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Lawson CM, Jones C, Herman M, Kim C, Mannino E, Omer E, Venegas C. Does Ileus Represent the Forgotten End Organ Failure in Critical Illness? Curr Gastroenterol Rep 2024; 26:166-171. [PMID: 38558135 DOI: 10.1007/s11894-023-00910-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 04/04/2024]
Abstract
PURPOSE OF REVIEW This review evaluates the current literature on ileus, impaired gastrointestinal transit (IGT), and acute gastrointestinal injury (AGI) and its impact on multiple organ dysfunction syndrome. RECENT FINDINGS Ileus is often under recognized in critically ill patients and is associated with significant morbidity and is potentially a marker of disease severity as seen in other organs like kidneys (ATN).
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Affiliation(s)
- Christy M Lawson
- Department of Trauma Surgery, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA.
| | - Chris Jones
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Michael Herman
- Department of Gastroenterology, Borland Groover Clinic, Fleming Island, FL, USA
| | - Cecilia Kim
- Department of Trauma Surgery, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Elizabeth Mannino
- Department of Trauma Surgery, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Endashaw Omer
- Department of Gastroenterology, University of Louisville, Louisville, KY, USA
| | - Carlas Venegas
- Department of Neurology, Mayo Clinc, Jacksonville, FL, USA
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2
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Roller MD, Panchal A, Duesing L, Mikhailov TA. Incidence of opioid-induced constipation in the pediatric intensive care unit: A descriptive cohort study. JPEN J Parenter Enteral Nutr 2024; 48:354-359. [PMID: 38142301 DOI: 10.1002/jpen.2592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 11/23/2023] [Accepted: 12/13/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Opioid-induced constipation (OIC) is a well-known phenomenon, although there is limited literature evaluating the incidence of OIC in children admitted to the pediatric intensive care unit (PICU). The primary aim of this study was to determine the incidence of OIC in the PICU and to determine if it is associated with a higher rate of morbidities or prolonged length of stay (LOS). METHODS We conducted a single-center retrospective chart review from July 1, 2014, to June 30, 2015, in our PICU. We included all patients aged ≤18 years with a PICU stay of ≥96 h who received opioids during their admission. Data were collected on the frequency of bowel movements and characteristics of opioid administration. Demographic and clinical data were obtained from Virtual Pediatric Systems, LLC. RESULTS Of the 94 patients who met the study criteria, 39.4% developed constipation. These patients tended to be older (P = 0.06) and were noted to weigh more (P = 0.03). There was no significant difference in the total or median daily doses, duration of opioid treatment, or mode of administration. Constipation rates did not differ by the severity of illness. There was a higher incidence of constipation in the patients who were admitted for neurological issues or after trauma or abdominal surgery (P = 0.002). Patients with constipation had a longer LOS than patients without constipation, but the difference was not statistically significant. CONCLUSION These results indicate that opioid use is not the sole risk factor for constipation in the PICU setting.
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Affiliation(s)
- Meghan D Roller
- Department of Pediatrics, Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Apurva Panchal
- Critical Care, Children's Mercy Hospital and Clinics, Kansas City, Missouri, USA
| | - Lori Duesing
- Children's Wisconsin, Milwaukee, Wisconsin, USA
- Department of General Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Theresa A Mikhailov
- Department of Pediatrics, Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Children's Wisconsin, Milwaukee, Wisconsin, USA
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3
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Liu X, Yu N, Lu H, Zhang P, Liu C, Liu Y. Effect of opioids on constipation in critically ill patients: A meta-analysis. Aust Crit Care 2024; 37:338-345. [PMID: 37586897 DOI: 10.1016/j.aucc.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/09/2023] [Accepted: 06/11/2023] [Indexed: 08/18/2023] Open
Abstract
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.
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Affiliation(s)
- Xuefang Liu
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ning Yu
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Huaihai Lu
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Pei Zhang
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chao Liu
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ya Liu
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, Shijiazhuang, China.
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Nishiyama S, Uchino S, Sasabuchi Y, Masuyama T, Lefor AK, Sanui M. Naldemedine is associated with earlier defecation in critically ill patients with opioid-induced constipation: A retrospective, single-center cohort study. PLoS One 2024; 19:e0295952. [PMID: 38170714 PMCID: PMC10763934 DOI: 10.1371/journal.pone.0295952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 11/28/2023] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION There are few reports describing the association of naldemedine with defecation in critically ill patients with opioid-induced constipation. The purpose of this study was to determine whether naldemedine is associated with earlier defecation in critically ill patients with opioid-induced constipation. METHODS In this retrospective cohort study, patients admitted to the Intensive Care Unit (ICU) without defecation for 48 hours while receiving opioids were eligible for enrollment. The primary endpoint was the time of the first defecation within 96 hours after inclusion. Secondary endpoints included presence of diarrhea, duration of mechanical ventilation, ICU length of stay, ICU mortality, and in-hospital mortality. The Cox proportional hazard regression analysis with time-dependent covariates was used to evaluate the association naldemedine with earlier defecation. RESULTS A total of 875 patients were enrolled and were divided into 63 patients treated with naldemedine and 812 patients not treated. Defecation was observed in 58.7% of the naldemedine group and 48.8% of the no-naldemedine group during the study (p = 0.150). The naldemedine group had statistically significantly prolonged duration of mechanical ventilation (8.7 days vs 5.5 days, p < 0.001) and ICU length of stay (11.8 days vs 9.2 days, p = 0.001) compared to the no-naldemedine group. However, the administration of naldemedine was significantly associated with earlier defecation [hazard ratio:2.53; 95% confidence interval: 1.71-3.75, p < 0.001]. CONCLUSION The present study shows that naldemedine is associated with earlier defecation in critically ill patients with opioid-induced constipation.
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Affiliation(s)
- Seiya Nishiyama
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Omiya, Saitama, Japan
| | - Shigehiko Uchino
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Omiya, Saitama, Japan
| | - Yusuke Sasabuchi
- Data Science Center, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Tomoyuki Masuyama
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Omiya, Saitama, Japan
| | - Alan Kawarai Lefor
- Department of Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Omiya, Saitama, Japan
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Umbrello M, Venco R, Palandri C, Racagni M, Muttini S. Peripherally-active mu-opioid receptor antagonists for constipation in critically ill patients receiving opioids: A case-series and a systematic review and meta-analysis of the literature. Neurogastroenterol Motil 2023; 35:e14694. [PMID: 37869768 DOI: 10.1111/nmo.14694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 09/15/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Constipation is frequent in critically ill patients, and potentially related to adverse outcomes. Peripherally-active mu-opioid receptor antagonists (PAMORAs) are approved for opioid-induced constipation, but information on their efficacy and safety in critically ill patients is limited. We present a single-center, retrospective, case-series of the use of naldemedine for opioid-associated constipation, and we systematically reviewed the use of PAMORAs in critically ill patients. METHODS Case-series included consecutive mechanically-ventilated patients; constipation was defined as absence of bowel movements for >3 days. Naldemedine was administered after failure of the local laxation protocol. Systematic review: PubMed was searched for studies of PAMORAs to treat opioid-induced constipation in adult critically ill patients. PRIMARY OUTCOMES time to laxation, and number of patients laxating at the shortest follow-up. SECONDARY OUTCOMES gastric residual volumes and adverse events. KEY RESULTS A total of 13 patients were included in the case-series; the most common diagnosis was COVID-19 ARDS. Patients had their first bowel movement 1 [0;2] day after naldemedine. Daily gastric residual volume was 725 [405;1805] before vs. 250 [45;1090] mL after naldemedine, p = 0.0078. Systematic review identified nine studies (two RCTs, one prospective case-series, three retrospective case-series and three case-reports). Outcomes were similar between groups, with a trend toward a lower gastric residual volume in PAMORAs group. CONCLUSIONS & INFERENCES In a highly-selected case-series of patients with refractory, opioid-associated constipation, naldemedine was safe and associated to reduced gastric residuals and promoting laxation. In the systematic review and meta-analysis, the use of PAMORAs (mainly methylnaltrexone) was safe and associated with a reduced intolerance to enteral feeding but no difference in the time to laxation.
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Affiliation(s)
- Michele Umbrello
- SC Rianimazione e Anestesia, Ospedale Nuovo di Legnano, ASST Ovest Milanese, Legnano, Italy
| | - Roberto Venco
- SC Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo, Milano, Italy
| | - Chiara Palandri
- SC Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo, Milano, Italy
| | - Milena Racagni
- SC Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo, Milano, Italy
| | - Stefano Muttini
- SC Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo, Milano, Italy
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Park YG, Kim BS, Kang KT, Ha YC. Effects of Abdominal Massage for Preventing Acute Postoperative Constipation in Hip Fractures: A Prospective Interventional Study. Clin Orthop Surg 2023; 15:546-551. [PMID: 37529190 PMCID: PMC10375809 DOI: 10.4055/cios22091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 10/03/2022] [Accepted: 10/10/2022] [Indexed: 08/03/2023] Open
Abstract
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.
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Affiliation(s)
- Yong-Gum Park
- Department of Surgery, Chung-Ang University Hospital, Chung-Ang University School of Medicine, Seoul, Korea
| | - Boo Seop Kim
- Department of Orthopedic Surgery, Chung-Ang University H.C.S. Hyundae General Hospital, Namyangju, Korea
| | - Kyu-Tae Kang
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University School of Medicine, Seoul, Korea
| | - Yong-Chan Ha
- Department of Orthopedic Surgery, Seoul Bumin Hospital, Seoul, Korea
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7
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Rizwan MZ, Garcia R, Mara K, Nei S. Evaluating the Safety and Efficacy of Naloxegol in Critically Ill Opioid-Induced Constipation Patients. Cureus 2023; 15:e41422. [PMID: 37546147 PMCID: PMC10403335 DOI: 10.7759/cureus.41422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2023] [Indexed: 08/08/2023] Open
Abstract
Background Opioid-induced constipation (OIC) has become more common in the intensive care unit (ICU) due to increased opioid utilization. Traditional laxatives often prove ineffective against OIC, leading to the increased utilization of naloxegol. However, further research is needed to confirm naloxegol's effectiveness and safety in critical care. This study aimed to explore the safety and efficacy of this intervention in critically ill OIC patients. Methods A single-center retrospective study was conducted on 353 patients who received one or more doses of naloxegol from January 1, 2019, to June 30, 2020, for OIC at a tertiary care center. The primary endpoint of this study was to evaluate serious adverse events such as reduced analgesic effect, gastrointestinal perforation, seizure, acute myocardial infarction (AMI), or ventricular arrhythmias using Naranjo Scale in critically ill patients. The secondary goal was to assess the efficacy of naloxegol, measured by the time of the first bowel movement. Results The average duration of naloxegol use was three days, with the first bowel movement occurring at an average of 11.3 hours. Furthermore, 59.8% of individuals had their first bowel movement within 20 hours of receiving naloxegol. There was a low level of causality between naloxegol use and adverse events such as gastrointestinal perforation, seizures, AMI, cardiovascular mortality, stroke, and ventricular arrhythmia. Additionally, reduction in analgesia showed no strong relationship with naloxegol use indicated by the Naranjo Scale assessment. Conclusion Naloxegol showed promising safety and efficacy profiles in treating OIC amongst critically ill patients, though our findings require further validation through prospective studies. This research paves the way for further investigation into naloxegol's role in OIC management, emphasizing the necessity of personalized treatment strategies in critical care settings.
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Affiliation(s)
| | | | - Kristin Mara
- Department of Biostatistics, Mayo Clinic, Rochester, USA
| | - Scott Nei
- Department of Pharmacy, Mayo Clinic, Rochester, USA
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8
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Schlebusch S, Graham RMA, Jennison AV, Lassig-Smith MM, Harris PNA, Lipman J, Ó Cuív P, Paterson DL. Standard rectal swabs as a surrogate sample for gut microbiome monitoring in intensive care. BMC Microbiol 2022; 22:99. [PMID: 35413802 PMCID: PMC9004175 DOI: 10.1186/s12866-022-02487-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 03/04/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The purpose of this study was to investigate the use of routinely available rectal swabs as a surrogate sample type for testing the gut microbiome and monitoring antibiotic effects on key gut microorganisms, of patients hospitalised in an intensive care unit. A metagenomic whole genome sequencing approach was undertaken to determine the diversity of organisms as well as resistance genes and to compare findings between the two sampling techniques. RESULTS No significant difference was observed in overall diversity between the faeces and rectal swabs and sampling technique was not demonstrated to predict microbial community variation. More human DNA was present in the swabs and some differences were observed only for a select few anaerobes and bacteria also associated with skin and/or the female genitourinary system, possibly reflecting sampling site or technique. Antibiotics and collections at different times of admission were both considered significant influences on microbial community composition alteration. Detection of antibiotic resistance genes between rectal swabs and faeces were overall not significantly different, although some variations were detected with a potential association with the number of human sequence reads in a sample. CONCLUSION Testing the gut microbiome using standard rectal swab collection techniques currently used for multi-resistant organism screening has been demonstrated to have utility in gut microbiome monitoring in intensive care. The use of information from this article, in terms of methodology as well as near equivalence demonstrated between rectal swabs and faeces will be able to support and potentially facilitate the introduction into clinical practice.
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Affiliation(s)
- Sanmarié Schlebusch
- University of Queensland Centre for Clinical Research, Herston, Brisbane, Queensland, Australia. .,Q-PHIRE Genomics and Public Health Microbiology, Forensic and Scientific Services, Coopers Plains, Brisbane, Queensland, Australia. .,Pathology Queensland, Queensland Health, Herston, Brisbane, Queensland, Australia.
| | - Rikki M A Graham
- Q-PHIRE Genomics and Public Health Microbiology, Forensic and Scientific Services, Coopers Plains, Brisbane, Queensland, Australia
| | - Amy V Jennison
- Q-PHIRE Genomics and Public Health Microbiology, Forensic and Scientific Services, Coopers Plains, Brisbane, Queensland, Australia
| | - Melissa M Lassig-Smith
- Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Patrick N A Harris
- University of Queensland Centre for Clinical Research, Herston, Brisbane, Queensland, Australia.,Pathology Queensland, Queensland Health, Herston, Brisbane, Queensland, Australia
| | - Jeffrey Lipman
- University of Queensland Centre for Clinical Research, Herston, Brisbane, Queensland, Australia.,Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Páraic Ó Cuív
- Mater Research Institute, Translational Research Institute, University of Queensland, Brisbane, Queensland, Australia
| | - David L Paterson
- University of Queensland Centre for Clinical Research, Herston, Brisbane, Queensland, Australia
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McClave SA. Nutrition, defecation, and the lower gastrointestinal tract during critical illness. Curr Opin Clin Nutr Metab Care 2022; 25:110-115. [PMID: 35026804 DOI: 10.1097/mco.0000000000000814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Stephen A McClave
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky, USA
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10
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Asrani VM, McArthur C, Bissett I, Windsor JA. The intensivist's assessment of gastrointestinal function: A pilot study. Aust Crit Care 2021; 35:636-643. [PMID: 34895985 DOI: 10.1016/j.aucc.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 11/30/2022] Open
Abstract
Gastrointestinal dysfunction/failure (GDF) is a common cause of concern in critically ill patients. Although the gut plays an important role in the genesis of organ failure, its exclusion from organ severity scoring systems has made it challenging for intensivists to score it sufficiently at the bedside. We aimed to survey intensive care specialists about their perceptions, attitudes, and approaches towards the assessment of the gut in Australia and New Zealand intensive care units (ICUs). An electronic (online) questionnaire was used to survey intensive care specialists from the Australia and New Zealand Intensive Care Society (ANZICS). The survey comprised 10 questions focused on four key areas: (i) the extent of the problem with GDF in ICUs, (ii) the use and reliability of the current gut scoring tools, (iii) personal approaches and practices associated with GDF assessment, and (4) potential value of a novel GDF scoring system and its incorporation into an organ severity score. Our results showed that GDF was a significant concern amongst ICUs in Australia and New Zealand intensivists (84%; 66/79), with a small number of participants (14%; 3/79) using a gut scoring tool in their ICUs. Despite this, we have no established objective scoring tool for its assessment. The survey highlighted the need for developing a novel scoring tool to assess the gut was considered important amongst majority of the intensivists (92%; 72/78), which would prove useful in clinical practice and potentially lead to incorporation into an organ severity score in the future.
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Affiliation(s)
- Varsha M Asrani
- Surgical and Translational Research (STaR) Centre, Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Nutrition and Dietetics, Auckland City Hospital, Auckland, New Zealand; Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand.
| | - Colin McArthur
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Ian Bissett
- Surgical and Translational Research (STaR) Centre, Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - John A Windsor
- Surgical and Translational Research (STaR) Centre, Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
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11
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Yan Y, Chen Y, Zhang X. The effect of opioids on gastrointestinal function in the ICU. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:370. [PMID: 34689805 PMCID: PMC8543814 DOI: 10.1186/s13054-021-03793-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/12/2021] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Yun Yan
- Department of Anaesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.,Department of Critical Care Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Yu Chen
- Department of Anaesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China. .,Department of Critical Care Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.
| | - Xijing Zhang
- Department of Anaesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China. .,Department of Critical Care Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.
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12
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Factors associated with enteral nutrition and the incidence of gastrointestinal disorders in a cohort of critically ill adults. NUTR HOSP 2021; 38:429-435. [PMID: 33648344 DOI: 10.20960/nh.03245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction Introduction: adults in intensive care commonly receive enteral nutrition (EN). Data describing the conditions associated with EN in critically ill patients are limited. Objective: to describe the incidence of gastrointestinal disorders and to identify conditions associated with the use of EN. Methods: a prospective cohort, single-center study of critically ill adults. The patients were followed daily for the first 10 days of hospitalization in the intensive care unit (ICU) or until ICU discharge or death. Clinical, nutritional variables and gastrointestinal disorders were compared between patients who did and did not receive EN. Univariate and multivariate regression identified the conditions associated with EN with the proposed variables. Results: of the 157 included adults, 62 % received EN. The EN group had higher APACHE II (23.6 ± 7.6 vs. 15 ± 7.2, p < 0.001) and SOFA scores on the day of ICU admission [7 (5-10.5) vs. 4 (2-6); p < 0.001], and higher ICU mortality (32 % vs. 10 %, p = 0.002). Diarrhea and need for gastric decompression were more frequent in the EN group (39.7 % vs. 11.7 %, p < 0.001 and 34 % vs. 13.3 %, p = 0.004, respectively). The multivariate analysis showed that neurological deficit (OR: 16.7 [95 % CI: 5.9-46.9]; p < 0.001), previous enteral tube feeding (OR: 45.1 [95 % CI: 5.3-380]; p < 0.001), and SOFA score on the day of ICU admission (OR: 1.2 [95 % CI: 1.01-1.3]; p = 0.03) were associated with EN. Conclusions: conditions related to the severity of critically ill patients, such as higher SOFA scores, greater neurological deficit, and prior enteral tube feeding, were more commonly associated with EN. Diarrhea and need for gastric decompression were more frequent in patients who received EN.
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Seilitz J, Edström M, Sköldberg M, Westerling-Andersson K, Kasim A, Renberg A, Jansson K, Friberg Ö, Axelsson B, Nilsson KF. Early Onset of Postoperative Gastrointestinal Dysfunction Is Associated With Unfavorable Outcome in Cardiac Surgery: A Prospective Observational Study. J Intensive Care Med 2020; 36:1264-1271. [PMID: 32772778 PMCID: PMC8494005 DOI: 10.1177/0885066620946006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: The distribution of postoperative gastrointestinal (GI) dysfunction and its association with outcome were investigated in cardiac surgery patients. Gastrointestinal function was evaluated using the Acute Gastrointestinal Injury (AGI) grade proposed by the European Society of Intensive Care Medicine. Design: Prospective observational study at a single center. Setting: University hospital. Patients: Consecutive patients presenting for elective cardiac surgery with extracorporeal circulation (ECC). Interventions: None. Results: Daily assessment using the AGI grade was performed on the first 3 postoperative days in addition to standard care. For analysis, 3 groups were formed based on the maximum AGI grade: AGI 0, AGI 1, and AGI ≥2. Five hundred and one patients completed the study; 32.7%, 65.1%, and 2.2% of the patients scored a maximum AGI 0, AGI 1, and AGI ≥2, respectively. Patients with AGI grade ≥2 had more frequently undergone thoracic aortic surgery and had longer surgery duration and time on ECC. Patients with AGI grade ≥2 had statistically significant higher frequency of GI complications within 30 days (63.6% vs 1.2% and 5.5% in patients with AGI 0 and AGI 1) and higher 30-day mortality (9.1% vs 0.0% and 1.8% in patients with AGI 0 and AGI 1). Conclusions: Early GI dysfunction following cardiac surgery was associated with an unfavorable outcome. Increased attention to GI dysfunction in cardiac surgery patients is warranted and the AGI grade could be a helpful adjunct to a structured approach.
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Affiliation(s)
- Jenny Seilitz
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Måns Edström
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Martin Sköldberg
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kristian Westerling-Andersson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Alhamsa Kasim
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anja Renberg
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kjell Jansson
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Örjan Friberg
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Birger Axelsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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14
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Launey Y, Painvin B, Roquilly A, Dahyot-Fizelier C, Lasocki S, Rousseau C, Frasca D, Gacouin A, Seguin P. Factors associated with time to defecate and outcomes in critically ill patients: a prospective, multicentre, observational study. Anaesthesia 2020; 76:218-224. [PMID: 32662524 DOI: 10.1111/anae.15178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2020] [Indexed: 12/20/2022]
Abstract
Delayed defecation is common in patients on intensive care. We aimed to determine factors associated with time to defecation after admission to intensive care and in turn its association with length of stay and mortality. We studied 396 adults admitted to one of five intensive care units in whom at least 2 days' invasive ventilation was anticipated during an expected stay of at least 3 days. The median (IQR [range]) time to defecate by the 336 out of 396 (84%) patients who did so before intensive care discharge was 6 (4-8 [1-18]) days. Defecation was independently associated with five factors, hazard ratio (95%CI), higher values indicating more rapid defecation: alcoholism, 1.32 (1.05-1.66), p = 0.02; laxatives before admission, 2.35 (1.79-3.07), p < 0.001; non-invasive ventilation, 0.54 (0.36-0.82), p = 0.004; duration of ventilation, 0.78 (0.74-0.82), p < 0.001; laxatives after admission, 1.67 (1.23-2.26), p < 0.001; and enteral nutrition within 48 h of admission, 1.43 (1.07-1.90), p = 0.01. Delayed defecation was associated with prolonged intensive care stay but not mortality.
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Affiliation(s)
- Y Launey
- Department of Anaesthesia and Critical Care, University Hospital, Rennes, France
| | - B Painvin
- Department of Anaesthesia and Critical Care, University Hospital, Rennes, France
| | - A Roquilly
- Department of Anaesthesia and Critical Care, University Hospital, Nantes, France
| | - C Dahyot-Fizelier
- Department of Anaesthesia and Critical Care, University Hospital, Poitiers, France
| | - S Lasocki
- Department of Anaesthesia and Critical Care, University Hospital, Angers, France
| | - C Rousseau
- Department of Clinical Investigation, University Hospital, Rennes, France
| | - D Frasca
- Department of Anaesthesia and Critical Care, University Hospital, Poitiers, France
| | - A Gacouin
- Medical Intensive Care and Infectious Diseases, University Hospital, Rennes, France
| | - P Seguin
- Department of Anaesthesia and Critical Care, University Hospital, Rennes, France
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15
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Charlesworth M, Ashworth AD. The evolution of evidence-based medicine in critical care: have we left 'time to defecation' behind? Anaesthesia 2020; 76:161-164. [PMID: 32662063 DOI: 10.1111/anae.15183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2020] [Indexed: 01/16/2023]
Affiliation(s)
- M Charlesworth
- Department of Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester, UK
| | - A D Ashworth
- Department of Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester, UK
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16
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Abstract
Bowel dysfunction, especially ileus, has been increasingly recognized in critically ill patients. Ileus is commonly associated to constipation, however abnormal motility can also concern the upper digestive tract, therefore impaired gastrointestinal transit (IGT) seems to be a more appropriate term. IGT, especially constipation, is common among patients under mechanical ventilation, occurring in up to 80% of the patients during the first week, and has been associated with worse outcome in intensive care unit (ICU). It is acknowledged that the most relevant definition for constipation in ICU is the absence of stool for the first six days after admission. Concerning the upper digestive intolerance (UDI), the diagnosis should rely only on vomiting and the systematic gastric residual volume (GRV) monitoring should be avoided. IGT results from a complex pathophysiology in which both the critical illness and its specific treatments may have a deleterious role. Both observational and experimental studies have shown the deleterious effect of sepsis, multiorgan failure, sedation (especially opioids) and mechanical ventilation on gut function. To date few studies have reported effect of treatment on IGT and the level of evidence is low. However, cholinesterase inhibitors seem safe and could probably be used in case of constipation but remains poorly prescribed. Prevention with bowel management protocol using osmotic laxatives appears to be safe but did not demonstrate its effectiveness. For patients treated with high posology of opioids during sedation, enteral opioid antagonists may be a promising strategy.
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Affiliation(s)
- Philippe Ariès
- Clermont-Tonnerre Military Teaching Hospital, Brest, France.,Val-de-Grâce French Military Health Service Academy, Paris, France.,Department of Anesthesia and Surgical Intensive Care, Brest Teaching Hospital, Brest, France
| | - Olivier Huet
- Department of Anesthesia and Surgical Intensive Care, Brest Teaching Hospital, Brest, France - .,UFR of Medicine, University of Western Brittany, Brest, France
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17
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Methylnaltrexone for the treatment of opioid-induced constipation and gastrointestinal stasis in intensive care patients. Results from the MOTION trial. Intensive Care Med 2020; 46:747-755. [PMID: 32016532 PMCID: PMC7223905 DOI: 10.1007/s00134-019-05913-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/23/2019] [Indexed: 02/07/2023]
Abstract
Purpose Constipation can be a significant problem in critically unwell patients, associated with detrimental outcomes. Opioids are thought to contribute to the mechanism of bowel dysfunction. We tested if methylnaltrexone, a pure peripheral mu-opioid receptor antagonist, could reverse opioid-induced constipation. Methods The MOTION trial is a multi-centre, double blind, randomised placebo-controlled trial to investigate whether methylnaltrexone alleviates opioid-induced constipation (OIC) in critical care patients. Eligibility criteria included adult ICU patients who were mechanically ventilated, receiving opioids and were constipated (had not opened bowels for a minimum 48 h) despite prior administration of regular laxatives as per local bowel management protocol. The primary outcome was time to significant rescue-free laxation. Secondary outcomes included gastric residual volume, tolerance of enteral feeds, requirement for rescue laxatives, requirement for prokinetics, average number of bowel movements per day, escalation of opioid dose due to antagonism/reversal of analgesia, incidence of ventilator-associated pneumonia, incidence of diarrhoea and Clostridium difficile infection and finally 28 day, ICU and hospital mortality. Results A total of 84 patients were enrolled and randomized (41 to methylnaltrexone and 43 to placebo). The baseline demographic characteristics of the two groups were generally well balanced. There was no significant difference in time to rescue-free laxation between the groups (Hazard ratio 1.42, 95% CI 0.82–2.46, p = 0.22). There were no significant differences in the majority of secondary outcomes, particularly days 1–3. However, during days 4–28, there were fewer median number of bowel movements per day in the methylnaltrexone group, (p = 0.01) and a greater incidence of diarrhoea in the placebo group (p = 0.02). There was a marked difference in mortality between the groups, with ten deaths in the methylnaltrexone group and two in the placebo group during days 4–28 (p = 0.007). Conclusion We found no evidence to support the addition of methylnaltrexone to regular laxatives for the treatment of opioid-induced constipation in critically ill patients; however, the confidence interval was wide and a clinically important difference cannot be excluded. Electronic supplementary material The online version of this article (10.1007/s00134-019-05913-6) contains supplementary material, which is available to authorized users.
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18
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Fair K, Dunlap DG, Fitch A, Bogdanovich T, Methé B, Morris A, McVerry BJ, Kitsios GD. Rectal Swabs from Critically Ill Patients Provide Discordant Representations of the Gut Microbiome Compared to Stool Samples. mSphere 2019; 4:e00358-19. [PMID: 31341070 PMCID: PMC6656869 DOI: 10.1128/msphere.00358-19] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/12/2019] [Indexed: 02/03/2023] Open
Abstract
The role of the gut microbiome in critical illness is being actively investigated, but the optimal sampling methods for sequencing studies of gut microbiota remain unknown. Stool samples are generally considered the reference standard but are not practical to obtain in the intensive care unit (ICU), and thus, rectal swabs are often used. However, the reliability of rectal swabs for gut microbiome profiling has not been established in the ICU setting. In this study, we compared 16S rRNA gene sequencing results between rectal swab and stool samples collected at three time points from mechanically ventilated critically ill adults. Rectal swabs comprised 89% of the samples collected at the baseline time point, but stool samples became more extensively available at later time points. Significant differences in alpha-diversity and beta-diversity between rectal swabs and stool samples were observed, but these differences were primarily due to baseline samples. Higher relative abundances of members of the Actinobacteria phylum (typically skin microbes) were present in rectal swabs than in stool samples (P = 0.05), a difference that was attenuated over time. The progressively increasing similarity of rectal swabs and stool samples likely resulted from increasing levels of stool coating of the rectal vault and direct soiling of the rectal swabs taken at later time points. Therefore, inferences about the role of the gut microbiome in critical illness should be drawn cautiously and should take into account the type and timing of samples analyzed.IMPORTANCE Rectal swabs have been proposed as potential alternatives to stool samples for gut microbiome profiling in outpatients or healthy adults, but their reliability in assessment of critically ill patients has not been defined. Because stool sampling is not practical and often not feasible in the intensive care unit, we performed a detailed comparison of gut microbial sequencing profiles between rectal swabs and stool samples in a longitudinal cohort of critically ill patients. We identified systematic differences in gut microbial profiles between rectal swabs and stool samples and demonstrated that the timing of the rectal swab sampling had a significant impact on sequencing results. Our methodological findings should provide valuable information for the design and interpretation of future investigations of the role of the gut microbiome in critical illness.
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Affiliation(s)
- Katherine Fair
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Daniel G Dunlap
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adam Fitch
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tatiana Bogdanovich
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Barbara Methé
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alison Morris
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bryan J McVerry
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Georgios D Kitsios
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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19
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20
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Hay T, Bellomo R, Rechnitzer T, See E, Ali Abdelhamid Y, Deane AM. Constipation, diarrhea, and prophylactic laxative bowel regimens in the critically ill: A systematic review and meta-analysis. J Crit Care 2019; 52:242-250. [PMID: 30665795 DOI: 10.1016/j.jcrc.2019.01.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/24/2018] [Accepted: 01/08/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Prophylactic laxative bowel regimens may prevent constipation in enterally-fed critically ill patients. However, their use may also increase diarrhea. We performed a systematic review to: 1. Explore the epidemiology of constipation and/or diarrhea in critically ill patients; and 2. Appraise trials evaluating prophylactic laxative bowel regimens. METHODS We searched MEDLINE, Embase, and CINAHL for publications that reported constipation or diarrhea in critically ill adult patients and/or prophylactic laxative bowel regimens. RESULTS The proportion of critically ill patients experiencing constipation was reported between 20% and 83% and the proportion experiencing diarrhea was reported between 3.3% and 78%. Six studies of prophylactic laxative bowel regimens were identified but only 3 randomised controlled trials were identified, and these were subjected to meta-analysis. Compared with placebo, a prophylactic laxative bowel regimen increased the risk of diarrhea (RR 1.58, 95% CI 1.22 to 2.04) but did not reduce the risk of constipation (RR 0.39, 95% CI 0.14 to 1.05), and did not affect the duration of mechanical ventilation, duration of ICU admission, or mortality. CONCLUSIONS Constipation and diarrhea occur frequently in the critically ill but data evaluating prophylactic laxative bowel regimens in such patients are sparse and do not support their use.
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Affiliation(s)
- Tyler Hay
- The University of Melbourne, Melbourne Medical School, Parkville, Victoria, Australia
| | - Rinaldo Bellomo
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, VIC 3050, Australia; Intensive Care Unit, The Austin Hospital, Heidelberg, Victoria, Australia; Intensive Care Unit, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Tom Rechnitzer
- Intensive Care Unit, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Emily See
- Intensive Care Unit, The Austin Hospital, Heidelberg, Victoria, Australia
| | | | - Adam M Deane
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, VIC 3050, Australia; Intensive Care Unit, The Royal Melbourne Hospital, Parkville, Victoria, Australia.
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21
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Batassini É, Beghetto MG. Constipation in a cohort prospective in adult critically ill patients: How much occurs and why? ENFERMERIA INTENSIVA 2018; 30:127-134. [PMID: 30553741 DOI: 10.1016/j.enfi.2018.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 05/02/2018] [Accepted: 05/22/2018] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- É Batassini
- Postgraduate Program in Nursing, Nursing School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brasil; Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brasil.
| | - M G Beghetto
- Postgraduate Program in Nursing, Nursing School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brasil
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Deane AM, Chapman MJ, Reintam Blaser A, McClave SA, Emmanuel A. Pathophysiology and Treatment of Gastrointestinal Motility Disorders in the Acutely Ill. Nutr Clin Pract 2018; 34:23-36. [PMID: 30294835 DOI: 10.1002/ncp.10199] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Gastrointestinal dysmotility causes delayed gastric emptying, enteral feed intolerance, and functional obstruction of the small and large intestine, the latter functional obstructions being frequently termed ileus and Ogilvie syndrome, respectively. In addition to meticulous supportive care, drug therapy may be appropriate in certain situations. There is, however, considerable variation among individuals regarding what gastric residual volume identifies gastric dysmotility and would encourage use of a promotility drug. While the administration of either metoclopramide or erythromycin is supported by evidence it appears that, dual-drug therapy (erythromycin and metoclopramide) reduces the rate of treatment failure. There is a lack of evidence to guide drug therapy of ileus, but neither erythromycin nor metoclopramide appear to have a role. Several drugs, including ghrelin agonists, highly selective 5-hydroxytryptamine receptor agonists, and opiate antagonists are being studied in clinical trials. Neostigmine, when infused at a relatively slow rate in patients receiving continuous hemodynamic monitoring, may alleviate the need for endoscopic decompression in some patients.
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Affiliation(s)
- Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.,Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, Australia
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia.,Center of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Stephen A McClave
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Anton Emmanuel
- Department of Neuro-Gastroenterology, University College London, London, UK
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Abstract
OBJECTIVE Most of the studies have defined constipation as a period without stool after ICU admission. We aimed to test the impact of both duration and timing of infrequent defecation in critical care patients. PATIENTS AND METHODS We performed a prospective, bi-center, observational study. Patients were divided into three subgroups: 'not constipated', '3-5 days', and 'at least 6 days' (longest period without stool passage, respectively, shorter than 3 days, 3-5 days, and ≥6 days). Furthermore, 'early' constipated patients were defined as those for whom the longest time to stool passage occurred just after ICU admission, whereas for 'late' constipated patients the longest period without stool occurred later during ICU stay. RESULTS A total of 182 patients were included: the mean age was 67.2 years (54.4-78.9 years), 80 were women, and simplified acute physiology score II was 42 (34-52). In all, 42 (23.1%), 82 (45.1%), and 58 (31.8%) belonged to the nonconstipated, 3-5 days, or greater than or equal to 6 days subgroup of patients, respectively. Time spent under mechanical ventilation and ICU length of stay was longer in the greater than or equal to 6 days subgroups as compared with both other subgroups. ICU stay was longer in the 3-5 days subgroup as compared with the not constipated patients. Furthermore, the late patients of the greater than or equal to 6 days subgroups exhibited worse survival as compared with all other patients. CONCLUSION Both timing and duration of infrequent defecation seem to have an impact on critical care patient's outcome, and should therefore be included in the diagnostic criteria.
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Wesselink E, Koekkoek KWAC, Looijen M, van Blokland DA, Witkamp RF, van Zanten ARH. Associations of hyperosmolar medications administered via nasogastric or nasoduodenal tubes and feeding adequacy, food intolerance and gastrointestinal complications amongst critically ill patients: A retrospective study. Clin Nutr ESPEN 2018; 25:78-86. [PMID: 29779822 DOI: 10.1016/j.clnesp.2018.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 04/02/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Adequate nutrition is essential during critical illness. However, providing adequate nutrition is often hindered by gastro-intestinal complications, including feeding intolerance. It is suggested that hyperosmolar medications could be causally involved in the development of gastro-intestinal complications. The aims of the present study were 1) to determine the osmolality of common enterally administered dissolved medications and 2) to study the associations between nasogastric and nasoduodenal administered hyperosmolar medications and nutritional adequacy as well as food intolerance and gastro-intestinal symptoms. METHODS This retrospective observational cohort study was performed in a medical-surgical ICU in the Netherlands. Adult critically ill patients receiving enteral nutrition and admitted for a minimum ICU duration of 7 days were eligible. The osmolalities of commonly used enterally administrated medications were measured using an osmometer. Patients were divided in two groups: Use of hyperosmolar medications (>500 mOsm/kg) on at least one day during the first week versus none. The associations between the use of hyperosmolar medications and nutritional adequacy were assessed using multiple logistic regression analysis. The associations between hyperosmolar medication and food intolerance as well as gastrointestinal symptoms were assessed using ordinal logistic regression. RESULTS In total 443 patients met the inclusion criteria. Of the assessed medications, only three medications were found hyperosmolar. We observed no associations between the use of hyperosmolar medications and nutritional adequacy in the first week of ICU admission (caloric intake β -0.27 95%CI -1.38; 0.83, protein intake β 0.32 95%CI -0.90; 1.53). In addition, no associations were found for enteral feeding intolerance, diarrhea, obstipation, gastric residual volume, nausea and vomiting in ICU patients receiving hyperosmolar medications via a nasogastric tube. A subgroup analysis of patients on duodenal feeding showed that postpyloric administration of hyperosmolar medications was associated with increased risk of diarrhea (OR 138.7 95%CI 2.33; 8245). CONCLUSIONS Our results suggest that nasogastric administration of hyperosmolar medication via a nasogastric tube does not affect nutritional adequacy, development of enteral feeding intolerance and other gastro-intestinal complications during the first week after ICU admission. During nasoduodenal administration an increased diarrhea incidence may be encountered.
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Affiliation(s)
- Evertine Wesselink
- Division of Human Nutrition, Wageningen University, Stippeneng 4, 6708 WE, Wageningen, The Netherlands.
| | - Kristine W A C Koekkoek
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716, Ede, The Netherlands.
| | - Martijn Looijen
- Department of Information Technology and Datawarehouse, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP, Ede, The Netherlands.
| | - Dick A van Blokland
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716, Ede, The Netherlands.
| | - Renger F Witkamp
- Division of Human Nutrition, Wageningen University, Stippeneng 4, 6708 WE, Wageningen, The Netherlands.
| | - Arthur R H van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716, Ede, The Netherlands.
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25
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Schörghuber M, Fruhwald S. Effects of enteral nutrition on gastrointestinal function in patients who are critically ill. Lancet Gastroenterol Hepatol 2018. [DOI: 10.1016/s2468-1253(18)30036-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Patejdl R, Kästner M, Kolbaske S, Wittstock M. Clinical nutrition and gastrointestinal dysfunction in critically ill stroke patients. Neurol Res 2017; 39:959-964. [PMID: 28828964 DOI: 10.1080/01616412.2017.1367545] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background Data on the epidemiology and risk factors of altered gastrointestinal motility (AGIM) is virtually lacking for patients suffering from non-traumatic neurologic diseases and stroke. This study investigated whether patterns of AGIM differ between patients with stroke and other severe acute brain diseases. Methods Clinical records of stroke and non-stroke patients treated at a neurological intensive care unit (ICU) were reviewed at day 1-5 and at day 10 after admission. The data was analyzed for the course of enteral/parenteral nutrition and for and for signs and symptoms of gastrointestinal dysfunction. The study included data of 76 patients, 57 with stroke (stroke group, SG) and 19 with other neurological diseases (non-stroke group, NSG). Results Basic demographic as well as clinical baseline characteristics and alimentation regime were similar in both groups. At least one sign of AGIM was seen in 33/57 (58%) SG and in 15/19 (79%) NSG patients (P = 0.099). Regurgitation was significantly more frequent among patients from the NSG (P < 0.05). Subjects from the NSG also spent a higher proportion of time with at least one symptom of AGIM present (P < 0.05). Conclusions For the first time, this study investigated the prevalence of AGIM in patients suffering from severe stroke. The prevalence of disturbed gastrointestinal function was found to be high in stroke patients, but was lower than in a group of non-stroke patients with similar general disease severity and baseline characteristics.
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Affiliation(s)
- Robert Patejdl
- a Department of Physiology , University of Rostock , Rostock , Germany
| | - Matthias Kästner
- b Department of Neurology , University of Rostock , Rostock , Germany
| | - Stephan Kolbaske
- b Department of Neurology , University of Rostock , Rostock , Germany
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Is Hydrogen Breath Test with Lactulose Feasible for Measuring Gastrocecal Transit in Critically Ill Children? Pilot Study about Modification of the Technique. BIOMED RESEARCH INTERNATIONAL 2017; 2017:5878659. [PMID: 28246601 PMCID: PMC5299192 DOI: 10.1155/2017/5878659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 12/18/2016] [Accepted: 12/28/2016] [Indexed: 12/26/2022]
Abstract
Introduction. Gastrocecal transit time (GCTT) can be measured by exhaled hydrogen after lactulose intake (lactulose-eH2 test). The objectives were to assess whether it is possible to carry out this test in critically ill children with and without mechanical ventilation (MV) and to analyze whether the results are consistent with clinical findings. Methods. Patients admitted to the Pediatric Intensive Care Unit (PICU) for more than 3 days were included. Those with gastrointestinal disease prior to admission were excluded. A modified technique to obtain eH2 from the ventilator tubes was performed. Results. Sixteen patients (37.5% boys) with a median age of 19 (5-86.5) months were included. Five patients (31.2%) were breathing spontaneously but lactulose-eH2 test could not be performed while it could be performed successfully in the 11 patients with MV. Seven patients (63.3%) did not show an eH2 peak. The other 4 showed a median time of 130 min (78.7-278.7 min) from lactulose intake to a 10 ppm eH2 peak. Children with an eH2 peak had intestinal movements earlier [6.5 (1.5-38.5) versus 44 (24-72) hours p = 0.545]. Conclusion. Although the designed adaption is useful for collecting breath samples, lactulose-eH2 test may not be useful for measuring GCTT in critically ill children.
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Chokhavatia S, John ES, Bridgeman MB, Dixit D. Constipation in Elderly Patients with Noncancer Pain: Focus on Opioid-Induced Constipation. Drugs Aging 2016; 33:557-74. [PMID: 27417446 PMCID: PMC5012150 DOI: 10.1007/s40266-016-0381-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Constipation is a common and often debilitating condition in the elderly, which may be caused by underlying disease conditions, structural abnormalities in the bowel, and a variety of medications such as anticholinergics, antidepressants, and opiates. In this review, we focus on opioid-induced constipation (OIC), which is often underrecognized and undertreated in the elderly. When opioid therapy is initiated, healthcare providers are encouraged to evaluate risk factors for the development of constipation as part of a thorough patient history. To this end, the patient assessment should include the use of validated instruments, such as the Bristol Stool Scale and Bowel Function Index, to confirm the diagnosis and provide a basis for evaluating treatment outcomes. Healthcare providers should use a stepwise approach to the treatment of OIC in the elderly. Conventional laxatives are a first-line option and considered well tolerated with short-term use as needed; however, evidence is lacking to support their effectiveness in OIC. Moreover, because of the risk of adverse events and other considerations, such as chewing difficulties and swallowing disorders, conventional oral laxatives may be inappropriate for the treatment of OIC in the elderly. Thus, the availability of new pharmacologic agents such as the peripherally acting µ-opioid receptor antagonists methylnaltrexone and naloxegol, which target the underlying causes of OIC, and the secretagogue lubiprostone may provide more effective treatment options for elderly patients with OIC.
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Affiliation(s)
- Sita Chokhavatia
- Division of Gastroenterology and Hepatology, Rutgers, Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, MEB Room 478C, New Brunswick, NJ, 08901, USA.
- Internal Medicine, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA.
| | - Elizabeth S John
- Division of Gastroenterology and Hepatology, Rutgers, Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, MEB Room 478C, New Brunswick, NJ, 08901, USA
- Internal Medicine, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Mary Barna Bridgeman
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
- Internal Medicine, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Deepali Dixit
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
- Critical Care, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
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Patel PB, Brett SJ, O'Callaghan D, Anjum A, Cross M, Warwick J, Gordon AC. Protocol for a randomised control trial of methylnaltrexone for the treatment of opioid-induced constipation and gastrointestinal stasis in intensive care patients (MOTION). BMJ Open 2016; 6:e011750. [PMID: 27412108 PMCID: PMC4947806 DOI: 10.1136/bmjopen-2016-011750] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Gastrointestinal dysmotility and constipation are common problems in intensive care patients. The majority of critical care patients are sedated with opioids to facilitate tolerance of endotracheal tubes and mechanical ventilation, which inhibit gastrointestinal motility and lead to adverse outcomes. Methylnaltrexone is a peripheral opioid antagonist that does not cross the blood-brain barrier and can reverse the peripheral side effects of opioids without affecting the desired central properties. This trial will investigate whether methylnaltrexone can reverse opioid-induced constipation and gastrointestinal dysmotility. METHODS This is a single-centre, multisite, double-blind, randomised, placebo-controlled trial. 84 patients will be recruited from 4 intensive care units (ICUs) within Imperial College Healthcare NHS Trust. Patients will receive intravenous methylnaltrexone or placebo on a daily basis if they are receiving opioid infusion to facilitate mechanical ventilation and have not opened their bowels for 48 hours. All patients will receive standard laxatives as per the clinical ICU bowel protocol prior to randomisation. The primary outcome of the trial will be time to significant rescue-free laxation following randomisation. Secondary outcomes will include tolerance of enteral feed, gastric residual volumes, incidence of pneumonia, blood stream and Clostridium difficile infection, and any reversal of central opioid effects. ETHICS AND DISSEMINATION The trial protocol, the patient/legal representative information sheets and consent forms have been reviewed and approved by the Harrow Research Ethics Committee (REC Reference 14/LO/2004). An independent Trial Steering Committee and Data Monitoring Committee are in place, with patient representation. On completion, the trial results will be published in peer-reviewed journals and presented at national and international scientific meetings. TRIAL REGISTRATION NUMBER 2014-004687-37; Pre-results.
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Affiliation(s)
- Parind B Patel
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, London, UK
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Stephen J Brett
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, London, UK
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
| | - David O'Callaghan
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, London, UK
| | - Aisha Anjum
- Imperial Clinical Trials Unit, Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Mary Cross
- Imperial Clinical Trials Unit, Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Jane Warwick
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Anthony C Gordon
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, London, UK
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
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Prat D, Messika J, Le Meur M, Ricard JD, Sztrymf B. Constipation en réanimation : physiopathologie, définition, valeur pronostique, prise en charge. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1203-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Risk factors for late defecation and its association with the outcomes of critically ill patients: a retrospective observational study. J Intensive Care 2016; 4:33. [PMID: 27134753 PMCID: PMC4850650 DOI: 10.1186/s40560-016-0156-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 04/21/2016] [Indexed: 02/07/2023] Open
Abstract
Background Late defecation was recently reported to be associated with worse clinical outcomes in critically ill patients. However, more research is needed to examine the causes and clinical significance of late defecation. The objectives of this study were to investigate the risk factors for late defecation and its association with the outcomes of intensive care unit (ICU) patients. Methods Patients in an ICU for ≥7 days between January and December 2011 were retrospectively assessed. Based on the time between admission and the first defecation, they were assigned to early (<6 days; n = 186) or late (≥6 days; n = 96) defecation groups. Changes in clinical variables between admission and ICU day 7 were assessed to investigate the effects of late defecation. The clinical outcomes were ICU mortality, length of ICU stay, and length of mechanical ventilation. Results Late enteral nutrition (odds ratio (OR) 3.42; 95 % confidence interval (CI) 1.88–6.22; P < 0.001), sedatives (OR 3.07; 95 % CI 1.71–5.52; P < 0.001), and surgery (OR 1.86; 95 % CI 1.01–3.42; P = 0.047) were the independent risk factors for late defecation. The median (interquartile) changes in body temperature (0.3 [−0.4 to 1.0] vs 0.7 [0.1 to 1.5] °C; P = 0.004), serum C-reactive protein concentration (1.6 [−0.5 to 6.6] vs 3.5 [0.7 to 8.5] mg/dL; P = 0.035), and Sequential Organ Failure Assessment score (−1 [−2 to 1] vs 0 [−1 to 2]; P = 0.008) between admission and ICU day 7 were significantly greater in the late defecation group than in the early defecation group. ICU stay was significantly longer in the late defecation group (12 [9 to 19] vs 16 [10 to 23] days; P = 0.021), whereas ICU mortality and the length of mechanical ventilation were similar in both groups. Conclusions Late enteral nutrition, sedatives, and surgery were independent the risk factors for late defecation in critically ill patients. Late defecation was associated with prolonged ICU stay.
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Rojano I Luque X, Sánchez Ferrin P, Salvà A. [Hospital complications in the elderly]. Med Clin (Barc) 2016; 146:550-4. [PMID: 26961393 DOI: 10.1016/j.medcli.2015.12.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 12/29/2015] [Accepted: 12/31/2015] [Indexed: 01/02/2023]
Affiliation(s)
- Xavier Rojano I Luque
- Fundació Salut i Envelliment Universitat Autònoma de Barcelona, Institut d'Investigació Biomèdica Sant Pau, Barcelona, España.
| | - Pau Sánchez Ferrin
- Pla director sociosanitari, Departament de Salut, Generalitat de Catalunya, Barcelona, España
| | - Antoni Salvà
- Fundació Salut i Envelliment Universitat Autònoma de Barcelona, Institut d'Investigació Biomèdica Sant Pau, Barcelona, España
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Park JH, Yun SO, Kim SH, Yu MG, Ham EJ. Constipation in Patients following Orthopedic Surgery: Incidence and Influencing Factors. ACTA ACUST UNITED AC 2016. [DOI: 10.7475/kjan.2016.28.6.637] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
| | - Sun Ok Yun
- Unit Manager, Department of Nursing, Asan Medical Center, Seoul, Korea
| | | | - Mi Gyeong Yu
- Nurse, Department of Nursing, Asan Medical Center, Seoul, Korea
| | - Eun Jin Ham
- Nurse, Department of Nursing, Asan Medical Center, Seoul, Korea
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Staller K, Khalili H, Kuo B. Constipation prophylaxis reduces length of stay in elderly hospitalized heart failure patients with home laxative use. J Gastroenterol Hepatol 2015; 30:1596-602. [PMID: 25969162 DOI: 10.1111/jgh.13011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2015] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Elderly, hospitalized patients suffer disproportionately from constipation; however, little data suggest that constipation prophylaxis reduces length of stay (LOS). We performed a retrospective analysis of elderly patients admitted to our hospital with congestive heart failure (CHF) to determine the effects of constipation prophylaxis on LOS. METHODS Patients ≥ 65 years old admitted with the diagnosis of CHF in 2012 were evaluated for home and hospital laxative use on admission. Our primary outcome was LOS. We used linear regression modeling to independently evaluate the impact of constipation prophylaxis on LOS. RESULTS Among 618 patients who were eligible for our study, 201 (32.5%) were using laxatives at home, whereas 254 (41.1%) were started on a prophylactic laxative on admission. There was no significant difference in LOS between patients receiving prophylaxis versus those who did not (P = 0.32). Patients with home laxative use had a 1 day longer LOS compared to those without laxative use (6 vs 5, P = 0.03). Among patients with home laxative use, there were 2 days longer LOS in those who were not given constipation prophylaxis on admission (8 vs 6, P = 0.002). After multivariate adjustment, failure to use constipation prophylaxis in patients with home laxative use was the only independent predictor of increased LOS (P = 0.03). CONCLUSIONS Among elderly patients admitted for CHF exacerbations, failure to use constipation prophylaxis in patients with home laxative use is associated with a significantly longer LOS. Our data suggest that routine use of bowel prophylaxis for elderly CHF patients with preexisting constipation may reduce LOS.
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Affiliation(s)
- Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Braden Kuo
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Constipation in the Critically Ill Child: Frequency and Related Factors. J Pediatr 2015; 167:857-861.e1. [PMID: 26254837 DOI: 10.1016/j.jpeds.2015.06.046] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 05/26/2015] [Accepted: 06/24/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To analyze the incidence and factors associated with constipation in critically ill children. STUDY DESIGN We performed a prospective observational study that included children admitted to the pediatric intensive care unit for more than 3 days. Constipation was defined as more than 3 days without a bowel movement. Relationships between constipation and demographic data; clinical severity score; use of mechanical ventilation, use of vasoconstrictors, sedatives, and muscle relaxants; nutritional data; electrolyte disturbances; and clinical course were analyzed. RESULTS Constipation developed in 46.7% of the 150 patients studied (mean age, 34.3 ± 7.1 months). It was most common in postoperative, older, and higher-body-weight patients, and in those with fecal continence (P < .01). Compared with patients without constipation, patients with constipation had higher severity scores and more frequently received midazolam, fentanyl, muscle relaxants, and inotropic support (P < .05). Patients with constipation also started nutrition later and with a lower volume of nutrition (P < .01). There were no between-group differences in mortality or length of pediatric intensive care unit stay. In multivariate analysis, independent factors associated with constipation were body weight (OR, 1.08; 95% CI, 1.03-1.13), Pediatric Index of Mortality 2 score (OR, 1.05; 95% CI, 1.02-1.09), admission after surgery (OR, 7.64; 95% CI, 2.56-22.81), and treatment with vasoconstrictors (OR, 10.28; 95% CI, 3.53-29.93). CONCLUSION Constipation is common in critically ill children. Body weight, Pediatric Index of Mortality 2 clinical severity score, admission after surgery, and the need for vasoconstrictor therapy are major independent risk factors associated with constipation.
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de Azevedo RP, Freitas FGR, Ferreira EM, Pontes de Azevedo LC, Machado FR. Daily laxative therapy reduces organ dysfunction in mechanically ventilated patients: a phase II randomized controlled trial. Crit Care 2015; 19:329. [PMID: 26373705 PMCID: PMC4572636 DOI: 10.1186/s13054-015-1047-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 08/22/2015] [Indexed: 01/28/2023] Open
Abstract
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.
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Affiliation(s)
- Rodrigo Palacio de Azevedo
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 6° andar - Vila Clementino, CEP: 04024-002, São Paulo, SP, Brazil.
| | - Flávio Geraldo Resende Freitas
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 6° andar - Vila Clementino, CEP: 04024-002, São Paulo, SP, Brazil.
| | - Elaine Maria Ferreira
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 6° andar - Vila Clementino, CEP: 04024-002, São Paulo, SP, Brazil.
| | - Luciano Cesar Pontes de Azevedo
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 6° andar - Vila Clementino, CEP: 04024-002, São Paulo, SP, Brazil.
| | - Flávia Ribeiro Machado
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 6° andar - Vila Clementino, CEP: 04024-002, São Paulo, SP, Brazil.
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de Azevedo RP, Machado FR. Constipation in critically ill patients: much more than we imagine. Rev Bras Ter Intensiva 2015; 25:73-4. [PMID: 23917968 PMCID: PMC4031826 DOI: 10.5935/0103-507x.20130014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Rodrigo Palácio de Azevedo
- Hospital São Domingos São Luiz MA, Brazil
- Corresponding author: Rodrigo Palácio Azevedo, Avenida Jerônimo de
Albuquerque, 540 - Angelim, Zip code: 65060-642 - São Luís (MA), Brazil. E-mail:
| | - Flávia Ribeiro Machado
- Division of Anesthesiology, Pain and Intensive Care, Universidade
Federal de São Paulo - UNIFESP - São Paulo (SP), Brazil
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Guerra TLDS, Mendonça SS, Marshall NG. Incidence of constipation in an intensive care unit. Rev Bras Ter Intensiva 2015; 25:87-92. [PMID: 23917972 PMCID: PMC4031832 DOI: 10.5935/0103-507x.20130018] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Accepted: 06/18/2013] [Indexed: 12/21/2022] Open
Abstract
Objectives To evaluate the incidence of constipation in critical patients on enteral
nutrition in a hospital intensive care unit and to correlate this incidence with
the variables found for critical patients. Methods The present investigation was a retrospective analytical study conducted in the
intensive care unit of Hospital Regional da Asa Norte (DF) via the analysis of
medical records of patients admitted during the period from January to December
2011. Data on the incidence of constipation and enteral nutritional support,
gastrointestinal changes, stool frequency, ventilatory support, and outcomes were
collected and analyzed. Results The initial sample consisted of 127 patients admitted to the unit during the
period from January to December 2011. Eighty-four patients were excluded, and the
final sample consisted of 43 patients. The incidence of constipation, defined as
no bowel movement during the first 4 days of hospitalization, was 72% (n=31). The
patients were divided into a control group and a constipated group. The group of
constipated patients reached the caloric target, on average, at 6.5 days, and the
control group reached the caloric target in 5.6 days (p=0.51). Constipation was
not associated with the length of hospital stay, suspension of nutritional
support, or outcome of hospitalization. There was an association between
evacuation during hospitalization and a longer duration of hospitalization for a
subgroup of patients who did not evacuate during the entire period (p=0.009). Conclusion The incidence of constipation in the unit studied was 72%. Only the absence of
evacuation during hospitalization was associated with longer hospital stays.
Constipation was not associated with the length of hospital stay, suspension of
nutritional support, or outcome of hospitalization.
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Affiliation(s)
- Tatiana Lopes de Souza Guerra
- Residency Program in Clinical Nutrition, Hospital Regional da Asa Norte, Secretaria de Estado de Saúde do Distrito Federal - Brasília DF, Brazil
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Standardized application of laxatives and physical measures in neurosurgical intensive care patients improves defecation pattern but is not associated with lower intracranial pressure. Crit Care Res Pract 2014; 2014:367251. [PMID: 25628896 PMCID: PMC4297633 DOI: 10.1155/2014/367251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 12/15/2014] [Accepted: 12/15/2014] [Indexed: 02/07/2023] Open
Abstract
Background. Inadequate bowel movements might be associated with an increase in intracranial pressure in neurosurgical patients. In this study we investigated the influence of a structured application of laxatives and physical measures following a strict standard operating procedure (SOP) on bowel movement, intracranial pressure (ICP), and length of hospital stay in patients with a serious acute cerebral disorder. Methods. After the implementation of the SOP patients suffering from a neurosurgical disorder received pharmacological and nonpharmacological measures to improve bowel movements in a standardized manner within the first 5 days after admission to the intensive care unit (ICU) starting on day of admission. We compared mean ICP levels, length of ICU stay, and mechanical ventilation to a historical control group. Results. Patients of the intervention group showed an adequate defecation pattern significantly more often than the patients of the control group. However, this was not associated with lower ICP values, fewer days of mechanical ventilation, or earlier discharge from ICU. Conclusions. The implementation of a SOP for bowel movement increases the frequency of adequate bowel movements in neurosurgical critical care patients. However, this seems not to be associated with reduced ICP values.
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Kadamani I, Itani M, Zahran E, Taha N. Incidence of aspiration and gastrointestinal complications in critically ill patients using continuous versus bolus infusion of enteral nutrition: A pseudo-randomised controlled trial. Aust Crit Care 2014; 27:188-93. [DOI: 10.1016/j.aucc.2013.12.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Revised: 11/29/2013] [Accepted: 12/24/2013] [Indexed: 01/15/2023] Open
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Orejana Martín M, Torrente Vela S, Murillo Pérez MA, García Iglesias M, Cornejo Bauer C, Morales Sánchez C, López López C, Cuenca Solanas M, Alted López E. [Analysis of constipation in severe trauma patients]. ENFERMERIA INTENSIVA 2013; 25:46-51. [PMID: 24332844 DOI: 10.1016/j.enfi.2013.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Revised: 10/03/2013] [Accepted: 11/05/2013] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To evaluate the incidence and risk factors of constipation in patients with severe trauma (ST). MATERIALS AND METHOD A retrospective observational study (January-December 2011) of medical records in ST-patients with a minimum stay of 5 days was performed. Descriptive analysis of variables, inferential analysis: Student's T test and Chi-square of SPSS 17.0. Significance level P<.05. RESULTS A total of 80 patients fulfilled the inclusion criteria, but only 69 could be analyzed. Of these, 84.06% showed constipation (according to its definition by the Work Group for Metabolism and Nutrition SEMICYUC). The most frequent day of first stool was day 7 and 9 after tolerance of enteral nutrition. Statistical significance (S.S.) of constipation was found with stay, days of sedation/relaxation/opiates, and mechanical ventilation. There was no S.S. between early enteral nutrition (EEN) and constipation (P>.05). CONCLUSIONS There is a very high incidence of constipation in ST patients. ICU stay, days of analgesic sedation, relaxation, and mechanical ventilation are risk factors that influence the occurrence of this problem. Laxatives should be prescribed prophylactically.
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Affiliation(s)
- M Orejana Martín
- Enfermería de la Unidad de Cuidados Intensivos (UCI) de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, España.
| | - S Torrente Vela
- Enfermería de la Unidad de Cuidados Intensivos (UCI) de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, España
| | - M A Murillo Pérez
- Enfermería de la Unidad de Cuidados Intensivos (UCI) de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, España
| | - M García Iglesias
- Enfermería de la Unidad de Cuidados Intensivos (UCI) de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, España
| | - C Cornejo Bauer
- Enfermería de la Unidad de Cuidados Intensivos (UCI) de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, España
| | - C Morales Sánchez
- Enfermería de la Unidad de Cuidados Intensivos (UCI) de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, España
| | - C López López
- Enfermería de la Unidad de Cuidados Intensivos (UCI) de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, España
| | - M Cuenca Solanas
- Enfermería de la Unidad de Cuidados Intensivos (UCI) de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, España
| | - E Alted López
- UCI de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, España
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Iovino P, Chiarioni G, Bilancio G, Cirillo M, Mekjavic IB, Pisot R, Ciacci C. New onset of constipation during long-term physical inactivity: a proof-of-concept study on the immobility-induced bowel changes. PLoS One 2013; 8:e72608. [PMID: 23977327 PMCID: PMC3748072 DOI: 10.1371/journal.pone.0072608] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 07/12/2013] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The pathophysiological mechanisms underlining constipation are incompletely understood, but prolonged bed rest is commonly considered a relevant determinant. AIMS Our primary aim was to study the effect of long-term physical inactivity on determining a new onset of constipation. Secondary aim were the evaluation of changes in stool frequency, bowel function and symptoms induced by this prolonged physical inactivity. METHODS Ten healthy men underwent a 7-day run-in followed by 35-day study of experimentally-controlled bed rest. The study was sponsored by the Italian Space Agency. The onset of constipation was evaluated according to Rome III criteria for functional constipation. Abdominal bloating, flatulence, pain and urgency were assessed by a 100mm Visual Analog Scales and bowel function by adjectival scales (Bristol Stool Form Scale, ease of passage of stool and sense of incomplete evacuation). Daily measurements of bowel movements was summarized on a weekly score. Pre and post bed rest Quality of Life (SF-36), general health (Goldberg's General Health) and depression mood (Zung scale) questionnaires were administered. RESULTS New onset of functional constipation fulfilling Rome III criteria was found in 60% (6/10) of participants (p=0.03). The score of flatulence significantly increased whilst the stool frequency significantly decreased during the week-by-week comparisons period (repeated-measures ANOVA, p=0.02 and p=0.001, respectively). Stool consistency and bowel symptoms were not influenced by prolonged physical inactivity. In addition, no significant changes were observed in general health, in mood state and in quality of life at the end of bed rest. CONCLUSIONS Our results provide evidence that prolonged physical inactivity is relevant etiology in functional constipation in healthy individuals. The common clinical suggestion of early mobilization in bedridden patients is supported as well.
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Affiliation(s)
- Paola Iovino
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy.
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43
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Abstract
Patients in the setting of the intensive care unit can develop intra-abdominal complications that may worsen outcome. Clinical suspicion of such complications coupled with early diagnosis and treatment may reduce morbidity and mortality associated with these processes. This article addresses the diagnosis and management of some of the common causes of intra-abdominal catastrophes.
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Affiliation(s)
- Joao B Rezende-Neto
- Department of Surgery, St. Michael's Hospital, 30 Bond Street 16CC-044, Toronto, Ontario M5B1W8, Canada
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44
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Impaired gastrointestinal transit and its associated morbidity in the intensive care unit. J Crit Care 2013; 28:537.e11-7. [PMID: 23333042 DOI: 10.1016/j.jcrc.2012.12.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 11/24/2012] [Accepted: 12/05/2012] [Indexed: 12/22/2022]
Abstract
PURPOSE To determine the proportion of critically ill adults developing impaired gastrointestinal transit (IGT) using a clinically pragmatic definition, its associated morbidity and risk factors. MATERIALS AND METHODS Critically ill adult patients receiving enteral nutrition for ≥ 72 hours and mechanically ventilated for ≥ 48 hours were prospectively identified. IGT was defined as absence of a bowel movement for ≥ 3 days, treatment for constipation, and one of the following: (1) radiologic confirmed ileus, (2) feed intolerance, (3) abdominal distention, or (4) gastric decompression. RESULTS One thousand patients were screened, and 248 were included for analysis. Fifty patients (20.1%; 95% confidence interval, 15.1-25.6%) developed IGT persisting for 6.5 ± 2.5 days. Patients with IGT had longer lengths of intensive care unit stay and were less likely to reach nutrition targets compared to patients without IGT or traditional definitions of constipation. Daily opioid use and pharmacological constipation prophylaxis were identified risk factors for IGT. CONCLUSION Traditional definitions of constipation or ileus in intensive care unit patients are simplistic and lack clinical relevance. Pragmatically defined IGT is a common complication of critical illness and is associated with significant morbidity. Future interventional studies for IGT in critically ill adults should use a more clinically relevant definition and evaluate energy deficits and lengths of stay as clinically relevant outcomes.
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45
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Catafesta J, Francesconi C. Association between medication use and adverse gastroenterologic events in patients receiving enteral nutrition therapy at a University Hospital. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2012; 77:161-6. [DOI: 10.1016/j.rgmx.2012.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 05/19/2012] [Accepted: 06/28/2012] [Indexed: 11/24/2022]
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46
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The Effect of a Sweet Potato, Footbath, and Acupressure Intervention in Preventing Constipation in Hospitalized Patients With Acute Coronary Syndromes. Gastroenterol Nurs 2012; 35:271-7. [DOI: 10.1097/sga.0b013e31825ed7bc] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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47
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[Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): patient with polytrauma]. Med Intensiva 2012; 35 Suppl 1:68-71. [PMID: 22309757 DOI: 10.1016/s0210-5691(11)70014-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patients with polytrauma can be viewed as paradigmatic of the critically-ill patient. These previously healthy patients undergo a life-threatening aggression leading to an organic response that is no different from that in other types of patients. The profile of trauma patients has changed and currently corresponds to patients who are somewhat older, with a higher body mass index and greater comorbidity. Severe injuries lead to intense metabolic stress, posing a risk of malnutrition. Therefore, early nutritional support, preferentially through the enteral route, with appropriate protein intake and glutamine supplementation, provides advantages over other routes and types of nutritional formula. To avoid overnutrition, reduced daily calorie intake can be considered in obese patients and in those with medullary lesions. However, little information on this topic is available in patients with medullary lesions.
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48
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Sawh SB, Selvaraj IP, Danga A, Cotton AL, Moss J, Patel PB. Use of methylnaltrexone for the treatment of opioid-induced constipation in critical care patients. Mayo Clin Proc 2012; 87:255-9. [PMID: 22386181 PMCID: PMC3498420 DOI: 10.1016/j.mayocp.2011.11.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 11/28/2011] [Accepted: 11/28/2011] [Indexed: 01/15/2023]
Abstract
Gastrointestinal dysmotility and constipation are common problems in critical care patients. The majority of critical care patients are treated with opioids, which inhibit gastrointestinal (GI) motility and lead to adverse outcomes. We reasoned that methylnaltrexone (MNTX), a peripheral opioid antagonist approved for the treatment of opioid-induced constipation in patients with advanced illness receiving palliative care when response to laxative therapy has not been sufficient, could improve GI function in critically ill patients. The present study included all patients in our intensive care unit who required rescue medication for GI stasis during the 10-week period from September 1 to November 15, 2009. We compared conventional rescue therapy with subcutaneous MNTX. We performed a retrospective chart review of the 88 nonsurgical critical care patients receiving fentanyl infusions, 15 (17%) of whom met the criteria of absence of laxation within 72 hours of intensive care unit admission despite treatment with senna and sodium docusate. Eight of these 15 patients subsequently received conventional rescue therapy (combination of sodium picosulfate [5 mg] and 2 glycerin suppositories [4-g mold]), and 7 patients received MNTX (subcutaneous injection, 0.15 mg/kg). Laxation occurred within 24 hours in 6 of the 7 MNTX patients (86%) but in none of the 8 patients receiving conventional rescue therapy (P=.001). The median difference in time to laxation between the 2 groups was 3.5 days (P<.001). Although not statistically significant, all 7 patients treated with MNTX, but only 4 of 8 (50%) who received conventional rescue therapy, progressed to full target enteral feeding (P=.08). Intensive care unit mortality was 2 of 7 MNTX patients (29%) vs 4 of 8 (50%) in the standard therapy group (P=.61). We hypothesize that MNTX may play an important role in restoration of bowel function in critically ill patients.
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Affiliation(s)
- Sergio B. Sawh
- Department of Emergency Medicine, Charing Cross Hospital, London, United Kingdom
| | - Ibrahim P. Selvaraj
- Department of Advanced Pain, Hillingdon Hospital, Uxbridge, Middlesex, United Kingdom
| | - Akila Danga
- Department of Medicine, Queens Hospital, London, United Kingdom
| | - Alison L. Cotton
- Department of Pharmacology, Hammersmith Hospital, London, United Kingdom
| | - Jonathan Moss
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Parind B. Patel
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
- Correspondence: Address to Parind B. Patel, MBBS, FRAC, FFICM, Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, Hammersmith Hospital, DuCane Rd, London W12 0HS, United Kingdom
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49
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Gastrointestinal function in intensive care patients: terminology, definitions and management. Recommendations of the ESICM Working Group on Abdominal Problems. Intensive Care Med 2012; 38:384-94. [PMID: 22310869 PMCID: PMC3286505 DOI: 10.1007/s00134-011-2459-y] [Citation(s) in RCA: 304] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 12/20/2011] [Indexed: 12/11/2022]
Abstract
Purpose Acute gastrointestinal (GI) dysfunction and failure have been increasingly recognized in critically ill patients. The variety of definitions proposed in the past has led to confusion and difficulty in comparing one study to another. An international working group convened to standardize the definitions for acute GI failure and GI symptoms and to review the therapeutic options. Methods The Working Group on Abdominal Problems (WGAP) of the European Society of Intensive Care Medicine (ESICM) developed the definitions for GI dysfunction in intensive care patients on the basis of the available evidence and current understanding of the pathophysiology. Results Definitions for acute gastrointestinal injury (AGI) with its four grades of severity, as well as for feeding intolerance syndrome and GI symptoms (e.g. vomiting, diarrhoea, paralysis, high gastric residual volumes) are proposed. AGI is a malfunctioning of the GI tract in intensive care patients due to their acute illness. AGI grade I = increased risk of developing GI dysfunction or failure (a self-limiting condition); AGI grade II = GI dysfunction (a condition that requires interventions); AGI grade III = GI failure (GI function cannot be restored with interventions); AGI grade IV = dramatically manifesting GI failure (a condition that is immediately life-threatening). Current evidence and expert opinions regarding treatment of acute GI dysfunction are provided. Conclusions State-of-the-art definitions for GI dysfunction with gradation as well as management recommendations are proposed on the basis of current medical evidence and expert opinion. The WGAP recommends using these definitions for clinical and research purposes. Electronic supplementary material The online version of this article (doi:10.1007/s00134-011-2459-y) contains supplementary material, which is available to authorized users.
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50
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Hewson-Conroy KM, Burrell AR, Elliott D, Webb SAR, Seppelt IM, Taylor C, Glass P. Compliance with Processes of Care in Intensive Care Units in Australia and New Zealand – A Point Prevalence Study. Anaesth Intensive Care 2011; 39:926-35. [DOI: 10.1177/0310057x1103900520] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There are indications that compliance with routine clinical practices in intensive care units (ICU) varies widely internationally, but it is currently unknown whether this is the case throughout Australia and New Zealand. A one-day point prevalence study measured the prevalence of routine care processes being delivered in Australian and New Zealand ICUs including the assessment and/or management of: nutrition, pain, sedation, weaning from mechanical ventilation, head of bed elevation, deep venous thrombosis prophylaxis, stress ulcer prophylaxis, blood glucose, pressure areas and bowel action. Using a sample of 50 adult ICUs, prevalence data were collected for 662 patients with a median age of 65 years and a median Acute Physiology and Chronic Health Evaluation II score of 18. Wide variations in compliance were evident in several care components including: assessment of nutritional goals (74%, interquartile range [IQR] 51 to 89%), pain score (35%, IQR 17 to 62%), sedation score (89%, IQR 50 to 100%); care of ventilated patients e.g. head of bed elevation >30 degrees (33%, IQR 7 to 62%) and setting weaning plans (50%, IQR 28 to 78%); pressure area risk assessment (78%, IQR 18 to 100%) and constipation management plan (43%, IQR 6 to 87%). Care components that were delivered more consistently included nutrition delivery (100%, IQR 100 to 100%), deep venous thrombosis (96%, IQR 89 to 100%) and stress ulcer (90%, IQR 78 to 100%) prophylaxis, and checking blood sugar levels (93%, IQR 88 to 100%). This point prevalence study demonstrated variability in the delivery of ‘routine’ cares in Australian and New Zealand ICUs. This may be driven in part by lack of consensus on what is best practice in intensive care units, prompting the need for further research in this area.
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Affiliation(s)
- K. M. Hewson-Conroy
- New South Wales Intensive Care Coordination and Monitoring Unit, Penrith, New South Wales, Australia
| | - A. R. Burrell
- New South Wales Intensive Care Coordination and Monitoring Unit, Penrith, New South Wales, Australia
| | - D. Elliott
- New South Wales Intensive Care Coordination and Monitoring Unit, Penrith, New South Wales, Australia
- Faculty of Nursing, Midwifery and Health, University of Technology
| | - S. A. R. Webb
- New South Wales Intensive Care Coordination and Monitoring Unit, Penrith, New South Wales, Australia
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia
| | - I. M. Seppelt
- New South Wales Intensive Care Coordination and Monitoring Unit, Penrith, New South Wales, Australia
- Department of Intensive Care Medicine, The Nepean Hospital
| | - C. Taylor
- New South Wales Intensive Care Coordination and Monitoring Unit, Penrith, New South Wales, Australia
- Critical Care and Trauma Division, The George Institute for Global Health
| | - P. Glass
- New South Wales Intensive Care Coordination and Monitoring Unit, Penrith, New South Wales, Australia
- Divisional Manager, Critical Care and Trauma Division, The George Institute for Global Health
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