Recomendaciones para el tratamiento nutrometabólico especializado del paciente crítico: sepsis y shock séptico. Grupo de Trabajo de Metabolismo y Nutrición de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) / Recommendations for specialized nutritional-metabolic treatment of the critical patient: Sepsis and septic shock. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)

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Epidemiología y pronóstico tardío de la sepsis en ancianos / Epidemiology and long-term outcome of sepsis in elderly patients

OBJETIVOS: Examinar los datos epidemiológicos de pacientes sépticos mayores de 65 años con ingreso en UCI e identificar predictores de supervivencia a 2 años. DISEÑO: Estudio de cohortes prospectivo. PACIENTES: Criterios de sepsis al ingreso a UCI. Ámbito: UCI de 40 camas en un hospital terciario. RESULTADOS: El estudio incluyó a 237 pacientes ancianos (≥ 65 años de edad) y 281 controles (< 65 años), n = 518. Al menos una enfermedad subyacente estaba presente en el 70% de los pacientes ancianos en comparación con solo el 56,1% en controles (p < 0,01). Entre los mayores de 65 años se registró mayor prevalencia de enfermedades crónicas (diabetes, enfermedad obstructiva pulmonar crónica e insuficiencia cardíaca crónica), presentación más frecuente como shock séptico (52,3 vs. 42%; p < 0,05) y abdomen como foco (52 vs. 36%; p < 0,01). El 9% de los pacientes dados de alta hospitalaria falleció en el seguimiento posterior de 2 años, aumentando hasta el 20% en los ancianos. Los predictores independientes de mortalidad a 2 años en los pacientes ancianos fueron: insuficiencia cardíaca crónica (hazard ratio ajustada [aHR] 2,24; intervalo de confianza del 95% [IC 95%] 1,28-3,94; p < 0,01), insuficiencia renal aguda (aHR 3,64; IC 95% 2,10-6,23; p < 0,01), insuficiencia respiratoria aguda (aHR 3,67; IC 95%: 2,31-5,86; p < 0,01) y antibioterapia empírica inadecuada (aHR 2,19; IC 95% 1,32-3,62; p < 0,01).Conclusiones La sepsis en mayores de 65 años presenta diferencias relevantes en sus características demográficas y presentación clínica. Tras ajustar por potenciales factores de confusión, la terapia antimicrobiana empírica inadecuada se asoció con una reducción del doble en la supervivencia a los 2 años

OBJECTIVES: A study was made of the epidemiological data of sepsis requiring admission to the ICU in patients over 65 years of age, with an evaluation of independent predictors of survival at 2 years. DESIGN: A prospective cohort study was made. PATIENTS: Patients meeting criteria for sepsis upon admission to the ICU. SETTING: A 40-bed ICU in a tertiary hospital. RESULTS: The study group included 237 elderly patients (≥ 65 years of age) and 281 controls (< 65 years of age) (n = 518). At least one chronic comorbid condition was present in 70% of the elderly patients as compared to only 56.1% of patients under age 65 (P < .01). There were several epidemiological differences between the groups: the prevalence of chronic diseases (diabetes, chronic obstructive pulmonary disease, and chronic heart failure), presentation as septic shock (52.3% vs 42%; P < .05), and the abdomen as the source of sepsis (52% vs 36%; P < .01) were all more frequent in elderly patients. Nine percent of the global patients discharged from hospital died in the 2-year follow-up period, but this rate reached 20% among the elderly. Independent predictors of 2-year mortality in the elderly were: chronic heart failure (adjusted hazard ratio [aHR] 2.24, 95% confidence interval [CI 95%] 1.28-3.94; P < .01), acute renal failure (aHR 3.64, 95%CI 2.10-6.23; P < .01), acute respiratory failure (aHR 3.67, 95%CI 2.31-5.86; P < .01), and inappropriate empirical antimicrobial therapy (aHR 2.19, 95%CI 1.32-3.62; P < .01). CONCLUSIONS: Sepsis showed different demographic characteristics and clinical presentations in the elderly. In the aging cohort, after adjusting for potential confounders, inadequate empirical antimicrobial therapy was associated to a 2-fold decrease in survival at two years

De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock.

PURPOSES: We set out to assess the safety and the impact on in-hospital and 90-day mortality of antibiotic de-escalation in patients admitted to the ICU with severe sepsis or septic shock. METHODS: We carried out a prospective observational study enrolling patients admitted to the ICU with severe sepsis or septic shock. De-escalation was defined as discontinuation of an antimicrobial agent or change of antibiotic to one with a narrower spectrum once culture results were available. To control for confounding variables, we performed a conventional regression analysis and a propensity score (PS) adjusted-multivariable analysis. RESULTS: A total of 712 patients with severe sepsis or septic shock at ICU admission were treated empirically with broad-spectrum antibiotics. Of these, 628 were evaluated (84 died before cultures were available). De-escalation was applied in 219 patients (34.9%). By multivariate analysis, factors independently associated with in-hospital mortality were septic shock, SOFA score the day of culture results, and inadequate empirical antimicrobial therapy, whereas de-escalation therapy was a protective factor [Odds-Ratio (OR) 0.58; 95% confidence interval (CI) 0.36-0.93). Analysis of the 403 patients with adequate empirical therapy revealed that the factor associated with mortality was SOFA score on the day of culture results, whereas de-escalation therapy was a protective factor (OR 0.54; 95% CI 0.33-0.89). The PS-adjusted logistic regression models confirmed that de-escalation therapy was a protective factor in both analyses. De-escalation therapy was also a protective factor for 90-day mortality. CONCLUSIONS: De-escalation therapy for severe sepsis and septic shock is a safe strategy associated with a lower mortality. Efforts to increase the frequency of this strategy are fully justified.

[Epidemiology and long-term outcome of sepsis in elderly patients]. / Epidemiología y pronóstico tardío de la sepsis en ancianos.

OBJECTIVES: A study was made of the epidemiological data of sepsis requiring admission to the ICU in patients over 65 years of age, with an evaluation of independent predictors of survival at 2 years. DESIGN: A prospective cohort study was made. PATIENTS: Patients meeting criteria for sepsis upon admission to the ICU. SETTING: A 40-bed ICU in a tertiary hospital. RESULTS: The study group included 237 elderly patients (≥ 65 years of age) and 281 controls (<65 years of age) (n=518). At least one chronic comorbid condition was present in 70% of the elderly patients as compared to only 56.1% of patients under age 65 (P<.01). There were several epidemiological differences between the groups: the prevalence of chronic diseases (diabetes, chronic obstructive pulmonary disease, and chronic heart failure), presentation as septic shock (52.3% vs 42%; P<.05), and the abdomen as the source of sepsis (52% vs 36%; P<.01) were all more frequent in elderly patients. Nine percent of the global patients discharged from hospital died in the 2-year follow-up period, but this rate reached 20% among the elderly. Independent predictors of 2-year mortality in the elderly were: chronic heart failure (adjusted hazard ratio [aHR] 2.24, 95% confidence interval [CI 95%] 1.28-3.94; P<.01), acute renal failure (aHR 3.64, 95%CI 2.10-6.23; P<.01), acute respiratory failure (aHR 3.67, 95%CI 2.31-5.86; P<.01), and inappropriate empirical antimicrobial therapy (aHR 2.19, 95%CI 1.32-3.62; P<.01). CONCLUSIONS: Sepsis showed different demographic characteristics and clinical presentations in the elderly. In the aging cohort, after adjusting for potential confounders, inadequate empirical antimicrobial therapy was associated to a 2-fold decrease in survival at two years.

Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus SEMICYUC-SENPE: Critically-ill burnt patient / Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Paciente quemado crítico

The response to severe burns is characterized by hypermetabolism (the most hypermetabolic existing model of aggression) and hypercatabolism, with a high degree of destruction of the skeletal musculature. Metabolic disorders are most evident in the first two weeks after the burn, although they can be prolonged in direct relation to the complications that these patients develop. Nutritional-metabolic support is an essential part of the treatment of these patients and should be started early, preferentially through the enteral route, with parenteral nutrition as complementary support. Exact calculation of calorie-protein requirements in these patients is difficult, even when indirect calorimetry is used, due to the high loss of proteins and CO2through the skin. Specific pharmaco nutrients are indicated, with a high dose of micronutrients. The use of drugs or medications with anabolic effects is also sometimes indicated (AU)

La respuesta que se objetiva tras una agresión térmica grave se caracteriza por hipermetabolismo (es el modelo de agresión más hipermetabólica que existe) e hipercatabolismo, con una elevada destrucción de la musculatura esquelética. Los trastornos metabólicos son más evidentes en las 2 primeras semanas tras la quemadura, aunque pueden prolongarse en relación directa con las complicaciones aparecidas. El soporte nutro metabólico forma parte indiscutible del tratamiento de estos pacientes y debe ser precoz, utilizando preferentemente la vía enteral y la nutrición parenteral complementaria. Es dificultoso el cálculo exacto de los requerimientos calórico proteicos, aun empleando calorimetría indirecta, debido a las elevadas pérdidas cutáneas de proteínas y Co2. Cabe destacar la indicación de farmaconutrientes específicos, de dosis elevadas de micronutrientes y, en algunas situaciones, del empleo de medicaciones o fármacos con efectos anabólicos (AU)

Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus SEMICYUC-SENPE: Septic patient / Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Paciente séptico

Nutritional metabolic management, together with other treatment and support measures used, is one of the mainstays of the treatment of septic patients. Nutritional support should be started early, after initial life support measures, to avoid the consequences of malnutrition, to provide adequate nutritional intake and to prevent the development of secondary complications such as superinfection or multiorgan failure. As in other critically-ill patients, when the enteral route cannot be used to ensure calorie-protein requirements, the association of parenteral nutrition has been shown to be safe in this subgroup of patients. Studies evaluating the effect of specific pharmaconutrients in septic patients are scarce and are insufficient to allow recommendations to be made. To date, enteral diets with a mixture of substrates with distinct pharmaconutrient properties do not seem to be superior to standard diets in altering the course of sepsis, although equally there is no evidence that these diets are harmful. There is insufficient evidence to recommend the use of glutamine in septic patients receiving parenteral nutrition. However, given the good results and absence of glutamine-related adverse effects in the various studies performed in the general population of critically-ill patients, these patients could benefit from the use of this substance. Routine use of omega-3 fatty acids cannot be recommended until further evidence has been gathered, although the use of lipid emulsions with a high omega-6 fatty acid content should be avoided. Septic patients should receive an adequate supply of essential trace elements and vitamins. Further studies are required before the use of high-dose selenium can be recommended (AU)

El manejo metabólico nutricional constituye, junto al resto de medidas de tratamiento y soporte, uno de los pilares del tratamiento del paciente séptico. Debe iniciarse precozmente, tras la resucitación inicial, con el objetivo de evitar las consecuencias de la desnutrición, proveer el adecuado aporte de nutrientes y prevenir el desarrollo de complicaciones secundarias como la sobreinfección y el fracaso multiorgánico. Al igual que en el resto de pacientes críticos, cuando la ruta enteral es insuficiente para asegurar las necesidades caloricoproteicas, la asociación de nutrición parenteral ha demostrado ser segura en este subgrupo de pacientes. Los estudios que evalúan el efecto de farmaconutrientes específicos en el paciente séptico son escasos y no permiten establecer recomendaciones al respecto. Respecto a las dietas enterales con mezcla de sustratos con diferente capacidad farmaconutriente, su uso no parece aportar, hasta el momento actual, beneficios claros sobre la evolución de la sepsis respecto a las dietas estándar, aunque tampoco hay clara evidencia de que sean perjudiciales. A pesar de que no hay suficiente evidencia para recomendar el empleo de glutamina en el paciente séptico que recibe nutrición parenteral, este podría beneficiarse de su uso, dados los buenos resultados y la ausencia de efectos adversos atribuible a la glutamina en los diferentes estudios llevados a cabo en el conjunto de pacientes críticos. No se puede recomendar el empleo rutinario de ácidos grasos ω-3 hasta que dispongamos de mayor evidencia, aunque debe evitarse en estos pacientes el empleo de emulsiones lipídicas con alto contenido en ácidos grasos ω-6. El paciente séptico debe recibir un adecuado aporte de oligoelementos y vitaminas. El empleo de selenio a dosis altas requiere de mas estudios para poder recomendarlo (AU)

Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Introducción y metodología / Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): Introduction and methodology

El Grupo de Trabajo de Metabolismo y Nutrición de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) elaboró en 2005 unas recomendaciones para el soporte nutricional especializado del paciente crítico. Dado el tiempo transcurrido se consideró oportuno la revisión y actualización de dichas recomendaciones, planificándolas como un documento de consenso con la Sociedad Española de Nutrición Parenteral y Enteral (SENPE). El objetivo primario planteado para el establecimiento de las recomendaciones fue evaluar la mejor evidencia científica disponible para las indicaciones del soporte nutricional y metabólico especializado en el paciente crítico. Las recomendaciones se han realizado por un panel de expertos con amplia experiencia en el soporte nutricional y metabólico de los pacientes en situación crítica y se han llevado a cabo entre octubre de 2009 y marzo de 2011. Se analizaron metaanálisis, estudios clínicos aleatorizados y observacionales, revisiones sistemáticas y puestas al día referentes a pacientes críticos en edad adulta en MEDLINE de 1966 a 2010, EMBASE reviews de 1991 a 2010 y Cochrane Database of Systematic Reviews hasta 2010. Se seleccionaron los criterios medotodológicos establecidos en la Scottish Intercollegiate Guidelines Network y los de la Agency for Health Care Policy and Research, además de la escala de valoración de la calidad de Jadad, ajustando la gradación de la evidencia y la potencia de las recomendaciones siguiendo la propuesta del Grupo GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group). Se seleccionaron 16 situaciones patológicas que fueron desarrolladas, cada una, por grupos de 3 expertos, estableciéndose un sistema de feedback con los 5 miembros del Comité de Redacción y con la totalidad del Grupo de Trabajo. En diferentes reuniones se discutieron y consensuaron todas las discrepancias, poniéndose especial énfasis en el repaso de los niveles de evidencia y grados de recomendación establecidos. El Comité de Redacción procedió al ajuste final para su presentación y aprobación definitiva por todos los miembros del Grupo de Trabajo. Finalmente, el documento se presentó a los comités científicos de las dos sociedades participantes del consenso para su aprobación definitiva. Las presentes recomendaciones pretenden servir de guía para los clínicos con responsabilidades en el manejo y tratamiento de los pacientes críticos y para todos los especialistas interesados en el tratamiento nutricional del paciente hospitalizado (AU)

The Recommendations for Specialized Nutritional Support in Critically-Ill patients were drafted by the Metabolism and Nutrition Working Group of the Spanish Society of Intensive Care Medicine and Coronary Units (SEMICYUC) in 2005. Given the time elapsed since then, these recommendations have been reviewed and updated as a Consensus Document in collaboration with the Spanish Society of Parenteral and Enteral Nutrition (SENPE). The primary aim of these Recommendations was to evaluate the best available scientific evidence for the indications of specialized nutritional and metabolic support in critically-ill patients. The Recommendations have been formulated by an expert panel with broad experience in nutritional and metabolic support in critically-ill patients and were drafted between October 2009 and March 2011. The studies analyzed encompassed metaanalyses, randomized clinical trials, observational studies, systematic reviews and updates relating to critically-ill adults in MEDLINE from 1966 to 2010, EMBASE reviews from 1991 to 2010 and the Cochrane Database of Systematic Reviews up to 2010. The methodological criteria selected were those established in the Scottish Intercollegiate Guidelines Network and the Agency for Health Care policy and Research, as well as those of the Jadad Quality Scale. Adjustment for the level of evidence and grade of recommendation was performed following the proposal of the GRADE group (Grading of RecommendationsAssessment, Development and Evaluation Working Group). Sixteen pathological scenarios were selected and each of them was developed by groups of three experts. A feedback system was established with the five members of the Editorial Committee and with the entire Working Group. All discrepancies were discussed and consensus was reached over several meetings, with special emphasis placed on reviewing the levels of evidence and grades of recommendation. The Editorial Committee made the final adjustments before the document was approved by all the members of the Working Group. Finally, the document was submitted to the Scientiic Committees of the two Societies participating in the Consensus for final approval. The present Recommedations aim to serve as a guide for clinicians involved in the management and treatment of critically-ill patients and for any specialists interested in the nutritional treatment of hospitalized patients (AU)

Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Paciente quemado crítico / Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): Critically- burned patient

La respuesta que se objetiva tras una agresión térmica grave se caracteriza por hipermetabolismo (es el modelo de agresión más hipermetabólica que existe) e hipercatabolismo, con una elevada destrucción de la musculatura esquelética. Los trastornos metabólicos son más evidentes en las 2 primeras semanas tras la quemadura, aunque pueden prolongarse en relación directa con las complicaciones aparecidas. El soporte nutrometabólico forma parte indiscutible del tratamiento de estos pacientes y debe ser precoz, utilizando preferentemente la vía enteral y la nutrición parenteral complementaria. Es dificultoso el cálculo exacto de los requerimientos caloricoproteicos, aun empleando calorimetría indirecta, debido a las elevadas pérdidas cutáneas de proteínas y CO2. Cabe destacar la indicación de farmaconutrientes específicos, de dosis elevadas de micronutrientes y, en algunas situaciones, del empleo de medicaciones o fármacos con efectos anabólicos (AU)

The response to severe burns is characterized by hypermetabolism (the most hypermetabolic existing model of aggression) and hypercatabolism, with a high degree of destruction of the skeletal musculature. Metabolic disorders are most evident in the first two weeks after the burn, although they can be prolonged in direct relation to the complications that these patients develop. Nutritional-metabolic support is an essential part of the treatment of these patients and should be started early, preferentially through the enteral route, with parenteral nutrition as complementary support. Exact calculation of calorie-protein requirements in these patients is dificult, even when indirect calorimetry is used, due to the high loss of proteins and CO2 through the skin. Specific pharmaconutrients are indicated, with a high dose of micronutrients. The use of drugs or medications with anabolic effects is also sometimes indicated (AU)

Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Paciente séptico / Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): Patient with sepsis

El manejo metabólico nutricional constituye, junto al resto de medidas de tratamiento y soporte, uno de los pilares del tratamiento del paciente séptico. Debe iniciarse precozmente, tras la resucitación inicial, con el objetivo de evitar las consecuencias de la desnutrición, proveer el adecuado aporte de nutrientes y prevenir el desarrollo de complicaciones secundarias como la sobreinfección y el fracaso multiorgánico. Al igual que en el resto de pacientes críticos, cuando la ruta enteral es insuficiente para asegurar las necesidades caloricoproteicas, la asociación de nutrición parenteral ha demostrado ser segura en este subgrupo de pacientes. Los estudios que evalúan el efecto de farmaconutrientes específicos en el paciente séptico son escasos y no permiten establecer recomendaciones al respecto. Respecto a las dietas enterales con mezcla de sustratos con diferente capacidad farmaconutriente, su uso no parece aportar, hasta el momento actual, beneficios claros sobre la evolución de la sepsis respecto a las dietas estándar, aunque tampoco hay clara evidencia de que sean perjudiciales. A pesar de que no hay suficiente evidencia para recomendar el empleo de glutamina en el paciente séptico que recibe nutrición parenteral, éste podría beneficiarse de su uso, dados los buenos resultados y la ausencia de efectos adversos atribuible a la glutamina en los diferentes estudios llevados a cabo en el conjunto de pacientes críticos. No se puede recomendar el empleo rutinario de ácidos grasos w-3 hasta que dispongamos de mayor evidencia, aunque debe evitarse en estos pacientes el empleo de emulsiones lipídicas con alto contenido en ácidos grasos w-6. El paciente séptico debe recibir un adecuado aporte de oligoelementos y vitaminas. El empleo de selenio a dosis altas requiere de más estudios para poder recomendarlo (AU)

Nutritional metabolic management, together with other treatment and support measures used, is one of the mainstays of the treatment of septic patients. Nutritional support should be started early, after initial life support measures, to avoid the consequences of malnutrition, to provide adequate nutritional intake and to prevent the development of secondary complications such as superinfection or multiorgan failure. As in other critically-ill patients, when the enteral route cannot be used to ensure calorie-protein requirements, the association of parenteral nutrition has been shown to be safe in this subgroup of patients. Studies evaluating the effect of specific pharmaconutrients in septic patients are scarce and are insuficient to allow recommendations to be made. To date, enteral diet s with a mixture of substrat es with distinct pharmaconutrient properties do not seem to be superior to standard diets in altering the course of sepsis, although equally there is no evidence that these diets are harmful. There is insuficient evidence to recommend the use of glutamine in septic patients receiving parenteral nutrition. However, given the good results and absence of glutamine-related adverse effects in the various studies performed in the general population of critically-ill patients , these patients could benefit from the use of this substance. Routine use of omega-3 fatty acids cannot be recommended until further evidence has been gathered, although the use of lipid emulsions with a high omega-6 fatty acid content should be avoided. Septic patients should receive an adequate supply of essential trace elements and vitamins. Further studies are required before the use of high-dose selenium can be recommended (AU)

[Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): introduction and methodology]. / Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: introducción y metodología.

The Recommendations for Specialized Nutritional Support in Critically-Ill patients were drafted by the Metabolism and Nutrition Working Group of the Spanish Society of Intensive Care Medicine and Coronary Units (SEMICYUC) in 2005. Given the time elapsed since then, these recommendations have been reviewed and updated as a Consensus Document in collaboration with the Spanish Society of Parenteral and Enteral Nutrition (SENPE). The primary aim of these Recommendations was to evaluate the best available scientific evidence for the indications of specialized nutritional and metabolic support in critically-ill patients. The Recommendations have been formulated by an expert panel with broad experience in nutritional and metabolic support in critically-ill patients and were drafted between October 2009 and March 2011. The studies analyzed encompassed metaanalyses, randomized clinical trials, observational studies, systematic reviews and updates relating to critically-ill adults in MEDLINE from 1966 to 2010, EMBASE reviews from 1991 to 2010 and the Cochrane Database of Systematic Reviews up to 2010. The methodological criteria selected were those established in the Scottish Intercollegiate Guidelines Network and the Agency for Health Care policy and Research, as well as those of the Jadad Quality Scale. Adjustment for the level of evidence and grade of recommendation was performed following the proposal of the GRADE group (Grading of Recommendations Assessment, Development and Evaluation Working Group). Sixteen pathological scenarios were selected and each of them was developed by groups of three experts. A feedback system was established with the five members of the Editorial Committee and with the entire Working Group. All discrepancies were discussed and consensus was reached over several meetings, with special emphasis placed on reviewing the levels of evidence and grades of recommendation. The Editorial Committee made the final adjustments before the document was approved by all the members of the Working Group. Finally, the document was submitted to the Scientific Committees of the two Societies participating in the Consensus for final approval. The present Recommendations aim to serve as a guide for clinicians involved in the management and treatment of critically-ill patients and for any specialists interested in the nutritional treatment of hospitalized patients.

[Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): critically-burned patient]. / Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: paciente quemado crítico.

The response to severe burns is characterized by hypermetabolism (the most hypermetabolic existing model of aggression) and hypercatabolism, with a high degree of destruction of the skeletal musculature. Metabolic disorders are most evident in the first two weeks after the burn, although they can be prolonged in direct relation to the complications that these patients develop. Nutritional-metabolic support is an essential part of the treatment of these patients and should be started early, preferentially through the enteral route, with parenteral nutrition as complementary support. Exact calculation of calorie-protein requirements in these patients is difficult, even when indirect calorimetry is used, due to the high loss of proteins and CO(2) through the skin. Specific pharmaconutrients are indicated, with a high dose of micronutrients. The use of drugs or medications with anabolic effects is also sometimes indicated.

[Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): patient with sepsis]. / Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: paciente séptico.

Nutritional metabolic management, together with other treatment and support measures used, is one of the mainstays of the treatment of septic patients. Nutritional support should be started early, after initial life support measures, to avoid the consequences of malnutrition, to provide adequate nutritional intake and to prevent the development of secondary complications such as superinfection or multiorgan failure. As in other critically-ill patients, when the enteral route cannot be used to ensure calorie-protein requirements, the association of parenteral nutrition has been shown to be safe in this subgroup of patients. Studies evaluating the effect of specific pharmaconutrients in septic patients are scarce and are insufficient to allow recommendations to be made. To date, enteral diets with a mixture of substrates with distinct pharmaconutrient properties do not seem to be superior to standard diets in altering the course of sepsis, although equally there is no evidence that these diets are harmful. There is insufficient evidence to recommend the use of glutamine in septic patients receiving parenteral nutrition. However, given the good results and absence of glutamine-related adverse effects in the various studies performed in the general population of critically-ill patients, these patients could benefit from the use of this substance. Routine use of omega-3 fatty acids cannot be recommended until further evidence has been gathered, although the use of lipid emulsions with a high omega-6 fatty acid content should be avoided. Septic patients should receive an adequate supply of essential trace elements and vitamins. Further studies are required before the use of high-dose selenium can be recommended.

Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: critically-ill burnt patient.

The response to severe burns is characterized by hypermetabolism (the most hypermetabolic existing model of aggression) and hypercatabolism, with a high degree of destruction of the skeletal musculature. Metabolic disorders are most evident in the first two weeks after the burn, although they can be prolonged in direct relation to the complications that these patients develop. Nutritional-metabolic support is an essential part of the treatment of these patients and should be started early, preferentially through the enteral route, with parenteral nutrition as complementary support. Exact calculation of calorie-protein requirements in these patients is difficult, even when indirect calorimetry is used, due to the high loss of proteins and CO2 through the skin. Specific pharmaconutrients are indicated, with a high dose of micronutrients. The use of drugs or medications with anabolic effects is also sometimes indicated.

Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: septic patient.

Nutritional metabolic management, together with other treatment and support measures used, is one of the mainstays of the treatment of septic patients. Nutritional support should be started early, after initial life support measures, to avoid the consequences of malnutrition, to provide adequate nutritional intake and to prevent the development of secondary complications such as superinfection or multiorgan failure. As in other critically-ill patients, when the enteral route cannot be used to ensure calorie-protein requirements, the association of parenteral nutrition has been shown to be safe in this subgroup of patients. Studies evaluating the effect of specific pharmaconutrients in septic patients are scarce and are insufficient to allow recommendations to be made. To date, enteral diets with a mixture of substrates with distinct pharmaconutrient properties do not seem to be superior to standard diets in altering the course of sepsis, although equally there is no evidence that these diets are harmful. There is insufficient evidence to recommend the use of glutamine in septic patients receiving parenteral nutrition. However, given the good results and absence of glutamine-related adverse effects in the various studies performed in the general population of critically-ill patients, these patients could benefit from the use of this substance. Routine use of omega-3 fatty acids cannot be recommended until further evidence has been gathered, although the use of lipid emulsions with a high omega-6 fatty acid content should be avoided. Septic patients should receive an adequate supply of essential trace elements and vitamins. Further studies are required before the use of high-dose selenium can be recommended.

Superinfection during treatment of nosocomial infections with tigecycline.

We performed a retrospective and observational study of 51 patients treated with tigecycline, as the treatment for nosocomial infections due to multidrug-resistant microorganisms, to evaluate the superinfection rate and their etiologies. Superinfections were diagnosed in 12 (23.5%) patients (seven due to Pseudomonas aeruginosa, 13.7%) and one patient had P. aeruginosa colonization. Five patients with superinfection died (41.6%), three due to superinfections and two to underlying diseases. The superinfection rate observed during tigecycline treatment is higher than that previously reported. Pseudomonas aeruginosa is the most frequent agent, being the cause of 58.5% of all superinfections.

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

[IV Debate Forum of the SENPE: questions on nutrition research]. / IV Foro de Debate SENPE: problemática de la investigación en nutrición.

The IV Debate Forum of the SENPE values from a multidisciplinary and multi-professional perspective the questions on clinical research in nutrition in Spain, focusing on enteral nutrition due to the lack of legislation on this issue. The concluding remarks point out the SENPE commitment with promoting quality, education and facilitation of research, greater help to emergent groups, looking for financial support, and timely information on the several summons from public systems and reference centers

IV Foro de Debate SENPE: problemática de la investigación en nutrición / IV debate forum of the SENPE: questions on nutrition research

El IV Foro de Debate SENPE valora desde un punto de vista multidisciplinar y multiprofesional la problemática de la investigación clínica en nutrición en España centrándose, debido a la falta de legislación, en la nutrición enteral. Se concluye en el compromiso de la SENPE en la potenciación de la calidad, en la formación y facilitación de la investigación, en una mayor ayuda a los grupos investigadores emergentes, en la búsqueda de financiación y en una puntual información sobre las diferentes convocatorias de los sistemas públicos y sobre los centros de referencia

The IV Debate Forum of the SENPE values from a multidisciplinary and multi-professional perspective the questions on clinical research in nutrition in Spain, focusing on enteral nutrition due to the lack of legislation on this issue. The concluding remarks point out the SENPE commitment with promoting quality, education and facilitation of research, greater help to emergent groups, looking for financial support, and timely information on the several summons from public systems and reference centers

[Pharmacological treatment neuromuscular impairments in critically ill patients]. / Tratamiento farmacológico de las alteraciones neuromusculares en el paciente crítico.

The use of drugs for treating neuromuscular impairments that present in the patient admitted to the Intensive Care Unit is virtually inexistent. The use of intravenous immunoglobulins for managing polyneuropathy of the critically ill patient (PCIP) is supported by no evidence. More important is prophylactic therapy, as is the administration of insulin perfusion to prevent hyperglycemia that is associated to increased development of PCIP. New data suggest that the protective mechanism of this perfusion, which normalizes glucose levels, is achieved through the modulation of endothelial dysfunction and lowering levels of asymmetrical di-methyl arginine (ADMA). As for myopathy of the critically ill patient or conditions with prolonged neuromuscular blockade, treatment consists in avoiding the use of several drugs known to be associated with development of these conditions, such as muscle relaxants and aminoglycosides. In relation to acute flaccid paralysis -an infection caused by the Western Nile Virus, anecdotic cases have been reported of improvement with the use steroids or interferon, although routine management remains to be established.