Post on 26-Mar-2015
Enteral Nutrition In Critically Ill Patients
Role of Prokinetics
Done by Dr Khaled Al Sewify MD, MRCP, EDIC
Focus on IV Erythromycin
Preserves the intestinal mucosal integrity :
Maintains mucosal immunity. Prevents of increased mucosal
permeability. Decreases bacterial translocation.
Marik, Zaloga CCM 2005
SB and colon contain 1010 anaerobes and 107 aerobes Enough Endotoxins to kill us 1000 X.
Magnotti & Deitch 2005 JOABA
It is more physiological, is easier to begin and more convenient.
Spare both gastropancreatic reflexes and gastrin release.
Buffers gastric acid well.
Syndrome of Upper (GIT) Intolerance
Syndrome of Upper (GIT) Intolerance
Mentec H (2001)– Crit Care Med 29 : 1955-1961
Mentec H (2001)– Crit Care Med 29 : 1955-1961
Feeding intolerance
Incidence of Nosocomial Pneumonia
Mentec H (2001)– Crit Care Med 29 : 1955-1961
Feeding intolerance
Mortality Rate
So probably the gastric feeding may not always be as safe as it is sometimes considered.
The net result is Aspiration Syndrome.
Heyland DK 199-AM J Respir Crit Care Med 159:1249-1256.
Real Threat
1. 70% with altered LOC. 2. > 70% of trauma patients at
injury. 3. > 40% of patients with EN.
Bowman, et al CCNQ 2005
Real ThreatReal Threat
TPNTPN
Small Bowel Feeding
Small Bowel Feeding
ProkineticsProkinetics
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.
Metoclopramide : Site of action : dopaminergic receptors.
Role ControversialRole Controversial
*Jooste C & others : Metoclopramide improves gastric motility in critically ill patients. Intensive Care Med 1999; 25:464–468
*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 *MacLaren R & othes : : A randomized, placebo-controlled, crossover study. Crit Car Med 2000; 28:438–444
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
Nguyen NQ & others : Erythromycin is more effective than metoclopramide for treatment of feed intolerance in critical illness. Crit Care Med 2007; 35:483–489
P < 0.0001
Erythromycin is much more effective than Metoclopramide
Metoclopramide became intolerant early
After 24 hrs of rescue combination therapy 92% achieved & remained tolerant for 5 days.
Australian double blinded RCT
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.
Prokinetic therapy for feed intolerance in critical illnes : one drug or two ?
Gastric residual volume was significantly lower after 24 hrs
293 ±45 mL
136 ± 23 mL
P =.04
Erythromycin alone
Erythromycin Metoclopramide
Nguyen NQ - Crit Care Med. 2007 Nov;35(11):2561-7.
Most of the well powered trials used erythromycin IV.
No head to head trials.
Metoclopramide : extrapyramidal syndrome.
Erythromycin : bacterial resistance & cardiac toxicity.
Both : rapid tachyphylaxis.
Motilin derivatives : Long term efficacy is unknown. Very rapid tachyphylaxis. Cholecystokinin antagonist :
Loxiglumide 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
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.
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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YOU