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Gastrointestinal Complications (related to enteral nutrition) in
Critically Ill Patients
Liz Goddard
IntroductionEarly enteral nutrition is
recommendedGIT Complications
limit the ability to deliver adequate enteral nutrition
affect morbidity and mortality
Risk Factors of GIT complicationsShockPoor gut perfusionGastroparesis - medication/disease processImpaired digestive enzyme secretionIncreased gut permeabilityCholestasisDiarrhoeaConstipation
Metabolic Abnormalities Commonly Associated With Bowel DysfunctionHyperglycaemia - Dysmotility noted at 150mg/dL - Dysmotility almost linear with blood glucoseHypokalaemia - k+ < 4mmol/LHypomagnasaemia - Mg < 2 mmol/LHypophosphataemia - Po4 < 3.5 mg/dlpH <7.27 - Transporter activity affected firstPositive fluid balanceNegative fluid balance
GIT ComplicationsRelated to route of access for ENAbdominal distensionExcessive gastric residuesVomitingDiarrhoeaConstipationGIT haemorrhage
Aspiration 1.9%
Vomiting 17.9%
Abdominal distension 13.2%
Excessive gastric residues 4.7%
Diarrhoea 11.3%
Gastrointestinal haemorrhage 0.9%
Constipation 33-55%
GIT Complications
Overall incidence GIT complications 11.5-15%
Adults (%) Children (%)
Frequency 50-60 10-20
Withdrawal of the nutrition 15 2-7
Moderate Vomits 12 18
Abdominal distension,
excessive gastric residues
13-40 6-15
Diarrhoea 10-20 6-11
Constipation 5-80 ND
Gastrointestinal haemorrhage 1-2 0.2-1
Necrotizing enterocolitis,
small bowel necrosis,
nonocclusive ischaemia
ND 0.5
ND, no data
Gastrointestinal complications in adults and children
GIT Symptoms related to Enteral Feeds
GIT symptoms : diarrhoea, bloating, abdominal discomfort
Treatment :Change the method of EN deliveryRate of infusion - continuous vs bolusFeed sterility - closed systems - change delivery sets 12 hourly - strict hygieneTemperature - refrigeration
Route of Enteral nutritionNasogastric
Most widely used, easy to place, safe & well toleratedMore physiological
NasojejunalEnables adequate energy deliveryReduces gastric residuesLess time stopped for theatre , extubationWidely used for :GORD ,Cardiacs,Disordered motility
Difficulties with NJMore difficult to site & keep in, Do not give: Bolus feeds, Water – risk of necrozing
bowelComplications: Misplaced, Perforation
NO DIFFERENCE IN COMPLICATIONS
Continuous vs BolusBolus
More physiological but ICU is not a normal environment!
Difficulties with monitoring toleranceRequires additional nursing time
ContinuousLess time consuming, Easier to monitorMay delay gastric emptying [adult ICU]
Pro’s & Cons to bothOften remains preference of unitComplication rate re gastric residues and
tracheal aspiration were similar
Abdominal Distension and Increased Gastric Residues
Excess gastric residues is a common complicationExcessive gastric volume = >50% of volume of
feed given in the previous 4hMechanism – 2° to alteration in GIT motilityAetiology – multifactorial - underlying illness – with cerebral, gastric,
peritoneal disease - hyperglycaemia - diet – consistency, temp, osmolarity,
composition - drugs – sedatives, catecholamines
Abdominal Distension and Increased Gastric ResiduesComplications - risk of aspiration - bacterial overgrowth -enteral feedsTreatment - reduce drugs that GIT motility - prokinetic agents erythromycin metaclopramide
VomitingIncidence of GOR in critically ill children is high
Aggravating factors:Increased gastric residuesSupine position presence of NG tubedysfunction of LOSRecommendations:semi-recumbent positionsmall calibre NG tubesnasojejunal feeds
ConstipationNo standard definition in critically ill
childrenIncidence 33-50%Aetiology - immobilization - dehydration - drug administration - diet low in fibreConstipation leads to abdominal
distension and affects tolerance of feed
ConstipationTreatment - use a diet with fibre - decrease drugs which GIT motility
(opioids, sedatives, catecholamines, muscle relaxants)
- laxatives, naloxone, enemas
DiarrhoeaIncidence ??No standard definition in children - 1 loose stool 75% patients - ≥ 3 loose stools 35% patients - ≥ 4 loose stools 20% patients
- ≥ 2 loose stools for 2 days 10% patients
Diarrhoea
Causes: DiverseInfections
Rotavirusclostridium difficile
AntibioticsDrugsenteral nutrition
high osmolar feedroute of feed
presence of hypoalbuminaemiaunderlying disease (shock)
DiarrhoeaTreatment - Diet with fibre - Probiotics, prebiotics
No studies in children
GIT HaemorrhageIncidence 1 - 10%
Overt GIT bleed 10%Clinically significant bleed 1.0%
Risk FactorsOrgan failureHigh pressure ventilationPresence of a coagulopathy
Treatment?? Prophylactic treatment to prevent GIT bleeds
Cost?increase in nosocomial pneumonia
SummaryEarly EN in critically ill children is recommendedGIT complications are a major cause of
inadequate enteral feedsSHOCK is a major risk factor for GIT
complicationsNo consensus on definitions of excessive gastric
residues, constipation and diarrhoeaIncreased mortality in children with GIT
complicationsBe aware of the complications : prevent or Rx
early
Figure 1. A suggested flow chart for the management of patients with diarrhoea or other abdominal symptoms complicating enteral nutrition. FODMAPs, Fermentable, Oliogo-, Di-, Mono-saccharides, And Polols; HACCP, Hazard Analysis and Critical Control Point guideline
Diarrhoea or abdominal bloating/pain complicating
enteral nutrition
Confirm diarrhoea. Check stool chart, discuss with nursing staff
No diarrhoea, continue current
management
Yes diarrhoeaevident
Medication involvement?Antibiotics, sorbitol-
containing medications,laxatives
Positive for C difficile? Potential sites of contamination (HACCP)?
Yes improve handling of formula
and equipment
Yes, treat
No
Does formula contain FODMAPs?
Is osmolality of formula or feeding regimen high?
Does modifying fiber content improve symptoms?
Yes switch to a FODMAPs-free
formula
Yes, trial continuous
or low energy density formula
Trial fiber or fiber-free formula
No
Consider elemental formula or parenteral nutrition if unsuccessful