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 SAJCC August 2007, Vol. 23, No. 1 conditions. Under stress, flow is markedly diminished. markedly is flow stress, Under conditions. resting under even sluggish is so nutrients of delivery than rather absorption for intended is enterocytes the brain. and kidneys heart, the as such organs vital to diverted is flow blood as illness critical in reduced also is circulation splanchnic the to supply blood the but reduced, nutrients luminal are only Not diminished. markedly is nutrition of source this starvation, of period a by accompanied invariably almost is illness critical As lumen. gut the from obtained is enterocytes by required nutrition the of cent per Seventy nutrients. of supply a requires still cells of types both of activity metabolic basal the but illness critical as such stress physiological of times in reduced is function Secretory absorptive. or secretory either are Enterocytes physiology enterocyte Basic cancer colorectal as diseases diverse such from outcomes improved of terms in apparent becoming are that benefits has enterocytes of function Anesthesiologists (ASA), the 2/4/6/8 rule (Table I). (Table rule 2/4/6/8 the (ASA), Anesthesiologists of Society American the by advocated is formula simple A anaesthesia. from emergence and control, airway to prior induction, anaesthetic during aspiration of risk the reduce to advocated been has Fasting aspiration. and regurgitation of risk at were anaesthesia mask Mendelson of findings the from arose (NPM) mouth’ per ‘nil patients Keeping procedures. surgical to prior fasting of period the is hospitals many in teams surgical and anaesthetic the between contention of bones major the of One starvation pre-operative Minimise levels. nutrient luminal of maintenance on concentrate will review this so ICU in approaches therapeutic other many to central is flow blood of Maintenance flow. blood splanchnic maintain and nutrients luminal provide to therefore is integrity enterocyte maintaining of challenge The blood even under resting conditions. resting under even blood with supplied well least the are but body the in cells active metabolically most the among are Enterocytes Eric Hodgson, MB ChB Hons, FCA (Crit Care) (Crit FCA Hons, ChB MB Hodgson, Eric Durban Medicine, of School Mandela R Nelson Anaesthesia, of Department ARTICLE Enterocyte protection – a new goal in ICU ICU in goal nutrition new a – protection Enterocyte 4 6 that obstetric patients undergoing undergoing patients obstetric that 1 2 5 Maintaining Maintaining and pneumonia. and Blood flow to to flow Blood 7 4 3 • • • • • status: fasting to relation in surgery emergency of timing the regarding firstly caveats, of number a has rule This • • constituents: their on depending effects beneficial of number a have pre-operatively administered Fluids fluids oral Pre-operative • enterocytes: the of maintenance the to specifically more relates caveats of group second The pressure. cricoid of application with induction sequence rapid or intubation awake including aspiration, prevent to precautions necessary with anaesthetised be should above groups the in Patients I. Table

Patients who have undergone recent trauma or or trauma recent undergone have who Patients and satisfaction. and comfort patient improves also hydration Adequate oedema. postoperative of generation the in implicated been have that fluids intravenous for requirement required. NOT IS investigations radiological for Fasting airway. or tract (GI) gastrointestinal the involves contemplated procedure the UNLESS fasted be to need not do tracheostomy or tube endotracheal by control airway with ICU the in are who Patients surgery. before period. fasting of irrespective risk in result will that reasons obstruction) bowel or (gastric mechanical or pregnancy) (diabetes, metabolic have may Patients period. fasting of irrespective risk at remain opioids received Water: maintains hydration and reduces the the reduces and hydration maintains Water: hours 2 to up fluids clear receive SHOULD Patients Clear fluid (including black tea/coffee) 2 tea/coffee) black (including fluid Clear milk/formula Breast dairy) (including food Solid meal fatty Large, consumed Food 8

anaesthesia related to food food to related anaesthesia to prior fasting of Period consumed

4 6 8 (hours) fasting of Period 9

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17 15 The enterocytes can thus 14 This reduction may be exacerbated 5 Gastric feeding may be considered if gastric 15 The protocol followed at Addington Hospital is 16 nutrition does not preclude continued attempts to feed enterally. The aim should be to establish gastric feeding with reduction of parenteral feeding as goals are met. Once full gastric nutrition is established, both nasojejunal and parenteral feeding can be stopped. Systemic nutrition With enterocyte nutrition being maintained by nasojejunal feeding, systemic nutrition may be provided by the route most likely to prove successful. Systemic nutrition during the initial phase of ICU admission is most commonly confined to 5 - 10% dextrose to limit ketosis. During this phase emphasis is placed on resuscitation with restoration of circulation and oxygenation. Within 48 - 72 hours the condition of the patient should have stabilised to the extent that systemic nutrition should be considered. A nasogastric tube will be in place so gastric feeding is also an option. Tolerance of gastric feeding is deemed to indicate that the distal ileum is no longer at risk of NOMI. aspirate within a 6-hour period is less than 150 - 200 ml. shown in Fig. 1. In the early stages of ICU admission a central line is still likely to be in place. Should gastric feeding be unsuccessful, the use of parenteral nutrition should be considered at this stage. Commencing parenteral commenced as soon as the patient arrives in the ICU. Semi-elemental feeds are absorbed in the absence of peristalsis and do not require an increase in secretory or digestive function. receive nutrition without an increase in oxygen requirement. The nasojejunal tube is not intended to provide systemic nutrition as this would require an increase in the digestive and secretory functions of the enterocytes with a resultant increase in oxygen requirements. In the early postoperative phase, splanchnic circulation may be reduced. by pre-existing vascular disease or the use of inotropes, such as dopamine and adrenaline, which promote splanchnic vasoconstriction. Attempting to feed a full dose of enteral nutrition via a nasojejunal tube will result in feed intolerance, diarrhoea and even perforation of the terminal ileum. This perforation arises as a result of an increase in oxygen requirements that cannot be met by increased blood flow, as the terminal ileum lies in a watershed area between the superior and inferior mesenteric circulations, making it particularly vulnerable to ischaemia, progressing to perforation, a process with the acronym of NOMI (non- occlusive mesenteric ischaemia). The nasojejunal tube is extremely useful in maintaining enterocyte integrity. With the tube in place, a low dose (10 - 30 ml/h) of a semi-elemental feed may be 13 12 10 1 replicated in other centres, 2 11 Carbohydrates: reduce the catabolic response generated by starvation and surgery. Insulin sensitivity and tissue integrity are maintained. Commence sip feeds within 6 hours of admission to ward carbohydrate and peptides Limiting intra-operative IV fluids to maintenance plus losses Laparoscopic dissection with specimen retrieval via Pfannenstiel incision Clear fluids up to 2 hours pre-operatively, including Peptides: maintain enterocyte function and muscle strength. • This tube is preferable to the placement of a feeding jejunostomy as the potential for morbidity is reduced. the upper GI tract (including gastrectomy and pancreatectomy) do not allow for early enteral nutrition via the stomach. In these cases, a fine-bore feeding tube placed via the nose beyond the pylorus (or surgical anastomosis) into the proximal jejunum (nasojejunal tube) as part of the laparotomy may be very useful. Early enteral nutrition after emergency surgery Emergency surgical procedures involving the abdominal contents and elective operations involving The success of programmes such as this requires a team approach with contributions from members including, but not limited to, surgeons, anaesthesiologists, intensivists, physiotherapists and dieticians. This has been supported by the ESPEN guidelines, which state that there is no reason to fast elective surgical patients postoperatively. • Thoracic epidural analgesia • Stop IV fluids on discharge from recovery room • • Aim for full enteral nutrition within 24 hours. • • • NO nasogastric tube/abdominal drains resection with a period of fasting of only 8 - 10 hours and re-establishment of full enteral nutrition within 24 hours of surgery. This approach has become known as ‘fast-track colonic surgery’ and relies on a multimodal approach including: • nutrition Patients who undergo elective abdominal surgery do not necessarily develop an ileus requiring postoperative fasting with nasogastric drainage. Work from Copenhagen, has demonstrated that patients can undergo colonic Lipids are not recommended as lipid emulsions are unstable in the acid environment of the stomach and may become particulate with a risk of aspiration. Early postoperative enteral • Pg 6-8.indd 7 Pg 6-8.indd 8

 SAJCC August 2007, Vol. 23, No. 1 either enterally or parenterally for 2 weeks. At this stage stage this At weeks. 2 for parenterally or enterally either fed were mice where study, animal an to led infections infections. pulmonary and wound both of rate reduced a and function dehiscence. anastomotic of rate reduced a with associated contrast, by is, demand) oxygen enteral increase not does (which feed semi-elemental a of use Early anastomosis. bowel and surgery after perforation bowel of risk at patients place not does nutrition enteral Early nutrition enterocyte of Advantages Addington. (MgSO sulphate magnesium g 2 so illness, critical in low be may that transfer energy for cofactor major a also is Magnesium dextrose. (NaCl)/5% chloride sodium 0.9% ml 200 in protocol as for potassium choride (KCl) – 40 mmol K mmol 40 – (KCl) choride potassium for as protocol same the by potassium-hydrogen-phosphate of form the in intravenously supplemented is Phosphate feeding. commencing of hours 6 within and to prior phosphate check to essential therefore is It bone. from phosphate of mobilisation slow the by met be not may that phosphate for demand increased an is there refeeding On losses. phosphate urinary increased with starvation in reduced is compounds these of Synthesis (ATP). triphosphate adenine as such molecules energy-transfer high-energy all of component essential an is Phospate hypophosphataemia. acute is which of component main the syndrome, refeeding the of risk at are hours 48 exceeding starvation of period a following fed Patients syndrome Refeeding benefit. systemic provide to amounts limited leaving enterocytes, by up taken avidly is glutamine as continued be may glutamine with supplementation Parenteral Fig. 1. Approach to gastric feeding at Addington Hospital. Addington at feeding gastric to Approach 1. Fig. Feed for 11 hours – spigot for 1 hour and aspirate aspirate and hour 1 for spigot – hours 11 for Feed Stop feeding after 5 hours and spigot NG tube NG spigot and hours 5 after feeding Stop Gastric residual in previous 6 hours < 150 ml 150 < hours 6 previous in residual Gastric Increase feed rate by 20 - 40 ml/h every 12 - 24 24 - 12 every ml/h 40 - 20 by rate feed Increase Commence standard gastric feed at 40 ml/h 40 at feed gastric standard Commence Response dependent on volume of aspirate: of volume on dependent Response When aspirate is < 50 ml on two occasions: two on ml 50 < is aspirate When Wait for 1 hour and then aspirate NG tube NG aspirate then and hour 1 for Wait 20 There is also an earlier return of bowel bowel of return earlier an also is There > 150 ml – repeat after 6 hours 6 after repeat – ml 150 > (check for feed intolerance) feed for (check 4 ) is added to this supplement at at supplement this to added is ) 18 < 150 ml – repeat – ml 150 < 21 The reduction in pulmonary pulmonary in reduction The hours ↓ ↓ ↓ ↓ 19

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19. 15. 8. 16. 5. 6. 2. 14. 12. 7. 20. 23. 18. 17. 13. 11. 3. 22. 21. 4. 10. 9. nutrition. systemic for appropriate as used be may feeding parenteral or gastric either while enterocytes for used be may feeds semi-elemental nasojejunal, Low-dose, nutrition. systemic and enterocyte between made be should differentiation required, is feeding tube Where possible. as soon as feeds oral providing and fasting operative pre- reducing to given be should Consideration nutrition. enteral early and fasting pre-operative including management, patient operative peri- of cows’ ‘holy the of some to approaches fresh require will nutrients luminal Maintaining body. the throughout integrity epithelial of but function, bowel of only not maintenance to central considered be should but attention great commanded not have Enterocytes Conclusion epithelium. respiratory and skin the including surfaces, epithelial other at function barrier of maintenance in results function (GALT), tissue lymphoid gut-associated thus and enterocyte, mice. fed enterally the than greater 50% pneumonia subsequent 1. of of inoculation intratracheal similar a received animals all Escherichia coli Escherichia Bugg NC, Jones JA. Hypophosphataemia: pathophysiology, effects and management on management pathophysiology,and Hypophosphataemia: effects JA. Jones NC, Bugg Melis M, Fichera A, Ferguson MK. Bowel necrosis associated with early jejunal tube jejunal early with associated necrosis Bowel MK. Ferguson A, Fichera M, Melis Soreide E, Ljungqvist O. Modern preoperative fasting guidelines: a summary of the of summary a guidelines: fasting preoperative Modern O. Ljungqvist E, Soreide Kreymanna KG, Bergerb MM, Deutz NEP,Deutz MM, Bergerb KG, Kreymanna critical and sepsis trauma, in support metabolic IT.and Campbell Nutritional CL, Reid Mendelson C. The aspiration of stomach contents into the lungs during obstetric during lungs the into contents stomach of aspiration The C. Mendelson J, Hopkinson GL, Carlson M, Soop Bongers T, Griffiths RD. Are there any real differences between enteral feed formulations feed enteral between differences real any there Are T,RD. Bongers Griffiths survival in Improvement RF,DJ. McKee Hole CS, WotherspoonH, McArdle IG, Finlay and fasting preoperative for guidelines Practice Anesthesiologists. of Society American Mechanick JI. Practical aspects of nutritional support for wound-healing patients. wound-healing for support nutritional of aspects Practical JI. Mechanick Dhaliwal R, Daren K, Heyland DK. Nutrition and infection in the intensive care unit: what unit: care intensive the in infection and Nutrition DK. Heyland K, Daren R, Dhaliwal MF,Meyenfeldt von Glutamine RR, VanWA,PB. Hulst TieboschBuurman Soeters der A, Sax HC, Illig KA, Ryan CK, Hardy DJ. Low-dose enteral feeding is beneficial during total during beneficial is feeding enteral Low-dose DJ. Hardy CK, Ryan KA, Illig HC, Sax small and agents prokinetic nutrition: enteral of Establishment R. Bellomo AR, Davies Henriksen M, Hessov I, Dela F,Dela I, Hessov M, Henriksen Kudsk KA, Li J, Renegar KB. Loss of upper respiratory tract immunity with parenteral with immunity tract respiratory upper of Loss KB. Renegar J, Li KA, Kudsk Wu Y, Kudsk KA, DeWitt RC, Tolley EA, Li J. Route and type of nutrition influence IgA- influence nutrition of type and Route J. TolleyLi RC, DeWittY,WuEA, KA, Kudsk Torosian MH. Perioperative nutrition support for patients undergoing gastrointestinal undergoing patients for support nutrition TorosianPerioperative MH. care intensive in P,disturbances Holzer motility S, Intestinal Fruhwald H. Metzler Ljungqvist O, Nygren J, Thorell A. Modulation of post-operative insulin resistance by pre- by resistance insulin post-operative of Modulation A. Thorell J, Nygren O, Ljungqvist does the evidence show? evidence the does cytokines. intestinal mediating recommendations. and analysis Critical surgery: Surg unit. care intensive the humans. in cells immune intestinal and nutrition. parenteral care. Intensive nutrition. enteral postoperative of complication A feeding. ill? critically the in used tubes. feeding bowel cancer.colorectal for surgery following surgery.abdominal in function muscle and nutrition mobilization, response, endocrine postoperative on peptides loading. carbohydrate operative Care support. nutrition perioperative of Management LL. Maerz RG, Martindale 483-491. 20: 2006; questions. remaining and recommendations present procedures. elective undergoing patients healthy to application aspiration: pulmonary of risk the reduce to agents pharmacologic of use the anesthesia. illness. impact. clinical and pathogenesis patients feeding. protocol. recovery enhanced an in surgery colorectal major to responses metabolic on nutrition enteral immediate transplantation. organ including Surgery Weimanna A, Bragab M, Harsanyic L, Harsanyic M, Bragab WeimannaA, 2006; 12: 290-294. 12: 2006; 2004; 188: 52S–56S. 188: 2004; Curr Anaesth Crit Care Crit Anaesth Curr Ann Surg Ann 22 23 Am J Obstet Gynecol Obstet J Am It therefore appears that maintaining maintaining that appears therefore It

Clin Nutr Clin 1996; 223: 629-635. 223: 1996; Am J Surg J Am Curr Opin Crit Car Crit Opin Curr Anaesthesia Curr Opin Crit Care Crit Opin Curr 2006; 25: 210-223. 25: 2006; . Parenterally fed mice had a rate of of rate a had mice fed Parenterally . Curr Opin Crit Care Crit Opin Curr Br J Surg J Br 2004; 15: 336-349. 15: 2004; et al et Acta Anaesthesiol Scand Anaesthesiol Acta 1996; 171: 587-590. 171: 1996; Ann Surg Ann Proc Nutr Soc Nutr Proc 1946; 52: 191-205. 52: 1946; et al et . Effects of preoperative oral carbohydrates and carbohydrates oral preoperative of Effects . 1998; 53: 895-902. 53: 1998; 2004; 91: 1138-1145. 91: 2004; et al et . Randomized clinical trial of the effects of effects the of trial clinical Randomized . Br J Surg J Br e 2004; 10: 156-161. 10: 2004; e J Parenter Enteral Nutr Enteral Parenter J 1999; 229: 662-667. 229: 1999; Clin Nutr Clin et al et . ESPEN guidelines on enteral nutrition: enteral on guidelines ESPEN . Intensive Care Med Care Intensive 2006; 12: 131-135. 12: 2006; 2005; 11: 461-467. 11: 2005; 2002; 61: 329-335. 61: 2002; . ESPEN Guidelines on Enteral Nutrition: Enteral on Guidelines ESPEN . 2005; 92: 1008-1013. 92: 2005; World J Surg WorldJ 2006; 25: 224-244. 25: 2006; Anesthesiology Best Pract Res Clin Anaesthesiol Clin Res Pract Best 2003; 47: 191-199. 47: 2003; Arch Surg Arch 1999; 23: 565-569. 23: 1999; 2007; 33: 36-44. 33: 2007; 1997; 21: 310-315. 21: 1997; 1999; 90: 896-905. 90: 1999; 2006; 141: 701-704. 141: 2006; Curr Opin Crit Opin Curr Am J Am 8/2/07 3:10:10 PM