Recommendations for specialized nutritional-metabolic treatment of the critical patient
Recommendations for specialized nutritional-metabolic treatment of the critical patient: Neurocritical patients. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units
Recomendaciones para el tratamiento nutrometabólico especializado del paciente crítico: pacientes neurocríticos. Grupo de trabajo de Metabolismo y Nutrición de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias
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Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "69" "paginaFinal" => "72" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.A. Acosta, J.F. Fernández Ortega, S. Pérez Quesada" "autores" => array:3 [ 0 => array:4 [ "nombre" => "J.A." "apellidos" => "Acosta" "email" => array:1 [ 0 => "acostesc@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.F." "apellidos" => "Fernández Ortega" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "S." 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Grupo de trabajo de Metabolismo y Nutrición de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Neurocritical (NC) patients with lesions of traumatic, vascular or neoplastic origin require specialized nutritional support (SNS) due to the impossibility of providing sufficient oral feeding and the intense hypermetabolism and hypercatabolism inherent to such lesions. No comparative studies have been made of the nutritional aspects among patients with lesions of traumatic, vascular or neoplastic origin; the present recommendations are therefore all made under the same grouping of NC patients. Individuals with acute spinal cord injuries are addressed in a specific section at the end of the chapter.</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">Do the energy and protein requirements of these patients differ from those of the rest of critical patients?</span><p id="par0010" class="elsevierStylePara elsevierViewall">The energy requirements of NC patients vary according to the extent of brain damage and the depth of coma. A systematic review by Foley et al.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">1</span></a> found calorie consumption under conditions of mechanical ventilation (MV) with sedation and relaxation to range between 86 and 121% of the basal values calculated from predictive formulas. These figures increased to 140% after the withdrawal of sedation, temperature elevation or the appearance of infection.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In NC patients it is advisable to establish calorie calculation based on indirect calorimetry, or to obtain approximate values using predictive formulas. Energy supply should be started gradually until covering the calculated requirements in the first 48<span class="elsevierStyleHsp" style=""></span>h following the start of feeding. An observational study<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">2</span></a> including patients from 341 Intensive Care Units (ICUs) found the administered mean overall calorie supply to vary in the order of 58% of the programmed calorie values. The study concluded that a drastic decrease in energy supply is related to increased ICU stay and mortality.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Härtl et al.,<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">3</span></a> in a prospective observational study of traumatic brain injury (TBI) patients, quantified the energy administered in the first 7 days of admission to the ICU and concluded that calorie supply is an independent marker of patient mortality and stay in the ICU, documenting a 40% increase in mortality when the calorie supply drops to under 10<span class="elsevierStyleHsp" style=""></span>kcal/kg/day.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A randomized trial in trauma and surgical patients<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">4</span></a> requiring admission to the ICU, in which the calorie supply was in the order of 50% of the calculated requirements, recorded no associated increase in patient morbidity–mortality. The summarized conclusion of these studies is that both a decrease of 50% and an increase of over 100% in administered calories can contribute to increase patient mortality and duration of stay in the ICU.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">With regard to protein supply, a gradual increase is indicated over the first two weeks, due to the intense catabolism that becomes further accentuated over time. A study in trauma patients including individuals with TBI<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">6</span></a> recorded a tendency toward normalization of the nitrogen balance with a protein supply of over 2<span class="elsevierStyleHsp" style=""></span>g/kg/day. Another observational study in seriously ill subjects in general<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">7</span></a> found the administration of at least 80% of the calculated protein needs to be accompanied by lesser mortality versus patients falling short of that percentage supply.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In sum, we recommend an energy supply of close to 80% of the calorie requirements and a protein supply in the first two weeks of 1.4–1.6<span class="elsevierStyleHsp" style=""></span>g/kg/day, with a gradual increase to 2<span class="elsevierStyleHsp" style=""></span>g/kg/day, coinciding with the rehabilitation phase.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Two prospective studies have been evaluated in relation to the timing of the start of nutritional support. Chourdakis et al.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">8</span></a> recorded no differences in patient mortality or infection rate, and Azim et al.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">9</span></a> found early enteral nutrition (EN) to be associated to an increased incidence of pneumonia. A review and meta-analysis concluded that recommendations cannot be made, due to the low homogeneity of the evaluated studies, attributable to the important differences in sample size, type of population and administration route involved.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">10,11</span></a> However, there is agreement that early EN exerts a favorable effect in terms of lessened patient mortality<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">11</span></a> and improved neurological recovery, with a prolongation of ICU stay.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">What is the best feeding route for neurocritical patients? Is routine postpyloric feeding indicated?</span><p id="par0045" class="elsevierStylePara elsevierViewall">Different randomized trials have compared ICU mortality and stay in relation to intravenous versus enteral feeding in patients with severe TBI. A study with a limited sample size recorded no differences in mortality or infection rate.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">12</span></a> A meta-analysis<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">11</span></a> documented a favorable effect in terms of ICU mortality and stay with parenteral nutrition (PN) versus EN. This observation could be explained by the fact that PN affords a greater energy and protein supply, facilitates early feeding, and significantly reduces substrate losses due to increased gastric residual volume (IGR). However, on extrapolating the findings in the general critical care population, where PN is associated to greater risks compared with EN, most of the guides continue to recommend the start of EN in severely ill patients in general and its preferential use in NC patients.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Neurocritical, polytraumatized and major burn patients are the subjects that most often present IGR.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">13</span></a> Its effect is related to the decrease in peristaltic wave frequency in the pyloric antrum and an increase in its muscle tone. Intracranial hypertension episodes, diminished level of consciousness and older age favor IGR. To these independent factors we also must add ventilatory support and the use of sedatives and muscle relaxants. On the other hand, the use of prokinetic medication does not reduce the number of episodes of IGR, the partial or definitive diet suspension rate, or the incidence of pneumonia.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">14</span></a> A randomized clinical trial (RCT)<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">15</span></a> and a meta-analysis<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">16</span></a> have shown postpyloric feeding to increase the administered nutritional volume, significantly reduce the incidence of ventilator associated pneumonia (VAP), and tend to reduce mortality, without modifying the duration of ICU stay.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">What is the best formula for the specialized nutritional management of neurocritical patients? Do diets enriched with glutamine and other pharmaconutrients play a role?</span><p id="par0055" class="elsevierStylePara elsevierViewall">The administration of glutamine dipeptide increases the brain glutamine levels, but without incrementing the brain glutamate concentrations. A study<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">17</span></a> comparing two enteral diets – standard versus a glutamine enriched diet with low carbohydrate and high fatty acid content – revealed no differences in infection or mortality rate, or ICU stay. No randomized clinical trials have confirmed that glutamine dipeptide enriched diets (administered via the enteral or parenteral route) in NC patients have a favorable effect upon the clinical<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">18</span></a> and neurological outcome parameters – though such an effect has been observed in critical patients in general, receiving PN supplemented with glutamine. There are no validated studies in NC patients involving the administration of arginine, and thus no evidence on its use. Experimental and clinical studies in patients with chronic brain injuries have demonstrated improvement in the degree of the neurological sequelae with the late administration of ω-3 fatty acids. However, there are no studies in acute phase NC patients demonstrating that their use improves the sequelae, and it is not known at what point in time their administration proves most favorable.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">What is the recommended glycemia range in neurocritical patients?</span><p id="par0060" class="elsevierStylePara elsevierViewall">The acute phase in NC patients is characterized by alteration of the blood-brain barrier and of the brain/plasma glucose ratio. Cerebral hypoglycemia is associated to negative effects in terms of survival, due to increased expansion of the secondary damage and the glutamate and lactate concentrations, particularly in areas of the brain exhibiting low perfusion, with worsening of the ischemia. According to the different studies<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">20,21</span></a> and meta-analyses,<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">22</span></a> strict glycemia control increases the risk of hypoglycemia and worsens brain damage in the first week of the patient clinical course. A safe range for NC patients is 120–150<span class="elsevierStyleHsp" style=""></span>mg/dl.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">What are the calorie/protein requirements in patients with acute spinal cord injury?</span><p id="par0065" class="elsevierStylePara elsevierViewall">Following spinal cord injury there is a significant decrease in body cell mass and an increase in fatty mass, as well as an increase in the consumption of vitamins A, B1 and B2.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">23</span></a> The calorie/protein requirements are dependent upon three factors: (1) the level of the spinal cord damage (paraplegia or tetraplegia); (2) depth and extent measured by the Asia score; and (3) the clinical evolutive stage of the patient (hypermetabolic or normometabolic). In the initial hypermetabolic phase the patients require respiratory and hemodynamic support, and there is a high incidence of IGR and paralytic ileus.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The calorie/protein supply should be similar to that administered to any other critical patient, with a calorie content of 15–20<span class="elsevierStyleHsp" style=""></span>kcal/kg and a protein supply of 1.4–1.6<span class="elsevierStyleHsp" style=""></span>g/kg/day. Following the stabilization phase, which usually coincides with the suspension of ventilatory support and the start of rehabilitation, patients present a progressive hypometabolic state. Different studies<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">24,25</span></a> have used indirect calorimetry to demonstrate that the energy consumption in patients with acute spinal cord injury ranges between 19–22<span class="elsevierStyleHsp" style=""></span>kcal/kg/day in the case of tetraplegic patients and 25–30<span class="elsevierStyleHsp" style=""></span>kcal/kg/day in the case of paraplegic individuals. The recommended protein supply ranges between 1.2 and 1.5<span class="elsevierStyleHsp" style=""></span>g/kg/day, due to its effect upon normalization of the nitrogen balance.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">26</span></a>.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Recommendations</span><p id="par0075" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0080" class="elsevierStylePara elsevierViewall">The suggested calorie supply target in NC patients is 60–100% of the calories calculated on the basis of indirect calorimetry or using predictive formulas (Level of evidence: low. Grade of recommendation: moderate).</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0085" class="elsevierStylePara elsevierViewall">It is advisable to increase protein supply in patients with severe TBI (Level of evidence: low. Grade of recommendation: moderate).</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0090" class="elsevierStylePara elsevierViewall">In NC patients with repeated IGR episodes, it is advisable to administer EN via the postpyloric route (Level of evidence: moderate. Grade of recommendation: high).</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0095" class="elsevierStylePara elsevierViewall">The administration of enteral diets enriched with mixtures of pharmaconutrients (arginine, ω-3 fatty acids, antioxidants) is recommended in patients with severe TBI (Level of evidence: low. Grade of recommendation: low).</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0100" class="elsevierStylePara elsevierViewall">Strict glycemia control (80–110<span class="elsevierStyleHsp" style=""></span>mg/dl) is not indicated in NC patients (Level of evidence: moderate. Grade of recommendation: moderate).</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0105" class="elsevierStylePara elsevierViewall">In patients with isolated acute spinal cord injury it is advisable to reduce the calorie supply once the acute phase has been left behind, due to the decrease in metabolic demand – this decrease being proportional to the level and depth of the spinal cord injury (Level of evidence: expert opinion. Grade of recommendation: low).</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">Dr. Acosta-Escribano and Dr. Pérez-Quesada declare that they have no conflicts of interest. Dr. Fernández-Ortega has received payment from Fresenius nutrition division and Vegenat for conferences, and funding from <span class="elsevierStyleGrantSponsor" id="gs1">Vegenat</span> for participation in training courses.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Note to supplement</span><p id="par0115" 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:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:3 [ "identificador" => "sec0010" "titulo" => "Questions" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Do the energy and protein requirements of these patients differ from those of the rest of critical patients?" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "What is the best feeding route for neurocritical patients? Is routine postpyloric feeding indicated?" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "What is the best formula for the specialized nutritional management of neurocritical patients? Do diets enriched with glutamine and other pharmaconutrients play a role?" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "What is the recommended glycemia range in neurocritical patients?" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "What are the calorie/protein requirements in patients with acute spinal cord injury?" ] ] ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Recommendations" ] 3 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 4 => array:2 [ "identificador" => "sec0050" "titulo" => "Note to supplement" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-10-11" "fechaAceptado" => "2020-01-25" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Acosta JA, Fernández Ortega JF, Pérez Quesada S. Recomendaciones para el tratamiento nutrometabólico especializado del paciente crítico: pacientes neurocríticos. Grupo de trabajo de Metabolismo y Nutrición de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias. Med Intensiva. 2020;44:69–72.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:26 [ 0 => array:3 [ "identificador" => "bib0135" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hypermetabolism following moderate to severe traumatic acute brain injury: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "N. Foley" 1 => "S. Marshall" 2 => "J. Pikul" 3 => "K. Salter" 4 => "R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 6 | 10 |
| 2024 October | 42 | 39 | 81 |
| 2024 September | 45 | 44 | 89 |
| 2024 August | 48 | 42 | 90 |
| 2024 July | 31 | 21 | 52 |
| 2024 June | 35 | 39 | 74 |
| 2024 May | 47 | 40 | 87 |
| 2024 April | 58 | 39 | 97 |
| 2024 March | 32 | 28 | 60 |
| 2024 February | 34 | 45 | 79 |
| 2024 January | 31 | 33 | 64 |
| 2023 December | 36 | 41 | 77 |
| 2023 November | 36 | 42 | 78 |
| 2023 October | 25 | 40 | 65 |
| 2023 September | 35 | 41 | 76 |
| 2023 August | 21 | 25 | 46 |
| 2023 July | 46 | 35 | 81 |
| 2023 June | 23 | 19 | 42 |
| 2023 May | 39 | 41 | 80 |
| 2023 April | 19 | 32 | 51 |
| 2023 March | 57 | 36 | 93 |
| 2023 February | 51 | 34 | 85 |
| 2023 January | 17 | 30 | 47 |
| 2022 December | 48 | 33 | 81 |
| 2022 November | 72 | 29 | 101 |
| 2022 October | 34 | 31 | 65 |
| 2022 September | 28 | 41 | 69 |
| 2022 August | 21 | 40 | 61 |
| 2022 July | 22 | 35 | 57 |
| 2022 June | 13 | 30 | 43 |
| 2022 May | 22 | 38 | 60 |
| 2022 April | 27 | 33 | 60 |
| 2022 March | 25 | 55 | 80 |
| 2022 February | 17 | 31 | 48 |
| 2022 January | 19 | 46 | 65 |
| 2021 December | 23 | 36 | 59 |
| 2021 November | 21 | 35 | 56 |
| 2021 October | 26 | 63 | 89 |
| 2021 September | 18 | 28 | 46 |
| 2021 August | 13 | 32 | 45 |
| 2021 July | 9 | 28 | 37 |
| 2021 June | 12 | 14 | 26 |
| 2021 May | 22 | 42 | 64 |
| 2021 April | 26 | 36 | 62 |
| 2021 March | 29 | 31 | 60 |
| 2021 February | 13 | 20 | 33 |
| 2021 January | 21 | 12 | 33 |
| 2020 December | 18 | 8 | 26 |
| 2020 November | 12 | 18 | 30 |
| 2020 October | 5 | 9 | 14 |
| 2020 July | 14 | 17 | 31 |
| 2020 June | 1 | 2 | 3 |
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