Diet and Nutrition in Critical Care

212 Pages·2021·4.941 MB·English

by  Rajkumar Rajendram, Victor R. Preedy, Vinood B. Patel (eds.)

DietandNutritioninCriticalCare
DOI10.1007/978-1-4614-8503-2_105-1
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Enteral Nutrition in The Open Abdomen after Injury
ClayCothrenBurlew*
DepartmentofSurgery,DenverHealthMedicalCenter,UniversityofColoradoSchoolofMedicine,Denver,CO,USA
Abstract
The optimal nutrition therapy for a critically injured patient is enteral nutrition. Despite initial
hesitancy, recent literature supports the initiation of enteral nutrition in the open abdomen. Enteral
nutrition inthiscomplex,post-injury patient populationhas beenshown todecreaseseptic compli-
cations,increasefascialclosurerates,andreducemortality.Followingpost-traumaresuscitationand
stabilization, all patients should be considered for enteral nutrition therapy to improve outcomes.
Abbreviations
ACS Abdominal compartment syndrome
ATI Abdominal trauma index
DCS Damage control surgery
EN Enteral nutrition
g Grams
ICU Intensive care unit
ISS Injury severity score
NPO Nil-per-os
SPN Supplemental parenteral nutrition
TPN Total parenteral nutrition
Introduction
Enteral nutrition (EN) has been advocated in the critically ill surgical patient to reduce septic
complications (Moore and Jones 1986; Moore et al. 1989, 1992; Kudsk et al. 1992; Adams
et al. 1986; McClave et al. 2009; Biffl et al. 2002; Taylor et al. 1999; Doig et al. 2009; Windsor
et al. 1998; Heyland et al. 2003). Historically, there has been hesitancy by clinicians to start EN in
patientswithapost-injuryopenabdomen.Itisunclearwhetherthisisduetoconcernsaboutbowel
edema following acute resuscitation, difficulty in EN access, worry about postoperative ileus, or
questions of enterocyte functionality. Recent literature, however, supports the institution of EN in
theopenabdomenafterinjury(Dissanaikeetal.2008;Byrnesetal.2010;Collieretal.2007;Burlew
etal.2012a).EarlyENinthispatientpopulationaffectsfascialclosurerates,complicationrates,and
mortality.
*Email:[email protected]
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The Importance of Enteral Nutrition
The optimal nutrition therapy for any critically ill patient is enteral nutrition (EN) initiated within
24–48 h of ICU admission. This practice is supported by one level 1 study and 13 level II studies
(Canadian Clinical Practice Guidelines 2013). In patients sustaining major abdominal trauma, the
reduction in septic complications with institution of early EN is particularly notable (Moore and
Jones1986;Mooreetal.1989,1992;Kudsketal.1992).Inoneofthefirstprospectiverandomized
controlled trials, patients with an abdominal trauma index (ATI) > 15 undergoing emergent
laparotomy were managed as either no nutrition (control group) versus early EN for the first
5 days postoperatively (Moore and Jones 1986). This anatomic index, ATI, was chosen as it has
been proven sensitive and reasonably specific for predicting septic morbidity in the post-injury
patient(Mooreetal.1981).Therefore,thoseenrolledinthetrialhadsignificantabdominalinjuries.
In those enterally fed, nitrogen balance was significantly improved and septic complications were
lower. Specifically, rates of abdominal infection and pneumonia were markedly reduced in those
receiving EN. An additional randomized study in a similar trauma population identified similar
outcomes(Kudsketal.1992).InthatstudytheENgroupsufferedlesspneumonia,intra-abdominal
abscesses,andlinesepsiscomparedtotheTPNgroup(12%vs.31%forpneumonia,2%vs.13%
for abdominal abscess, 2 % vs. 13 % for line sepsis). A subsequent meta-analysis of eight
prospective randomized trials comparing outcomes between EN and total parenteral nutrition
(TPN) confirmed this reduction in septic complications in enterally fed trauma patients (Moore
etal.1992).Excludingthosepatientswithcatheter-relatedsepsis(whichcouldpotentiallyconfound
theresults),thedifferenceinsepticcomplicationswasprofound,particularlyintraumapatients.For
all trauma patients the difference in septic complications was 33 % in the TPN group compared to
19%intheENgroup.Subdividingfurther,forblunttraumapatientsthesepticcomplicationratewas
41 % in the TPN group versus 21 % in the EN group.
Extrapolating the results of these studies to the patient relegated to the open abdomen is natural.
The majority of open abdomen patients are sequelae of damage control surgery (DCS) and the
abdominal compartment syndrome (ACS) – these patients are the sickest of the sick abdominal
traumapatients.Therefore,theymirrorthepatientpopulationenrolledinthesepriorstudiesthatare
shown to have the most clinical benefit from EN. However, management of the open abdomen
causes hesitation for some clinicians. The extrusion of abdominal viscera is, at times, daunting
(Fig. 1). Although intensive care management of these patients should adhere to the general
principlesofICUcare,therearesomecaveatsofopenabdomenmanagementthatdeservemention.
Etiologies of and Management of the Open Abdomen
The most common etiologies resulting in an open abdomen are the ACS and DCS, and DCS
techniques can be employed for either trauma or general surgery. The ACS is typified by intra-
abdominal hypertension due to either intra-abdominal injury or following massive resuscitation.
Decompressionoftheabdomenistypicallyperformedviaamidlinelaparotomyincisionperformed
in the operating room; this allows egress of peritoneal fluid or blood as well as evisceration of the
edematous bowel (Fig. 2). DCS, the other etiology of the post-injury open abdomen, includes
fundamental techniques to limit the operation to essential interventions; following control of
hemorrhage and enteric contamination, the patient is transported to the intensive care unit (ICU)
for correction of the “bloody viscous cycle” of hypothermia, coagulopathy, and acidosis
(Wyrzykowski and Feliciano 2012). For any patient relegated to the open abdomen, temporary
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Fig.1 Theextrusionofabdominalvisceracanbeimpressivelydaunting
Fig.2 Amidlinelaparotomyincisionallowsegressofperitonealfluidorbloodaswellaseviscerationoftheedematous
bowel
Fig.3 OnemethodoftemporaryclosureinvolvesplacementofaSteri-Drapeovertheabdominalcontentsandunderthe
fasciawithtwoJPdrainsalongthefascialedges(a);Iobanclosureaffordsquick,occlusivecovering(bandc)
coverageoftheabdominalvisceraisnecessary.Thecurrentlypreferredmethodoftemporaryclosure
is 1010 Steri-Drape and Ioban closure which is quick and easy to apply (Burlew 2012; Fig. 3).
Following the operation, the patient is transported to the ICU for physiologic restoration.
Management of the patient with an open abdomen is not markedly different from the care of any
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Fig.4 Peritonealdialysateisinstilledviaoperativelyplacedcatheters(a)resultinginadecreaseinboweledema(bandc)
criticallyillpatient.Patientsshouldreceivedirectedresuscitation,rewarmingtechniques,correction
of coagulopathy and acidosis, lung protective ventilation (once resuscitated), strategies to prevent
ventilator-associated pneumonia, treatment of adrenal suppression, and management of hypergly-
cemia. Issues specific to the patient with the open abdomen include fluid administration, nutrition
support, and management of enteric injuries.
Duringthefirst12–24hpost-injury,goal-directedresuscitationisperformed;thisisaccomplished
withinitialvolumeloadingtoattainadequatepreload,followedbyjudicioususeofinotropicagents
or vasopressors (Moore et al. 2006). The severely ill patient may require infusion volumes greater
than10lduringtheinitial6–12h.Withtheabdominalviscerapracticallyswellinginfrontofone’s
eyes, balancing fluid administration and cardiac performance versus generating visceral and retro-
peritonealedemaischallenging.Althoughperhapsappealinginthesepatients,evidencetodatedoes
not support the administration of early colloid infusion (Finfer et al. 2004). One consideration in
patients with markedly edematous bowel is direct peritoneal resuscitation (Smith et al. 2010).
Peritoneal dialysateisinstilled viaoperatively placed catheters intheabdomento bathetheviscera
(Fig. 4). This technique is done using similar temporary closure techniques as some of the wound
vacuum dressings do not permit egress of thedialysate through the sponge material. Investigations
haveshownanincreaseinvisceralbloodflow,adecreaseinboweledema,andanincreaseinratesof
fascial closure. Once physiologic restoration is complete, the patient is returned to the operating
room for definitive repair of injuries and attempts at fascial closure.
One caveat in ICU care of the open abdomen patient relates to the extent of nutritional therapy
these patients require. Due to the egress of albumin-rich ascitic fluid from the open abdomen, one
mustincreasetheadditionalproteinneededforthepatient’soptimalnutritionaltherapysupport.One
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shouldaddapproximately2gofnitrogentothepatient’sdailyproteinrequirement(i.e.,thenitrogen
balance calculation) for every liter of abdominal fluid output from the open abdomen (Cheatham
et al. 2007).
Enteral Nutrition Access Options
Enteric access for EN is broken into two broad categories – temporary and long-term techniques.
Temporaryoptionsincludeentericfeedingtubessuchasastandardnasogastrictube,anasoduodenal
tube(oftentermedaDobhofftube),oranasojejunaltube.Theformeraretypicallyplacedblindlyat
thebedsideandadequateplacementconfirmedwithplainradiography(GopalanandKhanna2003).
Nasojejunaltubesareoftenplacedwiththeassistanceofendoscopyorfluoroscopy(ByrneandFang
2006).Surgical,long-termoptionsshouldbeconsideredinpatientswithanopenabdomenasaccess
totheperitonealcavityisnotanissue.Despitetheedematousandinflamedbowel,enteralaccesshas
beendemonstratedtobereasonableinthecomplexopenabdomenpatient(Cothrenetal.2004).One
caveat shouldbeconsidered, however.Inpatientswithrepeatedtripstotheoperating roomandfor
thoseundergoingsequentialfascialclosuretechniques(Burlewetal.2012b),optimaltimingoftube
placementshouldbeconsidered.Ifoperativelyplacedgastrostomyorjejunostomytubesareplaced
earlyintheprocess,anymanipulationofthebowelonrepeatedlaparotomytripscoulddislodgethe
tubeorpotentiateatube-siteleak.Therefore,ifoperativelyplacedtubesareconsidered,theyshould
beplacedatthesameoperationthattheadjacentfasciaisclosedinparallel,hencelimitingadditional
movement of the bowel in this area.
Which of these options for enteral access one chooses may depend upon patient physiology and
any associated comorbidities. For example, operative gastrostomy in a patient with preexistent
cirrhosiswithascitesisnotanoptimalprocedure.Alternatively,inanopenabdomenpatientwithan
associatedtraumaticbraininjury,long-termenteralaccessisoftenbeneficialandmorecomfortable
for the patient. Multiple studies have attempted to answer the question whether gastric or post-
pyloric feedings are better (Montecalvo et al. 1992; Kearns et al. 2000; Hsu et al. 2009; Marik and
Zalogna 2003; Ho et al. 2006; White et al. 2009; Davies et al. 2012). Some of these studies
demonstrate patients reach higher caloric goals with post-pyloric tube feeding (Montecalvo
et al. 1992; Kearns et al. 2000; Hsu et al. 2009), while others argue that gastric delivery of enteral
nutrition results in earlier delivery of nutrition (Marik and Zalogna 2003; White et al. 2009) with
fewer tube placement issues (Ho et al. 2006).
Timing of Initiation of Nutrition Therapy
Nutrition support is pivotal in the management of the critically ill patient. Numerous studies
demonstrate that early, appropriate nutrition in these patients impacts patient outcome. The ideal
nutrition therapy for a critically ill patient, as discussed previously, is EN within 48 h of ICU
admission. Additionally, EN is less expensive and associated with fewer complications than
parenteral nutrition. There has been some support for initiation of EN regardless of infusion rates;
data in the acute lung injury population demonstrated equivalent ventilator-free days, infectious
complications,andmortalityinthosepatientsreceivingtrophicEN(rate(cid:1)20mL/h)versusstandard
EN advancement to caloric goals (National Heart, Lung, and Blood Institute Acute Respiratory
Distress Syndrome (ARDS) Clinical Trials Network et al. 2012; Rice et al. 2011).
However, patients may have contraindications to full enteral feeding (Table 1).
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Table1 Contraindicationstoenteralnutrition
Hemodynamicinstability/vasopressoragents
Bowelobstruction
Boweldiscontinuity
Bowelischemia
Severeileus
Severepancreatitis
High-outputentericfistula
Shortgutsyndrome
Recentsurgeryorrecentbowelanastomosis
The use of TPN, once referred to as total poisonous nutrition, in the ICU continues to be
controversial. A recent study of TPN in the ICU promulgates this concept (Casaer et al. 2011).
This randomized controlled trial demonstrated that patients in the late initiation TPN group (TPN
afterday7)hada6%higherlikelihoodofbeingdischargedfromtheICUandhospitalearlierwith
equalfunctionalstatustotheearlyTPNgroup(within48h).Withalowercomplicationrate,lower
infection rate, fewer ventilator days, fewer renal replacement days, and overall reduction in health
care costs in the late TPN group, they concluded that late initiation of parenteral nutrition was
associated with faster recoverand fewer complications.The strength ofthe studyisits randomized
design and its overall numbers (over 4,600 patients enrolled); criticism of this study focuses on
potentialbiasofthepatientpopulationselected.Forexample,patientspotentiallynotrequiringTPN
(i.e., post elective open heart surgery with a short stay in the ICU) were included; 39 % of patients
lefttheICUbyday3and50%byday5.Amorerecentstudydoesnotconfirmtheharmfuleffectsof
TPNnotedintheCasearstudy(Doigetal.2013).Incriticallyillpatientswhohadcontraindications
toEN,TPNwasinitiatedwithin24hofICUadmissioninthestudygroupversusroutineNPOstatus
inthecontrolgroup.Theauthorsfoundnodifferenceinmortality,ICUorhospitalstay,orinfection
rates but noted a significant reduction in ventilator days. An additional study looked at the role of
supplemental TPN(Heidegger etal.2013). Forpatients staying intheICU longer than5dayswho
hadlessthan60%oftheirenergyneedsmetbyEN,theywererandomizedtoreceivesupplemental
parenteralnutrition(SPN)orcontinueENalone.PatientsreceivingSPNhadabouta30%decreased
riskofdevelopingnosocomialinfections,moreantibiotic-freedays,and1dayshorteronmechanical
ventilation.
Soitappearsthattherealquestioniswhoisnutritionallyatriskandwouldbenefitfromnutrition
therapy. In general there are two groups that benefit the most from nutrition support: malnourished
patientsandthosewhoareintheICUforprolongedstaysandhenceareatriskforenergyandprotein
deficits.SoalthoughsupplementalTPNmaybeindicatedinthiscriticallyillandinjuredpopulation,
whatistheroleforEN?TherehasbeendemonstrationofsuccessfulENinitiationimmediatelyafter
fascial closure (Cothren et al. 2004), but what is the role of EN in the open abdomen? Should we
even consider it prior to repeat laparotomy and eventual abdominal closure?
Impact of Enteral Nutrition on Patient Outcomes with an Open Abdomen
The literature to date evaluating EN in the post-injury, open abdomen patient contains disparate
results (Table 2). The first dedicated evaluation of EN in the open abdomen was in 2007 (Collier
etal.2007).Thisstudyreviewed78patientsrequiringopenabdomenmanagementpastpost-injury
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Table2 ComparisonofthefourpublishedstudiesofENinopenabdomen:impactofENonthevariableslisted
Pneumonia Fascialclosurerate Allinfectiouscomplications Mortality
Collieretal.(2007) Noimpact Increased
Byrnesetal.(2010) Noimpact Noimpact
Dissanaikeetal.(2008) Decreased Noimpact
Burlewetal.(2012b) Noimpact Increased Decreased Decreased
day4;thestudypopulationwasamixofbluntandpenetratingtraumapatients,aswellasACSand
DCSpatients.ThoseopenabdomenpatientswithearlyEN,definedasinitiationpriortoday4,had
higher fascial closure rates (74 % vs. 49 %) and a lower fistula rate (9 % vs. 26 %); there was no
reported difference in infectious complications. It is unclear whether patients with bowel injuries
were included in the analysis. The multicenter Glue Grant group analyzed the effect of early EN,
defined as initiation within 36 h after completed resuscitation, in 100 blunt trauma patients
(Dissanaike et al. 2008). Patients with bowel injuries were excluded from analysis. Patients in the
earlyENgrouphadalowerrateofpneumonia(44%vs.72%).Therewerenoreporteddifferences
intimetoclosureorinfascialclosurerates;ofnote,however,over90%ofthestudypopulationin
either patient group attained abdominal closure with an average of three laparotomies per patient.
A third study of EN in the open abdomen included 23 patients with blunt and penetrating trauma
with over half ofthe patients sustaining abowel injury (Byrnes etal. 2010). In the group receiving
EN,fascialclosurewasdelayedcomparedtotheNPOgroup(day7vs.day3.4).Successfulfascial
closure was attained in 66 % of the total study population, but stratification by enteral feeding was
notperformed.Ventilator-associatedpneumoniaratesweresimilarbetweenthosewhoreceivedEN
and those who did not.
The largest study to date on EN in the open abdomen is from the Western Trauma Association
multicenter trials group (Burlew et al. 2012a). They reported their analysis of almost 600 patients
from 11 trauma centers. Their population was seriously injured with a mean injury severity score
(ISS)of31.Themajority(92%)ofpatientshadanopenabdomenfollowingdamagecontrolsurgery
(DCS), while the remainder suffered the abdominal compartment syndrome (ACS). The mean
abdominal trauma index (ATI) for those patients undergoing DCS was 26.8 (cid:3) 0.6. Of the
597 patients, 230 (39 %) had EN initiated prior to closure of the abdomen; this was started on
post-injuryday3.6(cid:3)1.2.ComparingthosepatientswithanopenabdomenwhoreceivedENversus
those who did not and remained NPO, there was an independent association between enteral
nutrition and ultimate fascial closure following logistic regression (controlling for site, ISS, mech-
anism of injury, closure at second laparotomy, total 24-h infused volume). By logistic regression
there was no association between EN and complication rate, but there was an association between
EN and decreased mortality. In subgroup analysis, however, the advantages of EN became more
notable. In those patients without a bowel injury, patients given EN had significantly more
operations (3.4 vs. 2.7) and a longer duration of the open abdomen (7 vs. 4 days), but a higher
incidence of fascial closure (84 % vs. 50 %) compared to the NPO group. Ventilator-free days and
ICU-freedaysweresimilarbetweenthetwogroups,whilehospitallengthofstayforsurvivorswas
significantlylongerinthegroupreceivingEN(31vs.24days).Mortality,however,waslowerinthe
EN group compared to the NPO group (10 % vs. 23 %).
Logistic regression was performed for the 307 patients without a bowel injury; the EN and NPO
groups were compared while controlling for site, ISS, mechanism of injury, closure at second laparot-
omy, and total 24-h infused volume. There was a strong independent association between EN and
successful fascial closure (OR ¼ 5.3, p < 0.01). There was a significant association between EN and
decreased complications (OR ¼ 0.46, p ¼ 0.02) and decreased mortality (OR ¼ 0.30, p ¼ 0.01).
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Whilehigherfascialclosureratesandlowerinfectiouscomplicationshavebeenpreviouslysuggestedin
the literature, this is the first study to identify a significant difference in mortality between post-injury
openabdomenpatientsreceivingENcomparedtothoseremainingNPO.
TheUseofEnteralNutrition inPatientswithanOpenAbdomenandBowel
Injuries
UseofENintheopenabdomenpatientwithoutabowelinjurymaysoundlikeareasonabledirective
in light of the literature on the importance of EN to prevent septic complications as well as the
literaturesupportingearlierfascialclosureratesanddecreasedmortality.However,inpatientwitha
recentbowelanastomosis,shouldENbestarteddespitetheopenabdomen?IntheWesternTrauma
Association multicenter trial (Burlew et al. 2012a), 290 (49 %) patients in the DCS group had
identified bowel injuries: 95 small bowel, 74 colon, and 121 combined small bowel and colon. All
patients with a bowel injury had a repair or anastomosis performed except for nine patients with
isolated colonic injuries managed with colostomy. In patients with an enteric injury, 74 (26 %)
patientshadENstartedwiththeirabdomenopen.Comparingpatientswithanentericinjurywhohad
EN vs. those kept NPO, logistic regression revealed no significant association between EN and
fascial closure (OR ¼ 0.6, p ¼ 0.2), complication rate (OR ¼ 1.7, p ¼ 0.19), and mortality (OR ¼
0.79, p ¼ 0.69). Hence EN appears to be neither advantageous nor detrimental in these patients.
Summary Points
(cid:129) Enteral nutrition in the post-injury open abdomen is feasible.
(cid:129) Once resuscitation is complete, initiation of enteral nutrition should be considered in all injured
patients.
(cid:129) Enteral access can be obtained operatively but should be delayed until the appropriate level of
fascial closure.
(cid:129) For patients without a bowel injury, enteral nutrition in the open abdomen is associated with a
marked increase in successful fascial closure, a decrease in complications, and a decrease in
mortality.
(cid:129) Although enteral nutrition in patients with bowel injuries does not appear to alter fascial closure
rates, complications, or mortality, prospective trials are warranted to further clarify the role of
enteral nutrition in this subgroup.
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