{"id":1890,"date":"2023-04-05T10:45:40","date_gmt":"2023-04-05T13:45:40","guid":{"rendered":"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/?p=1890"},"modified":"2023-04-05T10:45:40","modified_gmt":"2023-04-05T13:45:40","slug":"manejo-trato-gastroinestinal","status":"publish","type":"post","link":"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/manejo-trato-gastroinestinal\/","title":{"rendered":"Como deve ser feito o manejo da disfun\u00e7\u00e3o do trato gastrointestinal em pacientes na UTI?"},"content":{"rendered":"<p>N\u00e3o \u00e9 novidade que o <strong>manejo da disfun\u00e7\u00e3o do trato gastrointestinal tem reflexo direto no desfecho cl\u00ednico dos pacientes admitidos em unidades de terapia intensiva. <\/strong>Tal afirma\u00e7\u00e3o leva em conta que problemas na fun\u00e7\u00e3o dessa parte do organismo s\u00e3o comuns em ambientes de UTI<sup>1<\/sup>.<\/p>\n<p>Dessa forma, torna-se fundamental reconhecer a natureza dos problemas mais comuns. Al\u00e9m disso, os profissionais respons\u00e1veis pelo acompanhamento do quadro devem se atentar para otimizar os benef\u00edcios de eventuais interven\u00e7\u00f5es nutricionais, conforme a <a href=\"https:\/\/www.braspen.org\/_files\/ugd\/cbac6c_fc1bdc762c254488a0a5670ec75d4433.pdf\">diretriz nacional sobre o tema.<\/a><\/p>\n<p>&nbsp;<\/p>\n<h2>A fun\u00e7\u00e3o gastrointestinal em pacientes graves<\/h2>\n<p>H\u00e1 alguns quadros cl\u00ednicos que podem afetar a motilidade do trato gastrointestinal<strong>. Um dos aspectos mais prevalentes s\u00e3o as altera\u00e7\u00f5es nas contra\u00e7\u00f5es musculares provocadas pelo estresse relacionado \u00e0 doen\u00e7a. Al\u00e9m disso, o paciente pode ter preju\u00edzos na secre\u00e7\u00e3o e absor\u00e7\u00e3o de nutrientes, bem como na composi\u00e7\u00e3o e comportamento da microbiota intestinal<sup>2<\/sup>.<\/strong><\/p>\n<p>Com isso, h\u00e1 evid\u00eancias que corroboram a altera\u00e7\u00e3o da fun\u00e7\u00e3o gastrointestinal com a trajet\u00f3ria cl\u00ednica de pacientes em estados graves. Em tal contexto, pacientes com disbiose (desequil\u00edbrio da microbiota intestinal) t\u00eam aumento da permeabilidade intestinal e modula\u00e7\u00e3o imune, favorecendo estados pr\u00f3-inflamat\u00f3rios<sup>3,4,5<\/sup>.<\/p>\n<p>Logo, a literatura dispon\u00edvel refor\u00e7a a import\u00e2ncia e a relev\u00e2ncia cl\u00ednica de um intestino funcional em pacientes graves<sup>1<\/sup>.<\/p>\n<p>Alguns dos problemas no trato gastrointestinal presentes em pacientes cr\u00edticos e que devem ser identificados e monitorados s\u00e3o<sup>1<\/sup>:<\/p>\n<p>&nbsp;<\/p>\n<ul>\n<li>refluxo gastroesof\u00e1gico;<\/li>\n<li>gastroparesia;<\/li>\n<li>diarreia;<\/li>\n<li>constipa\u00e7\u00e3o;<\/li>\n<li>\u00edleo adin\u00e2mico.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>Todas essas condi\u00e7\u00f5es podem ter etiologias variadas e diferentes escalas de gravidade. <strong>Portanto, cada uma delas exige diferentes recursos para o diagn\u00f3stico adequado, bem como para condu\u00e7\u00e3o do quadro \u00e0 medida que o paciente evolui no ambiente de UTI. <\/strong><\/p>\n<p>&nbsp;<\/p>\n<h2>Avalia\u00e7\u00e3o e monitoramento da fun\u00e7\u00e3o gastrointestinal<\/h2>\n<p>Assim, \u00e9 fundamental refor\u00e7ar que o in\u00edcio da doen\u00e7a grave muda de imediato o ambiente do trato gastrointestinal. Isso favorece altera\u00e7\u00f5es que levam a complica\u00e7\u00f5es abdominais e extra-abdominais. \u00c9 necess\u00e1ria, portanto, a adequa\u00e7\u00e3o a uma s\u00e9rie de procedimentos, para garantir que complica\u00e7\u00f5es relacionadas a fun\u00e7\u00e3o gastrointestinal de pacientes cr\u00edticos n\u00e3o se reflitam em uma maior mortalidade.<\/p>\n<p>Parte essencial desse acompanhamento envolve o pronto reconhecimento de epis\u00f3dios de agress\u00e3o gastrointestinal aguda, compondo um cuidado essencial para os respons\u00e1veis pelo cuidado nesses cen\u00e1rios. A classifica\u00e7\u00e3o do est\u00e1gio da agress\u00e3o gastrointestinal \u00e9 delimitada por meio de uma escala que vai de I a IV.\u00a0 Desse modo, a progress\u00e3o da gravidade eleva o risco de fal\u00eancia dos \u00f3rg\u00e3os e aumenta a chance de morte<sup>6<\/sup>.<\/p>\n<p>Al\u00e9m disso, h\u00e1 outros escores que podem ser utilizados para estimar o progn\u00f3stico do paciente em estado grave em ambiente de UTI<sup>1<\/sup>. Uma das mais comuns \u00e9 a pontua\u00e7\u00e3o de fal\u00eancia gastrointestinal (conhecida pela sigla GIF). Ela \u00e9 mensurada pelos sintomas abdominais e pela press\u00e3o intra-abdominal<sup>7<\/sup>.<\/p>\n<p>Por outro lado, a presen\u00e7a isolada da press\u00e3o intra-abdominal n\u00e3o \u00e9 suficiente para caracterizar a disfun\u00e7\u00e3o gastrointestinal, uma vez que a GIF tem como principal objetivo fazer um diagn\u00f3stico precoce de problemas no trato gastrointestinal. Para avalia\u00e7\u00e3o das disfun\u00e7\u00f5es gastrointestinais \u00e9 poss\u00edvel utilizar a escala GIDS (escore de disfun\u00e7\u00e3o gastrointestinal)<sup>1,7<\/sup>.<\/p>\n<p>&nbsp;<\/p>\n<p><em>Veja tamb\u00e9m:<\/em><a href=\"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/entenda-tudo-sobre-a-nutricao-parenteral-na-unidade-de-terapia-intensiva\/\"><em> tudo o que voc\u00ea precisa saber sobre a nutri\u00e7\u00e3o parenteral na unidade de terapia intensiva<\/em><\/a><\/p>\n<p><em>\u00a0<\/em><\/p>\n<h2>O cuidado nutricional no manejo da disfun\u00e7\u00e3o do trato gastrointestinal<\/h2>\n<p>&nbsp;<\/p>\n<p><strong>A maioria das diretrizes dispon\u00edveis recomenda a introdu\u00e7\u00e3o da terapia nutricional enteral em intervalos entre 24 e 48 horas ap\u00f3s a admiss\u00e3o em UTI diante da s\u00e9rie de benef\u00edcios que isso oferece<sup>8-11<\/sup>. <\/strong><\/p>\n<p>No caso de pacientes com dano \u00e0 fun\u00e7\u00e3o gastrointestinal, tal recomenda\u00e7\u00e3o \u00e9 acompanhada do monitoramento toler\u00e2ncia do paciente em rela\u00e7\u00e3o \u00e0 nutri\u00e7\u00e3o enteral. Dessa maneira, \u00e9 poss\u00edvel iniciar precocemente interven\u00e7\u00f5es nutricionais ap\u00f3s tratamento de anormalidades do trato gastrointestinal<sup>1<\/sup>. Logo, em nenhuma hip\u00f3tese, deve-se suspender a interven\u00e7\u00e3o nutricional sem evid\u00eancia clara de intoler\u00e2ncia<sup>1<\/sup>.<\/p>\n<p><strong>Os pacientes que n\u00e3o atingirem a <\/strong><strong>recomenda\u00e7\u00e3o nutricional<\/strong><strong> por meio da nutri\u00e7\u00e3o enteral, na primeira semana de UTI, devem considerar os benef\u00edcios e os riscos da nutri\u00e7\u00e3o parenteral<sup>1<\/sup>.<\/strong> Apesar disso, a introdu\u00e7\u00e3o desses recursos n\u00e3o deve ser feita at\u00e9 que sejam esgotadas todas as solu\u00e7\u00f5es para maximizar a toler\u00e2ncia gastrointestinal<sup>8<\/sup>.<\/p>\n<p><strong>Em todo o caso, a prioridade deve ser a utiliza\u00e7\u00e3o da <\/strong><a href=\"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/indicacao-nutricao-parenteral\/\"><strong>nutri\u00e7\u00e3o parenteral <\/strong><\/a><strong>suplementar. Os n\u00fameros para essa indica\u00e7\u00e3o variam de acordo com a diretriz consultada. Em m\u00e9dia, quando a oferta cal\u00f3rica \u00e9 inferior a 60% das necessidades di\u00e1rias, por pelo menos 3 dias ap\u00f3s admiss\u00e3o da UTI, a nutri\u00e7\u00e3o parenteral suplementar deve ser iniciada<sup>8<\/sup>.<\/strong>\u00a0 Tal demanda energ\u00e9tica deve ser mensurada por calorimetria indireta, sempre que poss\u00edvel<sup>8<\/sup>.\u00a0 Por outro lado, para nutri\u00e7\u00e3o parenteral total, a recomenda\u00e7\u00e3o geral passa por aguardar, ao menos, 7 dias para certificar-se de que o paciente n\u00e3o alcan\u00e7a a capacidade de ingest\u00e3o oral volunt\u00e1ria e\/ou a nutri\u00e7\u00e3o enteral permanece invi\u00e1vel<sup>9<\/sup>.<\/p>\n<p>Levando tudo isso em conta, os cuidados em rela\u00e7\u00e3o ao manejo da disfun\u00e7\u00e3o do trato gastrointestinal est\u00e3o relacionados com o impacto desse quadro no desfecho cl\u00ednico, conforme j\u00e1 citado.\u00a0 <strong>Isso inclui desde o reconhecimento e avalia\u00e7\u00e3o a partir de sintomas iniciais, assim como todas as interven\u00e7\u00f5es necess\u00e1rias para otimizar a toler\u00e2ncia da terapia nutricional, o que permite um melhor aproveitamento dos nutrientes e manuten\u00e7\u00e3o ou recupera\u00e7\u00e3o do estado nutricional do nosso paciente. <\/strong><\/p>\n<p>&nbsp;<\/p>\n<p>Aproveite e veja mais sobre a<a href=\"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/monitorizacao-terapia-nutricional-importancia\/\"> import\u00e2ncia da monitoriza\u00e7\u00e3o da terapia nutricional.<\/a><\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Refer\u00eancias<\/strong><\/p>\n<p>&nbsp;<\/p>\n<ol>\n<li>Barreto, P., de Assis, T., Castro, M. G., Rosenfeld, R. S., Duprat, G., Costa, R., &#8230; &amp; Gon\u00e7alves, T. J. M. Posicionamento BRASPEN\u2013Manejo da disfun\u00e7\u00e3o trato gastrointestinal na UTI. Dispon\u00edvel em: <a href=\"https:\/\/www.braspen.org\/_files\/ugd\/cbac6c_fc1bdc762c254488a0a5670ec75d4433.pdf\">https:\/\/www.braspen.org\/_files\/ugd\/cbac6c_fc1bdc762c254488a0a5670ec75d4433.pdf<\/a> Acesso jan. 2023.<\/li>\n<li>Heinonen T, Ferrie S, Ferguson C. Gut function in the intensive care unit: what is &#8216;normal&#8217;? Aust Crit Care. 2020;33(2):151-4. Dispon\u00edvel em: <a href=\"https:\/\/www.australiancriticalcare.com\/article\/S1036-7314(18)30099-7\/fulltext\">https:\/\/www.australiancriticalcare.com\/article\/S1036-7314(18)30099-7\/fulltext<\/a> Acesso nov. 2022.<\/li>\n<li>McClave SA, Lowen CC, Martindale RG. The 2016 ESPEN Arvid Wretlind lecture: the gut in stress. Clin Nutr. 2018;37(1):19-36. Dispon\u00edvel em: <a href=\"https:\/\/www.clinicalnutritionjournal.com\/article\/S0261-5614(17)30256-X\/fulltext\">https:\/\/www.clinicalnutritionjournal.com\/article\/S0261-5614(17)30256-X\/fulltext<\/a> Acesso nov. 2022.<\/li>\n<li>Assimakopoulos SF, Triantos C, Thomopoulos K, Fligou F, Maroulis I, Marangos M, et al. Gut-origin sepsis in the critically ill patient: pathophysiology and treatment. Infection. 2018;46(6):751-60. Dispon\u00edvel em: <a href=\"https:\/\/link.springer.com\/article\/10.1007\/s15010-018-1178-5\">https:\/\/link.springer.com\/article\/10.1007\/s15010-018-1178-5<\/a> Acessojan. 2023.<\/li>\n<li>Potruch A, Schwartz A, Ilan Y. The role of bacterial translocation in sepsis: a new target for therapy. Therap Adv Gastroenterol. 2022;15:17562848221094214. Dispon\u00edvel em: <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC9092582\/\">https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC9092582\/<\/a> Acesso jan. 2023.<\/li>\n<li>Reintam Blaser A, Poeze M, Malbrain ML, Bj\u00f6rck M, Oudemansvan Straaten HM, Starkopf J; Gastro-Intestinal Failure Trial Group. Gastrointestinal symptoms during the first week of intensive care are associated with poor outcome: a prospective multicentre study. Intensive Care Med. 2013;39(5):899-909. Dispon\u00edvel em https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC3625421\/Acesso mar. 2023.<\/li>\n<li>Reintam Blaser A, Padar M, M\u00e4ndul M, Elke G, Engel C, Fischer K, et al. Development of the Gastrointestinal Dysfunction Score (GIDS) for critically ill patients: a prospective multicenter observational study (iSOFA study). Clin Nutr. 2021;40(8):4932-40.Dispon\u00edvel em <a href=\"https:\/\/www.clinicalnutritionjournal.com\/article\/S0261-5614(21)00349-6\/fulltext\">https:\/\/www.clinicalnutritionjournal.com\/article\/S0261-5614(21)00349-6\/fulltext<\/a> Acesso mar.2023.<\/li>\n<li>Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48-79. https:\/\/www.clinicalnutritionjournal.com\/article\/S0261-5614(18)32432-4\/fulltext Acesso jan. 2023.<\/li>\n<li>McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, et al; Society of Critical Care Medicine; American Society for Parenteral and Enteral Nutrition. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40(2):159-211.\u00a0 Dispon\u00edvel em: <a href=\"https:\/\/aspenjournals.onlinelibrary.wiley.com\/doi\/full\/10.1177\/0148607115621863\">https:\/\/aspenjournals.onlinelibrary.wiley.com\/doi\/full\/10.1177\/0148607115621863<\/a> Acesso jan. 2023.<\/li>\n<li>Castro MG, Ribeiro PC, Souza IAO, Cunha HFR, Silva MHN, Rocha EEM, et al. Diretriz brasileira de terapia nutricional em pacientes graves. BRASPEN J. 2018;33(Supl 1):2-36 Dispon\u00edvel em: <a href=\"https:\/\/www.braspen.org\/_files\/ugd\/a8daef_695255f33d114cdfba48b437486232e7.pdf\">https:\/\/www.braspen.org\/_files\/ugd\/a8daef_695255f33d114cdfba48b437486232e7.pdf<\/a> Acesso em jan. 2023.<\/li>\n<li>Preiser JC, Arabi YM, Berger MM, Casaer M, Casaer M, McClave S, Montejo-Gonz\u00e1lez JC, et al. A guide to enteral nutrition in intensive care units: 10 expert tips for the daily practice. Crit Care. 2021;25(1):424 Dispon\u00edvel em: <a href=\"https:\/\/ccforum.biomedcentral.com\/articles\/10.1186\/s13054-021-03847-4\">https:\/\/ccforum.biomedcentral.com\/articles\/10.1186\/s13054-021-03847-4<\/a> Acesso em jan. 2023.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>N\u00e3o \u00e9 novidade que o manejo da disfun\u00e7\u00e3o do trato gastrointestinal tem reflexo direto no desfecho cl\u00ednico dos pacientes admitidos em unidades de terapia intensiva. Tal afirma\u00e7\u00e3o leva em conta que problemas na fun\u00e7\u00e3o dessa parte do organismo s\u00e3o comuns em ambientes de UTI1. Dessa forma, torna-se fundamental reconhecer a natureza dos problemas mais comuns. [&hellip;]<\/p>\n","protected":false},"author":5902,"featured_media":1891,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[47],"tags":[214,81,216,213,215],"class_list":["post-1890","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-artigo-4","tag-disfuncao","tag-nutricao-clinica","tag-paciente-grave","tag-trato-gastrintestinal","tag-unidade-de-terapia-intensiva"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Veja como deve ser feito o manejo da disfun\u00e7\u00e3o do trato gastrointestinal.<\/title>\n<meta name=\"description\" content=\"O manejo da disfun\u00e7\u00e3o do trato gastrointestinal \u00e9 fundamental para progress\u00e3o do quadro cl\u00ednico de pacientes graves.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, 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