Recommendations for specialized nutritional-metabolic treatment of the critical patient
Recommendations for specialized nutritional-metabolic treatment of the critical patient: Pharmaconutrients, specific nutrients, fiber, synbiotics. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)
Recomendaciones para el tratamiento nutrometabólico especializado del paciente crítico: farmaconutrientes, nutrientes específicos, fibra, simbióticos. Grupo de Trabajo de Metabolismo y Nutrición de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC)
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Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "39" "paginaFinal" => "43" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.C. Montejo González, E. de la Fuente O’Connor, F. Martínez-Lozano Aranaga, L. Servià Goixart" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J.C." "apellidos" => "Montejo González" "email" => array:1 [ 0 => "juancarlos.montejo@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "?" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "E." "apellidos" => "de la Fuente O’Connor" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "F." "apellidos" => "Martínez-Lozano Aranaga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Servià Goixart" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital General Universitario Reina Sofía, Murcia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Hospital Universitario Arnau de Vilanova, Lleida, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "?" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recomendaciones para el tratamiento nutrometabólico especializado del paciente crítico: farmaconutrientes, nutrientes específicos, fibra, simbióticos. Grupo de Trabajo de Metabolismo y Nutrición de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC)" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pharmaconutrients are substrates which in addition to their intrinsic nutritional properties also stimulate immune-favoring mediators, inhibit proinflammatory factors and attenuate the response to injury or aggression. Pharmaconutrients include certain amino acids such as glutamine and arginine, ?-3 fatty acids and some oligoelements and vitamins. At present, due to its effects upon the intestinal barrier and microbiome, dietary fiber is also considered to be a pharmaconutrient.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Since the first description 30 years ago of diets enriched with pharmaconutrients and their clinical application, important controversy has persisted as to the potential usefulness of diets of this kind in the critically ill.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Questions</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Does the supply of pharmaconutrients and other specific nutrients improve the inflammatory response to injury in the critically ill?</span><p id="par0015" class="elsevierStylePara elsevierViewall">Different studies have evidenced that pharmaconutrients can modulate the inflammatory and immune response, modify catabolism, protein synthesis and the use of substrates, and exert a positive influence upon the healing mechanisms. The existing evidence is mainly referred to basic research, though data from clinical studies are also available.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> The effects are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">What critical patients benefit from diets with a mixture of pharmaconutrients?</span><p id="par0020" class="elsevierStylePara elsevierViewall">There are a number of enteral nutrition solutions enriched with mixtures of nutrients with the aim of modulating the inflammatory/immune response in the critically ill. The most commonly used mixtures are those containing ?-3 fatty acids (eicosapentaenoic acid [EPA], docosahexaenoic acid [DHA]), gamma-linolenic acid [GLA]) and antioxidants, and those enriched with arginine, ?-3 fatty acids, nucleotides and antioxidants.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A series of meta-analyses have been published on the effects of diets enriched with pharmaconutrients (arginine, ?-3 fatty acids, antioxidants) in the critically ill. All report a decrease in infectious complications, and some of them also evidence a decrease in the duration of hospital stay and of mechanical ventilation.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> However, the meta-analyses are characterized by heterogeneity in the composition of the diets employed and in the patient populations included in the studies. Interpretation of the meta-analyses is also a source of controversy.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Diets enriched with ?-3 fatty acids, GLA and antioxidants have been studied in patients with respiratory failure and in subjects with sepsis. In acute respiratory distress syndrome, such diets can reduce mortality and the duration of mechanical ventilation.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> In sepsis, the use of diets of this kind has been associated to a decrease in patient mortality and in progression towards multiorgan failure.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The impact of pharmaconutrition in surgical patients appear to be different, particularly when surgery is elective.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> A meta-analysis of patients following gastrointestinal surgery has shown pharmaconutrition via the enteral route to be superior to other types of nutrition, since it reduces infectious complications, anastomotic leakage and patient mortality.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Good results have been recorded in severe trauma patients (modulation of the inflammatory response, reduction of infection and improved healing) with the use of diets enriched with pharmaconutrients.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Do critical patients benefit from the administration of glutamine?</span><p id="par0045" class="elsevierStylePara elsevierViewall">In quantitative terms, glutamine is the most important amino acid in the body. It represents 50% of the pool of amino acids circulating in plasma. Furthermore, glutamine has important physiological functions referred to tissue protection, antiinflammatory action, immune regulation, the preservation of tissue metabolic functions in situations of stress, and antioxidant action.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The decrease in glutamine levels seen in situations of stress may be accompanied by deleterious effects such as lessened antioxidant capacity, impaired cell defense mechanisms, diminished intestinal barrier function or increased muscle protein catabolism.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The augmented use of glutamine in situations of metabolic stress is not compensated by the increase in endogenous synthesis of this amino acid; glutamine is therefore considered to be a semi-essential amino acid in the critically ill.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The supply of large amounts of glutamine during nutritional therapy has been investigated in different groups of critical patients.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The results of the studies that investigate glutamine supply via the enteral route have been contradictory. Overall, the only observed outcome has been a decrease in the duration of hospital stay.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Nevertheless, in severe burn patients, glutamine supply is associated to a decrease in mortality.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In contrast, studies that have used glutamine as part of nutritional therapy via the parenteral route have largely evidenced benefits for the patients,<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16–18</span></a> such as fewer infectious complications, a shorter hospital stay and decreased in-hospital mortality. Some studies have reported no positive results or even negative results with the administration of glutamine.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The REDOX study<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> found glutamine administration to be accompanied by deleterious effects when high doses are used, independently of the nutritional regimen involved, and in extremely ill patients (shock with multiorgan failure). The patients investigated in the latter study did not correspond to the group of individuals in which glutamine use is considered in routine clinical practice, however.</p><p id="par0065" class="elsevierStylePara elsevierViewall">It should be noted that the studies that have investigated the effects of parenteral glutamine are heterogeneous both in design and in the form of glutamine used (free glutamine or glutamine dipeptides). On analyzing the studies that have used alanine-glutamine dipeptides as part of the nutritional regimen, a favorable effect is seen in terms of infectious complication, hospital stay or mortality.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Is there evidence supporting the use of pharmaconutrients dissociated from the administration of specialized nutritional therapy?</span><p id="par0070" class="elsevierStylePara elsevierViewall">Some authors have investigated the strategy of supplying pharmaconutrients independently and dissociated from nutritional therapy with the purpose of covering the nutritional objectives (dissociated pharmaconutrition). This allows the administration of “therapeutic” doses of pharmaconutrients without awaiting patient tolerance of all the enteral nutrition. However, this strategy generates controversy regarding the timing of pharmaconutrient supply, the indicated administration route, and whether such dissociated pharmaconutrition offers advantages for the patients.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The administration of glutamine supplements via the enteral route, independently of nutritional therapy, can reduce the duration of multiorgan dysfunction,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> though other studies have evidenced that this strategy does not result in beneficial effects for the patient.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> When using the parenteral route, dissociated glutamine supplementing likewise does not afford beneficial effects.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> The enteral and parenteral supply of high doses of glutamine in patients under conditions of shock and multiorgan dysfunction has been found to have harmful effects (increased mortality).<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The dissociated provision of ?-3 fatty acids via both the enteral<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">25</span></a> and the parenteral route<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">26</span></a> has yielded contradictory results in terms of the inflammatory reaction markers. This treatment strategy is not accompanied by beneficial clinical effects for the patients. In contrast, it may be associated to a prolongation of mechanical ventilation, organ dysfunction, and a longer stay in intensive care.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Should all critical patients with enteral nutrition receive fiber? What type of fiber is indicated?</span><p id="par0085" class="elsevierStylePara elsevierViewall">Diet fibers are plant oligosaccharides or polysaccharides that cannot by hydrolyzed by the endogenous small bowel enzymes of humans. There are two types of fiber: insoluble and soluble. The main effect of insoluble fiber is mechanical (conformation of the fecal bolus). The main risk associated to this type of fiber is intestinal obstruction and ischemia, given the motility problems of the critically ill.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Soluble (fermentable) fiber in turn gives rise to short chain fatty acids (SCFAs) thanks to the action of the intestinal microbiota. Short chain fatty acids constitute a source of energy for the colon mucosal cells and exert effects upon colon epithelial cell proliferation and differentiation, with an increase in blood flow, a decrease in colon pH, the stimulation of pancreatic secretion, increased water and sodium absorption, and the regulation of intestinal motility and of the microbiota.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The use of the different types of fiber and the amounts to be supplied have been the subject of many studies and meta-analyses, though few firm conclusions have been drawn, due to the heterogeneity of the studies, formulas used and doses administered.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">27</span></a> In general, soluble fiber appears to reduce the frequency of diarrhea associated to enteral nutrition.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">28</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Do the critically ill benefit from the administration of probiotics or a mixture of prebiotics and probiotics (synbiotics)?</span><p id="par0100" class="elsevierStylePara elsevierViewall">The intestinal flora has important functions in terms of protection against infection, drug metabolism, vitamin synthesis and the response to disease. In the critically ill, many circumstances lead to loss of the normal intestinal microbiota and to the intraluminal overgrowth of pathogens (dysbiosis).<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">29</span></a> The consequences of this are catastrophic, for in addition to loss of the capacity to maintain barrier functions, alteration of the microbiota in the critically ill is associated to an increased production of cytokines, cell apoptosis and immunosuppression, and all this leads to bacterial translocation into the systemic and lymphatic circulation, nosocomial infection and, ultimately, multiorgan dysfunction.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The use of probiotics (defined by the World Health Organization [WHO] as non-pathogenic live microorganisms which when supplied in adequate amounts afford health benefits) and of prebiotics (fermentable fiber) seeks to restore the balance between beneficial and pathogenic bacteria. Synbiotics are formulations containing both probiotics and prebiotics, favoring survival of the administered strains and, in sum, restoration of the intestinal flora.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The published meta-analyses of studies that have investigated the consequences of administering probiotics and synbiotics in the critically ill describe a decrease in infectious complications<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">30</span></a> and a positive effect in terms of the prevention of ventilator-associated pneumonia.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">31</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">However, the use of probiotics in the critically ill is not without risks particularly in the form of intestinal ischemia and the development of fungal infections – though these are infrequent.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Recommendations</span><p id="par0120" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0125" class="elsevierStylePara elsevierViewall">The use of pharmaconutrients could be considered as a therapeutic strategy seeking to modulate the inflammatory/immune response in the critically ill (Level of evidence: low. Degree of recommendation: low).</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0130" class="elsevierStylePara elsevierViewall">The use of enteral diets enriched with mixtures of pharmaconutrients (arginine, ?-3 fatty acids, antioxidants) is suggested in postsurgery critically ill patients and in cases of severe trauma (Level of evidence: moderate. Degree of recommendation: moderate).</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0135" class="elsevierStylePara elsevierViewall">The use of enteral diets enriched with ?-3 fatty acids, docosahexaenoic acid (DHA) and antioxidants could be considered in patients with sepsis (Level of evidence: low. Degree of recommendation: low).</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0140" class="elsevierStylePara elsevierViewall">Glutamine dipeptide at adequate doses (0.25–0.35?g of glutamine/kg b.w./day), in the absence of contraindications, is suggested as part of nutritional therapy in the critically ill receiving parenteral nutrition (Level of evidence: moderate. Degree of recommendation: moderate).</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0145" class="elsevierStylePara elsevierViewall">Glutamine supplementing via the enteral route is suggested in burn patients (Level of evidence: moderate. Degree of recommendation: moderate).</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0150" class="elsevierStylePara elsevierViewall">The supply of pharmaconutrients dissociated from the nutritional regimen is not routine practice and is not suggested in the critically ill (Level of evidence: moderate. Degree of recommendation: moderate).</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0155" class="elsevierStylePara elsevierViewall">The use of diets containing 100% insoluble fiber in the critically ill is not recommended (Level of evidence: low. Degree of recommendation: high).</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0160" class="elsevierStylePara elsevierViewall">The routine use of diets containing fiber mixtures (insoluble/fermentable) for the prevention of diarrhea associated to enteral nutrition is not advised (Level of evidence: expert opinion. Degree of recommendation: low).</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0165" class="elsevierStylePara elsevierViewall">Diets with a high soluble fiber content are advised among the measures for controlling diarrhea associated to enteral nutrition (Level of evidence: expert opinion. Degree of recommendation: moderate).</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0170" class="elsevierStylePara elsevierViewall">The routine use of probiotics in critically ill patients receiving enteral nutrition is not advised (Level of evidence: low. Degree of recommendation: moderate).</p></li></ul></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0175" class="elsevierStylePara elsevierViewall">Dr. Montejo-González has received payment for participation in activities financed by B. Braun, Vegenat Nutrición, Nestlé Healthcare Nutrition, Abbott Nutrition, Baxter and Nutricia in the form of conferences, counseling, the organization of scientific congresses, courses, scientific meetings, and for participation in congresses and scientific meetings. Dr. de la Fuente O’Connor declares that she has no conflicts of interest. Dr. Martínez-Lozano has received funding from <span class="elsevierStyleGrantSponsor" id="gs0005">Nestlé and Nutricia</span> for participation in scientific congresses, and from <span class="elsevierStyleGrantSponsor" id="gs0010">Vegenat</span> for participation in scientific meetings. Dr. Serviá-Goixart has received payment from <span class="elsevierStyleGrantSponsor" id="gs0015">Fresenius Kabi and Abbott</span> for participation in congresses and scientific meetings.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Note to supplement</span><p id="par0180" class="elsevierStylePara elsevierViewall">This article forms part of the supplement “Recommendations for specialized nutritional-metabolic management of the critical patient. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)”, with the sponsorship of Abbott Nutrition.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:3 [ "identificador" => "sec0010" "titulo" => "Questions" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Does the supply of pharmaconutrients and other specific nutrients improve the inflammatory response to injury in the critically ill?" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "What critical patients benefit from diets with a mixture of pharmaconutrients?" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Do critical patients benefit from the administration of glutamine?" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Is there evidence supporting the use of pharmaconutrients dissociated from the administration of specialized nutritional therapy?" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Should all critical patients with enteral nutrition receive fiber? What type of fiber is indicated?" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Do the critically ill benefit from the administration of probiotics or a mixture of prebiotics and probiotics (synbiotics)?" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Recommendations" ] ] ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Note to supplement" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-09-30" "fechaAceptado" => "2019-12-09" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "?" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Montejo González JC, de la Fuente O’Connor E, Martínez-Lozano Aranaga F, Servià Goixart L. Recomendaciones para el tratamiento nutrometabólico especializado del paciente crítico: farmaconutrientes, nutrientes específicos, fibra, simbióticos. Grupo de Trabajo de Metabolismo y Nutrición de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC). Med Intensiva. 2020;44:39–43.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Inflammation/immunity \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Catabolism/synthesis \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Use of substrates \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Healing \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Antioxidant effect \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Glutamine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Arginine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ramified amino acids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Taurine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cysteine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nucleotides \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vitamin C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vitamin A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Zinc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Selenium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2328338.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Effects of different pharmaconutrients upon metabolic response, inflammation, immune response and healing in situations of injury or aggression.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:31 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pharmaconutrition review: physiological mechanisms" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.F. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 22 | 4 | 26 |
| 2024 October | 70 | 50 | 120 |
| 2024 September | 82 | 39 | 121 |
| 2024 August | 105 | 68 | 173 |
| 2024 July | 96 | 38 | 134 |
| 2024 June | 74 | 48 | 122 |
| 2024 May | 63 | 39 | 102 |
| 2024 April | 68 | 44 | 112 |
| 2024 March | 73 | 20 | 93 |
| 2024 February | 89 | 44 | 133 |
| 2024 January | 83 | 60 | 143 |
| 2023 December | 55 | 51 | 106 |
| 2023 November | 101 | 76 | 177 |
| 2023 October | 70 | 43 | 113 |
| 2023 September | 54 | 48 | 102 |
| 2023 August | 55 | 32 | 87 |
| 2023 July | 69 | 34 | 103 |
| 2023 June | 50 | 25 | 75 |
| 2023 May | 73 | 37 | 110 |
| 2023 April | 48 | 20 | 68 |
| 2023 March | 95 | 40 | 135 |
| 2023 February | 72 | 27 | 99 |
| 2023 January | 57 | 23 | 80 |
| 2022 December | 78 | 36 | 114 |
| 2022 November | 127 | 46 | 173 |
| 2022 October | 102 | 38 | 140 |
| 2022 September | 63 | 35 | 98 |
| 2022 August | 44 | 61 | 105 |
| 2022 July | 33 | 43 | 76 |
| 2022 June | 39 | 27 | 66 |
| 2022 May | 59 | 35 | 94 |
| 2022 April | 69 | 46 | 115 |
| 2022 March | 65 | 56 | 121 |
| 2022 February | 22 | 31 | 53 |
| 2022 January | 20 | 36 | 56 |
| 2021 December | 29 | 66 | 95 |
| 2021 November | 26 | 52 | 78 |
| 2021 October | 29 | 93 | 122 |
| 2021 September | 21 | 53 | 74 |
| 2021 August | 26 | 67 | 93 |
| 2021 July | 13 | 40 | 53 |
| 2021 June | 22 | 24 | 46 |
| 2021 May | 22 | 41 | 63 |
| 2021 April | 36 | 57 | 93 |
| 2021 March | 29 | 36 | 65 |
| 2021 February | 16 | 24 | 40 |
| 2021 January | 22 | 25 | 47 |
| 2020 December | 16 | 10 | 26 |
| 2020 November | 13 | 15 | 28 |
| 2020 October | 10 | 12 | 22 |
| 2020 July | 11 | 16 | 27 |
| 2020 June | 1 | 2 | 3 |
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