| Background: nutritional support is an indispensable part of comprehensive treatment for critically ill patients,and it is the clinical consensus that enteral nutrition is the preferred way of feeding critically ill patients.Major guidelines recommend that post-pyloric feeding should be initiated in critically ill patients deemed to be at high risk for aspiration or intolerant of intragastric feeding.However,the implementation of post-pyloric feeding is a challenging task because it is difficult to establish the route of post-pyloric feeding successfully.Recently,prokinetic agent as an adjuvant for post-pyloric placement of spiral nasoenteric tubes has been a pivotal method for establishing the route of post-pyloric feeding in critically ill patients.Erythromycin and metoclopramide are recommended as the first-line prokinetic agents by ICU nutrition guidelines.Metoclopramide's safety and efficacy for post-pyloric placement of spiral nasoenteric tubes have been demonstrated by the previous study in critically ill patients.However,the effect of erythromycin on the post-pyloric placement of spiral nasoenteric tubes in critically ill patients remains controversial.Besides,successfully post-pyloric placement of nasoenteric tubes aims to initiate post-pyloric feeding to reduce the risk of regurgitation and aspiration.However,there is controversy over whether post-pyloric feeding via nasoenteric tubes could prevent VAP in critically ill patients,and few studies focus on neurocritical care patients who are at high risk for VAP.1.Erythromycin versus metoclopramide for post-pyloric spiral nasoenteric tube placement in critically ill patientsObjectives: a prospective,multicenter,open-label,parallel,and non-inferiority randomized controlled trial was performed to explore if erythromycin is non-inferiority to metoclopramide in facilitating post-pyloric placement of spiral nasoenteric tubes in critically ill patients.Methods: metoclopramide was set as the positive control drug and erythromycin as the experimental drug,and the non-inferiority margin was-10%.Patients were randomly assigned to the erythromycin group and the metoclopramide group at 1:1.The primary outcome was procedure success defined as post-pyloric placement(spiral NETs reached the first portion of the duodenum or beyond confirmed by abdominal radiography 24 h after tube insertion).The a priori defined secondary outcome parameters were the success rate of post-D1(reaching the second portion of the duodenum or beyond),post-D2(reaching the third portion of the duodenum or beyond),post-D3(reaching the fourth portion of the duodenum or beyond),and proximal jejunum placement 24 h after tube insertion.The differences in the success rate of post-pyloric placement between the two groups and its 95% CI were adjusted by average risk difference approach.All results in this trial were analyzed based on the intention-to-treat analysis,and the per-protocol analysis was performed for primary and second outcomes.Finally,post-hoc subgroup analysis was performed to explore the differences in placement success rate between the two groups in different population.Results: a total of 332 patients were enrolled,of whom 167 were assigned to the erythromycin group and 165 to the metoclopramide group.In the intention-to-treat analysis,the success rate of post-pyloric placement was 57.5%(96/167)in the erythromycin group and 50.3%(83/165)in the metoclopramide group.The unadjusted difference of the success rate of post-pyloric placement between the two groups and it's 95% CI was 7.2%(-3.5%?17.9%),and the adjusted difference was 7.2%(-3.4%?17.8%).The prespecified margin of-10% was not included in the 95% CI for the difference of the procedure success rate from the metoclopramide group,and one-side P value for the non-inferiority test were both <0.025.Additionally,the results of this trial were reliable because the conclusions were consistent in the intention-to-treat analysis and per-protocol analysis.There were no significant differences between the two groups in post-D1,post-D2,post-D3,and proximal jejunum placement,overall adverse events,placement attempts,tube migration distance and subgroup analysis(P>0.05).Conclusions: erythromycin was non-inferior to metoclopramide in facilitating post-pyloric placement of spiral nasoenteric tubes in critically ill patients,indicating that erythromycin could safely and effectively enhance the success rate of post-pyloric placement of a spiral nasoenteric tube.2.Post-pyloric feeding by spiral nasoenteric tubes for the prevention of VAP in neurocritical care patients.Objectives: a retrospective propensity score matching(PSM)analysis was performed to explore the impact of post-pyloric feeding by the successfully post-pyloric placement of spiral nasoenteric tubes on VAP in neurocritical care patients.Methods: clinical data of neurocritical care patients from the first part trial and our previous randomized controlled trials on the post-pyloric placement of spiral nasoenteric tubes in aid of prokinetic agents were retrospectively analyzed.Patients in the post-pyloric feeding group and gastric feeding group were paired at 1:1 by propensity score matching.Univariate analysis and multivariate logistic regression analysis were employed to explore the independent risk factors of VAP in neurocritical care patients.Furthermore,the VAP differences between patients with various tube tip sites and with different stratification factors were compared.Results: a total of 175 neurocritical care patients who received mechanical ventilation ?48h were enrolled in this study,and 42 patients occurred VAP(24.0%).After PSM,there were both 43 patients in the post-pyloric feeding group and gastric feeding group,and the baseline data were well balanced between the two groups(P>0.05).In the all patient cohort,the VAP rate in the post-pyloric feeding group was significantly lower than gastric feeding group(14.0% vs.28.8%,P=0.032).And the result in the PSM cohort also showed that post-pyloric feeding could reduce the incidence of VAP(11.6% vs.30.2%,P=0.034).Before and after PSM,the multiple Logistic regression showed that post-pyloric feeding was the independent protective factor for reducing VAP rate(OR,0.360;95% CI,0.151?0.857;P=0.021;OR,0.266;95% CI,0.082?0.864;P=0.028).And lower VAP rate appeared on patients with SOFA <12 and AGI grade ?? fed by post-pyloric route according to the results of subgroup analysis(P<0.05).Conclusions: post-pyloric feeding has a possible influence to reduce the incidence of VAP in neurocritical care patients and could be set as a potential measure for the prevention of VAP. |
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