PubMed · 8151963
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K Kida. 1994. [Intractable pneumonia].. https://pubmed.ncbi.nlm.nih.gov/8151963/
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OBJECTIVE: This study aimed to a) compare the efficacy of metoclopramide and erythromycin in the treatment of feed intolerance in critical illness; and b) determine the effectiveness of "rescue" combination therapy in patients who fail monotherapy. DESIGN: Randomized controlled trial. SETTING: Level III mixed medical and surgical intensive care unit. PATIENTS: Ninety mechanically ventilated, medical patients with feed-intolerance (gastric residual volume>or=250 mL). INTERVENTIONS: Patients received either metoclopramide 10 mg intravenously four times daily (n=45) or erythromycin 200 mg intravenously twice a day (n=45) in a double-blind, randomized fashion. After the first dose, nasogastric feeding was commenced and 6-hourly nasogastric aspirates were performed. If a gastric residual volume>or=250 mL recurred on treatment, open-label, combination therapy was given. Patients were studied for 7 days. Successful feeding was defined as 6-hourly gastric residual volume<250 mL with a feeding rate>or=40 mL/hr. MEASUREMENTS AND MAIN RESULTS: Demographic data, blood glucose levels, and use of inotropes, opioids, and benzodiazepines were similar between the two groups. After 24 hrs of treatment, both monotherapies reduced the mean gastric residual volume (metoclopramide, 830+/-32 mL to 435+/-30 mL, p<.0001; erythromycin, 798+/-33 mL to 201+/-19 mL, p<.0001) and improved the proportion of patients with successful feeding (metoclopramide=62% and erythromycin=87%). Treatment with erythromycin was more effective than metoclopramide, but the effectiveness of both treatments declined rapidly over time. In patients who failed monotherapy, rescue combination therapy was highly effective (day 1=92%) and maintained its effectiveness for the study duration (day 6=67%). High pretreatment gastric residual volume was associated with poor response to prokinetic therapy. CONCLUSIONS: In critical illness, erythromycin is more effective than metoclopramide in treating feed intolerance, but the rapid decline in effectiveness renders both treatments suboptimal. Rescue combination therapy is highly effective, and further study is required to examine its role as the first-line therapy.
OBJECTIVE: The environment in our intensive care units (ICUs) often serves the convenience of the staff who work in the ICU, rather than the critically ill patients and their loved ones who are, as a family unit, the objects of our care. OBSERVATIONS: Critically ill patients, especially those with high acuity, require close bedside attention. Continuous monitoring, frequent physical evaluations, invasive procedures, and other demands of bedside care are just some of the processes in the ICU that require heightened attention from ICU clinicians. But the fact that we "have a lot to do" at the bedside of critically ill patients has led to an unfortunate environment in many ICUs, one in which the needs of families are not only considered secondary to the convenience of ICU personnel, but are frequently dismissed as burdensome, unreasonable, and even counter to good-quality patient care. Perhaps this is why there are reports in the literature of family concerns about less than satisfactory interactions with ICU clinicians. The attitude we have toward families is an important part of the care we offer to patients in the ICU, and it can have a profound effect on the health of our patients' families. In palliative care circles, it has long been understood that the "unit of care" is both the patient and the family. Although we are moving in that direction in critical care, many ICUs may not always reflect an appreciation of the therapeutic potential or devastating consequences of the attitudes in the ICU. CONCLUSION: The evolution of our understanding of care for critical illness should include a different approach to families and visiting hours in the ICU. One that balances the need of family members to be with their loved ones at a time of critical illness and the need of ICU clinicians to conduct efficient bedside care.
Thrombocytopenia is a common finding in critically ill patients. Heparin-induced thrombocytopenia is an infrequent cause of a low platelet count. Intensivists should use the diagnostic classification system developed by the International Society on Thrombosis and Haemostasis to diagnose heparin-induced thrombocytopenia. The clinical relevance of the presence of anti-heparin/platelet factor 4 complex autoantibodies in the absence of clinical heparin-induced thrombocytopenia remains unknown.