Annika Blaser (Luzern, Switzerland)
Updates covered: ESPEN guidelines, GI Bleed prophylaxis, Future studies in GI dysfunction
Recent evidence suggests Early Full nutrition (any route) is harmful
- In health, glucose infusion suppresses endog. glucose production
- NOT seen in crit illness e.g. burns, sepsis, trauma, pancreatitis etc –> ongoing endog. glucose production and energy expenditure. Early Full feeding results in OVERFEEDING
Autophagy: Evolutionary stress response which removes damaged organelles and degrades pathogens
- In catabolic state, cells may be more effective at autophagy and more resilient to various stressors
- Autophagy and catabolism likely inevitable in critical illness; nutrition suppresses autophagy –>> Don’t be too afraid of catabolism in early phase of acute illness
All pts on ICU >48hrs with critical illness are at risk of malnutrition
* EN increases splanchnic blood flow and O2 demand, which may not be met early on in critical illness despite additional O2 delivery –> risk mesenteric ischaemia in early full EN (vs PN)
Summary:
a. No specific feeding recommendation for specific pt sub-groups
b. Focus on Not causing harm through overfeeding, refeeding, underfeeding or GI complications
c. Nutritional support cannot be individualised using only clinical diagnosis / pt demographics without considering changes and adaptation in metabolism (however no metabolic monitor available)
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GI Bleed Prophylaxis
BMJ rapid recommendations triggered by SUP-ICU trial showing no benefit of stress ulcer prophylaxis in pts at risk
Multitude of risk factors for GI bleed in ICU pts incl. mech ventilation, coagulopathy, shock sepsis, renal / hepatic failure etc… Enteral nutrition is the ONLY protective factor
Recommend:
a. Restrict acid suppression to pts with >4% GIB risk
b. PPI preferable, H2 antagonist also acceptable, NOT sucralfate
* Suggested mortality risk with PPI in severe illness – needs exploring, future SUP may be even further restricted
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GI Dysfunction in Critical Illness
Proposed 32 studies to facilitate overview of GI dysfunction and plan future research
Areas needing consensus:
- EN intolerance
- core set daily monitoring of GI function
- core set outcomes
- US protocol to assess GI function
- descriptive definition of non-occlusive mesenteric ischaemia
- reference methods to measure gastric emptying / nutrient absorption / barrier dysfunction