Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Fisiologia Renal
Fisiologia Renal
Fisiologia Renal
1-Introducción.
2-Desarrollo de la estancia docente. Objetivos docentes y evaluación.
3-Documentos.
4-Evaluación de la cumplimentación de informes de seguimiento nutricional.
5-Evaluación de la calidad de los informes de seguimiento nutricional.
6- Guía de ayuda del servicio de nutrición.
7- Formulario de productos parenterales y enterales.
8-Guía para la monitorización del soporte nutricional.
9-Guías generales para el manejo de la hipofosfatemia, hipomagnesemia,
hipopotasemia e hipocalcemia.
10- Conclusiones.
11- Bibliografía recomendada.
1-INTRODUCCIÓN
Yo pasé visita con el equipo y el tutor (tres veces a la semana con el Prof.
Dickerson, una vez a la semana con la Dra. Minard y otra con el Dr. Mash).
EVALUACIÓN
Se comunica bien con los pacientes y con los profesionales sanitarios (5%)
Diagnóstico: 4 puntos
Nivel de Criterio de realización Comentarios
realización
1-Sustratos disponibles
A. Carbohidratos (3.4 kcal/g)
1% 100 kcal/L
1.5 % 150 kcal/L
2% 200 kcal/L
2.5 % 250 kcal/L
3% 300 kcal/L
4% 400 kcal/L
C. Proteínas
Clinasol 3 % 30 g/L
Clinasol 3 % 40 g/L
Clinasol 3 % 50 g/L
Clinasol 3 % 60 g/L
Clinasol 3 % 70 g/L
Clinasol 3 % 80 g/L
Hepatasol 2% 20 g/L
Hepatasol 3% 30 g/L
Hepatasol 4% 40 g/L
2-Fórmula Standard :
D20 W + Travasol 5% + Intralipid 2 %
15 mM Na phosphate/L 30 mEq NaCl/L 40 mEq K acetate/L 5 mEq Ca gluc/L
12 mEq MgSO4 Infuvite adult 10 mL/ d MTE-5 3 mL/d
3-Fósforo
Na phosphate K phosphate
7.5 mM = 10 mEq Na 7.5 mM = 11 mEq K
15 mM = 20 mEq Na 15 mM = 22 mEq K
22.5 mM = 30 mEq Na 22.5 mM = 33 mEq K
30mM = 40 mEq Na 30 mM = 44 mEq K
5-Valoración nutricional
A. Historia nutricional previa y exploración física
B. Peso ideal (IBW)
1. Mujeres = 45 kg por 5 foot + 2.3 kg por cada pulgada por encima de 5
foot
2- Hombres = 50 kg por 5 foot.+ 2.3 kg por cada pulgada por encima de 5
foot
C. Porcentaje del IBW peso actual / peso ideal x 100
1. malnutrición moderada: 70-79 %
2. malnutrición severa < 70 %
3. obesidad > 130 % IBW
G. Tipos de malnutrición
1. Marasmo: proteínas séricas normales, disminución de peso total, masa muscular
y tejido adiposo.
2. Kwashiorkor: disminución de proteínas séricas y posible de masa muscular,
tejido adiposo normal ó incrementado.
3. Kwashiorkor-Marasmo mixto: disminución de proteínas séricas, disminución de
peso total, masa muscular y tejido adiposo.
4. Obesidad- ver datos de IMC (arriba)
I. Valoración Hemodinámica
Fracción de Eyección Indice volumen final Indice volumen final
diastólico sujeto normal diastólico paciente crítico
20 200 240
30 150 180
35 125 150
40 100 120
50 50 60
6 .Requerimientos
A. Calorías totales
1.1 Ecuación Mifflin-St.Jeor
(preferente para pacientes obesos con IRA ó IRC ó encefalopatía hepática
cuando no es adecuado administrar una dieta hipocalórica e hiperprotéica).
a. mujeres = (10 x peso)+( 6.25 x alt )-( 5 x edad)-161
b. hombres = (10 x peso) + ( 6.25 x alt )-( 5 x edad) + 5
peso (kg), altura (cm), edad (años)
B. Proteína
1. Dosis
a. mantenimiento 0.8-1 g/kg/d
b. stress moderado ó repleción 1.5 – 2 g/kg/d
c. stress severo 2-2.5 g/kg/d
d. insuficiencia renal 0.6-2 g/kg/d (IRA, IRC)
e. hipocalórica IMC< 40 2 g/kg peso ideal / d
IMC ≥ 40 2.5 g/kg peso ideal /d
5. Infusión continua de insulina humana regular para pacientes con IRA ó IRC (se
denomina protocolo de insulina “modificado y modificado” para diferenciar del resto
de protocolos de insulina):
7. FORMULARIO DE PRODUCTOS
Parenteral
1-Glucosa- todas las concentraciones de glucosa se obtienen a partir de G 70%.
La mayoría de las NPT llevan una concentración final de glucosa entre 10-35%.
2-Lipidos-emplean el Intralipid 30%.(emulsión stock). La mayoría de los pacientes
llevan en la NPT una concentración final entre el 1-4%.
3-Solución Standard de aminoácidos (solución stock 15%). Clinasol
3%,4%,5%,6%,7%,8%.
4-Solución de aminoácidos para encefalopatía hepática (solución stock 8 %).
Hepatasol 2%, 3%, 4%.
Enteral
1-Dieta enteral Standard por sonda-Jevity 1.0
2-Dieta enteral Standard con proteina moderada por sonda – FiberSource HN
3-Dieta enteral Standard con alto contenido en proteina-Replete with Fiber
4-Suplementos orales-Glucerna Select, Ensure Plus, Enlive Fruti.
5-Dieta peptídica- Vivonex RTF
6-Restricción de fluidos- Nutren 2.0
7-Insuficiencia hepática con encefalopatía- NutriHep.
8-Insuficiencia renal aguda ó IRC- Renalcal (sin electrolitos).
9-IRA ó IRC en hemodiálisis- NovaSource Renal
10-Módulos- Proteinex (proteína liquida 1 g / 2 mL)
11-Dieta enteral baja en hidratos de carbono y alta en lipidos con Fibra –
DiabetiSource AC.
12-Dieta enteral con inmunomoduladores( arginina, alfa linoleico, glutamina y fibra-
Impact Glutamina.
13-Dieta enteral para SDRA- Oxepa
1. Leer todas las órdenes médicas realizadas desde la última visita por el equipo
de nutrición. Prestar atención a:
a. cambios en pauta de fluidos intravenosos.
b. administración de electrólitos ó insulina.
c. nuevos antibióticos pautados para el manejo de la infección.
d. nuevos medicamentos pautados ó suspendidos que puedan afectar al balance
electrolítico, causen diarrea, disminuyan el apetito.
e. plan de intervenciones ó procedimientos quirúrgicos.
f. nuevas ordenes de administración de fármacos vasoactivos.
g. cambios en función respiratoria ó modalidad ventilación mecánica (ej.
desconexión del ventilador, PEEP, % oxigeno).
2-Leer todos los informes de evolución de la historia clínica del paciente. Incluir los
siguientes ítems:
a. cambios en el estado general del paciente (ej. mejoría, empeoramiento, sin
cambios, sin eventos).
b. nuevos diagnósticos.
c. resultado de pruebas (RX, endoscopia, BAL, scanner, medicina nuclear,
ultrasonidos).
d. problemas relacionados con la nutrición, el balance electrolítico, diarrea, estado
de hidratación (PVC, EDVI; .)
e. resultado de la exploración abdominal en pacientes con nutrición enteral ó que la
van a recibir.
f. presencia ó ausencia de ruidos intestinales.
g. informe de quirófano: procedimientos realizados, etc.
3. Visita al paciente. ¡Es lo más importante que harás en el día! Incluir los
siguientes ítems:
a. realizar preguntas al paciente de tipo abierto si este puede hablar contigo.
b. comprobar que la nutrición colgada que le están administrado al paciente es la
correcta (comprobar nombre del paciente, tipo de fórmula, electrolitos, insulina….)
c. comprobar ritmo correcto de las bombas de infusión de nutrición y fluidos IV.
d. valorar la aparición de edemas si procede.
e. valorar la distensión abdominal y ruidos intestinales.
f. comentarios subjetivos que refiera el paciente (ej. nausea, bienestar, molestias
gástricas, acidez.)
9.1 HIPOFOSFATEMIA
Estas dosis NO DEBEN ser utilizadas en pacientes con insuficiencia renal.
9.2 HIPOMAGNESEMIA
Estas dosis NO DEBEN ser utilizadas en pacientes con insuficiencia renal.
Para tratar una hipomagnesemia de forma adecuada se requieren normalmente de
3 a 5 días de tratamiento.
9.3 HIPOPOTASEMIA
Los bolos de KCL sólo se deben administrar por una vía central. Se puede
administrar KCL a una velocidad de 20 mEq/ h solamente si el paciente está
siendo monitorizado con ECG en UCI. La velocidad de 10 mEq / h es la más
segura si el paciente está asintomático ó no se encuentra en UCI. El KCL viene
prediluido con 20 y 40 mEq de K en agua estéril para inyección. Las soluciones
intravenosas para administración periférica no deben contener más de 40 a 60
mEq de KCL/ L.
Para un paciente standard ( ej 65-90 kg con función renal NORMAL y sin
excesivas pérdidas ( ej. furosemida, anfotericina B, etc );
9.4 HIPOCALCEMIA
El calcio puede estar falsamente bajo en presencia de hipoalbuminemia. Por cada
descenso de 1g/dL en la albúmina sérica por debajo de 4.0, el calcio sérico
desciende en 0.8 mg/dL. En el caso de pacientes críticos con hipoalbuminemia
esta relación puede no ser real por lo que es preciso solicitar el calcio iónico.
Los bolos de calcio IV han de ser empleados con EXTREMA PRECAUCIÓN in
pacientes con hipopotasemia severa o en aquellos que reciban glucósidos
digitálicos.
10-CONCLUSIONES
11. BIBLIOGRAFÍA
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