Early Enteral Nutrition Tolerance in Patients With Cardiogenic Shock Requiring Mechanical Circulatory Support

Abstract

Background: Enteral nutrition (EN) is recommended within the first 24–48 h for patients with hemodynamic stability, following admission to an intensive care unit (ICU). However, for patients with approximate stable hemodynamics requiring mechanical circulatory support and vasoactive drugs, the application of early EN remains controversial. We sought to evaluate the tolerance of early EN in patients with cardiogenic shock who required vasoactive drugs and mechanical circulatory support after cardiac surgery.Methods: This single-center, prospective observational study included patients with cardiogenic shock, requiring vasoactive drugs and mechanical circulatory support after cardiac surgery, undergoing EN. The primary endpoint was EN tolerance and secondary endpoints were mortality, length of mechanical ventilation, and length of ICU stay.Results: From February 2019 to December 2020, 59 patients were enrolled, of which 25 (42.37%) developed intolerance within 3 days of starting EN. Patients in the EN intolerant group had a longer median length of mechanical ventilation (380 vs. 128 h, p = 0.006), a longer median ICU stay (20 vs. 11.5 days, p = 0.03), and a higher proportion of bloodstream infections (44 vs. 14.71%, p = 0.018). The median EN calorie levels for all patients in the first 3 days of EN were 4.00, 4.13, and 4.28 kcal/kg/day, respectively. Median protein intake levels of EN in the first 3 days were 0.18, 0.17, and 0.17 g/kg/day, respectively. No significant difference was observed in the median dose of vasoactive drugs between the groups (0.035 vs. 0.05 μg/kg/min, p = 0.306).Conclusions: Patients with cardiogenic shock after cardiac surgery had a high proportion of early EN intolerance, and patients with EN intolerance had a worse prognosis, but no significant correlation was identified between EN tolerance and the dose of vasoactive drugs.

Nutrition support for patients on mechanical circulatory support

“…Patients who developed enteral nutrition intolerance had longer median duration of mechanical ventilation (380 versus 128 h, P = 0.006), longer median ICU LOS (20 versus 11.5 days, P = 0.03), and increased rate of bloodstream infections (44 versus 14.71%, P = 0.018). The results indicate that patients on MCS and receiving vasoactive drugs may be at increased risk to develop EN intolerance and consequently worse patient outcome [25].…”

“…The results indicate that patients on MCS and receiving vasoactive drugs may be at increased risk to develop EN intolerance and consequently worse patient outcome [25].…”

“…In this context, Liu et al [25] evaluated early EN tolerance in patients with cardiogenic shock receiving vasoactive drugs and MCS ( n = 59) in a single-center, prospective observational study.…”

“…In general, the initiation of EN within the first 24-48 h after ICU admission is recommended for hemodynamically stable patients [20][21][22]. However, as patients receiving high dose of vasoactive drugs and/or MCS for achieving hemodynamic stability, they are often supposed to be at increased risk for gastrointestinal [23] and abdominal [24] complications, cardiointestinal syndrome [24], and EN intolerance [25]. Thus, early initiation of EN is controversially discussed, without objective reasoning behind.…”

Improving nutrition practices for postoperative high‐risk heart transplant and ventricular assist device implant patients in circulatory compromise: A quality improvement pre– and post–protocol intervention outcome study

“…9,10 These patients are often difficult to feed enterally in the setting of intra-and postoperative complications. 11 The potential for mesenteric perfusion alterations as a result of extended cardiopulmonary bypass (CPB) and aortic cross-clamp times, bleeding that requires large volume blood resuscitation, ventricular dysfunction or failure, mechanical circulatory support (MCS), use of an intraaortic balloon pump (IABP), venoarterial extracorporeal membrane oxygenation (VA-ECMO), early onset of oliguric or anuric acute kidney injury, and low cardiac output (CO) requiring prolonged higher-dose vasopressor therapy (postoperative need for norepinephrine > 0.1 mcg/kg/min) contributes to enteral feeding challenges and severe GI complications such as mesentery ischemia. [12][13][14][15] Cardiac surgery populations with these intra-and postoperative complications are at a higher risk of nonocclusive bowel ischemia (NOBI) (0.16%-9%).…”