Faecal diversion system usage in an adult intensive care unit.

OBJECTIVE: To determine the frequency, indications and complications associated with the use of faecal diversion systems (rectal tubes) in critically ill patients. DESIGN: A single centre observational study over 15 months. SETTING: Intensive care unit (ICU). PARTICIPANTS: Patients admitted during this period. MAIN OUTCOME MEASURES: Frequency of rectal tubes utilisation in ICU, as well as associated adverse events, with major events defined as lower gastrointestinal bleeding associated with defined blood transfusion of two or more units of red cells or endoscopy or surgical intervention. RESULTS: Of 3418 admission episodes, there were 111 episodes of rectal tubes inserted in 99 patients. Rectal tubes remained indwelling for a median of 5 days (range, 1-23) for a total of 641 patient-days. The most frequent indication for insertion was excessive bowel motions. A major adverse event was observed in three patients (3%; 0.5 events per 100 device days). Two patients underwent laparotomy and one patient sigmoidoscopy. These patients received between two and 23 units of packed red blood cells. Patients who had a rectal tube inserted had a substantially greater duration of ICU admission (mean, 14 days [SD, 14] v 2.8 days [SD, 3.7]) and hospital mortality (15% v 7.7%; risk ratio, 2.0; 95% CI, 1.2-3.4) as well as an overall higher Australian and New Zealand Risk of Death (ANZROD) score (mean, 27 [SD, 22] v 12.6 [SD, 20]). CONCLUSION: Rectal tubes appear to be frequently inserted and can lead to major adverse events in critically ill patients.

The hospital-based evaluation of laxative prophylaxis in ICU (HELP-ICU): A pilot cluster-crossover randomized clinical trial.

PURPOSE: Prophylactic laxative regimens may prevent constipation but may increase diarrhea and subsequent rectal tube insertion. Our aim was to compare three prophylactic laxative regimens on the rate of rectal tube insertion (primary outcome) and major constipation- or diarrhea-associated complications. MATERIAL AND METHODS: We conducted a cluster-crossover trial. Three pods in a single ICU were each randomized to one of three regimens for four months with rolling cross-over. All mechanically-ventilated and enterally-fed adult patients received either regimen: A) one coloxyl with senna BD from day one; B) two coloxyl with senna +20 ml lactulose BD commencing on day 3; or C) two coloxyl with senna tablets +20 ml lactulose BD commencing on day 6. RESULTS: We enrolled 570 patients (A = 170, B = 205, C = 195) with similar baseline features. Overall, 53 (9.3%) patients received a rectal tube, and insertion rate was not statistically different between the three regimens (A = 12.9%, B = 7.8%, C = 7.7%; p = 0.15). The proportions of patients with other major constipation- or diarrhea-associated complications were similar, as were major patient-centred outcomes. CONCLUSION: Earlier commencement of a prophylactic coloxyl-based laxative regimen (day 1 or 3) did not affect the rates of complications associated with constipation or diarrhea when compared to delayed introduction (day 6).

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.