Publique en esta revista
Información de la revista
Vol. 35. Núm. S1.
Recomendaciones para el Soporte Nutricional del paciente crítico
Páginas 81-85 (Noviembre 2011)
Compartir
Compartir
Descargar PDF
Más opciones de artículo
Vol. 35. Núm. S1.
Recomendaciones para el Soporte Nutricional del paciente crítico
Páginas 81-85 (Noviembre 2011)
Acceso a texto completo
Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Paciente cardíaco
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): Cardiac patient
Visitas
...
F.J. Jiménez Jiméneza,??
Autor para correspondencia
fjavierjimenez@telefonica.net

Autor para correspondencia.
, M. Cervera Montesb, A.L. Blesa Malpicac
a Hospital Universitario Virgen del Rocío, Sevilla, España
b Hospital Arnau de Vilanova, Valencia, España
c Hospital Clínico San Carlos, Madrid, España
Información del artículo
Resumen
Bibliografía
Descargar PDF
Estadísticas
Resumen

El paciente con patología cardíaca puede presentar 2 tipos de desnutrición: la caquexia cardíaca, que aparece en situaciones de insuficiencia cardíaca congestiva crónica, y una malnutrición secundaria a complicaciones de la cirugía cardíaca o de cualquier cirugía mayor realizada en pacientes con cardiopatía.

Se debe intentar una nutrición enteral precoz si no se puede utilizar la vía oral. Cuando la función cardíaca esté profundamente comprometida la nutrición enteral es posible, pero a veces precisará suplementación con nutrición parenteral.

La hiperglucemia aguda sostenida en las primeras 24h en pacientes ingresados por síndrome coronario agudo, sean o no diabéticos, es un factor de mal pronóstico en términos de mortalidad a los 30 días. En el paciente crítico cardíaco con fallo hemodinámico en situación estable, un soporte nutricional de 20-25 kcal/kg/día es eficaz para mantener un estado nutricional adecuado.

El aporte proteico debe ser de 1,2–1,5 g/kg/día. Se administrarán fórmulas poliméricas o hiperproteicas habituales, según la situación nutricional previa del paciente, con restricción de sodio y volumen según su situación clínica.

La glutamina es la mayor fuente de energía para el miocito, vía conversión a glutamato, protegiendo además a la célula miocárdica de la isquemia en situaciones críticas. La administración de 1g/día de w-3 (EPA+DHA), en forma de aceite de pescado, puede prevenir la muerte súbita en el tratamiento del síndrome coronario agudo y también puede contribuir a una disminución de los ingresos hospitalarios, por eventos cardiovasculares, en la insuficiencia cardíaca crónica.

Palabras clave:
Paciente crítico cardíaco
Caquexia cardíaca
Ácidos grasos omega-3
Hiperglucemia
Abstract

Patients with cardiac disease can develop two types of malnutrition: cardiac cachexia, which appears in chronic congestive heart failure, and malnutrition due to the complications of cardiac surgery or any other type of surgery in patients with heart disease.

Early enteral nutrition should be attempted if the oral route cannot be used. When cardiac function is severely compromised, enteral nutrition is feasible, but supplementation with parenteral nutrition is sometimes required.

Sustained hyperglycemia in the first 24 hours in patients admitted for acute coronary syndrome, whether diabetic or not, is a poor prognostic factor for 30-day mortality. In criticallyill cardiac patients with stable hemodynamic failure, nutritional support of 20–25kcal/kg/day is effective in maintaining adequate nutritional status.

Protein intake should be 1.2*–1.5g/kg/day. Routine polymeric or high protein formulae should be used, according to the patient's prior nutritional status, with sodium and volume restriction according to the patient's clinical situation.

The major energy source for myocytes is glutamine, through conversion to glutamate, which also protects the myocardial cell from ischemia in critical situations. Administration of 1 g/ day of omega-3 (EPA+DHA) in the form of fish oil can prevent sudden death in the treatment of acute coronary syndrome and can also help to reduce hospital admission for cardiovascular events in patients with chronic heart failure.

Keywords:
Critically-ill cardiac patient
Cardiac cachexia
Omega-3 fatty acids
Hyperglycemia
El Texto completo está disponible en PDF
Bibliografía
[1.]
S. Von Haehling, W. Doehner, S.D. Anker.
Nutrition, metabolism, and the complex pathophysiology of cachexia in chronic heart failure.
Cardiovasc Res, 73 (2007), pp. 298-309
[2.]
A. Sandek, W. Doehner, S.D. Anker, S. Von Haehling.
Nutrition in heart failure: an update.
Curr Opin Clin Nutr Metab Care, 12 (2009), pp. 384-391
[3.]
S.D. Anker, M. John, P.U. Pedersen, C. Raguso, M. Cicoira, E. Dardai, et al.
DGEM (German Society for Nutritional Medicine); ESPEN (European Society for Parenteral and Enteral Nutrition). ESPEN Guidelines on Enteral Nutrition: Cardiology and pulmonology.
Clin Nutr, 25 (2006), pp. 311-318
[4.]
C. Berry, A.L. Clark.
Catabolism in chronic heart failure.
Eur Heart J, 21 (2000), pp. 521-532
[5.]
S.D. Anker, A. Laviano, G. Filippatos, M. John, A. Paccagnella, P. Ponikowski, et al.
ESPEN. ESPEN Guidelines on Parenteral Nutrition: on cardiology and pneumology.
Clin Nutr, 28 (2009), pp. 455-460
[6.]
G. Azhar, J.Y. Wei.
Nutrition and cardiac cachexia.
Curr Opin Clin Nutr Metab Care, 9 (2006), pp. 18-23
[7.]
J.S. Meltzer, V.K. Moitra.
The nutritional and metabolic support of heart failure in the intensive care unit.
Curr Opin Clin Nutr Metab Care, 11 (2008), pp. 140-146
[8.]
M.M. Berger, J.P. Revelly, M.C. Cayeux, R.L. Chiolero.
Enteral nutrition in critically ill patients with severe hemodynamic failure after cardiopulmonary bypass.
Clin Nutr, 24 (2005), pp. 124-132
[9.]
M.M. Berger, R.L. Chiolero.
Enteral nutrition and cardiovascular failure: from myths to clinical practice.
JPEN J Parenter Enteral Nutr, 33 (2009), pp. 702-709
[10.]
S.B. Heymsfield, K. Casper.
Congestive heart failure: clinical management by use of continuous nasoenteric feeding.
Am J Clin Nutr, 50 (1989), pp. 539-544
[11.]
D. Rapp-Kesek, P.O. Joachimsson, T. Karlsson.
Splanchnic blood flow and oxygen consumption: effects of enteral nutrition and dopexamine in the elderly cardiac surgery patient.
Acta Anaesthesiol Scand, 51 (2007), pp. 570-576
[12.]
S.A. McClave, R.G. Martindale, V.W. Vanek, M. McCarthy, P. Roberts, B. Taylor, ASPEN, Board of Directors; American College of Critical Care Medicine; Society of Critical Care Medicine, et al.
Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN).
JPEN J Parenter Enteral Nutr, 33 (2009), pp. 277-316
[13.]
C. Scurlock, J. Raikhelkar, J.I. Mechanick.
Impact of new technologies on metabolic care in the intensive care unit.
Curr Opin Clin Nutr Metab Care, 12 (2009), pp. 196-200
[14.]
A. Mijan de la Torre, B. Mateo-Sillera, A.M. Pérez-García.
Nutrición y enfermedad cardiaca.
Tratado de Nutrición, pp. 599-629
[15.]
S.E. Inzucchi.
Clinical practice Management of hyperglycemia in the hospital setting.
N Engl J Med, 355 (2006), pp. 1903-1911
[16.]
S.W. Zarich, R.W. Nesto.
Implications and treatment of acute hyperglycemia in the setting of acute myocardial infarction.
Circulation, 115 (2007), pp. e436-e439
[17.]
A. Dziewierz, D. Giszterowicz, Z. Siudak, T. Rakowski, W. Mielecki, M. Suska, et al.
Impact of admission glucose level and presence of diabetes mellitus on mortality in patients with non-ST segment elevation acute coronary syndrome treated conservatively.
Am J Cardiol, 103 (2009), pp. 954-958
[18.]
K. Malmberg.
Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus: DIGAMI (Diabetes Mellitus, Insulin Glucose Infusión in Acute Myocardial Infarction). Study group.
BMJ, 314 (1997), pp. 1512-1515
[19.]
R. Díaz, E.A. Paolasso, L.S. Piegas, C.D. Tajer, M.G. Moreno, R. Corvalan, et al.
Metabolic modulation of acute myocardial infarction. The ECLA (Estudios Cardiologicos Latinoamerica) Collaborative Group.
Circulation, 98 (1998), pp. 2227-2234
[20.]
K. Malmberg, L. Ryden, H. Wedel, K. Birkeland, A. Bootsma, K. Dickestein, DIGAMI-2 Investigators, et al.
Intense metabolic control by means of insulin in patients with diabetes mellitus and acute myocardial infarction (DIGAMI-2): effects on mortality and morbidity.
Eur Heart J, 26 (2005), pp. 650-661
[21.]
S.R. Mehta, S. Yusuf, R. Díaz, J. Zhu, P. Pais, D. Xavier, CREATEECLA Trial Group Investigators, et al.
Effect of glucose-insulin-potassium infusion on mortality in patients with acute ST-segment elevation myocardial infarction: the CREATE-ECLA randomized controlled trial.
JAMA, 293 (2005), pp. 437-446
[22.]
S. Von Haehling, M. Lainscak, J. Springer, S.D. Anker.
Cardiac cachexia: a systematic overview.
Pharmacol Ther, 121 (2009), pp. 227-252
[23.]
A. Mijan, E. Martin, B. De Mateo.
Cardiac cachexia.
Nutr Hosp, 21 (2006), pp. 84-93
[24.]
M. Herrmann, O. Taban-Shomal, U. Hubner, M. Bohm, W. Herrmann.
A review of homocysteine and heart failure.
Eur J Heart Fail, 8 (2006), pp. 571-576
[25.]
V. Soukoulis, J.B. Dihu, M. Sole, S.D. Anker, J. Cleland, G.C. Fonarow, et al.
Micronutrient deficiencies an unmet need in heart failure.
J Am Coll Cardiol, 54 (2009), pp. 1660-1673
[26.]
F. Novak, D.K. Heyland, A. Avenell, J.W. Drover, X. Su.
Glutamine suplementation in serious illness: a systematic review of the evidence.
Crit Care Med, 30 (2002), pp. 2022-2029
[27.]
S.E. Khogali, S.D. Pringle, B.K. Weryk, M.J. Rennie.
Is glutamine beneficial in ischemic heart disease?.
Nutrition, 18 (2002), pp. 123-126
[28.]
D. Kelly, P.E. Wischmeyer.
Role of L-glutamine in critical illness: new insights.
Curr Opin Clin Nutr Metab Care, 6 (2003), pp. 217-222
[29.]
R.H. Böger.
L-arginine therapy in cardiovascular pathologies: beneficial or dangerous?.
Curr Opin Clin Nutr Metab Care, 11 (2008), pp. 55-61
[30.]
A. Leaf, J.X. Kang, Y.F. Xiao, G.E. Billman.
Clinical prevention of sudden cardiac death by n-3 polyunsaturade fatty acids and mechanism of prevention of arrhytmias by n-3 fish oils.
Circulation, 107 (2003), pp. 2646-2652
[31.]
R. Schrepf, T. Limmert, P. Claus Weber, K. Theisen, A. Sellmayer.
Immediate effects of n-3 fatty acid infusion on the induction of sustained ventricular tachycardia.
Lancet, 363 (2004), pp. 1441-1442
[32.]
W.S. Harris, C.W. Poston, C. Haddock.
Tissue n-3 and n-6 fatty acids and risk for coronary heart disease events.
[33.]
R. Marchioli, F. Barzi, E. Bomba, C. Chieffo, D. Di Gregorio, R. Di Mascio, GISSI-Prevenzione Investigators, et al.
Early protection against sudden death by n-3 polyunsaturated fatty acids after myocardial infarction: time-course analysis of the results of the Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico (GISSI)-Prevenzione.
Circulation, 105 (2002), pp. 1897-1903
[34.]
L. Tavazzi, A.P. Maggioni, R. Marchioli, S. Barlera, M.G. Franzosi, R. Latini, Gissi-HF Investigators, et al.
Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSIHF trial): a randomised, double-blind, placebo-controlled trial.
Lancet, 372 (2008), pp. 1223-1230
[35.]
D. Kromhout, E.J. Giltay, Geleijnse JM.
Alpha Omega Trial Group. n-3 fatty acids and cardiovascular events after myocardial infarction.
N Engl J Med, 363 (2010), pp. 2015-2026
[36.]
R. Tepaske, H. Velthuis, H.M. Oudemans-van Straaten, S.H. Heisterkamp, S.J. Van Deventer, C. Ince, et al.
Effect of preoperative oral immune-enhancing nutritional supplement on patients at high risk of infection after cardiac surgery: a randomised placebocontrolled trial.
Lancet, 358 (2001), pp. 696-701
[37.]
S. Alsafwah, S.P. Laguardia, M. Arroyo, B.K. Dockery, S.K. Bhattacharya, R.A. Ahokas, et al.
Congestive heart failure is a systemic illness: a role for minerals and micronutrients.
Clin Med Res, 5 (2007), pp. 238-243
[38.]
F. Darcel, C. Roussin, J.M. Vallat, C. Charlin, P. Tournebize, E. Doussiet.
Polyneuropathies in vitamin B1 deficiency in Reunion and Mayotte islands in 70 patients of Maori and Comorian descent.
Bull Soc Pathol Exot, 102 (2009), pp. 167-172

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 a la newsletter

Opciones de artículo
Herramientas
es en

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

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