1. Allison Kliewer
Baptist Dietetic Internship
April 10, 2013

2. Outline
 Introduction
 Patient Profile
 Disease background of Ileus
 Trophic feeds in the Critically Ill
 Admission
 Nutrition Care Process
 Summary and Reflection

3. Patient Profile
 Stay: 1/25 – 2/06
 77 year old white female
 Lives independently
 Two daughters and friend
 Does not drink, smoke or use drugs
 Family Hx: mother passed away at 86
from MI; father passed away from
prostate cancer

4. Pt Profile
 Allergy to hydrocodone
 PMH: CVA, sacral fracture, HTN,
dyslipidemia, CAD, osteoporosis,
deconditioning
 Past surgical Hx: hernia repair,
hysterectomy, diskectomy, exploratory
surgery and pyloroplasty form perforated
duodenal ulcer, cholestectomy and
sacroplasty

5. Pt Profile
 Chief complaint: coffee ground emesis
 Vomited for 24 hrs before admission
 Midepigastric pain and weakness
 Chronic aspirin use
 Lungs are clear
 Good bowel sounds

6. Impression
 Acute upper gastrointestinal tract bleed
 With hematemesis, coffee ground in
nature
 NPO
 IV fluids
 Proton pump inhibitors
 d/c aspirin and Fosamax
 Plan endoscopy
 GI consult

7. Ileus
 Refers to the partial or complete
blockage of the small and/or large
intestine due to either impaired
peristalsis or a mechanical obstruction
 Most common complication in critically ill
 May affect all parts of the GI tract
 Degree of impairment of intestinal
motility is correlated to the severity of
illness and mortality
(Madl and Druml, 2003)

8. Symptoms
 Nausea
 Vomiting
 Constipation
 Gastric Pain
 Discomfort
 Characterized by abdominal distention,
lack of bowel sounds, accumulation of
gas and fluids in the bowel and
decreased GI passage with delayed or
absent defecation
(Allen et al, 2012)

9. Etiology
 Blockage of small or large intestine
 Mechanical and paralytic bowel
obstruction outside or within the gut wall,
or intraluminal
 Surgical procedures
(Madl and Druml, 2003)

10. Etiology
 Intraperitonial or retroperitoneal infection
 Edema 2/2 to massive fluid resuscitation
 Bacterial or parasitic infection
 Toxic megacolon
 Abdominal arterial injury
 Venous injury
 Retroperitoneal or intra-abdominal
hematomas
 Metabolic disturbances
(Madl and Druml, 2003)

11. Pathophysiology
 Loss of synchronization resulting in
impaired peristalsis
 GI dysmotility = luminal pressure and
intestinal dilatation
 Intestinal dilatation leads to neutrophils
invading and damaging muscle layer
 = release of nitric oxide = paralyses
muscle cells
(Madl and Druml, 2003)

12. Pathophysiology
 Dilatation and pressure = Gut wall
ischemia = system uptake of cytokines
and other inflammatory mediators
 Inflammatory response contributes to
the systemic symptoms of ileus and
correlates with severity of ileus
(Madl and Druml, 2003)

13. Aspiration
 Impaired motility promotes reflux of
intestinal juices back into stomach
 = gastric residuals
 = gastric colonization with intestinal
bacteria
 Ascension of microorganisms into the
esophagus, into the pharynx, into the
trachiobranchial tree
 risk of pneumonia
(Madl and Druml, 2003)

14. Hypovolemia
 distention and intra-luminal pressure =
compromises intestinal profusion,
impairs microcirculation, and ultimately
results in fluid sequestration into the
intestinal wall and lumen
 Inflammation promotes fluid loss into
luminal space
 = hypovolemia and circulation
impairment
(Madl and Druml, 2003)

15. Bacterial Overgrowth
 Ileus associated with alterations in
intestinal flora and overgrowth of
bacteria
 Microorgansisms and/or
endotoxins/exotoxins may invade
mucosa
 = mucosal inflammation, mucosal
perfusion and hypersectrection
(Madl and Druml, 2003)

16. Bacterial Translocation
 Intestinal wall impaired or systemic
immunocompetence is compromised =
spillover of microorganisms into the
lymphatic system and/or portal
circulation
 = systemic infections or septicemia
 Bacterial overgrowth, inflammation and
impairment of barrier function of the
intestinal wall, impaired
immunocompetence
(Madl and Druml, 2003)

17. Impaired Cardiac Output
 intraluminal pressure and intrathoracic
pressure affects venous return, cardiac
filling, ventricular compliance, and
contractility
 cardiac output
 mean arterial pressure
(Madl and Druml, 2003)

18. Decreased Respiratory
Function
 Compressed pulmonary parenchyma
 Drop in functional residual capacity
 Negative affect on lung mechanics and
chest wall
 ↓ lung compliance
 = atelectasis
 alveolar pressure
 Negative influences gas exchange
(Madl and Druml, 2003)

19. Nutrition Considerations
 EN for restoration and maintenance of
intestinal function, perfusion, motility,
and barrier function
 Minimal EN can help support intestinal
function in pts whom sufficient EN is
impossible
(Madl and Druml, 2003)

20. Prognosis
 Outcome depends on the cause of the
blockage
 Consequences and recovery time vary
 Underlying cause, time taken to
diagnose, and treatment
 Margin of complications and mortality
range from 12 to 27%
 Mean length of stay is 15 days
(Rojas, 2012)

21. Feeds in Critically Ill
 Associating between inadequate feeding
and poor clinically outcome in critically ill
patients
 EN has been shown to attenuate
hypermetabolism of critical illness,
decrease infectious complications, and
shorten ICU stays compared to PN, and
reduce mortality
 EN supports intestinal structure and
function, prevents increased permeability,
bacterial translocation, systemic
inflammation
(Heyland et al, 2010)

22. Enteral Nutrition
 Stimulates epithelial cell growth and
proliferation
 Maintains mucosal mass and microvilli
height
 Preserves tight junctions between
epithelial cells
 Promotes blood flow
 Enhances brush-border enzyme activity
(Rice et al, 2011)

23. Trophic Feeds
 Trophic feeds appropriate for patients
deemed unsuitable for high volume
intragastric feeds
 Feeding small volume of enteral feeds in
order to stimulate the GI tract
 Improves GI enzyme activity, hormone
release, blood flow, motility, and
microbial flora
(Rice et al, 2011)

24. Trophic Feeds
 ARF affects more than 3 million pts in
US and is the single most common
reason ICU pts cannot eat
 Conclusive evidence supports early
feeds in the ICU
 Lack of conclusive evidence regarding
the caloric intake dose required for the
ICU pt
(Rice et al, 2011)

25. Trophic vs. EN
Study Design Subjects Purpose Intervention Results
Rice and
colleagues
2011
’03-’09
Random
open-
label
study
200 pts with
acute
respiratory
failure
expected to
require
ventilation for
over 72 hrs
Compare
clinical
outcomes and
GI
complications
with trophic
feeds and full-
energy EN
Randomly
received
trophic feeds
(10 ml/hr) or
full energy
EN for the
initial 6 days
of ventilation
Trophic feeds
resulted in
similar clinical
outcomes
with fewer
episodes of
GI intolerance
ARDS
clinical
trials
‘08-’11
Random
Open-
label
study
1000 pts
44 hospitals
With acute
lung injury
Requiring
ventillation
Determine if
trophic feeds
would
increase
ventillator-
free days and
decrease GI
intolerance
Randomly
received
trophic or full
EN for first 6
days
Trophic feeds
did not
improve VFD,
60-day
mortality, or
infectious
complications
Trophic feeds
had less GI
intolerance

26. Progression of Disease
 Acute Upper GI bleed with coffee
ground emesis
 Ileus with gastritis and esophagitis
 Fever and left lobe pneumonia
 Acute respiratory distress and
transferred to the ICU
 NPO Clear liquid Full

27. Progression of Disease
 Ileus
 Erosive esophagitis and gastritis
 Aspiration pneumonia
 Hypoxia
 Hypokalemia, hypophosphatemia,
hypomagnesemia
 Leukopenia
 Sepsis
 Began TPN

28. Progression of Disease
 Metabolic disorder
 Small bowel obstruction
 Intubated and sedated with mechanical
vent
 Decreasing respiratory status
 Failed extibation to BIPAP
 TPN + Trophic Feeds
 Comfort Care

29. Nutrition Care Process
 BMI: 16.8
 80 % IBW
 N/V/C and loss of appetite
 Wt gain (30-35 kcal/kg actual wt)
 1420-1700 kcals/day
 56-71 g protein (1.2-1.5 g/kg actual wt)
 1420-1700 ml/day (1ml/kcal/kg actual
wt)

30. NCP
 Severely compromised nutrition status
 PES: Inadequate oral food intake related
to her current condition as evidence by
intake record, BMI, and albumin lab
values
 Rec Mighty Shake BID

31. NCP
 TPN assessment
 Pt met ASPEN criteria for TPN with
nonfunctional GI tract (ileus)
 Rec feeds of 85 g amino acids, 275 g
dextrose, 40 g lipids
 Provide 1675 kcals with 2.3 glucose
infusion rate

32. NCP
 TPN + insulin
 + EN trophic feeds of Pulmocare @ 20
ml/hr
 Hold for NG residuals >200 cc
 Adjust ENN for IBW
 1300- 1600 kcals (22-27 kcal/kg IBW)
 88-118 g protein (1.2- 2.0 g/kg IBW)

33. NCP
 PES: Altered GI function related to ileus
as evidence by PN and EN
 Rec continue trophic feeds with Vital AF
1.2 at 20 ml/hr to help manage
inflammation and promote GI tolerance

34. Reflection
 Effective nutritional support for critically
ill patients represents a difficult aspect of
overall management of complex patients
 The is a need to challenge commonly
used nutritional support practices and to
achieve an individualized, evidence-
based approach for optimal nutritional
therapy

35. References
 Allen, A. M., Antosh, D. D., Grimes, C. L., Crisp, C. C., Smith, A. L.,
Friedman, S., Mcfadden, B. L., Gutman, R. E., & Rogers, R. G. (2012).
Management of ileus and small-bowel obstruction following benign
gynecologic surgery. International Journal of Gynecology and
Obstetrics.121: 56-59.
 Heyland, D. K., Cahill, N. E., Dhaliwal, R., Wang, M., Day, A. G.,
Alenzi, A., Aris, F., Muscedere, J., Drover, J. W., & McClave, S. A.
(2010). Enhanced protein-energy provision via the enteral route in
critically ill patients: A single center feasibility of the PEP uP
protocol. Critical Care. 14: R78.
 Madl, C., & Druml, W. (2003). Systemic consequences of ileus. Best
Practice & Research Clinical Gastroenterology. 17(3): 445-456.
 Rice, T. W., Mogan, S., Hays, M. A., Bernard, G. R., Jensen, G., L., &
Wheeler, A. P. (2011) A randomized trial of initial trophic versus full-energy
enteral nutrition in mechanically ventilated patients with acute respiratory
failure. Critical Care Medicine. 39(5): 967-974.
 Rojas, D. J., Martinez-Ordaz, J. L., & Romero- Hernandez, T. (2012). Biliary
ileus: 10-years experience. Case Series. Cirugia y Cirujanos. 80(3): 228-
232.