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Guidelines for specialized nutritional and metabolic support in the critically-ill patient: Update. Consensus SEMICYUC-SENPE: Introduction and methodology
Mesejo,A.; Vaquerizo Alonso,C.; Acosta Escribano,J.; Ortiz Leiba,C.; Montejo González,J.C.;
Nutrición Hospitalaria , 2011,
Abstract: the recommendations for specialized nutritional support in critically-ill patients were drafted by the metabolism and nutrition working group of the spanish society of intensive care medicine and coronary units (semicyuc) in 2005. given the time elapsed since then, these recommendations have been reviewed and updated as a consensus document in collaboration with the spanish society of parenteral and enteral nutrition (senpe). the primary aim of these recommendations was to evaluate the best available scientific evidence for the indications of specialized nutritional and metabolic support in critically-ill patients. the recommendations have been formulated by an expert panel with broad experience in nutritional and metabolic support in critically-ill patients and were drafted between october 2009 and march 2011. the studies analyzed encompassed metaanalyses, randomized clinical trials, observational studies, systematic reviews and updates relating to critically-ill adults in medline from 1966 to 2010, embase reviews from 1991 to 2010 and the cochrane database of systematic reviews up to 2010. the methodological criteria selected were those established in the scottish intercollegiate guidelines network and the agency for health care policy and research, as well as those of the jadad quality scale. adjustment for the level of evidence and grade of recommendation was performed following the proposal of the grade group (grading of recommendations assessment, development and evaluation working group). sixteen pathological scenarios were selected and each of them was developed by groups of three experts. a feedback system was established with the five members of the editorial committee and with the entire working group. all discrepancies were discussed and consensus was reached over several meetings, with special emphasis placed on reviewing the levels of evidence and grades of recommendation. the editorial committee made the final adjustments before the document was appro
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.;
Nutrición Hospitalaria , 2011,
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 enteralparenteral nutrition if an effective nutritional volume of more than 60% cannot be obtained. total calore 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.
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,J. A.;
Nutrición Hospitalaria , 2011,
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, routinelyused 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. howe - ver, 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 interpreti
Guidelines for specialized nutritional and metabolic support in the critically-ill patient: Update. Consensus SEMICYUC-SENPE: Nutritional assessment
Ruiz-Santana,S.; Arboleda Sánchez,J. A.; Abilés,J.;
Nutrición Hospitalaria , 2011,
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.
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.;
Nutrición Hospitalaria , 2011,
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.
Guidelines for specialized nutritional and metabolic support in the critically-ill patient: Update. Consensus SEMICYUC-SENPE: Septic patient
Ortiz Leyba,C.; Montejo González,J. C.; Vaquerizo Alonso,C.;
Nutrición Hospitalaria , 2011,
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.
Guidelines for specialized nutritional and metabolic support in the critically-ill patient: Update. Consensus SEMICYUC-SENPE: Cardiac patient
Jiménez Jiménez,F. J.; Cervera Montes,M.; Blesa Malpica,A. L.;
Nutrición Hospitalaria , 2011,
Abstract: patients with cardiac disease can develop two types of malnutrition: cardiac cachexia, which appears in chronic congestive heart failure, and malnutrition due to the complications of cardiac surgery or any other type of surgery in patients with heart disease. early enteral nutrition should be attempted if the oral route cannot be used. when cardiac function is severely compromised, enteral nutrition is feasible, but supplementation with parenteral nutrition is sometimes required. sustained hyperglycemia in the first 24 hours in patients admitted for acute coronary syndrome, whether diabetic or not, is a poor prognostic factor for 30-day mortality. in critically-ill cardiac patients with stable hemodynamic failure, nutritional support of 20-25 kcal/kg/day is effective in maintaining adequate nutritional status. protein intake should be 1.2-1.5 g/kg/day. routine polymeric or high protein formulae should be used, according to the patient's prior nutritional status, with sodium and volume restriction according to the patient's clinical situation. the major energy source for myocytes is glutamine, through conversion to glutamate, which also protects the myocardial cell from ischemia in critical situations. administration of 1 g/day of omega-3 (epa+dha) in the form of fish oil can prevent sudden death in the treatment of acute coronary syndrome and can also help to reduce hospital admission for cardiovascular events in patients with chronic heart failure.
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,J. F.; Herrero Meseguer,J. I.; Martínez García,P.;
Nutrición Hospitalaria , 2011,
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 mana gement of their illness.
Guidelines for specialized nutritional and metabolic support in the critically-ill patient: Update. Consensus SEMICYUC-SENPE: Liver failure and liver transplantation
Montejo González,J. C.; Mesejo,A.; Bonet Saris,A.;
Nutrición Hospitalaria , 2011,
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 altera tions 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 regi men. 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.
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,J. A.; Serón Arbeloa,C.;
Nutrición Hospitalaria , 2011,
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 conti - nuous renal replacement techniques, patients with severe burns and alcoholics, although the specific requirements in each of these types of patient have not yet been esta - blished. 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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