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
123
Patients at risk
Feeding tolerance monitoring tools
Interventions
Patients at risk for nausea and vomiting in ICUAdmission 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
occurs
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
123
Defining diarrhoea
Etiology: Breaking down diarrhoea to identify the causes
Diarrhoea Points of Discussion
345
Supportive methods: PN
Summary (Do not interrupt feeding protocol)
Conclusion
Defining DiarrhoeaFrequency >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
osmolality 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)
FiberFiber 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
12
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
of 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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