Cardiff Critical Care Standard Operating Procedures
Bowel Management in ICU
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Author(s): Amelia Jukes
Internal reviewer: Craig Spencer
External reviewer: None
Version: 1.0 Issue Date: 07/05/2019 Review Date: May 2022
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Introduction:
Critical Care patients receiving enteral tube feeding should be commenced on the
appropriate bowel protocol, unless contra-indicated. The protocols include:
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General protocol that is suitable for the majority of patients
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A spinal injury protocol
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A hepatic encephalopathy protocol.
Contra-indication to bowel protocol:
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Patients with bowel obstruction
Relative contra-indications to bowel protocol:
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Patients post bowel surgery, or who have a stoma
Feed type:
Patients should be commenced on alternating Osmolite HP/Jevity Promote unless
contra-indicated e.g. bowel surgery or malabsorption (consult Dietitian).
General bowel protocol:
1. Start Senna, 15 ml bd within 24 hr of starting and tolerating enteral feeding.
2. If BNO by day 3 (i.e. 6 doses of senna), a PR examination should be undertaken:
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If empty – add lactulose 15 ml bd until bowels open then stop lactulose
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If full/soft – prescribe 2 x 2g glycerine suppositories
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If impacted – prescribe arachis oil enema
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Repeat suppository or enema after 24hr if required
3. If BNO by day 5 undertake a further PR examination and refer to above for action
Once bowels open:
Stop lactulose and review prescription of Senna.
Aim for bowels open daily/alternate day, by adjusting the dose e.g.
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If diarrhoea, stop Senna
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If frequent or loose, omit Senna for 24 hours
Spinal injury protocol (Rookwood protocol)
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Senna 15 ml bd and 2 Bisacodyl suppositories nocte
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Reduce Bisacodyl suppositories to alternate day when bowels open
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Cardiff Critical Care SOP 008! !
Cardiff Critical Care Standard Operating Procedures
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Adjust as required - aim for one bowel motion per day
Hepatic encephalopathy protocol
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30 ml Lactulose tds
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Aim for 2-3 bowel motions per day
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Adjust the dose and/or frequency daily to avoid diarrhea
Guidelines for the management of diarrhoea:
1. If clinically indicated send stool sample for C. Diff toxin. If diarrhoea is
present on admission to Critical Care send sample for MC&S also.
2. Review prescription chart:
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Ensure all laxatives have been withheld or stopped.
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Review the need for prokinetics (Metoclopramide and Erythromycin).
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Avoid giving Sando-K via the enteral feeding tube. Add potassium chloride to the
feed or give intravenously as appropriate.
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Avoid giving Phosphate-Sandoz via the enteral feeding tube. If very low give IV
phosphate polyfusor, if marginally low review serum trends and clinical status.
Refer to Critical Care guideline for testing and replacement of phosphate.
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Avoid enteral water as a continuous infusion – bolus 150-200 ml water every 4-6
hours e.g. between feed bottles or give intravenous fluids.
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Ensure fibre feed is given unless contra-indicated – if using Osmolite range,
alternate with Jevity equivalent.
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If pancreatic insufficiency is suspected use Perative and send stool sample for
faecal elastase to biochemistry.
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Consider loperamide 2 mg tds. If C. Diff is suspected wait for stool culture
before prescribing loperamide.
3. Consider drainable faecal collector (Hollister) to protect skin
If diarrhoea persists despite above measures, the drainable faecal collector will
not adhere to the patients’ skin, or skin is compromised consider faecal
management system (FMS).
Before using the FMS please discuss with the shift co-coordinator and refer to the
manufacturer’s guidelines for insertion, irrigation and removal.
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Document PR examination and procedure in medical notes
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Observe each shift for pain, necrosis, bleeding or abdominal distension
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Empty the collection bag and record the amount drained daily
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Maximum length of time in-situ - 28 days
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Cardiff Critical Care SOP 008! !
