Early metabolic support for critically ill trauma patients: A prospective randomized controlled trial.

BACKGROUND: There is a lack of consensus regarding the optimal nutritional support for trauma patients. We hypothesize that early postinjury metabolic support focusing on adequate protein would modify the metabolic signature and alter the inflammatory environment for critically ill trauma patients. METHODS: We conducted a prospective randomized controlled pilot trial for adult patients admitted to the surgical intensive care unit following traumatic injury. Patients were randomized to receive early metabolic support (EMS) (peripheral amino acid infusions) or standard of care (enteral nutrition as soon as feasible). Routine laboratory assessments, nitrogen balance, cytokines, and metabolomic analyses were assessed at baseline and day 5 after intervention. RESULTS: A total of 42 trauma patients were randomized into well-balanced groups with similar age (32 years), Injury Severity Score (25), and body mass index (27.4 kg/m2). Early metabolic support provided significantly more protein (1.43 g/kg vs. 0.35 g/kg; p < 0.0001) and more calories (12.6 kcal/kg vs. 7.5 g/kg; p = 0.0012) over the first 5 days as compared with the standard of care. Early metabolic support modified protein catabolism and synthesis as demonstrated by a larger median negative nitrogen balance (-16.3 g vs. -5.3 g; p = 0.03) and a unique metabolomic profile at day 5. The biochemical profile of patients who received EMS was defined by greater declines in circulating levels of stress hormone precursors and increased levels of amino acids. The inflammatory response following EMS resulted in a greater decrease in interleukin-1B (p = 0.02) and increase in soluble interleukin-6 receptor (p = 0.01) between baseline and day 5 as compared with the standard of care. The EMS group had a decreased length of stay (15 vs. 22 days) and decreased surgical intensive care unit length of stay (8 vs. 9 days); however, this disappeared after adjustment for Injury Severity Score in this small population. CONCLUSIONS: Early metabolic support with amino acid is safe, modifies metabolism, and may downregulate the inflammatory state associated with significant trauma, warranting a larger trial to assess for improved outcomes. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

[Nutrition in the prevention and healing of chronic wounds. Importance in improving the diabetic foot]. / La nutrición en la prevención y curación de heridas crónicas. Importancia en la mejora del pie diabético.

INTRODUCTION: Nutrition plays an essential role in chronic wound healing as extra nutrients are needed for tissue repair and to restore losses through wound exudate. Insufficient intake of energy, protein, antioxidants (vitamin C, A, and zinc) and vitamin D are common in patients with chronic wounds and have been linked to delayed wound healing and dehiscence. Other risk factors such as obesity, diabetes, advanced age, corticosteroid use, and dehydration can also reduce or impede the healing process, and nutritional screening is important to identify patients with malnutrition. Proteins, amino acids (arginine, glutamine and methionine), vitamins C and A, and zinc have been used as pharmacological nutrients in pressure ulcer healing; however, omega-3 fatty acids, although they appear to slow progression, do not show improved healing rates. In patients with diabetic foot, supplementation with vitamins D, C, A, and E, magnesium, zinc, omega-3 fatty acids, and probiotics reduces ulcer size and improves glycemic control, although they have not been associated with complete healing; however, supplementation with arginine, glutamine, and ß-hydroxy-ß-methylbutyrate does show wound healing, although further evidence is needed to confirm these results.

INTRODUCCIÓN: La nutrición tiene un papel esencial en la cicatrización de las heridas crónicas ya que se necesita un aporte extra de nutrientes en la reparación tisular y para restablecer las pérdidas originadas a través del exudado de la herida. El aporte insuficiente de energía, proteínas, antioxidantes (vitamina C, vitamina A y zinc) y vitamina D es frecuente en los pacientes con heridas crónicas y se ha relacionado con retrasos en la curación y dehiscencia de la herida. También otros factores de riesgo como la obesidad, la diabetes, la edad avanzada, el consumo de glucocorticoides y la deshidratación pueden disminuir o impedir el proceso de la cicatrización, siendo importante la realización de un cribado nutricional para identificar a los pacientes con desnutrición. Las proteínas, los aminoácidos (arginina, glutamina y metionina), las vitaminas C y A, y el zinc se han utilizado como nutrientes farmacológicos para la cicatrización de las úlceras por presión; sin embargo, los ácidos grasos omega-3, aunque parecen disminuir su progresión, no muestran mejores tasas de curación. En los pacientes con pie diabético, la suplementación con vitaminas D, C, A y E, magnesio, zinc y ácidos grasos omega-3, así como la administración de probióticos, reduce el tamaño de la úlcera y mejora el control glucémico, aunque no se han relacionado con una cicatrización completa; sin embargo, la suplementación con arginina, glutamina y ß-hidroxi-ß-metilbutirato logra la curación de la herida, aunque es necesaria una mayor evidencia que confirme estos resultados.

La nutrición en la prevención y curación de heridas crónicas. Importancia en la mejora del pie diabético / Nutrition in the prevention and healing of chronic wounds. Importance in improving the diabetic foot

La nutrición tiene un papel esencial en la cicatrización de las heridas crónicas ya que se necesita un aporte extra de nutrientes en la reparación tisular y para restablecer las pérdidas originadas a través del exudado de la herida. El aporte insuficiente de energía, proteínas, antioxidantes (vitamina C, vitamina A y zinc) y vitamina D es frecuente en los pacientes con heridas crónicas y se ha relacionado con retrasos en la curación y dehiscencia de la herida. También otros factores de riesgo como la obesidad, la diabetes, la edad avanzada, el consumo de glucocorticoides y la deshidratación pueden disminuir o impedir el proceso de la cicatrización, siendo importante la realización de un cribado nutricional para identificar a los pacientes con desnutrición. Las proteínas, los aminoácidos (arginina, glutamina y metionina), las vitaminas C y A, y el zinc se han utilizado como nutrientes farmacológicos para la cicatrización de las úlceras por presión; sin embargo, los ácidos grasos omega-3, aunque parecen disminuir su progresión, no muestran mejores tasas de curación. En los pacientes con pie diabético, la suplementación con vitaminas D, C, A y E, magnesio, zinc y ácidos grasos omega-3, así como la administración de probióticos, reduce el tamaño de la úlcera y mejora el control glucémico, aunque no se han relacionado con una cicatrización completa; sin embargo, la suplementación con arginina, glutamina y β-hidroxi-β-metilbutirato logra la curación de la herida, aunque es necesaria una mayor evidencia que confirme estos resultados. (AU)

Nutrition plays an essential role in chronic wound healing as extra nutrients are needed for tissue repair and to restore losses through wound exudate. Insufficient intake of energy, protein, antioxidants (vitamin C, A, and zinc) and vitamin D are common in patients with chronic wounds and have been linked to delayed wound healing and dehiscence. Other risk factors such as obesity, diabetes, advanced age, corticosteroid use, and dehydration can also reduce or impede the healing process, and nutritional screening is important to identify patients with malnutrition. Proteins, amino acids (arginine, glutamine and methionine), vitamins C and A, and zinc have been used as pharmacological nutrients in pressure ulcer healing; however, omega-3 fatty acids, although they appear to slow progression, do not show improved healing rates. In patients with diabetic foot, supplementation with vitamins D, C, A, and E, magnesium, zinc, omega-3 fatty acids, and probiotics reduces ulcer size and improves glycemic control, although they have not been associated with complete healing; however, supplementation with arginine, glutamine, and β-hydroxy-β-methylbutyrate does show wound healing, although further evidence is needed to confirm these results. (AU)

Reflecting on success in trauma research: experiences from the SGCNS and SIR studies.

The inclusion of British Service Personnel (SP) lacking capacity into research studies from the point of injury through to medium-term rehabilitation had not previously been undertaken until work to support operations in Afghanistan (2001-2014). The Surgeon General's Casualty Nutrition Study and the Steroids and Immunity from Injury through to Rehabilitation Study sought to address the nutrition, endocrine and immune responses in a military patient cohort. A fundamental part of research is to feedback to patients, their relatives and ward staff on data collection and outcomes, and how future research may be improved to better support both injured SP and trauma patients in the UK. This paper will provide an experiential view on the delivery, operations and infrastructure requirements that should be considered when developing military research at a role-3 facility, before, during and after a study.

Recomendaciones para el tratamiento nutrometabólico especializado del paciente crítico: paciente politraumatizado y paciente quemado crítico. Grupo de Trabajo de Metabolismo y Nutrición de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) / Recommendations for specialized nutritional-metabolic management of the critical patient: Special situations, polytraumatisms and critical burn patients. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)

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Analgesic Efficacy, Practicality and Safety of Inhaled Methoxyflurane Versus Standard Analgesic Treatment for Acute Trauma Pain in the Emergency Setting: A Randomised, Open-Label, Active-Controlled, Multicentre Trial in Italy (MEDITA).

INTRODUCTION: Inhaled low-dose methoxyflurane is approved in Europe for emergency relief of moderate-to-severe trauma-related pain in adults, but data versus active comparators are sparse. The phase IIIb Methoxyflurane in Emergency Department in ITAly (MEDITA) trial investigated the analgesic efficacy, practicality and safety of methoxyflurane versus standard analgesic treatment (SAT) for acute trauma pain. METHODS: This was a randomised, active-controlled, parallel-group, open-label trial conducted in 15 Italian emergency units. Adults with limb trauma and pain score ≥ 4 on numerical rating scale (NRS) were randomised 1:1 to inhaled methoxyflurane 3 mL or SAT [intravenously administered (IV) morphine 0.1 mg/kg for severe pain (NRS ≥ 7); IV paracetamol 1 g or IV ketoprofen 100 mg for moderate pain (NRS 4-6)]. The primary endpoint was overall change in visual analogue scale (VAS) pain intensity from baseline (time of randomisation) to 3, 5 and 10 min. Non-inferiority and superiority of methoxyflurane versus SAT were concluded if the upper 95% confidence interval (CI) for the treatment comparison (methoxyflurane-SAT) was less than 1 and less than 0, respectively. RESULTS: Between 8 February 2018 and 8 February 2019, 272 patients were randomised (136 per treatment group). A total of 270 patients (mean age 51 years; 49% male; 34% with severe pain; mean baseline VAS 67 mm) were treated and analysed for efficacy and safety. Superiority of methoxyflurane was demonstrated for moderate-to-severe pain (adjusted mean treatment difference - 5.94 mm; 95% CI - 8.83, - 3.06 mm), moderate pain (- 5.97 mm; 95% CI - 9.55, - 2.39 mm) and severe pain (- 5.54 mm; 95% CI - 10.49, - 0.59 mm). Median onset of pain relief was 9 min for methoxyflurane and 15 min for SAT. Practicality of methoxyflurane treatment was rated "Excellent", "Very Good" or "Good" by 90% of clinicians vs. 64% for SAT. Adverse events (all non-serious) were reported by 17% of methoxyflurane-treated patients and 3% of SAT-treated patients. CONCLUSION: Methoxyflurane provided superior pain relief to SAT in patients with moderate-to-severe trauma pain and may offer a simple, fast, effective non-opioid treatment option. TRIAL REGISTRATION: Trial registered with EudraCT (2017-001565-25) on 2 March 2018 and ClinicalTrials.gov (NCT03585374) on 13 July 2018. FUNDING: Mundipharma Pharmaceuticals S.r.l.

Factors affecting the caloric and protein intake over time in critically ill trauma patients.

BACKGROUND: Major trauma leads to increased nutritional requirements. However, little is known about the actual amount of calories and protein administered and the factors affecting the intake over time in critically ill trauma patients. METHODS: Prospective study including 100 trauma patients admitted to the Los Angeles County + University of Southern California Medical Center intensive care unit between March 2014 and October 2014. Inclusion criteria were age > 16 y, surgery at admission, and no oral nutrition. The caloric and protein intake was recorded, and requirements were calculated daily for 28 d. The nutritional intake and the impact of clinical factors on the intake over time were assessed using mixed model analysis. RESULTS: The caloric and protein intake significantly increased over time, but the median intake did not meet the median calculated requirements at any time. Multivariable analysis revealed a smaller increase of the nutritional intake over time in patients with an injury severity score > 45, whereas penetrating injury and laparotomy were associated with a higher increase of the intake. Body mass index scores ≥ 30 kg/m2, traumatic brain injury, and gastrointestinal tract injuries were associated with a smaller increase of the caloric intake over time. CONCLUSIONS: The median nutritional intake did not meet the median calculated requirements over time. A smaller increase of the nutritional intake over time was found in patients with a higher injury burden, whereas penetrating injury and laparotomy were associated with a higher increase of the intake. Higher body mass index scores, traumatic brain injury, and gastrointestinal tract injuries were associated with a smaller increase of the caloric intake over time. These clinical factors can help to adjust the nutritional support in critically ill trauma patients.

Screening in Trauma for Opioid Misuse Prevention (STOMP): study protocol for the development of an opioid risk screening tool for victims of injury.

BACKGROUND: Opioid addiction and overdose are epidemic in the U.S. Victims of traumatic injury are at greater than average risk for opioid misuse and related complications. Potential risk screens and preventive interventions in this clinical population remain under-investigated. The current project seeks to develop and pilot the implementation of a screening tool for opioid risk at American College of Surgeons (ACS) Level I and Level II trauma centers. METHODS: The project began with an online survey, which was sent to Wisconsin trauma center medical directors and trauma coordinators for the purpose of gathering information on current substance use screening practices. Next, a focus group of trauma center staff was convened to discuss barriers and facilitators to screening, resources available and needed to support trauma patients with opioid use disorders, and measurable clinical observations that could indicate a patient's potential risk for opioid misuse. Data from the surveys and focus group were combined to inform the data collection instruments that are currently being administered to patients recruited from the University of Wisconsin Hospital Trauma Inpatient and Orthopedic Surgery Services. Eligible and consenting patients complete standardized measures of socio-demographics, substance use history, opioid misuse risk, mental health, medical history, and injury and pain severity. Follow up visits at weeks 4, 12, and 24 after hospital discharge assess hypothesized risk factors for opioid addiction and opioid use disorder diagnosis. At the completion of patient data collection, a forward stepwise regression will identify factors of most significant risk of the development of opioid use disorder after traumatic injury. This modeling will inform the development of a novel opioid risk screening tool, which will undergo pilot implementation at 4 Wisconsin ACS Level I and Level II trauma centers, using an evidence-based implementation strategy with roots in systems engineering. DISCUSSION: Positive findings from the proposed work would lead to improved, standardized opioid risk screening practices among victims of traumatic injury. The ultimate goal of this and future work is to reduce the likelihood of opioid misuse, addiction, and related complications, such as overdose and death. Trial registration Clinicaltrials.gov registration number: NCT02861976. Date of registration: Feb 9, 2016.

Improving the quality of nutrition in pediatric trauma.

Purpose Nutrition plays a key role in the recovery of pediatric trauma patients. A catabolic state in trauma patients may hinder recovery and inadequate nutrition may increase morbidity, mortality and length of hospital stay. The purpose of this paper is to review the current nutrition support practices for pediatric trauma patients at McMaster Children's Hospital (MCH), describe patient demographics and identify areas to improve the quality of patient care. Design/methodology/approach A retrospective chart review was conducted on pediatric trauma patients (age<18 years) identified through the trauma registry of MCH. Pediatric trauma patients admitted from January 2010 to March 2014 with an Injury Severity Score (ISS)=12 and a hospitalization of =24 hours were included. Findings In total, 130 patients were included in this study, 61.1 percent male, median age ten years (range: 0-17 years) and median ISS of 17 (range: 12-50). Blunt trauma accounted for 97.7 percent of patients admitted and 73.3 percent had trauma team activation. In total, 93 patients (71.5 percent) had ICU stays. The median time to feed was 29 hours (interquartile range: 12.5-43 hours) from the time of admission. An increased hospital length of stay was associated with longer time to initiation of nutrition support, a higher ISS and greater number of surgeries ( p<0.05). Originality/value Local nutritional support practices for pediatric trauma patients correspond with recommended principles of early feeding and preferential enteral nutrition. Harmonization of paper-based and electronic data collection is recommended to ensure that prescribed nutritional support is being delivered and nutritional needs of pediatric trauma patients are being met.

Intestinal dysfunction in the critical trauma patients - An early and frequent event / Disfunción intestinal en los traumatizados críticos. Un suceso precoz y frecuente

Background: Small-bowel dysfunction exerts a relevant prognostic impact in the critically ill patients. Citrullinemia has been used in the evaluation of the intestinal function and it is considered an objective parameter of the functional enterocyte mass. Present study proposes to determine the intestinal dysfunction prevalence and the citrullinemia kinetic profi le in severe trauma patients and to investigate its correlation with severity indicators and clinical outcome. Methods: A prospective study including 23 critical trauma patients was performed. Aminoacidemias were quantified, by ion exchange chromatography, at the admission and at the first and third days. Severity and outcome parameters were registered. Results: In severe trauma patients, severe hypocitrullinemia (< 20 μmol/L) prevalence at admission was high (69.6%) and mean citrullinemia was low (19.5 ± 11.1 μmol/L). Baseline citrullinemia was inversely and significantly correlated with shock index (r = -55.1%, p = 0.008) and extent of invasive ventilation support (r = -42.7%, p = 0.042). Citrullinemia < 13.7 μmol/L at admission, observed in 17.4% of patients, was associated with higher shock index (1.27 ± 0.10 versus 0.75 ± 0.18, p = 0.0001) and longer duration of invasive ventilation support (20.3 ± 7 versus 11.2 ± 7.1 days, p = 0.029) and intensive care unit stay (22 ± 5.9 versus 12.2 ± 8.8 days, p = 0.048). A citrullinemia decrease in the first day after admittance superior to 12.7% constituted a significant predictive factor of in-hospital mortality (75 versus 14.3%, p = 0.044; odds ratio = 7.8; accuracy = 65.2%; specificity = 92.3%; negative predictive value = 85.7%] and lower actuarial survival (69.8 ± 41.6 versus 278.1 ± 37.4 days, p = 0.034). Conclusions: Those results confirm the high prevalence and the prognostic relevance of hypocitrullinemia, considered a biomarker of enterocyte dysfunction, in severe trauma patients (AU)

Introducción: la disfunción intestinal ejerce un importante impacto pronóstico en los pacientes críticamente enfermos. La citrulinemia se ha utilizado en la evaluación de la función intestinal. El presente estudio propone determinar la prevalencia de la disfunción intestinal y el perfil cinético de la citrulinemia en enfermos con trauma grave e investigar su correlación con la gravedad y la evolución clínica. Métodos: se realizó un estudio prospectivo incluyendo 23 pacientes traumatizados críticos. Las aminoacidemias se cuantificaron, mediante cromatografía de intercambio iónico, en la admisión y en el primer y tercer días. Se registraron los parámetros de gravedad y evolución clínica. Resultados: la prevalencia de la hipocitrulinemia grave (< 20 μmol/L) en la admisión fue alta (69,6%) y citrulinemia media fue baja (19,5 ± 11,1 μmol/L). La citrulinemia basal se correlacionó con el índice de choque (r = -55,1%, p = 0,008) y la duración de asistencia ventilatoria invasiva (r = -42,7%, p = 0,042). La citrulinemia < 13,7 μmol/L en la admisión se asoció con mayor índice de choque (1,27 ± 0,1 versus 0,75 ± 0,18, p = 0,0001) y mayor duración de ventilación invasiva (20,3 ± 7 versus 11,2 ± 7,1 días, p = 0,029) y hospitalización en la unidad de cuidados intensivos (22 ± 5,9 versus 12,2 ± 8,8 días, p = 0,048). La disminución de la citrulinemia en el primer día superior al 12,7% fue un factor predictor signifi cativo de mortalidad hospitalaria (75 versus 14,3%, p = 0,044; odds ratio = 7,8; precisión = 65,2%; especificidad = 92,3%; valor predictivo negativo = 85,7%] y menor supervivencia actuarial (69,8 ± 41,6 versus 278,1 ± 37,4 días, p = 0,034). Conclusiones: estos resultados confirman la alta prevalencia y la importancia pronóstica de la hipocitrulinemia, biomarcador de disfunción enterocitaria, en los pacientes con trauma severo (AU)

The Effect of Oral Medication on Wound Healing.

GENERAL PURPOSE: The purpose of this learning activity is to provide information about the effects of oral medications on wound healing. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Identify oral medications that aid in wound healing.2. Recognize oral medications that interfere with wound healing. ABSTRACT: Given the accelerated medical discoveries of recent decades, there is a surprising lack of oral medications that directly improve wound healing. Of the oral medications available, most target ancillary aspects of wound care such as pain management, infection mitigation, and nutrition. This article describes oral pharmacologic agents intended to build new tissue and aid in wound healing, as well as an introduction to oral medications that interfere with wound healing. This review will not discuss the pharmacology of pain management or treatment of infection, nor will it address nutritional supplements.

Nutrition in Wound Care Management: A Comprehensive Overview.

Wound care is a multidisciplinary specialty requiring many physiologic and immunologic processes as well as physical, social, and societal factors to achieve successful wound closure. Most wounds are treated with combinations of antimicrobials, protective barriers, and topical growth agents, including skin and biologic grafts.The role of nutrition in wound healing may be overlooked in the wound care patient. Like the specialty, it is often multifaceted, with many nutritional components playing a variety of roles in the wound healing process. Suboptimal nutrition can alter immune function, collagen synthesis, and wound tensile strength, all of which are essential in the wound healing process. It is also important to remember that not all wounds are equal: a burn is different from a diabetic foot ulcer, which is different from a pressure ulcer. Nonetheless, nutrition is a common denominator for all wound patients, and what is studied in 1 wound population is often relevant in another. Due to the complexities of monitoring and measuring both wound healing and dietary intake, randomized, controlled trials of wound care patients are difficult to conduct, and much of the data concerning nutrition in wound care relies on combined supplements. In summary, it appears that some nutrients are necessary only if deficient, whereas others may become conditionally essential and serve a therapeutic role. All of the nutrients discussed should be viewed as a component of a broader, complete diet. This article is a summary of wound healing and the roles of a variety of macronutrients and micronutrients in the process.

En la naturaleza está la respuesta: "Micronutrientes: las vitaminas, agentes terapéuticos en las heridas" / The answer is in nature: "micronutrients: the vitamins, therapeutic agents in wounds"

El estado nutricional ejerce un poder supremo sobre todos los procesos de la vida del ser humano, pero, ¿qué evidencia clínica actual tenemos del la implicación de las vitaminas, en el proceso de curación de las heridas?, ¿Se pueden usar como instrumentos naturales en la prevención y tratamiento de las heridas? Tras realizar numerosas búsquedas bibliográficas en las principales bases biomédicas, se ha obtenido como resultado pocos estudios dedicados a investigar en esta materia, con diseño metodológico precario y hallazgos controvertidos. Las vitaminas más estudiadas han sido la A, C, E y D, las menos estudiadas el complejo B y la K. Se investiga por igual en suplementación mixta como en el aporte exclusivo de una vitamina. En las heridas, el patrón mas trabajado ha sido las heridas crónicas y en concreto las UPP, además, los trabajos de investigación los orientan principalmente a intervenciones en prevención secundaria, dejando grietas en la investigación con heridas de otra etiología e intervenciones en prevención primaria. Actualmente, con los datos que disponemos, se puede afirmar con cierta seguridad que las vitaminas son instrumentos terapéuticos baratos y eficaces en la prevención y tratamiento de la herida, aunque se precisa más estudios y con mejor calidad metodológica que lo respalde. No debemos desistir y seguir profundizando y perfeccionando las lagunas existentes en esta materia. "Haciendo lo evidente, científico" (AU)

The nutritional state exercises a supreme power on over the processes of the life of the Human Being, but, "what clinical evidence do we have of the implication of vitamins, in the process of cure of the injuries, at present? Can they serve the purpose of natural instruments in prevention and treatment of the wounds?" After having numerous bibliographic searches in the main biomedical databases, it has been obtained as to result few studies dedicated to investigate in this matter, with design precarious methodological and controversial findings. The more studied vitamins have been the A, C, E and D, the least studied the complex B and the K. It is investigated equally in mixed supplementation as in the exclusive input of a vitamin. In the injuries the more worked pattern has been the chronic wounds and in short the pressure ulcers, besides, the research works orientate them principally to interventions in secondary prevention, leaving cracks in the investigation with wounds of another etiology and interventions in primary prevention. Now, with the data that we have, it is safe to say that vitamins are therapeutic cheap and efficacious instruments in prevention and treatment of the wound , although requires to more studies and with better quality methodological that backs it. We do not have to quit on and keep on deepening and perfecting the existing gaps in this matter". Making what's evident, scientist" (AU)

Negative pressure wound therapy in infants and children: a single-institution experience.

BACKGROUND: Information regarding the use of negative pressure wound therapy (NPWT) in the pediatric population is limited. Because of adverse outcomes in adult patients, the Food and Drug Administration issued a warning in 2011 about the use of NPWT in infants and children. METHODS: We performed an institutional review board-approved, single-institution, retrospective review of pediatric patients who had undergone NPWT from 2007-2011. We collected the types of wounds for which NPWT was initiated, the NPWT outcomes, and the complications encountered. RESULTS: The data from 290 consecutive patients were reviewed. Their average age was 9.3 y (range 12 d to 18 y), and their average weight was 46.5 kg (range 1.1-177). Of the wounds, 66% were classified as acute, 10% as chronic, and 24% as traumatic. The two most common indications were surgical wound dehiscence (n = 47) and skin grafting (n = 41). NPWT was used in 15 wounds containing surgical hardware, with 2 devices requiring eventual removal. NPWT was used for a median of 9 d per patient (two dressing changes). Complications occurred in 5 patients (1.7%). Documentation problems were noted in 44 patients. After NPWT, about one-third of the patients (n = 95 patients) were able to undergo delayed primary closure. CONCLUSIONS: NPWT is an effective adjunct in wound healing and closure in the pediatric population, with no mortality ascribed to NPWT. Also, the complication rates were low.

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

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

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

[Immunonutrition after trauma]. / Immunonutrition nach Trauma.

Immunonutrition may be superior to standard clinical nutrition in specific clinical situations. After severe trauma, an enteral immuno-enhancing diet, enriched with arginine, omega-3 fatty acids, and nucleotides, decreases infectious complications. During acute respiratory distress syndrome, a continuous enteral diet with high-dose omega-3 fatty acids, gamma-linolenic acid, and antioxidants improved clinical outcome. Glutamine should be administered enterally or parenterally whenever total parenteral nutrition is indicated.