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.

ß-Caryophyllene: A Therapeutic Alternative for Intestinal Barrier Dysfunction Caused by Obesity.

Obesity is an excessive accumulation of fat that exacerbates the metabolic and inflammatory processes. Studies associate these processes with conditions and dysregulation in the intestinal tract, increased concentrations of lipopolysaccharides (LPSs) in the blood, differences in the abundance of intestinal microbiota, and the production of secondary metabolites such as short-chain fatty acids. ß-Caryophyllene (BCP) is a natural sesquiterpene with anti-inflammatory properties and with the potential purpose of fighting metabolic diseases. A diet-induced obesity model was performed in 16-week-old C57BL/6 mice administered with BCP [50 mg/kg]. A reduction in the expression of Claudin-1 was observed in the group with a high-fat diet (HFD), which was caused by the administration of BCP; besides BCP, the phylaAkkermansia and Bacteroidetes decreased between the groups with a standard diet (STD) vs. HFD. Nevertheless, the use of BCP in the STD increased the expression of these phyla with respect to fatty acids; a similar effect was observed, in the HFD group that had a decreasing concentration that was restored with the use of BCP. The levels of endotoxemia and serum leptin increased in the HFD group, while in the HFD + BCP group, similar values were found to those of the STD group, attributing the ability to reduce these in conditions of obesity.

Antioxidant Supplementation Modulates Neutrophil Inflammatory Response to Exercise-Induced Stress.

The aim of the present report was to evaluate the inflammatory response to a 2000-m running test considering neutrophil myeloperoxidase as an inflammatory marker, and to verify if supplements rich in antioxidants could modulate Post-test antioxidant and anti-inflammatory responses. To this end, a 21-day homogenization period was carried out with three groups: a control group, a supplemented group taking an almond beverage enriched with vitamins C and E and a third group consuming the same beverage but enriched with Lippia citriodora extract. At the end of this period, participants performed a 2000-m run, and blood samples were obtained the day before and immediately after the running test. Plasma and neutrophils were isolated. As a result, plasma creatine kinase and myoglobin increased, indicating Post-test muscle damage. Plasma oxidative markers were increased in all groups, except in the group supplemented with the almond beverage. Neutrophil antioxidant enzymes were significantly increased only in the control group, suggesting an antioxidant effect of the supplements provided in the other groups. Myeloperoxidase activity was significantly increased after the test in the control group, while increased enzyme levels were detected in plasma of the supplement groups. Therefore, antioxidant consumption seems to favour myeloperoxidase release. The connection of this observation with post-exercise recovery will require further investigation.

Alliin, an Allium sativum Nutraceutical, ReducesMetaflammation Markers in DIO Mice.

Obesity generates a chronic low-grade inflammatory state which promotes oxidativestress and triggers comorbidities. Alliin is the main organosulfur compound in garlic and has beenshown to induce a decrease in the expression of proinflammatory cytokines; its systemic effect onmetabolic parameters and adipose tissue is not yet known, however. After nine weeks of HFD andwith obesity established in C57BL/6 mice, we observed that a daily treatment with alliin for 3.5weeks (15 mg/kg) did not affect body weight, but significantly improved insulin sensitivity andglucose tolerance, both evaluated through a blood glucose monitoring system. Once alliin treatmentwas completed, serum, adipose tissue, and organs of interest related to metabolism were removedfor further analysis. We observed that alliin significantly decreased the size of adipocytes fromepididymal adipose tissue, evaluated via microscopy. A decrease in gene expression and serumprotein levels of the adipocytokines leptin and resistin, as well as decreased serum IL-6concentration, were detected by qRT-PCR and ELISA, respectively. It did not, however, affectmRNA expression of antioxidant enzymes in the liver. Taken altogether, these results indicate thattreatment with alliin reduces metaflammation markers in DIO mice and improves some metabolicparameters without affecting others.

Phytochemicals That Influence Gut Microbiota as Prophylactics and for the Treatment of Obesity and Inflammatory Diseases.

Gut microbiota (GM) plays several crucial roles in host physiology and influences several relevant functions. In more than one respect, it can be said that you "feed your microbiota and are fed by it." GM diversity is affected by diet and influences metabolic and immune functions of the host's physiology. Consequently, an imbalance of GM, or dysbiosis, may be the cause or at least may lead to the progression of various pathologies such as infectious diseases, gastrointestinal cancers, inflammatory bowel disease, and even obesity and diabetes. Therefore, GM is an appropriate target for nutritional interventions to improve health. For this reason, phytochemicals that can influence GM have recently been studied as adjuvants for the treatment of obesity and inflammatory diseases. Phytochemicals include prebiotics and probiotics, as well as several chemical compounds such as polyphenols and derivatives, carotenoids, and thiosulfates. The largest group of these comprises polyphenols, which can be subclassified into four main groups: flavonoids (including eight subgroups), phenolic acids (such as curcumin), stilbenoids (such as resveratrol), and lignans. Consequently, in this review, we will present, organize, and discuss the most recent evidence indicating a relationship between the effects of different phytochemicals on GM that affect obesity and/or inflammation, focusing on the effect of approximately 40 different phytochemical compounds that have been chemically identified and that constitute some natural reservoir, such as potential prophylactics, as candidates for the treatment of obesity and inflammatory diseases.

Immunomodulation and anti-inflammatory effects of garlic compounds.

The benefits of garlic to health have been proclaimed for centuries; however, only recently have Allium sativum and its derivatives been proposed as promising candidates for maintaining the homeostasis of the immune system. The complex biochemistry of garlic makes it possible for variations in processing to yield different preparations with differences in final composition and compound proportion. In this review, we assess the most recent experimental results, which indicate that garlic appears to enhance the functioning of the immune system by stimulating certain cell types, such as macrophages, lymphocytes, natural killer (NK) cells, dendritic cells, and eosinophils, by mechanisms including modulation of cytokine secretion, immunoglobulin production, phagocytosis, and macrophage activation. Finally, because immune dysfunction plays an important role in the development and progress of several diseases, we critically examined immunoregulation by garlic extracts and compounds isolated, which can contribute to the treatment and prevention of pathologies such as obesity, metabolic syndrome, cardiovascular disorders, gastric ulcer, and even cancer. We concluded that A. sativum modulates cytokine secretion and that such modulation may provide a mechanism of action for many of their therapeutic effects.

Effect of polyphenol supplements on redox status of blood cells: a randomized controlled exercise training trial.

PURPOSE: The effect of endogenous antioxidants can be either an immediate response (relying on enzymatic activities) or a long-term adaptation (relying on gene modulation events), both susceptible to be modified by antioxidants from diet and supplementation. The aim of this work was to delve in these aspects in circulating white blood cells in a group of volunteers (n = 33, 20-22 years) performing eccentric exercises and consuming or not (n = 8) different polyphenolic antioxidants (Lippia citriodora extract-PLX(®) n = 8, almond beverage n = 9 or a mixture of both n = 8) during 21 days. METHODS: We have designed a single-blind, parallel-group, randomized controlled trial. Antioxidant enzyme activities, oxidative stress markers, and antioxidant gene expression were determined. RESULTS: Neutrophils and lymphocytes expressed high amounts of oxidative markers compared to plasma. Concerning enzymatic activities, increased superoxide dismutase levels were detected when certain supplements were consumed. However, catalase levels did not change. As for glutathione peroxidase levels, no differences were detected in lymphocytes, while neutrophils expressed increased levels in both placebo and PLX(®) groups. Glutathione reductase activity was decreased in all groups, except in neutrophils of PLX(®) group. At the level of gene expression, neither PLX(®) nor the almond beverage interfered with the expression of genes coding for the corresponding enzymes. However, the combined intake of both supplements affected the expression of glutathione reductase and Cu-Zn and Mn-superoxide dismutases in neutrophils. CONCLUSIONS: Altogether, these results suggest that blood cell types respond and adapt differently to exercise-induced oxidative damage.

Effect of lemon verbena supplementation on muscular damage markers, proinflammatory cytokines release and neutrophils' oxidative stress in chronic exercise.

Intense exercise is directly related to muscular damage and oxidative stress due to excessive reactive oxygen species (ROS) in both, plasma and white blood cells. Nevertheless, exercise-derived ROS are essential to regulate cellular adaptation to exercise. Studies on antioxidant supplements have provided controversial results. The purpose of this study was to determine the effect of moderate antioxidant supplementation (lemon verbena extract) in healthy male volunteers that followed a 90-min running eccentric exercise protocol for 21 days. Antioxidant enzymes activities and oxidative stress markers were measured in neutrophils. Besides, inflammatory cytokines and muscular damage were determined in whole blood and serum samples, respectively. Intense running exercise for 21 days induced antioxidant response in neutrophils of trained male through the increase of the antioxidant enzymes catalase, glutathione peroxidase and glutathione reductase. Supplementation with moderate levels of an antioxidant lemon verbena extract did not block this cellular adaptive response and also reduced exercise-induced oxidative damage of proteins and lipids in neutrophils and decreased myeloperoxidase activity. Moreover, lemon verbena supplementation maintained or decreased the level of serum transaminases activity indicating a protection of muscular tissue. Exercise induced a decrease of interleukin-6 and interleukin-1ß levels after 21 days measured in basal conditions, which was not inhibited by antioxidant supplementation. Therefore, moderate antioxidant supplementation with lemon verbena extract protects neutrophils against oxidative damage, decreases the signs of muscular damage in chronic running exercise without blocking the cellular adaptation to exercise.