1 / 31

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. Artificial Nutritional Support. Enteral Nutrition. Preserves the intestinal mucosal integrity : Maintains mucosal immunity.

breanna
Download Presentation

Enteral Nutrition In Critically Ill Patients

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

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

  2. Artificial Nutritional Support

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

  4. The Gut is the Motor of Sepsis

  5. Theory of BT • SB and colon contain 1010 anaerobes and 107aerobesEnough Endotoxins to kill us 1000 X. Magnotti & Deitch 2005 JOABA

  6. 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.

  7. What are The Problems Associated with Gastric Feeding in Critical Illiness ?

  8. Gastric Ilieus Syndrome of Upper (GIT) Intolerance

  9. Incidence of UGIT Intolerance to Gastric Feeding Mentec H (2001)– Crit Care Med 29 : 1955-1961

  10. What Are The Sequelae Of Upper GIT Intolerance To Enteral Nutrition?

  11. Hazards of UGIT Intolerance Incidence of Nosocomial Pneumonia Feeding intolerance

  12. Hazards of UGIT Intolerance Mortality Rate Feeding intolerance

  13. 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 RespirCrit Care Med 159:1249-1256. Real Threat

  14. Aspiration Syndrome 1. 70% with altered LOC. 2. > 70% of trauma patients at injury. 3. > 40% of patients with EN. Bowman, et al CCNQ 2005 Real Threat Real Threat

  15. They Have To Balance TPN Small Bowel Feeding Prokinetics

  16. Prokineticsvs 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 differencesbetween 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.

  17. 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; 25:464–468 *MacLaren R & othes : : A randomized, placebo-controlled, crossover study. Crit Car Med 2000; 28:438–444

  18. 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 > 5h & Feeding Tolerance up to 24h.

  19. Erythromycin VS Metoclopramide Nguyen 2007 trial : • RCT, Multicenter,Double blind. • 107 patients enrolled. • Metoclopramide10mg/6hvs 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

  20. Erythromycin versus Metoclopramide 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

  21. 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.

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

  23. Tolerance &Failure of therapy Erythromycin alone Erythromycin Metoclopramide

  24. Combination Therapy vs Erythromycin Alone Over 7 Days Nguyen NQ - Crit Care Med. 2007 Nov;35(11):2561-7.

  25. Oral vs IV Erythromycin • Most of the well powered trials used erythromycin IV. • No head to head trials.

  26. Pro-kinetic drugs are not free from side effects

  27. Side Effects of Prokinetics • Metoclopramide : extrapyramidal syndrome. • Erythromycin : bacterial resistance & cardiac toxicity. • Both : rapid tachyphylaxis.

  28. 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 2004;287:G363-G369 * CremoniniF,etal.Am J Gastroenterol 2005;100:625-663

  29. 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.

  30. SUMMARY • Combination of both Metoclopramide and Erythromycin is much more effective than either of them alone with much less incidence of tachyphylaxis.

  31. THANK YOU

More Related