NUTRICIÓN

EN SEPSIS

MR. A. Héctor Ramos Bravo

UCI-H.N.E.R.M.
HECTOR RAMOS BRAVO
GENERALIDADES
• Respuesta sistemica
inflamatoria en respuesta
a una infeccion.

• Infeccion > Sepsis >

Sepsis Severa > MODS

HECTOR RAMOS BRAVO Angus DC . Critical Care 2001

 AGE-ADJUSTED INCIDENCE RATES OF SEPSIS AMONG HOSPITALIZED
PATIENTS, STRATIFIED BY AGE 65
(DASHED LINE) OR 65 (SOLID LINE

Greg S. Martin, MD, MSc; David M. Mannino, MD; Marc Moss, MD,
The effect of age RAMOS
HECTOR on the development
BRAVO and outcome of adult sepsis*Crit Care Med 2006 Vol. 34, No. 1
INCIDENCIA DE HOSPITALIZACION POR SEPSIS
DE 2000 A 2008

HECTOR RAMOS BRAVO

RAZONES DE INCREMENTO DE SEPSIS
• Desarrollo de microorganismos resistentes a
antibioticos
• Aumento de comorbilidades con tratamientos invasivos

• Aumento de esperanza de vida en el mundo

• Desarrollo de mayor desnutrición en pacientes

cronicamente enfermos

HECTOR RAMOS BRAVO

Global Sespsis Alliance 2012
THE RESPONSE
TO PATHOGENS

Richard S. Hotchkiss, M.D., and Irene E. Karl, Ph.D. The Pathophysiology and Treatment of Sepsis n engl j m
348;2 january 2003
HECTOR RAMOS BRAVO
SD
• asd

HECTOR RAMOS BRAVO

Cortesia: Ruth Kleinpell
DYSFUNCTION OF THE VASCULAR
ENDOTHELIUM

HECTOR RAMOS BRAVO

 THE RELATIONSHIP BETWEEN THE CELLULAR
IMMUNE RESPONSE AND THE SYSTEMIC
INFLAMMATORY RESPONSE

The relationship between the cellular immune response

(——)HECTOR
and the RAMOS
systemicBRAVO
inflammatory response (– – –) to multiple
insults (fl). + , Positive; - , negative.
IMMUNOLOGIC RESPONSE OF THREE
HYPOTHETICAL PATIENTS WITH SEPSIS.

Richard S. Hotchkiss, M.D., and Irene E. Karl, Ph.D. The Pathophysiology and Treatment of Sepsis n engl j m
348;2 january 2003
HECTOR RAMOS BRAVO
HIPERCATABLISMO

HECTOR RAMOS BRAVO

RESPUESTA INFLAMATORIA SISTEMICA.

HECTOR RAMOS BRAVO

Cortesia :Stefanie Chalmers
RESPUESTA INFLAMATORIA
SISTEMICA.

I
HIPERMETABOLISMO N HIPERCATABOLISMO
(Aumento GER) F
E
C
C
I
O
N

HECTOR RAMOS BRAVO

Dr. Marco Delgado
RESPUESTA
INFLAMATORIA
SISTEMICA.

I
HIPERMETABOLISMO N HIPERCATABOLISMO
(Aumento GER) F
E
C
C
I
O
N

HECTOR RAMOS BRAVO

Dr. Marco Delgado
ROL DE LA NUTRICION
EN SEPSIS
NUTRICION ENTERAL
• La nutricion enteral beneficia a la pacientes
criticamente enfermos
• Previene nuevas infecciones
• Inmunonutricion, modula la respuesta
• La incidencia de isquemia intestinal asociada con NE
es baja
• NE debe iniciarse una vez iniciada la resusitacion con
adecuada perfusion

Cohen and Dat, Nutricion and Sepsis, Nutricion intensive care, Karger 2013
HECTOR RAMOS BRAVO
NUTRICION ENTERAL
• Requerimiento calorico 25 cal/kilo de peso -> 35 cal /k

• Administrar NE por la via Gastrica o Naso yeyunal

• El inicio de la nu rición enteral (NE) debe ser precoz, dentro de

las primeras 24-48 h

• NP complementaria si t ras 72 h de ingreso no se logra un

aporte calorico proteico de al menos el 60% de las necesidades

Cohen and Dat, Nutricion and Sepsis, Nutricion intensive care, Karger 2013
HECTOR RAMOS BRAVO
 SURVIVAL OF PATIENTS IN THE EARLY AND LATE ENTERAL
NUTRITION
GROUPS.

Imran Khalid, Pratik Doshi and Bruno DiGiovine Vasopressors and Mechanical Ventilation
EarlyHECTOR
EnteralRAMOS
Nutrition
BRAVOand Outcomes of Critically Ill Patients Treated With, Am J Crit Care 2010
• Conclusions: In mechanically ventilated patients with
mildly elevated gastric residual volumes and already
receiving nasogastric nutrition, early nasojejunal nutrition
did not increase energy delivery and did not appear to
reduce the frequency of pneumonia.
• The rate of minor gastrointestinal hemorrhage was
increased. Routine placement of a nasojejunal tube in such
patients is not recommended.
(Crit Care Med 2012; 40: 2342–2348)
HECTOR RAMOS BRAVO
EARLY OR LATE PARENTERAL
NUTRITION: ASPEN VS ESPEN
Controversy exists about the timing of the initiation of
parenteral nutrition (PN) in critically ill adults in whom
caloric targets cannot be met by enteral nutrition (EN)
alone.
Conclusion
• Late-initiation of PN was associated with faster
recovery and fewer complications, when compared with
earlyinitiation
Critical care-2012

HECTOR RAMOS BRAVO

 ENTERAL NUTRITION IS ASSOCIATED WITH
IMPROVED OUTCOME IN PATIENTS WITH
SEVERE SEPSIS

Kaplan–Meier curves for overall survival and

secondary infections
HECTOR RAMOS BRAVO
A secondary analysis of the VISEP trial-2013
 SOME CONTROVERSIES IN METABOLIC
SUPPORT

Jean-Louis Vincent, MD, PhD, FCCM Metabolic support in sepsis and multiple organ failure: More
questions than
HECTOR answers
RAMOS . . ., Crit Care Med 2007 Vol
BRAVO
 POTENTIALLY BENEFICIAL EFFECTS OF
GLUTAMINE. HSP, HEAT SHOCK PROTEIN.

Jean-Louis Vincent, MD, PhD, FCCM Metabolic support in sepsis and multiple organ failure: More
questions than
HECTOR answers
RAMOS . . ., Crit Care Med 2007 Vol
BRAVO
 • At 28 days, there was a trend toward
increased mortality among patients who
received glutamine as compared with
patients who did not receive glutamine
(32.4% vs. 27.2%

HECTOR RAMOS BRAVO

 Effect on Mortality

High Dose

Low Dose

.01 0.1 1 10 100

Dosis >0.5 g/k/d
0.3 g/kg/d and 0.5 g/kg/d
<0.3 g/kg/d Novak CCM 2002;30:2022
HECTOR RAMOS BRAVO Heyland 2013
HECTOR RAMOS BRAVO
 Supplementation with
Antioxidants in the Critically
Ill: systematic review and meta-
analysis
• Critical illness is characterized by oxidative stress, which is a
major promoter of systemic inflammation and organ failure due
to excessive free radical production, depletion of antioxidant
defenses, or both.
• Selenium, ―zinc‖, ―copper‖, ―manganese‖, ―vitamins A, C and E‖

• We hypothesized that exogenous supplementation of trace

elements and vitamins could restore antioxidant status,
improving clinical outcomes.
William Manzanares1, Rupinder Dhaliwal2, Xuran Jiang2, Lauren Murch2 and Daren K Heyland2,3cAntioxidant
micronutrients in the critically ill: a systematic review and meta-analysis Critical Care 2012,
HECTOR RAMOS BRAVO
 Effect of Combined Antioxidant
Strategies in the Critically Ill
Effect on Mortality

HECTOR RAMOS BRAVO

William Manzanares1, Rupinder Dhaliwal2, Xuran Jiang2, Lauren Murch2 and Daren K Heyland2,3cAntioxidant
 Effect of Combined Antioxidant
Strategies in the Critically Ill
Effect of combined antioxidant therapy on
ventilation days (n = 4).

William Manzanares1, Rupinder Dhaliwal2, Xuran Jiang2, Lauren Murch2 and Daren K Heyland2,3cAntioxidant
micronutrients in the critically ill: a systematic review and meta-analysis Critical Care 2012,
HECTOR RAMOS BRAVO
EPA + GLA Modulate
Inflammation

HECTOR RAMOS BRAVO Hegazi and Wischmeyer Critical Care 2011, 15:234
Investigating Nutritional Therapy
with EPA, GLA and Antioxidants
Role in SEPsis Treatment
(INTERSEPT)
 Multicenter, Randomized, Double-blinded trial
(14 Clinical Sites – Brazil)
 200 Patients in the early stages of sepsis,
Fish oil/borage oil/antioxidant vs standard
polymeric

HECTOR RAMOS BRAVO

Pontes-Arruda Crit Care 2011;15:R144
Investigating Nutritional Therapy with EPA, GLA
and Antioxidants Role in SEPsis Treatment
(INTERSEPT)

HECTOR RAMOS BRAVO

Pontes-Arruda Crit Care 2011;15:R144
Investigating Nutritional Therapy with EPA, GLA
and Antioxidants Role in SEPsis Treatment
(INTERSEPT)
Variable Study (n=53) Control P Value
(n=53)
Use of mechanical ventilation, n (%)
Invasive 10 (18.9%) 18 (34%) .03984
Non-invasive 5 (9.4%) 6 (11.3%) NS
Number of days using mechanical 7 (4-12) 15 (9-21) .0033
ventilation*
Number of ICU days* 7 (4-12) 13 (9-18) <.0001
Number of hospital days* 9 (6-14) 19 (13-24) <.0001

HECTOR RAMOS BRAVO

Pontes-Arruda Crit Care 2011;15:R144
Parenteral nutrition without ω-3 fatty acid supplementation.
391 participants have been included / NO DISMINUYE MORTALIDAD

HECTOR RAMOS BRAVO Critical Care Medicine –ENERO 2013

 arginina:
INTERACTIONS DIMETHYLARGININE ADMA

ADMA competes with arginine by blocking the formation of nitric oxide from arginine by NOS directly
asymmetric dimethylarginine (ADMA) SDMA, symmetric dimethylarginine; PRMTs, protein arginine methyltransferases. dimethylarginine dimethylaminohydrolase(DDAH
Saskia J.H. Brinkmanna,b,
HECTOR Myrte C. de Boerb, Nikki Buijsb, and Paul A.M. van Leeuwen, Asymmetric dimethylarginine and critical
RAMOS BRAVO
illness , Curr Opin Clin Nutr Metab Care 2014, 17
IN HUMANS, NITRIC OXIDE IS FORMED BY THREE ISOFORMS OF NOS BY USING ARGININE AS A SUBSTRATE
(ENDOTHELIAL, NEURONAL, AND INDUCIBLE NOS)

HECTOR RAMOS BRAVO

 Optimal NO-Balance

cNOS

- Microcirculation 
- Immune augmentation 

Arginine / NO
availability
Harmful

cNOS + iNOS

- Hemodynamic instability
- Immune Suppression
- Cytotoxicity
- Organe dysfunction

Hector Ramos Bravo

Suchner Brit J Nutrition 2001
Cortesia Daren K. Heyland
The beneficial and harmful effects of
arginine supplementation. NO, nitric
oxide.

Hector Ramos Bravo

ARGININA Overall Effect on
Mortality

Hector Ramos Bravo

Criticalcare nutrition -2010
HECTOR RAMOS BRAVO Hegazi and Wischmeyer Critical Care 2011, 15:234
GRACIAS
MR. A. Héctor Ramos Bravo
HECTOR RAMOS BRAVO
UCI-H.N.E.R.M.