Déficit calorique du patient de réanimation : à traiter ou à contempler ?
Tóm tắt
La prise en charge multidisciplinaire d’un patient hospitalisé en réanimation présente de multiples défis. Outre l’instabilité hémodynamique et respiratoire, l’équilibre métabolique est profondément altéré chez ces patients. Le catabolisme et un apport nutritionnel compromis simultané induisent un déficit protéinoénergétique aux conséquences négatives. La quantité de calories à administrer chez ces patients reste toutefois un sujet controversé. L’insuffisance aussi bien que l’excès d’apport calorique pouvant être délétères pour les patients, il est par conséquent primordial de déterminer précocement leurs besoins énergétiques. La calorimétrie indirecte (CI) est la méthode recommandée. En l’absence de celle-ci, des équations prédictives pondérées par des facteurs de correction sont utilisées, mais restent imprécises. En pratique, la Société européenne de nutrition (ESPEN) recommande des formules simplifiées, basées sur le poids corporel anamnestique. Une fois les besoins énergétiques déterminés, il faut choisir la voie d’administration appropriée. La nutrition entérale (NE) doit être le premier choix de soutien si le tube digestif est fonctionnel. Cependant, la voie entérale est souvent associée à un déficit d’apport calorique cumulé, qui aggrave l’état de dénutrition du patient en réanimation et augmente l’incidence des complications secondaires (mortalité, morbidité, durée de ventilation mécanique et du séjour hospitalier). L’ajout d’une nutrition parentérale (NP) en complément est une des alternatives proposées afin de pallier ce déficit calorique. La sensibilisation des équipes soignantes sur les conséquences potentiellement graves de la dénutrition et leur adhérence à des protocoles nutritionnels s’intègre dans un processus de qualité de soins.
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