Gastrointestinal Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference

CONTEXT Prior criteria to define pediatric multiple organ dysfunction syndrome (MODS) did not include gastrointestinal dysfunction. OBJECTIVES Our objective was to evaluate current evidence and to develop consensus criteria for gastrointestinal dysfunction in critically ill children. DATA SOURCES Electronic searches of PubMed and EMBASE were conducted from January 1992 to January 2020, using medical subject heading terms and text words to define gastrointestinal dysfunction, pediatric critical illness, and outcomes. STUDY SELECTION Studies were included if they evaluated critically ill children with gastrointestinal dysfunction, performance characteristics of assessment/scoring tools to screen for gastrointestinal dysfunction, and assessed outcomes related to mortality, functional status, organ-specific outcomes, or other patient-centered outcomes. Studies of adults or premature infants, animal studies, reviews/commentaries, case series with sample size ≤10, and non-English language studies with inability to determine eligibility criteria were excluded. DATA EXTRACTION Data were abstracted from each eligible study into a standard data extraction form along with risk of bias assessment by a task force member. RESULTS The systematic review supports the following criteria for severe gastrointestinal dysfunction: 1a) bowel perforation, 1b) pneumatosis intestinalis, or 1c) bowel ischemia, present on plain abdominal radiograph, computed tomography (CT) scan, magnetic resonance imaging (MRI), or gross surgical inspection, or 2) rectal sloughing of gut mucosa. LIMITATIONS The validity of the consensus criteria for gastrointestinal dysfunction are limited by the quantity and quality of current evidence. CONCLUSIONS Understanding the role of gastrointestinal dysfunction in the pathophysiology and outcomes of MODS is important in pediatric critical illness.

Gender Was Associated with Depression but Not with Gastrointestinal Dysfunction in Patients with Parkinson’s Disease

Objective. To investigate the association between gender and gastrointestinal (GI) dysfunctions, as well as gender and other motor symptoms/nonmotor symptoms, in a sample of PD patients. Methods. 186 patients with PD were recruited into this study and divided into male PD group (M-PD) and female PD group (FM-PD). Demographic and PD-related clinical information of the participants were collected by the same neurologist. PD patients were objectively assessed by a spectrum of rating scales of motor symptoms and nonmotor symptoms (including GI dysfunctions). The data were analyzed by SPSS 20 statistical software. Results. Totally 95 cases (51.08%) were in the M-PD group and 91 cases (48.92%) in the FM-PD group. There were no significant differences in age, BMI, and lifestyles between the two groups (P > 0.05). Males had higher educational level (P = 0.002). Females were more likely to have early satiety and loss of appetite (P = 0.025, P = 0.001). There were no significant differences in LED disease duration, age of motor symptoms onset, types of motor symptoms onset, location of motor symptoms onset, and phenotype of motor symptoms between the two groups (P > 0.05). Females had significantly higher UPDRS-III and HAMD scores than males (P = 0.037, P = 0.034). There were no significant differences in PQSI, ESS, RLS, RBD, HAMA, HAMD, and MoCA scores between the two groups. Gender was associated with HAMD (OR = 0.682, P = 0.019). Conclusions. Gender is a risk factor for depression, but not for GI dysfunctions in patients with PD.

A RANDOMIZED INTERVENTIONAL STUDY ON EFFECT OF CHEWING GUM ON RECOVERY OF GASTROINTESTINAL FUNCTIONS IN POSTOPERATIVE PATIENTS FOLLOWING ABDOMINAL SURGERIES IN THE DEPARTMENT OF OBSTETRICS AND GYNECOLOGY, SMS MEDICAL COLLEGE, JAIPUR

Background: Post- operative gastrointestinal dysfunction is one of the complications following abdominal surgery which results in delayed return of bowel motility. It causes discomfort, prolonged hospital stay; hospital acquired infection and enhanced treatment cost. This study was conducted with an aim to analyze the clinical outcome of effect of chewing gum mainly to avoid post-operative gastrointestinal dysfunction and to compare the different gastrointestinal variables between cases and control group. Methods: In this study 80 patients were included, 40 Cases and 40. The cases were given chewing gum for duration of 15 minutes at 2nd , 4th and 6thhour of surgery. Bowel sound was auscultated at 3rd, 5th and 7th hour of surgery and outcomes were compared with control group. Control group were given only standard post-operative care. Results: Among cases Mean duration of 1st bowel sound appeared was 9.23±2.2 hours whie among control group was 15.99±3.48 hours and with operating time <1 hour is 5.1 ± 1.04 hours in cases and 6.2 ± .66 hours in control group while with operating time >1 hour it was 5.2 ± 1.03 hours cases and 6.3 ± 0.7 hours in control group. Mean duration of 1st flatus passed among cases was 13.3±2.24 hours while among control group was 26.62 ±2.6 hours and with operating time <1 hour was 13.8 ± 1.03 hours in cases and 16.25 ± 1.5 hours in control group, while it was 13.12 ± 1.96 hours in cases and 17.12 ± 1.5 hours in control group with operating time >1 hour. Mean duration of 1st motion passed among cases was 31.33±2.24 hours and was 44.62± 2.6 hours in control group and it was 48.8 ± 1.2 hours in cases and 50.7 ± 1.27 hours in control group with operating time <1 hour, while it was 48.8 ± 1.2 hours in cases and 51.1 ± 1.46 hours in control group with operating time >1 hour. Result was statistically significant P value (0.001).

Prognosis of liver transplantation: Does postoperative ileus matter?

Background Nowadays, liver transplantation has become a main therapy for end-stage liver disease. However, studies show that there are high mortality and severe complications after liver transplantation. Although gastrointestinal dysfunction is a common and major complication after liver transplantation, there was rarely relative research. This study aims to elucidate the factors about ileus after liver transplantation and patients’ survival. Methods We collected and analyzed the data (n = 318, 2016–2019) from the First Affiliated Hospital of Xi’an Jiaotong University. After excluding cases, a total of 293 patients were included for this study. The subjects were divided into a non-ileus group and an ileus group. We reviewed 38 variables (including preoperative, operative and postoperative relative factors). Additionally, other complications after liver transplantation and survival data were compared between two groups. Results Of the 293 patients, 23.2% (n = 68) experienced postoperative ileus. Ileus patients were not different with non-ileus patients in preoperative, operative and postoperative factors. HBV-positive patients with ileus had a lower MELD score (P = 0.025), and lower postoperative total bilirubin was correlated with ileus (P = 0.049). Besides, Child–Pugh score of HCC patients with ileus was low (P = 0.029). The complications after liver transplantation were not different between two groups. Compared with the patients without ileus, the patients with ileus had a higher mortality rate. Conclusion According to our research, ileus-patients had a lower 1-year survival rates. The preoperative MELD score and postoperative total bilirubin of HBV-positive patients with ileus were lower, and Child–Pugh score of HCC patients with ileus was also lower.

Estimating the time point for nutritional failure in patients suffering from acute brain attacks in the intensive care unit

Background: Severe brain attack patients demonstrate hypermetabolic state and gastrointestinal dysfunction, leading to faster onset of nutritional failure. Aim: To estimate the time point where the development of nutritional failure is more probable among patients with acute brain attacks in the intensive care unit (ICU). Methods: Direct bedside observation for selected nutritional parameters was performed. When enteral nutrition was initiated, observation was performed at five points over 9 days. Findings: 84 patients with 55% mortality risk and on mechanical ventilation were included. Over the observation period, gastric residual volume increased (144 ml vs 196 ml), body weight decreased (79.4 kg vs 74.3 kg), and serum albumin reduced (3.6 g/dl to 3.1 g/dl). Caloric attainment and malnutrition score deteriorated, and feeding-related complications increased. Nutritional failure was evidently prevalent between the third and fifth day of observation. Conclusion: An earlier period of enteral nutrition entails higher probability of nutritional failure among severe brain attack patients in the ICU.

0.9% saline versus Plasma-Lyte 148 for intravenous fluid therapy

<p>BACKGROUND Intravenous fluid therapy is one of the most common interventions used in acute medicine. Worldwide, there are variations in the prescription of intravenous fluids and no consensus on the best intravenous fluid to use. Currently, 0.9% saline is the most frequently prescribed intravenous fluid; however, there is emerging evidence to suggest that 0.9% saline may be associated with an increased risk of acute kidney injury (AKI), increased blood transfusion requirements and gastrointestinal dysfunction when compared to a buffered crystalloid fluid, such as Plasma-Lyte 148. METHODS Study one: A prospective, multicentre, randomised, double-blind, cluster, double crossover study conducted over 28 weeks in four New Zealand intensive care units (ICU) comparing 0.9% saline to Plasma-Lyte 148. The primary outcome was the proportion of patients with either AKI or renal failure according to the RIFLE criteria definitions based on serum creatinine levels. Study two: An exploratory subgroup analysis of cardiac surgical patients enrolled in study one to compare the effects of 0.9% saline vs. Plasma-Lyte 148 on the need for blood transfusions. The primary outcome was the proportion of patients receiving blood or blood products in the ICU. Additionally, an in-depth single-centre nested cohort study comparing the effect of 0.9% saline vs. Plasma-Lyte 148 on blood loss and blood products was also conducted. Study three: A single-centre nested study within study one comparing the effect of 0.9% saline vs. Plasma-Lyte 148 on gastrointestinal dysfunction in patients expected to be mechanically ventilated for >48 hours and receiving enteral nutrition via the nasogastric route. The primary outcome was the proportion of patients with gastrointestinal intolerance (high gastric residual volumes (GRV), vomiting, and diarrhoea). RESULTS Study one: 2262 patients were enrolled and analysed, 1152 patients were allocated to receive Plasma-Lyte 148 and 1110 participants were allocated to receive 0.9% saline. In the Plasma-Lyte 148 group, 102 of 1067 patients (9.6%) developed AKI, compared with 94 of 1025 patient (9.2%) in the 0.9% saline group (RR 1.05; 95% CI, 0.78 to 1.41; p=0.76). Overall, 87 of 1152 patients (7.6%) in the Plasma-Lyte 148 group and 95 of 1110 patients (8.6%) in the 0.9% saline group died in hospital (RR, 0.88; 95% CI 0.67 to 1.17; p=0.40). Study two: 954 cardiac surgical patients were included, 475 patients were allocated to receive Plasma-Lyte 148 and 479 were allocated to receive 0.9% saline. 128 of 475 patients (26.9%) in the Plasma-Lyte 148 group received blood or a blood product compared with 94 of 479 (19.6%) patients in the 0.9% saline group (OR [95% CI], 1.51 [1.11-2.05]; p=0.008). Within the nested cohort (n=251, 131 assigned to Plasma-Lyte 148 and 120 assigned to 0.9% saline), there were no differences between groups in chest drain losses at 12 hours. Study three: 69 patients were enrolled and analysed, with 35 allocated to receive Plasma-Lyte 148 and 34 allocated to receive 0.9% saline. In the Plasma-Lyte 148 group, 21 of 35 patients (60.0%) developed gastrointestinal feeding intolerance, compared with 22 of 34 patients (64.7%) in the 0.9% saline group (OR, 0.82; 95% CI, 0.31–2.17; p=0.69). A high GRV was seen in 4 of 35 patients (11.4%) in the Plasma-Lyte 148 group, and in 11 of 34 patients (32.4%) in the 0.9% saline group (OR, 0.27; 95% CI, 0.08–0.96; p=0.04). CONCLUSION This research programme provides data from the first interventional study conducted in critically unwell patients on the comparative effectiveness of 0.9% saline compared to a buffered crystalloid solution for intravenous fluid therapy. Among patients receiving crystalloid fluid in the ICU, allocation to Plasma-Lyte 148 compared to 0.9% saline did not influence the risk of AKI. Within a subgroup of patients undergoing cardiac surgery allocation to Plasma-Lyte 148 was associated with an increased requirement for blood or blood products. Among mechanically ventilated patients receiving nasogastric feeding, the use of Plasma-Lyte 148 compared to 0.9% saline did not reduce the proportion of patients developing gastrointestinal feeding intolerance but was associated with a decreased incidence of high GRV. These findings suggest that Plasma-Lyte 148 as compared with 0.9% saline may have differing effects within the biological/organ systems and sub-groups of patients admitted to the ICU. Further large randomised clinical trials (RCT) are needed to assess the efficacy in higher-risk populations and to measure ongoing areas of uncertainty in clinically important outcomes such as mortality.</p>

0.9% saline versus Plasma-Lyte 148 for intravenous fluid therapy

<p>BACKGROUND Intravenous fluid therapy is one of the most common interventions used in acute medicine. Worldwide, there are variations in the prescription of intravenous fluids and no consensus on the best intravenous fluid to use. Currently, 0.9% saline is the most frequently prescribed intravenous fluid; however, there is emerging evidence to suggest that 0.9% saline may be associated with an increased risk of acute kidney injury (AKI), increased blood transfusion requirements and gastrointestinal dysfunction when compared to a buffered crystalloid fluid, such as Plasma-Lyte 148. METHODS Study one: A prospective, multicentre, randomised, double-blind, cluster, double crossover study conducted over 28 weeks in four New Zealand intensive care units (ICU) comparing 0.9% saline to Plasma-Lyte 148. The primary outcome was the proportion of patients with either AKI or renal failure according to the RIFLE criteria definitions based on serum creatinine levels. Study two: An exploratory subgroup analysis of cardiac surgical patients enrolled in study one to compare the effects of 0.9% saline vs. Plasma-Lyte 148 on the need for blood transfusions. The primary outcome was the proportion of patients receiving blood or blood products in the ICU. Additionally, an in-depth single-centre nested cohort study comparing the effect of 0.9% saline vs. Plasma-Lyte 148 on blood loss and blood products was also conducted. Study three: A single-centre nested study within study one comparing the effect of 0.9% saline vs. Plasma-Lyte 148 on gastrointestinal dysfunction in patients expected to be mechanically ventilated for >48 hours and receiving enteral nutrition via the nasogastric route. The primary outcome was the proportion of patients with gastrointestinal intolerance (high gastric residual volumes (GRV), vomiting, and diarrhoea). RESULTS Study one: 2262 patients were enrolled and analysed, 1152 patients were allocated to receive Plasma-Lyte 148 and 1110 participants were allocated to receive 0.9% saline. In the Plasma-Lyte 148 group, 102 of 1067 patients (9.6%) developed AKI, compared with 94 of 1025 patient (9.2%) in the 0.9% saline group (RR 1.05; 95% CI, 0.78 to 1.41; p=0.76). Overall, 87 of 1152 patients (7.6%) in the Plasma-Lyte 148 group and 95 of 1110 patients (8.6%) in the 0.9% saline group died in hospital (RR, 0.88; 95% CI 0.67 to 1.17; p=0.40). Study two: 954 cardiac surgical patients were included, 475 patients were allocated to receive Plasma-Lyte 148 and 479 were allocated to receive 0.9% saline. 128 of 475 patients (26.9%) in the Plasma-Lyte 148 group received blood or a blood product compared with 94 of 479 (19.6%) patients in the 0.9% saline group (OR [95% CI], 1.51 [1.11-2.05]; p=0.008). Within the nested cohort (n=251, 131 assigned to Plasma-Lyte 148 and 120 assigned to 0.9% saline), there were no differences between groups in chest drain losses at 12 hours. Study three: 69 patients were enrolled and analysed, with 35 allocated to receive Plasma-Lyte 148 and 34 allocated to receive 0.9% saline. In the Plasma-Lyte 148 group, 21 of 35 patients (60.0%) developed gastrointestinal feeding intolerance, compared with 22 of 34 patients (64.7%) in the 0.9% saline group (OR, 0.82; 95% CI, 0.31–2.17; p=0.69). A high GRV was seen in 4 of 35 patients (11.4%) in the Plasma-Lyte 148 group, and in 11 of 34 patients (32.4%) in the 0.9% saline group (OR, 0.27; 95% CI, 0.08–0.96; p=0.04). CONCLUSION This research programme provides data from the first interventional study conducted in critically unwell patients on the comparative effectiveness of 0.9% saline compared to a buffered crystalloid solution for intravenous fluid therapy. Among patients receiving crystalloid fluid in the ICU, allocation to Plasma-Lyte 148 compared to 0.9% saline did not influence the risk of AKI. Within a subgroup of patients undergoing cardiac surgery allocation to Plasma-Lyte 148 was associated with an increased requirement for blood or blood products. Among mechanically ventilated patients receiving nasogastric feeding, the use of Plasma-Lyte 148 compared to 0.9% saline did not reduce the proportion of patients developing gastrointestinal feeding intolerance but was associated with a decreased incidence of high GRV. These findings suggest that Plasma-Lyte 148 as compared with 0.9% saline may have differing effects within the biological/organ systems and sub-groups of patients admitted to the ICU. Further large randomised clinical trials (RCT) are needed to assess the efficacy in higher-risk populations and to measure ongoing areas of uncertainty in clinically important outcomes such as mortality.</p>

A study of the effect of combination of acupuncture and Chinese medicine (Ban Xia Xie Xin Decoction) on patients with sepsis-induced gastrointestinal dysfunction

Purpose: To investigate the therapeutic effect of combination of acupuncture and Ban Xia Xie Xin Decoction (BXXXD) in patients with sepsis-induced gastrointestinal dysfunction.Methods: A total of 100 patients with sepsis and gastrointestinal dysfunction admitted to our hospitalfrom June 2019 to December 2020 were randomly assigned to a control group and a study group for a retrospective analysis. Both groups received acupuncture treatment, while BXXXD was given to the study group, in addition to acupuncture. Treatment effectiveness, incidence of adverse reactions, degree of recurrence at 1, 2 and 3 months after treatment, gastrointestinal dysfunction scores after 1week of treatment, quality of life index (QLI) scores, frequencies of flatulence and defecation within 48 h, number of bowel rumblings, as well as levels of gastrin and cholecystokinin (CCK), were determined and compared between the two groups.Results: The group with BXXXD intervention demonstrated superior treatment effectiveness, QLI cores, frequencies of flatulence and defecation within 48 h, number of bowel rumblings, and level of gastrin than those who received only acupuncture treatment (p < 0.05). There was strong evidence of lower incidence of adverse reactions, recurrence at 1, 2, and 3 months after treatment; gastrointestinal dysfunction scores and CCK levels after 1 week of treatment was higher in the study group than in the control group (p < 0.05).Conclusion: The combination of acupuncture and BXXXD is superior to acupuncture alone in sepsis patients with gastrointestinal dysfunction. The combination therapy produces its effect by decreasing clinical symptoms, promoting recovery of the patients, and elevating their quality of life.