The effects of erythromycin on nutrient absorption in critical illness
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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
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
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Background
• Gastrointestinal motility in the critically
ill
• Erythromycin as a prokinetic
• Absorption in the small intestine
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Aims
• Primary– Glucose absorption
• Secondary– Blood glucose– Lipid absorption– Small intestinal transit
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Methods
• Randomised, double-blinded, crossover
study
• Ethics Committee approval
• Written informed consent from next of kin
• ANZCTR number 12610000615088
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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
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Glucose absorption
• 3-O-Methylglucose (3-OMG)
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Lipid absorption
• 13C Triolein
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Small intestinal transit
• Technetium-99m
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Statistics
• Sample size, pilot data
• Power calculation
• Non parametric tests
• Time points – ‘early’ and ‘overall’
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ResultsNumber of patients = 20
Age (years) 53 (20 – 77)
Gender (M:F) 14 : 6
Body Mass Index (kg/m2) 28.7 (20.5 – 42.2)
APACHE II 19 (8 – 38)
Days in ICU 5 (2 -15)
Tolerating feeds (n)YesNo
713
Admission Diagnosis (n) Pneumonia or Sepsis (4)Multi-trauma (4)Cardiac (4)Neurosurgical (2)Other (6)
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Results
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Results
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Results
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Results
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Summary
• Glucose absorption
• Blood glucose level
• Lipid absorption
• Small intestinal transit
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Limitations
• Interim analysis
• Single dose of erythromycin
• Applicability to other nutrients
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Future directions
• Additional number of subjects
• Use of non-antibiotic motilides
• Small intestinal biopsy
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Conclusion
• Erythromycin has no effect on nutrient
absorption in critically ill patients
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Motilin and the MMC
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Nutrient absorption in critical illness
• Disordered flow of chyme
• Impaired mucosal function
• Splanchnic hypoperfusion
• Small intestinal transit time
• Possible reduction in SGLT1
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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
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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)
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Lipid absorption
(Deane, et al Clin Nutr. 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.
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Concerns with erythromycin
• Bacterial resistance
• Cardiac toxicity
• Drug interactions
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Deane, et al.
Critical Care & Resuscitation 2009
Healthy control
Critically ill patient
Delayed gastric emptying in the critically ill
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