Complicações gastrointestinais pós-operatórias em cirurgias de grande porte

Abstract

Problems of the digestive tract are common manifestations in patients of major surgeries and there is evidence that they are associated with longer hospital stays and hospital mortality. Citrulline and intestinal fatty acid binding protein (I-FABP) have been postulated as possible markers of small bowel function and injury, but their clinical applications in the diagnosis and management of gastrointestinal tube dysfunction (DTGI) are still uncertain. Objectives: to evaluate the DTGI incidence with the AGI score and the impact on the length of hospital stay, other organ dysfunctions and death; and to know the role of TGI lesion biomarkers to improve the diagnosis and monitor its evolution. Methods: Prospective, observational and multicenter study. All non-cardiac surgical patients admitted to the intensive care units (ICU), within a period of 1 month, were evaluated and followed up until discharge from the ICU or for a maximum of 7 days, to determine complications. Mortality rates at 28 days postoperatively, in the ICU and in the hospital were assessed. Citrulline and I-FABP biomarkers were measured by ELISA and a possible correlation was verified with the presence of acute gastrointestinal injury (AGI), as defined by the European Society for Intensive Care Medicine, 2012. Results: 824 patients were involved and 77 patients were biomarkers (BM) of gastrointestinal injury were collected. AGI was identified in 40.3% of patients in the subgroup with BM and in 6.2% of patients in the General Group. In the BM subgroup, AGI level I was identified in 27.3%; AGI level II by 5.2%; AGI level III by 5.2%; and AGI level IV in 2.6% of patients. AGI patients were older (66 vs. 58 years, p = 0.046) and more severe according to SAPS 3 (49 [41-54] vs. 40 [34-50]). AGI patients had more organ dysfunctions using the SOFA score (5 [4-8] vs. 4 [2-5], p = 0.041), longer ICU stay (4 days [2-7 days] vs 2 days [2-3 days], p = 0.008) and hospital (10 days [8-20 days] vs. 7.5 days [4.8-12.5 days], p = 0.013), compared to patients without AGI. Cardiovascular (71% vs. 46%, p = 0.027) and renal or metabolic (55% vs. 28%, p = 0.019) complications were significantly more frequent in patients with AGI. Mortality rates in the ICU (19.4% vs. 0%) and hospital (22.6% vs. 2.17%) were significantly higher in the AGI group than in the group without AGI (p <0.05 for both). I-FABP values demonstrated good accuracy to discriminate AGI and sepsis. I-FABP and citrulline demonstrated moderate and good accuracy for death, respectively. In the multivariate analysis, urinary I-FABP and fluid balance were independent predictors of AGI (OR: 1.007; CI: 1.000-1.013; p = 0.005 and OR: 1.002; CI: 1.001-1.004; p = 0.000, respectively) and urinary I-FABP was a predictor of sepsis (OR: 1.005; CI: 1,000-1,010; p = 0.030). Conclusions: The occurrence of AGI is underestimated in ICUs, and is associated with factors such as older age, severity at the patient's admission, more positive fluid balance and worse outcomes. I-FABP and citrulline, particularly urinary I-FABP on the second day, were independent predictors of progression with AGI and sepsis.