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Home , Enema

10/30/2019

Objectives

Let’s Talk About • Identify patients with a neurogenic bowel

Poop- The • Discuss prevention in the Neurogenic infant/toddler Bowel • Review various strategies to Kristina M. Booth, MSN, FNP Cheryl Baxter, MSN, CPNP help patients prevent constipation and achieve Nationwide Children’s Hospital Center for Colorectal and Pelvic Reconstruction continence

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Poop at a Urology Neurogenic Bowel Conference? Spina bifida • is devastating problem Spinal cord injury • Under estimated Caudal regression syndrome • Long term impact on quality of life (emotional, Spine tumors physical and psychological distress) Other patients to consider: Who is going to help? Anorectal malformation Tethered cord

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Oral Medications Toilet Training Age

• Lubricants () • Stool Softeners () Goal is to prevent constipation/fecal • Osmotic impaction AND achieve continence. – Miralax (Maintenance dose- 0.4 gm/kg daily) – (Daily dose- 2.5-10 mLs) • Stimulant laxatives Usually achieved by doing a daily – Senna (2 mg/kg daily) mechanical bowel regimen. – • Fiber (fiber rich foods vs daily fiber supplement)

Initial Imaging Bowel Management Program

A way to control the colon and thereby keep the patient clean

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Bowel Management Options Cone Enema

• Rectal enemas – Cone enemas – Foley catheter enemas • Peristeen Anal Irrigation System • Antegrade options for enemas – Malone appendicostomy – Cecostomy tube • Sigmoid Resection (select patient population) The cone acts like a plug. This is very helpful to patients who have a weak sphincter muscle, or have little control over their sphincter muscle, such as patients with neurogenic bowel.

Foley Enema Foley Enema

• 24 F Foley catheter • 5 ml balloon can be inflated up to 30 mls of water or air • 30 mls balloon up to 90 mls • Pull tension on catheter during administration to prevent leaking • Hold enema for 10 minutes • Goal is a total sit time of 30-45 minutes or less • Scheduled teaching session with nursing staff

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Enema Constituents: Enema Regimen

• TRIAL AND ERROR Base • Give the flush at the same time everyday • Solution (20mL/kg/dose) • Our goal is no accidents in between the enemas • Water • If accidents happen, it can be due to the flush being too strong OR not strong enough to empty the colon. Irritants • The only way to know which it is with an X-ray and patient • Glycerin (10– 30ml) report • Castile soap (9 – 36ml) • Baby (10-30ml) • Bisacodyl enema solution 10 mg/30 ml The X-ray will help determine if patient needs a • Phosphate (Fleet)- concern for with long term use. Also concern for stronger/larger volume flush or weaker/smaller volume flush hyperphosphatemia and hypocalcemia.

Follow up Imaging Tips and Tricks Abdominal X-ray- provides information • Complaints of cramping  slow down infusion, warm regarding stool burden solution, consider using baby soap as irritant. • Complaints of /vomiting  slow down infusion, warm solution, consider changing irritant and volume of enema, change timing of flush (allow 2 hours before/after meals). • Complaints of gas  consider changing irritant. • X-ray  directly after flush.

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Peristeen Anal Irrigation Antegrade Enema Options System

• Allows for independence • More complete evacuation of colon- can often due irrigation every other day

Questions

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