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.

[Influence of temperature on food intake in hospitalized patients]. / Influencia de la temperatura en la ingesta de pacientes hospitalizados.

BACKGROUND AND OBJECTIVES: Prevalence of hyponutrition in hospitalized patients is very high and it has been shown to be an important prognostic factor. Most of admitted patients depend on hospital food to cover their nutritional demands being important to assess the factors influencing their intake, which may be modified in order to improve it and prevent the consequences of inadequate feeding. In previous works, it has been shown that one of the worst scored characteristics of dishes was the temperature. The aim of this study was to assess the influence of temperature on patient's satisfaction and amount eaten depending on whether the food was served in isothermal trolleys keeping proper food temperature or not. MATERIAL AND METHODS: We carried out satisfaction surveys to hospitalized patients having regular diets, served with or without isothermal trolleys. The following data were gathered: age, gender, weight, number of visits, mobility, autonomy, amount of orally taken medication, intake of out-of-hospital foods, qualification of food temperature, presentation and smokiness, amount of food eaten, and reasons for not eating all the content of the tray. RESULTS: Of the 363 surveys, 134 (37.96%) were done to patients with isothermal trays and 229 (62.04%) to patients without them. Sixty percent of the patients referred having eaten less than the normal amount within the last week, the most frequent reason being decreased appetite. During lunch and dinner, 69.3% and 67.7%, respectively, ate half or less of the tray content, the main reasons being as follows: lack of appetite (42% at lunch time and 40% at dinner), do not like the food (24.3 and 26.2%) or taste (15.3 and 16.8%). Other less common reasons were the odor, the amount of food, having nausea or vomiting, fatigue, and lack of autonomy. There were no significant differences in the amount eaten by gender, weight, number of visits, amount of medication, and level of physical activity. The food temperature was classified as adequate by 62% of the patients, the presentation by 95%, and smokiness by 85%. When comparing the patients served with or without isothermal trays, there were no differences with regards to baseline characteristics analyzed that might have had an influence on amount eaten. Ninety percent of the patients with isothermal trolley rated the food temperature as good, as compared with 57.2% of the patients with conventional trolley, the difference being statistically significant (P = 0.000). Besides, there were differences in the amount of food eaten between patients with and without isothermal trolley, so that 41% and 27.7% ate all the tray content, respectively, difference being statistically significant (P = 0.007). There were no differences in smokiness or presentation rating. CONCLUSIONS: Most of the patients (60%) had decreased appetite during hospital admission. The percentage of hospitalized patients rating the food temperature as being good is higher among patients served with isothermal trolleys. The amount of food eaten by the patients served with isothermal trolleys is significantly higher that in those without them.

Influencia de la temperatura en la ingesta de pacientes hospitalizados / Influence od temperatura on food intake in hospitalizad patients

Antecedentes y objetivos: La prevalencia de desnutrición en los pacientes hospitalizados es muy elevada y se ha demostrado que constituye un factor pronóstico importante. La mayoría de los pacientes ingresados dependen de la comida hospitalaria para cubrir sus requerimientos nutricionales siendo importante el análisis de los factores que influyen en la ingesta y que se puedan modificar, para conseguir mejorarla y así evitar las consecuencias derivadas de una nutrición inadecuada. En anteriores trabajos se ha demostrado que una de las características de la comida peor valoradas por los pacientes es la temperatura. El objetivo de este trabajo fue evaluar la influencia de la temperatura en la satisfacción y cantidad ingerida en función de que se sirviese o no en carros isotérmicos que mantienen una temperatura adecuada de la comida. Material y métodos: Se realizaron encuestas de satisfacción a pacientes del hospital con y sin carros isotérmicos con dietas basales. Se recogieron los siguientes datos: edad, sexo, peso, número de visitas, movilidad, autonomía, cantidad de medicación por vía oral, ingestión de alimentos traídos de fuera del hospital, calificación de la temperatura, presentación y humedad, cantidad de comida ingerida y motivos por los que no se ingirió todo el contenido del carro isotérmico. Resultados: De las 363 encuestas, 134 de ellas (37,96%) se realizaron en pacientes con bandeja térmica y 229 (62,04%) en pacientes sin ella. El 60% de los pacientes referían haber comido menos de lo normal en la última semana siendo la causa más frecuente la disminución de apetito. En el almuerzo y cena comieron la mitad o menos del contenido de la bandeja el 69,3% y 67,7% respectivamente, siendo las causas más frecuentes las siguientes: la falta de apetito (42% en almuerzo y 40% en cena), no gustarles la comida (24,3 y 26,2%) y el sabor (15,3 y 16,8%). Otras causas menos frecuentes fueron el olor, la cantidad de comida, presentar náuseas o vómitos, cansancio y falta de autonomía. No hubo diferencias significativas en la cantidad de ingesta en función del sexo, peso, número de visitas, cantidad de medicación y grado de actividad. La temperatura de la comida fue clasificada como buena por el 62% de los pacientes, la presentación por el 95% y la humedad por el 85%. Al comparar a los pacientes con y sin carro isotérmico, no hubo diferencias en las características basales analizadas que pudiesen influir en la cantidad ingerida. Calificaron la temperatura como buena un 90% de los pacientes con carro isotérmico y un 57,2% sistema tradicional, siendo esta diferencia estadísticamente significativa (P = 0,000). Además hubo diferencias en la cantidad de comida ingerida entre los pacientes con y sin carro isotérmico, de modo que se lo comieron todo un 41% frente al 27,7% respectivamente siendo esta diferencia estadísticamente significativa (P = 0,007). No hubo diferencias en la calificación de humedad y presentación. Conclusiones: La mayoría de los pacientes (60%) presentan disminución de apetito durante el ingreso. La proporción de ingresados que califican la temperatura como buena es mayor en los pacientes con el sistema de carros isotérmicos. La cantidad ingerida por los pacientes con carros isotérmicos es significativamente mayor que en los pacientes sin ellos (AU)

Background and objectives: Prevalence of hyponutrition in hospitalized patients is very high and it has been shown to be an important prognostic factor. Most of admitted patients depend on hospital food to cover their nutritional demands being important to assess the factors influencing their intake, which may be modified in order to improve it and prevent the consequences of inadequate feeding. In previous works, it has been shown that one of the worst scored characteristics of dishes was the temperature. The aim of this study was to assess the influence of temperature on patient's satisfaction and amount eaten depending on whether the food was served in isothermal trolleys keeping proper food temperature or not. Material and methods: We carried out satisfaction surveys to hospitalized patients having regular diets, served with or without isothermal trolleys. The following data were gathered: age, gender, weight, number of visits, mobility, autonomy, amount of orally taken medication, intake of out-of-hospital foods, qualification of food temperature, presentation and smokiness, amount of food eaten, and reasons for not eating all the content of the tray. Results: Of the 363 surveys, 134 (37.96%) were done to patients with isothermal trays and 229 (62.04%) to patients without them. Sixty percent of the patients referred having eaten less than the normal amount within the last week, the most frequent reason being decreased appetite. During lunch and dinner, 69.3% and 67.7%, respectively, ate half or less of the tray content, the main reasons being as follows: lack of appetite (42% at lunch time and 40% at dinner), do not like the food (24.3 and 26.2%) or taste (15.3 and 16.8%). Other less common reasons were the odor, the amount of food, having nausea or vomiting, fatigue, and lack of autonomy. There were no significant differences in the amount eaten by gender, weight, number of visits, amount of medication, and level of physical activity. The food temperature was classified as adequate by 62% of the patients, the presentation by 95%, and smokiness by 85%. When comparing the patients served with or without isothermal trays, there were no differences with regards to baseline characteristics analyzed that might have had an influence on amount eaten. Ninety percent of the patients with isothermal trolley rated the food temperature as good, as compared with 57.2% of the patients with conventional trolley, the difference being statistically significant (P = 0.000). Besides, there were differences in the amount of food eaten between patients with and without isothermal trolley, so that 41% and 27.7% ate all the tray content, respectively, difference being statistically significant (P = 0.007). There were no differences in smokiness or presentation rating. Conclusions: Most of the patients (60%) had decreased appetite during hospital admission. The percentage of hospitalized patients rating the food temperature as being good is higher among patients served with isothermal trolleys. The amount of food eaten by the patients served with isothermal trolleys is significantly higher that in those without them (AU)

[The quality of the care in parenteral nutrition: the benefits after the incorporation of a nutritional support team]. / Calidad asistencial en nutrición parenteral: beneficios tras la incorporación de un equipo de soporte nutricional.

GOALS: The purpose of the study was to analyze the quality of the prescription and follow-up of the total parenteral nutrition (PNT) before and after the incorporation of a nutritional support team (NST). MATERIAL AND METHODS: A random sample of 96 patients was selected retrospectively, with 48 prior to the incorporation of the NST (the Non-NST group) and 48 after its incorporation (the NST group), to whom TPN was prescribed. The following points were assessed: 1. The existence of a minimum analytical and nutritional assessment, prior to the incorporation of TPN; 2. The follow-up of the same. RESULTS: The average duration of TPN per patient was 13.8 days without differences between the two groups. There is a written record of the weight and height in 15% and 10% of cases, respectively, in the Non-NST group as opposed to 100% and 99% in the NST group (p < 0.0001). Prior to the incorporation of the NST, the nutritional requirement was not verified in any patients (0%) as opposed to 97% afterwards. Statistically significant differences were detected in the measurement of albumin prior to the start of TPN (p < 0.01). During the analytical follow-up, statistically significant differences were detected in the measurement of: blood tests (p < 0.05); basic biochemistry (p < 0.01); general biochemistry, magnesium, zinc, pre-albumin, transferrin and nitrogen balance (p < 0.0001). In the TPN follow-up, the Non-NST group did not change any of the components contained in it (in terms of volume, macro or micronutrients) in 81% of patients, while 17% had one change and 2% had 2 or more changes, as opposed to 27%, 42% and 31%, respectively in the NST group (p < 0.0001). There were no significant differences in metabolic complications between the two groups. CONCLUSIONS: The implementation of a nutritional support team in charge of the prescription and follow-up of TPN has notably improved the quality of these follow-up studies.

Calidad asistencial en nutrición parenteral: beneficios tras la incorporación de un equipo de soporte nutricional / Quality of assistance in parenteral nutrition: benefits following the incorporation of a nutritional support team

Objetivos: El objetivo del trabajo fue analizar la calidad de la prescripción y seguimiento de la nutrición parenteral total (NPT) antes y después de la incorporación de un equipo de soporte nutricional (ESN).Material y métodos: Se seleccionó retrospectivamente una muestra aleatoria de 96 pacientes, 48 previos a la incorporación del ESN (grupo NOESN) y 48 posteriores (grupo ESN), a los que se les prescribió NPT. Se evaluó: l) la existencia de una valoración nutricional y analítica mínima, previa a la instauración de la NPT y 2) el seguimiento de la misma.Resultados: La duración media de la NPT por paciente fue de 13,8 días sin diferencias en ambos grupos. Existía constancia escrita del peso y la talla (respectivamente) en el 15 por ciento y 10 por ciento de los casos, en el grupo NOESN, frente al 100 por ciento y 99 por ciento en el ESN (p 2 modificaciones en el 2 por ciento, frente al 27 por ciento, 42 por ciento y 31 por ciento, respectivamente, en el grupo ESN (p < 0,0001). No existieron diferencias significativas en cuanto a complicaciones metabólicas entre los dos grupos.Conclusiones: La implantación de un equipo de soporte nutricional, encargado de la prescripción y seguimiento de la NPT, ha mejorado notablemente la calidad en el seguimiento de las mismas (AU)

Goals: The purpose of the study was to analyze the quality of the prescription and follow-up of the total parenteral nutrition (PNT) before and after the incorporation of a nutritional support team (NST). Material and methods: A random sample of 96 patients was selected retrospectively, with 48 prior to the incorporation of the NST (the Non-NST group) and 48 after its in-corporation (the NST group), to whom TPN was prescribed. The following points were assessed: 1. The existence of a minimum analytical and nutritional assessment, prior to the incorporation of TPN; 2. The follow-up of the same. Results: The average duration of TPN per patient was 13.8 days without differences between the two groups. There is a written record of the weight and height in 15% and 10% of cases, respectively, in the Non-NST group as opposed to 100% and 99% in the NST group (p < 0.0001). Prior to the incorporation of the NST, the nutritional requirement was not verified in any patients (0%) as opposed to 97% afterwards. Statistically significant differences were detected in the measurement of albumin prior to the start of TPN (p < 0.01). During the analytical follow-up, statistically significant differences were detected in the measurement of: blood tests (p < 0.05); basic biochemistry (p < 0.01); general biochemistry, magnesium, zinc, pre-albumin, transferrin and nitrogen balance (p < 0.0001). In the TPN follow-up, the Non-NST group did not change any of the components contained in it (in terms of volume, macro or micronutrients) in 81% of patients, while 17% had one change and 2% had 2 or more changes, as opposed to 27%, 42% and 31 %, respectively in the NST group (p < 0.0001). There were no significant differences in metabolic complications between the two groups. Conclusions: The implementation of a nutritional support team in charge of the prescription and follow-up of TPN has notably improved the quality of these follow-up studies (AU)