Constipation in critically ill adults

Table 5 Suggested approach to management of constipation in the intensive care unit

Phase/criteria	Management
On admission (< 24 hours)	Patient history: Frequency of bowel movements, stool consistency, timing of last stool, baseline laxative use, history of bowel disorders
	Identify risk factors: Opiate use, immobility, neurological impairment, surgery, etc. Minimize risk factors where possible
	Preventive strategies	Correct fluid and electrolyte imbalances (potassium, calcium, magnesium)
		Ensure adequate hydration
		Initiate early enteral nutrition
	Consider initiating daily prophylactic laxatives in high-risk patients
> 24 hours since last defecation	Review and minimize constipating agents (e.g. opioids, anticholinergics)
	Perform abdominal and rectal examination
	Start first-line laxative therapy (e.g. lactulose, PEG, senna, bisacodyl); increase dose if already on therapy
	Reassess and adjust therapy daily
> 48 hours since last defecation (escalation phase)	Repeat rectal exam to assess impaction
	Consider	Abdominal X-ray to evaluate for ileus or obstruction
		Combination/adjunctive therapy
		Rectal interventions (e.g. enemas)
Refractory constipation	Consider advanced investigations and interventions	Abdominal CT to rule out mechanical obstruction
		Neostigmine (especially in suspected acute colonic pseudo-obstruction)
		Manual rectal dis-impaction if indicated
		Surgical decompression as last resort
Discontinuation criteria	Presence of diarrhea or resolution of symptoms
Contraindications to bowel management protocol	Renal disease
	Major abdominal surgery/bowel obstruction
	Neutropenia (or bone marrow transplant)
	Nausea and vomiting, undiagnosed abdominal pain
	Thrombocytopenia

CT: Computed tomography; PEG: Poly-ethylene glycol; ICU: Intensive care unit.