The efficacy and safety of prokinetics in critically ill adults receiving gastric feeding tubes: A systematic review and meta-analysis

Abstract

Background Intolerance to gastric feeding tubes is common among critically ill adults and may increase morbidity. Administration of prokinetics in the ICU is common. However, the efficacy and safety of prokinetics are unclear in critically ill adults with gastric feeding tubes. We conducted a systematic review to determine the efficacy and safety of prokinetics for improving gastric feeding tube tolerance in critically ill adults. Methods Randomized controlled trials (RCTs) were identified by systematically searching the Medline, Cochrane and Embase databases. Two independent reviewers extracted the relevant data and assessed the quality of the studies. We calculated pooled relative risks (RRs) for dichotomous outcomes and the mean differences (MDs) for continuous outcomes with the corresponding 95% confidence intervals (CIs). We assessed the risk of bias using the Cochrane risk-of-bias tool and used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to rate the quality of the evidence. Results Fifteen RCTs met the inclusion criteria. A total of 10 RCTs involving 846 participants were eligible for the quantitative analysis. Most studies (10 of 13, 76.92%) showed that prokinetics had beneficial effects on feeding intolerance in critically ill adults. In critically ill adults receiving gastric feeding, prokinetic agents may reduce the ICU length of stay (MD -2.03, 95% CI -3.96, -0.10; P = 0.04; low certainty) and the hospital length of stay (MD -3.21, 95% CI -5.35, -1.06; P = 0.003; low certainty). However, prokinetics failed to improve the outcomes of reported adverse events and all-cause mortality. Conclusion As a class of drugs, prokinetics may improve tolerance to gastric feeding to some extent in critically ill adults. However, the certainty of the evidence suggesting that prokinetics reduce the ICU or hospital length of stay is low. Prokinetics did not significantly decrease the risks of reported adverse events or all-cause mortality among critically ill adults.

Serial Measurements of Refractive Index, Glucose and Protein to Assess Gastric Liquid Nutrient Transport—A Proof-of-Principal Study

“…The same applies to the observed reduction in transport rates in the four patients on prokinetics which may not be overinterpreted but may simply reflect a reaction of the medical ICU staff to subtle clinical signs of gastric dysmotility. The fact that prokinetics evidently did not effectively restore gastric transport is in line with previous reports on their unsatisfactory efficiency in real world settings (44,45).…”

Should we believe the benefit of intravenous erythromycin in critically ill adults with gastric feeding intolerance? Reinspecting the pieces of evidence from a series of meta‐analyses

“…We also performed an umbrella review (a review of systematic reviews), and one systematic review with meta-analysis in this topic has been reported following the ESPEN guideline. 22 However, the review pooled many kinds of prokinetic agents for meta-analysis, including metoclopramide, erythromycin, cisapride, mosapride, GSK962040, and Chinese herbs or natural medicines. In this systematic review, the authors enrolled another two RCTs investigating the effects of intravenous erythromycin for critically ill adults.…”

“…By using the advanced methodologies in statistics, the beneficial effect of intravenous erythromycin on feeding intolerance in critically ill adults that was mentioned in the ESPEN guideline disappeared. We also performed an umbrella review (a review of systematic reviews), and one systematic review with meta‐analysis in this topic has been reported following the ESPEN guideline 22 . However, the review pooled many kinds of prokinetic agents for meta‐analysis, including metoclopramide, erythromycin, cisapride, mosapride, GSK962040, and Chinese herbs or natural medicines.…”

Use of prokinetic agents in hospitalised adult patients: Protocol for a scoping review

“…4 Prokinetic agents are also used for other indications in hospitalised patients, including nausea and vomiting, pseudo-obstruction, functional dyspepsia, gastroparesis and to improve visualisation during gastroscopy. [4][5][6][7] Several prokinetic agents with different mechanisms of action exist, including dopamine receptor antagonists, motilin receptor agonists, serotonin (5-hydroxytryptamine type 4) receptor agonists, cholinesterase inhibitors and ghrelin agonists. 8,9 We aim to systematically outline and explore the body of evidence on the use of prokinetic agents for any indication in hospitalised adults.…”

“…Clinicians use prokinetic agents to improve GI motility 4 . Prokinetic agents are also used for other indications in hospitalised patients, including nausea and vomiting, pseudo‐obstruction, functional dyspepsia, gastroparesis and to improve visualisation during gastroscopy 4–7 …”