LAUSR

Initial correspondence from Dr. Li et al. Dear Editor, In view of the wide use of prokinetic agents in clinical practice, we read Hu et al.’s article with great interest [1]. It is a well-organized multicenter randomized controlled trial (RCT) and demonstrates that erythromycin is noninferior to metoclopramide in facilitating post-pyloric placement of spiral tubes in critically ill patients. With exposure to prokinetic agents and dose accumulation, safety issues need to be taken seriously because cardiotoxicity and the development of bacterial resistance were reported to occur in critical patients, possibly caused by erythromycin, and neurological reactions were related to metoclopramide [2]. Actually, it is repeatedly reported that placement of a trans-pyloric tube can be performed with high success rates without requiring prokinetic drugs, which is also the current practice in our center. In our ICU, we place trans-pyloric tubes by an ultrasound-assisted method without prokinetic agents, and the success rate can reach more than 90% [3]. We performed a pilot study comparing the ultrasound-assisted method vs. traditional endoscopy method in 53 severe acute pancreatitis patients during a 12-month period. There were 28 patients [28/30 (93.3%)] with confirmed successful post-pyloric placement in the ultrasound-assisted group without prokinetics and 22 patients [22/23 (95.6%)] in the endoscopy group. Therefore, adding a placebo group should be considered in further studies on this topic. In conclusion, considering the potential harm to critically ill patients caused by prokinetics, safer and quicker bedside methods could possibly serve as the primary choice. Further studies comparing prokinetics with placebo control are warranted to guide current clinical practice.