Failure of gut homeostasis is an important factor in the pathogenesis and progression of systemic inflammation, which can culminate in multiple organ failure and fatality. Pathogenic events in ...critically ill patients include mesenteric hypoperfusion, dysregulation of gut motility, and failure of the gut barrier with resultant translocation of luminal substrates. This is followed by the exacerbation of local and systemic immune responses. All these events can contribute to pathogenic crosstalk between the gut, circulating cells, and other organs like the liver, pancreas, and lungs. Here we review recent insights into the identity of the cellular and biochemical players from the gut that have key roles in the pathogenic turn of events in these organ systems that derange the systemic inflammatory homeostasis. In particular, we discuss the dangers from within the gastrointestinal tract, including metabolic products from the liver (bile acids), digestive enzymes produced by the pancreas, and inflammatory components of the mesenteric lymph.
Gastrointestinal (GI) dysfunction is frequent in the critically ill but can be overlooked as a result of the lack of standardization of the diagnostic and therapeutic approaches. We aimed to develop ...a research agenda for GI dysfunction for future research. We systematically reviewed the current knowledge on a broad range of subtopics from a specific viewpoint of GI dysfunction, highlighting the remaining areas of uncertainty and suggesting future studies.
This systematic scoping review and research agenda was conducted following successive steps: (1) identify clinically important subtopics within the field of GI function which warrant further research; (2) systematically review the literature for each subtopic using PubMed, CENTRAL and Cochrane Database of Systematic Reviews; (3) summarize evidence for each subtopic; (4) identify areas of uncertainty; (5) formulate and refine study proposals that address these subtopics; and (6) prioritize study proposals via sequential voting rounds.
Five major themes were identified: (1) monitoring, (2) associations between GI function and outcome, (3) GI function and nutrition, (4) management of GI dysfunction and (5) pathophysiological mechanisms. Searches on 17 subtopics were performed and evidence summarized. Several areas of uncertainty were identified, six of them needing consensus process. Study proposals ranked among the first ten included: prevention and management of diarrhoea; management of upper and lower feeding intolerance, including indications for post-pyloric feeding and opioid antagonists; acute gastrointestinal injury grading as a bedside tool; the role of intra-abdominal hypertension in the development and monitoring of GI dysfunction and in the development of non-occlusive mesenteric ischaemia; and the effect of proton pump inhibitors on the microbiome in critical illness.
Current evidence on GI dysfunction is scarce, partially due to the lack of precise definitions. The use of core sets of monitoring and outcomes are required to improve the consistency of future studies. We propose several areas for consensus process and outline future study projects.
Gastrointestinal dysfunction/failure (GDF) is a common feature of critical illness. There is no consensus on the best way to measure severity of GDF. The aim of this systematic review was to evaluate ...and compare all gastrointestinal dysfunction scoring tools (GDSTs) to determine aspects that might be useful to construct a new gut scoring tool for intensive care patients. A comprehensive database search of MEDLINE and EMBASE on GDSTs in acute, surgical, and critically ill patients was conducted. Extraction of data was conducted for study characteristics, GDST domains, feasibility of the scoring process, clinical outcomes, and quality of life attributes; independent authors conducted the search, applied the selection criteria, and extracted the data. Methodological quality of studies was assessed. A GDST matrix was created using 14 scoring tools and was evaluated for validity. The 14 GDSTs identified were used in different clinical settings, including critical illness, acute intestinal failure, gastrointestinal disorders, and postoperative patients. There was marked variation between these GDSTs. There is a lack of emphasis in the use of objective laboratory parameters and gut‐specific biomarkers to measure GDF in majority of the studies. The overall quality of evidence was poor, and most tools lacked formal validation. This review has highlighted the lack of an agreed and validated approach to scoring GDF in critical illness. The identified aspects of GDF relevant to critical illness should now be incorporated in a new scoring tool and prospectively tested in intensive care patients.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK, VSZLJ
4.
Gastrointestinal problems in intensive care Dobos, Nicola M.; Warrillow, Stephen J.
Anaesthesia & intensive care medicine/Anaesthesia and intensive care medicine,
01/2024, Volume:
25, Issue:
1
Journal Article
Peer reviewed
Open access
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Goal of this study was to describe incidence and outcome of gastrointestinal failure (GIF) in ICU patients, evaluate its additive role to SOFA score in mortality prediction and describe GIF according ...to etiology.
A retrospective study with prospective data collection was conducted in mixed adult ICU patients admitted 2004–2015. GIF was considered present if ≥3 of following 6 symptoms occurred in 1 day: maximum gastric residual volume ≥ 500 mL; absent bowel sounds; vomiting or regurgitation; diarrhea; suspected or radiologically confirmed bowel distension; gastrointestinal bleeding. Division into primary (gastrointestinal pathology causing GIF) and secondary (due to other conditions) GIF was made based on origin of syndrome.
GIF developed in 413 (10.4%) of 3959 patients. Primary GIF occurred in 61.3% and secondary GIF in 38.7% of patients. Development of GIF was associated with longer mechanical ventilation, ICU stay and higher ICU, 30-day and 90-day mortality. Outcomes of patients with primary and secondary GIF were similar. All SOFA sub-scores and number of gastrointestinal symptoms on admission day independently predicted 90-day mortality.
Gastrointestinal failure, independent of origin, is associated with worse ICU outcome. Similar to other organ failures included in SOFA score, GIF independently predicts mortality.
•Gastrointestinal failure (GIF) was defined as presence of ≥3 GI symptoms in 1 day.•GIF occurred in 10.4% of 3959 mixed adult ICU patients.•GIF associated with longer mechanical ventilation, ICU stay and higher mortality.•No outcome difference noted in patients with different etiologies of GIF.•Like SOFA sub-scores, higher number of GI symptoms independently predicts mortality.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
6.
Gastrointestinal failure, big data and intensive care Singer, Pierre; Robinson, Eyal; Raphaeli, Orit
Current opinion in clinical nutrition and metabolic care,
2023-Sep-01, 2023-09-00, 20230901, Volume:
26, Issue:
5
Journal Article
Peer reviewed
Enteral feeding is the main route of administration of medical nutritional therapy in the critically ill. However, its failure is associated with increased complications. Machine learning and ...artificial intelligence have been used in intensive care to predict complications. The aim of this review is to explore the ability of machine learning to support decision making to ensure successful nutritional therapy.
Numerous conditions such as sepsis, acute kidney injury or indication for mechanical ventilation can be predicted using machine learning. Recently, machine learning has been applied to explore how gastrointestinal symptoms in addition to demographic parameters and severity scores, can accurately predict outcomes and successful administration of medical nutritional therapy.
With the rise of precision and personalized medicine for support of medical decisions, machine learning is gaining popularity in the field of intensive care, first not only to predict acute renal failure or indication for intubation but also to define the best parameters for recognizing gastrointestinal intolerance and to recognize patients intolerant to enteral feeding. Large data availability and improvement in data science will make machine learning an important tool to improve medical nutritional therapy.
Purpose of Review
Efforts to provide early enteral nutrition in critical illness are thwarted by gastrointestinal dysfunction and feeding intolerance. While many of the signs and symptoms of this ...dysfunction reflect gastroparesis and intestinal dysmotility, other symptoms which may or may not be related are often included such as diarrhea, bleeding, and intra-abdominal hypertension. This paper discusses the need to monitor tolerance of nutritional therapy in the critical care setting and reviews the results of those clinical trials which have helped establish objective measures, define feeding intolerance, and provide a tool to guide continued delivery of the enteral regimen.
Recent Findings
While definitions vary, the presence of gastrointestinal dysfunction and feeding intolerance correlates with adverse clinical outcomes, including prolonged duration of mechanical ventilation, greater length of stay in the intensive care unit, and increased mortality.
Summary
Despite their prognostic value, it is not clear to what extent these scoring systems should direct nutritional therapy. The clinician should be astute in the careful selection of monitors, in identifying and addressing signs and symptoms of intolerance, and by responding appropriately with feeding strategies that are effective and safe. Early enteral feeding in critical illness has been shown to be optimized by following protocols which allow monitoring patient tolerance while providing individualized care.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
A prolonged stay in the intensive care unit (ICU) is associated with gastrointestinal failure, which may have a destructive effect on functional status within 1 year after hospital ...discharge. The aim was to investigate the effects of a daily exercise session, using a bedside cycle ergometer, on gastrointestinal functions, such as diarrhea, gastric retention, and vomiting, in patients with severe pneumonia who received mechanical ventilation (MV).
Methods
The study was a randomized controlled trial, and its setting was the ICU of a tertiary hospital in Eastern China. A total of 102 critically ill patients who received MV were recruited only when their cardiorespiratory function was deemed stable to perform a bedside cycling exercise. Those patients were expected to spend a minimum of 7 days in the ICU. All subjects received respiratory physiotherapy and performed a daily standardized passive or active motion session of their limbs. The patients were randomized into two groups, namely, the treatment group, which were administered passive or active leg exercise intervention for 20 min/day using a bedside ergometer, and the control group, which did not. Gastrointestinal (GI) functions and the nutritional status of both groups were evaluated on the first, fourth, and seventh days of training and at discharge.
Results
During the 7 days of the study, the number of patients with diarrhea in the treatment group was significantly lower than that in the control group. In contrast, there were significantly more patients in the treatment group with increased bowel sounds (
P
< 0.05). However, there was no significant difference in the number of patients with vomiting and gastric retention between these two groups. Moreover, when the patients were discharged from the hospital, the albumin level and lymphocyte count were significantly higher in the treatment group (
P
< 0.05). In addition, the number of invasive ventilation days in the treatment group was less than that in the control group (
P
< 0.05). While the ICU length of stay and the total hospitalization time were not significantly different between the two groups.
Conclusion
Early exercise training in critical ICU survivors who received MV enhanced the recovery of gastrointestinal functions and improved the patient’s nutrition status at hospital discharge.
The Chinese herb da huang (DH) (Rhubarb) is commonly used for GIF intensive care unit (ICU)/pediatric intensive care unit (PICU) gastrointestinal failure (GIF) patients in China. However, the ...potential preventive and therapeutic effect of DH in these patients has not yet been studied systematically.
The aim of this study was to evaluate the preventive and therapeutic effects of DH in treating ICU/PICU GIF patients with the most recent evidence.
We systematically searched 7 databases from inception to March 30, 2018. RevMan 5.3 software was used to perform a meta-analysis. GRADE methodology was applied to evaluate the quality of evidence for each outcome. The review protocol was registered on PROSPERO (CRD42018092710) in advance.
Seven studies comprising 788 pediatric or adult participants were included in this analysis. Three indicators, including GIF occurrence rates (gastrointestinal mucosal hemorrhage, enteroplegia), multiple organ dysfunction syndrome (MODS)-related items (occurrence rates of MODS, mortality rates of MODS) and duration in the ICU was analyzed. The GIF occurrence rate meta-analysis result was (RR 0.47, CI 95% 0.37-0.60; P = .95); MODS related items indicator result was (RR 0.44, CI 95% 0.33-0.59; P = .41); ICU duration ICU result was (RR -2.87, CI 95% -3.53--2.21; P = .40). The safety of Chinese herb DH (Rhubarb) remains unclear.
Current evidence suggests that the Chinese herb rhubarb (DH) powder combined with Western medicine was inferior to Western medicine alone in terms of preventive and therapeutic effects in ICU/PICU patients in terms of decreasing GIF occurrence rates (gastrointestinal mucosal hemorrhage and enteroplegia), occurrence rates of MODS, mortality from MODS, and shortened duration time in the ICU/PICU. However, larger sample sizes and rigorously-designed studies are necessary to conclusively determine the association between DH powder and outcomes in ICU/PICU GIF patients.
Acute gastrointestinal injury (AGI) is commonly present in patients with acute pancreatitis (AP). It is often difficult to predict gastrointestinal function in the early stage due to lack of reliable ...markers. We aimed to assess whether early plasma trefoil factor 2 (TFF-2) is a potential predictor for AGI.Fifty one patients were included for the onset of AP (from developing abdominal pain) within 72 hours in this prospective observational single-center study from January 2013 to July 2015. Among them 23 patients were classified as mild, 17 as moderately severe, and 11 as severe according to 2012 Atlanta classification. Plasma samples were collected only once at admission to the ICU. Twenty samples of healthy adults were also collected as control. The TFF-2 levels were determined by using a human TFF-2 enzyme-linked immunoassay. AGI grades from 1st to 7th day after admission were observed.The plasma TFF-2 levels among AP patients in early stage were significantly higher than healthy controls (766.41 ng/mL vs 94.37 ng/mL, P < .0001). The correlations between TFF-2 levels and AGI grades from 1st to 4th day after admission were positive (r = 0.47, 0.43, 0.42, 0.40 respectively, P < .05). As a predictor of acute gastrointestinal failure, plasma TFF-2 was superior to others: Acute Physiology and Chronic Health Evaluation II, sequential organ failure assessment, procalcitonin, C-reactive protein, serum calcium. In addition, TFF-2 increased along with the severity of AP (r = 0.554, P < .0001) and associated with Acute Physiology and Chronic Health Evaluation II, sequential organ failure assessment, C-reactive protein, serum calcium.The plasma TFF-2 levels were increased in patients in early stage of AP and correlated with AGI grades and disease severity in our study. TFF-2 might be a potential predictor for acute gastrointestinal failure in patients with AP.
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