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Gastrointestinal Complications (related to enteral nutrition) in Critically Ill Patients. Liz Goddard. Introduction. Early enteral nutrition is recommended GIT Complications limit the ability to deliver adequate enteral nutrition affect morbidity and mortality.

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gastrointestinal complications related to enteral nutrition in critically ill patients
Gastrointestinal Complications (related to enteral nutrition) in Critically Ill Patients

Liz Goddard

introduction
Introduction
  • Early enteral nutrition is recommended
  • GIT Complications
    • limit the ability to deliver adequate enteral nutrition
    • affect morbidity and mortality
risk factors of git complications
Risk Factors of GIT complications
  • Shock
  • Poor gut perfusion
  • Gastroparesis

- medication/disease process

  • Impaired digestive enzyme secretion
  • Increased gut permeability
  • Cholestasis
  • Diarrhoea
  • Constipation
metabolic abnormalities commonly associated with bowel dysfunction
Metabolic Abnormalities Commonly Associated With Bowel Dysfunction
  • Hyperglycaemia

- Dysmotility noted at 150mg/dL

- Dysmotility almost linear with blood glucose

  • Hypokalaemia

- k+ < 4mmol/L

  • Hypomagnasaemia

- Mg < 2 mmol/L

  • Hypophosphataemia

- Po4 < 3.5 mg/dl

  • pH <7.27

- Transporter activity affected first

  • Positive fluid balance
  • Negative fluid balance
git complications
GIT Complications
  • Related to route of access for EN
  • Abdominal distension
  • Excessive gastric residues
  • Vomiting
  • Diarrhoea
  • Constipation
  • GIT haemorrhage
git complications1
GIT Complications

Overall incidence GIT complications 11.5-15%

git symptoms related to enteral feeds
GIT Symptoms related to Enteral Feeds

GIT symptoms : diarrhoea, bloating, abdominal discomfort

Treatment :

  • Change the method of EN delivery
  • Rate of infusion

- continuous vs bolus

  • Feed sterility

- closed systems

- change delivery sets 12 hourly

- strict hygiene

  • Temperature

- refrigeration

route of enteral nutrition
Route of Enteral nutrition
  • Nasogastric
    • Most widely used, easy to place, safe & well tolerated
    • More physiological
  • Nasojejunal
    • Enables adequate energy delivery
    • Reduces gastric residues
    • Less time stopped for theatre , extubation
    • Widely used for :GORD ,Cardiacs,Disordered motility
  • Difficulties with NJ
      • More difficult to site & keep in,
      • Do not give: Bolus feeds, Water – risk of necrozing bowel
      • Complications: Misplaced, Perforation
  • NO DIFFERENCE IN COMPLICATIONS
continuous vs bolus
Continuous vs Bolus
  • Bolus
    • More physiological but ICU is not a normal environment!
    • Difficulties with monitoring tolerance
    • Requires additional nursing time
  • Continuous
    • Less time consuming, Easier to monitor
    • May delay gastric emptying [adult ICU]
  • Pro’s & Cons to both
    • Often remains preference of unit
    • Complication rate re gastric residues and tracheal aspiration were similar
abdominal distension and increased gastric residues
Abdominal Distension and Increased Gastric Residues
  • Excess gastric residues is a common complication
  • Excessive gastric volume = >50% of volume of feed given in the previous 4h
  • Mechanism – 2° to alteration in GIT motility
  • Aetiology – multifactorial

- underlying illness –  with cerebral, gastric, peritoneal disease

- hyperglycaemia

- diet – consistency, temp, osmolarity, composition

- drugs – sedatives, catecholamines

abdominal distension and increased gastric residues1
Abdominal Distension and Increased Gastric Residues
  • Complications

- risk of aspiration

- bacterial overgrowth

-enteral feeds

  • Treatment

- reduce drugs that GIT motility

- prokinetic agents

erythromycin

metaclopramide

vomiting
Vomiting

Incidence of GOR in critically ill children is high

Aggravating factors:

  • Increased gastric residues
  • Supine position
  • presence of NG tube
  • dysfunction of LOS

Recommendations:

  • semi-recumbent position
  • small calibre NG tubes
  • nasojejunal feeds
constipation
Constipation
  • No standard definition in critically ill children
  • Incidence 33-50%
  • Aetiology

- immobilization

- dehydration

- drug administration

- diet low in fibre

  • Constipation leads to abdominal distension and affects tolerance of feed
constipation1
Constipation
  • Treatment

- use a diet with fibre

- decreasedrugs which  GIT motility (opioids, sedatives, catecholamines, muscle relaxants)

- laxatives, naloxone, enemas

diarrhoea
Diarrhoea
  • Incidence ??
  • 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

diarrhoea1
Diarrhoea

Causes: Diverse

  • Infections

Rotavirus

    • clostridium difficile
  • Antibiotics
  • Drugs
  • enteral nutrition
    • high osmolar feed
    • route of feed
  • presence of hypoalbuminaemia
  • underlying disease (shock)
diarrhoea2
Diarrhoea
  • Treatment

- Diet with fibre

- Probiotics, prebiotics

  • No studies in children
git haemorrhage
GIT Haemorrhage
  • Incidence 1 - 10%
    • Overt GIT bleed 10%
    • Clinically significant bleed 1.0%
  • Risk Factors
    • Organ failure
    • High pressure ventilation
    • Presence of a coagulopathy
  • Treatment
    • ?? Prophylactic treatment to prevent GIT bleeds
      • Cost
      • ?increase in nosocomial pneumonia
summary
Summary
  • Early EN in critically ill children is recommended
  • GIT complications are a major cause of inadequate enteral feeds
  • SHOCK is a major risk factor for GIT complications
  • No consensus on definitions of excessive gastric residues, constipation and diarrhoea
  • Increased mortality in children with GIT complications
  • Be aware of the complications : prevent or Rx early
slide22

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

Consider elemental formula or

parenteral nutrition if unsuccessful