Investigation On Early Diarrhea During Enteral Nutrition In Critically Ill Patients Admitted To ICU

Objective:We aimed to explore the epidemiology of diarrhea and factors associated with diarrhea,therefore providing guidance for the optimization of enteral nutrition.Methods:A prospective cross-sectional study was conducted between June 1 and October 1 in 2016 in 29 ICUs of 28 general hospitals of Zhejiang Province.Patients who were admitted to ICU required for enteral nutrition were included and continuously observed for over 7 days or until been discharged from ICU.Data were collected and categorized as:(1)common data,including sex,age,body mass index(BMI),admission diagnosis;(2)disease severity-associated data,including acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ)score,nutritional risk screening score(NRS)-2002,mechanical ventilation,use of vasoactive agent,serum albumin level;(3)enteral nutrition(EN)-associated data,including the timing,daily volume,daily calories,route,methods of EN as well as the use of prokinetics;(4)diarrhea-associated data,including frequency and property of stool,white blood cell count in stool routine,treatment modalities containing interruption of EN,use of antidiarrheic drugs,probiotics etc.;(5)prognosis data,including returned to general ward,referred to other ICU,been discharged against medical advice either for death or disease aggravated or other reasons.Multiariable logistic regression was performed to analysis risk factors associated with diarrhea and in-hospital mortality.Results:(1)General dataA total of 533 critically ill patients were enrolled in this study.Male accounts for 66.4%of the patient group(354).Age ranged between 19 and 96 years for all of them,with a median age of 67(51,79)years.The median BMI was 22.0(19.5,23.9)kg/m2.The median APACHE Ⅱ score was 18.0(13.0,23.0).The median NRS-2000 score was 4.0(3.0,5.0).The median ICU length of stay was 10.0 days(6.0,15.0).The overall mortality was 17.3%(n = 92).(2)Enteral nutritionThe median time for EN was the first day(1,2)during ICU stay.87.4%(466)of the patients group were pre-pyloric enteral feeding,the others were post-pyloric enteral feeding.81.6%(435)of patients group were administrated continuously infusion,the others were intermittently infusion.During EN,44.5%(237)of them were given prokinetic drugs,the others were not given prokinetic drugs.The daily volume of EN and daily calories were significantly different between groups(all P<0.05),which were gradually increased until day 7.(3)DiarrheaThe overall incidence of diarrhea was 30.8%(n = 164),4.1%of them were categorized as infective.Diarrhea occurred most frequently on day 1-3 of EN,which persisted until 2(1,3)days,with a median daily number of stool of 4 times.The daily incidence of diarrhea were significantly different between groups(all P<0.05),which were gradually reduced until day 7.Tertiary hospitals showed more incidence of diarrhea compared with secondary hospitals.There were no significantly differrent between groups(P>0.05).In the diagnosis of different diseases,the incidence of diarrhea was 61.5%in patients with respiratory and cardiac arrest,and the incidence of diarrhea in patients with cardiovascular disease was 17.8%.There were significantly differrent between groups(P<0.05).(4)Risk factors for diarrheaMultiariable logistic regression analysis showed that prokinetic drugs(OR 1.82;95%CI:1.24-2.65),APACHE Ⅱ score(OR 1.04;95%Cl:1.02-1.07),post-pylorus enteral feeding(OR 1.90;95%CI:1.11-3.36)were independent risk factors for diarrhea.(5)Diarrhea management70.7%of diarrhea patients were correspondingly treated.Methods included use of antidiarrheic drugs(59.1%)and probiotics(33.5%),interruption of EN(28.0%),and other methods(1.2%).Most frequently used antidiarrheal agents were dioctahedral smectite(84.6%)and loperamide(8.2%).There were 82 patients(8.2%)were given combined treatment with dioctahedral smectite and loperamide.In those who rceived interruption of EN,the median hours for interruption of EN was 10(3,24).Two patients were treated with oral antibiotics.(6)Prognosis analysisUnivariate analysis analysis revealed that diarrhea was associated with significantly prolonged mechanical ventilation(6.0 d vs 5.0 d,P =0.003)and ICU length of stay(11.0 d vs 9.0 d,P =0.000)as well as increased in-hospital mortality(23.2%vs 14.6%,P =0.016).Multiariable Logistic regression analysis showed that interruption of EN(OR 3.74;95%CI:1.85-7.54),APACHE Ⅱ score(OR 1.07;95%CI:1.04-1.11),vasoactive agent(OR 2.31;95%CI:1.42-3.77),and timing(>48 h)(OR 2.00;95%CI:1.08-3.70)were independent risk factors for in-hospital mortality.Conclusion:The incidence of diarrhea following EN in our patient group was 30.8%.Diarrhea occurred most frequently on day 1-3 of EN,lasting for a median time of 2 days(1,3).APACHE II score,the use of prokinetic drugs,and post-pylorus enteral feeding were risk factors for diarrhea.Patients suffering diarrhoea experienced increased ICU length of stay,increased the time of mechanical ventilation and inhospital mortality compared with patiects without diarrhoea.Interruption of EN induced by diarrhea significantly increased the risk of in-hospital mortality.