Management

Patients must be kept clean to maintain their dignity and comfort, to prevent excoriation of the skin, to minimize contamination of the surrounding area with potentially pathogenic organisms, and for a pleasant working environment. A soft rectal tube can reduce soiling when diarrhea is profuse, but care is needed to avoid mucosal ulceration or perforation. Enteric isolation precautions are needed if an infectious cause for diarrhea is suspected or proven.

Any fluid and electrolyte deficiency must be corrected and ongoing losses replaced. Fluids are usually given intravenously in the ICU, but oral rehydration solutions provide a potentially cheaper alternative. The main electrolyte losses are sodium, potassium, chloride, and bicarbonate, but losses of magnesium, zinc, and copper may also cause these ions to be depleted. When patients are receiving enteral feeds and develop diarrhea it is common practice to reduce the volume and/or dilute the feed. This is a logical response when the diarrhea occurs after prolonged fasting, but not under other circumstances.

The history taken should include recent travels, past history of bowel disease, and both current and recent medications. Physical examination may reveal dehydration, evidence of malabsorption or poor nutrition, or features of inflammatory bowel disease. A fever is so common in ICU patients as to be unhelpful in indicating an infective cause. Rectal examination is essential to exclude spurious diarrhea.

Laboratory investigations include plasma electrolyte and urea concentrations, and stool microscopy and culture. C. difficile toxin should be excluded in patients receiving current or recent antibiotics. A stool osmotic gap of more than 100 mosmol/kg (2 * stool [Na + + K+] - serum osmolality) demonstrates osmotic diarrhea from sorbitol-containing medications etc., enteral feeds, or malabsorption.

If an infective cause is excluded, treatment with an antidiarrheal agent produces rapid symptomatic relief in most patients. Loperamide 4 mg orally or enterally initially followed by 2 mg up to six times daily appears to be the most satisfactory agent.

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