Nutrition

Nutrition – General Principles

Trauma and serious illness imply extraordinary strains on the body that generate an absolute requirement for adequate nutrient supply so that the body is not catabolic and the disease is prolonged or aggravated. Nutrition in anesthesia and intensive care forms a basic part of medical treatment that can be categorized in enteral (via the intestines) and parenteral nutrition (via the blood). Complete intravenous nutrition is commonly called Total Parenteral Nutrition (TPN).

Enteral nutrition (EN) should always be firts-choice and it should be given to all ICU patients who are not expected to be taking a full oral diet within three days. It should have begun during the first 24 h using a standard high-protein formula. During the acute and initial phases of critical illness an exogenous energy supply in excess of 20–25 kcal/kg BW/day should be avoided, whereas, during recovery, the aim should be to provide values of 25–30 total kcal/kg BW/day. Supplementary parenteral nutrition remains a reserve tool and should be given only to those patients who do not reach their target nutrient intake on EN alone. There is no general indication for immune-modulating formulae in patients with severe illness or sepsis and an APACHE II Score > 15. Glutamine should be supplemented in patients suffering from burns or trauma.

The human body needs supplemental carbohydrates, fat, proteins, minerals, trace elements and vitamins. In TPN, solutions of a fat emulsion, a carbohydrate solution and an amino acid solution are usually given. Parenteral nutritional solutions are usually based on egg, soya or peanut proteins and a fat emulsion. Fat emulsions are based on soybean oil, corn oil and egg phospholipids. Additionally, electrolytes are added to daily necessities, vitamines, such as Soluvit and Vitalipid and trace elements, such as Tracel. This add-on is often shortened as “SVT”. Contraindications on parenteral nutrition may be egg, soya or peanut allergy or severe liver failure, hyperlipidemia and severe coagulation disorders. If the plasma from the patient treated with TPN, is milky or opalescent, the planned infusion should be discontinued.

Any acute disease induces a catabolic phase in the human body followed by a prolonged anabolic phase upon recovery. Severe disease involves increased energy metabolism and oxygen consumption. It also means increased gluconeogenesis, lipolysis and fat oxidation. In addition, retention of water and sodium in the extracellular space occurs with edema as a result. Increased protein breakdown with loss of muscle mass and increased nitrogen loss in urine, decreased glutamate content and reduced protein synthesis in skeletal and musculature. Edema produces poorer organ function, risk of breathing failure, impaired protein synthesis and poorer cellular function with failure of vital enzymes. Follow daily TPN fluid balance with weighing the patient at least three days a week as well as a clinical assessment of the patient’s nutritional status (SGA class). The patient can be categorized as well- nourished, somewhat undernourished or very malnourished. Subjective Global Assessment of Nutritional Status is called SGA classification and divides the patient into 3 categories, SGA Class A, B or C (well- nourished, somewhat undernourished or very malnourished).

The basic energy requirement is 25-30 kcal/kg/day, which corresponds to approximately 90 kJ/kg/day. The need for glucose is about 150-200 g/day. The need for fat is about 1-2 g/kg/day, usually 50-200 g/day. The need for nitrogen is 0.15-0.20 g/kg and day, 7-20 g N per day with a body weight of 45-100 kg. In severe catabolic conditions, the need for nitrogen is 0.20-0.25 g nitrogen/kg/day. Basal fluid requirement is approximately 30 ml/kg/day. A healthy adult has a daily need of water of about 1500-2500 ml. The basal need for electrolytes is approximately 80 mmol sodium, 40 mmol potassium, 20 mmol magnesium and 20 mmol phosphate per day.

Nutritional Risc ScoreTotal Score: 0-7 p
Score:0 points1 points2 points3 points
Age:< 70 years: >=70 years:
The patient's current nutritional status*:Normal BMI, food intake and nutritional statusSome of the following: Weight loss> 5% last 3 months, Dietary intake <50-75% last v, BMI <22.5Weight Loss> 5% last 2 months, food intake <25-60% last v, BMI <20.5Weight Loss> 5% last 1 month, food intake <0-25% last v, BMI <18.5
Severity of the disease **:HealthyAcute-on-chronic disease in the heart, lungs, liver, hemodialysis etc, hip fractureMajor abdominal surgery, stroke, pneumonia, malignancyCritical disease
*) NOTE! To simplify, NRS is automatically calculated based on BMI. If the pat meets a higher score according to criteria for weight loss or food intake, this should be taken into account.
**) INTENSIVE CARE PATIENTS always get 3 p in the calculation.

Increased body temperature increases the energy requirement by about 10% per degree of temperature increase. The need for energy supply to intensive care patients can be calculated by means of indirect calorimetry or by using a standardized nutritional supplement, see guidance in this chapter. In hyperglycemia, insulin is given according to a particular schedule; the energy supply is usually not reduced. A B-glucose is sought between 5-9 mmol/L. Parenteral nutrition solutions should not be given at a rate greater than 2-3 ml/kg/hour. The amount of intravenously administered fat should not normally exceed 3 g/kg body weight and day (150-300 g/d). The highest recommended infusion rate is 1.6 ml/min, which corresponds to an infusion time of at least 5 hours for 500 ml TPN.

In parenteral nutrition, daily temperature should be monitored as well as a total fluid balance and B-glucose. Nitrogen balance can be calculated as needed by following urine in urine and serum. Check at least once a week S-Albumin, S-Phosphate, S-Mg, S-Zn, liver enzymes, S-Creatinine, S-Nitrogen, and S-Triglycerides.

If possible, enteral nutrition should be used as early as possible in treatment taking into account the risk retention of gastric contents (gastroparesis), vomiting, aspiration, intestinal paralysis, ileus and aggravation of the patient’s condition. Enteral nutrition should be chosen before parenteral nutrition whenever possible. Enteral nutrients typically yield 1 kcal/ml in energy value. If stomach and bowel need to be relieved by a nasogastric cannula, it is better for parenteral nutrition to be delivered intravenously. Initially, only carbohydrate rich sugar solutions are given, while delivery of fat and proteins can last for 5-7 days.

When parenteral nutrition is to be initiated, scientific evidence is controversial. An old practice says that if the patient will not be able to support himself within seven days, you should start parenteral nutrition within 3 to 7 days. New findings say that in that case one should rather wait for seven days while a common practice is to start with parenteral nutrition on the third day and during day one and two only provide glucose solutions. A common procedure is to use a combination of moderate enteral nutrition plus parenteral support (glucose).



Parenteral Nutritional Solutions

Parenteral Solutions - Energy Content and Electrolytes

Solution for InfusionEnergy content (kcal)Sodium (mmol/l)Potassium (mmol/l)Chlorides (mmol/l)Acetate (mmol/l)
Glucose 5% (50 mg/ml)2000000
Glucose 10% (100 mg/ml)4000000
Glucose 20% (200 mg/ml)8000000
Glucose 5 % with sodium and potassium (50 mg/ml)2004020601
Glucose 10 % with sodium and potassium (100 mg/ml)4004020601
Glucose 2,5 % buffered (25 mg/ml)1007004525
Glucose 5 % buffered (50 mg/ml)2007004525
Intralipid 200 mg/ml2000/1000 ml----
Intralipid 300 mg/ml3000/1000 ml----
Kabiven 1026 ml90032244639
Kabiven 1540 ml140048367058
Kabiven 2053 ml190064489378
Kabiven 2566 ml2300806011697
Nutriflex Lipid Peri 1250 ml99550304840
Nutriflex Lipid Plus 1250 ml126550354545
Nutriflex Lipid Special 1250 ml147550306060
Oliclinomel N4-550E 1000 ml65021163330
Oliclinomel N4-550E 1500 ml91032245046
Oliclinomel N4-550E 2000 ml121542326661
Oliclinomel N4-550E 2500 ml152053408376
Oliclinomel N5-800E 1000 ml91532244449
Oliclinomel N5-800E 1500 ml137048366674
Oliclinomel N5-800E 2000 ml182564488898
Oliclinomel N5-800E 2500 ml22808060110122
Oliclinomel N6-900E 1000 ml101532244653
Oliclinomel N6-900E 1500 ml152548366979
Oliclinomel N6-900E 2000 ml2030644892106
Oliclinomel N6-900E 2500 ml25408060115132
Oliclinomel N7-1000E 1000 ml120032244857
Oliclinomel N7-1000E 1500 ml180048367286
Oliclinomel N7-1000E 2000 ml2400644896114
Oliclinomel N7-1000E 2500 ml30008060120143
Omegaven1120----
Rehydrex with glucose 2,5 % (25 mg/ml)1007004525
SMOF Kabiven 493 ml55020151852
SMOF Kabiven 986 ml1100403035104
SMOF Kabiven 1477 ml1600604552157
SMOF Kabiven 1970 ml2200806070209
SMOF Kabiven 2463 ml27001007489261
SMOF Kabiven Perifer 1206 ml80030232779
SMOF Kabiven Perifer 1448 ml100036283296
SMOF Kabiven Perifer 1904 ml1300483642125
StructoKabiven 986 ml1100403035104
StructoKabiven 1477 ml1600604572157
StructoKabiven 1970 ml2100806070209
Structolipid 200 mg/ml 250/500 ml1960/1000 ml0-1500-150--
Vamin 14 g/N/l35000-90
Vamin 18 g/N/l46000-110
Vamin-Glucose g/N/l6500-1500-150--
Vaminolac240----
Parenteral Nutrition Solutions - Energy and Nitrogen Content, Amino Acids, Glucose and Lipids
Solution for InfusionEnergy value (kcal)Nitrogen (g)Amino Acids (g)Glucose (g)Lipids (g)
Intralipid 200 mg/ml2000/1000 ml---100 g/500 ml
Intralipid 300 mg/ml3000/1000 ml---150 g/500 ml
Glavamin54022,4134--
Kabiven 1026 ml9005,43410040
Kabiven 1540 ml14008,15115060
Kabiven 2053 ml190010,86820080
Kabiven 2566 ml230013,585250100
Nutriflex Lipid Peri 1250 ml9955,7408050
Nutriflex Lipid Plus 1250 ml12656,84815050
Nutriflex Lipid Special 1250 ml14751071,818050
Oliclinomel N4-550E 1000 ml6503,6228020
Oliclinomel N4-550E 1500 ml9105,43312030
Oliclinomel N4-550E 2000 ml12157,34416040
Oliclinomel N4-550E 2500 ml15209,15520050
Oliclinomel N5-800E 1000 ml9154,62810040
Oliclinomel N5-800E 1500 ml13706,94215060
Oliclinomel N5-800E 2000 ml18259,25620080
Oliclinomel N5-800E 2500 ml228011,670250100
Oliclinomel N6-900E 1000 ml10155,63412040
Oliclinomel N6-900E 1500 ml15258,45118060
Oliclinomel N6-900E 2000 ml203011,26824080
Oliclinomel N6-900E 2500 ml254014,085300100
Oliclinomel N7-1000E 1000 ml12006,64016040
Oliclinomel N7-1000E 1500 ml18009,96024060
Oliclinomel N7-1000E 2000 ml240013,28032080
Oliclinomel N7-1000E 2500 ml300016,5100400100
Omegaven1120----
SMOF Kabiven 493 ml5504256319
SMOF Kabiven 986 ml110085012538
SMOF Kabiven 1477 ml1600127518756
SMOF Kabiven 1970 ml22001610025075
SMOF Kabiven 2463 ml27002012531394
SMOF Kabiven Perifer 1206 ml8006,2388534
SMOF Kabiven Perifer 1448 ml10007,44610341
SMOF Kabiven Perifer 1904 ml13009,86013554
StructoKabiven 986 ml110085012538
StructoKabiven 1477 ml1600127518756
StructoKabiven 1970 ml21001610025075
Structolipid 200 mg/ml 250/500 ml1960/1000 ml---200
Vamin 14 g/N/l35013,585--
Vamin 18 g/N/l46018114--
Vamin-Glucose g/N/l6509,470,2100-
Vaminolac240-65,3--


Suggestions of Parenteral Nutrition

Suggestions for parenteral nutrition to a lightweight adult person (40-60 kg) with varying nutritional status.
Days after hospitalizationWell-nourishedSomewhat malnourishedStrongly malnourished
Day 1Glucose 5 % 1500 mlGlucose 5 % 1500 mlGlucose 10 % 1500 ml
Day 2Glucose 10 % 1500 mlSMOF Kabiven 986 ml (1100 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Nutriflex Lipid Peri 1250 ml (955 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Oliclinomel N5-800E 1000 ml (915 kcal) + Glucose 5 % 1000 ml (200 kcal)
SMOF Kabiven 986 ml (1100 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Nutriflex Lipid Peri 1250 ml (955 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Oliclinomel N5-800E 1000 ml (915 kcal) + Glucose 5 % 1000 ml (200 kcal)
Day 3 and thereafterSMOF Kabiven 986 ml (1100 kcal) alt.

Nutriflex Lipid Peri 1250 ml (955 kcal) alt.

Oliclinomel N5-800E 1000 ml (915 kcal)
SMOF Kabiven 986 ml (1100 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Nutriflex Lipid Peri 1250 ml (955 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Oliclinomel N5-800E 1000 ml (915 kcal) + Glucose 5 % 1000 ml (200 kcal)
SMOF Kabiven 986 ml (1100 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Nutriflex Lipid Peri 1250 ml (955 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Oliclinomel N5-800E 1000 ml (915 kcal) + Glucose 5 % 1000 ml (200 kcal)
Suggestions for Parenteral Nutrition to a Normal Weighted Adult (60-80 kg) at varying Nutritional Status
Days after hospitalizationWell-nourishedSomewhat malnourishedStrongly malnourished
Day 1Glucose 5 % 2000 mlGlucose 5 % 2000 mlGlucose 10 % 2000 ml
Day 2Glucose 10 % 2000 mlSMOF Kabiven 1477 ml (1600 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Nutriflex Lipid Peri 1875 ml (1435 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Oliclinomel N6-900E 1500 ml (1525 kcal) + Glucose 5 % 1000 ml (200 kcal)
SMOF Kabiven 1477 ml (1600 kcal) + Glucose 10 % 1000 ml (400 kcal) alt.

Nutriflex Lipid Peri 1875 ml (1435 kcal) + Glucose 10 % 1000 ml (400 kcal) alt.

Oliclinomel N6-900E 1500 ml (1525 kcal) + Glucose 10 % 1000 ml (400 kcal)
Day 3 and thereafterSMOF Kabiven 986 ml (1100 kcal) alt.

Nutriflex Lipid Plus 1250 ml (1265 kcal) alt.

Oliclinomel N5-800E 1500 ml (1370 kcal) alt.
SMOF Kabiven 1477 ml (1600 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Nutriflex Lipid Peri 1875 ml (1435 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Oliclinomel N6-900E 1500 ml (1525 kcal) + Glucose 5 % 1000 ml (200 kcal)
SMOF Kabiven 1477 ml (1600 kcal) + Glucose 10 % 1000 ml (400 kcal) alt.

Nutriflex Lipid Peri 1875 ml (1435 kcal) + Glucose 10 % 1000 ml (400 kcal) alt.

Oliclinomel N6-900E 1500 ml (1525 kcal) + Glucose 10 % 1000 ml (400 kcal)
Suggestions for parenteral nutrition to a heavy-weight adult person (> 80 kg) at varying nutritional status.
Day after hospitalizationWell-nourishedSomewhat malnourishedStrongly malnourished
Day 1Glucose 5 % 2500 mlGlucose 5 % 2500 mlGlucose 10 % 2500 ml
Day 2Glucose 10 % 2500 mlSMOF Kabiven 1477 ml (1600 kcal) + Glucose 10 % 1000 ml (400 kcal) alt.

Nutriflex Lipid Peri 2500 ml (1910 kcal) + Glucose 10 % 1000 ml (400 kcal) alt.

Oliclinomel N5-800E 2000 ml (1825 kcal) + Glucose 10 % 1000 ml (400 kcal)
SMOF Kabiven 1970 ml (2200 kcal) + Glucose 10 % 1500 ml (600 kcal) alt.

Nutriflex Lipid Peri 2500 ml (1910 kcal) + Glucose 10 % 1500 ml (600 kcal) alt.

Oliclinomel N6-900E 2000 ml (2030 kcal) + Glucose 10 % 1500 ml (600 kcal)
Day 3 and thereafterSMOF Kabiven 1477 ml (1600 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Nutriflex Lipid Peri 2500 ml (1910 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Oliclinomel N5-800E 2000 ml (1825 kcal) + Glucose 5 % 1000 ml (200 kcal)
SMOF Kabiven 1477 ml (1600 kcal) + Glucose 10 % 1000 ml (400 kcal) alt.

Nutriflex Lipid Peri 2500 ml (1910 kcal) + Glucose 10 % 1000 ml (400 kcal) alt.

Oliclinomel N5-800E 2000 ml (1825 kcal) + Glucose 10 % 1000 ml (400 kcal)
SMOF Kabiven 1970 ml (2200 kcal) + Glucose 10 % 1500 ml (600 kcal) alt.

Nutriflex Lipid Peri 2500 ml (1910 kcal) + Glucose 10 % 1500 ml (600 kcal) alt.

Oliclinomel N6-900E 2000 ml (2030 kcal) + Glucose 10 % 1500 ml (600 kcal)

Enteral Nutritional Solutions

Enteral Nutrition - Energy Value and Content of Protein, Glucose and Lipids of Different Solutions
Solution for Enteral NutritionEnergy value/100 ml (kcal)Protein (g)Lipids (g)Carbohydrates (g)
Impact Enteral1015,62,813,4
Isosource Energy1576,16,219,3
Isosource Energy Fiber1606,16,219,3
Isosource Standard Fiber1033,93,413,5
Isosource MCT1013,92,216,5
Isosource Mix1094,43,714
Isosource Protein1306,74,416
Isosource Protein Fibre1336,74,416
Isosource Standard1003,93,413,5
Novasource Diabet1034,63,812
Novasource Diabet Plus12065,312
Novasource GI Control1104,13,514,5
Nutrison Pre50226,2
Nutrison Multi Fibre10043,912,3
Nutrison Standard10043,912,3
Nutrison Energy15065,818,4
Nutrison Energy Multi Fibre15065,818,4
Nutrison Low Energy Multi Fibre7532,99,3
Nutrison Protein Plus1256,34,914,2
Nutrison Protein Plus Multi Fibre1256,34,914,2
Nutrison Soya10043,912,3
Fresubin Original1003,83,413,8
Fresubin Original Fibre1003,83,413
Fresubin Energy1505,65,818,8
Fresubin Energy Fibre1505,65,818,8
Fresubin HP Energy1507,55,817
Fresubin 2 kcal HP/Fibre200101017,5
Fresubin Soya Fibre1003,83,612,1
Fresubin 1000 complete1005,52,712,5
Fresubin 1200 complete12064,16

Suggestions of Enteral Nutrition

Suggested enteral nutrition for a lightweight adult (40-60 kg) with varying nutritional status.
Days after hospitalizationWell-nourishedSomewhat malnourishedStrongly malnourished
Day 1Tube feeding 25 ml/h 600 ml/day + Glucose 5 % 1000 mlTube feeding 25 ml/h 600 ml/day + Glucose 10 % 1000 mlTube feeding 25 ml/t 600 ml/day + Glucose 5 % 1000 ml
Day 2Tube feeding 40 ml/h 1000 ml/day + Glucose 10 % 500 mlTube feeding 40 ml/h 1000 ml/day + Glucose 10 % 500 mlTube feeding 30 ml/t 800 ml/day + Glucose 5 % 1000 ml
Day 3 and thereafterTube feeding 60 ml/h 1500 ml/day Tube feeding 60 ml/h 1500 ml/day Tube feeding 50 ml/t 1200 ml/day
Suggested enteral nutrition for a normal weighted adult (60-80 kg) with varying nutritional status
Days after hospitalizationWell-nourishedSomewhat malnourishedStrongly malnourished
Day 1Tube feeding 25 ml/h 600 ml/day + Glucose 5 % 1500 mlTube feeding 25 ml/h 600 ml/day + Glucose 10 % 1500 mlTube feeding 25 ml/h 600 ml/day + Glucose 10 % 1500 ml
Day 2Tube feeding 40 ml/h 1000 ml/day + Glucose 10 % 1000 mlTube feeding 40 ml/h 1000 ml/day + Glucose 10 % 1000 mlTube feeding 40 ml/h 1000 ml/day + Nutriflex Lipid Peri 1250 ml (955 kcal)
Day 3 and thereafterTube feeding 80 ml/h 2000 ml/day Tube feeding 80 ml/h 2000 ml/day Tube feeding 80 ml/h 2000 ml/day
Suggestions for enteral nutrition to a heavy-weight adult (> 80 kg) with varying nutritional status.
Days after hospitalizationWell-nourishedSomewhat malnourishedStrongly malnourished
Day 1Tube feeding 25 ml/h 600 ml/day + Glucose 5 % 2000 mlTube feeding 25 ml/h 600 ml/day + Glucose 10 % 2000 mlTube feeding 25 ml/h 600 ml/day + Glucose 10 % 2000 ml
Day 2Tube feeding 60 ml/h 1500 ml/day + Glucose 10 % 1000 mlTube feeding 60 ml/h 1500 ml/day + Glucose 10 % 1000 mlTube feeding 60 ml/h 1500 ml/day + Nutriflex Lipid Peri 1250 ml (955 kcal)
Day 3 and thereafterTube feeding 100 ml/h 2400 ml/day Tube feeding 100 ml/h 2400 ml/day Tube feeding 100 ml/h 2400 ml/day

Nutritional Beverages

Nutritional beverages for oral use. Energy value and content of protein, glucose and lipids
Solution for oral/enteral nutritionEnergy value/100 ml (kcal)Protein content (g)Lipid content (g)Carbohydrates (g)
Impact Enteral1015,62,813,4
Isosource Energy1576,16,219,3
Isosource Energy Fiber1606,16,219,3
Isosource Standard Fiber1033,93,413,5
Isosource MCT1013,92,216,5
Isosource Mix1094,43,714
Isosource Protein1306,74,416
Isosource Protein Fibre1336,74,416
Isosource Standard1003,93,413,5
Novasource Diabet1034,63,812
Novasource Diabet Plus12065,312
Novasource GI Control1104,13,514,5
Nutrison Pre50226,2
Nutrison Multi Fibre10043,912,3
Nutrison Standard10043,912,3
Nutrison Energy15065,818,4
Nutrison Energy Multi Fibre15065,818,4
Nutrison Low Energy Multi Fibre7532,99,3
Nutrison Protein Plus1256,34,914,2
Nutrison Protein Plus Multi Fibre1256,34,914,2
Nutrison Soya10043,912,3
Fresubin Original1003,83,413,8
Fresubin Original Fibre1003,83,413
Fresubin Energy1505,65,818,8
Fresubin Energy Fibre1505,65,818,8
Fresubin HP Energy1507,55,817
Fresubin 2 kcal HP/Fibre200101017,5
Fresubin Soya Fibre1003,83,612,1
Fresubin 1000 Complete1005,52,712,5
Fresubin 1200 Complete12064,16

Obstipation

Gastrointestinal Motility Stimulants

Movicol

Dosage bags – contains a dose granulate (Macrogol) that inhibits constipation. Movicol is a laxative for temporary treatment of constipation in adults, adolescents and elderly people. It is not recommended for children under 12 years of age. The time of treatment with Movicol for occasional constipation is usually approximately 2 weeks.

Dosage: 1 dose bag dissolved in 125 ml (1/2 glass) water is given 1-3 times daily depending on the severity of constipation. For the treatment of fecaloma you may need to give up to 8 dose bags of Movicol per day. Each bag of bag is dissolved in 125 ml (1/2 glass) of water. The 8 dosage bags should be taken within 6 hours for up to 3 days if necessary. Movicol is also available in a ready-to-drink oral solution.

Metoclopramid (Primperan)

Injection solution, 5 mg/ml.

Dosage: 2 ml (10 mg) x 2-3 i.v. (possible dose reduction in renal failure).

  • Promotes gastric emptying
  • Counteracts dopamine’s inhibitory effect on motor skills
  • Sensitizes the intestine to acetylcholine
  • Increases sphincter tone in cardia
  • Risk of interaction with other medicines
  • High doses may cause extrapyramidal side effects

 

Naloxone Hydrochloride

Oral ex tempore preparation 1 mg/ml.

Dosage: 5-8 ml x 3 in a nasogastric tube can be tested if the above has not given the intended effect in concomitant opioid treatment.

  • Counteracts the opioid’s inhibitory effect on gastrointestinal motility by blocking the opioid effect on intestinal receptors
  • Reduces the risk of nosocomial pneumonia
  • Naloxone is resorbed from the gastrointestinal tract, but is metabolized in the liver
  • Should not be given in case of severe liver failure. May cause systemic effects with opioid antagonism due to impaired hepatic metabolism

Sodium picosulfate monohydrate (Laxoberal®) drops

Oral drops, solution 7.5 mg/ml, 10-20 drops (5-10 mg) per day) 2 days after start of enteral nutrition, 10-20 drops are given at 22

Bisakodyl (Dulcolax®)

Suppositories (10 mg) or tablets (5 mg) (Bisakodyl) 10 mg in the morning after the onset of enteral nutrition. Can be repeated daily until results are achieved.

On day seven, a clyx (rectal solution 1 mg/ml + 250 mg/ml) may also be required, and start with 30 ml x 1 of Laktulos (oral solution 670 mg/ml).

If no faeces occur in 10-12 days, consider oil enema. Mix 300 ml of oil into 700 ml of lukewarm water. Begin with the patient on the left side, give 1/3 of the enema, then give 1/3 in back position and 1/3 on the right side. Do not give laxation to spinal cord injured patients or in suspicion of obstructive intestinal injury. Take care with SAB with spasm risk.

Other gastrointestinal motility stimulants:

  • Dulcolax®, tablets 5 mg
  • Pursennid® Ex-Lax, coated tablet 12 mg, 20 pieces in blister pack
  • Microlax® Rectall Solution, 12 x 5 milliliters Tub
  • Inolaxol® Granules in a bag, 50 pieces of bags.
  • Resource Active, ready-to-use solution for oral use with prunes 200 ml
  • Vi-Siblin® Granulate, 610 mg/g 500 grams in bag
  • Lunelax® Powder, for oral suspension, dispense 100-piece sachets.
  • Resulax® (Sorbitol), rectangular solution 8.5 g 4 pieces in tub.
  • Fruit & fiber tablets, dietary fiber 30 pcs.
  • Duphalac® oral solution, 670 mg/ml in 1000 ml bottle
  • Laxido Orange Powder, for oral solution, 20 dose bags.
  • Relaxit® Suppository, 20 pieces in blister pack
  • DulcoSoft (macrogol) bag bags, 20 pcs. 4000
  • Cabbage plums are found in the pharmacy as a drinkable juice that can be given to counteract obstipation. A package corresponds to about 15 prunes. Dosage from 7 years: a 200 ml pack is given per day in case of temporary complaints.

Prophylaxis of Gastric Ulcer

By Oscar Cavefors, Resident.

Department of Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg.

Serious gastrointestinal haemorrhage (GI bleeding) has been reported in scientific studies in 1.5-8.5% of intensive care patients and in some studies has been shown to be related to increased mortality1. In recent studies, the risk of gastrointestinal haemorrhage appears to be lower, probably due to generally better intensive care or better ulcer prophylaxis2.

Gastric ulcer can occur in all critically ill patients within hours due to severe stress, serious injury, surgery, shock or infection. Ulcerations may vary between erosive gastritis to perforated ulcer, they are usually superficial, with less capillary bleeding, but may erode into the submucosa and become more profound. Underlying vessels may be damaged and cause bleeding, or in rare cases perforation of the mucosa. Ulcerations are probably due to an imbalance between protective mucous membrane and acid production in the stomach.

The mucous membrane contains glycoproteins, which provide physical protection, but also bind bicarbonate which neutralizes the acid in the stomach. In many intensive care patients, the function of the mucous layer is impaired due to impaired bleeding. Reflux of bile and unreacted toxins can damage the mucous membrane3.

Acid production in the stomach is increased in head injury patients, but probably not in other intensive care patients4. Helicobacter pylori infection can be a contributing factor to gastric ulcer5.

Gastric ulcer is most common in fundus and corpus ventriculi, but may also occur in other parts of the gastrointestinal tract such as duodenum and distal esophagus6.

In a larger prospective multicenter study, a significantly increased risk of gastric ulcer was observed in patients treated for 48 hours in a ventilator and/or coagulopathy, compared to other intensive care patients7. There are also studies indicating an increased risk in other serious conditions such as head injury, shock, sepsis, liver and kidney failure, trauma, major burns, organ transplants, previous upper gastrointestinal bleeding and high SOFA scores8-13.

Enteral nutrition, by itself, has a protective effect by buffering the stomach acid, increasing mucosal blood flow and inducing cytoprotective prostaglandines and mucous secretion15.

Gastric Ulcer Prophylaxis

In order to reduce the risk of developing ulcer, pharmacological prophylaxis is usually used in intensive care patients, either parenterally or orally. The three types of drugs that are mainly used for prophylaxis are proton pump inhibitors (PPIs), histamine-2 receptor blockers or sucralfat. Which patients who will receive pharmacological prophylaxis and the effect of prophylaxis are not fully understood. Indications for prophylaxis and drug selection vary between countries. Scientific support for routine administration of ulcer prophylaxis in all intensive care patients is lacking. Recent studies have shown doubtful effects of prophylaxis with PPI19, but have not been shown to cause any major damage.

Currently, pharmacological ulcer prophylaxis is recommended in patients with:

  • Time on a ventilator over 48 hours
  • Coagulopathy (TPC <50, PK/INR> 1.5x reference value, APTT > 2x reference value)
  • Gastrointestinal bleeding in recent years
  • Traumatic brain injury, traumatic spinal injury or major burns
  • Two of the following parameters: sepsis, intensive care longer than 1 week, occult gastrointestinal bleeding > 6 days, cortisone treatment (> 250 mg hydrocortisone/day)

For other patients, an individual decision can be made taken into account the patient’s risk factors.

Choice of prophylaxis can be based on local routines, but oral medication should be used if the patient tolerates this.

Enteral nutrition is probably protective and should be initiated early, but today there is not enough knowledge to prevent an ulcer if belonging to a risk group despite enteral nutrition.

Ulcus prophylaxis should be evaluated and terminated when the patient no longer belongs to any risk group or when the intensive care ceases.

The three drug types used for prophylaxis are proton pump inhibitors (PPIs), histamine-2 receptor blockers and sucralfate. It seems that PPI is more effective than H2 blockers to prevent gastric ulcer 20,21, however, there are some studies showing the opposite 22. The choice of drugs often depends on local routines, but proton pump inhibitors appear to be more commonly used (in Sweden) more than other Brands. Sucralfate provides less protection against stress ulcer, but possibly even lower risk of nosocomial pneumonia.

However, it is uncertain whether one can wait for pharmacological prophylaxis despite ongoing enteral nutrition 16,17. One study has shown that H2 blockers in enterally nutrient patients actually led to increased mortality 18.

Risks

Ulcus prophylaxis leads to a higher pH in the stomach that allows bacterial growth in the gastrointestinal tract. Via reflux, these bacteria are swallowed where they can then be aspirated into the airways which can result in a pneumonia, a so-called ventilator-associated pneumonia (VAP). There may be an increased risk of VAP when treating patients with prophylaxis against gastric ulcer. This risk may be greater with PPI than sucralfate and H2 receptor blockers 23. There is also an increased risk of clostridum difficile gastroenteritis due to the increased pH in the stomach 24.

Drugs for Gastric Ulcer

Proton pump inhibitors

These drugs are substituted benzimidazoles that reduce the secretion of hydrochloric acid through a specific blockade of the parietal cell proton pumps. Usually, omeprazole, esomeprazole or pantoprazole are given. The drugs have an equivalent effect. The drugs are converted into active form in the acidic environment of the parietal cells, where they inhibit the H +/K + -ATPase enzyme, that is, the last step in hydrochloric acid production in the stomach. This inhibits the basal and stimulant hydrochloric acid secretion of the stomach and is independent of stimulatory systems such as acetylcholine, histamine and gastrin 25. Omeprazole, like any acid-blocking drug, may reduce the absorption of vitamin B12 (cyanocobalamin) due to hypo- or achlorhydri. Another side effect may be hypomagnesaemia.

Omeprazole

Proton pump inhibitors. Available as enterocapsules and enterotablets.

Omeprazole is a racemate of two enantiomers that specifically inhibit the acid pump in the parietal cell. It provides a rapid insertion effect and the effect on acid secretion is reversible in daily administration.

Omeprazole is a weak base that is concentrated and converted into active form in the very acidic environment of the parietal cell secretory channels, where it inhibits the enzyme H + K + -ATPas acid pump. The effect of the last step in the acid secretion process is dose dependent and provides a very effective inhibition of both basal and stimulated acid secretion, regardless of the type of stimulation.

Brand names: Omeprazol®, Losec®, Omecat®, Omestad®, Omezomyl®.

Standard dose: 20-40 mg p.o. x 1.

Dosage in bleeding ulcer: 40 mg x 2

Cave: Possible dose adjustment in pregnant liver failure, possible clinical interaction with clopidogrel (decreased effect), interaction with certain HIV drugs, azoles.

Esomeprazole

Proton pump inhibitor, the S-isomer of omeprazole. Available for intravenous and oral use. Fully metabolised via P450, mainly CYP2C19. Can be used during pregnancy.

Brand names: Esomeprazol®, Nexium®, Vimovo®.

Standard dose: 40 mg i.v. x 1; 20-40 mg p o x 1 granules or enterotablets. Bleeding ulcer: 40 mg i.v. x 2

Cave: Possible dose adjustment in pregnant liver failure, possible clinical interaction with clopidogrel (decreased effect), interaction with certain HIV drugs, azoles.

Pantoprazole

Proton pump inhibitors. Available for intravenous and oral use. Basically complete hepatic metabolism via P-450, predominantly CYP2C19.

Brand names: Pantoprazol®, Pantoloc®.

Standard dose: 40 mg i.v. x1; 20-40 mg p.o. x 1 as enterotablett

Dosage in bleeding ulcer: 40 mg i.v. x 2

Cave: Possible dose adjustment in pregnant liver failure, interaction with certain HIV drugs, rifampicin and St. John’s wort.

 

Histamine-2 receptor blockers (H2 blockers)

H2 receptor blockers are chemically substituted aminoalcyl furans which competitively block the effect of histamine on H2 receptors. This leads to decreased activation of parietal cells and inhibits basal as well as stimulated acid secretion. Tachyphylaxi, however, occurs over time, with reduced effect on the stomach pH. The most common preparation is ranitidine. H2 receptor blockers are secreted mainly via the kidneys, probably via active secretion.

Brand names: Ranitidin®, Inside Brus®, Rani-Q®, Stomacid®, Zantac®, Zantac Brus®.

Standard dose: 50 mg i.v. x 3 alt. 150 mg p.o. x 2 as a tablet or oral solution. If S-Krea> 200 μmol/l, CRRT, IHD is given lower dose: 25 mg i.v. x 3 alt. 150 mg p.o. x 1.

Cave: Risk of bradycardia with rapid infusion, possibly. Dose adjustment in pregnant liver failure

 

Sucralfate

Sucralfate is an alkaline and contains aluminum saccharose sulfate. It binds to the mucous membrane and provides mechanical protection as well as stimulation of mucous membrane factors that increase its resistance to harmful agents. Preferred 30 minutes before food intake.

Brand name: Andapsin®. Available as a tablet of Andapsin 1 g or oral suspension 200 mg/ml.

Standard dose: 1 g (5 ml) x 4

Cave: Affects the absorption of other drugs in the gastrointestinal tract, risk of defecation

 

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