Page 1469 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

1008 PART 9: Gastrointestinal Disorders

when given intravenously. The typical dose is 2 mg IV given over 3 to • Gungabissoon U, Hacquoil K, Bains C, et al. Prevalence, risk
5 minutes and may be repeated once. Contraindications included hyper- factors, clinical consequences, and treatment of enteral feed
sensitivity to the drug and gastrointestinal or genitourinary mechanical intolerance during critical illness. JPEN J Parenter Enteral Nutr.
obstruction. Caution should be exercised administering neostigmine 2014. [Epub ahead of print].
to patients with recent myocardial infarction, asthma, bradycardia, or
renal failure. The most common side effects are abdominal cramping, • Jain A, Vargas HD. Advances and challenges in the management of
excessive salivation, and bradycardia. Administration of neostigmine acute colonic pseudo-obstruction (ogilvie syndrome). Clin Colon
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should only be done with cardiac monitoring and atropine available at Rectal Surg. 2012;25(1):37-45.
the bedside. Of note, the administration of neostigmine to a patient with • Knab LM, Boller AM, Mahvi DM. Cholecystitis. Surg Clin North
a mechanical colonic obstruction can also precipitate bowel perforation. Am. 2014;94(2):455-470.
To date, neostigmine use for ACPO has been reported in over 140 patients, • McClave SA, Martindale RG, Vanek VW, et al. Guidelines for
with a pooled success rate of 87% and recurrence rate of 10%. A ran- the Provision and Assessment of Nutrition Support Therapy in
112
domized controlled study of 24 patients by van der Spoel et al examined the Adult Critically Ill Patient: Society of Critical Care Medicine
the use of an IV infusion of 0.4 to 0.8 mg/h of neostigmine to treat (SCCM) and American Society for Parenteral and Enteral Nutrition
colonic ileus in mechanically ventilated critically ill patients. The (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2009;33(3):277-316.
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study found significant success in obtaining stool passage, but an exclu-
sion criterion of the study was Ogilvie syndrome, and thus these results • McFee RB, Abdelsayed GG. Clostridium difficile. Dis Mon.
are not immediately generalizable to critical care patients with ACPO. 2009;55(7):439-470.
Sgouros et al performed a randomized controlled trial investigating • Seltman AK. Surgical management of Clostridium difficile colitis.
the effect of administration of polyethylene glycol (PEG) solution after Clin Colon Rectal Surg. 2012;25(4):204-209.
decompression of ACPO with the aim of decreasing recurrence rates. • Sticova E, Jirsa M. New insights in bilirubin metabolism and
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Their study of 30 patients revealed a significant reduction in relapse their clinical implications. World J Gastroenterol. 2013;19(38):
(0 of 15 as compared with 5 of 15 patients) after the daily administration 6398-6407.
of 29.5 g of PEG in 500 mL of water in two divided doses for 1 week. 123 • Wiesen P, Van GA, Preiser JC. Diarrhoea in the critically ill. Curr
The use of lidocaine infusions to reduce the duration of postoperative
ileus is also an area of active investigation. 124,125 Success with treatment Opin Crit Care. 2006;12(2):149-154.
of colonic pseudoobstruction with IV naloxone has also been reported.
126
Methylnaltrexone and alvimopan, both peripherally acting opioid
antagonists, have recently been introduced to clinical practice and REFERENCES
although they have not yet been reported to help with ACPO, their
utility in treating opioid-induced bowel dysfunction is a promising area Complete references available online at www.mhprofessional.com/hall
of investigation 106,127 and studies for ACPO are underway.
Endoscopic decompression for ACPO is now mainly used only
in those patients who fail neostigmine or have a contraindication to
its use. Success rates in large retrospective series approach 80% with CHAPTER Gastrointestinal
recurrence rates of 20% to 40%. 115,116,128 The difficulty in negotiating an Hemorrhage
perforation rate of 2%. Placement of a decompression tube has been 105
unprepared bowel with minimal insufflation contributes to the reported
120
shown to reduce the recurrence rate in some small studies and as such, Emad Qayed
is recommended. 112,129,130 Of note, if colonoscopy demonstrates ischemia, Ram M. Subramanian
discontinuation of the procedure and immediate surgical consultation
are advised.
Surgical management of ACPO is reserved for bowel ischemia or KEY POINTS
perforation. Historical use of surgical management of ACPO resulted • Aggressive intravenous resuscitation with fluids and blood, and
in mortality rates double that of medical or endoscopic management airway protection are crucial in the management of the acutely
(10%-14% vs 30%-35%). 113,115 Thus, surgery is only used for patients bleeding patient.
who fail endoscopic and pharmacologic efforts, and for those in whom
another indication for surgery exists. • Endoscopy should be performed with therapeutic intent for both
upper and lower gastrointestinal bleeding.
Finally, although percutaneous cecostomy—placed either radiologically
or endoscopically—has been reported for the treatment of refractory • Pharmacologic therapy should be used as an adjunct to endoscopic
cases, experience with this technique is limited. Less than 25 cases have therapy.
been reported for the treatment of colonic pseudoobstruction, and many • An early team approach, involving medical, radiologic, and surgical
of these were patients with chronic bowel conditions. 131-137 Reported com- personnel, should be implemented.
plications of this procedure include fecal peritonitis and death, and as • In the setting of severe bleeding or bleeding refractory to endo-
131
such, this procedure is not currently recommended for ACPO. scopic therapy, angiographic and surgical therapies should be
instituted promptly.
KEY REFERENCES
• Bauer AJ, Schwarz NT, Moore BA, Turler A, Kalff JC. Ileus in criti- Gastrointestinal (GI) hemorrhage continues to be a frequent indication
cal illness: mechanisms and management. Curr Opin Crit Care. for intensive care management, with estimated rates of acute hospitaliza-
2002;8(2):152-157. tions of 375,000 annually in the United States. Upper GI (UGI) bleeding
1
• Debast SB, Bauer MP, Kuijper EJ. European Society of Clinical has continued to predominate, with lower GI (LGI) bleeding constitut-
2
Microbiology and Infectious Diseases: update of the treatment ing approximately 25% of all GI bleeding. Despite improved diagnostic
guidance document for Clostridium difficile infection. Clin and therapeutic modalities in the last two decades, the mortality rates
Microbiol Infect. 2014;20(suppl 2):1-26. for upper and lower GI hemorrhage have demonstrated different trends.
Mortality from UGI bleeding has remained stable at 10%, which could
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