[NEMS: a new predictor of mortality in the critical patient?]. / NEMS: ¿nuevo predictor de mortalidad en el paciente crítico?

Numerical scales are commonly used in intensive care units to predict hospital mortality and to assess the therapeutic effort and care that critically ill patients require. The aim of this work was to study whether the NEMS value can be used as a predictor of mortality, comparing it with the APACHE II. A prospective study in a 24 intensive care unit beds was conducted. The APACHE II and NEMS values were stratified into three levels. Demographic data and the first 24 hours values of APACHE II and NEMS scales were collected. A total of 1257 patients were included, 16.4% of whom died. 69.6% were surgical; median stay was 2 days (1-4). Median age was 66 years (50-77), 59.3% were men. The median APACHE II and NEMS for the living and the dead in the subsequent course was 10 (6-20) versus 22.5 (17.25 to 29) (p <0.001) and 24 (18-29) versus 34 (25 to 39.7) (p<0.001) respectively. The correlation between both scales was rho=0.457 (p<0.01). Logistic regression controlled for age, sex and APACHE II showed an OR of 3.1 (95% CI: 1.5-6.6) only for high NEMS, compared to the lowest level. According to the results NEMS should not be used as a predictor of mortality, although the risk of death increases by three times with high NEMS.

[Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): cardiac patient]. / Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: paciente cardíaco.

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 of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): patient with polytrauma]. / Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: paciente politraumatizado.

Patients with polytrauma can be viewed as paradigmatic of the critically-ill patient. These previously healthy patients undergo a life-threatening aggression leading to an organic response that is no different from that in other types of patients. The profile of trauma patients has changed and currently corresponds to patients who are somewhat older, with a higher body mass index and greater comorbidity. Severe injuries lead to intense metabolic stress, posing a risk of malnutrition. Therefore, early nutritional support, preferentially through the enteral route, with appropriate protein intake and glutamine supplementation, provides advantages over other routes and types of nutritional formula. To avoid overnutrition, reduced daily calorie intake can be considered in obese patients and in those with medullary lesions. However, little information on this topic is available in patients with medullary lesions.

[Nutritional support in sepsis]. / Nutrición artificial en la sepsis.

Although it is considered that metabolic and nutritional support must be part of the management of septic patients, it has not been conclusively shown that nutritional support will improve survival or complications from sepsis. Specific data on this issue are scarce since there are few studies that have investigated specialized nutritional support in septic patients. Thus, most of the recommendations are based on outcomes obtained in severely ill patients with different pathologies. It is assumed that nutritional support should be carried out through the enteral route whenever possible, as in other critically ill patients. The energetic waste in these patients is highly variable, although in general terms the hypermetabolic situation may be classified as moderate. An adjustment factor of 1.25-1.30 is recommended for the Harris-Benedict's equation to calculate the caloric intake. Septic patients should receive a hyperproteic intake. The amount of glucose administered should not exceed 70% of non-protein calories, and lipids intake should not exceed 40%. With regards to micronutrients, it is recommended to increase the supply of those with antioxidant properties (vitamin E, carotenes, vitamin C, selenium). There are data to consider that the use of diets enriched with pharmaco-nutrients (both with parenteral and enteral routes) may be beneficial in septic patients, although there is some controversy when interpreting the outcomes.

[Nutritional support in the critically ill patient: to whom, how, and when?]. / Soporte nutricional del paciente crítico: a quién, cómo y cuándo?

Existing data about indication and time of onset of nutritional support are not homogeneous. However, the presence of a deterioration of the nutritional status is accompanied by harmful effects so that, broadly speaking, specialized nutritional support onset would be advisable if a fasting period longer than 5-7 days is foreseen. Parenteral nutrition routinely administered to critically ill patients may increase their morbidity and mortality. Whenever possible, enteral nutrition should be the preferred route of nutrients intake since it has been shown to have a favorable effect on infectious complications rates. Enteral nutrition should be started early on (within the first 36 hours of admission). Although transpyloric nutrients administration may however reduce bronchoaspiration and increase the diet effective volume received by patients, there are no data for recommending routinary usage of the transpyloric route for nutritional support in the critically ill patients.

[Recommendations for nutritional assessment and specialized nutritional support of critically ill patients]. / Recomendaciones para la valoración nutricional y el soporte nutricional especializado de los pacientes críticos.

Due to the characteristics of critically ill patients, elaborating recommendations on nutritional support for these patients is difficult. Usually the time of onset of nutritional support or its features are not well established, so that its application is based on experts' opinion. In the present document, recommendations formulated by the Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Medicine and Coronary Units (SEMICYUC) are presented. Recommendations are based on the literature analysis and further discussion by the working group members in order to define, consensually, the more relevant issues of metabolic and nutritional support of patients in a critical condition. Several clinical situations have been considered which are developed in the following articles of this publication. The present recommendations aim at providing a guideline for the less experienced clinicians when considering the metabolic and nutritional issues of critically ill patients.

[Multiple trauma and burns]. / Politraumatismos y quemados.

Patients with multiple injuries and burns are the paradigm of critically-ill patients. Their cases are acute, severe and, fortunately, reversible in a large number of situations. The severe aggressions leading to this kind of condition is the rigger for a maelstrom of inflammatory mediators, metabolic and neuro-endocrinal response, leading to an acceleration in the combustion of the injured organ. This "internal combustion" process takes nourishment from organic reserves, using them up and thus producing dysfunctions in various organs. This is where nutritional support has a role, always remedying the metabolic response to inflammation and attempting to modify it. For this reason, nutritional support plays an undisputed part in the treatment of such patients. This nutritional support, so necessary in situations with a high degree of stress, must be individually tailored in terms of quantity and quality to the process and to the patient in question. Thus, adapting the support to requirements appears as a priority of nutritional assessment. While it is important to provide nourishment to needy patients, it is just as important if not more so to avoid over-nourishment. Indirect calorimetry continues to be the most accurate indicator for determining the needs of each patient and, in view of the lack of knowledge of this technique mainly as a result of economic factors, many different methods and formulas have been proposed to attempt to carry out these adjustments. The characteristics and distribution of the macronutrients will be connected with the pathologies to be treated. And finally, the route for providing this nourishment seems ever more clearly to be as prompt first-line administration through the digestive tube. There are situations in which parenteral support will complement or replace the enteral route when the latter is insufficient or unavailable; in certain circumstances, the parenteral route even seems to be superior to enteral support, as in the case of pure head injury. As these patients are particularly prone to suffer from infections, another aspect of increasing interest in the nutritional support of these patients is the use of immunity-modulating diets, where a better response can be expected. The components of the immunity-modulating diets have been shown to be able to modify the immune response in different ways, sometimes favouring the replication of lymphocytes and at other times stimulating the production of certain types of cytokines and attenuating the release of others, in short balancing the inflammatory response.

[Audit of artificial nutrition in an intensive care unit]. / Auditoría de la nutrición artificial en una Unidad de Medicina Intensiva.

OBJECTIVE: To study compliance with an artificial nutrition protocol at an Intensive Care Unit. During a second stage and after introducing the modifications considered appropriate in the protocol, to verify its implementation and compare both series. REFERENCE POPULATION: All patients with artificial nutrition support were included. Artificial nutrition (AN) was deemed to be the dispensation of commercial preparations for enteral nutrition, formulas with amino acids and glucose and the parenteral provision of fat, including propofol in this case, even where it was the only source of energy. The provision of crystalloid solutions was not considered to be AN. The period of observation was two months in both cases. INTERVENTION: The provision of AN to all such patients was systematically recorded on a daily basis. After analysis of the first series, the members at the unit agreed to increase the nitrogen provision. A second series was recorded, with the data being collected for patients with AN during a similar period. RESULTS: The study of the first series revealed the provisions of energy and nitrogen were below theoretical levels (both in the corrected Harris-Benedict test and at the fixed prescription of 25 kcal/kg). In the second series, there was greater agreement between the theoretical values and the amounts actually received. The deviation in energy and nitrogen was significantly less in the second series. And although the total nitrogen load per patient did not reveal any differences, there were discrepancies in the daily provision per patient. On most days, the diet provided covered over 75% of the energy requirements. With parenteral nutrition on its own or in combination with enteral nutrition, the requirements of energy and nitrogen were exceeded. There were no differences between the two series. The type of provision was enteral on 55% of the days and parenteral on 18%. There was no difference in the type of provision between the two series, although there was a difference in the type of diet administered in that the second series saw a significant increase in the provision of hyperproteic diets, both enterally and through patenteral formulations, rising from 9-13 grammes to 18-20 grammes of nitrogen. Using the enteral route on its own, there was a discreet increase in the energy load in the second series, but this did not occur in the other types of provision. Both series revealed over-nutrition in terms of both calories and nitrogen when enteral and parenteral nutrition were used together, although there was no difference between the series. CONCLUSIONS: Early enteral nutrition is possible in critically-ill patients, while artificial nutrition was used most frequently and for longer in our patients. The existence of nutrition protocols allow acceptable levels of nutritional provision. Their controlled use allows the correction of deviations between real and theoretical provisions, customizing the nutrition for each patient. The use of parenteral formulas with high levels of nitrogen requires more accurate adjustment in order to avoid over-nutrition.

Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: multiple trauma patient.

Patients with polytrauma can be viewed as paradigmatic of the critically-ill patient. These previously healthy patients undergo a life-threatening aggression leading to an organic response that is no different from that in other types of patients. The profile of trauma patients has changed and currently corresponds to patients who are somewhat older, with a higher body mass index and greater comorbidity. Severe injuries lead to intense metabolic stress, posing a risk of malnutrition. Therefore, early nutritional support, preferentially through the enteral route, with appropriate protein intake and glutamine supplementation, provides advantages over other routes and types of nutritional formula. To avoid overnutrition, reduced daily calorie intake can be considered in obese patients and in those with medullary lesions. However, little information on this topic is available in patients with medullary lesions.

Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: cardiac patient.

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.

[Blood glucose levels in the first 24 hours of admission is not a risk factor for mortality in critical care patients]. / La glucemia de las primeras 24 horas no es un factor pronóstico de mortalidad en pacientes críticos.

INTRODUCTION: Glycemic alterations are known as a risk condition of death in several diseases, such as ischemic cardiovascular and neurological disorders. The fact that its tight control under narrow normality levels decreases mortality and morbidity have led to further studies seeking to confirm the results and expand them to other disease areas. OBJECTIVES: To determine whether glycemic changes by themselves are a mortality risk factor in a sample of patients within an Intensive Care Unit (ICU), among which predominates traumatic-surgical patients. METHODS: Demographic and analytical characteristics were revised, as well as common monitoring variables in an ICU, among a sample of 2,554 patients from admissions between 1st January 2004 and 31 December 2008. Data were obtained from a database which endorsed records compiled with the monitoring ICU patients program "Carevue". They were processed with dynamics sheets included in the Excel software with the following variables: initial glycemia, mean glycemia during the first 24 hours and number of determinations performed. We used the mean value in the admission day of the remaining analytical and monitoring variables and the number of test performed on this first day. The sample was stratified in two groups for the statistical analysis: a) General Sample (MG) and b) sample excluding patients admitted after a programmed surgery (EQP). In both cases the effect of initial and averaged glycemia was checked. Group b was divided in two, according to the number of determinations b1) a single blood glucose determination group (EQP1) and b2) a multiple determination group (EQPM). From this group of non-programmed surgical patients the study was repeated in those patients who stayed at the ICU 3 or more days (EQP3D). Chi-square and Mantel-Haenzel test for the ODD ratio determination were performed for qualitative variables; quantitative variables were examined with the Mann-Whitney test. At each analysis level, logistic regression was performed using mortality as the dependent variable, including those variables with p-values < 0.05 which represented more than 60% of the data. An initially saturated model with backward till the final equation was used. A p-value of 0.05 (i.e. p < 0.05) was set as the significant threshold for all statistical analysis. They were performed with SPSS and GSTAT 2 statistical software. RESULTS AND DISCUSSION: A total of 2,165 of the 2,554 admitted patients during the study period were included (96.5%). Exclusion criteria were absence of plasma glucose determinations. In the bivariate analysis, first and mean glucose blood levels showed significant differences in mortality rates in absolute figures and also when data were classified stratified in three levels (< 60 mg/dl; 60-110 mg/dl or > 110 mg/dl) or in two (normal values 60 to 110 mg/dl and unusual figures < 60 mg/dl or > 110 mg/dl). These significant differences were lost when a logistic model was applied. From the remaining variables, renal function and NEMS showed to be mortality risks factors in this sample. CONCLUSIONS: Hyperglycemia is a predominant phenomenon in critically ill patients. Hypoglycemia is less frequent and is associated with higher mortality rates. Initial glucose blood level, by itself, was not a mortality risk factor in the multivariate study and at none of the studied levels. Average glycemia did not add any prediction power. The changes in glucose blood levels seemed to be an adaptation process, which determined by itself a risk for the patient's discharge, at least in the first 24 hours period after ICU admission.

[Effect of two different tracheal cannula change schedules on microbiological contamination and patient comfort]. / Efecto sobre la contaminación microbiológica y de confort del paciente, ante dos diferentes pautas temporales de cambio de cánulas traqueales.

Tracheostomy is a commonly used technique in intensive care units, but there are no uniform criteria governing the periodicity with which tracheal cannulas should be changed. The objective of our study was to evaluate if different cannula-change schedules modified microbiological contamination and reduced the pain and bleeding related with cannula changes. In a comparative study of two groups, a control group in which the cannula was change every 48 hours and an experimental group in which the cannula was changed every 5 days were studied. Demographic differences, tracheostomy technique, microbiological study of the cannula, bronchial aspirate and stoma, clinical signs of stomal infection and secretions, and chest radiography were compared in the two groups. With each cannula change, we evaluated bleeding, pain, type of ventilation, hemodynamic disturbances, airway obstruction, opening of a false airway, oxygen saturation before and after cannula change, and recovery time. The study included 29 patients and 97 cannulas. In a homogeneous sample, the patients in the experimental group had a normal chest radiograph for a significantly longer time (p = 0.005). The stomas of the experimental group produced significantly less seepage (p = 0.04) and pain (p = 0.004). When the tracheostomy technique was correlated with the stoma, surgical tracheostomy performed in the unit showed significantly more reddening (p < 0.004) and seeping (p < 0.001). We conclude that prolonging cannula changes to every 5 days did not increase the incidence of contamination and reduced the pain of tracheostomized patients.

[Comments on the current treatment of fulminant liver failure]. / Comentarios sobre el tratamiento actual del fallo hepático fulminante.

The current treatment of fulminant liver failure, underscoring substitutive liver therapy, is reviewed. The usefulness of hemodialysis and hemofiltration with a high-permeability membrane, hemoperfusion with activated carbon, hemoperfusion with resins, plasma exchange, artificial cells and the combination of various techniques for the same patients has been studied. Finally, the indications for utility of these techniques and the role of liver transplantation are considered. Early onset of treatment is essential for achieving satisfactory results.

[Analysis of the use of nursing personnel in a general intensive care unit. Situation in other european ICUs]. / Análisis del uso de los recursos humanos enfermeros en una unidad de cuidados intensivos polivalente. Situación con el resto de UCIs europeas.

Nursing workloads form the basis for the appropriate provision of nursing personnel. In this study we used the nine equivalents of nursing manpower use score (NEMS) to determine and evaluate the use of nursing staff in our unit. In the first phase we determined the actual workload in the various shifts and diagnostic areas. Statistically significant differences were found among diagnostic areas but not among shifts. Then, to compare our situation with that of other European intensive care units (ICUs), dynamic parameters of the management and efficiency of the use of nursing staff were analyzed following the multicentric EURICUS-I study, which was performed over 4 months in 100 ICUs in 12 European countries. For the comparison, indexes such as the work utilization ratio (WUR), the level of care planned (LOC p) and the level of care operative (LOC op) were used. The results obtained reveal that although our workload is equivalent to the European average, efficiency is greater. Thus, the situation in our unit differs from the downward trend of the data obtained in other European countries.