{"id":1987,"date":"2024-08-28T08:44:05","date_gmt":"2024-08-28T11:44:05","guid":{"rendered":"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/?p=1987"},"modified":"2024-08-28T08:44:05","modified_gmt":"2024-08-28T11:44:05","slug":"repor-micronutrientes","status":"publish","type":"post","link":"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/repor-micronutrientes\/","title":{"rendered":"4 condi\u00e7\u00f5es em que pode ser preciso repor micronutrientes na pr\u00e1tica cl\u00ednica"},"content":{"rendered":"

A import\u00e2ncia de repor micronutrientes em determinadas circunst\u00e2ncias tem rela\u00e7\u00e3o direta com o papel essencial que esses elementos t\u00eam no organismo humano. Eles est\u00e3o envolvidos em diversos processos metab\u00f3licos de macronutrientes, em mecanismos do sistema imune e na manuten\u00e7\u00e3o da defesa antioxidante, <\/strong>entre outras fun\u00e7\u00f5es biol\u00f3gicas fundamentais (como processos de cicatriza\u00e7\u00e3o, por exemplo)1,2<\/sup>.<\/p>\n

Nesse contexto, v\u00e1rios quadros cl\u00ednicos podem exigir a necessidade de reposi\u00e7\u00e3o espec\u00edfica de diferentes micronutrientes<\/a>, incluindo vitaminas e elementos-tra\u00e7o (os oligoelementos). Em geral, essas demandas se d\u00e3o por conta do aumento das perdas em fun\u00e7\u00e3o da presen\u00e7a de algumas doen\u00e7as1,2<\/sup>. Al\u00e9m disso, em outros contextos, pode haver diminui\u00e7\u00e3o da ingest\u00e3o\/absor\u00e7\u00e3o ou aumento da demanda desses nutrientes1,2<\/sup>.<\/p>\n

Nos t\u00f3picos abaixo, mostramos alguns exemplos dessas condi\u00e7\u00f5es com as quais \u00e9 poss\u00edvel deparar-se na pr\u00e1tica cl\u00ednica.<\/p>\n

 <\/p>\n

1.\u00a0\u00a0\u00a0 S\u00edndrome do intestino curto<\/h2>\n

A s\u00edndrome do intestino curto (SIC) em adultos \u00e9 definida como um transtorno de m\u00e1 absor\u00e7\u00e3o provocado pela presen\u00e7a de um trecho do intestino delgado cont\u00ednuo menor do que 200 cm3<\/sup>. \u00a0Tamb\u00e9m pode acontecer de, mesmo na presen\u00e7a de intestino delgado maior do que 200 cm, haver uma manifesta\u00e7\u00e3o cl\u00ednica de SIC, o que \u00e9 definido como \u201cSIC funcional\u201d. Tal condi\u00e7\u00e3o evolui em fun\u00e7\u00e3o de preju\u00edzo na funcionalidade do trecho do intestino remanescente3<\/sup>.<\/p>\n

De qualquer forma, como a maior parte da absor\u00e7\u00e3o dos micronutrientes ocorre nos segmentos intestinais que ficam entre o duodeno e o \u00edleo, esse tipo de altera\u00e7\u00e3o pode provocar defici\u00eancias de muitos nutrientes4<\/sup><\/strong>. Entre as causas adquiridas da s\u00edndrome intestino curto est\u00e3o a doen\u00e7a de Crohn, isquemia mesent\u00e9rica, les\u00f5es intestinais ap\u00f3s acidente traum\u00e1tico, ader\u00eancias p\u00f3s-cir\u00fargicas e complica\u00e7\u00f5es p\u00f3s-operat\u00f3rias4<\/sup>.<\/p>\n

Pacientes com a s\u00edndrome do intestino curto geralmente apresentam car\u00eancias de <\/strong>ferro<\/strong><\/a>, cromo, zinco, f\u00f3sforo, cobre, niacina, tiamina, folato e de vitaminas lipossol\u00faveis1,2,4<\/sup>.<\/strong><\/p>\n

Por\u00e9m, isso tamb\u00e9m pode variar de acordo com o ponto onde houve a ressec\u00e7\u00e3o do \u00f3rg\u00e3o4<\/sup>. Esses indiv\u00edduos est\u00e3o tamb\u00e9m mais suscet\u00edveis a altera\u00e7\u00f5es no sistema imune e um maior tempo de recupera\u00e7\u00e3o de infec\u00e7\u00f5es5<\/sup>. Essa defici\u00eancia ainda amplia a chance de quadros infecciosos graves5<\/sup>.<\/p>\n

 <\/p>\n

2.\u00a0\u00a0\u00a0 Recupera\u00e7\u00e3o de cirurgias bari\u00e1tricas<\/h2>\n

As cirurgias bari\u00e1tricas s\u00e3o um meio importante de alcan\u00e7ar uma perda sustentada de peso em pacientes obesos<\/a>. Entretanto, \u00e9 preciso considerar que esse tipo de procedimento pode provocar algumas complica\u00e7\u00f5es6<\/sup>. Uma delas \u00e9 justamente a defici\u00eancia, tanto de macro quanto de micronutrientes, foco deste conte\u00fado6<\/sup>.<\/p>\n

Os mecanismos por tr\u00e1s desse problema est\u00e3o no tipo de t\u00e9cnica utilizada em cada procedimento. De um lado, a cirurgia bari\u00e1trica pode provocar dificuldades na absor\u00e7\u00e3o desses micronutrientes, por conta da limita\u00e7\u00e3o das \u00e1reas do trato gastrointestinal destinadas a isso6<\/sup>.<\/strong><\/p>\n

De outro, procedimentos restritivos reduzem o volume do est\u00f4mago, induzindo \u00e0 saciedade mais r\u00e1pido e, portanto, diminuindo a quantidade de alimento ingerida6<\/sup>. <\/strong>Por fim, pode haver uma intera\u00e7\u00e3o dos dois fatores combinados: redu\u00e7\u00e3o da superf\u00edcie de absor\u00e7\u00e3o e baixa ingest\u00e3o alimentar6<\/sup>.<\/p>\n

Outras vari\u00e1veis associadas \u00e0 defici\u00eancia desses elementos nesses pacientes s\u00e3o o consumo de \u00e1lcool, a falta de ader\u00eancia \u00e0 suplementa\u00e7\u00e3o para repor micronutrientes e outras complica\u00e7\u00f5es derivadas da cirurgia em si7<\/sup>.<\/p>\n

Al\u00e9m da defici\u00eancia de algumas vitaminas, \u00e9 comum que pacientes de cirurgias bari\u00e1tricas sofram com defici\u00eancias de oligoelmentos. O ferro, <\/strong>o zinco<\/strong><\/a>, o sel\u00eanio e o cobre s\u00e3o os que mais chamam a aten\u00e7\u00e3o6,7<\/sup>. <\/strong><\/p>\n

Desse modo, deve haver um refor\u00e7o para que pacientes submetidos a cirurgias bari\u00e1tricas recebam orienta\u00e7\u00f5es sobre esses riscos e sejam incentivados a mudan\u00e7as necess\u00e1rias na dieta, incluindo a ades\u00e3o \u00e0s suplementa\u00e7\u00f5es prescritas7<\/sup>.<\/p>\n

 <\/p>\n

3.\u00a0\u00a0\u00a0 \u00dalceras do p\u00e9 diab\u00e9tico<\/h2>\n

Pacientes com diabetes sofrendo com \u00falceras do p\u00e9 diab\u00e9tico precisam ser orientados sobre a import\u00e2ncia de uma nutri\u00e7\u00e3o adequada. Esse \u00e9 um componente essencial para a cicatriza\u00e7\u00e3o das feridas e, por consequ\u00eancia, para revers\u00e3o desse tipo de problema8<\/sup>. Por\u00e9m, nem sempre isso acontece.<\/p>\n

Exemplo desse risco vem de um estudo publicado em 2023 com<\/a> um grupo de 115 pacientes australianos com les\u00f5es relacionadas ao p\u00e9 diab\u00e9tico, apontando que a maior parte deles apresentava ingest\u00e3o inadequada de alguma vitamina ou oligoelemento (no caso analisado, era o zinco)8<\/sup>. <\/strong><\/p>\n

Enquanto 86% n\u00e3o atingia as recomenda\u00e7\u00f5es di\u00e1rias de ingest\u00e3o de vitamina E, defici\u00eancias no aporte de zinco foram identificadas em 37% da amostra8<\/sup>. Junto das prote\u00ednas, o zinco \u00e9 indispens\u00e1vel na constru\u00e7\u00e3o de novos tecidos, al\u00e9m de facilitar a resposta imune9<\/sup>.<\/p>\n

 <\/p>\n

Veja tamb\u00e9m: <\/em>Qual a import\u00e2ncia dos minerais antioxidantes na nutri\u00e7\u00e3o parenteral?<\/em><\/a><\/p>\n

 <\/p>\n

\"\"<\/p>\n

 <\/p>\n

1.\u00a0\u00a0\u00a0 Pacientes com queimaduras<\/h2>\n

As evid\u00eancias sustentam que les\u00f5es provenientes de queimaduras geram inflama\u00e7\u00e3o sist\u00eamica, induzindo uma resposta hipermetab\u00f3lica grave, pronunciada e persistente10<\/sup>. Al\u00e9m disso, esses danos geram estresse oxidativo com deple\u00e7\u00e3o das defesas antioxidantes end\u00f3genas, por meio de um aumento da excre\u00e7\u00e3o urin\u00e1ria e pela perda de fluidos e micronutrientes atrav\u00e9s das \u00e1reas queimadas11<\/sup><\/strong>. Com isso, pode haver impacto sobre a concentra\u00e7\u00e3o de micronutrientes antioxidantes, como cobre, sel\u00eanio e zinco11<\/sup>.<\/p>\n

Desse modo, a terapia nutricional adequada \u00e9 fundamental. Ela tem como objetivo promover a recupera\u00e7\u00e3o do paciente gravemente queimado por meio da modula\u00e7\u00e3o da resposta imunoinflamat\u00f3ria e pelo manejo da desnutri\u00e7\u00e3o aguda associada ao quadro cr\u00edtico (inclusive para repor micronutrientes)10<\/sup>.<\/p>\n

No entanto, \u00e9 preciso observar que \u00e9 poss\u00edvel que as demandas de determinados micronutrientes em grandes queimados sejam diferentes do que as normalmente recomendadas.\u00a0 <\/strong>Essas s\u00e3o as conclus\u00f5es de um artigo sobre o tema publicado em 2017<\/a>.\u00a0 Os respons\u00e1veis pela publica\u00e7\u00e3o analisaram a perda de elementos-tra\u00e7o por meio do exsudato das queimaduras e compararam isso com o n\u00edvel s\u00e9rico desses micronutrientes12<\/sup>. <\/strong><\/p>\n

Com esses resultados em m\u00e3os, foi poss\u00edvel constatar que a suplementa\u00e7\u00e3o de zinco n\u00e3o foi capaz de corrigir os patamares s\u00e9ricos do micronutriente, principalmente em pacientes com mais de 20% da superf\u00edcie do corpo lesionada pelas queimaduras12<\/sup>.<\/p>\n

Isso leva \u00e0 conclus\u00e3o de que alguns protocolos de suplementa\u00e7\u00e3o desse micronutriente em grandes queimados precisam ser revisados12<\/sup>. Enquanto isso, as recomenda\u00e7\u00f5es para suplementa\u00e7\u00e3o de sel\u00eanio foram suficientes para trazerem os patamares s\u00e9ricos a n\u00edveis apropriados ou mesmo at\u00e9 maiores do que os ideais12<\/sup>.<\/p>\n

Seja como for, independente da condi\u00e7\u00e3o cl\u00ednica que leve \u00e0 necessidade de repor micronutrientes, \u00e9 indispens\u00e1vel que a prescri\u00e7\u00e3o e o monitoramento desse tipo de aporte sejam acompanhados de perto por profissionais capacitados, ampliando a chance de desfechos positivos.<\/p>\n

Aproveite para saber mais sobre a import\u00e2ncia do uso de oligoelementos na nutri\u00e7\u00e3o parenteral<\/a>.<\/p>\n

 <\/p>\n

 <\/p>\n

Refer\u00eancias:<\/p>\n

    \n
  1. Castro MG, Ribeiro PC, Zambelli CMSF, Falc\u00e3o H, Silva Jr JM, Alves JTM, et al. Posicionamento BRASPEN sobre o uso de micronutrientes via parenteral em adultos. BRASPEN Journal. 2023;36(1):3-19. Dispon\u00edvel em: https:\/\/braspenjournal.org\/journal\/braspen\/article\/doi\/10.37111\/braspenj.AE.2021.36.1.01<\/a>. Acesso em 27 de mar\u00e7o de 2024.<\/li>\n
  2. Blaauw R, Osland E, Sriram K, Ali A, Allard JP, Ball P, et al. Parenteral provision of micronutrients to adult patients: an expert consensus paper. JPEN J Parenter Enteral Nutr. 2019;43(Suppl 1):S5-S23. Dispon\u00edvel em: <https:\/\/aspenjournals.onlinelibrary.wiley.com\/doi\/10.1002\/jpen.1525<\/a>> Acesso em 27 de mar\u00e7o de 2024.<\/li>\n
  3. Pironi L, Bozzetti F, Fearon K, et al. ESPEN guideline on chronic intestinal failure in adults\u2013Update 2023. Clin Nutr. 2023;42(10):1940-2021. Dispon\u00edvel em: <https:\/\/www.espen.org\/files\/ESPEN-Guidelines\/ESPEN_guideline_on_chronic_intestinal_failure_in_adults.pdf> Acesso em 8 de abril de 2023.<\/li>\n
  4. Rodriguez DN, Ruiz NC, Qian S, Kamel AY. Clinical Manifestations of Micronutrient Deficiencies in Short Bowel Syndrome: A Case Report. 2023 Apr 20;15(4):e37897. Dispon\u00edvel em: <https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC10202680\/<\/a>> Acesso em 27 de mar\u00e7o de 2024.<\/li>\n
  5. Maggini S, Pierre A, Calder PC. Immune function and micronutrient requirements change over the life course. 2018;10. Dispon\u00edvel em: <https:\/\/www.mdpi.com\/2072-6643\/10\/10\/1531<\/a>> Acesso em 27 de mar\u00e7o de 2024.<\/li>\n
  6. Patel JJ, et al. Micronutrient deficiencies after bariatric surgery: an emphasis on vitamins and trace minerals. Nutrition in Clinical Practice. 2017;32(4):471-480. Dispon\u00edvel em: <https:\/\/aspenjournals.onlinelibrary.wiley.com\/doi\/10.1177\/0884533617712226<\/a>> Acesso em 5 de mar\u00e7o de 2024.<\/li>\n
  7. Chizooma E, Fabyan S, Panda A, Ahmed MH, Panourgia M, Owles H, et al. Recurrent abdominal laparotomy wound infection and dehiscence in a patient with zinc and selenium deficiency associated with Roux-en-Y gastric bypass: Case report and literature review. Journal of Family Medicine and Primary Care. 2023;12(11):2979-2982. Dispon\u00edvel em: <https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC10771219\/<\/a>> Acesso em 27 de mar\u00e7o de 2024.<\/li>\n
  8. Donnelly HR, Clarke ED, Collins CE, Collins RA, Armstrong DG, Mills JL, et al. Most individuals with diabetes\u2010related foot ulceration do not meet dietary consensus guidelines for wound healing. International wound journal. 2024;21(3):e14483. Dispon\u00edvel em: <https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC10898395\/<\/a> > Acesso em 27 de mar\u00e7o de 2024.<\/li>\n
  9. Quain AM, Khardori NM. Nutrition in wound care management: a comprehensive overview. 2015;27(12):327\u2010335. Dispon\u00edvel em: <https:\/\/www.hmpgloballearningnetwork.com\/site\/wounds\/reviews\/nutrition-wound-care-management-comprehensive-overview<\/a>> Acesso em 27 de mar\u00e7o de 2024.]<\/li>\n
  10. Moreira E, Burghi G, Manzanares W. Update on metabolism and nutrition therapy in critically ill burned patients. Medicina Intensiva (English Edition). 2018;42(5):306-316. Dispon\u00edvel em: <https:\/\/www.sciencedirect.com\/science\/article\/abs\/pii\/S0210569117302231?via%3Dihub<\/a>> Acesso em 5 de mar\u00e7o de 2024.<\/li>\n
  11. Manzanares W, Langlois PL, Hardy G. Update on antioxidant micronutrients in the critically ill. Curr Opin Clin Nutr Metab Care. 2013;16:719—25. Dispon\u00edvel em: <https:\/\/journals.lww.com\/co-clinicalnutrition\/abstract\/2013\/11000\/update_on_antioxidant_micronutrients_in_the.20.aspx<\/a>> Acesso em 5 de mar\u00e7o de 2024.<\/li>\n
  12. Jafari P, Thomas A, Haselbach D, Watfa W, Pantet O, Michetti M, et al. Trace element intakes should be revisited in burn nutrition protocols: A cohort study. Clinical nutrition. 2018;37(3):958-964. Dispon\u00edvel em: <https:\/\/www.clinicalnutritionjournal.com\/article\/S0261-5614(17)30119-X\/abstract<\/a>> Acesso em 5 de mar\u00e7o de 2024.<\/li>\n<\/ol>\n

     <\/p>\n","protected":false},"excerpt":{"rendered":"

    A import\u00e2ncia de repor micronutrientes em determinadas circunst\u00e2ncias tem rela\u00e7\u00e3o direta com o papel essencial que esses elementos t\u00eam no organismo humano. Eles est\u00e3o envolvidos em diversos processos metab\u00f3licos de macronutrientes, em mecanismos do sistema imune e na manuten\u00e7\u00e3o da defesa antioxidante, entre outras fun\u00e7\u00f5es biol\u00f3gicas fundamentais (como processos de cicatriza\u00e7\u00e3o, por exemplo)1,2. Nesse contexto, […]<\/p>\n","protected":false},"author":5902,"featured_media":1996,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[47],"tags":[262,261,82,67,85],"class_list":["post-1987","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-artigo-4","tag-ma-absorcao","tag-manejo-clinico","tag-micronutrientes","tag-nutricao-parenteral","tag-oligoelementos"],"acf":[],"yoast_head":"\nEm que condi\u00e7\u00f5es cl\u00ednicas pode ser preciso repor micronutrientes?<\/title>\n<meta name=\"description\" content=\"Repor micronutrientes pode ser importante para garantir a recupera\u00e7\u00e3o adequada e evitar complica\u00e7\u00f5es em diferentes condi\u00e7\u00f5es cl\u00ednicas.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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