Sedation assessment in critically ill adults: 2001-2004 update

OBJECTIVE: To review recently published literature on the validity and reliability of sedation assessment tools in critically ill adults and evaluate the potential advantages and disadvantages of each. DATA SOURCES: A computerized search of MEDLINE and PubMed (2001-May 2004) was conducted. STUDY SELECTION AND DATA EXTRACTION: Sedation assessment tools used in adult intensive care units (ICUs) were identified. DATA SYNTHESIS: Six subjective and 3 objective assessment tools were identified. Four subjective assessment tools have reliability and 4 have validity data published that were not previously available. There are reliability data to further support the use of the previously published Motor Activity Assessment Scale. Additional reliability data exist for the Ramsay Scale and Glasgow Coma Scale. Conflicting evidence is available with the use of the Bispectral Index monitor in the ICU. Recently, the Patient State Index and Auditory Evoked Potentials were introduced for objective monitoring in critically ill patients. CONCLUSIONS: Increasing data on sedation assessment were published over the last few years, probably in response to supporting evidence that goal-driven sedation therapy improves patient outcomes. Reliability and/or validity testing exists for many of these scales. Several useful tools are available to guide sedation therapy in critically ill patients.     

Delirium assessment in the critically ill

Objective To compare available instruments for assessing delirium in critically ill adults that have undergone validity testing and provide clinicians with strategies to incorporate these instruments into clinical practice. Design Medline (1966–September 2006) was searched using the key words: delirium, cognitive dysfunction, assessment, intensive care unit, and critical illness to identify assessment tools that have been used to evaluate delirium in critically ill adults. A special emphasis was placed on delirium assessment tools that have been properly validated. Data on how these tools have been adopted into clinical practice as well as strategies for clinicians to improve delirium assessment in the ICU are highlighted. Measurements and results Six delirium assessment instruments including the Cognitive Test for Delirium (CTD), abbreviated CTD, Confusion Assessment Method–ICU, Intensive Care Delirium Screening Checklist, NEECHAM scale, and the Delirium Detection Score were identified. While each of these scales have undergone validation in critically ill adults, substantial differences exist among the scales in terms of the quality and extent of the validation effort, the specific components of the delirium syndrome each address, their ability to identify hypoactive delirium, their use in patients with a compromised level of consciousness, and their ease of use. Conclusions Incorporation of delirium assessment into clinical practice in the intensive care unit using a validated tool may improve patient care. Clinicians can adopt a number of different strategies to overcome the many barriers associated with routine delirium assessment in the ICU.     

A multicenter survey of Ontario intensive care unit nurses regarding the use of sedatives and analgesics for adults receiving mechanical ventilation

BACKGROUND: Nursing-directed sedation protocols have been shown to reduce the duration of mechanical ventilation and shorten the length of intensive care unit (ICU) stay among critically ill adult patients. METHODS: We designed a self-administered questionnaire to understand nurses' satisfaction with current sedation and analgesia practices as well as drug therapies in the ICU setting and the perceived relevance of sedation protocols to patient care and nursing autonomy. We surveyed nurses from 3 academic medical-surgical ICUs that were not using a sedation protocol or a sedation scale. Responses were based on a 5-point Likert scale and on text responses to open-ended questions. RESULTS: Of the 88 respondents, only 52.7% were satisfied (score, > or =4) overall with their local ICU's approach to sedation and analgesia. Nurses favored the use of morphine (85.0%), midazolam (71.2%), and fentanyl (59.6%) over that of lorazepam (38.6%) and haloperidol (15.4%). Some nurses (39.3%) were satisfied with the subjective methods used in their ICU to evaluate sedation adequacy. Almost all respondents believed that a nursing-directed sedation protocol combined with a sedation/agitation scoring system would be valuable to patient care (84.3%) as well as professional nursing practice (85.3%) and that a standardized approach by nurses and physicians was important (81.6%). CONCLUSIONS: In this survey of ICU nurses, we identified a perceived need for improvement in sedation and analgesia practices. Most respondents believed that the use of a nursing-directed sedation protocol in combination with a sedation scoring system would provide greater practice consistency among nurses and physicians and thus improve the care of critically ill patients.     

Role of the bispectral index in sedation monitoring in the ICU

OBJECTIVE: To review and critique evidence for the use of the bispectral index (BIS) in intensive care unit (ICU) patients. DATA SOURCES: A computer search of English-language articles in MEDLINE (1966-July 2005), International Pharmaceutical Abstracts (1971-July 2005), and Scientific Citation Index Expanded (1980-July 2005) was conducted. A manual search of abstracts was also performed using the key search terms BIS, sedation, and critical care. STUDY SELECTION AND DATA EXTRACTION: Case series, letters, editorials, and clinical studies that evaluated BIS in ICU patients were considered for inclusion. DATA SYNTHESIS: Nineteen studies comparing the BIS with sedation scales were evaluated, revealing that the BIS trends lower with increasing sedation. The BIS appeared to correlate better when sedation scores were grouped rather than individual values. However, correlations between BIS and subjective scales were low in most studies (r(2) 0.21-0.93). Additionally, there was poor correlation between drug dosage and the BIS. Randomized, controlled trials demonstrating improved outcomes with BIS monitoring have not been reported. CONCLUSIONS: Interpreting literature on the usefulness of the BIS in the ICU is difficult for reasons that include heterogeneous populations, different methods of collecting BIS data, and use of different versions of BIS software and hardware. Outcomes data are lacking. The 2002 Society of Critical Care Medicine Sedation Guidelines recommendation that more data are needed before the BIS should be used routinely in the ICU remains unchanged. We recommend that further studies be conducted to determine the optimal method of obtaining BIS data and evaluate the impact of the BIS on relevant patient outcomes.     

Intensive insulin therapy for critically ill patients

OBJECTIVE: To evaluate the clinical outcomes of glycemic control of intensive insulin therapy and recommend its place in the management of critically ill patients. DATA SOURCES: Searches of MEDLINE (1966-March 2004) and Cochrane Library, as well as an extensive manual review of abstracts were performed using the key search terms hyperglycemia, insulin, intensive care unit, critically ill, outcomes, and guidelines and algorithms. STUDY SELECTION AND DATA EXTRACTION: All articles identified from the data sources were evaluated and deemed relevant if they included and assessed clinical outcomes. DATA SYNTHESIS: Mortality among patients with prolonged critical illness exceeds 20%, and most deaths are attributable to sepsis and multisystem organ failure. Hyperglycemia is common in critically ill patients, even in those with no history of diabetes mellitus. Maintaining normoglycemia with insulin in critically ill patients has been shown to improve neurologic, cardiovascular, and infectious outcomes. Most importantly, morbidity and mortality are reduced with aggressive insulin therapy. This information can be implemented into protocols to maintain strict control of glucose. CONCLUSIONS: Use of insulin protocols in critically ill patients improves blood glucose control and reduces morbidity and mortality in critically ill populations. Glucose levels in critically ill patients should be controlled through implementation of insulin protocols with the goal to achieve normoglycemia, regardless of a history of diabetes. Frequent monitoring is imperative to avoid hypoglycemia.     

Sedation in the intensive care unit

OBJECTIVE: To describe the goals of sedative use in the intensive care unit and review the pharmacology of commonly used sedative drugs as well as to review pertinent publications in the literature concerning the comparative pharmacology of these drugs, with emphasis on outcomes related to sedation and comparative pharmacoeconomics. DATA SOURCES: Publications in the scientific literature. DATA EXTRACTION: Computer search of the literature with selection of representative articles. SYNTHESIS: Proper choice and use of sedative drugs is based on knowledge of the pharmacology of commonly used agents and is an essential component of caring for patients in the intensive care unit. The large variability in pharmacokinetics and pharmacodynamics in the critically ill make it difficult to directly compare agents. Midazolam provides rapid and reliable amnesia, even when administered for low levels of sedation. Propofol may be useful when deeper levels of sedation and more rapid awakening are required. Lorazepam can be used for long-term sedation in more stable patients if rapidity of effect is not required. Further investigation in assessment of depth of sedation in the critically ill is needed. Continued study of costs, side effects, and appropriate dosing strategies of all sedative agents is needed to answer questions not sufficiently addressed in the current literature. Conclusion: An individualized approach to sedation based on knowledge of drug pharmacology is needed because of confounding variables including concurrent patient illness, depth of sedation, and concomitant use of analgesic agents. (Crit Care Med 2000; 28:854-866) KEY WORDS: sedation; anxiolysis; critical care; midazolam; lorazepam; propofol; benzodiazepines; intensive care unit; pharmacoeconomics; critical illness     

Myopathy in critically ill patients

OBJECTIVE: To review myopathic changes occurring during intensive care treatment in the light of recent information about manifestation, clinical settings, pathophysiology, and histomorphologic changes. DATA SOURCES: The computerized MEDLINE database, bibliography of pertinent articles, and the author's personal files. STUDY SELECTION: Studies were selected according to their relevance to myopathic complications in critically ill patients. DATA EXTRACTION: All applicable data were extracted. DATA SYNTHESIS: Myopathic changes occur frequently in patients treated in the intensive care unit (ICU). Three main types have been identified: critical illness myopathy, myopathy with selective loss of myosin filaments, and acute necrotizing myopathy of intensive care. These histologic types probably represent variable expressions of a toxic effect not yet identified. Candidates for such myotoxic effects are the mediators of the systemic response in sepsis and high-dose administration of corticosteroids and muscle relaxants. The influence of these latter agents appears to be particularly important in the pathogenesis of myosin loss and myonecrosis. Experimental studies suggest that axonal damage attributable to critical illness neuropathy can be an additional factor triggering myopathies in the ICU. Muscle membrane inexcitability was recently identified as an alternative mechanism of severe weakness in ICU patients. CONCLUSIONS: Myopathic changes are surprisingly frequent in critically ill patients. The clinical importance of this finding is still unknown, but it is likely that weakness caused by myopathy prolongs ICU stay and rehabilitation. Because corticosteroids and muscle relaxants appear to trigger some types of ICU myopathy, they should be avoided or administered at the lowest doses possible. Sepsis, denervation, and muscle membrane inexcitability may be additional factors. Studies addressing the pathophysiology of myopathy in critically ill patients are urgently needed.     

Use of epoetin alfa in critically ill patients

OBJECTIVE: To discuss the controversies regarding the use of epoetin alfa (EPO) for reducing red blood cell (RBC) transfusions in critically ill patients with anemia. DATA SOURCES: A MEDLINE search (1966-July 2003) was conducted using the search terms anemia; critical illness; erythropoietin; epoetin alfa; and erythropoietin, recombinant. References of selected articles were reviewed for studies that may have been missed by the computerized search. STUDY SELECTION AND DATA EXTRACTION: Studies pertaining to the use of EPO for anemia of critical illness with an emphasis on data obtained from controlled trials. DATA SYNTHESIS: Anemia is a common complication in patients admitted to the intensive care unit (ICU). Two prospective, randomized studies have demonstrated decreased transfusion requirements associated with EPO administration in medical/surgical patients who were in the ICU for at least 3 days and had hematocrit concentrations <38%. No differences were found in length of stay or mortality. A multicenter trial found that a restrictive strategy of RBC transfusion (hemoglobin goal 7-9 g/dL) was associated with in-hospital mortality lower than that with a more liberal approach, which calls into question the 38% hematocrit goal in the EPO trials. Furthermore, preliminary results from an economic analysis of EPO use in the ICU setting have demonstrated that EPO is not cost-effective. CONCLUSIONS: Given the controversies surrounding EPO administration in critically ill patients, institutions are encouraged to develop EPO guidelines to help ensure the most appropriate use of this expensive product. Additional studies regarding patients most likely to benefit from EPO therapy, the most effective dosing regimen, and use of adjunctive therapies are needed.     

New ways to reduce unnecessary variation and improve outcomes in the intensive care unit

The care of critically ill patients and the advent of the modern day intensive care unit (ICU) present a large person power and cost burden to society. The high cost of critical care is attributed to high overhead expenses (eg, experienced staff and equipment), high resource utilization (eg, pharmaceutical resources, lab testing, imaging procedures), and high demand for services. Pathways to standardize numerous facets of patient care have been shown to improve the efficiency of delivery of care and to reduce resource utilization, and are becoming the most sought-after means of improving patient outcomes and reducing overall ICU expenditures. A number of large, randomized, prospective trials have demonstrated that protocol-based strategies can not only reduce variation and cost of ICU medicine but also improve morbidity and mortality of critically ill patients requiring ICU support. In this article, we discuss examples of these trials investigating four major areas of modern ICU medicine: ventilator management, ventilator weaning, sedation and analgesia, and blood transfusions.     

Use of exogenous erythropoietin in critically ill patients

OBJECTIVE: Review the literature regarding the use of recombinant human erythropoietin (rHuEPO) to prevent red blood cell (RBC) transfusion in critically ill patients. DATA SOURCES: A computerized search of MEDLINE and EMBASE from 1966 through June 2003 was conducted using the terms erythropoietin, anemia, hemoglobin, critical care, intensive care, surgery, trauma, burn, and transfusion. References of selected articles were reviewed. A manual search of critical care, surgery, trauma, burn, hematology, and pharmacy journals was conducted to identify relevant abstracts. RESULTS: Six randomized studies have evaluated exogenous administration of erythropoietin to prevent RBC transfusions in critically ill patients. Studies vary with respect to rHuEPO dosage regimens, dose of concurrently administered iron, patient characteristics, and transfusion thresholds. Administration of rHuEPO rapidly produces erythropoiesis to reduce the need for RBC transfusions. The largest study conducted to date used weekly rHuEPO administration and found a modest decrease in transfusion requirements although the time to first transfusion was delayed. Reduced intensive care unit (ICU) length of stay (LOS) was shown in only one study of surgical/trauma patients. Reduced LOS after ICU discharge was found in another study of severely ill patients (APACHE II score >22). Other clinical outcomes were not altered by rHuEPO use. No adverse events were associated with rHuEPO use although studies were not designed to evaluate safety. CONCLUSIONS: rHuEPO reduces the need for transfusions. A cost-effectiveness analysis of rHuEPO for this indication is needed. Defining an optimal dosage regimen, identifying patients most likely to respond to rHuEPO, and determining risk factors for ICU associated anaemia would provide information for appropriate rHuEPO utilization.     

A survey of sedation assessment and management in Australian and New Zealand paediatric intensive care patients requiring prolonged mechanical ventilation

INTRODUCTION: A retrospective analysis of sedation management for children receiving prolonged ventilation in one Australian paediatric intensive care unit (PICU) revealed no identifiable pattern in sedation management and an inadequacy in the sedation scoring system. Therefore, the investigators sought to explore the current practice of sedation in critically ill children in PICUs across Australia and New Zealand. METHOD: This study used a mail-out survey to audit sedation management within the eight dedicated Australian and New Zealand PICUs. Results: 100% of the units surveyed replied (n=8). There were a total of 6,133 admissions to 8 Australian and New Zealand PICUs, where 3036 (49.5%) required ventilation. Of these children, 888 (29.2%) required ventilation > or =72 hours. Only 4 units had written guidelines for sedation management. A combined sedation regime of benzodiazepines and opioids was employed in six units. Administration and titration of sedation agents was managed by nursing staff alone in six units. All units indicated that they aimed to achieve a 'moderate level' of sedation. Two units used designated assessment tools for sedation and withdrawal assessment. One unit utilised Bispectral Index (BIS) monitoring. CONCLUSION: There were similarities observed in the methods and types of sedation agents used within Australian and New Zealand PICUs. However, only half of the units had guidelines for sedation management, and most units did not use validated paediatric scales to assist staff in assessing patient sedation and pain levels. Therefore it is recommended that a standardised approach to sedation assessment and management of critically ill children requiring prolonged ventilation be developed and tested.     

Critical care nurses' decision making: sedation assessment and management in intensive care

Aims. This study was designed to examine the decision making processes that nurses use when assessing and managing sedation for a critically ill patient, specifically the attributes and concepts used to determine sedation needs and the influence of a sedation guideline on the decision making processes. Background. Sedation management forms an integral component of the care of critical care patients. Despite this, there is little understanding of how nurses make decisions regarding assessment and management of intensive care patients’ sedation requirements. Appropriate nursing assessment and management of sedation therapy is essential to quality patient care. Design. Observational study. Methods. Nurses providing sedation management for a critically ill patient were observed and asked to think aloud during two separate occasions for two hours of care. Follow‐up interviews were conducted to collect data from five expert critical care nurses pre‐ and postimplementation of a sedation guideline. Data from all sources were integrated, with data analysis identifying the type and number of attributes and concepts used to form decisions. Results. Attributes and concepts most frequently used related to sedation and sedatives, anxiety and agitation, pain and comfort and neurological status. On average each participant raised 48 attributes related to sedation assessment and management in the preintervention phase and 57 attributes postintervention. These attributes related to assessment (pre, 58%; post, 65%), physiology (pre, 10%; post, 9%) and treatment (pre, 31%; post, 26%) aspects of care. Conclusions. Decision making in this setting is highly complex, incorporating a wide range of attributes that concentrate primarily on assessment aspects of care. Relevance to clinical practice. Clinical guidelines should provide support for strategies known to positively influence practice. Further, the education of nurses to use such guidelines optimally must take into account the highly complex iterative process and wide range of data sources used to make decisions.     

Proton-pump inhibitors for stress ulcer prophylaxis in critically ill patients

OBJECTIVE: To evaluate the use of proton-pump inhibitors (PPIs) for stress ulcer prophylaxis in critically ill adults. DATA SOURCES: Computerized biomedical literature search of MEDLINE (1966-June 2002) was conducted using the MeSH headings proton-pump inhibitor, ulcer, critical care, and acid. References of selected articles were reviewed. A manual search of critical care, surgery, trauma, gastrointestinal, and pharmacy journals was conducted to identify relevant abstracts. DATA SYNTHESIS: Traditional medications used for stress ulcer prophylaxis include antacids, histamine(2) receptor antagonists (H(2)RAs), and sucralfate. Few studies have evaluated PPIs for stress ulcer prophylaxis. The majority of studies have demonstrated that enteral or intravenous administration of PPIs to critically ill patients elevates intragastric pH and consistently maintains pH > or =4.0. PPIs are safe and seem to be as efficacious as H(2)RAs or sucralfate for prevention of bleeding from stress-related mucosal damage (SRMD) and they may provide cost minimization. The small patient populations limit the results of comparative studies. CONCLUSIONS: Available data indicate that PPIs are safe and efficacious for elevating intragastric pH in critically ill patients. PPIs should be used only as an alternative to H(2)RAs or sucralfate since the superiority of PPIs over these agents for preventing SRMD-associated gastrointestinal bleeding has not been established. Additional comparative studies with adequate patient numbers and pharmacoeconomic analyses are needed before PPIs are considered the agents of choice for stress ulcer prophylaxis.     

Qualitative review of intensive care unit quality indicators

PURPOSE: The purpose of this study was to (1) conduct a systematic review of the literature to identify interventions that improve patient outcomes in the intensive care unit (ICU); (2) evaluate potential measures of quality based on the impact, feasibility, variability, and the strength of evidence to support each measure and to categorize these measures as outcome, process, access, or complication measures; and (3) select a list of candidate quality measures that can be broadly applied to improve ICU care. METHODS: We identified and independently reviewed all studies in Medline (1965-2000) and The Cochrane Library (Issue 3, 2001) that met the following criteria: design: observational studies, experimental trials, or systematic reviews; population: critically ill adults; and intervention: process or structure measure that was associated with improved patient outcomes: morbidity, mortality, complications, errors, costs, length of stay (LOS), and patient reported outcomes. Studies were grouped into categories by the type of outcome that was improved by the intervention. Potential quality measures were evaluated for: impact on morbidity, mortality, and costs; feasibility of the measure; and variability in the measure. We evaluated the strength of evidence for each intervention used to improve outcomes and using the Delphi method, assigned an over-all recommendation for each quality measure. RESULTS: A total of 3,014 citations were identified. Sixty-six studies that met selection criteria reported on a variety of interventions that were associated with improved patient outcomes. We identified 6 outcome measures: ICU mortality rate, ICU LOS greater than 7 days, average ICU LOS, average days on mechanical ventilation, suboptimal management of pain, and patient/family satisfaction; 6 process measures: effective assessment of pain, appropriate use of blood transfusions, prevention of ventilator-associated pneumonia, appropriate sedation, appropriate peptic ulcer disease prophylaxis, and appropriate deep venous thrombosis prophylaxis; 4 access measures: rate of delayed admissions, rate of delayed discharges, cancelled surgical cases, and emergency department by-pass hours; and 3 complication measures: rate of unplanned ICU readmission, rate of catheter-related blood stream infections, and rate of resistant infections. CONCLUSIONS: Further work is needed to create operational definitions and to pilot test the selected measures.The value of these measures will be determined by our ability to evaluate our current performance and implement interventions designed to improve the quality of ICU care.     

Spiritual assessment in intensive and cardiac care nursing

Aim: The aim of this paper is to explore various approaches to spiritual assessments in contemporary intensive and cardiac care (ICU/CCU) environments. Background: Despite the increasing recognition that spiritual care is essential for quality patient care, an agreed spiritual assessment approach and tool for use in ICU/CCU settings remains elusive. Method: An overview of spiritual assessment and spiritual assessment tools. Conclusion: It is suggested that the staff in ICU/CCU nursing settings choose or develop a formal assessment tool that most closely matches their considered collective definition of spirituality, which has been considered in light of their mission statement and philosophy of care. Relevance to clinical practice: Spiritual assessment is essential to formulate a care plan as spiritual care provides a powerful inner resource to critically ill patients in acute clinical environments.     

Cortical arousal in critically ill patients: an evoked response study

OBJECTIVE: Assessing the level of sedation in critically ill patients remains a challenge for the intensivist in order to avoid over or under-sedation. Clinical scoring systems may fail in patients with concomitant neurological disorders or requiring muscle relaxants. We evaluated auditory (AER) and median nerve somatosensory evoked responses (MnSSER) in critically ill patients sedated with sufentanil and propofol, in order to quantify the level of sedation during therapeutic interventions. DESIGN: Prospective clinical study. SETTING: Anaesthesiological intensive care unit (ICU) in a university hospital. PATIENTS AND PARTICIPANTS: Thirty-two patients following major abdominal or thoracic surgery requiring sedation during their stay on the ICU. INTERVENTIONS: During physiotherapy and following nursing care (tracheal suctioning) AER and MnSSER were recorded. The level of sedation was evaluated clinically in relation to vital parameters. Data were analysed by multivariate analyses of variance (Hotellings T2), Friedman test. MEASUREMENTS AND RESULTS: In comparison to baseline levels the AER latency Nb decreased, while the amplitude NaPa increased during physiotherapy and after tracheal suctioning (p < 0.001). In contrast, the MnSSER latency P25 decreased and the amplitude P25N35 increased after tracheal suctioning only (p < or = 0.001). Clinical sedation scores decreased and mean arterial blood pressure increased during physiotherapy and nursing care. CONCLUSIONS: Changes of AER or MnSSER waves indicated cortical arousal in ICU patients during nursing care and physiotherapy. Further studies with evoked responses are recommended to evaluate whether bolus injections of sedatives and/or analgesics reduce cortical arousal and thereby minimise the patient's stress during nursing care.     

Gastrointestinal promotility drugs in the critical care setting: a systematic review of the evidence

CONTEXT: Gastrointestinal promotility agents may improve tolerance to enteral nutrition, reduce gastroesophageal reflux and pulmonary aspiration, and therefore have the potential to improve outcomes of critically ill patients. OBJECTIVE: To systematically review and critically appraise studies of promotility agents in the critical care setting. DATA SOURCES: Computerized bibliographic search of published research (1980-2001), citation review of relevant articles, and contact with primary investigators. STUDY SELECTION: Randomized trials of critically ill adult patients that evaluated the effect of promotility agents on measures of gastrointestinal motility were included. DATA EXTRACTION: Relevant methods and outcome data were abstracted in duplicate by independent investigators. DATA SYNTHESIS: We reviewed 60 citations; 18 articles met the inclusion criteria (six studies of feeding tube placement, 11 studies evaluating gastrointestinal function, and one study of clinical outcomes). The heterogeneity of study methods and outcomes measured precluded a quantitative synthesis of the data. Although there are conflicting studies, the larger and more methodologically robust studies suggest that metoclopramide has no effect on feeding tube placement. Erythromycin has been shown to increase success rates with small-bowel tube placement in two studies. Eight of ten studies evaluating the effect of cisapride, metoclopramide, or erythromycin on measures of gastrointestinal transit demonstrated positive effects; the two studies that did not were relatively small (n = 27 and 10) and likely had inadequate power to detect a difference in treatment effect. No study demonstrated a positive effect on clinical outcomes. CONCLUSIONS: As a class of drugs, promotility agents appear to have a beneficial effect on gastrointestinal motility in critically ill patients. A one-time dose of erythromycin may facilitate small-bowel feeding tube insertion. Administration of 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.