Gastric Residual Volume Research Articles

The effect of different doses of neostigmine plus metoclopramide on the gastric residual volume in patients under enteral nutrition in intensive care unit

Background & Objective: Gastric motility disorder is common in patients admitted to an intensive care unit (ICU), leading to increased morbidity and mortality. We investigated the effects of different doses of neostigmine in combination with metoclopramide on gastric residual volume (GRV) in ICU patients on enteral feeding.
 Methods: In this double-blind clinical trial, 144 patients hospitalized in the ICU who were under enteral nutrition through nasogastric (NGT) or orogastric (OG) tube were randomly allocated to four groups. In all four groups, 20 mg of metoclopramide was prescribed IV slowly within one minute. In groups A, B, and C, 1, 1.5, and 2 mg of neostigmine were injected IV, respectively. Group D received only 20 mg of metoclopramide. All patients were gavaged every 4 h with 300 ml. The patient's head was kept at a 45° angle. To determine GRV, aspiration was done through NG tube or OG tube before the start of infusion and then at 3, 6, 9, and 12 h after the end of infusion.
 Results: There was no significant difference between the studied groups in terms of demographic variables such as age, blood pressure, heart rate and BMI (P > 0.05). The average difference of SOFA and APACHE and laboratory factors between the groups was not significant. The results of the comparison of the marginal averages of the residual volume of the stomach at different hours of the day showed that the amount of the residual volume at all hours had a significant average difference with each other. The addition of different doses of neostigmine had a significant effect on the residual volume of the stomach after 3 and 6 h (P < 0.05). Meanwhile, a dose of 2.0 mg of neostigmine had the most of the change 3 h after administration.
 Conclusion: Administration of neostigmine in combination with metoclopramide in ICU patients on enteral feeding significantly reduces the residual volume of the stomach within 12 hours after the treatment.
 Abbreviations: APACHE- Acute Physiology And Chronic Health Evaluation; GRV - Gastric Residual Volume; NG – Nasogastric; OG - Orogastric; SOFA- Sequential Organ Failure Assessment; VAP - ventilator-associated pneumonia
 Key words: APACHE; Enteral Nutrition; ICU; Metoclopramide; Neostigmine; SOFA
 Citation: Moshari M, Tahmasebi Z, Dahi M, Vosoughian M, Dabir S, Madadi F, Tabashi S, Ariannik M, Khatiri MAK. The effect of different doses of neostigmine plus metoclopramide on the gastric residual volume in patients under enteral nutrition in intensive care unit. Anaesth. pain intensive care 2024;28(1):33-38.
 DOI: 10.35975/apic.v28i1.2378
 Received: August 06, 2023; Reviewed: September 11, 2023; Accepted: September 21, 2023

Deimplementation of Gastric Residual Volume Monitoring to Enhance Patient Nutrition.

Routine gastric residual volume monitoring remains common in nursing practice. However, current evidence supports using a focused nursing assessment to identify signs and symptoms of enteral feeding intolerance such as abdominal pain, abdominal distension, and vomiting. At the author's institution, nurses and other clinicians began reporting inconsistencies in gastric residual volume monitoring along with frequent interruptions in the delivery of enteral nutrition. The quality improvement project included patients in the medical intensive care unit receiving enteral nutrition. Gastric residual volume monitoring was eliminated. Instead, enteral nutrition was suspended on the basis of signs and symptoms of enteral feeding intolerance. Multimodal education was provided to nurses, nurse practitioners, and physicians caring for these patients. Formative evaluation occurred via staff rounds, summative evaluation occurred through a staff survey, and nutritional adequacy was evaluated by tracking patient weight. The 6-week project included 37 patients on the medical intensive care unit service. Of these patients, 28 gained weight; the mean change in weight was +6.2%. The practice change was well perceived by staff and is now an established part of care for any patient receiving enteral feedings at the study hospital. The deimplementation of routine gastric residual volume monitoring is supported by evidence. Use of a focused gastrointestinal nursing assessment to identify enteral feeding intolerance is safe, feasible, and effective and improves nutrition delivery and nurses' workflow.

Preoperative Ultrasound Assessment Of Residual Gastric Volume In Patients With Delayed Gastric Emptying compared with normal adult patients Undergoing Elective Surgeries

Preoperative Ultrasound Assessment Of Residual Gastric Volume In Patients With Delayed Gastric Emptying compared with normal adult patients Undergoing Elective Surgeries

Nurses' Performance Regarding Gravity Gavage Way Versus Injection Force on Gastric Residual Volume Among Preterm Infants in NICU

Nurses' Performance Regarding Gravity Gavage Way Versus Injection Force on Gastric Residual Volume Among Preterm Infants in NICU

The Effect of Oral Fluid Administration 1 Hour before Surgery on Preoperative Anxiety and Gastric Volume in Pediatric Patients.

Today, preoperative fasting guidelines have changed, allowing clear liquid intake up to 1 h before surgery. However, concerns remain regarding the risk of aspiration associated with clear liquid intake. This study aimed to investigate the impact of clear fluid given 1 h before surgery on child anxiety and gastric volumes. A prospective, randomized, controlled study included 90 patients aged 5-12 years. The patients were randomly allocated into three groups by a computer-generated randomization: group F (n = 30): standard fasting group, group W (n = 30): patients who received oral water at a dose of 5 mL/kg 1 h before surgery, group C (n = 30): patients who received oral carbohydrate fluid at a dose of 5 mL/kg 1 h before surgery. All patients were assessed using the modified Yale Preoperative Anxiety Scale (m-YPAS) before and 1 h after fluid administration. Antral cross-sectional area (CSA) was measured with ultrasonography after intubation, and gastric residual volume (GRV) was calculated. Hemodynamic data, blood sugar level, and parental satisfaction were also recorded. The m-YPAS scores obtained after 1 h were significantly lower in group C than in the other groups (p < 0.001). Antral CSA and GRV values were lower in group C and group W than in the fasting group (p < 0.001). Parental satisfaction was highest in group C. This study suggests that allowing a carbohydrate-rich clear liquid intake 1 h before surgery can significantly reduce preoperative anxiety in pediatric patients without increasing the risk of aspiration.

Recent Advances in Paediatric Airway Management

Paediatric airway management is continuously evolving with the innovation of new devices and techniques. The paediatric airway presents notable anatomical and physiological challenges. The introduction of a wide array of videolaryngoscopes and flexible intubating video endoscopes in paediatric sizes has made airway management safer. In addition, second-generation supraglottic airways are increasingly utilised both independently and as a component of hybrid strategies. The introduction of various paediatric airway adjuncts such as Frova introducer, optical stylets and airway exchange catheters has been a valuable addition. Microcuff tubes have proven to be safe for use even in neonates and infants and reduce the number of endotracheal tube exchanges. Apnoeic oxygenation techniques using transnasal humidified rapid insufflation ventilatory exchange help in preventing desaturation during intubation. Point-of-care ultrasound has a multitude of applications in paediatric airway management and is useful technique for the identification of the cricothyroid membrane and assessment of gastric residual volume. Airway assessment and simulation in combination with three-dimensional printing can serve as useful adjuncts in difficult and complicated airways and help in training and skill development and retention. Artificial intelligence and machine learning are in the nascent stages but are continuously evolving and may revolutionise airway assessment in the near future. This narrative review describes the recent advances in airway devices and techniques that have revolutionised paediatric airway management over the past decade.

Measurements of enteral feeding intolerance in critically ill children: a scoping review.

To examine the measurements on enteral feeding intolerance (EFI) in critically ill children. The Joanna Briggs Institute methods for conducting a scoping review were followed. Articles published since 2004 which assessed EFI in critically ill children were identified. A full search strategy was executed in seven English databases (MEDLINE, EMBASE, PubMed, Web of Science, Cochrane Central Register of Controlled Trials, JBI EBP, CINAHL) and four Chinese databases (CNKI, VIP, Wanfang, Sinomed). Two reviewers screened records according to our inclusion and exclusion criteria, and conducted a full-text review of selected articles. The reference lists of all studied selected were screened for additional sources. Relevant data was extracted using a researcher-developed tool. Of the 627 articles identified, 32 were included in this scoping review. Most articles focused on the measurement of high gastric residual volume (n = 22), followed by diarrhea (n = 20), and vomiting (n = 9). Most of the studies were of observational-analytic design (13/32) and experimental design (8/32). This scoping review addressed the complexity and diversity of EFI measurements. Given the importance of adequacy of enteral nutrient intake, we highlighted the necessary to develop individual measurements of EFI, taking the age of children and disease condition into consideration. Further studies can also investigate accurate and objective physiological measurements of EFI to advance EN and improve outcomes in critically ill children.

Gastric residual volume, safety, and effectiveness of drinking 250 mL of glucose solution 2-3 hours before surgery in gastric cancer patients: a multicenter, single-blind, randomized-controlled trial.

Carbohydrate drinking 2-3 hours before surgery has been widely adopted in colorectal operations. However, there is little direct evidence regarding its application in gastric cancer surgery. We aimed to evaluate the gastric residual volume, safety, and effectiveness of drinking 250 mL of 5% glucose solution 2-3 hours before elective gastric cancer surgery. We conducted an investigator-initiated, multicenter, randomized-controlled, parallel group, and equivalence trial. Eighty-eight patients with gastric adenocarcinoma were randomized into study or control group. Patients in the control group followed the traditional routine of 6-8 hours preoperative fasting, while those in the study group drank 250 mL of 5% glucose solution 2-3 hours before surgery. Immediately following tracheal intubation, gastric contents were aspirated through gastroscopy. The primary outcome was preoperative gastric residual volume. Eighty-three patients were eventually analysed in the study (42 in the study group and 41 in the control group). Two groups were comparable at baseline characteristics. There were no statistical differences in residual gastric fluid volumes (35.86 ± 27.13 vs 27.70 ± 20.37 mL, P = 0.135) and pH values (2.81 ± 1.99 vs 2.66 ± 1.68, P = 0.708) between the two groups. Preoperative discomfort was significantly more decreased in the study group than in the control group (thirst score: 1.49 ± 1.23 vs 4.14 ± 2.07, P < 0.001; hunger score: 1.66 ± 1.18 vs 3.00 ± 2.32, P = 0.007). There was no statistical difference in the incidence of postoperative complications (19.05% vs 17.07%, P = 0.815). Drinking 250 mL of 5% glucose solution 2-3 hours before surgery in elective gastric cancer patients shows benefits in lowering thirst and hunger scores without increasing gastric residual volume and perioperative complications.

Comparison between Preoperative Overnight Fasting Versus Oral Rehydration Solution (ORS) Administration Until Two Hours before Abdominal Surgery Under General Anaesthesia

Background: Preoperative fasting is a major concern to protect the gastric aspiration which is very dangerous. However overnight fasting is uncomfortable and has many deleterious effects on the human body. In many countries fasting until 2 to 3 hours before surgery has been practiced but in Bangladesh, overnight fasting is still being practiced in routine cases.&#x0D; Objectives: The objective of this study was to compare the effectiveness between preoperative overnight fasting and oral rehydration solution administration until two hours before abdominal surgery under general anaesthesia.&#x0D; Methods: A total of 100 patients of ASA (American Society of Anesthesiologist) class I and II, age above 18 years, and BMI &lt; 30 kg/m2 were scheduled for abdominal surgery under GA (General Anaesthesia) were included in this study. Then all patients were randomized into two groups as patients who were on overnight fasting for 10 hours (Group A-Controlled, n=50), and patients who were on ORS until 2 hours before abdominal surgery (Group B-ORS, n=50). All patients had their last meal at 11 AM before the day of surgery. Patients in group A will not take anything orally or via any route, except their ongoing vital medications if present. Patients in group B received 500 ml of standard ORS in the early morning on the day of surgery after waking up from bed (from 05 AM to 06 AM) and another 500 ml until 2 hours before the surgery (06 AM to 07 AM). As the primary outcome gastric residual volume and gastric fluid pH in both group was measured immediately after anaesthesia induction. Several physiological measures (thirst and hunger, nausea/vomiting, cognitive function) were measured with the help of a preformed questionnaire.&#x0D; Results: Mean gastric residual volume immediately after induction was statistically significant (p&lt;0.05) between the two groups. However, the mean gastric fluid pH was statistically insignificant (p&gt;0.05). The ORS group (Group B) became less thirsty before surgery (P=0.001). Postoperative nausea/vomiting (PONV) was less in group B (P=0.029) than in group A. The patient’s recovery time was significantly less in ORS group (P=0.003). Postoperative cognitive performance was better in group B (P=0.001).&#x0D; Conclusions: Oral rehydration solution administration until two hours before surgery is effective and can be considered routinely before abdominal surgery conducted under general anaesthesia except for delayed gastric emptying.&#x0D; J Shaheed Suhrawardy Med Coll 2022; 14(1): 20-27

Effect of early enteral nutrition on short-term outcomes and survival in patients in the cardiothoracic intensive care unit: An inverse probability weighted retrospective study

ObjectivesThe merits of early enteral nutrition (EEN) in patients in the cardiothoracic intensive care unit (CTICU) remain unclear. This retrospective study aimed to address this issue. MethodsWe analyzed data from the MIMIC IV v2.0 database, including patients with a CTICU stay of ≥4 d. Patients were divided into early and delayed enteral nutrition (EN) groups. Differences in baseline data were corrected using an inverse probability weighting (IPW) approach. Generalized linear models (GLMs) were used to compare trends over time between groups, and survival effects were evaluated with weighted logistic and Cox regression, supplemented by weighted Kaplan–Meier curves. Subgroup analysis facilitated the exploration of potential interactions. ResultsThe study included 720 CTICU patients. Following IPW, all baseline variables were balanced. EEN led to shorter hospital and CTICU stays, lower incidence of respiratory and blood infections, and reduced total insulin usage in the first week of CTICU admission, albeit with an increased total gastric residual volume. Mortality risk between the groups did not significantly differ at 28 d or at 1 y. Excessive early energy and protein intake elevated the risk of 28-d mortality, but the relationship may not be linear. Overweight patients or those with fewer comorbidities had a higher mortality risk with EEN. ConclusionsEEN may improve short-term outcomes in CTICU patients without a clear survival benefit. Early high caloric and protein intake could lead to adverse outcomes, suggesting a careful evaluation for initiating EN in specific patients.

Gastric residual volume as predictor of clinical outcomes in critically ill patients at nutritionday: A machine learning (ML) approach

Gastric residual volume as predictor of clinical outcomes in critically ill patients at nutritionday: A machine learning (ML) approach

Gastric residual volume monitoring practices in UK intensive care units: A web-based survey.

Monitoring of gastric residual volume (GRV) to assess for enteral feeding intolerance is common practice in the intensive care unit (ICU) setting; however, evidence to support the practice is lacking. The aim of this study was: (i) to gain a perspective of current practice in adult ICUs in the UK around enteral feeding and monitoring of GRV, (ii) to characterise the threshold value used for a high GRV in clinical practice, (iii) to describe the impact of GRV monitoring on enteral feeding provision and (iv) to inform future research into the clinical value of GRV measurement in the adult ICU population. A web-based survey was sent to all UK adult ICUs. The survey consisted of questions pertaining to (i) nutritional assessment and enteral feeding practices, (ii) enteral feeding intolerance and GRV monitoring and (iii) management of raised GRV. Responses were received from 101 units. Ninety-eight percent of units reported routinely measuring GRV, with 86% of ICUs using GRV to define enteral feeding intolerance. Threshold values for a high GRV varied from 200 to 1000 ml with frequency of measurement also differing greatly from 2 to 12 hourly. Initiation of pro-kinetic medication was the most common treatment for a high GRV. Fifty-two percent of respondents stated that volume of GRV would influence their decision to stop enteral feeds a lot or very much. Only 28% of units stated that they had guidelines for the technique for monitoring GRV. Measurement of GRV is the most common method of determining enteral feeding intolerance in adult ICUs in the UK. The practice continues despite evidence of poor validity and reproducibility of this measurement. Further research should be undertaken into the benefit of ongoing GRV measurements in the adult ICU population and alternative markers of enteral feeding intolerance.

Evaluation of the 'Sip Til Send' regimen before elective caesarean delivery using bedside gastric ultrasound: A paired cohort pragmatic study.

Pre-operative fasting is routinely advocated to avoid pulmonary aspiration. The European Society of Anaesthesiology and Intensive Care (ESAIC) recommends a fasting period of 2 h for liquids before surgery. Liberal drinking policies such as the 'Sip Til Send' are a suggested alternative to maintain hydration before surgery. To compare residual gastric volumes in fully fasted nonlabouring parturients before elective caesarean delivery with the 'Sip Til Send' with water liberal drinking protocol. Our hypothesis was the 'Sip Til Send' would be noninferior to standard fasting at minimising the residual gastric volume immediately before surgery. A paired cohort prospective observational pragmatic study using gastric ultrasound, analysed by an operator blinded to the fasting status of each scan. A tertiary maternity hospital in Dublin, Ireland. The study was conducted between January and June 2023. Pregnant women about to undergo elective caesarean delivery who had followed ESAIC fasting guidelines before admission. Each participant underwent two pairs (semi-recumbent and the semi-recumbent right lateral positions) of standardised ultrasound examinations of the gastric antrum: the order of these scans was randomised. The first pair of scans occurred on admission before the 'Sip Til Send' protocol commenced, the other pair just before spinal anaesthesia for caesarean delivery, after a variable time following the 'Sip Til Send' protocol. The primary outcome was the difference in antral cross-sectional area (CSA) between the fully fasted women on admission and the same women after following the 'Sip Til Send' protocol until just before spinal anaesthesia. Fifty-eight women were randomised for the study: 55 and 54 scans in the semi-recumbent position on admission, and 55 and 54 scans in the right lateral position just before spinal anaesthesia. The mean differences (95% CI) in CSA in the semi-recumbent and RL positions were 0.07 (-0.39 to 0.53) cm 2 and 0.04 (-0.60 to 0.68) cm 2 , respectively. Since the of 95% CIs did not cross the predefined noninferiority margin of 0.88 cm 2 , 'Sip Til Send' was noninferior to fully fasting in in terms of the antral CSA. The 'Sip Til Send' protocol of liberal hydration with water was noninferior to standard fasting prior to elective caesarean delivery. NCT05783427 ClinicalTrials.gov.

The effect of pre-endoscopy maltodextrin beverage on gastric residual volume and patient’s well-being: a randomised controlled trial

Prolonged fasting prior to oesophagogastroduodenoscopy (OGDS) could be noxious to patients’ well-being. Strict fasting protocol has been used prior to OGDS with the concern of reduced visibility or suboptimal endoscopic assessment. Maltodextrin beverages were also commonly used as the pre-operative carbohydrate loading in enhanced recovery after surgery (ERAS) protocol. Our study aimed to look for the effects of maltodextrin beverage 2 h before OGDS on gastric residual volume and patient’s well-being scores. This was a single-blinded, stratified randomised controlled trial, comparing control group (A, received 400 ml of plain water) and carbohydrate loading group (B, received 400 ml of Carborie). The primary objectives were to measure the gastric residual volume (GRV) and patient’s well-being scores using visual analogue scale (VAS) scores for hunger, thirst, anxiety, tiredness and general discomfort. Of 80 randomised patients, 78 completed the study (38 received plain water and 40 Carborie). The median (IQR) GRV was not significantly different between group A and B (5.0 ml (20) vs 4.0 ml (19), p = 0.777). Both groups showed significant reduction in VAS scores in all five parameters (p ≤ 0.001). There were no complications attributed to endoscopy in either group. Pre-endoscopy maltodextrin beverage is as safe as clear water with improved patient’s well-being in both groups.Clinical Trial Registration: NCT05106933.

Peripherally-active mu-opioid receptor antagonists for constipation in critically ill patients receiving opioids: A case-series and a systematic review and meta-analysis of the literature.

Constipation is frequent in critically ill patients, and potentially related to adverse outcomes. Peripherally-active mu-opioid receptor antagonists (PAMORAs) are approved for opioid-induced constipation, but information on their efficacy and safety in critically ill patients is limited. We present a single-center, retrospective, case-series of the use of naldemedine for opioid-associated constipation, and we systematically reviewed the use of PAMORAs in critically ill patients. Case-series included consecutive mechanically-ventilated patients; constipation was defined as absence of bowel movements for >3 days. Naldemedine was administered after failure of the local laxation protocol. Systematic review: PubMed was searched for studies of PAMORAs to treat opioid-induced constipation in adult critically ill patients. time to laxation, and number of patients laxating at the shortest follow-up. gastric residual volumes and adverse events. A total of 13 patients were included in the case-series; the most common diagnosis was COVID-19 ARDS. Patients had their first bowel movement 1 [0;2] day after naldemedine. Daily gastric residual volume was 725 [405;1805] before vs. 250 [45;1090] mL after naldemedine, p = 0.0078. Systematic review identified nine studies (two RCTs, one prospective case-series, three retrospective case-series and three case-reports). Outcomes were similar between groups, with a trend toward a lower gastric residual volume in PAMORAs group. In a highly-selected case-series of patients with refractory, opioid-associated constipation, naldemedine was safe and associated to reduced gastric residuals and promoting laxation. In the systematic review and meta-analysis, the use of PAMORAs (mainly methylnaltrexone) was safe and associated with a reduced intolerance to enteral feeding but no difference in the time to laxation.

Pediatric Tui Na for Feeding Intolerance in Premature Infants: Protocol for a Systematic Review and Meta-Analysis.

Feeding intolerance (FI), frequently resulting from gastrointestinal immaturity, is prevalent among premature infants. Current practices are gradually prioritizing nonpharmacological treatments, such as massage or "Tui na," considering the potential side effects of prolonged medication use. Pediatric Tui na, a specialized massage therapy based on traditional Chinese medicine, has been widely studied for treating FI in premature infants. However, to our knowledge, no systematic review specifically focusing on the effectiveness and safety of traditional Chinese medicine-based pediatric Tui na for FI in premature infants has been published yet. This study aims to develop a protocol for a systematic review and meta-analysis for evaluating the safety and efficacy of pediatric Tui na for premature infants with FI. We will perform a comprehensive search in the following databases: Springer, Cochrane Library, Embase, MEDLINE, Clarivate Analytics, Physiotherapy Evidence Database (PEDro), CINAHL, PubMed, Scopus, World Health Organization (WHO) International Clinical Trials Registry Platform, and Chinese biomedical databases (Wanfang database, the China National Knowledge Infrastructure, Chinese Scientific Journals Database, and Chinese Biomedical Literature Databases), limited to studies published in Chinese and English languages between January 2000 and January 2023. The search strategy will use MeSH (Medical Subject Headings) terms and database-specific keywords. A total of 2 independent reviewers will initially screen the studies based on titles and abstracts, followed by a full-text evaluation of the eligible studies. Studies will include any nonrandomized controlled trials, nonrandomized clinical studies, randomized controlled trials, and quasi-experimental studies wherein the treatment group involves premature infants with FI given pediatric Tui na. Primary outcomes will be necrotizing enterocolitis, gastric residual volume, emesis, and stool blood. Secondary outcomes will be abdominal distension weight gain, time to achieve full enteral feeding, any adverse effects associated with pediatric Tui na, and length of hospital stay. The Cochrane Collaboration Risk of Bias Tool will be used to assess the risk of bias and methodological quality. Funnel plots will be used for evaluating publication bias. Meta-analysis will be conducted using the Review Manager software (version 5.4; Cochrane Collaboration). Subgroup analyses will be considered according to treatment received, country or setting, sex, and birth weight of premature infants (if heterogeneity is high, I2≥50%). This is a systematic review and meta-analysis protocol, so the results are not yet available. The protocol has been registered with PROSPERO (CRD42023390021). We are currently in the study selection phase. Results are expected to be completed by the end of 2023. Following this protocol, a comprehensive and rigorous literature synthesis will be developed to assess the impact of pediatric Tui na treatment on premature infants with FI, enabling the determination of its efficacy and safety. PROSPERO CRD42023390021; https://tinyurl.com/bdf4kn23. PRR1-10.2196/46375.

High protein provision of more than 1.2 g/kg improves muscle mass preservation and mortality in ICU patients: A systematic review and meta-analyses

ICU patients lose muscle mass rapidly and maintenance of muscle mass may contribute to improved survival rates and quality of life. Protein provision may be beneficial for preservation of muscle mass and other clinical outcomes, including survival. Current protein recommendations are expert-based and range from 1.2 to 2.0g/kg. Thus, we performed a systematic review and meta-analysis on protein provision and all clinically relevant outcomes recorded in the available literature. We conducted a systematic review and meta-analyses, including studies of all designs except case control and case studies, with patients aged ≥18 years with an ICU stay of ≥2 days and a mean protein provision group of ≥1.2g/kg as compared to <1.2g/kg with a difference of ≥0.2g/kg between protein provision groups. All clinically relevant outcomes were studied. Meta-analyses were performed for all clinically relevant outcomes that were recorded in ≥3 included studies. A total of 29 studies published between 2012 and 2022 were included. Outcomes reported in the included studies were ICU, hospital, 28-day, 30-day, 42-day, 60-day, 90-day and 6-month mortality, ICU and hospital length of stay, duration of mechanical ventilation, vomiting, diarrhea, gastric residual volume, pneumonia, overall infections, nitrogen balance, changes in muscle mass, destination at hospital discharge, physical performance and psychological status. Meta-analyses showed differences between groups in favour of high protein provision for 60-day mortality, nitrogen balance and changes in muscle mass. High protein provision of more than 1.2g/kg in critically ill patients seemed to improve nitrogen balance and changes in muscle mass on the short-term and likely 60-day mortality. Data on long-term effects on quality of life are urgently needed.

A systematic review of the safety and tolerability evaluation of enteral nutrition in a prone position with acute respiratory distress syndrome

To systematically review safety and tolerance of enteral nutrition (EN) in a prone position, as well as the risks of increased gastric residual volume (GRV), vomiting, aspiration, and ventilator-associated pneumonia, and determine the ways to improve EN tolerance in patients with acute respiratory distress syndrome (ARDS). Databases including PubMed, Embase and Wanfang Medical data of the English and Chinese literatures were retrieved up from January 1979 to January 2022 to collet the randomized controlled trial (RCT), non-RCT, and observational studies, concerning safety and tolerance of EN in a prone position with ARDS. All trials must have a minimum of two patient groups, one of which must be prone to ARDS and receive EN. Data searching extracting and quality evaluation were assessed by two reviewers independently. RevMan 5.4 software was used for analysis. A total of 9 studies were included, including 2 RCTs, 2 non-RCTs, 4 prospective observational studies, and 1 retrospective observational study. The starting and increasing rate of EN were typically well tolerated in the prone position compared to the supine position in patients with ARDS, there was no significant increase in GRV (mL: 95 vs. 110), and the incidence of vomiting was not noticeably higher (0%-35% vs. 33%-57%). The incidence of ventilator-associated pneumonia with EN was not significantly higher in the prone position than in the supine position in patients with ARDS (6%-35% vs. 15%-24%). Aspiration occurred at a similar rate in patients in the nasogastric tube and post-pyloric feeding groups with EN in patients with ARDS in the prone position (22% vs. 20%). EN tolerability with nasogastric and nasojejunal tubes was similar in prone positions, with no significant difference in EN intolerance incidences (15% vs. 22%). Head elevation (30 degree angle-45 degree angle) improved EN tolerance in the prone position in patients with ARDS, thereby increasing the early EN dose [odds ratio (OR) = 0.48, 95% confidence interval (95%CI) was 0.22-1.08, P = 0.08]. Additionally, prophylactic application of gastrointestinal motility drugs, such as erythromycin, at the start of EN in a prone position significantly improved patients' EN tolerance (OR = 1.14, 95%CI was 0.63-2.05, P = 0.67). The use of gastric tube for EN in prone position and similar feeding speed to the supine position in patients with ARDS is safe and well tolerated. The initiation and dosing of EN should not be delayed in the prone position. EN tolerance may be increased by elevating the head of the bed during enteral feeding in a prone position, and gastrointestinal motility medications should be promptly administered with EN initiation in patients with ARDS.

Clinical study of evaluating the clinical effect of Dachengqi decoction in the treatment of sepsis complication with gastrointestinal dysfunction via gastric antrum cross-sectional area measured by bedside ultrasound

To evaluate the clinical value of Dachengqi decoction in the treatment of sepsis complication with gastrointestinal dysfunction via gastric antrum cross-sectional area (CSA) measured by bedside ultrasound. A parallel group randomized controlled trial was conducted. A total of 80 patients with sepsis with gastrointestinal dysfunction admitted to the Second Affiliated Hospital of Nanjing University of Chinese Medicine from January 2021 to October 2022 were enrolled. According to whether patients agree to use Dachengqi decoction after admission, all patients were divided into Dachengqi decoction group (observation group) and conventional treatment group (control group) by 1 : 1 randomization, each group has 40 patients. Both groups were treated with fluid resuscitation, anti-infection, maintaining stable respiratory circulation, early nourishing feeding, promoting gastrointestinal motility, and regulating intestinal flora. The observation group was treated with Dachengqi decoction on the basis of western medicine, 30 mL decoction was taken in the morning and evening. Both groups were treated for 7 days. The CSA of the two groups was measured by bedside ultrasound before and after treatment. The gastric residual volume (GRV1 and GRV2) were calculated by formula and traditional gastric tube withdrawal method. The gastrointestinal dysfunction score, acute physiology and chronic health evaluation II (APACHE II), intraperitoneal pressure (IAP), serum preprotein (PA), albumin (Alb), white blood cell count (WBC), procalcitonin (PCT), hypersensitivity C-reactive protein (hs-CRP), length of intensive care unit (ICU) stay and incidence of aspiration were detected to evaluate the clinical efficacy of Dachengqi decoction, the correlation and advantages and disadvantages between CSA measured by bedside ultrasound and other evaluation indicators of gastrointestinal dysfunction in sepsis were also analyzed. There were no significant differences in the indicators before treatment between the two groups, which were comparable. In comparison with the pre-treatment period, CSA, GRV, gastrointestinal dysfunction score, APACHE II score, IAP, WBC, PCT, and hs-CRP of the two groups after treatment were significantly decreased, PA and Alb were significantly increased, and the observation group decreased or increased more significantly than the control group [CSA (cm2): 4.53±1.56 vs. 6.04±2.52, GRV1 (mL): 39.85±8.21 vs. 53.05±11.73, GRV2 (mL): 29.22±5.20 vs. 40.91±8.97, gastrointestinal dysfunction score: 0.87±0.19 vs. 1.35±0.26, APACHE II score: 11.54±3.43 vs. 14.28±3.07, IAP (cmH2O, 1 cmH2O ≈ 0.098 kPa): 9.79±2.01 vs. 13.30±2.73, WBC (×109/L): 9.35±1.24 vs. 12.35±1.36, PCT (μg/L): 3.68±1.12 vs. 6.43±1.45, hs-CRP (mg/L): 24.76±5.41 vs. 46.76±6.38, PA (mg/L): 370.29±45.89 vs. 258.33±34.58, Alb (g/L): 38.83±5.64 vs. 33.20±4.98, all P < 0.05]. The length of ICU stay (days: 10.56±3.19 vs. 14.24±3.45) and incidence of aspiration (12.5% vs. 25.0%) were lower than those in the control group (both P < 0.05). Correlation analysis showed that CSA measured by bedside ultrasound was positively correlated with GRV2, gastrointestinal dysfunction score, APACHE II score, and IAP (r values were 0.84, 0.78, 0.75, 0.72, all P < 0.01) and negatively correlated with PA and Alb (r values were -0.64 and -0.62, both P < 0.01). The Dachengqi decoction can significantly improve the clinical symptoms of septic patients with gastrointestinal dysfunction, reduce systemic inflammatory response, improve nutritional status, and shorten ICU hospital stay. Bedside ultrasound monitoring of CSA is a simple, accurate and effective means to evaluate gastrointestinal dysfunction, which is worthy of further clinical promotion.

Effects of ultrasound monitoring of gastric residual volume on feeding complications, caloric intake and prognosis of patients with severe mechanical ventilation.

Monitoring of gastric residual is an important approach for assessing gastric emptying in patients with mechanical ventilation. By monitoring gastric contents, the enteral nutrition scheme can be adjusted in time to ensure feeding safety. To investigate the effects of ultrasound monitoring on the incidence of feeding complications, daily caloric intake and prognosis of patients with severe mechanical ventilation. To analyze the clinical significance of ultrasound monitoring of gastric residual volume (GRV) up to 250 mL to provide a theoretical basis for clinical practice. Patients admitted to the department of emergency medicine of the Affiliated Hospital of Nantong University from January 2018 to June 2022 who received invasive mechanical ventilation and continuous enteral nutrition support within 24-48 h after admission were enrolled in this study. Medical records for patients within 7 d of hospitalization were retrospectively analyzed to compare the incidence of feeding complications, daily caloric intake and clinical prognosis between patients with gastric residual ≥ 250 mL and < 250 mL, as monitored by ultrasound on the third day. A total of 513 patients were enrolled in this study. Incidences of abdominal distension, diarrhea, and vomiting in the < 250 mL and ≥ 250 mL groups were: 18.4% vs 21.0%, 23.9% vs 32.3% and 4.0% vs 6.5%, respectively; mortality rates were 20.8% vs 22.65%; mechanical ventilation durations were 18.30 d vs 17.56 d while lengths of stay in the intensive care units (ICU) were 19.87 d vs 19.19 ± 5.19 d. Differences in the above factors between groups were not significant. Gastric residual ≥ 250 mL was not an independent risk factor for death and prolonged ICU stay. However, target feeding time of patients in the ≥ 250 mL group was longer than that of patients in the ≥ 250 mL group, and caloric intake (22.0, 23.6, 24.8, 25.3 kcal/kg/d) for patients in the ≥ 250 mL group from the 4th day to the 7th day of hospitalization was lower than that of patients in the ≥ 250 mL group (23.2, 24.8, 25.7, 25.8 kcal/kg/d). On the 4th day (Z = 4.324, P = 0.013), on the 5th day (Z = 3.376, P = 0.033), while on the 6th day (Z = 3.098, P = 0.04), the differences were statistically significant. The use of ultrasound to monitor GRV and undertaking clinical interventions when the monitoring value is ≥ 250 mL has no significant effects on incidences of feeding complications and clinical prognostic outcomes, however, it significantly prolongs the time to reach target feeding, reduces the daily intake of calories during ICU hospitalization, and increases the risk of insufficient nutrition of patients. The accuracy and necessity of monitoring gastric remnants and monitoring frequencies should be investigated further.