title: Changing clinical guidelines from delayed to early aperient administration for enterally fed intensive care patients was associated with increased diarrhoea: a before-and-after, intention-to-treat evaluation.
abstract: BACKGROUND
  The 14-bed intensive care unit of a tertiary referral hospital adopted a guideline to start docusate sodium with sennosides when enteral nutrition was started. This replaced a guideline to start aperients after 24h of enteral nutrition if no bowel action had occurred. We sought to determine the effect of this change on the incidence of diarrhoea and constipation in intensive care.
  
  
  METHODS
  Retrospective audit of the medical records of consecutive adult patients admitted to intensive care and given enteral nutrition, excluding those with a primary gastrointestinal system diagnosis, between Jan-Aug 2011 (the delayed group, n=175) and Jan-Aug 2012 (the early group, n=175). The early aperient guideline was implemented during Sep-Dec 2011.
  
  
  RESULTS
  The early and delayed groups were similar in age (median 62 years vs. 64 years; P=0.17), sex (males 65% vs. 63%; P=0.91), and postoperative cases (31% vs. 33%; P=0.82) and had similar proportions who received mechanical ventilation (95% vs. 95%; P=1.00), an inotrope or vasopressor (63% vs. 70%; P=0.17), renal replacement therapy (8% vs. 10%; P=0.71), opiates (77% vs. 80%; P=0.60), antibiotics (89% vs. 91%; P=0.72) and metoclopramide (46% vs. 55%; P=0.11). A significantly larger proportion of the early group received an aperient (54% vs. 29%, P<0.001) and experienced diarrhoea (38% vs. 27%, P=0.04), but the groups had similar proportions affected by constipation (42% vs. 43%, P=0.91).
  
  
  CONCLUSIONS
  Changing guidelines from delayed to early aperient administration was associated with an increase in the incidence of diarrhoea but was not associated with the incidence of constipation. These findings do not support changing guidelines from delayed to early aperient administration.
authors.affiliation: Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Australia.
authors.forename: Kammy
authors.initials: K
authors.lastname: Mok
authors.affiliation: Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Australia. Electronic address: roger.smith@svha.org.au.
authors.forename: Roger J
authors.initials: RJ
authors.lastname: Smith
authors.affiliation: Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Australia.
authors.forename: David A
authors.initials: DA
authors.lastname: Reid
authors.affiliation: Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Australia.
authors.forename: John D
authors.initials: JD
authors.lastname: Santamaria
mesh_terms: D003967:Diarrhea / Q000139:chemically induced*; D004143:Dioctyl Sulfosuccinic Acid / Q000008:administration & dosage; D004334:Drug Administration Schedule; D004750:Enteral Nutrition; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D012676:Senna Extract / Q000008:administration & dosage
chemical_list: D004143:Dioctyl Sulfosuccinic Acid; D012676:Senna Extract
keywords: Aperients; Constipation; Diarrhoea; Intensive care; Laxatives