Información del artículo
Resumen
El reflujo gastroesofágico (RGE) es uno de los principales factores de riesgo para la neumonía nosocomial, especialmente en pacientes bajo ventilación mecánica. En el ámbito clínico de la vida real, la identificación de las causas del RGE implica una complejidad diagnóstica indiscutible, que varía a medida que el paciente está bajo el cuidado crítico. El RGE es potencialmente modificable en estos pacientes, pero las intervenciones terapéuticas exigen la consideración de un diagnóstico integral de sus causas. La analogía del «pozo de petróleo» es una conceptualización integral de las causas de RGE que puede ser útil para mejorar y agilizar el proceso diagnóstico y terapéutico en pacientes críticamente enfermos. El tratamiento simple habitual de un procinético y/o antiácido aparenta ser insuficiente. Los pacientes pueden requerir y beneficiarse de estrategias adicionales específicas, diferenciales e inclusive cambiantes en el tiempo según cada caso y su evolución. La analogía del pozo de petróleo facilita el ejercicio diagnóstico multifactorial, resalta el carácter dinámico de dichas causas de RGE, y en consecuencia permite orientar la terapéutica de forma individualizada e igualmente dinámica en cada paciente.
Palabras clave:
Reflujo gastroesofágico
Ventilación mecánica
Neumonía
Prevención
Cuidados intensivos
Abstract
Gastroesophageal reflux (GER) is one of the major risk factors for nosocomial pneumonia, mainly in patients on mechanical ventilation. In a “real life” setting, identifying the causes of GER involves an indisputable diagnostic complexity, which varies as the patient is under critical care. The “oil well” analogy is a comprehensive conceptualisation of the causes of GER, which is potentially modifiable in these patients, although therapeutic interventions require a comprehensive assessment of its causes. The analogy appears to be useful to improve and expedite the diagnostic and therapeutic process in critically ill patients. The simple usual prokinetic and/or antacid treatment appears to be insufficient. Patients may require and benefit from specific, differential, and additional strategies that change with the time according to each case and its progression. The oil well analogy is an aid to the multifactorial diagnosis, and highlights the dynamic nature of these causes of GER, thus allowing the clinicians to offer therapeutic target both individually and dynamically in each patient.
Keywords:
Gastroesophageal reflux
Mechanical ventilation
Pneumonia
Prevention
Intensive care
Artículo
Opciones para acceder a los textos completos de la publicación Acta Colombiana de Cuidado Intensivo
Suscriptor
Comprar
Contactar
Teléfono para suscripciones e incidencias
De lunes a viernes de 9h a 18h (GMT+1) excepto los meses de julio y agosto que será de 9 a 15h
Llamadas desde España
932 415 960
Llamadas desde fuera de España
+34 932 415 960
E-mail
Bibliografía
[1]
P. Cantù, D. Savojardo, S. Carmagnola, R. Penagini.
Impact of referral for gastro-oesophageal reflux disease on the workload of an academic Gastroenterology Unit.
Dig Liver Dis., 37 (2005), pp. 735-740
[2]
R.C. Orlando.
Overview of the mechanisms of gastroesophageal reflux.
Am J Med., 111 (2001), pp. 174S-177S
[3]
F. Pace, G. Bianchi Porro.
Gastroesophageal reflux disease: a typical spectrum disease (a new conceptual framework is not needed).
Am J Gastroenterol., 99 (2004), pp. 946-949
[4]
G. Nind, W.H. Chen, R. Protheroe, K. Iwakiri, R. Fraser, R. Young, et al.
Mechanisms of gastroesophageal reflux in critically ill mechanically ventilated patients.
Gastroenterology, 128 (2005), pp. 600-606
[5]
V. Stanghellini, R. Cogliandro, L. Cogliandro, R. De Giorgio, G. Barbara, R. Corinaldesi.
Unsolved problems in the management of patients with gastric-oesophageal reflux disease.
Dig Liver Dis., 35 (2003), pp. 843-848
[6]
N.A. Metheny, M.E. Schallom, S.H. Edwards.
Effect of gastrointestinal motility and feeding tube site on aspiration risk in critically ill patients: a review.
Heart Lung., 33 (2004), pp. 131-145
[7]
J.M. Saxe, A.M. Ledgerwood, C.E. Lucas, W.F. Lucas.
Lower easophageal sphincter dysfunction precludes safe gastric feeding after head injury.
J Trauma., 37 (1994), pp. 581-584
[8]
M.B. Drakulovic, A. Torres, T.T. Bauer, J.M. Nicolas, S. Nogué, M. Ferrer.
Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial.
Lancet., 354 (1999), pp. 1851-1858
[9]
N.A. Metheny.
Risk factors for aspiration.
JPEN J Parenter Enteral Nutr., 26 (2002), pp. S26-S31
[10]
A. Dive, M. Moulart, P. Jonard, J. Jamart, P. Mahieu.
Gastroduodenal motility in mechanically ventilated critically ill patients: a manometric study.
Crit Care Med., 22 (1994), pp. 441-447
[11]
P. Frost, N. Edwards, D. Bihari.
Gastric emptying in the critically ill - the way forward?.
Intensive Care Med., 23 (1997), pp. 243-245
[12]
D.R. Goldhill, C.C. Toner, M.M. Tarling, K. Baxter, P.S. Withington, R. Whelpton.
Double-blind, randomized study of the effect of cisapride on gastric emptying in critically ill patients.
Crit Care Med., 25 (1997), pp. 447-451
[13]
P.E. Marik.
Aspiration pneumonitis and aspiration pneumonia.
N Engl J Med., 344 (2001), pp. 665-671
[14]
R. Avrahami, J.D. Cohen, M. Haddad, P. SinGOR, A. Zelikovski.
Gastric emptying after elective abdominal aortic aneurysm surgery: the case for early postoperative enteral feeding.
Eur J Vasc Endovasc Surg., 17 (1999), pp. 241-244
[15]
H.R. Collard, S. Saint, M.A. Matthay.
Prevention of ventilator-associated pneumonia: an evidence-based systematic review.
Ann Intern Med., 138 (2003), pp. 494-501
[16]
A. Hauenschild, H. Schnell-Kretschmer, J. Teichmann, P.D. Hardt, B. Santosa, D. Reiter, et al.
Prospective evaluation of novel system for jejunal feeding.
Surg Endosc., 17 (2003), pp. 452-456
[17]
D.K. Heyland, E. Konopad, C. Alberda, L. Keefe, C. Cooper, B. Cantwell.
How well do critically ill patients tolerate early, intragastric enteral feeding?. Results of a prospective, multicenter trial.
Nutr Clin Pract., 14 (1999), pp. 23-28
[18]
D.H. Rhoney, D. Parker Jr., C.M. Formea, C. Yap, W.M. Coplin.
Tolerability of bolus versus continuous gastric feeding in brain-injured patients.
Neurol Res., 24 (2002), pp. 613-620
[19]
T. Garrick, S. Mulvihill, S. Buack, M. Maeda-Hagiwara, Y. Tache.
Intracerebroventricular pressure inhibits gastric antral and duodenal contractility but not acid secretion in conscious rabbits.
Gastroenterology., 95 (1988), pp. 26-31
[20]
A. Chendrasekhar.
Jejunal feeding in the absence of reflux increases nasogastric output in critically ill trauma patients.
Am Surg., 62 (1996), pp. 887-888
[21]
A.R. Davies, P.R. Froomes, C.J. French, R. Bellomo, G.A. Gutteridge, I. Nyulasi, et al.
Randomized comparison of nasojejunal and nasogastric feeding in critically ill patients.
Crit Care Med., 30 (2002), pp. 586-590
[22]
N.E. Schindlbeck, M. Lippert, C. Heinrich, S.A. Muller-Lissner.
Intragastric bile acid concentrations in critically ill, artificially ventilated patients.
Am J Gastroenterol., 84 (1989), pp. 624-628
[23]
R.J. Phillips, E.K. Walls, T.L. Powley.
Duodenogastric reflux of intestinal infusions in rats is volume dependent.
Appetite., 27 (1996), pp. 79-90
[24]
C.B. Carlin, P.H. Scanlon, D.A. Wagner, L. Borghesi, J.W. Geiger, C.L. Long.
Gastric emptying in trauma patients.
Dig Surg., 16 (1999), pp. 192-196
[25]
M.T. DeMeo, K. Bruninga.
Physiology of the aerodigestive system and aberrations in that system resulting in aspiration.
JPEN J Parenter Enteral Nutr., 26 (2002), pp. S9-S17
[26]
A. Dive, F. Foret, J. Jamart, P. Bulpa, E. Installé.
Effect of dopamine on gastrointestinal motility during critical illness.
Intensive Care Med., 26 (2000), pp. 901-907
[27]
W. Meissner, B. Dohrn, K. Reinhart.
Enteral naloxone reduces gastric tube reflux and frequency of pneumonia in critical care patients during opioid analgesia.
Crit Care Med., 31 (2003), pp. 776-780
[28]
D.K. Heyland, J.W. Drover, R. Dhaliwal, J. Greenwood.
Optimizing the benefits and minimizing the risks or enteral nutrition in the critically ill: role of small bowel feeding.
JPEN J Parenter Enteral Nutr, 26 (2002), pp. S51-S55
[29]
P.J. Kearns, D. Chin, L. Mueller, K. Wallace, W.A. Jensen, C.M. Kirsch.
The incidence of ventilator-associated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: a randomized clinical trial.
Crit Care Med., 28 (2000), pp. 1742-1746
[30]
S.A. McClave, M.T. DeMeo, M.H. DeLegge, J.A. DiSario, D.K. Heyland, J.P. Maloney, et al.
North American Summit on Aspiration in the Critically Ill Patient: consensus statement.
JPEN J Parenter Enteral Nutr., 26 (2002), pp. S80-S85
[31]
I.K. Komenaka, K. Giffard, J. Miller, M. Schein.
Erythromycin and position facilitated placement of postpyloric feeding tubes in burned patients.
Dig Surg., 17 (2000), pp. 578-580
[32]
S.K. Pingleton.
Aspiration of enteral feeding in mechanically ventilated patients: how do we monitor?.
Crit Care Med., 22 (1994), pp. 1524-1525
[33]
A. Torres, J. Serra-Batlles, E. Ros, C. Piera, J. Puig de la Bellacasa, A. Cobos, et al.
Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position.
Ann Intern Med., 116 (1992), pp. 540-543
[34]
E.E. Douzinas, A. Tsapalos, A. Dimitrakopoulos, E. Diamanti-Kandaraskis, A.D. Rapidis, C. Roussos.
Effect of percutaneous endoscopic gastrostomy on gastroesophageal reflux in mechanically-ventilated patients.
World J Gastroenterol, 12 (2006), pp. 114-118
[35]
P. Ponderoux, E. Verdier, L. Muller, M. Benbabbaali, J.Y. Lefrant, P. Barbaste, et al.
Effect of assisted ventilation and position on gastroesophageal acid reflux after laparotomy.
Gastroenterol Clin Biol, 27 (2003), pp. 460-465
[36]
M. Orozco-Levi, A. Torres, M. Ferrer, C. Piera, M. el-Ebiary, J. Puig de la Bellacasa, et al.
Semirecumbent position protects from pulmonary aspiration but not completely from gastroesophageal reflux in mechanically ventilated patients.
Am J Respir Crit Care Med., 152 (1995), pp. 1387-1390
[37]
S.G. Dudek.
Nutrition essentials for nursing practice.
4th ed, PA: J.B. Lippincott, (2001),
[38]
H.C. Lin, G.W. van Citters.
Stopping enteral feeding for arbitrary gastric residual volume may not be physiologically sound: results of a computer simulation model.
JPEN J Parenter Enteral Nutr., 21 (1997), pp. 286-289
[39]
S.A. McClave, H.L. Snider.
Clinical use of gastric residual volumes as a monitor for patients on enteral tube feeding.
JPEN J Parenter Enteral Nutr., 26 (2002), pp. S43-S48
[40]
D.R. Kesek, L. Akerlind, T. Karlsson.
Early enteral nutrition in the cardiothoracic intensive care unit.
Clin Nutr, 21 (2002), pp. 303-307
[41]
M.A. Mateo.
Nursing management of enteral tube feedings.
Heart Lung., 25 (1996), pp. 318-323
[42]
K.J. Booker, L. Niedringhaus, B. Eden, J.S. Arnold.
Comparison of 2 methods of managing gastric residual volumes from feeding tubes.
Am J Crit Care., 9 (2000), pp. 318-324
[43]
E. Weekes, M. Elia.
Observations on the patterns of 24-hour energy expenditure changes in body composition and gastric emptying in head-injured patients receiving nasogastric tube feeding.
JPEN J Parenter Enteral Nutr., 20 (1996), pp. 31-37
[44]
S.A. McClave, J.K. Lukan, J.A. Stefater, C.C. Lowen, S.W. Looney, P.J. Matheson, et al.
Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients.
Crit Care Med, 33 (2005), pp. 324-330
[45]
L. Day, N.A. Stotts, A. Frankfurt, A. Stralovich-Romani, M. Volz, M. Muwaswes, et al.
Gastric versus duodenal feeding in patients with neurological disease: a pilot study.
J Neurosci Nurs., 33 (2001), pp. 148-149
[46]
N.A. Metheny, M.G. Titler.
Assessing placement of feeding tubes.
Am J Nurs., 101 (2001), pp. 36-45
[47]
L. Lord, L. Trumbore, G.P. Zaloga.
Enteral nutrition implementation and management. The ASPEN nutrition support manual.
MD: American Society for Parenteral and Enteral Nutrition, (1998),
[48]
A. Mallampalli, S.A. McClave, H.L. Snider.
Defining tolerance to enteral feeding in the intensive care unit.
Clin Nutr., 19 (2000), pp. 213-215
[49]
C.M. Booth, D.K. Heyland, W.G. Paterson.
Gastrointestinal promotility drugs in the critical care setting: a systematic review of the evidence.
Crit Care Med., 30 (2002), pp. 1429-1435
[50]
S.A. Tisherman, P.E. Marik, J. Ochoa.
Promoting enteral feeding.
Crit Care Med., 30 (2002), pp. 1653-1654
[51]
H. Seppala, T. Klaukka, J. Vuopio-Varkila, A. Muotiala, H. Helenius, K. Lager, Finnish Study Group for Antimicrobial Resistance, et al.
The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland.
N Engl J Med., 337 (1997), pp. 441-446
[52]
M. Orozco-Levi, M. Félez, M. Martínez-Miralles, J.F. Solsona, M.L. Blanco, J.M. Broquetas, et al.
Gastro-oesophageal reflux in mechanically ventilated patients: effects of an oesophageal balloon.
Eur Respir J., 22 (2003), pp. 348-353
[53]
J. Ibáñez, A. Peñafiel, P. Marse, P. Jorda, J.M. Raurich, F. Mata.
Incidence of gastroesophageal reflux and aspiration in mechanically ventilated patients using small-bore nasogastric tubes.
JPEN J Parenter Enteral Nutr., 24 (2000), pp. 103-106
[54]
M. Ferrer, T.T. Bauer, A. Torres, C. Hernández, C. Piera.
Effect of nasogastric tube size on gastroesophageal reflux and microaspiration in intubated patients.
Ann Intern Med., 130 (1999), pp. 991-994
[55]
D.L. Seidner.
Preventing enteral tube feeding-associated aspiration: something no one should get blue in the face over.
Nutr Clin Pract., 17 (2002), pp. 140-141
[56]
S.S. Lee, R.A. Mathiasen, C.A. Lipkin, S.D. Colquhoun, D.R. Margulies.
Endoscopically placed nasogastrojejunal feeding tubes: a safe route for enteral nutrition in patients with hepatic encephalopathy.
Am Surg., 68 (2002), pp. 196-200
[57]
J. Gowardman, J. Sleigh, N. Barnes, A. Smith, J. Havill.
Intermittent enteral nutrition—a comparative study examining the effect on gastric pH and microbial colonization rates.
Anaesthes Intensive Care., 31 (2003), pp. 28-33
[58]
J. Vallés, A. Artigas, J. Rello, N. Bonsoms, D. Fontanals, L. Blanch, et al.
Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia.
Ann Intern Med., 122 (1995), pp. 179-186
[59]
M.H. Kollef, N.J. Skubas, T.M. Sundt.
A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients.
Chest., 116 (1999), pp. 1339-1346
[60]
L.P. Berra.
New approaches for the prevention of airway infection in ventilated patients. Lessons learned from laboratory animal studies at the National Institutes of Health.
Minerva Anestesiol., 69 (2003), pp. 342-347
[61]
S. Atherton, D. White.
Stomach as source of bacteria colonizing respiratory tract during artificial ventilation.
Lancet., 2 (1978), pp. 968-969
[62]
G. DuMoulin, D. Paterson, J. Hedley-Whyte, A. Lisbon.
Aspiration of gastric bacteria in antacid-treated patients: a frequent cause of post-operative colonisation of the airway.
Lancet., 1 (1982), pp. 242-245
[63]
M.R. Driks, D.E. Craven, B.R. Celli, M. Manning, R.A. Burke, G.M. Garvin, et al.
Nosocomial pneumonia in intubated patients given sucralfate as compared with antacids or histamine type 2 blockers. The role of gastric colonization.
N Engl J Med., 317 (1987), pp. 1376-1382
