101
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Feeding intolerance in children with critical illness. Clin Nutr 2019; 39:609-611. [PMID: 31122791 DOI: 10.1016/j.clnu.2019.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 03/27/2019] [Accepted: 04/01/2019] [Indexed: 11/23/2022]
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102
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Heyland DK, van Zanten ARH, Grau-Carmona T, Evans D, Beishuizen A, Schouten J, Hoiting O, Bordejé ML, Krell K, Klein DJ, Gonzalez J, Perez A, Brown R, James J, Harris MS. A multicenter, randomized, double-blind study of ulimorelin and metoclopramide in the treatment of critically ill patients with enteral feeding intolerance: PROMOTE trial. Intensive Care Med 2019; 45:647-656. [PMID: 31062046 PMCID: PMC9121863 DOI: 10.1007/s00134-019-05593-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 03/04/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Enteral feeding intolerance (EFI) is a frequent problem in the intensive care unit (ICU), but current prokinetic agents have uncertain efficacy and safety profiles. The current study compared the efficacy and safety of ulimorelin, a ghrelin agonist, with metoclopramide in the treatment of EFI. METHODS One hundred twenty ICU patients were randomized 1:1 to ulimorelin or metoclopramide for 5 days. EFI was diagnosed by a gastric residual volume (GRV) ≥ 500 ml. A volume-based feeding protocol was employed, and enteral formulas were standardized. The primary end point was the percentage daily protein prescription (%DPP) received by patients over 5 days of treatment. Secondary end points included feeding success, defined as 80% DPP; gastric emptying, assessed by paracetamol absorption; incidences of recurrent intolerance (GRV ≥ 500 ml); vomiting or regurgitation; aspiration, defined by positive tracheal aspirates for pepsin; and pulmonary infection. RESULTS One hundred twenty patients were randomized and received the study drug (ulimorelin 62, metoclopramide 58). Mean APACHE II and SOFA scores were 21.6 and 8.6, and 63.3% of patients had medical reasons for ICU admission. Ulimorelin and metoclopramide resulted in comparable %DPPs over 5 days of treatment (median [Q1, Q3]: 82.9% [38.4%, 100.2%] and 82.3% [65.6%, 100.2%], respectively, p = 0.49). Five-day rates of feeding success were 67.7% and 70.6% when terminations unrelated to feeding were excluded, and there were no differences in any secondary outcomes or adverse events between the two groups. CONCLUSIONS Both prokinetic agents achieved similar rates of feeding success, and no safety differences between the two treatment groups were observed.
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Affiliation(s)
| | | | | | | | | | | | - Oscar Hoiting
- Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands
| | | | - Kenneth Krell
- Eastern Idaho Regional Medical Center, Idaho Falls, ID, USA
| | | | | | | | - Randy Brown
- Lyric Pharmaceuticals, San Francisco, CA, USA
| | - Joyce James
- Lyric Pharmaceuticals, San Francisco, CA, USA
| | - M Scott Harris
- Lyric Pharmaceuticals, San Francisco, CA, USA.
- Georgetown University School of Medicine, Washington, DC, USA.
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103
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Marino LV, Eveleens RD, Morton K, Verbruggen SCAT, Joosten KFM. Peptide nutrient-energy dense enteral feeding in critically ill infants: an observational study. J Hum Nutr Diet 2019; 32:400-408. [PMID: 30848864 DOI: 10.1111/jhn.12645] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Enteral feeding is challenging in critically ill infants. Target intakes are often not achieved as a result of fluid restriction, procedural interruptions and perceived enteral feeding intolerance. In those infants perceived to have poor feeding tolerance, the use of a peptide nutrient-energy dense enteral feed (PEF) may improve nutritional intake and minimise feeding interruptions as a result of gastrointestinal symptoms. The aim of this observational study was to characterise the use of a PEF amongst critically ill infants in two paediatric intensive care units (PICUs). METHODS Records from critically ill infants aged <12 months admitted to two PICUs were retrospectively reviewed with a PICU length of stay (LOS) ≥ 7 days. Achievement of nutritional targets for the duration of PEF was reviewed. Gastrointestinal symptoms, including gastric residual volume, constipation and vomiting, were evaluated as tolerance parameters. RESULTS In total, 53 infants were included, with a median age on admission of 2.6 months. Median admission weight was 3.9 kg in PICU-1 and 4.7 kg in PICU-2. Median (interquatile range) energy intake in PICU-1 and PICU-2 was 68 (47-92) and 90 (63-124) kcal kg-1 , respectively, and median (interquatile range) protein intake 1.7 (1.1-2.4) g kg-1 and 2.5 (1.6-3.2) g kg-1 , respectively. Feeding was withheld because of feeding intolerance in one infant (4%) on two occasions in PICU-1 for 2.5 h and in two infants (7%) on two occasions in PICU-2 for 19.5 h. Gastric residual mean (SD) volumes were 3.5 (5.4) mL kg-1 in PICU-1 and 16.9 (15.6) mL kg-1 in PICU-2. CONCLUSIONS Peptide nutrient-energy dense feeding in infants admitted to the PICU is feasible, well tolerated and nutritional targets are met. However, with this study design, it is not possible to draw any conclusions regarding the benefit of PEF over standard PE feed in critically ill children and future work is required to clarify this further.
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Affiliation(s)
- L V Marino
- Department of Dietetics and Speech & Language Therapy, University of Southampton, Southampton, UK.,NIHR Biomedical Research Centre Southampton, University Hospital Southampton NHS Foundation Trust, University of Southampton, Southampton, UK.,Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - R D Eveleens
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - K Morton
- Faculty of Health Sciences, University of Southampton, Southampton, UK.,Paediatric Intensive Care, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - S C A T Verbruggen
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - K F M Joosten
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
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104
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Ohbe H, Jo T, Matsui H, Fushimi K, Yasunaga H. Differences in effect of early enteral nutrition on mortality among ventilated adults with shock requiring low-, medium-, and high-dose noradrenaline: A propensity-matched analysis. Clin Nutr 2019; 39:460-467. [PMID: 30808573 DOI: 10.1016/j.clnu.2019.02.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 01/18/2019] [Accepted: 02/09/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS Despite extensive research on early enteral nutrition (EEN), it remains unclear whether EEN is effective for patients with shock requiring vasopressors. This study aimed to compare outcomes between EEN and late enteral nutrition (LEN) in ventilated patients with shock requiring low-, medium-, or high-dose noradrenaline. METHODS Using a national inpatient database in Japan, we identified ventilated patients admitted to intensive care units who had shock requiring catecholamines (noradrenaline or dobutamine) from July 2010 to March 2016. We defined patients who started enteral nutrition within 2 days after starting mechanical ventilation as EEN group and the others as LEN group. Propensity score matching was performed between patients undergoing EEN and LEN in each of the low- (<0.1 μg/kg/min), medium- (0.1-0.3 μg/kg/min), and high-dose (≥0.3 μg/kg/min) noradrenaline groups. RESULTS We identified 52,563 eligible patients during the 69-month study period, including 38,488, 11,042, and 3033 patients in the low-, medium-, and high-dose noradrenaline groups, respectively. One-to-two propensity score matching created 5,969, 2,162, and 477 one-to-two matched pairs in the low-, medium-, and high-dose noradrenaline groups, respectively. The 28-day mortality rate was significantly lower in the EEN than LEN group in the low-dose noradrenaline group (risk difference, -2.9%; 95% confidence interval [CI], -4.5% to -1.3%) and in the medium-dose noradrenaline group (risk difference, -6.8%; 95% CI, -9.6% to -4.0%). In the high-dose noradrenaline group, 28-day mortality did not differ significantly between the EEN and LEN groups (absolute risk difference, -1.4%; 95% CI, -7.4%-4.7%). CONCLUSIONS Although the size of the subgroup requiring high-dose noradrenaline may have been too small to demonstrate a significant difference, the results suggest that EEN was associated with a reduction in mortality in ventilated adults treated with low- or medium-dose noradrenaline but not in those requiring high-dose noradrenaline.
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Affiliation(s)
- Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.
| | - Taisuke Jo
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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105
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Hay T, Bellomo R, Rechnitzer T, See E, Ali Abdelhamid Y, Deane AM. Constipation, diarrhea, and prophylactic laxative bowel regimens in the critically ill: A systematic review and meta-analysis. J Crit Care 2019; 52:242-250. [PMID: 30665795 DOI: 10.1016/j.jcrc.2019.01.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/24/2018] [Accepted: 01/08/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Prophylactic laxative bowel regimens may prevent constipation in enterally-fed critically ill patients. However, their use may also increase diarrhea. We performed a systematic review to: 1. Explore the epidemiology of constipation and/or diarrhea in critically ill patients; and 2. Appraise trials evaluating prophylactic laxative bowel regimens. METHODS We searched MEDLINE, Embase, and CINAHL for publications that reported constipation or diarrhea in critically ill adult patients and/or prophylactic laxative bowel regimens. RESULTS The proportion of critically ill patients experiencing constipation was reported between 20% and 83% and the proportion experiencing diarrhea was reported between 3.3% and 78%. Six studies of prophylactic laxative bowel regimens were identified but only 3 randomised controlled trials were identified, and these were subjected to meta-analysis. Compared with placebo, a prophylactic laxative bowel regimen increased the risk of diarrhea (RR 1.58, 95% CI 1.22 to 2.04) but did not reduce the risk of constipation (RR 0.39, 95% CI 0.14 to 1.05), and did not affect the duration of mechanical ventilation, duration of ICU admission, or mortality. CONCLUSIONS Constipation and diarrhea occur frequently in the critically ill but data evaluating prophylactic laxative bowel regimens in such patients are sparse and do not support their use.
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Affiliation(s)
- Tyler Hay
- The University of Melbourne, Melbourne Medical School, Parkville, Victoria, Australia
| | - Rinaldo Bellomo
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, VIC 3050, Australia; Intensive Care Unit, The Austin Hospital, Heidelberg, Victoria, Australia; Intensive Care Unit, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Tom Rechnitzer
- Intensive Care Unit, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Emily See
- Intensive Care Unit, The Austin Hospital, Heidelberg, Victoria, Australia
| | | | - Adam M Deane
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, VIC 3050, Australia; Intensive Care Unit, The Royal Melbourne Hospital, Parkville, Victoria, Australia.
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106
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Tume LN, Valla FV, Floh AA, Goday P, Jotterand Chaparro C, Larsen B, Lee JH, Moreno YMF, Pathan N, Verbruggen S, Mehta NM. Priorities for Nutrition Research in Pediatric Critical Care. JPEN J Parenter Enteral Nutr 2018; 43:853-862. [DOI: 10.1002/jpen.1498] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 12/03/2018] [Indexed: 01/14/2023]
Affiliation(s)
- Lyvonne N. Tume
- Faculty of Health & Applied SciencesUniversity of the West of England Bristol UK
| | - Frédéric V. Valla
- Pediatric Intensive Care UnitHôpital Femme Mère EnfantHospices Civils de Lyon Lyon‐Bron France
| | - Alejandro A. Floh
- Department of PediatricsUniversity of Toronto Toronto Canada
- Cardiac Critical Care UnitDepartment of Critical CareThe Hospital for Sick Children Toronto Canada
| | - Praveen Goday
- Pediatric GastroenterologyNutrition Medical College of Wisconsin Milwaukee Wisconsin USA
| | - Corinne Jotterand Chaparro
- Department of Nutrition and DieteticsUniversity of Applied Sciences Western Switzerland (HES‐SO) Geneva Switzerland
- Pediatric Intensive Care UnitMedico‐Surgical Department of PediatricsUniversity Hospital of Lausanne Lausanne Switzerland
| | - Bodil Larsen
- Department of ALES (Human Nutrition)University of Alberta Edmonton Canada
| | - Jan Hau Lee
- Children's Intensive Care UnitKK Women's and Children's Hospital Singapore Singapore
- Duke‐NUS Medical School Singapore Singapore
| | - Yara M. F. Moreno
- Department of Nutrition and Postgraduate Program in NutritionSanta Catarina Federal UniversityHealth Sciences Centre Florianópolis Santa Catarina Brazil
| | - Nazima Pathan
- Addenbrooke's HospitalUniversity of Cambridge Cambridge England
| | - Sascha Verbruggen
- Pediatric Intensive Care UnitErasmus MC ‐ Sophia Children's Hospital Rotterdam the Netherlands
| | - Nilesh M. Mehta
- Department of AnesthesiologyCritical Care and Pain MedicineBoston Children's HospitalHarvard Medical School Boston Massachusetts USA
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107
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Virani FR, Peery T, Rivas O, Tomasek J, Huerta R, Wade CE, Lee J, Holcomb JB, Uray K. Incidence and Effects of Feeding Intolerance in Trauma Patients. JPEN J Parenter Enteral Nutr 2018; 43:742-749. [PMID: 30508254 DOI: 10.1002/jpen.1469] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 10/09/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Although feeding intolerance is a common complication in trauma patients, the incidence, development, and effects are poorly understood. METHODS We performed a retrospective study in which trauma patients were classified as having feeding intolerance based on time to reach feeding goal. Subsequently, we sorted patients by gastric residual volumes (GRVs) or symptoms of slowed gastrointestinal motility. RESULTS One-third of trauma patients experienced delayed time to reach feeding goal after diet initiation. Delayed feeding was associated with prolonged intensive care unit (ICU) stays, increased readmission rates, and increased incidence of sepsis. Patients with elevated GRV (>500 mL) had significantly prolonged ICU and hospital stays and increase incidence of sepsis. Patients with >2 symptoms of slowed gastrointestinal motility had prolonged ICU and hospital stays, delayed time to reach feeding goals, significantly increased readmission rates, increased incidence of infectious and thromboembolic complications and sepsis, decreased serum prealbumin levels, and increased CRP levels. CONCLUSION Decreased gastrointestinal motility in trauma patients is associated with worse outcomes and increased systemic inflammation.
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Affiliation(s)
- Farrukh R Virani
- Department of Otolaryngology, University of California Davis Medical Center, Sacramento, California, USA
| | - Travis Peery
- Department of Internal Medicine, University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas, USA
| | - Orlyn Rivas
- Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jeffrey Tomasek
- Department of Surgery and Center for Translational Injury Research, University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas, USA.,Memorial Hermann Red Duke Trauma Institute, Houston, Texas, USA
| | - Ravin Huerta
- Department of Surgery and Center for Translational Injury Research, University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas, USA.,Memorial Hermann Red Duke Trauma Institute, Houston, Texas, USA
| | - Charles E Wade
- Department of Surgery and Center for Translational Injury Research, University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas, USA.,Memorial Hermann Red Duke Trauma Institute, Houston, Texas, USA
| | - Jenny Lee
- Memorial Hermann Red Duke Trauma Institute, Houston, Texas, USA.,Department of Clinical Nutrition, Memorial Hermann Hospital, Houston, Texas
| | - John B Holcomb
- Department of Surgery and Center for Translational Injury Research, University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas, USA
| | - Karen Uray
- Department of Medical Chemistry, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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108
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Orinovsky I, Raizman E. Improvement of Nutritional Intake in Intensive Care Unit Patients via a Nurse-Led Enteral Nutrition Feeding Protocol. Crit Care Nurse 2018; 38:38-44. [PMID: 29858194 DOI: 10.4037/ccn2018433] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Enteral nutrition in intensive care unit patients has important prognostic clinical value. Feeding protocols are recommended by clinical practice guidelines as a key strategy to maximize the benefits and minimize the risks of enteral feedings. OBJECTIVE To examine whether enteral nutrition in critically ill patients could be improved by implementation of a nurse-led evidence-based feeding protocol. METHODS An interprofessional group of intensive care unit nurses, physicians, and a clinical dietitian designed a protocol to address and correct the shortcomings of enteral feeding. Data on feeding and clinical outcomes were collected retrospectively for patients for 12 months before (control group) and then for 12 months after (interventional group) implementation of the protocol. RESULTS Enteral feeding was started significantly earlier (P = .007) after admission to the intensive care unit in the intervention group (52.3 hours; SD, 42.6) than in the control group (70.3 hours; SD, 65.2). Use of the protocol resulted in a significant increase in nutritional intake; 90% of patients in the intervention group but only 34% in the traditional feeding group achieved their caloric target within 96 hours after admission (P < .001). After implementation of the protocol, cessation of feeding due to intolerance was significantly less (P = .03) in the intervention group (6%) than in the traditional feeding group (14 %), and no adverse events were detected. CONCLUSIONS Adherence to standardized guidelines with a written protocol for an early start and timely escalation of enteral feeding can improve nutritional intake among intensive care unit patients.
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Affiliation(s)
- Ira Orinovsky
- Ira Orinovsky is head nurse, Internal Medicine Department, Hadassah Mt. Scopus University Hospital, Jerusalem, Israel.,Ela Raizman is an academic consultant, Nursing Division, Hadassah Mt. Scopus University Hospital
| | - Ela Raizman
- Ira Orinovsky is head nurse, Internal Medicine Department, Hadassah Mt. Scopus University Hospital, Jerusalem, Israel. .,Ela Raizman is an academic consultant, Nursing Division, Hadassah Mt. Scopus University Hospital.
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109
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Tume LN, Valla FV. A review of feeding intolerance in critically ill children. Eur J Pediatr 2018; 177:1675-1683. [PMID: 30116972 DOI: 10.1007/s00431-018-3229-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 01/01/2023]
Abstract
Ensuring optimal nutrition is vital in critically ill children and enteral feeding is the main route of delivery in intensive care. Feeding intolerance is the most commonly cited reason amongst pediatric intensive care unit healthcare professionals for stopping or withholding enteral nutrition, yet the definition for this remains inconsistent, nebulous, and entirely arbitrary. Not only does this pose problems clinically, but research in this field frequently uses feeding intolerance as an endpoint and the heterogeneity in this definition makes the comparison of studies difficult and meta-analysis impossible. We reviewed the use of, and definitions of, the term feed intolerance in pediatric intensive care research papers in the last 20 years. Gastric residual volume remains the most common factor used to define feed intolerance, despite the lack of evidence for this. Healthcare professionals would benefit from further education to improve their awareness of the limitations of the markers to define feeding intolerance, and the international PICU community needs to agree a consistent definition of this phenomenon to improve consistency in both practice and research.Conclusion: This paper will provide a narrative review of the definitions of, evidence for, and markers of feeding intolerance in critically ill children. What is Known?: • Feeding intolerance is a commonly cited reason amongst pediatric intensive care unit healthcare professionals for stopping or withholding enteral nutrition. • There is no agreed definition for feeding intolerance in critically ill children. What is New?: • This paper provides an up to date review of the definitions of, evidence for, and markers of feeding intolerance in critically ill children. • Despite no evidence, gastric residual volume continues to drive clinical bedside decisions about enteral feeding and feeding tolerance.
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Affiliation(s)
- Lyvonne N Tume
- Faculty of Health and Applied Sciences, The University of the West of England, Glenside Campus, Blackberry Hill, Stapleton, Bristol, BS16 1DD, UK. .,Pediatric Intensive Care Unit, Bristol Children's Hospital, Upper Maudlin Street, Bristol, UK.
| | - Frédéric V Valla
- Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Lyon-Bron, France
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110
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Eveleens RD, Dungen DK, Verbruggen SCAT, Hulst JM, Joosten KFM. Weight improvement with the use of protein and energy enriched nutritional formula in infants with a prolonged PICU stay. J Hum Nutr Diet 2018; 32:3-10. [PMID: 30318663 DOI: 10.1111/jhn.12603] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Reaching an optimal nutritional intake is challenging in critically ill infants. One possible way to minimise nutritional deficits is the use of protein and energy-enriched (PE)-formulas. We aimed to describe weight achievement and gastrointestinal symptoms in infants admitted to the paediatric intensive care unit (PICU) while receiving PE-formula for a prolonged period. METHODS Records from infants admitted to a multidisciplinary PICU and using PE-formula were analysed retrospectively. Infants were eligible if they received PE-formula daily for at least 2 weeks. Weight achievement was determined as the difference between weight-for-age (WFA) Z-scores at the start and end of PE-formula use. Gastrointestinal symptoms, including gastric residual volume, constipation and vomiting, were evaluated as tolerance parameters. RESULTS Seventy infants with a median [interquartile range (IQR)] age of 76 (30-182) days were eligible. The PICU duration was 50 (35-83) days during which they received PE-formula for 30 (21-54) days. Predominant admission diagnoses were post-cardiac surgery, respiratory and cardiac diagnosis. A significant mean (SD) WFA Z-score increase of 0.48 (1.10) (P < 0.001) and a median (IQR) weight gain of 5.80 (3.28-9.04) g kg-1 day-1 was observed. Multivariate regression showed that a lower WFA Z-score at start was associated with a higher WFA Z-score increase during PE-formula use (β -0.35 (95% confidence interval = -0.50 to -0.19); P < 0.001). The maximum 24-h gastric residual volume was 8.1 mL (IQR = 2.2-14.3) for each 1 kg in bodyweight. Three (4%) infants were treated for diarrhoea and three infants were treated for vomiting. CONCLUSIONS The majority of infants with a prolonged PICU stay showed weight improvement when using PE-formula. PE-formula was well tolerated because gastrointestinal symptoms only occurred in few infants.
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Affiliation(s)
- R D Eveleens
- Department of Paediatrics and Paediatric Surgery, Intensive Care Unit, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - D K Dungen
- Department of Paediatrics and Paediatric Surgery, Intensive Care Unit, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - S C A T Verbruggen
- Department of Paediatrics and Paediatric Surgery, Intensive Care Unit, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - J M Hulst
- Division of Paediatric Gastroenterology, Department of Paediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - K F M Joosten
- Department of Paediatrics and Paediatric Surgery, Intensive Care Unit, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
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111
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Deane AM, Chapman MJ, Reintam Blaser A, McClave SA, Emmanuel A. Pathophysiology and Treatment of Gastrointestinal Motility Disorders in the Acutely Ill. Nutr Clin Pract 2018; 34:23-36. [PMID: 30294835 DOI: 10.1002/ncp.10199] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Gastrointestinal dysmotility causes delayed gastric emptying, enteral feed intolerance, and functional obstruction of the small and large intestine, the latter functional obstructions being frequently termed ileus and Ogilvie syndrome, respectively. In addition to meticulous supportive care, drug therapy may be appropriate in certain situations. There is, however, considerable variation among individuals regarding what gastric residual volume identifies gastric dysmotility and would encourage use of a promotility drug. While the administration of either metoclopramide or erythromycin is supported by evidence it appears that, dual-drug therapy (erythromycin and metoclopramide) reduces the rate of treatment failure. There is a lack of evidence to guide drug therapy of ileus, but neither erythromycin nor metoclopramide appear to have a role. Several drugs, including ghrelin agonists, highly selective 5-hydroxytryptamine receptor agonists, and opiate antagonists are being studied in clinical trials. Neostigmine, when infused at a relatively slow rate in patients receiving continuous hemodynamic monitoring, may alleviate the need for endoscopic decompression in some patients.
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Affiliation(s)
- Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.,Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, Australia
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia.,Center of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Stephen A McClave
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Anton Emmanuel
- Department of Neuro-Gastroenterology, University College London, London, UK
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112
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Toh Yoon EW. A novel semi-solidifying liquid formula via the nasogastric route to maintain enteral nutrition in the event of recurrent aspiration pneumonia: A case report. Clin Case Rep 2018; 6:1708-1712. [PMID: 30214747 PMCID: PMC6132133 DOI: 10.1002/ccr3.1668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 04/14/2018] [Accepted: 06/09/2018] [Indexed: 11/09/2022] Open
Abstract
Recurrent aspiration pneumonia can impede the continuation of enteral nutrition. Semi-solid feeds have been demonstrated to reduce the incidence of aspiration pneumonia but are difficult to administer via the nasogastric tube. A novel semi-solidifying enteral formula may be used instead to avoid the occurrence of severe gastroesophageal reflux.
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Affiliation(s)
- Ezekiel Wong Toh Yoon
- Department of Internal Medicine (Gastroenterology)Hiroshima Kyoritsu HospitalHiroshima CityJapan
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113
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Jin LM, Lin CL, Liu Q. Risk factors for intolerance to enteral nutrition in patients with severe acute pancreatitis. Shijie Huaren Xiaohua Zazhi 2018; 26:993-998. [DOI: 10.11569/wcjd.v26.i16.993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To identify the risk factors for intolerance to enteral nutrition in patients with severe acute pancreatitis (SAP) and provide clinical data for the early clinical application of enteral nutrition in these patients.
METHODS The clinical data of 243 patients who underwent enteral nutrition treatment for SAP at Tongde Hospital of Zhejiang Province from January 2012 to January 2018 were retrospectively analyzed. According to the presence of intolerance to enteral nutrition or not, the patients were divided into a tolerance group and an intolerance group. The risk factors for intolerance to enteral nutrition were determined by univariate analysis and multivariate logistic regression analysis.
RESULTS Eight-four (34.57%) of the 243 SAP patients had intolerance to enteral nutrition. Univariate analysis and multivariate logistic regression analysis showed that age > 60 years (OR = 5.212, 95%CI: 1.462-18.587, P = 0.011), fasting time > 72 h (OR = 3.683, 95%CI: 1.322-11.612, P = 0.012), intra-abdominal pressure (IAP) > 20 cmH2O (OR = 6.034, 95%CI: 2.431-20.114, P = 0.001), acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ) score > 20 (OR = 6.411, 95%CI: 2.512-22.239, P = 0.001), and serum albumin < 25 g/L (OR = 5.961, 95%CI: 2.318-20.001, P = 0.001) were risk factors for intolerance to enteral nutrition in SAP patients. Adding soluble fiber (OR = 0.221, P = 0.002, 95%CI: 0.067-0.693) was identified to be a protective factor for intolerance to enteral nutrition in SAP patients.
CONCLUSION The main risk factors for intolerance to enteral nutrition in SAP patients are age > 60 years, fasting time > 72 h, IAP > 20 cmH2O, APACHE Ⅱ score > 20, and serum albumin < 25 g/L. Soluble fiber diet is able to prevent the development of intolerance to enteral nutrition in SAP patients.
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Affiliation(s)
- Li-Mei Jin
- Department of Intensive Medicine, Tongde Hospital of Zhejiang Province, Hangzhou 310012, Zhejiang Province, China
| | - Chen-La Lin
- Department of Intensive Medicine, Tongde Hospital of Zhejiang Province, Hangzhou 310012, Zhejiang Province, China
| | - Qun Liu
- Department of Intensive Medicine, Tongde Hospital of Zhejiang Province, Hangzhou 310012, Zhejiang Province, China
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Fetterplace K, Deane AM, Tierney A, Beach LJ, Knight LD, Presneill J, Rechnitzer T, Forsyth A, Gill BMT, Mourtzakis M, MacIsaac C. Targeted Full Energy and Protein Delivery in Critically Ill Patients: A Pilot Randomized Controlled Trial (FEED Trial). JPEN J Parenter Enteral Nutr 2018; 42:1252-1262. [DOI: 10.1002/jpen.1166] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 02/27/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Kate Fetterplace
- Allied Health (Clinical Nutrition); Royal Melbourne Hospital; Melbourne Australia
- Department of Rehabilitation, Nutrition and Sport, School of Allied Health; La Trobe University; Melbourne Australia
- Department of Medicine; The University of Melbourne; Melbourne Australia
| | - Adam M. Deane
- Department of Medicine; The University of Melbourne; Melbourne Australia
- Department of Intensive Care Medicine; Royal Melbourne Hospital; Melbourne Australia
| | - Audrey Tierney
- Department of Rehabilitation, Nutrition and Sport, School of Allied Health; La Trobe University; Melbourne Australia
- Department of Clinical Therapies; University of Limerick; Limerick Ireland
| | - Lisa J. Beach
- Allied Health (Physiotherapy), Royal Melbourne Hospital; Melbourne Australia
| | - Laura D. Knight
- Allied Health (Physiotherapy), Royal Melbourne Hospital; Melbourne Australia
| | - Jeffrey Presneill
- Department of Medicine; The University of Melbourne; Melbourne Australia
- Department of Intensive Care Medicine; Royal Melbourne Hospital; Melbourne Australia
| | - Thomas Rechnitzer
- Department of Intensive Care Medicine; Royal Melbourne Hospital; Melbourne Australia
| | - Adrienne Forsyth
- Department of Rehabilitation, Nutrition and Sport, School of Allied Health; La Trobe University; Melbourne Australia
| | - Benjamin M. T. Gill
- Allied Health (Clinical Nutrition); Royal Melbourne Hospital; Melbourne Australia
- Department of Medicine; The University of Melbourne; Melbourne Australia
| | - Marina Mourtzakis
- Department of Kinesiology, Faculty of Applied Health Sciences; University of Waterloo; Waterloo Ontario Canada
| | - Christopher MacIsaac
- Department of Medicine; The University of Melbourne; Melbourne Australia
- Department of Intensive Care Medicine; Royal Melbourne Hospital; Melbourne Australia
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Fetterplace K, Deane AM, Tierney A, Beach L, Knight LD, Rechnitzer T, Forsyth A, Mourtzakis M, Presneill J, MacIsaac C. Targeted full energy and protein delivery in critically ill patients: a study protocol for a pilot randomised control trial (FEED Trial). Pilot Feasibility Stud 2018; 4:52. [PMID: 29484196 PMCID: PMC5819238 DOI: 10.1186/s40814-018-0249-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 02/02/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Current guidelines for the provision of protein for critically ill patients are based on incomplete evidence, due to limited data from randomised controlled trials. The present pilot randomised controlled trial is part of a program of work to expand knowledge about the clinical effects of protein delivery to critically ill patients. The primary aim of this pilot study is to determine whether an enteral feeding protocol using a volume target, with additional protein supplementation, delivers a greater amount of protein and energy to mechanically ventilated critically ill patients than a standard nutrition protocol. The secondary aims are to evaluate the potential effects of this feeding strategy on muscle mass and other patient-centred outcomes. METHODS This prospective, single-centred, pilot, randomised control trial will include 60 participants who are mechanically ventilated and can be enterally fed. Following informed consent, the participants receiving enteral nutrition in the intensive care unit (ICU) will be allocated using a randomisation algorithm in a 1:1 ratio to the intervention (high-protein daily volume-based feeding protocol, providing 25 kcal/kg and 1.5 g/kg protein) or standard care (hourly rate-based feeding protocol providing 25 kcal/kg and 1 g/kg protein). The co-primary outcomes are the average daily protein and energy delivered to the end of day 15 following randomisation. The secondary outcomes include change in quadriceps muscle layer thickness (QMLT) from baseline (prior to randomisation) to ICU discharge and other nutritional and patient-centred outcomes. DISCUSSION This trial aims to examine whether a volume-based feeding protocol with supplemental protein increases protein and energy delivery. The potential effect of such increases on muscle mass loss will be explored. These outcomes will assist in formulating larger randomised control trials to assess mortality and morbidity. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN: 12615000876594 UTN: U1111-1172-8563.
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Affiliation(s)
- Kate Fetterplace
- Department of Clinical Nutrition, Allied Health, Royal Melbourne Hospital, Melbourne, Australia
- Department of Rehabilitation, Nutrition and Sport, School of Allied Health, La Trobe University, Melbourne, Australia
- Department of Intensive Care Medicine, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Adam M. Deane
- Department of Intensive Care Medicine, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Audrey Tierney
- Department of Rehabilitation, Nutrition and Sport, School of Allied Health, La Trobe University, Melbourne, Australia
| | - Lisa Beach
- Department of Physiotherapy, Allied Health, Royal Melbourne Hospital, Melbourne, Australia
| | - Laura D. Knight
- Department of Physiotherapy, Allied Health, Royal Melbourne Hospital, Melbourne, Australia
| | - Thomas Rechnitzer
- Department of Intensive Care Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Adrienne Forsyth
- Department of Rehabilitation, Nutrition and Sport, School of Allied Health, La Trobe University, Melbourne, Australia
| | - Marina Mourtzakis
- Department of Kinesiology, Faculty of Applied Health Sciences, University of Waterloo, Waterloo, Canada
| | - Jeffrey Presneill
- Department of Intensive Care Medicine, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Christopher MacIsaac
- Department of Intensive Care Medicine, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
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Kuchnia AJ, Conlon B, Greenberg N. Natural Bioactive Food Components for Improving Enteral Tube Feeding Tolerance in Adult Patient Populations. Nutr Clin Pract 2018; 33:107-120. [PMID: 28820648 DOI: 10.1177/0884533617722164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2023] Open
Abstract
Tube feeding (TF) is the most common form of nutrition support. In recent years, TF administration has increased among patient populations within and outside hospital settings, in part due to greater insurance coverage, reduced use of parenteral nutrition, and improved formularies suitable for sole source nutrition. With increasing life expectancy and improved access to TFs, the number of adults dependent on enteral nutrition is expected to grow. However, enteral TF intolerance (ETFI) is the most common complication of TFs, typically presenting with at least 1 adverse gastrointestinal event, including nausea, diarrhea, and constipation. ETFI often leads to reductions in TF volume with associated energy and protein deficits. Potentially ensuing malnutrition is a major public health concern due its effects on increased risk of morbidity and mortality, infections, prolonged hospital length of stay, and higher healthcare costs. As such, there is a need for intervention strategies to prevent and reduce ETFI. Incorporating whole foods with bioactive properties is a promising strategy. Emerging research has elucidated bioactive properties of whole foods with specific benefits for the prevention and management of adverse gastrointestinal events commonly associated with TFs. However, lack of evidence-based recommendations and technological challenges have limited the use of such foods in commercial TF formulas. This review addresses research gaps by discussing 5 whole foods (rhubarb, banana, curcumin, peppermint oil, and ginger) with bioactive attributes identified through literature searches and clinical experience as having substantial scientific rationale to consider their application for ETFI in adult populations.
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Affiliation(s)
- Adam J Kuchnia
- Department of Food Science and Nutrition, University of Minnesota-Twin Cities, Saint Paul, Minnesota, USA
| | - Beth Conlon
- Nestlé Nutrition R&D Centers Inc, Bridgewater, New Jersey, USA
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Prevalence and duration of reasons for enteral nutrition feeding interruption in a tertiary intensive care unit. Nutrition 2018; 53:26-33. [PMID: 29627715 DOI: 10.1016/j.nut.2017.11.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 11/14/2017] [Accepted: 11/17/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Intensive care unit (ICU) enteral nutrition (EN) can involve frequent feeding interruption (FI). The prevalence, causes, and duration of such interruption were investigated. METHODS Reasons for EN FI identified from extensive literature review were prospectively collected in adult mechanically ventilated critically ill patients. Results were reported by descriptive statistics. Baseline and nutritional characteristics between patients who died and those alive at day 60 were compared. RESULTS A total of 148 patients receiving ≥1 day of EN for the full 12-day observational period were included in the analysis. About 332 episodes of EN FI were recorded and contributed to 12.8% (4190 hours) of the total 1367 evaluable nutrition days. For each patient, FI occurred for a median of 3 days and the total duration of FI for the entire ICU stay was 24.5 hours. Median energy and protein deficits per patient due to FI for the entire ICU stay were -1780.23 kcal and -100.58 g, respectively. Duration of FI, days with FI, and the amount of energy and protein deficits due to FI were not different between patients who had died and those who were still alive at day 60 (all P > 0.05). About 72% of the total duration of EN FI was due to procedural-related and potentially avoidable causes (primarily human factors), while only about 20% was due to feeding intolerances. CONCLUSIONS EN FI occurred primarily due to human factors, which may be minimized by adherence to an evidence-based feeding protocol as determined by a nutrition support team.
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118
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Reignier J, Boisramé-Helms J, Brisard L, Lascarrou JB, Ait Hssain A, Anguel N, Argaud L, Asehnoune K, Asfar P, Bellec F, Botoc V, Bretagnol A, Bui HN, Canet E, Da Silva D, Darmon M, Das V, Devaquet J, Djibre M, Ganster F, Garrouste-Orgeas M, Gaudry S, Gontier O, Guérin C, Guidet B, Guitton C, Herbrecht JE, Lacherade JC, Letocart P, Martino F, Maxime V, Mercier E, Mira JP, Nseir S, Piton G, Quenot JP, Richecoeur J, Rigaud JP, Robert R, Rolin N, Schwebel C, Sirodot M, Tinturier F, Thévenin D, Giraudeau B, Le Gouge A. Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2). Lancet 2018; 391:133-143. [PMID: 29128300 DOI: 10.1016/s0140-6736(17)32146-3] [Citation(s) in RCA: 325] [Impact Index Per Article: 54.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/20/2017] [Accepted: 07/17/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Whether the route of early feeding affects outcomes of patients with severe critical illnesses is controversial. We hypothesised that outcomes were better with early first-line enteral nutrition than with early first-line parenteral nutrition. METHODS In this randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2 trial) done at 44 French intensive-care units (ICUs), adults (18 years or older) receiving invasive mechanical ventilation and vasopressor support for shock were randomly assigned (1:1) to either parenteral nutrition or enteral nutrition, both targeting normocaloric goals (20-25 kcal/kg per day), within 24 h after intubation. Randomisation was stratified by centre using permutation blocks of variable sizes. Given that route of nutrition cannot be masked, blinding of the physicians and nurses was not feasible. Patients receiving parenteral nutrition could be switched to enteral nutrition after at least 72 h in the event of shock resolution (no vasopressor support for 24 consecutive hours and arterial lactate <2 mmol/L). The primary endpoint was mortality on day 28 after randomisation in the intention-to-treat-population. This study is registered with ClinicalTrials.gov, number NCT01802099. FINDINGS After the second interim analysis, the independent Data Safety and Monitoring Board deemed that completing patient enrolment was unlikely to significantly change the results of the trial and recommended stopping patient recruitment. Between March 22, 2013, and June 30, 2015, 2410 patients were enrolled and randomly assigned; 1202 to the enteral group and 1208 to the parenteral group. By day 28, 443 (37%) of 1202 patients in the enteral group and 422 (35%) of 1208 patients in the parenteral group had died (absolute difference estimate 2·0%; [95% CI -1·9 to 5·8]; p=0·33). Cumulative incidence of patients with ICU-acquired infections did not differ between the enteral group (173 [14%]) and the parenteral group (194 [16%]; hazard ratio [HR] 0·89 [95% CI 0·72-1·09]; p=0·25). Compared with the parenteral group, the enteral group had higher cumulative incidences of patients with vomiting (406 [34%] vs 246 [20%]; HR 1·89 [1·62-2·20]; p<0·0001), diarrhoea (432 [36%] vs 393 [33%]; 1·20 [1·05-1·37]; p=0·009), bowel ischaemia (19 [2%] vs five [<1%]; 3·84 [1·43-10·3]; p=0·007), and acute colonic pseudo-obstruction (11 [1%] vs three [<1%]; 3·7 [1·03-13·2; p=0·04). INTERPRETATION In critically ill adults with shock, early isocaloric enteral nutrition did not reduce mortality or the risk of secondary infections but was associated with a greater risk of digestive complications compared with early isocaloric parenteral nutrition. FUNDING La Roche-sur-Yon Departmental Hospital and French Ministry of Health.
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Affiliation(s)
- Jean Reignier
- Médecine Intensive Réanimation, CHU de Nantes, Nantes, France; Université de Nantes, Nantes, France.
| | - Julie Boisramé-Helms
- EA 7293, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Faculté de Médecine, Université de Strasbourg, Strasbourg, France; Medical Intensive Care Unit, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Laurent Brisard
- CHU de Nantes, Hôpital Laennec, Département d'Anesthésie et Réanimation, Nantes, France
| | - Jean-Baptiste Lascarrou
- Médecine Intensive Réanimation, CHU de Nantes, Nantes, France; Université de Nantes, Nantes, France
| | - Ali Ait Hssain
- Medical Intensive Care Unit, Hôpital Gabriel Montpied, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Nadia Anguel
- Medical Intensive Care Unit, CHU de Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Laurent Argaud
- Medical Intensive Care Unit, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Karim Asehnoune
- Surgical Intensive Care Unit, Hotel Dieu, CHU de Nantes, Nantes, France; Université de Nantes, Nantes, France
| | - Pierre Asfar
- Medical Intensive Care and Hyperbaric Oxygen Therapy Unit, Centre Hospitalier Universitaire Angers, Angers, France; Laboratoire de Biologie Neurovasculaire et Mitochondriale Intégrée, CNRS UMR 6214 - INSERM U1083, Université Angers, UBL, Angers, France
| | - Frédéric Bellec
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Montauban, Montauban, France
| | - Vlad Botoc
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Saint-Malo, Saint-Malo, France
| | - Anne Bretagnol
- Medical Intensive Care Unit, CHR Orléans, Orléans, France
| | - Hoang-Nam Bui
- Medical Intensive Care Unit, Hôpital Pellegrin, CHU Bordeaux, Bordeaux, France
| | - Emmanuel Canet
- Medical Intensive Care Unit, Saint Louis University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Daniel Da Silva
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Saint-Denis, Saint-Denis, France
| | - Michael Darmon
- Medical-Surgical Intensive Care Unit, University Hospital, Saint Etienne, France
| | - Vincent Das
- Medical-Surgical Intensive Care Unit, Centre Hospitalier Intercommunal André Grégoire, Montreuil, France
| | - Jérôme Devaquet
- Medical-Surgical Intensive Care Unit, Hôpital Foch, Suresnes, France
| | - Michel Djibre
- Medical-Surgical Intensive Care Unit, Tenon University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | | | - Maité Garrouste-Orgeas
- UMR 1137, IAME Team 5, Decision Sciences in Infectious Diseases (DeSCID), Control and Care, Sorbonne Paris Cité, Inserm-Paris Diderot University, Paris, France; Medical-Surgical Unit, Hôpital Saint-Joseph, Paris France; Medical Unit and Palliative Research Group, French and British Institute, Levallois-Perret, France; OUTCOMEREA Research Group, Drancy, France
| | - Stéphane Gaudry
- Medical-Surgical Intensive Care Unit, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris (AP-HP), Colombes, France; Université Paris Diderot, ECEVE, UMR 1123, Sorbonne Paris Cité, Paris, France
| | - Olivier Gontier
- Medical-Surgical Intensive Care Unit, Hôpital de Chartres, Chartres, France
| | - Claude Guérin
- Medical Intensive Care Unit, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France; Université de Lyon, IMRB INSERM 955, Lyon, France
| | - Bertrand Guidet
- Medical Intensive Care Unit, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; Sorbonne Université, UPMC Université Paris 06, INSERM, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Equipe: Epidémiologie Hospitalière Qualité et Organisation des Soins, Paris, France
| | | | - Jean-Etienne Herbrecht
- Medical Intensive Care Unit, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France; Faculté de Médecine U1121, Université de Strasbourg, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France
| | - Jean-Claude Lacherade
- Médecine Intensive Réanimation, Centre Hospitalier Départemental de la Vendée, La Roche sur Yon, France
| | - Philippe Letocart
- Medical-Surgical Intensive Care Unit, Hôpital Jacques Puel, Rodez, France
| | - Frédéric Martino
- Medical-Surgical Intensive Care Unit, CHU de Pointe-à-Pitre, Pointe-à-Pitre, France
| | - Virginie Maxime
- Medical-Surgical Intensive Care Unit, Hôpital Raymond Poincaré, Assistance Publique-Hôpitaux de Paris (AP-HP), Garches, France
| | - Emmanuelle Mercier
- Médecine Intensive Réanimation, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Jean-Paul Mira
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Saad Nseir
- Medical Intensive Care Unit, CHU Lille, Lille, France; Université Lille, Medicine School, Lille, France
| | - Gael Piton
- Medical Intensive Care Unit, CHRU Besançon, Besançon, France; EA3920, Université de Franche Comté, Besançon, France
| | - Jean-Pierre Quenot
- Medical-Surgical Intensive Care Unit, François Mitterrand University Hospital, Dijon, France; Lipness Team, INSERM UMR 866 and LabExLipSTIC, Université de Bourgogne, Dijon, France
| | - Jack Richecoeur
- Medical-Surgical Intensive Care Unit, Hôpital de Beauvais, Beauvais, France
| | | | - René Robert
- Medical Intensive Care Unit, CHU Poitiers, Poitiers, France; Université de Poitiers, INSERM CIC1402, Poitiers, France
| | - Nathalie Rolin
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Melun, Melun, France
| | - Carole Schwebel
- Medical Intensive Care Unit, CHU Albert Michallon Grenoble, Grenoble, France; Inserm U1039, Radiopharmaceutiques Biocliniques, Université Grenoble Alpes, La Tronche, France
| | - Michel Sirodot
- Medical-Surgical Intensive Care Unit, Centre Hospitalier Annecy-Genevois, Metz-Tessy, Pringy, France
| | | | - Didier Thévenin
- Medical-Surgical Intensive Care Unit, Centre Hospitalier Docteur Schaffner, Lens, France
| | - Bruno Giraudeau
- Inserm CIC 1415, Tours, France; Université de Tours, Tours, France; CHU Tours, Tours, France; Université François-Rabelais de Tours, PRES Centre-Val de Loire Université, Tours, France
| | - Amélie Le Gouge
- Inserm CIC 1415, Tours, France; Université de Tours, Tours, France; CHU Tours, Tours, France
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Abstract
The gastrointestinal (GI) tract is a highly efficient organ system with specialized structures to facilitate digestion and absorption of nutrients to meet the body's needs. The presence of nutrients in the GI tract supports optimal structure and function, stimulates regulatory hormones, and supports the microbiota, the population of microorganisms residing in the GI tract. A lack of enteral nutrition (EN) results in impaired GI integrity and serious patient complications, making EN a priority. Normal GI physiology is reviewed, and the regulatory impact of luminal nutrients on GI function is discussed.
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120
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Dehghan M, Fatehi Poor A, Mehdipoor R, Ahmadinejad M. Does abdominal massage improve gastrointestinal functions of intensive care patients with an endotracheal tube?: A randomized clinical trial. Complement Ther Clin Pract 2017; 30:122-128. [PMID: 29389471 DOI: 10.1016/j.ctcp.2017.12.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 12/14/2017] [Accepted: 12/29/2017] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Gastrointestinal dysfunction is one of the most common problems among patients hospitalized in intensive care units. Currently, medicinal and non-medicinal methods are being used to prevent gastrointestinal problems. Among non-medicinal methods, abdominal massage is considered as a relatively acceptable method. The present study aims to examine the effect of abdominal massage on gastrointestinal functions of the intensive care patients with an endotracheal tube. MATERIALS AND METHODS In this clinical trial, 70 intensive care patients with an endotracheal tube were chosen by convenience sampling and allocated to an intervention or a control group randomly. In the intervention group, a 15-min abdominal massage was conducted twice a day for three days, while the control group received only routine cares. The abdominal circumference, gastric residual volume, times of defecation, and frequency of constipation were measured. RESULTS Gastric residual volume decreased significantly in the intervention group and increased significantly in the control group; however, there was no significant difference between two groups (P = .15). There was a significant difference between two groups regarding abdominal circumference and it was decreased in the intervention group (P < .001). The defecation times significantly increased in the intervention group (P = .002). After the intervention, the prevalence of constipation was significantly decreased in the intervention group (P = .008). CONCLUSION The results revealed that abdominal massage could improve gastrointestinal functions in enterally fed patients with an endotracheal tube. It is suggested to use abdominal massage as an adjunct therapy for improving gastrointestinal functions in intensive care patients.
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Affiliation(s)
- Mahlagha Dehghan
- Nursing Research Center, Kerman University of Medical Sciences, Kerman, Haft Bagh Alavi road, Iran
| | - Amanollah Fatehi Poor
- Nursing Research Center, Kerman University of Medical Sciences, Kerman, Haft Bagh Alavi road, Iran.
| | - Roghayeh Mehdipoor
- Nursing Research Center, Kerman University of Medical Sciences, Kerman, Haft Bagh Alavi road, Iran
| | - Mehdi Ahmadinejad
- Fellow of Critical Care Medicine, Kerman University of Medical Sciences, Haft Bagh Alavi road, Kerman, Iran
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Xiaoyong W, Xuzhao L, Deliang Y, Pengfei Y, Zhenning H, Bin B, Zhengyan L, Fangning P, Shiqi W, Qingchuan Z. Construction of a model predicting the risk of tube feeding intolerance after gastrectomy for gastric cancer based on 225 cases from a single Chinese center. Oncotarget 2017; 8:99940-99949. [PMID: 29245951 PMCID: PMC5725142 DOI: 10.18632/oncotarget.21966] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 09/20/2017] [Indexed: 12/27/2022] Open
Abstract
Identifying patients at high risk of tube feeding intolerance (TFI) after gastric cancer surgery may prevent the occurrence of TFI; however, a predictive model is lacking. We therefore analyzed the incidence of TFI and its associated risk factors after gastric cancer surgery in 225 gastric cancer patients divided into without-TFI (n = 114) and with-TFI (n = 111) groups. A total of 49.3% of patients experienced TFI after gastric cancer. Multivariate analysis identified a history of functional constipation (FC), a preoperative American Society of Anesthesiologists (ASA) score of III, a high pain score at 6-hour postoperation, and a high white blood cell (WBC) count on the first day after surgery as independent risk factors for TFI. The area under the curve (AUC) was 0.756, with an optimal cut-off value of 0.5410. In order to identify patients at high risk of TFI after gastric cancer surgery, we constructed a predictive nomogram model based on the selected independent risk factors to indicate the probability of developing TFI. Use of our predictive nomogram model in screening, if a probability > 0.5410, indicated a high-risk patients would with a 70.1% likelihood of developing TFI. These high-risk individuals should take measures to prevent TFI before feeding with enteral nutrition.
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Affiliation(s)
- Wu Xiaoyong
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 710032, Xi'an, Shaanxi, China.,Department of Hepatobiliary Surgery, Shanxi Provincial People's Hospital, 030012, Taiyuan, Shanxi, China
| | - Li Xuzhao
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 710032, Xi'an, Shaanxi, China
| | - Yu Deliang
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 710032, Xi'an, Shaanxi, China
| | - Yu Pengfei
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 710032, Xi'an, Shaanxi, China
| | - Hang Zhenning
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 710032, Xi'an, Shaanxi, China
| | - Bai Bin
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 710032, Xi'an, Shaanxi, China
| | - Li Zhengyan
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 710032, Xi'an, Shaanxi, China
| | - Pang Fangning
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 710032, Xi'an, Shaanxi, China
| | - Wang Shiqi
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 710032, Xi'an, Shaanxi, China
| | - Zhao Qingchuan
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 710032, Xi'an, Shaanxi, China
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Abstract
OBJECTIVES Delayed gastric emptying occurs in critically ill patients and impairs the delivery, digestion, and absorption of enteral feeding. A pathophysiologic role of the enterohormones peptide YY and ghrelin is supported by preclinical data. To compare the circulating plasma levels of peptide YY and ghrelin in control subjects and in critically ill patients, during feeding and fasting, and to search for a correlation with gastric emptying. DESIGN A prospective observational trial. SETTINGS Mixed ICU of an academic hospital. SUBJECTS Healthy volunteers and patients expected to stay in ICU for at least 3 days in whom enteral nutrition was indicated. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Plasma peptide YY and ghrelin (enzyme-linked immunosorbent assay) were measured once in 10 fasting volunteers (controls) and daily from admission until day 5 of the ICU stay in 30 critically ill patients (median [interquartile range] age 63 [57-67] yr, median [interquartile range] Acute Physiology and Chronic Health Evaluation II score 21 [14-24]). Eight patients could not be fed (fasting group). In fed patients, 13 never had a gastric residual volume higher than 250 mL (low gastric residual volume group), in contrast to the high gastric residual volume group (n = 9). The plasma levels of peptide YY did not differ between patients (6.4 [0-18.1] pg/mL) and controls (4.8 [0.3-17.7] pg/mL). Ghrelin levels were lower in patients than in control (213 [54.4-522.7] vs 1,435 [1,321.9-1,869.3] pg/mL; p < 0.05). Plasma peptide YY or ghrelin did not differ between fasting and fed patients or between the high and low gastric residual volume groups. CONCLUSIONS In critically ill patients, plasma concentration of ghrelin significantly differs from that of controls, irrespective of the feeding status. No correlation was found between the temporal profile of ghrelin or peptide YY plasma concentration with bedside functional assessment of gastric emptying.
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Nasiri M, Farsi Z, Ahangari M, Dadgari F. Comparison of Intermittent and Bolus Enteral Feeding Methods on Enteral Feeding Intolerance of Patients with Sepsis: A Triple-blind Controlled Trial in Intensive Care Units. Middle East J Dig Dis 2017; 9:218-227. [PMID: 29255580 PMCID: PMC5726335 DOI: 10.15171/mejdd.2017.77] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND
Recent trials have shown controversial results on which enteral feeding methods has a lower
risk of enteral feeding intolerance. Therefore, we aimed to compare two methods of bolus and
intermittent feeding on enteral feeding intolerance of patients with sepsis.
METHODS
This triple-blind randomized controlled trial was conducted on 60 patients with sepsis, who
were fed through tubes for at least 3 days. The patients were randomly assigned into bolus feeding,
intermittent feeding, and control groups. Enteral feeding intolerance of all patients was recorded in
3 consecutive days by a researcher-made checklist including the data on gastric residual volume,
vomiting, diarrhea, constipation, and abdominal distension.
RESULTS
There were no significant differences between the three studied groups in none of the intervention
days pertaining to constipation, diarrhea, vomiting, abdominal distention, and gastric residual volume
(p > 0.05). Also, no statistically significant difference was found between all variables in the three
studied groups during the 3 days (p > 0.05).
CONCLUSION
As enteral feeding intolerance of patients with sepsis was similar in both bolus and intermittent
feeding methods, it can be concluded that bolus method can still be used as a standard method to
decrease the risk of enteral feeding intolerance if it is used properly
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Affiliation(s)
- Morteza Nasiri
- Gastroenterology and Hepatology Disease Research Center, Qom University of Medical Sciences, Qom, Ira
| | - Zahra Farsi
- Associate Professor, Department of Medical-Surgical, Faculty of Nursing, AJA University of Medical Sciences, Tehran, Iran
| | - Mojtaba Ahangari
- Department of Critical Care, Faculty of Nursing, AJA University of Medical Sciences, Tehran, Iran
| | - Fahimeh Dadgari
- Department of Psychiatric, Faculty of Nursing, AJA University of Medical Sciences, Tehran, Iran
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124
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Patejdl R, Kästner M, Kolbaske S, Wittstock M. Clinical nutrition and gastrointestinal dysfunction in critically ill stroke patients. Neurol Res 2017; 39:959-964. [PMID: 28828964 DOI: 10.1080/01616412.2017.1367545] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background Data on the epidemiology and risk factors of altered gastrointestinal motility (AGIM) is virtually lacking for patients suffering from non-traumatic neurologic diseases and stroke. This study investigated whether patterns of AGIM differ between patients with stroke and other severe acute brain diseases. Methods Clinical records of stroke and non-stroke patients treated at a neurological intensive care unit (ICU) were reviewed at day 1-5 and at day 10 after admission. The data was analyzed for the course of enteral/parenteral nutrition and for and for signs and symptoms of gastrointestinal dysfunction. The study included data of 76 patients, 57 with stroke (stroke group, SG) and 19 with other neurological diseases (non-stroke group, NSG). Results Basic demographic as well as clinical baseline characteristics and alimentation regime were similar in both groups. At least one sign of AGIM was seen in 33/57 (58%) SG and in 15/19 (79%) NSG patients (P = 0.099). Regurgitation was significantly more frequent among patients from the NSG (P < 0.05). Subjects from the NSG also spent a higher proportion of time with at least one symptom of AGIM present (P < 0.05). Conclusions For the first time, this study investigated the prevalence of AGIM in patients suffering from severe stroke. The prevalence of disturbed gastrointestinal function was found to be high in stroke patients, but was lower than in a group of non-stroke patients with similar general disease severity and baseline characteristics.
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Affiliation(s)
- Robert Patejdl
- a Department of Physiology , University of Rostock , Rostock , Germany
| | - Matthias Kästner
- b Department of Neurology , University of Rostock , Rostock , Germany
| | - Stephan Kolbaske
- b Department of Neurology , University of Rostock , Rostock , Germany
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125
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Effect of Intravenous Fluids and Analgesia on Dysmotility in Patients With Acute Pancreatitis: A Prospective Cohort Study. Pancreas 2017; 46:858-866. [PMID: 28697124 DOI: 10.1097/mpa.0000000000000864] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Analgesia and intravenous fluid resuscitation are cornerstones of initial patient management in acute pancreatitis (AP). The aim was to investigate the effect of intravenous fluids and analgesia on gastrointestinal motility in the early course of AP. METHODS Gastrointestinal dysmotility was assessed using the Gastroparesis Cardinal Symptom Index (GCSI). One-way analysis of variance and analysis of covariance were conducted, adjusting for age, sex, body mass index, severity of AP, preexisting diabetes mellitus, and time from first symptom onset to hospital admission. RESULTS A total of 108 patients with AP were prospectively enrolled. Opioid analgesia, when compared with nonopioid analgesia, was significantly associated with increase in total GCSI score in both unadjusted and adjusted analyses. There was no significant difference between aggressive and nonaggressive fluid resuscitation in both unadjusted and adjusted analyses. A combination of opioids and any intravenous fluids was associated with a significantly increased total GCSI score compared with opioids and no intravenous fluids in both unadjusted and adjusted analyses. Duration of symptoms was the confounder that significantly affected 6 of 9 studied associations. CONCLUSIONS Intravenous fluids and analgesia significantly affect motility independent of severity and other covariates. Guidelines on prudent use of opioids and fluids in AP need to be developed, particularly taking into account duration of symptoms from onset to hospitalization.
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Hu B, Sun R, Wu A, Ni Y, Liu J, Guo F, Ying L, Ge G, Ding A, Shi Y, Liu C, Xu L, Jiang R, Lu J, Lin R, Zhu Y, Wu W, Xie B. Severity of acute gastrointestinal injury grade is a predictor of all-cause mortality in critically ill patients: a multicenter, prospective, observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:188. [PMID: 28709443 PMCID: PMC5513140 DOI: 10.1186/s13054-017-1780-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 06/29/2017] [Indexed: 12/22/2022]
Abstract
Background In 2012, the European Society of Intensive Care Medicine proposed a definition for acute gastrointestinal injury (AGI) based on current medical evidence and expert opinion. The aim of the present study was to evaluate the feasibility of using the current AGI grading system and to investigate the association between AGI severity grades with clinical outcome in critically ill patients. Methods Adult patients at 14 general intensive care units (ICUs) with an expected ICU stay ≥24 h were prospectively studied. The AGI grade was assessed daily on the basis of gastrointestinal (GI) symptoms, intra-abdominal pressures, and feeding intolerance (FI) in the first week of admission to the ICU. Results Among the 550 patients enrolled, 456 patients (82.9%) received mechanical ventilation, and 470 patients were identified for AGI. The distribution of the global AGI grade was 24.5% with grade I, 49.4% with grade II, 20.6% with grade III, and 5.5% with grade IV. AGI grading was positively correlated with 28- and 60-day mortality (P < 0.0001). Univariate Cox regression analysis showed that age, sepsis, diabetes mellitus, coronary artery disease, the use of vasoactive drugs, serum creatinine and lactate levels, mechanical ventilation, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and the global AGI grade were significantly (P ≤ 0.02) associated with 60-day mortality. In a multivariate analysis including these variables, diabetes mellitus (HR 1.43, 95% CI 1.03–1.87; P = 0.05), the use of vasoactive drugs (HR 1.56, 95% CI 1.12–2.11; P = 0.01), serum lactate (HR 1.15, 95% CI 1.06–1.24; P = 0.03), global AGI grade (HR 1.65, 95% CI 1.28–2.12; P = 0.008), and APACHE II score (HR 1.04, 95% CI 1.02–1.06; P < 0.001) were independently associated with 60-day mortality. In a subgroup analysis of 402 patients with 7-day survival, in addition to clinical predictors and the AGI grade on the first day of ICU stay, FI within the first week of ICU stay had an independent and incremental prognostic value for 60-day mortality (χ2 = 41.9 vs. 52.2, P = 0.007). Conclusions The AGI grading scheme is useful for identifying the severity of GI dysfunction and could be used as a predictor of impaired outcomes. In addition, these results support the hypothesis that persistent FI within the first week of ICU stay is an independent determinant for mortality. Trial registration Chinese Clinical Trial Registry identifier: ChiCTR-OCS-13003824. Registered on 29 September 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1780-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bangchuan Hu
- ICU, Zhejiang Provincial People's Hospital, 158 Shangtang Road, Hangzhou, 310014, China
| | - Renhua Sun
- ICU, Zhejiang Provincial People's Hospital, 158 Shangtang Road, Hangzhou, 310014, China.
| | - Aiping Wu
- ICU, Zhejiang Provincial People's Hospital, 158 Shangtang Road, Hangzhou, 310014, China
| | - Yin Ni
- ICU, Zhejiang Provincial People's Hospital, 158 Shangtang Road, Hangzhou, 310014, China
| | - Jingquan Liu
- ICU, Zhejiang Provincial People's Hospital, 158 Shangtang Road, Hangzhou, 310014, China
| | - Feng Guo
- ICU, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, Zhejiang, China
| | - Lijun Ying
- ICU, Shaoxing People's Hospital, Zhongxing North Road, Shaoxing, 312000, China
| | - Guoping Ge
- ICU, Jinhua People's Hospital, 228 Xinhua Street, Jinhua, 321000, China
| | - Aijun Ding
- ICU, The Third Affiliated Hospital of Zhejiang Chinese Medical University, 219 Moganshan Road, Hangzhou, 310014, China
| | - Yunchao Shi
- ICU, The First Hospital of Jiaxing, 529 Hexin South Road, Jiaxing, 314000, China
| | - Changwen Liu
- ICU, Hangzhou First People's Hospital, 261 Huansha Road, Hangzhou, 310006, China
| | - Lei Xu
- ICU, Ningbo Medical Treatment Center, Lihuili Hospital, 57 Xingning Road, Ningbo, 315000, China
| | - Ronglin Jiang
- ICU, The First Affiliated Hospital of Zhejiang Chinese Medical University, 54 Youdian Road, Hangzhou, 310006, China
| | - Jun Lu
- ICU, The Second Affiliated Hospital of Zhejiang Chinese Medical University, 318 Chaowang Road, Hangzhou, 310005, China
| | - Ronghai Lin
- ICU, Taizhou Hospital of Zhejiang Province, 150 Ziyang Old Street, Linhai, 317000, China
| | - Yannan Zhu
- ICU, Zhuji People's Hospital of Zhejiang Province, 9 Jianming Road, Shaoxin, China
| | - Weidong Wu
- ICU, The Central Hospital of Lishui City, 15 Dazhong Street, Lishui, 323000, China
| | - Bo Xie
- ICU, Huzhou Central Hospital, 198 Hongqi Road, Huzhou, 313003, China
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Gu L, Ding C, Tian H, Yang B, Zhang X, Hua Y, Zhu Y, Gong J, Zhu W, Li J, Li N. Serial Frozen Fecal Microbiota Transplantation in the Treatment of Chronic Intestinal Pseudo-obstruction: A Preliminary Study. J Neurogastroenterol Motil 2017; 23:289-297. [PMID: 27840368 PMCID: PMC5383124 DOI: 10.5056/jnm16074] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 10/09/2016] [Accepted: 10/13/2016] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Chronic intestinal pseudo-obstruction (CIPO) is a serious, life-threatening motility disorder that is often related to bacterial overgrowth. Fecal microbiota transplantation (FMT) results in restoration of the normal intestinal microbial community structure. We investigated the efficacy of FMT in the treatment of CIPO patients. Methods Nine patients (age 18–53 years) with CIPO were enrolled in this prospective, open-label study. Patients received FMT for 6 consecutive days through nasojejunal (NJ) tubes and were followed up for 8 weeks after treatment. We evaluated the rate of clinical improvement and remission, feeding tolerance of enteral nutrition, and CT imaging scores of intestinal obstructions. Lactulose hydrogen breath tests were performed before FMT and 8 weeks after FMT to evaluate for the presence small intestinal bacterial overgrowth (SIBO). Results FMT significantly alleviated bloating symptoms, and symptoms of pain were relieved 2 weeks after FMT. Enteral nutrition administered through a NJ tube after FMT was well-tolerated by 66.7% (6/9) of patients. CT scores of intestinal obstructions were significantly reduced after FMT (P = 0.014). SIBO was eliminated in 71.0% (5/7) of patients. Conclusions This pilot study demonstrated the safety of using FMT. FMT may relieve symptoms in selected patients with CIPO. FMT may also improve patient tolerance of enteral nutrition delivered via a NJ tube.
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Affiliation(s)
- Lili Gu
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Chao Ding
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Hongliang Tian
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Bo Yang
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xuelei Zhang
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Yue Hua
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Yifan Zhu
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Jieshou Li
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Ning Li
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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128
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Zhao C, Xie T, Li J, Cheng M, Shi J, Gao T, Xi F, Shen J, Cao C, Yu W. Acute Colonic Pseudo-Obstruction with Feeding Intolerance in Critically Ill Patients: A Study according to Gut Wall Analysis. Gastroenterol Res Pract 2017; 2017:9574592. [PMID: 28386273 PMCID: PMC5366232 DOI: 10.1155/2017/9574592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 12/16/2016] [Accepted: 01/26/2017] [Indexed: 12/13/2022] Open
Abstract
Objective. To compare the differences between acute colonic pseudo-obstruction (ACPO) with and without acute gut wall thickening. Methods. ACPO patients with feeding tolerance were divided into ACPO with no obvious gut wall thickening (ACPO-NT) group and ACPO with obvious acute gut wall thickening (ACPO-T) group according to computed tomography and abdominal radiographs. Patients' condition, responses to supportive measures, pharmacologic therapy, endoscopic decompression, and surgeries and outcomes were compared. Results. Patients in ACPO-T group had a significantly higher APACHE II (11.82 versus 8.25, p = 0.008) and SOFA scores (6.47 versus 3.54, p < 0.001) and a significantly higher 28-day mortality (17.78% versus 4.16%, p = 0.032) and longer intensive care unit stage (4 versus 16 d, p < 0.001). Patients in ACPO-NT group were more likely to be responsive to supportive treatment (62.50% versus 24.44%, p < 0.001), neostigmine (77.78% versus 17.64%, p < 0.001), and colonoscopic decompression (75% versus 42.86%, p = 0.318) than those in ACPO-T group. Of the patients who underwent ileostomy, 81.25% gained benefits. Conclusions. ACPO patients with gut wall thickening are more severe and are less likely to be responsive to nonsurgical treatment. Ileostomy may be a good option for ACPO patients with gut wall thickening who are irresponsive to nonsurgical treatment.
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Affiliation(s)
- Chenyan Zhao
- Research Institute of General Surgery, Jinling Hospital, No. 305 Zhongshan East Road, Nanjing 210002, China
- Medical School, Nanjing University, No. 22 Hankou Road, Nanjing 210002, China
| | - Tingbin Xie
- Research Institute of General Surgery, Jinling Hospital, No. 305 Zhongshan East Road, Nanjing 210002, China
- Southern Medical University, No. 1023 Shatai South Road, Guangzhou 510515, China
| | - Jun Li
- Jining No.1 People's Hospital, No. 99 Jianshe West Road, Jining 272000, China
| | - Minhua Cheng
- Research Institute of General Surgery, Jinling Hospital, No. 305 Zhongshan East Road, Nanjing 210002, China
- Medical School, Nanjing University, No. 22 Hankou Road, Nanjing 210002, China
| | - Jialiang Shi
- Research Institute of General Surgery, Jinling Hospital, No. 305 Zhongshan East Road, Nanjing 210002, China
| | - Tao Gao
- Research Institute of General Surgery, Jinling Hospital, No. 305 Zhongshan East Road, Nanjing 210002, China
| | - Fengchan Xi
- Research Institute of General Surgery, Jinling Hospital, No. 305 Zhongshan East Road, Nanjing 210002, China
| | - Juanhong Shen
- Research Institute of General Surgery, Jinling Hospital, No. 305 Zhongshan East Road, Nanjing 210002, China
| | - Chun Cao
- Research Institute of General Surgery, Jinling Hospital, No. 305 Zhongshan East Road, Nanjing 210002, China
- Medical School, Nanjing University, No. 22 Hankou Road, Nanjing 210002, China
| | - Wenkui Yu
- Research Institute of General Surgery, Jinling Hospital, No. 305 Zhongshan East Road, Nanjing 210002, China
- Medical School, Nanjing University, No. 22 Hankou Road, Nanjing 210002, China
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Sun DL, Li WM, Li SM, Cen YY, Xu QW, Li YJ, Sun YB, Qi YX, Lin YY, Yang T, Lu QP, Xu PY. Comparison of multi-modal early oral nutrition for the tolerance of oral nutrition with conventional care after major abdominal surgery: a prospective, randomized, single-blind trial. Nutr J 2017; 16:11. [PMID: 28183318 PMCID: PMC5301361 DOI: 10.1186/s12937-017-0228-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 01/10/2017] [Indexed: 12/22/2022] Open
Abstract
Background & aims Early oral nutrition (EON) has been shown to improve recovery of gastrointestinal function, length of stay and mortality after abdominal surgery; however, early oral nutrition often fails during the first week after surgery. Here, a multi-modal early oral nutrition program is introduced to promote recovery of gastrointestinal function and tolerance of oral nutrition. Methods Consecutive patients scheduled for abdominal surgery were randomized to the multimodal EON group or a group receiving conventional care. The primary endpoint was the time of first defecation. The secondary endpoints were outcomes and the cost-effectiveness ratio in treating infectious complications. The rate of infectious-free patients was regarded as the index of effectiveness. Results One hundred seven patients were randomly assigned to groups. Baseline characteristics were similar for both groups. In intention-to-treat analysis, the success rate of oral nutrition during the first week after surgery in the multimodal EON group was 44 (83.0%) versus 31 (57.4%) in the conventional care group (P = 0.004). Time to first defecation, time to flatus, recovery time of bowel sounds, and prolonged postoperative ileus were all less in the multimodal EON group (P < 0.05). The median postoperative length of stay in the multimodal EON group was 8 days (6, 12) versus 10 days (7, 18) in the conventional care group (P < 0.001). The total cost of treatment and nutritional support were also less in the multi-modal early oral nutrition group (P < 0.001). The effectiveness was 84.9 and 79.9% in the multimodal EON and conventional care group, respectively (P = 0.475). However, the cost-effectiveness ratio was USD 537.6 (506.1, 589.3) and USD 637.8 (593.9, 710.3), respectively (P < 0.001). Conclusion The multi-modal early oral nutrition program was an effective way to improve tolerance of oral nutrition during the first week after surgery, decrease the length of stay and improve cost-effectiveness after abdominal surgery. Trial registration Registration number: ChiCTR-TRC-14004395. Registered 15 March 2014.
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Affiliation(s)
- Da-Li Sun
- Department of General Surgery, Wuhan Clinical School of Southern Medical University/Wuhan General Hospital of Guangzhou Military Command, Wuhan, 430070, China.,Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, China.,Research Center for Surgical Clinical Nutrition in Yun-Nan Province, Kunming, 650101, China
| | - Wei-Ming Li
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, China
| | - Shu-Min Li
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, China.,Research Center for Surgical Clinical Nutrition in Yun-Nan Province, Kunming, 650101, China
| | - Yun-Yun Cen
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, China.,Research Center for Surgical Clinical Nutrition in Yun-Nan Province, Kunming, 650101, China
| | - Qing-Wen Xu
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, China.,Research Center for Surgical Clinical Nutrition in Yun-Nan Province, Kunming, 650101, China
| | - Yi-Jun Li
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, China.,Research Center for Surgical Clinical Nutrition in Yun-Nan Province, Kunming, 650101, China
| | - Yan-Bo Sun
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, China.,Research Center for Surgical Clinical Nutrition in Yun-Nan Province, Kunming, 650101, China
| | - Yu-Xing Qi
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, China.,Research Center for Surgical Clinical Nutrition in Yun-Nan Province, Kunming, 650101, China
| | - Yue-Ying Lin
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, China.,Research Center for Surgical Clinical Nutrition in Yun-Nan Province, Kunming, 650101, China
| | - Ting Yang
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, China.,Research Center for Surgical Clinical Nutrition in Yun-Nan Province, Kunming, 650101, China
| | - Qi-Ping Lu
- Department of General Surgery, Wuhan Clinical School of Southern Medical University/Wuhan General Hospital of Guangzhou Military Command, Wuhan, 430070, China.
| | - Peng-Yuan Xu
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, China. .,Research Center for Surgical Clinical Nutrition in Yun-Nan Province, Kunming, 650101, China.
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MacLaren R. Measuring Gastric Emptying in the Critically Ill: More Than a Gut Feeling. JPEN J Parenter Enteral Nutr 2017; 41:1087-1089. [PMID: 28061316 DOI: 10.1177/0148607116686332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Robert MacLaren
- 1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
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Abstract
PURPOSE OF REVIEW The current review summarizes different aspects of assessment of gastrointestinal function and provides a practical approach to management of adult patients with gastrointestinal dysfunction in the ICU. RECENT FINDINGS Different ways to define gastrointestinal failure have been used in the past. Recently, the term 'acute gastrointestinal injury (AGI)' has been proposed to specifically describe gastrointestinal dysfunction as a part of multiple organ dysfunction syndrome. Possible pathophysiological mechanisms and different aspects in assessment of gastrointestinal function in adult ICU patients are presented. Currently, there is no single marker that could reliably describe gastrointestinal dysfunction. Therefore, monitoring and management is still based on complex assessment of different gastrointestinal symptoms and feeding intolerance, even though this approach includes a large amount of subjectivity. The possible role of biomarkers (citrulline, enterohormones, etc.) and additional parameters like intra-abdominal pressure remains to be clarified. SUMMARY Defining gastrointestinal failure remains challenging but broad consensus needs to be reached and disseminated soon to allow conduct of interventional studies. A systematic approach to management of gastrointestinal problems is recommended.
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Nutrition Therapy in Shock. CURRENT SURGERY REPORTS 2016. [DOI: 10.1007/s40137-016-0161-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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133
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Weimann A, Felbinger TW. Gastrointestinal dysmotility in the critically ill: a role for nutrition. Curr Opin Clin Nutr Metab Care 2016; 19:353-359. [PMID: 27341126 DOI: 10.1097/mco.0000000000000300] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW The role of enteral nutrition on gastrointestinal dysmotility in the critically ill remains controversial. RECENT FINDINGS The mechanisms of gastrointestinal dysmotility during critical illness remain poorly investigated. Low amounts of enteral feeding stimulate motility and have trophic effects. Therefore, enteral feeding is feasible even during gastrointestinal dysmotility as seen in the hemodynamically compromised patient. Rapid 'ramp-up' of administration rate of tube feeding bears the risk of overload and even detrimental ischemic bowel necrosis. The recent American Society for Parenteral and Enteral Nutrition guidelines do not recommend the measurement of gastric residual volume. The use of concentrated enteral solutions with 1.5 kcal/ml may result in greater calorie delivery. Biomarkers like plasma citrulline and plasma or urine intestinal fatty-acid-binding protein reflect the functional integrity of the bowel and may potentially support monitoring. SUMMARY To improve enteral nutrition protocols, the definitions of gastrointestinal dysfunction, gastric dysmotility, and feeding intolerance should be clearly defined in the future. In the concept of integrity of the gut, enteral nutrition should not be stopped completely during gastrointestinal dysfunction but restricted to a 'minimal' trophic feeding rate. In malnourished and high-risk patients intolerant to enteral feeding supplemental parenteral nutrition should be started on day 4 or earlier.
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Affiliation(s)
- Arved Weimann
- aDepartment of General Surgery and Clinical Nutrition, St. George Hospital, Leipzig bDepartment of Anesthesiology, Critical Care and Pain Medicine, Neuperlach and Harlaching Medical Center, The Munich Municipal Hospitals Ltd, Munich, Germany
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Kar P, Plummer MP, Chapman MJ, Cousins CE, Lange K, Horowitz M, Jones KL, Deane AM. Energy-Dense Formulae May Slow Gastric Emptying in the Critically Ill. JPEN J Parenter Enteral Nutr 2016; 40:1050-6. [PMID: 26038421 DOI: 10.1177/0148607115588333] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 04/11/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Enteral feed intolerance occurs frequently in critically ill patients and can be associated with adverse outcomes. "Energy-dense formulae" (ie, >1 kcal/mL) are often prescribed to critically ill patients to reduce administered volume and are presumed to maintain or increase calorie delivery. The aim of this study was to compare gastric emptying of standard and energy-dense formulae in critically ill patients. METHODS In a retrospective comparison of 2 studies, data were analyzed from 2 groups of patients that received a radiolabeled 100-mL "meal" containing either standard calories (1 kcal/mL) or concentrated calories (energy-dense formulae; 2 kcal/mL). Gastric emptying was measured using a scintigraphic technique. Radioisotope data were collected for 4 hours and gastric emptying quantified. Data are presented as mean ± SE or median [interquartile range] as appropriate. RESULTS Forty patients were studied (n = 18, energy-dense formulae; n = 22, standard). Groups were well matched in terms of demographics. However, patients in the energy-dense formula group were studied earlier in their intensive care unit admission (P = .02) and had a greater proportion requiring inotropes (P = .002). A similar amount of calories emptied out of the stomach per unit time (P = .57), but in patients receiving energy-dense formulae, a greater volume of meal was retained in the stomach (P = .045), consistent with slower gastric emptying. CONCLUSIONS In critically ill patients, the administration of the same volume of a concentrated enteral nutrition formula may not result in the delivery of more calories to the small intestine over time because gastric emptying is slowed.
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Affiliation(s)
- Palash Kar
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Mark P Plummer
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia National Health and Medical Research Council, Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | | | - Kylie Lange
- National Health and Medical Research Council, Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Michael Horowitz
- National Health and Medical Research Council, Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Karen L Jones
- National Health and Medical Research Council, Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Adam M Deane
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia National Health and Medical Research Council, Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
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Chapman MJ, Deane AM, O'Connor SL, Nguyen NQ, Fraser RJL, Richards DB, Hacquoil KE, Vasist Johnson LS, Barton ME, Dukes GE. The effect of camicinal (GSK962040), a motilin agonist, on gastric emptying and glucose absorption in feed-intolerant critically ill patients: a randomized, blinded, placebo-controlled, clinical trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:232. [PMID: 27476581 PMCID: PMC4967996 DOI: 10.1186/s13054-016-1420-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 07/20/2016] [Indexed: 02/08/2023]
Abstract
Background The promotility agents currently available to treat gastroparesis and feed intolerance in the critically ill are limited by adverse effects. The aim of this study was to assess the pharmacodynamic effects and pharmacokinetics of single doses of the novel gastric promotility agent motilin agonist camicinal (GSK962040) in critically ill feed-intolerant patients. Methods A prospective, randomized, double-blind, parallel-group, placebo-controlled, study was performed in mechanically ventilated feed-intolerant patients [median age 55 (19–84), 73 % male, APACHE II score 18 (5–37) with a gastric residual volume ≥200 mL]. Gastric emptying and glucose absorption were measured both pre- and post-treatment after intragastric administration of 50 mg (n = 15) camicinal and placebo (n = 8) using the 13C-octanoic acid breath test (BTt1/2), acetaminophen concentrations, and 3-O-methyl glucose concentrations respectively. Results Following 50 mg enteral camicinal, there was a trend to accelerated gastric emptying [adjusted geometric means: pre-treatment BTt1/2 117 minutes vs. post- treatment 76 minutes; 95 % confidence intervals (CI; 0.39, 1.08) and increased glucose absorption (AUC240min pre-treatment: 28.63 mmol.min/L vs. post-treatment: 71.63 mmol.min/L; 95 % CI (1.68, 3.72)]. When two patients who did not have detectable plasma concentrations of camicinal were excluded from analysis, camicinal accelerated gastric emptying (adjusted geometric means: pre-treatment BTt1/2 121 minutes vs. post-treatment 65 minutes 95 % CI (0.32, 0.91) and increased glucose absorption (AUC240min pre-treatment: 33.04 mmol.min/L vs. post-treatment: 74.59 mmol.min/L; 95 % CI (1.478, 3.449). In those patients receiving placebo gastric emptying was similar pre- and post-treatment. Conclusions When absorbed, a single enteral dose of camicinal (50 mg) accelerates gastric emptying and increases glucose absorption in feed-intolerant critically ill patients. Trial registration The study protocol was registered with the US NIH clinicaltrials.gov on 23 December 2009 (Identifier NCT01039805).
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Affiliation(s)
- Marianne J Chapman
- Department of Critical Care Services, Royal Adelaide Hospital, North Terrace, Adelaide, Australia. .,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.
| | - Adam M Deane
- Department of Critical Care Services, Royal Adelaide Hospital, North Terrace, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Stephanie L O'Connor
- Department of Critical Care Services, Royal Adelaide Hospital, North Terrace, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Nam Q Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Robert J L Fraser
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Adelaide, Australia
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Wang K, McIlroy K, Plank LD, Petrov MS, Windsor JA. Prevalence, Outcomes, and Management of Enteral Tube Feeding Intolerance: A Retrospective Cohort Study in a Tertiary Center. JPEN J Parenter Enteral Nutr 2016; 41:959-967. [DOI: 10.1177/0148607115627142] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Kailun Wang
- HBP/Upper GI Unit, Auckland City Hospital, Auckland, New Zealand
| | - Kerry McIlroy
- Nutrition Services, Auckland City Hospital, Auckland, New Zealand
| | - Lindsay D. Plank
- Department of Surgery, School of Medicine, University of Auckland, Auckland, New Zealand
| | - Max S. Petrov
- Department of Surgery, School of Medicine, University of Auckland, Auckland, New Zealand
| | - John A. Windsor
- HBP/Upper GI Unit, Auckland City Hospital, Auckland, New Zealand
- Department of Surgery, School of Medicine, University of Auckland, Auckland, New Zealand
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Toh Yoon E, Nishihara K, Murata H. Maintaining Enteral Nutrition in the Severely Ill using a Newly Developed Nasojejunal Feeding Tube with Gastric Decompression Function. Intern Med 2016; 55:2945-2950. [PMID: 27746430 PMCID: PMC5109560 DOI: 10.2169/internalmedicine.55.6915] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
For nutritional support of critically ill patients, the enteral route is preferred over the parenteral route. Although nasojejunal feeding can be superior to gastric feeding when gastrointestinal symptoms occur, it does not necessarily solve the problem of large gastric residual volumes. We report the successful use of a newly developed nasojejunal feeding tube with gastric decompression function in an 84-year-old man with severe pneumonia. After gastric feeding was considered not well tolerated, the use of this tube improved the delivery of nutrition until the patient was stable enough to undergo percutaneous endoscopic gastrostomy.
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Affiliation(s)
- Ezekiel Toh Yoon
- Department of Internal Medicine, Hiroshima Kyoritsu Hospital, Japan
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139
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Wilson B, Typpo K. Nutrition: A Primary Therapy in Pediatric Acute Respiratory Distress Syndrome. Front Pediatr 2016; 4:108. [PMID: 27790606 PMCID: PMC5061746 DOI: 10.3389/fped.2016.00108] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 09/20/2016] [Indexed: 12/18/2022] Open
Abstract
Appropriate nutrition is an essential component of intensive care management of children with acute respiratory distress syndrome (ARDS) and is linked to patient outcomes. One out of every two children in the pediatric intensive care unit (PICU) will develop malnutrition or have worsening of baseline malnutrition and present with specific micronutrient deficiencies. Early and adequate enteral nutrition (EN) is associated with improved 60-day survival after pediatric critical illness, and, yet, despite early EN guidelines, critically ill children receive on average only 55% of goal calories by PICU day 10. Inadequate delivery of EN is due to perceived feeding intolerance, reluctance to enterally feed children with hemodynamic instability, and fluid restriction. Underlying each of these factors is large practice variation between providers and across institutions for initiation, advancement, and maintenance of EN. Strategies to improve early initiation and advancement and to maintain delivery of EN are needed to improve morbidity and mortality from pediatric ARDS. Both, over and underfeeding, prolong duration of mechanical ventilation in children and worsen other organ function such that precise calorie goals are needed. The gut is thought to act as a "motor" of organ dysfunction, and emerging data regarding the role of intestinal barrier functions and the intestinal microbiome on organ dysfunction and outcomes of critical illness present exciting opportunities to improve patient outcomes. Nutrition should be considered a primary rather than supportive therapy for pediatric ARDS. Precise nutritional therapies, which are titrated and targeted to preservation of intestinal barrier function, prevention of intestinal dysbiosis, preservation of lean body mass, and blunting of the systemic inflammatory response, offer great potential for improving outcomes of pediatric ARDS. In this review, we examine the current evidence regarding dose, route, and timing of nutrition, current recommendations for provision of nutrition to children with ARDS, and the current literature for immune-modulating diets for pediatric ARDS. We will examine emerging data regarding the role of the intestinal microbiome in modulating the response to critical illness.
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Affiliation(s)
- Bryan Wilson
- Department of Emergency Medicine, University of Arizona College of Medicine , Tucson, AZ , USA
| | - Katri Typpo
- Department of Pediatrics, Steele Children's Research Center, University of Arizona College of Medicine , Tucson, AZ , USA
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Qiu C, Chen C, Zhang W, Kou Q, Wu S, Zhou L, Liu J, Ma G, Chen J, Chen M, Luo H, Zhang X, Lai J, Yu Z, Yu X, Liao W, Guan X, Ouyang B. Fat-Modified Enteral Formula Improves Feeding Tolerance in Critically Ill Patients: A Multicenter, Single-Blind, Randomized Controlled Trial. JPEN J Parenter Enteral Nutr 2015; 41:785-795. [PMID: 26350918 DOI: 10.1177/0148607115601858] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Improvement of fat digestion and absorption was supposed to relieve feeding intolerance. This trial aimed to evaluate the effect of a fat-modified enteral formula on feeding tolerance in critically ill patients. MATERIALS AND METHODS This trial was conducted in 7 hospitals in China. In total, 144 intensive care unit (ICU) patients with estimated need of enteral nutrition (EN) for at least 5 days were randomly given fat-modified enteral formula containing medium-chain triglycerides (MCT), carnitine, and taurine (interventional feed group, n = 71) or standard enteral formula (control feed group, n = 73). EN intake, feeding intolerance (diarrhea, vomiting, gastric retention, and abdominal distension) and outcomes (mechanical ventilator-free days of 28 days, length of ICU stay, length of hospital stay, and in-hospital mortality) were collected. RESULTS Daily calories and protein intake were increased in the interventional feed group compared with the control feed group ( P < .01). Total incidence of feeding intolerance was 42.3% in the interventional feed group and 65.7% in the control feed group ( P < .001). Daily incidence of feeding intolerance was 11.3%, 18.3%, 14.1%, 25.4%, and 26.1% in the interventional feed group and 31.5%, 32.9%, 34.2%, 34.2%, and 30.4% in the control feed group from study days 1-5 ( P = .0083). Incidence of feeding intolerance without abdominal distention was 32.9% in the interventional feed group and 49.3% in the control feed group ( P = .047), while the incidence of abdominal distension was 26.8% in the interventional feed group and 43.8% in the control feed group ( P = .03). No significant differences existed in outcomes between the 2 groups. CONCLUSIONS The fat-modified enteral formula containing MCT, carnitine, and taurine may improve feeding tolerance in critically ill patients.
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Affiliation(s)
- Chunfang Qiu
- 1 Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Chuanxi Chen
- 1 Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Weixing Zhang
- 2 Department of Intensive Care Unit, Peking University Shenzhen Hospital, Shenzhen, P.R. China
| | - Qiuye Kou
- 3 Department of Intensive Care Unit, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Shengnan Wu
- 4 Department of Gastrointestinal Surgery, Peking University Shenzhen Hospital, Shenzhen, P.R. China
| | - Lixin Zhou
- 5 Department of Intensive Care Unit, The First People's Hospital of Foshan, Foshan, P.R. China
| | - Jiyun Liu
- 6 Department of Intensive Care Unit, The First People's Hospital of Guangzhou, Guangzhou, P.R. China
| | - Gang Ma
- 7 Department of Intensive Care Unit, University Cancer Center, Guangzhou, P.R. China
| | - Juan Chen
- 1 Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Minying Chen
- 1 Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Hua Luo
- 2 Department of Intensive Care Unit, Peking University Shenzhen Hospital, Shenzhen, P.R. China
| | - Xiaofei Zhang
- 3 Department of Intensive Care Unit, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Jianbo Lai
- 4 Department of Gastrointestinal Surgery, Peking University Shenzhen Hospital, Shenzhen, P.R. China
| | - Zhihui Yu
- 5 Department of Intensive Care Unit, The First People's Hospital of Foshan, Foshan, P.R. China
| | - Xiaochun Yu
- 6 Department of Intensive Care Unit, The First People's Hospital of Guangzhou, Guangzhou, P.R. China
| | - Wei Liao
- 7 Department of Intensive Care Unit, University Cancer Center, Guangzhou, P.R. China
| | - Xiangdong Guan
- 1 Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Bin Ouyang
- 1 Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
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Impact of early nutrition and feeding route on outcomes of mechanically ventilated patients with shock: a post hoc marginal structural model study. Intensive Care Med 2015; 41:875-86. [PMID: 25792207 DOI: 10.1007/s00134-015-3730-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 03/02/2015] [Indexed: 12/13/2022]
Abstract
PURPOSE Few data are available about optimal nutrition modalities in mechanically ventilated patients with shock. Our objective was to assess associations linking early nutrition (<48 h after intubation), feeding route and calorie intake to mortality and risk of ventilator-associated pneumonia (VAP) in patients with invasive mechanical ventilation (IMV) and shock. METHODS In the prospective OutcomeRea database, we identified adults with IMV >72 h and shock (arterial systolic pressure <90 mmHg) within 48 h after intubation. A marginal structural Cox model was used to create a pseudo-population in which treatment was unconfounded by subject-specific characteristics. RESULTS We included 3,032 patients. Early nutrition was associated with lower day-28 mortality [HR 0.89, 95 % confidence interval (CI) 0.81-0.98, P = 0.01] and day-7 mortality (HR 0.76, CI 0.66-0.87, P < 0.001) but not with lower day-7 to day-28 mortality (HR 1.00, CI 0.89-1.12, P = 0.98). Early nutrition increased VAP risk over the 28 days (HR 1.08, CI 1.00-1.17, P = 0.046) and until day 7 (HR 7.17, CI 6.27-8.19, P < 0.001) but decreased VAP risk from days 7 to 28 (HR 0.85, CI 0.78-0.92, P < 0.001). Compared to parenteral feeding, enteral feeding was associated with a slightly increased VAP risk (HR 1.11, CI 1.00-1.22, P = 0.04) but not with mortality. Neither mortality nor VAP risk differed between early calorie intakes of ≥20 and <20 kcal/kg/day. CONCLUSION In mechanically ventilated patients with shock, early nutrition was associated with reduced mortality. Neither feeding route nor early calorie intake was associated with mortality. Early nutrition and enteral feeding were associated with increased VAP risk.
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Kulkarni AP. Proximal or distal? That is the question! Indian J Crit Care Med 2015; 19:65-6. [PMID: 25722544 PMCID: PMC4339904 DOI: 10.4103/0972-5229.151005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Atul P Kulkarni
- Department of Anaesthesiology, Division of Critical Care Medicine, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
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Brisard L, Le Gouge A, Lascarrou JB, Dupont H, Asfar P, Sirodot M, Piton G, Bui HN, Gontier O, Hssain AA, Gaudry S, Rigaud JP, Quenot JP, Maxime V, Schwebel C, Thévenin D, Nseir S, Parmentier E, El Kalioubie A, Jourdain M, Leray V, Rolin N, Bellec F, Das V, Ganster F, Guitton C, Asehnoune K, Bretagnol A, Anguel N, Mira JP, Canet E, Guidet B, Djibre M, Misset B, Robert R, Martino F, Letocart P, Silva D, Darmon M, Botoc V, Herbrecht JE, Meziani F, Devaquet J, Mercier E, Richecoeur J, Martin S, Gréau E, Giraudeau B, Reignier J. Impact of early enteral versus parenteral nutrition on mortality in patients requiring mechanical ventilation and catecholamines: study protocol for a randomized controlled trial (NUTRIREA-2). Trials 2014; 15:507. [PMID: 25539571 PMCID: PMC4307984 DOI: 10.1186/1745-6215-15-507] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 12/02/2014] [Indexed: 12/26/2022] Open
Abstract
Background Nutritional support is crucial to the management of patients receiving invasive mechanical ventilation (IMV) and the most commonly prescribed treatment in intensive care units (ICUs). International guidelines consistently indicate that enteral nutrition (EN) should be preferred over parenteral nutrition (PN) whenever possible and started as early as possible. However, no adequately designed study has evaluated whether a specific nutritional modality is associated with decreased mortality. The primary goal of this trial is to assess the hypothesis that early first-line EN, as compared to early first-line PN, decreases day 28 all-cause mortality in patients receiving IMV and vasoactive drugs for shock. Methods/Design The NUTRIREA-2 study is a multicenter, open-label, parallel-group, randomized controlled trial comparing early PN versus early EN in critically ill patients requiring IMV for an expected duration of at least 48 hours, combined with vasoactive drugs, for shock. Patients will be allocated at random to first-line PN for at least 72 hours or to first-line EN. In both groups, nutritional support will be started within 24 hours after IMV initiation. Calorie targets will be 20 to 25 kcal/kg/day during the first week, then 25 to 30 kcal/kg/day thereafter. Patients receiving PN may be switched to EN after at least 72 hours in the event of shock resolution (no vasoactive drugs for 24 consecutive hours and arterial lactic acid level below 2 mmol/L). On day 7, all patients receiving PN and having no contraindications to EN will be switched to EN. In both groups, supplemental PN may be added to EN after day 7 in patients with persistent intolerance to EN and inadequate calorie intake. We plan to recruit 2,854 patients at 44 participating ICUs. Discussion The NUTRIREA-2 study is the first large randomized controlled trial designed to assess the hypothesis that early EN improves survival compared to early PN in ICU patients. Enrollment started on 22 March 2013 and is expected to end in November 2015. Trial registration ClinicalTrials.gov Identifier:
NCT01802099 (registered 27 February 2013)
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jean Reignier
- UPRES EA-3826, Clinical and Experimental Therapies for Infections, University of Nantes, Nantes, France.
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Elke G, Felbinger TW, Heyland DK. Gastric residual volume in critically ill patients: a dead marker or still alive? Nutr Clin Pract 2014; 30:59-71. [PMID: 25524884 DOI: 10.1177/0884533614562841] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Early enteral nutrition (EN) is consistently recommended as first-line nutrition therapy in critically ill patients since it favorably alters outcome, providing both nutrition and nonnutrition benefits. However, critically ill patients receiving mechanical ventilation are at risk for regurgitation, pulmonary aspiration, and eventually ventilator-associated pneumonia (VAP). EN may increase these risks when gastrointestinal (GI) dysfunction is present. Gastric residual volume (GRV) is considered a surrogate parameter of GI dysfunction during the progression of enteral feeding in the early phase of critical illness and beyond. By monitoring GRV, clinicians may detect patients with delayed gastric emptying earlier and intervene with strategies that minimize or prevent VAP as one of the major risks of EN. The value of periodic GRV measurements with regard to risk reduction of VAP incidence has frequently been questioned in the past years. Increasing the GRV threshold before interrupting gastric feeding results in marginal increases in EN delivery. More recently, a large randomized clinical trial revealed that abandoning GRV monitoring did not negatively affect clinical outcomes (including VAP) in mechanically ventilated patients. The results have revived the discussion on the role of GRV monitoring in critically ill, mechanically ventilated patients receiving early EN. This review summarizes the most recent clinical evidence on the use of GRV monitoring in critically ill patients. Based on the clinical evidence, it discusses the pros and cons and further addresses whether GRV is a dead marker or still alive for the nutrition management of critically ill patients.
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Affiliation(s)
- Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Thomas W Felbinger
- Department of Anesthesiology, Critical Care and Pain Medicine, Neuperlach Medical Center, Munich, Germany
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
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Reintam Blaser A, Starkopf L, Deane AM, Poeze M, Starkopf J. Comparison of different definitions of feeding intolerance: A retrospective observational study. Clin Nutr 2014; 34:956-61. [PMID: 25467878 DOI: 10.1016/j.clnu.2014.10.006] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Revised: 10/07/2014] [Accepted: 10/21/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS While feeding intolerance (FI) is clinically important in the critically ill it is inconsistently defined. By evaluating definitions of FI based on relationships between symptoms and signs of gastrointestinal (GI) dysfunction and mortality the objective was to define FI using the definition that was most strongly associated with subsequent mortality. METHODS Data from all adult patients admitted to a single ICU between 2004 and 2011, and who were receiving enteral nutrition (EN), were analysed. The amount of EN administered, presence of absent bowel sounds (BS), vomiting and/or regurgitation, diarrhoea, bowel distension, and large gastric residual volumes (GRVs) were documented daily. A GRV ≥500 ml/day was considered as large and the sum of gastrointestinal (GI) symptoms including large GRV was calculated daily. Various definitions of FI were modelled. Definitions using only GRV, or GRV with other GI symptoms, or GRV and failure to reach preset EN targets were evaluated. The predictive power of FI on mortality was tested by adding the presence of FI (different definitions were tested one-by-one) into multiple regression analyses together with admission day demographic and severity of illness variables. RESULTS Of the 1712 patients included, 221 (12.9%) died in ICU and 495 (28.9%) had died within 90 days after ICU admission. The definition of FI based on the presence of at least three out of five GI symptoms was most strongly related to ICU-mortality (6.3% prevalence in survivors vs. 23.5% in non-survivors, p < 0.001, odds ratio (95%CI) 3.39 (2.23-5.14)), whereas EN <23% of caloric target was the strongest predictor for mortality 90 days after admission (50.7% prevalence among survivors vs 75.2% in non-survivors, p < 0.001, odds ratio (95% CI) 2.34 (1.80-3.04)). CONCLUSIONS FI is associated with increased mortality but the strength of this relationship depends on the definition used. The 'best' definition of FI for prediction of ICU-mortality is based on a complex assessment of GI symptoms (including large GRV), whereas enteral underfeeding is the definition of FI that is the strongest predictor of death within 90 days of admission. Our 'best' definitions are not immediately generalizable, but should help building up future studies.
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Affiliation(s)
- Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Puusepa 8, Tartu 51014, Estonia; Department of Anaesthesiology and Intensive Care Medicine, Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne 16, Switzerland.
| | - Liis Starkopf
- Department of Anaesthesiology and Intensive Care, University of Tartu, Puusepa 8, Tartu 51014, Estonia; Faculty of Mathematics and Computer Science, University of Tartu, J. Liivi 2, Tartu 50409, Estonia.
| | - Adam M Deane
- Discipline of Acute Care Medicine, University of Adelaide, Level 5, Eleanor Harrald Building, Frome St, Adelaide SA 5000, Australia; Department of Critical Care Services, Royal Adelaide Hospital, North Terrace, Adelaide SA 5000, Australia.
| | - Martijn Poeze
- Department of Surgery/Intensive Care Medicine, Maastricht University Medical Center, P. Debyelaan 25, 6202 AZ Maastricht, Netherlands.
| | - Joel Starkopf
- Department of Anaesthesiology and Intensive Care, University of Tartu, Puusepa 8, Tartu 51014, Estonia; Department of Anaesthesiology and Intensive Care, Tartu University Clinics, Puusepa 1A, Tartu 51014, Estonia.
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