What is the cornerstone of ileus management?

Cornerstone of Ileus Management

The cornerstone of ileus management is isotonic intravenous fluid administration to maintain euvolemia while avoiding fluid overload, combined with strict NPO status initially, correction of electrolyte abnormalities (particularly potassium and magnesium), and opioid-sparing analgesia. 1, 2

Initial Fluid and Electrolyte Management

• Administer isotonic IV fluids (lactated Ringer's or normal saline) to correct dehydration and maintain euvolemia, targeting weight gain of less than 3 kg by postoperative day three, as exceeding this threshold directly causes intestinal edema that prolongs ileus 2, 3

• Avoid fluid overloading—this is one of the most common and preventable causes of prolonged ileus, as excess fluid worsens intestinal edema and impairs gastrointestinal function 1, 2, 3

• Immediately correct potassium and magnesium deficiencies, as these electrolyte abnormalities directly impair intestinal motility 1, 2

• Continue IV rehydration until vital signs normalize, mental status returns to baseline, and ileus resolves 4, 1

NPO Status and Nutritional Considerations

• Maintain NPO status initially until bowel function begins to return 1

• Once bowel sounds return, encourage early oral intake with small portions, particularly after right-sided resections and small-bowel anastomoses 2, 3

• If oral intake will be inadequate for more than 7 days, initiate early tube feeding 3, 5

• Provide early parenteral nutrition if enteral feeding is contraindicated due to prolonged ileus 3

Pain Management Strategy

• Implement mid-thoracic epidural analgesia with local anesthetic as the single most effective intervention for preventing and treating ileus, as it avoids the gut-paralyzing effects of systemic opioids 2, 3

• Minimize systemic opioids through multimodal analgesia, as opioids directly inhibit gastrointestinal motility and are a primary modifiable cause of prolonged ileus 2, 3

• Substitute with regular paracetamol, NSAIDs (if not contraindicated), and tramadol as needed 5

Nasogastric Decompression

• Place a nasogastric tube for decompression only in patients with severe abdominal distention, vomiting, or risk of aspiration 1, 3

• Remove the nasogastric tube as early as possible, as prolonged nasogastric decompression paradoxically extends ileus duration rather than shortening it 2, 3

• Do not routinely use nasogastric tubes, as they may prolong rather than shorten ileus 3

Early Mobilization

• Begin ambulation immediately once the patient's condition allows, as early mobilization stimulates bowel function and prevents complications of prolonged bed rest 1, 2, 3

• Early removal of urinary catheters facilitates mobilization 1, 3

Pharmacological Interventions

• Administer bisacodyl 10-15 mg orally daily to three times daily once oral intake resumes 2, 3

• Consider oral magnesium oxide to promote bowel function 1, 2, 3

• For persistent ileus, consider metoclopramide 10-20 mg orally four times daily as a prokinetic agent 2, 3

• Chewing gum can help stimulate bowel function through cephalic-vagal stimulation 1, 3

Critical Pitfalls to Avoid

• Do NOT continue aggressive IV fluid administration beyond what is needed for euvolemia, as fluid overload is a major preventable cause of prolonged ileus 2, 3

• Do NOT continue high-dose opioids without considering opioid-sparing alternatives 2, 3

• Do NOT maintain prolonged nasogastric decompression unless there is severe distention, vomiting, or aspiration risk 2, 3

• Do NOT delay mobilization or oral intake based solely on absence of bowel sounds 3

Monitoring for Resolution

• Monitor for signs of bowel function return, including passage of flatus and return of bowel sounds 1, 2

• Resume oral intake gradually once bowel function returns, starting with clear liquids and advancing as tolerated 1