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Jo Butler wrote 10-21-2011 01:32:49 pm
I'm curious about the use of neostigmine for ileus. There is little evidence for it - a couple of small studies in patients with colonic pseudo-obstruction.

Matt, are you suggesting that if patients fail to poo, have no bowel sounds (? definition of ileus?) and have no obstructing lesion on the AXR you would give neostigmine?

Alex McKenzie wrote 10-04-2011 09:03:19 pm
Delightful topic Todd.

I am pretty proactive about this - since most people end up on narcotics in some fashion, I'm surprised anyone has normal bowel function in ICU at all.

I would suggest starting some sort of laxitive from day 1 of narcotics. I use coloxyl and senna as my first line agent. I don't use lactulose as I'm a bit concerned about it fermenting if someone does get an ileus. If there is no action by day 3, I use something from the bottom end. A stimulant like glyceryl or a fleet enema is what I go for.

This isn't protocolised where I work, but probably should be.

Oliver Arkell wrote 10-04-2011 09:05:38 pm
Agree with the narcotics thing. I always try to reduce the "precipitating factors" when I tick this box each day - drugs, dehydration, electrolyte disturbances, enhance mobility etc.

Todd Fraser wrote 10-04-2011 09:16:23 pm
Interesting comments.

Has anyone heard of using enteral naloxone? The anaesthetists say that using a very small dose of naloxone can reduce itch without impairing analgesic effects. I wonder if the same can be said for enteral naloxone. I thought I'd heard of someone using it somewhere.

Has anyone got experience with this?

Benjamin Tang wrote 10-05-2011 11:49:20 am
While we don't have a formal policy/protocol, most people in our unit do something similar to what Alex and Oliver had outlined.

I am not surprised that there is minimal interest in RCT or guidelines on this subject. For any subject area to attract investigator interest, there need to be some speculated correlation with increased mortality/morbidity. However, it will be difficult to demonstrate such an association in the context of bowel function in ICU. For the same reason, it will be difficult, for any intervention, to demonstrate an improvement in clinical outcome, given the large number of confounders likely to be present.

Important as it is, I suspect it will remain a relatively "non-sexy" subject and unlikely to attract investigators attention in the near future.

mat holland wrote 10-05-2011 08:03:24 pm
"If you don't poo you die" was always the adage from when I trained in townsville, which I still tell my juniors now.

I start docusate 200 mg bd and senna 20 ml bd to get things going, if nothing happens and the patient, with poo pr then enemas, if the pt is in ileus (no obstructing lesion) with dilated colon on AXR then iv neostigmine works well.

I have tried neostigmine in the past and it does seem to have an effect anecdotally, and in small studies.

Meissner et al Crit Care Med 2003 Vol. 31, No. 3
Enteral naloxone as prokinetic in ventilated patients.

8 mg qds ng

In a single center RCT 38 pts were randomised to naloxone enterally and compared with 43 treated with placebo.
Median gastric tube reflux volume was reduced in the treatment group (54 vs 129 ml p=0.03) and frequency of pneumonia was reduced (34% vs 56% p=0.04), though time to defaecation was not decreased and nor was LOS on ITU.
Fentanyl requirements were the same in both groups.

There is an ongoing trial comparing docusate and senna with docusate and naloxone, with primary outcome  time to first poo, which has now stopped recruiting and will hopefully tell us more.

Todd Fraser wrote 10-05-2011 08:49:29 pm
That's a very interesting point Ben.

I'm sure you could have said similar things about PaO2 on admission until a year or so ago, and now we know that's harmful too.

I'm sure with enough patients, trends could be identified. Who knows? Length of stay may be decreased. Calorie delivery reduced. Respiratory power reduced. Ventilator associated pneumonia reduced. And so on.

With some of the large patient databases now available, surely we can start to look at these types of issues.

mat holland wrote 10-06-2011 12:05:37 am
There is an interesting article on medscape and senna wins!
Pharmacologic Management of Constipation in the Critically Ill Patient
http://www.medscape.com/viewarticle/540711