Nutrición, cirugía y programas de rehabilitación multimodal

Hace algo más de una década que comenzaron a generalizarse, principalmente en pacientes programados para cirugía de colon y recto, los programas de rehabilitación multimodal (RHMM), también conocidos como programas “fast track” o “ERAS” (del inglés “Enhanced Recovery After Surgery”), basados en las ideas originarias de Henrik Kehlet sobre la posibilidad de disminuir el estrés quirúrgico aprovechando los avances de las técnicas anestésicas..

Factores predictores de hipertrigliceridemia en pacientes hospitalizados con nutrición parenteral total

Introducción:la nutrición parenteral total (NPT) es una modalidad de soporte nutricional indicada en aquellas situaciones donde el enfermo no puede cubrir sus requerimientos nutricionales por vía enteral. A pesar de ser una terapia segura y efi caz, no está exenta de complicaciones, entre las que cabe destacar, por su frecuencia, la hipertrigliceridemia. La etiología de esta complicación metabólica es compleja y multifactorial. Objetivos: el objetivo de este trabajo fue determinar los factores de riesgo asociados al desarrollo de hipertrigliceridemia en pacientes adultos hospitalizados no críticos que reciben NPT a corto plazo y evaluar el efecto que una emulsión lipídica enriquecida en ácidos grasos poliinsaturados omega-3 ejerce sobre esta complicación metabólica. Material y métodos: estudio observacional retrospectivo de cohortes donde se ha incluido a pacientes hospitalizados adultos no críticos que precisaron NPT durante un periodo superior a siete días. Se consideró la presencia de hipertrigliceridemia cuando los niveles plasmáticos de triglicéridos fueron superiores a 200 mg/dl. Las emulsiones lipídicas empleadas fueron una mezcla al 50% de triglicéridos de cadena larga (LCT) y de cadena media (MCT) o una combinación al 40% LCT/50% MCT/10% omega-3. Se recogieron variables clínicas, nutricionales y bioquímicas. Las determinaciones analíticas se realizaron antes del comienzo de la NPT y semanalmente hasta su retirada. Los factores predictores de la aparición de hipertrigliceridemia fueron identifi cados mediante modelos de regresión logística multivariante. Resultados: fueron incluidos 101 pacientes (61, 4% varones), de los cuales el 33% desarrolló hipertrigliceridemia. En el análisis multivariante los factores de riesgo independientes asociados a la presencia de hipertrigliceridemia fueron los niveles plasmáticos iniciales de triglicéridos, el índice de masa corporal (IMC) y un aporte de glucosa en la NPT superior a 3, 1 g/kg/día. La infusión de una emulsión lipídica enriquecida con ácidos grasos omega-3 se asoció con un descenso no signifi cativo del riesgo de aparición de hipertrigliceridemia. Conclusión: la situación clínica metabólica del paciente y la dosis de hidratos de carbono en la NPT resultan fundamentales en el desarrollo de la hipertrigliceridemia relacionada con la NPT. La administración de una emulsión lipídica enriquecida en ácidos grasos omega-3 es segura, aunque no se asoció a un efecto protector signifi cativo sobre el riesgo de aparición de esta complicación metabólica. Introduction: Total parenteral nutrition (TPN) is a kind of nutritional support indicated for patients whose clinical situation makes it impossible to cover their nutritional requirements enterally. Despite the fact that TPN is a safe and effective therapy, some complications have been described. One of the most frequent is hypertriglyceridemia. The etiology of this metabolic complication is complex and multifactorial. Objetive: The aim of this work was to determine risk factors associated with the development of hypertrilgyceridemia in adult inhospital non critical patients who carry TPN for a short term. A secondary aim was to evaluate the effect that a lipid emulsion fortified with omega-3 poliunsaturated fatty acids causes on this metabolic complication. Material and methods: This is an observational retrospective cohort study, in which adult inhospital non critical patients have been included. Only those who needed TPN during more than seven days were included. Hypertriglyceridemia was defined as plasma triglycerides levels higher than 200 mg/dl. The lipid emulsions were composed whether by a combination of 50% long-chain (LCT) and medium-chain (MCT) triglycerides or 40% LCT/50% MCT/10% omega-3. Clinical, nutritonal and biochemical parameters were included. Analitical samples were obtained before starting TPN, and weekly until withdrawal. Multivariate logistic regression analysis was used to identify predictive factors of the appearance of hypertriglyceridemia. Results: One hundred and one patients were included (61.4% male). Thirty-three per cent of them developed hypertriglyceridemia. In the multivariate analysis the independent risk factors associated with the presence of hypertriglyceridemia were the initial plasmatic triglycerides levels, the body mass index (BMI) and an input of glucose in the TPN higher than 3.1 g/kg/day. The infusion of a lipid emulsion fortified with 3-omega fatty acids was associated with a nonsignificant reduction of the risk of appearance of hypertriglyceridemia. Conclusion: The patient’s clinical metabolic situation, as well as the load of carbohydrates in the TPN are essential for the development of the TPN-associated hypertriglyceridemia. The administration of a lipid emulsion fortified with omega-3 fatty acids is safe, even though it was not associated with a significant protective effect over the risk of appearance of this metabolic complication

Regular insulin added to total parenteral nutrition vs subcutaneous glargine in non-critically ill diabetic inpatients, a multicenter randomized clinical trial: INSUPAR trial

Background: There is no established insulin regimen in T2DM patients receiving parenteral nutrition. Aims: To compare the effectiveness (metabolic control) and safety of two insulin regimens in patients with diabetes receiving TPN. Design: Prospective, open-label, multicenter, clinical trial on adult inpatients with type 2 diabetes on a non-critical setting with indication for TPN. Patients were randomized on one of these two regimens: 100% of RI on TPN or 50% of Regular insulin added to TPN bag and 50% subcutaneous Gl. Data were analyzed according to intention-to-treat principle. Results: 81 patients were on RI and 80 on GI. No differences were observed in neither average total daily dose of insulin, programmed or correction, nor in capillary mean blood glucose during TPN infusion (165.3 +/- 35.4 in RI vs 172.5 +/- 43.6 mg/dL in GI; p = 0.25). Mean capillary glucose was significantly lower in the GI group within two days after TPN interruption (160.3 +/- 45.1 in RI vs 141.7 +/- 43.8 mg/dL in GI; p = 0.024). The percentage of capillary glucose above 180 mg/dL was similar in both groups. The rate of capillary glucose <= 70 mg/dL, the number of hypoglycemic episodes per 100 days of TPN, and the percentage of patients with non-severe hypoglycemia were significantly higher on GI group. No severe hypoglycemia was detected. No differences were observed in length of stay, infectious complications, or hospital mortality. Conclusion: Effectiveness of both regimens was similar. GI group achieved better metabolic control after TPN interruption but non-severe hypoglycemia rate was higher in the GI group. (C) 2019 The Author(s). Published by Elsevier Ltd

Frinoderma secundario a déficit de vitamina A en un paciente con derivación biliopancreática Phrynoderma secondary to vitamin A deficiency in a patient with biliopancreatic diversion

La derivación biliopancreática (DBP) es una técnica bariátrica de predominio malabsortivo que puede dar lugar a la aparición de varias complicaciones nutricionales entre la que cabe destacar la deficiencia de vitaminas liposolubles. La suplementación rutinaria con vitaminas y oligoelementos y un estrecho seguimiento a largo plazo reducen estos riesgos nutricionales. La vitamina A esta implicada en la fisiología de la visión, la diferenciación de células epiteliales, el crecimiento y la embriogénesis. Han sido descritos varios casos de complicaciones oftalmológicas y fetales asociados a una deficiencia de vitamina A en pacientes sometidos a DBP. Pocos datos existen en la literatura acerca de las manifestaciones dermatológicas que pueden ocurrir en este tipo de pacientes. El frinoderma es un tipo de hiperqueratosis folicular localizada en las áreas de extensión de las extremidades cuya principal etiología es la deficiencia de vitamina A. Describimos un excepcional caso de afectación cutánea y oftalmológica severa en un paciente al que se le había practicado ua DBP con mala adherencia al tratamiento y seguimiento postoperatorio. Nuestro paciente presentaba de forma simultánea las lesiones cutáneas características de frinoderma junto con nictalopía y xeroftalmia en el contexto de unos niveles plasmáticos descendidos de vitamina A. El tratamiento con altas dosis de vitamina A consiguió la resolución de ambos procesos. Revisamos y discutimos la relación existente entre frinoderma, malnutrición y deficiencia de vitamina A.Biliopancreatic diversion (BPD) is a malabsorptivebariatric procedure can lead to the development of several nutritional complications, including fat-soluble vitamins deficiencies. Routine supplementation with vitamins and trace elements and a close follow-up long-term can prevent these nutritional risks. Vitamin A participates in ocular metabolism, epithelial differentiation, growth, and embryogenesis. Have been described several cases of ophthalmological and fetal complications associated with vitamin A deficiency in patients who have undergone BPD. Few information exists in literature about dermatologic manifestations that may occur in these patients. Phrynoderma is a type of follicular hyperkeratosis located on the extensor surfaces of the extremities whose main cause is vitamin A deficiency. We report an exceptional case of severe cutaneous and ocular complications in a patient who had undergone BPD with poor adherence to treatment and postoperative follow-up. Our patient presented simultaneously the characteristic skin lesions of phrynoderma with nytalopia and xerophthalmia in a setting of low serum levels of vitamin A. Treatment with high doses vitamin A obtained the resolution of both processes. We review and discuss the relationship between phrynoderma, malnutrition and vitamin A deficiency

Effects of Immunonutrition on Cancer Patients Undergoing Surgery: A Scoping Review

Introduction: There is a large body of evidence about immunonutrition formulas; however, there are still doubts about their usefulness in routine clinical practice as compared with standard formulas. In the age of personalized medicine, new studies appear every year regarding several types of patients; therefore, an updated point of view on these formulas is necessary. Methods: The Embase database was searched from 2016 to 14 March 2022. Our criteria were articles published in English and Spanish. The evidence quality was evaluated using GRADEpro, and the review was developed according to the PRISMA statement. Results: In this review, a total of 65 unique records were retrieved; however, 36 articles did not meet the inclusion criteria and were thus excluded. In total, 29 articles were included in the final analysis. In the last few years, many meta-analyses have attempted to identify additional existing studies of surgical patients with certain pathologies, mainly oncological patients. Immunonutrition prior to oncological surgery was shown to cause a decrease in inflammatory markers in most of the studies, and the main clinical events that changed were the infectious complications after surgery. The length of stay and mortality data are controversial due to the specific risk factors associated with these events. Conclusions: The use of immunonutrition in patients who have undergone oncological surgery decreases the levels of inflammatory markers and infectious postoperative complications in almost all localizations. However, more studies are needed to assess the use of immunonutrition based on Enhanced Recovery After Surgery (ERAS) protocols

Regular insulin added to total parenteral nutrition vs subcutaneous glargine in non-critically ill diabetic inpatients, a multicenter randomized clinical trial: INSUPAR trial.

There is no established insulin regimen in T2DM patients receiving parenteral nutrition. To compare the effectiveness (metabolic control) and safety of two insulin regimens in patients with diabetes receiving TPN. Prospective, open-label, multicenter, clinical trial on adult inpatients with type 2 diabetes on a non-critical setting with indication for TPN. Patients were randomized on one of these two regimens: 100% of RI on TPN or 50% of Regular insulin added to TPN bag and 50% subcutaneous GI. Data were analyzed according to intention-to-treat principle. 81 patients were on RI and 80 on GI. No differences were observed in neither average total daily dose of insulin, programmed or correction, nor in capillary mean blood glucose during TPN infusion (165.3 ± 35.4 in RI vs 172.5 ± 43.6 mg/dL in GI; p = 0.25). Mean capillary glucose was significantly lower in the GI group within two days after TPN interruption (160.3 ± 45.1 in RI vs 141.7 ± 43.8 mg/dL in GI; p = 0.024). The percentage of capillary glucose above 180 mg/dL was similar in both groups. The rate of capillary glucose ≤70 mg/dL, the number of hypoglycemic episodes per 100 days of TPN, and the percentage of patients with non-severe hypoglycemia were significantly higher on GI group. No severe hypoglycemia was detected. No differences were observed in length of stay, infectious complications, or hospital mortality. Effectiveness of both regimens was similar. GI group achieved better metabolic control after TPN interruption but non-severe hypoglycemia rate was higher in the GI group. This trial is registered at clinicaltrials.gov as NCT02706119