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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