PDA

View Full Version : Feeding Critically Ill Patients



CheneyHsiung
Fri 4th April '14, 3:30pm
Presentation of Case

http://images.nejm.org/editorial/supplementary/2014/critcare08_lg.jpg

A well-nourished 77-year-old man whose medical history includes treated hypertension and hypercholesterolemia, previous heavy alcohol intake, and mild cognitive impairment was admitted to the intensive care unit (ICU) of a university hospital from the operating room after a Hartmann’s procedure (resection of the rectosigmoid colon with closure of the rectal stump and formation of an end colostomy) performed for fecal peritonitis due to a perforated sigmoid colon. On arrival in the ICU, he was in septic shock. He is undergoing mechanical ventilation with the use of a low-tidal-volume protocol with positive end-expiratory pressure (PEEP). His arterial blood pressure is supported with a norepinephrine infusion. Analgesia is provided by a continuous morphine infusion. Slight bleeding from the surgical site and from the areas around arterial and central venous catheters is most likely due to low-grade disseminated intravascular coagulation and does not currently merit any specific treatment other than withholding previously prescribed heparin and repeating the laboratory tests in 8 to 12 hours. (In the previous installment of this case, there were 4272 votes on strategies for treating the patient’s bleeding and possible coagulopathy. All the respondents voted for stopping heparin, with 45% favoring repeated laboratory testing in 8 to 12 hours, 33% favoring transfusion of cryoprecipitate and fresh-frozen plasma or prothrombin complex concentrate, 11% favoring transfusion of packed red cells, platelets, cryoprecipitate, and fresh-frozen plasma or prothrombin complex concentrate, and 9% favoring transfusion of platelets plus the administration of an antifibrinolytic agent, such as epsilon-aminocaproic acid or tranexamic acid.)

Question

What strategy would you use to provide nutrition for this patient?

MMS: Error (http://www.nejm.org/doi/story/10.1056/feature.2014.03.11.24?query=BUL)