Publications by authors named "Annika Reintam Blaser"

55 Publications

Development of the Gastrointestinal Dysfunction Score (GIDS) for critically ill patients - A prospective multicenter observational study (iSOFA study).

Clin Nutr 2021 08 18;40(8):4932-4940. Epub 2021 Jul 18.

Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia; Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia.

Background & Aims: To develop a five grade score (0-4 points) for the assessment of gastrointestinal (GI) dysfunction in adult critically ill patients.

Methods: This prospective multicenter observational study enrolled consecutive adult patients admitted to 11 intensive care units in nine countries. At all sites, daily clinical data with emphasis on GI clinical symptoms were collected and intra-abdominal pressure measured. In five out of 11 sites, the biomarkers citrulline and intestinal fatty acid-binding protein (I-FABP) were measured additionally. Cox models with time-dependent scores were used to analyze associations with 28- and 90-day mortality. The models were estimated with stratification for study center.

Results: We included 540 patients (224 with biomarker measurements) with median age of 65 years (range 18-94), the Simplified Acute Physiology Score II score of 38 (interquartile range 26-53) points, and Sequential Organ Failure Assessment (SOFA) score of 6 (interquartile range 3-9) points at admission. Median ICU length of stay was 3 (interquartile range 1-6) days and 90-day mortality 18.9%. A new five grade Gastrointestinal Dysfunction Score (GIDS) was developed based on the rationale of the previously developed Acute GI Injury (AGI) grading. Citrulline and I-FABP did not prove their potential for scoring of GI dysfunction in critically ill. GIDS was independently associated with 28- and 90-day mortality when added to SOFA total score (HR 1.40; 95%CI 1.07-1.84 and HR 1.40; 95%CI 1.02-1.79, respectively) or to a model containing all SOFA subscores (HR 1.48; 95%CI 1.13-1.92 and HR 1.47; 95%CI 1.15-1.87, respectively), improving predictive power of SOFA score in all analyses.

Conclusions: The newly developed GIDS is additive to SOFA score in prediction of 28- and 90-day mortality. The clinical usefulness of this score should be validated prospectively.

Trial Registration: NCT02613000, retrospectively registered 24 November 2015.
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http://dx.doi.org/10.1016/j.clnu.2021.07.015DOI Listing
August 2021

The gut in COVID-19.

Intensive Care Med 2021 09 8;47(9):1024-1027. Epub 2021 Jul 8.

College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.

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http://dx.doi.org/10.1007/s00134-021-06461-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8265290PMC
September 2021

Deepening of sedation with propofol has limited effect on intra-abdominal pressure - An interventional study in mechanically ventilated adult patients with intra-abdominal hypertension.

J Crit Care 2021 May 28;65:98-103. Epub 2021 May 28.

Department of Anaesthesiology and Intensive Care, University of Tartu, L. Puusepa 8, 51014 Tartu, Estonia; Department of Intensive Care Medicine, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland.

Purpose: To evaluate the effect of deepening of sedation on intra-abdominal pressure (IAP).

Methods: 37 adult mechanically ventilated ICU patients with intra-abdominal hypertension received a bolus dose and subsequent infusion of propofol (bolus: 1 mg/kg, infusion: 3 mg/kg/h). IAP, mean arterial pressure (MAP), abdominal perfusion pressure (APP), depth of sedation according to Richmond Agitation-Sedation Scale (RASS), respiratory parameters, and vasopressor dose were assessed after bolus and at 15, 30 and 60 min of infusion of propofol.

Results: Median IAP at baseline was 15 (13-16) mm Hg. During the intervention, median IAP decreased by 1 mm Hg at all time points. In 24% of patients IAP decreased by ≥3 mm Hg. Compared to baseline, MAP and APP were reduced at all time points. Deepening of sedation per RASS was achieved in 70% of patients at all time points. No changes in respiratory tidal volumes nor plateau pressures were observed. Vasopressor therapy with noradrenaline was started or increased in 43% of patients, whereas the increase in patients already receiving noradrenaline prior to the intervention was not significant.

Conclusions: Deepening of sedation with propofol results in a small decrease in IAP and greater simultaneous decrease in MAP and APP, requiring increased vasopressor support in some cases.
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http://dx.doi.org/10.1016/j.jcrc.2021.05.015DOI Listing
May 2021

Intra-abdominal hypertension and hypoxic respiratory failure together predict adverse outcome - A sub-analysis of a prospective cohort.

J Crit Care 2021 Aug 17;64:165-172. Epub 2021 Apr 17.

Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili - Universidad del Valle, Cali, Colombia.

Purpose: To assess whether the combination of intra-abdominal hypertension (IAH, intra-abdominal pressure ≥ 12 mmHg) and hypoxic respiratory failure (HRF, PaO2/FiO2 ratio < 300 mmHg) in patients receiving invasive ventilation is an independent risk factor for 90- and 28-day mortality as well as ICU- and ventilation-free days.

Methods: Mechanically ventilated patients who had blood gas analyses performed and intra-abdominal pressure measured, were included from a prospective cohort. Subgroups were defined by the absence (Group 1) or the presence of either IAH (Group 2) or HRF (Group 3) or both (Group 4). Mixed-effects regression analysis was performed.

Results: Ninety-day mortality increased from 16% (Group 1, n = 50) to 30% (Group 2, n = 20) and 27% (Group 3, n = 100) to 49% (Group 4, n = 142), log-rank test p < 0.001. The combination of IAH and HRF was associated with increased 90- and 28-day mortality as well as with fewer ICU- and ventilation-free days. The association with 90-day mortality was no longer present after adjustment for independent variables. However, the association with 28-day mortality, ICU- and ventilation-free days persisted after adjusting for independent variables.

Conclusions: In our sub-analysis, the combination of IAH and HRF was not independently associated with 90-day mortality but independently increased the odds of 28-day mortality, and reduced the number of ICU- and ventilation-free days.
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http://dx.doi.org/10.1016/j.jcrc.2021.04.009DOI Listing
August 2021

A clinical approach to acute mesenteric ischemia.

Curr Opin Crit Care 2021 04;27(2):183-192

Intensive Care Department, King Abdulaziz Medical City, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.

Purpose Of Review: To summarize current evidence on acute mesenteric ischemia (AMI) in critically ill patients, addressing pathophysiology, definition, diagnosis and management.

Recent Findings: A few recent studies showed that a multidiscipliary approach in specialized centers can improve the outcome of AMI. Such approach incorporates current knowledge in pathophysiology, early diagnosis with triphasic computed tomography (CT)-angiography, immediate endovascular or surgical restoration of mesenteric perfusion, and damage control surgery if transmural bowel infarction is present. No specific biomarkers are available to detect early mucosal injury in clinical setting. Nonocclusive mesenteric ischemia presents particular challenges, as the diagnosis based on CT-findings as well as vascular management is more difficult; some recent evidence suggests a possible role of potentially treatable stenosis of superior mesenteric artery and beneficial effect of vasodilator therapy (intravenous or local intra-arterial). Medical management of AMI is supportive, including aiming of euvolemia and balanced systemic oxygen demand/delivery. Enteral nutrition should be withheld during ongoing ischemia-reperfusion injury and be started at low rate after revascularization of the (remaining) bowel is convincingly achieved.

Summary: Clinical suspicion leading to tri-phasic CT-angiography is a mainstay for diagnosis. Diagnosis of nonocclusive mesenteric ischemia and early intestinal injury remains challenging. Multidisciplinary team effort may improve the outcome of AMI.
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http://dx.doi.org/10.1097/MCC.0000000000000802DOI Listing
April 2021

Electrolyte disorders during the initiation of nutrition therapy in the ICU.

Curr Opin Clin Nutr Metab Care 2021 03;24(2):151-158

Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, The Netherlands.

Purpose Of Review: To summarize recent evidence on prevalence, risk factors, significance, treatment, and prevention of electrolyte disorders in critically ill with a specific focus on disorders during the initiation of nutrition.

Recent Findings: Electrolyte disturbances appear to occur often during critical illness, and most of them seem to be associated with impaired outcome. However, a recent systematic review indicated insufficient evidence to answer clinically relevant questions regarding hypophosphatemia. Similar questions (which thresholds of serum levels are clinically relevant; how serum levels should be corrected and how do different correction regimens/approaches influence outcome) are not clearly answered also for other electrolytes. The most crucial feature of electrolyte disturbances related to feeding is refeeding syndrome. Recent evidence supports that additionally to the correction of electrolyte levels, a temporary restriction of calories (reducing the magnitude of this metabolic feature, including electrolyte shifts) may help to improve outcome.

Summary: Diverse electrolyte disorders often occur in critically ill patients. Hypophosphatemia, hypokalemia, and hypomagnesemia that are encountered after initiation of feeding identify refeeding syndrome. Along with correction of electrolytes, reduction of caloric intake may improve the outcome of the refeeding syndrome.
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http://dx.doi.org/10.1097/MCO.0000000000000730DOI Listing
March 2021

Are Classic Bedside Exam Findings Required to Initiate Enteral Nutrition in Critically Ill Patients: Emphasis on Bowel Sounds and Abdominal Distension.

Nutr Clin Pract 2021 Feb 9;36(1):67-75. Epub 2020 Dec 9.

Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia.

The general physical examination of a patient is an axiom of critical care medicine, but evidence to support this practice remains sparse. Given the lack of evidence for a comprehensive physical examination of the entire patient on admission to the intensive care unit, which most clinicians consider an essential part of care, should clinicians continue the practice of a specialized gastrointestinal system physical examination when commencing enteral nutrition in critically ill patients? In this review of literature related to gastrointestinal system examination in critically ill patients, the focus is on gastrointestinal sounds and abdominal distension. There is a summary of what these physical features represent, an evaluation of the evidence regarding use of these physical features in patients after abdominal surgery, exploration of the rationale for and against using the physical findings in routine practice, and detail regarding what is known about each feature in critically ill patients. Based on the available evidence, it is recommended that an isolated symptom, sign, or bedside test does not provide meaningful information. However, it is submitted that a comprehensive physical assessment of the gastrointestinal system still has a role when initiating or administering enteral nutrition: specifically, when multiple features are present, clinicians should consider further investigation or intervention.
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http://dx.doi.org/10.1002/ncp.10610DOI Listing
February 2021

Hypophosphatemia in critically ill adults and children - A systematic review.

Clin Nutr 2021 04 8;40(4):1744-1754. Epub 2020 Oct 8.

Service of Adult Intensive care & Burns, Lausanne University Hospital, Lausanne, Switzerland. Electronic address:

Background & Aims: Phosphate is the main intracellular anion essential for numerous biological processes. Symptoms of hypophosphatemia are non-specific, yet potentially life-threatening. This systematic review process was initiated to gain a global insight into hypophosphatemia, associated morbidity and treatments.

Methods: A systematic review was conducted (PROSPERO CRD42020163191). Nine clinically relevant questions were generated, seven for adult and two for pediatric critically ill patients, and prevalence of hypophosphatemia was assessed in both groups. We identified trials through systematic searches of Medline, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science. Quality assessment was performed using the Cochrane risk of bias tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies.

Results: For all research questions, we identified 2727 titles in total, assessed 399 full texts, and retained 82 full texts for evidence synthesis, with 20 of them identified for several research questions. Only 3 randomized controlled trials were identified with two of them published only in abstract form, as well as 28 prospective and 31 retrospective studies, and 20 case reports. Relevant risk of bias regarding selection and comparability was identified for most of the studies. No meta-analysis could be performed. The prevalence of hypophosphatemia varied substantially in critically ill adults and children, but no study assessed consecutive admissions to intensive care. In both critically ill adults and children, several studies report that hypophosphatemia is associated with worse outcome (prolonged length of stay and the need for respiratory support, and higher mortality). However, there was insufficient evidence regarding the optimal threshold upon which hypophosphatemia becomes critical and requires treatment. We found no studies regarding the optimal frequency of phosphate measurements, and regarding the time window to correct hypophosphatemia. In adults, nutrient restriction on top of phosphate repletion in patients with refeeding syndrome may improve survival, although evidence is weak.

Conclusions: Evidence on the definition, outcome and treatment of clinically relevant hypophosphatemia in critically ill adults and children is scarce and does not allow answering clinically relevant questions. High quality clinical research is crucial for the development of respective guidelines.
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http://dx.doi.org/10.1016/j.clnu.2020.09.045DOI Listing
April 2021

Enteral Feeding Intolerance: Updates in Definitions and Pathophysiology.

Nutr Clin Pract 2021 Feb 26;36(1):40-49. Epub 2020 Nov 26.

Department of Intensive Care Medicine, University Hospital (Inselspital) Bern, University of Bern, Bern, Switzerland.

Enteral feeding intolerance (EFI) is a common feature in critically ill patients worldwide. However, there is no clear, widely agreed-upon definition available, with various studies rarely using the same definition. The term EFI is frequently used to describe vomiting or large gastric residual volumes associated with enteral feeding as a result of gastroparesis/delayed gastric emptying. However, the syndrome of EFI may represent the consequence of various pathophysiological mechanisms, and this heterogeneity may explain varying associations with outcomes. In clinical practice, a pragmatic definition may be useful. A pragmatic definition of EFI is that a clinician has decided to reduce the amount of enteral nutrition specifically because features of gastrointestinal dysfunction appeared during enteral feeding. For research purposes, a more detailed definition of EFI is required to improve knowledge and explore interventions that may improve patient-centered outcomes. The objective of this review is to summarize available evidence on existing definitions, pathophysiological mechanisms, and the clinical relevance of EFI in critically ill patients. Based on current knowledge, we propose a conceptual framework for a definition of EFI for a future consensus process.
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http://dx.doi.org/10.1002/ncp.10599DOI Listing
February 2021

Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: an updated systematic review and network meta-analysis of randomized trials.

Intensive Care Med 2020 11 24;46(11):1987-2000. Epub 2020 Aug 24.

Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.

Purpose: Motivated by a new randomized trial (the PEPTIC trial) that raised the issue of an increase in mortality with proton pump inhibitors (PPIs) relative to histamine-2 receptor antagonists (H2RAs), we updated our prior systematic review and network meta-analysis (NMA) addressing the impact of pharmacological gastrointestinal bleeding prophylaxis in critically ill patients.

Methods: We searched for randomized controlled trials that examined the efficacy and safety of gastrointestinal bleeding prophylaxis with PPIs, H2RAs, or sucralfate versus one another or placebo or no prophylaxis in adult critically ill patients. We performed Bayesian random-effects NMA and conducted analyses using all PEPTIC data as well as a restricted analysis using only PEPTIC data from high compliance centers. We used the GRADE approach to quantify absolute effects and assess the certainty of evidence.

Results: Seventy-four trials enrolling 39 569 patients proved eligible. Both PPIs (risk ratio (RR) 1.03, 95% credible interval 0.93 to 1.14, moderate certainty) and H2RAs (RR 0.98, 0.89 to 1.08, moderate certainty) probably have little or no impact on mortality compared with no prophylaxis. There may be no important difference between PPIs and H2RAs on mortality (RR 1.05, 0.97 to 1.14, low certainty), the 95% credible interval of the complete analysis has not excluded an important increase in mortality with PPIs. Both PPIs (RR 0.46, 0.29 to 0.66) and H2RAs (RR 0.67, 0.48 to 0.94) probably reduce clinically important gastrointestinal bleeding; the magnitude of reduction is probably greater in PPIs than H2RAs (RR 0.69, 0.45 to 0.93), and the difference may be important in higher, but not lower bleeding risk patients. PPIs (RR 1.08, 0.88 to 1.45, low certainty) and H2RAs (RR 1.07, 0.85 to 1.37, low certainty) may have no important impact on pneumonia compared with no prophylaxis.

Conclusion: This updated NMA confirmed that PPIs and H2RAs are most likely to have a similar effect on mortality compared to each other and compared to no prophylaxis; however, the possibility that PPIs may slightly increase mortality cannot be excluded (low certainty evidence). PPIs and H2RAs probably achieve important reductions in clinically important gastrointestinal bleeding; for higher bleeding risk patients, the greater benefit of PPIs over H2RAs may be important. PPIs or H2RAs may not result in important increases in pneumonia but the certainty of evidence is low.
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http://dx.doi.org/10.1007/s00134-020-06209-wDOI Listing
November 2020

Diarrhea and elevation of plasma markers of cholestasis are common and often occur concomitantly in critically ill patients.

J Crit Care 2020 12 8;60:120-126. Epub 2020 Aug 8.

Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia; Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland. Electronic address:

Purpose: We aimed to describe epidemiology of diarrhea and cholestasis in critically ill patients and explore associations between these two conditions.

Material And Methods: We performed a retrospective study including all consecutive patients who stayed in the ICU for at least 3 days and in whom plasma measurements of liver enzymes/cholestasis parameters were performed. Diarrhea was defined as 3 or more loose or liquid stools per day and cholestasis as increase of alkaline phosphatase (ALP) and gamma glutamyl transpeptidase (GGT) 1.5 times above the upper limit of normality.

Results: Diarrhea was observed in 26.1% and cholestasis in 27.9% of study patients, about one third of the cases in both diarrhea and cholestasis occurred beyond the first week of patient's ICU stay. Cholestasis occurred in 45.6% of patients with diarrhea vs 28.0% of patients without diarrhea (p < 0.001). In 94 patients (13.1%) both diarrhea and cholestasis occurred, cholestasis was more commonly (2/3 of cases) documented before manifestation of diarrhea.

Conclusions: Cholestasis is more common in patients with diarrhea and vice versa. Diarrhea and cholestasis both occur in approximately one quarter of ICU patients, with significant proportion manifesting beyond the first week in the ICU.
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http://dx.doi.org/10.1016/j.jcrc.2020.08.004DOI Listing
December 2020

Monitoring and parenteral administration of micronutrients, phosphate and magnesium in critically ill patients: The VITA-TRACE survey.

Clin Nutr 2021 02 14;40(2):590-599. Epub 2020 Jun 14.

KU Leuven, Department of Cellular and Molecular Medicine, Laboratory of Intensive Care Medicine, Leuven, Belgium. Electronic address:

Background & Aims: Despite the presumed importance of preventing and treating micronutrient and mineral deficiencies, it is still not clear how to optimize measurement and administration in critically ill patients. In order to design future comparative trials aimed at optimizing micronutrient and mineral management, an important first step is to gain insight in the current practice of micronutrient, phosphate and magnesium monitoring and administration.

Methods: Within the metabolism-endocrinology-nutrition (MEN) section of the European Society of Intensive Care Medicine (ESICM), the micronutrient working group designed a survey addressing current practice in parenteral micronutrient and mineral administration and monitoring. Invitations were sent by the ESICM research department to all ESICM members and past members.

Results: Three hundred thirty-four respondents completed the survey, predominantly consisting of physicians (321 [96.1%]) and participants working in Europe (262 [78.4%]). Eighty-one (24.3%) respondents reported to monitor micronutrient deficiencies through clinical signs and/or laboratory abnormalities, and 148 (44.3%) reportedly measure blood micronutrient concentrations on a routine basis. Two hundred ninety-two (87.4%) participants provided specific data on parenteral micronutrient supplementation, of whom 150 (51.4%) reported early administration of combined multivitamin and trace element preparations at least in selected patients. Among specific parenteral micronutrient preparations, thiamine (146 [50.0%]) was reported to be the most frequently administered micronutrient, followed by vitamin B complex (104 [35.6%]) and folic acid (86 [29.5%]). One hundred twenty (35.9%) and 113 (33.8%) participants reported to perform daily measurements of phosphate and magnesium, respectively, whereas 173 (59.2%) and 185 (63.4%) reported to routinely supplement these minerals parenterally.

Conclusion: The survey revealed a wide variation in current practices of micronutrient, phosphate and magnesium measurement and parenteral administration, suggesting a risk of insufficient prevention, diagnosis and treatment of deficiencies. These results provide the context for future comparative studies, and identify areas for knowledge translation and recommendations.
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http://dx.doi.org/10.1016/j.clnu.2020.06.005DOI Listing
February 2021

Gastrointestinal dysfunction in the critically ill: a systematic scoping review and research agenda proposed by the Section of Metabolism, Endocrinology and Nutrition of the European Society of Intensive Care Medicine.

Crit Care 2020 05 15;24(1):224. Epub 2020 May 15.

The University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Parkville, Victoria, 3050, Australia.

Background: Gastrointestinal (GI) dysfunction is frequent in the critically ill but can be overlooked as a result of the lack of standardization of the diagnostic and therapeutic approaches. We aimed to develop a research agenda for GI dysfunction for future research. We systematically reviewed the current knowledge on a broad range of subtopics from a specific viewpoint of GI dysfunction, highlighting the remaining areas of uncertainty and suggesting future studies.

Methods: This systematic scoping review and research agenda was conducted following successive steps: (1) identify clinically important subtopics within the field of GI function which warrant further research; (2) systematically review the literature for each subtopic using PubMed, CENTRAL and Cochrane Database of Systematic Reviews; (3) summarize evidence for each subtopic; (4) identify areas of uncertainty; (5) formulate and refine study proposals that address these subtopics; and (6) prioritize study proposals via sequential voting rounds.

Results: Five major themes were identified: (1) monitoring, (2) associations between GI function and outcome, (3) GI function and nutrition, (4) management of GI dysfunction and (5) pathophysiological mechanisms. Searches on 17 subtopics were performed and evidence summarized. Several areas of uncertainty were identified, six of them needing consensus process. Study proposals ranked among the first ten included: prevention and management of diarrhoea; management of upper and lower feeding intolerance, including indications for post-pyloric feeding and opioid antagonists; acute gastrointestinal injury grading as a bedside tool; the role of intra-abdominal hypertension in the development and monitoring of GI dysfunction and in the development of non-occlusive mesenteric ischaemia; and the effect of proton pump inhibitors on the microbiome in critical illness.

Conclusions: Current evidence on GI dysfunction is scarce, partially due to the lack of precise definitions. The use of core sets of monitoring and outcomes are required to improve the consistency of future studies. We propose several areas for consensus process and outline future study projects.
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http://dx.doi.org/10.1186/s13054-020-02889-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7226709PMC
May 2020

Update on nutritional assessment and therapy in critical care.

Curr Opin Crit Care 2020 04;26(2):197-204

Department of Medicine and Radiology, Melbourne Medical School, The University of Melbourne, Royal Melbourne Hospital, Melbourne, Victoria, Australia.

Purpose Of Review: To summarize recent data regarding nutritional assessment and interventions in the ICU.

Recent Findings: Current methods to assess nutritional risk do not allow identification of ICU patients who may benefit from specific nutritional intervention. Early full energy delivery does not appear to improve outcomes at the population level. Specific nutrient composition of formula has been shown to improve glycemic outcomes in patients with hyperglycemia but patient-centered outcomes are unaffected.

Summary: Based on recent studies, full energy feeding early during critical illness has no measurable beneficial effect, and may even be harmful, when applied to entire populations. The mechanisms underlying this are unknown and remain proposed theories. Tools to assess nutritional risk in the ICU that identify patients who will benefit from a specific nutritional intervention are lacking. The optimal composition of feeds, and indications for specific interventions for enteral feeding intolerance remain uncertain.
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http://dx.doi.org/10.1097/MCC.0000000000000694DOI Listing
April 2020

Abdominal Compartment Syndrome: Improving Outcomes With A Multidisciplinary Approach - A Narrative Review.

J Multidiscip Healthc 2019 19;12:1061-1074. Epub 2019 Dec 19.

Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia.

Abdominal compartment syndrome (ACS) refers to a severe increase in intra-abdominal pressure associated with single or multiorgan failure. ACS with specific pathophysiological processes and detrimental outcomes may occur in a variety of clinical conditions. Patients with ACS are predominantly managed in critical care settings, however, a wide range of multidisciplinary interventions are frequently required from medical, surgical, radiological and nursing specialties. The medical management, aiming to prevent the progression of intra-abdominal hypertension to ACS, is extensively reviewed. Timing and techniques of surgical decompression techniques, as well as management of open abdomen, are outlined. In summary, the current narrative review provides data on history, definitions, epidemiology and pathophysiology of the syndrome and highlights the importance of multidisciplinary approach in the management of ACS in adults.
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http://dx.doi.org/10.2147/JMDH.S205608DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6927564PMC
December 2019

Gastrointestinal bleeding prophylaxis for critically ill patients: a clinical practice guideline.

BMJ 2020 01 6;368:l6722. Epub 2020 Jan 6.

Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.

Clinical Question: What is the role of gastrointestinal bleeding prophylaxis (stress ulcer prophylaxis) in critically ill patients? This guideline was prompted by the publication of a new large randomised controlled trial.

Current Practice: Gastric acid suppression with proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) is commonly done to prevent gastrointestinal bleeding in critically ill patients. Existing guidelines vary in their recommendations of which population to treat and which agent to use.

Recommendations: This guideline panel makes a weak recommendation for using gastrointestinal bleeding prophylaxis in critically ill patients at high risk (>4%) of clinically important gastrointestinal bleeding, and a weak recommendation for not using prophylaxis in patients at lower risk of clinically important bleeding (≤4%). The panel identified risk categories based on evidence, with variable certainty regarding risk factors. The panel suggests using a PPI rather than a H2RA (weak recommendation) and recommends against using sucralfate (strong recommendation).

How This Guideline Was Created: A guideline panel including patients, clinicians, and methodologists produced these recommendations using standards for trustworthy guidelines and the GRADE approach. The recommendations are based on a linked systematic review and network meta-analysis. A weak recommendation means that both options are reasonable.

The Evidence: The linked systematic review and network meta-analysis estimated the benefit and harm of these medications in 12 660 critically ill patients in 72 trials. Both PPIs and H2RAs reduce the risk of clinically important bleeding. The effect is larger in patients at higher bleeding risk (those with a coagulopathy, chronic liver disease, or receiving mechanical ventilation but not enteral nutrition or two or more of mechanical ventilation with enteral nutrition, acute kidney injury, sepsis, and shock) (moderate certainty). PPIs and H2RAs might increase the risk of pneumonia (low certainty). They probably do not have an effect on mortality (moderate certainty), length of hospital stay, or any other important outcomes. PPIs probably reduce the risk of bleeding more than H2RAs (moderate certainty).

Understanding The Recommendation: In most critically ill patients, the reduction in clinically important gastrointestinal bleeding from gastric acid suppressants is closely balanced with the possibility of pneumonia. Clinicians should consider individual patient values, risk of bleeding, and other factors such as medication availability when deciding whether to use gastrointestinal bleeding prophylaxis. Visual overviews provide the relative and absolute benefits and harms of the options in multilayered evidence summaries and decision aids available on MAGICapp.
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http://dx.doi.org/10.1136/bmj.l6722DOI Listing
January 2020

Less is more in nutrition: critically ill patients are starving but not hungry.

Intensive Care Med 2019 11 17;45(11):1629-1631. Epub 2019 Sep 17.

Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.

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http://dx.doi.org/10.1007/s00134-019-05765-0DOI Listing
November 2019

When and how to manage enteral feeding intolerance?

Intensive Care Med 2019 07 24;45(7):1029-1031. Epub 2019 May 24.

Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.

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http://dx.doi.org/10.1007/s00134-019-05635-9DOI Listing
July 2019

Translating the European Society for Clinical Nutrition and Metabolism 2019 guidelines into practice.

Curr Opin Crit Care 2019 08;25(4):314-321

Department of Anaesthesiology and Intensive Care, University of Tartu, Estonia.

Purpose Of Review: To present a pragmatic approach to facilitate clinician's implementing the recent European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines on clinical nutrition in the intensive care unit.

Recent Findings: The ESPEN guidelines include 54 recommendations with a rationale for each recommendation. All data published since 1 January 2000 was reviewed and 31 meta-analyses were performed to inform these guidelines. An important aspect of the most recent ESPEN guidelines is an attempt to separate periods of critical illness into discrete - early acute, late acute and recovery - phases, with each exhibiting different metabolic profiles and requiring different strategies for nutritional and metabolic support.

Summary: A pragmatic approach to incorporate the recent ESPEN guidelines into everyday clinical practice is provided.
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http://dx.doi.org/10.1097/MCC.0000000000000619DOI Listing
August 2019

Gastrointestinal failure affects outcome of intensive care.

J Crit Care 2019 08 2;52:103-108. Epub 2019 Apr 2.

Department of Anaesthesiology and Intensive Care, University of Tartu, 50406 Tartu, Estonia; Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne, Switzerland. Electronic address:

Purpose: Goal of this study was to describe incidence and outcome of gastrointestinal failure (GIF) in ICU patients, evaluate its additive role to SOFA score in mortality prediction and describe GIF according to etiology.

Materials And Methods: A retrospective study with prospective data collection was conducted in mixed adult ICU patients admitted 2004-2015. GIF was considered present if ≥3 of following 6 symptoms occurred in 1 day: maximum gastric residual volume ≥ 500 mL; absent bowel sounds; vomiting or regurgitation; diarrhea; suspected or radiologically confirmed bowel distension; gastrointestinal bleeding. Division into primary (gastrointestinal pathology causing GIF) and secondary (due to other conditions) GIF was made based on origin of syndrome.

Results: GIF developed in 413 (10.4%) of 3959 patients. Primary GIF occurred in 61.3% and secondary GIF in 38.7% of patients. Development of GIF was associated with longer mechanical ventilation, ICU stay and higher ICU, 30-day and 90-day mortality. Outcomes of patients with primary and secondary GIF were similar. All SOFA sub-scores and number of gastrointestinal symptoms on admission day independently predicted 90-day mortality.

Conclusions: Gastrointestinal failure, independent of origin, is associated with worse ICU outcome. Similar to other organ failures included in SOFA score, GIF independently predicts mortality.
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http://dx.doi.org/10.1016/j.jcrc.2019.04.001DOI Listing
August 2019

Obesity in the critically ill: a narrative review.

Intensive Care Med 2019 06 19;45(6):757-769. Epub 2019 Mar 19.

Anesthesia and Critical Care Department (DAR-B), Saint Eloi, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier Cedex 5, France.

The World Health Organization defines overweight and obesity as the condition where excess or abnormal fat accumulation increases risks to health. The prevalence of obesity is increasing worldwide and is around 20% in ICU patients. Adipose tissue is highly metabolically active, and especially visceral adipose tissue has a deleterious adipocyte secretory profile resulting in insulin resistance and a chronic low-grade inflammatory and procoagulant state. Obesity is strongly linked with chronic diseases such as type 2 diabetes, hypertension, cardiovascular diseases, dyslipidemia, non-alcoholic fatty liver disease, chronic kidney disease, obstructive sleep apnea and hypoventilation syndrome, mood disorders and physical disabilities. In hospitalized and ICU patients and in patients with chronic illnesses, a J-shaped relationship between BMI and mortality has been demonstrated, with overweight and moderate obesity being protective compared with a normal BMI or more severe obesity (the still debated and incompletely understood "obesity paradox"). Despite this protective effect regarding mortality, in the setting of critical illness morbidity is adversely affected with increased risk of respiratory and cardiovascular complications, requiring adapted management. Obesity is associated with increased risk of AKI and infection, may require adapted drug dosing and nutrition and is associated with diagnostic and logistic challenges. In addition, negative attitudes toward obese patients (the social stigma of obesity) affect both health care workers and patients.
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http://dx.doi.org/10.1007/s00134-019-05594-1DOI Listing
June 2019

Gut dysmotility in the ICU: diagnosis and therapeutic options.

Curr Opin Crit Care 2019 04;25(2):138-144

Intensive Care Unit.

Purpose Of Review: To provide a comprehensive update of diagnosis and treatment of gastrointestinal dysmotility in the critically ill, with a focus on work published in the last 5 years.

Recent Findings: Symptoms and clinical features consistent with upper and/or lower gastrointestinal dysmotility occur frequently. Although features of gastrointestinal dysmotility are strongly associated with adverse outcomes, these associations may be because of unmeasured confounders. The use of ultrasonography to identify upper gastrointestinal dysmotility appears promising. Both nonpharmacological and pharmacological approaches to treat gastrointestinal dysmotility have recently been evaluated. These approaches include modification of macronutrient content and administration of promotility drugs, stool softeners or laxatives. Although these approaches may reduce features of gastrointestinal dysmotility, none have translated to patient-centred benefit.

Summary: 'Off-label' metoclopramide and/or erythromycin administration are effective for upper gastrointestinal dysmotility but have adverse effects. Trials of alternative or novel promotility drugs have not demonstrated superiority over current pharmacotherapies. Prophylactic laxative regimens to prevent non-defecation have been infrequently studied and there is no recent evidence to further inform treatment of established pseudo-obstruction. Further trials of nonpharmacological and pharmacological therapies to treat upper and lower gastrointestinal dysmotility are required and challenges in designing such trials are explored.
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http://dx.doi.org/10.1097/MCC.0000000000000581DOI Listing
April 2019

Acute intestinal failure: International multicenter point-of-prevalence study.

Clin Nutr 2020 01 15;39(1):151-158. Epub 2019 Jan 15.

Department of Digestive System, Center for Chronic Intestinal Failure, St Orsola-Malpighi Hospital, University of Bologna, Via Massarenti, 9, 40138, Bologna, Italy. Electronic address:

Background & Aims: Intestinal failure (IF) is defined from a requirement or intravenous supplementation due to failing capacity to absorb nutrients and fluids. Acute IF is an acute, potentially reversible form of IF. We aimed to identify the prevalence, underlying causes and outcomes of acute IF.

Methods: This point-of-prevalence study included all adult patients hospitalized in acute care hospitals and receiving parenteral nutrition (PN) on a study day. The reason for PN and the mechanism of IF (if present) were documented by local investigators and reviewed by an expert panel.

Results: Twenty-three hospitals (19 university, 4 regional) with a total capacity of 16,356 acute care beds and 1237 intensive care unit (ICU) beds participated in this study. On the study day, 338 patients received PN (21 patients/1000 acute care beds) and 206 (13/1000) were categorized as acute IF. The categorization of reason for PN was revised in 64 cases (18.9% of total) in consensus between the expert panel and investigators. Hospital mortality of all study patients was 21.5%; the median hospital stay was 36 days. Patients with acute IF had a hospital mortality of 20.5% and median hospital stay of 38 days (P > 0.05 for both outcomes). Disordered gut motility (e.g. ileus) was the most common mechanism of acute IF, and 71.5% of patients with acute IF had undergone abdominal surgery. Duration of PN of ≥42 days was identified as being the best cut-off predicting hospital mortality within 90 days. PN ≥ 42 days, age, sepsis and ICU admission were independently associated with 90-day hospital mortality.

Conclusions: Around 2% of adult patients in acute care hospitals received PN, 60% of them due to acute IF. High 90-day hospital mortality and long hospital stay were observed in patients receiving PN, whereas presence of acute IF did not additionally influence these outcomes. Duration of PN was associated with increased 90-day hospital mortality.
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http://dx.doi.org/10.1016/j.clnu.2019.01.005DOI Listing
January 2020

Incidence, Risk Factors, and Outcomes of Intra-Abdominal Hypertension in Critically Ill Patients-A Prospective Multicenter Study (IROI Study).

Crit Care Med 2019 04;47(4):535-542

Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia.

Objectives: To identify the prevalence, risk factors, and outcomes of intra-abdominal hypertension in a mixed multicenter ICU population.

Design: Prospective observational study.

Setting: Fifteen ICUs worldwide.

Patients: Consecutive adult ICU patients with a bladder catheter.

Interventions: None.

Measurements And Main Results: Four hundred ninety-one patients were included. Intra-abdominal pressure was measured a minimum of every 8 hours. Subjects with a mean intra-abdominal pressure equal to or greater than 12 mm Hg were defined as having intra-abdominal hypertension. Intra-abdominal hypertension was present in 34.0% of the patients on the day of ICU admission (159/467) and in 48.9% of the patients (240/491) during the observation period. The severity of intra-abdominal hypertension was as follows: grade I, 47.5%; grade II, 36.6%; grade III, 11.7%; and grade IV, 4.2%. The severity of intra-abdominal hypertension during the first 2 weeks of the ICU stay was identified as an independent predictor of 28- and 90-day mortality, whereas the presence of intra-abdominal hypertension on the day of ICU admission did not predict mortality. Body mass index, Acute Physiology and Chronic Health Evaluation II score greater than or equal to 18, presence of abdominal distension, absence of bowel sounds, and positive end-expiratory pressure greater than or equal to 7 cm H2O were independently associated with the development of intra-abdominal hypertension at any time during the observation period. In subjects without intra-abdominal hypertension on day 1, body mass index combined with daily positive fluid balance and positive end-expiratory pressure greater than or equal to 7 cm H2O (as documented on the day before intra-abdominal hypertension occurred) were associated with the development of intra-abdominal hypertension during the first week in the ICU.

Conclusions: In our mixed ICU patient cohort, intra-abdominal hypertension occurred in almost half of all subjects and was twice as prevalent in mechanically ventilated patients as in spontaneously breathing patients. Presence and severity of intra-abdominal hypertension during the observation period significantly and independently increased 28- and 90-day mortality. Five admission day variables were independently associated with the presence or development of intra-abdominal hypertension. Positive fluid balance was associated with the development of intra-abdominal hypertension after day 1.
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http://dx.doi.org/10.1097/CCM.0000000000003623DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6426342PMC
April 2019

ESPEN guideline on clinical nutrition in the intensive care unit.

Clin Nutr 2019 02 29;38(1):48-79. Epub 2018 Sep 29.

Department of Nutritional Medicine/Prevention, University of Hohenheim, Stuttgart, Germany.

Following the new ESPEN Standard Operating Procedures, the previous guidelines to provide best medical nutritional therapy to critically ill patients have been updated. These guidelines define who are the patients at risk, how to assess nutritional status of an ICU patient, how to define the amount of energy to provide, the route to choose and how to adapt according to various clinical conditions. When to start and how to progress in the administration of adequate provision of nutrients is also described. The best determination of amount and nature of carbohydrates, fat and protein are suggested. Special attention is given to glutamine and omega-3 fatty acids. Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy. Monitoring of this nutritional therapy is discussed in a separate document.
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http://dx.doi.org/10.1016/j.clnu.2018.08.037DOI Listing
February 2019

Pathophysiology and Treatment of Gastrointestinal Motility Disorders in the Acutely Ill.

Nutr Clin Pract 2019 Feb 7;34(1):23-36. Epub 2018 Oct 7.

Department of Neuro-Gastroenterology, University College London, London, UK.

Gastrointestinal dysmotility causes delayed gastric emptying, enteral feed intolerance, and functional obstruction of the small and large intestine, the latter functional obstructions being frequently termed ileus and Ogilvie syndrome, respectively. In addition to meticulous supportive care, drug therapy may be appropriate in certain situations. There is, however, considerable variation among individuals regarding what gastric residual volume identifies gastric dysmotility and would encourage use of a promotility drug. While the administration of either metoclopramide or erythromycin is supported by evidence it appears that, dual-drug therapy (erythromycin and metoclopramide) reduces the rate of treatment failure. There is a lack of evidence to guide drug therapy of ileus, but neither erythromycin nor metoclopramide appear to have a role. Several drugs, including ghrelin agonists, highly selective 5-hydroxytryptamine receptor agonists, and opiate antagonists are being studied in clinical trials. Neostigmine, when infused at a relatively slow rate in patients receiving continuous hemodynamic monitoring, may alleviate the need for endoscopic decompression in some patients.
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http://dx.doi.org/10.1002/ncp.10199DOI Listing
February 2019

Intestinal failure in adults: Recommendations from the ESPEN expert groups.

Clin Nutr 2018 12 18;37(6 Pt A):1798-1809. Epub 2018 Aug 18.

Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK.

Background & Aims: Intestinal failure (IF) is defined as "the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth". Functionally, it may be classified as type I acute intestinal failure (AIF), type II prolonged AIF and type III chronic intestinal failure (CIF) The ESPEN Workshop on IF was held in Bologna, Italy, on 15-16 October 2017 and the aims of this document were to highlight the current state of the art and future directions for research in IF.

Methods: This paper represents the opinion of experts in the field, based on current evidence. It is not a formal review, but encompasses the current evidence, with emphasis on epidemiology, classification, diagnosis and management.

Results: IF is the rarest form of organ failure and can result from a variety of conditions that affect gastrointestinal anatomy and function adversely. Assessment, diagnosis, and short and long-term management involves a multidisciplinary team with diverse expertise in the field that aims to reduce complications, increase life expectancy and improve quality of life in patients.

Conclusions: Both AIF and CIF are relatively rare conditions and most of the published work presents evidence from small, single-centre studies. Much remains to be investigated to improve the diagnosis and management of IF and future studies should rely on multidisciplinary, multicentre and multinational collaborations that gather data from large cohorts of patients. Emphasis should also be placed on partnership with patients, carers and government agencies in order to improve the quality of research that focuses on patient-centred outcomes that will help to improve both outcomes and quality of life in patients with this devastating condition.
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http://dx.doi.org/10.1016/j.clnu.2018.07.036DOI Listing
December 2018

Monitoring nutrition in the ICU.

Clin Nutr 2019 04 20;38(2):584-593. Epub 2018 Jul 20.

Department of General Intensive Care, Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Israel. Electronic address:

Background & Aims: This position paper summarizes theoretical and practical aspects of the monitoring of artificial nutrition and metabolism in critically ill patients, thereby completing ESPEN guidelines on intensive care unit (ICU) nutrition.

Methods: Available literature and personal clinical experience on monitoring of nutrition and metabolism was systematically reviewed by the ESPEN group for ICU nutrition guidelines.

Results: We did not identify any studies comparing outcomes with monitoring versus not monitoring nutrition therapy. The potential for abnormal values to be associated with harm was clearly recognized. The necessity to create locally adapted standard operating procedures (SOPs) for follow up of enteral and parenteral nutrition is emphasised. Clinical observations, laboratory parameters (including blood glucose, electrolytes, triglycerides, liver tests), and monitoring of energy expenditure and body composition are addressed, focusing on prevention, and early detection of nutrition-related complications.

Conclusion: Understanding and defining risks and developing local SOPs are critical to reduce specific risks.
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http://dx.doi.org/10.1016/j.clnu.2018.07.009DOI Listing
April 2019

Early or Late Feeding after ICU Admission?

Nutrients 2017 Nov 23;9(12). Epub 2017 Nov 23.

Service of Intensive Care and Burns, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland.

The feeding of critically ill patients has recently become a controversial issue, as several studies have provided unexpected and contradictory results. Earlier beliefs regarding energy requirements in critical illness-especially during the initial phase-have been challenged. In the current review, we summarize existing evidence about fasting and the impact of early vs. late feeding on the sick organism's responses. The most important points are the non-nutritional advantages of using the intestine, and recognition that early endogenous energy production as an important player in the response must be integrated in the nutrient prescription. There is as of yet no bedside tool to monitor dynamics in metabolism and the magnitude of the endogenous energy production. Hence, an early "full-feeding strategy" exposes patients to involuntary overfeeding, due to the absence of an objective measure enabling the adjustment of the nutritional therapy. Suggestions for future research and clinical practice are proposed.
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http://dx.doi.org/10.3390/nu9121278DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5748729PMC
November 2017

The black box revelation: monitoring gastrointestinal function.

Anaesthesiol Intensive Ther 2018 20;50(1):72-81. Epub 2017 Nov 20.

Department of Intensive Care Medicine and High Care Burn Unit Ziekenhuis Netwerk Antwerpen ZNA Stuivenberg Hospital, Antwerp, Belgium, Brussels, Belgium; Department of Intensive Care University Hospital Brussels (UZB) Jette, Belgium; Faculty of Medicine, Free University of Brussels (VUB) Brussels, Belgium.

The gastrointestinal tract comprises diverse functions. Despite recent developments in technology and science, there is no single and universal tool to monitor GI function in intensive care unit (ICU) patients. Clinical evaluation is complex and has a low sensitivity to diagnose pathological processes in the abdomen. We performed a MEDLINE and Pubmed search connecting abdominal assessment and critical care. Based on these findings we defined the following major categories of monitoring and diagnostic measures: clinical investigation; assessment of motility and digestive function; microbiome monitoring; perfusion monitoring; laboratory biomarkers and hormonal function; intra-abdominal pressure measurement; and imaging techniques. Only a few of these monitoring and assessment tools have found their way into clinical practice, as most of them have one or more significant objections preventing broad implementation in daily clinical practice. Further research should be directed to reaffirm and define the use of current techniques to ascertain their validity and usefulness to monitor gastrointestinal function in ICU patients.
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http://dx.doi.org/10.5603/AIT.a2017.0065DOI Listing
October 2019
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