Manutenção Nutricional do traumatizado: Complicações na nutrição - Como resolver

Complicações NUTRIÇÃO ENTÉRICA Abílio Cardoso Teixeira | Mestrando Ciências Enfermagem: ICBAS – UP (www.ic bas.up.pt)| Enfermeiro: SCI1 (www.sci.com.pt), CHP – HSA (www.hgsa.pt) [email_address] | facebook.com/abilio.cardosoteixeira | pt.linkedin.com/in/abiliocardosoteixeira | slideshare: abiliocardosoteixeira XIV congresso da spci | lagos | 22 maio 2011

Abílio Cardoso Teixeira | Mestrando Ciências Enfermagem: ICBAS – UP (www.ic bas.up.pt)| Enfermeiro: SCI1 (www.sci.com.pt), CHP – HSA (www.hgsa.pt) [email_address] | facebook.com/abilio.cardosoteixeira | pt.linkedin.com/in/abiliocardosoteixeira | slideshare: abiliocardosoteixeira

1. nutrição entérica – como, quando e onde? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Kreymann, K. G., Berger, M. M., Deutz, N. E. P., Hiesmayr, M., Jolliet, P., Kazandjiev, G., et al. (2006). ESPEN Guidelines on Enteral Nutrition: Intensive care. Clinical nutrition (Edinburgh, Scotland) , 25 (2), 210-23. doi: 10.1016/j.clnu.2006.01.021.

2. o que há de novo? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],1 McClave, S. a, Martindale, R. G., Vanek, V. W., McCarthy, M., Roberts, P., Taylor, B., et al. (2009). 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. Journal of parenteral and enteral nutrition, 33(3), 277-316. doi: 10.1177/0148607109335234. 2 European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (2009). Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel.

2. o que há de novo? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],1 Heyland, D. K., Cook, D. J., Malhotra, A., Rd, R. D., Henderson, W. R., Chittock, D. R., et al. (2009). Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data . Cmaj, 180(8). 821-7

2. o que há de novo? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],The Normoglycemia in Intensive Care Evaluation–Survival Using Glucose Algorithm Regulation (2009) Intensive versus Conventional Glucose Control in Critically Ill Patients. The new england journal of medicine , 360(13). 1283-97

2. o que há de novo? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Palese, A., Bello, A., & Magee, J. (2011). Triturating drugs for administration in patients with difficulties in swallowing: evaluation of the drug lost. Journal of clinical nursing, 20(3-4), 587-90. doi: 10.1111/j.1365-2702.2010.03577.x.

2. o que há de novo? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],1 Hurt, R. T., & McClave, S. a. (2010). Gastric residual volumes in critical illness: what do they really mean? Critical care clinics , 26 (3), 481-90, viii-ix. Elsevier Ltd. doi: 10.1016/j.ccc.2010.04.010. 2 DeLegge, M. H. (2011). Managing gastric residual volumes in the critically ill patient: an update. Current opinion in clinical nutrition and metabolic care, 14(2), 193-6. doi: 10.1097/MCO.0b013e328341ede7. Hurt & McClave (2010)

3. protocolos de administração ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

3. protocolos de administração ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Dhaliwal, R., Madden, S. M., Cahill, N., Jeejeebhoy, K., Kutsogiannis, J., Muscedere, J., et al. (2010). Guidelines, guidelines, guidelines: what are we to do with all of these North American guidelines? JPEN. Journal of parenteral and enteral nutrition, 34(6), 625-43. doi: 10.1177/0148607110378104.

4. a realidade do sci1 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

4. a realidade do sci1 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],4. a realidade do sci1 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Nutrition support therapy in the form of enteral nutrition (EN) should be initiated in the critically ill patient who is unable to maintain volitional intake C Enteral feeding should be started early within the first 24-48 hours following admission C

[object Object],4. a realidade do sci1 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],The feedings should be advanced toward goal over the next 48-72 hours E In the ICU patient population, neither the presence nor absence of bowel sounds nor evidence of passage of flatus and stool is required for the initiation of enteral feeding B The target goal of EN (defined by energy requirements) should be determined and clearly identified at the time of initiation of nutrition support therapy. C

4. a realidade do sci1 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Use of enteral feeding protocols increases the overall percentage of goal calories provided and should be implemented C

[object Object],4. a realidade do sci1 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],EN is the preferred route of feeding over parenteral nutrition (PN) for the critically ill patient who requires nutrition support therapy B

4. a realidade do sci1 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],4. a realidade do sci1 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Use of enteral feeding protocols increases the overall percentage of goal calories provided and should be implemented C The target goal of EN (defined by energy requirements) should be determined and clearly identified at the time of initiation of nutrition support therapy. C Use of enteral feeding protocols increases the overall percentage of goal calories provided and should be implemented C

[object Object],4. a realidade do sci1 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Inappropriate cessation of EN should be avoided E

[object Object],[object Object],[object Object],4. a realidade do sci1 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Holding EN for gastric residual volumes <500 mL in the absence of other signs of intolerance should be avoided B Agents to promote motility such as prokinetic drugs (metoclopramide and erythromycin) or narcotic antagonists (naloxone and alvimopan) should be initiated where clinically feasible C

[object Object],[object Object],4. a realidade do sci1 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],In all intubated ICU patients receiving EN, the head of the bed should be elevated 30°-45° C For high-risk patients or those shown to be intolerant to gastric feeding, delivery of EN should be switched to continuous infusion D

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],4. a realidade do sci1 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Use of enteral feeding protocols increases the overall percentage of goal calories provided and should be implemented C

4. a realidade do sci1 Lavagem da boca com clorexidina (solução oral, 6/6h e/ou SOS) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Use of chlorhexidine mouthwash twice a day should be considered to reduce risk of ventilator-associated pneumonia C Development of diarrhea associated with enteral tube feedings warrants further evaluation for etiology E

5. complicações ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Suspensão da NE como conseqüência da CGI’s não controláveis ocorreu em 15,2% dos pacientes. Montejo, J. C. (1999). Enteral nutrition-related gastrointestinal complications in critically ill patients: A multicenter study. Critical Care Medicine, 27 (8), 1447-1453 Complicação % Elevado resíduo gástrico 39 Obstipação 15,7 Diarreia 14,7 Distensão abdominal 13,2 Vómitos 12,2 Regurgitação 5,5

5. complicações ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Suspensão da NE como conseqüência da CGI’s não controláveis ocorreu em 15,2% dos pacientes. Montejo, J. C. (1999). Enteral nutrition-related gastrointestinal complications in critically ill patients: A multicenter study. Critical Care Medicine, 27 (8), 1447-1453 … E ainda… Complicação % Elevado resíduo gástrico 39 Obstipação 15,7 Diarreia 14,7 Distensão abdominal 13,2 Vómitos 12,2 Regurgitação 5,5

5. complicações ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Sanko, J. S. (2004). Aspiration assessment and prevention in critically ill enterally fed patients: evidence-based recommendations for practice. Gastroenterology nursing, 27(6), 279-85. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15632762.

5. complicações ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Fruhwald, S., Holzer, P., & Metzler, H. (2007). Intestinal motility disturbances in intensive care patients pathogenesis and clinical impact. Intensive care medicine, 33(1), 36-44. doi: 10.1007/s00134-006-0452-7.

5. complicações ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Fruhwald, S., Holzer, P., & Metzler, H. (2007). Intestinal motility disturbances in intensive care patients pathogenesis and clinical impact. Intensive care medicine, 33(1), 36-44. doi: 10.1007/s00134-006-0452-7.

5. complicações ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Fruhwald, S., Holzer, P., & Metzler, H. (2007). Intestinal motility disturbances in intensive care patients pathogenesis and clinical impact. Intensive care medicine, 33(1), 36-44. doi: 10.1007/s00134-006-0452-7.

5. complicações ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Fruhwald, S., Holzer, P., & Metzler, H. (2007). Intestinal motility disturbances in intensive care patients pathogenesis and clinical impact. Intensive care medicine, 33(1), 36-44. doi: 10.1007/s00134-006-0452-7.

5. complicações ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Trabal, J., Leyes, P., Hervás, S., Herrera, M., & Talló Forga, M. de. (2008). Factors associated with nosocomial diarrhea in patients with enteral tube feeding. Nutrición hospitalaria : organo oficial de la Sociedad Española de Nutrición Parenteral y Enteral, 23(5), 500-4. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19160901.

5. complicações ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Jack, L., Coyer, F., Courtney, M., & Venkatesh, B. (2010). Diarrhoea risk factors in enterally tube fed critically ill patients: a retrospective audit. Intensive & critical care nursing : the official journal of the British Association of Critical Care Nurses, 26(6), 327-34. Elsevier Ltd. doi: 10.1016/j.iccn.2010.08.001.

5. complicações ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Problema não frequente no SCI1. Grande parte dos doentes têm CVC. Por norma, cateterizada veia subclávia. Como recurso jugular interna ou femural (último local a ser cateterizado).

5. complicações ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],CVC em uso no SCI1 – 3 lumens; Respeito pela norma asséptica! Penso impermeável e transparente (IV3000 ® ), sendo isolados os 3 lumens, minimizando as portas de entrada. Troca dos sistemas de perfusão de NP de acordo com a estabilidade da solução; Uso preferencialmente de via única. Uso de filtros lipidicos!

5. complicações ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Uso de bombas infusoras; HBPM: clientes com alto risco!!

5. complicações ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

5. complicações ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],(Odley, 2010) cit. Magalhães, 2011 Hiperglicemia Hipoglicemia Causas “ Fluids infused too fast; too little insulin in infusion solution if diabetic; improper mixture of HPN solution; infection (hyperglycemia can be a very early warning sign, even before fever is present); certain medications (steroids and some hemotherapy agents).” “ HPN fluids stopped abruptly without adequate period of tapering; HPN bag finishing early due to malfunction of pump or decreased volume in bag; too much insulin in infusion solution. ” Prevenção “ Maintain aseptic technique at all times. Inspect labels of all HPN bags closely for consistency in formula; changes in formula should be indicated to you (…); Monitor temperature .” “ Verify volume of bag and that pump is functioning correctly , prior to infusing; report any discrepancies or problems to provider.”

5. complicações ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],(Odley, 2010) cit. Magalhães, 2011 Desidratação Causas “ Depletion of fluids/electrolytes due to increased losses from vomiting, diarrhea, fistula/ostomy output; inadequate intake of HPN infusion/extra fluids as ordered.” Prevenção “ Infuse complete volume of HPN and fluids as ordered (…); report any significant changes from usual pattern (…). Monitor weight at least 3 times per week .”

5. complicações ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],(Odley, 2010) cit. Magalhães, 2011 R/C CATÉTER Flebite Infecção Sistémica Infecção / Inflamação Causas “ Typically not an infectious problem, but rather an irritation of the vein caused by the insertion procedure.” “ Poor aseptic technique procedures; contaminated tubing or heparin or saline flushes; contaminated IV solution; exposure to illness outside body or inside body ; routine dental work without prophylactic antibiotic coverage.” “ Poor aseptic technique during site care; retained sutures in skin.” Prevenção “ None. (This complication occurs with approximately 15-20% of insertions.)” “ Use proper aseptic technique at all times. Inspect all solutions beforehand for clouding/particulate matter. Schedule routine dental checkups; “ Use proper aseptic technique during site care, including meticulous handwashing. ”

5.1. complicações – o doente em jejum ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

5.1. complicações – o doente em jejum ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

5.1. complicações – o doente em jejum ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Esquecimento? Erro? Decisão?

5.1. complicações – o doente em jejum ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],A … subsiste???

5.1. complicações – o doente em jejum ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],1 Rittler, P., & Jauch, K. -. (2007). Algorithms for nutritional therapy in surgical patients. [Ernährungsmedizinische algorithmen in der chirurgie] Aktuelle Ernahrungsmedizin, 32(6), 299-306. 2 Breuer, J. -., Von Heymann, C., & Spies, C. (2009). Perioperative nutrition - metabolic conditioning. [Perioperative ernährung - Metabolische konditionierung] Aktuelle Ernahrungsmedizin, 34(3), 107-113.

5.1. complicações – o doente em jejum ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],1 Sendelbach, S. (2010). Preoperative fasting doesnʼt mean nothing after midnight. The American journal of nursing , 110 (9), 64-5. doi: 10.1097/01.NAJ.0000388269.73122.3d.

5.1. complicações – o doente em jejum ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],1 Aguilar-Nascimento, J. E. D., Perrone, F., & Assunção Prado, L. Í. D. (2009). Jejum pré-operatório de 8 horas ou de 2 horas: o que revela a evidência? Revista do Colégio Brasileiro de Cirurgiões , 36 (4), 350-352. doi: 10.1590/S0100-69912009000400014.

5.1. complicações – o doente em jejum ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],1 Sutanto, L. B., Surani, S., Prasetyono, T. O. H., Syamsudin, E., Sugeng, A., & Muhidin, I. (2009). Role of Enteral Nutrition in Pre-operative Patients. Critical Care, 12(3), 95-99.

6. monitorização – qualidade? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],McClave, S. a, Martindale, R. G., Vanek, V. W., McCarthy, M., Roberts, P., Taylor, B., et al. (2009). 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. Journal of parenteral and enteral nutrition, 33(3), 277-316. doi: 10.1177/0148607109335234.

6. monitorização – qualidade? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],1 Weiner, B. J., Alexander, J. a, Shortell, S. M., Baker, L. C., Becker, M., & Geppert, J. J. (2006). Quality improvement implementation and hospital performance on quality indicators. Health services research , 41 (2), 307-34. doi: 10.1111/j.1475-6773.2005.00483.x.

7. Concluindo? Refletindo? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

8. bibliografia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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