What is the management approach for a patient with ileus?

From the Guidelines

The management of ileus should prioritize a multifaceted approach including minimally invasive surgery, optimized fluid management, opioid-sparing analgesia, early mobilization, early postoperative food intake, laxative administration, and omission or early removal of nasogastric intubation, as recommended by the most recent guidelines 1.

Key Components of Ileus Management

• Optimized fluid management to prevent fluid overload and ensure adequate resuscitation, aiming for a weight gain limited to < 3 kg at postoperative day three 1
• Opioid-sparing analgesia to minimize the risk of worsening ileus, with consideration of alternative pain management strategies such as epidural or regional anesthesia 1
• Early mobilization to promote intestinal function and reduce the risk of complications, with patients assisted to mobilize as soon as possible after surgery 1
• Early postoperative food intake, with small portions offered initially, especially after right-sided resections and small-bowel anastomosis, to maintain intestinal function and promote recovery 1

Monitoring and Reintroduction of Oral Intake

• Careful monitoring of abdominal examinations, vital signs, and electrolyte levels to assess the resolution of ileus and guide the reintroduction of oral intake
• Oral intake should be reintroduced gradually once bowel function returns, evidenced by passage of flatus or stool, reduced abdominal distension, and active bowel sounds

Considerations for Specific Patient Populations

• In patients with dynamical ileus due to intestinal overdistension, cautious usage of opiates is recommended to avoid exacerbating the ileus 1
• In elderly patients, alternative analgesia strategies may be considered to minimize adverse effects such as numbness, motor weakness, hypotension, and nausea/vomiting 1

From the Research

Management Approach for Ileus

The management approach for a patient with ileus involves addressing the underlying cause and providing supportive care.

• The main mechanisms of postoperative ileus pathophysiology include fluid overload, exogenous opioids, neurohormonal dysfunction, gastrointestinal stretch, and inflammation 2.
• Multiple medical interventions have been proposed, but their effectiveness is uncertain.

Medical Interventions

Some medical interventions that have been studied for the management of ileus include:

• Metoclopramide and erythromycin, which were found to be ineffective in expediting the resolution of ileus 2.
• Early enteral nutrition (EEN), which has been shown to facilitate the return of normal bowel function, achieve enteral nutrition goals, and reduce hospital length of stay 2.
• Subcutaneous neostigmine, which may be a reasonable option for the management of ileus, but its use should be avoided in patients with certain conditions, such as new-onset heart block or a history of second-degree heart block 3.
• Cholinesterase inhibitors, which may be safe and effective in treating constipation, but are poorly prescribed 4.

Prevention and Treatment

Prevention and treatment strategies for ileus may include:

• Bowel management protocols using osmotic laxatives, which appear to be safe but have not demonstrated effectiveness 4.
• Enteral opioid antagonists, which may be a promising strategy for patients treated with high doses of opioids during sedation 4.
• Avoiding certain medications, such as opioids, and minimizing their use when possible.

Patient Care

Patient care for ileus involves:

• Monitoring for signs of ileus, such as abdominal distension, nausea, and vomiting.
• Providing supportive care, such as fluid and electrolyte management, and pain control.
• Encouraging early mobilization and ambulation to help stimulate bowel function.
• Considering the use of medical interventions, such as EEN or subcutaneous neostigmine, as needed.