http://doi.org/10.33698/NRF0062   Suresh K. Sharma, Kuldeep Kaur, Rajnish Garg

Abstract : This prospective study was conducted on 50 consecutive purposively selected patients (age 12-55 years), who were admitted in selected ICUs of DMCH, Ludhiana. Daily follow-up of subjects ranged between 7-21 days with mean of 13.54±4.31 days and total 720 observations were made. Critically ill patients who were Nil per oral, consumed small amount of liquid diet (< 0.5L/24 hrs), consumed selected drugs (opioids, analgesics, anticonvulsants, antidepressants, sedatives, iron supplements and calcium preparation), unconscious (had no movement) had higher observations of absence of daily bowel movements and it was found highly statistical significant (P < 0.001).Patients who were on mechanical ventilator had higher number of absence of daily bowel movements and it was found statistically significant (P < 0.05). however, patients with 24 hours negative fluid balance had higher percentage of absence of daily bowel movement but it was not found statistical significant (P> 0.05). It is recommended that patients with above said predisposing conditions should be intensively monitored by nurses and effective intervention need to be planned and implemented in collaboration with physicians promptly. There is a need to develop and empirically test a specific constipation prevention protocol for these vulnerable patients.

Key words :

Factors, bowel movements, critically ill patients.

Correspondence at : Suresh K. Sharma

College of Nursing, DMCH, Ludhiana.

Introduction

The body must remove waste products of metabolism to sustain healthy functions. Attention to bowel functions occurs when there is deviation from what is perceived as normal elimination1. Effect of uncontrolled bowel action is threat to person’s independence and well-being1. Defecation is a basic body function that affects the quality of life. Dietary intake and gastrointestinal motility functions are important in critically-ill patients. However, scant attention has been given to motility disorders of lower gastrointestinal tract and problems of failure to defecate in critically-ill patients2. Constipation is a common complaint among critically ill patients. Poor dietary and fluid intake, impaired mobility leads to decreased muscle tone and decreased peristalsis, thus, contributing to development of constipation1. Hospitalised critically-ill patients receiving opiates, sedatives, anti- convulsants and many others drugs are more likely to develop lower gastrointestinal motility disorders. However, a study conducted by Zeilman & Grote (1995), revealed that motility disorder is common problem among persons receiving sedatives4. The incidence of constipation is high in this population; which is further supported by a Mostafa et al’s study, reflecting that constipation occur in 83% of critically-ill patients2. Critically-ill patients usually remain confined to bed because of underlying disease process as well as prescribed mechanical ventilation & pharmacological agents due to which there is decreased muscle tone and peristalsis. However, the occurrence of constipation and its implication in critically-ill patients is generally overlooked by the care providers in intensive care units. They generally monitor gastrointestinal functions and record features such as volume of gastric aspirate and occurrence of bowel opening rather than its absence (constipation). Because of shift working, several nurses care for the same patient and it is not surprising that it can be difficult to maintain a record of this function. Unfortunately, this potentially serious problem is often overlooked and under-managed 2. Although it seems to be a minor complication when compared to a life- threatening disease in critically-ill patients yet it can become detriment to quality of life if it is not well monitored and managed.

Objective

  1. To find out different factors affecting daily bowel movements in critically ill patients.

Materials and Methods

This prospective study was conducted in selected I.C.U.s of D.M.C.&H., Ludhiana during months of February and March 2006. It is an autonomous institute of medical education and is well known for its Intensive Care Unit services. A total of 50 consequently purposively selected patients were studied in seven selected ICUs. Fifty subjects were with different diagnosis related to systems such as hematological (4), neurological (15),pulmonary  (9), integumentary (7),gastroenterology (8), renal (2) and others (5). Patients between age group of 12 to 55 years were included in study but patients with history of bowel surgery, previous history of constipation or opioid addiction were excluded. An identification data sheet and observation proforma was prepared to collect data. Validity was established by seeking opinion of 5 experts who were from fields of research, nursing, medicine, gastroentrology and neurosurgery. Selected patients were followed daily from first day of admission to, till discharge (if discharged before 3 weeks) or till 3 weeks of stay in I.C.U. Follow-up of subjects ranged between 7-21 days with mean of 13.54±4.31 days. Total 720 observations were made to find out effect of different believed potential predisposing factors (type of feed, amount of feed, 24 hours fluid balance, activity of patient, type of ventilation and consumption of selected drugs (opioids, analgesics, anticonvulsants, antidepressants, sedatives, iron supplements and calcium preparation) on daily bowel movement in critically ill patients. The data were analysed and presented by using descriptive and inferential statistics.

Results

In present study 67% males and 36% females with mean age 49.4±18.5 years In methodology age group is with as 12-55 years who belonged to urban (54%), rural (44%) and slums (2%) areas were studied.Table 1 depicts association between type of feed consumed by patients and daily bowel movements. It revealed that patients who were Nil per oral (NPO) reported higher percentage of absence of daily bowel movements (78%) in comparison of patients, who consumed liquid (39.6%), semi-solid (37% ) and solid diet (33%) and it was found highly statistically significant (P<0.01). as per Chi square test.

Type 1: Type of feed and daily bowel movements.

 

 

Bowel movements

f (%)

Type  of feed  

Total Value

 

x2

Solid f (%) Liquid f (%) Semi-solid f (%) NPO*
Present 85

(35.9)

230

(60.4)

102

(62.9)

11

(22.0)

428  

32.98**

 

df = 3

Absent 42

(33.1)

151

(39.6)

60

(37.1)

39

(78.0)

292
Total 127 381 162 50 720

 

** Highly significant (p<0.001),

* Nil per Oral

Table 2 shows that subjects with feed intake of <0.5 litres/day or NPO had higher absence of daily bowel movements`i.e. (79%) & (78%) respectively as compared to feed intake >2.5 litres (38.1%), 1.5-2.5 litres (36.4%) and 0.5-1.5 liters (34.5%). It was found highly statistical significant (P<.001) as per Chi Square test.

Table 2 : Amount of feed (Litres / 24 hrs) and daily bowel movements

 

 

 

Bowel Movements

Amount of feed  

Total

 

X2

Value

< 0.5 f (%) 0.5-1.5 f (%) 1.5-2.5 f (%) >2.5 f (%) NPO*

f

Present 29

(36.7)

182

(65.5)

124

(63.5)

73

(61.8)

11

(22.0)

429  

 

51.19**

 

df = 4

Absent 50

(63.3)

96

(34.5)

71

(36.5)

45

(38.2)

39

(78.0)

291
Total 79 278 195 118 50 720

*NPO – Nil Per Orally, ** highly Significant (p<0.001)

Table 3 depicts the association between 24 hours fluid balance and daily bowel movements. Results revealed that patients with negative fluid balance had in higher percentage absence of daily bowel movements (54.1%) in comparison to patients with positive fluid balance (40.7%) but it was not statistically significant (p>0.05) as per Chi square test.

Table 3 : Fluid balance (litres/24 hrs) and daily bowel movements.

 

 

 

Daily bowel movements

Fluid balance  

Total f (%)

 

x2 Value

Positive

f (%)

Negative

f (%)

Present 405 (59.3) 17 (45.9) 422  

 

2.59NS

df = 1

Absent 278 (40.7) 20 (54.1) 298
Total 683 37 720

NS-Not Significant (p>0.05)

Table 4 depicts the association between extent of patients activity and daily bowel movements. It was found that patients with no movements reported in higher percentage (64.1%) absence of daily bowel movements in comparison to those who were moving limbs (47.1%) or moving in bed (28.4%) and it was found highly statistically significant (p<0.001) as per Chi square test.

Table 4: Extent of patients activity and daily bowel movements.

 

Daily

bowel movements

No  movement f (%) Moving limbs f(%) Moving in bed f(%) Total

 

f

 

x2 Value

Present 37 (35.9) 155 (52.9) 232 (71.6) 424  

48.4**

d.f. = 2

Absent 66 (64.1) 138 (47.1) 92 (28.4) 296
Total 103 293 324 720

** Highly significant (p<0.001)

An attempt was made to see the association between consumption of some selected drugs (opioids, analgesics, anticonvulsants, antidepressants, sedatives, iron supplements and calcium preparation) and daily bowel movement among subjects.

It was found that patients who were on selected drugs had in higher percentage absence of daily bowel movements (45.8%) in comparison to those who did not consume these drugs (34.1%) and it was found highly statistically significant (p<0.001) as per Chi square test.

Table 5: Intake of selected drugs and daily bowel movements.

 

 

Bowel movements

Selected drugs Consumed

f (%)

Selected drugs Not consumed f (%)  

Total f

x2 Value
Present 244 (54.2) 178 (65.9) 422  
Absent 206 (45.8) 92 (34.1) 298 12.97**

df = 1

Total 450 270 720  

 **Highly Significant p<0.001Table 6 shows association between type of ventilation and daily bowel movements. It was found that subjects who were on ventilator reported in higher percentage (70.6%) of absence of daily bowel movement in comparison to patients who were spontaneously ventilating (36.0%). Chi-square test was applied to see the statistical significance and it was found statistically significant (p<0.05).

Table 6: Type of ventilation and daily bowel movements

 

Bowel movements Spontaneous ventilation

f (%)

Mechanical ventilation f (%) Total

 

f

 

x 2

value

Present 391 (64.0) 32 (29.4) 423  

45.87*

d.f. = 1

Absent 220 (36.0) 77 (70.6) 297
Total 611 109 720

Significant (p<0.05)

Discussion

This perspective study was conducted on 67% males and 36% females with mean age 49.4±18.5 years (14-85 years) belongedto urban (54%), rural (44%) and slums (2%) areas.Subjects were followed daily from first day of admission to, discharge (if discharged before 3 weeks) or till 3 weeks of stay in I.C.U. Follow-up of subjects ranged between 7-21 days with mean of 13.54±4.31 days. Total 720 observations were made to find  effect of different believed potential predisposing factors on daily bowel movement in critically ill patients.Subjects who were Nil per orally (NPO) reported in higher percentage (78%) absence of daily bowel movements, in comparison of patients, who consumed liquid (39.6%), semi- solid (37%) and solid diet (33%) and it was found highly statistically significant (p<0.001). Hall et al conducted a study and established the protocol intervention for constipation that included definite type of diet  (fiber, fluids etc). and reported reduced incidence of constipation from 59% to 9%.

In relation to amount of feed, the subjects who were NPO or consuming < 0.5 liters diet/ 24 hours reported in higher percentage absence of daily bowel movements (63.3 %) whereas patients who were on > 2.5 liters diet/ 24 hours had only 38.2% observations with absence of bowel movements. Study findings were supported by Anti et al6 where he quoted that intake of 2.5 liters or more maintains bowel frequency.Results revealed that patients with negative fluid balance had in higher percentage absence of daily bowel movements (54.1%) in comparison to patients with positive fluid balance (40.7%) but it was not statistically significant (p>0.05). These findings were supported by Anti et al’s study6 where he concluded that positive fluid balance enhances the effect of fiber on stool frequency. Physical activity is the major detriment of bowel movement. Subjects who were confined to bed and did not have any activity at all reported in higher percentage(64.1%) absence of daily bowel movements in comparison to those who were moving limbs (47.1%) or moving in bed (28.4%) and it was found highly statistically significant (p<0.001). These findings are supported by Nakaji’s study7 which revealed that physical activities such as walking were useful in the maintenance of defecation (p = 0.049).The importance of medication3 and general medical illnesses in constipation remains uncertain. Multiple constipating drugs (opiates, sedatives, osmotic-diuretics, anticonvulsants) seem to be an important contributing factor in development of constipation7. In present study it was revealed subjects who were on selected drugs (opiods, analgesics, anti-convulsants, diuretics) had in higher percentage absence of daily bowel movements (45.8%) in comparison to those who did not consume these drugs (34.1%) and it was found highly statistically significant (p<0.001). Fur thermore, finding were supported by Tally et al’s study8 where they found that opioids (2.6%), osmotic diuretics (5.6%), anti-convulsants (5.7%) were associated with highest risk of constipation among medications.Mechanical ventilation is a lifesaving tool, but it is not without limitations. Numerous gastrointestinal complications are seen in critically-ill patients receiving mechanical ventilation9. Higher number of observations with absence of daily bowel movements (70.6%) were found among patients, who were on mechanical ventilation in comparison of patients with spontaneous ventilation (36%). it was found statistically significant (p<0.05). Different studies by Tamion et al9, Mutlu et al10 and Heyland11 supported the same phenomenon.

Conclusion

Critically ill patients who were NPO, consumed small amount of liquid diet (< 0.5L/ 24 hrs), consumed selected drugs (opioids, analgesics, anticonvulsants, antidepressants, sedatives, iron supplements and calcium preparation), unconscious (had no movement) had higher observation of absence of daily bowel movements and it was found highly statistical significant (P < 0.001).Patients who were on mechanical ventilator had higher number absence of daily bowel movement and it was found statistically significant (P < 0.05). however, patients with 24 hours negative fluid balance had higher percentage of absence of daily bowel movement but it was not found statistical significant ( P > 0.05). It is recommended that patients with all above said predisposing conditions should be intensively monitored by nurses and effective intervention need to be planned and implemented in collaboration with physicians. There is a need to develop and empirically test a specific constipation prevention protocol for patients with these predisposing factors.

References

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  2. Mostafa SM, Bhandari S, Ritchie G, Constipation and its implications in critically-ill patient. http://bja.oxfdjournals.org.
  3. Zeilman S, Grote The effects of long term sedation on intestinal function. Anaesthesist 1995 Dec; 44 (Suppl 3): S549-58.
  4. Anti et al. Water supplementation enhances the effect of high fiber diet on stool frequency and laxatives consumption in adult patients with functional constipation. Hepatogastroentrology 1998 May-Jun; 45(21): 727-32.
  5. i et al. Relationship between life style factors and defecation in a Japanese Population. Eur J Nutr 2002 Dec; 41(6): 244-8.
  6. Talley NJ, Jones M, Nuyts G, Dubois Risk factors for Chronic constipation based on a general practice sample. American Journal Gastroenterol 2003 May; 98(5): 1107-11.
  7. Tamoin F, Hamelin et al. Gastric emptying in mechanically ventilated critically-ill patients: effect of neuromuscular blocking Fabienne. tamion @ chu-roven.pr.
  8. Mutlu et al. G.I complications in patients receiving mechanical ventilation; chest journal.org.
  9. Heyland DK et Impaired gastric emptying in mechanically ventilated, critically ill patients. American Journal Gastroenterol 2004 May; 98(5): 1006-10.