Effect of Abdominal Massage on Clinical Outcomes of Enterally Fed Mechanically Ventilated Patients

Background: Ventilator-associated pneumonia was a severe healthcare associated infectionin intensive care units. Abdominal massage is non-pharmacological nursing intervention for decreasing elevated gastric residual, vomiting frequency and abdominal distension. Gastric distension and increased gastric residual are important risks for developing ventilatorassociated pneumonia. Mechanically ventilated patients who are enterally fed, abdominal massage decreases the duration of the nutrition passage through the gastrointestinal tract, induces peristaltic movement, and thus lowers intra-abdominal pressure and the risk of aspiration. Aim: Was to assess the effect of abdominal massage on Clinical Outcomes of Enterally Fed Mechanically Ventilated Patients. Method: a quasi-experimental study, purposive sample of 60 adult's patient will be enrolled sequentially into two groups, each group consists of (30) patients. Four tools were used to conduct the study. Tool I: Patient Assessment Tool, Tool II: Glasgow coma scale, Tool III: Enteral nutrition Assessment Tools which include five parts and Tool IV: Clinical Pulmonary Infection Score (CPIS) to assess Ventilator-Associated Pneumonia (VAP). Results: The present study showed that there was a significant differences found among the intervention group throughout 1 st , 3rd and 7th day of follow up regarding gastric residual volume assessments score pre and one hour post abdominal massage since p= 0.000*, 0.003*, 0.000* respectively. In addition; the study showed that 6.7% of the control group had≤6 Negative VAP compared to majority 86.7% of the study group have≤6 Negative VAP in the 7 th day of follow up. Conclusion: Based on the results of the current research, it can be argued that abdominal massage is beneficial on decreasing abdominal distension; nasogastric tube feeds side effects, gastric residual volume (GRV) and reducing Ventilator-Associated Pneumonia (VAP) in the study than control group. Moreover, the results established that minority of the control group have ≤6 Negative VAP compared to majority of the study group have ≤6 Negative VAP in the 7th day of follow up. Recommendations: Abdominal massage for mechanically ventilated patients with enteral nutrition should be performed as routine nursing care if not contraindicated to lower the aspiration risk and consequently Ventilator Associated Pneumonia (VAP). Key Wards: Clinical Outcomes, Abdominal Massage, Enteral Feeding, Mechanically Ventilated Patient. Tanta Scientific Nursing Journal( Print ISSN 2314 – 5595 ) ( Online ISSN 2735 – 5519 ) Vol. 21 No. 2 May, 2021 143 Introduction Mechanically ventilated patients need nutritional support because they are seriously ill and unable to take oral feeding. A catabolic condition with an elevated level of metabolic stress is frequent in ventilated patients as a result of a systemic inflammatory response. They're more likely to experience complications including ventilator-associated pneumonia or urinary tract infection, as well as organ failure, prolonged hospitalization, and death. Enteral feeding is also considered a treatment option for people who are unable to consume oral nutrition. Enteral feeding is believed to preserve gut health and thereby modulate the stress response to critical illness andreduce the disease severity. (1) Mechanical ventilator (MV) should help in exchange of gases without inducing pulmonary trauma. Unfortunately, it can also cause pulmonary effects such as strain and stress. High pressure and volume can result in pulmonary trauma, which can lead to biotrauma and atelectasis. Also, ventilator-associated pneumonia is another complication that may occur. (2) More than half of the patients in the critical care unit have irregular gastric motility, which causes sluggish gastric emptying. Delayed gastric emptying can cause a number of problems, including insufficient caloric intake and infrequent use of enteral nutrition in the intensive care unit (ICU). The risk of ventilator-associated pneumonia is increased by nausea, regurgitation, and aspiration . (3-4) As a result, assessing the gastric residual volume (GRV) is recommended to reduce the frequency of these complications. consequently, in cases of high GRV, it is important to reduce the amount of enteral feeding or the osmolality of the formula. The monitoring of gastric residual volume in critically ill patients undergoing mechanical ventilation has been the subject of many studies. Previous studies that found a correlation between GRV and VAP were not well designed to demonstrate GRV as a reliable marker of increased VAP risk, and they concluded that monitoring GRV in mechanically ventilated patients is unnecessary and provides no additional benefits. (5-7) . Ventilator-associated pneumonia is a form of nosocomial bacterial infection that affects patients who have had invasive ventilation for at least 48 hours before being diagnosed. It's a common form of Tanta Scientific Nursing Journal( Print ISSN 2314 – 5595 ) ( Online ISSN 2735 – 5519 ) Vol. 21 No. 2 May, 2021 144 pneumonia acquired in hospitals (HAP). When a chest X-ray reveals new infiltration and at least one of the following criteria is present: fever, leukocytosis, and purulent tracheobronchial secretions, it may be diagnosed. The second most common hospital-acquired infection is pneumonia caused by a ventilator. The average or crude mortality rate associated with VAP varies from 40% to 70%, depending on the underlying disease, the etiologic pathogen of lung infection, the associated bacteremia, and the sufficiency of prophylactic antibiotic treatment. (8,9) . Abdominal massage, was a nursing intervention for minimizing elevated gastric residual, vomiting frequency, and abdominal distension, has been indicated in numerous studies. Abdominal massage shortens the time it takes for food to pass through the digestive tract, stimulates and preserves peristaltic activity, and decreases intra-abdominal pressure. Furthermore, it was a nonpharmacological, noninvasive, and safe approach with no side effects . (10.) Moreover, abdominal massage often changes intra-abdominal pressure and increases vagal stimulation. This boosts gastric motility and improves gastric emptying. The favored nursing intervention for treating and decreasing gastrointestinal complications is the abdominal massage, because it has many benefits, including the simplicity of which nurses may apply it individually and the absence of side effects. (11,12) . Significance of the study Ventilator-associated pneumonia was defined as nosocomial pneumonia that occurs at least 48 hours after the initiation of mechanical ventilation and affects from 6 % to 52% of total cases of nosocomial infection in critical care units. Also, it accounts 9–13% of the total deaths in patients with ventilator support devices . There have been several risk factors reported for the incidence of ventilatorassociated pneumonia. It is possible to count factors relevant to the patient such as age and health condition, medication and care procedures such as enteral feeding, antacid prophylactic therapy, and infection control related factors. (13-15) Enteral feeding was shown to be a threefold increase in the development of ventilator-associated pneumonia in patients on mechanical ventilation. Reflux, aspiration, diarrhea, abdominal distention, constipation, and intestinal ischemia are also potential side effects. Patients who received enteral nutrition documented them in 62% of cases. (16-18) Increased gastric residual volume was observed in 32 % to 39 percent of enterally fed patients, as well as feeding intolerance in 60 percent. Increased gastric residual Tanta Scientific Nursing Journal( Print ISSN 2314 – 5595 ) ( Online ISSN 2735 – 5519 ) Vol. 21 No. 2 May, 2021 145 volume due to enteral feeding can cause pulmonary aspiration, which is one of the most dangerous mechanical problems and one of the major causes of Ventilatorassociated pneumonia VAP. Aspiration was seen at a rate of 8 percent to 95 percent in intensive care units. The true incidence remains unclear due to the lack of standardized diagnostic criteria and silent aspiration. (19-25) Gastric distention, high residual volume can be reduced by abdominal massage and this lowers the rate of ventilator-associated pneumonia. Several researches have shown that abdominal massage can affect constipation, gastric residual volume, and abdominal distention (26-29,30-34. ) There hasn't been any research conducted on the influence of abdominal massage on the growth of Ventilator-associated pneumonia VAP. As a result, the aim of this study was to evaluate how abdominal massage affected the enterally fed patient's clinical outcomes who are mechanically ventilated. Operational Definition of Clinical Outcomes: the clinical outcomes involved in this study include; tolerance of enteral nutrition as indicated by decreased occurrence of abdominal distension, constipation, diarrhea, vomiting, and low gastric residuals and decreased incidence of ventilatorassociated pneumonia (VAP). Aim of the study The Aim of the study was to assess the effect of abdominal massage on Clinical Outcomes of Enterally Fed Mechanically Ventilated Patients.