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Objective:To analyze the clinical characteristics and outcomes of critically ill pregnant and parturient women in intensive care unit (ICU), and to provide clinical experience for the subspecialty construction of critical obstetrics.Methods:The clinical data of critically ill pregnant and parturient women admitted to the department of critical care medicine, the Second Affiliated Hospital of Kunming Medical University from January 2011 to December 2019 were collected. The main reasons for maternal transfer to ICU, the causes of maternal death, and organ support measures, etc. were summarized.Results:A total of 39 567 critically ill pregnant and parturient women were admitted to the department of obstetrics in our hospital, and 360 were transferred to ICU, with an average ICU transfer rate of 0.91%. Since 2016, the number of obstetric admissions, the number of ICU transfers and the ICU transfer rate had increased significantly. The average age of severe maternals admitted to ICU was (30.9±5.7) years old. The average acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) score was 7 (4, 10). The average length of ICU stay was 1 (1, 2) day. The average ventilator duration was 9.0 (3.0, 17.5) hours. The main delivery mode of pregnant women in ICU was cesarean section (84.72%). Forty-eight patients (13.33%) underwent hysterectomy, of which 42 (87.5%) due to postpartum hemorrhage. The top 3 causes of ICU admission were severe postpartum hemorrhage [36.94% (133/360)], hypertensive disorders of pregnancy [21.67% (78/360)], pregnancy with cardiac disease [15.00% (54/360)]. The leading cause of postpartum hemorrhage in women transferred to ICU was placental abnormality [63.98% (103/161)], followed by uterine atony [28.57% (46/161)]. The average blood loss was (4 019±2 327) mL within 24 hours after delivery, and the number of women who underwent hysterectomy due to postpartum hemorrhage decreased year by year. During the study period, there were 2 maternal deaths, which were indirect obstetric deaths, 3 cases were discharged against-advice (expected death), including 1 indirect death and 2 direct obstetric death; the mortality in ICU was 1.39% (5/360).Conclusions:The most common reasons for pregnant and parturient women to be admitted to ICU were severe postpartum hemorrhage and hypertensive disorders of pregnancy. The leading cause of postpartum hemorrhage was placental problem. Indirect obstetric deaths exceeded direct obstetric deaths, mainly due to pregnancy complicated with cardiac disease and severe pneumonia. ICU has become an important battlefield for rescuing critically ill maternal and an important guarantee for reducing the maternal mortality.
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Objective:To compare and analyze the clinical characteristics between acute fatty liver of pregnancy (AFLP) and the hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome.Methods:This is a retrospective cohort study. The clinical data of 13 cases with AFLP and 34 cases with HELLP syndrome were collected from three tertiary referral centers in Yunnan (the First Affiliated Hospital of Kunming Medical University, the Second Affiliated Hospital of Kunming Medical University, and Yan'an Hospital of Kunming City) from January 2016 to December 2021. The patients were diagnosed to AFLP and HELLP syndrome according to the Swansea criteria and the Tennessee classification system. The general characteristics, clinical features, laboratory results within 24 hours after admission, complications, maternal and neonatal outcomes were compared to analysis the differences between the two groups.Results:① Maternal characteristics: compared with HELLP syndrome group, AFLP group had lower body mass index (BMI) and blood pressure at admission (both P < 0.01). ②Clinical features: the most common symptoms in AFLP patients were skin jaundice, abdominal pain, nausea and vomiting, edema. The main manifestations of patients with HELLP syndrome were albuminuria, hypertension, edema, headache. Some patients had multiple symptoms concurrently. ③ Laboratory results: compared with HELLP syndrome group, the levels of platelet count (PLT), total bilirubin (TBil), direct bilirubin (DBil), γ-glutamyl transferase (γ-GGT), alkaline phosphatase (ALP), total bile acid (TBA), serum creatinine (SCr) and international standardized ratio (INR) in AFLP group were significantly increased within 24 hours after admission [PLT (×10 9/L): 107.69±51.13 vs.76.71±43.25, TBil (μmol/L): 121.60 (83.20, 170.00) vs.15.25 (7.22, 29.05), DBil (μmol/L): 86.50 (58.60, 104.00) vs. 4.30 (2.22, 10.10), γ-GGT (U/L): 87.00 (37.00, 127.00) vs. 41.00 (19.00, 64.42), ALP (U/L): 199.10 (109.00, 349.20) vs. 125.50 (90.50, 155.25), TBA (μmol/L): 51.50 (16.20, 117.40) vs. 4.15 (2.02, 6.95), SCr (μmol/L): 155.80 (129.00, 237.00) vs. 79.00 (65.43, 113.70), INR: 1.28 (1.17, 1.63) vs. 0.94 (0.88, 1.08), all P < 0.05], prothrombin time (PT) was significantly prolonged [seconds: 16.10 (14.50, 19.20) vs. 12.40 (11.43, 13.40), P < 0.05]. The level of blood glucose (GLU), fibrinogen (FIB) and the activity of antithrombin Ⅲ (ATⅢ) decreased significantly [GLU (mmol/L): 5.18±1.33 vs. 6.33±1.19, FIB (g/L): 1.96±1.46 vs. 3.81±1.58, ATⅢ (%): 40.61±25.84 vs. 66.39±24.11, all P < 0.05]; ④ Complications: compared with HELLP syndrome group, the incidence of patients with hypoglycemia [30.77% (4/13) vs. 0% (0/34)], acute liver failure [53.85% (7/13) vs. 5.88% (2/34)], acute renal insufficiency [69.23% (9/13) vs. 8.82% (3/34)], coagulopathy [76.92% (10/13) vs. 38.24% (13/34)], disseminated intravascular coagulation (DIC) [53.85% (7/13) vs. 5.88% (2/34)], and multiple organ dysfunction syndrome (MODS) [53.85% (7/13) vs. 5.88% (2/34)] were significantly higher in AFLP group (all P < 0.05). ⑤ Maternal and neonatal outcome: all patients delivered after admission. The total length of hospital and intensive care unit stay were significantly longer in the AFLP group than in the HELLP syndrome group [days: 17.00 (11.00, 25.00) vs. 9.00 (7.00, 12.00), 12.00 (4.00, 22.00) vs. 3.91 (0, 7.00), both P < 0.01]. Two AFLP patients died, including one due to intracranial venous thrombosis and one due to multiple organ failure and cardiopulmonary arrest. There were no deaths in the HELLP syndrome group. Conclusions:There are significant differences in maternal characteristics, laboratory results and complications between AFLP and HELLP syndrome. TBil, γ-GGT, SCr, FIB, INR and ATⅢ activity may help to distinguish the two diseases.
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Pregnancy has increased susceptibility to H1N1 influenza virus infection. Maternal influenza infection is associated with increased risk of morbidity and mortality. A case of influenza A (H1N1) during late pregnancy (pregnancy 1, birth 0, pregnancy 30+2 weeks) was admitted to the Second Affiliated Hospital of Kunming Medical University on December 16th, 2018. The patient was set on mechanical ventilation with a FiO2 of 1.0, a positive end-expiratory pressure (PEEP) of 15 cmH2O (1 cmH2O = 0.098 kPa), and a tidal volume of 4-6 mL/kg (ideal body weight). However the pulse oxygen saturation (SpO2) could only be maintained at about 0.85. The disease was controlled by the treatments of anti-infection, mechanical ventilation, immune therapy, nutritional support, preventive anticoagulant treatment by heparin sodium, adequate negative fluid balance, and other organ support therapy. This article introduced the treatment process of the patient in detail, and provided experience for clinical treatment.
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Pregnancy has increased susceptibility to H1N1 influenza virus infection. Maternal influenza infection is associated with increased risk of morbidity and mortality. A case of influenza A (H1N1) during late pregnancy (pregnancy 1, birth 0, pregnancy 30+2 weeks) was admitted to the Second Affiliated Hospital of Kunming Medical University on December 16th, 2018. The patient was set on mechanical ventilation with a FiO2 of 1.0, a positive end-expiratory pressure (PEEP) of 15 cmH2O (1 cmH2O = 0.098 kPa), and a tidal volume of 4-6 mL/kg (ideal body weight). However the pulse oxygen saturation (SpO2) could only be maintained at about 0.85. The disease was controlled by the treatments of anti-infection, mechanical ventilation, immune therapy, nutritional support, preventive anticoagulant treatment by heparin sodium, adequate negative fluid balance, and other organ support therapy. This article introduced the treatment process of the patient in detail, and provided experience for clinical treatment.
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Objective To observe the effects of different doses of tranexamic acid (TXA) on bleeding volume and safety for patients undergoing simple scoliosis corrective operation. Methods A retrospective study was conducted, 58 patients who had undergone simple scoliosis orthopaedic operation admitted to the Second Affiliated Hospital of Kunming Medical University from January 2016 to December 2017 were enrolled, and they were divided into a high TXA dose group (100 mg/kg load dose and then maintaining dose 10 mg·kg-1·h-1, 32 cases) and a low TXA dose group (10 mg/kg load dose and then maintaining dose 1 mg·kg-1·h-1, 26 cases) according to the different TXA dosages used in the operation. The clinical data of intra-operative blood loss volume, intra-operative bleeding ratio, intra-operative volume of blood transfusion, wound drainage volume on the postoperative first day, blood transfusion percentage, postoperative continual use of TXA situation, the levels of creatinine (SCr), D-dimer, sequential organ failure assessment (SOFA) score, etc. on the day before operation and on the first day after operation were collected, and the postoperative and 28-day post-discharge complications in the two groups were analyzed. Results There were no statistical significant differences in intra-operative blood loss volume (mL: 467.2±362.0 vs. 445.0±255.9), bleeding ratio [(16.9±11.7)% vs. (19.0±10.6) %], intra-operative blood transfusion (mL: 421.90±94.80 vs. 561.90±111.06), wound drainage volume on the postoperative first day (mL: 287.3±163.0 vs. 325.2±155.5), blood transfusion percentage [9.4% (3/32) vs. 3.8% (1/26)] and proportion of continual use of TXA [37.5% (12/32) vs. 57.7% (15/26)] between high dose TXA group and small dose TXA group (all P > 0.05). After operation, the SOFA scores of the two groups were significantly higher than those before operation (high dose TXA group: 2.22±1.31 vs. 0.47±0.11, low dose TXA group: 2.85±1.49 vs. 0.35±0.09), but there was no statistical significant difference between the two groups (P > 0.05). No statistical significant difference in the level of SCr before and after operation in high dose TXA group was seen (μmol/L: 52.0±15.7 vs. 50.6±13.5, P > 0.05); the postoperative SCr level was significantly higher than that before operation in low dose TXA group (μmol/L: 51.3±13.5 vs. 46.2±15.0, P < 0.05), but there was no statistical significant difference in SCr level between the two groups after treatment (P > 0.05). The proportions of patients with D-dimer =0 mg/L and < 0.19 mg/L in high dose TXA group were higher than those in low dose TXA group [21.9% (7/32) vs. 15.4% (4/26) and 12.5% (4/32) vs. 0 (0/26), respectively], but there was no significant difference between the two groups (P > 0.05). No complications such as kidney injury, deep vein thrombosis, pulmonary embolism, epilepsy, etc were found in either group. Conclusions There were no significant differences between the use of high-dose and low-dose TXA in the reduction of intra-operative and postoperative bleeding volume and transfusion volume in patients undergoing simple scoliosis corrective operation. Therefore, the low dose TXA is recommended to be used in such procedure.
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Objective To investigate high risk factors of intensive care unit-acquired weakness (ICUAW) in patients with sepsis. Methods A retrospective study was conducted. 164 patients with mechanical ventilation (MV) who were diagnosed sepsis and multiple organ dysfunction syndrome (MODS), admitted to intensive care unit (ICU) of the Second Affiliated Hospital of Kunming Medical University from January 1st, 2015 to September 30th, 2017 were enrolled. The general situation, the basic diseases (hypertension, diabetes), body mass index (BMI), protopathy diseases, the level of albumin before ICU admission, the MV time, whether to use glucocorticoid and continuous renal replacement therapy (CRRT) or not, nutrition supply (nutritional way, nutrition initiation time, amino acid/protein supply, nutritional status on ICU 3 days and 7 days), myoglobin, the length of ICU stay, the length of hospital stay, and acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ) score were collected. The high risk factors of ICUAW in patients with sepsis complicated with MODS were analyzed further using multi-factor Logistic regression analysis. Multiple linear regression analysis was used to analyze the myoglobin related factors in sepsis patients. Results The ICUAW incidence was 25.6% (42/164). The risk factors with differences in univariate analysis were included in the multivariate Logistic regression analysis, and it was shown that the level of albumin before ICU [odds ratio (OR) = 0.232, 95% confidence interval (95%CI) = 0.061-0.885, P = 0.032], the MV time (OR = 0.380,95%CI = 0.154-0.935, P = 0.035), nutrition initiation time (OR = 2.642, 95%CI = 1.100-6.346, P = 0.030), myoglobin (OR = 4.129, 95%CI = 1.681-10.142, P =0.002) were the independent risk factors for ICUAW in sepsis patients with MODS. The linear regression showed that the level of myoglobin was positively correlated with APACHE Ⅱ score (β= 38.297, P = 0.000), negatively correlated with the length of hospital stay (β= -7.071, P = 0.048), and it had nothing to do with the MV time and the length of ICU stay. Conclusions Evaluation of muscle function should be a routine part of ICU examination. The levels of albumin,MV time, hemoglobin and nutritional start-up time were independent risk factors for ICUAW in sepsis patients with MODS. Myoglobin levels can be used as an indicator of severity.
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Objective To compared analgesic effect of sufentanil and fentanyl in surgery patients during mechanical ventilation, and to explore the rational dosage of analgesic and sedative drugs. Methods A prospective randomized controlled trial was conducted. 600 postoperative critically ill patients underwent mechanical ventilation for 12-72 hours admitted to Department of Critical Care Medicine of the Second Affiliated Hospital of Kunming Medical University from April 2013 to March 2015 were enrolled. They were randomly divided into two groups, sufentanil and fentanyl was used for analgesia respectively, and 300 patients in each group. The initiate dosage of sufentanil and fentanil was 5 μg/h and 50 μg/h, and the dosage was adjusted. A postoperative pain score (Prince-Henry score) of 0-1, and Richmond agitation-sedation scale (RASS) score -1-0 were targeted. 1 mg/kg of propofol was used if patient could not fall in sleep or felt anxious after loading dose of sufentanil (5 μg) or fentanil (50 μg) for 5 minutes. The use of analgesic drugs, the proportion and dosage of propofol was observed in the two groups, and adverse reactions were recorded. Results The mean dose of sufentanil for analgesia was (0.07±0.02) μg·kg-1·h-1, and the mean dose of fentanyl was (0.67±0.12) μg·kg-1·h-1. The patients in the two groups received propofol 40 to 60 mg/h in night, and the use proportion of propofol in sufentanil group was slightly less than that in fentanyl group (25.7% vs. 28.3%), but the difference was not statistically significant (P > 0.05). It was found by subgroup age analysis that, the mean analgesic dose of sufentanil or fentanyl in patients over 80 years old was lower than that in 70-79 years, 60-69 years and < 60 years groups but without statistical significance. There were 11 cases (3.7%) and 21 cases (7.0%) patients suffered from respiratory depression in sufentanil group and fentanyl group, respectively, without statistical significance (P = 0.069). The hemodynamics of patients in two groups was stable during analgesia, and no accidental extubation due to restlessness was found. Conclusions A smaller dose of sufentanil for postoperative patients underwent mechanical ventilation with satisfactory analgesia was (0.07±0.02) μg·kg-1·h-1, but need to be added with 40-60 mg/h and a small dose of propofol to improve anxiety and sleep. The proportion of patients needing propofol addition was slightly lower than that of fentanyl.
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Objective To investigate the accuracy and feasibility of brachial artery peak velocity variation (ΔVpeakbrach) and inferior vena cava variability (VIVC) as indicators of fluid responsiveness in critically ill patients. Methods A single-center prospective observation was conducted. The patients on mechanical ventilation with spontaneously breathing admitted to Department of Critical Care Medicine of the Second Affiliated Hospital of Kunming Medical University from June 2013 to August 2015 were enrolled. The patients were diagnosed as severe sepsis or sepsis shock. The peak velocity in brachial artery and diameter of the inferior vena cava at the end of inspiration and expiration was measured by bedside portable ultrasonic machine, and then ΔVpeakbrach and VIVC were calculated. The hemodynamic parameters were collected at baseline and after volume expansion (VE). The stroke volume (SV) was measured by pulse-indicated continuous cardiac output (PiCCO). Patients were classified as responders or non-responders according to the variation of SV (ΔSV) increased ≥ 15% or not after VE. Receiver operating characteristic curve (ROC) was plotted to evaluate the sensitivity and specificity of ΔVpeakbrach and VIVC in predicting volume responsiveness. Results Among 58 patients after VE, 32 patients were defined as responders and the rest 26 were defined as non-responders.There were no differences in gender, age, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score, dose of vasoactive agent, ventilator parameters and infection site. Compared with baseline hemodynamic parameters, heart rate (HR) was decreased (bpm: 95±18 vs. 103±21), and systolic blood pressure (SBP) was increased [mmHg (1 mmHg = 0.133 kPa): 92±8 vs. 80±7] after VE in responders; central venous pressure (CVP) was increased after VE in non-responders (mmHg: 11±4 vs. 8±3, all P < 0.05). The ΔVpeakbrach [(15.4±4.3)% vs. (11.2±3.5)%] and VIVC [(18.6±4.1)% vs. (14.3±3.6)%] in responders were significantly increased as compared with those of non-responders (both P < 0.05). The area under ROC curve (AUC) of ΔVpeakbrach for predicting volume responsiveness was 0.816. When the cut-off value of ΔVpeakbrach was ≥ 13.3%, the sensitivity was 71.9%, and the specificity was 80.8%. AUC of VIVC for predicting volume responsiveness was 0.733. When the cut-off value of VIVC was ≥ 19.25%, the sensitivity was 53.1%, and the specificity was 88.5%. Conclusion ΔVpeakbrach and VIVC are reliable indicators for predicting volume responsiveness in critical patients.
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Objective To investigate the potential risk factors of organ dysfunction and mortality in the early resuscitation of severe sepsis and septic shock patients.Methods Data were retrospectively analyzed from patients with severe sepsis and septic shock receiving non-cardiac operation and admitted to Department of Critical Care Medicine of the Second Affiliated Hospital of Kunming Medical University from January 1st,2013 to December 31st,2015.The patients were divided into the senior group (≥ 65 years old) and the younger group (＜ 65 years old),the high-procalcitonin (PCT) group (PCT ＞ 100 μg/L) and the control group (PCT ≤ 100 μg/L).The stage of early resuscitation was set to the first 6 hours.The diagnostic time and the incidence of acute respiratory distress syndrome (ARDS),acute kidney injury (AKI),and cardiac insufficiency were observed,which also included the usage of continuous renal replacement therapy (CRRT).The total fluid volume and the time of vasopressor usage during the first 6 hours of early goal-directed therapy (EGDT) were also recorded,which aslo included the 28-day mortality.Results 512patients with severe sepsis and septic shock receiving non-cardiac operation were treated according to the guidelines of Surviving Sepsis Campaign:international guidelines for management of severe sepsis and septic shock:2012.EGDT was used during the early resuscitation.The incidence of ARDS,AKI,and cardiac insufficiency was 80.9％ (414/512),71.3％ (365/512),and 61.9％ (317/512) respectively.There were 205 senior patients and 307 younger,as well as 154in high-PCT group and 358 in control group.The 28-day mortality was 30.3％ (155 died).90.8％ of patients (376/414)combined with ARDS were diagnosed before EGDT.95.1％ of patients (347/365) combined with AKI were diagnosed before EGDT,among whom 14.0％ (51/365) were treated with CRRT.153 senior patients combined with cardiac insufficiency were diagnosed no longer than 12 hours after EGDT.Compared with the younger group,the incidences of ARDS and cardiac insufficiency were higher in the senior group [85.9％ (176/205) vs.77.5％ (238/307),82.9％(170/205) vs.32.9％ (147/307),both P ＜ 0.05],so were the time of vasopressor usage during EGDT (hours:5.81 ±0.28vs.5.68 ± 0.52,P ＜ 0.05) was prolonged markedly and the 28-day mortality [42.9％ (88/205) vs.21.8％ (67/307),P ＜0.05] was increased significantly.But the incidence of AKI and the total fluid volume during EGDT were not significantly different between the senior group and the younger group [incidence of AKI:74.1％ (152/205) vs.69.4％ (213/307),total fluid volume (mL):2 769 ± 1 589 vs.2 804± 1 611,both P ＞ 0.05].Compared with the control group,the incidence of ARDS was higher in the high-PCT group [86.4％ (133/154) vs.78.5％ (281/358),P ＜ 0.05].But the incidences of AKI and cardiac insufficiency were not significantly differentiated between the high-PCT group and the control group [77.9％ (120/154) vs.68.4％ (245/358),58.4％ (90/154) vs.63.4％ (227/358),both P ＞ 0.05].Multiple logistic regression analysis showed that the risk factors of increase in mortality in patients with severe sepsis and septic shock included old age [odds ratio (OR) =1.782,95％ confidence interval (95％CI) =1.173-2.708,P =0.007],ARDS (OR =1.786,95％CI =1.028-3.102,P =0.040),AKI (OR =1.878,95％CI =1.145-3.079,P =0.012),and cardiac insufficiency (OR =4.177,95％CI =2.505-6.966,P =0.000),except for gender (OR =1.112,95％CI =0.736-1.680,P =0.614).Conclusions In the senior postoperative patients with severe sepsis or septic shock,the incidence of ARDS and cardiac insufficiency,and the mortality were increased.The incidence of ARDS was correlated to the severity of infection.Old age,surgery,and EGDT could be the potential risk factors of cardiac insufficiency.
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Objective To investigate the risk factors for postoperative delirium in patients undergoing noncardiac surgery. Methods From September-December 2009, 480 patients undergoing elective noncardiac surgery were included in this study. The criteria for enrolment of the patients in this study were (1) age ≥ 65 yr,(2) age ＜ 65 yr if associated with coronary artery disease, hypertension, diabetes mellitus, brain injury, cerebral hemorrhage, cerebral infarct, emphysema, chronic bronchitis; duration of operation ≥ 3 h and intraoperative blood loss was expected to exceed 20% of blood volume. The diagnosis of delirium was based on Confusion Assessment Method (CAM). Multivariate logistic regression was used to analyze the risk factors for postoperative delirium.Results Postoperative delirium developed in 79 patients during the first three postoperative days. The incidence of postoperative delirium was 16.5%. The logistic stepwise regression analysis indicated that the risk factors for delirium included advanced age, method of anesthesia, long operation, postoperative pain, emphysema and alcholic. Conclusion Age, method of anesthesia, long operation, postoperative pain, emphysema and alcholic are risk factors for postoperative delirium in patients undergoing noncardiac surgery.
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BACKGROUND:The success of cell therapy will depend on the ability to monitor the fate of transplanted cells in vivo.Superparamagnetic iron oxide(SPIO)labeling is an ideal magnetic resonance contrast medium,and it offers the potential for non-invasive tracking of implanted cells.The chlormethylbenzamido-1,1'-dioctadecyl-3,3,3',3'-tetramethylindocarbocyanine (CM-Dil)labeling does not have cytotoxicity,so it cannot influence cell growth.OBJECTIVE:To investigate the effects of SPIO and CM-Dil labeling and tracking on bone marrow mesenchymal stem cells(BMSCs).METHODS:Porcine BMSCs were isolated and cultured by the whole bone marrow method.BMSCs were labeled with SPIO containing 50 mg/L Ferrum and CM-Dil.The labeled BMSCs were transplanted into porcine myocardial infarction model via intracoronary infusion.The frozen sections of the cardiac tissues were obtained after 4 weeks.RESULTS AND CONCLUSION:Efficiency of SPIO and CM-Dil labeling BMSCs was nearly 100%.The SPIO and CM-Dil labeled BMSCs could be found in the cardiac muscle tissues at 4 weeks after transplantation.SPIO and CM-Dil labeling BMSCs were efficiently tracked in vivo.
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Objectives:To observe the role of nutritional support in patients after liver transplantation. Methods:Nutritional support was used in three patients after orthotopic liver transplantation(OLT).Total parenteral nutrition(TPN) was administered since the second day after the operation,the combination of enteral nutrition(EN) and parenteral nutrition(PN) was followed and then total enteral nutrition(TEN) was adopted.After that,oral intake of food was restored. Results:Postoperative patients were restored well. Conclusions:The supply of nutrition for patients after liver transplantation should be TPN→PN+EN→TEN,and then gradually increased.Once the gastroenteric functions of patients recover it is advisable to start EN as soon as possible.