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Randomized Controlled Trial
. 2022 Apr;48(4):458-466.
doi: 10.1007/s00134-022-06637-w. Epub 2022 Feb 22.

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

Gaël Piton  1   2 , Amélie Le Gouge  3   4 , Julie Boisramé-Helms  5   6 , Nadia Anguel  7 , Laurent Argaud  8 , Pierre Asfar  9 , Vlad Botoc  10 , Anne Bretagnol  11 , Laurent Brisard  12 , Hoang-Nam Bui  13 , Emmanuel Canet  14   15 , Delphine Chatelier  16 , Louis Chauvelot  17 , Michael Darmon  18 , Vincent Das  19 , Jérôme Devaquet  20 , Michel Djibré  21 , Frédérique Ganster  22 , Maité Garrouste-Orgeas  23 , Stéphane Gaudry  24 , Olivier Gontier  25 , Samuel Groyer  26 , Bertrand Guidet  27   28 , Jean-Etienne Herbrecht  29 , Yannick Hourmant  30 , Jean-Claude Lacherade  31 , Philippe Letocart  32 , Frédéric Martino  33 , Virginie Maxime  34   35 , Emmanuelle Mercier  36 , Jean-Paul Mira  37 , Saad Nseir  38   39 , Jean-Pierre Quenot  40   41   42 , Jack Richecoeur  43 , Jean-Philippe Rigaud  44 , Damien Roux  45 , David Schnell  46 , Carole Schwebel  47   48 , Daniel Silva  49 , Michel Sirodot  50 , Bertrand Souweine  51 , Nathalie Thieulot-Rolin  52 , François Tinturier  53 , Patrice Tirot  54 , Didier Thévenin  55 , Guillaume Thiéry  56 , Jean-Baptiste Lascarrou  14   15 , Jean Reignier  14   15 ; Clinical Research in Intensive Care and Sepsis (CRICS) group
Affiliations
Randomized Controlled Trial

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

Gaël Piton et al. Intensive Care Med. 2022 Apr.

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.

Keywords: Acute mesenteric ischemia; Critically ill; Enteral nutrition; Parenteral nutrition; Shock.

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