Abelardo García de Lorenzo

Liver dysfunction associated with artificial nutrition in critically ill patients.

IntroductionLiver dysfunction associated with artificial nutrition in critically ill patients is a complication that seems to be frequent, but it has not been assessed previously in a large cohort of critically ill patients.MethodsWe conducted a prospective cohort study of incidence in 40 intensive care units. Different liver dysfunction patterns were defined: (a) cholestasis: alkaline phosphatase of more than 280 IU/l, gamma-glutamyl-transferase of more than 50 IU/l, or bilirubin of more than 1.2 mg/dl; (b) liver necrosis: aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l, plus bilirubin of more than 1.2 mg/dl or international normalized ratio of more than 1.4; and (c) mixed pattern: alkaline phosphatase of more than 280 IU/l or gamma-glutamyl-transferase of more than 50 IU/l, plus aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l.ResultsSeven hundred and twenty-five of 3,409 patients received artificial nutrition: 303 received total parenteral nutrition (TPN) and 422 received enteral nutrition (EN). Twenty-three percent of patients developed liver dysfunction: 30% in the TPN group and 18% in the EN group. The univariate analysis showed an association between liver dysfunction and TPN (p < 0.001), Multiple Organ Dysfunction Score on admission (p < 0.001), sepsis (p < 0.001), early use of artificial nutrition (p < 0.03), and malnutrition (p < 0.01). In the multivariate analysis, liver dysfunction was associated with TPN (p < 0.001), sepsis (p < 0.02), early use of artificial nutrition (p < 0.03), and calculated energy requirements of more than 25 kcal/kg per day (p < 0.05).ConclusionTPN, sepsis, and excessive calculated energy requirements appear as risk factors for developing liver dysfunction. Septic critically ill patients should not be fed with excessive caloric amounts, particularly when TPN is employed. Administering artificial nutrition in the first 24 hours after admission seems to have a protective effect.

Use of percutaneous tracheostomy in intensive care units in Spain. Results of a national survey

Objectives To assess the use of percutaneous tracheostomy in Intensive Care Units (ICU) in Spain, its practice, and current opinions on the technique.Design and setting An e-mail or post survey was sent to 239 Spanish ICU directors. Pediatric ICUs and coronary units were excluded.Measurements and main results One hundred ICUs (41.8%) replied. The 44% (n=44) of the ICUs that answered belonged to university hospitals and 53% (n=53) had postgraduate teaching. Eighty-two percent (n=82) used percutaneous tracheostomy. Griggs’ Guide Wire Dilating Forceps and Ciaglia Blue Rhino were the most frequent techniques employed. In 30.5% of ICUs (n=25) endoscopic guidance was used, in 15.7% (n= 13) it was routine. In 24.4% (n=20) some kind of long-term follow-up was carried out, but only in 12.2% (n=10) was follow-up done routinely. In 58.5% of ICUs (n=48) in which percutaneous tracheostomy is performed is this technique considered safer than surgical tracheostomy and in 86.4% (n=70) percutaneous tracheostomy is the first choice for tracheostomy in the critically ill patient.Conclusions Percutaneous tracheostomy is a well-established technique in ICUs in Spain, and is considered the technique of choice for tracheostomy in critically ill patients. It is mainly performed without endoscopic guidance and follow-up is not usually carried out.

An exclusively based parenteral fish-oil emulsion reverses cholestasis

Prolonged parenteral nutrition (PN) leads to liver damage. Recent interest has focused on the lipid component of PN. A lipid emulsion based on w-3 fatty acids decrease conjugated bilirubin. A mixed lipid emulsion derived from soybean, coconut, olive, and fish oils reverses jaundice. Here we report the reversal of cholestasis and the improvement of enteral feeding tolerance in 1 infant with intestinal failure-associated liver disease. Treatment involved the substitution of a mixed lipid emulsion with one containing primarily omega-3 fatty acids during 37 days. Growth and biochemical tests of liver function improved significantly. This suggests that fat emulsions made from fish oils may be more effective means of treating this condition compared with an intravenous lipid emulsion containing soybean oil, medium -chain triglycerides, olive oil, and fish oil.

Prevalence and costs of malnutrition in hospitalized dysphagic patients: a subanalysis of the PREDyCES® study

INTRODUCTION dysphagia and malnutrition are conditions that frequently appear together in hospitalized patients. OBJECTIVES the main purpose of this study was to analyze the prevalence of malnutrition in patients with dysphagia included in the PREDyCES study as well as to determine its clinical and economic consequences. METHODS this is a substudy of an observational, cross-sectional study conducted in 31 sites all over Spain. RESULTS 352 dysphagic patients were included. 45.7% of patients presented with malnutrition (NRS-2002 ≥ 3) at admission and 42.2% at discharge. In elderly patients (≥ 70 years old) prevalence of malnutrition was even higher: 54.6% at admission and 57.5% at discharge. Also, prevalence of malnutrition was higher in urgent admissions versus those scheduled (45.7% vs 33.3%; p < 0.05) and when admitted to small hospitals vs. large hospitals (62.8% vs 43.9%; p < 0.001). In-hospital length of stay was higher in malnourished patients compared to those well-nourished (11.5 ± 7.1 days vs. 8.8 ± 6.05 days; p < 0.001), and in malnourished patients a tendency towards increase related-costs was also observed, even though it was not statistically significant (8 004 ± 5 854 € vs. 6 967 ± 5 630 €; p = 0.11). Length of stay was also higher in elderly patients (≥ 70 y/o) vs adults (< 70 y/o). 25% of dysphagic patients and 34.6% of malnourished patients with dysphagia received nutritional support during hospitalization. DISCUSSION these results confirm that in patients with dysphagia, malnutrition is a prevalent and under recognized condition, that also relates to prolonged hospitalizations.

Importancia de la codificación de la desnutrición hospitalaria en la gestión clínica

Resumen Los sistemas de informacion hospitalarios son herramientas basicas en la gestion hospitalaria. La desnutricion relacionada con la enfermedad sigue constituyendo un area sanitaria de interes relevante entre los paises miembros de la Union Europea (UE) por su elevada prevalencia y sus altos costes. La Estrategia 2008-2013 “Together for Health” planteada en el Parlamento Europeo insta a los Estados miembros a que desarrollen iniciativas en el ambito de la educacion poblacional, la formacion especializada, la investigacion y las buenas practicas clinicas. La Sociedad Espanola de Nutricion Parenteral y Enteral (SENPE) colabora en distintas areas de desarrollo de esta estrategia, que pretende situar la desnutricion relacionada con la enfermedad en el foco de atencion del Sistema Nacional Sanitario (SNS). Sabemos que la codificacion es un ejercicio clave en la gestion sanitaria que se rige por procedimientos bien establecidos. Una correcta codificacion de la desnutricion hospitalaria, como diagnostico principal o secundario, asi como de los procedimientos terapeuticos empleados, contribuye a conocer la realidad de la actividad asistencial y el consumo de recursos de cada centro. Conscientes de la importancia de estas medidas, la SENPE, conjuntamente con la Sociedad Espanola de Documentacion Medica (SEDOM), ha contribuido a la estrategia de la UE mediante el desarrollo del Documento de Consenso de Codificacion de la Desnutricion SENPE-SEDOM. Este documento ha permitido normalizar el proceso de codificacion de esta patologia con la asignacion de codigos especificos a terminos definitorios concretos y optimizar la informacion sobre la desnutricion, sus tipos y grados y los procedimientos empleados en los centros hospitalarios de nuestro SNS para prevenirla o tratarla.

In Memoriam: Pilar Marco Garde ( 1944-2018)

1De la Real Academia de Medicina y Cirugía de Valladolid. Presidente de Honor de la SENPE. Director Honorario de Nutrición Hospitalaria. Director de Journal of Negative and No Positive Results. acProfesor Titular de Cirugía. 2acCatedrático de Medicina Crítica y Metabolismo-UAM. Jefe de Servicio de Medicina Intensiva. Hospital Universitario La Paz-Carlos III/ IdiPAZ. Presidente de la Fundación SENPE. Académico de Honor de la Academia Española de Nutrición y Dietética

Are we near to the end of the standard dose of micafungin

We have carefully read the study titled “Population pharmacokinetics/pharmacodynamics of micafungin against Candida species in obese, critically ill, and morbidly obese critically ill patients” [1] and congratulate the authors for such an interesting initiative. The researchers conclude the lack of adequate micafungin exposure with a 100 mg/24 h dose regardless of the Candida species or the patient’s weight. Further, micafungin exposure was adequate to cover Candida albicans with a 150 mg/24 h dose for patients weighing up to 115 kg and with a 200 mg/24 h dose for those surpassing this weight. The 200 mg/24 h dose covered Candida glabrata for patients weighing up to 115 kg. These results could correlate with, and also support those that we previously obtained in the first study [2] published on the pharmacokinetics (PK) of micafungin in plasma and burn eschar tissue in critically ill patients with severe burn injuries, which were compared with the PK of micafungin in patients with intra-abdominal infections [3]. In our study, 15 burn patients were compared with ten patients with intra-abdominal infection; all patients were treated with 100 to 150 mg/day of micafungin. We also observed that the standard dose of micafungin, 100 mg/day, achieves optimal PK/pharmacodynamics (PD) targets in plasma for MIC values of 0.008 mg/L and 0.064 mg/L for non-parapsilosis Candida spp. and Candida parapsilosis, respectively. By increasing the dose to 200 mg/day, the optimal PK/PD targets in plasma could be achieved for MIC cutoff values that are twofold higher (0.016 mg/L and 0.125 mg/L, respectively). To these subpopulations of critically ill patients we must add patients with sepsis and mechanical ventilation [4]. The authors recommended dose of 100 mg/day of micafungin would be associated with a very low probability of reaching the AUC0-24/MIC ratio in cases of infection with C. albicans or C. glabrata with MIC ≥ 0.015 mg/L, as well as in almost all cases of infection due to C. parapsilosis. Finally, the conclusions presented above in relation to the most recent PK studies of micafungin, performed in different subpopulations of critically ill patients, would provide us with significant evidence that we should consider an increase in the standard dose (100 mg/day) for the treatment of invasive candidiasis and that it would be advisable, in our opinion, to propose PK/PD studies to patients in whom a lack of clinical or microbiological efficacy due to a suboptimal dose of treatment is suspected.

Bienvenida al nuevo gestor de contenidos de Nutrición Hospitalaria

De la Real Academia de Medicina y Cirugía de Valladolid y del Instituto de Biomedicina, IBIOMED. Universidad de León. Investigador colaborador externo, Instituto de Investigaciones Sanitarias. Hospital Universitario Fundación Jiménez Díaz. acProfesor Titular de Cirugía. Director de Nutrición Hospitalaria. Catedrático y Director de la Cátedra de Medicina Crítica y Metabolismo de la UAM. Jefe de Servicio de Medicina Intensiva del Hospital Universitario La Paz. Investigador Consolidado del IdiPAZ. Presidente de la Fundación SENPE. Redactor Jefe de Nutrición Hospitalaria. Madrid. España.

Tumor necrosis factor alpha: its relationship with clinical data

A large number of highly potent peptide factors, such us the various interleu-kins, interferons, colony stimulating factors (CSF) and Tumor Necrosis Factor (TNF), all of them referred as cytokines, have been discovered in the past 10–20 years. Cytokines regulate or modify cellular responses in inflammatory and immune reactions, and this feature is particularly important in cancer patients. Cytokines elicit biological responses upon binding to specific cell surface receptors of sensitive cells. Many of these receptors are expressed by more than one cell type and so, pleiotropism of action is a common property of cytokines [1]. TNF was first discovered by its capacity to induce hemorrhagic necrosis of certain transplantable tumors in mice. The term TNF is used to refer collectively to the two related factors: TNF-α or cachectin and TNF-β or lymphotoxin.