Enteral nutrition in septic shock: A pathophysiologic conundrum

Abstract

Septic shock is a public health burden and defined as a subset of sepsis whereby abnormalities in microcirculatory and cellular metabolism manifest as acute circulatory failure. At the level of the gut, septic shock impairs epithelial barrier function (EBF), and the gut initiates proinflammatory responses contributing to multiple organ dysfunction syndrome. The timing and dose of enteral nutrition (EN) in septic shock remains a conundrum. On the one hand, early EN preserves EBF. On the other hand, serious gastrointestinal complications such as bowel necrosis may limit EN initiation in septic shock. We (1) describe the pathophysiologic conundrum septic shock poses for EN initiation, (2) outline guideline-based recommendations for EN in septic shock, (3) identify the role of parenteral nutrition in septic shock, and (4) identify and appraise postguideline literature on the timing, dose, and titration of EN in septic shock.

Soporte Nutricional en Sepsis

“…Los resultados indicaron una reducción significativa en la tasa de mortalidad de aproximadamente un 19.4% y una disminución del 30% en la aparición de nuevos fallos multiorgánicos (10,11) .…”

“…Cabe destacar que este estudio, en el que solo el 30% de los pacientes eran sépticos, encontró que la administración de dosis relativamente altas de glutamina aumentó la mortalidad y el riesgo de fallo multiorgánico en los pacientes. Por lo tanto, es fundamental tener en cuenta esta información al recomendar sustratos para la nutrición en pacientes con sepsis (9,11).…”

<strong></strong>The Effect of Cluster Nursing in ICU on Treatment Compliance and Intestinal Barrier Function in Patients with Refractory Septic Shock

“…The results of the present study showed that care bundles resulted in significantly higher nursing efficiency and treatment compliance and a lower incidence of complications, suggesting the effectiveness of care bundles in the management of refractory septic shock. A study [18] found that patients with refractory septic shock are usually comorbid with severe circulatory impairment as well as metabolic dysfunctions, and another study [19] confirmed that intestinal dysfunction worsens in patients as their condition deteriorates, which compromises the intestinal barrier function of patients and exacerbates the inflammatory response [20]. In addition, patients receiving care bundles showed significantly lower IFABP, DAO, lactate, endotoxin, and intestinal dysfunction scores versus those with routine care, indicating that care bundles further improve intestinal barrier function and alleviate inflammatory response in patients with refractory septic shock compared to previous clinical routine care.…”

Enteral nutrition in septic shock: a call for a paradigm shift

“…Septic shock related activation of immune and inflammatory pathways incites a cytokine storm [1]. Cytokines such as tumor-necrosis factor alpha (TNF-a), interleukin-1 (IL-1), and interleukin-6 (IL-6) promote breakdown of barrier defenses [18,19].…”

“…The benefits from bathing the mucosa (with enteral nutrition) include supporting the population of the commensal microbiome, maintaining gut barrier defenses, and promoting a robust but appropriate immune response. Failing to take advantage of introducing enteral nutrition results in adverse consequences from not using the gut [18,19].…”