Administration of enteral nutrition and gastrointestinal complications in Covid-19 critical patients in prone position.

Background: The prone position (PP) used in the treatment of critically ill patients infected with SARS-CoV-2, may be a barrier to enteral nutrition (EN). This study aimed to analyze the effectiveness and complications of EN in the PP, as well as clinical outcomes. Methods: Prospective cohort study with patients in EN and coronavirus disease 2019 (COVID-19), on mechanical ventilation (MV), which whom needed or not PP. Gastrointestinal intolerances (GII) related to PP were evaluated, and correlated with possible confounding factors. EN, days on MV, Intensive Care Unit (ICU) length of stay, hospital length of stay, ventilator-associated pneumonia (VAP) and mortality were analyzed. The data were evaluated daily and compared prone group (PG=57) and supine group (SG=69). Results: The PP was associated with GII (P=0.000) and presented in 32 patients (26,44%) with no difference among groups. Association between epinephrine (P=0.003), vasopressin (P=0.018), and GII was observed. There was no difference between the total volume of enteral nutrition (TVEN) infused in the groups. However, the mean EN infused for the days when the patient was on PP was (70.0% ± 31.5) and for the days in supine position was (74.8% ± 27.3), P= 0.006. The PG had a longer time on MV (P=0.005) and ICU (P=0.003) and PP was associated with VAP (P=<0.001). The infused TVEN showed no association with VAP (P=0.09). Conclusion: PP was a determining factor in GII and proved to be a risk factor for VAP, but the EN protocol seems to have ensured an adequate EN supply in PP and be a safe alternative.

Beau's line in COVID-19 after a long ICU stay / Línea de Beau en COVID-19 después de un tiempo largo de internación en UCI

The 2019 coronavirus disease pandemic (COVID-19) overloads hospitalizations in intensive care units (ICUs) around the world and its severe form is a complex disease that is still being understood. Due to the lack of direct evidence in patients with SARS-CoV-2 infection, guidelines for nutritional management have been based on evidence from critically ill patients in general. Thus, it is known that intense metabolic stress and malnutrition precede the appearance of Beau’s lines. This is the case report of a 58-year-old man with the severe form of COVID-19 hospitalized for 33 days in the ICU and who presented the Beau´s lines after 4 months of discharge, even with the infusion of nutritional therapy following the current recommendations for the critical period of the disease (AU)

La pandemia de la enfermedad por coronavirus de 2019 (COVID-19) sobrecarga las hospitalizaciones en unidades de cuidados intensivos (UCI) en todo el mundo y su forma grave es una enfermedad compleja que aún se está comprendiendo. Debido a la falta de evidencia directa en pacientes con infección por SARS-CoV-2, las pautas para el manejo nutricional se han basado en la evidencia de pacientes críticos en general. Así, se sabe que el estrés metabólico intenso y la desnutrición preceden a la aparición de las líneas de Beau. Este es el caso clínico de un hombre de 58 años con la forma grave de COVID-19 hospitalizado durante 33 días en la UCI y que presentó las líneas de Beau después de 4 meses del alta, incluso con la infusión de terapia nutricional prescrita en consecuencia a las recomendaciones actuales para el periodo crítico de la enfermedad (AU)

Beau's line in COVID-19 after a long ICU stay.

Introduction: The 2019 coronavirus disease pandemic (COVID-19) overloads hospitalizations in intensive care units (ICUs) around the world and its severe form is a complex disease that is still being understood. Due to the lack of direct evidence in patients with SARS-CoV-2 infection, guidelines for nutritional management have been based on evidence from critically ill patients in general. Thus, it is known that intense metabolic stress and malnutrition precede the appearance of Beau's lines. This is the case report of a 58-year-old man with the severe form of COVID-19 hospitalized for 33 days in the ICU and who presented the Beau´s lines after 4 months of discharge, even with the infusion of nutritional therapy following the current recommendations for the critical period of the disease.

Introducción: La pandemia de la enfermedad por coronavirus de 2019 (COVID-19) sobrecarga las hospitalizaciones en unidades de cuidados intensivos (UCI) en todo el mundo y su forma grave es una enfermedad compleja que aún se está comprendiendo. Debido a la falta de evidencia directa en pacientes con infección por SARS-CoV-2, las pautas para el manejo nutricional se han basado en la evidencia de pacientes críticos en general. Así, se sabe que el estrés metabólico intenso y la desnutrición preceden a la aparición de las líneas de Beau. Este es el caso clínico de un hombre de 58 años con la forma grave de COVID-19 hospitalizado durante 33 días en la UCI y que presentó las líneas de Beau después de 4 meses del alta, incluso con la infusión de terapia nutricional prescrita en consecuencia a las recomendaciones actuales para el periodo crítico de la enfermedad.

Consensus on the standard terminology used in the nutrition care of adult patients with chronic kidney disease / Consenso sobre a terminologia padronizada do processo de cuidado em nutrição para pacientes adultos com doença renal crônica

Abstract This nutrition consensus document is the first to coordinate the efforts of three professional organizations - the Brazilian Association of Nutrition (Asbran), the Brazilian Society of Nephrology (SBN), and the Brazilian Society of Parenteral and Enteral Nutrition (Braspen/SBNPE) - to select terminology and international standardized tools used in nutrition care. Its purpose is to improve the training delivered to nutritionists working with adult patients with chronic kidney disease (CKD). Eleven questions were developed concerning patient screening, care, and nutrition outcome management. The recommendations set out in this document were developed based on international guidelines and papers published in electronic databases such as PubMed, EMBASE(tm), CINHAL, Web of Science, and Cochrane. From a list of internationally standardized terms, twenty nutritionists selected the ones they deemed relevant in clinical practice involving outpatients with CKD. The content validity index (CVI) was calculated with 80% agreement in the answers. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was used to assess the strength of evidence and recommendations. A total of 107 terms related to Nutrition Assessment and Reassessment, 28 to Diagnosis, nine to Intervention, and 94 to Monitoring and Evaluation were selected. The list of selected terms and identified tools will be used in the development of training programs and the implementation of standardized nutrition terminology for nutritionists working with patients with chronic kidney disease in Brazil.

Resumo Este consenso representa a primeira colaboração entre três organizações profissionais com foco em nutrição: Associação Brasileira de Nutrição (Asbran), Sociedade Brasileira de Nefrologia (SBN) e Sociedade Brasileira de Nutrição Parenteral e Enteral (Braspen/SBNPE), com o objetivo de identificar a terminologia e instrumentos padronizados internacionalmente para o processo de cuidado em nutrição. O foco é facilitar a condução de treinamentos de nutricionistas que trabalham com pacientes adultos com doenças renais crônicas (DRC). Foram levantadas onze questões relacionadas à triagem, ao processo de cuidado e à gestão de resultados em nutrição. As recomendações foram baseadas em diretrizes internacionais e em bancos de dados eletrônicos, como PubMed, EMBASE(tm), CINHAL, Web of Science e Cochrane. A partir do envio de listas de termos padronizados internacionalmente, vinte nutricionistas especialistas selecionaram aqueles que consideraram muito claros e relevantes para a prática clínica com pacientes ambulatoriais com DRC. Foi calculado o Índice de Validade de Conteúdo (IVC), com 80% de concordância nas respostas. O Grading of Recommendations, Assessment, Development and Evaluation (GRADE) foi usado para atribuir força de evidência às recomendações. Foram selecionados 107 termos de Avaliação e Reavaliação, 28 de Diagnóstico, 9 de Intervenção e 94 de Monitoramento e Aferição em Nutrição. A lista de termos selecionados e identificação de instrumentos auxiliará no planejamento de treinamentos e na implementação de terminologia padronizada em nutrição no Brasil, para nutricionistas que trabalham com pacientes renais crônicos.

Consensus on the standard terminology used in the nutrition care of adult patients with chronic kidney disease.

This nutrition consensus document is the first to coordinate the efforts of three professional organizations - the Brazilian Association of Nutrition (Asbran), the Brazilian Society of Nephrology (SBN), and the Brazilian Society of Parenteral and Enteral Nutrition (Braspen/SBNPE) - to select terminology and international standardized tools used in nutrition care. Its purpose is to improve the training delivered to nutritionists working with adult patients with chronic kidney disease (CKD). Eleven questions were developed concerning patient screening, care, and nutrition outcome management. The recommendations set out in this document were developed based on international guidelines and papers published in electronic databases such as PubMed, EMBASE(tm), CINHAL, Web of Science, and Cochrane. From a list of internationally standardized terms, twenty nutritionists selected the ones they deemed relevant in clinical practice involving outpatients with CKD. The content validity index (CVI) was calculated with 80% agreement in the answers. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was used to assess the strength of evidence and recommendations. A total of 107 terms related to Nutrition Assessment and Reassessment, 28 to Diagnosis, nine to Intervention, and 94 to Monitoring and Evaluation were selected. The list of selected terms and identified tools will be used in the development of training programs and the implementation of standardized nutrition terminology for nutritionists working with patients with chronic kidney disease in Brazil.

Recomendações brasileiras de ventilação mecânica 2013. Parte 2 / Brazilian recommendations of mechanical ventilation 2013. Part 2

O suporte ventilatório artificial invasivo e não invasivo ao paciente grave tem evoluído e inúmeras evidências têm surgido, podendo ter impacto na melhora da sobrevida e da qualidade do atendimento oferecido nas unidades de terapia intensiva no Brasil. Isto posto, a Associação de Medicina Intensiva Brasileira (AMIB) e a Sociedade Brasileira de Pneumologia e Tisiologia (SBPT) - representadas por seu Comitê de Ventilação Mecânica e sua Comissão de Terapia Intensiva, respectivamente, decidiram revisar a literatura e preparar recomendações sobre ventilação mecânica, objetivando oferecer aos associados um documento orientador das melhores práticas da ventilação mecânica na beira do leito, com base nas evidências existentes, sobre os 29 subtemas selecionados como mais relevantes no assunto. O projeto envolveu etapas que visaram distribuir os subtemas relevantes ao assunto entre experts indicados por ambas as sociedades, que tivessem publicações recentes no assunto e/ou atividades relevantes em ensino e pesquisa no Brasil, na área de ventilação mecânica. Esses profissionais, divididos por subtemas em duplas, responsabilizaram-se por fazer uma extensa revisão da literatura mundial. Reuniram-se todos no Fórum de Ventilação Mecânica, na sede da AMIB, na cidade de São Paulo (SP), em 3 e 4 de agosto de 2013, para finalização conjunta do texto de cada subtema e apresentação, apreciação, discussão e aprovação em plenária pelos 58 participantes, permitindo a elaboração de um documento final.

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.

Recomendações brasileiras de ventilação mecânica 2013. Parte I / Brazilian recommendations of mechanical ventilation 2013. Part I

O suporte ventilatório artificial invasivo e não invasivo ao paciente crítico tem evoluído e inúmeras evidências têm surgido, podendo ter impacto na melhora da sobrevida e da qualidade do atendimento oferecido nas unidades de terapia intensiva no Brasil. Isto posto, a Associação de Medicina Intensiva Brasileira (AMIB) e a Sociedade Brasileira de Pneumonia e Tisiologia (SBPT) - representadas pelo seus Comitê de Ventilação Mecânica e Comissão de Terapia Intensiva, respectivamente, decidiram revisar a literatura e preparar recomendações sobre ventilação mecânica objetivando oferecer aos associados um documento orientador das melhores práticas da ventilação mecânica na beira do leito, baseado nas evidencias existentes, sobre os 29 subtemas selecionados como mais relevantes no assunto. O projeto envolveu etapas visando distribuir os subtemas relevantes ao assunto entre experts indicados por ambas as sociedades que tivessem publicações recentes no assunto e/ou atividades relevantes em ensino e pesquisa no Brasil na área de ventilação mecânica. Esses profissionais, divididos por subtemas em duplas, responsabilizaram-se por fazer revisão extensa da literatura mundial sobre cada subtema. Reuniram-se todos no Forum de Ventilação Mecânica na sede da AMIB em São Paulo, em 03 e 04 de agosto de 2013 para finalização conjunta do texto de cada subtema e apresentação, apreciação, discussão e aprovação em plenária pelos 58 participantes, permitindo a elaboração de um documento final.

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumonia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.

Correlação entre medidas antropométricas e massa corporal gorda avaliado por bioimpedância em mulheres idosas não institucionalizadas / Correlation between anthropometric measures and fat body mass evaluated by bioimpedance in elderly women not institutionalized

O objetivo deste estudo foi verificar em mulheres idosas, não institucionalizadas, a correlação entre a massa corporal gorda (Kg) avaliada pela bioimpedância (BIA) e as medidas antropométricas: peso atual (PA), índice de massa corporal (IMC), pregas cutâneas, tricipital (PCT), BICIPITAL (PCB), subescapular (PCSUB), supra-espinal (PCSE) e a soma das quatro pregas avaliadas (SPC). Foram avaliadas 32 idosas, participantes do Serviço de Voluntários do Hospital de Clínicas da UFPR. As variáveis foram obtidas da seguinte maneira: altura: com estadiômetro; pregas cutâneas; com compasso de Lange; peso; com balança digital; IMC: calculado considerando peso e altura; MCC 9Kg), com aparelho de bioimpedância. A correlação entre a MCC (Kg) e as variáveis: PA. IMC, PCT, PCSUB, PCSE e SPC foram: r=0,87, r=0,94, r=9,73, r=0,71, r=0,64 e r=0,65 e r=0,79 respectivamente; p=0,000. Concluiu-se que existe correlação positiva entre a MCG (Kg) obtida pela BIA e todas as variáveis estudadas e que as correlações mais fortes foram, em ordem decrescente com: IMC , pa E spc

Zinco sérico e avaliação nutricional de idosos institucionalizados / Serum zinc and nutritional evaluation of institutionalized elderly people

As marcantes mudanças fisiológicas que caracterizam o processo de envelhecimento constituem-se indubitavelmente fontes de variabilidade importante nos parâmetros de avaliação nutrricional de populações sadias. Este estudo objetivou avaliar o estado nutricional de idosos institucionalizados em relação às concentrações séricas de zinco e de parâmetros antropométricos, capazes de predizer acuradamente a tendência do comportamento dessas variáveis comparando-as a padrões de referência. Para tanto, 32 indivíduos de ambos os sexos forama valiados quanto à sua concentração de zinco plasmático, determinada por espectometria de aborção atômica de chama, e submetidos à avaliação antropométrica, na qual foram tomadas as medidas do peso corporal, altura, circunferência da panturrilha, circunferência abdominal, meia envergadura do braço, prega cutânea triciptal e altura do joelho. Com os dados encontrados, observou-se que notadamente, os níveis encontrados nas mulheres, em média 30 por cento menores podem caracterizar, em longo prazo um quadro de deficiência do metal. Quando avaliado, IMC demonstrou haver um percentual aproximado de 50 por cento de indivíduos eutróficos e uma preocupante proporção de indivíduos com sobrepeso em ambos os sexos. A partir desse estudo foi possível concluir que os indivíduos avaliados mostraram uma tendência a manter concentrações séricas de zinco aquém daquelas que deveriam ser encontradas em indivíduos sadios, podendo indicar menor aproveitamento do micronutriente. Dos demais parâmetros antropométricos, a variabilidade da razão entre o peso e a altura representada pelo IMC deve ser motivo de preocupação em populações de idosos como a participante desse estudo, prementemente pela frequência cada vez maior de indivíduos nos extremos de magrezaa e sobrepeso

Basal energy expenditure and diet- induced modifications to thermogenesis in short bowel syndrome.

BACKGROUND & AIM: The influence of food intake on diet-induced thermogenesis, in the absence of parenteral nutrition, has not been assessed in short bowel syndrome (SBS) patients. We studied basal energy expenditure (BEE) and diet-induced thermogenesis in SBS patients (n=8) and paired healthy adult volunteer controls (n=8). METHODS: Energy expenditure was measured by indirect calorimetry (IC) before and after control diet intake. All study participants received oral control diet randomly given in 3 doses (A=1.0, B=1.5 and C=2.0)x1/6 of BEE calories. Bioelectric impedance was assessed. Pairing criteria for controls were: age, sex, body mass index. RESULTS: No significant differences were found between SBS and paired healthy control groups in relation to absolute BEE (P=0.146) and when it was adjusted for body mass index, lean and fat body mass (P=0.861, 0.208 and 0.574, respectively). All diets promoted thermogenesis in both groups. The interaction between the control diet (A, B and C) and SBS and healthy control groups for diet induced thermogenesis presented a significant difference (P=0.026). When comparing groups (SBS vs healthy controls) in relation to the control diet (B and C) we observed: P=0.030 and 0.004, respectively. CONCLUSION: In patients with SBS it was observed that: (1) BEE measured by IC in absolute values or adjusted by lean body mass is similar to healthy control group; (2) Diet-induced thermogenesis was lower than the healthy control group for higher caloric diets (B and C).

Fasting breath hydrogen concentration in short bowel syndrome patients with colon incontinuity before and after antibiotic therapy.

OBJECTIVE: Nutrition success in short bowel syndrome (SBS) depends on the intake nutrients and the intestinal absorption capacity. An evaluation of energy expenditure and oxidation of substrate can be obtained with indirect calorimetry by measuring O(2) and CO(2) in the respiration. Elevated colonic fermentation can occur in SBS, producing H(2) and CO(2), which can also be eliminated through respiration and as a consequence affect the results from indirect calorimetry. The objective of this study was to determine the fasting breath H(2) concentration and alterations before and after antibiotic therapy in patients with severe SBS with colon in continuity. METHODS: The study was conducted in two phases. In phase 1, the fasting breath H(2) concentrations were measured in 10 patients with severe SBS with colon incontinuity and a control group of 10 healthy volunteers. In phase 2, the fasting breath H(2) concentrations were re-evaluated after treatment for 7 d with antibiotics in six patients with high rates of H(2). The analyses were performed with a gas chromatograph (microanalyzer DP; Quintron Instruments, Milwaukee, WI, USA), with results of breath hydrogen and methane concentration expressed in parts per million (ppm). RESULTS: In phase 1, the levels of fasting breath H(2) were higher in the patients with severe SBS with colon incontinuity than in the healthy controls (32.00 +/- 17.77 versus 5.30 +/- 3.31 ppm; P < 0.001), with 7 of 10 patients presenting levels of H(2) above the normal rate (12 ppm). The presence of an ileocecal valve did not modify the results significantly. In phase 2, all six patients treated with antibiotics presented normalization in the levels of fasting breath H(2) (from 43.50 +/- 6.90 ppm to 1.33 +/- 1.03 ppm; P < 0.001) and concomitant improvement in the gastrointestinal symptoms. CONCLUSIONS: In relation to the healthy controls, patients with SBS with colon incontinuity presented higher levels of fasting breath H(2). Antibiotic therapy normalized the levels of fasting breath H(2) and improved the gastrointestinal symptoms. We suggest that the breath H(2) test may be performed routinely in patients with SBS to diagnose elevated intestinal fermentation, prevent errors in the interpretation of the indirect calorimetry, and treat eventual associated gastrointestinal symptoms.