Conduta nutricional no trauma para o clínico / Conduct in nutrition on trauma for clinical

JUSTIFICATIVA E OBJETIVOS: Trauma é um evento agudo que altera a homeostase do organismo, por desencadear reações neuroendócrinas e imunológicas que visam a manutenção da volemia, do débito cardíaco, da oxigenação tecidual e da oferta e utilização de substratos energéticos. Todas têm em comum um evento inicial agudo, alterando todo o equilíbrio do organismo e uma resposta fisiopatológica complexa. O objetivo deste estudo foi alertar sobre as necessidades energético-proteicas no trauma, consumo metabólico,formas mais seguras de administração da dieta e as possíveis complicações do suporte nutricional inadequado nessas situações. CONTEÚDO: A nutrição deve ser integrada no tratamento global do paciente criticamente doente a fim de minimizar as complicações de um tratamento mais prolongado. As prioridades imediatas após o trauma são: reanimação volêmica, oxigenação e a interrupção da hemorragia. Associados a esses fatores estão o estado hiperdinâmico da resposta ao trauma, bem como a dor, febre, exposição ao frio, acidose e hipovolemia, e possíveis infecções, aumentando a demanda metabólica. O suporte nutricional é parte essencial do tratamento metabólico desses pacientes. Ele deve ser instituído antes que haja perda significativa de peso, de preferência nas primeiras 24h da admissão no hospital, através de dietas orais ou enterais preferencialmente e parenterais, quando necessário. CONCLUSÃO: Uma dieta bem administrada é capaz de manter a massa celular corporal e a limitação da perda de peso a menos de 10% do peso na pré-lesão. O importante é o paciente ser constantemente reavaliado para ajuste da dieta de acordo com as necessidades diárias. Dentre as consequências de uma inadequada abordagem destes pacientes, tem-se a síndrome de realimentação, a cetose e a desnutrição.

BACKGROUND AND OBJECTIVES: Trauma is an acute event that alters the body's homeostasis, neuroendocrine and for triggering immune responses aimed at maintaining blood volume, cardiac output, tissue oxygenation and the supply and use of energy substrates. All have in common an acute initial event, changing the whole balance of the body and a complex pathophysiological response. The objective of this study was to make aware of the protein-energy needs in trauma, metabolic consumption, the bests ways of diet administration and the possible complications of inadequate nutritional support in these situations. CONTENTS: Nutrition must be integrated into the overal ltreatment of critically ill patients in order to minimize the complications of a longer treatment. The immediate priorities are thefollowing trauma fluid resuscitation, oxygenation and stopping the bleeding. These factors are associated with the state of a hyperdynamic response to trauma, as well as pain, fever, exposure to cold, acidosis and hypovolemia, and possible infections, increasing the metabolic demand. Nutritional support is an essential part of the metabolic treatment of these patients. It must be established before there is significant loss of weight, preferably within 24 hours of admission to the hospital, through diet or oral enteral and parenteral preferably when necessary. CONCLUSION: A well-managed diet is able to maintain body cell mass and limiting the weight loss to less than 10% weight inthe pre-injury. The important thing is to be constantly reassessed the patient to adjust the diet according to the daily needs. Among the consequences of an inadequate approach to these patients, are: Refeeding syndrome, ketosis, and malnutrition.

Comparison of a immunonutrition formula enriched arginine, glutamine and omega-3 fatty acid, with a currently high-enriched enteral nutrition for trauma patients.

The severe trauma or burn patients required aggressive resuscitation, operation and metabolic support to reduce morbidity and motality. Nutrition is one of the most important treatment for these patients, improving body protein and immune function, reducing rate of infection and shortening hospitalization. METHOD: To evaluate the metabolic and immune effects of dietary arginine, glutamine and omega-3 fatty acids (fish oil) supplementation, we performed a prospective study in patients age 15-60 yrs after severe trauma (Injury Severity Scores (ISS) 15-30) or burn patients (body surface area (BSA) 30-60%) in Siriraj Hospital. They were randomized to receive either Neomune or Traumacal. The nasogastric feeding was started in post-injury day 2 (PID2) with half of concentration at the rate of 30 ml/h. From PID3 to PID10, the normal concentration was administered at the rate of 80-100 ml/h depending on optimal caloric requirement. All patients received 5 per cent dextrose in half or full strength saline solution as clinically indicated. No other oral nutrients apart from study formula were allowed during the study. Blood sample was with-drawn on PID2, PID6 and PID11 for measurements of CBC, coagulogram, albumin, transferrin, CRP, LFT, BUN, Cr, CD3, CD19, CD4, CD8, C3, IgG, IgM, and IgA. Nitrogen balance was calculated from UUN. Unpaired student t-test was applied to compare variables between the two groups. RESULTS: 36 patients were selected (16 trauma and 20 burn), male = 29, mean age = 29.86 yrs. The patients were divided equally into two groups to receive Neomune or Traumacal. The data were compared and showed significance on total protein on PID11 (Neomune = 6.52 +/- 1.29, Traumacal = 5.59 +/- 1.21, p = 0.03) and serum triglycerides on PID11 (Neomune = 128.39 +/- 53.45, Traumacal = 186.25 +/- 84.07, p = 0.02). The ICU stay was observed shorter in Neomune than in Traumacal group (3.41 and 7.83 days) with no statistical significance. The wean-off respirator day was also shorter in Neomune than in Traumacal group (2.71 and 7.39 days). One patient in each group died. CONCLUSIONS: The feeding of Neomune in critically injured patients was well tolerated as Traumacal and significant improvement was observed in serum protein. Shorten ICU stay and wean-off respirator day may benefit from using the immunonutrient formula.

Soporte metabolico hipocalorico del paciente en estado septico / Hypocaloric metabolic support of the patient in septic state

El organismo requiere una provision calorica para atender sus necesidades fisiologicas y del metabolismo intermediario. En condiciones de stress se presenta un mayor gasto calorico, pero las formulas que han sido comunmente utilizadas para el calculo de la demanda calorica en el estado critico resultan en provisiones excesivas con efectos fisiologicos adversos. El Centro Medico de los Andes ha establecido protocolos fundamentados en el calculo de gasto metabolico basal mediante la ecuacion de Harris-Benedict, utilizando el peso ideal cuando hay obesidad y el peso actual en individuos desnutridos, con un factor de aumento por stress del orden de 5-15//, y hasta 30//, lo cual generalmente significa provisiones caloricas totales de menos de 1600 calorias/dia para adultos, cifra muy inferior a las provisiones del orden de 2500 cal/dia que son comunes en la actualidad. Tambien ha sido de gran valor practico la determinacion del gasto metabolico total a partir de la medicion de producccion de CO2 y de consumo de O2 utilizando la formula abreviada de Weir. Sin embargo, cuando el paciente se encuentra en estado critico y exhibe un elevado nivel de estres, a juzgar por hipermetabolismo, catabolismo exagerado y cuadro hiperdinamico, nuestra conducta es administrar una carga muy baja de carbohidratos de 200-600 cal/dia y un maximo aporte de proteina, regimen que permite la oxidacion de grasa endogena y que parece ser altamente ahorrador de proteina corporal. Este regimen solo es utilizado ...