Prophylactic use of laxative for constipation in critically ill patients

This study was designed to evaluate the use of laxative prophylaxis for constipation in intensive care unit [ICU] and the impact of early versus late bowel movement on patient's outcome. The study was a prospective, randomized controlled trial in critically ill ventilated adult patients, who were expected to stay on ventilator for >72 h. Control group did not receive any intervention for bowel movement for the first 72 h, whereas interventional group received prophylactic dose of lactulose 20 cc enterally every 12 h for the first 72 h. The parameters measured during the study were admission diagnosis, age, gender, comorbid conditions, admission Simplified Acute Physiologic Score [SAPS II], sedative and narcotic agents with doses and duration, timing and tolerance of nutrition, daily assessment of bowel movement, total use of prokinetic, doses of suppositories, and enema for first bowel movement, total number of days on ventilator, weaning failures, extubation or tracheostomy, ICU length of stay, and death or discharge. A total of 100 patients were enrolled, 50 patients in each control and interventional group. Mean age was 38.8 years, and both groups had male predominance. Mean SAPS II score for both was 35. Mean dose of Fentanyl [323.8 +/- 108.89 mcg/h in control and 345.83 +/- 94.43 mcg/h in interventional group] and mean dose of Midazolam [11.1 +/- 4.04 mg/h in control and 12.4 +/- 3.19 mg/h in interventional group]. There were only two [4%] patients in control, while nine [18%] patients in interventional group who had bowel movement in <72 h [P < 0.05]. Mean ventilator days were 16.19, and 17.36 days in control and interventional groups, respectively. Subgroup analysis showed that the patients who moved bowel in <5 days in both groups had mean ventilator days of 18.5, whereas it was 15.88 days for the patients who moved bowel after 5 days in both groups [P< 0.05]. Mean ICU days for control was 21.15 +/- 10.44 and 20.77 +/- 8.33 days for interventional group. Forty-eight [96%] patients in each group were discharged from the ICU. Two [4%] patients died in ICU in each group. Laxative prophylaxis can be used successfully to prevent constipation in ICU patients. Late bowel movement >5 days is associated with less ventilator days, compared to early <5 days bowel movement

Comparison of quantitative bronchoscopic lavage cultures [B-BAL] with blind NG Tube lavage [N-BAL] cultures in the diagnosis of ventilator associated pneumonia [VAP]

To compare quantitative Bronchoscopic Bronchoalveolar Lavage [B-BAL] cultures with blind nasogastric tube bronchoalveolar lavage [N-BAL] cultures in the diagnosis of Ventilator Associated Pneumonia [VAP]. Cross-sectional comparative study. The study was conducted in Medical ICU and Chest ICU at Liaquat National Hospital [LNH], Karachi, from January till August, 2007. Patients admitted in ICU with clinical suspicion of VAP, fulfilling inclusion criteria viz. fever, leukocytosis, new or worsening infiltrate in chest radiograph or purulent secretions were included. Exclusion criteria were deranged coagulopathy, extreme ventilatory and oxygenation demands and tracheal obstruction. All patients had N-BAL using 16 fr Nasogastric tube [NG] without lubrication followed by B-BAL. Samples collected were submitted to the laboratory for quantitative cultures and sensitivities. Results were documented on predesigned proforma. Fifty four patients underwent paired B-BAL and N-BAL sampling. The N-BAL sensitivity and specificity for N-BAL were 87.87% and 85.71% respectively and p-value was <0.001. N-BAL showed sensitivity of 87.87%, specificity of 75.71%, positive predictive value of 89.65%, negative predictive value of 77.77% and p <0.001, which was statistically significant. Significant differences in time required for sample collection and cost of both procedures were also observed. The results favour the use of blind NG tube bronchoalveolar lavage quantitative cultures as it is simple, safe, cost-effective and minimally invasive method of diagnosing VAP