الفهرس 
Enteral Nutrition in the Critically Ill PatientsOnly 14 pages are availabe for public view
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Abstract
The enteral route has become the preferred method of nutrient delivery in critically ill patients. The early initiation of EN is recommended by various international guidelines based on substantial evidence. The committee defined early enteral feeding as initiation of enteral nutrition within 24 to 48 hours after injury or arrival to an ICU.
Upper GI dysmotility in the critically ill is a common occurrence. Slow gastric emptying (GE), leading to intolerance of nasogastric (NG) feeding, occurs in 50% to 60% of these patients. Impaired GE not only results in inadequate nutritional support but also constitutes a major risk factor for gastroesophageal reflux and aspiration, potentially leading to increased morbidity and mortality.
Failure of delivery of nasogastric nutrition in critically ill patients is usually managed either by pharmacological intervention (prokinetic therapy) or non pharmacological approaches (30º head up, reducedosage of opiates or use of short-acting agents if required as sedation or analgesia and postpyloric feeding) to improve EN support in ICU patients before shift to pareneral nutrition with its subsequent complications.
Treatment with prokinetic drugs is usually regarded as first-line therapy. Despite its prominence in clinical practice, the data supporting the effectiveness of prolonged prokinetic therapy in feeding-intolerant critically ill patients are limited, with rapid development of tachyphylaxis.
Metoclopramide and erythromycin have been the recommended prokinetic drugs for the treatment of feeding intolerance in critical illness. However, whether they have beneficial effects on GE in critically ill patients remains controversial.
IV metoclopramide [10 mg TDS or QID iv] has been shown to improve feed intolerance and decrease (GRV) during critical illness but its therapeutic efficacy declines progressive over the 7 d (from 85% in the first days of therapy to less than 35% after 7 d of treatment.
This study compared ICU patients on IV metoclopramide (control group) and patients on IV metoclopraide with CPB who suffered from EN intolerance to evaluate the efficacy of celiac plexus block in improving gastric empty (GE) and enteral feeding intolerance and its useful for treating feeding intolerance when IV prokinetic drug therapy had failed to improve GI dysfunction in critically ill patients.
Bedside ultrasound-guided anterior approach celiac plexus block was performed using bilateral paramedian (double needle) technique and GE was assessed by measuring the aspirated gastric residual volume (GRV) before and 24h after the starting of EN, and gastric antral cross sectional area postprandially by using US to estimate GER.
Regarding results, antral CSA was more significantly decreased from 15 to 90 min after starting enteral feeding among CPB than control group (P<0.001) with significant increase in the median value of GER in celiac rather than control groups (P <0.001) which indicated that CPB improved GE in these patients. The mean GRV aspirated over 24h after starting EN was significantly reduced in celiac group (P ˂0.001), but in control group, there was no significant difference before and 24hs after EN (P ≥ 0.05), with successful enteral feeding in celiac group 70% vs control 5%, P< 0.001), the improvement in GI function was demonstrated by the fact that EN was tolerated in patients who had received celiac plexus block.
The results suggested that in critical illness, the celiac plexus block was effective for increasing GI motility and improving gastric empty and enteral feeding intolerance. So it was useful for treating feeding intolerance when IV prokinetic drug therapy had failed to improve GI dysfunction in critically ill patients.
Additional studies with larger sample size were recommended to determinate the outcomes that are clinically meaningful to the patient after improvement of EN intolerance as malnutrition, ventilator dependance days, ventilator-associated pneumonia (VAP), infection, length of ICU stay (LOS), cost and mortality, also to report major complication related to CPB technique as hematoma, neurologic complications, severe bleeding, infection, or mortality.