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 <7.27
- 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
GIT Complications
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%

Overall incidence GIT complications 11.5-15%

 Gastrointestinal complications in adults and
children
Adults (%) Children (%)
Frequency 50-60 10-20
Withdrawal of the nutrition 15 2-7
Moderate Vomits 12 18
Abdominal distension, 13-40 6-15
excessive gastric residues
Diarrhoea 10-20 6-11
Constipation 5-80 ND
Gastrointestinal haemorrhage 1-2 0.2-1
Necrotizing enterocolitis, ND 0.5
small bowel necrosis,
nonocclusive ischaemia

ND, no data
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 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
 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
 Diarrhoea or abdominal
bloating/pain complicating
enteral nutrition

No diarrhoea,
Confirm diarrhoea. Check stool
continue current
chart, discuss with nursing staff
management

Yes diarrhoea
evident

Medication involvement? Positive for C difficile? Potential sites of contamination

Antibiotics, sorbitol- (HACCP)?
containing medications,
laxatives

Yes, treat
Yes improve
handling of formula
No
and equipment

Does formula contain Is osmolality of formula or Does modifying fiber content

FODMAPs? feeding regimen high? improve symptoms?

Trial fiber or fiber-

Yes switch to a
Yes, trial free formula
FODMAPs-free
continuous
formula
or low energy
density formula
No

Consider elemental formula or

parenteral nutrition if unsuccessful

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