Enteral nutrition in critically ill patients

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Enteral Nutrition In Critically Ill Patients
Role of Prokinetics
Focus on IV Erythromycin
Done by Dr Khaled Al Sewify
MD, MRCP, EDIC
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Artificial Nutritional Support
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Enteral Nutrition

• Preserves the intestinal mucosal integrity
• Maintains mucosal immunity.
• Prevents of increased mucosal permeability.
• Decreases bacterial translocation.
• Marik, Zaloga CCM 2005

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The Gut is the Motor of Sepsis
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Theory of BT

• SB and colon contain 1010 anaerobes and 107
  aerobes Enough Endotoxins to kill us 1000
  X.
• 
  
• 
  
• Magnotti
  Deitch 2005 JOABA

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Advantages of gastric feeding 

• It is more physiological, is easier to begin and
  more convenient.
• Spare both gastropancreatic reflexes and gastrin
  release.
• Buffers gastric acid well.

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What are The Problems Associated with Gastric
Feeding in Critical Illiness ?
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Gastric Ilieus
Syndrome of Upper (GIT) Intolerance

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Incidence of UGIT Intolerance to Gastric
Feeding
Mentec H (2001) Crit Care Med 29
1955-1961
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What Are The Sequelae Of Upper GIT Intolerance
To Enteral Nutrition?
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Hazards of UGIT Intolerance
Incidence of Nosocomial Pneumonia


Feeding intolerance
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Hazards of UGIT Intolerance

Mortality Rate

Feeding intolerance
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Aspiration Syndrome.

• 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
  1591249-1256.

Real Threat
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Aspiration Syndrome

• 1. 70 with altered LOC.
• 2. gt 70 of trauma patients at injury.
• 3. gt 40 of patients with EN.
• 
  
• Bowman,
  et al CCNQ 2005

Real Threat
Real Threat
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They Have To Balance
TPN
Small Bowel Feeding
Prokinetics
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Prokinetics vs Small Bowel Feeding

• 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 291916-1919.

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Prokinetic Therapy For Feeding Intolerance

• Metoclopramide
• Site of action dopaminergic receptors.

Role Controversial
Jooste C others Metoclopramide improves
gastric motility in critically ill patients.
Intensive Care Med 1999 25464468
MacLaren R othes A randomized,
placebo-controlled, crossover study. Crit Car Med
2000 28438444
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Erythromycin

• 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 gt 5h
• Feeding Tolerance up to 24h.

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Erythromycin VS Metoclopramide

• 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 35483489
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Erythromycin versus Metoclopramide
After 24 hrs of rescue combination therapy 92
achieved remained tolerant for 5 days.
P lt 0.0001
Erythromycin is much more effective than
Metoclopramide
Metoclopramide became intolerant early
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Prokinetic therapy for feed intolerance in
critical illnes one drug or two ?

• 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.

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Gastric residual volume was significantly lower
after 24 hrs
136 23 mL
293 45 mL
P .04

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Tolerance Failure of therapy
Erythromycin alone
Erythromycin Metoclopramide
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Combination Therapy vs Erythromycin Alone Over 7
Days
Nguyen NQ - Crit Care Med. 2007
Nov35(11)2561-7.
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Oral vs IV Erythromycin

• Most of the well powered trials used erythromycin
  IV.
• No head to head trials.

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Pro-kinetic drugs are not free from side
effects
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Side Effects of Prokinetics

• Metoclopramide extrapyramidal syndrome.
• Erythromycin bacterial resistance
  cardiac toxicity.
• Both rapid tachyphylaxis.

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What is new ?

• 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
  2004287G363-G369
• Cremonini F,et al.Am J Gastroenterol
  2005100625-663

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SUMMARY

• 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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SUMMARY

• 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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