Background: The concept introduced by enhanced recovery after surgery protocols modifies perioperative traditional care in digestive surgery. The integration of these modern recommendations components during the perioperative period are highly important to ensure less postoperative complications, reduced length of hospital stay and decreased surgical costs. Aims: The aim of this position paper is to emphasize the most important points of a multimodal perioperative care protocol. Methods:  A careful analysis of each recommendation of both ERAS and ACERTO protocols is presented, justifying its inclusion in the recommended multimodal care of digestive surgery patients. Results: Enhanced recovery programs (ERPs) such as ERAS and ACERTO protocols are a cornerstone in modern perioperative care. Nutritional therapy is highly important in digestive surgery and thus both preoperative and postoperative nutrition care are key to ensure less postoperative complications and to reduce the length of hospital stay. The concept of prehabilitation is another key element in ERPs. Management of crystalloid fluids in a perfect balance in vital. Fluid overload may delay the recovery of patients and increase postoperative complications. Abbreviation of preoperative fast for 2h before anesthesia is now accepted by various guidelines of both surgical and anesthesiology societies. Combined with early postoperative refeeding, these prescriptions are not only safe but can also enhance recovery of patients undergoing digestive procedures. Conclusions: This Brazilian College of Digestive Surgery position paper strongly emphasizes that the implementation of ERPs in digestive surgery represents a paradigm shift in perioperative care, transcending traditional practices and embracing an intelligent approach to patient well-being.   Background: The concept introduced by enhanced recovery after surgery protocols modifies perioperative traditional care in digestive surgery. The integration of these modern recommendations components during the perioperative period are highly important to ensure less postoperative complications, reduced length of hospital stay and decreased surgical costs. Aims: The aim of this position paper is to emphasize the most important points of a multimodal perioperative care protocol. Methods:  A careful analysis of each recommendation of both ERAS and ACERTO protocols is presented, justifying its inclusion in the recommended multimodal care of digestive surgery patients. Results: Enhanced recovery programs (ERPs) such as ERAS and ACERTO protocols are a cornerstone in modern perioperative care. Nutritional therapy is highly important in digestive surgery and thus both preoperative and postoperative nutrition care are key to ensure less postoperative complications and to reduce the length of hospital stay. The concept of prehabilitation is another key element in ERPs. Management of crystalloid fluids in a perfect balance in vital. Fluid overload may delay the recovery of patients and increase postoperative complications. Abbreviation of preoperative fast for 2h before anesthesia is now accepted by various guidelines of both surgical and anesthesiology societies. Combined with early postoperative refeeding, these prescriptions are not only safe but can also enhance recovery of patients undergoing digestive procedures. Conclusions: This Brazilian College of Digestive Surgery position paper strongly emphasizes that the implementation of ERPs in digestive surgery represents a paradigm shift in perioperative care, transcending traditional practices and embracing an intelligent approach to patient well-being.

ABSTRACT Objective: To assess the 30-day unplanned readmission rate and its association with overlapping probable sarcopenia and malnutrition after major oncological surgery. Methods: A prospective bicentric observational cohort study performed with adult oncological patients undergoing major surgery. The primary outcome was unplanned readmission within 30 days after discharge and the association with probable sarcopenia and malnutrition. Nutritional status and probable sarcopenia were assessed just prior to surgery. Patients classified using subjective global assessment, as B and C were malnourished. Probable sarcopenia was defined using SARC-F (strength, assistance with walking, rise from a chair, climb stairs, falls) questionnaire ≥4 points and low HGS (handgrip strength) <27kg for males and <16kg for females. Results: Two hundred and thirty-eight patients (51.7% female) with a median age of 60 years were included. The 30-day readmission rate was 9.0% (n=20). Univariate analysis showed an association of malnutrition (odds ratio (OR) = 4.84; p=0.024) and probable sarcopenia (OR = 4.94; p=0.049) with 30-day readmission. Furthermore, when both conditions were present, the patient was almost nine times more likely to be readmitted (OR = 8.9; p=0.017). Multivariable logistic regression analysis showed that overlapping probable sarcopenia and malnutrition was an independent predictor of 30-day unplanned readmission (OR = 8.10, 95% confidence interval (95%CI) 1.20-0.55; p=0.032). Conclusion: The 30-day unplanned readmission rate was 9.0%, and the overlap of probable sarcopenia and malnutrition is an independent predictor for the 30-day unplanned readmission after major oncologic surgery. Objective 30day day surgery Methods 3 assessment malnourished SARCF SARC F strength, strength (strength walking chair stairs falls 4 ≥ handgrip 27kg kg 16kg females Results thirtyeight thirty eight 51.7% 517 51 7 (51.7 female 6 included 90 9 0 9.0 n=20. n20 n n=20 . 20 (n=20) odds OR 4.84 484 84 p=0.024 p0024 p 024 4.94 494 94 p=0.049 p0049 049 Furthermore present 8.9 89 8 p=0.017. p0017 p=0.017 017 p=0.017) 810 10 8.10 95 95%CI 95CI CI (95%CI 1.200.55 120055 1.20 0.55 1 55 1.20-0.55 p=0.032. p0032 p=0.032 032 p=0.032) Conclusion 51.7 5 (51. 9. n2 n=2 2 (n=20 4.8 48 p=0.02 p002 02 4.9 49 p=0.04 p004 04 8. p001 p=0.01 01 81 8.1 200 1.200.5 12005 120 1.2 055 0.5 1.20-0.5 p003 p=0.03 03 51. (51 n= (n=2 4. p=0.0 p00 1.200. 1200 12 1. 05 0. 1.20-0. (5 (n= p=0. p0 1.200 1.20-0 ( (n p=0 1.20- p=

ABSTRACT BACKGROUND: The concept introduced by protocols of enhanced recovery after surgery modifies perioperative traditional care in digestive surgery. The integration of these modern recommendations components during the perioperative period is of great importance to ensure fewer postoperative complications, reduced length of hospital stay, and decreased surgical costs. AIMS: To emphasize the most important points of a multimodal perioperative care protocol. METHODS: Careful analysis of each recommendation of both ERAS and ACERTO protocols, justifying their inclusion in the multimodal care recommended for digestive surgery patients. RESULTS: Enhanced recovery programs (ERPs) such as ERAS and ACERTO protocols are a cornerstone in modern perioperative care. Nutritional therapy is fundamental in digestive surgery, and thus, both preoperative and postoperative nutrition care are key to ensuring fewer postoperative complications and reducing the length of hospital stay. The concept of prehabilitation is another key element in ERPs. The handling of crystalloid fluids in a perfect balance is vital. Fluid overload can delay the recovery of patients and increase postoperative complications. Abbreviation of preoperative fasting for two hours before anesthesia is now accepted by various guidelines of both surgical and anesthesiology societies. Combined with early postoperative refeeding, these prescriptions are not only safe but can also enhance the recovery of patients undergoing digestive procedures. CONCLUSIONS: This position paper from the Brazilian College of Digestive Surgery strongly emphasizes that the implementation of ERPs in digestive surgery represents a paradigm shift in perioperative care, transcending traditional practices and embracing an intelligent approach to patient well-being. BACKGROUND stay costs AIMS protocol METHODS RESULTS (ERPs thus vital societies refeeding procedures CONCLUSIONS wellbeing. wellbeing well being. being well-being

RESUMO RACIONAL: O conceito introduzido pelos protocolos de recuperação após a cirurgia modifica os cuidados perioperatórios tradicionais em cirurgia digestiva. A integração desses componentes modernos de recomendações, durante o período perioperatório, é de grande importância para garantir menos complicações pós-operatórias, redução do tempo de internação hospitalar e diminuição dos custos cirúrgicos. OBJETIVOS: Enfatizar os pontos mais importantes de um protocolo multimodal de cuidados perioperatórios. MÉTODOS: Análise criteriosa de cada recomendação dos protocolos ERAS e ACERTO, justificando sua inclusão no atendimento multimodal recomendado para pacientes de cirurgia digestiva. RESULTADOS: Os programas de recuperação avançada (PRAs), tais como os protocolos ERAS e ACERTO, são a base dos cuidados perioperatórios modernos. A terapia nutricional é de grande importância na cirurgia digestiva e, portanto, tanto os cuidados nutricionais pré-operatórios, quanto pós-operatórios são fundamentais para garantir menos complicações pós-operatórias e reduzir o tempo de internação hospitalar. O conceito de pré-habilitação é outro elemento-chave nos PRAs. O manuseio de fluidos cristalóides em perfeito equilíbrio é vital. A sobrecarga de fluidos pode atrasar a recuperação dos pacientes e aumentar as complicações pós-operatórias. A abreviação do jejum pré-operatório para duas horas antes da anestesia é agora aceita por diversas diretrizes das sociedades cirúrgicas e de anestesiologia. Combinadas com a realimentação pós-operatória precoce, essas prescrições não são apenas seguras, mas também podem melhorar a recuperação de pacientes submetidos a procedimentos digestivos. CONCLUSÕES: Este posicionamento do Colégio Brasileiro de Cirurgia Digestiva enfatiza fortemente que a implementação de PRAs em cirurgia digestive, representa uma mudança de paradigma no cuidado perioperatório, transcendendo as práticas tradicionais e adotando uma abordagem inteligente para o bem-estar do paciente. RACIONAL recomendações perioperatório pósoperatórias, pósoperatórias pós operatórias, operatórias cirúrgicos OBJETIVOS MÉTODOS ACERTO RESULTADOS PRAs, , (PRAs) portanto préoperatórios, préoperatórios pré operatórios, operatórios pré-operatórios pósoperatórios préhabilitação habilitação elementochave elemento chave vital pósoperatórias. operatórias. préoperatório operatório anestesiologia pósoperatória operatória precoce seguras digestivos CONCLUSÕES digestive bemestar bem estar paciente (PRAs

ABSTRACT OBJECTIVES: To investigate the prevalence of sarcopenia according to five cut-off points for muscle strength and the association with undernutrition in Community dwelling older adults. METHODOLOGY: Cross-sectional study with 321 elderly subjects from community centers in Cuiabá-MT. The main variable was the prevalence of sarcopenia and association with undernutrition. Sarcopenia was diagnosed by low muscle strength (grip strength - GS; kg) according to five cut-off points and low calf circumference (CC; cm). Nutritional status was assessed by mini nutritional assessment-short form (MNA-SF®). RESULTS: The median age was 69 (64-74) years, and 24.7% were undernourished. The presence of sarcopenia ranged from 1.6 to 7.6%. This prevalence was lower using EWGSOP2 criteria compared to EWGSOP (p=0.005) and ESCEO and SDOC criteria (p<0.001). The older undernourished adults were almost 3.5 times more likely to have sarcopenia (OR=3.49; p=0.003) when ESCEO criteria was used and almost 2.5 times (OR=2.43; p=0.037) times using SDOC criteria. CONCLUSIONS: The prevalence of sarcopenia ranged from 1.6 to 7.6%. The older undernourished adults were almost 3.5 (ESCEO) and 2.5 (SDOC) times more likely to have sarcopenia.

The field of medicine has always been at the forefront of technological innovation, constantly seeking new strategies to diagnose, treat, and prevent diseases. Guidelines for clinical practice to orientate medical teams regarding diagnosis, treatment, and prevention measures have increased over the years. The purpose is to gather the most medical knowledge to construct an orientation for practice. Evidence-based guidelines follow several of the main characteristics of a systematic review, including systematic and unbiased search, selection, and extraction of the source of evidence. In recent years, the rapid advancement of artificial intelligence (AI) has provided clinicians and patients with access to personalized, data-driven insights, support and new opportunities for healthcare professionals to improve patient outcomes, increase efficiency, and reduce costs. One of the most exciting developments in AI has been the emergence of chatbots. A chatbot is a computer program to simulate conversation with human users. Recently, OpenAI, a research organization focused on machine learning, developed ChatGPT, a large language model that generates human-like text. ChatGPT uses a type of AI known as a deep learning model. ChatGPT can quickly search and select pieces of evidence through numerous databases to provide answers to complex questions, reducing the time and effort required to research a particular topic manually. Consequently, language models can accelerate the creation of clinical practice guidelines. While there is no doubt that ChatGPT has the potential to revolutionize the way healthcare is delivered, it is essential to note that it should not be used as a substitute for human healthcare professionals. Instead, ChatGPT should be seen as a tool that can be used to augment and support the work of healthcare professionals, helping them to provide better care to their patients.

A área da medicina sempre esteve na vanguarda da inovação tecnológica, buscando constantemente novas estratégias para diagnosticar, tratar e prevenir doenças. As diretrizes para a prática clínica são para orientar as equipes médicas quanto ao diagnóstico, tratamento e medidas de prevenção aumentaram ao longo dos anos. O objetivo é reunir o máximo de conhecimento médico para construir uma orientação para a prática. As diretrizes baseadas em evidências seguem várias das principais características de uma revisão sistemática, incluindo busca sistemática e imparcial, seleção e extração da fonte de evidência. Nos últimos anos, o rápido avanço da inteligência artificial (IA) forneceu aos médicos e pacientes acesso a informações personalizadas e baseadas em dados, suporte e novas oportunidades para os profissionais de saúde melhorarem os resultados dos pacientes, aumentarem a eficiência e reduzirem custos. Um dos desenvolvimentos mais empolgantes da IA foi o surgimento dos chatbots. Um chatbot é um programa de computador para simular conversas com usuários humanos. Recentemente, a OpenAI, uma organização de pesquisa focada em aprendizado de máquina, desenvolveu o ChatGPT, um grande modelo de linguagem que gera texto semelhante ao humano. O ChatGPT usa um tipo de IA conhecido como modelo de aprendizado profundo. O ChatGPT pode pesquisar e selecionar rapidamente evidências em vários bancos de dados para fornecer respostas a perguntas complexas, reduzindo o tempo e o esforço necessários para pesquisar um tópico específico manualmente. Consequentemente, os modelos de linguagem podem acelerar a criação de diretrizes de prática clínica. Embora não haja dúvida de que o ChatGPT tem potencial para revolucionar a forma como os cuidados de saúde são prestados, é essencial observar que não deve ser usado como substituto de profissionais de saúde humanos. Em vez disso, o ChatGPT deve ser visto como uma ferramenta que pode ser usada para aumentar e apoiar o trabalho dos profissionais de saúde, ajudando-os a prestar melhores cuidados aos seus pacientes.

RESUMO A área da medicina sempre esteve na vanguarda da inovação tecnológica, buscando constantemente novas estratégias para diagnosticar, tratar e prevenir doenças. As diretrizes para a prática clínica são para orientar as equipes médicas quanto ao diagnóstico, tratamento e medidas de prevenção aumentaram ao longo dos anos. O objetivo é reunir o máximo de conhecimento médico para construir uma orientação para a prática. As diretrizes baseadas em evidências seguem várias das principais características de uma revisão sistemática, incluindo busca sistemática e imparcial, seleção e extração da fonte de evidência. Nos últimos anos, o rápido avanço da inteligência artificial forneceu aos médicos e pacientes acesso a informações personalizadas e baseadas em dados, suporte e novas oportunidades para os profissionais de saúde melhorarem os resultados dos pacientes, aumentarem a eficiência e reduzirem custos. Um dos desenvolvimentos mais empolgantes da Inteligência Artificial foi o surgimento dos chatbots. Um chatbot é um programa de computador para simular conversas com usuários humanos. Recentemente, a OpenAI, uma organização de pesquisa focada em aprendizado de máquina, desenvolveu o ChatGPT, um grande modelo de linguagem que gera texto semelhante ao humano. O ChatGPT usa um tipo de inteligência artificial conhecido como modelo de aprendizado profundo. O ChatGPT pode pesquisar e selecionar rapidamente evidências em vários bancos de dados para fornecer respostas a perguntas complexas, reduzindo o tempo e o esforço necessários para pesquisar um tópico específico manualmente. Consequentemente, os modelos de linguagem podem acelerar a criação de diretrizes de prática clínica. Embora não haja dúvida de que o ChatGPT tem potencial para revolucionar a forma como os cuidados de saúde são prestados, é essencial observar que não deve ser usado como substituto de profissionais de saúde humanos. Em vez disso, o ChatGPT deve ser visto como uma ferramenta que pode ser usada para aumentar e apoiar o trabalho dos profissionais de saúde, ajudando-os a prestar melhores cuidados aos seus pacientes. tecnológica diagnosticar doenças diagnóstico anos imparcial evidência custos chatbots humanos Recentemente OpenAI máquina humano profundo complexas manualmente Consequentemente prestados disso ajudandoos ajudando

ABSTRACT The field of medicine has always been at the forefront of technological innovation, constantly seeking new strategies to diagnose, treat, and prevent diseases. Guidelines for clinical practice to orientate medical teams regarding diagnosis, treatment, and prevention measures have increased over the years. The purpose is to gather the most medical knowledge to construct an orientation for practice. Evidence-based guidelines follow several main characteristics of a systematic review, including systematic and unbiased search, selection, and extraction of the source of evidence. In recent years, the rapid advancement of artificial intelligence has provided clinicians and patients with access to personalized, data-driven insights, support and new opportunities for healthcare professionals to improve patient outcomes, increase efficiency, and reduce costs. One of the most exciting developments in Artificial Intelligence has been the emergence of chatbots. A chatbot is a computer program used to simulate conversations with human users. Recently, OpenAI, a research organization focused on machine learning, developed ChatGPT, a large language model that generates human-like text. ChatGPT uses a type of AI known as a deep learning model. ChatGPT can quickly search and select pieces of evidence through numerous databases to provide answers to complex questions, reducing the time and effort required to research a particular topic manually. Consequently, language models can accelerate the creation of clinical practice guidelines. While there is no doubt that ChatGPT has the potential to revolutionize the way healthcare is delivered, it is essential to note that it should not be used as a substitute for human healthcare professionals. Instead, ChatGPT should be considered a tool that can be used to augment and support the work of healthcare professionals, helping them to provide better care to their patients. innovation diagnose treat diseases diagnosis treatment years Evidencebased Evidence based review selection personalized datadriven data driven insights outcomes efficiency costs chatbots users Recently OpenAI humanlike like text questions manually Consequently delivered Instead

RESUMO - RACIONAL: Custos hospitalares em cirurgia constituem um peso para o sistema de saúde. Protocolos multimodais como o projeto ACERTO aceleram a recuperação pós-operatória. OBJETIVO: O objetivo deste estudo foi o de analisar custos hospitalares em pacientes submetidos a procedimentos cirúrgicos de grande porte no aparelho digestivo com ou sem as estratégias de cuidados perioperatórios proposta pelo projeto ACERTO. MÉTODOS: Foram coletados dados retrospectivos de pacientes eletivos submetidos a procedimentos cirúrgicos de grande porte no aparelho digestivo em um Hospital Universitário entre Janeiro de 2002 e Dezembro de 2011. O estudo envolveu duas fases: Entre Janeiro de 2002 a Dezembro 2005 envolvendo casos internados antes da implementação do protocolo ACERTO (período pré-ACERTO) e casos operados entre Janeiro de 2006 a Dezembro de 2011, após a implementação (período ACERTO). O desfecho primário foi a comparação de custos hospitalares entre os dois períodos. Como desfechos secundários, comparou-se o tempo de internação (LOS), complicações pós-operatórias, taxa de infecção de sitio cirúrgico (ISS) e a mortalidade. RESULTADOS: Foram analisados 381 pacientes (239 do período pré-ACERTO e 142 do período ACERTO) submetidos a procedimento cirúrgicos de grande porte no trato gastrointestinal. Pacientes operados dentro do protocolo ACERTO apresentaram mediana (IQR) mediana de tempo de internação três dias menor (p=0.001) quando comparados ao período pré-ACERTO (mediana (IQR): 10 (12) vs. 13 (12) dias). A mortalidade foi similar entre os dois períodos. Entretanto, o risco de complicações pós-operatórias foi 29% maior (RR: 1.29; IC95%: 1.11 - 1.50) no período pré-ACERTO (p=0.002). O risco de SSI também foi maior no período pré-ACERTO (RR: 1.33; 95%CI: 1.14-1.50). Custos (media e SE) per paciente foram de R$ 24562,84 (1349,33) antes da implementação e R$ 19912,81 (1459,89) após o protocolo ACERTO (p=0.02). CONCLUSÕES: A implementação do projeto ACERTO neste hospital universitário reduziu custos hospitalares em cirurgias digestivas de grande porte. Além disso, a prescrição de estratégias modernas de cuidados perioperatórios também reduziu riscos de complicações pós-operatórias e de SSI e o tempo de internação.

ABSTRACT - BACKGROUND: Hospital costs in surgery constitute a burden for the health system in all over the world. Multimodal protocols such as the ACERTO project enhance postoperative recovery. OBJECTIVE: The aim of this study was to analyze the hospital costs in patients undergoing major digestive surgical procedures with or without the perioperative care strategies proposed by the ACERTO project. METHODS: Retrospective data from elective patients undergoing major digestive surgical procedures in a university hospital between January 2002 and December 2011 were collected. The investigation involved two phases: between January 2002 and December 2005, covering cases admitted before the implementation of the ACERTO protocol (pre-ACERTO period), and cases operated between January 2006 and December 2011, after implementation (ACERTO period). The primary outcome was the comparison of hospital costs between the two periods. As secondary end point, we compared length of stay (LOS), postoperative complications, surgical-site infection (SSI) rate, and mortality. RESULTS: We analyzed 381 patients (239 of the pre-ACERTO period and 142 of the ACERTO period) who underwent major procedures on the gastrointestinal tract. Patients operated after within the ACERTO protocol postoperative LOS had a median of 3 days shorter (p=0.001) when compared with pre-ACERTO period [median (IQR): 10 (12) days vs. 13 (12) days]. Mortality was similar between the two periods. Postoperative complications risk, however, was 29% greater (RR: 1.29; 95%CI 1.11-1.50) in the pre-ACERTO period (p=0.002). SSI risk was also greater in pre-ACERTO period (RR: 1.33; 95%CI 1.14-1.50). Costs (mean and SE) per patients were R$24,562.84 (1,349.33) before the implementation and R$19,912.81 (1,459.89) after the ACERTO protocol (p=0.02). CONCLUSION: The implementation of the ACERTO project in this University Hospital reduced the hospital costs in major digestive procedures. Moreover, the implementation of this modern perioperative care strategy also reduced postoperative complications, SSI risks, and LOS.

RESUMO OBJETIVO: Determinar a frequência de hipofosfatemia como marcador da síndrome de realimentação (SR) antes e após o início da TN em pacientes críticos. MÉTODOS: Coorte retrospectiva realizada com 917 pacientes adultos de um hospital terciário em Cuiabá-MT. Foi determinada a frequência de hipofosfatemia (fósforo <2,5 mg/dl) como marcador de risco de SR, para valores de fósforo sérico da admissão (P1) e após o início da TN (P2). RESULTADOS: Foi observado um aumento significativo (36,3%) da hipofosfatemia entre P1 e P2 e, consequentemente, do risco de SR (25,6% vs 34,9%; p<0,001) com o início da TN. Após o início da TN, pacientes desnutridos apresentaram maior queda do fósforo sérico. Os pacientes com TN apresentaram aproximadamente 1,5 vez mais chance de desenvolver hipofosfatemia e risco de SR (OR=1,44 IC95% 1,10-1,89; p=0,01) quando comparado aos com dieta oral. Nutrição parenteral foi mais associada à hipofosfatemia versus nutrição enteral (p=0,001) e nutrição enteral suplementada com parenteral (p=0,002). CONCLUSÃO: A frequência de pacientes críticos com hipofosfatemia e em risco de SR é alta e esse risco aumenta após o início da TN, especialmente nos desnutridos e naqueles recebendo nutrição parenteral.

Summary OBJECTIVE: To investigate the prevalence of hypophosphatemia as a marker of refeeding syndrome (RFS) before and after the start of nutritional therapy (NT) in critically ill patients. METHODS: Retrospective cohort study including 917 adult patients admitted at the intensive care unit (ICU) of a tertiary hospital in Cuiabá-MT/Brasil. We assessed the frequency of hypophosphatemia (phosphorus <2.5mg/dl) as a risk marker for RFS. Serum phosphorus levels were measured and compared at admission (P1) and after the start of NT (P2). RESULTS: We observed a significant increase (36.3%) of hypophosphatemia and, consequently, a greater risk of RFS from P1 to P2 (25.6 vs 34.9%; p<0.001). After the start of NT, malnourished patients had a greater fall of serum phosphorus. Patients receiving NT had an approximately 1.5 times greater risk of developing RFS (OR= 1.44 95%CI 1.10-1,89; p= 0.01) when compared to those who received an oral diet. Parenteral nutrition was more associated with hypophosphatemia than either enteral nutrition (p=0,001) or parenteral nutrition supplemented with enteral nutrition (p=0,002). CONCLUSION: The frequency of critically ill patients with hypophosphatemia and at risk for RFS on admission is high and this risk increases after the start of NT, especially in malnourished patients and those receiving parenteral nutrition.

Abstract Background: the management of patients with enterocutaneous fistula (ECF) requires an interdisciplinary approach and poses a significant challenge to surgeons, gastroenterologists, intensivists, wound/stoma care specialists, and nutrition support clinicians. Available guidelines for optimizing nutritional status in these patients are often vague, based on limited and dated clinical studies, and typically rely on individual or institutional experience. Specific nutrient requirements, appropriate route of feeding, role of immune-enhancing nutrients, and use of somatostatin analogs in the management of patients with ECF remain a challenge for the clinician. The purpose of this clinical guideline is to develop recommendations for the nutritional care of adult patients with ECF. Methods: a systematic review of the best available evidence to answer a series of questions regarding clinical management of adults with ECF was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Group. An anonymous consensus process was used to develop the clinical guideline recommendations prior to peer review and approval by the A.S.P.E.N. and FELANPE Board of Directors. Questions: in adult patients with enterocutaneous fistula: 1) What factors best describe nutritional status? 2) What is the preferred route of nutritional therapy (oral diet, EN or PN)? 3) What protein and energy intake provide best clinical outcomes? 4) Is fistuloclysis associated with better outcomes than standard care? 5) Are immune-enhancing nutrients associated with better outcomes? 6) Does the use of somatostatin provide better outcomes than standard medical therapy? 7) When is home parenteral nutrition support indicated?

Resumen Introducción: el manejo de las fístulas enterocutáneas (FEC) es un reto que requiere un enfoque interdisciplinario y plantea un desafío importante. Las guías para optimizar el estado nutricional en estos pacientes están basadas en estudios que dependen de la experiencia individual y, ocasionalmente, institucional; que se focalizan en el tratamiento integral de las FEC, centrándose en el manejo médico y quirúrgico, mientras que la terapia nutricional se revisa solo superficialmente. Los requerimientos nutricionales, la vía de administración, el uso de inmunonutrición y el de análogos de la somatostatina en el tratamiento de estos pacientes no están bien definidos. El objetivo de esta guía clínica es desarrollar recomendaciones específicas para la terapia nutricional de los pacientes adultos con FEC. Método: revisión sistemática de la mejor evidencia disponible para responder a una serie de preguntas sobre la terapia nutricional de los adultos con FEC, evaluada utilizando la metodología GRADE. Se utilizó un proceso de consenso anónimo para desarrollar las recomendaciones de la guía clínica antes de la revisión por pares y la aprobación por las Juntas Directivas de ASPEN y FELANPE. Preguntas: 1) ¿Qué factores describen mejor el estado nutricional de los adultos con FEC? 2) ¿Cuál es la mejor vía para administrar la terapia nutricional (oral, nutrición enteral o parenteral)? 3) ¿Qué aporte energético y proteico proporciona mejores resultados clínicos? 4) ¿El uso de la fistuloclisis se asocia a mejores resultados? 5) ¿Las fórmulas inmunomoduladoras se asocian a mejores resultados? 6) ¿El uso de la somatostatina proporciona mejores resultados? 7) ¿Cuándo está indicada la terapia nutricional parenteral domiciliaria?

RESUMO Objetivo: Avaliar os efeitos da administração intravenosa de fluidos e sódio no primeiro dia de internação com a infusão de nutrição enteral em pacientes de terapia intensiva. Métodos: Estudo de coorte prospectivo realizado com pacientes críticos, não cirúrgicos, em ventilação mecânica internados pelo menos há 5 dias com nutrição enteral. Investigaram-se a quantidade de fluidos e sódio administrados por via venosa no primeiro dia e o volume de nutrição enteral infundido nos primeiros 5 dias. Comparou-se o volume de fluidos intravenosos do primeiro dia > 35mL/kg ou ≤ 35mL/kg de peso corporal e de sódio (acima ou abaixo do percentil 25), com o total de nutrição enteral infundida. Resultados: Estudaram-se 86 pacientes com média (± desvio padrão) de 65 ± 17 anos, sendo 54,7% do sexo feminino. Foram administrados, no primeiro dia, 3.393,7 ± 1.417,0mL de fluidos (48,2 ± 23,0mL/kg) e 12,2 ± 5,1g de sódio. Cinquenta e oito (67,4%) pacientes receberam mais de 35mL/kg de fluidos. Em 5 dias, foram ofertados 67 ± 19,8% (2.993,8 ± 1.324,4mL) da nutrição enteral. Os pacientes que receberam > 35mL/kg de fluidos intravenosos também receberam menos nutrição enteral em 5 dias (2.781,4 ± 1.337,9 versus 3.433,6 ± 1.202,2mL; p = 0,03) versus quem recebeu ≤ 35mL/kg. Pacientes com infusão de sódio intravenoso acima do percentil 25 (≥ 8,73g) no primeiro dia receberam menos volume de nutrição enteral em 5 dias (2.827,2 ± 1.398,0 versus 3.509,3 ± 911,9mL; p = 0,02). Conclusão: Os resultados deste estudo apoiam o pressuposto de que a administração de fluidos intravenosos no primeiro dia de internação > 35mL/kg e de sódio ≥ 8,73g pode contribuir para a menor infusão de nutrição enteral em pacientes críticos.

ABSTRACT Objective: To evaluate the effects of intravenous infusion of fluids and sodium on the first day of admission on infusion of enteral nutrition in the first 5 days in intensive care patients. Methods: A prospective cohort study was conducted with critical nonsurgical patients admitted for at least 5 days who were on mechanical ventilation and receiving enteral nutrition. The amount of intravenous fluids and sodium infused on the first day and the volume of enteral nutrition infused in the first 5 days were investigated. The volume of intravenous fluids > 35mL/kg or ≤ 35mL/kg of body weight and sodium (above or below the 25th percentile) infused on the first day was compared with infused enteral nutrition. Results: A total of 86 patients were studied, with a mean (± standard deviation) of 65 ± 17 years, of which 54.7% were female. On the first day, 3,393.7 ± 1,417.0mL of fluid (48.2 ± 23.0mL/kg) and 12.2 ± 5.1g of sodium were administered. Fifty-eight (67.4%) patients received more than 35mL/kg of fluids. In 5 days, 67 ± 19.8% (2,993.8 ± 1,324.4mL) of the prescribed enteral nutrition was received. Patients who received > 35mL/kg of intravenous fluids also received less enteral nutrition in 5 days (2,781.4 ± 1,337.9 versus 3,433.6 ± 1,202.2mL; p = 0.03) versus those who received ≤ 35mL/kg. Patients with intravenous sodium infusion above the 25th percentile (≥ 8.73g) on the first day received less enteral nutrition volume in 5 days (2,827.2 ± 1,398.0 versus 3,509.3 ± 911.9mL; p = 0.02). Conclusion: The results of this study support the assumption that the administration of intravenous fluids > 35mL/kg and sodium ≥ 8.73g on the first day of hospitalization may contribute to the lower infusion of enteral nutrition in critically ill patients.

Abstract Objective: To assess postoperative clinical data considering the association of preoperative fasting with carbohydrate (CHO) loading and intraoperative infusion of omega-3 polyunsaturated fatty acids (ω-3 PUFA). Methods: 57 patients undergoing coronary artery bypass grafting (CABG) were randomly assigned to receive 12.5% maltodextrin (200 mL, 2 h before anesthesia), (CHO, n=14); water (200 mL, 2 h before anesthesia), (control, n=14); 12.5% maltodextrin (200 mL, 2 h before anesthesia) plus intraoperative infusion of ω-3 PUFA (0.2 g/kg), (CHO+W3, n=15); or water (200 mL, 2 h before anesthesia) plus intraoperative infusion of ω-3 PUFA (0.2 g/kg), (W3, n=14). The need for vasoactive drugs was analyzed, in addition to postoperative inflammation and metabolic control. Results: There were two deaths (3.5%). Patients in CHO groups presented a lower incidence of hospital infection (RR=0.29, 95% CI 0.09-0.94; P=0.023), needed fewer vasoactive drugs during surgery and ICU stay (P<0.05); and had better blood glucose levels in the first six hours of recovery (P=0.015), requiring less exogenous insulin (P=0.018). Incidence of postoperative atrial fibrillation (POAF) varied significantly among groups (P=0.009). Subjects who receive ω-3 PUFA groups had fewer occurrences of POAF (RR=4.83, 95% CI 1.56-15.02; P=0.001). Patients in the W3 group had lower ultrasensitive-CRP levels at 36 h postoperatively (P=0.008). Interleukin-10 levels varied among groups (P=0.013), with the highest levels observed in the postoperative of patients who received intraoperative infusion of ω-3 PUFA (P=0.049). Conclusion: Fasting abbreviation with carbohydrate loading and intraoperative infusion of ω-3 PUFA is safe and supports faster postoperative recovery in patients undergoing on-pump CABG.

RESUMO Racional: Protocolos multimodais de cuidados perioperatórios melhoram significativamente resultados na cirurgia. Objetivo: Investigar fatores de risco para vários desfechos clínicos em pacientes submetidos às operações colorretais eletivas com o emprego do protocolo ACERTO. Métodos: Coorte analisando indivíduos expostos ou não expostos às variáveis de risco demográficas, clínicas e intervenções ACERTO, através de um modelo de regressão logística, determinando fatores independentes de risco para morbidade e mortalidade. Resultados: Duzentos e trinta e quatro pacientes foram submetidos a 156 (66,7%) operações retais e 78 (33,3%) colônicas. Mantiveram relação com tempo de internação ≥7 dias operação retal e escore NNIS alto; jejum pré-operatório > 4h e volume de cristalóides >30 ml/kg/dia. O risco de infecção de sítio cirúrgico foi aproximadamente quatro vezes maior em desnutridos; oito em operações retais; e quatro com NNIS alto. Tempo de jejum pré-operatório ≤4 h reduziu em 81,3% o risco de infecção de sitio cirúrgico. Risco aumentado para fístula ocorreu em desnutridos, operação retal e escore NNIS elevado. Tempo de jejum pré-operatório ≤4 h constituiu fator de proteção para ocorrência de fístulas. Os fatores associados à pneumonia/atelectasia foram câncer e operação retal, enquanto que tempo de jejum pré-operatório ≤4 h e volume de cristalóides intravenoso ≤30 ml/kg/dia foram fatores de proteção. Mortalidade foi menor com jejum ≤4 h e fluidos endovenosos ≤30 ml/kg/dia. Conclusão: Este estudo permite concluir que operações retais, presença de fator de risco NNIS, tempo de jejum pré-operatório superior a 4 h e fluidoterapia com cristaloides endovenosos superior a 30 ml/kg/dia nas primeiras 48 h de pós-operatório constituem-se em fatores de risco independentes e aplicáveis para: 1) tempo de internação pós-operatória prolongada; 2) para infecção do sítio cirúrgico e fístula anastomótica associadas à desnutrição; 3) para pneumonia/atelectasia no pós-operatório; e 4) para mortalidade pós-operatória.

ABSTRACT Background: Perioperative care multimodal protocol significantly improve outcome in surgery. Aim: To investigate risk factors to various endpoints in patients submitted to elective colorectal operations under the ACERTO protocol. Methods: Cohort study analyzing through a logistic regression model able to assess independent risk factors for morbidity and mortality, patients submitted to elective open colon and/or rectum resection and primary anastomosis who were either exposed or non-exposed to demographic, clinical, and ACERTO interventions. Results: Two hundred thirty four patients were analyzed and submitted to 156 (66.7%) rectal and 78 (33.3%) colonic procedures. The length of hospital postoperative stay (LOS) ≥ 7 days was related to rectal surgery and high NNIS risk index; preoperative fasting ≤4 h (OR=0.250; CI95=0.114-0.551) and intravenous volume of crystalloid infused > 30ml/kg/day (OR=0.290; CI95=0.119-0.706). The risk of postoperative site infection (SSI) was approximately four times greater in malnourished; eight in rectal surgery and four in high NNIS index. The duration of preoperative fasting ≤4 h was a protective factor by reducing by 81.3% the risk of surgical site infection (SSI). An increased risk for anastomotic fistula was found in malnutrition, rectal surgery and high NNIS index. Conversely, preoperative fasting ≤4 h (OR=0.11; CI95=0.05-0.25; p<0.0001) decreased the risk of fistula. Factors associated with pneumonia-atelectasis were cancer and rectal surgery, while preoperative fasting ≤ 4 h (OR=0.10; CI95=0.04-0.24; p<0.0001) and intravenous crystalloid ≤ 30 ml/kg/day (OR=0.36; CI95=0.13-0.97, p=0.044) shown to decrease the risk. Mortality was lower with preoperative fasting ≤4 h and intravenous crystalloids infused ≤30 ml/kg/day. Conclusion: This study allows to conclude that rectal procedures, high NNIS index, preoperative fasting higher than 4 h and intravenous fluids greater than 30 ml/kg/day during the first 48 h after surgery are independent risk factors for: 1) prolonged LOS; 2) surgical site infection and anastomotic fistula associated with malnutrition; 3) postoperative pneumonia-atelectasis; and 4) postoperative mortality.

Abstract Introduction: intravenous fluid overload may lead to dysmotility that may impair early enteral nutrition delivery in critically ill patients. Objectives: this study aimed to compare the volume of intravenous fluids (IF) with the occurrence of caloric and protein deficits in Intensive Care Unit (ICU) patients. Methods: this cohort study included critically ill patients with mechanical ventilation and receiving early enteral nutrition (target: 25-30 kcal/kg/day and 1.25-2.0 g of protein/kg/day). Over the first five days the volume of IF infused and caloric/protein deficits were calculated. Results: eighty-six critically ill patients (SAPS III score: 62 ± 10) with a mean age of 68 (18-91) years were enrolled. Patients received a median of 2,969 (920-5,960) ml/day of IF, which corresponded to a median of 41.6 (17.0-88.2) ml/kg/day and 10.7 (3.31-21.45) g of sodium/day. All patients had a caloric deficit (mean: 1,812 ± 850 kcal over five days) and in 23 (27%) this deficit exceeded 480 kcal/day. The mean protein deficit was 94.6 ± 5.9 g over five days, and 34 patients (40%) had more than 20 g of deficit/day. Patients with caloric deficit greater than 480 kcal/day received approximately 1.5 l of IF and 10 g of NaCl more than the other patients. Similarly, patients with protein deficit greater than 20 g/day received approximately 3 l of IF and 25 g of NaCl more than the other patients. Mortality was greater in patients with critical protein deficit (69% vs 41.1%; p = 0.01). Conclusion: in critically ill patients receiving enteral nutrition, the volume of intravenous fluids infused affected nutrition delivery and increased caloric and protein deficits.

Resumen Introducción: la sobrecarga de líquidos por vía intravenosa puede provocar dismotilidad que puede afectar el suministro de nutrición enteral temprana en pacientes críticos. Objetivos: este estudio tuvo como objetivo comparar el volumen de líquidos por vía intravenosa (IF) con la aparición de déficit calórico y proteico en pacientes de la Unidad de Cuidados Intensivos (UCI). Métodos: este estudio de cohorte incluyó a pacientes críticamente enfermos con ventilación mecánica que recibían nutrición enteral temprana (target: 25-30 kcal/kg/día y 1,25-2,0 g de proteína/kg/día. Durante los primeros cinco días calculamos el volumen de IF y el déficit calórico/proteico. Resultados: ochenta y seis pacientes críticamente enfermos (SAPS III: 62 ± 10) con una edad media de 68 (18-91) años fueron estudiados. Los pacientes recibieron una mediana de 2.969 (920-5.960) ml/día de IF, que correspondió a una mediana de 41,6 (17,0-88,2) ml/kg/día y a 10,7 (3,31-21,45) g de sodio/día. Todos los pacientes tenían déficit calórico (media: 1.812 ± 850 kcal en cinco días) y en 23 (27%) este déficit excedía las 480 kcal/día. El déficit medio de proteínas fue de 94,6 ± 5,9 g en cinco días y 34 pacientes (40%) tuvieron más de 20 g de déficit/día. Los pacientes con un déficit calórico superior a 480 kcal/día recibieron aproximadamente 1,5 l de IF y 10 g de NaCl más que los otros pacientes. De forma similar, los pacientes con un déficit de proteínas mayor de 20 g/día recibieron aproximadamente 3 l de IF y 25 g de NaCl más que los otros pacientes. La mortalidad fue mayor en pacientes con déficit proteico crítico (69% vs. 41,1%; p = 0,01). Conclusión: en pacientes críticamente enfermos que reciben nutrición enteral, el volumen de líquidos intravenosos infundidos afecta el suministro de nutrición y aumenta el déficit de calorías y proteínas.