| Part one Qualitative and quantitative assessment of gastric content with bedside ultrasound for healthy volunteersObjective: Pulmonary aspiration of the gastric contents is one of the most feared complications in intensive care unit.A reliable diagnostic tool to assess gastric volume is currently lacking.The aim of this study performed on volunteers was to evaluate the feasibility of ultrasonography to identify qualitative and quantitative gastric content.Methods: A standardized gastric scanning protocol was applied on 40 healthy volunteers to assess the gastric antrum in four different situations: fasting,after ingesting clear fluid 250ml(isotonic group),milk 250ml(milk group)and a solid meal 250g(sandwich group).A qualitative and quantitative assessment of the gastric content in the antrum was performed by a blinded sonographer.The antrum was considered either as empty,or containing clear or thick fluid,or solids.Total gastric volume was predicted based on a cross-sectional area of the antrum.Results: Seventy stomach ultrasound tests were performed on 40 volunteers,5 volunteers were excluded and 35 were analysed.Thirty eight of the 40 tests on fasting volunteers(95%)were considered empty by the examiner.In this case,the antrum appears round to oval and has been compared to a “target” or an image of a “bull's eye”.The gastric content of the 8 volunteers who ingested isotonic solution was considered liquid in 10 volunteers.With the presence of liquid in the stomach,the antrum appears with a distended rounded shape,fine walls and hypoechoic content.After the ingestion of 250 mL of milk,the examiner considered the gastric content as solid in 7 volunteers.With the intake of milk,the gastric antrum appears round and distended.Its contents,however,differ substantially from clear liquid,appearing with increased echogenicity.After ingestion of solid content,the examiner found gaseous content in 8 volunteers.The ingestion of solid food leads to the appearance of an image that resembles “frosted glass”.The result of the quantitative assessment of the gastric content,there was a significant difference between the data obtained from the fasting volunteers and those who ingested isotonic drinks,milk or a sandwich.The gastric volumes(F=10.93,P=0.01)and cross-sectional area(F=11.20,P=0.01)were significantly greater with the intake of any of these substances.There was no significant difference between groups who ingested isotonic drinks,milk or a sandwich(P>0.05).Conclusions: Bedside sonography can determine the nature of gastric content.Such information may be useful to estimate the risk of aspiration,particularly in situations when prandial status is unknown or uncertain.Part two Correlation between gastric antrum area and nasogastric tube aspiration in critically ill patients received enteral nutritionObjective: Enteral tube feed(ETF)intolerance occurs frequently in hospitalized critically ill patients.Most critical care nurses continue to assess gastric residual volume(GRV),especially among those with a history of ETF intolerance.We hypothesized that ultrasound assessment of GRV correlates directly with aspirated tube feed volume.Methods: A prospective study was conducted from January 2017 to December 2017 for patients admitted to an intensive care unit receiving ETF.The gastric antrum was imaged using the aorta and inferior vena cava(IVC)as landmarks concurrently and simultaneously by the same ultrasound group.Patients were scanned daily,up to 4 times a day(depending on sonographer availability),and before scheduled GRV check by nurses for at least 5 days.At our institution,a GRV check is performed every 6 hours,as deemed necessary by the nursing staff.A 50-mL syringe is used to aspirate tube feeds until no feeds are aspirated and charted as “gastric residuals.”Three anteroposterior diameter,craniocaudal(CC)diameter and cross-sectional area(CSA)of the gastric antrum were performed at each site.Meanwhile,the amount of transnasogastric tube aspiration was recorded to analyze the correlation between the above indexes.Results:Data from 52 patients were included in the analysis.Visualization of the gastric antrum was more frequent using the aorta as a landmark compared with the IVC(78%vs.58%),mostly due to overlying bowel gas or intragastric air.When visualized easily,aortic and IVC gastric antrum CSA were correlated tightly and could be used interchangeably(r= 0.98,P<0.001).Gastric antral CSA using IVC as a landmark(r= 0.92,P<0.001)and aorta as a landmark(r= 0.86,P<0001)correlated with aspirated volume.A craniocaudal diameter alone of <10 cm using the aorta as a landmark predicted a gastric volume of <500 ml and a craniocaudal diameter using the aorta as a landmark of <5 cm predicted GRV<150 ml.When imaging was possible,post-aspiration antral CSA was identical to CSA obtained for patients in whom GRV was<10 ml.Conclusions: Ultrasound assessment provides accurate assessment of gastric volume in real-life settings,and the CC diameter of the gastric antrum provides a simple surrogate of GRV.Part three Effect of abdominal massage on the gastric residual volume for critically ill patientsObjective: The main problem of hospitalized patients in intensive care units is feeding,and if the patient does not receive the daily caloric intake required to his body,he will have malnutrition and problems related to it.Abdominal massage is a method used to improve digestive function in various studies,but few studies have been conducted in intensive care units.Therefore,the present study is conducted with the aim of determining the effect of abdominal massage on the gastric residual volume in patients hospitalized in intensive care units.Methods: This study was conducted as a clinical trial from January 2017 to July 2018.Samples were 60 patients hospitalized in intensive care units who were randomly divided into massage and control groups.The intervention period for the case group was 3 days and twice daily for 20 min.Measuring the gastric residual volume was investigated before the intervention and 1 hour after the second massage each day.Results: A total of 87 patients were included in the study,including 45 in the massage group and 42 in the control group.The total GRV before intervention(total GRV in the observation period of 3 days)between the massage group and the control group(125.76 ±53.38 vs.122.67 ±30.53ml)was not statistically significant(t=0.33,P = 0.74).After the intervention,the total GRV in the massage group decreased,while that in the control group increased.The total GRV in the two groups was compared(100.44± 50.25 vs.160.42 ±40.76ml),and the difference was statistically significant(t=6.01,P< 0.01).At different observation times,GRV was compared between the two groups.Before the intervention of abdominal massage on day 1,day 2 and day 3,the GRV values of the two groups were very close,and the differences were not statistically significant(all P>0.05).After the intervention of abdominal massage,GRV in the massage group decreased significantly on day 1(35±14.35 vs.54±20ml,t=5.12,P<0.001),day 2(40±14vs.55±19ml,t=4.21,P<0.001),and day 3(31±16vs.50±18ml,t=5.21,P<0.001)compared with the control group.The difference was statistically significant.Conclusions: Results represent the effect of abdominal massage on reducing the gastric residual volume in patients hospitalized in intensive care units.Therefore,it is suggested that this method can be considered as a caring method in the daily care program for these patients. |
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