Nasogastric Route Research Articles

P0544 ENTERAL VS INTRAVENOUS THERAPY FOR CHILDREN WITH GASTROENTERITIS: A META-ANALYSIS OF RANDOMISED CONTROLLED TRIALS

Introduction: To review the available evidence for the relative efficacy and safety of enteral versus intravenous rehydration therapy in treating childhood gastroenteritis Methods: MEDLINE, EMBASE and the Cochrane Controlled Trials Register (to June 2003), were searched for randomised trials comparing enteral and intravenous therapy in children under 15 years of age with gastroenteritis. Known investigators and expert bodies were contacted to locate unpublished and ongoing studies. Review methods: Two reviewers independently identified studies and extracted data from eligible studies, which were then combined using a random effects model. Results: 16 trials involving 1545 children and conducted in 11 countries were identified. Compared with children treated with intravenous rehydration, children treated with oral rehydration had significantly fewer major adverse events including death or seizures (Relative Risk=0.36; 95% confidence interval 0.14 to 0.89) and had a significant reduction in length of hospital stay (21 hours: 95% CI 5 to 35). There was no difference in weight gain between the two groups (– 26 grams; 95% CI – 61 to 10). The overall failure rate of enteral therapy was 4.0% (95% CI 3.0 to 5.0). Conclusion: For childhood gastroenteritis, enteral rehydration is as effective, if not better than intravenous rehydration. Enteral rehydration by the oral or nasogastric route is associated with significantly fewer major adverse events and a shorter stay in hospital compared with intravenous therapy and is successful in the majority of children. Practitioners who manage this condition need to address the obstacles, which currently prevent a wider acceptance and usage of enteral rehydration. Reference(S): Supplied on request

Stress-related mucosal disease: Risk factors and prophylactic therapy

Background: The term stress-related mucosal disease (SRMD) represents a continuum of conditions ranging from stress-related injury (superficial mucosal damage) to stress ulcers (focal deep mucosal damage). Caused by mucosal ischemia, SRMD is most commonly seen in critically ill patients in the intensive care unit (ICU). Prophylaxis of stress ulcers may reduce major bleeding but has not yet been shown to improve survival. Objectives: This article reviews currently available agents for the prophylaxis of SRMD and discusses their uses and potential adverse effects. Methods: Relevant articles in the English-language literature were identified through a MEDLINE search (1968–2003) using the key words stress-related mucosal disease, stress-related injury, ulcer, prophylaxis, intensive care unit, and upper gastrointestinal bleeding. Results: The most widely used drugs for stress-related injury are the intravenous histamine 2-receptor antagonists. These drugs raise gastric pH but are associated with the development of tolerance and possible drug interactions and neurologic manifestations. Sucralfate, which can be administered by the nasogastric route, can protect the gastric mucosa without raising pH, but may decrease the absorption of concomitantly administered oral medications. The prostaglandin misoprostol has not been shown to be of benefit in the prophylaxis of SRMD. Antacids lower the risk of gastrointestinal bleeding, but large volumes of antacids are required and treatment is labor intensive. Proton pump inhibitors (PPIs) are the most potent acid-suppressive pharmacologic agents available. Esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole substantially raise gastric pH for up to 24 hours after a single dose. The availability of an intravenous formulation of pantoprazole may help improve the treatment of SRMD in ICU patients, particularly those receiving mechanical ventilation. Tolerance does not develop, and few adverse effects have been reported. Conclusions: Recent studies of PPIs have shown promising results in high-risk patients, making this class of drugs an option for the prophylaxis of SRMD.

Pharmacokinetic Parameters of Ciprofloxacin (500 mg/5 mL) Oral Suspension in Critically Ill Patients with Severe Bacterial Pneumonia: A Comparison of Two Dosages

The authors determined the pharmacokinetic parameters of a new immediate-release ciprofloxacin suspension in tube-fed intensive care patients with bacterial pneumonia, to compare two dosage regimens: 500 mg b.i.d and 750 mg b.i.d. in this prospective clinical trial. The 20 patients were critically ill and on mechanical ventilation and enteral feeding with bacterial pneumonia. They were randomized to receive two different ciprofloxacin dosages: 500 mg b.i.d (group 1) versus 750 mg b.i.d. (group 2). Blood samples were collected from these patients after reaching steady-state and the pharmacokinetic parameters were determined.The mean (range) serum steady-state concentration at 2 h after enteral administration was: Cmax 500 = 2.6 (1.2-4.3) mg/L in group 1 and Cmax 750 = 3.5 (1.5-5.9) mg/L in group 2. The mean (range) calculated 12-h area under the serum concentration was high in both groups: AUC0-12 (500) = 24.7 (12.9-36.2) mg.h/L in group 1 and AUC0-12 (750) = 28.9 (18.3-47.5) mg.h/L in group 2. In conclusion, ciprofloxacin oral suspension was well absorbed via nasogastric route in intensive care patients with severe pneumonia, achieving reliable pharmacokinetic parameters for most of the pathogens and important cost reduction compared to intravenous delivery. However, with less susceptible pathogens such as Staphylococcus aureus or Pseudomonas aeruginosa, higher dosages than 750 mg b.i.d. should be given.

A randomized, pharmacokinetic and pharmacodynamic, cross-over study of duodenal or jejunal administration compared to nasogastric administration of omeprazole suspension in patients at risk for stress ulcers

OBJECTIVES: The aim of this study was to characterize absorption and pH control of simplified omeprazole suspension (SOS), 2 mg/ml in 8.4% sodium bicarbonate, administered via the nasogastric versus jejunal or duodenal route. METHODS: Nine critically ill surgical patients, NPO and mechanically ventilated, were enrolled in this randomized cross-over study. Patients received a single 40 mg dose of SOS by the nasogastric and either the jejunal or duodenal route. Twenty-four-hour continuous intragastric pH monitoring was performed during the study period. Sequential blood samples were collected over 24 h to characterize SOS absorption and pharmacokinetic parameters. RESULTS: Nasogastric administration of SOS resulted in lower maximum mean ± SD serum concentrations compared to jejunal/duodenal dosing (0.970 ± 0.436 vs 1.833 ± 0.416 μg/ml, p = 0.006). SOS absorption was significantly slower when administered via nasogastric tube (108.3 ± 42.0 vs 12.1 ± 7.9 min, p < 0.001). However, all routes of administration resulted in similar SOS area under the serum concentration–time curves (AUC 0-∞) (415.1 ± 291.8 vs 396.7 ± 388.1 μg · h/ml, p = 0.91). Mean intragastric pH values remained >4 at 1 h after SOS administration and remained >4 for the entire 24-h study (6.32 ± 1.04, 5.57 ± 1.15, nasogastric vs jejunal/duodenal, p = 0.015), regardless of administration route. CONCLUSIONS: In critically ill surgical patients, pharmacokinetic parameters and subsequent pH control after the administration of SOS are similar by the jejunal, nasogastric, or duodenal route. SOS suspension offers an alternative acid control measure when patients are unable to take oral medications, yet have an enteral tube in place.

A Randomized, Pharmacokinetic and Pharmacodynamic, Cross-Over Study of Duodenal Or Jejunal Administration Compared To Nasogastric Administration of Omeprazole Suspension in Patients at Risk for Stress Ulcers

The aim of this study was to characterize absorption and pH control of simplified omeprazole suspension (SOS), 2 mg/ml in 8.4% sodium bicarbonate, administered via the nasogastric versus jejunal or duodenal route. Nine critically ill surgical patients, NPO and mechanically ventilated, were enrolled in this randomized cross-over study. Patients received a single 40 mg dose of SOS by the nasogastric and either the jejunal or duodenal route. Twenty-four-hour continuous intragastric pH monitoring was performed during the study period. Sequential blood samples were collected over 24 h to characterize SOS absorption and pharmacokinetic parameters. Nasogastric administration of SOS resulted in lower maximum mean +/- SD serum concentrations compared to jejunal/duodenal dosing (0.970 +/- 0.436 vs 1.833 +/- 0.416 microg/ml, p = 0.006). SOS absorption was significantly slower when administered via nasogastric tube (108.3 +/- 42.0 vs 12.1 +/- 7.9 min, p < 0.001). However, all routes of administration resulted in similar SOS area under the serum concentration-time curves (AUC(0-infinity)) (415.1 +/- 291.8 vs 396.7 +/- 388.1 microg x min/ml, p = 0.91) [corrected]. Mean intragastric pH values remained >4 at 1 h after SOS administration and remained >4 for the entire 24-h study (6.32 +/- 1.04, 5.57 +/- 1.15, nasogastric vs jejunal/duodenal, p = 0.015), regardless of administration route. In critically ill surgical patients, pharmacokinetic parameters and subsequent pH control after the administration of SOS are similar by the jejunal, nasogastric, or duodenal route. SOS suspension offers an alternative acid control measure when patients are unable to take oral medications, yet have an enteral tube in place.

The paracetamol absorption test: a useful addition to the enteral nutrition algorithm?

Background: Enteral nutrition in critically ill patients given via the nasogastric route is often decreased or stopped because of large gastric residual volumes. Aim: To assess the effect of continuing enteral nutrition in patients with an elevated gastric residual volume but normal gastric emptying by the paracetamol absorption test.Methods: The paracetamol absorption test was performed on all patients receiving enteral nutrition via a nasogastric tube who had a residual volume (assessed every 8 hours) of >150 ml or more than twice the hourly infusion rate. Patients were then divided into 2 groups according to the result of the test: Group 1 (n=8), normal gastric emptying; and Group II (n=24), abnormal gastric emptying. Group I continued to receive enteral nutrition. In Group II feeding was interrupted in 18 patients and prokinetic agents administered, while a subgroup of six patients continued to receive enteral nutrition without prokinetic agents. All patients were followed for evidence of delayed gastric emptying and aspiration.Results: Residual volumes were similarly elevated in both groups (p=0.25). Enteral nutrition was continued in Group I with no adverse effects. Prokinetic agents allowed enteral nutrition to be resumed in 88% of the 18 Group II patients. Enteral nutrition in the subgroup had to be stopped because of persistently elevated residual volumes.Conclusion: The paracetamol absorption test may be normal in patients with relatively high gastric residual volumes. These patients may continue to receive enteral nutrition.

Intestinal motility.

This review covers the recent advances that have been made in intestinal motility. Failure to stimulate the cephalic response when enteral tube feeding via the nasogastric route is important in contributing to enteral tube feeding related diarrhoea, which cannot be initially overcome by the use of fibre containing feeds. Dysfunction of the nervous system and visceral hypersensitivity appear to be important in contributing to the symptoms associated with irritable bowel syndrome.

Methods of Hydration in Palliative Care Patients

A strong and often polarized debate has taken place during recent years concerning the consequences of dehydration in the terminally ill patient. When a patient has a severely restricted oral intake or is found to be dehydrated, the decision to administer fluids should be individualized and made on the basis of a careful assessment that considers problems related to dehydration, potential risks and benefits of fluid replacement, and patients' and families' wishes. This review discusses the assessment of hydration status in the terminal cancer patient and the options for fluid administration in the cases where evaluation of the patients' condition has led to this indication. These include different modes of hypodermoclysis, intravenous hydration, use of the nasogastric route, and proctoclysis. Arguments for and against rehydration have been previously addressed by other authors and fall outside the scope of this review.

GUT TRANSIT TIME (GT) IN VERY LOW BIRTH WEIGHT INFANTS 499

Very low birth weight (VLBW) infants often have delayed passage of stools and feeding intolerance. There are no studies on total gut transit time in these infants. Sixteen VLBW infants (Birthweight 902±261g and gestational age 26±1.8 weeks) were enrolled when they were tolerating enteral feeds for more than 3 days. Infants with gastrointestinal malformations and those who developed necrotizing enterocolitis were excluded. None of the infants had hypothyroidism or cystic fibrosis. The GT was measured in each infant after administering 50 mg (0.5 ml) of carmine red dye by nasogastric route. The time of first appearance (T1) and the time of last appearance (T2) of red dye in stool was recorded. The study was repeated in each infant every 2 weeks until the infant reached a postmenstrual age of 36 weeks or was discharged from the hospital. Illness severity of each infant at the time of the study was assessed by the Neonatal Therapeutic Intervention Scoring System (NTISS). A total of 44 studies were performed in these 16 infants. Fourteen of the 16 infants were exposed to antepartum glucocorticosteroids and were fed mothers' milk.Table

Survival After a Massive Hydrofluoric Acid Ingestion

Hydrofluoric acid ingestion is known to have a very high mortality rate secondary to the rapid development of hypocalcemia and fatal arrhythmias. A 33-year-old man ingested an estimated dose of hydrofluoric acid 6 times that considered to be lethal. The patient survived with minimal morbidity despite having multiple ventricular fibrillation arrests. His survival is attributed to early, high dose calcium therapy given via the nasogastric and intravenous routes.

Nasogastric Tube Feeding in Infants on Peritoneal Dialysis

Enteral nutritional support is an important component of the care provided to infants receiving long-term peritoneal dialysis. In the majority of published experiences on this subject, the use of the nasogastric tube has facilitated the provision of required calorie and protein intake and resulted in an improved patient outcome. Advantages of the nasogastric route of nutritional support include the ease of administration, while recurrent emesis remains the most troublesome and frequent short-term complication associated with its use. Impaired oral-motor development may also result from nonoral feeding and should be addressed throughout the course of tube feeding.

1400 Nutritional support in head and neck cancer patients

Nutritional support is an important consideration in the overall management of the head and neck cancer patient. Anti tumour therapies impair nutritional intake: extensive surgical resection can interfere with mastication and deglutition; radiotherapy may limit oral intake by reactive changes. This study is a review of the nutritional management provided for all patients undergoing enteral feeding via nasogastric (NG) and gastrostomy (PEG) routes concurrent to radiotherapy treatment at the Clatterbridge Centre for Oncology July 1993–present. Mean nutritional requirements, method of delivery, type and composition of enteral feed, duration of nutritional support, percentage weight changes and alterations in body mass index (BMI) for each method of enteral feeding will be analysed and the outcome of each feeding method determined. Preliminary results indicate the feeding methods to be equally effective at maintaining body weight (NG = −10.8% to +20.1%, PEG = −9% to +19%) and BMI (NG = −2.3% to +3, PEG = 2.4 to +4). There are marked differences in the method of delivery of the feed between the two groups; NG feeding is predominantly administered continuously [n = 42 (85.7%)]. Whereas PEG feeding is delivered via bolus [n = 11 (39.3%)] and continuous methods [n = 10 (35.7%)]. PEG feeding via bolus method allows an increase in the quality of life for the patient by allowing normal feeding patterns and increased mobility. The placement of a PEG in preference to an NG tube is considered to be more discreet and cosmetically pleasing for the patient.

Oxidation of glutamic acid by the splanchnic bed in humans.

[1,2-13C2]glutamate and [ring-2H5]phenylalanine were infused for 7 h into postabsorptive healthy subjects on two occasions. The tracer infusion was by the intravenous route for 3.5 h and by the nasogastric route for 3.5 h. The order of tracer infusion routes was switched between the two occasions. From the plasma tracer enrichment measurements at plateau during the intravenous and enteral infusion periods, we determined that 33 +/- 3% of the enterally delivered phenylalanine and 96 +/- 1% of the glutamate were removed on the first pass by the splanchnic bed; 78 +/- 3% of the enterally delivered [13C]glutamate tracer was recovered as exhaled CO2 compared with 79 +/- 2% of the intravenously infused tracer. The fraction of the enterally delivered tracer that was sequestered specifically on the first pass by the splanchnic bed was 75 +/- 2%. These results verify the previously reported large uptake of [15N]glutamate by the splanchnic bed [Matthews et al. Am. J. Physiol. 264 (Endocrinol. Metab. 27): E848-E854, 1993] and demonstrate that the uptake of tracer is not due to an artifactual loss of the 15N tracer by reversible transamination but to glutamate uptake for oxidation.

Gastric tonometry in multiple trauma patients.

Splanchnic ischemia, leading to intestinal mucosal damage, is thought to be common in patients after severe trauma. The adequacy of mucosal oxygenation can indirectly be determined by gastric intramucosal pH (pHi) measurement. We prospectively examined the posttraumatic gastric pHi values in 15 multiple trauma patients. In all patients gastric pHi was measured using a tonometer via the nasogastric route. A pHi value < or = 7.32 was used to differentiate between normal and low gastric pHi. Six hours after the injury four patients showed abnormally low pHi levels. Four other patients with normal initial pHi values exhibited low pHi values during one or more of the next measuring periods. Three of these eight patients developed major complications (two, ARDS) and two of them subsequently died. The seven remaining patients never had abnormal pHi levels and all patients had an uncomplicated recovery. Although intestinal ischemia was expected to be a common condition in multiple trauma patients, no consistent pattern of abnormal pHi measurements in the direct posttraumatic course could be discovered. No correlation was found between initial pHi values (at 6 hours) and ISS, shock, and lactic acidosis or APACHE II scores on admission. It is concluded that monitoring gastric pHi is useful in severely injured patients admitted to the ICU.

Acetylsalicylic acid and misoprostol combination in adjuvant arthritis of rats

The combined effect of acetylsalicylic acid (ASA) and misoprostol (MISO) on adjuvant arthritis was investigated on rats. Alteration by various doses of MISO and fixed dose of ASA was studied. Drugs were given by the nasogastric route each day beginning from the day of adjuvant injection (day 0) and continued until the 16th day. Paw swelling was measured on days 4, 17, and 29, and secondary lesions were assessed on days 17 and 29. Pathological examination of tibiodorsal junction was also evaluated on the 29th day. The results clearly showed that the combination of MISO with ASA did not inhibit the antiinflammatory effect of ASA. Unexpectedly, MISO increased the antiinflammatory effect of ASA at some dosage regimens.

Splanchnic bed utilization of glutamine and glutamic acid in humans

To study the fate of enterally delivered nonessential amino acids, glutamine and glutamate, 14 healthy adults were infused in the postabsorptive state with [2-15N]glutamine and [15N]glutamate for 7 h by intravenous (iv) and nasogastric (ng) tube routes. The amount of enterally delivered tracer that was sequestered by the splanchnic bed on the first pass was 54 +/- 4 and 88 +/- 2% for the [2-15N]glutamine and [15N]glutamate tracers, respectively. Only 46 and 12% of the ng glutamine and glutamate tracers entered systemic blood, respectively. The relative amount of 15N transferred from glutamate to glutamine, the transaminating amino acids leucine, isoleucine, valine, and alanine, and to proline was significantly higher when the [15N]glutamate was infused by the ng vs. iv route. The same was also true for [2-15N]glutamine, which presumably transferred 15N after it was converted to glutamate. Thus we conclude that the splanchnic bed sequesters over one-half of the glutamine and almost all of the glutamate delivered to it in the postabsorptive state. There is production of transaminating amino acids in the splanchnic bed, and the splanchnic bed produces simultaneously both glutamine from glutamate and glutamate from glutamine.

Splanchnic bed utilization of leucine and phenylalanine in humans

To study the fate of enterally delivered essential amino acids, leucine and phenylalanine, 14 healthy adults were infused in the postabsorptive state with [1-13C]leucine, [5,5,5-2H3]leucine, and [phenyl-2H5]phenylalanine for 7 h in a crossover design by intravenous and nasogastric tube routes. The amount of enterally delivered tracer that was sequestered by the splanchnic bed on the first pass was 21 +/- 1, 17 +/- 3, and 29 +/- 2 for the [13C]leucine, [2H]leucine, and [2H]phenylalanine tracers, respectively. Less than 2% of the nasogastric [1-13C]leucine tracer was oxidized on the first pass. We estimate that 40% of the nasogastric leucine tracer that was sequestered on the first pass was converted to alpha-ketoisocaproate and released, and 50% was incorporated into newly synthesized proteins. Assuming that less phenylalanine is incorporated into protein than leucine because of the lower abundance of phenylalanine in protein compared with leucine, we estimate that 80% of the extracted nasogastric phenylalanine tracer was converted to tyrosine. The study design also indicated a significant effect of duration of tracer infusion on the results, presumably due to recycling of tracer from rapidly turning over protein.

Enteral Nutrition in Anorexia Nervosa

Biochemical and anthropometric data were collected in 9 subjects with anorexia nervosa before and after enteral nutrition by the nasogastric route. All subjects but one accepted the treatment which was stopped as soon as an adequate spontaneous food intake was resumed. Enteral nutrition caused a significant increase of mid-arm muscle circumference and of tricipital skinfold. Body weight gain was remarkable, averaging a rate of 8.22 kg/month. This value was not different from the levels attained by anorectic subjects put on total parenteral nutrition. Furthermore, a significant rise of some biochemical indexes, namely prealbumin and total iron binding capacity, was achieved. The most impressive drawbacks of enteral nutrition were occasional hypophosphatemia and moderate rise of serum aspartate and alanine aminotransferases. Both of these abnormalities were transient and apparently not associated with clinical disturbances.

Use of concurrent monitoring and a preprinted note to modify prescribing of i.v. cimetidine and ranitidine in a teaching hospital

The use of concurrent monitoring and an informational note to modify physician prescribing of i.v. cimetidine and ranitidine is described. The study population consisted of all patients for whom i.v. cimetidine and ranitidine therapy was prescribed by house-staff physicians at an 850-bed, tertiary-care, university-affiliated hospital during February, March, and April 1987. Phase 1 of the trial consisted of an initial drug-use review of all eligible patients receiving therapy. In phase 2, the study population was divided into an intervention group and a control group. When therapy could be changed from the i.v. to the oral or nasogastric (NG) route of administration, an informational note was placed in the chart of the patients in the intervention group. Patients in the control group were also assessed daily for the appropriateness of conversion to oral or NG therapy. The following outcome measures were used to test the effectiveness of the intervention in modifying physician prescribing: mean number of i.v. doses and days of i.v. therapy per patient and mean number of inappropriate i.v. doses and days of i.v. therapy per patient. The drug acquisition costs for both groups were also analyzed. A total of 233 patients were monitored during the study period. The percentage of patients who did not receive oral therapy as soon as possible was not significantly different between the intervention (55%) and control (58%) groups. Patients in the intervention group received three to six fewer i.v. doses than patients in the control group and three to six additional oral doses.(ABSTRACT TRUNCATED AT 250 WORDS)

Tube feeding enteral nutritional support in patients receiving radiation therapy for advanced head and neck cancer.

A retrospective study evaluated the role of tube feeding enteral nutritional support in patients receiving radiation therapy (RT) for Stage III and IV squamous cell carcinoma of the head and neck. Tube feeding (TF) by either nasogastric, cervical esophagostomy, or gastrostomy route was based on individual physician preference and patient acceptance. TF feeding starting before and continuing through RT (planned TF) was completed in 17 patients, whereas 9 patients did not receive TF until they lost weight during RT (interventional TF). No tube feeding was performed in 63 patients. By the end of RT, the planned TF group lost an average of 4.8% of initial body weight, compared to 7.1% in the no TF group and 9.4% in the interventional TF group. At the end of RT, only 6% of the planned TF group had lost over 10% of initial body weight, compared to 24% of the no TF group and 44% of the interventional group. Excluding patients who continued to lose weight after the end of RT due to rapidly recurrent tumor, 49% of the no TF group had a post-RT nadir weight loss over 10% of initial body weight, compared to 0% of the planned RT group. However, failure to receive the full RT dose and/or lengthy rest periods during RT were just as likely to occur in the planned TF group as in the no TF group. This retrospective review also could not demonstrate improved survival in the planned TF group. Complications, including peptic ulcer disease, aspiration pneumonia, cervical stoma abscess, and hepatic encephalopathy, occurred in 7 of the 26 patients (27%) receiving either planned or interventional TF. We conclude that TF will help minimize weight loss due to side effects of RT for head and neck cancer, particularly when TF is instituted before the onset of significant weight loss due to RT side effects. Survival differences, however, were not apparent.