Parenteral Nutrition in the Critically Ill Patient

N Engl J Med. 2009 Sep 10;361(11):1088-97. doi: 10.1056/NEJMct0806956.

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.

Publication types

  • Research Support, N.I.H., Extramural
  • Review

MeSH terms

  • Aged
  • Catheterization, Central Venous
  • Contraindications
  • Critical Illness*
  • Diabetes Mellitus, Type 2 / complications
  • Female
  • Humans
  • Intensive Care Units
  • Ischemia / etiology
  • Ischemia / surgery
  • Mesentery / blood supply
  • Parenteral Nutrition* / adverse effects
  • Parenteral Nutrition* / methods
  • Postoperative Complications / therapy*
  • Practice Guidelines as Topic
  • Protein-Energy Malnutrition / therapy*