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CRITICAL CARE

Evaluation of Feeding Intolerance in Patients with Pentobarbital-Induced Coma

Assistant Professor of Pharmacy Practice, Saint Louis College of Pharmacy, St. Louis, MO

Janine E Then, PharmD

Clinical Pharmacy Specialist, Adult Critical Care, Hershey Medical Center, Hershey, PA

Karen M Frock, PharmD

Critical Care Pharmacist, Department of Pharmacy, York Hospital, York, PA

Bruce A Crookes, MD

Director of Trauma Services, Fletcher Allen Health Care and the University of Vermont, Burlington, VT

Christopher Commichau, MD

Director of Neurocritical Care, Fletcher Allen Health Care and the University of Vermont

Brian T Marden, PharmD

Medication Safety Pharmacist, Department of Pharmacy, Maine Medical Center, Portland, ME

Bonnie J Beynnon, RD

Clinical Dietician, Department of Nutrition, Fletcher Allen Health Care

Jill A Rebuck, PharmD BCPS FCCM

Critical Care Clinical Pharmacy Specialist, Department of Pharmacy, Lancaster General Hospital, Lancaster, PA

Reprints: Dr. Rebuck, Lancaster General Hospital, Pharmacy Services, 555 North Duke St., PO Box 3555, Lancaster, PA 17604, fax 717/544-5442, jarebuck{at}lancastergeneral.org

BACKGROUND: There is considerable debate regarding the appropriateness of feeding patients by the enteral route in conjunction with pentobarbital coma therapy.

OBJECTIVE: To determine the incidence of feeding intolerance (FI) in patients receiving pentobarbital in conjunction with enteral nutrition (EN).

METHODS: A retrospective, observational evaluation of patients (>14 y of age) who received a therapeutic pentobarbital coma in combination with EN was conducted. Patients were divided into groups, based on the occurrence of FI defined as aspiration of gastric residuals greater than 75 mL for 2 consecutive measurements.

RESULTS: Forty-eight percent (29 of 61) of patients experienced FI based on our definition. The median pentobarbital infusion rate did not differ significantly between patients who experienced FI versus those who did not (median [intraquartile range, IQR] 1.8 mg/kg/h [1.4, 2.1] vs 1.7 mg/kg/h [1.4, 2.5]; p = 0.680). The total pentobarbital bolus dose during the first 24 hours of therapy was lower in patients who experienced FI (700 mg [225, 980] vs 1000 mg [600, 1475]; p = 0.029). Median duration of pentobarbital therapy was comparable between groups (141.0 h [93.3, 217.3] vs 116.3 h [64.0, 174.8]; p = 0.115). Other factors with the potential to influence FI, such as catecholamines, neuromuscular blockade, and hyperglycemia, were similar between groups. The higher narcotic doses and greater percentage of patients receiving benzodiazepines in the FI group warrants further study.

CONCLUSIONS: Pentobarbital therapy did not preclude use of EN in the entire study population. In addition, FI did not occur at a greater frequency in patients who received a higher dosage, a longer duration, or an earlier initiation of pentobarbital therapy.

Key Words: brain injuries, enteral nutrition, gastric emptying, pentobarbital

Published Online, March 25, 2008. www.theannals.com, DOI 10.1345/aph.1K555