Incertidumbre clínica durante la prescripción de proteína al paciente en estado crítico de Latinoamérica

Palabras clave: EFFORT, cuidados críticos, dosis de proteína, soporte nutricional, ensayos clínicos basados en registros

Resumen

Las Guías de Práctica Clínica recomiendan una dosis proteica en pacientes en estado crítico de 1,2 a 2,0 g/kg/día. A pesar de esta recomendación, la cantidad real oscila entre 0,5 y 3,8 g/kg/ día, por lo cual existe en el mundo una controversia significativa acerca de la cantidad de proteína prescrita y la administrada.
Esta revisión introduce el concepto de “equiponderación” clínica, balance o equilibrio en las estrategias de dosificación óptima de proteína. Además, se resalta la contribución limitada de pacientes de Latinoamérica (LATAM) en los Ensayos Clínicos Aleatorizados (ECA) existentes y cuestiona la generalización o extrapolación de sus resultados. Este escrito muestra la evidencia a favor y en contra de la prescripción de proteína en dosis altas e introduce el estudio Efecto de una Dosis Alta de Proteína en Pacientes Críticos (EFFORT) el cual intenta dar respuesta a la pregunta: ¿cuál es la mejor dosis de proteína para este tipo de pacientes?

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Arabi YM, Casaer MP, Chapman M, et al. The intensive care medicine research agenda in nutrition and metabolism. Intensive Care Med. 2017;43(9):1239-1256. doi:10.1007/s00134-017-4711-6.

Taylor BE, McClave SA, Martindale RG, 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 (A.S.P.E.N.). Crit Care Med. 2016;44(2).

http://journals.lww.com/ccmjournal/Fulltext/2016/02000/Guidelines_for_the_Provision_and_Assessment_of.20.aspx.

Heyland DK, Weijs PJM, Coss-Bu JA, et al. Protein Delivery in the Intensive Care Unit: Optimal or Suboptimal? Nutr Clin Pract. 2017;32(1 Suppl):58S-71S. doi:10.1177/0884533617691245.

Arabi YM, Aldawood AS, Haddad SH, et al. Permissive Underfeeding or Standard Enteral Feeding in Critically Ill Adults. N Engl J Med. 2015;372(25):2398-2408. doi:10.1056/NEJMoa1502826.

Rice TW, Wheeler AP, Thompson BT, et al. Initial Trophic vs Full Enteral Feeding in Patients With Acute Lung Injury: The EDEN Randomized Trial. JAMA J Am Med Assoc. 2012;307(8):795-803. doi:10.1001/jama.2012.137.

Casaer MP, Hermans G, Wilmer A, Van den Berghe G. Impact of early parenteral nutrition completing enteral nutrition in adult critically ill patients (EPaNIC trial): A study protocol and statistical analysis plan for a randomized controlled trial. Trials. 2011. doi:10.1186/1745-6215-12-21.

Cahill NE, Dhaliwal R, Day AG, Jiang X, Heyland DK. Nutrition therapy in the critical care setting: what is “best achievable” practice? An international multicenter observational study. Crit Care Med. 2010;38(2):395-401. doi:10.1097/CCM.0b013e3181c0263d.

Nicolo M, Heyland DK, Chittams J, Sammarco T, Compher C. Clinical Outcomes Related to Protein Delivery in a Critically Ill Population: A Multicenter, Multinational Observation Study. JPEN J Parenter Enteral Nutr. 2016;40(1):45-51. doi:10.1177/0148607115583675.

Allingstrup MJ, Esmailzadeh N, Wilkens Knudsen A, et al. Provision of protein and energy in relation to measured requirements in intensive care patients. Clin Nutr. 2012. doi:10.1016/j.clnu.2011.12.006.

Weijs PJM, Looijaard WGPM, Beishuizen A, Girbes ARJ, Oudemans-van Straaten HM. Early high protein intake is associated with low mortality and energy overfeeding with high mortality in non-septic mechanically ventilated critically ill patients. Crit Care. 2014. doi:10.1186/s13054-014-0701-z.

Vallejo KP, Martínez CM, Matos Adames AA, et al. Current clinical nutrition practices in critically ill patients in Latin America: a multinational observational study. Crit Care. 2017;21(1):227. doi:10.1186/s13054-017-1805-z.

Barreto EF, Kanderi T, DiCecco SR, et al. Sarcopenia Index Is a Simple Objective Screening Tool for Malnutrition in the Critically Ill. JPEN J Parenter Enteral Nutr. 2018. doi:10.1002/jpen.1492.

Canales C, Elsayes A, Yeh DD, et al. Nutrition Risk in Critically Ill Versus the Nutritional Risk Screening 2002: Are They Comparable for Assessing Risk of Malnutrition in Critically Ill Patients? JPEN J Parenter Enteral Nutr. 2018. doi:10.1002/jpen.1181.

Verghese PP, Mathai AS, Abraham V, Kaur P. Assessment of malnutrition and enteral feeding practices in the critically ill: A single-centre observational study. Indian J Anaesth. 2018;62(1):29-35. doi:10.4103/ija.IJA_513_17.

Alberda C, Gramlich L, Jones N, et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med. 2009;35(10):1728-1737. doi:10.1007/s00134-009-1567-4.

Heyland DK, Patel J, Bear D, et al. The Effect of Higher Protein Dosing in Critically Ill Patients: A Multicenter Registry-Based Randomized Trial: The EFFORT Trial. JPEN J Parenter Enteral Nutr. 2018. doi:10.1002/jpen.1449.

Heyland DK, Stapleton R, Compher C. Should We Prescribe More Protein to Critically Ill Patients? Nutrients. 2018;10(4). doi:10.3390/nu10040462.

Liebau F, Sundstrom M, van Loon LJC, Wernerman J, Rooyackers O. Short-term amino acid infusion improves protein balance in critically ill patients. Crit Care. 2015;19:106. doi:10.1186/s13054-015-0844-6.

Dickerson RN, Pitts SL, Maish GO 3rd, et al. A reappraisal of nitrogen requirements for patients with critical illness and trauma. J Trauma Acute Care Surg. 2012;73(3):549-557. doi:10.1097/TA.0b013e318256de1b.

Rosselli D, Rugeles S-J, Rueda J-D, Díaz C-E. Hyperproteic hypocaloric enteral nutrition in the critically ill patient: A randomized controlled clinical trial. Indian J Crit Care Med. 2013. doi:10.4103/0972-5229.123438.

Ferrie S, Allman-Farinelli M. Commonly used “nutrition” indicators do not predict outcome in the critically ill: a systematic review. Nutr Clin Pract. 2013;28(4):463-484. doi:10.1177/0884533613486297.

Heyland DK, Cahill N, Day AG. Optimal amount of calories for critically ill patients: depends on how you slice the cake! Crit Care Med. 2011;39(12):2619-2626. doi:10.1097/CCM.0b013e318226641d.

Heyland DK, Stephens KE, Day AG, McClave S a. The success of enteral nutrition and ICU-acquired infections: A multicenter observational study. Clin Nutr. 2011;30(2):148-155. doi:10.1016/j.clnu.2010.09.011.

Wei X, Day AG, Ouellette-Kuntz H, Heyland DK. The Association Between Nutritional Adequacy and Long-Term Outcomes in Critically Ill Patients Requiring Prolonged Mechanical Ventilation: A Multicenter Cohort Study. Crit Care Med. 2015;43(8):1569-1579. doi:10.1097/CCM.0000000000001000.

Hoffer LJ, Bistrian BR. Why critically ill patients are protein deprived. JPEN J Parenter Enter Nutr. 2013;37. doi:10.1177/0148607113478192.

Doig GS, Simpson F, Bellomo R, et al. Intravenous amino acid therapy for kidney function in critically ill patients: a randomized controlled trial. Intensive Care Med. 2015;41(7):1197-1208. doi:10.1007/s00134-015-3827-9.

Puthucheary ZA, Rawal J, McPhail M, et al. Acute skeletal muscle wasting in critical illness. JAMA - J Am Med Assoc. 2013. doi:10.1001/jama.2013.278481.

Koekkoek WACK, van Setten CHC, Olthof LE, Kars JCNH, van Zanten ARH. Timing of PROTein INtake and clinical outcomes of adult critically ill patients on prolonged mechanical VENTilation: The PROTINVENT retrospective study. Clin Nutr. 2018. doi:10.1016/j.clnu.2018.02.012.

Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med. 2011;365. doi:10.1056/NEJMoa1102662.

Braunschweig CL, Freels S, Sheean PM, et al. Role of timing and dose of energy received in patients with acute lung injury on mortality in the Intensive Nutrition in Acute Lung Injury Trial (INTACT): a post hoc analysis. Am J Clin Nutr. 2017;105(2):411-416. doi:10.3945/ajcn.116.140764.

Gunst J, Vanhorebeek I, Thiessen SE, Van den Berghe G. Amino acid supplements in critically ill patients. Pharmacol Res. 2018;130:127-131. doi:10.1016/j.phrs.2017.12.007.

Gaudry S, Hajage D, Schortgen F, et al. Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit. N Engl J Med. 2016;375(2):122-133. doi:10.1056/NEJMoa1603017.

Btaiche IF, Mohammad RA, Alaniz C, Mueller BA. Amino Acid requirements in critically ill patients with acute kidney injury treated with continuous renal replacement therapy. Pharmacotherapy. 2008;28(5):600-613. doi:10.1592/phco.28.5.600.

Roberts PR, Black KW, Zaloga GP. Enteral feeding improves outcome and protects against glycerol-induced acute renal failure in the rat. Am J Respir Crit Care Med. 1997;156(4 Pt 1):1265-1269. doi:10.1164/ajrccm.156.4.9607003.

Bellomo R, Seacombe J, Daskalakis M, et al. A prospective comparative study of moderate versus high protein intake for critically ill patients with acute renal failure. Ren Fail. 1997;19(1):111-120.

Bellomo R, Tan HK, Bhonagiri S, et al. High protein intake during continuous hemodiafiltration: impact on amino acids and nitrogen balance. Int J Artif Organs. 2002;25(4):261-268.

Scheinkestel CD, Adams F, Mahony L, et al. Impact of increasing parenteral protein loads on amino acid levels and balance in critically ill anuric patients on continuous renal replacement therapy. Nutrition. 2003;19(9):733-740.

Fiaccadori E, Maggiore U, Rotelli C, et al. Effects of different energy intakes on nitrogen balance in patients with acute renal failure: a pilot study. Nephrol Dial Transplant. 2005;20(9):1976-1980. doi:10.1093/ndt/gfh956.

Doig GS, Simpson F, Finfer S, et al. Effect of evidence-based feeding guidelines on mortality of critically ill adults: a cluster randomized controlled trial. JAMA. 2008;300. doi:10.1001/jama.2008.826.

Doig GS, Simpson F, Sweetmant EA, Bellomo R. Improved Nutritional Support Is Associated with Reduced Renal Dysfunction in Critical Illness: A Post-Hoc Exploratory Subgroup Analysis. In: A41. CLINICAL TRIALS IN ICU. American Thoracic Society International Conference Abstracts. American Thoracic Society; 2009:A1567. doi:doi:10.1164/ajrccm-conference.2009.179.1_MeetingAbstracts.A1567.

Abel RM, Beck CHJ, Abbott WM, Ryan JAJ, Barnett GO, Fischer JE. Improved survival from acute renal failure after treatment with intravenous essential L-amino acids and glucose. Results of a prospective, double-blind study. N Engl J Med. 1973;288(14):695-699. doi:10.1056/NEJM197304052881401.

Singer P. High-dose amino acid infusion preserves diuresis and improves nitrogen balance in non-oliguric acute renal failure. Wien Klin Wochenschr. 2007;119(7-8):218-222. doi:10.1007/s00508-007-0794-3.

Zhu R, Allingstrup MJ, Perner A, Doig GS, Nephro-Protective Trial Investigators Group. The Effect of IV Amino Acid Supplementation on Mortality in ICU Patients May Be Dependent on Kidney Function: Post Hoc Subgroup Analyses of a Multicenter Randomized Trial. Crit Care Med. 2018;46(8):1293-1301. doi:10.1097/CCM.0000000000003221.

Mueller C, Compher C, Ellen DM, Directors the AS for P and EN (A. SPEN. B of. A.S.P.E.N. Clinical Guidelines: Nutrition Screening, Assessment, and Intervention in Adults. J Parenter Enter Nutr . 2011;35(1):16-24. doi:10.1177/0148607110389335.

Publicado
2019-05-01
Cómo citar
Ortiz-Reyes, L. A., & Heyland, D. (2019). Incertidumbre clínica durante la prescripción de proteína al paciente en estado crítico de Latinoamérica. Revista De Nutrición Clínica Y Metabolismo, 2(1), 47-53. https://doi.org/10.35454/rncm.v2n1.058
Sección
Artículos de revisión