Diarrhea During Critical Illness: An Interim Analysis
CCCF ePoster library. Dionne J. Nov 8, 2018; 233398; 76 Disclosure(s): None
Dr. Joanna Dionne
Dr. Joanna Dionne
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Introduction: Diarrhea is a frequent concern in the Intensive Care Unit (ICU) and its incidence varies from 2-95%. This variation may be due to the absence of a consistent definition of diarrhea and inattention to this clinical problem.


Objectives: The objectives of this study were to describe the epidemiology of diarrhea in critically ill patients including the incidence, risk factors, and consequences of diarrhea, and the incidence of Clostridium difficile-associated diarrhea.


Methods; This prospective cohort study was undertaken over 10 weeks in 9 ICUs in Canada and the United States. We included all patients >18 years old who were admitted to the ICU for >24 hours and followed them daily until ICU discharge. The bedside nurse documented all bowel movements, classifying them using the Bristol and Bliss Stool Charts. We defined diarrhea in 3 ways: 1) WHO Criteria of >3 liquid bowel movements per day (Bristol type 7), 2) any Bristol type 6 or 7 stool, and 3) any Bliss score of 4. Daily data on pertinent life support, laboratory values (e.g., electrolytes), treatment (e.g., medications, fecal management devices, nutrition), and outcomes (including mortality) were evaluated using multivariate methods.


Results:  Among 865 patients, the incidence of diarrhea varied based on the definition (WHO Criteria: 77.3%; 95% CI 774.4-80.0, Bristol Stool Chart definition: 56.8%; 95% CI 53.5-60.1, Bliss Stool Chart definition: 39.9%; 95% CI 36.7-43.2). Risk factors associated with diarrhea on multivariable analysis included total number of antibiotic days OR 1.17 (95% CI 1.10-1.24) use of sorbitol-containing medications 1.76(95% CI 1.27-2.45) and enteral nutrition OR 2.24 (95% CI 1.56-3.22), while opiates were associated with a lower risk OR 0.22 ( 95%CI 0.13-0.36).  Diarrhea often prompted cessation of enteral nutrition, prokinetics or stool softeners, or fecal management device insertion.  Overall mortality was not different between diarrhea (78.6%) and non-diarrhea (73.8%) groups (p=0.184). Only 18/56 (32%) of Clostridium difficile toxin positive patients met the definition of Clostridium difficile-associated diarrhea.


Conclusion: In this multicenter cohort of critically ill patients, diarrhea occurred frequently; although the reported incidence differed based on the definition employed. Clostridium difficile-associated diarrhea was rare. Antibiotics exposure, hyperosmolar medications use and enteral nutrition increased the risk of diarrhea; opiates reduced it.


Grant acknowledgement: Hamilton Regional Medical Associates, Hamilton Health Sciences Department of Medicine, Physicians Services Incorporated of Ontario, Canadian Association of Gastroenterology, Canadian Institute for Health Research.

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