TO HEAR THE PODCAST, CLICK THE PLAYER BELOW
Direct Download Podcast
Scenario 1
Patient is on narcotics and you want to prevent constipation
Choice 1. Polyethylene glycol (PEG) 17g/1 glass per day. Up to 3 doses daily if needed
Choice 2. PEG + fecal inotrope/stimulant. Senna first choice
Choice 3. Docusate + Senna
Docusate alone is probably not sufficient to prevent constipation in a patient on narcotics. The problem with narcotics is that they slow gut motility. Docusate works by breaking down fats, making stool soft/slick and also works as a weak osmotic laxative. This creates a soft stool that is still sitting in the colon. It’s like a fast car propped up on cinderblocks. If docusate is used in combination with a stimulant like senna, laxation improves significantly.
Warning: Bulking agents are often recommended as constipation prophylaxis for patients on narcotics. This may expand the diameter of the colonic lumen without moving anything though.
Scenario 2
Patient is on narcotics and is now constipated
Step 1. Manually disimpact if needed and place an enema in the ED.
Step 2. 2mg PO naloxone before ED discharge
Step 3. Disimpaction dose of PEG (1.5g/kg/day or easy dosing 4 glasses per day). Take for 6 days or until soft stool passes, whichever comes first
Step 4. Maintenance PEG. (0.3-0.8g/kg/day or easy dosing 1 glass per day). Take for 2 weeks and slowly taper
Scenario 3
Need a soft stool because of a sore anus (fissure, hemorrhoids, abscess, etc)
Choice 1. Bulking agent like methylcellulose or psyllium. Must drink at least 1.5 liters of water per day, or the stool will become a colon shaped piece of concrete.
Choice 2. Docusate
Scenario 4
Constipated kids older than 1
1. I will often place a saline enema while the patient is in the ED.
2. Another option in the ED, especially for younger kids who may not be able to hold in an enema, is a glycerin suppository. Glycerin softens stool and makes the passageway slick, but more importantly, acts as a stimulant and increases intestinal propulsion. See The Suppository Conundrum for details on how to place an suppository.
3. Outpatient treatment: PEG disimpaction dose (1.5g/kg/day) for 6 days or until soft stool passes, followed by a maintenance dose of 0.3-0.8g/kg/day for two weeks followed by a slow taper
4. Lactulose also a laxative option
5. Stress a diet with lots of fiber and water
6. Don’t hold it in Kids should defecate when the urge strikes. Waiting may make the urge pass with the result being a harder, drier, more impacted stool. Then, like an overdue baby, it won’t want to leave its happy home. Kids will keep playing rather than going to the bathroom, and some have angst with pooping so they hold it in. We need to talk to our patients/parents about this.
Disimpaction Action
Below is Whit Fisher’s famous Disimpaction Action video. One thing I do differently than Whit is that I don’t tape my wrists (you’ll know what this means after watching the video). I realize the risk of ‘debris’ getting up the sleeve, but there is often need to remove the outer glove during or after the procedure. Also, I don’t want to unwind tape around my wrists using a glove smeared with fecal matter, which is inevitable in this procedure. Enjoy.
The Constipation Manifesto Cast of Characters
Joe Lex – Free Emergency Medicine Talks
Andy Sloas – PEM ED podcast
zdoggMD -zdoggMD.com
Graham Walker- The NNT, MD Calc, Emergency Medicine News
Mike Phillips
Aaron Wohl
Hey -- was just listening to Larry Raney’s lecture on the effectiveness of non-opioid analgesics over at Joe Lex’s site and his last 2 minutes on Ketamine made me think of your podcast on constipation. How about pain dosed ketamine for narcotic bowel while you are taking them off dilaudid to get their bowels moving again? I’m sure there are no studies on this, but what do you think?
Thank you for the very interesting episode. I now believe I know much more on the subject than I actually do. When I read “The Constipation Manifesto,” I also pooped in my drawers from laughing so hard: you might want to try giving patients a copy of the episode before giving other forms of treatment.
The Constipation Manifesto. A suggested motto or two:
You have the god-given right to be constipated!
Forget communism: embrace constipation!
Naw. Now that I think of it, none of this is funny…..
Great episode RobO: one question.
If you use the “Bomb” (bottle of mag citrate) as your disimpaction agent, is it reasonable to follow on with:
Step 4. Maintenance PEG. (0.3-0.8g/kg/day or easy dosing 1 glass per day). Take for 2 weeks and slowly taper
Also, during the step 4 phase can you go to increased fiber via a bulking agent like metamucil or is it wise to wait a bit so you don’t plug them up again?
I rarely use mag citrate, but I think a gentle landing with a week or two of PEG is not a bad idea whenever disimpaction is needed.
As far as bulking agents, I’m not a big fan of them in the disimpaction phase. I generally use them if a soft fluffy stool is needed, such as with hemorrhoids, fissures, etc.
Hi Rob. I love your podcast and had a question about oral narcan. Do we just use IV narcan orally, or is there a special oral form?
I use 2mg of the IV formulation and put it in apple juice.