Evaluación y terapia nutricional - ::: Grupo Mexicano ... · Plan de cuidado nutricional...

Evaluación y terapia nutricional

Dr. Oscar Iván Flores Rivera

Medicina Critica

Grupo Mexicano para el Estudio de la Medicina Intensiva.

Médica Sur.


Introducción

Enfermedad Critica

Alteraciones metabólicas

Catabolismo muscular incrementado

Hiperglucemia – insulino - resistencia

Lipolisis

Factores predisponentes

Desnutrición preexistente

Anorexia

Obesidad

Edad avanzada

Stephen A. McClave, et al Feeding the Critically Ill Patient Crit Care Med 2014; 42:2600–2610


Introducción

Ruta

Dosis

Tiempo de Inicio

Contenido del Substrato energético

Terapia

Controversias

Soporte Adjunto en UCI

Objetivo Primario

Exceso de Confianza en NPT

Mas de 200 artículos 2014



Objetivos

Preservar masa corporal

Mantener la función inmune

Evitar complicaciones metabólicas

Atenuar respuesta metabólica al estrés Prevenir estrés oxidativo

Modular la respuesta inmune


Valoración nutricional

Valorar el estado basal nutricional del paciente en la unidad

Riesgo de desnutrición

Plan de cuidado nutricional

Monitorización de la eficacia

Historia de Nutrición.

Parámetros antropométricos

Impedancia bioeléctrica

Elizabeth Mahanna, et al. Fahy Nutrition and metabolic support for critically ill patients Curr Opin Anesthesiol 2015, 28:131 – 138


Sarcopenia: Pérdida de la masa muscular esquelética y de la fuerza. Ancianos

Valoración de la masa muscular por TAC o USG


Valoración nutricional

Sistemas de valoración nutricional

Valoración Global Subjetiva

“The Nutrition and Rehabilitation Investigators Consortium score”

Elizabeth Mahanna, et al. Fahy Nutrition and metabolic support for critically ill patients Curr Opin Anesthesiol 2015, 28:131 – 138


Gasto energético

25 a 30 kcal/Kilogramo/día

Harris - Benedict

Calorimetría indirecta

Proteínas 1.2 a 2 gr/kg/día



Calorimetría Harris- Benedict

TICACOS

Monitoreo multimodal continuo del estado nutricional


Nutrición enteral (NE)

Iniciar de manera temprana

Reduce infección, días de estancia hospitalaria, mortalidad.

Escenarios quirúrgicos también

Interrupción no recomendable

Protocolos guiados por enfermería.

Infección, DEH, Mortalidad


Volumen Gástrico Residual

Vaciamiento Gástrico afectado en el paciente critico.

REGANE

NUTRIREA 1

Uso racional y adecuado de procineticos

Eritromicina

Nutrición post pilórica.


Michael P. Casaer, et al Nutrition in the Acute Phase of Critical Illness N Engl J Med 2014;370:1227-36


Selección de la Formula enteral

Dieta polimérica estándar ( 1 – 1.5 kcal/ml)

Cirugía

Arginina Aceite de pescado

Nucleótidos

Disminuyen

Infección DEH

Glutamina

Quemados Trauma

Neurocritico


Probióticos

Neumonía asociado a la ventilación

DEH

Diarrea

Auxiliares metabólicos

Beta bloqueadores

Estatinas

Insulina : Efectos tróficos en intestino

Leucina : Estimula síntesis proteica

Citrulina: Substrato síntesis de arginina

Carnitina : Oxidación mitocondrial



Nutrición parenteral


En los primeros 7 días en pacientes con adecuado estado de nutrición

En las primeras 48 horas en los pacientes desnutridos

Valorar en pacientes desnutridos , en el perioperatorio en cirugía mayor.( 5-7 días)

Nutrición suplementaria en pacientes que no se logra alcanzar requerimientos.

No cambios en la mortalidad.

Menor cantidad de infecciones nosocomiales.


Macronutrientes

Aminoácidos

Glutamina

Arginina: Postoperatorio

Lípidos

Ácidos graso Omega -3 : Antiinflamatorio

Ácidos graso Omega -9 : Inmunomodulador

Ácidos grasos Onega -6 : Proinflamatorio

Estudio OMEGA No beneficios


Micronutrientes

Tiamina

Potasio

Fosfato

Selenio



Conclusion

In the ICU, optimal nutrition support should prevent both

energy deficit and overfeeding, thereby improving the clin-

ical outcome. Parenteral nutrition should be limited to en-

teral nutrition contraindications or failure. Parenteral nu-

trition is a safe therapy for ICU patients as long as over-

feeding and hyperglycaemia are avoided. Inadequate use

of parenteral nutrition is associated with an increased in-

fection rate and liver dysfunction. The prescription of par-

enteral nutrition to supplement insufficient enteral nutrition

(i.e., the “SPN concept”) should be initiated 24–72 hours

after ICU admission, since it results in improving clinical

outcome and cost-savings. The safe use of parenteral nu-

trition is of great interest, since it could preserve fat-free

mass in patients presenting more and more to a certain ex-

tent with clinical situations of ageing, sarcopenic obesity,

chronic diseases and pre-existing undernutrition.

Funding / potential competing interests: R Thibault and C

Pichard are supported by research grants from the public

Nutrition 2000 Plus foundation.

R. Thibault received financial support as unrestricted academic

research grant from public institutions (Geneva University

Hospital), as well as unrestricted research grants and

consulting fees from Baxter, BBraun, Fresenius-Kabi, Nestlé,

and Nutricia.

Claudia P. Heidegger received financial support as research

grants and unrestricted academic research grant from public

institutions (Geneva University Hospital) and consulting fees

from: B. Braun, Fresenius-Kabi AG, and Nestle Medical

Nutrition.

Mette M. Berger received financial support in the form of

research grants & an unrestricted academic research grant

from public institutions (Fonds National Suisse de la Recherche

Scientifique) and from the industry: Aguettant, Baxter, B. Braun,

Fresenius-Kabi AG, Nestle Medical Nutrition, and Novartis.

Table 3: Monitoring of PN during the different phases of critical illness.

Criteria Objective Evaluation methods Period of ICU stay

Measurement of energy

expenditure by indirect calorimetry

If available, at postacute and

rehabilitation phases

Energy target Prevention of energy deficit

Predictive formulas At any time, during the 48h post-

admission, and at postacute and


Protein target Prevention of energy and protein

deficit




Macro-nutrients provision: total

energy, cumulated energy deficit,

provision in protein, carbohydrate,

fat

Prevention of energy and protein

deficit, and overfeeding

Monitoring sheet

Computerised software

Several times daily to tailor

nutrition support according to

delivery and target

Adequation between

nutritional provision and

target

Micro-nutrients provision: vitamins

and trace-elements

Prevention of micronutrient

deficiency and optimization of

macronutrient metabolism

Monitoring sheet


Daily

Glycaemia Prevention of overfeeding and

hypoglycaemia

Venous, arterial, or capillary blood

collection

Several times daily at the acute

phase, then daily adaptation

Glycaemic control

Insulin doses Prevention of overfeeding and

hypoglycaemia

Monitoring sheet

Computerized software

Dynamic therapeutical algorithm



Blood sodium, potassium,

phosphates, magnesium, urea,

creatinin

Prevention of refeeding syndrome Venous blood collection

Liver tests Prevention of overfeeding and

PN-related liver disease

Venous blood collection

At the initiation of nutritional

support, then daily if abnormalities

then at least several times a week

a nutrition

Biological monitoring

Albumin / Transthyretin Follow up of nutritional status in

the absence of inflammation

Venous blood collection Weekly during the post-acute and

the rehabilitation phases

Not at the acute phase because of

inflammation

Weight: weighing bed or chair-

weigh scale

Post-acute and rehabilitation

phases


hydration variations

Weight, weight loss, body mass

index

Evaluation of nutritional status

Height: heel-knee distance Post-acute and rehabilitation

phases

Fat-free mass, fat mass, total ±

intra- and extra-cellular water

Evaluation of body composition

including fat-free mass loss

(nutritional status)

Bioimpedance analysis Absence of fluid retention


phases

Phase angle Evaluation of clinical prognosis?

(under evaluation)

Bioimpedance analysis At any time?

(under evaluation)

Skeletal muscular mass index Evaluation of body composition



Third lumbar vertebrae-targeted

computerised tomography

At each abdominal routine scan?

(under evaluation)

Muscular strength Evaluation of muscular function Dynamometer Post-ICU rehabilitation phase

Body composition

assessment

Quality of life Evaluation of overall health and

muscular function

Specific questionnaires Post-ICU rehabilitation phase

Review art icle: Current opinion Swiss Med Wkly. 2014;144:w13997

Swiss Medical Weekly · PDF of the online version · www.smw.ch Page 6 of 9

Ronan Thibaulta, Claudia P. Heideggerb, Mette M. Bergerc, Claude Pichard Parenteral nutrition in the intensive care unit: cautious use improves outcome. Swiss Med Wkly. 2014;144:w13997


Conclusion

In the ICU, optimal nutrition support should prevent both

energy deficit and overfeeding, thereby improving the clin-

ical outcome. Parenteral nutrition should be limited to en-

teral nutrition contraindications or failure. Parenteral nu-

trition is a safe therapy for ICU patients as long as over-

feeding and hyperglycaemia are avoided. Inadequate use

of parenteral nutrition is associated with an increased in-

fection rate and liver dysfunction. The prescription of par-

enteral nutrition to supplement insufficient enteral nutrition

(i.e., the “SPN concept”) should be initiated 24–72 hours

after ICU admission, since it results in improving clinical

outcome and cost-savings. The safe use of parenteral nu-

trition is of great interest, since it could preserve fat-free

mass in patients presenting more and more to a certain ex-

tent with clinical situations of ageing, sarcopenic obesity,

chronic diseases and pre-existing undernutrition.

Funding / potential competing interests: R Thibault and C

Pichard are supported by research grants from the public

Nutrition 2000 Plus foundation.

R. Thibault received financial support as unrestricted academic

research grant from public institutions (Geneva University

Hospital), as well as unrestricted research grants and

consulting fees from Baxter, BBraun, Fresenius-Kabi, Nestlé,

and Nutricia.

Claudia P. Heidegger received financial support as research

grants and unrestricted academic research grant from public

institutions (Geneva University Hospital) and consulting fees

from: B. Braun, Fresenius-Kabi AG, and Nestle Medical

Nutrition.

Mette M. Berger received financial support in the form of

research grants & an unrestricted academic research grant

from public institutions (Fonds National Suisse de la Recherche

Scientifique) and from the industry: Aguettant, Baxter, B. Braun,

Fresenius-Kabi AG, Nestle Medical Nutrition, and Novartis.

Table 3: Monitoring of PN during the different phases of critical illness.

Criteria Objective Evaluation methods Period of ICU stay

Measurement of energy

expenditure by indirect calorimetry

If available, at postacute and


Energy target Prevention of energy deficit




Protein target Prevention of energy and protein

deficit




Macro-nutrients provision: total

energy, cumulated energy deficit,

provision in protein, carbohydrate,

fat

Prevention of energy and protein

deficit, and overfeeding

Monitoring sheet


Several times daily to tailor

nutrition support according to

delivery and target

Adequation between

nutritional provision and

target

Micro-nutrients provision: vitamins

and trace-elements

Prevention of micronutrient

deficiency and optimization of

macronutrient metabolism

Monitoring sheet


Daily

Glycaemia Prevention of overfeeding and

hypoglycaemia

Venous, arterial, or capillary blood

collection



Glycaemic control

Insulin doses Prevention of overfeeding and

hypoglycaemia

Monitoring sheet

Computerized software

Dynamic therapeutical algorithm



Blood sodium, potassium,

phosphates, magnesium, urea,

creatinin

Prevention of refeeding syndrome Venous blood collection

Liver tests Prevention of overfeeding and

PN-related liver disease

Venous blood collection

At the initiation of nutritional

support, then daily if abnormalities

then at least several times a week

a nutrition

Biological monitoring

Albumin / Transthyretin Follow up of nutritional status in

the absence of inflammation

Venous blood collection Weekly during the post-acute and

the rehabilitation phases


inflammation

Weight: weighing bed or chair-

weigh scale


phases


hydration variations

Weight, weight loss, body mass

index

Evaluation of nutritional status

Height: heel-knee distance Post-acute and rehabilitation

phases

Fat-free mass, fat mass, total ±

intra- and extra-cellular water

Evaluation of body composition



Bioimpedance analysis Absence of fluid retention


phases

Phase angle Evaluation of clinical prognosis?

(under evaluation)

Bioimpedance analysis At any time?

(under evaluation)

Skeletal muscular mass index Evaluation of body composition



Third lumbar vertebrae-targeted

computerised tomography

At each abdominal routine scan?

(under evaluation)

Muscular strength Evaluation of muscular function Dynamometer Post-ICU rehabilitation phase

Body composition

assessment

Quality of life Evaluation of overall health and

muscular function

Specific questionnaires Post-ICU rehabilitation phase

Review art icle: Current opinion Swiss Med Wkly. 2014;144:w13997

Swiss Medical Weekly · PDF of the online version · www.smw.ch Page 6 of 9

Conclusiones


Proceso fundamental en la unidad de Cuidados Intensivos, estado nutricional requiere valoración constante, y el ajuste cotidiano.

Impacta directamente en los desenlaces de los enfermos.

Evaluación y terapia nutricional - ::: Grupo Mexicano ... · Plan de cuidado nutricional...

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