Impact of Enteral Feeding on Vasoactive Support in Septic Shock: A Retrospective Observational Study

Abstract

Background: Introducing enteral nutrition (EN) during hemodynamic instability may induce the splanchnic steal phenomenon, which may worsen systemic oxygen delivery and increase vasopressor dose. We aimed to determine the change in vasopressor dose in septic shock patients who received concomitant EN. We hypothesize that EN delivery is not associated with worsening hemodynamic instability, as defined by an increase in vasopressor dose ≥50% at 24 hours. Methods: This is a retrospective observational cohort study of adult patients with septic shock who were admitted to the intensive care unit from January 2015 to June 2015 and received EN. Vasopressor and EN parameters were collected at 6-hour intervals for the first 24 hours. Results: Data were available for 28 consecutive patients. The mean age was 60 years (SD = 18), and 54% were females. Norepinephrine (NE) was used in 100%. EN and vasopressor overlap totaled 36 hours (interquartile range [IQR], 27-69). Median NE dose when starting EN was 5.9 μg/min (IQR, 3.88). Median change in dose from 0 to 6 hours was 0.85 μg/min (95% CI, 0.681.06; P = 0.136), corresponding to a median increase of 14.5%. Total NE duration was 60.5 hours (IQR, 47.5-75.5). No serious complications occurred. Conclusion: The median vasopressor dose did not increase by ≥50% during the first 24 hours of EN. This suggests early EN delivered during septic shock is not associated with worsening hemodynamic instability. Limitations include a small sample size and residual confounding. Prospective data are needed.

Improving nutrition practices for postoperative high‐risk heart transplant and ventricular assist device implant patients in circulatory compromise: A quality improvement pre– and post–protocol intervention outcome study

“…Given the negative effects of epinephrine on splanchnic perfusion and GI motility, 72 patients requiring significant doses of epinephrine vs norepinephrine may experience more EN‐related intolerance and complications. Patients with septic shock who were administered only norepinephrine 73,74 had significantly greater EN tolerance than our pre‐HRNSP group, which only used epinephrine. This may be due to the variances in splanchnic receptor properties between these two agents.…”

Association of Vasopressors Dose Trajectories with Enteral Nutrition Tolerance in Patients with Shock: A Prospective Observational Study

“…Current literature indicates conflicting results regarding the feasibility and safety of EN in patients with shock. Previous studies showed that the safety cut-off value of EN was likely to be less than 0.3 µg/kg/min in these patients [6][7][8][9][10][11][12][13][14]16]. NUTRIREA-2 study, a large multicenter randomized controlled trial, reported that early EN with 0.56 µg/kg/min norepinephrine infusion was associated with an increased risk of gastrointestinal adverse events in the patients with shock [26].…”

“…Numerous studies have demonstrated the feasibility and safety of EN in patients with shock; however, in clinical practices, the management of EN in these patients is still a difficult task [6][7][8][9][10][11][12][13][14][15][16]. Current guidelines offer vague and inconsistent recommendations [17][18][19][20][21][22].…”

Enteral nutrition in septic shock: A pathophysiologic conundrum

“…Second, 0 (of 269) patients developed NOBN. One retrospective study evaluating the change in vasopressor dose after EN initiation in patients with septic shock did not find a significant difference in the change in NE dose in patients receiving trophic or full‐dose EN 35 …”

“…One retrospective study evaluating the change in vasopressor dose after EN initiation in patients with septic shock did not find a significant difference in the change in NE dose in patients receiving trophic or full-dose EN. 35 Since 2011, seven RCTs with at least one EN arm have enrolled patients with circulatory shock. 22,23,[36][37][38][39][40] Two of seven trials (REDOX and NUTRIREA-2) had circulatory shock as an inclusion criteria, and nonocclusive mesenteric ischemia occurred in 0.3% and 2% in those receivingEN, respectively.…”