COMPOSICÃO CORPORAL NA UTI: O que deve preocupar

o Intensivista ?

XX CBMI Costa do Sauípe, BA

Novembro, 2015 Obesidade Sarcopênica: Já sabemos qual seu impacto na UTI?

C

Sarcopenia e Fraqueza UTI:

Tratamento

Autofagia

Haroldo Falcão R. Cunha

Intensivista AMIB

Nutrólogo ABRAN

SBNPE – Capítulo RJ

Sem potencial conflito de interesse em relação ao tema proposto

MECANISMOS

PARADOXO DA OBESIDADE

POPULAÇÃO EM GERAL IMC>30

DOENÇAS -  ICC -  DM -  DPOC

Reserva ?

Anti-citocinas

Idade ?

Pickkers et al. Crit Care Med 2013; 41:1878–1883.

Clinical Investigations

www.ccmjournal.org 1881

there were no firm conclusions concerning the effect of BMI on the overall mortality rate. These meta-analyses were statisti-cally very heterogeneous, which indicates the need for caution in interpreting pooled estimates. Importantly, adjustments, for example, severity of illness and age were not applied, and some studies reported more than 30% of the data missing, compared with 7.8% of the patients in our study. Our database of over 150,000 patients now makes it clear that an inverse J-shaped outcome association with BMI for critically ill patients actu-ally exists, and the mortality rate is greatest for patients with cachexia. This rate becomes progressively lower for normal, overweight, and obese patients and only tends to increase again

for patients who are morbidly obese. The optimal BMI for criti-cally ill patients appears to be higher than that of patients whose illness is not critical (19).

There are several limitations inherent to the observational nature of our study. Some may argue that these observational associations are not real phenomena but reflect selection bias with the more severe patients or those with poorer progno-ses. That is to say, due to the presence of, for example, malig-nancies, they have lower BMIs as an epiphenomenon of their poorer outcomes. Furthermore, obese patients who are less ill may be admitted earlier to the ICU because of the need for more nursing staff not available on the ward. This could affect the unadjusted data presented in the previous meta-analyses but appears to be less important in the adjusted data of this study. Although it is likely that unmeasured or residual con-founding factors remain, adjusted odds ratios in our analysis show that BMI influences outcome independently of gender, neoplasm, and severity of disease. Importantly, the distribution of BMI in ICU patients (BMI > 25 kg/m2, 48%; 25–30 kg/m2, 34%; and > 30 kg/m2, 14%) is very similar to that of the gen-eral Dutch population (BMI > 25 kg/m2, 47%; 25–30 kg/m2, 36%; and > 30 kg/m2, 12%) (20, 21), also arguing against bias. In addition, our study shows that reverse causality (e.g., when occult or preexisting diseases [such as cancer] that increase mortality also cause weight loss) does not explain the higher mortality rate of patients with a lower BMI.

Naturally, our study is not suited to explain the mecha-nism of the observed beneficial effect of obesity, and we are not able to determine whether body fat distribution modifies the observed association. Previous studies have shown that after adjustment for BMI, waist circumference and the waist-to-hip ratio were strongly associated with the risk of death for nonhospitalized patients (1), whereas a higher mortality rate was observed for adults with a thigh circumference less than 60 cm (22).

Thus, although obesity is associated with various comorbid conditions, physiologic derangements, physical limitations, and pharmacologic alterations, all of which may complicate acute illness and impede therapeutic measures, obese patients still have a better outcome. This may not be as counterintui-tive as it seems when we consider that, during human evo-lution, a better nutritional state enabled people to overcome periods of physical crisis. Nevertheless, this does not explain the mechanism or nature of the potential protective factors, and the influence of obesity on acute illnesses is still poorly understood. Several explanations have been put forward to explain the apparently beneficial effects of obesity on critically ill patients, including more nutritional reserves, higher levels of anti-inflammatory cytokines (9, 23), and the higher choles-terol and lipid levels common in obese patients, which bind endotoxin during critical illness and provide the precursors for adrenal steroid synthesis (24). In addition, neutrophil dys-function, attenuation of acute lung injury (25), and diaphrag-matic remodeling due to chronically increased weight (26) and chronically increased intra-abdominal pressure (27) are

TABLE 2. Estimated Odds Ratio of Confounding Variables in Logistic Regression Model

Variable Odds Ratio 95% CI

SAPS II, per 10 points 1.57 1.52–1.63

Log (SAPS II +1) 3.36 2.85–3.96

Sex (female) 0.95 0.92–0.98

Age, per 10 yr 1.14 1.13–1.16

Surgical admission 0.74 0.71–0.77

Neoplasm 1.02 0.95–1.08

AIDS 0.51 0.40–0.66

Hematologic malignancy 1.07 0.97–1.19

Immunologic insufficiency 1.31 1.23–1.40

Mechanical ventilation 0.97 0.93–1.00

Calendar time (yr) 0.93 0.92–0.93

Body-mass index (kg/m2)

Relative risk

0.25

0.5

1.0

2.5

5

10

20

10 20 30 40 50

15

20

25

30

Absolute mortality rate (%)

Figure 2. Relative risks for hospital mortality with respect to body mass index (BMI) (kg/m²). Relative risks adjusted for Simplified Acute Physiology Score II, age, gender, admission type, neoplasm, AIDS, hematologic malignancy, immunologic insufficiency, mechanical ventilation, and calendar year. A reference value of BMI = 25.0 was used. The upper lines and lower lines represent 95% CIs for the estimated relative risks.

Medicina Intensiva

Magreza

Eutrófico Sobrepeso

I III II

M. Adiposa

Torso / SC & visceral

Gluteo-femoral

Ectópica

M. Magra

Músculo

Órgãos

IMC

Padrões de composição corporal

IMM

IMA

SUMO

Body- builders Anorexia

Obesidade Sarcopênica

Duloo, Int J Obes, 2010

Idoso Sarcopenico

M. Adiposa

Torso / SC & visceral

Gluteo-femoral

Ectópica

M. Magra

Músculo

Órgãos

IMC

OBESIDADE SARCOPÊNICA

IMC >30 + Sarcopenia: H: <55.4 cm2/m2

M: <38.9 cm2/m2

(Mourtzakis 2008)

Idosos

DM2

ICC

Cancer

UTI ?

Estudos Observacionais

Sarcopenia = 60% Ob. Sarcopenica = 25%

Sheean, 2013 UTI+VM TC até D14 INTACT Trial

JPEN 2014;38(7): 873–879.

Moisey, 2013 Estudo retrospectivo Idosos – politrauma

TC na admissão

Sarcopenia: 71% Ob. Sarcopenica:34%

Morte = 32 vs. 14 tUTI e tVM (+++) IMC = !

Moisey et al. Critical Care 2013, 17:R206

Weijs, 2014

Mortalidade geral = 29% Sexo: M>H: 37% vs. 23% Área muscular

M: 47.5% vs.20.0%, p=0.008 H: 32.3% vs. 7.5%; p<0.001

Massa magra vs. IMC

Critical Care 2014 18:R12.

Problematizando…

Idade, Sexo e Qualidade Muscular

Tratamento diferenciado do obeso Arabi et al. Critical Care 2013, 17:R72

Composição corporal no pcte. grave

Gasto energético, reserva alostática

IMC = efeito “caixa-preta”

O.S. = frequente na UTI C XX CBMI Costa do Sauípe, BA

Obrigado.

Métodos de composição corporal.

Massa magra = melhor prognóstico

haroldo.falcao@nutroclin.com.br

Poucos estudos

Intervenção nutroterápica precoce ?