Gastrointestinal symptoms during the first week of intensive care are associated with poor outcome: a prospective multicentre study

Annika Reintam Blaser, Martijn Poeze, Manu L N G Malbrain, Martin Björck, Heleen M Oudemans-van Straaten, Joel Starkopf, Gastro-Intestinal Failure Trial Group, Inneke De laet, Rob J Bosman, Ioana Grigoras, Mihaela Blaj, Willem Stockman, Piet Lormans, Carlos A Ordoñez, Mikhail Kirov, Juan Duchesne, Nicola Brienza, Luis Alejandro Sanchez Hurtado, Theodossis Papavramidis, Kadri Tamme, Guadalupe Aguirre-Avalos, Dariusz Onichimowski, Shaikh Nissar, Andrey Litvin, Karel Balihar, Matti Reinikainen, Ivana Zykova, Manhaz Edalatnejad, Davide Chiumello, Crystal Wilson, Javier Izura, Caridad Soler, Aleksandr Koroljov, Milan Kaska, Martin Max, Mayada Hussien, Pavel Szturz, Ulrike Holzinger, Raido Paasma, Ivan Palibrk, Natasa Kovac, Gaetan Plantefeve, Michael Cheatham, Rao Ivatury, Ivan Ramos Palomino, Pille Parm, Piyush Ranjan, Gumersindo González Díaz, Jan De Waele, Dieter Debergh, Annika Reintam Blaser, Martijn Poeze, Manu L N G Malbrain, Martin Björck, Heleen M Oudemans-van Straaten, Joel Starkopf, Gastro-Intestinal Failure Trial Group, Inneke De laet, Rob J Bosman, Ioana Grigoras, Mihaela Blaj, Willem Stockman, Piet Lormans, Carlos A Ordoñez, Mikhail Kirov, Juan Duchesne, Nicola Brienza, Luis Alejandro Sanchez Hurtado, Theodossis Papavramidis, Kadri Tamme, Guadalupe Aguirre-Avalos, Dariusz Onichimowski, Shaikh Nissar, Andrey Litvin, Karel Balihar, Matti Reinikainen, Ivana Zykova, Manhaz Edalatnejad, Davide Chiumello, Crystal Wilson, Javier Izura, Caridad Soler, Aleksandr Koroljov, Milan Kaska, Martin Max, Mayada Hussien, Pavel Szturz, Ulrike Holzinger, Raido Paasma, Ivan Palibrk, Natasa Kovac, Gaetan Plantefeve, Michael Cheatham, Rao Ivatury, Ivan Ramos Palomino, Pille Parm, Piyush Ranjan, Gumersindo González Díaz, Jan De Waele, Dieter Debergh

Abstract

Purpose: The study aimed to develop a gastrointestinal (GI) dysfunction score predicting 28-day mortality for adult patients needing mechanical ventilation (MV).

Methods: 377 adult patients from 40 ICUs with expected duration of MV for at least 6 h were prospectively studied. Predefined GI symptoms, intra-abdominal pressures (IAP), feeding details, organ dysfunction and treatment were documented on days 1, 2, 4 and 7.

Results: The number of simultaneous GI symptoms was higher in nonsurvivors on each day. Absent bowel sounds and GI bleeding were the symptoms most significantly associated with mortality. None of the GI symptoms alone was an independent predictor of mortality, but gastrointestinal failure (GIF)--defined as three or more GI symptoms--on day 1 in ICU was independently associated with a threefold increased risk of mortality. During the first week in ICU, GIF occurred in 24 patients (6.4%) and was associated with higher 28-day mortality (62.5 vs. 28.9%, P = 0.001). Adding the created subscore for GI dysfunction (based on the number of GI symptoms) to SOFA score did not improve mortality prediction (day 1 AUROC 0.706 [95% CI 0.647-0.766] versus 0.703 [95% CI 0.643-0.762] in SOFA score alone).

Conclusions: An increasing number of GI symptoms independently predicts 28 day mortality with moderate accuracy. However, it was not possible to develop a GI dysfunction score, improving the performance of the SOFA score either due to data set limitations, definition problems, or possibly indicating that GI dysfunction is often secondary and not the primary cause of other organ failure.

Figures

Fig. 1
Fig. 1
Enrolment flow-chart
Fig. 2
Fig. 2
Kaplan–Meier survival plot for patients with GIF versus without GIF. Grey line shows less than three GI symptoms concomitantly during the first week in ICU. Black line shows at least three GI symptoms concomitantly during the first week in ICU. P < 0.001 between the groups (Log-rank test)

References

    1. Montejo JC. Enteral nutrition-related gastrointestinal complications in critically ill patients: a multicenter study: the Nutritional and Metabolic Working Group of the Spanish Society of Intensive Care Medicine and Coronary Units. Crit Care Med. 1999;27:1447–1453. doi: 10.1097/00003246-199908000-00006.
    1. Mutlu GM, Mutlu EA, Factor P. GI complications in patients receiving mechanical ventilation. Chest. 2001;119:1222–1241. doi: 10.1378/chest.119.4.1222.
    1. Mentec H, Dupont H, Bocchetti M, Cani P, Ponche F, Bleichner G. Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications. Crit Care Med. 2001;29:1955–1961. doi: 10.1097/00003246-200110000-00018.
    1. Reintam A, Parm P, Kitus R, Kern H, Starkopf J. Gastrointestinal symptoms in intensive care patients. Acta Anaesthesiol Scand. 2009;53:318–324. doi: 10.1111/j.1399-6576.2008.01860.x.
    1. Carrico CJ, Meakins JL, Marshall JC, Fry D, Maier RV. Multiple-organ-failure syndrome. Arch Surg. 1986;121:196–208. doi: 10.1001/archsurg.1986.01400020082010.
    1. Clark JA, Coopersmith CM. Intestinal crosstalk: a new paradigm for understanding the gut as the “motor” of critical illness. Shock. 2007;28:384–393. doi: 10.1097/shk.0b013e31805569df.
    1. Reintam Blaser A, Malbrain ML, Starkopf J, Fruhwald S, Jakob SM, De Waele J, Braun JP, Poeze M, Spies C. Gastrointestinal function in intensive care patients: terminology, definitions and management. Recommendations of the ESICM Working Group on abdominal problems. Intensive Care Med. 2012;38:384–394. doi: 10.1007/s00134-011-2459-y.
    1. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H, Reinhart CK, Suter PM, Thijs LG. The SOFA (sepsis-related organ failure assessment) score to describe organ dysfunction/failure. Intensive Care Med. 1996;22:707–710. doi: 10.1007/BF01709751.
    1. Reintam A, Parm P, Kitus R, Starkopf J, Kern H. Gastrointestinal failure score in critically ill patients: a prospective observational study. Crit Care. 2008;12:R90. doi: 10.1186/cc6958.
    1. Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992;101:1644–1655. doi: 10.1378/chest.101.6.1644.
    1. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818–829. doi: 10.1097/00003246-198510000-00009.
    1. Malbrain ML, Cheatham ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J, Balogh Z, Leppaniemi A, Olvera C, Ivatury R, D’Amours S, Wendon J, Hillman K, Johansson K, Kolkman K, Wilmer A. Results from the international conference of experts on intra-abdominal hypertension and abdominal compartment syndrome. I. Definitions. Intensive Care Med. 2006;32:1722–1732. doi: 10.1007/s00134-006-0349-5.
    1. McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G, ASPEN Board of Directors. American College of Critical Care Medicine. Society of Critical Care Medicine Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN) JPEN J Parenter Enteral Nutr. 2009;33:277–316. doi: 10.1177/0148607109335234.
    1. Dalfino L, Tullo L, Donadio I, Malcangi V, Brienza N. Intra-abdominal hypertension and acute renal failure in critically ill patients. Intensive Care Med. 2008;34:707–713. doi: 10.1007/s00134-007-0969-4.
    1. Malbrain ML, Chiumello D, Pelosi P, Bihari D, Innes R, Ranieri VM, Del Turco M, Wilmer A, Brienza N, Malcangi V, Cohen J, Japiassu A, De Keulenaer BL, Daelemans R, Jacquet L, Laterre PF, Frank G, de Souza P, Cesana B, Gattinoni L. Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study. Crit Care Med. 2005;33:315–322. doi: 10.1097/01.CCM.0000153408.09806.1B.
    1. Kim IB, Prowle J, Baldwin I, Bellomo R. Incidence, risk factors and outcome associations of intra-abdominal hypertension in critically ill patients. Anaesth Intensive Care. 2012;40:79–89.
    1. Ferreira FL, Bota DP, Bross A, Mélot C, Vincent JL. Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA. 2001;286:1754–1758. doi: 10.1001/jama.286.14.1754.
    1. Timsit JF, Fosse JP, Troché G, De Lassence A, Alberti C, Garrouste-Orgeas M, Bornstain C, Adrie C, Cheval C, Chevret S, OUTCOMEREA Study Group, France Calibration and discrimination by daily logistic organ dysfunction scoring comparatively with daily sequential organ failure assessment scoring for predicting hospital mortality in critically ill patients. Crit Care Med. 2002;30:2003–2013. doi: 10.1097/00003246-200209000-00009.
    1. Peres Bota D, Mélot C, Lopes Ferreira F, Nguyen BV, Vincent JL. The multiple organ dysfunction score (MODS) versus the sequential organ failure assessment (SOFA) score in outcome prediction. Intensive Care Med. 2002;28:1619–1624. doi: 10.1007/s00134-002-1491-3.
    1. Gatt M, MacFie J, McNaughton L, et al. Gut function is an independent indicator of patient outcome: proof of principle. Clin Nutr. 2007;2(Suppl 2):108.
    1. Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet P, Kazandjiev G, Nitenberg G, van den Berghe G, Wernerman J, DGEM (German Society for Nutritional Medicine) Ebner C, Hartl W, Heymann C, Spies C, ESPEN (European Society for Parenteral and Enteral Nutrition) ESPEN guidelines on enteral nutrition: intensive care. Clin Nutr. 2006;25:210–223. doi: 10.1016/j.clnu.2006.01.021.
    1. Casaer MP, Mesotten D, Hermans G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L, Dubois J, Van Assche A, Vanderheyden S, Wilmer A, Van den Berghe G. Early versus late parenteral nutrition in critically ill adults. N Engl J Med. 2011;365(6):506–517. doi: 10.1056/NEJMoa1102662.
    1. Rice TW, Mogan S, Hays MA, Bernard GR, Jensen GL, Wheeler AP. Randomized trial of initial trophic versus full-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure. Crit Care Med. 2011;39:967–974. doi: 10.1097/CCM.0b013e31820a905a.
    1. Heyland DK, Cahill N, Day AG. Optimal amount of calories for critically ill patients: depends on how you slice the cake! Crit Care Med. 2011;39:2619–2626. doi: 10.1097/CCM.0b013e31821201a5.
    1. Piton G, Manzon C, Cypriani B, Carbonnel F, Capellier G. Acute intestinal failure in critically ill patients: is plasma citrulline the right marker? Intensive Care Med. 2011;37:911–917. doi: 10.1007/s00134-011-2172-x.
    1. Noordally SO, Sohawon S, Semlali H, Michely D, Devriendt J, Gottignies P. Is there a correlation between circulating levels of citrulline and intestinal dysfunction in the critically ill? Nutr Clin Pract. 2012;27:527–532. doi: 10.1177/0884533612449360.
    1. Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, De Backer D, Gerlach H, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Pugin J, Wernerman J, Zhang H. Year in review in Intensive Care Medicine 2010: II. Pneumonia and infections, cardiovascular and haemodynamics, organization, education, haematology, nutrition, ethics and miscellanea. Intensive Care Med. 2011;37:196–213. doi: 10.1007/s00134-010-2123-y.

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