Drug-induced Gastrointestinal Hypomotility and Current Issues on Safety of Prokinetics in Critically Ill Patients

Kim, Hyung Sook

Abstract

Impaired gastrointestinal (GI) motility is extremely common in the intensive care unit (ICU), affecting up to 50% of mechanically ventilated patients and up to 80% of patients with traumatic brain injury. This includes disturbances in esophageal, gastric, small intestinal, and colonic function; alone or in combination. Impaired upper GI motility can lead to reflux, aspiration, vomiting, high gastric residuals, and interruptions in enteral nutrition. In critically ill patients, prolonged constipation may cause delayed weaning from mechanical ventilation, lengthened ICU stay, and inability to take in enteral nutrition; at least one study has suggested an association between delayed defecation and both increased bacterial infections and mortality. Drugs used for analgesia and sedation are commonly associated with impaired gastric and small intestinal motility in critically ill patients. Drugs frequently impair gastric motility via one or more mechanisms, and the precise mechanisms of drug-induced hypomotility are often unknown. Therefore, measures to prevent drug-induced motility disturbances include correction of fluid and electrolyte imbalances, early enteral feeding, and judicious use of drugs known to alter motility. Prokinetic agents are currently the mainstay of therapy for impaired GI motility in the critically ill. Of the available prokinetic agents, current information, while limited, suggests that erythromycin or metoclopramide (alone or in combination) are effective in management of feeding intolerance for the critically ill in terms of evidence-based practice. Based on the current evidence evaluating the adverse effects of prokinetic agents in critical illnesses and the lack of prokinetic agents with a safer adverse effect profile, the ongoing need for prokinetic drugs in these patients should be reviewed daily in order to minimize avoidable adverse effects.