EXPLORADOR DE SOLUCIONES

The characteristics of ETF and the duration of ETF administered to patients following admission to the ICU are presented in Table 4.2. All study participants received full-strength enteral feed formula. In total, patients were ETF over 449 patient admission days.

Table 4.2

Enteral Nutrition Characteristics of Study One (n = 50)

Variable Number (n) Percent (%) Median Range

Enteral nutrition by type

Jevity Plus 37 74 - -

Jevity 6 12 - -

Nepro 7 14 - -

Time to ETF commence following ICU admission

< 24 hour 29 58 - -

24–48 hour 17 34 - -

> 48 hour 4 8 - -

ETF formula changed during ICU admission

2 x ETF formulae changes 9 18 - -

3 x ETF formulae changes 1 2 - -

4 x ETF formulae changes 1 2 - -

ETF ceased in ICU 27 54 - -

Time to start ETF (hour)* - - 20* 2–86*† ETF duration (days)* - - 9* 3–14*†

Note. - = Statistic not reported since it is not appropriate for this variable; *Data rounded to

whole numbers for continuously scored variables. †Maximum data collection was14 days.

4.2.2 Medications

The majority of the sample examined in Study One received aperient, prokinetic, sedation, neuromuscular blockade and antibiotic medications (see Table 4.3).

Table 4.3

Medications Administered and Observed Days of Medication Administration (n = 50)

Number of Patients who received the medication

Number of observed days of medication

administration Medications administered Number (n) Percent (%) Median Range

Aperients 42 84 9* 0–12*† Coloxyl/Senna 39 78 6* 0–12*† Bisacodyl supp†† 32 64 0* 0–10*† Lactulose 24 48 0* 0–9*† Glycerine supp†† 6 12 0* 0–3*† Microlax 5 10 - - Other 1 2 - - Prokinetics 42 84 7* 0–14*† Maxalon 41 82 6* 0–14*† Erythromycin 21 42 0* 0–10*†

Sedation and opioids†††

Sedation 44 88 11* 0–14*† Opioid 48 96 7* 0–14*† Morphine 37 74 4* 0–14*† Fentanyl 30 60 3* 0–14*† Midazloam 44 88 4* 0–14*† Neuromuscular blocker Vecuronium 31 62 1* 0–12*†

Antibiotic (AB) combinations 46 92 11* 0–14*†

Number of AB One AB 46 92 4* 0–13*† Two AB 39 78 3* 0–13*† Three AB 25 50 1* 0–10*† Four AB 14 28 0* 0–7*† Five AB 5 10 - - Six AB 1 2 - - Seven AB 1 2 - -

Note. - = Data not reported for small sample size ≤10 patients; *Data rounded to whole

numbers for continuously scored variables; †Maximum data collection was14 days; †Supp = suppository; ††Sedation = medication co-administration, for example, opioid/midazolam, morphine/fentanyl.

4.2.3 Clinical indicators

The majority of the sample experienced hyperglycaemia, hypoalbuminaemia, elevated WCC, elevated INR and infection (see Table 4.4). Hypoglycaemia and multiresistant infection were rare events (10 or less) and no analyses were made using these clinical indicators (see Table 4.4).

Table 4.4

Clinical Indicators Experienced (n = 50)

Number of patients who experienced clinical indicators

Number of observed days of clinical indicator derangement Clinical indicators Number (n) Percent (%) Median Range

Hypoglycaemia 3 6 - - Hyperglycaemia 46 92 4* 0–10*† Hypoalbuminaemia 47 94 7* 0–14*† Elevated WCC 47 94 6* 0–14*† Elevated INR 40 80 3* 0–14*† Infection 33 66 - - Multiresistant infection 5 10 - -

Note. - = Data not reported for small sample size ≤10 patients or dichotomous scored

variable; *Data rounded to whole numbers for continuously scored variables; †Maximum data collection was 14 days.

4.3

Research Question 1

What is the period prevalence of diarrhoea in ETF patients in the ICU?

The majority of patients experienced bowel activity during their ICU admission (see Table 4.5). The characteristics of the patients’ bowel function and diarrhoea are presented in Table 4.5. The period prevalence of diarrhoea in Study One was 78% (n = 39). The number of events of diarrhoea per patient ranged from 0 to 8 events each day, with the cumulative number of events of diarrhoea per patient ranging from 0 to 29 events (Mdn = 5). The aggregate number of diarrhoea events was 326, which were observed over 120 patient admission days. The cumulative incidence rate of

diarrhoea was 0.64 events per patient observation day, with the individual patient incidence rate of diarrhoea ranging from 0 to 2.90 events per patient observation day (see Table 4.5).

Table 4.5

Bowel Activity Characteristics of Study One (n = 50)

Bowel activity Number

(n)

Percent (%)

Median Range

Bowel activity occurred - -

Males 24/27 89 - -

Females 22/23 96 - -

Time to initial bowel activity (hour)* - - 114* 5–206*

Diarrhoea - -

Males 23/27 85 - -

Females 16/23 70 - -

Number of diarrhoea events* - - 5* 0–29* Diarrhoea duration (days)* - - 2* 0–10* Diarrhoea incidence rate per

patient observation day*

- - 0.42 0–2.90

Note. - = Statistic not reported since it is not appropriate for this variable; *Data rounded to

whole numbers for continuously scored variables (time to initial bowel activity and diarrhoea duration).

Characteristics of the four patients who experienced no bowel activity during their ICU admission are presented in Table 4.6. Three patients were male (n = 3) and one patient was female (n = 1). Two of the patients who had no bowel activity developed a non-multiresistant infection and the other two developed a multiresistant infection during the data collection period. All of these patients received antibiotics during the data collection period.

Table 4.6

Characteristics of Patients Who Experienced no Bowel Activity during Study One (n = 4)

Variable Median Range

Age (years) 46* 22–66*

Actual ICU LOS (days) 6* 5–8*

Time to start ETF (hour) 32* 8–36*

Duration of ETF (days) 6* 3–7*

Duration no bowel activity (hour) 139* 122–192*

Aperients duration (days) 3* 0–16*

Prokinetics duration (days) 2* 0–5*

Antibiotic duration (days) 8* 2–16*

Sedation duration (days) 8* 6–13*

Note.*Data rounded to whole numbers for continuously scored variables.

4.4

Research Question 2

Is there a relationship between the number of events of diarrhoea and the duration of diarrhoea in ETF critically ill patients?

Analyses were conducted using the Spearman’s r correlation coefficient to examine the association between the number of events of diarrhoea and the duration of diarrhoea in ETF critically ill patients. A statistically significant and positive correlation was identified between the number of events of diarrhoea and the duration of diarrhoea (Spearman’s r = 0.93, p < .001). As would be expected, this finding suggests that patients who are observed to experience diarrhoea over a longer period of time are also more likely to experience more events of diarrhoea. The occurrence of diarrhoea and the incidence rate of diarrhoea will now be examined within the context of diarrhoea and associated risk factors.

4.5

Research Question 3

Are clinical indicators such as hypoalbuminaemia, hypoglycaemia, elevated WCC, elevated INR and infection associated with diarrhoea in this study?

Bivariate (Chi-squared) analyses were made to determine the association between the occurrence of diarrhoea and a range of clinical indicators and are presented in Table 4.7. There was a statistically significant association between the occurrence of

diarrhoea and the occurrence of hypoalbuminaemia and also between the occurrence of diarrhoea and the occurrence of an infection (see Table 4.7). Study participants who developed hypoalbuminaemia or an infection during their ICU admission were more likely to have an event of diarrhoea recorded during that admission. No other statistically significant associations were identified in these analyses, suggesting that the occurrence of diarrhoea was not associated with the occurrence of the remaining clinical indicators including hyperglycaemia, elevated WCC and elevated INR. Table 4.7

Association Between Diarrhoea Occurrence and Clinical Indicator Occurrence (n = 50)

Clinical indicator occurrence Continuity Correction χ21 p value

Hyperglycaemia 0.00 1.00

Hypoalbuminaemia 6.99 0.008*

Elevated WCC 0.00 1.00

Elevated INR 1.23 0.27

Infection 7.34 0.007*

Note. *Statistical significance at p (two-tailed) < .05.

Further bivariate analyses to examine the association between the incidence rate of diarrhoea and the occurrence of clinical indicators are presented in Table 4.8. There was a statistically significant association between the incidence rate of diarrhoea and the occurrence of hypoalbuminaemia, and the incidence rate of diarrhoea and the occurrence of an infection. In both cases a higher incidence rate of diarrhoea was associated with the presence of these clinical indicators (see Table 4.8). No significant difference was found between the incidence rate of diarrhoea and the occurrence of other clinical indicators including hyperglycaemia, elevated WCC and elevated INR.

Table 4.8

Incidence Rate of Diarrhoea by Clinical Indicator Occurrence Associations (n = 50)

Clinical indicator occurrence

z p value Median incidence

rate of diarrhoea with clinical indicator Median incidence rate of diarrhoea without clinical indicator Hyperglycaemia - 0.43 .67 .43 .30 Hypoalbuminaemia - 2.40 .02* .43 .00 Elevated WCC - 0.35 .73 .42 .64 Elevated INR - 1.90 .06 .50 .13 Infection - 2.30 .02* .50 .17

Note. *Statistical significance at p (two-tailed) < 0.05.

Analyses using GEE modelling were conducted to examine individual clustered patient variance between the occurrence of diarrhoea, the occurrence of clinical indicators and the duration of ETF (see Table 4.9). A statistically significant association was identified between the occurrence of diarrhoea, the occurrence of clinical indicators including infection, hyperglycaemia, hypoalbuminaemia and elevated WCC and the duration of ETF (see Table 4.9). The GEE analysis identified that critically ill patients who were ETF for a longer period of time were more likely to experience an occurrence of diarrhoea when an occurrence of these clinical indicator derangements were experienced.

Table 4.9

Multivariate Associations Between Diarrhoea Occurrence, Clinical Indicator Occurrence and Control for ETF Duration (n = 50)

Clinical indicator occurrence Estimated coefficient 95% confidence interval p value Infection .07 .04 – .10 < .001* Hyperglycaemia .06 .03 – .09 < .001* Hypoalbuminaemia .06 .03 – .09 < .001* Elevated WCC .06 .03 – .09 < .001*

Separate analyses were conducted using the Spearman’s r correlation coefficient to examine the association between the incidence rate of diarrhoea and the number of days of clinical indicator derangement for a range of clinical indicators (see Table 4.10). A statistically significant association was observed between the incidence rate of diarrhoea and the number of days of hyperglycaemia, hypoalbuminaemia and elevated INR with a higher incidence rate of diarrhoea associated with more days of clinical indicator derangement (see Table 4.10). These findings might be associated with the duration of participant observation. No significant difference was found between the incidence rate of diarrhoea and the duration of elevated WCC (see Table 4.10).

Table 4.10

Association Between the Incidence Rate of Diarrhoea and the Number of Days of Clinical Indicator Derangement (n = 50)

Number of days of clinical indicator derangement Spearman’s r p value Hyperglycaemia .29 .04* Hypoalbuminaemia .31 .03* Elevated WCC .20 .18 Elevated INR .30 .04*

Note.*Statistical significance at p (two-tailed) < .05.

4.6

Research Question 4

Is diarrhoea in ETF patients associated with:

 The type of ETF formulae?

Analyses were conducted using the Kruskal-Wallis test to examine the association between the incidence rate of diarrhoea and the type of ETF formula (see Table 4.11). No statistically significant differences were identified between the incidence rate of diarrhoea and the three types of ETF formula (see Table 4.11). Although no statistically significant result was observed, of particular note was that Nepro formulae had a higher median incidence rate of diarrhoea (Mdn = 0.92) when compared with the other two formulae of Jevity and Jevity Plus (see Table 4.11).

However, the low number of participants receiving Jevity and Nepro formulae suggests that these results should be considered with caution.

Table 4.11

Incidence Rate of Diarrhoea and ETF Formula (n = 50)

ETF formula Number of

participants receiving formula H(2) p value Median diarrhoea incidence rate 3.73 .16 Jevity Plus 37 .43 Jevity 6 .25 Nepro 7 .92

Note. *Statistical significance at p (two-tailed) < .05; H(2) = two degrees of freedom.

 The time to commencement of ETF following ICU admission? The association between the occurrence of diarrhoea and the time to ETF commencement was examined using the Mann-Whitney U test. No statistically significant difference was identified between those patients who developed diarrhoea and those patients who did not develop diarrhoea and the time to ETF

commencement (z = -1.07, p = .29).

Analyses were also conducted using the Mann-Whitney U test to examine the association between the incidence rate of diarrhoea and the timing to ETF

commencement. Due to the low numbers of people who commenced ETF more than 48 hours following ICU admission, the categories of ETF commenced within 24–48 hours and more than 48 hours following ICU admission were pooled into ETF

commenced more than 24 hours following ICU admission. No statistically significant difference was observed between the incidence rate of diarrhoea and ETF

commenced < 24 hours (Mdn = .5, n = 29) and ETF commenced > 24 hours (Mdn = .2, n = 21) following ICU admission (z = - 1.34, p = .18).

Further analyses using the Spearman’s r correlation coefficient were conducted to examine the association between the incidence rate of diarrhoea and the time to ETF commencement (time in exact hours). No statistically significant difference was

observed between the incidence rate of diarrhoea and the time to ETF commencement (Spearman’s r = - 0.12, p = .42).

 The duration of ETF?

The association between the occurrence of diarrhoea and the duration of ETF were examined using the Mann-Whitney U test. A statistically significant difference was identified between those patients who developed diarrhoea (Mdn = 11.0, n = 39) and those patients who did not develop diarrhoea (Mdn = 6.0, n = 11) and the duration of ETF (z = -3.73, p = < .001).

Analyses were also conducted using the Spearman’s r correlation coefficient to examine the association between the incidence rate of diarrhoea and the duration of ETF. A statistically significant association (Spearman’s r = 0.39, p = .006) was identified, suggesting that those participants who were ETF for a longer period of time experienced a higher incidence rate of diarrhoea.

 Gender, age, Study ICU LOS and APACHE II scores?

Analyses were conducted to examine the association between the occurrence of diarrhoea and gender. The Chi-square test for independence suggested that diarrhoea was not associated with gender (Continuity Correction χ2 = 0.97, p = .32). Further, the association between the occurrence of diarrhoea and age, Study ICU LOS and severity of illness (APACHE II score) were examined using the Mann-Whitney U test. There was a statistically significant association between Study ICU LOS and the occurrence of diarrhoea (see Table 4.12) suggesting that patients who were admitted to the ICU for a longer period of time were more likely to experience an occurrence of diarrhoea. Apart from the findings for Study ICU LOS, no significant associations were identified between the occurrence of diarrhoea and other demographic or clinical variables (see Table 4.12).

Table 4.12

Diarrhoea Occurrence by Age, Study ICU LOS and Severity of Illness (n = 50)

Diarrhoea occurrence

z p value Median age, Study

ICU LOS, APACHE II score

with the occurrence of

diarrhoea

Median age, Study ICU LOS, APACHE

II score without the occurrence of

diarrhoea

Age (years) - 0.13 .90 53.0 52.0 Study ICU LOS

(days)

- 3.81 < .001* 12.0 7.0 APACHE II score - 0.22 .82 11.0 13.0

Note. *Statistical significance at p (two-tailed) < 0.05.

Analyses were also conducted to examine the association between the incidence rate of diarrhoea and gender. The Mann-Whitney U test identified that there was no association between the incidence rate of diarrhoea and gender (z = - 1.32, p = .19). Analyses were also conducted using the Spearman’s r correlation coefficient to examine the association between the incidence rate of diarrhoea and age, Study ICU LOS and APACHE II scores (see Table 4.13). There was a statistically significant association identified between the incidence rate of diarrhoea and the Study ICU LOS (Spearman’s r = 0.44, p = < .002) (see Table 4.13) with those patients admitted for a longer period more likely to have a higher incidence rate of diarrhoea. No other statistically significant associations were identified between the incidence rate of diarrhoea and the patient’s age and APACHE II scores.

Table 4.13

Association Between the Incidence Rate of Diarrhoea and Age, Study ICU LOS and Severity of Illness (n = 50)

Patient characteristic Spearman’s r p value

Age (years) .12 .93

Study ICU LOS (days) .44 .002*

APACHE II score .14 .35

 The duration of aperient, prokinetic, sedation, neuromuscular blockade and antibiotic medication administration?

Analyses were conducted to examine the association between the incidence rate of diarrhoea and medication administration (see Table 4.14). The association between the incidence rate of diarrhoea and dichotomously scored medications were

examined using the Mann-Whitney U test (see Table 4.14). In addition, analyses using the Spearman’s r correlation coefficient were used to examine the association between two continuous variables: the incidence rate of diarrhoea and the duration of medication administration (see Table 4.14).

The significant associations arising from these analyses suggest that patients are more likely to experience a higher incidence rate of diarrhoea when the duration of antibiotic administration is longer and when combinations of three antibiotics are administered to ETF critically ill patients (see Table 4.14). There was also a statistically significant association between the incidence rate of diarrhoea and the longer duration of antibiotic administration as well as the longer duration of

combinations of three antibiotics being administered to ETF critically ill patients (see Table 4.14). No other statistically significant associations were identified between the incidence rate of diarrhoea, the administration of medications and the number of days of medication administration during the data collection period.

Table 4.14

Incidence Rate of Diarrhoea by Medications Administered (n = 50) Number of

patients

Medications administered Number of

days of medication administration

Mann-Whitney U test Spearman’s r

(n) (%) z p Median incidence rate of diarrhoea with medication Median incidence rate of diarrhoea without medication r p Aperients 42 84 - 0.72 .47 0.39 0.50 - 0.95 .51 Coloxyl/Senna 39 78 - 1.79 .07 0.31 0.77 - 0.22 .88 Bisacodyl supp 32 64 - 0.35 .72 0.42 0.32 0.01 .96 Lactulose 24 48 - 0.90 .37 0.59 0.33 0.13 .36 Glycerine supp 6 12 - - - - Microlax enema 5 10 - - - - Other 1 2 - - - - Prokinetics 42 84 - 1.17 .24 0.36 0.81 0.20 .89 Metoclopramide 41 82 - 1.54 .12 0.31 0.86 0.12 .90 Erythromycin 21 42 - 1.62 .11 0.60 0.30 0.25 .09 Sedation 44 88 - 1.39 .16 0.43 0.10 0.67 .65 Opioids 48 96 - 0.10 .32 0.43 0.18 0.25 .08 Morphine 37 74 - 0.98 .33 0.46 0.24 0.04 .77 Fentanyl 30 60 - 1.01 .31 0.52 0.32 0.24 .09 Midazolam 44 88 - 1.88 .61 0.46 0.10 0.14 .34 Neuromuscular blocker Vecuronium 31 62 - 0.74 .46 0.43 0.20 0.18 .22 Antibiotic (AB) combinations 46 92 - 1.30 .20 0.43 0.08 0.36 .01* Number of AB One AB 46 92 - 1.30 .20 0.43 0.08 0.08 .56 Two AB 39 78 - 1.78 .08 0.50 0.17 0.01 .94 Three AB 25 50 - 2.22 .03* 0.64 0.29 0.32 .03* Four AB 14 28 - 1.82 .07 0.64 0.30 0.23 .12 Five AB 5 10 - - - - Six AB 1 2 - - - - Seven AB 1 2 - - - -

Note. - = Data not reported for small sample size ≤10 patients; *Statistical significance at p

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