Abstract
To investigate the effect of methylnaltrexone (MNTX) on OBD in the critical care setting. MNTX is a peripheral opioid receptor antagonist that does not cross the blood-brain-barrier in humans. In phase 2 and 3 clinical trials with the SC formulation, methylnaltrexone has been demonstrated to reverse OBD in patients with advanced illness without reversal of analgesia or withdrawal. In a phase 2 post-operative bowel dysfunction study with IV MNTX, bowel recovery was accelerated by 20 hours without reversal of analgesia or withdrawal. We hypothesized that MNTX might benefit critically ill patients with OBD by resolving GI dysmotility and improving enteral feeding. A 21-year old male had been admitted to the ICU for a 30% burn injury incurred by a fire and explosion. He underwent excision and skin grafting and was receiving 60–100 mg/kg morphine via continuous infusion and intermittent boluses. He was extubated but was unable to effectively feed enterally due to high gastric residuals and a lack of bowel sounds over 4 days. Average enteral feeds of 1200 cc/day resulted in gastric residuals of 750 cc/day. With approval from the University of Chicago IRB, he received 8 doses of MNTX (0.3 mg/kg, IV over 10 minutes, q6 hours) over 48 hours. He continued receiving morphine via bolus and continuous infusion. MNTX was well tolerated and did not elicit pain or withdrawal symptoms at any time. Flatus occurred immediately during the first dose of MNTX. Over the subsequent 48 hours, gastric residuals decreased to 0 cc/day. The patient was able to tolerate enteral feeds and averaged over 2400 cc/day during this time (below). By day 5 he was tolerating solid food by mouth. Although prophylaxis of ileus has been described using peripheral opioid antagonists in elective surgical patients, treatment of OBD in critically ill patients has not been previously reported. The immediate improvement in feeding, gastric residuals, and gut function in this patient suggests a role for methylnaltrexone in the critical care setting. [figure 1]Figure 1
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