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Nakamura K, Yamamoto R, Higashibeppu N, Yoshida M, Tatsumi H, Shimizu Y, Izumino H, Oshima T, Hatakeyama J, Ouchi A, Tsutsumi R, Tsuboi N, Yamamoto N, Nozaki A, Asami S, Takatani Y, Yamada K, Matsuishi Y, Takauji S, Tampo A, Terasaka Y, Sato T, Okamoto S, Sakuramoto H, Miyagi T, Aki K, Ota H, Watanabe T, Nakanishi N, Ohbe H, Narita C, Takeshita J, Sagawa M, Tsunemitsu T, Matsushima S, Kobashi D, Yanagita Y, Watanabe S, Murata H, Taguchi A, Hiramoto T, Ichimaru S, Takeuchi M, Kotani J. The Japanese Critical Care Nutrition Guideline 2024. J Intensive Care 2025; 13:18. [PMID: 40119480 PMCID: PMC11927338 DOI: 10.1186/s40560-025-00785-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2025] [Accepted: 02/23/2025] [Indexed: 03/24/2025] Open
Abstract
Nutrition therapy is important in the management of critically ill patients and is continuously evolving as new evidence emerges. The Japanese Critical Care Nutrition Guideline 2024 (JCCNG 2024) is specific to Japan and is the latest set of clinical practice guidelines for nutrition therapy in critical care that was revised from JCCNG 2016 by the Japanese Society of Intensive Care Medicine. An English version of these guidelines was created based on the contents of the original Japanese version. These guidelines were developed to help health care providers understand and provide nutrition therapy that will improve the outcomes of children and adults admitted to intensive care units or requiring intensive care, regardless of the disease. The intended users of these guidelines are all healthcare professionals involved in intensive care, including those who are not familiar with nutrition therapy. JCCNG 2024 consists of 37 clinical questions and 24 recommendations, covering immunomodulation therapy, nutrition therapy for special conditions, and nutrition therapy for children. These guidelines were developed in accordance with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system by experts from various healthcare professionals related to nutrition therapy and/or critical care. All GRADE-based recommendations, good practice statements (GPS), future research questions, and answers to background questions were finalized by consensus using the modified Delphi method. Strong recommendations for adults include early enteral nutrition (EN) within 48 h and the provision of pre/synbiotics. Weak recommendations for adults include the use of a nutrition protocol, EN rather than parenteral nutrition, the provision of higher protein doses, post-pyloric EN, continuous EN, omega-3 fatty acid-enriched EN, the provision of probiotics, and indirect calorimetry use. Weak recommendations for children include early EN within 48 h, bolus EN, and energy/protein-dense EN formulas. A nutritional assessment is recommended by GPS for both adults and children. JCCNG 2024 will be disseminated through educational activities mainly by the JCCNG Committee at various scientific meetings and seminars. Since studies on nutritional treatment for critically ill patients are being reported worldwide, these guidelines will be revised in 4 to 6 years. We hope that these guidelines will be used in clinical practice for critically ill patients and in future research.
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Affiliation(s)
- Kensuke Nakamura
- Department of Critical Care Medicine, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.
| | - Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Higashibeppu
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Minoru Yoshida
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Hiroomi Tatsumi
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yoshiyuki Shimizu
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Hiroo Izumino
- Acute and Critical Care Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Taku Oshima
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba City, Japan
| | - Junji Hatakeyama
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Akira Ouchi
- Department of Adult Health Nursing, College of Nursing, Ibaraki Christian University, Hitachi, Japan
| | - Rie Tsutsumi
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, Hiroshima, Japan
| | - Norihiko Tsuboi
- Department of Critical Care Medicine and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Natsuhiro Yamamoto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University School of Medicine, Kanagawa, Japan
| | - Ayumu Nozaki
- Department of Pharmacy, Kyoto-Katsura Hospital, Kyoto, Japan
| | - Sadaharu Asami
- Department of Cardiology, Musashino Tokushukai Hospital, Tokyo, Japan
| | - Yudai Takatani
- Department of Primary Care and Emergency Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Kohei Yamada
- Department of Traumatology and Critical Care Medicine, National Defense Medical College Hospital, Saitama, Japan
| | - Yujiro Matsuishi
- Adult and Elderly Nursing, Faculty of Nursing, Tokyo University of Information Science, Chiba, Japan
| | - Shuhei Takauji
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Akihito Tampo
- Department of Emergency Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Yusuke Terasaka
- Department of Emergency Medicine, Kyoto Katsura Hospital, Kyoto, Japan
| | - Takeaki Sato
- Tohoku University Hospital Emergency Center, Miyagi, Japan
| | - Saiko Okamoto
- Department of Nursing, Hitachi General Hospital, Hitachi, Japan
| | - Hideaki Sakuramoto
- Department of Acute Care Nursing, Japanese Red Cross Kyushu International College of Nursing, Munakata, Japan
| | - Tomoka Miyagi
- Anesthesiology and Critical Care Medicine, Master's Degree Program, Graduate School of Medicine, Yokohama City University, Kanagawa, Japan
| | - Keisei Aki
- Department of Pharmacy, Kokura Memorial Hospital, Fukuoka, Japan
| | - Hidehito Ota
- Department of Pediatrics, School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Taro Watanabe
- Department of Intensive Care Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Nobuto Nakanishi
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroyuki Ohbe
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Sendai, Japan
| | - Chihiro Narita
- Department of Emergency Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Masano Sagawa
- Department of Surgery, Tokyo Women's Medical University Adachi Medical Center, Tokyo, Japan
| | - Takefumi Tsunemitsu
- Department of Preventive Services, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinya Matsushima
- Department of Physical Therapy, Faculty of Health Science, Kyorin University, Tokyo, Japan
| | - Daisuke Kobashi
- Department of Critical Care and Emergency Medicine, Japanese Red Cross Maebashi Hospital, Gunma, Japan
| | - Yorihide Yanagita
- Department of Health Sciences, Institute of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Shinichi Watanabe
- Department of Physical Therapy, Faculty of Rehabilitation, Gifu University of Health Science, Gifu, Japan
| | - Hiroyasu Murata
- Department of Rehabilitation Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Akihisa Taguchi
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Takuya Hiramoto
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
| | - Satomi Ichimaru
- Food and Nutrition Service Department, Fujita Health University Hospital, Aichi, Japan
| | - Muneyuki Takeuchi
- Department of Critical Care Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
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Tao H, Liu L, Lu W, Ni Z, Chen X, Nahata MC, Peng L. The Effects of Prophylactic Laxative Use on Critically Ill Patients Requiring Mechanical Ventilation: A Retrospective Cohort Study. Diseases 2024; 12:274. [PMID: 39589948 PMCID: PMC11593228 DOI: 10.3390/diseases12110274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2024] [Revised: 10/21/2024] [Accepted: 10/25/2024] [Indexed: 11/28/2024] Open
Abstract
Objective: To investigate the effects of prophylactic use of stimulant laxatives and/or docusate on the clinical outcomes in critically ill patients who required mechanical ventilation (MV). Methods: A single-center, retrospective, cohort study was conducted. Patients who received MV in the first 24 h after intensive care unit (ICU) admission were enrolled and divided into four groups: non-laxative, stimulant laxatives, docusate, and stimulant laxatives-docusate combination. The primary outcome was in-hospital mortality. The major secondary outcomes included ICU-free days and ventilator-free days at 28 days; the other outcomes were ventilation-associated pneumonia (VAP), enterobacterial infection, diarrhea, and electrolyte disturbances. Inverse probability treatment weighting (IPTW) was used to adjust for confounders. Results: A total of 2129 patients were included in this study, 263 of whom received stimulant laxatives, 253 received docusate, 368 received a combination, and 1245 did not receive any laxative. The prophylactic use of docusate was associated with a decreased risk of in-hospital mortality (OR: 0.59, 95% CI 0.42 to 0.83, p = 0.002) and VAP (OR: 0.62, 95% CI 0.47 to 0.81, p = 0.001). It was also associated with an increase in ICU-free days at 28 days (β: 0.89, 95% CI 0.83 to 0.95, p < 0.001). Importantly, laxatives prophylaxis was not associated with increased risks of diarrhea, electrolyte disturbances, and enterobacterial infections. Conclusions: Prophylactic use of docusate may improve certain prognoses and does not demonstrate any adverse events. However, further research is necessary to determine the optimal regimen and dosage of prophylactic laxatives in this specific population.
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Affiliation(s)
- Heqing Tao
- Department of Gastroenterology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China; (H.T.); (W.L.); (Z.N.); (X.C.)
| | - Ligang Liu
- Institute of Therapeutic Innovations and Outcomes, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA;
| | - Weipeng Lu
- Department of Gastroenterology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China; (H.T.); (W.L.); (Z.N.); (X.C.)
| | - Ziyan Ni
- Department of Gastroenterology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China; (H.T.); (W.L.); (Z.N.); (X.C.)
| | - Xueqing Chen
- Department of Gastroenterology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China; (H.T.); (W.L.); (Z.N.); (X.C.)
| | - Milap C. Nahata
- Institute of Therapeutic Innovations and Outcomes, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA;
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Liang Peng
- Department of Gastroenterology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China; (H.T.); (W.L.); (Z.N.); (X.C.)
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Tobben D, Carpenter S, Kolar R, Merritt T, Young T, Hauser P, Collier T. Naloxegol versus Methylnaltrexone for Opioid-Induced Constipation in Critically Ill Patients. Ann Pharmacother 2024; 58:678-684. [PMID: 37881915 DOI: 10.1177/10600280231205023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Constipation impacts 58% to 83% of critically ill patients and is associated with increased time on mechanical ventilation, delirium, and increased length of stay (LOS) in the intensive care unit (ICU). OBJECTIVE The purpose of this study was to evaluate the efficacy of enteral naloxegol (NGL) versus subcutaneous methylnaltrexone (MNTX) for the management of opioid-induced constipation (OIC) in critically ill patients. METHODS A retrospective analysis was conducted on adult patients admitted to the ICU who received a parenteral opioid infusion for at least 4 hours and experienced no bowel movement (BM) within the 48-hour period preceding the administration of NGL or MNTX. The primary outcome was time to first BM from the start of NGL or MNTX therapy. Secondary outcomes included number of BMs 72 hours following NGL or MNTX administration, ICU LOS, and cost-effectiveness. RESULTS After exclusion criteria were applied, 110 and 51 patients were included in the NGL and MNTX groups, respectively. With a 10% noninferiority margin, NGL was noninferior to MNTX (Wald statistic = 1.67; P = 0.047). Median time to first BM was 23.7 hours for NGL and 18.3 hours for MNTX patients. Median LOS was 14 days (NGL) and 12 days (MNTX), and the average number of BMs in 72 hours was 3.9 for NGL and 3.8 for MNTX. Using wholesale acquisition cost (WAC), the cost per BM for NGL and MNTX was $21.74 and $170.00, respectively. CONCLUSION AND RELEVANCE This study determined that NGL and MNTX had similar time to BM. NGL appears to be a safe and effective alternative with cost-saving potential in treating OIC in critically ill patients.
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Affiliation(s)
- Daniel Tobben
- Department of Pharmacy, UNC Health Rex, Raleigh, NC, USA
| | | | - Rachel Kolar
- Department of Pharmacy, UNC Health Rex, Raleigh, NC, USA
| | - Tyler Merritt
- Department of Pharmacy, UNC Health Rex, Raleigh, NC, USA
| | - Tramaine Young
- Department of Pharmacy, UNC Health Rex, Raleigh, NC, USA
| | - Paloma Hauser
- UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Tia Collier
- Department of Pharmacy, UNC Health Rex, Raleigh, NC, USA
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Liu X, Yu N, Lu H, Zhang P, Liu C, Liu Y. Effect of opioids on constipation in critically ill patients: A meta-analysis. Aust Crit Care 2024; 37:338-345. [PMID: 37586897 DOI: 10.1016/j.aucc.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/09/2023] [Accepted: 06/11/2023] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVES This meta-analysis evaluated the effect of opioids on constipation in ICU patients. REVIEW METHOD USED Systematic review and meta-analysis. DATA SOURCES PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang DATA databases. REVIEW METHODS Random or fixed-effects meta-analyses were used. Subgroup analysis was performed according to the definition of constipation (three vs. six days), opioids (fentanyl vs. morphine), study design (prospective vs. retrospective), adjustment of confounders (No vs. Yes), and patient's age (adults vs. children). We used sensitivity analysis to test the robustness of results with significant statistical heterogeneity. RESULTS Seven studies (2264 patients) were included. Opioid use in ICU patients was associated with an increased risk of constipation (relative risk [RR]=1.14; 95% confidence interval [CI]=1.05 to 1.24; I2=49.8%). Subgroup analysis further showed that adjustment form, category of opioid, study design, and patient's age significantly influenced the relationship between opioid use and the risk of constipation. Sensitivity analysis confirmed the robustness of pooled results. CONCLUSION Opioids significantly increase the risk of constipation in critically ill patients, especially children. It is worth noting that the adjustment of the constipation definition used for ICU significantly influenced the relationship between opioid use and the risk of constipation. Therefore, It is necessary to clearly define ICU constipation and conduct time-based layered treatment. Additional prospective studies are needed to investigate the consistent definition of ICU constipation.
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Affiliation(s)
- Xuefang Liu
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ning Yu
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Huaihai Lu
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Pei Zhang
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chao Liu
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ya Liu
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, Shijiazhuang, China.
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Nishiyama S, Uchino S, Sasabuchi Y, Masuyama T, Lefor AK, Sanui M. Naldemedine is associated with earlier defecation in critically ill patients with opioid-induced constipation: A retrospective, single-center cohort study. PLoS One 2024; 19:e0295952. [PMID: 38170714 PMCID: PMC10763934 DOI: 10.1371/journal.pone.0295952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 11/28/2023] [Indexed: 01/05/2024] Open
Abstract
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.
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Affiliation(s)
- Seiya Nishiyama
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Omiya, Saitama, Japan
| | - Shigehiko Uchino
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Omiya, Saitama, Japan
| | - Yusuke Sasabuchi
- Data Science Center, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Tomoyuki Masuyama
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Omiya, Saitama, Japan
| | - Alan Kawarai Lefor
- Department of Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Omiya, Saitama, Japan
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Satoh K, Nakae H. Daijokito Administration in Critically Ill Patients Increasing the Stool Volume: A Retrospective Observational Study. Front Nutr 2021; 8:749570. [PMID: 34708065 PMCID: PMC8542686 DOI: 10.3389/fnut.2021.749570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Daijokito, a traditional Japanese herbal medicine (Kampo), has been used to treat abdominal distention of the middle yang stage pattern. The use of Daijokito has not been thoroughly investigated in critical care. To investigate a new Kampo approach to defecation control in critically ill patients, our study aimed to assess the effects of Daijokito on fecal management. Methods: We analyzed 30 consecutive patients treated with Daijokito in the intensive care unit (ICU) between March 2017 and February 2021. The eligibility criteria were patients who were newly prescribed Daijokito in the ICU during the study period. Exclusion criteria were patients who were started on other laxatives within one day of beginning Daijokito. The study's primary outcome was defecation volume three days before and three days after starting Daijokito. We recorded the most dominant stool quality within three days after the start of Daijokito. Results: Twenty-one patients were included in the analysis. The median age was 69.0 years, and the median sequential organ failure assessment score on admission to the ICU was 6.0. Major diseases included trauma, pancreatitis, and burns. Administration of Daijokito resulted in defecation in 17 of twenty-one patients (81.0%). Comparison of defecation volume between 3 days before Daijokito administration and three days, including the day of Daijokito administration, showed that defecation volume increased significantly after Daijokito administration, with a median of 0 to 360 g (p < 0.001). At the three-day follow-up, six of 17 (35.3%) patients defecated on the day of Daijokito administration, and nine (52.9%) defecated on the day after administration. One patient was judged to have excessive defecation, and Daijokito administration was discontinued. Stool quality was normal in one (5.9%) of the 17 patients, soft-formed in two (11.8%), loose-unformed in 11 (64.7%), and liquid in three (17.6%). Discussion: Daijokito administration in critically ill patients caused defecation in 81% of the patients and significantly increased stool volume. The novelty of this study is that it sheds light on the Kampo treatment of defecation control in critically ill patients. In addition to the present report, further studies are warranted to quantify the therapeutic efficacy and safety of Daijokito.
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Affiliation(s)
- Kasumi Satoh
- Advanced Emergency and Critical Care Center, Akita University Hospital, Akita, Japan
| | - Hajime Nakae
- Advanced Emergency and Critical Care Center, Akita University Hospital, Akita, Japan
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Launey Y, Painvin B, Roquilly A, Dahyot-Fizelier C, Lasocki S, Rousseau C, Frasca D, Gacouin A, Seguin P. Factors associated with time to defecate and outcomes in critically ill patients: a prospective, multicentre, observational study. Anaesthesia 2020; 76:218-224. [PMID: 32662524 DOI: 10.1111/anae.15178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2020] [Indexed: 12/20/2022]
Abstract
Delayed defecation is common in patients on intensive care. We aimed to determine factors associated with time to defecation after admission to intensive care and in turn its association with length of stay and mortality. We studied 396 adults admitted to one of five intensive care units in whom at least 2 days' invasive ventilation was anticipated during an expected stay of at least 3 days. The median (IQR [range]) time to defecate by the 336 out of 396 (84%) patients who did so before intensive care discharge was 6 (4-8 [1-18]) days. Defecation was independently associated with five factors, hazard ratio (95%CI), higher values indicating more rapid defecation: alcoholism, 1.32 (1.05-1.66), p = 0.02; laxatives before admission, 2.35 (1.79-3.07), p < 0.001; non-invasive ventilation, 0.54 (0.36-0.82), p = 0.004; duration of ventilation, 0.78 (0.74-0.82), p < 0.001; laxatives after admission, 1.67 (1.23-2.26), p < 0.001; and enteral nutrition within 48 h of admission, 1.43 (1.07-1.90), p = 0.01. Delayed defecation was associated with prolonged intensive care stay but not mortality.
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Affiliation(s)
- Y Launey
- Department of Anaesthesia and Critical Care, University Hospital, Rennes, France
| | - B Painvin
- Department of Anaesthesia and Critical Care, University Hospital, Rennes, France
| | - A Roquilly
- Department of Anaesthesia and Critical Care, University Hospital, Nantes, France
| | - C Dahyot-Fizelier
- Department of Anaesthesia and Critical Care, University Hospital, Poitiers, France
| | - S Lasocki
- Department of Anaesthesia and Critical Care, University Hospital, Angers, France
| | - C Rousseau
- Department of Clinical Investigation, University Hospital, Rennes, France
| | - D Frasca
- Department of Anaesthesia and Critical Care, University Hospital, Poitiers, France
| | - A Gacouin
- Medical Intensive Care and Infectious Diseases, University Hospital, Rennes, France
| | - P Seguin
- Department of Anaesthesia and Critical Care, University Hospital, Rennes, France
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Abstract
Bowel dysfunction, especially ileus, has been increasingly recognized in critically ill patients. Ileus is commonly associated to constipation, however abnormal motility can also concern the upper digestive tract, therefore impaired gastrointestinal transit (IGT) seems to be a more appropriate term. IGT, especially constipation, is common among patients under mechanical ventilation, occurring in up to 80% of the patients during the first week, and has been associated with worse outcome in intensive care unit (ICU). It is acknowledged that the most relevant definition for constipation in ICU is the absence of stool for the first six days after admission. Concerning the upper digestive intolerance (UDI), the diagnosis should rely only on vomiting and the systematic gastric residual volume (GRV) monitoring should be avoided. IGT results from a complex pathophysiology in which both the critical illness and its specific treatments may have a deleterious role. Both observational and experimental studies have shown the deleterious effect of sepsis, multiorgan failure, sedation (especially opioids) and mechanical ventilation on gut function. To date few studies have reported effect of treatment on IGT and the level of evidence is low. However, cholinesterase inhibitors seem safe and could probably be used in case of constipation but remains poorly prescribed. Prevention with bowel management protocol using osmotic laxatives appears to be safe but did not demonstrate its effectiveness. For patients treated with high posology of opioids during sedation, enteral opioid antagonists may be a promising strategy.
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Affiliation(s)
- Philippe Ariès
- Clermont-Tonnerre Military Teaching Hospital, Brest, France.,Val-de-Grâce French Military Health Service Academy, Paris, France.,Department of Anesthesia and Surgical Intensive Care, Brest Teaching Hospital, Brest, France
| | - Olivier Huet
- Department of Anesthesia and Surgical Intensive Care, Brest Teaching Hospital, Brest, France - .,UFR of Medicine, University of Western Brittany, Brest, France
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Alikiaii B, Majedi MA, Hashemi ST, Kiani M. Comparing the Efficacy of Two Drugs Senalin and Bisacodyl in Treatment of Constipation in Intensive Care Units' Patients. Adv Biomed Res 2019; 8:17. [PMID: 30993087 PMCID: PMC6425743 DOI: 10.4103/abr.abr_165_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Constipation is an intestinal syndrome that can be created alone or in the context of another disease in patients admitted to intensive care units (ICUs). Given the role of sennosides in increasing the transfer rate of materials from the large intestine, we aimed to compare the effect of senalin with bisacodyl on the treatment of constipation in patients admitted to ICUs. Materials and Methods In this randomized, double-blind study, 70 patients admitted to the ICU were divided into two groups. The senalin recipient group received senalin with a dose of 500 mg daily for 3 days. The bisacodyl recipient group received bisacodyl with a dose of 10 mg daily for 3 days. Results The mean of defecation frequency during the 2nd day of treatment of constipation was significantly higher in the group receiving bisacodyl than in the senalin group (P < 0.01). There was no significant difference between the two groups in terms of fecal consistency in any of the study days (P < 0.05). The prevalence of complications in the 3rd day of treatment was significantly higher in bisacodyl group than in the senalin group (P = 0.04). Conclusion Given the lack of difference in the efficacy of two drugs, fecal consistency, daily defecation frequency and fewer complications of senalin compared to bisacodyl, it s eems that this drug can be used as an appropriate treatment for constipation in patients admitted to ICUs.
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Affiliation(s)
- Babak Alikiaii
- Department of Anesthesia and Critical Care, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Azad Majedi
- Department of Anesthesiology, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Seyed Taghi Hashemi
- Department of Anesthesia and Critical Care, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Kiani
- Department of Anesthesia and Critical Care, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Hay T, Bellomo R, Rechnitzer T, See E, Ali Abdelhamid Y, Deane AM. Constipation, diarrhea, and prophylactic laxative bowel regimens in the critically ill: A systematic review and meta-analysis. J Crit Care 2019; 52:242-250. [PMID: 30665795 DOI: 10.1016/j.jcrc.2019.01.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/24/2018] [Accepted: 01/08/2019] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Tyler Hay
- The University of Melbourne, Melbourne Medical School, Parkville, Victoria, Australia
| | - Rinaldo Bellomo
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, VIC 3050, Australia; Intensive Care Unit, The Austin Hospital, Heidelberg, Victoria, Australia; Intensive Care Unit, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Tom Rechnitzer
- Intensive Care Unit, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Emily See
- Intensive Care Unit, The Austin Hospital, Heidelberg, Victoria, Australia
| | | | - Adam M Deane
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, VIC 3050, Australia; Intensive Care Unit, The Royal Melbourne Hospital, Parkville, Victoria, Australia.
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Abstract
OBJECTIVE Most of the studies have defined constipation as a period without stool after ICU admission. We aimed to test the impact of both duration and timing of infrequent defecation in critical care patients. PATIENTS AND METHODS We performed a prospective, bi-center, observational study. Patients were divided into three subgroups: 'not constipated', '3-5 days', and 'at least 6 days' (longest period without stool passage, respectively, shorter than 3 days, 3-5 days, and ≥6 days). Furthermore, 'early' constipated patients were defined as those for whom the longest time to stool passage occurred just after ICU admission, whereas for 'late' constipated patients the longest period without stool occurred later during ICU stay. RESULTS A total of 182 patients were included: the mean age was 67.2 years (54.4-78.9 years), 80 were women, and simplified acute physiology score II was 42 (34-52). In all, 42 (23.1%), 82 (45.1%), and 58 (31.8%) belonged to the nonconstipated, 3-5 days, or greater than or equal to 6 days subgroup of patients, respectively. Time spent under mechanical ventilation and ICU length of stay was longer in the greater than or equal to 6 days subgroups as compared with both other subgroups. ICU stay was longer in the 3-5 days subgroup as compared with the not constipated patients. Furthermore, the late patients of the greater than or equal to 6 days subgroups exhibited worse survival as compared with all other patients. CONCLUSION Both timing and duration of infrequent defecation seem to have an impact on critical care patient's outcome, and should therefore be included in the diagnostic criteria.
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The Mexican consensus on chronic constipation. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2018. [DOI: 10.1016/j.rgmxen.2018.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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The Mexican consensus on chronic constipation. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2018; 83:168-189. [PMID: 29555103 DOI: 10.1016/j.rgmx.2017.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 12/08/2017] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Significant advances have been made in the knowledge and understanding of the epidemiology, pathophysiology, diagnosis, and treatment of chronic constipation, since the publication of the 2011 guidelines on chronic constipation diagnosis and treatment in Mexico from the Asociación Mexicana de Gastroenterología. AIMS To present a consensus review of the current state of knowledge about chronic constipation, providing updated information and integrating the new scientific evidence. METHODS Three general coordinators reviewed the literature published within the time frame of January 2011 and January 2017. From that information, 62 initial statements were formulated and then sent to 12 national experts for their revision. The statements were voted upon, using the Delphi system in 3 voting rounds (2 electronic and one face-to-face). The statements were classified through the GRADE system and those that reached agreement >75% were included in the consensus. RESULTS AND CONCLUSIONS The present consensus is made up of 42 final statements that provide updated knowledge, supplementing the information that had not been included in the previous guidelines. The strength of recommendation and quality (level) of evidence were established for each statement. The current definitions of chronic constipation, functional constipation, and opioid-induced constipation are given, and diagnostic strategies based on the available diagnostic methods are described. The consensus treatment recommendations were established from evidence on the roles of diet and exercise, fiber, laxatives, new drugs (such as prucalopride, lubiprostone, linaclotide, plecanatide), biofeedback therapy, and surgery.
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Oczkowski SJW, Duan EH, Groen A, Warren D, Cook DJ. The Use of Bowel Protocols in Critically Ill Adult Patients: A Systematic Review and Meta-Analysis. Crit Care Med 2017; 45:e718-e726. [PMID: 28350645 DOI: 10.1097/ccm.0000000000002315] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Constipation is common among critically ill patients and has been associated with adverse patient outcomes. Many ICUs have developed bowel protocols to treat constipation; however, their effect on clinical outcomes remains uncertain. We conducted a systematic review to determine the impact of bowel protocols in critically ill adults. DATA SOURCES We searched MEDLINE, Embase, CINAHL, CENTRAL, ISRCTN, ClinicalTrials.gov, and conference abstracts until January 2016. STUDY SELECTION Two authors independently screened titles and abstracts for randomized controlled trials comparing bowel protocols to control (placebo, no protocol, or usual care) in critically ill adults. DATA EXTRACTION Two authors independently, and in duplicate, extracted study characteristics, outcomes, assessed risk of bias, and appraised the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. DATA SYNTHESIS We retrieved 4,520 individual articles, and excluded 4,332 articles during title and abstract screening and 181 articles during full-text screening. Four trials, including 534 patients, were eligible for analysis. The use of a bowel protocol was associated with a trend toward a reduction in constipation (risk ratio, 0.50 [95% CI, 0.25-1.01]; p = 0.05; low-quality evidence); no reduction in tolerance of enteral feeds (risk ratio, 0.94 [95% CI, 0.62-1.42]; p = 0.77; low-quality evidence), and no change in the duration of mechanical ventilation (mean difference, 0.01 d [95% CI, -2.67 to 2.69 d]; low-quality evidence). CONCLUSIONS Large, rigorous, randomized control trials are needed to determine whether bowel protocols impact patient-important outcomes in critically ill adults.
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Affiliation(s)
- Simon J W Oczkowski
- 1Department of Medicine, McMaster University, Hamilton, ON, Canada.2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.3St Joseph's Healthcare Hamilton, Hamilton, ON, Canada.4Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, Devon, United Kingdom.5Faculty of Health and Human Sciences, University of Plymouth, Devon, United Kingdom
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Prat D, Messika J, Le Meur M, Ricard JD, Sztrymf B. Constipation en réanimation : physiopathologie, définition, valeur pronostique, prise en charge. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1203-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Risk factors for late defecation and its association with the outcomes of critically ill patients: a retrospective observational study. J Intensive Care 2016; 4:33. [PMID: 27134753 PMCID: PMC4850650 DOI: 10.1186/s40560-016-0156-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 04/21/2016] [Indexed: 02/07/2023] Open
Abstract
Background Late defecation was recently reported to be associated with worse clinical outcomes in critically ill patients. However, more research is needed to examine the causes and clinical significance of late defecation. The objectives of this study were to investigate the risk factors for late defecation and its association with the outcomes of intensive care unit (ICU) patients. Methods Patients in an ICU for ≥7 days between January and December 2011 were retrospectively assessed. Based on the time between admission and the first defecation, they were assigned to early (<6 days; n = 186) or late (≥6 days; n = 96) defecation groups. Changes in clinical variables between admission and ICU day 7 were assessed to investigate the effects of late defecation. The clinical outcomes were ICU mortality, length of ICU stay, and length of mechanical ventilation. Results Late enteral nutrition (odds ratio (OR) 3.42; 95 % confidence interval (CI) 1.88–6.22; P < 0.001), sedatives (OR 3.07; 95 % CI 1.71–5.52; P < 0.001), and surgery (OR 1.86; 95 % CI 1.01–3.42; P = 0.047) were the independent risk factors for late defecation. The median (interquartile) changes in body temperature (0.3 [−0.4 to 1.0] vs 0.7 [0.1 to 1.5] °C; P = 0.004), serum C-reactive protein concentration (1.6 [−0.5 to 6.6] vs 3.5 [0.7 to 8.5] mg/dL; P = 0.035), and Sequential Organ Failure Assessment score (−1 [−2 to 1] vs 0 [−1 to 2]; P = 0.008) between admission and ICU day 7 were significantly greater in the late defecation group than in the early defecation group. ICU stay was significantly longer in the late defecation group (12 [9 to 19] vs 16 [10 to 23] days; P = 0.021), whereas ICU mortality and the length of mechanical ventilation were similar in both groups. Conclusions Late enteral nutrition, sedatives, and surgery were independent the risk factors for late defecation in critically ill patients. Late defecation was associated with prolonged ICU stay.
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Constipation incidence and impact in medical critical care patients: importance of the definition criterion. Eur J Gastroenterol Hepatol 2016; 28:290-6. [PMID: 26709885 DOI: 10.1097/meg.0000000000000543] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Constipation incidence and impact remain controversial in the ICU. This may depend on the definition criterion used in the previous studies on the field. We aimed to determine the frequency and significance of constipation according to its definition criterion. METHODS This is a prospective observational study. Adult patients without a cause of transit time modification and laxative intake within the first 3 days were screened. Constipation was defined by a first stool passage occurring after 3 days of ICU stay. Thereafter, we identified two subgroups of patients: absence of stool passage more than 3 days but less than 6 days (3-day subgroup), and no stool passage for 6 days or more (6-day subgroup). Survival, length of stay and time spent under mechanical ventilation (MV) were compared according to constipation status. RESULTS Among 189 included patients [age 60.8 (49.5-74.2) years, SAPS II 44 (34-53)], 98 (51.9%) exhibited constipation (3-day subgroup n=53, 6-day subgroup n=45). Constipated patients were more likely to receive MV, sedation, vasopressors, enteral nutrition and neuromuscular blocking agents. ICU length of stay and time spent under MV was longer in the 6-day subgroup but not in the 3-day subgroup of patients. CONCLUSION With regard to outcomes, defining constipation by the absence of stool passage less than 6 days after ICU admission does not identify a specific subset of population. Further studies on the management of this condition should focus on these 'long-term' constipated patients.
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Constipation in the Critically Ill Child: Frequency and Related Factors. J Pediatr 2015; 167:857-861.e1. [PMID: 26254837 DOI: 10.1016/j.jpeds.2015.06.046] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 05/26/2015] [Accepted: 06/24/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To analyze the incidence and factors associated with constipation in critically ill children. STUDY DESIGN We performed a prospective observational study that included children admitted to the pediatric intensive care unit for more than 3 days. Constipation was defined as more than 3 days without a bowel movement. Relationships between constipation and demographic data; clinical severity score; use of mechanical ventilation, use of vasoconstrictors, sedatives, and muscle relaxants; nutritional data; electrolyte disturbances; and clinical course were analyzed. RESULTS Constipation developed in 46.7% of the 150 patients studied (mean age, 34.3 ± 7.1 months). It was most common in postoperative, older, and higher-body-weight patients, and in those with fecal continence (P < .01). Compared with patients without constipation, patients with constipation had higher severity scores and more frequently received midazolam, fentanyl, muscle relaxants, and inotropic support (P < .05). Patients with constipation also started nutrition later and with a lower volume of nutrition (P < .01). There were no between-group differences in mortality or length of pediatric intensive care unit stay. In multivariate analysis, independent factors associated with constipation were body weight (OR, 1.08; 95% CI, 1.03-1.13), Pediatric Index of Mortality 2 score (OR, 1.05; 95% CI, 1.02-1.09), admission after surgery (OR, 7.64; 95% CI, 2.56-22.81), and treatment with vasoconstrictors (OR, 10.28; 95% CI, 3.53-29.93). CONCLUSION Constipation is common in critically ill children. Body weight, Pediatric Index of Mortality 2 clinical severity score, admission after surgery, and the need for vasoconstrictor therapy are major independent risk factors associated with constipation.
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Guerra TLDS, Mendonça SS, Marshall NG. Incidence of constipation in an intensive care unit. Rev Bras Ter Intensiva 2015; 25:87-92. [PMID: 23917972 PMCID: PMC4031832 DOI: 10.5935/0103-507x.20130018] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Accepted: 06/18/2013] [Indexed: 12/21/2022] Open
Abstract
Objectives To evaluate the incidence of constipation in critical patients on enteral
nutrition in a hospital intensive care unit and to correlate this incidence with
the variables found for critical patients. Methods The present investigation was a retrospective analytical study conducted in the
intensive care unit of Hospital Regional da Asa Norte (DF) via the analysis of
medical records of patients admitted during the period from January to December
2011. Data on the incidence of constipation and enteral nutritional support,
gastrointestinal changes, stool frequency, ventilatory support, and outcomes were
collected and analyzed. Results The initial sample consisted of 127 patients admitted to the unit during the
period from January to December 2011. Eighty-four patients were excluded, and the
final sample consisted of 43 patients. The incidence of constipation, defined as
no bowel movement during the first 4 days of hospitalization, was 72% (n=31). The
patients were divided into a control group and a constipated group. The group of
constipated patients reached the caloric target, on average, at 6.5 days, and the
control group reached the caloric target in 5.6 days (p=0.51). Constipation was
not associated with the length of hospital stay, suspension of nutritional
support, or outcome of hospitalization. There was an association between
evacuation during hospitalization and a longer duration of hospitalization for a
subgroup of patients who did not evacuate during the entire period (p=0.009). Conclusion The incidence of constipation in the unit studied was 72%. Only the absence of
evacuation during hospitalization was associated with longer hospital stays.
Constipation was not associated with the length of hospital stay, suspension of
nutritional support, or outcome of hospitalization.
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Affiliation(s)
- Tatiana Lopes de Souza Guerra
- Residency Program in Clinical Nutrition, Hospital Regional da Asa Norte, Secretaria de Estado de Saúde do Distrito Federal - Brasília DF, Brazil
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Knowles S, Lam LT, McInnes E, Elliott D, Hardy J, Middleton S. Knowledge, attitudes, beliefs and behaviour intentions for three bowel management practices in intensive care: effects of a targeted protocol implementation for nursing and medical staff. BMC Nurs 2015; 14:6. [PMID: 25663819 PMCID: PMC4320841 DOI: 10.1186/s12912-015-0056-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 01/12/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bowel management protocols have the potential to minimize complications for critically ill patients. Targeted implementation can increase the uptake of protocols by clinicians into practice. The theory of planned behaviour offers a framework in which to investigate clinicians' intention to perform the behaviour of interest. This study aimed to evaluate the effect of implementing a bowel management protocol on intensive care nursing and medical staffs' knowledge, attitude, subjective norms, perceived behavioural control, behaviour intentions, role perceptions and past behaviours in relation to three bowel management practices. METHODS A descriptive before and after survey using a self-administered questionnaire sent to nursing and medical staff working within three intensive care units before and after implementation of our bowel management protocol (pre: May - June 2008; post: Feb - May 2009). RESULTS Participants had significantly higher knowledge scores post-implementation of our protocol (pre mean score 17.6; post mean score 19.3; p = 0.004). Post-implementation there was a significant increase in: self-reported past behaviour (pre mean score 5.38; post mean score 7.11; p = 0.002) and subjective norms scores (pre mean score 3.62; post mean score 4.18; p = 0.016) for bowel assessment; and behaviour intention (pre mean score 5.22; post mean score 5.65; p = 0.048) for administration of enema. CONCLUSION This evaluation, informed by the theory of planned behaviour, has provided useful insights into factors that influence clinician intentions to perform evidence-based bowel management practices in intensive care. Addressing factors such as knowledge, attitudes and beliefs can assist in targeting implementation strategies to positively affect clinician behaviour change. Despite an increase in clinicians' knowledge scores, our implementation strategy did not, however, significantly change clinician behaviour intentions for all three bowel management practices. Further research is required to explore the influence of opinion leaders and organizational culture on clinicians' behaviour intentions related to bowel management for intensive care patients.
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Affiliation(s)
- Serena Knowles
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Australia, and Clinical Nurse Specialist, Intensive Care Service, St. Vincent's Hospital, Sydney, Australia
| | - Lawrence T Lam
- Department of Health and Physical Education, The Hong Kong Institute of Education, Hong Kong, Hong Kong
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Australia (Syd) and Australian Catholic University, Sydney, NSW Australia
| | - Doug Elliott
- Faculty of Health, University of Technology, Sydney, Australia
| | - Jennifer Hardy
- Sydney Nursing School, University of Sydney, Sydney, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Australia (Syd) and Australian Catholic University, Executive Suite, Level 5, deLacy Building, St. Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW Australia
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Standardized application of laxatives and physical measures in neurosurgical intensive care patients improves defecation pattern but is not associated with lower intracranial pressure. Crit Care Res Pract 2014; 2014:367251. [PMID: 25628896 PMCID: PMC4297633 DOI: 10.1155/2014/367251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 12/15/2014] [Accepted: 12/15/2014] [Indexed: 02/07/2023] Open
Abstract
Background. Inadequate bowel movements might be associated with an increase in intracranial pressure in neurosurgical patients. In this study we investigated the influence of a structured application of laxatives and physical measures following a strict standard operating procedure (SOP) on bowel movement, intracranial pressure (ICP), and length of hospital stay in patients with a serious acute cerebral disorder. Methods. After the implementation of the SOP patients suffering from a neurosurgical disorder received pharmacological and nonpharmacological measures to improve bowel movements in a standardized manner within the first 5 days after admission to the intensive care unit (ICU) starting on day of admission. We compared mean ICP levels, length of ICU stay, and mechanical ventilation to a historical control group. Results. Patients of the intervention group showed an adequate defecation pattern significantly more often than the patients of the control group. However, this was not associated with lower ICP values, fewer days of mechanical ventilation, or earlier discharge from ICU. Conclusions. The implementation of a SOP for bowel movement increases the frequency of adequate bowel movements in neurosurgical critical care patients. However, this seems not to be associated with reduced ICP values.
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Gibson CM, Pass SE. Enteral naloxone for the treatment of opioid-induced constipation in the medical intensive care unit. J Crit Care 2014; 29:803-7. [DOI: 10.1016/j.jcrc.2014.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 04/03/2014] [Accepted: 04/11/2014] [Indexed: 02/04/2023]
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Knowles S, McInnes E, Elliott D, Hardy J, Middleton S. Evaluation of the implementation of a bowel management protocol in intensive care: effect on clinician practices and patient outcomes. J Clin Nurs 2013; 23:716-30. [PMID: 24354900 DOI: 10.1111/jocn.12448] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2013] [Indexed: 12/26/2022]
Abstract
AIMS AND OBJECTIVES To evaluate the effect of a multifaceted implementation of a bowel management protocol on outcomes for intensive care patients, in particular the incidence of constipation and diarrhoea, and on clinicians' bowel management practices. BACKGROUND Complications associated with poor bowel management for critically ill patients result in adverse outcomes. Implementation of protocols requires strategies proven to change clinician behaviour. DESIGN Before and after study. METHODS Our bowel management protocol was implemented using three evidence-based elements: education sessions, printed educational materials in the form of a fact sheet and reminders. We retrospectively collected data from patients' medical records admitted at two time points within three Sydney metropolitan intensive care units (preimplementation, n = 101; postimplementation, n = 107). RESULTS No significant difference was found in the incidence of constipation and diarrhoea pre and postimplementation of the protocol. Seventy-two per cent (n = 73) of patients preimplementation and 70% (n = 75) of patients postimplementation experienced one or more episodes of constipation (bowels not open for 72 hours or greater), and 16% (n = 16) of patients preimplementation and 20% (n = 21) of patients postimplementation experienced one or more episodes of diarrhoea. There was a slight nonsignificant increase in bowel assessment on admission by medical officers postimplementation (pre, 47%, n = 48; post, 60%, n = 64). CONCLUSION Targeted multifaceted implementation of a bowel management protocol did not have an impact on the incidence of constipation or diarrhoea for intensive care patients or on clinician practices. The lack of impact on patient outcomes may be due to clinicians' nonadherence to our bowel management protocol. Reasons clinicians' practices did not change may include the influences of clinical decision-making on behaviour. RELEVANCE TO CLINICAL PRACTICE This study highlights difficulties inherent in changing clinician behaviour and practices to improve patient outcomes despite using an evidence-based multifaceted implementation strategy. Further research is required to ascertain the most effective implementation strategies.
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Affiliation(s)
- Serena Knowles
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, NSW, Australia; Intensive Care Service, St. Vincent's Hospital, Sydney, NSW, Australia
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Orejana Martín M, Torrente Vela S, Murillo Pérez MA, García Iglesias M, Cornejo Bauer C, Morales Sánchez C, López López C, Cuenca Solanas M, Alted López E. [Analysis of constipation in severe trauma patients]. ENFERMERIA INTENSIVA 2013; 25:46-51. [PMID: 24332844 DOI: 10.1016/j.enfi.2013.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Revised: 10/03/2013] [Accepted: 11/05/2013] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To evaluate the incidence and risk factors of constipation in patients with severe trauma (ST). MATERIALS AND METHOD A retrospective observational study (January-December 2011) of medical records in ST-patients with a minimum stay of 5 days was performed. Descriptive analysis of variables, inferential analysis: Student's T test and Chi-square of SPSS 17.0. Significance level P<.05. RESULTS A total of 80 patients fulfilled the inclusion criteria, but only 69 could be analyzed. Of these, 84.06% showed constipation (according to its definition by the Work Group for Metabolism and Nutrition SEMICYUC). The most frequent day of first stool was day 7 and 9 after tolerance of enteral nutrition. Statistical significance (S.S.) of constipation was found with stay, days of sedation/relaxation/opiates, and mechanical ventilation. There was no S.S. between early enteral nutrition (EEN) and constipation (P>.05). CONCLUSIONS There is a very high incidence of constipation in ST patients. ICU stay, days of analgesic sedation, relaxation, and mechanical ventilation are risk factors that influence the occurrence of this problem. Laxatives should be prescribed prophylactically.
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Affiliation(s)
- M Orejana Martín
- Enfermería de la Unidad de Cuidados Intensivos (UCI) de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, España.
| | - S Torrente Vela
- Enfermería de la Unidad de Cuidados Intensivos (UCI) de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, España
| | - M A Murillo Pérez
- Enfermería de la Unidad de Cuidados Intensivos (UCI) de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, España
| | - M García Iglesias
- Enfermería de la Unidad de Cuidados Intensivos (UCI) de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, España
| | - C Cornejo Bauer
- Enfermería de la Unidad de Cuidados Intensivos (UCI) de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, España
| | - C Morales Sánchez
- Enfermería de la Unidad de Cuidados Intensivos (UCI) de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, España
| | - C López López
- Enfermería de la Unidad de Cuidados Intensivos (UCI) de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, España
| | - M Cuenca Solanas
- Enfermería de la Unidad de Cuidados Intensivos (UCI) de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, España
| | - E Alted López
- UCI de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, España
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Bader S, Dürk T, Becker G. Methylnaltrexone for the treatment of opioid-induced constipation. Expert Rev Gastroenterol Hepatol 2013; 7:13-26. [PMID: 23265145 DOI: 10.1586/egh.12.63] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Opioids are the drugs of choice for treating moderate-to-severe pain, especially for patients in the end stage of cancer or other advanced illnesses, and also in critical care or for the treatment of chronic pain. Side effects such as nausea, pruritus, dizziness and constipation have to be controlled in order to use these drugs to their full potential. Opioid-induced bowel syndrome and constipation caused by activation of μ-receptors in the gut can have such distressing effects that some patients prefer to forego adequate pain control. Methylnaltrexone is a μ-opioid receptor antagonist that, unlike naltrexone or naloxone, does not pass the blood-brain barrier, and therefore does not impair the centrally mediated analgesic effect of opioids. It is licensed for the treatment of opioid-induced constipation in palliative care in more than 50 countries. This article presents practically relevant pharmacological data, basic research results and evidence from clinical research about methylnaltrexone, and outlines potential future therapeutic options for this promising drug.
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Affiliation(s)
- Sabine Bader
- Department of Palliative Care, University Medical Center Freiburg, Robert-Koch-Str. 3, D-79106 Freiburg, Germany.
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Catafesta J, Francesconi C. Association between medication use and adverse gastroenterologic events in patients receiving enteral nutrition therapy at a University Hospital. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2012; 77:161-6. [DOI: 10.1016/j.rgmx.2012.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 05/19/2012] [Accepted: 06/28/2012] [Indexed: 11/24/2022]
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Ulbricht C, Conquer J, Costa D, Hamilton W, Higdon ERB, Isaac R, Rusie E, Rychlik I, Serrano JMG, Tanguay-Colucci S, Theeman M, Varghese M. An evidence-based systematic review of senna (Cassia senna) by the Natural Standard Research Collaboration. J Diet Suppl 2012; 8:189-238. [PMID: 22432689 DOI: 10.3109/19390211.2011.573186] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
An evidence-based systematic review, including written and statistical analysis of scientific literature, expert opinion, folkloric precedent, history, pharmacology, kinetics/dynamics, interactions, adverse effects, toxicology, and dosing.
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Pfab F, Nowak-Machen M, Napadow V, Fleckenstein J. Alternatives to prokinetics to move the pylorus and colon. Curr Opin Clin Nutr Metab Care 2012; 15:166-73. [PMID: 22234164 DOI: 10.1097/mco.0b013e32834f3000] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Gastrointestinal motility disorders (GMDs) are common in the ICU. When encountering these problems, one typically thinks of prokinetics. This review summarizes current evidence of treatments. RECENT FINDINGS Prokinetics are not the first-line therapy for GMDs. In fact, the clinical implications of using prokinetic agents are rather controversial. Current evidence on alternative treatment modalities such as fluid and electrolyte management, laxatives, opioid antagonists, purgative enemas, acupuncture, physical therapies and probiotics is growing. SUMMARY Current state of the art to treat GMDs is primarily focused at the elimination of underlying trigger factors. Fluid and electrolyte management as well as laxatives and peripherally acting μ-opioid receptor antagonists are the recommended first-line therapies that can be complemented with prokinetics. Acupuncture as well as physical modalities, such as massage or warming of the abdomen, is promising with few side-effects and should be considered as well.
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Affiliation(s)
- Florian Pfab
- Department of Preventive and Rehabilitative Sports Medicine, Technische Universität München, Munich, Germany.
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McPeake J, Gilmour H, MacIntosh G. The implementation of a bowel management protocol in an adult intensive care unit. Nurs Crit Care 2011; 16:235-42. [PMID: 21824228 DOI: 10.1111/j.1478-5153.2011.00451.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
AIM A study to explore the impact of implementing a bowel management protocol in a tertiary referral intensive care unit (ICU) in the West of Scotland. METHODS A three phase study was implemented. Phase 1 - a baseline audit reviewing 26 patients' medical notes and a baseline focus group reviewing the multidisciplinary team's (MDT's) opinions with regard to bowel care management in the ICU. Phase 2 - the implementation of a protocol, updated bowel care chart and education sessions for members of the MDT. Phase 3 - an end of study audit reviewing 27 patients' notes after the implementation of phase 2. Additionally, a further focus group examined the MDT's experiences of the protocol in clinical practice. RESULTS AND FINDINGS During the phase 1 data collection period, it was evident that there was a haphazard approach to bowel care in the ICU, resulting in poor bowel care documentation and a high incidence of constipation and diarrhoea days. After the interventions of phase 2, bowel care documentation days increased by 13% (p = 0.0003), constipation incidence decreased by 20.7% (p = 0.13) and diarrhoea days reduced by 15.2% (p = 0.18). CONCLUSION Although further evaluation is planned, the protocol implemented in this particular study appears to be a useful tool for the delivery of bowel care in the ICU. RELEVANCE TO CLINICAL PRACTICE Ensuring appropriate and timely bowel care in the ICU has major implications for the critically ill patients.
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Affiliation(s)
- Joanne McPeake
- Intensive Care Unit, Glasgow Royal Infirmary, Glasgow, UK.
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Abstract
The objective of this article is to describe adverse drug events related to the liver and gastrointestinal tract in critically ill patients. PubMed and other resources were used to identify information related to drug-induced acute liver failure, gastrointestinal hypomotility, constipation, diarrhea, gastrointestinal bleeding, and pancreatitis in critically ill patients. This information was reviewed, and data regarding pathophysiology, common drug causes, and guidelines for prevention and management were collected and summarized. In cases in which data in critically ill patients were unavailable, data were extrapolated from other patient populations. Drug-induced acute liver failure can be caused by many drugs routinely used in the intensive care unit and may be associated with significant morbidity and mortality. Drug-related hypomotility and constipation and drug-related diarrhea are reported with many drugs, and these are common adverse drug events in critically ill patients that can substantially complicate the care of these patients. Drug-induced gastrointestinal bleeding and drug-induced pancreatitis occur less frequently, can range in disease severity, and can be associated with morbidity and mortality. Many drugs used in critically ill patients are associated with adverse drug events related to the liver and gastrointestinal tract. Critical care clinicians should be aware of common drug causes of drug-induced acute liver failure, gastrointestinal hypomotility, constipation, diarrhea, gastrointestinal bleeding, and pancreatitis, and should be familiar with the prevention and management of these diverse conditions.
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Btaiche IF, Chan LN, Pleva M, Kraft MD. Critical illness, gastrointestinal complications, and medication therapy during enteral feeding in critically ill adult patients. Nutr Clin Pract 2010; 25:32-49. [PMID: 20130156 DOI: 10.1177/0884533609357565] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Critically ill patients who are subjected to high stress or with severe injury can rapidly break down their body protein and energy stores. Unless adequate nutrition is provided, malnutrition and protein wasting may occur, which can negatively affect patient outcome. Enteral nutrition (EN) is the mainstay of nutrition support therapy in patients with a functional gastrointestinal (GI) tract who cannot take adequate oral nutrition. EN in critically ill patients provides the benefits of maintaining gut functionality, integrity, and immunity as well as decreasing infectious complications. However, the ability to provide timely and adequate EN to critically ill patients is often hindered by GI motility disorders and complications associated with EN. This paper reviews the GI complications and intolerances associated with EN in critically ill patients and provides recommendations for their prevention and treatment. It also addresses the role of commonly used medications in the intensive care unit and their impact on GI motility and EN delivery.
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Affiliation(s)
- Imad F Btaiche
- University of Michigan Hospitals and Health Centers, Pharmacy Services, UHB2D301, 1500 E. Med. Center Drive, Ann Arbor, MI 48109-0008, USA.
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Nassar AP, da Silva FMQ, de Cleva R. Constipation in intensive care unit: Incidence and risk factors. J Crit Care 2009; 24:630.e9-12. [DOI: 10.1016/j.jcrc.2009.03.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2007] [Revised: 03/26/2009] [Accepted: 03/28/2009] [Indexed: 12/26/2022]
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Patient care guidelines: a telephone survey of intensive care practices in New South Wales. Aust Crit Care 2009; 23:21-9. [PMID: 19914086 DOI: 10.1016/j.aucc.2009.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2008] [Revised: 06/21/2009] [Accepted: 10/07/2009] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND There are a number of practice areas highlighted in the literature as important for the care of critically ill patients. However, the current implementation of evidence into clinical practice for these areas is largely unknown. The development of clinical practice guidelines can translate the current evidence into useful tools to guide clinicians in providing evidence based care. AIM To identify existence of current guidelines and informal routine procedures and clinicians' views of same within New South Wales (NSW) Intensive Care Units (ICUs) and High Dependency Units (HDUs) for 11 practice areas, namely, bowel management, endotracheal tube (ETT) stabilisation, tracheostomy tube stabilisation, feeding, analgesia, sedation, thromboembolic prevention, head of bed elevation, ulcer prophylaxis and glucose control. METHOD A telephone survey conducted with a representative from NSW ICUs and HDUs. RESULTS There was variation in the number of guidelines and informal routine procedures reported for the 11 practice areas within the study units. Larger ICUs (Joint Faculty of Intensive Care Medicine Level II and Level III) and those who employed an onsite CNC were significantly more likely to have formal guidelines in place. Overall, there were very few audits reportedly conducted for the 11 practice areas. Bowel management was the area of practice most respondents reported as a neglected area of critical care nursing practice and the one they were least satisfied with. CONCLUSION This survey provides a baseline of current practice and guideline use within NSW ICUs and HDUs. It also highlights areas for consideration to further develop clinical practice guidelines that could benefit critically ill patients.
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[Opioid-induced bowel dysfunction: a literature analysis on pathophysiology and treatment]. Wien Med Wochenschr 2009; 158:621-6. [PMID: 19052708 DOI: 10.1007/s10354-008-0589-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Accepted: 06/17/2008] [Indexed: 12/26/2022]
Abstract
Bowel dysfunction is a frequent and serious side effect of opioid analgetics. In spite of its common occurrence, in the course of clinical routine, it is frequently ignored or underestimated. Authors of the analysed literature widely agree that a prophylactic and routine pharmacotherapy is necessary. For this purpose, laxatives, enemas and suppositories, prokinetic agents and opioid antagonists can be considered. Bulk-forming laxatives did not prove to be effective, since the quantity of fluid intake required for the action usually cannot be provided. Furthermore, the benefit of emollient agents is doubted. As a monotherapy they are not sufficient. By contrast, stimulant and osmotic laxatives proved to be active. Prokinetic drugs are not recommended because of their serious side effects. Effective abatement of opioid-induced obstipation by opioid antagonists has been proven in numerous studies. However, the loss of analgesia and opioid withdrawal symptoms were described as adverse effects. Development of quaternary opioid antagonists such as methylnaltrexone was allowed for mitigating these adverse effects.
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Herbert MK, Holzer P. Standardized concept for the treatment of gastrointestinal dysmotility in critically ill patients--current status and future options. Clin Nutr 2007; 27:25-41. [PMID: 17933437 DOI: 10.1016/j.clnu.2007.08.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2007] [Accepted: 07/20/2007] [Indexed: 12/22/2022]
Abstract
Inhibition of gastrointestinal motility is a major problem in critically ill patients. Motor stasis gives rise to subsequent complications including intolerance to enteral feeding, enhanced permeability of the atrophic intestinal mucosa and conditions as severe as systemic inflammatory response syndrome, sepsis and multiple organ failure. Although the diagnosis of motility disturbances in critically ill patients is difficult, the type and site of the disturbance are important to consider in the analysis of the condition and in the choice of therapeutic approach. The pharmacological treatment of impaired gastrointestinal motility is difficult to handle for the clinician, because the underlying mechanisms are complex and not fully understood and the availability of pharmacological treatment options is limited. In addition, there is a lack of controlled studies on which to build an evidence-based treatment concept for critically ill patients. Notwithstanding this situation, there has been remarkable progress in the understanding of the integrated regulation of gastrointestinal motility in health and disease. These advances, which largely relate to the organization of the enteric nervous system and its signaling mechanisms, enable the intensivist to develop a standardized concept for the use of prokinetic agents in the treatment of impaired gastrointestinal motility in critically ill patients.
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Affiliation(s)
- Michael K Herbert
- Department of Anaesthesiology, University of Wuerzburg, Oberduerrbacher Str. 6, 97080 Wuerzburg, Germany.
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