[Incidence of catheter-related infection and associated risk factors in hospitalized patients with parenteral nutrition]. / Incidencia de infección asociada a catéter y factores de riesgo relacionados en pacientes hospitalizados con nutrición parenteral.

INTRODUCTION: The most severe complication of parenteral nutrition (PTN) is catheter-related infection (CRI). OBJECTIVES: To study the incidence rate and factors associated to CRI. MATERIAL AND METHODS: 271 patients followed at the Nutrition Unit for 6 months. The composition of the PTN was calculated according to the metabolic demands. 20.3% received a lipid solution enriched with omega-3 fatty acids (SMOF Fresenius Kabi®) and 79.7% with olive oil (Clinoleic Baxter®). RESULTS: The rate of CRI was 25 per 1,000 days of PTN (55 patients: 61.7±17.8 years, 60.3% males, 29.3±10.6 days of hospital stay and 10.4% mortality). Coagulase-negative Staphylococcus was the most frequently isolated microorganism. There were no differences by age, gender, mortality, or composition of the PTN between patients with or without infection. The patients treated with omega-3 received more calories with the PTN, at the expense of higher intake of glucose and lipids. However, the rate of infection was similar, although there was a not significant trend towards a lower infection rate when using the omega-3 composition (14.5% vs. 23.1%, respectively, p = 0.112). The duration of the nutritional support was higher in patients with CRI (13.0 ± 9.7 vs. 9.3 ± 8.1, p = 0.038). Total mortality (16.9%) was independent of the presence or absence of CRI (10.4% vs. 18.7%, p = 0.090) or of the use of omega-3 lipids or olive oil in the PTN (10.9% vs. 18.5%, p = 0.125). CONCLUSION: Patients submitted to PTN have a high rate of CRI. The presence of infection is related to the duration of the PTN, being independent of the age, gender, and composition of the solution. The use of omega-3 lipid solutions may be beneficial although further studies are needed to confirm this.

[Anemia in critically ill and surgical patient: treatment with intravenous iron]. / Anemia del paciente crítico y quirúrgico: tratamiento con hierro intravenoso.

BACKGROUND: Anemia is a common condition among surgical and critically ill patients and it is usually treated with allogenic blood transfusion (ABT). As ABT is associated with increased morbidity and mortality, alternative therapies for anemia in these patients are actively investigated. OBJECTIVES: To asses the potential usefulness of intravenous iron therapy in critically-ill or surgical patients with anemia. METHODS: Review of published papers with intravenous iron in these patients. Bibliographical search on database Medline (www.ncvi.nlm.nih.gov). RESULTS AND DISCUSSION: Treatment with intravenous iron is not sufficient to treat the anemia of critically ill patients. Its association with erythropoietin (EPO) may have an effect on the rate of ABT, but it has not been shown to improve morbidity, mortality or length of hospital stay. In gastrointestinal or trauma surgery there is no evidence to support the routine preoperative treatment with intravenous iron, although it may be beneficial when it is used with erythropoietin. Intravenous iron alone or in combination with EPO in the postoperative period has not been proved useful for rapid correction of anemia, reduction of hospital stay or mortality.

Anemia del paciente crítico y quirúrgico; tratamiento con hierro intravenoso / Anemia in critically ill and surgical patient; treatment with intravenous iron

Introducción: La anemia es la anomalía hematológica y analítica más frecuente entre los pacientes críticos y quirúrgicos. Habitualmente se trata con transfusión de sangre alogénica (TSA), la cuál está relacionada con aumento de la morbimortalidad, por lo que se plantea la búsqueda de alternativas para el tratamiento de la anemia grave. Objetivos: Valorar la posible utilidad de la terapia con hierro intravenoso en pacientes con enfermedad crítica oquirúrgica que presentan anemia. Métodos: Revisión de los trabajos publicados con hierro intravenoso en este tipo de pacientes. Búsqueda en la base de datos Medline (www.ncvi.nlm.nih.gov) y búsqueda manual. Resultado y discusión: El tratamiento con hierro intravenoso no es suficiente para tratar la anemia del paciente crítico. Su asociación a eritropoyetina sí puede tener un efecto sobre la tasa de transfusiones aunque no se ha demostrado que mejore la morbimortalidad ni la estancia hospitalaria. En cirugía digestiva o traumatológica no hay evidencia que apoye el tratamiento sistemático pericirugía con hierro intravenoso, pudiendo encontrarse beneficio cuando se utiliza junto con eritropoyetina. La utilización de hierro intravenoso solo o asociado a EPO en el postoperatorio no ha demostrado ser útil para una corrección rápida de la anemia, disminuir la estancia hospitalaria ni disminuir la mortalidad (AU)

Background: Anemia is a common condition among surgical and critically ill patients and it is usually treated with allogenic blood transfusion (ABT). As ABT is associated with increased morbidity and mortality, alternative therapies for anemia in these patients are actively investigated. Objectives: To asses the potential usefulness of intravenous iron therapy in critically-ill or surgical patients with anemia. Methods: Review of published papers with intravenousiron in these patients. Bibliographical search on data base Medline (www.ncvi.nlm.nih.gov).Results and discussion: Treatment with intravenousiron is not sufficient to treat the anemia of critically ill patients. Its association with erythropoietin (EPO) may have an effect on the rate of ABT, but it has not been shown to improve morbidity, mortality or length of hospital stay. In gastrointestinal or trauma surgery there is no evidence to support the routine preoperative treatment with intravenous iron, although it may be beneficial when it is used with erythropoietin. Intravenous iron alone or incombination with EPO in the postoperative period has not been proved useful for rapid correction of anemia, reduction of hospital stay or mortality (AU)

[Micronutrient supplementation in parenteral nutrition in Spanish hospitals]. / Utilización de micronutrientes en nutrición parenteral en los hospitales Españoles.

Several years ago, it was recommended not to add vitamins or oligoelements to parenteral nutrition (PN) solutions and to administer them immediately after the addition of the micronutrients to avoid their decay. Nowadays, it has been observed that with multilayer bags, ternary mixtures and sunlight protection vitamins degradation is minimal. Daily intake of micronutrients is necessary in the critically ill, malnourished or long-term PN patients. Aiming at knowing the schedules of use of micronutrients in PN in Spanish hospitals and the way PN bags are prepared regarding the factors conditioning their stability, we undertook a telephone survey to the pharmacists in charge of PN at the different hospitals. We compared the data obtained with those from other surveys performed in 2001 and 2003. Pharmacists from 97 hospitals answered the questionnaire (answer rate 88%). The hospital sizes ranged 104-1728 beds. As compared to the data form preceding years, we observed a better adequacy to the current recommendations, although there are still 30% of the hospitals that administer micronutrients on an every other day basis independent of the clinical situation of the patients. In most of the hospitals, multilayer bags are used and/or sunlight protection and ternary mixtures. According to these results showing the different criteria for administering vitamins and oligoelements in PN solutions, it seems necessary to elaborate consensus documents that adapt to the reality of the diverse practices besides promoting the performance of well-designed clinical studies establishing the requirements under special clinical situations.

Utilización de micronutrientes en nutrición parenteral en los hospitales españoles / Micronutrient supplementation in parenteral nutrition in spanish hospitals

Hace años se recomendó no añadir conjuntamente vitaminas y oligoelementos a las nutriciones parenterales (NP) y administrarlas inmediatamente después de la adición de los micronutrientes para evitar su degradación. Actualmente se ha visto que con bolsas multicapa, mezclas ternarias y fotoprotección la degradación de vitaminas es mínima. El aporte diario de micronutrientes es necesario al menos en pacientes críticos, malnutridos o con NP a largo plazo. Con el objetivo de conocer las pautas de utilización de los micronutrienes en NP en los hospitales españoles y la forma de preparación de las bolsas de NP, en relación a los factores condicionantes de su estabilidad, se realizó una encuesta telefónica a los farmacéuticos responsables del área de NP de los diferentes hospitales. Los datos obtenidos se compararon con otras encuestas realizadas en 2001 y 2003. Respondieron la encuesta 97 hospitales de los 110 hospitales a los que se llamó (tasa de respuesta 88%), cuyo número de camas estaba comprendido entre 104 y 1728. En comparación con los datos de años anteriores se observa una mayor adecuación a las recomendaciones vigentes, aunque todavía casi un 30% de los hospitales aportan los micronutrientes en días alternos con independencia de la situación clínica del paciente. La mayoría de los hospitales utilizan bolsas multicapa y/o fotoprotección y mezclas ternarias. A la vista de los resultados, en los que se pone en evidencia la disparidad de criterios en la administración de vitaminas y oligoelementos en las soluciones de NP parece necesario elaborar documentos de consenso que se adecuen a la realidad de las distintas prácticas además de favorecer la realización de estudios clínicos minuciosamente diseñados para establecer los requerimientos en situaciones clínicas especiales (AU)

Several years ago, it was recommended not to add vitamins or oligoelements to parenteral nutrition (PN) solutions and to administer them immediately after the addition of the micronutrients to avoid their decay. Nowadays, it has been observed that with multilayer bags, ternary mixtures and sunlight protection vitamins degradation is minimal. Daily in take of micronutrients is necessary in the critically ill, malnourished or long-term PN patients. Aiming at knowing the schedules of use of micronutrients in PN in Spanish hospitals and the way PN bags are prepared regarding the factors conditioning their stability, we undertook a telephone survey to the pharmacists in charge of PN at the different hospitals. We compared the data obtained with those from other surveys performed in 2001 and 2003. Pharmacists from 97 hospitals answered the questionnaire(answer rate 88%). The hospital sizes ranged 104-1728 beds. As compared to the data form preceding years, we observed a better adequacy to the current recommendations, although there are still 30% of the hospitals that administer micronutrients on an every other day basis independent of the clinical situation of the patients. In most of the hospitals, multilayer bags are used and/or sunlight protection and ternary mixtures. According to these results showing the different criteria for administering vitamins and oligoelements in PN solutions, it seems necessary to elaborate consensus documents that adapt to the reality of the diverse practices besides promoting the performance of well-designed clinical studies establishing the requirements under special clinical situations (AU)

Parenteral nutrition supplemented with glutamine in patients undergoing bone marrow transplantation.

UNLABELLED: The objective of the study is to evaluate if the administration of glutamine in parenteral nutrition (PN) solution reduces the need for antibiotics, the risk of liver disease and the duration of hospital stay in bone marrow transplantation. MATERIAL AND METHODS: Retrospective observational study in 68 adult patients undergoing a bone marrow transplantation who required PN for mucositis. Of these patients, 40 were given PN with 2,063 +/- 294 kcal/day and 98.6 +/- 13.9 g of amino acids/day, supplemented with Lglutamine (13.5-27 g/day), and 28 were given isocaloric (1,966 +/- 307 kcal/day) and isonitrogenated (92 +/- 16.3 g of amino acids/day) PN with standard glutamine-free amino acid solution. Antibiotic consumption and duration of hospital stay were analysed. Of the total cohort, hepatic profile was studied at the beginning and on day 7 of PN in 50 patients without liver disease at the start of PN. RESULTS: There were no differences between both groups with regard to total number and duration of antibiotics prescribed or hospital stay. Of the 50 patients without hepatic alterations at the beginning of PN, 2 patients in the control group and 5 in the glutamine group developed a hepatic profile compatible with liver disease secondary to PN. Comparing both groups, there were no differences in hepatic enzyme values. CONCLUSIONS: Supplementation with PN glutamine does not improve the variables studied, but the actual clinical use of glutamine in this haematological treatment should be studied further and its potential advantages identified.

Parenteral nutrition supplemented with glutamine in patients undergoing bone marrow transplantation / Nutrición parenteral suplementada con glutamina en pacientes sometido a trasplante de médula ósea

The objective of the study is to evaluate if the administration of glutamine in parenteral nutrition (PN) solution reduces the need for antibiotics, the risk of liver disease and the duration of hospital stay in bone marrow transplantation. Material and methods: Retrospective observational study in 68 adult patients undergoing a bone marrow transplantation who required PN for mucositis. Of these patients, 40 were given PN with 2,063 ± 294 kcal/day and 98.6 ± 13.9 g of amino acids/day, supplemented with Lglutamine (13.5-27 g/day), and 28 were given isocaloric (1,966 ± 307 kcal/day) and isonitrogenated (92 ± 16.3 g of amino acids/day) PN with standard glutamine-free amino acid solution. Antibiotic consumption and duration of hospital stay were analysed. Of the total cohort, hepatic profile was studied at the beginning and on day 7 of PN in 50 patients without liver disease at the start of PN. Results: There were no differences between both groups with regard to total number and duration of antibiotics prescribed or hospital stay. Of the 50 patients without hepatic alterations at the beginning of PN, 2 patients in the control group and 5 in the glutamine group developed a hepatic profile compatible with liver disease secondary to PN. Comparing both groups, there were no differences in hepatic enzyme values. Conclusions: Supplementation with PN glutamine does not improve the variables studied, but the actual clinical use of glutamine in this haematological treatment should be studied further and its potential advantages identified (AU)

El objetivo del estudio es determinar si la administración de glutamina en la solución de nutrición parenteral (NP) disminuye la necesidad de antibióticos, el riesgo de hepatopatía y la duración de la estancia hospitalaria en trasplante de células hematológicas. Material y método: Estudio observacional retrospectivo, con 68 pacientes adultos sometidos a trasplante de células hematológicas, que precisaron NP por mucositis. De ellos, 40 pacientes recibieron NP con 2.063 ± 294 kcal/día y 98,6 ± 13,9 g de aminoácidos/día, suplementada con L-glutamina (13,5-27 g/día) y 28 recibieron una NP isocalórica (1.966 ± 307 kcal/día) e isonitrogenada (92 ± 16,3 g de aminoácidos/día) con solución de aminoácidos estándar libre de glutamina. Se analizó el consumo de antibióticos y la duración de la estancia hospitalaria. De la cohorte total, en 50 pacientes sin hepatopatía al inicio de la NP se estudió el perfil hepático al inicio y en el día 7 de la NP. Resultados: No hubo diferencias entre ambos grupos respecto al número total y duración de antibióticos prescritos, ni en estancia hospitalaria. De los 50 pacientes sin alteraciones hepáticas al inicio de la NP, 2 pacientes en el grupo control y 5 en el grupo glutamina desarrollaron un perfil hepático compatible con hepatopatía secundaria a NP. Comparando ambos grupos no hubo diferencias en los valores de enzimas hepáticas. Conclusiones: La suplementación con glutamina de NP no mejora las variables estudiadas, pero se debe continuar investigando el uso clínico real de glutamina en este tratamiento hematológico, identificando sus potenciales ventajas (AU)

Complicaciones asociadas al tratamiento en niños con nutrición parenteral domiciliaria / Complications associated with the treatment of children on home parenteral nutrition

Cuando no se puede conseguir un estado nutricional adecuado por la vía enteral como consecuencia de una situación de fracaso intestinal, el único medio de mantener una situación nutricional correcta es la nutrición parenteral (NP). No obstante, su uso prolongado puede ocasionar complicaciones graves. Objetivo: Conocer la tasa de incidencia de complicaciones asociadas a la nutrición parenteral domiciliaria (NPD) en el periodo 1993-2005. Material y métodos: Análisis retrospectivo de las historias clínicas de los 22 pacientes (13 niñas y 9 niños) que recibieron NPD en ese periodo. Resultados: La duración total del programa fue de 4.324 días, con una duración media por paciente de 196 días. En 19 niños el acceso venoso fue un catéter tunelizado y en 3 un reservorio subcutáneo. Encontramos un total de 23 complicaciones, con una media de 1,95 por paciente y año. La tasa de complicaciones infecciosas fue de 3 por cada 1.000 días de NPD(11 bacteriemias y 2 infecciones en el punto de salida). Las complicaciones mecánicas supusieron 1,8 episodios por cada1.000 días. En cinco ocasiones en que se produjo la rotura del catéter fue posible repararlo con el kit de reparación. No se produjo ningún episodio de trombosis venosa. Sólo dos pacientes presentaron complicaciones hepáticas graves, y uno de ellos precisó trasplante hepatointestinal. Ninguna de las complicaciones fue causa de muerte. Sólo en dos ocasiones fue preciso el recambio del catéter, en una por pérdida accidental y en otra por obstrucción del catéter. Cuatro niños continúan actualmente en el programa de NPD. Conclusiones: La NPD es una técnica segura con bajo índice de complicaciones, por lo que continúa siendo una alternativa válida al trasplante intestinal. Las complicaciones más frecuentes fueron las de causa infecciosa(AU)

When it is not possible to achieve an adequate nutritional status via the enteral route as a consequence of intestinal failure, the only way to maintain a satisfactory nutritional situation is through parenteral nutrition (PN). Nevertheless, its long term use may lead to serious complications. Objective: to determine the incidence rate of complications associated with home parenteral nutrition (HPN) during the period 1993-2005.Materials and methods: the retrospective analysis of the medical histories of the 22 patients (13 girls and 9 boys) who received HPN during that period. Results: the total duration of the programme was 4,324 days, with an average duration per patient of 196 days. In the case of 19 children the venous access was a tunnelled catheter and in the case of 3 children a subcutaneous reservoir. We found a total of 23 complications, with an average of 1.95 per patient and year. The rate of infectious complications was 3 for every 1,000 days of HPN (11 bacteraemias and 2 exit site infections). Mechanical complications accounted for 1.8 episodes for every 1,000 days. On 5 of the occasions when the catheter broke it was possible to repair it using the repair kit. There were no episodes of venous thrombosis. Only two patients developed severe hepatic complications, and one of those patients required an hepatointestinal transplantation. None of the complications resulted in death. Only on two occasions was a catheter exchange required, in one case as a result of accidental loss and in the other as a result of the occlusion of the catheter. Four children are currently still on the HPN programme. Conclusions: the HPN is a safe technique with a low complication rate and, therefore, continues to be a valid alternative to an intestinal transplantation. The most common complications were those caused by infections(AU)

Nutrición parenteral domiciliaria en pacientes con cáncer avanzado: experiencia en un solo centro a lo largo de diez años / Home parenteral nutrition in patients with advanced cancer: experience of a single centre over ten years

El uso de la nutrición parenteral domiciliaria (NPD) en pacientes con cáncer avanzado sin tratamiento curativo continúa siendo objeto de controversia y conlleva una considerable carga emocional. Sin embargo, este grupo de pacientes constituye la primera indicación de NPD en muchos programas. Objetivo: Presentar las características de una serie de pacientes incluidos en un programa de NPD en los últimos diez años. Método: Estudio retrospectivo de las historias clínicas de los once pacientes que recibieron NPD en este período. Se recogieron los datos demográficos, clínicos, complicaciones y evolución y se compararon con la del grupo de pacientes con enfermedad benigna que recibieron NPD en el mismo período. Para las comparaciones se utilizó la t de Student y el test de la Chi-cuadrado cuando estuvieron indicados. Se consideró significación estadística si p < 0,05. Resultados: Once pacientes recibieron NPD, nueve a causa de una obstrucción intestinal irresoluble y dos por una fístula de alto débito. La edad media del inicio de la NPD fue de 50,8 ± 12,7 años frente a los 37,3 ± 17,2 en el grupo con enfermedad benigna (p < 0,05). La duración media del NPD fue de 71,05 ± 217 días en el primer grupo, sensiblemente inferior al segundo (387,12 ± 995,85; p < 0,05), con un rango entre 5 y 760 días. Los pacientes recibieron la infusión a través de un reservorio subcutáneo ya previamente implantado (n: 9) y en dos ocasiones, de forma electiva, a través de un catéter tunelizado. La tasa de infección fue superior en el grupo con cáncer (0,34 episodios/paciente y 1.000 días de NPD) que en el grupo con enfermedad benigna (0,08 episodios; p < 0,05). Sólo en uno de los pacientes se suspendió la NPD antes de los 5 días previos al fallecimiento, por deterioro clínico. Dos pacientes precisaron ingreso por una complicación asociada a la técnica. En los dos casos se trató de una fungemia que obligó a la retirada del catéter. La calidad de vida medida mediante una escala de actividad fue similar al inicio de la NPD en ambos grupos. Ninguno de los pacientes que fueron incluidos en el programa continúa vivo. Conclusiones: la NPD ofrece al paciente con cáncer avanzado y grave disfunción intestinal la posibilidad de tratamiento en su domicilio, con un bajo índice de complicaciones. Si consideramos la corta duración media de la NPD, la inclusión en el programa ha de valorarse de forma individual y revisarse periódicamente (AU)

The use of Home Parenteral Nutrition (HPN) in patients with advanced cancer without the possibility of curative treatment continues to be a controversial subject entailing a considerable emotional burden. Sonetheless, this group of patients constitutes the main indication for HPN in many programmes. Goal: to present the characteristics of a series of patients included on an HPN programme over the last ten years. Method: Retrospective study of the case histories of the 11 patients who received HPN over this period. The demographic and clinical details were noted along with their complications and evolution for comparison with those of a control group of patients with benign disease receiving HPN over the same period. For the comparisons, Student´s t test and the chi-squared test were used as and when indicated. Results were considered statistically significant if p < 0.05. Results: Eleven patients received HPN, nine of them because of an irresoluble intestinal obstruction and two because of a high flow fistula. The mean age at the start of HPN was 50.8 ± 12.7 years versus 37.3 ± 17.2 years for the group with benign disease (p < 0.05). the mean duration of HPN was 71.05 ± 217 days in the first group, notably less than the second (387.15 ± 995.85; p < 0.05), with a range between 5 and 760 days. The patients received the infusion through a previously implanted subcutaneous reservoir (n = 9) and on two occasions, electively, through a tunnelled catheter. The infection rate was higher in the group with cancer (0.34 episodes per patient and 1,000 days on HPN) than in the group with benign disease (0.08 episodes; p < 0.05). HPN was suspended in only one of the patients more than 5 days prior to death due to clinical deterioration. Two patients required admission due to a complication associated with the technique. In both cases, a fungal infection of the blood made it necessary to withdraw the catheter. The quality of life, measured by means of an activity scale, was similar at the start of HPN in both groups. None of the patients included on the programme is still alive. Conclusions: HPN offers patients with advanced cancer and severe intestinal dysfunction the possibility of an at-home treatment with a low complication rate. If we take into account the short mean duration of HPN, inclusion on the programme must be assessed individually and regularly revised (AU)

[Therapeutic alternatives in intestinal failure]. / Alternativas terapéuticas en el fracaso intestinal.

BACKGROUND: Long-term parenteral nutrition is effective in the treatment of intestinal failure. Equally, the results of intestinal transplantation (IT) are promising. The choice of one or other form of treatment depends on the balance between the advantages and disadvantages of each. Based on these premises, we analyzed the outcome of home parenteral nutrition (HPN) for intestinal failure in our patients. METHODS: Intestinal failure was considered when parenteral nutrition was required for more than 5 months. In the 14 patients included in the HPN program since 1993, we reviewed the indication of HPN as well as their suitability for IT. RESULTS: Five of the 14 patients received HPN for causes other than intestinal failure. Of the remaining nine patients, four had severe motility disorder, three had short bowel syndrome, and two had protracted diarrhea of infancy. All these patients would be potential candidates for IT. Five patients were weaned off HPN because of intestinal adaptation between 2.5 and 13 months after starting HPN. One patient died because of lack of venous access. Three patients currently continue on HPN. CONCLUSION: Intestinal rehabilitation constitutes the best option for patients with intestinal failure. HPN offers the best interim treatment while waiting for adaptation. IT should be reserved for those patients with severe complications due to HPN. Nevertheless, it may become a real option for those with indefinite HPN. HPN and IT should be considered as complementary treatments.

Alternativas terapéuticas en el fracaso intestinal / Therapeutic alternatives in intestinal failure

Antecedentes: La nutrición parenteral prolongada es eficaz en el tratamiento del fracaso intestinal. Paralelamente asistimos al desarrollo de programas de trasplante intestinal con resultados esperanzadores. El reto de elegir una u otra forma de tratamiento dependerá del balance entre ventajas e inconvenientes de ambas posibilidades. Bajo estas premisas se analiza la evolución de nuestros pacientes con nutrición parenteral domiciliaria (NPD) por fracaso intestinal. Métodos: Consideramos fracaso intestinal cuando se precisó nutrición parenteral más de 5 meses. Se revisó la indicación, la evolución y la idoneidad como candidato a trasplante en los 14 niños incluidos en el programa de NPD desde 1993.Resultados: Cinco de los 14 pacientes recibieron NPD por causas distintas del fracaso intestinal. De los otros nueve, cuatro padecían una grave alteración de la motilidad; tres un síndrome de intestino corto y dos una diarrea intratable del lactante. Todos serían potenciales candidatos para trasplante intestinal. En cinco niños fue posible suspender la nutrición parenteral por conseguir adaptación intestinal entre 2 meses y medio y 13 meses desde el inicio de la NPD. Una paciente falleció por falta de accesos venosos. Tres pacientes continúan actualmente con NPD. Conclusión: La rehabilitación intestinal constituye la mejor opción para pacientes con fracaso intestinal. La NPD constituye el mejor tratamiento provisional en espera de la adaptación intestinal. El trasplante intestinal debería reservarse para aquellos pacientes que presenten complicaciones graves asociadas a la NPD. Sin embargo, podría considerarse como alternativa para quienes dependen indefinidamente de NPD. Ambas técnicas, NPD y trasplante deben considerarse tratamientos complementarios (AU)

¿Se debe limitar el esfuerzo terapéutico en nutrición artificial? / Should the therapeutic effort in artificial nutrition be limited?

Fundamento. Existe acuerdo general entre los expertos en Bioética en no mantener un tratamiento si éste es considerado fútil. Sin embargo, no existe unanimidad sobre si la sueroterapia, la nutrición enteral (NE) y la parenteral (NP) son medidas terapéuticas o forman parte del concepto de cuidado paliativo. Objetivo. Conocer la opinión de usuarios y trabajadores sanitarios del Sistema Nacional de Salud (SNS) en estas cuestiones. Diseño. Estudio descriptivo transversal. Ámbito. Atención Primaria y especializada. Métodos. Se distribuyó una encuesta a 219 individuos (84 usuarios del SNS, 135 trabajadores sanitarios), que incluía variables sociodemográficas, la opinión sobre diferentes aspectos de ética y soporte nutricional y qué medidas se consideran como cuidado paliativo. Resultados. La mayoría de los encuestados opinan que la NE (70,8 por ciento; IC 95 por ciento: 64,2-76,8) y NP (54,8 por ciento; IC 95 por ciento: 47,9-61,6) forman parte de los cuidados básicos, con diferencias entre el personal sanitario y los usuarios del SNS. El 50,2 por ciento considera que no existen diferencias entre instaurar o retirar soporte nutricional. El 71,3 por ciento de los profesionales sanitarios responden que esta decisión depende del médico y el 60,5 por ciento de los usuarios del SNS opinan que depende del propio enfermo y/o familiares. Todas las medidas interrogadas se consideran como cuidados básicos, independientemente de las características del encuestado. Conclusiones. La nutrición artificial se entiende como un cuidado básico, independientemente de la situación y calidad de vida del paciente. Mientras los profesionales sanitarios opinan que la decisión de iniciar/retirarlas depende del médico, los usuarios del SNS consideran que depende del enfermo/familia en caso de incapacidad de éste (AU)

[Should the therapeutic effort in artificial nutrition be limited?]. / Se debe limitar el esfuerzo terapéutico en nutrición artificial?

BASIS: There exists general agreement among the experts in Bioethics in order not to maintain a treatment if it is considered that it is useless. However, there is no unanimity about if serotherapy, enteral nutrition (EN), and parenteral nutrition (PN) are really therapeutic measures or else they are measures that they are part of the concept of palliative care. OBJECTIVE: Know the opinion of users and health workers of National Health System (NHS) in these issues. DESIGN: Cross-sectional descriptive study. AREA: Primary and specialized care. METHODS: A survey was distributed to 219 individuals (84 users of the NHS, 135 health workers), that it included sociodemographic parameters, the opinion on different aspects of ethics and nutritional support, and the measures regarded as palliative care. RESULTS: The majority of the respondents think that the EN (70.8%; 95% IC: 64.2-76.8) and PN (54.8%; 95% IC: 47.9-61.6) are part of the basic care, with differences between the health personnel and the users of the NHS. 50.2% considers that there are no differences between applying or removing nutritional support. 71.3% of the health professionals answer that this decision depends on the medical, 60.5% of the users of the NHS thinks that it depends on the patient himself and/or its family members. All the evaluated measures are regarded as basic care, regardless of the characteristics of the respondent. CONCLUSIONS: Artificial nutrition is understood as a basic care, regardless of the situation and quality of life of the patient. While the health professionals think that the decision to initiate/to retire artificial nutrition depends on the physician, the users of the NHS consider that it depends on the patient/family in case of disability of this.

[Corn starch in the treatment of patients with glycogenosis type I and III]. / Almidón de maíz crudo en el tratamiento de pacientes con glucogenosis tipo I y III.

RATIONALE: Administering raw corn starch can maintain normoglycemia for long periods after being ingested, thus facilitating control in patients with type I and III glycogenosis. METHODS: The metabolic effects and the effects on the nutritional status of a treatment with fractionated administrations of raw starch are assessed in two patients with type I glycogenosis (ages 18 and 12 years) and one patient with type III glycogenosis (aged 13 years). In the first two cases the response was previously studied after administering a load of raw corn starch in a water suspension, in an amount similar to the estimated rate of endogenous glucose production during the fasting period (5 mg/kg/minute). RESULTS: The results of the overload of starch showed a normoglycemia and an absence of lactoacidosis between 4 and 6 hours after its ingestion. The three patients were given two doses of raw corn starch (2 g/kg/dose) at 1.00 and 5.00 hours during the night. After one year of treatment, all patients showed glycemia levels at 9.00 AM that were greater than 90 mg/dl and lactic acid levels that were lower than 2.4 mmol/l. Moreover, in two of the cases there was an increase in the growth rate. In all cases the amount of the hepatomegaly decreased as did the size of the hepatic adenomas that were present in two of the cases. CONCLUSIONS: In patients with type I and III glycogenosis, raw corn starch can balance the results of the nightly gastric glucose infusion, both with regard to the metabolic control and with regard to the growth.

[Effect of total parenteral nutrition on bone metabolism]. / Efecto de la nutrición parenteral total en el metabolismo óseo.

Total parenteral nutrition (TPN) for a prolonged period of time can be associated with bone pain and osteomalacia. We performed a study on the phosphorus/calcium metabolism and serum levels of osteocalcin (BGP), a protein proposed as constituting the bone turnover index in 31 patients receiving TPN (age 57 +/- 14 years, 22 males and 9 females) diagnosed as suffering from pathology of the digestive tract or geno-urinary pathology. The duration of the TPN was from 9.1 +/- 6.6 days (range 2-31 days). We observed and increase of FA (178 +/- 101 U/l), with a significant decrease of BGP (2.2 +/- 2.0 ng/ml vs. 3.7 +/- 1.3 ng/ml in controls; p less than 0.001). Serum levels of phosphorus and calcium corrected according to proteins were within normal limits. Hypercalciuria was detected in the urine (328 +/- 278 mg/24 hours), and phosphaturia (607 +/- 522 mg/24 hours). Based on the BGP results, we can conclude that patients subjected to TPN for a short period of time undergo a decrease in bone turnover.