Parenteral Nutrition in the Critically Ill Patient

• Type of Material: Article
• Authors: Thomas R Ziegler, Emory University
• Language: English
• Date: 2009-09-10
• Publisher: Massachusetts Medical Society
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2009 Massachusetts Medical Society.
• Final Published Version (URL): http://www.nejm.org/doi/full/10.1056/NEJMct0806956
• Title of Journal or Parent Work: New England Journal of Medicine
• ISSN: 0028-4793
• Volume: 361
• Issue: 11
• Start Page: 1088
• End Page: 1097
• Grant/Funding Information: Supported by grants from the National Institutes of Health (U01-DK069322, K24-RR023356, and UL1-RR025008).; National Center for Research Resources : NCRR; National Institute of Diabetes and Digestive and Kidney Diseases : NIDDK
• Research Categories: Health Sciences, Nutrition

Abstract

A 67-year-old woman with type 2 diabetes mellitus undergoes extensive resection of the small bowel and right colon with a jejunostomy and colostomy because of mesenteric ischemia. In the surgical intensive care unit, severe systemic inflammatory response syndrome with possible sepsis develops. The patient is treated with volume resuscitation, vasopressor support, mechanical ventilation, broad-spectrum antibiotics, and intravenous insulin infusion. Low-dose tube feedings are initiated postoperatively through a nasogastric tube. However, these feedings are discontinued after the development of escalating vasopressor requirements, worsening abdominal distention, and increased gastric residual volume, along with an episode of emesis. The hospital nutritional-support service is consulted for feeding recommendations. A discussion with the patient's family reveals that during the previous 6 months, she lost approximately 15% of her usual body weight and decreased her food intake because of abdominal pain associated with eating. Her preoperative body weight was 51 kg (112 lb), or 90% of her ideal body weight. The physical examination reveals mild wasting of skeletal muscle and fat. Blood tests show hypomagnesemia, hypophosphatemia, and normal hepatic and renal function. Central venous parenteral nutrition is recommended.