Abstract
Patients requiring long term intensive care and/or prolonged ventilatory support, are frequently undergoing progressive malnutrition, occasionally complicated by a hypercatabolic state. Sepsis, fever and the requirements for postoperative healing will add further nutritional demands on such patients. In contrast to starvation, critically ill patients maintained on protein-free energy-deficient diet do not adapt to utilization of their lipid to provide energy needs. Mobilization of endogenous fat stores is reduced, and this reduction leads to increased gluconeogenesis from amino acids derived from muscle protein to meet the increased energy needs. Low serum albumin, possible low surfactant production, devitalization of the alveolo-capillary membrane and impaired immunocompetence could contribute to the development of pulmonary transudation, alveolar collapse, low compliance and pulmonary infection. Such sequelae of a protein-free energy-deficient diet would delay weaning patients off prolonged mechanical ventilation. Nutritional assessment, which may be determined serially, and means of nutritional support are outlined.
Résumé
Les grands malades qui requièrent des soins intensifs à long terme, avec ou sans ventilation mécanique prolongée, évoluent souvent vers un état de dénutrition compliqué occasionnellement d’ hypercatabolisme. L’infection, l’hyperthermie et la cicatrisation post-opératoire sont autant de facteurs qui viennent encore augmenter les besoins nutritionnels. Contrairement à ce qui survient dans le jeûne, il n’y a pas dans ces cas d’adaptation à l’utilisation des lipides comme source d’énergie lorsque les apports ne contiennent pas d’acides aminés et sont inférieurs aux besoins énergétiques. La mobilisation des réserves lipidiques endogènes est réduite et cette réduction conduit à une néoglucogénèse augmentée comme source d’énergie et ceci, aux dépens des amines aminés des protéines musculaires (y compris les muscles intercostaux et le diaphragme). Des albumines sériques abaissées, une production de surfactant diminuée, la dévitalisation de la membrane alvéolo-capillaire et un système immunologique d’efficacité réduite, peuvent contribuer à la survenue de transsudations pulmonaires, de collapsus alvéolaires, à de basses compliances et à l’infection pulmonaire. Une diète insuffisante en apport énergétique et sans apports aminés chez les grands malades peut done être un faeteur important dans les difficultés que l’on retrouve au sevrage de malades en ventilation prolongée. II est essentiel de bien évaluer l’état nutritionnel dans ces situations. Les diverses méthodes de supports nutritionnels sont discutées.
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Supported by the St. Joseph’s Hospital (Toronto) Research Foundation.
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Bassili, H.R., Deitel, M. Nutritional support in long term intensive care with special reference to ventilator patients: A review. Canad. Anaesth. Soc. J. 28, 17–21 (1981). https://doi.org/10.1007/BF03007284
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DOI: https://doi.org/10.1007/BF03007284