Terapia medico nutricional en pacientes que reciben terapia de oxigenación por membrana extracorpórea: conocimiento en progreso / Medical nutrition therapy in patients receiving extracorporeal membrane oxygenation: knowledge in progress

Resumen El soporte nutricional (SN) en pacientes adultos que reciben terapia de oxigenación por membrana extracorpórea (ECMO, extracorporeal membrane oxygenation) es controvertido. Si bien existen guías para el SN en pacientes pediátricos con ECMO, en adultos no se cuenta con estos lineamientos para el uso, tipo, ruta y momento de la terapia nutricional. En pacientes críticamente enfermos es bien sabido que la nutrición enteral (NE) temprana es beneficiosa, no obstante existe la posibilidad de que en pacientes con ECMO la NE temprana condicione complicaciones gastrointestinales. Asimismo, no se han establecido metas calóricas, proteicas y dosis o tipos de micronutrimentos que usar para esta población en específico, siendo un reto para el clínico encargado de brindar el SN. Aunado a esto los pacientes con ECMO son algunos de los más gravemente enfermos en las unidades de cuidados intensivos, donde la desnutrición se asocia con una mayor morbilidad y mortalidad. En cuanto al uso de nutrición parenteral (NP), no se tiene descrito si implica riesgo de falla en el circuito al momento de introducir lípidos al oxigenador. Por lo anterior es imperativa una correcta evaluación e intervención nutricional específica, realizada por expertos en el tema para mejorar el pronóstico y la calidad de vida en esta población, siendo un objetivo primordial en los cuidados de los pacientes adultos que reciben terapia de ECMO.

Abstract Nutritional support in adult patients receiving extracorporeal membrane oxygenation (ECMO) therapy is controversial. Although there are guidelines for the NS (Nutritional support) in pediatric patients with ECMO, in adults these guidelines are not available for the use, type, route and timing of nutritional therapy. In critically ill patients it is well known that early enteral nutrition is beneficial, however there is the possibility that in patients with ECMO early enteral nutrition leads to gastrointestinal complications. Likewise, there have not been established caloric targets, proteins and doses or types of micronutrients to use for this specific population being a challenge for the clinician. In addition, patients with ECMO are some of the most seriously ill in intensive care units, where malnutrition is associated with increased morbidity and mortality. Regarding the use of parenteral nutrition (NP) it has not been described if it implies a risk of circuit failure at the time of introducing lipids to the oxygenator. Therefore, a correct evaluation and specific nutritional intervention by experts in the field is imperative to improve the prognosis and quality of life in this population, which is a primary goal in the care of adult patients receiving extracorporeal membrane oxygen.

Medical nutrition therapy in patients receiving extracorporeal membrane oxygenation: knowledge in progress.

Nutritional support in adult patients receiving extracorporeal membrane oxygenation (ECMO) therapy is controversial. Although there are guidelines for the NS (Nutritional support) in pediatric patients with ECMO, in adults these guidelines are not available for the use, type, route and timing of nutritional therapy. In critically ill patients it is well known that early enteral nutrition is beneficial, however there is the possibility that in patients with ECMO early enteral nutrition leads to gastrointestinal complications. Likewise, there have not been established caloric targets, proteins and doses or types of micronutrients to use for this specific population being a challenge for the clinician. In addition, patients with ECMO are some of the most seriously ill in intensive care units, where malnutrition is associated with increased morbidity and mortality. Regarding the use of parenteral nutrition (NP) it has not been described if it implies a risk of circuit failure at the time of introducing lipids to the oxygenator. Therefore, a correct evaluation and specific nutritional intervention by experts in the field is imperative to improve the prognosis and quality of life in this population, which is a primary goal in the care of adult patients receiving extracorporeal membrane oxygen.

El soporte nutricional (SN) en pacientes adultos que reciben terapia de oxigenación por membrana extracorpórea (ECMO, extracorporeal membrane oxygenation) es controvertido. Si bien existen guías para el SN en pacientes pediátricos con ECMO, en adultos no se cuenta con estos lineamientos para el uso, tipo, ruta y momento de la terapia nutricional. En pacientes críticamente enfermos es bien sabido que la nutrición enteral (NE) temprana es beneficiosa, no obstante existe la posibilidad de que en pacientes con ECMO la NE temprana condicione complicaciones gastrointestinales. Asimismo, no se han establecido metas calóricas, proteicas y dosis o tipos de micronutrimentos que usar para esta población en específico, siendo un reto para el clínico encargado de brindar el SN. Aunado a esto los pacientes con ECMO son algunos de los más gravemente enfermos en las unidades de cuidados intensivos, donde la desnutrición se asocia con una mayor morbilidad y mortalidad. En cuanto al uso de nutrición parenteral (NP), no se tiene descrito si implica riesgo de falla en el circuito al momento de introducir lípidos al oxigenador. Por lo anterior es imperativa una correcta evaluación e intervención nutricional específica, realizada por expertos en el tema para mejorar el pronóstico y la calidad de vida en esta población, siendo un objetivo primordial en los cuidados de los pacientes adultos que reciben terapia de ECMO.

Terapia médico-nutricional en pacientes politraumatizados: una carrera contra el tiempo.

A polytraumatized patient is defined as one who has multiple lesions involving different organs and systems, which are usually serious and lead to life-threatening respiratory or circulatory dysfunction. Traumatic stress in the polytraumatized patient results in many metabolic changes that are evident from the first days, but usually persist for weeks, requiring adequate nutritional support as they influence outcomes. Nutritional treatment should be a priority in the comprehensive treatment of polytraumatized patients since it attenuates the metabolic response to trauma and prevents the deterioration of body reserves. It should be noted that some patients present previous nutritional risk. Nutritional intervention should be considered at the same level as any other therapy that supports organic functions, especially in patients in the intensive care unit. Nutritional intervention in polytraumatized patients is a pillar of treatment that has multiple benefits and can improve prognosis. All efforts must be aimed at the early detection of malnourished patients at nutritional risk and providing timely therapies that improve clinical outcomes.

El paciente politraumatizado se define como aquel que tiene múltiples lesiones que involucran diferentes órganos y sistemas, suelen ser graves y conllevan una disfunción respiratoria o circulatoria que pone en riesgo la vida. El estrés traumático en el paciente politraumatizado da lugar a muchos cambios metabólicos que son evidentes desde los primeros días, pero suelen persistir durante semanas y exigen un adecuado soporte nutricional, ya que influyen en los desenlaces. El tratamiento nutricional debe ser una prioridad en el tratamiento integral de los pacientes politraumatizados, porque atenúa la respuesta metabólica al trauma y evita el deterioro de las reservas corporales (cabe mencionar que algunos pacientes presentan riesgo nutricional previo). La intervención nutricional debe considerarse al mismo nivel que cualquier otra terapia que apoye las funciones orgánicas, sobre todo en pacientes en la unidad de terapia intensiva. La intervención nutricional en pacientes politraumatizados es un pilar en el tratamiento que tiene múltiples beneficios y puede mejorar el pronóstico. Todo esfuerzo debe ir encaminado a la detección temprana de pacientes desnutridos o en riesgo nutricional, y proporcionar de manera oportuna terapias que mejores los desenlaces clínicos.

The Benefit of Perineural Injection Treatment with Dextrose for Treatment of Chondromalacia Patella in Participants Receiving Home Physical Therapy: A Pilot Randomized Clinical Trial.

Introduction: Chondromalacia patella is the degeneration of articular cartilage on the posterior facet of the patella and may indicate the onset of osteoarthritis. Conservative management is the main treatment option, and surgical intervention is considered the last option in a small percentage of patients. Perineural Injection Treatment (PIT) is a recently developed treatment option that is directed adjacent to the peripheral nerves that are the source of pathology causing neurogenic inflammation and pain. Objective: The objective of this study was to evaluate the efficacy of PIT combined with a home physical therapy program in patients with a diagnosis of chondromalacia patella compared with a control group receiving physical therapy only. Methods: Two patient groups were involved in this randomized clinical trial. The first received PIT combined with physical therapy (PIT + PT group) and the second was managed with physical therapy alone (PT group). Both groups were indicated to follow a 6-week home therapy plan afterward. The Western Ontario and McMaster Osteoarthritis Index was used to assess the patients at baseline and 6 months after therapy interventions. Results: Fifty patients (38 women and 12 men, median age 54.7 ± 14.8 years) were included; sex distribution and age did not differ between groups. Both groups had chondromalacia grade II or III, but the degree of gonarthrosis did not differ significantly between groups. The PIT + PT group outperformed PT group for pain (7.3 ± 3.5 vs. 3.2 ± 2.9 points; p < 0.010), stiffness (3 ± 1.69 vs. 1.6 ± 1.5 points; p < 0.010), and functional capacity (23.2 ± 10.7 vs. 11.1 ± 8.9 points; p < 0.010). Conclusions: Compared with physical therapy alone, PIT plus physical therapy reduced pain and stiffness and restored functional capacity. ClinicalTrials.gov Register Number #NCT03515720.

Medical Nutrition Therapy in Hospitalized Patients With SARS-CoV-2 (COVID-19) Infection in a Non-critical Care Setting: Knowledge in Progress.

PURPOSE OF REVIEW: As of 13 September 2020, almost 28 million confirmed cases of COVID-19 including more than 920,000 deaths have been reported to the World Health Organization. The SARS-CoV-2 pandemic represents a potential threat to patients and healthcare systems worldwide. Patients with the worst outcomes and higher mortality are reported to include older adults, polymorbid individuals, and malnourished people in general. The purpose of this review is to provide concise guidance for the nutritional management of individuals with COVID-19 based on the current literature and focused on those in the non-ICU setting or with an older age and polymorbidity, which are independently associated with malnutrition and its negative impact on mortality. RECENT FINDINGS: Prolonged hospital stays are reported to be required for individuals with COVID-19, and longer acute setting stays may directly worsen or cause malnutrition, with severe loss of skeletal muscle mass and function, which may lead to poor quality of life and additional morbidity. Nutritional therapy is among the mainstay of therapeutic principles and one of the core contents of comprehensive treatment measures. The current COVID-19 pandemic is unprecedented. The prevention, diagnosis, and treatment of malnutrition should therefore be routinely included in the management of individuals with COVID-19.

Platelet-rich plasma and its effect in bone regeneration in mandibular fractures. Controlled clinical trial / Plasma rico en plaquetas y su efecto en la regeneración ósea en fracturas mandibulares. Ensayo clínico controlado

Background: Currently there is great interest in developing clinical applications of platelet-rich plasma to enhance bone repair. Aim: To assess bone regeneration in mandibular fractures, with the application of this adjuvant. Methods: Twenty patients with mandibular fractures were included in a randomized clinical trial. Patients of the experimental group (n = 10) were submitted to internal fracture reduction and administration of platelet-rich plasma, and patients of the control group (n = 10) were submitted to the same surgical procedure without plasma application. Radiologic assessment was made before and at 1 and 3 months after surgery. X-rays were digitalized for analyze intensity and density as reflection of bone regeneration. Results: The average age was 32 ± 11.3 years and 31.2 ± 8.48 years respectively (p = 0.76). The radiographic intensity and density in the experimental group at the 1st and 3rd month were higher in contrast to the control group (p < 0.005). Bone regeneration time was 3.7 ± 0.48 and 4.5 ± 0.52 weeks respectively (p = 0.002). There was no morbidity related to the application of the platelet-rich plasma. Conclusion: The platelet-rich plasma increased the bone intensity and density in the fracture trace allowing bone regeneration and recovery in shorter time than patients in which it was not used.

Antecedentes: Actualmente existe interés en el desarrollo de aplicaciones clínicas del plasma rico en plaquetas (PRP) para mejorar la regeneración ósea (RO). Objetivo: Evaluar la RO en fracturas mandibulares con la aplicación de PRP. Métodos: Ensayo clínico controlado. Se incluyeron 20 pacientes con fractura de ángulo mandibular. El grupo de estudio (n = 10) se sometió a reducción de la fractura, fijación interna y aplicación de PRP, y el grupo control (n = 10) al mismo procedimiento sin administración de plasma. Se evaluaron en el preoperatorio y al primer y tercer mes posterior a la reducción mediante digitalización radiográfica para evaluar la regeneración ósea. Resultados: El promedio de edad fue de 32 ± 11.3 y 31.2 ± 8.48 años, respectivamente (p = 0.76). La intensidad y la densidad radiográfica al mes y a los 3 meses fueron superiores en el grupo de estudio que en el grupo control (p< 0.005). El tiempo de regeneración fue de 3.7 ± 0.48 y 4.5 ± 0.52 semanas, respectivamente (p = 0.002). Conclusiones: El PRP aumentó la intensidad y la densidad ósea en el trazo de las fracturas, sugestivas de RO, y recuperación en menor tiempo, en contraste con el grupo control.

Oral glutamine reduces myocardial damage after coronary revascularization under cardiopulmonary bypass. A randomized clinical trial.

BACKGROUND: Glutamine is the most abundant free amino acid in the body. It modulates immune cell function and is an important energy substrate for cells in critically ill patients. Reduction of injury cardiac markers had been observed in patients receiving intravenous glutamine and in a pilot study with oral glutamine. The aim of this study was to analyze the effect of preoperative oral supplementation of glutamine on postoperative serum levels of cardiac injury markers. METHODS: A randomized clinical trial was performed in 28 Mexican patients with ischemic heart disease who underwent cardiopulmonary bypass with extracorporeal circulation. Patients were randomly assigned to receive oral glutamine (0.5 g/kg/day) or maltodextrin 3 days before surgery. Cardiac injury markers as troponin-I, creatine phosphokinase, and creatine phosphokinase-Mb were measured at 1, 12, and 24 hours postoperatively. RESULTS: At 12 and 24 hours serum markers levels were significantly lower in the glutamine group compared with controls (p = 0.01 and p = 0.001, respectively) (p = 0.004 and p < 0.001, respectively). Overall, complications were significantly lower in the glutamine group (p = 0.01, RR = 0.54, 95% CI 0.31-0.93). Mortality was observed with 2 cases of multiple organ failure in control group and 1 case of pulmonary embolism in glutamine group (p = 0.50). CONCLUSION: Preoperative oral glutamine standardized at a dose of 0.5 g/kg/day in our study group showed a significant reduction in postoperative myocardial damage. Lower cardiac injury markers levels, morbidity and mortality were observed in patients receiving glutamine.

Oral glutamine reduces myocardial damage after coronary revascularization under cardiopulmonary bypass. A randomized clinical trial / La glutamina oral reduce el daño miocárdico tras revascularización coronaria bajo derivación cardiopulmonar. Un ensayo clínico aleatorizado

Background: Glutamine is the most abundant free amino acid in the body. It modulates immune cell function and is an important energy substrate for cells in critically ill patients. Reduction of injury cardiac markers had been observed in patients receiving intravenous glutamine and in a pilot study with oral glutamine. The aim of this study was to analyze the effect of preoperative oral supplementation of glutamine on postoperative serum levels of cardiac injury markers. Methods: A randomized clinical trial was performed in 28 Mexican patients with ischemic heart disease who underwent cardiopulmonary bypass with extracorporeal circulation. Patients were randomly assigned to receive oral glutamine (0.5 g/kg/day) or maltodextrin 3 days before surgery. Cardiac injury markers as troponin-I, creatine phosphokinase, and creatine phosphokinase-Mb were measured at 1, 12, and 24 hours postoperatively. Results: At 12 and 24 hours serum markers levels were significantly lower in the glutamine group compared with controls (p = 0.01 and p = 0.001, respectively) (p = 0.004 and p < 0.001, respectively). Overall, complications were significantly lower in the glutamine group (p = 0.01, RR = 0.54, 95% CI 0.31-0.93). Mortality was observed with 2 cases of multiple organ failure in control group and 1 case of pulmonary embolism in glutamine group (p = 0.50). Conclusion: Preoperative oral glutamine standardized at a dose of 0.5 g/kg/day in our study group showed a significant reduction in postoperative myocardial damage. Lower cardiac injury markers levels, morbidity and mortality were observed in patients receiving glutamine (AU)

Introducción: la glutamina es el aminoácido libre más abundante en el cuerpo. Modula funciones celulares inmunológicas y es un sustrato importante de energía. Se observó reducción de los marcadores de daño cardiaco en pacientes que recibieron tanto glutamina intravenosa como oral en un estudio piloto. Nuestro objetivo fue analizar el efecto preoperatorio con suplementación de glutamina oral sobre los niveles postoperatorios de los marcadores de lesión cardiaca. Métodos: ensayo clínico aleatorizado con 28 pacientes mexicanos con cardiopatía isquémica y sometidos a bypass cardiopulmonar con circulación extracorpórea. Los pacientes fueron asignados al azar para recibir glutamina oral (0,5 g/kg/día) o maltodextrina 3 días antes de ser operados. La troponina-I, creatinina fosfoquinasa y creatinina fosfoquinasa-Mb fueron medidas a la hora, 12 y 24 horas postoperatorias. Resultados: a las 12 y 24 horas los niveles séricos de marcadores fueron menores en el grupo de glutamina comparado con los controles (p = 0,01 y p = 0,001, respectivamente) (p = 0,004 y p < 0,001, respectivamente). Las complicaciones fueron menores en el grupo de glutamina (p = 0,01, RR = 0,54, 95% IC 0,31-0,93). La mortalidad ocurrió en 2 casos con dos falla orgánica múltiple en el grupo control y 1 caso de tromboembolia pulmonar en el grupo de glutamina (p = 0,50). Conclusión: la administración estandarizada de glutamina oral de manera preoperatoria (0,5 g/kg/día) en nuestro estudio demostró una reducción significativa del daño miocárdico postoperatorio. Los niveles séricos de marcadores cardiacos, la morbilidad y mortalidad fueron menores en los pacientes que recibieron glutamina (AU)

Antioxidant drugs to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis: What does evidence suggest?

AIM: To determine whether or not the use of antioxidant supplementation aids in the prevention of post- endoscopic retrograde cholangiopancreatography pancreatitis. METHODS: A systematic review of randomized controlled trials (RCTs) was made to evaluate the preventive effect of prophylactic antioxidant supplementation in post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). The inclusion criteria included: acute post-endoscopic retrograde cholangiopancreatography pancreatitis in adults; randomized clinical trials with the use of any antioxidant as an intervention compared with placebo, to reduce PEP. The outcome measure was the incidence and severity of PEP. Twelve RCTs involving 3110 patients since 1999 were included. The antioxidants used were selenite, ß-carotene, and pentoxifylline (each one in one trial), N-acetylcysteine (NAC) in three trials, and allopurinol in six trials. The group of patients treated with NAC received different doses; either oral or intravenous, and allopurinol-treated patients received five different oral doses in two different administration periods. The results are expressed with raw numbers, proportions, as well as mean and standard deviations. The incidence of pancreatitis between groups was analyzed with Pearson's χ(2) test or Fisher's exact test (F). The main outcome is expressed as relative risks and 95%CI. RESULTS: The incidence of pancreatitis in all antioxidant treatment groups was 8.6%, whereas it was 9.7% in the control group. The antioxidants used were selenite, ß-carotene, and pentoxifylline (each one in one trial), NAC in three trials, and allopurinol in six trials. In allopurinol trials, three different dosifications were used; two trials reported a low dosage (of less than 400 mg), two trials reported a moderate dose (600 mg) and the remaining two employed higher doses (more than 900 mg). Supplementation was not associated with a significant reduction in the incidence of PEP [relative risk (RR) = 0.93; 95%CI: 0.82-1.06; P = 0.28]. In addition, the incidences of PEP in patients treated with allopurinol and those treated with other antioxidants were similar to that observed in patients who received the placebo (RR for trials with allopurinol, 0.92; 95%CI: 0.78-1.08; P = 0.31) and, with the use of other antioxidants, the incidence of PEP was 8.9%, whereas it was 9.7% in the control group (RR = 0.95; 95%CI: 0.77-1.18; P = 0.19). CONCLUSION: Antioxidant supplementation shows no beneficial effect on the incidence of PEP. There is a lack of robust trials to support the use of antioxidants for prevention.

L-alanyl-L-glutamine-supplemented parenteral nutrition decreases infectious morbidity rate in patients with severe acute pancreatitis.

BACKGROUND: The effect of parenteral GLN on recovery from severe acute pancreatitis has not been thoroughly investigated. The aims of this study were to determine whether parenteral GLN improves nutrition status and immune function, and to determine its ability to reduce morbidity and mortality in patients with this condition. METHODS: In a randomized clinical trial, 44 patients with severe acute pancreatitis were randomly assigned to receive either standard PN (n = 22) or l-alanyl-l-glutamine-supplemented PN (n = 22) after hospital admission. Nitrogen balance, counts of leukocytes, total lymphocytes, and CD4 and CD8 subpopulations, and serum levels of immunoglobulin A, total protein, albumin, C-reactive protein, and serum interleukin (IL)-6 and IL-10 were measured on days 0, 5, and 10. Hospital stay, infectious morbidity, and mortality were also evaluated. RESULTS: Demographics, laboratory characteristics, and pancreatitis etiology and severity at entry to the study were similar between groups. The study group exhibited significant increases in serum IL-10 levels, total lymphocyte and lymphocyte subpopulation counts, and albumin serum levels. Nitrogen balance also improved to positive levels in the study group and remained negative in the control group. Infectious morbidity was more frequent in the control group than in the study group. The duration of hospital stay was similar between groups, as was mortality. CONCLUSION: The results suggest that treatment of patients with GLN-supplemented PN may decrease infectious morbidity rate compared with those who treated with nonenriched PN.

L-alanyl-L-glutamine-supplemented parenteral nutrition improves infectious morbidity in secondary peritonitis.

BACKGROUND & AIMS: A growing number of randomized clinical trials suggest that glutamine (Gln) supplementation may be beneficial in a selected group of patients and conditions. However, the effects of Gln-enriched total parenteral nutrition (TPN) on recovery from acute intra-abdominal infection have not been thoroughly investigated. Therefore, the aim of this study was to investigate whether the provision of Gln-enriched TPN after surgical and medical treatment of secondary peritonitis improves infectious morbidity. METHODS: Thirty-three patients with secondary peritonitis were randomly assigned to receive either standard (n=16) TPN or L-alanyl-L-glutamine-supplemented (n=17) TPN, after medical and surgical treatment of the infectious focus. The two TPN formulae were isonitrogenous and isocaloric, which commenced the morning after surgery and ran continuously for 10 consecutive days. The control group received standard TPN, while the treatment group was given L-alanyl-L-glutamine, 0.40 g/kg/d (Dipeptiven, Fresenius Kabi, Bad Homburg, Germany). Infectious morbidity, nitrogen balance, leukocytes, lymphocytes, subpopulations CD(4) and CD(8), Immunoglobulin A (IgA), total proteins, albumin, hospital and intensive care unit (ICU) stays, and mortality were evaluated. Statistical analysis included one-way ANOVA, the unpaired Student's t-test, the Mann-Whitney U-test, chi(2) test, or Fisher's exact test. RESULTS: Patients in both groups were comparable prior to the operation. Nitrogen balance and the levels of albumin and IgA were significantly better than those in the control group. Also, a significant reduction in the infectious morbidity was found in the Gln-treated group. Lymphocyte counts as well as subpopulations CD(4) and CD(8), and proteins showed a propensity to improvement and a tendency to reduced rates of mortality were observed when comparing the groups. Hospital and ICU stays were similar. CONCLUSION: L-alanyl-L-glutamine-supplemented TPN improved the infectious morbidity of patients with secondary peritonitis. Gln supplementation to parenteral nutrition may be an alternative for enhancing host defenses and improving infectious morbidity.