The use of a prophylactic laxative bowel regimen in enterally-fed critically ill patients has been proposed as a method to prevent constipation. However, their use may also increase diarrhea. Given the potential adverse effects associated with both absence of treatment (constipation or non-defecation) and treatment (diarrhea), the role of prophylactic laxative bowel regimens in the critically ill remains uncertain. (1) The main question is to determine whether constipation is just a marker of severity and poor prognosis in critically ill patients or if it constitutes a dysfunction that must be prevented and treated because it effectively contributes to a worsening clinical condition for the patient. (1)
Feasibility/Equipment: A recent trial treated adult patients with: A) one coloxyl with senna BD from day one; B) two coloxyl with senna +20 ml lactulose BD commencing on day 3; or C) two coloxyl with senna tablets +20 ml lactulose BD commencing on day 6. (2) Previously, three trials implemented a lactulose-based prophylactic laxative bowel regimen, with one trial also implementing a third polyethylene glycol (PEG)-based treatment arm (3-5)
Scoring information: Bristol stool score: type 1-7.
Acute intestinal pseudoobstruction was defined as a clinical syndrome with distended abdomen, diminished passage of stools, and colonic distention of >10 cm on a plain abdominal radiograph. (3)
Cost: Costs of measurement are low; the insertion of a rectal tube implies severe diarrhea.
Evidence: Constipation and diarrhea occur frequently in the critically ill. A recent systematic review suggests that prophylactic laxative bowel regimens in critically ill patients are sparse and do not support their use. (1) Furthermore, no difference were observed when comparing earlier versus delayed laxative regimens on the the rates of complications associated with constipation or dhiarrhea. (2)
Accuracy / measurement properties: 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. (1) Earlier commencement of a prophylactic coloxyl-based laxative regimen (day 1 or 3) did not affect the rates of complications associated with constipation or diarrhea when compared to delayed introduction (day 6). (2)
References:
1 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 Aug;52:242-250. doi: 10.1016/j.jcrc.2019.01.004. Epub 2019 Jan 10. PMID: 30665795.
2 Hay T, Deane AM, Rechnitzer T, et al. The hospital-based evaluation of laxative prophylaxis in ICU (HELP-ICU): A pilot cluster-crossover randomized clinical trial. Journal of Critical Care. 2019 Aug;52:86-91. DOI: 10.1016/j.jcrc.2019.04.010. PMID: 30986760.
3 van der Spoel JI, Oudemans-van Straaten HM, Kuiper MA, van Roon EN, Zandstra DF, van der Voort PH. Laxation of critically ill patients with lactulose or polyethylene glycol: a two-center randomized, double-blind, placebo-controlled trial. Crit Care Med. 2007 Dec;35(12):2726-31. doi: 10.1097/01.CCM.0000287526.08794.29. PMID: 17893628.
4 de Azevedo RP, Freitas FG, Ferreira EM, Pontes de Azevedo LC, Machado FR. Daily laxative therapy reduces organ dysfunction in mechanically ventilated patients: a phase II randomized controlled trial. Crit Care. 2015 Sep 16;19(1):329. doi: 10.1186/s13054-015-1047-x. PMID: 26373705; PMCID: PMC4572636.
5 Masri Y, Abubaker J, Ahmed R. Prophylactic use of laxative for constipation in critically ill patients. Ann Thorac Med. 2010 Oct;5(4):228-31. doi: 10.4103/1817-1737.69113. PMID: 20981183; PMCID: PMC2954377.