ACERTO Project - 15 years changing perioperative care in Brazil.

The ACERTO project is a multimodal perioperative care protocol. Implemented in 2005, the project in the last 15 years has disseminated the idea of a modern perioperative care protocol, based on evidence and with interdisciplinary team work. Dozens of published studies, using the protocol, have shown benefits such as reduced hospital stay, postoperative complications and hospital costs. Disseminated in Brazil, the project is supported by the Brazilian College of Surgeons and the Brazilian Society of Parenteral and Enteral Nutrition, among others. This article compiles publications by the authors who belong to the CNPq research group "Acerto em Nutrição e Cirurgia", refers to the experience of other national authors in various surgical specialties, and finally outlines the evolution of the ACERTO project in the timeline.

Acerto Project - 15 years changing perioperative care in Brazil / Projeto Acerto - 15 anos modificando cuidados perioperatórios no Brasil

ABSTRACT The ACERTO project is a multimodal perioperative care protocol. Implemented in 2005, the project in the last 15 years has disseminated the idea of a modern perioperative care protocol, based on evidence and with interdisciplinary team work. Dozens of published studies, using the protocol, have shown benefits such as reduced hospital stay, postoperative complications and hospital costs. Disseminated in Brazil, the project is supported by the Brazilian College of Surgeons and the Brazilian Society of Parenteral and Enteral Nutrition, among others. This article compiles publications by the authors who belong to the CNPq research group "Acerto em Nutrição e Cirurgia", refers to the experience of other national authors in various surgical specialties, and finally outlines the evolution of the ACERTO project in the timeline.

RESUMO O projeto ACERTO é um protocolo multimodal de cuidados perioperatórios. Implementado em 2005, o projeto, nos últimos 15 anos, tem disseminado a ideia de moderno protocolo de cuidados perioperatórios baseados em evidência e com atuação interprofissional. Dezenas de estudos publicados com o uso do protocolo têm mostrado benefícios como redução do tempo de internação, complicações pós-operatórias e custos hospitalares. Disseminado pelo Brasil, o projeto tem apoio do Colégio Brasileiro de Cirurgiões e da Sociedade Brasileira de Nutrição Parenteral e Enteral, entre outros. Este artigo compila publicações dos autores que compõem o grupo de pesquisa do CNPq "Acerto em Nutrição e Cirurgia", cita a experiência de outros autores nacionais em diversas especialidades cirúrgica e finalmente, delineia a evolução do projeto ACERTO ao longo da linha do tempo.

Hypophosphatemia and risk of refeeding syndrome in critically ill patients before and after nutritional therapy.

OBJECTIVE: To investigate the prevalence of hypophosphatemia as a marker of refeeding syndrome (RFS) before and after the start of nutritional therapy (NT) in critically ill patients. METHODS: Retrospective cohort study including 917 adult patients admitted at the intensive care unit (ICU) of a tertiary hospital in Cuiabá-MT/Brasil. We assessed the frequency of hypophosphatemia (phosphorus <2.5mg/dl) as a risk marker for RFS. Serum phosphorus levels were measured and compared at admission (P1) and after the start of NT (P2). RESULTS: We observed a significant increase (36.3%) of hypophosphatemia and, consequently, a greater risk of RFS from P1 to P2 (25.6 vs 34.9%; p<0.001). After the start of NT, malnourished patients had a greater fall of serum phosphorus. Patients receiving NT had an approximately 1.5 times greater risk of developing RFS (OR= 1.44 95%CI 1.10-1,89; p= 0.01) when compared to those who received an oral diet. Parenteral nutrition was more associated with hypophosphatemia than either enteral nutrition (p=0,001) or parenteral nutrition supplemented with enteral nutrition (p=0,002). CONCLUSION: The frequency of critically ill patients with hypophosphatemia and at risk for RFS on admission is high and this risk increases after the start of NT, especially in malnourished patients and those receiving parenteral nutrition.

Hypophosphatemia and risk of refeeding syndrome in critically ill patients before and after nutritional therapy

Summary OBJECTIVE: To investigate the prevalence of hypophosphatemia as a marker of refeeding syndrome (RFS) before and after the start of nutritional therapy (NT) in critically ill patients. METHODS: Retrospective cohort study including 917 adult patients admitted at the intensive care unit (ICU) of a tertiary hospital in Cuiabá-MT/Brasil. We assessed the frequency of hypophosphatemia (phosphorus <2.5mg/dl) as a risk marker for RFS. Serum phosphorus levels were measured and compared at admission (P1) and after the start of NT (P2). RESULTS: We observed a significant increase (36.3%) of hypophosphatemia and, consequently, a greater risk of RFS from P1 to P2 (25.6 vs 34.9%; p<0.001). After the start of NT, malnourished patients had a greater fall of serum phosphorus. Patients receiving NT had an approximately 1.5 times greater risk of developing RFS (OR= 1.44 95%CI 1.10-1,89; p= 0.01) when compared to those who received an oral diet. Parenteral nutrition was more associated with hypophosphatemia than either enteral nutrition (p=0,001) or parenteral nutrition supplemented with enteral nutrition (p=0,002). CONCLUSION: The frequency of critically ill patients with hypophosphatemia and at risk for RFS on admission is high and this risk increases after the start of NT, especially in malnourished patients and those receiving parenteral nutrition.

RESUMO OBJETIVO: Determinar a frequência de hipofosfatemia como marcador da síndrome de realimentação (SR) antes e após o início da TN em pacientes críticos. MÉTODOS: Coorte retrospectiva realizada com 917 pacientes adultos de um hospital terciário em Cuiabá-MT. Foi determinada a frequência de hipofosfatemia (fósforo <2,5 mg/dl) como marcador de risco de SR, para valores de fósforo sérico da admissão (P1) e após o início da TN (P2). RESULTADOS: Foi observado um aumento significativo (36,3%) da hipofosfatemia entre P1 e P2 e, consequentemente, do risco de SR (25,6% vs 34,9%; p<0,001) com o início da TN. Após o início da TN, pacientes desnutridos apresentaram maior queda do fósforo sérico. Os pacientes com TN apresentaram aproximadamente 1,5 vez mais chance de desenvolver hipofosfatemia e risco de SR (OR=1,44 IC95% 1,10-1,89; p=0,01) quando comparado aos com dieta oral. Nutrição parenteral foi mais associada à hipofosfatemia versus nutrição enteral (p=0,001) e nutrição enteral suplementada com parenteral (p=0,002). CONCLUSÃO: A frequência de pacientes críticos com hipofosfatemia e em risco de SR é alta e esse risco aumenta após o início da TN, especialmente nos desnutridos e naqueles recebendo nutrição parenteral.

Early enteral nutrition with whey protein or casein in elderly patients with acute ischemic stroke: a double-blind randomized trial.

OBJECTIVE: The aim of this study was to investigate the effects of an early enteral formula containing whey protein, in comparison to a standard enteral formula containing casein as the protein source, on the levels of glutathione and inflammatory markers in aged patients with acute ischemic stroke. METHODS: Thirty-one elderly patients (12 males and 19 females; median age = 74 [range,65-90] y old) with ischemic stroke were randomized to receive early nasogastric feeding (35 kcal/kg/d and 1.2 g of protein/kg/d) with either a formula containing polymeric [corrected] casein (casein group, n =16) or another isocaloric and isonitrogenous formula containing hydrolyzed whey protein (WP group, n = 15) for 5 d. The primary endpoints of the study were the changes in the serum levels of glutathione peroxidase, C-reactive protein (CRP), and interleukin 6 (IL-6). RESULTS: Twenty-five patients completed the study (10 in the WP group and 15 in the casein group). Mortality was similar between groups (33%; P = 1.00) and was associated with higher serum IL-6 (73.7 ± 24.7 versus 16.6 ± 2.4 pg/dL; P = 0.04) and CRP (82.0 ± 35.6 versus 48.3 ± 14.5 mg/L; P = 0.02) levels. Albumin levels dropped from the first to the fifth feeding day only in the casein group (P < 0.01). Serum IL-6 decreased (62.7 ± 47.2 to 20.6 ± 10.3 pg/dL; P = 0.02) and glutathione increased (32.2 ± 2.1 to 39.9 ± 6.8 U/G Hb; P = 0.03) only in the WP group. Serum IL-6 was lower (P = 0.03) and glutathione was higher (P = 0.03) in whey protein-fed patients than in the casein group. CONCLUSION: Enteral formula containing whey protein may decrease inflammation and increase antioxidant defenses in elderly patients with ischemic stroke, compared to casein-containing formula.

Role of enteral nutrition and pharmaconutrients in conditions of splanchnic hypoperfusion.

In critically ill patients there is consistent evidence that significant benefits are achieved if nutrients are delivered within the gut compared with the parenteral route. However, in conditions related to gut hypoflux, enteral nutrition may play a double role in counterbalancing the installed low-flow state. On the one hand, enteral-induced postprandial hyperemia may preserve the mucosal barrier and ameliorate immune competence; on the other hand, feeding by the gut may pose a theoretical risk of intestinal ischemia. Despite limited investigation, a strategic temporary minimal enteral nutrition with hypocaloric content has been recommended recently aiming to avoid the overfeeding syndrome and the menace of gut hypoperfusion. Under these conditions, the early luminal delivery of key nutrients such as arginine, glutamine dipeptides, antioxidants, and butyrate are an attractive option for this subset of patients. Arginine may prevent intestinal injury due to hypoperfusion but may harm the gut if ischemia is established. In contrast, glutamine may promote benefits in both conditions. Further investigations by randomized trials in this field are necessary.

Effects of budesonide and probiotics enemas on the systemic inflammatory response of rats with experimental colitis.

PURPOSE: The aim of this study was to investigate the effect of enemas containing probiotics and budesonide on the systemic inflammatory response in experimental colitis. METHODS: Fifty male Wistar rats with experimental colitis induced by 10% acetic acid enema were randomized to five groups (10 rats each) according to the treatment: group 1--saline solution, group 2--budesonide (0.75 mg/kg/day), group 3--probiotics (1mg/day), group 4--probiotics plus budesonide, and group 5--control, with not-treated rats. The following variables were studied: body weight, serum levels of albumin, C-reactive protein and interleucine-6 (IL-6). RESULTS: All animals lost weight between the beginning and the end of the experiment (280+ 16 mg versus 249+21 mg, p< 0.001). There was a significant decrease in the serum albumin between the normal pre-induction level (3.45 + 0.49 mg/dL) and the 1st day after colitis induction (1.61+051 mg/dL, p< 0.001) in all treated groups when compared to the control group. C- reactive protein increased after induction and diminished on the 7th day in all groups. In the control group there was an increase in the IL-6 after colitis induction. None of the treated groups significantly differed from IL-6 pre-colitis status (p>0.05). Only probiotic rats presented a significant decrease of IL-6 than controls (0,30+/-0,08 mg/dL vs. 0,19+/-0,03 mg/dL; p<0.01). CONCLUSION: Probiotics are effective to diminished inflammatory status mediated by IL-6 in experimental colitis.

Effects of budesonide and probiotics enemas on the systemic inflammatory response of rats with experimental colitis

PURPOSE: The aim of this study was to investigate the effect of enemas containing probiotics and budesonide on the systemic inflammatory response in experimental colitis. METHODS: Fifty male Wistar rats with experimental colitis induced by 10 percent acetic acid enema were randomized to five groups (10 rats each) according to the treatment: group 1 - saline solution, group 2 - budesonide (0.75 mg/kg/day), group 3 - probiotics (1mg/day), group 4 - probiotics plus budesonide, and group 5 - control, with not-treated rats. The following variables were studied: body weight, serum levels of albumin, C-reactive protein and interleucine-6 (IL-6). RESULTS: All animals lost weight between the beginning and the end of the experiment (280+ 16 mg versus 249+21 mg, p< 0.001). There was a significant decrease in the serum albumin between the normal pre-induction level (3.45 + 0.49mg/dL) and the 1st day after colitis induction (1.61+051mg/dL, p< 0.001) in all treated groups when compared to the control group. C- reactive protein increased after induction and diminished on the 7th day in all groups. In the control group there was an increase in the IL-6 after colitis induction. None of the treated groups significantly differed from IL-6 pre-colitis status (p>0.05). Only probiotic rats presented a significant decrease of IL-6 than controls (0,30±0,08 mg/dL vs. 0,19±0,03 mg/dL; p<0.01). CONCLUSION: Probiotic associated with budesonida Probiotics are effective to diminished inflammatory status mediated by IL-6 in experimental colitis.

OBJETIVO: Investigar o efeito da administração retal de probióticos e budesonida na resposta inflamatória de ratos com colite experimental. MÉTODOS: Cinqüenta ratos Wistar com colite experimental induzida pelo acido acético à 10 por cento foram randomizados em 5 grupos (n=10 por grupo) para diferentes tratamentos: grupo 1 - solução fisiológica; grupo 2 budesonida (0,75mg/kg/dia); grupo 3 - probióticos (1 g/dia); grupo 4 - probióticos associados a budesonida; e finalmente grupo 5 - controle, composto por ratos sem tratamento. As seguintes variáveis foram estudadas: peso corporal, dosagens séricas de albumina, proteína C reativa (PCR) e interleucina-6 (IL-6). RESULTADOS: Todos os animais perderam peso entre o inicio e o fim do experimento (280±16 vs 249±21g; p<0.001). Ocorreu uma queda significativa da albumina sérica entre o normal (3,45±0,49g/dL) e o 1° dia de colite (grupo 5 = 1,61±0,51 g/dL; p <0.001) em todos grupos com tratamento em relação ao grupo controle. A PCR aumentou após a indução da colite, diminuindo no sétimo dia de colite em todos os grupos. No grupo controle houve um aumento da IL-6 após a indução da colite. Nenhum dos grupos de tratamento diferiu significantemente dos valores de IL-6 antes da indução a colite (p>0.05). As comparações entre o grupo controle (0,30±0,08 mg/dL) e outros mostraram que houve uma queda significante nos níveis de IL-6 apenas no grupo probiótico (0,19±0,03 mg/dL; p<0.01). CONCLUSÃO: Probióticos são efetivos na diminuição do estado inflamatório mediado pela IL-6 na colite experimental.