Guía Práctica EsPEN: nutrición enteral domiciliaria / ESPEN practical guideline: Home enteral nutrition

Esta guía práctica de la European Society for Clinical Nutrition and Metabolism (ESPEN) proporciona información a médicos, enfermeras, dietistas, farmacéuticos, cuidadores y otros proveedores de nutrición enteral domiciliaria (NED) de forma concisa, sobre las indicaciones y contraindicaciones de la NED, así como sobre su administración y seguimiento. Esta guía también ofrece información a los pacientes interesados que necesiten NED. La nutrición parenteral domiciliaria no está incluida, pero se abordará en otra guía de la ESPEN. La guía se basa en la guía científica de la ESPEN publicada anteriormente, que consta de 61 recomendaciones (que se han reproducido y renumerado), junto con los comentarios asociados (que se han resumido en relación a la guía científica). Se indican los grados de evidencia y los niveles de consenso. La ESPEN encargó y financió la guía y seleccionó también a los miembros del grupo.(AU)

This ESPEN practical guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home enteral nutrition (HEN) providersin a concise way about the indications and contraindications for HEN, as well as its implementation and monitoring. This guideline will also informinterested patients requiring HEN. Home parenteral nutrition is not included but will be addressed in a separate ESPEN guideline. The guideline isbased on the ESPEN scientific guideline published before, which consists of 61 recommendations that have been reproduced and renumbered,along with the associated commentaries that have been shorted compared to the scientific guideline. Evidence grades and consensus levels areindicated. The guideline was commissioned and financially supported by ESPEN and the members of the guideline group were selected by ESPEN.(AU)

Systematic review of service improvements for home enteral tube feeding in adults.

BACKGROUND: Patients receiving home enteral tube feeding (HETF) have a high risk of complications and readmission to hospital. This study aims to evaluate effectiveness of staff- and/or patient-focused service-improvement strategies on clinical, patient-reported, and economic outcomes for patients receiving HETF across adult settings. METHODS: The search was conducted using MEDLINE, EMBASE, and CINAHL databases. Quality of studies were appraised using the Cochrane Collaboration Risk of Bias tool and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessment. RESULTS: Eleven studies met the inclusion criteria. Pooled data found targeted HETF education with patients, carers, and staff significantly improved knowledge immediately after education and was sustained at 3-6 months. Multimodal interventions, including the formation of specialist HETF teams, significantly reduced complications such as infection, gastrostomy blockage, tube displacement, and feed intolerance but do not significantly reduce unplanned hospital encounters (outpatient clinic visits, hospitalizations, and emergency presentations). Owing to the high risk of bias in the included studies, there is low-quality evidence to support staff training, patient education, and dedicated HETF teams. CONCLUSION: This review highlights the need for further quality research to allow higher-level evidence for determining the usefulness of interventions aimed at improving outcomes for patients receiving HETF. Future research needs to include greater assessment of quality of life, quantification of the value of interventions in economic terms, and use of translational research frameworks. However, effective staff and patient education programs, along with comprehensive multidisciplinary care, should be considered standard care until a larger research base is developed.

ESPEN practical guideline: Home enteral nutrition.

This ESPEN practical guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home enteral nutrition (HEN) providers in a concise way about the indications and contraindications for HEN, as well as its implementation and monitoring. This guideline will also inform interested patients requiring HEN. Home parenteral nutrition is not included but will be addressed in a separate ESPEN guideline. The guideline is based on the ESPEN scientific guideline published before, which consists of 61 recommendations that have been reproduced and renumbered, along with the associated commentaries that have been shorted compared to the scientific guideline. Evidence grades and consensus levels are indicated. The guideline was commissioned and financially supported by ESPEN and the members of the guideline group were selected by ESPEN.

Guía de práctica clínica para el manejo de la nutrición enteral en el recién nacido prematuro con muy bajo peso al nacer / Guide to Clinical Practice for the Management of Enteral Nutrition in the Premature Newborn with Very Low Birth Weight

El bajo peso al nacer (BPN) se define como un peso inferior a 2500 g, según la Organización Mundial de la Salud (OMS). A la vez el BPN se clasifica a su vez en muy bajo peso al nacer (MBPN, <1500 g) y extremadamente bajo peso al nacer (EBPN, <1000 g) [1]. Los recién nacidos con muy bajo peso al nacer (MBPN) comprenden entre el 4 y el 8% de los nacidos vivos, pero un tercio de las muertes durante el periodo neonatal se producen en este grupo de recién nacidos [2]. La nutrición postnatal es importante en estos recién nacidos para conseguir un crecimiento postnatal similar al crecimiento fetal y que vaya acompañado de resultados de desarrollo adecuados a largo plazo [3-5]. Sin embargo, la restricción del crecimiento postnatal (RCP) se observa con frecuencia en muchos de los RNMBPN en las unidades de cuidados intensivos neonatales durante las primeras semanas y meses de vida [6, 7]. Por ello, el Seguro Social de Salud (EsSalud) priorizó la realización de la presente guía de práctica clínica (GPC) para establecer lineamientos basados en evidencia y gestionar de la mejor manera los procesos y procedimientos asistenciales para el manejo de la nutrición enteral en el recién nacido prematuro con muy bajo peso al nacer. Esta GPC fue realizada por la Dirección de Guías de Práctica Clínica, Farmacovigilancia y Tecnovigilancia del Instituto de Evaluación de Tecnologías en Salud e Investigación (IETSI) de EsSalud.

Development and external validation of a prediction model for tube feeding dependency for at least four weeks during chemoradiotherapy for head and neck cancer.

BACKGROUND & AIMS: Patients who receive chemoradiotherapy or bioradiotherapy (CRT/BRT) for locally advanced head and neck squamous cell carcinoma (LAHNSCC) often experience high toxicity rates interfering with oral intake, causing tube feeding (TF) dependency. International guidelines recommend gastrostomy insertion when the expected use of TF exceeds 4 weeks. We aimed to develop and externally validate a prediction model to identify patients who need TF ≥ 4 weeks and would benefit from prophylactic gastrostomy insertion. METHODS: A retrospective multicenter cohort study was performed in four tertiary head and neck cancer centers in the Netherlands. The prediction model was developed using data from University Medical Center Utrecht and the Netherlands Cancer Institute and externally validated using data from Maastricht University Medical Center and Radboud University Medical Center. The primary endpoint was TF dependency ≥4 weeks initiated during CRT/BRT or within 30 days after CRT/BRT completion. Potential predictors were extracted from electronic health records and radiotherapy dose-volume parameters were calculated. RESULTS: The developmental and validation cohort included 409 and 334 patients respectively. Multivariable analysis showed predictive value for pretreatment weight change, texture modified diet at baseline, ECOG performance status, tumor site, N classification, mean radiation dose to the contralateral parotid gland and oral cavity. The area under the receiver operating characteristics curve for this model was 0.73 and after external validation 0.62. Positive and negative predictive value for a risk of 90% or higher for TF dependency ≥4 weeks were 81.8% and 42.3% respectively. CONCLUSIONS: We developed and externally validated a prediction model to estimate TF-dependency ≥4 weeks in LAHNSCC patients treated with CRT/BRT. This model can be used to guide personalized decision-making on prophylactic gastrostomy insertion in clinical practice.

ESPEN practical guideline: Clinical nutrition in surgery.

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.

The effect of higher versus lower protein delivery in critically ill patients: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: The optimal protein dose in critical illness is unknown. We aim to conduct a systematic review of randomized controlled trials (RCTs) to compare the effect of higher versus lower protein delivery (with similar energy delivery between groups) on clinical and patient-centered outcomes in critically ill patients. METHODS: We searched MEDLINE, EMBASE, CENTRAL and CINAHL from database inception through April 1, 2021.We included RCTs of (1) adult (age ≥ 18) critically ill patients that (2) compared higher vs lower protein with (3) similar energy intake between groups, and (4) reported clinical and/or patient-centered outcomes. We excluded studies on immunonutrition. Two authors screened and conducted quality assessment independently and in duplicate. Random-effect meta-analyses were conducted to estimate the pooled risk ratio (dichotomized outcomes) or mean difference (continuous outcomes). RESULTS: Nineteen RCTs were included (n = 1731). Sixteen studies used primarily the enteral route to deliver protein. Intervention was started within 72 h of ICU admission in sixteen studies. The intervention lasted between 3 and 28 days. In 11 studies that reported weight-based nutrition delivery, the pooled mean protein and energy received in higher and lower protein groups were 1.31 ± 0.48 vs 0.90 ± 0.30 g/kg and 19.9 ± 6.9 versus 20.1 ± 7.1 kcal/kg, respectively. Higher vs lower protein did not significantly affect overall mortality [risk ratio 0.91, 95% confidence interval (CI) 0.75-1.10, p = 0.34] or other clinical or patient-centered outcomes. In 5 small studies, higher protein significantly attenuated muscle loss (MD -3.44% per week, 95% CI -4.99 to -1.90; p < 0.0001). CONCLUSION: In critically ill patients, a higher daily protein delivery was not associated with any improvement in clinical or patient-centered outcomes. Larger, and more definitive RCTs are needed to confirm the effect of muscle loss attenuation associated with higher protein delivery. PROSPERO registration number: CRD42021237530.

Feasibility of achieving different protein targets using a hypocaloric high-protein enteral formula in critically ill patients.

BACKGROUND AND AIMS: Combining energy and protein targets during the acute phase of critical illness is challenging. Energy should be provided progressively to reach targets while avoiding overfeeding and ensuring sufficient protein provision. This prospective observational study evaluated the feasibility of achieving protein targets guided by 24-h urinary nitrogen excretion while avoiding overfeeding when administering a high protein-to-energy ratio enteral nutrition (EN) formula. METHODS: Critically ill adult mechanically ventilated patients with an APACHE II score > 15, SOFA > 4 and without gastrointestinal dysfunction received EN with hypocaloric content for 7 days. Protein need was determined by 24-h urinary nitrogen excretion, up to 1.2 g/kg (Group A, N = 10) or up to 1.5 g/kg (Group B, N = 22). Variables assessed included nitrogen intake, excretion, balance; resting energy expenditure (REE); phase angle (PhA); gastrointestinal tolerance of EN. RESULTS: Demographic characteristics of groups were similar. Protein target was achieved using urinary nitrogen excretion measurements. Nitrogen balance worsened in Group A but improved in Group B. Daily protein and calorie intake and balance were significantly increased in Group B compared to Group A. REE was correlated to PhA measurements. Gastric tolerance of EN was good. CONCLUSIONS: Achieving the protein target using urinary nitrogen loss up to 1.5 g/kg/day was feasible in this hypercatabolic population. Reaching a higher protein and calorie target did not induce higher nitrogen excretion and was associated with improved nitrogen balance and a better energy intake without overfeeding. PhA appears to be related to REE and may reflect metabolism level, suggestive of a new phenotype for nutritional status. Trial registration 0795-18-RMC.

Practice patterns and adherence to nutrition guidelines in acute pancreatitis: An international physician survey.

BACKGROUND: There is agreement among GI society guidelines for recommending early oral nutrition with non-liquid diet in patients with mild acute pancreatitis (AP). There is less agreement regarding administration of tube feedings (TF) in AP. Data on physicians' adherence to nutrition guidelines and practice variations are limited. AIMS: To report practice patterns in the nutritional management of different severity profiles of AP. METHODS: We conducted an anonymous electronic survey among physician members of the International Association of Pancreatology and the American Pancreatic Association. We assessed nutrition practices based on severity of AP, and asked relevant questions regarding the preferred administration strategies for enteral nutrition. Responses were compared by practice location and subspecialty. RESULTS: A total of 178 physicians, mostly medical pancreatologists (40.4%) and surgeons (34.8%) from Europe (43.4%) and North America (32%) responded. Overall, only 26.7% initiated oral nutrition in mild AP on day 1, 40.9% waited >48 h, and 57.3% initiated nutrition with liquid diets. Physicians reported frequently using TF in patients with moderately-severe (30-75%, depending on the amount and location of necrosis) and severe AP (75-80%). Two-thirds of physicians preferred initiating TF after 48 h, administering it post-pylorically, and using semi-elemental or polymeric formulas. Median TF duration was 11 days (IQR, 7-21). Significant variations were noted based on geographic location and physician subspecialty for several aspects of nutritional practices in both mild and non-mild AP. CONCLUSION: Adherence to oral nutrition guideline recommendations for mild AP is low. There is significant variability in the use of TF in AP. Our study highlights opportunities for improving consistency of nutrition care in AP and identify potential areas for research.

Supply of enteral diets in the Espirito Santo state public health system in Brazil / Suministro de dietas enterales en el sistema público de salud del estado de Espirito Santo en Brasil

BACKGROUND: Brazil includes food as a social right, making the State responsible to the courts for the sufficient and adequate supply of enteral food. OBJECTIVES: to evaluate the supply of enteral diets in pharmacies in the state of Espirito Santo. METHODS: to do this, we used the forms filled out by patients or legal representatives, containing medical records, to analyze the nutritional and social profiles of the users over two years, and the compliance of the administrative processes with the ordinance that instituted enteral food supplies was verified. RESULTS: the sample was comprised of 204 patients receiving enteral nutrition, and the administrative procedures required to supply these patients were surveyed in seven (7/9) pharmacies. The data showed that the most common group was that of women (51 %), who were white (51 %), legally represented (91 %), and 73.5 years old (11 to 109 years). Information regarding missing anthropometric data, use of terms and calculations for obtaining enteral food other than those recommended, incomplete documents, alterations to the physical examinations suggestive of error, and nonobservance of inclusion and exclusion criteria were collected for this study. CONCLUSIONS: this study revealed that there were gaps in the process of enteral diet supply by the Espírito Santo pharmacies, both concerning compliance with the protocol and patient follow-up by the professional who assists both the patient and the pharmacist who provides the input

ANTECEDENTES: Brasil incluyó la alimentación como un derecho social, haciendo que el Estado sea responsable ante los tribunales del suministro suficiente y adecuado de alimentos. OBJETIVOS: evaluar el suministro de dietas enterales en las farmacias estatales de Espírito Santo. MÉTODOS: para hacer esto utilizamos los formularios cumplimentados por los pacientes y representantes legales que contienen registros médicos con el fin de analizar los perfiles nutricionales y sociales de los usuarios durante dos años; además, se verificó el cumplimiento de los procesos administrativos con la ordenanza que instituyó el suministro de alimentos. RESULTADOS: la muestra comprendió 204 pacientes que recibieron nutrición enteral, investigándose los procedimientos administrativos requeridos para suministrar a estos pacientes en siete (7/9) farmacias. Los datos mostraron que el grupo más común era el de mujeres (51 %), de raza blanca (51 %) y representadas legalmente (91 %), de 73,5 años de edad (11 a 109 años). Para este estudio se recopiló información sobre los datos antropométricos faltantes, el uso de términos y cálculos para obtener alimentos distintos a los recomendados, documentos incompletos, alteraciones en los exámenes físicos sugestivos de error y la no observancia de los criterios de inclusión y exclusión. CONCLUSIONES: este estudio reveló que había vacíos en el proceso de suministro de dietas enterales por parte de las farmacias de Espírito Santo en lo que respecta tanto al cumplimiento del protocolo como al seguimiento del paciente por el profesional que lo atiende y el farmacéutico que proporciona la información

Application effect of initiation of enteral nutrition at different time periods after surgery in neonates with complex congenital heart disease: A retrospective analysis.

ABSTRACT: Early enteral nutrition (EN) promotes the recovery of critically ill patients, but the initiation time for EN in neonates after cardiac surgery remains unclear.This study aimed to investigate the effect of initiation time of EN after cardiac surgery in neonates with complex congenital heart disease (CHD).Neonates with complex CHD admitted to the CICU from January 2015 to December 2017 were retrospectively analyzed. Patients were divided into the 24-hour Group (initiated at 24 hours after surgery in 2015) (n = 32) and 6-hour Group (initiated at 6 hours after surgery in 2016 and 2017) (n = 66). Data on the postoperative feeding intolerance, nutrition-related laboratory tests (albumin, prealbumin, retinol binding protein), and clinical outcomes (including duration of mechanical ventilation, CICU stay, and postoperative hospital stay) were collected.The incidence of feeding intolerance was 56.3% in 24-hour Group and 39.4%, respectively (P = .116). As compared to 24-hour Group, prealbumin and retinol binding protein levels were higher (160.7 ±â€Š64.3 vs 135.2 ±â€Š28.9 mg/L, P = .043 for prealbumin; 30.7 ±â€Š17.7 vs 23.0 ±â€Š14.1 g/L P = .054 for retinol-binding protein). The duration of CICU stay (9.4 ±â€Š4.5 vs 13.3 ±â€Š10.4 day, P = .049) and hospital stay (11.6 ±â€Š3.0 vs 15.8 ±â€Š10.3 day, P = .028) were shorter in 6-hour Group.Early EN improves nutritional status and clinical outcomes in neonates with complex CHD undergoing cardiac surgery, without significant feeding intolerance.

Semi-elemental versus polymeric formula for enteral nutrition in brain-injured critically ill patients: a randomized trial.

BACKGROUND: The properties of semi-elemental enteral nutrition might theoretically improve gastrointestinal tolerance in brain-injured patients, known to suffer gastroparesis. The purpose of this study was to compare the efficacy and tolerance of a semi-elemental versus a polymeric formula for enteral nutrition (EN) in brain-injured critically ill patients. METHODS: Prospective, randomized study including brain-injured adult patients [Glasgow Coma Scale (GCS) ≤ 8] with an expected duration of mechanical ventilation > 48 h. INTERVENTION: an enteral semi-elemental (SE group) or polymeric (P group) formula. EN was started within 36 h after admission to the intensive care unit and was delivered according to a standardized nurse-driven protocol. The primary endpoint was the percentage of patients who received both 60% of the daily energy goal at 3 days and 100% of the daily energy goal at 5 days after inclusion. Tolerance of EN was assessed by the rate of gastroparesis, vomiting and diarrhea. RESULTS: Respectively, 100 and 95 patients were analyzed in the SE and P groups: Age (57[44-65] versus 55[40-65] years) and GCS (6[3-7] versus 5[3-7]) did not differ between groups. The percentage of patients achieving the primary endpoint was similar (46% and 48%, respectively; relative risk (RR) [95% confidence interval (CI)] = 1.05 (0.78-1.42); p = 0.73). The mean daily energy intake was, respectively, 20.2 ± 6.3 versus 21.0 ± 6.5 kcal/kg/day (p = 0.42). Protein intakes were 1.3 ± 0.4 versus 1.1 ± 0.3 g/kg/day (p < 0.0001). Respectively, 18% versus 12% patients presented gastroparesis (p = 0.21), and 16% versus 8% patients suffered from diarrhea (p = 0.11). No patient presented vomiting in either group. CONCLUSION: Semi-elemental compared to polymeric formula did not improve daily energy intake or gastrointestinal tolerance of enteral nutrition. TRIAL REGISTRATION: EudraCT/ID-RCB 2012-A00078-35 (registered January 17, 2012).

Optimal outcome measures for a trial of not routinely measuring gastric residual volume in neonatal care: a mixed methods consensus process.

BACKGROUND: Routine measurement of gastric residual volume to guide feeding is widespread in neonatal units but not supported by high-quality evidence. Outcome selection is critical to trial design. OBJECTIVE: To determine optimal outcome measures for a trial of not routinely measuring gastric residual volume in neonatal care. DESIGN: A focused literature review, parent interviews, modified two-round Delphi survey and stakeholder consensus meeting. PARTICIPANTS: Sixty-one neonatal healthcare professionals participated in an eDelphi survey; 17 parents were interviewed. 19 parents and neonatal healthcare professionals took part in the consensus meeting. RESULTS: Literature review generated 14 outcomes, and parent interviews contributed eight additional outcomes; these 22 outcomes were then ranked by 74 healthcare professionals in the first Delphi round where four further outcomes were proposed; 26 outcomes were ranked in the second round by 61 healthcare professionals. Five outcomes were categorised as 'consensus in', and no outcomes were voted 'consensus out'. 'No consensus' outcomes were discussed and voted on in a face-to-face meeting by 19 participants, where four were voted 'consensus in'. The final nine consensus outcomes were: mortality, necrotising enterocolitis, time to full enteral feeds, duration of parenteral nutrition, time feeds stopped per 24 hours, healthcare-associated infection; catheter-associated bloodstream infection, change in weight between birth and neonatal discharge and pneumonia due to milk aspiration. CONCLUSIONS AND RELEVANCE: We have identified outcomes for a trial of no routine measurement of gastric residual volume to guide feeding in neonatal care. This outcome set will ensure outcomes are important to healthcare professionals and parents.

Manual de monitorização do volume prescrito e infundido em terapia nutricional enteral / Manual for monitoring the volume prescribed and infused in enteral nutritional therapy

Esse Manual foi elaborado com a intenção de orientá-lo, quanto a importância do controle do prescrito e infundido na terapia nutricional enteral. Contém informações bem simples e seguras e que abrange toda a equipe multiprofissional.

Nitrogen balance in mechanically ventilated obese patients / Balanço nitrogenado em pacientes obesos em ventilação mecânica invasiva

ABSTRACT Objective This study aimed to evaluate if the protein intake recommendations for obese critically ill requiring mechanical ventilation are sufficient to promote a positive or neutral nitrogen balance. Methods Cross-sectional study that included 25 obese, ≥18 years old, undergoing mechanical ventilation and who were target to receive high-protein enteral nutrition therapy (2.0-2.5g/kg ideal body weight). Clinical, nutritional and biochemical variables were analyzed. Nitrogen balance was performed when patient was receiving full enteral nutrition therapy and was classified: positive when intake was greater than excretion; negative when excretion was greater than intake; neutral when both were equal. Results The characteristics of patients evaluated were 64.1±9.4 years old, clinical treatment 88%, body mass index 36.5±5.1kg/m2, nitrogen balance 0.3g/day (-5.3 to 4.8g/day), protein intake 2.1g/day (2.0-2.3g/kg) ideal body weight. Of individuals analyzed, 52% showed positive or neutral nitrogen balance with median of 4.23g/day 2.41 to 6.40g/day) in comparison to negative group with median of -5.27g/day (-10.38 to -3.86g/day). Adults had higher ratio of negative nitrogen balance (57.1%) than elderly (44.4%), with protein intake of 2.0 versus 2.1g/day, respectively. No correlation was found between nitrogen balance and variables assessed. Conclusion High-protein enteral nutrition therapy contributed to positive or neutral nitrogen balance for approximately half of obese ventilated individuals. With similar protein intake, elderly showed a higher proportion of positive or neutral nitrogen balance. Nitrogen balance can be influenced by various factors, so further studies are required to identify different protein needs in obese critically.

RESUMO Objetivo Avaliar se as recomendações de ingestão proteica para obesos em ventilação mecânica invasiva são suficientes para promover balanço nitrogenado positivo ou em equilíbrio. Métodos Estudo transversal que analisou 25 obesos adultos, em ventilação mecânica invasiva e submetidos à terapia nutricional enteral hiperproteica (2,0-2,5g/kg de peso ideal). Variáveis clínicas, nutricionais e bioquímicas foram analisadas. O balanço nitrogenado foi realizado após a oferta plena da nutrição enteral e classificado como: positivo quando ingestão maior que excreção; negativo quando excreção maior que ingestão; neutro quando ambas foram iguais. Resultados As características dos pacientes avaliados foram idade 64,1±9,4 anos, índice de massa corporal 36,5±5,1kg/m2, tratamento clínico 88%, balanço nitrogenado 0,3g/dia (-5,3 a 4,8g/dia), ingestão proteica 2,1g/dia (2,0-2,3g/kg) de peso ideal. Dos indivíduos analisados, 52% apresentaram balanço nitrogenado positivo ou neutro com mediana de 4,23g/dia (2,41 a 6,40g/dia), comparado ao grupo com balanço negativo -5,27g/dia (-10,38 a -3,86g/dia). Adultos apresentaram maior proporção de balanço nitrogenado negativo (57,1%) do que idosos (44,4%), respectivamente, com ingestão proteica semelhante de 2,0 versus 2,1g/dia. Não foi observada correlação entre balanço nitrogenado e variáveis analisadas. Conclusão A terapia nutricional enteral hiperproteica promoveu um balanço nitrogenado positivo ou neutro em cerca de metade dos obesos em ventilação mecânica invasiva. Com ingestão proteica semelhante, idosos apresentaram maior proporção de balanço positivo ou neutro do que adultos. O balanço nitrogenado pode ser influenciado por diversos fatores e por esse motivo mais estudos são necessários para identificar diferentes necessidades proteicas em pacientes obesos críticos.

Results from an Epidemiological Follow-Up Survey on Home Artificial Nutrition in Switzerland from 2010 to 2015.

BACKGROUND: Home artificial nutrition (HAN) is an established treatment for malnourished patients. Since July 2012, the costs for oral nutrition supplements (ONS) are covered by the compulsory health insurance providers in Switzerland if the patient has a medical indication based on the Swiss Society for Clinical Nutrition guidelines. Therefore, the purpose of our study was to analyse the development of HAN, including ONS, before and after July 2012. METHODS: We obtained the retrospective and anonymized data from the Swiss association for joint tasks of health insurers (SVK), who registered patients on HAN. Since not all health insurers are working with SVK, this retrospective study recorded nearly 65% of all new patients on HAN in Switzerland from January 1, 2010, to December 31, 2015. RESULTS: A total of 33,410 patients (49.1% men and 50.9% women) with a mean BMI of 21.3 ± 4.5 kg/m2 and mean age of 68.9 ± 17.8 years were recorded. The number of patient cases on ONS increased from 808 cases in 2010 to 18,538 cases in 2015, while patient cases on home enteral nutrition (HEN) and home parenteral nutrition (HPN) remained approximately the same. The relative distribution of type of HAN changed from 26.2% cases on ONS, 68.7% cases on HEN and 5.1% cases on HPN in 2010 to 86.1% cases on ONS, 12.8% cases on HEN, and 1.1% cases on HPN in 2015. Treatment duration decreased for ONS from 698 ± 637 days to 171 ± 274 days, for HEN from 416 ± 553 days to 262 ± 459 days, and for HPN from 96 ± 206 days to 72 ± 123 days. Mean costs per patient decreased for ONS from 1,330 CHF in 2010 to 606 CHF in 2015. Total costs for HAN increased from 16,895,373 CHF in 2010 to 32,868,361 CHF in 2015. CONCLUSION: Our epidemiological follow-up study showed an immense increase in number of patients on HAN in Switzerland after July 2012. Due to shorter therapy duration and reduced mean costs per patient, total costs were only doubled while the number of patients increased 7-fold.

Comparación de las recomendaciones de expertos sobre nutrición clínica en pacientes hospitalizados con COVID-19 / Comparison of expert recommendations on clinical nutrition for hospitalized patients with COVID-19

INTRODUCCIÓN: la infección por SARS-CoV-2 implica riesgo nutricional debido a la dificultad de cubrir los requerimientos nutricionales aumentados en presencia de una sintomatología que dificulta la ingesta y la absorción de nutrientes. Por otro lado, las complicaciones respiratorias agudas requieren estancias prolongadas en unidades de cuidados intensivos (UCI) y esto predispone a una mayor desnutrición y a pérdida de masa y función del músculo esquelético, que a su vez puede conducir a una mala calidad de vida, discapacidad y morbilidad mucho después del alta. Por este motivo, las principales sociedades y asociaciones de nutrición clínica del mundo consideran que la terapia nutricional debe considerarse parte del tratamiento básico de los pacientes con COVID-19. MÉTODOS: se han revisado y comparado 9 recomendaciones de expertos (RE) publicadas por sociedades y asociaciones de nutrición clínica de China, España, Brasil, Europa, Colombia, Australia, América y Reino Unido, a raíz de la pandemia por COVID-19, en relación a los pacientes hospitalizados críticos y no críticos. CONCLUSIONES: las 9 RE revisadas coinciden en la importancia del tratamiento nutricional en los pacientes hospitalizados críticos y no críticos con COVID-19, así como en la detección precoz del riesgo nutricional, la intervención y el seguimiento. Aun así, cada documento publicado tiene sus propias particularidades e incide especialmente en algún aspecto

INTRODUCTION: in SARS-CoV-2-infected patients nutritional requirements are increased. These patients present symptoms that make food intake and nutrient absorption difficult, therefore involving nutritional risk. On the other hand, acute respiratory complications require prolonged ICU stays, and this predisposes to increased malnutrition and loss of skeletal muscle mass and function, which can lead to poor quality of life, disability and morbidity long after discharge. For this reason, the world's leading nutrition societies and associations believe that nutritional therapy should be considered a part of the basic treatment of patients with COVID-19. METHODS: we have reviewed and compared 9 expert recommendations (ER) published by nutrition societies and associations from China, Spain, Brazil, Europe, Colombia, Australia, America, and the United Kingdom, in relation to critical and non-critical hospitalized patients due to the COVID-19 pandemic. CONCLUSIONS: the 9 ERs reviewed agree on the importance of nutritional management in critical and non-critical hospitalized patients with COVID-19, as well as on the early detection of nutritional risk, the intervention, and subsequent follow-up. Even so, each published document has its own particularities and puts a special stress on some specific aspect

Biomarkers in critical care nutrition.

The goal of nutrition support is to provide the substrates required to match the bioenergetic needs of the patient and promote the net synthesis of macromolecules required for the preservation of lean mass, organ function, and immunity. Contemporary observational studies have exposed the pervasive undernutrition of critically ill patients and its association with adverse clinical outcomes. The intuitive hypothesis is that optimization of nutrition delivery should improve ICU clinical outcomes. It is therefore surprising that multiple large randomized controlled trials have failed to demonstrate the clinical benefit of restoring or maximizing nutrient intake. This may be in part due to the absence of biological markers that identify patients who are most likely to benefit from nutrition interventions and that monitor the effects of nutrition support. Here, we discuss the need for practical risk stratification tools in critical care nutrition, a proposed rationale for targeted biomarker development, and potential approaches that can be adopted for biomarker identification and validation in the field.

Relevant Nutrition Therapy in COVID-19 and the Constraints on Its Delivery by a Unique Disease Process.

Worldwide, as of July 2020, >13.2 million people have been infected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. The spectrum of coronavirus disease 2019 (COVID-19) ranges from mild illness to critical illness in 5% of cases. The population infected with SARS-CoV-2 requiring an intensive care unit admission often requires nutrition therapy as part of supportive care. Although the various societal guidelines for critical care nutrition meet most needs for the patient with COVID-19, numerous factors, which impact the application of those guideline recommendations, need to be considered. Since the SARS-CoV-2 virus is highly contagious, several key principles should be considered when caring for all patients with COVID-19 to ensure the safety of all healthcare personnel involved. Management strategies should cluster care, making all attempts to bundle patient care to limit exposure. Healthcare providers should be protected, and the spread of SARS-CoV-2 should be limited by minimizing procedures and other interventions that lead to aerosolization, avoiding droplet exposure through hand hygiene and use of personal protective equipment (PPE). PPE should be preserved by decreasing the number of individuals providing direct patient care and by limiting the number of patient interactions. Enteral nutrition (EN) is tolerated by the majority of patients with COVID-19, but a relatively low threshold for conversion to parenteral nutrition should be maintained if increased exposure to the virus is required to continue EN. This article offers relevant and practical recommendations on how to optimize nutrition therapy in critically ill patients with COVID-19.