Nonocclusive bowel necrosis occurring in critically ill trauma patients receiving enteral nutrition manifests no reliable clinical signs for early detection

BACKGROUND: Nonocclusive bowel necrosis (NOBN) has been associated with ear ly enteral nutrition (EN). The purpose of this study was to determine the i ncidence of this complication in our trauma intensive care unit population and to define a typical patient profile vulnerable to NOBN. METHODS: Thirteen cases of NOBN were identified among 4,311 patients (0.3%) over a 64-month period ending October 1998. Their charts were analyzed for a variety of clinical data, including prospective EN tolerance data in 4. RESULTS: Twelve (92%) patients were enterally fed prior to diagnosis for 10 +/- 8 days (range 3 to 21). Tachycardia (n = 12, 92%); fever/hypothermia, (0 = 12, 92%), and an abnormal white blood cell count (0 = 11, 85%) were co nsistently present. Abdominal distention was common but tended to be a late sign (0 = 12), Seven (56%) survived. In 4 patients with tolerance data, 3 reached the goal rate of feeds prior to diagnosis. Two became distended at >12 hours from diagnosis. Gastric tonometry demonstrated a decreased NgpHi (<7.30) after starting EN in all 3 in whom it was monitored. CONCLUSIONS: NOBN developed in 0.3% of our trauma patients. Onset occurs in the second week in high-acuity patients who have had a period of EN tolera nce. Clinical findings resemble bacterial sepsis with tachycardia, fever, a nd leukocytosis. Gastrointestinal specific signs are not consistent or occu r late. Thus, we could not identify an early, useful clinical indicator. Ga stric carbon dioxide tonometry may detect a vulnerable subgroup of patients . (C) 2000 by Excerpta Medica, Inc.