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Steel C, Wile H. Dietitian's approach to managing enteral nutrition intolerance when a formula change is indicated: A clinical practice survey. Nutr Clin Pract 2024; 39:641-650. [PMID: 37589316 DOI: 10.1002/ncp.11069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 06/20/2023] [Accepted: 08/14/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Enteral nutrition intolerance (ENI) is often defined as one or more gastrointestinal (GI) symptoms related to enteral nutrition (EN) and may have significant impact on patient outcomes. There are multiple strategies to help manage ENI, such as changing the EN formula. The objective of this practice survey was to understand prevalence of ENI, management of ENI symptoms, and EN formula features considered when changing formulas to manage ENI. METHODS Canadian clinical dietitians working across care settings (n = 4827) were invited to complete a 28-question online survey if involved in the management of adult and/or pediatric patients receiving EN. RESULTS Five hundred seventeen surveys were analyzed. Significantly more dietitians in adult vs pediatric settings (83.4% and 59.1%, respectively; P = 0.0012), reported ENI in <40% of patients. Assessing medications, elevating the head of the bed, and changing EN infusion rate, volume, or feeding regimen were the highest-ranked strategies to manage ENI symptoms. Most (>90%) respondents change the EN formula <50% of the time to manage ENI. Dietitians consider caloric density and protein form as the most important EN features to manage upper-GI symptoms vs fiber source, osmolality, and form of protein to manage lower-GI symptoms. EN with real-food ingredients was ranked higher in importance for managing upper- and lower-GI symptoms by dietitians in pediatric vs adult settings. CONCLUSION To manage ENI symptoms, dietitians consider multiple strategies before deciding to change the EN formula. When a formula change is indicated, dietitians consider different EN features for the management of upper- and lower-GI symptoms.
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Affiliation(s)
- Cindy Steel
- Nestlé Health Science Canada, North York, Ontario, Canada
| | - Heather Wile
- Nestlé Health Science Canada, North York, Ontario, Canada
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2
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Zheng YM, Wu HY, Ye MM, Cai JY, Yuan Y, Xie WR, Xu JT, Liu T, He XX, Wu LH. Comparison of the use of a spiral nasojejunal tube and transendoscopic enteral tubing in washed microbiota transplantation via the mid-gut route. Heliyon 2024; 10:e30310. [PMID: 38742080 PMCID: PMC11089310 DOI: 10.1016/j.heliyon.2024.e30310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/20/2024] [Accepted: 04/23/2024] [Indexed: 05/16/2024] Open
Abstract
Background Methods for washed microbiota transplantation (WMT) through the mid-gut include transendoscopic enteral tubing (TET) and manual spiral nasojejunal tube (SNT) placement have not been studied. Methods This prospective interventional study was performed at a single centre. Patients were divided into the SNT and mid-gut TET groups based on their conditions and wishes. In the SNT group, an SNT was passively inserted into the stomach, and abdominal X-rays were taken within 24 h to confirm tube placement in the small intestine. In the mid-gut TET group, mid-gut TET was placed in the small intestine for gastroscopy. Data on the clinical efficacy of WMT, intubation time, cost, overall comfort score, adverse reactions, etc., were collected from the two groups. Results Sixty-three patients were included in the study (SNT group (n = 40) and mid-gut TET group (n = 23)). The clinical efficacy of WMT in the SNT and mid-gut TET groups was 90 % and 95.7 %, respectively (P = 0.644). Compared with the mid-gut TET group, the SNT group showed a shorter operation time (120 s vs. 258 s, P = 0.001) and a lower average cost (641.7 yuan vs. 1702.1 yuan, P = 0.001). There was no significant difference in the overall comfort score or the incidence of common discomfort symptoms between the two groups. Conclusion The different implantation methods have different advantages; compared with mid-gut TET placement, manual SNT placement provides some benefits.
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Affiliation(s)
- Ya-Mei Zheng
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
| | - Hui-Yi Wu
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
| | - Meng-Meng Ye
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
| | - Jie-Yi Cai
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
| | - Yu Yuan
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
| | - Wen-Rui Xie
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
| | - Jia-Ting Xu
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
| | - Tao Liu
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
| | - Xing-Xiang He
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
| | - Li-Hao Wu
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
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Nguyen DL, Schott LL, Lowen CC, Desai AM, Baumer DL, Miranowski MK, Cao Z, Torres KA. Characteristics and feeding intolerance in critically ill adult patients receiving peptide-based enteral nutrition: A retrospective cross-sectional study. Clin Nutr ESPEN 2024; 59:270-278. [PMID: 38220386 DOI: 10.1016/j.clnesp.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/17/2023] [Accepted: 12/05/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND & AIMS Patients who experience gastrointestinal (GI) intolerance and hyperglycemia (or glucose intolerance) may not achieve appropriate caloric requirements and experience poor outcomes. The aim was to examine patient characteristics, disease severity, and enteral nutrition (EN) formula use in relation to feeding intolerance and healthcare resource utilization. METHODS A retrospective, cross-sectional design using real-world data from PINC AI™ Healthcare Database, 2015-2019 was used. Critically ill hospitalized adults who required ≥3 days of 100% whey peptide-based EN, other peptide-based diets, or intact-protein standard and diabetic EN formulas were included. Primary outcomes were enteral feeding intolerance, including GI intolerance and hyperglycemia. Pairwise comparisons of other peptide-based and standard intact-protein groups with 100% whey-peptide were completed. Associations between EN group with GI intolerance and hyperglycemia, respectively, were evaluated via multivariable logistic regressions. RESULTS Across 67 US hospitals, 19,679 inpatients (3242,100% whey-peptide, 3121 other peptide-based, and 13,316 standard intact-protein) were included. The 100% whey-peptide group had higher severity of illness and frequencies of comorbidities compared with other peptide-based and standard intact-protein groups. Hospital length of stay, intensive care unit stay, and 30-day readmission were similar across peptide-based cohorts. After controlling for demographic, visit, and severity characteristics, odds of GI intolerance were 18% higher for the other peptide-based group and 15% higher for the standard intact-protein group compared with the 100% whey-peptide group (each P < 0.03). In secondary analysis, odds of hyperglycemia were 81% higher for the other peptide-based group compared with the subgroup of very high-protein/low carbohydrate 100% whey-peptide (P < 0.001). CONCLUSIONS Lower GI intolerance and greater glycemic control were associated with the use of 100% whey-peptide formulas relative to other formulas. Appropriate and optimal delivery of EN using specialized peptide-based formulas is a strategy to minimize feeding intolerance and benefit critically ill patients.
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Affiliation(s)
- Douglas L Nguyen
- Loma Linda University Medical Center, 11234 Anderson St., Loma Linda, CA, 92354, USA.
| | - Laura L Schott
- PINC AI™ Applied Sciences, Premier Inc., 13034 Ballantyne Corporate Pl, Charlotte, NC, 28277, USA.
| | - Cynthia C Lowen
- Nestlé Health Science, 1041 US Highway 202, Bridgewater, NJ, 08807, USA.
| | - Amarsinh M Desai
- Nestlé Health Science, 1041 US Highway 202, Bridgewater, NJ, 08807, USA.
| | - Dorothy L Baumer
- PINC AI™ Applied Sciences, Premier Inc., 13034 Ballantyne Corporate Pl, Charlotte, NC, 28277, USA.
| | - Mary K Miranowski
- Nestlé Health Science, 1041 US Highway 202, Bridgewater, NJ, 08807, USA.
| | - Zhun Cao
- PINC AI™ Applied Sciences, Premier Inc., 13034 Ballantyne Corporate Pl, Charlotte, NC, 28277, USA.
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Crone V, Møller MH, Baekgaard ES, Perner A, Bytzer P, Alhazzani W, Krag M. Use of prokinetic agents in hospitalised adult patients: A scoping review. Acta Anaesthesiol Scand 2023; 67:588-598. [PMID: 36847067 DOI: 10.1111/aas.14222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 02/09/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Gastrointestinal motility is important for adequate uptake of fluids and nutrition but is often impaired in hospitalised patients. Prokinetic agents enhance gastrointestinal motility and are prescribed for many hospitalised patients. In this scoping review, we aimed to systematically describe the body of evidence on the use of prokinetic agents in hospitalised patients. We hypothesised, that the body of evidence would be limited and derive from heterogeneous populations. METHODS We conducted this scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews statement. We searched Medline, Embase, Epistemonikos and the Cochrane Library for studies assessing the use of prokinetic agents on any indication and outcome in adult hospitalised patients. We used a modified version of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to assess the certainty of evidence. RESULTS We included 102 studies with a total of 8830 patients. Eighty-six studies were clinical trials (84%), and 52 (60%) of these were conducted in the intensive care unit, with feeding intolerance as the main indication. In the non-intensive care setting the indications were wider; most studies assessed use of prokinetic agents before gastroscopy to improve visualisation. The most studied prokinetic agent was metoclopramide (49% of studies) followed by erythromycin (31%). In total 147 outcomes were assessed with only 67% of the included studies assessing patient-centred outcomes, and with gastric emptying as the most frequently reported outcome. Overall, the data provided no firm evidence on the balance between the desirable and undesirable effects of prokinetic agents. CONCLUSIONS In this scoping review, we found that the studies addressing prokinetic agents in hospitalised adults had considerable variations in indications, drugs and outcomes assessed, and that the certainty of evidence was judged to be low to very low.
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Affiliation(s)
- Vera Crone
- Department of Intensive Care, Holbaek Hospital, Holbaek, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Peter Bytzer
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Gastroenterology, Zealand University Hospital, Køge, Denmark
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mette Krag
- Department of Intensive Care, Holbaek Hospital, Holbaek, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Feeding intolerance during prolonged prone position in overweight and obese patients with severe COVID-19. NUTR HOSP 2023; 40:250-256. [PMID: 36880718 DOI: 10.20960/nh.04553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
Abstract
OBJECTIVE the aim of this study was to compare the incidence rate of feeding intolerance (FI) during supine (SP) or prone positioning (PP) in critically ill COVID-19 patients. METHODS this was a retrospective cohort study of critically ill patients with overweight or obesity who received enteral nutrition (EN) in prone or supine positioning continuously during the first five days of mechanical ventilation. Nutritional risk, anthropometric measurements and body composition were assessed at the first 24 hours upon Intensive Care Unit (ICU) admission. Biochemical and clinical variables (Sequential Organ Failure Assessment [SOFA], Acute Physiology and Chronic Health Evaluation II [APACHE II], Acute Kidney Injury [AKI] or comorbidities diagnosis) were collected. Pharmacotherapy (prokinetics, sedatives or neuromuscular blocking agents) and FI incidence (gastric residual volume [GRV] ≥ 200 ml or ≥ 500 ml, vomiting or diarrhea) were daily recorded. Constipation was defined as the absence of evacuation for five consecutive days. RESULTS eighty-two patients were included. Higher rate of prophylactic prokinetic prescription was observed in PP (42.8 vs 12.5 %, p = 0.002). GRV ≥ 200 in supine position was not different when compared to PP (p = 0.47). Vomiting episodes in supine compared to PP showed no difference between groups (15 % vs 24 %, p = 0.31). No differences in diarrhea events were detected (10 % vs 4.7 %, p = 0.36). Constipation was common in both groups (95 % vs 82 %, p = 0.06). CONCLUSION FI during prone position was not different in comparison to supine position. Routinely use of prokinetics in continuous prone position may help to prevent FI incidence. Algorithm development is necessary for FI prevention and treatment so to avoid EN interruptions and adverse clinical outcomes.
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El Khoury D, Pardo E, Cambriel A, Bonnet F, Pham T, Cholley B, Quesnel C, Verdonk F. Gastric Cross-Sectional Area to Predict Gastric Intolerance in Critically Ill Patients: The Sono-ICU Prospective Observational Bicenter Study. Crit Care Explor 2023; 5:e0882. [PMID: 36960310 PMCID: PMC10030198 DOI: 10.1097/cce.0000000000000882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
To evaluate the correlation between gastric cross-sectional area (GCSA) and the occurrence of gastric intolerance in critically ill patients within 24 hours of the measurement. DESIGN Two-center prospective observational study. SETTING Two academic ICUs in France between June 2020 and August 2021. PATIENTS All surgical intubated ICU patients greater than or equal to 18 years old receiving enteral feeding for greater than 12 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Forty-four patients were included, 11 (25%) of whom presented digestive intolerance. Primary outcome was assessment of the association between GCSA and the occurrence of gastric intolerance within 24 hours of the measurement. GCSA value was significantly higher in patients with upper digestive intolerance compared to those without (553 mm2 [interquartile range (IQR), 500-649 mm2] vs 970 mm2 [IQR, 777-1,047]; p < 0.001, respectively). The optimal threshold for predicting upper digestive intolerance was 720 mm2 (area under the receiver operating characteristic curve 0.86; positive predictive value 62.5%; negative predictive value 96.4%; sensibility 0.91; and specificity 0.81). Multivariate analysis (weighted by propensity score), including known risk factors, showed that GCSA above the 720 mm2 threshold was independently associated with the occurrence of upper digestive intolerance (odds ratio, 1.85; 1.37-2.49; p < 0.0002). Measurement quality was "good" (i.e., liver, aorta, superior mesenteric vein, and pancreas were all visualized) in 81% of cases. CONCLUSIONS Measurement of GCSA by ultrasound would allow prediction of gastric intolerance in critically ill patients. This should be confirmed by a prospective score validation and interventional trials.
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Affiliation(s)
- Daniel El Khoury
- Department of Anaesthesiology and Intensive Care, Hôpital Saint-Antoine Assistance Publique des Hôpitaux de Paris and Sorbonne University, GRC 29, DMU DREAM, Paris, France
| | - Emmanuel Pardo
- Department of Anaesthesiology and Intensive Care, Hôpital Saint-Antoine Assistance Publique des Hôpitaux de Paris and Sorbonne University, GRC 29, DMU DREAM, Paris, France
| | - Amelie Cambriel
- Department of Anaesthesiology and Intensive Care, Hôpital Saint-Antoine Assistance Publique des Hôpitaux de Paris and Sorbonne University, GRC 29, DMU DREAM, Paris, France
| | - Francis Bonnet
- Department of Anaesthesiology and Intensive Care, Hôpital Saint-Antoine Assistance Publique des Hôpitaux de Paris and Sorbonne University, GRC 29, DMU DREAM, Paris, France
| | - Tai Pham
- Department of Intensive Care Medicine, Hôpital Kremlin Bicêtre Hospital and Paris Saclay University, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Bernard Cholley
- Department of Anaesthesiology and Critical Care Medicine, Hôpital Européen Georges Pompidou-Assistance Publique Hôpitaux de Paris, and Université Paris Cité, INSERM, Innovative Therapies in Haemostasis, Paris, France
| | - Christophe Quesnel
- Department of Anaesthesiology and Intensive Care, Hôpital Saint-Antoine Assistance Publique des Hôpitaux de Paris and Sorbonne University, GRC 29, DMU DREAM, Paris, France
| | - Franck Verdonk
- Department of Anaesthesiology and Intensive Care, Hôpital Saint-Antoine Assistance Publique des Hôpitaux de Paris and Sorbonne University, GRC 29, DMU DREAM, Paris, France
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Taylor SJ, Sayer K, White P. Nasointestinal tube placement: Techniques that increase success. J Intensive Care Soc 2023; 24:62-70. [PMID: 36874290 PMCID: PMC9975804 DOI: 10.1177/17511437221095336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Delayed gastric emptying (DGE) is a major cause of undernutrition that can be overcome using nasointestinal (NI) feeding, but tube placement often fails. We analyse which techniques enable successful NI tube placement. Methods Efficacy of tube technique was determined at each of six anatomical points: Nose, nasopharynx-oesophagus, stomach-upper and -lower, duodenum part-1 and intestine. Results In 913 first NI tube placements, significant associations with tube advancement were found in the pharynx (head tilt, jaw thrust, laryngoscopy), stomach_upper (air insufflation, 10 cm or 20-30 cm flexible tube tip ± reverse Seldinger manoeuvre), stomach_lower (air insufflation, possibly flexible tip and wire stiffener) and duodenum part-1 and beyond part-2 (flexible tip and combinations of micro-advance, slack removal, wire stiffener or prokinetic drugs). Conclusion This is the first study to show what techniques are associated with tube advancement and the alimentary tract level they are specific to.
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Affiliation(s)
- Stephen J Taylor
- Department of Nutrition and Dietetics, Southmead Hospital Bristol, Bristol, UK
| | - Kaylee Sayer
- Department of Nutrition and Dietetics, Southmead Hospital Bristol, Bristol, UK
| | - Paul White
- Mathematics and Statistics Research Group, University of the West of England, Bristol, UK
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Major Publications in the Critical Care Pharmacotherapy Literature: 2021. Crit Care Explor 2022; 4:e0823. [PMID: 36567788 PMCID: PMC9760627 DOI: 10.1097/cce.0000000000000823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
To summarize the most impactful articles relevant to the pharmacotherapy of critically ill adult patients published in 2021. DATA SOURCE PubMed/MEDLINE. STUDY SELECTION Randomized controlled trials, prospective studies, or systematic review/meta-analyses of adult critical care patients assessing a pharmacotherapeutic intervention and reporting clinical endpoints published between January 1, 2021, and December 31, 2021. DATA EXTRACTION Candidate articles were organized by clinical domain based on the emerging themes from all studies. A modified Delphi process was applied to obtain consensus on the most impactful publication within each clinical domain based on overall contribution to scientific knowledge and novelty to the literature. DATA SYNTHESIS The search revealed 830 articles, of which 766 were excluded leaving 64 candidate articles for the Delphi process. These 64 articles were organized by clinical domain including: emergency/neurology, cardiopulmonary, nephrology/fluids, infectious diseases, metabolic, immunomodulation, and nutrition/gastroenterology. Each domain required the a priori defined three Delphi rounds. The resultant most impactful articles from each domain included five randomized controlled trials and two systematic review/meta-analyses. Topics studied included sedation during mechanical ventilation, anticoagulation in COVID-19, extended infusion beta-lactams, interleukin-6 antagonists in COVID-19, balanced crystalloid resuscitation, vitamin C/thiamine/hydrocortisone in sepsis, and promotility agents during enteral feeding. CONCLUSIONS This synoptic review provides a summary and perspective of the most impactful articles relevant to the pharmacotherapy of critically ill adults published in 2021.
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Aziz M, Haghbin H, Gangwani MK, Weissman S, Patel AR, Randhawa MK, Samikanu LB, Alyousif ZA, Lee-Smith W, Kamal F, Nawras A, Howden CW. Erythromycin Improves the Quality of Esophagogastroduodenoscopy in Upper Gastrointestinal Bleeding: A Network Meta-Analysis. Dig Dis Sci 2022; 68:1435-1446. [PMID: 36112271 DOI: 10.1007/s10620-022-07698-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/12/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND/AIM Upper gastrointestinal bleeding (UGIB) usually requires esophagogastroduodenoscopy (EGD) for diagnostic and-potentially-therapeutic purposes. However, blood within the gastric lumen may hinder the procedure. Administration of prokinetics like erythromycin has shown efficacy. This network meta-analysis investigates the efficacy of this intervention prior to EGD. METHODS We performed a systematic literature search of Embase, PubMed/Medline, and other databases through March 8, 2022 to include randomized controlled trials (RCTs) comparing prokinetic use in EGD for UGIB. We used the DerSimonian-Laird approach to pool data and compare outcomes including need for repeat endoscopy and blood transfusion. Pooled prevalence of proportional outcomes, 95% confidence interval (CI), and p-values were calculated. RESULTS We included eight RCTs with four distinct intervention groups (erythromycin, placebo to erythromycin, nasogastric (NG) lavage and NG lavage + erythromycin) published between 2002 and 2020 with a total of 721 patients (mean age 60.0 ± 3.1 years; 73.2% male). The need for second look endoscopy was significantly lower with erythromycin than placebo (relative risk: 0.42, CI 0.22-0.83, p = 0.01). Using the frequentist approach, the combination of NG lavage and erythromycin (92.2) was rated highest, followed by erythromycin alone (73.1) for higher rates of empty stomach. Erythromycin was rated highest for lower need for packed red blood cell transfusion (72.8) as well as mean endoscopy duration (66.0). CONCLUSION Erythromycin improved visualization at EGD, reduced requirements for blood transfusion and repeat EGD, and shortened hospital stay. The combination of erythromycin and NG lavage showed reduced mortality.
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Affiliation(s)
- Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA.
| | - Hossein Haghbin
- Division of Gastroenterology, Ascension Providence Southfield, Southfield, MI, USA
| | | | - Simcha Weissman
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Arti R Patel
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Manraj K Randhawa
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Luke B Samikanu
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | | | - Wade Lee-Smith
- University of Toledo Libraries, University of Toledo, Toledo, OH, USA
| | - Faisal Kamal
- Division of Gastroenterology, University of California San Francisco, San Francisco, CA, USA
| | - Ali Nawras
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
| | - Colin W Howden
- Division of Gastroenterology, University of Tennessee College of Medicine, Memphis, TN, USA
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10
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Crone V, Møller MH, Perner A, Alhazzani W, Krag M. Use of prokinetic agents in hospitalised adult patients: Protocol for a scoping review. Acta Anaesthesiol Scand 2022; 66:1024-1026. [PMID: 35675417 PMCID: PMC9545779 DOI: 10.1111/aas.14099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 05/30/2022] [Indexed: 12/04/2022]
Abstract
Background Gastrointestinal motility is an important contributor to the effective uptake of water and nutrition. However, it is often impaired in acutely ill hospitalised patients. Amongst other indications, prokinetic agents are used to improve GI motility, but the body of evidence is not well described. Accordingly, we aim to systematically describe and explore the body of evidence on the use of prokinetic agents in hospitalised adults. Methods In accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for Scoping Reviews statement, we plan to conduct a scoping review of studies assessing the use of prokinetic agents, for any indication, in hospitalised adults. We plan to assess study design, population, agents, indications and outcomes across included studies. When applicable, we plan to assess the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results We plan to provide descriptive analyses of the included studies accompanied by tabulated results and characterise knowledge gaps. Conclusion The outlined scoping review will provide a summary of the body of evidence on the use, indications, effects and side effects of prokinetic agents in hospitalised adults.
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Affiliation(s)
- Vera Crone
- Department of Intensive Care, Holbaek Hospital, Holbaek, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Mette Krag
- Department of Intensive Care, Holbaek Hospital, Holbaek, Denmark.,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Denmark
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Arunachala Murthy T, Chapple LAS, Lange K, Marathe CS, Horowitz M, Peake SL, Chapman MJ. Gastrointestinal dysfunction during enteral nutrition delivery in intensive care unit (ICU) patients: Risk factors, natural history, and clinical implications. A post-hoc analysis of The Augmented versus Routine approach to Giving Energy Trial (TARGET). Am J Clin Nutr 2022; 116:589-598. [PMID: 35472097 PMCID: PMC9348974 DOI: 10.1093/ajcn/nqac113] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 04/24/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Slow gastric emptying occurs frequently during critical illness and is roughly quantified at bedside by large gastric residual volumes (GRVs). A previously published trial (The Augmented versus Routine approach to Giving Energy Trial; TARGET) reported larger GRVs with energy-dense (1.5 kcal/mL) compared with standard (1.0 kcal/mL) enteral nutrition (EN), warranting further exploration. OBJECTIVE To assess the incidence, risk factors, duration, and timing of large GRVs (≥250 mL) and its relation to clinical outcomes in mechanically ventilated adults. METHODS A post-hoc analysis of TARGET data in patients with ≥1 GRV recorded. Data are n (%) or median [IQR]. RESULTS Of 3876 included patients, 1777 (46%) had ≥1 GRV ≥250 mL, which was more common in males (50 compared with 39%; P < 0.001) and in patients receiving energy-dense compared with standard EN (52 compared with 40%; RR = 1.27 (95% CI: 1.19, 1.36); P < 0.001) in whom it also lasted longer (1 [0-2] compared with 0 [0-1] d; P < 0.001), with no difference in time of onset after EN initiation (day 1 [0-2] compared with 1 [0-2]; P = 0.970). Patients with GRV ≥250 mL were more likely to have the following: vasopressor administration (88 compared with 76%; RR = 1.15 [1.12, 1.19]; P < 0.001), positive blood cultures (16 compared with 8%; RR = 1.92 [1.60, 2.31]; P < 0.001), intravenous antimicrobials (88 compared with 81%; RR = 1.09 [1.06, 1.12]; P < 0.001), and prolonged intensive care unit (ICU) stay (ICU-free days to day 28; 12.9 [0.0-21.0] compared with 20.0 [3.9-24.0]; P < 0.001), hospital stay (hospital-free days to day 28: 0.0 [0.0-12.0] compared with 7.0 [0.0-17.6] d; P < 0.001), ventilatory support (ventilator-free days to day 28: 16.0 [0.0-23.0] compared with 22.0 [8.0-25.0]; P < 0.001), and a higher 90-d mortality (29 compared with 23%; adjusted: RR = 1.17 [1.05, 1.30]; P = 0.003). CONCLUSION Large GRVs were more common in males and those receiving energy-dense formulae, occurred early and were short-lived, and were associated with a number of negative clinical sequelae, including increased mortality, even when adjusted for illness severity. This trial was registered at clinicaltrials.gov as NCT02306746.
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Affiliation(s)
| | - Lee-anne S Chapple
- Adelaide Medicine School, University of Adelaide, Adelaide, Australia,Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia,Centre for Research Excellence in Nutritional Physiology, Adelaide, Australia
| | - Kylie Lange
- Adelaide Medicine School, University of Adelaide, Adelaide, Australia,Centre for Research Excellence in Nutritional Physiology, Adelaide, Australia
| | - Chinmay S Marathe
- Adelaide Medicine School, University of Adelaide, Adelaide, Australia,Centre for Research Excellence in Nutritional Physiology, Adelaide, Australia,The Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Michael Horowitz
- Adelaide Medicine School, University of Adelaide, Adelaide, Australia,Centre for Research Excellence in Nutritional Physiology, Adelaide, Australia,The Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Sandra L Peake
- Adelaide Medicine School, University of Adelaide, Adelaide, Australia,The Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, Australia,School of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
| | - Marianne J Chapman
- Adelaide Medicine School, University of Adelaide, Adelaide, Australia,Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia,Centre for Research Excellence in Nutritional Physiology, Adelaide, Australia,School of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
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12
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Tharanon V, Putthipokin K, Sakthong P. Drug-related problems identified during pharmaceutical care interventions in an intensive care unit at a tertiary university hospital. SAGE Open Med 2022; 10:20503121221090881. [PMID: 35465635 PMCID: PMC9021480 DOI: 10.1177/20503121221090881] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 03/11/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: Drug-related problems could potentially worsen the clinical outcomes in critically ill patients. Critically ill patients are generally considered more vulnerable to harm from drug-related problems due to frequent medication-related events and complicated clinical courses. However, drug-related problems identified by on-ward clinical pharmacists in medical intensive care units in Thailand are not well reported. This study reports clinically relevant data with the description of identified problems, common causes of drug-related problems, and pharmacists’ interventions performed in real world, so that it may serve as an educational material for pharmacists who implement a pharmaceutical care and participate in medical intensive care units. Methods: A retrospective descriptive study was conducted at a tertiary university hospital in Bangkok, Thailand, from January 2015 to December 2020. The drug-related problems were categorized according to Cipolle et al.’s classification. The severity of drug-related problems in this study was rated by modifying the definition of The National Coordinating Council for Medication Error Reporting and Prevention Taxonomy of Medication Error to report harm from drug-related problem-related patient outcomes. Results: A total of 698 drug-related problems were detected in 374 critically ill patients. The prevalence of drug-related problems occurring in critically ill patients admitted to the medical intensive care unit was 73.9%. The most frequent drug-related problems were dosage too high (27.7%), ineffective drug (17.2%), need for additional drug therapy (15.3%), unnecessary drug therapy (14.6%), dosage too low (14.3%), adverse drug reaction (9.7%), and non-adherence (1.2%). The severity of drug-related problems in the medical intensive care unit was assessed as a drug-related problem with no harm (78.2%). Pharmacists’ interventions were advised according to drug-related problem identification to provide personalized pharmacotherapy optimization in critically ill patients. Conclusion: The most frequent drug-related problem identified during pharmaceutical care interventions in the medical intensive care unit at tertiary university hospital is dosage too high. The severity of drug-related problems is mostly determined as drug-related problems with no harm.
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Affiliation(s)
- Vichapat Tharanon
- Clinical Pharmacy Section, Pharmacy Division, Ramathibodi Hospital, Bangkok, Thailand
| | - Krongtong Putthipokin
- Clinical Pharmacy Section, Pharmacy Division, Ramathibodi Hospital, Bangkok, Thailand
| | - Phantipa Sakthong
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
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13
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Allami A, Kianimajd S, Mavandadi S, Paybast S. Evaluation of domperidone efficacy to prevent aspiration pneumonia in patients with acute ischemic stroke: a randomized clinical trial. Acta Neurol Belg 2022; 122:1337-1342. [PMID: 35420362 DOI: 10.1007/s13760-022-01925-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/08/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND AND AIM Aspiration pneumonia is an essential complication of acute ischemic stroke (AIS), which is responsible for increased three-fold mortality within a month. There is an interest towards the effect of prokinetics on prevention of stroke-associated pneumonia. The present study aimed to investigate the effect of domperidone to prevent pneumonia in patients with AIS. METHODS In this randomized clinical trial, 150 patients with AIS were assigned to receive either domperidone 10 mg daily or placebo during hospitalization. The clinical outcomes including of aspiration pneumonia occurrence, gastrointestinal discomfort, the need for intensive care unit admission, the length of hospitalization, final mRs, and mortality were then evaluated in both groups. RESULTS 150 [Mean age 67.5 ± 13.5 years, 90 men and 60 women] were randomized in a 1:1 ratio. Both groups were similar in terms of baseline characteristics. The domperidone group experienced significantly less dysphagia, nausea and vomiting, and aspiration pneumonia (P < 0.005). Although domperidone did not considerably reduce the mortality (P = 0.978), it resulted in lower mean mRS and shorter length of hospitalization (P < 0.001). CONCLUSION Domperidone is an effective and well tolerated agent which could be considered as a promising agent to prevent stroke-associated pneumonia leading to a better clinical recovery.
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14
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Deng LX, Lan-Cao, Zhang LN, Dun-Tian, Yang-Sun, Qing-Yang, Yan-Huang. The effects of abdominal-based early progressive mobilisation on gastric motility in endotracheally intubated intensive care patients: A randomised controlled trial. Intensive Crit Care Nurs 2022; 71:103232. [DOI: 10.1016/j.iccn.2022.103232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 02/15/2022] [Accepted: 03/01/2022] [Indexed: 02/08/2023]
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15
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A systematic review of the definitions and prevalence of feeding intolerance in critically ill adults. Clin Nutr ESPEN 2022; 49:92-102. [DOI: 10.1016/j.clnesp.2022.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/08/2022] [Accepted: 04/15/2022] [Indexed: 12/12/2022]
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16
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Affiliation(s)
- Yaseen M. Arabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, and Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia,Address for correspondence: Dr. Yaseen M. Arabi, Intensive Care Department, King Abdulaziz Medical City, ICU2, Mail Code 1425, PO Box 22490, Riyadh - 11426, Saudi Arabia. E-mail:
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17
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Vijayaraghavan R, Maiwall R, Arora V, Choudhary A, Benjamin J, Aggarwal P, Jamwal KD, Kumar G, Joshi YK, Sarin SK. Reversal of Feed Intolerance by Prokinetics Improves Survival in Critically Ill Cirrhosis Patients. Dig Dis Sci 2022; 67:4223-4233. [PMID: 34392492 PMCID: PMC8364303 DOI: 10.1007/s10620-021-07185-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/19/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS Feed intolerance (FI) is common in cirrhosis patients in intensive care units (ICU). Prokinetics are the first line treatment for FI but their efficacy and safety in critically ill patient with cirrhosis is unknown. We evaluated the role of prokinetics in reversal of FI and clinical outcomes. METHODS Consecutive patients admitted in ICU developing new-onset FI, were randomized to receive either intravenous metoclopramide (Gr.A, n = 28), erythromycin (Gr.B, n = 27) or placebo (Gr.C, n = 28). FI was defined with the presence of 3 of 5 variables- absence of bowel sounds, gastric residual volume ≥ 500 ml, vomiting, diarrhoea and bowel distension. Primary end-point was complete resolution of FI (≥ 3 variables resolved) within 24-h and secondary end-points included resolution within 72-h and survival at 7-days. RESULTS Of the 1030 ICU patients, 201 (19.5%) developed FI and 83 patients were randomized. Baseline parameters between the groups were comparable. Complete resolution at 24-h was higher in Gr.A (7.14%) and B (22.2%) than C (0%, p = 0.017). Overall, 58 (69.9%) patients achieved resolution within 72 h, more with metoclopramide (n = 24, 85.7%) and erythromycin (n = 25, 92.6%) than with placebo (n = 9, 32.1%, p < 0.001). The 7-day survival was better in patients who achieved resolution within 72-h (65.5 vs. 36%, p = 0.011) than non-responders. High lactate (OR-3.32, CI-1.45-7.70, p = 0.005), shock at baseline (OR-6.34, CI-1.67-24.1, p = 0.007) and resolution of FI within 72 h (OR-0.11, CI, 0.03-0.51, p = 0.04) predicted 7-day mortality. CONCLUSIONS FI is common in critically-ill cirrhosis patients and non-resolution carries high mortality. Early recognition and treatment with prokinetics is recommended to improve short-term survival.
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Affiliation(s)
- Rajan Vijayaraghavan
- grid.418784.60000 0004 1804 4108Department of Hepatology, Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070 India
| | - Rakhi Maiwall
- grid.418784.60000 0004 1804 4108Department of Hepatology, Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070 India
| | - Vinod Arora
- grid.418784.60000 0004 1804 4108Department of Hepatology, Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070 India
| | - Ashok Choudhary
- grid.418784.60000 0004 1804 4108Department of Hepatology, Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070 India
| | - Jaya Benjamin
- grid.418784.60000 0004 1804 4108Department of Clinical Nutrition, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Prashant Aggarwal
- grid.418784.60000 0004 1804 4108Department of Anaesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Kapil Dev Jamwal
- grid.464746.30000 0004 1761 4703Department of Gastroenterology, Artemis Hospitals, Gurugram, Haryana India
| | - Guresh Kumar
- grid.418784.60000 0004 1804 4108Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Y. K. Joshi
- grid.418784.60000 0004 1804 4108Department of Clinical Nutrition, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv K. Sarin
- grid.418784.60000 0004 1804 4108Department of Hepatology, Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070 India
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18
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Abstract
Gastroparesis is characterized by symptoms suggestive of, and objective evidence of, delayed gastric emptying in the absence of mechanical obstruction. This review addresses the normal emptying of solids and liquids from the stomach and details the myogenic and neuromuscular control mechanisms, including the specialized function of the pyloric sphincter, that result in normal emptying, based predominantly on animal research. A clear understanding of fundamental mechanisms is necessary to comprehend derangements leading to gastroparesis, and additional research on human gastric muscles is needed. The section on pathophysiology of gastroparesis considers neuromuscular diseases that affect nonsphincteric gastric muscle, disorders of the extrinsic neural control, and pyloric dysfunction that lead to gastroparesis. The potential cellular basis for gastroparesis is attributed to the effects of oxidative stress and inflammation, with increased pro-inflammatory and decreased resident macrophages, as observed in full-thickness biopsies from patients with gastroparesis. Predominant diagnostic tests involving measurements of gastric emptying, the use of a functional luminal imaging probe, and high-resolution antral duodenal manometry in characterizing the abnormal motor functions at the gastroduodenal junction are discussed. Management is based on supporting nutrition; dietary interventions, including the physical reduction in particle size of solid foods; pharmacological agents, including prokinetics and anti-emetics; and interventions such as gastric electrical stimulation and pyloromyotomy. These are discussed briefly, and comment is added on the potential for individualized treatments in the future, based on optimal gastric emptying measurement and objective documentation of the underlying pathophysiology causing the gastroparesis.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Kenton M. Sanders
- Department of Physiology and Cell Biology, University of Nevada, Reno School of Medicine, Reno, NV
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19
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Preiser JC, Arabi YM, Berger MM, Casaer M, McClave S, Montejo-González JC, Peake S, Reintam Blaser A, Van den Berghe G, van Zanten A, Wernerman J, Wischmeyer P. A guide to enteral nutrition in intensive care units: 10 expert tips for the daily practice. Crit Care 2021; 25:424. [PMID: 34906215 PMCID: PMC8669237 DOI: 10.1186/s13054-021-03847-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/27/2021] [Indexed: 12/15/2022] Open
Abstract
The preferential use of the oral/enteral route in critically ill patients over gut rest is uniformly recommended and applied. This article provides practical guidance on enteral nutrition in compliance with recent American and European guidelines. Low-dose enteral nutrition can be safely started within 48 h after admission, even during treatment with small or moderate doses of vasopressor agents. A percutaneous access should be used when enteral nutrition is anticipated for ≥ 4 weeks. Energy delivery should not be calculated to match energy expenditure before day 4–7, and the use of energy-dense formulas can be restricted to cases of inability to tolerate full-volume isocaloric enteral nutrition or to patients who require fluid restriction. Low-dose protein (max 0.8 g/kg/day) can be provided during the early phase of critical illness, while a protein target of > 1.2 g/kg/day could be considered during the rehabilitation phase. The occurrence of refeeding syndrome should be assessed by daily measurement of plasma phosphate, and a phosphate drop of 30% should be managed by reduction of enteral feeding rate and high-dose thiamine. Vomiting and increased gastric residual volume may indicate gastric intolerance, while sudden abdominal pain, distension, gastrointestinal paralysis, or rising abdominal pressure may indicate lower gastrointestinal intolerance.
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Affiliation(s)
- Jean-Charles Preiser
- Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070, Brussels, Belgium.
| | - Yaseen M Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mette M Berger
- Adult Intensive Care, Lausanne University Hospital, CHUV, 1011, Lausanne, Switzerland
| | - Michael Casaer
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Stephen McClave
- Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Juan C Montejo-González
- Intensive Care Medicine, Hospital Universitario, 12 de Octubre, Instituto de Investigación imas12, Madrid, Spain
| | - Sandra Peake
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, SA, Australia.,Department of Critical Care Research, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Annika Reintam Blaser
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.,Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
| | - Greet Van den Berghe
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Arthur van Zanten
- Ede and Division of Human Nutrition and Health, Gelderse Vallei Hospital, Wageningen University and Research, Wageningen, The Netherlands
| | - Jan Wernerman
- Division of Anaesthesiology and Intensive Care Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Paul Wischmeyer
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, NC, USA
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20
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Al-Dorzi HM, Arabi YM. Nutrition support for critically ill patients. JPEN J Parenter Enteral Nutr 2021; 45:47-59. [PMID: 34897737 DOI: 10.1002/jpen.2228] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/16/2021] [Accepted: 07/16/2021] [Indexed: 12/12/2022]
Abstract
Nutrition support is an important aspect of the management of critically ill patients. This review highlights the emerging evidence on critical care nutrition and focuses on the pathophysiologic interplay between critical illness, the gastrointestinal tract, and nutrition support and the evidence on the best route, dose, and timing of nutrition. Although indirect calorimetry is recommended to measure energy expenditure, predictive equations are commonly used but are limited by their inaccuracy in individual patients. The current evidence supports early enteral nutrition (EN) in most patients, with a gradual increase in the daily dose over the first week. Delayed EN is warranted in patients with severe shock. According to recent trials, parenteral nutrition seems to be as effective as EN and may be started if adequate EN is not achieved by the first week of critical illness. A high protein dose has been recommended, but the best timing is unclear. Immuno-nutrition should not be routinely provided to critically ill patients. Patients receiving artificial nutrition should be monitored for metabolic derangements. Additional adequately powered studies are still needed to resolve many unanswered questions.
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Affiliation(s)
- Hasan M Al-Dorzi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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21
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Bae E, Kim J, Jang J, Kim J, Kim S, Chang Y, Kim MY, Jeon M, Kang S, Lee JK, Kim TG. Effects of a low-FODMAP enteral formula on diarrhea on patients in the intensive care unit. Nutr Res Pract 2021; 15:703-714. [PMID: 34858549 PMCID: PMC8601948 DOI: 10.4162/nrp.2021.15.6.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/01/2021] [Accepted: 05/13/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/OBJECTIVES A dietary restriction on the intake of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) has been reported to be effective in the treatment of gastrointestinal (GI) tract complications. Enteral nutrition (EN) is widely used for patients who cannot obtain their nutritional requirements orally, but many studies have reported EN complications, especially diarrhea, in up to 50% of patients. SUBJECTS/METHODS We performed a single-center, non-randomized, controlled trial to determine the effects of a low-FODMAP enteral formula on GI complications in patients in intensive care units (ICUs). Patients in the ICU who needed EN (n = 66) were alternately assigned to the low-FODMAP group (n = 33) or the high-FODMAP group (n = 33). RESULTS Anthropometric and biochemical parameters were measured, and stool assessment was performed using King's Stool Chart. We excluded patients who received laxatives, GI motility agents, proton pump inhibitors, antifungal agents, and antibiotics other than β-lactams. There were no differences in GI symptoms during 7 days of intervention, including bowel sound, abdominal distension, and vomiting between the 2 groups. However, diarrhea was more frequent in the high-FODMAP group (7/33 patients) than the low-FODMAP group (1/33 patients) (P = 0.044). CONCLUSIONS Our results suggest that a low-FODMAP enteral formula may be a practical therapeutic approach for patients who exhibit enteral formula complications. Our study warrants further randomized clinical trials and multicenter trials. Trial Registration Clinical Research Information Service Identifier: KCT0005660
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Affiliation(s)
- Eunjoo Bae
- Department of Food and Nutrition, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam 13496, Korea.,Department of Medical Nutrition, Kyung Hee University, Yongin 17104, Korea
| | - Jiyoon Kim
- Department of Food and Nutrition, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam 13496, Korea
| | - Jinyoung Jang
- Department of Neurosurgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam 13496, Korea
| | - Junghyun Kim
- Division of Pulmonology, Allergy, and Critical Care Medicine, Department of Internal Medicine, CHA Bundang Medical Center, School of Medicine, CHA University, Seongnam 13496, Korea
| | - Suyeon Kim
- Department of Pharmacy, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam 13496, Korea
| | - Youngeun Chang
- Department of Food and Nutrition, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam 13496, Korea
| | - Mi Yeon Kim
- Department of Nursing, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam 13496, Korea
| | - Mira Jeon
- Department of Nursing, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam 13496, Korea
| | - Seongsuk Kang
- Department of Nursing, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam 13496, Korea
| | - Jung Keun Lee
- Department of Neurosurgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam 13496, Korea
| | - Tae Gon Kim
- Department of Neurosurgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam 13496, Korea
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22
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Berger FA, van Weteringen W, van der Sijs H, Hunfeld NGM, Bunge JJH, de Groot NMS, van den Bemt PMLA, van Gelder T. Dynamics of the QTc interval over a 24-h dose interval after start of intravenous ciprofloxacin or low-dose erythromycin administration in ICU patients. Pharmacol Res Perspect 2021; 9:e00865. [PMID: 34697899 PMCID: PMC8546217 DOI: 10.1002/prp2.865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 08/07/2021] [Accepted: 08/10/2021] [Indexed: 11/17/2022] Open
Abstract
QTc interval prolongation is an adverse effect associated with the use of fluoroquinolones and macrolides. Ciprofloxacin and erythromycin are both frequently prescribed QTc-prolonging drugs in critically ill patients. Critically ill patients may be more vulnerable to developing QTc prolongation, as several risk factors can be present at the same time. Therefore, it is important to know the QTc-prolonging potential of these drugs in the intensive care unit (ICU) population. The aim of this study was to assess the dynamics of the QTc interval over a 24-hour dose interval during intravenous ciprofloxacin and low-dose erythromycin treatment. Therefore, an observational study was performed in ICU patients (≥18 years) receiving ciprofloxacin 400 mg t.i.d. or erythromycin 100 mg b.i.d. intravenously. Continuous ECG data were collected from 2 h before to 24 h after the first administration. QT-analyses were performed using high-end holter software. The effect was determined with a two-sample t-test for clustered data on all QTc values. A linear mixed model by maximum likelihood was applied, for which QTc values were assessed for the available time intervals and therapy. No evident effect over time on therapy with ciprofloxacin and erythromycin was observed on QTc time. There was no significant difference (p = 0.22) in QTc values between the ciprofloxacin group (mean 393 ms) and ciprofloxacin control group (mean 386 ms). The erythromycin group (mean 405 ms) and erythromycin control group (mean 404 ms) neither showed a significant difference (p = 0.80). In 0.6% of the registrations (1.138 out of 198.270 samples) the duration of the QTc interval was longer than 500 ms. The index groups showed slightly more recorded QTc intervals over 500 ms. To conclude, this study could not identify differences in the QTc interval between the treatments analyzed.
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Affiliation(s)
- Florine A. Berger
- Department of Hospital PharmacyErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
| | - Willem van Weteringen
- Department of Paediatric SurgeryErasmus MC Sophia Children’s Hospital, University Medical Center RotterdamRotterdamthe Netherlands
| | - Heleen van der Sijs
- Department of Hospital PharmacyErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
| | - Nicole G. M. Hunfeld
- Department of Hospital PharmacyErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
- Department of Intensive CareErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
| | - Jeroen J. H. Bunge
- Department of Intensive CareErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
- Department of CardiologyErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
| | - Natasja M. S. de Groot
- Department of CardiologyErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
| | - Patricia M. L. A. van den Bemt
- Department of Hospital PharmacyErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
- Department of Clinical Pharmacy and PharmacologyUniversity Medical Center GroningenGroningenthe Netherlands
| | - Teun van Gelder
- Department of Hospital PharmacyErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
- Department of Clinical Pharmacy and ToxicologyLeiden University Medical CenterLeidenthe Netherlands
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Costa CPD, Gomes DL, Franco MCA. Management of gastrointestinal complications of enteral nutritional therapy in the ICU. Rev Assoc Med Bras (1992) 2021; 67:889-894. [PMID: 34709336 DOI: 10.1590/1806-9282.20201068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 02/20/2021] [Indexed: 11/22/2022] Open
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Martin GL, Trioux T, Gaudry S, Tubach F, Hajage D, Dechartres A. Association Between Lack of Blinding and Mortality Results in Critical Care Randomized Controlled Trials: A Meta-Epidemiological Study. Crit Care Med 2021; 49:1800-1811. [PMID: 33927122 DOI: 10.1097/ccm.0000000000005065] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To investigate whether intervention effect estimates for mortality differ between blinded and nonblinded randomized controlled trials conducted in critical care. We used a meta-epidemiological approach, comparing effect estimates between blinded and nonblinded randomized controlled trials for the same research question. DATA SOURCES Systematic reviews and meta-analyses of randomized controlled trials evaluating a therapeutic intervention on mortality in critical care, published between January 2009 and March 2019 in high impact factor general medical or critical care journals and by Cochrane. DATA EXTRACTION For each randomized controlled trial included in eligible meta-analyses, we evaluated whether the trial was blinded (i.e., double-blinded and/or reporting adequate methods) or not (i.e., open-label, single-blinded, or unclear). We collected risk of bias evaluated by the review authors and extracted trial results. DATA SYNTHESIS Within each meta-analysis, we compared intervention effect estimates between blinded and nonblinded randomized controlled trials by using a ratio of odds ratio (< 1 indicates larger estimates in nonblinded than blinded randomized controlled trials). We then combined ratio of odds ratios across meta-analyses to obtain the average relative difference between nonblinded and blinded trials. Among 467 randomized controlled trials included in 36 meta-analyses, 267 (57%) were considered blinded and 200 (43%) nonblinded. Intervention effect estimates were statistically significantly larger in nonblinded than blinded trials (combined ratio of odds ratio, 0.91; 95% CI, 0.84-0.99). We found no heterogeneity across meta-analyses (p = 0.72; I2 = 0%; τ2 = 0). Sensitivity analyses adjusting the main analysis on risk of bias items yielded consistent results. CONCLUSIONS Intervention effect estimates of mortality were slightly larger in nonblinded than blinded randomized controlled trials conducted in critical care, but confounding cannot be excluded. Blinding of both patients and personnel is important to consider when possible in critical care trials, even when evaluating mortality.
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Affiliation(s)
- Guillaume L Martin
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Département de Santé Publique, Paris, France
| | - Théo Trioux
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Département de Santé Publique, Paris, France
| | - Stéphane Gaudry
- Département de réanimation médico-chirurgicale, APHP, Hôpital Avicenne, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France
- Common and Rare Kidney Diseases, Sorbonne Université, INSERM, UMR-S 1155, Paris, France
| | - Florence Tubach
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Département de Santé Publique, Paris, France
| | - David Hajage
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Département de Santé Publique, Paris, France
| | - Agnès Dechartres
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Département de Santé Publique, Paris, France
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Ouyang X, Qu R, Hu B, Wang Y, Yao F, Lv B, Sun C, Deng Y, Chen C. Is metoclopramide beneficial for the postpyloric placement of nasoenteric tubes? A systematic review and meta-analysis of randomized controlled trials. Nutr Clin Pract 2021; 37:316-327. [PMID: 34155678 PMCID: PMC9292665 DOI: 10.1002/ncp.10725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background Metoclopramide is frequently prescribed as an adjuvant for the postpyloric placement of nasoenteric tubes (NETs). However, a recent meta‐analysis showed that metoclopramide was not beneficial in adults. Thus, this study aimed to reevaluate the effect of metoclopramide on the postpyloric placement of NETs. Methods A systematic search of PubMed, Embase, the Cochrane Library, Web of Science, Chinese National Knowledge Infrastructure (CNKI), and Wanfang data was conducted up to August 2020 for randomized controlled trials (RCTs) comparing metoclopramide with placebo or no intervention. Trial sequential analysis (TSA) was used for the primary outcomes (the success rate of the postpyloric placement of NETs). Results Seven eligible RCTs that included 520 participants were identified. The results of the pooled effect sizes showed that metoclopramide significantly facilitated the postpyloric placement of NETs (relative risk [RR], 1.48; 95% CI, 1.11–1.97; P = .007; I2 = 37%). However, the risk‐of‐bias assessment and the TSA results indicated that the qualities of the RCTs and the sample sizes were insufficient to confirm the efficacy of metoclopramide. Further subgroup analysis revealed that successful postpyloric placement was more pronounced in studies in which spiral NETs were employed (RR, 1.85; 95% CI, 1.41–2.43; P < .001; I2 = 0%). Additionally, overall adverse events were minimal. Conclusions The evidence accumulated so far was not strong enough to demonstrate metoclopramide's beneficial effects on the postpyloric placement of NETs. Further high‐quality, large‐sample RCTs are required to elucidate the effects of metoclopramide.
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Affiliation(s)
- Xin Ouyang
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Rong Qu
- Department of Critical Care Medicine, Huizhou Municipal Central Hospital, Huizhou, Guangdong, China
| | - Bei Hu
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Yifan Wang
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Fen Yao
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Bo Lv
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Cheng Sun
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Yiyu Deng
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Chunbo Chen
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China.,Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
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Juan-Díaz M, Mateu-Campos ML, Sánchez-Miralles A, Martínez Quintana ME, Mesejo-Arizmendi A. Recommendations for specialized nutritional-metabolic management of the critical patient: Monitoring and safety. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC). Med Intensiva 2021; 44 Suppl 1:44-51. [PMID: 32532410 DOI: 10.1016/j.medin.2019.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/21/2019] [Accepted: 12/15/2019] [Indexed: 12/20/2022]
Affiliation(s)
- M Juan-Díaz
- Servicio de Medicina Intensiva, Hospital Clínico Universitario de Valencia, Valencia, España.
| | - M L Mateu-Campos
- Servicio de Medicina Intensiva, Hospital General Universitario de Castellón, Castellón, España
| | - A Sánchez-Miralles
- Servicio de Medicina Intensiva, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, España
| | - M E Martínez Quintana
- Servicio de Medicina Intensiva, Hospital General Universitario Los Arcos del Mar Menor, Pozo Aledo, Murcia, España
| | - A Mesejo-Arizmendi
- Servicio de Medicina Intensiva, Hospital Clínico Universitario de Valencia, Valencia, España
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Abstract
Gastric motility disorders present both diagnostic and therapeutic challenges and likely are under-recognized in small animal practice. This review includes a comparative overview of etiopathogenesis and clinical presentation of gastric motility disorders, suggests a practical approach to the diagnosis of these conditions, and provides an update on methods to evaluate gastric motor function. Furthermore, management of gastric dysmotility is discussed, including a review of the documented effect of gastric prokinetics.
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Affiliation(s)
- Roman Husnik
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Purdue University, 625 Harrison Street, West Lafayette, IN 47907, USA.
| | - Frédéric Gaschen
- Department of Veterinary Clinical Sciences, Louisiana State University School of Veterinary Medicine, Skip Bertman Drive, Baton Rouge, LA 70803, USA
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Huang KS, Pan BL, Lai WA, Bin PJ, Yang YH, Chou CP. Could prokinetic agents protect long-term nasogastric tube-dependent patients from being hospitalized for pneumonia? A nationwide population-based case-crossover study. PLoS One 2021; 16:e0249645. [PMID: 33819293 PMCID: PMC8021154 DOI: 10.1371/journal.pone.0249645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 03/23/2021] [Indexed: 11/18/2022] Open
Abstract
Background Some studies have indicated that the use of prokinetic agents may reduce pneumonia risk in some populations. Nasogastric tube insertion is known to increase the risk of pneumonia because it disrupts lower esophageal sphincter function. The aim of this study was to evaluate whether prokinetic agents could protect long-term nasogastric tube-dependent patients in Taiwan from being hospitalized for pneumonia. Methods A case-crossover study design was applied in this study. Long-term nasogastric tube-dependent patients who had a first-time admission to a hospital due to pneumonia from 1996 to 2013 that was recorded in the Taiwan National Health Insurance Research Database were included. The case period was set to be 30 days before admission, and two control periods were selected for analysis. Prokinetic agent use during those three periods was then assessed for the included patients. Conditional logistic regression was used to calculate the odds ratio (OR) for pneumonia admission with the use of prokinetic agents. Results A total of 639 first-time hospitalizations for pneumonia among patients with long-term nasogastric tube dependence were included. After adjusting the confounding factors for pneumonia, no negative association between prokinetic agent use and pneumonia hospitalization was found, and the adjusted OR was 1.342 (95% CI 0.967–1.86). In subgroup analysis, the adjusted ORs were 1.401 (0.982–1.997), 1.256 (0.87–1.814), 0.937 (0.607–1.447) and 2.222 (1.196–4.129) for elderly, stroke, diabetic and parkinsonism patients, respectively. Conclusion Prokinetic agent use had no negative association with pneumonia admission among long-term nasogastric tube-dependent patients in Taiwan.
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Affiliation(s)
- Kun-Siang Huang
- Department of Family Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Bo-Lin Pan
- Department of Family Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wei-An Lai
- Department of Family Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Pin-Jie Bin
- Department of Family Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yao-Hsu Yang
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
- Health Information and Epidemiology Laboratory of Chang Gung Memorial Hospital, Chiayi, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Pei Chou
- Department of Family Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- * E-mail:
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Elango M, Papalois V. Working towards an ERAS Protocol for Pancreatic Transplantation: A Narrative Review. J Clin Med 2021; 10:1418. [PMID: 33915899 PMCID: PMC8036565 DOI: 10.3390/jcm10071418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/24/2021] [Accepted: 03/27/2021] [Indexed: 12/11/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) initially started in the early 2000s as a series of protocols to improve the perioperative care of surgical patients. They aimed to increase patient satisfaction while reducing postoperative complications and postoperative length of stay. Despite these protocols being widely adopted in many fields of surgery, they are yet to be adopted in pancreatic transplantation: a high-risk surgery with often prolonged length of postoperative stay and high rate of complications. We have analysed the literature in pancreatic and transplantation surgery to identify the necessary preoperative, intra-operative and postoperative components of an ERAS pathway in pancreas transplantation.
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Affiliation(s)
- Madhivanan Elango
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK;
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Camilleri M. Relationship of motor mechanisms to gastroparesis symptoms: toward individualized treatment. Am J Physiol Gastrointest Liver Physiol 2021; 320:G558-G563. [PMID: 33566731 PMCID: PMC8238170 DOI: 10.1152/ajpgi.00006.2021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Following a classical paper by Dr. Keith A. Kelly published in this journal, and over the past 40 years, there has been increased understanding of the functions of different regions of the stomach, specifically the fundus, antrum, and pylorus. Several of the important physiological principles were based on in vivo animal studies that led to the appreciation of regional function and control mechanisms. These include the roles of the extrinsic parasympathetic vagal innervation, the gastric enteric nervous system and electrical syncytium consisting of pacemaker cells and smooth muscle cells, and duodenogastric reflexes providing feedback regulation following the arrival of food and hydrogen ions stimulating the release of hormones and vagal afferent mechanisms that inhibit gastric motility and stimulate pyloric contractility. Further insights on the role of regional motor functions in gastric emptying were obtained from observations in patients following diverse gastric surgeries or bariatric procedures, including fundoplication, Billroth I and sleeve gastrectomy, and sleeve gastroplasty. Antropyloroduodenal manometry and measurements of pyloric diameter and distensibility index provided important assessments of the role of antral hypomotility and pylorospasm, and these constitute specific targets for individualized treatment of patients with gastroparesis. Moreover, in patients with upper gastrointestinal symptoms suggestive of gastroparesis, the availability of measurements of gastric accommodation and pharmacological agents to reduce gastric sensitivity or enhance gastric accommodation provide additional specific targets for individualized treatment. It is anticipated that, in the future, such physiological measurements will be applied in patients to optimize choice of therapy, possibly including identifying the best candidate for pyloric interventions.
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Affiliation(s)
- Michael Camilleri
- Division of Gastroenterology and Hepatology, Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, Minnesota
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Elmokadem EM, El Borolossy RM, Bassiouny AM, Hanna MG, Darweesh EAG, Sabri NA. The efficacy and safety of itopride in feeding intolerance of critically ill patients receiving enteral nutrition: a randomized, double-blind study. BMC Gastroenterol 2021; 21:126. [PMID: 33740892 PMCID: PMC7976729 DOI: 10.1186/s12876-021-01712-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/04/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Enteral feeding intolerance (EFI) is a frequent problem in the Intensive care unit (ICU) and is associated with poor clinical outcomes leading to worse prognosis in terms of mortality and ICU stay. Nowadays, prokinetic drugs are the mainstay of therapy in EFI. However, available prokinetics have uncertain efficacy and safety profiles. Itopride, is a prokinetic agent which is different and unique from the available prokinetics because of its dual mode of action as well as its tolerability and safety. The current study compared the efficacy and safety of Itopride against metoclopramide for EFI in critically ill patients. Moreover, it tested the utility and applicability of ultrasonography to measure gastric residual volume (GRV) in this population. METHODS This randomized, double-blind study included 76 EFI patients who were randomly assigned to either Itopride or metoclopramide group. The primary outcome was to measure GRV by ultrasonography. Secondary outcomes included the percentage ratio of enteral feed volume, energy and protein received by patients over 7 days of treatment, ICU length of stay, safety parameters and occurrence of infectious complications or vomiting. RESULTS Thirty-five patients of each group completed the study. At day 7, itopride significantly decreased GRV compared with metoclopramide group (p = 0.001). Moreover, there was a significant increase in the ratios of received enteral nutrition feed volume, calories, and protein after the one-week therapy in the itopride group more than the metoclopramide group (p = 0.001), (p = 0.002), (p = 0.01), respectively and there were no differences in any secondary outcomes or adverse events between the two groups. CONCLUSION In critically ill patients with EFI, itopride was well tolerated with superior efficacy to metoclopramide. In addition, we demonstrated that ultrasonography is a simple, non-invasive, inexpensive, and undemanding method for GRV measurements and can offer reliable assessments in the gastric emptying modality. TRIAL REGISTRATION The trial was registered in ClinicalTrials.gov (NCT03698292). Date: October 5, 2018.
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Affiliation(s)
- Eman Mohamed Elmokadem
- Faculty of Pharmaceutical Sciences and Pharmaceutical Industries, Future University in Egypt, Cairo, Egypt.
| | | | | | | | | | - Nagwa A Sabri
- Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Cerise A, Chen JM, Powelson JA, Lutz AJ, Fridell JA. Pancreas transplantation would be easy if the recipients were not diabetic: A practical guide to post-operative management of diabetic complications in pancreas transplant recipients. Clin Transplant 2021; 35:e14270. [PMID: 33644895 DOI: 10.1111/ctr.14270] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/03/2021] [Accepted: 02/16/2021] [Indexed: 01/22/2023]
Abstract
Diabetes mellitus remains a major public health problem throughout the United States with over $300 billion spent in total cost of care annually. In addition to being a leading cost of kidney failure, diabetes causes a host of secondary hyperglycemic-related complications including gastroparesis and orthostatic hypotension. While pancreas transplantation has been established as an effective treatment for diabetes, providing long-term normoglycemia in recipients, the secondary complications of diabetes mellitus persist complicating the post-operative course of an otherwise successful pancreas transplantation. This review describes the mechanism and impact of diabetic gastroparesis and orthostatic hypotension in the post-operative course of pancreas transplant patients and analyzes the various treatment modalities, based on current data and extensive experience at our institution, to treat these respective complications. While gastroparesis and orthostatic hypotension remain challenging post-operative conditions, the establishment of institutional protocols and step-up treatment algorithms can help define more effective therapies.
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Affiliation(s)
- Adam Cerise
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeanne M Chen
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John A Powelson
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Andrew J Lutz
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jonathan A Fridell
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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Characterization of esophageal motor activity, gastroesophageal reflux, and evaluation of prokinetic effectiveness in mechanically ventilated critically ill patients: a high-resolution impedance manometry study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:54. [PMID: 33557860 PMCID: PMC7870125 DOI: 10.1186/s13054-021-03479-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/25/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Motility disorders of upper gastrointestinal tract are common in critical illness and associated with significant clinical consequences. However, detailed quantitative and qualitative analyses of esophageal motor functions are lacking. Therefore, we aimed to characterize the key features of esophageal motility functions using high-resolution impedance manometry (HRIM) and to evaluate an objective link between esophageal motor patterns, gastric emptying, and gastroesophageal reflux. We also studied the prokinetic effects of metoclopramide. METHODS We prospectively performed HRIM for 16 critically ill hemodynamically stable patients. Patients were included if they had low gastric volume (LGV; < 100 mL/24 h, n = 8) or high gastric volume (HGV; > 500 mL/24 h, n = 8). The HRIM data were collected for 5 h with intravenous metoclopramide administration (10 mg) after the first 2 h. RESULTS The findings were grossly abnormal for all critically ill patients. The esophageal contraction vigor was markedly increased, indicating prevailing hypercontractile esophagus. Ineffective propulsive force was observed for 73% of esophageal activities. Panesophageal pressurization was the most common pressurization pattern (64%). Gastroesophageal reflux predominantly occurred with transient lower esophageal sphincter relaxation. The common features of the LGV group were a hyperreactive pattern, esophagogastric outflow obstruction, and frequent reflux. Ineffective motility with reduced lower esophageal sphincter tone, and paradoxically fewer reflux episodes, was common in the HGV group. Metoclopramide administration reduced the number of esophageal activities but did not affect the number of reflux episodes in either group. CONCLUSION All critically ill patients had major esophageal motility abnormalities, and motility patterns varied according to gastric emptying status. Well-preserved gastric emptying and maintained esophagogastric barrier functions did not eliminate reflux. Metoclopramide failed to reduce the number of reflux episodes regardless of gastric emptying status. Trial registration ISRCTN, ISRCTN14399966. Registered 3.9.2020, retrospectively registered. https://www.isrctn.com/ISRCTN14399966 .
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Wu J, Ye Z, Xue A, Huang Y. Can domperidone decrease transit time of pediatric video capsule endoscopy? A randomized controlled trial. Transl Pediatr 2021; 10:344-349. [PMID: 33708520 PMCID: PMC7944175 DOI: 10.21037/tp-20-273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The complete examination rate of video capsule endoscopy can be increased by reduced gastric transit time (GTT) and or small bowel transit time (SBTT). This study aims to examine whether the prokinetic domperidone reduces GTT and/or SBTT in pediatric patients undergoing video capsule endoscopy (VCE). METHODS We performed a single-center randomized controlled trial (n=200) to evaluate the effect of domperidone on GTT and SBTT among pediatric patients in a tertiary university-affiliated hospital for children. We explored whether patients randomized to domperidone had increased GTT, SBTT (primary outcomes) or higher complete examination rate (secondary outcome). The safety outcomes were the adverse effects in the domperidone group. This study was registered on ClinicalTrials.gov (NCT03662113). RESULTS Demographic features including gender and age were similar between the 100 patients of the domperidone group and the 100 patients of the control group. The median GTT was 67.5 minutes (44.8-117.5) in the domperidone group and 80.0 minutes (42.0-128.0) in the control group, while the median SBTT was 317 minutes (231-436) and 323 minutes (225-426), respectively. There were no significant differences in GTT (P=0.49) and SBTT (P=0.52) between the two groups. The complete examination rate was 97% and 98% in the domperidone and control groups, respectively (P=1.00). CONCLUSIONS Domperidone shows no effect on GTT, SBTT and complete examination rate in pediatric patients receiving VCE.
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Affiliation(s)
- Jie Wu
- Department of Gastroenterology, Children's Hospital of Fudan University, Shanghai, China
| | - Ziqing Ye
- Department of Gastroenterology, Children's Hospital of Fudan University, Shanghai, China
| | - Aijuan Xue
- Department of Gastroenterology, Children's Hospital of Fudan University, Shanghai, China
| | - Ying Huang
- Department of Gastroenterology, Children's Hospital of Fudan University, Shanghai, China
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Ohbe H, Jo T, Matsui H, Fushimi K, Yasunaga H. Effect of Daikenchuto for Mechanically Ventilated Patients With Enteral Feeding Intolerance: A Propensity Score-Matched Analysis Using a Nationwide Administrative Inpatient Database. JPEN J Parenter Enteral Nutr 2021; 45:1703-1713. [PMID: 33483948 DOI: 10.1002/jpen.2076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Daikenchuto, a Japanese herbal Kampo medicine, is used to improve gastrointestinal motility in critically ill patients with enteral feeding intolerance (EFI) in Japan. The present study aimed to investigate the effect of Daikenchuto for critically ill patients with EFI. METHODS Using the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018, we identified mechanically ventilated patients in intensive care units (ICUs) who had EFI during mechanical ventilation. We defined EFI as receipt of intravenous metoclopramide during mechanical ventilation. Patients who started Daikenchuto within 2 days of EFI onset were defined as the Daikenchuto group, and the remaining patients were defined as the control group. Propensity score-matched analyses were performed to compare the outcomes between the 2 groups. RESULTS A total of 61,454 patients were included. Of these, 8842 patients (14%) were in the Daikenchuto group. One-to-one propensity score matching created 8701 matched pairs. After propensity score matching, the total number of days receiving enteral nutrition within 28 days of EFI onset was significantly longer in the Daikenchuto group than in the control group (risk difference, 0.9 days; 95% CI, 0.5-1.3 days). There were no significant differences in 28-day in-hospital mortality, hospital-acquired pneumonia, ventilator-free days, length of ICU stay, time to discharge alive, and adverse complications. CONCLUSION This nationwide observational study suggested that use of Daikenchuto may increase the total number of days receiving enteral nutrition in mechanically ventilated patients with EFI.
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Affiliation(s)
- Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Taisuke Jo
- Department of Health Services Research, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
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Shaikh N, Nainthramveetil MM, Nawaz S, Hassan J, Shible AA, Karic E, Singh R, Al Maslamani M. Optimal dose and duration of enteral erythromycin as a prokinetic: A surgical intensive care experience. Qatar Med J 2021; 2020:36. [PMID: 33447536 PMCID: PMC7802089 DOI: 10.5339/qmj.2020.36] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 06/06/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Enteral feeding has various advantages over parenteral feeding in critically ill patients. Acutely ill patients are at risk of developing enteral feeding intolerance. Prokinetic medications improve gastrointestinal mobility and enteral feed migration and absorption. Among the available prokinetic agents, erythromycin is the most potent. Erythromycin is used in different dosages and durations with variable efficacy. Intravenous erythromycin has an early and high rate of tachyphylaxis; hence, enteral route is preferred. Recently, the combination of prokinetic medications has been increasingly used because they accelerate the prokinetic action and decrease the adverse effects. AIM This study aimed to determine the optimal effective prokinetic dose and duration of administering enteral erythromycin in combination with metoclopramide in critically ill patients. PATIENTS AND METHODS This study has a prospective observation design. After obtaining permission from the medical research center of the institution, all patients in the surgical and trauma intensive care unit having enteral feed intolerance and those who were already on metoclopramide for 24 hour (h) were enrolled in the study. Patients' demographic data, diagnosis, surgical intervention, disease severity scores, erythromycin dose, duration of administration, any adverse effects, factors affecting erythromycin response, and outcome were recorded. All patients received 125 mg syrup erythromycin twice daily through a nasogastric tube (NGT). The NGT was clamped for 2 h, and half amount of previous enteral feeds was resumed. If the patient did not tolerate the feeds, the erythromycin dose was increased every 24 h in the increment of 250, 500, and 1000 mg (Figure 1). Statistical significance was considered at P < 0.05. A total of 313 patients were enrolled in the study. Majority of the patients were male, and the mean age was 45 years. RESULTS Majority (48.2%) of the patients (96) with feed intolerance were post laparotomy. Ninety percent (284) of the patients responded to prokinetic erythromycin therapy, and 54% received lower dose (125 mg twice daily). In addition, 14% had diarrhea, and none of these patients tested positive for Clostridium difficile toxin or multidrug resistance bacteria. The mean duration of erythromycin therapy was 4.98 days. The most effective prokinetic dose of erythromycin was 125 mg twice daily (P = 0.001). Erythromycin was significantly effective in patients with multiple organ dysfunction and shock (P = 0.001). Patients with high disease severity index and multiple organ dysfunction had significantly higher mortality (p < 0.05). Patients not responding to erythromycin therapy also had a significant higher mortality (p = 0.001). CONCLUSION Post-laparotomy patients had high enteral feed intolerance. Enteral erythromycin in combination with metoclopramide was effective in low dose and was required for short duration. Patients who did not tolerate feeds despite increasing dose of erythromycin had higher mortality.
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Affiliation(s)
- Nissar Shaikh
- Surgical Intensive care, Hamad Medical Corporation, Doha, Qatar E-mail:
| | | | - Shoaib Nawaz
- Surgical Intensive care, Hamad Medical Corporation, Doha, Qatar E-mail:
| | - Jazib Hassan
- Surgical Intensive care, Hamad Medical Corporation, Doha, Qatar E-mail:
| | - Ahmed A Shible
- Clinical Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | - Edin Karic
- Critical Care, Al Wakrah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Rajvir Singh
- Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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Peng R, Li H, Yang L, Zeng L, Yi Q, Xu P, Pan X, Zhang L. The efficacy and safety of prokinetics in critically ill adults receiving gastric feeding tubes: A systematic review and meta-analysis. PLoS One 2021; 16:e0245317. [PMID: 33428672 PMCID: PMC7799841 DOI: 10.1371/journal.pone.0245317] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 12/28/2020] [Indexed: 12/13/2022] Open
Abstract
Background Intolerance to gastric feeding tubes is common among critically ill adults and may increase morbidity. Administration of prokinetics in the ICU is common. However, the efficacy and safety of prokinetics are unclear in critically ill adults with gastric feeding tubes. We conducted a systematic review to determine the efficacy and safety of prokinetics for improving gastric feeding tube tolerance in critically ill adults. Methods Randomized controlled trials (RCTs) were identified by systematically searching the Medline, Cochrane and Embase databases. Two independent reviewers extracted the relevant data and assessed the quality of the studies. We calculated pooled relative risks (RRs) for dichotomous outcomes and the mean differences (MDs) for continuous outcomes with the corresponding 95% confidence intervals (CIs). We assessed the risk of bias using the Cochrane risk-of-bias tool and used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to rate the quality of the evidence. Results Fifteen RCTs met the inclusion criteria. A total of 10 RCTs involving 846 participants were eligible for the quantitative analysis. Most studies (10 of 13, 76.92%) showed that prokinetics had beneficial effects on feeding intolerance in critically ill adults. In critically ill adults receiving gastric feeding, prokinetic agents may reduce the ICU length of stay (MD -2.03, 95% CI -3.96, -0.10; P = 0.04; low certainty) and the hospital length of stay (MD -3.21, 95% CI -5.35, -1.06; P = 0.003; low certainty). However, prokinetics failed to improve the outcomes of reported adverse events and all-cause mortality. Conclusion As a class of drugs, prokinetics may improve tolerance to gastric feeding to some extent in critically ill adults. However, the certainty of the evidence suggesting that prokinetics reduce the ICU or hospital length of stay is low. Prokinetics did not significantly decrease the risks of reported adverse events or all-cause mortality among critically ill adults.
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Affiliation(s)
- Rong Peng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
- Department of Clinical Nutrition, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Hailong Li
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Lijun Yang
- Department of General Practice Medicine, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Linan Zeng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Qiusha Yi
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Peipei Xu
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Xiangcheng Pan
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Lingli Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
- * E-mail:
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OPSFELDER LAK, WENDT GW, SILVA DRPD, MASSAROLLO MD, FERRETO LED, VIEIRA AP. Nutritional response and clinical complications in patients with post-pyloric and gastric enteral tubes. REV NUTR 2021. [DOI: 10.1590/1678-9865202032e200283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
ABSTRACT Objective The present study assessed the differences in nutritional markers (albumin, transferrin, total body fat, and body mass index) and clinical complications (diarrhea, vomiting, and diet interruptions) associated with enteral nutrition. Methods This is an open-label, randomized, two-arm parallel-group controlled clinical trial. Out of 105 patients assessed for eligibility, 35 adult patients were randomly divided into two groups and followed for 28 days. The sample comprised a heterogeneous group of severely ill individuals initially treated in the intensive care units. Neurological conditions (i.e., strokes and brain tumours) were the most common reasons for hospitalization. Patients had one singularity: the clinical need for exclusive enteral nutrition therapy. One group received the diet via gastric tube and the other via a post-pyloric tube. Results The groups presented increases in the calories prescribed and administered, as well as reduced diet discontinuation. Although similar values were observed up to day 21, the post-pyloric group showed increased albumin levels compared to the gastric group on Day 28. Transferrin levels increased over time in both groups. Conclusion There were no differences in the complications recorded between groups, albeit serum albumin significantly increased in the post-pyloric group.
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Rangan V, Ukleja A. Gastroparesis in the Hospital Setting. Nutr Clin Pract 2020; 36:50-66. [PMID: 33336872 DOI: 10.1002/ncp.10611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/04/2020] [Indexed: 12/15/2022] Open
Abstract
Gastroparesis (GP) is commonly seen in hospitalized patients. Refractory vomiting and related dehydration, electrolyte abnormalities, and malnutrition are indications for hospital admission. In addition, tube feeding intolerance is a common sign of gastric dysmotility in critically ill patients. The diagnosis and management of GP in the hospital setting can be quite challenging. Diagnostic tests are often deferred because of patient intolerance of the oral meal for standard scintigraphy or severity of the primary disease. The diagnosis of GP is often established on the basis of clinical scenario and risk factors for gastric motor dysfunction. Medical therapy in GP is directed toward controlling nausea and vomiting by prokinetic and antinausea medications and correcting nutrition risks or treating malnutrition with nutrition therapy. Enteral nutrition is the preferred nutrition intervention for patients with GP. Delayed gastric emptying in critically ill patients has a negative impact on the timely delivery of enteral feeding and meeting the energy and protein goals. Measures to improve gastric tolerance or provide feeding beyond the stomach are often needed, since early enteral nutrition has been an important target of therapy for critically ill patients. This review will address the current understanding of the mechanisms of GP and feeding intolerance in critical illness, diagnostic workup, drug therapies, and interventions to improve the provision of enteral nutrition in hospital settings when gastric dysmotility is present or suspected.
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Affiliation(s)
- Vikram Rangan
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew Ukleja
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Reintam Blaser A, Deane AM, Preiser J, Arabi YM, Jakob SM. Enteral Feeding Intolerance: Updates in Definitions and Pathophysiology. Nutr Clin Pract 2020; 36:40-49. [DOI: 10.1002/ncp.10599] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Annika Reintam Blaser
- Department of Intensive Care Medicine Lucerne Cantonal Hospital Lucerne Switzerland
- Department of Anaesthesiology and Intensive Care University of Tartu Tartu Estonia
| | - Adam M. Deane
- Department of Medicine and Radiology The University of Melbourne Melbourne Medical School Royal Melbourne Hospital Parkville Victoria Australia
| | | | - Yaseen M. Arabi
- College of Medicine King Saud bin Abdulaziz University for Health Sciences (KSAU‐HS) and King Abdullah International Medical Research Center Riyadh Saudi Arabia
| | - Stephan M. Jakob
- Department of Intensive Care Medicine University Hospital (Inselspital) Bern University of Bern Bern Switzerland
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Heming N, Azabou E, Cazaumayou X, Moine P, Annane D. Sepsis in the critically ill patient: current and emerging management strategies. Expert Rev Anti Infect Ther 2020; 19:635-647. [PMID: 33140679 DOI: 10.1080/14787210.2021.1846522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Introduction: Sepsis, a dysregulated host response to infection, is a major cause of morbidity and mortality worldwide. Early identification and evidence-based treatment of sepsis are associated with improved outcomes.Areas covered: This narrative review was undertaken following a PubMed search for English language reports published before July 2020 using the terms 'sepsis,' 'septic shock,' 'fluids,' 'fluid therapy,' 'albumin,' 'corticosteroids,' 'vasopressor.' Emerging management strategies were identified following a search of the ClinicalTrails.gov database using the term 'sepsis.' Additional reports were identified by examining the reference lists of selected articles and based on personnel knowledge of the field of sepsis.Expert opinion: The core treatment of sepsis relies on source control, early antibiotics, and organ support. The main emerging strategies focus on immunomodulation, artificial intelligence, and on multi-omics approaches for a personalized therapy.
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Affiliation(s)
- Nicholas Heming
- Department of Intensive Care, Raymond Poincaré Hospital, GHU APHP Université Paris Saclay, Garches, France.,Laboratory Inflammation & Infection, U1173, School of Medicine Simone Veil, Université Paris Saclay-UVSQ and - INSERM 2 Avenue De La Source De La Bièvre, Montigny-le-Bretonneux, France.,FHU SEPSIS (Saclay and Paris Seine Nord Endeavour to PerSonalize Interventions for SEPSIS).,RHU RECORDS (Rapid rEcognition of CORticosteroiD Resistant or Sensitive Sepsis)
| | - Eric Azabou
- Laboratory Inflammation & Infection, U1173, School of Medicine Simone Veil, Université Paris Saclay-UVSQ and - INSERM 2 Avenue De La Source De La Bièvre, Montigny-le-Bretonneux, France.,FHU SEPSIS (Saclay and Paris Seine Nord Endeavour to PerSonalize Interventions for SEPSIS).,RHU RECORDS (Rapid rEcognition of CORticosteroiD Resistant or Sensitive Sepsis).,Clinical Neurophysiology and Neuromodulation Unit, Department of Physiology, Raymond Poincaré Hospital, GHU APHP Université Paris Saclay, Garches, France
| | - Xavier Cazaumayou
- Department of Intensive Care, Raymond Poincaré Hospital, GHU APHP Université Paris Saclay, Garches, France
| | - Pierre Moine
- Department of Intensive Care, Raymond Poincaré Hospital, GHU APHP Université Paris Saclay, Garches, France.,Laboratory Inflammation & Infection, U1173, School of Medicine Simone Veil, Université Paris Saclay-UVSQ and - INSERM 2 Avenue De La Source De La Bièvre, Montigny-le-Bretonneux, France.,FHU SEPSIS (Saclay and Paris Seine Nord Endeavour to PerSonalize Interventions for SEPSIS).,RHU RECORDS (Rapid rEcognition of CORticosteroiD Resistant or Sensitive Sepsis)
| | - Djillali Annane
- Department of Intensive Care, Raymond Poincaré Hospital, GHU APHP Université Paris Saclay, Garches, France.,Laboratory Inflammation & Infection, U1173, School of Medicine Simone Veil, Université Paris Saclay-UVSQ and - INSERM 2 Avenue De La Source De La Bièvre, Montigny-le-Bretonneux, France.,FHU SEPSIS (Saclay and Paris Seine Nord Endeavour to PerSonalize Interventions for SEPSIS).,RHU RECORDS (Rapid rEcognition of CORticosteroiD Resistant or Sensitive Sepsis)
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Hrdy O, Vrbica K, Strazevska E, Suk P, Souckova L, Stepanova R, Sas I, Gal R. Comparison of continuous versus intermittent enteral nutrition in critically ill patients (COINN): study protocol for a randomized comparative effectiveness trial. Trials 2020; 21:955. [PMID: 33228772 PMCID: PMC7682133 DOI: 10.1186/s13063-020-04866-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 11/03/2020] [Indexed: 01/03/2023] Open
Abstract
Background Enteral nutrition is part of the treatment of critically ill patients. Administration of enteral nutrition may be associated with signs of intolerance, such as high gastric residual volumes, diarrhea, and vomiting. Clinical trials regarding the effects of the mode of administration of enteral nutrition on the occurrence of these complications have yielded conflicting results. This trial aims to investigate whether the mode of administration of enteral nutrition affects the time to reach nutritional targets, intolerance, and complications. Methods COINN is a randomized, monocentric study for critically ill adult patients receiving enteral nutrition. Patients will be randomly assigned to two groups receiving (1) continuous or (2) intermittent administration of enteral nutrition. Enhancement of enteral nutrition will depend on signs of tolerance, mainly the gastric residual volume. The primary outcome will be the time to reach the energetic target. Secondary outcomes will be the time to reach the protein target, tolerance, complications, hospital and ICU lengths of stay, and 28-day mortality. Discussion This trial aims to evaluate whether the mode of application of enteral nutrition affects the time to reach nutritional targets, signs of intolerance, and complications. Trial registration ClinicalTrials.gov NCT03573453. Registered on 29 June 2018
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Affiliation(s)
- Ondrej Hrdy
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Kamil Vrbica
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Eva Strazevska
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Petr Suk
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Lenka Souckova
- Department of Pharmacology, Faculty of Medicine, Masaryk University, VVI CZECRIN, Brno, Czech Republic
| | - Radka Stepanova
- Department of Pharmacology, Faculty of Medicine, Masaryk University, VVI CZECRIN, Brno, Czech Republic
| | - Igor Sas
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Roman Gal
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Charoensareerat T, Bhurayanontachai R, Sitaruno S, Navasakulpong A, Boonpeng A, Lerkiatbundit S, Pattharachayakul S. Efficacy and Safety of Enteral Erythromycin Estolate in Combination With Intravenous Metoclopramide vs Intravenous Metoclopramide Monotherapy in Mechanically Ventilated Patients With Enteral Feeding Intolerance: A Randomized, Double-Blind, Controlled Pilot Study. JPEN J Parenter Enteral Nutr 2020; 45:1309-1318. [PMID: 32895971 DOI: 10.1002/jpen.2013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/09/2020] [Accepted: 09/04/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND In this pilot study, we aimed to determine the efficacy and safety of enteral erythromycin estolate in combination with intravenous metoclopramide compared to intravenous metoclopramide monotherapy in mechanically ventilated patients with enteral feeding intolerance. METHODS This randomized, double-blind, controlled pilot study included 35 mechanically ventilated patients with feeding intolerance who were randomly assigned to receive 10-mg metoclopramide intravenously every 6-8 hours in combination with 250-mg enteral erythromycin estolate (study group) or placebo every 6 hours for 7 days. The primary outcome was an administered-to-target energy ratio of ≥80% at 48 hours, indicating a successful feeding. Secondary, prespecified outcomes were daily average gastric residual volume (GRV), total energy intake, administered-to-target energy ratio, hospital length of stay, in-hospital mortality, and 28-day mortality. RESULTS The rate of successful feeding was not significantly different between the study and placebo groups (47.1% and 61.1%, respectively; P = .51). The average daily GRV was significantly lower in the study group than in the placebo group (β = 91.58 [95% Wald CI, -164.35 to -18.8]), determined by generalized estimating equation. Other secondary outcomes were comparable, and the incidence of adverse events was not significantly different between the 2 groups. One common complication was cardiac arrhythmia, which was mostly self-terminated. CONCLUSION Although the combination therapy of enteral erythromycin estolate and intravenous metoclopramide reduced GRV, the successful feeding rate and other patient-specific outcomes did not improve in mechanically ventilated patients with feeding intolerance.
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Affiliation(s)
| | - Rungsun Bhurayanontachai
- Critical Care Medicine Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Sirima Sitaruno
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Songkhla, Thailand
| | - Asma Navasakulpong
- Respiratory and Respiratory Critical Care Medicine Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Apinya Boonpeng
- School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Sanguan Lerkiatbundit
- Department of Pharmacy Administration, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Songkhla, Thailand
| | - Sutthiporn Pattharachayakul
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Songkhla, Thailand
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Pardo E. [Nutritional support for critically ill patients suffering from SARS-CoV-2 infection]. LE PRATICIEN EN ANESTHESIE REANIMATION 2020; 24:218-224. [PMID: 32837212 PMCID: PMC7351417 DOI: 10.1016/j.pratan.2020.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with severe cases of COVID-19 are at high nutritional risk during their ICU stay. Prolonged immobilization associated with an exacerbated systemic inflammatory response is a major provider of ICU-acquired muscle weakness. Early enteral nutrition is recommended to gradually reach the energy target of 25 kcal/kg/day and protein target of 1.3 g/kg/day around D4. The occurrence of a Refeeding syndrome should be closely monitored. In case of feeding intolerance refractory to a prokinetic treatment, complementary or total parenteral nutrition is advised, favouring new generation mixed lipid emulsions (containing fish oil) and regular monitoring of triglyceridemia. Nutrition care of critically ill patients should be carried out with limited procedures that may pose a risk of contamination for the healthcare staff.
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Affiliation(s)
- Emmanuel Pardo
- Service d'anesthésie-réanimation, hôpital Saint-Antoine, AP-HP, Paris, France
- Sorbonne universités, UPMC Université Paris 06, Paris, France
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Abstract
Bowel dysfunction, especially ileus, has been increasingly recognized in critically ill patients. Ileus is commonly associated to constipation, however abnormal motility can also concern the upper digestive tract, therefore impaired gastrointestinal transit (IGT) seems to be a more appropriate term. IGT, especially constipation, is common among patients under mechanical ventilation, occurring in up to 80% of the patients during the first week, and has been associated with worse outcome in intensive care unit (ICU). It is acknowledged that the most relevant definition for constipation in ICU is the absence of stool for the first six days after admission. Concerning the upper digestive intolerance (UDI), the diagnosis should rely only on vomiting and the systematic gastric residual volume (GRV) monitoring should be avoided. IGT results from a complex pathophysiology in which both the critical illness and its specific treatments may have a deleterious role. Both observational and experimental studies have shown the deleterious effect of sepsis, multiorgan failure, sedation (especially opioids) and mechanical ventilation on gut function. To date few studies have reported effect of treatment on IGT and the level of evidence is low. However, cholinesterase inhibitors seem safe and could probably be used in case of constipation but remains poorly prescribed. Prevention with bowel management protocol using osmotic laxatives appears to be safe but did not demonstrate its effectiveness. For patients treated with high posology of opioids during sedation, enteral opioid antagonists may be a promising strategy.
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Affiliation(s)
- Philippe Ariès
- Clermont-Tonnerre Military Teaching Hospital, Brest, France.,Val-de-Grâce French Military Health Service Academy, Paris, France.,Department of Anesthesia and Surgical Intensive Care, Brest Teaching Hospital, Brest, France
| | - Olivier Huet
- Department of Anesthesia and Surgical Intensive Care, Brest Teaching Hospital, Brest, France - .,UFR of Medicine, University of Western Brittany, Brest, France
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Impact of a natural versus commercial enteral-feeding on the occurrence of diarrhea in critically ill cardiac surgery patients. A retrospective cohort study. Int J Nurs Stud 2020; 108:103605. [PMID: 32502821 DOI: 10.1016/j.ijnurstu.2020.103605] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 03/05/2020] [Accepted: 04/04/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Diarrhea is an important complication in critically ill patients undergoing enteral feeding. The occurrence of diarrhea may lead to systemic and local complications and negatively impacts on nursing workload and patient's wellbeing. An enteral feeding based on blenderized natural food could be beneficial in reducing the risk of diarrhea. No study has compared natural and commercial enteral feedings in critically ill cardiac surgery patients. OBJECTIVE The aim of this study was to compare the risk of diarrhea occurrence in two cohorts of patients fed a blenderized natural food diet or commercial enteral feeding preparations, respectively. DESIGN Retrospective cohort study. SETTING Cardiac-Surgery Intensive Care Unit of a University Hospital. PARTICIPANTS Two-hundred and fifteen patients admitted to the postoperative cardiac surgery intensive care unit were included, 103 fed blenderized natural enteral feeding and 112 fed commercial formulas. METHODS Commercial enteral formulas were delivered by continuous pump administration, while natural enteral feeding by bolus 3 times per day. Diarrhea was documented in the presence of three or more evacuations of loose or watery stool (or an amount above 250 ml) per day. The presence of diarrhea was recorded daily from the beginning to the end of the enteral feeding, up to a maximum of 8 days. The unadjusted time to the first event of diarrhea between the two enteral feeding groups was compared. Adjusted comparison was then performed by fitting a multivariable Cox Proportional-Hazards model, adjusted for potential confounders for diarrhea occurrence (i.e. administration of inotropes, vasopressors, prokinetics, antibiotics, oral nutritional supplements, antifungal agents, sedatives, opioids, probiotics, laxatives). RESULTS In unadjusted survival analysis the probability of diarrhea was significantly lower in the natural enteral feeding group (log rank test: p = 0.023). In the multivariable model patients in natural enteral feeding cohort showed a non-significant trend towards an almost halved risk of experiencing diarrhea (hazard ratio: 0.584; 95% confidence interval: 0.335-1.018; p = 0.058) compared to those fed commercial enteral feeding. CONCLUSIONS Administration of a blenderized diet based on natural food for enteral feeding can reduce the incidence of diarrhea in cardiac surgery critically ill patients. This strategy may reduce the risk of diarrhea-associated malnutrition and systemic and local complications, also having a positive impact on nursing workload and patient wellbeing.
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Reintam Blaser A, Preiser JC, Fruhwald S, Wilmer A, Wernerman J, Benstoem C, Casaer MP, Starkopf J, van Zanten A, Rooyackers O, Jakob SM, Loudet CI, Bear DE, Elke G, Kott M, Lautenschläger I, Schäper J, Gunst J, Stoppe C, Nobile L, Fuhrmann V, Berger MM, Oudemans-van Straaten HM, Arabi YM, Deane AM. Gastrointestinal dysfunction in the critically ill: a systematic scoping review and research agenda proposed by the Section of Metabolism, Endocrinology and Nutrition of the European Society of Intensive Care Medicine. Crit Care 2020; 24:224. [PMID: 32414423 PMCID: PMC7226709 DOI: 10.1186/s13054-020-02889-4] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/13/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Gastrointestinal (GI) dysfunction is frequent in the critically ill but can be overlooked as a result of the lack of standardization of the diagnostic and therapeutic approaches. We aimed to develop a research agenda for GI dysfunction for future research. We systematically reviewed the current knowledge on a broad range of subtopics from a specific viewpoint of GI dysfunction, highlighting the remaining areas of uncertainty and suggesting future studies. METHODS This systematic scoping review and research agenda was conducted following successive steps: (1) identify clinically important subtopics within the field of GI function which warrant further research; (2) systematically review the literature for each subtopic using PubMed, CENTRAL and Cochrane Database of Systematic Reviews; (3) summarize evidence for each subtopic; (4) identify areas of uncertainty; (5) formulate and refine study proposals that address these subtopics; and (6) prioritize study proposals via sequential voting rounds. RESULTS Five major themes were identified: (1) monitoring, (2) associations between GI function and outcome, (3) GI function and nutrition, (4) management of GI dysfunction and (5) pathophysiological mechanisms. Searches on 17 subtopics were performed and evidence summarized. Several areas of uncertainty were identified, six of them needing consensus process. Study proposals ranked among the first ten included: prevention and management of diarrhoea; management of upper and lower feeding intolerance, including indications for post-pyloric feeding and opioid antagonists; acute gastrointestinal injury grading as a bedside tool; the role of intra-abdominal hypertension in the development and monitoring of GI dysfunction and in the development of non-occlusive mesenteric ischaemia; and the effect of proton pump inhibitors on the microbiome in critical illness. CONCLUSIONS Current evidence on GI dysfunction is scarce, partially due to the lack of precise definitions. The use of core sets of monitoring and outcomes are required to improve the consistency of future studies. We propose several areas for consensus process and outline future study projects.
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Affiliation(s)
- Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Sonja Fruhwald
- Department of Anaesthesiology and Intensive Care Medicine, Division of Anesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Alexander Wilmer
- Department of Medical Intensive Care, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Jan Wernerman
- Department of Anaesthesiology and Intensive Care Medicine, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Carina Benstoem
- Department of Intensive Care Medicine, Medical Faculty RWTH Aachen University, Aachen, Germany
- Cardiovascular Critical Care & Anesthesia Research and Evaluation (3CARE), Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Michael P. Casaer
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Joel Starkopf
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Arthur van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Olav Rooyackers
- Department of Anesthesiology and Intensive Care, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Stephan M. Jakob
- Department of Intensive Care Medicine, Inselspital, Bern, Switzerland
- University of Bern, Bern, Switzerland
| | - Cecilia I. Loudet
- Department of Intensive Care, Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina
| | - Danielle E. Bear
- Departments of Critical Care and Nutrition and Dietetics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King’s College London, London, UK
| | - Gunnar Elke
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Matthias Kott
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Ingmar Lautenschläger
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Jörn Schäper
- Department of Anaesthesiology, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Christian Stoppe
- Department of Intensive Care Medicine, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Leda Nobile
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Medicine B, University of Münster, Münster, Germany
| | - Mette M. Berger
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | - Yaseen M. Arabi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) and King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia
| | - Adam M. Deane
- The University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Parkville, Victoria 3050 Australia
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Abstract
Nausea and vomiting are common symptoms in the hospital setting, with numerous causes. Common precipitants leading to or complicating inpatient hospital admissions include nausea and vomiting secondary to drugs, gastrointestinal disturbances, metabolic aberrancies, and vestibular pathologies. Appropriate selection and prescribing of antiemetic drugs is therefore important for healthcare professionals. There are numerous antiemetics available to physicians, ranging from muscarinic, dopaminergic and serotoninergic drugs, each acting on a different part of the nausea-vomiting cascade. This review describes the main pathophysiological processes involved in the development of symptomatic nausea and vomiting, and gives an overview of how common antiemetic drugs function to alleviate symptoms, alongside cautions and contraindications in their usage.
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Affiliation(s)
- Mansimran S Dulay
- Department of Acute Medicine, Chelsea and Westminster Hospital, London, UK
| | - Jasbir S Dulay
- Department of Acute Medicine, University Hospital Southampton, Southampton, UK
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50
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Abstract
Sufficient energy and essential nutrients are vital for normal growth and development in childhood. Ideally, nutrition should be provided orally. However, if the gastrointestinal system is functional, enteral tube feeding can be used when nutritional requirements cannot be provided orally, thus providing nutritional benefits and enabling positive disease management in pediatric patients. Postoperative care in children allows monitoring of the position and functionality of the tube; performing nutrition intolerance, growth, hydration, and nutritional assessments; and performing metabolic and complication follow-ups. Tube feeding in pediatric patients is beneficial and has positive effects in controlling and managing diseases and providing appropriate nutrition in children. However, in postoperative patients, it is important to prevent potential complications, which can be classified into 5 groups: mechanical, gastrointestinal, metabolic, infectious, and pulmonary complications. Important points for managing complications include having enteral nutrition practices based on evidence-based guidelines, sharing outcomes with nurses working in clinical settings, creating enteral feeding guides in clinical settings, providing patients/patients' family with training in line with these guides, and maintaining follow-ups at home. This literature review discusses complications and practices regarding the management of complications after percutaneous endoscopic gastrostomy.
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