[Analysis of constipation in severe trauma patients]

Diarrhoea and constipation during artificial nutrition in intensive care unit: A prospective observational study

PURPOSE

To describe the occurrence of gastrointestinal (GI) complications, specifically diarrhoea and constipation, in artificially (enterally or parenterally) fed critically ill patients within their first seven-day stay in Intensive Care Unit (ICU).

METHODS

Observational prospective study conducted from September 1st to October 30th, 2019 and from August 1st to October 30th, 2021, in an ICU of a 1000-bed third-level hospital. General characteristics, nutritional variables, and medications administered were recorded and analysed. This study was registered on ClinicalTrials.gov (Identifier: NCT05473546).

RESULTS

In total, 100 critically ill patients were included. Diarrhoea was present in 44 patients (44.0%), while constipation occurred in 22 (22.0%) patients. Patients with diarrhoea were generally those admitted for respiratory failure, whereas patients without diarrhoea were mostly affected by neurological disorders (22.7% vs 25%, respectively; p = 0.002). Likewise, patients with constipation were primarily those admitted for trauma (36.4%). Trauma patients were almost 24 times more likely to be constipated than patients with respiratory failure (OR 23.99, CI 1.38-418.0) and patients receiving diuretics were over 16 times more likely to have diarrhoea than patients not receiving diuretics (OR 16.25, IC 1.89-139.86).

CONCLUSION

GI complications of enteral nutrition represent still a very common issue in ICU. The main predictor of constipation was an admission for trauma whereas the main predictor of diarrhoea was the use of diuretics. Clinicians should consider and integrate these findings into more personalized nutritional and management protocols to avoid gastrointestinal complications.

Effects of Abdominal Massage for Preventing Acute Postoperative Constipation in Hip Fractures: A Prospective Interventional Study

Background

This prospective randomized controlled study aimed to determine the effects of abdominal massage on constipation management in elderly patients with hip fractures.

Methods

From August 2017 to December 2018, patients aged above 65 years with hip fractures (n = 88) were randomly assigned to a massage group that received a bowel massage (n = 48) or a control group that did not receive a bowel massage (n = 40). Patients in the bowel massage group received a bowel massage from a trained caregiver after breakfast at approximately 9:00 AM for an hour. On admission, 5 days after surgery, and on the day of discharge, the patient's normal and actual defecation pattern, stool consistency, and any problems with defecation were assessed through a structured interview. The questionnaire comprising the Bristol Stool Scale, patient assessment of constipation, time to defecation, medication for defecations, failure to defecate, cause of admission, admission period, and date of surgery were recorded. Statistical analyses were performed 5 days after surgery and on the day of discharge.

Results

The mean age of the study cohort was 81.4 years (range, 65-99 years). The number of constipation remedies was significantly lower in the massage group than in the control group on postoperative day (POD) 5 and at discharge (9 vs. 15, p = 0.049 and 6 vs. 11, p = 0.039, respectively). The number of defecation failures was significantly lower in the massage group than in the control group (10 vs. 17, p = 0.028) on POD 5. However, the number of defecation failures at discharge was not significantly different between the two groups (p = 0.131). The development of postoperative ileus (p = 0.271) and length of hospital stay (p = 0.576) were not different between the groups.

Conclusions

The number of constipation remedies was significantly lower in the massage group than in the control group on POD 5 and discharge, and the number of defecation failures was significantly lower in the massage group than in the control group on POD 5. Therefore, abdominal massage may be considered as an independent nursing initiative for constipation management.

Constipation in a cohort prospective in adult critically ill patients: How much occurs and why?

OBJECTIVE

To assess the incidence and factors associated with constipation in adult critical care patients.

DESIGN

Prospective cohort study.

SETTING

Intensive care unit (ICU) of a high-complexity hospital from November 2015 to October 2016.

PATIENTS

Adults who were hospitalized for at least 72h in the ICU were followed from their admission to the ICU until their departure.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In the 157 patients followed up, the incidence of constipation was 75.8%. The univariate analysis showed that constipated patients were younger, used more sedation and showed more respiratory and postoperative causes for hospitalization, while non-constipated patients were hospitalized more for gastrointestinal reasons. The use of vasoactive substances, mechanical ventilation and haemodialysis was similar between the constipated and non-constipated patients. Multivariate analysis, days of use of docusate+bisacodyl (HR: .79; 95% CI: .65-.96) of omeprazole or ranitidine (HR: .80; 95%CI: .73-.88) and lactulose (HR: .87; 95%CI: .76-.99) were independent protection factors for constipation.

CONCLUSION

Constipation has a high incidence among adult critical care patients. Days of drug use acting on the digestive tract (lactulose, docusate+bisacodyl and omeprazole and/or ranitidine) are able to prevent this outcome.

Evaluation and handling of constipation in critical patients

OBJECTIVE

To evaluate the effectiveness of nursing care against constipation and to identify, analyze and evaluate causes and consequences.

METHODOLOGY

Observational, descriptive and prospective study in polyvalent ICU tertiary hospital (2013-2015).

INCLUSION CRITERIA

>18 years, stay >7 days, connected to respiratory support, with nasogastric tube and enteral or mixed nutrition. Patients with gastrointestinal pathology, encephalopathic and jejunostomy/ileostomy were excluded. The studied variables (age, sex, weight, height, pathology, medical treatment, nutrition and volume type, depositional characteristics, quantity and frequency, corrective measures and complications) were collected by ad hoc grill. It is authorized by the CEIC.

RESULTS

139 patients with a mean age of 62 years and average stay of 11 days were analyzed; 63% suffered from constipation. Opiates and antacid were the drugs administered most frequently (99%), even though patients who took muscle relaxants, iron supplements and/or calcium and anti-hypertensive were the ones who suffered most from constipation (77%; 75%; 70%) The fiber free diet was the most widely used (60% constipated), followed by dietary fiber (51% constipated), and the combination of both (85% constipated). 56% used laxatives as a corrective measure, Magnesium Hydroxide being the most widely used; 54% began the first day. Gastric retention was the most relevant complication (49%).

CONCLUSION

Constipation is a real multifactorial problem. We recommend: • Intensified surveillance in patients with drugs that promote constipation. • Use high-fiber diets from the outset. • Apply laxatives and prokinetics early and in combination. We need to create a protocol for prophylaxis and management of constipation.

Daily laxative therapy reduces organ dysfunction in mechanically ventilated patients: a phase II randomized controlled trial

INTRODUCTION

Constipation is a common problem in intensive care units. We assessed the efficacy and safety of laxative therapy aiming to promote daily defecation in reducing organ dysfunction in mechanically ventilated patients.

METHODS

We conducted a prospective, randomized, controlled, nonblinded phase II clinical trial at two general intensive care units. Patients expected to remain ventilated for over 3 days were randomly assigned to daily defecation or control groups. The intervention group received lactulose and enemas to produce 1-2 defecations per day. In the control group, absence of defecation was tolerated up to 5 days. Primary outcome was the change in Sequential Organ Failure Assessment (SOFA) score between the date of enrollment and intensive care unit discharge, death or day 14.

RESULTS

We included 88 patients. Patients in the treatment group had a higher number of defecations per day (1.3 ± 0.42 versus 0.7 ± 0.56, p < 0.0001) and lower percentage of days without defecation (33.1 ± 15.7% versus 62.3 ± 24.5%, p < 0.0001). Patients in the intervention group had a greater reduction in SOFA score (-4.0 (-6.0 to 0) versus -1.0 (-4.0 to 1.0), p = 0.036) with no difference in mortality rates or in survival time. Adverse events were more frequent in the treatment group (4.5 (3.0-8.0) versus 3.0 (1.0-5.7), p = 0.016), including more days with diarrhea (2.0 (1.0-4.0) versus 1.0 (0-2.0) days, p < 0.0001). Serious adverse events were rare and did not significantly differ between groups.

CONCLUSIONS

Laxative therapy improved daily defecation in ventilated patients and was associated with a greater reduction in SOFA score.

TRIAL REGISTRATION

Clinical Trials.gov NCT01607060, registered 24 May 2012.

Changing clinical guidelines from delayed to early aperient administration for enterally fed intensive care patients was associated with increased diarrhoea: a before-and-after, intention-to-treat evaluation

BACKGROUND

The 14-bed intensive care unit of a tertiary referral hospital adopted a guideline to start docusate sodium with sennosides when enteral nutrition was started. This replaced a guideline to start aperients after 24h of enteral nutrition if no bowel action had occurred. We sought to determine the effect of this change on the incidence of diarrhoea and constipation in intensive care.

METHODS

Retrospective audit of the medical records of consecutive adult patients admitted to intensive care and given enteral nutrition, excluding those with a primary gastrointestinal system diagnosis, between Jan-Aug 2011 (the delayed group, n=175) and Jan-Aug 2012 (the early group, n=175). The early aperient guideline was implemented during Sep-Dec 2011.

RESULTS

The early and delayed groups were similar in age (median 62 years vs. 64 years; P=0.17), sex (males 65% vs. 63%; P=0.91), and postoperative cases (31% vs. 33%; P=0.82) and had similar proportions who received mechanical ventilation (95% vs. 95%; P=1.00), an inotrope or vasopressor (63% vs. 70%; P=0.17), renal replacement therapy (8% vs. 10%; P=0.71), opiates (77% vs. 80%; P=0.60), antibiotics (89% vs. 91%; P=0.72) and metoclopramide (46% vs. 55%; P=0.11). A significantly larger proportion of the early group received an aperient (54% vs. 29%, P<0.001) and experienced diarrhoea (38% vs. 27%, P=0.04), but the groups had similar proportions affected by constipation (42% vs. 43%, P=0.91).

CONCLUSIONS

Changing guidelines from delayed to early aperient administration was associated with an increase in the incidence of diarrhoea but was not associated with the incidence of constipation. These findings do not support changing guidelines from delayed to early aperient administration.