Thread by @WellingtonICU

This week's journal club #Tweetorial is written by @oweepower. Its a meta-analysis of bowel regimens in the critically ill by Hay et al, published in JCC this month. Paper here:
sciencedirect.com/science/articl…

Constipation is frequent in critically ill patients with potential serious sequelae. Prophylactic laxative regimens have been long administered as a way to prevent this in enterally-fed critically ill patients.

However, laxatives may increase diarrhoea which has potential adverse effects of its own. Role of prophylactic laxative regimen remains largely unknown. This review attempts to address this.

Primary hypothesis: constipation & diarrhoea are frequent in critical illness & associated with adverse outcomes. Secondary hypothesis: in enterally-fed critically ill patients, prophylactic laxative regimen reduces constipation risk but increases diarrhoea risk without adversity

Systematic review of multiple databases using MESH terms: critical care, aperients, constipation & diarrhoea to 1st May 2018. Assessed for bias using validated tools. Statistical analysis as per standardised guidelines.

7516 citations identified. 78 retrieved for full text review, 22 suitable for inclusion (16 observational, 3 sequential period studies, 3 RCTs). Quality of observational studies low to moderate, quality of sequential period studies moderate, RCTs moderate.

Risk of bias moderate to high for majority of studies that were examined – except single RCT was deemed low risk of bias (van der Spoel et al: insights.ovid.com/crossref?an=00… )

Wide variation in taxonomy used to define constipation & diarrhoea. Constipation frequent (20-83%). Many reported constipation associated with increased no. days ventilation & length of ICU stay.

Diarrhoea also frequent (3.3-78%) & associated with adverse outcomes: discomfort, duration of ICU admission & mortality.

6 studies prophylactic laxative regimens conducted: 3 sequential period studies, 3 RCTs . 2 of 3 sequential period studies reported reduction in constipation with prophylactic regime. Interestingly, 2 of 3 studies also reported reduction in diarrhoea with prophylactic regime

3 RCTs closely examined. Overall estimate of effect calculated by performing meta-analysis of 3 RCTs on 4 quantitative end points.
Point estimate risk ratio constipation 0.39 (favours laxatives)
Point estimate risk ratio diarrhoea 1.58 (favours controls)

No significant difference in duration mechanical ventilation, ICU LOS or mortality found.

Limitations: scarcity of data, variability of taxonomy used, lack of definition of 'normal' or 'expected' bowel movements in critically ill patients on continuous liquid diet.

Does lack of bowel movements in liquid feeding reflect successful & complete absorption of feed, GI dysmotility or both? Non-defecation in critically ill may not be the same constipation in the general population.

Conclusions:
1. Both constipation & diarrhoea prevalence are high in critically ill patients
2. Relationship between constipation or diarrhoea & adverse clinical outcomes are variable

Conclusions:
3. Available evidence does not support clinical use of prophylactic laxative bowel regimens but limited by lack of high quality evidence
4. Which agents are most effective & whether regimens improve patient-centred outcomes unknown. Only osmotic laxatives studied

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