Download PG 26 – Update in Surgical Critical Care – GI/Nutrition Clay Cothren

PG 26 – Update in Surgical Critical Care – GI/Nutrition
Clay Cothren Burlew, MD FACS
Director, Surgical Intensive Care Unit
Program Director, Surgical Critical Care Fellowship
Program Director, Trauma & Acute Care Surgery Fellowship
Denver Health Medical Center
Associate Professor of Surgery
University of Colorado School of Medicine
Denver, CO
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Current Management of C. difficile Infection
Clostridium difficile infections (CDI) are increasing in incidence and severity; it is the
leading cause of hospital-associated infectious diarrhea. Predisposing factors include antibiotic
use (most commonly fluoroquinolones, cephalosporins and clindamycin), older age,
immunosuppression, GI surgery, inflammatory bowel disease, and hospitalization. Although the
clinical presentation can vary, up to 10% of cases are considered severe or “fulminant”.
Diagnosis of a CDI is based on a combination of clinical findings and laboratory testing positive
for the C. difficile antigen and toxin.
The historical cornerstones of treatment for CDI include discontinuing the inciting
antibiotics, antimicrobial therapy, and organ support. Antibiotic treatment options for CDI
include intravenous metronidazole, oral vancomycin, and vancomycin enemas. Recently, oral
fidaxomicin has been shown to have equivalent rates of clinical cure for CDI with a lower
recurrence of the infection compared to vancomycin treated patients. Due to the increasing
incidence and the emergence of resistant CDI, fecal microbial transplantation has been suggested
as an alternative therapy. Originally described in 1958, recent trials of fecal transplantation in
highly selected patients have supported its use in refractory cases. Surgical management of CDI
is reserved for patients with marked clinical deterioration or shock. Colectomy with ileostomy is
the definitive surgical option. More recently colon-sparing surgery for CDI has been proposed
with diverting loop ileostomy and colonic lavage to reduce patient morbidity.
The Role of Total Parenteral Nutrition
Nutrition support is pivotal in the management of the critically ill patient. In general
there are 2 groups that benefit the most from nutrition support: malnourished patients (BMI<25,
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BMI>35) and those who are in the ICU for prolonged stays and hence are at risk for energy and
protein deficits. Enteral nutrition is less expensive and associated with fewer complications than
parenteral nutrition. Additionally, early enteral nutrition in critically injured patients has been
shown to decrease septic complications. Therefore, the ideal nutrition therapy for a critically ill
patient is enteral nutrition within 24-48 hours of ICU admission. However, patients may have
contraindications to full enteral feeding (vasopressors, recent surgery, bowel discontinuity,
ileus). In patients who are low risk (normal BMI, short ICU stay, low mortality risk), delaying
TPN until after hospital day 7 is associated with fewer complications and faster recovery, but no
difference in mortality. However, in high risk patients unable to tolerate enteral nutrition,
parenteral nutrition is associated with decreased nosocomial infections and shorter duration of
mechanical ventilation; in these high risk patients, TPN should be initiated early in the patient’s
ICU course.
Immunonutrition
Immunonutrition, also referred to as an immunomodulating formula for enteral feeding,
is one of the many classes of enteral nutrition that is commercially available. These formulas
contain nutrients such as glutamine, arginine, omega-3 fatty acids, nucleotides, and antioxidants
added to standard enteral formulas. Immunonutrition is hypothesized to enhance the
immunologic response and reduce the inflammatory response. Studies to date, however, have
shown mixed outcomes with immunonutrition. Current guidelines from the SCCM and ASPEN
recommend that immune-modulating formulations should be used in appropriate patient
populations (trauma, burn, head and neck cancers, and major elective surgery). Interestingly,
subset analysis demonstrated an increase in mortality in severely septic patients receiving
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immune-enhancing enteral formulas. Experts believe that the component likely causing harm is
the nutrient arginine.
Bibliography:
1. Neal MD, Alverdy JC, Hall DE, Simmons RL, Zuckerbraun BS. Diverting loop ileostomy
and colon lavage: An alternative to total abdominal colectomy for the treatment of severe,
complicated clostridium difficile associated disease. Ann Surg 2011;254:423-426.
2. Singer P, Pichard C. Reconciling divergent results of the latest parenteral nutrition studies in
the ICU. Curr Opin Clin Nutr Metab Care. 2013;16(2):187-93.
3. Canadian Clinical Practice Guidelines. http://www.criticalcarenutrition.com.
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