The frequency, risk factors, and complications of gastrointestinal dysfunction during enteral nutrition in critically ill patients

The effect of abdominal massage and in-bed ROM exercise on gastrointestinal complications and comfort in intensive care unit patients receiving enteral nutrition: A randomized controlled trial

AIM

Abdominal massage facilitates gastric and colonic motility, reduces intra-abdominal distension and increases circulation. In-bed range of motion (ROM) exercise has effects on muscle strength, cardiac parameters and excretion. The aim of this study was to assess the effects of abdominal massage and in-bed ROM exercise on gastrointestinal complications and patient comfort in intensive care patients receiving enteral nutrition.

METHODS

This randomized controlled trial was conducted in the internal intensive care units of two tertiary public hospitals. The sample consisted of 130 patients randomly assigned to three groups (abdominal massage = 44, in-bed ROM exercise = 43, control = 43). The individuals received abdominal massage and in-bed ROM exercises every morning before enteral feeding for 3 days. We assessed gastrointestinal complications and comfort levels of the patients 24 h after each intervention.

RESULTS

While the differences in abdominal distention, defecation status, constipation, and gastric residual volume complications were significant (p < .05), there was no significant difference in diarrhea and vomiting (p > .05). Comfort level showed a statistically significant change in the experimental groups in the in-group comparison (p < .05).

CONCLUSION

Abdominal massage and in-bed ROM exercise reduce abdominal distention, constipation and gastric residual volume. Abdominal massage affects the frequency of defecation; and, both interventions increase the comfort while reducing the pain level over time.

Prevalence and Risk Factors of Enteral Feeding Intolerance in Critically Ill Patients and the Effectiveness of Preventive Treatments: A Prospective Study

Background

Feeding intolerance (FI) is a prevalent cause of enteral nutrition (EN) disruption. Factors that can prevent FI are poorly described.

Objectives

To determine the prevalence and risk factors associated with FI in critically ill patients and the effectiveness of preventive treatments.

Patients and Methods

This prospective observational study included critically ill patients admitted to the ICU of a general hospital who received EN through a nasogastric or nasointestinal tube from March 2020 to October 2021. Independent sample t-test, repeated measurement analysis of variance, and multivariate analysis were used to explore independent risk factors and the efficacy of preventive treatments.

Results

The study included 200 critically ill patients (mean age: 59.1 ± 17.8 years), of whom 131 were male. Most patients (58.50%) developed FI after a median EN duration of 2 days. The independent risk factors for FI were fasting for >3 days, high APACHE II score, and acute gastrointestinal injury (AGI) grade I before EN (P < 0.05). During EN, whole protein was found to be an independent preventive treatment that significantly decreased FI (P < 0.05), while before EN, early use of enema and gastric motility drugs in patients with abdominal distention/constipation significantly decreased FI (for both, P < 0.05). The preventive treatment group had significantly higher intake of the nutrient solution and significantly shorter invasive mechanical ventilation duration than the without preventive treatment group (for both, P < 0.05).

Conclusion

In ICU patients receiving nasogastric or nasointestinal tube feeding, FI was frequent, occurred early, and was more frequent in patients with fasting >3 days, a high APACHE II score, and an AGI grade before EN. Preventive treatments can reduce FI prevalence and result in patients consuming more nutrient solutions and having shorter invasive mechanical ventilation duration.

Chinese Clinical Trial Registry Registration no

ChiCTR-DOD-16008532.

Gastric ultrasound, citrulline, and intestinal fatty acid-binding protein as markers of gastrointestinal dysfunction in critically ill patients: A pilot prospective cohort study

BACKGROUND

Gastrointestinal (GI) dysfunction is common in the intensive care unit (ICU), although there is no consensus on biomarkers of GI dysfunction. We aimed to evaluate ultrasound-based gastric antrum measurements and serum intestinal fatty acid-binding protein (IFABP) and citrulline levels in relation to GI dysfunction in critically ill patients.

METHODS

Adult critically ill patients receiving enteral nutrition and stayed for in the ICU for ≥48 h was included. GI dysfunction was described using Gastrointestinal Dysfunction Score (GIDS). Gastric antrum measurements, including craniocaudal (CC) diameter, anteroposterior diameter, and antral-cross sectional area (CSA), as well as serum levels for IFABP and citrulline, were prospectively recorded at baseline and on day 3 and day 5 of enteral nutrition. The receiver operating characteristic (ROC) analysis was performed to evaluate gastric ultrasound parameters, serum IFABP, and citrulline concentrations in predicting GI dysfunction.

RESULTS

Thirty-nine participants with a median age of 60 years were recruited and 46.2% of participants had GI dysfunction. ROC analysis revealed that the cutoff value of CSA score to predict GI dysfunction was 4.48 cm² , which provided 72.7% sensitivity and 77.2% specificity (area under the curve = 0.768, 95% CI: 0.555-0.980). At baseline, gastric residual volume was highly correlated with CC diameter and CSA (r = 0.764, P < 0.001 and r = 0.675, P < 0.001, respectively). Serum IFABP and citrulline levels had no correlation with GI dysfunction or gastric ultrasound parameters (P > 0.05).

CONCLUSION

CSA was associated with GI dysfunction in critically ill patients. Serum IFABP and citrulline concentrations were poor in predicting GI dysfunction.

Dose-response relationship between diarrhea quantity and mortality in critical care patients: A retrospective cohort study

BACKGROUND

Previous studies have shown that diarrhea, defined as a dichotomized cutoff, is associated with increased mortality of patients in intensive care units (ICUs). This study aimed to examine the dose-response relationship between the quantity of diarrhea and mortality in ICU patients with newly developed diarrhea.

METHODS

We conducted this single-center retrospective cohort study. We consecutively included all adult patients with newly developed diarrhea in the ICU between January 2017 and December 2018. Newly developed diarrhea was defined according to the World Health Organization definition. The consistency of diarrhea was evaluated by the Bristol stool chart scale, and the quantity of diarrhea was assessed on the day when patients newly developed diarrhea. The primary outcome was in-hospital mortality. The risk ratio (RR) and 95% confidence interval (CI) for the association between diarrhea quantity and mortality were estimated using multivariable modified Poisson regression models.

RESULTS

Among the 231 participants, 68.4% were men; the median age was 72 years. The median diarrhea quantity was 401g (interquartile range [IQR] 230‒645g), and in-hospital mortality was 22.9%. More diarrhea at baseline was associated with higher in-hospital mortality; the adjusted RR (95% CI) per 200-g increase was 1.10 (1.01‒1.20), p = 0.029. In sensitivity analyses with near quartile categories of diarrhea quantity (<250g, 250-399g, 400-649g, ≥650g), the adjusted RRs for each respective category were 1.00 (reference), 1.02 (0.51-2.04), 1.29 (0.69-2.43), and 1.77 (0.99-3.21), p for trend = 0.033.

CONCLUSIONS

A greater quantity of diarrhea was an independent risk factor for in-hospital mortality. The diarrhea quantity may be an indicator of disease severity in ICU patients.

Combined Omics Analysis Further Unveils the Specific Role of Butyrate in Promoting Growth in Early-Weaning Animals

Abnormal mutations in the microbial structure of early-weaning mammals are an important cause of enteritis. Based on the multiple known beneficial functions of butyrate, we hypothesized that butyrate would alleviate the imbalance of intestinal homeostasis induced by early weaning in animals. However, the mechanisms of action between butyrate and intestinal microbes are still poorly explored. In this study, we aimed to investigate whether butyrate exerts beneficial effects on the structure of the intestinal flora of weanling rabbits and their intestinal homeostasis, growth and development, and we attempted to elucidate the potential mechanisms of action through a combined omics analysis. We found that dietary butyrate upregulated the transcription of tight junction-related proteins in the epithelial barrier and improved the intestinal microbial structure by suppressing harmful bacteria and promoting beneficial ones. Intestinal and plasma metabolomes were also altered. The bile acid secretion, α-linolenic acid, apoptotic, and prostate cancer pathways responded to the positive dietary butyrate-induced metabolic changes in the weanling rabbits, resulting in the inhibition of inflammation, improved antioxidant capacity, increased rates of cell proliferation and survival, and decreased levels of apoptosis. Additionally, dietary butyrate suppressed the release of pro-inflammatory factors and enhanced positive appetite regulation, which increased the average daily gain of the rabbits. These results demonstrated that dietary butyrate can help maintain the integrity of the intestinal epithelial barrier, improve the structural composition of the intestinal microflora, enhance organismal metabolism, inhibit inflammation, reduce post-weaning anorexia, and promote growth and development in early-weaning rabbits. These positive effects of dietary butyrate were exerted via the modulation of the microbe-gut-brain axis.

Development of a prediction model for enteral feeding intolerance in intensive care unit patients: A prospective cohort study

BACKGROUND

Enteral nutrition (EN) is essential for critically ill patients. However, some patients will have enteral feeding intolerance (EFI) in the process of EN.

AIM

To develop a clinical prediction model to predict the risk of EFI in patients receiving EN in the intensive care unit.

METHODS

A prospective cohort study was performed. The enrolled patients’ basic information, medical status, nutritional support, and gastrointestinal (GI) symptoms were recorded. The baseline data and influencing factors were compared. Logistic regression analysis was used to establish the model, and the bootstrap resampling method was used to conduct internal validation.

RESULTS

The sample cohort included 203 patients, and 37.93% of the patients were diagnosed with EFI. After the final regression analysis, age, GI disease, early feeding, mechanical ventilation before EN started, and abnormal serum sodium were identified. In the internal validation, 500 bootstrap resample samples were performed, and the area under the curve was 0.70 (95%CI: 0.63-0.77).

CONCLUSION

This clinical prediction model can be applied to predict the risk of EFI.

Gut Microbiota and Enteral Nutrition Tolerance in Non-Abdominal Infection Septic ICU Patients: An Observational Study

Background: The effect of gut microbiota on enteral nutrition tolerance in critically ill patients is unclear. Methods: Non-abdominal sepsis patients in an ICU, sorted by whether they reached 20 Kcal/kg/day on the 3rd day of EN, were divided into tolerance and intolerance groups. Their feces on day 1 and day 3 of EN initiation were collected for 16s rDNA and short-chain fatty acid (SCFA) testing. Results: There were 14 patients included in the tolerance group and 10 in the intolerance group. On EN day 1, the OTUs and microbiota diversity were higher in the tolerance group than in the intolerance group. The ratio of Firmicutes to Bacteroidetes was higher in the intolerance group on EN day 1. The genus Parabacteroides were the most significantly elevated in the tolerance group. On EN day 3, the genus Escherichia-Shigella was the most significantly elevated in the tolerance group. On EN day 3, the levels of SCFA decreased more significantly in the intolerance group. Conclusion: Enteral nutrition tolerance is associated with microbiota features and short-chain fatty acid levels. A higher ratio of Firmicutes to Bacteroidetes and microbiota diversity on EN day 1 may help in the early prediction of EN tolerance.

Prevalence and risk factors of enteral nutrition intolerance in intensive care unit patients: a retrospective study

BACKGROUND

Feeding intolerance (FI) among intensive care unit (ICU) patients undergoing early continuous enteral nutrition (EN) is related to poor outcomes. This study aimed to explore the prevalence and risk factors of FI in ICU patients.

METHODS

We retrospectively enrolled 1057 patients who received early continuous EN via a nasogastric tube between January 2014 and August 2019. The prevalence of FI during the first 7 days of ICU stay was calculated, and the risk factors were investigated using multivariate logistic regression analysis.

RESULTS

The prevalence of FI during the first 7 days of ICU stay was 10.95%. FI occurred in 159 of 1057 (15.04%) patients on ICU day 2, 114 of 977 (11.67%) patients on ICU day 3, and 86 of 715 (12.03%) patients on ICU day 7. Mechanical ventilation (MV) (odds ratio [OR]: 1.928, 95% confidence interval [CI]: 1.064-3.493, P  = 0.03) was an independent risk factor for FI defined by a gastric residual volume (GRV) of 200 mL and/or vomiting, and acute renal failure (OR: 3.445, 95% CI: 1.115-10.707, P  = 0.032) was an independent risk factor of FI defined by a GRV of 500 mL and/or vomiting. Continuous renal replacement therapy (CRRT) was an independent predictor regardless of the FI defined by a GRV of 200 mL (OR: 2.064, 95% CI: 1.233-3.456, P  = 0.006) or 500 mL (OR: 6.199, 95% CI: 2.108-18.228, P  = 0.001) in the ICU patients.

CONCLUSIONS

FI occurs frequently in early ICU days, especially in patients receiving MV and CRRT. However, further investigation of a consensus definition of FI and risk factors is still warranted in future studies.

Evaluating a symptom-triggered gastric residual volume policy in a surgical trauma intensive care unit: Simple and safe

BACKGROUND

Routine checking of gastric residual volumes (GRVs) during enteral feeding within surgical trauma intensive care units (STICUs) is a common practice. However, data on the necessity of this practice and its impact on nutrient delivery are limited. We aim to study the association between the replacement of a routine GRV (rGRV) policy with a triggered GRV (tGRV) policy and the safe achievement of daily nutrition goals.

METHODS

We prospectively collected data on patients after we instituted a tGRV policy and compared them with a historical cohort of patients who had rGRV assessments in our STICU at a level 1 trauma center. The primary end point was achieving 80% of prescribed nutrient goals. Secondary end points included aspiration pneumonia, witnessed emesis, and glycemic control.

RESULTS

A total of 145 patients accounting for 1405 STICU days were treated under the tGRV policy, and 156 patients accounting for 1694 STICU days were treated under the rGRV policy. There were no statistically significant differences between the tGRV and rGRV groups with regard to the proportion of days meeting or exceeding protein (56.7% vs 56.2%) or calorie (56.4% vs 56.0%) goals. After adjusting for in-hospital deaths, injury severity score, complications, and STICU time, the predictive margins for meeting caloric and protein goals were higher among the tGRV patients (57% vs 56%), but these differences were not statistically significant.

CONCLUSION

A tGRV policy did not change protein or calorie delivery among patients or increase the risk of emesis compared with traditional monitoring methods.

Gastrointestinal Complications in Critically Ill Children: Experience from A Resource-Limited Country

Objectives:

To determine the frequency and predictors of outcome of gastrointestinal complications (GIC) in critically ill children.

Methods:

This descriptive study was prospectively conducted in The Pediatric Intensive Care Unit (PICU), The Aga Khan University Hospital (AKUH), Karachi, from September 2015 to January 2017. After obtaining approval from the Ethical Review Committee of AKUH and informed consent from the parents, all children (aged one month to 18 years), of either gender, admitted to the Pediatric Intensive Care Unit (PICU) during the study period were included. The frequency of the defined GIC: vomiting, high gastric residue volume (GRV), diarrhea, constipation, and gastrointestinal bleed were recorded daily for the first week of the PICU stay. The data was collected by the primary investigator on a predesigned data collection form with inclusion of variables and predictors in light of existing literature and local expertise. The questionnaire was shared with the Pediatric Critical Care Medicine faculty and a consensus was sought on the elements to be incorporated.

Results:

GIC developed within the first 48 hours of admission in 78 (41%) patients. Of the patients who developed GIC, 37 (47.4%) patients developed high GRV: 31 (39.7%) patients developed constipation, 18 (23.1%) patients developed vomiting, 14 (17.9%) patients developed abdominal distension. With regards to prevalence by occurrence, 32/78 (41%) of patients presented with two GI complications, followed by 21 patients (27%) who presented with a single GIC. Only 11 patients (14%) presented with more than three complications. Median length of stay was higher in patients with GIC (8 days) than with those who did not develop GIC (4 days). The frequency of gastrointestinal complications was significantly higher in children receiving mechanical ventilation, on sedatives and relaxants and those with multiorgan dysfunction syndrome (MODS) and inotropes

Conclusion:

GI complications are a frequent occurrence in the PICU and are associated with worse clinical outcomes. The use of sedative drugs and the presence of shock with MODS were amongst the important contributing factors.

Safety and tolerance of enteral nutrition in COVID-19 critically ill patients, a retrospective study

BACKGROUND

There is a lack of evidence about the tolerance of enteral nutrition (EN) in COVID-19 critically ill patients. However, several gastrointestinal manifestations related to COVID-19 have been described. The aims of this study were to analyze the incidence of gastrointestinal intolerance (GI) associated to EN (diarrhea, vomiting, gastroparesis and constipation) and to describe energy/protein provision along with biochemical alterations during the first week of EN.

METHODS

A retrospective cohort of COVID-19 critically ill patients under mechanical ventilation. We reported daily enteral nutrition infusion and gastrointestinal manifestations within the first week of intubation and enteral nutrition initiation.

RESULTS

Fifty-two patients were included; 40.3% were overweight and 46.2% were obese. During the first 7 days of EN, manifestations of GI intolerance such as vomiting, diarrhea and gastroparesis were present in 18 patients (32.4%). Hypernatremia (39%) was the most frequent electrolyte abnormality. Only Acute Kidney Injury (AKI) diagnosis was associated with a higher energy deficit on day 7. No associations between drug prescription and GI intolerance were observed. On day 4, 94.5% of patients were receiving more than 80% of energy requirements and 94.2% of protein requirements. Accumulated energy and protein deficits at day 3 were 2171.2 ± 945 kcal and 114.9 ± 49.2 g, respectively; and 2586.4 ± 1151 kcal, 133.3 ± 60.4 g at day 7.

CONCLUSION

Enteral nutrition is feasible and well-tolerated in COVID-19 patients with mechanical ventilation within the first week of enteral nutrition initiation. More studies are needed to elucidate the impact of nutritional therapy on infection course and outcomes.

Factors associated with length of stay and death in tube-fed patients: A cross-sectional multicentre study

OBJECTIVES

To analyse the factors associated with length of stay (LOS) and death in nasogastric/nasoenteric tube (NG/NET)-fed patients.

DESIGN

A cross-sectional multicentre study.

METHOD

Data collection took place from October 2017-April 2019, and the sample consisted of 365 participants from seven Brazilian hospitals. Demographic, clinical and therapeutic data were collected from the patients' medical records. Data analysis was performed using bivariate and multivariate tests, considering a significance level of p<.05.

RESULTS

Most patients were male, older adults, with high risk of death and highly dependent on nursing care. The LOS was associated with age, patient care complexity and length of NG/NET use. Death was associated with patient age. In the multivariate analysis, patients highly dependent on nursing care, and intensive and semi-intensive care had a greater chance of dying when compared with patients receiving minimal care. Screening for factors affecting LOS and death is important to plan effective nursing care.

Risks in Management of Enteral Nutrition in Intensive Care Units: A Literature Review and Narrative Synthesis

Critically ill patients in the intensive care unit (ICU) have a high risk of developing malnutrition, and this is associated with poorer clinical outcomes. In clinical practice, nutrition, including enteral nutrition (EN), is often not prioritized. Resulting from this, risks and safety issues for patients and healthcare professionals can emerge. The aim of this literature review, inspired by the Rapid Review Guidebook by Dobbins, 2017, was to identify risks and safety issues for patient safety in the management of EN in critically ill patients in the ICU. Three databases were used to identify studies between 2009 and 2020. We assessed 3495 studies for eligibility and included 62 in our narrative synthesis. Several risks and problems were identified: No use of clinical assessment or screening nutrition assessment, inadequate tube management, missing energy target, missing a nutritionist, bad hygiene and handling, wrong time management and speed, nutritional interruptions, wrong body position, gastrointestinal complication and infections, missing or not using guidelines, understaffing, and lack of education. Raising awareness of these risks is a central aspect in patient safety in ICU. Clinical experts can use a checklist with 12 identified top risks and the recommendations drawn up to carry out their own risk analysis in clinical practice.

Gastrointestinal complications are associated with a poor outcome in non-critically ill pneumonia patients

Background

Development of gastrointestinal (GI) complications is adversely associated with prognosis in the critically ill. However, little is known about their impact on the outcome of non-critically ill patients. In this study, we aimed to investigate the incidence of GI complications and their influence on prognosis of hospitalized pneumonia patients.

Methods

Adult patients admitted with a diagnosis of pneumonia from 2012 to 2014 were included. Medical records were reviewed to obtain patients’ demographics, physical signs, comorbidities, laboratory results, clinical events, and the Confusion, Urea, Respiratory rate, Blood pressure and age ≥ 65 (CURB-65) score was calculated to assess the severity of pneumonia. GI complications, including bowel distension, diarrhea, GI bleeding and ileus, were evaluated during the first 3 days of hospitalization and their association with patient outcomes, such as hospital mortality and length of stay, was analyzed.

Results

A total of 1001 patients were enrolled, with a mean age of 73.7 years and 598 (59%) male. Among them, 114 (11%) patients experienced at least one GI complication and diarrhea (5.2%) was the most common. The hospital mortality was 14% and was independently associated with an increase in the CURB-65 score (odds ratio [OR] 1.952 per point increase; 95% confidence interval [CI] 1.516–2.514), comorbid malignancy (OR 1.943; 95% CI 1.209–3.123), development of septic shock (OR 25.896; 95% CI 8.970–74.765), and the presence of any GI complication (OR 1.753; 95% CI 1.003–3.065).

Conclusions

Compared to a critical care setting, GI complications are not commonly observed in a non-critical care setting; however, they still have a negative impact on prognosis of pneumonia patients, including higher mortality and prolonged length of hospital stay.

Effect of abdominal massage on bowel evacuation in neurosurgical intensive care patients

BACKGROUND

There are many factors, which affect the bowel evacuation of neurosurgical intensive care unit (NICU) patients, resulting in constipation.

AIM AND OBJECTIVES

The aim of this study was to investigate effect of abdominal massage on bowel evacuation and the risk of constipation in NICU patients.

DESIGN

A prospective, randomized-controlled clinical trial.

METHODS

The sample of this study included 80 NICU patients. The patients were randomly assigned to abdominal massage and control groups. The constipation risk of all the patients was assessed with Constipation Risk Assessment Scale (CRAS). The patients in the abdominal massage group received a total of 30 minutes of massage, 15 minutes every morning and evening, until the first defecation. The bowel sounds of all patients in the abdominal massage and control groups were assessed on a daily basis. The days when bowel sounds were heard and the first defecation took place were recorded in a Bowel Evacuation Form.

RESULTS

The risk of constipation was higher in the patients in the abdominal massage (CRAS score 19.02 ± 1.81) and control groups (CRAS score 20.45 ± 2.61). The time of return of bowel sounds and the time of the first defecation were earlier in the abdominal massage group, compared to the control group (P < .05). In the control group, there was a weak correlation (P = .004) between the CRAS score and the time of return of bowel sounds, while there was a moderate correlation between the CRAS score and the time of the first defecation (P < .001).

CONCLUSION

Our study results show that the risk of constipation is high in NICU patients, and abdominal massage is an effective nursing intervention to shorten the time of return of bowel sounds and the time of the first defecation.

RELEVANCE TO CLINICAL PRACTICE

Nurses can safely apply abdominal massage to improve bowel evacuation in NICU patients.

Pelvic Floor Considerations in COVID-19

BACKGROUND

Much of the research and clinical commentary on COVID-19 have been focused on respiratory function. Pelvic floor therapists understand that both respiratory dysfunction and hospitalization can have an impact on pelvic floor function. This clinical commentary provides context as to how the long-term effects of COVID-19 could affect the pelvic floor as well as some generalized treatment considerations.

DISCUSSION

The respiratory diaphragm has an impact on the ability of the pelvic floor to contract and relax in a manner that will allow for both continence and elimination. COVID-19 survivors often have disability in this muscle of respiration that can lead to implications for both overactive and underactive pelvic floor. Commonly, this population is hospitalized for long periods of time, which can have long-term consequences on both bladder and bowel functioning including, but not limited to, incontinence, urinary retention, and constipation. Pelvic floor therapists must be prepared to adjust both their evaluation and treatment methods in consideration of this novel treatment population.

CONCLUSIONS

Because of the pervasive nature of this virus, pelvic floor physical therapists should be a part of the rehabilitation team treating these patients once they have become medically stable.Video abstract with sound available at http://links.lww.com/JWHPT/A36.

Nutrition and Gastrointestinal Dysmotility in Critically Ill Burn Patients: A Retrospective Observational Study

BACKGROUND

Gastrointestinal (GI) dysmotility impedes nutrient delivery in critically ill patients with major burns. We aimed to quantify the incidence, timing, and factors associated with GI dysmotility and subsequent nutrition delivery.

METHODS

A 10-year retrospective observational study included mechanically ventilated, adult, critically ill patients with ≥15% total body surface area (TBSA) burns receiving nutrition support. Patients with a single gastric residual volume ≥250 mL were categorized as having GI dysmotility. Daily medical and nutrition data were extracted for ≤14 days in the intensive care unit (ICU). Data are mean (SD) or median (interquartile range). Factors associated with GI dysmotility and the effect on nutrition and clinical outcomes were assessed.

RESULTS

Fifty-nine patients were eligible; 51% (n = 30) with GI dysmotility and 49% (n = 29) without. Baseline characteristics (dysmotility vs no dysmotility) were age (48 [33-60] vs 34 [26-46] years); Acute Physiology and Chronic Health Evaluation II score (16 [12-17] vs 13 [10-16]); sex ([men] 80% vs 86%); and TBSA (49% [35%-59%] vs 38% [26%-55%]). Older age was associated with increased probability of dysmotility (P = .049). GI dysmotility occurred 32 (19-63) hours after ICU admission but was not associated with reduced nutrient delivery. Postpyloric tube insertions were attempted in 83% (n = 25) of patients, with 72% (n = 18) being successful. Postpyloric feeding achieved higher nutrition adequacy than gastric feeding (energy: 82% [95% CI, 70-94] vs 68% [95% CI, 63-74], P = .036; protein: 75% [95% CI, 65-86] vs 61% [95% CI, 56-65], P = .009).

CONCLUSION

GI dysmotility occurs early in critically ill burn patients, and postpyloric feeding improves nutrition delivery.

Ileus in the critically ill: causes, treatment and prevention

Bowel dysfunction, especially ileus, has been increasingly recognized in critically ill patients. Ileus is commonly associated to constipation, however abnormal motility can also concern the upper digestive tract, therefore impaired gastrointestinal transit (IGT) seems to be a more appropriate term. IGT, especially constipation, is common among patients under mechanical ventilation, occurring in up to 80% of the patients during the first week, and has been associated with worse outcome in intensive care unit (ICU). It is acknowledged that the most relevant definition for constipation in ICU is the absence of stool for the first six days after admission. Concerning the upper digestive intolerance (UDI), the diagnosis should rely only on vomiting and the systematic gastric residual volume (GRV) monitoring should be avoided. IGT results from a complex pathophysiology in which both the critical illness and its specific treatments may have a deleterious role. Both observational and experimental studies have shown the deleterious effect of sepsis, multiorgan failure, sedation (especially opioids) and mechanical ventilation on gut function. To date few studies have reported effect of treatment on IGT and the level of evidence is low. However, cholinesterase inhibitors seem safe and could probably be used in case of constipation but remains poorly prescribed. Prevention with bowel management protocol using osmotic laxatives appears to be safe but did not demonstrate its effectiveness. For patients treated with high posology of opioids during sedation, enteral opioid antagonists may be a promising strategy.

Impact of a natural versus commercial enteral-feeding on the occurrence of diarrhea in critically ill cardiac surgery patients. A retrospective cohort study

BACKGROUND

Diarrhea is an important complication in critically ill patients undergoing enteral feeding. The occurrence of diarrhea may lead to systemic and local complications and negatively impacts on nursing workload and patient's wellbeing. An enteral feeding based on blenderized natural food could be beneficial in reducing the risk of diarrhea. No study has compared natural and commercial enteral feedings in critically ill cardiac surgery patients.

OBJECTIVE

The aim of this study was to compare the risk of diarrhea occurrence in two cohorts of patients fed a blenderized natural food diet or commercial enteral feeding preparations, respectively.

DESIGN

Retrospective cohort study.

SETTING

Cardiac-Surgery Intensive Care Unit of a University Hospital.

PARTICIPANTS

Two-hundred and fifteen patients admitted to the postoperative cardiac surgery intensive care unit were included, 103 fed blenderized natural enteral feeding and 112 fed commercial formulas.

METHODS

Commercial enteral formulas were delivered by continuous pump administration, while natural enteral feeding by bolus 3 times per day. Diarrhea was documented in the presence of three or more evacuations of loose or watery stool (or an amount above 250 ml) per day. The presence of diarrhea was recorded daily from the beginning to the end of the enteral feeding, up to a maximum of 8 days. The unadjusted time to the first event of diarrhea between the two enteral feeding groups was compared. Adjusted comparison was then performed by fitting a multivariable Cox Proportional-Hazards model, adjusted for potential confounders for diarrhea occurrence (i.e. administration of inotropes, vasopressors, prokinetics, antibiotics, oral nutritional supplements, antifungal agents, sedatives, opioids, probiotics, laxatives).

RESULTS

In unadjusted survival analysis the probability of diarrhea was significantly lower in the natural enteral feeding group (log rank test: p = 0.023). In the multivariable model patients in natural enteral feeding cohort showed a non-significant trend towards an almost halved risk of experiencing diarrhea (hazard ratio: 0.584; 95% confidence interval: 0.335-1.018; p = 0.058) compared to those fed commercial enteral feeding.

CONCLUSIONS

Administration of a blenderized diet based on natural food for enteral feeding can reduce the incidence of diarrhea in cardiac surgery critically ill patients. This strategy may reduce the risk of diarrhea-associated malnutrition and systemic and local complications, also having a positive impact on nursing workload and patient wellbeing.

Gut dysmotility in the ICU: diagnosis and therapeutic options

PURPOSE OF REVIEW

To provide a comprehensive update of diagnosis and treatment of gastrointestinal dysmotility in the critically ill, with a focus on work published in the last 5 years.

RECENT FINDINGS

Symptoms and clinical features consistent with upper and/or lower gastrointestinal dysmotility occur frequently. Although features of gastrointestinal dysmotility are strongly associated with adverse outcomes, these associations may be because of unmeasured confounders. The use of ultrasonography to identify upper gastrointestinal dysmotility appears promising. Both nonpharmacological and pharmacological approaches to treat gastrointestinal dysmotility have recently been evaluated. These approaches include modification of macronutrient content and administration of promotility drugs, stool softeners or laxatives. Although these approaches may reduce features of gastrointestinal dysmotility, none have translated to patient-centred benefit.

SUMMARY

'Off-label' metoclopramide and/or erythromycin administration are effective for upper gastrointestinal dysmotility but have adverse effects. Trials of alternative or novel promotility drugs have not demonstrated superiority over current pharmacotherapies. Prophylactic laxative regimens to prevent non-defecation have been infrequently studied and there is no recent evidence to further inform treatment of established pseudo-obstruction. Further trials of nonpharmacological and pharmacological therapies to treat upper and lower gastrointestinal dysmotility are required and challenges in designing such trials are explored.

Meeting Calorie and Protein Needs in the Critical Care Unit: A Prospective Observational Pilot Study

Background:

Inadequate calorie and protein intake during critical illness is associated with poor clinical outcomes. Unfortunately, most critically ill patients do not consume adequate levels of these nutrients. An enteral formula with appropriate macronutrient composition may assist patients in meeting nutritional goals.

Design:

This study was a single center, prospective, observational study of 29 adults in the medical intensive care unit who required enteral nutrition for at least 3 days. Subjects received a calorically dense, enzymatically hydrolyzed 100% whey peptide-based enteral formula for up to 5 days to assess the ability to achieve 50% of caloric goals within the first 3 days (primary outcome), the daily percentage of protein goals attained and gastrointestinal tolerance (secondary outcomes).

Result:

A total of 29 subjects consented and began the study. Four subjects dropped out before first day and 25 subjects were included in analyses. Subjects were aged 55.5 ± 16.9 years with mean body mass index (BMI) of 27.9 ± 7.5 kg/m². Most (92%) subjects were on a mechanical ventilator and experienced organ failure. At least 50% of caloric and protein goals were achieved in 78.9% and 73.7% of the subjects, respectively, during the first 3 days. Overall, 75.0 ± 26.3% and 69.3 ± 26.7% of calorie and protein goals were achieved using the study formula.

Conclusions:

Subjects fed enterally with a calorically dense, enzymatically hydrolyzed 100% whey peptide-based enteral formula exceeded 50% of caloric and protein goals in most critically ill subjects included in this study. Use of study formula did not lead to severe gastrointestinal intolerance.

Risk Factors and Predictive Model of Diarrhea Among Patients with Severe Stroke

OBJECTIVE

To investigate the risk factors and predictive model of diarrhea among patients with severe stroke.

METHODS

The study analyzed the retrospective clinical data of patients with new-onset stroke who had been admitted to the intensive care unit at the Department of Neurology of X Hospital, between September 2017 and April 2018. All data were analyzed with a binary logistic regression, and a logistic regression equation was used to build a predictive model of diarrhea among patients with severe stroke.

RESULTS

A total of 153 patients with severe stroke were included in this study, including 45 patients (29.41%) with diarrhea. The binary logistic multivariate analysis showed that the National Institutes of Health Stroke Scale score at admission (odds ratio [OR], 1.123; 95% confidence interval [CI], 1.016-1.242), the Glasgow Coma Scale score at admission (OR, 1.563; 95% CI, 1.048-2.330), antibiotic use (OR, 2.168; 95% CI, 1.041-4.514), gavage feeding time (OR, 1.260; 95% CI, 1.098-1.445), and hospital stay before the occurrence of diarrhea (OR, 0.652; 95% CI, 0.552-0.770). The receiver operating characteristic curve was 0.862 (95% CI, 0.799-0.925), the specificity was 0.778, and the sensitivity was 0.843.

CONCLUSIONS

The National Institutes of Health Stroke Scale score at admission, the Glasgow Coma Scale score at admission, antibiotic use, gavage feeding time, and hospital stay before the occurrence of diarrhea independently predict diarrhea among patients with severe stroke. This model can be used to predict the risk of diarrhea among patients with severe stroke.

What Is the Impact of Diet on Nutritional Diarrhea Associated with Gut Microbiota in Weaning Piglets: A System Review

Piglets experience severe growth challenges and diarrhea after weaning due to nutritional, social, psychological, environmental, and physiological changes. Among these changes, the nutritional factor plays a key role in postweaning health. Dietary protein, fibre, starch, and electrolyte levels are highly associated with postweaning nutrition diarrhea (PWND). In this review, we mainly discuss the high protein, fibre, resistant starch, and electrolyte imbalance in diets that induce PWND, with a focus on potential mechanisms in weaned piglets.

Diarrhea and patient outcomes in the intensive care unit: Systematic review and meta-analysis

PURPOSE

We aimed to determine whether diarrhea experienced by patients in the intensive care unit (ICU) is related to their clinical outcomes.

MATERIAL AND METHODS

We performed a systematic review and meta-analysis. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and the World Health Organization International Clinical Trials Registry Platform between inception and August 2018. The primary outcome was ICU mortality, and secondary outcomes included hospital mortality, ICU length of stay, hospital length of stay. The quality of evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

Twelve studies (enrolling 13,140 patients) compared patients with diarrhea to patients without diarrhea in the ICU. Diarrhea was related to ICU mortality (relative risk [RR]: 1.43; 95% confidence interval [CI]: 1.03 to 1.98). The mean difference (MD) in ICU length of stay between patients with and without diarrhea was 8.08 days (95% CI: 5.85 to 10.32), while the MD in hospital length of stay was 9.67 (95% CI: 2.17 to 17.16). The certainty of evidence for these outcomes was low.

CONCLUSIONS

The diarrhea experienced by patients may be associated with higher mortality and prolonged length of stay in the ICU and hospital.

Prediction of Prolonged ICU Stay in Cardiac Surgery Patients as a Useful Method to Identify Nutrition Risk in Cardiac Surgery Patients: A Post Hoc Analysis of a Prospective Observational Study

BACKGROUND

Cardiovascular surgery patients with a prolonged intensive care unit (ICU) stay may benefit most from early nutrition support. Using established scoring systems for nutrition assessment and operative risk stratification, we aimed to develop a model to predict a prolonged ICU stay ≥5 days in order to identify patients who will benefit from early nutrition interventions.

METHODS

This is a retrospective analysis of a prospective observational study of patients undergoing elective valvular, coronary artery bypass grafting, or combined cardiac surgery. The nutrition risk was assessed by well-established screening tools. Patients' preoperative EuroSCORE (European System for Cardiac Operative Risk Evaluation), primary disease, and intraoperative cardiopulmonary bypass (CPB) time were included as independent variables in a multivariate logistic regression analysis to predict a prolonged ICU stay (>4 days).

RESULTS

The number of cardiac surgery patients included was 1193. Multivariate analysis revealed that for prediction of ICU stay >4 days, both Nutritional Risk Screening 2002 (area under the curve (AUC): 0.716, P = .020) and Mini Nutritional Assessment (MNA) score (AUC: 0.715, P = .037) were significant, whereas for prediction of ICU stay >5 days, only the MNA score showed significant results (AUC: 0.762, P = .011).

CONCLUSION

Present data provide first evidence about the combined use of EuroSCORE, primary disease, CPB time, and nutrition risk screening tools for prediction of prolonged ICU stay in cardiac surgery patients. If prospectively evaluated in adequately designed studies, this model may help to identify patients with prolonged ICU stay to initiate early postoperative nutrition therapy and thus, facilitate an enhanced recovery.