Effects of combined prokinetic administration on gastric emptying in critically ill patients

Background and study aims: Combination of prokinetic drugs with different mechanisms of action is frequently used when feeding intolerance is not improved with a single agent. In this study, we evaluated the effect of combined infusion of neostigmine and metoclopramide on gastric passage in critically ill patients in the intensive care unit (ICU). Patients and methods: This study is a randomized double-blind controlled trial in 90 patients between 20 and 60 years of age who were under mechanical ventilation and had gastric residual volumes (GRVs) > 120 mL 3 h after the last lavage. Patients were randomly assigned to one of the following three groups: intravenous neostigmine 2.5 mg, intravenous metoclopramide 20 mg, and combination of both agents at the mentioned doses. Gastric volume aspiration was first performed before starting the study and then at 3, 6, 9, and 12 h after the infusion of study drugs was finished. Increase in gastric lavage was defined as an aspiration volume of > 120 mL. Results: In total, 86 cases in the three groups completed the treatment (all 90 patients included in the study were analysed according to an intention-to-treat approach). There was no significant difference detected at baseline in age, intubation duration, albumin, haemoglobin, haematocrit, total leucocytic count (WBC), Na, K, Mg, and sequential organ failure assessment score between the study groups. In the combination group, 96.7% of patients showed GRV improvement (GRV < 120 cc), whereas in the metoclopramide and neostigmine groups, 50% and 43.3% of the patients, respectively, showed improvement (p < 0.001). The frequency of overall adverse effects in the metoclopramide, neostigmine, and combination groups were 3.3%, 16.7%, and 10%, respectively (p = 0.28). Conclusions: The present results suggested that combination therapy with metoclopramide and neostigmine decreases GRV in critically ill patients with a higher efficacy than monotherapies. (C) 2017 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.