Publique en esta revista
Información de la revista
Vol. 35. Núm. S1.Noviembre 2011
Recomendaciones para el Soporte Nutricional del paciente crítico
Páginas 1-85
Compartir
Compartir
Descargar PDF
Más opciones de artículo
Vol. 35. Núm. S1.Noviembre 2011
Recomendaciones para el Soporte Nutricional del paciente crítico
Páginas 1-85
DOI: 10.1016/S0210-5691(11)70015-8
Acceso a texto completo
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
Visitas
2904
C. Ortiz Leybaa,??
Autor para correspondencia
carlos.ortiz.sspa@juntadeandalucia.es

Autor para correspondencia.
, J.C. Montejo Gonzálezb, C. Vaquerizo Alonsoc
a Hospital Universitario Virgen del Rocío, Sevilla, España
b Hospital Universitario 12 de Octubre, Madrid, España
c Hospital Universitario de Fuenlabrada, Madrid, España
Este artículo ha recibido
2904
Visitas
Información del artículo
Resumen

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 est ablecer 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 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 más estudios para poder recomendarlo.

Palabras clave:
Sepsis
Shock séptico
Glutamina
Arginina
Abstract

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.

Keywords:
Sepsis
Septic shock
Glutamine
Arginine
El Texto completo solo está disponible en PDF
Bibliografía
[1.]
R.P. Dellinger,M.M. Levy,J.M. Carlet,J. Bion,M.M. Parker,R. Jaeschke
Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008
[2.]
A. García de Lorenzo,C. Ortiz Leyba,M. Planas,J.C. Montejo,R. Núñez,F.J. Ordóñez
Parenteral administration of different amounts of branch-chain amino acids in septic patients: clinical and metabolic aspects
Crit Care Med, 25 (1997), pp. 418-424
[3.]
C. Galbán,J.C. Montejo,A. Mesejo,P. Marco,S. Celaya,J.M. Sánchez-Segura
An immune-enhancing enteral diet reduces mortality rate and episodes of bacteremia in septic intensive care unit patients
Crit Care Med, 28 (2000), pp. 643-648
[4.]
A. Pontes-Arruda,A.M. Aragao,J.D. Albuquerque
Effects of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in mechanically ventilated patients with severe sepsis and septic shock
Crit Care Med, 34 (2006), pp. 2325-2333 http://dx.doi.org/10.1097/01.CCM.0000234033.65657.B6
[5.]
C.D. Schunn,J.M. Daly
Small bowel necrosis associated with postoperative jejunal tube feeding
J Am Coll Surg, 180 (1995), pp. 410-416
[6.]
C. Frey,J. Takala,L. Krahenbuhl
Non-occlusive small bowel necrosis during gastric tube feeding: A case report
Intensive Care Med, 27 (2001), pp. 1422-1425
[7.]
S.A. McClave,W.K. Chang
Feeding the hypotensive patient: does enteral feeding precipitate or protect against ischemic bowel?
Nutr Clin Pract, 18 (2003), pp. 279-284
[8.]
G. Elke,D. Schädler,C. Engel,H. Bogatsch,I. Frerichs,M. Ragaller
German Competence Network Sepsis (SepNet) Current practice in nutritional support and its association with mortality in septic patients--results from a national, prospective, multicenter study
Crit Care Med, 36 (2008), pp. 1762-1767 http://dx.doi.org/10.1097/CCM.0b013e318174dcf0
[9.]
C. Ortiz-Leyba,J. Garnacho-Montero,A.C. Domínguez
Sepsis, mortality, and parenteral nutrition: the risk of dualism on nutritional support
[10.]
G. Bertolini,G. Lapichino,D. Radrizzani,R. Facchini,B. Simini,P. Bruzzone
Early enteral immunonutrition in patients with severe sepsis: results of an interim analysis of a randomized multicentre clinical trial
Intensive Care Med, 29 (2003), pp. 834-840 http://dx.doi.org/10.1007/s00134-003-1711-5
[11.]
H. Kieft,A.N. Roos,J.D. Van Drunen,A.J. Bindels,J.G. Bindels,Z. Hofman
Clinical outcome of immunonutrition in a heterogeneous intensive care population
Intensive Care Med, 31 (2005), pp. 524-532 http://dx.doi.org/10.1007/s00134-005-2564-x
[12.]
D.K. Heyland,F. Novak,J.W. Drover,M. Jain,X. Su,U.L. Suchner
Should immunonutrition become routine in critically ill patients: a systematic review of the evidence
JAMA, 286 (2001), pp. 944-953
[13.]
J.C. Montejo,A. Zarazaga,J. López-Martínez,G. Urrutia,M. Roqué,A.L. Blesa
Spanish Society of Intensive Care Medicine and Coronary Units Immunonutrition in the intensive care unit. A systematic review and consensus statement
Clin Nutr, 22 (2003), pp. 221-233
[14.]
P.E. Marik,G.P. Zaloga
Immunonutrition in critically ill patients: a systematic review and analysis of the literature
Intensive Care Med, 34 (2008), pp. 1980-1990 http://dx.doi.org/10.1007/s00134-008-1213-6
[15.]
T. Grau Carmona,V. Morán García,A. García de Lorenzo,G. Heras de la Calle,B. Quesada Bellver,J. López Martínez
Effect of an enteral diet enriched with eicosapentaenoic acid, gammalinolenic acid and anti-oxidants on the outcome of mechanically ventilated, critically ill, septic patients
Clin Nutr, (2011),
[16.]
Y.C. Luiking,M. Poeze,M. Hendrikx,P. Breedveld,C.H.C. Dejong,P.W. De Feiter
Continuous l-arginine infusion does not deteriorate the hemodynamic condition in patients with severe sepsis [abstract]
Clin Nutr, 24 (2005), pp. 612-613
[17.]
Y.C. Luiking,M. Poeze,J. Preiser
L-arginine infusion in severely septic patients does not enhance protein nitrosylation or haemodynamic instability
e-SPEN, 1 (2006), pp. 14-15
[18.]
J.A. Lorente,L. Landín,R. De Pablo,E. Renes,D. Liste
L-arginine pathway in the sepsis syndrome
Crit Care Med, 21 (1993), pp. 1287-1295
[19.]
S. Villalpando,J. Gopal,A. Balasubramanyam,V.P. Bandi,K. Guntupalli,F. Jahoor
In vivo arginine production and intravascular nitric oxide synthesis in hypotensive sepsis
Am J Clin Nutr, 84 (2006), pp. 197-203
[20.]
Y.C. Luiking,M. Poeze,G. Ramsay,N.E.P. Deutz
Reduced citrulline production in sepsis is related to diminished de novo arginine and nitric oxide production
Am J Clin Nutr, 89 (2009), pp. 142-152 http://dx.doi.org/10.3945/ajcn.2007.25765
[21.]
P. Dechelotte,M. Hasselmann,L. Cynober,B. Allaouchiche,M. Coëffier,B. Hecketsweiler
L-alanyl-L-glutamine dipeptide–supplemented total parenteral nutrition reduces infectious complications and glucose intolerance in critically ill patients: The French controlled, randomized, double-blind, multicenter study
Crit Care Med, 24 (2006), pp. 598-604
[22.]
T. Grau,A. Bonet,E. Miñambres,L. Piñeiro,J.A. Irles,A. Robles,the Metabolism, Nutrition Working Group, SEMICYUC, Spain
The effect of l-alanyl-l-glutamine dipeptide supplemented total parenteral nutrition on infectious morbidity and insulin sensitivity in critically ill patients
Crit Care Med, 39 (2011), pp. 1263-1268 http://dx.doi.org/10.1097/CCM.0b013e31820eb774
[23.]
T.R. Ziegler,L.G. Ogden,K.D. Singleton,M. Luo,C. Fernández-Estívariz,D.P. Griffith
Parenteral glutamine increases serum heat shock protein 70 in critically ill patients
Intensive Care Med, 31 (2005), pp. 1079-1086 http://dx.doi.org/10.1007/s00134-005-2690-5
[24.]
R.J. Beale,T. Sherry,K. Lei,L. Campbell-Stephen,J. McCook,J. Smith
Early enteral supplementation with key pharmaconutrients improves Sequential Organ Failure Assessment score in critically ill patients with sepsis: outcome of a randomized, controlled, double-blind trial
[25.]
A.R. Heller,S. Rossler,R.J. Litz,S.N. Stehr,S.C. Heller,R. Koch
Omega-3 fatty acids improve the diagnosis-related clinical outcome
[26.]
S. Friesecke,C. Lotze,J. Kohler,A. Heinrich,S.B. Felix,P. Abel
Fish oil supplementation in the parenteral nutrition of critically ill medical patients: a randomised controlled trial
Intensive Care Med, 34 (2008), pp. 1411-1420 http://dx.doi.org/10.1007/s00134-008-1072-1
[27.]
V.M. Barbosa,E.A. Miles,C. Calhau,E. Lafuente,P.C. Calder
Effects of a fish oil containing lipid emulsion on plasma phospholipid fatty acids, inflammatory markers, and clinical outcomes in septic patients: a randomized, controlled clinical trial
Critical Care, 14 (2010), pp. R5 http://dx.doi.org/10.1186/cc8844
[28.]
M.M. Berger,R.L. Chioléro
Antioxidant supplementation in sepsis and systemic inflammatory response syndrome
Crit Care Med, 35 (2007), pp. S584-S590 http://dx.doi.org/10.1097/01.CCM.0000279189.81529.C4
[29.]
M.W. Angstwurm,L. Engelmann,T. Zimmermann,C. Lehmann,C.H. Spes,P. Abel
Selenium in Intensive Care (SIC): Results of a prospective randomized, placebo-controlled, multiple-center study in patients with severe systemic inflammatory response syndrome, sepsis, and septic shock
[30.]
X. Forceville,B. Laviolle,D. Annane,D. Vitoux,G. Bleichner,J.M. Korach
Effects of high doses of selenium, as sodium selenite, in septic shock: a placebo-controlled, randomized, double-blind, phase II study
Crit Care., 11 (2007), pp. R73 http://dx.doi.org/10.1186/cc5960
[31.]
Trial of Glutamine and Antioxidant Supplementation in Critically Ill Patients (REDOXS) [consultado 13-2-2011]. Disponible en: http://clinicaltrials.gov/ct2/show/NCT00133978?term=REDOX&rank=17

SEMICYUC: Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias. SENPE: Sociedad Española de Nutrición Parenteral y Enteral.

Copyright © 2011. Sociedad Española de Medicina Intensiva, Critica y Unidades Coronarias (SEMICYUC) and Elsevier España, S.L.
Idiomas
Medicina Intensiva

Suscríbase al Newsletter

Opciones de artículo
Herramientas
es en
Política de cookies Cookies policy
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here.
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?