Дане керівництво перекладено ГО «M-Gate» під редакцією ГО «Асоціації анестезіологів України». Всі права належать Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. Список скорочень: ВАІТ-відділення анестезіології та інтенсивної терапії ГКН-гостра кишкова недостатність ІМТ-індекс маси тіла КН-кишкова недостатність КШФ-кишково-шкірні фістули ПНЖК-поліненасичені жирні кислоти ПХ-парентеральне харчування СТГ-середньоланцюгові тригліцериди ХКН-хронічна кишкова недостатність ХПАПХ-хвороба печінки, асоційована з парентеральним харчуванням ШКТ-шлунково-кишковий тракт

Background: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are increasingly recognized as aetiologies of organ failure and mortality among a wide variety of patient populations. Since the first global survey in 2007, several surveys have been conducted. However, it remains unclear to what extent healthcare professionals in clinical practice are aware of the widely accepted definitions and recommendations proposed in the World Society of the Abdominal Compartment Syndrome (WSACS) guidelines and whether these recommendations are being applied clinically. Methods:We conducted an international cross-sectional survey to determine the impact of the 2013 WSACS IAH/ACS Consensus Definitions and Clinical Management Guidelines on IAH/ACS clinical awareness and management. We also aimed to compare the results to the findings of the global survey conducted in 2007. Results:The survey had 559 respondents with most respondents being physicians from Europe, and who worked in mixed intensive care units (87.3%; n = 448). The majority of respondents (73.2%) were aware of WSACS (the Abdominal Compartment Society), with a greater percentage being aware of the WSACS guidelines compared to the 2007 survey (60.2% vs. 28.4%). A considerable proportion of respondents (18%) never measure intra-abdominal pressure (IAP), with the most common reason for not measuring IAP being reliance on physical examination (39%; n = 38). Analysis of the 11 questions related to knowledge and clinical practice of IAH, ACS and WSACS consensus definitions showed an improvement from the first survey (42.7% of questions answered correctly in comparison to 48.0% in this survey, P = 0.0001). The responses to how physicians managed IAH and ACS were different to the previous survey, with diuretics being used "usually" or "frequently" (49.2%), more than inotropes (38.6%), decompressive laparotomy (37.0%), paracentesis (36.5%), and fluids/blood products (24.2%). Most respondents would perform/request a decompressive laparotomy in cases of ACS. Polycompartment syndrome was something considered by 39% (n = 218) in their daily practice. Almost two thirds of respondents (63.5%; n = 355) thought that gastrointestinal injury should be added to the Sequential Organ Failure Assessment (SOFA) score. Conclusions:This survey shows an improvement in general awareness and knowledge regarding IAP, IAH and ACS, although the level of understanding and awareness

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Background There is a lack of population‐based studies on acute mesenteric ischemia (AMI). We have therefore performed a nationwide epidemiological study in Estonia, addressing incidence, demographics, interventions and mortality of AMI. Methods A retrospective population‐based review was conducted of all adult cases of AMI accrued from the digital Estonian Health Insurance Fund and Causes of Death Registry for 2016–2020 based on international classification of diseases (ICD‐10) diagnostic codes and procedure codes (NOMESCO). Results Overall, 577 cases of AMI were identified—an annual incidence of 8.7 per 100,000. The median age was 79 (range 32–104) and 57% were female. Predominating comorbidities included hypertensive disease (81%), atherosclerosis (67%), and atrial fibrillation (52%). The majority of cases (60%) were caused by superior mesenteric artery occlusion (thrombosis 54%, embolism 12%, and unclear 34%). Inferior mesenteric artery occlusion occurred in 7%, non‐occlusive mesenteric ischemia in 7%, venous thrombosis in 4%, whereas the type remained unclear in 21% of cases. 40% of patients received intervention (revascularization and/or intestinal resection) and 13% active non‐operative treatment. In 21% an exploratory laparotomy or laparoscopy revealed unsalvageable bowel prompting end‐of‐life care, which was the only management in a further 25% of cases. Conclusions The population‐based annual incidence of AMI in Estonia was 8.7 per 100,000 during the study period. The overall hospital mortality and 1 year mortality were 64% and 74%, respectively. In the 53% of patients who received active treatment hospital mortality was 32% and 1 year all‐cause mortality was 51%. Trial registration ClinicalTrials.gov Identifier NCT04867499.

Purpose of reviewBiomarkers proposed to provide prognosis or to determine the response to enteral nutrition have been assessed in a number of experimental and clinical studies which are summarized in the current review. Recent findingsThere are several pathophysiological mechanisms identified which could provide biomarkers to determine response to enteral nutrition. Several biomarkers have been studied, most of them insufficiently and none of them has made its way to clinical practice. Available studies have mainly assessed a simple association of a biomarker with outcomes, but are less focused on dynamic changes in the biomarker levels. Importantly, studies on pathophysiology and clinical features of gastrointestinal dysfunction, including enteral feeding intolerance, are also needed to explore the mechanisms potentially providing specific biomarkers. Not only an association of the biomarker with any adverse outcome, but also a rationale for repeated assessment to assist in treatment decisions during the course of illness is warranted. SummaryThere is no biomarker currently available to reliably provide prognosis or determine the response to enteral nutrition in clinical practice, but identification of such a biomarker would be valuable to assist in clinical decision-making.

Background: General pathophysiological mechanisms regarding associations between fluid administration and intra-abdominal hypertension (IAH) are evident, but specific effects of type, amount, and timing of fluids are less clear. Objectives: This review aims to summarize current knowledge on associations between fluid administration and intra-abdominal pressure (IAP) and fluid management in patients at risk of intra-abdominal hypertension and abdominal compartment syndrome (ACS). Methods: We performed a structured literature search from 1950 until May 2021 to identify evidence of associations between fluid management and intra-abdominal pressure not limited to any specific study or patient population. Findings were summarized based on the following information: general concepts of fluid management, physiology of fluid movement in patients with intra-abdominal hypertension, and data on associations between fluid administration and IAH. Results: We identified three randomized controlled trials (RCTs), 38 prospective observational studies, 29 retrospective studies, 18 case reports in adults, two observational studies and 10 case reports in children, and three animal studies that addressed associations between fluid administration and IAH. Associations between fluid resuscitation and IAH were confirmed in most studies. Fluid resuscitation contributes to the development of IAH. However, patients with IAH receive more fluids to manage the effect of IAH on other organ systems, thereby causing a vicious cycle. Timing and approach to de-resuscitation are of utmost importance, but clear indicators to guide this decision-making process are lacking. In selected cases, only surgical decompression of the abdomen can stop deterioration and prevent further morbidity and mortality. Conclusions: Current evidence confirms an association between fluid resuscitation and secondary IAH, but optimal fluid management strategies for patients with IAH remain controversial.

The gastrointestinal (GI) system is responsible for digestion and absorption, but also has important endocrine, immune and barrier functions. Additionally, the GI system plays a major role in fluid, electrolyte and acid-base balance. The GI system is regulated by complex myogenic, neural and humoral mechanisms, and, in health, these are affected by the presence of luminal nutrient, thereby modulating function of the GI system. Accordingly, GI function varies depending on whether a person is fasted or in the postprandial state. Adequate fasting and postprandial perfusion, motility and exocrine secretion are required for ‘normal’ functioning. The protective mechanisms of the GI system consist of physical (intact gut mucosa), non-immune (gastric acid, intestinal mucin, bile and peristalsis) and immune (gut-associated lymphoid tissue, GALT) elements. Disruption of GI protection is a putative mechanism underlying the development of multiple-organ dysfunction syndrome. Maintenance of GI function is increasingly recognised as an important factor underlying survival in critical illness.

BackgroundThis Rapid Practice Guideline provides an evidence‐based recommendation to address the question: in adults with sepsis or septic shock, should we recommend using or not using intravenous vitamin C therapy?MethodsThe panel included 21 experts from 16 countries and used a strict policy for potential financial and intellectual conflicts of interest. Methodological support was provided by the Guidelines in Intensive Care, Development, and Evaluation (GUIDE) group. Based on an updated systematic review, and the grading of recommendations, assessment, development, and evaluation approach, we evaluated the certainty of evidence and developed recommendations using the evidence‐to‐decision framework. We conducted an electronic vote, requiring >80% agreement among the panel for a recommendation to be adopted.ResultsAt longest follow‐up, 90 days, intravenous vitamin C probably does not substantially impact (relative risk 1.05, 95% confidence interval [CI] 0.94 to 1.17; absolute risk difference 1.8%, 95% CI −2.2 to 6.2; 6 trials, n = 2148, moderate certainty). Effects of vitamin C on mortality at earlier timepoints was of low or very low certainty due to risk of bias of the included studies and significant heterogeneity between study results. Few adverse events were reported with the use of vitamin C. The panel did not identify any major differences in other outcomes, including duration of mechanical ventilation, ventilator free days, hospital or intensive care unit length of stay, acute kidney injury, need for renal replacement therapy. Vitamin C may result in a slight reduction in duration of vasopressor support (MD −18.9 h, 95% CI −26.5 to −11.4; 21 trials, n = 2661, low certainty); but may not reduce sequential organ failure assessment scores (MD −0.69, 95% CI −1.55 to 0.71; 24 trials, n = 4002, low certainty). The panel judged the undesirable consequences of using IV vitamin C to probably outweigh the desirable consequences, and therefore issued a conditional recommendation against using IV vitamin C therapy in sepsis.ConclusionsThe panel suggests against use of intravenous vitamin C in adult patients with sepsis, beyond that of standard nutritional supplementation. Small and single center trials on this topic should be discouraged.