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 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.

Introduction: Malnutrition in hospitalized patients is not evaluated frequently. However, it is a critical issue given that it has been related to a high rate of infectious complications and increased mortality rates. There is a high prevalence of patients with nutritional impairment in the home environment, which favors their clinical worsening, the increase of re-hospitalizations and, consequently, the increase in public health expenditures. Objective: Nutrition experts have thoroughly discussed and written this positioning paper on hospital and homecare malnutrition to describe the prevalence of malnutrition in Brazil. Best practice recommendations for nutrition therapy of patients in hospital and homecare, in particular the use of oral nutritional supplements (ONS), to those who are at risk of malnutrition or malnourished were evaluated, and the impact on clinical and economic data were assessed. In addition, they emphasize that investments in oral nutritional supplementation are also important in the homecare environment (home or nursing homes). Materials and methods: Selected scientific articles on disease-related malnutrition, especially those carried out in Brazil, were assessed. Data on prevalence, clinical outcomes, and economic burdens were reviewed. Results and conclusion: Several studies have shown the importance of in-hospital nutritional assessment for early detection of malnutrition and early intervention with nutrition therapy, in particular with oral nutritional therapy. Unfortunately, hospital malnutrition remains high in Brazil, with severe consequences for patients. The implementation of universal nutritional screening and diagnosis as well as the therapeutic approach of malnutrition, particularly with the use, when possible, of oral nutrition supplements as the first step to address this condition is still low, and demands the investment in educational resources to change practices. Routine use of nutritional therapy in hospital and homecare settings improves clinical outcomes, is cost effective, and would be expected to help reduce healthcare costs.

Introducción: la desnutrición en pacientes hospitalizados no se evalúa con frecuencia. Sin embargo, es un problema crítico dado que se ha relacionado con una alta tasa de complicaciones infecciosas y con el incremento de la mortalidad. Se observa una alta prevalencia de pacientes desnutridos en el entorno domiciliario, lo que favorece su deterioro clínico, el aumento de las rehospitalizaciones y, como consecuencia, el aumento del gasto sanitario público. Objetivo: expertos en nutrición realizaron una revisión detallada de los estudios para redactar un posicionamiento sobre la situación en Brasil respecto a la prevalencia de la desnutrición hospitalaria y domiciliaria. Se identificaron las mejores prácticas recomendadas para la terapia nutricional de los pacientes hospitalarios y en domicilio en riesgo de desnutrición o desnutridos y se evaluó la utilidad de los suplementos nutricionales orales (SNO) a través de datos clínicos y económicos. Adicionalmente, se evidenció que las inversiones en suplementos nutricionales orales son también importantes en el entorno domiciliario (domicilio o residencia). Materiales y métodos: se evaluaron artículos científicos seleccionados, especialmente los realizados en Brasil, sobre la desnutrición relacionada con enfermedades. Se revisaron los datos sobre la prevalencia, los resultados clínicos y las cargas económicas. Resultados y conclusión: varios estudios han demostrado la importancia de la evaluación nutricional en el hospital para la detección precoz de la desnutrición y la intervención temprana con terapia nutricional oral, siempre que sea posible, como estrategia inicial para abordar el problema. Desafortunadamente, la desnutrición hospitalaria continúa siendo elevada en Brasil, con consecuencias graves para los pacientes. La identificación del estado nutricional deficiente a través del cribado y el inicio de la terapia nutricional, particularmente con el uso, cuando es posible, de suplementos nutricionales orales, como primera etapa para combatir la desnutrición no está aún establecida y requiere una inversión en recursos educativos para cambiar las prácticas actuales. El uso rutinario de la terapia nutricional en el entorno hospitalario y domiciliario mejora los resultados clínicos y tiene un impacto positivo en la disminución de los costes asociados y, de esta forma, se espera que contribuya a la reducción de los costes de atención sanitaria.

RESUMO Racional: Trabalhos atuais associam longos períodos de jejum com diversas consequências adversas. A abreviação do jejum de 2 h para líquidos claros associado ao uso de bebidas contendo carboidratos atenua resposta endocrinometabólica ao trauma, porém frequentemente as crianças são orientadas a não ingerir alimentos a partir das 00:00 h do dia anterior à operação, independente do horário do procedimento cirúrgico. Objetivo: Avaliar a segurança de um protocolo de abreviação do jejum pré-operatório, com o uso de bebida contendo carboidratos, e realimentação precoce. Métodos: Foram avaliados prospectivamente 36 crianças submetidas a procedimentos cirúrgicos eletivos de pequeno e médio porte. Cinco foram posteriormente excluídos do estudo. Todos os 31 remanescentes receberam suplemento nutricional com maltodextrina 12,5% em 150 ml de água aproximadamente 2 h antes do procedimento. Foram coletados dados do tempo de jejum pré-operatório, complicações anestésicas e tempo de realimentação. Resultados: Vinte e três (74,2%) eram do gênero masculino, com idade mediana de cinco anos e peso mediano de 20 kg. O tempo mediano de jejum pré-operatório foi de 145 min e o tempo mediano para realimentação foi de 135 min. Não houve eventos adversos durante a anestesia ou operação. No período pós-operatório, duas (6,5%) crianças vomitaram. Conclusão: A abreviação de jejum pré-operatório para 2 h com uso de bebida contendo carboidratos, em operações eletivas de crianças, é seguro e não está associado ao maior risco de broncoaspiração pulmonar. Realimentação precoce pode ser prescrita nos procedimentos cirúrgicos analisados.

ABSTRACT Background: Current researches associate long fasting periods to several adverse consequences. The fasting abbreviation to 2 h to clear liquids associated with the use of drinks containing carbohydrates attenuates endocrinometabolic response to surgical trauma, but often is observed children advised to not intake food from 00:00 h till the scheduled surgical time, regardless of what it is. Aim: To evaluate the safety of a protocol of preoperative fasting abbreviation with a beverage containing carbohydrates, and early postoperative feeding in children underwent elective small/mid-size surgical procedures during a national task-force on pediatric surgery. Methods: Thirty-six patients were prospectively included, and for several reasons five were excluded. All 31 who remained in the study received a nutritional supplement containing 150 ml of water plus 12.5% maltodextrin 2 h before the procedure. Data of the pre-operative fasting time, anesthetic complications and time of postoperative refeeding, were collected. Results: Twenty-three (74.2%) were males, the median age was 5 y, and the median weight was 20 kg. The median time of pre-operative fasting was 145 min and the time of post-operative refeeding was 135 min. There were no adverse effects on the anesthetic procedures or during surgery. Post-operatively, two children (6.5%) vomited. Conclusion: The abbreviation of pre-operative fasting to 2 h with beverage containing carbohydrate in pediatric surgery is safe. Early refeeding in elective small/mid-size procedures can be prescribed.