Presentation is loading. Please wait.

Presentation is loading. Please wait.

Acute intestinal failure

Similar presentations


Presentation on theme: "Acute intestinal failure"— Presentation transcript:

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

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.

3

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

7 b) According to the type
With so many causes, IF may have various degrees of severity and duration: b) According to the type Type 1: self-limiting IF – usually following abdominal surgery Type 2: IF in severely affected patients with extensive intestinal resections, with septic, metabolic and nutritional complications, and necessitating a multidisciplinary approach Type 3: chronic IF – patients need long-term PN. North American clinicians generally regard intestinal failure chiefly as a chronic condition, synonymous with short bowel syndrome, to be treated either by long-term home parenteral nutrition or, increasingly, intestinal transplantation. In contrast, European authors refer to this condition as type III intestinal failure, but also recognize acute syndromes in which intestinal failure can be said to exist. In this context, type I intestinal failure describes a very short-lived, and self-limiting state, commonly seen in the postoperative period, whereas type II intestinal failure principally relates to the development of surgical complications associated with abdominal sepsis and, in particular, intestinal fistulation. Although type II intestinal failure may also be selflimiting (e.g. when an intestinal fistula heals spontaneously), it tends to follow a course of several weeks or months and is likely to require surgical treatment, as opposed to simply supportive care.

8 Physiological Background

9 Small intestine 5-7 meters long.
The mucosal surfaces have finger-like projections called villi that increase 20-fold the surface area for absorption. On the epithelial surface there is a brush border of microvilli to further enhance absorption.

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 Overview of nutrient absorption in the small intestine.

12 Type I Intestinal Failure

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

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: Abdominal distension Vomiting Constipation Radiological findings of Dilated small intestine.

15 Mechanical intestinal obstruction
Causes: Open abdominal surgery in the infracolic compartment (colectomy or ileoanal pouch surgery) Emergency surgery (Appendicectomy) Postoperative small bowel obstruction is most likely to occur in patients who undergo; Open abdominal surgery in the infracolic compartment, especially colectomy or ileoanal pouch surgery, Or emergency surgery, particularly appendicectomy when there has been appendicular perforation [6].

16 after laparoscopic surgery
Mechanical obstruction after open surgery Adhesions Nasogastric drainage and intravenous feeding. Managed conservatively, using (within the first 7 days) after laparoscopic surgery port-site herniation In the majority of cases in which early small bowel obstruction develops after open surgery, the obstruction is the result of adhesions and can be managed conservatively, using nasogastric drainage and intravenous feeding. The obstruction settles spontaneously in at least 70% of cases within 14 days, with a negligible risk of intestinal strangulation [6]. Most of the cases that settle spontaneously do so within the first 7 days, however, and the frequency of spontaneous resolution falls off markedly at that point, leading some to suggest that consideration for laparotomy should be given to those In contrast, obstruction developing after laparoscopic surgery is much more commonly the result of port-site herniation [7] and early laparotomy should be considered in order to avoid strangulated obstruction. laparotomy should be considered

17 Mechanical Obstruction
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 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 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 to 24 hours The stomach to 48 hours The colon to 72 hours Whereas it may affect all segments of bowel, the pattern of recovery differs according to the portion of the intestinal tract affected, with recovery occurring notably quicker in the small intestine than in the stomach or the colon The return of colonic motility appears to be the key factor responsible for the clinical resolution of postoperative ileus

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

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

23 There Are Numerous Risk Factors for POI
Surgical Site Extent of Bowel Manipulation POI Is Expected to Affect Almost Every Patient Who Undergoes Abdominal Surgery Patient Factors Operation Time There Are Numerous Risk Factors for POI Risk factors for the development of POI include patient factors, surgical site, extent of bowel manipulation, operation time and opioid use. The duration of POI correlates with the extent of surgical trauma, and is particularly extensive following colonic surgery. Extensive bowel manipulation and lengthy operation time contribute to greater sympathetic activation, stress and inflammatory responses; collectively these negatively impact bowel motility. Opioids are commonly used for postoperative analgesia. Mediated primarily by µ-opioid receptors, opioid effects in the gastrointestinal tract contribute to POI (Table). Cali et al demonstrated a significant correlation between increasing morphine dose (by patient controlled analgesia) and longer time to return of bowel function in 40 patients following colectomy. Opioid Effects in the Gastrointestinal Tract Pharmacologic Clinical Decreased gastric motility Increased GI reflux Inhibition of small intestinal propulsion Delayed absorption of medications Inhibition of large intestinal propulsion Straining, incomplete evacuation, bloating, abdominal distension Increased amplitude of non-propulsive segmental contractions Spasm, abdominal cramps, and pain Constriction of sphincter of Oddi Biliary colic, epigastric discomfort Increased anal sphincter tone, impaired reflex relaxation with Impaired ability to evacuate bowel rectal distension Diminished gastric, biliary, pancreatic and intestinal secretions. Hard, dry stool Increased absorption of water from bowel contents Resnick J, Greenwald D, Brandt L. Delayed gastric emptying and postoperative ileus after nongastric abdominal surgery: part I. Am J Gastroenterol. 1997;92: Resnick J, Greenwald D, Brandt L. Delayed gastric emptying and postoperative ileus after nongastric abdominal surgery: part II. Am J Gastroenterol. 1997;92: Senagore AJ. Pathogenesis and clinical and economic consequences of postoperative ileus. Am J Health-Syst Pharm. 2007;64(suppl 13):S3-S7. Senagore AJ, Bauer J, Du W, Techner L. Alvimopan accelerates gastrointestinal recovery after bowel resection regardless of age, gender, race, or concomitant medication use. Surgery. 2007;142: Kurz A, Sessler D. Opioid-induced bowel dysfunction. Pathophysiology and potential new therapies. Drugs. 2003;63: Pappagallo M. Incidence, prevalence, and management of opioid bowel dysfunction. Am J Surg. 2001;182;11S-18S. Cali R, Meade P, Swanson M, Freeman C. Effect of morphine and incision length on bowel function after colectomy. Dis Colon Rectum. 2000;43: Patient Health Amount of Opioids Systemic Infections Senagore AJ. Am J Health-Syst Pharm. 2007;64(suppl 13):S3-S7. Senagore AJ, et al. Surgery. 2007;142:

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 Preventive and Therapeutic Management Options for POI Numerous strategies have been applied to the management of patients at risk for the development of POI. Consensus guidelines for POI are lacking. Strategies implemented to reduce the risk or extent of POI include surgical technique, choice and route of anesthesia, opioid-sparing analgesics, and peripheral opioid receptor antagonists. Supportive measures studied include patient education and optimization, use of nasogastric tubes, early mobilization, and early oral, enteral or sham feeding. With the multifactorial etiology of POI, a multimodal approach incorporating several individual management strategies applied simultaneously is increasingly recognized as a beneficial component of the clinical pathway for patients undergoing bowel resection procedures. Luckey A, Livingston E, Tache Y. Mechanisms and treatment of postoperative ileus. Arch Surg. 2003;138: Person B. Wexner S. The management of postoperative ileus. Curr Probl Surg. 2006;43:12-65. 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 Management Options for POI
Nonpharmacologic Options Management Potential Mechanism Impact on Bowel Function, Length of Stay NG tube Gastric/small bowel decompression Removal of NG tube associated with earlier return of bowel function, reduction in pulmonary complications, shorter length of stay Early feeding (including sham feeding) Stimulates GI motility by eliciting reflex response and stimulating release of hormonal factors Some studies report a reduction in POI with early feeding, meta-analyses suggest a modest (non-significant) reduction in length of stay Early ambulation Possible mechanical stimulation; possible stimulation of intestinal function No effect on duration of POI; beneficial for prevention of lower extremity thromboembolism Laparoscopic surgery Decreased opiate requirements, decreased pain, less abdominal wall trauma, less intestinal manipulation Earlier passage of flatus, earlier bowel movement, shortened length of stay Management Options for POI Nonpharmacologic options for the management of POI include the use of nasogastric tubes, early feeding, early ambulation, and laparoscopic surgical techniques. The routine use of nasogastric tubes for gastric decompression following abdominal surgery has been challenged by evidence that suggests that NG tubes do not in fact hasten the return of bowel function, increase patient comfort or reduce hospital stay. A meta-analysis by Nelson et al. revealed that patients without routine NG tube use had significantly earlier return of bowel function, a significant reduction in pulmonary complications, and a shorter length of hospital stay compared with patients using NG tubes.1 Early feeding can stimulate GI motility through the gastrocolic reflex and the stimulation of gastrointestinal hormones. Holte and Kehlet presented data from 7 studies comparing early feeding vs traditional feeding on the duration of postoperative ileus. Significant reduction of ileus was reported in 3 studies, although the benefit was modest.2 Several authors have reported meta-analyses of early versus later enteral feeding following colorectal, gynecologic or abdominal surgeries.3-5 Each of these analyses reported slightly reduced length of stay with early feeding, and supported the safety of early nutrition in each of the patient populations. Importantly, there was no benefit demonstrated by restricting postoperative oral nutrition. Gum chewing (a form of sham feeding) has also been evaluated as a means to stimulate gastrointestinal motility and reduce the duration of POI. A recent review identified 9 clinical trials with 437 patients in which gum chewing was compared with standard care following elective intestinal surgery.6 Each of the outcome measures was significantly reduced in patients who chewed gum compared with traditional care (time to flatus, -14 hr; time to bowel movement, -23 hr; length of hospital stay, -1.1 days). Rigorous investigation is required to determine the true efficacy of gum chewing for POI, however for those individuals who are not at risk of choking due to swallowing difficulties, this inexpensive intervention may be beneficial. Early ambulation has demonstrated benefits for the prevention of lower extremity thromboembolism and other postoperative complications, but the theory that early ambulation should enhance the resumption of normal bowel function and reduce the duration of POI is not supported by the literature.7,8 Reduction of surgical stress with less invasive surgical techniques may contribute to the reduced duration of POI as demonstrated in a number of studies comparing laparoscopy and open surgery. A meta-analysis of 22 studies of colorectal surgery demonstrated a significant reduction in postoperative pain as assessed by visual analog scale, earlier passage of flatus, earlier bowel movement, and shortened hospital length of stay associated with laparoscopic compared with open surgery.9 Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev. 2007;(3):CD Holte K, Kehlet H. Postoperative ileus: a preventable event. Br J Surgery. 2000;87: Andersen H, Lewis S, Thomas S. Early enteral nutrition within 24h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database Syst Rev. 2006;(4):CD Charoenkwan K, Phillipson G, Vutyavanich T. Early versus delayed oral fluids and food for reducing complications after major abdominal gynaecologic surgery. Cochrane Database Syst Rev. 2007;(4):CD Lewis S, Andersen H, Thomas S. Early enteral nutrition within 24 hours of intestinal surgery versus later commencement of feeding: a systemic review and meta-analysis. J Gastrointest Surg. 2009;13: Noble E, Harris R, Hosie K, Thomas S, Lewis S. Gum chewing reduces postoperative ileus? A systematic review and meta-analysis. Int J Surg. 2009;7: Waldhausen J, Schirmer B. The effect of ambulation on recovery from postoperative ileus. Ann Surg. 1990;212: Zutshi M, Delaney C, Senagore A, Fazio V. Shorter hospital stay associated with fasttrack postoperative care pathways and laparoscopic intestinal resection are not associated with increased physical activity. Colorectal Dis. 2004;6: Schwenk W, Haase O, Neudecker J, Müller J. Short term benefits for laparoscopic colorectal resection. Cochrane Database Rev. 2005;(3):CD

26 Management Options for POI
Pharmacologic Options Treatment or Prevention Potential Mechanism Impact on Bowel Function, Length of Stay Epidural (thoracic) anesthesia/analgesia Inhibits sympathetic reflex at cord level; opioid-sparing analgesia Earlier bowel movement, reduced duration of POI compared with systemic analgesic regimens NSAIDs Opiate-sparing analgesia, inhibits COX-mediated prostaglandin synthesis Earlier bowel movement, earlier ambulation, no change in length of stay compared with morphine PCA Metoclopramide Dopamine antagonist, cholinergic agonist, prokinetic agent No benefit on the duration of POI Erythromycin Motilin receptor agonist, prokinetic effect Laxatives Help to induce bowel movement Limited data from small nonrandomized study suggests benefit; additional study required Peripherally selective mu-receptor antagonists Block enteric mu-receptors and minimize opioid effects on GI function, without impacting CNS-mediated analgesia Clinical trials with alvimopan demonstrated reduced time to recovery of GI function, reduced time to discharge order written compared with placebo Management Options for POI Pharmacologic options investigated for the management of POI include epidural anesthesia/analgesia, NSAIDs, prokinetic agents such as metoclopramide, and peripherally selective µ-opioid receptor antagonists. Intraoperative inhaled or intravenous anesthetics can temporarily inhibit GI motility. The adjunctive use of epidural anesthesia with general anesthesia may help to minimize these GI effects by blocking inhibitory sympathetic reflexes, preventing the release of afferent pain neurotransmitters, and increasing splanchnic blood flow. Patient-controlled analgesia (PCA) with intravenous opioids is very effective for the control of postoperative pain, but has direct inhibitory effects on GI motility. Numerous studies have demonstrated a reduction in the duration of postoperative ileus with epidural analgesia in the postoperative period compared with systemic opioids.1 The postoperative use of nonsteroidal antiinflammatory drugs (NSAIDs) is another avenue for reducing the opioid burden. Analgesic and anti-inflammatory properties of NSAIDs are beneficial for patients with POI, and a randomized, double-blind study of morphine PCA with or without ketorolac in 79 patients who underwent colorectal surgeries demonstrated a 29% reduction in morphine use, earlier first bowel movement, and earlier ambulation in those patients receiving the morphine/ketorolac combination.2 The prokinetic agent, metoclopramide has been investigated in several placebo-controlled clinical trials of patients undergoing abdominal surgeries; however a beneficial effect on the duration of POI has not been demonstrated.3 Placebo-controlled studies with erythromycin (motilin receptor agonist) have failed to demonstrate a beneficial effect for POI. Limited data are available on the efficacy of laxative therapy for POI, and well designed, randomized trials are needed to evaluate their utility for POI. The effects of opioids on GI motility are mediated primarily by binding to µ-opioid receptors in the GI tract. Methylnaltrexone and alvimopan antagonize opioid binding at µ-opioid receptors, but do not cross the blood brain barrier, and consequently do not compromise the analgesic properties of opioids.4 A phase 2 study in patients undergoing segmental colectomy demonstrated that treatment with methylnaltrexone was associated with earlier time to first bowel movement and earlier tolerance of full liquids compared with placebo treatment. Publication of data from phase 3 studies of methylnaltrexone for POI is awaited. Alvimopan treatment for POI has been studied in multiple phase 3 studies. Treatment of patients undergoing bowel resection with alvimopan was associated with accelerated return of bowel function, reduced time to discharge order written, and reduced POI-related morbidity. Alvimopan was approved by the FDA in 2008 to accelerate the restoration of normal bowel function in adult patients undergoing partial large or small bowel resection surgery. Person B, Wexner S. The management of postoperative ileus. Curr Probl Surg. 2006;43:12-65. Chen JY, Wu G, Mok M, et al. Effect of adding ketorolac to intravenous morphine patient-controlled analgesia on bowel function in colorectal surgery patients – a prospective, randomized, double-blind study. Acta Anaesthesiol Scand. 2005;49: Luckey A, Livingston E, Tache Y. Mechanisms and treatment of postoperative ileus. Arch Surg. 2003;138: Becker G, Blum H. Novel opioid antagonists for opioid-induced bowel dysfunction and postoperative ileus. Lancet. 2009;373(9670): Person B, Wexner S. Curr Probl Surg. 2006;43:12-65. 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 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 POI: Peripheral Opioid Antagonism The gastrointestinal effects of opioids include inhibition of enteric nerve activity, inhibition of propulsive motor activity, inhibition of secretory activity, and alterations in immune cell function. These effects are mediated primarily by opioid binding to µ receptors in the GI tract. Traditional opioid antagonists such as naloxone, nalmefene, and naltrexone have the potential to improve opioid-induced GI adverse effects, however because they cross the blood brain barrier, reversal of analgesia and opioid withdrawal are likely outcomes. Alvimopan and methylnaltrexone are peripherally acting µ-opioid receptor antagonists that do not compromise the central analgesic properties of opioids because they do not cross the blood brain barrier. Alvimopan is highly selective for the µ-opioid receptor relative to its affinity for  and κ opioid receptors, and has a greater binding affinity for the µ receptor compared with methylnaltrexone. The use of a peripheral µ-opioid receptor antagonist in patients treated with postoperative opioids is a promising strategy for reducing the duration and morbidity associated with POI. Kurz A, Sessler DI. Opioid-induced bowel dysfunction: pathophysiology and potential new therapies. Drugs. 2003;63: Taguchi A, Sharma N, Saleem RM, et al. Selective postoperative inhibition of gastrointestinal opioid receptors. N Engl J Med. 2001;345: Becker G, Blum H. Novel opioid antagonists for opioid-induced bowel dysfunction and postoperative ileus. Lancet. 2009;373(9670): Becker G, Blum H. Lancet. 2009;373(9670):

28 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? NG tube removal Opioid sparing Laparoscopic surgery Laxatives, prokinetics What is “Fast-Track Recovery”? Fast-track recovery is an interdisciplinary multimodal concept to accelerate postoperative convalescence and reduce general morbidity (including POI) by simultaneously applying several interventions. The components of a fast-track, multimodal protocol may include patient optimization and education, minimally invasive surgical techniques (where appropriate), epidural anesthesia/analgesia, opioid-sparing analgesia, limited use of postoperative nasogastric tubes, early oral/enteral/sham feeding, early ambulation, and peripheral opioid antagonism. This approach has been demonstrated to accelerate recovery from postoperative ileus, reduce the length of hospital stay, and improve patient comfort following abdominal surgeries. Mattei P, Rombeau J. Review of the pathophysiology and management of postoperative ileus. World J Surg. 2006;30: Person B, Wexner S. The management of postoperative ileus. Curr Probl Surg. 2006;43:6-65. Epidural anesthetics Early/sham* feeding, Optimal fluid management Mobilization? *such as gum chewing Mattei P. Rombeau J. World J Surg. 2006;30: Person B, Wexner S. Curr Probl Surg. 2006;43:6-65.

29 Fast-Track Example (Colectomy)
Day Standard Fast-Track Pre-operative Consent, epidural (local anesthetic [LA] with opioid) Consent and educate, anti-emetic, anxiolytic, epidural (LA with opioid) Day of surgery Admit to SICU*, NG out with order, i.v. fluids to body weight, continuous epidural or PCA, anti-emetic, nothing by mouth, sitting Admit to floor post PACU, NG out with extubation, limit i.v. fluid, continuous epidural (limit systemic opioids), NSAID, laxative, mobilize to chair, short walk, soft foods POD 1 Admit to floor, epidural or PCA, clear oral liquids and i.v. fluids, out of bed, remove drains and Foley Transition to oral opioids or NSAIDs (limit epidural and systemic opioids), regular diet, mobilize > 8 hr, walk twice daily, remove drains and Foley POD 2 Epidural or PCA, laxative, mashed food, out of bed Remove epidural, plan discharge POD 3 Transition to oral opioids (limit epidural and systemic opioids), out of bed Oral opioids or NSAIDs, fully mobilize, discharge POD 8 Extract staples, discharge pending orders Outpatient clinic, extract staples Fast-Track Example (Colectomy) Raue et al conducted a study with 52 consecutive patients who had laparoscopic sigmoidectomy surgeries. Patients received either standardized, regular perioperative treatment or a multimodal (fast-track) rehabilitation program. The investigators measured pulmonary function, duration of POI, pain perception, fatigue, morbidity, and mortality through their postoperative course. Distinguishing features with the fast-track protocol included preoperative patient education and medication (anxiolytic, anti-emetic), prompt NG tube removal, early ambulation and mobilization, early enteral feeding, limited systemic opioids, and early planned discharge. Patients in the fast-track group (N = 23) had better forced vital capacity on postoperative day 1 (P = 0.01) [but no differences on subsequent days], earlier return to a hospital diet (P < 0.01), earlier bowel movement (P < 0.01), and earlier discharge (P < 0.001) compared with standard care patients (N = 29). Pain scores and morbidity were not different between the two patient groups. Collectively, these results suggest that a multimodal, fast-track approach can further improve upon the postoperative course for patients undergoing laparoscopic colectomy. Wind et al. conducted an analysis of 6 studies (512 patients) of randomized or clinical controlled trials in which a fast-track/multimodal perioperative approach was compared with traditional care for patients undergoing bowel resection surgery. This pooled analysis demonstrated a significant reduction in primary hospital stay (-1.56 days) and significant reduction in morbidity for the fast-track programs compared with traditional care. The need for reinsertion of NG tubes, time until first bowel movement, and time to tolerance of solid food were reduced for patients in the fast-track groups compared with traditional care. Readmission rates between the two approaches were not significantly different. Raue W, Haase O, Junghans T, Scharfenberg M, Müller J, Schwenk W. “Fast-track” multimodal rehabilitation program improves outcome after laparoscopic sigmoidectomy. Surg Endosc. 2004;18: Wind J, Polle S, Fung Kon Jin P, et al. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg. 2006;93: *Not all centers admit patients to the SICU under standard care SICU = surgical intensive care unit PACU = postanesthetic care unit Raue W, et al. Surg Endosc. 2004;18:

30 Prevention and treatment for POI
The establishment of multimodal care pathways, including the avoidance of mechanical bowel preparation and perioperative fluid overload, the use of epidural analgesia and individually optimized perioperative fluid regimens, together with preoperative carbohydrate loading, early mobilization and reintroduction of oral fluids and diet,maybe associated with a significant reduction in the incidence of postoperative ileus [18] in the absence of complications such as intra-abdominal infection and anastomotic leakage. Evidence from randomized controlled trials of individual components of enhanced recovery programmes suggest that the key elements of the enhanced recovery programme that hasten the postoperative recovery of gastrointestinal function are the use of epidural analgesia [19]and avoidance of excessive perioperative fluid, sodium and chloride administration [20]. Interestingly, the evidence that laparoscopic surgery per se reduces ileus, when undertaken within a conventional postoperative management pathway, is inconclusive [21]. Other techniques which have been recently studied with a view to promoting the rapid return of postoperative intestinal activity include the use of chewing gum [22], and µ opioid receptor anatagonists [23,24], whereas other agents that may show future promise in prevention or treatment of paralytic ileus include motilin analogues [25].

31 Type II intestinal failure

32 Type II intestinal failure
Type II intestinal failure is a serious condition 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. In contrast to type I intestinal failure, which generally requires little more than careful conservative management with high-quality nutritional support and exclusion of correctable underlying causes, type II intestinal failure is a serious condition with a considerable associated mortality and a predominantly surgical cause [4].

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

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

37 The Prompt Diagnosis And Treatment Of Abdominal Sepsis
(the most important) 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 wherever early diagnosis of a potentially ischaemic intestine or by adopting a careful surgical approach aiming to prevent adhesions and avoid technical errors that may lead to intra-abdominal sepsis or fistula development. The most important single aspect of any therapeutic strategy in the management of patients with type II intestinal failure is thus prompt diagnosis and treatment of abdominal sepsis. Inadequately treated abdominal sepsis was recognized as the most common cause of death in patients with intestinal fistulas almost 30 years ago [28], and a recent review of more than 400 patients with type II intestinal failure associated with intestinal fistulation has shown that little has changed, with patients with type II intestinal failure who present with sepsis being almost 30 times as likely to die as patients who present without sepsis [29]. Inadequately treated abdominal sepsis was recognized as the most common cause of death in patients with intestinal fistulas almost 30 years ago [28], Management of sepsis associated with type II intestinal failure involves adequate radiological localization, usually by contrast-enhanced computed tomography (which, in experienced hands, has a diagnostic accuracy of more than 97% [30]) and percutaneous drainage whenever possible, thus avoiding the ‘second hit’ associated with a difficult further laparotomy in a patient who is usually already critically ill. Percutaneous drainage may be impractical, impossible, or ineffective in certain circumstances, notably in patients with multiple abscess between intestinal loops, or when abdominal sepsis is associated with complete anastomotic discontinuity, and in those patients early laparotomy should be considered. Surgical treatment early in the management of type II intestinal failure will usually involve prompt exteriorization of fistulating intestine or at the very least, a proximal defunctioning stoma and effective drainage of a focus of sepsis. In such patients, age, severity of acute illness and therapeutic delay beyond 48 h have significant negative prognostic implications [31]. Whereas failure to improve after apparent source control is also a significant negative prognostic factor [32], and has previously led some to suggest that patients with severe abdominal sepsis should be repeatedly taken back to theatre for planned relaparotomy until no focus of sepsis can be shown to remain within the abdomen, this strategy has proved controversial [33] 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 The Prompt Diagnosis And Treatment Of Abdominal Sepsis
(the most important) Classical signs; pyrexia(may be absent when?),leukocytosis, & cachexia, hypoalbuminaemia and abnormalities in liver function. Cultures & Swabs (other sites ?!) Adequate radiological localization (US , CT) 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 wherever early diagnosis of a potentially ischaemic intestine or by adopting a careful surgical approach aiming to prevent adhesions and avoid technical errors that may lead to intra-abdominal sepsis or fistula development. The most important single aspect of any therapeutic strategy in the management of patients with type II intestinal failure is thus prompt diagnosis and treatment of abdominal sepsis. Inadequately treated abdominal sepsis was recognized as the most common cause of death in patients with intestinal fistulas almost 30 years ago [28], and a recent review of more than 400 patients with type II intestinal failure associated with intestinal fistulation has shown that little has changed, with patients with type II intestinal failure who present with sepsis being almost 30 times as likely to die as patients who present without sepsis [29]. Inadequately treated abdominal sepsis was recognized as the most common cause of death in patients with intestinal fistulas almost 30 years ago [28], Management of sepsis associated with type II intestinal failure involves adequate radiological localization, usually by contrast-enhanced computed tomography (which, in experienced hands, has a diagnostic accuracy of more than 97% [30]) and percutaneous drainage whenever possible, thus avoiding the ‘second hit’ associated with a difficult further laparotomy in a patient who is usually already critically ill. Percutaneous drainage may be impractical, impossible, or ineffective in certain circumstances, notably in patients with multiple abscess between intestinal loops, or when abdominal sepsis is associated with complete anastomotic discontinuity, and in those patients early laparotomy should be considered. Surgical treatment early in the management of type II intestinal failure will usually involve prompt exteriorization of fistulating intestine or at the very least, a proximal defunctioning stoma and effective drainage of a focus of sepsis. In such patients, age, severity of acute illness and therapeutic delay beyond 48 h have significant negative prognostic implications [31]. Whereas failure to improve after apparent source control is also a significant negative prognostic factor [32], and has previously led some to suggest that patients with severe abdominal sepsis should be repeatedly taken back to theatre for planned relaparotomy until no focus of sepsis can be shown to remain within the abdomen, this strategy has proved controversial [33]

39 The Prompt Diagnosis And Treatment Of Abdominal Sepsis
(the most important) Antibiotic therapy, guided by results of aspirate culture, Surgical treatment (multiple interloop abscesses, a high-output enteric fistula feeding the cavity, marked lack of intestinal continuity or obstruction distally, or extensive anastamotic breakdown) In cases of recurrent severe abdominal sepsis, adequate source control may necessitate management of the patient with an open abdomen (laparostomy) Indications include extensive abdominal contamination, combined with an inability to defunction fistulating intestine with a proximal stoma because of the severity of abdominal adhesions. In such cases, attempts to resect fistulating intestine may lead to injury to otherwise normal intestine, resulting in extensive enterectomy and type III intestinal failure. Loss of normal intestine following management of abdominal septic complications in this manner has, in fact, been shown to be the most common cause of type III intestinal failure in Crohn’s disease

40

41 Effective Nutritional Support
Nutritional intervention should be considered whenever; ● Starvation for longer than 5 days is expected or has occurred, whether as a result of impaired intake or gastrointestinal disease. ● The underlying disease has led to an increase in nutritional requirements beyond that which can be provided by a ‘normal diet’. ● Nutritional depletion already existed prior to the onset of acute gastrointestinal failure. . Developments in techniques for combining stoma care and enteral feeding have, however, recently allowed effective enteral feeding (‘fistuloclysis’) in selected patients with high-output intestinal fistulation [49,50], by combining drainage of intestinal effluent and infusion of enteral feed, with or without reinfusion of chyme, in selected patients with type II intestinal failure, and either proximal stomas or in whom there is enterocutaneous continuity at the site of fistulation. Whereas these techniques are certainly better tolerated and less costly than parenteral nutrition, they are not simple to undertake, may not be applicable to patients with a very high fistula or stoma output and long-term comparative data on clinical efficacy are currently unavailable.

42 Effective Nutritional Support
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. . Developments in techniques for combining stoma care and enteral feeding have, however, recently allowed effective enteral feeding (‘fistuloclysis’) in selected patients with high-output intestinal fistulation [49,50], by combining drainage of intestinal effluent and infusion of enteral feed, with or without reinfusion of chyme, in selected patients with type II intestinal failure, and either proximal stomas or in whom there is enterocutaneous continuity at the site of fistulation. Whereas these techniques are certainly better tolerated and less costly than parenteral nutrition, they are not simple to undertake, may not be applicable to patients with a very high fistula or stoma output and long-term comparative data on clinical efficacy are currently unavailable.

43 Effective Nutritional Support
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. . Developments in techniques for combining stoma care and enteral feeding have, however, recently allowed effective enteral feeding (‘fistuloclysis’) in selected patients with high-output intestinal fistulation [49,50], by combining drainage of intestinal effluent and infusion of enteral feed, with or without reinfusion of chyme, in selected patients with type II intestinal failure, and either proximal stomas or in whom there is enterocutaneous continuity at the site of fistulation. Whereas these techniques are certainly better tolerated and less costly than parenteral nutrition, they are not simple to undertake, may not be applicable to patients with a very high fistula or stoma output and long-term comparative data on clinical efficacy are currently unavailable.

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 . . Developments in techniques for combining stoma care and enteral feeding have, however, recently allowed effective enteral feeding (‘fistuloclysis’) in selected patients with high-output intestinal fistulation [49,50], by combining drainage of intestinal effluent and infusion of enteral feed, with or without reinfusion of chyme, in selected patients with type II intestinal failure, and either proximal stomas or in whom there is enterocutaneous continuity at the site of fistulation. Whereas these techniques are certainly better tolerated and less costly than parenteral nutrition, they are not simple to undertake, may not be applicable to patients with a very high fistula or stoma output and long-term comparative data on clinical efficacy are currently unavailable.

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. . Developments in techniques for combining stoma care and enteral feeding have, however, recently allowed effective enteral feeding (‘fistuloclysis’) in selected patients with high-output intestinal fistulation [49,50], by combining drainage of intestinal effluent and infusion of enteral feed, with or without reinfusion of chyme, in selected patients with type II intestinal failure, and either proximal stomas or in whom there is enterocutaneous continuity at the site of fistulation. Whereas these techniques are certainly better tolerated and less costly than parenteral nutrition, they are not simple to undertake, may not be applicable to patients with a very high fistula or stoma output and long-term comparative data on clinical efficacy are currently unavailable.

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), . Developments in techniques for combining stoma care and enteral feeding have, however, recently allowed effective enteral feeding (‘fistuloclysis’) in selected patients with high-output intestinal fistulation [49,50], by combining drainage of intestinal effluent and infusion of enteral feed, with or without reinfusion of chyme, in selected patients with type II intestinal failure, and either proximal stomas or in whom there is enterocutaneous continuity at the site of fistulation. Whereas these techniques are certainly better tolerated and less costly than parenteral nutrition, they are not simple to undertake, may not be applicable to patients with a very high fistula or stoma output and long-term comparative data on clinical efficacy are currently unavailable.

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 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. . Developments in techniques for combining stoma care and enteral feeding have, however, recently allowed effective enteral feeding (‘fistuloclysis’) in selected patients with high-output intestinal fistulation [49,50], by combining drainage of intestinal effluent and infusion of enteral feed, with or without reinfusion of chyme, in selected patients with type II intestinal failure, and either proximal stomas or in whom there is enterocutaneous continuity at the site of fistulation. Whereas these techniques are certainly better tolerated and less costly than parenteral nutrition, they are not simple to undertake, may not be applicable to patients with a very high fistula or stoma output and long-term comparative data on clinical efficacy are currently unavailable. Irrespective of the route chosen for venous access, a strict aseptic technique is essential

48 Multidisciplinary team
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 Medical management of Underlying disease.
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 The ‘Sepsis-Nutrition-Anatomy-Plan’ approach to the management of intestinal failure
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 The ‘Sepsis-Nutrition-Anatomy-Plan’ approach to the management of intestinal failure
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 The case 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

53 1. Postoperative ileus can result from:
Opioids Parsympathetic stimulation Excessive intraoperative fluids Excessive manipulations intraoperatively

54 2. Postoperative ileus can be prevented & treated by:
Early NG tube removal Open surgery Chewing gums Early ambulation

55 3. Pharmacological treatment of postoperative ileus:
Erythromycin metoclopramide Methylnaltrexone Fentanyl

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

57

58


Download ppt "Acute intestinal failure"

Similar presentations


Ads by Google