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How to provide nutritional support: In response
LETTERS TO THE EDITOR
How to Provide Nutritional Support
REFERENCES
To the Editor: In a recent Resident’s Column, Dr. Finck has provided us with an easy method to calculate requirements.1 However, the calorie recommendations are too excessive for universal use. Providing all the calculated calorie requirements is not considered essential in critically ill patients and in fact leads to more complications. Protein breakdown and gluconeogenesis do not seem to be affected by calorie intake. The American College of Chest Physicians (ACCP) consensus statement issued in 1997 recommends that 25 total kcal/d is adequate for most patients in the intensive care unit.2 Thirty to 70% of total calories are to be provided as glucose, 15–30% as fats, and 15–20% as protein. If non-protein calories are used in calculations, then a figure of 20 kcal/d may be sufficient. Most physicians in critical care would initiate “hypocaloric” nutritional support and increase the carbohydrate and fat calorie intake cautiously and with adequate monitoring and justification. A recent article on nutrition support in the 21st century predicts that less emphasis will be placed on calories and that protein requirements must be satisfied.3 Although all formulas and calculations are only guidelines and cannot replace clinical judgment, health-care professionals must be aware of the newer recommendations.
1. Finck C. How to provide nutritional support. Nutrition 2000;16:155 2. Cerra FB, Benitez MR, Blackburn, GL, et al. ACCP consensus statement: applied nutrition in ICU patients. Chest 1997;111:769 3. Wilmore DW. Nutrition and metabolic support in the 21st century. JPEN 2000; 24:1
Krishnan Sriram, FRCSC, FACS Professor of Surgery and Surgical Critical Care Sri Ramachandra Medical College Madras 600116 India
Nutrition 16:791, 2000 ©Elsevier Science Inc., 2000. Printed in the United States. All rights reserved.
PII S0899-9007(00)00396-8 In Response: I appreciate the comments and suggestions of Dr. Sriram. The original article “How to Provide Nutritional Support” was intended to provide a baseline of formulas for residents to use for all types of patients, not just the critically ill. Questions regarding these base formulas commonly appear on the US Surgical Inservice exams. The point about overfeeding is an important one. The Consensus Statement of the ACCP recommends 25 kcal/kg/d usual body weight. In addition, there is currently more emphasis placed on satisfying protein requirements, especially in the critically ill.
Christine Finck, MD Resident’s Column Editor Chief Resident in General Surgery Upstate Medical University Syracuse, New York, USA PII S0899-9007(00)00397-X
0899-9007/00/$20.00
How to Provide Nutritional Support
REFERENCES
To the Editor: In a recent Resident’s Column, Dr. Finck has provided us with an easy method to calculate requirements.1 However, the calorie recommendations are too excessive for universal use. Providing all the calculated calorie requirements is not considered essential in critically ill patients and in fact leads to more complications. Protein breakdown and gluconeogenesis do not seem to be affected by calorie intake. The American College of Chest Physicians (ACCP) consensus statement issued in 1997 recommends that 25 total kcal/d is adequate for most patients in the intensive care unit.2 Thirty to 70% of total calories are to be provided as glucose, 15–30% as fats, and 15–20% as protein. If non-protein calories are used in calculations, then a figure of 20 kcal/d may be sufficient. Most physicians in critical care would initiate “hypocaloric” nutritional support and increase the carbohydrate and fat calorie intake cautiously and with adequate monitoring and justification. A recent article on nutrition support in the 21st century predicts that less emphasis will be placed on calories and that protein requirements must be satisfied.3 Although all formulas and calculations are only guidelines and cannot replace clinical judgment, health-care professionals must be aware of the newer recommendations.
1. Finck C. How to provide nutritional support. Nutrition 2000;16:155 2. Cerra FB, Benitez MR, Blackburn, GL, et al. ACCP consensus statement: applied nutrition in ICU patients. Chest 1997;111:769 3. Wilmore DW. Nutrition and metabolic support in the 21st century. JPEN 2000; 24:1
Krishnan Sriram, FRCSC, FACS Professor of Surgery and Surgical Critical Care Sri Ramachandra Medical College Madras 600116 India
Nutrition 16:791, 2000 ©Elsevier Science Inc., 2000. Printed in the United States. All rights reserved.
PII S0899-9007(00)00396-8 In Response: I appreciate the comments and suggestions of Dr. Sriram. The original article “How to Provide Nutritional Support” was intended to provide a baseline of formulas for residents to use for all types of patients, not just the critically ill. Questions regarding these base formulas commonly appear on the US Surgical Inservice exams. The point about overfeeding is an important one. The Consensus Statement of the ACCP recommends 25 kcal/kg/d usual body weight. In addition, there is currently more emphasis placed on satisfying protein requirements, especially in the critically ill.
Christine Finck, MD Resident’s Column Editor Chief Resident in General Surgery Upstate Medical University Syracuse, New York, USA PII S0899-9007(00)00397-X
0899-9007/00/$20.00