{"id":668,"date":"2013-03-01T15:47:21","date_gmt":"2013-03-01T20:47:21","guid":{"rendered":"https:\/\/med.virginia.edu\/ginutrition\/?p=668"},"modified":"2026-06-01T20:11:47","modified_gmt":"2026-06-02T00:11:47","slug":"march-2013-e-journal-club","status":"publish","type":"post","link":"https:\/\/med.virginia.edu\/ginutrition\/2013\/03\/01\/march-2013-e-journal-club\/","title":{"rendered":"March 2013 E-Journal Club"},"content":{"rendered":"

Greetings,<\/strong><\/p>\n

March came in like a lion, with our biggest snowfall of the year, but fortunately most of the snow was gone in time for the arrival of our Weekend Warrior Program.\u00a0 We had a super group here for the March 16-17th Weekend Warrior program.\u00a0 We like meeting our peers from around the county, and when everyone contributes and asks questions, it makes it more enjoyable for everyone participating.<\/p>\n

February Citation:<\/strong><\/p>\n

Mancl EE, Muzevich KM.\u00a0 Tolerability and Safety of Enteral Nutrition in Critically Ill Patients Receiving Intravenous Vasopressor Therapy.\u00a0 JPEN 2013 Jan 17 [epub ahead of print].<\/p>\n

Summary:\u00a0<\/strong><\/p>\n

This was a retrospective, observational study using the electronic medical record for a 1 year period of 259 patients who simultaneously received enteral nutrition (EN) and an intravenous vasopressor medication.\u00a0 The primary outcome of this study was EN tolerance, as defined by the absence of: gastric residuals \u2265300 mL, emesis, positive finding on KUB or abdominal CT, and bowel ischemia\/perforation.\u00a0 The secondary outcomes included rates of adverse events, charac\u00adterization of IV vasopressor dosages during overlap episodes, and mortality rates. The investigators looked for any potential relationship between administration of a given IV vasopressor as well as vasopressor dose and EN tolerability. \u00a0Additional medical, demographic and nutrition data were collected as mentioned in the results section.\u00a0 Vasopressor dosages were converted to norepinephrine equivalents = [norepinephrine (mcg\/min)] + [dopamine (mcg\/kg\/min) \u00f7 2] + [epinephrine (mcg\/min)] + [phenylephrine (mcg\/min) \u00f7 10] + [vasopressin (units\/h) \u00d7 8.33].<\/p>\n

The authors also provided details of the clinical course of the 3 patients that developed ischemic bowel during this observational study \u2013 I recommend reading the full text of this study for the valuable points made in the paper, and for full information on the cases.<\/p>\n

Inclusion and Exclusion Criteria were:<\/strong><\/p>\n

Inclusion criteria<\/em>:<\/p>\n

Patients with a charted EN volume while receiving an IV vasopressor (dopamine, epinephrine, norepinephrine, phenylalanine, and\/or vasopressin.)<\/p>\n

Exclusion criteria<\/em>:<\/p>\n

Age \u226418 years old and were treated in a pedi\u00adatric or neonatal ICU, overlap of EN and IV vasopressor \u22641 hour, or if data were identified as missing or incomplete during chart review.<\/p>\n

Major Results:<\/strong><\/p>\n

The review identified 346 episodes of feeding\/vasopressor overlap in 259 patients (some patients had reoccurrences of episodes of feeding with vasopressors).\u00a0 There were 259 cases of EN tolerance, and 87 episodes of patients meeting the study definition of feeding intolerance while receiving vasopressor medications.\u00a0 The average blood pressure during overlap was similar between groups.<\/p>\n

Emesis occurred in 31 (9.0%), elevated gastric residuals (\u2265300 mL) in 50 (14.5%) and increased serum lac\u00adtate in 106 (30.6%) overlap episodes.\u00a0 Serum lactate only rose to >2mmol\/L in half of the patients with elevated lactate, and the maximum lactate during overlap was not significantly different between groups. \u00a0Abdominal radiograph (KUB) was obtained in 11.9% and CT in 4% of overlap cases, with 36.6% of the abdominal KUBs and 0.9% of the abdominal CTs reported to have positive findings for intolerance (ileus, small bowel obstruction, or signs of bowel ischemia\/perforation).<\/p>\n

There were 3 cases of bowel isch\u00ademia\/perforation identified (0.12% of patients)<\/p>\n

A dose-response relationship was observed between maxi\u00admum norepinephrine equivalent and likelihood of tolerating EN. \u00a0Patients who tolerated EN received a lower maxi\u00admum norepinephrine equivalent dose compared with those who did not tolerate EN (12.5 vs 19.4 mcg\/min, p<\/em> = 0.0009).\u00a0 Patients who were never pre\u00adscribed vasopressin during the overlap episode were more likely to tolerate EN compared with those who received vaso\u00adpressin (77.9% vs. 58.9%, p<\/em> = 0.0027).\u00a0 Patients who never received dopamine tolerated EN more frequently than those who received dopamine (77.6% vs. 63.8%, p<\/em> = 0.018), and patients who received phenyleph\u00adrine were more likely to tolerate EN compared with those who did not receive phenylephrine (100.0% vs. 73.0%, p<\/em> = 0.0023).\u00a0 None of these associations were dose related.\u00a0 Patients who tolerated EN were less likely to receive a promotility agent compared with those who did not tolerate EN (15.0% vs. 44.0%, p<\/em> < 0.0001).<\/p>\n

The median duration of feeding\/vasopressor over\u00adlap was significantly shorter in the group that tolerated EN (26 vs. 65 hours, p<\/em> = 0.0002) and the mean caloric intake was higher in the group that had objective tolerability (13.6 vs. 10.9 kcal\/kg\/d, p<\/em> = 0.0034). \u00a0The univariate analysis showed that patients who tolerated EN were less likely to experience a rise in serum lactate com\u00adpared with those who did not tolerate EN (25.5% vs. 46.0%, p<\/em> = 0.0003), however, serum lactate was not significantly associated with intolerance in multivariate analysis.<\/p>\n

Author\u2019s Conclusions:<\/strong><\/p>\n

\u201cEN is relatively well tolerated in patients receiving IV vasopressor support equivalent to 12.5 mcg\/min of norepinephrine or less. Tolerability was less likely in patients receiving higher doses of IV vasopressors and in those receiving dopamine or vasopressin. These patients should be monitored more closely for signs of intolerance. In summary, critically ill patients receiving IV vasopressor sup\u00adport generally tolerate EN.\u201d<\/p>\n

Evaluation:<\/strong><\/p>\n

This study is valuable because it adds to the very limited pool of data about the interaction between patients that receive vasopressor medications and EN.\u00a0 However, as the authors point out in the discussion section, it is a retrospective study design with inherent selection bias.\u00a0 Results of associations should not be used to imply causality and, as the authors state, \u201care meant to be hypothesis generating and ideally would lend support for a prospective study.\u201d\u00a0 The significant association between use of prokinetic medications and feeding intolerance reported by this study is one example where it is intuitive that the medication is unlikely to have caused the intolerance. \u00a0It is important to remember that any association between feeding intolerance and vasopressor medication may also not be cause-and-effect.<\/p>\n

One issue that we discussed is the use of relatively physiologic amounts of gastric residuals (300 mL) as an indicator feeding intolerance, and the possibility that some patients that were classified as intolerant may actually have been fine.\u00a0 Certainly a 305 mL residual by itself would generally not be considered in the same category of feeding intolerance as bowel ischemia or perforation.\u00a0 It would be helpful to see potential feeding intolerance (elevated residuals) separated from negative clinical outcomes.<\/p>\n

The case reports of the patients that had ischemic bowel are remarkable in that all of the patients were reportedly receiving intragastric feeding, in contrast to most other case reports.\u00a0 As mentioned above, these are worth reading in full.<\/p>\n

Our Take Home Message (s)<\/strong><\/p>\n

Most patients that are hemodynamically stable and receiving modest doses of vasopressor medications tolerate EN.<\/p>\n

The association between a particular dose of vasopressor medication and feeding tolerance needs to be tested in randomized studies before being worked into clinical guidelines, etc.<\/p>\n

\u00a0<\/strong><\/p>\n

Other News on the UVAHS GI Nutrition Website:<\/u><\/em><\/strong> (www.ginutrition.virginia.edu<\/a>):<\/strong><\/p>\n

Upcoming Webinars:<\/strong><\/p>\n

–Tuesday, April 16th–Considerations for Nutrition Support in the Adult Cystic Fibrosis Patient–Christie Rogers, MS, RD, CNSC<\/p>\n

–Tuesday, May 14th–The Role of Fiber in Nutrition Support–Joe Krenitsky, MS, RD<\/p>\n

–Tuesday, June 18th–Nutrition Management of Food Allergies in the Pediatric Patient–Brandis Roman, RD<\/p>\n

Check out What\u2019s New<\/strong>:<\/p>\n

–\u201c Resources for the Nutrition Support Clinician<\/a>\u201d<\/p>\n

Latest Practical Gastroenterology article<\/strong>:<\/p>\n

–Carey, S.\u00a0 Bone Health After Major Upper Gastrointestinal Surgery. Practical Gastroenterology 2013;XXXVII(3):46.<\/p>\n

Joe Krenitsky MS, RD<\/p>\n

Carol Rees Parrish MS, RD<\/p>\n

PS \u2013 Please feel free to forward on to friends and colleagues.<\/em><\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"

Greetings, March came in like a lion, with our biggest snowfall of the year, but fortunately most of the snow was gone in time for the arrival of our Weekend Warrior Program.\u00a0 We had a super group here for the March 16-17th Weekend Warrior program.\u00a0 We like meeting our peers from around the county, and […]<\/p>\n","protected":false},"author":208,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":"","_links_to":"","_links_to_target":""},"categories":[6],"tags":[17],"class_list":["post-668","post","type-post","status-publish","format-standard","hentry","category-ejournal","tag-delete"],"acf":false,"yoast_head":"\nMarch 2013 E-Journal Club - GI Nutrition Support Team<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/med.virginia.edu\/ginutrition\/2013\/03\/01\/march-2013-e-journal-club\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"March 2013 E-Journal Club - 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