Recommendations of the GARIN group for managing non-critically ill patients with diabetes or stress hyperglycaemia and artificial nutrition / Recomendaciones del grupo GARIN para el manejo de pacientes no críticos con diabetes o hiperglucemia de estrés y nutrición artificial

Background & aims: By means of this update, the GARIN working group aims to define its position regarding the treatment of patients with diabetes or stress hyperglycaemia and artificial nutrition. In this area there are many aspects of uncertainty, especially in non-critically ill patients. Methods: Bibliographical review, and specific questions in advance were discussed and answered at a meeting in the form of conclusions. Results: We propose a definition of stress hyperglycaemia. The indications and access routes for artificial nutrition are no different in patients with diabetes/stress hyperglycaemia than in non-diabetics. The objective must be to keep pre-prandial blood glucose levels between 100 and 140 mg/dl and post-prandial levels between 140 and 180 mg/dl. Hyperglycemia can be prevented through systematic monitoring of capillary glycaemias and adequately calculate energy-protein needs. We recommend using enteral formulas designed for patients with diabetes (high monounsaturated fat) to facilitate metabolic control. The best drug treatment for treating hyperglycaemia/diabetes in hospitalised patients is insulin and we make recommendations for adapt the theoretical insulin action to the nutrition infusion regimen. We also addressed recommendations for future investigation. Conclusions: This recommendations about artificial nutrition in patients with diabetes or stress hyperglycaemia can add value to clinical work (AU)

Introducción y objetivos: En el tratamiento de los pacientes con diabetes o hiperglucemia de estrés y la nutrición artificial existen muchas áreas de incertidumbre, sobre todo en pacientes no críticos. El grupo de trabajo GARIN tiene como objetivo definir su posición en este campo. Material y métodos: Revisión bibliográfica previa y reunión presencial en la que se discutieron y contestaron preguntas específicas sobre el tema. Resultados: Proponemos una definición de hiperglucemia de estrés. Las indicaciones y las rutas de acceso a la nutrición artificial no difieren en los pacientes con hiperglucemia de estrés o diabetes respecto a los no diabéticos. El objetivo debe ser mantener los niveles de glucemia preprandial entre 100 y 140 mg/dl y postprandial entre 140 y 180 mg/dl. La hiperglucemia puede prevenirse a través de una monitorización sistemática de las glucemias capilares y un cálculo adecuado de las necesidades energético-proteicas. Recomendamos el uso de fórmulas enterales diseñadas para pacientes con diabetes (alto contenido en grasas monoinsaturadas) para facilitar el control metabólico. El mejor tratamiento farmacológico para tratar la hiperglucemia/diabetes en pacientes hospitalizados es la insulina, aconsejando adaptar la acción teórica de la insulina al régimen de infusión de la nutrición. También realizamos recomendaciones para investigaciones futuras. Conclusiones: Estas recomendaciones aportan respuestas concretas sobre cuestiones comunes en la asistencia a pacientes con diabetes o hiperglucemia de estrés y nutrición artificial (AU)

Recommendations of the GARIN group for managing non-critically ill patients with diabetes or stress hyperglycaemia and artificial nutrition.

BACKGROUND & AIMS: By means of this update, the GARIN working group aims to define its position regarding the treatment of patients with diabetes or stress hyperglycaemia and artificial nutrition. In this area there are many aspects of uncertainty, especially in non-critically ill patients. METHODS: Bibliographical review, and specific questions in advance were discussed and answered at a meeting in the form of conclusions. RESULTS: We propose a definition of stress hyperglycaemia. The indications and access routes for artificial nutrition are no different in patients with diabetes/stress hyperglycaemia than in non-diabetics. The objective must be to keep pre-prandial blood glucose levels between 100 and 140 mg/dl and post-prandial levels between 140 and 180 mg/dl. Hyperglycemia can be prevented through systematic monitoring of capillary glycaemias and adequately calculate energy-protein needs. We recommend using enteral formulas designed for patients with diabetes (high monounsaturated fat) to facilitate metabolic control. The best drug treatment for treating hyperglycaemia/diabetes in hospitalised patients is insulin and we make recommendations for adapt the theoretical insulin action to the nutrition infusion regimen. We also addressed recommendations for future investigation. CONCLUSIONS: This recommendations about artificial nutrition in patients with diabetes or stress hyperglycaemia can add value to clinical work.

Acalasia: Manejo nutricional de un paciente complicado / Acalasia: Nutritional management of a complicated patient

El soporte nutricional para el paciente hospitalario debe ir evolucionando con la situación clínica del paciente y adecuarse a sus necesidades nutricionales en cada momento. Este caso es la descripción de un paciente con acalasia en el que tras la recurrencia de síntomas se decide resolver mediante cirugía. A su ingreso para la intervención se inicia una nutrición parenteral preoperatoria con unas características según recomendaciones actuales, que es cambiada tras la intervención por una nutrición postoperatoria adecuada. A continuación, tras la entrada del paciente en una situación séptica, se hace un repaso de las recomendaciones más actuales sobre nutrición parenteral en paciente crítico para luego describir el tipo de elaborado utilizado y cómo ésta nutrición va cambiando para adaptarse a los nuevos requerimientos nutricionales, consiguiendo así una mejoría del paciente (AU)

Nutritional support for the hospital patient must evolve with the patient’s clinical condition and fit his nutritional needs at all times. This case is the description of a patient with acalasia in which case the recurrence of symptoms it is hereby resolved by surgery. After admission to the intervention surgery begins with preoperative parenteral nutrition as current recommendations, which is changed after the intervention by an adequate postoperative nutrition. After the patient reaches sepsis state we review the most current recommendations on parenteral nutrition for critical ill patients. Afterwards the used compound and the used type of nutrition are described, and how this nutrition is adapted to the new nutritional requirements, thus achieving the patient’s improvement (AU)

Posible utilidad de la calcitonina sérica en pacientes sépticos en riesgo de desarrollar SIRPA / Possible utility of serum calcitonin in septic patients at risk of ARDS

El desarrollo del síndrome de insuficiencia respiratoria progresiva del adulto (SIRPA) es una complicación grave en pacientes de terapia intensiva y su diagnóstico usualmente es tardío. Recientemente se reportó que la determinación sérica de calcitonina puede identificar a los pacientes quemados que desarrollan insuficiencia respiratoria. Describimos un caso de SIRPA secundario a sepsis abdominal, en el cual la determinación de calcitonina sérica se reportó en 100 pg/mL, sin otros factores condicionales de hipercalcitoninemia al momento del problema respiratorio, con evolución a falla multiorgánica y muerte. Se discuten los mecanismos probables de hipercalcitoninemia en el enfermo crítico, con énfasis en su posible utilidad clínica en presencia de insuficiencia respiratoria.

Excitation by irritant chemical substances of sensory afferent units in the cat's cornea.

1. Single-unit electrical activity was recorded from thin myelinated sensory nerve fibres innervating the cornea of deeply anaesthetized cats. 2. Based on their responses to mechanical (calibrated von Frey hairs), chemical (10 mM-acetic acid and/or 616 mM-NaCl) and thermal (ice-cold or heat up to 51 degrees C) stimuli, corneal A delta fibres were classified as polymodal nociceptors (63%), high-threshold mechanoceptors (22%) and mechano-heat nociceptors (15%). Thin myelinated fibres responding only to cold were found in the limbus of the eye. 3. Application of 10 mM-acetic acid on the corneal surface for 30 s evoked in polymodal fibres a brisk discharge of impulses often followed by a low-frequency impulse activity. NaCl (616 mM) produced a more gradual and sustained firing response. 4. The responses of polymodal fibres to acid were proportional to extracellular pH values (pH range: 4.5-6.0). After sensitization to repeated heating, most mechano-heat units developed a sensitivity to acidic stimulation. 5. Topical 0.33 mM-capsaicin excited polymodal nociceptors of the cornea; 5 min after capsaicin about 15% of these fibres were inactivated to all subsequent stimuli. In the rest of the fibres, chemical and thermal sensitivity disappeared after 0.33-3.3 mM-capsaicin, but mechanosensitivity was preserved. 6. Corneal mechanoceptors and limbal cold receptors were not affected by capsaicin (up to 33 mM). 7. These experiments demonstrate that the cornea of the cat is innervated by polymodal as well as mechanoceptive A delta nociceptors. In polymodal nociceptive fibres, mechanical and chemical sensitivities appear to be subserved by separate transduction mechanisms.

Effects of capsaicin on corneal wound healing.

This study examined whether the depletion of neuropeptides from sensory nerve terminals induced by capsaicin modifies the healing rate of experimental corneal wounds in adult rabbits. Capsaicin (33 or 3.3 mM solutions) was administered topically and/or by a single retrobulbar injection to one eye while the fellow eye, treated with the vehicle, served as a control. After 1-3 weeks of treatment, an epithelial wound was made in the center of the cornea of both eyes with n-heptanol. Migration rates of epithelial cells surrounding the wound and estimated wound closure times were calculated by measuring the reduction in wound size. Combined treatment with 33 mM retrobulbar and 3.3 mM topical capsaicin for 3 weeks induced a significant delay in epithelial migration rates and in wound closure times (P less than 0.05). Topical or retrobulbar capsaicin alone for 3 weeks and combined treatment lasting only 1 week were not sufficient to modify wound healing times. The substance P antagonist, spantide (3 mM), applied topically for 1-3 weeks before or immediately after corneal wounding was also ineffective in changing wound closure rates. These findings suggest that the delayed wound healing observed after prolonged treatment with capsaicin could be due to a sustained depletion of neuropeptides from corneal sensory endings, supporting the hypothesis that trophic effects of sensory nerves on corneal epithelium are, at least in part, mediated by neuropeptides contained in peripheral nerve terminals.