Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for Indian Scenario.

BACKGROUND AND AIM: Intensive-care practices and settings may differ for India in comparison to other countries. While international guidelines are available to direct the use of enteral nutrition (EN), there are no recommendations specific to Indian settings. Advisory board meetings were arranged to develop the practice guidelines specific to Indian context, for the use of EN in critically ill patients and to overcome challenges in this field. METHODS: Various existing guidelines, meta-analyses, randomized controlled trials, controlled trials, and review articles were reviewed for their contextual relevance and strength. A systematic grading of practice guidelines by advisory board was done based on strength of the supporting evidence. Wherever Indian studies were not available, references were taken from the international guidelines. RESULTS: Based on the literature review, the recommendations for developing the practice guidelines were made as per the grading criteria agreed upon by the advisory board. The recommendations were to address challenges regarding EN versus parenteral nutrition; nutrition screening and assessment; nutrition in hemodynamically unstable; route of nutrition; tube feeding and challenges; tolerance; optimum calorie-protein requirements; selection of appropriate enteral feeding formula; micronutrients and immune-nutrients; standard nutrition in hepatic, renal, and respiratory diseases and documentation of nutrition practices. CONCLUSION: This paper summarizes the optimum nutrition practices for critically ill patients. The possible solutions to overcome the challenges in this field are presented as practice guidelines at the end of each section. These guidelines are expected to provide guidance in critical care settings regarding appropriate critical-care nutrition practices and to set up Intensive Care Unit nutrition protocols.

Haemodynamic studies during the management of severe tetanus.

Detailed invasive haemodynamic studies were performed in 27 of 32 patients with severe tetanus. Nineteen had severe uncomplicated tetanus and eight had associated major complications, chiefly infection and pulmonary complications. The results were compared with those obtained from 15 healthy male volunteers who served as controls. There were two deaths in 32 patients (mortality 6.25 per cent). Severe tetanus without major complications was characterized by a high output hyperkinetic circulatory state with tachycardia (heart rate 131 (19.2) beats/minute), increased stroke volume index (43.1 (10.7) ml/m2), increased cardiac index (5.48 (0.94) l/min/m2) and a normal left ventricular stroke work index (60.5 (15.9) g/m/m2). Volume loading demonstrated a significant haemodynamic response and increased vascular capacitance. Even so the maximum percent rise from baseline values of these indices after volume load was significantly higher in controls (p < 0.001). Autonomic cardiovascular disturbances affected both sympathetic and parasympathetic activity. Hypertension and tachycardia alternating with hypotension and bradycardia were related to sudden fluctuations in systemic vascular resistance. Our studies suggested some degree of myocardial dysfunction in patients with severe uncomplicated tetanus. The haemodynamics of severe tetanus were masked and altered by complicating infection, pneumonia, and atelectasis.

The maximal expiratory flow-volume curve in normal subjects in India.

Data on pulmonary function, with particular reference to flow-volumes, were obtained in 760 normal healthy Indians in Bombay, who had never smoked and who had no symptom or history of cardiorespiratory disease. Prediction equations were derived for spirometric parameters and for maximal expiratory flows. The maximal expiratory flow-volume curves showed considerable intersubject variability. Both flow and volume decreased with advancing age, with the flow-volume curve appearing increasingly convex towards the volume axis in its second half with increase in age. The maximal expiratory flows in our study were significantly lower compared to values reported by workers in the West.