Aggressive approach to intravenous feeding of the critically ill patient.

Intravenous nutrition has become a necessary part of comprehensive critical care. The guidelines that surround the technique render it both safe and effective, but are not always practical in the patient with sepsis or multisystem failure who has a shortage of sites for catheter insertion. After an 8 year experience in a multidisciplinary ICU in which 40 per cent of patients admitted are fed parenterally, modified techniques have been developed so a more aggressive and liberal approach can be used for treating acutely ill patients. Additional crystalloid fluids and medications can be administered through the TPN catheter, high calorie levels can be used initially, and TPN can be stopped abruptly and insulin dosages as high as 28 U. per hour administered safely. When critically ill patients undergo major surgery TPN may be continued. This is made possible by a well oriented and well trained staff, competent to both follow and act on the results of very close monitoring in a special care area with efficient stat laboratory backing. Complication rates have to be kept low by rigorous supervision of both catheter insertion and aftercare. This has made frequent catheter changes a practical safety measure. Management and monitoring protocols are presented. The well established protocols for the management of TPN are adhered to for the routine support of nutrition.