Treating delayed gastric emptying

Incidence and effect

DGE occurs in 30-70% of ICU patients [Columb et al, 1992] and contributes to few patients (22%) receiving their EN prescription [McClave et al, 1999]. However, despite recommendations to improve EN delivery using prokinetic drugs (metoclopramide, erythromycin) or NI feeding [Heyland et al, 2009] only 58% of patients suffering DGE receive these treatments [Cahill et al, 2010].

Feeding via an NI vs nasogastric (NG) tube reduces ventilator acquired pneumonia (VAP)-risk when combining deep tip placement and gastric acidification attained. NI feeding may reduce gastroesophageal regurgitation (NI vs NG: 25% vs 40%) and microaspiration (3.9% vs 7.5%, ns) [Heyland et al, 2001] particularly if the tube is sited in the distal duodenum or jejunum [Metheny et al, 2011]. However, a recent RCT confirms a reduction in VAP-risk in NI vs NG-fed patients [Hsu et al, 2009] possibly by simultaneously increasing EN delivered, reduced vomiting and gastric acidification. These data contradict meta-analysis showing similar VAP-risk from NI vs NG feeding [Marik and Zaloga, 2003] because they used measures to counter increased gastroduodenal reflux during NI feeding [Dive et al, 1999], increased GRVs [Taylor et al, 2010b] and oesophageal regurgitation [Lien et al, 2000]. Crucially, the above studies used ICU patients from admission; a greater effect might be expected by restricting treatment to those suffering DGE.

Prokinetics

Metoclopramide and erythromycin improve gastric emptying [gastric residual volumes (GRVs) decline [MacLaren et al, 2008] and fewer people vomit (35% vs 70%)] [Reignier et al, 2002]. However, the treatment effect fails within 2-3 days on a single drug and 6 days on combined drugs due to tachyphlaxis [Nguyen et al, 2007]. There are case-report concerns regarding erythromycin-induced bacterial resistance and cardiac effects [Heyland et al, 2009] but it remains the most potent prokinetic drug and inadequate EN represents a higher risk [Heyland et al, 2009]. However, patients with DGE are under-treated (prokinetics: 59%, NI feeding: 15%) and most centres don’t always treat DGE (prokinetics: 22%, NI feeding: 3%) and some never treat DGE (prokinetics: 15%, NI feeding: 58%) [Cahill et al, 2010].

NI feeding

                                                      Figure 1: Cumulative deficit as a percentage of daily energy goal. Figure 1: Cumulative deficit as a percentage of daily energy goal.

Small intestinal function is usually retained in cases of DGE [Grahm et al, 1989] therefore NI feeding can deliver more EN than NG feeding [Montecalvo et al, 1992; Kearns et al, 2000]. However, delayed NI tube placement means that NG feeding is quicker to start (11.2h vs. 27h) and achieve the goal rate (28.8h vs. 43h) [Neumann and DeLegge, 2002] and, in DGE, NG feeding plus erythromycin delivered more EN [Boivin et al, 2000]. In addition, blind NI tube placement has poor success whereas procedures that give better success through visualisation are costly and incur more risk by being invasive (endoscopic) or ‘off-ICU’ (fluoroscopic).

In contrast, electromagnetically-guided nasointestinal tube placement (EGNT) minimizes the risk of trancheobronchial misplacement, time delay to NI intubation and cumulative nutrition deficit compared to NG feeding plus prokinetic drugs (See: Figure 1) [Taylor et al, 2010a; Foote et al, 2004].
 

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Article Summary: 
Delayed gastric emptying (DGE) contributes to underfeeding, particularly in ICU patients. Prokinetics and nasointestinal (NI) feeding are effective but underused methods of treating DGE; best therapy has not been determined.