Gastric Emptying in Critically Ill Children

Abstract

A majority of our study cohort had delayed GE. Bedside EN intolerance assessments, particularly GRV, did not predict delayed GE or rate of EN advancement. Delayed gastric emptying predicted slow EN advancement. Novel tests for delayed GE and EN intolerance are needed.

A review of feeding intolerance in critically ill children

“…Gastric dysmotility, a problem in the critically ill child, is defined by Martinez et al as Bthe functional capacity of the stomach to move the contents forward by abnormally slow and/or uncoordinated activity of the gastric or antroduodenal musculature^ [20]. This results in the phenomena of delayed gastric emptying which is estimated to occur in around half of critically ill children [21]. The causes for delayed gastric emptying are multifactorial; alterations in hormonal responses (increased levels of ghrelin, motilin, cholecystokinin, glucagon-like-peptide-1, peptide-YY, amylin) and alterations of vagal tonus, vasoactive intestinal peptide, and nitric oxide secretion are combined with the side effects of opiates, sedatives, neuromuscular blocking agents, and catecholamines alter GI motility and slow transit time, usually in a dose-dependent manner [20].…”

“…However, the evidence for it as a valid marker of gastric emptying is not supported [21]. An increased GRV can occur in up to 50% critically ill children [21,46].…”

“…However, the evidence for it as a valid marker of gastric emptying is not supported [21]. An increased GRV can occur in up to 50% critically ill children [21,46]. GRV comprises both the enteral feed administered, in addition to gastric secretions produced, and many clinicians fail to consider the large impact of the latter on this volume.…”

“…Furthermore, there is an inaccurate assumption that the relationship between feed volume infused and GRV is linear [46]. However, a prospective study in critically ill children showed higher GRVs did not correlate with delayed gastric emptying [21]. The volume of GRV obtained is known to be affected by multiple factors: patient position, feeding tube tip position and diameter of feeding tube being aspirated, the type of tube (rigid aspiration tube or soft silicone or polyurethane nutrition tube), the syringe size used to aspirate, the nurses' technique in aspiration, and the type of feeding delivery method used (bolus versus continuous) [1,46].…”

“…Testing of a new feeding protocol GRV > 3 ml/kg or evidence of EN intolerance after 4 h of feeding Yoshimuru et al 2015 [50] Before and after study Testing of a new feeding protocol GRV > half of the quartering dose after 2 h of feed delivery Somnez-Duzkaya et al 2016 [37] RCT Continuous post pyloric vs intermittent gastric feeding on VAP GRV greater than 2/3 of the last feed in intermittent gastric bolus feeding Fayazi et al 2016 [7] RCT Continuous versus intermittent feeding GRV > 100 ml after 4 h of feeding by either method Martinez et al 2017 [21] Prospective observational To assess delayed GE in critically ill children > 12 months of age GRV > 3ml/kg or > 150 ml or if one of the following were recorded in a 24-h period: 2 or more episodes of emesis, bilious or non-bilious; 3 or more episodes of loose stool; abdominal distention defined as 2 or more increases in abdominal girth or subjective abdominal discomfort adults [27,30,42]. For children, an arbitrary cutoff volume is not useful given the wide weight and age variations.…”