Vous êtes sur la page 1sur 13

Guideline for the management of bowel irrigation (rectal

washout) for under one year old infants and children


Ownership
Published
Review date

Leeds neonatal and paediatric services


August 2011
August 2014

Aim
To rationalise and streamline the procedure of bowel washouts in infants and children
who have Hirschsprungs disease, meconium ileus, a cloaca or have a distal stoma
requiring irrigation.
Objectives
To provide details of the procedures and equipment used.
To identify potential problems
To provide the evidence collated
To provide an abdominal assessment tool for guidance
To prevent potentially hazardous bowel infections
Background
Bowel irrigation is a means of emptying and cleaning the large intestine using a
catheter and sodium chloride 0.9%.
Currently there is no available national consensus regarding the procedure of rectal
Washout (RWO) or Distal Loop Washout (DLWO) at less than one year of age. A
literature search highlights the variability of how much sodium chloride 0.9% is used
either per instillation or per procedure; which type of tube should be inserted or how
far to advance the rectal tube.
However, the scanty literature found, lends itself to some of the current practice at
the Leeds Teaching Hospitals NHS Trust for procedures such as:

a time intensive procedure as in Hirschsprungs disease


a less time consuming intervention for meconium ileus
a brief sterile distal loop washout as for a baby who has cloaca
or a non sterile brief DLWO/RWO once per month.

Assessment of the infant


Initial assessment of the sick infant who has or potentially has Hirschsprungs
Disease shows an indication of the urgency for a rectal washout to be undertaken.
The guide illustrated on page 11 shows information in a methodical way for nursing
and medical teams, taken from clinical practice at the Leeds Teaching Hospitals NHS
Trust.

Types of bowel irrigation


1

Hirschsprungs Disease (HD)

The infant with this condition is unable to pass stool effectively, due to the absence of
ganglion cells within the intestinal mucosa which initiates peristalsis. Therefore, rectal
washouts for suspected or confirmed Hirschsprungs Disease are the most essential
part of the whole safe management of these patients in prevention of Hirschsprungs
Enterocolitis (HE). This involves RWO starting at 2 - 3 times daily after surgeons
review, reducing to once daily prior to discharge, and using approximate volumes of
100mL/ kg of sodium chloride 0.9% for irrigation.
2

Meconium Ileus (MI)

This condition presents itself in the neonatal period causing intestinal obstruction due
to thick, sticky Meconium within the intestines usually found as an indicator of Cystic
Fibrosis. Acetylcysteine solution (10mL/kg/dose of 5% solution) used as a rectal
washout assists in breaking down the Meconium so it may be passed more easily.
Using smaller volumes of sodium chloride 0.9%, 50mL/kg, leave the Acetylcysteine in
situ for 10 minutes and then irrigate the bowel again with sodium chloride 0.9% until
clear.
3

Post stomal surgery distal loop washout (DLWO)

Where an ano-rectal malformation is diagnosed and a colostomy is subsequently


formed, it is essential to ensure the large intestinal segment from the mucus fistula to
the anus is clean. Therefore once per month 20mL/kg of sodium chloride 0.9% is
used in 10 - 20ml increments into the mucus fistula and allowed to drain out again
until the solution is clear.
4

Cloaca

A colostomy may need to be formed as a neonate for imperforate anus but there may
be connecting fistulae from the colon to the vagina or bladder. The DLWO would
need to be undertaken under aseptic techniques with 20mL/Kg sodium chloride 0.9%
to prevent cross contamination.

Hirschsprungs Disease
Equipment
Warm sodium chloride 0.9% (100mL/kg)
Lubricating gel - alcohol free
Bowl
Measuring jug
Large bore, soft catheter (from at least size 12)
50mL bladder syringe
Apron
Gloves
Large towel/disposable pad
Changing mat
Baby wipes
Disposable bag

Procedure
1
2
3
4
5
6
7

8
9

10
11

12
13
14

Prepare equipment and ensure a warm environment.


Wash hands and apply apron and gloves.
Place on a changing mat in a comfortable position.
Wrap a towel around the upper half of the body and expose the buttocks.
Observe their behaviour, perfusion and feel the abdomen before and after the
procedure.
Remove plunger from the syringe, connect empty syringe to the catheter.
Lay onto the left side or supine to aid the flow into the large intestine. Apply
lubricating gel to the tip and length of the catheter (approx 10cm), and the anus.
(An empty catheter inserted at the beginning releases flatus before the start of
the washout). Run 10mL sodium chloride 0.9% through the catheter and kink the
tubing.
Gently insert the catheter into the rectum and unkink the tubing allowing the
sodium chloride 0.9% to run in whilst advancing the tubing until resistance is felt.
Allow the sodium chloride 0.9% to drain out into a bowl.
Holding the catheter in position with one hand, fill the syringe barrel to 20mL and
allow the fluid to run in. Abdominal massage at this point is helpful to move the
stool, if tolerated. Lower the syringe and allow the fluid to flow out again holding
the syringe in a way that you can measure the output, pour into the large
collecting bowl.
The procedure should be repeated until the sodium chloride 0.9% in the jug has
been used or the fluid draining out is clear.
Gently and slowly withdraw the catheter in 2cm increments from the anus whilst
massaging the abdomen. Only remove the catheter if the tube becomes blocked
with thick stool if really necessary, gently re-insert. Observe the colour,
consistency and smell of the effluent.
Wash and dry the buttocks, apply barrier cream.
Measure the fluid in the bowl, approximately 50mL may be short due to spillages
or fluid escaping around the catheter during the washout.
The aim is to irrigate the large bowel with 100mL/kg and gain 100mL/kg with stool
by the end of the procedure.
3

15 Dispose of the soiled fluid. Wash thoroughly and dry the equipment.
16 Change the consumables weekly.

Signs of Infection

Offensive smell from stools.


Unusual colour of stools.
Looser consistency, explosive stools.
Blood in the stools.
Lethargy, poor feeding, vomiting, pallor.

Post procedure
If the final result of the washout for HD is not entirely clear, it may be necessary to
repeat the procedure later in the day. However, take notice of the abdomen and
further soiled nappies later, it may not be necessary to repeat the procedure.
If there was a good result from the washout (HD) but later the baby appears to be
uncomfortable and has a full abdomen, the rectal tube can be passed into the
rectum, without sodium chloride 0.9%; the relief from expelling flatus may be all that
is required.
Problem solving for rectal washout in HD
Most of the problems with the process of the washout involve the stools that are too
thick and block the tube or prevent the tube from passing into the rectum.
Hold the syringe barrel high and rapidly squeeze and release the catheter tubing.
Place plunger in top of syringe and press very gently until the sodium chloride
0.9% starts to flow then remove the plunger.
Gently move tube around to re-position tip of tube.
As a last resort, remove the tube, rinse through the catheter and re-insert.
Occasional specks of blood are seen in the tubing, due to irritation of the tube with
the intestinal tract.
Fresh bleeding down the catheter - stop the rectal washout and retry after a couple
of hours.
As weeks go by there may be some difficulty passing the tube initially, this can be
eased by introducing the catheter and advancing the tube whilst the sodium
chloride 0.9% is flowing in.

Meconium Ileus
Follow the procedure as for Hirschsprung's Disease except use 50mL/kg in total of
warmed sodium chloride 0.9%, in 20mL increments. Instil Acetylcysteine solution,
leave for 10-15 minutes, and allow draining out via rectal tube.
Drug

Route

Dose

Comments
Preparation:

Oral (or via


feeding tube)

Meconium ileus:
4-8mL 5% acetylcysteine solution 2-3
times a day.

Acetylcysteine injection can be administered


orally or rectally but must be diluted first.
Acetylcysteine 5% solution is prepared by
diluting 1mL of acetylcysteine 20% injection
with 3mL of sodium chloride 0.9% or water for
injection.

Acetylcysteine
Rectal enema

Meconium ileus:
10mL/kg/dose of a 5% acetylcysteine
solution instilled every 6 hours

Recommended rectal contact time of 10 - 15


minutes.
REF: Leeds Teaching Hospitals NHS Trust
Pharmacy Department
Rebecca Lilley Pharmacist

Equipment
Warm sodium chloride 0.9% (50mL/kg)
Lubricating gel - alcohol free
Bowl
Measuring jug
Large bore, soft catheter - at least size 10Fg
50mL bladder syringe
Apron
Gloves
Large towel/disposable pad
Changing mat
Baby wipes
Disposable bag
Procedure
1
2
3
4
5

Prepare equipment and ensure a warm environment.


Wash hands and apply apron and gloves.
Place on a changing mat in a comfortable position.
Wrap a towel around the upper half of the body and expose the buttocks.
Observe behaviour and perfusion, and feel the abdomen before and after
procedure.
6 Remove plunger from the syringe, connect empty syringe to the catheter.
7 Lay onto left side or supine to aid the flow into the large intestine. Apply lubricating
gel to the tip and length of the catheter (approx 10cm), and the anus. An empty
catheter inserted at the beginning releases flatus before the start of the washout.
Run 10mL sodium chloride 0.9% through the catheter and kink the tubing.
8 Gently insert the catheter into the rectum and unkink the tubing allowing the
sodium chloride 0.9% to run in whilst advancing the tubing until resistance is felt.
Allow the sodium chloride 0.9% to drain out into a bowl. Instil Acetylcysteine as
per pharmacy guidance.
5

9
10

11
12
13
14
15
16
17
18

Allow the Acetylcysteine to remain in situ for 10 - 15 mins if possible. Drain out
the fluid before continuing the procedure.
Holding the catheter in position with one hand, fill the syringe barrel to 20mL and
allow the fluid to run in. Lower the syringe and allow the fluid to flow out again
holding the syringe in a way that you can measure the output, pour into the large
collecting bowl.
The procedure should be repeated until the sodium chloride 0.9% in the jug has
been used or the fluid draining out is clear.
Gently and slowly withdraw the catheter in 2cm increments from the anus whilst
massaging the abdomen.
Observe the colour, consistency and smell of the effluent.
Wash and dry the buttocks, apply barrier cream.
Measure the fluid in the bowl to ensure most of the fluid has been excreted.
The aim is to irrigate the large bowel with 50mL/kg and gain 50mL/kg with stool by
the end of the procedure.
Dispose of the soiled fluid. Wash and dry the equipment thoroughly.
Change the consumables weekly.

Distal Loop Washout (DLWO)


Equipment
Warm sodium chloride 0.9% (100mL bag)
Pair of scissors
Lubricating gel - alcohol free
Bowl
Measuring jug
Size 6 and 8 ng tubes or size 10 rectal tubes
20mL bladder syringe
Apron
Gloves
Large towel/disposable pad
Changing mat
Baby wipes
Disposable bag
Procedure
NB:

Liaise with the Consultant Paediatric Surgeon prior to the procedure


regarding potential problems.
IE; some infants may have a fistula between the bowel and genitourinary
tract and therefore may develop a urinary tract infection.

1
2
3
4
5
6
7

Prepare equipment and ensure a warm environment.


Wash hands and apply apron and gloves.
Place on a changing mat, in a comfortable position.
Wrap a towel around the upper half of the body and expose the mucous fistula.
Observe and feel the abdomen before and after procedure.
Remove the plunger from the syringe; connect the empty syringe to ng tube.
Run 10mL of warmed sodium chloride 0.9% through the syringe barrel and tube,
kink the tubing to prevent the flow.
8 Lubricate the tip of the tube with lubricating gel.

9 Gently insert the catheter into the mucous fistula allowing sodium chloride 0.9% to
run in whilst advancing the tubing until resistance is felt. Allow the sodium
chloride 0.9% to drain out into a bowl.
10 Holding the catheter in position with one hand, fill the syringe barrel to 20mL and
allow the fluid to run in. Lower the syringe and allow the fluid to flow out again
holding the syringe in a way that you can measure the output, pour into the large
collecting bowl. There may be a delay in drainage. If so, remove the tube and run
through with 5mL of sodium chloride 0.9% to clear the tube. The mucous within
the fistula is often thick and blocks the small tube.
11 Insert the tube again and allow the sodium chloride 0.9% to drain out of the
fistula.
12 Turn baby from side to side a couple of times to allow mucous to be dislodged
and mixed with sodium chloride 0.9%.
13 Observe the colour, consistency and smell of the effluent.
14 Wash and dry the area, advise the family that there might be some natural
drainage later.
15 Measure the drainage in comparison to what was started with, if possible.
16 Dispose of the soiled fluid.
17 Discard all consumables. Repeat the process monthly or as directed by the
Consultant Paediatric Surgeon.

Cloaca
Equipment
Warm sodium chloride 0.9% (100mL bag) or 20mLkg
Pair of scissors
Lubricating gel - alcohol free
Bowl
Measuring jug
Size 6 and 8 ng tubes
Size 10 rectal tube
20mL bladder syringe
Apron
Large towel/disposable pad
Changing mat
Baby wipes
Disposable bag
Sterile dressing pack and sterile gloves (powder free)
Procedure
NB:

Liaise with the Consultant Paediatric Surgeon prior to the procedure


regarding potential problems.

IE; some infants may have a fistula between the bowel and genitourinary
tract and therefore may develop a urinary tract infection. There is also
a risk of bacterial translocation through the gut wall, which may in
turn lead to a bacteraemia.

1 Prepare equipment and ensure a warm environment.


2 Wash hands and apply apron and gloves.
7

3
4
5
6
7
8
9
10

11
12
13
14
15
16
17

Place on a changing mat in a comfortable position.


Wrap a towel around the upper half of the baby and expose the mucous fistula.
Observe and feel the abdomen before and after procedure.
Remove the plunger from the syringe; connect the empty syringe to ng tube.
Run 10mL of warmed sodium chloride 0.9% through the syringe barrel and ng
tube, kink the tubing to prevent the flow.
Lubricate the tip of the tube with aquajel.
Gently insert the catheter into the mucous fistula tubing allowing sodium chloride
0.9% to run in whilst advancing the tubing until resistance is felt.
Holding the catheter in position with one hand, fill the syringe barrel to 20mL and
allow the fluid to run in. Lower the syringe and allow the fluid to flow out again
holding the syringe in a way that you can measure the output, pour into the large
collecting bowl. There may be a delay in drainage, if so, remove the tube and run
through with 5mL of sodium chloride 0.9% to clear the tube. The mucous within
the fistula is often thick and blocks the small tube.
Insert the tube again and allow the sodium chloride 0.9% to drain out of the
fistula.
Turn from side to side a couple of times to allow mucous to be dislodged and
mixed with sodium chloride 0.9%.
Observe the colour, consistency and smell of the effluent.
Wash and dry the area, advise the family that there might be some natural
drainage later.
Measure the drainage in comparison to what was started with.
Dispose of the soiled fluid. Discard all consumables. Repeat the process monthly
or as directed by the Consultant Paediatric Surgeon.
Advise parent of potential pyrexia post procedure and what action to take. Ensure
contact telephone numbers of professional advice is available.

An additional person is required to assist, this enables the procedure to


be as clean as possible.

It is essential to document the following information for the parent/carers and


nurses prior to discharge into primary care with all competencies completed
and signed by an expert in undertaking all the documented procedures in this
guideline.
The practitioner will:

Record the reason why the baby is having rectal washouts


The size and type of catheter to be used
How far to insert the catheter
The volume of fluid
The type of fluid
The temperature of the fluid
Discuss the principles of effective hand washing
Demonstrate effective hand washing and drying
Discuss the consequences of ineffective hand washing
Discuss the preparation of the environment before and after performing
the rectal washout
State how often the rectal washouts need to be performed
Competently demonstrate the correct procedure
Discuss how the procedure may affect the baby
Discuss the potential problems which may occur
Discuss the strategies to overcome the problems

RECTAL WASHOUT
TEACHING CHECKLIST FOR PARENTS AND CARERS DELIVERING CARE

NAME

Date shown

Date

Date

Date

Date

Sign when

practiced

practiced

practiced

practiced

competent

DISCUSSION
SAFETY & HYGIENE
PREPARING EQUIPMENT
POSITIONING
ASSESSING ABDOMEN
PRE & POST WASHOUT
INSERTING TUBE
GRAVITY WASHOUT
POTENTIAL PROBLEMS
PROBLEM SOLVING
CLEANING EQUIPMENT
DISPOSAL OF FLUID
ORDERING SUPPLIES
CONTACT NUMBERS
ONE WEEK BEFORE
SURGERY:
BOTTOM PREPARATION
CLEAR FLUIDS X 48HRS

10

11

Authors:

A Broadbent - Surgical Outreach Sister,


Neonatal Surgery, Leeds Teaching Hospitals
NHS Trust
A Aspin - Nurse Consultant, Neonatal Surgery,
Leeds Teaching Hospitals NHS Trust

Date:

August 2011

Review Date:

August 2014

Audit:

Once yearly Audit to be conducted by


Neonatal Surgical team, indicated in the target
professional group.
Audit of safe and effective management of bowel
irrigation. Results will be presented to Surgical Audit,
Neonatal and Surgical Benchmarking groups and
possibly Paediatric Stoma care group.
Actions arising from recommendations made following
the audit will be monitored by surgical outreach team.

Target Population:

Less than one year old

Target Professional Groups:

Nurses secondary and Primary Care


Consultant Paediatric Surgeons and
Paediatricians

Development Group advised:

Consultant Paediatric Surgeons, Bowel Nurse


Specialists, Matron for Neonatal Units,
Neonatal Clinical Governance Group, Neonatal
Improving Care Group, Consultant
Neonatologists

Abbreviations used:
1

RWO
HD
HE

Rectal washout
Hirschsprungs Disease
Hirschsprungs Enterocolitis

MI

Meconium Ileus

DLWO

Distal Loop Washout


12

References
Bradnock T and Walker G (2008). The current management of Hirschsprungs
Disease in the UK: A National Summary of Practice.
Carman M (2005). Management Medical Treatment Bowel Irrigation with Sodium
chloride 0.9% Solution? Colon and Rectal Surgery. Oxford
Chattopadhyay, Anindya, Prakash, Bhanu, Vepakomma, Deepti, Nagendhar, Yoga,
Vijsyskumsr (2004). A prospective comparison of two regimes of bowel preparation
for paediatric colorectal procedures: sodium chloride 0.9% with added potassium vs.
polyethylene glycol. Paediatric Surgery International. Vol 20, No. 2, p127 - 129 (3)
Clinical Guidelines (Hospital). Neonatal Bowel Washout.
http://www.rch.org.au/rchcpg/index.cfm?doc_id=9220
Gabra H, Stewart R, Nour S (2007). Mid-gut malrotation and associated
Hirschsprungs Disease: a diagnostic dilemma. Pediatric Surgery International. 23 :
703 - 705
Hosseini S, Foroutan H, Zeraation S, Sabet B (2008). Botulinium toxins, as bridge to
transanal pull through in neonate with Hirschsprungs Disease. Journal of Indian
Association of Paediatric Surgeons. Vol 13, Iss 2, p69 - 71
Junj K, Masahiro N, Norihiro N, Shuichi Y, Yoshihirok, Akiko K (2003). Preoperative
Colonic Decompression and Irrigation Through a Transanal Tube to Perform the OneStage Pull-Through procedure for Hirschsprungs Disease. Journal of the Japanese
Society of Paediatric Surgeons. Vol 39, No 1, p73 - 78
Kessman J (2006). Hirschsprungs Disease: Diagnosis and Management. American
Family Physician. 74: 1319 - 1322/1327 - 1328.
http://www.aafp.org/afp/AFPprimter/20061015/1319/html
Lee S, Puapong D, Dubois J (2006). Hirschsprungs Disease. eMedicine http://www.emedicine.com/med/TPOIC1016.HTM
Molenaar J and Meijers C (1998). Hirschsprungs Disease in Paediatric Surgery
(Chapter 23).
In: Paediatric Surgery London. Ed Arnold Publishers
Parithan P, Chiengkriwate P, Chow Chuvech V, Patrapinyoleuls, Sangkhathat S
(2007). Bowel prescription for pull-through operation in Hirschsprungs Disease.
Sangkla Medical Journal. 25 (5): 401 - 406
Robb A and Lander A (2008). Hirschsprungs Disease. Surgery (Oxford). Vol 26, Iss
7, P288 - 290

13