2. Advantage of enteral nutrition in critically ill
metabolic, immunologic and mucosal barrier protection
against bacterial translocation
Post injury hypermetabolic response and magnitude of translocation: prevention by early enteral
nutrition. Gianotti L, Nelson JL, Alexander JW, et al. Nutrition. 1994;10:225-231
Early enteral nutrition within 24 hours of admission
is recommended
ESPEN guidelines on enteral nutrition: intensive care.
Kreymann KG, Berger MM, Deutz NE, et al. Clin Nutr. 2006;25:210-223.
3. EPIDEMIOLOGY
Intolerance to feed: 60%
Delayed gastric emptying: 50-80%
Enteral tube feeding in the intensive care unit: factors impeding adequate delivery.
McClave SA, Sexton LK, Spain DA, et al. Crit Care Med. 1999;27:1252-1256.
Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications.
Mentec H, Dupont H, Bocchetti M, et al. Crit Care Med. 2001;29:1955-1961
IMPACT ON PATIENT CARE
Increased complication
HAP
bacterial translocation leading to sepsis and multi-organ failure
Nutritional deficiency
Absorption of enterally given drugs
Increased hospital stay and mortality
4. GI MOTILITY- PHYSIOLOGY
Peristalsis
reflex wave of contraction in oro-caudal direction in response to
stretching of wall by luminal content
Basal electrical activity (BEA)
spontaneous rhythmic fluctuation in membrane potential.
Initiated by stellate muscle like pacemaker cells.
function is to co ordinate peristaltic activity.
Migrating motor complex
during fasting, cycles of motor activity migrate from stomach to distal ileum.
Immediately stopped on ingestion of food.
Each MMC consists of
Phase I- quiescent period
Phase II- irregular contraction
Phase III- burst of regular contraction
Function
unsettled
Probably clears stomach and small intestine of luminal contents
in preparation for next meal.
6. FACTORS AFFECTING GASTRIC EMPTYING
Increasing age and female gender- delayed gastric emptying
FOOD
Volume- more volume – more rapid emptying
•caloric density/ unit volume - high caloric density – slow gastric emptying
•Tightly controlled Nutrient delivery- 200 Kcal/ h ( 2-3 Kcal/min) into duodenum
•osmolality- high osmolalty- slow gastric emptying
• nutrient content- carb> protien>fat
Intragastric pH- omeprazole delays gastric emptying
Temperature- low tempreature- delays gastric emptying
Physio. Res. 2003;1-30
Neurohumoral control of gastrointstinal motility.
MB Hansen
7. CONTROL AND REGULATION OF GI MOTILITY
Hormonal factors
Cholecystokinin (CCK), peptide tyrosine tyrosine (P YY), motilin, glucagon like peptide (GPP 1)
fundal relaxation and inhibit gastric emptying
Dopamine
decreases gastric emptying and intestinal peristalsis
Motilin
amplifies and induces MMC activity
Opioids and serotonin ( 5HT)
Neural factors
ENS--↔-ANS--↔-CNS
8. GI MOTILITY DYSFUNCTION IN CRITICALLY ILL
PATHOPHYSIOLOGY
stomach
•absent phase III MMC activity
•delayed fundal relaxation, prolonged recovery
•Reduced antral motility
•increased isolated pyloric activity
Diminished functional association
between
proximal and distal gastric motility
•Gastroparesis
9. GI MOTILITY DYSFUNCTION IN CRITICALLY ILL
PATHOPHYSIOLOGY
Altered GI Motility in Critically Ill Patients: Current Understanding of Pathophysiology, Clinical
Impact, and Diagnostic Approach
Andrew Ukleja, MD. Nutr Clin Pract. 2010;25:16-25
10. GI MOTILITY DYSFUNCTION IN CRITICALLY ILL
PATHOPHYSIOLOGY
•proximal gastric relaxation is delayed
•fundic wave activity is reduced
•the recovery of proximal gastric volumes to pre-stimulation levels is delayed.
World J Gastroenterol 2006 July 21; 12(27): 4383-4388
Proximal gastric response to small intestinal nutrients is abnormal
in mechanically ventilated critically ill patients
Nguyen N, Fraser R, Chapman M, Bryant R, Holloway R, Vozzo R, Feinle-Bisset
11. GI MOTILITY DYSFUNCTION IN CRITICALLY ILL
PATHOPHYSIOLOGY
Abnormal antro-pyloro-duodenal response
Absence of antral activity and
frequent isolated pyloric pressure waves
A five minute recording of pressure waves during small intestinal infusion of nutrient
Gut 2005;54:1384-1590
Antro-pyloro-duodenal response to gastric and duodenal nutrient in the critically ill patients.
Chapman M, Fraser R, Vozzo R, Bryant L, Tam W, Nguyen N, Zacharakis B, Butler R, Davidson G, Horowitz M.
12. GI MOTILITY DYSFUNCTION IN CRITICALLY ILL
PATHOPHYSIOLOGY
P <0.01
Plasma CCK concentration during fasting and duodenal stimulation
Crit Care Med 2007; 35: 82-88
intolerance in critical illness is associated with increased basal and nutrient-stimulated
plasma cholecystokinin concentrations.
Nguyen N, Fraser R, Chapman M, Bryant L, Holloway R, Vozzo R, Wishart J, Feinle-Bisset C, Horowitz M.
13. GI MOTILITY DYSFUNCTION IN CRITICALLY ILL
PATHOPHYSIOLOGY
In critical illness association between proximal and distal gastric motility is abnormal
Changes in gastric volume during nutrient infusion
Fundic waves(FW) and propagated antral waves(PAW)
during fasting and duodenal nutrient stimulation
Intensive Care Med 2008; 34:1246–1255
Diminished functional association between proximal and distal gastric motility
in critically ill patients.
Nguyen NQ, Fraser RJ, Bryant LK, et al.
continues
14. Intensive Care Med 2008; 34:1246–1255
Diminished functional association between proximal and distal gastric motility
in critically ill patients.
Nguyen NQ, Fraser RJ, Bryant LK, et al.
Trans-mural
potential
difference
Outline of study technique and position of recording assemblies
15. GI MOTILITY DYSFUNCTION IN CRITICALLY ILL
PATHOPHYSIOLOGY
Small intestine
•Increased retrograde MMC III activity
•Persistence of MMC phase III during feeding
•MMC activity starting in duodenum instead of antrum
•ileus
Colon
•Reduced flushing of nutrient content
•MMC disorganization:
phase I- increased,
phase II- decreased,
phase III- retrograde
•Pseudo-obstruction
(Ogilivie syndrome)
Current Opinion in Clinical Nutrition and Metabolic Care 2009, 12:161–167
Motility disorders in the ICU: recent therapeutic options and clinical practice
Kerstin D. Rohm, Joachim Boldt, Swen N. Piper.
16. GI MOTILITY DYSFUNCTION IN CRITICALLY ILL
ETIOLOGY AND RISK FACTORS
Surgery
Abdominal, head or spinal
SIRS/ Sepsis
Hypoperfusion- systemic or regional
Hypoxaemia
Acid- base or electrolyte imbalance
Glucose or fluid imbalance
Drugs
17. GI MOTILITY DYSFUNCTION IN CRITICALLY ILL
ETIOLOGY AND RISK FACTORS
SURGERY
Cannon WB, Murphy FT:
The movement of the stomach and intestine in some surgical conditions.
Ann Surg 1906, 43:512–536.
mechanism
NEURONAL
Local manipulation
HUMORAL
Macropahage/ monocytes
↑NO from inhibitory motor neurons
↑NO, PGs
↑VIP
19. GI MOTILITY DYSFUNCTION IN CRITICALLY ILL
ETIOLOGY AND RISK FACTORS
Opioids
Fundal relaxation
Reduced antral contraction
Reduced MMC phase III
Ketamine seems to have no advantage over fentanyl
Schmittner, Vajkoczy, Horn. Effects of fentanyl and S(+) ketamine on cerebral hemodynamics, gastrointestinal motility and
need for vasopressors in patients with intracranial pathology: apilot study. J neurosurg Anesthesiol
Propofol showed beneficial gut effects over midazolam.
Nguyen NQ, Chapman MJ, Fraser RJ, et al. The effects of sedation on gastricemptying and
intra-gastric meal distribution in critical illness. Intensive Care Med 2008; 34:454–460
20. GI MOTILITY DYSFUNCTION IN CRITICALLY ILL
ETIOLOGY AND RISK FACTORS
Hyperglycemia:
Gastric feeding was equally successful in diabetics as in non diabetics
Nguyen NZ et al. Gastric feed intolerance is not increased in critically ill patients with type II diabetes.
Inten Car Med 2007;33:1740-1745
Normoglycemia attained by intensive insulin therapy seems to minimize
feed intolerance in critical illness.
Nguyen et al. the relationship between blood glucose control and intolerance to enteral feeding during critical illness.
Inten Car Med 2007;33:2085-2092
Vasopressors
decreased antral contractions and orocaecal transit and longer ICU length of stay
Dive A, Foret F, Jamart J, et al. Effect of dopamine on gastrointestinal motility during critical illness.
Intensive Care Med 2000; 26:901–907.
21. GI MOTILITY DYSFUNCTION IN CRITICALLY ILL
ETIOLOGY AND RISK FACTORS
Fluid balance
Liberal fluid balance prolongs the duration of motility disturbances
and is associated with longer latency to first gastric emptying and first passage of flatus and stool as well as to
hospital discharge.
Effect of salt and water balance on recovery of gastrointestinal function after
elective colonic resection: a randomised controlled trial.
Lobo DN, Bostock KA, Neal KR,Perkins AC, Rowlands BJ, Allison SP. Lancet 2002;359:1812–1818
Effect of intraoperative fluid management on outcome after intraabdominalsurgery.
Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S, Matot I. Anesthesiology 2005; 103:25–32
Dehydration and or hypovolemia may be associated with post operative GI dysfunction
and that increased perioperative fluid administration has been associated with
improved indices of gut perfusion and reduced PGID
Goal-directed intraoperativefluid administration reduces length of hospital stay after major surgery
Gan TJ, Soppitt A, Maroof M, et al. Anesthesiology 2002;97:820–6.
Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery
Mythen MG, Webb AR. Arch Surg 1995;130:423–9.
22. GI MOTILITY DYSFUNCTION IN CRITICALLY ILL
ETIOLOGY AND RISK FACTORS
Co morbidity
•Diabetes, thyroid disorders
•neurological disorders,
•Collagen vascular disorders
•Functional GI motility disorders
Substance abuse
Alcohol
nicotine
Regular use of laxative
23. ASSESSMENT OF GI DYSMOTILITY
Gastroparesis
Gastric residual volume (GRV)
Ileus
Bowel sounds
defecation
tolerance of EN
•pain and/ or distention,
•physical exam- distended, tense abdomen, raised IAP
• passage of flatus and stool,
•abdominal radiographs
Physiological stool frequency
1-2 evacuations/ day to 1 evacuation Q3-4 day
evidence of bowel motility is not required to initiate enteral feeding
24. ASSESSMENT OF GI DYSMOTILITY
GRV
weak relationship with gastric emptying
Depends on position of tube, tube collapsibility, tube size,
volume of syringe used
Operator performing the test
25% patients with GRV >150ml have normal gastric emptying and do not require prokinetic
In patients with normal gastric emptying
GRV- 232-464 ml during enteral feeding @ 25-125ml/hr
two large studies in critically ill patients
most GRVs <150 ml
Crit Care Clin 26 (2010) 481–490
Gastric Residual Volumes in Critical Illness: What Do They Really Mean?
Ryan T. Hurt, Stephen A. McClave.
25. MANAGEMENT
• in critically ill patients mechanism underlying dysmotility are usually complex
•Relative contribution of control systems to regulation of GI motility varies
along the alimentary canal and disease nature and course
•Propulsive motility occurs only when there is co-coordinated pattern of
contraction and relaxation along the length of gut
It is unrealistic
one single drug alone is able to promote propulsive motility over entire GI tract
27. PROKINETIC DRUGS
ERYTHROMYCIN
•IV administration is more potent than oral
•Effect to facilitate gastric emptying and improving tolerance to enteral feeding has been
confirmed in 2 RCTs
•Effect on colonic transit time is controversial
•Lack beneficial effect in post op ileus
Microbial resistance
no evidence that short term, low dose regimen of erythromycin increases resistance
QT prolongation
risk increases above plasma level approx 30 mg/ml.
this is above level which can be achieved by 100 mg ivi dose.
Caution
has to be taken in cardiomypathy, CHF, CAD, AFib, bradycardia,
hypokalemia, hypomagnesemia
28. PROKINETIC DRUGS
METOCLOPERAMIDE
•Effect limited to upper GI tract, no effect on large bowel
•Beneficial effect on GI transit and enteral feed tolerance when give IV,
ineffective when given TNG
•Duration of post op ileus remains unaltered.
NALOXONE
may be beneficial in GI motor disturbances that are unrelated to opiate use
NEOSTIGMINE
•Effect remains controversial
•Found to be ineffective in post op ileus at dose 0.5 mg IMI Q3H total 3 doses.
•Prompt colonic decompression following orthopedics surgery at dose 2 mg IVI.
•Acute colonic pseudo obstruction- 2-2.5 mg ivi over 3-3- min caused resolution
with a success rate of 80-90%.
29. PROKINETIC DRUGS
Combination of metocloperamide and neostigmine
•Release of ACh by metocloperamide+ inhibition of breakdown by neostigmine
•Dose should be kept in indicated range and duration of infusion limited to 2 hours.
Adverse effects
•Symptomatic bradycardia
•Increased tracheo-bronchial secretions and salivation
•Tracheal suction should be avoided- additional vagal stimulation
Contra indication
•Mechanical bowel obstruction, gastrointestinal ischemia or perforation,
•pregnancy, uncontrolled arrhythmias, severe bronchospasm
30. Crit Care Med. 2007 Feb;35(2):483-9.
Erythromycin is more effective than metoclopramide in the treatment of feed intolerance
in critical illness.
Nguyen NQ, Chapman MJ, Fraser RJ, Bryant LK, Holloway RH.
Kaplan Meier plots comparing the effects
• Erythromycin is more effective than metoclopramide in treating feed intolerance
• But rapid decline in effectiveness renders both treatments suboptimal.
•Rescue combination therapy is highly effective
further study is required to examine its role as the first-line therapy
31. ALGORYTHM FOR TREATMENT OF GI DYSMOTILITY
Early use of supportive therapeutic options
Stimulant and osmotic laxative
Opioid receptor antagonist
Reduced use of drugs with
inhibitory effect onGI motility
Goal directed specific therapy-PROKINETICS
gastroparesis
gastroparesis and
Intestinal motor inhibition
intestinal motor inhibition
without gastroparesis
Clin Nutr 2008; 27:25–41
Standardized concept for the treatment of gastrointestinaldysmotility in critically ill patients:current
status and future options.
Herbert MK, Holzer P..
32. ALGORYTHM FOR TREATMENT OF GI DYSMOTILITY
Opioid receptor antagonist
Naloxone
3-12 mg PO Q8h
Impaired gastric emptying
1st line
Erythromycine
100 mg ivi Q8H for 3 days
2nd line
Metocloperamide
10 mg ivi
3rd line
Domperidone
30-40 mg PO
Gastroparesis and impaired intestinal motility
1st line
Erythromycin
After 24 hours
Metocloperamide +
neostigmine
100 mg ivi Q8H for 3 days
10-30 mg ivi +
0.5-1.5 mg ivi Q24H
(in 250 ml NS over 1-2 hours)
Impaired intestinal motility without gastroparesis
1st line
Ceruletide
Metocloperamide +
Neostigmine
40 mg ivi Q24H
( in 100 ml NS over 30-60 min)
10-30 mg ivi +
0.5-1.5 mg ivi Q24H
(in 250 ml NS over 1-2 hours
Clin Nutr 2008; 27:25–41
Standardized concept for the treatment of gastrointestinaldysmotility in critically ill patients:
current status and future options.
Herbert MK, Holzer P
33. SPECIAL CONSIDERATION FOR USE OF PROKINETICS
Reduce dose
Opioids, sedatives, alpha agonist and catecholamines
as soon and as much possible
Only one stimulation per day
Dose should not be increased
Tachyphylaxis, increased stimulation- tetany
If no benefit over use of several consecutive days
Holiday of 1 day
Clin Nutr 2008; 27:25–41
Standardized concept for the treatment of gastrointestinaldysmotility in critically ill patients:
current status and future options.
Herbert MK, Holzer P
34. recommendations for using GRV in an enteral nutrition protocol
Check GRV Q4h
GRV<500 ml- return feed to patient
GRV>400 ml
nContinue
EN at the current rate
nright lateral decubitus position for 30 minutes
nMetocloperamide 10 mg, ivi Q6h; naloxone 8 mg in 10 ml saline TNG Q6h
Recheck GRV in 4 hours
>400 ml- hold NG feed
Recheck GRV every 2 hours
GRV < 400 ml- restart NG feeding
Tolerance
restart at same rate
intolerance
consider reducing rate by 25 mL/h
or to baseline of 25 mL/h
Crit Care Clin 26 (2010) 481–490
Gastric Residual Volumes in Critical Illness: What Do They Really Mean?
Ryan T. Hurt, Stephen A. McClave.
36. PROKINETICS WITHDRAWN FROM MARKET
Itopride
lack of efficacy,
further development stopped in 2006 by Axcan Pharma
Available in Japan, few European countries, India
Tegaserod
ischemic colitis, cardio toxicity,
withdrawn in US in 2007,
available in some European countries
37. ACUTE COLONIC PSEUDO OBSTRUCTION
OGILIVIE SYNDROME
Massive dilatation of colon with obstructive symptoms, in the absence of mechanical obstruction
Ogilvie H.
Large-intestine colic due to sympathetic deprivation; a new clinical syndrome.
Br Med J 1948; 2:671–673.
Risk of ischemia and perforation
3-15% leading to mortality of 50%
Advanced age, large ceacal diameter (>10 cm), and duration of distension
Supportive measures
•bowel rest, fluid and electrolyte optimization
•Rectal tube may be effective
•Stop drugs delaying motility- opioids, anticholinergics, CCB
•Laxatives particularly osmotic are contra indicated
…continued
38. ACUTE COLONIC PSEUDO OBSTRUCTION
OGILIVIE SYNDROME
Neostigmine
3 double blind RCT have documented effectiveness
•Watch for secretions, bradycardia, hypotension, bronchospasm
•Risk can be reduced by iv infusion compared to bolus
The benefit derived from one or two doses of neostigmine largely outweigh the risk of administration
Relative contra indication
•Recent history or signs of perforation or peptic ulcer
•Myocardial infarction, use of beta blockers
•Obstructive airway disease
•S.creatinine>3 mg/dl
•Neostigmine for the treatment of the acute colonic pseudo-obstruction.
Ponec RJ, Saunders MD, Kimmey MB. N Engl J Med 1999; 341: 137–141
•Neostigmine infusion: new standard ofcare for acute colonic pseudo-obstruction?
Amaro R, Rogers AI. Am J Gastroenterol 2000; 95: 304–305.
•Neostigmine resolves critical illness-related colonic ileus in intensive care patients with multiple organ
failure: a prospective, double-blind, placebo-controlled trial.
van der Spoel JI, Oudemans-van Straaten HM, Stoutenbeek CP, Bosman RJ, Zandstra DF. Intensive Care Med 2001; 27: 822–827.
…continued
39. ACUTE COLONIC PSEUDO OBSTRUCTION
OGILIVIE SYNDROME
Polyethylene glycol (PEG)
•significant reduction in recurrent caecal dilatation,
• increased in stool and flatus evacuation,
•decrease in caecal and colonic diameter
•reduction in abdominal circumference.
(after initial resolution using neostigmine or decompression)
Effect of polyethylene glycol electrolyte balanced solution on patients with acute colonic pseudo-obstruction after resolution of
colonic dilatation: a prospective, randomized, placebo controlled trial.
Sgouros SN, Vlachogiannakos J, Vassiliadis K, Bergele C, Stefanidis G, Nastos H et al. Gut 2006; 55: 638–642
Endoscopic decompression
•Efficacy has not been assessed in RCT
•Reported to be successful in 80%,
•Laborious and hazardous
•High suspicion of ischemia- should be carried out in OT
Surgery
mortality 30-60%
40. EFFECT OF ENTERLA NUTRITION ON GUT MOTILITY
No evidence that impaired intestinal motility in critically ill
improves from enteral nutrition,
either standard formulae or immune modulating formulae or
enriched with antioxidant or fiber
Clin Nutr 2008; 27:25–41
Standardized concept for the treatment of gastrointestinaldysmotility in critically ill patients:
current status and future options.
Herbert MK, Holzer P
41. NON PROKINETIC THERAPY
Post pyloric feeding
Failure of NG feeding and no improvement with prokinetics
Systemic lidocaine administration
during induction and peri/post operative period
Epidural anesthesia in
post op period
42. REVIEW OF LITERATURE
Crit Care Med. 2002 Jul;30(7):1429-35.
Gastrointestinal promotility drugs in the critical care setting: a systematic review
of the evidence
Booth CM, Heyland DK, Paterson WG
Computerized bibliographic search of published research (1980-2001)
18 studies
•6 studies of feeding tube placement,
•11 studies evaluating gastrointestinal function
•1 study of clinical outcomes
•As a class of drugs, promotility agents appear to have a beneficial effect
on GI motility in critically ill patients.
•A one-time dose of erythromycin may facilitate small-bowel feeding tube insertion.
•metoclopramide appears to increase physiologic indexes of gastrointestinal transit
and feeding tolerance.
•Concerns about safety and lack of effect on clinically important outcomes
preclude strong treatment recommendations
43. REVIEW OF LITERATURE
Crit Care Med. 2000 May;28(5):1408-11.
Metoclopramide for preventing pneumonia in critically ill patients receiving enteral tube feeding:
a randomized controlled trial.
Yavagal DR, Karnad DR, Oak JL
Prospective, randomized, controlled trial.
total of 305 consecutive patients requiring placement of a nasogastric tube for >24 hrs.
•Metoclopramide delayed the development of nosocomial pneumonia,
•But it did not decrease its frequency rate
•No effect on the mortality rate in critically ill patients receiving NG feeding.
44. REVIEW OF LITERATURE
Crit Care Med 2007; 35(11).
Prokinetic therapy for feed intolerance in critical illness: one drug or two?
Nguyen N, Chapman, M, Fraser, R, Bryant, L, Holloway, RH
Prospective, randomized, controlled trial.
Seventy-five mechanically ventilated, medical patients with feed intolerance (GRV >250 mL).
• combination therapy- erythromycin 200mg ivi Q12H + metoclopramide 10mg ivi Q6H (n 37)
OR erythromycin alone (n 38)
•Gastric feeding was re-commenced
•6-hourly NG aspirates performed. Duration of study- 7 days
•
•Successful feeding - GRV<250 mL with the feeding rate >40 mL/hr
…continued
45. Crit Care Med 2007; 35(11).
Prokinetic therapy for feed intolerance in critical illness: one drug or two?
Nguyen N, Chapman, M, Fraser, R, Bryant, L, Holloway, RH
P <0.01 vs erythromycin
•combination therapy with erythromycin and metoclopramide is more effective
•should be considered as the first-line treatment.
•Tachyphylaxis was less with combination therapy.
•no difference in the length of hospital stay or mortality rate
•Watery diarrhea was more common with combination therapy but was not associated with enteric infections,
including Clostridium difficile.
46. REVIEW OF LITERATURE
Crit Care Med. 2007 Feb;35(2):483-9.
Erythromycin is more effective than metoclopramide in the treatment of feed intolerance
in critical illness.
Nguyen NQ, Chapman MJ, Fraser RJ, Bryant LK, Holloway RH.
Prospective, randomized, controlled trial.
90 mechanically ventilated, medical patients with feed-intolerance (GRV ≥250 ml).
• Given either metoclopramide 10 mg ivi Q6H (n=45) or erythromycin 200 mg ivi Q12H (n=45).
• After the first dose, NG feeding commenced
•Q6H NG aspirates performed
•If GRV>or=250 ml, open-label, combination therapy was given.
•Duration of study- 7 days.
•Successful feeding-6-hourly GRV<250 mL with a feeding rate>or=40 mL/hr
…continued
47. The only thing that interferes with my learning is my education.
Albert Einstein
HANK OU
48. Gut 2005;54:1384-1590
Antro-pyloro-duodenal response to gastric and duodenal nutrient in the critically ill patients.
Chapman M, Fraser R, Vozzo R, Bryant L, Tam W, Nguyen N, Zacharakis B, Butler R, Davidson G, Horowitz M.
Aims
n
To characterise antro-pyloro-duodenal motility during fasting, and in response to gastric and
duodenal nutrient,
n
evaluate the relationship between gastric emptying and motility, in the critically ill.
Subjects
Fifteen mechanically ventilated patients from a mixed intensive care unit; 10 healthy volunteers.
Methods
•Antro-pyloro-duodenal pressures were recorded during fasting, after intragastric administration
(100 ml; 100 kcal), and during small intestinal infusion of liquid nutrient (6 hours; 1 kcal/min).
•Gastricemptying was measured using a 13C octanoate breath test.
continued
49. Gut 2005;54:1384-1590
Antro-pyloro-duodenal response to gastric and duodenal nutrient in the critically ill patients.
Chapman M, Fraser R, Vozzo R, Bryant L, Tam W, Nguyen N, Zacharakis B, Butler R, Davidson G, Horowitz M.
Results
In healthy subjects, neither gastric nor small intestinal nutrient affected
antro-pyloro-duodenal pressures.
• In patients, duodenal nutrient infusion reduced antral activity compared with
both fasting and healthy subjects
•Basal pyloric pressure and the frequency of phasic pyloric pressure waves were increased in patients
during duodenal nutrient infusion compared with healthy subjects and with fasting
• Gastric emptying was delayed in patients and inversely related to the number of pyloric pressure waves
Conclusions
Stimulation of pyloric and suppression of antral pressures by duodenal nutrient are enhanced
in the critically ill and related to decreased gastric emptying.
continued
50. Gut 2005;54:1384-1590
Antro-pyloro-duodenal response to gastric and duodenal nutrient in the critically ill patients.
Chapman M, Fraser R, Vozzo R, Bryant L, Tam W, Nguyen N, Zacharakis B, Butler R, Davidson G, Horowitz M.
Measurement of Gastric emptying
•13C octanoate breath test
•100 ml octanoate was mixed with 100 ml Ensure and instilled into the stomach over five minutes
via a nasogastric tube.
• In patients, end expiratory breath samples were collected from the ventilation tube
•using a T adapter (Datex-Engstrom, Helsinki, Finland) and holder for vacutainers (blood needle holder; Reko, Lisarow, Australia),
•containing a needle (VenoJect; Terumo Corporation, Tokyo, Japan). This technique allowed the reliable filling of collection tubes
•(Exetainer, Buckinghamshire, UK).
•Healthy subjects fully expired into sample tubes for collection of end expiratory breath samples.
•Breath samples were collected immediately before instillation of the Ensure,
every 5 minutes for the first hour, and every 15 minutes thereafter for a further 3 hours.
•Breath samples were analysed for 13CO2 concentration using an isotope ratio mass spectrometer
•The 13CO2 concentration in each sample was plotted over time and
the area under the recovery curve was used to calculate the gastric emptying coefficient(GEC).
51. Intensive Care Med 2008; 34:1246–1255
Diminished functional association between proximal and distal gastric motility
in critically ill patients.
Nguyen NQ, Fraser RJ, Bryant LK, et al.
AIM
To examine effects of critical illness on the relationship between proximal and distal gastric motor
activity during fasting and duodenal nutrient stimulation.
n
n
Prospective, case-controlled study.
Ten critically ill patients and ten healthy volunteers.
INTERVENTIONS
: Concurrent proximal gastric (barostat) and antro-pyloro-duodenal (manometry) motility were recorded
during fasting and during two 60-min duodenal nutrient infusions (at 1 kcal/min and 2 kcal/min)
in random order, separated by a 2-h wash-out period.
continued
52. RESULTS
•Baseline proximal gastric volumes were similar between the two groups.
•At 10 min nutrient-induced fundic relaxation was lower in patients than healthy subjects
•In patients the frequency and volume amplitude of fundic waves were also lower.
•There were fewer propagated antral waves in patients than in healthy subjects
during both fasting and nutrient infusion.
•These were more retrograde, shorter in length and associated with a pyloric contraction.
•
•The proportion of fundic waves followed by a distally propagated antral wave was
•significantly less in patients
CONCLUSIONS
In critical illness, in addition to impairment of proximal and distal gastric motor activity,
the association between the two gastric regions is abnormal.
continued
53. Intensive Care Med 2008; 34:1246–1255
Diminished functional association between proximal and distal gastric motility
in critically ill patients.
Nguyen NQ, Fraser RJ, Bryant LK, et al.
Minimal
distending
pressure
Trans-mural
potential
difference
Outline of study technique and position of recording assemblies
