Diarrhoea in the ICU: respective contribution of feeding and antibiotics

Nutritional therapy for the prevention of post-intensive care syndrome

Post-intensive care syndrome (PICS) is a triad of physical, cognitive, and mental impairments that occur during or following the intensive care unit (ICU) stay, affecting the long-term prognosis of the patient and also the mental health of the patient's family. While the severity and duration of the systemic inflammation are associated with the occurrence of ICU-acquired weakness (ICU-AW), malnutrition and immobility during the treatment can exacerbate the symptoms. The goal of nutrition therapy in critically ill patients is to provide an adequate amount of energy and protein while addressing specific nutrient deficiencies to survive the inflammatory response and promote recovery from organ dysfunctions. Feeding strategy to prevent ICU-AW and PICS as nutrition therapy involves administering sufficient amounts of amino acids or proteins later in the acute phase after the hyperacute phase has passed, with specific attention to avoid energy overfeeding. Physiotherapy can also help mitigate muscle loss and subsequent physical impairment. However, many questions remain to be answered regarding the potential role and methods of nutrition therapy in association with ICU-AW and PICS, and further research is warranted.

Naldemedine is associated with earlier defecation in critically ill patients with opioid-induced constipation: A retrospective, single-center cohort study

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.

Reducing diarrhoea in an adult surgical intensive care unit: A quality improvement study

BACKGROUND

Although diarrhoea is a real source of morbidity for critically ill patients, this issue has been little studied, making it difficult to understand its mechanisms and management.

AIMS

We conducted a quality improvement study in an adult surgical intensive care unit before/after the implementation of a specific protocol to firstly improve diarrhoea management for patient benefit and secondly to understand the impact on caregivers.

STUDY DESIGN

The first part of this before/after study consisted in assessing the proportion of patients receiving an anti-diarrheal treatment before (phase I)/after (phase II) the implementation of the protocol. The second part of the study was to survey the caregivers on this topic.

RESULTS

Sixty four adults were included (33 in phase I; 31 in phase II) with 280 diarrheal episodes (129 in phase I; 151 in phase II). The proportion of patients who received at least one anti-diarrheal treatment was similar between the two phases (79% (26/33) vs. 68% (21/31), p = .40). Diarrhoea incidence was also similar (9% (33 patients/368 admissions) vs. 11% (31 patients/275 admissions), p = .35). The delay to initiate at least one treatment was significantly shorter in phase II (2 days [1-7] vs. 0 day [0-2]; p < .001). The patients' rehabilitation was no longer impacted by the occurrence of a diarrheal episode in phase II (39% (13/33) vs. 0% (0/31), p < .001). Eighty team members completed the surveys in phase I and 70 in phase II. Caregivers perceived diarrhoea like a burden and its economic impact remained high.

CONCLUSIONS

The implementation of a protocol for the management of ICU diarrhoea did not increase the proportion of patients treated, but it did significantly improve the delay to initiate a treatment. The patients' rehabilitation was no longer affected by diarrhoea.

RELEVANCE TO CLINICAL PRACTICE

The use of specific anti-diarrhoea guidelines may help to reduce the burden of diarrhoea in an ICU.

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.

<i>Clostridioides difficile</i> infection: diagnosis, treatment, and prevention Clinical guidelines of the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientific Society of Russia, and the North- West Society of Gastroenterologists and Hepatologists

   Clostridioides difficile infection (CDI) is the most common cause of antibiotic-associated diarrhea, and an important cause of nosocomial infection. Since the publication of the National Guidelines (2016, 2017), new data have been accumulated on the genetic structure and pathogenic properties of the most common causative agent of severe forms of antibiotic- associated diarrhea, which has led to the reclassifi cation of the pathogen, formerly known as Clostridium diffi cile, to Clostridioides difficile. Laboratory algorithms have been developed to diagnose CDI and determine the toxigenicity of strains reliably. New data on the effectiveness of antibacterials  have been published, monoclonal antibodies to toxin B (bezlotoxumab) have been introduced into clinical practice to prevent CDI recurrence, and fecal microbiota transplantation has been proposed. Over the past 5 years, many international guidelines on the management of adult patients with CDI have also been updated (USA, EU). In the last decade, including due to the COVID-19 pandemic, there has been an increase in CDI incidence. Considering therelevance of CDI, new data on the pathogen, and domestic features, the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientific Society of Russia, and the North-West Society of Gastroenterologists and Hepatologists developed these clinical guidelines.

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.

The effect of fiber supplementation on the prevention of diarrhea in hospitalized patients receiving enteral nutrition: A meta-analysis of randomized controlled trials with the GRADE assessment

Introduction

Enteral nutrition (EN) in hospitalized patients has several advantages. However, post-feeding diarrhea occurs frequently and has been linked to negative outcomes. The EN formula itself may have an impact on how diarrhea develops, and fiber supplements may theoretically help patients experience less diarrhea. This study aimed to thoroughly evaluate whether adding fiber to EN decreases the likelihood of developing diarrhea and whether different types of fibers pose different effects on diarrhea (PROSPERO CRD 42021279971).

Methods

We conducted a meta-analysis on fiber supplementation in hospitalized adult patients receiving EN. We thoroughly searched PubMed, Medline, Embase, Scopus, Web of Science, CENTRAL, and ClinicalTrials.gov databases from inception to 1 September 2022. Only randomized controlled trials (RCTs) were included. Pooled results on the incidence of diarrhea were calculated using a random-effects model. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was applied. Only fiber types from soy polysaccharides (n = 4), psyllium (n = 3), mixed soluble/insoluble fiber (mixed fiber, n = 3), pectin (n = 2), and partially hydrolyzed guar gum (PHGG, n = 2) were examined in the sensitivity analysis.

Results

Among the 4,469 titles found, a total of 16 RCTs were included. Overall, compared to fiber-free formulas, fiber supplementation reduced the occurrence of diarrhea in patients receiving EN by 36% (pooled risk ratio [RR] of 0.64 [95% confidence interval (CI): 0.49-0.82, p = 0.005; I ² = 45%]), with GRADE showing the evidence of moderate certainty. Only mixed fiber and PHGG significantly decreased the incidence of diarrhea according to the sensitivity analyses for fiber types (RR 0.54, 95%CI: 0.39-0.75, I ² = 0% and RR 0.47, 95%CI: 0.27-0.83, I ² = 0%, respectively). The results for the remaining fiber types were unclear.

Conclusion

According to a meta-analysis, fiber supplements help lessen post-feeding diarrhea in hospitalized patients receiving EN. However, not all fiber types produced successful outcomes. Diarrhea was significantly reduced by PHGG and mixed soluble/insoluble fiber.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=279971, identifier: PROSPERO CRD 42021279971.

Related Factor Analysis and Nursing Strategies of Diarrhea in Critically Ill Patients with Enteral Nutrition

Objective. To explore the related factors of diarrhea in critically ill patients with enteral nutrition (EN) in the intensive care unit (ICU). Methods. This single-center retrospective study analyzed the occurrence of intolerant diarrhea in ICU patients receiving EN treatment in our hospital. By collecting clinical data, univariate and multivariate logistic regression analysis was used to screen the risk factors for diarrhea. Results. Among 120 patients included in the study, 68 (48.33%) had diarrhea. Age (OR = 2.599, $P=0.027$ ), use of antibiotics (OR = 3.496, $P=0.007$ ), ICU hospitalization time (OR = 1.311, $P=0.001$ ), and mechanical ventilation time (OR = 1.273, $P=0.035$ ) were all independent risk factors for diarrhea in EN. Conclusion. Older age, frequent use of antibiotics, long ICU stay, and mechanical ventilation time can lead to diarrhea in ICU patients receiving EN treatment. It is necessary to effectively analyze the above independent factors and implement targeted interventions to improve the incidence of diarrhea in patients.

When is parenteral nutrition indicated?

The indications and contraindications of parenteral nutrition (PN) are discussed in view of recent clinical findings. For decades, PN has been restricted to patients unable to tolerate enteral nutrition (EN) intake owing to the perceived risk of severe side-effects. The evolution of the PN substrate composition and delivery of nutrition via all-in-one bags has dramatically improved the application prospects of PN. Recent studies show similar complication rates of nutrition therapy administered through enteral and intravenous routes. Therefore, indications of PN have, based on evidence, extended beyond complete gastrointestinal (GI) failure to include conditions such as insufficient EN generating persistent negative energy balance and insufficient protein intakes, malabsorption, or specific needs that are impossible to cover with EN feeds.

Estimating the time point for nutritional failure in patients suffering from acute brain attacks in the intensive care unit

BACKGROUND

Severe brain attack patients demonstrate hypermetabolic state and gastrointestinal dysfunction, leading to faster onset of nutritional failure.

AIM

To estimate the time point where the development of nutritional failure is more probable among patients with acute brain attacks in the intensive care unit (ICU).

METHODS

Direct bedside observation for selected nutritional parameters was performed. When enteral nutrition was initiated, observation was performed at five points over 9 days.

FINDINGS

84 patients with 55% mortality risk and on mechanical ventilation were included. Over the observation period, gastric residual volume increased (144 ml vs 196 ml), body weight decreased (79.4 kg vs 74.3 kg), and serum albumin reduced (3.6 g/dl to 3.1 g/dl). Caloric attainment and malnutrition score deteriorated, and feeding-related complications increased. Nutritional failure was evidently prevalent between the third and fifth day of observation.

CONCLUSION

An earlier period of enteral nutrition entails higher probability of nutritional failure among severe brain attack patients in the ICU.

Effect of Probiotics on Incident Ventilator-Associated Pneumonia in Critically Ill Patients: A Randomized Clinical Trial

IMPORTANCE

Growing interest in microbial dysbiosis during critical illness has raised questions about the therapeutic potential of microbiome modification with probiotics. Prior randomized trials in this population suggest that probiotics reduce infection, particularly ventilator-associated pneumonia (VAP), although probiotic-associated infections have also been reported.

OBJECTIVE

To evaluate the effect of Lactobacillus rhamnosus GG on preventing VAP, additional infections, and other clinically important outcomes in the intensive care unit (ICU).

DESIGN, SETTING, AND PARTICIPANTS

Randomized placebo-controlled trial in 44 ICUs in Canada, the United States, and Saudi Arabia enrolling adults predicted to require mechanical ventilation for at least 72 hours. A total of 2653 patients were enrolled from October 2013 to March 2019 (final follow-up, October 2020).

INTERVENTIONS

Enteral L rhamnosus GG (1 × 1010 colony-forming units) (n = 1321) or placebo (n = 1332) twice daily in the ICU.

MAIN OUTCOMES AND MEASURES

The primary outcome was VAP determined by duplicate blinded central adjudication. Secondary outcomes were other ICU-acquired infections including Clostridioides difficile infection, diarrhea, antimicrobial use, ICU and hospital length of stay, and mortality.

RESULTS

Among 2653 randomized patients (mean age, 59.8 years [SD], 16.5 years), 2650 (99.9%) completed the trial (mean age, 59.8 years [SD], 16.5 years; 1063 women [40.1%.] with a mean Acute Physiology and Chronic Health Evaluation II score of 22.0 (SD, 7.8) and received the study product for a median of 9 days (IQR, 5-15 days). VAP developed among 289 of 1318 patients (21.9%) receiving probiotics vs 284 of 1332 controls (21.3%; hazard ratio [HR], 1.03 (95% CI, 0.87-1.22; P = .73, absolute difference, 0.6%, 95% CI, -2.5% to 3.7%). None of the 20 prespecified secondary outcomes, including other ICU-acquired infections, diarrhea, antimicrobial use, mortality, or length of stay showed a significant difference. Fifteen patients (1.1%) receiving probiotics vs 1 (0.1%) in the control group experienced the adverse event of L rhamnosus in a sterile site or the sole or predominant organism in a nonsterile site (odds ratio, 14.02; 95% CI, 1.79-109.58; P < .001).

CONCLUSIONS AND RELEVANCE

Among critically ill patients requiring mechanical ventilation, administration of the probiotic L rhamnosus GG compared with placebo, resulted in no significant difference in the development of ventilator-associated pneumonia. These findings do not support the use of L rhamnosus GG in critically ill patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02462590.

Diarrhea in tube-fed hospitalized patients: Feeding formula is not the most common cause

BACKGROUND AND AIM

Clostridium difficile-associated diarrhea (CDAD) and enteral nutrition (EN)-associated diarrhea are the most common recognized etiologies of nosocomial diarrhea. However, in clinical practice, the data regarding how each etiology contributes to the diarrheal episodes are limited. We identify the causes and factors associated with post-feeding diarrhea.

METHODS

Using the data of patients enrolled in "Effect of Psyllium Fiber Supplementation on Diarrhea Incidence in Enteral Tube-Fed Patients: A Prospective, Randomized, and Controlled Trial", the randomized controlled trial showed no difference in diarrheal incidences between fiber-added and fiber-free formulas. Hence, we analyzed the data of all enrolled patients. The causes of diarrhea were classified according to pre-specified definitions. The factors associated with diarrhea were analyzed using logistic regression.

RESULTS

Diarrhea was found in 37.3% (n = 31/83). The most common cause was medication associated (61.3%). CDAD and EN-associated diarrhea were found in only 9.7% and 6.5%, respectively. Patients with baseline albumin <3 g/dL and underlying cerebrovascular disease were more likely to develop diarrhea (adjusted odds ratio 5.70, 95% confidence interval 1.79-20.51, and adjusted odds ratio 10.83, 95% confidence interval 2.96-48.57, respectively). Compared with those without diarrhea, the length of hospital stay in CDAD patients was significantly longer (+23.1 days, P = 0.02), a trend of longer hospital stay in patients with diarrhea from other causes was observed (+3.2 days, P = 0.096).

CONCLUSIONS

Our study found that the most common cause of post-feeding diarrhea is medication associated. Review and cessation of possible drugs should be undertaken before EN modification. CDAD accounts for <10% of diarrhea causes, but it impacts the clinical outcome and should be identified and treated properly.

Fiber in the ICU: Should it Be a Regular Part of Feeding?

PURPOSE OF REVIEW

To highlight the controversy of fiber use in the current critical care nutrition guidelines; review the effect of fiber on the gut microbiota in the critically ill; and examine the data on fiber and outcomes in the intensive care setting.

RECENT FINDINGS

Fiber is increasingly recognized as a necessary component of colonic health and nutrition support. In critical illness there is a shift toward gut dysbiosis and immune dysregulation. Through fermentation and the generation of short-chain fatty acids, fiber has a role in maintaining intestinal homeostasis, immune function, and supporting commensal bacteria. In contrast to fermentable fiber, recent animal models suggest that non-fermentable fiber can also favorably alter intestinal homeostasis in a mechanism distinct from short chain fatty acids. In the critically ill, RCTs and meta-analyses suggest that soluble and mixed fiber supplemented enteral nutrition can reduce diarrhea and is well tolerated. Based on limited data, there may be benefits in reducing length of hospital stay, certain infections, and glucose metabolism. Nonetheless, the role of fiber enriched nutrition in critically ill patients is controversial as evident in the conflicting guidelines. Despite shortcomings in the literature, soluble and mixed fiber supplemented enteral nutrition is safe and beneficial in most hemodynamically stable intensive care patients. More research is necessary to determine optimal fiber composition.

Critical Care Management of the Patient with Clostridioides difficile

OBJECTIVES

To review published clinical evidence on management of Clostridioides difficile infection in critically ill patients.

DATA SOURCES

We obtained relevant studies from a PubMed literature review and bibliographies of reviewed articles.

STUDY SELECTION

We selected English-language studies addressing aspects of C. difficile infection relevant to critical care clinicians including epidemiology, risk factors, diagnosis, treatment, and prevention, with a focus on high-quality clinical evidence.

DATA EXTRACTION

We reviewed potentially relevant studies and abstracted information on study design, methods, patient selection, and results of relevant studies. This is a synthetic (i.e., not systematic) review.

DATA SYNTHESIS

C. difficile infection is the most common healthcare-associated infection in the United States. Antibiotics are the most significant C. difficile infection risk factor, and among antibiotics, cephalosporins, clindamycin, carbapenems, fluoroquinolones, and piperacillin-tazobactam confer the highest risk. Age, diabetes mellitus, inflammatory bowel disease, and end-stage renal disease are risk factors for C. difficile infection development and mortality. C. difficile infection diagnosis is based on testing appropriately selected patients with diarrhea or on clinical suspicion for patients with ileus. Patients with fulminant disease (C. difficile infection with hypotension, shock, ileus, or megacolon) should be treated with oral vancomycin and IV metronidazole, as well as rectal vancomycin in case of ileus. Patients who do not respond to initial therapy should be considered for fecal microbiota transplant or surgery. Proper infection prevention practices decrease C. difficile infection risk.

CONCLUSIONS

Strong clinical evidence supports limiting antibiotics when possible to decrease C. difficile infection risk. For patients with fulminant C. difficile infection, oral vancomycin reduces mortality, and adjunctive therapies (including IV metronidazole) and interventions (including fecal microbiota transplant) may benefit select patients. Several important questions remain regarding fulminant C. difficile infection management, including which patients benefit from fecal microbiota transplant or surgery.

Gastrointestinal complications are associated with a poor outcome in non-critically ill pneumonia patients

Background

Development of gastrointestinal (GI) complications is adversely associated with prognosis in the critically ill. However, little is known about their impact on the outcome of non-critically ill patients. In this study, we aimed to investigate the incidence of GI complications and their influence on prognosis of hospitalized pneumonia patients.

Methods

Adult patients admitted with a diagnosis of pneumonia from 2012 to 2014 were included. Medical records were reviewed to obtain patients’ demographics, physical signs, comorbidities, laboratory results, clinical events, and the Confusion, Urea, Respiratory rate, Blood pressure and age ≥ 65 (CURB-65) score was calculated to assess the severity of pneumonia. GI complications, including bowel distension, diarrhea, GI bleeding and ileus, were evaluated during the first 3 days of hospitalization and their association with patient outcomes, such as hospital mortality and length of stay, was analyzed.

Results

A total of 1001 patients were enrolled, with a mean age of 73.7 years and 598 (59%) male. Among them, 114 (11%) patients experienced at least one GI complication and diarrhea (5.2%) was the most common. The hospital mortality was 14% and was independently associated with an increase in the CURB-65 score (odds ratio [OR] 1.952 per point increase; 95% confidence interval [CI] 1.516–2.514), comorbid malignancy (OR 1.943; 95% CI 1.209–3.123), development of septic shock (OR 25.896; 95% CI 8.970–74.765), and the presence of any GI complication (OR 1.753; 95% CI 1.003–3.065).

Conclusions

Compared to a critical care setting, GI complications are not commonly observed in a non-critical care setting; however, they still have a negative impact on prognosis of pneumonia patients, including higher mortality and prolonged length of hospital stay.

Diarrhea and elevation of plasma markers of cholestasis are common and often occur concomitantly in critically ill patients

PURPOSE

We aimed to describe epidemiology of diarrhea and cholestasis in critically ill patients and explore associations between these two conditions.

MATERIAL AND METHODS

We performed a retrospective study including all consecutive patients who stayed in the ICU for at least 3 days and in whom plasma measurements of liver enzymes/cholestasis parameters were performed. Diarrhea was defined as 3 or more loose or liquid stools per day and cholestasis as increase of alkaline phosphatase (ALP) and gamma glutamyl transpeptidase (GGT) 1.5 times above the upper limit of normality.

RESULTS

Diarrhea was observed in 26.1% and cholestasis in 27.9% of study patients, about one third of the cases in both diarrhea and cholestasis occurred beyond the first week of patient's ICU stay. Cholestasis occurred in 45.6% of patients with diarrhea vs 28.0% of patients without diarrhea (p < 0.001). In 94 patients (13.1%) both diarrhea and cholestasis occurred, cholestasis was more commonly (2/3 of cases) documented before manifestation of diarrhea.

CONCLUSIONS

Cholestasis is more common in patients with diarrhea and vice versa. Diarrhea and cholestasis both occur in approximately one quarter of ICU patients, with significant proportion manifesting beyond the first week in the ICU.

Impact of a natural versus commercial enteral-feeding on the occurrence of diarrhea in critically ill cardiac surgery patients. A retrospective cohort study

BACKGROUND

Diarrhea is an important complication in critically ill patients undergoing enteral feeding. The occurrence of diarrhea may lead to systemic and local complications and negatively impacts on nursing workload and patient's wellbeing. An enteral feeding based on blenderized natural food could be beneficial in reducing the risk of diarrhea. No study has compared natural and commercial enteral feedings in critically ill cardiac surgery patients.

OBJECTIVE

The aim of this study was to compare the risk of diarrhea occurrence in two cohorts of patients fed a blenderized natural food diet or commercial enteral feeding preparations, respectively.

DESIGN

Retrospective cohort study.

SETTING

Cardiac-Surgery Intensive Care Unit of a University Hospital.

PARTICIPANTS

Two-hundred and fifteen patients admitted to the postoperative cardiac surgery intensive care unit were included, 103 fed blenderized natural enteral feeding and 112 fed commercial formulas.

METHODS

Commercial enteral formulas were delivered by continuous pump administration, while natural enteral feeding by bolus 3 times per day. Diarrhea was documented in the presence of three or more evacuations of loose or watery stool (or an amount above 250 ml) per day. The presence of diarrhea was recorded daily from the beginning to the end of the enteral feeding, up to a maximum of 8 days. The unadjusted time to the first event of diarrhea between the two enteral feeding groups was compared. Adjusted comparison was then performed by fitting a multivariable Cox Proportional-Hazards model, adjusted for potential confounders for diarrhea occurrence (i.e. administration of inotropes, vasopressors, prokinetics, antibiotics, oral nutritional supplements, antifungal agents, sedatives, opioids, probiotics, laxatives).

RESULTS

In unadjusted survival analysis the probability of diarrhea was significantly lower in the natural enteral feeding group (log rank test: p = 0.023). In the multivariable model patients in natural enteral feeding cohort showed a non-significant trend towards an almost halved risk of experiencing diarrhea (hazard ratio: 0.584; 95% confidence interval: 0.335-1.018; p = 0.058) compared to those fed commercial enteral feeding.

CONCLUSIONS

Administration of a blenderized diet based on natural food for enteral feeding can reduce the incidence of diarrhea in cardiac surgery critically ill patients. This strategy may reduce the risk of diarrhea-associated malnutrition and systemic and local complications, also having a positive impact on nursing workload and patient wellbeing.

How to choose the best route of feeding during critical illness

Increased and specific nutritional requirements occurring during critical illness need to be covered by appropriate administration of energy, nitrogen and micronutrients, especially in case of pre-existing malnutrition, chronic insufficient oral intakes or expected delay before recovery of eating. The use of artificial nutrition (enteral or parenteral) is recommended whenever the oral intakes are insufficient, in order to avoid the detrimental consequences of malnutrition and promote the best possible outcome of severely ill patients. This paper aims to provide an overview and practical recommendations of artificial nutrition therapy in the ICU setting.

Diarrhoea in critical care is rarely infective in origin, associated with increased length of stay and higher mortality

Diarrhoea, defined as > 3 loose or liquid stools per day, affects 9.7-41% of intensive care unit patients, negatively impacting on patient dignity, intensifying nursing workload and increasing morbidity. Its pathogenesis is poorly understood, but infective agents, intensive care unit therapies (such as enteral feed) and critical illness changes in the gut microbiome are thought to play a role. We analysed a consecutive cohort of 3737 patients admitted to a mixed general intensive care unit. Diarrhoea prevalence was lower than previously reported (5.3%), rarely infective in origin (6.5%) and associated with increased length of stay (median (inter-quartile range) 2.3 (1.0-5.0) days vs. 10 days (5.0-22.0), p < 0.001, sub-distribution hazard ratio 0.55 (95% CI 0.48-0.63), p < 0.001) and mortality (9.5% vs. 18.1%, p = 0.005, sub-distribution hazard ratio 1.20 (95% CI 0.79-1.81), p = 0.40), compared to patients without diarrhoea. In addition, 17.1% of patients received laxatives <24 h prior to diarrhoea onset. Further research on diarrhoea's pathogenesis in critical care is required; robust treatment protocols, investigation rationalisation and improved laxative prescribing may reduce its incidence and improve related outcomes.

The epidemiology of overfeeding in mechanically ventilated intensive care patients

BACKGROUND AND AIMS

Nutrition research in the Intensive Care Unit (ICU) typically focusses on the epidemiology of underfeeding, particularly early in the ICU admission. Once the acute phase of critical illness has resolved, patients may be at risk of overfeeding. We assessed for the frequency and consequences of potential overfeeding in ICU patients mechanically ventilated (MV) for at least 10 days.

METHODS

Retrospective analysis of 105 MV patients including caloric input, estimated caloric requirements using the Schofield equation, and association between caloric input and several pre-defined clinical outcomes. To increase likelihood of detecting overfeeding, we conducted a post-hoc sensitivity analysis for sub-groups of patients who received on average < 25 kcal/kg/day (N = 55) and >30 kcal/kg/day (N = 17) between day 7-10 and performed repeat ANOVA.

RESULTS

There were no differences in the pre-defined outcomes for those given over, and below 25 kcal/kg/day. On each study day, approximately 25% of patients received >30 kcal/kg/day. Higher caloric delivery was statistically associated with increased minute ventilation on each study day (Spearman Rho approx 0.27;p ≤ 0.007) and also in sub-group analysis (p< 0.001). Higher caloric delivery was also associated with more frequent diarrhoea (p= 0.02) and greater insulin requirement. However, these differences did not translate into increased duration of mechanical ventilation, length of stay, or increased mortality. Higher caloric intake was less strongly associated with serum urea and creatinine, but not associated with agitation, abnormal liver function tests, fever, or antibiotic prescription.

CONCLUSIONS

Delivery of more than 25 kcal/kg/day was not associated with adverse outcomes. On post-hoc analysis, delivery of more than 30 kcal/kg/day was associated with increased minute ventilation, diarrhoea and insulin requirements but no differences in length of ventilation or in-hospital mortality.

Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM)

PURPOSE

Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function.

METHODS

The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process.

RESULTS

In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices.

CONCLUSION

The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).

Diarrhoea: interventions, consequences and epidemiology in the intensive care unit (DICE-ICU): a protocol for a prospective multicentre cohort study

INTRODUCTION

Diarrhoea is a frequent concern in the intensive care unit (ICU) and is associated with prolonged mechanical ventilation, increased length of ICU stay, skin breakdown and renal dysfunction. However, its prevalence, aetiology and prognosis in the critically ill have been poorly studied. The primary objectives of this study are to determine the incidence, risk factors and consequences of diarrhoea in critically ill adults. The secondary objectives are to estimate the incidence of Clostridium difficile-associated diarrhoea (CDAD) in ICU patients and to validate the Bristol Stool Chart and Bliss Stool Classification System characterising bowel movements in the ICU. Our primary outcome is the incidence of diarrhoea . Our secondary outcomes include: CDAD, ICU and hospital mortality and ICU and hospital length of stay.

METHODS AND ANALYSIS

This international prospective cohort study will enrol patients over 10 weeks in 12 ICUs in Canada, the USA, Poland and Saudi Arabia. We will include all patients 18 years of age and older who are admitted to the ICU for at least 24 hours and follow them daily until ICU discharge. Our primary outcome is the incidence of diarrhoea based on the WHO definition, during the ICU stay. Our secondary outcomes include: CDAD, ICU and hospital mortality and ICU and hospital length of stay. We will use logistic regression to identify factors associated with diarrhoea (as defined using WHO criteria) and the kappa statistic to measure agreement on diarrhoea rates between the WHO definition and the Bristol Stool Chart and Bliss Stool Classification System.

ETHICS AND DISSEMINATION

The protocol has been approved by the research ethics board of all participating centres. The diarrhoea interventions, consequences and epidemiology in the intensive care unit (DICE-ICU) study will generate evidence about diarrhoea and its frequency, predisposing factors and consequences, to inform critical care practice and future research.

LAY SUMMARY

Diarrhoea is a frequent clinical problem for hospitalised patients including those who are critically ill in the ICU. Diarrhoea can cause complications such as skin damage, dehydration and kidney problems. It is not clear how common diarrhoea is in the ICU, the factors that cause it or the best way for clinicians to assess it. The DICE-ICU study is an international prospective observational study to examine the frequency, risk factors and outcomes of diarrhoea during critical illness.

Evaluating probiotics for the prevention of ventilator-associated pneumonia: a randomised placebo-controlled multicentre trial protocol and statistical analysis plan for PROSPECT

INTRODUCTION

Ventilator-associated pneumonia (VAP) is the most common healthcare-associated infection in critically ill patients. Prior studies suggest that probiotics may reduce VAP and other infections in critically ill patients; however, most previous randomised trials were small, single centre studies. The Probiotics: Prevention of Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT) aims to determine the impact of the probiotic Lactobacillus rhamnosus GG on VAP and other clinically important outcomes in critically ill adults.

METHODS

PROSPECT is a multicentre, concealed, randomised, stratified, blinded, controlled trial in patients ≥18 years old, anticipated to be mechanically ventilated ≥72 hours, in intensive care units (ICUs) in Canada, the USA and Saudi Arabia. Patients receive either 1×10¹⁰ colony forming units of L. rhamnosus GG twice daily or an identical appearing placebo. Those at increased risk of probiotic infection are excluded. The primary outcome is VAP. Secondary outcomes are other ICU-acquired infections including Clostridioides difficile infection, diarrhoea (including antibiotic-associated diarrhoea), antimicrobial use, ICU and hospital length of stay and mortality. The planned sample size of 2650 patients is based on an estimated 15% VAP rate and will provide 80% power to detect a 25% relative risk reduction.

ETHICS AND DISSEMINATION

This protocol and statistical analysis plan outlines the methodology, primary and secondary analyses, sensitivity analyses and subgroup analyses. PROSPECT is approved by Health Canada (#9427-M1133-45C), the research ethics boards of all participating hospitals and Public Health Ontario. Results will be disseminated via academic channels (peer reviewed journal publications, professional healthcare fora including international conferences) and conventional and social media. The results of PROSPECT will inform practice guidelines worldwide.

TRIALREGISTRATION NUMBER

NCT02462590; Pre-results.

Diarrhea and patient outcomes in the intensive care unit: Systematic review and meta-analysis

PURPOSE

We aimed to determine whether diarrhea experienced by patients in the intensive care unit (ICU) is related to their clinical outcomes.

MATERIAL AND METHODS

We performed a systematic review and meta-analysis. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and the World Health Organization International Clinical Trials Registry Platform between inception and August 2018. The primary outcome was ICU mortality, and secondary outcomes included hospital mortality, ICU length of stay, hospital length of stay. The quality of evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

Twelve studies (enrolling 13,140 patients) compared patients with diarrhea to patients without diarrhea in the ICU. Diarrhea was related to ICU mortality (relative risk [RR]: 1.43; 95% confidence interval [CI]: 1.03 to 1.98). The mean difference (MD) in ICU length of stay between patients with and without diarrhea was 8.08 days (95% CI: 5.85 to 10.32), while the MD in hospital length of stay was 9.67 (95% CI: 2.17 to 17.16). The certainty of evidence for these outcomes was low.

CONCLUSIONS

The diarrhea experienced by patients may be associated with higher mortality and prolonged length of stay in the ICU and hospital.

Global burden of Clostridium difficile infections: a systematic review and meta-analysis

Background

Clostridium difficile is a leading cause of morbidity and mortality in several countries. However, there are limited evidence characterizing its role as a global public health problem. We conducted a systematic review to provide a comprehensive overview of C. difficile infections (CDI) rates.

Methods

Seven databases were searched (January 2016) to identify studies and surveillance reports published between 2005 and 2015 reporting CDI incidence rates. CDI incidence rates for health care facility-associated (HCF), hospital onset-health care facility-associated, medical or general intensive care unit (ICU), internal medicine (IM), long-term care facility (LTCF), and community-associated (CA) were extracted and standardized. Meta-analysis was conducted using a random effects model.

Results

229 publications, with data from 41 countries, were included. The overall rate of HCF-CDI was 2.24 (95% confidence interval CI = 1.66-3.03) per 1000 admissions/y and 3.54 (95%CI = 3.19-3.92) per 10 000 patient-days/y. Estimated rates for CDI with onset in ICU or IM wards were 11.08 (95%CI = 7.19-17.08) and 10.80 (95%CI = 3.15-37.06) per 1000 admission/y, respectively. Rates for CA-CDI were lower: 0.55 (95%CI = 0.13-2.37) per 1000 admissions/y. CDI rates were generally higher in North America and among the elderly but similar rates were identified in other regions and age groups.

Conclusions

Our review highlights the widespread burden of disease of C. difficile, evidence gaps, and the need for sustainable surveillance of CDI in the health care setting and the community.

Constipation, diarrhea, and prophylactic laxative bowel regimens in the critically ill: A systematic review and meta-analysis

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.

Guidelines for Antibiotic Prescription in Intensive Care Unit

How to cite this article: Khilnani GC, Zirpe K, Hadda V, Mehta Y, Madan K, Kulkarni A, Mohan A, Dixit S, Guleria R, Bhattacharya P. Guidelines for Antibiotic Prescription in Intensive Care Unit. Indian Journal of Critical Care Medicine 2019;23 (Suppl 1):1-63.

The effect of enteral versus parenteral nutrition for critically ill patients: A systematic review and meta-analysis

STUDY OBJECTIVE

To analyze the effect of enteral nutrition compared with parenteral nutrition in critically ill patients.

DESIGN

Systematic review and meta-analysis of randomized controlled trials.

SETTING

Intensive care unit.

PATIENTS

23 trials containing 6478 patients met our inclusion criteria.

INTERVENTION

A systematical literature search was conducted to identify eligible trials in electronic databases including PubMed, Embase, Scopus, EBSCO and Cochrane Library. The primary outcome was mortality, the secondary outcomes were gastrointestinal complications, bloodstream infections, organ failures, length of stay in ICU and hospital. We performed a predefined subgroup analyses to explore the treatment effect by mean age, publication date and disease types.

MAIN RESULTS

The result showed no significant effect on overall mortality rate (OR 0.98, 95%CI 0.81 to 1.18, P = 0.83, I² = 19%) and organ failure rate (OR 0.87, 95%CI 0.75 to 1.01, P = 0.06, I² = 16%). The use of EN had more beneficial effects with fewer bloodstream infections when compared to PN (OR 0.59, 95%CI 0.43 to 0.82, P = 0.001, I² = 27%) and this was more noteworthy in the subgroup analysis for critical surgical patients (OR 0.36, 95%CI 0.22 to 0.59, P < 0.0001, I² = 0%). EN was associated with reduction in hospital LOS (MD -0.90, 95%CI -1.63 to -0.17, P = 0.21, I² = 0%) but had an increase incidence of gastrointestinal complications (OR 2.00, 95%CI 1.76 to 2.27, P < 0.00001, I² = 0%).

CONCLUSION

For critically ill patients, the two routes of nutrition support had no different effect on mortality rate. The use of EN could decrease the incidence of bloodstream infections and reduce hospital LOS but was associated with increased risk of gastrointestinal complications.

Determining the impact of a bowel management protocol on patients and clinicians' compliance in cardiac intensive care: A mixed-methods approach

BACKGROUND

Bowel management protocols standardise care and, potentially, improve the incidence of diarrhoea and constipation in intensive care. However, little research exists reporting compliance with such protocols in intensive care throughout patients' stay. Furthermore, there is a limited exploration of the barriers and enablers to bowel management protocols following their implementation, an important aspect of improving compliance.

AIM AND OBJECTIVE

To investigate the impact of a bowel management protocol on the incidence of constipation and diarrhoea, levels of compliance, and to explore the enablers and barriers associated with its use in intensive care.

METHODS

A mixed-methods study was conducted in cardiac intensive care using two phases: (a) a retrospective case review of patients' hospital notes, before and after the protocol implementation, establishing the levels of diarrhoea and constipation and levels of compliance; (b) focus groups involving users of the protocol, 6 months following its implementation, exploring the barriers and enablers in practice.

RESULTS AND FINDINGS

Fifty-one patients' notes were reviewed during phase one: 30 pre-implementation and 21 post-implementation. Following the protocol implementation, there was a tendency for a higher incidence of constipation and less severe cases of diarrhoea. Overall compliance with the protocol was low (2.3%). However, there was evidence of behavioural change following protocol implementation, including less variation in aperients given and a shorter, less varied time period between starting enteral feed and administering aperients. Several themes emerged from the focus groups: barriers and enablers to the protocol characteristics and dissemination; barriers to bowel assessment; nurse as a barrier; medical involvement and protocol outcomes.

CONCLUSIONS

The bowel management protocol implementation generated some positive outcomes to bowel care practices. However, compliance was low and until there is improvement, through overcoming the barriers identified, the impact of such protocols in practice will remain largely unknown.

Parenteral nutrition in the ICU: Lessons learned over the past few years

Since the early 1990s enteral nutrition (EN) has been considered the optimal route of feeding rather than parenteral nutrition (PN), which was considered harmful in critically ill patients with intense inflammation. The aim of this review was to summarize recent developments and progress in PN, which have changed the view on this feeding technique. PubMed and personal databases were searched for studies and reviews reporting historical development of PN, and for clinical trials conducted after 2010 investigating PN in critical illness, comparing it to EN or not. Trials from the past decade have explored modalities and timing of artificial feeding. Trials based on equation-estimated energy targets and applying an early full feeding strategy have generally had negative results in terms of complications (infections, prolonged ventilation, and intestinal complications with EN). The few trials that based their targets on measured energy targets have achieved reduction of complications regardless of the route. Opposing enteral and parenteral feeding is no longer rational in the critical care setting. A pragmatic and reasonable approach offers better options for the individual patient. Although PN is simpler to deliver than EN, its metabolic consequences are more complicated to handle. A combination of both techniques may be a more reasonable approach in the sickest patients.

Parenteral or enteral nutrition: do you have the choice?

PURPOSE OF REVIEW

The review focuses on the use of parenteral nutrition and enteral nutrition in critically ill patients to optimize the nutrition care throughout the ICU stay. The key message is: you have the choice!

RECENT FINDINGS

Enteral nutrition has been recommended for critically ill patients, whereas parenteral nutrition has been considered harmful and to be avoided. However, recent studies have challenged this theory. They demonstrated that enteral nutrition is frequently associated with energy and protein undernutrition, whereas parenteral nutrition becomes deleterious only if overfeeding is induced. Measuring energy expenditure by indirect calorimetry, in most cases, enables accurate determination of the energy needs to optimize the prescription of nutrition. Protein targets should also be considered for adequate feeding. Parenteral nutrition can be used as a supplement or as an alternative to enteral nutrition in case of gastrointestinal intolerance, to enable adequate energy, and protein provision.

SUMMARY

Parenteral nutrition is a powerful tool to optimize nutrition care of critically ill patients to improve clinical outcome, if prescribed according to the individual needs of the patients. After 3-4 days of attempt to feed enterally, enteral nutrition or parenteral nutrition can be used alternatively or combined, as long as the target is reached with special attention to avoid hypercaloric feeding.

Parenteral nutrition in intensive care patients: medicoeconomic aspects

PURPOSE OF REVIEW

Parenteral nutrition (PN) alone or as supplemental parenteral nutrition (SPN) has been shown to prevent negative cumulative energy balance, to improve protein delivery and, in some studies, to reduce infectious morbidity in ICU patients who fail to cover their needs with enteral nutrition (EN) alone.

RECENT FINDINGS

The optimization of energy provision to an individualized energy target using either early PN or SPN within 3-4 days after admission has recently been reported to be a cost-saving strategy mediated by a reduction of infectious complications in selected intensive care patients.

SUMMARY

EN alone is often insufficient, or occasionally contraindicated, in critically ill patients and results in growing energy and protein deficit. The cost benefit of using early PN in patients with short-term relative contraindications to EN has been reported. In selected patients SPN has been associated with a decreased risk of infection, a reduced duration of mechanical ventilation, a shorter stay in the ICU. Altogether four studies have investigated the costs associated with these interventions since 2012: two of them from Australia and Switzerland have shown that optimization of energy provision using SPN results in cost reduction, conflicting with other studies. The latter encouraging findings require further validation.

Feasibility of a Lactobacillus casei Drink in the Intensive Care Unit for Prevention of Antibiotic Associated Diarrhea and Clostridium difficile

Background: Over 70% of patients are prescribed antibiotics during their intensive care (ICU) admission. The gut microbiome is dramatically altered early in an ICU stay, increasing the risk for antibiotic associated diarrhea (AAD) and Clostridium difficile infections (CDI). Evidence suggests that some probiotics are effective in the primary prevention of AAD and CDI. Aim: To demonstrate safety and feasibility of a probiotic drink in ICU patients. Methods: ICU patients initiated on antibiotics were recruited, and matched with contemporary controls. Study patients received two bottles daily of a drink containing 10 billion Lactobacillus casei which was bolused via feeding tube. Tolerance to probiotics and enteral nutrition, development of adverse events, and incidence of AAD was recorded. CDI rates were followed for 30 days post antibiotic treatment. Results: Thirty-two patients participated in the trial. There were no serious adverse events in the probiotic group, compared to three in the control group. AAD was documented in 12.5% of the probiotic group and 31.3% in the control group. One patient in the probiotic group developed CDI compared to three in the control group. Discussion: A probiotic containing drink can safely be delivered via feeding tube and should be considered as a preventative measure for AAD and CDI in ICU.

Protein Requirements in Critically Ill Older Adults

Critically ill elderly patients' nutritional needs are not well understood and vary with the phase of illness and recovery. Patients' nutritional needs should be assessed early in hospitalization and re-assessed throughout the stay with additional attention during the transitions from critical illness, to severe illness, to post-hospital rehabilitation. In this review, we summarize recent findings and highlight recommendations for protein supplementation in critically ill geriatric patients throughout the stages of recovery. Future research specifically focusing on protein dose, its relationship with caloric needs, and delivery modality must be conducted to provide more specific guidelines for clinical practice.

The frequency, risk factors, and complications of gastrointestinal dysfunction during enteral nutrition in critically ill patients

BACKGROUND

Gastrointestinal (GI) motility disorders in intensive care patients remain relatively unexplored. Nowadays, the frequency, risk factors and complications of GI dysfunction during enteral nutrition (EN) become more questionable.

AIM

To evaluate the frequency, risk factors and complications of GI dysfunction during EN in the first 2 weeks of the intensive care unit (ICU) stay and to identify precautions to prevent the development of GI dysfunction and avoid complications.

METHODS

In this prospective observational study, we deliberately targeted at-risk patients. A total of 137 patients who received nasogastric tube feeding in an ICU of a tertiary hospital were enrolled.

RESULTS

The incidence of GI dysfunction that was found to be 63% which was associated mainly between MDR bacteria positivity and negative fluid balance. Diarrhea was observed in 36 patients (26%) and on 147 patient-days (incidence rate, 5.5 per 100 patient-days). The median day of diarrhea onset was 6 days after the initiation of EN. Forty patients (29%) presented with constipation (85% during the first week). Fifty patients (36%) exhibited upper digestive intolerance on 212 patient-days (incidence rate, 7.9 per 100 patient-days), after a median EN duration of 6 days (range, 2-14 days). Logistic regression analysis revealed MDR bacteria growth in the culture (OR, 1.75; 95% CI, 1.15-2.67; P=0.008) and negative fluid balance (OR, 0.57; 95% CI, 0.34-0.94; P=0.03) as the risk factors for GI dysfunction. We also showed that GI dysfunction was associated with high SOFA score, hypoalbuminemia, catecholamine use, and prolonged length of stay (LOS). GI dysfunction, on the other hand, can cause some complications including inadequate nutrition, and newly developed decubitus ulcers.

CONCLUSION

GI dysfunction should be considered a clinical predictor of inadequate nutrition and prolonged LOS. In addition, the most dramatic risk for GI dysfunction was observed in patients with MDR bacteria growth in the culture and patients in negative fluid balance. Intensivists provide appropriate nutrition for patients, as well as prompt intervention and the development of treatment strategies in the event of GI dysfunction.

Stool cultures at the ICU: get rid of it!

Background

Stool cultures for Campylobacter, Salmonella and Shigella and/or Yersinia spp. are frequently ordered in critically ill patients with diarrhea. The aim of this study is to analyze the diagnostic yield in a large cohort of critically ill patients. Therefore, we performed a cohort study at the Department of Intensive Care Medicine of a University Hospital (11 ICUs).

Results

From all patients who were admitted to the ICU between 2010 and 2015, stool cultures were taken from 2.189/36.477 (6%) patients due to diarrhea. Results of all stool cultures tested for Campylobacter, Salmonella and Shigella and/or Yersinia spp. were analyzed. Overall, 5.747 tests were performed; only six were positive (0.1%). In four of these, Campylobacter spp. were detected; diarrhea started within 48 h after ICU admission. Two patients with Salmonella spp. detection were chronic shedders. On the contrary, testing for Clostridium difficile via GDH- and toxin A/B-EIA yielded positive results in 179/2209 (8.1%) tests and revealed 144/2.189 (6.6%) patients with clinically relevant C. difficile infection.

Conclusions

Stool testing for enteric pathogens other than C. difficile should be avoided in ICU patients and is only reasonable when diarrhea commenced less than 48 h after hospital admission.

The effect of a natural food based tube feeding in minimizing diarrhea in critically ill neurological patients

BACKGROUND & AIMS

Diarrhea has negative consequences for patients, health care staff and health care costs when neurological patients are fed enterally over long periods. We examined the effect of tube feeding with natural foods in reducing the number of fluid stool evacuations and diarrhea in critically ill neurological patients.

METHODS

A multicenter, prospective, open-label and randomized controlled trial (RCT) was conducted at facilities in Germany specializing in early rehabilitation after neurological damage. Patients of the INTERVENTION group were fed by tube using a commercially available product based on real foods such as milk, meat, carrots, whereas CONTROL patients received a standard tube-feed made of powdered raw materials. All received enteral nutrition over a maximum of 30 days. The number of defecations and the consistency of each stool according to the Bristol Stool Chart (BSC) were monitored. In addition, daily calories, liquids and antibiotic-use were recorded.

RESULTS

118 Patients who had suffered ischemic stroke, intracerebral hemorrhage, traumatic brain injury or hypoxic brain damage and requiring enteral nutrition were enrolled; 59 were randomized to receive the intervention and 59 control feed. There were no significant differences in clinical screening data, age, sex, observation period or days under enteral nutrition between the groups. Patients in both groups received equivalent amount of calories and fluids. In both groups antibiotics were frequently prescribed (69.5% in the INTERVENTION group and 75.7% in the CONTROL group) for 10-11 days on average. In comparison to the CONTROL group, patients in the INTERVENTION group had a significant reduction of the number of watery stool evacuations (type 7 BSC) (minus 61%, IRR = 0.39, p < 0.001). Further statistical evaluations using the following corrections: major diarrhea-associated confounders (number and duration of antibiotics); shorter observation period of 15 days; excluding patients with Clostridium difficile associated diarrhea (CDAD) and the Per Protocol Population, confirmed the primary hypothesis. The number of days with diarrhea was significantly lower in the INTERVENTION group (0.8 ± 1.60 days versus 2.0 ± 3.46 days).

CONCLUSIONS

Tube feeding with natural based food was effective in reducing the number of watery defecations and diarrhea in long term tube-fed critically ill neurological patients, compared to those fed with standard tube feeding.

Incontinence-associated dermatitis in the critically ill patient: an intensive care perspective

BACKGROUND

Incontinence-associated dermatitis is a skin disorder evident as a complication of incontinence. It is characterized by perineal, buttock and groin erythema and skin breakdown. Incontinence-associated dermatitis is a ubiquitous, nosocomial condition commonly present in critically ill patients in the intensive care unit. Critically ill patients, by the nature of their critical illness and therapies used to treat their presenting condition, are commonly predisposed to faecal incontinence and are consequently at high risk of developing incontinence-associated dermatitis. However, this condition is under-explored and under-reported in the intensive care literature.

OBJECTIVE

The aim of this paper is to provide a review of the literature relating to incontinence-associated dermatitis from the critically ill patients in the intensive care setting.

DISCUSSION

There is a paucity of literature addressing this condition in the intensive care context, with only 11 studies identified. This paper will provide an overview of the definitions, prevalence and incidence of incontinence-associated dermatitis. Furthermore, an exposition of incontinence-associated dermatitis from the critically ill patient and intensive care nursing perspectives will be presented through a review of the skin barrier function, clinical presentation, risk factors, clinical assessment and severity categorization, prevention and management of incontinence-associated dermatitis.

CONCLUSION

It is imperative that critical care nurses have an appreciation of incontinence-associated dermatitis as a common, yet preventable condition, and are equipped with knowledge to appropriately prevent and manage this common complication.

Enteral Formula Containing Egg Yolk Lecithin Improves Diarrhea

Diarrhea often occurs during enteral nutrition. Recently, several reports showed that diarrhea improves by adding egg yolk lecithin, an emulsifier, in an enteral formula. Therefore, we evaluated if this combination could improve diarrhea outcomes. We retrospectively investigated the inhibitory effects on watery stools by replacing a polymeric fomula with that containing egg yolk lecithin. Then, we investigated the emulsion stability in vitro. Next, we examined the lipid absorption using different emulsifiers among bile duct-ligated rats and assessed whether egg yolk lecithin, medium-chain triglyceride, and dietary fiber can improve diarrhea outcomes in a rat model of short bowel syndrome. Stool consistency or frequency improved on the day after using the aforementioned combination in 13/14 patients. Average particle size of the egg yolk lecithin emulsifier did not change by adding artificial gastric juice, whereas that of soy lecithin and synthetic emulsifiers increased. Serum triglyceride concentrations were significantly higher in the egg yolk lecithin group compared with the soybean lecithin and synthetic emulsifier groups in bile duct-ligated rats. In rats with short bowels, the fecal consistency was a significant looser the dietary fiber (+) group than the egg yolk lecithin (+) groups from day 6 of test meal feedings. The fecal consistency was also a significant looser the egg yolk lecithin (-) group than the egg yolk lecithin (+) groups from day 4 of test meal feeding. The fecal consistency was no significant difference between the medium-chain triglycerides (-) and egg yolk lecithin (+) groups. Enteral formula emulsified with egg yolk lecithin promotes lipid absorption by preventing the destruction of emulsified substances by gastric acid. This enteral formula improved diarrhea and should reduce the burden on patients and healthcare workers.

A randomized controlled pilot study to evaluate the effect of an enteral formulation designed to improve gastrointestinal tolerance in the critically ill patient-the SPIRIT trial

Background

Diarrhea is frequent in patients in intensive care units (ICU) and is associated with discomfort and complications and may increase the length of stay and nursing workload.

Methods

This was a prospective, double-blind, randomized, controlled single-center pilot study to assess the incidence and frequency of diarrhea and the respective effects of a modified enteral diet (intervention: Peptamen® AF, rich in proteins, medium chain triglycerides and fish oil) compared to a standard diet (control: Isosource® Energy) in 90 randomized adult patients (intervention, n = 46; control, n = 44) with an ICU stay ≥5 days and tube feeding ≥3 days. Tube feeding was initiated within 72 h of ICU admission and continued up to 10 days. The caloric goal was adjusted to needs by indirect calorimetry. Gastrointestinal function, nutritional intake, and nursing workload were recorded. Follow-up was until 28 days after randomization.

Results

Median age was 63.3 (interquartile range (IQR) 51.0–73.2) years and Simplified Acute Physiology Score (SAPS) II was 61.0 (IQR 47.8–74). Time to reach caloric goal (intervention: 2.2 (0.8–3.7) days (median, IQR); control: 2.0 (1.3–2.7) days; p = 0.16), length of time on study nutrition (intervention: 5.0 (3.6–6.4) days; control: 7.0 (5.3–8.7) days; p = 0.26), and calorie intake (intervention: 18.0 (12.5–20.9) kcal/kg/day; control 19.7 (17.3–23.1) kcal/kg/day; p = 0.08) did not differ between groups, with a higher protein intake for Peptamen® group (1.13 (0.78–1.31) g/kg/day vs 0.80 (0.70–0.94); p < 0.001). No difference in diarrhea incidence (intervention group: 29 (64%); control group: 31 (70%); p = 0.652), use of fecal collectors (23 (51%) vs. 24 (55%); p = 0.83), or diarrhea-free days (161 (64%) vs 196 (68%); p = 0.65) was found. Nursing workload and cost for diarrhea care were not different between the groups. In a post-hoc analysis, adjusted for treatment group, age, sex, and SAPS II score, diarrhea was associated with length of mechanical ventilation (9.5 (6.0–13.1) vs. 3.9 (3.2–4.6) days; p = 0.006) and length of ICU stay (11.0 (8.9–13.1) vs. 5.0 (3.8–6.2) days; p = 0.001).

Conclusions

In this pilot study, we found a high incidence of diarrhea, which was not attenuated by Peptamen® AF. Patients with diarrhea stayed longer in the ICU.

Trial registration

ClinicalTrials.gov identifier, NCT01581957. Registered on 18 April 2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1730-1) contains supplementary material, which is available to authorized users.

Clinical effects of supplemental parenteral nutrition in critically ill patients

AIM

To investigate the clinical value of supplemental parenteral nutrition (SPN) in critically ill patients.

METHODS

The clinical data of 108 critically ill patients hospitalized at our hospital from June 2014 to June 2016 were analyzed retrospectively. According to the method of nutrition used, the patients were divided into an enteral nutrition (EN) group (control group) and an EN combined with SPN group (observation group). The clinical effects were compared between the two groups.

RESULTS

After 1 wk of SPN, serum albumin, prealbumin and hemoglobin were significantly higher in the observation group than in the control group (P < 0.05). The upper arm circumference between the two groups had no significant differences (P > 0.05). The incidence of infection and hospitalization time in the observation group were significantly lower than those of the control group (P < 0.05). The mortality of two groups was not statistically different (P > 0.05).

CONCLUSION

SPN can effectively improve the nutritional status of critically ill patients, reduce the incidence of infection, and shorten the length of hospital stay.

Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines

Purpose

To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness.

Methods

We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined “early” EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds.

Results

We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion.

Conclusions

We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-016-4665-0) contains supplementary material, which is available to authorized users.