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1.
[DGEM Guideline "Clinical Nutrition in Critical Care Medicine" - short version].
Elke, G, Hartl, WH, Kreymann, KG, Adolph, M, Felbinger, TW, Graf, T, de Heer, G, Heller, AR, Kampa, U, Mayer, K, et al
Anasthesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie : AINS. 2019;(1):63-73
Abstract
PURPOSE Variations of clinical nutrition may affect outcome of critically ill patients. Here we present the short version of the updated consenus-based guideline (S2k classification) "Clinical nutrition in critical care medicine" of the German Society for Nutritional Medicine (DGEM) in cooperation with 7 other national societies. The target population of the guideline was defined as critically ill adult patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g. mechanical ventilation) to maintain organ function. METHODS The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. We considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of international societies. The liability of each recommendation was indicated using linguistic terms. Each recommendation was finally validated and consented by a Delphi process. RESULTS The short version presents a summary of all 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in the target population. A specific focus is the adjustment of nutrition according to the phases of critical illness, and to the individual tolerance to exogenous substrates. Among others, recommendations include the assessment of nutritional status, the indication for clinical nutrition, the timing, route, magnitude and composition of nutrition (macro- and micronutrients) as well as distinctive aspects of nutrition therapy in obese critically ill patients and those with extracorporeal support devices. CONCLUSION The current short version of the guideline provides a concise summary of the updated recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring pharmacological and/or mechanical support. The validity of the guideline is approximately fixed at five years (2018 - 2023).
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2.
[Recommendations of the GARIN group for dietary managing of patient with chronic kidney disease].
Alhambra Expósito, MR, Molina Puerta, MJ, Olveira, G, Arraiza Irigoyen, C, Fernández Soto, M, García Almeida, JM, García Luna, PP, Gómez Pérez, AM, Irles Rocamora, JA, Molina Soria, JB, et al
Nutricion hospitalaria. 2019;(1):183-217
Abstract
Background and objectives: by means of this update, the GARIN working group aims to define its position regarding the dietary treatment of patients with chronic kidney disease (CKD). In this area there are many aspects of uncertainty. Material and methods: bibliographical review and specific questions in advance were discussed and answered at a meeting in the form of conclusions. Results: the therapeutic action must be individualized and taking into account the degree of renal failure that the patient presents and their comorbidities. Regarding nutritional medical therapy, our group proposes three different levels of action, in which the recommendations of protein intake, fiber, fatty acids or potassium are different. In addition, we suggest using the phosphorus/protein ratio concept in adjusting the diet of the patient with CKD. We give recommendations regarding treatment in diabetes and artificial supplementation. Conclusions: these recommendations about dietary issues in patients with CKD can add value to clinical work.
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3.
The Mexican consensus on non-cardiac chest pain.
Gómez-Escudero, O, Coss-Adame, E, Amieva-Balmori, M, Carmona-Sánchez, RI, Remes-Troche, JM, Abreu Y Abreu, AT, Cerda-Contreras, E, Gómez-Castaños, PC, González-Martínez, MA, Huerta-Iga, FM, et al
Revista de gastroenterologia de Mexico (English). 2019;(3):372-397
Abstract
INTRODUCTION Non-cardiac chest pain is defined as a clinical syndrome characterized by retrosternal pain similar to that of angina pectoris, but of non-cardiac origin and produced by esophageal, musculoskeletal, pulmonary, or psychiatric diseases. AIM: To present a consensus review based on evidence regarding the definition, epidemiology, pathophysiology, and diagnosis of non-cardiac chest pain, as well as the therapeutic options for those patients. METHODS Three general coordinators carried out a literature review of all articles published in English and Spanish on the theme and formulated 38 initial statements, dividing them into 3 main categories: (i)definitions, epidemiology, and pathophysiology; (ii)diagnosis, and (iii)treatment. The statements underwent 3rounds of voting, utilizing the Delphi system. The final statements were those that reached >75% agreement, and they were rated utilizing the GRADE system. RESULTS AND CONCLUSIONS The final consensus included 29 statements. All patients presenting with chest pain should initially be evaluated by a cardiologist. The most common cause of non-cardiac chest pain is gastroesophageal reflux disease. If there are no alarm symptoms, the initial approach should be a therapeutic trial with a proton pump inhibitor for 2-4weeks. If dysphagia or alarm symptoms are present, endoscopy is recommended. High-resolution manometry is the best method for ruling out spastic motor disorders and achalasia and pH monitoring aids in demonstrating abnormal esophageal acid exposure. Treatment should be directed at the pathophysiologic mechanism. It can include proton pump inhibitors, neuromodulators and/or smooth muscle relaxants, psychologic intervention and/or cognitive therapy, and occasionally surgery or endoscopic therapy.
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4.
Perioperative management of adult diabetic patients. Specific situations.
Cheisson, G, Jacqueminet, S, Cosson, E, Ichai, C, Leguerrier, AM, Nicolescu-Catargi, B, Ouattara, A, Tauveron, I, Valensi, P, Benhamou, D, et al
Anaesthesia, critical care & pain medicine. 2018;:S31-S35
Abstract
Ambulatory surgery can be carried out in diabetic patients. By using a strict organisational and technical approach, the risk of glycaemic imbalance is minimised, allowing the patients to return to their previous way of life more quickly. Taking into account the context of ambulatory surgery, with a same day discharge, the aims are to minimise the changes to antidiabetic treatment, to maintain adequate blood sugar control and to resume oral feeding as quickly as possible. The preoperative evaluation is the same as for a hospitalised patient and recent glycaemic control (HbA1c) is necessary. Perioperative management and the administration of treatment depend on the number of meals missed. The patient can return home after taking up usual feeding and treatment again. Hospitalisation is necessary if significant glycaemic imbalance occurs. In pregnancy, it is necessary to distinguish between known pre-existing diabetes (T1D or T2D) and gestational diabetes, defined as glucose intolerance discovered during pregnancy. During labour, blood sugar levels should be maintained between 0.8 and 1.4g/L (4.4-8.25mmol/L). Control of blood sugar levels is obtained by using a continuous administration of insulin using an electronic syringe (IVES) together with a glucose infusion. Post-partum, management depends on the type of diabetes: in T1D and T2D patients a basal-bolus scheme is restarted with decreased doses while in gestational diabetes insulin therapy is stopped after delivery. Antidiabetic treatment is again necessary if blood sugar levels remain>1.26g/L (7mmol/L).
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5.
Perioperative management of adult diabetic patients. The role of the diabetologist.
Cheisson, G, Jacqueminet, S, Cosson, E, Ichai, C, Leguerrier, AM, Nicolescu-Catargi, B, Ouattara, A, Tauveron, I, Valensi, P, Benhamou, D, et al
Anaesthesia, critical care & pain medicine. 2018;:S37-S38
Abstract
A patient should be referred to a diabetologist perioperatively in several circumstances: preoperative recognition of a previously unknown diabetes or detection of glycaemic imbalance (HbA1c <5% or >8%); during hospitalisation, recognition of a previously unknown diabetes, persisting glycaemic imbalance despite treatment or difficulty resuming previously used chronic treatment; postoperatively and after discharge from hospital, for all diabetic patients in whom HbA1c is >8%.
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6.
Perioperative management of adult diabetic patients. Postoperative period.
Cheisson, G, Jacqueminet, S, Cosson, E, Ichai, C, Leguerrier, AM, Nicolescu-Catargi, B, Ouattara, A, Tauveron, I, Valensi, P, Benhamou, D, et al
Anaesthesia, critical care & pain medicine. 2018;:S27-S30
Abstract
Follow on from continuous intravenous administration of insulin with an electronic syringe (IVES) is an important element in the postoperative management of a diabetic patient. The basal-bolus scheme is the most suitable taking into account the nutritional supply and variable needs for insulin, reproducing the physiology of a normal pancreas: (i) slow (long-acting) insulin (=basal) which should immediately take over from IVES insulin simulating basal secretion; (ii) ultra-rapid insulin to simulate prandial secretion (=bolus for the meal); and (iii) correction of possible hyperglycaemia with an additional ultra-rapid insulin bolus dose. A number of schemes are proposed to help calculate the dosages for the change from IV insulin to subcutaneous insulin and for the basal-bolus scheme. Postoperative resumption of an insulin pump requires the patient to be autonomous. If this is not the case, then it is mandatory to establish a basal-bolus scheme immediately after stopping IV insulin. Monitoring of blood sugar levels should be continued postoperatively. Hypoglycaemia and severe hyperglycaemia should be investigated. Faced with hypoglycaemia <3.3mmol/L (0.6g/L), glucose should be administered immediately. Faced with hyperglycaemia >16.5mmol/L (3g/L) in a T1D or T2D patient treated with insulin, investigations for ketosis should be undertaken systematically. In T2D patients, unequivocal hyperglycaemia should also call to mind the possibility of diabetic hyperosmolarity (hyperosmolar coma). Finally, the modalities of recommencing previous treatments are described according to the type of hyperglycaemia, renal function and diabetic control preoperatively and during hospitalisation.
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7.
Perioperative management of adult diabetic patients. Preoperative period.
Cheisson, G, Jacqueminet, S, Cosson, E, Ichai, C, Leguerrier, AM, Nicolescu-Catargi, B, Ouattara, A, Tauveron, I, Valensi, P, Benhamou, D, et al
Anaesthesia, critical care & pain medicine. 2018;:S9-S19
Abstract
In diabetic patients undergoing surgery, we recommend assessing glycaemic control preoperatively by assessing glycated haemoglobin (HbA1c) levels and recent capillary blood sugar (glucose) levels, and to adjust any treatments accordingly before surgery, paying particular attention to specific complications of diabetes. Gastroparesis creates a risk of stasis and aspiration of gastric content at induction of anaesthesia requiring the use of a rapid sequence induction technique. Cardiac involvement can be divided into several types. Coronary disease is characterised by silent myocardial ischaemia, present in 30-50% of T2D patients. Diabetic cardiomyopathy is a real cause of heart failure. Finally, cardiac autonomic neuropathy (CAN), although rarely symptomatic, should be investigated because it causes an increased risk of cardiovascular events and a risk of sudden death. Several signs are suggestive of CAN, and confirmation calls for close perioperative surveillance. Chronic diabetic kidney disease (diabetic nephropathy) aggravates the risk of perioperative acute renal failure, and we recommend measurement of the glomerular filtration rate preoperatively. The final step of the consultation concerns the management of antidiabetic therapy. Preoperative glucose infusion is not necessary if the patient is not receiving insulin. Non-insulin drugs are not administered on the morning of the intervention except for metformin, which is not administered from the evening before. The insulins are injected at the usual dose the evening before. The insulin pump is maintained until the patient arrives in the surgical unit. It should be remembered that insulin deficiency in a T1D patient leads to ketoacidosis within a few hours.
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8.
Recommendations from the United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis.
Dominguez-Munoz, JE, Drewes, AM, Lindkvist, B, Ewald, N, Czakó, L, Rosendahl, J, Löhr, JM, ,
Pancreatology : official journal of the International Association of Pancreatology (IAP) ... [et al.]. 2018;(8):847-854
Abstract
BACKGROUND In collaboration with United European Gastroenterology, the working group on 'Harmonizing diagnosis and treatment of chronic pancreatitis across Europe' (HaPanEU) developed European guidelines for the management of chronic pancreatitis using an evidence-based approach. METHODS Recommendations of multidisciplinary review groups based on systematic literature reviews to answer predefined clinical questions are summarised. Recommendations are graded using the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS Recommendations covered topics related to the clinical management of chronic pancreatitis: aetiology, diagnosis of chronic pancreatitis with imaging, diagnosis of pancreatic exocrine insufficiency, surgical therapy, medical therapy, endoscopic therapy, treatment of pancreatic pseudocysts, pancreatic pain, nutrition and malnutrition, diabetes mellitus and the natural course of the disease and quality of life. CONCLUSIONS The HaPanEU/United European Gastroenterology guidelines provide evidence-based recommendations concerning key aspects of the medical and surgical management of chronic pancreatitis based on current available evidence. These recommendations should serve as a reference standard for existing management of the disease and as a guide for future clinical research. This article summarises the HaPanEU recommendations and statements.
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9.
[Recommendations for clinical practice in diabetes and obesity. The Madrid Agreements. Document agreed by the working groups of the scientific societies: SENDIMAD, SOMAMFYC, SEMG Madrid, SEMERGEN Madrid and RedGDPS].
De Cos, AI, Gutiérrez Medina, S, Luca, B, Galdón, A, Simon Chacín, J, De Mingo, ML, Trifu, D, Artola, S, Egocheaga, I, Soriano, T, et al
Nutricion hospitalaria. 2018;(4):971-978
Abstract
The increase in the prevalence of type 2 diabetes and the worldwide expansion of overweight and obesity are intrinsically linked. The percentage of diabetes attributable to weight gain amounts to more than 80% in many countries. This relationship is addressed in a Spanish Consensus Document from SEMI, SED, redGDPS, SEC, SEEDO, SEEN, SEMERGEN and SEMFYC published in 2015 and which gathers best available evidences. Based on the statements of this consensus document, we propose five recommendations for clinical practice to establish a diagnosis of precision and the most appropriate treatment for joint diabetes and obesity. These recommendations have been agreed by the SENDIMAD, SOMAMFYC, SEMG Madrid and RedGDPS Working Groups: 1. For every patient with diabetes and obesity, in addition to the calculation of the body mass index, the percentage of body fat and the approximation to the assessment of body composition should be evaluated throughout the whole process (both at the beginning and follow up). 2. The approximation to the degree and distribution of body fat requires the measurement and recording of the waist circumference of these patients. 3. The integrated assessment of the patient with type 2 diabetes-obesity requires the evaluation of the degree of physical activity and/or characterization of the sedentary condition. 4. The prescription of lifestyle changes should be incorporated into therapeutic education (individualized, flexible, autonomous and sustainable diet and physical activity plan. 5. The pharmacological approach in the treatment of type 2 diabetes-obesity implies the choice of anti-diabetic drugs that facilitate the loss of fat.
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10.
Perioperative management of adult diabetic patients. Intraoperative period.
Cheisson, G, Jacqueminet, S, Cosson, E, Ichai, C, Leguerrier, AM, Nicolescu-Catargi, B, Ouattara, A, Tauveron, I, Valensi, P, Benhamou, D, et al
Anaesthesia, critical care & pain medicine. 2018;:S21-S25
Abstract
Perioperative hyperglycaemia (>1.80g/L or 10mmol/L) increases morbidity (particularly due to infection) and mortality. Hypoglycaemia can be managed in the perioperative period by decreasing blood sugar levels with insulin between 0.90 and 1.80g/L but it may occur more frequently when the goal is strict normoglycaemia. We propose continuous administration of insulin therapy via an electronic syringe (IVES) in type-1 diabetes (T1D) and type-2 diabetes (T2D) patients if required or in cases of stress hyperglycaemia. Stopping a personal insulin pump requires immediate follow on with IVES insulin. We recommend 4mg dexamethasone for the prophylaxis of nausea and vomiting, rather than 8mg, combined with another antiemetic drug. The use of regional anaesthesia (RA), when possible, allows for better control of postoperative pain and should be prioritised. Analgesic requirements are higher in patients with poorly controlled blood sugar levels than in those with HbA1c<6.5%. The struggle to prevent hypothermia, the use of RA and multimodal analgesia (which allow for a more rapid recovery of bowel movements), limitation of blood loss, early ambulation and minimally invasive surgery are the preferred measures to regulate perioperative insulin resistance. Finally, diabetes does not change the usual rules of fasting or of antibiotic prophylaxis.