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Vol. 35. Núm. S1.
Recomendaciones para el Soporte Nutricional del paciente crítico
Páginas 57-62 (Noviembre 2011)
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Vol. 35. Núm. S1.
Recomendaciones para el Soporte Nutricional del paciente crítico
Páginas 57-62 (Noviembre 2011)
Acceso a texto completo
Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Paciente obeso
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): Obese patient
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...
A. Mesejoa,??
Autor para correspondencia
mesejo_alf@gva.es

Autor para correspondencia.
, C. Sánchez Álvarezb, J.A. Arboleda Sánchezc
a Hospital Clínico Universitario, Valencia, España
b Hospital General Universitario Reina Sofía, Murcia, España
c Hospital Regional Universitario Carlos Haya, Málaga, España
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Bibliografía
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Resumen

El paciente obeso crítico, como respuesta al estrés metabólico, tiene igual riesgo de depleción nutricional que el paciente no obeso, pudiendo desarrollar una malnutrición energeticoproteica, con una acelerada degradación de masa muscular.

El primer objetivo del soporte nutricional en estos pacientes debe ser minimizar la pérdida de masa magra y realizar una evaluación adecuada del gasto energético. Sin embargo, la aplicación de las fórmulas habituales para el cálculo de las necesidades calóricas puede sobrestimarlas si se utiliza el peso real, por lo que sería más correcto su aplicación con el peso ajustado o el peso ideal, aunque la calorimetría indirecta es el método de elección. La controversia se centra en si hay que aplicar un criterio estricto de soporte nutricional ajustado a los requerimientos o se aplica un cierto grado de hiponutrición permisiva.

La evidencia actual sugiere que la nutrición hipocalórica puede mejorar los resultados, en parte debido a una menor tasa de complicaciones infecciosas y a un mejor control de la hiperglucemia, por lo que la nutrición hipocalórica e hiperproteica, tanto enteral como parenteral, debe ser la práctica estándar en el soporte nutricional del paciente obeso crítico si no hay contraindicaciones para ello.

Las recomendaciones generalmente admitidas se centran en no exceder el 60–70% de los requerimientos o administrar 11–14 o 22–25kcal/kg peso ideal/día, con 2–2,5g/kg peso ideal/día de proteínas. En sentido amplio puede considerarse la nutrición hipocalórica-hiperproteica como específica del paciente obeso crítico, aunque las complicaciones ligadas a su comorbilidad hace que se planteen otras posibilidades terapéuticas, con nutrientes específicos para hiperglucemia, síndrome del distrés respiratorio agudo (SDRA) y sepsis. Sin embargo, no existe ningún estudio prospectivo y aleatorio con este tipo de nutrientes en este subgrupo concreto de población y los datos de que disponemos se extraen de una población general de pacientes críticos, por lo que deben tomarse con mucha precaución.

Palabras clave:
Obeso crítico
Nutrición hipocalórica
Calorimetría indirecta
Ecuaciones predictivas
Abstract

As a response to metabolic stress, obese critically-ill patients have the same risk of nutritional deficiency as the non-obese and can develop protein-energy malnutrition with accelerated loss of muscle mass.

The primary aim of nutritional support in these patients should be to minimize loss of lean mass and accurately evaluate energy expenditure. However, routinely-used formulae can overestimate calorie requirements if the patient's actual weight is used. Consequently, the use of adjusted or ideal weight is recommended with these formulae, although indirect calorimetry is the method of choice. Controversy surrounds the question of whether a strict nutritional support criterion, adjusted to the patient's requirements, should be applied or whether a certain degree of hyponutrition should be allowed.

Current evidence suggested that hypocaloric nutrition can improve results, partly due to a lower rate of infectious complications and better control of hyperglycemia. Therefore, hypocaloric and hyperproteic nutrition, whether enteral or parenteral, should be standard practice in the nutritional support of critically-ill obese patients when not contraindicated. Widely accepted recommendations consist of no more than 60–70% of requirements or administration of 11–14kcal/kg current body weight/day or 22–25kcal/kg ideal weight/day, with 2–2.5g/kg ideal weight/day of proteins.

In a broad sense, hypocaloric-hyperprotein regimens can be considered specific to obese critically-ill patients, although the complications related to comorbidities in these patients may require other therapeutic possibilities to be considered, with specific nutrients for hyperglycemia, acute respiratory distress syndrome (ARDS) and sepsis. However, there are no prospective randomized trials with this type of nutrition in this specific population subgroup and the available data are drawn from the general population of critically-ill patients. Consequently, caution should be exercised when interpreting these data.

Keywords:
Critically-ill obese patients
Hypocaloric nutrition
Indirect calorimetry
Predictive equations
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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.
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