10/30/2019 Objectives Let’s Talk About • Identify patients with a neurogenic bowel Poop- The • Discuss constipation prevention in the Neurogenic infant/toddler Bowel • Review various bowel management 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 ………………..…………………………………………………………………………………………………………………………………….. Poop at a Urology Neurogenic Bowel Conference? Spina bifida • Fecal incontinence 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 1 10/30/2019 Oral Medications Toilet Training Age • Lubricants (Mineral oil) • Stool Softeners (Docusate) Goal is to prevent constipation/fecal • Osmotic laxatives impaction AND achieve continence. – Miralax (Maintenance dose- 0.4 gm/kg daily) – Lactulose (Daily dose- 2.5-10 mLs) • Stimulant laxatives Usually achieved by doing a daily – Senna (2 mg/kg daily) mechanical bowel regimen. – Bisacodyl • 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 2 10/30/2019 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 3 10/30/2019 Enema Constituents: Enema Regimen • TRIAL AND ERROR Base Solution • Give the flush at the same time everyday • Saline 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 Shampoo (10-30ml) • Bisacodyl enema solution 10 mg/30 ml The X-ray will help determine if patient needs a • Phosphate (Fleet)- concern for colitis 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 nausea/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. ………………..…………………………………………………………………………………………………………………………………….. 4 10/30/2019 Peristeen Anal Irrigation Antegrade Enema Options System • Allows for independence • More complete evacuation of colon- can often due irrigation every other day Questions 5.