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[Nutrition and fluid management in palliative medicine: do food and drink keep body and soul together?].
Gaser, E, Meissner, W, ,
Der Anaesthesist. 2012;(1):63-8
Abstract
Induction, implementation and continuation of an invasive nutrition or fluid administration in patients with advanced, life-limiting illnesses is an often controversial but also very emotionally discussed topic. This article summarizes the current state of knowledge based mainly on the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines and is intended as a simple guide for clinical practice. In the early phase of disease the induction of an invasive food and fluid administration may be indicated in order to prevent undernutrition and cachexia, to enhance compliance with anti-tumor treatment, to control some adverse effects of anti-tumor therapy and to improve the quality of life. If oral or enteral feeding is possible this should be preferred. Patients in the final stage of a disease rarely suffer from hunger or thirst. In this phase of the disease other things, such as monitoring of patients and relatives play a much more important role.
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2.
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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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: 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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6.
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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7.
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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8.
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.
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9.
Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: macronutrient and micronutrient requirements.
Bonet Saris, A, Márquez Vácaro, JA, Serón Arbeloa, C, ,
Nutricion hospitalaria. 2011;:16-20
Abstract
Energy requirements are altered in critically-ill patients and are influenced by the clinical situation, treatment, and phase of the process. Therefore, the most appropriate method to calculate calorie intake is indirect calorimetry. In the absence of this technique, fixed calorie intake (between 25 and 35 kcal/kg/day) or predictive equations such as the Penn State formula can be used to obtain a more accurate evaluation of metabolic rate. Carbohydrate administration should be limited to a maximum of 4 g/kg/day and a minimum of 2 g/kg/day. Plasma glycemia should be controlled to avoid hyperglycemia. Fat intake should be between 1 and 1.5 g/kg/day. The recommended protein intake is 1-1.5 g/kg/day but can vary according to the patient's clinical status. Particular attention should be paid to micronutrient intake. Consensus is lacking on micronutrient requirements. Some vitamins (A, B, C, E) are highly important in critically-ill patients, especially those undergoing continuous renal replacement techniques, patients with severe burns and alcoholics, although the specific requirements in each of these types of patient have not yet been established. Energy and protein intake in critically-ill patients is complex, since both clinical factors and the stage of the process must be taken into account. The first step is to calculate each patient's energy requirements and then proceed to distribute calorie intake among its three components: proteins, carbohydrates and fat. Micronutrient requirements must also be considered.
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10.
Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: acute renal failure.
López Martínez, J, Sánchez-Izquierdo Riera, JA, Jiménez Jiménez, FJ, ,
Nutricion hospitalaria. 2011;:21-6
Abstract
Nutritional support in acute renal failure must take into account the patient's catabolism and the treatment of the renal failure. Hypermetabolic failure is common in these patients, requiring continuous renal replacement therapy or daily hemodialysis. In patients with normal catabolism (urea nitrogen below 10 g/day) and preserved diuresis, conservative treatment can be attempted. In these patients, relatively hypoproteic nutritional support is essential, using proteins with high biological value and limiting fluid and electrolyte intake according to the patient's individual requirements. Micronutrient intake should be adjusted, the only buffering agent used being bicarbonate. Limitations on fluid, electrolyte and nitrogen intake no longer apply when extrarenal clearance techniques are used but intake of these substances should be modified according to the type of clearance. Depending on their hemofiltration flow, continuous renal replacement systems require high daily nitrogen intake, which can sometimes reach 2.5 g protein/kg. The amount of volume replacement can induce energy overload and therefore the use of glucose-free replacement fluids and glucose-free dialysis or a glucose concentration of 1 g/L, with bicarbonate as a buffer, is recommended. Monitoring of electrolyte levels (especially those of phosphorus, potassium and magnesium) and of micronutrients is essential and administration of these substances should be individually-tailored.