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Recommendations Summary

CI: Monitoring Criteria in Critical Illness 2006

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.

  • Recommendation(s)

    CI: Monitoring Patient position

    Evaluating patient position should be part of an EN monitoring plan. To decrease the incidence of aspiration pneumonia and reflux of gastric contents into the esophagus and pharnyx, critically ill patients should be placed in a 45-degree head of bed elevation, if not contraindicated.

    Rating: Strong

    CI: Monitoring Gastric Residual Volume

    Evaluating gastric residual volume (GRV) in critically ill patients is an optional part of a monitoring plan to assess tolerance of EN. Enteral nutrition should be held when a GRV greater than or equal to 250ml is documented on two or more consecutive occasions. Holding EN when GRV is less than 250ml is associated with delivery of less EN. Gastric residual volume may not be a useful tool to assess the risk of aspiration pneumonia. Adequately-powered studies have not been conducted to evaluate the impact of GRV on aspiration pneumonia.

    Rating: Consensus

    CI: Monitoring and promotility agents

    If the patient exhibits a history of gastroparesis or repeated high GRVs, then consider the use of a promotility agent in critically ill ICU patients, if there are no contraindications. The use of a promotility agent (e.g., Metoclopramide) has been associated with increased GI transit, improved feeding tolerance, improved EN delivery and possibly reduced risk of aspiration.

    Rating: Strong

    • Risks/Harms of Implementing This Recommendation

      Patient Positioning

      • Raising the head of bed to 45 degrees may be contraindicated in specific medical conditions that require the patient to be supine (e.g., back and neck surgery, hypotension)
      • Long-term use of 45-degree head of bed elevation may be associated with increased pressure over the ischial tuberosities and may expose the patient to greater shearing forces due to gravity-related sliding in the bed (Wipke-Tevis et al, 2004).

      Gastric Residual Volume

      • Potential for reduced EN delivery if formula is repeatedly stopped or held.

      Promotility Agents

      • Metoclopramide may be contraindicated in specific medical conditions and should not be given (Pasricha et al, 2006)
      • Metoclopramide should not be used whenever stimulation of the GI motility might be dangerous, (i.e., in the presence of GI hemorrhage, mechanical obstruction or perforation)
      • Metoclopramide is contraindicated in patients with pheochro-mocytoma
      • Metoclopramide is contraindicated in patients with known sensitivity or intolerance to the drug
      • Metoclopramide should not be used in epileptics or patients receiving other drugs which are likely to cause extrapyramidal reactions, since the frequency and severity of seizures or extrapyramidal reactions may be increased
      • Adverse reactions that have been documented in RCTs with the use of metaclopromide include: Depression, high blood pressure,  headache, skin rash, fatigue, fever, insomnia, decrease of libido, nausea, sedation, tremor and agitation, dyslalia and dysphagia (Silva et al, 2002) 
      • Because erythromycin may impact antibiotic resistance in critically ill patients, metoclopramide may be a better choice in patients where use of the drug is not contraindicated.

    • Conditions of Application

      Patient Positioning and Promotility Agents

      • No conditions limit the application of this recommendation.

      Gastric Residual Volume

      • Small amounts of emesis (<100ml), associated with routine suctioning and pulmonary toilet will occur
      • EN should not be held with small amounts of emesis associated with these procedures
      • Potential barriers:
        • Tube position in stomach may interfere with obtaining GRV
        • Widely varying institutional policy.

    • Potential Costs Associated with Application

      • No obvious costs are associated with the application of this recommendation for GRV or patient positioning
      • Additional cost may be incurred with use of promotility agents.

    • Recommendation Narrative

      Patient Positioning

      • The data are congruent from one well-designed and executed prospective cross-over trial of positive quality (Drakulovic et al, 1999), two positive quality meta-analyses (Heyland et al, 2002; Collard et al, 2003), one positive quality consensus statement (McClave et al, 2002) and one negative quality RCT (Ibanez et al, 1992) that semirecumbent positioning should be used to reduce risk of aspiration pneumonia
        • Both clinically-suspected and culture-confirmed pneumonias were reduced by semirecumbent positioning (34% to 8%, P=0.003; 23% vs. 5%, P=0.018) (Drakulovic et al, 1999).
      • Two trials of neutral quality (Torres et al, 1992; Orozco-Levi et al 1995) as well as one negative quality medical opinion statement (Bowton et al, 1999) also agree that semi-recumbent positioning, to a 45-degree head of bed elevation in patients fed gastrically in the ICU, is effective at reducing the volume of aspirated gastroesophageal secretions.

      Gastric Residual Volume

      • Two PRCTs demonstrated that using a higher GRV had benefits in terms of greater formula intake and fewer intolerance events
        • The first PRCT of neutral quality (Taylor et al, 1999) compared a protocol using 200ml GRV vs. 150ml, to guide holding of EN
        • The second PRCT of neutral-quality compared 150ml vs. 250ml, the latter with mandatory prokinetic agent use (Pinilla et al, 2001).
      • The Canadian Clinical Practice Guidelines (Heyland et al, 2003), based on a series of meta-analysis findings and expert consensus (McClave et al, 2002), both of positive quality, agree with a residual volume of 250ml for gastric EN
      • Seven other PRCTs of negative quality used GRVs of 150ml to 200ml, but were underpowered to detect significant differences in aspiration pneumonia (Montecalvo et al, 1992; Kortbeek et al, 1999; Esparza et al, 2000; Davies et al, 2002; Montejo et al, 2002; Neumann and DeLegge, 2002)
      • Post-pyloric feeding to decrease risk of aspiration pneumonia is supported by the positive quality consensus statement from the North American Summit on Aspiration in Critically Ill Patients (McClave et al, 2002)
      • While power analysis of number of subjects needed to detect a difference in mortality were not found in the literature, aspiration pneumonia occurs more frequently than mortality, thus mortality outcomes will require larger groups of patients than pneumonia
        • One positive quality PRCT (Drakulevic et al, 1999) calculated that 184 patients were needed to detect a 50% reduction in pneumonia with 80% power and P<0.05
        • One neutral quality PRCT (Montejo et al, 2002) suggested that 152 patients were needed to detect a 50% reduction in aspiration pneumonia.
          • Most of the studies reviewed included far less than 100 patients.

      Promotility Agents

      • In two positive quality systematic reviews (Booth et al, 2002; Heyland et al, 2003),  one consensus statement also of positive quality (McClave et al, 2002) and in one PRCT of neutral quality (Yavagal et al, 2002), prokinetic agents used with gastric EN were shown to increase GI transit, feeding tolerance and EN delivery
      • In one less robust negative quality PRCT (Boivin et al, 2001),  no differences in GRV in gastric feedings using erythromycin than in post-pyloric feedings were found
      • One PRCT of negative quality (Esparza et al, 2001) used a promotility agent only if residuals were greater than 150ml
        • In this study, patients that were prescribed promotility agents had no aspiration events, when compared to patients who had 10% aspiration rate without promotility agents.
      • In a negative quality PRCT (Pinilla et al, 2001), incidence of feeding intolerance was reduced by use of 250ml residual volume and manditory prokinetics
      • One underpowered PRCT of neutral quality (Yavagal et al, 2000) detected a delay in pneumonia, but no difference in final prevalence.

    • Recommendation Strength Rationale

      Patient Positioning

      • The data are consistent and congruent in regards to decrease incidence of both gastric reflux and aspiration pneumonia
      • Conclusion statements are Grade I (decrease gastric reflux) and II (decreased risk of aspiration penumonia), respectively.

      Gastric Residual Volume

      • High GRVs have not been correlated with abdominal distention or aspiration by X-ray
      • Many studies have been small in size and underpowered to detect clinical differences in regards aspiration and aspiration pnemonia
      • Conclusion statements are Grade III, IV and V.

      Promotility Agents

      • Sub-therapeutic doses of erythromycin (prokinetic dose) may not be optimal in the ICU patient when considered with the emergence of antibiotic-resistant micro-organisms
      • Conclusion statement is Grade II.