Nutrition support in the critically ill patient.

Despite an absence of well-controlled studies demonstrating a clear mortality benefit, providing nutrition support in the critically ill patient has become routine in most ICU settings. Unless clearly contraindicated, patients should be fed enterally, using conventional isotonic feedings employing gastric or postpyloric access. When to begin nutrition support varies, depending on baseline nutritional status, anticipated time until oral feedings are resumed, and the degree of stress. Energy and protein requirements should be assessed routinely with minimum goals of avoiding overfeeding and minimizing any net negative nitrogen balance. All patients receiving feedings require close surveillance to identify predictable complications and to tailor therapy to achieve nutritional goals. Adjunctive therapies should be employed as needed to help achieve nutritional goals, eg, insulin infusions to control serum glucose and prokinetic agents to improve gastric emptying. When feasible and safe, parenterally fed patients should be transitioned to enteral or oral feedings when appropriate.

No difference in catheter sepsis between standard and antiseptic central venous catheters. A prospective randomized trial.

OBJECTIVE: To determine the efficacy of antiseptic compared with standard triple lumen central venous catheters (CVCs) in reducing the incidence of catheter sepsis and catheter site infection in patients with CVCs for total parenteral nutrition. DESIGN: A prospective, randomized, controlled trial. SETTING: Truman Medical Center, the public teaching hospital for University of Missouri, Kansas City, School of Medicine. PATIENTS: Seventy-two inpatients on the Metabolic Support Service received a CVC for the infusion of total parenteral nutrition. Diagnoses included pancreatic disease, cancer, bowel obstruction, and intestinal surgery, among others. Patients who had a higher risk for contamination during insertion, such as those with a catheter placed through an introducer, inserted in the emergency department, or changed over a guidewire were excluded from the study. INTERVENTION: The control group received a standard CVC without antiseptics. The treatment group received a CVC with a coating of silver sulfadiazine and chlorhexidine gluconate. Each CVC was inspected for infection or malfunction by the Metabolic Support Service 5 times per week. A transparent occlusive dressing was changed every 7 days or more often if there were signs of infection or nonocclusion. When the CVC was removed, the catheter tip, the blood, and the insertion site were cultured. MAIN OUTCOME MEASURES: Although 88 catheters were inserted, only 72 catheters were evaluable. There were 40 patients in the standard group and 32 in the antiseptic group. There were no statistically significant differences between the 2 groups for diagnosis, sex, age, length of stay, days with a CVC, or catheter location. The catheter sepsis rate in the standard group was 8% and in the antiseptic group it was 6%. There were no statistically significant differences between the 2 groups in frequency of site infections or catheter sepsis. CONCLUSIONS: In this study, there were no statistically significant differences in the incidence of catheter-related sepsis or catheter site infections between the standard and antiseptic groups. Future prospective, randomized controlled trials with a larger number of antiseptic catheters are encouraged to confirm or refute these results.