Diarrhoea
A predefined (liquid stool >=3 times a day) number of liquid stools daily with volume > 250 g/day. Diarrhoea may be associated with intestinal infection or malabsorption as well as ischemia [1].
Feasibility/Equipment: Diarrhoea is a clinical sign, no specific equipment or training is necessary.
Scoring information: Present or absent
Cost: None
Evidence: Diarrhoea has been assessed in multiple prospective studies [2-5]. Diarrhoea can either be a sign of GI dysfunction or a sign of infectious disease [5]. In a prospective study of 422 patients, diarrhoea occurred 38 (14%) of patients and clostridium difficile incidence was 0.7% [5]. In a cohort of 377 patients, diarrhoea occurred in 81 patients (21.5 %) over the time of 7 days and was not associated with ICU mortality [4]. Diarrhoea is a defining symptom in the GIDS score for acute gastrointestinal dysfunction, with severe diarrhoea (Bristol scale 6-7 for >=5 times/day or >=1000 ml with stool collector/day) defining higher grade of GIDS [6].
Accuracy / measurement properties: Correlations: Diarrhoea was not associated with increased mortality (p = 0.32 and p = 0.293 for 28-day and 90-day mortality respectively) [6].
References
1. Reintam Blaser A, Malbrain ML, Starkopf J, Fruhwald S, Jakob SM, De Waele J, Braun JP, Poeze M, Spies C: Gastrointestinal function in intensive care patients: terminology, definitions and management. Recommendations of the ESICM Working Group on Abdominal Problems. Intensive Care Med 2012, 38(3):384-394.
2. Reintam A, Parm P, Kitus R, Kern H, Starkopf J: Gastrointestinal symptoms in intensive care patients. Acta Anaesthesiol Scand 2009, 53(3):318-324.
3. Ferrie S, East V: Managing diarrhoea in intensive care. Aust Crit Care 2007, 20(1):7-13.
4. Reintam Blaser A, Poeze M, Malbrain ML, Bjorck M, Oudemans-van Straaten HM, Starkopf J, Gastro-Intestinal Failure Trial G: Gastrointestinal symptoms during the first week of intensive care are associated with poor outcome: a prospective multicentre study. Intensive Care Med 2013, 39(5):899-909.
5. Thibault R, Graf S, Clerc A, Delieuvin N, Heidegger CP, Pichard C: Diarrhoea in the ICU: respective contribution of feeding and antibiotics. Crit Care 2013, 17(4):R153.
6. Reintam Blaser A, Padar M, Mandul M, Elke G, Engel C, Fischer K, Giabicani M, Gold T, Hess B, Hiesmayr M et al: Development of the Gastrointestinal Dysfunction Score (GIDS) for critically ill patients – A prospective multicenter observational study (iSOFA study). Clin Nutr 2021, 40(8):4932-4940.
Absence of stool passage
Absence of stool passage refers to the patient not passing faeces or no output from an intestinal stoma within a defined period of time. No agreement currently exists as to the defined period of time in which absence of stool passage becomes clinically significant.
Feasibility/Equipment: Monitoring of stool output is already a routine part of nursing care in the critical care unit and requires no special equipment.
Scoring information: Stool output is measured by the numbers of times stool is passed each day and the consistency of the output. No agreement currently exists on the time period in which the absence of stool passage becomes clinically significant.
Cost: Cost are low, and no specific training is necessary.
Evidence: The time period used to define absence of stool passage or constipation varies between studies with incidence of constipation in critical care patients varying from 5-90.5% (Vincent and Presier, 2015). Absence of stool passage has been associated with prolonged ICU stay, prolonged mechanical ventilation, increased APACHE II scores, intolerance to enteral nutrition and increased mortality (Mostafa et al, 2003, van der Spoel et al 2006 & 2007, Gacouin et al 2010, Patanwala et al, 2006, Montejo et al 1999, Nguyen et al. 2013).
Accuracy / measurement properties: More patients with absence of stool passage (42.5%) failed to wean from mechanical ventilation than non-constipated patients (0%), P<0.05 (Mostafa 2003). Absence of stool passage of > 6 days was associated with increased length of stay (12.6 +/-6.1 vs 21.4 +/- 14.6 days, p=0.017) and increased duration of mechanical ventilation (10.9 +/- 6.92 vs 19.2 +/- 13.69 days, p=0.018) (van der Spoel 2006).
References
- Vincent, J.L. and Preiser, J.C., 2015. Getting critical about constipation. Practical Gastroenterology, 144, pp.14-25.
- Mostafa SM, Bhandari S, Ritchie G, et al. Constipation and its implications in the critically ill patient. Br J Anaesth 2003;91:815-9.
- van der Spoel JI, Schultz MJ, van der Voort PH, et al. Influence of severity of illness, medication and selective decontamination on defecation. Intensive Care Med 2006;32:875-80.
- Gacouin A, Camus C, Gros A, et al. Constipation in longterm ventilated patients: associated factors and impact on intensive care unit outcomes. Crit Care Med 2010;38:1933- 8.
- van der Spoel JI, Oudemans-van Straaten HM, Kuiper MA, et al. Laxation of critically ill patients with lactulose or polyethylene glycol: a two-center randomized, double-blind, placebo-controlled trial. Crit Care Med 2007;35:2726-31.
- Patanwala AE, Abarca J, Huckleberry Y, et al. Pharmacologic management of constipation in the critically ill patient. Pharmacotherapy 2006;26:896-902
- Montejo JC. Enteral nutrition-related gastrointestinal complications in critically ill patients: a multicenter study. The Nutritional and Metabolic Working Group of the Spanish Society of Intensive Care Medicine and Coronary Units. Crit Care Med 1999;27:1447-53.
- Nguyen T, Frenette AJ, Johanson C, et al. Impaired gastrointestinal transit and its associated morbidity in the intensive care unit. J Crit Care 2013;28:537