الفهرس 
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Abstract
Gastrointestinal motility disorders and feeding intolerance such as excessive GRV, abdominal distension, constipation, vomiting and aspiration are common amongst critically ill patients and have been associated with significant complications that may lead to increased morbidity and mortality. Several measures can be taken to treat impaired gastrointestinal motility and improve EF in critically ill patients, these measures include optimizing fluid intake, correcting electrolyte disturbances, avoiding or minimizing the use of medications that slow gastrointestinal motility, and using pharmacological agents to restore gastrointestinal motility.
Additionally to these measures, many studies have shown that abdominal massage as a non-pharmacological therapy, non-invasive, free of harmful side-effects, and requires no special equipment can play an important role in improving gastrointestinal outcomes of enterally fed mechanically ventilated patients through stimulation of parasympathetic activity resulting in decreasing GRV, vomiting and aspiration. Also the abdominal massage speeds peristalsis by changing intra-abdominal pressure and creating mechanical and reflexive effect on the intestines, decreasing abdominal distension and constipation.
Therefore, the current study aimed to evaluate the effect of abdominal massage on gastrointestinal outcomes of enterally fed mechanically ventilated patients.
Materials and Method
This study was conducted in the following ICUs, unit I, unit II and unit III at Alexandria Main University Hospital.
A convenience sample of 60 male adult mechanically ventilated patients and on nasogastric enteral-feeding from 18-60 years, hemodynamically stable, no active bleeding, no dysrhythmia requiring the administration of a new anti-arrhythmic agent, and adequate oxygenation. The patients with continuous feeding, abdominal wound, recent abdominal surgery and radiotherapy, GI bleeding, spinal cord injury intestinal obstruction, ileus, diarrhea, hemodynamic instability and oxygenation inadequacy were excluded from the study.
One tool was used for data collection: “Gastrointestinal Outcomes of Abdominal Massage Assessment Record”.
This tool was developed by the researcher after reviewing the relevant literature to assess the gastrointestinal outcomes after implementation of the abdominal massage and it includes 3 parts:
Part I: patients’ related data: It consists of patients’ characteristics, physiological parameters, ventilation parameters, and administered medications.
Part II: Feeding-related data: It consists of type, source, content, formula density, and amount of feeding.
Part III: Gastrointestinal outcomes occurrence included: gastric residual volume, abdominal distension, constipation, vomiting, and aspiration.
An official letter from the faculty of nursing was delivered to the hospital authorities at Alexandria Main University Hospital and approval to conduct this study was obtained after providing explanation of the aim of the study. Content validity was done by a jury of six experts in the field of the study including professors of critical care medicine and critical care nursing and emergency. Written informed consent was obtained from patients families. A pilot study was carried out on six patients to evaluate the clarity and applicability of the research tool and necessary modifications were done. Data collection was started from September 2016 till October 2017.
The main results of the current study:
Part I: Description of the study and control groups before abdominal massage regarding patients’ characteristics, administered medications and physiological parameters. It was revealed that, there was no significant difference between the study and the control groups before abdominal massage.
Part II: Description of the study and control groups regarding patients’ ventilation parameters. It can be observed that, slightly more than half of the patients (53.3%) in the study group were on CPAP mode compared to (46.7%) in the control group, and there was no statistically significant difference between the two groups in relation to the ventilation mode, type of breathing, FiO2, PEEP, Vt, and RR (p= 0.547, p= 0.635, p=0.486, p=0.582, p=0.389, p=0.791) respectively.
PART III: Comparison between the study and control groups patients’ after abdominal massage regarding physiological parameters (hemodynamic and oxygenation parameters) and gastrointestinal outcomes (gastric residual volume, abdominal distension, constipation, vomiting and aspiration).
In relation to physiological parameters including heart rate, mean arterial pressure and respiratory rate. It was noted that study group exhibited lower heart rate , mean arterial pressure, and respiratory rate than the control group, with a significant difference was found between the both groups on 5th day (p=0.035, p= 0.048, p= 0.001) respectively. Moreover, there was a significant difference between 1st day and 5th day in the study group regarding the HR, MAP, and RR after abdominal massage (p=0.020, p= 0.001, p= 0.001) respectively, meanwhile the control group did not show such significant difference (p= 319, p= 0.096, p= 0.214) respectively. Also, it was noted that, there was no significant difference between the both study and control groups regarding oxygen saturation (SaO2) and fraction of inspired oxygen (FIO2).
Regarding gastrointestinal outcomes involving gastric residual volume, abdominal distension, constipation, vomiting and aspiration. The findings of the current study revealed that, gastric residual volume in the study group was lower than the control group after abdominal massage in all days of the study, with a significant difference was found between the both groups in last three days of the study (p=0.038, p=0.020, p=0.009) respectively. It was also indicated that, abdominal distension, constipation, vomiting and aspiration in the study group were less than the control group in all days of the study, with a significant difference was found between both groups in the last two days 4th and 5th of the study.
Furthermore, in the findings of the current study it can be observed that, a significant difference was found between the 1st day and 5th day after abdominal massage in the study group regarding to the gastric residual volume, abdominal distension, constipation, vomiting and aspiration (p= 0.009, p= 0.028, p= 0.001, p= 0.010, p=0.020) respectively, meanwhile the control group did not show such significant difference (p= 0.793, p= 0.598, p= 0.301, p= 0.739, p= 1.00) respectively.
In accordance with the findings of the current study, it can be concluded that abdominal massage was an effective intervention in improvement of gastrointestinal outcomes of enterally fed mechanically ventilated patients as it leads to reduction in gastric residual volume, abdominal distension, constipation, vomiting, as well as incidence of aspiration. Furthermore, it helps in improvement of patients’ physiological parameters as; heart rate, respiratory rate, and mean arterial blood pressure.
Based on the findings of the current study, it can be recommended that:
• Critically ill patients should be assessed carefully before applying abdominal massage for any contraindications.
• Abdominal massage should be considered as a part of routine nursing care in enterally fed mechanically ventilated patients.
• Continuous educational training program should be implemented about abdominal massage as a non- pharmacological method to enhance gastrointestinal motility for critically ill patients.
• Appropriate time and duration to perform abdominal massage for critically ill patients should be scheduled.
• Booklets and videos in ICU about abdominal massage technique for critically ill patients should be available.
• Replication of the study with large probability sample of both genders to allow for greater generalization of the results.
• Further researches are needed for investigating effect of the abdominal massage on gastrointestinal functions and physiological parameters among patients hospitalized in ICUs.