[Nutrition (therapy) in gastrointestinal failure]

BACKGROUND

The presence of gastrointestinal dysfunction is an outcome-relevant complication in critically ill ICU patients.

AIMS, MATERIALS AND METHODS

The following review aims to show the importance of gastrointestinal dysfunction. Multimodal therapy for gastroparesis and paralytic ileus is discussed.

CONCLUSION

Erythromycin and metoclopramide are options for gastroparesis, while neostigmine is commonly used for paralytic ileus.

Preoperative ultrasound assessment of gastric content in patients with diabetes: A meta-analysis based on a systematic review of the current literature

STUDY OBJECTIVE

To conduct a systematic literature review of the current evidence on the effect of diabetes mellitus on gastric volume observed during a preoperative ultrasound examination. Using the results of this systematic literature review, a meta-analysis was performed to investigate whether there was an association between diabetes mellitus and an increased risk of presenting with a high-risk stomach (gastric volume associated with an increased risk of pulmonary aspiration).

DESIGN

Review article and meta-analysis.

SETTING

Review of published literature.

PATIENTS

A total of 3366 patients underwent surgery.

INTERVENTION

Gastric ultrasound examination.

MEASUREMENTS

Data for the meta-analysis and literature review were collected from the PubMed/Medline, Embase, Web of Science, and Google Scholar databases of the National Library of Medicine from the date of inception to January 2023. All included studies measured the gastric antral cross-sectional area and/or gastric residual volume in patients with diabetes and those without diabetes. The data utilized in the meta-analysis included all studies that evaluated the incidence of high-risk stomachs based on ultrasonographic measurements of the gastric antral cross-sectional area or gastric residual volume.

MAIN RESULTS

Most collated studies revealed that diabetes mellitus was associated with increased antral cross-sectional area and gastric residual volume. A meta-analysis of published reports indicated that patients with diabetes have an increased rate of high-risk stomachs.

CONCLUSIONS

Diabetes mellitus is associated with an increased rate of high-risk stomachs. The authors recommend large prospective trials to ascertain the safety of the current fasting guidelines for patients with diabetes undergoing surgery.

Assessment of residual gastric volume using point-of-care ultrasonography in adult patients who underwent elective surgery

BACKGROUND

Aspiration pneumonitis remains a dreaded complication that may lead to almost 9% of anaesthesia-related deaths. The presence of gastric contents has always been a contributing factor to an increased risk of aspiration. Preoperative gastric ultrasound has been suggested as a modality for determining residual volume in special populations and conditions. We conducted an observational study to determine the gastric residual volume in preoperative patients of elective surgery with gastric ultrasound and to study its correlation with patient factors.

METHODS

We enrolled 411 patients in the age group of 18-80 with ASA-PS I and II having BMI less than 35 kg/m². Patients with prior gastrointestinal surgery and parturients were excluded from the present study. Gastric antrum in both supine and right lateral decubitus positions was measured using USG in the immediate preoperative period, and gastric residual volume was calculated, which was subsequently correlated with various patient factors.

RESULTS

On qualitative assessment, 97 and 118 patients were observed to have distended stomachs in the supine and right lateral decubitus positions, respectively. On quantitative assessment, 336 had safe GRV, 60 patients were classified as having a low risk of aspiration (GRV < 1.5 ml/kg) while 13 had a high risk of aspiration (> 1.5 ml/kg). Eight patients with a fasting duration of more than ten hours and five who fasted between 6 and 10 h had a gastric residual volume of more than 1.5 ml/h. Patients who were premedicated with histamine blockers had a statistically significant higher antral cross-sectional area (p-value - 0.022*) and GRV (p-value - 0.018*) in the right lateral decubitus position compared to patients who had taken proton pump inhibitors (PPIs). As BMI increased, there was a statistically significant (p-value < 0.001) increase in mean antral CSA in both supine and right lateral decubitus positions. There was a statistically significant association found between type 2 diabetes (p-value 0.045*) with antral grade.

DISCUSSION

Patients can have significant residual volume (> 1.5 ml/kg) despite adequate fasting, and preoperative gastric ultrasound can help in assessing the same and guiding perioperative airway management. PPIs are more effective in reducing gastric residual volume as compared to histamine blockers. Patients with a BMI of more than 30 and type 2 diabetes mellitus have significant correlation with increased gastric residual volume mandating preoperative gastric ultrasound assessment for effective management.

CONCLUSIONS

Patients with BMI over 30 and type 2 diabetes may benefit from POCGUS to guide perioperative airway management by stratifying GRV. Trial registration Name of registry-Clinical Trial Registry of India. Trial registration number-2020/03/024083. Date of registration-19.3.2020. URL- http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=39961&EncHid=&userName=.

Serial Ultrasonographic-measurement of Gastric Residual Volume in Critically Ill Patients for Prediction of Gastric Tube Feed Intolerance: Views

How to cite this article: Pratyusha K, Jindal A. Serial Ultrasonographic-measurement of Gastric Residual Volume in Critically Ill Patients for Prediction of Gastric Tube Feed Intolerance: Views. Indian J Crit Care Med 2023;27(1):79.

Evaluation of gastric contents using ultrasound in full-term pregnant women fasted for 8 h: a prospective observational study

BACKGROUND

We aimed to evaluate the gastric volume and contents after an 8-h fasting period in full-term, non-laboring, pregnant women following a standardized meal.

METHODS

In this prospective observational study, we included full-term pregnant women scheduled for elective cesarean delivery. The participants were instructed to fast after a standardized meal (apple juice, bread, and cheese). Participants were scanned in the semi-recumbent and right-lateral positions 8 h after the standardized meal. The primary outcome was the proportion of patients with gastric volume > 1.5 mL kg^-1 calculated by two equations. Secondary outcomes included the antral cross-sectional area and gastric volume. Data are expressed as frequency (%, 95% confidence interval [CI]), mean ± standard deviation (95% CI of the mean), or median (quartiles) as appropriate.

RESULTS

Forty-one women were available for the final analysis. For the primary outcome, one participant (2.4%, 95% CI of 0.06 to 12.8%) had gastric volume > 1.5 mL kg^-1, and none had solids in the antrum. For the secondary outcomes, the mean (95% CI of the mean) of the antral cross-sectional area was 2.11 ± 0.72 (1.88 to 2.34) cm² and 4.08 ± 1.80 (3.51 to 4.65) cm² during the semi-recumbent and right-lateral position, respectively. The median (quartiles) gastric volume was 0.53 (0.32, 0.66) mL kg^-1 and 0.33 (0.13, 0.52) mL kg^-1 as estimated by Perlas et al. and Roukhomovsky et al. equations, respectively.

CONCLUSION

After 8-h fasting following a standardized meal, full-term pregnant non-laboring women are less likely to have a high residual gastric volume.

The effects of diabetes mellitus on gastric emptying: A prospective observational cohort study

STUDY OBJECTIVE

Our goal was to evaluate the effect of diabetic severity and duration on preoperative residual gastric volume. Secondarily we compared ultrasonic estimates of residual gastric volume with actual volume determined by aspiration during endoscopy.

DESIGN

This was a prospective, observational cohort study that included adults with a history of diabetes mellitus and/or opioid use scheduled for gastrointestinal endoscopic procedures.

SETTING

Endoscopy unit at Cleveland Clinic Main Campus from 2017 to 2019.

PARTICIPANT

Adults scheduled for upper endoscopy with or without colonoscopy.

INTERVENTION AND MEASUREMENTS

Residual gastric volumes were primarily determined by aspiration during endoscopy, and secondarily estimated with ultrasound. We evaluated the relationship between gastric residual volume and preoperative HBA1C concentration and duration of diabetes. Secondarily, we conducted an agreement analysis between the two gastric volume measurement techniques.

MAIN RESULTS

Among 145 enrolled patients, 131 were diabetic and 17 were chronic opioid users. Among 131 diabetic patients, the mean ± SD HbA1c was 7.2 ± 1.5% and the median (Q1, Q3) duration of diabetes was 8.5 (3, 15) years. Neither HbA1c nor duration of diabetes was associated with residual gastric volume. The adjusted mean ratio of residual gastric volume was 1.07 (98.3% CI: 0.89, 1.28; P = 0.38) for 1% increase in HbA1c concentration, and 0.84 (98.3% CI: 0.63, 1.14; P = 0.17) for each 10-year increase induration of diabetes. The median [Q1-Q3] absolute difference between gastric ultrasound measurement and endoscopic measurement was 25 [15, 65] ml.

CONCLUSIONS

In this prospective observational cohort study, neither the duration nor severity of diabetes influenced preoperative residual gastric volume. Gastric ultrasound can help identify patients who have excessive residual volumes despite overnight fasting.

Effect of Tubular Feeding with the Measurement of Gastric Residual Volume on Ventilator Associated Pneumonia

Background

Several measures have been taken to prevent the onset of ventilator-associated pneumonia (VAP), one of which is measuring the gastric residual volume. The purpose of this study is to compare the effect of two tube feeding methods with and without gastric residual volume measurement on VAP.

Materials and Methods

This clinical trial was performed on the study population of patients with endotracheal tubes hospitalized in Intensive Care Units 1 and 2 of Golestan hospital, Ahvaz, Iran. Overall, 70 patients who met the inclusion criteria were randomly divided into groups 1 and 2. Groups 1 and 2 were fed with and without measuring gastric residual volume, respectively. The incidence of pneumonia was assessed using the Modified Clinical Pulmonary Infection Score prior to the intervention and on the fifth day post- intervention. The data were analyzed by the SPSS software version 22.

Results

The incidence of VAP was 9.12% in the group with gastric residual volume measurement and 7.14% in the other group. There was no significant difference between the two groups (P=0.827) regarding VAP prevalence.

Conclusion

Monitoring gastric residual v olume requires aspiration and repeated measurements of gastric contents, resulting in increased nursing workload. Moreover, if the gastric residual volume is high, the patient will be deprived of calorie intake and subjected to malnutrition. As a result, removing the monitoring of gastric residual volume from the care setting and focusing on interventions proven to reduce VAP can be more helpful.

Measurement of Gastric Residual Volume via Ultrasound after Receiving Intravenous Ondansetron, Metoclopramide, and Neostigmine in Critically Ill Patients: A Double-Blind Clinical Trial

Background

Gastric residual volume (GRV) is considered an important parameter for gastric emptying and nutrition tolerance. This volume is measured before any nutrition and has a direct effect on the volume and timing of the next nutrition. The present study aimed to examine the GRV via ultrasound after receiving intravenous ondansetron, metoclopramide, and neostigmine.

Materials and Methods

In the present study, 40 patients were included in the study, 10 patients were excluded from the study due to death during treatment, and 30 patients were divided into three groups of 10(10 patients in each group).The first, second, and third groups received 2.5, 10, and 8 mg neostigmine, metoclopramide, and ondansetron every 8 h, respectively. The drugs were infused as a micro set in 100 ml normal saline into patients within 30 min. The patients underwent ultrasound imaging and GRV measurement by an intensive care unit (ICU) subspecialty fellow, who was not aware of the drugs received by the patients, in the 1^st h of hospitalization, 6 h after drug injection, and once daily for 4 days.

Results

A total of 40 patients entered the study based on inclusion and exclusion criteria. The effect of neostigmine on reducing GRV (Gastric residual volume) in ICU patients was better than those of the other two drugs, which was significant.

Conclusion

The results of this study showed that neostigmine has a better and significant effect on reducing GRV in ICU patients, compared to those of ondansetron and metoclopramide.

The efficacy and safety of itopride in feeding intolerance of critically ill patients receiving enteral nutrition: a randomized, double-blind study

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.

Can they stomach it? Parent and practitioner acceptability of a trial comparing gastric residual volume measurement versus no gastric residual volume in UK NNU and PICUs: a feasibility study

BACKGROUND

Routine measurement of gastric residual volume (GRV) to guide feeding in neonatal and paediatric intensive care is widespread. However, this practice is not evidence based and may cause harm. As part of a feasibility study, we explored parent and practitioner views on the acceptability of a trial comparing GRV measurement or no GRV measurement.

METHODS

A mixed-methods study involving interviews and focus groups with practitioners and interviews with parents with experience of tube feeding in neonatal and/or paediatric intensive care. A voting system recorded closed question responses during practitioner data collection, enabling the collection of quantitative and qualitative data. Data were analysed using thematic analysis and descriptive statistics.

RESULTS

We interviewed 31 parents and nine practitioners and ran five practitioner focus groups (n=42). Participants described how the research question was logical, and the intervention would not be invasive and potential benefits of not withholding the child's feeds. However, both groups held concerns about the potential risk of not measuring GRV, including delayed diagnosis of infection and gut problems, increased risk of vomiting into lungs and causing discomfort or pain. Parent's views on GRV measurement and consent decision making were influenced by their views on the importance of feeding in the ICU, their child's prognosis and associated comorbidities or complications.

CONCLUSIONS

The majority of parents and practitioners viewed the proposed trial as acceptable. Potential concerns and preferences were identified that will need careful consideration to inform the development of the proposed trial protocol and staff training.

Comparison of continuous versus intermittent enteral nutrition in critically ill patients (COINN): study protocol for a randomized comparative effectiveness trial

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

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

How to cite this article: Kulkarni AP, Govil D, Gupta S. The Seventh Organ—Gastrointestinal Tract: Neglect at Your Own Peril!. Indian J Crit Care Med 2020;24(Suppl 4):S143–S145.

Is discard better than return gastric residual aspirates: a systematic review and meta-analysis

BACKGROUND

The assessment of residual gastric volume is common practice in critical care units. However, the effects and safety of discarding or returning gastric aspirates remain uncertain. Therefore, we aimed to evaluate the role of discarding or returning gastric aspirates on the gastric residual volumes in critically ill patients.

METHODS

A comprehensive, systematic meta-analysis of randomized controlled trials (RCTs) on the efficacy and safety of discarding or returning gastric aspirates in critical ill patients was performed. Studies were identified by searching Pubmed and other databases (from inception to 31 Sept 2018). Summary odd ratios (ORs) or mean differences (MDs) with 95% confidence intervals were calculated using fixed- or random-effects model for outcome assessment.

RESULTS

Four RCTs, with a total number of 314 adult patients, were included in the analysis. No significant differences were found in the 48th hour residual volume (MD = 8.89, 95% CI: 11.97 to 29.74), the average potassium level (MD = 0.00, 95% CI: - 0.16 to 0.16), the episodes of gastric emptying delay (OR = 0.98, 95% CI: 0.35 to 2.80), the incidence of aspiration pneumonia (OR = 0.93, 95% CI: 0.14 to 6.17), the episodes of nausea or vomiting (OR = 0.53, 95% CI: 0.07 to 4.13) and diarrhea (OR = 0.99, 95% CI: 0.58 to 1.70).

CONCLUSIONS

No evidence confirms that returning residual gastric aspirates provides more benefits than discarding them without increasing potential complications. Rigorously designed, multi-center, large-sample randomized controlled trials must be further conducted to validate the role of discarding or returning residual gastric aspirates.

A multicenter, randomized, double-blind study of ulimorelin and metoclopramide in the treatment of critically ill patients with enteral feeding intolerance: PROMOTE trial

PURPOSE

Enteral feeding intolerance (EFI) is a frequent problem in the intensive care unit (ICU), but current prokinetic agents have uncertain efficacy and safety profiles. The current study compared the efficacy and safety of ulimorelin, a ghrelin agonist, with metoclopramide in the treatment of EFI.

METHODS

One hundred twenty ICU patients were randomized 1:1 to ulimorelin or metoclopramide for 5 days. EFI was diagnosed by a gastric residual volume (GRV) ≥ 500 ml. A volume-based feeding protocol was employed, and enteral formulas were standardized. The primary end point was the percentage daily protein prescription (%DPP) received by patients over 5 days of treatment. Secondary end points included feeding success, defined as 80% DPP; gastric emptying, assessed by paracetamol absorption; incidences of recurrent intolerance (GRV ≥ 500 ml); vomiting or regurgitation; aspiration, defined by positive tracheal aspirates for pepsin; and pulmonary infection.

RESULTS

One hundred twenty patients were randomized and received the study drug (ulimorelin 62, metoclopramide 58). Mean APACHE II and SOFA scores were 21.6 and 8.6, and 63.3% of patients had medical reasons for ICU admission. Ulimorelin and metoclopramide resulted in comparable %DPPs over 5 days of treatment (median [Q1, Q3]: 82.9% [38.4%, 100.2%] and 82.3% [65.6%, 100.2%], respectively, p = 0.49). Five-day rates of feeding success were 67.7% and 70.6% when terminations unrelated to feeding were excluded, and there were no differences in any secondary outcomes or adverse events between the two groups.

CONCLUSIONS

Both prokinetic agents achieved similar rates of feeding success, and no safety differences between the two treatment groups were observed.

[Clinical trials of acupuncture of Jiaji (EX-B2) for treatment of gastrointestinal dysfunction in sepsis patients]

OBJECTIVE

To observe the clinical therapeutic effect of acupuncture of Huatuo Jiaji (EX-B2) in the treatment of gastrointestinal dysfunction in sepsis patients, aiming at providing new clinical approach and evidence for improving septic gastrointestinal activity.

METHODS

A total of 40 patients with septic gastrointestinal dysfunction who met our inclusive criteria were randomly divided into control group and treatment group (n＝20 cases in each). Patients in the control group received routine treatment of nasogastric mosapride citrate (5 mg/time, three times a day) and tifidobacterium triple viable capsules (420 mg, twice a day), intravenous infusion of omeprazole (40 mg, twice a day), rational dose of antibiotics, maintenance treatment of functions of the heart, lung, brain, kidney and other important organs and water electrolyte balance, as well as symptomatic treatment. Patients of the treatment group were treated by acupuncture of EX-B2 on the basis of routine treatment mentioned above in the control group. The acupuncture needle was inserted into EX-B2, twirled for a while and retained for 30 min, once a day for 10 successive days. The acute physiology and chronic health evaluation (APACHE II) score was given according to Knaus and colleagues' method, the intra-abdominal pressure was detected by using a manometer which was connected to an inserted canal in the urinary bladder, and the intragatric residul volume detected by using an injection syriange pumping via a nasal feeding tube.

RESULTS

After the treatment, the APACHE II score, intra-abdominal pressure and intragastric residual volume on day 10 were significantly decreased in both groups in comparison with their own pre-treatment (P<0.05), while the borborygmus levels on day 10 were considerably increased in both groups relevant to their own pre-treatment (P<0.05). The APACHE II scores, intra-abdominal pressure and intragastric residual volume on day 3, 6 and 10 were significantly lower in the treatment group than those in the control group (P<0.05), whereas the borborygmus levels at the 3^rd , 6^th and 10^th day in the treatment group were apparently higher than those of the control group (P<0.05)．.

CONCLUSION

Acupuncture stimulation of EX-B2 has a good curative effect in improving gastrointestinal dysfunction in sepsis patients.

Effects of not monitoring gastric residual volume in intensive care patients: A meta-analysis

BACKGROUND

Monitoring gastric residual volume has been a common practice in intensive care patients receiving enteral feeding worldwide. Recent studies though, have challenged the reliability and necessity of this routine monitoring process. Several studies even reported improvements in the delivery of enteral feeding without monitoring gastric residual volume, while incurring no additional adverse events. However, the benefit of monitoring gastric residual volume remains controversial in intensive care patients.

OBJECTIVE

The aim of this review is to identify the effects of not monitoring gastric residual volume in intensive care patients through a meta-analysis of the data pooled from published studies that meet our inclusion criteria.

DESIGN

A systematic review DATA SOURCES: An electronic search of Embase, Pubmed, and the Cochrane Library was completed up to April 2018. The data included basic population characteristics, related complications, mortality, duration of mechanical ventilation and intensive care unit length of stay.

REVIEW METHODS

Eligibility and methodological quality of the studies were assessed by two researchers independently according to the Joanna Briggs Institute guidelines. The Review Manager Software was used to calculate the pooled risk ratio (RR), weighted mean difference, and the corresponding 95% confidential interval (95% CI). Sensitivity analyses were done by excluding each study. Publication bias analyses were conducted to avoid the exaggerated effect of the overall estimates.

RESULTS

Five studies involving 998 patients were included in this meta-analysis. Compared with monitoring gastric residual volume, not monitoring gastric residual volume decreased the rate of feeding intolerance in critically ill patients (RR = 0.61, 95%CI 0.51-0.72), and did not result in an increment in the rate of mortality (RR = 0.97, 95%CI 0.73-1.29, P = 0.84) or the rate of ventilator-associated pneumonia (RR = 1.03, 95%CI 0.74-1.44, P = 0.85). There were also no differences in the duration of mechanical ventilation (MD = 0.09, 95%CI, -0.99 to 1.16, P = 0.88) or intensive care unit length of stay (MD=-0.18, 95%CI, -1.52 to 1.17, P = 0.79).

CONCLUSION

Except for an increased risk of vomiting, the absence of monitoring gastric residual volume was not inferior to routine gastric residual volume monitoring in terms of feeding intolerance development, mortality, and ventilator-associated pneumonia in intensive care patients. There is encouraging evidence that not measuring gastric residual volume does not induce additional harm to the patients. More multicenter, randomized clinical trials are required to verify these findings.

[Application of bedside ultrasound in measuring gastric residual volume in neurosurgical critical patients with enteral nutrition support]

Objective: To explore the effect of bedside ultrasound in measuring gastric residual volume in neurosurgical critical patients with enteral nutrition support. Method: From March to August 2016, 70 critically neurological patients with continues enteral nutrition who admitted in Intensive Care Unit (ICU) were randomized into two groups. The observation group applied the bedside ultrasound monitoring gastric residual volume every day to guide the implementation of enteral nutrition. The control group used syringes withdrawing every 8 hours to measure the gastric residual volume. Results: There was no statistically significant difference in the incidence of complications include regurgitation and aspiration in this two group patients (P=0.356; P=1.000), while the times of interrupting enteral nutrition was lower in the observation group(25.7% vs 5.7%, 74.3% vs 94.3%, P=0.045), the length of target feeding time and the length of ICU stay, the operation time was shortened, with a statistically significant difference[(2.37±0.69) d vs (3.49±0.74) d, P=0.028; (8.52±5.45) d vs (6.40±2.71) d, P=0.022; (58.29±11.22)s vs (67.60±7.05) s, P=0.000]. Conclusion: The application of bedside ultrasound to measure gastric residual volume can be a scientific method to guide enteral nutrition in neurosurgical critical patients, which can reduce the times of interrupting enteral nutrition and shorten the length of target feeding time and ICU length of stay, reduce the workload of nurses.

Gastric residual volume measurement in the intensive care unit: an international survey reporting nursing practice

BACKGROUND

Gastric residual volume measurement is routinely used to evaluate the feeding tolerance and gastro-oesophageal reflux in patients receiving enteral feeding therapy in the intensive care unit. However, little supportive evidence for this intervention is available as the usefulness of gastric residual volume measurements in patients receiving enteral feeding therapy in the intensive care is controversial.

AIM

The aim of this study was to assess the practice of intensive care unit nurses related to gastric residual volume measurement in patients receiving enteral nutrition.

METHODS

A survey was conducted among a sample of intensive care unit nurses (n = 832) from four hospitals in Turkey (n = 182) and attendees of the Annual Congress of the Flemish Society for Critical Care Nurses in Flanders, Belgium (n = 650). The survey instrument was developed by the researchers based on the related literature.

RESULTS

A total of 480 nurses completed the questionnaire (response rate = 73%). Gastric residual volume is measured by 98·0% of respondents, with wide variations in the frequency of measuring. A 50-200 mL gastric residual volume is considered problematic by 45·5% (n = 183) of the participants, and only 18·4% (n = 81) reported their practice to be based on a current guideline. Strikingly, more experienced intensive care unit nurses appear to perform gastric residual volume measurements more commonly than their less experienced colleagues (p = 0·004), while the practice is more often reported to be performed in Belgium than in Turkey (p < 0·001).

CONCLUSION

Gastric residual volume management could be improved by applying current evidence to daily nursing practice.

RELEVANCE TO CLINICAL PRACTICE

Our results show that increased awareness of these guidelines by nurses is needed to reduce inefficient use of working time and resources, streamline clinical practices and improve patient outcomes. Current gastric residual volume measurement guidelines and up-to-date, relevant training should be provided to nurses.

Measuring gastric residual volumes in critically ill burn patients - A systematic review

PURPOSE

Measuring gastric residual volumes (GRV) is common in intensive care units (ICU) in patients receiving enteral nutrition (EN) and are a common source of feeding interruptions. Interruptions in EN yield adverse outcomes and are an area of improvement in burn care. The objectives of this study are to summarize the literature's ICU GRV practices and offer practical suggestions to GRV management in the burn patient.

METHODS

PubMed, SCOPUS, and OvidSP Medline were systematically reviewed using the keywords: burns; thermal injury; gastric residual volume; enteral feeding; tube feeding; enteral nutrition; gastric intolerance; ICU; critical illness. Reviews, case reports, and consensus and opinion papers were excluded.

RESULTS

26 articles were identified. Six burn-specific studies were identified. GRV practices vary widely and are a common cause of EN interruption. Elevated GRVs do not equate to gastrointestinal intolerance and do not always reflect aspiration risk.

CONCLUSIONS

We advocate a GRV threshold of 500mL should be used to optimize the benefits of EN in burn ICUs. A single incident of elevated GRVs should not mandate immediate EN rate reduction or cessation but should prompt a thoughtful examination of secondary causes of gastrointestinal intolerance. Randomized controlled trials are needed to define the ideal GRV threshold and re-evaluate its role in burn care.

Associations of hyperosmolar medications administered via nasogastric or nasoduodenal tubes and feeding adequacy, food intolerance and gastrointestinal complications amongst critically ill patients: A retrospective study

BACKGROUND

Adequate nutrition is essential during critical illness. However, providing adequate nutrition is often hindered by gastro-intestinal complications, including feeding intolerance. It is suggested that hyperosmolar medications could be causally involved in the development of gastro-intestinal complications. The aims of the present study were 1) to determine the osmolality of common enterally administered dissolved medications and 2) to study the associations between nasogastric and nasoduodenal administered hyperosmolar medications and nutritional adequacy as well as food intolerance and gastro-intestinal symptoms.

METHODS

This retrospective observational cohort study was performed in a medical-surgical ICU in the Netherlands. Adult critically ill patients receiving enteral nutrition and admitted for a minimum ICU duration of 7 days were eligible. The osmolalities of commonly used enterally administrated medications were measured using an osmometer. Patients were divided in two groups: Use of hyperosmolar medications (>500 mOsm/kg) on at least one day during the first week versus none. The associations between the use of hyperosmolar medications and nutritional adequacy were assessed using multiple logistic regression analysis. The associations between hyperosmolar medication and food intolerance as well as gastrointestinal symptoms were assessed using ordinal logistic regression.

RESULTS

In total 443 patients met the inclusion criteria. Of the assessed medications, only three medications were found hyperosmolar. We observed no associations between the use of hyperosmolar medications and nutritional adequacy in the first week of ICU admission (caloric intake β -0.27 95%CI -1.38; 0.83, protein intake β 0.32 95%CI -0.90; 1.53). In addition, no associations were found for enteral feeding intolerance, diarrhea, obstipation, gastric residual volume, nausea and vomiting in ICU patients receiving hyperosmolar medications via a nasogastric tube. A subgroup analysis of patients on duodenal feeding showed that postpyloric administration of hyperosmolar medications was associated with increased risk of diarrhea (OR 138.7 95%CI 2.33; 8245).

CONCLUSIONS

Our results suggest that nasogastric administration of hyperosmolar medication via a nasogastric tube does not affect nutritional adequacy, development of enteral feeding intolerance and other gastro-intestinal complications during the first week after ICU admission. During nasoduodenal administration an increased diarrhea incidence may be encountered.

The predictive value of hunger score on gastric evacuation after oral intake of carbohydrate solution

BACKGROUND

Surgical patients are asked to fast for a sufficient duration to ensure that the amount of residual liquid in the stomach is within the safe range, thereby reducing the risk of gastric reflux perioperatively. The authors hypothesized that subjective hunger numerical rating scale (NRS) score could also help assess the process of gastric emptying and determine the amount of fluid remaining in the stomach.

METHODS

The current study consisted of healthy volunteers recruited by advertisement and mutual introduction. Participants were asked to rate their subjective hunger feeling every 30 min after oral administration of 8 mL/kg carbohydrate nutrient solution that contained 10% maltodextrin and 2.5% sucrose. Consecutively, the gastric residual fluid was measured by magnetic resonance imagining (MRI). The Spearman's correlation coefficient, the ROC curves and the stepwise regression were used to analyze the predictive value of NRS for the gastric emptying process.

RESULTS

The cohort consisted of 29 healthy volunteers enrolled in this study. The area under ROC curves estimated by the NRS score for the gastric residual volume of 2 mL/kg, 1 mL/kg, and 0.5 mL/kg were AUC2.0 = 0.78, AUC1.0 = 0.76, and AUC0.5 = 0.72, respectively. The correlation coefficient between the NRS score and the residual liquid in the stomach was -0.57 (P < 0.01). The correlation coefficient between the increase of the NRS score and the decrease of gastric liquid residual volume was 0.46 (P < 0.01). The standardized estimate of NRS score for the residual volume was -0.18 (P < 0.01) and the standardized estimate of fasting time was -0.73 (P < 0.01).

CONCLUSIONS

The subjective hunger NRS score can not accurately predict the gastric residual volume, but it can provide a reference for clinicians to judge the gastric emptying process and it should be used as a second check after oral intake of clear fluids before surgery according to the new fasting protocol.

Does abdominal massage improve gastrointestinal functions of intensive care patients with an endotracheal tube?: A randomized clinical trial

INTRODUCTION

Gastrointestinal dysfunction is one of the most common problems among patients hospitalized in intensive care units. Currently, medicinal and non-medicinal methods are being used to prevent gastrointestinal problems. Among non-medicinal methods, abdominal massage is considered as a relatively acceptable method. The present study aims to examine the effect of abdominal massage on gastrointestinal functions of the intensive care patients with an endotracheal tube.

MATERIALS AND METHODS

In this clinical trial, 70 intensive care patients with an endotracheal tube were chosen by convenience sampling and allocated to an intervention or a control group randomly. In the intervention group, a 15-min abdominal massage was conducted twice a day for three days, while the control group received only routine cares. The abdominal circumference, gastric residual volume, times of defecation, and frequency of constipation were measured.

RESULTS

Gastric residual volume decreased significantly in the intervention group and increased significantly in the control group; however, there was no significant difference between two groups (P = .15). There was a significant difference between two groups regarding abdominal circumference and it was decreased in the intervention group (P < .001). The defecation times significantly increased in the intervention group (P = .002). After the intervention, the prevalence of constipation was significantly decreased in the intervention group (P = .008).

CONCLUSION

The results revealed that abdominal massage could improve gastrointestinal functions in enterally fed patients with an endotracheal tube. It is suggested to use abdominal massage as an adjunct therapy for improving gastrointestinal functions in intensive care patients.

[A comparative study of using Brix meter versus ultrasonic monitoring of gastric residual volume in patients with enteral nutrition]

To investigate the accuracy and feasibility of Brix value on monitoring gastric residual volume (GRV) in patients with enteral nutrition. Fifty patients with enteral nutrition via nasogastric tube were enrolled. The GRV was measured by both ultrasonography and Brix value. The results were compared according to the methods. The Pearson correlation coefficients showed that GRV measured by these two ways was positively correlated (r=0.986, P<0.05). Moreover paired sample t-test showed that the discrepancy was not statistically significant (P>0.05) between different measurements. The consistency was analyzed by Bland-Altman graph, showing that the two measurements were consistent. Brix value is recommended to measure GRV due to its convenience and easy operation.

Peptide-based enteral formula improves tolerance and clinical outcomes in abdominal surgery patients relative to a whole protein enteral formula

AIM

To compare a dipeptide- and tripeptide-based enteral formula with a standard enteral formula for tolerance and nutritional outcomes in abdominal surgery patients.

METHODS

A retrospective study was performed to assess the differences between a whole-protein formula (WPF) and a dipeptide- and tripeptide-based formula (PEF) in clinical outcomes. Seventy-two adult intensive care unit (ICU) patients with serum albumin concentrations less than 3.0 g/dL were enrolled in this study. Patients were divided into two groups (WPF group = 40 patients, PEF group = 32 patients). The study patients were fed for at least 7 d, with ≥ 1000 mL of enteral formula infused on at least 3 of the days.

RESULTS

The mean serum albumin level on postoperative day (POD) 10, prealbumin levels on POD-5 and POD-10, and total lymphocyte count on POD-5 were significantly higher in the PEF group compared to those in the WPF group (P < 0.05). The average maximum gastric residual volume of the PEF patients during their ICU stays was significantly lower than that for WPF patients.

CONCLUSION

Dipeptide- and tripeptide-based enteral formulas are more efficacious and better tolerated than whole-protein formulas.

Do we need new prokinetics to reduce enteral feeding intolerance during critical illness?

Gastrointestinal feeding intolerance and critical illness-associated gastric motility dysfunction are common. Although recent guidelines recommend not interrupting gastric feeding when gastric residual volume (GRV) is lower than 500 mL or to completely abandon measurement of GRV, it may seem that the relevance of prokinetics is reduced.

In patients at risk for aspiration and in multimodal strategies to enhance feeding performance, however, use of prokinetics is still advocated. Metoclopramide and erythromycin are commonly used promotility agents, although with relevant side effects.

Potential targets for new agents and early study results are addressed.

Evaluation of the effect on patient parameters of not monitoring gastric residual volume in intensive care patients on a mechanical ventilator receiving enteral feeding: A randomized clinical trial

PURPOSE

This study aimed to evaluate the effects of not measuring gastric residual volume (GRV) in intensive care patients on a mechanical ventilator and receiving enteral feeding on the feeding intolerance, gastroesophageal reflux (GER) risk, and nutritional adequacy.

METHODS

This randomized clinical study was performed in 2 medical intensive care units of 2 university hospitals in Ankara, Turkey. The patients were randomized into 2 groups. In the group with GRV monitoring, GRV was measured 3 times a day, and the GRV threshold was accepted as 250 mL. In addition, 24-hour pH monitoring was used in this group to assess the risk of GER. In the group without GRV monitoring, GRV was not measured. The patients were followed-up for 5 days.

RESULTS

The feeding targets were reached more quickly in the group without GRV monitoring (n = 26) with no increase in the complication rate (P < .05). No significant relationship was found between GRV and GER in the group with GRV monitoring (n = 25) (P > .05).

CONCLUSION

The discrepancies in GRV measurement make it unreliable for monitoring feeding intolerance and GER. The use of GRV measurements may therefore be discontinued as part of the standard care protocol in medical intensive care units.

Evaluation of delivery of enteral nutrition in mechanically ventilated Malaysian ICU patients

Background

There are numerous challenges in providing nutrition to the mechanically ventilated critically ill ICU patient. Understanding the level of nutritional support and the barriers to enteral feeding interruption in mechanically ventilated patients are important to maximise the nutritional benefits to the critically ill patients. Thus, this study aims to evaluate enteral nutrition delivery and identify the reasons for interruptions in mechanically ventilated Malaysian patients receiving enteral feeding.

Methods

A cross sectional prospective study of 77 consecutive patients who required mechanical ventilation and were receiving enteral nutrition was done in an open 14-bed intensive care unit of a tertiary hospital. Data were collected prospectively over a 3 month period. Descriptive statistical analysis were made with respect to demographical data, time taken to initiate feeds, type of feeds, quantification of feeds attainment, and reasons for feed interruptions. There are no set feeding protocols in the ICU. The usual initial rate of enteral nutrition observed in ICU was 20 ml/hour, assessed every 6 hours and the decision was made thereafter to increase feeds. The target calorie for each patient was determined by the clinician alongside the dietitian. The use of prokinetic agents was also prescribed at the discretion of the attending clinician and is commonly IV metoclopramide 10 mg three times a day.

Results

About 66% of patients achieved 80% of caloric requirements within 3 days of which 46.8% achieved full feeds in less than 12 hours. The time to initiate feeds for patients admitted into the ICU ranged from 0 – 110 hours with a median time to start feeds of 15 hours and the interquartile range (IQR) of 6–59 hours. The mean time to achieve at least 80% of nutritional target was 1.8 days ± 1.5 days. About 79% of patients experienced multiple feeding interruptions. The most prevalent reason for interruption was for procedures (45.1%) followed by high gastric residual volume (38.0%), diarrhoea (8.4%), difficulty in nasogastric tube placement (5.6%) and vomiting (2.9%).

Conclusion

Nutritional inadequacy in mechanically ventilated Malaysian patients receiving enteral nutrition was not as common as expected. However, there is still room for improvement with regards to decreasing the number of patients who did not achieve their caloric requirement throughout their stay in the ICU.

Use of gastric residual volume to guide enteral nutrition in critically ill patients: a brief systematic review of clinical studies

OBJECTIVE

In critically ill patients, the optimal procedure to monitor upper gastrointestinal function is controversial. Several authors have proposed gastric residual volume (GRV) as a tool to guide enteral nutrition. The aim of this contribution is to briefly discuss corresponding studies.

METHODS

We electronically searched MEDLINE, EMBASE, and CINAHL for studies relevant to the subject.

RESULTS

Six randomized controlled trials (RCTs) and six prospective observational studies were identified. Each analyzed different thresholds of GRV to guide enteral nutrition and to avoid complications (e.g., vomiting, aspiration, nosocomial pneumonia) in artificially ventilated patients. Due to heterogeneity in outcome measures, patient populations, type and diameter of feeding tubes, and randomization procedures, combination of the results of the six RCTs into a meta-analysis was not appropriate. High-quality RCTs studying medical patients could not demonstrate an association between complication rate and the magnitude of GRV. The only observational study that adjusted results to potential confounders and that studied surgical patients found, however, that the frequency of aspiration increased significantly if a GRV > 200 mL was registered more than once.

CONCLUSION

For mechanically ventilated patients with a medical diagnosis at admission to the intensive care unit, monitoring of GRV appears unnecessary to guide nutrition. Surgical patients might profit, however, from a low GRV threshold (200 mL).