Print friendly page The assessment of respiratory function and metabolic state with blood gas analysis, combined with continuous monitoring from pulse oximetry and capnography is routinely performed in patients during anaesthesia, in resuscitation and in the critically ill. Blood gas measurement Blood gas analysers report a wide range of results, but the only parameters directly measured are the partial pressures of oxygen pO2 and carbon dioxide pCO2 and blood pH.
Additional assessment prior to initiation of nutrition therapy should include an evaluation of comorbid conditions, function of the GI tract, and risk of aspiration.
Serum albumin, pre-albumin, and transferrin should not be used as markers of nutritional status but instead should be considered surrogate markers of risk and level of inflammation Serum albumin levels alone at the time of admission may provide valuable prognostic information prior to a surgical procedure Neither albumin nor pre-albumin should be used as a marker for adequacy of nutrition therapy, as their levels will only rise once the inflammation and degree of oxidative stress abates.
C-reactive protein alone or in combination with pre-albumin may provide some useful information to the clinician Osce assessment of critically ill patient regard to changes in the level of inflammation and resolution of the systemic inflammatory response syndrome.
Aside from basic measures of height, weight, and BMI, anthropometric measures such as mid-arm muscle circumference, creatinine-height index, and skin fold thickness are inaccurate, poorly reproducible, and provide little accurate information with regard to overall nutritional status for the hospitalized patient For clinicians, IC is the gold standard, as results correlate well with direct whole-chamber calorimetry If IC is not available or easily accessible, a weight-based equation e.
Furthermore, a number of predictive equations e. Equations derived from measurements on hospitalized patients Ireton—Jones, American College of Chest Physicians, Penn State, Swinamer are no more accurate than equations derived in research labs by measuring ambulatory healthy volunteers Harris—Benedict, Mifflin-St Jeor These predictive equations should be used with caution, with an understanding of the potential errors in estimates for specific groups such as patients with extreme obesity In the past, providing 1.
Protein needs may be even higher in patients with trauma or large wounds Besides the weight-based equation above, protein requirements may be determined by calculating the nitrogen balance using a h urine collection to measure urine urea nitrogen UUN with the following calculation: How should enteral access be achieved, and at what level of the GI tract should EN be infused?
A nasogastric or orogastric feeding tube should be used as the initial access device for starting EN in a hospitalized patient conditional recommendation, very low level of evidence.
Radiologic confirmation of placement in the stomach should be carried out prior to feeding except with the use of electromagnetic transmitter-guided feeding tubes.
Conversion to a post-pyloric feeding tube should be carried out only when gastric feeding has been shown to be poorly tolerated or the patient is at high risk for aspiration strong recommendation, moderate-to-high level of evidence.
When long-term enteral access is needed in a patient with gastroparesis or chronic pancreatitis, a jejunostomy tube should be placed conditional recommendation, very low level of evidence.
A percutaneous gastrostomy should be placed preferentially in the gastric antrum in order to facilitate conversion to a GJ tube in the event that the patient is intolerant to gastric feeding conditional recommendation, very low level of evidence.
For the patient at high risk for tube displacement, steps should be taken proactively to secure the access device at the time of placement conditional recommendation, very low level of evidence.
Gastric feeding is successful in the vast majority of patients requiring nasoenteric feeding in the hospital Greater disease severity, however, is associated with a worsening degree of ileus and GI dysmotility, and, in those circumstances, there may be more of a need for small bowel feeding Radiologic confirmation of placement of a nasoenteric or an oroenteric tube in the stomach or small bowel is required Alternative methods to confirm the location of the tube tip in the GI tract below the diaphragm, such as auscultation, detection of CO2, and measurement of pH are not accurate enough to confirm placement New optical guidance feeding tubes have recently been approved by the Federal Drug Administration but will require further validation studies before radiologic confirmation can be avoided The incidence of reflux, regurgitation, and aspiration all decrease significantly as the level of infusion of formula is diverted lower in the GI tract, from the stomach to the proximal jejunum A meta-analysis of 12 RCTs showed a reduction in ventilator-associated pneumonia with small bowel compared with gastric feeding; yet, duration of mechanical ventilation, hospital length of stay, and mortality did not change These findings suggest that the appearance of an infiltrate on chest X-ray in a patient on enteral tube feeding may have minimal consequences.
Placement of a feeding tube in the small bowel requires greater expertise, which may lead to delays in initiation of feeding For these reasons, it is best to start with gastric feeds, take additional steps to promote tolerance, and to monitor closely while awaiting expertise for small bowel placement if subsequently required.
Long-term jejunal access is best achieved by the use of a jejunostomy tube placed endoscopically, radiologically, or surgically, depending upon available expertise.
Because of frequent displacement of the jejunal extension tube back into the stomach with a GJ device, this is generally not a good long-term option. Recent changes in the design of tubes such as the use of a stiffer double pigtail catheter with a spring in the jejunal portion of the tubehowever, seem to result in less displacement.
Given the greater ease of placement compared with a direct jejunostomy, reconsideration of the use of such GJ tubes may be warranted.
If the duration of provision of EN is anticipated to exceed 4 weeks, then a percutaneous enteral access device is generally indicated. The 4-week cutoff, although arbitrary, is based on the potential morbidity of a nasoenteric tube, which includes erosion of the nares, an increase in aspiration pneumonia, sinusitis, and esophageal ulceration or stricture Certain institutional practices may dictate early placement of a tracheostomy and percutaneous gastrostomy tube in trauma patients.
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•If patient his hypotensive and overloaded, they need inotropes •If patient is still hypotensive despite adequate fluid resuscitation (30ml/kg), they need vasopressors. clinical skills: the 'dr abcde' assessment **These tools are for revision purposes only and should be supported by use of National and Local Guidelines** rutadeltambor.com Osce Assessment of Critically Ill Patient.
Topics: Respiratory rate (RCUK, ). It is a systematic approach that can assess the severity of the critically ill patient, assess and treat life threatening conditions and have rapid intervention when needed (Grindrod, ).