Gastro-intestinal failure. ICU Fellowship Training Radboudumc

Transcription

1 Gastro-intestinal failure ICU Fellowship Training Radboudumc

2 Case history (1) Male, 47 No previous medical history Mechanical ventilation for severe CAP Stable HD on NE 0.04 μg/kg/min Early enteral nutrition (nasogastric route) Selective decontamination + PPI

3 Case history (2) Day 3 - Stable HD on NE 0.02 μg/kg/min PSV with FiO2 55% and PEEP 12 Gastric aspirate volume has been > 500 ml over the previous day on EN1000 ml Slight abdominal distention and diminished bowel sounds

4 ICU fellow raises simple question What is the meaning of this and what is the influence on the prognosis?

5 Incidence GI symptoms in general ICU No ,9% 0,4% 3,7% 59.1% had at least 1 symptom during 1 ICU day 10,4% No 40,9% Those with 2 or more symptoms were older and more severely ill 13,8% N = ,9% EN unsuccessful in 84% if 2 symptoms Reintam A. Acta Anaesthesiol Scand 2009;53:

6 GI symptoms Absent or abnormal bowel sounds Vomiting Nasogastric aspirate > 500 ml/day Diarrhoea Bowel distension GI bleeding

7 Timing Reintam A. Acta Anaesthesiol Scand 2009;53:

8 GI symptoms and LOS LOS (days) No Number of symptoms Reintam A. Acta Anaesthesiol Scand 2009;53:

9 Prognosis Reintam A. Acta Anaesthesiol Scand 2009;53:

10 Gastrointestinal Failure score Points Clinical symptomatology 0 Normal gastrointestinal function 1 EN < 50% calculated needs or no feeding 3 days after abdominal surgery 2 Food intolerance or intra-abdominal hypertension 3 Food intolerance and intra-abdominal hypertension 4 Abdominal compartment syndrome N = 264 Reintam A. Crit Care 2008;12:R90

11 GIF score and mortality 60 57,1 ICU mortality (%) ,4 11,5 4,4 < or higher Mean GIF score first 3 days in ICU Reintam A. Crit Care 2008;12:R90

12 Case history (3) On day 4 the patient receives post pyloric feeding Gastric aspirate volumes decrease but the abdomen is slightly more distended, bowel sounds are diminished and bowel movements are absent

13 Case history (4) Enteral feeding is stopped - parenteral feeding is started including additional glutamine supplementation

14 ICU fellow raises two simple questions Are there any markers by which we can judge the severity of the mucosal damage? What is the evidence that glutamine improves gastro-intestinal barrier function and outcome in this situation?

15 Potential markers for mucosal damage Citrulline Intestinal fatty acid binding protein (I-FABP)

16 Made only in enterocyte

17 Citrulline Low plasma citrulline correlates with small bowel toxicity following chemotherapy and radiotherapy Low plasma citrulline correlates with the occurrence bacteremia (barrier function) Early indicator of rejection following SB Tx Biomarker of reduced enterocyte mass

18 I-FABP Located at the tips of of intestinal vili 2-3% of total protein of the enterocyte Generally undetectable in circulation Measure for enterocyte ischaemia/damage

19 I-FABP and citrulline in acute pancreatitis 220 I-FABP (μmol/l) Mild pancreatitis Severe pancreatitis 11,00 Citrulline (μmol/l) 8,25 5,50 2,75 0,00 Mild pancreatitis Severe pancreatitis N = 32 Pan L. Pancreas 2010;39:

20 I-FABP and citrulline in acute pancreatitis Pan L. Pancreas 2010;39:

21 Citrulline at 24 hours and outcome N = 67 Piton G. Intensive Care Med 2010;36:

22 Case history (5) On the sixth day the abdomen is less distended and he passed stools after the i.v. infusion of neostigmine Enteral feeding is restarted but severe diarrhea develops. Because insufficient calories may be provided, TPN is restarted

23 ICU fellow raises three simple questions How should we evaluate diarrhea in the ICU? Should we give lactose free enteral feeding? Are probiotics useful in this situation?

24 Aetiologies Pathophysiology Diagnostic Secretory absorption or secretion of electrolytes (reduced osmotic gap) Infectious Microorganisms (especially during antibiotic therapy) Motor Gut hypermotility or reduced contact area Bacterial - mainly CD anaerobes Exudative Release of colloids, liquids, electrolytes, desquamated cells and necrotic membranes Non-infectious Other causes Gut ischemia/hypoperfusion Hypoalbuminaemia Osmotic Reduced water absorption due to non-absorbable molecules Drug associated Gut dysmotility Wiessen P. Curr Opin Crit Care 2006;12:

25 With enteral feeding

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27 Lactase deficiency

28 Lactose deficiency in ICU Many articles state that lactase deficiency is very frequent in the ICU due to loss of villi and brush border However - Literature search negative

29 Case history (6) Lactose free enteral feeding reintroduced No recurrence of diarrhea Subsequently uncomplicated clinical course Discharge on D 15

30 Questions Is there evidence to continue the use of stress ulcer prophylaxis? Does (parenteral) glutamine protect GI barrier function and does it improve mortality? What is the role of neostigmine to stimulate bowel movements in ICU patients? Are probiotics useful in treating critically ill patients with diarrhea?

31 Risk of GI bleeding Marik PE. Crit Care Med 2010;38:

32 Risk of HAP Marik PE. Crit Care Med 2010;38:

33 Mortality Marik PE. Crit Care Med 2010;38:

34 Parenteral glutamine and barrier function No human studies available PP WernermanJ. Annals of Intensive Care 2011;1:25

35 Andrews PJD. BMJ 2011;342::d1542

36 Glutamine supplement MC RCT (40) with 2 2 design (glutamine and antioxidant supplementation for 28 D) Mechanical ventilation + organ failures Glutamine 0.35 mg/kg IBW Antioxidants: selenium, zinc, beta carotene, Vitamins E and C Heyland D. N Engl J Med 2013

37 Glutamine supplement Glutamine No glutamine Antioxidants No antioxidants 40 P = 0.05 P = ,4 27, ,8 28,8 Secondary outcomes Glutamine No glutamine P-value % 20 % 20 In-hospital mortality 37.2% 31% M mortality 43,7% 37,2% Mortality 28 D 0 Mortality 28 D Urea 13,4% 4% < No interaction between glutamine and antioxidants N = 1218 Heyland D. N Engl J Med 2013

38 Subgroup analysis Heyland D. N Engl J Med 2013

39 Antioxidants Double edged sword Oxygen radicals essential for immune activation Jaine M. Am J Respir Crit Care Med 2013

40 Crit Care Resusc Sep;13(3): Cardiac arrest complicating neostigmine use for bowel opening in a critically ill patient. Maher L, Young PJ. Source Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand. lesleymaher@gmail.com Critical Illness Related Colonic Ileus 3 patients with ischemic colonic complications 7-10 D later Cross over Acute colonic pseudo-obstruction Ponec RJ. N Eng J Med 1999 van der Spoel. Intensive Care Med 2001;27:

41 Probiotics and diarrhea 8 Lactobacillus rhamnosus GG Days or Numbers Lactobacillus GG Placebo Duration of diarrhea Number of loose stools/day (over 2 weeks) RCT - N = 36 Ferrie S. JPEN 2011;35:43-49

42 Only 4 trials (1 abstract) - no difference

43 Definition Normal abdominal pressure 5-7 mm Hg Intra-abdominal hypertension Sustained IA pressure 12 mm Hg Grade 1: 12-15, Grade 2: 16-20, Grade 3: 21-25, Grade 4: > 25 Abdominal compartment syndrome IA pressure > 20 mm Hg associated with new organ failure

44 Definition Primary: associated with disease/injury in the abdominopelvic region - frequently requires surgery/radiological intervention Secondary: without disease in abdominopelvic region - e.g. sepsis Recurrent: redevelops after previous medical or surgical therapy for primary or secondary ACS

45 Peritonitis Primary - without GI perforation abscess Secondary - with GI perforation abscess Tertiary - persistent following secondary peritonitis

46 Point prevalence IAH = 58.8% ACS = 8.2% N = 97 Respiratory Cardiovascular Neurological Renal Hepatic Hematological Percentage patients > 20 9% 9% 18% 9% 18% 36% Maximal IAP (mm Hg) Associated with BMI, renal failure, coagulation disturbances, fluid resuscitation Organ failure Malbrain MLNG. Intensive Care Med 2004

47 Abdominal compliance Pressure Abdominal wall compliance decrease due to hematoma muscle activity, edema Normal Volume

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49 Measurement Transvesical - end expiration - supine Continuous - zero at midaxillary line Installation volume 20 ml Not with intrapelvic mass Measure abdominal perfusion pressure (MAP - IAP) which should be > 60 mm Hg Malbrain MLNG. Intensive Care Med 2004

50 Abdominal compartment syndrome Peak pressure Bladder pressure Tidal volume Decompression mm Hg and cm H 2 O Hours Ertel W. Crit Care Med 2000

51 Abdominal compartment syndrome CVP Decompression Bladder pressure 50 Cardiac output Lactate mm Hg Diuresis Hours Ertel W. Crit Care Med 2000

52 Renal blood flow Renal venous pressure Renal perfusion pressure Microvascular flow index Wauters J. J Trauma 2009;66:

53 Abdominal compartment syndrome CO (ml/min/kg) R = CVD (mm Hg) Schachtrupp A. J Trauma 2003

54 Abdominal compartment syndrome R = 0.86 CO (ml/min/kg) ITBV (ml/kg) Schachtrupp A. J Trauma 2003

55 Intra-abdominal hypertension and ICP ICP CPP Bladder pressure 100 Decompression 75 mm Hg Hours Ertel W. Crit Care Med 2000

56 Intra-abdominal hypertension and neurotrauma Before After mm Hg ,5 ** ** ** ** 14,3 15,5 11,9 12,0 10,4 6,2 4,7 0 IAP CVP VJIP ICP Citerio G. Crit Care Med 2001

57 Volume therapy with ACS CVD CO Blaasdruk ,0 5,0 3,5 4,5 0

58 Treatment Non-surgical Evacuate intraluminal contents Evacuate extraluminal contents Sedation and neuromuscular blockers Correction of positive fluid balance

59 Muscle relaxation IAP CVD T=0 T=15 T=30 T=60 T=120 Tijd na cisatracurium toediening (minuten) De laet I. Intensive Care Med 2007;33:

60 Open abdomen Extensive fluid loss Infection Enterocutaneous fistulae Ventral hernia Cosmetic dysfunction Rescue therapy if conservative measures fail

61 Open abdomen With pressure > 20 and progressive organ failure despite conservative measures Temporary abdominal closure Bogota bag Zipper-Wittman patch Vacuum-assisted closure