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Antimotility agents for the treatment of acute noninfectious diarrhea in critically ill patients

A practice management guideline from the Eastern Association for the Surgery of Trauma

Bugaev, Nikolay MD; Bhattacharya, Bishwajit MD; Chiu, William C. MD; Como, John J. MD, MPH; Cripps, Michael W. MD; Ferrada, Paula MD; Gelbard, Rondi B. MD; Gondek, Stephen MD, MPH; Kasotakis, George MD, MPH; Kim, Dennis MD; Mentzer, Caleb DO; Robinson, Bryce R. H. MD; Salcedo, Edgardo S. MD; Yeh, D. Dante MD

Journal of Trauma and Acute Care Surgery: October 2019 - Volume 87 - Issue 4 - p 915–921
doi: 10.1097/TA.0000000000002449
GUIDELINES
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BACKGROUND Acute noninfectious diarrhea is a common phenomenon in intensive care unit patients. Multiple treatments are suggested but the most effective management is unknown. A working group of the Eastern Association for the Surgery of Trauma, aimed to evaluate the effectiveness of loperamide, diphenoxylate/atropine, and elemental diet on acute noninfectious diarrhea in critically ill adults and to develop recommendations applicable to daily clinical practice.

METHODS The literature search identified 11 randomized controlled trials (RCT) appropriate for inclusion. The Grading of Recommendations Assessment, Development, and Evaluation methodology was applied to evaluate the effect of loperamide, diphenoxylate/atropine, and elemental diet on the resolution of noninfectious diarrhea in critically ill adults based on selected outcomes: improvement in clinical diarrhea, fecal frequency, time to the diarrhea resolution, and hospital length of stay.

RESULTS The level of evidence was assessed as very low. Analyses of 10 RCTs showed that loperamide facilitates resolution of diarrhea. Diphenoxylate/atropine was evaluated in three RCTs and was as effective as loperamide and more effective than placebo. No studies evaluating elemental diet as an intervention in patients with diarrhea were found.

CONCLUSION Loperamide and diphenoxylate/atropine are conditionally recommended to be used in critically ill patients with acute noninfectious diarrhea.

LEVEL OF EVIDENCE Systematic Review/Guidelines, level III.

From the Division of Trauma & Acute Care Surgery (N.B.), Tufts Medical Center, Tufts University School of Medicine. Boston, Massachusetts; Department of Surgery (B.B.), Yale School of Medicine, New Haven, Connecticut; Department of Surgery (W.C.C.), University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland; Department of Surgery (J.J.C.), MetroHealth Medical Center, Cleveland, Ohio; Trauma Division of General and Acute Care Surgery, Department of Surgery (M.W.C.), The University of Texas Southwestern Medical Center at Dallas, Texas; Virginia Commonwealth University (P.F.), Richmond, Virginia; Emory University School of Medicine (R.B.G.), Department of Surgery, Division of Trauma and Surgical Critical Care, Grady Memorial Hospital, Atlanta, Georgia; Division of Trauma and Surgical Critical Care (S.G.), Vanderbilt University Medical Center, Nashville, Tennessee; Division of Trauma and Critical Care Surgery, Department of Surgery (G.K.), Duke University School of Medicine, Durham, North Carolina; Division of Trauma/Acute Care Surgery/Surgical Critical Care (D.K.), LA County Harbor-UCLA Medical Center, Torrance, California; Division of Trauma, Critical Care, & Acute Care Surgery (C.M.), Spartanburg Medical Center, Spartanburg, South Carolina; Harborview Medical Center (B.R.H.R.), University of Washington, Seattle, Washington; Division of Trauma, Acute Care Surgery and Surgical Critical Care, Department of Surgery (E.S.S.), University of California Davis, Sacramento, California; and University of Miami (D.D.Y.), Ryder Trauma Center, Miami, Florida.

Submitted: June 12, 2019, Accepted: June 20, 2019, Published online: July 19, 2019.

This article was presented as a podium presentation at the 32nd EAST Annual Scientific Assembly on January 15 to 19, 2019, at the JW Marriott Austin in Austin, Texas.

Address for reprints: Nikolay Bugaev, MD, Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, 800 Washington St, 4488, Boston, MA 0211; email: nbugaev@tuftsmedicalcenter.org.

Online date: July 22, 2019

© 2019 Lippincott Williams & Wilkins, Inc.