[How should anesthesiologists perform ultrasound examinations? Diagnostic use of ultrasound in emergency and intensive care and medicine]. / In welcher Weise sollte ein Anästhesist sonographieren können? Diagnostischer Einsatz des Ultraschalls in der Akut- und Intensivmedizin.

Ultrasound imaging has attained great significance as a tool for diagnostics in emergency and intensive care medicine. The major advantages of this technique are its instantaneous bedside availability and the possibility to perform repeatable examinations. These advantages are based on recent developments, such as portable ultrasound devices offering excellent imaging quality as well as a quick-start-function. Ultrasound imaging in critically ill patients is frequently performed under pressure of time depending on the current acute physical state. All standard examinations in echocardiography, vascular, abdominal and thoracic ultrasound scanning can be applied in these patients. Based on the clinical scenario the duration of examinations may vary from seconds during cardiopulmonary resuscitations to time-consuming repeated scanning. The transition from basic to subject-specific detailed examinations is flowing and has to be adjusted to local conditions. In the field of emergency and intensive care medicine the technique used is whole-body sonography. The goal is to classify the patient's present physical state and to define a targeted therapeutic approach. The characteristics of whole-body sonography are similar to the field of anesthesiology which is an interdisciplinary one. Currently, these characteristics deserve more attention in training in sonography.

Caracterización y registro del polen atmosférico en la ciudad de Temuco / Characterization and registry of the atmospheric pollen in Temuco, Chile

Se realizó un estudio con el objetivo de cuantificar y caracterizar la carga polínica en la ciudad de Temuco, entre los años 2006-2009. Para el muestreo aerobiológico se utilizó un captador volumétrico Burkard Seven Day Volumetric Spore-Trap®. Las muestras obtenidas fueron analizadas semana tras semanas durante el período en estudio. Con los resultados del conteo polínico semanal se determinaron las 11 principales especies de flora urbana anemófilas de Temuco más susceptibles de producir polinosis. Las mayores concentraciones de polen se obtienen entre septiembre y marzo, siendo las especies más importantes: Pastos (Gramineae/Poaceae), Ciprés (Cupressus sp) y Acedera (Rumex sp).

The aim of this study was to quantify and to characterize the amount ofpollen in the atmosphere of the city of Temuco, Chile from 2006 to 2009. Aerobiological sampling was carried out by using a Seven Day Volumetric Spore-Trap Burkard and the samples were analyzed weekly during the period of study. Results: We determined the 11 principal anemophilus species of urban flora in Temuco responsible for pollinosis. The highest concentration ofpollen were present from september till march, being the most important species the Grasses (Gramineae/Poaceae), Cypress (Cupressus sp), and Sorrell (Rumex sp.).

Vacunas en reumatología: seguridad y eficacia, uso de drogas biológicas y desarrollo de autoinmunidad / Vaccines in rheumatology: safety and efficacy, use of biological drugs and autoimmune development

La presente revisión compendia los estudios existentes sobre el uso de vacunas en pacientes con enfermedades reumatológicas, tanto en lo referente a su indicación, seguridad, inmunogenicidad, aparición de exacerbaciones, efecto sobre los tratamientos farmacológicos inmunosupresores empleados y de éstos sobre la respuesta a la vacunación Los estudios muestran que cuando una vacuna es correctamente indicada, constituye una valiosa herramienta en la protección de pacientes inmunodeprimidos. Además, no generan exacerbaciones clínicas de la enfermedad autoinmune y pueden inducir una adecuada respuesta inmunológica aunque ésta puede ser subóptima en comparación con controles sanos. Finalmente se hace referencia al desarrollo de autoinmunidad con posterioridad a la vacunación.

The present review sumnarizes the existing studies about the use of vaccines in patients with autoimmune rheumatic diseases, both with reference to indication, safety inmunogenicity flare development, effect on inmunosuppressive pharmacologic treatment used, and their response to the vaccinations. Studies show that when a vaccine is correctly indicated, it represents a valuable instrument for the protection of immunedepressed patients. Besides, it does not generate clinical exacerbation of autoimmune diseases and can induce a suitable immunologic response, although this is can be lower than that of healthy controls. Finally, we refer to the development of autoimmunity after vaccination.

[III Working Meeting SENPE-Baxter: complementary parenteral nutrition in the critically ill patient]. / III Mesa de Trabajo SENPE-Baxter: nutrición parenteral complementaria en el paciente crítico.

In the setting of a multidisciplinary debate, and after reviewing the available evidence as well as the experience from experts, the indications and management guidelines for Complementary Parenteral Nutrition (CPN) in the critically ill patient are established. The conclusion refers to the importance of its indication in all the cases where enteral nutrition (EN) is insufficient to cover at least 60% of the caloric-protein target. At least 80% of the patient's caloric requirements should be covered with EN and CPN, with the recommendation of targeting 100% of the demands.

III Mesa de Trabajo SENPE-Baxter: nutrición parenteral complementaria en el paciente crítico / III working meeting senpe-baxter: complementary parenteral nutrition in the critically ill patient

En un debate multidisciplinario y tras revisar la evidencia disponible así como la experiencia de los expertos se establecen las indicaciones y pautas de manejo de la Nutrición Parenteral Complementaria (NPC) en el paciente críticamente enfermo. Se concluye en la importancia de su indicación en todos los casos en que la nutrición enteral (NE) sea insuficiente para cubrir al menos el 60% del objetivo calórico-proteico. El paciente debe cubrir con la NE y la NPC al menos el 80% de sus objetivos calóricos, recomendándose el objetivo del 100%

In the setting of a multidisciplinary debate, and after reviewing the available evidence as well as the experience from experts, the indications and management guidelines for Complementary Parenteral Nutrition (CPN) in the critically ill patient are established. The conclusion refers to the importance of its indication in all the cases where enteral nutrition (EN) is insufficient to cover at least 60% of the caloric-protein target. At least 80% of the patient’s caloric requirements should be covered with EN and CPN, with the recommendation of targeting 100% of the demands

Efecto del SIDA en la evolución de la artritis reumatoídea: el síndrome de reconstitución inmune / Rheumatoid arthritis and AIDS: the immune reconstruction syndrome

El SIDA es una enfermedad que tiene una forma de presentación clínica variada; una de ellas, son las de tipo reumatológico. Por otra parte, el SIDA puede modificar el curso de una enfermedad como la Artritis reumatoídea, cuando pasa del estado portador de HIV a la etapa SIDA. En este artículo, que es un caso clínico de nuestro Departamento de Reumatología del Hospital San Juan de Dios, analizaremos a una enferma con Artritis reumatoídea cuya evolución clínica se caracterizó por una artritis agresiva y destructiva en un lapso corto de tiempo, de difícil control médico, en estado portador de HIV, y que frente a una nueva etapa de SIDA pudo inactivar totalmente su Artritis reumatoídea.Esta revisión analiza, por una parte, las manifestaciones del HIV y sus presentaciones en las enfermedades reumatológicas y, por otro lado, revisa el Síndrome de Reconstitución Inmune, una forma de manifestación del tratamiento del SIDA y cómo éste incide en enfermedades como la Artritis reumatoídea.

AIDS is a disease with various clinical manifestations, among them are those of rheumatic nature. On the other hand, AIDS can modify the course of rheumatoid arthritis when it passes from the HIV positive to an AIDS stage. We present a clinical case from our Department of Rheumatology at the San Juan de Dios Hospital, of a HIV-positive woman with an aggressive and rapidly destructive case of rheumatoid arthritis, which became totally inactive with the manifestation of AIDS. We review, on one hand, HIV manifestations and its presence in rheumatic diseases and, on the other hand, the immune reconstruction syndrome, a manifestation of AIDS treatment, and how this affects diseases like rheumatoid arthritis.

[Glutamine, an almost essential amino acid in the critically ill patient]. / La glutamina, un aminoácido casi indispensable en el enfermo crítico.

Glutamine is the most abundant amino acid in the human body and plays an important role in a number of metabolic pathways. Specifically, it is involved in amino acid and nucleotide synthesis, in the tricarboxylic acid cycle and in ureagenesis. Glutamine has been classified as a non-essential amino acid because the body can synthesize it, but under severe clinical conditions, the pool of glutamine is depleted and could be considered as conditionally essential. Low levels of glutamine are associated with a decrease in the immune response, changes in the structure and function of the intestinal mucose and the gut associated lymphoid tissue, a decreased anti-oxidant capacity and changes of the insulin sensitivity in critically ill patients. Administration of supplemental glutamine by enteral or parenteral route has produced controversial results. Most of the studies published support the hypothesis that glutamine can change the morbidity-mortality of the critically ill patients. There are unresolved questions related to the dose of glutamine and the best way to administer it, and particularly the subgroups of patients who will really benefit from this treatment.

La glutamina, un aminoácido casi indispensable en el enfermo crítico / Glutamine, an almost essential amino acidin the critically ill patient

La glutamina es el aminoácido más abundante del organismo y está implicada en numerosos procesos del metabolismo intermediario, sobre todo en la síntesis de aminoácidos y purinas, en el ciclo de los ácidos tricarboxílicos y en la generación de urea. Aunque se ha considerado un aminoácido no esencial debido a que puede ser sintetizado por el organismo, existen situaciones clínicas graves que cursan con una depleción marcada, por lo que ha sido considerado como condicionalmente esencial. Los niveles bajos de glutamina se asocian con alteraciones de la función inmune, con cambios en la estructura y función de la mucosa intestinal y del tejido linfático asociado, con disminución de la capacidad oxidante y con modificaciones de la sensibilidad a la insulina en el enfermo grave. La administración de suplementos clínicos de glutamina, tanto por vía enteral como parenteral, han dado resultados contradictorios pero, en su mayor parte, apoyan la hipótesis de que los aportes de glutamina pueden modificar la morbimortalidad de los enfermos graves. Quedan cuestiones pendientes de resolver como la dosis adecuada y la vía de administración, y más importante, definir aquellos subgrupos de pacientes que pueden beneficiarse más de su empleo

Glutamine is the most abundant amino acid in the human body and plays an important role in a number of metabolic pathways. Specifically, it is involved in amino acid and nucleotide synthesis, in the tricarboxylic acid cycle and in ureagenesis. Glutamine has been classified as a non-essential amino acid because the body can synthesize it, but under severe clinical conditions, the pool of glutamine is depleted and could be considered as conditionally essential. Low levels of glutamine are associated with a decrease in the immune response, changes in the structure and function of the intestinal mucose and the gut associated lymphoid tissue, a decreased anti-oxydant capacity and changes of the insulin sensitivity in critically ill patients. Administration of supplemental glutamine by enteral or parenteral route has produced controversial results. Most of the studies published support the hypothesis that glutamine can change the morbidity-mortality of the critically ill patients. There are unresolved questions related to the dose of glutamine and the best way to administer it, and particularly the subgroups of patients who will really benefit from this treatment

Crioglobulinemias / Cryoglobulinemia

Cryoglobulinemia is a systemic vasculitis that principally affects small and medium caliber vessels. It is thought that the inmunocomplex deposit made up of cryoglobulins that precipitate at temperatures under 38°C activate vessel wall complement, which in turn causes damage to the same. The cryoglobulins have been found in a wide spectrum of pathologies, though generally transitory and with no clinical importance. Monoclonal cryoglobulinemia is associated with hematologic diseases, while mixed cryoglobulinemias are found in infectious and systemic diseases. The association between the hepatitis C (VHC) virus and mixed cryoglobulinemias (MC) is more and more evident, and estimates show that 90 percent of cases include this infection. Clinical manifestations are varied and are due to the tissular ischemia caused by vessel occlusion, affecting the skin and visceral organs. Chronic VHC infection induces a persistent stimulation of the immune system, generating a constellation of autoimmune and neoplastic diseases.

Estudio multicéntrico de incidencia de las complicaciones de la nutrición parenteral total en el paciente grave. Estudio ICOMEP 1ª parte / Multicenter study on incidence of total parenteral nutrition complications in the critically-ill patient. Icomep study. Part I

Objetivo: Valorar la incidencia de complicaciones de la nutrición parenteral en una cohorte prospectiva de enfermos ingresados en UCI. Material y método: Estudio prospectivo, multicéntrico de pacientes ingresados en UCI y que recibieron nutrición parenteral total. Se realizó una encuesta con 14 ítem Se registraron el número total de ingresos, pacientes tratados con NPT. Se incluyeron datos demográficos, diagnóstico, APACHE II, índice de disfunción multiorgánica e indicaciones de NPT. Cada complicación se definió previamente, se relacionaron con la vía, administración, diselectrolitemias, principios inmediatos, disfunción hepática, e infecciones nosocomiales. Las bases de datos fueron tratadas por un grupo independiente. Los datos se expresan en valores absolutos o con su mediana y percentil (25-75). Se determinan la tasa y la densidad de incidencia de las complicaciones. Resultados: El número ingresos en el período de estudio fue de 3.409, 370 (11%) fueron casos válidos que se trataron con NP. 237 pacientes eran hombres, 142 pacientes ingresaron por patología médica, 195 quirúrgica y 33 traumática. 120 pacientes estaban moderada o severamente desnutridos, 181 pacientes recibieron NP durante 7 días (3-11) y 189 recibieron NP y NE. La principal indicación de la NP fue el ilio paralítico, 145 pacientes. La NPT se suprimió por paso a NE en 121 casos y por complicaciones en 5 casos. Se contabilizaron 3220 días de NP. La incidencia de complicaciones fue: vía de acceso 9,32%, mantenimiento 19,7 % y 0,8 por 100 días. Administración 5,6% y 6,4 por 100 días. Por los nutrientes; 94,3% y 10,8 por 100 días. Sepsis por catéter 5,9% y 0,44 bacteriemias por 100 días de catéter . Infección nosocomial 54,6% y 6,27 por 100 días NPT. Conclusiones: La hiperglucemia y la disfunción hepática tienen mayor incidencia La hiperglucemia, las diselectrolitemias y las complicaciones de los catéteres tienen mayor numero de intervenciones terapéuticas, pero ello no implica que haya de retirarse la NPT (AU)

Objective: To assess parenteral nutrition complications in a prospective cohort of patients admitted to the ICU. Material and methods: Prospective, multicenter study of patients admitted to the ICU and that received total parenteral nutrition (TPN). A 14-item questionnaire was done. Total number of admissions and TPN-treated patients were recorded. Demographical data, diagnosis, APACHE II, multiorgan dysfunction index and TPN indications were included. Each complication was previously defined and was related to the route, administration, serum electrolytes unbalances, active ingredients, liver dysfunction, and nosocomial infections. An independent group managed the databases. Data were expressed in absolute values or by their median and percentile (25-75). The rate and incidence density of complications are determined. Results: The number of admissions during the study period was 3,409. Three hundred and seventy (11%) were valid cases that were treated with PN. Two hundred and thirty seven were men, 142 patients were admitted for medical causes, 195 for surgical causes and 33 for trauma. One hundred and twenty patients were moderately or severely underfed, 181 received PN for 7 days (3-11), and 189 received PN and EN. The main indication for PN was paralytic ileus, in 145 patients. TPN was withdrawn for switching to EN in 121 cases and for complications in 5 cases. PN summed up 3,220 days. The incidence of complications was: access route 9.32%, maintenance 19.7% and 0.8 per 100 days. Administration, 5.6% and 6.4 per 100 days. Nutrients, 94.3% and 10.8 per 100 days. Catheter-induced sepsis, 54.6% and 0.44 bacteriemias per 100 days with catheter. Nosocomial infection, 54.6% and 6.27 per 100 days on TPN. Conclusions: hyperglycemia and liver dysfunction have a greater incidence. Hyperglycemia, electrolyte unba-lances and catheter complications have a greater number of therapeutic interventions, but does not mean that TPN should be withdrawn (AU)

Estudio multicéntrico de incidencia de las complicaciones de la nutrición enteral total en el paciente grave. Estudio ICOMEP 2ª parte / Multicenter study on incidence of total parenteral nutrition complications in the critically-ill patient. Icomep study. Part II

Objetivo: Valorar la incidencia de complicaciones de la nutrición enteral en una cohorte prospectiva de enfermos ingresados en UCI. Material y métodos: Estudio prospectivo, multicéntrico de pacientes ingresados en UCI y que recibieron nutrición enteral. Se incluyeron datos demográficos, diagnóstico principal e índices nutricionales y de gravedad. Las complicaciones se definieron previamente y se agruparon en gastrointestinales e infecciosas. Un grupo independiente trató la base de datos y realizó el análisis estadístico. Se determinaron la tasas, la densidad de incidencia de las complicaciones y la razón de probabilidad para las complicaciones. Resultados: De 3.409 pacientes, 544 recibieron nutrición enteral. 303 pacientes ingresaron por patología médica, 149 quirúrgica y 92 traumática. 99 estaban desnutridos y el índice de riesgo nutricional fue de 69,7. La incidencia de complicaciones gastrointestinales fue de 6 episodios por 100 días de nutrición y obligó a la suspensión definitiva de la dieta en 89 pacientes. La nutrición enteral precoz no dio lugar a más complicaciones que la tardía. Los vómitos fueron más frecuente en la tardía (O.R. 0,4; IC95%: 0,2-0,7). La retirada temporal de la dieta en 140 enfermos fue la maniobra más utilizada, lo que dió lugar a menos aporte calórico (2 kcal/kg/d de mediana) que el programado. Las tasas de incidencia de infección nosocomial fueron de 7,47% de sepsis por catéter y 51% de otras infecciones nosocomiales y 35% desarrollaron neumonía. Conclusiones: Las complicaciones gastrointestinales de la nutrición enteral son frecuentes, producen un aporte calórico insuficiente y una suspensión definitiva de la dieta en un número significativo de casos. La nutrición enteral precoz no tiene una mayor incidencia de complicaciones. Los episodios de aumento del residuo gástrico no incrementan la incidencia de neumonía. Las demás complicaciones infecciosas están en el rango de lo publicado y parecen modificarse poco por el uso de la nutrición enteral (AU)

Objective: To assess enteral nutrition complications in a prospective cohort of patients admitted to the ICU. Material and methods: Prospective, multicenter study of patients admitted to the ICU and that received enteral nutrition (EN). Demographical data, main diagnosis, and nutritional and severity indexes were included. Complications were previously defined and were categorized as gastrointestinal or infectious. An independent group managed the databases and performed the statistical analysis. Data were expressed in absolute values or by their median and percentile (25-75). The rate and incidence density of complications and the odds ratio for complications were determined. Results: 544 out of 3,409 patients received enteral nutrition. Three hundred and three patients were admitted for medical causes, 149 for surgical causes and 92 for trauma. Ninety nine patients were underfed, and the nutritional risk index was 69.7. The incidence of gastrointestinal complications was 6 episodes per 100 days of nutrition, and in 89 patient they resulted in enteral nutrition withdrawal. Early enteral nutrition did not yield more complications than late EN. Vomiting was more frequent in late EN (OR 0.4; 95%CI: 0.2-0.7). Temporary withdrawal of diet in 140 patients was the most used procedure, which resulted in a lower caloric intake (median of 2 kcal/kg/d) than programmed. Nosocomial infection rates were 7.47% for catheter-induced sepsis and 51% for other nosocomial infections, and 35% developed pneumonia. Conclusions: Gastrointestinal complications with enteral nutrition are frequent, result in insufficient caloric intake and definitive withdrawal of diet in a significant number of cases. Early enteral nutrition is not associated with an increased number of complications. Episodes of increase of the gastric residue do not increase the incidence of pneumonia. Other infectious complications are within the range of what has been published and seem to be little modified by the use of enteral nutrition (AU)

[Multicenter study on incidence of total parenteral nutrition complications in the critically-ill patient. ICOMEP study. Part I]. / Estudio multicéntrico de incidencia de las complicaciones de la nutrición parenteral total en el paciente grave. Estudio ICOMEP 1a parte.

OBJECTIVE: To assess parenteral nutrition complications in a prospective cohort of patients admitted to the ICU. MATERIAL AND METHODS: Prospective, multicenter study of patients admitted to the ICU and that received total parenteral nutrition (TPN). A 14-item questionnaire was done. Total number of admissions and TPN-treated patients were recorded. Demographical data, diagnosis, APACHE II, multiorgan dysfunction index and TPN indications were included. Each complication was previously defined and was related to the route, administration, serum electrolytes unbalances, active ingredients, liver dysfunction, and nosocomial infections. An independent group managed the databases. Data were expressed in absolute values or by their median and percentile (25-75). The rate and incidence density of complications are determined. RESULTS: The number of admissions during the study period was 3409. Three hundred and seventy (11%) were valid cases that were treated with PN. Two hundred and thirty seven were men, 142 patients were admitted for medical causes, 195 for surgical causes and 33 for trauma. One hundred and twenty patients were moderately or severely underfed, 181 received PN for 7 days (3-11), and 189 received PN and EN. The main indication for PN was paralytic ileus, in 145 patients. TPN was withdrawn for switching to EN in 121 cases and for complications in 5 cases. PN summed up 3220 days. The incidence of complications was: access route 9.32%, maintenance 19.7% and 0.8 per 100 days. Administration, 5.6% and 6.4 per 100 days. Nutrients, 94.3% and 10.8 per 100 days. Catheter-induced sepsis, 54.6% and 0.44 bacteriemias per 100 days with catheter. Nosocomial infection, 54.6% and 6.27 per 100 days on TPN. CONCLUSIONS: hyperglycemia and liver dysfunction have a greater incidence. Hyperglycemia, electrolyte unbalances and catheter complications have a greater number of therapeutic interventions, but does not mean that TPN should be withdrawn.

[Multicenter study on incidence of total parenteral nutrition complications in the critically-ill patient. ICOMEP study. Part II]. / Estudio multicéntrico de incidencia de las complicaciones de la nutrición enteral total en el paciente grave. Estudio ICOMEP 2a parte.

OBJECTIVE: To assess enteral nutrition complications in a prospective cohort of patients admitted to the ICU. MATERIAL AND METHODS: Prospective, multicenter study of patients admitted to the ICU and that received enteral nutrition (EN). Demographical data, main diagnosis, and nutritional and severity indexes were included. Complications were previously defined and were categorized as gastrointestinal or infectious. An independent group managed the databases and performed the statistical analysis. Data were expressed in absolute values or by their median and percentile (25-75). The rate and incidence density of complications and the odds ratio for complications were determined. RESULTS: 544 out of 3409 patients received enteral nutrition. Three hundred and three patients were admitted for medical causes, 149 for surgical causes and 92 for trauma. Ninety nine patients were underfed, and the nutritional risk index was 69.7. The incidence of gastrointestinal complications was 6 episodes per 100 days of nutrition, and in 89 patient they resulted in enteral nutrition withdrawal. Early enteral nutrition did not yield more complications than late EN. Vomiting was more frequent in late EN (OR 0.4; 95%CI: 0.2-0.7). Temporary withdrawal of diet in 140 patients was the most used procedure, which resulted in a lower caloric intake (median of 2 kcal/kg/d) than programmed. Nosocomial infection rates were 7.47% for catheter-induced sepsis and 51% for other nosocomial infections, and 35% developed pneumonia. CONCLUSIONS: Gastrointestinal complications with enteral nutrition are frequent, result in insufficient caloric intake and definitive withdrawal of diet in a significant number of cases. Early enteral nutrition is not associated with an increased number of complications. Episodes of increase of the gastric residue do not increase the incidence of pneumonia. Other infectious complications are within the range of what has been published and seem to be little modified by the use of enteral nutrition.

Ultrasound-guided epidural catheter insertion in children.

UNLABELLED: Epidural catheters (EC) are often used in pediatric patients for intraoperative and postoperative pain relief. The small anatomical structures and catheter insertion under general anesthesia make it more difficult to perform EC and to prevent damage. In this study we investigated the use of ultrasound (US) in detecting neuraxial structures during insertion and placement of EC in children. ASA I-II children scheduled for elective surgery under combined general and epidural anesthesia were studied. Patients received balanced anesthesia using sevoflurane, opioids and rocuronium. Before EC insertion US examination in a lateral position was done to visualize and identify neuraxial structures. Quality of visualization and site and depth of structures were recorded. Using a sterile kit to hold the US probe in position and enable the visualization of the neuraxial structures, an epidural cannula was inserted, using the loss of resistance technique, as the EC passed under US control to the desired level. Of 25 children, 23 were evaluated. Epidural space, ligamentum flavum, and dural structures were clearly identified and the depth to skin level estimated in all patients. Loss of resistance was visualized in all patients with a lumbar epidural approach. Correlation of US measured depth and depth of loss of resistance was 0.88. In eight of 23 patients EC could be visualized during insertion and in 11 others it could be visualized with additional US planes. US is an excellent tool to identify neuraxial structures in both infants and children. The size and the incomplete ossification of the vertebra allow exact visualization and localization of the depth of the epidural space, the loss of resistance, and all relevant neuraxial structures. IMPLICATIONS: Epidural catheters in children are mostly inserted under sedation or general anesthesia. This study showed that the use of ultrasound could help visualize all relevant neuraxial structures and their site and depth from the skin.

[Early enteral nutrition in the critically-ill patient]. / La nutrición enteral precoz en el enfermo grave.

Enteral nutrition has demonstrated to be a useful and safe method to nourish critically ill patients admitted to the Intensive Care Unit. Although the time a severely ill patient can stand without nutrition is unknown, accelerated catabolism and fasting may be deleterious in those patients, and the more common recommendation is to start on artificial nutrition when a fasting period longer than seven days is foreseen. At an experimental level, advantages of enteral nutrition over parenteral nutrition are evident since the use of nutritional substrates via the gastrointestinal tract improves the local and systemic immune response and maintains the barrier functions of the gut. Clinical studies have demonstrated that early enteral nutrition administered within the first 48 hours of admission decreases the incidence of nosocomial infections in these patients, but not the mortality, with the exception of special groups of patients, particularly surgical ones. The major inconvenience of enteral nutrition is its digestive intolerance and the transpyloric approach, necessary when there is gastroparesia. Its efficacy is also questioned when the patient has tissue ischemia. For early enteral nutrition to be effective, a treatment strategy must be implemented that includes from simple measures, such as uprising the bed headrest, to more sophisticated ones, such as the transpyloric approach or the use of nutrients with immunomodulatory capabilities. To date, the use of early enteral nutrition is the best method for nutritional support in this kind of patients provided that it is individualized according to each patient clinical status and that is done following an adequate therapeutic strategy.

La nutrición enteral precoz en el enfermo grave / Early enteral nutrition in the critically-ill patient

La nutrición enteral se ha demostrado como un método eficaz y seguro de nutrir a los enfermos graves ingresados en una Unidad de Cuidados Intensivos. Aunque se desconoce cuánto tiempo puede estar un enfermo grave sin nutrición, el catabolismo acelerado y el ayuno pueden ser deletéreos en el enfermo grave y la recomendación más frecuente es la de empezar la nutrición artificial cuando se prevea un período de ayuno superior a los siete días. Las ventajas de la nutrición enteral sobre la nutrición parenteral son evidentes a nivel experimental inmune tanto local como sistémica y mantiene las funciones de barrera del intestino. Estudios clínicos han demostrado que la nutrición enteral precoz, administrada en las primeras 48 horas de ingreso, disminuye la incidencia de infecciones nosocomiales en estos enfermos aunque no la mortalidad, salvo en grupos concretos de pacientes, especialmente en enfermos quirúrgicos. El mayor inconveniente de la nutrición enteral es su intolerancia digestiva y el abordaje trans-pilórico, necesario cuando se produce gastroparesia. También existen dudas de su eficacia cuando el enfermo está en situación de isquemia tisular. Para que la nutrición enteral precoz sea eficaz hace falta instaurar una estrategia terapéutica que incluye tanto medidas sencillas como la elevación del cabecero de la cama, a medidas más sofisticadas como el abordaje trans-pilórico o el uso de nutrientes con capacidad inmunomoduladora. El uso de nutrición enteral precoz es, hoy por hoy, el mejor método de soporte nutricional en estos enfermos si se individualiza su uso en función de la situación clínica de cada paciente y se realiza mediante una estrategia terapéutica adecuada (AU)

Enteral nutrition has demonstrated to be a useful and safe method to nourish critically ill patients admitted to the Intensive Care Unit. Although the time a severely ill patient can stand without nutrition is unknown, accelerated catabolism and fasting may be deleterious in those patients, and the more common recommendation is to start on artificial nutrition when a fasting period longer than seven days is foreseen. At an experimental level, advantages of enteral nutrition over parenteral nutrition are evident since the use of nutritional substrates via the gastrointestinal tract improves the local and systemic immune response and maintains the barrier functions of the gut. Clinical studies have demonstrated that early enteral nutrition administered within the first 48 hours of admission decreases the incidence of nosocomial infections in these patients, but not the mortality, with the exception of special groups of patients, particularly surgical ones. The major inconvenience of enteral nutrition is its digestive intolerance and the transpyloric approach, necessary when there is gastroparesia. Its efficacy is also questioned when the patient has tissue ischemia. For early enteral nutrition to be effective, a treatment strategy must be implemented that includes from simple measures, such as uprising the bed headrest, to more sophisticated ones, such as the transpyloric approach or the use of nutrients with immunomodulatory capabilities. To date, the use of early enteral nutrition is the best method for nutritional support in this kind of patients provided that it is individualized according to each patient clinical status and that is done following an adequate therapeutic strategy (AU)

[Evaluation of palatability of two special oral diets for institutionalized elderly diabetics, Glucerna SR vs Resource Diabet]. / Estudio de palatabilidad de dos dietas orales especiales para pacientes diabéticos en residencias geriátricas, Glucerna SR vs Resource Diabet.

OBJECTIVES: To evaluate the organoleptic characteristics of two specific nutritional supplements for diabetes (Glucerna SR and Resource Suport) and compare them. SETTING: An evaluation was made of 456 patients with Type 2 diabetes (most of them receiving OADs or insulin) from 34 centers. They were non-smoking elderly patients (mean age 73 to (71-78) admitted to nursing homes or homes for the aged distributed all over the Spanish territory. INTERVENTIONS: Palatability was studied using a modified wine tasting scale assessing 6 parameters (appearance, smell, body, sweetness, aftertaste and taste) that were scored individually, with a total score ranging from 0 (most unfavorable) to 20 (most favorable). Each brand was evaluated in two flavors (vanilla and strawberry) according to a crossover, double-blind design. RESULTS: A total of 906 evaluable observations were made, and highly statistically significant differences favorable to Glucerna RS were found in all parameters considered both absolutely and relatively, exception for sweetness, for which statistical significance was not reached because it was relatively evaluated. No statistical differences were found between the two flavors (vanilla and strawberry). The only significant confusing factor found was age; the older the age, the more the differences were noted between the two brands. CONCLUSIONS: Glucerna SR has a better flavor than Resource Suport for institutionalized elderly diabetic patients.

Estudio de palatabilidad de dos dietas orales especiales para pacientes diabéticos en residencias geriátricas, Glucerna SR® vs Resource Diabet® / Evaluation of palatability of two special oral diets for institutionalized elderly diabetics, Glucerna SR® vs Resource Diabet®

Objetivos: Evaluar las características organolépticas de dos suplementos nutricionales específicos para diabetes (Glucerna SR® y Resource Diabet®) y compararlos entre sí. Ámbito: Se evaluó a 456 pacientes diabéticos tipo 2 (que en su mayoría estaban recibiendo ADO o insulina) en 34 centros. Se trataba de ancianos con una edad media de 73 años (71-78), ingresados en centros asistidos o residencias distribuidas por todo el territorio español y que no eran fumadores. Intervenciones: La palatabilidad se estudió con una escala de cata de vinos modificada que valora 6 parámetros (apariencia, aroma, cuerpo, dulzura, regusto y sabor), que se puntuaban individualmente, siendo la puntuación total de 0 (la más desfavorable) a 20 (la más favorable). Cada producto se evaluó con dos sabores (vainilla y fresa) mediante un control en paralelo con triple enmascaramiento. Resultados: Se realizaron un total de 906 observaciones válidas, encontrándose unas diferencias estadísticamente significativas a favor de Glucerna SR® en todos los parámetros considerados tanto de forma absoluta como relativa a excepción del dulzor que al evaluarlo de forma relativa no alcanza la significación estadística. No se encontraron diferencias estadísticas entre los dos sabores (vainilla y fresa). El único factor de confusión que ha resultado significativo es la edad, de modo que a más edad se aprecia más las diferencias entre las dos marcas. Conclusiones: Glucerna SR® presenta un mejor sabor que Resource Diabet® para los diabéticos ancianos institucionalizados (AU)

Objectives: To evaluate the organoleptic characteristcs of two specific nutritional supplements for diabetes (Glucerna SR® and Resource Suport®) and compare them. Setting: An evaluation was made of 456 patients with Type 2 diabetes (most of them receiving OADs or insulin) from 34 centers. They were non-smoking elderly patients (mean age 73 to (71-78) admitted to nursing homes or homes for the aged distributed all over the Spanish territory. Interventions: Palatability was studied using a modified wine tasting scale assessing 6 parameters (appearance, smell, body, sweetness, aftertaste and taste) that were scored individually, with a total score ranging from 0 (most unfavorable) to 20 (most favorable). Each brand was evaluated in two flavors (vanilla and strawberry) according to a crossover, double-blind design. Results: A total of 906 evaluable observations were made, and highly statistically significant differences favorable to Glucerna RS® were found in all parameters considered both absolutely and relatively, exception for sweetness, for which statistical significance was not reached because it was relatively evaluated. No statistical differences were found between the two flavors (vanilla and strawberry). The only significant confusing factor found was age; the older the age, the more the differences were noted between the two brands. Conclusions: Glucerna SR® has a better flavor than Resource Suport® for institutionalized elderly diabetic patients (AU)