Foro de debate: seguridad de las alternativas a la transfusión alogénica en el paciente quirúrgico y/o crítico / Forum for debate: Safety of allogeneic blood transfusion alternatives in the surgical/critically ill patient

Estos últimos años han aparecido alertas de seguridad, no siempre bien sustentadas, que cuestionan el uso de algunas alternativas farmacológicas a la transfusión de sangre alogénica y/o lo restringen en indicaciones establecidas. Asistimos también a la preconización de otras alternativas, incluyendo productos hemáticos y fármacos antifibrinolíticos, sin que haya una base científica sólida que lo justifique. Por iniciativa del Grupo de Estudios Multidisciplinares sobre Autotransfusión y del Anemia Working Group España se reunió a un panel multidisciplinar de 23 expertos del área de cuidados de la salud en un foro de debate para: 1) analizar las diferentes alertas de seguridad en torno a ciertas alternativas a la transfusión; 2) estudiar los antecedentes que las han propiciado, la evidencia que las sustentan y las consecuencias que conllevan para la práctica clínica, y 3) emitir una valoración argumentada de la seguridad de cada alternativa a la transfusión cuestionada, según el uso clínico de la misma. Los integrantes del foro mantuvieron contactos por vía telemática y una reunión presencial en la que presentaron y discutieron las conclusiones sobre cada uno de los elementos examinados. Se elaboró un primer documento que fue sometido a 4 rondas de revisión y actualización hasta alcanzar un consenso, unánime en la mayoría de los casos. Presentamos la versión final del documento, aprobada por todos los miembros del panel, esperando sea de utilidad para nuestros colegas

In recent years, several safety alerts have questioned or restricted the use of some pharmacological alternatives to allogeneic blood transfusion in established indications. In contrast, there seems to be a promotion of other alternatives, based on blood products and/or antifibrinolytic drugs, which lack a solid scientific basis. The Multidisciplinary Autotransfusion Study Group and the Anemia Working Group España convened a multidisciplinary panel of 23 experts belonging to different healthcare areas in a forum for debate to: 1) analyze the different safety alerts referred to certain transfusion alternatives; 2) study the background leading to such alternatives, the evidence supporting them, and their consequences for everyday clinical practice, and 3) issue a weighted statement on the safety of each questioned transfusion alternative, according to its clinical use. The members of the forum maintained telematics contact for the exchange of information and the distribution of tasks, and a joint meeting was held where the conclusions on each of the items examined were presented and discussed. A first version of the document was drafted, and subjected to 4 rounds of review and updating until consensus was reached (unanimously in most cases). We present the final version of the document, approved by all panel members, and hope it will be useful for our colleagues

[Training model for integral treatment of patients with eating disorders resistant to change]. / Modelo de capacitación para el tratamiento integral de pacientes con trastornos de la conducta alimentaria resistentes al cambio.

The need to find effective treatments for patients with Anorexia or Bulimia nervosa has led to the professionals who care for them to develop new forms of treatment that take into account the variables that cause resistance to change. Patients in this study (2006-2009) have the following characteristics: 340 patients who have 7 or more years of evolution and/or have tried numerous previous treatments without having succeeded in starting and / or maintaining the desired changes, that allowed them to recover steadily. As the proposed treatment, the patient-treatment team is based on the principles of the training model. It considers the patient holistically, it informs and provides him with resources to increase its commitment to change. Teaches the patient to take care physically and mentally as a way to regain their health and leave the disorder in a stable way. Includes family members as essential support in the recovery of their closest. Therapists require extensive experience in the treatment of ED, flexibility, ability to integrate with other team members even if they use different theoretical models, skills for group sessions, ability to handle negative emotions and frustration tolerance. Finally, the model presented below has been implemented, recovered patients whose stay in the disorder exceeded 15 years of development and led to permanent occupational disability.

Modelo de capacitación para el tratamiento integral de pacientes con trastornos de la conducta alimentaria resistentes al cambio / Training model for integral treatment of patients with eating disorders resistant to change

La necesidad de buscar tratamientos eficaces para los pacientes con Anorexia o Bulimia nerviosa ha inducido a los profesionales que les atienden a elaborar nuevas formas de tratamiento que tengan en cuenta las variables causantes de su resistencia al cambio. Los pacientes del presente estudio (2006-2009) presentan las siguientes características: 340 pacientes que llevan 7 o más años de evolución y/ o han intentado numerosos tratamiento previos sin que se haya logrado iniciar y/o mantener los cambios deseados, que les hayan permitido recuperarse de forma estable. En cuanto al tratamiento propuesto, la relación paciente-equipo terapéutico se apoya en los principios del modelo de capacitación. Éste, considera al paciente de forma integral, le informa y le provee de recursos para que incremente su compromiso de cambio. Enseña al paciente a cuidarse física y psíquicamente como medio de recuperar su salud y salir del trastorno de forma estable. Incluye a los familiares como apoyo esencial en la recuperación de su allegado/a. Los terapeutas requieren amplia experiencia en el tratamiento de TCA, flexibilidad, capacidad para integrarse con otros compañeros aunque utilicen modelos teóricos diferentes, habilidades para realizar sesiones grupales, capacidad para manejar emociones negativas y tolerancia a la frustración. Finalmente, el modelo que a continuación se presenta se ha puesto en práctica, ha recuperado a pacientes cuya permanencia en el trastorno superaba 15 años de evolución y laboralmente tenían la invalidez permanente (AU)

The need to find effective treatments for patients with Anorexia or Bulimia nervosa has led to the professionals who care for them to develop new forms of treatment that take into account the variables that cause resistance to change. Patients in this study (2006-2009) have the following characteristics: 340 patients who have 7 or more years of evolution and/or have tried numerous previous treatments without having succeeded in starting and / or maintaining the desired changes, that allowed them to recover steadily. As the proposed treatment, the patient-treatment team is based on the principles of the training model. It considers the patient holistically, it informs and provides him with resources to increase its commitment to change. Teaches the patient to take care physically and mentally as a way to regain their health and leave the disorder in a stable way. Includes family members as essential support in the recovery of their closest. Therapists require extensive experience in the treatment of ED, flexibility, ability to integrate with other team members even if they use different theoretical models, skills for group sessions, ability to handle negative emotions and frustration tolerance. Finally, the model presented below has been implemented, recovered patients whose stay in the disorder exceeded 15 years of development and led to permanent occupational disability (AU)

Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus SEMICYUC-SENPE: Critically-ill burnt patient / Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Paciente quemado crítico

The response to severe burns is characterized by hypermetabolism (the most hypermetabolic existing model of aggression) and hypercatabolism, with a high degree of destruction of the skeletal musculature. Metabolic disorders are most evident in the first two weeks after the burn, although they can be prolonged in direct relation to the complications that these patients develop. Nutritional-metabolic support is an essential part of the treatment of these patients and should be started early, preferentially through the enteral route, with parenteral nutrition as complementary support. Exact calculation of calorie-protein requirements in these patients is difficult, even when indirect calorimetry is used, due to the high loss of proteins and CO2through the skin. Specific pharmaco nutrients are indicated, with a high dose of micronutrients. The use of drugs or medications with anabolic effects is also sometimes indicated (AU)

La respuesta que se objetiva tras una agresión térmica grave se caracteriza por hipermetabolismo (es el modelo de agresión más hipermetabólica que existe) e hipercatabolismo, con una elevada destrucción de la musculatura esquelética. Los trastornos metabólicos son más evidentes en las 2 primeras semanas tras la quemadura, aunque pueden prolongarse en relación directa con las complicaciones aparecidas. El soporte nutro metabólico forma parte indiscutible del tratamiento de estos pacientes y debe ser precoz, utilizando preferentemente la vía enteral y la nutrición parenteral complementaria. Es dificultoso el cálculo exacto de los requerimientos calórico proteicos, aun empleando calorimetría indirecta, debido a las elevadas pérdidas cutáneas de proteínas y Co2. Cabe destacar la indicación de farmaconutrientes específicos, de dosis elevadas de micronutrientes y, en algunas situaciones, del empleo de medicaciones o fármacos con efectos anabólicos (AU)

Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus SEMICYUC-SENPE: Multiple trauma patient / Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Paciente politraumatizado

Patients with polytrauma can be viewed as paradigmatic of the critically-ill patient. These previously healthy patients undergo a life-threatening aggression leading to an organic response that is no different from that in other types of patients. The profile of trauma patients has changed and currently corresponds to patients who are somewhat older, with a higher body mass index and greater comorbidity. Severe injuries lead to intense metabolic stress, posing a risk of malnutrition. Therefore, early nutritional support, preferentially through the enteral route, with appropriate protein intake and glutamine supplementation, provides advantages over other routes and types of nutritional formula. To avoid over nutrition, reduced daily calorie intake can be considered in obese patients and in those with medullary lesions. However, little information on this topic is available in patients with medullary lesions (AU)

El paciente traumatizado puede considerarse el paradigma del paciente crítico que, previamente sano, sufre una agresión que pone su vida en riesgo y que determina una respuesta orgánica en nada diferente a la presente en otro tipo de pacientes. El perfil del paciente traumático ha cambiado, siendo en la actualidad algo más mayores, con índices de masa corporal más elevados y con una mayor comorbilidad. Cuando la agresión es grave, su respuesta metabólica es intensa y condiciona un riesgo nutricional. por ello, el soporte nutricional precoz, de preferencia enteral, con aporte proporcionado de proteínas y suplementado con glutamina, condiciona ventajas competitivas con otras vías y tipos de fórmulas nutricionales. La presencia de obesidad y/o lesión medular debe hacernos considerar una disminución proporcionada dela porte calórico diario, evitando la sobre nutrición, aunque en los pacientes con lesión medular es escasa la información disponible (AU)

Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Paciente quemado crítico / Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): Critically- burned patient

La respuesta que se objetiva tras una agresión térmica grave se caracteriza por hipermetabolismo (es el modelo de agresión más hipermetabólica que existe) e hipercatabolismo, con una elevada destrucción de la musculatura esquelética. Los trastornos metabólicos son más evidentes en las 2 primeras semanas tras la quemadura, aunque pueden prolongarse en relación directa con las complicaciones aparecidas. El soporte nutrometabólico forma parte indiscutible del tratamiento de estos pacientes y debe ser precoz, utilizando preferentemente la vía enteral y la nutrición parenteral complementaria. Es dificultoso el cálculo exacto de los requerimientos caloricoproteicos, aun empleando calorimetría indirecta, debido a las elevadas pérdidas cutáneas de proteínas y CO2. Cabe destacar la indicación de farmaconutrientes específicos, de dosis elevadas de micronutrientes y, en algunas situaciones, del empleo de medicaciones o fármacos con efectos anabólicos (AU)

The response to severe burns is characterized by hypermetabolism (the most hypermetabolic existing model of aggression) and hypercatabolism, with a high degree of destruction of the skeletal musculature. Metabolic disorders are most evident in the first two weeks after the burn, although they can be prolonged in direct relation to the complications that these patients develop. Nutritional-metabolic support is an essential part of the treatment of these patients and should be started early, preferentially through the enteral route, with parenteral nutrition as complementary support. Exact calculation of calorie-protein requirements in these patients is dificult, even when indirect calorimetry is used, due to the high loss of proteins and CO2 through the skin. Specific pharmaconutrients are indicated, with a high dose of micronutrients. The use of drugs or medications with anabolic effects is also sometimes indicated (AU)

Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Paciente politraumatizado / Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): Patient with polytrauma

El paciente traumatizado puede considerarse el paradigma del paciente crítico que, previamente sano, sufre una agresión que pone su vida en riesgo y que determina una respuesta orgánica en nada diferente a la presente en otro tipo de pacientes. El peril del paciente traumático ha cambiado, siendo en la actualidad algo más mayores, con índices de masa corporal más elevados y con una mayor comorbilidad. Cuando la agresión es grave, su respuesta metabólica es intensa y condiciona un riesgo nutricional. Por ello, el soporte nutricional precoz, de preferencia enteral, con aporte proporcionado de proteínas y suplementado con glutamina, condiciona ventajas competitivas con otras vías y tipos de fórmulas nutricionales. La presencia de obesidad y/ o lesión medular debe hacernos considerar una disminución proporcionada del aporte calórico diario, evitando la sobrenutrición, aunque en los pacientes con lesión medular es escasa la información disponible (AU)

Patients with polytrauma can be viewed as paradigmatic of the critically-ill patient. These previously healthy patients undergo a life-threatening aggression leading to an organic response that is no different from that in other types of patients. The profile of trauma patients has changed and currently corresponds to patients who are somewhat older, with a higher body mass index and greater comorbidity. Severe injuries lead to intense metabolic stress, posing a risk of malnutrition. Therefore, early nutritional support, preferentially through the enteral route, with appropriate protein intake and glutamine supplementation, provides advantages over other routes and types of nutritional formula. To avoid over nutrition, reduced daily calorie intake can be considered in obese patients and in those with medullary lesions. However, little information on this topic is available in patients with medullary lesions (AU)

[Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): critically-burned patient]. / Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: paciente quemado crítico.

The response to severe burns is characterized by hypermetabolism (the most hypermetabolic existing model of aggression) and hypercatabolism, with a high degree of destruction of the skeletal musculature. Metabolic disorders are most evident in the first two weeks after the burn, although they can be prolonged in direct relation to the complications that these patients develop. Nutritional-metabolic support is an essential part of the treatment of these patients and should be started early, preferentially through the enteral route, with parenteral nutrition as complementary support. Exact calculation of calorie-protein requirements in these patients is difficult, even when indirect calorimetry is used, due to the high loss of proteins and CO(2) through the skin. Specific pharmaconutrients are indicated, with a high dose of micronutrients. The use of drugs or medications with anabolic effects is also sometimes indicated.

[Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): patient with polytrauma]. / Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: paciente politraumatizado.

Patients with polytrauma can be viewed as paradigmatic of the critically-ill patient. These previously healthy patients undergo a life-threatening aggression leading to an organic response that is no different from that in other types of patients. The profile of trauma patients has changed and currently corresponds to patients who are somewhat older, with a higher body mass index and greater comorbidity. Severe injuries lead to intense metabolic stress, posing a risk of malnutrition. Therefore, early nutritional support, preferentially through the enteral route, with appropriate protein intake and glutamine supplementation, provides advantages over other routes and types of nutritional formula. To avoid overnutrition, reduced daily calorie intake can be considered in obese patients and in those with medullary lesions. However, little information on this topic is available in patients with medullary lesions.

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

The response to severe burns is characterized by hypermetabolism (the most hypermetabolic existing model of aggression) and hypercatabolism, with a high degree of destruction of the skeletal musculature. Metabolic disorders are most evident in the first two weeks after the burn, although they can be prolonged in direct relation to the complications that these patients develop. Nutritional-metabolic support is an essential part of the treatment of these patients and should be started early, preferentially through the enteral route, with parenteral nutrition as complementary support. Exact calculation of calorie-protein requirements in these patients is difficult, even when indirect calorimetry is used, due to the high loss of proteins and CO2 through the skin. Specific pharmaconutrients are indicated, with a high dose of micronutrients. The use of drugs or medications with anabolic effects is also sometimes indicated.

Traumatismo craneoencefálico y manejo nutricional del pacienteneurológico en estado crítico / Head trauma and nutritional management of the neurological patient in a critical status

Los pacientes con traumatismo craneoencefálico (TCE) y los neurocríticos constituyen uno de los paradigmas en la agresión aguda grave pues aunque son agudos y graves son, afortunadamente, recuperables en una gran proporción de las ocasiones. La muy importante agresión que determina este tipo de patología es el detonante de una tormenta de mediadores inflamatorios, respuesta metabólica y alteración neuro-endocrina que condicionan una aceleración en el proceso de combustión del organismo lesionado. Esta combustión interna se nutre delas reservas orgánicas, determinando su consumo y con ello, disfunción de los diferentes órganos. En este capítulo se efectúa una revisión y puesta al día de los mecanismos fisiopatológicos que se producen en estas situaciones, de su repercusión metabólica y de las posibilidades que un soporte nutrometabólico -específico y dirigido- ofrece. Se dedica una especial atención a lahiperglucemia en el seno del trauma craneoencefálico y al aporte de farmaconutrientes (glutamina) en estas situaciones (AU)

Head trauma (HT) and critically ill neurological patients represent one of the paradigms in severe acute lesion since, although being acutely and severely ill, many of them may recover. The extremely severe aggression determining this type of pathology is the trigger of a thunderstorm of inflammatory mediators, metabolic response, and neuroendocrine impairment that condition a burst in the combustion process of the injured organism. This internal combustion is nurtured by the organic reserves leading to their consumption and, thus, the dysfunction of the different organ systems.In this chapter a review is performed with an update of the pathophysiologic mechanisms that occur in these situations,their metabolic impact, and the possibilities for a specific and targeted nutritional and metabolic support.Special attention is paid to hyperglycaemia in the setting of head trauma and the support with pharmaconutrients (glutamine) in these situations (AU)

¿Las mujeres y los niños primero? / Women and kids first?

El fin del Sistema Nacional de Salud (SNS), no consiste en distribuir a todo el mundo una dosis idéntica de servicio sanitario, sino en establecer un equilibrio entre los que están enfermos y los que están sanos en el curso de su vida, concentrando su intervención en aquellos que están peor. En un sistema sanitario avanzado son muy pocas las intervenciones sanitarias que pueden ser valoradas en "vidas salvadas", la mayor parte de las veces, éstas logran retrasar el final y, en ocasiones, se limitan a mejorar la calidad de los años de vida, sin alargarla. Se manifiesta, por tanto, la necesidad de encontrar unidades de medida adecuadas para valorar los beneficios y la utilidad de todos los procedimientos sanitarios. Al realizar un estudio coste/utilidad, y al valorarlos resultados obtenidos, hay que diferenciar entre la calidad de vida (personal), la utilidad (personal) y la utilidad del procedimiento o proceso al aplicarlo a nuestros enfermos. Esa utilidad se determina en calidad y cantidad de vida ganados, y se mide utilizando una única unidad: AVAC o QALY, pero en los pacientes que por su edad avanzada o enfermedad degenerativa tienen una calidad y/o esperanza de vida acortada el análisis coste/eficacia se verá condicionado, induciendo la distribución de los recursos a favor de los jóvenes. Para equilibrar esta situación, se propone el empleo de medidas correctoras como el EQALY. Consideramos que la edad ni la enfermedad son, por sí mismas, limitaciones para la aplicación de un recurso siempre que demostremos que éste resulta útil para el paciente (AU)

The goal of the National Health System (SNS in its Spanish acronym) does not consist in distributing to everyone an identical dose of health services but in establishing a balance between those who are ill and those who are healthy in the course of their lives, and concentrating its interventions on those who are worse. In an advanced health care system, there are very few actions by health personnel that can be assessed as “lives saved”: more often than not, these actions manage to delay the end and are occasionally limited to improving the quality of the years patients live, without extending their number. It is therefore clearly necessary to find appropriate units of measurement to assess the benefits and utility of all health-related procedures. When effecting a cost-effectiveness study and assessing the results obtained, it is necessary to differentiate between quality of life (personal), utility (personal) and the utility of the procedure or process when applied to our patients. This utility is determined by means of the additional quality and quantity of life, measured in a single unit, QALY, but this cost-effectiveness analysis would be constrained in patients with a shortened life expectancy and/or reduced quality of life due to old age or degenerative disease, thus skewing the distribution of resources in favour of younger population groups. In order to redress this situation, the use of corrective measurements such as EQALY is proposed. We believe that neither age nor illness in themselves limit the application of resources, providing that we can prove a useful result for the patient (AU)

[Structured lipids in nutritional support]. / Lípidos estructurados en el soporte nutricional.

Currently there are many studies in international medical literature which show the effectiveness and safety of the different lipid emulsions existing on the market, both in clinical and experimental studies. When referring to lipid emulsions, we mean those based exclusively on LCT and those which provide physical combinations of LCT/MCT oils, and especially the new presentations of chemical combinations known as structured lipid emulsions. These structured lipids generated in a random structuring of LCT and MCT inside the same trialcylglycerol molecule should be considered not only from the standpoint of their nutrient effects, but also from the standpoint of their particular properties and future pharmacological possibilities. These exceed the nutrient effect itself as well as the tolerance, since they open up a field towards the intake of fatty acids, amino acids or drugs in one single molecule of triglyceride. Structured lipids also have great possibilities in the field of enteral nutrition, and it has been shown that the structuring of more conventional lipids with omega-3 series lipids has a great future in immuno-nutrition.

[Micronutrients in severe septic aggression. Their usefulness as prognostic markers]. / Micronutrientes en la agresión séptica severa. Utilidad como marcadores pronósticos.

The object of this is to evaluate the influence of several micronutrients on the survival rate of septic patients following abdominal surgery. A retrospective assessment was done of sixty-one patients suffering from neoplastic or non-neoplastic pathology associated to septicemia. On admission the following parameters were determined: number of total lymphocytes, serum albumin, transferrin, zinc, copper, magnesium, iron, calcium, phosphorus, and copper/zinc levels. The differences obtained between surviving and non-surviving patients were analyzed. The most relevant findings revealed statistically significant lower serum albumin, zinc and transferrin values in the latter group. We conclude by stating that such parameters may be of prognostic value in this type of patients, and that supplemental micronutrients must be administered in order to improve prognosis.