Save $$$ on Metoclopramide purchased online

ABSTRACT. Background: Administration of gastric enteral nutrition (EN) in the intensive care unit (ICU) is commonly impeded by high gastric residual volumes (GRV). This study evaluated gastric emptying in patients with limited GRV (tolerant group) vs volumes 150 mL (intolerant group) and whether prokinetic therapy improves gastric motility in intolerant patients. Methods: To assess gastric motility, mechanically ventilated patients received acetaminophen 975 mg, and peak plasma concentration (Cmax), concentration at 60 minutes (C^sub 60^), time to Cmax (Tmax), and area under the concentration-time curve from 0 to 60 minutes (AUC^sub 0-60^) were determined. This evaluation was repeated in intolerant patients after 24 hours of either erythromycin 250 mg or metoclopramide 10 mg therapy, both administered intravenously every 6 hours. Results: Ten tolerant and 20 intolerant patients were studied. Tolerant patients had significantly greater Cmax (14.12 7.25 vs 9.28 5.22 mg/L; p

Most Popular
How To Become A Time Champion
Strategies To Make Online Job Hunting Worthy
Managing & Communicating Change
Job Hunting After 40
Managers Can - and Should - Learn How to Manage

The initiation of early gastric enteral nutrition (EN) in critically ill patients increases secretion of mucosal immune factors and enhances the integrity of the gastrointestinal wall to limit septic complications and possibly decrease the overall cost and length of intensive care unit (ICU) and hospital stays.1-4 Consequently, expert opinions recommend initiating EN within 24 hours of ICU admission.5-7 Only 42%-76% of critically ill patients achieve goal caloric rate and 43%-63% of patients are unable to tolerate gastric EN.8-17 The development of high gastric residual volumes (GRV) impedes the delivery of gastric EN, occurring in 30%-51% of patients.8-17 Patients with high GRV are at increased risk of aspiration and have lengthened ICU stays and higher mortality rates.17
Gastrointestinal motility dysfunction is the primary reason for intolerance and is associated with several factors, including medications (opioid agonists, dopamine), hyperglycemia, electrolyte disturbances, ischemia/ hypoxia, burns, trauma, surgery, sepsis, increased intracranial pressure, and the administration of calorically dense or hyperosmolar formulas.18-21 Impaired motility is attributed to alterations of the interstitial cells of Cajal, which are concentrated in the gastric antrum and act as the “pacemaker” of gastrointestinal motility and disturbances of the interdigestive motility pattern known as the migrating motor complex.22,23
Most experts recommend monitoring GRV as a method of assessing gastrointestinal motility and initiating therapy with a prokinetic agent (erythromycin or metoclopramide) when these volumes are elevated.4-7,20,21, 27 Unfortunately, definitions of elevated GRV vary widely across recommendations and studies, likely because data in ICU patients relating gastrointestinal motility function to GRV are few. Studies have demonstrated that prokinetic agents enhance motility and reduce GRV in ICU patients with intolerance to facilitate EN administration, but other clinical outcomes, such as aspiration, have not been adequately studied.28-33 The purpose of this study was to comparatively evaluate gastric emptying function, using the acetaminophen absorption method34,35 in patients with limited GRV and in those with increased GRV, and to subsequently determine if prokinetic therapy improves gastric motility in patients with intolerance.
MATERIALS AND METHODS
Patients
The study protocol was approved by the institutional review board of the University of Colorado at Denver and Health Sciences Center. Patients were enrolled from 1 of 3 ICUs at the University of Colorado Hospital (16-bed medical ICU, 16-bed surgical ICU, and 8-bed neurologic ICU), resulting in a heterogeneous study population. Written informed consent and authorization in compliance with the Health Insurance Portability and Accountability Act were obtained from the patient or next of kin/legal representative.
Critically ill, mechanically ventilated patients between the ages of 18 and 85 years were eligible for enrollment if they were receiving continuous naso- or orogastric administration of EN and were either tolerant or intolerant to EN. Tolerance was denned as the administration of EN at a feeding rate sufficient to supply at least 75% of the patient’s daily energy requirements (as determined by an ICU dietitian) and a cumulative GRV 120 mL in the 24-hour period preceding enrollment, with each individually measured GRV 30 mL. Intolerance was defined as a single aspirated GRV 150 mL within the 24-hour period preceding enrollment, unless this volume was measured within 4 hours of enteral administration of contrast media, sterile water, or medications. GRVs were measured by a bedside nurse every 4 hours, using the aspiration-by-syringe technique through an 18-Fr large-diameter tube. EN was administered through this tube. As outlined by an institution-specific EN administration protocol that existed before this study was initiated, EN is started as early as possible, according to physician discretion and after consultation with an ICU dietitian. The protocol starts gastric EN at a rate of 20 mL/h with increases of 20 mL/h every 8 hours until the goal rate is achieved. For patients receiving continuous administration of vasopressor agents (see exclusion criteria for definitions) or neuromuscular blocking agents, the rate is started at 10 mL/h and increased by 10 mL/h every 12 hours. The protocol stipulates that EN be discontinued for 4 hours after the development of intolerance and then restarted at half the previous rate and increased by 10 mL/h every 8 hours as tolerated. Volumes