PhilSPEN Online Journal of Parenteral and Enteral Nutrition

(Article 131 | POJ_0123)

Original Clinical Investigation

Risk Factors for Diarrhea among Critically Ill Patients in St. Luke's Medical Center

Abstract | Introduction | Methodology | Results | Discussion | Conclusion | References | Back to Total Name and Codes page2

Submitted: | Posted:

Authors:

    1. Karna Igasan, MD; Clinical Nutrition Service, St. Luke's Medical Center, Quezon City, Philippines
    2. Luisito O. Llido, MD; Clinical Nutrition Service, St. Luke’s Medical Center, Quezon City, Philippines
    Corresponding Author: Dr. Karna Igasan

Institution where research was conducted

Clinical Nutrition Sevice, St. Luke’s Medical Center, E. Rodriguez Avenue, Quezon City, Metro-Manila, Philippines

 

ABSTRACT: | Back

Background:

Diarrhea is a common problem in the critically ill patient, with incidence estimated at between 2% and 95% depending on definition and setting. (1) Little is known about diarrhea incidence and the role of the different risk factors alone or in combination. (4) Currently there are some data and local guideline on the causes of diarrhea and its management in the critical care patient.

Since one of the culprit in causing diarrhea is the enteral feeding, most often than not it is being put on hold affecting the delivery of calories and proteins to the critically ill patients. If the factors associated with diarrhea will be identified, then this will provide information on the most common and various causes of diarrhea as to address each causes individually avoiding interruption of feeding which is mostly blamed. 

Objective:

The data will also provide information for future researches on the guidelines and management of diarrhea in the critically ill.

Methodology:

We enrolled 260 subjects in the critical care unit of SLMC, all without diarrhea prior to admission; Data was gathered by reviewing the critical care flowsheet which provide information such as current medications, the types of feeding, dilution, fiber content and bowel movement.

Results:

Diarrhea is common in Critical Care Unit with a reported prevalence of 42% (105/155). Of the 260 patients, 105 had diarrhea and 155 patients did not develop diarrhea. Among the risk factor studied, diarrhea incidence are as follows:
> Probiotics 6% (15/245) P value ≤ 0.001,
> Prokinetics 50% (23/45) P value ≤0.09,
> laxatives 55% (92/168) P value ≤0.06,
> Antibiotics 90% (235/25) P value ≤0.001,
> Sorbitol containing medications 103% (15/109) P value ≤0.014,
> Route of feeding 68% (105/155) P value ≤0.001
> and fiber content 64% (81/127) P value 0.970.

Of the 105 patients with diarrhea, only 48 patients underwent clostridium difficile test. Of the 48 patients only 2 patients was positive for clostridium difficile. Length of stay was also noted to increased the odds incidence of diarrhea.

Conclusion:

Diarrhea was common in St. Lukes Medical Center with a prevalence of 42% (105/155). Enteral feeding with oligomeric/monomeric formula was highest. Feeding dilution was also significant with 2:1 dilution having the most incidence of diarrhea and 1:1 dilution with the least.

 

KEYWORDS: diarrhea, enteral nutrition, prevalence, critical care

 

INTRODUCTION | Back

The Diarrhea  is a common problem in the critically ill patient, with incidence estimated at between 2% and 95% depending on definition and setting. (1) Critically ill patients with diarrhoea are at risk of malnutrition, haemodynamic instability, metabolic acidosis, contamination of wounds and catheters and mineral loss, leading to arrhythmias and impaired wound healing. (2) There is evidence that development of GI problems is related to worse outcome in critically ill patients. (3)

Little is known about diarrhoea incidence and the role of the different risk factors alone or in combination. (4) Currently there is no data and and local guideline on the causes of diarrhea and its management in the critical care. Management strategies vary depending on the cause of the diarrhoea, however in all cases rehydration, electrolyte replacement and continuation of enteral feed are important. Even though the etiology of diarrhea in patients receiving ETF is diverse, it is still common to associate it with its administration before considering other potential causes.(5) Interrupting the enteral feeding when it is not the real perpetrator causes mismanagement of diarrhea in the critical care unit.

This study aims to determine the factors associated with diarrhea in the critically ill and if it affects the length of hospital stay. This study will also provide a baseline data on the incidence and factors associated with diarrhea in the critical care unit of SLMC, its association to Length of stay. Since One of the culprit in causing diarrhea is the enteral feeding, most often than not it is being put on hold affecting the delivery of calories and proteins to the critically ill patients. If the factors associated with diarrhea will be identified, then this will provide information on the most common and various causes of diarrhea  as to address each causes individually avoiding interruption of feeding which is mostly blamed.  The data will also provide information for future researches on the guidelines and management  of diarrhea in the critically ill.

Objectives of the study: General: To assess the proportion value of risk factors associated with diarrhea in the critical care unit of St. Luke’s Medical Center. Specific: To compare the Length of Stay between patients with or without diarrhea in the critical care unit.

 

METHODOLOGY | Back

This is a prospective, observational cohort design study of subjects  admitted in the critical care unit of St Luke’s Medical Center (ICU, NCCU, ICCU) from Agugust 2018 to March 2019. Inclusion criteria: Patients age 18 years old and above admitted in the critical care unit without diarrhea and that diarrhea started in the ICU and not prior to its admission in the critical care units. Data collection was done at the critical care units of St. Luke’s Medical Center. Data was gathered by reviewing the critical care flowsheet which provided information such as current intravenous medication, the types, dilution and volume of feeding per hour and bowel movement within 24 hours. Baseline information was collected using the Data Collection form. There was no patient contact or interview at all during the data collection. The protocol was purely a chart review. All patients admitted in the critical unit of St. Luke’s Medical Center – Quezon City who on routine history and physical satisfied our inclusion criteria was  included in our study.

The outcome of the study was incidence of diarrhea among patients admitted at the critical care units, the risk factors associated with diarrhea and its association to length of stay.

Operational Definitions:

Diarrhea - In our study, Diarrhoea was defined as having 3 or more loose or liquid stools per day with stool volume greater than 250 ml/ day. This data is charted at the critical care flow sheet of every patients. 

Types of feeding formula - Commercially prepared formulas for enteral nutrition are those produced by industry. They are delivered as liquids of various viscosities or in a powder form. The nutritional contents, dilution and osmolality are provided by the manufacturer for reference. They usually fall under one of the following categories:

  1. Polymeric formula- nutritionally complete and comprise mostly of intact nutrients. Their composition reflects the reference values for macronutrients and micronutrients. Nutrients are not hydrolyzed, so the osmolality is reasonably close to physiological levels (300 mOsmol.l)
  2. Oligomeric and monomeric enteral formulas contain macronutrients that have been enzymatically hydrolysed to varying degrees. They require minimal digestion and are almost completely absorbed.
  3. Disease specific formulas- formulations for patients with unique disease specific or organ specific nutritional requirements. Specially designed formulas are available for liver disease, renal diseases, diabetes, pulmonary insufficiency, heart failure, GI dysfunction as well as for situations of metabolic stress.
  4. Modular formulas- is an incomplete liquid supplement that contains specific nutrients, usually macronutrient (carbohydrate, protein or fat). They can be coadministered via a feeding tube to further individualize enteral nutrition provision to meet specific nutrition goals.

Parenteral nutrition- nutrients are provided intravenously.

Feeding dilution - Feeding dilution varies from 0.5-1 kcal.ml is useful for initiating enteral feeding
1.5-2 kcal.ml may provide increased needs as well as respond to the need for fluid restrictions

Fiber contents - Fiber is divided into soluble (highly fermentable) and insoluble (poorly fermentable). Insoluble fibres, rich in cellulose and lignin, increase fecal mass by entrapping water. They therefore help to prevent constipation, improve gastrointestinal function and regulate GI transit time. Soluble fibres are well fermented by colonic anaerobic microflora and provide substrates, which maintain the structure and function of the colon.

Study duration: 8 months

Sample Size Estimation:  Sample size was calculated based on the incidence of diarrhea among those given antibiotics vs those given a combination of prokinetics and antibiotics. Assuming that incidence of diarrhea Among those on antibiotics is 30% and among those given a combination of antibiotics and pro kinetics, 49% ( Nguyen NQ, 2008) with an alpha error 5% power of 80%. Factors such as antibiotic use, sorbitol containing, laxative, clostridium positive, use of probiotics, feeding formula types, dilution and fibre content 1 tailed alternative hypothesis sample size calculated is 81 per group or 162 per 2 groups. Controlling for 6 more variables in the analysis with an additional 20% for each control variable. Final sample size requires 325.

Data Management and Analysis: Determination of factors affecting diarrhea among ICU patient was analysed using multivariate statistics. Chi square test and logistic regression was used in the univariate analysis for quantitative and qualitative predictors respectively. Determination of the odds of diarrhea based on the length of hospital stay was analyzed using logistic regression. Odds ratio and the 95% confidence interval was also calculated.


RESULTS | Back

karna1

 

 

 

karna8

 

DISCUSSION: | Back

A total of 260 subjects were enrolled, 105 had diarrhea and 155 did not have diarrhea. The mean ages of patients with and without diarrhea did not differ significantly (66.7 ± 16.26 versus 66±16.49, p value of 0.748). Over-all more female patients are included in the study at 139 subjects, however it is noted that the proportion of male patients was significantly higher in those with diarrhea compared to female patients. There is a significant difference in the distribution of patients among those with and without diarrhea in the critical care unit of SLMC with P value of 0.007. Majority of the subjects were from ICU, Patients confined in the ICU had significantly higher incidence of diarrhea than those confined in the ICCU and NCCU.

Of the various reasons for critical care admissions only those with neurologic, Immunologic and Respiratory diseases had significant difference in the incidence of diarrhea. Specifically, those with immunologic and respiratory diseases had significantly higher incidence of diarrhea compared to those without them. However, those without neurological diseases had significantly higher incidence of diarrhea compared to those with neurological problems. The rest of the diseases did not have a significant difference. Of the 105 patients with diarrhea, 48 patients underwent clostridium  difficile test the remaining 57 was not subjected to clostridium difficile test. Of the 48 patients tested, only 2 patients was positive for clostridium difficile.

Among the medications used, Probiotics, laxatives, Antibiotics, sorbitol containing medications showed a significant difference in the incidence of diarrhea. Furthermore, incidence of diarrhea was significantly higher on patients with these medications.

The route of feeding also showed a significant difference in the incidence of diarrhea. Those on enteral nutrition had significantly higher incidence of diarrhea and those on oral route has the least incidence of diarrhea in comparison to other routes of feeding. There is a significant difference in the distribution of diarrhea among the types of feeding used with P value ≤0.001. Among the enteral formula used disease specific was the most common 55% (101/183). However, Patients on Oligomeric/Monomeric type of feeding had significantly higher incidence of diarrhea than those under other types of feeding; those on polymeric had the least. Likewise the formula dilution was also significant at P value of 0.02. Those with 2:1 dilution had the highest incidence of diarrhea compared to the lower dilution.

Length of stay was also noted to increased the odds of diarrhea. For every 1 day increase in hospital stay the odds of diarrhea increased by 16%. It can increase by as low as 7% to as high as 15%. Considering the multiple risk factors identified for the increase incidence of diarrhea, this will avoid interruption of feeding which is mostly blamed and properly address each cause individually.

 

CONCLUSION: | Back

Diarrhea was common in St. Lukes Medical Center with a prevalence of 42% (105/155). Enteral feeding with oligomeric/monomeric formula was highest. Feeding dilution was also significant with 2:1 dilution having the most incidence of diarrhea and 1:1 dilution with the least

 

REFERENCES: | Back

  1. Thibault R, Graf S, Clerc A, Delieuvin N, Heideffer C, Pichard C. Diarrhoea in the ICU: retrospective contribution of feeding and antibiotics. Critical Care 2013, 17: R153
  2. Reintam Blaser A, Malbrain ML, Starkopf J, et al. Gastrointestinal function in intensive care patients: terminology, definitions and management. Recommendations of the ESICM Working Group on Abdominal Problems. Intensive Care Med 2012; 38: 384–394
  3. Martin B. Prevention of Gastrointestinal Complications in the Critically Ill Patient. AACN Advanced Critical Care 2007; 2:.158–166
  4. Ione de Brito‐Ashurst MSc, PhD, RD Jean‐Charles Preiser MD, PhD. Diarrhea in Critically Ill Patients The Role of Enteral Feeding JPEN J Parenter Enteral Nutr. 2016 Sep;40(7):913-23
  5. Schwaber MJ, Simhon A, Block C, Roval V, Ferderber N, Sha- piro M. Factors associated with nosocomial diarrhea and Clostridium difficile-associated disease on the adult wards of an urban tertiary care hospital. Eur J Clin Microbiol Infect Dis 2000; 19:9-15.
  6. Kelly TW, Patrick MR, Hillman KM. Study of diarrhea in critically ill patients. Crit Care Med. 1983 Jan; 11(1):7-9
  7. Mc Farland LV. Risk factor for antibiotic-associated diarrhea. A review of the literature. Ann Med Interne (Paris). 1998 Sep;149(5):261-6.
  8. Smith CE1, Marien L, Brogdon C, Faust-Wilson P, Lohr G, Gerald KB, Pingleton S. Diarrhea associated with tube feeding in mechanically ventilated critically ill patients. Nurs Res. 1990 May-Jun;39(3):148-52.
  9. Marc ARitz M.D, RobertFraser M.B.B.S., Ph.D., William Tam M.B.B.S., JohnDent M.D., Ph.D. Impacts and patterns of disturbed gastrointestinal function in critically ill patients. The American Journal of Gastroenterology Volume 95, Issue 11, November 2000, Pages 3044-3052

 

Abstract | Introduction | Methodology | Results | Discussion | References | Back to Total Name and Codes page2