Validation of the nutritrauma concept for the detection of potential harmful effects of medical nutritional treatment in critically ill patients in real life.

INTRODUCTION: medical nutritional treatment (MNT) can be complex and may be associated with potential metabolic complications, which has been recently described as nutritrauma. OBJECTIVE: the aim of our work is to describe whether the application of the nutritrauma concept in real life is feasible and useful to detect the metabolic complications associated with the prescription of MNT. MATERIAL AND METHODS: in this descriptive, prospective study at a single center we enrolled 30 consecutive critically ill patients in a 14-bed medical-surgical intensive care unit. The nutritrauma strategy implementation was based in four "M" steps: Metabolic screening, MNT prescription, biochemical Monitoring, and nutritional Management. RESULTS: we analyzed 28 patients (mean age, 69.7 ± 11.3 years; APACHE II, 18.1 ± 8.1; SOFA, 7.5 ± 3.7; Nutric Score, modified, 4.3 ± 2.01, and mean BMI, 27.2 ± 3.8). The main cause of admission was sepsis (46.4 %). Length of ICU stay was 20.6 ± 15.1 days; 39.3 % of subjects died during their ICU stay. Enteral nutrition (82.1 %) was more frequent than parenteral nutrition (17.9 %). During nutritional monitoring, 54 specific laboratory determinations were made. Hyperglycemia was the most frequent metabolic alteration (83.3 % of measurements). Electrolyte disturbances included hypocalcemia (50 %), hypophosphatemia (29.6 %) and hypokalemia (27.8 %). The most frequent lipid profile abnormalities were hypocholesterolemia (64.8 %) and hypertriglyceridemia (27.8 %). Furthermore, nutritional prescription was modified for 53.6 % of patients: increased protein dosage (25 %), increased calorie dosage (21.4 %) and change to organ-specific diet (17.8 %). CONCLUSIONS: in conclusion, the application of the nutritrauma approach facilitates detection of metabolic complications and an evaluation of the appropriate prescription of MNT.

Smartfeeding: A Dynamic Strategy to Increase Nutritional Efficiency in Critically Ill Patients-Positioning Document of the Metabolism and Nutrition Working Group and the Early Mobilization Working Group of the Catalan Society of Intensive and Critical Care Medicine (SOCMiC).

Adequate medical nutrition therapy for critically ill patients has an impact on their prognoses. However, it requires an individualized approach that takes into account the activity (phases of metabolic stress) and particularity of these patients. We propose a comprehensive strategy considering the patients' nutritional status and the set of modifiable circumstances in these patients, in order to optimize/support nutritional efficiency: (1) A detailed anamnesis and an adequate initial nutritional assessment must be performed in order to implement medical nutrition therapy that is in line with the needs and characteristics of each patient. Furthermore, risks associated with refeeding syndrome, nutritrauma or gastrointestinal dysfunction must be considered and prevented. (2) A safe transition between nutrition therapy routes and between health care units will greatly contribute to recovery. The main objective is to preserve lean mass in critically ill patients, considering metabolic factors, adequate protein intake and muscle stimulation. (3) Continuous monitoring is required for the successful implementation of any health strategy. We lack precise tools for calculating nutritional efficiency in critically ill patients, therefore thorough monitoring of the process is essential. (4) The medical nutrition approach in critically ill patients is multidisciplinary and requires the participation of the entire team involved. A comprehensive strategy such as this can make a significant difference in the functional recovery of critically ill patients, but leaders must be identified to promote training, evaluation, analysis and feedback as essential components of its implementation, and to coordinate this process with the recognition of hospital management.

Trends in mortality in septic patients according to the different organ failure during 15 years.

BACKGROUND: The incidence of sepsis can be estimated between 250 and 500 cases/100.000 people per year and is responsible for up to 6% of total hospital admissions. Identified as one of the most relevant global health problems, sepsis is the condition that generates the highest costs in the healthcare system. Important changes in the management of septic patients have been included in recent years; however, there is no information about how changes in the management of sepsis-associated organ failure have contributed to reduce mortality. METHODS: A retrospective analysis was conducted from hospital discharge records from the Minimum Basic Data Set Acute-Care Hospitals (CMBD-HA in Catalan language) for the Catalan Health System (CatSalut). CMBD-HA is a mandatory population-based register of admissions to all public and private acute-care hospitals in Catalonia. Sepsis was defined by the presence of infection and at least one organ dysfunction. Patients hospitalized with sepsis were detected, according ICD-9-CM (since 2005 to 2017) and ICD-10-CM (2018 and 2019) codes used to identify acute organ dysfunction and infectious processes. RESULTS: Of 11.916.974 discharges from all acute-care hospitals during the study period (2005-2019), 296.554 had sepsis (2.49%). The mean annual sepsis incidence in the population was 264.1 per 100.000 inhabitants/year, and it increased every year, going from 144.5 in 2005 to 410.1 in 2019. Multiorgan failure was present in 21.9% and bacteremia in 26.3% of cases. Renal was the most frequent organ failure (56.8%), followed by cardiovascular (24.2%). Hospital mortality during the study period was 19.5%, but decreases continuously from 25.7% in 2005 to 17.9% in 2019 (p < 0.0001). The most important reduction in mortality was observed in cases with cardiovascular failure (from 47.3% in 2005 to 31.2% in 2019) (p < 0.0001). In the same way, mean mortality related to renal and respiratory failure in sepsis was decreased in last years (p < 0.0001). CONCLUSIONS: The incidence of sepsis has been increasing in recent years in our country. However, hospital mortality has been significantly reduced. In septic patients, all organ failures except liver have shown a statistically significant reduction on associated mortality, with cardiovascular failure as the most relevant.

Positive-pressure needleless connectors did not increase rates of catheter hub colonization respecting the use of neutral-pressure needleless connectors in a prospective randomized trial / Los conectores sin aguja de presión positiva no aumentaron las tasas de colonización de las conexiones de catéteres en comparación con el uso de conectores sin aguja de presión neutra en un estudio aleatorizado prospectivo

INTRODUCTION: The aim of this study was to compare the colonization rates of central venous catheter (CVC) and arterial catheter (ArtC) hubs fitted with two types of needleless connectors (NCs). METHODS: We designed a prospective randomized study to compare rates of catheter hub colonization of CVC and ArtC hubs fitted with two types of needleless connectors: neutral-pressure NCs (NP-NCs) and positive-pressure NCs (PP-NCs) in critically ill patients. All NCs were replaced every 7 days of use. RESULTS: We obtained 326 cultures from 146 catheters (81 CVC and 65 ArtC) in 70 patients. The total cumulative days of risk were 1250 catheter-days. Global swab cultures were positive in NP-NCs in 29/198 (14.6%) versus 17/128 (13.3%) in PP-NCs during catheter use. We did not observe any cases of CRBSI. CONCLUSIONS: In our experience, the use of PP-NCs did not result in significantly more frequent hub colonization with respect to NP-NCs

INTRODUCCIÓN: El objetivo de este estudio fue comparar las tasas de colonización de las conexiones de catéteres venosos centrales (CVC) y catéteres arteriales (ArtC) equipados con 2 tipos diferentes de conector desinfectable (CD) en pacientes críticos. MÉTODOS: Realizamos un estudio aleatorizado prospectivo. Los 2 tipos de conectores desinfectables comparados fueron un conector de presión neutra (CDPN) y un conector de presión positiva (CDPP). Todos los CD fueron reemplazados cada 7 días de uso. RESULTADOS: Obtuvimos 326 frotis de las conexiones de 146 catéteres (81 CVC y 65 ArtC) en 70 pacientes, con un total de días de riesgo de 1.250. Los cultivos fueron positivos en 29/198 (14,6%) de los CDPN respecto a 17/128 (13,3%) en los CDPP (p: NS). No hubo ningún caso de bacteriemia por catéter. CONCLUSIONES: En nuestra experiencia, el uso de CDPP no supone un aumento en la tasa de colonización de las conexiones respecto a los CDPN

Positive-pressure needleless connectors did not increase rates of catheter hub colonization respecting the use of neutral-pressure needleless connectors in a prospective randomized trial.

INTRODUCTION: The aim of this study was to compare the colonization rates of central venous catheter (CVC) and arterial catheter (ArtC) hubs fitted with two types of needleless connectors (NCs). METHODS: We designed a prospective randomized study to compare rates of catheter hub colonization of CVC and ArtC hubs fitted with two types of needleless connectors: neutral-pressure NCs (NP-NCs) and positive-pressure NCs (PP-NCs) in critically ill patients. All NCs were replaced every 7 days of use. RESULTS: We obtained 326 cultures from 146 catheters (81 CVC and 65 ArtC) in 70 patients. The total cumulative days of risk were 1250 catheter-days. Global swab cultures were positive in NP-NCs in 29/198 (14.6%) versus 17/128 (13.3%) in PP-NCs during catheter use. We did not observe any cases of CRBSI. CONCLUSIONS: In our experience, the use of PP-NCs did not result in significantly more frequent hub colonization with respect to NP-NCs.

The Role of Water Homeostasis in Muscle Function and Frailty: A Review.

Water, the main component of the body, is distributed in the extracellular and intracellular compartments. Water exchange between these compartments is mainly governed by osmotic pressure. Extracellular water osmolarity must remain within very narrow limits to be compatible with life. Older adults lose the thirst sensation and the ability to concentrate urine, and this favours increased extracellular osmolarity (hyperosmotic stress). This situation, in turn, leads to cell dehydration, which has severe consequences for the intracellular protein structure and function and, ultimately, results in cell damage. Moreover, the fact that water determines cell volume may act as a metabolic signal, with cell swelling acting as an anabolic signal and cell shrinkage acting as a catabolic signal. Ageing also leads to a progressive loss in muscle mass and strength. Muscle strength is the main determinant of functional capacity, and, in elderly people, depends more on muscle quality than on muscle quantity (or muscle mass). Intracellular water content in lean mass has been related to muscle strength, functional capacity, and frailty risk, and has been proposed as an indicator of muscle quality and cell hydration. This review aims to assess the role of hyperosmotic stress and cell dehydration on muscle function and frailty.

Nutritrauma: A Key Concept for Minimising the Harmful Effects of the Administration of Medical Nutrition Therapy.

Critically ill patients often require life support measures such as mechanical ventilation or haemodialysis. Despite the essential role of nutrition in patients' recovery, the inappropriate use of medical nutrition therapy can have deleterious effects, as is the case with the use of respiratory, circulatory, or renal support. To increase awareness and to monitor the effects of inappropriate medical nutrition therapy, we propose to introduce the concept of nutritrauma in clinical practice, defined as metabolic adverse events related to the inappropriate administration of medical nutrition therapy or inadequate nutritional monitoring.

Intracellular Water Content in Lean Mass is Associated with Muscle Strength, Functional Capacity, and Frailty in Community-Dwelling Elderly Individuals. A Cross-Sectional Study.

High intracellular water (ICW) content has been associated with better functional performance and a lower frailty risk in elderly people. However, it is not clear if the protective effect of high ICW is due to greater muscle mass or better muscle quality and cell hydration. We aimed to assess the relationship between ICW content in lean mass (LM) and muscle strength, functional performance, frailty, and other clinical characteristics in elderly people. In an observational cross-sectional study of community-dwelling subjects aged ≥75 years, ICW and LM were estimated by bioelectrical impedance, and the ICW/LM ratio (mL/kg) calculated. Muscle strength was measured as hand grip, frailty status was assessed according to Fried criteria, and functional status was assessed by Barthel score. For 324 recruited subjects (mean age 80 years), mean (SD) ICW/LM ratio was 408 (29.3) mL/kg. The ICW/LM ratio was negatively correlated with age (rs = -0.249; p < 0.001). A higher ICW/LM ratio was associated with greater muscle strength, better functional capacity, and a lower frailty risk, even when adjusted by age, sex, nº of co-morbidities, and LM. ICW content in LM (including the muscle) may influence muscle strength, functional capacity and frailty. However, further studies are needed to confirm this hypothesis.

Differences in Hypotensive vs. Non-Hypotensive Sepsis Management in the Emergency Department: Door-to-Antibiotic Time Impact on Sepsis Survival.

BACKGROUND: Sepsis diagnosis can be incorrectly associated with the presence of hypotension during an infection, so the detection and management of non-hypotensive sepsis can be delayed. We aimed to evaluate how the presence or absence of hypotension, on admission at the emergency department, affects the initial management and outcomes of patients with community-onset severe sepsis. METHODS: Demographic, clinical, laboratory, process of care, and outcome variables were recorded for all patients, at the emergency department of our university hospital, who presented with community-onset severe sepsis, between 1 March and 31 August in three consecutive years. Patient management consisted of standardized bundled care with five measures: Detection, blood cultures and empirical antibiotics, oxygen supplementation and fluid resuscitation (if needed), clinical monitoring, and noradrenalin administration (if needed). We compared all variables between patients who had hypotension (mean arterial pressure <65 mmHg), on admission to the emergency department, and those who did not. RESULTS: We identified 153 episodes (84 (54.5%) men; mean age 73.6 ± 1.2; mean Sequential Organ Failure Assessment (SOFA) score 4.9 ± 2.7, and 41.2% hospital mortality). Hypotension was present on admission to the emergency department in 57 patients (37.2%). Hemodynamic treatment was applied earlier in patients who presented hypotension initially. Antibiotics were administered 48 min later in non-hypotensive sepsis (p = 0.08). A higher proportion of patients without initial hypotension required admission to the intensive care unit (ICU) (43.1% for patients initially hypotensive vs. 56.9% in those initially non-hypotensive, p < 0.05). Initial hypotension was not associated with mortality. A delay in door-to-antibiotic administration time was associated with mortality [OR 1.150, 95%CI: 1.043⁻1.268). CONCLUSIONS: Initial management of patients with community-onset severe sepsis differed according to their clinical presentation. Initial hypotension was associated with early hemodynamic management and less ICU requirement. A non-significant delay was observed in the administration of antibiotics to initially non-hypotensive patients. The time of door-to-antibiotic administration was related to mortality.

Non-oncotic properties of albumin. A multidisciplinary vision about the implications for critically ill patients.

INTRODUCTION: Effective resuscitation with human albumin solutions is achieved with less fluid than with crystalloid solutions. However, the role of albumin in today's critical care unit is also linked to its multiple pharmacological effects. Areas covered: The potential clinical benefits of albumin in select populations of critically ill patients like sepsis seem related to immunomodulatory and anti-inflammatory effects, antibiotic transportation and endothelial stabilization. Albumin transports many drugs used in critically ill patients. Such binding to albumin is frequently lessened in critically ill patients with hypoalbuminemia. These changes could result in sub-optimal treatment. Albumin has immunomodulatory capacity by binding several bacterial products. Albumin also influences vascular integrity, contributing to the maintenance of the normal capillary permeability. Moreover, the albumin molecule encompasses several antioxidant properties, thereby significantly reducing re-oxygenation injury, which is especially important in sepsis. In fact, most studies of albumin administration are a combination of a degree of resuscitation with a degree of maintenance or supplementation of albumin. Expert commentary: The potential clinical benefits of the use of albumin in selected critically ill patients such as sepsis seem related to its immunomodulatory and anti-inflammatory effects, antioxidant properties, antibiotic transportation and endothelial stabilization. Additional studies are warranted to further elucidate the underlying physiologic and molecular rationale.

Detección precoz de la sepsis: adaptarse o morir / Early detection of sepsis: To adapt or to die

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Epidemiology of sepsis in Catalonia: analysis of incidence and outcomes in a European setting.

BACKGROUND: Up-to-date identification of local trends in sepsis incidence and outcomes is of considerable public health importance. The aim of our study was to estimate annual incidence rates and in-hospital mortality trends for hospitalized patients with sepsis in a European setting, while avoiding selection bias in relation to different complexity hospitals. METHODS: A large retrospective analysis of a 5-year period (2008-2012) was conducted of hospital discharge records obtained from the Catalan Health System (CatSalut) Minimum Basic Data Set for Acute-Care Hospitals (a mandatory population-based register of admissions to all public and private acute-care hospitals in Catalonia). Patients hospitalized with sepsis were detected on the basis of ICD-9-CM codes used to identify acute organ dysfunction and infectious processes. RESULTS: Of 4,761,726 discharges from all acute-care hospitals in Catalonia, 82,300 cases (1.72%) had sepsis diagnoses. Annual incidence was 212.7 per 100,000 inhabitants/year, rising from 167.2 in 2008 to 261.8 in 2012. Length of hospital stay fell from 18.4 to 15.3 days (p < .00001), representing a relative reduction of 17%. Hospital mortality fell from 23.7 to 19.7% (p < .0001), representing a relative reduction of 16.9%. These differences were confirmed in the multivariate analysis (adjusted for age group, sex, comorbidities, ICU admission, emergency admission, organ dysfunction, number of organ failures, sepsis source and bacteraemia). CONCLUSIONS: Sepsis incidence has risen in recent years, whereas mortality has fallen. Our findings confirm reports for other parts of the world, in the context of scarce administrative data on sepsis in Europe.

Oral Drugs Related with Muscle Wasting and Sarcopenia. A Review.

Sarcopenia is a geriatric syndrome characterized by progressive and generalized loss of skeletal muscle mass and function. Reported prevalence of this geriatric syndrome, differs depending on the definition, the population and the method used to identify sarcopenia. The causes of sarcopenia are multifactorial, and can include genetic influence, immobility or disuse, endocrine factors, inflammation and nutritional deficiencies. These disorders involve an imbalance between anabolic and catabolic pathways that rules muscle mass. Many drugs taken regularly for common conditions may interact with some mechanisms that can alter the balance between protein synthesis and degradation. This may lead to a harmful or a beneficial effect on muscle mass and strength. Widely prescribed drugs could play an important role during the time of onset and development of sarcopenia. In this paper, we reviewed the current understanding of how can drugs contribute positively or negatively on sarcopenia and muscle wasting. We decided to focus this review on oral common drugs, which are usually prescribed in older adults, leaving aside other drugs as hormone therapy.

Epidemiología de la sepsis grave adquirida en la comunidad. Estudio de base poblacional / Epidemiology of community-acquired severe sepsis. A population-based study

Antecedentes y objetivo: La mayoría de los estudios destinados a conocer la incidencia de sepsis grave poseen limitaciones metodológicas que condicionan resultados difícilmente comparables y poco aplicables a la hora de estimar los recursos necesarios. Nuestro objetivo es conocer la incidencia real de sepsis grave de adquisición comunitaria que requieren de UCI y analizar aspectos epidemiológicos relacionados. Pacientes y método: Estudio observacional prospectivo en una base poblacional de 180.000 adultos>15 años y un hospital general de 350 camas de hospitalización con 14 camas de UCI. Se registrarontodos los pacientes con sepsis grave o shock séptico adquiridos en la comunidad, con requerimiento de ingreso en UCI, durante un período de 9 años. Las variables recogidas fueron: edad, sexo, SAPS II, días de estancia en UCI, tipo de infección, microorganismo aislado y fallecimientos (durante su estancia en UCI). Se ha realizado un análisis estadístico bivariante y una regresión logística múltiple. Resultados: Se incluyeron 917 episodios en pacientes con una edad media de 65,2 años. El foco infeccioso más frecuente es el respiratorio (55,2%). El índice de gravedad SAPS II medio fue de 37,87 y la mortalidad de 19,7%. La incidencia anual media de las sepsis graves adquiridas en la comunidad ha sido de 51,54 episodios por 100.000 habitantes, precisando 1,97 camas de UCI/día. En el análisis multivariante el SAPS II y tener etiología conocida se muestran como factores de riesgo de mortalidad. Conclusiones: El estudio aporta datos epidemiológicos desde una perspectiva de base poblacional que contribuyen a cuantificar la necesidad de recursos asistenciales para atender la sepsis grave adquirida en la comunidad en nuestra área geográfica. La incidencia anual media es de 51,5 casos por 100.000 habitantes adultos, lo que supone la necesidad de disponer de 2 camas de UCI/día para atender a dicha población (AU)

Background and objective: Most studies aimed at getting to know the incidence of severe sepsis have methodological limitations which condition results that are difficult to compare and are inapplicable when it comes to estimating the necessary resources. Our objective is to evaluate the incidence and epidemiological aspects of community-acquired severe sepsis which require intensive care unit admission. Patients and method: Prospective observational population-based study in a population of 180,000 adults over 15 years old and a general hospital with 350 beds and 14 ICU beds. All episodes of community-acquired infection requiring admission to ICU due to severe sepsis were registered over a period of 9 years. The variables analyzed were: age, sex, SAPS II score, length of stay in ICU, type of infection, isolated microorganism, and deaths during their ICU admission. A statistical bivariate analysis and a multiple logistic regression were performed. Results: Nine hundred and seventeen episodes with an average age of 65.2 years. The most frequent infectious focus was pulmonary (55.2%). The average SAPS II severity score index was 37.87 and mortality 19.7%. The annual incidence was 51.54 episodes per 100,000 adult inhabitants, meaning 1.97 ICU beds per day. In the multivariate analysis, the SAPS II score and a known aetiology were demonstrated as mortality risk factors. Conclusions: This study brings us some epidemiological data from a population-based perspective which help us to care for patients better in our geographical area. The average annual incidence is 51.5 cases per 100,000 adult inhabitants which means that 2 ICU beds per day to attend this population (AU)