Publication: Nutrición enteral en pacientes con inestabilidad hemodinámica en el curso posoperatorio de cirugía cardíaca
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2017-02-10
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Universidad Complutense de Madrid
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Abstract
La mayor parte de los pacientes intervenidos de cirugía cardíaca no requieren soporte nutricional artificial dado que son capaces de reiniciar la dieta oral en los 2-3 primeros días del posoperatorio. Sin embargo, algunos de estos pacientes presentan un posoperatorio inmediato complicado, requiriendo ventilación mecánica prolongada así como soporte hemodinámico farmacológico y/o mecánico por inestabilidad hemodinámica. Estos pacientes presentan frecuentemente una situación hipercatabólica y no pueden alimentarse por sí mismos durante periodos de al menos 5-7 días, aumentando de esta manera el riesgo de malnutrición. Esta situación, así como el desarrollo de balances energéticos negativos en el paciente crítico se asocia a varias complicaciones, aumentando en consecuencia la estancia hospitalaria y los costes. Además, la falta de nutrientes en la luz intestinal promueve la rotura de la barrera intestinal y puede favorecer la evolución hacia el síndrome de disfunción multiorgánica. La fisiopatología de la circulación esplácnica en estos pacientes es compleja, y permite explicar conceptos fundamentales como la hipoperfusión intestinal oculta. En el paciente ventilado mecánicamente, particularmente en aquellos pacientes más graves, la nutrición enteral (NE) administrada de forma precoz se correlaciona con una menor estancia hospitalaria y en la Unidad de Cuidados Intensivos (UCI), con una disminución de las complicaciones infecciosas, así como con una tendencia a una menor mortalidad en la UCI...
Most patients undergoing cardiac surgery do not require nutrition therapy since they are able to resume oral feeding within 2–3 days. However, in some of these patients, the postoperative course is more complicated, and prolonged mechanical ventilation as well as pharmacological and/or mechanical circulatory support are needed for hemodynamic failure. These patients are often hypercatabolic and are unable to ingest food for 5–7 days, thus increasing the risk of malnutrition. In critically ill patients this situation, as well as the development of negative energy balances, has been linked to several possible complications, prolonging hospital stay and elevating healthcare costs. Moreover, the lack of nutrients in the intestinal lumen promotes intestinal barrier disruption and may facilitate the development of multiple organ dysfunction syndrome. In such patients, the pathophysiology of the splanchnic circulation is a complex phenomenon which can explain key concepts as occult gut hypoperfusion. In mechanically ventilated patients, particularly the sickest patients, early enteral nutrition (EN) has been correlated with reductions in intensive care unit (ICU) and hospital stay, infectious complications, as well as a trend towards a lower mortality in the ICU. Nevertheless, EN is often contraindicated and is even considered dangerous in patients with circulatory failure because of the risk of splanchnic ischemia, a scarcely known and described but very serious complication. Thus, current american and european guidelines state that EN should be withheld in patients with circulatory compromise until they are fully resuscitated and/or hemodynamically stable...
Most patients undergoing cardiac surgery do not require nutrition therapy since they are able to resume oral feeding within 2–3 days. However, in some of these patients, the postoperative course is more complicated, and prolonged mechanical ventilation as well as pharmacological and/or mechanical circulatory support are needed for hemodynamic failure. These patients are often hypercatabolic and are unable to ingest food for 5–7 days, thus increasing the risk of malnutrition. In critically ill patients this situation, as well as the development of negative energy balances, has been linked to several possible complications, prolonging hospital stay and elevating healthcare costs. Moreover, the lack of nutrients in the intestinal lumen promotes intestinal barrier disruption and may facilitate the development of multiple organ dysfunction syndrome. In such patients, the pathophysiology of the splanchnic circulation is a complex phenomenon which can explain key concepts as occult gut hypoperfusion. In mechanically ventilated patients, particularly the sickest patients, early enteral nutrition (EN) has been correlated with reductions in intensive care unit (ICU) and hospital stay, infectious complications, as well as a trend towards a lower mortality in the ICU. Nevertheless, EN is often contraindicated and is even considered dangerous in patients with circulatory failure because of the risk of splanchnic ischemia, a scarcely known and described but very serious complication. Thus, current american and european guidelines state that EN should be withheld in patients with circulatory compromise until they are fully resuscitated and/or hemodynamically stable...
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Tesis inédita de la Universidad Complutense de Madrid, Facultad de Medicina, Departamento de Cirugía, leída el 17-09-2015