Chinese expert consensus on the diagnosis and treatment of small bowel obstruction (2023 edition) / 中华胃肠外科杂志

Small bowel obstruction is a common surgical acute abdomen, with high rates of missed diagnosis, misdiagnosis, mortality and disability. The majority of patients with small bowel obstruction can be relieved by early non-operative treatment and intestinal obstruction catheter. However, there are still many controversies about the window of observation, the time of emergency operation and the method of operation. In recent years, the basic and clinical research on small bowel obstruction has made further progress, but there is no authoritative reference in clinical practice, and there is no relevant consensus and guidelines to standardize the diagnosis and treatment of small bowel obstruction in China. Accordingly, on the initiative of the Chinese Society for Parenteral and Enteral Nutrition and Enhanced Recovery after Surgery Branch of China International Health Care Promotion Exchange Association. The experts in this field of our country constitute the editorial committee, and refer to the main results of the current domestic and foreign research. According to the GRADE system of evidence quality assessment and recommendation intensity grading, the Chinese expert consensus on the diagnosis and treatment of small bowel obstruction was formulated for the study and reference of related specialties. It is expected to improve the overall level of diagnosis and treatment of small bowel obstruction in our country.

Value of the combined use of aminotransferase-to-platelet ratio index and total bile acid for predicting parenteral nutrition-associated cholestasis in preterm infants with gestational age <34 weeks / 中国当代儿科杂志

OBJECTIVES@#To explore the value of the combined use of aspartate aminotransferase-to-platelet ratio index (APRI) and total bile acid (TBA) for predicting parenteral nutrition-associated cholestasis (PNAC) in preterm infants with gestational age <34 weeks.@*METHODS@#A retrospective analysis was performed on medical data of 270 preterm infants born at <34 weeks of gestation who received parenteral nutrition (PN) during hospitalization in the First Affiliated Hospital of Wannan Medical College from January 2019 to September 2022, including 128 infants with PNAC and 142 infants without PNAC. The medical data between the two groups were compared, and predictive factors for the development of PNAC were explored through multivariate logistic regression analysis. The receiver operating characteristic (ROC) curve was used to evaluate the value of APRI alone, TBA alone, and the combination of both for predicting PNAC.@*RESULTS@#TBA levels in the PNAC group after 1, 2, and 3 weeks of PN were higher than those in the non-PNAC group (P<0.05). APRI in the PNAC group after 2 and 3 weeks of PN was higher than that in the non-PNAC group (P<0.05). Multivariate logistic regression analysis showed that elevated APRI and TBA after 2 weeks of PN were predictive factors for PNAC in preterm infants (P<0.05). ROC curve analysis showed that the sensitivity, specificity, and area under the curve (AUC) for predicting PNAC by combining APRI and TBA after 2 weeks of PN were 0.703, 0.803, and 0.806, respectively. The AUC for predicting PNAC by combining APRI and TBA was higher than that of APRI or TBA alone (P<0.05).@*CONCLUSIONS@#After 2 weeks of PN, the value of combining APRI and TBA for predicting PNAC is high in preterm infants with gestational age <34 weeks.

Association between early parenteral nutrition and the development of bronchopulmonary dysplasia in preterm infants / 中国当代儿科杂志

OBJECTIVES@#To study the relationship between early parenteral nutrient intake and the development of bronchopulmonary dysplasia (BPD) in preterm infants with gestational age less than 32 weeks who could not receive enteral nutrition within one week after birth.@*METHODS@#A retrospective study was conducted on preterm infants born between October 2017 and August 2022 with gestational age less than 32 weeks who were admitted to the Neonatal Intensive Care Unit in Children's Hospital of Soochow University within 24 hours after birth and relied solely on parenteral nutrition within the first week of life. The study population included 79 infants with BPD and 73 infants without BPD. Clinical data during hospitalization were compared between the two groups.@*RESULTS@#The proportions of infants with weight loss of more than 10% after birth, extrauterine growth retardation, and parenteral nutrition-associated cholestasis in the BPD group were higher than in the non-BPD group (P<0.05). The time to regain birth weight, time to achieve full enteral feeding, and corrected gestational age at discharge were longer in the BPD group than in the non-BPD group. The Z-scores of physical growth at corrected gestational age of 36 weeks were lower in the BPD group than in the non-BPD group (P<0.05). The BPD group had a higher fluid intake and a lower calories intake in the first week than the non-BPD group (P<0.05). The starting dose and total amount of amino acids, glucose, and lipids in the first week were lower in the BPD group than in the non-BPD group (P<0.05). The BPD group had a higher glucose-to-lipid ratio on the third day and higher energy-to-nitrogen and glucose-to-lipid ratios on the seventh day after birth than the non-BPD group (P<0.05).@*CONCLUSIONS@#Preterm infants with BPD had lower intake of amino acids and lipids and a lower proportion of calories provided by amino acids and lipids in the first week of life, which suggests an association between early parenteral nutrition intake and the development of BPD.

Atuação da psicologia em unidade neonatal no contexto da pandemia da covid-19 / The work of psychology in a neonatal unit in the covid-19 pandemic / Actuación de la psicología en una unidad neonatal en el contexto de la pandemia de la covid-19

A pandemia de covid-19 provocou intensas mudanças no contexto do cuidado neonatal, exigindo dos profissionais de saúde a reformulação de práticas e o desenvolvimento de novas estratégias para a manutenção da atenção integral e humanizada ao recém-nascido. O objetivo deste artigo é relatar a atuação da Psicologia nas Unidades Neonatais de um hospital público de Fortaleza (CE), Brasil, durante o período de distanciamento físico da pandemia de covid-19. Trata-se de estudo descritivo, do tipo relato de experiência, que ocorreu no período de março a agosto de 2020. No contexto pandêmico, o serviço de Psicologia desenvolveu novas condutas assistenciais para atender às demandas emergentes do momento, como: atendimento remoto; registro e envio on-line de imagens do recém-nascido a seus familiares; visitas virtuais; e reprodução de mensagens de áudio da família para o neonato. Apesar dos desafios encontrados, as ações contribuíram para a manutenção do cuidado centrado no recém-nascido e sua família, o que demonstra a potencialidade do fazer psicológico.(AU)

The COVID-19 pandemic brought intense changes to neonatal care and required health professionals to reformulate practices and develop new strategies to ensure comprehensive and humanized care for newborn. This study aims to report the experience of the Psychology Service in the Neonatal Units of a public hospital in Fortaleza, in the state of Ceará, Brazil, during the social distancing period of the COVID-19 pandemic. This descriptive experience report study was conducted from March to August 2020. During the pandemic, the Psychology Service developed new care practices to meet the emerging demands of that moment, such as remote care, recordings and online submission of newborns' pictures and video images for their family, virtual tours, and reproduction of family audio messages for the newborns. Despite the challenges, the actions contributed to the maintenance of a care that is centered on the newborns and their families, which shows the potential of psychological practices.(AU)

La pandemia de la COVID-19 ha traído cambios intensos en el contexto de la atención neonatal, que requieren de los profesionales de la salud una reformulación de sus prácticas y el desarrollo de nuevas estrategias para asegurar una atención integral y humanizada al recién nacido. El objetivo de este artículo es reportar la experiencia del Servicio de Psicología en las Unidades Neonatales de un hospital público de Fortaleza, en Ceará, Brasil, durante el periodo de distanciamiento físico en la pandemia de la COVID-19. Se trata de un estudio descriptivo, un reporte de experiencia, que se llevó a cabo de marzo a agosto de 2020. En el contexto pandémico, el servicio de Psicología desarrolló nuevas conductas asistenciales para atender a las demandas emergentes del momento, tales como: atención remota; grabación y envío em línea de imágenes del recién nacido; visitas virtuales; y reproducción de mensajes de audio de la familia para el recién nacido. A pesar de los desafíos encontrados, las acciones contribuyeron al mantenimiento de la atención centrada en el recién nacido y su familia, lo que demuestra el potencial de la práctica psicológica.(AU)

Existence of advanced glycation / lipoxidation end-products in parenteral nutrition solutions and effects of infusion conditions on their levels

Abstract Infusion solutions must be stable from the production stage until the infusion stage. Some infusion fluids contain degradation products, known as advanced glycation end products (AGEs); however, it is unknown whether AGEs exist in parenteral nutrition solutions. We aimed to investigate this question and test the effect of infusion conditions on AGE formation in parenteral nutrition solution. Nine parenteral nutrition solutions were supplied by the pharmacy with which we collaborated. To simulate the infusion conditions, the solutions were held in a patient room with standard lighting and temperature for 24 hours. Samples were taken at the beginning (group A) and the end (24th hour, group B) of the infusion period. The degradation products were 3-deoxyglucosone, pentosidine, N-carboxymethyl lysine, and 4-hydroxynonenal, which we investigated by high-performance liquid chromatography-mass spectrometry (LC-MS) and Q-TOF LC/MS methods. Two of four degradation products, 4-hydroxynonenal and N-carboxymethyl lysine, were detected in all samples, and Group B had higher levels of both compounds compared to Group A, who showed that the quantities of these compounds increased in room conditions over time. The increase was significant for 4-hydroxynonenal (p=0.03), but not for N-carboxymethyl lysine (p=0.23). Moreover, we detected in the parenteral nutrition solutions a compound that could have been 4-hydroxy-2-butynal or furanone

Gastritis enfisematosa. Reporte de un caso en el adulto mayor / Emphysematous gastritis. Report of a case in the elderly

Introducción: la gastritis enfisematosa es una patología poco común pero con alta mortalidad, su presentación clínica es insidiosa, la imagen por tomografía se distingue por un patrón de burbujas lineales con engrosamiento de la pared gástrica. Caso clínico: paciente masculino de 78 años, previamente sano, funcional, que fue ingresado por fractura pertrocantérica de cadera izquierda, quien durante la hospitalización presenta delirium hiperactivo, distención abdominal con disminución de perístalsis además de hipotensión arterial, se realiza tomografía abdominal con evidencia de dilatación gástrica y múltiples burbujas de aire en pared. Es manejado con antibiótico de amplio espectro, fluidoterapia y nutrición parenteral, con respuesta favorable.Conclusiones: la edad avanzada no conlleva por sí misma un peor pronóstico de la enfermedad, la evidencia apoya que un diagnóstico precoz y la intervención terapéutica temprana, son las medidas que han demostrado ser efectivas para la disminución de la mortalidad en pacientes con gastritis enfisematosa

Introduction: Emphysematous gastritis is an uncommon pathology but with high mortality, its clinical presentation is insidious, the tomography image is distinguished by a pattern of linear bubbles with thickening of the gastric wall.Background: This is a 78-year-old male, previously healthy, functional, who was admitted for pertrochanteric fracture of the left hip, who during hospitalization presented hyperactive delirium, abdominal distention with decreased perstalsis in addition to arterial hypotension, an abdominal tomography with evidence of gastric dilation and multiple air bubbles in the wall. He is managed with a broad spectrum antibiotic, fluid therapy and parenteral nutrition, with a favorable response.Conclusions: Advanced age does not in itself lead to a worse disease prognosis, the evidence supports that early diagnosis and early therapeutic intervention are the easures that have proven to be more effective in reducing mortality in patients with emphysematous gastritis.

Progress in intestinal adaptation after enterectomy / 中华胃肠外科杂志

Intestinal adaptation is a spontaneous compensation of the remanent bowel after extensive enterectomy, which improves the absorption capacity of the remanent bowel to energy, fluid and other nutrients. Intestinal adaptation mainly occurs within 2 years after enterectomy, including morphological changes, hyperfunction and hyperphagia. Intestinal adaptation is the key factor for patients with short bowel syndrome to weaning off parenteral nutrition dependence and mainly influenced by length of remanent bowel, type of surgery and colon continuity. In addition, multiple factors including enteral feeding, glucagon-like peptide 2 (GLP-2), growth hormone, gut microbiota and its metabolites regulate intestinal adaptation via multi-biological pathways, such as proliferation and differentiation of stem cell, apoptosis, angiogenesis, nutrients transport related protein expression, gut endocrine etc. Phase III clinical trials have verified the safety and efficacy of teduglutide (long-acting GLP-2) and somatropin (recombinant human growth hormone) in improving intestinal adaptation, and both have been approved for clinical use. We aim to review the current knowledge about characteristics, mechanism, evaluation methods, key factors, clinical strategies of intestinal adaptation.

Complicações metabólicas relacionadas à terapia de nutrição parenteral em pacientes hospitalizados / Metabolic complications related to parenteral nutrition therapy in hospitalized patients

Investigar as complicações metabólicas relacionadas à administração da terapia nutricional parenteral (TNP) e sua relação com o desfecho clínico de pacientes hospitalizados. Métodos: Estudo longitudinal retrospectivo realizado com pacientes internados em hospital público referência no atendimento de urgências e emergências da cidade de Goiânia no período de setembro de 2020 a fevereiro de 2021. A coleta de dados foi realizada por meio de consulta aos prontuários eletrônicos. As informações foram coletadas após o primeiro dia de uso da NP até o desfecho clínico -alta, óbito ou descontinuidade da NP. Resultados: A amostra foi constituída por 28 pacientes em uso de nutrição parenteral no hospital durante a etapa de coleta dedados. Desses pacientes a maioria era do sexo masculino, com média de idade de 46,78 anos. As indicações mais frequentes para o uso da terapia nutricional parenteral foram: repouso,abdome agudo e pós-operatório. As complicações mais prevalentes foram a hipocalemia, hipomagnesemia, uremia e a hiponatremia e o desfecho clínico mais frequente foi o óbito. Encontrou-se relação entre desfecho clínico e presença de hipernatremia (p=0,010), ocorrendo a alta hospitalar exclusivamente naqueles pacientes que não apresentaram hipernatremia. E ainda houve relação marginal (p=0,053) entre desfecho clínico e local da internação, sendo que foi mais frequente o óbito naqueles admitidos na unidade de terapia intensiva. Conclusão: Não houve associação entre a TNP e as complicações metabólicas. Todavia, observou-se relação entre hipernatremia e mortalidade, sendo esta mais prevalente em pacientes internados nas unidades de terapia intensiva (UTIs). Nessa amostra, a complicação metabólica mais observada foi a hipocalemia

To investigate the metabolic complication related to administration of the Parenteral Nutrition Therapy (PNT) and their relation to the clinical outcome of hospitalized patients. Methods: retrospective longitudinal study carried with interned patients at a public hospital of standart in the urgency and emergency care from the Goiânia city during the period from september2020 to february 2021. The data capture was realized through consultation to the electronic record. The information was collected after the first day use of NP to clinical outcome -discharge, death or discontinuation of NP. Results: The sample was composed by 28 patients in use of parenteral nutrition at hospital during the data capture. The majority of these patients were male, with mean age of 46-78 anos. The indications more frequent to the use of parenteral nutrition therapy were: rest, acute abdomen and pos-operative. The complications more prevalent were hypokalemia, hypomagnesemia, uremia and hyponatremia. And the clinical outcome more frequent was death. A relationship between clinical outcome and hypernatremia presence (p=0,010) was found, occurring the hospitalar discharge exclusively in those patients which did not submit to hypernatremia. And there was still a marginal relationship (p=0,053) between clinical outcome and hospitalization, which was more frequent the death in those admitted in intensive care units. Conclusion: There was no association between the PNT and the metabolic complications. However, there was an observed relationship between hypernatremia and mortality, while more prevalent in patients staying in the intensive care unit (ICU). In this sample, the metabolic complication most observed was hypokalemia

Expert consensus on clinical application of multi-chamber bag for parenteral nutrition (2022) / 中华外科杂志

Parenteral nutrition has become a routine clinical nutritional treatment. The guidelines at home and abroad unanimously recommend and standardize the application of "all in one" parenteral nutrition."Multi-chamber bag" parenteral nutrition encapsulates nutrients such as fat emulsion, amino acid and glucose in a non polyvinyl chloride soft bag composed of two or three cavities. When in use, the inner cavity separator is opened. The multi-chamber bag preparation has a variety of specifications and has the characteristics of reasonable prescription, strict quality standards, ready-to-use, and other characteristics, which can reduce prescription and configuration errors, reduce bloodstream infections, and meet the clinical nutritional needs of most patients. In view of the non-standard application of multi-chamber bag, the Chinese Society for Parenteral and Enteral Nutrition organized domestic experts in general surgery, critical care medicine, gastroenterology, geriatrics, nutrition, clinical pharmacy, and evidence-based medicine to write this expert consensus in accordance with the latest guidelines, expert consensus, and the latest clinical evidence. According to the improved Delphi method, 43 experts discussed and modified 23 recommendations one by one in the first round, and 219 experts voted and put forward modification suggestions in the second round. Each recommendation shall be established only when the approval rate of ≥ 90%. It is hoped that this consensus can promote the rational application of multi-chamber bag for parenteral nutrition.

Relación entre el consumo materno de carne vacuna durante el embarazo y los niveles de ferritina en el cordón umbilical / Relationship between maternal beef consumption during pregnancy and umbilical cord ferritin concentration / Relação entre o consumo materno de carne bovina durante a gravidez e os níveis de ferritina no cordão umbilical

Antecedentes: la nutrición durante el embarazo impacta en la salud del recién nacido, con efectos a nivel epigenético determinando consecuencias neurológicas a largo plazo. Las necesidades de hierro durante el embarazo se estiman en 27 mg/día. El hierro hemo que se absorbe mejor se encuentra en la carne. La determinación de ferritina en sangre de cordón umbilical permite evaluar los depósitos de hierro alcanzados durante la etapa fetal. Sus niveles se asociaron con efectos a largo plazo sobre el desarrollo infantil. Objetivos: el objetivo de este estudio de carácter exploratorio es determinar la relación entre el consumo de carnes rojas durante el tercer trimestre de gestación y el nivel de ferritina en el cordón umbilical. Métodos: se realizó un estudio observacional descriptivo con datos recolectados prospectivamente durante un año en el Departamento de Neonatología del Centro Hospitalario Pereira Rossell (CHPR) en Montevideo, Uruguay. Un total de 188 pacientes cumplieron los criterios de inclusión. Se extrajo sangre del cordón umbilical después de un pinzamiento estricto del cordón pasado un minuto de vida. La ferritina se midió utilizando el método de quimioinmunofluorescencia. Se aplicó una encuesta nutricional materna (cualitativo-cuantitativa) que midió la frecuencia de consumo de alimentos con fuente de hierro y las cantidades aproximadas consumidas durante el último trimestre del embarazo. Esta encuesta se centró en el consumo materno de carne vacuna como principal fuente de hierro hemínico en Uruguay. Se analizó la relación entre estas variables. Resultados: el déficit latente de hierro (ferritina en el cordón umbilical <100 ng/ml) se asoció con un menor consumo de carne vacuna durante el embarazo. Valor p de Fisher: 0,0133, OR: 3,71, IC del 95% (1,25-11,05). Conclusiones: este estudio considera adecuada la evidencia que relaciona que los niveles bajos de consumo total de hierro y de carne vacuna durante el tercer trimestre de gestación determinarán un mayor riesgo de déficit latente de hierro y de ferritina medido en el cordón umbilical. Los niveles descendidos de ferritina en cordón umbilical se asocian con un mayor riesgo de efectos adversos a largo plazo sobre la mielinización y el desarrollo neurocognitivo.

Background: nutrition during pregnancy impacts the foetus and the newborn health, it has consequences at the epigenetic level and determines long-term neurological consequences. Iron requirements during pregnancy are estimated at 27 mg/day. Iron is blood absorption from is most efficient from beef. Umbilical cord blood ferritin levels can be used to assess iron deposits reached during the foetal stage. Ferritin levels are linked to the child's long-term development. Objective: this exploratory study's objective is to determine the relationship between beef consumption during the first quarter of pregnancy and ferritin levels in the umbilical cord. Methods: we carried out a descriptive, observational study with prospectively collected data for one-year at the Neonatology Department of the Pereira Rossell Hospital Center (CHPR) in Montevideo, Uruguay. A total of 188 patients met the inclusion criteria. We extracted umbilical cord blood after a strict cord clamping after one minute of life. Ferritin was measured using the chemoimmunofluorescence method. We carried out a maternal nutritional survey using a qualitative-quantitative method and measured the frequency and approximate quantity of iron source food consumption during the last quarter of pregnancy. This survey was focused on maternal beef consumption as the major heme iron source in Uruguay. We analyzed the relationship between these variables. Results: latent iron deficiency (ferritin in the umbilical cord <100 ng / ml) was associated with lower beef consumption during pregnancy. Fisher p-value: 0.0133, OR: 3.71, 95% CI (1.25 - 11.05). Conclusions: this study agrees with the evidence that shows that low levels of total iron and beef consumption during pregnancy determine an increased risk of latent iron deficiency and lower levels of ferritin in newborns, and therefore, greater risk of long-term adverse effects on myelination and neurocognitive development.

Contexto: a nutrição durante a gravidez tem impacto sobre a saúde do recém-nascido, com efeitos no nível epigenético, determinando consequências neurológicas a longo prazo. As necessidades de ferro durante a gravidez são estimadas em 27 mg / dia. O ferro heme de melhor absorção e aquele encontrado na carne vacuna. A determinação da ferritina no sangue do cordão umbilical permite avaliar os depósitos de ferro atingidos na fase fetal. Seus níveis foram associados a efeitos de longo prazo no desenvolvimento das crianças. Objetivos: o objetivo deste estudo exploratório é determinar a relação entre o consumo de carne vermelha durante o terceiro trimestre de gestação e o nível de ferritina no cordão umbilical. Métodos: foi realizado um estudo observacional descritivo com dados coletados prospectivamente durante um ano no Departamento de Neonatologia do Centro Hospitalar Pereira Rossell (CHPR) em Montevidéu, Uruguai. Um total de 188 pacientes cumpriram os critérios de inclusão. O sangue do cordão umbilical foi coletado após clampeamento estrito do cordão após um minuto de vida da criança. A ferritina foi medida pelo método de quimioimunofluorescência. Aplicamos um inquérito nutricional materno (qualitativo-quantitativo) que mediu a frequência de consumo de alimentos com fonte de ferro e as quantidades aproximadas consumidas durante o último trimestre da gravidez. Esta pesquisa enfocou o consumo materno de carne bovina como principal fonte de ferro heme no Uruguai. A relação entre essas variáveis foi analisada. Resultados: a deficiência latente de ferro (ferritina no cordão umbilical <100 mg / ml) foi associada ao menor consumo de carne bovina durante a gestação. Valor de p de Fisher: 0,0133, OR: 3,71, IC 95% (1,25-11,05). Conclusões: este estudo concorda com as evidências que relacionam que os baixos níveis de ferro total e consumo de carne bovina durante o terceiro trimestre de gestação determinam um maior risco de déficit de ferro latente e ferritina mensurado no cordão umbilical. A redução dos níveis de ferritina no cordão umbilical está associada a um risco aumentado de efeitos adversos de longo prazo na mielinização e no desenvolvimento neurocognitivo.

Evaluation of the effect of antibiotics used during parenteral nutrition treatment on Candidemia

SUMMARY OBJECTIVE: Parenteral nutrition is an important risk factor for candidemia. In this risk analysis study, the effect of previous antibiotic administration apart from the length of hospital stay, duration of Parenteral nutrition treatment, and Candida score parameters on developing candidemia was evaluated in the non-neutropenic patients receiving Parenteral nutrition treatment. METHODS: In this double center, retrospective, and cross-sectional study, the data of patients who received Parenteral nutrition treatment were collected. Patients with or without candidemia after the initiation of Parenteral nutrition treatment were compared in terms of demographic features, Candida score, length of hospital stay, duration of Parenteral nutrition treatment, and previous use of antibiotics. Then, predictor factors affecting the probability of candidemia during Candida growth time were determined by the Cox regression analysis. RESULTS: A total of 148 patients (59.5% males) were included and 16 (10.81%) of these had candidemia after initiation of parenteral nutrition treatment. The median (min-max) duration of parenteral nutrition treatment was 11 (4-72) days and the Candida growth time was 13 (7-29) days. Statistically significant differences were found between patients with or without candidemia groups in terms of length of hospital stay (p<0.001), duration of parenteral nutrition treatment (p<0.001), and Candida score (p<0.001). To determine the effect of these variables and antibiotics on candidemia, length of hospital stay [Hazard Ratio 1.030; p=0.021] and piperacillin-tazobactam (Hazard Ratio 5.626; p=0.030) were found significant and independent risk factors on the development of candidemia. CONCLUSION: There are some well-known risk factors including length of hospital stay, duration of Parenteral nutrition treatment, and Candida score; the potential impact of piperacillin-tazobactam administration should also be considered since they may be effective on the development of candidemia.

Alimentação oral e gástrica na pancreatite aguda grave / Gastric and oral feeding in severe acute pancreatitis

ABSTRACT BACKGROUND: There is controversy about the initiation of gastric or oral feeding in patients with severe acute pancreatitis (SAP) because they could increase pancreatic stimulation and exacerbate symptoms and complications. OBJECTIVE: To describe the clinical characteristics and results of patients with SAP who underwent gastric tube or oral feeding versus parenteral or jejunal feeding. METHODS: A retrospective study was carried out on patients over 18 years old with SAP diagnostic, who had been treated in critical care units. We excluded patients coming from other hospitals and those with incomplete medical records. RESULTS: Thirty patients with SAP were included, fifty three percent of them tolerated the gastric tube or oral feeding, and most of them were females and older than patients who received parenteral or jejunal feeding. Other clinical characteristics and outcomes were similar in both groups. Conclusion: Gastric tube or oral feeding is no absolute contraindication for SAP.

RESUMO CONTEXTO Há controvérsias sobre o início da alimentação gástrica ou oral em pacientes com pancreatite aguda grave (PAG), pois elas podem aumentar a estimulação pancreática e exacerbar os sintomas e complicações. OBJETIVO Descrever as características clínicas e os resultados de pacientes com PAG submetidos à alimentação por sonda gástrica ou via oral versus alimentação parenteral ou jejunal. MÉTODOS Foi realizado um estudo retrospectivo em pacientes maiores de 18 anos com diagnóstico de PAG, atendidos em unidades de terapia intensiva. Excluímos pacientes procedentes de outros hospitais e aqueles com prontuário incompleto. RESULTADOS Trinta pacientes com PAG foram incluídos, 53% deles toleravam a sonda gástrica ou alimentação via oral, e a maioria era do sexo feminino e tinha mais idade do que os pacientes que receberam alimentação parenteral ou jejunal. Outras características clínicas e resultados foram semelhantes em ambos os grupos. CONCLUSÃO A sonda gástrica ou alimentação oral não é contra-indicação absoluta para PAG.

Tratamiento conservador del quilotórax posquirúrgico en paciente pediátrico / Conservative treatment of post-surgical chylothorax in pediatric patient

INTRODUCCIÓN. El quilotórax resulta de un daño al conducto torácico por ruptura, laceración, desgarro o compresión. Es una patología rara de derrame pleural en la edad pediátrica, pero frecuente como complicación posterior a cirugía cardiotorácica. La base del tratamiento conservador se ha fundamentado en: drenaje inicial, modificación de la dieta, uso de somatostatina o análogos sintéticos como octreotide, cirugía, prevención y manejo de complicaciones. Fue preciso describir la experiencia institucional clínica así como su abordaje. CASO CLÍNICO. Paciente masculino de 4 meses de edad, que ingresó a la Unidad Pediátrica Área de Emergencias del Hospital de Especialidades Carlos Andrade Marín, el 13 de septiembre de 2019 con antece-dente quirúrgico de atresia de esófago corregida en etapa neonatal. Acudió con dificultad respiratoria, radiografía de tórax que evidenció derrame pleural derecho, toracentesis diagnóstica con salida de líquido de aspecto turbio y lechoso; se colocó tubo de tórax derecho. Se prescribió ayuno inicial, nutrición parenteral durante 4 semanas hasta comprobar resolución del quilotórax. Fue dado de alta en condición estable tras 43 días de hospitalización. DISCUSIÓN. La evidencia científica registró que el tratamiento conservador del quilotórax se basó en: drenaje, reposo digestivo inicial, nutrición parenteral, modificación cualitativa de la dieta enteral y uso de octreotide; el mismo que fue aplicado al paciente de este caso clínico con evolución favorable. CONCLUSIÓN. El tratamiento conservador y multidisciplinario en el abordaje del qui-lotórax fue exitoso y no necesitó manejo quirúrgico.

INTRODUCTION. Chylothorax results from damage to the thoracic duct by rupture, la-ceration, tear or compression. It is a rare pathology of pleural effusion in pediatric age, but frequent as a complication after cardiothoracic surgery. The basis of conservative treatment has been based on: initial drainage, diet modification, use of somatostatin or synthetic analogues such as octreotide, surgery, prevention and management of complications. It was necessary to describe the clinical institutional experience as well as its approach. CLINICAL CASE. A 4-month-old male patient was admitted to the Emergency Area Pediatric Unit of the Carlos Andrade Marín Specialties Hospital on september 13, 2019 with a surgical history of esophageal atresia corrected in the neonatal stage. He went with respiratory distress, chest X-ray that showed right pleural effusion, diagnostic thoracentesis with outflow of cloudy and milky fluid; a right chest tube was placed. Initial fasting was prescribed, parenteral nutrition for 4 weeks until resolution of the chylothorax was verified. He was discharged in stable condition after 43 days of hospitalization. DISCUSSION. The scientific evidence recorded that the conservative treatment of chylothorax was based on: drainage, initial digestive rest, parenteral nutrition, qualitative modification of enteral diet and use of octreotide; the same that was applied to the patient of this clinical case with favorable evolu-tion. CONCLUSION. Conservative and multidisciplinary treatment in the approach to chylothorax was successful.

Guía clínica para el manejo de la falla intestinal secundaria a síndrome de intestino corto en pediatría / Clinical guidelines for the managment of intestinal failure secondary to pediatric short bowel syndrome

La falla intestinal secundaria a síndrome de intestino corto en pediatría es una entidad poco frecuente, de alta morbimortalidad. Requiere de un equipo interdisciplinario para su abordaje, lo cual ha demostrado que disminuye la morbimortalidad y aumenta la posibilidad de que los pacientes logren la autonomía intestinal. Existe una falta de evidencia científica en diferentes abordajes de la patología. Consideramos necesario el desarrollo de esta Guía para el Manejo Clínico construida sobre la base de la metodología Delphi modificada, en la Asociación Argentina de Nutrición Enteral y Parenteral, por 16 expertos que se reunieron para discutir y consensuar los principales aspectos de tratamiento clínico. Se analizaron 4 aspectos: definiciones y epidemiología; nutrición enteral, nutrición parenteral; tratamientos farmacológicos y quirúrgicos,y criterios de derivación a centros de alta complejidad. Sin duda este documento será de utilidad para los pacientes, los profesionales y las instituciones, así como para los diferentes financiadores del sistema de salud.

Intestinal failure secondary to short bowel syndrome in pediatrics, is a rare condition with high morbimortality. A follow up multidisciplinary team is necessary to minimize complications and optimize the intestinal rehabilitation. There are no gold standard guidelines for the management of this group of complex patients. The development of clinical guidelines may contribute for an adequate management of patients with intestinal failure and short bowel syndrome. This Clinical Guideline for the Management was developed by 16 experts based on modified Delphi methodology. The meetings were held at the Argentinian Association of Enteral and Parenteral Nutrition (Asociación Argentina de Nutrición Enteral y Parenteral); the topics analyzed were definitions, epidemiology, enteral and parenteral nutrition, pharmacological and surgical treatments, and criteria for referring patients to intestinal rehabilitation centers. The document is aimed to provide basic scientific knowledge for medical institutions, health providers, healthcare providers, patients and families.

Efeitos da nutrição parenteral ou enteral, associadas ou não à glutamina, sobre a motilidade gastrintestinal em equinos submetidos à inanição e realimentação / Effects of parenteral or enteral nutrition, associated or not with glutamine, on gastrointestinal motility in horses submmited to starvation and refeeding

Este estudo teve por objetivo avaliar os efeitos da nutrição parenteral total ou enteral, associadas ou não à glutamina, sobre a motilidade gastrintestinal em equinos submetidos à inanição e realimentação. Foram utilizados 16 equinos adultos hígidos, sem raça definida, de ambos os sexos, quatro machos e 12 fêmeas, com idade variando entre quatro e 14 anos e peso corporal médio de 248,40 + 2,28 kg, divididos em quatro grupos, quatro animais por grupo: Grupo I (ENTGL): fluidoterapia enteral com eletrólitos associada a glutamina; Grupo II (PARGL): Nutrição parenteral total (NPT) associada a glutamina; Grupo III (ENTFL): fluidoterapia enteral com eletrólitos; Grupo IV (PARFL): fluidoterapia parenteral. O delineamento experimental foi inteiramente ao acaso, em um esquema fatorial 4x12 (grupos x tempo de colheita), para cada fase, e suas médias comparadas pelo teste de Duncan ao nível de 5% de significância. Independente do grupo experimental ocorreu redução da motilidade gastrintestinal durante a fase de inanição, mais pronunciada nos grupos PARGL e PARFL. Uma vez restabelecida a alimentação a motilidade gastrintestinal retornou à normalidade.

This study aimed to evaluate the effects of enteral or total parenteral nutrition, associated or not with glutamine, on gastrointestinal motility in horses subjected to starvation and refeeding. 16 healthy, mixed-breed adult horses of both sexes, four geldings and 12 mares, with ages ranging from four to 14 years and an average body weight of 248.40 + 2.28 kg, were divided into four groups, four animals per group: Group I (ENTGL): enteral fluid therapy with electrolytes associated with glutamine; Group II (PARGL): total parenteral nutrition (TPN) associated with glutamine; Group III (ENTFL): enteral fluid therapy with electrolytes; Group IV (PARFL): parenteral fluid therapy. The experimental design was entirely randomized, in a 4x12 factorial scheme (groups x harvest time), for each phase, and their means compared by the Duncan test at the level of 5% significance. Regardless of the experimental group, there was a reduction in gastrointestinal motility during the starvation phase, which was more pronounced in the PARGL and PARFL groups. Once the food was restored, gastrointestinal motility returned to normal.

Nutritional research and fetal programming: parental nutrition influences the structure and function of the organs / Investigación nutricional y programación fetal: la nutrición parental influye en la estructura y función de los órganos

SUMMARY: Rodents are animals extensively used in biomedical and nutrition research, a necessary step before the research in humans. The composition and type of administration of the experimental diets are relevant and should be thought, considering each type of animal used in the research. It is particularly important to consider, among others, the metabolic differences between species and food needs in macro- and micronutrients to avoid possible bias. The American Institute of Nutrition (AIN) made recommendations for rodents, adapted to the period of growth (AIN-93G), which are pivotal in fetal programming studies. The experiments can be compared among different studies and better translated into humans, considering these limitations in the nutrition of parents and offspring. The review addresses different compositions of experimental food for rodents during development with the ability to induce fetal programming in the offspring and chronic diseases in adulthood due to the nutrition of the mother and father. The 'developmental origins of health and disease' (DOHaD) concept due to maternal nutrition is commented considering the protein restriction, vitamin D restriction, obesity, and intake of fructose or fish-oil. The 'paternal origins of health and disease transmission' (POHaD), because of the nutritional state of the father, were also analyzed in the review, primarily considering the obesity of the father. The review proposes some diet compositions to experimental research considering varied nutritional situations, hoping to assist young researchers or researches not familiar with experimental diet manipulations in the elaboration of the projects.

RESUMEN: Los roedores son animales utilizados frecuentemente en la investigación biomédica y nutricional, un paso necesario antes de la investigación en humanos. La composición y el tipo de administración de las dietas experimentales son relevantes y se debe considerar cada tipo de animal utilizado en los estudios. Es particularmente importante considerar las diferencias metabólicas entre las especies y las necesidades alimentarias de macro y micronutrientes para evitar posibles sesgos. El Instituto Americano de Nutrición (AIN) estableció recomendaciones para los roedores, adaptadas al período de crecimiento (AIN-93G), que son fundamentales en los estudios de programación fetal. Los experimentos se pueden comparar entre diferentes estudios y aplicar en humanos, considerando estas limitaciones en la nutrición de padres e hijos. La revisión aborda diferentes composiciones de alimentos para estudios experimentales en roedores durante su desarrollo, con la capacidad de inducir programación fetal en la descendencia y enfermedades crónicas en la adultez, considerando la nutrición de los padres. El concepto de 'orígenes del desarrollo de la salud y la enfermedad' (DOHaD) debido a la nutrición materna se comenta considerando la restricción de proteínas, la restricción de vitamina D, la obesidad y la ingesta de fructosa o aceite de pescado. Los 'orígenes paternos de la salud y transmisión de enfermedades' (POHaD), debido al estado nutricional del padre, también fueron analizados considerando principalmente la obesidad del padre. La revisión propone algunas composiciones dietéticas a la investigación experimental considerando situaciones nutricionales variadas, con la esperanza de ayudar a jóvenes investigadores o investigadores no familiarizados con las manipulaciones experimentales de la dieta en la elaboración de los proyectos.

Soporte nutricional y cumplimiento de objetivos nutricionales en la UCI Pediátrica del Hospital Metropolitano / Nutritional support and compliance with nutritional goals in the Pediatric ICU of Hospital Metropolitano

RESUMEN Objetivos: Describir el soporte nutricional que se administra en la UCI Pediátrica del Hospital Metropolitano y evaluar nuestra capacidad de alcanzar los objetivos nutricionales recomendados en guías clínicas internacionales. Métodos: Análisis retrospectivo de datos recolectados prospectivamente desde el 09/01/2018 hasta el 12/31/2019 de todos los pacientes con soporte nutricional. Resultados: Durante el periodo de estudio ingresaron a la UCIP 124 pa-cientes y, de éstos, 31% requirieron soporte nutricional. La edad promedio fue 40 meses, los varones fueron 63%, el diagnóstico fue médico en 63% de los casos, la estadía promedio fue de 3 días y la mortalidad de esta cohorte fue de 4,8%. Se implementó nutrición enteral (NE) en 71,8% de los niños, nutrición parenteral (NP) 15,4%, y nutrición mixta, enteral y parenteral en 12,8%. La NE se inició dentro de las primeras 48 horas en 56,4% de los casos. Al comparar el soporte administrado frente a los objetivos nutricionales, el aporte de energía alcanzó el 75% del objetivo calculado mediante la ecuación de Schofield al día 4 y el 100% al día 8. En los niños desnutridos el 75% del objetivo calórico se alcanzó al día 8. Mediante la NE, el 75% del objetivo se alcanzó al día 4 y el 100% al día 5. El objetivo proteico mínimo se alcanzó al día 7 con NE y al día 3 con NP. El aporte promedio de energía a la población estudiada fue de 42,6 kcal/kg/día y 18,5% de los pacientes recibió un promedio de 57 kcal/kg/día. El aporte promedio de proteínas a esta cohorte fue de 1,43 g/kg/día y 42% de ellos recibió un promedio de 1,5 g/kg/día. Conclusiones: Los objetivos recomendados mínimos de energía y proteínas de 57 kcal/kg/día y 1,5 g/kg/día, respectivamente, para alcanzar anabolismo y balance nitrogenado positivo, no fueron alcanzados en nuestros pacientes durante la primera semana después del ingreso.

ABSTRACT Aims & Objectives: To describe the nutritional support (NS) implemented in our PICU and to evaluate our capacity to achieve the recommended nutritional goals (NG). Methods: Retrospective analysis of prospectively recollected data from 09/01/2018-12/31/2019 of all patients on NS. Results: During the study period 124 patients were admitted and 31% needed NS, mean age 40 months, males 63%, medical diagnosis 63%, surgical diagnosis 22%, length of stay 3 days, mortality 4,8%. Enteral nutrition (EN) was implemented in 71,8%, parenteral nutrition (PN) in 15,4%, and mixed EN/PN in 12,8%. EN was started ≤ 48 hours in 56,4%. In the comparison between intake and recommended NG, energy intake achieved 75% of NG (Schofield) at day 4 and ≥ 100% at day 8. In malnourished patients 75% of NG was achieved at day 8. With EN, 75% of NG were achieved at day 4 and ≥ 100% at day 5. Minimum protein goal was achieved at day 5, in malnourished patients, at day 4. Protein goal was achieved with EN at day 7 and with PN at day 3. Average energy administered was 42,6 kcal/kg/day and 18.5% of the patients reached 57 kcal/kg/day. Average protein administered was 1,43 g/kg/day and 42% reach a mean of 1,5 g/kg/day. Conclusions: Minimum recommended energy and protein goals of 57 kcal/kg/d and 1,5 g/kg/d (to achieve anabolism and positive nitrogen balance) were not accomplished in our patients during the first week after admission.

Mechanism of gut-microbiota-liver axis in the pathogenesis of intestinal failure-associated liver disease / 中华胃肠外科杂志

Intestinal failure (IF) is defined as the critical reduction of functional intestines below the minimum needed to absorb nutrients and fluids, so that intravenous supplementation with parenteral nutrition (PN) is required to maintain health and/or growth. Although the benefits are evident, patients receiving PN can suffer from serious cholestasis due to lack of enteral feeding and small intestinal bacterial overgrowth (SIBO). One such complication that may arise is intestinal failure-associated liver disease (IFALD). Evidences from recent studies suggest that alterations in the intestinal microbiota, as well as intraluminal bile acid driven signaling, may play a critical role in both hepatic and intestinal injury. Since Marshall first proposed the concept of the gut-liver axis in 1998, the role of gut-liver axis disorders in the development of IFALD has received considerable attention. The conversation between gut and liver is the key to maintain liver metabolism and intestinal homeostasis, which influences each other and is reciprocal causation. However, as a "forgotten organ" , intestinal microbiota on the pathogenesis of IFALD has not been well reflected. As such, we propose, for the first time, the concept of gut-microbiota-liver axis to emphasize the importance of intestinal microbiota in the interaction of gut-liver axis. Analysis and research on gut-microbiota-liver axis will be of great significance for understanding the pathogenesis of IFALD and improving the prevention and treatment measures.

The role of fistuloclysis in the treatment of patients with enteroatmospheric fistulas / O papel da fistuloclise no tratamento de pacientes com fístulas enteroatmosféricas

ABSTRACT Background: Enterocutaneous fistulas represent a connection between the gastrointestinal tract and adjacent tissues. Among them, there is a subdivision - the enteroatmospheric fistulas, in which the origin is the gastrointestinal tract in connection with the external environment through an open wound in the abdomen. Due to the high output in enterocutaneous fistulas, the loss of fluids, electrolytes, minerals and proteins leads to complications such as sepsis, malnutrition and electrolyte derangements. The parenteral nutrition has its secondary risks, and the fistuloclysis, that consist in the infusion of enteral feeding and also the chyme through the distal fistula, represents an alternative to the management of these patients until the definitive surgical approach. Aim: To evaluate the current evidence on the fistuloclysis technique, its applicability, advantages and disadvantages for patients with high output fistulas. Method: A systematic literature search was conducted in May 2020 with the headings "fistuloclysis", "chyme reinfusion" and "succus entericus reinfusion", in the PubMed, Medline and SciELO databases. Results: There were 29 articles selected for the development of this narrative synthesis, from 2003 to 2020, including reviews and case reports. Conclusion: Fistuloclysis is a safe method which optimizes the clinical, nutritional, and immunological conditions of patients with enteroatmospheric fistulas, increasing the chances of success of the reconstructive procedure. In cases where the definitive repair is not possible, chances of reducing or even stopping the use of nutrition through the parental route are increased, thus representing a promising modality for the management of most challenging cases.

RESUMO Racional: As fístulas enterocutâneas representam uma conexão entre o trato gastrointestinal e os tecidos adjacentes. Dentre elas, há uma subdivisão - as fístulas enteroatmosféricas, em que a origem é o trato gastrointestinal em conexão com o meio externo por meio de uma ferida aberta no abdômen. Devido ao alto débito nas fístulas enterocutâneas, a perda de fluidos, eletrólitos, minerais e proteínas levam a complicações como sepse, desnutrição e desequilíbrios eletrolíticos. A nutrição parenteral tem seus riscos secundários, e a fistuloclise, que consiste na infusão de nutrição enteral e também do quimo pela fístula distal, representa uma alternativa no manejo desses pacientes até a abordagem cirúrgica definitiva. Objetivo: Avaliar as evidências atuais sobre a técnica de fistuloclise, sua aplicabilidade, vantagens e desvantagens para pacientes com fístulas de alto débito. Método: Foi realizada uma busca sistemática da literatura em maio de 2020 com os títulos "fistuloclysis", "chyme reinfusion" e "succus entericus reinfusion", nas bases de dados PubMed, Medline e SciELO. Resultados: Foram selecionados 29 artigos para o desenvolvimento desta síntese narrativa, no período de 2003 a 2020, incluindo revisões e relatos de caso. Conclusão: A fistuloclise é um método seguro que otimiza as condições clínicas, nutricionais e imunológicas dos pacientes com fístulas enteroatmosféricas, aumentando as chances de sucesso do procedimento de reconstrução. Nos casos em que o reparo definitivo não é possível, aumentam as chances de reduzir ou mesmo interromper o uso da nutrição pela via parental, representando uma modalidade promissora para o manejo dos casos mais desafiadores.