DOI: https://doi.org/10.22141/2224-0586.16.1.2020.196927

Enteral tolerance in critically ill patients (literature review)

L.O. Maltseva, О.О. Mishchenko, A.B. Kutovyi, M.F. Mosentsev, V.M. Lisnycha, N.A. Kazimirova

Abstract


Enteral nutrition (EN) in critically ill patients better supports the structure and function of the gastrointestinal mucosa than parenteral nutrition. Difficulties and complications associated with EN include metabolic disorders, gastrointestinal complications. Regardless of the route of administration, gastrointestinal disorders can be caused by underlying disease, mechanical ventilation mode, use of certain medicines. Intestinal intolerance of EN is of particular importance. Mechanisms responsible for gastrointestinal disorders can be classified as mucous membrane insufficiency, decreased peristalsis, gastrointestinal mucous membrane atrophy, and intestinal tissue reduction related to lymphatic system. In order to avoid gastrointestinal complications, EN should be started with a small amount of nutritional mixture, and the volume should be increased gradually. Measures to reduce the risk of aspiration include: head elevation (from 30 to 45°), switching to continued administration of EN, administration of prokinetic agents or opioid antagonists in order to increase gastrointestinal motility, postpyloric feeding. As diarrhea criteria, frequency of defecations (more then 3–5 per day) or amount of faeces (more than 200–300 g per day) are used. Prolonged diarrhea can cause: blood volume reduction; metabolic acidosis due to loss of electrolytes and bicarbonate; electrolyte imbalance with the loss of potassium, magnesium, zinc; contamination of surgical wounds and pressure ulcers; increased mortality. It is important to establish the cause of diarrhea, which often occurs after EN initiation and depends on the route, amount and rate of administration. Measures to prevent diarrhea associated with EN are as follows: shift from intermittent to continued infusion; changing the route of administration from postpyloric to gastric one; thoughtful selection of prokinetic agents; use of phytotherapy and antidiarrheals; formula must include fibers, hypoosmolar solution, peptide as a source of nitrogen, and should not include fat, lactose or milk proteins. Causes and factors of diarrhea that is not associated with EN: hyperosmolar medicine overdose; use of broad spectrum antibiotics; pseudomembranous enteritis caused by Clostridioides (Clostridium difficile); inflammatory bowel diseases; bone marrow transplantation; application of antitumor agents; fever or hypothermia; infection; hypoalbuminemia; sepsis; multiple organ dysfunction syndrome. EN should not be terminated without serious reasons and should be continued in a small amount. If diarrhea is not resolved despite appropriate treatment, EN should be stopped or interrupted, and parenteral nutrition must be initiated.

Keywords


enteral nutrition; tolerance; intolerance; gastrointestinal disorders; diarrhea; review

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