THE ROUTE OF NUTRITIONAL SUPPORT IN THE CRITICALLY ILL - PHYSIOLOGICAL AND ECONOMICAL CONSIDERATIONS

Although it generally is accepted that early enteral nutrition is of b enefit to critically ill patients, there is little evidence to support this assertion. Nevertheless, enteral nutrition has many advantages o ver total parenteral nutrition (TPN), the latter being associated with several complications. Animal studies have shown that injury and infe ction can lead to gut atrophy and increased mucosal permeability. Tran slocation of bacteria and endotoxin in these animal models may initiat e a systemic inflammatory response and cause multiple organ failure (M OF). Again, there is little direct evidence to suggest that similar me chanisms operate in humans. As a cause of MOF, simple splanchnic ische mia and reperfusion may be sufficient with no absolute requirement for translocation. In this setting, enteral nutrition may preserve splanc hnic blood flow and prevent mucosal breakdown. Unfortunately there is a widespread misconception that gastric stasis, the absence of bowel s ounds, and recent abdominal surgery preclude enteral feeding. There ar e few absolute contraindications to early enteral feeding and with mot ivated staff the use of prokinetics, and the availability of jejunal f eeding tubes. the majority of intensive care patients can be fed enter ally. Enteral feeding is more cost effective than TPN, but TPN remains a common therapeutic intervention in the intensive care unit and repr esents a significant burden on health care budgets. Nutrition support teams have led to savings, particularly by identifying patients who ha ve been inappropriately prescribed TPN and also by preventing excessiv e enteral feeding. (C) Elsevier Science Inc. 1997.