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Enteral nutrition (EN) in critically ill patients requiring vasoactive drug (VAD) support is controversial. This study assesses the tolerability and safety of EN in such patients.This prospective observational study was conducted in 23 intensive care units (ICUs) over 30 months. Inclusion criteria were a need for VADs and/or mechanic circulatory support (MCS) over a minimum of 48 h, a need for ≥48 h of mechanical ventilation, an estimated life expectancy72 h, and ≥72 h of ICU stay. Patients with refractory shock were excluded. EN was performed according to established protocols during which descriptive, daily hemodynamic and efficacy, and safety data were collected. An independent research group conducted the statistical analysis.Of 200 patients included, 30 (15%) required MCS and 145 (73%) met early multiorgan dysfunction criteria. Mortality was 24%. Patients needed a mean dose of norepinephrine in the first 48 h of 0.71 mcg/kg/min (95% CI, 0.63-0.8) targeting a mean arterial pressure of 68 mm Hg (95% CI, 67-70) during the first 48 h. EN was started 34 h (95% CI, 31-37) after ICU admission. Mean energy and protein delivered by EN/patient/day were 1159 kcal (95% CI, 1098-1220) and 55.6 g (95% CI, 52.4-58.7), respectively. Daily energy balance during EN/patient/day was -432 (95% CI, -496 to -368). One hundred and fifty-four (77%) patients experienced EN-related complications. However, severe complications, such as mesenteric ischemia, were recorded in only one (0.5%) patient.EN in these patients seems feasible, safe, and unrelated to serious complications. Reaching the energy target only through EN is difficult.

Critical care 26, 240 (2022). doi:10.1186/s13054-022-04113-x, Published by Springer, Berlin ; Heidelberg

Sedation is necessary in the management of critically ill patients, both to alleviate suffering and to cure patients with diseases that require admission to the intensive care unit. Such sedation should be appropriate to the patient needs at each timepoint during clinical evolution, and neither too low (undersedation) nor too high (oversedation). Adequate sedation influences patient comfort, safety, survival, subsequent quality of life, bed rotation of critical care units and costs. Undersedation is detected and quickly corrected. In contrast, oversedation is silent and difficult to prevent in the absence of management guidelines, collective awareness and teamwork. The Zero Oversedation Project of the Sedation, Analgesia and Delirium Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units aims to offer a practical teaching and collective awareness tool for ensuring patient comfort, safety and management with a view to optimizing the clinical outcomes and minimizing the deleterious effects of excessive sedation. The tool is based on a package of measures that include monitoring pain, analgesia, agitation, sedation, delirium and neuromuscular block, keeping patients pain-free, performing dynamic sedation according to clinical objectives, agreeing upon the multidisciplinary protocol to be followed, and avoiding deep sedation where not clinically indicated.

Palliative care provides a holistic approach and care for patients with a terminal illness and their families. In palliative care physical complaints as well as emotional, social and spiritual aspects are considered. Nutritional care should be also considered within palliative support. For those working in the nutritional support field, to withhold or withdraw nutritional support may be an ethical dilemma in this scenario. The controversy starts when considering nutrition and hydration as basic care or a treatment. The goals of nutrition support in palliative care patients differ from common ones, aiming to improve quality of life, survival or both. The decision should be based on a consideration of prognosis (length of survival), quality of life, and risks-benefits ratio. Regarding oral nutrition (with or without oral supplements) the idea prevails of "comfort feeding", based on providing oral feeding till discomfort or avoidance develop. There is no evidence on the benefit of specific nutrients, despite the fact that omega-3 FAs may have some positive effects in patients with cancer. Regarding nutritional support (enteral or parenteral), no scientific evidence is present, so the decision needs to be agreed according to the desires and beliefs of the patient and their family, and based on a consensus with the interdisciplinary team on the aims of this support.Los cuidados paliativos proporcionan una atención integral que tiene en cuenta los aspectos físicos, emocionales, sociales y espirituales del paciente con enfermedad terminal y su entorno familiar. El tratamiento nutricional debe formar parte activa de los equipos de cuidados paliativos. La necesidad de iniciar o no un tratamiento nutricional sigue siendo, desde hace décadas, uno de los principales problemas éticos a los que se enfrentan los profesionales dedicados a la nutrición clínica. El origen de tal controversia radica, fundamentalmente, en cómo se consideran la nutrición y la hidratación: cuidado/soporte o tratamiento médico. Los objetivos fundamentales del tratamiento nutricional en los pacientes en cuidados paliativos deben ser otros: la mejoría de la calidad de vida, de la supervivencia o de ambas. La decisión de indicar o no el tratamiento nutricional en cuidados paliativos debe tomarse tras considerar el pronóstico, la calidad de vida y la relación “riesgo/beneficio”. En relación a la alimentación por vía oral (con o sin suplementos orales), prevalece la idea de la “alimentación de confort”, que se basa en intentos de alimentación oral hasta que se produzcan la incomodidad y/o el rechazo del paciente. No existen evidencias que justifiquen el uso de nutrientes específicos, aunque desde hace años se señala la posibilidad de lograr beneficios cuando se utilizan ácidos grasos omega-3 en los pacientes con cáncer. En cuanto al tratamiento nutricional (enteral o parenteral), en ausencia de evidencia, las decisiones sobre si iniciar una nutrición artificial en un paciente paliativo deben tomarse teniendo en cuenta los deseos y creencias del paciente y sus familiares, y basarse en el consenso del equipo interdisciplinar sobre los objetivos que se persiguen al iniciarla.

Summary Background Staphylococcus aureus remains a common cause of ventilator-associated pneumonia, with little change in incidence over the past 15 years. We aimed to evaluate the efficacy of suvratoxumab, a monoclonal antibody targeting the α toxin, in reducing the incidence of S aureus pneumonia in patients in the intensive care unit (ICU) who are on mechanical ventilation. Methods We did a multicentre, randomised, double-blind, placebo-controlled, parallel-group, phase 2 pilot trial at 31 hospitals in Belgium, the Czech Republic, France, Germany, Greece, Hungary, Portugal, Spain, and Switzerland. Eligible patients were in the ICU, aged ≥18 years, were intubated and on mechanical ventilation, were positive for S aureus colonisation of the lower respiratory tract, as assessed by quantitative PCR (qPCR) analysis of endotracheal aspirate, and had not been diagnosed with new-onset pneumonia. Patients were excluded if they had confirmed or suspected acute ongoing staphylococcal disease; had received antibiotics for S aureus infection for more than 48 h within 72 h of randomisation; had a Clinical Pulmonary Infection Score of 6 or higher; had an acute physiology and chronic health evaluation II score of 25 or higher with a Glasgow coma scale (GCS) score of more than 5, or an acute physiology and chronic health evaluation II score of at least 30 with a GCS score of 5 or less; had a Sequential Organ Failure Assessment score of 9 or higher; or had active pulmonary disease that would impair the ability to diagnose pneumonia. Colonised patients were randomly assigned (1:1:1), by use of an interactive voice or web response system, to receive either a single intravenous infusion of suvratoxumab 2000 mg, suvratoxumab 5000 mg, or placebo. Randomisation was done in blocks of size four, stratified by country and by whether patients had received systemic antibiotics for S aureus infection. Patients, investigators, and study staff involved in the treatment or clinical evaluation of patients were masked to patient assignment. The primary efficacy endpoint was the incidence of S aureus pneumonia at 30 days, as determined by a masked independent endpoint adjudication committee, in all patients who received their assigned treatment (modified intention-to-treat [ITT] population). Primary safety endpoints were the incidence of treatment-emergent adverse events at 30 days, 90 days, and 190 days after treatment, and the incidence of treatment-emergent serious adverse events, adverse events of special interest, and new-onset chronic disease at 190 days after treatment. All primary safety endpoints were assessed in the modified ITT population. This trial is registered with ClinicalTrials.gov ( NCT02296320 ) and the EudraCT database (2014-001097-34). Findings Between Oct 10, 2014, and April 1, 2018, 767 patients were screened, of whom 213 patients with confirmed S aureus colonisation of the lower respiratory tract were randomly assigned to the suvratoxumab 2000 mg group (n=15), the suvratoxumab 5000 mg group (n=96), or the placebo group (n=102). Two patients in the placebo group did not receive treatment after randomisation because their clinical conditions changed and they no longer met the eligibility criteria for dosing. As adjudicated by the data monitoring committee at an interim analysis, the suvratoxumab 2000 mg group was discontinued on the basis of predefined pharmacokinetic criteria. At 30 days after treatment, 17 (18%) of 96 patients in the suvratoxumab 5000 mg group and 26 (26%) of 100 patients in the placebo group had developed S aureus pneumonia (relative risk reduction 31·9% [90% CI −7·5 to 56·8], p=0·17). The incidence of treatment-emergent adverse events at 30 days were similar between the suvratoxumab 5000 mg group (87 [91%]) and the placebo group (90 [90%]). The incidence of treatment-emergent serious adverse events at 30 days were also similar between the suvratoxumab 5000 mg group (36 [38%]) and the placebo group (32 [32%]). No significant difference in the incidence of treatment-emergent adverse events between the two groups at 90 days (89 [93%] in the suvratoxumab 5000 mg group vs 92 [92%] in the placebo group) and at 190 days (93 [94%] vs 93 [93%]) was observed. 40 (40%) patients in the placebo group and 50 (52%) in the suvratoxumab 5000 mg group had a serious adverse event at 190 days. In the suvratoxumab 5000 mg group, one (1%) patient reported at least one treatment-emergent serious adverse event related to treatment, two (2%) patients reported an adverse event of special interest, and two (2%) reported a new-onset chronic disease. Interpretation In patients in the ICU receiving mechanical ventilation with qPCR-confirmed S aureus colonisation of the lower respiratory tract, the incidence of S aureus pneumonia at 30 days was not significantly lower following treatment with 5000 mg suvratoxumab than with placebo. Despite these negative results, monoclonal antibodies still represent one promising therapeutic option to reduce antibiotic consumption that require further exploration and studies. Funding AstraZeneca, with support from the Innovative Medicines Initiative Joint Undertaking.

Epidemiology; Preventive medicine Epidemiologia, Medicina preventiva Epidemiología; Medicina preventiva Using categorical principal component analysis, we aimed to determine the relationship between health care-associated infections (HAIs) and diagnostic categories (DCs) in patients with acute heart disease using data collected in the Spanish prospective ENVIN-HELICS intensive care registry over a 10-year period (2005–2015). A total of 69,876 admissions were included, of which 5597 developed HAIs. Two 2-component CATPCA models were developed. In the first model, all cases were included; the first component was determined by the duration of the invasive devices, the ICU stay, the APACHE II score and the HAIs; the second component was determined by the type of admission (medical or surgical) and by the DCs. No clear association between DCs and HAIs was found. Cronbach’s alpha was 0.899, and the variance accounted for (VAF) was 52.5%. The second model included only admissions that developed HAIs; the first component was determined by the duration of the invasive devices and the ICU stay; the second component was determined by the inflammatory response, the mortality in the ICU and the HAIs. Cronbach’s alpha value was 0.855, and VAF was 46.9%. These findings highlight the role of exposure to invasive devices in the development of HAIS in patients with acute heart disease.

espanolActualmente, la nutricion enteral forma parte de las medidas de tratamiento que se aplican a los pacientes criticos. Es una tecnica que, procedente del antiguo Egipto, solo tuvo un rapido desarrollo desde principios del siglo XX hasta nuestros dias. Los diferentes avances en este campo, relacionados con las indicaciones, la metodologia de aplicacion, la seleccion de las dietas, el manejo de las complicaciones, el seguimiento de la eficacia y el diseno y aplicacion de los protocolos asistenciales, han permitido que la nutricion enteral pueda aplicarse con seguridad y eficacia a los pacientes criticos. A pesar de ello, quedan aun muchos aspectos por desarrollar con el fin de conseguir que los pacientes se beneficien de manera optima del tratamiento con nutricion enteral. EnglishEnteral nutrition is part of the treatment plan designed for a great number of critically ill patients. After a first description in ancient Egypt, enteral nutrition was only rapidly developed during the last century. Advances in indications, tube feeding methods, enteral formula selection, diagnosis and treatment of gastrointestinal-related complications, efficacy monitorization, and use of protocols for enteral nutrition administration in clinical practice make this nutritional technique more feasible and secure for critically ill patients. Nevertheless, several issues in this field need more investigation to increase enteral nutrition development, efficacy, and safety in these patients.

This paper from the ethics Working Group presents a summary of the recommendations of the nutritional management of patients with advanced dementia.En este documento del Grupo de Trabajo de Ética se presenta un resumen sobre las recomendaciones del manejo nutricional de pacientes con demencia avanzada.

Resumen Antecedentes y objetivo Un origen frecuente de los pacientes que ingresan en la UCI es el Servicio de Urgencias. Es necesario analizar el pronostico a corto plazo de estos pacientes, pero tambien su evolucion tras el alta hospitalaria, puesto que es una preocupacion importante de los enfermos. Nuestro objetivo es describir las caracteristicas epidemiologicas de los pacientes que ingresan en la UCI desde Urgencias y analizar su evolucion. Pacientes y metodo Estudio de cohortes observacional y prospectivo. Incluye 269 pacientes ingresados consecutivamente en la UCI desde Urgencias durante 18 meses. Los factores asociados a la mortalidad hospitalaria se presentan en odds ratio (OR) y a la mortalidad a largo plazo como hazard ratio (HR). El nivel de significacion aceptado fue del 5%. La supervivencia global se analizo mediante curvas de Kaplan-Meier. Resultados La mortalidad hospitalaria fue del 15%, las complicaciones desarrolladas en la UCI fueron las variables con mayor impacto en la misma: insuficiencia renal aguda (OR 22,7) y distres respiratorio (OR 51,2). Tras el alta hospitalaria, la mortalidad acumulada a los 12, 24 y 36 meses fue del 6, 11 y 15%, respectivamente. El grado de dependencia funcional (HR 3,7), el cancer (HR 3,4) y las arritmias (HR 2,4) fueron los factores relacionados con la mortalidad a largo plazo. Conclusiones El pronostico a corto plazo de los pacientes que ingresan en la UCI se relaciona con su edad y comorbilidad, pero sobre todo con las caracteristicas de la enfermedad aguda. Sin embargo, la evolucion a largo plazo esta mas asociada a las caracteristicas del paciente.

En este documento del Grupo de Trabajo de Etica se presenta un resumen sobre las recomendaciones del manejo nutricional de pacientes con demencia avanzada.

espanolLa “polineuropatia del paciente critico”, un cuadro que cursa con debilidad generalizada durante la estancia de los pacientes en la UCI, fue inicialmente atribuida a una afectacion de los nervios perifericos. No obstante, a medida que ha progresado la investigacion en este campo ha podido describirse el papel fundamental de la alteracion muscular en este cuadro de “debilidad muscular adquirida en la UCI” (DMA-UCI). La afectacion muscular es frecuente en pacientes criticos. Puede ser cualitativa (debilidad muscular), cuantitativa (disminucion de la masa muscular) o, con frecuencia, de ambos tipos. Los efectos de la afectacion muscular comprometen la recuperacion de los pacientes tanto en la UCI como en el hospital y se extienden hasta despues del alta hospitalaria durante un periodo que puede ser prolongado. El origen de la alteracion muscular suele ser multifactorial, estando implicados factores como el reposo prolongado, la inadecuada ingesta de nutrientes o la exposicion a farmacos que pueden afectar a la estructura muscular y a la funcion contractil. La valoracion de la masa muscular mediante tecnicas de imagen como la ecografia o la tomografia computarizada puede servir de ayuda para el seguimiento de los pacientes. La prevencion y el tratamiento de la DMA-UCI requiere un abordaje multimodal recurriendo al empleo de movilizacion y ejercicio precoces, tratamiento nutricional adecuado y, ocasionalmente, farmacos con efecto estimulante sobre la sintesis proteica muscular. Estudios en marcha permitiran una mejor definicion de las alteraciones musculares durante la enfermedad critica y la mejor forma de abordar su prevencion y tratamiento. EnglishPolyneuropathy in the critically ill patient was defined as a generalized weakness, acquired during Intensive Care Unit (ICU) admittance and attributed to lesion of the peripheral nerve. Research in this field progressed over time, revealing the crucial role of muscle injury in this disease, to the point of re-naming the disorder as ICU adquired weakness (ICUAW). Muscle damage is common in severe illness, and may be classified in qualitative (weakness) or quantitative (decrease in mass) muscle loss. The most frequent scenario in these patients, is simultaneous change in quality and quantity of muscle; resulting in a challenging and delayed recovery during hospital admittance and after discharge. Multiple causes have been identified in the pathogenesis of this disorder, such as: prolonged bed rest, inadequate intake of nutrients and exposure to drugs that affect muscle structure and contraction. The assessment of muscle mass using images provided by ultrasound or computerized tomography may guide follow up. The prevention and treatment of ICUAW requires a multimodal approach: early mobilization and exercise, appropriate nutritional prescription and, occasionally, muscle protein synthesis stimulants. Further studies will clarify more aspects regarding critically ill patients suffering from muscle injury, in order to better address prevention and treatment of ICUAW.

Fluid resuscitation is one of the most prevalent treatment in critical care. There is not definitive evidence about the best fluid for resuscitation. The aim of this review will be to asses the efficacy and safety of buffered solution versus saline. We will perform an electronic search in Medline, Embase, and Central. Studies will be eligible if they are clinical trials who including critical ill patients. Primary outcomes are mortality and renal failure. All findings will be tabulated and synthesized. We will perform a meta-analysis according to Cochrane Review standards. We will design a summary of findings table.

the effective contribution of enteral nutrition (EN) in intensive care units (ICU) is due to multiple factors.to determine the efficacy of caloric intake in critically ill patients with traumatic pathology receiving enteral nutrition, and to analyze cause and time of interruption of EN.prospective observational study (November 2015 - August 2016).patient with EN ≥ 48 hours and age ≥ 18 years.patient with oral and/or parenteral nutrition.demographic, day of EN, prescribed and administered kilocalories (kcal), caloric difference, caloric objective and variables related to the interruptions of the EN. The handling of EN and interruptions are made according to the unit's internal protocol. Kcal/patient are calculated according to the Harris-Benedict equation and multiplied by a stress factor depending on the type of trauma of the patient.sixty-nine patients were included, 79.71% were men, with a median age of 46 (34-58) years. A total of 1,112 days of EN were monitored. As of the third day of admission to the ICU (979 days monitored), the nutritional efficacy was optimal (caloric intake80%): 92.43% (72.8-97.5). The optimal caloric goal was maintained in 67.9% of these days. The most frequent causes of interruption of NE were procedures unrelated to airway, with holding time of three (1-7.25) hours. CONCLUSIONS at the third day, the patients with traumatic pathology received at least 80% of the prescribed caloric intake. Among the most frequent causes of interruption of EN were the procedures unrelated to airway.INTRODUCCIÓN: el aporte efectivo de la nutrición enteral (NE) en las unidades de cuidados intensivos (UCI) se ve afectado por múltiples factores. OBJETIVOS: determinar la eficacia en el aporte calórico a los pacientes críticos con patología traumática que reciben nutrición enteral. Analizar causa y tiempo de interrupción de NE. MÉTODO: estudio observacional prospectivo (de noviembre de 2015 a agosto de 2016). Criterios de inclusión: paciente con NE ≥ 48 horas y edad ≥ 18 años. Criterios de exclusión: paciente con dieta oral y/o parenteral. Variables: demográficas, día de NE, kilocalorías (kcal) prescritas, administradas, diferencia calórica, objetivo calórico y relacionadas con las interrupciones de la NE. El manejo de NE e interrupciones se realiza según protocolo interno de la unidad. Las kcal/paciente se calculan según la ecuación de Harris-Benedict y multiplicando por un factor de estrés en función del tipo de trauma del paciente. RESULTADOS: se incluyeron 69 pacientes (el 79,71% eran hombres) con una mediana de edad de 46 (34-58) años. Se monitorizaron un total de 1.112 días de NE. A partir del tercer día de ingreso en UCI (979 días monitorizados) la eficacia nutricional fue óptima (aporte calórico80%): 92,43% (72,8-97,5). Mantenemos el objetivo calórico óptimo en el 67,9% de estos días. Observamos como causa más frecuente de interrupción de la NE los procedimientos no relacionados con la vía aérea, con un tiempo de parada de tres (1-7,25) horas. CONCLUSIÓN: el aporte calórico del paciente crítico con patología traumática se logra de forma óptima a partir del día 3. Entre las causas de interrupción de la NE más frecuentes se encuentran los procedimientos no relacionados con la vía aérea.

El aporte efectivo de la nutrición enteral (NE) en las unidades de cuidados intensivos (UCI), se ve afectada por múltiples factores. Objetivos: determinar la eficacia en el aporte calórico a los pacientes críticos con patología traumática que reciben nutrición enteral. Analizar causa y tiempo de interrupción de NE.Estudio observacional prospectivo: noviembre de 2015 - agosto de 2016. Criterios inclusión: paciente con NE ≥48 horas y edad ≥18 años. Criterios exclusión: paciente con dieta oral y/o parenteral. Variables: demográficas, día de NE, kilocalorías (Kcal) prescritas, administradas, diferencia calórica, objetivo calórico y relacionadas con las interrupciones de la NE. El manejo de NE e interrupciones se realizan según protocolo interno de la unidad. Las Kcal/paciente se calculan según ecuación de Harris-Benedict y multiplicando por un factor de estrés en función del tipo de trauma del paciente.Se incluyeron 69 pacientes, el 79,71% eran hombres, con una mediana de edad de 46 (34-58) años. Se monitorizaron un total de 1112 días de NE. A partir del tercer día 3 de ingreso en UCI (979 días monitorizados) la eficacia nutricional fue óptima (aporte calórico>80%): 92,43% (72,8-97,5). Mantenemos objetivo calórico óptimo en el 67,9% de estos días.Observamos como causa más frecuente de interrupción de NE los procedimientos no relacionados con la vía aérea, con un tiempo de parada 3(1-7,25) horas.El aporte calórico del paciente crítico con patología traumática, se logra de forma óptima a partir del día 3. Entre las causas de interrupción de NE más frecuentes se encuentran los procedimientos no relacionados con vía aérea.Palabras clave: nutrición enteral, unidad de cuidados intensivos, procedimientos quirúrgicos, enfermedades gastrointestinales, protocolos enfermería.ABSTRACTThe effective contribution of enteral nutrition (EN) in the intensive care units (ICU) is due to multiple factors. Objectives: to determine the efficacy in the caloric intake of critically ill patients with the traumatic pathology receiving enteral nutrition. Analyze cause and time of interruption of ENProspective observational study: November 2015 - August 2016. Inclusion criteria: patient with EN ≥48 hours and age ≥18 years. Exclusion criteria: patient with oral and/or parenteral diet. Variables: demographic, day of EN, kilocalories (Kcal) prescribed, administered, caloric difference, caloric objective and related to the interruptions of the EN. The handling of EN and interruptions are made according to the unit's internal protocol. The Kcal/patient are calculated according to the Harris-Benedict equation and multiplied by a stress factor depending on the type of trauma of the patient.69 patients were included, 79.71% were men, with a median age of 46 (34-58) years. A total of 1112 days of EN were monitored. As of the third day 3 of admission to the ICU (979 days monitored), the nutritional efficacy was optimal (caloric intake> 80%): 92.43% (72.8-97.5). We maintain the optimal caloric goal in 67.9% of these days. We observed as the most frequent cause of interruption of NE the procedures not related to airway, with holding time 3 (1-7,25) hours.The optimal caloric intake in critical patient with traumatic pathology, achieve as of the third day 3. Among the most frequent causes of interruption of EN were the procedures not related to airway.Key words: enteral nutrition, intensive care units, surgical procedures, gastrointestinal diseases, nursing protocol.

After the publication of the new definition for sepsis and septic shock, our objective is to analyse the evolution of patients admitted to ICU with an infection process using the previous and new recommendations.This is a sub-analysis of a previous observational prospective study. We included 98 patients admitted to ICU from the emergency department due to infection during an 18-month period. We studied the clinical evolution during ICU admission and hospital mortality.According to Sepsis-2 definition, 78% percent had septic shock and using Sepsis-3 criteria, 52%; hospital mortality was 29 and 41%, respectively. The RR of hospital mortality of septic shock was 10.3 (95% CI: 2.8-37.5) compared to patients without shock. The 30-day probability survival of patients with sepsis and septic shock were 78% and 68%, respectively (long rank 0.001).In our experience, the incorporation of the SOFA score and lactate levels to the new definition could help improve the evaluation of risk of hospital death.

To identify prehospital and on-arrival factors associated with hospital outcome in patients with traumatic cardiac arrest (TCA) discharged with recovered spontaneous circulation from the emergency department.Multipurpose prospective cohort study of patients with TCA who recovered after treatment at a tertiary care hospital emergency department between 2003 and 2016. We gathered data on epidemiologic variables, type and cause of injuries, and prehospital and hospital emergency care. The outcome was overall hospital mortality.A total of 130 TCA cases were included; 123 patients (94.6%) had received blunt trauma injuries and 65 (50%) had been in traffic accidents. The mean (SD) age was 39 (16) years, and 96 (73.8%) were male. Fifty patients (65%) were in asystole and 42 (32.3%) had pulseless electrical activity. Sixteen (12.3%) survived to be discharged; 13 of the survivors (81.3%) had recovered neurological activity. Factors that were independently associated with hospital mortality were asystole on arrival of first responders (odds ratio [OR], 25; 95% CI, 2.5-247; P=.006), nonreactive pupils on arrival at the hospital (OR, 13; 95% CI, 2.0-79; P=.006), and an Injury Severity Score over 25 (OR, 13; 95% CI, 1.8-94; P=.011).Twelve percent of patients in this cohort survived to discharge after TCA and 8 out of 10 of the surviving patients recovered neurologically. Asystole at start of prehospital care, nonreactive pupils on hospital arrival, and a severity score over 25 may indicate poor prognosis after TCA.Identificar los factores pronóstico a la llegada a urgencias y los resultados al alta hospitalaria de los pacientes en parada cardiaca traumática (PCT), documentada por un servicio de emergencias médicas (SEM), con posterior recuperación de la circulación espontánea (RCE).Estudio de cohorte multipropósito de pacientes con PCT recuperada atendidos en un servicio de urgencias (SU) de un hospital universitario de tercer nivel de 2003 a 2016. Se recogieron variables epidemiológicas, tipo y mecanismo del traumatismo, datos de la atención extrahospitalaria y del SU. La variable de resultado fue la mortalidad global intrahospitalaria.Se incluyeron 130 PCT, de los cuales 123 (94,6%) sufrieron un traumatismo cerrado y 65 (50%) tuvieron un accidente de tráfico. La edad media fue de 39 (DE 16) años y 96 (73,8%) fueron varones. Cincuenta pacientes (65%) presentaron asistolia y 42 (32,3%) actividad eléctrica sin pulso (AESP). Dieciséis (12,3%) sobrevivieron al alta, de los cuales 13 (81,3%) tuvieron recuperación neurológica favorable. Un ritmo de asistolia en la primera atención de extrahospitalaria (OR = 25; IC 95% 2,5-247; p = 0,006), las pupilas arreactivas a la llegada al hospital (OR = 13; IC 95% 2,0-79; p = 0,006), y una puntuación25 de la Injury Severity Score (ISS) (OR = 13; IC 95% 1,8-94; p = 0,011) se asociaron de forma independiente con la mortalidad intrahospitalaria.En nuestra serie, la supervivencia intrahospitalaria de la PCT fue un 12% siendo la recuperación neurológica favorable en ocho de cada diez vivos. El ritmo inicial en asistolia en la atención extrahospitalaria, la pupilas arreactivas a la llegada al hospital y una puntuación25 de ISS podrían implicar un mal pronóstico.

The condition of critically ill patients in the emergency department (ED) varies from moment to moment. The aims of this study are to quantify sequential organ failure assessment (SOFA) and changes in SOFA scores over time and determine its prognostic impact.This is a prospective observational cohort study. We included 269 patients consecutively admitted to the ICU from the ED over 18 months. The SOFA scores at ED admission (ED-SOFA) and ICU admission (ICU-SOFA) were obtained. Relative changes in SOFA scores were calculated as follows: Δ-SOFA=ICU-SOFA-ED-SOFA. Patients were divided into two groups depending on the Δ-SOFA score: (a) Δ-SOFA=0-1; and (b) Δ-SOFA more than or equal to 2.The median ED-SOFA score was two points (interquartile range: 1-4.5) and the Δ-SOFA score was 2 points (interquartile range: 0-3). The Δ-SOFA score was more powerful (area under the curve: 0.81) than the ED-SOFA score (area under the curve: 0.75) in predicting hospital mortality. Sixteen (6%) patients had a Δ-SOFA score less than 0, 116 (43%) patients had a Δ-SOFA=0-1, and 137 (51%) patients had a Δ-SOFA of at least 2 points. The probability of being alive at hospital discharge was 51 and 86.5% in Δ-SOFA of at least 2 and Δ-SOFA=0-1 groups, respectively (P0.001). Risk factors for an increase of two or more SOFA points were age, cirrhosis, a diagnosis of sepsis, and a prolonged ED stay.SOFA and changes in the SOFA score over time are potentially useful tools for risk stratification when applied to critically ill patients admitted to ICUs from the ED.

Enteral nutrition (EN) is controversial in patients with circulatory compromise. This study assesses the feasibility and safety of EN given early after cardiac surgery in patients with hemodynamic failure.Prospective observational study conducted in a surgical intensive care unit (ICU) of a tertiary hospital over 17 months.Cardiac surgery patients with hemodynamic failure (dependence on 2 or more vasoactive drugs and/or mechanical circulatory support) requiring more than 24 hours of mechanical ventilation. Variables Examined: Descriptive data, daily hemodynamic data, and variables related to the efficacy and safety of EN. EN was performed according to our EN protocol.Of 642 patients admitted to the ICU, 37 (5.8%) met the inclusion criteria. Of these, 11 (29.7%) required mechanical circulatory support, and 25 (68.0%) met the criteria for early multiorgan dysfunction. Mortality was 13.5%. Mean EN duration was 12.3 days (95% confidence interval [CI], 9.6-15.0). The mean EN diet volume delivered/patient/d was 1199 mL (95% CI, 1118.7-1278.8), and mean EN energy delivered/patient/d was 1228.4 kcal (95% CI, 1145.8-1311). The set energy target was achieved in 15 patients (40.4%). The most common EN-related complication was constipation. No case of mesenteric ischemia was detected.Our findings indicate that early EN is feasible in this type of patients and not associated with serious complications. However, it is difficult to attain an appropriate energy target by EN alone. These observations point to a need for monitoring of daily energy delivery and balance, as well as careful monitoring of warning signs of intestinal ischemia.

Purpose: To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness. Methods: We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined “early” EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds. Results: We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion. Conclusions: We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access., SCOPUS: re.j, info:eu-repo/semantics/published

Background and objective A frequent source of critically-ill patients admitted to the ICU is the Emergency Department. It is essential to analyze the short-term prognosis of these patients, but also their evolution after their discharge from the hospital, since this is one of the major concerns of these patients. The aim of this study is to describe the epidemiological characteristics of patients admitted to the ICU from the Emergency Department and to analyze their outcome. Patients and method This consisted of an observational prospective cohorts study which included 269 Emergency Department patients consecutively admitted to the ICU over an 18-month period. Factors associated with hospital mortality were presented as an odds ratio (OR) and factors associated with long-term mortality were presented as a hazard ratio (HR). A P-value lower than .05 was accepted as significant. The overall survival was analyzed on the basis of the Kaplan–Meier curves. Results Hospital mortality was 15%, ICU complications where the variables with the greatest impact on short-term mortality: acute renal failure (OR 22.7) and respiratory distress syndrome (OR 51.2). After hospital discharge, the cumulative mortality at 12, 24 and 36 months was 6, 11 and 15%, respectively. The degree of functional dependence (HR 3.7), cancer (HR 3.4) and arrhythmias (HR 2.4) were factors related to long-term mortality. Conclusions The short-term outcome of ICU patients is related to age and comorbidity, but more significantly to the characteristics of the acute illness. However, the long-term outcome is more closely associated with the patients’ characteristics.

Summary Background & aims To assess the effect of an enteral diet enriched with eicosapentaenoic acid (EPA), gamma-linolenic acid (GLA), and anti-oxidants on the incidence of organ dysfunction and nosocomial infections in septic patients with acute lung injury or acute respiratory distress syndrome (ARDS) compared with a standard enteral diet. Methods This prospective, randomized, open-label study was performed in 11 Spanish intensive care units (ICU). Adult patients with sepsis and acute lung injury or ARDS were randomly allocated to receive either an EPA-GLA diet or a control diet. Results Of the 198 patients that were eligible, 160 were randomized and 132 were studied. Patient demographics, APACHE II and SOFA scores, and nutritional variables on admission were similar between the EPA-GLA diet and control diet groups. The EPA-GLA diet group showed a trend toward a decreased SOFA score, but it was not significant. No differences were observed in the PaO 2 /FiO 2 ratio or the days on mechanical ventilation between the groups. Incidence of infections was similar in the groups. The control group stayed longer in the ICU than the EPA-GLA diet group (16 vs. 18; p = 0.02). Conclusions A diet enriched with EPA, GLA, and anti-oxidants does not improve gas exchange or decrease the incidence of novel organ failures in critically ill septic patients with acute lung injury or ARDS. Patients treated with the EPA-GLA diet stayed in the ICU for less time, but we did not find any differences in infectious complications.

Como Coordinadora del Grupo de Ética de la Sociedad Española de Nutrición Clínica y Metabolismo (SENPE), me complace remitirle el documento elaborado por nuestro grupo de trabajo, del que nos sentimos especialmente satisfechos, en relación al tratamiento nutricional en la esclerosis lateral amiotrófica (ELA): MANEJO NUTRICIONAL DE LA ESCLEROSIS LATERAL AMIOTRÓFICA: RESUMEN DE RECOMENDACIONES. Agradeceríamos fuese valorado para publicación en el órgano de expresión de nuestra Sociedad, la revista Nutrición Hospitalaria, como documento de Grupos de Trabajo. Esperamos que dicho texto sea útil y sirva como guía terapéutica orientativa a los profesionales que tratan pacientes con dicha patología, en el ámbito de la Nutrición, y redunde en la mejoría de la atención a nuestros pacientes con ELA.

Resumen Objetivos Describir la evolucion y los cuidados posquirurgicos del primer trasplante multivisceral (TM) de adulto en Espana: higado, pancreas, bazo, estomago e intestino delgado. Descripcion del caso Mujer de 32 anos diagnosticada de sindrome de Gardner con tumor desmoides. Tiempo quirurgico: 15 h. Primer dia postrasplante: APACHE II, 13; SAPS II, 27. Analisis de cuidados posquirugicos y distintas variables durante los primeros 10 dias postrasplante: 1. Cardiovascular • Control hemodinamico : presion arterial media 99 ± 5 mmHg, frecuencia cardiaca 91 ± 11 latidos/min, gasto cardiaco 5 ± 2 l/min, presion venosa central 9 ± 2 mmHg. • Politransfusion : mediana de 3 concentrados de hematies, 2 pool de plaquetas, 2.025 ml de plasma. • Administracion de noradrenalina : 1,71 dias a 0,111 ± 0,107 μg/kg/min. • Tecnicas de depuracion extracorporea : volumen extraccion/dia (VEd) 3.322 ± 1.780 ml/dia, hemodialfiltracion venovenosa continua 31,58 dias. 2. Respiratorio • Control respiratorio : saturacion arterial de oxigeno (SatO 2 ) 100%, fraccion inspiratoria de oxigeno (FiO 2 ) 59 ± 12%, PO 2 /FiO 2 241 ± 59. • Control del grado de sedoanalgesia : midazolam y morfina 4,96 dias a 0,36 ± 0,06 mg/kg/h y 0,031 ± 0,007 mg/kg/h, respectivamente. • Cuidados del paciente con via aerea artificial y conectado a ventilacion mecanica : tiempo total ventilacion mecanica 22,25 dias, soporte ventilatorio total 10,42 dias y parcial 11,82 dias. 3. Inmunosupresion : concentracion de tacrolimus 18 ± 8 ng/ml, alemtuzumab 30 mg preoperatorio y el 3. er dia postrasplante mas 3 dosis de metilprednisolona 1 g/dia por rechazo hiperagudo intestinal. 4. Nutricional-metabolico • Control glucemico : glucemia 153 ± 18 mg/dl, insulina 106 ± 57 UI/dia. • Soporte nutricional : nutricion parenteral 27,7 dias; se inicio nutricion enteral tras 22 dias y alcanzo autonomia digestiva a los 38,75 dias postrasplante. 5. Herida quirurgica, drenajes y estomas • Curas protocolarizadas : laparotomia abierta mas malla de goretex, 4 Jackson Pratt, ileostomia y gastrostomia. • Control del debito : drenajes 911 ± 1.026 ml/dia, gastrostomia 403 ± 257 ml/dia e ileostomia 341 ± 650 ml/dia. 6. Infeccioso : aislamiento protector, ratio enfermera:paciente 1:1. Estancia en UCI 41 dias y hospitalaria 169 dias. Therapeutic Intervention Scoring System 28 (TISS) 52 ± 6. El cuestionario de salud SF-36 aumento al ano un 32,95%. Comentarios La paciente presento multiples complicaciones que desencadenaron inestabilidad hemodinamica y destete largo. El postoperatorio fue mas largo y complicado que el de los pacientes con trasplante de intestino aislado. El TISS alto y el aislamiento protector determinaron una ratio enfermera:paciente de 1:1. La paciente ha mejorado su calidad de vida.

Because of the organ shortage, non-heart-beating donors have been proposed as a possible source of grafts for orthotopic liver transplantation (OLT). Despite the widespread use of controlled non-heart-beating donors, there are only a few published studies reporting the outcomes with uncontrolled non-heart-beating donors (UNHBDs). A prospective case-control study on adult patients undergoing OLT was designed. We used normothermic extracorporeal membrane oxygenation (NECMO) in all UNHBDs. Matching 2:1 ratio comparison was performed between a study group (UNHBDs) and a brain death donor (BDD) control group. Between January 2006 and March 2008, a total of 60 patients were included: 20 in the UNHBD group and 40 in the control group. The incidence of ischemic cholangiopathy was 5% (n = 1) for the UNHBD group and 0% for the BDD group (P = 0.15). The rate of primary nonfunction was 10% (n = 2) in UNHBD recipients and 2.5% (n = 1) in BDD recipients (P = 0.21), with graft loss in all of them. Three patients were retransplanted in the UNHBD group (15%), 2 of them because of primary nonfunction and 1 because of ischemic cholangiopathy; no patient was retransplanted in the control group (P = 0.012). After a mean follow-up of 330.4 +/- 224.9 days, 1-year cumulative patient survival was 85.5% for the UNHBD group and 87.5% for the BDD group (P = 0.768). One-year cumulative graft survival was 80% in the UNHBD group and 87.5% in the BDD group (P = 0.774). In conclusion, UNHBDs under NECMO are a potential source of organs for OLT with encouraging outcomes potentially comparable to those obtained with BDDs.

Anidulafungin is a new echinocandin that appears to have several advantages over existing antifungals. It is unique because it slowly degrades in humans, undergoing a process of biotransformation rather than being metabolized. It exhibits high in vitro and in vivo activities against Candida spp. and Aspergillus spp. In several clinical studies investigating Candida esophagitis; candidemia and invasive candidiasis, the clinical efficacy of this echinocandin was similar, or even superior, to that of established antifungals in candidemia. Antifungal activity against strains no longer susceptible to conventional antifungal agents, such as fluconazole and amphotericin B suggests that anidulafungin can be used as salvage therapy in life-threatening fungal infections. The limited toxicity profile, minimal drug-drug interactions and the fact that does not require dosage adjustment in subjects with hepatic or renal impairment, establishes this echinocandin as an attractive new option for the treatment of invasive fungal infections.

La anidulafungina es una nueva equinocandina que inhibe la sintesis de s-1,3-D-glucano sintasa e interrumpe la sintesis de la pared celular del hongo. Presenta una marcada actividad frente a Candida spp. y Aspergillus spp., incluyendo las especies resistentes a anfotericina B y triazoiles. Debido a su limitada biodisponibilidad oral unicamente se administra en la clinica por via parenteral. La anidulafungina sufre un proceso de degradacion espontanea en la sangre, no precisando de metabolizacion hepatica y siendo eliminada por via fecal en su mayoria como metabolitos inactivos. La eliminacion urinaria del farmaco es inferior al 1%. No precisa ajuste de dosis en insuficiencia hepatica ni renal. La anidulafungina es generalmente bien tolerada. Los efectos adversos notificados no se relacionan ni con la dosis ni con el tipo de infusion. La mayoria de los efectos adversos son flebitis, cefalea, nauseas, vomitos y fiebre. El limitado perfil de toxicidad y las minimas interacciones con otros farmacos (ciclosporina, tacrolimus y corticoesteroides) hacen de la anidulafungina una nueva opcion terapeutica para las infecciones fungicas invasoras, especialmente en pacientes receptores de trasplantes.

"Pharmaconutrient" is a term applicable to those compounds which. in addition to their nutritional function, play a role as aids in the treatment of patients with severe pathologies, including sepsis, trauma, burns and major surgery, In general, enrichment of enteral an parenteral formulas with pharmaconutrients contribute to positively modulate the inflammatory response, infection and controlling the internal milieu, which in turn can be evaluated through lower mortality, hospital and intensive care units stay, days of mechanical ventilation and other parameters allowing to asses their effects. Arginine, glutamine, nucleotides, omega-3 fatty acids and antioxidant micronutrients, make up the nucleus of pharmaconutrients used with that aim, usually as mixtures of them. In the present review current evidence about the effects, indications, limitations, doses, potential adverse risks and even counter-indications is analysed.El término farmaconutriente se aplica a aquellos compuestos que poseen un efecto añadido al meramente nutricional y que se utilizan como terapia coadyuvante en pacientes con patologías graves que incluyen sepsis, traumatismos, grandes quemados y enfermos quirúrgicos. En general, con su enriquecimiento en las fórmulas enterales o parenterales se pretende modular positivamente la respuesta inflamatoria, la infección y el control del medio interno, valorables a través de mortalidad, tiempo de estancia en hospital y en UCI, días de ventilación mecánica y otros parámetros que permiten dimensionar los efectos de su utilización. Arginina, glutamina, nucleótidos, ácidos grasos omega-3 y micronutrientes antioxidantes constituyen el núcleo de los farmaconutrientes utilizados con la finalidad antedicha, habitualmente en forma de mezclas. En la presente revisión se analiza la evidencia actual acerca de sus efectos, indicaciones, limitaciones, cantidades a aportar, peligros potenciales e incluso contraindicaciones.

Introduction Although standard enteral nutrition is universally accepted, the use of disease-specific formulas for hyperglycemic patients is still controversial. This study examines whether a high-protein diabetes-specific formula reduces insulin needs, improves glycemic control and reduces ICU-acquired infection in critically ill, hyperglycemic patients on mechanical ventilation (MV). Methods This was a prospective, open-label, randomized (web-based, blinded) study conducted at nine Spanish ICUs. The patient groups established according to the high-protein formula received were: group A, new-generation diabetes-specific formula; group B, standard control formula; group C, control diabetes-specific formula. Inclusion criteria were: expected enteral nutrition ≥5 days, MV, baseline glucose >126 mg/dL on admission or >200 mg/dL in the first 48 h. Exclusion criteria were: APACHE II ≤10, insulin-dependent diabetes, renal or hepatic failure, treatment with corticosteroids, immunosuppressants or lipid-lowering drugs and body mass index ≥40 kg/m2. The targeted glucose level was 110–150 mg/dL. Glycemic variability was calculated as the standard deviation, glycemic lability index and coefficient of variation. Acquired infections were recorded using published consensus criteria for critically ill patients. Data analysis was on an intention-to-treat basis. Results Over a 2-year period, 157 patients were consecutively enrolled (A 52, B 53 and C 52). Compared with the standard control formula, the new formula gave rise to lower insulin requirement (19.1 ± 13.1 vs. 23.7 ± 40.1 IU/day, p p p p p p p p Conclusions In these high-risk ICU patients, both diabetes-specific formulas lowered insulin requirements, improved glycemic control and reduced the risk of acquired infections relative to the standard formula. Compared with the control-specific formula, the new-generation formula also improved capillary glycemia. Trial registration Clinicaltrials.gov NCT1233726.

Patients treated with mechanical ventilation in the prone position (PP) could have an increased risk for feeding intolerance. However, the available evidence supporting this hypothesis is limited and contradictory.To examine the feasibility and efficacy of enteral nutrition (EN) support and its associated complications in patients receiving mechanical ventilation in PP.Prospective observational study including 34 mechanically ventilated intensive care patients who were turned to the prone position over a 3-year period. End points related to efficacy and safety of EN support were studied.In total, more than 1200 patients were admitted to the intensive care unit over a period of 3 years. Of these, 34 received mechanical ventilation in PP. The mean days under EN were 24.7 ± 12.3. Mean days under EN in the supine position were significantly higher than in PP (21.1 vs 3.6; P.001), but there were no significant differences in gastric residual volume adjusted per day of EN (126.6 vs 189.2; P = .054) as well as diet volume ratio (94.1% vs 92.8%; P = .21). No significant differences in high gastric residual events per day of EN (0.06 vs 0.09; P = .39), vomiting per day of EN (0.016 vs 0.03; P = .53), or diet regurgitation per day of EN (0 vs 0.04; P = .051) were found.EN in critically ill patients with severe hypoxemia receiving mechanical ventilation in PP is feasible, safe, and not associated with an increased risk of gastrointestinal complications. Larger studies are needed to confirm these findings.

BACKGROUND Despite its benefits, early enteral nutrition (EN) is considered controversial in critically ill patients with severe hemodynamic failure. OBJECTIVE To evaluate the tolerance and safety of early EN in a consecutive group of patients receiving venoarterial (VA) extracorporeal membrane oxygenation (ECMO) for severe hemodynamic failure. MATERIALS AND METHODS Prospective observational study performed in a cardiac surgical intensive care unit (ICU) during a 1-year period. All adult patients receiving VA ECMO for severe hemodynamic failure unresponsive to conventional therapies were included. Nutrition support was provided during the study period following the established ICU nutrition protocol. Energy target was 25 kcal/kg, to be reached over 4 days. Nutrition tolerance was defined as the ratio of delivered nutrition to target nutrition, expressed as a percentage. Special interest was made to detect possible adverse effects attributable to EN. The authors performed a descriptive statistical analysis. RESULTS Of 553 patients admitted in the cardiac surgical ICU during the study period, 7 were treated with ECMO. EN was the only nutrition source. More than 70% nutrition tolerance was achieved within the first week in all cases. No serious adverse events that could be attributable to EN were noted. CONCLUSION The present study shows that, under proper medical supervision, early EN is possible and safe in patients with severe hemodynamic failure receiving VA ECMO. No serious adverse events were attributable to EN. More studies are warranted to confirm these findings.

Invasive fungal infections are a significant cause of morbidity and mortality among immunocompromised patients. Although several new antifungal agents have been developed in the past few years, the management of serious fungal infections continues to be problematic.To review the pharmacodynamics and pharmacokinetics of a new antifungal agent: micafungin.A systematic review of biomedic databases (EBSCO Open Journals, Ovid Online, Proquest Medical Library, PubMed/Medline, Science Direct, Springer Links and Wiley Interscience) has been performed. Search was conducted from 2000 to 2008. Supplementary sources included abstracts from the Interscience Conference on Antimicrobial Agents (ICAAC) and Chemotherapy and the Infectious Diseases Society of America (IDSA) from 1998 to 2008.Micafungin has a potent mechanism of action: inhibits beta-1,3-D-glucan synthase interfering with fungal cell wall synthesis. This agent shares with caspofungin an identical spectrum of in vitro activity against Candida albicans, non-albicans Candida species, and Aspergillus. Due to the limited oral availability, micafungin is available for parenteral administration only. Micafungin is characterized by a linear pharmacokinetic profile and substantially fewer toxic effects. Micafungin is a poor substrate for the cytochrome P450 enzymes, and compared to azoles, fewer drug interactions have been described. No dose reduction is required in renal impairment or in mild to moderate liver failure.The pharmacodynamic and pharmacokinetic profiles of micafungin imply that this drug is a safe alternative for the treatment of fungal infections. Micafungin can be safely co-administered with most drugs without the need for dosage adaptation even in patients with renal o liver function impairment.

Anidulafungin is a new echinocandin antifungal agent which inhibits beta-1,3-D-glucan synthase and disrupts fungal cell-wall synthesis. It has marked antifungal activity against Candida spp. and Aspergillus spp., including amphotericin B and triazole resistant strains. Due to the limited oral availability, anidulafungin in clinical use is available for parenteral administration only. Elimination of anidulafungin takes place via slow non-enzymatic degradation to inactive metabolites. Less than 10% and 1% of the initially administered drug is excreted unchanged into feces and urine, respectively. It does not require dosage adjustment in subjects with hepatic or renal impairment established. Anidulafungin is generally well tolerated. Adverse events appear not to be dose or infusion related. The most common treatment related adverse events are phlebitis, headache, nausea, vomiting and pyrexia. The lack of interactions with tacrolimus, cyclosporine and corticosteroids and its limited toxicity profile places anidulafungin as an attractive new option for the treatment of invasive fungal infections especially in transplant patients.

Anidulafungin is a new echinocandin that appears to have several advantages over existing antifungals. It is unique because it slowly degrades in humans, undergoing a process of biotransformation rather than being metabolized. It exhibits high in vitro and in vivo activities against Candida spp. and Aspergillus spp. In several clinical studies investigating Candida esophagitis; candidemia and invasive candidiasis, the clinical efficacy of this echinocandin was similar, or even superior, to that of established antifungals in candidemia. Antifungal activity against strains no longer susceptible to conventional antifungal agents, such as fluconazole and amphotericin B suggests that anidulafungin can be used as salvage therapy in life-threatening fungal infections. The limited toxicity profile, minimal drug-drug interactions and the fact that does not require dosage adjustment in subjects with hepatic or renal impairment, establishes this echinocandin as an attractive new option for the treatment of invasive fungal infections.

Undernutrition affects 30 to 50% of hospitalized patients. The identification of patients with undernutrition or in risk to become undernourished is of utmost importance to prescribe a timely nutritional support. This article performs a critical review of anthropometrical, biochemical and functional parameters used for nutritional assessment. Prognostic indexes and other parameters used for the assessment of nutritional risk are also discussed. Some tools are proposed for the diagnosis of hospital malnutrition.

Undernutrition affects 30 to 50% of hospitalized patients. The identification of patients with undernutrition or in risk to become undernourished is of utmost importance to prescribe a timely nutritional support. This article performs a critical review of anthropometrical, biochemical and functional parameters used for nutritional assessment. Prognostic indexes and other parameters used for the assessment of nutritional risk are also discussed. Some tools are proposed for the diagnosis of hospital malnutrition (Rev Méd Chile 2006; 134: 1051-8).

Dear Editor We read with interest the article by Ferrie et al. [1] on nutritional support in adult patients receiving extracorporeal membrane oxygenation (ECMO). The authors retrospectively audited 86 patients who received ECMO [venovenous (VV) or venoarterial (VA) mode] and fed using protocols that emphasize early enteral nutrition (EN). It is believed that the hemodynamic alterations which occur in these patients can lead to serious complications, such as mesenteric ischemia. The main finding of this elegant study is that early EN can be well tolerated in such patients (average 79.7 % of target nutrition). However, some obstacles to adequate nutrition were identified, such as the use of propofol for sedation, and 18 patients required parenteral support due to EN intolerance. Intolerance did not differ between ECMO modes. We would like to discuss our recent findings on this subject as a complement to this study by Ferrie et al. [1]. We have recently reported a prospective case series of early EN in seven patients receiving VA ECMO for severe hemodynamic failure unresponsive to conventional therapies [2], as well as a prospective study involving 37 cardiac surgery patients with hemodynamic failure [3]. Although some differences are present in these two studies regarding the applied nutrition protocol and definition of nutritional goal, we came to the same main conclusion: early EN is possible and not associated with serious complications. However, we did note significant energy deficits, especially in patients with a long stay in the ICU ([14 days). Complications such as abdominal distention, diarrhea, and constipation were frequent ([25 % of included patients). These complications barely received any mention in the paper published by Ferrie et al. [1]. We would therefore like to ask the authors about their experience with energy balances using EN alone, as well as a more detailed description of EN-related complications. Despite current recommendations regarding nutritional support in patients with hemodynamic failure [4], we agree with the authors that EN is possible in ECMO patients, always under proper medical supervision. Although controversial, we also consider that EN is also feasible in cardiac surgery patients with hemodynamic failure [5]. More studies are clearly warranted to confirm these findings.

For Emergency Department (ED) patients the timing of transfer to the Intensive Care Unit (ICU) to receive the most appropriate treatments and early life-sustaining therapies may be an important determinant of outcome.