Fallo intestinal en el paciente crítico
Reconocimiento, abordaje multidisciplinario y unidades dedicadas
DOI:
https://doi.org/10.29193/RMU.37.2.8Palabras clave:
FALLO INTESTINAL, DISFUNCIÓN INTESTINAL, ENFERMEDADES INTESTINALES, UNIDADES DE CUIDADOS INTENSIVOSResumen
Introducción: en el paciente crítico el intestino es protagonista de la respuesta al estrés. Los síntomas de insuficiencia intestinal en las unidades de cuidados intensivos no son específicos y no se incluyen en escalas de gravedad comúnmente usadas, sin embargo, el 62% de los pacientes críticos presenta síntomas gastrointestinales al menos una vez al día. Demostrándose la relación existente entre la aparición de problemas gastrointestinales y la mortalidad en pacientes críticos.
Objetivo: proporcionar el conocimiento teórico necesario sobre el fallo intestinal como entidad exclusiva, su reconocimiento en el paciente grave, clasificación y enfoque multidisciplinario del tratamiento.
Métodos: se realizó una revisión cualitativa y sistemática en los idiomas inglés y español de la literatura publicada y actualizada hasta febrero del 2020.
Conclusiones: las alteraciones gastrointestinales son frecuentes en el paciente crítico y un determinante en su mortalidad. Reconocer el fallo y disfunción intestinal permite optimizar el tratamiento, reducir la mortalidad e incidencia de complicaciones, las unidades dedicadas con un equipo de experiencia en el manejo del fallo intestinal agudo constituyen un aspecto clave en este sentido.
Citas
1) Sánchez AC, Espinosa BL, Martínez LAF. Fallo gastrointestinal agudo en el paciente crítico. Nutr Clín Med 2017; 11(2):59-73.Disponible: http://www.aulamedica.es/nutricionclinicamedicina/pdf/5050.pdfMont (Consulta: 26 octubre 2019).
2) Salvo-Romero E, Alonso Cotoner C, Pardo Camacho C, Casado Bedmar M, Vicario M. The intestinal barrier function and its involvement in digestive disease. Rev Esp Enferm Dig 2015; 107(11):686-96. Disponible en: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-1082015001100007&lng=es (Consulta: 16 febrero 2019).
3) Andoh A. Physiological role of gut microbiota for maintaining human health. Digestion 2016; 93(3):176-81.
4) Berg G, Rybakova D, Fischer F, Cernava T, Vergès M-CC, Charles T, et al. Microbiome definition re-visited: old concepts and new challenges. Microbiome 2020; 8:103.
5) Klingensmith NJ, Coopersmith CM. The gut as the motor of multiple organ dysfunction in critical illness. Crit Care Clin 2016; 32(2):203-12.
6) Ritz MA, Fraser R, Tam W, Dent J. Impacts and patterns of disturbed gastrointestinal function in critically ill patients. Am J Gastroenterol 2000; 95(11):3044-52.
7) Reintam Blaser A, Poeze M, Malbrain ML, Björck M, Oudemans-van Straaten HM, Starkopf J; Gastro-Intestinal Failure Trial Group. Gastrointestinal symptoms during the first week of intensive care are associated with poor outcome: a prospective multicentre study. Intensive Care Med 2013; 39(5):899-909.
8) Pironi L, Arends J, Baxter J, Bozzetti F, Peláez RB, Cuerda C, et al; Home Artificial Nutrition & Chronic Intestinal Failure; Acute Intestinal Failure Special Interest Groups of ESPEN. ESPEN endorsed recommendations. Definition and classification intestinal of failure in adults. Clin Nut 2015; 34:171-80.
9) Pironi L, Arends J, Bozzetti F, Cuerda C, Gillanders L, Jeppesen PB, et al. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr 2016; 35:247-307.
10) Lal S, Teubner A, Shaffer JL. Review article: intestinal failure. Aliment Pharmacol Ther 2006; 24:19-31.
11) Reintam Blaser AR, Malbrain ML, Starkopf J, Fruhwald S, De Waele J, Braun JP. Gastrointestinal function in intensive care patients: terminology, definitions and management. Recommendations of the ESICM working group on abdominal problems. Intensive Care Med 2012; 38(3):384-94.
12) Balogh ZJ, Lumsdaine W, Moore EE, Moore FA. Postinjury abdominal compartment syndrome: from recognition to prevention. Lancet 2014; 384(9952):1466-75.
13) Kirkpatrick AW, Roberts DJ, De Waele J, Jaeschke R, Malbrain ML, De Keulenaer B, et al; Pediatric Guidelines Sub-Committee for the World Society of the Abdominal Compartment Syndrome. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med 2013; 39(7):1190-206.
14) Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 2019; 38(1):48-79.
15) Iyer KR. Surgical management of short bowel syndrome. JPEN J Parenter Enteral Nutr 2014; 38(1 Suppl):53S-59S.
16) Bechtold ML, McClave SA, Palmer LB, Nguyen DL, Urben LM, Martindale RG, et al. The pharmacologic treatment of short bowel syndrome: new tricks and novel agents. Curr Gastroenterol Rep 2014; 16(7):392.
17) Crenn P, Messing B, Cynober L. Citrulline as a biomarker of intestinal failure due to enterocyte mass reduction. Clin Nutr 2008; 27(3):328-39.
18) López-Tejero MD, Virgili N, Targarona J, Ruiz J, García N, Oró D, et al. Apo AIV and citrulline plasma concentrations in short bowel syndrome patients: the influence of short bowel anatomy. PLoS One 2016; 11(9):e0163762.
19) Barzal JA, Szczylik C, Rzepecki P, Jaworska M, Anuszewska E. Plasma citrulline level as a biomarker for cancer therapy-induced small bowel mucosal damage. Acta Biochim Pol 2014; 61(4):615-31.
20) Crenn P, Coudray-Lucas C, Thuillier F, Cynober L, Messing B. Postabsorptive plasma citrulline concentration is a marker of absorptive enterocyte mass and intestinal failure in humans. Gastroenterology 2000; 119(6):1496-505.
21) Cadena ME, Vinck EE, Santivañez JJ, Gómez AV. Biomarkers for intestinal failure in short bowel syndrome: a new era in GI rehabilitation?. Rev Colomb Cir 2019; 34(3):277-82.Disponible en: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S2011-75822019000300277&lng=en (Consulta: 16 febrero 2020).
22) Klek S, Forbes A, Gabe S, Holst M, Wanten G, Irtun O, et al. Management of acute intestinal failure: a position paper from the european society for clinical nutrition and metabolism (ESPEN) Special Interest Group. Clin Nutr 2016; 35(6):1209-18.
23) Adaba F, Vaizey CJ, Warusavitarne J. Management of intestinal failure: the high-output enterostomy and enterocutaneous fistula. Clin Colon Rectal Surg 2017; 30(3):215-22.
24) Malbrain ML, Langer T, Annane D, Gattinoni L, Elbers P, Hahn RG, et al. Intravenous fluid therapy in the perioperative and critical care setting: executive summary of the International Fluid Academy (IFA). Ann Intensive Care 2020; 24:10(1):64. doi: 10.1186/s13613-020-00679-3.
25) Malbrain ML, Van Regenmortel N, Saugel B, De Tavernier B, Van Gaal PJ, Joannes-Boyau O, et al. Principles of fluid management and stewardship in septic shock: it is time to consider the four D’s and the four phases of fluid therapy. Ann Intensive Care. 2018; 8(1):66.
26) Pironi L, Corcos O, Forbes A, Holst M, Joly F, Jonkers C, et al; ESPEN Acute and Chronic Intestinal Failure Special Interest Groups. intestinal failure in adults: recommendations from the ESPEN expert groups. Clin Nutr 2018; 37(6 Pt A):1798-1809.
27) Campos AC, Andrade DF, Campos GM, Matias JE, Coelho JC. An multivariate model to determine prognostic factors in gastrointestinal fistulas. J Am Coll Surg 1999; 188(5):483- 90.
28) Gribovskaja-Rupp I, Melton GB. Enterocutaneous fistula: proven strategies and updates. Clin Colon Rectal Surg 2016; 29(2):130-7.
29) Taylor BE, McClave SA, Martindale RG, Warren MM, Johnson DR, Braunschweig C, et al. 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.). Crit Care Med 2016; 44:390-438.
30) Thibault R, Picot D. Chyme reinfusion or enteroclysis in nutrition of patients with temporary double enterostomy or enterocutaneous fistula. Curr Opin Clin Nutr Metab Care 2016; 19(5):382-7.
31) Casaer MP, Mesotten D, Hermans G, Wouters PJ, Schetz M, Meyfroidt G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011; 365:506e17.
32) Heidegger CP, Berger MM, Graf S, Zingg W, Darmon P, Costanza MC, et al. Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial. Lancet 2013; 381:385e93.
33) Doig GS, Simpson F, Sweetman EA, Finfer SR, Cooper DJ, Heighes PT, et al; Early PN Investigators of the ANZICS Clinical Trials Group. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial. JAMA 2013; 309:2130-8.
34) Allingstrup MJ, Kondrup J, Wiis J, Claudius C, Pedersen UG, Hein-Rasmussen R, et al. Early goal-directed nutrition versus standard of care in adult intensive care patients: the single-centre, randomised, outcome assessor-blinded EAT-ICU trial. Intensive Care Med 2017; 43:1637-47.
35) Ashkenazi I, Turégano-Fuentes F, Olsha O, Alfici R. Treatment options in gastrointestinal cutaneous fistulas. Surg J (N Y) 2017; 3(1):e25-e31.
36) Datta V, Engledow A, Chan S, Forbes A, Cohen CR, Windsor A. The management of enterocutaneous fistula in a regional unit in the United Kingdom: a prospective study. Dis Colon Rectum 2010; 53(2):192-9.
37) Goulet O, Dabbas-Tyan M, Talbotec C, Kapel N, Rosilio M, Souberbielle JC, et al. Effect of recombinant human growth hormone on intestinal absorption and body composition in children with short bowel syndrome. JPEN J Parenter Enteral Nutr 2010; 34(5):513-20.
38) Naberhuis JK, Tappenden KA. Teduglutide for safe reduction of parenteral nutrient and/or fluid requirements in adults: a systematic review. J Parenter Enter Nutr 2016; 40(8): 1096-05.
39) Jeppesen PB, Gilroy R, Pertkiewicz M, Allard JP, Messing B, O’Keefe SJ. Randomised placebo-controlled trial of teduglutide in reducing parenteral nutrition and/or intravenous fluid requirements in patients with short bowel syndrome. Gut 2011; 60(7):902-14.
40) Schwartz LK, O’Keefe SJ, Fujioka K, Gabe SM, Lamprecht G, Pape UF, et al. Long-term teduglutide for the treatment of patients with intestinal failure associated with short bowel syndrome. Clin Transl Gastroenterol 2016; 7(2):e142.
41) Martínez MI, Rumbo C, García D, Trentadue J, Gondolesi G, Fernández A. Experiencia con el uso de teduglutide en pacientes pediátricos con fallo intestinal en un centro de Argentina. Acta Gastroenterol Latinoam 2020; 50(3):257-63.
42) Kumar P. Classification of negative pressure wound therapy. Plast Aesthet Res 2019; 6:32.
43) Bobkiewicz A, Walczak D, Smolinski S, Kasprzyk T, Studniarek A, Borejsza-Wysocki M, et al. Management of enteroatmospheric fistula with negative pressure wound therapy in open abdomen treatment: a multicentre observational study. Int Wound J 2017; 14(1):255-64.
44) Haack CI, Galloway JR, Srinivasan J. Enterocutaneous fistulas: a look at causes and management. Appl Phys B 2014; 2(10):1-10.
2) Salvo-Romero E, Alonso Cotoner C, Pardo Camacho C, Casado Bedmar M, Vicario M. The intestinal barrier function and its involvement in digestive disease. Rev Esp Enferm Dig 2015; 107(11):686-96. Disponible en: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-1082015001100007&lng=es (Consulta: 16 febrero 2019).
3) Andoh A. Physiological role of gut microbiota for maintaining human health. Digestion 2016; 93(3):176-81.
4) Berg G, Rybakova D, Fischer F, Cernava T, Vergès M-CC, Charles T, et al. Microbiome definition re-visited: old concepts and new challenges. Microbiome 2020; 8:103.
5) Klingensmith NJ, Coopersmith CM. The gut as the motor of multiple organ dysfunction in critical illness. Crit Care Clin 2016; 32(2):203-12.
6) Ritz MA, Fraser R, Tam W, Dent J. Impacts and patterns of disturbed gastrointestinal function in critically ill patients. Am J Gastroenterol 2000; 95(11):3044-52.
7) Reintam Blaser A, Poeze M, Malbrain ML, Björck M, Oudemans-van Straaten HM, Starkopf J; Gastro-Intestinal Failure Trial Group. Gastrointestinal symptoms during the first week of intensive care are associated with poor outcome: a prospective multicentre study. Intensive Care Med 2013; 39(5):899-909.
8) Pironi L, Arends J, Baxter J, Bozzetti F, Peláez RB, Cuerda C, et al; Home Artificial Nutrition & Chronic Intestinal Failure; Acute Intestinal Failure Special Interest Groups of ESPEN. ESPEN endorsed recommendations. Definition and classification intestinal of failure in adults. Clin Nut 2015; 34:171-80.
9) Pironi L, Arends J, Bozzetti F, Cuerda C, Gillanders L, Jeppesen PB, et al. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr 2016; 35:247-307.
10) Lal S, Teubner A, Shaffer JL. Review article: intestinal failure. Aliment Pharmacol Ther 2006; 24:19-31.
11) Reintam Blaser AR, Malbrain ML, Starkopf J, Fruhwald S, De Waele J, Braun JP. Gastrointestinal function in intensive care patients: terminology, definitions and management. Recommendations of the ESICM working group on abdominal problems. Intensive Care Med 2012; 38(3):384-94.
12) Balogh ZJ, Lumsdaine W, Moore EE, Moore FA. Postinjury abdominal compartment syndrome: from recognition to prevention. Lancet 2014; 384(9952):1466-75.
13) Kirkpatrick AW, Roberts DJ, De Waele J, Jaeschke R, Malbrain ML, De Keulenaer B, et al; Pediatric Guidelines Sub-Committee for the World Society of the Abdominal Compartment Syndrome. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med 2013; 39(7):1190-206.
14) Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 2019; 38(1):48-79.
15) Iyer KR. Surgical management of short bowel syndrome. JPEN J Parenter Enteral Nutr 2014; 38(1 Suppl):53S-59S.
16) Bechtold ML, McClave SA, Palmer LB, Nguyen DL, Urben LM, Martindale RG, et al. The pharmacologic treatment of short bowel syndrome: new tricks and novel agents. Curr Gastroenterol Rep 2014; 16(7):392.
17) Crenn P, Messing B, Cynober L. Citrulline as a biomarker of intestinal failure due to enterocyte mass reduction. Clin Nutr 2008; 27(3):328-39.
18) López-Tejero MD, Virgili N, Targarona J, Ruiz J, García N, Oró D, et al. Apo AIV and citrulline plasma concentrations in short bowel syndrome patients: the influence of short bowel anatomy. PLoS One 2016; 11(9):e0163762.
19) Barzal JA, Szczylik C, Rzepecki P, Jaworska M, Anuszewska E. Plasma citrulline level as a biomarker for cancer therapy-induced small bowel mucosal damage. Acta Biochim Pol 2014; 61(4):615-31.
20) Crenn P, Coudray-Lucas C, Thuillier F, Cynober L, Messing B. Postabsorptive plasma citrulline concentration is a marker of absorptive enterocyte mass and intestinal failure in humans. Gastroenterology 2000; 119(6):1496-505.
21) Cadena ME, Vinck EE, Santivañez JJ, Gómez AV. Biomarkers for intestinal failure in short bowel syndrome: a new era in GI rehabilitation?. Rev Colomb Cir 2019; 34(3):277-82.Disponible en: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S2011-75822019000300277&lng=en (Consulta: 16 febrero 2020).
22) Klek S, Forbes A, Gabe S, Holst M, Wanten G, Irtun O, et al. Management of acute intestinal failure: a position paper from the european society for clinical nutrition and metabolism (ESPEN) Special Interest Group. Clin Nutr 2016; 35(6):1209-18.
23) Adaba F, Vaizey CJ, Warusavitarne J. Management of intestinal failure: the high-output enterostomy and enterocutaneous fistula. Clin Colon Rectal Surg 2017; 30(3):215-22.
24) Malbrain ML, Langer T, Annane D, Gattinoni L, Elbers P, Hahn RG, et al. Intravenous fluid therapy in the perioperative and critical care setting: executive summary of the International Fluid Academy (IFA). Ann Intensive Care 2020; 24:10(1):64. doi: 10.1186/s13613-020-00679-3.
25) Malbrain ML, Van Regenmortel N, Saugel B, De Tavernier B, Van Gaal PJ, Joannes-Boyau O, et al. Principles of fluid management and stewardship in septic shock: it is time to consider the four D’s and the four phases of fluid therapy. Ann Intensive Care. 2018; 8(1):66.
26) Pironi L, Corcos O, Forbes A, Holst M, Joly F, Jonkers C, et al; ESPEN Acute and Chronic Intestinal Failure Special Interest Groups. intestinal failure in adults: recommendations from the ESPEN expert groups. Clin Nutr 2018; 37(6 Pt A):1798-1809.
27) Campos AC, Andrade DF, Campos GM, Matias JE, Coelho JC. An multivariate model to determine prognostic factors in gastrointestinal fistulas. J Am Coll Surg 1999; 188(5):483- 90.
28) Gribovskaja-Rupp I, Melton GB. Enterocutaneous fistula: proven strategies and updates. Clin Colon Rectal Surg 2016; 29(2):130-7.
29) Taylor BE, McClave SA, Martindale RG, Warren MM, Johnson DR, Braunschweig C, et al. 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.). Crit Care Med 2016; 44:390-438.
30) Thibault R, Picot D. Chyme reinfusion or enteroclysis in nutrition of patients with temporary double enterostomy or enterocutaneous fistula. Curr Opin Clin Nutr Metab Care 2016; 19(5):382-7.
31) Casaer MP, Mesotten D, Hermans G, Wouters PJ, Schetz M, Meyfroidt G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011; 365:506e17.
32) Heidegger CP, Berger MM, Graf S, Zingg W, Darmon P, Costanza MC, et al. Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial. Lancet 2013; 381:385e93.
33) Doig GS, Simpson F, Sweetman EA, Finfer SR, Cooper DJ, Heighes PT, et al; Early PN Investigators of the ANZICS Clinical Trials Group. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial. JAMA 2013; 309:2130-8.
34) Allingstrup MJ, Kondrup J, Wiis J, Claudius C, Pedersen UG, Hein-Rasmussen R, et al. Early goal-directed nutrition versus standard of care in adult intensive care patients: the single-centre, randomised, outcome assessor-blinded EAT-ICU trial. Intensive Care Med 2017; 43:1637-47.
35) Ashkenazi I, Turégano-Fuentes F, Olsha O, Alfici R. Treatment options in gastrointestinal cutaneous fistulas. Surg J (N Y) 2017; 3(1):e25-e31.
36) Datta V, Engledow A, Chan S, Forbes A, Cohen CR, Windsor A. The management of enterocutaneous fistula in a regional unit in the United Kingdom: a prospective study. Dis Colon Rectum 2010; 53(2):192-9.
37) Goulet O, Dabbas-Tyan M, Talbotec C, Kapel N, Rosilio M, Souberbielle JC, et al. Effect of recombinant human growth hormone on intestinal absorption and body composition in children with short bowel syndrome. JPEN J Parenter Enteral Nutr 2010; 34(5):513-20.
38) Naberhuis JK, Tappenden KA. Teduglutide for safe reduction of parenteral nutrient and/or fluid requirements in adults: a systematic review. J Parenter Enter Nutr 2016; 40(8): 1096-05.
39) Jeppesen PB, Gilroy R, Pertkiewicz M, Allard JP, Messing B, O’Keefe SJ. Randomised placebo-controlled trial of teduglutide in reducing parenteral nutrition and/or intravenous fluid requirements in patients with short bowel syndrome. Gut 2011; 60(7):902-14.
40) Schwartz LK, O’Keefe SJ, Fujioka K, Gabe SM, Lamprecht G, Pape UF, et al. Long-term teduglutide for the treatment of patients with intestinal failure associated with short bowel syndrome. Clin Transl Gastroenterol 2016; 7(2):e142.
41) Martínez MI, Rumbo C, García D, Trentadue J, Gondolesi G, Fernández A. Experiencia con el uso de teduglutide en pacientes pediátricos con fallo intestinal en un centro de Argentina. Acta Gastroenterol Latinoam 2020; 50(3):257-63.
42) Kumar P. Classification of negative pressure wound therapy. Plast Aesthet Res 2019; 6:32.
43) Bobkiewicz A, Walczak D, Smolinski S, Kasprzyk T, Studniarek A, Borejsza-Wysocki M, et al. Management of enteroatmospheric fistula with negative pressure wound therapy in open abdomen treatment: a multicentre observational study. Int Wound J 2017; 14(1):255-64.
44) Haack CI, Galloway JR, Srinivasan J. Enterocutaneous fistulas: a look at causes and management. Appl Phys B 2014; 2(10):1-10.
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Publicado
2021-06-10
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1.
Agüero A, Infante K. Fallo intestinal en el paciente crítico: Reconocimiento, abordaje multidisciplinario y unidades dedicadas. Rev. Méd. Urug. [Internet]. 10 de junio de 2021 [citado 21 de diciembre de 2024];37(2):e37209. Disponible en: https://revista.rmu.org.uy/index.php/rmu/article/view/710
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