Bowel Management in Critical Care

Publication: 17/11/2014  --
Last review: 31/07/2018  
Next review: 16/09/2021  
Clinical Guideline
UNDER REVIEW 
ID: 4018 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Bowel management in Adult Critical Care (ACC) patients

For spinal injury patients please refer to spinal guidelines-
Digital rectal stimulation and manual evacuation of faeces in adults

Please refer to Marsden manual (LTHT Internal Only) for additional information on constipation, diarrhoea; pharmalogical and non-pharmalogical support for faecal elimination; and procedure information for digital rectal examination (PR).

Summary of Guideline

The use of a bowel management guideline in ACC can be linked with a reduction in the incidence of constipation (Ritchie et al 2008) and can be a useful tool for the maintaining good bowel function (McPeake et al, 2011).

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Aims

  • To maintain the patient’s usual bowel function with early recognition and treatment of bowel dysfunction.
  • To ensure patients receive evidence based procedures and auditable high standards of care.
  • To ensure LTH infection control and isolation procedures are followed and reduce the spread of infection
  • To standardise and optimise the safe and appropriate use of a Faecal Collection/ Management Device.

The aims of Faecal Collection / Management Systems :

  • Reduce the risk of spread of infection
  • Protect skin integrity/Reduce the risk of skin breakdown
  • Protect wounds/Surgical sites
  • Improve and restore patient comfort

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Background

Constipation and diarrhoea are not uncommon in ACC.
Gut motility can be altered due to

  • immobility
  • effects of particular medications,
  • infection,
  • Admitting diagnosis.

The maintenance of usual bowel function is desirable to promote recovery

Definitions

Constipation
Paralysis of the lower gastrointestinal (GI) tract - the inability the bowel to pass stool due to impaired peristalsis. Clincial sign can include Absence of stool for three or more consecutive days without mechanical obstruction regardless of bowel sounds. Lack of bowel sounds are unreliable and should not form part of a diagnosis of constipation.(Vincent JL and Preiser JC (2015)

Diarrhoea
can be characterized according to its:

  • Onset and duration (acute or chronic) or
  • Type (e.g. secretory, osmotic or malabsorptive) (Bell 2001)

and defined in terms of :

  • Stool frequency,
  • Consistency,
  • Volume or
  • Weight.

Contributing factors

Constipation

  • Spinal cord injury
  • Neuromuscular disease, such as amyolateral sclerosis
  • Underlying dysmotility
  • Abdominal surgery
  • Immobility
  • Use of opioids or other medications that contribute to hypomotility
  • Sepsis
  • Electrolyte disturbances
  • Insufficient or too much fluid administration
  • Inappropriate use of diuretics

(Vincent JL and Preiser JC (2015)

Diarrhoea

  • Enteral nutrition
  • Infection
  • Altered intestinal function
  • Disease reactivation
  • Malabsorption e.g. Pancreatitis / Bariatric surgery

Drugs associated with diarrhoea (Yassin & Wyncoll, 2005)

Laxatives

Senna, lactulose, Sodium docusate

Prokinetics

Metoclopramide, Erythromycin

Antibiotics

Cephalosporin’s, Clindamycin

Proton pump inhibitors

Omeprazole, Lanzoprazole

Diuretics

Furosemide, Thiazides

Antihypertensive

β-blockers, ACE inhibitors

Antiarrhythmic

Digoxin

Cytotoxic drugs

 

Bronchodilators

Theophylline, Aminophylline

Complications

Constipation

  • Abdominal distension and discomfort
  • Vomiting
  • Delayed gastric emptying and intolerance of enteral feeding
  • Increase intraabdominal hypertension
  • Intestinal ischemia and perforation
  • Colonic pseudo obstruction
  • Bacterial overgrowth and translocation?
  • Pulmonary aspiration
  • Prolonged mechanical ventilation and ICU length of stay

(Vincent JL and Preiser JC (2015)

Diarrhoea

  • Dehydration
  • Electrolyte imbalance
  • Confusion
  • Hypotension
  • Skin damage
  • Death

(Bayon Garcia C , Binks R De Luca E et al 2013)

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SOP Treatment / Management

Make it a priority to re-establish, and then maintain, regular bowel movements.

Please see the embedded SOP (1) for overall Bowel Management for patients whilst on ACC

When involved in handling faecal matter staff should maintain safe infection prevention and control practices

Management of constipation
An active prophylactic approach is used within ACC at LTHT

Guardiola (2015) and Masri (2010) demonstrated beneficial effects of this approach in critically ill patients

However early mobilisation is a cheap and effective way to stimulate gut function and motility.
See SOP (2) for management of stool that is present in the rectum

Management of diarrhoea
Chemical
Loperamide slows gut motility and reduces volume of diarrhoea. If commencing as part of the diarrhoea flow chart prescribe Loperamide dispersible tablets. NB Loperamide should not be given if an infective cause is suspected.

Proton pump inhibitors (PPIs) may be associated with a higher risk for Clostridium difficile–associated diarrhoea (CDAD). As a precaution, patients should take the lowest dose of a PPI for the shortest duration that is appropriate for the condition being treated (Lowes, 2012).The use of both PPIs and ranitidine as stress ulcer prophylaxis should be reviewed daily as the patient’s condition changes and/or they are on established enteral feeding.

Bulking agents
Refer to Dietician and seek advice

Containment of faeces devices
For the use in immobile patients with liquid or semi-liquid stool in whom the use of pads is no longer providing adequate skin protection or containment of the loose stool.

Indications for use of any collection device:

  • Patients who are experiencing ‘excess’ loose stool
  • Patients with skin damage due to various causes including faecal contamination
  • Patients who cannot be ‘isolated’ in a single room but need containment of faeces to assist in preventing spread of infection.

Insertable devices

Caution
Before using an insertable device consider the patients clotting status and or liver function

Contraindications

  • Consent refused. If patient unable to consent need to consider if it is in their best interest.
  • Patients under 18
  • Sensitivity to or have had an allergic reaction to Silicone and or Latex
  • Faecal impaction
  • lower large bowel or rectal surgery within the last 12 months
  • Suspected or confirmed rectal mucosa impairment
  • Rectal or anal injuries
  • Severe rectal or anal stricture or stenosis
  • Confirmed rectal or anal tumours
  • Severe hemorrhoids
  • Established spinal cord lesions
  • Unable to provide high frequency skin observations (raised ICP)
  • Unable to use a dynamic mattress (Spinal instability / ICP concerns )

See SOP(3) for decision making tree and ongoing care of faecal collection / management device

Patients must not be sat out of bed with an insertable collection device- if it is felt that this is affecting rehabilitation, discuss risks of continued use with the MDT, document the decision made.
If mobilisation is thought to be beneficial but the device is to remain in situ then the patient should only be sat out for a maximum of 1 hour.

If the insertable device is temporarily removed (i.e. < 1 hour), it may be rinsed and re-inserted otherwise the device should be discarded as per local Trust policy.

Skin Care
Skin breakdown is likely to occur if bowel contents are in contact with the skin for any length of time.
Aim to keep skin as clean and dry as possible
Use barrier creams where possible
Seek additional advice form TV champions and TV nurses

Patient involvement in care
Where possible seek the patient opinion on management of their condition
Provide them with verbal and written information

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Provenance

Record: 4018
Objective:
Clinical condition:

Bowel management

Target patient group: Adult Critical care patients
Target professional group(s): Registered Nurses Working in Critical Care
Adapted from:

Evidence base

References:
Adams S (1994) Aspects of current research in enteral nutrition in the critically ill. Care of the Critically Ill. Vol. 10 No. 6 p246-251 (Graded C)
Bayon Garcia C, Binks R, De Luca E et al (2013) Expert recommendations for managing acute faecal incontinence with diarrhoeas in the intensive care unit. Journal of the Intensive Care society Supplement 2 volume 14 (4) October
Guenter P, Settle R, Perimutter S, Marino P, Delimore G and Rolandelli R (1991) Tube feeding related diarrhoea in acutely ill patients. Journal of Parenteral and Enteral Nutrition. Vol. 15. No. 3 p277-280 (Graded B)
Lowes, Robert. (Feb 2012) Proton Pump Inhibitors Linked to C difficile Diarrhoea, Medscape Medical News
Masri, Y, Abubaker, J Ahmed, R. (2010) Prophylactic use of laxative for constipation in critically ill patients. Annals of Thoracic Medicine Vol 5, no. 4 228-231
McPeake, J, Gilmour, H & MacIntosh, G. (2011) The implementation of a bowel protocol in an adult intensive care unit. Nursing in Critical Care Vol. 16 no 5 235-242
Mok K, Smith R J, Reid D A et al (2015) Changing Clincial guidelines from delayed to early aperient administrations for enterally fed intensive care patients was associated with increased diarrhoea: A before and after intention to treat evaluation. Australian Critical Care 28 208-201
Mostafa, S, Bhandari, S, Ritchie, G, Gratton, N, Wenston, R (2003) Constipation and its Implications in the Critically Ill Patient. British Journal of Anaesthesia, 91 (6), 815-819.
Nazarko L. (1996) Preventing constipation in older people. Professional Nurse. Vol. 11 No. 12 September p826-818 (Graded C)
Oczkowski s J, Duan F H, Groen A et al (2017) the use of bowel protocols in critically ill adults patients: A systematic review and meta-analysis. Critical care Journal July 45(7) e718e726
Palacio de Azevedo R, Freitas F G R, Ferreira E M et al 92015) Daily laxative therapy reduces organ dysfunction in mechanically ventilated patients: a phase ii randomised controlled trial. Critical care 19: 329
Ring M (2011) Implementation of a bowel care protocol within intensive care. The world of Critical care nursing 8 (1)n 17-20
Ritchie, G. Burgess, L, Mostafa, S, Wenstone, R. (2008) Preventing constipation in critically ill patients. Nursing Times 104: 42-44
Royal College of Nursing (2003) Digital rectal examination and removal of faeces: guidance for nurses. (Graded C)
Royal Marsden Manual online 8th edition, Wiley-Blackwell, 2011 Chapter 6 Faecal Elimination
Vincent J L, Preiser J C (2015) Getting critical about constipation. Nutrition Issues in Gastroenterology Series #144 Practical Gastroenterology August 14-25
Yassin, J. Wyncoll, D (2005) Management of intractable diarrhoea in the critically ill. Care of the Critically Ill. Vol 21 no. 1 20-24
Bibliography
Bouchier I, Allan R, Hodgson H. and Keighley M (1993) Gastroenterology: clinical science and practice. 2nd ed W.B. Saunders Co Ltd. London (Graded C)
Day A (2001) the Nurses role in managing constipation. Nursing standard 16(8) 41-4. (Graded C)
Edwards G, Tomlin J and Read N (1988) Fibre and constipation. The British Journal of Clinical Practice Vol. 42. No. 1 p26-31 (Graded C)
Evans L (1996) Movement through change. Nursing Times. Vol. 92. Vol. 21. May 22 p30-31
Jamie-Bass D, Forman L, Alramis S and Hiveh A (1996) The effect of dietary fibre in tube fed elderly patients. Journal of Gerontological Nursing. October p37-43 (Graded C)
Levinson M. and Bryce, A. (1993) Enteral feeding: gastric colonisation and diarrhoea in the critically ill patient: is there a relationship? Anaesthetic Intensive Care. Vol 21. p85-88 (Graded C)
Maestr-Banhs A. (1996) Assessing constipation. Nursing Times. Vol. 92. No. 21 p28-30 (Graded C)
Pritchard A and Mallett J. (editors) (1992) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 3rd edition. Blackwell Scientific Publications. London. P83 (Graded C)

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

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