Discusión de Soporte Nutricional del Paciente Adulto

El presente documento presenta un ejercicio de consenso sobre los aspectos más relevantes a los que se ven enfrentados los profesionales que se encargan de la nutrición clínica.

A diferencia de las guías de práctica clínica, los procedimientos de consenso intentan conciliar las diferentes visiones que se tienen sobre un problema, teniendo en cuenta las condiciones propias del medio donde se desarrollan las acciones. Este documento representa las posiciones de múltiples profesionales que ejercen en instituciones de diferente carácter y en diferentes zonas geográficas del país, por lo que las conclusiones son de fácil aplicación en el contexto general y ayudan a disminuir la heterogeneidad en los tratamientos, además de ofrecer una opción para un manejo más costoefectivo de los pacientes que requieren nutrición.

Aunque en muchos de los temas se logró consenso, otros temas demostraron la variabilidad clínica existente entre profesionales que practican la nutrición. Es, entonces, función de la Asociación liderar un proceso que permita alcanzar el consenso en estos aspectos. Entre los más importantes, se deben mencionar los relacionados con la estructura de los grupos y sus procesos, lo mismo que en los indicadores y el mecanismo de evaluación del desempeño de los grupos. En el contexto actual del sistema de salud, demostrar no solo que las cosas se hacen bien, sino el efecto que esto tiene sobre los pacientes, su calidad de vida y sobre las finanzas del sistema, es absolutamente necesario para garantizar la supervivencia y el desarrollo de los grupos de nutrición clínica. También, es relevante sugerir mecanismos que motiven a los diferentes profesionales implicados a participar en reuniones de actualización y a realizar investigación que permita mejorar progresivamente la calidad del cuidado nutricional en el país.

Nutritional support in the adult. Consensus meeting of the Colombian Association of Clinical Nutrition

Abstract

Introduction: Nutritional support is the only therapeutic strategy for patients with difficulties in food ingestion. This document tries to unify concepts about nutrition in adults and to develop a simple and easy to consult tool.

Material and methods: A consensus development method was chosen. The Colombian Association for Clinical Nutrition selected experts based on their leadership in nutritional support groups, their profession and place of work. Twenty five people answered the surveys and three groups were assembled: one to define the structure of nutritional support groups, to calculate caloric requirements; and to discuss enteral and parenteral access methods. Question about each subject were previously defined and the answers were categorized. After three rounds, the consensus method was closed.

Results: It was possible to attain a consensus on the necessity to have nutritional support group to manage adults patients with enteral or parenteral nutrition|; the group should include a physician, a nutritionist, a nurse and pharmaceutical chemist with specific functions; patients should be assessed daily; the HarrisBenedict formula should be used to calculate energy requirements; protein, fat and caloric contribution doses; enteral tube should be made of silicone or polyurethane; indications of enteral tubes; indication of duodenal tubes; indication of percutaneous endoscopic gastrostomy as the definitive way of enteral nutrition; time to begin enteral nutrition; management of enteral tubes for medicine administration; indications of parenteral nutrition; use of central vein catheter and dressings; way and place of catheter insertion and time of change.

Conclusion: There are recommendations in nutritional support that are widely accepted and allow a standardization of processes.

Key words: consensus development conference; nutrition personnel; nutrition programs; enteral nutrition; parenteral nutrition, total.

Referencias

1. Stratton RJ, Elia M. Who benefits from nutritional support: What is the evidence? Eur J Gastroenterol Hepatol. 2007;19:3538.
2. Allison SP. Malnutrition, disease, and outcome. Nutrition. 2000;16:5903.
3. PayneJames J, Silk D. Clinical nutrition support. BMJ. 1990;301:12.
4. Pritchard C, Duffy S, Edington J, Pang F. Enteral nutrition and oral nutrition supplements: A review of the economics literature. JPEN J Parenter Enteral Nutr. 2006;30:529.
5. Strickland A, Brogan A, Krauss J, Martindale R, Cresci G. Is the use of specialized nutritional formulations a costeffective strategy? A national database evaluation. JPEN J Parenter Enteral Nutr. 2005;29:S8191.
6. Tchekmedyian NS. Costs and benefits of nutrition support in cancer. Oncology (Williston Park). 1995;9:7984.
7. Villa K. Situación actual de los equipos interdisciplinarios de terapia nutricional metabólica en los hospitales de tercer y cuarto nivel en Colombia. Bogotá: Pontificia Universidad Javeriana; 2012.
8. Bischoff SC, Kester L, Meier R, Radziwill R, Schwab D, Thul P. Organization, regulations, preparation and logistics of parenteral nutrition in hospitals and homes; the role of the nutrition support team Guidelines on Parenteral Nutrition. Ger Med Sci. 2009;7: Doc20.
9. Saalwachter AR, Evans HL, Willcutts KF, O’Donnell KB, Radigan AE, McElearney ST, et al. A nutrition support team led by general surgeons decreases inappropriate use of total parenteral nutrition on a surgical service. Am Surg. 2004;70:110711.
10. Schneider PJ. Nutrition support teams: An evidencebased practice. Nutr Clin Pract. 2006;21:627.
11. Anker SD, Laviano A, Filippatos G, John M, Paccagnella A, Ponikowski P, et al. ESPEN Guidelines on Parenteral Nutrition: On cardiology and pneumology. Clin Nutr. 2009;28:45560.
12. Bozzetti F, Arends J, Lundholm K, Micklewright A, Zurcher G, Muscaritoli M. ESPEN Guidelines on Parenteral Nutrition: Nonsurgical oncology. Clin Nutr. 2009;28:4454.
13. Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann A, Bozzetti F. ESPEN Guidelines on Parenteral Nutrition: Surgery. Clin Nutr. 2009;28:37886.
14. Cano NJ, Aparicio M, Brunori G, Carrero JJ, Cianciaruso B, Fiaccadori E, et al. ESPEN Guidelines on Parenteral Nutrition: Adult renal failure. Clin Nutr. 2009;28:40114.
15. Gianotti L, Meier R, Lobo DN, Bassi C, Dejong CH, Ockenga J, et al. ESPEN Guidelines on Parenteral Nutrition: Pancreas. Clin Nutr. 2009;28:42835.
16. Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nut.r 2003;27:35573.
17. Pittiruti M, Hamilton H, Biffi R, MacFie J, Pertkiewicz M. ESPEN Guidelines on Parenteral Nutrition: Central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr. 2009;28:36577.
18. Plauth M, Cabre E, Campillo B, Kondrup J, Marchesini G, Schutz T, et al. ESPEN Guidelines on Parenteral Nutrition: Hepatology. Clin Nutr. 2009;28:43644.
19. Singer P, Berger MM, van den Berghe G, Biolo G, Calder P, Forbes A, et al. ESPEN Guidelines on Parenteral Nutrition: Intensive care. Clin Nutr. 2009;28:387400.
20. Sobotka L, Schneider SM, Berner YN, Cederholm T, Krznaric Z, Shenkin A, et al. ESPEN Guidelines on Parenteral Nutrition: Geriatrics. Clin Nutr. 2009;28:4616.
21. Staun M, Pironi L, Bozzetti F, Baxter J, Forbes A, Joly F, et al. ESPEN Guidelines on Parenteral Nutrition: Home parenteral nutrition (HPN) in adult patients. Clin Nutr. 2009;28:46779.
22. van GA, Cabre E, Hebuterne X, Jeppesen P, Krznaric Z, Messing B, et al. ESPEN Guidelines on Parenteral Nutrition: Gastroenterology. Clin Nutr. 2009;28:41527.
23. Lewis JS. Assessing physician variability in parenteral nutrition orders given a set of patient parameters as a means of determining educational needs. Hosp Pharm. 1993;28:52539
24. Street JL, Montgomery D, Alder SC, Lambert DK, Gerstmann DR, Christensen RD. Implementing feeding guidelines for NICU patients 25. Vanek VW, Sharnek LK, Snyder DM, Kupensky DT, Rutushin AL. Assessment of physicians’ ability to prescribe parenteral nutrition support in a community teaching hospital. J Am Diet Assoc. 1997;97:8569.
26. Black N, Murphy M, Lamping D, McKee M, Sanderson C, Askham J, et al. Consensus development methods: A review of best practice in creating clinical guidelines. J Health Serv Res Policy. 1999;4:23648.
27. Hasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs. 2000;32:100815.
28. Jones J, Hunter D. Consensus methods for medical and health services research. BMJ. 1995;311:37680.


Correspondencia: Charles Bermúdez, MD, MSc (C.)
Correo electrónico: chebermud@yahoo.com
Bogotá, D.C., Colombia

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