Factors associated with time to defecate and outcomes in critically ill patients: a prospective, multicentre, observational study

Effect of opioids on constipation in critically ill patients: A meta-analysis

OBJECTIVES

This meta-analysis evaluated the effect of opioids on constipation in ICU patients.

REVIEW METHOD USED

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang DATA databases.

REVIEW METHODS

Random or fixed-effects meta-analyses were used. Subgroup analysis was performed according to the definition of constipation (three vs. six days), opioids (fentanyl vs. morphine), study design (prospective vs. retrospective), adjustment of confounders (No vs. Yes), and patient's age (adults vs. children). We used sensitivity analysis to test the robustness of results with significant statistical heterogeneity.

RESULTS

Seven studies (2264 patients) were included. Opioid use in ICU patients was associated with an increased risk of constipation (relative risk [RR]=1.14; 95% confidence interval [CI]=1.05 to 1.24; I2=49.8%). Subgroup analysis further showed that adjustment form, category of opioid, study design, and patient's age significantly influenced the relationship between opioid use and the risk of constipation. Sensitivity analysis confirmed the robustness of pooled results.

CONCLUSION

Opioids significantly increase the risk of constipation in critically ill patients, especially children. It is worth noting that the adjustment of the constipation definition used for ICU significantly influenced the relationship between opioid use and the risk of constipation. Therefore, It is necessary to clearly define ICU constipation and conduct time-based layered treatment. Additional prospective studies are needed to investigate the consistent definition of ICU constipation.

Development and validation of a clinical score for early diagnosis of constipation in critically ill children

Constipation affects almost 50% of critically ill pediatric patients and is related to their morbidity and mortality. However, little attention is paid to it and it is diagnosed late and when there are already complications. The objective of this study is to develop and validate a score to identify critically ill children with high risk of constipation 48 h after admission. A single center two phase-study was carried out; the first one (retrospective observational study) to develop the score and the second one to validate it in another prospective observational study. Children between 15 days of life and 18 years old admitted to the PICU for more than 3 days were included. Demographic and clinical data during the first 48 h after PICU admission were collected. Univariate and multivariate analysis and ROC curves were used to develop and validate the score. Data from 145 patients (62.8% boys) with a mean age of 34.9 ± 7.3 months were used to develop the score. Independent factors identified to develop the score were: weight > 7 kg, admission to PICU after surgery, need of vasoconstrictors, doses of fentanyl ≥ 2 mcg/kg/h, and initiation of enteral nutrition later than 48 h after admission. Two cut-off values were identified to set low constipation risk (< 5.7 points) and high constipation risk (> 6.2 points). This score was validated in 124 patients showing a sensibility of 63.2%, specificity of 95.5% and a positive/negative predictive values (P/NPV) of 100% and 82.1% respectively to identify constipated patients. This is the first score to identify high constipation risk in critically ill children. This score is easy to apply, and internal validation has shown a PPV of 100%.

Gastrointestinal dysfunction is associated with mortality in severe burn patients: a 10-year retrospective observational study from South China

BACKGROUND

Data on severe and extensive burns in China are limited, as is data on the prevalence of a range of related gastrointestinal (GI) disorders [such as stress ulcers, delayed defecation, opioid-related bowel immotility, and abdominal compartment syndrome (ACS)]. We present a multicentre analysis of coincident GI dysfunction and its effect on burn-related mortality.

METHODS

This retrospective analysis was conducted on patients with severe [≥ 20% total burn surface area (TBSA)] and extensive (> 50% TBSA or > 25% full-thickness TBSA) burns admitted to three university teaching institutions in China between January 1, 2011 and December 31, 2020. Both 30- and 90-day mortality were assessed by collating demographic data, burn causes, admission TBSA, % full-thickness TBSA, Baux score, Abbreviated Burn Severity Index (ABSI) score, and Sequential Organ Failure Assessment (SOFA) score, shock at admission and the presence of an inhalation injury. GI dysfunction included abdominal distension, nausea/vomiting, diarrhoea/constipation, GI ulcer/haemorrhage, paralytic ileus, feeding intolerance and ACS. Surgeries, length of intensive care unit (ICU) stay, pain control [in morphine milligram equivalents (MME)] and overall length of hospital stay (LOHS) were recorded.

RESULTS

We analyzed 328 patients [75.6% male, mean age: (41.6 ± 13.6) years] with a median TBSA of 62.0% (41.0-80.0%); 256 (78.0%) patients presented with extensive burns. The 90-day mortality was 23.2% (76/328), with 64 (84.2%) of these deaths occurring within 30 d and 25 (32.9%) occurring within 7 d. GI dysfunction was experienced by 45.4% of patients and had a significant effect on 90-day mortality [odds ratio (OR) = 14.070, 95% confidence interval (CI) 5.886-38.290, P < 0.001]. Multivariate analysis showed that GI dysfunction was associated with admission SOFA score and % full-thickness TBSA. Overall, 88.2% (67/76) of deceased patients had GI dysfunction [hazard ratio (HR) for death of GI dysfunction = 5.951], with a survival advantage for functional disorders (diarrhoea, constipation, or nausea/vomiting) over GI ulcer/haemorrhage (P < 0.001).

CONCLUSION

Patients with severe burns have an unfavourable prognosis, as nearly one-fifth died within 90 d. Half of our patients had comorbidities related to GI dysfunction, among which GI ulcers and haemorrhages were independently correlated with 90-day mortality. More attention should be given to severe burn patients with GI dysfunction.

Effects of Nalbuphine on Gastrointestinal Function in Post-Operative Critical Ill Patients Admitted to the ICU: A Multicenter Randomized Controlled Trial

Background

Gastrointestinal (GI) function can be a significant problem in critically ill patients and is associated with detrimental outcomes. The administration of opioids for pain reduction is thought to contribute to GI dysfunction. We tested whether nalbuphine, a mixed agonist/antagonist opioid modulator, can promote GI recovery in postoperative critical patients admitted to the intensive care unit (ICU) and compared it with fentanyl, a selective mu opioid receptor (MOR) agonist.

Methods

This is a multicenter, single-blind, randomized controlled trial to investigate whether nalbuphine improves the GI recovery in ICU patients after surgery, and compared it with fentanyl. The primary outcome was the time to first defecation. Secondary outcomes included the use of sedatives, enemas or laxatives, the acute gastrointestinal injury (AGI) grade, the incidence of vomiting, and the lengths of ICU and hospital stays.

Results

We randomized 436 patients, and a total of 369 patients were included in the modified intention-to-treat population (mITT) (185 to the nalbuphine group and 184 to the fentanyl group). The baseline demographic characteristics of the two groups were comparable after randomization. There was no significant difference in the time to defecation between the two groups [hazard ratio (HR) 0.94, 95% CI 0.74–1.19, p = 0.62]. There was no significant difference in the secondary outcomes between the two groups.

Conclusion

We found no evidence that nalbuphine administration can improve the GI function in postoperative critical patients admitted to the ICU compared with fentanyl. However, the CI was wide and we could not exclude the clinically important difference.

Nutrition, defecation, and the lower gastrointestinal tract during critical illness

PURPOSE OF REVIEW

The goal of this report is to delineate the correlation between constipation as a manifestation of impaired gastrointestinal transit with adverse clinical outcomes, to identify risk factors, which predispose to this condition, and outline a management scheme for prophylactic treatment.

RECENT FINDINGS

Constipation is common in the ICU, affecting upwards of 60-85% of critically ill patients. As suggested by case series and observational studies, constipation may be an independent prognostic factor identifying patients with greater disease severity, higher likelihood of organ dysfunction, longer duration of mechanical ventilation, prolonged hospital length of stay, and possibly reduced survival. Treating constipation is a low priority for intensivists often relegated to the nursing service, and few ICUs have well designed protocols in place for a bowel regimen. Small randomized controlled trials show improvement in certain outcome parameters in response to a daily lactulose therapy; hospital length of stay, sequential organ failure assessment scores, and duration of mechanical ventilation. However, aggregating the data from these studies in two separate meta-analyses showed that the effect of a bowel regimen on these three endpoints were not statistically different.

SUMMARY

No causal relationship can be determined between constipation and adverse outcomes. Nonetheless, a clinical correlation seems to exist. Whether constipation is an epiphenomenon or simply a reflection of greater severity of critical illness, at some point it may contribute to worsening morbidity in the ICU. A graded prophylactic bowel regimen should help reverse impairment of the gastrointestinal transit and aid in reducing its deleterious impact on the hospital course of the critically ill patient.

Epidemiology of constipation in critically ill patients and its impact on in-hospital mortality: a retrospective observational study

PURPOSE

There are several causes for delayed constipation in critically ill patients. Constipation in critically ill patients is reportedly associated with poor outcomes. However, a consistent definition for constipation and reports on the prognosis of critically ill patients with constipation are lacking. Therefore, we aimed to determine the epidemiology of constipation during critical illness, and assess the association between constipation and in-hospital mortality based on the two definitions of constipation used in previous studies.

METHODS

This retrospective cohort study comprised adult patients in a general intensive care unit (ICU) during 2011-2018. We retrieved the information regarding their bowel movements and assessed the impact of constipation on the in-hospital mortality based on the previous definitions (absence of defecation for 72 and 144 h).

RESULTS

Among the 1933 adult ICU patients included, the proportion of patients with constipation decreased with a longer duration of constipation (72 h: 67%, 144 h: 36%). In-hospital mortality in the constipation group was much lower than that in the non-constipation group in the univariable analysis (72 h, 27% vs. 13%; 144 h, 31% vs. 21%). However, constipation was not associated with in-hospital mortality in the multivariable analysis (adjusted odds ratio: 0.91, 95% confidence interval: 0.64-1.30 and adjusted odds ratio: 1.14, 95% confidence interval: 0.70-1.85 at 72 and 144 h, respectively).

CONCLUSIONS

Constipation in critically ill patients was not associated with in-hospital mortality based on any definition of constipation used in previous studies. Further prospective studies are necessary to validate our findings.

The effect of opioids on gastrointestinal function in the ICU

Gastrointestinal (GI) dysfunction is common in the critical care setting and is highly associated with clinical outcomes. Opioids increase the risk for GI dysfunction and are frequently prescribed to reduce pain in critically ill patients. However, the role of opioids in GI function remains uncertain in the ICU. This review aims to describe the effect of opioids on GI motility, their potential risk of increasing infection and the treatment of GI dysmotility with opioid antagonists in the ICU setting.

Pandemic risk management using engineering safety principles

The containment of infectious diseases is challenging due to complex transmutation in the biological system, intricate global interactions, intense mobility, and multiple transmission modes. An emergent disease has the potential to turn into a pandemic impacting millions of people with loss of life, mental health, and severe economic impairment. Multifarious approaches to risk management have been explored for combating an epidemic spread. This work presents the implementation of engineering safety principles to pandemic risk management. We have assessed the pandemic risk using Paté-Cornell's six levels of uncertainty. The susceptible, exposed, infected, quarantined, recovered, deceased (SEIQRD), an advanced mechanistic model, along with the Monte Carlo simulation, has been used to estimate the fatality risk. The risk minimization strategies have been categorized into hierarchical safety measures. We have developed an event tree model of pandemic risk management for distinct risk-reducing strategies realized due to natural evolution, government interventions, societal responses, and individual practices. The roles of distinct interventions have also been investigated for an infected individual's survivability with the existing healthcare facilities. We have studied the Corona Virus Disease of 2019 (COVID-19) for pandemic risk management using the proposed framework. The results highlight effectiveness of the proposed strategies in containing a pandemic.