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      Beneficios de un programa de formación y de un algoritmo clínico de soporte nutricional mixto para mejorar la nutrición del paciente crítico: estudio antes-después Translated title: Benefits of an education program and a clinical algorithm in mixed nutritional support to improve nutrition for the critically ill patient: a before-and-after study

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          Abstract

          Resumen Introducción: la nutrición óptima del paciente crítico es clave para su recuperación. Objetivos: promover la formación y difusión del conocimiento acerca del soporte nutricional mixto (SNM) mediante un algoritmo clínico entre los intensivistas para mejorar el estado nutricional de los pacientes críticos. Métodos: estudio antes-después con la participación de 19 unidades de cuidados intensivos (UCI) polivalentes en 10 comunidades autónomas. Cinco miembros del comité científico formaron a los formadores mediante presentaciones orales y el algoritmo de SNM. Los formadores fueron responsables de la formación de los intensivistas en sus propias UCI. El cuestionario de 30 ítems fue completado por 179 y 105 intensivistas antes y después de la intervención, respectivamente. Resultados: se observó un aumento del conocimiento en seis (20 %) preguntas específicas relacionadas con el SNM. En 11 ítems (36,6 %), el conocimiento adecuado sobre diferentes aspectos del soporte nutricional que ya estaban presentes antes de la formación se mantuvieron, y en cinco ítems (16,7 %) hubo un aumento de la tasa de respuestas correctas. En cuatro ítems (13,3 %), las respuestas correctas no mejoraron y en otros cuatro (13,3 %), los porcentajes de respuestas correctas disminuyeron. Conclusiones: el algoritmo de SNM ha logrado una sólida consolidación de los principales conceptos de esta estrategia. Algunos aspectos referentes a cómo manejar al paciente desnutrido, cómo identificarlo y qué tipo de nutrición pautar desde el inicio del ingreso en la UCI, los aportes nutricionales en situaciones especiales y el seguimiento de posibles complicaciones como la realimentación, son áreas que requerirían estrategias formativas adicionales.

          Translated abstract

          Abstract Introduction: optimal nutrition in the critically ill patient is a key aspect for recovery. Objectives: to promote training in and knowledge of mixed nutrition support (MNS) by means of a clinical algorithm among intensivists for improving the nutritional status of critically ill patients. Methods: a before-and-after study with the participation of 19 polyvalent intensive care units (ICUs) in 10 autonomous communities. Five members of the scientific committee trained the trainers by means of oral presentations and a clinical algorithm on MNS. Then, trainers were responsible for explaining the algorithm to local intensivists in their ICUs. The 30-item study questionnaire was completed before and after the intervention by 179 and 105 intensivists, respectively. Results: a clear improvement of knowledge was found in six (20 %) specific MNS-related questions. In 11 items (36.6 %), adequate knowledge on different aspects of nutritional support that were already present before the intervention were maintained, and in five items (16.7 %) an improvement in the rate of correct responses was recorded. There were no improvements in correct responses for four items (13.3 %), and for four (13.3 %) additional items the percentage of correct responses decreased. Conclusions: the use of the MNS algorithm has achieved a solid consolidation of the main concepts of MNS. Some aspects regarding how to manage the malnourished patient, how to identify them and what type of nutrition to guide from the beginning of admission to the ICU, nutritional contributions in special situations, and the monitoring of possible complications such as refeeding are areas for which further training strategies are needed.

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          Most cited references28

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          Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).

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            The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study.

            The objective of this study was to examine the relationship between the amount of energy and protein administered and clinical outcomes, and the extent to which pre-morbid nutritional status influenced this relationship. We conducted an observational cohort study of nutrition practices in 167 intensive care units (ICUs) across 21 [corrected] countries. Patient demographics were collected, and the type and amount of nutrition received were recorded daily for a maximum of 12 days. Patients were followed prospectively to determine 60-day mortality and ventilator-free days (VFDs). We used body mass index (BMI, kg/m2) as a marker of nutritional status prior to ICU admission. Regression models were developed to evaluate the relationship between nutrition received and 60-day mortality and VFDs, and to examine how BMI modifies this relationship. Data were collected on 2,772 mechanically ventilated patients who received an average of 1,034 kcal/day and 47 g protein/day. An increase of 1,000 cal per day was associated with reduced mortality [odds ratio for 60-day mortality 0.76; 95% confidence intervals (CI) 0.61-0.95, p = 0.014] and an increased number of VFDs (3.5 VFD, 95% CI 1.2-5.9, p = 0.003). The effect of increased calories associated with lower mortality was observed in patients with a BMI or =35 with no benefit for patients with a BMI 25 to or =35.
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              Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial.

              Enteral nutrition (EN) is recommended for patients in the intensive-care unit (ICU), but it does not consistently achieve nutritional goals. We assessed whether delivery of 100% of the energy target from days 4 to 8 in the ICU with EN plus supplemental parenteral nutrition (SPN) could optimise clinical outcome. This randomised controlled trial was undertaken in two centres in Switzerland. We enrolled patients on day 3 of admission to the ICU who had received less than 60% of their energy target from EN, were expected to stay for longer than 5 days, and to survive for longer than 7 days. We calculated energy targets with indirect calorimetry on day 3, or if not possible, set targets as 25 and 30 kcal per kg of ideal bodyweight a day for women and men, respectively. Patients were randomly assigned (1:1) by a computer-generated randomisation sequence to receive EN or SPN. The primary outcome was occurrence of nosocomial infection after cessation of intervention (day 8), measured until end of follow-up (day 28), analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00802503. We randomly assigned 153 patients to SPN and 152 to EN. 30 patients discontinued before the study end. Mean energy delivery between day 4 and 8 was 28 kcal/kg per day (SD 5) for the SPN group (103% [SD 18%] of energy target), compared with 20 kcal/kg per day (7) for the EN group (77% [27%]). Between days 9 and 28, 41 (27%) of 153 patients in the SPN group had a nosocomial infection compared with 58 (38%) of 152 patients in the EN group (hazard ratio 0·65, 95% CI 0·43-0·97; p=0·0338), and the SPN group had a lower mean number of nosocomial infections per patient (-0·42 [-0·79 to -0·05]; p=0·0248). Individually optimised energy supplementation with SPN starting 4 days after ICU admission could reduce nosocomial infections and should be considered as a strategy to improve clinical outcome in patients in the ICU for whom EN is insufficient. Foundation Nutrition 2000Plus, ICU Quality Funds, Baxter, and Fresenius Kabi. Copyright © 2013 Elsevier Ltd. All rights reserved.
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                Author and article information

                Journal
                nh
                Nutrición Hospitalaria
                Nutr. Hosp.
                Grupo Arán (Madrid, Madrid, Spain )
                0212-1611
                1699-5198
                June 2021
                : 38
                : 3
                : 436-445
                Affiliations
                [3] Valencia orgnameHospital Universitario Dr. Peset orgdiv1Servicio de Medicina Intensiva España
                [4] Palma de Mallorca orgnameHospital Universitari Son Espases orgdiv1Servicio de Medicina Intensiva España
                [5] Tarragona orgnameHospital Universitari Joan XXIII orgdiv1Servicio de Endocrinología y Nutrición España
                [2] Valencia orgnameHospital Clínic Universitari de València orgdiv1Unidad de Medicina Intensiva España
                [1] Barcelona orgnameUniversitat Autònoma de Barcelona orgdiv1Hospital Universitari Germans Trias i Pujol orgdiv2Servicio de Medicina Intensiva España
                Article
                S0212-16112021000300436 S0212-1611(21)03800300436
                10.20960/nh.03415
                74930109-c47c-44ad-9ff1-233d20073c9e

                This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

                History
                : 28 October 2020
                : 14 March 2021
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 28, Pages: 10
                Product

                SciELO Spain

                Categories
                Trabajos Originales

                Soporte nutricional mixto,Clinical algorithm,Critical patient,Enteral nutrition,Parenteral nutrition,Mixed nutritional support,Nutrición enteral,Nutrición parenteral,Paciente crítico,Algoritmo clínico

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