Gastrointestinal Complications (related to enteral nutrition) in

Critically Ill Patients

Liz Goddard

IntroductionEarly enteral nutrition is

recommendedGIT Complications

limit the ability to deliver adequate enteral nutrition

affect morbidity and mortality

Risk Factors of GIT complicationsShockPoor gut perfusionGastroparesis - medication/disease processImpaired digestive enzyme secretionIncreased gut permeabilityCholestasisDiarrhoeaConstipation

Metabolic Abnormalities Commonly Associated With Bowel DysfunctionHyperglycaemia - Dysmotility noted at 150mg/dL - Dysmotility almost linear with blood glucoseHypokalaemia - k+ < 4mmol/LHypomagnasaemia - Mg < 2 mmol/LHypophosphataemia - Po4 < 3.5 mg/dlpH <7.27 - Transporter activity affected firstPositive fluid balanceNegative fluid balance

GIT ComplicationsRelated to route of access for ENAbdominal distensionExcessive gastric residuesVomitingDiarrhoeaConstipationGIT haemorrhage

Aspiration 1.9%

Vomiting 17.9%

Abdominal distension 13.2%

Excessive gastric residues 4.7%

Diarrhoea 11.3%

Gastrointestinal haemorrhage 0.9%

Constipation 33-55%

GIT Complications

Overall incidence GIT complications 11.5-15%

Adults (%) Children (%)

Frequency 50-60 10-20

Withdrawal of the nutrition 15 2-7

Moderate Vomits 12 18

Abdominal distension,

excessive gastric residues

13-40 6-15

Diarrhoea 10-20 6-11

Constipation 5-80 ND

Gastrointestinal haemorrhage 1-2 0.2-1

Necrotizing enterocolitis,

small bowel necrosis,

nonocclusive ischaemia

ND 0.5

ND, no data

Gastrointestinal complications in adults and children

GIT Symptoms related to Enteral Feeds

GIT symptoms : diarrhoea, bloating, abdominal discomfort

Treatment :Change the method of EN deliveryRate of infusion - continuous vs bolusFeed sterility - closed systems - change delivery sets 12 hourly - strict hygieneTemperature - refrigeration

Route of Enteral nutritionNasogastric

Most widely used, easy to place, safe & well toleratedMore physiological

NasojejunalEnables adequate energy deliveryReduces gastric residuesLess time stopped for theatre , extubationWidely used for :GORD ,Cardiacs,Disordered motility

Difficulties with NJMore difficult to site & keep in, Do not give: Bolus feeds, Water – risk of necrozing

bowelComplications: Misplaced, Perforation

NO DIFFERENCE IN COMPLICATIONS

Continuous vs BolusBolus

More physiological but ICU is not a normal environment!

Difficulties with monitoring toleranceRequires additional nursing time

ContinuousLess time consuming, Easier to monitorMay delay gastric emptying [adult ICU]

Pro’s & Cons to bothOften remains preference of unitComplication rate re gastric residues and

tracheal aspiration were similar

Abdominal Distension and Increased Gastric Residues

Excess gastric residues is a common complicationExcessive gastric volume = >50% of volume of

feed given in the previous 4hMechanism – 2° to alteration in GIT motilityAetiology – multifactorial - underlying illness – with cerebral, gastric,

peritoneal disease - hyperglycaemia - diet – consistency, temp, osmolarity,

composition - drugs – sedatives, catecholamines

Abdominal Distension and Increased Gastric ResiduesComplications - risk of aspiration - bacterial overgrowth -enteral feedsTreatment - reduce drugs that GIT motility - prokinetic agents erythromycin metaclopramide

VomitingIncidence of GOR in critically ill children is high

Aggravating factors:Increased gastric residuesSupine position presence of NG tubedysfunction of LOSRecommendations:semi-recumbent positionsmall calibre NG tubesnasojejunal feeds

ConstipationNo standard definition in critically ill

childrenIncidence 33-50%Aetiology - immobilization - dehydration - drug administration - diet low in fibreConstipation leads to abdominal

distension and affects tolerance of feed

ConstipationTreatment - use a diet with fibre - decrease drugs which GIT motility

(opioids, sedatives, catecholamines, muscle relaxants)

- laxatives, naloxone, enemas

DiarrhoeaIncidence ??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

Diarrhoea

Causes: DiverseInfections

Rotavirusclostridium difficile

AntibioticsDrugsenteral nutrition

high osmolar feedroute of feed

presence of hypoalbuminaemiaunderlying disease (shock)

DiarrhoeaTreatment - Diet with fibre - Probiotics, prebiotics

No studies in children

GIT HaemorrhageIncidence 1 - 10%

Overt GIT bleed 10%Clinically significant bleed 1.0%

Risk FactorsOrgan failureHigh pressure ventilationPresence of a coagulopathy

Treatment?? Prophylactic treatment to prevent GIT bleeds

Cost?increase in nosocomial pneumonia

SummaryEarly EN in critically ill children is recommendedGIT complications are a major cause of

inadequate enteral feedsSHOCK is a major risk factor for GIT

complicationsNo consensus on definitions of excessive gastric

residues, constipation and diarrhoeaIncreased mortality in children with GIT

complicationsBe aware of the complications : prevent or Rx

early

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

Diarrhoea or abdominal bloating/pain complicating

enteral nutrition

Confirm diarrhoea. Check stool chart, discuss with nursing staff

No diarrhoea, continue current

management

Yes diarrhoeaevident

Medication involvement?Antibiotics, sorbitol-

containing medications,laxatives

Positive for C difficile? Potential sites of contamination (HACCP)?

Yes improve handling of formula

and equipment

Yes, treat

No

Does formula contain FODMAPs?

Is osmolality of formula or feeding regimen high?

Does modifying fiber content improve symptoms?

Yes switch to a FODMAPs-free

formula

Yes, trial continuous

or low energy density formula

Trial fiber or fiber-free formula

No

Consider elemental formula or parenteral nutrition if unsuccessful