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Cited by 163Clinical Nutrition and GastroenterologyGastrointestinal motility and disordersEnhanced Recovery After Surgery

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The efficacy and safety of prokinetic agents in critically ill patients receiving enteral nutrition: a systematic review and meta-analysis of randomized trials

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Lewis, Kim, Alqahtani, Zuhoor, Mcintyre, Lauralyn, Almenawer, Saleh, Alshamsi, Fayez, Rhodes, Andrew, Evans, Laura, Angus, Derek C., Alhazzani, Waleed·2016·Critical Care
DOI 10.1186/s13054-016-1441-zPMC PMC4986344
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Abstract

BACKGROUND: Intolerance to enteral nutrition is common in critically ill adults, and may result in significant morbidity including ileus, abdominal distension, vomiting and potential aspiration events. Prokinetic agents are prescribed to improve gastric emptying. However, the efficacy and safety of these agents in critically ill patients is not well-defined. Therefore, we conducted a systematic review and meta-analysis to determine the efficacy and safety of prokinetic agents in critically ill patients. METHODS: We searched MEDLINE, EMBASE, and Cochrane Library from inception up to January 2016. Eligible studies included randomized controlled trials (RCTs) of critically ill adults assigned to receive a prokinetic agent or placebo, and that reported relevant clinical outcomes. Two independent reviewers screened potentially eligible articles, selected eligible studies, and abstracted pertinent data. We calculated pooled relative risk (RR) for dichotomous outcomes and mean difference for continuous outcomes, with the corresponding 95 % confidence interval (CI). We assessed risk of bias using Cochrane risk of bias tool, and the quality of evidence using grading of recommendations assessment, development, and evaluation (GRADE) methodology. RESULTS: Thirteen RCTs (enrolling 1341 patients) met our inclusion criteria. Prokinetic agents significantly reduced feeding intolerance (RR 0.73, 95 % CI 0.55, 0.97; P = 0.03; moderate certainty), which translated to 17.3 % (95 % CI 5, 26.8 %) absolute reduction in feeding intolerance. Prokinetics also reduced the risk of developing high gastric residual volumes (RR 0.69; 95 % CI 0.52, 0.91; P = 0.009; moderate quality) and increased the success of post-pyloric feeding tube placement (RR 1.60, 95 % CI 1.17, 2.21; P = 0.004; moderate quality). There was no significant improvement in the risk of vomiting, diarrhea, intensive care unit (ICU) length of stay or mortality. Prokinetic agents also did not significantly increase the rate of diarrhea. CONCLUSION: There is moderate-quality evidence that prokinetic agents reduce feeding intolerance in critically ill patients compared to placebo or no intervention. However, the impact on other clinical outcomes such as pneumonia, mortality, and ICU length of stay is unclear.

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Crossref · 10.1186/s13054-016-1441-z

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Figures

Fig. 1 Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow chart. Description of the study selection process
Fig. 1 Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow chart. Description of the study selection processCC BY · PubMed Central
Fig. 2 Risk of bias assessment. Summary of risk of bias in individual randomized controlled trials in this systematic review; green circles low risk of bias, yellow circles unclear risk of bias, red circles indicate high risk of bias
Fig. 2 Risk of bias assessment. Summary of risk of bias in individual randomized controlled trials in this systematic review; green circles low risk of bias, yellow circles unclear risk of bias, red circles indicate high risk of biasCC BY · PubMed Central
Fig. 3 Feeding intolerance outcome. Forest plot includes pooled estimates for randomized controlled trials comparing prokinetic agents to placebo or no intervention for feeding intolerance outcome. IV inverse variance, CI confidence interval
Fig. 3 Feeding intolerance outcome. Forest plot includes pooled estimates for randomized controlled trials comparing prokinetic agents to placebo or no intervention for feeding intolerance outcome. IV inverse variance, CI confidence intervalCC BY · PubMed Central
Fig. 4 High gastric residual volume (>250 ml). Forest plot includes pooled estimates for randomized controlled trials comparing prokinetic agents to placebo or no intervention for high gastric residual volume outcome. IV inverse variance, CI confidence interval
Fig. 4 High gastric residual volume (>250 ml). Forest plot includes pooled estimates for randomized controlled trials comparing prokinetic agents to placebo or no intervention for high gastric residual volume outcome. IV inverse variance, CI confidence intervalCC BY · PubMed Central
Fig. 5 Successful post-pyloric feeding tube placement. Forest plot includes pooled estimates for randomized controlled trials comparing prokinetic agents to placebo or no intervention for successful insertion of post-pyloric tube outcome. IV inverse variance, CI confidence interval
Fig. 5 Successful post-pyloric feeding tube placement. Forest plot includes pooled estimates for randomized controlled trials comparing prokinetic agents to placebo or no intervention for successful insertion of post-pyloric tube outcome. IV inverse variance, CI confidence intervalCC BY · PubMed Central
Fig. 6 ICU-acquired pneumonia outcome. Forest plot includes pooled estimates for randomized controlled trials comparing prokinetic agents to placebo or no intervention for ICU-acquired pneumonia outcome. IV inverse variance, CI confidence interval
Fig. 6 ICU-acquired pneumonia outcome. Forest plot includes pooled estimates for randomized controlled trials comparing prokinetic agents to placebo or no intervention for ICU-acquired pneumonia outcome. IV inverse variance, CI confidence intervalCC BY · PubMed Central

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Citations

Cites

Research works printed but not linked: 5

  1. Barclay M, Fraser R, Tournadre J, et al. Small intestinal and gastric motility in patients in the intensive care unit following elective abdominal aortic aneurysm repair. Gastro. 1997;112:A694.
  2. Alverdy J, Aoys E, Moss G. TPN promotes bacterial translocation from the gut. Surgery. 1988;104(2):185–90.
  3. Dive A, Garrino M, Nizet H, et al. Gastric microbial overgrowth and retrograde colonization of the ventilated lung: effect of a digestive prokinetic therapy. 7th European Congress of Intensive Care Medicine. Insbrück, Austria: The International Symposium on Intensive Care and Emergency Medicine; June 14–17, 1994, pp 757.
  4. Calcroft R, Joynt G, Hung V. Gastric emptying in critically ill patients: a randomized, blinded, prospective comparison of metoclopramide with placebo. Intensive Care Med. 1997;23(Suppl):S138.
  5. MacLaren R, Hall R, Patrick W, et al. Cisapride versus metoclopramide for facilitating gastric emptying and tolerance to intragastric nutrition. Crit Care Med. 2000;28(Suppl):A104.

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Metadata

Authors
Lewis, K., Alqahtani, Z., Mcintyre, L., Almenawer, S., Alshamsi, F., Rhodes, A., Evans, L., Angus, D. C., & Alhazzani, W.
Affiliations
  • McMaster University (CA)
  • University of Ottawa (CA)
  • United Arab Emirates University (AE)
  • St George's Hospital (GB)
  • New York University (US)
  • University of Pittsburgh (US)
  • St. Joseph’s Healthcare Hamilton (CA)
Corresponding author
Alhazzani, Waleed
ORCID
Venue
Critical Care
Publisher
Springer Science and Business Media LLC
Published
2016-08-15
Volume
20
Issue
1
Pages
259-259
ISSN
1364-8535 (ISSN-L)
DOI
10.1186/s13054-016-1441-z
PMC
PMC4986344
OpenAlex
W2514961948
Cited by
163
References
65
Citations by year
2026: 19 · 2025: 15 · 2024: 11 · 2023: 14 · 2022: 16 · 2021: 22 · 2020: 26 · 2019: 20 · 2018: 9 · 2017: 9 · 2016: 2
FWCI
1.78
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • Critical Care (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • St George's Online Research Archive (St George's University of London) (acceptedVersion)
  • uO Research (University of Ottawa) (submittedVersion, public-domain)
Topics
  • Health Sciences › Nursing › Nutrition and Dietetics › Clinical Nutrition and Gastroenterology
  • Health Sciences › Medicine › Gastroenterology › Gastrointestinal motility and disorders
  • Health Sciences › Medicine › Surgery › Enhanced Recovery After Surgery
Keywords
prokinetic agents, enteral nutrition, critically ill patients, feeding intolerance, gastric emptying, gastric residual volume, vomiting, diarrhea, ICU length of stay, mortality
MeSH terms
Diarrhea, Domperidone, Enteral Nutrition, Erythromycin, Gastric Emptying, Humans, Intensive Care Units, Length of Stay, Metoclopramide, Residual Volume, Vomiting, Chi-Square Distribution, Critical Illness, Dopamine Antagonists

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