Diarrhoea in the critically ill

Patient care guidelines: a telephone survey of intensive care practices in New South Wales

BACKGROUND

There are a number of practice areas highlighted in the literature as important for the care of critically ill patients. However, the current implementation of evidence into clinical practice for these areas is largely unknown. The development of clinical practice guidelines can translate the current evidence into useful tools to guide clinicians in providing evidence based care.

AIM

To identify existence of current guidelines and informal routine procedures and clinicians' views of same within New South Wales (NSW) Intensive Care Units (ICUs) and High Dependency Units (HDUs) for 11 practice areas, namely, bowel management, endotracheal tube (ETT) stabilisation, tracheostomy tube stabilisation, feeding, analgesia, sedation, thromboembolic prevention, head of bed elevation, ulcer prophylaxis and glucose control.

METHOD

A telephone survey conducted with a representative from NSW ICUs and HDUs.

RESULTS

There was variation in the number of guidelines and informal routine procedures reported for the 11 practice areas within the study units. Larger ICUs (Joint Faculty of Intensive Care Medicine Level II and Level III) and those who employed an onsite CNC were significantly more likely to have formal guidelines in place. Overall, there were very few audits reportedly conducted for the 11 practice areas. Bowel management was the area of practice most respondents reported as a neglected area of critical care nursing practice and the one they were least satisfied with.

CONCLUSION

This survey provides a baseline of current practice and guideline use within NSW ICUs and HDUs. It also highlights areas for consideration to further develop clinical practice guidelines that could benefit critically ill patients.

No inhibition of gastro-intestinal propulsion after propofol- or propofol/ketamine-N2O/O2 anaesthesia. A comparison of gastro-caecal transit after isoflurane anaesthesia

BACKGROUND

Gastrointestinal motility may be considerably reduced by anaesthesia and or surgery resulting in postoperative ileus. Inhibition of propulsive gut motility is especially marked after an opioid-based technique. Little, however, is known of the gastrointestinal effects of the hypnotic propofol when given continuously over a longer period of time, which is the case in total intravenous anaesthesia (TIVA) and in intensive care sedation. We therefore set out to study the effects of a propofol-based nitrous oxide/oxygen anaesthesia (group PO) on gastro-caecal transit time. The results were compared with a propofol-ketamine technique (group PK) and an isoflurane-based anaesthesia (group I; each group n = 20).

METHODS

Gastro-caecal transit was determined by measurement of endexpiratory hydrogen concentration (ppm). Following gastral installation of lactulose at the end of the operation, the disaccharide was degraded by bacteria in the caecum, resulting in the liberation of hydrogen which was expired. A 100% increase in endexpiratory hydrogen concentration compared to the preinduction period was considered the end-point of gastro-caecal transit.

RESULTS

There was no significant difference with regard to gastro-caecal transit in the three groups of patients. In the propofol group mean gastro-caecal transit was 119 (+/- 50.6 SD) min, in the propofol-ketamine group it was 147 (+/- 57.4 SD) min, and in the isoflurane group transit time was 122 (+/- 48.6 SD) min.

CONCLUSION

The data suggest that propofol, even when given as a continuous infusion, does not alter gastrointestinal tract motility more than a standard isoflurane anaesthesia. The data may be particularly relevant to patients who are likely to develop postoperative ileus. They also suggest that in an ICU setting propofol does not alter gut motility more than a sedation technique with the analgesic ketamine.

The effects of psyllium hydrophilic mucilloid on diarrhea in enterally fed patients

OBJECTIVE

To investigate the efficacy of psyllium hydrophilic mucilloid (PHM) for prevention of diarrhea and to compare methods of PHM delivery.

DESIGN

Experimental.

SETTING

University-affiliated Department of Veterans Affairs Medical Center.

SUBJECTS

Sixty patients from medical-surgical and intensive care units who received newly initiated enteral feeding via feeding tube.

OUTCOME MEASURES

Diarrhea, stool frequency and consistency, and feeding tube obstruction.

INTERVENTION

Receipt of PHM (7 gm, twice-daily) added to continuous feeding or given as a bolus with intermittent feeding, or receipt of No PHM for 7 days after initiation of enteral feeding.

RESULTS

Fifteen subjects (25%) developed diarrhea (defined as 3 or more liquid stools per day, or 2 or more liquid stools on successive days). There were no significant differences in incidence of diarrhea or percentage of days of diarrhea between subjects who did and did not receive PHM. However, subjects who received PHM in their continuous feedings had a significantly higher number of gelatinous stools, and the combined PHM groups had a significantly lower number of liquid stools and a higher number of normal stools than did subjects who did not receive PHM. For the combined PHM groups, there was a 12% incidence of small-bore feeding tube occlusion--requiring replacement.

CONCLUSIONS

Further study with a larger sample is necessary to evaluate trends found in this pilot study and to determine PHM efficacy for prevention of diarrhea. PHM administration may result in small-bore feeding tube obstruction, and thus requires adequate dilution and close monitoring.

Reversal by short-chain fatty acids of colonic fluid secretion induced by enteral feeding

Diarrhoea complicates enteral feeding in up to 25% of patients. In-vivo perfusion studies in healthy subjects have shown secretion of salt and water in the ascending colon in response to enteral feeding. This study investigated the effect of short-chain fatty acids (SCFA) on this secretory response. Six healthy volunteers underwent segmental in-vivo colonic perfusion. First, baseline fasting colonic water and electrolyte movement was established, then a standard polymeric enteral diet was infused into the stomach while the colon was perfused with either a control electrolyte solution or a test solution containing SCFA. The electrolyte concentrations and osmolality of the two perfusates were identical. In the fasting state water was absorbed throughout the colon. During the control infusion there was significant (p < 0.05) secretion of water in the ascending colon (median rate 1.0 mL per min [95% CI 2.8 mL per min secretion to 0.8 mL per min absorption]). During the SCFA infusion the secretion was significantly reversed (p < 0.05) and there was net absorption (1.6 [0.8-3.7] mL per min). In the distal colon water absorption was significantly greater during the control infusion than during fasting (3.7 [2.5-4.6] vs 1.3 [0.3-2.2] mL per min); during the test infusion this absorption persisted (2.8 [1.3-3.6] mL per min). Movement of sodium, chloride, and potassium ions was similar to that of water in all stages of the study. Bicarbonate movement did not significantly change at any stage. Infusion of SCFA directly into the caecum reverses the fluid secretion seen in the ascending colon during enteral feeding. This finding could have implications for the management of diarrhoea related to enteral feeding.

Oral rehydration therapy: a Third World solution applied to intensive care

Oral rehydration therapy (ORT)--World Health Organisation formula--has reduced the mortality of severe diarrhoea tenfold but its use in Intensive Care has not been reported. ORT was administered via a nasogastric tube to 3 adult intensive care patients who developed severe diarrhoea and post-operative acute renal impairment. The median intake of ORT was 2.21/day (range 1.5-3.0) and the mean duration of therapy was 7 days (range 6-10). Renal function improved (creatinine fell from 389 to 165 mmol/l) and both haemodynamic and metabolic stability (Na, K, Mg, PO4 and urea) were maintained. While it may not reduce the volume of diarrhoea, ORT provides a cheap, effective and physiological solution to severe gastrointestinal losses in intensive care and may have wider application in both adult and paediatric practice.

Diarrhoea during enteral feeding in the critically ill: a comparison of feeds with and without fibre

This randomised double-blind study examined the frequency of diarrhoea in intensive care unit patients given a fibre-containing feed, Enrich, and a fibre-free feed, Ensure. A daily 'diarrhoea score' was calculated from the frequency, volume and consistency of the stools. A score greater than 12 indicated diarrhoea, and greater than 50 severe diarrhoea. Ninety one patients met the criteria for participation: Enrich 45, Ensure 46. The groups were similar in age, sex ratio, feed volume, antibiotic usage, upper gastro-intestinal bleeding prophylaxis and plasma albumin concentrations. Diarrhoea occurred in 16 patients given Enrich and 13 given Ensure, severe diarrhoea affecting 5 and 9 respectively (NS). Forty seven of 343 (14%) Enrich feeding days and 51 of 342 (15%) Ensure feeding days were complicated by diarrhoea--severe diarrhoea: 8 and 12 feeding days (NS). We conclude soy polysaccharide (21 g/L) did not reduce diarrhoea in intensive care unit patients given enteral feeds.

Diarrhea complicating enteral feeding after liver transplantation

In this case report we present in detail the complex nature of enteral feeding, diarrhea, hypoalbuminemia, and edema in a critically ill patient. We also discuss the use of a peptide-elemental formula in this patient, who suffered continuous diarrhea for 15 weeks after liver transplantation. Use of this formula was associated with cessation of the diarrhea and permitted adequate nutritional delivery. After 26 weeks of mechanical pulmonary ventilation, extubation was possible. This case illustrates the ineffectiveness of parenteral albumin infusions for treatment of enteral edema and demonstrates the restoration of normal intestinal absorptive capacity when ultrafiltration was instituted and the patient's generalized edematous state was corrected.