Pdf aula 2014 cremerj haroldo - nutrição pré-operatória

FÓRUM DA CÂMARA TÉCNICA DE NUTROLOGIA DO CREMERJ

Terapia Nutricional em Cirurgia 13 de agosto de 2014

NUTRIÇÃO NO PRÉ-OPERATÓRIO: POR QUE INDICAR ?

A cirurgia eletiva é um trauma

com hora marcada

Alta Óbito

Scalpel by Patrick Morrison

Composição Corporal

Sistema Imune

Eixo Neuro- Endócrino- Metabólico

Desnutrição Associada à Doença

Modulação Imunológica

Modulação Metabólica




40

Sorensen et al. EuroOOPS: An interna0onal, mul0centre study to implement nutri0onal risk screening and evaluate clinical outcome Clin Nutr (2008);27:340-‐9

3 VS. 28% OR 13 OR 12

Alert by Joris Hoogendoom Cemetery by Hrag Chanchanian

Sorensen et al. EuroOOPS: An interna0onal, mul0centre study to implement nutri0onal risk screening and evaluate clinical outcome Clin Nutr (2008);27:340-‐9

DOENÇA PRIMÁRIA

TIPO DE COMPLICAÇÃO

ESTADO NUTRICIONAL

PROBABILIDADE DE COMPLICAÇÃO

:

Pacientes cirúrgicos

apresentam frequentemente

perda de peso, anorexia,

caquexia, neoplasias,

obstrução / disfunção de TGI.

28 44 22

Pac. Cirúrgicos (n=244) Desnutrição moderada a grave: 94 (39%)

Bruun et al., Clin Nutr 1999;18(3):141-147

IMC <20: Perda >5%

0

5

10

15

20

25

30

< 20% perda >20% perda

Vivos Mortos

Percentage of weight loss: a basic indicator of surgical risk in patients with chronic peptic ulcer. Studley HO, JAMA 1936; 106(6):458-460.

# Complicações 15% 40% Complics. graves 15% 54%

T. Internação 4d 10d

Risco Baixo Risco Alto

p<0.001 Schiesser, Clin Nutr 27(4):565-570, 2008

MUITO DADO SOBRE PREVALÊNCIA, MAS…

e sobre eficácia? Q.!

TNO TNE TNP

Keele et al. Gut (1997);40:393-9 Beattie et al. Gut (2000);46:813-8

TNO

Redução de complicações Maior força muscular (handgrip) Perda de peso & Antropometria Qualidade de vida

Cirúrgicos; VO vs. VO+TNO

0

15

30

45

60

COMPLICS (%) T. INTERNAÇÃO (d)

CONTROLE NUT. PRÉ-OP

N=1085, Cir. Abdominal, NRS >2 NE ou NPT, (7-10d pré-op >10kcal.kg-1.d-1)

Jie et al. Nutrition 2012

50,6%

26,5% (p=0,008)

17d 13d

(p=0,018)

NNT = 4

IMPACTO DO TRATAMENTO ÓBITO EVENTOS Ñ FATAIS

NNT < 25 Muito Grande Grande

NNT 25-50 Grande Moderado

NNT 50-100 Moderado Pequeno

Metformina vs. cuidado padrão – 14 AAS na prevenção de IAM não-fatal (1ano de uso) – 15 Estatina na prevenção secundária de IAM – 16 a 23

NNT = 4

NPT •  Bozzetti et al. JPEN 2000;24:7–14 •  90 pcs. CA gástrico e colônico •  NPT PRÉ-OP vs. Cuidado padrão. •  COMPLICS. – 37% VS. 57% – NÁO INFECCIOSAS: 12 VS. 34%), – NPT > LOS, – SEM NPT 5 MORTES.

Tempo mínimo 7 – 10d pré op.

Alert by Joris Hoogendoom









Modulação Imune

ARGININA

CITRULINA

Catabolismo

iONS ON

Arginase ORN PRO PoliN

Ochoa, Ann Surg, 2001

0

20

40

60

80

CTRL TRAUMA SEPSE

mM de Arginina plasmática

Plasma Intracellular Pribis – JPEN 2011 Zhu – JPEN 2011

O arginina participa das vias metabólicas envolvidas nos processos de proliferação, memória e função de linfócitos, cicatrização, vasodilatação (microcirculação)

AMINO ÁCIDO

CONDICIONALMENTE

ESSENCIAL ?

QUEDA DO NÍVEL SÉRICO =

ESTADO DE DEFICIÊNCIA ?

PROCESSOS BIOLÓGICOS SERIAM AFETADOS ?

Deficiência do macronutriente

Alteração Bioquímica

Alteração da Fisiologia

Repercussão clínica

Desfecho desfavorável Tratamento eficaz

THE YALE JOURNAL OF BIOLOGY AND MEDICINE 49, 175-195 (1976)

Causation and Disease:The Henle-Koch Postulates Revisited'

ALFRED S. EVANSWorld Health Organization Serum Reference Bank, Department of

Epidemiology and Public Health, Yale University School ofMedicine,333 Cedar Street, New Haven, Connecticut 06510

Received December 22, 1975

The Henle-Koch postulates are reviewed in terms of their full validity in Koch's day and inlight of subsequent developments. The changing guidelines developed for viral diseases, forviruses in relation to cancer and to chronic central nervous system infection, and for causativeagents in chronic diseases are discussed chronologically. A set of guidelines for both acute in-fectious and chronic diseases is presented. The need for recognizing the role of the host and thespectrum of host responses, for sound biologic sense in evaluating causal roles of agents indisease, and for flexibility in adapting our guidelines to new knowledge are emphasized.

For nearly 100 years the Henle-Koch postulates have been used as a referencepoint in evaluating the causal relationship of a new infectious agent to a clinicaldisease with which it is associated. The postulates have also served as a point of de-parture for many concepts of causation of chronic diseases. This paper will reviewchronologically the concepts as they were first presented and their evolution andshortcomings in the elements of causation attending viral infections, chronic disease,and cancer.

In 1840, Jakob Henle enunciated the concepts of causation in a book which hasbeen translated into English by Dr. George Rosen (1). Henle was then 31 years oldand just starting his duties as professor of anatomy in Zurich (Fig. 1).2 These con-cepts were further developed by Henle's pupil, Robert Koch (Fig. 2) and presentedas part of lectures in 1884 and 1890 (2, 3). The essence of the postulates is included inhis 1890 presentation before the International Congress in Berlin and is reproducedbelow in the original German:

Wenn es sich nun aber nachweisen liess: erstens, dass der Parasit in jedem einzelnen Falle derbetreffenden Krankheit anzutreffen ist, und zwar unter Verhaltnissen, welche den pathologischenVeranderungen und dem klinischen Verlauf der Krankheit entsprechen: zweitens, dass er bei keineranderen Krankheit als zufalliger und nicht pathogener Schmarotzer vorkommt; und drittens, dass er,von dem Korper vollkommen isolirt und in Reinculturen hinreichend oft umgezuchtet, im Stande ist,von Neuem die Krankheit zu erzeugen; dann konnte er nicht mehr zufalliges Accidens der Krankheitsein, sondern liess sich in diesem Falle kein anderes Verhaltnis mehr zwischen Parasit und Krankheitdenken, als dass der Parasit die Ursache der Krankheit ist.

Translated into English, the three basic concepts can be summarized as shown inTable 1. He concluded that, if all these conditions could be satisfied, then the "occur-

'The helpful criticism and encouragement in the preparation of this manuscript by Dr. Abraham Lilien-feld, Professor of Epidemiology, Johns Hopkins School of Hygiene and Public Health, is gratefully ac-knowledged. I also wish to thank Drs. Werner Henle, Robert Huebner, Richard Johnson, and AbrahamLilienfeld for their photographs and permission to include them.

This work was supported by grants from the National Cancer Institute (CA-12952) and the National In-stitute of Allergy and Infectious Diseases (AI0873 1).

2Henle was born in Furth, Germany, later the birthplace of Henry Kissinger.

175Copyright © 1976 by Academic Press, Inc.All rights of reproduction in any form reserved.

Arg w3 5nt

Substrato: ON, Orn, Pro (Ochoa, Ann Surg, 2001)

Precursor LT ímpar Mod. Arginase I (Bansal, JPEN 2005)

Síntese DNA/RNA Síntese de Arg (Yamauchi, Nutrition 2002)

Arg w3 5nt

Substrato: ON, Orn, Pro (Ochoa, Ann Surg, 2001)

Precursor LT ímpar Mod. Arginase I (Bansal, JPEN 2005)

Síntese DNA/RNA Síntese de Arg (Yamauchi, Nutrition 2002)

Drover et al. J Am Coll Surg (2011);212:385-‐99

•  CENÁRIOS

•  CIRURGIA ONCOLÓGICA TGI •  CABEÇA E PESCOÇO •  POLITRAUMA •  SEM SEPSE GRAVE

Marik, JPEN 2010;34:378-ss Waitzberg et al., 2006

Inf. Nosocomial Redução 38 – 61% OR 0,49 Ferida Cirúrgica Redução 9 – 60% OR 0,60

T. Internação - 3 dias $$$ complicação Aprox. -50%

Marimuthu et al Annals of Surgery ! Volume 255, Number 6, June 2012

FIGURE 2. Forest plot of comparison of immune modulating nutrition (IMN) and standard enteral diet for postoperative infectiouscomplications. M-H indicates Mantel-Haenszel method.

FIGURE 3. Forest plot comparison between immune modulating nutrition (IMN) and standard enteral diet for noninfectiouscomplications. M-H indicates Mantel-Haenszel method.

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

1064 | www.annalsofsurgery.com C⃝ 2012 Lippincott Williams & Wilkins

NNT Complicações infecciosas: 11

Marimuthu et al Annals of Surgery ! Volume 255, Number 6, June 2012

FIGURE 2. Forest plot of comparison of immune modulating nutrition (IMN) and standard enteral diet for postoperative infectiouscomplications. M-H indicates Mantel-Haenszel method.

FIGURE 3. Forest plot comparison between immune modulating nutrition (IMN) and standard enteral diet for noninfectiouscomplications. M-H indicates Mantel-Haenszel method.


1064 | www.annalsofsurgery.com C⃝ 2012 Lippincott Williams & Wilkins

NNT Não-infecciosas: 21

Annals of Surgery ! Volume 255, Number 6, June 2012 Immune Modulating Nutrition

FIGURE 4. Forest plot comparison for length of hospital stay between immune modulating nutrition (IMN) and standard enteraldiet. IV indicates Inverse Variance.

FIGURE 5. Forest plot comparison between immune modulating nutrition (IMN) and standard enteral diet for postoperativemortality. M-H indicates Mantel-Haenszel method.


C⃝ 2012 Lippincott Williams & Wilkins www.annalsofsurgery.com | 1065

Tempo de internação




Scalpel by Patrick Morrison Triathlon by James Fenton

ESTRESSE PRÉ-OPERATÓRIO

Resistência Insulínica

Proteólise Muscular

Disfunção Translocação Bacteriana

é Tempo de Internação ê Reabilitação

JEJUM Pós-absortivo, glicogênio (-), Ptn + Lipolise

SIRS Citocinas

& hormônios estressores

0

20

40

60

80

100

CVL Hernia CCA Colo-retal

SENSIBILIDADE À INSULINA

Thorell, A et al. Insulin resistance: a marker of surgical stress. Curr Opin Clin Nutr Metab Care, 1999. 2(1): p. 69-78.

-50

-40

-30

-20

-10

0 Glicose IV Glicose VO

CTRL INTERVENÇÃO

0

2

4

6

8

10

12

0h 4h 8h 12h 16h 20h 24h

Qua

ntid

ade

Inge

rida (

g) Jejum

CHO

Sham

Luttikhold, Clin Nutr 2013

CHO PRÉ-OP

Massa Muscular (Yuill, Clin Nutr 2005)

Função Muscular “Handrip” (Noblet, Colorect Dis, 2006)

Uso de inotrópico pós-CRVM (Anest Analg 2006)

Stress oxidativo (van Hoorn, 2005)

Reserva de ATP hepático e intestinal (van Hoorn 2005)

EFEITOS DA CARGA

DE CHO

Motilidade F(x) e massa musculares

Sede e Fome Náuseas e Dor Delirium e Ansiedade

Abordagem MULTI-MODAL

CARGA de CHO

CONCLUSÃO







TNO / TNE / TNP + tempo

Fórmula imunomoduladora

Carga CHO 2h pré-op

Pacientes em pré-op cir. abdominal de grande porte

Triagem NRS

Desnutrição moderada a grave

Cir Oncológica TGI alto

“Não” 2xPostergar cirurgia

VO / NE / NPT 14d pré-op

5 - 7 d pré-op Imunonutrição

Redução do tempo de jejum pré operatório Medidas para recuperação acelerada (ERAS, ACERTO, etc.)

Planejar acesso se jejum prologado ou aporte baixo for provável

a) jejum pos-op prolongado b) aporte insuficiente

c) Complicações peri-op / SIRSNE, NPE+TS e NPT Reinício de dieta VO

[email protected]

Isto tudo funciona ? Q.!

Indicadores: “duros” vs. substitutos

Estudos heterogêneos (I2 > 80%)

Mortalidade baixa: 2.6% (necessidade de # 103)

Magnifying glass by iconoci

Aporte Dietético

(2x10)

Composição Corporal &

Biomarcadores (2x20) Desfecho Clínico

Complicações Tempo de Internação

Qualidade de vida Custos

2 x 100-200

F(x) Orgânica Muscular

Imune, Mental

(2 x 40)

A Nutrição Pré-operatória…

•  …atua de forma múltipla: composição corporal, imunológica, metabólica.

•  …não se destina apenas a pacientes desnutridos;

•  ...melhora a qualidade da assistência, o desfecho clínico e os custos totais.

Health & Medicine

Pdf aula 2014 cremerj haroldo - nutrição pré-operatória