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Prokinetic Therapy for Feed Intolerance in Critical Illness: One Drug Or Two?

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Prokinetic Therapy for Feed Intolerance in Critical Illness: One Drug Or Two? Prokinetic therapy for feed intolerance in critical illness: One drug or two? Nam Q. Nguyen, MBBS (Hons), FRACP; Marianne Chapman, BMBS, FANZCA, FJFICM; Robert J. Fraser, MBBS, FRACP, PhD; Laura K. Bryant, BHSc; Carly Burgstad, BHSc (Hons); Richard H. Holloway, MBBS, FRACP, MD Objective: To compare the efficacy of combination therapy, with combination therapy, compared with erythromycin alone Over the 7 days, patients .(04. ؍ with erythromycin and metoclopramide, to erythromycin alone in (136 ؎ 23 mL vs. 293 ؎ 45 mL, p the treatment of feed intolerance in critically ill patients. treated with combination therapy had greater feeding success, Design: Randomized, controlled, double-blind trial. received more daily calories, and had a lower requirement for Setting: Mixed medical and surgical intensive care unit. postpyloric feeding, compared with erythromycin alone. Tachy- Patients: Seventy-five mechanically ventilated, medical pa- phylaxis occurred in both groups but was less with combination tients with feed intolerance (gastric residual volume >250 mL). therapy. Sedation, higher pretreatment gastric residual volume, Interventions: Patients received either combination therapy and hypoalbuminemia were significantly associated with a poor mg of intravenous erythromycin twice daily ؉ 10 mg response. There was no difference in the length of hospital stay or 200 ;37 ؍ n) of intravenous metoclopramide four times daily) or erythromycin mortality rate between the groups. Watery diarrhea was more mg of intravenous erythromycin twice daily) in 200 ;38 ؍ alone (n (01. ؍ common with combination therapy (20 of 37 vs. 10 of 38, p a prospective, randomized fashion. Gastric feeding was re-com- but was not associated with enteric infections, including Clos- menced and 6-hourly gastric aspirates performed. Patients were tridium difficile. studied for 7 days. Successful feeding was defined as a gastric Conclusions: In critically ill patients with feed intolerance, residual volume <250 mL with the feeding rate >40 mL/hr, over 7 days. Secondary outcomes included daily caloric intake, vom- combination therapy with erythromycin and metoclopramide is iting, postpyloric feeding, length of stay, and mortality. more effective than erythromycin alone in improving the delivery Measurements and Main Results: Demographic data; use of of nasogastric nutrition and should be considered as the first-line inotropes, opioids, or benzodiazepines; and pretreatment gastric treatment. (Crit Care Med 2007; 35:2561–2567) residual volume were similar between the two groups. The gastric KEY WORDS: enteral feeding; erythromycin; metoclopramide; nu- residual volume was significantly lower after 24 hrs of treatment trition; critical illness; prokinetic dequate enteral nutritional status and increasing the risk of gastro- agonist), are usually regarded as the first- support is important in critical esophageal reflux and aspiration (3–5), line therapy (10–12). Metoclopramide illness as it is cheaper, has which adversely affect both morbidity and has been reported to improve gastric fewer septic complications, mortality (4–6). emptying in critically ill patients (13–15), Aand is associated with preservation of gut Current therapeutic options for the but its efficacy on the success of feeding mucosal barrier function, compared with management of feed intolerance in criti- in feed-intolerant patients remains con- the parenteral route (1–6). However, cally ill patients are prokinetic therapy, troversial (14, 15). In small studies, a slow gastric emptying and subsequent in- postpyloric feeding, or total parenteral single dose of enterally administered tolerance of nasogastric (NG) feeding oc- nutrition (7–10). Of these, prokinetic metoclopramide had no effect on the gas- cur in up to 50% of critically ill patients agents, such as metoclopramide (a dopa- tric residual volume (GRV), and only (1–3), compromising their nutritional mine agonist) or erythromycin (a motilin modest reductions in volume were ob- served after three doses (14, 15). In con- trast, low-dose (3–7 mg/kg/day) erythro- From the Departments of Gastroenterology and The authors have not disclosed any potential con- mycin increased both gastric emptying Hepatology (NQN, CB, RHH) and Anaesthesia and flicts of interest. and the success of feeding in critically ill Intensive Care (MC) and the Discipline of Medicine Address requests for reprints to: Nam Nguyen, patients with feed intolerance (16–19). (NQN, RJF, RHH), University of Adelaide, Royal Ad- MBBS (Hons), FRACP, Department of Gastroenterology elaide Hospital; and Investigation and Procedures and Hepatology, Royal Adelaide Hospital, North Ter- Comparative data among prokinetic Unit (RJF, LKB), Repatriation General Hospital; South race, Adelaide, South Australia 5000. E-mail: agents have shown that enterally admin- Australia. [email protected] istered metoclopramide and cisapride Supported, in part, by project grant 349329 from Copyright © 2007 by the Society of Critical Care may have a faster onset of action than the National Health and Medical Research Council Medicine and Lippincott Williams & Wilkins (NHMRC) of Australia. Dr Nam Nguyen is an NHMRC erythromycin, but the impact of these DOI: 10.1097/01.CCM.0000286397.04815.B1 Clinical Research Fellow. drugs on the GRV in the critically ill is Crit Care Med 2007 Vol. 35, No. 11 2561 similar (15). Recently, intravenous (iv) was defined as a GRV Ն250 mL Ն6 hrs after Successful feeding was defined as the erythromycin has been shown to be more the commencement of feeding at a rate Ն40 maintenance of a feeding rate Ն40 mL/hr with effective than metoclopramide, but rapid mL/hr (Nutrison Standard: gluten and lactose GRVs Ͻ250 mL (12, 16, 18, 20, 21). In these tachyphylaxis develops with both drugs free feed; 100 kcal, 4 g of protein, 12.3 g of patients, the assigned therapy was continued (20). In the patients who failed mono- carbohydrate, 3.9 g of fat per 100 mL; Nutricia for 7 days or until discharge. The adequacy of enteral nutrition or daily calorie intake was therapy, rescue combination therapy N.V., Zoetermeer, The Netherlands). A 12-Fr (or larger) NG tube was placed into the stom- expressed as the administered/prescribed ca- with erythromycin and metoclopramide ach before the study, with the distal tip 10 cm loric ratio over 24 hrs duration. Failure of was highly effective and tachyphylaxis below the gastroesophageal junction and either therapy was defined as 1) two or more was less prominent (20). Combination clearly visible in the stomach on a routine high GRVs (i.e., Ն250 mL) within the first 24 therapy may therefore be a better first- abdominal radiograph. Radiologic confirma- hrs; or 2) any 6-hourly GRV Ն250 mL there- line approach to therapy; however, no tion of tube position was performed daily over after while on Ն40 mL/hr of enteral feeding. data are available on the effectiveness of the 7-day study period to ensure that the tube In these patients, the study drugs were discon- this strategy in the management of feed had not migrated into the duodenum. tinued and enteral feeding was temporarily intolerance in the critically ill. Patients were excluded from the study if ceased. A postpyloric feeding tube was inserted The primary aims of the current study they 1) had received prokinetic drugs (meto- endoscopically for patients who required on- going nutritional support. were to compare the effectiveness of com- clopramide, cisapride, or erythromycin) within the previous 24 hrs; 2) had a known Data Collection and Analysis. Data on pri- bination therapy against erythromycin mary outcomes were collected prospectively alone as the first-line treatment for feed allergy to a macrolide antibiotic or metoclo- pramide; 3) were receiving drugs known to over the 7 days of treatment: 6 hourly GRVs, intolerance and to determine factors as- interact with erythromycin (carbamazepine, amount of daily prescribed and administered sociated with resistance to treatment in cyclosporine, theophylline, aminophylline, feeds, occurrence of vomiting, and require- critically ill patients. The impact of dif- digoxin, oral anticoagulants); 4) had under- ment for postpyloric feeding tube insertion. ferent prokinetic regimens on the follow- gone major gastrointestinal surgery (laparot- Secondary outcomes (length of hospital stay ing secondary outcomes was also exam- omy with part of the gastrointestinal tract and mortality) and potential side effects of ined: administered/prescribed caloric removed or repaired) within the previous 6 therapy (particularly the development of diar- intake, incidence of vomiting, rate of wks or had a past history of esophagectomy or rhea) were also monitored up to 4 wks after postpyloric tube insertion and feeding, partial or total gastrectomy; 5) were suspected the commencement of the therapy. Diarrhea was defined as frequent (Ն3/day) loose, liquid of having bowel obstruction or perforation; 6) side effects, length of hospital stay, and stool with an estimated total daily volume had evidence of liver dysfunction (i.e., Ͼ3 ϫ mortality. Ͼ250 mL (22). In all patients with diarrhea, elevation above the upper end of normal range stool specimens were evaluated for blood, of bilirubin, ␥-glutamyl transferase, aspartate white cells, bacteria, and parasites using mi- MATERIALS AND METHODS transaminase, alanine transaminase, or lactate croscopy, culture, and special stains. In addi- dehydrogenase); or 7) had myasthenia gravis. Study Design. The study was conducted as tion, all specimens were tested for Clostridium Protocol.
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