Aim To provide guidance on initial bowel management in critical care Scope All adult Critical Care patients receiving enteral nutrition excluding patients with chronic liver disease or spinal cord injury ID: 913019
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Slide1
Background
Bowel Management in Critical Care
Aim To provide guidance on initial bowel management in critical careScope All adult Critical Care patients receiving enteral nutrition excluding patients with chronic liver disease or spinal cord injury
Adapted from Plymouth Hospitals– M MacKinnon 22.11.2016
Raigmore Critical Care Guidelines
Gut dysfunction, both constipation and diarrhoea, is common in the critically ill although there exists little evidence to guide management
Constipation is linked to adverse outcome such as patient distress, bowel obstruction or perforation, increased weaning times from ventilation and reduced absorption of enteral feeding.DefinitionsConstipation: as absence of bowel movement for three or more days 1,6 Diarrhoea: 3 or more liquid or unformed stools in a day (WHO) or stool that conforms to the pot it is in.
Management of Constipation
Management of Diarrhoea
Early enteral feeding, optimal fluid status and the administration of prokinetic agents where indicated reduce gut dysfunction but do not prevent constipation in some patients. Prokinetics work on the stomach and small intestine but do not appear to affect the colon. Laxitives: Stimulants such as: senna/sodium docusate to stimulate colonic nerves and move faecal mass Osmotic laxatives such as lactulose to draw fluid into the colon. Osmotic laxatives rely on good fluid intake for a more beneficial effect. Both types of laxative may cause bloating and distension. Osmotic>stimulant Enteral naloxone may be used where opioids are considered to be the contributing factor for constipation.Glycerine suppositories may be indicated if PR examination reveals stool in the rectumAbdominal x-ray to exclude of bowel obstruction may be indicated.
Review of drug therapy
Exclusion of infection.
Consideration of rectal drainage systems.
Early enteral feeding, low osmolality high fibre feeds may prevent onset of diarrhoea in some cases Wiesen
7
.
Meticulous hygiene where manipulation of the feeding system occurs may reduce gut contamination
Opioids or loperamide may be used with caution when infection is excluded.
Slide2Absorbing?
YES
NO
See enteral feeding protocol regarding use of pro-kinetic agents (erythromycin and metoclopramide)
Bowels open at 24 hours?
YES
NO
Motions formed?
YES
Continue
NO
Review chart
Antibiotics, laxatives, medications with laxative side-effects
If persists beyond 24 hours then send for MC&S
Exclude infection
If persists for further 24 hours then consider Flexi-seal and isolate patient
Prevent possible cross-infection
If persists for further 24 hours then add sodium
docusate
* up to 500mg in divided doses
If persists for 72 hours then perform digital rectal examination (DRE)
Stool in rectum?
YES
NO
1 x 4g glycerin suppository*, moistened with water
Consider repeating after 2 hours if no result
Request plain abdominal x-ray
Is there an obstructing lesion?
follow neostigmine infusion
protocol
If still no result then consider Fleet phosphate enema*
Feed as per protocol
When at full feed rate
Add 10mL
senna
nocte
*
Increase senna to 20ml
nocte
Bowel Management Protocol