Cuidado Nutricional No Paciente Crítico (Ipgs)

Cuidado Nutricional
no Paciente crítico
Profª Flávia Moraes Silva

Tópicos
 Triagem de risco nutricional

 Avaliação Nutricional
 Planejamento da Terapia Nutricional
Desnutrição no paciente crítico
Fischer. Nutr Clin Pract.2015: 1-10.

Desnutrição no paciente crítico
 Revisão sistemática com 20 estudos observacionais
 ASG/ MAN/ NRS-2002/ MUST/ SNAQ
Maior mortalidade
Maior TIH
Maior TI - UTI
Han Lee CC. JPEN J Parenter Enteral Nutr. 2016: 1-15.

Risco nutricional no paciente crítico
Risco de complicações ou desfechos adversos que poderiam ser prevenidos

Comprometimento nutricional com terapia nutricional adequada
Nenhum Severidade da doença
Leve
Moderado
Grave
Tempo
Risco de eventos adversos
AGUDA INANIÇÃO CRÔNICA
Idade Estado nutricional

Deficiência de nutrientes DESFECHOS
APACHE Mortalidade
Perda de MM
SOFA Dias livres de VM
Disfunção imune
AGUDA INFLAMAÇÃO CRÔNICA
Heyland. Critical Care. 2011;15(6):R268

Estudo observacional de marcadores de sepse – análise secundária
3 UTI clínica e cirúrgica Reino Unido – pacientes com TI previsto > 24 horas
Pacientes de UTI com TI previsto > 24 horas
Coleta de dados prospectiva – entrevista com familiares
Heyland et al. Critical Care 2011, 15:R268

Hipótese: paciente com alto escore do

NUTRIC poderiam ser beneficiados de
TN a fim de reduzir mortalidade em 28
dias de UTI

 597 pacientes incluídos no estudo

 211 pacientes incluídos na avaliação da influência do escore na relação BE e desfecho


 Análise secundária de um ECR com pacientes críticos com falência orgânica - N = 1199
 NUTRIC sem IL-6
 Desfecho: mortalidade em 28 dias
Rahman. Clinical Nutrition. 2016; 35: 158-162.

Morte
OR = 2,1
(IC 95% 1,5 – 2,95)
Interação com a
adequacidade da dieta
Mukhopadhyay A. Clinical Nutrition xxx (2016) 1e6

Seis etapas propostas por Beaton e colaboradores
Rosa M. Clinical Nutrition ESPEN 14 (2016) 31e36

Rosa M. Clinical Nutrition ESPEN 14 (2016) 31e36

Como identificar pacientes em risco nutricional?
NRS> 3 = RN NUTRIC > 5 = RN

NRS >5 = alto RN (sem IL-6)
ASPEN. JPEN. 2016; 40 (2): 159 – 211.

Nutrition Risk Screening -2002 (NRS-2002):
Screening inicial Sim Não
1 IMC < 20,5 kg/m2 ?

2 O paciente perdeu peso nos últimos 3 meses?
3 O Paciente reduziu o consumo alimentar na última semana?
4 O Paciente está severamente doente (UTI)?
SIM para qualquer uma das perguntas: responder a tabela de TRN
NÃO para todas as questões: repetir TRN semanalmente
Kondrup J. Clin Nutr. 2003; 22(4):415

Screening final
Idade > 70 anos  adiciona 1 ponto
Kondrup J. Clin Nutr. 2003; 22(4):415

Diagnósticos em Nutrição
História nutricional Avaliação laboratorial
DIAGNÓSTICO EM NUTRIÇÃO
Avaliação da composição
Avaliação dietética
corporal
Avaliação antropométrica Exame físico
Instrumentos integrados de
avaliação do EN
ASBRAN. Manual de Sistematização do Cuidado de Nutrição. 2014.

Diagnósticos em Nutrição no Paciente Crítico
Diagnósticos em Nutrição no Paciente Crítico
História nutricional Avaliação laboratorial
Avaliação da composição
Avaliação dietética
corporal
Avaliação antropométrica Exame físico
Instrumentos integrados de
avaliação do EN
ASBRAN. Manual de Sistematização do Cuidado de Nutrição. 2014.

Indicadores nutricionais no paciente crítico
Ferrie S. Nutirtion in Clinical Practice. 2013; 28 (4):463 – 484.

Ferrie S. Nutirtion in Clinical Practice. 2013; 28 (4):463 – 484.

ASG Avaliação da MM
EMAP Marcadores laboratoriais
AF - BIA
ASG
História do paciente
1. Alteração ponderal nos últimos 6 meses e nas últimas duas semanas
2. Alteração ingestão alimentar (consistência/ quantidade)
3. Sintomas gastrointestinais (>2 semanas)
4. Capacidade funcional
5. Doença e sua relação com necessidades nutricionais
Exame Físico
Perda de gordura subcutânea
Perda de massa muscular
Edema (tornozelo e sacral)
Ascite
Em risco ou Gravemente
Bem nutrido
Moderadamente desnutrido Desnutrido
DETSKY e cols. JPEN J Parenter Enteral Nutr 1987;11:8-13.

ASG
Avaliação subjetiva global
 57 pacientes críticos em VM
ANÁLISE UNIVARIADA!!
Bector S. J of Intensive Care Medicine.2015; 1-5.

 Estudo observacional prospectivo – UTI Hospital Felício Rocho

 185 pacientes críticos
 EN: ASG (paciente ou acompanhante), antropometria, exames laboratoriais
 Desfechos: morbimortalidade
D. Fontes et al. Clinical Nutrition 33 (2014) 291e295

Chance de morte 8,12 vezes MAIOR (IC 2,94 – 22,42)

nos pacientes com desnutrição em comparação
àqueles bem nutridos
D. Fontes et al. Clinical Nutrition 33 (2014) 291e295

 Estudo observacional prospectivo

 UTI cirúrgica – HNSC (POA – RS)
 N = 76 pacientes
GATTERMAN T. Nutr Clin Pract. 2019; 34 (1):131-136



Estudos com análises univariadas ou não ajustadas – real desempenho em predizer

desfechos considerando potenciais confundidores?
Na prática, em quantos pacientes as informações da ASG podem ser coletadas?

Espessura do músculo adutor do polegar
 Estudo observacional prospectivo Valores anormais de EMAP

 246 pacientes críticos – HC UFMT < P10 ( 9 mm)
 EMAP/ ASG
 TIH/ TI – UTI/ mortalidade
Caparossi FS. Nutr Hosp. 2012;27:490-495

 Estudo observacional transversal

 UTI – IFUC (POA – RS)
20,5% ASG - B
16,9% ASG - C
Sens/ VPP
Karst F. Rev Bras Ter Intensiva. 2015;27(4):369-375


 127 pacientes críticos de um hospital terciário do Irã (42,8% cirúrgicos)
Ghorabi S. Nutr Clin Pract. 2016;31:523-526)

Estudos com resultados contraditórios
Na prática, em quantos pacientes é possível aferir o EMAP?
35,8% Caparossi FS. Nutr Hosp. 2012;27:490-495

Ângulo de fase
 Estudo de coorte multicêntrico

 10 centros em 9 países
 Massa livre de gordura – AF
 Desfecho– mortalidade em 28 dias
Thibault R. Intensive Care Med (2016) 42:1445–1453

Ângulo de fase
Ângulo de fase < 3,49o
Ângulo de fase + APACHE II

+ idade + diagnóstico da internação
Ângulo de fase  mais um marcador

prognóstico na admissão na UTI
Thibault R. Intensive Care Med (2016) 42:1445–1453

Ângulo de fase em UTI
 AF e razão de impedância como marcadores de muscularidade, EN e desfechos

 Pacientes com TC (AME – 3ª vértebra lombar) – BIA em até 72h após admissão na UTI
 71 pacientes críticos (62% homens, 57±16 anos, 61% com excesso de peso pelo IMC)
Kuchnia A. JPEN J Parenter Enteral Nutr2016:1-8

Ângulo de fase
Kuchnia A. JPEN J Parenter Enteral Nutr2016:1-8

Ângulo de fase
Poucos estudos com AF no paciente crítico
Medida fácil, simples e de baixo custo
Pontos de corte para definir baixa muscularidade/ desnutrição ?

Massa muscular esquelética

 149 pacientes idosos com TC na admissão na UTI
Moisey et al. Critical Care 2013, 17:R206

 63 pacientes críticos (UTI de hospital de Londres)

 TC área transversal reto-femoral nos dias 1, 3, 7 e 10.
 Biópsia do músculo - razão proteína/DNA
 Dosagem de creatina quinase e mioglobina
-17,7% (-25,9 a 08,1%)
Puthucheary ZA. JAMA. 2013;310(15):1591-1600.



 Revisão sistemática com sete estudos com 300 pacientes

 Avaliação da MM por US
Em seis estudos, alterações na arquitetura muscular foram evidenciadas e

associadas com o tempo de internação na UTI
Perda muscular variou entre -6%/dia a -1,6%/dia
US – cofiabilidade e utilidade clínica para avaliação da perda MM
Paris MT. JPEN J Parenter Enteral Nutr. 2016: 1-10.

Como diagnosticar desnutrição no paciente crítico?
Grande desafio! ASG
Perda de MM e MG em resposta ao estresse

EMAP*
NUTRIC Risco nutricional = Risco de desfechos desfavoráveis
AF*
Desnutrição = Preditor de prognóstico ruim
MM*
Métodos tradicionais e validados
para DN com baixa aplicabilidade
na UTI Medidas seriadas
E além da desnutrição?
 Massa muscular
Caquexia # Desnutrição # Sarcopenia
Fadiga, anemia  massa corporal que Perda de mobilidade , 

Albumina , força PODE estar associada à de força muscular, perda
muscular , ingestão inflamação, ingestão  , funcional
, inflamação perda funcional
Clinical Nutrition. 2015; 34: 335-340.

Sarcopenia
J of Clinical Densitometry.2015; 4:499-505

Como estimar peso e estatura?
PESO CORPORAL: Soma de todos os componentes corporais
PESO ATUAL: verificado em uma balança calibrada, onde o individuo é posicionado de

pé, descalço, no centro da balança e com roupas leves.
PESO USUAL: Utilizado como referencia na avaliação das mudanças de peso. Peso
informado pelo paciente. Peso dos últimos seis meses.
Peso aferido
Peso
informado
Peso
estimado X
Peso visual
Errors in weight estimation in the emergency department: comparing performance by providers and patients.
J Emerg Med 2004; 27:219-224.
The Accuracy of Visual Estimation of Body Weight in the ED.

Am J Emerg Med 2004; 22:526-529.
Who Should Be Estimating a Patient’s Weight in the Emergency Department?

Academic Emergency Medicine 2005; 12:262-266.
X
A better way to estimate adult patient’s weight.
Am J Emerg Med 2009; 27:1060-1064. Peso visual
Peso estimado
CB = circunferência do braço (cm)
Equação Chumlea, 1988
AJ = Altura dos joelhos (cm)
Sexo feminino
Negro : 19-59 anos= (AJ X 1,24) + (CB X 2,97) – 82,48
60-80 anos= (AJ X 1,50) + (CB X 2,58) – 84,22
Branco: 19-59 anos= (AJ X 1,01) + (CB X 2,81) – 66,04
60-80 anos= (AJ X 1,09) + (CB X 2,68) – 65,51
Sexo Masculino
Negro: 19-59 anos= (AJ X 1,09) + (CB X 3,14) – 83,72
60-80 anos= (AJ X 0,44) + (CB X 2,86) – 39,21
Branco: 19-59 anos= (AJ X 1,19) + (CB X 3,14) – 86,82
60-80 anos= (AJ X 1,10) + (CB X 3,07) – 75,81
Chumlea WC. J Am Diet Assoc. 1994; 94: 1385-88
Estatura estimada: quando não é possível a sua aferição
Equação de Chumlea, 1985
Negro : = 89,58 + (1,61 x AJ) - (0,17 x idade)
Branco: = 82,21 + (1,85 x AJ) - (0,21 x idade)
Negro: = 79,69 + (1,85 x AJ) - (0,14 x idade)
Branco: = 78,31 + (1,94 x AJ) - (0,14 x idade)
J Am Geriatr Soc. 1985;33(2):116-20.

Luft VC. Nutr Clin Pract. 2008; 23: 424

Luft VC. Nutr Clin Pract. 2008; 23: 424

Medidas alternativas para estimativa da estatura: altura da ulna
http://www.bapen.org.uk/must_tool.html
Ulna length is the most accurate alternative anthropometric measurement proposed by

Malnutrition Universal Screening Tool (MUST) to estimate body height in inpatients
 Estudo observacional – Emergência do HNSC (Porto Alegre, RS)

 N = 427 pacientes
Estatura estimada pela AU Estatura estimada pela AJ Estatura informada
Silva FM, Figueira L. Nutrition, 2016.

Como posso monitorar o estado nutricional?
Exame físico
SBNEP. Projeto Diretrizes. Triagem e Avaliação Nutricional, 2011.

Como posso monitorar o estado nutricional?
AF EMAP Exame físico
Circunferência
do braço Massa gordurosa
Circunferência
Massa muscular
da panturrilha
Como planejar a terapia nutricional?
Controle glicêmico
Comorbidades
Escores de gravidade
Critical illness Severity APACHE
SOFA
Diabetes/ disfunção hepática/ disfunção renal/ uso abusivo de álcool e/ou drogas/ desnutrição
Controle Tolerância Síndrome de

glicêmico proteica realimentação
NRS-2002
NUTRIC
Dose de vasopressor
Gasometria
PAM
CAUTELA NUTRIÇÃO
Nutrição permissiva
Exame físico
Diarreia
Vômitos
Quando*iniciar*a*TN*?*
Por*qual*via*iniciar*a*TN?*
Se*TNE,*onde*posicionar*a*SNE?*
Qual*fórmula*enteral*uAlizar?*
Qual*NC*e*N*Ptn?**
Quando*iniciar*a*TN*?*
Precocemente,*desde*que:**
*
paciente*esteja*estável*hemodinamicamente!!!*
Quando iniciar a terapia nutricional?
 6 ECR com NE nas primeiras 24 horas da admissão na UTI

Mortalidade
DOING. Intensive Care Med (2009) 35:2018–2027

Pneumonia
DMSO
DOING. Intensive Care Med (2009) 35:2018–2027

DOING. Injury, Int. J. Care Injured 42 (2011) 50–56

DOING. Injury, Int. J. Care Injured 42 (2011) 50–56

 15 ECR com introdução precoce da NE em pacientes com resecção GI

 1240 pacientes
Complicações
OSLAND. JPEN J Parenter Enteral Nutr. 2011;35:473-487

Mortalidade

Rompimento de
anastomoses

Tempo de internação hospitalar WMD = -1,28 (-2,94 a 0,38)
Tempo para primeira movimentação

WMD= -0,28 (-1,2 a 0,64)
intestinal
Tempo para primeira

WMD= -0,42 (-1,12 a 0,28)
eliminação de flatos

Dentro das primeiras 48 horas, quando iniciar?

Benefício em iniciar nas primeiras 24h x 48 horas?
FREMONT RD. Curr Opin Gastroenterol. 2014 ; 30(2): 178–181

Nutrição enteral precoce
Oferta de NE nas primeiras 48 horas de hospitalização
ausência de nutrientes no TGI

= hipotrofia dos enterócitos
Infecção = quebra da barreira imunológica

= maior permeabilidade intestinal
= maior risco de translocação bacteriana
Mortalidade
Nutrição enteral precoce
Oferta de NE nas primeiras 48 horas de hospitalização

= menor perda ponderal
= menor perda de massa magra
= maior vantagem em relação a NPT
Iniciar terapia nutricional enteral ou parenteral?
NE
 Mais fisiológica TGI funcionante plena ou parcialmente

 Mais simples
 Mais barata
 Menos complicações O que pode dificultar??
íleo paralítico/ distensão abdominal/ náuseas/ vômitos
Iniciar terapia nutricional enteral ou parenteral?
NE x NP é segura
Menores complicações
infecciosas e TI-UTI
ASPEN. Journal of Parenteral and Enteral Nutrition. 2016; 40(2):159–211

0 20 40 60 80 100
percent -4 -2 0 2 4
Contents lists available at SciVerse
LogRR ScienceDirect
No Unclear Yes
Fig. 4. Funnel plot for the assessment of potential publication bias in risk of pneu-
Clinical Nutrition
SNE em posição gástrica ou pós-pilórica?
graph showing overall frequency of compliance with methodologic quality
monia. This is a scatter plot of the SE(standard error) of log RRon vertical axis plotted
s meta-analysis.
on horizontal line (log RR) from individual studies plotted on horizontal line (RR) and
esian sensitivity analyses

SNE*em*posição*gástrica*ou*pósPpilórica?*
vertical axis (SE of the RR).
j our nal homepage: ht t p://www.el sevi er .com/l ocat e/cl nu
4. Discussion
Reviewin a sensitivity analysis using
bove results were similar
an random-effects model (Table 2). Use of post-pyloric The principal finding of the present study was that the use of
Effect of gastric versus post-pyloric feeding on the incidence of pneumonia in
was associated with reduction in pneumonia compared post-pyloric feeding instead of gastric feeding in patients with
mpared with gastric feeding (RR, 0.57; 95% confidence critical illness was associated with a decrease in the incidence of
critically ill patients: Observations from traditional and Bayesian random-effects
CI], 0.35e0.81, s ¼ 0.30). The probability (RR 1) was pneumonia, whether accurate diagnosis of VAP or nonspecific
meta-analysis
he result was similar of these six studies that used a more clinical diagnosis pneumonia. These results were not consistent
and accurate diagnosis of VAP(RR, 0.60; 95%CI, 0.38e 0.90; with the results of previous systematic reviews.1,8,9 Although there
1,36
, probability (RR Jing 98.8%). a
1) ¼Jiyong ,*
, Huang Tiancha , Wang Huiqin a, Jguidelines,
Within five studies of b,*were two nutritional
in Jingfen athe recommendations have
fic clinical diagnosis, the trend was toward decreased risk been inconclusive and/or conflicting. Canadian nutritional guide-
a
oping pneumonia (probability (RR < 1) ¼ 94.9%, Table 2); lines recommended the use of small-bowel feeding in ICUs.1 Zhejiang Province, China
Neurological Intensive Care Unit, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88#, Hangzhou 310009,
b
RS*com*metanálise*de*15*estudos*primários*
Intensive Care Unit, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
the heterogeneity was substantial (s ¼ 1.04). Beneficial Guidelines of Society of Critical Care Medicine (SCCM) and Amer-
J. Jiyong et al. / Clinical Nutrition 32 (2013) 8e15
as shown similar in all subgroup analyses, and all the ican Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) rec-
ties (RR 1) were more than 90%(Table 2). ommended that either gastric or small bowel was acceptable in the
ar t i c l e i n f o su mmar y
Study ID RR (95% CI)
Article history: Background & aims: Administration of enteral feeding is associated with a higher risk of nosocomial
Received 8 April 2012 J. Jiyong et al. / Clinical Nutrition 32 (2013) 8e15 13
pneumonia. Herein, we systematically review the impact of gastric versus post-pyloric feeding on the
Accepted 11 July 2012 Events, Events, %
incidence of pneumonia. Events, Events, %
Study ID Methods: We searched RR (95% the CI)MEDLINE , EMB
Treatment high quality
ASEWeight
Control , Web of Science, and CCTRD (1966 to August 2011) for
Study ID RR (95% CI) Treatment Control Weight
Keywords: studies comparing gastric and post-pyloric feeding in critically ill patients. Two reviewers reviewed the
Post-pyloric feeding Kearns,et al. (2000)
quality of the studies and performed data extraction independently. Main outcome measures were the 1.83 (0.50, 6.7
Montecalvo, et alGastric
(1992) feeding 0.20 (0.01, 3.91) 0/19 2/19 0.82 high quality
incidence of nosocomial pneumonia, aspiration, and vomiting. The meta-analysis was performed using
Critical illness
traditional and Bayesian random-effects Kamat, et al. (2008)
model. Kearns,et al. (2000) 1.83 (0.50, 6.72) 5/21 3/23 6.30
Kortbeek, et al (1999)
Pneumonia 0.65 (0.34, 1.22) 10/37 18/43 17.84
Aspirations Results: Our initial searches yielded 563 studies. Of these, we identified
Kamat, et al. (2008)15 randomized clinical trials 2/17 0/27 1.21
Kearns, etal (2000) 1.46 (0.37, 5.78) 4/21 3/23Acosta−Escribano,
3.82 et al. (2010) 0.22 (0.01, 4.3
Meta-analysis enrolling 966 participants. Post-pyloric feeding was associated with reduction
Acosta−Escribano, in pneumonia compared
et al. (2010) 0.22 (0.01, 4.39) 0/50 2/54 1.18
2
Day, et al. (2001) with gastric feeding 0.16(relative risk
(0.01, 3.03) 0/14[RR] 0.63,
2/11 95%confidence
0.83
Subtotal (¦Ö2 =interval
2.83,
Subtotal [C I]= 2.83,
0.48e
I−squared
(¦Ö2 0.83,
I−squared ¼ 0.001;
=p29.4%,
= 29.4%, p =p
0.243) ¼ 0%).
=I 0.243) 1.59 (0.34, 7.41) 7/88 5/104 8.69 1.59 (0.34, 7.4
The risk of aspiration (RR, 1.11; 95%CI, 0.80e 1.53, p ¼ 0.55; I2 ¼ 0%) and vomiting (RR, 0.80; 95%CI,
Davies, et al. (2002) 2.26 (0.22, 23.71) 2/31 1/35 1.31
0.38e 1.67, p ¼0.56; I2 ¼65.3%) were not significantly differentlow between
quality
patientstreated with gastric and
Montejo, et al. (2002) post-pyloric feeding.0.82 (0.48, 1.39) 16/50 20/51 25.77
Esparza, et al. (2001) 1.69 (0.31, 9.26) 3/24 2/27 3.69
Kumar, et al. (2006) Conclusions: Comparing with
3.40 (0.15, 77.34)gastric 0/16lowpost-pyloric
1/14 feeding, quality route can reduce incidence of pneumonia in
0.74
Heyland, et al. (2001) 0.64 (0.26, 1.56) 4/12 11/21 13.28
critically ill patients.
Hsu, et al. (2009) 0.35 (0.14, 0.90) 5/59 15/62 8.04
Ó 2012 Elsevier Ltd and European Society Esparza, et al.
for Clinical (2001)
Neumann, et al. (2002)
Nutrition and Metaboli sm. All rights reserved. 3.00 (0.13, 70.83)1/30 0/30 1.07 1.69 (0.31, 9.2
White, et al. (2009) 0.49 (0.18, 1.31) 5/50 11/54 7.44 Meert, et al. (2004) 1.12 (0.77, 1.65) 20/30 19/32 73.27
Heyland, et al. (2001)
Subtotal (¦Ö2 = 2.03, I−squared = 0.0%, p = 0.566) 1.06 (0.75, 1.50) 28/96 32/110 91.31 0.64 (0.26, 1.5
Acosta−Escribano, et al. (2010) 0.56 (0.35, 0.89) 16/50 31/54 33.40
Kamat, et al. (2008) . (., .) 0/17 0/27Neumann,

0.00 et al. (2002)
Heterogeneity between groups: p = 0.441
3.00 (0.13, 70
Overall (¦Ö2 = 8.03, I−squared = 0.0%, p = 0.532)
1. Introduction Selection
0.63 (0.48, 0.83) 59/362 of100.00
103/395 a feeding
Meert, method
et al. (2004)
Overall (¦Ö2 = 5.46,
either I −squared = 0.0%,
intragastric orp =post-pyloric
0.487) 1.11 (0.80, 1.53) 35/184 37/214 100.00 1.12 (0.77, 1.6
can beimportant in selected patients. Intolerance to gastric feeding
Nutrition support has a major effect on morbidity and outcome due to impaired Subtotal gastric = 2.03, I−squared
(¦Ö2emptying is common, = 0.0%,
and largep = 0.566)
gastric 1.06 (0.75, 1.5
and enteral nutrition (EN) is increasingly being recognized as an residual volumes may contribute to bacterial .00654colonization of the 1 153
.00846 1 118
integral component in the management of critically ill patients.1,2 stomach and aspiration pneumonia in critically ill patients. Post-
Fig. 5. Forest plot showing the effect of post-pyloric feeding on proportion of patients with aspiration. High quality means low risk of bias; low quality means high risk of bias.
However, enteral feeding is associated with a higher risk of ten
st plot showing the effect of post-pyloric feeding on proportion of patients developing pneumonia from aspi- pyloric
randomized feeding
trials. One has
trial 13 was
Heterogeneity theoretical
excluded because ofadvantages
between groups: p =because
no 0.441 it could
3
ration, which
RR e relative risk; CI e confidence interval. may contribute to nosocomial pneumonia. The re- reduce the risk ICU setting and small-bowel feeding was risk
of gastroesophageal reflux and the of aspiration
Reduz*incidência*de*pneumonia*
ported incidence of aspiration pneumonia varies between 10%and
40% of patients receiving EN in the intensive care unit (ICU). 4
pneumonia.Overall
The advantages
high risk (¦Ö2 = 5.46, I−squared
for aspiration.
of were
post-pyloric
36
as opposed
Sem*diferença*na*incidência*de*aspiração*
feasible
= 0.0%, p = 0.487)
to reviews
in the patients at
gastric feeding,
found. The possible explanation may be that there are many risk
factors associated with pneumonia and there is a need 1.11to(0.80,
aspirate 1.5
There three published system on the similar gastric contents during post-pyloric feeding but not performed in
Nosocomial pneumonia continue to be a significant cause of especially fortopics. the 8e10
nosocomial pneumonia
The meta-analysis, have not
performed by been
Heyland wellet al.,10 the most studies, reducing the beneficial effect of post-pyloric
morbidity, mortality, and added costs in the ICU.5 documented6demonstrated
and the European the beneficial
Society for effect of post-pyloric
Clinical Nutritionfeeding
and on feeding on pneumonia.37e40 Another possible explanation is that
Cochrane Database of Systematic Reviews
Publication statusand date: New, published in Issue8, 2015.
Review content assessed asup-to-date: 31 October 2013.

Citation: AlkhawajaS, Martin C, Butler RJ, Gwadry-Sridhar F. Post-pyloric versusgastric tubefeedingfor preventing pneumoniaand
improving nutritional outcomes in critically ill adults. CochraneDatabase of Systematic Reviews2015, Issue 8. Art. No.: CD008875.
DOI: 10.1002/14651858.CD008875.pub2.
Copyright © 2015
Post-pyloric versusgastric tube feeding
TheCochraneCollaboration. forbypreventing
Published John Wiley & Sons, Ltd.
pneumonia and improving nutritional outcomesin critically ill
adults(Review)
A BST RA C T
Background
Alkhawaja S, Martin C, Butler RJ, Gwadry-Sridhar F
Nutritional support is an essential component of critical care. Malnutrition has been associated with poor outcomes among patients
in intensive care units(ICUs). Evidence suggests that in patientswith afunctional gut, nutrition should be administered through the
enteral route. Oneof themain concernsregarding use of the enteral route isthereduction in gastric motility that isoften responsible
for limited caloric intake. Thisincreases the risk of aspiration pneumonia as well. Post-pyloric feeding, in which the feed is delivered
directly into theduodenum or thejejunum, could solvetheseissuesand provideadditional benefitsover routinegastric administration
of thefeed.
Objectives
To evaluate the effectiveness and safety of post-pyloric feeding versus gastric feeding for critically ill adults who require enteral tube
feeding.
Search methods
Wesearched thefollowing databases: CochraneCentral Register of Controlled Trials(CENTRAL;2013 Issue10), MEDLINE (Ovid)
(1950 to October 2013), EMBASE (Ovid) (1980 to October 2013) and theCumulativeIndex to Nursing and Allied Health Literature
Alkhawaja S, Martin C, Butler RJ, Gwadry-Sridhar F.
(CINAHL)
Post-pyloric via EBSCO
versus gastric tube feedinghost (1982 pneumonia
for preventing to October 2013). nutritional
and improving We reran the search
outcomes onill 4
in critically February 2015 and will deal with the one study of
adults.
interest
Cochrane whenSystematicReviews
Databaseof weupdate thereview. 2015, Issue 8. Art. No.: CD008875.
DOI: 10.1002/14651858.CD008875.pub2.
Selection criteria
www.cochranelibrary.com
Randomized or quasi-randomized controlled trialscomparing post-pyloric versusgastric tube feeding in critically ill adults.
Data collection and analysis
We extracted data using the standard methods of the Cochrane Anaesthesia, Critical and Emergency Care Group and separately
Post-pyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
evaluated trial quality and data extraction asperformed by each review author. We contacted trialsauthorsto request missing data.

Analysis 1.1. Comparison 1 Post-pyloric versus gastric tube feeding in critically ill adult patients, O utcome 1
Post-pyloric versusgastric tube feeding for preventing
Pneumonia.
Review: Post-pyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults
adults(Review)
Comparison: 1 Post-pyloric versus gastric tube feeding in critically ill adult patients
Outcome: 1 Pneumonia
Study or subgroup Post-pyloric Gastric Risk Ratio Weight Risk Ratio
M- M-
H,Random,95% H,Random,95%
n/N n/N CI CI
1 clear acceptable definition for pneumonia

Acosta-Escribano 2010 16/50 31/54 28.5 % 0.56 [ 0.35, 0.89 ]
Davies 2002 2/31 1/35 1.1 % 2.26 [ 0.22, 23.71 ]
Davies 2012 18/91 19/89 18.6 % 0.93 [ 0.52, 1.65 ]
Hsu 2009 5/59 15/62 6.9 % 0.35 [ 0.14, 0.90 ]
Kortbeek 1999 10/37 18/43 15.2 % 0.65 [ 0.34, 1.22 ]
Montecalvo 1992 0/19 2/19 0.7 % 0.20 [ 0.01, 3.91 ]
Montejo 2002 16/50 20/51 22.0 % 0.82 [ 0.48, 1.39 ]
Alkhawaja
WhiteS, Martin C, Butler RJ, Gwadry-Sridhar
2009 F.
5/50 11/54 6.3 % 0.49 [ 0.18, 1.31 ]
Post-pyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults.
Subtotal
Cochrane (95% CI)
Databaseof SystematicReviews 2015,387 407
Issue 8. Art. No.: CD008875. 99.3 % 0.66 [ 0.52, 0.85 ]
DOI:
Total10.1002/14651858.CD008875.pub2.
events: 72 (Post-pyloric), 117 (Gastric)
Heterogeneity: Tau2 = 0.0; Chi2 = 6.22, df = 7 (P = 0.51); I2 =0.0%
Test for overall effect: Z = 3.26 (P = 0.0011)
2 no clear definition for pneumonia
Pneumonia
Day 2001 0/14 2/11 0.7 % 0.16 [ 0.01, 3.03 ]
Subtotal (95% CI) 14 11

Post-pyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults (Review) 0.7 % 0.16 [ 0.01, 3.03 ]
Total events: 0 (Post-pyloric), 2 (Gastric) Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD008875.

Mortality.

pneumonia
Comparison: and
1 Post-pyloric improving
versus nutritional
gastric tube feeding in outcomesin critically ill
critically ill adult patients
adults(Review)
Outcome: 3 Mortality
Study or subgroup Post-pyloric Gastric Risk Ratio Weight Risk Ratio

Alkhawaja S, Martin C, Butler RJ, Gwadry-Sridhar F M- M-
H,Random,95% H,Random,95%
n/N n/N CI CI
Acosta-Escribano 2010 6/50 9/54 5.4 % 0.72 [ 0.28, 1.88 ]
Boivin 2001 7/39 7/39 5.5 % 1.00 [ 0.39, 2.58 ]
Davies 2002 4/34 5/39 3.2 % 0.92 [ 0.27, 3.14 ]
Davies 2012 13/91 12/89 9.3 % 1.06 [ 0.51, 2.19 ]
Esparza 2001 10/27 11/27 11.0 % 0.91 [ 0.47, 1.78 ]
Hsu 2009 26/59 24/62 27.3 % 1.14 [ 0.74, 1.74 ]
Kearns 2000 5/21 6/23 4.7 % 0.91 [ 0.33, 2.55 ]
Kortbeek 1999 4/37 3/43 2.4 % 1.55 [ 0.37, 6.48 ]
Montecalvo 1992 5/19 5/19 4.4 % 1.00 [ 0.35, 2.90 ]
Montejo 2002 19/50 22/51 21.9 % 0.88 [ 0.55, 1.42 ]

Post-pyloric
White 2009versus gastric tube feeding for preventing pneumonia
11/50 5/54 and improving nutritional outcomes in critically ill adults. 5.1 % 2.38 [ 0.89, 6.36 ]
Cochrane Databaseof SystematicReviews 2015, Issue 8. Art. No.: CD008875.
Total (95% CI)
DOI: 10.1002/14651858.CD008875.pub2. 477 500 100.0 % 1.03 [ 0.83, 1.29 ]
Total events: 110 (Post-pyloric), 109 (Gastric)
Heterogeneity: Tau2 = 0.0; Chi2 = 4.50, df = 10 (P = 0.92); I2 =0.0%
Test for overall effect: Z = 0.29 (P = 0.78) Mortalidade
Test for subgroup differences: Not applicable
Post-pyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes
0.02 0.1 in critically
1 ill adults
10 (Review)
50
Favours Post-pyloric Favours Gastric
Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD008875.

T ime required to achieve full nutritional target (in hours) .
adults(Review)
Outcome: 7 Time required to achieve full nutritional target (in hours)
Alkhawaja S, Martin C, Butler RJ, Gwadry-Sridhar F Mean Mean

Study or subgroup Post-pyloric Gastric Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95%CI IV,Random,95%CI
1 fluoroscopic guidance or endoscopic insertion of feeding tube

Davies 2002 34 23.2 (22.74) 39 23 (21.23) 19.2 % 0.20 [ -9.94, 10.34 ]
Kortbeek 1999 37 34 (7.1) 43 43.8 (22.6) 22.0 % -9.80 [ -16.93, -2.67 ]
Subtotal (95% CI) 71 82 41.2 % -5.48 [ -15.19, 4.23 ]

Heterogeneity: Tau2 = 30.00; Chi2 = 2.50, df = 1 (P = 0.11); I2 =60%
2 blind insertion of feeding tube
Hsu 2009 59 32.4 (27.1) 62 54.5 (51.4) 15.3 % -22.10 [ -36.64, -7.56 ]
Neumann 2002 26 43 (24.1) 28 28.8 (15.9) 18.5 % 14.20 [ 3.22, 25.18 ]
White 2009 50 14 (6.7) 54 10.5 (5.3) 25.1 % 3.50 [ 1.17, 5.83 ]
Subtotal (95% CI) 135 144

58.8 % -0.33 [ -15.04, 14.37 ]
Tau2 = 142.47;
Heterogeneity:Post-pyloric Chi
versus
2 = 15.53, df = 2 (P = 0.00042); I2 =87%
gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults.
Test for overallCochrane
effect: Z Databaseof
= 0.04 (P =SystematicReviews
0.96) 2015, Issue 8. Art. No.: CD008875.
Total (95%DOI:
CI)10.1002/14651858.CD008875.pub2.
206 226 100.0 % -1.99 [ -10.97, 6.99 ]
Heterogeneity: Tau2 = 82.35; Chi2= 27.51, df = 4 (P = 0.00002); I2 =85%
Tempo para atingir alvo
Test for subgroup differences: Chi2 = 0.33, df = 1 (P = 0.57), I2 =0.0%
nutricional
-50 -25 0 25 50
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Favours post-pyloric Favours gastric

ICU length of stay (in days).
adults(Review)
Outcome: 9 ICU length of stay (in days)

Mean Mean
Study or subgroup Post-pyloric Gastric Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95%CI IV,Random,95%CI
Acosta-Escribano 2010 50 16 (9) 54 18 (7) 24.6 % -2.00 [ -5.12, 1.12 ]
Davies 2002 34 13.9 (10.5) 39 10.4 (7.49) 13.8 % 3.50 [ -0.74, 7.74 ]
Hsu 2009 59 18.2 (11.8) 62 18.2 (11.2) 14.7 % 0.0 [ -4.10, 4.10 ]
Kearns 2000 21 17 (9.17) 23 16 (9.59) 8.2 % 1.00 [ -4.54, 6.54 ]
Montecalvo 1992 19 11.7 (8.2) 19 12.3 (10.8) 6.8 % -0.60 [ -6.70, 5.50 ]
Montejo 2002 50 15 (10) 51 18 (16) 9.3 % -3.00 [ -8.19, 2.19 ]
White 2009 50 7.1 (6) 54 9.1 (10.5) 22.7 % -2.00 [ -5.26, 1.26 ]
Total (95% CI)S, Martin C, Butler RJ,

Alkhawaja 283Gwadry-Sridhar F. 302 100.0 % -0.70 [ -2.31, 0.91 ]
Post-pyloric
2 versus gastric
2 tube feeding for preventing pneumonia
2 and improving nutritional outcomes in critically ill adults.
Heterogeneity: Tau = 0.21; Chi = 6.28, df = 6 (P = 0.39); I =4%
DOI: 10.1002/14651858.CD008875.pub2.
Test for subgroup differences: Not applicable
Tempo de internação
-50 -25 0 25 50
Favours Post-pyloric Favours gastric
na UTI

adults(Review)
Complicações
We found that post-pyloric
Duração da VM feeding appeared to reduce therate of pneumonia and increase the amount of nutrition delivered to
Vômitos
patient. Its use did not result in fewer daysthat a person needed to be dependentrelacionadas
on a breathing amachine
SNE nor in fewer deaths. T
target amount of feeding for aperson fed with apost-pyloric tubewasreached without delay. Insertion of apost-pyloric feeding t
appearssafeand did not increasethelikelihood of complications.
Sem diferença entre as intervenções
Quality of the evidence
Wefound evidenceof moderatequality for theoutcomesof rateof pneumonia, duration of dependency on abreathing machinea
We
ratefound
of death,that post-pyloric
mainly because feeding appearedstudies
identified to reduce were thepoorly
rate ofconducted.
pneumonia With and increase
regardthe
to amount
the totalofquantity
nutritionof
delivered to the
nutrients that can
patient.
delivered Itsto use did not result in fewer days that a person neededand to be dependent on a breathing machine nor in fewer deaths. The asl
Alkhawaja S,patientsand complicationsrelated
Martin C, Butler RJ, Gwadry-Sridhar F. to insertion maintenance of thetube, thequality of evidencewasassessed
target amount of feeding
Post-pyloric versus for aforperson fed with apost-pyloric tube wasreached without delay. Insertion of apost-pyloric feeding tube
Evidence for thegastric tube feeding
timerequired preventing pneumonia and improving
to reach thetarget
nutritional outcomes
amount ofin critically ill adults.
feeding was very low in that resultswerenot similar acrossstudiesa
appearssafeand did not increasethelikelihood of complications.
study design issueshindered assessment.
DOI: 10.1002/14651858.CD008875.pub2.
Qualitywww.cochranelibrary.com
of the evidence
Werecommend that apost-pyloric feeding tubeshould beused routinely for all ICU patients, when thisapproach isfeasible.
Wefound evidence of moderate quality for theoutcomesof rateof pneumonia, duration of dependency on a breathing machine and
rate of death, mainly because identified studies were poorly conducted. With regard to the total quantity of nutrients that can be
delivered to©patientsand
Copyright complications
2015 The Cochrane Collaboration. Published by John Wiley &related
Sons, Ltd. to insertion and maintenance of thetube, the quality of evidence was assessed aslow.
ith improvements in glycemic control, protocolized EN delivery is reduced with a greater number of symptoms of
management, and new lipid emulsions. GI intolerance. A greater number of signs of intolerance may
SNE*em*posição*gástrica*ou*pósPpilórica?* warrant increased vigilance as EN is started and may necessi-
: Is the clinical evidence of contractility (bowel
621863
resear ch-article 2016
tate further clinical evaluation.
PEN40210.1 177/01486071 15621863Journal of Parenteral and Enteral Nutrition Taylor et al
latus) required prior to initiating EN in critically

patients? Question: What is the preferred level of infusion of EN
Clinical Guidelines
within the GI tract for critically ill patients? How does
Based on expert consensus, we suggest that, in the
the level of infusion of EN affect patient outcomes?
rity of M I CU and SI CU patient populations, while Guidelines for the Provision and Assessment of Nutrition
ontractility factors should be evaluated when Support
B4a. W eTrecommend
herapy in the Adult
that Critically
the level I ll Patient:
of infusion Society
be diverted
ting EN, overt signs of contractility should not be oflower
Critical CareGIM edicine
in the tract in(SCCM ) and American
those critically Society
ill patients at
for Parenteral
high risk for and Enteral(see
aspiration Nutrition
section(A.S.P.E.N.)
D4) or those who
red prior to initiation of EN.
have shown intolerance to gastric EN.
e: The literature supports the concept that bowel Stephen A. M cClave, M D 1* ; Beth E. T aylor, RD, DCN 2* ; Robert G. M ar tindale, M D, PhD
nd evidence of bowel function (ie, passing flatus or M[Quality ofren,
alissa M . W ar Evidence:
RD 4; DebbieMR.oderate to H
Johnson, RN, MS igh]
5
; Car ol Braunschweig, RD, PhD 6;
M ar y S. M cCar thy, RN, PhD ; Evangelia Davanos, Phar mD 8; T odd W . Rice, M D, M Sc9;
7
e not required for initiation of EN. GI dysfunction in Gail A. Cresci, RD, PhD 10; Jane M . Gervasio, Phar mD 11; Gordon S. Sacks, Phar mD 12;
setting occurs in 30%–70% of patients, depending on B4b.R.Based
Pamela Roberts,on expert
MD 13 consensus
; Char lene Compher,we RD, suggest
PhD 14; andthat, in most
the Society of Critical Ca
† †
nosis, premorbid condition, ventilation mode, medica- Mcritically
edicine and ill
the patients,
American Society
it is for Par enteral and
acceptable to Enteral
initiate Nutrition
EN in the
d metabolic state. 70 K eywords
stomach.
sed mechanisms of ICU and postoperative GI dysfunc- nutrition; critical care; intensive care unit; enteral; parenteral; evidence-based medicine; Grading of R
Development, and
Rationale: Evaluation criteria;
Initiating guidelines in the stomach is technically
EN therapy
related to mucosal barrier disruption, altered motility,
of the mucosa, and reduced mass of GALT. GI intoler- easier and may decrease the time to initiation of EN. The
been variably defined (eg, absence or abnormal bowel Preliminary
choice of level Remarks
of infusion(I ntentwithin
of the GI tract (ie,Periodic
whether Guideline
the Review
vomiting, bowel dilatation, diarrhea, GI bleeding, high tipGuidelines)
of the feeding tube is in the stomach, different This segments ofis an updat
particular report
published by A.S.P.E.N. and SCC
esidual volumes [GRVs]) and appears to occur in up to theA.S.P.E.N.
duodenum and SCCM are both nonprofit organizations com-
[D1, D2, D3, or D4], or the
posed of multidisciplinary healthcare professionals. The mis-
jejunum) may be
of both A.S.P.E.N. and SCCM ha
patients on mechanical ventilation. Bowel sounds are determined by ispatient
sion of A.S.P.E.N. to improveselection
patient carewithin ICUthepractitioners’
by advancing lines be updatedinsti-
every 3–5 years
science and practice of clinical nutrition and metabolism. controlled trials (RCTs) that serv
e only of contractility and do not necessarily relate to tutional framework (ease and feasibility ofThe
placing small bowel
ysis of the literature was assemb
mission of SCCM is to secure the highest-quality care for all
 Distensão abdominal
 Vômitos
 Diarreia
BRASPEN J 2018; 33 (Supl 1):2-36
Author M anuscript
JAMA. Author manuscript; available in PMC 2013 August 14.
Iniciar terapia nutricional trópica ou plena?
Published in final edited form as:
JAMA. 2012 February 22; 307(8): 795–803. doi:10.1001/jama.2012.137.
Initial Trophic vs Full Enteral Feeding in Patients With Acute

Lung Injury:
The EDEN Randomized Trial
The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome
(ARDS) Clinical Trials Network
Abstract
ECR multicêntrico open-label
 1000 pacientes
Context—The críticos
amount of enteral nutrition patients with acute lung injury need is unknown.
 TN
Objective—To
introduzida nas primeiras
determine 48 horas
if initial lower-volume apósenteral
trophic injúria respiratória
feeding would increase– VM
ventilator-free days and decrease gastrointestinal intolerances compared with initial full enteral
 TN trófica ( n = 508) x TN plena nos primeiros seis dias (n = 492) – após
feeding. todos os
Design, Setting, and Participants—The EDEN study, a randomized, open-label, multicenter
pacientes seguiram
trial conducted from Januaryo 2,protocolo
2008, through daApril
TN12,plena
2011. Participants were 1000 adults
within 48 hours of developing acute lung injury requiring mechanical ventilation whose
physicians intended to start enteral nutrition at 44 hospitals in the National Heart, Lung, and Blood
Institute ARDS Clinical Trials Network.
Interventions—Participants were randomized to receive either trophic or full enteral feeding for
the first 6 days. After day 6, the care of all patients who were still receiving mechanical ventilation
was managed according to the full feeding protocol.
Main Outcome Measures—Ventilator-free days to study day 28.
Results—Baseline characteristics were similar between the trophic-feeding (n=508) and full- JAMA. 2012; 307(8): 795–803
Author M anuscript

Lung Injury: Table 2
TheClinical
EDEN Randomized
Outcomes Trial
NIH-PA Author Manuscript
Trophic Feeding Full Feeding P
Outcome (n = 508) (n = 492) Value
Ventilator-free days, No. (95% CI) 14.9 (13.9–15.8) 15.0 (14.1–15.9) .89
Abstract
Failure-free days, No. (95% CI)
Context—The amount of enteral nutrition patients with acute lung injury need is unknown.
Cardiovascular 19.1 (18.2–20.0) 18.9 (18.1–19.8) .75
Objective—To determine if initial lower-volume trophic enteral feeding would increase
Renal
ventilator-free days and decrease gastrointestinal20.0 (19.0–20/9)compared19.4
intolerances with(18.4–20.5) .43
initial full enteral
feeding.
Hepatic 22.0 (21.2–22.9) 22.6 (21.8–23.5) .37
Design, Setting, and Participants—The EDEN
Coagulation study, a randomized,
22.3 (21.4–23.1) 23.1open-label,
(22.3–23.9) multicenter
.16
trial conducted from January 2, 2008, through April 12, 2011. Participants were 1000 adults
ICU-free
within days, No.
48 hours (95% CI) acute lung injury 14.4
of developing (13.5–15.3)
requiring 14.7 (13.8–15.6)
mechanical ventilation whose .67
physicians intended
60-d mortality, to[95%
No. (%) start CI]
enteral nutrition at 44(23.2)
118 hospitals in the National
[19.6–26.9] Heart,
109 (22.2) Lung, and Blood
[18.5–25.8] .77
Development of infections, No. (%) [95% CI]
VAP 37 (7.3) [5.0–9.5] 33 (6.7) [4.5–8.9] .72
was manageddifficile
Clostridium according 15 (3.0) [1.5–4.4]
to the full feeding protocol.
colitis 13 (2.6) [1.2–4.1] .77
Main Outcome
Bacteremia, Measures—Ventilator-free59days
No. (%) (11.6)
to[8.8–14.4]
study day 28. 46 (9.3) [6.8–11.9] .24
NIH-P
Results—Baseline characteristics were similar between the trophic-feeding (n=508) and full-
Abbreviations: ICU, intensive care unit; VAP, ventilator-associated pneumonia.
feeding (n=492) groups. The full-feeding group received more enteral calories for the first
JAMA.6 days,
2012; 307(8): 795–803
Author M anuscript

Lung Injury: Table 2
TheClinical
EDEN Randomized
Outcomes Trial
NIH-PA Author Manuscript
Trophic Feeding Full Feeding P
Outcome (n = 508) (n = 492) Value
Ventilator-free days, No. (95% CI) 14.9 (13.9–15.8) 15.0 (14.1–15.9) .89
Abstract
Failure-free days, No. (95% CI)
Context—The amount of enteral nutrition patients with acute lung injury need is unknown.
Cardiovascular 19.1 (18.2–20.0) 18.9 (18.1–19.8) .75
Objective—To determine if initial lower-volume trophic enteral feeding would increase
Renal
ventilator-free days and decrease gastrointestinal20.0 (19.0–20/9)compared19.4
intolerances with(18.4–20.5) .43
initial full enteral
feeding.
Hepatic 22.0 (21.2–22.9) 22.6 (21.8–23.5) .37
Design, Setting, and Participants—The EDEN
Coagulation study, a randomized,
22.3 (21.4–23.1) 23.1open-label,
(22.3–23.9) multicenter
.16
trial conducted from January 2, 2008, through April 12, 2011. Participants were 1000 adults
ICU-free
within days, No.
48 hours (95% CI) acute lung injury 14.4
of developing (13.5–15.3)
requiring 14.7 (13.8–15.6)
mechanical ventilation whose .67
physicians intended
60-d mortality, to[95%
No. (%) start CI]
enteral nutrition at 44(23.2)
118 hospitals in the National
[19.6–26.9] Heart,
109 (22.2) Lung, and Blood
[18.5–25.8] .77
Development of infections, No. (%) [95% CI]
VAP 37 (7.3) [5.0–9.5] 33 (6.7) [4.5–8.9] .72
was manageddifficile
Clostridium according 15 (3.0) [1.5–4.4]
to the full feeding protocol.
colitis 13 (2.6) [1.2–4.1] .77
Main Outcome
Bacteremia, Measures—Ventilator-free59days
No. (%) (11.6)
to[8.8–14.4]
study day 28. 46 (9.3) [6.8–11.9] .24
NIH-P
Results—Baseline characteristics were similar between the trophic-feeding (n=508) and full-
Abbreviations: ICU, intensive care unit; VAP, ventilator-associated pneumonia.
feeding (n=492) groups. The full-feeding group received more enteral calories for the first
JAMA.6 days,
2012; 307(8): 795–803
• Revisão sistemática com metanálise de 6 ECR
• 2 ECR dieta normocalórica (77% NN) x nutrição enteral trófica (20% NN) – 6 dias
• 4 ECR dieta normocalórica (72% NN) x nutrição enteral permissiva (49% NN) –
durante a internação na UTI
• NE trófica ou permissiva – pior resposta imune – aumento do risco de infecção?

Infecção/ sepse hospitalar

Mortalidade hospitalar
Tempo de permanência hospitalar

Iniciar terapia*
Iniciar*terapia nutricional
nutricional*trópica
trópica*ou
ou*plena?
plena?*
NE trófica = 10 – 20 ml/h = 10 – 20 kcal/ h = < 500 kcal/dia
NE permissiva
40 - 70% do alvo nutricional
E quando o início com NE não é tolerado?
JAMA. 2012; 307(8): 795–803

 ECR multicêntrico
 N = 4640 pacientes críticos com risco nutricional (NRS > 3 pontos)
 Coleta entre 2007 e 2010
NP precoce (48 horas) – n= 2312
NE precoce
NP tardia ( 8 dias) – n = 2328
Caeser. N Engl J Med 2011;365:506-17.

Sem diferença
 Mortalidade
Diferença
 Infecção (> NPP)

 Inflamação (> NPT)
 Duração VM (> NPP)
 Duração da TSR (> NPP)
 TI na UTI (> NPP)
 TI hospitalar (> NPP)
Caeser. N Engl J Med 2011;365:506-17.

1.00 to 1.13; P=0.04), without evidence of decreased functional status at hospital
discharge. Ratesof death in theICUand in thehospital and ratesof survival at 90 days
were similar Einquando
the twomed
n ew en gl an d j ou r n al
The
o início
groups.
ofi ci n e
com
Patients NElanão
in the étion
te-initia tolerado?
group, as compared
with theearly-initiation group, had fewer ICUinfections(22.8%vs. 26.2%, P=0.008)
and alower incide or i gi nalnce ar t iof
cl echolestasis (P <0.001). Thelate-initiation group had arelative
reduction of 9.7% in the proportion of patients requiring more than 2 days of me-
Early versus
chanical ventilaLate tionPare nte
(P =ra l Nutrition
0.006), amedian reduction of 3 daysin theduration of renal-
replaceme innt Critica
thera lly
pyIll(P Adults
=0.008), and amean reduction in health carecosts of €1,110
Michael P. Casaer, M.D., Dieter Mesotten, M.D., Ph.D.,
(about $1,600)
Greet Hermans, (P
M.D., Ph.D.,= 0.04).
Pieter J. Wouters, R.N., M.Sc.,
Miet Schetz, M.D., Ph.D., Geert Meyfroidt, M.D., Ph.D.,
Sophie Van Cromphaut, M.D., Ph.D., Catherine Ingels, M.D.,
Philippe Meersseman, M.D., Jan Muller, M.D., Dirk Vlasselaers, M.D., Ph.D.,
Concl usions
Yves Debaveye, M.D., Ph.D., Lars Desmet, M.D., Jasperina Dubois, M.D.,
Aime Van Assche, M.D., Simon Vanderheyden, B.Sc.,
Lateinitiation of parenteral nutrition was associated with faster recovery and fewer
Alexander Wilmer, M.D., Ph.D., and Greet Van den Berghe, M.D., Ph.D.
complications,Abst asrcompare
act d with early initiation. (Funded by the Methusalem pro-
gram of the Flemish government and others; EPaNIC ClinicalTrials.gov number,
Backgr ound
ensive Care
M.S., G.M.,
NC
Controve T00512122.)
rsy exists about the timing of the initiation of parenteral nutrition in criti-
cally ill adults in whom caloric targets cannot be met by enteral nutrition alone.
L.D., S.V.,
ensive Care
al Medicine
Met hods
Hospitals of In this randomized, multicenter trial, we compared early initiation of parenteral nu-
ven, Leuven; trition (European guidelines) with lateinitiation (American and Canadian guidelines)
sthesia and
als, Hasselt in adultsin theintensivecareunitn(IC engl jm
U) to supple ed
me 365;6nt enejm
nt insufficie .or g
nteral nutrition. august 11, 2011
m. Address In 2312 patients, parenteral nutrition was initiated within 48 hours after ICUadmis-
n Berghe at sion (early-initiation group), whereas in 2328 patients, parenteral nutrition was not
Care Medi-
ven, Univer-
The New England Journal of Medicine
initiated before day 8 (late-initiation group). A protocol for the early initiation of
Belgium, or enteral nutrition was applied to both groups, and insulin was infused to achieve
aded from nejm.org on August 30, 2016. For personal use only. No other uses without permission.
kuleuven.be. normoglycemia.
102662) was Copyright © 2011 Massachusetts Medical Society. All rights reserved.
Resul t s
NEJM.org.
Patients in thelate-initiation group had arelativeincreaseof 6.3%in thelikelihood
7. of being discharged alive earlier from the ICU (hazard ratio, 1.06; 95%confidence
cal Society.
interval [CI], 1.00 to 1.13; P=0.04) and from thehospital (hazard ratio, 1.06; 95%CI, Caeser. N Engl J Med 2011;365:506-17.
1.00 to 1.13; P=0.04), without evidence of decreased functional status at hospital
discharge. Ratesof death in theICUand in thehospital and ratesof survival at 90 days
crease with initiation of PN. In those patients, advancement of feed-
al PN
Question: E*
ing should
E quando*
be slower,
Whatquando o*
o início*
taking
is the optimal 3–4
início com*
days
com
timing NE*
forto
NE não*
reach
não
initiating é*
goal.
é tolerado?*
Use of
tolerado?
vided protocols and
supplemental PNnutrition
when EN support teams
does not meethave been
energy
260–262
or shown to
tional
protein goals in the patient at low or high nutritionPermissive
decrease PN-associated complications. risk?
ned
tients underfeeding has also been shown to be a potential short-
RIInCan G3. approach
term W e recommendto avoid that, in patients
some of these atcomplications
either low or(see
high
3notafter section H2). 263–266
nutrition risk, use of supplemental PN be considered
nd aspro- after 7–10 days if unable to meet >60% of energy and
pared protein requirements by the enteral route alone. I nitiating
only a Question: In the appropriate candidate for PN (high risk
day 9 or severely malnourished), should the dose be adjusted
h con- over the first week of hospitalization in the ICU?
tients H 2. W e suggest that hypocaloric PN dosing ( 20 kcal/
tiated kg/d or 80% of estimated energy needs) with adequate
nS ocie
tyfo
rPa
ren
ter
alan
d En
te
ralNutr
itio
n(A.S
.P.E
.N.)onD ec
ember8,2
016
being protein ( 1.2 g protein/kg/d) be considered in
1.00– appropriate patients (high risk or severely malnourished)
initi- requiring PN, initially over the first week of
o late hospitalization in the I CU.
.02),
reater [Quality of Evidence: L ow]
0 (P =
240
Cautela naqueles com risco de SR
Jejum
Reintrodução da
alimentação
Desnutrição
Depleção de
íons
SR
Complicações
Nutrition. 2014;30(11-12):1448-55
Cautela naqueles instáveis hemodinamicamente
Sinais vitais Frequência cardíaca/ PAM (> 65 mmHg)
Débito cardíaco (cateter de artéria pulmonar)/

Perfusão Saturação venosa de O2/ lactato sérico (não
reestabelecimento da perfusão –
desequilíbrio entre produção e depuração)
Gasometria Acidose metabólica
Perfusão intestinal comprometida (fluxo

Droga vasoativa
sanguíneo esplâncnico dependente do DC)
TOLEDO. Nutrição no Paciente Crítico, Rubio, 2015.
Droga vasoativa
Os vasopressores agem elevando a pressão arterial, enquanto os inotrópios

aumentam o débito cardíaco, ambos com a finalidade de manter a adequada
perfusão tecidual, atuando cada droga em receptor adrenérgico específico
O aumento da dose de agentes vasoativos provoca diminuição da oxigenação

intestinal, aumentando o risco de isquemia e necrose tecidual
Não existe consenso em relação ao ponto de corte para as doses de

vasopressores que impediriam o início da terapia nutricional
TOLEDO. Nutrição no Paciente Crítico, Rubio, 2015.

Droga vasoativa
ALLEN. Nutr Clin Pract. 2012;27:335-339

Droga vasoativa
 Fase de ressuscitação volêmica

 Hipotensão (PAM < 60 mmHg)
 Pacientes iniciando DVA ou em ascensão de dose
 Presença de acidose lática (microperfusão)
BRASPEN J 2018; 33 (Supl 1):2-36
o- E. Selection of Appropriate Enteral
d Formulation
y Qual*fórmula*enteral*uAlizar?*
Question: Which formula should be used when initiating
of
EN in the critically ill patient?
ts
i- E1. Based on expert consensus, we suggest using a
y 174standard polymeric formula when initiating EN in the Journal of Par
as I CU setting. W e suggest avoiding the routine use of all
McClave et al
specialty formulas in critically ill patients in a M I CU terms of mortality (17 st
and disease-specific
Question: formulas
In adult critically in thewhat
ill patients, SI CU.
are the tious complications
adjunctive (9cri
therapy in the st
oP
ar
ente
ra
lan
dindications, if any, for enteral formulations containing
En
te
ra
lNu
tr
itio
n(A.S
.P
.E
.N
.)o
nDe
cem
be
r8,2
016 (11 studies,
diarrhea and is147 patients
receiving as
Rationale: Foror the
soluble fiber majority
small of patients in an ICU setting, a
peptides? Unfortunately,
enteral formula? few s
standard polymeric isotonic or near isotonic 1- to 1.5-kcal/mL pharmaconutrients, their
E4a. W e suggest that a commercial mixed fiber formula F1.This
Based
formula is appropriate and will be well tolerated. This recom- ing. bodyon expert
of literatu
not be used routinely in the adult critically ill patient fermentable
mendation is one of exclusion in that no clear benefit to patient neity of studies,soluble
perform
prophylactically to promote bowel regularity or prevent oligossaccharides
outcome has been shown in the literature for the routine use of populations, with a [FO
var
diarrhea. routine use in all hemo
specialty formulas in a general ICU setting, including those formulations. Multiple
patients placed on a st
that are designed to be disease specific (diabetes), organ spe-
[Quality of Evidence: L ow] being immune or metabo
suggest that 10–20 g
cific (pulmonary, renal, hepatic), semielemental, elemental, or in their makeup and dos
supplement be given in
immune
E4b.modulating.
Based on expertOne consensus,
exception would be the
we suggest use of an
considering more costly. It is not cl
adjunctive therapy if th
Qual*a*necessidade*calórica*e*proteica?*
ESPEN*
Fase*aguda*=*20*–*25*kcal/kg/dia*
Fase*estável*=*25*–*30*kcal/kg*
ASPEN*
25*–*30*kcal/kg/dia*
IDEAL*
Equações preditivas concordam com a CI em

apenas 50% das vezes
Qual a necessidade calórica e proteica?
Tabela 1: Equações preditivas para estimativa do gasto energético de pacientes críticos.
EQUAÇÃO FÓRM ULA

Harris Benedict Homens: GEB kcal/dia = 66 + (13,75 x Peso) + (5 x Altura) – (6,75 x Idade)
Mulheres: GEB kcal/dia = 655 + (9,56 x Peso) + (1,85 x Altura) – (4,67 x
Idade)
I reton-Jones Gasto energético (GE) = 1784 – 11 x Idade + 5 x Peso + 244 x Sexo + 239 x
Trauma + 804 x Queimadura
(pacientes c/ VM )
I reton-Jones Kcal/dia = (606 x G) + (9 x P) x – (12 x Idade) + (1400 x V) + 1444
(pacientes obesos)
M ifflin–St. Joers Homens kcal/dia: 10 x (Peso) + 6.25(Altura) – 5(Idade) + 5

Mulheres kcal/dia: 10(Peso) + 6.25(Altura) – 5(Idade) – 161
Penn State RE kcal/dia: Mifflin(0.96) + (Tmax)167 + (Ve)31– 6212
Penn State modificada RE kcal/dia: Mifflin(0.71) + (Tmax)85 + (Ve)64 – 3085

67898
2015
PENXXX10.1177/01486071 14567898 Journal of Parenteral and Enteral Nutrition Tatucu-Babet et al

Review
Journal of Parenteral and Enteral
Nutrition
The Prevalence of Underprescription or Overprescription Volume XX Number X
Month 201X 1 –14
of Energy Needs in Critically I ll M echanically Ventilated © 2015 American Society
for Parenteral and Enteral Nutrition
Adults as Determined by I ndirect Calorimetry: A DOI: 10.1177/0148607114567898
Systematic Literature Review jpen.sagepub.com
hosted at
13 – 90% subestimaram o GE
online.sagepub.com
 18 estudos
Oana A. Tatucu-Babet, APD, BNutDiet(Hons) 1,2; Emma J. Ridley, APD, MPH 1,3;
 Audrey
160 variações de 13 0 – 88% superestimaram o GE
and C. Tierney, APD, PhDequações
1,4 preditivas
Tatucu-Babet et al 9
Abstract
Table 2.Background:
Rates of Underprescription and Overprescription
Underfeeding and overfeeding of with
has been associated Energy Needs
adverse at aoutcomes.
patient Group Level.
Resting energy expenditure can be measured
using indirect calorimetry. In its absence, predictive equations are used. A systematic literature review was conducted to determine the
Predictive Underestimation:
prevalence of underprescription No. ofof energy needs in adult
and overprescription Overestimation: No. of critically ill 38%
mechanically ventilated No. ofbyPredictive
patients comparingEquations
predictive
Equation Subgroup equations to indirect calorimetry measurements.
Estimates <90% of IC Values Methods: Ovid MEDLINE, CINAHL
Estimates >110% of IC Values Plus, Scopus, and EMBASE
Compared to databases
IC Measurements
were searched in May 2013 to identify studies that used both predictive equations and indirect calorimetry to determine energy expenditure.
Fixed prescriptions 13 (39%)
Reference lists of included publications 4 (12%)
were also searched. The number of predictive Subestimaram
33
equations that underestimated or overestimated em > 10%
HB energy expenditure by ±10% when31compared
(54%) to indirect calorimetry measurements were noted at both an individual and group level.
4 (7%) 57
Results: In total, 2349 publications were retrieved, with 18 studies included. Of the 160 variations of 13 predictive equations reviewed
IJ 2 (20%) 4 (40%) 10
at a group level, 38% underestimated and 12% overestimated energy expenditure by more than 10%. The remaining 50% of equations
Other estimated energy expenditure to within8 (21%) 7 (18%) 38
±10 of indirect calorimetry measurements. Superestimaram
On an individual patient level, predictive equations em > 10%
PSU underestimated and overestimated energy expenditure in 13–90% and 0–88% of patients,
6 (27%) 0 (0%)respectively. Differences of up to 43% below22and
Total 66% above indirect calorimetry values were observed. Conclusions: Large discrepancies
60 (38%) 19 (12%) exist between predictive equation estimates
160and
12%
indirect calorimetry measurements in individuals and groups. Further research is needed to determine the influence of indirect calorimetry
and predictiveIC,
HB, Harris-Benedict; equation limitations
indirect in contributing
calorimetry; to thesePSU,
IJ, Ireton-Jones; observed differences. ( JPEN J Parenter Enteral Nutr . XXXX;xx:xx-xx)
Penn-State.
Tatucu-Babet. JPEN. 2015: 1-14.
Keywords
ESPEN*
2006
2016 ASPEN*
IDEAL*
DITEN
2018
15 – 20 Kcal/ kg/ dia nos 1os 4 dias (50-70% CI)
25 – 30 kcal/ kg após o 4 dia
2018 ESPEN
ESPEN*
2016
ASPEN*
IDEAL*
DITEN
2018
Clinical Nutrition xxx (2018) 1e32
2018 ESPEN
ESPEN*
2016
ASPEN*
IDEAL*
DITEN
2018
Clinical Nutrition xxx (2018) 1e32
account. In the absence of IC, no one predictive equation is
better than another in AKI. Experts agree on using usual body
weight for normal weight patients and ideal body weight for
obese and critically ill patients. Energy needs can be deter-
mined by IC, published predictive equations, or a simplistic
weight-based equation (25–30 kcal/kg/d). 306–310 Specialty
formulations lower in certain electrolytes (eg, phosphate and
potassium) than standard products may be beneficial in ICU
patients with AKI.306,308
Question: In adult critically ill patients with AKI

receiving hemodialysis or CRRT, what are appropriate
targets for protein intake to support increased nitrogen
losses?
J2. W e recommend that patients receiving frequent
184hemodialysis or CRRT receive increased protein, up to a Journal of Parenteral and Enteral Nu
maximum of 2.5 g/kg/d. Protein should not be restricted
in patients with renal insufficiency as a means to avoid best determined by IC.319 Historically, prote
or delay initiating dialysis therapy. was used to help reduce risk from hepatic enc
but such strategy may worsen nutrition status,
a
re
nte
ra
lan
dE
[Quality of Evidence: Very L ow]
n
te
ra
lNu
tr
itio
n(A.S
.P
.E
.N
.)o
nDe
cem
be
r8,2
016
muscle mass, and ironically lead to less ammo
Therefore, protein should not be restricted as a
Rationale: A significant amino acid loss (10–15 g/d) is associ- strategy aimed at reducing hepatic encephalopa
ated with CRRT.310 Lean body mass catabolism inferred from reverse may occur as a result. 319,320 Protein req
BRASPEN J 2018; 33 (Supl 1):2-36

Quais as recomendações para condições específicas?
• Novo cenário....
DIARREIA = 2-3 evacuações líquidas/ dia ou > 250 g de fezes líquidas/dia
Tipo e quantidade de fibra na NE

Osmolaridade
Método de administração
Temperatura
Quantidade de FOODMAPS
Contaminação
Medicamentos
Infecção (Clostridium)
Marcadenti A e Silva FM. Dietoterapia nas doenças do adulto. Rubio, 2018

Como monitorar o paciente crítico?
Instabilidade Funcionamento intestinal

hemodinâmica
Exames laboratoriais Exame físico
Modo ventilatório Medicamentos
Infusão da dieta Vômitos/ aspiração

Como monitorar o paciente crítico?
Boa leitura!!
Cuidado Nutricional
no Paciente crítico
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Obrigada!!!!

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