{"id":4289,"date":"2015-09-23T10:00:49","date_gmt":"2015-09-23T10:00:49","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/hda-guia-resumido-de-condutas-desde-admissao-a-alta-hospitalar\/"},"modified":"2022-06-10T12:38:58","modified_gmt":"2022-06-10T12:38:58","slug":"hda-guia-resumido-de-condutas-desde-admissao-a-alta-hospitalar","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/hda-guia-resumido-de-condutas-desde-admissao-a-alta-hospitalar\/","title":{"rendered":"HDA: guia resumido de condutas desde admiss\u00e3o \u00e0 alta hospitalar"},"content":{"rendered":"<p>A <a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/proposta-de-algoritmo-de-atendimento-da-hda\/\" target=\"_blank\" rel=\"noopener\">hemorragia digestiva alta (HDA)<\/a> \u00e9 definida como o sangramento intra-luminal proximal ao ligamento de Treitz. Quanto \u00e0 etiologia, pode ser classificada em HDA varicosa e HDA n\u00e3o-varicosa. Hemat\u00eamese e melena s\u00e3o sinais e\/ou sintomas gerais da HDA.<\/p>\n<p>Os diagn\u00f3sticos mais frequentes s\u00e3o: \u00falcera p\u00e9ptica (37-55%), eros\u00f5es gastroduodenais (6-24%), varizes gastroesof\u00e1gicas (10-23%), esofagite (4-6%).<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<h2><strong>AVALIA\u00c7\u00c3O INICIAL<\/strong><\/h2>\n<p>&nbsp;<\/p>\n<ul>\n<li>Obten\u00e7\u00e3o da\u00a0hist\u00f3ria cl\u00ednica, exame f\u00edsico com toque retal, e dos par\u00e2metros hemodin\u00e2micos (PA, FC, SatO2).<\/li>\n<li>Hemograma, coagulograma, eletr\u00f3litos (s\u00f3dio, pot\u00e1ssio), ur\u00e9ia, creatinina.<\/li>\n<li>Tipagem sangu\u00ednea\u00a0nos casos com suspeita de sangramento volumoso.<\/li>\n<li>Interna\u00e7\u00e3o em UTI: idosos, com comorbidades, sangramento varicoso ou grave.<\/li>\n<li>Prote\u00e7\u00e3o das vias a\u00e9reas com IOT: hemat\u00eamese volumosa ou rebaixamento do n\u00edvel de consci\u00eancia.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<h2><strong>ESTRATIFICA\u00c7\u00c3O DO RISCO<\/strong><\/h2>\n<p>&nbsp;<\/p>\n<p>Utiliza\u00e7\u00e3o do escore de Glasgow-Blatchford (EGB), ver tabela abaixo:<\/p>\n<div id=\"attachment_3064\" style=\"width: 310px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/09\/score.png\" data-rel=\"penci-gallery-image-content\" ><img fetchpriority=\"high\" decoding=\"async\" aria-describedby=\"caption-attachment-3064\" class=\"size-medium wp-image-3064\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/score.png\" alt=\"Tabela: Escore de Glasgow Blatchford.\" width=\"300\" height=\"262\" \/><\/a><p id=\"caption-attachment-3064\" class=\"wp-caption-text\">Tabela: Escore de Glasgow Blatchford.<\/p><\/div>\n<ul>\n<li>Se EGB \u2265 1: casos de alto risco de interven\u00e7\u00e3o ou morte, com sensibilidade &gt; 99%.<\/li>\n<li>Se EGB = 0 casos\u00a0de baixo risco e podem receber alta precoce, com realiza\u00e7\u00e3o da EDA ambulatorialmente no dia seguinte.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h2><strong><span style=\"text-decoration: underline;\">RESSUSCITA\u00c7\u00c3O VOL\u00caMICA<\/span><\/strong><\/h2>\n<ul>\n<li>Obter dois acessos perif\u00e9ricos calibrosos para infus\u00e3o de solu\u00e7\u00f5es cristal\u00f3ides.<\/li>\n<li>Objetivo de alcan\u00e7ar uma PAS de 90 a 100 mmHg e FC abaixo de 100 bpm.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<h2><strong>HEMOTRANSFUS\u00c3O<\/strong><\/h2>\n<p>&nbsp;<\/p>\n<ul>\n<li>Transfus\u00e3o de hem\u00e1cias para manuten\u00e7\u00e3o de Hb s\u00e9rico entre 7 e 8 g\/dL.<\/li>\n<li>Idosos ou cardiopatas podem necessitar de n\u00edveis mais altos de hemoglobina.<\/li>\n<li>Transfus\u00e3o de plaquetas e plasma fresco congelado, uso de vitamina K ou sulfato de protamina, devem ser considerados nos pacientes com\u00a0dist\u00farbios da coagula\u00e7\u00e3o\u00a0e sangramento grave.<\/li>\n<li>N\u00e3o h\u00e1 consenso para a corre\u00e7\u00e3o da coagulopatia e plaquetopenia nos pacientes cirr\u00f3ticos com HDA.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<h2><strong>LAVAGEM COM SONDA NASOG\u00c1STRICA<\/strong><\/h2>\n<p>&nbsp;<\/p>\n<ul>\n<li>O aspirado pela SNG sem sangue n\u00e3o exclui a necessidade de EDA.<\/li>\n<li>Pode ser considerada na necessidade de lavagem da c\u00e2mara g\u00e1strica para remo\u00e7\u00e3o de res\u00edduos, sangue e co\u00e1gulos com objetivo de facilitar o exame endosc\u00f3pico.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<h2><strong>DROGAS PROCIN\u00c9TICAS<\/strong><\/h2>\n<p>&nbsp;<\/p>\n<ul>\n<li>Casos de\u00a0HDA e suspeita de terem quantidade significativa de sangue e co\u00e1gulos na c\u00e2mara g\u00e1strica.<\/li>\n<li>Eritromicina intravenosa (IV) na dose de 250 mg, dilu\u00edda em 100 mL de soro fisiol\u00f3gico (0.9%), com infus\u00e3o em 30 min e cerca de 30 a 60 min antes da EDA.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<h2><strong>INIBIDORES DE BOMBA DE PR\u00d3TONS<\/strong><\/h2>\n<p>&nbsp;<\/p>\n<ul>\n<li>Na suspeita de HDA n\u00e3o-varicosa.<\/li>\n<li>Iniciar a infus\u00e3o do IBP anteriormente a EDA.<\/li>\n<li>Omeprazol em altas doses: <em>bolus<\/em> de 80 mg, seguido por 8 mg\/h<\/li>\n<li>Manter o IBP IV em altas doses por 72 h nos casos de UP com Forrest IA, IB, IIA e IIB<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<div id=\"attachment_3061\" style=\"width: 310px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/09\/forrest.png\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" aria-describedby=\"caption-attachment-3061\" class=\"size-medium wp-image-3061\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/forrest.png\" alt=\"Tabela: Classifica\u00e7\u00e3o de Forrest.\" width=\"300\" height=\"190\" \/><\/a><p id=\"caption-attachment-3061\" class=\"wp-caption-text\">Tabela: Classifica\u00e7\u00e3o de Forrest.<\/p><\/div>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<h2><strong>INFEC\u00c7\u00c3O POR HELICOBACTER PYLORI<\/strong><\/h2>\n<p>&nbsp;<\/p>\n<ul>\n<li>Todos os casos de HDA por \u00falcera p\u00e9ptica (UP) devem ser pesquisados para a infec\u00e7\u00e3o por H. pylori, e se for constatada o tratamento deve ser oferecido.<\/li>\n<li>Teste r\u00e1pido com urease realizado durante a EDA \u00e9 o mais utilizado na pr\u00e1tica cl\u00ednica, por ser de baixo custo, com r\u00e1pido resultado e f\u00e1cil execu\u00e7\u00e3o.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<h2><strong>ANTIBIOTICOPROFILAXIA<\/strong><\/h2>\n<p>&nbsp;<\/p>\n<ul>\n<li>Nos pacientes cirr\u00f3ticos com HDA, com ou sem ascite.<\/li>\n<li>Norfloxacino 400 mg por via oral, 2x\u00a0ao dia, por 7 dias.<\/li>\n<li>Pacientes com cirrose hep\u00e1tica avan\u00e7ada e HDA: ceftriaxona intravenosa (1g\/dia) \u00a0por 7 dias.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<h2><strong>DROGAS VASOATIVAS<\/strong><\/h2>\n<p>&nbsp;<\/p>\n<ul>\n<li>Na suspeita de HDA varicosa.<\/li>\n<li>Iniciar infus\u00e3o anteriormente a EDA.<\/li>\n<li>Terlipressina com\u00a0dose de ataque IV de 2 mg, com dose de manuten\u00e7\u00e3o a cada 4 horas de acordo com o peso corporal: 1,0 mg para pacientes com at\u00e9 50 kg, 1,5 mg para pacientes entre 50 e 70 kg ou 2,0 mg para pacientes com mais de 70 kg.<\/li>\n<li>A terlipressina\u00a0deve ser mantida at\u00e9 que o sangramento tenha sido controlado por 24 horas. E a dura\u00e7\u00e3o da terapia medicamentosa poder\u00e1 estender-se por at\u00e9 5 dias.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<h2><strong>EDA NA HDA N\u00c3O-VARICOSA<\/strong><\/h2>\n<p>&nbsp;<\/p>\n<ul>\n<li>EDA deve ser realizada nas primeiras 24 horas.<\/li>\n<li>Em pacientes de alto risco de eventos adversos, dado por EGB\u00a0\u2265 12, EDA deve ser realizada nas primeiras 12 horas.<\/li>\n<li>A terap\u00eautica endosc\u00f3pica nos pacientes com UP est\u00e1 indicada se: Forrest IA, IB e IIA.<\/li>\n<li>Considerar terapia endosc\u00f3pica se UP com Forrest IIB, especialmente nos pacientes com alto risco de ressangramento.<\/li>\n<li>Dar prefer\u00eancia para uso da terapia combinada (inje\u00e7\u00e3o de adrenalina + segundo m\u00e9todo), ou monoterapia com m\u00e9todo t\u00e9rmico ou hemoclipe.<\/li>\n<\/ul>\n<h2><strong><em>\u201cSecond-look\u201d endosc\u00f3pico<\/em><\/strong><\/h2>\n<ul>\n<li>N\u00e3o realizar de rotina.<\/li>\n<li>Considerar em pacientes selecionados com alto risco de ressangramento.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<h2><strong>EDA NA HDA VARICOSA<\/strong><\/h2>\n<p>&nbsp;<\/p>\n<ul>\n<li>EDA deve ser realizada nas primeiras 12 horas.<\/li>\n<li>Dar prefer\u00eancia ao uso da ligadura el\u00e1stica.<\/li>\n<li>A escleroterapia deve permanecer como op\u00e7\u00e3o quando a ligadura n\u00e3o \u00e9 dispon\u00edvel ou quando esta n\u00e3o \u00e9 poss\u00edvel devido \u00e0 dificuldade t\u00e9cnica.<\/li>\n<\/ul>\n<div id=\"attachment_3023\" style=\"width: 304px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/09\/ligadura.jpg\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" aria-describedby=\"caption-attachment-3023\" class=\"size-medium wp-image-3023\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/ligadura.jpg\" alt=\"Figura: ligadura el\u00e1stica de variz esof\u00e1gica.\" width=\"294\" height=\"300\" \/><\/a><p id=\"caption-attachment-3023\" class=\"wp-caption-text\">Figura: ligadura el\u00e1stica de variz esof\u00e1gica.<\/p><\/div>\n<div id=\"attachment_3026\" style=\"width: 310px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/09\/esclerose.jpg\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3026\" class=\"size-medium wp-image-3026\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/esclerose.jpg\" alt=\"Figura: Esclerose de variz esof\u00e1gica.\" width=\"300\" height=\"287\" \/><\/a><p id=\"caption-attachment-3026\" class=\"wp-caption-text\">Figura: Esclerose de variz esof\u00e1gica.<\/p><\/div>\n<p>&nbsp;<\/p>\n<h2><strong><em>EDA na HDA varicosa por varizes g\u00e1stricas<\/em><\/strong><\/h2>\n<ul>\n<li>Hemostasia com\u00a0inje\u00e7\u00e3o de cianoacrilato.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<h2><strong>SANGRAMENTO PERSISTENTE E RESSANGRAMENTO<\/strong><\/h2>\n<p>&nbsp;<\/p>\n<ul>\n<li>Uma segunda tentativa de tratamento endosc\u00f3pico pode ser realizada. Deve-se considerar a utiliza\u00e7\u00e3o de m\u00e9todo terap\u00eautico endosc\u00f3pico diferente do utilizado anteriormente.<\/li>\n<li>Se a\u00a0hemorragia n\u00e3o for interrompida r\u00e1pida e efetivamente com a segunda\u00a0terap\u00eautica endosc\u00f3pica, deve-se proceder com a realiza\u00e7\u00e3o de medidas de resgate.<\/li>\n<li>Medidas de resgate na HDA n\u00e3o-varicosa: emboliza\u00e7\u00e3o por arteriografia e cirurgia.<\/li>\n<li>Medidas de resgate na HDA varicosa: uso tempor\u00e1rio de bal\u00e3o de <em>Sengstaken<\/em>&#8211;<em>Blakemore <\/em>(m\u00e1x de 24h)<em>,\u00a0<\/em>TIPS e\u00a0Cirurgia.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<h2><strong>ANTES DA ALTA HOSPITALAR NA HDA N\u00c3O-VARICOSA<\/strong><\/h2>\n<p>&nbsp;<\/p>\n<ul>\n<li>IBP oral de acordo com achados da EDA.<\/li>\n<li>Tratamento da infec\u00e7\u00e3o por H. pylori em casos de UP.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<h2><strong>ANTES DA ALTA HOSPITALAR NA HDA VARICOSA<\/strong><\/h2>\n<p>&nbsp;<\/p>\n<ul>\n<li>Iniciar propranalol assim que haja compensa\u00e7\u00e3o hemodin\u00e2mica. A dose inicial \u00e9 20 mg, por via oral, a cada 12 horas, e deve ser titulada para a dose m\u00e1xima tolerada pelo paciente.<\/li>\n<li>Ligadura el\u00e1stica a cada 1 a 3 semanas at\u00e9 erradica\u00e7\u00e3o das varizes esof\u00e1gicas.<\/li>\n<li>Casos de varizes de fundo g\u00e1strico: profilaxia secund\u00e1ria com inje\u00e7\u00e3o de cianoacrilato.<\/li>\n<\/ul>\n<p>Acesse o <a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/\">Endoscopia Terap\u00eautica<\/a> para tomar contato com mais artigos comentados, assuntos gerais, casos cl\u00ednicos, quizzes, classifica\u00e7\u00f5es e mais!<\/p>\n<p><b>Confira tamb\u00e9m: <\/b><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/hemorragia-digestiva-media\/\">Hemorragia digestiva m\u00e9dia<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A hemorragia digestiva alta (HDA) \u00e9 definida como o sangramento intra-luminal proximal ao ligamento&hellip;<\/p>\n","protected":false},"author":3495,"featured_media":5032,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[],"ano":[282],"tipo":[153],"volume":[147],"class_list":["post-4289","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","ano-282","tipo-endoscopia-digestiva-alta","volume-volume-ii"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.2 (Yoast SEO v27.2) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>HDA: guia resumido de condutas desde admiss\u00e3o \u00e0 alta hospitalar &#8226; Endoscopia Terapeutica<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/hda-guia-resumido-de-condutas-desde-admissao-a-alta-hospitalar\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"HDA: guia resumido de condutas desde admiss\u00e3o \u00e0 alta hospitalar\" \/>\n<meta property=\"og:description\" content=\"A hemorragia digestiva alta (HDA) \u00e9 definida como o sangramento intra-luminal proximal ao ligamento de Treitz. 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