Creatine supplementation attenuates pulmonary and systemic effects of lung ischemia and reperfusion injury.

BACKGROUND: Creatine (Cr) is a dietary supplement that presents beneficial effects in experimental models of heart and brain ischemia and reperfusion (I/R) injury. It can improve adenosine 5'-triphosphate generation and reduce cell damage. This study evaluated the effects of Cr supplementation in a model of lung I/R. METHODS: Forty male Wistar rats were divided into 4 groups: sham operated, Cr+sham, I/R, and Cr+I/R. We investigated the effects of 5 days of Cr supplementation (0.5 g/kg/day by gavage) before left pulmonary artery ischemia (90 minutes) and reperfusion (120 minutes) on pulmonary and systemic response. RESULTS: Cr inhibited the I/R-induced increase in exhaled nitric oxide (p < 0.05), total cells (p < 0.01), and neutrophils (p < 0.001) in bronchoalveolar lavage fluid and in the systemic circulation (p < 0.001). The levels of interleukin-1ß (p < 0.05), tissue damping, and tissue elastance (p < 0.05) were also minimized. Cr also inhibited pulmonary edema formation (total proteins in bronchoalveolar lavage fluid, p < 0.001; histologic edema index, p < 0.001) and neutrophils accumulation in lung tissue (p < 0.001). As possible mechanisms underlying Cr effects, we observed a reduced expression of caspase 3 (p < 0.05), reduced expression of Toll-like receptor (TLR) 4, and increased expression of TLR7 in lung tissue (p < 0.001). CONCLUSIONS: Cr supplementation presents pulmonary and systemic protective effects in acute lung injury induced by I/R in rats. These beneficial effects seem to be related to the anti-inflammatory and anti-oxidant properties of Cr and modulation of TLRs.

Nutrition therapy in sepsis: characterization and implications for clinical prognosis / La terapia nutricional en la sepsis: Caracterizacion e implicaciones para el pronostico clinico

Introduction: the inflammatory response caused by sepsis leads to metabolic changes, which may result in significant lean mass loss in septic patient. Because of this, when digestive tract is functional, nutritional therapy (NT) must be initiated within 48 hours of intensive treatment to reduce protein loss. Objective: to evaluate enteral nutritional therapy (ENT) in adult septic patients with exclusive ENT for ≥ 72 hours and length of stay ≥7 days in Intensive Care Unit and its relationship with clinical prognosis. Methods: we prospectively analyzed the adequacy of enteral nutrition administered, factors associated with non-conformity, gastrointestinal tolerance and outcome. Statistical tests of chi-square and Student’s t as well as Mann-Whitney and Spearman and Pearson correlations (p < 0.05) were used. A multiple logistic regression model has been done by using the stepwise method to evaluate the association between predictors of clinical outcome. Results: 53 patients, 67.9% male and 52.8% elderly were enrolled in this study. The average time for starting ENT was 30 (23.5) hours, and 88.7% of patients achieved nutritional goal in 48 hours. The mean volume delivered in relation to prescribed was 78.9%. When the sample was stratified according to administered/ prescribed calories, patients who received < 80% had a higher mortality rate (p = 0.001) and the caloric intake ≥ 80% was the determining factor in patients’ clinical prognosis (p = 0.021). Conclusion: septic patients received early enteral nutrition. The nutritional goal and the mean volume delivered in relation to the prescribed volume meet the intensive care guidelines. The nutritional support was associated with clinical outcome, and caloric intake ≥ 80% determining the clinical prognosis. The pauses caused by reflux were significant in the group of patients who died and it may be related to disease severity (AU)

Introducción: la respuesta inflamatoria causada por sepsis provoca cambios metabolicos que pueden provocar una perdida de masa magra significativa en pacientes septicos. Debido a ello, cuando el tracto digestivo es funcional la terapia nutricional (NT) debe iniciarse dentro de las 48 horas de tratamiento intensivo para reducir la perdida de proteina. Objetivo: evaluar la terapia nutricional enteral (TNE) en pacientes septicos adultos con TNE exclusivo para ≥ 72 horas y duracion de ≥ 7 dias de estancia en la Unidad de Cuidados Intensivos y su relacion con el pronostico clinico. Métodos: se analizaron prospectivamente la adecuacion de la nutricion enteral administrada, los factores asociados con la falta de conformidad, la tolerancia gastrointestinal y el resultado. Se utilizaron pruebas estadisticas de chi-cuadrado y la t de Student, asi como las correlaciones de Mann-Whitney y Spearman y Pearson (p < 0,05). Se ha realizado un modelo de regresion logistica multiple mediante el metodo paso a paso para evaluar la asociacion entre factores de prediccion de la evolucion clinica. Resultados: 53 pacientes, 67,9% hombres y 52,8% ancianos se inscribieron en este estudio. El tiempo promedio para el inicio de ENT fue de 30 (23,5) horas, y el 88,7% de los pacientes alcanzaron el objetivo nutricional en 48 horas. El volumen medio entregado en relacion con el prescrito fue 78,9%. Cuando la muestra se estratifico segun calorias prescritas/administradas, los pacientes que recibieron < 80% tenian una tasa de mortalidad mas alta (p = 0,001) y el consumo de calorias ≥ 80% fue el factor determinante en el pronostico clinico de los pacientes (p = 0,021). Conclusión: los pacientes septicos recibieron nutricion enteral precoz. El objetivo nutricional y el volumen medio entregado en relacion con el volumen prescrito cumplen las directrices de cuidados intensivos. El soporte nutricional se asocio con el resultado clinico y la ingesta calorica ≥ 80% para determinar el pronostico clinico. Las pausas causadas por el reflujo fueron significativas en el grupo de pacientes que murieron y que pueden estar relacionadas con la gravedad de la enfermedad (AU)

NUTRITION THERAPY IN SEPSIS: CHARACTERIZATION AND IMPLICATIONS FOR CLINICAL PROGNOSIS.

INTRODUCTION: the inflammatory response caused by sepsis leads to metabolic changes, which may result in significant lean mass loss in septic patient. Because of this, when digestive tract is functional, nutritional therapy (NT) must be initiated within 48 hours of intensive treatment to reduce protein loss. OBJECTIVE: to evaluate enteral nutritional therapy (ENT) in adult septic patients with exclusive ENT for ≥ 72 hours and length of stay ≥7 days in Intensive Care Unit and its relationship with clinical prognosis. METHODS: we prospectively analyzed the adequacy of enteral nutrition administered, factors associated with non-conformity, gastrointestinal tolerance and outcome. Statistical tests of chi-square and Student's t as well as Mann-Whitney and Spearman and Pearson correlations (p < 0.05) were used. A multiple logistic regression model has been done by using the stepwise method to evaluate the association between predictors of clinical outcome. RESULTS: 53 patients, 67.9% male and 52.8% elderly were enrolled in this study. The average time for starting ENT was 30 (23.5) hours, and 88.7% of patients achieved nutritional goal in 48 hours. The mean volume delivered in relation to prescribed was 78.9%. When the sample was stratified according to administered/ prescribed calories, patients who received < 80% had a higher mortality rate (p = 0.001) and the caloric intake ≥ 80% was the determining factor in patients' clinical prognosis (p = 0.021). CONCLUSION: septic patients received early enteral nutrition. The nutritional goal and the mean volume delivered in relation to the prescribed volume meet the intensive care guidelines. The nutritional support was associated with clinical outcome, and caloric intake ≥ 80% determining the clinical prognosis. The pauses caused by reflux were significant in the group of patients who died and it may be related to disease severity.

Introducción: la respuesta inflamatoria causada por sepsis provoca cambios metabolicos que pueden provocar una perdida de masa magra significativa en pacientes septicos. Debido a ello, cuando el tracto digestivo es funcional la terapia nutricional (NT) debe iniciarse dentro de las 48 horas de tratamiento intensivo para reducir la perdida de proteina. Objetivo: evaluar la terapia nutricional enteral (TNE) en pacientes septicos adultos con TNE exclusivo para ≥ 72 horas y duracion de ≥ 7 dias de estancia en la Unidad de Cuidados Intensivos y su relacion con el pronostico clinico. Métodos: se analizaron prospectivamente la adecuacion de la nutricion enteral administrada, los factores asociados con la falta de conformidad, la tolerancia gastrointestinal y el resultado. Se utilizaron pruebas estadisticas de chi-cuadrado y la t de Student, asi como las correlaciones de Mann-Whitney y Spearman y Pearson (p < 0,05). Se ha realizado un modelo de regresion logistica multiple mediante el metodo paso a paso para evaluar la asociacion entre factores de prediccion de la evolucion clinica. Resultados: 53 pacientes, 67,9% hombres y 52,8% ancianos se inscribieron en este estudio. El tiempo promedio para el inicio de ENT fue de 30 (23,5) horas, y el 88,7% de los pacientes alcanzaron el objetivo nutricional en 48 horas. El volumen medio entregado en relacion con el prescrito fue 78,9%. Cuando la muestra se estratifico segun calorias prescritas/administradas, los pacientes que recibieron < 80% tenian una tasa de mortalidad mas alta (p = 0,001) y el consumo de calorias ≥ 80% fue el factor determinante en el pronostico clinico de los pacientes (p = 0,021). Conclusión: los pacientes septicos recibieron nutricion enteral precoz. El objetivo nutricional y el volumen medio entregado en relacion con el volumen prescrito cumplen las directrices de cuidados intensivos. El soporte nutricional se asocio con el resultado clinico y la ingesta calorica ≥ 80% para determinar el pronostico clinico. Las pausas causadas por el reflujo fueron significativas en el grupo de pacientes que murieron y que pueden estar relacionadas con la gravedad de la enfermedad.

Adequação dos balanços energético e proteico na nutrição por via enteral em terapia intensiva: quais são os fatores limitantes? / Adequacy of energy and protein balance of enteral nutrition in intensive care: what are the limiting factors?

Objetivo: Determinar os fatores que influenciam na adequação da terapia nutricional enteral em uma unidade de terapia intensiva. Métodos: Estudo prospectivo e observacional realizado em uma unidade de terapia intensiva entre 2010 e 2012. Foram incluídos pacientes >18 anos em terapia nutricional enteral exclusiva por ≥72 horas. As necessidades de energia e proteínas foram calculadas segundo protocolo da unidade. Foram coletados diariamente dados relacionados à nutrição enteral, causas de não conformidade e exames bioquímicos. Resultados: Dentre os pacientes internados na unidade, 93 foram avaliados, 82% iniciaram a terapia nutricional enteral precocemente e 80% atingiram a meta nutricional em <36 horas. Foram administrados 81,6% (±15,4) de volume de terapia nutricional enteral, com adequação de 82,2% (±16,0) de calorias, 82,2% (±15,9) de proteínas e balanço energético médio de -289,9 kcal/dia (±277,1). Houve correlação negativa da proteína C-reativa com o volume administrado e os balanços energético e proteico, e correlação positiva com o tempo para atingir a meta nutricional. A pausa para extubação foi a principal causa de interrupções (29,9% das horas de pausa) e os pacientes >60 anos apresentaram menor porcentagem de recuperação da via oral em relação aos mais jovens (p=0,014). Conclusão: O início precoce da terapia nutricional enteral, e a adequação do volume administrado, de energia e de proteínas estiveram de acordo com as diretrizes. A inadequação dos balanços energético e proteico parece estar associada à resposta inflamatória aguda (proteína C-reativa elevada). A principal causa de interrupção da oferta da terapia nutricional foi a pausa para extubação. .

Objective: To determine the factors that influence the adequacy of enteral nutritional therapy in an intensive care unit. Methods: This prospective observational study was conducted in an intensive care unit between 2010 and 2012. Patients >18 years of age underwent exclusive enteral nutritional therapy for ≥72 hours. The energy and protein requirements were calculated according to the ICU protocols. The data regarding enteral nutrition, the causes of non-compliance, and the biochemical test results were collected daily. Results: Ninety-three patients admitted to the intensive care unit were evaluated. Among these patients, 82% underwent early enteral nutritional therapy, and 80% reached the nutritional goal in <36 hours. In addition, 81.6%±15.4% of the enteral nutrition volume was infused, with an adequacy of 82.2%±16.0% for calories, 82.2%±15.9% for proteins, and a mean energy balance of -289.9±277.1kcal/day. A negative correlation of C-reactive protein with the volume infused and the energy and protein balance was observed. In contrast, a positive correlation was found between C-reactive protein and the time required to reach nutritional goals. Extubation was the main cause for interrupting the enteral nutritional therapy (29.9% of the interruption hours), and the patients >60 years of age exhibited a lower percentage of recovery of the oral route compared with the younger patients (p=0.014). Conclusion: Early enteral nutritional therapy and the adequacy for both energy and protein of the nutritional volume infused were in accordance with the established guidelines. Possible inadequacies of energy and protein balance appeared to be associated with an acute inflammatory response, which was characterized by elevated C-reactive protein levels. The main cause of interruption of the enteral nutritional therapy was the time spent in extubation. .

Terapia Nutricional Enteral em UTI: seguimento longitudinal / Enteral Nutrition Therapy in ICU: longitudinal follow-up

Monitoring the adequacy of enteral nutrition therapy is an indispensable strategy to improve the quality of nutritional assistance. The study presents the results of enteral nutrition therapy monitoring in an Intensive Care Unit between 2005 and 2009. Adult patients with exclusive enteral nutrition therapy for at least 72 h were included. The adequacy percentage for values of energy and protein calculated, prescribed and administered were analyzed, as well as the causes for feeding interruptions. The quality indicators proposed by the International Life Sciences Institute Brazil were applied. Confidence intervals and t Student and Mann-Whitney tests were used in the statistical analysis. We followed up 147 patients. The improvement in the nutritional assistance was demonstrated by a statistically significant increase in the administered/prescribed ratio from 74% in 2005 to 87% in 2009. Internal factors were the causes of most feeding interruptions; however, since 2006 problems related to the tube and pauses for routine procedures have been reduced. Among the external causes, tracheotomy is the one which most contributes. The quality indicators also reflect the evolution of the nutritional assistance. The results highlight the importance of continuously monitoring the adequacy of enteral nutrition therapy in order to identify aspects that need to be improved and develop strategies to correct inadequacies, leading to an optimized enteral feeding. The Multidisciplinary Team and continued education activities are fundamental to guarantee that practices resulting in achievement of the goals in patients receiving enteral nutrition are implemented and maintained over time.

La monitorización de la Terapia Nutricional Enteral (TNE) es fundamental para la calidad en la asistencia nutricional. Este estudio presenta el acompañamiento de la oferta nutricional en una Unidad de Terapia Intensiva entre 2005 y 2009. Fueron incluidos adultos que recibieron TNE exclusiva por un mínimo de 72 horas. Se analizó el porcentaje de adecuación entre valores de energía y proteínas calculados, prescritos y administrados y los motivos de la interrupción de la TNE. Fueron aplicados indicadores de calidad propuestos por el International Life Sciences Institute Brasil. Para análisis estadística se utilizó el intervalo deconfianza y los test t de Student y U de Mann-Whitney. Fueron evaluados 147 pacientes. Se observó mejoría en la asistencia nutricional, con aumento significativo de la razón administrado/ prescrito de 74% en 2005 para 87% en 2009. Predominaron motivos de interrupción internosa la unidad, pero desde de 2006 se redujeron los problemas con la sonda y las pausas de rutina. Dentro de las causas externas, la traqueotomía fue la que más contribuyó para inadecuación en la administración de la TNE. Los indicadores de calidad también reflejan la evolución de la asistencia nutricional. Los resultados enfatizan la importancia de la monitorización rutinera de la TNE, que posibilita la identificación de puntos a ser mejorados y el desarrollo de estrategias para corregir las inadecuaciones, resultando en mejoría de la oferta nutricional. La participación del Equipo Multiprofesional de Terapia Nutricional y actividades de Educación continuada son fundamentales para que prácticas que permiten alcanzar metas en pacientes recibiendo TNE sean implementadas y mantenidas a lo largo del tiempo.

A monitorização da Terapia Nutricional Enteral (TNE) é fundamental para a qualidade na assistência nutricional. Este estudo apresenta o acompanhamento da oferta nutricional em uma Unidade de Terapia Intensiva entre 2005 e 2009. Foram incluídos adultos que receberam TNE exclusiva por no mínimo 72 horas. Analisou-se a porcentagem de adequação entre valores de energia e proteínas calculados, prescritos e administrados e os motivos de interrupção da TNE. Foram aplicados indicadores de qualidade propostos pelo International Life Sciences Institute Brasil. Para análise estatística utilizou-se o intervalo de confiança e os testes t de Student e U de Mann-Whitney. Foram avaliados 147 pacientes. Observou-se melhora na assistência nutricional, com aumento significativo da razão administrado/prescrito de 74% em 2005 para 87% em 2009. Predominaram motivos de interrupção internos à unidade, mas desde 2006 conseguiu-se reduzir os problemas com a sonda e as pausas de rotina. Dentre as causas externas, a traqueostomia é a que mais contribui para inadequação na administração da TNE. Os indicadores de qualidade também refletem a evolução da assistência nutricional. Os resultados enfatizam a importância da monitorização rotineira da TNE, que possibilita a identificação de pontos a serem melhorados e o desenvolvimento de estratégias para corrigir as inadequações, resultando em melhora da oferta nutricional. A atuação da Equipe Multiprofissional de Terapia Nutricional e atividades de educação continuada sãofundamentais para que práticas que permitam alcançar metas em pacientes recebendo TNE sejam implementadas e mantidas ao longo do tempo.

Terapia nutricional enteral: aplicação de indicadores de qualidade / Enteral nutritional therapy: application of quality indicators

OBJETIVOS: Monitorar a adequação da terapia nutricional enteral na unidade de terapia intensiva visando à melhoria da qualidade da assistência nutricional. MÉTODOS: Estudo prospectivo e observacional desenvolvido na unidade de terapia intensiva adulto entre 2005 e 2008. Participaram da amostra pacientes maiores de 18 anos com terapia nutricional enteral exclusiva por mais de 72h. Analisou-se os valores médios e a adequação percentual de energia e proteínas calculados, prescritos e administrados em cada ano. Os fatores responsáveis pela não conformidade na administração planejada foram classificados em causas externas ou internas à unidade de terapia intensiva. Foram aplicados os indicadores de qualidade propostos pelo International Life Sciences Institute (ILSI) Brasil, sendo expressos em metas percentuais. Nas análises estatísticas utilizou-se o intervalo de confiança e os testes t Student e Mann-Whitney (p<0,05), segundo o programa Epi Info. RESULTADOS: Foram acompanhados 116 pacientes. Os valores médios de energia e proteínas administrados em 2005 e em 2006 apresentaram diferenças estatísticas quando comparados a 2008. A adequação calculado/prescrito permaneceu próxima a 100 por cento em todos os levantamentos e a adequação administrado/prescrito aumentou de 74 por cento em 2005, para 89 por cento em 2008. Constatou-se o aumento nas interrupções da terapia nutricional enteral por fatores externos e a diminuição das interrupções por fatores internos à unidade. Os indicadores de qualidade igualmente refletem a evolução da assistência prestada. CONCLUSÃO: Nos quatro levantamentos anuais verificou-se a melhora progressiva da oferta nutricional. Os indicadores de qualidade são uma nova perspectiva na avaliação da terapia nutricional enteral, permitindo monitorar a evolução da qualidade da assistência nutricional e a comparação com dados de outros serviços.

OBJECTIVE: Monitor the adequacy of enteral nutritional therapy at the intensive care unit aiming to improve the quality of nutritional assistance. METHODS: Prospective and observational study developed at the adult intensive care unit from 2005 to 2008. Patients over 18 years of age with exclusive enteral nutritional therapy for over 72h participated in the sample. The average values and the percentile adequacy of energy and proteins calculated, prescribed and administered in each year were analyzed. The factors responsible for the non-conformity of the administration planned were classified into intensive care unit extrinsic or intrinsic causes. The quality indicators proposed by the ILSI Brazil were applied, and expressed into percentile goals. In the statistic analyses, confidence interval and the t Student e Mann-Whitney (p<0.05) tests were used, according to the Epi Info program. RESULTS: One hundred and sixteen patients were followed up. There were statically difference in values of energy and protein administered in 2005 and in 2006, when compared to those in 2008. The adequacy calculated/prescribed remained close to 100 percent in all the surveys and the adequacy administered/prescribed increased from 74 percent in 2005, to 89 percent in 2008. An increase in interruptions of enteral nutritional therapy for external factors and the decrease in interruptions for intensive care unit internal factors were verified. The quality indicators equally reflect the evolution of the patient care. CONCLUSION: In the four yearly surveys, a progressive enhancement of nutritional support was verified. Quality indicators allow nutritional care evolution monitoring, the comparison to other services data, and are a new perspective for enteral nutritional therapy assessment.

Terapia nutricional parenteral em UTI: aplicação dos indicadores de qualidade / Nutrición parenteral en UTI: utilización de índices de calidad / Parenteral nutritional therapy in UTI: application of quality indexes

O objetivo desta pesquisa foi avaliar a Terapia Nutricional Parenteral (TNP) de pacientes internados na Unidade de Terapia Intensiva (UTI) adultos, com aplicação de indicadores de qualidade. Optou-se por um estudo retrospectivo aprovado pelo Comitê de Ética em Pesquisa do HU-USP. Foram levantados dados das fichas de acompanhamento nutricional, sendo aplicados os indicadores de qualidade de acordo com a proposta da Força Tarefa em Nutrição Clínica (ILSI, 2008). Os dados foram descritos por distribuição de freqüência simples, média e desvio padrão e processados no programa Excel. A amostra estudada (N=25) foi composta de 64% de pacientes do gênero masculino, com idade média de 64,4 anos, sendo 96% de pacientes cirúrgicos e 4% clínicos. O tempo médio de permanência na UTI foi de 21,8 dias (mais ou menos 9,8), com permanência média em TNP de 16,6 dias (mais ou menos 13,11). A estimativa média das necessidades nutricionais foi de 24,41kcal/kg (mais ou menos 2,87) para energia e 0,96 g/kg (mais ou menos 0,14) para proteínas. A adequação da fórmula parenteral considerando a relação administrado/prescrito foi de 96,87% para energia e 97,01% para proteínas. A frequência de administração nutrição parenteral com aporte inadequado foi 11% para calorias e 11% para proteínas, sendo as metas propostas: <11% e <20% respectivamente. Com relação a análise dos exames bioquímicos, 74% dos pacientes apresentavam todos os exames antes do início da TNP. Do total de pacientes, 44% evoluíram para a via oral (meta maior que 30%). Concluiu-se que a aplicação dos indicadores de qualidade permitiu a avaliação da TNP com a perspectiva de elaboração de estratégias para melhor adequação da TNP na prática clínica.

El objetivo de esta investigación fue evaluar la nutrición parenteral (NP) de pacientes internados en Unidades de Cuidados Intensivos adultas (UCI) con el uso de índices de calidad. Se trata de un estudio retrospectivo aprobado por el Comité de Ética en la Investigación de HUUSP. Recogimos datos sobre registros de cuidados alimenticios y aplicamos índices de calidad según propuesta de ILSI (2008). Los datos fueron descritos por frecuencia simple y media de distribución y d desviación estándar procesadas por el programa Excel. La muestra estudiada (N=25) abarcó a 64 pacientes varones con edad media de 64.4 años, siendo el 96% pacientes quirúrgicos y 4% pacientes clínicos. El periodo medio de la permanencia en UCI fue 21.8 días (más o menos 9.8), con una permanencia media en NP de 16.6 días (más o menos 13.11). La estimación media de necesidades alimenticias fue 24,41kcal/kg (más o menos 2.87) para energía y 0.96 g/kg (más o menos 0.14) para proteínas. La suficiencia de la fórmula parenteral considerando la relación prescrito/administrado fue 96.87% para energía y 97.01% para las proteínas. La frecuencia de administración inadecuada de nutrición parenteral fue el 11% para las calorías y el 11% para las proteínas respecto a las metas propuestas de <11% y <20% respectivamente. Respecto al análisis de exámenes bioquímicos, el 74% de los pacientes presentaron todos los exámenes antes de comenzar NP. Del total de pacientes, el 44% han pasado a la alimentación oral (meta mayor que 30%). Uno concluyó que el uso de índices de calidad permitió la evaluación de NP de la perspectiva de la elaboración de estrategias para una mejor suficiencia de la NP en la práctica clínica.

The objective of this research was to evaluate the Parenteral Nutrition Therapy (PNT) of patients interned in adult Intensive Care Units (ICU) with the application of quality indexes. This is a retrospective study approved by the Committee of Ethics in Research of HU-USP. We collected data on nutritional care registries, and applied quality indexes according to ILSI (2008) proposal. Data were described by simple and medium frequency of distribution and standard deviation processed by Excel program. The studied sample (N=25) comprised 64% male patients, with average age of 64,4 years, being 96% surgical and 4% clinical patients. The average time of permanence in ICU was 21.8 days (more or less 9.8), with an average permanence in PNT of 16.6 days (more or less 13.11). The average estimate of nutritional necessities was 24,41kcal/kg (more or less 2.87) for energy and 0.96 g/kg (more or less 0.14) for proteins. The adequacy of the parenteral formula considering the relationship prescribed/administered was 96.87% for energy and 97.01% for proteins. Apport-inadequate parenteral nutrition administration frequency was 11% for calories and 11% for proteins for goals proposals of <11% and <20% respectively. With regard to the analysis of biochemical exams, 74% of the patients presented all exams before beginning PNT. From the total of patients, 44% evolved to oral feeding (goal more than 30). One concluded that the application of quality indexes allowed the evaluation of PNT from the perspective of elaborating strategies for better adequacy of PNT in clinical practice.

Enteral nutritional therapy: application of quality indicators. / Terapia nutricional enteral: aplicação de indicadores de qualidade.

OBJECTIVE: Monitor the adequacy of enteral nutritional therapy at the intensive care unit aiming to improve the quality of nutritional assistance. METHODS: Prospective and observational study developed at the adult intensive care unit from 2005 to 2008. Patients over 18 years of age with exclusive enteral nutritional therapy for over 72h participated in the sample. The average values and the percentile adequacy of energy and proteins calculated, prescribed and administered in each year were analyzed. The factors responsible for the non-conformity of the administration planned were classified into intensive care unit extrinsic or intrinsic causes. The quality indicators proposed by the ILSI Brazil were applied, and expressed into percentile goals. In the statistic analyses, confidence interval and the t Student e Mann-Whitney (p<0.05) tests were used, according to the Epi Info program. RESULTS: One hundred and sixteen patients were followed up. There were statically difference in values of energy and protein administered in 2005 and in 2006, when compared to those in 2008. The adequacy calculated/prescribed remained close to 100% in all the surveys and the adequacy administered/prescribed increased from 74% in 2005, to 89% in 2008. An increase in interruptions of enteral nutritional therapy for external factors and the decrease in interruptions for intensive care unit internal factors were verified. The quality indicators equally reflect the evolution of the patient care. CONCLUSION: In the four yearly surveys, a progressive enhancement of nutritional support was verified. Quality indicators allow nutritional care evolution monitoring, the comparison to other services data, and are a new perspective for enteral nutritional therapy assessment.

Monitoração da terapia nutricional enteral em UTI: indicador de qualidade? / Terapia alimenticia enteral en ucis: ¿un indicador de calidad? / Enteral nutritional therapy monitoring in icus: a quality indicator?

A depleção nutricional é característica de pacientes em Unidade de Terapia Intensiva (UTI). Ao mesmo tempo, os parâmetros de avaliação nutricional apresentam importantes limitações, tornando fundamental a apresentação de propostas para favorecer a qualidade na assistência destes pacientes. O objetivo desse estudo foi monitorar a Terapia Nutricional Enteral (TNE) em pacientes de UTI em dois períodos distintos e compará-los, visando a utilizar a avaliação de adequação da TNE como indicador de qualidade assistencial. Esse é um estudo de caráter prospectivo observacional da oferta nutricional e intercorrências em pacientes admitidos na UTI adulto com TNE exclusiva por período superior a 72h. Foram avaliados 30 pacientes em 2006 e 33 em 2005. As médias dos valores de energia e proteínas calculados, prescritos e administrados, não apresentaram diferença estatística significante. A adequação calculado/prescrito foi próxima a 100 por cento e dos valores administrado/ prescrito foi de 74 por cento em 2005 e em torno de 80 por cento em 2006. O número de pausas na infusão da TNE em 2006 foi de 93, tendo como principal causa os procedimentos, e, dentre estes, a extubação orotraqueal. Já em 2005 foram 139 pausas, sendo a principal causa as interrupções de rotina. Os resultados encontrados estão de acordo com o preconizado pela literatura e indicaram a continuidade na qualidade da assistência. Foi fundamental o seguimento de protocolo de conduta, que permitiu identificar e adotar estratégias frente às interrupções da TNE identificadas em 2005. A porcentagem de adequação da TNE é um indicador de qualidade possível de ser empregado diante das dificuldades na obtenção de outros parâmetros para avaliação nutricional de pacientes graves.

Nutritional depletion is a frequent condition in patients in Intensive Care Units, (ICUs). At the same time, the parameters of nutritional evaluation have important limitations, making vital the presentation of proposals to favor the quality of care given to these patients. The objective of this study was to monitor Enteral Nutritional Therapy (ENT) in patients in ICUs in two distinct periods and to compare them, aiming at using ENT adequacy as an indicator of care quality. This is a study of a observational prospective character of nutritional offers and intercurrences in patients admitted to adult ICUs with an exclusive ENT for a period of more than 72 hours. We evaluated 30 patients in 2006 and 33 in 2005. The averages of values of energy and proteins calculated, prescribed and administered did not present statistically significant differences. The adequacy calculated/prescribed was next to 100 per cent and the values for the adequacy administered/prescribed were 74 per cent in 2005 and about 80 per cent in 2006. The number of interruptions in ENT infusion in 2006 was 93, having as main cause the procedures, and, amongst these, orotracheal extubation. In 2005, there were 139 pauses, and the main cause was routine interruptions. Results found are consistent to those proposed by literature and indicated the continuity in the quality of the assistance. Following the behavior protocol was vital, and allowed to identify and to adopt strategies regarding ENT interruptions identified in 2005. ENT adequacy percentage is an indicator of quality that we can use for coping with the difficulties in the attainment of other parameters for nutritional evaluation of patients is a severe state.

El agotamiento alimenticio es una condición frecuente en pacientes en unidades de cuidado intensivo (UCI). Al mismo tiempo, los parámetros de la evaluación alimenticia tienen limitaciones importantes, haciendo vitales propuestas que favorezcan el cuidado recibido por estos pacientes. El objetivo de este estudio fue monitorear la Terapia Alimenticia Enteral (TAE) en pacientes en UCIs en dos períodos distintos y compararlos, teniendo como objetivo la adecuación de la TAE como indicador de la calidad del cuidado. Éste es un estudio de carácter prospectivo observacional de ofertas nutricionales alimenticios y de intercurrencias en los pacientes admitidos a UCIs adultos con TAE exclusiva por un período de más de 72 horas. Evaluamos a 30 pacientes en 2006 y 33 en 2005. Las medias de valores de energía y de proteínas calculadas, prescritas y administradas no presentaron diferencias estadísticas significativas. La adecuación calculado/prescrito fue casi 100 per ciento y los valores para la adecuación administrado/prescrito llegaran a los 74 per ciento en 2005 y casi 80 per ciento en 2006. El número de interrupciones en la infusión TAE en 2006 fue 93, teniendo como causa principal los procedimientos, y, entre éstos, la extubación oral-traqueal. En 2005, hubo 139 pausas, y la causa principal fueran interrupciones rutinarias. Los resultados encontrados son consistentes con los propuestos por la literatura e indicaron la continuidad en la calidad de la ayuda. El respecto al protocolo fue vital, permitiendo identificar y adoptar estrategias respecto a las interrupciones de la TAE identificadas en 2005. El porcentaje de la adecuación TAE es un indicador de calidad que podemos utilizar para hacer frente a las dificultades en el logro de otros parámetros para la evaluación alimenticia de pacientes en estado grave.

Effect of olive oil-based emulsion on human lymphocyte and neutrophil death.

BACKGROUND: The incorporation of lipid emulsions in parenteral diets is a requirement for energy and essential fatty acid supply to critically ill patients. The most frequently used IV lipid emulsions (LE) are composed with long-chain triacylglycerols rich in omega-6 polyunsaturated fatty acids (PUFA) from soybean oil, but these LE promote lymphocyte and neutrophil death. A new emulsion containing 20% soybean oil and 80% olive oil rich in omega-9 monounsaturated fatty acids (MUFA) has been hypothesized not to cause impairment of immune function. In this study, the toxicity of an olive oil-based emulsion (OOE) on lymphocytes and neutrophils from healthy volunteers was investigated. METHODS: Twenty volunteers were recruited and blood was collected before a 6-hour infusion of an OOE, immediately after infusion, and again 18 hours postinfusion. Lymphocytes and neutrophils were isolated by gradient density. The cells were studied immediately after isolation and after 24 hours or 48 hours in culture. The following determinations were carried out: triacylglycerol levels and fatty acid composition and levels in plasma, lymphocyte proliferation, production of reactive oxygen species, and parameters of lymphocyte and neutrophil death (viability, DNA fragmentation, phosphatidylserine externalization, mitochondrial depolarization, and neutral lipid accumulation). RESULTS: OOE decreased lymphocyte proliferation, provoked lymphocyte necrosis, and had no effect on the proportion of viable neutrophils. The mechanism of cell death induced by OOE involved neutral lipid accumulation but had no effect on mitochondrial membrane depolarization. CONCLUSIONS: The OOE given as a single dose of 500 mL induced low toxicity to lymphocytes from healthy volunteers, probably by necrosis.

Yo jyo hen shi ko, a novel Chinese herbal, prevents nonalcoholic steatohepatitis in ob/ob mice fed a high fat or methionine-choline-deficient diet.

BACKGROUND: Oxidative stress plays a role in the pathogenesis of nonalcoholic steatohepatitis (NASH). Yo jyo hen shi ko (YHK) is a complex compound purported to reduce reactive oxygen species (ROS) by blocking the propagation of radical-induced reactions. The aim of this study was to evaluate the role of the effect of YHK in experimental NASH. METHODS: NASH was induced in male ob/ob mice by a high-fat (HF) diet or methionine/choline-deficient (MCD) diet for 4 weeks. YHK-treated animals received YHK solution orally (20 mg/kg/day) in both experimental diets (n=6; each group) while control animals received only vehicle. RESULTS: The MCD and HF groups developed moderate diffuse macrosteatosis, hepatocellular ballooning, and a diffuse inflammatory infiltrate. With the addition of YHK, there was a marked reduction in macrosteatosis in both groups. This was associated with decreased lipoperoxide and reduced glutathione-GSH concentrations as well as reduced serum aminotransferases and improved histological markers of inflammation. These changes were also associated with weight loss in the MCD+YHK group and diminished weight gain in the HF+YHK group. CONCLUSION: YHK therapy blunts the development of macrosteatosis in these models of NASH and significantly reduces markers of oxidative stress. YHK also diminishes weight gain in this obesity prone model. Our findings warrant further study on the mechanisms involved with these effects.

Effect of docosahexaenoic acid-rich fish oil supplementation on human leukocyte function.

BACKGROUND: The effect of a docosahexaenoic acid (DHA)-rich fish oil (FO) supplementation on human leukocyte function was investigated. METHODS: Ten male volunteers were supplemented with 3g/day FO containing 26% eicosapentaenoic acid (EPA, 20:5, n-3) and 54% DHA (22:6, n-3) for 2 months. RESULTS: FO supplementation changed the fatty acid (FA) composition of leukocytes resulting in an increase of n-3/n-6 ratio from 0.18 to 0.62 in lymphocytes and from 0.15 to 0.70 in neutrophils. DHA-rich FO stimulated an increase in phagocytic activity by 62% and 145% in neutrophils and monocytes, respectively. Neutrophil chemotactic response was increased by 128%. The rate of production of reactive oxygen species by neutrophils was also increased, as it was with lymphocyte proliferation. These changes were partially reversed after a 2-month wash out period. With respect to cytokine production by lymphocytes, interleukin (IL)-4 release was not altered, whereas secretions of IL-10, interferon (IFN)-gamma and tumor necrosis factor (TNF)-alpha were raised. These results are in contrast to those described by others using EPA-rich FO supplementation. Lymphocyte pleiotropic gene expression was analyzed by a macroarray technique. Of the analyzed genes (588 in total), 77 were modified by the supplementation. FO supplementation resulted in up-regulation of 6 genes (GATA binding protein 2, IL-6 signal transducer, transforming growth factor alpha, TNF, heat shock 90kDa protein 1-alpha and heat shock protein 70kDa 1A) and a down regulation of 71 genes (92.2% of total genes changed). The largest functional group of altered genes was that related to signaling pathways (22% of the total modified genes). CONCLUSIONS: Therefore, although EPA and DHA are members of n-3 FA family, changes in the proportion of DHA and EPA exert different effects on neutrophil, monocyte and lymphocyte function, which may be a result of specific changes in gene expression.

Toxicity of a soybean oil emulsion on human lymphocytes and neutrophils.

BACKGROUND: The incorporation of lipid emulsions in parenteral diets is a requirement for energy and essential fatty acid supply to critically ill patients. In this study, the toxicity of a lipid emulsion rich (60%) in triacylglycerol of omega-6 polyunsaturated fatty acids on leukocytes from healthy volunteers was investigated. METHODS: Eleven volunteers were recruited, and blood samples were collected before infusion of a soybean oil emulsion, immediately afterwards, and 18 hours later. The cells were studied immediately after isolation and again after 24 hours or 48 hours in culture. The following determinations were made: composition and concentration of fatty acids in plasma, lymphocytes and neutrophils, lymphocyte proliferation, levels of cell viability, DNA fragmentation, phosphatidylserine externalization, mitochondrial depolarization, reactive oxygen species production, and neutral lipid accumulation. RESULTS: Soybean oil emulsion decreased lymphocyte proliferation and provoked neutrophil and lymphocyte apoptosis and necrosis. Evidence is presented herein that soybean oil emulsion is less toxic to neutrophils than to lymphocytes. The mechanism of cell death induced by this oil emulsion was characterized by mitochondrial membrane depolarization and neutral lipid accumulation but did not alter reactive oxygen species production. CONCLUSIONS: Soybean oil emulsion given as a single dose of 500 mL promotes lymphocyte and neutrophil death that may enhance the susceptibility of the patients to infections.