{"id":1895,"date":"2023-04-26T15:52:45","date_gmt":"2023-04-26T18:52:45","guid":{"rendered":"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/?p=1895"},"modified":"2023-04-26T15:54:05","modified_gmt":"2023-04-26T18:54:05","slug":"hipofosfatemia-nutricao-parenteral","status":"publish","type":"post","link":"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/hipofosfatemia-nutricao-parenteral\/","title":{"rendered":"Hipofosfatemia e nutri\u00e7\u00e3o parenteral: o que \u00e9 essa poss\u00edvel complica\u00e7\u00e3o e como evitar?"},"content":{"rendered":"<p>O paciente em estado grave est\u00e1 exposto ao risco de uma s\u00e9rie de dist\u00farbios metab\u00f3licos e de eletr\u00f3litos, que se n\u00e3o controlados podem gerar complica\u00e7\u00f5es, inclusive associado ao uso de terapia nutricional. Exemplo disso est\u00e1 na rela\u00e7\u00e3o entre hipofosfatemia e nutri\u00e7\u00e3o parenteral.<\/p>\n<p>Assim, \u00e9 essencial ter ci\u00eancia dos riscos e caracter\u00edsticas das complica\u00e7\u00f5es geradas pela hipofosfatemia. A partir disso, \u00e9 poss\u00edvel conhecer condutas para evitar a defici\u00eancia de f\u00f3sforo e atuar para reverter tal condi\u00e7\u00e3o.<\/p>\n<p>&nbsp;<\/p>\n<h2>Afinal, o que \u00e9 a hipofosfatemia?<\/h2>\n<p>A hipofosfatemia \u00e9 caracterizada por n\u00edveis, abaixo do ideal, da concentra\u00e7\u00e3o de f\u00f3sforo s\u00e9rico<sup>1,2<\/sup>. Portanto, um quadro de hipofosfatemia \u00e9 identificado quando o f\u00f3sforo s\u00e9rico for menor que 2.5 miligramas por decilitro (mg\/dL) de sangue<sup>1,2<\/sup>. Considerando, o papel essencial desse micronutriente em diversas fun\u00e7\u00f5es metab\u00f3licas e celulares, tal redu\u00e7\u00e3o traz impactos significativos para a sa\u00fade do paciente<sup>1<\/sup>.<\/p>\n<p>Em pessoas que adotam dietas convencionais, a defici\u00eancia de f\u00f3sforo \u00e9 rara. Esse micronutriente est\u00e1 amplamente dispon\u00edvel em diversos alimentos, como carne vermelha, peixes, latic\u00ednios, nozes e soja<sup>3<\/sup>. Assim, o dist\u00farbio eletrol\u00edtico na concentra\u00e7\u00e3o de f\u00f3sforo pode ser consequ\u00eancia de uma s\u00e9rie de quadros cl\u00ednicos. Entre os mais comuns est\u00e3o<sup>2<\/sup>:<\/p>\n<p>&nbsp;<\/p>\n<ul>\n<li>recupera\u00e7\u00e3o de cetoacidose diab\u00e9tica;<\/li>\n<li>abuso regular de \u00e1lcool;<\/li>\n<li>queimaduras graves;<\/li>\n<li>alcalose respirat\u00f3ria grave;<\/li>\n<li>realimenta\u00e7\u00e3o ap\u00f3s longo per\u00edodo de desnutri\u00e7\u00e3o;<\/li>\n<li>introdu\u00e7\u00e3o de nutri\u00e7\u00e3o parenteral.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>A preval\u00eancia da hipofosfatemia \u00e9 variada e se altera de acordo com a condi\u00e7\u00e3o de base do paciente, com incid\u00eancia que varia entre 5% e 80% dos pacientes<sup>1<\/sup>. Em geral, tal problema \u00e9 assintom\u00e1tico sendo diagnosticado em achados acidentais de exames laboratoriais<sup>1<\/sup>. Entretanto, quadros graves contam com manifesta\u00e7\u00f5es cl\u00ednicas, ainda que inespec\u00edficas.<\/p>\n<h2><\/h2>\n<h2>Qual a rela\u00e7\u00e3o entre hipofosfatemia e nutri\u00e7\u00e3o parenteral?<\/h2>\n<p>Al\u00e9m de uma s\u00e9rie de condi\u00e7\u00f5es cl\u00ednicas, a hipofosfatemia pode estar relacionada tamb\u00e9m \u00e0 introdu\u00e7\u00e3o da <a href=\"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/vantagens-da-nutricao-parenteral-pronta-para-uso\/\">nutri\u00e7\u00e3o parenteral<\/a>. \u00a0A presen\u00e7a deste dist\u00farbio est\u00e1 fortemente relacionada \u00e0 chamada s\u00edndrome de realimenta\u00e7\u00e3o, que geralmente se manifesta nas primeiras 72 horas ap\u00f3s o in\u00edcio da interven\u00e7\u00e3o nutricional<sup>4 -8<\/sup>.<\/p>\n<p>A s\u00edndrome de realimenta\u00e7\u00e3o atinge pacientes que recebem terapia nutricional ap\u00f3s<a href=\"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/o-impacto-economico-da-desnutricao-relacionada-a-doenca-na-america-latina\/\"> desnutri\u00e7\u00e3o prolongada <\/a>ou catabolismo acentuado<sup>10-12<\/sup>. A partir do momento em que o corpo n\u00e3o recebe aporte nutricional adequado, o organismo deixa de oxidar glicose para gerar energia e passa a metabolizar \u00e1cidos graxos e prote\u00ednas, concentradas nos m\u00fasculos. Quando a alimenta\u00e7\u00e3o \u00e9 fornecida novamente, os n\u00edveis de glicose voltam ao normal<sup>3,9<\/sup>.<\/p>\n<p>A partir disso, a secre\u00e7\u00e3o da insulina tamb\u00e9m retorna e h\u00e1 aumento da demanda celular por elementos como o f\u00f3sforo, o magn\u00e9sio e o c\u00e1lcio devido a uma s\u00e9rie de processos celulares anab\u00f3licos. No caso do f\u00f3sforo, ele se combina com o oxig\u00eanio na forma de fosfato e desempenha papel essencial para s\u00edntese celular de adenosina trifosfato (ATP). Diante desse cen\u00e1rio, h\u00e1 deslocamento intenso dos micronutrientes dispon\u00edveis para o interior das c\u00e9lulas. Logo, o n\u00edvel s\u00e9rico do f\u00f3sforo, e outros eletr\u00f3litos, tende a cair, levando \u00e0 hipofosfatemia<sup>3.10<\/sup>.<\/p>\n<p>Quando est\u00e3o presentes apenas os desequil\u00edbrios eletrol\u00edticos, a s\u00edndrome de realimenta\u00e7\u00e3o \u00e9 caracterizada como iminente. A partir do momento em que h\u00e1 manifesta\u00e7\u00f5es cl\u00ednicas, ela recebe o nome de \u201cs\u00edndrome de realimenta\u00e7\u00e3o manifesta\u201d<sup>11<\/sup>. N\u00e3o h\u00e1 exame espec\u00edfico para o diagn\u00f3stico dessa condi\u00e7\u00e3o, ent\u00e3o a avalia\u00e7\u00e3o cuidadosa de toda suspeita \u00e9 indispens\u00e1vel. Os sintomas mais comuns s\u00e3o inespec\u00edficos e incluem edemas, taquicardia e taquipneia<sup>10- 13<\/sup>. Em m\u00e9dia, esta condi\u00e7\u00e3o atinge entre 14% e 28% dos pacientes clinicamente graves, ap\u00f3s in\u00edcio da dieta<sup>11<\/sup>.<\/p>\n<p>&nbsp;<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter wp-image-1896 size-full\" src=\"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/wp-content\/uploads\/sites\/3\/2023\/04\/imagem-1-unidos-lam138.png\" alt=\"\" width=\"940\" height=\"702\" srcset=\"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/wp-content\/uploads\/sites\/3\/2023\/04\/imagem-1-unidos-lam138.png 940w, https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/wp-content\/uploads\/sites\/3\/2023\/04\/imagem-1-unidos-lam138-300x224.png 300w, https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/wp-content\/uploads\/sites\/3\/2023\/04\/imagem-1-unidos-lam138-768x574.png 768w, https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/wp-content\/uploads\/sites\/3\/2023\/04\/imagem-1-unidos-lam138-502x375.png 502w\" sizes=\"auto, (max-width: 940px) 100vw, 940px\" \/><\/p>\n<p>&nbsp;<\/p>\n<h2>Quais os sintomas da hipofosfatemia grave?<\/h2>\n<p>Diante da defici\u00eancia grave de f\u00f3sforo, os sintomas e desdobramentos mais comuns s\u00e3o<sup>10<\/sup>:<\/p>\n<p>&nbsp;<\/p>\n<ul>\n<li>comprometimento da fun\u00e7\u00e3o neuromuscular (parestesias);<\/li>\n<li>confus\u00e3o mental;<\/li>\n<li>convuls\u00f5es;<\/li>\n<li>coma;<\/li>\n<li>c\u00e3ibras e fraqueza muscular;<\/li>\n<li>hipoventila\u00e7\u00e3o e, eventualmente, insufici\u00eancia respirat\u00f3ria aguda;<\/li>\n<li>rabdomi\u00f3lise;<\/li>\n<li>trombocitopenia;<\/li>\n<li>coagulopatia;<\/li>\n<li>disfun\u00e7\u00e3o leucocit\u00e1ria e eritroc\u00edtica.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>O diagn\u00f3stico da hipofosfatemia \u00e9 feito pela mensura\u00e7\u00e3o laboratorial do f\u00f3sforo s\u00e9rico. Sem interven\u00e7\u00e3o adequada, a s\u00edndrome de realimenta\u00e7\u00e3o e a hipofosfatemia levam \u00e0 morte<sup>10<\/sup>.<\/p>\n<p><em>\u00a0<\/em><\/p>\n<p><em>Leia tamb\u00e9m<a href=\"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/importancia-dos-micronutrientes-nutricao-parenteral\/\">: qual a import\u00e2ncia dos micronutrientes na nutri\u00e7\u00e3o parenteral?<\/a><\/em><\/p>\n<p>&nbsp;<\/p>\n<h2>Como a hipofosfatemia pode ser evitada e o que fazer quando ela j\u00e1 se instalou?<\/h2>\n<p>Antes da introdu\u00e7\u00e3o da terapia nutricional, todo paciente grave deve passar por dosagem de eletr\u00f3litos. A reposi\u00e7\u00e3o de f\u00f3sforo, magn\u00e9sio e c\u00e1lcio e outros eletr\u00f3litos \u00e9 recomendada mesmo se o n\u00edvel s\u00e9rico constatado for normal ou pouco abaixo do limite inferior de refer\u00eancia<sup>10,11<\/sup>.<\/p>\n<p>Al\u00e9m disso, a oferta cal\u00f3rica a pacientes desnutridos deve ser pequena nos primeiros dias, logo que a terapia nutricional \u00e9 iniciada. Deve-se sempre priorizar uma progress\u00e3o gradual, em per\u00edodos que variam entre 5 e 10 dias at\u00e9 se atingir a meta estabelecida<sup>11<\/sup>. No mais, \u00e9 essencial refor\u00e7ar o monitoramento nas primeiras 72 horas ap\u00f3s a introdu\u00e7\u00e3o da nutri\u00e7\u00e3o parenteral<sup>9,11<\/sup>.<\/p>\n<p>Se identificada a presen\u00e7a da s\u00edndrome, \u00e9 essencial agir para lidar com a condi\u00e7\u00e3o de base, bem como contornar a defici\u00eancia por meio de suplementa\u00e7\u00e3o apropriada, como vimos anteriormente. Dessa forma, os profissionais de sa\u00fade respons\u00e1veis pelo acompanhamento precisam manter-se atentos diante da rela\u00e7\u00e3o entre hipofosfatemia e nutri\u00e7\u00e3o parenteral.<\/p>\n<p>&nbsp;<\/p>\n<p>Para saber mais, veja a <a href=\"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/importancia-dos-micronutrientes-nutricao-parenteral\/\">import\u00e2ncia dos micronutrientes na nutri\u00e7\u00e3o parenteral.<\/a><\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Refer\u00eancias<\/strong><\/p>\n<ol>\n<li>Sharma S, Hashmi MF, Castro D. Hypophosphatemia. [Updated 2022 Sep 12]. In: StatPearls [Internet]. StatPearls Publishing; 2022 Jan-. Ddispon\u00edvel em <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK493172\">https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK493172<\/a> Acesso fev. 2023.<\/li>\n<li>III, James L. Lewis. Hypophosphatemia. <em>MSD Manual Professional Edition<\/em>, MSD Manuals, 18 Nov. 2022. Dispon\u00edvel em: <a href=\"http:\/\/www.msdmanuals.com\/professional\/endocrine-and-metabolic-disorders\/electrolyte-disorders\/hypophosphatemia\">msdmanuals.com\/professional\/endocrine-and-metabolic-disorders\/electrolyte-disorders\/hypophosphatemia<\/a>. Acesso fev 2023.<\/li>\n<li>Bezerra, A. R., dos Santos, P. A. A., Santos, L. S., &amp; Petrib\u00fa, M. D. M. V. (2021). Preval\u00eancia de hipofosfatemia e risco de s\u00edndrome de realimenta\u00e7\u00e3o em idosos internados em uma unidade de terapia intensiva. <em>DEMETRA: Alimenta\u00e7\u00e3o, Nutri\u00e7\u00e3o &amp; Sa\u00fade<\/em>, <em>16<\/em>, 53791. Dispon\u00edvel em: <a href=\"https:\/\/www.e-publicacoes.uerj.br\/index.php\/demetra\/article\/view\/53791\">https:\/\/www.e-publicacoes.uerj.br\/index.php\/demetra\/article\/view\/53791<\/a> Acesso fev. 2023.<\/li>\n<li>Olthof LE, Koekkoek WAC, Van Setten C, Kars JCN, Van Blokland D, Van Zanten ARH. Impact of caloric intake in critically ill patients with, and without, refeeding syndrome: A retrospective study. Clin Nutr. 2018;37(5):1609-1617. Dispon\u00edvel em: <a href=\"https:\/\/doi.org\/10.1016\/j.clnu.2017.08.001\">https:\/\/doi.org\/10.1016\/j.clnu.2017.08.001<\/a> Acesso fev. 2023.<\/li>\n<li>Co\u015fkun R, G\u00fcndo\u011fan K, Baldane S, G\u00fcven M, Sungur M. Refeeding hypophosphatemia: a potentially fatal danger in the intensive care unit. Turk J Med Sci. 2014; 44:369-374. https:\/\/doi.org\/10.3906\/sag-1211-49 Dispon\u00edvel em: <a href=\"https:\/\/journals.tubitak.gov.tr\/medical\/vol44\/iss3\/4\/\">https:\/\/journals.tubitak.gov.tr\/medical\/vol44\/iss3\/4\/<\/a> Acesso fev. 2023.<\/li>\n<li>Fuentes E, Yeh DD, Quraishi SA, Johnson EA, Kaafarani H, Lee J, et al. Hypophosphatemia in Enterally Fed Patients in the Surgical Intensive Care Unit. Nutr Clin Pract. 2016; 32(2):252-257. <a href=\"https:\/\/doi.org\/10.1177\/0884533616662988\">https:\/\/doi.org\/10.1177\/0884533616662988<\/a>. Dispon\u00edvel em: <a href=\"https:\/\/aspenjournals.onlinelibrary.wiley.com\/doi\/abs\/10.1177\/0884533616662988\">https:\/\/aspenjournals.onlinelibrary.wiley.com\/doi\/abs\/10.1177\/0884533616662988<\/a> Acesso dez. 2022<\/li>\n<li>Ralib A, Ismail CA, Hassan MZ, Ibrahim TM. Refeeding hypophosphatemia in a Malaysian intensive care unit: incidence, risk factors, and outcomes. Brunei Int Med J. 2015; 11:65\u201373. Dispon\u00edvel em: <a href=\"http:\/\/irep.iium.edu.my\/43768\/\">http:\/\/irep.iium.edu.my\/43768\/<\/a> Acesso dez. 2022.<\/li>\n<li>Boot R, Koekkoek K, van Zanten A. Refeeding syndrome: relevance for the critically ill patient. Curr Opin Crit Care. 2018;24(4):235-240. Dispon\u00edvel em: <a href=\"https:\/\/journals.lww.com\/co-criticalcare\/Abstract\/2018\/08000\/Refeeding_syndrome__relevance_for_the_critically.4.aspx%20Acesso%20nov.%202022\">https:\/\/journals.lww.com\/co-criticalcare\/Abstract\/2018\/08000\/Refeeding_syndrome__relevance_for_the_critically.4.aspx Acesso nov. 2022<\/a>.<\/li>\n<\/ol>\n<ol start=\"9\">\n<li>Sad, M. H., Parra, B. F. C. S., Ferrer, R., da Silva J\u00fanior, A. V., do Amaral Pfeilsticker, F. J., de Matos, L. B. N., &amp; Toledo, D. O. Manejo nutricional em pacientes com risco de s\u00edndrome de realimenta\u00e7\u00e3o. Dispon\u00edvel em: <a href=\"http:\/\/arquivos.braspen.org\/journal\/out-dez-2019\/artigos\/18-Sindrome-de-realimentacao.pdf\">http:\/\/arquivos.braspen.org\/journal\/out-dez-2019\/artigos\/18-Sindrome-de-realimentacao.pdf<\/a> Acesso fev. 2023.<\/li>\n<li>Friedli N, Stanga Z, Culkin A, Crook M, Laviano A, Sobotka L, et al. Management and prevention of refeeding syndrome in medical inpatients: an evidence-based and consensus-supported algorithm. Nutrition. 2018;47:13-20. Dispon\u00edvel em: <a href=\"https:\/\/www.sciencedirect.com\/science\/article\/abs\/pii\/S0899900717302071?via%3Dihub\">https:\/\/www.sciencedirect.com\/science\/article\/abs\/pii\/S0899900717302071?via%3Dihub<\/a> Acesso dez. 2022.<\/li>\n<li>Aubry E, Friedli N, Schuetz P, Stanga Z. Refeeding syndrome in the frail elderly population: prevention, diagnosis and management. Clin Exp Gastroenterol. 2018;11:255-64. Dispon\u00edvel em: <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC6045900\/\">https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC6045900\/<\/a> Acesso fev. 2023.<\/li>\n<li>Doig GS, Simpson F, Heigles PT, Bellomo R, Chesher D, Caterson ID, et al. Restricted versus continued standard caloric intake during the management of refeeding syndrome in critically ill adults: a randomised, parallel-group, multicentre, single-blind controlled trial. Lancet Respir Med. 2015;3(12):943-52. Dispon\u00edvel em: <a href=\"https:\/\/www.thelancet.com\/journals\/lanres\/article\/PIIS2213-2600(15)00418-X\/fulltext\">https:\/\/www.thelancet.com\/journals\/lanres\/article\/PIIS2213-2600(15)00418-X\/fulltext<\/a> Acesso dez. 2022.<\/li>\n<li>Koekkoek WAC, Van Zanten ARH. Is refeeding syndrome relevant for critically ill patients? Curr Opin Clin Nutr Metab Care. 2018;21(2):130-7. Dispon\u00edvel em: <a href=\"https:\/\/journals.lww.com\/co-clinicalnutrition\/Abstract\/2018\/03000\/Is_refeeding_syndrome_relevant_for_critically_ill.12.aspx\">https:\/\/journals.lww.com\/co-clinicalnutrition\/Abstract\/2018\/03000\/Is_refeeding_syndrome_relevant_for_critically_ill.12.aspx<\/a> Acesso dez. 2022.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>O paciente em estado grave est\u00e1 exposto ao risco de uma s\u00e9rie de dist\u00farbios metab\u00f3licos e de eletr\u00f3litos, que se n\u00e3o controlados podem gerar complica\u00e7\u00f5es, inclusive associado ao uso de terapia nutricional. Exemplo disso est\u00e1 na rela\u00e7\u00e3o entre hipofosfatemia e nutri\u00e7\u00e3o parenteral. Assim, \u00e9 essencial ter ci\u00eancia dos riscos e caracter\u00edsticas das complica\u00e7\u00f5es geradas pela [&hellip;]<\/p>\n","protected":false},"author":5902,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[49],"tags":[200,220,219,67,88],"class_list":["post-1895","post","type-post","status-publish","format-standard","hentry","category-artigo-5","tag-desnutricao-clinica","tag-fosforo","tag-hipofosfatemia","tag-nutricao-parenteral","tag-sindrome-de-realimentacao"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Entenda qual a rela\u00e7\u00e3o entre hipofosfatemia e nutri\u00e7\u00e3o parenteral<\/title>\n<meta name=\"description\" content=\"Hipofosfatemia e nutri\u00e7\u00e3o parenteral est\u00e3o comumente associadas, o que exige aten\u00e7\u00e3o total dos 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