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Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: respiratory failure.
Grau Carmona, T, López Martínez, J, Vila García, B, ,
Nutricion hospitalaria. 2011;:37-40
Abstract
Severe acute respiratory failure requiring mechanical ventilation is one of the most frequent reasons for admission to the intensive care unit. Among the most frequent causes for admission are exacerbation of chronic obstructive pulmonary disease and acute respiratory failure with acute lung injury (ALI) or with criteria of acute respiratory distress syndrome (ARDS). These patients have a high risk of malnutrition due to the underlying disease, their altered catabolism and the use of mechanical ventilation. Consequently, nutritional evaluation and the use of specialized nutritional support are required. This support should alleviate the catabolic effects of the disease, avoid calorie overload and, in selected patients, to use omega-3 fatty acid and antioxidant-enriched diets, which could improve outcome.
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Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: liver failure and liver transplantation.
Montejo González, JC, Mesejo, A, Bonet Saris, A, ,
Nutricion hospitalaria. 2011;:27-31
Abstract
Patients with liver failure have a high prevalence of malnutrition, which is related to metabolic abnormalities due to the liver disease, reduced nutrient intake and alterations in digestive function, among other factors. In general, in patients with liver failure, metabolic and nutritional support should aim to provide adequate nutrient intake and, at the same time, to contribute to patients' recovery through control or reversal of metabolic alterations. In critically-ill patients with liver failure, current knowledge indicates that the organ failure is not the main factor to be considered when choosing the nutritional regimen. As in other critically-ill patients, the enteral route should be used whenever possible. The composition of the nutritional formula should be adapted to the patient's metabolic stress. Despite the physiopathological basis classically described by some authors who consider amino acid imbalance to be a triggering factor and key element in maintaining encephalopathy, there are insufficient data to recommend "specific" solutions (branched-chain amino acid-enriched with low aromatic amino acids) as part of nutritional support in patients with acute liver failure. In patients undergoing liver transplantation, nutrient intake should be started early in the postoperative period through transpyloric access. Prevention of the hepatic alterations associated with nutritional support should also be considered in distinct clinical scenarios.
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3.
Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: nutritional assessment.
Ruiz-Santana, S, Arboleda Sánchez, JA, Abilés, J, ,
Nutricion hospitalaria. 2011;:12-5
Abstract
Current parameters to assess nutritional status in critically-ill patients are useful to evaluate nutritional status prior to admission to the intensive care unit. However, these parameters are of little utility once the patient's nutritional status has been altered by the acute process and its treatment. Changes in water distribution affect anthropometric variables and biochemical biomarkers, which in turn are affected by synthesis and degradation processes. Increased plasma levels of prealbumin and retinol -proteins with a short half-life- can indicate adequate response to nutritional support, while reduced levels of these proteins indicate further metabolic stress. The parameters used in functional assessment, such as those employed to assess muscular or immune function, are often altered by drugs or the presence of infection or polyneuropathy. However, some parameters can be used to monitor metabolic response and refeeding or can aid prognostic evaluation.
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4.
Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: gastrointestinal surgery.
Sánchez Álvarez, C, Zabarte Martínez de Aguirre, M, Bordejé Laguna, L, ,
Nutricion hospitalaria. 2011;:41-5
Abstract
Gastrointestinal surgery and critical illness place tremendous stress on the body, resulting in a series of metabolic changes that may lead to severe malnutrition, which in turn can increase postsurgical complications and morbidity and mortality and prolong the hospital length of stay. In these patients, parenteral nutrition is the most widely used form of nutritional support, but administration of enteral nutrition early in the postoperative period is effective and well tolerated, reducing infectious complications, improving wound healing and reducing length of hospital stay. Calorie-protein requirements do not differ from those in other critically-ill patients and depend on the patient's underlying process and degree of metabolic stress. In patients intolerant to enteral nutrition, especially if the intolerance is due to increased gastric residual volume, prokinetic agents can be used to optimize calorie intake. When proximal sutures are used, tubes allowing early jejunal feeding should be used. Pharmaconutrition is indicated in these patients, who benefit from enteral administration of arginine, omega 3 and RNA, as well as parenteral glutamine supplementation. Parenteral nutrition should be started in patients with absolute contraindication for use of the gastrointestinal tract or as complementary nutrition if adequate energy intake is not achieved through the enteral route.
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5.
Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: septic patient.
Ortiz Leyba, C, Montejo González, JC, Vaquerizo Alonso, C, ,
Nutricion hospitalaria. 2011;:67-71
Abstract
Nutritional metabolic management, together with other treatment and support measures used, is one of the mainstays of the treatment of septic patients. Nutritional support should be started early, after initial life support measures, to avoid the consequences of malnutrition, to provide adequate nutritional intake and to prevent the development of secondary complications such as superinfection or multiorgan failure. As in other critically-ill patients, when the enteral route cannot be used to ensure calorie-protein requirements, the association of parenteral nutrition has been shown to be safe in this subgroup of patients. Studies evaluating the effect of specific pharmaconutrients in septic patients are scarce and are insufficient to allow recommendations to be made. To date, enteral diets with a mixture of substrates with distinct pharmaconutrient properties do not seem to be superior to standard diets in altering the course of sepsis, although equally there is no evidence that these diets are harmful. There is insufficient evidence to recommend the use of glutamine in septic patients receiving parenteral nutrition. However, given the good results and absence of glutamine-related adverse effects in the various studies performed in the general population of critically-ill patients, these patients could benefit from the use of this substance. Routine use of omega-3 fatty acids cannot be recommended until further evidence has been gathered, although the use of lipid emulsions with a high omega-6 fatty acid content should be avoided. Septic patients should receive an adequate supply of essential trace elements and vitamins. Further studies are required before the use of high-dose selenium can be recommended.
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6.
Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: critically-ill burnt patient.
García de Lorenzo y Mateos, A, Ortiz Leyba, C, Sánchez, SM, ,
Nutricion hospitalaria. 2011;:59-62
Abstract
The response to severe burns is characterized by hypermetabolism (the most hypermetabolic existing model of aggression) and hypercatabolism, with a high degree of destruction of the skeletal musculature. Metabolic disorders are most evident in the first two weeks after the burn, although they can be prolonged in direct relation to the complications that these patients develop. Nutritional-metabolic support is an essential part of the treatment of these patients and should be started early, preferentially through the enteral route, with parenteral nutrition as complementary support. Exact calculation of calorie-protein requirements in these patients is difficult, even when indirect calorimetry is used, due to the high loss of proteins and CO2 through the skin. Specific pharmaconutrients are indicated, with a high dose of micronutrients. The use of drugs or medications with anabolic effects is also sometimes indicated.
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7.
Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: neurocritical patient.
Acosta Escribano, J, Herrero Meseguer, I, Conejero García-Quijada, R, ,
Nutricion hospitalaria. 2011;:72-5
Abstract
Neurocritical patients require specialized nutritional support due to their intense catabolism and prolonged fasting. The preferred route of nutrient administration is the gastrointestinal route, especially the gastric route. Alternatives are the transpyloric route or mixed enteral-parenteral nutrition if an effective nutritional volume of more than 60% cannot be obtained. Total calorie intake ranges from 20-30 kcal/kg/day, depending on the period of the clinical course, with protein intake higher than 20% of total calories (hyperproteic diet). Nutritional support should be initiated early. The incidence of gastrointestinal complications is generally higher to other critically-ill patients, the most frequent complication being an increase in gastric residual volume. As in other critically-ill patients, glycemia should be closely monitored and maintained below 150 mg/dL.
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8.
Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: obese patient.
Mesejo, A, Sánchez Álvarez, C, Arboleda Sánchez, JA, ,
Nutricion hospitalaria. 2011;:54-8
Abstract
As a response to metabolic stress, obese critically-ill patients have the same risk of nutritional deficiency as the non-obese and can develop protein-energy malnutrition with accelerated loss of muscle mass. The primary aim of nutritional support in these patients should be to minimize loss of lean mass and accurately evaluate energy expenditure. However, routinely used formulae can overestimate calorie requirements if the patient's actual weight is used. Consequently, the use of adjusted or ideal weight is recommended with these formulae, although indirect calorimetry is the method of choice. Controversy surrounds the question of whether a strict nutritional support criterion, adjusted to the patient's requirements, should be applied or whether a certain degree of hyponutrition should be allowed. Current evidence suggested that hypocaloric nutrition can improve results, partly due to a lower rate of infectious complications and better control of hyperglycemia. Therefore, hypocaloric and hyperproteic nutrition, whether enteral or parenteral, should be standard practice in the nutritional support of critically-ill obese patients when not contraindicated. Widely accepted recommendations consist of no more than 60-70% of requirements or administration of 11-14 kcal/kg current body weight/day or 22-25 kcal/kg ideal weight/day, with 2-2.5 g/kg ideal weight/day of proteins. In a broad sense, hypocaloric-hyperprotein regimens can be considered specific to obese critically-ill patients, although the complications related to comorbidities in these patients may require other therapeutic possibilities to be considered, with specific nutrients for hyperglycemia, acute respiratory distress syndrome (ARDS) and sepsis. However, there are no prospective randomized trials with this type of nutrition in this specific population subgroup and the available data are drawn from the general population of critically-ill patients. Consequently, caution should be exercised when interpreting these data.
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9.
Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: indications, timing and routes of nutrient delivery.
Fernández-Ortega, JF, Herrero Meseguer, JI, Martínez García, P, ,
Nutricion hospitalaria. 2011;:7-11
Abstract
This article discusses basic features of nutritional support in critically-ill patients: general indications, the route of administration and the optimal timing for the introduction of feeding. Although these features form the bedrock of nutritional support, most of the questions related to these issues are lacking answers based on the highest grade of evidence. Moreover, prospective randomized trials that might elucidate some o f these questions would probably be incompatible with good clinical practice. Nevertheless, nutritional support in critically-ill patients unable to voluntarily meet their own nutritional requirements is currently an unquestionable part of their treatment and care and is essential to the successful management of their illness.
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10.
Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: hyperglycemia and diabetes mellitus.
Vaquerizo Alonso, C, Grau Carmona, T, Juan Díaz, M, ,
Nutricion hospitalaria. 2011;:46-9
Abstract
Hyperglycemia is one of the main metabolic disturbances in critically-ill patients and is associated with increased morbidity and mortality. Consequently, blood glucose levels must be safely and effectively controlled, that is, maintained within a normal range, avoiding hypoglycemia on the one hand and elevated glucose concentrations on the other. To accomplish this aim, insulin is often required, avoiding protocols designed to achieve tight glycemic control. To prevent hyperglycemia and its associated complications, energy intake should be adjusted to patients' requirements, avoiding overnutrition and excessive glucose intake. Protein intake should be adjusted to the degree of metabolic stress. Whenever patients require artificial feeding, the enteral route, if not contraindicated, should be used since parenteral nutrition is associated with a higher frequency of hyperglycemia and greater insulin requirements. Enteral nutrition should be administered early, preferably within the first 24 hours of admission to the intensive care unit, after hemodynamic stabilization. Specific diets for hyperglycemia, containing low glycemic index carbohydrates and fibre and enriched with monounsaturated fatty acids, can achieve good glycemic control with lower insulin requirements.