Nutricion uci

Notas del editor

• #5: Existe la preocupación de que EN en choque pone en peligro la ya deteriorada perfusión esplácnica. En menos del 1% de los pacientes se ha observado necrosis intestinal no oclusiva o isquemia mesentérica no oclusiva (NOMI) [11, 12], sin evidencia de relación causal entre shock, vasopresores, EN y NOMI. En un gran estudio observacional, EEN (<48 h) en pacientes con hemodinámica "estable" después de la cita de reabsorción de fluido, mientras recibía al menos un vasopresor, se asoció con una reducción de la mortalidad en comparación con EN tardía (> 48 h) -----Prospectively collected data in a multi-institutional medical intensive care unit database were analyzed retrospectively. A total of 1174 patients were identified who required mechanical ventilation for more than 2 days and were treated with vasopressor agents to support blood pressure --- El efecto beneficioso de la alimentación temprana fue más evidente en los pacientes más enfermos, es decir, aquellos tratados con vasopresores múltiples y aquellos sin mejoría temprana These results suggest that the use of concomitant vasopressors (especially with stable or decreasing doses) should not preclude a trial of EN, despite a high prevalence of feeding intolerance En pacientes muy inestables, la EN puede no tener prioridad y los posibles efectos positivos de la EN son poco probables de ayudar a mejorar la inestabilidad. La persistencia de la acidosis láctica puede ayudar a identificar el shock no controlado. No hay RCT, estudios 4 prospectivo, 4 retrospectivo, 2 revisiones
• #6: No hat RCT ni evidencia directa La justificación para retener EN en pacientes con hipoxemia, hipercapnia y acidosis es limitar el consumo de oxígeno y la producción de CO 2. Sin embargo, el proceso de hambre moviliza las reservas endógenas y consume energía [17]. La acidosis puede representar choque persistente y posiblemente contribuir a la disfunción intestinal. La identificación y tratamiento de la causa del choque tiene prioridad sobre el inicio de EN. De manera similar, en la hipoxemia e hipercapnia peligrosas que amenazan la vida, la EN debe retrasarse hasta que los síntomas se resuelvan. There are no data suggesting EN in patients with chronic, subacute, compensated or permissive hypercapnia is unsafe or not feasible.
• #7: One prospective study was identified, reporting similar gastric emptying as measured by gastric residual volume (GRV) in sedated patients with or without concomitant use of neuromuscular blocking agents. The critical condition necessitating the use of neuromuscular blocking agents always needs to be considered, but these agents per se should not preclude EN. Analgosedation is known to slow gastric emptying. Increased rate of EN intolerance is expected in deeply sedated patients with/without concomitant use of neuromuscular blocking agents. During therapeutic hypothermia, energy metabolism might be markedly reduced. The rationale to withhold EN during therapeutic hypothermia is based on the presumed decrease in gut motility due to hypothermia and required analgosedation. It has been suggested that EN could be successfully administered to these patients. --La tolerancia a la alimentación enteral se deterioró durante la hipotermia, pero mejoró durante el recalentamiento Para ecmo solo 4 series de caso Los datos sobre tolerancia de EN en posición prona son controvertidos. Los estudios observacionales encontraron retraso vaciamiento gastrico similares en la posición prona y supina, mientras que la pobre tolerancia a la alimentación mejoró con la posición semi-decúbito durante los períodos de decúbito supino y procinético. Aunque no se dispone de RCT sobre tolerancia a EN durante la posición prona, los estudios reportados no apoyan la retención de EN en posición prona. El vaciamiento gástrico no parece estar significativamente influenciado por la posición prona y los eventos adversos en la mayoría de los estudios no aumentan.
• #9: NET entendida según como la definieron los estudios, como menor a 48h en PAS según como la definen los estudios o con SAP calculado
• #11: En el analisis de datos net no reduce mortalidad o infecciones comparatada con NPT o NE (intervalos de cofieanza sobrepasan a unidad) , pero el conscenso de expertos A large RCT compared EEN (“as soon as pos- sible”) to no nutrition within 7 days and reported a trend towards reduction of long-term mortality (6  months) with EN, with an increased risk of poor neurologic outcome in survivors Seven observational studies (one prospective cohort study, three retrospective cohort studies and four case series) were identified; two studies compared EEN (different definitions) vs delayed EN and reported higher rate of early abdominal closure, less fistula formation and lower incidence of ventilator-associated pneumonia in the “early” EN group
• #12: We identified no clinical studies, but physiological knowledge and common sense support withholding EN in patients with overt bowel ischaemia. However, patients with endoscopic evidence of mild to moderate large bowel mucosal ischaemia, without signs of transmural ischaemia or bowel distension, might profit from low dose EN. In this case we support considering EN. En un reciente estudio retrospectivo, los supervivientes fueron alimentados con más frecuencia enteramente antes del diagnóstico de isquemia mesentérica aguda, pero no se demostró asociación independiente entre EN y mortalidad All studies reported high incidence of feeding intolerance associated with intra-abdominal hypertension, but data are not conclusive regarding causality. A recently published study demonstrated that EEN did not increase intra-abdominal pressure, but values exceeding 15  mmHg were associated with higher rates of feeding intolerance in patients with severe acute pancreatitis
• #18: High-dose glutamine (above 0.5 g/kg/day) was used in six trials, and four trails used glutamine at doses less than 0.3 g/kg /day; the other eight trails used glutamine at doses between 0.3 g/kg/day and 0.5 g/kg/day.
• #19: Hospital mortality and six-month mortality were not significantly different between glutamine group and control group (RR 1.01; 95% CI, 0.86 to 1.19; P = 0.87; RR 0.97; 95% CI, 0.79 to 1.19; P = 0.78)
• #20: There was a trend toward reduced mortality among patients who received glutamine as compared with patients who did not receive glutamine (10.8% versus14.4%; RR 0.77; 95% CI, 0.48 to 1.23), but this finding was not statistically significant ( P = 0.27). In the medical ICU and mixed ICU subgroups, however, there was no significant difference in mortality between the glutamine group and the control group
• #21: In three subgroups, there was no significant difference in mortality between patients who received glutamine and patients who did not receive glutamine
• #22: dosages (above 0.5 g/kg/day, between 0.3 g/kg/day and 0.5 g/kg/day and below 0.3 g/kg/day) In the high dosagesubgroup (above 0.5 g/kg/day), the mortality rate in the glutamine group was significantly higher than that of the control group (33.5% versus 28.2%; RR 1.18; 95% CI, 1.02 to 1.38; P = 0.03). In the other two subgroups, however, no difference was found in the treatment effect on mortality between the glutamine and control groups
• #23: The incidence of nosocomial infections in the glutamine group was significantly lower than that of the control group (RR 0.85; 95% CI, 0.74 to 0.97; P = 0.02).
• #24: specific patient populations (medical ICU, surgical ICU or mixed ICU). In the surgical ICU subgroup, glutamine supplementation statistically reduced the rate of nosocomial infections (44.7% versus 60.2%; RR 0.70; 95% CI, 0.52 to 0.94; P = 0.04). However, in the medical ICU and mixed ICU subgroups, no statistically significant difference was found between the glutamine group and the control group
• #25: High-dose glutamine (above 0.5 g/kg/day) was used in six trials, and four trails used glutamine at doses less than 0.3 g/kg /day; the other eight trails used glutamine at doses between 0.3 g/kg/day and 0.5 g/kg/day.