Tolerability of Enteral Nutrition in Mechanically Ventilated Patients With Septic Shock Who Require Vasopressors

Abstract

Based on our observation, early EN may be tolerated and safely administered in patients with septic shock who are adequately fluid resuscitated and receive doses of < 0.14 μg/kg/min of norepinephrine equivalents.

Vasopressors and Nutrition Therapy: Safe Dose for the Outset of Enteral Nutrition?

“…Nutrition support is the key to sustaining life. Currently, the evidence points to the early initiation of nutrition therapy in critically ill patients, that is, up to 48 hours after admission to the ICU, provided that they are adequately resuscitated in relation to blood volume and with hemodynamic stability [6,7,11,12].…”

“…Furthermore, in Canada, the critical care nutrition group question the obligatory hemodynamic stability to initiate EN, as there is enough evidence about the benefits of early EN in ICU patients. In fact, according to current literature, EN have demonstrated maintenance of mucosal integrity of TGI, decreased bacterial translocation, increased splanchnic blood flow, improved wound healing, improved immune function, and modulated response to tissue damage [6,7,11,14]. In addition, in endotoxic and septic shock models, enteral feeding improved hepatic artery and portal vein blood flow, superior mesenteric artery blood flow, intestinal mucosal microcirculatory flow, hepatic microcirculatory flow, hepatic and intestinal tissue oxygenation, and hepatic energy stores [15][16][17].…”

“…Regarding the dose of vasoactive drug, studies have found different outcomes. Doses around 0.14 μg/kg/min were shown for patients who tolerated the diet, including doses of ≤12.5 mcg/min of norepinephrine, although another study presented a dose of 0.25 μg/kg/min for patients who did not tolerate diet [3,7,26].…”

“…Enteral Nutrition erapy (ENT) is part of the essential care of patients in the intensive care unit (ICU) [5]. It is recommended, due to several studies that demonstrate better outcomes [6], that nutritional support should be started 24 to 48 hours after admission to the ICU, since the patient has been resuscitated and with hemodynamic stability [7].…”

Nutrición enteral (temprana) y estado hemodinámico en el paciente críticamente enfermo: ¿Qué debe saber el clínico de soporte nutricional?

“…Aquellos pacientes con intolerancia mostraron mayor mortalidad, aunque solo podría ser un reflejo de la gravedad (recibieron mayor dosis de aminas y mostraron mayor intolerancia). Los autores reportan el uso de nutrición enteral (gástrica) trófica por al menos 37 horas durante la administración de vasopresores, junto con monitoreo de signos de intolerancia (28) . Es importante mencionar que en este estudio se utilizó como parte de la definición de intolerancia el uso de residuo gástrico (> 250 mL) e incluso fue el signo mayormente encontrado, lo cual es una práctica que debería ser abandonada y que al eliminarla la incidencia de intolerancia podría disminuir modificando los resultados de manera considerable (29) .…”