The concept 25 years ago was to administer relatively high caloric intake to cope with the catabolic state, and that we could administer this support parenterally just as easily as enterally. Since then, we have learned that gut-associated lymphatic tissue represents a major immune barrier and that enteral feeding promotes its activation, while total parenteral nutrition without enteral feeding induces gut-associated lymphatic tissue atrophy and increased risk of infection. Evidence has shown that overfeeding is not only useless but also potentially deleterious and that the enteral route is superior to the parenteral route; either the former route is actually better (to preserve gut structure and integrity), and/or the latter route is worse (for increasing infectious complications in particular). cialis professional online
We now start enteral nutrition early, without waiting for bowel sounds to be present, even in conditions such as pancreatitis or in postoperative states. We often use prokinetic agents to minimize gastroesophageal aspiration in patients with impaired gut motility, although the evidence in support of this practice is controversial. Despite the theoretical advantages of immunonutrition, such feeds have not been demonstrated consistently to be safe or effective.
Increased use of liver transplantation has reduced mortality from acute liver disease. The application of extracorporeal systems such as the molecular adsorbent recirculating system has not been shown to decrease mortality.
The development of continuous techniques of blood purification and fluid regulation enables us to avoid the “ups and downs” of intermittent dialysis on fluid, electrolytes, and osmotic shifts/balances. Initially developed as a simple arteriovenous circuit, the technique has evolved into a continuous venovenous system with relatively complex instruments. We have learned to use more biocompatible membranes in dialysis filters and not to aggressively promote ultrafiltration if it induces hemodynamically significant intravascular hypovolemia. We are not yet sure about the ideal intensity or dose of extracorporeal epura-tion techniques.