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

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Presentation on theme: "Enteral Nutrition In Critically Ill Patients Role of Prokinetics Done by Dr Khaled Al Sewify MD, MRCP, EDIC Focus on IV Erythromycin."— Presentation transcript:

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

2 Artificial Nutritional Support Improves wound healing Improves outcome Decreases complications Decreases the hypermetabolic response to tissue injury (DO2/VO2)

3 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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5 SB and colon contain anaerobes and 10 7 aerobes Enough Endotoxins to kill us 1000 X. Magnotti & Deitch 2005 JOABA

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

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8 High doses Opiates Benzodiazepines Muscle relaxants Catecholamines Syndrome of Upper (GIT) Intolerance Syndrome of Upper (GIT) Intolerance

9 Mentec H (2001)– Crit Care Med 29 :

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11 Feeding intolerance Incidence of Nosocomial Pneumonia

12 Mentec H (2001)– Crit Care Med 29 : Feeding intolerance Mortality Rate

13 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: Real Threat

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

15 Early commencing of enteral nutrition Early achievement of optimum caloric needs Facing the problem of upper GIT intolerance & its realted Sequaele TPN Small Bowel Feeding Prokinetics

16 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 Crit Care Med 29:

17 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 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 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

20 P < 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.

21 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 ?

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

23 Erythromycin alone Erythromycin Metoclopramide

24 Greater feeding success Received more daily calories Lower requirement for post pyloric feeding Nguyen NQ - Crit Care Med Nov;35(11):

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

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27 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 * Cremonini F,et al.Am J Gastroenterol 2005;100:

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

31 THANK YOU


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