- •ICU Protocols
- •Preface
- •Acknowledgments
- •Contents
- •Contributors
- •1: Airway Management
- •Suggested Reading
- •2: Acute Respiratory Failure
- •Suggested Reading
- •Suggested Reading
- •Website
- •4: Basic Mechanical Ventilation
- •Suggested Reading
- •Suggested Reading
- •Websites
- •Suggested Reading
- •Websites
- •7: Weaning
- •Suggested Reading
- •8: Massive Hemoptysis
- •Suggested Reading
- •9: Pulmonary Thromboembolism
- •Suggested Reading
- •Suggested Reading
- •Websites
- •11: Ventilator-Associated Pneumonia
- •Suggested Readings
- •12: Pleural Diseases
- •Suggested Reading
- •Websites
- •13: Sleep-Disordered Breathing
- •Suggested Reading
- •Websites
- •14: Oxygen Therapy
- •Suggested Reading
- •15: Pulse Oximetry and Capnography
- •Conclusion
- •Suggested Reading
- •Websites
- •16: Hemodynamic Monitoring
- •Suggested Reading
- •Websites
- •17: Echocardiography
- •Suggested Readings
- •Websites
- •Suggested Reading
- •Websites
- •19: Cardiorespiratory Arrest
- •Suggested Reading
- •Websites
- •20: Cardiogenic Shock
- •Suggested Reading
- •21: Acute Heart Failure
- •Suggested Reading
- •22: Cardiac Arrhythmias
- •Suggested Reading
- •Website
- •23: Acute Coronary Syndromes
- •Suggested Reading
- •Website
- •Suggested Reading
- •25: Aortic Dissection
- •Suggested Reading
- •26: Cerebrovascular Accident
- •Suggested Reading
- •Websites
- •27: Subarachnoid Hemorrhage
- •Suggested Reading
- •Websites
- •28: Status Epilepticus
- •Suggested Reading
- •29: Acute Flaccid Paralysis
- •Suggested Readings
- •30: Coma
- •Suggested Reading
- •Suggested Reading
- •Websites
- •32: Acute Febrile Encephalopathy
- •Suggested Reading
- •33: Sedation and Analgesia
- •Suggested Reading
- •Websites
- •34: Brain Death
- •Suggested Reading
- •Websites
- •35: Upper Gastrointestinal Bleeding
- •Suggested Reading
- •36: Lower Gastrointestinal Bleeding
- •Suggested Reading
- •37: Acute Diarrhea
- •Suggested Reading
- •38: Acute Abdominal Distension
- •Suggested Reading
- •39: Intra-abdominal Hypertension
- •Suggested Reading
- •Website
- •40: Acute Pancreatitis
- •Suggested Reading
- •Website
- •41: Acute Liver Failure
- •Suggested Reading
- •Suggested Reading
- •Websites
- •43: Nutrition Support
- •Suggested Reading
- •44: Acute Renal Failure
- •Suggested Reading
- •Websites
- •45: Renal Replacement Therapy
- •Suggested Reading
- •Website
- •46: Managing a Patient on Dialysis
- •Suggested Reading
- •Websites
- •47: Drug Dosing
- •Suggested Reading
- •Websites
- •48: General Measures of Infection Control
- •Suggested Reading
- •Websites
- •49: Antibiotic Stewardship
- •Suggested Reading
- •Website
- •50: Septic Shock
- •Suggested Reading
- •51: Severe Tropical Infections
- •Suggested Reading
- •Websites
- •52: New-Onset Fever
- •Suggested Reading
- •Websites
- •53: Fungal Infections
- •Suggested Reading
- •Suggested Reading
- •Website
- •55: Hyponatremia
- •Suggested Reading
- •56: Hypernatremia
- •Suggested Reading
- •57: Hypokalemia and Hyperkalemia
- •57.1 Hyperkalemia
- •Suggested Reading
- •Website
- •58: Arterial Blood Gases
- •Suggested Reading
- •Websites
- •59: Diabetic Emergencies
- •59.1 Hyperglycemic Emergencies
- •59.2 Hypoglycemia
- •Suggested Reading
- •60: Glycemic Control in the ICU
- •Suggested Reading
- •61: Transfusion Practices and Complications
- •Suggested Reading
- •Websites
- •Suggested Reading
- •Website
- •63: Onco-emergencies
- •63.1 Hypercalcemia
- •63.2 ECG Changes in Hypercalcemia
- •63.3 Superior Vena Cava Syndrome
- •63.4 Malignant Spinal Cord Compression
- •Suggested Reading
- •64: General Management of Trauma
- •Suggested Reading
- •65: Severe Head and Spinal Cord Injury
- •Suggested Reading
- •Websites
- •66: Torso Trauma
- •Suggested Reading
- •Websites
- •67: Burn Management
- •Suggested Reading
- •68: General Poisoning Management
- •Suggested Reading
- •69: Syndromic Approach to Poisoning
- •Suggested Reading
- •Websites
- •70: Drug Abuse
- •Suggested Reading
- •71: Snakebite
- •Suggested Reading
- •72: Heat Stroke and Hypothermia
- •72.1 Heat Stroke
- •72.2 Hypothermia
- •Suggested Reading
- •73: Jaundice in Pregnancy
- •Suggested Reading
- •Suggested Reading
- •75: Severe Preeclampsia
- •Suggested Reading
- •76: General Issues in Perioperative Care
- •Suggested Reading
- •Web Site
- •77.1 Cardiac Surgery
- •77.2 Thoracic Surgery
- •77.3 Neurosurgery
- •Suggested Reading
- •78: Initial Assessment and Resuscitation
- •Suggested Reading
- •79: Comprehensive ICU Care
- •Suggested Reading
- •Website
- •80: Quality Control
- •Suggested Reading
- •Websites
- •81: Ethical Principles in End-of-Life Care
- •Suggested Reading
- •82: ICU Organization and Training
- •Suggested Reading
- •Website
- •83: Transportation of Critically Ill Patients
- •83.1 Intrahospital Transport
- •83.2 Interhospital Transport
- •Suggested Reading
- •84: Scoring Systems
- •Suggested Reading
- •Websites
- •85: Mechanical Ventilation
- •Suggested Reading
- •86: Acute Severe Asthma
- •Suggested Reading
- •87: Status Epilepticus
- •Suggested Reading
- •88: Severe Sepsis and Septic Shock
- •Suggested Reading
- •89: Acute Intracranial Hypertension
- •Suggested Reading
- •90: Multiorgan Failure
- •90.1 Concurrent Management of Hepatic Dysfunction
- •Suggested Readings
- •91: Central Line Placement
- •Suggested Reading
- •92: Arterial Catheterization
- •Suggested Reading
- •93: Pulmonary Artery Catheterization
- •Suggested Reading
- •Website
- •Suggested Reading
- •95: Temporary Pacemaker Insertion
- •Suggested Reading
- •96: Percutaneous Tracheostomy
- •Suggested Reading
- •97: Thoracentesis
- •Suggested Reading
- •98: Chest Tube Placement
- •Suggested Reading
- •99: Pericardiocentesis
- •Suggested Reading
- •100: Lumbar Puncture
- •Suggested Reading
- •Website
- •101: Intra-aortic Balloon Pump
- •Suggested Reading
- •Appendices
- •Appendix A
- •Appendix B
- •Common ICU Formulae
- •Appendix C
- •Appendix D: Syllabus for ICU Training
- •Index
Acute Diarrhea |
37 |
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Mahesh Kumar Goenka and Nisha D. Kapoor |
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A 40-year-old male patient with no signiÞcant previous medical history was admitted to the ICU with 1-day history of passing watery diarrhea, about 20Ð25 episodes with crampy pain in the abdomen. On examination, he was afebrile with signs of dehydration in the form of dry skin, loss of skin turgor, pulse of 100/min, and BP of 90/60 mmHg. He was drowsy and had the reduced urinary output. His central venous pressure (CVP) was 3, and arterial blood gas (ABG) analysis revealed metabolic acidosis.
Acute severe diarrhea in the ICU may be seen in two situations: a patient with acute severe diarrhea gets admitted to the ICU or a patient admitted to the ICU for any other illness develops a new-onset diarrhea.
Step 1: Initiate resuscitation
¥After taking care of airway and breathing, ßuid and electrolyte resuscitation is the mainstay of therapy. It is important to assess the severity of dehydration and treat it.
¥Check vital signs such as tachycardia, hypotension, orthostatic hypotension, skin turgor, sunken eyes, sensorium, and dry mucous membranes.
¥AbdomenÑbowel sounds, distension, and tenderness.
¥Place the central line and check CVP. Give ßuids to maintain CVP between 8 and 12 cm H2O.
M.K. Goenka, D.M., M.N.A.M.S. (*)
Institute of Gastrosciences, Apollo Gleneagles Hospitals, Kolkata, India e-mail: mkgkolkata@gmail.com
N.D. Kapoor, M.D., D.N.B.
Department of Gastroenterology, Columbia Asia Hospital, New Delhi, India
R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach, |
299 |
DOI 10.1007/978-81-322-0535-7_37, © Springer India 2012 |
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300 |
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M.K. Goenka and N.D. Kapoor |
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Table 37.1 Various causes of diarrhea |
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1. |
Infectious causes: |
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a. |
BacteriaÑVibrio cholerae, Shigella, Salmonella, Campylobacter, E. coli |
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b. |
VirusÑRotavirus, Adenovirus, Norovirus |
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c. |
ParasitesÑGiardia, amoeba, Microsporidium, Cryptosporidium, Cyclospora, |
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Strongyloides |
2. Inßammatory causes: Inßammatory bowel disease, Ischemic colitis, Diverticulitis |
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3. |
Food poisoning/allergy |
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4. First presentation of any chronic diarrhea |
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5. |
Medications: |
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a. |
Acid-reducing agents (e.g., histamine H2-receptor antagonists and proton pump |
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inhibitors) and antacids (e.g., those that contain magnesium) |
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b. |
Antiarrhythmics (e.g., quinidine) |
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c. |
Antibiotics (most) |
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d. |
Anti-inßammatory agents (e.g., nonsteroidal anti-inßammatory drugs [NSAIDs], gold |
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salts, and 5-aminosalicylates) |
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e. |
Antihypertensives (e.g., b-adrenergic receptor blocking drugs) |
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f. |
Antineoplastic agents (many) |
g.Antiretroviral agents
h.Colchicine
i. Herbal products, heavy metals j. Theophylline
k. Vitamin and mineral supplements (e.g., vitamin C and magnesium) l. Recent antibiotic use or hospitalization
m. Prostaglandin (e.g., misoprostol) n. Hyperosmolar feeds
o. Laxatives, Sorbital
¥Fluids to be used:
ÐRingerÕs lactate
ÐNormal saline with potassium chloride 20 mEq/L
¥Additional potassium and magnesium are required as suggested by the biochemistry results.
¥Place FoleyÕs catheter and measure hourly urinary output.
Step 2: Take detail history from the patient/family
Take a detail history of the following:
¥Duration of symptoms, frequency, characteristics of stool, amount, and weight loss
¥Medications (see Table 37.1)Ñvery common causes of diarrhea in the ICU
¥Abdominal symptoms or constitutional symptoms
¥Travel, food habits, and sexual activity
¥Water source
¥Sick contacts
37 Acute Diarrhea |
301 |
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¥Comorbidities (e.g., diabetes and pancreatitis)
¥Family history or past history of bowel disease (e.g., inßammatory bowel disease)
Step 3: Identify the cause of diarrhea
Severe diarrhea is usually of infective origin. However, other etiologies should be kept in mind (Table 37.1).
Step 4: Send investigations
Detailed investigations should be done if the patient has any one of the following:
¥Profuse diarrhea with dehydration
¥Grossly bloody stools
¥Fever of more than 38¡C
¥Duration of more than 48 h without improvement
¥Recent antibiotic use
¥New community outbreak
¥Associated severe abdominal pain in the patient older than 50 years
¥Elderly (>70 years)
¥Immunocompromised patients
Investigations
¥Hematology
ÐHemoglobin and hematocrit, total leukocyte count, and differential count
ÐBiochemistryÑarterial blood gases, renal functions, liver functions and electrolytes, and blood glucose
¥Stool tests
ÐFecal WBCsÑsuggest mucosal invasion, especially in Shigella, Campylobacter, EHEC (Entero Hemorrhagic Escherichia coli), and EIEC (Entero Invasive Escherichia coli)
ÐAbsent fecal WBCs in viruses, ETEC (Enterotoxic Escherichia coli), amebiasis, Giardiasis.
ÐC. difficile toxin
ÐAerobic cultureÑfor bacteria
ÐOva/parasites
ÐThe hanging drop for cholera
¥SerologyÑamebic serology
¥ImagingÑplain abdominal radiograph can detect partial obstruction, perforation, colonic dilatation, contrast-enhanced computed tomography (CECT) of the abdomen is advised in protracted cases
Optional investigations
¥AntigenÑGiardia, rotavirus
¥ELISA and PCR for viruses
¥Dark Þeld/phase contrast microscopy for Campylobacter
302 |
M.K. Goenka and N.D. Kapoor |
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¥Stool osmolal gap = stool osmolalityÐ2 × (Na++K+); gap of more than 40Ð60 suggests osmotic diarrhea
¥Endoscopy
Step 5: Specific pharmacotherapy
¥May be given empirically in all severe diarrheas
¥Usually Quinolones, Trimethoprim/sulfamethoxazole, Erythromycin, or Doxycycline are used
¥If Giardiasis or Amebiasis suspectedÑMetronidazole
¥If C. difficile suspectedÑMetronidazole or oral Vancomycin
¥Antivirals (Acyclovir, Ganciclovir)Ñherpes simplex virus, cytomegalovirus
¥AntihelminthicsÑStrongyloidiasis
¥Empirical antibiotics are usually recommended especially in:
a.Elderly
b.Immunocompromised
c.Mechanical heart valves
d.Vascular grafts
Step 6: Symptom-relief agents
¥If the cause of diarrhea is not known, palliative treatment can be started to decrease ßuid loss and the patientÕs discomfort.
¥Reduced stool frequency and stool weight may even relieve cramps, but close monitoring is required for complications.
ÐOpiate derivativesÑloperamide 2Ð4 mg four times a day
ÐAnticholinergicsÑdiphenoxylate 2.5Ð5 mg four times a day
ÐRacecadotril (enkephalinase inhibitor), antisecretory activity without affecting intestinal transitÑ1.5 mg/kg thrice a day
ÐSomatostatin analogsÑoctreotide 50Ð250 mcg thrice a day subcutaneously in GVHD and immunodeÞciency syndrome and other causes of secretory diarrhea
Step 7: Probiotics
Variousstudieshaveshownthatprobiotics,especiallyLactobacillus,Bifidobacterium, Saccharomyces boulardii, and combination of various preand probiotics, are helpful in avoiding recurrence of diarrhea and even C. difficile. However, they should be avoided in immunosuppressed patients (Fig. 37.1).
Case Scenario B
A 60-year-old diabetic man, known diabetic and hypertensive, was admitted to the ICU with cerebrovascular accident. After 1 week of stay, he had developed watery diarrhea.
37 Acute Diarrhea |
303 |
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Severe diarrhea
Fluid and electrolytes
Stool microbiology
Pathogen found
No |
Yes |
Empirical therapy + further evaluation |
Specific Rx |
(sigmoidoscopy/colonoscopy and biopsy, |
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UGI Endoscopy and biopsy/aspirate, etc.) |
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Fig. 37.1 Management of acute severe diarrhea
Step 1: Know the causes of acute-onset diarrhea in the ICU
¥Tube feedingÑmost likely to occur with calorie-dense formulas infused directly into the small bowel, a variant of dumping syndrome
¥Antibiotic-associated diarrhea, other medications as listed before (Table 37.1)
¥Pseudomembranous enterocolitisÑClostridium difficile
¥Underlying disease relatedÑdiabetic autonomic neuropathy
¥Laxatives, lactose intolerance
¥Fecal impaction with overßow diarrhea
¥Ischemic colitis
¥Diverticulitis
¥First-time presentation of a disease such as malignancy, radiation colitis, inßammatory bowel disease, and AddisonÕs disease
Step 2: Management is same as mentioned above with a few changes
¥There should be a lower threshold for performing sigmoidoscopy/colonoscopy in these patients.
¥For tube-feed-related diarrhea:
ÐSlow the rate of infusion.
ÐDilute the feeds.
ÐModify the formula to increase Þber.
ÐGive an antidiarrheal agent such as loperamide or diphenoxylate.
¥For antibiotic/laxative/other medication-related diarrhea, stop the offender.