CURRENT Essentials of Critical Care.pdf

162 Current Essentials of Critical CareAdynamic (Paralytic) Ileus■ Essentials of Diagnosis• Mild to moderate continuous abdominal pain, vomiting, obstipation• Massive abdominal distention with localized tenderness common;decreased or absent bowel sounds• Hemoconcentration; volume and electrolyte depletion with prolongedvomiting, sequestration into distended bowel loops• Leukocytosis and elevated amylase can be present• Radiographs demonstrate gas-filled loops of bowel and multipleair-fluid levels; air may be evident in rectum• Barium swallow with small bowel follow-through or contrastenema will differentiate ileus from mechanical obstruction• Associated with neurogenic or muscular impairment of smallorlarge-bowel function• Precipitating factors: recent abdominal surgery, ruptured viscus,peritonitis, pancreatitis, medications, anoxic injury, spinal cordtrauma, uremia, diabetic coma, hypokalemia■ Differential Diagnosis• Idiopathic small-bowel pseudoobstruction• Colonic pseudoobstruction (Ogilvie syndrome)• Small- or large-bowel mechanical obstruction■ Treatment• Identify and treat precipitating event or remove causative agent;decrease or avoid opioids• Restrict oral intake• Replete fluids and electrolytes with isotonic fluids• Nasogastric suction useful for symptomatic relief but probablydoes not improve clinical outcome• Postoperative ileus: NSAIDs help reduce opioid use and maydecrease bowel inflammation• Prokinetic agents including erythromycin or metoclopramide• After failure of conservative therapy, a trial of neostigmine maybe beneficial for Ogilvie syndrome• Colonoscopy if colonic dilation present• Surgery rarely needed■ PearlRecent abdominal surgery is the most common cause of adynamicileus in the ICU; function returns to the small bowel generally within24 hours but may take several days to return to normal motility in thecolon.ReferenceLuckey A et al: Mechanism and treatment of postoperative ileus. Arch Surg2003;138:206. [PMID: 12578422]