Analysis of the nutritional management practices in intensive care: Identification of needs for improvement

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Lázaro-Martín, M. Catalán-González, C. García-Fuentes, L. Terceros-Almanza, J.C. Montejo-González" "autores" => array:5 [ 0 => array:4 [ "nombre" => "N.I." "apellidos" => "Lázaro-Martín" "email" => array:1 [ 0 => "lazaronoelia@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Catalán-González" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "García-Fuentes" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Terceros-Almanza" ] 4 => array:2 [ "nombre" => "J.C." "apellidos" => "Montejo-González" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Intensive Care Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Análisis de los cambios en las prácticas de nutrición en UCI tras una intervención en el proceso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 969 "Ancho" => 1630 "Tamanyo" => 70673 ] ] "descripcion" => array:1 [ "en" => "Mean and standard deviation (SD) of the mean nutritional ratio per day of admission in the first phase of the study. This figure shows the mean and SD of the mean nutritional ratio, i.e., the proportion of calories administered by artificial nutrition in relation to the requirements per day of admission." ] ] ] "textoCompleto" => "IntroductionArtificial nutrition forms part of the management of critically ill patients that cannot receive an oral diet. The benefits of artificial nutrition go beyond the provision of nutrients and can modify host response to aggression and patient outcome.<a class="elsevierStyleCrossRef" href="#bib0085">1</a> Many studies have shown denutrition in critical patients to be associated to an increase in infectious complications and a longer stay in the Intensive Care Unit (ICU).<a class="elsevierStyleCrossRefs" href="#bib0090">2,3</a> Consequently, one of the quality indicators in the management of critical patients is the early start of nutritional support.Different recommendations and clinical practice guides on the metabolic and nutritional management of critical patients have been published both in Spain<a class="elsevierStyleCrossRef" href="#bib0085">1</a> and in other countries.<a class="elsevierStyleCrossRefs" href="#bib0100">4–6</a> Although the methodology followed by the different recommendations is similar, the conclusions drawn sometimes differ depending on how the same available scientific evidence is interpreted. In this regard, one of the issues subject to debate refers to the early start of nutritional treatment or the use of pharmaconutrients.<a class="elsevierStyleCrossRef" href="#bib0115">7</a> This requires the physician in charge of prescribing nutritional support in critical patients to decide which recommendation is best suited to each individual patient.In the context of routine clinical practice, a number of studies have shown that it is difficult to reach the caloric targets in the first few days of admission to the ICU. Indeed, in most cases it is not possible to exceed 60% of the prescribed daily energy intake.<a class="elsevierStyleCrossRefs" href="#bib0110">6,8</a> The concomitant administration of parenteral nutrition (PN) is therefore recommended as a complement to enteral nutrition (EN) when the caloric target is not reached by day four of admission or during two consecutive days.<a class="elsevierStyleCrossRef" href="#bib0085">1</a> Nevertheless, the early introduction of PN is also subject to debate, with contradictory recommendations being found in the different guides.<a class="elsevierStyleCrossRefs" href="#bib0100">4,5</a>The present study analyzes the nutritional treatment practices in the Department of Intensive Care Medicine (DICM) of a high-complexity hospital center with the purpose of identifying weak points and adopting measures for improvement based on the existing recommendations.Patients and methodsA three-phase prospective observational study was carried out. The first phase involved monitoring of compliance with nutrition practices according to the nutritional support protocol used in the DICM. This protocol is based on the recommendations of the SEMICYUC-SENPE,<a class="elsevierStyleCrossRef" href="#bib0085">1</a> and is periodically revised in order to adapt it to the existing scientific evidence and the type of patient involved. The nutrition protocol was not modified during this phase of the study.The second phase involved an analysis of the data obtained, with the definition of proposals for improvement and their distribution within the ICUs.The third phase in turn consisted of a new monitoring period, with assessment of the nutritional practices, in order to analyze compliance with the changes proposed in the previous study phase.Two ICUs of the DICM participated in the study: a Unit specialized in trauma and emergency care, and a polyvalent Unit. We included adult critical patients with indications of nutritional support (artificial nutrition upon admission, or expected impossibility of oral feeding during the first three days of admission). Patients who did not receive nutritional treatment were excluded.Data collection was carried out by an observer who did not participate in the clinical decisions (NLM). The following data were collected for all included patients: age, weight, height, reason for admission, stay in the ICU, condition at discharge, mechanical ventilation (duration), PN (start, type, duration, metabolic complications), EN (type, duration, mean effective volume [ratio of administered diet/calculated diet], complications, cause of suspension), oral diet, nutritional requirements (calculated using the Harris–Benedict equation corrected for stress) and mean nutritional ratio (proportion of calories administered in relation to the daily requirements). Calculation of the kcal supplied per day was based on the sum of the energy provided by EN, PN and other lipid infusions (propofol). Daily assessment was also made of whether the indications of nutritional support complied with the nutrition protocol (nutrient administration route, calorie supply, definition and management of complications related to EN). These data were collected from the time of inclusion in the study until patient discharge from the Unit.The complications associated to EN were considered based on the critical patient nutritional intervention algorithms<a class="elsevierStyleCrossRef" href="#bib0125">9</a>: increase in gastric residue, abdominal distension, diarrhea, constipation, nausea and vomiting-regurgitation. An increase in gastric residue was defined as the presence of a volume of over 500ml obtained at each evaluation of residue. Abdominal distension was assessed on the basis of changes in the abdominal exploration, with the presence of tympanism, and with or without the presence of peristaltic sounds. Diarrhea associated to EN in turn was defined as a number of depositions of 5 or more in a period of 24h, or as at least two depositions, each with an estimated volume of 1000ml, over a period of 24h. Constipation was defined as the absence of depositions during four days from the start of EN, or the absence of depositions during three consecutive days from the second week of EN. Lastly, regurgitation was defined as the presence of diet material in the oropharyngeal cavity, detected at exploration of the oral cavity or in the course of patient oral hygiene care.The first study phase covered a period of 2 months (from 1 February 2010 to 31 March 2010). The results obtained were analyzed internally by two of the investigators (CGF, JMG), and a number of measures for improvement were proposed based on the recommendations of the scientific societies.<a class="elsevierStyleCrossRefs" href="#bib0085">1,6</a> The proposed measures were presented by both investigators to the healthcare personnel (physicians, nurses and nursing assistants) of each Unit in specific sessions, in which the results of the observation period (phase 1) were commented. Two sessions were held per Unit. The measures were decided by consensus and consisted of the following: increase in the percentage of patients receiving EN, restriction of diets enriched with pharmaconutrients (arginine, omega-3 fatty acids, docosahexaenoic acid [DHA], nucleotides, glutamine) after the first week of admission, increase in protein supply with EN (administration of hyperproteic diets), the convenience of daily monitoring of the nutritional ratio, and the use of complementary PN conditioned to the mentioned ratio (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The third phase again comprised a 2-month data collection period in the same Units. In order to determine whether the proposed measures had been adequately put into effect in routine clinical practice, we decided to conduct the second observation period following a prolonged interval after the first phase, in order to avoid immediacy effects in implementing the proposed measures (i.e., changes made in the first few months after the sessions of the second phase of the study). Accordingly, data collection was performed from 1 February 2011 to 31 March 2011 in the trauma and emergency care Unit, and from 15 September 2011 to 25 December 2011 in the polyvalent Unit.The results were analyzed using the IBM SPSS® version 19 statistical package. Quantitative variables exhibiting a normal distribution were reported as the mean±standard deviation (SD), while qualitative variables were reported as absolute (numbers) or relative frequencies (percentages). Comparisons were made using the Student t-test in the case of quantitative variables exhibiting a normal distribution and homogeneous variance. The Pearson chi-squared test in turn was used to compare qualitative variables. Statistical significance was considered for p<0.05.Since this was an observational, non-interventional and anonymized study, informed consent for data collection was not considered necessary. The study was approved by the Clinical Research Ethics Committee of the hospital.ResultsIn the first phase of the study, a total of 162 patients were admitted to both Units. Of these, 110 were included in the study: 34 patients in the trauma and emergency care Unit (66 admissions) and 76 patients in the polyvalent Unit (96 admissions). In the third phase of the study a total of 215 patients were admitted to both Units. Of these, 119 were included in the study: 20 patients in the trauma and emergency care Unit (75 admissions) and 99 patients in the polyvalent Unit (140 admissions).<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the characteristics of the patients. The distribution by diseases differed between the two data collection phases, with a larger number of polytraumatized patients in the third phase. The patients in the third phase presented a higher frequency (and a longer duration) of mechanical ventilation. The duration of stay in the ICU and the mortality rate were also higher in this phase. Nevertheless, the severity level upon admission, as assessed by the APACHE II score, was similar in both phases.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Compliance with the established nutrition protocol was optimum in both study phases, independently of the modifications introduced in the second phase. There were no alterations in the parameters analyzed: nutrient administration route, recommended energy supply, or definition and management of gastrointestinal complications of EN. The incidence of gastrointestinal complications related to EN was similar in both periods (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Two patients (one in each group) suffered metabolic complications probably related to EN (one case of hypertriglyceridemia and one case of hyperbilirubinemia), though no special treatment measures were required.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>In relation to monitoring of the measures for improvement, we noted an increase in the use of EN during the third phase of the study, in which 87.2% of the patients received EN versus 55.5% in the first phase (p<0.0001) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Regarding the type of diet used, no decrease in the administration of diets enriched with pharmaconutrients was achieved (64.6% versus 64.9% of the days with EN) – though the use of hyperproteic diets effectively increased (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).The mean nutritional ratio (volume of administered diet/calculated diet) during the data collection periods of the study was 0.56±0.28 in the first phase and 0.61±0.27 in the third phase, with no significant differences between the two phases (p=0.56) (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). Nevertheless, calculation of the nutritional ratio in clinical practice and its inclusion in the patient records (nursing charts or medical evolution comments) was merely anecdotal: in most cases no such calculations were entered in the records.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>The use of PN−another of the proposed measures for improvement–was not seen to increase in the third study phase (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).DiscussionOur DICM has used an artificial nutrition protocol since 1996. The protocol is regularly updated to adapt it to the advances in knowledge, the recommendations of the scientific societies, and the work routines of the DICM. It is important to mention that all the healthcare personnel involved in the process (physicians, nurses and nursing assistants) intervene in the different versions of the protocol. As a result, the degree of implication in complying with the protocol is very high, as reflected by its correct application in the scenarios analyzed in our study.With a well implemented artificial nutrition protocol, the purpose of our study was to assess the points amenable to improvement, with a view to updating the protocol. The results indicate that divulgating actions alone for presenting the measures for improvement are not enough to ensure that such measures are adequately incorporated to clinical practice. In effect, only two of the 5 proposed recommendations were correctly implemented: increased use of EN and increase administration of hyperproteic diets.The preferential use of EN in patients who do not present contraindications to this form of nutrition is clearly accepted by the scientific community.<a class="elsevierStyleCrossRef" href="#bib0085">1</a> Critical patients requiring mechanical ventilation also receive EN in most cases. This circumstance may have conditioned the increased use of EN recorded in the third phase of our study, since the patients in this phase presented a greater need for mechanical ventilation, and ventilation moreover lasted longer. These were also patients with a longer stay in the ICU and with greater mortality, compared with the first phase. Thus, the differences in the population of patients admitted might explain the change in the use of EN between the two study phases.Some authors<a class="elsevierStyleCrossRef" href="#bib0130">10</a> have analyzed the reasons why critical patients do not receive the amount of EN they need according to the calculated energy requirements. The mean nutritional ratio recorded in different studies in critical patients is between 50% and 90%. The reasons for this decrease in diet supply are diverse and include factors related to the patient disease condition, the type of nutritional catheter used, the timing of the start of EN, and interruptions in diet supply (due to the performance of tests, nursing procedures, surgery or complications of any kind). In the present study we likewise recorded an inadequate nutritional ratio in the context of EN in critical patients, though the study was not designed to analyze the reasons for this decrease in ratio.Changes in nutritional practices designed to increase the effectiveness of nutritional treatment in critical patients have been evaluated by a number of authors. In a study of the implementation of a nutritional protocol in the ICU, Barr et al.<a class="elsevierStyleCrossRef" href="#bib0135">11</a> compared different variables before and after introducing the protocol. The authors found the use of EN to be more frequent after introducing the protocol, with no changes in calorie supply by day four of nutritional support. The main difference between their study and our own is that the mentioned Unit had no previously implemented protocol, though the existing nutritional practices facilitated adoption of the protocol.Other authors have published their experience with the introduction of changes in the nutritional management of critical patients. Jones et al.<a class="elsevierStyleCrossRef" href="#bib0140">12</a> conducted a randomized clinical study to assess the adoption of 17 measures recommended to improve nutritional treatment in different DICMs divided into two groups: Departments with an educational program including the intervention of a nutritionist to facilitate access to and diffusion of the measures, and Departments in which the measures were simply distributed to each Unit. The results after a period of 12 months showed no differences in clinical evolution between the two groups, with the exception of blood glucose control in the intervention group. The factors complicating introduction of the changes in the nutritional process were related to the medical professional (reluctance to accept change, lack of knowledge and lack of experience), the clinical characteristics of the patient, the characteristics of the institution (limited resources, bureaucracy, care overload) and aspects related to the clinical practice guides (obsolete or limited evidence, and multiple or complicated recommendations). In turn, the factors facilitating introduction of the changes were their incorporation to routine practice, training, facility of access and application of the guides, as well as the adoption of reminder strategies (checklists, protocols, multidisciplinary sessions).Cabana<a class="elsevierStyleCrossRef" href="#bib0145">13</a> classified the obstacles facing adequate compliance with the clinical practice guides into 7 categories: lack of knowledge, lack of familiarity, lack of agreement, self-efficacy, expected benefit, motivation and external barriers.Doig et al.<a class="elsevierStyleCrossRef" href="#bib0150">14</a> defined 18 interventions grouped into categories for the implementation of measures designed to improve nutritional support. They identified a leader per Unit, conducted visits and meetings, included the role of the nutritionist, and produced algorithms and posters. The adoption of these measures resulted in statistically significant improvements in the provision of nutrition, but no associated changes in hospital mortality were recorded. In a study carried out in a Brazilian ICU, the introduction of a nutritional protocol following an educational program improved the quality of nutrition practice.<a class="elsevierStyleCrossRef" href="#bib0155">15</a> Cheater et al.,<a class="elsevierStyleCrossRef" href="#bib0160">16</a> in a systematic review of the interventions that can modify clinical practice, concluded that the efficacy of the interventions is generally modest, and that the particularities of each institution seem to be more important than the type of measures used to introduce change. The best approach therefore would be to analyze the characteristics of each individual Unit referred to the presence of protocols and check their daily implementation. This in turn should be followed by an analysis of the results obtained, with definition of those circumstances that facilitate or complicate application of the protocols, with a view to proposing corrective changes for incorporation to daily practice. The way in which the protocols are diffused, and the control of compliance, should be adapted to each individual Unit and scenario in order to secure significant changes.Our study has some limitations. On one hand, this was a single-center study. However, as has been mentioned above, knowledge of the characteristics inherent to each individual Unit appears to be decisive in selecting the measures to be introduced and their success. On the other hand, our study included no control group to allow us to affirm that the changes observed were attributable to the program and not to other external factors. The study was not designed for comparison with a control group, and such comparison moreover would not have been possible, since there were no other Units using the same nutrition protocol. Another of the limitations of our study refers to the differences in the patient populations of the two data collection phases. These differences are attributable to chance and probably to the short data collection time period involved (2 months). A longer period probably would have contributed to minimize the differences between the groups. Nevertheless, since this was a study designed to evaluate the impact of passive (educational) interventions upon changes in patient care, such changes could have manifested in the same way. Lastly, our study was not designed to analyze the causes of success or failure of the implementation of measures to improve nutritional support; rather, it was limited to describing the impact of an intervention upon the process.In sum, our results indicate that the simple recommendation of changes in the nutritional support of critical patients induces minor modifications in clinical practice, but is not accompanied by increased effectiveness of nutritional treatment. The data obtained support the need to apply active measures of an educational nature, with evaluation of the results, in order to guarantee effective change of clinical relevance for the patients.Financial supportThis project was financed in part by a research grant from Abbott Nutrición, España.Conflict of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres817751" "titulo" => "Abstract" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Design" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Setting" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Participants" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Primary endpoints" ] 5 => array:2 [ "identificador" => "abst0030" "titulo" => "Results" ] 6 => array:2 [ "identificador" => "abst0035" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec814880" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres817752" "titulo" => "Resumen" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "abst0040" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0045" "titulo" => "Diseño" ] 2 => array:2 [ "identificador" => "abst0050" "titulo" => "Ámbito" ] 3 => array:2 [ "identificador" => "abst0055" "titulo" => "Participantes" ] 4 => array:2 [ "identificador" => "abst0060" "titulo" => "Variables de interés principales" ] 5 => array:2 [ "identificador" => "abst0065" "titulo" => "Resultados" ] 6 => array:2 [ "identificador" => "abst0070" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec814879" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Financial support" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 10 => array:2 [ "identificador" => "xack274385" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-01-15" "fechaAceptado" => "2015-04-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec814880" "palabras" => array:4 [ 0 => "Critically ill patient" 1 => "Enteral nutrition" 2 => "Parenteral nutrition" 3 => "Quality indicators" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec814879" "palabras" => array:4 [ 0 => "Paciente crítico" 1 => "Nutrición enteral" 2 => "Nutrición parenteral" 3 => "Indicadores de calidad" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectivesTo analyze the nutritional management practices in Intensive Care (ICU) to detect the need for improvement actions. Re-evaluate the process after implementation of improvement actions. DesignProspective observational study in 3 phases: (1) observation; (2) analysis, proposal development and dissemination; (3) analysis of the implementation. SettingICU of a hospital of high complexity. ParticipantsAdult ICU forecast more than 48h of artificial nutrition. Primary endpointsParenteral nutrition (PN), enteral nutrition (EN) (type, average effective volume, complications) and average nutritional ratio. ResultsA total of 229 patients (phase 1: 110, phase 3: 119), after analyzing the initial results, were proposed: increased use and precocity of EN, increased protein intake, nutritional monitoring effectiveness and increased supplementary indication NP. The measures were broadcast at specific meetings. During phase 3 more patients received EN (55.5 vs. 78.2%, P=.001), with no significant difference in the start time (1.66 vs. 2.33 days), duration (6.82 vs. 10.12 days) or complications (37.7 vs. 47.3%). Use of hyperproteic diets was higher in phase 3 (0 vs. 13.01%, P<.05). The use of NP was similar (48.2 vs. 48.7%) with a tendency to a later onset in phase 3 (1.25±1.25 vs. 2.45±3.22 days). There were no significant differences in the average nutritional ratio (0.56±0.28 vs. 0.61±0.27, P=.56). ConclusionsThe use of EN and the protein intake increased, without appreciating effects on other improvement measures. Other methods appear to be necessary for the proper implementation of improvement measures." "secciones" => array:7 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Design" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Setting" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Participants" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Primary endpoints" ] 5 => array:2 [ "identificador" => "abst0030" "titulo" => "Results" ] 6 => array:2 [ "identificador" => "abst0035" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivosAnalizar las prácticas de tratamiento nutricional en un Servicio de Medicina Intensiva (SMI) para detectar la necesidad de acciones de mejora. Reevaluar el proceso tras la implementación de las acciones de mejora. DiseñoEstudio observacional prospectivo en 3 fases: 1) observación; 2) análisis, elaboración de propuestas y su difusión; 3) análisis de la implantación. ÁmbitoSMI de un hospital de alta complejidad. ParticipantesAdultos en UCI con previsión de nutrición artificial de más de 48 h. Variables de interés principalesNutrición parenteral (NP), nutrición enteral (NE) (tipo, volumen eficaz medio, complicaciones) y ratio nutricional media. ResultadosParticiparon 229 pacientes (fase 1: 110; fase 3: 119). Tras el análisis de los resultados, se propusieron: incremento en uso y precocidad de NE, incremento en aporte proteico, monitorización de la eficacia nutricional y mayor indicación de NP complementaria. Las medidas fueron difundidas en reuniones específicas. Durante la fase 3 hubo más pacientes con NE (55,5 vs. 78,2%; p=0,001), sin diferencia significativa en el tiempo de inicio de NE (1,66 vs. 2,33 días), duración (6,82 vs. 10,12 días) o complicaciones (37,7 vs. 47,3%).La utilización de dietas hiperproteicas fue mayor en la fase 3 (0 vs. 13,01%; p<0,05). El empleo de NP fue similar (48,2 vs. 48,7%) con tendencia al inicio más tardío en la fase 3 (1,25±1,25 vs. 2,45±3,22 días; p=NS). No hubo diferencias significativas en la ratio nutricional media (0,56±0,28 vs. 0,61±0,27; p=0,56). ConclusionesSe incrementó la utilización de la NE y el aporte proteico sin apreciarse efectos sobre el resto de las medidas propuestas. Otros métodos parecen ser necesarios para la adecuada implantación de medidas de mejora." "secciones" => array:7 [ 0 => array:2 [ "identificador" => "abst0040" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0045" "titulo" => "Diseño" ] 2 => array:2 [ "identificador" => "abst0050" "titulo" => "Ámbito" ] 3 => array:2 [ "identificador" => "abst0055" "titulo" => "Participantes" ] 4 => array:2 [ "identificador" => "abst0060" "titulo" => "Variables de interés principales" ] 5 => array:2 [ "identificador" => "abst0065" "titulo" => "Resultados" ] 6 => array:2 [ "identificador" => "abst0070" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Lázaro-Martín NI, Catalán-González M, García-Fuentes C, Terceros-Almanza L, Montejo-González JC. Análisis de los cambios en las prácticas de nutrición en UCI tras una intervención en el proceso. Med Intensiva. 2015;39:530–536." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 969 "Ancho" => 1630 "Tamanyo" => 70673 ] ] "descripcion" => array:1 [ "en" => "Mean and standard deviation (SD) of the mean nutritional ratio per day of admission in the first phase of the study. This figure shows the mean and SD of the mean nutritional ratio, i.e., the proportion of calories administered by artificial nutrition in relation to the requirements per day of admission." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1094 "Ancho" => 1646 "Tamanyo" => 93984 ] ] "descripcion" => array:1 [ "en" => "Mean and standard deviation (SD) of the mean nutritional ratio per day of admission in the third phase of the study. This figure shows the mean and SD of the mean nutritional ratio, i.e., the proportion of calories administered by artificial nutrition in relation to the requirements per day of admission." ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Modification of the nutrition practices in the DICM \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Increase in use of EN. Consider preferential indication of EN in patients without contraindications to EN \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diets enriched with pharmaconutrients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Use restricted to the first week of admission (which usually coincides the phase of greatest metabolic stress) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Assess longer use in patients with persistently severe conditions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Select diet enriched with fish oil for patients with acute respiratory distress syndrome \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">“Chronic phase” diets (from the second week of admission) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Use preferably in stable patients after the first week of admission. A hyperproteic diet with a mixture of dietetic fiber is proposed \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nutritional monitoring \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">The case history should reflect (comments on evolution/nursing chart) the calories supplied each day and the administered calories/calculated required calories (nutritional ratio) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Use of complementary PN \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suggestions: prescribe if no more than 60% of the calculated requirements are supplied by day 4 of enteral nutrition (nutritional ratio<60%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1374531.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Proposed measures for improvement." ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "The results of quantitative variables are expressed as the mean±standard deviation (x±SD). The results of qualitative variables are expressed as n and percentage.Phase 2 corresponds to the educational period in which no data collection was carried out.The significant results appear in boldface." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Phase 1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Phase 3 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P-value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients included \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">110 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">119 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) (x±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52.10±16.128 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55.03±15.874 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">APACHE II (x±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.0±10.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.36±9.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Diagnoses upon admission (n and % with respect to total)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Medical disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75 (68.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">79 (66.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgical disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (8.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23 (19.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Polytraumatisms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 (23.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.017 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Days on mechanical ventilation (x±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.97±5.974 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.85±8.278 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with mechanical ventilation n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">81 (73.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">110 (92.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stay (days) (x±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.89±7.4282 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.74±10.1723 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Survival n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">102 (92.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">94 (79.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.003 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nutritional requirements (kcal) (x±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1891.58±341.631 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2127.17±368.943 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with enteral nutrition n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61 (55.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">93 (78.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with parenteral nutrition n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53 (48.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58 (48.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Start of enteral nutrition (days) (x±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.66±0.998 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.33±2.050 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Start of parenteral nutrition (days) (x±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.25±1.254 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.45±3.224 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of enteral nutrition (x±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.82±7.239 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.12±9.416 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of parenteral nutrition (x±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.53±4.191 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.61±5.037 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Complications of PN n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1374533.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of the patients and of the nutritional treatment." ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "Phase 2 corresponds to the educational period in which no data collection was carried out." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Phase 1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Phase 3 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P-value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with EN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Complications of EN<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a>n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (37.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44 (47.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Increase in gastric residue<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a>n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (14.75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (16.13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diarrhea<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a>n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (8.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (16.13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abdominal distension<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a>n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (4.91) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (4.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Constipation<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a>n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (21.31) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (20.43) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nausea<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a>n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.64) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.07) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vomiting<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a>n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (8.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (15.05) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of days of EN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">421 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">907 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Type of diet administered to the patients<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a>n (%)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pharmaconutrition diet \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">272 (64.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">589 (64.94) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Normoproteic fiber diet \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">139 (33) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">173 (19) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hyperglycemia diet \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (1.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oligomeric diet \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (1.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (1.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hyperproteic diet \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">118 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1374532.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Number of patients with complications and percentage with respect to the total patients administered EN." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Number of days with each type of diet and percentage with respect to the total of days of EN." ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of enteral nutrition (EN) in the study phases." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Indicaciones, momento de inicio y vías de aporte" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.F. Fernandez-Ortega" 1 => "J.I. Herrero Meseguer" 2 => "P. Martinez Garcia" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Med Intensiv" "fecha" => "2011" "volumen" => "35" "numero" => "Suppl. 1" "paginaInicial" => "7" "paginaFinal" => "11" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0090" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The link between nutritional status and clinical outcome: can nutritional intervention modify it?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.T. Dempsey" 1 => "J.L. Mullen" 2 => "G.P. Buzby" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Am J Clin Nutr" "fecha" => "1988" "volumen" => "47" "numero" => "Suppl. 2" "paginaInicial" => "352" "paginaFinal" => "356" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3124596" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0095" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The Canadian critical care nutrition guidelines in 2013: an update on current recommendations and implementation strategies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R. Dhaliwal" 1 => "N. Cahill" 2 => "M. Lemieux" 3 => "D.K. Heyland" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/0884533613510948" "Revista" => array:6 [ "tituloSerie" => "Nutr Clin Pract" "fecha" => "2014" "volumen" => "29" "paginaInicial" => "29" "paginaFinal" => "43" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24297678" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0100" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ESPEN guidelines on enteral nutrition: intensive care" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K.G. Kreymann" 1 => "M.M. Berger" 2 => "N.E. Deutz" 3 => "M. Hiesmayr" 4 => "P. Jolliet" 5 => "G. 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Analysis of the nutritional management practices in intensive care: Identification of needs for improvement

Análisis de los cambios en las prácticas de nutrición en UCI tras una intervención en el proceso

N.I. Lázaro-Martín

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lazaronoelia@hotmail.com

Corresponding author.

, M. Catalán-González, C. García-Fuentes, L. Terceros-Almanza, J.C. Montejo-González

Department of Intensive Care Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain

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        "autoresLista" => "N&#46;I&#46; L&#225;zaro-Mart&#237;n, M&#46; Catal&#225;n-Gonz&#225;lez, C&#46; Garc&#237;a-Fuentes, L&#46; Terceros-Almanza, J&#46;C&#46; Montejo-Gonz&#225;lez"
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        "titulo" => "An&#225;lisis de los cambios en las pr&#225;cticas de nutrici&#243;n en UCI tras una intervenci&#243;n en el proceso"
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Mean and standard deviation &#40;SD&#41; of the mean nutritional ratio per day of admission in the first phase of the study&#46; This figure shows the mean and SD of the mean nutritional ratio&#44; i&#46;e&#46;&#44; the proportion of calories administered by artificial nutrition in relation to the requirements per day of admission&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Artificial nutrition forms part of the management of critically ill patients that cannot receive an oral diet&#46; The benefits of artificial nutrition go beyond the provision of nutrients and can modify host response to aggression and patient outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Many studies have shown denutrition in critical patients to be associated to an increase in infectious complications and a longer stay in the Intensive Care Unit &#40;ICU&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2&#44;3</span></a> Consequently&#44; one of the quality indicators in the management of critical patients is the early start of nutritional support&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Different recommendations and clinical practice guides on the metabolic and nutritional management of critical patients have been published both in Spain<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> and in other countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4&#8211;6</span></a> Although the methodology followed by the different recommendations is similar&#44; the conclusions drawn sometimes differ depending on how the same available scientific evidence is interpreted&#46; In this regard&#44; one of the issues subject to debate refers to the early start of nutritional treatment or the use of pharmaconutrients&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> This requires the physician in charge of prescribing nutritional support in critical patients to decide which recommendation is best suited to each individual patient&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the context of routine clinical practice&#44; a number of studies have shown that it is difficult to reach the caloric targets in the first few days of admission to the ICU&#46; Indeed&#44; in most cases it is not possible to exceed 60&#37; of the prescribed daily energy intake&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6&#44;8</span></a> The concomitant administration of parenteral nutrition &#40;PN&#41; is therefore recommended as a complement to enteral nutrition &#40;EN&#41; when the caloric target is not reached by day four of admission or during two consecutive days&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Nevertheless&#44; the early introduction of PN is also subject to debate&#44; with contradictory recommendations being found in the different guides&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The present study analyzes the nutritional treatment practices in the Department of Intensive Care Medicine &#40;DICM&#41; of a high-complexity hospital center with the purpose of identifying weak points and adopting measures for improvement based on the existing recommendations&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Patients and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">A three-phase prospective observational study was carried out&#46; The first phase involved monitoring of compliance with nutrition practices according to the nutritional support protocol used in the DICM&#46; This protocol is based on the recommendations of the SEMICYUC-SENPE&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> and is periodically revised in order to adapt it to the existing scientific evidence and the type of patient involved&#46; The nutrition protocol was not modified during this phase of the study&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The second phase involved an analysis of the data obtained&#44; with the definition of proposals for improvement and their distribution within the ICUs&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The third phase in turn consisted of a new monitoring period&#44; with assessment of the nutritional practices&#44; in order to analyze compliance with the changes proposed in the previous study phase&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Two ICUs of the DICM participated in the study&#58; a Unit specialized in trauma and emergency care&#44; and a polyvalent Unit&#46; We included adult critical patients with indications of nutritional support &#40;artificial nutrition upon admission&#44; or expected impossibility of oral feeding during the first three days of admission&#41;&#46; Patients who did not receive nutritional treatment were excluded&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Data collection was carried out by an observer who did not participate in the clinical decisions &#40;NLM&#41;&#46; The following data were collected for all included patients&#58; age&#44; weight&#44; height&#44; reason for admission&#44; stay in the ICU&#44; condition at discharge&#44; mechanical ventilation &#40;duration&#41;&#44; PN &#40;start&#44; type&#44; duration&#44; metabolic complications&#41;&#44; EN &#40;type&#44; duration&#44; mean effective volume &#91;ratio of administered diet&#47;calculated diet&#93;&#44; complications&#44; cause of suspension&#41;&#44; oral diet&#44; nutritional requirements &#40;calculated using the Harris&#8211;Benedict equation corrected for stress&#41; and mean nutritional ratio &#40;proportion of calories administered in relation to the daily requirements&#41;&#46; Calculation of the kcal supplied per day was based on the sum of the energy provided by EN&#44; PN and other lipid infusions &#40;propofol&#41;&#46; Daily assessment was also made of whether the indications of nutritional support complied with the nutrition protocol &#40;nutrient administration route&#44; calorie supply&#44; definition and management of complications related to EN&#41;&#46; These data were collected from the time of inclusion in the study until patient discharge from the Unit&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The complications associated to EN were considered based on the critical patient nutritional intervention algorithms<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a>&#58; increase in gastric residue&#44; abdominal distension&#44; diarrhea&#44; constipation&#44; nausea and vomiting-regurgitation&#46; An increase in gastric residue was defined as the presence of a volume of over 500<span class="elsevierStyleHsp" style=""></span>ml obtained at each evaluation of residue&#46; Abdominal distension was assessed on the basis of changes in the abdominal exploration&#44; with the presence of tympanism&#44; and with or without the presence of peristaltic sounds&#46; Diarrhea associated to EN in turn was defined as a number of depositions of 5 or more in a period of 24<span class="elsevierStyleHsp" style=""></span>h&#44; or as at least two depositions&#44; each with an estimated volume of 1000<span class="elsevierStyleHsp" style=""></span>ml&#44; over a period of 24<span class="elsevierStyleHsp" style=""></span>h&#46; Constipation was defined as the absence of depositions during four days from the start of EN&#44; or the absence of depositions during three consecutive days from the second week of EN&#46; Lastly&#44; regurgitation was defined as the presence of diet material in the oropharyngeal cavity&#44; detected at exploration of the oral cavity or in the course of patient oral hygiene care&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The first study phase covered a period of 2 months &#40;from 1 February 2010 to 31 March 2010&#41;&#46; The results obtained were analyzed internally by two of the investigators &#40;CGF&#44; JMG&#41;&#44; and a number of measures for improvement were proposed based on the recommendations of the scientific societies&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;6</span></a> The proposed measures were presented by both investigators to the healthcare personnel &#40;physicians&#44; nurses and nursing assistants&#41; of each Unit in specific sessions&#44; in which the results of the observation period &#40;phase 1&#41; were commented&#46; Two sessions were held per Unit&#46; The measures were decided by consensus and consisted of the following&#58; increase in the percentage of patients receiving EN&#44; restriction of diets enriched with pharmaconutrients &#40;arginine&#44; omega-3 fatty acids&#44; docosahexaenoic acid &#91;DHA&#93;&#44; nucleotides&#44; glutamine&#41; after the first week of admission&#44; increase in protein supply with EN &#40;administration of hyperproteic diets&#41;&#44; the convenience of daily monitoring of the nutritional ratio&#44; and the use of complementary PN conditioned to the mentioned ratio &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The third phase again comprised a 2-month data collection period in the same Units&#46; In order to determine whether the proposed measures had been adequately put into effect in routine clinical practice&#44; we decided to conduct the second observation period following a prolonged interval after the first phase&#44; in order to avoid immediacy effects in implementing the proposed measures &#40;i&#46;e&#46;&#44; changes made in the first few months after the sessions of the second phase of the study&#41;&#46; Accordingly&#44; data collection was performed from 1 February 2011 to 31 March 2011 in the trauma and emergency care Unit&#44; and from 15 September 2011 to 25 December 2011 in the polyvalent Unit&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The results were analyzed using the IBM SPSS<span class="elsevierStyleSup">&#174;</span> version 19 statistical package&#46; Quantitative variables exhibiting a normal distribution were reported as the mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation &#40;SD&#41;&#44; while qualitative variables were reported as absolute &#40;numbers&#41; or relative frequencies &#40;percentages&#41;&#46; Comparisons were made using the Student <span class="elsevierStyleItalic">t</span>-test in the case of quantitative variables exhibiting a normal distribution and homogeneous variance&#46; The Pearson chi-squared test in turn was used to compare qualitative variables&#46; Statistical significance was considered for <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Since this was an observational&#44; non-interventional and anonymized study&#44; informed consent for data collection was not considered necessary&#46; The study was approved by the Clinical Research Ethics Committee of the hospital&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">In the first phase of the study&#44; a total of 162 patients were admitted to both Units&#46; Of these&#44; 110 were included in the study&#58; 34 patients in the trauma and emergency care Unit &#40;66 admissions&#41; and 76 patients in the polyvalent Unit &#40;96 admissions&#41;&#46; In the third phase of the study a total of 215 patients were admitted to both Units&#46; Of these&#44; 119 were included in the study&#58; 20 patients in the trauma and emergency care Unit &#40;75 admissions&#41; and 99 patients in the polyvalent Unit &#40;140 admissions&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the characteristics of the patients&#46; The distribution by diseases differed between the two data collection phases&#44; with a larger number of polytraumatized patients in the third phase&#46; The patients in the third phase presented a higher frequency &#40;and a longer duration&#41; of mechanical ventilation&#46; The duration of stay in the ICU and the mortality rate were also higher in this phase&#46; Nevertheless&#44; the severity level upon admission&#44; as assessed by the APACHE II score&#44; was similar in both phases&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Compliance with the established nutrition protocol was optimum in both study phases&#44; independently of the modifications introduced in the second phase&#46; There were no alterations in the parameters analyzed&#58; nutrient administration route&#44; recommended energy supply&#44; or definition and management of gastrointestinal complications of EN&#46; The incidence of gastrointestinal complications related to EN was similar in both periods &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Two patients &#40;one in each group&#41; suffered metabolic complications probably related to EN &#40;one case of hypertriglyceridemia and one case of hyperbilirubinemia&#41;&#44; though no special treatment measures were required&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">In relation to monitoring of the measures for improvement&#44; we noted an increase in the use of EN during the third phase of the study&#44; in which 87&#46;2&#37; of the patients received EN versus 55&#46;5&#37; in the first phase &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Regarding the type of diet used&#44; no decrease in the administration of diets enriched with pharmaconutrients was achieved &#40;64&#46;6&#37; versus 64&#46;9&#37; of the days with EN&#41; &#8211; though the use of hyperproteic diets effectively increased &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The mean nutritional ratio &#40;volume of administered diet&#47;calculated diet&#41; during the data collection periods of the study was 0&#46;56<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;28 in the first phase and 0&#46;61<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;27 in the third phase&#44; with no significant differences between the two phases &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;56&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; Nevertheless&#44; calculation of the nutritional ratio in clinical practice and its inclusion in the patient records &#40;nursing charts or medical evolution comments&#41; was merely anecdotal&#58; in most cases no such calculations were entered in the records&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The use of PN&#8722;another of the proposed measures for improvement&#8211;was not seen to increase in the third study phase &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">Our DICM has used an artificial nutrition protocol since 1996&#46; The protocol is regularly updated to adapt it to the advances in knowledge&#44; the recommendations of the scientific societies&#44; and the work routines of the DICM&#46; It is important to mention that all the healthcare personnel involved in the process &#40;physicians&#44; nurses and nursing assistants&#41; intervene in the different versions of the protocol&#46; As a result&#44; the degree of implication in complying with the protocol is very high&#44; as reflected by its correct application in the scenarios analyzed in our study&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">With a well implemented artificial nutrition protocol&#44; the purpose of our study was to assess the points amenable to improvement&#44; with a view to updating the protocol&#46; The results indicate that divulgating actions alone for presenting the measures for improvement are not enough to ensure that such measures are adequately incorporated to clinical practice&#46; In effect&#44; only two of the 5 proposed recommendations were correctly implemented&#58; increased use of EN and increase administration of hyperproteic diets&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The preferential use of EN in patients who do not present contraindications to this form of nutrition is clearly accepted by the scientific community&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Critical patients requiring mechanical ventilation also receive EN in most cases&#46; This circumstance may have conditioned the increased use of EN recorded in the third phase of our study&#44; since the patients in this phase presented a greater need for mechanical ventilation&#44; and ventilation moreover lasted longer&#46; These were also patients with a longer stay in the ICU and with greater mortality&#44; compared with the first phase&#46; Thus&#44; the differences in the population of patients admitted might explain the change in the use of EN between the two study phases&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Some authors<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> have analyzed the reasons why critical patients do not receive the amount of EN they need according to the calculated energy requirements&#46; The mean nutritional ratio recorded in different studies in critical patients is between 50&#37; and 90&#37;&#46; The reasons for this decrease in diet supply are diverse and include factors related to the patient disease condition&#44; the type of nutritional catheter used&#44; the timing of the start of EN&#44; and interruptions in diet supply &#40;due to the performance of tests&#44; nursing procedures&#44; surgery or complications of any kind&#41;&#46; In the present study we likewise recorded an inadequate nutritional ratio in the context of EN in critical patients&#44; though the study was not designed to analyze the reasons for this decrease in ratio&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Changes in nutritional practices designed to increase the effectiveness of nutritional treatment in critical patients have been evaluated by a number of authors&#46; In a study of the implementation of a nutritional protocol in the ICU&#44; Barr et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> compared different variables before and after introducing the protocol&#46; The authors found the use of EN to be more frequent after introducing the protocol&#44; with no changes in calorie supply by day four of nutritional support&#46; The main difference between their study and our own is that the mentioned Unit had no previously implemented protocol&#44; though the existing nutritional practices facilitated adoption of the protocol&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Other authors have published their experience with the introduction of changes in the nutritional management of critical patients&#46; Jones et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> conducted a randomized clinical study to assess the adoption of 17 measures recommended to improve nutritional treatment in different DICMs divided into two groups&#58; Departments with an educational program including the intervention of a nutritionist to facilitate access to and diffusion of the measures&#44; and Departments in which the measures were simply distributed to each Unit&#46; The results after a period of 12 months showed no differences in clinical evolution between the two groups&#44; with the exception of blood glucose control in the intervention group&#46; The factors complicating introduction of the changes in the nutritional process were related to the medical professional &#40;reluctance to accept change&#44; lack of knowledge and lack of experience&#41;&#44; the clinical characteristics of the patient&#44; the characteristics of the institution &#40;limited resources&#44; bureaucracy&#44; care overload&#41; and aspects related to the clinical practice guides &#40;obsolete or limited evidence&#44; and multiple or complicated recommendations&#41;&#46; In turn&#44; the factors facilitating introduction of the changes were their incorporation to routine practice&#44; training&#44; facility of access and application of the guides&#44; as well as the adoption of reminder strategies &#40;checklists&#44; protocols&#44; multidisciplinary sessions&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Cabana<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> classified the obstacles facing adequate compliance with the clinical practice guides into 7 categories&#58; lack of knowledge&#44; lack of familiarity&#44; lack of agreement&#44; self-efficacy&#44; expected benefit&#44; motivation and external barriers&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Doig et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> defined 18 interventions grouped into categories for the implementation of measures designed to improve nutritional support&#46; They identified a leader per Unit&#44; conducted visits and meetings&#44; included the role of the nutritionist&#44; and produced algorithms and posters&#46; The adoption of these measures resulted in statistically significant improvements in the provision of nutrition&#44; but no associated changes in hospital mortality were recorded&#46; In a study carried out in a Brazilian ICU&#44; the introduction of a nutritional protocol following an educational program improved the quality of nutrition practice&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> Cheater et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> in a systematic review of the interventions that can modify clinical practice&#44; concluded that the efficacy of the interventions is generally modest&#44; and that the particularities of each institution seem to be more important than the type of measures used to introduce change&#46; The best approach therefore would be to analyze the characteristics of each individual Unit referred to the presence of protocols and check their daily implementation&#46; This in turn should be followed by an analysis of the results obtained&#44; with definition of those circumstances that facilitate or complicate application of the protocols&#44; with a view to proposing corrective changes for incorporation to daily practice&#46; The way in which the protocols are diffused&#44; and the control of compliance&#44; should be adapted to each individual Unit and scenario in order to secure significant changes&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Our study has some limitations&#46; On one hand&#44; this was a single-center study&#46; However&#44; as has been mentioned above&#44; knowledge of the characteristics inherent to each individual Unit appears to be decisive in selecting the measures to be introduced and their success&#46; On the other hand&#44; our study included no control group to allow us to affirm that the changes observed were attributable to the program and not to other external factors&#46; The study was not designed for comparison with a control group&#44; and such comparison moreover would not have been possible&#44; since there were no other Units using the same nutrition protocol&#46; Another of the limitations of our study refers to the differences in the patient populations of the two data collection phases&#46; These differences are attributable to chance and probably to the short data collection time period involved &#40;2 months&#41;&#46; A longer period probably would have contributed to minimize the differences between the groups&#46; Nevertheless&#44; since this was a study designed to evaluate the impact of passive &#40;educational&#41; interventions upon changes in patient care&#44; such changes could have manifested in the same way&#46; Lastly&#44; our study was not designed to analyze the causes of success or failure of the implementation of measures to improve nutritional support&#59; rather&#44; it was limited to describing the impact of an intervention upon the process&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In sum&#44; our results indicate that the simple recommendation of changes in the nutritional support of critical patients induces minor modifications in clinical practice&#44; but is not accompanied by increased effectiveness of nutritional treatment&#46; The data obtained support the need to apply active measures of an educational nature&#44; with evaluation of the results&#44; in order to guarantee effective change of clinical relevance for the patients&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Financial support</span><p id="par0155" class="elsevierStylePara elsevierViewall">This project was financed in part by a research grant from <span class="elsevierStyleGrantSponsor" id="gs1">Abbott Nutrici&#243;n</span>&#44; Espa&#241;a&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflict of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Patients and methods"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Results"
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          "identificador" => "sec0020"
          "titulo" => "Discussion"
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        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Financial support"
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        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Conflict of interest"
        ]
        10 => array:2 [
          "identificador" => "xack274385"
          "titulo" => "Acknowledgements"
        ]
        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2015-01-15"
    "fechaAceptado" => "2015-04-27"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec814880"
          "palabras" => array:4 [
            0 => "Critically ill patient"
            1 => "Enteral nutrition"
            2 => "Parenteral nutrition"
            3 => "Quality indicators"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec814879"
          "palabras" => array:4 [
            0 => "Paciente cr&#237;tico"
            1 => "Nutrici&#243;n enteral"
            2 => "Nutrici&#243;n parenteral"
            3 => "Indicadores de calidad"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyze the nutritional management practices in Intensive Care &#40;ICU&#41; to detect the need for improvement actions&#46; Re-evaluate the process after implementation of improvement actions&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Prospective observational study in 3 phases&#58; &#40;1&#41; observation&#59; &#40;2&#41; analysis&#44; proposal development and dissemination&#59; &#40;3&#41; analysis of the implementation&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">ICU of a hospital of high complexity&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Participants</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Adult ICU forecast more than 48<span class="elsevierStyleHsp" style=""></span>h of artificial nutrition&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Primary endpoints</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Parenteral nutrition &#40;PN&#41;&#44; enteral nutrition &#40;EN&#41; &#40;type&#44; average effective volume&#44; complications&#41; and average nutritional ratio&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A total of 229 patients &#40;phase 1&#58; 110&#44; phase 3&#58; 119&#41;&#44; after analyzing the initial results&#44; were proposed&#58; increased use and precocity of EN&#44; increased protein intake&#44; nutritional monitoring effectiveness and increased supplementary indication NP&#46; The measures were broadcast at specific meetings&#46; During phase 3 more patients received EN &#40;55&#46;5 vs&#46; 78&#46;2&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; with no significant difference in the start time &#40;1&#46;66 vs&#46; 2&#46;33 days&#41;&#44; duration &#40;6&#46;82 vs&#46; 10&#46;12 days&#41; or complications &#40;37&#46;7 vs&#46; 47&#46;3&#37;&#41;&#46; Use of hyperproteic diets was higher in phase 3 &#40;0 vs&#46; 13&#46;01&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#46; The use of NP was similar &#40;48&#46;2 vs&#46; 48&#46;7&#37;&#41; with a tendency to a later onset in phase 3 &#40;1&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;25 vs&#46; 2&#46;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;22 days&#41;&#46; There were no significant differences in the average nutritional ratio &#40;0&#46;56<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;28 vs&#46; 0&#46;61<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;27&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;56&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The use of EN and the protein intake increased&#44; without appreciating effects on other improvement measures&#46; Other methods appear to be necessary for the proper implementation of improvement measures&#46;</p></span>"
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          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Design"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Setting"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Participants"
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          4 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Primary endpoints"
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            "identificador" => "abst0030"
            "titulo" => "Results"
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          6 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Objetivos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Analizar las pr&#225;cticas de tratamiento nutricional en un Servicio de Medicina Intensiva &#40;SMI&#41; para detectar la necesidad de acciones de mejora&#46; Reevaluar el proceso tras la implementaci&#243;n de las acciones de mejora&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Dise&#241;o</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional prospectivo en 3 fases&#58; 1&#41; observaci&#243;n&#59; 2&#41; an&#225;lisis&#44; elaboraci&#243;n de propuestas y su difusi&#243;n&#59; 3&#41; an&#225;lisis de la implantaci&#243;n&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">&#193;mbito</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">SMI de un hospital de alta complejidad&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Participantes</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Adultos en UCI con previsi&#243;n de nutrici&#243;n artificial de m&#225;s de 48&#160;h&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Variables de inter&#233;s principales</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Nutrici&#243;n parenteral &#40;NP&#41;&#44; nutrici&#243;n enteral &#40;NE&#41; &#40;tipo&#44; volumen eficaz medio&#44; complicaciones&#41; y ratio nutricional media&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Participaron 229 pacientes &#40;fase 1&#58; 110&#59; fase 3&#58; 119&#41;&#46; Tras el an&#225;lisis de los resultados&#44; se propusieron&#58; incremento en uso y precocidad de NE&#44; incremento en aporte proteico&#44; monitorizaci&#243;n de la eficacia nutricional y mayor indicaci&#243;n de NP complementaria&#46; Las medidas fueron difundidas en reuniones espec&#237;ficas&#46; Durante la fase 3 hubo m&#225;s pacientes con NE &#40;55&#44;5 vs&#46; 78&#44;2&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; sin diferencia significativa en el tiempo de inicio de NE &#40;1&#44;66 vs&#46; 2&#44;33 d&#237;as&#41;&#44; duraci&#243;n &#40;6&#44;82 vs&#46; 10&#44;12 d&#237;as&#41; o complicaciones &#40;37&#44;7 vs&#46; 47&#44;3&#37;&#41;&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La utilizaci&#243;n de dietas hiperproteicas fue mayor en la fase 3 &#40;0 vs&#46; 13&#44;01&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; El empleo de NP fue similar &#40;48&#44;2 vs&#46; 48&#44;7&#37;&#41; con tendencia al inicio m&#225;s tard&#237;o en la fase 3 &#40;1&#44;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;25 vs&#46; 2&#44;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;22 d&#237;as&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>NS&#41;&#46; No hubo diferencias significativas en la ratio nutricional media &#40;0&#44;56<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;28 vs&#46; 0&#44;61<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;27&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;56&#41;&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusiones</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Se increment&#243; la utilizaci&#243;n de la NE y el aporte proteico sin apreciarse efectos sobre el resto de las medidas propuestas&#46; Otros m&#233;todos parecen ser necesarios para la adecuada implantaci&#243;n de medidas de mejora&#46;</p></span>"
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            "identificador" => "abst0040"
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            "titulo" => "Dise&#241;o"
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          2 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "&#193;mbito"
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          3 => array:2 [
            "identificador" => "abst0055"
            "titulo" => "Participantes"
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          4 => array:2 [
            "identificador" => "abst0060"
            "titulo" => "Variables de inter&#233;s principales"
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            "identificador" => "abst0065"
            "titulo" => "Resultados"
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          6 => array:2 [
            "identificador" => "abst0070"
            "titulo" => "Conclusiones"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; L&#225;zaro-Mart&#237;n NI&#44; Catal&#225;n-Gonz&#225;lez M&#44; Garc&#237;a-Fuentes C&#44; Terceros-Almanza L&#44; Montejo-Gonz&#225;lez JC&#46; An&#225;lisis de los cambios en las pr&#225;cticas de nutrici&#243;n en UCI tras una intervenci&#243;n en el proceso&#46; Med Intensiva&#46; 2015&#59;39&#58;530&#8211;536&#46;</p>"
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Mean and standard deviation &#40;SD&#41; of the mean nutritional ratio per day of admission in the first phase of the study&#46; This figure shows the mean and SD of the mean nutritional ratio&#44; i&#46;e&#46;&#44; the proportion of calories administered by artificial nutrition in relation to the requirements per day of admission&#46;</p>"
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Mean and standard deviation &#40;SD&#41; of the mean nutritional ratio per day of admission in the third phase of the study&#46; This figure shows the mean and SD of the mean nutritional ratio&#44; i&#46;e&#46;&#44; the proportion of calories administered by artificial nutrition in relation to the requirements per day of admission&#46;</p>"
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        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Modification of the nutrition practices in the DICM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Increase in use of EN&#46; Consider preferential indication of EN in patients without contraindications to EN</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Diets enriched with pharmaconutrients</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Use restricted to the first week of admission &#40;which usually coincides the phase of greatest metabolic stress&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Assess longer use in patients with persistently severe conditions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Select diet enriched with fish oil for patients with acute respiratory distress syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8220;Chronic phase&#8221; diets &#40;from the second week of admission&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Use preferably in stable patients after the first week of admission&#46; A hyperproteic diet with a mixture of dietetic fiber is proposed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Nutritional monitoring</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>The case history should reflect &#40;comments on evolution&#47;nursing chart&#41; the calories supplied each day and the administered calories&#47;calculated required calories &#40;nutritional ratio&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Use of complementary PN</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Suggestions&#58; prescribe if no more than 60&#37; of the calculated requirements are supplied by day 4 of enteral nutrition &#40;nutritional ratio<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Proposed measures for improvement&#46;</p>"
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          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">The results of quantitative variables are expressed as the mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation &#40;x<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#41;&#46; The results of qualitative variables are expressed as n and percentage&#46;</p><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Phase 2 corresponds to the educational period in which no data collection was carried out&#46;</p><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">The significant results appear in boldface&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Phase 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Phase 3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Patients included</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">110&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">119&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age &#40;years&#41; &#40;x</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52&#46;10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;128&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&#46;03<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;874&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">APACHE II &#40;x</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#46;36<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Diagnoses upon admission &#40;n and &#37; with respect to total&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Medical disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75 &#40;68&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">79 &#40;66&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Surgical disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;8&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23 &#40;19&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Polytraumatisms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26 &#40;23&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17 &#40;14&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Days on mechanical ventilation &#40;x</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;97<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;974&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;85<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;278&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Patients with mechanical ventilation n&#160;&#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">81 &#40;73&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">110 &#40;92&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Stay &#40;days&#41; &#40;x</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;89<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;4282&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;1723&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Survival n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">102 &#40;92&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">94 &#40;79&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Nutritional requirements &#40;kcal&#41; &#40;x</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1891&#46;58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>341&#46;631&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2127&#46;17<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>368&#46;943&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Patients with enteral nutrition n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61 &#40;55&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">93 &#40;78&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Patients with parenteral nutrition n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53 &#40;48&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58 &#40;48&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Start of enteral nutrition &#40;days&#41; &#40;x</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;66<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;998&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;050&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Start of parenteral nutrition &#40;days&#41; &#40;x</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;254&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;224&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Duration of enteral nutrition &#40;x</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;82<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;239&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;12<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;416&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Duration of parenteral nutrition &#40;x</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;191&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;61<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;037&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Complications of PN n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Phase 2 corresponds to the educational period in which no data collection was carried out&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Phase 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Phase 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Patients with EN</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Complications of EN</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;37&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44 &#40;47&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Increase in gastric residue<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;14&#46;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;16&#46;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diarrhea<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;8&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;16&#46;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Abdominal distension<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;4&#46;91&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;4&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Constipation<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;21&#46;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19 &#40;20&#46;43&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nausea<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1&#46;64&#41;&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2015.04.002

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	10	9	19
2024 October	39	51	90
2024 September	37	26	63
2024 August	62	51	113
2024 July	78	35	113
2024 June	51	46	97
2024 May	41	32	73
2024 April	47	46	93
2024 March	46	28	74
2024 February	29	40	69
2024 January	39	36	75
2023 December	46	43	89
2023 November	38	33	71
2023 October	37	34	71
2023 September	32	37	69
2023 August	30	18	48
2023 July	42	23	65
2023 June	27	18	45
2023 May	44	38	82
2023 April	33	13	46
2023 March	45	33	78
2023 February	50	31	81
2023 January	25	16	41
2022 December	54	29	83
2022 November	71	28	99
2022 October	43	26	69
2022 September	79	27	106
2022 August	83	33	116
2022 July	51	32	83
2022 June	38	37	75
2022 May	46	35	81
2022 April	50	33	83
2022 March	63	66	129
2022 February	32	30	62
2022 January	46	29	75
2021 December	53	49	102
2021 November	46	42	88
2021 October	89	71	160
2021 September	53	32	85
2021 August	73	61	134
2021 July	43	38	81
2021 June	40	32	72
2021 May	61	40	101
2021 April	105	81	186
2021 March	76	19	95
2021 February	62	33	95
2021 January	51	32	83
2020 December	50	28	78
2020 November	71	29	100
2020 October	52	36	88
2020 September	46	20	66
2020 August	38	19	57
2020 July	33	25	58
2020 June	44	21	65
2020 May	54	20	74
2020 April	43	24	67
2020 March	79	15	94
2020 February	146	32	178
2020 January	89	23	112
2019 December	91	22	113
2019 November	79	27	106
2019 October	61	21	82
2019 September	53	32	85
2019 August	41	28	69
2019 July	36	34	70
2019 June	25	6	31
2019 May	45	30	75
2019 April	32	8	40
2019 March	48	30	78
2019 February	37	32	69
2019 January	37	27	64
2018 December	47	38	85
2018 November	91	41	132
2018 October	44	27	71
2018 September	22	8	30
2018 August	28	14	42
2018 July	18	9	27
2018 June	30	10	40
2018 May	10	6	16
2018 April	23	10	33
2018 March	16	8	24
2018 February	20	8	28
2018 January	32	12	44
2017 December	22	9	31
2017 November	26	8	34
2017 October	26	12	38
2017 September	17	7	24
2017 August	20	13	33
2017 July	24	8	32
2017 June	33	11	44
2017 May	36	11	47
2017 April	34	22	56
2017 March	5	13	18
2017 February	7	9	16
2017 January	7	6	13
2016 December	38	9	47
2016 November	47	13	60
2016 October	51	16	67
2016 September	44	11	55
2016 August	28	2	30
2016 July	29	11	40
2016 March	2	0	2

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