Gastro-Intestinal Support
Nutrition Stress Ulcer Prophylaxis Regurgitation and Aspiration Diarrhoea Liver Support Acute Severe Pancreatitis Acute Cholecystitis Abdominal Compartment Syndrome Nutrition Description Critically ill patients have increased nutritional requirements due to an increased metabolic rate. Therefore, they require careful management of their nutritional requirements. General Measures Commence nutritio
Abdominal Compartment Syndrome
Nutrition
Description
Critically ill patients have increased nutritional requirements due to an increased metabolic rate. Therefore, they require careful management of their nutritional requirements.
General Measures
- Commence nutritional support as soon as possible.
- Oral, enteral or parenteral route should be initiated once it is safe to reduce the risk of adverse events associated with the overuse of enteral/parenteral feeding.
- Consider choice of feed to meet patient-specific fluid, caloric, and protein requirements.
Referral
- Consult dietitian as appropriate and refer to the National Department of Health Clinical Nutrition Guidelines (https://criticalpoint.co.za/wpcontent/uploads/2016/10/DOH-enteral-nutrition-guidelines.pdf and https://criticalpoint.co.za/wp-content/uploads/2017/09/DOHParenteralnutrition-guidelines.pdf).
See: Nutritional support
Stress Ulcer Prophylaxis
ICD-10 code: K25.0/K25.1/K25.2/K25.3/K25.9/K26.0/K26.1/K26.2/K26.3/K26.9/K27.0/K27.1/K27.2/K27.3 /K27.9
Description
Stress-related mucosal disease is an acute, erosive gastritis comprising conditions that range from stress-related injury to stress ulcers. Stress-related injury is due to superficial mucosal damage that manifests as erosions, while stress ulcers are due to deep, focal mucosal damage penetrating the submucosa. Stress ulcers occur in up to 9% of all patients admitted to critical care units, and the risk is higher in those that do not receive stress ulcer prophylaxis. Stress ulcers can cause clinically important gastrointestinal bleeding and lead to hemodynamic instability, an increased need for red blood cell transfusions, increased length of stay in the ICU, as well as increased mortality.
General Measures
- Initiate oral or enteral feeding as soon as it is safe to do so.
Medicine Treatment
- Pantoprazole, IV, 40mg daily.
- Stop stress ulcer prophylaxis once the patient is tolerating enteral feeds as prolonged PPI use increases the risk of hospital acquired pneumonia.
Regurgitation and Aspiration
ICD-10 code: K21.0/K21.9/J69.0
Description
Gastroesophageal reflux is common in patients treated in critical care units. Contributing factors include mechanical ventilation causing elevated intrathoracic pressure, reduced/absent lower oesophageal sphincter tone, and GI dysmotility. Gastroesophageal reflux is an important risk factor for aspiration, pneumonia, and acute lung injury.
General Measures
- Avoid regurgitation of gastric contents by decreasing intragastric pressure.
- Nurse patient at 30-45 degrees with the head up.
- Obtain Chest X-ray to confirm suspected aspiration.
- Use a nasogastric tube and confirm placement with x-ray imaging and/or pH analysis of aspirate.
- Maintain oropharyngeal hygiene.
- If aspiration suspected, suction oropharynx and endotracheal tube thoroughly.
Diarrhoea
ICD-10 code: A09.0/K52.8/K52.9
Description
Up to 62% of critically ill patients experience at least one episode of diarrhoea during their admission. Risk factors include the use of enteral nutrition (particularly those with high osmolarity), duration of antimicrobial use, and the use of suppositories. Diarrhoea increases the risk of complications including renal dysfunction, dehydration, electrolyte disturbance, as well as impairment of dermal integrity. There is also evidence that the development of GI problems is associated with worse outcome in critically ill patients.
General Measures
- Send stool specimens to evaluate potential causes. Consider Clostridium (Clostridioides) difficile diarrhoea.
- (See: Clostridium difficile diarrhoea) and feed-related diarrhoea as potential causes.
Medicine Treatment
- Treatment will depend on the identified aetiology.
- See: Diarrhoea for specific treatment (Amoebic Dysentery, Bacterial Peritonitis, Cholera, Clostridium Difficile Diarrhoea, Diarrhoea, Acute Non-inflammatory, Dysentery (Acute Inflammatory Diarrhoea), Giardiasis and Typhoid).
Liver Support
See: Liver Failure, Acute.
Referral
Consult specialist unit to evaluate suitability for liver transplantation.
Acute Severe Pancreatitis
ICD-10 code: K85.0/K85.1/K85.2/K85.3/K85.8/K85.9
Description
Approximately 10–30% of patients with acute pancreatitis develop a severe form that requires management in a critical care unit. Acute severe pancreatitis is a life-threatening disease with an in-hospital mortality rate of up to 15%. The severity of acute pancreatitis is determined by the development of organ failure for >48 hours and local complications including infected (peri-) pancreatic necrosis, haemorrhagic or systemic complications, and infective pancreatitis.
General Measures
For general management of acute pancreatitis, see: Pancreatitis, Acute.
Measures specific to critical care management
- Provide supportive therapy for organ failure, including fluid support (see: Fluid therapy for shock).
- Address the underlying cause e.g. gall stones.
- Treat sepsis (see: Sepsis in ICU).
Referral
Refer for surgical consultation for complications including:
- Pancreatic abscess.
- Pancreatic necrosis.
- Pancreatic pseudocyst.
- Abdominal compartment syndrome.
Acute Cholecystitis
ICD-10 code: K81.0
Description
Acute acalculous cholecystitis is a specific complication of critical illness that warrants organ support, antimicrobial therapy, and consultation for surgical intervention.
General Measures
See: Cholecystitis, acute and cholangitis, acute.
Referral
All patients for surgical consultation and intervention.
Abdominal Compartment Syndrome
ICD-10 code: R19.8
Description
Abdominal compartment syndrome is defined as the presence of intraabdominal hypertension, with sustained intra-abdominal pressures exceeding 20 mmHg, along with evidence of new-onset organ dysfunction. Abdominal compartment syndrome can be classified as primary, i.e. due to direct injury of the abdomen or pelvic region, or secondary, i.e. referred pressure from other compartments. Mechanisms of causes resulting in abdominal compartment syndrome can be broadly categorised into decreased abdominal wall compliance, increased intraluminal contents, collection of contents in the abdominal cavity, and capillary leak and fluid resuscitation. Abdominal compartment syndrome is associated with severe critical illness and multiorgan failure and has a high risk of mortality (40-100%) which necessitates urgent intervention.
General Measures
Relieve intra-abdominal pressure via:
- nasogastric tube
- sedation
- urinary catheter
- analgesia
- drainage of intraabdominal collections
- muscle relaxation (if ventilated)
- appropriate positioning
- surgical decompression
Referral
- Consider surgical consultation for decompression.
Standard Treatment Guidelines and Essential Medicines List for South Africa Adult Hospital _Chapter 23: Adult Critical Care_NEMLC Medicine Recommendations Review Cycle_ 2020_2023
Drugs mentioned
ICD-10 codes
- A09.0Other and unspecified gastroenteritis and colitis of infectious origin
- J69.0Pneumonitis due to food and vomit
- K21.0Gastro-oesophageal reflux disease with oesophagitis
- K21.9Gastro-oesophageal reflux disease without oesophagitis
- K25.0Gastric ulcer, acute with haemorrhage
- K25.1Gastric ulcer, acute with perforation
- K25.2Gastric ulcer, acute with both haemorrhage and perforation
- K25.3Gastric ulcer, acute without haemorrhage or perforation
- K25.9Gastric ulcer, unspecified as acute or chronic, without haemorrhage or perforation
- K26.0Duodenal ulcer, acute with haemorrhage
- K26.1Duodenal ulcer, acute with perforation
- K26.2Duodenal ulcer, acute with both haemorrhage and perforation
- K26.3Duodenal ulcer, acute without haemorrhage or perforation
- K26.9Duodenal ulcer, unspecified as acute or chronic, without haemorrhage or perforation
- K27.0Peptic ulcer, site unspecified, acute with haemorrhage
- K27.1Peptic ulcer, site unspecified, acute with perforation
- K27.2Peptic ulcer, site unspecified, acute with both haemorrhage and perforation
- K27.3Peptic ulcer, site unspecified, acute without haemorrhage or perforation
- K27.9Peptic ulcer, site unspecified, unspecified as acute or chronic, without haemorrhage or perforation
- K52.8Other specified noninfective gastroenteritis and colitis
- K52.9Noninfective gastroenteritis and colitis, unspecified
- K81.0Acute cholecystitis
- K85.0Idiopathic acute pancreatitis
- K85.1Billiary acute pancreatitis
- K85.2Alcohol-induced acute pancreatitis
- K85.3Drug-induced acute pancreatitis
- K85.8Other acute pancreatitis
- K85.9Acute pancreatitis, unspecified
- R19.8Other specified symptoms and signs involving the digestive system and abdomen