Evaluación de un programa de dolor agudo: eficiencia, seguridad y percepción de la atención por parte de los pacientes, experiencia Clínica Alemana, Santiago-Chile / Evaluation of a program of acute pain: efficiency, safety and perception of care by patients, experience Clínica Alemana, Santiago-Chile

La falta de alivio adecuado del dolor postoperatorio tiene efectos negativos en los resultados de la cirugía y en la satisfacción de los pacientes. Hoy en día el dolor continúa siendo sub tratado en muchos lugares del mundo La incidencia de dolor moderado a severo está entre 30 a 80 por ciento de los postoperados. Un programa de dolor agudo (PDA) es muy recomendable en las instituciones y debe basarse en guías clínicas con la mejor evidencia disponible. Objetivos: Evaluación del PDA de Clínica Alemana de Santiago con respecto a la eficacia y seguridad del tratamiento del dolor y a las opiniones del paciente sobre su experiencia de dolor y la atención recibida por el equipo de dolor (EDA) y enfermeras. Material y Métodos: Revisamos los datos electrónicos de todos los pacientes manejados por el PDA entre diciembre de 2010 y septiembre de 2011 (993 pacientes). También se realizó una encuesta con 9 preguntas a una muestra de 163 pacientes por investigadores ciegos. Resultados: El promedio de edad fue 51,4 +/- 18 años con un 51 por ciento de mujeres y 49 por ciento hombres. Los pacientes tenían dolor agudo postoperatorio (93 por ciento) y dolor agudo no quirúrgico (7 por ciento).El promedio de control por el PDA fue de 2,6 +/- 1,19 días. Las técnicas analgésicas fueron multimodales en todos los casos. La frecuencia de las técnicas utilizadas fue: PCA IV 46 por ciento, catéteres peridurales 35 por ciento y catéteres perineurales 18 por ciento. La morfina fue el opioide más usado (63,8 por ciento). Todos los pacientes recibieron de 1 a 3 analgésicos no opioides. En 11 por ciento se usó medicación coadyuvante. El promedio de intensidad del dolor registrado el primer día fue de 1,4 en reposo y 3,3 dinámico (escala 0 a 10) y estos valores disminuyeron a 0,86 y 2,5 respectivamente el día del alta del programa. Casi todos los valores estuvieron en el rango de dolor leve (0 a 3). No se presentaron complicaciones en relación a los métodos de analgesia...

Lack of adequate postoperative pain relief has negative effects on patient outcome and satisfaction. Nowadays pain continues being undertreated all over the world. Incidence of moderate to severe pain is between 30 to 80 percent of postoperative patients. An Acute Pain Program (APP) is strongly recommended in institutions and must be based on clinical guidelines with the best evidence available. Objectives: Evaluation of the APP of Clínica Alemana regarding the efficacy and safety of pain management and patients’ opinion about their pain experience and care provided by the pain team and nurses. Methods: We reviewed the electronic data of all patients treated by the APP between December 2010 and September 2011 (993 patients). Also a group of 163 patients was interviewed with a survey of nine questions by blind investigators. Results: Mean age was 51.4 +/- 18 years; 51 percent female and 49 percent male. Patients had acute postoperative pain (93 percent) and non-surgical acute pain (7 percent). The mean stay in APP control was 2.6 +/- 1.19days. Analgesic techniques were multimodal analgesia: iv PCA 46 percent, epidural catheters 35 percent and perineural catheters 18 percent. Morphine was the more used opioid (63.8 percent). All patients were treated with 1 to 3 non opioid analgesics. Adjuvant medication was used in 11 percent of the patients. The mean pain intensity registered the first day was 1.4 at rest and 3.3 dynamic (0-10 scale) and these values decreased to 0.86 and 2.5 respectively on the day of discharge. Almost all values were in range of mild pain (0-3). No complications occurred related to analgesia methods...

Inverse association between trans isomeric and long-chain polyunsaturated fatty acids in cord blood lipids of full-term infants.

BACKGROUND: Previous studies showed significant inverse correlations between values of trans isomeric and long-chain polyunsaturated fatty acids in plasma lipids of preterm infants and healthy children aged 1-15 y. OBJECTIVE: We sought to evaluate the same correlations in full-term infants at birth. DESIGN: We studied healthy full-term infants (n = 42) born after normal pregnancies and deliveries. All infants had a family history of atopy (both parents or one of the parents and a sibling had atopic symptoms). The fatty acid composition of venous cord blood lipids was determined by high-resolution capillary gas-liquid chromatography. RESULTS: The mean (+/-SEM) sum of trans fatty acids was 0.49 +/- 0.02% by wt in phospholipids, 2.47 +/- 0.20% by wt in cholesterol esters, 1.73 +/- 0.09% by wt in triacylglycerols, and 1.59 +/- 0.07% by wt in nonesterified fatty acids. Linear correlation analysis showed significant inverse correlations between the sum of trans fatty acids and both arachidonic acid and docosahexaenoic acid in phospholipids (r = -0.56, P < 0.001, and r = -0.48, P = 0.01, respectively), cholesterol esters (r = -0.52, P < 0.001, and r = -0.39, P = 0.018, respectively), and nonesterified fatty acids (r = -0.41, P = 0.007, and r = -0.41, P = 0.006, respectively). CONCLUSION: Because trans fatty acids in the fetal circulation must originate from the maternal diet, our results indicate that maternal exposure to trans fatty acids may represent a previously neglected variable that inversely influences long-chain polyunsaturated fatty acid status in full-term infants at birth.

[Optimized nutrition for alpine athletes]. / Optimierung der Ernährung im alpinen Bergsport.

Nutritional habits of athletes usually don't differ from those of the remaining population. Psychic as well as physical capability are nutritionally dependent. In order to achieve uttermost capability for athletic activities, an optimisation of the daily nutrition, and of the "nutrition at the mountain" is necessary. The alpine athlete must adapt his diet to the intensity of his physical burden on the one hand and to the changed conditions in the height on the other hand. Nutritional recommendations are discussed.

Plasma amino acid concentrations, indexes of protein metabolism and growth in healthy, full-term infants fed partially hydrolyzed infant formula.

BACKGROUND: It has been reported that feeding extensively hydrolyzed infant formula influenced the availability of arginine, glycine, histidine, lysine and threonine in full-term infants investigated during the first 2 months of life. In the present study, the nutritional effects of feeding partially hydrolyzed formula (PHF) were investigated. METHODS: Term infants fed conventional formula (F; n = 11) or PHF (n = 11) were investigated at the ages of 5, 30, 60, 90, and 120 days. Anthropometric data were obtained, and plasma amino acid concentrations and biochemical indices of protein metabolism were measured. RESULTS: Plasma concentrations (in micromoles per liter) of lysine on day 90: 117 (21) versus 143 (24); of threonine on day 30: 140 (53) versus 263 (87); of ornithine on day 90: 56 (21) versus 78 (29); and of tyrosine on day 30: 52 (17) versus 77 (20), on day 60: 56 (14) versus 87 (19) and on day 90: 46 (9) versus 81 (17) were significantly lower in infants receiving PHF than in those fed F. Values are median (range from 1st to 3rd quartile), PHF versus F; p < 0.05. At day 120, infants fed PHF showed significantly lower serum albumin concentrations than did infants receiving F (43.3 +/- 3.4 versus 48.9 +/- 3.5, g/l; mean +/- SD; p < 0.05). Serum creatinine, urea nitrogen, uric acid and total protein concentrations and gain in weight, length, and head circumference did not differ throughout the study. CONCLUSIONS: In this study, feeding PHF did not affect the majority of plasma amino acid concentrations, some indices of protein metabolism, and basic parameters of growth in full-term infants. However, plasma concentrations of lysine, threonine, tyrosine, ornithine, and albumin were, on at least one occasion, significantly lower in infants fed PHF than in those receiving F.

Plasma amino acid concentrations in healthy, full-term infants fed hydrolysate infant formula.

The effect of feeding hydrolysate infant formula (HF) on protein and amino acid metabolism was investigated in healthy, full-term infants who were either breast-fed (BF, n = 10) or received conventional formula (CF, n = 10) or HF based on soy and beef collagen (n = 10) with equal total protein equivalent contents. There were no differences between groups for gain in weight, length, and head and chest circumferences throughout the study. Plasma concentrations of total proteins, albumin, urea nitrogen, uric acid, and creatinine as well as total amino acid and total essential amino acid concentrations did not differ at the ages of 2, 4, and 8 weeks. In contrast, significant differences were seen in concentrations of five free amino acids. Arginine concentrations were significantly higher at the age of 4 weeks in the infants fed HF than in the other groups (71 +/- 12 versus 27 +/- 6 and 30 +/- 4, mumol/L, mean +/- SEM, HF versus BF and CF, p < 0.01). Plasma histidine concentrations were also higher in infants receiving HF (4 weeks: 217 +/- 33 versus 91 +/- 18, HF versus BF, p < 0.01; 8 weeks: 218 +/- 33 versus 105 +/- 20, HF versus CF, p < 0.01). The most pronounced feeding-related differences were seen in plasma glycine concentrations (2 weeks: 653 +/- 89 versus 345 +/- 55, HF versus BF, p < 0.01; 8 weeks: 613 +/- 74 versus 385 +/- 56 and 312 +/- 46, HF versus BF and CF, p < 0.01), with the mean value exceeding the upper limit of the normal range in infants fed HF. Although the biological importance of the differences observed remains to be clarified, further investigations on amino acid metabolism are needed to establish the final nutritional safety of feeding hydrolysate infant formulae.

Vitamin K in breast milk: no influence of maternal dietary intake.

There is limited information available on the vitamin K intake of lactating mothers, concentration of vitamin K1 in breast milk, and the effect of long-term vitamin K1 supplementation of lactating mothers on the vitamin K1 concentration in breast milk. In a randomized study, we followed 20 mothers who received a daily oral vitamin K1 supplement (average 88 micrograms, supplemented group) and 16 mothers receiving no supplement (control group) from 4 throughout 91 days postpartum. Maternal vitamin K intakes (weighed dietary intake) at 4-6, 25-29 and 87-91 days postpartum ranged between 73 and 1735 micrograms/day. Differences between the groups were statistically not significant. Average intake exceeded the recommended dietary intake for lactating women of 55 micrograms/day by 670%. In the supplemented group, mean breast-milk vitamin K1 concentrations (HPLC) at 5, 26 and 88 days postpartum were 1.73 (SD 0.74), 1.36 (SD 0.81) and 1.67 (SD 2.01) ng/ml, respectively. Corresponding values in the control group were 1.44 (SD 0.57), 1.68 (SD 0.70) and 1.78 (SD 1.05) ng/ml. The latter were not statistically different from values in the supplemented group. Mean daily vitamin K1 intakes of infants breast-fed by supplemented mothers were 0.69 (SD 0.42), 0.93 (SD 0.51) and 1.25 (1.53) micrograms, respectively on days 5, 26 and 88. Corresponding values in the control group were 0.69 (SD 0.30), 1.07 (SD 0.58) and 1.31 (SD 0.95) micrograms and were statistically not different from values in the supplemented group. Average vitamin K1 intakes corresponded to 7-13% of the recommended dietary intake of 10 micrograms/d for infants.(ABSTRACT TRUNCATED AT 250 WORDS)

[Nutritional and fluid requirements of the child involved in sports]. / Ernährung und Flüssigkeitsbedarf des sportbetreibenden Kindes.

Between generally accepted recommendations and individually ascertained values for need of energy, nutrients and water, which are evaluated more exactly only by laboratories of nutritional physiology and of sportsmedicine, wide variations are possible. For practical purpose regular controls of physical development, competitiveness, regular weighing, measuring and testing alone, give the possibility to assess, whether food-intake meets quantitatively the need. Qualitatively deficient nutrient-intake is only shown after some time elapsed by reduced competitiveness or reduced nutritional recommendations are to performed, which are summarized in the ten rules of prudent nutrition (DGE). In competitive sports, basic for optimal, sporty nutrition are controls of physical development and of nutritional intake (nutritional anamnesis). To avoid nutritional deficiencies and their consequences in children doing intensive sport, following minimal demands should be performed: 1. Children, regularly highly trained are classified to "children at risk" and are to be looked after by physician with a degree in sportsmedicine, familiar with the development of children (pediatrician). 2. Physical development of children performing competitive sports has to be investigated and documented in two-monthly periods (training-protocols, growth-charts) minimal. 3. Minimum twice a year, by a nutritional well qualified person (physician in sports, nutritional scientist, dietitian) a nutritional advisory has to be done to the children together with parents and trainer. 4. If physical development or competitiveness will be disturbed, the individual need of energy and nutrients has to be ascertained, basic for an following nutritional advisory. 5. Assumption of energy-need for children performing competitive sports has to be done individually. Basic for assumption is the "biological age".(ABSTRACT TRUNCATED AT 250 WORDS)

The clinical use of direct calorimetry for measuring energy expenditure.

Energy output measurements are an actual problem since the 18th century. Together with the technical development very good solutions for direct calorimetry are available. Vienna Whole Body Calorimeter is a measuring system in which man can live 24 and more hours under defined activity and well known diet. Utilisation of ingested food energy is discussed and unmeasured energy shown during overfeeding. Beside increasing energy content of body mass gaining weight costs 1969 kcal/kg. Comparison of direct and indirect measurement is necessary to define energy need in different catabolic situations.

Calorimetric results in man: energy output in normal and overweight subjects.

In order to test the practicability of 24-hr investigations with the gradient-free Vienna Whole-Body Calorimeter, energy output was measured over 24-hr periods in 18 human subjects. Heat loss was partitioned into dry and evaporative components. Sixteen female subjects were divided into normal-weight (less than 100% according to the Broca index), overweight (100%--120%), and obese (over 120%) groups. A male with severe hypothyroidism, and a female with no signs of impairment of thyroid function who had weight problems that were suspected to be due to low energy expenditure, were studied separately. Subjects reported that the calorimeter chamber was sufficiently comfortable for at least a 24-hour investigation. Overweight and obese subjects showed both greater total heat output and greater inter-individual variability than the normal weight group. Normal and overweight subjects were on steady levels of food intake that were representative of usual intake. For normal subjects there was a relatively close correspondence between energy intake and output, but not for overweight subjects. Thyroid hormone therapy produced a large increase in energy output in the hypothyroid patient. Energy expenditure was found to be unusually low in the patient with weight problems and was increased by about 50% after thyroid hormone administration.

[Protein deficiency in hospital food. Possibilities of using protein preparations]. / Eiweissdefizit in der Krankenhauskost Möglichkeiten der Verwendung von Eiweisspräparaten.

During a twenty days period, the daily supply of protein with the normal diet was investigated for thirty patients of an emergency station. The system of food distribution allowed precise weighing of each patient's portion. According to the calculation by the "kleine Nährwerttabelle" an average daily protein allowance of 12.4 kcal% at an average daily energy allowance of 2100 kcal with an average worth of material of 20 öS was found. The nitrogen loss accounted in the literature for different stress situations enables to calculate a far higher protein need. The use of protein preparations is discussed for satisfying the need. The possibility to use milk-protein for food preparations was tested. In a trial was found that 46.2% of the patients accepted the given protein-enriched soup. Thus the share of protein in total daily calories should be lifted from 12.4 kcal% to 14.6 kcal% spending only 4.44 öS more than before. Elevating the protein portion with normal food is possible only by spending multiple costs.

[Changes in body composition during various reducing diets]. / Anderung der Köperzusammensetzung unter verschiedenen Reduktionskostformen

A method of measuring body density is presented which allows much greater precision in calculating the fat content of the human body than the usual methods of under-water weighing. Using this method, body fat was determined for three groups: normal weight, moderately overweight, and obese subjects. In spite of vast amounts of energy stored in the obese patient, no advantages for the pre- or post-surgical phase result. The explanation for this paradoxical situation is seen in two factors: 1. The cardiovascular system is not capable of delivering more energy because mobilisation of fat depends on corresponding oxygen intake. 2. Aside from this, a metabolic limiting factor exists in the mobilisation of protein reserves for the production of glucose, which leads to a considerable protein loss the first few weeks of a period of abstinence. In posttraumatic or post-operative situations, this protein mobilisation is particularly strong, especially when connected with a high metabolic intake. The high nitrogen loss and/or the high metabolic rate, is illustrated on the basis of severe skull and brain traumas. The differences between absolute fasting and a 200kcal-protein formula diet were experimentally investigated. The nitrogen loss under the protein diet was decisively less. An anabolic phase even reappeared after three weeks of the diet. The 200kcal-diet therefore represents a means of pre-operative weight reduction without protein loss. The alterations in body composition are almost exclusively the results of reduction in excess fat. This is demonstrated by means of clinical examples.