Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Adults / Consenso Brasileiro de Nutrição em Transplante de Células-Tronco Hematopoiéticas: Adultos

ABSTRACT The nutritional status of patients submitted to hematopoietic stem cell transplant is considered an independent risk factor, which may influence on quality of life and tolerance to the proposed treatment. The impairment of nutritional status during hematopoietic stem cell transplant occurs mainly due to the adverse effects resulting from conditioning to which the patient is subjected. Therefore, adequate nutritional evaluation and follow-up during hematopoietic stem cell transplant are essential. To emphasize the importance of nutritional status and body composition during treatment, as well as the main characteristics related to the nutritional assessment of the patient, the Brazilian Consensus on Nutrition in Hematopoietic Stem Cell Transplant: Adults was prepared, aiming to standardize and update Nutritional Therapy in this area. Dietitians, nutrition physicians and hematologists from 15 Brazilian centers thar are references in hematopoietic stem cell transplant took part.

RESUMO O estado nutricional do paciente submetido ao transplante de células-tronco hematopoéticas é considerado fator de risco independente, podendo influenciar na qualidade de vida e na tolerância ao tratamento proposto. O comprometimento do estado nutricional durante o transplante de células-tronco hematopoéticas ocorre principalmente devido aos efeitos adversos decorrentes do condicionamento ao qual o paciente é submetido. Desta forma, a adequada avaliação nutricional e o acompanhamento durante o transplante de células-tronco hematopoéticas tornam-se imprescindíveis. Com o objetivo de salientar a importância do estado nutricional e da composição corporal durante o tratamento, bem como as principais características relacionadas à avaliação nutricional do paciente, o Consenso Brasileiro de Nutrição em Transplante de Células-Tronco Hematopoiéticas: Adulto foi elaborado visando uniformizar e atualizar a Terapia Nutricional nesta área. Com a participação de nutricionistas, nutrólogos e hematologistas de 15 centros brasileiros referências em transplante de células-tronco hematopoéticas

Ascitis quilosa postraumática tratada con nutrición parenteral total y octreótido / Post-trauma Chylous Ascites Treated with Total Parenteral Nutrition and Octreotide

La ascitis quilosa es la acumulación de quilo en la cavidad peritoneal por ruptura u obstrucción de los conductos linfáticos abdominales. Aunque es infrecuente, se describe mayor probabilidad de aparición después de traumas abdominales. Se presenta un paciente masculino de 46 años que sufre herida por arma blanca tóracoabdominal por lo que requirió tratamiento quirúrgico de urgencia. Luego de varias cirugías se constató la presencia de líquido abdominal blanquecino, con triglicéridos elevados. Se confirmó la ascitis quilosa, que se reabsorbió en 45 días con nutrición parenteral y octreótido(AU)

Chylous ascites is the accumulation of lipid-rich lymph in the peritoneal cavity due to rupture or obstruction of the abdominal lymph ducts. Although it is rare, greater probability is described for its onset after abdominal traumas. The case is presented of a 46-year-old male patient who suffers from a thorax-abdomen knife wound and therefore required emergency surgical treatment. After several surgeries, the presence of whitish abdominal liquid was detected, with elevated triglycerides. Chylous ascites was confirmed, which was reabsorbed in 45 days with parenteral nutrition and octreotide(AU)

Resultados de la implementación de un protocolo de soporte nutricional en grandes quemados pediátricos internados en la Unidad de Cuidados Intensivos / Results of the implementation of a nutritional support protocol for major burn pediatric patients hospitalized in the Intensive Care Unit

Introducción: "Gran quemado" es quien sufre lesiones por daño térmico que afectan más del 30% de su superficie corporal (SC). El hipercatabolismo secundario causa pérdida de masa magra y retraso de la cicatrización de heridas. Objetivo: Describir y analizar los resultados de la implementación de un protocolo de soporte nutricional en niños quemados graves internados en una Unidad de Cuidados Intensivos durante las primeras 6 semanas evolutivas. Población y métodos: Diseño analítico, prospectivo, observacional y longitudinal. Se midieron peso, talla, porcentaje de SC quemada, días de internación en la Unidad de Cuidados Intensivos y mortalidad. Se analizaron tasa metabólica basal por calorimetría indirecta y fórmula de Schofield, cobertura de aporte energético y proteico, prealbúmina, proteína C reactiva, vitaminas A, D, E, cobre y zinc semanales. Resultados: Se incluyeron 18 pacientes (media: 3,9 años, 49% de SC quemada). Se alcanzó la media de objetivo energético en la segunda semana y el requerimiento proteico en la semana 6. Doce pacientes requirieron nutrición parenteral complementaria sin complicaciones. Se hallaron parámetros de hipermetabolismo, que se normalizaron a las 4-6 semanas del ingreso, excepto la proteína C reactiva. Las vitaminas A y E y elementos traza (zinc y cobre) estaban descendidos al ingreso con mejoría posterior. La vitamina D persistió en valores bajos. Un paciente falleció. Conclusiones: La implementación del protocolo permitió lograr el aporte de la totalidad del requerimiento energético; la cobertura del requerimiento proteico se postergó hasta la semana 6. Es necesario hacer hincapié en resolver las limitaciones para alcanzar este último.

Introduction. "Major burn" is used to describe a person who suffers thermal damage affecting more than 30% of his/her total body surface area (TBSA). The secondary hypercatabolism causes lean body mass loss and delayed wound healing. Objective. To describe and analyze the results of implementing a nutritional support protocol for pediatric burn patients hospitalized in the intensive care unit in the first 6 weeks. Population an d methods. Analytical, prospective, observational, and longitudinal design. Weight, height, %TBSA, length of stay in the intensive care unit, and mortality were measured. The basal metabolic rate was measured by indirect calorimetry and the Schofield equation, and protein and energy intake, prealbumin, C-reactive protein, vitamins A, D, E, copper, and zinc levels were analyzed every week. Results. Eighteen patients were included (mean: 3.9 years old, 49%TBSA). The mean energy target was achieved by week 2 and protein requirements were met by week 6. Twelve patients required complementary parenteral nutrition and there were no complications. Hypermetabolism parameters were observed, which returned to normal 4-6 weeks after hospitalization, except for C-reactive protein. Vitamins A and E and trace elements (zinc and copper) were reduced at the time of admission and showed a subsequent improvement. Vitamin D remained low. One patient died. Conclusions. Implementing the protocol was useful to cover the total energy requirement; the coverage of protein requirements was delayed until week 6. It is necessary to focus on solving limitations to achieve the latter.

Tratamiento conservador de perforación duodenal intraperitoneal secundaria a colangiopancreatografía retrógrada endoscópica en un paciente pediátrico / Conservative treatment of intra-peritoneal duodenal perforation after endoscopic retrograde cholangiopancreatography in a pediatric patient

Introducción: las perforaciones duodenales son consideradas lesiones de extrema gravedad a cualquier edad. Su etiología puede ser por traumatismos, o después de la realización de un procedimiento endoscópico digestivo. Debido a la elevada morbilidad y mortalidad de estas lesiones, su tratamiento quirúrgico ha sido el método de elección durante años en la mayoría de los casos. Más recientemente se ha reportado con éxito el tratamiento no quirúrgico en pacientes seleccionados. Presentación del caso: se presenta el caso de tratamiento exitoso no quirúrgico en un adolescente de 13 años con una perforación duodenal intraperitoneal después de una colangiopancreatografía retrógrada endoscópica. Las medidas terapéuticas en este caso fueron: la suspensión de la vía oral, el uso de nutrición parenteral total, la administración de análogo de la somatostatina y los antibióticos sistémicos. Conclusiones: la perforación duodenal intraperitoneal después de una colangiopancreatografía retrógrada endoscópica en niños puede ser diagnosticada precozmente. El tratamiento médico basado en la observación estricta del enfermo, la nutrición parenteral total, la suspensión de la alimentación oral, la aspiración nasogástrica octeotride y la administración de antibióticos sistémicos, es eficaz en enfermos selectos(AU)

Introduction: duodenal perforations are considered extremely serious lesions at any age. Its etiology may be due to trauma, or after performing a digestive endoscopic procedure. Due to the high morbidity and mortality of these injuries, surgical treatment has been the method of choice for years in most cases. More recently, non-surgical treatment has been reported successfully in selected patients. Case presentation: it is presented a case of successful non-surgical treatment in a 13-year-old adolescent with intra-peritoneal duodenal perforation after endoscopic retrograde cholangiopancreatography. Therapeutic measures in this case were: the suspension of the oral route, the use of total parenteral nutrition, the administration of the somatostatin analog and systemic antibiotics. Conclusions: intra-peritoneal duodenal perforation after endoscopic retrograde cholangiopancreatography in children can be diagnosed early. Medical treatment based on strict observation of the patient, total parenteral nutrition, suspension of oral feeding, nasogastric octeotride aspiration; and administration of systemic antibiotics is effective in selected patients(AU)

Hipercalcemia e hipofosfatemia en prematuros que reciben nutrición parenteral agresiva / Hypercalcemia and hypophosphatemia among preterm infants receiving aggressive parenteral nutrition

Introducción. La nutrición parenteral agresiva constituye un estándar de cuidado en prematuros de muy bajo peso. Sin embargo, investigaciones recientes evaluaron su impacto en los resultados a corto plazo, como la homeostasis mineral y electrolítica. El objetivo fue comparar la prevalencia de hipercalcemia e hipofosfatemia en prematuros que recibían nutrición parenteral agresiva o estándar. Métodos. Estudio observacional retrospectivo que comparó a un grupo de prematuros menores de 1250 gramos que recibían nutrición parenteral agresiva con un grupo control histórico. Se calculó la prevalencia de hipercalcemia y se buscó la asociación con nutrición parenteral agresiva ajustando por confundidores. Se estimó la media de fosfatemia del grupo control mediante regresión lineal y se la comparó con el otro grupo. Resultados. Se incluyeron 40 pacientes por grupo. La prevalencia de hipercalcemia fue mayor en el grupo de nutrición parenteral agresiva (87,5% vs. 35%, p= 0,001). La nutrición parenteral agresiva se asoció con hipercalcemia al ajustar por peso al nacer, restricción del crecimiento intrauterino, aporte de aminoácidos y calorías (ORa 21,8; IC 95%: 3,7-128). La media de calcemia fue diferente entre ambos grupos (p= 0,002). El grupo de nutrición parenteral agresiva presentó más sepsis sin alcanzar significancia estadística y su fosfatemia media resultó menor que la estimada para el grupo control (p= 0,04). La prevalencia de hipofosfatemia en este grupo fue de 90% (IC 95%: 76-97%). Conclusiones. Nuestros datos muestran una asociación entre hipercalcemia/hipofosfatemia y nutrición parenteral agresiva. Se recomienda monitorizar la calcemia y la fosfatemia frecuentemente, ya que pueden estar asociadas con resultados clínicos adversos.

Introduction. Aggressive parenteral nutrition is the standard of care among very-low-birth weight preterm infants. However, in recent studies, its impact on short-term outcomes, has been evaluated. The objective was to compare the prevalence of hypercalcemia and hypophosphatemia among preterm infants receiving aggressive or standard parenteral nutrition. Methods. Observational, retrospective study comparing a group of preterm infants weighing less than 1250 grams who received aggressive parenteral nutrition with a historical control group. The prevalence of hypercalcemia was estimated and its association with aggressive parenteral nutrition was searched adjusting by confounders. The mean phosphate level was estimated for the control group by linear regression and was compared to the value in the other group. Results. Forty patients per group were included. The prevalence of hypercalcemia was higher in the group who received aggressive parenteral nutrition (87.5% versus 35%, p= 0.001). Aggressive parenteral nutrition was associated with hypercalcemia when adjusting by birth weight, intrauterine growth restriction, amino acid, and calorie intake (adjusted odds ratio: 21.8, 95% confidence interval -amp;#91;CI-amp;#93;: 3.7-128). The mean calcium level was different between both groups (p= 0.002). Infants who received aggressive parenteral nutrition had more sepsis without reaching statistical significance and the mean phosphate level was lower than that estimated for the control group (p= 0.04). The prevalence of hypophosphatemia in this group was 90% (95% CI: 76-97%). Conclusions. Our data show an association between hypercalcemia/hypophosphatemia and aggressive parenteral nutrition. It is recommended to frequently monitor calcium and phosphate levels since they might be associated with adverse clinical outcomes.

Composición y costos de la nutrición parenteral para neonatos en Cuba durante el decenio 2006-2015 / Composition and costs of neonatal parenteral nutrition in Cuba during the ten-year period 2006-2015

Introducción: la nutrición parenteral permite mejorar la calidad de vida y una reducción en la morbilidad y mortalidad neonatal. Objetivos: caracterizar y estimar los costos de producción de las nutriciones parenterales para neonatos elaboradas por el Centro de Nutrición Parenteral del Hospital Pediátrico Docente Centro Habana en 2006, 2010 y 2015. Métodos: estudio de consumo descriptivo retrospectivo y de descripción de costos. Se trabajó con el universo de las nutriciones parenterales para neonatos. Se tomó la información del registro de nutriciones del servicio. Resultados: los macronutrientes más consumidos fueron: dextrosa 5 por ciento (99,81 por ciento), traximin 10 por ciento (91,45 por ciento) y lipofundin 20 por ciento (18,2 por ciento). Los micronutrientes fueron: cloruro de sodio (94,68 por ciento), vitamina C (94,57 por ciento) y sulfato de magnesio (78,64 por ciento). Los costos no tienen diferencia entre los años, con valores de 18,09; 17,43; y 17,3 pesos. El material gastable y los medicamentos aportaron aproximadamente el 96 por ciento del costo unitario. Conclusiones: se incrementa el consumo en el tiempo, predomina la nutrición parcial; y los costos totales aumentan, aunque los unitarios se mantienen similares por año, menores a 20,00 CUP(AU)

Introduction: parenteral nutrition makes it possible to improve the quality of life and reduce neonatal morbidity and mortality. Objectives: characterize and estimate the costs of production of neonatal parenteral nutrition solutions processed by the Center for Parenteral Nutrition at Centro Habana Pediatric University Hospital in 2006, 2010 and 2015. Methods: a retrospective descriptive cost and consumption study was conducted of the universe of neonatal parenteral nutrition solutions. Information was obtained from the nutrition records kept by the service. Results: the macronutrients most commonly consumed were dextrose 5 percent (99.81 percent), traximin 10 percent (91.45 percent) and lipofundin 20 percent (18.2 percent). The micronutrients were sodium chloride (94.68 percent), vitamin C (94.57 percent) and magnesium sulfate (78.64 percent). Costs did not show any differences between the study years, with values of 18.09, 17.43 and 17.3 pesos. Consumable goods and drugs accounted for approximately 96 percent of the unit cost. Conclusions: time consumption increases, partial nutrition predominates, and total costs rise, though unit costs remain similar per year, i.e. below 20.00 CUP(AU)

Estado nutricional de pacientes críticos en un hospital universitario de España / Nutritional state of critically-ill patients in Spain university hospital

Introducción: debido a las circunstancias especiales de los pacientes críticos, resulta complicado determinar el aporte energético. Objetivo: determinar la prevalencia del estado nutricional de los pacientes críticos ingresados en la Unidad de Cuidados Intensivos del Hospital Universitario de Burgos (España), y si se les aportó el 60 por ciento de los requerimientos energéticos al cuarto día de ingreso. Métodos: estudio observacional, descriptivo y de prevalencia. Fueron incluidos 47 pacientes, a los que se realizó una evaluación nutricional al ingreso, mediante antropometría, escalas nutricionales validadas y calculando el aporte energético que precisaban. Resultados: el porcentaje de desnutrición al ingreso, según el Índice de Masa Corporal era de un 6,38 por ciento (1,3; 17,5), siendo superior en el sexo masculino. Con la Valoración Global Subjetiva, se obtuvo un resultado de 31,91 por ciento (19,1; 47,1) de sospecha de malnutrición, y un 8,51 por ciento (2,4; 20,4) de malnutrición. El porcentaje de riesgo de desnutrición con la Mini Nutritional Assessment, fue de 36,17 por ciento (22,7; 51,5), y de desnutrición de un 17,02 por ciento (7,6; 30,8). Según la ecuación de Ireton-Jones, a un 77 por ciento de los pacientes se les administró, al menos, el 60 por ciento de los requerimientos energéticos al cuarto día, mientras que con la de Harris-Benedict se obtuvo un 70 por ciento. Conclusiones: la elevada prevalencia de desnutrición y de riesgo de desnutrición en el paciente crítico, evidencia la importancia que supone realizar una valoración nutricional integral para adecuar los requerimientos individualmente. Resulta apropiado suplementar la nutrición enteral con la parenteral si no alcanzan los requerimientos energéticos necesarios(AU)

Introduction: Due to the special circumstances of critically-ill patients, the energy input is difficult to determine. Objective: To determine the prevalence of nutritional status of critically-ill patients admitted to the Intensive Care Unit of the University Hospital in Burgos, Spain, and whether 60 percent of the energy requirements were given on the fourth day of admission. Methods: Observational, descriptive and prevalence study. We included 47 patients, who underwent nutritional assessment at admission, using anthropometry, validated nutritional scales and calculating the energy input they needed. Results: The percentage of malnutrition at admission according to body mass index was 6.38 percent (1.3, 17.5), being higher in males. With subjective global assessment, we obtained a result of 31.91 percent (19.1, 47.1) of suspected malnutrition and 8.51 percent (2.4; 20.4) of malnutrition. The percentage of risk for malnutrition with the mini-nutritional assessment was 36.17 percent (22.7, 51.5), and malnutrition was 17.02 percent (7.6, 30.8). According to the Ireton-Jones equation, 77 percent of the patients were given at least 60 percent of energy requirements on the fourth day, while the Harris-Benedict rate was 70 percent. Conclusions: The high prevalence of undernutrition and risk for malnutrition in critically-ill patients shows the importance of performing an integral nutritional assessment to adapt individual requirements. Supplementing enteral nutrition with the parenteral one is appropriate if they do not meet necessary energy requirements(AU)

Insuficiencia intestinal secundaria a síndrome de intestino corto: resultados de un programa multidisciplinario de rehabilitación intestinal / Intestinal failure due to short bowel syndrome: impact of a multidisciplinary intestinal rehabilitation program

Background: In patients suffering intestinal failure due to short bowel, the goal of an Intestinal Rehabilitation Program is to optimize and tailor all aspects of clinical management, and eventually, wean patients off lifelong parenteral nutrition. Aim: To report the results of our program in patients suffering intestinal failure. Patients and Methods: A registry of all patients referred to the Intestinal Failure unit between January 2009 and December 2015 was constructed. Initial work up included prior intestinal surgery, blood tests, endoscopic and imaging studies. Also demographic data, medical and surgical management as well as clinical follow-up, were registered. Results: Data from 14 consecutive patients aged 26 to 84 years (13 women) was reviewed. Mean length of remnant small bowel was 100 cm and they were on parenteral nutrition for a median of eight months. Seven of 14 patients had short bowel secondary to mesenteric vascular events (embolism/thrombosis). Medical management and autologous reconstruction of the bowel included jejuno-colic anastomosis in six, enterorraphies in three, entero-rectal anastomosis in two, lengthening procedures in two, ileo-colic anastomosis in one and reversal Roux-Y gastric bypass in one. Thirteen of 14 patients were weaned off parenteral nutrition. Conclusions: Our Multidisciplinary Intestinal Rehabilitation Program, allowed weaning most of the studied patients off parenteral nutrition.

Nutritional practices and postnatal growth restriction in preterm newborns / Práticas nutricionais e restrição de crescimento pós-natal em prematuros

SUMMARY Objective: to assess the nutritional practices in neonatal intensive care units (NICU) associated with growth retardation in premature (preterm) infants. Methods: retrospective study of preterm infants weighing between 500 and 1,499g admitted to NICU. Evolution of growth and parenteral (PN) and enteral (EN) nutrition practices were analyzed. Results: among 184 preterm infants divided into G1 (500 to 990g; n=63) and G2 (1000 to 1499g; n=121), 169 received PN (G1=63, G2=106). Compared with the recommendations, PN was started late, its progress was slow and the maximum glucose, amino acid, lipid and energy supplies were low in both groups. The initial supply of amino acid and lipid and initial and maximum glucose and energy were lower in G1. The onset of EN was early (1-2 days), the time to reach exclusive EN was appropriate (11-15 days) and the use of human milk was possible in a reasonable amount of time (7-13 days). The multivariate analysis showed that respiratory distress syndrome and obtaining a supply of 120 kcal/kg/day too late increased the chance of weight loss greater than 10%. Sepsis, maximum energy supply for PN <60 kcal/kg/day and obtaining a supply of 120 kcal/kg/day too late increased the chance of regaining birth weight after 14 days, while small for gestational age (SGA) at birth reduced this chance. SGA at birth, sepsis and achieving exclusive enteral nutrition after 14 days increased the chance of being SGA at post-conceptual age of term. Conclusion: improving nutritional practices in the NICU can reduce the growth deficit in premature infants of very low birth weight.

RESUMO Objetivo: avaliar as práticas nutricionais em unidade de cuidados intensivos neonatais (UCIN) associadas a déficit de crescimento em recém-nascidos pré-termo (RNPT). Métodos: estudo retrospectivo de RNPT com peso entre 500 e 1.499 g internados em UCIN. Analisaram-se: evolução do crescimento e práticas de nutrição parenteral (NP) e enteral (NE). Resultados: dentre 184 RNPT divididos em G1 (500 a 990 g; n=63) e G2 (1.000 a 1.499 g; n=121), 169 receberam NP (G1=63; G2=106). Comparando-se com as recomendações, a NP foi iniciada tardiamente, sua progressão foi lenta e as ofertas máximas de glicose, aminoácidos, lipídios e energia foram baixas nos dois grupos. A oferta inicial de aminoácido e lipídio e a inicial e máxima de glicose e energia foram menores no G1. O início da NE foi precoce (1 a 2 dias), o tempo para atingir NE exclusiva foi adequado (11 a 15 dias), e o uso de leite humano foi possível por tempo razoável (7 a 13 dias). A análise multivariada mostrou que a síndrome do desconforto respiratório e o alcance tardio da oferta de 120 kcal/kg/dia aumentaram a chance de perda de peso superior a 10%. Sepse, oferta energética máxima por NP < 60 kcal/kg/dia e alcance tardio da oferta de 120 kcal/kg/dia aumentaram a chance de recuperar o peso de nascimento após 14 dias, enquanto a condição de pequeno para idade gestacional (PIG) ao nascimento reduziu essa chance. PIG ao nascimento, sepse e alcance de NE exclusiva após 14 dias aumentaram a chance de ser PIG na idade pós-conceptual de termo. Conclusão: aprimorar as práticas nutricionais em UCIN pode reduzir o déficit de crescimento em prematuros de muito baixo peso ao nascer.

Prevalência de violência física por parceiro íntimo em homens e mulheres de Florianópolis, Santa Catarina, Brasil: estudo de base populacional / Prevalence of intimate partner physical violence in men and women from Florianópolis, Santa Catarina State, Brazil: a population-based study / La prevalencia de la violencia física en parejas íntimas entre hombres y mujeres de Florianópolis, Santa Catarina, Brasil: estudio basado en la población

Investigou-se a associação entre sexo e violência física entre parceiros íntimos. Encontrou-se prevalência de sofrer qualquer violência física (17%), violência física moderada (16,6%) e violência física grave (7,3%). Não houve diferença significativa para violência física moderada em homens e mulheres, porém, quanto mais grave o ato maior a ocorrência deste nas mulheres. Por meio de regressão logística testou-se a associação da violência com o sexo, ajustando-se às variáveis exploratórias. Mulheres de maior idade, viúvas/separadas, pobres, menos escolarizadas e pretas registram maior probabilidade de sofrer violência. Nos homens, a prevalência de violência física grave apresentou alteração significativa apenas para estado civil. Uso abusivo de álcool por mulheres representou maior chance de sofrer violência física.

This study investigated the association between gender and intimate partner physical violence. A random cluster sample was chosen as the baseline cohort population in a cross-sectional design. Lifetime prevalence rates were as follows: any physical violence (17%), moderate physical violence (16.6%), and severe physical violence (7.3%). There were no significant differences between genders in moderate physical violence, but women were more likely to suffer severe abuse. Logistic regression was used to identify associations between violence and gender, adjusting for exploratory variables. Women that were older, widowed/separated, had less schooling or lower income, and African-descendants were all more likely to have suffered intimate partner violence. Prevalence of severe physical violence experienced by men only changed significantly according to marital status. Alcohol abuse by women increased the odds of suffering physical violence.

Se investigó la asociación entre el sexo y la violencia física entre parejas íntimas. La prevalencia de sufrir violencia física (17%), la violencia física moderada (16,6%) y la violencia física grave (7,3%). No hubo diferencia significativa en la violencia física moderada en hombres y mujeres, sin embargo, más grave es la mayor ocurrencia de este hecho en las mujeres. Por regresión logística se evaluó la relación entre la violencia y el sexo, y el ajuste de las variables exploratorias. Las mujeres mayores de edad, viudas/separadas, más pobres, menos educadas y negras son más propensas a sufrir violencia. En los hombres, la prevalencia de la violencia física grave cambió significativamente sólo con el estado civil. El abuso de alcohol por mujeres representan un mayor riesgo de sufrir violencia.

Should pediatric parenteral nutrition be individualized? / Deve-se individualizar a nutrição parenteral pediátrica?

INTRODUCTION: Parenteral nutrition (PN) formulations are commonly individualized, since their standardization appears inadequate for the pediatric population. This study aimed to evaluate the nutritional state and the reasons for PN individualization in pediatric patients using PN, hospitalized in a tertiary hospital in Campinas, São Paulo. METHODS: This longitudinal study comprised patients using PN followed by up to 67 days. Nutritional status was classified according to the criteria established by the World Health Organization (WHO) (2006) and WHO (2007). The levels of the following elements in blood were analyzed: sodium, potassium, ionized calcium, chloride, magnesium, inorganic phosphorus, and triglycerides (TGL). Among the criteria for individualization, the following were considered undeniable: significant reduction in blood levels of potassium (<3mEq/L), sodium (<125mEq/L), magnesium (<1mEq/L), phosphorus (<1.5mEq/L), ionic calcium (<1mmol), and chloride (<90mEq/L), or any value above the references. RESULTS: Twelve pediatric patients aged 1 month to 15 years were studied (49 individualizations). Most patients were classified as malnourished. It was observed that 74/254 (29.2%) of examinations demanded individualized PN for indubitable reasons. CONCLUSION: The nutritional state of patients was considered critical in most cases. Thus, the individualization performed in the beginning of PN for energy protein adequacy was indispensable. In addition, the individualized PN was indispensable in at least 29.2% of PN for correction of alterations found in biochemical parameters...

INTRODUÇÃO: As formulações da nutrição parenteral (NP) são comumente individualizadas, visto que a padronização destas parece inadequada para a população pediátrica. O objetivo do estudo foi avaliar o estado nutricional e os motivos para individualização da NP dos pacientes pediátricos em uso de NP internados em um hospital terciário de Campinas-SP. MÉTODOS: Estudo longitudinal conduzido com pacientes acompanhados por até 67 dias de uso de NP. Para a classificação do estado nutricional, foram utilizados os critérios propostos pela World Health Organization (WHO) (2006) e WHO (2007). As dosagens sanguíneas analisadas foram: sódio, potássio, cálcio iônico, cloreto, magnésio, fósforo inorgânico e triglicerídeo (TGL). Foram considerados motivos indubitáveis para individualização da NP quando esses elementos apresentavam redução expressiva dos níveis sanguíneos (potássio <3 mEq/L; sódio <125 mEq/L; magnésio <1 mEq/L; fósforo <1,5 mEq/L; cálcio iônico <1 mmol/L; cloreto <90 mEq/L) ou qualquer valor superior aos de referência. RESULTADOS: Foram estudados 12 pacientes (49 individualizações) com idade de 1 mês a 15 anos. A maioria dos pacientes foi classificada como desnutrida. Observou-se que 74/254 (29,2%) dos exames demandaram NP individualizada por motivos indubitáveis. CONCLUSÃO: O estado nutricional dos pacientes foi considerado crítico, na maioria dos casos. Desta forma, a individualização realizada no início da NP para a adequação energética proteica foi essencial. Além disto, a NP individualizada foi indispensável em, no mínimo, 29,2% das NP, para correção das alterações encontradas nos exames...

Glutamine-Supplemented Parenteral Nutrition and Probiotics in Four Adult Autoimmune Enteropathy Patients

To evaluate the effects of glutamine-supplemented parenteral nutrition (PN) and probiotics in adult autoimmune enteropathy (AIE) patients. Four adult AIE patients were identified from April 2006 to January 2012. Clinical and nutritional data were obtained from the patients' medical records. Glutamine-supplemented PN started immediately when the AIE diagnosis was confirmed. The total PN duration was 351 days. According to the PN prescription, the average caloric intake ranged from 20 to 25 kcal/kg/day, and the protein intake ranged from 1.2 to 1.5 g/kg/day. Alanyl-glutamine (20 g/day) was administered to AIE patients for 4 weeks followed by a 2-week break, and this treatment schedule was repeated when PN lasted for more than 6 weeks. Body weight gain and an increased serum albumin level were achieved after PN, and defecation frequency and quality also improved. Each patient received oral supplements, 250 mL of Ensure and two probiotics capsules (each capsule containing 0.5x10(8) colonies) three times a day when enteral nutrition started. Three AIE patients were successfully weaned off PN, and one patient died of pneumonia. Glutamine-supplemented PN and probiotics show promise in managing patients with AIE and related malnutrition.

Interação fármaco-nutriente em unidade de terapia intensiva: revisão da literatura e recomendações atuais / Drug-nutrient interactions in the intensive care unit: literature review and current recommendations

OBJETIVO: Descrever as interações entre fármacos e nutriente e sua frequência nas unidades de terapia intensiva bem como avaliar o grau de consciência a esse respeito por parte da equipe de profissionais. MÉTODOS: Foram revisados, na base de dados eletrônica PubMed, especificamente no MeSH, os unitermos: "drug interactions" e "nutrition therapy". Os estudos foram sistematicamente revisados para a descrição de tipos de interações entre fármacos e nutrientes, suas frequências e consequências. RESULTADOS: Foram encontrados 67 artigos. Dentre estes, 20 artigos estavam adequados à metodologia adotada e atingiram os objetivos do estudo. Destes, 14 artigos descreviam interações entre fármacos e nutrição enteral, 3 descreviam interações entre fármacos e nutrição parenteral, e 3 descreviam a importância e os cuidados para evitar tais interações. CONCLUSÃO: A literatura referente a interações entre fármacos e nutrientes é escassa e sugere a fragilidade das equipes assistenciais em reconhecer o potencial para interações. Possivelmente a construção de um protocolo para avaliação de interação fármaco-nutriente aumente a segurança e eficácia dos processos terapêuticos.

OBJECTIVE: To describe the interactions between drugs and nutrients and their frequency in the intensive care unit and to assess the professional team's awareness regarding this subject. METHODS: The keywords "drug interactions" and "nutrition therapy" were searched in the PubMed (specifically MeSH) electronic database. The studies were systematically reviewed for descriptions of the types of interactions between drugs and nutrients, including their frequency and consequences. RESULTS: Sixty-seven articles were found. Among these, 20 articles were appropriate for the methodology adopted and accomplished the objectives of the study. Of these 20 articles, 14 articles described interactions between drugs and enteral nutrition, three described interactions between drugs and parenteral nutrition, and three described the importance and care required to avoid such interactions. CONCLUSIONS: The literature about drug and nutrient interactions is limited and suggests the inability of health care teams to recognize the potential for these interactions. Possibly, the elaboration of a protocol to evaluate drug-nutrient interactions will increase the safety and efficacy of therapeutics.

Cyclic parenteral nutrition does not change the intestinal microbiota in patients with short bowel syndrome / Nutrição parenteral cíclica não altera a microbiota intestinal em pacientes com a síndrome do intestino curto

PURPOSE: To characterize of the intestinal microbiota of patients with short bowel syndrome (SBS) admitted to the Metabolic Unit of a University Hospital. METHODS: Fecal samples were evaluated, and biochemical tests were conducted only in the case of SBS patients. The nutritional status was assessed via anthropometric measurements and evaluation of food intake by means of a food questionnaire. The pathogenic strains were detected with the aid of cultures and specific biochemical tests in aerobic medium, for determination of species belonging to the Family enterobacteriaceae. Anti-sera were applied to each isolated E. coli strain, for determination of their possible pathogenicity. Molecular methodology was employed for establishment of the intestinal bacterial microbiota profile RESULTS: A lower amount of microorganisms of the family enterobacteriaceae per gram of stool was observed in the case of patients with SBS. However, molecular analysis showed maintenance of the bacterial species ratio, which is equivalent to a healthy intestinal microbiota. CONCLUSION: Despite the massive removal of the small bowel, frequent use of antibiotics, immune system depression, presence of non-digested food in the gastrointestinal tract, and accelerated intestinal transit, the ratio between intestinal bacterial species remain similar to normality.

OBJETIVO: Caracterizar a microbiota intestinal de pacientes com síndrome do intestino curto (SIC) internados na Unidade Metabólica do Hospital Universitário. MÉTODOS: Foram avaliadas amostras de fezes e exames bioquímicos, estes últimos somente dos pacientes. A avaliação do estado nutricional foi feita a partir de medidas antropométricas e a avaliação do consumo alimentar por meio de inquérito alimentar. Para detecção de cepas patogênicas foram realizados cultivos e testes bioquímicos específicos em meio aeróbico para determinação de espécies da família enterobacteriaceae. Em cada cepa de E. coli isolada foram aplicados anti-soros para determinação de possível patogenicidade. Metodologia molecular também foi utilizada para determinação do perfil da microbiota intestinal bacteriana. RESULTADOS: Observou-se menor quantidade de microorganismos da família enterobacteriaceae por grama de fezes em pacientes com SIC. Porém a análise molecular mostrou a manutenção na proporção de espécies bacterianas, equivalente a microbiota intestinal saudável. CONCLUSÃO: Nossos resultados sugerem que apesar da retirada maciça do intestino delgado, uso freqüente de antibióticos, depressão do sistema imune, presença de alimentos não digeridos no trato gastrintestinal e trânsito intestinal acelerado, a proporção entre as espécies bacterianas intestinais permanecem similares à normalidade.

Nutrição na sepse / Nutritional support in sepsis

JUSTIFICATIVA E OBJETIVOS: A sepse está entre as principais causas de êxito letal nas unidades de terapia intensiva (UTI) em todo o mundo. A adequada abordagem desta condição mórbida - incluindo os aspectos nutricionais - é de suma relevância para o sucesso terapêutico. Diante desta perspectiva, o escopo do presente manuscrito é apresentar elementos do suporte nutricional na sepse. Para isso procedeu-se revisão de literatura, com busca no Pubmed e no Scielo, utilizando-se as palavras chave, sepsis e nutrition. A busca realizada permitiu a obtenção de 320 citações, dentre as quais foram selecionados 33 artigos. A pesquisa bibliográfica foi complementada por textos acessórios, incluindo livros da área de nutrição, terapia intensiva, infectologia e diretrizes nacionais e estrangeiras. CONTEÚDO: A sepse cursa habitualmente com aumentodo metabolismo - caracterizando um estado hipercatabólico - destacando-se, em termos terapêuticos, a instituição de suporte nutricional efetivo como uma das medidas importantes para o tratamento dos enfermos. A via de administração - enteral (NE)ou parenteral (NP) - permanece como motivo de debate, devendo-se pontuar que a primeira tem se mostrado menos onerosa e mais fisiológica e segura, além de manter a função e a estrutura do trato gastrintestinal, ao passo que a NP resulta em melhor alcance das metas nutricionais, mas se associa ao maior risco de infecção. CONCLUSÃO: Apesar das controvérsias relativas à via de administração, é consensual que a terapia nutricional influencia positivamente o prognóstico dos enfermos com sepse.

BACKGROUND AND OBJECTIVES: Sepsis is the leading cause of morbidity and mortality in intensive care units (ICU) worldwide. The appropriate approach of this morbid condition - including the nutritional aspects - is very important for successful treatment. Thus, the objective of this paper is to introduce elements of nutritional support in sepsis. In this case we made are view of the literature, searching Pubmed and Scielo, using the keywords nutrition and sepsis. The search performed allowed the obtainment of 320 citations, of which 33 articles were selected. The literature search was supplemented by other sources, including books in the nutrition area, intensive care and infectious diseases and national and international guidelines. CONTENTS: Sepsis usually evolves with increased metabolism - featuring a hypercatabolic state - where, in therapeutic terms,the institution of effective nutritional support stands out as one of the important approaches for the treatment of the patients.The route of administration - enteral (EN) or parenteral (PN) - remains a subject of debate, and one should point out that the former has been less costly and more physiological and safe, and maintains the function and structure of the gastrointestinal tract, while the latter results in better achievement of nutritional goals, but is associated with increased risk of infection. CONCLUSION: Despite controversies regarding the route of administration, nutritional therapy positively influences the prognosis of the patient with sepsis.

Nutrición en el paciente con pancreatitis grave: recomendaciones basadas en la evidencia / Nutrition in patients with severe pancreatitis: evidence-based recommendations

En pacientes con pancreatitis aguda grave debe asegurarse el aporte nutricional adecuado. Se presentan algunas propuestas para el tratamiento de estos enfermos críticos en la unidad de cuidados intensivos

Selección de pacientes candidatos a nutrición enteral domiciliaria / Selection of patients candidates home enteral nutrition

La alimentación es una acción fundamental por medio de la cual se adquieren los nutrientes necesarios para la nutrición celular. Todo paciente que cuente con un tracto gastrointestinal funcional puede recibir nutrición enteral domiciliaria (NED). La implementación de la NED, debe contemplar aspectos sociales. La NED tiene como objetivo principal mejorar la calidad de vida del paciente. El paciente y su familia deben recibir y entender correctamente la información necesaria sobre su enfermedad de base y la necesidad de NED.

Food is a basic action through which they acquire the nutrients necessary for cellular nutrition. Any patient that has a functional gastrointestinal tract may receive home enteral nutrition (HEN). The implementation of the HEN should include social aspects. The HEN's main objective is to improve the quality of life of patients. The patient and family should receive and understand properly the necessary information on the underlying disease and the need for HEN.

Nutrición enteral y parenteral en la alimentación del niño con Cáncer / Enteral and parenteral feeding in children with cancer

En muchas oportunidades, en los niños con cáncer, no se logra ofrecer toda la alimentación que el niño requiere por la boca, motivo por el cual son utilizadas algunas alternativas que han demostradas ser eficaces para evitar la malnutrición, como la nutrición enteral y la parenteral, las cuales deben ser determinadas por el pediatra o nutricionista infantl del niño. Cuando la nutrición enteral, no es suficiente, es requerida la nutrición parenteral, incluso en casa.

On many occasions, in children with cancer are not able to provide all nutrition required by the child's mouth, which is why some alternatives are used that have proven effective in preventing malnutrition, such as enteral nutrition and parenteral, which must be determined by the pediatrician or infant nutritionist. When enteral nutrition is insufficient, parenteral nutrition is required, even at home.

Efeito da infusão pré-operatória de emulsão lipídica parenteral de óleo de peixe sobre a resposta imunológica pós-operatória e a evolução clínica imediata de pacientes com câncer gastrintestinal / Effect of the preoperative infusion of fish oil parenteral lipid emulsion on postoperative immune response and immediate clinical outcome of patients with gastrointestinal cancer

INTRODUÇÃO: Emulsão lipídica parenteral composta por óleo de peixe, rica em ácidos graxos ômega-3, é infundida associada a emulsões lipídicas convencionais, como parte da terapia nutricional parenteral. Em pacientes cirúrgicos, a infusão perioperatória de emulsão lipídica de óleo de peixe se associa à preservação de funções imunológicas e modulação favorável de mediadores inflamatórios pós-operatórios, com redução na frequência de complicações infecciosas e no tempo de internação em unidade de terapia intensiva e hospitalar. Os benefícios descritos encorajam a infusão parenteral isolada de emulsão lipídica de óleo de peixe, como fármaconutriente adjuvante no tratamento de pacientes cirúrgicos, independente da indicação de terapia nutricional parenteral. OBJETIVO: O presente estudo avaliou o efeito da infusão parenteral pré-operatória, por curto prazo, de emulsão lipídica de óleo de peixe isolada sobre a resposta imunológica pósoperatória e a evolução clínica imediata de pacientes com câncer gastrintestinal. MÉTODOS: Estudo prospectivo, aleatório, duplo-cego e controlado em 63 pacientes cirúrgicos eletivos com câncer gastrintestinal. Os doentes receberam infusão por veia periférica (0,2g gordura/kg de peso corpóreo/dia) de emulsão lipídica parenteral de óleo de peixe (Omegaven® 10% - Fresenius-Kabi) ou emulsão lipídica parenteral controle (Lipovenos MCT® 10% - Fresenius-Kabi) durante os 3 últimos dias pré-operatórios. Amostras de sangue foram coletadas antes e após a infusão parenteral das emulsões lipídicas e nos 3º e 6º (apenas para citocinas) dias pósoperatórios. Analisou-se a concentração plasmática de IL-6 e IL-10 e a migração, fagocitose, explosão oxidativa e expressão de moléculas HLA-DR e CD32 leucocitárias. A frequência de complicações infecciosas e tempo de internação na unidade de terapia intensiva e hospitalar também foram avaliados no período pós-operatório imediato...

BACKGROUND: Parenteral lipid emulsion composed by fish oil, rich in omega-3 fatty acids, is infused in addition to other standard lipid emulsions, as part of parenteral nutrition therapy. In surgical patients, the perioperative infusion of fish oil lipid emulsion is associated with immune functions preservation and favorably modulation of postoperative inflammatory mediators, with decreased infectious complications and length of intensive care unit and hospital stay. These reported benefits encourage the use of fish oil lipid emulsion alone, as a pharmacological adjuvant agent for the treatment of surgical patients, independent of parenteral nutritional therapy indication. AIM: This clinical trial assessed the effect of short-term preoperative infusion of fish oil lipid emulsion alone on postoperative immune response and immediate clinical outcomes of patients with gastroenterological cancer. METHOD: In a prospective, randomized, controlled and double-blind design, elective surgical patients with gastrointestinal cancer (n= 63) received, for the last 3 pre-operative days, peripheral infusion (0.2g fat/kg of body weight./d) of fish oil lipid emulsion (Omegaven® 10% - Fresenius-Kabi) or control lipid emulsion (Lipovenos MCT® 10% - Fresenius-Kabi). Peripheral blood samples were collected before and after lipid emulsion infusion at the 3rd and 6th (only for cytokines) postoperative days to analyze plasma concentration of IL-6 and IL-10, as well as leukocyte migration, phagocytosis, oxidative burst and expression of HLADR and CD32 molecules. Postoperative infections, length of intensive care unit and hospital stay were also measured. RESULTS: At postoperative period, patients treated with fish oil lipid emulsion had increase of IL-10 (day 3, p < 0.0001), decrease of IL-6 (day 3, p = 0.029) and IL-10 (day 6, p<0.0001), lower decrease of leukocyte oxidative burst...