Defining and reporting diarrhoea during enteral tube feeding: do health professionals agree?

A comparative, randomised MRI study of the physiological and appetitive responses to gelling (alginate) and non-gelling nasogastric tube feeds in healthy men

Inclusion in nasogastric tube feeds (NGTF) of acid-sensitive, seaweed-derived alginate, expected to form a reversible gel in the stomach, may create a more normal intragastric state and modified gastrointestinal responses. This may ameliorate NGTF-associated risk of diarrhoea, upper gastrointestinal symptoms and appetite suppression. In a randomised, crossover, comparison study, undertaken in twelve healthy males, an alginate-containing feed (F + ALG) or one that was alginate-free (F-ALG) (300 ml) was given over 1 h with a 7-14-d washout period between treatments. Baseline and for 4-h post-feed initiation, MRI measurements were made to establish small bowel water content (SBWC), gastric contents volume (GCV) and appearance, and superior mesenteric artery blood flux. Blood glucose and gut peptides were measured. Subjective appetite and upper gastrointestinal symptoms scores were obtained. Ad libitum pasta consumption 3-h post-feeding was measured. F + ALG exhibited a gastric appearance consistent with gelling surrounded by a freely mobile water halo. Significant main effects of feed were seen for SBWC (P = 0·03) and peptide YY (PYY) (P = 0·004) which were attributed to generally higher values for SBWC with F + ALG (max difference between adjusted means 72 ml at 210 min) and generally lower values for PYY with F + ALG. GCV showed a faster reduction with F + ALG, less between-participant variation and a feed-by-time interaction (P = 0·04). Feed-by-time interactions were also seen with glucagon-like-peptide 1 (GLP-1) (P = 0·02) and glucose-dependent insulinotropic polypeptide (GIP) (P = 0·002), both showing a blunted response with F + ALG. Apparent intragastric gelling with F + ALG and subsequent differences in gastrointestinal and endocrine responses have been demonstrated between an alginate-containing and alginate-free feed.

Diarrhea in Critically Ill Patients: The Role of Enteral Feeding

This tutorial presents a systematic approach to the management of diarrhea in the critical care setting. Diarrhea is a common and prevalent problem in critically ill patients. Despite the high prevalence, its management is far from simple. Professionals are confronted with a myriad of definitions based on frequency, consistency, and volume. The causes are complex and multifactorial, yet enteral tube feeding formula is believed to be the perpetrator. Potential causes for diarrhea are discussed, and 3 case reports provide context to examine the treatment from a nutrition perspective. Each scenario is comprehensively addressed discussing potential causes and providing specific clinical strategies contributing to improved bowel function in this patient group. The approach used for diarrhea management is based on a complete understanding of enteral tube formula, their composition, and their impact in the presence of gut dysfunction. Choosing the right feeding formula may positively influence bowel function and contribute to improved nutrition.

The burden of diarrhea in the intensive care unit (ICU-BD). A survey and observational study of the caregivers' opinions and workload

BACKGROUND

Diarrhea as a common complication affects 14% patients in our intensive care unit. Risk factors for diarrhea and its clinical consequences for patients are well known, but the impact of diarrhea on caregivers' workload remains undocumented.

OBJECTIVES

This study aims at establishing the impact of diarrhea on costs and human burden in intensive care unit caregivers.

DESIGN

A survey and observational study.

SETTINGS

A mixed 36-bed medical and surgical intensive care unit.

PARTICIPANTS

All intensive care unit caregivers (nurses and nursing aides).

METHODS

A questionnaire was designed by a multidisciplinary team and completed by intensive care unit caregivers analyzing the clinical and human impact of diarrhea on their workload. Time measurements for the management of liquid stools were performed. Human related costs of diarrhea were analyzed according to caregivers' years of clinical experience.

RESULTS

Questionnaires were completed by 146 of 204 intensive care unit caregivers (75% nurses; 73% nursing aides). Dealing with diarrhea patients is a painful aspect of their work (69% nurses) with tiredness as main feeling and a source of conflict or misunderstanding among caregivers. The mean time measurement for managing one liquid stool in 50 diarrhea episodes was 17min and 33s, involving an average of 1.4 nurses and 0.8 nursing aides. Average human resources cost burden was 26.60 CHF per liquid stool.

CONCLUSION

Dealing with diarrhea increases workload for intensive care unit caregivers with consequences on their well-being. Human related costs of diarrhea are substantial and highlight the economic burden of diarrhea episodes in the intensive care unit. A multidisciplinary approach and specific protocols could positively impact the burden of diarrhea in the intensive care unit.

TRIAL REGISTRATION

Clinical Trials gov NCT01922570.

Too Early Initiation of Enteral Nutrition is Not Nutritionally Advantageous for Comatose Acute Stroke Patients

BACKGROUND

Comatose acute stroke patients are at high risk of malnutrition, especially hypoproteinemia. However, when to start and how to provide nutrition to these patients are unclear. The purpose of this study was to determine the optimum timing and methods of nutritional supplementation to comatose acute stroke patients.

METHODS

A total of 273 comatose acute stoke patients who were unable to eat were enrolled. They received peripheral intravenous low-calorie solutions for the first 4 days after admission (days 0-3), and serum protein concentrations were measured on days 2, 3, and 4. From day 4, 5 different nutritional regimens were administered (25 kcal/kg/day), (including enteral nutrition [EN], total parenteral nutrition [TPN], tube feeding of 20% glucose solution, and combinations of these nutritional supplementations),. Serum concentrations of total protein and albumin were measured on days 10, 14, and 21. The patients who had EN until day 21 from day 4 were defined as EN group, and who had TPN were as TPN group.

RESULTS

Serum protein concentrations decreased slightly on day 2 and decreased significantly on days 3 and 4. From day 4 to 14, the recovery of serum protein was better in the TPN group than in the EN group. Conversely, after day 14, recovery from hypoproteinemia was better in the EN group than in the TPN group. However, when diarrhea was caused by EN, further hypoproteinemia occurred and caused patients to require TPN. The recovery from hypoproteinemia was earliest in patients receiving TPN with 20% glucose fed through a nasogastric tube from day 4 to 13 followed by EN after day 14. Hospitalization was statistically shorter for patients with a nutritionally early recovery than for patients with a delayed recovery, but clinical outcome did not differ significantly between the groups.

CONCLUSION

It is nutritionally disadvantageous not to start nutritional support within 3 days after admission in comatose acute stroke patients. However, starting EN too early is not nutritionally beneficial, and TPN with 20% glucose fed through a tube is recommended as adequate nutrition for these patients. However, TPN should not be employed for longer than 10 days, because switching to EN after this period contributes to better nutritional recovery than continuing TPN.

Qualitative development of a patient-reported outcome symptom measure in diarrhea-predominant irritable bowel syndrome

OBJECTIVES

Despite a documented clinical need, no patient reported outcome (PRO) symptom measure meeting current regulatory requirements for clinically relevant end points is available for the evaluation of treatment benefit in diarrhea-predominant IBS (IBS-D).

METHODS

Patients (N=113) with IBS-D participated in five study phases: (1) eight concept elicitation focus groups (N=34), from which a 17-item IBS-D Daily Symptom Diary and four-item IBS-D Symptom Event Log (Diary and Event Log) were developed; (2) one-on-one cognitive interviews (N=11) to assess the instrument's comprehensiveness, understandability, appropriateness, and readability; (3) four data triangulation focus groups (N=32) to confirm the concepts elicited; (4) two hybrid (concept elicitation and cognitive interview) focus groups (N=16); and (5) two iterative sets of one-on-one cognitive interviews (N=20) to further clarify the symptoms of IBS-D and debrief a revised seven-item Diary and four-item Event Log.

RESULTS

Of thirty-six concepts initially identified, 22 were excluded because they were not saturated, not clinically relevant, not critical symptoms of IBS-D, considered upper GI symptoms, or too broad or vaguely defined. The remaining concepts were diarrhea, immediate need (urgency), bloating/pressure, frequency of bowel movements, cramps, abdominal/stomach pain, gas, completely emptied bowels/incomplete evacuation, accidents, bubbling in intestines (bowel sounds), rectal burning, stool consistency, rectal spasm, and pain while wiping. The final instrument included a daily diary with separate items for abdominal and stomach pain and an event log with four items completed after each bowel movement as follows: (1) a record of the bowel movement/event and an assessment of (2) severity of immediacy of need/bowel urgency, (3) incomplete evacuation, and (4) stool consistency (evaluated using the newly developed Astellas Stool Form Scale). Based on rounds of interviews and clinical input, items considered secondary or nonspecific to IBS-D (rectal burning, bubbling in intestines, spasms, and pain while wiping) were excluded.

CONCLUSIONS

The IBS-D Symptom Diary and Event Log represent a rigorously developed PRO instrument for the measurement of the IBS-D symptom experience from the perspective of the patient. Its content validity has been supported, and future work should evaluate the instrument's psychometric properties.

Jordanian nurses' knowledge and responsibility for enteral nutrition in the critically ill

BACKGROUND

Poor nursing adherence to evidence-based guidelines has negative consequences leading to higher mortality rates, delayed recovery and longer length of stay. Evidence-based practice has the potential to minimize complications and discrepancies between nurses.

AIM

This study aimed to assess nurses' practice and perception of their knowledge and responsibility in relation to enteral nutrition (EN) in the critically ill.

DESIGN AND METHODS

This descriptive correlational design was applied to nurses working in intensive care units (ICUs) from three health care sectors in Jordan (Governmental, Military and Private sectors). Nurses were recruited using a stratified sampling technique. A pre-prepared questionnaire focusing on nurses' practice and perception towards EN was used.

RESULTS

A total of 253 ICU nurses completed the questionnaire. Nurses revealed a tendency to undertake nutritional care despite the recognition clinical nutrition is a secondary role. In terms of nursing processes, nurses showed greater levels of knowledge and responsibility for 'preventing complications' and 'evaluation' more than 'assessment' and 'identifying goals'. Nurses inadequately assess both gastric residuals and tube placement before feeding. Diarrhoea was the most frequent complication followed by abdominal pain, vomiting, tube dislodgment and weight loss. However, nurses realized that the incidences of complications is less likely when applying evidence-based protocol.

CONCLUSION

It is necessary to establish a preliminary assessment for patients' nutritional needs prior to using EN. Aspiration reduction measures are still deficient and need further attention. An evidence-based protocol for EN should be adopted in the critically ill.

RELEVANCE TO CLINICAL PRACTICE

This article provides insight into the current practice of Jordanian intensive care nurses in different health care sectors. The study can contribute to redirect the perception of nurses towards nutrition in the critically ill in addition to enhance positive adherence to evidence base.

Mechanisms and effectiveness of prebiotics in modifying the gastrointestinal microbiota for the management of digestive disorders

The gastrointestinal microbiota is a complex ecosystem with each human individual hosting at least 160 different bacterial strains. Our understanding of its role is rapidly expanding as a result of the molecular microbiological techniques that can accurately characterise its composition and 'omics' technologies that measure its metabolic activity. Since 1995, extensive research has investigated the prebiotic concept, which describes how supplementation of some non-digestible oligosaccharides can stimulate the growth and/or activity of specific genera including bifidobacteria. However, the vast majority of studies are in healthy human subjects, with few undertaken in patients with disorders relevant to clinical nutrition. Marked alterations of the luminal microbiota have been demonstrated in patients with digestive disorders, highlighting mechanisms through which they might be involved in their pathogenesis, including higher clostridia in patients who develop diarrhoea during enteral nutrition and the influence of bifidobacteria on intestinal dendritic cell phenotype in Crohn's disease. The impact of prebiotics on the intestinal microbiota of healthy people has not been consistently replicated in patients with digestive disorders. For example, a number of studies show that inulin/oligofructose do not increase bifidobacteria in enteral nutrition and Crohn's disease. Indeed, in Crohn's disease and irritable bowel syndrome there is evidence that some prebiotics in high doses worsen functional symptoms. Unlike healthy human subjects, patients experience a number of issues that may alter their gastrointestinal microbiota (disease, antibiotics and inflammation) and the use of microbiota modifying therapies, such as prebiotics, do not always elicit the same effects in patients as they do in healthy people.

A case of pressure ulceration and associated haemorrhage in a patient using a faecal management system

Diarrhoea is a difficult patient problem to manage in the intensive care setting, causing odour, discomfort and embarrassment for the patient and potential for loss of skin integrity and cross contamination. Caring for these patients is resource-intensive. A recently developed product for the management of faecal incontinence is the Flexi-Seal Faecal Management System (FMS(©)). Whilst this product is usually effective for managing diarrhoea, there are uncommon but serious complications associated with its use. Rectal bleeding attributed to pressure ulceration of the rectal mucosa can be severe, especially in conjunction with the use of anticoagulation. We report a case of severe rectal bleeding requiring surgical intervention and administration of large amounts of blood products, caused by pressure ulceration as a result of the use of a Flexi-Seal FMS(©). The case report is followed by a review of the literature. Similar complications have been described by others. Although, based on the number of reported complications, the incidence of serious complications appears to be low, a publication bias cannot be ruled out. Knowledge of the complications associated with the device is important for evaluating the appropriateness of insertion and for ensuring the safe and effective on going care of patients using Flexi-Seal FMS(©).

Definitions, attitudes, and management practices in relation to diarrhea during enteral nutrition: a survey of patients, nurses, and dietitians

BACKGROUND

Diarrhea is a common complication in patients receiving enteral nutrition (EN), and understanding this problem among patients and healthcare professionals is required. The aim of the study was to investigate patients', nurses', and dietitians' definitions of diarrhea during EN, the attitudes of nurses and patients toward it, and the management practices of nurses and dietitians in response to diarrhea during EN.

METHODS

Twenty-two patients receiving EN, 57 nurses, and 33 dietitians were recruited and interviewed in a cross-sectional study, using a questionnaire that had been developed following an extensive literature review and pretested for clarity.

RESULTS

The ratings assigned by the 3 groups differed significantly for all the characteristics used to define diarrhea: frequency (P = .006), quantity (P < .001), consistency (P = .003), color (P < .001), odor (P < .001), and incontinence (P < .001). Patients gave incontinence the highest rank when defining diarrhea, whereas the healthcare professionals gave fecal consistency and frequency the highest ranks. Patients and nurses rated the unpleasantness of each characteristic of diarrhea during EN differently, with patients rating incontinence and fecal frequency and nurses rating odor and changing the patients' underwear as the most unpleasant characteristics. Nurses and dietitians differed in the frequency with which they adopted various strategies to manage patients who developed diarrhea during EN.

CONCLUSIONS

Patients have different definitions and attitudes toward diarrhea during EN from those of nurses and dietitians. Patients' perceptions need to be understood and respected by healthcare professionals to improve patient-centered care.

Diarrhoea risk factors in enterally tube fed critically ill patients: a retrospective audit

OBJECTIVE

Diarrhoea in the enterally tube fed (ETF) intensive care unit (ICU) patient is a multi-factorial problem. Diarrhoeal aetiologies in this patient cohort remain debatable; however, the consequences of diarrhoea have been well established and include electrolyte imbalance, dehydration, bacterial translocation, peri anal wound contamination and sleep deprivation. This study examined the incidence of diarrhoea and explored factors contributing to the development of diarrhoea in the ETF, critically ill, adult patient.

METHOD

After institutional ethical review and approval, a single centre medical chart audit was undertaken to examine the incidence of diarrhoea in ETF, critically ill patients. Retrospective, non-probability sequential sampling was used of all emergency admission adult ICU patients who met the inclusion/exclusion criteria.

RESULTS

Fifty patients were audited. Faecal frequency, consistency and quantity were considered important criteria in defining ETF diarrhoea. The incidence of diarrhoea was 78%. Total patient diarrhoea days (r=0.422; p=0.02) and total diarrhoea frequency (r=0.313; p=0.027) increased when the patient was ETF for longer periods of time. Increased severity of illness, peripheral oxygen saturation (Sp02), glucose control, albumin and white cell count were found to be statistically significant factors for the development of diarrhoea.

CONCLUSION

Diarrhoea in ETF critically ill patients is multi-factorial. The early identification of diarrhoea risk factors and the development of a diarrhoea risk management algorithm is recommended.

Probiotics in the critically ill patient: a double blind, randomized, placebo-controlled trial

PURPOSE

Probiotics have been shown to be able to restore a non-pathogenic digestive flora, to prevent digestive colonization by pathogenic bacteria, and to modulate immunity. The aim of this study was to assess the effects of prophylactic probiotic administration in patients ventilated for up to 2 days.

METHODS

This study was performed as a double-blind, concealed randomized, placebo-controlled trial in a French medical intensive care unit (ICU). Adult patients mechanically ventilated for a period of more than 48 h received enterally administered probiotics (Ergyphilus, 2 x 10(10) lactic acid bacteria, mostly Lactobacillus rhamnosus GG, once a day) or placebo until successful weaning.

RESULTS

A total of 167 patients were included. The two groups were comparable at baseline. The 28-day mortality rates were not different in the probiotic (25.3%) and placebo groups (23.7%). Mortality rates in ICU and at 90 days were also unaffected by the treatment. The incidence of ICU-acquired infections did not differ significantly except for that of catheter-related bloodstream infections that was lowered by probiotics. On a prespecified subgroup analysis, we found a reduction of the 28-day mortality among severe sepsis patients (total n = 101) treated with probiotics (n = 52) with an odds ratio (OR) for death at 0.38 (95% CI 0.16-0.93, p = 0.035). By contrast, probiotics were associated with a higher mortality rate in non-severe sepsis patients (OR 3.09, 95% CI 0.87-11.01, p = 0.08).

CONCLUSIONS

Although numerous uncertainties remain (type and the number of strains to use, delay and length of administration), and despite an acceptable safety profile, the daily prophylactic administration of probiotics cannot be encouraged in the critically ill patient.

Comparison of complications attributable to enteral and parenteral nutrition in predicted severe acute pancreatitis: a systematic review and meta-analysis

Enteral nutrition (EN) reduces infectious complications and mortality compared with parenteral nutrition (PN) in patients with predicted severe acute pancreatitis. However, to date the complications attributable to the administration of EN and PN in this patient group have not been comprehensively studied. The aim of the study was to systematically review the complications related to the use of nutrition in patients with predicted severe acute pancreatitis receiving EN v. PN. The Cochrane Library, MEDLINE and Scopus were searched. Randomised controlled trials (RCT) of EN v. PN in predicted severe acute pancreatitis were selected. Pooled estimates of complications were expressed as OR with corresponding 95 % CI. Data from five RCT were meta-analysed. Diarrhoea occurred in six of ninety-two (7 %) patients receiving PN and twenty-four of eighty-two (29 %) patients receiving EN (OR 0.20; 95 % CI 0.09, 0.43; P < 0.001). Hyperglycaemia developed in twenty-one of ninety-two (23 %) patients receiving PN and nine of eighty-two (11 %) receiving EN (OR 2.59; 95 % CI 1.13, 5.94; P = 0.03). Given a significant reduction in infectious complications and mortality associated with the use of EN over PN that has been consistently demonstrated in previous studies, the former should be the treatment of choice in acute pancreatitis. Further clinical studies should investigate the strategies to mitigate the complications of enteral tube feeding in patients with acute pancreatitis.

Strategies to manage gastrointestinal symptoms complicating enteral feeding

Diarrhea and abdominal distension are common complications associated with enteral feeding. Often the cause is unknown, the enteral formula is blamed and changes to the mode of delivery or formula are instituted. However, the evidence base for many strategies used is limited. Altering the osmolality and temperature of the formula and/or the rate of infusion are commonly practiced but evidence for their benefit is largely anecdotal. Preventing microbial contamination of the feed is important and clear guidelines exist to achieve this. The formulation itself can be modified. While the addition of fiber is well supported theoretically, outcome data are less convincing. Avoidance of osmotically active, poorly absorbed short-chain carbohydrates in the formula (often used as the major carbohydrate source) is a new tactic to minimize diarrhea. It has compelling theoretical support, but requires further investigation. A methodical clinical approach to gastrointestinal complications of enteral feeding is warranted and an algorithm for management is proposed.

Diarrhoea in the critically ill

PURPOSE OF REVIEW

The purpose of this review is to update the knowledge on diarrhoea, a common problem in critically ill patients. Epidemiological data will be discussed, with special emphasis on diarrhoea in tube-fed patients and during antibiotic therapy. The possible preventive and therapeutic measures will be presented.

RECENT FINDINGS

The need for concise definitions of diarrhoea was recently re-emphasized. The use of pump-driven continuous instead of intermittent enteral feeding is less often associated with diarrhoea. The discontinuation of enteral feeding during diarrhoea is not justified. Clostridium difficile-associated diarrhoea is frequent during antibiotic therapy with quinolones and cephalosporins. Formulas enriched with water-soluble fibres are probably effective to prevent diarrhoea, and promising data on the modulation of gut microflora with probiotics and prebiotics were recently released.

SUMMARY

Diarrhoea is common in critically ill patients, especially when sepsis and hypoalbuminaemia are present, and during enteral feeding and antibiotic therapy. The management of diarrhoea includes generous hydration, compensation for the loss of electrolytes, antidiarrheal oral medications, the continuation of enteral feeding, and metronidazole or glycopeptides in the case of moderate to severe C. difficile colitis. The place of enteral formulas enriched with water-soluble fibres, probiotics and prebiotics is not yet fully defined.

Formula delivery in patients receiving enteral tube feeding on general hospital wards: the impact of nasogastric extubation and diarrhea

OBJECTIVE

In contrast to the intensive care unit, little is known of the percentage of formula delivered to patients receiving enteral tube feeding (ETF) on general wards or of the complications that affect its delivery. This study prospectively investigated the incidence of nasogastric extubation and diarrhea in patients starting ETF on general wards and examined their effect on formula delivery.

METHODS

In a prospective observational study, the volume of formula delivered to patients receiving ETF on general wards was compared with the volume prescribed. The incidence of nasogastric extubation and diarrhea was measured and its effect on formula delivery calculated.

RESULTS

Twenty-eight patients were monitored for a total of 319 patient days. The mean +/- SD volume of formula prescribed was 1460 +/- 213 mL/d, whereas the mean volume delivered was only 1280 +/- 418 mL/d (P < 0.001), representing a mean percentage delivery of 88 +/- 25% of prescribed formula. Nasogastric extubation occurred in 17 of 28 patients (60%), affecting 53 of the 319 patient days (17%). The percentage of formula delivered on days when the nasogastric tube remained in situ was 96 +/- 12% and on days when nasogastric extubation occurred it was only 45 +/- 31% (P < 0.001). Diarrhea affected 39 of 319 patient days (12%) but there was no difference in formula delivery on days when diarrhea did or did not occur (78% versus 89%, P = 0.295). There was a significant, albeit small, negative correlation between the daily stool score and formula delivery (correlation coefficient -0.216, P < 0.001).

CONCLUSIONS

Formula delivery is marginally suboptimal in patients receiving ETF on general wards. Nasogastric extubation is common and results in an inherent cessation of ETF until the nasogastric tube is replaced and is therefore a major factor impeding formula delivery. Diarrhea is also common but does not result in significant reductions in formula delivery.

Enteral feeding in the critically ill: are nursing practices contributing to hypocaloric feeding?

INTRODUCTION

Enteral feeding is the preferred method of nutritional support for the critically ill; however, a significant number of these patients are under-fed. It is possible that common nursing practices associated with the delivery of enteral feeding may contribute to under-feeding although there is little data available describing nursing practice in this area.

METHOD

A descriptive survey-based design was used to explore the enteral feeding practices of 376 critical care nurses (response rate 50.5%). Participants completed a 57-item survey that focused on general enteral feeding practice and the management of feeding intolerance and complications.

RESULTS

The enteral feeding practice of critical care nurses varied widely and included some practices that could contribute to under-feeding in the critically ill. Practices associated with the measurement of gastric residual volumes (GRV) were identified as the most significant potential contributor to under-feeding. GRV measurements were commonly used to assess feeding tolerance (n = 338; 89.9%) and identified as a reason to delay feeding (n = 246; 65.4%). Delayed gastric emptying was frequently managed by prokinetic agents (n = 237; 63%) and decreasing the rate of feeding (n = 247; 65.7%) while nursing measures, such as changing patient position (n = 81; 21.5%) or checking tube placement (n = 94; 25%) were less frequently reported.

CONCLUSION

The findings of this survey support the contention that nursing practices associated with the delivery of enteral feeds may contribute to under-feeding in the critically ill patient population.

Enteral feeding: the effect on faecal output, the faecal microflora and SCFA concentrations

Enteral tube feeding is common in both the hospital and community environment; however, patients can suffer alterations in faecal output that can have serious clinical sequelae. Problems associated with accurate characterisation of faecal output and definition of diarrhoea impede the comparison of research studies and prevent standardised assessment of therapeutic interventions in clinical practice. The colonic microflora may protect the patient against diarrhoea by preventing enteropathogenic infection and by producing SCFA that stimulate colonic water absorption. However, studies in healthy volunteers suggest that the composition of the enteral formula may have a negative impact on the microflora and SCFA concentrations. The addition of fructo-oligosaccharides to the enteral formula may partially prevent negative alterations to the microflora, although conclusive data from studies in patients are not yet available. Modification of the microflora with probiotics and prebiotics may hold potential in prophylaxis against diarrhoea during enteral tube feeding.

Assessment of fecal output in patients receiving enteral tube feeding: validation of a novel chart

OBJECTIVE

To develop a practical, valid and reliable chart to assist in the accurate visual characterization of fecal output in patients receiving enteral tube feeding (ETF).

DESIGN

A chart incorporating verbal and pictorial descriptors of fecal output was developed. Validity and reliability were assessed by a questionnaire survey of health professionals and a clinical study of patients commencing ETF. Content validity was assessed from the results of the questionnaire, construct validity by contrasting groups analysis, concurrent validity by comparison of the chart with actual fecal weight and inter-rater reliability by independent characterization of the same fecal sample by two nurses.

SETTING

St George's Hospital, London, UK.

SUBJECTS

In all, 35 health professionals completed a questionnaire with respect to the chart. The chart was then used to monitor fecal output in 36 patients commencing ETF for a total of 171 patient-days, during which time nurses used the chart to characterize 269 fecal samples, of which 59 were subsequently weighed.

RESULTS

The results of the questionnaire suggested good content validity. The chart demonstrated statistically significant differences in fecal frequency, fecal consistency, fecal score and incidence of diarrhea for contrasting patient groups expected to have different fecal output (P < 0.05). The inter-rater reliability was almost perfect for fecal consistency (95% agreement, kappa = 0.91) and substantial for fecal weight (83%, kappa = 0.75). In all, 83% of fecal samples were assigned to the correct weight category (kappa = 0.75).

CONCLUSION

The chart has good content, construct and concurrent validity and inter-rater reliability, and is suitable for both research and clinical use.

SPONSORSHIP

This research was jointly supported by King's College London and Nestlé, UK.