From the Guidelines
Yes, patients can develop paralytic ileus after spinal anesthesia, though it is not a common complication. Paralytic ileus is a temporary impairment of bowel motility that can occur following various surgical procedures and anesthetic techniques. After spinal anesthesia, the sympathetic nervous system blockade affects gastrointestinal function by creating an imbalance between sympathetic and parasympathetic innervation of the bowel. This autonomic imbalance can lead to decreased peristalsis and bowel motility.
Risk Factors and Management
Risk factors that increase the likelihood of developing paralytic ileus after spinal anesthesia include:
- The use of opioids for postoperative pain management
- Prolonged surgery
- Manipulation of abdominal contents during surgery
- Pre-existing conditions like diabetes or electrolyte imbalances Management typically involves:
- Bowel rest
- Intravenous fluids
- Correction of electrolyte abnormalities
- Early ambulation
- Possibly prokinetic medications in more severe cases Most cases resolve within 2-4 days with conservative management.
Preventive Measures
Preventive measures include:
- Minimizing opioid use
- Early mobilization
- Considering multimodal pain management strategies that reduce the need for medications that slow bowel function, as recommended by the ERAS society 1 A multifaceted approach to minimizing postoperative ileus, including minimally invasive surgery, optimized fluid management, opioid-sparing analgesia, early mobilization, early postoperative food intake, laxative administration, and omission/early removal of nasogastric intubation, should be used 1. The use of epidural analgesia has been associated with a lower incidence of paralytic ileus, attenuation of the surgical stress response, improved intestinal blood flow, improved analgesia, and reduction of opioid use 1. Perioperative use of chewing gum has a positive effect on postoperative duration of ileus, and oral magnesium oxide was demonstrated to promote postoperative bowel function in a double-blinded RCT in abdominal hysterectomy and in reports from a well-established enhanced-recovery program in colonic resection 1. Alvimopan (a m-opioid receptor antagonist approved for clinical use in postoperative ileus) given via the oral route accelerates gastrointestinal recovery and reduces the length of stay in patients undergoing open colonic resection having postoperative opioid analgesia 1. Bisacodyl (10 mg, p.o.) administered twice a day from the day before surgery to the third postoperative day improved postoperative intestinal function in a RCT with 189 patients undergoing colorectal surgery 1. Laparoscopic-assisted colonic resection leads to faster return of bowel function, as well as resumption of an oral diet, compared with open surgery, and avoidance of nasogastric decompression may reduce the duration of postoperative ileus 1. Mid-thoracic epidural analgesia as compared with intravenous opioid analgesia is highly effective at preventing postoperative ileus, and fluid overloading during and after surgery impairs gastrointestinal function and should be avoided 1. Patient-controlled analgesia (PCA) either intravenous or epidural provides superior postoperative pain control and patient satisfaction, even if it increased amount of opioid consumption 1. Thoracic epidural analgesia (TEA) use has been associated with a lower incidence of paralytic ileus, attenuation of the surgical stress response, improved intestinal blood flow, improved analgesia, and reduction of opioid use 1.
From the Research
Paralytic Ileus after Spinal Anesthesia
- Paralytic ileus is a condition where the motor activity of the bowel is impaired, usually not associated with a mechanical cause 2.
- It can occur after spinal surgery, with a higher risk in patients with preexisting neurogenic bowel dysfunction 3.
- The condition is marked by the cessation of bowel motility, and can lead to severe patient morbidity, including abdominal pain, malnutrition, and prolonged hospital stay 4.
Risk Factors and Prevention
- Spinal surgery in the prone position may increase the likelihood of radiographic paralytic ileus occurrence 5.
- Prophylactic gastrointestinal motility medications, such as scopolamine butylbromide and metoclopramide hydrochloride, may not be effective in preventing symptomatic paralytic ileus after spinal surgery 5.
- Alvimopan, a µ-opioid receptor antagonist, may be useful for preventing ileus in high-risk orthopedic and spine surgery patients, although prospective studies are needed to test this hypothesis 6.
Management and Treatment
- Management of paralytic ileus depends on the knowledge of the most likely cause and the perceived chance of resolution without operation 2.
- Early diagnosis and correct management are essential in reducing complications, and may include minimization of opioids, early patient mobilization, pharmacologic intervention, and multidisciplinary care 4.
- Adjunctive homeopathic therapy may be a promising treatment option in patients with complex bowel dysfunction after abdominal surgery who do not adequately respond to conventional treatment 3.