The effects of sedation on gastric emptying and intra-gastric meal distribution in critical illness. Intensive Care Med. 2008;34:454-460. [PMID: 18060542 DOI: 10.1007/s00134-007-0942-2]

Diagnostic value of digital continuous bowel sounds in critically ill patients with acute gastrointestinal injury: A prospective observational study

BACKGROUND

Acute gastrointestinal injury (AGI) is common in intensive care unit (ICU) and worsens the prognosis of critically ill patients. The four-point grading system proposed by the European Society of Intensive Care Medicine is subjective and lacks specificity. Therefore, a more objective method is required to evaluate and determine the grade of gastrointestinal dysfunction in this patient population. Digital continuous monitoring of bowel sounds and some biomarkers can change in gastrointestinal injuries. We aimed to develop a model of AGI using continuous monitoring of bowel sounds and biomarkers.

AIM

To develop a model to discriminate AGI by monitoring bowel sounds and biomarker indicators.

METHODS

We conducted a prospective observational study with 75 patients in an ICU of a tertiary-care hospital to create a diagnostic model for AGI. We recorded their bowel sounds, assessed AGI grading, collected clinical data, and measured biomarkers. We evaluated the model using misjudgment probability and leave-one-out cross-validation.

RESULTS

Mean bowel sound rate and citrulline level are independent risk factors for AGI. Gastrin was identified as a risk factor for the severity of AGI. Other factors that correlated with AGI include mean bowel sound rate, amplitude, interval time, Sequential Organ Failure Assessment score, Acute Physiology and Chronic Health Evaluation II score, platelet count, total protein level, blood gas potential of hydrogen (pH), and bicarbonate (HCO3 -) level. Two discriminant models were constructed with a misclassification probability of < 0.1. Leave-one-out cross-validation correctly classified 69.8% of the cases.

CONCLUSION

Our AGI diagnostic model represents a potentially effective approach for clinical AGI grading and holds promise as an objective diagnostic standard for AGI.

Influences of different sedatives on gastric antrum contraction in patients with acute brain injury

Background

Patients with acute brain injury (ABI) often exhibit gastrointestinal motility disorder and the administration of sedatives may exacerbate the gastrointestinal dysfunction. This study aims to evaluate the influences of different sedatives on gastric antrum contraction in patients with acute brain injury (ABI).

Methods

A prospective observational study was performed in 37 adult ICU patients with ABI, and 18 adult healthy volunteers were recruited as normal controls. Gastric motility, including frequency (ACF), amplitude (ACA), and motility index (MI), was measured with ultrasound before and after using sedatives, either propofol (Group A), midazolam (Group B), or dexmedetomidine (Group C). The influences of different sedatives on gastric motility were analyzed.

Results

All patients with acute brain injury (n = 37) exhibited decreased ACF and MI compared with those in healthy control (n = 18) (ACF: 2.41 ± 0.89 times/2 min in ABI vs. 4.5 ± 0.39 times/2 min in control, MI: 1.25 ± 0.57 in ABI vs. 3.59 ± 0.24 in control, p = 0.001). All sedatives, either propofol, midazolam, or dexmedetomidine, had inhibited effects on gastric motilities [In Group A (n = 13), 1.14(0.59, 1.44) before vs. 0.84(0.09, 0.83) after, p = 0.002; In group B (n = 12), 1.48(0.73, 1.62) before vs. 0.31(0.04, 0.58) after, p = 0.007; In Group C (n = 12), 2.74(1.70, 3.01) before vs. 1.39(0.70, 2.28)]. However, dexmedetomidine showed significantly less inhibition either on ACA or MI compared with propofol and midazolam (ACA 20.67 ± 33.59% in dexmedetomidine, 51.50 ± 32.83% in propofol, 60.43 ± 22.40% in midazolam, p = 0.002; MI 36.00 ± 34.77% in dexmedetomidine, 60.69 ± 27.49% in propofol, 68.81 ± 20.84% in midazolam, p = 0.012).

Conclusion

Patients with ABI exhibited decreased gastric motility. All sedatives, either propofol, midazolam, or dexmedetomidine, had inhibited effects on gastric motilities. Dexmedetomidine has less inhibitory effects on ACA and MI compared with propofol and midazolam.

Considerations for medical nutrition therapy management of the critically ill patient with hematological malignancies: A narrative review

Patients with hematological malignancies (HMs) are more frequently admitted now than in the past to the intensive care unit (ICU) due to more aggressive approaches in primary therapy of HMs and the need for critical care support. Pathophysiological alterations derived from HMs and the different hematological therapies, such as chemotherapy, negatively affect gastrointestinal (GI) function, metabolism, and nutrition status. Further, malnutrition strongly influences outcomes and tolerance of the different hematological therapies. In consequence, these critically ill patients frequently present with malnutrition and pathophysiological alterations that create challenges for the delivery of medical nutrition therapy (MNT) in the ICU. Frequent screening, gauging tolerance, and monitoring nutrition status are mandatory to provide individualized MNT and achieve nutrition objectives. The present review discusses how HM impact GI function and nutrition status, the importance of MNT in patients with HM, and specific considerations for guidance in providing adequate MNT to these patients when admitted to the ICU.

Enteral feeding tolerance during pharmacologic neuromuscular blockade

A common misperception is that critically ill patients who receive paralytic therapy will not tolerate enteral nutrition. As a result, some clinicians empirically withhold enteral feedings for critically ill patients who receive neuromuscular blocker pharmacotherapy (NMB). The intent of this review is to examine the evidence regarding enteral feeding tolerance for critically ill patients given NMB. Studies evaluating enteral feeding during paralytic therapy are provided and critiqued. Evidence examining enteral feeding tolerance during NMB is limited. Enteral feeding intolerance is more likely attributable to the underlying illnesses and concurrent opioid analgesia, sedation, and vasopressor therapies. Most critically ill patients can be successfully fed during NMB. Prokinetic pharmacotherapy may be warranted in some patients.

Prediction of prokinetic agents in critically ill patients with feeding intolerance: a prospective observational clinical study

Background

Prokinetic agents are currently considered the first-line therapy to improve gastric emptying when feeding intolerance occurred in critically ill adults. In this study, we developed a technique to assess the feasibility of predicting prokinetic agent efficacy in critically ill patients.

Methods

The first images of each patient were obtained after EFI had occurred but before the first dose of prokinetic agents was administered and additional images were obtained every morning until the seventh day. The gastric antrum echodensity was recorded based on grayscale values (50th percentile, ED50; 85th percentile, ED85; mean, EDmean) and daily energy and protein intake was collected as the judgment for effective and ineffective group. A receiver operating characteristic curve was analyzed to distinguish the thresholds between the two groups and thus determine the ability of the gastric antrum echodensity to predict the efficacy of prokinetic agents.

Results

In total, 83 patients were analyzed. Patients in the ineffective group had a higher ED50 (58.13 ± 14.48 vs. 49.88 ± 13.78, p < 0.001, difference 95% CI: 5.68, 10.82), ED85 (74.81 ± 16.41 vs. 65.70 ± 16.05, p < 0.001, difference 95% CI:6.16, 12.05), and EDmean (60.18 ± 14.31 vs. 51.76 ± 14.08, p < 0.001, difference 95% CI: 5.85, 11.00) than those in the effective group. Patients in the effective group more easily reached the target energy 16.21 ± 7.98 kcal/kg vs. 9.17 ± 6.43 kcal/kg (p < 0.001), 0.72 ± 0.38 g/kg vs. 0.42 ± 0.31 g/kg (p < 0.001) than in the ineffective group intake by day.

Conclusion

The gastric antrum echodensity might serve as a tool for judging the efficacy of prokinetic agents, helping clinicians to decide whether to use prokinetic agents or place a post-pyloric tube when feeding intolerance occurs in critically ill patients.Clinical trial registration:http://www.chictr.org.cn/addproject2.aspx, ChiCTR2200058373. Registered 7 April 2022.

Stomach position evaluated using computed tomography is related to successful post-pyloric enteral feeding tube placement in critically ill patients: a retrospective observational study

BACKGROUND

Post-pyloric enteral feeding reduces respiratory complications and shortens the duration of mechanical ventilation. Blind placement of post-pyloric enteral feeding tubes (EFT) in patients with critical illnesses is often the first-line method because endoscopy or fluoroscopy cannot be easily performed at bedside; however, difficult placements regularly occur. We reported an association between the stomach position caudal to spinal level L1-L2, evaluated by abdominal radiographs after placement, and difficult placement; however, this method could not indicate difficulty before EFT placement. The aim of our study was to evaluate the association between stomach position, estimated using computed tomography (CT) images taken before the blind placement of the post-pyloric EFT, and the difficulty of EFT placement.

METHODS

Data from patients aged ≥ 20 years who underwent post-pyloric EFT in our intensive care unit were obtained retrospectively. Logistic regression analysis was used to evaluate the association between successful initial EFT placement and explanatory variables, including stomach position estimated by CT. Two cut-off values were used: caudal to L1-L2 based on a previous study and the best cut-off value calculated by the receiver operating characteristic curve. Variable selection was performed backward stepwise using Akaike's Information Criterion.

RESULTS

Of the total of 453 patients who were enrolled, the success rate of the initial EFT placement was 43.5%. The adjusted odds ratio for successful initial EFT placement of the stomach position caudal to L1-L2 was 0.61 (95% confidence interval: 0.41-1.07). Logistic regression analysis, including the stomach position caudal to L2-L3, calculated as the best cut-off value, indicated that stomach position was an independent factor for failure of initial EFT placement (adjusted odds ratio, 0.55; 95% confidence interval: 0.33-0.91).

CONCLUSIONS

Stomach position evaluated using CT images was associated with successful initial post-pyloric EFT placement. The best cut-off value of the greater curvature of the stomach to predict the success or failure of the first attempt was spinal level L2-L3. Trial registration University Hospital Medical Information Network Clinical Trials Registry (UMIN000046986; February 28, 2022). https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000052151.

Gastric feeding intolerance in critically ill patients during sustained pharmacologic neuromuscular blockade

BACKGROUND

The purpose of this study was to assess gastric feeding intolerance for critically ill patients who received sustained neuromuscular blocker (NMB) pharmacotherapy.

METHODS

Adult patients (>17 years of age) admitted to the trauma intensive care unit who received continuous intravenous NMB pharmacotherapy (rocuronium, cisatracurium, vecuronium, or pancuronium) for ≥48 h during continuous intragastric enteral nutrition (EN) were retrospectively evaluated. Gastric feeding intolerance was defined by initiation of a prokinetic agent (metoclopramide, erythromycin, or both) for an elevated gastric residual volume (GRV) >300 ml and with distention of the abdomen by physical examination, observation of regurgitation or emesis, temporary discontinuation of EN with low intermittent gastric suctioning, or initiation of parenteral nutrition (PN). Patients were evaluated for gastric feeding intolerance for the first 3 days of combined EN and NMB pharmacotherapy. A P value < 0.05 was considered statistically significant.

RESULTS

Ten patients of the 47 patients (21%) were intolerant to EN during NMB pharmacotherapy. No statistically or clinically relevant differences in patient characteristics were found between patients who tolerated EN vs those who experienced gastric feeding intolerance, except for a higher median maximum GRV of 125 ml (28, 200) vs 300 (250, 400) ml, respectively (P < 0.001). Five patients responded to prokinetic therapy and five required PN.

CONCLUSION

Most patients tolerated intragastric EN during sustained NMB pharmacotherapy. Presence of NMB pharmacotherapy is not an absolute contraindication for EN.

Serial Measurements of Refractive Index, Glucose and Protein to Assess Gastric Liquid Nutrient Transport—A Proof-of-Principal Study

Delayed gastric emptying contributes to complications as aspiration or malnutrition. Among patients suffering from acute neurological diseases, motility disorders are prevalent but poorly understood. Thus, methods to measure gastric emptying are required to allow for appropriate adaptions of individual enteral nutrition algorithms. For enterally fed patients repetitive concentration measurements of gastric content have been proposed to assess gastric emptying. This approach can be used to calculate the gastric residual volume (GRV) and transport of nutrition formula (NF), but it has not yet been implemented in clinical routine. The aim of this study was to investigate whether refractometry or other likewise straightforward analytical approaches produce the best results under in vitro conditions mimicking the gastric milieu. We measured NF in different known concentrations, either diluted in water or in simulated gastric fluid (SGF), with each of the following methods: refractometer, handheld glucose meter, and Bradford protein assay. Then, in enterally fed patients suffering from acute neurological disease, we calculated GRVs and nutrition transport and tested possible associations with clinical parameters. In water dilution experiments, NF concentrations could be assessed with the readout parameters of all three methods. Refractometry yielded the most precise results over the broadest range of concentrations and was biased least by the presence of SGF (detection range for Fresubin original fibre, given as volume concentration/normalized error of regression slope after incubation with water or SGF: 0–100 vs. 0–100%/0.5 vs. 3.9%; glucose-measurement: 5–100 vs. 25–100%/7.9 vs. 6.1%; Bradford-assay: 0–100 vs. 0–100%/7.8 vs. 15.7%). Out of 28 enterally fed patients, we calculated significant slower nutrition transport in patients with higher blood glucose (Rho −0.391; p = 0.039) and in patients who received high-dose sufentanil (Rho −0.514; p = 0.005). Also, the calculated nutrition transport could distinguish patients with and without feeding intolerance (Median 6 vs. 17 ml/h; Mann-Whitney test: p = 0.002). The results of our study prove that serial refractometry is a suitable and cost-effective method to assess gastric emptying and to enhance research on gastrointestinal complications of stroke.

Fasting does not guarantee empty stomach in the intensive care unit: A prospective ultrasonographic evaluation (The NUTRIGUS study)

BACKGROUND

In the intensive care unit (ICU), a fasting period is usually respected to avoid gastric aspiration during airway management procedures. Since there are no recognised guidelines, intensive care physicians balance the aspiration risk with the negative consequences of underfeeding. Our objective was to determine the impact of fasting on gastric emptying in critically ill patients by using gastric ultrasound.

MATERIAL AND METHODS

Among the 112 patients that met the inclusion criteria, 100 patients were analysed. Gastric ultrasonography was performed immediately before extubation. Patients with either 1/ an absence of visualised gastric content (qualitative evaluation) or 2/ a gastric volume < 1.5 mll/kg in case of clear fluid gastric content (quantitative evaluation) were classified as having an empty stomach.

MAIN FINDINGS

In our study, twenty-six (26%) patients had a full stomach at the time of extubation. The incidence of full stomach was not significantly different between patients who fasted < 6 h or patients who fasted ≥ 6 h. Among the 57 patients receiving enteral nutrition (EN) within the last 48 h, there was no correlation between the duration of EN interruption and the GAA. The absence of EN was not associated with an empty stomach.

CONCLUSION

At the time of extubation, the incidence of full stomach was high and not associated with the fasting characteristics (duration/absence of EN). Our results support the notions that fasting before airway management procedures is not a universal paradigm and that gastric ultrasound might represent a useful tool in the tailoring process. CLINICALTRIALS.GOV: NCT04245878.

The effect of opioids on gastrointestinal function in the ICU

Gastrointestinal (GI) dysfunction is common in the critical care setting and is highly associated with clinical outcomes. Opioids increase the risk for GI dysfunction and are frequently prescribed to reduce pain in critically ill patients. However, the role of opioids in GI function remains uncertain in the ICU. This review aims to describe the effect of opioids on GI motility, their potential risk of increasing infection and the treatment of GI dysmotility with opioid antagonists in the ICU setting.

Interventional treatment of acute myocardial infarction-related cardiogenic shock

PURPOSE OF REVIEW

Acute revascularization is with some evidence the only intervention proven to improve the prognosis in myocardial infarction-related cardiogenic shock but several interventions are continuously being investigated in order to increase survival among these patients. In this review, several aspects related to the interventional treatment of cardiogenic shock are discussed chronologically from symptom debut to leaving the cardiac catheterization laboratory.

RECENT FINDINGS

In the randomized CULPRIT-SHOCK trial, a culprit-only revascularization strategy was reported superior to immediate complete revascularization among patients with multivessel disease. Recent large-scale observational data underline the marked prognostic importance of time from medical contact to revascularization in acute myocardial infarction-related cardiogenic shock. Moreover, studies suggest a potential beneficial effect of a transradial vascular access as well as early initialization of mechanical circulatory support in carefully selected patients. This, however, needs further validation.

SUMMARY

Acute revascularization remains a crucial part of the initial management of acute myocardial infarction-related cardiogenic shock. Among cardiogenic shock patients presenting with multivessel disease, a culprit-only approach should be the routine strategy. Time to revascularization plays a crucial role in the setting of cardiogenic shock, why prehospital optimization and triaging may be the most important factors in order to improve prognosis in AMI-related cardiogenic shock.

Enteral Nutrition Safety With Advanced Treatments: Extracorporeal Membrane Oxygenation, Prone Positioning, and Infusion of Neuromuscular Blockers

This review aims at assessing the safety and efficacy of enteral nutrition in critically ill patients receiving extracorporeal membrane oxygenation, prone positioning, and infusion of neuromuscular blockers. Existing data from randomized controlled trials demonstrate the survival benefit of early enteral nutrition in critically ill patients. Observational data have demonstrated that enteral nutrition in patients receiving extracorporeal membrane oxygenation, prone positioning, and infusion of neuromuscular blockers is generally safe. However, these patients are at increased risk for gastrointestinal complications from enteral nutrition because of critical illness-induced gastrointestinal dysfunction; associated shock; the concomitant use of vasopressor agents, sedatives, and narcotics; possibly mesenteric circulatory compromise; and regurgitation associated with prone positioning. Therefore, early enteral nutrition is generally recommended in these patients in the absence of severe gastrointestinal dysfunction or shock. To reduce the complications, early nutrition should be advanced gradually (trophic feeding or permissive underfeeding), the bed should be tilted to a maximum of 30°, and concentrated nutritional formulae and the use of prokinetics may be considered to treat enteral feeding intolerance. Physicians should be vigilant about monitoring for early signs of acute mesenteric ischemia, which should lead to holding enteral feeding. Parenteral nutrition may be utilized in patients who cannot receive enteral nutrition or are unable to reach their nutrition goals by the end of the first week.

A study protocol for a multicentre, prospective, before-and-after trial evaluating the feasibility of implementing targeted SEDation after initiation of mechanical ventilation in the emergency department (The ED-SED Pilot Trial)

INTRODUCTION

Sedation is a cornerstone therapy in the management of patients receiving mechanical ventilation and is highly influential on outcome. Early sedation depth appears especially influential, as early deep sedation is associated with worse outcome when compared with light sedation. Our research group has shown that patients receiving mechanical ventilation in the emergency department (ED) are exposed to deep sedation commonly, and ED sedation depth is impactful on intensive care unit (ICU) care and clinical outcomes. While extensive investigation has occurred for patients in the ICU, comparatively little data exist from the ED. Given the influence that ED sedation seems to carry, as well as a lack of ED-based sedation trials, there is significant rationale to investigate ED-based sedation as a means to improve outcome.

METHODS AND ANALYSIS

This is a multicentre (n=3) prospective, before-and-after pilot trial examining the feasibility of implementing targeted sedation in the immediate postintubation period in the ED. A cohort of 344 patients receiving mechanical ventilation in ED will be included. Feasibility outcomes include: (1) participant recruitment; (2) proportion of Richmond Agitation-Sedation Scale (RASS) scores in the deep sedation range; (3) reliability (agreement) of RASS measurements performed by bedside ED nurses; and (4) adverse events. The proportion of deep sedation measurements before and after the intervention will be compared using the χ² test. Logistic regression will be used to compare before-and-after differences, adjusting for potential confounders. The inter-rater correlation coefficient will be used to assess paired observations between a study team member and bedside ED nurses, and to describe reliability of RASS measurements.

ETHICS AND DISSEMINATION

The Human Research Protection Office at Washington University in St. Louis School of Medicine has approved the study. The publication of peer-reviewed manuscripts and the presentation of abstracts at scientific meetings will be used to disseminate the work.

REGISTRATION

ClinicalTrials.gov identifier NCT04410783; Pre-results.

Glycoprotein IIb/IIIa inhibitors for cardiogenic shock complicating acute myocardial infarction: a systematic review, meta-analysis, and meta-regression

Background

Cardiogenic shock complicates 5–10% of myocardial infarction (MI) cases. Data about the benefit of glycoprotein IIb/IIIa inhibitors (GPI) in these patients is sparse and conflicting.

Methods

We performed a systematic review, meta-analysis, and meta-regression of studies assessing the impact of GPI use in the setting of MI complicated cardiogenic shock on mortality, angiographic success, and bleeding events. We systematically searched for studies comparing GPI use as adjunctive treatment versus standard care in this setting. Random-effects meta-analysis and meta-regression were performed.

Results

Seven studies with a total of 1216 patients (GPI group, 720 patients; standard care group, 496 patients) were included. GPI were associated with a 45% relative reduction in the odds of death at 30 days (pooled OR 0.55; 95% CI 0.35–0.85; I² = 57%; P = 0.007) and a 49% reduction in the odds of death at 1 year (pooled OR 0.51; 95% CI 0.32–0.82; I² = 58%; P = 0.005). Reduction in short-term mortality seemed to be more important before 2000, as this benefit disappears if only the more recent studies are analyzed. GPI were associated with a 2-fold increase in the probability of achieving TIMI 3 flow (pooled OR, 2.05; 95% CI 1.37–3.05; I² = 37%, P = 0.0004). Major bleeding events were not increased with GPI therapy (pooled OR, 1.0; 95% CI 0.55–1.83; I² = 1%, P = 0.99). Meta-regression identified that patients not receiving an intra-aortic balloon pump seemed to benefit the most from GPI use (Z = − 1.57, P = 0.005).

Conclusion

GPI therapy as an adjunct to standard treatment in cardiogenic shock was associated with better outcomes, including both short- and long-term survival, without increasing the risk of bleeding.

Codeine delays gastric emptying through inhibition of gastric motility as assessed with a novel diagnostic intragastric balloon catheter

BACKGROUND

The use of opioids as analgesic is on the rise, despite their inhibitory effect on gastric emptying. A novel feeding catheter with integrated intragastric balloon was developed to continuously assess gastric motility, enabling to investigate the effect of opioids on motility and emptying simultaneously. We aimed to discriminate normal and pharmacologically impaired gastric motility and its impact on gastric emptying in healthy adults.

METHODS

The VIPUN Gastric Monitoring System comprises a nasogastric balloon catheter and a monitoring unit. In a four-way randomized, single-blinded, cross-over study, subjects received either placebo or 58.8 mg codeine phosphate in combination with either an uninflated or an inflated (180 mL) balloon catheter. Motility-induced pressure changes were recorded for 6 hours. During the first 2 hours, nutrients were infused (225 kcal, 75 mL/h). Gastric emptying was assessed with a ¹³ C-octanoate breath test and expressed as gastric half-emptying time (GET½). An algorithm, designed to detect phasic contractility, converted pressure changes to a gastric balloon motility index (GBMI). Results are presented as mean(SD).

KEY RESULTS

Eighteen subjects completed the investigation (32(13) years, 22(2) kg/m² ). After codeine, GBMI was lower (0.31(0.16)) and GET½ was longer (233(57) minutes) compared with placebo (GBMI: 0.48(0.15), P < .01 and GET½: 172(12) minutes, P < .001). Within-subject ΔGET½ correlated significantly with ΔGBMI (r = -0.77 and P < .001).

CONCLUSIONS AND INFERENCES

The VIPUN Gastric Monitoring System allowed to assess gastric motility safely and continuously. The correlation between pharmacologically decreased gastric emptying and motility indicates a strong link between both. Gastric motility, measured with this innovative device, can be an indicator for gastrointestinal intolerance.

Opioid-Induced Foregut Dysfunction

The impact of opioid use on the lower gastrointestinal tract is well described, but recent opioid crisis has caused increased awareness of the detrimental effects of these drugs on esophageal and gastroduodenal motility. Opioid use has been associated with increased incidence of spastic esophageal motility disorders and gastroduodenal dysfunction. Opioid receptors are present with high abundance in the myenteric and submucosal plexus of the enteric nervous system. Activation of these receptors leads to suppressed excitability of the inhibitory musculomotor neurons and unchecked tonic contraction of the autogenic musculature (such as the lower esophageal sphincter and the pylorus).

Effects of Midazolam and Midazolam-Butorphanol on Gastrointestinal Transit Time and Motility in Cockatiels (Nymphicus hollandicus)

Positive contrast gastrointestinal (GI) studies are performed frequently in avian medicine to identify GI obstruction, luminal distension, and intracoelomic mass effects. However, repeated manual restraint and radiographic positioning may result in a stress-response and associated morbidity in birds, which can be attenuated by administration of sedative drugs. In mammals, many sedative drugs have been shown to affect GI transit times and motility. In this randomized, blinded, controlled prospective study, the effects of midazolam (M; 6 mg/kg IM) and midazolam-butorphanol (MB; 3 mg/kg each IM) on GI transit times were evaluated in 12 healthy cockatiels (Nymphicus hollandicus). Iohexol (20 mL/kg) was administered by crop gavage 15 minutes after induction of sedation, and fluoroscopic images were obtained at different time points. Both sedation protocols significantly affected GI transit times and motility, and the MB protocol had more pronounced effects. Overall median (range) GI transit times were 60 (30-120), 90 (30-120), and 120 (120-180) minutes for the control, M, and MB groups, respectively. Ventricular contractions were markedly reduced with both sedation protocols, while esophageal boluses were reduced only in the MB group. Visualization of the GI tract after iohexol administration was graded highest in the control group and poorest in the MB group. Our results show that commonly used sedative drugs have significant effects on GI transit time and motility in birds. Therefore, GI transit times obtained in sedated birds should not be compared to available reference transit times obtained from unsedated animals.

From dysmotility to virulent pathogens: implications of opioid use in the ICU

PURPOSE OF REVIEW

Gastrointestinal dysmotility occurs frequently in the critically ill. Although the causes underlying dysmotility are multifactorial, both pain and its treatment with exogenous opioids are likely causative factors. The purpose of this review is to describe the effects of pain and opioids on gastrointestinal motility; outline the rationale for and evidence supporting the administration of opioid antagonists to improve dysmotility; and describe the potential influence opioids drugs have on the intestinal microbiome and infectious complications.

RECENT FINDINGS

Opioid drugs are frequently prescribed in the critically ill to alleviate pain. In health, opioids cause gastric dysmotility, yet the evidence for this in critical illness is inconsistent and limited to observational studies. Administration of opioid antagonists may improve gastrointestinal motility, but data are sparse, and these agents cannot be recommended outside of clinical trials. Although critical illness is associated with alterations in the microbiome, the extent to which opioid administration influences these changes, and the subsequent development of infection, remains uncertain.

SUMMARY

Replication of clinical studies from ambulant populations in critical care is required to ascertain the independent influence of opioid administration on gastrointestinal motility and infectious complications.

Evaluation of gastric motility through surface electrogastrography in critically ill septic patients. Comparison of metoclopramide and domperidone effects: A pilot randomized clinical trial

INTRODUCTION AND AIMS

Critically ill patients present with a broad spectrum of gastrointestinal motility disorders that affect the digestive tract. Our aim was to compare the effect of two prokinetic drugs on gastric electrical rhythm in critically ill septic patients, measured through surface electrogastrography (EGG).

MATERIAL AND METHODS

A prospective triple-blinded randomized study was conducted on 36 patients admitted to the intensive care unit (ICU) with the diagnosis of septic shock. They were randomized to receive metoclopramide or domperidone. We assessed dominant frequency (DF), percentage distribution over time, and dominant power (DP), which represents the strength of contraction, before and after administration of the study drugs.

RESULTS

Reliable electrogastrograms were achieved in all patients. In relation to the distribution of DF over time, 64% of patients had dysrhythmia, the mean baseline DF was 2.9 cpm, and the mean DP was 56.5μv After drug administration, 58% of the patients had dysrhythmia, the mean DF increased to 5.7 cpm (P<.05), and the DP did not change (57.4μv²). There were no significant differences between drugs. In the metoclopramide group, the baseline DF was 2.1 cpm and the baseline DP was 26.1μv². The post-drug values increased to 5.4 cpm and 34.1μv², respectively. In the domperidone group, the baseline DF was 3.7 cpm and the baseline DP was 86.9μv². After drug administration, the DF increased to 6.1 cpm and the DP decreased to 83.5μv².

CONCLUSIONS

Both metoclopramide and domperidone similarly increased the DF of gastric pacemaker activity and improved gastric motility by restoring a normogastric pattern. Gastric dysmotility is frequent in septic patients.

Identification of risk factors for enteral feeding intolerance screening in critically ill patients

Objectives:

To identify risk factors for enteral feeding intolerance screening in critically ill patients, thereby, provide some reference for healthcare staff to assess the risk of feeding intolerance, and lay the foundation for future scale development.

Methods:

This study used a mixed methodology, including a literature review, semi-structured interviews, the Delphi technique, and the analytic hierarchy process. We used the literature review and semi-structured interviews (n=22) to draft a preliminarily item pool for feeding intolerance, Delphi technique (n=30) to screen and determine the items, and the analytic hierarchy process to calculate the weight of each item. The study was conducted between June 2014 and September 2015 in Daping Hospital, Third Military Medical University, Chongqing, China.

Results:

Twenty-three risk factors were selected for the scale, including 5 dimensions. We assigned a weight to each item according to their impact on the feeding intolerance, with a higher score indicating a greater impact. The weight of each dimension was decreasing as follows: patient conditions, weight score equals 42; general conditions, weight score equals 23; gastrointestinal functions, weight score equals 15; biochemical indexes, weight score equals 14; and treatment measures, weight score equals 6.

Conclusion:

Developed list of risk factors based on literature review, survey among health care professionals and expert consensus should provide a basis for future studies assessing the risk of feeding intolerance in critically ill patients.

The frequency, risk factors, and complications of gastrointestinal dysfunction during enteral nutrition in critically ill patients

BACKGROUND

Gastrointestinal (GI) motility disorders in intensive care patients remain relatively unexplored. Nowadays, the frequency, risk factors and complications of GI dysfunction during enteral nutrition (EN) become more questionable.

AIM

To evaluate the frequency, risk factors and complications of GI dysfunction during EN in the first 2 weeks of the intensive care unit (ICU) stay and to identify precautions to prevent the development of GI dysfunction and avoid complications.

METHODS

In this prospective observational study, we deliberately targeted at-risk patients. A total of 137 patients who received nasogastric tube feeding in an ICU of a tertiary hospital were enrolled.

RESULTS

The incidence of GI dysfunction that was found to be 63% which was associated mainly between MDR bacteria positivity and negative fluid balance. Diarrhea was observed in 36 patients (26%) and on 147 patient-days (incidence rate, 5.5 per 100 patient-days). The median day of diarrhea onset was 6 days after the initiation of EN. Forty patients (29%) presented with constipation (85% during the first week). Fifty patients (36%) exhibited upper digestive intolerance on 212 patient-days (incidence rate, 7.9 per 100 patient-days), after a median EN duration of 6 days (range, 2-14 days). Logistic regression analysis revealed MDR bacteria growth in the culture (OR, 1.75; 95% CI, 1.15-2.67; P=0.008) and negative fluid balance (OR, 0.57; 95% CI, 0.34-0.94; P=0.03) as the risk factors for GI dysfunction. We also showed that GI dysfunction was associated with high SOFA score, hypoalbuminemia, catecholamine use, and prolonged length of stay (LOS). GI dysfunction, on the other hand, can cause some complications including inadequate nutrition, and newly developed decubitus ulcers.

CONCLUSION

GI dysfunction should be considered a clinical predictor of inadequate nutrition and prolonged LOS. In addition, the most dramatic risk for GI dysfunction was observed in patients with MDR bacteria growth in the culture and patients in negative fluid balance. Intensivists provide appropriate nutrition for patients, as well as prompt intervention and the development of treatment strategies in the event of GI dysfunction.

In Search of the Ideal Promotility Agent: Optimal Use of Currently Available Promotility Agents for Nutrition Therapy of the Critically Ill Patient

PURPOSE OF REVIEW

Enteral nutrition therapy is essential in the management of critically ill patients. Prokinetic agents have been used successfully to aid in the delivery of nutrition and improve feeding tolerance in patients in the intensive care unit (ICU). The aim of this report is to review the existing promotility agents available for use in the critically ill as well as outline the role of potential investigative drugs in order to provide a guide to the management of this difficult and important clinical dilemma.

RECENT FINDINGS

While no single currently available agent currently meets all of the desired goals in the critical care setting, there are an increasing number of available agents from which to choose including motilin receptor agonists, 5HT4 receptor agonists, D2 receptor antagonists, and Mu opioid receptor antagonists. We recommend a multifaceted approach to optimizing enteral nutrition in the critical care setting which should include the early, prophylactic use of promotility agents and should focus on the management of reversible causes of impaired gastrointestinal motility.

Clinical nutrition and gastrointestinal dysfunction in critically ill stroke patients

Background Data on the epidemiology and risk factors of altered gastrointestinal motility (AGIM) is virtually lacking for patients suffering from non-traumatic neurologic diseases and stroke. This study investigated whether patterns of AGIM differ between patients with stroke and other severe acute brain diseases. Methods Clinical records of stroke and non-stroke patients treated at a neurological intensive care unit (ICU) were reviewed at day 1-5 and at day 10 after admission. The data was analyzed for the course of enteral/parenteral nutrition and for and for signs and symptoms of gastrointestinal dysfunction. The study included data of 76 patients, 57 with stroke (stroke group, SG) and 19 with other neurological diseases (non-stroke group, NSG). Results Basic demographic as well as clinical baseline characteristics and alimentation regime were similar in both groups. At least one sign of AGIM was seen in 33/57 (58%) SG and in 15/19 (79%) NSG patients (P = 0.099). Regurgitation was significantly more frequent among patients from the NSG (P < 0.05). Subjects from the NSG also spent a higher proportion of time with at least one symptom of AGIM present (P < 0.05). Conclusions For the first time, this study investigated the prevalence of AGIM in patients suffering from severe stroke. The prevalence of disturbed gastrointestinal function was found to be high in stroke patients, but was lower than in a group of non-stroke patients with similar general disease severity and baseline characteristics.

Modified B-ultrasound method for measurement of antral section only to assess gastric function and guide enteral nutrition in critically ill patients

AIM

To establish a modified B-ultrasound method of measuring the antral section only to assess gastric motility in healthy people, and evaluate its application in guiding enteral nutrition (EN) in critically ill patients.

METHODS

First, 30 healthy volunteers were selected. The modified B-ultrasound method and the traditional B-ultrasound method were applied to assess gastric function. The correlation of indices of gastric function between the two groups was analyzed statistically. In addition, 64 critically ill patients were selected, and the modified B-ultrasound method and the gastric juice withdrawal method were applied to guide the implementation of EN. Daily caloric value, the time required to achieve complete EN, ICU stay, hospitalization time, and serum prealbumin and albumin levels were recorded and compared between the two groups. Kaplan-Meier survival curve was used to compare the complications of EN between the two groups.

RESULTS

In healthy subjects, there was a good correlation among gastric emptying time, antral contraction frequency and antral motility index between the two groups (r = 0.57, 0.61 and 0.54, respectively). The study on critically ill patients also revealed that a better effect of EN was achieved in the modified B-ultrasound method group, in which patients had shorter ICU stay and hospitalization time and higher levels of serum prealbumin and albumin. The Kaplan-Meier survival analysis revealed that the improved B-ultrasound method was associated with significantly fewer EN complications (P = 0.031).

CONCLUSION

The modified B-ultrasound method can provide a good real-time assessment of gastric function and has a better effect than the traditional method in guiding EN in critically ill patients.

Intestinal T lymphocyte homing is associated with gastric emptying and epithelial barrier function in critically ill: a prospective observational study

Background

Impaired gastric emptying is common in critically ill patients. Intestinal dysmotility, a major cause of feed intolerance, may foster infectious complications due to mucosal barrier disruption. However, little is known about gut-directed immune activation, intestinal barrier function and its association with impaired gastric emptying in critically ill patients at ICU admission.

Methods

We conducted a prospective observational study at two tertiary care medical ICUs. Fifty consecutive patients needing invasive mechanical ventilation were recruited within 24 h of ICU admission, prior to any nutritional support. The acute physiology and chronic health evaluation (APACHE) II score, the sequential organ failure assessment (SOFA) score and the multiple organ dysfunction score (MODS) were used to assess illness severity and multiple organ dysfunction. Gastric emptying was assessed by paracetamol absorption test. Peripheral blood mononuclear cells were freshly isolated and cultured for 24 h, and TNF-α, IL-1β and IL-10 measured in cell culture supernatants and in serum by ELISA. The intestinal epithelial barrier was assessed, quantifying serum concentrations of intestinal fatty acid binding protein (I-FABP), ileal bile-acid binding protein (I-BABP) and zonulin-1 by ELISA. Small bowel homing T lymphocytes (CD4+ α4β7 + CCR9+) were analyzed by flow cytometry. The Mann-Whitney test and Spearman correlation were used in statistical evaluation.

Results

CD4 + α4β7 + CCR9+ T lymphocytes were inversely correlated with gastric emptying. Patients with delayed gastric emptying at ICU admission (n = 35) had significantly higher serum and PBMC-induced TNF-α and IL-1β and increased intestinal barrier disruption reflected by higher I-FABP, I-BABP and zonulin-1. Patients who died in the ICU had significantly impaired gastric empting at admission compared to ICU survivors. No differences were observed in APACHE II, SOFA or MODS in patients with delayed gastric emptying compared to patients with normal gastric emptying.

Conclusions

Exaggerated CD4 + α4β7 + CCR9+ T lymphocyte homing with increased pro-inflammatory cytokine release and intestinal epithelial barrier disruption are associated with delayed gastric emptying. This is not simply due to differences in overall severity of illness at ICU admission and may represent a pathophysiological mechanism of gut-directed immune activation leading to impaired barrier function in the critically ill.

Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines

Purpose

To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness.

Methods

We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined “early” EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds.

Results

We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion.

Conclusions

We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-016-4665-0) contains supplementary material, which is available to authorized users.

Metoclopramide as intermittent and continuous infusions in critically ill patients: a pilot randomized clinical trial

AIM

Metoclopramide is commonly used as a prokinetic agent in critically ill patients with enteral feeding intolerance. In this study, noninferiority of metoclopramide as intermittent versus continuous infusion was examined in critically ill patients with enteral feeding intolerance.

METHODS

Forty critically ill adults patients were assigned to receive metoclopramide as either intermittent (10 mg every 6 h) or continuous (2 mg/h) infusion. Frequency of feeding intolerance and adverse effects of metoclopramide were assessed during 7 days of study.

RESULTS

Number of patients with feeding intolerance during different times of the course was not different between the groups. Although not statistically significant, diarrhea and cardiac rhythm were more common in continuous than intermittent infusion group.

CONCLUSION

Continuous and intermittent infusions of metoclopramide showed equivalent effectiveness in critically ill patients.

Gut Motility Issues in Critical Illness

Acute gastrointestinal injury (AGI) is common in critical illness and negatively affects outcome. A variety of definitions have been used to describe AGI, which has led to clinical confusion and hampered comparison of research studies across institutions. An international working group of the European Society of Intensive Care Medicine was convened to standardize definitions for AGI and provide current evidence-based understanding of its pathophysiology and management. This disorder is associated with a wide variety of signs and symptoms and may be difficult to detect, therefore a high index of suspicion is warranted.

Anti-platelet Therapy Resistance - Concept, Mechanisms and Platelet Function Tests in Intensive Care Facilities

It is well known that critically ill patients require special attention and additional consideration during their treatment and management. The multiple systems and organ dysfunctions, typical of the critical patient, often results in different patterns of enteral absorption in these patients. Anti-platelet drugs are the cornerstone in treating patients with coronary and cerebrovascular disease. Dual anti-platelet therapy with aspirin and clopidogrel is the treatment of choice in patients undergoing elective percutaneous coronary interventions and is still widely used in patients with acute coronary syndromes. However, despite the use of dual anti-platelet therapy, some patients continue to experience cardiovascular ischemic events. Recurrence of ischemic events is partly attributed to the fact that some patients have poor inhibition of platelet reactivity despite treatment. These patients are considered low- or non-responders to therapy. The underlying mechanisms leading to resistance are not yet fully elucidated and are probably multifactorial, cellular, genetic and clinical factors being implicated. Several methods have been developed to asses platelet function and can be used to identify patients with persistent platelet reactivity, which have an increased risk of thrombosis. In this paper, the concept of anti-platelet therapy resistance, the underlying mechanisms and the methods used to identify patients with low responsiveness to anti-platelet therapy will be highlighted with a focus on aspirin and clopidogrel therapy and addressing especially critically ill patients.

Oesophageal bezoar as a complication of enteral nutrition in critically ill patients. Two case studies

Enteral nutrition has a relatively low incidence of major complications. The most common complications are mechanical problems, bronchoaspiration and diarrhoea. A rare complication associated with the use of enteral nutrition is oesophageal bezoar. A bezoar is a body of undigested and partially digested matter in the gastrointestinal tract. The main risks factors are gastric motility dysfunction and the use of opiates or sucralfate. The aim of this paper was to present two cases of oesophageal obstruction resulting from the formation of bezoars due to enteral nutrition. Both patients experienced prolonged stays in the intensive care unit and were receiving enteral nutrition, and both cases involved an obstruction of the nasogastric tube and the regurgitation of solid chunks of enteral nutrition through the mouth and the nose. Impactions of solidified enteral nutrition in the distal parts of the oesophagus were confirmed with gastroscopies. Enzymatic complexes containing papain, cellulose, pancreatin, pepsin and diastase were used to successfully dissolve the bezoars in both cases.

Gastric vs Small Bowel Feeding in Critically Ill Neurologically Injured Patients: Results of a Multicenter Observational Study

BACKGROUND

To evaluate gastric compared with small bowel feeding on nutrition and clinical outcomes in critically ill, neurologically injured patients.

MATERIALS AND METHODS

International, prospective observational studies involving 353 intensive care units (ICUs) were included. Eligible patients were critically ill, mechanically ventilated with neurological diagnoses who remained in the ICU and received enteral nutrition (EN) exclusively for at least 3 days. Sites provided data, including patient characteristics, nutrition practices, and 60-day outcomes. Patients receiving gastric or small bowel feeding were compared. Covariates including age, sex, body mass index, and Acute Physiology and Chronic Health Evaluation II score were used in the adjusted analyses.

RESULTS

Of the 1691 patients who met our inclusion criteria, 1407 (94.1%) received gastric feeding and 88 (5.9%) received small bowel feeding. Adequacy of calories from EN was highest in the gastric group (60.2% and 52.3%, respectively, unadjusted analysis; P = .001), but this was not significant in the adjusted model (P = .428). The likelihood of EN interruptions due to gastrointestinal (GI) complications was higher for the gastric group (19.6% vs 4.7%, unadjusted model; P = .015). There were no significant differences in the rate of discontinuation of mechanical ventilation (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.66-1.12; P = .270) or the rate of being discharged alive from the ICU (HR, 0.94; 95% CI, 0.72-1.23; P = .641) and hospital (HR, 1.16; 95% CI, 0.87-1.55; P = .307) after adjusting for confounders.

CONCLUSIONS

Despite a higher likelihood of EN interruptions due to GI complications, gastric feeding may be associated with better nutrition adequacy, but neither route is associated with better clinical outcomes.

Gastric Dysmotility in Critically Ill Children: Pathophysiology, Diagnosis, and Management

OBJECTIVE

We aimed to review gastric dysmotility in critically ill children: 1) its pathophysiology, with a focus on critical care diseases and therapies that affect gastric motility, 2) diagnostic methodologies, and 3) current and future potential therapies.

DATA SOURCES

Eligible studies were identified from PubMed and MEDLINE.

STUDY SELECTION

Literature search included the following key terms: "gastric emptying," "gastric motility/dysmotility," "gastrointestinal motility/dysmotility," "nutrition intolerance," and "gastric residual volume."

DATA EXTRACTION

Studies since 1995 were extracted and reviewed for inclusion by the authors related to the physiology, pathophysiology, diagnostic methodologies, and available therapies for gastric emptying.

DATA SYNTHESIS

Delayed gastric emptying, a common presentation of gastric dysmotility, is present in up to 50% of critically ill children. It is associated with the potential for aspiration, ventilator-associated pneumonia, and inadequate delivery of enteral nutrition and may affect the efficacy of enteral medications, all of which may be result in poor patient outcomes. Gastric motility is affected by critical illness and its associated therapies. Currently available diagnostic tools to identify gastric emptying at the bedside have not been systematically studied and applied in this cohort. Gastric residual volume measurement, used as an indirect marker of delayed gastric emptying in PICUs around the world, may be inaccurate.

CONCLUSIONS

Gastric dysmotility is common in critically ill children and impacts patient safety and outcomes. However, it is poorly understood, inadequately defined, and current therapies are limited and based on scant evidence. Understanding gastric motility and developing accurate bedside measures and novel therapies for gastric emptying are highly desirable and need to be further investigated.

Phenytoin inhibits contractions of rat gastrointestinal and portal vein smooth muscle by inhibiting calcium entry

BACKGROUND

Phenytoin is widely used as a second-line treatment for status epilepticus. Besides its well-known cardiac pro-arrhythmogenicity, side effects on other organ systems have received less attention.

METHODS

This study investigates the effects of phenytoin on gastrointestinal tissue function using an in vitro model of smooth muscle preparations from rats by combining registrations of pharmacological effects on mechanical contractions, electric field potentials, and dynamic intravital fluorescence microscopy.

KEY RESULTS

When added to the bathing solution at a concentration of 30 μM, phenytoin reduced the frequency of spontaneous activity significantly in antrum and portal vein preparations to 72.2 ± 36.5% (p = 0.022) and 80.7 ± 24.4% (p = 0.037) of control values, respectively. At a concentration of 100 μM, the height of spontaneous contractions declined to 9.8 ± 19.6% (p = 0.005) (antrum), 15.7 ± 28.2% (p = 0.004) (portal vein), and 31.8 ± 31.3% (p = 0.005) (colon) in comparison to the control conditions before the application of phenytoin. Depolarization triggered increases in calcium dependent fluorescence signals were reduced by 52.8 ± 39.1% (p = 0.012) The inhibition of spontaneous activity caused by phenytoin was reduced in the presence of the L-type calcium channel agonist BAY K8644(-).

CONCLUSIONS & INFERENCES

Phenytoin exerts strong inhibitory effects on the spontaneous and stimulated contractile activity of smooth muscles from both the upper and lower gastrointestinal tract. The mechanism underlying this effect is not related to the sodium channel blocking activity of phenytoin, but is rather caused by an inhibition of calcium entry through voltage dependent L-type calcium channels. The results of this study should raise vigilance to gastrointestinal complications in patients treated with phenytoin.

The impact of therapeutic hypothermia on on-treatment platelet reactivity and clinical outcome in cardiogenic shock patients undergoing primary PCI for acute myocardial infarction: Results from the ISAR-SHOCK registry

INTRODUCTION

Mild therapeutic hypothermia (TH) is standard of care after cardiac arrest of any cause. However, its impact on on-treatment platelet reactivity and clinical outcome in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock and undergoing PCI with P2Y12 receptor inhibitor treatment is less clear.

METHODS AND RESULTS

For the ISAR-SHOCK registry, 145 patients with AMI, cardiogenic shock and primary PCI in two centers (Deutsches Herzzentrum München and Klinikum rechts der Isar, Technical University Munich) between January 2009-May 2012 were analysed. Of these, 64 (44%) patients received TH treatment. The median [IQR] ADP-induced platelet aggregation following thienopyridine loading dose administration (clopidogrel in 95 and prasugrel in 50 patients) did not differ between the two groups (419 [283-684] for TH vs. 355 [207-710] AU x min for non-TH patients, P=0.22). After 30days follow-up, no significant differences were observed between both groups for mortality (42 vs. 44 %, HR: 0.93, 95% CI [0.56-1.53], p=0.77), MI (6 vs. 6%, HR: 0.99 95% CI [0.27-3.7], p=0.99) and TIMI minor bleedings (17 vs. 17%, HR 0.99 95% CI [0.45-2.18], p=0.98). TIMI major bleedings were numerically higher in the TH vs. non-TH cohort (25 % vs. 12 %, HR: 2.1 95% CI [0.95-4.63], p=0.07). Three definite stent thrombosis (ST) were observed in this registry and all STs occurred in the TH group of patients (p=0.09).

CONCLUSION

Results of this registry suggest that TH does not negatively impact on platelet reactivity in shock patients receiving either clopidogrel or prasugrel. The numerically higher rate of major bleedings and the clustering of STs in the TH cohort warrant further investigation.

Complicated and uncomplicated peptic ulcer disease: altered symptom response to a nutrient challenge linked to gastric motor dysfunction

BACKGROUND

Bleeding peptic ulcer (BPU) frequently occurs in the absence of preceding dyspeptic symptoms. We have observed that patients with BPU had a diminished symptom response to nutrient challenge test compared to uncomplicated peptic ulcer disease (uPUD). We postulated that more symptoms are manifest in patients with uPUD than BPU because there are greater derangements in gastric motor function.

AIM

To assess gastric emptying in patients with BPU, uPUD and healthy controls (HC).

METHODS

We studied 17 patients with BPU, 10 with uPUD, and 15 HC. After an 8-hour fast, subjects ingested 200 ml of an enteral feeding solution, containing 5 MBq (99m)Tc-rhenium sulphide colloid, every 5 min up to a cumulative volume of 800 ml. Gastric emptying was measured by scintigraphy for the total, proximal and distal stomach.

RESULTS

Patients with uPUD had significantly higher gastric retention in the proximal and total stomach at 100 min than HC and BPU, while BPU had similar percent retention to HC. Patients with uPUD had significantly higher cumulative symptom response to the nutrient challenge than did HC and BPU, while BPU had similar symptom responses to HC.

CONCLUSIONS

Patients with uPUD have significantly delayed gastric emptying compared to HC and BPU. Data suggest that in addition to alterations of visceral sensory function, altered gastric motor function occurs during a nutrient challenge in uPUD but not BPU. Gastric motor function may contribute to the manifestation of dyspeptic symptoms in PUD.

Temperature effects on haemostasis in whole blood from ticagrelor- and aspirin-treated patients with acute coronary syndrome

BACKGROUND

Comatose survivors after cardiac arrest are treated with mild induced hypothermia and potent platelet- inhibiting drugs after coronary stenting. Previous studies have shown an increased incidence of stent thrombosis during clopidogrel and aspirin treatment in conjunction with induced hypothermia. The aim of this study was to investigate the in vitro effect of induced hypo- and hyperthermia on blood from patients undergoing ticagrelor- and aspirin-mediated platelet inhibition.

METHODS

Whole blood from 15 patients with acute coronary syndrome who were treated with ticagrelor and aspirin and from eight healthy volunteers was incubated for 1 hour at 28, 33, 37, and 39°C.

RESULTS

In blood from patients with acute coronary syndrome, the activated clotting time (Sonoclot) was prolonged in mild hypothermic (33°C) compared to normothermic (37°C) samples. Sonoclot, clotting rate and platelet function were decreased in hypothermic compared to normothermic samples. Platelet-induced activation and aggregation (Multiplate) was unchanged in mild hypothermic compared to normothermic samples. In contrast, mild hypothermia supported increased platelet activation as measured with flow cytometry with up-regulation of PAC-1 and P-selectin on the platelet surface.

CONCLUSION

In acute coronary syndrome patients treated with ticagrelor and aspirin, in vitro hypothermia to 33°C markedly increased platelet activity measured with flow cytometry, whereas viscoelastic coagulation test (Sonoclot) revealed a hypocoagulative response. Prospective clinical trials studying platelet inhibition at different temperatures and correlating changes in platelet function to bleeding or stent occlusion are needed.

Platelet aggregation and clot formation in comatose survivors of cardiac arrest treated with induced hypothermia and dual platelet inhibition with aspirin and ticagrelor; a prospective observational study

INTRODUCTION

We conducted a prospective observational study in cardiac arrest survivors treated with mild induced hypothermia, evaluating different platelet function tests at hypo- and normothermia. We also investigated the relation between gastric emptying and vasodilator stimulated phosphoprotein (VASP).

METHODS

Comatose survivors of out of hospital cardiac arrest were included and divided into two groups, depending on whether dual platelet inhibition with peroral ticagrelor and aspirin was given or not. The first blood samples (T1) were collected 12-24 hours after reaching target temperature (33°C) and were compared to blood samples collected 12-28 hours after reaching normothermia (37°C) (T2) within each group. All samples were analysed by Sonoclot viscoelasticity, flow cytometry based VASP and with multiple electrode aggregometry, Multiplate®; adenosine diphosphate (ADP), collagen (COL), thrombin receptor agonist peptide (TRAP) and arachidonic acid (ASPI). Sonoclot and Multiplate® instruments were set on in vivo temperatures. Gastric secretion from the nasogastric tube was measured to assess absorption of per orally administered antiplatelet drugs. Differences between T1 and T2 within each group were calculated using Wilcoxon matched pairs signed test. Significance levels were set at P <0.01.

RESULTS

In total, 23 patients were included. In patients with dual platelet inhibition (n =14) Multiplate®-analyses showed no changes in ADP stimulated platelets. COL, TRAP and ASPI aggregations were higher at T2 compared to T1. Sonoclot-analyses showed that activated clotting time (ACT) was unchanged but both clot rate (CR) and platelet function (PF) were higher at T2 compared to T1. VASP decreased from 53 ± 28(T1) to 24 ± 22(T2), (P <0.001). The average volume of gastric secretion aspirated before T1 correlated well with VASP (T1), r =0.81 (P <0.001). In patients with no platelet inhibition, (n =9) similar changes between T1 and T2 were seen as in patients with dual platelet inhibition while VASP was unchanged.

CONCLUSIONS

We have demonstrated increased platelet aggregation and strengthened clot formation over time in out of hospital cardiac arrest patients treated with hypothermia. In patients on oral dual platelet inhibition, the effect of ticagrelor was delayed, probably due to slow gastric emptying.

Pharmacological therapy of feed intolerance in the critically ills

Feed intolerance in the setting of critical illness is associated with higher morbidity and mortality, and thus requires promptly and effective treatment. Prokinetic agents are currently considered as the first-line therapy given issues relating to parenteral nutrition and post-pyloric placement. Currently, the agents of choice are erythromycin and metoclopramide, either alone or in combination, which are highly effective with relatively low incidence of cardiac, hemodynamic or neurological adverse effects. Diarrhea, however, can occur in up to 49% of patients who are treated with the dual prokinetic therapy, which is not associated with Clostridium difficile infection and settled soon after the cessation of the drugs. Hence, the use of prokinetic therapy over a long period or for prophylactic purpose must be avoided, and the indication for ongoing use of the drug(s) must be reviewed frequently. Second line therapy, such as total parenteral nutrition and post-pyloric feeding, must be considered once adverse effects relating the prokinetic therapy develop.

High rates of prasugrel and ticagrelor non-responder in patients treated with therapeutic hypothermia after cardiac arrest

INTRODUCTION

After cardiac arrest due to acute coronary syndromes (ACS) therapeutic hypothermia (HT) is the standard care to reduce neurologic damage. Additionally, the concomitant medical treatment with aspirin and a P2Y12 receptor inhibitor like clopidogrel (Cl), prasugrel (Pr) or ticagrelor (Ti) is mandatory. The platelet inhibitory effect of these drugs under hypothermia remains unclear.

METHODS

164 patients with ACS were prospectively enrolled in this study. 84 patients were treated with HT, 80 patients were under normothermia (NT). All patients were treated with aspirin and one of the P2Y12 receptor inhibitors Cl, Pr or Ti. 24h after the initial loading dose the platelet reactivity index (PRI/VASP-index) was determined to achieve the platelet inhibitory effect.

RESULTS

In the HT-group the PRI/VASP-index was significantly higher compared to the NT-group (54.86%±25.1 vs. 28.98%±22.8; p<0.001). In patients under HT receiving Cl, the platelet inhibition was most markedly reduced (HT vs. NT: 66.39%±19.1 vs. 33.36%±22.1; p<0.001) compared to Pr (HT vs. NT: 37.6%±25.0 vs. 27.04%±25.5; p=0.143) and Ti (HT vs. NT: 41.5%±21.0 vs. 17.83%±14.5; p=0.009). The rate of non-responder defined as PRI/VASP-index>50% was increased in HT compared to NT (60.7% vs. 22.5%; p<0.001) with the highest rates in the group receiving Cl (CL: 82% vs. 26%, p<0.001; Pr: 32% vs. 23%; n.s.; Ti: 30% vs. 8%, n.s.).

CONCLUSION

The platelet inhibitory effect in patients treated with HT after cardiac arrest is significantly reduced. This effect was most marked with the use of Cl. The new P2Y12-inhibitors Pr and Ti improved platelet inhibition in HT, but could not completely prevent non-responsiveness.

Gastric emptying measurement of liquid nutrients using the (13)C-octanoate breath test in critically ill patients: a comparison with scintigraphy

PURPOSE

Scintigraphy is considered the most accurate technique for the measurement of gastric emptying (GE) but, for patients in the intensive care unit, it is technically demanding, involves radiation and can interfere with care. The (13)C-octanoate breath test ((13)C-OBT) is a simple, non-invasive technique that does not involve radiation exposure.

AIM

To evaluate the performance of the (13)C-OBT in the assessment of GE in critically ill patients.

METHODS

The GE was assessed in 33 mechanically ventilated patients (23 M; 54.3 ± 3.0 yrs; APACHE II: 22.0 ± 1.1). Following test meal administration (100 ml Ensure(®)), concurrent scintigraphic measurement and breath samples ((13)C-OBT) were collected over 4 h. Scintigraphic meal retention was determined and the gastric emptying coefficient (GEC) and half emptying time [t50(BT)] were calculated for the (13)C-OBT. Delayed GE was defined as meal retention >13 % at 180 min.

RESULTS

Delayed GE was identified in 27/33 patients. Meal retention correlated modestly with t50(BT) (r = 0.55-0.66; P < 0.001) and well with GEC (r = -0.63 to -0.74; P < 0.0001). The strength of agreement between the two techniques was highest between GEC and retention at 120 min. The best cut-off GEC for defining delayed GE was 3.25 (AUC = 0.75; 95 % CI = 0.52-0.99; P = 0.05), with 89 % sensitivity and 67 % specificity to detect delayed GE. The GE was delayed in all (23/23) patients with feed intolerance (GRV > 250 ml) on scintigraphy and 91 % (21/23) patients on (13)C-OBT.

CONCLUSION

In critical illness, there was a correlation between (13)C-OBT and gastric scintigraphy, with GEC performing as a better and more sensitive marker of detecting delayed GE than t50. However the relatively wide 95 % confidence intervals suggest that (13)C-OBT is more suitable as a technique to assess GE in a group setting for research studies rather than for individual patients in clinical practice.

Drug absorption, distribution, metabolism and excretion considerations in critically ill adults

INTRODUCTION

All critically ill patients require medication to treat organ dysfunction. However, the pharmacokinetics of drugs used to treat these patients is complex due to frequent alterations in drug absorption, distribution, metabolism, and excretion (ADME).

AREAS COVERED

This review examines pharmacokinetic aspects of drug administration for adult intensive care unit (ICU) patients. Specifically, the authors examine the ADME changes that occur and which should be considered by clinicians when delivering drug therapy to critically ill patients.

EXPERT OPINION

Dosage pharmacokinetics determined from single-dose or limited-duration administration studies in healthy volunteers may not apply to critically ill patients. Organ dysfunction among these patients may be due to pre-existing disease or the effects of a systemic or locoregional inflammatory response precipitated by their illness. Alterations in pharmacokinetics observed among the critically ill include altered bioavailability after enteral administration, increased volume of distribution and blood-brain barrier permeability and changes in P-glycoprotein and cytochrome P450 enzyme function. However, the effect of these changes on clinically important outcomes remains uncertain and poorly studied. Future investigations should examine not only pharmacokinetic changes among the critically ill, but also whether recognition of these changes and alterations in drug therapy directed as a consequence of their observation alters patient outcomes.

Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit

OBJECTIVE

To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002.

METHODS

The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding.

CONCLUSION

These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.

Gastrointestinal dysmotility: evidence and clinical management

PURPOSE OF REVIEW

Gastrointestinal dysmotility and dysfunction underlie our difficulties in providing adequate nutrition by the enteral route to our critically ill patients.

RECENT FINDINGS

Recent studies have quantified gastric emptying and nutrient absorption. Slow gastric emptying is common and probably mediated by cholecystokinin and reduced active ghrelin concentrations. The cause of impaired nutrient absorption is not yet fully understood but may be related to small intestinal blood flow and/or mucosal factors. The absorption of the different macronutrients may be affected in different ways both by critical illness and by therapies. A better understanding of this may optimize the design of nutrient formulations in the future. New treatment modalities for gastrointestinal dysfunction are being investigated and include small intestinal feeding, nonpharmacological options such as acupuncture, and drugs including novel motilin receptor agonists, and opioid antagonists.

SUMMARY

We are gradually developing a better understanding of how the gut works during critical illness, which has implications for optimizing the delivery of nutrition and thereby improving nutritional and clinical outcomes.