What is the best way to manage constipation pre-operatively in a patient?

From the Guidelines

The best way to manage constipation pre-operatively is through a multi-faceted approach that includes both lifestyle modifications and medications, starting with osmotic laxatives like polyethylene glycol (MiraLAX) 17 grams mixed in 8 ounces of water daily, as recommended by the most recent and highest quality study 1. To manage constipation pre-operatively, the following steps can be taken:

• Increase fluid intake to 2-3 liters per day and add fiber-rich foods to the diet, as suggested by 1 and 1.
• For medication management, begin with osmotic laxatives like polyethylene glycol (MiraLAX) 17 grams mixed in 8 ounces of water daily, which draws water into the intestines to soften stool, as recommended by 1.
• If needed, add a stimulant laxative such as bisacodyl (Dulcolax) 5-10 mg orally or senna 8.6-17.2 mg at bedtime to increase intestinal motility, as suggested by 1 and 1.
• For more severe cases, consider a combination approach with both osmotic and stimulant laxatives, or add docusate sodium 100 mg twice daily as a stool softener, as recommended by 1.
• Begin this regimen at least 2-3 days before surgery, as constipation can worsen post-operatively due to anesthesia, pain medications, and reduced mobility, as noted by 1 and 1. Some key points to consider when managing constipation pre-operatively include:
• Ensuring privacy and comfort to allow a patient to defaecate normally, as suggested by 1.
• Positioning (to assist gravity, a small footstool may help patient exert pressure more easily), as recommended by 1.
• Increased activity and increased mobility within patient limits (even bed to chair), as suggested by 1.
• Anticipatory management of constipation when opioids are prescribed, as recommended by 1. It's particularly important for abdominal and pelvic surgeries where bowel function directly impacts surgical outcomes, as noted by 1 and 1.

From the FDA Drug Label

USE • relieves occasional constipation (irregularity) • generally produces a bowel movement in 1 to 3 days The best way to manage constipation pre-operatively in a patient is to use polyethylene glycol (PO), as it relieves occasional constipation and generally produces a bowel movement in 1 to 3 days 2.

• This option is suitable for pre-operative management of constipation due to its effectiveness in producing a bowel movement within a few days.
• It is essential to follow the recommended usage to achieve the desired outcome.

From the Research

Preoperative Bowel Preparation Methods

The best way to manage constipation pre-operatively in a patient can vary depending on the type of surgery and individual patient needs. Here are some methods that have been studied:

• Mechanical bowel preparation using oral polyethylene glycol solution or oral sodium phosphate solution with or without bisacodyl 3
• Oral antibiotic bowel preparation using oral neomycin and erythromycin or metronidazole 3
• Combined mechanical and oral antibiotic bowel preparation, which has been shown to reduce the incidence of surgical site infections and anastomotic leakage in elective colorectal surgery 4
• Low-volume bowel preparation using polyethylene glycol-based formulations, which has been shown to be effective and well-tolerated for colonoscopy 5

Comparison of Bowel Preparation Methods

Studies have compared different bowel preparation methods, including:

• A randomized controlled trial that compared two different bowel preparation methods (Method 1: oral magnesium citrate, glycerin enema, and bisacodyl suppository; Method 2: oral magnesium citrate, oral picosulfate, and bisacodyl suppository) and found that Method 2 was associated with reduced patient discomfort and easier nursing care 6
• A randomized clinical trial that compared preoperative bowel preparation with no preparation before spinal surgery and found no benefit from bowel preparation in terms of gastrointestinal function 7

Considerations for Preoperative Bowel Preparation

When considering preoperative bowel preparation, it is essential to take into account the type of surgery, individual patient needs, and potential side effects of the preparation method. For example:

• Patient selection is critical when using outpatient bowel preparation, and education is needed to reduce the rate of complications 3
• The use of combined mechanical and oral antibiotic bowel preparation may be associated with a lower incidence of postoperative complications, but the evidence is not yet conclusive 4