CC GI

Gastrointestinal (GI) and Nutrition in the ICU

Assessment of the GI System

• Health History: Chief complaint, present illness, past health, family, personal and social history.

• Abdominal Assessment

• Nutritional Assessment

Laboratory Studies

• Liver, Pancreatic Function, Basic Metabolic Panel (BMP), Complete Blood Count (CBC).

• High-Risk Lab Notes: Total Cholesterol: 248 mg/dL, Direct: 164 mg/dL, HDL: 158 mg/dL, LDL: 189 mg/dL, Triglycerides: 122 mg/dL.

Radiologic Studies

• Diagnostic Studies: Supine, Barium, Endoscopy, Paracentesis, Hemoccult/Gastroccult tests.

Disorders of the GI Tract

GI Bleed

• Upper GI Bleed

  • Possible Sources: Esophageal, gastric, or duodenal.

  • Assessment:

    • Patient History: Peptic ulcer disease (PUD), liver disease, alcohol/tobacco use, NSAID use.

    • Physical Exam: Hematemesis (vomiting blood), melena (black tarry stools), hemodynamic changes (e.g., low blood pressure), nausea, dizziness.

• Lower GI Bleed

  • Possible Sources: Tumors, polyps, ulcerative colitis (UC), Crohn’s disease, diverticulitis.

  • Assessment:

    • Patient History: Abdominal surgeries, inflammatory bowel disease (IBD), liver disease.

    • Physical Exam: Hematochezia (bright red blood in stool), hemodynamic changes.

Diagnostics for GI Bleeding

• Laboratory Studies: Hemoglobin (hgb), Hematocrit (hct), White Blood Cell (WBC) count, clotting factors, oxygen levels, lactic acid levels.

• Radiologic Studies: X-ray, CT scans.

• Endoscopy: Esophagogastroduodenoscopy (EGD), colonoscopy.

• Interventional Radiology

Management of GI Bleeding

• Continuous monitoring of vital signs and laboratory results.

• Maintain intravenous (IV) access; prepare for resuscitation.

• Medications:

  • Pantoprazole (proton pump inhibitor to reduce acid).

  • Octreotide (reduces portal pressure).

• Procedures:

  • Balloon Tamponade (using a Blakemore Tube).

  • Transjugular Intrahepatic Portosystemic Shunt (TIPS).

Balloon Tamponade

• A balloon catheter to exert direct pressure on bleeding varices for hemostasis.

• Typically has two balloons (stomach, esophagus); exerts traction to compress the gastroesophageal junction.

• Can remain inflated for 24 hours.

TIPS Procedure

• Radiologic procedure creating an intrahepatic shunt to decrease portal pressure.

• Employed when other methods for managing esophageal varices have failed.

Bowel Obstruction

• Possible Causes: Adhesions, hernias, tumors, inflammatory bowel disease (IBD), medications.

• Assessment:

  • Abdominal distention, decreased/absent bowel sounds, nausea/vomiting (N/V), constipation, abdominal pain.

• Diagnostics:

  • Laboratory Studies: CBC, BMP.

  • Radiologic Studies: X-ray, CT scans.

• Management:

  • NPO (nothing by mouth).

  • Nasogastric (NG) tube for suctioning.

  • Fluid and electrolyte repletion.

  • Potential surgical intervention.

  • Monitor for perforation.

Disorders of the Pancreas

Review of the Pancreas

• Critical role in digestive and endocrine systems.

• Exocrine Tissues: Produce digestive enzymes (e.g., amylase, lipase, trypsin).

• Endocrine Tissues: Produce hormones (e.g., insulin, glucagon).

Acute Pancreatitis

• Acute inflammation of the pancreas, potentially impacting surrounding tissues.

• Severity Levels:

  • Mild: No organ dysfunction or complications; recovery within a week.

  • Moderate: Transient organ failure or local complications.

  • Severe: Persistent organ failure $\gt$ 48 hours, resulting in pancreatic necrosis and hemorrhage.

• Possible Causes: Gallstones, alcohol use disorder, hypercalcemia, total parenteral nutrition (TPN).

Assessment of Acute Pancreatitis

• Symptoms: Abdominal pain (often severe), diffuse abdominal tenderness and guarding, Nausea/vomiting, hypoactive or absent bowel sounds, mild fever.

• Physical Signs:

  • Gray Turner sign (bruising in the flank area – indicates retroperitoneal hemorrhage).

  • Cullen sign (periumbilical bluish discoloration – sign of peritoneal hemorrhage).

  • Jaundice.

Diagnosis

• Requires $\ge$ two of three features:

  • Abdominal pain consistent with pancreatitis.

  • Serum lipase levels $\ge$ three times greater than normal.

  • Characteristic findings on radiologic studies.

• Laboratory Studies: Amylase, lipase, WBC count.

• Radiologic Studies: CT, MRI, ultrasound.

Management of Acute Pancreatitis

• Initial Treatment: Fluid and electrolyte replacement, pain management, bowel rest (NPO status), monitoring nutritional status, possible surgical intervention.

Disorders of the Liver

Functions of the Liver

• Roles: Drug metabolism, toxin removal, albumin synthesis, glucose regulation, production of clotting factors.

Hypoalbuminemia

• Definition: Abnormally low albumin level in the bloodstream.

• Consequences: Ascites (fluid accumulation in abdomen), peripheral edema (swelling).

• Mechanism: Decreased albumin leads to increased venous pressure in GI tract, causing dilation of GI veins (varices) prone to rupture and bleeding.

Varices

• Dilation of gastrointestinal veins.

• Locations: Esophagus (prone to rupture/bleeding), stomach, Caput Medusae (dilation radiating from umbilicus).

• Life-Threatening Symptoms: Hematemesis, melena, hypotension, tachycardia.

Lab Findings in Liver Dysfunction

• Elevated bilirubin.

• Accumulation of ammonia and other toxins can lead to hepatic encephalopathy (symptoms: asterixis (flapping tremor), mental status changes, potentially coma).

Cirrhosis

• Definition: Irreversible fibrotic changes to the liver leading to chronic liver dysfunction and failure.

• Pathophysiology: Inflammation, fibrosis, increased hepatic vascular resistance $\rightarrow$ portal hypertension.

• Common Causes: Chronic hepatitis C virus (HCV) infection, alcohol abuse.

• Common Assessment Findings: Fatigue, edema, loss of appetite, nausea, jaundice.

Diagnostics for Cirrhosis

• Laboratory Studies: Aspartate aminotransferase (AST), Alanine aminotransferase (ALT) levels.

• Radiologic Studies: Ultrasound, CT, MRI.

• Liver Biopsy: Definitive diagnosis.

Management of Cirrhosis

• Lifestyle Changes: Avoid alcohol, low sodium diet (for fluid retention), avoid hepatotoxic medications.

• Drug Therapy: Beta blockers (for portal hypertension), diuretics (for fluid management).

• Liver transplant (last resort).

Management in the ICU

• Nutrition Monitoring: Weight, supplemental nutrition, fluid/electrolyte balance, oxygenation, diuretics.

• Intake and Output (I&O) Monitoring: Strict recording.

• Assess Respiratory Function: Oxygenation, work of breathing.

• Monitor for Bleeding: Coagulation factors.

• Management of TIPS Procedure: Decrease ammonia levels.

• Monitoring Level of Consciousness (LOC): Early detection of hepatic encephalopathy.

• Administering Lactulose: To manage ammonia levels.

• Management of Ascites: Albumin, paracentesis.

• Monitor for Complications: Hepatorenal syndrome (kidney failure secondary to liver failure).

Nutritional Management in the ICU

• Goals: Maintain appropriate nutritional delivery to improve patient outcomes.

• Factors Influencing Malnutrition: Physiological stressors alter metabolic and energy demands.

• Labs to Monitor Nutritional Status: Pre-albumin, albumin, Hemoglobin & Hematocrit levels.

Types of Nutrition

Enteral Nutrition

• Definition: Administered directly into the gastrointestinal tract.

• Delivery Methods: Gastric or post-pyloric tubes (duodenal or jejunal).

• Types of Feeding: Continuous, bolus, intermittent.

• Management: Advance feeding rates per orders; monitor flush rates.

• Complications: Aspiration, diarrhea, intolerance, tube dislodgement/clogging, fluid and electrolyte imbalances.

Parenteral Nutrition

• Definition: Administered intravenously.

• Types:

  • Total Parenteral Nutrition (TPN): Central venous line (CVL), dedicated line.

  • Peripheral Parenteral Nutrition (PPN): Peripheral intravenous line (PIV), for $\lt$ 10-14 days.

Nursing Care for a Client Receiving Parenteral Nutrition

• Monitoring: Blood glucose levels, electrolyte balance, prevention of infection.