What is the management of paralytic ileus?

Management of Paralytic Ileus

The management of paralytic ileus should focus on bowel rest, fluid resuscitation, electrolyte correction, and avoidance of opioids, with isotonic intravenous fluids being the primary treatment until bowel function returns. 1, 2

Initial Management

• Bowel Rest

  • Avoid oral intake to rest the bowel
  • Consider nasogastric decompression for significant distention 2

• Fluid and Electrolyte Management

  • Administer isotonic IV fluids (lactated Ringer's or normal saline) based on degree of dehydration 1, 2
  • Continue IV hydration until pulse, perfusion, and mental status normalize 1
  • Maintain near-zero fluid balance to avoid fluid overload which can worsen ileus 2
  • Correct electrolyte imbalances, particularly potassium, calcium, and magnesium 2

• Pain Management (Opioid-Sparing Approach)

  • Thoracic epidural analgesia is optimal for pain control in ileus 2
  • Use acetaminophen/paracetamol (1g IV every 6 hours) as an adjunct 2
  • Add NSAIDs if not contraindicated 2
  • Minimize opioid use as they worsen ileus 2, 3

Pharmacologic Interventions

• Prokinetic Agents

  • Consider metoclopramide (10-20 mg PO QID) to stimulate upper GI motility 1, 2
  • Note: Evidence for metoclopramide in ileus is limited 4

• For Opioid-Induced Constipation

  • Methylnaltrexone 0.15 mg/kg subcutaneously every other day (except in post-op ileus and mechanical bowel obstruction) 1, 2
  • Alvimopan (peripherally acting μ-opioid receptor antagonist) if opioids must be used 2

• Other Medications

  • Laxatives may be necessary if other measures fail 2
  • Consider bisacodyl 10-15 mg daily-TID with goal of one non-forced bowel movement every 1-2 days 1

Non-Pharmacologic Interventions

• Early Mobilization

  • Encourage patient mobility as soon as possible to stimulate bowel function 2

• Nutrition Considerations

  • Once bowel function begins to return, start clear liquids and advance diet as tolerated 2
  • If prolonged ileus is expected, consider enteral nutrition via nasogastric or nasoenteric tube 2
  • When oral intake resumes, encourage small, frequent meals (4-6/day) rather than large meals 2
  • Ensure adequate fluid intake (at least 1.5 L daily) 2
  • Gradually increase fiber intake through fruits, vegetables, and whole grains 2

• Complementary Therapies

  • Chewing gum may have positive effects on ileus duration 2

Monitoring

• Clinical Assessment
  • Vital signs every 4 hours 2
  • Daily abdominal examinations to assess for:
    • Return of bowel sounds
    • Reduction in abdominal distention
    • Passage of flatus or stool 2
  • Monitor for signs of peritonitis which may indicate perforation or ischemia 2
  • Check lactate levels if bowel ischemia is suspected 2
  • Monitor for intra-abdominal hypertension 2

When to Consider Surgical Intervention

Surgical intervention is rarely needed for functional ileus but may be necessary if:

• Evidence of mechanical obstruction
• Perforation is suspected
• Patient shows signs of peritonitis
• Clinical deterioration despite medical management 2

Special Considerations

• Post-operative Setting
  • Laparoscopic procedures lead to faster return of bowel function compared to open surgery 2
  • Ensure proper epidural placement and regular assessment of sensory block if using epidural analgesia 2
  • IV lidocaine infusion may be considered as it has shown some benefit in shortening the duration of post-operative ileus 5

By following this algorithmic approach to managing paralytic ileus, clinicians can optimize patient outcomes while minimizing complications and length of hospital stay.