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

http://www.acclaimimages.com/_gallery/_pages/0041-0709-1906-3525.html

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.

THANK

YOU