Estabelecimento de critérios para posicionamento e reposicionamento da sonda de alimentação em pacientes adultos em estado crítico

Abstract

Background: The administration of enteral diets by feeding tube is a procedure often indicated for feeding critically ill patients. The difficulties associated with obtaining the post-pyloric positioning of the feeding tube, on many occasions impairs the early administration of the enteral diet and contributes to the onset and / or aggravation of nutritional deficiencies. The objectives of the study were to elaborate protocols establishing criteria for positioning and repositioning the end of the feeding tube in critically ill patients, submitted to mechanical ventilation (MV), hospitalized in the Adult Intensive Care Unit (ICU) of a University Hospital. Materials and Methods: Observational and longitudinal study, developed from March 2015 to December 2017. Critically ill patients (n=75), aged ≥ 20 years, of both sexes, in MV, administered an enteral diet after admission to the ICU. In Phase 1, the patients were evaluated in relation to the usual nutritional therapy practices (PH-TN), adopted in the ICU. Through specific forms, information regarding the risk of bronchoaspiration was recorded; frequency of gastrointestinal intolerance; parameters of enteral nutritional therapy; periods of ICU and hospital stay; positioning and repositioning of the feeding tube; and mortality rate. In Phase 2, protocols were developed for positioning and repositioning the tip of the feeding tube for critically ill adult patients submitted to mechanical ventilation, and at the same time training professionals from the ICU Health Team in relation to the established protocols. Results: The majority of the patients were male (n=51, 68% of the sample) with a mean age of 45.1 ± 17.3 years, and admission diagnosis for head trauma (p=0.057). All patients evaluated by NRS-2002 (p=0.538) were classified as at nutritional risk. The mean SAPS 3 score was similar between male and female patients (p=0.485). No differences were identified in the medians of the follow-up period in the study (p=0.672); period of mechanical ventilation (p=0.749), ICU stay (p=0.425); and hospital admission (p=0.917), among patients with a gastric or post-pyloric feeding tube. Deaths were registered exclusively for patients with post-pyloric positioning of the tube (n=20; 28.6%). After initiation of the enteral diet, a lower frequency of gastrointestinal intolerance was demonstrated for patients with gastric tube (p=0.013). Diet administration increased the risk of bronchoaspiration independently of the positioning site of the tube tip. Patients with tube in the gastric position had a higher total fasting period (p=0.000). The energy provision (p=1,000) and protein (p=0.593) were similar between the two evaluated groups. The inadvertent deposition of the probe tip was the main reason for repositioning the tube. Conclusion: The lower frequency of gastrointestinal intolerance and the non-occurrence of deaths indicate greater benefits with the gastric positioning of the feeding tube for critically ill patients. The increase in the fasting period between patients with gastric positioning of the feeding tube and the risk of bronchoaspiration among all critically ill patients illustrates the need for new studies concerning the specific investigation of these issues.