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2.1 AGI grade I (risk of developing GI dysfunction or considered in this state, when prokinetic therapy
failure)the function of the GI tract is partially is not effective (grade 2D).
impaired, expressed as GI symptoms related to a 2.3 AGI grade III (gastrointestinal failure)loss of GI
known cause and perceived as transient. function, where restoration of GI function is not
Rationale Condition is clinically seen as occur- achieved despite interventions and the general
rence of GI symptoms after an insult, which condition is not improving.
expectedly has temporary and self-limiting Rationale Clinically seen as sustained intoler-
nature. ance to enteral feeding without improvement
Examples Postoperative nausea and/or vomiting after treatment (e.g. erythromycin, postpyloric
during the first days after abdominal surgery, tube placement), leading to persistence or wors-
postoperative absence of bowel sounds, dimin- ening of MODS.
ished bowel motility in the early phase of Examples Despite treatment, feeding intolerance
shock. is persistinghigh gastric residuals, persisting
Management The general condition is usually GI paralysis, occurrence or worsening of bowel
improving and specific interventions for GI dilatation, progression of IAH to grade II (IAP
symptoms are not needed, except the replace- 1520 mmHg), low abdominal perfusion pres-
ment of fluid requirements by intravenous sure (APP) (below 60 mmHg). Feeding
infusions. Early enteral feeding, started within intolerance is present and possibly associated
2448 h after the injury, is recommended [17, with persistence or worsening of MODS.
18] (grade 1B). The use of drugs impairing GI Management Measures to prevent worsening of
motility (e.g. catecholamines, opioids) has to be GI failure are warranted (e.g. monitoring and
limited whenever possible [1922] (grade 1C). targeted treatment of IAH [23], grade 1D).
2.2 AGI grade II (gastrointestinal dysfunction)the GI Presence of undiagnosed abdominal problem
tract is not able to perform digestion and (cholecystitis, peritonitis, bowel ischaemia)
absorption adequately to satisfy the nutrient should be excluded. The medications promoting
and fluid requirements of the body. There are GI paralysis have to be discontinued as far as
no changes in general condition of the patient possible [1922] (grade 1C). Early parenteral
related to GI problems. feeding (within the first 7 days of ICU stay)
Rationale The condition is characterized by supplementary to insufficient enteral nutrition is
acute occurrence of GI symptoms requiring associated with higher incidence of hospital
therapeutic interventions for achievement of infections and should be avoided [27] (grade
nutrient and fluid requirements. This condition 2B). Challenges with small amounts of EN
occurs without previous GI interventions or is should be regularly considered (grade 2D).
more severe than might be expected in relation to 2.4 AGI grade IV (gastrointestinal failure with severe
the course of preceding abdominal procedures. impact on distant organ function)AGI has pro-
Examples Gastroparesis with high gastric resid- gressed to become directly and immediately life-
uals or reflux, paralysis of the lower GI tract, threatening, with worsening of MODS and shock.
diarrhoea, intra-abdominal hypertension (IAH) Rationale Situation when AGI has led to an acute
grade I (intra-abdominal pressure (IAP) critical deterioration of the general condition of the
1215 mmHg), visible blood in gastric content patient with distant organ dysfunction(s).
or stool. Feeding intolerance is present if at least Examples Bowel ischaemia with necrosis, GI
20 kcal/kg BW/day via enteral route cannot be bleeding leading to haemorrhagic shock, Ogilvies
reached within 72 h of feeding attempt. syndrome, abdominal compartment syndrome
Management Measures to treat the condition and (ACS) requiring decompression.
to prevent the progression to GI failure need to be Management Condition requires laparotomy or
undertaken (e.g. treatment of intra-abdominal other emergency interventions (e.g., colonoscopy
hypertension [23], grade 1D; or measures to for colonic decompression) for life-saving indica-
restore the motility function of GI tract, such as tions [2830] (grade 1D). There is no proven
prokinetic therapy [2426], grade 1C). Enteral conservative approach to resolve this situation.
feeding should be started or continued; in cases of
high gastric residuals/reflux or feeding intoler- As differentiation of the acute GI problem from
ance regular challenges with small amounts of previously existing chronic condition might be very
enteral nutrition (EN) should be regularly con- difficult, we suggest using the same definitions also
sidered (grade 2D). In patients with gastroparesis, in cases where the condition (e.g. GI bleeding,
initiation of postpyloric feeding should be diarrhoea, etc.) might be due to a chronic GI disease
387
(e.g. Crohns disease). In patients on chronic application of prokinetics and/or laxatives [3234]
parenteral feeding, GI failure (equal to AGI III) (grade 1C), and controlling IAP. Challenges with
should be considered chronically present, and no small amounts of EN should be regularly considered.
new acute interventions to restore function are In patients not tolerating enteral feeding, supplemental
indicated. However, monitoring of IAH and exclu- parenteral nutrition should be considered [35, 36]
sion of the new acute abdominal problems should (grade 2D). Recent data suggest that delay for 1 week
be performed similarly as in AGI grade III with parenteral nutrition enhances recovery when
management. compared to early intravenous feeding [27] (grade
2B).
2.5 Primary and secondary AGI
4. Intra-abdominal hypertension (IAH)
another method, such as clips, thermocoagula- quadrants, repeated at least once within a tight
tion or sclerosant injection [72] (grade 1A). time frame. Palpation of the abdomen before the
Routine second endoscopy is not recommended, auscultation may stimulate peristalsis causing
but in cases of rebleeding, a second attempt for subsequent bowel sounds that may not have been
endoscopic therapy is recommended [72] (grade there otherwise [82].
1A). In cases of a negative upper endoscopy with
evidence of GI bleeding, colonoscopy should be 5.6.1 Absent peristalsisno bowel sounds are heard at
performed, followed by small bowel exploration cautious auscultation.
using push enteroscopy if colonoscopy is nega- Rationale Complete lack of bowel
tive [75] (grade 2C). In cases of ongoing sounds is abnormal [83]. However, it
bleeding with negative endoscopies, abdominal should be recognized that presence of
surgery with intraoperative endoscopy or inter- bowel sounds does not confirm normal
ventional radiology should be considered [76, motility, and that reoccurrence of bowel
77] (grade 2C). sounds does not correlate with improve-
5.5 Paralysis of lower GI tract (paralytic ileus) is the ment of paralysis.
inability of the bowel to pass stool due to 5.6.2 Hyperperistalsis is present if excessive bowel
impaired peristalsis. Clinical signs include sounds are heard on auscultation.
absence of stool for three or more consecutive Rationale Hyperperistalsis is a state of
days without mechanical obstruction. Bowel excessive motility of the digestive tract.
sounds may or may not be present. It can be present during bowel obstruc-
Rationale Outside of the ICU, the terms consti- tion occurring in parts of the bowel as
pation and obstipation include uncomfortable or attempts to overcome obstruction [84].
infrequent bowel movements, hard stool and Management There are no special man-
painful defecation. Because these symptoms may agement suggestions for absent/abnormal
not be expressed in ICU patients, it is suggested bowel sounds.
to use the term paralysis of lower GI tract. A cut- 5.7 Bowel dilatation is present if colonic diameter
off level of 3 days has been used in most of the exceeds 6 cm (greater than 9 cm for caecum) or
epidemiological ICU studies [78, 79]. small bowel diameter exceeds 3 cm, diagnosed
Management Inhibitory drugs for GI motility either on plain abdominal X-ray or CT scan [85,
(e.g. catecholamines, sedatives, opioids) must be 86].
withdrawn if possible and conditions impairing Rationale Bowel dilatation is a common sign in
motility (e.g. hyperglycemia, hypokalaemia) obstruction at any level of the GI tract. Bowel
corrected [1921] (grade 1C). Because of their dilatation may also appear without an obstruc-
delayed onset of action, laxative drugs must be tion; the terms toxic megacolon following colitis
started early or given prophylactically [24, 25] and acute colonic pseudo-obstruction or Ogil-
(grade 1D). vies syndrome, are used to describe acute severe
Because of unknown long-term efficacy and colonic dilatation.
safety the routine use of opioid antagonists Management Next to the correction of fluid and
cannot be recommended [80, 81] (grade 2B). electrolyte imbalance, nasogastric decompres-
Prokinetics like domperidone, metoclopramide sion may be helpful [29, 87] (grade 1D),
and erythromycin are used to stimulate the upper although routine usage of nasogastric tubes after
GI tract (stomach and small bowel), whereas elective laparotomy is not recommended [88]
neostigmine stimulates small bowel and colonic (grade 1A). After exclusion of mechanical
motility [25, 30]. Despite the lack of well- obstruction, intravenous neostigmine could be
controlled studies and sufficient evidence, we considered in patients with a caecal diameter
recommend a standardised approach in using [10 cm and without improvement within 24 h
prokinetics for management of motility disorders [29, 89] (grade 2B). Colonoscopy is recom-
[24, 25] (grade 1D). mended for non-surgical decompression in
5.6 Abnormal bowel sounds patients with a caecal diameter [10 cm and no
Rationale Normal frequency of bowel sounds improvement after 2448 h of conservative
may range between 5 and 35 sounds/min [82]; treatment [29, 87, 90] (grade 1C). Colonoscopic
the clinical significance of abnormal bowel decompression is effective in up to 80%, but
sounds is not clear. No technique of auscultation carries a certain morbidity/mortality risk [30].
has been proven to be superior [83]. The authors Conservative treatment together with colonos-
suggest auscultation for at least 1 min in two copy may be continued for 4872 h unless the
390
caecum is [12 cm wide [30, 91] (grade 2C). [95]. European Society for Parenteral and Enteral
In cases of unresponsiveness to conservative Nutrition (ESPEN) guidelines are available with
treatment, surgery is indicated due to the threat- recommendations for nutrition in intensive care [58].
ening risk of perforation [29, 30] (grade 1D). Feeding protocols based on these guidelines should be
Usage of a laparoscopic technique with thoracic implemented in every institution. Periods of interrup-
epidural anaesthesia where appropriate enhances tion of enteral feeding due to various interventions in
bowel function after abdominal surgery [9294] the hospital (surgery, diagnostic or therapeutic inter-
(grade 1B), and may therefore prevent bowel ventions, extubation) should be remembered and
dilatation. minimized [96, 97]. Daily assessment of adequacy of
6. Feeding protocols enteral nutrition is required.
Decreased food intake and resulting malnutrition 7. A schematic guideline for the management of patients
are independent risk factors for in-hospital mortality with AGI is presented in Fig. 1.
Fig. 1 Schematic guideline for Guideline for diagnosis and management of AGI
the management of patients
with AGI. EF enteral feeding, Enteral feeding >80% of calculated needs Aim 100 % of calculated needs
yes
EN enteral nutrition, PN Check prescribed vs. delivered
parenteral nutrition Re-evaluate daily
no
no
no
Severe, general condition not
improving
GI symptoms present? yes
no Increase EF
yes Condition improving? no
Re-evaluate
AGI IV
yes
Intervention
391
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