''Terapia Nutricional en El Paciente COVID19
''Terapia Nutricional en El Paciente COVID19
''Terapia Nutricional en El Paciente COVID19
I. Introducción
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Terapia Nutricional en el Paciente Crítico con Covid-19. Consideraciones Actuales
II. Metodología
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Terapia Nutricional en el Paciente Crítico con Covid-19. Consideraciones Actuales
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crónica) y la malnutrición crónica La edad avanzada y la presencia de
comorbilidades se asocian a malnutrición con grados variables de sarcopenia,
factores que son independientes del índice de masa corporal (IMC).9 Por otro
lado, un IMC aumentado parece estar relacionado con un mal pronóstico lo cual
avala un posible rol de la obesidad sarcopénica en el pronóstico de estos
pacientes con COVID-19.10 Por otra parte, bajos niveles de prealbúmina sérica
predicen la progresión de la falla respiratoria inicial al SDRA de acuerdo a lo
demostrado por Wu et al.11
Al igual que todas las intervenciones relacionadas con la atención del paciente
con COVID-19, la terapia nutricional debe considerar los siguientes aspectos: 15
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Terapia Nutricional en el Paciente Crítico con Covid-19. Consideraciones Actuales
1. “Atención por cohortes”, lo que significa que deberán agruparse los pacientes
y brindar la asistencia nutricional al grupo con el objetivo de minimizar la
exposición del personal de salud.
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Terapia Nutricional en el Paciente Crítico con Covid-19. Consideraciones Actuales
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Terapia Nutricional en el Paciente Crítico con Covid-19. Consideraciones Actuales
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se mantienen en balance nitrogenado (BN) negativo. El trabajo respiratorio
representa una gran parte del gasto energético (hasta un 25%), habiéndose
demostrado que el balance calórico negativo puede coadyuvar al deterioro
respiratorio. 44 Por su parte, los efectos de la NE temprana en aquellos pacientes
que requieren VNI no han sido ampliamente investigados. Sin embargo, es
posible afirmar que la indicación de NE se asocia a algunas complicaciones
cuando el paciente requiere VNI, sobre todo en aquellos en los que esta
modalidad ventilatoria se prolonga. En tal sentido, Kogo et al. observaron que
más del 50% de los pacientes fueron incapaces de mantener la vía oral y en
ellos la tasa de complicaciones fue mayor (53% [32/60] frente a 32% [15/47], p =
0,03), así como los tiempos de ventilación mecánica (16 [7-43] versus 8 [5-20]
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días, P = 0.02) en favor de aquellos pacientes que recibieron NE.
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Terapia Nutricional en el Paciente Crítico con Covid-19. Consideraciones Actuales
Van den Berghe et al. en un análisis secundario del estudio PEPANIC han
definido que el inicio muy temprano de proteínas puede asociarse con resultados
adversos, posiblemente secundarios a la inhibición de la autofagia. 56
Recientemente el estudio PROCASEPT, ha sugerido que los efectos del aporte
proteico son variables en los pacientes con sepsis con relación a otros pacientes
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críticos no sépticos. En estado crítico, la administración de proteína debe ser
prioridad y sobre la base de la información limitada y no hacer daño, se puede
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Terapia Nutricional en el Paciente Crítico con Covid-19. Consideraciones Actuales
En pacientes obesos, el cálculo de 1,3 g/kg/día se debe hacer con peso ajustado.
Se calcula el peso corporal ajustado como peso corporal ideal + (peso corporal
actual - peso corporal ideal) * 0.33. 59 En la actualidad, el estudio EFFORT
(NCT03160547), hasta el momento el ensayo clínico más grande, tiene como
objetivo resolver la controversia entre las dosis altas (>2.2 g/kg/d) y bajas de
proteínas. 60
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Terapia Nutricional en el Paciente Crítico con Covid-19. Consideraciones Actuales
30% en la primera semana de la UCI) parece ser beneficioso. Después del día
tres, se deben hacer incrementos para alcanzar el 80-100%.61 62
Peso ajustado = Peso ideal + 20–25% de diferencia entre el peso real e ideal (peso real - peso ideal)
Peso ideal: para hombres: 0.9 × (altura en cm - 100); para las mujeres: 0.9 × (altura en cm - 106)
(sugerido en las pautas ESPEN, no hay una sugerencia específica para calcular el Peso ideal en las pautas ASPEN)
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Terapia Nutricional en el Paciente Crítico con Covid-19. Consideraciones Actuales
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Terapia Nutricional en el Paciente Crítico con Covid-19. Consideraciones Actuales
Por otra parte, en los pacientes críticos la deficiencia absoluta, o al menos los
bajos niveles séricos son frecuentes debido a la fuga capilar característica de la
inflamación sistémica, por lo que debe asegurarse la repleción de estos.84
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Terapia Nutricional en el Paciente Crítico con Covid-19. Consideraciones Actuales
Las dosis de antioxidantes superiores a diez veces el DRI no deben usarse en entornos
clínicos sin deficiencia severa comprobada.
Abreviaturas: ALA-GLN: alanina gluramina; GPx: Seleno-proteína glutatión peroxidasas; DHA:
ácido docosaexaenoico; EPA: ácido eicosapentaenoico; UI: unidades internacionales.
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