, of a
patient is clearly the first step in deciding the degree of nutritional support required. General
loss of body weight associated with a catabolic process leading to loss of muscle mass as a
result of protein and calorie deficits, provides a gross indicator of inadequate nutritional
intake. However, in the critically ill patient, oedema formation occurs frequently and accurate
weighing is often impossible, such that nutritional deficits are not always obvious. In an ideal
situation, a measure of body mass index (BMI): weight (kg) divided by height (m) squared is
a useful indicator of nutritional state.

Body mass index = Weight(kg)/Height (m)2


Unintentional weight loss greater than 10% in the six months before hospital treatment has
been shown to reflect clinical outcome in a general surgical population.2 Anthropometry is
widely used in some hospital patients to determine skin fold thickness and skeletal muscle
mass as an index of nutritional state, but is of limited value in the ICU setting. Muscle
function tests such as hand grip strength can also be performed, but again they are of little use
since an awake, alert and co-operative patient is usually required. In addition, the
interpretation of such data is complicated by metabolic derangements such as hypercapnoea,
hypoxia, hypophosphataemia and the effect of various medications. However, pre-operative
handgrip dynamometry and respiratory muscle strength assessment (maximal voluntary
ventilation and vital capacity and maximal airway pressures) have been shown to predict
postoperative complications.3
Aspects of immune function are altered by nutritional depletion and this can be assessed by
measures such as delayed hypersensitivity responses to a variety of antigens -again this has
been little used in the critically-ill patient. Plasma protein concentrations - usually albumin or
less frequently transferrin, retinol binding protein or prealbumin have also been used to
monitor nutritional status. These biochemical indices are generally fairly insensitive in terms
of reflecting nutritional deficit since production may be influenced by factors other than
nutritional status and plasma half-lives also vary. In addition, the normal rate of albumin
exchange between intra- and extra-vascular compartments is more than ten times the rate of
either synthesis or degradation. In view of this, even relatively minor variations between
these compartments can have profound effects on circulating albumin levels. Plasma albumin
concentrations are usually not affected by nutritional intake and will not increase in
metabolically stressed patients until the cause of the stress is removed. In fact in chronic
nutritional depletion, plasma albumin levels may even increase due to a combination of
dehydration, decreased protein degradation and movement of extra-vascular albumin into the
intra-vascular compartment.4 Several body composition analysers are available and although
some have been used in critically ill patients5 at present these remain research tools. In
summary, there is no good indicator of nutritional status in the critically ill patient (Table 1).
Table 1: Tests for nutritional deficit
Body weight >10% ideal body weight - currently best measure
Anthropometry
Muscle function tests

Hand grip dynamometry

Respiratory muscle strength

Plasma proteins

Albumin

Transferrin

Retinol binding protein

Prealbumin

Cellular immunity or delayed cutaneous hypersensitivity


Impedance / conductance / neutron activation measurements of body composition

Why is it that critically ill patients become nutritionally depleted? Various disease processes,
common to ICU and high dependency units (HDU), cause changes in substrate metabolism
which lead to changes in body composition and, ultimately, relative deficiencies of some
nutrients. The body has reserves from which it can liberate calories for the production of
energy - essentially these are as carbohydrates and fats. Some tissues have an absolute
requirement for glucose and small amounts of glucose are also required for metabolism of fat.
Although reserves of glucose are relatively small (glucose in the circulation and glycogen in
liver and muscle), glucose can also be formed from certain amino acids by a process called
gluconeogenesis. During starvation, i.e. nutritional deficit due to inadequate intake of all
nutrients, increased oxidation of fat provides the main source of energy, and nitrogen losses
are reduced by enhanced fat mobilisation. In the early phase of starvation, both fat and
protein are consumed but protein loss is minimised and only limited muscle breakdown
occurs to enable gluconeogenesis. However, severe muscle wasting can occur late in
starvation when fat reserves are depleted. In conditions such as sepsis, where
hypermetabolism occurs, there is accelerated protein breakdown both to provide energy by
gluconeogenesis and also to liberate the amino acids required for increased protein synthesis.
However, the situation is obviously not that simple since the provision of even a great excess
of calories above and beyond requirements, does not eliminate the protein breakdown seen in
most long stay ICU patients.
GENERAL GOALS OF NUTRITIONAL SUPPORT
The overall aim of nutritional support is to provide patients with their general nutrient
requirements. However, it should be remembered that requirements will need to be modified
according to individual patient needs and specific disease processes. Requirements for
particular nutrients depend upon both utilisation and rate of loss. Nutritional support is often
considered in terms of macronutrients and micronutrients. As a first step to working out what
form of nutrition the patient needs it is often best to start with estimating total fluid
requirements. As a rule of thumb this will be between 30 and 40 ml/kg/day or 1 ml water per
calorie for an adult, but this will need to be supplemented should fluid losses be excessive.
These losses can be either overt (excess urine, upper gastrointestinal losses or diarrhoea) and
insensible - it is only possible to guess what these latter losses are. In ICU and HDU patients,
excessive insensible losses can occur as a result of pyrexia or through the use of high loss air
mattresses where evaporative loss from the skin is increased.
Total calorie requirements can be either estimated or calculated. Although calorie overload
has been shown to be harmful and should be avoided, precisely balancing calorie input with
energy expenditure has not been shown to improve outcome. To measure energy expenditure
it is usual to measure oxygen consumption using a metabolic cart. Energy requirement can
also be calculated by measuring nitrogen balance using 24 h urinary urea and in relation to

blood urea and albumin. Knowing the nitrogen loss it is then possible to calculate calorie
requirement since each gram of nitrogen produced uses 100-150kcal of energy. However,
more usually used techniques estimate rather than calculate, calorie requirement. The HarrisBenedict equation can be used or even more simply, requirements can be guessed - 25 total
kilocalories /kg/day is the estimate most often used. Calories can be given in three forms:

Carbohydrate: 30 to 70% of the total calories can be given as carbohydrate. This is


usually given as glucose but fructose and sorbitol are used in some countries. Insulin
may be required to maintain blood glucose concentration within normal limits,
especially since insulin resistance is often seen as part of the response to stress.

Fat: 20 to 50% of the total calories can be given as fat. Critically ill patients often
utilize fat better than carbohydrate as an energy source and although our normal diet
contains around 30% fat (much higher in some western diets), it is often advantageous
to provide more than this to patients on ICU or HDU. Provision of fat also provides
essential fatty acids required as normal constituents of cells. Omega-6polyunsaturated fatty acid (PUFA) triglycerides should be provided to prevent
essential fatty acid deficiency - at least 7% of total calories. Medium and long chain
triglycerides can also be used as a source of calories and the precise ratio of medium
to long chain triglycerides is dependent on which product is used and route of
administration. There is no clear evidence to confirm the superiority of any particular
triglyceride regimen over any other in the typical critically ill patient.

Protein: 15 to 20% of the total calories per day can be administered as protein or
amino acids depending on route of administration.
Finally, micronutrient requirements should be considered. Approximately 1mmol/kg of both
sodium and potassium are usually given but this figure will need to be altered when there are
excessive losses - this is particularly common from excess sweating and gastrointestinal
losses. Other electrolytes, e.g. magnesium, iron, copper, zinc and selenium are also necessary,
but in much smaller amounts. Patients on long-term nutritional supplementation will need to
have levels of these electrolytes checked periodically. An often forgotten electrolyte is
phosphate and this is important since it is required for normal metabolic processes resulting
in the formation of ATP. Muscle weakness associated with a long-term requirement for
ventilatory support, and failure in weaning from ventilation is associated with
hypophosphataemia.
Other micronutrients include fat (vitamins A, carotene) and water-soluble vitamins (B, C, D,
E). The precise requirements for specific vitamins remains unclear, although several studies
have shown extremely low circulating concentrations.6
The Harris-Benedict equation: used to calculate resting energy expenditure, REE, along
with the usual multiplication factors to provide adeqaute calorie intake
Women: REE = 655 + (9.6 X weight in kg) + (1.7 X height in cm) - (4.7 X age in years)
Men: REE = 66 + (13.7 X weight in kg) + (5.0 X height in cm) - (6.8 X age in years)
Calorie requirements/day = 1.25 X REE (for each 1C above 37 add 10% extra allowance

ROUTE OF ADMINISTRATION
Enteral Route
This is the preferred route for nutritional support since the gut barrier and immune functions
are preserved and systemic infections and other complications are reduced.7 Many studies
support the implementation of enteral nutrition as soon as possible after resuscitation. Of
course, enteral feeding requires adequate gastric motility and a gastric residual volume in
excess of 150 ml will usually require feeding solutions to be administered slowly. However, it
is not necessary to have bowel sounds for successful enteral nutrition. Persistently inadequate
gastric emptying may dictate small bowel feeding techniques (duodenal or jejunal) or
supplemental intravenous nutritional support. The main disadvantage with enteral feeding is
that if feeding needs to be stopped periodically to allow gastric emptying, then the calorie
target will not be met. Indeed, it has recently been suggested that the combination of enteral
and parenteral may be appropriate for most critically ill patients, with enteral feeding
increasing as tolerance to the feed increases.8
Agents which promote gastric and intestinal motility such as metoclopramide and
erythromycin can be used although cisapride has recently been withdrawn for use in the USA
and UK due to it's ability to cause serious dysrythmias. Cisapride selectively enhances
cholinergic motor activity throughout the gastro-intestinal tract; erythromycin increases
motilin, a substance which enhances contractile activity of the gastric antrum and duodenum;
metoclopramide is a selective dopamine-2-receptor antagonist which increases peristaltic
contractility of the oesophagus, gastric antrum and jejunum. Neither erythormycin nor
metoclopramide have effects that may affect healing in the large bowel. A single enteral dose
of any of these agents promotes gastric emptying in critically ill patients with gastric motility
dysfunction but further studies are required to assess the benefit in terms of increasing
tolerance to enteral feeding.9,10
If factors affecting the ability to tolerate early postoperative enteral feeding can be identified,
perhaps these factors can be minimised. In a recent study, 200 patients undergoing colon
resection received early post-operative feeding comprising clear fluids on the second postoperative day and a normal diet on day 3. Only 27 (13.5%) of patients failed to tolerate early
feeding, the majority of whom were men. Importantly, there were no anastomotic leaks or
abdominal abscesses. There was no effect of metoclopramide on the tolerance to early
feeding in a sub-group of patients, and no increase in anastomosis breakdown. These data
suggest that early post-operative feeding is safe and effective, with reduced hospital stays.11
The absence of bowel sounds or passage of flatus do not preclude enteral feeding, especially
when this is instituted distal to the pylorus. Small bowel feeding is now generally advocated
in mild or resolving pancreatitis and low output enterocutaneous fistulae (<500ml/day). Two
problems, however, may limit the use of this and other forms of enteral nutrition - abdominal
distension (which may be sufficient to result in compromised respiratory function) and
diarrhoea (which although usually secretory and associated with a high osmotic load to the
colon may be associated with Clostridium difficile enterocolitis).
There is some evidence that enteral nutrition may be better than total parenteral nutrition
(TPN) in terms of infection rate.12 TPN may of course be associated with a higher infection
rate rather than enteral feeding reducing the incidence of infections. Enteral feeding preserves
the gastrointestinal barrier function that can prevent or decrease translocation of bacteria

across the bowel wall which may decrease nosocomial infections. However, enteral feeding
does increase the risk of ventilator associated pneumonia,13 probably because it increases
gastric pH and promotes gastric colonisation. In addition, the gastric tube compromises lower
oesophageal sphincter function.
Parenteral Route
This should only be used when the enteral route is either not possible or cannot provide
sufficient nutrient input. Complications are more frequent with the parenteral route and are
usually related to catheter insertion and infection. It should be remembered that TPN can be
delivered into peripheral veins via very fine-bore catheters, as well as through central lines.
Lines used for TPN should be inserted under full aseptic technique and TPN should be
delivered through a dedicated catheter. Interruptions and reconnections should be kept to a
minimum and again carried out under aseptic conditions. A TPN team, responsible for
inserting the feeding catheters, prescribing the feed required, adjusting the nutritional
regimen as necessary in individual patients and monitoring the occurrence of line-associated
sepsis, is used in many hospitals.
Although it is generally assumed that TPN may provide targeted nutritional support for
critically ill patients, it has been shown that in many patients calorie and nitrogen target
intakes were not reached, and underfeeding may be a genuine problem in some patients.14
The use of TPN in the critically ill has been summarised in a meta-analysis which included
26 randomised trials involving 2211 patients, although only 6 of the studies included were
based in ICU15. There was no effect on mortality although there was a slight but not
statistically significant decrease in major complications in those patients given TPN. The
authors suggested that TPN should only be used in those critically ill patients who cannot
tolerate enteral nutrition. However, it is not clear how many critically ill patients cannot
really tolerate enteral nutrition. The authors, perhaps, should have suggested that TPN be
used only for the pre-operative treatment of nutritionally depleted surgical patients who
cannot tolerate feeds given by the enteral route.16
SPECIFIC CONSIDERATIONS
Sepsis
Sepsis is characterised by a catabolic state such that total calorie requirements are increased
and rapid net protein breakdown occurs. Increases in calorie intakes of about 10-20% and
higher nitrogen intakes may be required. Micronutrient and electrolyte requirement are also
increased and electrolyte concentrations should be monitored frequently. Hyperglycaemia
may be present and there may be a requirement for intravenous infusion of insulin.
Hypertriglyceridaemia with lipaemic serum may occur and fat intake may need to be
decreased. The sedative agent propofol is prepared in a fat emulsion and may cause excess fat
intake in those patients receiving propofol infusions.
LIVER FAILURE
Patients with liver failure may have marked pre-existing electrolyte abnormalities and may
have been treated by fluid restriction in an attempt to decrease the formation of ascites. Such
patients commonly have increased potassium, magnesium and zinc losses and may be quite

severely hyponatraemic despite having high total body sodium concentrations. Rapid
correction of plasma sodium concentration should be avoided since total body sodium is
often abnormally high and central pontine myelinolysis may result.
Acute liver failure is often accompanied by encephalopathy that may be due to accumulation
of ammonia as a result of defects in the urea cycle in the damaged liver. Administration of
certain amino acids can exacerbate encephalopathy and nitrogen sources with increased
branched chain amino acids and reduced aromatic sulphur containing amino acids are
available.
RESPIRATORY FAILURE
Overfeeding is the major problem associated with feeding patients with compromised
respiratory function. The ratio of carbon dioxide production to oxygen consumption is called
the respiratory quotient - R/Q - and this is normally between 0.85 and 0.90. Metabolism of fat
is associated with an R/Q of 0.7, whilst glucose metabolism gives an R/Q of 1.0. Patients
with respiratory failure may have difficulty in eliminating carbon dioxide and a feed regimen
associated with lower R/Q has been suggested. In practice, this has little impact while
patients are undergoing mechanical ventilation, but may be important when patients are
weaned from the ventilator.17 It is probably more important to ensure that calorie intake is the
minimum required and an R/Q greater than 1.0 (which usually indicates overfeeding) should
be avoided.
Although, in theory, administration of protein is associated with an increase in oxygen
consumption this is of little practical importance since small increases in inspired oxygen
tension overcomes the problem.
RENAL FAILURE
Nutritional support in patients with renal failure depends both on the frequency and type of
renal support therapy and whether the renal failure is acute or chronic. Most patients are
sensitive to excess fluid loads and care, therefore, is required with electrolyte administration,
particularly potassium, magnesium and phosphate. Low volume/low sodium feeds are
available for enteral nutrition in patients with renal compromise. Nitrogen intake may also
need to be reduced to between 0.5 and 0.8g N2/kg/day in patients with chronic renal failure.
Amino acids will be lost during haemodialysis or haemofiltration and intake may require
increasing, although there is no advantage in giving only the essential amino acids. Fluids
used in peritoneal dialysis usually contain glucose providing a 'hidden' source of calorie
intake in such patients.
ACUTE PANCREATITIS
Eating during an episode of acute pancreatitis causes pain and increased pancreatic enzyme
release and this has led to many studies that have evaluated various alternative feeding
regimens. TPN has little stimulatory effects on pancreatic secretion and intravenous lipids are
usually well tolerated. The effect of enteral feeding is unclear. Some studies have shown no
effect on pancreatic secretion during jejunal feeding while others show a stimulatory effect.
Jejunal feeding in patients with mild to moderate pancreatitis was well tolerated and less
expensive, as shown in a recent study. 18 Although only 82% of enterally fed patients received

their target calorie intake, compared with 96% of patients given TPN, clinical outcome was
the same. There are no randomised controlled trials which have evaluated the clinical efficacy
of nutritional support by any particular route in patients with severe pancreatitis.
NUTRITIONAL ADDITIVES FOR SPECIAL PURPOSES
Branched chain amino acids
The branched chain amino acids leucine, isoleucine and valine are essential amino acids
required for synthesis of proteins. The clinical benefit of preparations containing these amino
acids has been evaluated in several small randomised controlled trials in patients with liver
disease and these have been summarised in a meta-analysis.19
Although a small statistically significant improvement in recovery from encephalopathy in
the short-term was reported, some of the original publications may have inadvertently
favoured the patients receiving the branched-chain amino acids. The benefit of branched
chain amino acids in improving outcome generally in ICU and HDU patients is unproven.
There is some evidence that the respiratory centre is stimulated and muscle function is
improved, leading to their use in patients who are difficult to wean from ventilator support.
Peptides and elemental diets for enteral nutrition
Protein absorption and tolerance of enteral nutrition may be improved by the use of feeds
containing peptides rather than whole proteins. The role of such formulations in improving
outcome in the critically ill has yet to be determined, although these feeds are helpful in
specific malabsorption conditions such as Crohn's disease.
Immuno-nutrients
Arginine is an amino acid required for variety of metabolic functions including urea
synthesis, lymphocyte proliferation and wound healing. Arginine also stimulates the release
of hormones including insulin, prolactin and growth hormone and is needed for nitric oxide
production, which regulates blood flow. These effects may be beneficial in, for example, the
gastrointestinal tract.20,21 Arginine has been given postoperatively in doses of up to 30 g/day
to adult patients but the benefit remains unclear.
Glutamine has also been used as a nutritional supplement. It is a so-called conditionally
essential amino acid, since although dietary intake is normally adequate, under certain
conditions such as serious illness, requirements are increased and supplementation may be
needed. It is one of the three amino acids in the important antioxidant compound glutathione
and it is used as a substrate for metabolism by leucocytes and enterocytes. Leucocytes can
derive almost as much energy from the metabolism of glutamine as glucose, and glutamine,
therefore, can augment lymphocyte and macrophage function. Omega-3 polyunsaturated fatty
acids are currently being evaluated as both immune modulators and antiinflammatory agents
and doses of up to 5 g/day have been used in critically ill patients with sepsis.
The effect of combinations of immunonutrients on outcome has been investigated. Enteral
feeds supplemented with omega-3 fatty acids, arginine and ribonucleic acids, and also
glutamine in some studies, have been compared with standard enteral feeds in critically ill
patients, including medical, surgical and trauma patients. 22-26

A trend towards higher early mortality in immunonutrienttreated patients was seen in one
study: less multi-organ failure, fewer infection-related complications, and reduced
requirements for mechanical ventilation have been reported.
In one study of parenteral feeding, patients were followed up for 6 months and survival was
better in patients who had received glutamine supplemented TPN.27 A meta-analysis of 11
randomised trials of supplemented enteral feeds revealed a significant decrease in the risk of
developing major infectious complications in the immunonutrition groups and decreased
hospital stay.28 However, there was also an increased risk of death although this did not reach
statistical significance.
Nucleic acids
The role of specific replacement of nucleic acids in feeding regimens remains to be
determined and a meta-analysis concluded that little evidence supports the use of such
supplementation in humans despite the theoretical effects on cell-mediated immunity and
lymphocyte function.29
Fibre
Fibre can be added to enteral nutrition preparations and has beneficial effects on colonocyte
function. Studies in rats have shown that fibre or glutamine-supplemented enteral feeds
promote healing of experimental colonic anastomoses.30
Growth hormone
Growth hormone is released endogenously during critical illness as part of the stress
response, but administration of exogenous growth hormone has been used for its anabolic
effects. These include increased fat oxidation and protein synthesis and improved immune
responsiveness. Although there have been many individual case reports and small case series
showing benefit, particularly in burns patients, a recent large multi-centre study, however, has
shown significantly higher mortality in long stay ICU patients treated with growth
hormone.31 However, growth hormone may still have a role in patients with burns,
particularly children.
CONCLUSION
For both enteral and parenteral nutritional support, it is clear that many critically ill patients
do not receive their target intake, due to elective interruption as a result of intolerance,
interruption due to other therapeutic interventions, and practical factors such as inadequate
stock of feeding solutions. Early enteral feeding has been suggested to be beneficial in the
critically ill, but dogged adherence to the enteral route alone might mean that many patients
are inadequately fed. The mode of delivery of nutritional support should be determined by
needs and for many patients this will mean combinations of enteral and parenteral nutrition,
adjusted as tolerance to enteral feeding increases.
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Copyright date: 9th October 2000
Correspondence: Professor N.R. Webster, Anaesthesia and Intensive Care, Institute of
Medical Sciences, Foresterhill, Aberdeen AB25 2ZD, U.K.
Email: n.r.webster@abdn.ac.uk
2000 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb. 373-379

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