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

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

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

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 < Transporter activity affected first Positive fluid balance Negative fluid balance

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

Aspiration 1.9% Vomiting17.9% Abdominal distension13.2% Excessive gastric residues4.7% Diarrhoea11.3% Gastrointestinal haemorrhage 0.9% Constipation33-55% GIT Complications Overall incidence GIT complications %

Adults (%)Children (%) Frequency Withdrawal of the nutrition152-7 Moderate Vomits1218 Abdominal distension, excessive gastric residues Diarrhoea Constipation 5-80ND Gastrointestinal haemorrhage Necrotizing enterocolitis, small bowel necrosis, nonocclusive ischaemia ND0.5 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 delivery Rate of infusion - continuous vs bolus Feed sterility - closed systems - change delivery sets 12 hourly - strict hygiene Temperature - refrigeration

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

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

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

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

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

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

Constipation Treatment - use a diet with fibre - decrease drugs which  GIT motility (opioids, sedatives, catecholamines, muscle relaxants) - laxatives, naloxone, enemas

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

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

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

GIT Haemorrhage Incidence % 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

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

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 diarrhoea evident 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