Correlation analysis of norepinephrine dose on enteral nutrition tolerance and prognosis in patients with septic shock

BACKGROUND

To explore correlation between the dose of norepinephrine and the timing of starting enteral nutrition in septic shock (SS) patients.

METHODS

Totally 150 SS patients treated with enteral nutrition (EN) in Shiyan People's Hospital from Dece20 to July 2022 were included in this retrospective analysis. Patients were divided into tolerance group (n = 97) and intolerance group (n = 53) according to whether EN was tolerated or not. The study indexes include baseline characteristics [gender, age, weight, body mass index (BMI), scores of acute physiology and chronic health evaluation II system (APACHE II), comorbidity, time in-hospital, prognosis], clinical indexes [mean arterial pressure (MAP), time of mechanical ventilation (MV), norepinephrine dose at the time of starting EN, using of sedative drug, gastrointestinal motility drugs and cardiotonic drugs], EN indexes (timing of starting EN, speed of EN infusion, calorie of EN per day, EN target percent), and gastrointestinal intolerance index [residual gastric volume > 250 ml, vomiting, aspiration, gastrointestinal bleeding, blood lactic acid (BLA)]. Student-t test and Mann-Whitney test were used for test of measurement data. Chi-square test and fisher exact test were used for comparison of categorical data.

RESULTS

There were 51 (52.58%) male and 46 (47.42%) female patients with a median age of 66.4 ± 12.8 years old in tolerance group. There were 29 (54.72%) male and 24 (45.28%) female patients with a median age 67.3 ± 12.5 years old in intolerance group. The weight and BMI were significantly higher in intolerance group than those of tolerance group (both P < 0.001). There was no significant difference of comorbidity rate between two groups (all P > 0.05). Before the overlapping time of EN and norepinephrine, there were significantly more patients receiving gastrointestinal motility drugs in intolerance group compared with tolerance group (58.49% vs. 20.62%, P < 0.001). Patients in tolerance group had significantly less residual volume in gastric than that of intolerance group (188.00 ± 52.32 vs. 247.83 ± 34.95, P < 0.001). The rate of residual volume in gastric > 250ml (9.28% vs. 37.74%, P < 0.001), vomiting (15.46% vs. 35.85%, P = 0.004) and aspiration(16.49% vs. 33.96%, P = 0.018) were significantly lower in tolerance group than those of intolerance group. The BLA in tolerance group was significantly lower than that of intolerance group (1.84 ± 0.63 vs. 2.90 ± 1.5 3mmol/L,P < 0.001). There were significantly more patients with increased BLA (75.47% vs. 30.93%, P < 0.001) and > 2mmol BLA rising (43.40% vs. 8.25%, P < 0.001) in intolerance group than those of tolerance group. Patients in tolerance group had significantly lower time of starting EN (40.97 ± 9.53 vs. 49.85 ± 11.61 h, P < 0.001), dose of NE(0.23 ± 0.07 vs. 0.28 ± 0.10 ug/kg/min, P = 0.049), mortality in hospital (18.56% vs. 49.06%, P < 0.001) and mortality in ICU (16.49% vs. 37.74%, P < 0.001) compared with intolerance group. The EN target percent (92.78% vs. 56.60%, P < 0.001) and calorie of EN during overlapping period (20.22 ± 5.99 vs. 16.21 ± 2.52 kcal/kg/day, P < 0.001) in tolerance group were significantly higher than those of intolerance group.

CONCLUSIONS

SS patients should be comprehensively evaluated according to their condition. Obese patients are more prone to EN intolerance, and those who can tolerate EN should be implemented as soon as possible. The use dose of NE is significantly related to EN tolerance. When the use dose is low, EN tolerance is greater.

Nonocclusive mesenteric ischemia associated with postoperative jejunal tube feeding: Indicators for clinical management

Postoperative nutrition via a jejunal tube after major abdominal surgery is usually well tolerated. However, some patients develop nonocclusive mesenteric ischemia (NOMI). This morbid complication has a grave prognosis with a mortality rate of 41% to 100%. Early symptoms are nonspecific, and no treatment guideline is available. We reviewed cases of NOMI at our institution and cases described in the literature to identify factors that impact the clinical course. Among five patients, three had no necrosis and one had segmental necrosis and perforation. These patients recovered with limited resection and decompression of the bowel and abdominal compartment. In one patient with extended bowel necrosis at the time of re-laparotomy, NOMI progressed and the patient died of multiple organ failure. The extent of small bowel necrosis at the time of re-laparotomy is a relevant prognostic factor. Therefore, early diagnosis and treatment of NOMI can improve the prognosis. Clinical symptoms of abdominal distension, cramps and high reflux plus paraclinical signs of leukocytosis, hypotension and computed tomography findings of a distended small bowel with pneumatosis intestinalis and portal venous gas can help to establish the diagnosis. We herein introduce an algorithm for the diagnosis and management of NOMI associated with jejunal tube feeding.

Non-occlusive mesenteric ischemia associated with enteral feeding after esophagectomy for esophageal cancer: report of two cases and review of the literature

Background

Non-occlusive mesenteric ischemia (NOMI) is a rare but life-threatening complication of early postoperative enteral feeding. We herein report two patients who developed NOMI during enteral feeding after esophagectomy.

Case presentation

In case 1, a 75-year-old man with no medical history was diagnosed with multiple primary cancers of the esophagus, stomach, and kidney. He underwent percutaneous endoscopic gastrostomy tube placement followed by thoracoscopic esophagectomy and cervical esophagostomy placement as the first-stage operation. Gastrostomy feeding was started on postoperative day (POD) 3 with a polymeric formula (ENSURE H®). On POD 7, he developed acute abdominal pain and distension with bloody drainage through the gastrostomy tube. Dynamic computed tomography showed massive hepatic portal venous gas and pneumatosis intestinalis. Angiography showed diffuse spasms in the branches of the superior mesenteric artery. Under a diagnosis of NOMI, we started intra-arterial infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 48.

In case 2, a 68-year-old man with diabetes and atrial fibrillation was diagnosed with esophageal cancer. His medical history was significant for pylorus-preserving gastrectomy for gastric cancer and small bowel resection for trauma. He underwent thoracoscopic esophagectomy, open total gastrectomy, colonic reconstruction, and jejunostomy tube placement. Adhesiolysis for abdominal severe adhesions caused by previous operations was difficult. Jejunostomy feeding was started on POD 3 with a polymeric formula (Racol®). On POD 7, he developed persistent diarrhea and cervical anastomotic leakage. On POD 9, he developed acute abdominal pain and distension with bloody drainage through the jejunostomy tube. Dynamic computed tomography showed the same findings as in case 1. Under a diagnosis of NOMI, we started intravenous infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 28.

Conclusions

The causes of feeding-related NOMI may include the use of a high-osmolarity formula, preoperative malnutrition, abdominal adhesiolysis, systemic inflammation after anastomotic leakage, and a medical history of diabetes and atrial fibrillation. NOMI should be considered as a differential diagnosis in patients with these risk factors and clinical features such as acute abdominal pain and distension during enteral feeding.

Tube Feed Necrosis after Major Gastrointestinal Oncologic Surgery: Institutional Lessons and a Review of the Literature

BACKGROUND

Small bowel necrosis after enteral feeding through a jejunostomy tube (tube feed necrosis, TFN) is a rare, serious complication of major abdominal surgery. However, strategies to reduce the incidence and morbidity of TFN are not well established. Here, in the largest series of TFN presented to date, we report our institutional experience and a comprehensive review of the literature.

METHODS

Eight patients who experienced TFN from 2000 to 2014 after major abdominal surgery for oncologic indications at the University of Cincinnati were reviewed. Characteristics of post-operative courses and outcomes were reviewed prior to and after a change in tube-feeding protocol. The existing literature addressing TFN over the last three decades was also reviewed.

RESULTS

Patients with TFN ranged from 50 to 74 years old and presented with upper gastrointestinal tract malignancies amenable to surgical resection. Six and two cases of TFN occurred following pancreatectomy and esophagectomy, respectively. Prior to TF protocol changes, which included initiation at a low rate, titrating up more slowly and starting at one-half strength TF, three of six cases of TFN (50%) resulted in mortality. With the new TF protocol, there were no deaths, goal TF rate was achieved 3 days later, symptoms of TFN were recognized 3 days earlier, and re-operation was conducted 1 day earlier.

CONCLUSION

This case series describes a change in clinical practice that is associated with decreased morbidity and mortality of TFN. Wider implementation and further refinement of this tube-feeding protocol may reduce TFN incidence at other institutions and in patients with other conditions requiring enteral nutrition.

Feeding Jejunostomy-Associated Small Bowel Necrosis After Elective Esophago-Gastric Resection

BACKGROUND

Feeding jejunostomy has increasingly become a standard adjunctive procedure during major esophago-gastric resections. They provide nutritional support during the post-operative period as required. However, significant early complications have been reported, most notably small bowel necrosis. Literature reports have been restricted to case reports or series. This study aims to determine the frequency of this complication in a cohort of patients undergoing esophago-gastric resection, and identify any difference in the risk of this complication between patients undergoing esophagectomy and gastrectomy.

METHODS

Consecutive patients who had esophago-gastric resections for malignancy and who had a feeding jejunostomy placed were identified from a prospectively maintained database at Leicester Royal Infirmary during the years 2009-2015. Case notes were reviewed to extract information relating to demographics, presenting features and clinical outcome.

RESULTS

The study included 360 patients, 285 of which had esophagectomy and 75 had gastrectomy. There were no small bowel complications among esophagectomy patients (0%), while six patients who had total gastrectomy developed small bowel ischemia or necrosis (8%), p = 0.05, in spite of an identical feeding regimen. Every patient that developed the complication underwent surgery with five out six having resection of the infarcted segment and double-barrel stoma formation. A 6-8-week period of parenteral nutrition was required before stoma reversal. One patient had leucocytosis on the day of diagnosis. The other five patients showed no derangements in biochemical or clinical parameters in the preceding 48 h. Five of the six patients survived.

CONCLUSIONS

Small bowel necrosis and perforation is a life-threatening complication of feeding jejunostomy. In our cohort, it happened exclusively in total gastrectomy patients. Antecedent signs were lacking. The condition requires prompt attention with earlier use of CT scanning and a return to the operating room. The presence of pneumatosis intestinalis on CT scan should prompt surgical intervention that improves survival.

Early enteral nutrition in critically ill patients with hemodynamic instability: an evidence-based review and practical advice

Early enteral nutrition (EEN) in critically ill patients is associated with significant benefit as well as elevated risk of complications. Concomitant use of EEN with vasopressors has been associated with nonocclusive bowel necrosis in critically ill patients with hemodynamic instability. The decision when to initiate enteral nutrition in hemodynamically unstable patients that require vasoactive substances remains a clinical dilemma. This review summarizes the effect of EEN and vasoactive agents on gastrointestinal blood flow and perfusion in critically ill patients, based on current evidence. Animal and clinical data involving simultaneous administration of EEN and vasoactive agents for hemodynamic instability are reviewed, and the factors related to the safety and effectiveness of EEN support in this patient population are analyzed. Moreover, practical recommendations are provided. Additional randomized clinical trials are warranted to provide cutting-edge evidence-based guidance about this issue for practitioners of critical care.