Safety and Tolerance of Enteral Nutrition in the Medical and Surgical Intensive Care Unit Patient Receiving Vasopressors

Abstract

Background Multiple societal guidelines recommend enteral nutrition (EN) be initiated within 24 to 48 hours of admission to the intensive care unit (ICU) once a patient is hemodynamically stable. Gastrointestinal intolerance and occurrence of bowel ischemia have been a concern for patients receiving vasopressors while concurrently receiving luminal nutrients. The study objective was to determine whether patients receiving vasopressors while concomitantly receiving enteral nutrients had more incidences of bowel ischemia and intolerance than those receiving EN without vasopressor agents. Methods This retrospective study included 319 medical and surgical ICU patients from a level 1 trauma center. The patients were either receiving vasopressors simultaneously with EN (n = 178) or EN alone (n = 141). Data regarding gastric residual volume (GRV), new abdominal pain, emesis, and bowel ischemia were collected. Results There were more patients who had elevated GRV in the group that received vasopressors than patients who did not (20% vs 7%; P‐value < .01). There were no differences between rates of bowel ischemia, emesis, or new abdominal pain between the 2 groups. Conclusion Based on our findings, EN is generally well tolerated and safe for those patients simultaneously receiving vasopressors.

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

“…The HRNSP specified the use of the vasopressor agent epinephrine because of its first‐line use in our CVICU for cardiogenic shock, cardiopulmonary resuscitation, cardiac arrest, and low CO after cardiac surgery 67 . To date, most studies investigating EN tolerance and vasopressor therapy target MICU/SICU patient populations with septic shock and norepinephrine or equivalent dosing 68,69 . Norepinephrine equivalent dosing is expressed as a sum of all vasopressors with 1 mg of epinephrine equivalent to 1 mg of norepinephrine, 70 suggesting these two agents exert equivalent splanchnic vasoconstricting effects at all dose ranges.…”

“…67 To date, most studies investigating EN tolerance and vasopressor therapy target MICU/SICU patient populations with septic shock and norepinephrine or equivalent dosing. 68,69 Norepinephrine equivalent dosing is expressed as a sum of all vasopressors with 1 mg of epinephrine equivalent to 1 mg of norepinephrine, 70 suggesting these two agents exert equivalent splanchnic vasoconstricting effects at all dose ranges.…”

When is enteral nutrition indicated?

“…A retrospective study ( N = 120) of enteral tolerability in MICU patients with septic shock receiving vasopressor support found that a GRV >250 ml was the most common reason for enteral intolerance; 74% of those with enteral intolerance had a GRV >250 ml (34 of 46) 8 . In a 2020 study by Sabino et al, GRVs >300 ml were almost three times more likely in those receiving EN and vasopressors ( N = 178) when compared with those only receiving EN ( N = 141) (20% vs 7%; P < 0.01) 7 . Professional societies differ in opinion regarding GRVs.…”

“…However, once adjusted for confounders, statistical significance between lactate and EN tolerance was not maintained 1 . Recent case studies by Sabino et al also demonstrate that serum lactate levels are inconsistent before the onset of bowel ischemia and point out that elevations may be a delayed response to an existing ischemic bowel 7 . At this time, there are insufficient data to support utilizing lactate as a monitoring parameter.…”

Enteral nutrition in septic shock: A pathophysiologic conundrum

“…26 Other observational studies, not exclusively in septic shock patients, noted safety, tolerance, and associated improved clinical outcomes with EN in circulatory shock. [28][29][30][31][32][33] In a large observational study evaluating outcomes of mechanically ventilated patients with circulatory shock receiving early vs late EN, Ohbe et al found bowel ischemia occurred in 21 of 8606 (0.2%) patients who received early EN and 50 of 17,216 (0.3%) patients who received late EN. 34 Approximately one-third of patients had septic shock.…”