Utilización de glutamina en nutrición parenteral en paciente crítico: efectos sobre la morbi-mortalidad / Glutamine use for parenteral nutritin in the critically ill patient: effects on morbimortality

Objetivos: Determinar la relación entre aditivar dipéptidos de glutamina a la nutrición parenteral (NP) y la morbi-mortalidad en paciente crítico. Material y métodos: Estudio retrospectivo de casos y controles. Como casos se recogieron pacientes a los que se administró NP suplementada con 2 g de nitrógeno (glutamina) durante el período 2001-2004. Los controles fueron pacientes con NP sin glutamina recogidos durante el 2000. Todos los pacientes incluidos presentaban infección definida como la presencia de un foco infeccioso más 2 de los siguientes criterios: leucocitos > 12.000 x 106/L, fiebre > 38 ºC, frecuencia cardíaca > 90 latidos/minuto o PCO2 100 mg/L o fístula. Se excluyeron los pacientes con insuficiencia renal, diálisis previa, encefalopatía hepática o dieta mixta. Las variables de morbi-mortalidad registradas fueron: hiperglucemia, fracaso renal, días con NP, días en UCI, días de hospitalización y mortalidad. Resultados: Se incluyeron 202 pacientes (75 casos y 127 controles). En el estudio univariante previo no aparecieron diferencias significativas para las variables independientes entre los 2 grupos. En el estudio multivariante, la aditivación de glutamina se asoció significativamente a menor incidencia de fracaso renal (OR:0,28; IC:0,08-1,00), menor hiperglucemia (OR:0,38; IC:0,19-0,75), menos días de hospitalización (OR:0,64; IC: 0,44-0,92) y menos días en UCI (OR:0,64; IC: 0,45-0,93). Para la variable exitus, la adición de glutamina mostró tendencia a la inclusión en el modelo (p = 0,097). En cuanto a los días con NP la variable glutamina no se incluyó en modelo Conclusiones: En pacientes críticos, la adición de glutamina a la NP conlleva una recuperación más rápida y menor incidencia de hiperglucemia y fracaso renal. Dados estos resultados, la adición de glutamina a las NP de determinados pacientes es un recurso efectivo para acelerar su recuperación y evitar determinadas complicaciones

Objective: To determine the relationship between adding glutamine dipeptides to parenteral nutrition (PN) and morbimortality in the critically ill patient. Material and methods: Case-control retrospective study. The cases were patients to whom PN supplemented with 2 g of nitrogen (glutamine) was administered during the period 2001-2004. Controls were patients with PN without glutamine, collected during the year 2000. All included patients had infection defined as the presence of an infectious site plus more than two of the following criteria: leucocytes > 12.000 x 106/L, fever > 38 ºC, heart rate > 90 bmp, or PCO2 100 mg/L or a fistula. Patients with renal failure, previous dialysis, hepatic encephalopathy, or mixed diet were excluded from the study. Morbimortality variables collected were: hyperglycemia, renal failure, days on PN, days in the ICU, hospitalization days, and mortality. Results: Two hundred and two patients (75 cases and 127 controls) were included. In the previous univariate analysis no significant differences appeared for independent variables between both groups. In the multivariate analysis, glutamine addition was significantly associated to lower renal failure incidence (OR: 0.28; CI: 0.08- 1.00), lower hyperglycemia (OR: 0.38; CI: 0.19-0.75), less hospitalization days (OR: 0.64; CI: 0.44-0.92), and fewer days in the ICU (OR: 0.64; CI: 0.45-0.93). For the variable “exitus”, glutamine addition showed a trend towards inclusion into the model (p = 0.097). About the days on PN, the variable glutamine was not included into the model. Conclusions: In critically ill patients, adding glutamine to PN leads to quicker recovery and lower incidence of hyperglycemia and renal failure. In view of these results, adding glutamine to PN of particular patients is an effective measure to speed up their recovery and avoid certain complications

[Glutamine use for parenteral nutrition in the critically ill patient: effects on morbimortality]. / Utilización de glutamina en nutrición parenteral en paciente crítico: efectos sobre la morbi-mortalidad.

OBJECTIVE: To determine the relationship between adding glutamine dipeptides to parenteral nutrition (PN) and morbimortality in the critically ill patient. MATERIAL AND METHODS: Case-control retrospective study. The cases were patients to whom PN supplemented with 2 g of nitrogen (glutamine) was administered during the period 2001-2004. Controls were patients with PN without glutamine, collected during the year 2000. All included patients had infection defined as the presence of an infectious site plus more than two of the following criteria: leucocytes > 12.000 x 10(6)/L, fever > 38 degrees C, heart rate > 90 bmp, or PCO2 < 31 mmHg. Besides, they had to have prealbumin plasma levels < 15 g/L or albumin levels < 25 g/L, and CRP > 100 mg/L or a fistula. Patients with renal failure, previous dialysis, hepatic encephalopathy, or mixed diet were excluded from the study. Morbimortality variables collected were: hyperglycemia, renal failure, days on PN, days in the ICU, hospitalization days, and mortality. RESULTS: Two hundred and two patients (75 cases and 127 controls) were included. In the previous univariate analysis no significant differences appeared for independent variables between both groups. In the multivariate analysis, glutamine addition was significantly associated to lower renal failure incidence (OR: 0.28; CI: 0.081.00), lower hyperglycemia (OR: 0.38; CI: 0.19-0.75), less hospitalization days (OR: 0.64; CI: 0.44-0.92), and fewer days in the ICU (OR: 0.64; CI: 0.45-0.93). For the variable "exitus", glutamine addition showed a trend towards inclusion into the model (p = 0.097). About the days on PN, the variable glutamine was not included into the model. CONCLUSIONS: In critically ill patients, adding glutamine to PN leads to quicker recovery and lower incidence of hyperglycemia and renal failure. In view of these results, adding glutamine to PN of particular patients is an effective measure to speed up their recovery and avoid certain complications.

Intoxicaciones agudas en el servicio de urgencias de un hospital universitario de nivel III: cambios producidos en los últimos 10 años / Acute poisoning in the emergency department of a level III universitary hospital: changes produced in the last 10 years

El objetivo fue evaluar los cambios epidemiológicos enlas intoxicaciones agudas (IA) entre 1994 y 2004. Para ello seestudiaron todos los casos atendidos en Urgencias con el diagnósticode intoxicación aguda, mediante un estudio transversal descriptivoanalítico desarrollado en dos períodos de un mes separados por 10 años, y comparando los resultados. Se registraron los datosdemográficos, clínicos y toxicológicos.La prevalencia de IA en Urgencias entre los períodos estudiadosaumentó significativamente (0,83 vs 1,25%) mientras que lahospitalización por esta causa pasó del 30,5% al 6,34%. La edadmedia se mantuvo entre los 32-33 años, así como la relaciónhombre/mujer, que osciló alrededor de 1. No se registraronfallecimientos.Los medicamentos fueron el tóxico más frecuente (51,3% y 62,7%respectivamente) con un aumento debido principalmente a lasbenzodiazepinas (BDZ). Asimismo, el alcohol incrementó supresencia en intoxicaciones múltiples, disminuyendo como agenteúnico. Las admisiones por drogas de abuso experimentaron unretroceso, del 26 al 19%. Los pacientes que recibieron tratamiento dealgún tipo disminuyeron aunque no de forma significativa, del 52,8 al44,4% y, a pesar del aumento de las BDZ, la utilización deflumazenilo varió de un 7% a un 8,5% de los casos. La utilización denaloxona disminuyó a la mitad.Los intentos de suicidio aumentaron el 25%, lo que supuso el 65% deltotal de la IA en el segundo período estudiado. La hospitalización, porel contrario, pasó de un 45% a un 6% en estos pacientes. Losfármacos, y entre ellos los psicotropos, fueron el tóxico másfrecuente, implicados en el 62% y 78% de los intentos de suicidio. Laasociación fármaco y alcohol aumentó de manera significativa (10% vs 22%). El registro de pacientes con antecedentes psiquiátricos seincrementó del 29% al 75%. En el intervalo de 21 a 30 años, elporcentaje de mujeres implicadas es el doble que el de hombres enambos períodos.La prevalencia de la IA experimentó un incremento significativo,paralelamente a los intentos de autolisis; sin embargo los ingresos enunidades de hospitalización, disminuyeron considerablemente tanto en el global de la IA como en los intentos de suicidio. Losmedicamentos, y entre ellos las BDZ fueron el tóxico más frecuente(AU)

The aim was to evaluate the epidemiological changes in the acutepoisonings (AP) between 1994 and 2004. For this purpose, all thecases attended at the Emergency Service with the diagnosis of acutepoisoning were studied, by means of a transverse descriptiveanalytical study developed in two periods of one month separated for 10 years, and comparing the results. The demographic, clinical andtoxicological data were recorded.The acute poisoning's prevalence in the Emergency Service increasedsignificantly (0,83 vs. 1,25%) whereas the hospitalization for thisreason decreased from 30,5% to 6,34%. The average age of our serieswere unchanged, (between 32-33 years) as well as the relation man /woman,that it ranged about 1. No deaths were recorded.Drugs were the most frequent poisoning agent (51,3% and 62,7%respectively) with an increase due principally to the benzodiazepines.Likewise, the alcohol increased its presence in multiple poisonings, diminishing as the only agent. The admissions for drugs of abuseexperienced a setback, from 26 to 19%. The patients who receivedany type of treatment diminished but not in a significant form, from 52,8 to 44,4% and, in spite of the benzodiazepines increase, theutilization of flumazenil changed from 7% to 8,5% of the cases. Theutilization of naloxone diminished to the half.The attempts of suicide increased 25%, which supposed 65% of thewhole of the IA in the second studied period. The hospitalization, onthe contrary, descended from 45% to 6% in these patients. Drugs, andamong them the psychotropes, were the most frequent poisoningagent, implied in 62% and 78% of the suicide attempts. Theassociation drug and alcohol increased in a significant way (10% vs.22%). The patients' record with psychiatric precedents was increasedfrom 29% to 75%. In the age interval from 21 to 30, the percentage ofwomen is twice than that of men in both periods.The prevalencia of the IA experienced a significant increase, parallelto the attempts of autolisis; nevertheless the admission inhospitalization units, diminished both in the global of the IA and inthe suicide attempts. Drugs, and among them the benzodiacepineswere the toxic agent most frequently involved(AU)

[Automation of parenteral nutrition elaboration: adaptation to in force legislation]. / Automatización de la elaboración de nutrición parenteral: adecuación a la legislación actual.

INTRODUCTION: Quality and efficiency criteria of allowances associated to technological procedures are developing in a setting that values quality, and from there the Real Decree RD175/2001 has been issued by which the rules of correct elaboration and quality control of formulations and pharmacy preparations. Parenteral nutrition (PN) is a formulation and, as such, its elaboration and control have to agree with the in force regulations. With this aim, at the Bellvitge University Hospital we have developed a project for automation of elaboration of PN mixtures with the MicroMacro Pump 23 Baxa Compounder. OBJECTIVES: To assess the impact of implementing an automated system of volumetric control in PN elaboration. MATERIAL AND METHODS: The project development may be divided into two differentiated aspects. The first one consisted in the implementation and optimization of the automated system of volumetric control (ASVC). The second aspect comprehends the comparative control performed between the new system and the previous one, and which consisted of a gravimetric system with visual control. For that, real weights were gathered and were compared to predicted weights, and the time of elaboration per bag before and at two times after the implementation of the automated system was registered; the first time just after implementation of the system, and the second time within one year. RESULTS: For the comparison study between both systems used, 141 preparations in total, corresponding to individualized PN, were analyzed: 47 elaborated by means of the gravimetric system (GS), 47 with the ASVC during the implementation period (PN ASVC period 1), 47 PN elaborated with the ASVC within one year of implementation (PN ASVC period 2). The average variation between real weight and predicted weight at the three periods (pre-ASVC, NP ASVC period 1, NP ASVC period 2) was 2.41%, 1.35% and 1.25% respectively (table I). This decrease was statistically significant (p = 0.014). When analyzing the percentage of preparations out of the 3% variation range, we observed a significant reduction (p = 0.00001) by comparing the three periods (Table II). The average elaboration time with the ASVC increased approximately in 4 minutes by bag (3 min 58 sec) during the first studied period, and 3 min 10 sec during the second period, as compared with the study period with the GS. CONCLUSIONS: The new bag-filling system by means of volumetric control represents an improvement in accuracy control and a decrease in the risk for surpassing the acceptable limits. The implementation of a new technological procedure is a difficult task that implies the change of many aspects of the daily practice and that requires a "cultural" change in the PN Unit with the aim of optimizing the process. However, these issues allow for an adaptation to legal requisites in force regarding the regulations of proper elaboration and quality control of formulations as well as an improvement in the integral quality of care.

Implantación y evaluación del análisis de peligros y puntos de control críticos (APPCC) en las industrias tinerfeñas productoras de Gofio / Implementation and evaluation of critical hazards and check points analysis (chcpa) in gofio-producing industries from Tenerife

Objetivo: Implantar de manera satisfactoria el Sistema de Análisis de Peligros y Puntos de Control Críticos. Ámbito: la Isla de Tenerife. Sujetos: 15 industrias. Intervención: se procedió realizando visitas a las fábricas productoras de gofio, con el fin de asesorar a los empresarios y operarios de las mismas, posteriormente se valoró la intervención verificando condiciones higiénico-sanitarias de la industria y la correcta aplicación del Sistema de Autocontrol establecido. Resultados: Después de la intervención de asesoramiento, se observa que determinados parámetros tenidos en cuenta desde el punto de vista higiénico-sanitario se han corregido, como modificar sus instalaciones para adecuarlas a las normativas vigentes o pedir que los proveedores certifiquen las materias primas. En cuanto al proceso de producción del alimento, la intervención fue efectiva para que más de la mitad de las industrias redujeran el tiempo de aquellas fases más susceptibles de contaminación y para que se llevaran a cabo los de registros de control que se establecieron. Conclusiones: Todas las industrias instauraron el sistema de autocontrol mediante cuadros de registros de cada una de las fases de elaboración. El 86% de las industrias han introducido materiales más higiénicos. Un 60% aplicaron una reducción en los plazos de tiempo intermedios en las fases de producción. Un 26% realizaron alguna sustitución de maquinaria obsoleta, modernizando las instalaciones (AU)

Objective: To satisfactorily implement the critical hazards and check points analysis. Setting: Tenerife Island. Subjects: 15 industries. Intervention: visits to gofio-manufacturing industries were done with the aim of giving advice to employers and workers, and thereafter, the intervention was assessed verifying the hygiene and sanitary conditions of the industry and the correct application of the established auto-control system. Results: After the advising intervention, we observed that certain parameters taken into account from the hygiene and sanitary perspective have been corrected, such as modifying the facilities to adapt them to in force regulations, or asking the suppliers to certify raw materials. With regards to food production process, the intervention was effective in such a way that more than have of the industries reduced the time of those phases with higher contamination susceptibility and to carry out the control registries that were established. Conclusions: All industries implemented the autocontrol system by means of registration charts of each one of the elaboration phases. - 86% of the industries have introduced more hygienic materials. - 60% implemented a reduction in intermediate times of production phases. - 26% performed some obsolete machinery replacement modernizing the facilities (AU)