Recommendations for specialized nutritional-metabolic management of the critical patient
Recommendations for specialized nutritional-metabolic treatment of the critical patient: The chronic critical patient. 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: paciente crítico crónico. 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" => "81" "paginaFinal" => "84" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Cervera Montes, R.M. Gastaldo Simeón, E. Portugal Rodríguez" "autores" => array:3 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Cervera Montes" "email" => array:1 [ 0 => "cervera_manmon@gva.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "R.M." "apellidos" => "Gastaldo Simeón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Portugal Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Doctor Peset, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital de Manacor, Balearic Islands, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Clínico Universitario de Valladolid, Valladolid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "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: paciente crítico crónico. 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">The decrease in mortality due to early multiorgan failure has generated a growing population of patients that do not die but remain in the Intensive Care Unit (ICU) with residual vital organ and system functions that cause them to be highly dependent, with a poor prognosis and (among the survivors) poor quality of life: these are the so-called <span class="elsevierStyleItalic">chronic critical patients</span> (CCP).</p><p id="par0010" class="elsevierStylePara elsevierViewall">Between 5% and 10% of all patients subjected to mechanical ventilation (MV) progress towards CCP status, with age and comorbidities being risk factors for this condition. Recurrent reactivation of the immune-neuroendocrine axis may lie at the root of the process, inducing an allostatic overload, in CPPs.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> On the other hand, a coincidence in time has been observed in the genic expression of innate immunity (systemic inflammatory response syndrome [SIRS]) and adaptive or suppressive immunity (compensatory anti-inflammatory response syndrome [CARS]), with patient progression towards CCP status being conditioned to the magnitude and direction of these changes in genic expression.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Clinically, CCPs exhibit the following features: prolonged MV, weakness secondary to polyneuromyopathy, altered body composition (sarcopenia, fat infiltration, osteopenia and anasarca), neuroendocrine changes (loss of pulsatile growth hormone [GH] secretion), cerebral dysfunction (delirium, coma) and susceptibility to infection. Although 50% of these patients are freed from MV, the in-hospital mortality rate reaches 49%, and the survival rate after 1 year is only 30%. Chronic critical patients may recover or evolve towards a new late organ dysfunction phenotype associated to a state of persistent inflammation causing increased anabolic/catabolic imbalance and a state known as <span class="elsevierStyleItalic">persistent inflammation, immunosuppression and catabolic syndrome</span> (PICS). In most cases, however, these patients slowly progress towards a fatal outcome or require admission to a long-stay care institution.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Chronic critical patients are characterized by a certain genomic substrate, though it is still not clear why some of them recover while others progress towards PICS.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There is no established specific treatment for these patients. The attempts to control the neuroendocrine problem lying at the heart of the problem have had no clear impact upon the patient outcome. Prevention is crucial, with interventions in the acute phase of the process, seeking control of the inflammation and endocrine-metabolic alterations and the prevention of muscle dysfunction, being key elements.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The present chapter addresses the nutritional-metabolic interventions that prove useful in CCPs, together with other associated therapies that complete the so-called “<span class="elsevierStyleItalic">anabolic nutrition</span>” strategy.</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">1. Do the energy and protein requirements of these patients differ from those of the rest of critical patients?</span><p id="par0030" class="elsevierStylePara elsevierViewall">There is no evidence supporting a specific nutritional strategy for CCPs and patients with PICS. The persistence of inflammation, hypercatabolism and anabolic resistance leads to a state of sarcopenia/cachexia; the “<span class="elsevierStyleItalic">anabolic nutrition</span>” strategy is the best option for combating this situation, together with resistance exercises. In addition to other actions, “<span class="elsevierStyleItalic">anabolic nutrition</span>” proposes a caloric supply of 25–30<span class="elsevierStyleHsp" style=""></span>kcal/kg/day and a protein supply of 1.5–2<span class="elsevierStyleHsp" style=""></span>g/kg/day.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–9</span></a> Special attention should focus on glycemic control (glycemia <150 mg/dl, minimizing its variability), with the avoidance of an excessive caloric supply.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">2. What is the most adequate feeding route?</span><p id="par0035" class="elsevierStylePara elsevierViewall">Enteral nutrition (EN) is recommended as first-line nutrition support strategy in patients with a functioning gastrointestinal tract. Feeding initially is via a nasogastric tube (NGT); the nasojejunal route offers no objective advantages in this regard.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> Enteral nutrition, initially on a continuous basis, can be applied intermittently to facilitate other therapeutic actions (e.g., active exercise, early mobilization, etc.).<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In any case, it is advisable to have an EN administration protocol based on volumetric objectives and controlled by nursing staff.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Percutaneous endoscopic gastrostomy (PEG) should be considered in patients that tolerate EN via NGT if a prolonged duration of feeding is expected (>30 days). It should be considered in the second-third week in those patients with inadequate intake and a moderate to severe risk of malnutrition. The decision to perform PEG should be made on an individualized basis, taking into account the patient preferences, diagnosis and life expectancy.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> In the recovery phase, CCPs should be evaluated for safety of feeding via the oral route and the suspension of feeding via NGT or PEG once the nutritional targets have been reached.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">3. What is the most adequate specialized nutrition support formula in these patients?</span><p id="par0045" class="elsevierStylePara elsevierViewall">No data are available regarding the most adequate nutritional formula in CCPs/PICS, though in general a hyperproteic polymeric diet is indicated. Some authors advise the use of formulas enriched with pharmaconutrients, based on studies that describe improvements in terms of immune function and inflammation, together with a decrease in infections and shortened stay and duration of MV.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The chosen nutritional formula should afford sufficient protein, avoid excessive calories and ensure an adequate provision of micronutrients.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">4. What specific nutrients and micronutrients are required?</span><p id="par0050" class="elsevierStylePara elsevierViewall">Trace elements (TEs) such as Cu, Mn, Zn and Fe, and certain vitamins (Vi) such as vitamin E, C and E, and β-carotene, are crucial as coenzymes and antioxidants.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> These elements are usually deficient in CCPs as a result of redistribution, hemodilution, insufficient intake and treatments such as continuous renal replacement therapy. There is a negative correlation between micronutrient deficit and the severity of the disease process.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> In a systematic review, Manzanares et al. sought to determine whether TE and Vi replacement is of benefit. The authors concluded that high doses of TEs and Vi improve the clinical outcomes in critical patients, particularly in the more serious cases.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> However, there is an important gap in knowledge regarding the normal levels, the dosage and the effect of each TE considered isolatedly. What does seem clear is that the existing commercial mixtures are unable to cover the requirements.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Controversy remains regarding the administration of pharmaconutrients such as arginine, glutamine, leucine, beta-hydroxy-beta-methylbutyrate and creatine, despite their acknowledged immunological, enteroprotective and anabolic actions. There are no studies of sufficient quality to clearly establish the usefulness of these nutrients in critical patients in general and in CCPs in particular.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21–23</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">5. What other nutritional-metabolic interventions are useful in these patients?</span><p id="par0060" class="elsevierStylePara elsevierViewall">The endocrine-metabolic scenario, together with concomitant factors such as disuse, make a determinant contribution to sarcopenia, cachexia and immune depression in CCPs and PICS.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Hormone replacement therapy could correct the consequences of the endocrine anomalies, though studies involving the administration of growth hormone, thyroxin and corticosteroids in CCPs have found such measures to be ineffective.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> In rare instances, a lack of effective hypothalamic-pituitary stimulation can result in functional insufficiency requiring replacement with corticosteroids and thyroxin.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Chronic critical patients suffer bone metabolic disorders (elevated reabsorption) – the recognizable risk factors being cytokines, immobilization, endocrine alterations, the administration de corticosteroids, electrolyte and micronutrient disturbances (Mg, P, K, vitamin C, K and D) and secondary hyperparathyroidism. Nevertheless, the clinical benefits of administering bisphosphonates, calcium and vitamin D are subject to controversy – though there is agreement regarding the administration of vitamin D in highly deficient patients.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26–28</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Prolonged immobilization and disuse are crucial contributors to the appearance of sarcopenia and weakness. A systematic review revealed no impact upon short- and middle term mortality, though improved mobility and muscle strength was recorded.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> In contrast, other studies have highlighted the benefits of an early rehabilitation program guided by objectives consistent with the patient condition.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> In general, early mobilization is advised, with resistance exercises or neuromuscular electrical stimulation – though the indicated duration and frequency are not clear.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Other pharmacological treatments with anabolic effects are currently under study, such as ghrelin, insulin-like growth factor type 1 and muscle modulators such as the myostatin inhibitors and melanocortin-4 receptor antagonists. Due to its anabolic and appetite-stimulating properties, ghrelin improves the symptoms and muscle weakness of chronic patients with cachexia,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> and therefore could afford benefits in the rehabilitation of CCPs.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Recommendations</span><p id="par0080" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall">In the nutritional strategy of chronic critical patients, a hyperproteic polymeric diet is advised (1.5–2<span class="elsevierStyleHsp" style=""></span>g/kg/day), avoiding caloric overload (25–30<span class="elsevierStyleHsp" style=""></span>kcal/kg/day) (Quality of evidence [QE]: moderate in favor).</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0090" class="elsevierStylePara elsevierViewall">Systematic pharmaconutrition is not advised; the incorporation of L-leucine, beta-hydroxy-beta-methylbutyrate and L-carnitine to the diet is an option currently subjected to study (QE: low in favor).</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">Enteral nutrition via the nasogastric route is recommended. Feeding through a percutaneous endoscopic gastrostomy (PEG) should be evaluated if prolonged nutrition is expected (>30 days). Recovery of the oral route is desirable (QE: moderate in favor).</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall">Periodic supplementing with vitamins and oligoelements may be decided, particularly in patients subjected to continuous or frequent intermittent renal replacement therapy (QE: low in favor).</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall">Vitamin D supplements are suggested in chronic critical patients with confirmed deficits of this vitamin (QE; low in favor).</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0110" class="elsevierStylePara elsevierViewall">Early mobilization is indicated, with resistance exercises and neurostimulation guided by objectives whenever possible (Grade of recommendation: moderate in favor).</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">Dr. R. Gastaldo-Simeón has collaborated with Fresenius, participating in congresses, and in a study on parenteral nutrition. She has collaborated with Menarini in training workshops in cardiopulmonary resuscitation. Dr. Esther Portugal has received aids from the drug industry for participation in medical congresses (Abbott) and nutrition-related courses (Abbott, Nestle, Vegenat, Fresenius). In addition, she has given a talk for the drug industry (Vegenat). Dr. Cervera declares that he has no conflicts of interest.</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:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "1. Do the energy and protein requirements of these patients differ from those of the rest of critical patients?" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "2. What is the most adequate feeding route?" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "3. What is the most adequate specialized nutrition support formula in these patients?" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "4. What specific nutrients and micronutrients are required?" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "5. What other nutritional-metabolic interventions are useful in these patients?" ] ] ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Recommendations" ] 3 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-10-18" "fechaAceptado" => "2019-12-09" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cervera Montes M, Gastaldo Simeón RM, Portugal Rodríguez E. Recomendaciones para el tratamiento nutrometabólico especializado del paciente crítico: paciente crítico crónico. Grupo de Trabajo de Metabolismo y Nutrición de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC). Med Intensiva. 2020;44:81–84.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This article forms part of the supplement “Recommendations for specialized nutritional-metabolic management of the critical patient. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 5 | 7 |
| 2024 October | 24 | 60 | 84 |
| 2024 September | 47 | 37 | 84 |
| 2024 August | 44 | 44 | 88 |
| 2024 July | 35 | 27 | 62 |
| 2024 June | 41 | 46 | 87 |
| 2024 May | 38 | 32 | 70 |
| 2024 April | 30 | 48 | 78 |
| 2024 March | 20 | 25 | 45 |
| 2024 February | 27 | 47 | 74 |
| 2024 January | 28 | 51 | 79 |
| 2023 December | 23 | 61 | 84 |
| 2023 November | 26 | 75 | 101 |
| 2023 October | 20 | 41 | 61 |
| 2023 September | 23 | 48 | 71 |
| 2023 August | 16 | 18 | 34 |
| 2023 July | 20 | 30 | 50 |
| 2023 June | 14 | 10 | 24 |
| 2023 May | 37 | 39 | 76 |
| 2023 April | 28 | 18 | 46 |
| 2023 March | 77 | 27 | 104 |
| 2023 February | 25 | 28 | 53 |
| 2023 January | 17 | 19 | 36 |
| 2022 December | 60 | 30 | 90 |
| 2022 November | 47 | 26 | 73 |
| 2022 October | 62 | 26 | 88 |
| 2022 September | 23 | 31 | 54 |
| 2022 August | 19 | 34 | 53 |
| 2022 July | 17 | 31 | 48 |
| 2022 June | 19 | 21 | 40 |
| 2022 May | 18 | 33 | 51 |
| 2022 April | 23 | 39 | 62 |
| 2022 March | 24 | 32 | 56 |
| 2022 February | 24 | 17 | 41 |
| 2022 January | 19 | 19 | 38 |
| 2021 December | 21 | 32 | 53 |
| 2021 November | 21 | 31 | 52 |
| 2021 October | 34 | 66 | 100 |
| 2021 September | 19 | 23 | 42 |
| 2021 August | 22 | 36 | 58 |
| 2021 July | 10 | 25 | 35 |
| 2021 June | 23 | 13 | 36 |
| 2021 May | 16 | 43 | 59 |
| 2021 April | 24 | 46 | 70 |
| 2021 March | 25 | 17 | 42 |
| 2021 February | 14 | 18 | 32 |
| 2021 January | 20 | 15 | 35 |
| 2020 December | 17 | 16 | 33 |
| 2020 November | 9 | 17 | 26 |
| 2020 October | 6 | 9 | 15 |
| 2020 July | 8 | 12 | 20 |
| 2020 June | 1 | 2 | 3 |
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