Prophylactic use of laxative for constipation in critically ill patients

Introduction

The aim of this study was to evaluate the use of laxative prophylaxis for constipation in the ICU and the impact of early versus late bowel movement on patient outcome.

Methods

After informed consent, all adults in the ICU who were expected to stay on a ventilator for >72 hours were randomized to Control and Interventional groups. Patients who had major bowel surgery were excluded. The Control group did not receive any intervention for bowel movement for the first 72 hours, while the Interventional group received a prophylactic dose of Lactulose 20 cc orally every 12 hours for the first 72 hours. After 72 hours the management of constipation in the both groups was left to the physician's discretion. Data were collected for age, sex, diagnosis, Simplified Acute Physiology Score (SAPS) II, doses of narcotics and sedatives, enteral nutrition, ventilator days, ICU days, bowel movement <72 hours and days of first bowel movement.

Results

Over a 6-month period a total of 100 patients were enrolled, 50 patients in each Control and Interventional group. Mean age was 38.8 years in Control and 37.5 years in Interventional group. Both groups had a predominance of male patients. The most common diagnosis in both groups was polytrauma. Mean SAPS II for both was 35. One hundred percent of patients were ventilated, with a mean dose of fentanyl (323.8 ± 108.89 μg/hour in Control and 345.83 ± 94.43 μg/hour in Interventional group) and a mean dose of midazolam (11.1 ± 4.04 mg/hour in Control and 12.4 ± 3.19 mg/hour in Interventional group). Enteral nutrition was maintained and tolerated by 100% of patients. There were only two (4%) patients in the Control group and nine (18%) patients in the Interventional group who had bowel movement in <72 hours (P < 0.05). Twenty-three (46%) patients in the Control and 29 (58%) patients in the Interventional group had bowel movement after 5 days. Mean ventilator days were 16.19 and 17.36 days in the Control and Interventional groups. Subgroup analysis showed that the patients who moved their bowel in <5 days in both groups had mean ventilator days of 18.5, while it was 15.88 days for the patients who moved their bowel after 5 days in both groups (P < 0.05). Forty-eight (96%) patients in each group were discharged from the ICU. Mean ICU days for the Control group was 21.15 ± 10.44 and was 20.77 ± 8.33 days for the Interventional group. A total of two (4%) patients died in each group.

Conclusions

Laxative prophylaxis can be used successfully to prevent constipation in ICU patients. Late bowel movement >5 days is associated with less ventilator days, compared with early <5 days bowel movement.