title: Special commentary: a call for intensive metabolic support.
abstract: OBJECTIVE
  This special commentary addresses recent clinical reviews regarding appropriate nutrition and metabolic support in the critical care setting.
  
  
  RESULTS
  There are divergent approaches between North America and Europe for the use of early nutrition support and combined enteral nutrition and parenteral nutrition support possibly due to the commercial availability of specific parenteral nutrients. The advent of intensive insulin therapy has changed the landscape of metabolic support in the intensive care unit, and previous notions about infective risk of parenteral nutrition will need to be re-addressed. Patients with brain failure may benefit from an intensive insulin therapy with a blood glucose target that is higher than that used in patients without brain failure. Patients with heart failure may benefit from the addition of nutritional pharmacology that targets proximate oxidative pathophysiological pathways. Intradialytic parenteral nutrition may be viewed as another form of supplemental parenteral nutrition when enteral nutrition is insufficient in patients on hemodialysis in the intensive care unit.
  
  
  CONCLUSIONS
  It is proposed that intensive metabolic support be routinely implemented in the intensive care unit based on the following steps: intensive insulin therapy with an appropriate blood glucose target, nutrition risk assessment, early and if needed combined enteral nutrition and parenteral nutrition to target 20-25 kcal/kg/day and 1.2-1.5 g protein/kg/day, and nutritional and metabolic monitoring.
authors.affiliation: Division of Endocrinology, Diabetes and Bone Disease, Mount Sinai School of Medicine, New York, New York, USA. jmechanick@aol.com
authors.forename: Jeffrey I
authors.initials: JI
authors.lastname: Mechanick
authors.forename: Rene
authors.initials: R
authors.lastname: Chiolero
mesh_terms: D001786:Blood Glucose; D003422:Critical Care; D003956:Dialysis; D044882:Glucose Metabolism Disorders / Q000628:therapy*; D006801:Humans; D007328:Insulin / Q000009:adverse effects / Q000627:therapeutic use*; D007362:Intensive Care Units; D018529:Nutritional Support / Q000379:methods*; D018805:Sepsis / Q000628:therapy
chemical_list: D001786:Blood Glucose; D007328:Insulin