Multidisciplinary consensus on nutritional and metabolic therapy in enhanced recovery after abdominal surgery programs: NutRICA Project.

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) care pathways include evidence-based items designed to accelerate recovery after surgery. Interdisciplinarity is one of the key points of ERAS programs. OBJECTIVE: To prepare a consensus document among the members of the Nutrition Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Group for Multimodal Rehabilitation (GERM), in which the goal is to homogenize the nutritional and metabolic management of patients included in an ERAS program. METHODS: 69 specialists in Endocrinology and Nutrition and 85 members of the GERM participated in the project. After a literature review, 79 statements were proposed, divided into 5 sections: 17 of general characteristics, 28 referring to the preoperative period, 4 to the intraoperative, 13 to the perioperative and 17 to the postoperative period. The degree of consensus was determined through a Delphi process of 2 circulations that was ratified by a consistency analysis. RESULTS: Overall, in 61 of the 79 statements there was a consistent agreement, with the degree of consensus being greater among members of the SEEN (64/79) than members of the GERM (59/79). Within the 18 statements where a consistent agreement was not reached, we should highlight some important nutritional strategies such as muscle mass assessment, the start of early oral feeding or pharmaconutrition. CONCLUSION: Consensus was reached on the vast majority of the nutritional measures and care included in ERAS programs. Due to the lack of agreement on certain key points, it is necessary to continue working closely with both societies to improve the recovery of the surgical patients.

Multidisciplinary consensus on nutritional and metabolic therapy in enhanced recovery after abdominal surgery programs: NutRICA Project. / Consenso multidisciplinar sobre la terapia nutricional y metabólica en los programas de recuperación intensificada en cirugía abdominal: Proyecto NutRICA.

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) care pathways include evidence-based items designed to accelerate recovery after surgery. Interdisciplinarity is one of the key points of ERAS programs. OBJECTIVE: To prepare a consensus document among the members of the Nutrition Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Group for Multimodal Rehabilitation (GERM), in which the goal is to homogenize the nutritional and metabolic management of patients included in an ERAS program. METHODS: 69 specialists in Endocrinology and Nutrition and 85 members of the GERM participated in the project. After a literature review, 79 statements were proposed, divided into 5 sections: 17 of general characteristics, 28 referring to the preoperative period, 4 to the intraoperative, 13 to the perioperative and 17 to the postoperative period. The degree of consensus was determined through a Delphi process of 2 circulations that was ratified by a consistency analysis. RESULTS: Overall, in 61 of the 79 statements there was a consistent agreement, with the degree of consensus being greater among members of the SEEN (64/79) than members of the GERM (59/79). Within the 18 statements where a consistent agreement was not reached, we should highlight some important nutritional strategies such as muscle mass assessment, the start of early oral feeding or pharmaconutrition. CONCLUSION: Consensus was reached on the vast majority of the nutritional measures and care included in ERAS programs. Due to the lack of agreement on certain key points, it is necessary to continue working closely with both societies to improve the recovery of the surgical patients.

[A real-world study to evaluate a peptidic oral supplement in adults with altered intestinal function after parenteral nutrition]. / Un estudio en la vida real para evaluar un suplemento oral peptídico en adultos con alteración de la función intestinal tras la nutrición parenteral.

INTRODUCTION: Objectives: in routine clinical practice many disorders are found that can disrupt the sequence of reactions in digestion and absorption, leading to malnutrition and requiring the use of oral nutritional supplements (ONS). The objective of our study was to evaluate in a real world setting the use of and compliance with a peptide-based ONS in malnourished adult patients with intestinal compromise after more than 14 days of parenteral nutrition. Material and methods: the study was carried out in 44 malnourished patients who required total parenteral nutrition for at least 14 days without using the oral route during their hospital stay. All patients were administered, on an outpatient basis, 1 brick per day of Vital 1.5® for 12 weeks. At the beginning of treatment and after the intervention period evaluated, the following variables were collected: weight, height, body mass index (BMI), global subjective assessment test, nutritional biochemistry, 3-day nutritional survey, adverse effects generated by the formula, and completion rate. Results: 44 patients were enrolled. Mean age was 70.4 ± 10.4 years (20 women & 24 men). After the intervention the following parameters had increased: BMI (0.51 ± 0.1 kg/m2; p = 0.02), weight (1.4 ± 0.3 kg; p = 0.03), prealbumin (3.5 ± 4.1 mg/dl; p = 0.01), albumin (1.3 ± 0.1 mg/dl; p = 0.03), and transferrin (71.5 ± 24.1 mg/dl; p = 0.02). Dietary intake of the ONS represented 14.4 % of the diet's total caloric intake at 3 months, 17.5 % of carbohydrates, 12.9 % of proteins, and 12.3 % of fats. Mean compliance was 87.7 ± 7.2 % of the prescribed intakes. In relation to the nutritional situation, at the beginning of the study, 52.3 % (n = 23) of patients were in the global subjective assessment test in category B (moderate malnutrition or nutritional risk), and 47.7 % (n = 21) in category C (severe malnutrition). After the intervention, 75 % of patients were in category A (n = 33), 13.6 % (n = 6) in category B, and 11.4 % (n = 5) in category C. Conclusions: the use of a peptide-based ONS with short-chain triglycerides in outpatients showed a beneficial effect on biochemical and anthropometric parameters, and improved the nutritional status of patients with high compliance and good tolerance rates.

INTRODUCCIÓN: Objetivos: en la práctica clínica habitual existen multitud de situaciones y patologías que pueden interrumpir la digestión y la absorción intestinal, cursando con desnutrición y requiriendo el uso de suplementos orales nutricionales (SON). El objetivo de nuestro estudio fue evaluar, en el contexto de la vida real, el uso de un SON basado en péptidos, y el cumplimiento con el mismo, en pacientes adultos desnutridos con compromiso intestinal tras más de 14 días de nutrición parenteral. Material y métodos: el estudio se realizó en 44 pacientes desnutridos que requirieron nutrición parenteral total al menos 14 días, sin utilización de la vía oral durante el ingreso hospitalario. Se les administró de manera ambulatoria 1 brik al día de Vital 1.5® para su consumo durante 12 semanas. Al inicio del tratamiento y tras el periodo de intervención se les recogieron las variables siguientes: peso, talla, IMC, test de valoración subjetiva global, bioquímica nutricional, encuesta nutricional, efectos adversos generados por la fórmula y cumplimentación. Resultados: se incluyeron 44 pacientes con una edad media de 70,4 ± 10,4 años (20 mujeres/24 hombres). Tras la intervención aumentaron el IMC (0,51 ± 0,1 kg/m2; p = 0,02), el peso (1,4 ± 0,3 kg; p = 0,03), la prealbúmina (3,5 ± 4,1 mg/dl; p = 0,01), la albúmina (1,3 ± 0,1 mg/dl; p = 0,03) y la transferrina (71,5 ± 24,1 mg/dl; p = 0,02). La toma del SON represento a los 3 meses un 14,4 % del aporte calórico total de la dieta, un 17,5 % de los hidratos de carbono, un 12,9 % de las proteínas y un 12,3 % de las grasas. La cumplimentación media del grupo fue del 87,7 ± 7,2 % de las tomas prescritas. En relacion a la situacion nutricional, a la entrada del estudio un 52,3 % (n = 23) de los pacientes presentaban en el test de valoración subjetiva global la categoría B (malnutrición moderada o riesgo nutricional) y un 47,7 % (n = 21) la categoría C (desnutrición severa). Tras la intervención, un 75 % de los pacientes presentaban la categoría A (buena situación nutricional (n = 33), un 13,6 % (n = 6) de los pacientes presentaban la categoría B y un 11,4 % (n = 5) la categoría C. Conclusiones: la utilización de un suplemento peptídico con triglicéridos de cadena corta en pacientes ambulatorios tras haber recibido una nutrición parenteral total muestra un efecto beneficioso sobre los parametros bioquímicos y antropométricos, y la situación nutricional, con una alta cumplimentación y buena tolerancia.

Fish Oil Enriched Intravenous Lipid Emulsions Reduce Triglyceride Levels in Non-Critically Ill Patients with TPN and Type 2 Diabetes. A Post-Hoc Analysis of the INSUPAR Study.

There are no studies that have specifically assessed the role of intravenous lipid emulsions (ILE) enriched with fish oil in people with diabetes receiving total parenteral nutrition (TPN). The objective of this study was to assess the metabolic control (glycemic and lipid) and in-hospital complications that occurred in non-critically ill inpatients with TPN and type 2 diabetes with regard to the use of fish oil emulsions compared with other ILEs. We performed a post-hoc analysis of the Insulin in Parenteral Nutrition (INSUPAR) trial that included patients who started with TPN for any cause and that would predictably continue with TPN for at least five days. The study included 161 patients who started with TPN for any cause. There were 80 patients (49.7%) on fish oil enriched ILEs and 81 patients (50.3%) on other ILEs. We found significant decreases in triglyceride levels in the fish oil group compared to the other patients. We did not find any differences in glucose metabolic control: mean capillary glucose, glycemic variability, and insulin dose, except in the number of mild hypoglycemic events that was significantly higher in the fish oil group. We did not observe any differences in other metabolic, liver or infectious complications, in-hospital length of stay or mortality.

Effect of Two Meal Replacement strategies on Cardiovascular Risk Parameters in Advanced Age Patients with Obesity and Osteoarthritis.

BACKGROUND AND AIMS: Meal replacement diets consist of replacing one or more meals with an artificial nutritional supplement. The objective of this study was to compare the effect of one against two meal replacement strategies on body composition and cardiovascular risk parameters in patients with obesity. METHODS: A randomized clinical trial was designed with a modified hypocaloric diet with an artificial nutritional preparation replacing one or two meals for three months in patients with obesity and osteoarthritis pending orthopedic surgery. An anthropometric evaluation and a measurement of the body composition were done with bioelectrical impedance measurement at the beginning and at three months. RESULTS: A total of 112 patients were recruited. Fifty-two patients (46.4%) were randomized to one replacement and 60 patients (53.6%) to two meal replacements. Eighty-one patients (72.3%) were women, and the average age was 61 (11.03) years. The percentage of weight loss at three months was 8.27 (4.79)% (one meal replacement: 7.98 (5.97)%; two meal replacements: 8.50 (3.48)%; p = 0.56). A decrease in fat mass measured by the fat mass index (FMI) was detected (one meal replacement: -2.15 (1.45) kg/m2 vs. two meal replacements: -2.78 (2.55) kg/m2; p > 0.05), and a relative increase in fat-free mass was observed (one meal replacement: +3.57 (4.61)% vs. two meal replacements: +2.14 (4.45)%; p > 0.05). A decrease in HOMA-IR, systolic blood pressure (SBP), and total cholesterol was observed in both groups without differences between them. CONCLUSIONS: The substitution strategies of one or two meal replacements were effective in weight loss and fat mass decrease without differences between the two groups. An improvement in lipid parameters, glycemic control, and systolic blood pressure was observed without differences between strategies.

Repercusiones clínicas y económicas de la desnutrición relacionada con la enfermedad en un servicio quirúrgico / Clinical and economic implications of disease-related malnutrition in a surgical service

Introducción: la desnutrición relacionada con la enfermedad (DRE) tiene una alta prevalencia e importantes repercusiones clínicas y económicas. Nuestro objetivo es valorar la factibilidad e importancia de establecer una estrategia de cribado nutricional en nuestro medio. Pacientes y métodos: estudio prospectivo realizado en una planta quirúrgica. Se realizó el Malnutrition Universal Screening Tool (MUST) al ingreso y semanalmente, hasta el alta hospitalaria, a todos los pacientes. Cuando fue necesario, se realizó valoración e intervención nutricional así como codificación al alta de los diagnósticos y procedimientos nutricionales. Datos de estancia hospitalaria (EH), costes hospitalarios y parámetros clínicos fueron analizados posteriormente. Resultados: en un 15,6% de pacientes, el MUST detectó riesgo de desnutrición (≥ 2 puntos). Los pacientes con desnutrición al ingreso (DI) presentaron una estancia hospitalaria (EH) cuatro días superior y mayor tasa de mortalidad y de reingresos urgentes (2,4 y 2,0 veces, respectivamente), un año después del alta hospitalaria. La edad y el ingreso urgente fueron los factores asociados a mayor tasa de mortalidad anual. Un 9% de los pacientes con MUST < 2 inicial sufrieron un deterioro del estado nutricional (DEN) durante el ingreso. Estos pacientes, tuvieron mayor EH (siete días) a igualdad de comorbilidad. Considerando los costes relacionados con la EH, en los pacientes que presentaron DI o DEN se observó un sobrecoste del 57% y el 145%, respectivamente. Conclusión: los pacientes con DI presentaron mayor EH y tasa de mortalidad y de reingresos urgentes un año después del alta hospitalaria. Los pacientes con DI o DEN ocasionan un sobrecoste económico. El cribado nutricional es indispensable para el manejo y la detección precoz de la DRE

Introduction: disease-related malnutrition (DRM) is currently a major challenge in our hospitals, both because of its high prevalence and because of the clinical and economic impact. Our study aims to assess the feasibility and importance of establishing a nutritional screening strategy in our Health Care System. Patients and methods: this is a prospective study carried out in a Surgery Ward. The nutritional risk was assessed by applying to patients MUST at admission and weekly until discharge. Nutritional evaluation and nutritional intervention were performed if required, as well as coding of diagnoses and nutritional procedures at discharge. Clinical data, length of stay (LOS) and hospital costs were analyzed. Results: MUST detected 15.6% of patients at risk of malnutrition at admission. Patients with malnutrition at admission (MA) had four days longer LOS, higher annual mortality rate and urgent hospital readmissions in 2.4 and 2.0 times, respectively, one year after discharge. Age and urgent hospital admission were the factors associated with a higher annual mortality rate. Nine per cent of patients with an initial MUST < 2 suffered deterioration in their nutritional status during admission (DNS). These patients had longer LOS in seven days with equal comorbidity. Considering only the costs related to LOS in patients who presented MA or DNS, an overcost of 57% and 145%, respectively, was observed. Conclusion: patients with malnutrition on admission had longer LOS, higher mortality rate and urgent hospital readmissions one year after discharge. Patients who present MA or DNE cause an economic cost overrun. A nutritional screening tool is essential for the management and early detection of DRM

Estudio de tolerancia y aceptación de una fórmula enteral con alta densidad energética en pacientes de una unidad de coronarias / Study of tolerance and acceptance of a high energy density enteral formula in patients coronary unit study

Objetivo: el objetivo de nuestro trabajo fue evaluar la tolerancia de una fórmula enteral con alta densidad energetica en pacientes hospitalizados en una unidad de coronarias con indicación de soporte enteral al menos durante cinco días. Métodos: estudio abierto, no comparativo, no aleatorizado, descriptivo, para evaluar la tolerancia de una fórmula enteral con alta densidad energética en pacientes ingresados en una unidad coronaria. Resultados: se incluyeron 31 pacientes con una media de edad de 67,32 ± 13,8 años y de los cuales el 66,7% eran varones. El volumen medio final prescrito de Nutrison Energy® fue de 928,5 ± 278,5 ml/día (rango: 800-1.500 ml/día). La duración media de la nutrición enteral fue de 11,2 ± 3,2 días. El aporte final promedio de calorías fue de 1.392 ± 417 cal/día, con 169,9 ± 50,9 g/día de hidratos de carbono, 53,8 ± 16,1 g/día de grasas y 55,7 ± 16,9 g/día de proteínas. Tras la administracion existió un aumento significativo de los niveles de transferrina. Un total de 3 pacientes habían presentado algún episodio de diarrea (9,7%). El número de pacientes que presentaron al menos un episodio de residuo gástrico fue de 5 (16,1%) que no obligo en ningún caso a la suspensión de la nutrición enteral, obligando en 2 pacientes a disminuir el volumen del aporte nutricional durante 24 horas. Durante el soporte nutricional, solo en 3 pacientes fue necesario disminuir el volumen aportado el día previo de la fórmula energética. Con respecto a los vómitos, solo en 1 paciente se constató esta situación (3,2%). Ningún paciente presentó en el estudio otras complicaciones digestivas asociadas a la administración de la fórmula de nutrición enteral. Por último, no se registraron acontecimientos adversos relacionados con la fórmula administrada. Conclusiones: los resultados reflejan que una fórmula enteral con alta densidad energética es una fórmula bien tolerada con una muy baja frecuencia de síntomas gastrointestinales, lo que favorece el cumplimiento de la pauta (AU)

Objective: The aim of our study was to evaluate the tolerance of enteral formula with high energetic density in patients hospitalized in a coronary care unit requering enteral support for at least fi ve days. Methods: Opened, non-comparative, nonrandomized, descriptive study, evaluating the tolerance of enteral formula with high energy density in patients admitted to a coronary care unit. Results: 31 patients were included with a mean age of 67.32 ± 13.8 years, 66.7% were male. The average prescribed final volume Nutrison Energy® was 928.5 ± 278.5 mL/day (range: 800-1,500 mL/day). The average duration of enteral nutrition was 11.2 ± 3.2 days. The average calorie intake was 1,392 ± 417 cal/day, with 169.9 ± 50.9 g/day of carbohydrates, 53.8 ± 16.1 g/day of fat and 55.7 ± 16.9 g/day of protein. After administration there was a significant increased levels of transferrin. A total of 3 patients had an episode of diarrhea (9.7%). The number of patients experiencing at least one episode of gastric residue was 5 (16.1%) not forced in any way to withdrawing enteral nutrition, forcing in 2 patients to diminish the nutritional intake volume for 24 hours. During nutritional support, in only 3 patients it was required to decrease the volume made the previous day energy formula. With regard to vomiting, in 1 patient this situation (3.2%) was verified. No patient in the study presented any digestive complications associated with the administration of the enteral nutrition formula. Finally, no adverse events related to the administered formulation were recorded. Conclusions: The results show that enteral formula with high energy density is a well-tolerated formula with a very low frequency of gastrointestinal symptoms, which favors compliance (AU)

Efecto del tratamiento dietoterápico de la obesidad sobre el metabolismo óseo / Effect of dietary treatment of obesity on bone metabolism

La obesidad interfiere con el metabolismo óseo a través de factores mecánicos, hormonales e inflamatorios. El principal tratamiento de dicha enfermedad es la dieta, modificación de la cantidad y tipo de alimento. Este tratamiento nutricional tiene una influencia sobre el metabolismo óseo en dos sentidos: modifica el efecto del sobrepeso y la obesidad sobre el hueso e interviene directamente en el turnover óseo a través de las características de los nutrientes utilizados. Esta revisión analiza la evidencia del efecto sobre el hueso del descenso de peso y del patrón dietético utilizado. Por otra parte, se valorarán las modificaciones que se pueden realizar en la dieta indicada en un paciente obeso para prevenir la pérdida ósea, a corto y largo plazo, y disminuir el riesgo de fractura (AU)

Obesity interferes with bone metabolism through mechanical, hormonal and inflammatory factors. The main treatment of this disease is the diet with modification of the amount and type of food. This nutritional therapy has an influence on bone metabolism in two ways: It modifies the effect of overweight and obesity on bone; and it intervenes in bone turnover through the characteristics of the nutrients used. This review examines the evidence of the effect on bone of weight loss and dietary pattern used. Moreover, we will assess the modifications that can be made in weight-reduction diet to prevent short and long term bone loss and reduce the risk of fracture (AU)