Letícia Faria Serpa

Effects of continuous versus bolus infusion of enteral nutrition in critical patients

PURPOSE Enteral alimentation is the preferred modality of support in critical patients who have acceptable digestive function and are unable to eat orally, but the advantages of continuous versus intermittent administration are surrounded by controversy. With the purpose of identifying the benefits and complications of each technique, a prospective controlled study with matched subjects was conducted. PATIENTS AND METHODS Twenty-eight consecutive candidates for enteral feeding were divided into 2 groups (n = 14 each) that were matched for diagnosis and APACHE II score. A commercial immune-stimulating polymeric diet was administered via nasogastric tube by electronic pump in the proportion of 25 kcal/kg/day, either as a 1-hour bolus every 3 hours (Group I), or continuously for 24 hours (Group II), over a 3-day period. Anthropometrics, biochemical measurements, recording of administered drugs and other therapies, thorax X-ray, measurement of abdominal circumference, monitoring of gastric residue, and clinical and nutritional assessments were performed at least once daily. The principal measured outcomes of this protocol were frequency of abdominal distention and pulmonary aspiration, and efficacy in supplying the desired amount of nutrients. RESULTS Nearly half of the total population (46.4%) exhibited high gastric residues on at least 1 occasion, but only 1 confirmed episode of pulmonary aspiration occurred (3.6%). Both groups displayed a moderate number of complications, without differences. Food input during the first day was greater in Group II (approximately 20% difference), but by the third day, both groups displayed similarly small deficits in total furnished volume of about 10%, when compared with the prescribed diet. CONCLUSIONS Both administration modalities permitted practical and effective administration of the diet with frequent registered abnormalities but few clinically significant problems. The two groups were similar in this regard, without statistical differences, probably because of meticulous technique, careful monitoring, strict patient matching, and conservative amounts of diet employed in both situations. Further studies with additional populations, diagnostic groups, and dietetic prescriptions should be performed in order to elucidate the differences between these commonly used feeding modalities.

Predictive validity of the Braden scale for pressure ulcer risk in critical care patients

Este estudo metodologico foi desenvolvido em quatro unidades de terapia intensiva de um hospital geral, com o objetivo de avaliar a validade preditiva da escala de Braden em pacientes criticos. Apos aprovacao do projeto pelo Comite de Etica em Pesquisa, da instituicao, durante seis meses, pacientes adultos com escore total de Braden <18 e sem ulceras por pressao (UP) foram avaliados na admissao e a cada 48 horas, enquanto permaneceram em risco ou ate o desenvolvimento de UP, alta, morte ou transferencia da UTI. Os escores de Braden 12, 13 e 13, respectivamente na primeira, segunda e terceira avaliacao apresentaram sensibilidade de 85,7, 71,4 e 71,4% e especifidade de 64,6, 81,5 e 83,1%. As areas sob a curva ROC (Receiver Operating Characteristics) revelaram acuracia muito boa para os escores de corte obtidos. O escore de corte da escala de Braden igual a 13, na terceira avaliacao, apresentou a melhor performance preditiva em pacientes criticos.

Desnutrição como fator de risco para o desenvolvimento de úlceras por pressão

La desnutricion - como aspecto fundamental en la genesis y cicatrizacion de las ulceras por presion (UP) - es el tema de esta atualizacion. Muchos estudios destacan la desnutricion, los cambios del funcionamiento imunologico, la hipoalbuminemia, los bajos niveles de hemoglobina asi como la baja aceptacion alimentaria como los responsables del aumento del riesgo para el desarrollo de las UP. En conclusion, es fundamental incluir la evaluacion del estado nutricional en los protocolos de prevencion y tratamiento de las UP. Esa evaluacion debe incluir medidas objetivas, seguimiento de la ingestion calorica y proteica y ademas de las dificultades para el aprovechamiento de los nutrientes.A desnutricao - como aspecto fundamental tanto na genese como na cicatrizacao das ulceras por pressao - e objeto deste artigo de atualizacao. Inumeros estudos salientam a desnutricao, alteracoes da funcao imune, hipoalbuminemia, niveis baixos de hemoglobina bem como a baixa aceitacao dietetica como responsaveis por aumentar o risco para o desenvolvimento dessas lesoes. E, portanto, fundamental incluir a avaliacao do estado nutricional - monitorizacao da ingestao calorico-proteica e das dificuldades para o aproveitamento dos nutrientes nos protocolos de prevencao e tratamento desse tipo de ferida cronica.

Predictive Validity of Waterlow Scale for Pressure Ulcer Development Risk in Hospitalized Patients

AIM We sought to evaluate the predictive validity of the Waterlow Scale in hospitalized patients. SUBJECTS AND SETTING The study was conducted at a general private hospital with 220 beds and a mean time of hospitalization of 7.4 days and a mean occupation rate of approximately 80%. Adult patients with a Braden Scale score of 18 or less and a Waterlow Scale score of 16 or more were studied. The sample consisted of 98 patients with a mean age of 71.1 ± 15.5 years. METHODS Skin assessment and scoring by using the Waterlow and Braden scales were completed on alternate days. Patients were examined at least 3 times to be considered for analysis. The data were submitted to sensitivity and specificity analysis by using receiver operating characteristic (ROC) curves and positive (+LR) and negative (—LR) likelihood ratios. RESULTS The cutoff scores were 17, 20, and 20 in the first, second, and third assessment, respectively. Sensitivity was 71.4%, 85.7%, and 85.7% and specificity was 67.0%, 40.7%, and 32.9%, respectively. Analysis of the area under the ROC curve revealed good accuracy (0.64, 95% confidence interval [CI]: 0.35–0.93) only for the cutoff score 17 in the first assessment. The results also showed probabilities of 14%, 10%, and 9% for the development of pressure ulcer when the test results were positive (+LR) and of 3% (—LR) when the test results were negative for the cutoff scores in the first, second, and third assessment, respectively. CONCLUSION The Waterlow Scale achieved good predictive validity in predicting pressure ulcer in hospitalized patients when a cutoff score of 17 was used in the first assessment.

Validade preditiva da Escala de Braden para o risco de desenvolvimento de úlcera por pressão em pacientes críticos

Este estudo metodologico foi desenvolvido em quatro unidades de terapia intensiva de um hospital geral, com o objetivo de avaliar a validade preditiva da escala de Braden em pacientes criticos. Apos aprovacao do projeto pelo Comite de Etica em Pesquisa, da instituicao, durante seis meses, pacientes adultos com escore total de Braden <18 e sem ulceras por pressao (UP) foram avaliados na admissao e a cada 48 horas, enquanto permaneceram em risco ou ate o desenvolvimento de UP, alta, morte ou transferencia da UTI. Os escores de Braden 12, 13 e 13, respectivamente na primeira, segunda e terceira avaliacao apresentaram sensibilidade de 85,7, 71,4 e 71,4% e especifidade de 64,6, 81,5 e 83,1%. As areas sob a curva ROC (Receiver Operating Characteristics) revelaram acuracia muito boa para os escores de corte obtidos. O escore de corte da escala de Braden igual a 13, na terceira avaliacao, apresentou a melhor performance preditiva em pacientes criticos.

Malnutrition as a risk factor for the development of pressure ulcers

La desnutricion - como aspecto fundamental en la genesis y cicatrizacion de las ulceras por presion (UP) - es el tema de esta atualizacion. Muchos estudios destacan la desnutricion, los cambios del funcionamiento imunologico, la hipoalbuminemia, los bajos niveles de hemoglobina asi como la baja aceptacion alimentaria como los responsables del aumento del riesgo para el desarrollo de las UP. En conclusion, es fundamental incluir la evaluacion del estado nutricional en los protocolos de prevencion y tratamiento de las UP. Esa evaluacion debe incluir medidas objetivas, seguimiento de la ingestion calorica y proteica y ademas de las dificultades para el aprovechamiento de los nutrientes.A desnutricao - como aspecto fundamental tanto na genese como na cicatrizacao das ulceras por pressao - e objeto deste artigo de atualizacao. Inumeros estudos salientam a desnutricao, alteracoes da funcao imune, hipoalbuminemia, niveis baixos de hemoglobina bem como a baixa aceitacao dietetica como responsaveis por aumentar o risco para o desenvolvimento dessas lesoes. E, portanto, fundamental incluir a avaliacao do estado nutricional - monitorizacao da ingestao calorico-proteica e das dificuldades para o aproveitamento dos nutrientes nos protocolos de prevencao e tratamento desse tipo de ferida cronica.

Validity of the Braden and Waterlow subscales in predicting pressure ulcer risk in hospitalized patients

The aim of this study was to evaluate the validity of the Braden and Waterlow subscales in predicting pressure ulcer risk in hospitalized patients. This is a secondary analysis of a prospective cohort study. Braden sensory perception and friction/shear subscales and Waterlow mobility and appetite subscales were the most relevant predictors.

Validity of the Braden Nutrition Subscale in predicting pressure ulcer development.

PURPOSE: The purpose of this study was to analyze the validity of the nutrition subscale from the Braden Scale for Predicting Pressure Sore Risk in hospitalized patients. DESIGN: A prospective, quasi-experimental, repeated-measures design guided data collection and analysis. SUBJECTS AND SETTINGS: One hundred seventy adult patients from 2 private hospitals located in urban areas in Southeastern Brazil, with a Braden Scale score of 18 or less, and who agreed to participate in the study were assessed between January and August 2006. Participants were primarily male (57.0%) and had a mean age of 67.0 ± 15.4 years (mean ± SD). METHODS: Objective assessment and subjective global assessment of nutritional status were performed on admission. Every 2 days, patients deemed at potential risk for pressure ulcer development underwent evaluation of protein-energy intake, skin assessment, and repeated risk assessment for pressure ulcer development via the Braden Scale. Univariate and multivariate logistic regression analyses were used to assess the predictive power of nutritional variables related to risk for pressure ulcer development. RESULTS: The mean length of stay among patients was 17.8 ± 16.8 days. Multivariate regression analysis revealed that serum albumin levels (odds ratio = 5.226; P < .001) and subjective global nutritional assessment (odds ratio = 3.246; P < .001) were the best nutritional predictors of pressure ulcer development. CONCLUSION: We did not find the Braden nutrition subscale score to be predictive for pressure ulcer development in hospitalized patients. Serum albumin levels and subjective global nutritional assessment were the best nutritional predictors of pressure ulcer development.

Risk Assessment in Pressure Ulcers

This chapter approaches the most important topics related to pressure ulcer (PU) risk assessment. Firstly, intrinsic and extrinsic risk factors for PU development are covered. The authors present classic and updated models. The chapter also includes the main validated tools applied for PU risk assessment as one of the most relevant strategies for PU prevention. The Norton, Gosnell, Waterlow, Cubbin and Jackson, Braden and Braden Q scales, as well as the Neonatal Skin Risk Assessment Scale and Neonatal Skin Condition Scale are described.

Validez predictiva de la Escala de Braden para el riesgo de úlceras por presión en pacientes críticos

Este estudo metodologico foi desenvolvido em quatro unidades de terapia intensiva de um hospital geral, com o objetivo de avaliar a validade preditiva da escala de Braden em pacientes criticos. Apos aprovacao do projeto pelo Comite de Etica em Pesquisa, da instituicao, durante seis meses, pacientes adultos com escore total de Braden <18 e sem ulceras por pressao (UP) foram avaliados na admissao e a cada 48 horas, enquanto permaneceram em risco ou ate o desenvolvimento de UP, alta, morte ou transferencia da UTI. Os escores de Braden 12, 13 e 13, respectivamente na primeira, segunda e terceira avaliacao apresentaram sensibilidade de 85,7, 71,4 e 71,4% e especifidade de 64,6, 81,5 e 83,1%. As areas sob a curva ROC (Receiver Operating Characteristics) revelaram acuracia muito boa para os escores de corte obtidos. O escore de corte da escala de Braden igual a 13, na terceira avaliacao, apresentou a melhor performance preditiva em pacientes criticos.