What is the optimal management of constipation in a patient with a history of hemorrhagic stroke?

From the Guidelines

To manage constipation in a patient with a history of hemorrhagic stroke, a bowel management program should be implemented, focusing on adequate hydration, a high-fiber diet, and regular toileting schedule, with the use of stool softeners and laxatives as needed, as recommended by the guidelines for adult stroke rehabilitation care 1. The goal of managing constipation in these patients is to prevent complications such as increased intracranial pressure and to improve quality of life. Key components of the bowel management program include:

• Adequate hydration, with a goal of at least 1.5-2 liters of fluid daily
• A high-fiber diet, aiming for 25-30 grams of fiber daily
• Early mobilization, as the patient's condition allows
• A regular toileting schedule, ideally consistent with the patient's previous bowel habits
• The use of stool softeners, such as docusate sodium (Colace) 100 mg twice daily, and laxatives, such as polyethylene glycol (MiraLAX) 17 grams in 8 ounces of water once daily, as needed 1. It is essential to monitor bowel movements regularly, aiming for at least one bowel movement every 2-3 days, and to avoid straining during bowel movements, which can increase intracranial pressure and worsen the patient's neurological status. The management of constipation in patients with a history of hemorrhagic stroke requires a proactive and individualized approach, taking into account the patient's specific needs and medical history, as emphasized in the guidelines for adult stroke rehabilitation care 1.

From the Research

Optimal Management of Constipation in Hemorrhagic Stroke Patients

The optimal management of constipation in patients with a history of hemorrhagic stroke is crucial to improve their quality of life.

• Constipation is a common complication in stroke patients, with a higher incidence in those who have had a hemorrhagic stroke (66%) compared to ischemic stroke (51%) 2.
• The management of constipation in these patients should be tailored to their individual needs, taking into account their medical history, current medications, and overall health status.
• There is no specific guideline for the management of constipation in hemorrhagic stroke patients, but general principles of constipation management can be applied, such as increasing fluid intake, dietary fiber, and physical activity.
• Medications that can exacerbate constipation, such as anticholinergics and opioids, should be avoided or used with caution 2.

Blood Pressure Management

Blood pressure management is critical in patients with hemorrhagic stroke, as high blood pressure can increase the risk of hematoma expansion and worsen outcomes.

• The optimal blood pressure target in acute hemorrhagic stroke is still debated, but recent studies suggest that aggressive blood pressure reduction may not be beneficial in all cases 3.
• The management of blood pressure in patients with hemorrhagic stroke should be individualized, taking into account their underlying medical conditions, such as hypertension, and their overall clinical status.

Timing of Medications

The timing of starting certain medications, such as direct oral anticoagulants (DOACs), is important in patients with hemorrhagic stroke.

• The start of DOACs may be delayed in patients with parenchymal hematoma (PH) compared to those with hemorrhagic infarction (HI) or no hemorrhagic transformation (HT) 4.
• The timing of starting DOACs should be individualized, taking into account the patient's clinical status, the type of HT, and the risk of recurrent ischemic stroke or new intracranial hemorrhage.