PROCEDURE FOR COLONIC LAVAGE THROUGH DIVERTING LOOP ILEOSTOMY

  1. Safety
  2. Choose Correct Feeding Set
  3. Alternate Set
  4. Insert Fecal Drainage Catheter
  5. Prepare Irrigation Fluid
  1. Administer Irrigant
  2. Measure Intake and Output
  3. Abdominal Pressure Monitoring
  4. Assessment
  5. Documentation

 

Background:

This procedure is based on the published protocol from the Department of Surgery, University of Pitssburgh1. It is indicated in the treatment of severe, complicated or fulminant Clostridium Difficile colitis as an option to potentially avoid total colectomy.

Protocol Description:

A loop ileostomy (terminal ileum) is created laparoscopically (if possible). A Malecot(TM) or similar type of catheter is inserted through the stoma and directed toward the cecum. Intraoperatively, 8 Litres of warm polyethylene glycol 3350 with balanced electrolyte solution (GoLytelyTM) is infused into the colon through the catheter. A fecal drainage system is used to collect irrigant.

Postoperatively, the same irrigation process is used to administer 500 mg vancomycin in 500 ml of Ringers Lactate over 15-30 minutes (by gravity) q8h for 10-14 days. Metronidazole 500 mg IV q8h is also administered.

The following procedure outlines the steps to performing this protocol, including safety standards for administration into an enteral system.

 

Path of Irrigation


Figure 1: Schematic of irrigation pathway


Malecot Tip

Figure 1: Tip of a Malecot Tube

PROCEDURE RATIONALE FOR PROCEDURE

 1.

Safety

The procedure includes the administration of vancomycin in ringers lactate solution via the enteral route. The metronidazole is infused intravenously.

Any medication or solution for enteral administration must be delivered using a system that is not IV compatible. This protocol has been developed to comply with this safety standard.

Perform hand hygiene before and after patient or environmental contact. Contact precautions are required for patients with C-Diff. A mask and eye shield is required when handling irrigant and drainage.

 1.



There have been numerous published case reports of inadvertent administration of enteral products via the parenteral route. Medication safety standards prohibit the administration of enteral products using IV compatible tubing or administration sets.

To protect this patient from additional infection, to protect yourself from exposure and to prevent horizontal spread to other patients.

 


 2.

Obtain Correct Enteral Feeding Set:

An enteral feeding bag set with a roller clamp for gravity administration is required.

Obtain a set that is used for the gravity administration of enteral contrast. HMMS #4440.

Gravity_Set

 2.

The vancomycin solution is administered over 15-30 minutes by gravity flow.



 3.

Alternative: No Gravity Set Available

If no gravity set is available, an enteral feeding pump set (anti-gravity) can be used. Because these pumps cannot be programmed to deliver an hourly rate of 1 Litre, you will need to delivery the volume by setting up a bolus as follows:

  1. Turn Kangaroo(TM) on and clear previous patient.
  2. Select "more"
  3. Choose "intermittent feed".
  4. Select "done" X 2
  5. Select "adjust bolus"
  6. Select bolus rate and choose bolus maximum (999 ml)
  7. Enter bolus as "1 bolus"
  8. Enter bolus volume as "500 ml"
  9. Choose "run" when ready

 3.

Gravity administration is preferred as a simplified approach.

 4.

Insert Fecal Drainage System

Insert fecal drainage catheter and closed drainage system.  Do not use a straight rectal tube.

For patient's unable to tolerated indwelling fecal drainage system, consider fecal ostomy pouch to collect irrigation fluid.

 4.

A closed system is used to contain the C Diff. Rectal tubes are stiff and potentially more injurious to the rectal mucosa.

 5.

Prepare Irrigation Fluid

Pharmacy will provide vancomycin 500 mg in 500 ml lactated ringers bags. These will have a special label to flag users that this is NOT for IV use. The bag will have a spike attached (shown).

Open the feeding tube bag.  Unscrew the luer lock cap on the bottom of the spike and empty the contents into the enteral feeding bag.

Spike

NOTE: Lactated ringers is not available in 500 ml size bags in CCTC. If this product must be mixed at the bedside (e.g., during the middle of the night), vancomycin 1 gm / 1 Litre will need to be prepared. Spikes are available on the dialysis cart. The nurse will need to empty 1/2 of the 1 L solution into the enteral feeding bag and recap the luer lock connection if a 1 L bag has been prepared.

 5.

The unique labeling and connection of the spike makes this product look unique. This is intended to alert users that this is NOT for IV use.

The luer-lock on the spike is not compatible with standard IV infusion set.  When the cap is opened, the flow rate will be very rapid allowing for quick filling of the enteral feeding bag.

Avoid administration of cold irrigate as this may induce vasoconstriction and mucosal ischemia or discomfort.

6.

Administer Irrigant

Administer irrigant at room temperature over 15-30 minutes by gravity.

 6.

 



7.

Measure Intake and Output of Irrigant

Record irrigant volume and fecal output on fluid balance record.

If 24 hour fecal output is less than 75% of irrigant volume, notify General Surgery.

 7.

Output should be almost equal to or greater than irrigant volume.

8.

Abdominal Pressure Monitoring

Monitor intra-abdmoninal pressure via bladder catheter q4h and prn during colonic irrigation.

Report elevated pressures to General Surgery..

 8.

 

Patients with C Diff Colitis are at risk for intra-abdominal compartment syndrome from bowel inflammation/edema. Intra-abdominal compartment syndrome can cause ischemia or infarction of the bowel, and lead to cardiorespiratory or renal failure. 

9

Assessment

Monitor ileostomy stoma q4h and with each irrigation for color and tube placement. Do not remove the anchor that holds the tube in place.

Assess fecal drainage system and perianal areas for inflammation or skin breakdown q4h.

Notify General Surgery for concerns or changes to stoma appearance, or any change in patient status.


 0.

 

Complications include bowel ischemia/perforation, bowel dehiscence at stoma, stomal ischemia or septic shock.

10.

Documentation

Document vancomycin enteral irrigation on MAR.

Document irrigant and fecal output on fluid balance.

Identify "ileostomy/fecal drainage" on problem list and document findings each shift and prn.

 10.

 

Developed: Februray 19, 2013

Update: February 19, 2013; January 27, 2016

Last Reviewed: January 27, 2016

Brenda Morgan RN BScN MSc CNCC, CCTC

Gina Souliere, RN BScN, CCTC

Lynne Kelly BSc Pharm, CCTC

REFERENCES

1.  Matthew, N., Alverdy, J., Hall, D,. Simmons, R. and Zuckerbraun, B. (2011). Diverting Loop Ileostomy and Colonic Lavage
An Alternative to Total Abdominal Colectomy for the Treatment of Severe, Complicated Clostridium difficile Associated Disease.
Annals of Surgery,
254(3), pp 423-429.

LHSCHealth Professionals

Last Updated January 27, 2016 | © 2007, LHSC, London Ontario Canada