A 70-year-old man had been an inpatient on the intensive care unit for nearly 40 days after a complicated recovery following mitral valve replacement. He was being gradually weaned from the ventilator via tracheostomy but required no other invasive organ support. His intensive care unit stay had been complicated by recurrent respiratory sepsis treated with antibiotics and aggressive physiotherapy. Up until this point he had been fed by a nasogastric tube but began to exhibit signs suggestive of impaired absorption including large nasogastric aspirates and a requirement for higher levels of parenteral electrolyte administration.
Prokinetic treatment with metoclopramide 10mg TDS for 24 hours failed to improve the high aspirate levels which remained in excess of 300ml every four hours. Erythromycin 250mg BD was added with little improvement. Following discussion with gastroenterology colleagues an agreement to place a post-pyloric nasojejunal feeding tube was made; unfortunately this procedure was delayed by a further 48 hours as no endoscopist was free to attend. Parenteral feeding was initiated at this point in order to maintain calorific intake.
A forty-year-old motorcyclist was admitted to the ITU following a road traffic accident involving a stationary vehicle. She sustained a fractured right distal radius and multiple left sided rib fractures, involving ribs 2 to 9, with a free floating flail segment. She developed respiratory distress due to underlying lung contusions and a haemopneumothorax and was treated with two left sided intercostal drains, endotracheal intubation and invasive ventilation. She developed ARDS with bilateral infiltrates and PF ratio of <200mmHg, with normal cardiac function on transthoracic echocardiography. She was tracheostomised on day 12, and had a protracted ventilatory wean further complicated by a ventilator associated pneumonia. She was enterally fed during this period but began to develop an ileus and gut dysmotility, resistant to prokinetic treatment, leading to large volume gastric aspirates. She became visibly malnourished and was commenced temporarily on parenteral nutrition and IV glutamine. The ileus resolved over the following week and weaning recommenced, having ceased due to diaphragmatic splinting. She eventually weaned from the ventilator and was discharged from the ITU on day 40. She was profoundly weak due to a critical illness acquired weakness.
What is the role of glutamine supplementation in critical illness?Read More »
A 19 year old man presented to the surgical team complaining of abdominal pain. He underwent a laparoscopic appendicectomy and a perforated appendix was removed. He returned to the surgical ward and three days later was ready for discharge. Unfortunately he then developed worsening abdominal pain, fevers and breathlessness. He underwent a CT scan and this demonstrated multiple collections of infected matter within his abdomen in addition to bi-basal atelectasis. He was admitted to the intensive care unit for haemodynamic monitoring, oxygen therapy and broad spectrum antibiotics. He underwent three intra-abdominal washouts of infected material over an eight day admission. During this time he had attempted enteral feeding via a nasogastric tube but had very high gastric aspirates, with no absorption, as a result of a prolonged ileus. He was started on parenteral nutrition on day eight of his ICU admission.
When should parenteral nutrition be initiated in those that are failing to meet caloric targets with enteral feeding alone?
A 55-year-old previously healthy lady was admitted with pancreatitis secondary to gallstones. Her admission modified Glasgow Score was 4, and CT scan showed approximately 70% necrosis of the pancreas encompassing the neck, body and tail with sparing of the head. She rapidly developed ARDS, AKI and vasoplegia, and subsequently developed abdominal compartment syndrome requiring decompressive laparotomy. Her later complications included intraabdominal collections requiring percutaneous drainage, upper GI bleeding, and staged closure of her laparostomy. She was initially commenced on enteral NG feeding but developed high NG aspirates despite pro-kinetics. Parenteral nutrition (PN) was commenced in combination with a ‘trophic’ enteral feed. Four weeks into her admission her triglyceride level was found to be elevated, necessitating lipid free PN and cessation of propofol. This led to a drop in her triglyceride level.
How should we manage the provision of nutrition in acute pancreatitis?
A middle aged man is admitted with abdominal pain and vomiting. He has a history of alcohol excess. A CT scan shows evidence of pancreatic necrosis. Supportive care is initiated and an NGT placed for supplementary enteral nutrition. After 3 days, he is referred to ICU as his oxygen requirements have increased and he is requiring non-invasive ventilation. It is noted that he has had very large gastric aspirates. Parenteral nutrition is commenced at this point.
What is the evidence for enteral versus parenteral feed as a source of nutrition in critically ill patients?Read More »
A young man is admitted to the surgical unit with several months of worsening abdominal pain. It has become much more severe over the last 24 hours. A CT scan shows evidence of acute pancreatitis with no gallstones or biliary duct dilatation.. He is normally well with no history of alcohol excess. His triglyceride level is elevated at 83.7mmol/L and a diagnosis of hypertriglyceridaemia induced acute pancreatitis is made.
What is hypertriglyceridaemia induced acute pancreatitis and how is it treated?
A middle aged woman presented with an acute abdomen. At laparotomy she was found to have generalised peritonitis secondary to small bowel perforation due to adhesional obstruction. She remained ventilated and on noradrenaline support for several days post-op. Trophic enteral feeds were introduced at 24hrs post-op, but NG aspirates remained high for a further 48 hours despite prokinetics. The decision was made to institute parenteral nutrition if no improvement at day 5 post-op, but was never commenced as NG aspirates improved and enteral nutrition was gradually increased.
What is the evidence for enteral versus parenteral feed as a source of nutrition in critical ill patients?Read More »