Applied nutritional investigationHypocaloric enteral tube feeding in critically ill obese patients
Introduction
Nutrition support in critically ill, obese patients can pose unique problems for clinicians. Many of these patients have preexisting chronic diseases related to their obesity such as diabetes mellitus, coronary artery disease, hypertension, respiratory abnormalities, hyperlipidemia, degenerative joint disease, endocrine abnormalities, and hepatobiliary disease that are likely to complicate even routine hospital care. In addition, obese patients are more likely than their non-obese counterparts to develop postoperative complications such as wound dehiscense, nosocomial infections, respiratory complications, and delayed cardiac recuperation.1, 2, 3 Specialized nutrition support is often given to obese patients during the perioperative period if the patient cannot eat in an effort to reduce morbidity. Unfortunately, energy expenditure of obese patients is widely variable and their energy needs are difficult to predict accurately.4 As a result, nutrition intake could easily be given in excess, leading to problems of overfeeding that may further exacerbate some of their chronic diseases. Clinicians have recognized this problem and have developed alternative approaches to the metabolic management of obese hospitalized patients, which include hypocaloric, high-protein feeding.5, 6, 7
Data for the use of hypocaloric, high-protein feeding were developed in obese patients receiving parenteral nutrition. From a practical standpoint, it is easier to change the macronutrient content of parenteral nutrition solutions than to alter the components of preformulated enteral solutions. However, the benefits of enteral feeding over parenteral feeding are well established,8 and clinicians have made substantial efforts to provide enteral nutrition whenever possible to critically ill patients. A literature search was unsuccessful in identifying any published reports regarding the use of hypocaloric feeding by the enteral tube feeding route in critically ill, obese patients. The purpose of this study was to evaluate the nutritional and clinical efficacies of hypocaloric versus eucaloric enteral feedings in critically ill, obese patients.
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Materials and methods
Forty critically ill, obese patients admitted to the Elvis Presley Trauma Center or Surgical Intensive Care Unit of the Regional Medical Center at Memphis who received enteral tube feedings were studied retrospectively. Patients were identified from the Nutrition Support Service records from December 1996 to January 2000. Entry criteria included adult patients, 18 to 69 y old, who had sustained multiple trauma and required enteral tube feeding for at least 7 d. Only patients with
Results
Forty enterally fed, obese patients from the trauma or surgical ICU were enrolled into the study. Fourteen (10 hypocalorically fed and 4 eucalorically fed) patients were collected during the first 13 mo, 9 (5 hypocalorically fed and 4 eucalorically fed) patients from the second year, and 17 (13 hypocalorically fed and 4 eucalorically fed) patients were identified from the final 13 mo of the study collection period. Twenty-seven patients sustained multiple injuries after a motor vehicle
Discussion
Critical illness is associated with hypercatabolism and the resultant loss of body cell mass.18 Despite aggressive nutrition support, critically ill patients continue to exhibit net protein catabolism because the anabolic effects of nutrition support cannot overcome the profound catabolic effects of critical illness.19, 20 Providing aggressive, hypercaloric nutrition support can be particularly problematic in critically ill, obese patients because they have physiologic alterations that may
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