Indian Journal of Critical Care Medicine

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2020 | September | Volume 24 | Issue S4

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Sachin Gupta

The Seventh Organ—Gastrointestinal Tract: Neglect at Your Own Peril!

[Year:2020] [Month:September] [Volume:24] [Number:S4] [Pages:3] [Pages No:S143 - S145]

   DOI: 10.5005/jp-journals-10071-23639  |  Open Access | 



Gastrointestinal Tract: A Neglected Guardian Angel?

[Year:2020] [Month:September] [Volume:24] [Number:S4] [Pages:6] [Pages No:S146 - S151]

   DOI: 10.5005/jp-journals-10071-23616  |  Open Access | 


Role of the gastrointestinal (GI) system is not limited to the digestion of food and absorption of water and nutrients. Gastrointestinal mucosa forms a barrier preventing translocation of microbes into the blood. Upper GI tract performs important function of swallowing and prevention of aspiration, failure of which mandates enteral tube feeding. Rate of gastric emptying depends on gastric volume and contents and delayed emptying is observed both in solid and in fatty food. Cricoid pressure during intubation is an important intervention for prevention of aspiration in critically ill patients who are considered as full stomach. To utilize mucosal barrier function optimally, hemodynamically stable patients should preferably receive enteral nutrition even if they are on small doses of vasopressors. Post-pyloric feeds may reduce risk of aspiration and hence are recommended for patients who are deemed to have high risk for aspiration. Bowel sounds have poor reproducibility, sensitivity, specificity, accuracy, and interobserver agreement, and absent bowel sounds should not be considered as a contraindication to enteral feeding.



Shiva K Narayan, Kiran K Gudivada

Assessment of Nutritional Status in the Critically Ill

[Year:2020] [Month:September] [Volume:24] [Number:S4] [Pages:5] [Pages No:S152 - S156]

   DOI: 10.5005/jp-journals-10071-23617  |  Open Access | 



Ischemic Gut in Critically Ill (Mesenteric Ischemia and Nonocclusive Mesenteric Ischemia)

[Year:2020] [Month:September] [Volume:24] [Number:S4] [Pages:5] [Pages No:S157 - S161]

Keywords: Computed tomographic angiography, Damage control surgery, Mesenteric ischemia

   DOI: 10.5005/jp-journals-10071-23611  |  Open Access | 


Ischemic gut or splanchnic hypoperfusion is a life-threatening emergency and it is associated with high mortality. It requires prompt diagnosis and intervention to establish the mesenteric blood flow, hence an attempt to avoid gut necrosis. Despite the understanding of pathogenesis of acute mesenteric ischemia and advanced treatment and revascularization techniques, it still remains a big diagnostic dilemma for the clinicians. Any delay in diagnosis and appropriate treatment affects the overall outcome of the patient. The high incidence of sepsis and multiorgan failure requires high-quality intensive care management.



Anindya Kishore Debnath

Clostridium difficile and Antibiotic-associated Diarrhea

[Year:2020] [Month:September] [Volume:24] [Number:S4] [Pages:6] [Pages No:S162 - S167]

Keywords: Antibiotic, Clostridium difficile infection, Diarrhea

   DOI: 10.5005/jp-journals-10071-23619  |  Open Access | 



Shweta R Chandankhede

Acute Intestinal Failure

[Year:2020] [Month:September] [Volume:24] [Number:S4] [Pages:7] [Pages No:S168 - S174]

Keywords: Acute intestinal failure, Critically ill, Enteral feeding, Intra-abdominal pressure, Multiorgan dysfunction syndrome, Parenteral nutrition, Short bowel syndrome

   DOI: 10.5005/jp-journals-10071-23618  |  Open Access | 


Acute intestinal failure (AIF), “reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, requiring parenteral nutrition”, is common, but very often neglected part of multiorgan dysfunction syndrome (MODS) in the critically ill patients. It is now increasingly being recognized as a cause of prolonged ICU and hospital stay and poor outcome. Multidisciplinary team approach, systematic approach to management with treatment of sepsis, early mobilization and enteral feeding with prokinetics if required, control of intra-abdominal pressure and surgical intervention, when mandated, can help treat AIF and improve patient outcomes.



Gastrointestinal Stomas and Fistulas: What is Lost and What to Do?

[Year:2020] [Month:September] [Volume:24] [Number:S4] [Pages:4] [Pages No:S175 - S178]

Keywords: Enteral nutrition, Enterocutaneous fistula, Parenteral nutrition, Sepsis, Surgical stomas

   DOI: 10.5005/jp-journals-10071-23620  |  Open Access | 


Abnormal connections between gastrointestinal tract (GIT) and skin are called enterocutaneous fistulas (ECFs). Presence of ECF is associated with significant morbidity and mortality. A stoma refers to a surgically created opening in the abdomen to divert feces or urine to the outside of the body, to compensate for partial or complete loss of bowel function. Gastrointestinal (GI) stomas and postoperative ECFs present a unique challenge to the intensivist due to development of malnutrition, dehydration, and sepsis leading to high morbidity and mortality. This review focuses on the basic concepts about the type of fistula and stomas, their indications and complications, and management. Principles of clinical management include replacement of fluid and electrolyte losses, control of sepsis along with reducing fistula output, prevention of malnutrition and psychological support, and skin care.



Gastrointestinal Motility Disorders in Critically Ill

[Year:2020] [Month:September] [Volume:24] [Number:S4] [Pages:4] [Pages No:S179 - S182]

Keywords: Gastroparesis, Ileus, Intensive care, Motility disorder, Pseudo-obstruction

   DOI: 10.5005/jp-journals-10071-23614  |  Open Access | 


Gastrointestinal (GI) motility disorders are a common problem in the intensive care unit (ICU) and are associated with increased morbidity, complications like feeding intolerance, malnutrition, bacterial translocation, sepsis, multiple organ failure, prolonged hospital stay and increased risk of mortality. Several risk factors in intensive care setting that contribute to GI dysmotility include mechanical ventilation, vasopressor support, use of opioids, etc. Degree of GI motility dysfunction correlates with severity of critical illness. So, it is important to identify the dysfunction early so that targeted therapy could be prescribed to prevent worsening of clinical outcomes.



Emergency Laparotomies: Causes, Pathophysiology, and Outcomes

[Year:2020] [Month:September] [Volume:24] [Number:S4] [Pages:7] [Pages No:S183 - S189]

Keywords: Emergency laparotomy, Perioperative care, Perioperative mortality, Quality improvement

   DOI: 10.5005/jp-journals-10071-23612  |  Open Access | 


Emergency laparotomies have remained a challenging entity since many decades. Only during the past 10 years, serious efforts have been made to improve their outcome by conducting audits and designing care pathways. Indications for emergency laparotomies can be broadly classified into trauma and non-trauma surgeries, which are either done for control of hemorrhage or/and done for control of sepsis and organ dysfunction. Goal-directed resuscitation for septic/hemorrhagic shock, consultant-led multidisciplinary teams, and timely transfer to intensive care units form core principles of management for these patients. Global inequity in access to standard and affordable emergency surgeries is an area of concern requiring integrated efforts at international level.



Gastrointestinal Manifestations of Systemic Diseases in Critically Ill

[Year:2020] [Month:September] [Volume:24] [Number:S4] [Pages:3] [Pages No:S190 - S192]

Keywords: Acute liver failure, Acute pancreatitis, COVID-19, Dengue

   DOI: 10.5005/jp-journals-10071-23610  |  Open Access | 


Systemic disorders can have gastrointestinal (GI) manifestations which are characterized by nausea, vomiting, diarrhea, constipation, abdominal pain, jaundice, and abnormal liver function tests. These gastrointestinal symptoms can be signs of various immunologic, infectious, and endocrine diseases. Gastrointestinal manifestations can be the first signs and symptoms for which the patient can be admitted in a critical care unit. In this article, we will discuss the GI manifestations of various topical diseases, endocrine diseases, and immunological diseases which are the major bulk of patients in intensive care unit (ICU).



Udit Dhingra

Open Abdomen in a Critically Ill Patient

[Year:2020] [Month:September] [Volume:24] [Number:S4] [Pages:8] [Pages No:S193 - S200]

Keywords: Abdominal compartment syndrome, Enteroatmospheric fistula, Negative pressure wound therapy, Open abdomen, Peritoneal sepsis, Primary or temporary abdominal closure

   DOI: 10.5005/jp-journals-10071-23613  |  Open Access | 


One of the damage control strategies used to avoid or treat abdominal compartment syndrome is “open abdomen (OA),” where the facial edges and the skin is left open, exposing the abdominal viscera. Although it reduces the mortality both in trauma and non-trauma abdominal complications, it does create a significant challenge in an intensive care setting, as it has physiological consequences that need early recognition and prompt treatment both in the intensive care unit and in the operating room. The article aims to review literature on “open abdomen,” describe the challenges in such cases, and proposes a guideline for the intensivist in managing a patient with an OA.



Praveen Khilnani, Nidhi Rawal

Gastrointestinal Issues in Critically Ill Children

[Year:2020] [Month:September] [Volume:24] [Number:S4] [Pages:4] [Pages No:S201 - S204]

Keywords: Constipation, Critically ill children, Dysmotility, Feeding intolerance, Gastrointestinal bleeding

   DOI: 10.5005/jp-journals-10071-23637  |  Open Access | 


Due to lack of uniform diagnostic criteria, gastrointestinal (GI) complications in critically ill occur with variable frequency,1 and overall incidence of such complications seems to be less in children compared to adults. Major risk factors are use of catecholamines, sedatives, and muscle relaxants in patients with shock. GI dysmotility in critically ill patients is the main reason behind abdominal distension, increased gastric residual volume, and constipation. GI bleeding is described in about 10% of patients with critical illness with about 1.6% have clinically significant bleeding, particularly in patients with coagulopathy, respiratory failure, or PRISM scores >10.2 In this review, the most common GI issues encountered in children will be discussed as mentioned earlier. In addition management of acute GI bleeding will also be discussed.



Martin Thomas, Riddhi Joshi, Manish Bhandare

Complications after Supramajor Gastrointestinal Surgery: Role of Enhanced Recovery after Surgery

[Year:2020] [Month:September] [Volume:24] [Number:S4] [Pages:6] [Pages No:S205 - S210]

Keywords: Acute kidney injury, Anastomotic leak, Catheter-associated urinary tract infection, Enhanced recovery after surgery, Epidural analgesia, Gastrointestinal surgery, Pancreatic fistula, Perioperative medicine, Postoperative complications, Surgical site infection

   DOI: 10.5005/jp-journals-10071-23615  |  Open Access | 


Background: Enhanced recovery after surgery (ERAS) is currently the standard of care in perioperative medicine, but it is widely underutilized in our healthcare setting because of the lack of awareness of benefits exerted by ERAS and its components. ERAS is a multidisciplinary collaboration, where intensivists play an important role in the implementation of the protocol during the perioperative period. Aim: This review article aims to appraise the role of ERAS pathway on complications following supramajor gastrointestinal surgery. Review: A summary and review of evidence was conducted on the role of ERAS and its elements on non-specific and surgery-specific complications. Enhanced recovery pathways (ERPs) and its elements were directly found to be associated with lower incidence of hospital-associated infections, postoperative ileus, and postoperative pulmonary complications. Although there are no specific elements of ERPs found to have beneficial effect in preventing major adverse cardiac and cerebrovascular events, and surgery-specific complications such as postoperative pancreatic fistula, delayed gastric emptying, post-pancreatectomy hemorrhage, post-hepatic liver failure, bile, and anastomotic leak, studies have demonstrated that implementation of an ERP bundle can decrease the incidence of these complications. Implementation of an ERP was associated with an increase in the incidence of acute kidney injury with minor elevations in creatinine that returned to baseline before discharge. Conclusion: Although there is ample evidence that ERAS is beneficial in reducing complications and hospital stay following supramajor gastrointestinal surgery, there is scope for further research to unravel the role of ERAS on patient-reported outcomes.



Balaji Venkatachalam, Babu Kuruvilla Abraham

Should We Fiddle with Gut Microbiome in Critically Ill?

[Year:2020] [Month:September] [Volume:24] [Number:S4] [Pages:4] [Pages No:S211 - S214]

Keywords: Dysbiosis, Fecal microbial transplantation, Gut–lung axis, Microbiome, Pathobiome, Probiotics, Synbiotics

   DOI: 10.5005/jp-journals-10071-23627  |  Open Access | 


The gut that we took for granted in the critically ill, as just a conduit for food passage has over the decade or so shown us that it is an active endocrine and exocrine organ with over 40 trillion microorganisms living commensally within it. This cosmos of microorganisms that is called the gut microbiome comprises roughly 1,000 different species and put together is more DNA than the entire human genome. Under normal circumstances, in a healthy individual multiple elements of the gut viz intestinal epithelium, gut barrier function, the microbiomes, all put together offer protection against infection and this is crucial in maintenance of health. Any change to the norm, be it in the form of surgical interventions, the introduction of medications, or the pathophysiological effects of systemic disease leads to a 360° alteration in this finely construed ecosystem leading to devastating effects that go beyond the boundaries of the gut itself. Intestinal epithelium helps to absorb nutrients as well as acts as the coordinator of mucosal immunity (first line of immune defense). During ill health, gut epithelial apoptosis occurs, alterations happen in the tight epithelial junctions leading to loss of gut barrier function and loss of the mucosal immunity leading to mucosal damage and hyperpermeability. Lastly, the microbiome is transformed into a pathobiome, with resultant increase in pathogenic bacteria and induction of virulence in commensal gut bacteria. Multiple organ damage starts to set in, caused by toxins leaving the intestine via both portal blood flow and mesenteric lymph. This review article traces the gut microbiomic ecology in health and sickness, modern tools that are used to manipulate gut microbiome in the search for the prevention and treatment of critical illness and will explore if appropriate manipulation of gut microbiome can influence or modulate the course of critical illness.



Critical Analysis of a Randomized Controlled Trial

[Year:2020] [Month:September] [Volume:24] [Number:S4] [Pages:8] [Pages No:S215 - S222]

Keywords: Critical analysis, Evidence based medicine, Randomized control trial

   DOI: 10.5005/jp-journals-10071-23638  |  Open Access | 


In the era of evidence-based medicine, healthcare professionals are bombarded with plenty of trials and articles of which randomized control trial is considered as the epitome of all in terms of level of evidence. It is very crucial to learn the skill of balancing knowledge of randomized control trial and to avoid misinterpretation of trial result in clinical practice. There are various methods and steps to critically appraise the randomized control trial, but those are overly complex to interpret. There should be more simplified and pragmatic approach for analysis of randomized controlled trial. In this article, we like to summarize few of the practical points under 5 headings: “5 ‘Rs’ of critical analysis of randomized control trial” which encompass Right Question, Right Population, Right Study Design, Right Data, and Right Interpretation. This article gives us insight that analysis of randomized control trial should not only based on statistical findings or results but also on systematically reviewing its core question, relevant population selection, robustness of study design, and right interpretation of outcome.


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