Combination of arterial lactate levels and Cv-aCO2/Da-vO2 ratio to predict early allograft dysfunction after liver transplantation.

PURPOSE: We examined the ability of the P(v-a)CO2/Da-vO2 ratio combined with elevated lactate levels to predict early allograft dysfunction (EAD). MATERIALS AND METHODS: Patients were classified into four groups according to lactate levels and P(v-a)CO2/Da-vO2 ratio: Group 1; lactate >2.0 mmol/L and P(v-a)CO2/Da-vO2 ratio >1.0; Group 2; lactate >2.0 mmol/L and P(v-a)CO2/Da-vO2 ratio <1.0; group 3; lactate<2.0 mmol/L and P(v-a)CO2/Da-vO2 ratio >1.0; group 4; lactate<2.0 mmol/L and P(v-a)CO2/Da-vO2 ratio <1.0. We defined EAD according to Olthoff criteria. RESULTS: One-hundred and fifty patients were included. EAD occurred in 41 patients (27.3%), and was associated with worse graft survival at 1 year (92% vs. 73%; P = ,003) as well as a higher re-transplantation rate (4,6% vs. 17,1%; P = ,019). The multivariate analysis revealed that P(v-a)CO2/Da-vO2 ratio at T6 [OR 7.05(CI95% 2.77-19.01, P<.001)] was an independent predictor for EAD. Belonging to group 1 at 6 h was associated with worse clinical outcomes but no association was found with 1-year graft survival or 1-year patient survival. CONCLUSIONS: In this single center, prospective, observational study in patients who received an OLT, we found that elevated lactate levels combined with a high Cv-aCO2/Da-vO2 after 6 h was associated with the development of EAD and worse clinical outcomes in the early postoperative period.

Buffered Solutions Versus Isotonic Saline for Resuscitation in Nonsurgical Critically Ill: Protocol for Cochrane Review.

Fluid resuscitation is one of the most prevalent treatment in critical care. There is not definitive evidence about the best fluid for resuscitation. The aim of this review will be to asses the efficacy and safety of buffered solution versus saline. We will perform an electronic search in Medline, Embase, and Central. Studies will be eligible if they are clinical trials who including critical ill patients. Primary outcomes are mortality and renal failure. All findings will be tabulated and synthesized. We will perform a meta-analysis according to Cochrane Review standards. We will design a summary of findings table.

Diabetes-specific enteral nutrition formula in hyperglycemic, mechanically ventilated, critically ill patients: a prospective, open-label, blind-randomized, multicenter study.

INTRODUCTION: Although standard enteral nutrition is universally accepted, the use of disease-specific formulas for hyperglycemic patients is still controversial. This study examines whether a high-protein diabetes-specific formula reduces insulin needs, improves glycemic control and reduces ICU-acquired infection in critically ill, hyperglycemic patients on mechanical ventilation (MV). METHODS: This was a prospective, open-label, randomized (web-based, blinded) study conducted at nine Spanish ICUs. The patient groups established according to the high-protein formula received were: group A, new-generation diabetes-specific formula; group B, standard control formula; group C, control diabetes-specific formula. Inclusion criteria were: expected enteral nutrition ≥5 days, MV, baseline glucose >126 mg/dL on admission or >200 mg/dL in the first 48 h. Exclusion criteria were: APACHE II ≤10, insulin-dependent diabetes, renal or hepatic failure, treatment with corticosteroids, immunosuppressants or lipid-lowering drugs and body mass index ≥40 kg/m(2). The targeted glucose level was 110-150 mg/dL. Glycemic variability was calculated as the standard deviation, glycemic lability index and coefficient of variation. Acquired infections were recorded using published consensus criteria for critically ill patients. Data analysis was on an intention-to-treat basis. RESULTS: Over a 2-year period, 157 patients were consecutively enrolled (A 52, B 53 and C 52). Compared with the standard control formula, the new formula gave rise to lower insulin requirement (19.1 ± 13.1 vs. 23.7 ± 40.1 IU/day, p <0.05), plasma glucose (138.6 ± 39.1 vs. 146.1 ± 49.9 mg/dL, p <0.01) and capillary blood glucose (146.1 ± 45.8 vs. 155.3 ± 63.6 mg/dL, p <0.001). Compared with the control diabetes-specific formula, only capillary glucose levels were significantly reduced (146.1 ± 45.8 vs. 150.1 ± 41.9, p <0.01). Both specific formulas reduced capillary glucose on ICU day 1 (p <0.01), glucose variability in the first week (p <0.05), and incidences of ventilator-associated tracheobronchitis (p <0.01) or pneumonia (p <0.05) compared with the standard formula. No effects of the nutrition formula were produced on hospital stay or mortality. CONCLUSIONS: In these high-risk ICU patients, both diabetes-specific formulas lowered insulin requirements, improved glycemic control and reduced the risk of acquired infections relative to the standard formula. Compared with the control-specific formula, the new-generation formula also improved capillary glycemia. TRIAL REGISTRATION: Clinicaltrials.gov NCT1233726 .

Implementation of the ESPEN guideline on clinical nutrition in the intensive care unit (ICU): It is time to move forward!: A position paper from the 'nutrition in the ICU' ESPEN special interest group.

Nutritional assessment and provision of nutritional therapy are a core part of intensive care unit (ICU) patient treatment. The ESPEN guideline on clinical nutrition in the ICU was published in 2019. However, uncertainty and difficulties remain regarding its full implementation in daily practice. This position paper is intended to help ICU healthcare professionals facilitate the implementation of ESPEN nutrition guidelines to ensure the best care for their patients. We have aimed to emphasize the guideline recommendations that need to be implemented in the ICU, are advised, or are optional, and to give practical directives to improve the guideline recommendations in daily practice. These statements were written by the members of the ICU nutrition ESPEN special interest group (SIG), based on a survey aimed at identifying current practices relating to key issues in ICU nutrition. The ultimate goal is to improve the ICU patients quality of care.

ESPEN practical and partially revised guideline: Clinical nutrition in the intensive care unit.

Following the new ESPEN Standard Operating Procedures, the previous 2019 guideline to provide best medical nutritional therapy to critically ill patients has been shortened and partially revised. Following this update, we propose this publication as a practical guideline based on the published scientific guideline, but shortened and illustrated by flow charts. The main goal of this practical guideline is to increase understanding and allow the practitioner to implement the Nutrition in the ICU guidelines. All the items discussed in the previous guidelines are included as well as special conditions.

The Effect of Enteral Immunonutrition in the Intensive Care Unit: Does It Impact on Outcomes?

Background: The present research aimed to evaluate the effect on outcomes of immunonutrition (IMN) enteral formulas during the intensive care unit (ICU) stay. Methods: A multicenter prospective observational study was performed. Patient characteristics, disease severity, nutritional status, type of nutritional therapy and outcomes, and laboratory parameters were collected in a database. Statistical differences were analyzed according to the administration of IMN or other types of enteral formulas. Results: In total, 406 patients were included in the analysis, of whom 15.02% (61) received IMN. Univariate analysis showed that patients treated with IMN formulas received higher mean caloric and protein intake, and better 28-day survival (85.2% vs. 73.3%; p = 0.014. Unadjusted Hazard Ratio (HR): 0.15; 95% CI (Confidence Interval): 0.06−0.36; p < 0.001). Once adjusted for confounding factors, multivariate analysis showed a lower need for vasopressor support (OR: 0.49; 95% CI: 0.26−0.91; p = 0.023) and continuous renal replacement therapies (OR: 0.13; 95% CI: 0.01−0.65; p = 0.049) in those patients who received IMN formulas, independently of the severity of the disease. IMN use was also associated with higher protein intake during the administration of nutritional therapy (OR: 6.23; 95% CI: 2.59−15.54; p < 0.001), regardless of the type of patient. No differences were found in the laboratory parameters, except for a trend toward lower triglyceride levels (HR: 0.97; 95% CI: 0.95−0.99; p = 0.045). Conclusion: The use of IMN formulas may be associated with better outcomes (i.e., lower need for vasopressors and continuous renal replacement), together with a trend toward higher protein enteral delivery during the ICU stay. These findings may ultimately be related to their modulating effect on the inflammatory response in the critically ill. NCT Registry: 03634943.

Study of risk factors for healthcare-associated infections in acute cardiac patients using categorical principal component analysis (CATPCA).

Using categorical principal component analysis, we aimed to determine the relationship between health care-associated infections (HAIs) and diagnostic categories (DCs) in patients with acute heart disease using data collected in the Spanish prospective ENVIN-HELICS intensive care registry over a 10-year period (2005-2015). A total of 69,876 admissions were included, of which 5597 developed HAIs. Two 2-component CATPCA models were developed. In the first model, all cases were included; the first component was determined by the duration of the invasive devices, the ICU stay, the APACHE II score and the HAIs; the second component was determined by the type of admission (medical or surgical) and by the DCs. No clear association between DCs and HAIs was found. Cronbach's alpha was 0.899, and the variance accounted for (VAF) was 52.5%. The second model included only admissions that developed HAIs; the first component was determined by the duration of the invasive devices and the ICU stay; the second component was determined by the inflammatory response, the mortality in the ICU and the HAIs. Cronbach's alpha value was 0.855, and VAF was 46.9%. These findings highlight the role of exposure to invasive devices in the development of HAIS in patients with acute heart disease.

[Nutrition in palliative care: guidelines from the Working Group on Bioethics, Spanish Society of Clinical Nutrition and Metabolism (SENPE)]. / Nutrición en cuidados paliativos: resumen de recomendaciones del Grupo de Trabajo de Ética de la SENPE.

Introduction: Palliative care provides a holistic approach and care for patients with a terminal illness and their families. In palliative care physical complaints as well as emotional, social and spiritual aspects are considered. Nutritional care should be also considered within palliative support. For those working in the nutritional support field, to withhold or withdraw nutritional support may be an ethical dilemma in this scenario. The controversy starts when considering nutrition and hydration as basic care or a treatment. The goals of nutrition support in palliative care patients differ from common ones, aiming to improve quality of life, survival or both. The decision should be based on a consideration of prognosis (length of survival), quality of life, and risks-benefits ratio. Regarding oral nutrition (with or without oral supplements) the idea prevails of "comfort feeding", based on providing oral feeding till discomfort or avoidance develop. There is no evidence on the benefit of specific nutrients, despite the fact that omega-3 FAs may have some positive effects in patients with cancer. Regarding nutritional support (enteral or parenteral), no scientific evidence is present, so the decision needs to be agreed according to the desires and beliefs of the patient and their family, and based on a consensus with the interdisciplinary team on the aims of this support.

Introducción: Los cuidados paliativos proporcionan una atención integral que tiene en cuenta los aspectos físicos, emocionales, sociales y espirituales del paciente con enfermedad terminal y su entorno familiar. El tratamiento nutricional debe formar parte activa de los equipos de cuidados paliativos. La necesidad de iniciar o no un tratamiento nutricional sigue siendo, desde hace décadas, uno de los principales problemas éticos a los que se enfrentan los profesionales dedicados a la nutrición clínica. El origen de tal controversia radica, fundamentalmente, en cómo se consideran la nutrición y la hidratación: cuidado/soporte o tratamiento médico. Los objetivos fundamentales del tratamiento nutricional en los pacientes en cuidados paliativos deben ser otros: la mejoría de la calidad de vida, de la supervivencia o de ambas. La decisión de indicar o no el tratamiento nutricional en cuidados paliativos debe tomarse tras considerar el pronóstico, la calidad de vida y la relación "riesgo/beneficio". En relación a la alimentación por vía oral (con o sin suplementos orales), prevalece la idea de la "alimentación de confort", que se basa en intentos de alimentación oral hasta que se produzcan la incomodidad y/o el rechazo del paciente. No existen evidencias que justifiquen el uso de nutrientes específicos, aunque desde hace años se señala la posibilidad de lograr beneficios cuando se utilizan ácidos grasos omega-3 en los pacientes con cáncer. En cuanto al tratamiento nutricional (enteral o parenteral), en ausencia de evidencia, las decisiones sobre si iniciar una nutrición artificial en un paciente paliativo deben tomarse teniendo en cuenta los deseos y creencias del paciente y sus familiares, y basarse en el consenso del equipo interdisciplinar sobre los objetivos que se persiguen al iniciarla.

Enteral nutrition in critically ill patients under vasoactive drug therapy: The NUTRIVAD study.

BACKGROUND: Enteral nutrition (EN) in critically ill patients requiring vasoactive drug (VAD) support is controversial. This study assesses the tolerability and safety of EN in such patients. METHODS: This prospective observational study was conducted in 23 intensive care units (ICUs) over 30 months. Inclusion criteria were a need for VADs and/or mechanic circulatory support (MCS) over a minimum of 48 h, a need for ≥48 h of mechanical ventilation, an estimated life expectancy >72 h, and ≥72 h of ICU stay. Patients with refractory shock were excluded. EN was performed according to established protocols during which descriptive, daily hemodynamic and efficacy, and safety data were collected. An independent research group conducted the statistical analysis. RESULTS: Of 200 patients included, 30 (15%) required MCS and 145 (73%) met early multiorgan dysfunction criteria. Mortality was 24%. Patients needed a mean dose of norepinephrine in the first 48 h of 0.71 mcg/kg/min (95% CI, 0.63-0.8) targeting a mean arterial pressure of 68 mm Hg (95% CI, 67-70) during the first 48 h. EN was started 34 h (95% CI, 31-37) after ICU admission. Mean energy and protein delivered by EN/patient/day were 1159 kcal (95% CI, 1098-1220) and 55.6 g (95% CI, 52.4-58.7), respectively. Daily energy balance during EN/patient/day was -432 (95% CI, -496 to -368). One hundred and fifty-four (77%) patients experienced EN-related complications. However, severe complications, such as mesenteric ischemia, were recorded in only one (0.5%) patient. CONCLUSION: EN in these patients seems feasible, safe, and unrelated to serious complications. Reaching the energy target only through EN is difficult.

[The XI SENPE Jesús Culebras Lecture. Enteral nutrition in critically ill patients. History of an evolution]. / XI Lección Jesús Culebras. Nutrición enteral en el paciente crítico. Historia de una evolución.

INTRODUCTION: Enteral nutrition is part of the treatment plan designed for a great number of critically ill patients. After a first description in ancient Egypt, enteral nutrition was only rapidly developed during the last century. Advances in indications, tube feeding methods, enteral formula selection, diagnosis and treatment of gastrointestinal-related complications, efficacy monitorization, and use of protocols for enteral nutrition administration in clinical practice make this nutritional technique more feasible and secure for critically ill patients. Nevertheless, several issues in this field need more investigation to increase enteral nutrition development, efficacy, and safety in these patients.

INTRODUCCIÓN: Actualmente, la nutrición enteral forma parte de las medidas de tratamiento que se aplican a los pacientes críticos. Es una técnica que, procedente del antiguo Egipto, solo tuvo un rápido desarrollo desde principios del siglo XX hasta nuestros días. Los diferentes avances en este campo, relacionados con las indicaciones, la metodología de aplicación, la selección de las dietas, el manejo de las complicaciones, el seguimiento de la eficacia y el diseño y aplicación de los protocolos asistenciales, han permitido que la nutrición enteral pueda aplicarse con seguridad y eficacia a los pacientes críticos. A pesar de ello, quedan aún muchos aspectos por desarrollar con el fin de conseguir que los pacientes se beneficien de manera óptima del tratamiento con nutrición enteral.

Muscle weakness: Understanding the principles of myopathy and neuropathy in the critically ill patient and the management options.

Myo-neuropathy of the critically ill patient is a difficult nosological entity to understand and manage. It appears soon after injury, and it is estimated that 20-30% of patients admitted to Intensive Care Units will develop it in some degree. Although muscular and nervous involvement are related, the former has a better prognosis. Myo-neuropathy associates to more morbidity, longer stay in Intensive Care Unit and in hospital, and also to higher costs and mortality. It is considered part of the main determinants of the new entities: the Chronic Critical Patient and the Post Intensive Care Syndrome. This update focuses on aetiology, pathophysiology, diagnosis and strategies that can prevent, alleviate and/or improve muscle (or muscle-nerve) weakness.

[Muscle in critically ill patients]. / Papel del músculo en el paciente crítico.

INTRODUCTION: Polyneuropathy in the critically ill patient was defined as a generalized weakness, acquired during Intensive Care Unit (ICU) admittance and attributed to lesion of the peripheral nerve. Research in this field progressed over time, revealing the crucial role of muscle injury in this disease, to the point of re-naming the disorder as ICU adquired weakness (ICUAW). Muscle damage is common in severe illness, and may be classified in qualitative (weakness) or quantitative (decrease in mass) muscle loss. The most frequent scenario in these patients, is simultaneous change in quality and quantity of muscle; resulting in a challenging and delayed recovery during hospital admittance and after discharge. Multiple causes have been identified in the pathogenesis of this disorder, such as: prolonged bed rest, inadequate intake of nutrients and exposure to drugs that affect muscle structure and contraction. The assessment of muscle mass using images provided by ultrasound or computerized tomography may guide follow up. The prevention and treatment of ICUAW requires a multimodal approach: early mobilization and exercise, appropriate nutritional prescription and, occasionally, muscle protein synthesis stimulants. Further studies will clarify more aspects regarding critically ill patients suffering from muscle injury, in order to better address prevention and treatment of ICUAW.

INTRODUCCIÓN: La "polineuropatía del paciente crítico", un cuadro que cursa con debilidad generalizada durante la estancia de los pacientes en la UCI, fue inicialmente atribuida a una afectación de los nervios periféricos. No obstante, a medida que ha progresado la investigación en este campo ha podido describirse el papel fundamental de la alteración muscular en este cuadro de "debilidad muscular adquirida en la UCI" (DMA-UCI). La afectación muscular es frecuente en pacientes críticos. Puede ser cualitativa (debilidad muscular), cuantitativa (disminución de la masa muscular) o, con frecuencia, de ambos tipos. Los efectos de la afectación muscular comprometen la recuperación de los pacientes tanto en la UCI como en el hospital y se extienden hasta después del alta hospitalaria durante un periodo que puede ser prolongado. El origen de la alteración muscular suele ser multifactorial, estando implicados factores como el reposo prolongado, la inadecuada ingesta de nutrientes o la exposición a fármacos que pueden afectar a la estructura muscular y a la función contráctil. La valoración de la masa muscular mediante técnicas de imagen como la ecografía o la tomografía computarizada puede servir de ayuda para el seguimiento de los pacientes. La prevención y el tratamiento de la DMA-UCI requiere un abordaje multimodal recurriendo al empleo de movilización y ejercicio precoces, tratamiento nutricional adecuado y, ocasionalmente, fármacos con efecto estimulante sobre la síntesis proteica muscular. Estudios en marcha permitirán una mejor definición de las alteraciones musculares durante la enfermedad crítica y la mejor forma de abordar su prevención y tratamiento.

Application of the new Sepsis-3 definition in a cohort of patients with severe sepsis and septic shock admitted to Intensive Care Unit from the Emergency Department. / Aplicación de la nueva definición Sepsis-3 en una cohorte de pacientes con sepsis grave y shock séptico ingresados en unidad de cuidados intensivos desde el Servicio de Urgencias.

BACKGROUND AND OBJECTIVES: After the publication of the new definition for sepsis and septic shock, our objective is to analyse the evolution of patients admitted to ICU with an infection process using the previous and new recommendations. MATERIALS AND METHODS: This is a sub-analysis of a previous observational prospective study. We included 98 patients admitted to ICU from the emergency department due to infection during an 18-month period. We studied the clinical evolution during ICU admission and hospital mortality. RESULTS: According to Sepsis-2 definition, 78% percent had septic shock and using Sepsis-3 criteria, 52%; hospital mortality was 29 and 41%, respectively. The RR of hospital mortality of septic shock was 10.3 (95% CI: 2.8-37.5) compared to patients without shock. The 30-day probability survival of patients with sepsis and septic shock were 78% and 68%, respectively (long rank < 0.001). CONCLUSIONS: In our experience, the incorporation of the SOFA score and lactate levels to the new definition could help improve the evaluation of risk of hospital death.

[Nutritional management of advanced dementia: summary of recommendations of the SENPE Ethic Group]. / Manejo nutricional de la demencia avanzada: resumen de recomendaciones del Grupo de Trabajo de Ética de la SENPE.

INTRODUCTION: This paper from the ethics Working Group presents a summary of the recommendations of the nutritional management of patients with advanced dementia.

INTRODUCCIÓN: En este documento del Grupo de Trabajo de Ética se presenta un resumen sobre las recomendaciones del manejo nutricional de pacientes con demencia avanzada.

[Anidulafungin: a new therapeutic approach in antifungal therapy. Pharmacology of anidulafungin]. / Nueva aportación en terapia antifúngica: Anidulafungina. Aspectos farmacológicos de la anidulafungina.

Anidulafungin is a new echinocandin antifungal agent which inhibits beta-1,3-D-glucan synthase and disrupts fungal cell-wall synthesis. It has marked antifungal activity against Candida spp. and Aspergillus spp., including amphotericin B and triazole resistant strains. Due to the limited oral availability, anidulafungin in clinical use is available for parenteral administration only. Elimination of anidulafungin takes place via slow non-enzymatic degradation to inactive metabolites. Less than 10% and 1% of the initially administered drug is excreted unchanged into feces and urine, respectively. It does not require dosage adjustment in subjects with hepatic or renal impairment established. Anidulafungin is generally well tolerated. Adverse events appear not to be dose or infusion related. The most common treatment related adverse events are phlebitis, headache, nausea, vomiting and pyrexia. The lack of interactions with tacrolimus, cyclosporine and corticosteroids and its limited toxicity profile places anidulafungin as an attractive new option for the treatment of invasive fungal infections especially in transplant patients.

[Therapeutic efficacy of anidulafungin for the treatment of oesophageal candidiasis, candidemia and invasive candidiasis]. / Utilidad clínica de la anidulafungina en el tratamiento de las candidiasis esofágicas, candidemias y candidiasis invasoras.

Anidulafungin is a new echinocandin that appears to have several advantages over existing antifungals. It is unique because it slowly degrades in humans, undergoing a process of biotransformation rather than being metabolized. It exhibits high in vitro and in vivo activities against Candida spp. and Aspergillus spp. In several clinical studies investigating Candida esophagitis; candidemia and invasive candidiasis, the clinical efficacy of this echinocandin was similar, or even superior, to that of established antifungals in candidemia. Antifungal activity against strains no longer susceptible to conventional antifungal agents, such as fluconazole and amphotericin B suggests that anidulafungin can be used as salvage therapy in life-threatening fungal infections. The limited toxicity profile, minimal drug-drug interactions and the fact that does not require dosage adjustment in subjects with hepatic or renal impairment, establishes this echinocandin as an attractive new option for the treatment of invasive fungal infections.

[The efficacy of caloric intake in critically ill patients with traumatic pathology]. / Eficacia del aporte calórico en pacientes con patología traumática.

BACKGROUND: the effective contribution of enteral nutrition (EN) in intensive care units (ICU) is due to multiple factors. OBJECTIVES: to determine the efficacy of caloric intake in critically ill patients with traumatic pathology receiving enteral nutrition, and to analyze cause and time of interruption of EN. METHOD: prospective observational study (November 2015 - August 2016). INCLUSION CRITERIA: patient with EN ≥ 48 hours and age ≥ 18 years. EXCLUSION CRITERIA: patient with oral and/or parenteral nutrition. VARIABLES: demographic, day of EN, prescribed and administered kilocalories (kcal), caloric difference, caloric objective and variables related to the interruptions of the EN. The handling of EN and interruptions are made according to the unit's internal protocol. Kcal/patient are calculated according to the Harris-Benedict equation and multiplied by a stress factor depending on the type of trauma of the patient. RESULTS: sixty-nine patients were included, 79.71% were men, with a median age of 46 (34-58) years. A total of 1,112 days of EN were monitored. As of the third day of admission to the ICU (979 days monitored), the nutritional efficacy was optimal (caloric intake > 80%): 92.43% (72.8-97.5). The optimal caloric goal was maintained in 67.9% of these days. The most frequent causes of interruption of NE were procedures unrelated to airway, with holding time of three (1-7.25) hours. CONCLUSIONS at the third day, the patients with traumatic pathology received at least 80% of the prescribed caloric intake. Among the most frequent causes of interruption of EN were the procedures unrelated to airway.

INTRODUCCIÓN: el aporte efectivo de la nutrición enteral (NE) en las unidades de cuidados intensivos (UCI) se ve afectado por múltiples factores. OBJETIVOS: determinar la eficacia en el aporte calórico a los pacientes críticos con patología traumática que reciben nutrición enteral. Analizar causa y tiempo de interrupción de NE. MÉTODO: estudio observacional prospectivo (de noviembre de 2015 a agosto de 2016). Criterios de inclusión: paciente con NE ≥ 48 horas y edad ≥ 18 años. Criterios de exclusión: paciente con dieta oral y/o parenteral. Variables: demográficas, día de NE, kilocalorías (kcal) prescritas, administradas, diferencia calórica, objetivo calórico y relacionadas con las interrupciones de la NE. El manejo de NE e interrupciones se realiza según protocolo interno de la unidad. Las kcal/paciente se calculan según la ecuación de Harris-Benedict y multiplicando por un factor de estrés en función del tipo de trauma del paciente. RESULTADOS: se incluyeron 69 pacientes (el 79,71% eran hombres) con una mediana de edad de 46 (34-58) años. Se monitorizaron un total de 1.112 días de NE. A partir del tercer día de ingreso en UCI (979 días monitorizados) la eficacia nutricional fue óptima (aporte calórico > 80%): 92,43% (72,8-97,5). Mantenemos el objetivo calórico óptimo en el 67,9% de estos días. Observamos como causa más frecuente de interrupción de la NE los procedimientos no relacionados con la vía aérea, con un tiempo de parada de tres (1-7,25) horas. CONCLUSIÓN: el aporte calórico del paciente crítico con patología traumática se logra de forma óptima a partir del día 3. Entre las causas de interrupción de la NE más frecuentes se encuentran los procedimientos no relacionados con la vía aérea.

Incidence, Risk Factors and Outcomes of Early Acute Kidney Injury After Heart Transplantation: An 18-year Experience.

BACKGROUND: Little is known about the incidence of acute kidney injury (AKI), as defined using the Kidney Disease Improving Global Outcome classification, after heart transplantation (HT). Our objective was to evaluate the impact of AKI in a cohort of HT recipients. (Setting: University Hospital.) METHODS: We studied 310 consecutive HT recipients from 1999 to 2017, with AKI being defined according to the Kidney Disease Improving Global Outcome criteria. Risk factors were analyzed by multivariable analyses, and survival by Kaplan-Meier curves and a risk-adjusted Cox proportional hazards regression model. RESULTS: One hundred twenty-five (40.3%) patients developed AKI, with 73 (23.5%), 18 (5.8%), and 34 (11%) patients having AKI stages 1, 2, and 3, respectively. Cardiac tamponade (odds ratio [OR], 16.82; 95% confidence interval [CI], 1.06-138), acute right ventricular failure (OR, 3.54; 95% CI, 1.82-6.88), and major bleeding (OR, 2.46; 95% CI, 1.18-5.1) were the principal risk factors for AKI. Patients with AKI had a greater hospital mortality (3.8% vs 16%, P < 0.05), especially those requiring renal replacement therapy (46.9% vs 5.4%, P = 0.006). Acute kidney injury requiring renal replacement therapy was independently associated with hospital mortality (OR, 11.03; 95% CI, 4.08-29.8). With a median follow-up after hospital discharge of 6.7 years (interquartile range, 2.4-11.6), overall survival at 1, 5, and 10 years was 95.4%, 85.1%, and 75.4% versus 85.2%, 69.8% and 63.5% among patients without AKI and with AKI stages 2 to 3, respectively (P = 0.08). CONCLUSIONS: The onset of AKI after HT is mainly associated with postoperative complications. Only severe AKI stage predicts worse short-term outcome, with this impact appearing to be lost at long-term follow-up.