Gastrointestinal function in intensive care patients_ESICM推荐意见

Annika Reintam Blaser Manu L. N. G. Malbrain Joel Starkopf Sonja Fruhwald Stephan M. Jakob Jan De Waele Jan-Peter Braun Martijn Poeze Claudia Spies Gastrointestinal function in intensive care patients: terminology, definitions and management. Recommendations of the ESICM Working Group on Abdominal Problems Received: 27 June 2011 Accepted: 20 December 2011 Published online: 7 February 2012 � The Author(s) 2012. This article is published with open access at Springerlink.com On behalf of the Working Group on Abdominal Problems of the European Society of Intensive Care Medicine (ESICM WGAP). 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. A. Reintam Blaser ()) � J. Starkopf Clinic of Anaesthesiology and Intensive Care, University of Tartu, Puusepa 8, 51014 Tartu, Estonia e-mail: annika.reintam@ut.ee; annika.reintam.blaser@ut.ee Tel.: ?372-5-142281 Fax: ?372-5-3318406 A. Reintam Blaser � S. M. Jakob Department of Intensive Care Medicine, University Hospital (Inselspital) and University of Bern, 3010 Bern, Switzerland M. L. N. G. Malbrain Intensive Care Unit, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060 Antwerpen, Belgium J. Starkopf Clinic of Anaesthesiology and Intensive Care, Tartu University Hospital, Puusepa 8, 51014 Tartu, Estonia S. Fruhwald Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria J. De Waele Department of Critical Care Medicine, Ghent University Hospital and Ghent Medical School, De Pintelaan 185, 9000 Ghent, Belgium J.-P. Braun � C. Spies Department of Anaesthesiology and Intensive Care, Charite´, Universita¨tsmedizin Berlin, Charite´platz 1, 10117 Berlin, Germany M. Poeze Division of Traumatology, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6202 AZ Maastricht, The Netherlands Abstract Purpose: Acute gastro- intestinal (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 con- vened 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 pathophysiol- ogy. 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 vol- umes) 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 dys- function (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 imme- diately life-threatening). Current evidence and expert opinions regard- ing 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 recom- mends using these definitions for clinical and research purposes. Keys Gastrointestinal function � Failure � Symptoms � Feeding intolerance � Intensive care � Definitions � Classification Intensive Care Med (2012) 38:384–394 DOI 10.1007/s00134-011-2459-y CONFERENCE REPORTS AND EXPERT PANEL lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 Introduction More than 10 years ago a round-table conference on gut dysfunction in critical illness concluded that intestinal function is an important determinant in the outcome of patients admitted to the intensive care unit (ICU), but that there is no objective and clinically relevant definition of gastrointestinal (GI) dysfunction in critical illness. In addition, it was stated that the definition developed in the future should grade the severity of dysfunction [1]. The problems in defining GI dysfunction start with defining GI function. Next to the digestive tract, the GI tract also carries out endocrine, immune and barrier functions. The clinical assessment of the impairment of these functions today is more intuitive than objective. Therefore, endocrine, immune and barrier dysfunctions will not be addressed in detail in the present paper. Several studies have confirmed that GI symptoms are frequent in the ICU with up to 62% of patients exhibiting at least one GI symptom for at least 1 day [2–4]. There is also increasing evidence that development of GI problems is related to worse outcome in critically ill patients [2, 5–7]. Different definitions for separate GI symptoms have been used. The lack of markers for the measurement of GI function has suppressed studies in this field as well as the assessment of GI dysfunction as an organ failure. Although plasma citrulline and intestinal fatty acid binding protein have been proposed as possible markers for small bowel function [8], their clinical use in diag- nosis and management of GI dysfunction is still unclear. At least partly due to the lack of a formal definition and classification, treatment strategies for GI problems have been difficult to develop and are currently based on experience, rather than evidence. There is increasing evidence that early protocolized and goal-oriented care can improve organ function and the patients’ outcome during critical illness [9–12]. Improving the definition of GI dysfunction as a part of the multiple organ dysfunction syndrome (MODS) and its derived sequential organ failure assessment score (SOFA) [13] will establish the base for setting up the bundle of preventive and therapeutic measures and support the development of novel treatment strategies. For these reasons, the Working Group on Abdominal Problems (WGAP) as part of the Perioperative Intensive Care (POIC) section of the European Society of Intensive Care Medicine (ESICM) proposes a set of definitions and grading system of GI dysfunction in critical illness that are applicable both for clinical and research purposes. Methods Several key elements were used as a starting point for defining acute GI organ failure. An organ failure was considered as a dichotomous event that is either present or absent, whereas organ dysfunction is a continuum of physiologic derangement [14]. The expression ‘‘GI dys- function’’ is used to describe the large variety of GI symptoms (diarrhoea, vomiting) and diagnoses (gastro- enteritis) outside of the ICU setting; therefore, the expression ‘‘acute GI injury’’ was introduced. Current definitions and management recommendations (according to Table 1; [15]) were developed on the basis of the available evidence and current understanding of the pathophysiology. Definitions serve as expert opinion, with their reasoning given in each ‘‘rationale’’ subsection. The working method is described in detail in the electronic supplementary file. Results The WGAP suggests using the following terminology and definitions: 1. Gastrointestinal function The human GI tract has many functions including facilitating digestion to absorb nutrients and water, barrier control to modulate absorption of intraluminal microbes (and their products), endocrine and immune functions. Perfusion, secretion, motility and a coordi- nated gut–microbiome interaction are prerequisites for an adequate function [16]. It needs to be underlined that because we currently lack the tool or marker to measure GI function we cannot reliably decide about normal GI function in the acute setting. 2. Acute gastrointestinal injury (AGI) and its different grades Acute GI injury (AGI) is malfunctioning of the GI tract in critically ill patients due to their acute illness. According to severity the following grades of AGI can be distinguished: Table 1 Grading of the quality of evidence and strength of recommendations Quality of evidence Rationale A High RCT or meta-analyses B Moderate Downgraded RCTs or upgraded observational studies C Low Well-done observational studies D Very low Case series or expert opinion Strength of recommendation Grade 1 Strong We recommend Grade 2 Weak We suggest RCT randomized controlled trial 385 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 2.1 AGI grade I (risk of developing GI dysfunction or failure)—the function of the GI tract is partially impaired, expressed as GI symptoms related to a known cause and perceived as transient. Rationale Condition is clinically seen as occur- rence of GI symptoms after an insult, which expectedly has temporary and self-limiting nature. Examples Postoperative nausea and/or vomiting during the first days after abdominal surgery, postoperative absence of bowel sounds, dimin- ished bowel motility in the early phase of shock. Management The general condition is usually improving and specific interventions for GI symptoms are not needed, except the replace- ment of fluid requirements by intravenous infusions. Early enteral feeding, started within 24–48 h after the injury, is recommended [17, 18] (grade 1B). The use of drugs impairing GI motility (e.g. catecholamines, opioids) has to be limited whenever possible [19–22] (grade 1C). 2.2 AGI grade II (gastrointestinal dysfunction)—the GI tract is not able to perform digestion and absorption adequately to satisfy the nutrient and fluid requirements of the body. There are no changes in general condition of the patient related to GI problems. Rationale The condition is characterized by acute occurrence of GI symptoms requiring therapeutic interventions for achievement of nutrient and fluid requirements. This condition occurs without previous GI interventions or is more severe than might be expected in relation to the course of preceding abdominal procedures. Examples Gastroparesis with high gastric resid- uals or reflux, paralysis of the lower GI tract, diarrhoea, intra-abdominal hypertension (IAH) grade I (intra-abdominal pressure (IAP) 12–15 mmHg), visible blood in gastric content or stool. Feeding intolerance is present if at least 20 kcal/kg BW/day via enteral route cannot be reached within 72 h of feeding attempt. Management Measures to treat the condition and to prevent the progression to GI failure need to be undertaken (e.g. treatment of intra-abdominal hypertension [23], grade 1D; or measures to restore the motility function of GI tract, such as prokinetic therapy [24–26], grade 1C). Enteral feeding should be started or continued; in cases of high gastric residuals/reflux or feeding intoler- ance regular challenges with small amounts of enteral nutrition (EN) should be regularly con- sidered (grade 2D). In patients with gastroparesis, initiation of postpyloric feeding should be considered in this state, when prokinetic therapy is not effective (grade 2D). 2.3 AGI grade III (gastrointestinal failure)—loss of GI function, where restoration of GI function is not achieved despite interventions and the general condition is not improving. Rationale Clinically seen as sustained intoler- ance to enteral feeding without improvement after treatment (e.g. erythromycin, postpyloric tube placement), leading to persistence or wors- ening of MODS. Examples Despite treatment, feeding intolerance is persisting—high gastric residuals, persisting GI paralysis, occurrence or worsening of bowel dilatation, progression of IAH to grade II (IAP 15–20 mmHg), low abdominal perfusion pres- sure (APP) (below 60 mmHg). Feeding intolerance is present and possibly associated with persistence or worsening of MODS. Management Measures to prevent worsening of GI failure are warranted (e.g. monitoring and targeted treatment of IAH [23], grade 1D). Presence of undiagnosed abdominal problem (cholecystitis, peritonitis, bowel ischaemia) should be excluded. The medications promoting GI paralysis have to be discontinued as far as possible [19–22] (grade 1C). Early parenteral feeding (within the first 7 days of ICU stay) supplementary to insufficient enteral nutrition is associated with higher incidence of hospital infections and should be avoided [27] (grade 2B). Challenges with small amounts of EN should be regularly considered (grade 2D). 2.4 AGI grade IV (gastrointestinal failure with severe impact on distant organ function)—AGI has pro- gressed to become directly and immediately life- threatening, with worsening of MODS and shock. Rationale Situation when AGI has led to an acute critical deterioration of the general condition of the patient with distant organ dysfunction(s). Examples Bowel ischaemia with necrosis, GI bleeding leading to haemorrhagic shock, Ogilvie’s syndrome, abdominal compartment syndrome (ACS) requiring decompression. Management Condition requires laparotomy or other emergency interventions (e.g., colonoscopy for colonic decompression) for life-saving indica- tions [28–30] (grade 1D). There is no proven conservative approach to resolve this situation. As differentiation of the acute GI problem from previously existing chronic condition might be very difficult, we suggest using the same definitions also in cases where the condition (e.g. GI bleeding, diarrhoea, etc.) might be due to a chronic GI disease 386 Administrator 文本高亮工具 Administrator 文本高亮工具 Administrator 文本高亮工具 Administrator 文本高亮工具 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 (e.g. Crohn’s disease). In patients on chronic parenteral feeding, GI failure (equal to AGI III) should be considered chronically present, and no new acute interventions to restore function are indicated. However, monitoring of IAH and exclu- sion of the new acute abdominal problems should be performed similarly as in AGI grade III management. 2.5 Primary and secondary AGI 2.5.1 Primary AGI is associated with primary disease or direct injury to organs of the GI system (first hit). Rationale Condition may usually be observed early (during the first day) after the insult to the GI system. Examples Peritonitis, pancreatic or hepatic pathology, abdominal surgery, abdominal trauma, etc. 2.5.2 Secondary AGI develops as the consequence of a host response in critical illness without primary pathology in the GI system (second hit). Rationale Condition develops without direct insult to the GI tract. Examples GI malfunction in a patient with pneumonia, cardiac pathology, non- abdominal surgery or trauma, postresus- citation state. 3. Feeding intolerance syndrome (FI) FI is a general term indicating intolerance of enteral feeding for whatever clinical reason (vomiting, high gastric residuals, diarrhoea, GI bleeding, presence of entero-cutaneous fistulas, etc.). Rationale Diagnosis is based on complex clinical evaluation. There is no single clear-cut symptom or value that defines FI [31]. Several symptoms are commonly present. FI should be considered present if at least 20 kcal/ kg BW/day via enteral route cannot be reached within 72 h of feeding attempt or if enteral feeding has to be stopped for whatever clinical reason. FI should not be considered as present if enteral feeding is electively not prescribed or is withheld/interrupted due to procedures. FI in special conditions: in a patient with postpyloric feeding, FI is defined similarly to gastric feeding. If a patient is not fed enterally due to the presence of entero- atmospheric fistulas, FI should be considered present. If the patient undergoes a surgical intervention for ACS or for changing of surgical dressings of an open abdomen, FI should be considered present immediately after surgery unless enteral feeding can be administered. Management FI requires efforts to maintain/restore GI function: limiting the use of drugs impairing motility, application of prokinetics and/or laxatives [32–34] (grade 1C), and controlling IAP. Challenges with small amounts of EN should be regularly considered. In patients not tolerating enteral feeding, supplemental parenteral nutrition should be considered [35, 36] (grade 2D). Recent data suggest that delay for 1 week with parenteral nutrition enhances recovery when compared to early intravenous feeding [27] (grade 2B). 4. Intra-abdominal hypertension (IAH) 4.1 IAH is present if IAP is found to be 12 mmHg or higher, confirmed by at least two measurements, 1–6 h apart [37]. Rationale Normal IAP is around 5–7 mmHg [38]. There are inherent variations and fluctuations in the IAP. IAH should also be considered present if the mean of the IAP measurements of the day is 12 mmHg or higher provided that at least four measurements were performed [39]. Management Monitoring of fluid resuscitation is necessary to avoid over-resuscitation [23] (grade 1C). Continuous thoracic epidural analgesia may decrease IAP in postoperative patients with primary IAH [40] (grade 2B). Nasogastric/colonic decompression is suggested for evacuation of intraluminal contents [23] (grade 2D). In patients with intraperitoneal fluids, percutaneous catheter decompression is recommended [23] (grade 1C). Elevation of head of bed above 20� should be considered as an additional risk for development of IAH [23] (grade 2C). Neuromuscular blockade decreases the IAP [41], but due to many undesir- able effects it should be considered only in selected patients (grade 2C). 4.2 Abdominal compartment syndrome (ACS) is defined as a sustained (minimally two standard- ized measurements, performed 1–6 h apart) increase in IAP above 20 mmHg with new onset organ failure [37]. Management Although decompression remains the only definite management for ACS, the exact indications and timing of this procedure still remain controversial [42]. Currently it is recom- mended (1) to perform surgical decompression as a life-saving intervention in patients with ACS that is refractory to other treatment options [28, 43] (grade 1D), and (2) to consider pre-emptive decompression at the time of laparotomy in patients who demonstrate multiple risk factors for IAH/ACS [23] (grade 1D). In most severe cases of ruptured abdominal aortic aneurysm or abdominal trauma the initial use of mesh closure avoids development of ACS [44, 45] (grade 1C). 387 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 lzou 高亮 5. Gastrointestinal symptoms 5.1 Vomiting (emesis) is the occurrence of any visible regurgitation of gastric content irrespective of the amount. Rationale Vomiting is commonly defined as the oral expulsion of GI contents resulting from contractions of gut and thoracoabdominal wall musculature [46]. Vomiting is contrasted with regurgitation, which is the effortless passage of gastric contents into the mouth [46]. In ICU patients the forcefulness of the act is often not detectable; therefore, regurgitation and vomiting should be assessed together. Management Several guidelines for prevention and management of postoperat