Michelli Cristina Silva de Assis

Improved Oral Anticoagulation After a Dietary Vitamin K–Guided Strategy. A Randomized Controlled Trial

Background— Dietary vitamin K is thought to be an important factor that interferes with anticoagulation stability, but the clinical applicability of this interaction has not been evaluated adequately in prospective studies. Methods and Results— In a randomized controlled trial that enrolled outpatients with a recent international normalized ratio (INR) outside the therapeutic target, we compared 2 strategies to optimize long-term oral anticoagulation: (1) a conventional approach based on changes in anticoagulant prescription and (2) a dietary vitamin K–guided strategy based on simple modifications of the amount of vitamin K–rich foods ingested per week. The primary efficacy end point was the percentage of patients who achieved a prespecified INR target at 90 days after randomization. Study population (n=132) predominantly included men with mechanical heart prostheses (58%) or atrial fibrillation (35%). Over time, patients allocated to the vitamin K–guided strategy reached the prespecified INR more frequently so that after 90 days of follow-up, 74% were on target compared with 58% of patients managed conventionally (P=0.04). Patients allocated to the dietary vitamin K–guided strategy had the same magnitude and direction of INR variation as those observed with the conventional approach in the short term (15 days) for both underanticaogulated and overanticoagulated patients. Minor bleeding or use of parenteral vitamin K were also marginally less frequent in patients managed according to the dietary intervention (1 [1.5%] versus 7 [11%]; P=0.06). Conclusions— A vitamin K–guided management strategy to adjust long-term oral anticoagulation is feasible and safe and may result in an increased chance of reaching target levels of INR.

Dietary vitamin K intake and anticoagulation in elderly patients.

Purpose of reviewVitamin K is an essential co-factor for the synthesis of several coagulation factors. Oral anticoagulants competitively inhibit enzymes that participate in vitamin K metabolism. The purpose of this review is to evaluate the potential interaction of dietary vitamin K and coagulation stability, particularly in the elderly patient. Recent findingsRecent prospective evidences suggest that dietary vitamin K plays an essential role in anticoagulation stability. Vitamin K intake of more than 250 μg/day was shown to decrease warfarin sensitivity in anticoagulated patients consuming regular diets. In a randomized crossover study, brief periods of changes on vitamin K intake also had significant effects on coagulation parameters. Patients that were allocated to an 80% decrease of intake increased International Normalized Ratio (INR) by almost 30% 7 days after the intervention. Similarly, it was estimated by dietary records that for each increase in 100 μg of vitamin K intake, the INR would be reduced by 0.2. A recent study also demonstrated that over-the-counter multivitamin supplements contain enough vitamin K1 to significantly alter coagulation parameters. SummaryContemporary data strengthen the concept that the interaction between dietary vitamin K and coumarin derivatives is clinically relevant and plays a major role in INR fluctuations in chronic anticoagulated patients.

Nutrição enteral: diferenças entre volume, calorias e proteínas prescritos e administrados em adultos

OBJETIVO: Diferentes condicoes determinam que pacientes criticos recebam volumes, aportes energeticos e proteicos de nutricao enteral menores que o prescrito. O objetivo do presente estudo foi avaliar a diferenca entre a nutricao enteral prescrita e administrada a adultos internados em centro de terapia intensiva. METODOS: Durante 30 dias de 2009, pacientes foram acompanhados do inicio do uso de nutricao enteral ate a sua suspensao, ou ate a alta do centro de terapia intensiva. Foram usados testes parametricos e nao parametricos para identificar diferencas entre o prescrito e administrado. RESULTADOS: Foram incluidos 85 pacientes, com 58,6±18,0 anos, sendo 40% do sexo masculino, que permaneceram internados por 29,5 dias (IQ: 15,2 - 48,7) e utilizaram nutricao enteral por 10 (IQ: 4,2 - 27,5) dias. Os pacientes receberam menos volume (-428±243 ml/dia), calorias (-665±412 Kcal/dia) e proteinas (-30±19 g de proteina/dia) do que prescrito. Quando avaliadas as diferencas diarias entre o prescrito e o administrado para cada paciente, observou-se que cerca de 40% do volume nao foi administrado. Os principais motivos para interrupcao da dieta foram: nauseas e vomitos, distensao abdominal, constipacao e complicacoes clinicas (52%); realizacao de procedimentos diagnosticos (41,6%); e transicao para via oral (5,6%). CONCLUSAO: Pacientes internados em centro de terapia intensiva recebem menos nutricao enteral que o prescrito. A rotina de cuidados e a ocorrencia de complicacoes do trato gastrointestinal motivam interrupcoes da nutricao enteral, contribuindo para que pacientes de centro de terapia intensiva recebam menor aporte calorico do que prescrito.

Association of Braden subscales with the risk of development of pressure ulcer

Pressure ulcers (PU) may increase the incidence of hospital complications, and one should prevent this damage. The Braden Scale stands out as a tool to assess the risk of PU. The study aimed to identify changes in the score of the Braden subscales are associated with the risk of developing PCU. Logistic regression was used in a retrospective cohort study conducted in Hospital de Clínicas de Porto Alegre in adults hospitalized in surgical clinical units from October 2005 to June 2006. We evaluated the records database of 1503 patients with a mean aged 55.5 +/- 16 years, 52.7% female. The incidence of PU was 1.8% and was associated with diabetes and heart failure. There was a higher PU in patients worst in sensory perception, mobility, and activity and the presence of moisture. No association was found between nutrition and PU. Except nutrition, the other Braden sub-scales shown to be predictive of PU.Ulceras por pressao (UP) podem aumentar a incidencia de complicacoes hospitalares, devendo-se prevenir este dano. A Escala de Braden destaca-se como instrumento para avaliar o risco de UP. O estudo objetivou identificar quais alteracoes, na pontuacao das subescalas de Braden, estao associadas com o risco do desenvolvimento de UP. Empregou-se regressao logistica em uma coorte retrospectiva realizada no Hospital de Clinicas de Porto Alegre, em adultos hospitalizados em unidades clinicas e cirurgicas, de outubro de 2005 a junho de 2006. Foram avaliados os registros de banco de dados de 1503 pacientes, com idade de 55,5±16 anos, sendo 52,7% do sexo feminino. A incidencia de UP foi de 1,8%, e foi associada com diabetes e insuficiencia cardiaca. Houve mais UP em pacientes com pior percepcao sensorial, mobilidade, atividade e na presenca de umidade. Nao houve associacao entre nutricao e UP. Exceto nutricao, as demais subescalas de Braden mostraram-se preditivas de UP.

Associação das sub-escalas de Braden com o risco do desenvolvimento de úlcera por pressão

Pressure ulcers (PU) may increase the incidence of hospital complications, and one should prevent this damage. The Braden Scale stands out as a tool to assess the risk of PU. The study aimed to identify changes in the score of the Braden subscales are associated with the risk of developing PCU. Logistic regression was used in a retrospective cohort study conducted in Hospital de Clínicas de Porto Alegre in adults hospitalized in surgical clinical units from October 2005 to June 2006. We evaluated the records database of 1503 patients with a mean aged 55.5 +/- 16 years, 52.7% female. The incidence of PU was 1.8% and was associated with diabetes and heart failure. There was a higher PU in patients worst in sensory perception, mobility, and activity and the presence of moisture. No association was found between nutrition and PU. Except nutrition, the other Braden sub-scales shown to be predictive of PU.Ulceras por pressao (UP) podem aumentar a incidencia de complicacoes hospitalares, devendo-se prevenir este dano. A Escala de Braden destaca-se como instrumento para avaliar o risco de UP. O estudo objetivou identificar quais alteracoes, na pontuacao das subescalas de Braden, estao associadas com o risco do desenvolvimento de UP. Empregou-se regressao logistica em uma coorte retrospectiva realizada no Hospital de Clinicas de Porto Alegre, em adultos hospitalizados em unidades clinicas e cirurgicas, de outubro de 2005 a junho de 2006. Foram avaliados os registros de banco de dados de 1503 pacientes, com idade de 55,5±16 anos, sendo 52,7% do sexo feminino. A incidencia de UP foi de 1,8%, e foi associada com diabetes e insuficiencia cardiaca. Houve mais UP em pacientes com pior percepcao sensorial, mobilidade, atividade e na presenca de umidade. Nao houve associacao entre nutricao e UP. Exceto nutricao, as demais subescalas de Braden mostraram-se preditivas de UP.

Is duration of postoperative fasting associated with infection and prolonged length of stay in surgical patients

OBJECTIVE Verify whether the postoperative fasting period increases the risk for infection and prolonged length of stay. METHODS Prospective cohort study. Elective surgery patients were included. Excluded: those with no conditions for nutritional assessment, admitted in minimal care units, as well as with <72h in-hospital stay. Postoperative fasting was recorded from the days of no nutrition therapy. The length of stay was considered prolonged when above the average according to the specialty and type of surgery. Logistic regression was used to assess associations and adjust for confounding factors. RESULTS 521 patients were analyzed, 44.1% were fasted for a period ≥1 day, 91% for ≥3 days and 5.6% for more than 5 days. Patients with more than 5 days fasting were more eutrophic, more admitted to intensive care units, and had more postoperative surgical complications. After adjustment for confounding variables, it was noted that ≥1 day of postoperative fasting increased the infection risk by 2.04 (CI95%: 1.20 to 3.50), ≥3 days 2.81 (CI95%: 1.4-5.8), and in fasting for more than 5 days the infection risk was 2.88 times higher (CI95%: 1.17 to 7.16). The risk for prolonged hospitalization was 2.4 (CI95%: 1.48 to 3.77) among patients who had ≥1 day fasting, 4.44 (CI95%: 2.0 to 9.8)and 4.43 times higher (CI95%: 1.73 to 11.3) among patients with ≥3 days fasting and more than 5 days, respectively. CONCLUSION The longer duration of postoperative fasting was an independent risk factor both for infection and for prolonged hospital stay.

Enteral feeding tubes: Are insertion techniques and positioning based on anatomical evidence?

Patients in whom oral energy intake is insufficient for daily needs may develop malnutrition and its complications, such as increased infection rates, increased length of hospitalization, and death. Enteral feeding is beneficial for these patients. However, this therapy is not without complications related to the insertion and placement of enteral feeding tubes. This review aims to identify from the literature different techniques for insertion and the methods used to evaluate the placement of enteral feeding tubes.

Food intake reported versus nursing records: is there agreement in surgical patients?

OBJECTIVES To evaluate the agreement between oral feeding by patients and chart records of this acceptance. METHOD Besides the food intake surveys of surgical patients, the nursing records of nutrition were evaluated. Is was considered good oral feeding: intake ≥ 75% of total calories prescribed at the day; medium acceptance: 50 to 74.9%; low acceptance: < 50% and NPO (nothing per oral). The Kappa coefficient was adopted to assess agreement. RESULTS There were similar answers between patient and nursing records in 91.3% of NPO situations, 87.1% for good oral feeding, 17.8% for medium acceptance and 16.5% for low acceptance (Kappa = 0.45). CONCLUSION Agreement between patients reports and nursing records was moderate to low. A higher proportion of similar answers were observed when the patients related good oral feeding or NPO.

Decreased calorie and protein intake is a risk factor for infection and prolonged length of stay in surgical patients: A prospective cohort study

Objective The aim was to assess whether postoperative calorie and protein intakes increase the risk of infection and prolonged length of stay in a tertiary care university hospital in Southern Brazil. Methods This is a prospective cohort study approved by the hospitals Research Ethics Committee. The sample consisted of adult patients undergoing elective surgery. The exclusion criteria included patients who could not undergo nutritional assessment and those with a planned hospital stay of fewer than 72 hours. Nutritional status was assessed on admission and every seven days thereafter until hospital discharge or death. Demographic and clinical data, as well as information regarding independent and outcome variables, were collected from the patients records. Food intake assessment was conducted by researchers six times a week. Calorie and protein intakes were considered adequate if equal to or greater than 75% of the prescribed amount, and length of stay was considered prolonged when above the average for specialty and type of surgery. Data was analyzed using Poisson regression. Results Of the 519 study patients, 16.2% had adequate nutritional therapy. Most of these patients were men with ischemic heart disease and acquired immunodeficiency syndrome. After adjusting for confounders, inadequate nutritional therapy increased risk of infection by 121.0% (RR=2.21; 95%CI=1.01-4.86) and risk of prolonged length of stay by 89.0% (RR=1.89; 95%CI=1.01-3.53). Conclusion Most patients did not have adequate nutritional therapy. Those with inadequate nutritional therapy had a higher risk of infection and longer length of stay.

Evaluación de las subescalas de Braden en una corte de pacientes hospitalizados

Pressure ulcers (PU) may increase the incidence of hospital complications, and one should prevent this damage. The Braden Scale stands out as a tool to assess the risk of PU. The study aimed to identify changes in the score of the Braden subscales are associated with the risk of developing PCU. Logistic regression was used in a retrospective cohort study conducted in Hospital de Clínicas de Porto Alegre in adults hospitalized in surgical clinical units from October 2005 to June 2006. We evaluated the records database of 1503 patients with a mean aged 55.5 +/- 16 years, 52.7% female. The incidence of PU was 1.8% and was associated with diabetes and heart failure. There was a higher PU in patients worst in sensory perception, mobility, and activity and the presence of moisture. No association was found between nutrition and PU. Except nutrition, the other Braden sub-scales shown to be predictive of PU.Ulceras por pressao (UP) podem aumentar a incidencia de complicacoes hospitalares, devendo-se prevenir este dano. A Escala de Braden destaca-se como instrumento para avaliar o risco de UP. O estudo objetivou identificar quais alteracoes, na pontuacao das subescalas de Braden, estao associadas com o risco do desenvolvimento de UP. Empregou-se regressao logistica em uma coorte retrospectiva realizada no Hospital de Clinicas de Porto Alegre, em adultos hospitalizados em unidades clinicas e cirurgicas, de outubro de 2005 a junho de 2006. Foram avaliados os registros de banco de dados de 1503 pacientes, com idade de 55,5±16 anos, sendo 52,7% do sexo feminino. A incidencia de UP foi de 1,8%, e foi associada com diabetes e insuficiencia cardiaca. Houve mais UP em pacientes com pior percepcao sensorial, mobilidade, atividade e na presenca de umidade. Nao houve associacao entre nutricao e UP. Exceto nutricao, as demais subescalas de Braden mostraram-se preditivas de UP.