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      Gastrointestinal function in intensive care patients: terminology, definitions and management. Recommendations of the ESICM Working Group on Abdominal Problems

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          Abstract

          Purpose

          Acute gastrointestinal (GI) dysfunction and failure have been increasingly recognized in critically ill patients. The variety of definitions proposed in the past has led to confusion and difficulty in comparing one study to another. An international working group convened to standardize the definitions for acute GI failure and GI symptoms and to review the therapeutic options.

          Methods

          The Working Group on Abdominal Problems (WGAP) of the European Society of Intensive Care Medicine (ESICM) developed the definitions for GI dysfunction in intensive care patients on the basis of the available evidence and current understanding of the pathophysiology.

          Results

          Definitions for acute gastrointestinal injury (AGI) with its four grades of severity, as well as for feeding intolerance syndrome and GI symptoms (e.g. vomiting, diarrhoea, paralysis, high gastric residual volumes) are proposed. AGI is a malfunctioning of the GI tract in intensive care patients due to their acute illness. AGI grade I = increased risk of developing GI dysfunction or failure (a self-limiting condition); AGI grade II = GI dysfunction (a condition that requires interventions); AGI grade III = GI failure (GI function cannot be restored with interventions); AGI grade IV = dramatically manifesting GI failure (a condition that is immediately life-threatening). Current evidence and expert opinions regarding treatment of acute GI dysfunction are provided.

          Conclusions

          State-of-the-art definitions for GI dysfunction with gradation as well as management recommendations are proposed on the basis of current medical evidence and expert opinion. The WGAP recommends using these definitions for clinical and research purposes.

          Electronic supplementary material

          The online version of this article (doi:10.1007/s00134-011-2459-y) contains supplementary material, which is available to authorized users.

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          Most cited references75

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          ESPEN Guidelines on Enteral Nutrition: Intensive care.

          K. G. Kreymann, M Berger, N Deutz … (2006)
          Enteral nutrition (EN) via tube feeding is, today, the preferred way of feeding the critically ill patient and an important means of counteracting for the catabolic state induced by severe diseases. These guidelines are intended to give evidence-based recommendations for the use of EN in patients who have a complicated course during their ICU stay, focusing particularly on those who develop a severe inflammatory response, i.e. patients who have failure of at least one organ during their ICU stay. These guidelines were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They were discussed and accepted in a consensus conference. EN should be given to all ICU patients who are not expected to be taking a full oral diet within three days. It should have begun during the first 24h using a standard high-protein formula. During the acute and initial phases of critical illness an exogenous energy supply in excess of 20-25 kcal/kg BW/day should be avoided, whereas, during recovery, the aim should be to provide values of 25-30 total kcal/kg BW/day. Supplementary parenteral nutrition remains a reserve tool and should be given only to those patients who do not reach their target nutrient intake on EN alone. There is no general indication for immune-modulating formulae in patients with severe illness or sepsis and an APACHE II Score >15. Glutamine should be supplemented in patients suffering from burns or trauma.
          Article 0 comments Cited 287 times – based on 0 reviews     Review now
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            Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).

            Stephen A McClave, Robert Martindale, Vincent Vanek … (2009)
            Article 0 comments Cited 275 times – based on 0 reviews     Review now
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              International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding.

              Alan N Barkun, Marc Bardou, Ernst J. Kuipers … (2010)
              A multidisciplinary group of 34 experts from 15 countries developed this update and expansion of the recommendations on the management of acute nonvariceal upper gastrointestinal bleeding (UGIB) from 2003. The Appraisal of Guidelines for Research and Evaluation (AGREE) process and independent ethics protocols were used. Sources of data included original and published systematic reviews; randomized, controlled trials; and abstracts up to October 2008. Quality of evidence and strength of recommendations have been rated by using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Recommendations emphasize early risk stratification, by using validated prognostic scales, and early endoscopy (within 24 hours). Endoscopic hemostasis remains indicated for high-risk lesions, whereas data support attempts to dislodge clots with hemostatic, pharmacologic, or combination treatment of the underlying stigmata. Clips or thermocoagulation, alone or with epinephrine injection, are effective methods; epinephrine injection alone is not recommended. Second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended. Preendoscopy proton-pump inhibitor (PPI) therapy may downstage the lesion; intravenous high-dose PPI therapy after successful endoscopic hemostasis decreases both rebleeding and mortality in patients with high-risk stigmata. Although selected patients can be discharged promptly after endoscopy, high-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis. For patients with UGIB who require a nonsteroidal anti-inflammatory drug, a PPI with a cyclooxygenase-2 inhibitor is preferred to reduce rebleeding. Patients with UGIB who require secondary cardiovascular prophylaxis should start receiving acetylsalicylic acid (ASA) again as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days); ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding.
              Article 0 comments Cited 250 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                : +372-5-142281 , +372-5-3318406 , annika.reintam@ut.ee , annika.reintam.blaser@ut.ee
                Journal
                Journal ID (nlm-ta): Intensive Care Med
                Title: Intensive Care Medicine
                Publisher: Springer-Verlag (Berlin/Heidelberg )
                ISSN (Print): 0342-4642
                ISSN (Electronic): 1432-1238
                Publication date (Electronic): 7 February 2012
                Publication date PMC-release: 7 February 2012
                Publication date (Print): March 2012
                Volume: 38
                Issue: 3
                Pages: 384-394
                Affiliations
                [1 ]Clinic of Anaesthesiology and Intensive Care, University of Tartu, Puusepa 8, 51014 Tartu, Estonia
                [2 ]Department of Intensive Care Medicine, University Hospital (Inselspital) and University of Bern, 3010 Bern, Switzerland
                [3 ]Intensive Care Unit, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060 Antwerpen, Belgium
                [4 ]Clinic of Anaesthesiology and Intensive Care, Tartu University Hospital, Puusepa 8, 51014 Tartu, Estonia
                [5 ]Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
                [6 ]Department of Critical Care Medicine, Ghent University Hospital and Ghent Medical School, De Pintelaan 185, 9000 Ghent, Belgium
                [7 ]Department of Anaesthesiology and Intensive Care, Charité, Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
                [8 ]Division of Traumatology, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6202 AZ Maastricht, The Netherlands
                Article
                Publisher ID: 2459
                DOI: 10.1007/s00134-011-2459-y
                PMC ID: 3286505
                PubMed ID: 22310869
                SO-VID: 10beade5-3408-4cd2-9cbe-ca87c7c8994f
                Copyright © © The Author(s) 2012
                History
                Date received : 27 June 2011
                Date accepted : 20 December 2011
                Categories
                Subject: Conference Reports and Expert Panel
                Custom metadata
                issue-copyright-statement © Copyright jointly held by Springer and ESICM 2012

                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: symptoms,intensive care,definitions,gastrointestinal function,failure,classification,feeding intolerance
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: symptoms, intensive care, definitions, gastrointestinal function, failure, classification, feeding intolerance

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