Postoperative Ileus
Patient Presentation:
S.M. is a healthy 14 year old girl who underwent a Posterior Spinal Fusion (PSF) 4 days ago. Her only past medical history is Adolescent Idiopathic Scoliosis which she developed as she underwent her pubescent growth spurt. She was fused at the levels of T2-L3 to gain maximal correction of her 63 degree curve. Now on POD 4, the RN notes that her bowel sounds remain hypoactive, the patient denies passing flatus and her abdomen is distended, tympanic to percussion and the patient reports abdominal discomfort. She denies cramping or pain in any specific region; she states “I feel like I swallowed a balloon”. The patient was NPO until POD 1 since when she has barely tolerated sips of clear liquids/bites of Jell-O and has needed Zofran® every 8 hours to control nausea/vomiting. The patient has been receiving peripheral IVF D5+0.45NS+20meq KCl at 100ml/hr to supplement hydration and her urine output is adequate. In addition, S.M. has had poor pain control and had been receiving IV Hydromorphone (Dilaudid®) via PCA until POD 3 when she was noted to be consistently drowsy, overmedicated and then she was transitioned to oral Oxycodone-APAP (Percocet®) 5/325mg 2 tablets every 4-5 hours. Vital signs remain stable. Of note, she has been unable to progress with Physical Therapy secondary to her pain and/or level of sedation. She has taken just a couple steps forward and back twice a day and cannot tolerate sitting in a chair yet.
Differential Diagnosis:
Postoperative Ileus, Pancreatitis, Narcotic induced constipation, Abdominal Bleed, Mechanical obstruction, Anorexia
Labs/Tests:
The MD evaluated S.M. and ordered a CBC and Basic Metabolic Panel. The remarkable labs include: Na+ 129 (hyponatremia secondary to decreased oral intake and continuous IVF), K+ 3.6, Hgb 8.3 (typical anemia seen secondary to large blood loss during surgery). MD also ordered an abdominal X-ray to evaluate presence of air in the colon, cecum, large and small bowel. The X-ray results showed elevated diaphragm (likely secondary to trapped air) and small intestine dilatation with moderate amounts of air.
Treatment:
The treatment in this case is typically supportive treatment, increased ambulation and avoiding offenders of slow gastric motility. Therefore the MD added standing IV famotidine (Pepcid®), daily bisacodyl (Dulcolax®) Suppositories, and changed the Percocet® order to standing Extra Strength Tylenol® with PRN 5 or 10 mg oxycodone every 6 hours (Surgeon prohibits use of NSAIDS as adjunct pain management in these patients due to its effects on coagulability). IVF changed to D5+0.9NS+20meqKCl to correct hyponatremia as electrolyte imbalances (Na, K, Mg) can contribute to ileus, as well. Though Metoclopramide (Reglan®) is preferred and NG Tubes are sometimes placed in adults, we avoid this for the pediatric population. Teaching was done with the patient and family re: side effects of narcotics on ileus, non-pharmacologic pain management, and benefit of increase ambulation. Some believe chewing gum helps facilitate motility, as well.
Outcome:
Prognosis is good with our PSF patients once ileus is noted. The above treatment plan helped S.M. to finally pass flatus on POD 5 and she experienced almost immediate relief of symptoms. Once the patient increased ambulation, her appetite quickly increased and her pain subsided substantially. She was eventually discharged on POD 8.
Case created by Sarah Metz, 2011.