Effect of Abdominal Massage on Gastrointestinal Complications and Intra-Abdominal Pressure of Critical-Enteral-Feed Patients: A Randomized Control Trial

Background: critically ill patient need a nursing practice that can enhance him to get all benefits of enteral feeding and overlapping the GI complications and maintain the intra-abdominal pressure.Objective: This work aimed to explore the effect of abdominal massage on gastrointestinal complications and intra-abdominal pressure of criticalenteral-feed patients. Methods: A randomized controlled trial was applied on 74 eligibly enteral-fed patients at Trauma and General ICUs. Of these, the trail was completed on sixty patients who distributed randomly to equal intervention and control groups. The manipulation was two times for 15mins of abdominal massage for five days. The effect was measured on enteral feeding complications (GRV, abdominal circumference and distention, vomiting) and intra-abdominal pressure as compared with control group who didn't receive the massage.Results: the GRV difference between the massage group and control group subjects was statistically significant (P<0.001) in the 3, 4, and 5 days indicating higher GRV among control group. The abdominal circumference between the five days was not significantly in the two groups. The difference between the two groups in relation to the distension was statistically significant (p < 0.05) in day 3, 4 and5. None of intervention patients were vomited along the study period (5days) in compared to 5% of control patients without statistical significant. Conclusions: The abdominal massage was significantly effective in lowering GRV, preventing distension and avoiding vomiting. Besides, the abdominal massage maintained the IAP without any statistical significant support. Therefore, it is recommended that this practice can be applied as a caring procedure in the daily ICU care program.


Intra-abdominal pressure (IAP) of enteral-fed patients
The pressure arising from abdominal organs, viscera and abdominal wall is accepted to be less than 5 mmHg in adult. Increasing the IAP level is expected among the intensive care patients according to many factors especially that affect the stability of abdominal cavity either by the pathology of the disease itself or the treatment modalities. However, the abdominal compliance is limited and is considered intra-abdominal hypertension (IAH) as 12: 20 mmHg and abdominal compartment syndrome (ACS) as more than 21mmHg (Christensen, Craft, & Nursing, 2018). In literature, IAP disturbs the organ tissue perfusion, possibly leading to severe ischemic or circulatory changes. It was found also correlation between the increased IAP and organ dysfunction which leading to worsening the patient's status and used now as predictors of morbidity and mortality of critically ill patients (Dehghan, Mehdipoor, & Ahmadinejad, 2018;Malbrain & De Waele, 2013).

Role of critical care nurses (CCN)
Critical care nurses are usually occupied with improving the patient' status and trying to decrease his suffering or complications derived from ICU management. Critical care nurses are in charge for the assessment of enteral-fed patients. Most of enteral feeding complications that progress as a result of feeding intolerance can be prevented by nursing care. According to nurse scholars, nutrition is a part of nursing care as well as medical treatment (Persenius, Larsson, Hall-Lord, & Nursing, 2006) (Marshall, West, & Nursing, 2006). Nurses perform a significant role starting from the assessment phase of a patient's requirement of feeding, until planning and applying the feeding safely and efficiently. Most of the success in enteral tube feeding depends on the role of CCN in giving the nutrition, continuous monitoring and evaluation the patient (N. Uysal, Eser, & Akpinar, 2012). The accountability of IAP monitoring usually is under CCN role through continuous observation and identifying of subtle and dynamic changes in the status of critically ill patients (Newcombe, Mathur, & Ejike, 2012). Previously, (Cole & Shanley, 1998) stated that massage is a therapeutic, complementary method in terms of nurses' enhancing professional roles. Recently, (Dehghan, Mokhtarabadi, Heidari, & Medicine, 2018;Ghaedi, Dehghan, Salari, Sheikhrabori, & medicine, 2017) stated that the massage therapy as a type of complementary therapy can be used in palliative management.

Abdominal massage:
Abdominal massage is one of complementary therapy that can be applied to enhance the digestive system functions, improve the intestinal movements and decrease intra-abdominal pressure (Preece & Midwifery, 2002;Pyszora & Krajnik, 2010;Sinclair & therapies, 2011). Some researchers studied the effect of abdominal massage on the prevention or treatment the enteral feeding complications. For example, (Kahraman & Ozdemir, 2015), and (N. Uysal et al., 2012) found that abdominal massage decreased the residual volume and distention in patients fed by a gastric tube among the mechanically ventilated and neurosurgical/medical patients respectively. Other studies publicized that abdominal massage reduced constipation among patients with multiple sclerosis with no adverse effects (McClurg, Hagen, Hawkins, & Lowe-Strong, 2011), chronic constipation (Lämås, Lindholm, Stenlund, Engström, &Jacobsson, 2009), andcancer (Lai et al., 2011).
Abdominal massage can stimulate parasympathetic activity that enhancing the gastrointestinal function. Abdominal massage accelerates peristalsis by changing intra-abdominal pressure and producing a mechanical and reflexive effect on the intestines, decreasing abdominal distension and increasing intestinal movements (Harrington & Haskvitz, 2006) (Liu et al., 2005). Avery few studies applied the abdominal massage to examine its effect on GI intolerance and intra-abdominal pressure in randomized trials. The researchers recommended further research on this topic with different patients, diagnosis and areas to generalize and compare the results (Lämås, Graneheim, & Jacobsson, 2012;McClurg et al., 2011). Therefore, the present study aims to explore the effect of abdominal massage practice on enteral feeding complications and intra-abdominal pressure of enteralfed patients

Nursing implication of this study:
Gastrointestinal complications still the major problem that facing the critically ill patients' especially enteral-fed one and can increase the suffering (Mohamed et al., 2013). In the meantime, several studies have focused on the roles of ICU' nurses to perform such intervention (Jamaati et al., 2015). The main focus problem that studied the effectiveness of abdominal massage on patients was constipation. Therefore, this research was carried out trying to help the nurses to find out the solution for all GI complications (GRV, abdominal circumference, Distention and vomiting) by applying the costless, safe and simple strategy which is abdominal massage. Moreover, this study aimed to explore the effect of abdominal massage on IAP reading for first time. Previously, the authors assumed the effectiveness of massage on IAP without actually randomized studies.

Design:
A randomized controlled trial was applied in this study to explore the effect of abdominal massage (independent variable) on enteral feeding complications and intra-abdominal pressure (dependent variables) of enteral-fed patients.

Settings and patients:
The study was conducted at 2018 (March to September) in the Trauma and General ICUs at Assiut University Hospitals. Patients' families gave informed consent prior to the study. According to Power Analysis and Sample Size (PASS) program with 0.80 powers and 0.05 margin errors, the total showed 60 patients. Inclusion criteria were intermittent enteral-fed, adult age, physiological parameter stability, free GI assessment and using only H2 receptor antagonists as gastric prophylaxis. The exclusion conditions were under sedation, GI surgery, trauma, pain and ileus, and using pro-kinetic agents. To control variables and prevent contamination of data, the patient who developed diarrhea or constipation within study period were excluded because of diarrhea can be related to infection and the constipation related to immobility.

Randomization:
The patients were randomly assigned to equal control and intervention patients. The researcher made 30 cards with symbol A (control patient) and 30 card with symbol B (intervention patient) and put it in a box. Then, the researcher picked randomly each card to assign patient per group until emptying the box. The patients who discharged, died or cease EN were not included in the study (see the flow chart).

Tool
: the researcher developed two-part tool to collect the data, one including the patient' medical characteristics (age, sex, diagnosis) and the second part for following the GI information (abdominal girth, distension, vomiting, GRV, and intra-abdominal pressure).

2.5.
The tool was verified for content validity. First, the researcher designed the tool based on valuable scientific publications and books (Emly, 2008). Second, the tool distributed to five nursing and anesthesiologist staff at Assiut University. Then, their opinions were followed as mark the patient' status as stable or unstable instead of MV setting' data and vital signs. Finally, the study was piloted on three patients to test the feasibility and applicability of the tool then their results were excluded from the actual study.

Intervention:
 Both group were received the routine ICU protocol of the intermittent enteral feeding as the type, frequency and amount and flow rate of formula per day.
is an omnibus test statistic and was used to determine whether there are any statistically significant differences between the means of IAP and circumference at the five days. The independent t-test is an inferential statistical test that determines whether there is a statistically significant difference regarding mean of GRV between the two groups. P values minus 0.05 were considered as significant.

Results
The basic characteristics (Table 1) reveals no significant between the intervention and the control group. The mean age of intervention group was 48.43+ 11.49 and was 44.03+12.84 among the control group. Sixty percent of intervention and 76.67 % of control patients were male. Head Injury was the first reason for admission into ICUs by 66.67 % of intervention and 60.00% of control patients. Table 2 shows that the GRV difference between the intervention group and control group subjects was statistically significant (P<0.001) in the 3 rd , 4 th , and 5 th days indicating higher GRV among control group. In addition, GRV of intervention group was slightly increased but still within acceptable level (less than 50ml out of 200ml feeding) through the 5 days. However, GRV of control group was dramatically increased (near to half of 200ml feeding) significantly ((P<0.001). Table2 also presents that the abdominal circumference between the five days were not significantly in the two group (p=1.000, p=0.878) respectively. However, the difference between the two groups in relation to the distension was statistically significant (p < 0.05) in day 3, 4 and5. Regarding vomiting, none of intervention patients were vomited along the study period (5days) in compared to 5% of control patients without statistical significant.
One-way ANOVA of IAP (Table 3) illustrates that mean of IAP of intervention group in the five days was the same (8.17+ 1.37). In the control group the mean of IAP was slightly increased in day 5 than first day (7.87±2.47) without intra-group statistical significant.
A significant positive correlation between GRV and IAP (figure 2) in the control group (r=0.788) and the intervention group (r=0.817)) respectively.

Discussion
Many CCN stated that the GI complications associated enteral feeding still occurred and need to alleviated. In previous research in the same Trauma ICU setting Abdelhafez A, etal, 2013 found that 57.5% (40 patients) of control patients developed GI complications; of these 20% and 12.5% had vomiting and abdominal distention respectively.
In the current study the GRV among the intervention patients were sloped significantly along the five days of abdominal massage and usually less than control patients. On the contrary, The GRV of the control group is increased significantly along the five days. This may be attributed to the exposure to 15min twice per day and for five days can improve the stomach function and increase the speed of gastric empty. This finding is supported by (Bastin, Kulikowski, Piagnerelli, Thirry, & Vincent, 2004) who found that the amount of GRV was decreased among the abdominal massage group. In 2017, (N. J. E. J. o. I. M. Uysal, 2017) published that 8.0% of abdominal massage group developed excess GRV as compared with 34.0% of the control group. In this respect, (Dehghan, Mehdipoor, et al., 2018) reported that GRV was increased significantly in the control group and decreased significantly in the intervention group; however, there was no significant difference between two groups (P = 0.15). in another study (Momenfar, Abdi, Salari, Soroush, & Hemmatpour, 2018) the abdominal massage lowered the GRV on the second and third day of massage than before the massage (p value< 0.05).
The study represented that the abdominal massage was not effective on abdominal circumference over the five days. However, the massage was effective on abdominal distension. This is not supported with results of researchers (Dehghan, Mehdipoor, et al., 2018) who applied 15-minute abdominal massage twice a day for three days found a significant difference in the abdominal circumference between the intervention and control groups. Research in 2015 (Wang et al., 2015) who examined the effects of 15-min gentle abdominal massage was administered bi-daily for 3 days showed improvements abdominal bloating significantly.
The current results also revealed that the massage was effective on preventing occurrence of vomiting along the study period (5days). This is may be refer to the massage timing before feeding which enhance gastric empty. Vomiting associated enteral feeding is common and approximately 20% of critically ill patients suffering from it. Other literatures, reported that the incidence of vomiting ranged from 12% to 50 % (Momenfar et al., 2018). Nurses should be routinely monitor GRV to ensure gastric empty (Mohamed et al., 2013) Critically ill patient recognized to have IAP up to 7 mmHg, developed IAH at 12 mmHg and considered ACS at 20mmHg with organ dysfunction (Milanesi & Caregnato, 2016). In the present trail, the IAP readings of both groups are within accepted level and not exceed to be IAH. This is attributed to the capability of abdominal massage on peristaltic movement, digestion and GI circulation. other researchers (Pyszora & Krajnik, 2010;Sinclair & therapies, 2011) stated that the IAP is lowered among the abdominal massage group. The other reason is the inclusion criteria which all patients had stability in the heamodynamic status and no GI problems.