the effects of erythromycin on nutrient absorption in critical illness n.
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The effects of erythromycin on nutrient absorption in critical illness. Dr Gerald Wong FANZCA FCICM Gerald Wong, Anna DiBartolomeo , Marianne Chapman, Matthew Summers, Anthony Zaknic , Max Bellon , Anne Maddox, Robert Fraser, Michael Horowitz, Adam Deane

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the effects of erythromycin on nutrient absorption in critical illness

The effects of erythromycin on nutrient absorption in critical illness

Dr Gerald Wong FANZCA FCICM

Gerald Wong, Anna DiBartolomeo, Marianne Chapman, Matthew Summers, Anthony Zaknic,

Max Bellon, Anne Maddox, Robert Fraser, Michael Horowitz, Adam Deane

Intensive Care Unit, Royal Adelaide Hospital

Discipline of Anaesthesia and Intensive Care, University of Adelaide

National Health and Medical Research Council of Australia Centre for Clinical Research and Excellence in Nutritional Physiology and Outcomes, Adelaide, South Australia

Department of Nuclear Medicine, Royal Adelaide Hospital

background
Background
  • Gastrointestinal motility in the critically ill
  • Erythromycin as a prokinetic
  • Absorption in the small intestine
slide3
Aims
  • Primary
    • Glucose absorption
  • Secondary
    • Blood glucose
    • Lipid absorption
    • Small intestinal transit
methods
Methods
  • Randomised, double-blinded, crossover study
  • Ethics Committee approval
  • Written informed consent from next of kin
  • ANZCTR number 12610000615088
methods1
Methods
  • Study Drug = Erythromycin 200mg or Placebo from t = -20 mins to 0 min
  • Study feed = 60mls Ensure from t = 0 min to t = 30 mins
  • * Blood sample for measurement of 3-OMG and Glucose
  • # Breath sample for measurement of Triolein absorption
glucose absorption
Glucose absorption
  • 3-O-Methylglucose (3-OMG)
lipid absorption
Lipid absorption
  • 13C Triolein
statistics
Statistics
  • Sample size, pilot data
  • Power calculation
  • Non parametric tests
  • Time points – ‘early’ and ‘overall’
summary
Summary
  • Glucose absorption
  • Blood glucose level
  • Lipid absorption
  • Small intestinal transit
limitations
Limitations
  • Interim analysis
  • Single dose of erythromycin
  • Applicability to other nutrients
future directions
Future directions
  • Additional number of subjects
  • Use of non-antibiotic motilides
  • Small intestinal biopsy
conclusion
Conclusion
  • Erythromycin has no effect on nutrient absorption in critically ill patients
nutrient absorption in critical illness
Nutrient absorption in critical illness
  • Disordered flow of chyme
  • Impaired mucosal function
  • Splanchnichypoperfusion
  • Small intestinal transit time
  • Possible reduction in SGLT1
inclusion eligibility
Inclusion eligibility
  • Patients admitted to a tertiary referral ICU
  • Aged 18 years or older
  • Likely to remain mechanically ventilated > 72 hours
  • Receiving or suitable to receive post-pyloric enteral nutrition
exclusion criteria
Exclusion criteria
  • Pregnancy
  • Contraindication to enteral feeding
  • Previous surgery on the oesophagus, stomach , or duodenum
  • History of diabetes mellitus
  • Contraindication to opiate sedation
  • Receiving erythromycin at antimicrobial dose
  • Liver dysfunction (ALT > 3x ULN)
lipid absorption1
Lipid absorption

(Deane, et al ClinNutr. 2010)

Potential for intrasubject variability and/or inaccuracy using isotope breath tests in the critically ill. Measurement inaccuracies may occur because of impairment of (1) absorption or (2) hepatic metabolism, as well as (3) variations in endogenous CO2 production.

concerns with erythromycin
Concerns with erythromycin
  • Bacterial resistance
  • Cardiac toxicity
  • Drug interactions
delayed gastric emptying in the critically ill
Delayed gastric emptying in the critically ill

Healthy control

Critically ill patient

Deane, et al.

Critical Care & Resuscitation 2009