How do comatose patients evacuate their bowels?

From the Guidelines

Comatose patients evacuate their bowels through involuntary defecation or with medical assistance, typically involving a bowel management program that includes digital stimulation, manual disimpaction, stool softeners, and stimulant laxatives. The goal of this program is to prevent constipation and maintain regularity, as comatose patients cannot control their bowel movements due to compromised neurological control of defecation 1.

Bowel Management Program

The program usually involves:

• Digital stimulation, where a gloved finger is inserted into the rectum to stimulate the defecation reflex
• Manual disimpaction if necessary
• Stool softeners like docusate sodium (100-200 mg daily) to prevent constipation
• Stimulant laxatives such as bisacodyl (5-10 mg) to promote intestinal motility
• Scheduled bowel program, often every 2-3 days, to maintain regularity
• Enemas may be used when other methods fail, with options including normal saline, soap solution, osmotic micro-enema, hypertonic sodium phosphate, and docusate sodium enemas 1

Nutritional Management

Adequate fiber and hydration are essential to maintain stool consistency, and healthcare providers monitor for complications like impaction or diarrhea 1. The autonomic nervous system continues to move waste through the digestive tract, but the lack of conscious awareness and voluntary muscle control necessitates medical assistance for bowel evacuation.

Considerations

It is crucial to consider the potential risks and benefits of each intervention, including the risk of water intoxication with large volume watery enemas, chemical irritation with soap solution enemas, and abdominal discomfort with bisacodyl enemas 1. Additionally, the use of laxatives and enemas should be cautious in patients with renal impairment or other underlying medical conditions.

From the Research

Bowel Evacuation in Comatose Patients

• Comatose patients often experience alterations in bowel habits, and bowel protocols are used to manage constipation in critically ill patients 2.
• These protocols typically involve the use of laxatives, such as senna and bisacodyl, and may include procedures like enemas and suppositories 2.
• In cases of fecal impaction, treatment options include manual disimpaction, softening or washout procedures, and oral or nasogastric tube placement for polyethylene glycol solutions 3, 4.
• For comatose patients, management of constipation is part of ongoing supportive care, which involves preventing medical complications associated with mechanical ventilation and prolonged immobility 5.

Treatment Options

• Oral GoLytely solution has been used to relieve refractory fecal impaction in patients who have not responded to conventional medical treatment 4.
• Other treatment options for constipation include lifestyle modifications, such as scheduled toileting and increased fluid and fiber intake, as well as the use of osmotic laxatives, stool softeners, and stimulant laxatives 6.
• In some cases, surgical intervention may be necessary to treat fecal impaction or other bowel complications 3.

Care of Comatose Patients

• Management of the comatose patient typically takes place in an intensive care unit, with neurointensivists often involved in care 5.
• Ongoing supportive care for comatose patients includes aggressive prevention of medical complications, as well as waiting for recovery and potentially providing neurorehabilitation 5.