Comparison of the clinical characteristics and prognosis of primary versus secondary acute gastrointestinal injury in critically ill patients

Abdominal physical examinations in early stages benefit critically ill patients without primary gastrointestinal diseases: a retrospective cohort study

Background

Gastrointestinal (GI) function is critical for patients in intensive care units (ICUs). Whether and how much critically ill patients without GI primary diseases benefit from abdominal physical examinations remains unknown. No evidence from big data supports its possible additive value in outcome prediction.

Methods

We performed a big data analysis to confirm the value of abdominal physical examinations in ICU patients without GI primary diseases. Patients were selected from the Medical Information Mart for Intensive Care (MIMIC)-IV database and classified into two groups depending on whether they received abdominal palpation and auscultation. The primary outcome was the 28-day mortality. Statistical approaches included Cox regression, propensity score matching, and inverse probability of treatment weighting. Then, the abdominal physical examination group was randomly divided into the training and testing cohorts in an 8:2 ratio. And patients with GI primary diseases were selected as the validation group. Several machine learning algorithms, including Random Forest, Gradient Boosting Decision Tree, Adaboost, Extra Trees, Bagging, and Multi-Layer Perceptron, were used to develop in-hospital mortality predictive models.

Results

Abdominal physical examinations were performed in 868 (2.63%) of 33,007 patients without primary GI diseases. A significant benefit in terms of 28-day mortality was observed among the abdominal physical examination group (HR 0.75, 95% CI 0.56-0.99; p = 0.043), and a higher examination frequency was associated with improved outcomes (HR 0.62, 95%CI 0.40-0.98; p = 0.042). Machine learning studies further revealed that abdominal physical examinations were valuable in predicting in-hospital mortality. Considering both model performance and storage space, the Multi-Layer Perceptron model performed the best in predicting mortality (AUC = 0.9548 in the testing set and AUC = 0.9833 in the validation set).

Conclusion

Conducting abdominal physical examinations improves outcomes in critically ill patients without GI primary diseases. The results can be used to predict in-hospital mortality using machine learning algorithms.

Acute gastrointestinal injury and altered gut microbiota are related to sepsis-induced cholestasis in patients with intra-abdominal infection: a retrospective and prospective observational study

Background

Sepsis-associated liver dysfunction (SALD) has high incidence and mortality in patients with intra-abdominal infection (IAI). The associations between acute gastrointestinal injury (AGI), gut microbiota, and SALD were evaluated in patients with IAI.

Methods

A retrospective study was conducted to assess the relationship between AGI and SALD in patients with IAI. Patients were divided into non-SALD and sepsis-induced cholestasis (SIC) groups, which is a subtype of SALD. SIC was defined as total bilirubin >2 mg/dL. AGI incidences between the two groups were compared using Chi-square test. Subsequently, a prospective study was conducted to investigate the gut microbiota differences between patients without SALD and those with SIC. Fecal samples were collected on days 1, 3, and 7 after admission to analyze changes in gut microbiota using 16S ribosomal ribonucleic acid sequencing.

Results

One hundred thirty-four patients with IAI were included retrospectively, with 77 SALD and 57 non-SALD cases. Among patients with SALD, 71 were diagnosed with SIC. Patients with SIC had a higher incidence of AGI compared to those without SALD (28.07% vs. 56.34%, p < 0.05), and a severity-dependent relationship was found between AGI grade and SIC occurrence. Subsequently, 20 patients with IAI were recruited prospectively, with 10 patients each assigned to the non-SALD and SIC groups. Patients with SIC had a more severe gut microbiota disorder on day 7 than those without SALD, including lower microbiota diversities, decreased abundance of Firmicutes and Bacteroidetes, and increased abundance of Proteobacteria and Actinobacteria at the phylum level. Furthermore, Burkholderia - Caballeronia - Paraburkholderia and Delftia, the two most abundant genera, were significantly higher in the SIC group than in the non-SALD group. Functional prediction analysis showed that the top three KEGG pathways were ribosome, pyrimidine metabolism, and the two-component system. During the first week, the abundance of Proteobacteria decreased significantly, whereas Cyanobacteria increased in the non-SALD group; however, the phyla taxa did not change significantly in the SIC group.

Conclusion

There exists a severity-dependent relationship between AGI grade and SIC occurrence in adult patients with IAI. A severe gut microbiota disorder was discovered in SIC during the first week of the intensive care unit stay.

Acute gastrointestinal failure is associated with worse hemodynamic and perfusion parameters over 48 h after admission in patients with septic shock: Retrospective cohort study

BACKGROUND

This study aimed to investigate the relationship between acute gastrointestinal injury (AGI) and hemodynamic and perfusion parameters in the first week of intensive care unit (ICU) admission and evaluate the association of AGI with ICU and hospital outcomes in patients with septic shock undergoing mechanical ventilation.

METHODS

This retrospective cohort study applied the criteria proposed by the European Society of Intensive Medicine to classify the participants into risk/dysfunction group (AGI grade I and II) and failure group (AGI grade III and IV). Hemodynamic and perfusion parameters data previously collected in the first 48 h after ICU admission (admission, 12, 24, 48 h) were analyzed.

RESULTS

A total of 163 were included and classified into AGI grades I (n = 79), II (n = 64), III (n = 20), and IV (none). Groups consisted of AGI risk/dysfunction (n = 143, 87.8%) and AGI failure (n = 20, 12.2%) patients. Patients with AGI failure had higher heart rate and mottling score (MS) at admission, lower mean arterial pressure, and an oliguria incidence at 12 h compared with those without AGI failure. Skin MS and abdominal primary site of infection were risk factors for AGI failure. AGI failure tended to be a risk factor for ICU mortality (risk ratio [95% CI]: 1.37 [0.99-1.89]; P = 0.053).

CONCLUSION

AGI was frequently observed in patients with septic shock in the first week of ICU admission. Higher heart rate and MS and lower mean arterial pressure and incidence of oliguria were identified in patients with AGI failure compared with those without. AGI failure was associated with ICU mortality.

Acute gastrointestinal injury in critically ill children: Impact on clinical outcome

AIM

To estimate acute gastrointestinal injury (AGI) in critically ill children and association of its severity with mortality.

METHODS

In a prospective cohort study, critically ill children (1 month-18 years) were enrolled. Gastrointestinal symptoms over the first week of admission were classified into AGI grades 1 through 4, using a paediatric adaptation of European Society of Intensive Care Medicine AGI definitions. Performance of AGI grades in predicting 28-day mortality was evaluated.

RESULTS

Of 151 children enrolled, 71 (47%, 95% confidence interval (CI): 38.9-55.3%) developed AGI, with AGI grades 1, 2, 3 and 4 in 22.5%, 15.9%, 6.6% and 2%, respectively. The 28-day mortality progressively increased with AGI grade 0 (15%), 1 (35%), 2 (50%), 3 (70%), through 4 (100%), P < 0.001. Association of AGI grades with 28-day mortality was significant even after adjustment for disease severity, age and nutritional status (odds ratio (OR) = 2.152, 95% CI: 1.455, 3.184). Among AGI grades, and paediatric logistic organ dysfunction-2 score components, cardiovascular (OR = 1.525, 95% CI: 1.142, 2.037) and haematological (OR = 1.719, 95% CI: 1.067, 2.772) components of paediatric logistic organ dysfunction-2 score and AGI grades (OR = 1.565, 95% CI: 1.001, 2.449) showed significant association with 28-day mortality.

CONCLUSIONS

Nearly half of the critically ill children developed AGI. AGI grades were independently associated with increased mortality, and mortality progressively increased with AGI grade.

The Serum Citrulline and D-Lactate are Associated with Gastrointestinal Dysfunction and Failure in Critically Ill Patients

Objective

This study attempted to screen and combine effective biomarkers to analyse the association between these biomarkers and gastrointestinal failure (GIF) in critically ill patients.

Methods

A total of 110 critically ill patients with acute gastrointestinal injury (AGI) admitted to ICU were enrolled. The AGI grade was determined by the AGI classification proposed by ESICM. There were 67 patients in gastrointestinal dysfunction (GID) group (AGI grade II), 43 patients in GIF group (AGI grade III–IV), and 41 healthy adults in healthy control (HC) group. APACHE II and SOFA score were used to evaluate the disease severity. Peripheral blood samples of patients were collected within 24 hours of admission to the ICU (prior-treatment) and after the conventional medication therapy for 7 consecutive days (post-treatment). Citrulline serum level was detected by high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) method, and D-lactate and lipopolysaccharide (LPS) serum levels were measured by ELISA. Pearson correlation, logistic regression, and ROC curve analysis were used.

Results

Patients with GID or GIF had lower serum level of citrulline, while higher levels of D-lactate and LPS than HC. Compared with GID patients, serum level of citrulline was reduced, while D-lactate and LPS were elevated in GIF patients. Correlation analysis displayed that serum levels of citrulline, D-lactate, and LPS were associated with the APACHE II and SOFA score in patients with GID or GIF. Logistics regression analysis showed that citrulline and D-lactate were risk for both GID and GIF. ROC curve analysis exhibited that combination of citrulline and D-lactate had relatively high value to distinguish GID from HC, GIF from GID, and GIF from HC.

Conclusion

Serum citrulline and D-lactate were associated with severity of GIF, combination of citrulline and D-lactate improved the diagnostic efficacy to identify GIF in critically ill patients.

Early Onset of Postoperative Gastrointestinal Dysfunction Is Associated With Unfavorable Outcome in Cardiac Surgery: A Prospective Observational Study

Objective:

The distribution of postoperative gastrointestinal (GI) dysfunction and its association with outcome were investigated in cardiac surgery patients. Gastrointestinal function was evaluated using the Acute Gastrointestinal Injury (AGI) grade proposed by the European Society of Intensive Care Medicine.

Design:

Prospective observational study at a single center.

Setting:

University hospital.

Patients:

Consecutive patients presenting for elective cardiac surgery with extracorporeal circulation (ECC).

Interventions:

None.

Results:

Daily assessment using the AGI grade was performed on the first 3 postoperative days in addition to standard care. For analysis, 3 groups were formed based on the maximum AGI grade: AGI 0, AGI 1, and AGI ≥2. Five hundred and one patients completed the study; 32.7%, 65.1%, and 2.2% of the patients scored a maximum AGI 0, AGI 1, and AGI ≥2, respectively. Patients with AGI grade ≥2 had more frequently undergone thoracic aortic surgery and had longer surgery duration and time on ECC. Patients with AGI grade ≥2 had statistically significant higher frequency of GI complications within 30 days (63.6% vs 1.2% and 5.5% in patients with AGI 0 and AGI 1) and higher 30-day mortality (9.1% vs 0.0% and 1.8% in patients with AGI 0 and AGI 1).

Conclusions:

Early GI dysfunction following cardiac surgery was associated with an unfavorable outcome. Increased attention to GI dysfunction in cardiac surgery patients is warranted and the AGI grade could be a helpful adjunct to a structured approach.

Heparin-binding protein as a biomarker of gastrointestinal dysfunction in critically ill patients: a retrospective cross-sectional study in China

OBJECTIVE

To investigate the association of plasma heparin-binding protein (HBP) with the development of acute gastrointestinal injury (AGI) in critically ill patients.

DESIGN

Clinical retrospective cross-sectional study.

SETTING

A general teaching hospital in China.

PARTICIPANTS

Adult patients (age ≥18 years) admitted to our department with an intensive care unit (ICU) stay ≥5 days.

MAIN OUTCOME MEASURES

HBP levels were recorded twice or more within 5 days after admission. The initial AGI grades and the worst AGI grades within 5 days after admission, the number of patients receiving total enteral nutrition (TEN) and the number of patients with feeding intolerance (FI) and with sepsis were also recorded, along with some clinical severity and outcome variables.

RESULTS

From June 2018 to May 2019, 221 patients were enrolled in this study. We divided patients into four groups based on the HBP values: HBP ≤20 ng/mL, 20<HBP ≤50 ng/mL, 50<HBP ≤100 ng/mL and HBP >100 ng/mL. Significant differences were found in the ratios of AGI deterioration and TEN and the incidence rates of FI and sepsis among the four groups. Differences were also found among the groups regarding the worst AGI grades. The area under receiver operating characteristic curves for AGI deterioration, severe AGI (grades II or above), TEN and FI were 0.738 (p=0.001), 0.774 (p<0.001), 0.810 (p<0.001) and 0.729 (p=0.001), respectively. The optimal HBP cut-off values for AGI deterioration and severe AGI were 53.27 ng/mL and 41.26 ng/mL, respectively. However, no differences in ICU duration or 28-day mortality were found.

CONCLUSIONS

HBP levels were associated with gastrointestinal dysfunction in critically ill patients. Increased HBP was positively correlated with sepsis but it was not correlated with 28-day mortality.

Association between nutrition support and acute gastrointestinal injury in critically ill patients during the first 72 hours

BACKGROUND & AIMS

The impact of nutrition support on patients with acute gastrointestinal injury (AGI) has not been fully determined. This study aimed to 1) investigate the relationship between nutrition support and AGI, as well as nutrition support and prognosis in critically ill AGI patients and 2) evaluate the prognostic benefits of nutrition support in different severity categories of AGI patients.

METHODS

This prospective study included 379 patients in whom AGI occurred in the first 72 h after admission from 12 teaching hospitals in China. Clinical characteristics including demographics, APACHE II score, modified NUTRIC score, SOFA score, calories of nutrition, and 7 and 28-day mortality were recorded. Multiple logistic regression analysis was applied to identify the risk factors for mortality. The survival benefit of nutrition support as reflected by calories of nutrition in 72 h was evaluated for patients categorized according to their APACHE II, modified NUTRIC, and SOFA scores.

RESULTS

Patients were classified into Grades I (n = 141), II (n = 173), III (n = 48), and IV (n = 17). Significant differences were observed among different AGI grade cohorts (I-IV) in terms of APACHE II, SOFA, and modified NUTRIC scores and calories of enteral nutrition (EN), parenteral nutrition (PN), and EN + PN. Ordinal logistic regression analysis showed that only SOFA score was an independent risk factor for AGI grades (P < 0.001). APACHE II score, mechanical ventilation (MV), AGI grades, and calories of EN + PN intake were independent risk factors for 28-d mortality. Increased nutritional intake was associated with reduced mortality in severely ill patients with APACHE II scores ≥15 (P = 0.007).

CONCLUSIONS

AGI grade affected the intake of calories and was one of the risk factors for 28-d mortality. The nutrition intake of patients with AGI grade III to IV was almost only PN. The positive association between nutrition support and prognosis was more apparent in AGI patients with higher APACHE II scores.

Serum ammonia levels on admission for predicting sepsis patient mortality at D28 in the emergency department: A 2-center retrospective study

We assessed the predictive value of serum ammonia level on admission for the 28-day mortality of patients with sepsis.We retrospectively included septic patients admitted to the emergency department of West China Hospital, Sichuan University and The Fourth People's Hospital of Zigong city from June 2017 to May 2018. Patients were divided into 2 groups according to 28-day survival. Comparisons of serum ammonia level and sequential organ failure assessment (SOFA) score were made between 2 groups. Multivariate logistic regression models were employed to determine independent risk factors affecting 28-day mortality rate, and receiver operating characteristic (ROC) curve was also used to evaluate the efficacy of risk factors.Total of 316 patients were included into the study, 221 survived to 28 days and 95 were died before 28 days. The 28-day mortality rate was 30.06%. Multivariate logistic regression analyses revealed that the ammonia level, C reactive protein, SOFA score, and the leukocyte were independent risk factors for the 28-day mortality rate. In predicting the 28-day mortality rate, the SOFA score presented an area under the ROC curve (AUC) of 0.815, and the ammonia levels presented the AUC of 0.813.The ammonia level, C reactive protein, SOFA score, and the leukocyte are independent risk factors for 28-day mortality rate in septic patients. Moreover, the serum ammonia and SOFA score have similar predictive values. The serum ammonia level is also a suitable early indicator for prognostic evaluation of patients with sepsis as well.

Severity of acute gastrointestinal injury grade is a good predictor of mortality in critically ill patients with acute pancreatitis

BACKGROUND

Gastrointestinal (GI) dysfunction is a common and important complication of acute pancreatitis (AP), especially in patients with severe AP. Despite this, there is no consensus means of obtaining a precise assessment of GI function.

AIM

To determine the association between acute gastrointestinal injury (AGI) grade and clinical outcomes in critically ill patients with AP.

METHODS

Patients with AP admitted to our pancreatic intensive care unit from May 2017 to May 2019 were enrolled. GI function was assessed according to the AGI grade proposed by the European Society of Intensive Care Medicine in 2012, which is mainly based on GI symptoms, intra-abdominal pressure, and feeding intolerance in the first week of admission to the intensive care unit. Multivariate logistic regression analysis was performed to assess the association between AGI grade and clinical outcomes in critically ill patients with AP.

RESULTS

Among the 286 patients included, the distribution of patients with various AGI grades was 34.62% with grade I, 22.03% with grade II, 32.52% with grade III, and 10.84% with grade IV. The distribution of mortality was 0% among those with grade I, 6.35% among those with grade II, 30.11% among those with grade III, and 61.29% among those with grade IV, and AGI grade was positively correlated with mortality (χ² = 31.511, P < 0.0001). Multivariate logistic regression analysis showed that age, serum calcium level, AGI grade, persistent renal failure, and persistent circulatory failure were independently associated with mortality. Compared with the Acute Physiology and Chronic Health Evaluation II score (area under the curve: 0.739 vs 0.854; P < 0.05) and Ranson score (area under the curve: 0.72 vs 0.854; P < 0.01), the AGI grade was more useful for predicting mortality.

CONCLUSION

AGI grade is useful for identifying the severity of GI dysfunction and can be used as a predictor of mortality in critically ill patients with AP.

Gastrointestinal failure affects outcome of intensive care

PURPOSE

Goal of this study was to describe incidence and outcome of gastrointestinal failure (GIF) in ICU patients, evaluate its additive role to SOFA score in mortality prediction and describe GIF according to etiology.

MATERIALS AND METHODS

A retrospective study with prospective data collection was conducted in mixed adult ICU patients admitted 2004-2015. GIF was considered present if ≥3 of following 6 symptoms occurred in 1 day: maximum gastric residual volume ≥ 500 mL; absent bowel sounds; vomiting or regurgitation; diarrhea; suspected or radiologically confirmed bowel distension; gastrointestinal bleeding. Division into primary (gastrointestinal pathology causing GIF) and secondary (due to other conditions) GIF was made based on origin of syndrome.

RESULTS

GIF developed in 413 (10.4%) of 3959 patients. Primary GIF occurred in 61.3% and secondary GIF in 38.7% of patients. Development of GIF was associated with longer mechanical ventilation, ICU stay and higher ICU, 30-day and 90-day mortality. Outcomes of patients with primary and secondary GIF were similar. All SOFA sub-scores and number of gastrointestinal symptoms on admission day independently predicted 90-day mortality.

CONCLUSIONS

Gastrointestinal failure, independent of origin, is associated with worse ICU outcome. Similar to other organ failures included in SOFA score, GIF independently predicts mortality.