Gastrointestinal Complications (related to enteral nutrition) in Critically Ill Patients

1. Gastrointestinal Complications (related to enteral nutrition) in Critically Ill Patients Liz Goddard

2. Introduction • Early enteral nutrition is recommended • GIT Complications • limit the ability to deliver adequate enteral nutrition • affect morbidity and mortality

3. Risk Factors of GIT complications • Shock • Poor gut perfusion • Gastroparesis - medication/disease process • Impaired digestive enzyme secretion • Increased gut permeability • Cholestasis • Diarrhoea • Constipation

4. Metabolic Abnormalities Commonly Associated With Bowel Dysfunction • Hyperglycaemia - Dysmotility noted at 150mg/dL - Dysmotility almost linear with blood glucose • Hypokalaemia - k+ < 4mmol/L • Hypomagnasaemia - Mg < 2 mmol/L • Hypophosphataemia - Po4 < 3.5 mg/dl • pH <7.27 - Transporter activity affected first • Positive fluid balance • Negative fluid balance

5. GIT Complications • Related to route of access for EN • Abdominal distension • Excessive gastric residues • Vomiting • Diarrhoea • Constipation • GIT haemorrhage

6. GIT Complications Overall incidence GIT complications 11.5-15%

7. Gastrointestinal complications in adults and children ND, no data

8. GIT Symptoms related to Enteral Feeds GIT symptoms : diarrhoea, bloating, abdominal discomfort Treatment : • Change the method of EN delivery • Rate of infusion - continuous vs bolus • Feed sterility - closed systems - change delivery sets 12 hourly - strict hygiene • Temperature - refrigeration

9. Route of Enteral nutrition • Nasogastric • Most widely used, easy to place, safe & well tolerated • More physiological • Nasojejunal • Enables adequate energy delivery • Reduces gastric residues • Less time stopped for theatre , extubation • Widely used for :GORD ,Cardiacs,Disordered motility • Difficulties with NJ • More difficult to site & keep in, • Do not give: Bolus feeds, Water – risk of necrozing bowel • Complications: Misplaced, Perforation • NO DIFFERENCE IN COMPLICATIONS

10. Continuous vs Bolus • Bolus • More physiological but ICU is not a normal environment! • Difficulties with monitoring tolerance • Requires additional nursing time • Continuous • Less time consuming, Easier to monitor • May delay gastric emptying [adult ICU] • Pro’s & Cons to both • Often remains preference of unit • Complication rate re gastric residues and tracheal aspiration were similar

11. Abdominal Distension and Increased Gastric Residues • Excess gastric residues is a common complication • Excessive gastric volume = >50% of volume of feed given in the previous 4h • Mechanism – 2° to alteration in GIT motility • Aetiology – multifactorial - underlying illness –  with cerebral, gastric, peritoneal disease - hyperglycaemia - diet – consistency, temp, osmolarity, composition - drugs – sedatives, catecholamines

12. Abdominal Distension and Increased Gastric Residues • Complications - risk of aspiration - bacterial overgrowth -enteral feeds • Treatment - reduce drugs that GIT motility - prokinetic agents erythromycin metaclopramide

13. Vomiting Incidence of GOR in critically ill children is high Aggravating factors: • Increased gastric residues • Supine position • presence of NG tube • dysfunction of LOS Recommendations: • semi-recumbent position • small calibre NG tubes • nasojejunal feeds

14. Constipation • No standard definition in critically ill children • Incidence 33-50% • Aetiology - immobilization - dehydration - drug administration - diet low in fibre • Constipation leads to abdominal distension and affects tolerance of feed

15. Constipation • Treatment - use a diet with fibre - decreasedrugs which  GIT motility (opioids, sedatives, catecholamines, muscle relaxants) - laxatives, naloxone, enemas

16. Diarrhoea • Incidence ?? • No standard definition in children - 1 loose stool 75% patients - ≥ 3 loose stools 35% patients - ≥ 4 loose stools 20% patients - ≥ 2 loose stools for 2 days 10% patients

17. Diarrhoea Causes: Diverse • Infections Rotavirus • clostridium difficile • Antibiotics • Drugs • enteral nutrition • high osmolar feed • route of feed • presence of hypoalbuminaemia • underlying disease (shock)

18. Diarrhoea • Treatment - Diet with fibre - Probiotics, prebiotics • No studies in children

19. GIT Haemorrhage • Incidence 1 - 10% • Overt GIT bleed 10% • Clinically significant bleed 1.0% • Risk Factors • Organ failure • High pressure ventilation • Presence of a coagulopathy • Treatment • ?? Prophylactic treatment to prevent GIT bleeds • Cost • ?increase in nosocomial pneumonia

20. Summary • Early EN in critically ill children is recommended • GIT complications are a major cause of inadequate enteral feeds • SHOCK is a major risk factor for GIT complications • No consensus on definitions of excessive gastric residues, constipation and diarrhoea • Increased mortality in children with GIT complications • Be aware of the complications : prevent or Rx early

22. Figure 1. A suggested flow chart for the management of patients with diarrhoea or other abdominal symptoms complicating enteral nutrition. FODMAPs, Fermentable, Oliogo-, Di-, Mono-saccharides, And Polols; HACCP, Hazard Analysis and Critical Control Point guideline Consider elemental formula or parenteral nutrition if unsuccessful