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 Patients at risk 2 Feeding tolerance monitoring tools 3 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 Hyperglycaemia, hypokalaemia, hypophosphatemia, Hyponatremia Biochemical abnormalities Diabetes mellitus, renal insufficiency, endocrine diseases, prior GIT surgery Clinical history 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 Pain, anxiety, infection Others 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 Consider small If on If If bolus malabsorption bowel polymeric feeding occurs feeding feed change to semi-elemental. due to pancreatic Nasoduodenal (post change to continuous insufficiency- add pyloric) / Nasojejunal feeding Consider supplemental pancreatic enzymes (post ligament of treitz) TPN if requirements cannot be met using EN Nutrition Practice guidelines for Adults, 2016 ; Mahan et al,, 2012; Miller et al, 2011

Diarrhoea Points of Discussion 1 Defining diarrhoea 2 Etiology: Breaking down diarrhoea to identify the causes 3

Diarrhoea Points of Discussion 3 Supportive methods: PN 4 Summary (Do not interrupt feeding protocol) 5 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 (Thorson et al, 2008) 735 mOsm/kg 871 mOsm/kg 683 mOsm/kg 1905 mOsm/kg ONS- Semi-elemental needed? Food consumed by the hospitalized patients have a higher osmolality when, compared to some of our polymeric oral supplements

Diarrhoea  Isotonic=  Gradual  Frequent (280-375 return to small meals mOsm/kg) normal diet (Reintam Blaser et al, 2015)

Enteral Diet: Pre - Check 02 *Enterococcus, Enterobacter cloacae and Klebsiella oxytoca 01 bacterial count correlated directly with severity of illness, and the time the systems were used Ensure contamination prevention practices of feeds Exclude infection/ and feeding tools are not a medication possible cause induced diarrhoea (Mathus-Vliegen et al, 2006)

Should we adjust feeding administration? 1. Feed rate 2. Osmolality & Protein type 3. Positioning of feeding tubes

Feed Rate In ICU- continues feeds are protocol in most units to establish the lowest possible 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. (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 More fermented and Fiber type higher viscosity Insoluble Soluble Bulk Absorbs water Blend of these fibers = ↑ time stool moves through intestines Keep stool soft ↑ fecal SCFA concentration + stool formation. Equally important properties of fiber Viscous Fermentable Gel forming properties Metabolized by colonic bacteria

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 Probiotics 2 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 of FODMAPs in the formulas would not alter the diarrhoea’s physiopathology (Silk & Bowling, 2017)

Carbohydrates - Sources Sucrose Maltodextrin Fructose Corn Starch Glucose 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 It is generally estimated that close to 100% of HIV-positive patients in the developing world may suffer from chronic diarrhoea Partial Infect Enterocytes & villous Malabsorption HIV Enteropathy damage atrophy function

HIV associated diarrhoea Destruct immune-competent Intestinal dysfunction cells in intestine HIV incl. diarrhoea (Intestines= largest immunological organ)

Role of bovine colostrum in treatment of HIV associated diarrhoea Background: Bovine colostrum is the first milk the lactating cow