Diarrhea During Mechanical Ventilation: A Multicenter Study
CCCF ePoster library. Dionne J. Nov 8, 2018; 234195; 77 Disclosure(s): None
Dr. Joanna Dionne
Dr. Joanna Dionne
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result in the insertion of rectal devices.  The objective of this nested substudy within the PROSPECT Trial was to describe the incidence,  risk factors for diarrhea in mechanically ventilated patients at the two-thirds enrolment mark.

Methods: PROSPECT Research Coordinators collected baseline and daily data on patients enrolled in a randomized placebo-controlled trial testing the effect of twice daily Lactobacillus rhamnosus GG on infectious outcomes and diarrhea. Patients were considered as a cohort rather than in 2 groups. Bedside Nurses prospectively documented daily bowel movements [BMs], recording the number, frequency, and Bristol Stool Form type. We defined diarrhea as either >3BMs per day or >1 Bristol type 6 or 7 stool.  

Results: Among 1,243 invasively mechanically ventilated patients, 70.2% received inotropes, 13.4% received renal replacement therapy and 1.5% were on extracorporeal membrane oxygenation (ECMO) at some time in ICU. The mean age was 60.3 (standard deviation [SD] 16.4) years, and the mean APACHE II Score was 22.1 (SD 8.0). Over 16,685 ICU patient-days, every BM was characterized. The incidence of diarrhea was 59.5% when defined as >3 Bristol Type 6/7 BMs on any day, and 84.2% when defined as >1 Bristol Type 6-7 stool on any day. No BMs were passed on 5,985 patient-days. Multivariate Cox proportional hazards regression showed that age, illness severity and history of Clostridium difficile were not associated with diarrhea.  However, frailty (Hazard Ratio [HR] 1.21, 95% CI 1.04-1.42) and prior gastrointestinal disease (inflammatory bowel disease, irritable bowel syndrome or celiac disease) (HR 1.77,95%CI 1.21-2.60) significantly increased the risk.  In terms of daily events and exposures, advanced life supports (vasopressors and renal replacement therapy) and motility agents (prokinetics and opiates) were not associated with diarrhea.  However, antibiotics (HR 1.70, 95%CI 1.38-2.09), enteral nutrition (HR 1.35, 95%CI 1.01-1.79), laxatives (HR 2.11, 95%CI 1.75-2.53), and ICU-acquired Clostridium difficile infection (HR 3.48, 95%CI 1.75-6.93) significantly increased the risk of diarrhea.  Acid suppression with proton pump inhibitors were associated with diarrhea (HR 1.29, 95%CI 1.06-1.57), whereas histamine-2-receptor antagonists were not (HR 1.11, 95%CI 0.91-1.36). 


Conclusions: This analysis shows that diarrhea affects the majority of mechanically ventilated patients. While some baseline factors increase the chance of diarrhea during critical illness (e.g., frailty, and gastrointestinal comorbidity associated with diarrhea), some potentially modifiable time-dependent factors also increase the risk (e.g., antibiotics, enteral nutrition, Clostridium difficile infection and proton pump inhibitors).


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