What's new on defining diarrhea in tube-feeding studies?

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Dose-response relationship between diarrhea quantity and mortality in critical care patients: A retrospective cohort study

BACKGROUND

Previous studies have shown that diarrhea, defined as a dichotomized cutoff, is associated with increased mortality of patients in intensive care units (ICUs). This study aimed to examine the dose-response relationship between the quantity of diarrhea and mortality in ICU patients with newly developed diarrhea.

METHODS

We conducted this single-center retrospective cohort study. We consecutively included all adult patients with newly developed diarrhea in the ICU between January 2017 and December 2018. Newly developed diarrhea was defined according to the World Health Organization definition. The consistency of diarrhea was evaluated by the Bristol stool chart scale, and the quantity of diarrhea was assessed on the day when patients newly developed diarrhea. The primary outcome was in-hospital mortality. The risk ratio (RR) and 95% confidence interval (CI) for the association between diarrhea quantity and mortality were estimated using multivariable modified Poisson regression models.

RESULTS

Among the 231 participants, 68.4% were men; the median age was 72 years. The median diarrhea quantity was 401g (interquartile range [IQR] 230‒645g), and in-hospital mortality was 22.9%. More diarrhea at baseline was associated with higher in-hospital mortality; the adjusted RR (95% CI) per 200-g increase was 1.10 (1.01‒1.20), p = 0.029. In sensitivity analyses with near quartile categories of diarrhea quantity (<250g, 250-399g, 400-649g, ≥650g), the adjusted RRs for each respective category were 1.00 (reference), 1.02 (0.51-2.04), 1.29 (0.69-2.43), and 1.77 (0.99-3.21), p for trend = 0.033.

CONCLUSIONS

A greater quantity of diarrhea was an independent risk factor for in-hospital mortality. The diarrhea quantity may be an indicator of disease severity in ICU patients.

A high-protein peptide-based enteral formula improves diarrhea in tube-fed patients: A prospective multicenter study

BACKGROUND

Diarrhea is a common problem in tube-fed patients. The relevant guidelines suggest using a peptide-based enteral formula in patients with diarrhea; however, sufficient evidence to support this recommendation is currently lacking.

AIM

This study aimed to evaluate the effects of a high-protein peptide-based formula on gastrointestinal intolerance, mainly focusing on diarrhea symptoms in patients who were intolerant to polymeric formula feeding.

METHODS

This prospective, single-arm, open-label, multicenter study was conducted from March 2021 to March 2022 at two tertiary-care hospitals. Patients who presented with diarrhea during tube feeding with polymeric formula were assigned to receive a high-protein peptide-based formula for ≤7 days. Stool weight and frequency were monitored at baseline, on day 3, and on day 7 (or end of the study) as the primary outcomes.

RESULTS

Twenty-eight tube-fed patients with diarrhea were recruited. After switching their feeding formula from polymeric to peptide based, significant improvements in stool frequency and stool weight were observed on day 3 and day 7 compared with the baseline (median [IQR] stool frequency: 5 (2), 2.5 (3.5), and 3 (3) times/day, respectively, p <0.001; median stool weight: 500 (370), 170 (285), and 275 (385) gram/day, respectively, p = 0.015). Stool consistency was assessed using the Bristol Stool Score and showed significant improvement with time. No serious adverse events were reported.

CONCLUSION

A high-protein peptide-based enteral formula was effective in reducing stool weight and frequency in patients who experienced diarrhea during tube feeding with a polymeric formula.Trial registration: TCTR20210302006.

Defining and Assessing Tolerance in Enteral Nutrition

Nutrition support has become widely recognized as an essential component of optimal care for acutely ill patients. Enteral nutrition is preferred over parenteral routes when possible. However, prescribed enteral nutritional regimens are sometimes met with side effects and even complications. These adverse events have been collectively termed "intolerance," and forms of intolerance occur in a spectrum from bothersome at least to life threatening when most severe. Here we discuss nutritional access and its maintenance, introduce and define intolerance, and then review the current literature with regard to principal forms of enteral nutrition intolerance.

Monitoring Enteral Nutrition Support Tolerance in Infants and Children

Enteral nutrition support is used extensively in the care of infants and children, both for acute and chronic conditions. Monitoring a child's tolerance of enteral feedings is an ongoing challenge. Monitoring routines vary significantly between institutions, practitioners, and patient settings, and a number of definitions are used for "intolerance." Some guidelines have scientific basis and others are passed along in a more anecdotal fashion. This review describes commonly used monitors for tolerance to enteral nutrition for infants and children and discusses pertinent data relevant to practice.

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.

Enteral tube feeding of patients with acute stroke: when does the risk of diarrhoea increase?

BACKGROUND/AIM

We aimed to evaluate the relationship between the length of time acute stroke patients underwent enteral tube feeding (ETF) and episodes of diarrhoea, and to investigate the temporal cut-off point at which diarrhoea risk increases.

METHODS

An observational, retrospective study was conducted on patients with acute stroke admitted to a Stroke Centre. Patients undergoing ETF (ETF group) and those not undergoing ETF (control group) were analysed and matched by age and stroke severity. Data regarding demographic and clinical variables were recorded. The analysis was conducted using a receiver operating characteristic (ROC) curve and multivariate analyses.

RESULTS

A total of 130 inpatients was included (age 75.08 ± 11.53 years, 56.2% men). The ETF group had higher diarrhoea frequency (27.7% vs 6.2%, P = 0.001). The length of time on ETF was associated with diarrhoea development (odds ratio (OR), 1.12 increment per day; 95% confidence interval (CI) 1.05-1.18; P < 0.001), after adjusting for confounders. The ROC curve showed 7 days on ETF as a cut-off point for diarrhoea risk. Seven days or more on ETF was independently associated with diarrhoea (OR, 6.26; 95% CI 1.66-23.62; P = 0.007), whereas less than 7 days was not when compared with the control group (OR, 0.38; 95% CI 0.04-3.91; P = 0.413).

CONCLUSIONS

The length of time on ETF is associated with diarrhoea development in patients with acute stroke, demonstrating a temporal cut-off point. Seven days or longer on ETF is related to the occurrence of diarrhoea, whereas less than 7 days on ETF does not show this effect.

Preventing diarrhoea in enteral nutrition: the impact of the delivery set hang time

BACKGROUND

To meet the current recommendations for enteral tube feeding (ETF), we updated our previous practice in 2011 and began to use a 24-h delivery set hang time (DSHT). We evaluated the impact of this update on the risk of diarrhoea and in diarrhoea-free survival.

METHODS

Observational, retrospective study with historical controls on ischaemic and haemorrhagic stroke patients undergoing ETF. Diarrhoea occurrence (≥ 3 liquid stools in 24 h) was compared between patients with a 24 h DSHT (2011-2014) and a 72/96 h DSHT (2010-2011). The analysis was conducted using Kaplan-Meier curves and a Cox regression model.

RESULTS

A total of 175 patients were included [median age 81 years (IQR = 12), 46.9% males], 103 in the group with a 24 h DSHT and 72 in the group with a 72/96 h DSHT. The group with a 24 h DSHT had a lower diarrhoea frequency (13.6% vs. 34.7%, risk ratio: 0.39, 95% CI: 0.22-0.70, p = 0.001) and a lower diarrhoea incidence rate (0.87 vs. 2.32 cases of diarrhoea/100 patient*day, rate ratio: 0.37, 95% CI: 0.19-0.72, p = 0.004). The Kaplan-Meier curves showed a longer diarrhoea-free survival for this group (p = 0.003, log-rank test). A 24 h DSHT was associated with a lower risk of diarrhoea (HR = 0.27, 95% CI: 0.12-0.61, p = 0.002), adjusted by albumin, stroke severity, intravenous thrombolysis, the administration of clindamycin and cefotaxime, and the administration of an enteral formula for diabetic patients.

CONCLUSIONS

The 24 h DSHT was independently associated with a lower risk of diarrhoea and longer diarrhoea-free survival in hospitalised patients with acute stroke under ETF, compared with a 72/96 h DSHT.

Enteral Nutrition for Adults in the Hospital Setting

In patients unable to tolerate oral intake, multiple options of nutrient delivery are available to the clinician. Administration of enteral nutrition (EN) has long been considered the standard of care for nutrition support among patients unable to meet energy and protein requirements orally. Healthcare practitioners must make careful decisions related to ordering, administering, and monitoring EN therapy. In the hospital setting, the registered dietitian is a key resource in enteral formula selection and method of administration, monitoring for and troubleshooting EN-related complications, and transitioning to oral feeding. The hospital setting also presents many unique challenges in providing optimal nutrition to the enterally fed patient.

Fiber and prebiotic supplementation in enteral nutrition: A systematic review and meta-analysis

AIM: To investigate fiber and prebiotic supplementation of enteral nutrition (EN) for diarrhea, fecal microbiota and short-chain fatty acids (SCFAs).

METHODS: MEDLINE, EMBASE, Cochrane Library, CINAHL, Academic Search Premier, and Web of Science databases were searched for human experimental and observational cohort studies conducted between January 1990 and June 2014. The keywords used for the literature search were fiber, prebiotics and enteral nutrition. English language studies with adult patient populations on exclusive EN were selected. Abstracts and/or full texts of selected studies were reviewed and agreed upon by two independent researchers for inclusion in the meta-analysis. Tools used for the quality assessment were Jadad Scale and the Scottish Intercollegiate Guidelines Network Critical Appraisal of the Medical Literature.

RESULTS: A total of 456 possible articles were retrieved, and 430 were excluded due to lack of appropriate data. Of the 26 remaining studies, only eight investigated the effects of prebiotics. Results of the meta-analysis indicated that overall, fiber reduces diarrhea in patients receiving EN (OR = 0.47; 95%CI: 0.29-0.77; P = 0.02). Subgroup analysis revealed a positive effect of fiber supplementation in EN towards diarrhea in stable patients (OR = 0.31; 95%CI: 0.19-0.51; P < 0.01), but not in critically ill patients (OR = 0.89; 95%CI: 0.41-1.92; P = 0.77). Prebiotic supplementation in EN does not improve the incidence of diarrhea despite its manipulative effect on bifidobacteria concentrations and SCFA in healthy humans. In addition, the effect of fiber and/or prebiotic supplementation towards fecal microbiota and SCFA remain disputable.

CONCLUSION: Fiber helps minimize diarrhea in patients receiving EN, particularly in non-critically ill patients. However, the effect of prebiotics in moderating diarrhea is inconclusive.

Standardized application of laxatives and physical measures in neurosurgical intensive care patients improves defecation pattern but is not associated with lower intracranial pressure

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.

Evaluation of the implementation of a bowel management protocol in intensive care: effect on clinician practices and patient outcomes

AIMS AND OBJECTIVES

To evaluate the effect of a multifaceted implementation of a bowel management protocol on outcomes for intensive care patients, in particular the incidence of constipation and diarrhoea, and on clinicians' bowel management practices.

BACKGROUND

Complications associated with poor bowel management for critically ill patients result in adverse outcomes. Implementation of protocols requires strategies proven to change clinician behaviour.

DESIGN

Before and after study.

METHODS

Our bowel management protocol was implemented using three evidence-based elements: education sessions, printed educational materials in the form of a fact sheet and reminders. We retrospectively collected data from patients' medical records admitted at two time points within three Sydney metropolitan intensive care units (preimplementation, n = 101; postimplementation, n = 107).

RESULTS

No significant difference was found in the incidence of constipation and diarrhoea pre and postimplementation of the protocol. Seventy-two per cent (n = 73) of patients preimplementation and 70% (n = 75) of patients postimplementation experienced one or more episodes of constipation (bowels not open for 72 hours or greater), and 16% (n = 16) of patients preimplementation and 20% (n = 21) of patients postimplementation experienced one or more episodes of diarrhoea. There was a slight nonsignificant increase in bowel assessment on admission by medical officers postimplementation (pre, 47%, n = 48; post, 60%, n = 64).

CONCLUSION

Targeted multifaceted implementation of a bowel management protocol did not have an impact on the incidence of constipation or diarrhoea for intensive care patients or on clinician practices. The lack of impact on patient outcomes may be due to clinicians' nonadherence to our bowel management protocol. Reasons clinicians' practices did not change may include the influences of clinical decision-making on behaviour.

RELEVANCE TO CLINICAL PRACTICE

This study highlights difficulties inherent in changing clinician behaviour and practices to improve patient outcomes despite using an evidence-based multifaceted implementation strategy. Further research is required to ascertain the most effective implementation strategies.

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.

Psychometric properties of DAPonDEN: definitions, attitudes and practices in relation to diarrhea during enteral nutrition questionnaire

OBJECTIVES

To investigate the psychometric properties of the developed 21 item questionnaire to measure definitions, attitudes and management practices in relation to diarrhea during enteral nutrition (DAPonDEN).

METHODS

Data were analyzed using exploratory factor analysis from a cross sectional study of 102 nurses aged 18 and over, conducted from December 2011 to February 2012 in Malaysia. Face and content validity of DAPonDEN were first evaluated by few expert panels and patients. For this study, adult nurses were recruited from the adult wards.

RESULTS

In the final model, three items in DAPonDEN were dropped. In the exploratory factor analysis, five factors were extracted that explained a total of 55% of the variation in the remaining 18 items. The Kaiser-Meyer-Olkin (KMO) value was 0.723. For definition, there were two underlying factors: 'Key items in defining diarrhea' and 'non-key items in defining diarrhea'. For attitude there was a single factor. For practice, there were two underlying factors: 'enteral nutrition (EN) related' and 'awareness related'.

CONCLUSION

The items in each of the underlying dimensions seem to measure the respective concepts for definition, attitude and practices adequately. The 18-items DAPonDEN instrument can be a suitable education tool to be used in relation to diarrhea during EN.

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.

The implementation of a bowel management protocol in an adult intensive care unit

AIM

A study to explore the impact of implementing a bowel management protocol in a tertiary referral intensive care unit (ICU) in the West of Scotland.

METHODS

A three phase study was implemented. Phase 1 - a baseline audit reviewing 26 patients' medical notes and a baseline focus group reviewing the multidisciplinary team's (MDT's) opinions with regard to bowel care management in the ICU. Phase 2 - the implementation of a protocol, updated bowel care chart and education sessions for members of the MDT. Phase 3 - an end of study audit reviewing 27 patients' notes after the implementation of phase 2. Additionally, a further focus group examined the MDT's experiences of the protocol in clinical practice.

RESULTS AND FINDINGS

During the phase 1 data collection period, it was evident that there was a haphazard approach to bowel care in the ICU, resulting in poor bowel care documentation and a high incidence of constipation and diarrhoea days. After the interventions of phase 2, bowel care documentation days increased by 13% (p = 0.0003), constipation incidence decreased by 20.7% (p = 0.13) and diarrhoea days reduced by 15.2% (p = 0.18).

CONCLUSION

Although further evaluation is planned, the protocol implemented in this particular study appears to be a useful tool for the delivery of bowel care in the ICU.

RELEVANCE TO CLINICAL PRACTICE

Ensuring appropriate and timely bowel care in the ICU has major implications for the critically ill patients.

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.

Diarrhoea in the enterally fed patient

Diarrhoea complicating enteral feeding is very common in all clinical settings. The major risk factor is the use of concomitant antibiotics. The underlying mechanisms for the diarrhoea mainly relate to alterations in the colonic flora and physiological responses to the mode of feed delivery although a clear understanding of what is actually happening in vivo remains elusive. Management of diarrhoea includes rationalising medications, excluding relevant comorbidity and using antidiarrhoeal medications. Altering the method and site of feed delivery-for example, continuous to bolus, gastric to postpyloric-can also be tried in the more difficult cases.

Measurement issues in trials of pediatric acute diarrheal diseases: a systematic review

BACKGROUND

Worldwide, diarrheal diseases rank second among conditions that afflict children. Despite the disease burden, there is limited consensus on how to define and measure pediatric acute diarrhea in trials.

OBJECTIVES

In RCTs of children involving acute diarrhea as the primary outcome, we documented (1) how acute diarrhea and its resolution were defined, (2) all primary outcomes, (3) the psychometric properties of instruments used to measure acute diarrhea and (4) the methodologic quality of included trials, as reported.

METHODS

We searched CENTRAL, Embase, Global Health, and Medline from inception to February 2009. English-language RCTs of children younger than 19 years that measured acute diarrhea as a primary outcome were chosen.

RESULTS

We identified 138 RCTs reporting on 1 or more primary outcomes related to pediatric acute diarrhea/diseases. Included trials used 64 unique definitions of diarrhea, 69 unique definitions of diarrhea resolution, and 46 unique primary outcomes. The majority of included trials evaluated short-term clinical disease activity (incidence and duration of diarrhea), laboratory outcomes, or a composite of these end points. Thirty-two trials used instruments (eg, single and multidomain scoring systems) to support assessment of disease activity. Of these, 3 trials stated that their instrument was valid; however, none of the trials (or their citations) reported evidence of this validity. The overall methodologic quality of included trials was good.

CONCLUSIONS

Even in what would be considered methodologically sound clinical trials, definitions of diarrhea, primary outcomes, and instruments employed in RCTs of pediatric acute diarrhea are heterogeneous, lack evidence of validity, and focus on indices that may not be important to participants.

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.

[Enteral feeding of critical patients]

Artificial nutrition support forms part of the basic care of critical patients. Enteral feeding has been shown to be better than total parenteral nutrition at improving morbidity (infectious complications) and reducing the length of hospital stays, number of days with mechanical ventilation, and costs. As with any other treatment, enteral feeding has associated complications and side effects which should be understood and treated in order to obtain the greatest benefit from it and reduce possible adverse effects. In this review, we attempt to provide a practical summary of the use of enteral feeding in critical patients. We cover the management of the most frequent associated complications, based on new studies and current scientific evidence. The review is intended to serve as a practice guide for the routine care of severely ill patients.

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.

Re-examination of risk factors for non-Clostridium difficile-associated diarrhoea in hospitalized patients

AIM

This paper is a report of a study to determine the incidence of non-Clostridium difficile-associated diarrhoea in hospitalized patients and to re-evaluate clinical characteristics and other risk factors related to non-C. difficile-associated diarrhoea.

BACKGROUND

Numerous factors are thought to be responsible for diarrhoea in hospitalized patients. Reports about the diarrhoeal effects of some medications administered concomitantly with tube feeding have stimulated reappraisal of the influence of tube feeding as a potential cause.

METHOD

This study was a secondary analysis of data of 154 hospitalized patients collected during a prospective epidemiological study from 1992 to 1993. The secondary analysis was completed in 2006 in order to investigate unanswered questions of current importance.

FINDINGS

The sample was predominantly male and middle aged; approximately 50% were tube fed, and 25% were in an intensive care unit. The incidence of diarrhoea was 35%. Increased severity of illness as well as the combination of sorbitol-containing medication administration and tube feeding were found to be statistically significant factors in the development of diarrhoea.

CONCLUSION

As diarrhoea in hospitalized patients appears to be multifactorial, use of an algorithm to systematically evaluate and manage related factors is recommended.

Diarréia nosocomial em unidade de terapia intensiva: incidência e fatores de risco

RACIONAL: Diarréia nosocomial parece ser comum em unidades de terapia intensiva, embora sua epidemiologia seja pouco documentada em nosso meio. OBJETIVO: Determinar a incidência e fatores de risco de diarréia entre pacientes adultos internados em unidade de terapia intensiva. MÉTODOS: Foram incluídos prospectivamente 457 pacientes no período entre outubro de 2005 e outubro de 2006. Dados demográficos, clínicos e bioquímicos, bem como aspecto e número de evacuações eram registrados diariamente até a saída do paciente do setor. RESULTADOS: Diarréia ocorreu em 135 (29,5%) pacientes, durando em média 5,4 dias. O tempo do seu início em relação à internação foi de 17,8 dias e casos similares de diarréia no mesmo período foram registrados em 113 (83,7%) pacientes. A mortalidade hospitalar foi maior nos pacientes com diarréia do que naqueles sem esta intercorrência. Na análise multivariada através de modelo de regressão logística, apenas o número de antibióticos (OR 1,65; IC 95% = 1,39-1,95) e o número de dias de antibioticoterapia (OR 1,16; IC 95% = 1,12-1,20) associaram-se estatisticamente com a ocorrência de diarréia. Cada dia de acréscimo a mais da antibioticoterapia aumentou em 16% o risco de diarréia (IC 12% a 20%), enquanto a adição de um antibiótico a mais ao esquema antimicrobiano aumentou as chances de ocorrência de diarréia em 65% (IC 39% a 95%). CONCLUSÃO: A incidência de diarréia nosocomial na unidade de terapia intensiva é elevada (29,5%). Os principais fatores de risco para sua ocorrência foram número de antibióticos prescritos e duração da antibioticoterapia. Além das precauções entéricas, a prescrição judiciosa e limitada de antimicrobianos, provavelmente reduzirá a ocorrência de diarréia neste setor.

Enteral-tube-feeding diarrhoea: manipulating the colonic microbiota with probiotics and prebiotics

Diarrhoea is a common and serious complication of enteral tube feeding. Its pathogenesis involves antibiotic prescription, enteropathogenic colonization and abnormal colonic responses, all of which involve an interaction with the colonic microbiota. Alterations in the colonic microbiota have been identified in patients receiving enteral tube feeding and these changes may be associated with the incidence of diarrhoea. Preventing negative alterations in the colonic microbiota has therefore been investigated as a method of reducing the incidence of diarrhoea. Probiotics and prebiotics may be effective because of their suppression of enteropathogenic colonization, stimulation of immune function and modulation of colonic metabolism. Randomized controlled trials of probiotics have produced contrasting results, although Saccharomyces boulardii has been shown to reduce the incidence of diarrhoea in patients in the intensive care unit receiving enteral tube feeding. Prebiotic fructo-oligosaccharides have been shown to increase the concentration of faecal bifidobacteria in healthy subjects consuming enteral formula, although this finding has not yet been confirmed in patients receiving enteral tube feeding. Furthermore, there are no clinical trials investigating the effect of a prebiotic alone on the incidence of diarrhoea. Further trials of the efficacy of probiotics and prebiotics, alone and in combination, in preventing diarrhoea in this patient group are warranted.

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.