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Elmahdi A, Eisa M, Omer E. Aspiration pneumonia in enteral feeding: A review on risks and prevention. Nutr Clin Pract 2023; 38:1247-1252. [PMID: 37227191 DOI: 10.1002/ncp.11020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 04/02/2023] [Accepted: 04/30/2023] [Indexed: 05/26/2023] Open
Abstract
Enteral feeding plays a critical role in the management of hospitalized patients, especially in intensive care units. In addition to delivering important nutrients, it also maintains the integrity of the gut and microbiota. Enteral feeding is also associated with complications and adverse events, some are related to access placement, metabolic and electrolytes disturbances, and aspiration pneumonia. In tube-fed patients, aspiration pneumonia has a prevalence ranging from 4% to 95% with a mortality rate of 17%-62%. Our review has not showed any significant difference in the incidence of aspiration pneumonia between gastric and postpyloric feeding and, given the ease of gastric access, we therefore suggest using gastric feeding as an initial strategy for the delivery of nutrition unless postpyloric access is otherwise indicated for other clinical reasons.
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Affiliation(s)
- Alsiddig Elmahdi
- Internal Medicine, Virginia Commonwealth University Health Systems, Richmond, Virginia, USA
| | - Mohamed Eisa
- Allegheny Center for Digestive Health, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Endashaw Omer
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky, USA
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Saavedra R, Fahy BN. Artificial Nutrition in Patients with Advanced Malignancy. Surg Oncol Clin N Am 2021; 30:505-518. [PMID: 34053665 DOI: 10.1016/j.soc.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Cancer is a progressive disease that can lead to malnutrition and cachexia. Artificial nutrition is a medical therapy used to combat malnutrition in these patients. In this article, the authors discuss factors affecting the decision to use artificial nutrition, including the patient's mental and physical health, technical factors of the procedures used to deliver artificial nutrition, and the oncologic factors affecting treatment. Through this review, the authors provide guidelines on who is and is not likely to benefit from therapy, available routes of administration, and necessary factors to consider for appropriate decision-making for palliative patients and those with advanced cancers."
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Affiliation(s)
- Ramses Saavedra
- Department of Surgery, University of New Mexico, 1 University of New Mexico, MSC 07-4025, Albuquerque, NM 87131, USA
| | - Bridget N Fahy
- Department of Surgery, University of New Mexico, 1 University of New Mexico, MSC 07-4025, Albuquerque, NM 87131, USA; Division of Palliative Medicine, University of New Mexico, Albuquerque, NM, USA.
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Li Y, Yang J, Sun S, Huang J, Zhang A, Tang X. Effects of intermittent feeding versus continuous feeding on enteral nutrition tolerance in critically ill patients: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e23528. [PMID: 33327299 PMCID: PMC7738118 DOI: 10.1097/md.0000000000023528] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 11/06/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Nutritional support is an indispensable treatment for critically ill patients. Enteral nutrition intolerance is one of the obstacles to the smooth progress of enteral nutrition.Enteral nutrition can be divided into continuous feeding and intermittent feeding. However, the effectiveness and safety of the 2 ways of nutrition infusion are controversial clinically. Therefore, this meta-analysis further evaluated the effect of intermittent feeding versus continuous feeding on enteral nutrition tolerance in critically ill patients. METHODS Cochrane Library, PubMed, Web of Science, EMbase, China Biology Medicine disc (CBM), China Science and Technology Journal Database (VIP), China Journal full-text Database (CNKI), and Wanfang Database were searched for all randomized controlled trials (RCTs) on the effects of intermittent and continuous feeding on enteral nutrition tolerance in critically ill patients. The quality of literatures was strictly evaluated and the data were extracted by 2 investigators. Meta-analysis was carried out by applying RevMan 5.5 software. RESULTS The results of this meta-analysis are published in peer-reviewed journals. CONCLUSIONS This study provides reliable evidence-based support for the effects of intermittent and continuous feeding on enteral nutrition tolerance in critically ill patients. OSF REGISTRATION NUMBER DOI 10.17605/OSF.IO/4BP5X.
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Shahi N, Skillman HE, Phillips R, Cooper EH, Shirek GP, Goldsmith A, Meier MR, Kaizer AM, Recicar JF, Banks A, Moulton SL. Why Delay? Early Enteral Nutrition in Pediatric Burn Patients Improves Outcomes. J Burn Care Res 2020; 42:171-176. [PMID: 32810219 DOI: 10.1093/jbcr/iraa129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Children who sustain moderate to large surface area burns present in a hypermetabolic state with increased caloric and protein requirements. A policy was implemented at our institution in 2017 to initiate enteral nutrition (EN) in pediatric burn patients within 4 hours of admission. The authors hypothesize that early EN (initiated within 4 hours of admission) is more beneficial than late EN (initiated ≥ 4 hours from admission) for pediatric burn patients and is associated with decreased rates of pneumonia, increased calorie and protein intake, fewer feeding complications, a shorter Intensive Care Unit (ICU) length of stay (LOS), and a reduced hospital LOS. Children who sustained a total body surface area (TBSA) burn injury ≥ 10% between 2011 and 2018 were identified in a prospectively maintained burn registry at Children's Hospital Colorado. Patients were stratified into two groups for comparison: early EN and late EN. The authors identified 132 pediatric burn patients who met inclusion criteria, and most (60%) were male. Approximately half (48%) of the study patients were in the early EN group. The early EN group had lower rates of underfeeding during the first week (P = .014) and shorter ICU LOS (P = .025). Achieving and sustaining adequate nutrition in pediatric burn patients with moderate to large surface area burn injuries are critical to recovery. Early EN in pediatric burn patients is associated with decreased underfeeding and reduced ICU LOS. The authors recommend protocols to institute feeding for patients with burns ≥ 10% TBSA within 4 hours of admission at all pediatric burn centers.
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Affiliation(s)
- Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora.,Department of Surgery, University of Massachusetts, Worcester.,Department of Surgery, University of Colorado School of Medicine, Aurora
| | | | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora.,Department of Surgery, University of Colorado School of Medicine, Aurora
| | - Emily H Cooper
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora
| | | | - Adam Goldsmith
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora
| | - Maxene R Meier
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora
| | - Alexander M Kaizer
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora
| | - John F Recicar
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora
| | - Ashley Banks
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora
| | - Steven L Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora.,Department of Surgery, University of Colorado School of Medicine, Aurora
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A comparative study of risk of pneumonia and mortalities between nasogastric and jejunostomy feeding routes in surgical critically ill patients with perforated peptic ulcer. PLoS One 2019; 14:e0219258. [PMID: 31269088 PMCID: PMC6608947 DOI: 10.1371/journal.pone.0219258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 06/19/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Enteral nutrition (EN) is important in the management of critically illness. Yet, the best route (e.g. pre-pyloric or post-pyloric) for EN in critically ill patients remains to be investigated, especially in specific surgical patients group. In addition, EN could be associated with a higher risk of aspiration pneumonia. Therefore, we evaluate the effect of various EN routes in surgical critically ill perforated peptic ulcer (PPU) patients who underwent surgery and required mechanical ventilation. METHOD We collected data of surgical critically ill PPU patients admitted to intensive care unit. The patients were managed with appropriate care bundle and program. To reduce the impact of surgery types, we excluded those who had received other surgical procedures and included patients that only received simple closure. Patients were classified into nasogastric and jejunostomy feeding groups. The demographics, severity scores (e.g.: APACHE II, SOFA, and POSSUM), body mass index (BMI), comorbidities, ventilator days, use of proton pump inhibitors (PPIs), pneumonia occurrence, mortality and complications were collected for analysis. RESULTS A total of 136 critically ill PPU patients that received surgery and mechanical ventilation were enrolled. There were 53 patients in NG group and 83 patients in FJ group. There were no differences in demographics, severity scores, BMI, comorbidities, ventilator days, use of PPIs, pneumonia occurrence, mortalities and complications between groups. CONCLUSION Our study indicates that there are no differences in mortalities and pneumonia occurrence using nasogastric or feeding jejunostomy in surgical critically ill PPU patients underwent surgery. However, further studies are required.
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Affiliation(s)
- Sarita Singhal
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY.,Digestive Diseases and Nutrition Center, Women and Children's Hospital of Buffalo, Kaleida Health, Buffalo, NY
| | - Susan S Baker
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY.,Digestive Diseases and Nutrition Center, Women and Children's Hospital of Buffalo, Kaleida Health, Buffalo, NY
| | - Georgina A Bojczuk
- Digestive Diseases and Nutrition Center, Women and Children's Hospital of Buffalo, Kaleida Health, Buffalo, NY
| | - Robert D Baker
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY.,Digestive Diseases and Nutrition Center, Women and Children's Hospital of Buffalo, Kaleida Health, Buffalo, NY
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Alkhawaja S, Martin C, Butler RJ, Gwadry‐Sridhar F. Post-pyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults. Cochrane Database Syst Rev 2015; 2015:CD008875. [PMID: 26241698 PMCID: PMC6516803 DOI: 10.1002/14651858.cd008875.pub2] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nutritional support is an essential component of critical care. Malnutrition has been associated with poor outcomes among patients in intensive care units (ICUs). Evidence suggests that in patients with a functional gut, nutrition should be administered through the enteral route. One of the main concerns regarding use of the enteral route is the reduction in gastric motility that is often responsible for limited caloric intake. This increases the risk of aspiration pneumonia as well. Post-pyloric feeding, in which the feed is delivered directly into the duodenum or the jejunum, could solve these issues and provide additional benefits over routine gastric administration of the feed. OBJECTIVES To evaluate the effectiveness and safety of post-pyloric feeding versus gastric feeding for critically ill adults who require enteral tube feeding. SEARCH METHODS We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL;2013 Issue 10), MEDLINE (Ovid) (1950 to October 2013), EMBASE (Ovid) (1980 to October 2013) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host (1982 to October 2013). We reran the search on 4 February 2015 and will deal with the one study of interest when we update the review. SELECTION CRITERIA Randomized or quasi-randomized controlled trials comparing post-pyloric versus gastric tube feeding in critically ill adults. DATA COLLECTION AND ANALYSIS We extracted data using the standard methods of the Cochrane Anaesthesia, Critical and Emergency Care Group and separately evaluated trial quality and data extraction as performed by each review author. We contacted trials authors to request missing data. MAIN RESULTS We pooled data from 14 trials of 1109 participants in a meta-analysis. Moderate quality evidence suggests that post-pyloric feeding is associated with low rates of pneumonia compared with gastric tube feeding (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.51 to 0.84). Low-quality evidence shows an increase in the percentage of total nutrient delivered to the patient by post-pyloric feeding (mean difference (MD) 7.8%, 95% CI 1.43 to 14.18).Evidence of moderate quality revealed no differences in duration of mechanical ventilation or in mortality. Intensive care unit (ICU) length of stay was similar between the two groups. The effect on the time required to achieve the full nutrition target was uncertain (MD -1.99 hours 95% CI -10.97 to 6.99) (very low-quality evidence). We found no evidence suggesting an increase in the rate of complications during insertion or maintenance of the tube in the post-pyloric group (RR 0.51, 95% CI 0.19 to 1.364; RR1.63, 95% CI 0.93 to 2.86, respectively); evidence was assessed as being of low quality for both.Risk of bias was generally low in most studies, and review authors expressed concern regarding lack of blinding of the caregiver in most trials. AUTHORS' CONCLUSIONS We found moderate-quality evidence of a 30% lower rate of pneumonia associated with post-pyloric feeding and low-quality evidence suggesting an increase in the amount of nutrition delivered to these participants. We do not have sufficient evidence to show that other clinically important outcomes such as duration of mechanical ventilation, mortality and length of stay were affected by the site of tube feeding.Low-quality evidence suggests that insertion of a post-pyloric feeding tube appears to be safe and was not associated with increased complications when compared with gastric tube insertion. Placement of the post-pyloric tube can present challenges; the procedure is technically difficult, requiring expertise and sophisticated radiological or endoscopic assistance.We recommend that use of a post-pyloric feeding tube may be preferred for ICU patients for whom placement of the post-pyloric feeding tube is feasible. Findings of this review preclude recommendations regarding the best method for placing the post-pyloric feeding tube. The clinician is left with this decision, which should be based on the policies of institutional facilities and should be made on a case-by-case basis. Protocols and training for bedside placement by physicians or nurses should be evaluated.
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Affiliation(s)
- Sana Alkhawaja
- University of Western Ontario, London Health Science CentreDepartment of Critical Care MedicineDivision of Critical Care MedicineLondon, OntarioCanadaN6J 2X7
| | - Claudio Martin
- University of Western Ontario, London Health Science CentreDepartment of Critical Care MedicineDivision of Critical Care MedicineLondon, OntarioCanadaN6J 2X7
| | - Ronald J Butler
- University of Western Ontario, London Health Sciences Centre, University HospitalDepartment of Anesthesia and Critical Care339 Windermere RdLondon, OntarioCanadaN6A 5A5
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Williams ML, Nolan JP. Is enteral feeding tolerated during therapeutic hypothermia? Resuscitation 2014; 85:1469-72. [PMID: 25193798 DOI: 10.1016/j.resuscitation.2014.08.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 08/12/2014] [Accepted: 08/15/2014] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To determine whether patients undergoing therapeutic hypothermia following cardiac arrest tolerate early enteral nutrition. METHODS We undertook a single-centre longitudinal cohort analysis of the tolerance of enteral feeding by 55 patients treated with therapeutic hypothermia following resuscitation from cardiac arrest. The observation period was divided into three phases: (1) 24h at target temperature (32-34 °C); (2) 24h rewarming to 36.5 °C; and (3) 24h maintained at a core temperature below 37.5 °C. RESULTS During period 1, patients tolerated a median of 72% (interquartile range (IQR) 68.7%; range 31.3-100%) of administered feed. During period 2 (rewarming phase), a median of 95% (IQR 66.2%; range 33.77-100%) of administered feed was tolerated. During period 3 (normothermia) a median of 100% (IQR 4.75%; range 95.25-100%) of administered feed was tolerated. The highest incidence of vomiting or regurgitation of feed (19% of patients) occurred between 24 and 48 h of therapy. CONCLUSIONS Patients undergoing therapeutic hypothermia following cardiac arrest may be able to tolerate a substantial proportion of their daily nutritional requirements. It is possible that routine use of prokinetic drugs during this period may increase the success of feed delivery enterally and this could usefully be explored.
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Affiliation(s)
- Marie-Louise Williams
- Intensive Therapy Unit, Royal United Hospital, Combe Park, Bath BA1 3NG, United Kingdom.
| | - Jerry P Nolan
- Intensive Therapy Unit, Royal United Hospital, Combe Park, Bath BA1 3NG, United Kingdom
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Lee J, Spratling R. Care of Gastrostomy Feeding Tube in Children With Developmental Disabilities. Rehabil Nurs 2014; 39:221-4. [DOI: 10.1002/rnj.144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2013] [Indexed: 01/02/2023]
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Effect of gastric versus post-pyloric feeding on the incidence of pneumonia in critically ill patients: Observations from traditional and Bayesian random-effects meta-analysis. Clin Nutr 2013; 32:8-15. [DOI: 10.1016/j.clnu.2012.07.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2012] [Revised: 07/01/2012] [Accepted: 07/11/2012] [Indexed: 12/11/2022]
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Metheny NA, Stewart BJ, McClave SA. Relationship between feeding tube site and respiratory outcomes. JPEN J Parenter Enteral Nutr 2011; 35:346-55. [PMID: 21527596 DOI: 10.1177/0148607110377096] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND It is unclear if placing feeding tubes postpylorically to prevent respiratory complications is worth the extra effort. This study sought to determine the extent to which aspiration and pneumonia are associated with feeding site (controlling for the effects of severity of illness, degree of head-of-bed elevation, level of sedation, and use of gastric suction). METHODS A retrospective analysis was performed on a large data set gathered prospectively to evaluate aspiration in critically ill, mechanically ventilated patients. Feeding site was designated by attending physicians and confirmed by radiography. Each patient participated in the study for 3 consecutive days, with pneumonia assessed by the simplified Clinical Pulmonary Infection Score on the fourth day. Tracheal secretions were assayed for pepsin in a research laboratory; the presence of pepsin served as a proxy for aspiration. A total of 428 patients were included in the regression analyses performed to address the research objectives. RESULTS As compared with the stomach, the percentage of aspiration was 11.6% lower when feeding tubes were in the first portion of the duodenum, 13.2% lower when in the second/third portions of the duodenum, and 18.0% lower when in the fourth portion of the duodenum and beyond (all significant at P < .001). Pneumonia occurred less often when feedings were introduced at or beyond the second portion of the duodenum (P = .020). CONCLUSIONS The findings support feeding critically ill patients with numerous risk factors for aspiration in the mid-duodenum and beyond to reduce the risk of aspiration and associated pneumonia.
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Affiliation(s)
- Norma A Metheny
- School of Nursing, Saint Louis University, St Louis, Missouri 63104, USA.
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Reintam A, Parm P, Kitus R, Starkopf J, Kern H. Gastrointestinal failure score in critically ill patients: a prospective observational study. Crit Care 2008; 12:R90. [PMID: 18625051 PMCID: PMC2575570 DOI: 10.1186/cc6958] [Citation(s) in RCA: 139] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Revised: 07/08/2008] [Accepted: 07/14/2008] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION There are no universally accepted diagnostic criteria for gastrointestinal failure in critically ill patients. In the present study we tested whether the occurrence of food intolerance (FI) and intra-abdominal hypertension (IAH), combined in a 5-grade scoring system for assessment of gastrointestinal function (the Gastrointestinal Failure [GIF] score), predicts mortality. The prognostic value of the GIF score alone and in combination with the Sequential Organ Failure Assessment (SOFA) score is evaluated, and the incidence and outcome of gastrointestinal failure is described relative to the GIF score. METHODS A total of 264 subsequently hospitalized patients, who were mechanically ventilated on admission and stayed in the intensive care unit (ICU) for longer than 24 hours, were prospectively studied. GIF score was documented daily as follows: 0 = normal gastrointestinal function; 1 = enteral feeding with under 50% of calculated needs or no feeding 3 days after abdominal surgery; 2 = FI or IAH; 3 = FI and IAH; and 4 = abdominal compartment syndrome (ACS). Admission parameters and mean GIF and SOFA scores for the first 3 days were used to predict ICU outcome. RESULTS FI developed in 58.3%, IAH in 27.3%, and both together in 22.7% of patients. The mean GIF score for the first 3 days in the ICU was identified as an independent risk factor for mortality (odds ratio = 3.02, 95% confidence interval = 1.63 to 5.59; P < 0.001). The GIF score integrated into the SOFA score allowed better prediction of ICU mortality than did the SOFA score alone, and was an independent predictor of mortality (odds ratio = 1.49, 95% confidence interval = 1.28 to 1.74; P < 0.001). The development of gastrointestinal failure (FI plus IAH) was associated with significantly higher ICU and 90-day mortality. CONCLUSION The GIF score is useful for classifying information on the gastrointestinal system. The mean GIF score during the first 3 days in the ICU had high prognostic value for ICU mortality. Development of gastrointestinal failure is associated with significantly impaired outcome.
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Affiliation(s)
- Annika Reintam
- Clinic of Anaesthesiology and Intensive Care, University of Tartu, Puusepa, Tartu 51014, Estonia
- Department of Anaesthesiology and Intensive Care, East Tallinn Central Hospital, Ravi, Tallinn 10138, Estonia
| | - Pille Parm
- Clinic of Anaesthesiology and Intensive Care, Tartu University Hospital, Puusepa, Tartu 51014, Estonia
| | - Reet Kitus
- Clinic of Anaesthesiology and Intensive Care, University of Tartu, Puusepa, Tartu 51014, Estonia
- Clinic of Anaesthesiology and Intensive Care, Tartu University Hospital, Puusepa, Tartu 51014, Estonia
| | - Joel Starkopf
- Clinic of Anaesthesiology and Intensive Care, University of Tartu, Puusepa, Tartu 51014, Estonia
- Clinic of Anaesthesiology and Intensive Care, Tartu University Hospital, Puusepa, Tartu 51014, Estonia
| | - Hartmut Kern
- Clinic of Anaesthesiology and Intensive Care, University of Tartu, Puusepa, Tartu 51014, Estonia
- Klinik für Anästhesiologie und Intensivmedizin, DRK Kliniken Berlin Köpenick, Salvador-Allende-Straße, Berlin 12559, Germany
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