Diarrhoea & Vomiting in the ICU Lindie Mosehuus RD, SA - - PowerPoint PPT Presentation

Diarrhoea & Vomiting in the ICU

Lindie Mosehuus RD, SA

Introduction

Despite the high prevalence, the management is far from simple The causes are complex and multifactorial, yet enteral tube feeding formula is believed to be the perpetrator The aim: Provide context to examine and treat it from a nutrition perspective Vomiting Diarrhoea

Vomiting Points of Discussion

1 2 3

Patients at risk Feeding tolerance monitoring tools Interventions

Patients at risk for nausea and vomiting in ICU

Admission diagnosis

Head injury/spinal cord injury, central nervous system diseases, major surgery, pancreatitis, sepsis, burns

Biochemical abnormalities

Hyperglycaemia, hypokalaemia, hypophosphatemia, Hyponatremia

Clinical history

Diabetes mellitus, renal insufficiency, endocrine diseases, prior GIT surgery

Formula related issues

Osmolality, large volume/rapid infusion of formula, formula pH, infusion of very cold formula, high-fat formula/type of fat, bacterial or fungal infection of formula, inappropriate formula

Others

Pain, anxiety, infection

Medicines

Opioids (particularly pentobarbital), hypnotics, inotropes, sedatives, analgesics

Monitoring tools to prevent nausea and vomiting

• GIT function and tolerance= daily to determine the initiation of appropriate

feeding and tolerance of feeds.

• bowel sounds
• Nasogastric/fistula drainage
• Abdominal distension (measure circumference)
• Intra-abdominal pressures
• Abdominal x-ray/sonar
• failure to pass flatus/stool
• vomiting and diarrhoea (test for C. difficle)
• Severe constipation

(Nutrition Practice guidelines for Adults, 2016; Garett et al, 2003)

Monitoring tools to prevent nausea and vomiting

• Correct imbalances (Ca, K, PO4, Na)
• Nausea, headache, and oliguria are common indications of hyponatremia, which

can cause cerebral edema and death if untreated

• Vomiting= loss of e- = ↓K & life-threatening dysrhythmias

(Nutrition Practice guidelines for Adults, 2016; Garett et al, 2003)

Interventions to treat feeding associated nausea and vomiting

If bolus feeding If on polymeric feed

If malabsorption

• ccurs

change to continuous feeding change to semi-elemental. Consider supplemental TPN if requirements cannot be met using EN due to pancreatic insufficiency- add pancreatic enzymes

Consider small bowel feeding

Nasoduodenal (post pyloric) / Nasojejunal (post ligament of treitz)

Nutrition Practice guidelines for Adults, 2016 ; Mahan et al,, 2012; Miller et al, 2011

Diarrhoea Points of Discussion

1 2 3

Defining diarrhoea Etiology: Breaking down diarrhoea to identify the causes

Diarrhoea Points of Discussion

3 4 5

Supportive methods: PN Summary (Do not interrupt feeding protocol) Conclusion

Defining Diarrhoea

Frequency >3 stools/ d OR >3 abnormal stools/ d OR Increased frequency above baseline Consistency Loose/ watery: 5-7 Bristol stool chart Duration Acute: < 2 Weeks VS Chronic: > 2 Weeks Volume >200g at a time OR >750ml / 24 hours *Weight: Realistic in ICU setting? Staff compliance? Time consuming?

Greenwood2018; Blaser et al, 2015; WHO, 2013; Lankish et al, 2013; Sabol & Carlson, 2007

Etiology: Breaking down diarrhoea to identify cause

Diet-related: Oral Diet

871 mOsm/kg 735 mOsm/kg 683 mOsm/kg 1905 mOsm/kg

ONS- Semi-elemental needed? Food consumed by the hospitalized patients have a higher

• smolality when, compared to some of our polymeric oral

supplements

(Thorson et al, 2008)

Diarrhoea

Isotonic= (280-375 mOsm/kg) Frequent small meals Gradual return to normal diet

(Reintam Blaser et al, 2015)

Enteral Diet: Pre - Check

01

Exclude infection/ medication induced diarrhoea

02

Ensure contamination prevention practices of feeds and feeding tools are not a possible cause

*Enterococcus, Enterobacter cloacae and Klebsiella oxytoca bacterial count correlated directly with severity of illness, and the time the systems were used

(Mathus-Vliegen et al, 2006)

Should we adjust feeding administration?

1. Feed rate 2. Osmolality & Protein type 3. Positioning of feeding tubes

Feed Rate

Argument not in favour of continues feeds: Some studies no association between feed rate, osmolality and diarrhoea in ICU when assessed in isolation. Continues feeding may affect feeding adequacy, with delivery ↓ by 50-60% of prescribed volume due to interruptions in ICU Intermitted/ bolus feeds- more likely to reach prescribed goal without changes in bowel function. In ICU- continues feeds are protocol in most units to establish the lowest possible feed rate.

(Heyland et al, 2013)

Arguments in favour of cont. feeds Feeds > 60 % of target ↑ diarrhoea X 1.75 = These latter data suggest that in very sick patients there may be a small intestinal threshold of nutrient absorption and beyond such a level, malabsorption and diarrhoea occur.

(Savino, 2018; Savino, 2018; Travares et al, 2014; Deane et al, 2014; Thibault et al, 2013 )

Osmolality, protein type (elemental, semi-elemental) Polymeric feeds alone may not affect the frequency or duration of diarrhoea. Combination with secondary factors such as hypoalbuminemia

(Savino, 2018)

Malabsorption: consider the use of elemental + Isotonic formula (280-375 mOsm/kg)

(de Brito-Ashurst & Preiser, 2016; McClave et al, 2016)

Positioning

Stomach= tol. high-osmolality formulas better Intestine = isotonic or hypo-osmolar

(McClave et al, 2016)

Fats in Formulas

• The literature does not recommend the use of lower

fat formulas to reduce episodes of diarrhoea

• Formulas based on MCTs and fish oil =

better tolerated

• Fat malabsorption: low fat or MCT containing feeds

(Pitta et al, 2019)

Fiber

Fiber type Equally important properties of fiber

Insoluble Soluble Bulk Absorbs water ↑ time stool moves through intestines Keep stool soft Viscous Fermentable Gel forming properties Metabolized by colonic bacteria More fermented and higher viscosity Blend of these fibers = ↑ fecal SCFA concentration + stool formation.

Fiber

It is important to highlight the use of 10–20 g of soluble fibers per day in hemodynamically stable patients when the persistent diarrhoea diagnosis is confirmed

(Majid et al, 2015)

*With the exception of hemodynamic instability, it is noticeable that fiber-enriched enteral diets have benefits in both in the prevention and improvement of the patient’s diarrhoea condition, regardless of whether the patient is in the intensive care unit (ICU)

(Yagmurdur & Pac, 2016; Klosterbuer et al, 2011)

Adjusting the gut microbiome

1 2

Probiotics FODMAPS & Prebiotics

Probiotics

Potentially ↓ diarrhoea

(de Bristo-Ashurst & Presier, 2016; MsClave et al, 2016; Chang & Huang, 2013; Theodorakopoulou et al, 2013; Btaiche et al, 2010)

The American Society for Parenter and Enteral Nutrition suggests that it should be limited to a select surgical patient group and does not define which indications for the critical population The CCN indicates the use of probiotics in the critical context but does not recommend period, dosage, or strain to be utilized

(Halmos & Bogatyrev, 2017; Manzanares et al, 2016; Chang Huang, 2013)

C-diff/ AAD: Benefit of probiotics usage, critical or not Dosage, duration, strain, time of intervention- need more research

(McFarland & Evans, 2018; Squellati, 2018; Parker et al, 2018; Manzanares et al, 2016; Canadian, 2015)

Pre-biotics

• Pectin and partially hydrolysed guar gum have been reported to ↓the incidence of

diarrhoea

• Prebiotic based enteral formulas = significantly ↓ stool frequency + more formed stools

compared to non-fiber formulas.

(Halmos et al, 2017; Yoon et al, 2015; Halmos et al, 2010)

FODMAPS

Low FODMAP content may be associated with lower diarrhoea incidence and severity when the condition is already present A relevant analytical study has shown that formulas with high maltodextrin content tend to generate overestimated results in reference of FODMAPs concentration; it concludes that the amount

• f FODMAPs in the formulas would not alter the diarrhoea’s

physiopathology

(Silk & Bowling, 2017)

Carbohydrates - Sources

Fructose Glucose Sucrose Corn Starch Maltodextrin

The restriction of fructose, and/or sucrose should be taken into account in diarrheal processes developed during antimicrobial therapy.

de Brito-Ashurst & Preiser, 2016; McClave et al, 2016; Tavares et al, 2014; Barett et al, 2010

Glutamine

Some authors suggest that the exogenous supplementation can improve intestinal mucosal atrophy and permeability, possibly leading to a bacterial translocation reduction. However, the clinical meaning of these results has not been clearly established.

(Wischmeyer et al, 2016; Stroster et al, 2015)

HIV associated diarrhoea

HIV

Enteropathy

Partial villous atrophy

Infect Enterocytes & damage function

It is generally estimated that close to 100% of HIV-positive patients in the developing world may suffer from chronic diarrhoea

Malabsorption

HIV associated diarrhoea

HIV

Destruct immune-competent cells in intestine (Intestines= largest immunological organ) Intestinal dysfunction

• incl. diarrhoea

Role of bovine colostrum in treatment of HIV associated diarrhoea

Background:

Bovine colostrum is the first milk the lactating cow

Characteristics

Lactoferrin: transport essential iron to hematopoietic cells and prevent harmful viruses and bacteria from getting the iron they need for their growth. Very high level of several bioactive components: immunoglobulins, growth factors, some whey proteins and proteinase inhibitors, vitamins and minerals. Growth factors (IGF-1 and TGF-β2): Identical to that found in humans. Promote mucosal recovery and gut integrity in patients with severe diarrheal illness. High Zn and Se high in colostrum

Parenteral Nutrition

• In GI tract dysfunction, associated or not with absorptive disorders e.g. cases of difficult-to

control diarrhoea and threatened nutrition status= PN therapy is indicated

(Blaser et al, 2015)

• Current evidence supports the use of TPN/ SPN, depending on the severity of symptoms and

measures already taken—in those patients who do not receive the calculated needs after 3 days in therapy

(Singer et al, 2009)

Summary: non-infectious diarrhoea management

Conclusion

Diarrhoea is a symptom. Accordingly, only diagnosing and then treating the underlying cause may solve the problem. Exclude / confirm infectious diarrhoea- treat + exclude possible medication induced diarrhoea before adjusting enteral feed prescription Little evidence to support delaying / withdrawing enteral nutrition in patients with diarrhoea. Recommended to continue with enteral nutrition whenever possible.

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