[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): macro-and micronutrient requirements]. / Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: requerimientos de macronutrientes y micronutrientes.

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 2g/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 continuous renal replacement techniques, patients with severe burns and alcoholics, although the specific requirements in each of these types of patient have not yet been established. 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.

[Requeriments of macronutrients and micronutrients]. / Requerimientos de macronutrientes y micronutrientes.

Critically ill patients have important modifications in their energetic requirements, in which the clinical situation, treatment applied and the time course take part. Thus, the most appropriate method to calculate the caloric intake is indirect calorimetry. When this test is not available, calculations such as Harris-Benedict's may be used, although not using the so high correction factors as previously recommended in order to avoid hypercaloric intakes. The intake of a fixed caloric amount (comprised between 25-30 KcalKg/min) is adequate for most critically ill patients. Carbohydrates intake must be of 5 g/kg/day) maximum. Glucose plasma levels must be controlled in order to avoid hyperglycemia. With regards to fat intake, the maximum limit should be 1.5 g/kg/day. The recommended protein intake is 1.0-1.5 g/kg/day, according to the clinical situation characteristics. Special care must be taken with micronutrients intake, an issue that is many times undervalued. In this sense, there are data to consider some micronutrients such as Zn, CU, Mn, Cr, Se, Mo and some vitamins (A, B, C, and E) of great importance for patients in a critical condition, although specific requirements for each one of them have not been established.

[A computer program for hospital artificial nutrition]. / Programa informático de nutrición artificial hospitalaria.

In this study we present a computer program of artificial nutrition, designed with the aim of obtaining a useful and simple working tool, which simplifies the different steps to be taken when the need for artificial nutrition is indicated in a patient. It has been developed, by the authors, with the aim of organizing and improving the artificial nutrition at the level of our facility. This is a General Hospital with 300 beds, without a nutrition unit, and with an Intensive Care Unit which acts as a nutritional consultant for patients admitted to other departments. In our experience, it has proven to be of great use, with the following advantages: criteria of all the aspects referring to artificial nutrition have been unified (indications, requirements...), the time needed to calculate the requirements and make up the nutritional formula has been reduced, protocolization has been simplified, as well as the nutritional follow up, and it has allowed us to individualize the nutritional treatment, adjusting it to the evolutive changes of our patients.

[Nutritional parameters in long-stay critical patients]. / Parámetros nutricionales en pacientes críticos de larga estancia.

A study is made of the evolution of the nutritional biochemical parameters, albumin, prealbumin, cholesterol, creatinine index/height and transferrin, as well as the nutrition route, SAPS, APACHE II, chronic age score, and maximum degree of metabolic stress reached, involving all patients requiring artificial nutrition during at least 14 days, admitted to our intensive medicine unit during an 18 months period, with the aim of finding differences between survivors and those who died. The following conclusions were reached: 1) In patients with severe metabolic stress, like those of the present study, artificial nutrition manages to maintain the nutritional parameters within the limits of moderate malnutrition, improving the nitrogenation balance, without achieving its balance not reducing the consumption of lean body mass, represented by the progressive and significant reduction of the ICALT. 2) In our series, the nutritional parameters behave in a notably different manner with regard to the evolution. In survivors, improvements are seen in albumin, cholesterol, and prealbumin, without variations in transferrin, these changes not being seen in those who died, the latter also showing a significant drop in transferrin, and 3) The greater age and poorer prior health status, despite a lower APS, of those who died appears to be the determining factors for the mortality, and probably also for the different evolution of the nutritional parameters for the usual nutritional standards, maybe due to a lower response capacity to stress.

[Energy requirements in the ICU. Calorimetry and expert opinion]. / Requerimientos energéticos en UCI. Calorimetría y opinión de expertos.

GOAL: To compare the method for calculating the energy requirements in critical patients as calculated by our computer software with those measured using calorimetry and using the recommendations of experts in nutritional support. REFERENCE POPULATION: 18 critical patients with mechanical ventilation and admitted to our ICU during 1998. ACTIONS TAKEN: Indirect calorimetry was carried out over a 24 hour period in critical patients with mechanical ventilation and their requirements were calculated using computer software. Ten of the measurements were placed on Internet web pages in order to receive the comments and recommendations of nutritional support experts. Those responses which fell into the range between 80% and 120% of the calorimetric measurement were considered correct. RESULTS: Calorimetric determinations were effected on 31 occasions in 18 patients, with an average APACHE score of 19 +/- 3. The energy requirements measured by calorimetry were 34 +/- 3 kcal/kg/day with 0.34 +/- 16 g/kg/day of nitrogen in urine, whereas the recommendations of the computer programme were 31 +/- 1 kcal/kg/day and 0.28 +/- 0.04 g/kg/day of nitrogen in urine, i.e. 92 +/- 8% of the former values. The responses by the experts to 10 of these measurements came very close to those of the programme, with 33 +/- 6 kcal/kg/day and 0.29 +/- 0.06 gr/kg/day of nitrogen, with a percentage of correct responses of around 68%. CONCLUSIONS: The method for calculating the energy requirements used by our computer software constitutes around 92% of the calorimetric measurements in critical patients with mechanical ventilation and the responses are very similar to the average of the responses given by experts in nutritional support.

[Descriptive analysis of the nutritional support in a polyvalent intensive care unit. Complications of enteral nutrition]. / Análisis descriptivo del soporte nutricional en una UCI polivalente. Complicaciones de la nutrición enteral.

OBJECTIVE: Description of the nutritional support in an intensive care unit. REFERENCE POPULATION: Patients hospitalized in our ICU over a period of 48 months (October 1994-September 1998). INTERVENTIONS: The study was carried out by means of a review of the two data bases generated, one by using the clinical history management program, and the other by using the artificial nutrition program. RESULTS: Nutritional support is used in 31% of the non-coronary patients, predominantly medical (61%), and followed by surgical (29%) and trauma (9%) cases. These patients presented an APACHE (17.7 +/- 15), a hospitalization (15.8 +/- 14.9) and a mortality (26%) that was greater than that in non-coronary patients who did not require the nutritional support. The delay in starting the nutritional support is 2.8 +/- 1.9 days. In decreasing order, the nutritional support is most used in medical (42%), trauma (37%) and surgical (18%) patients. The access route is similar, enteral in 55% of the cases, with a predominance of medical patients, and parenteral in 45% of the cases, with a predominance of surgical patients. In 100 patients with a nutritional support in excess of 10 days, it was found that 87% at some time were given this enterally. In this group we studied the gastrointestinal complications, finding these in 61% of these patients, with the most frequent complication being an increase in the gastric residue (44%). Diarrhea was found in 14% and broncho-aspiration in 3.4%. The enteral route as the initial access failed in 25% of these cases, thus requiring parenteral nutrition. CONCLUSIONS: In our unit we used nutritional support in 31% of the non coronary patients, and these presented a greater severity, longer hospitalization, and higher mortality than those patients who did not require this. The beginning of the nutritional support is relatively early. The gastrointestinal complications derived from enteral nutrition are very common, with a predominance of gastric retention. In 25% of the critical patients who begin enteral nutrition, this fails, and thus they require parenteral nutrition.

[Evaluation of a high protein diet in critical care patients]. / Evaluación de un alto aporte proteico en pacientes críticos.

OBJECTIVE: To verify the hypothesis that a high nitrogen intake leads to better nutritional results in critical patients. REFERENCE POPULATION: Patients hospitalized in the critical care unit between 1995 and 1998 with nutritional support for 14 days, excluding patients with liver and/or kidney failure. INTERVENTIONS: The calculation of the requirements was made using a computerized program for determining the eliminated nitrogen, depending on the degree of stress. At the end of the second year the formulae for calculating the requirements were changed, thus we had two groups of patients with a different protein intake. The nutritional biochemical parameters are usually analyzed on days 1, 4, and 14, as were the characteristics of the nutrition used during the first and second week of treatment in both periods. RESULTS: 32 patients were included in the first period, and 50 in the second. It was seen that there were no significant differences between them. The characteristics of the administered nutrition showed a greater caloric supply in the first week of the first period (35.14 +/- 4.4 vs. 30.04 +/- 6.1 cal/kg), with there not being any difference in the protein intake (0.26 +/- 0.04 vs. 0.24 +/- 0.09 grams of nitrogen/kg) and a greater protein intake in the second week of the second period (0.34 +/- 0.06 vs. 0.28 +/- 0.04 grams of nitrogen/kg), with there not being any differences in the caloric intake (34.08 +/- 5.6 vs. 34.13 +/- 3.1 cal/kg). The analyzed parameters did not present any significant differences between the periods. The evolution of these was similar for each period, although in the second period the transferrin improved with respect to the first period, and the decrease in the height creatinine index was stopped in the second week. The nitrogen balance could not be improved. CONCLUSIONS: The increase in the protein intake above certain limits only very slightly improves some of the nutritional biochemical parameters, without improving the nitrogen balance as a result of an increased elimination thereof.

[Nutritional support response in critically ill patients; differences between medical and surgical patients]. / Respuesta al soporte nutricional de una población de pacientes críticos; diferencias entre pacientes médicos y quirúrgicos.

OBJECTIVE: To assess the nutritional response of a group of critically ill patients, as well as the differences in the response to nutritional support between medical and surgical patients. METHODS: One-year long retrospective study including critically ill patients on artificial nutrition for 7 days. Throughout the first week, three nutritional biochemical controls were done that included albumin, prealbumin, transferrin, cholesterol, and electrolytes. Other data gathered were: nutritional risk index, age, gender, weight, height, APACHE, delay of onset of nutritional support, access route, predicted and real caloric intake, medical or surgical patient, hospital stay, duration of the central venous catheter, urinary tube, and/or mechanical ventilation, incidence and density of incidence of nosocomial infections. RESULTS: Sixty-three patients were studied, 30 (47%) medical and 33 (53%) surgical/trauma patients, with a usage of EN higher among medical patients (16/30, 53% vs. 5/33, 15%), PN higher among surgical patients (25/33, 76%), and mixed nutrition similar in both groups (5 medical and 3 surgical patients) (p = 0.001). There were no differences between medical and surgical patients regarding: both predicted and real caloric and nitrogenous intake, APACHE, delay of onset of nutrition, phosphorus, magnesium or glucose levels, mortality and incidence of nosocomial infections. There were no differences either in hospital stay or use of mechanical ventilation, although these tended to be lower in surgical patients. The baseline biochemical parameters did not show differences between both groups, although they were worse among surgical patients. These patients presented during the study period steady albumin levels with improvement in the remaining parameters, whereas medical patients showed a decrease in albumin and transferrin levels, steady prealbumin levels, and slightly improvement in cholesterol levels. CONCLUSIONS: We have observed higher usage of PN among surgical patients, which showed worse baseline nutritional biochemical parameters and responded better to nutritional support and having a trend towards shorter hospital stay and lower mechanical ventilation use than medical patients. We have not observed differences regarding the mortality or nosocomial infection.

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

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 continuous renal replacement techniques, patients with severe burns and alcoholics, although the specific requirements in each of these types of patient have not yet been established. 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.

A retrospective study about the influence of early nutritional support on mortality and nosocomial infection in the critical care setting.

BACKGROUND & AIMS: To determine whether early nutritional support reduces mortality and the incidence of nosocomial infection, in critically ill patients in the current practice. METHODS: A retrospective observational study was conducted in all critically ill patients who had been prescribed nutritional support, throughout one year, in an Intensive Care Unit. The time to start and the route of delivery of nutritional support were determined by the attending clinician's assessment of gastrointestinal function and hemodynamic stability. Age, gender, severity of illness, start time and route of nutritional support, prescribed and delivered daily caloric intake for the first 7 days, whether they were a medical or surgical patient, length of stay in ICU, incidence rate of nosocomial infections and ICU mortality were recorded. Patients were classified according to whether or not they received nutritional support within 48 h of their admission to ICU and Binary Logistic Regression was performed to assess the effect of early nutritional support on ICU mortality and ICU nosocomial infections after controlling for confounders. RESULTS: Ninety-two consecutive patients were included in the study. Start time of nutritional support showed a mean of 3.1 ± 1.9 days. Patients in the early nutritional support group had a lower ICU mortality in an unadjusted analysis (20% vs. 40.4%, p = 0.033). Early nutritional support was found to be an independent predictor of mortality in the regression analysis model (OR 0,28; 95% confidence interval, 0.09 to 0,84; p = 0.023). Our study did not demonstrate any association between early nutritional support and the incidence of nosocomial infection (OR 0.77; 95%. confidence interval, 0.26 to 2,24; p = 0.63), which was related to the route of nutritional support and the caloric intake. The delayed nutritional support group showed a longer length of stay and nosocomial infections than the early group, although these differences were not statistically significant. CONCLUSIONS: Our study shows that early nutrition support reduces ICU mortality in critically ill patients, although it does not demonstrate any influence over nosocomial infection in the current practice in intensive care.

[Nutritional support outcomes in critical care]. / Resultados del soporte nutricional en una UCI polivalente.

BACKGROUND & AIMS: To revise the effect of our nutritional support practices on outcomes from critical care patients and propose new study hypothesis. METHODS: Retrospective observational study was conducted in all critically ill patients who had been prescribed nutritional support, through a year time, in an Intensive Care Unit. The nutritional support practices are described. Severity of illness (Simplified Acute Physiology Score II), timing and route of nutritional support, prescribed and delivered daily caloric intake for a maximum of 7 days, medical or surgical patient, length of stay in ICU, incidence rate and incidence density of nosocomial infections, and presence of gastrointestinal complications were recorded. Relationships between timing and route of nutritional support and percentage of received/ prescribed calories with mortality, nosocomial infections, days of mechanical ventilation and length of stay in the Intensive Care Unit were studied. RESULTS: 102 patients of our intensive care patients received nutritional support and were selected for the study. EN was used in 42 patients (41%), 41 (40%) received TPN and 19 patients (19%) received mixed nutrition. Timing of nutritional support showed a mean of 3.1 ± 1.9 days and was statistically different between patients who survived or died (2.82 ± 1.65 vs. 3.74 ± 2.33 days). Patients received 58 ± 28% of their requirements but this data did not show any difference with mortality and morbidity. There was a statistical difference between the route of nutrition and the following data: type of patient, caloric intake in the study period, length of stay in ICU and days of mechanical ventilation. CONCLUSIONS: Our study demonstrates that nutritional support patients are more severely ill than nonnutritional support patients. Timing of nutritional support was shorter in survivors. Our study confirms a low caloric input in the critically ill patient during the first week of illness, especially in the enteral nutrition group. However this finding was not associated with mortality or morbidity. Parenteral route did show better clinical outcomes than enteral or mixed nutrition. Our findings suggest that a moderate and early caloric intake could obtain better outcomes, independently of the route of nutritional support.