{"id":1897,"date":"2023-05-03T14:27:00","date_gmt":"2023-05-03T17:27:00","guid":{"rendered":"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/?p=1897"},"modified":"2023-05-03T14:27:00","modified_gmt":"2023-05-03T17:27:00","slug":"inicio-nutricao-parenteral","status":"publish","type":"post","link":"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/inicio-nutricao-parenteral\/","title":{"rendered":"Veja o que voc\u00ea precisa saber sobre o in\u00edcio da nutri\u00e7\u00e3o parenteral total"},"content":{"rendered":"<p>Uma vez que a desnutri\u00e7\u00e3o cl\u00ednica est\u00e1 associada a maiores riscos de desfechos negativos, \u00e9 fundamental refor\u00e7ar os benef\u00edcios das terapias nutricionais<strong>. Ainda assim, h\u00e1 d\u00favidas sobre o in\u00edcio da nutri\u00e7\u00e3o parenteral total, por exemplo. Esse procedimento deve ser baseado em orienta\u00e7\u00f5es que apontam os cuidados necess\u00e1rios para minimizar riscos. <\/strong><\/p>\n<p>Desse modo, tanto profissionais de sa\u00fade quanto pacientes se beneficiam em conhecer as diretrizes de utiliza\u00e7\u00e3o da nutri\u00e7\u00e3o parenteral. Al\u00e9m disso, compreender as recomenda\u00e7\u00f5es a partir das principais evid\u00eancias dispon\u00edveis amplia a efici\u00eancia do recurso, sem ignorar a seguran\u00e7a ao longo do processo.<\/p>\n<p>&nbsp;<\/p>\n<h2>Quais s\u00e3o as indica\u00e7\u00f5es para o in\u00edcio da nutri\u00e7\u00e3o parenteral total?<\/h2>\n<p><strong>O fornecimento de alimenta\u00e7\u00e3o hospitalar equilibrada e de boa qualidade \u00e9 suficiente para garantir a manuten\u00e7\u00e3o do bom estado nutricional entre a maior parte dos pacientes<sup>1<\/sup>.<\/strong> Todavia em pacientes em estado grave nem sempre \u00e9 poss\u00edvel atingir as necessidades nutricionais por meio dessa forme de suporte.<\/p>\n<p>Portanto, nesses casos, as exig\u00eancias nutricionais podem ser supridas por meio do oferecimento do suporte cl\u00ednico nutricional. <strong>As alternativas mais empregadas s\u00e3o a suplementa\u00e7\u00e3o oral, a alimenta\u00e7\u00e3o por sonda enteral e a nutri\u00e7\u00e3o parenteral, que pode ser parcial (tamb\u00e9m chamada de suplementar) ou total<sup>1<\/sup>.<\/strong><\/p>\n<p>A <strong>nutri\u00e7\u00e3o parenteral \u00e9 estabelecida por meio da infus\u00e3o intravenosa de nutrientes diretamente na circula\u00e7\u00e3o<sup>2<\/sup><\/strong>. Logo, o paciente tem garantidos a energia, as prote\u00ednas, os micronutrientes e os fluidos para atender suas demandas fisiol\u00f3gicas.<\/p>\n<p>A nutri\u00e7\u00e3o parenteral suplementar pode ser oferecida em complementa\u00e7\u00e3o \u00e0 nutri\u00e7\u00e3o enteral<sup>3<\/sup>. <strong>No sentido oposto, todo paciente que n\u00e3o conta mais com fun\u00e7\u00e3o gastrointestinal pode ter a recomenda\u00e7\u00e3o da introdu\u00e7\u00e3o da nutri\u00e7\u00e3o parenteral.<\/strong><\/p>\n<p>A diretriz da <a href=\"https:\/\/www.espen.org\/files\/ESPEN-Guidelines\/ESPEN_guideline-on-clinical-nutrition-in-the-intensive-care-unit.pdf\">ESPEN (The European Society for Clinical Nutrition and Metabolism)<\/a><u>, <span style=\"text-decoration: line-through\">no seu Guideline<\/span> para pacientes cr\u00edticos, publicado em 2019,<\/u> aponta que todos os pacientes que n\u00e3o alcancem a demanda nutricional por vias normais, e n\u00e3o tolerem a nutri\u00e7\u00e3o enteral, devem ser avaliados para receber a nutri\u00e7\u00e3o parenteral dentro de 3 a 7 dias<sup>4<\/sup>. J\u00e1 para a ASPEN (<a href=\"https:\/\/aspenjournals.onlinelibrary.wiley.com\/doi\/epdf\/10.1177\/0148607115621863\">American Society for Parenteral and Enteral Nutrition<\/a>), todo paciente com sinal de desnutri\u00e7\u00e3o que n\u00e3o tolera a nutri\u00e7\u00e3o enteral deve ter a nutri\u00e7\u00e3o parenteral introduzida o mais r\u00e1pido poss\u00edvel<sup>5<\/sup>.<\/p>\n<p>Claro que isso n\u00e3o deve ignorar contraindica\u00e7\u00f5es. <strong>Todavia, situa\u00e7\u00f5es de fase aguda ap\u00f3s trauma, choque circulat\u00f3rio n\u00e3o resolvido, hip\u00f3xia, acidose grave e altos \u00edndices de lactato contraindicam a nutri\u00e7\u00e3o parenteral<sup>1<\/sup>.<\/strong><\/p>\n<p>&nbsp;<\/p>\n<h2>Como s\u00e3o definidas as vias de acesso?<\/h2>\n<p><strong>A <\/strong><a href=\"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/boas-praticas-de-administracao-da-nutricao-parenteral\/\"><strong>administra\u00e7\u00e3o da nutri\u00e7\u00e3o parenteral<\/strong><\/a><strong> pode variar de acordo com a via de acesso escolhida e a dura\u00e7\u00e3o da interven\u00e7\u00e3o<sup>6<\/sup><\/strong>.\u00a0\u00a0 Podem ser escolhidas vias perif\u00e9ricas ou centrais para alcan\u00e7ar o sistema venoso. Assim, os acessos centrais (como a jugular, a veia femoral ou a subcl\u00e1via) s\u00e3o indicados para <sup>1,6<\/sup>:<\/p>\n<p>&nbsp;<\/p>\n<ul>\n<li>tratamentos com prazo superior a um m\u00eas;<\/li>\n<li>altas necessidades nutricionais;<\/li>\n<li>restri\u00e7\u00e3o grave de l\u00edquidos;<\/li>\n<li>paciente que n\u00e3o apresenta acessos perif\u00e9ricos de f\u00e1cil acesso;<\/li>\n<li>necessidade de m\u00faltiplos acessos venosos;<\/li>\n<li>introdu\u00e7\u00e3o de f\u00f3rmulas hiperosmolares.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>No mais, existem diferentes tipos de cateter. Eles s\u00e3o escolhidos conforme a vantagem que cada um oferece no contexto cl\u00ednico avaliado. <strong>Em todo caso, a recomenda\u00e7\u00e3o \u00e9 de que a posi\u00e7\u00e3o do cateter seja certificada com o suporte de ultrassom ou controlado por meio de radiografia<sup>6<\/sup><\/strong>. Entretanto, a coloca\u00e7\u00e3o via cir\u00fargica deve ser evitada, diante dos custos e do maior risco de infec\u00e7\u00e3o e trombose<sup>6<\/sup>.<\/p>\n<p>Outrossim, os cuidados em rela\u00e7\u00e3o \u00e0 higiene do cateter s\u00e3o fundamentais para minimizar a chance de infec\u00e7\u00f5es. Por isso, entre os aspectos essenciais para fortalecer essa preven\u00e7\u00e3o est\u00e3o a assepsia das m\u00e3os durante o manuseio e administra\u00e7\u00e3o da nutri\u00e7\u00e3o parenteral. Al\u00e9m disso, \u00e9 indispens\u00e1vel acompanhar a condi\u00e7\u00e3o do ponto de sa\u00edda do cateter. A limpeza adequada tamb\u00e9m ajuda a reduzir a forma\u00e7\u00e3o de fibrinas ou trombos<sup>1<\/sup>.<\/p>\n<p>&nbsp;<\/p>\n<p>Leia tamb\u00e9m: <a href=\"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/nutricao-parenteral-adultos-macronutrientes\/\">veja quais s\u00e3o as recomenda\u00e7\u00f5es de macronutrientes para a nutri\u00e7\u00e3o parenteral em adultos<\/a><\/p>\n<p>&nbsp;<\/p>\n<h2>Como deve ser feito o monitoramento para evitar os principais riscos?<\/h2>\n<p>Mesmo ap\u00f3s avalia\u00e7\u00e3o da prescri\u00e7\u00e3o e introdu\u00e7\u00e3o da nutri\u00e7\u00e3o parenteral, deve haver o monitoramento adequado. Ainda que a nutri\u00e7\u00e3o parenteral n\u00e3o exponha o paciente a um risco maior de morte<sup>1<\/sup>, ela pode estar associada a algumas complica\u00e7\u00f5es<strong>. Entre as principais est\u00e3o a s\u00edndrome de realimenta\u00e7\u00e3o, hiperglicemia, desmineraliza\u00e7\u00e3o \u00f3ssea e, as j\u00e1 mencionadas, infec\u00e7\u00f5es do cateter<sup>1<\/sup>. <\/strong><\/p>\n<p>Portanto, a\u00e7\u00f5es adequadas de monitoramento reduzem as chances de problemas e os custos atrelados \u00e0 terapia<sup>9<\/sup>. Logo, os seguintes par\u00e2metros devem ser acompanhados de perto, de forma regular <sup>7,8,9,<\/sup>:<\/p>\n<p>&nbsp;<\/p>\n<ul>\n<li>taxa de infus\u00e3o e quantidade total de nutrientes\/solu\u00e7\u00e3o fornecida;<\/li>\n<li>cumprimento de metas nutricionais;<\/li>\n<li>peso corporal;<\/li>\n<li>sinais de desnutri\u00e7\u00e3o;<\/li>\n<li>edema\/estado de hidrata\u00e7\u00e3o;<\/li>\n<li>estado de consci\u00eancia;<\/li>\n<li>estado abdominal;<\/li>\n<li>fun\u00e7\u00f5es vitais;<\/li>\n<li>fun\u00e7\u00e3o renal e hep\u00e1tica;<\/li>\n<li>fun\u00e7\u00f5es metab\u00f3licas.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>O monitoramento deve ser aprofundado e refinado em pacientes com fun\u00e7\u00e3o renal ou hep\u00e1tica j\u00e1 comprometida, bem como aqueles <a href=\"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/entenda-tudo-sobre-a-nutricao-parenteral-na-unidade-de-terapia-intensiva\/\">admitidos em UTI.<\/a> <strong>Por fim, preocupa\u00e7\u00e3o similar deve acompanhar pacientes em nutri\u00e7\u00e3o parenteral de longo prazo<\/strong>. Eles devem seguir procedimentos padronizados e capazes tamb\u00e9m de avaliar o metabolismo \u00f3sseo<sup>7<\/sup>.<\/p>\n<p><strong>O in\u00edcio da nutri\u00e7\u00e3o parenteral total \u00e9 um momento que exige toda a aten\u00e7\u00e3o dos respons\u00e1veis pelo acompanhamento do paciente.<\/strong> A partir disso, ponderando os riscos, \u00e9 poss\u00edvel obter os benef\u00edcios esperados dessa interven\u00e7\u00e3o, garantindo que tudo transcorra da melhor forma poss\u00edvel.<\/p>\n<p>Aproveite e veja mais sobre o que voc\u00ea precisa saber sobre as<a href=\"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/indicacao-nutricao-parenteral\/\"> principais indica\u00e7\u00f5es da 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<p>&nbsp;<\/p>\n<ol>\n<li>FRESENIU KABI. Comp\u00eandio de Nutri\u00e7\u00e3o Parenteral. Dispon\u00edvel em: <a href=\"https:\/\/www.fresenius-kabi.com\/br\/documents\/compendio_10_05_2018.pdf\">https:\/\/www.fresenius-kabi.com\/br\/documents\/compendio_10_05_2018.pdf<\/a> Acesso jan. 2023.<\/li>\n<li>NICE: National Collaborating Centre for Acute Care. Nutrition support in adults: Oral nutrition support, enteral tube feeding and parenteral nutrition. Methods evidence and guidance. London: 2006. Dispon\u00edvel em: <a href=\"https:\/\/www.nice.org.uk\/guidance\/cg32\">https:\/\/www.nice.org.uk\/guidance\/cg32<\/a> Acesso em jan. 2023.<\/li>\n<li>Heidegger CP, Berger MM, Graf S et al. Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial. Lancet. 2013 Feb 2;381(9864):385-93. Dispon\u00edvel em <a href=\"https:\/\/www.thelancet.com\/journals\/lancet\/article\/PIIS0140-6736(12)61351-8\/fulltext\">https:\/\/www.thelancet.com\/journals\/lancet\/article\/PIIS0140-6736(12)61351-8\/fulltext<\/a> Acesso nov. 2022.<\/li>\n<li>Singer, P., Blaser, A. R., Berger, M. M., Alhazzani, W., Calder, P. C., Casaer, M. P., &#8230; &amp; Bischoff, S. C. (2019). ESPEN guideline on clinical nutrition in the intensive care unit. <em>Clinical nutrition<\/em>, <em>38<\/em>(1), 48-79. Dispon\u00edvel em: <a href=\"https:\/\/www.espen.org\/files\/ESPEN-Guidelines\/ESPEN_guideline-on-clinical-nutrition-in-the-intensive-care-unit.pdf\">https:\/\/www.espen.org\/files\/ESPEN-Guidelines\/ESPEN_guideline-on-clinical-nutrition-in-the-intensive-care-unit.pdf<\/a> Acesso jan. 2023.<\/li>\n<li>McClave SA, Martindale RG, Vanek VW et al. 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. 2009;33:277-316. 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>Pittiruti M, Hamilton H, Bifi R, Macie J, Pertkiewicz M. ESPEN Guidelines on Parenteral Nutrition: Central Venous Catheters (access, care, diagnosis and therapy of complications). Clin Nutr. 2009;28:365- 377. Dispon\u00edvel em: <a href=\"https:\/\/www.clinicalnutritionjournal.com\/article\/S0261-5614(09)00078-8\/fulltext\">https:\/\/www.clinicalnutritionjournal.com\/article\/S0261-5614(09)00078-8\/fulltext<\/a> Acesso jan. 2023.<\/li>\n<li>Hartl W, Jauch KW, Parhofer K, Rittler P. Complications and monitoring &#8211; Guidelines on parenteral nutrition chapter 9. Ger Med Sci. 2009;7:Doc 17-. Dispon\u00edvel em: <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/20049074\/\">https:\/\/pubmed.ncbi.nlm.nih.gov\/20049074\/<\/a> Acesso jan. 2023.<\/li>\n<li>Druml, W., &amp; Jadrna, K. (2008). Recommendations for enteral and parenteral nutrition in adults.\u00a0<em>English Edition\/Pocket Version<\/em>.. Vienna: 2008<\/li>\n<li>A.S.P.E.N. Parenteral Nutrition Handbook. 2009.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>Uma vez que a desnutri\u00e7\u00e3o cl\u00ednica est\u00e1 associada a maiores riscos de desfechos negativos, \u00e9 fundamental refor\u00e7ar os benef\u00edcios das terapias nutricionais. Ainda assim, h\u00e1 d\u00favidas sobre o in\u00edcio da nutri\u00e7\u00e3o parenteral total, por exemplo. Esse procedimento deve ser baseado em orienta\u00e7\u00f5es que apontam os cuidados necess\u00e1rios para minimizar riscos. Desse modo, tanto profissionais de [&hellip;]<\/p>\n","protected":false},"author":5902,"featured_media":1898,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[49],"tags":[222,221,70,67,216],"class_list":["post-1897","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-artigo-5","tag-beneficios","tag-desfechos-clinicos","tag-desnutricao","tag-nutricao-parenteral","tag-paciente-grave"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Saiba o que \u00e9 levado em conta para o in\u00edcio da nutri\u00e7\u00e3o parenteral total<\/title>\n<meta name=\"description\" content=\"Diante dos benef\u00edcios, a nutri\u00e7\u00e3o parenteral total \u00e9 um recurso importante para manuten\u00e7\u00e3o do bom estado nutricional de pacientes graves\" \/>\n<meta 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