Effect Of Non-pharmaceutical Therapy On Acute Gastrointestinal Injury In Patients Requiring Mechanical Ventilation

Part 1.Efficacy and Safety of Early Rehabilitation on Acute Gastrointestinal Injury during Mechanical Ventilation in Patients with Sepsis----A Pilot Randomized Controlled TrialObjective:To investigate the effect of early rehabilitation on incidence,mitigation and outcome of Acute Gastrointestinal injury(AGI)in septic patients receiving mechanical ventilation.Methods:A randomized controlled trial(RCT)was conducted in ICU patients diagnosed as sepsis and requiring mechanical ventilation from May 2017 to December 2017 in Zhujiang Hospital of Southern Medical University.Patients were block-randomized and designated to either intervention group or control group.Both groups received standard treatment of sepsis.On this basis,early rehabilitation was performed as soon as patients were medical stable in the intervention group.The outcomes measures included the the change of AGI,ICU 28-day mortality,the duration and outcomes of mechanical ventilation as well as the length of ICU stay.Results:A total of 35 patients completed the rehabilitation program,of which 17 cases were in intervention group and 18 cases in control group.The AGI incidences were 94.1%(16/17)in the intervention group and 100%(18/18)in the control group at recruitment,respectively(P>0.05).The AGI scores were significantly decreased after treatment and the differences in AGI scores were(-1.8±0.6)scores in the intervention group and(0.9±0.4)scores in the control group(P<0.05).There were no significant differences between the two groups in the ICU 28-day mortality rate,the duration and outcomes of mechanical ventilation,and the length of ICU stay,etc.(P>0.05).The incidence of physical therapy related adverse event was 3.28%,no severe organ injury or death were reported.Conclusions:The rehabilitation program is of clinical feasibility and safety.Early physical therapy could reduce AGI scores and alleviate gastrointestinal symptoms in patients with sepsis during mechanical ventilation.However,the results should be further verified through well-designed large sample clinical trial.Part 2.Effects of Continuous versus Intermittent Enteral Feeding by Gastric Route on Outcomes in Mechanically Ventilated Patient at High Risk for Acute Gastrointestinal Injury:A Meta-analysisObjective:Nasogastric enteral feeding continued to be a routine care practice in critically ill patients across various Intensive Care Units(ICU).In this study,we investigated the effects of continuous versus intermittent nasogastric enteral feeding on outcomes in mechanically ventilated patients at high risk for acute gastrointestinal injury(AGI).Methods:We searched PubMed,the Cochrane Library and China National Knowledge Infrastructure(CNKI)Numeric Library for randomized controlled trials(RCTs)from February 1981 to May 2017.Data were synthesized and risk ratios calculated to evaluate the effects of nasogastric enteral feeding patterns on enteral nutrition(EN)intolerance,nutrient delivery,ventilator-associated pneumonia(VAP)and ICU mortality.Results:Eight RCTs were included with 529 participants.When compared to continuous feeding,intermittent EN increased the risk for diarrhea(RR = 0.62;95%CI = 0.39 to 0.98;P=0.04),but might reduce constipation(RR = 2.54;95%CI = 1.15 to 5.60;P = 0.02).No differences were found between two feeding patterns in short-term mortality,incidences of VAP,aspiration,vomiting and high gastric residual volumes(HGRVs)(all P>0.05).Conclusions:The limited evidence suggests that nasogastric EN patterns have exerted no influence on clinical outcomes in mechanically ventilated patients at high risk for AGI using either continuous or intermittent nasogastric feeding.Part 3.A Systematic Review of Non-Pharmaceutical Therapy on Acute Gastro-intestinal Injury in Critically Ill Patient Receiving Mechanical VentilationObjective:To investigate the effect of non-pharmaceutical interventions,including enteral nutrition and acupuncture therapy,on incidence,mitigation and outcome of Acute Gastrointestinal injury(AGI)in critically ill patient receiving mechanical ventilation.Methods:A systematic literature search using PubMed,the Cochrane Library and China National Knowledge Infrastructure(CNKI)Numeric Library was conducted.Search was limited to studies on human published in English and Chinese from May 2009 to March 2017.Randomized controlled trials were eligible for systematic review if efficacy of non-pharmaceutical intervention on incidence,mitigation or outcomes of AGI were described.Results:A total of 13 randomized controlled studies were included with 1,593 participants.Interventions adopted in these studies included acupuncture versus regular therapy,gastric versus jejunal enteral nutrition and intermittent bolus versus continuous enteral feeding.Meta-analysis shown that small bowel feeding decreased the rate of ventilator-associated pneumonia(RR = 2.02;95%CI=1.17 to 3.49;P = 0.01;I2=50%).Three researches examined acupuncture therapy and found improved AGI symptoms or signs regarding gastric residual volumes,bowel sounds,abdominal distension or intra-abdominal pressure(P<0.05),Nonetheless,non-pharmacotherapy shown insignificant differences between interventional and control groups in duration of mechanical ventilation,length of ICU stay and ICU mortality.Conclusions:Small bowel feeding reduces the incidence of ventilator-associated pneumonia.Acupuncture attenuates AGI symptoms and improves gastrointestinal function.However,several studies exist high risk of bias,the results should be further verified through large-scale clinical trials.