From the Guidelines
Paralytic ileus treatment primarily involves a multifaceted approach to minimize its occurrence and supportive care while the bowel function recovers, as recommended by the most recent guidelines 1. The initial management includes bowel rest with nothing by mouth (NPO), intravenous fluid administration to maintain hydration and electrolyte balance, and consideration of nasogastric tube placement to decompress the stomach and prevent vomiting, with daily revaluation of the need for NGI and removal as early as possible 1. Pain management with opioid-sparing medications is important, as opioids can worsen ileus. Ambulation and early mobilization should be encouraged as movement stimulates bowel function, with patients being assisted to mobilize as soon as possible after surgery 1. A multifaceted approach to minimizing postoperative ileus, including minimally invasive surgery, optimized fluid management, opioid-sparing analgesia, early mobilization, early postoperative food intake, laxative administration, and omission/early removal of nasogastric intubation should be used 1. Prokinetic medications like metoclopramide or erythromycin may be used to stimulate gut motility, and Alvimopan can be considered for postoperative ileus. Electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, should be corrected as they can worsen gut dysmotility. Underlying causes such as infections or medications should be identified and addressed. Nutrition support with parenteral nutrition may be needed if ileus persists beyond 5-7 days, with early tube feeding initiated in patients in whom early oral nutrition cannot be started, and in whom oral intake will be inadequate for more than 7 days 1. Some key points to consider in the management of paralytic ileus include:
- Early mobilization and ambulation
- Opioid-sparing pain management
- Minimally invasive surgery when possible
- Optimized fluid management
- Early removal of nasogastric tubes
- Use of laxatives to stimulate bowel function
- Correction of electrolyte abnormalities
- Identification and treatment of underlying causes
- Consideration of parenteral nutrition if ileus persists. The most recent and highest quality study 1 provides the best guidance for the management of paralytic ileus, and its recommendations should be followed to optimize patient outcomes.
From the FDA Drug Label
INDICATIONS & USAGE Diabetic Gastroparesis (Diabetic Gastric Stasis) Metoclopramide Injection (metoclopramide hydrochloride, USP) is indicated for the relief of symptoms associated with acute and recurrent diabetic gastric stasis The FDA drug label does not answer the question.
From the Research
Treatment for Paralytic Ileus
- The treatment for paralytic ileus depends on the underlying cause and may involve supportive care and addressing the underlying condition 2.
- Early enteral nutrition (EEN) has been shown to facilitate the return of normal bowel function, achieve enteral nutrition goals, and reduce hospital length of stay in patients with postoperative ileus 3.
- Promotility agents such as metoclopramide and erythromycin have been proposed as treatments for ileus, but their effectiveness is uncertain 3, 4.
- Neostigmine is commonly used to treat paralytic ileus 4.
- Parenteral nutrition may be necessary in patients with intestinal failure who are unable to tolerate enteral feedings 5.
- Metoclopramide has been shown to improve the success rate of blind bedside post-pyloric placement of feeding tubes in critically ill children 6.
Medical Interventions
- EEN is strongly recommended to expedite the resolution of ileus in patients who have undergone abdominal surgery 3.
- The use of metoclopramide and erythromycin to hasten the resolution of ileus is not recommended due to low levels of evidence 3.
- Neostigmine may be considered as a treatment option for paralytic ileus 4.