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Gastrointestinal Dysfunction and Feeding Intolerance in Critical Illness: Do We Need an Objective Scoring System?

  • Nutrition and Obesity (S McClave, Section Editor)
  • Published:
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Abstract

Purpose of Review

Efforts to provide early enteral nutrition in critical illness are thwarted by gastrointestinal dysfunction and feeding intolerance. While many of the signs and symptoms of this dysfunction reflect gastroparesis and intestinal dysmotility, other symptoms which may or may not be related are often included such as diarrhea, bleeding, and intra-abdominal hypertension. This paper discusses the need to monitor tolerance of nutritional therapy in the critical care setting and reviews the results of those clinical trials which have helped establish objective measures, define feeding intolerance, and provide a tool to guide continued delivery of the enteral regimen.

Recent Findings

While definitions vary, the presence of gastrointestinal dysfunction and feeding intolerance correlates with adverse clinical outcomes, including prolonged duration of mechanical ventilation, greater length of stay in the intensive care unit, and increased mortality.

Summary

Despite their prognostic value, it is not clear to what extent these scoring systems should direct nutritional therapy. The clinician should be astute in the careful selection of monitors, in identifying and addressing signs and symptoms of intolerance, and by responding appropriately with feeding strategies that are effective and safe. Early enteral feeding in critical illness has been shown to be optimized by following protocols which allow monitoring patient tolerance while providing individualized care.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Gungabissoon U, Hacquoil K, Bains C, Irizarry M, Dukes G, Williamson R, et al. Prevalence, risk factors, clinical consequences, and treatment of enteral feed intolerance during critical illness. JPEN J Parenter Enteral Nutr. 2015;39(4):441–8. https://doi.org/10.1177/0148607114526450.

    Article  PubMed  Google Scholar 

  2. Nguyen T, Frenette AJ, Johansen C, et al. Impaired gastrointestinal transit and its associated morbidity in the intensive care unit. J Crit Care. 2013;28(4):537. e11-17. https://doi.org/10.1016/j.jcrc.2012.12.003.

    Article  PubMed  Google Scholar 

  3. Stupak DP, Abdelsayed GG, Soloway GN. Motility disorders of the upper gastrointestinal tract in the intensive care unit: pathophysiology and contemporary management. J Clin Gastroenterol. 2012;46(6):449–56. https://doi.org/10.1097/MCG.0b013e31824e14c1.

    Article  PubMed  Google Scholar 

  4. Klodell CT, Carroll M, Carillo E, Spain DA. Routine intragastric feeding following traumatic brain injury is safe and well tolerated. Am J Surg. 2000;179(3):168–71.

    Article  CAS  Google Scholar 

  5. Parkman HP. Idiopathic gastroparesis. In: Principles of gender-specific medicine. second ed. Amsterdam: Elsevier; 2010.

    Google Scholar 

  6. Marik PE. Feeding critically ill patients the right ‘whey’: thinking outside of the box. A personal view. Ann Intensive Care. 2015;5(1):11–9. https://doi.org/10.1186/s13613-015-0051-2.

    Article  PubMed Central  Google Scholar 

  7. Braga M, Vignali A, Gianotti L, et al. Laparoscopic versus open colorectal surgery: a randomized trial on short-term outcome. Ann Surg. 2002;236(6):759–66 discussion 767.

    Article  Google Scholar 

  8. Bauer VP. The evidence against prophylactic nasogastric intubation and oral restriction. Clin Colon Rectal Surg. 2013;26:182–5. https://doi.org/10.1055/s-0033-1351136.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Lassen K, Soop M, Nygren J. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) group recommendations. Arch Sing. 2009;144:961–9. https://doi.org/10.1001/archsurg.2009.170.

    Article  Google Scholar 

  10. McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, et al. Compher C; Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40(2):159–211.

    Article  CAS  Google Scholar 

  11. •• Blaser AR, Starkopf J, Kirsimagi U, Deane AM. Definition, prevalence, and outcome of feeding intolerance in intensive care: a systematic review and meta-analysis. Acta Anaesthesiol Scand. 2014;58:914–22. https://doi.org/10.1111/aas.12302 This systematic review best summarizes the work done by Reintam Blaser’s group of investigators, showcasing the results of five trials addressing the correlation between evidence of GI dysfunction and adverse outcomes.

    Article  PubMed  Google Scholar 

  12. •• Blaser AR, Malgrain MLNG, Starkopf J, Fruhwald S, Jakob SM, DeWaele J, et al. Gastrointestinal function in intensive care patients: terminology, definitions and management. Recommendations of the ESICM working group on abdominal problems. Intensive Care Med. 2012;38(3):384–94. https://doi.org/10.1007/s00134-011-2459-y This paper best demonstrates a graded definition for GI dysfunction.

    Article  Google Scholar 

  13. Blaser AR, Poeze M, Malbrain MLNG, Bjorck M, Oudemans-vanStraaten HM, Starkopf J, et al. Gastrointestinal symptoms during the first week of intensive care are associated with poor outcome: a prospective multicenter study. Intensive Care Med. 2013;39(5):899–909. https://doi.org/10.1007/s00134-013-2831-1.

    Article  Google Scholar 

  14. Reintam A, Parm P, Redlich U, Tooding L-M, Starkopf J, Kohler F, et al. Gastrointestinal failure in intensive care: a retrospective clinical study in three different intensive care units in Germany and Estonia. BMC Gastroenterol. 2006;6:19. https://doi.org/10.1186/1471-230X-6-19.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Reintam A, Parm P, Kitus R, Starkopf J, Kern H. Gastrointestinal failure score in critically ill patients: a prospective observational study. Crit Care. 2008;12(4):R90. https://doi.org/10.1186/cc6958.

    Article  PubMed  PubMed Central  Google Scholar 

  16. •• Hu B, Sun R, Wu A, Ni Y, Liu J, Guo F, et al. Severity of acute gastrointestinal injury grade is a predictor of all-cause mortality in critically ill patients: a multicenter, prospective, observational study. Crit Care. 2017;21(1):188. https://doi.org/10.1186/s13054-017-1780-4 This report provides the most impressive correlation between increasing grades of GI dysfunction and reduced survival.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Prioni L, Arends J, Bozzetti F, Cuerda C, Gillanders L, Jeppesen PB, et al. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr. 2016;35(2):247–307. https://www.ncbi.nlm.nih.gov/pubmed/26944585. https://doi.org/10.1016/j.clnu.2016.01.020.

    Article  Google Scholar 

  18. Blaser AR, Starkopf L, Deane AM, Poeze M, Starkopf J. Comparison of different definitions of feeding intolerance: a retrospective observational study. Clin Nutr. 2015;34(5):956–61. https://doi.org/10.1016/j.clnu.2014.10.006.

    Article  Google Scholar 

  19. Ronco C, Ferrari F, Ricci Z. Recovery after acute kidney injury: a new prognostic dimension of the syndrome. Am J Respir Crit Care Med. 2017;195:711–4. https://doi.org/10.1164/rccm.201610-1971ED.

    Article  CAS  PubMed  Google Scholar 

  20. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock 2012. Crit Care Med. 2013;41:500–637. https://doi.org/10.1097/CCM.0b013e31827e83af.

    Article  Google Scholar 

  21. Rhodes A, Evans LE, Alhazzani W, Levy MM, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock. 2016. Crit Care Med. 2017;43(3):304–77. https://doi.org/10.1007/s00134-017-4683-6.

    Article  Google Scholar 

  22. Reigneir J, Mercier E, LeGouge A, Boulain T, et al. Effect of not monitoring residual gastric volume on risk of ventilator pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA. 2013;309:249–56. https://doi.org/10.1001/jama.2012.196377.

    Article  Google Scholar 

  23. Hurt RT, McClave SA. Gastric residual volumes in critical illness: what do they really mean? Crit Care Clin. 2010;26(3):481–90.

    Article  Google Scholar 

  24. Chapman MJ, Besanko LK, Burgstad CM, et al. Gastric emptying of a liquid nutrient meal in the critically ill: relationship between scintigraphic and carbon breath test measurement. Gut. 2011;60:1336–43.

    Article  CAS  Google Scholar 

  25. Landzinski J, Kiser TH, Fish DN, Wischmeyer PE, MacLaren R. Gastric motility function in critically ill patients tolerant vs intolerant to gastric nutrition. JPEN J Parenter Enteral Nutr. 2008;32(1):45–50.

    Article  Google Scholar 

  26. Cohen J, Aharon A, Singer P. The paracetamol absorbtion test: a useful addition to the enteral nutrition algorithm. Clin Nutr. 2000;19:233–6.

    Article  CAS  Google Scholar 

  27. McClave SA, Lukan JK, Stefater JA, Lowen CC, Looney SW, Matheson PJ, et al. Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Crit Care Med. 2005;33(2):324–30.

    Article  Google Scholar 

  28. Tarling MM, Toner CC, Withington PS, Baxter MK, et al. A model of gastric emptying using paracetamol absorbtion in intensive care patients. Intensive Care Med. 1997;23:256–9.

    Article  CAS  Google Scholar 

  29. Montejo JC, Miñambres E, Bordéje L, Mesejo A, et al. Gastric residual volume during enteral nutrition in ICU patients: the REGANE study. Intensive Care Med. 2010;36(8):1386–93. https://doi.org/10.1007/s00134-010-1856-y.

    Article  CAS  Google Scholar 

  30. Kudsk KA, Tolley EA, DeWitt RC, Janu PG, Blackwell AP, Yeary S, et al. Preoperative albumin and surgical site identify surgical risk for major postoperative complications. JPEN J Parenter Enteral Nutr. 2003;27(1):1–9.

    Article  Google Scholar 

  31. Lacy M, Roesch J, Langsjoen J. Things we do for no reason: prealbumin testing to diagnose malnutrition in the hospitalized patient. J Hosp Med. 2018;14(4):239–41. https://doi.org/10.12788/jhm.3088.

    Article  Google Scholar 

  32. McClave SA, Snider HL, Lowen CC, et al. Use of residual volume as a marker for enteral feeding intolerance: prospective blinded comparison with physical examination and radiographic findings. JPEN J Parenter Enteral Nutr. 1992;16(2):99–105.

    Article  CAS  Google Scholar 

  33. McClave SA, Sexton LK, Spain DA, et al. Enteral tube feeding in the intensive care unit: factors impeding adequate delivery. Crit Care Med. 1999;27:1252–6.

    Article  CAS  Google Scholar 

  34. Patel JJ, Martindale RG, McClave SA. Controversies surrounding critical care nutrition: an appraisal of permissive underfeeding, protein, and outcomes. JPEN J Parenter Enteral Nutr. 2017;1:148607117721908. https://doi.org/10.1177/0148607117721908.

    Article  Google Scholar 

  35. McClave SA, Saad MA, Esterle M, Anderson M, Jotautas AE, Franklin GA, et al. Volume-based feeding in the critically ill patient. JPEN J Parenter Enteral Nutr. 2015;39(6):707–12.

    Article  Google Scholar 

  36. Benya R, Layden TJ, Mobarhan S. Diarrhea associated with tube feeding: the importance of using objective criteria. J Clin Gastroenterol. 1991;13:167–72.

    Article  CAS  Google Scholar 

  37. Edes TE, Walk BE, Austin JL. Diarrhea in tube-fed patients: feeding formula not necessarily the cause. Am J Med. 1990;88:91–3.

    Article  Google Scholar 

  38. •• Parrish CR, McCray S. Part I: enteral feeding barriers: pesky bowel sounds & gastric residual volumes. Nutrition Issues in Gastroenterology, Series 183. Pract Gastroenterol. 2019:35–50 This paper best discusses the limitations of gastric residual volume (GRV) as a monitor of GI dysfunction.

  39. Deane AM, Summers MJ, Zaknic AV, et al. Glucose absorption and small intestinal transit in critical illness. Crit Care Med. 2011;39(6):1282–8. https://doi.org/10.1097/CCM.0b013e31820ee21f.

    Article  PubMed  Google Scholar 

  40. Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P, Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr. 2003;27(5):355–73.

    Article  Google Scholar 

  41. McClave SA, Martindale RG. Why do current strategies for optimal nutritional therapy neglect the microbiome? Nutrition. 2019;60:100–5. https://doi.org/10.1016/j.nut.2018.09.024.

    Article  PubMed  Google Scholar 

  42. Sun JK, Mu XW, Li WQ, et al. Effects of early enteral nutrition on immune function of severe acute pancreatitis patients. World J Gastroenterol. 2013;19(6):917–22. https://doi.org/10.3748/wjg.v19.i6.917.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA

    Stephen A. McClave, Jill Gualdoni, Luis S. Marsano & Kathryn Bandy

  2. Division of Gastroenterology, Hepatology & Nutrition, University of Louisville School of Medicine, 550 South Jackson Street, Louisville, KY, 40202, USA

    Stephen A. McClave

  3. Department of Surgery, Oregon Health Sciences University, Portland, OR, USA

    Annie Nagengast & Robert G. Martindale

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  1. Stephen A. McClave
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Correspondence to Stephen A. McClave.

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McClave, S.A., Gualdoni, J., Nagengast, A. et al. Gastrointestinal Dysfunction and Feeding Intolerance in Critical Illness: Do We Need an Objective Scoring System?. Curr Gastroenterol Rep 22, 1 (2020). https://doi.org/10.1007/s11894-019-0736-z

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