Transcript Enteral nutrition in critically ill patients

Enteral Nutrition In
Critically Ill Patients
Role of
Prokinetics
Focus on IV
Erythromycin
Done by Dr Khaled Al Sewify
MD, MRCP, EDIC
Improves wound healing
Improves outcome
Decreases complications
Decreases the hypermetabolic
response to tissue injury
(DO2/VO2)
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Preserves the intestinal mucosal
integrity :
Maintains mucosal immunity.
Prevents of increased mucosal
permeability.
Decreases bacterial translocation.
Marik, Zaloga CCM 2005
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SB and colon contain 1010 anaerobes and
107 aerobes
Enough Endotoxins to
kill us 1000 X.
Magnotti & Deitch 2005 JOABA
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It is more physiological, is easier to begin and
more convenient.
Spare both gastropancreatic reflexes and gastrin
release.
Buffers gastric acid well.
High doses
Opiates
Benzodiazepines
Muscle relaxants
Catecholamines
Syndrome of Upper (GIT) Intolerance
Mentec H (2001)– Crit Care Med 29 : 1955-1961
Incidence of Nosocomial Pneumonia
Feeding intolerance
Mentec H (2001)– Crit Care Med 29 : 1955-1961
Mortality Rate
Feeding intolerance
Mentec H (2001)– Crit Care Med 29 : 1955-1961
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So probably the gastric feeding may not always
be as safe as it is sometimes considered.
The net result is Aspiration Syndrome. Real Threat
Heyland DK 199-AM J Respir Crit Care Med 159:1249-1256.
1. 70% with altered LOC.
2. > 70% of trauma patients at injury.
3. > 40% of patients with EN.
Real Threat
Real Threat
Bowman, et al CCNQ 2005
TPN
Small Bowel
Feeding
Prokinetics
Early
commencing of
enteral nutrition
Early achievement of
optimum caloric
needs
Facing the problem
of upper GIT
intolerance & its
realted Sequaele
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One study (80 patients) compared the use of
prokinetic drugs (erythromycin) in patients
receiving gastric feeding with small bowel
feeding (without erythromycin) and it found
no differences between the 2 groups in the
adequacy of EN, mortality & duration of ICU
stay.
Gastric feeding with erythromycin is equivalent to transpyloric feeding in critically ill.2001.
Crit Care Med 29:1916-1919.
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Metoclopramide :
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Site of action : dopaminergic receptors.
Role
Controversial
*Jooste C & others : Metoclopramide improves gastric motility in critically ill patients. Intensive
Care Med 1999; 25:464–468
*MacLaren R & othes : : A randomized, placebo-controlled, crossover study. Crit Car Med 2000; 28:438–444
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Site of action : motilin receptors.
Dose : 3-7 mg/kg.
Optimum dose : 200mg IV bid to 250mg
q 6 h.
Half life : 1.5h
But
Antrum Motility > 5h &
Feeding Tolerance up to 24h.
Nguyen 2007 trial :
 RCT, Multicenter,Double blind.
 107 patients enrolled.
 Metoclopramide 10mg/6h vs Erythromycin
200mg/12hrs.
 1ry endpoint : tolerance to gastric feed and
tachyphylaxis.
Nguyen NQ & others : Erythromycin is more effective than metoclopramide for
treatment of feed intolerance in critical illness.
Crit Care Med 2007; 35:483–489
After 24 hrs of rescue combination
therapy 92% achieved & remained
tolerant for 5 days.
P < 0.0001
Erythromycin is much more
effective than Metoclopramide
Metoclopramide became
intolerant early
Prokinetic therapy for feed intolerance in
critical illnes : one drug or two ?
Australian double blinded RCT
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75 Patients enrolled.
Erythromycin (200mg IV bd) alone vs
Erythromycin
Metocclopramide (10mg q
6h).
1ry endpoint : successful feeding over 7 days
2ry endpoint : daily caloric intake, vomiting,
post pyloric feeding requirement, LOS &
mortality.
Gastric residual volume was
significantly lower after 24 hrs
136 ± 23 mL
293 ±45 mL
P =.04
4.5
0.5
6.5
0.5
Erythromycin alone
Erythromycin
Metoclopramide
Greater feeding
success
Received more daily
calories
Lower requirement for
post pyloric feeding
Nguyen NQ - Crit Care Med. 2007 Nov;35(11):2561-7.
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Most of the well powered trials used
erythromycin IV.
No head to head trials.
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Metoclopramide : extrapyramidal syndrome.
Erythromycin :
bacterial resistance & cardiac
toxicity.
Both : rapid tachyphylaxis.
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Motilin derivatives :
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Long term efficacy is unknown.
Very rapid tachyphylaxis.
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Cholecystokinin antagonist : Loxiglumide
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Very recent.
Accelerate gastric emptying in healthy
humans.
No trials in critically ill patients.
* Castllo E, et al .Am J Physiol 2004;287:G363-G369
* Cremonini F,et al.Am J Gastroenterol 2005;100:625-663
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Enteral Nutrition is very Crucial for critically
ill patients.
UGIT Intolerance is very common with critical
illness.
Prokinetics are the easiest option to overcome
this problem.
Erythromycin in IV form is more effective
than Metoclopramide in achieving tolerance to
gastric feeding but both therapy are associated
with tachyphylaxis.
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Combination of both Metoclopramide
and Erythromycin is much more
effective than either of them alone with
much less incidence of tachyphylaxis.
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