Gastrointestinal motility disorders in Critically ill patients

Gastrointestinal motility disorders in Critically ill patients: 

Gastrointestinal motility disorders in Critically ill patients Ubaidur Rahaman Senior Resident, Critical Care Medicine, SGPGIMS, Lucknow, India

GI MOTILITY- PHYSIOLOGY: 

GI MOTILITY- PHYSIOLOGY reflex wave of contraction in oro-caudal direction in response to stretching of wall by luminal content spontaneous rhythmic fluctuation in membrane potential. Initiated by stellate muscle like pacemaker cells . function is to co ordinate peristaltic activity. during fasting, cycles of motor activity migrate from stomach to distal ileum. Immediately stopped on ingestion of food. Each MMC consists of Phase I- quiescent period Phase II- irregular contraction Phase III- burst of regular contraction Function unsettled Probably clears stomach and small intestine of luminal contents in preparation for next meal. Peristalsis Basal electrical activity (BEA) Migrating motor complex

GI MOTILITY- PHYSIOLOGY GASTRIC EMPTYING: 

GI MOTILITY- PHYSIOLOGY GASTRIC EMPTYING

FACTORS AFFECTING GASTRIC EMPTYING: 

FACTORS AFFECTING GASTRIC EMPTYING Increasing age and female gender- delayed gastric emptying Volume - more volume – more rapid emptying caloric density/ unit volume - high caloric density – slow gastric emptying Tightly controlled Nutrient delivery- 200 Kcal/ h ( 2-3 Kcal/min) into duodenum osmolality - high osmolalty- slow gastric emptying nutrient content- carb> protien>fat Intragastric pH- omeprazole delays gastric emptying Temperature - low tempreature- delays gastric emptying Physio. Res. 2003;1-30 neurohumoral control of gastrointstinal motility . MB Hansen FOOD

CONTROL AND REGULATION OF GI MOTILITY: 

CONTROL AND REGULATION OF GI MOTILITY Cholecystokinin (CCK), peptide tyrosine tyrosine (P YY), motilin, glucagon like peptide (GPP 1) fundal relaxation and inhibit gastric emptying Dopamine decreases gastric emptying and intestinal peristalsis Motilin amplifies and induces MMC activity Opioids and serotonin ( 5HT) ENS--↔-ANS--↔-CNS Hormonal factors Neural factors

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absent phase III MMC activity delayed fundal relaxation, prolonged recovery Reduced antral motility increased isolated pyloric activity Diminished functional association between proximal and distal gastric motility Gastroparesis GI MOTILITY DYSFUNCTION IN CRITICALLY ILL PATHOPHYSIOLOGY stomach

World J Gastroenterol 2006 July 21; 12(27): 4383-4388 Proximal gastric response to small intestinal nutrients is abnormal in mechanically ventilated critically ill patients Nguyen N, Fraser R, Chapman M, Bryant R, Holloway R, Vozzo R, Feinle-Bisset: 

World J Gastroenterol 2006 July 21; 12(27): 4383-4388 Proximal gastric response to small intestinal nutrients is abnormal in mechanically ventilated critically ill patients Nguyen N, Fraser R, Chapman M, Bryant R, Holloway R, Vozzo R, Feinle-Bisset proximal gastric relaxation is delayed fundic wave activity is reduced the recovery of proximal gastric volumes to pre-stimulation levels is delayed. GI MOTILITY DYSFUNCTION IN CRITICALLY ILL PATHOPHYSIOLOGY

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Gut 2005;54:1384-1590 Antro-pyloro-duodenal response to gastric and duodenal nutrient in the critically ill patients . Chapman M, Fraser R, Vozzo R, Bryant L, Tam W, Nguyen N, Zacharakis B, Butler R, Davidson G, Horowitz M. Manometric tracing during duodenal feeding Absence of antral activity and frequent isolated pyloric pressure waves GI MOTILITY DYSFUNCTION IN CRITICALLY ILL PATHOPHYSIOLOGY Abnormal antro-pyloro-duodenal response

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Crit Care Med 2007; 35: 82-88 intolerance in critical illness is associated with increased basal and nutrient-stimulated plasma cholecystokinin concentrations . Nguyen N, Fraser R, Chapman M, Bryant L, Holloway R, Vozzo R, Wishart J, Feinle-Bisset C, Horowitz M. GI MOTILITY DYSFUNCTION IN CRITICALLY ILL PATHOPHYSIOLOGY P <0.01 Plasma CCK concentration during fasting and duodenal stimulation

Intensive Care Med 2008; 34:1246–1255 Diminished functional association between proximal and distal gastric motility in critically ill patients. Nguyen NQ, Fraser RJ, Bryant LK, et al. : 

Intensive Care Med 2008; 34:1246–1255 Diminished functional association between proximal and distal gastric motility in critically ill patients. Nguyen NQ, Fraser RJ, Bryant LK, et al. GI MOTILITY DYSFUNCTION IN CRITICALLY ILL PATHOPHYSIOLOGY Fundic waves(FW) and propagated antral waves(PAW) during fasting and duodenal nutrient stimulation Changes in gastric volume during nutrient infusion In critical illness association between proximal and distal gastric motility is abnormal

GI MOTILITY DYSFUNCTION IN CRITICALLY ILL PATHOPHYSIOLOGY: 

GI MOTILITY DYSFUNCTION IN CRITICALLY ILL PATHOPHYSIOLOGY Reduced flushing of nutrient content MMC disorganization: phase I- increased, phase II- decreased, phase III- retrograde Pseudo-obstruction (Ogilivie syndrome) Increased retrograde activity Persistence of MMC phase III during feeding ileus Current Opinion in Clinical Nutrition and Metabolic Care 2009, 12:161–167 Motility disorders in the ICU: recent therapeutic options and clinical practice Kerstin D. Rohm, Joachim Boldt, Swen N. Piper. Small intestine Colon

GI MOTILITY DYSFUNCTION IN CRITICALLY ILL ETIOLOGY AND RISK FACTORS : 

GI MOTILITY DYSFUNCTION IN CRITICALLY ILL ETIOLOGY AND RISK FACTORS Surgery Abdominal, head or spinal Drugs Glucose or fluid imbalance Acid- base or electrolyte imbalance Hypoxaemia Hypoperfusion- systemic or regional SIRS/ Sepsis

GI MOTILITY DYSFUNCTION IN CRITICALLY ILL ETIOLOGY AND RISK FACTORS : 

GI MOTILITY DYSFUNCTION IN CRITICALLY ILL ETIOLOGY AND RISK FACTORS SURGERY Cannon WB, Murphy FT: The movement of the stomach and intestine in some surgical conditions . Ann Surg 1906 , 43:512–536. mechanism NEURONAL Local manipulation ↑ NO from inhibitory motor neurons ↑VIP HUMORAL Macropahage/ monocytes ↑NO, PGs

GI MOTILITY DYSFUNCTION IN CRITICALLY ILL ETIOLOGY AND RISK FACTORS: 

Anesthetics - halothane sedatives - midazolam, propofol analgesics- opioids, ketamine Catecholamines alpha agonists- clonidine, dexmedetomidine Calcium channel blockers Proton pump inhibitors GI MOTILITY DYSFUNCTION IN CRITICALLY ILL ETIOLOGY AND RISK FACTORS Drugs

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Opioids Fundal relaxation Reduced antral contraction Reduced MMC phase III Ketamine seems to have no advantage over fentanyl Schmittner, Vajkoczy, Horn. Effects of fentanyl and S(+) ketamine on cerebral hemodynamics, gastrointestinal motility and need for vasopressors in patients with intracranial pathology: apilot study. J neurosurg Anesthesiol Propofol showed beneficial gut effects over midazolam. Nguyen NQ, Chapman MJ, Fraser RJ, et al. The effects of sedation on gastricemptying and intra-gastric meal distribution in critical illness. Intensive Care Med 2008; 34:454–460 GI MOTILITY DYSFUNCTION IN CRITICALLY ILL ETIOLOGY AND RISK FACTORS

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Hyperglycemia: Gastric feeding was equally successful in diabetics as in non diabetics Nguyen NZ et al. Gastric feed intolerance is not increased in critically ill patients with type II diabetes. Inten Car Med 2007;33:1740-1745 Normoglycemia attained by intensive insulin therapy seems to minimize feed intolerance in critical illness. Nguyen et al. the relationship between blood glucose control and intolerance to enteral feeding during critical illness. Inten Car Med 2007;33:2085-2092 Vasopressors decreased antral contractions and orocaecal transit and longer ICU length of stay Dive A, Foret F, Jamart J, et al. Effect of dopamine on gastrointestinal motility during critical illness. Intensive Care Med 2000; 26:901–907. GI MOTILITY DYSFUNCTION IN CRITICALLY ILL ETIOLOGY AND RISK FACTORS

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Liberal fluid balance prolongs the duration of motility disturbances and is associated with longer latency to first gastric emptying and first passage of flatus and stool as well as to hospital discharge. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lobo DN, Bostock KA, Neal KR,Perkins AC, Rowlands BJ, Allison SP. Lancet 2002;359:1812–1818 Effect of intraoperative fluid management on outcome after intraabdominalsurgery. Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S, Matot I. Anesthesiology 2005; 103:25–32 Neuromuscular blockers do not affect GI motility. Gastric emptying in mechanically ventilated critically ill patients: effect of neuromuscular blocking agent. Tamion F, Hamelin K, Duflo A et al. Intensive Care Med 2003;29:1717-22. GI MOTILITY DYSFUNCTION IN CRITICALLY ILL ETIOLOGY AND RISK FACTORS Dehydration and or hypovolemia may be associated with post operative GI dysfunction and that increased perioperative fluid administration has been associated with improved indices of gut perfusion and reduced PGID Goal-directed intraoperativefluid administration reduces length of hospital stay after major surgery. Gan TJ, Soppitt A, Maroof M, et al. Anesthesiology 2002;97:820–6 . Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery . Mythen MG, Webb AR. Arch Surg 1995;130:423–9 . Fluid balance

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Diabetes, thyroid disorders neurological disorders, Collagen vascular disorders Functional GI motility disorders Alcohol nicotine Regular use of laxative GI MOTILITY DYSFUNCTION IN CRITICALLY ILL ETIOLOGY AND RISK FACTORS Co morbidity Substance abuse

ASSESSMENT OF GI DYSMOTILITY: 

ASSESSMENT OF GI DYSMOTILITY Gastroparesis Gastric residual volume (GRV) Ileus Bowel sounds defecation tolerance of EN pain and/ or distention, physical exam- distended, tense abdomen, raised IAP passage of flatus and stool, abdominal radiographs Physiological stool frequency 1-2 evacuations/ day to 1 evacuation Q3-4 day evidence of bowel motility is not required to initiate enteral feeding

ASSESSMENT OF GI DYSMOTILITY: 

ASSESSMENT OF GI DYSMOTILITY weak relationship with gastric emptying Depends on position of tube, tube collapsibility, tube size, volume of syringe used Operator performing the test 25% patients with GRV >150ml have normal gastric emptying and do not require prokinetic In patients with normal gastric emptying GRV- 232-464 ml during enteral feeding @ 25-125ml/hr two large studies in critically ill patients most GRVs <150 ml Crit Care Clin 26 (2010) 481–490 Gastric Residual Volumes in Critical Illness: What Do They Really Mean? Ryan T. Hurt, Stephen A. McClave. GRV

MANAGEMENT: 

MANAGEMENT in critically ill patients mechanism underlying dysmotility are usually complex Relative contribution of control systems to regulation of GI motility varies along the alimentary canal and disease nature and course Propulsive motility occurs only when there is co-coordinated pattern of contraction and relaxation along the length of gut It is unrealistic one single drug alone is able to promote propulsive motility over entire GI tract

DRUGS: 

DRUGS PROKINETIC metocloperamide, Domperidone, Cisapride, Itopride OPIOID ANTAGONIST Naloxone, Alvimopan, methylnaltrexone MOTILIN AGONIST Erythromycin AChE INHIBITOR Neostigmine 5HT4 AGONIST tegaserod

PROKINETIC DRUGS : 

PROKINETIC DRUGS IV administration is more potent than oral Effect to facilitate gastric emptying and improving tolerance to enteral feeding has been confirmed in 2 RCTs Effect on colonic transit time is controversial Lack beneficial effect in post op ileus Microbial resistance no evidence that short term, low dose regimen of erythromycin increases resistence QT prolongation risk increases above plasma level approx 30 mg/ml. this is above level which can be achieved by 100 mg ivi dose. Caution has to be taken in cardiomypathy, CHF, CAD, AFib, bradycardia, hypokalemia, hypomagnesemia ERYTHROMYCIN

PROKINETIC DRUGS : 

Effect limited to upper GI tract, no effect on large bowel Beneficial effect on GI transit and enteral feed tolerance when give IV, ineffective when given TNG. 87, 88, 89 Duration of post op ileus remains unaltered.90,91 Effect remains controversial Found to be ineffective in post op ileus at dose 0.5 mg IMI Q3H total 3 doses.96 Prompt colonic decompression following orthopedics surgery at dose 2 mg IVI. 97 Acute colonic pseudo obstruction- 2-2.5 mg ivi over 3-3- min caused resolution with a success rate of 80-90%. PROKINETIC DRUGS METOCLOPERAMIDE NEOSTIGMINE may be beneficial in GI motor disturbances that are unrelated to opiate use NALOXONE

PROKINETIC DRUGS : 

Release of ACh by metocloperamide+ inhibition of breakdown by neostigmine Dose should be kept in indicated range and duration of infusion limited to 2 hours. Adverse effects Symptomatic bradycardia Increased tracheo-bronchial secretions and salivation Tracheal suction should be avoided- additional vagal stimulation Contra indication Mechanical bowel obstruction, gastrointestinal ischemia or perforation, pregnancy, uncontrolled arrhythmias, severe bronchospasm PROKINETIC DRUGS Combination of metocloperamide and neostigmine

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Computerized bibliographic search of published research (1980-2001) Crit Care Med. 2002 Jul;30(7):1429-35. Gastrointestinal promotility drugs in the critical care setting: a systematic review of the evidence Booth CM , Heyland DK , Paterson WG reviewed 60 citations; 18 articles met the inclusion criteria 6 studies of feeding tube placement, 11 studies evaluating gastrointestinal function one study of clinical outcomes) As a class of drugs, promotility agents appear to have a beneficial effect on GI motility in critically ill patients. A one-time dose of erythromycin may facilitate small-bowel feeding tube insertion. metoclopramide appears to increase physiologic indexes of gastrointestinal transit and feeding tolerance. Concerns about safety and lack of effect on clinically important outcomes preclude strong treatment recommendations REVIEW OF LITERATURE

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Prospective, randomized, controlled trial. Crit Care Med. 2007 Feb;35(2):483-9. Erythromycin is more effective than metoclopramide in the treatment of feed intolerance in critical illness. Nguyen NQ , Chapman MJ , Fraser RJ , Bryant LK , Holloway RH . 90 mechanically ventilated, medical patients with feed-intolerance (GRV ≥250 ml). Given either metoclopramide 10 mg ivi Q6H (n=45) or erythromycin 200 mg ivi Q12H (n=45). After the first dose, NG feeding commenced Q6H NG aspirates performed If GRV>or=250 ml, open-label, combination therapy was given. Duration of study- 7 days. Successful feeding-6-hourly GRV<250 mL with a feeding rate>or=40 mL/hr REVIEW OF LITERATURE …continued

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Erythromycin is more effective than metoclopramide in treating feed intolerance But rapid decline in effectiveness renders both treatments suboptimal. Rescue combination therapy is highly effective further study is required to examine its role as the first-line therapy Kaplan Meier plots comparing the effects Crit Care Med. 2007 Feb;35(2):483-9. Erythromycin is more effective than metoclopramide in the treatment of feed intolerance in critical illness. Nguyen NQ , Chapman MJ , Fraser RJ , Bryant LK , Holloway RH .

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Prospective, randomized, controlled trial. Crit Care Med 2007; 35(11). Prokinetic therapy for feed intolerance in critical illness: one drug or two? Nguyen N, Chapman, M, Fraser, R, Bryant, L, Holloway, RH Seventy-five mechanically ventilated, medical patients with feed intolerance (GRV >250 mL). combination therapy- erythromycin 200mg ivi Q12H + metoclopramide 10mg ivi Q6H (n 37) OR erythromycin alone (n 38) Gastric feeding was re-commenced 6-hourly NG aspirates performed. Duration of study- 7 days Successful feeding - GRV<250 mL with the feeding rate >40 mL/hr REVIEW OF LITERATURE …continued

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combination therapy with erythromycin and metoclopramide is more effective should be considered as the first-line treatment. Tachyphylaxis was less with combination therapy. no difference in the length of hospital stay or mortality rate Watery diarrhea was more common with combination therapy but was not associated with enteric infections, including Clostridium difficile . P <0.01 vs erythromycin Crit Care Med 2007; 35(11). Prokinetic therapy for feed intolerance in critical illness: one drug or two? Nguyen N, Chapman, M, Fraser, R, Bryant, L, Holloway, RH

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Prospective, randomized, controlled trial. Crit Care Med. 2000 May;28(5):1408-11 . Metoclopramide for preventing pneumonia in critically ill patients receiving enteral tube feeding: a randomized controlled trial. Yavagal DR , Karnad DR , Oak JL total of 305 consecutive patients requiring placement of a nasogastric tube for >24 hrs. Metoclopramide delayed the development of nosocomial pneumonia, But it did not decrease its frequency rate No effect on the mortality rate in critically ill patients receiving NG feeding. REVIEW OF LITERATURE

ALGORYTHM FOR TREATMENT OF GI DYSMOTILITY: 

ALGORYTHM FOR TREATMENT OF GI DYSMOTILITY Early use of supportive therapeutic options Stimulant and osmotic laxative Reduced use of drugs with inhibitory effect onGI motility Goal directed specific therapy- PROKINETICS Opioid receptor antagonist gastroparesis gastroparesis and Intestinal motor inhibition intestinal motor inhibition without gastroparesis Clin Nutr 2008; 27:25–41 Standardized concept for the treatment of gastrointestinaldysmotility in critically ill patients:current status and future options. Herbert MK, Holzer P..

ALGORYTHM FOR TREATMENT OF GI DYSMOTILITY: 

ALGORYTHM FOR TREATMENT OF GI DYSMOTILITY Opioid receptor antagonist Naloxone 3-12 mg PO Q8h Impaired gastric emptying 1 st line Erythromycine 100 mg ivi Q8H for 3 days 2 nd line Metocloperamide 10 mg ivi 3 rd line Domperidone 30-40 mg PO Gastroparesis and impaired intestinal motility 1 st line Erythromycin 100 mg ivi Q8H for 3 days After 24 hours Metocloperamide + neostigmine 10-30 mg ivi + 0.5-1.5 mg ivi Q24H (in 250 ml NS over 1-2 hours) Impaired intestinal motility without gastroparesis 1 st line Ceruletide 40 g ivi Q24H ( in 100 ml NS over 30-60 min) Metocloperamide + Neostigmine 10-30 mg ivi + 0.5-1.5 mg ivi Q24H (in 250 ml NS over 1-2 hours Clin Nutr 2008; 27:25–41 Standardized concept for the treatment of gastrointestinaldysmotility in critically ill patients: current status and future options. Herbert MK, Holzer P

SPECIAL CONSIDERATION FOR USE OF PROKINETICS: 

SPECIAL CONSIDERATION FOR USE OF PROKINETICS Reduce dose Opioids, sedatives, alpha agonist and catecholamines as soon and as much possible Only one stimulation per day Dose should not be increased Tachyphylaxis, increased stimulation- tetany If no benefit over use of several consecutive days Holiday of 1 day Clin Nutr 2008; 27:25–41 Standardized concept for the treatment of gastrointestinaldysmotility in critically ill patients: current status and future options. Herbert MK, Holzer P

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Check GRV Q4h GRV>400 ml Continue EN at the current rate right lateral decubitus position for 30 minutes Metocloperamide 10 mg, ivi Q6h; naloxone 8 mg in 10 ml saline TNG Q6h >400 ml- hold NG feed GRV<500 ml- return feed to patient Recheck GRV in 4 hours Recheck GRV every 2 hours GRV < 400 ml- restart NG feeding intolerance consider reducing rate by 25 mL/h or to baseline of 25 mL/h Tolerance restart at same rate recommendations for using GRV in an enteral nutrition protocol Crit Care Clin 26 (2010) 481–490 Gastric Residual Volumes in Critical Illness: What Do They Really Mean? Ryan T. Hurt, Stephen A. McClave.

FUTURE PHARMACOLOGICAL OPTIONS: 

FUTURE PHARMACOLOGICAL OPTIONS 5 HT receptor agonist Levosulpiride Renazapride CCK receptor antagonist Cerulein Dexloxiglumide Motilin agonist Alemicinal, Mitemcinal Gherlin receptor agonist TZP-101

PROKINETICS WITHDRAWN FROM MARKET: 

PROKINETICS WITHDRAWN FROM MARKET Itopride lack of efficacy, further development stopped in 2006 by Axcan Pharma Available in Japan, few European countries, India Tegaserod ischemic colitis, cardio toxicity, withdrawn in US in 2007, available in some European countries

ACUTE COLONIC PSEUDO OBSTRUCTION OGILIVIE SYNDROME: 

ACUTE COLONIC PSEUDO OBSTRUCTION OGILIVIE SYNDROME Ogilvie H. Large-intestine colic due to sympathetic deprivation; a new clinical syndrome . Br Med J 1948 ; 2 :671–673. Massive dilatation of colon with obstructive symptoms, in the absence of mechanical obstruction Risk of ischemia and perforation 3-15% leading to mortality of 50% Advanced age, large ceacal diameter and delay in decompression bowel rest, fluid and electrolyte optimization Rectal tube may be effective Stop drugs delaying motility- opioids, anticholinergics, CCB Laxatives particularly osmotic are contra indicated Supportive measures …continued

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3 double blind RCT have documented effectiveness Neostigmine for the treatment of the acute colonic pseudo-obstruction. Ponec RJ, Saunders MD, Kimmey MB. N Engl J Med 1999; 341 : 137–141 Neostigmine infusion: new standard ofcare for acute colonic pseudo-obstruction ? Amaro R, Rogers AI. Am J Gastroenterol 2000; 95 : 304–305. Neostigmine resolves critical illness-related colonic ileus in intensive care patients with multiple organ failure: a prospective, double-blind, placebo-controlled trial. van der Spoel JI, Oudemans-van Straaten HM, Stoutenbeek CP, Bosman RJ, Zandstra DF. Intensive Care Med 2001; 27 : 822–827. Watch for secretions, bradycardia, hypotension, bronchospasm Risk can be reduced by iv infusion compared to bolus Neostigmine The benefit derived from one or two doses of neostigmine largely outweigh the risk of administration Relative contra indication Recent history or signs of perforation or peptic ulcer Myocardial infarction, use of beta blockers Obstructive airway disease S.creatinine>3 mg/dl ACUTE COLONIC PSEUDO OBSTRUCTION OGILIVIE SYNDROME …continued

Effect of polyethylene glycol electrolyte balanced solution on patients with acute colonic pseudo-obstruction after resolution of colonic dilatation: a prospective, randomized, placebo controlled trial. Sgouros SN, Vlachogiannakos J, Vassiliadis K, Bergele C, Stefanidis G, Nastos H et al. Gut 2006; 55: 638–642: 

Effect of polyethylene glycol electrolyte balanced solution on patients with acute colonic pseudo-obstruction after resolution of colonic dilatation: a prospective, randomized, placebo controlled trial. Sgouros SN, Vlachogiannakos J, Vassiliadis K, Bergele C, Stefanidis G, Nastos H et al . Gut 2006; 55 : 638–642 significant reduction in recurrent caecal dilatation, increased in stool and flatus evacuation, decrease in caecal and colonic diameter reduction in abdominal circumference. (after initial resolution using neostigmine or decompression) Polyethylene glycol (PEG) Efficacy has not been assessed in RCT Reported to be successful in 80%, Laborious and hazardous High suspicion of ischemia- should be carried out in OT Endoscopic decompression mortality 30-60% Surgery ACUTE COLONIC PSEUDO OBSTRUCTION OGILIVIE SYNDROME

EFFECT OF ENTERLA NUTRITION ON GUT MOTILITY: 

EFFECT OF ENTERLA NUTRITION ON GUT MOTILITY Clin Nutr 2008; 27:25–41 Standardized concept for the treatment of gastrointestinaldysmotility in critically ill patients: current status and future options. Herbert MK, Holzer P No evidence that impaired intestinal motility in critically ill improves from enteral nutrition, either standard formulae or immune modulating formulae or enriched with antioxidant or fiber

NON PROKINETIC THERAPY: 

NON PROKINETIC THERAPY Post pyloric feeding Failure of NG feeding and no improvement with prokinetics Epidural anesthesia in post op period Systemic lidocaine administration during induction and peri/post operative period

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T HANK Y OU The only thing that interferes with my learning is my education. Albert Einstein