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Acute intestinal failure Presented by Marwa A. Khairy Ass. Lecturer of Anesthesia Uncommon name for common conditions.

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Presentation on theme: "Acute intestinal failure Presented by Marwa A. Khairy Ass. Lecturer of Anesthesia Uncommon name for common conditions."— Presentation transcript:

1 Acute intestinal failure Presented by Marwa A. Khairy Ass. Lecturer of Anesthesia Uncommon name for common conditions

2 Page 2 By the end of this lecture… Define intestinal Failure. Identify types of intestinal Failure. Know the management of each type and its implication on clinical practice.

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4 Page 4 Definition Intestinal Failure The term Intestinal Failure was originally defined by Fleming and Remington as a reduction in the functioning gut mass below the minimal amount necessary for adequate digestion and absorption of food. (Fleming CR and Remington M. Nutrition and the surgical patient pp. 219– 235.)

5 Page 5 Definition hydration and electrolyte balance This definition was subsequently modified to include failure of the intestinal tract to maintain adequate hydration and electrolyte balance in the absence of artificial fluid and electrolyte support. ( Nightingale JMD. Intestinal failure; ; pp. ix–x.)

6 Page 6 With so many causes, Intestinal Failure (IF) may have various degrees of severity and duration: a)According to the duration a)According to the duration, IF may be Acute (reversible within 6 months) Chronic (longer than 6 months, and even permanent);

7 Page 7 With so many causes, IF may have various degrees of severity and duration: According to the type b) According to the type Type 1 Type 1: self-limiting IF – usually following abdominal surgery Type 2 Type 2: IF in severely affected patients with extensive intestinal resections, with septic, metabolic and nutritional complications, and necessitating a multidisciplinary approach Type 3 Type 3: chronic IF – patients need long-term PN.

8 Physiological Background

9 Page 9 Small intestine meters long. villi The mucosal surfaces have finger-like projections called villi that increase 20-fold the surface area for absorption. microvilli On the epithelial surface there is a brush border of microvilli to further enhance absorption.

10 Page 10 Small intestine Anatomically, the small intestine is divided into the duodenum, jejunum and ileum. The duodenojejunal flexure is supported by the ligament of Treitz, an arbitrary point used by clinicians to distinguish upper (proximal to the ligament of Treitz) from lower gastrointestinal bleeding. The jejunum is slightly thicker and has a greater number of mucosal folds compared to the ileum

11 Page 11 Overview of nutrient absorption in the small intestine.

12 Type I Intestinal Failure

13 Page 13 Type I Intestinal Failure Mechanical Mechanical intestinal obstruction Nonmechanical Nonmechanical (i.e.paralytic) ileus

14 Page 14 Mechanical intestinal obstruction Developing within 30 days of Surgery, after resumption of Gastrointestinal function, and With radiological or surgical Evidence of MO. As many as 10% of patients undergoing abdominal surgery S&S S&S: Abdominal distension Vomiting Constipation Radiological findings of Dilated small intestine.

15 Page 15 Mechanical intestinal obstruction Causes: Open abdominal surgery in the infracolic compartment ( (colectomy or ileoanal pouch surgery) Emergency surgery (Appendicectomy)

16 Page 16 Mechanical obstruction after open surgery Adhesions Managed conservatively, Managed conservatively, using Nasogastric drainage and intravenous feeding. (within the first 7 days) after laparoscopic surgery port-site herniation laparotomy should be considered

17 Page 17 Mechanical Obstruction relaparotomy Those patients who require relaparotomy can be extremely challenging to manage. The abdominal cavity can be hostile in the early postoperative period and inadvertent intestinal injury, Even if recognized and treated immediately, is associated with a high incidence of abdominal sepsis, intestinal fistulation and type II intestinal failure.

18 Postoperative Ileus

19 Page 19 A familiar history…. Male patient a 66-year-old man, status-post colectomy Postop management included NPO and morphine PCA On POD 6, the patient is still unable to eat, has some N/V, mild abdominal distension Despite laxatives he has not yet passed flatus nor had a bowel movement

20 Page 20 Postoperative ileus Frequent cause of type I intestinal failure The most common reason for delayed discharge following abdominal surgery (complications?!) The average duration of ileus after major abdominal surgery varies depending on what part of the digestive system affected Small Intestine 0 to 24 hours The stomach 24 to 48 hours The colon 48 to 72 hours

21 Page 21 Causes of ileus Multifactorial Abdominal Surgery Critical illness states and nonabdominal surgical procedures Hip surgery, retroperitoneal spinal procedures, lower limb orthopaedic and neurosurgery

22 Page 22 Sympathetic Nervous System Inhibitory neural reflexes Excessive IV fluids Intestinal edema Pharmacologic Exogenous opioids Multiple Pathways Disorganized electrical activity proinflammatory Mediators Macrophage and neutrophil infiltration, IL-1, tumor necrosis factor, IL-6 IL = interleukin. Pathogenesis of POI Is Multifactorial

23 Page 23 There Are Numerous Risk Factors for POI POI Is Expected to Affect Almost Every Patient Who Undergoes Abdominal Surgery Surgical Site Extent of Bowel Manipulation Operation Time Patient Health Systemic Infections Amount of Opioids Patient Factors Senagore AJ. Am J Health-Syst Pharm. 2007;64(suppl 13):S3-S7. Senagore AJ, et al. Surgery. 2007;142:

24 Page 24 Preventive and Therapeutic Management Options for POI Physical Options –Nasogastric tube –Early postoperative feeding –Sham feeding, gum chewing –Early ambulation Surgical Technique –Laparoscopy Psychological Perioperative Information Anesthesia and Analgesia –Epidural –NSAIDs Pharmacologic –Prokinetic agents –Opioid (PAMOR) antagonists –Other agents Perioperative Care Plan(s) –Multimodal clinical pathways PAMOR = peripherally acting µ-opioid receptor antagonist Luckey A, et al. Arch Surg. 2003;138: Person B, Wexner S. Curr Probl Surg. 2006;43:12-65.

25 Page 25 Management Options for POI

26 Page 26 Management Options for POI Management Options for POI Person B, Wexner S. Curr Probl Surg. 2006;43: Chen JY, et al. Acta Anaesthesiol Scand. 2005;49: Luckey A, et al. Arch Surg. 2003;138: Becker G, Blum H. Lancet. 2009;373(9670):

27 Page 27 POI: Peripheral Opioid Antagonism Most patients require opioids Opioids inhibit GI propulsive motility and secretion; the GI effects of opioids are mediated primarily by µ-opioid receptors within the bowel Naloxone and naltrexone reduce opioid bowel dysfunction but can reverse analgesia in higher doses An ideal POI treatment is a peripheral opioid receptor antagonist that reverses GI side effects without compromising postoperative analgesia –Alvimopan –Methylnaltrexone Becker G, Blum H. Lancet. 2009;373(9670):

28 Page 28 What Is Fast-Track Recovery? What Is Fast-Track Recovery? An interdisciplinary multimodal concept to accelerate postoperative convalescence and reduce general morbidity (including POI) by simultaneously applying several interventions What are the appropriate choices in constructing fast-track, multimodal protocols? Opioid sparing Laparoscopic surgery Early/sham* feeding, Optimal fluid management Mobilization? Epidural anesthetics Laxatives, prokinetics NG tube removal Mattei P. Rombeau J. World J Surg. 2006;30: Person B, Wexner S. Curr Probl Surg. 2006;43:6-65. *such as gum chewing

29 Page 29 Fast-Track Example (Colectomy Fast-Track Example (Colectomy) Raue W, et al. Surg Endosc. 2004;18: SICU = surgical intensive care unit PACU = postanesthetic care unit *Not all centers admit patients to the SICU under standard care

30 Page 30 Prevention and treatment for POI

31 Type II intestinal failure

32 Page 32 Type II intestinal failure Type II intestinal Type II intestinal failure is a serious condition Type II failure Type II failure may be self-limiting, (simple intestinal fistulation, spontaneous healing with effective nutritional and metabolic support). As a result of complications of abdominal surgery, leaving them with severe abdominal sepsis and intestinal fistulation.

33 Page 33 Disease spectrum of patients with Type 2 intestinal failure admitted to Hope Hospital intestinal failure unit (2002–2005; n= 134).

34 Page 34 Another common story….. A patient malnourished following intestinal resection, for example, who develops intestinal fistula and abdominal sepsis secondary to anastamotic breakdown, Intestinal failure in such a patient will not only result from a short bowel secondary to resection and fistula formation, but also from the indirect effect of sepsis on gastro-intestinal function

35 Page 35 Management Sepsis and fistulation Sepsis and fistulation are the primary factors associated with the development of intestinal failure in more than 70% of patients, although approximately 10% will also have a significant reduction in absolute bowel length even at diagnosis (i.e. they will go on to develop type III intestinal failure, irrespective of treatment).

36 Page 36 Management First: The Prompt Diagnosis And Treatment Of Abdominal Sepsis. First: The Prompt Diagnosis And Treatment Of Abdominal Sepsis. Second: Effective Nutritional Support Second: Effective Nutritional Support Third: Definitive Therapy Third: Definitive Therapy

37 Page 37 The detrimental effect on survival is multifactorial : Impairment of GIT functions ; nutrient transport, intestinal motility, enterocyte proliferation and apoptosis. Spontaneous healing of fistulas is less likely Increased metabolic need progressive weight loss The Prompt Diagnosis And Treatment Of Abdominal Sepsis (the most important) Aggressive nutritional support is unlikely to be successful until the Sepsis is investigated and treated; This concept is fundamental to the SNAP approach of managing Type 2 intestinal failure. Aggressive nutritional support is unlikely to be successful until the Sepsis is investigated and treated; This concept is fundamental to the SNAP approach of managing Type 2 intestinal failure.

38 Page 38 Classical signs;Classical signs; pyrexia(may be absent when?),leukocytosis, & cachexia, hypoalbuminaemia and abnormalities in liver function. Cultures & SwabsCultures & Swabs (other sites ?!) Adequate radiological localization (Adequate radiological localization (US, CT) Immediate drainage:Immediate drainage: CT guided Percutaneous drainage whenever possible, thus avoiding the second hit associated with a difficult further laparotomy. trans-gastric, trans-gluteal, trans-vaginal, trans-rectal or even trans-hepatic approaches to facilitate drainage of deep-seated collections The Prompt Diagnosis And Treatment Of Abdominal Sepsis (the most important)

39 Page 39 Antibiotic therapy Antibiotic therapy, guided by results of aspirate culture, Surgical treatmentSurgical treatment (multiple interloop abscesses, a high- output enteric fistula feeding the cavity, marked lack of intestinal continuity or obstruction distally, or extensive anastamotic breakdown) an open abdomen (laparostomy) In cases of recurrent severe abdominal sepsis, adequate source control may necessitate management of the patient with an open abdomen (laparostomy) The Prompt Diagnosis And Treatment Of Abdominal Sepsis (the most important)

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41 Page 41 Effective Nutritional Support Nutritional intervention should be considered whenever; Starvation Starvation for longer than 5 days is expected or has occurred, whether as a result of impaired intake or gastrointestinal disease. underlying disease The underlying disease has led to an increase in nutritional requirements beyond that which can be provided by a normal diet. Nutritional depletion Nutritional depletion already existed prior to the onset of acute gastrointestinal failure.

42 Page 42 Effective Nutritional Support Enteral nutrition Enteral nutrition the enteral route should be used for nutritional support whenever possible. Enteral feeding is safer, more physiological, may preserve intestinal mucosal integrity and is certainly far less expensive than parenteral nutrition. In acute intestinal failure, however, enteral feeding may be impractical or inappropriate.

43 Page 43 Effective Nutritional Support low output distal ileal or colonic fistula Enteral nutrition may prove satisfactory in patients with a low output distal ileal or colonic fistula but is inappropriate when there is obstruction or a fistula of the upper gastrointestinal tract, unless access can be gained to the gut below the diseased segment.

44 Page 44 Effective Nutritional Support It may be possible to place an enteral feeding tube directly into the small intestine through an entero-cutaneous fistula. The output of the fistula can be collected, mixed with enteral feed and infused into the distal, healthy gut, but the technique is demanding for nursing staff, unpleasant.

45 Page 45 Effective Nutritional Support Parenteral Nutrition: The preferred modality of nutritional support. This may either be because of the presence of disease of the intestine, which precludes satisfactory enteral nutrition, an inability to tolerate enteral nutrition or altered nutritional requirements such as those associated with severe sepsis or injury.

46 Page 46 Effective Nutritional Support If the anticipated period of nutritional support is fewer than 14 days, parenteral nutrition can be provided safely via a peripheral vein. The chief attraction of peripheral total parenteral nutrition (TPN) is that it requires little in the way of special expertise and is not associated with the potential morbidity of central venous cannulation. This can be minimized by the use of lipid-containing regimens (which have a lower osmolality than glucose-based regimens and are therefore less irritant to venous endothelium),

47 Page 47 Effective Nutritional Support Also by adding heparin and hydrocortisone to the feed and by the application of nitrate patches to promote venodilatation at the feeding site. Central venous TPN Central venous TPN is therefore recommended in patients with large fluid requirements or acutely ill adult patients, who may have energy requirements greater than 2000 kcal/day. Central venous TPN is also necessary where it is evident that a prolonged period of parenteral feeding is likely to be required. Irrespective of the route chosen for venous access, a strict aseptic technique is essential

48 Page 48 Definitive treatment Multidisciplinary team After resolving of infection and improving nutritional status. Reconstructive surgery cannot take place until a detailed knowledge of the patients residual intestinal anatomy has been acquired. Pathologist plays a critical role in assessing the histological specimens of all patients with intestinal failure.

49 Page 49 Definitive treatment Medical management of Underlying disease. Short bowel syndrome can be treated with bowel rehabilitation, parenteral nutrition, or intestinal transplantation. Consequences depend on the extent and site of bowel resection.

50 Page 50 The Sepsis-Nutrition-Anatomy-Plan approach to the management of intestinal failure Sepsis Cultures and swabs Abdominal imaging Other sources of infection: e.g. respiratory tract infection, bacterial endocarditis Nutrition Dietetic assessment Supplemental feeding and route: enteral vs. parenteral (peripheral vs. central) Anatomy Contrast studies for intestinal length and fistulae definition

51 Page 51 The Sepsis-Nutrition-Anatomy-Plan approach to the management of intestinal failure Plan Multidisciplinary approach Timing of surgery if indicated (early to resolve uncontrolled sepsis vs. elective) Metabolic and nutritional optimization Wound/stoma care Management of short bowel syndrome Management of underlying disease and complications related to therapy Training and support if home enteral or parenteral nutrition required

52 Page 52 The case Male patient a 66-year-old man, status-post colectomy Male patient a 66-year-old man, status-post colectomy Postop management included NPO and morphine PCA Postop management included NPO and morphine PCA On POD 6, the patient is still unable to eat, has some N/V, mild abdominal distension On POD 6, the patient is still unable to eat, has some N/V, mild abdominal distension Despite laxatives he has not yet passed flatus nor had a bowel movement Despite laxatives he has not yet passed flatus nor had a bowel movement

53 Page Postoperative ileus can result from: a.Opioids b.Parsympathetic stimulation c.Excessive intraoperative fluids d.Excessive manipulations intraoperatively

54 Page Postoperative ileus can be prevented & treated by: a.Early NG tube removal b.Open surgery c.Chewing gums d.Early ambulation

55 Page Pharmacological treatment of postoperative ileus: a.Erythromycin b.metoclopramide c.Methylnaltrexone d.Fentanyl

56 Page A patient malnourished following intestinal resection, for example, who develops intestinal fistula and abdominal sepsis secondary to anastamotic breakdown Which statement is true: a.Nutrition is the priority b.Prevention of sepsis is the priority c.No reconstructive therapy until resolution of sepsis d.CT may have a role

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