Factors associated with acute mesenteric ischemia among critically ill ventilated patients with shock: a post hoc analysis of the NUTRIREA2 trial.

Abstract

PURPOSE:

Acute mesenteric ischemia (AMI) is a rare, but life-threatening condition occurring among critically ill patients. Several factors have been associated with AMI, but the causal link is debated, most studies being retrospective. Among these factors, enteral nutrition (EN) could be associated with AMI, in particular among patients with shock. We aimed to study the factors independently associated with AMI in a post hoc analysis of the NUTRIREA-2 trial including 2410 critically ill ventilated patients with shock, randomly assigned to receive EN or parenteral nutrition (PN).

METHODS:

Post hoc analysis of the NUTRIREA-2 trial was conducted. Ventilated adults with shock were randomly assigned to receive EN or PN. AMI was assessed by computed tomography, endoscopy, or laparotomy. Factors associated with AMI were studied by univariate and multivariate analysis.

RESULTS:

2410 patients from 44 French intensive care units (ICUs) were included in the study: 1202 patients in the enteral group and 1208 patients in the parenteral group. The median age was 67 [58-76] years, with 67% men, a SAPS II score of 59 [46-74], and a medical cause for ICU admission in 92.7%. AMI was diagnosed among 24 (1%) patients, mainly by computed tomography (79%) or endoscopy (38%). The mechanism of AMI was non-occlusive mesenteric ischemia (n = 12), occlusive (n = 4), and indeterminate (n = 8). The median duration between inclusion in the trial and AMI diagnosis was 4 [1-11] days. Patients with AMI were older, had a higher SAPS II score at ICU admission, had higher plasma lactate, creatinine, and ASAT concentrations and lower hemoglobin concentration, had more frequently EN, dobutamine, and CVVHDF at inclusion, developed more frequently bacteremia during ICU stay, and had higher 28-day and 90-day mortality rates compared with patients without AMI. By multivariate analysis, AMI was independently associated with EN, dobutamine use, SAPS II score ≥ 62 and hemoglobin concentration ≤ 10.9 g/dL.

CONCLUSION:

Among critically ill ventilated patients with shock, EN, dobutamine use, SAPS II score ≥ 62 and hemoglobin ≤ 10.9 g/dL were independently associated with AMI. Among critically ill ventilated patients requiring vasopressors, EN should be delayed or introduced cautiously in case of low cardiac output requiring dobutamine and/or in case of multiple organ failure with high SAPS II score.

• Authors: Gaël Piton, Amélie Le Gouge, Julie Boisramé-Helms, Nadia Anguel, Laurent Argaud, Pierre Asfar, Vlad Botoc, Anne Bretagnol, Laurent Brisard, Hoang-Nam Bui, Emmanuel Canet, Delphine Chatelier, Louis Chauvelot, Michael Darmon, Vincent Das, Jérôme Devaquet, Michel Djibré, Frédérique Ganster, Maité Garrouste-Orgeas, Stéphane Gaudry, Olivier Gontier, Samuel Groyer, Bertrand Guidet, Jean-Etienne Herbrecht, Yannick Hourmant, Jean-Claude Lacherade, Philippe Letocart, Frédéric Martino, Virginie Maxime, Emmanuelle Mercier, Jean-Paul Mira, Saad Nseir, Jean-Pierre Quenot, Jack Richecoeur, Jean-Philippe Rigaud, Damien Roux, David Schnell, Carole Schwebel, Daniel Silva, Michel Sirodot, Bertrand Souweine, Nathalie Thieulot-Rolin, François Tinturier, Patrice Tirot, Didier Thévenin, Guillaume Thiéry, Jean-Baptiste Lascarrou, Jean Reignier, Clinical Research in Intensive Care and Sepsis (CRICS) group
• Journal: Intensive care medicine (Intensive Care Med) Vol. 48 Issue 4 Pg. 458-466 (Apr 2022) ISSN: 1432-1238 [Electronic] United States
• PMID: 35190840 (Publication Type: Journal Article, Randomized Controlled Trial)
• Copyright: © 2022. Springer-Verlag GmbH Germany, part of Springer Nature.

Topics

• Adult
• Aged
• Critical Illness (therapy)
• Female
• Humans
• Intensive Care Units
• Male
• Mesenteric Ischemia (etiology, therapy)
• Parenteral Nutrition (methods)
• Respiration, Artificial (adverse effects)
• Retrospective Studies