Clinical Guidelines (Nursing)

Bowel washout rectal

  • Introduction

    Rectal washouts are performed to decompress the lower intestine and deflate the abdomen by removing gas and stool using small amounts of Sodium Chloride 0.9% (normal saline).

    They are:

    a.    Performed in babies and children to relieve low intestinal obstruction, e.g. suspected Hirschsprung disease (HD), meconium plug disease, meconium ileus or intestinal dysmotility.

    b.    Used as a mode of temporary management in proven cases of Hirschsprungs Disease until definitive surgery is performed (for 4-12 weeks depending on each case).

    c.    Used in the management of patients admitted with enterocolitis.

    d.    Used preoperatively in patients undergoing closure of stoma procedures.

    e.    May be used in the management of constipation in children

    Neonatal procedure must be performed initially by a surgeon and further washouts need to be ordered by the consulting surgical team following patient review.

    Aim

    This guideline is to assist clinicians performing rectal washouts for patients of all ages at the RCH.

    Definition of terms

    • Meconium Plug:  Inspissated and immobile meconium causes a transient form of distal colonic or rectal obstruction.
    • Hirschsprung Disease:  It always affects the rectum and usually a variable length of the distal large bowel. It is characterised by a lack of normal development of the nerve supply to the bowel wall (ganglion cells). This prevents effective peristalsis and results in a functional intestinal obstruction.
    • Meconium Ileus: This form of obstruction is caused by thick, tenacious meconium which is unable to be propelled through the small intestine. Usually the bowel is not damaged and remains in continuity.  It may also be associated with volvulus, intestinal atresia or perforation.
    • Peristeen® : Peristeen ®is a bowel washout system that can be used to manage faecal incontinence and chronic constipation for children over 3 years of age.

    Assessment

    Link to nursing assessment guideline.

    Physical

    Assess and record any signs of bowel obstruction. These include:

    1. Vomiting

    • Frequency
    • Colour (containing bile, blood)
    • Amount

    2. Increasing Nasogastric aspirate

    • Colour
    • Amount

    Note: Green vomitus/nasogastric aspirate indicates the presence of bile, making bowel obstruction more likely. If present, notify surgical team immediately.

    3.    Abdominal distension

    • Describe e.g. tight, shiny, soft, visible bowel loops, visible veins
    • Describe degree of distension of the abdomen prior to performing rectal washout

    4. Bowel action

    • Time of each bowel action
    • Note - frequency, amount, consistency, colour, +/- blood  

    Note: Routine measurement of abdominal girth is not used as an accurate method of determining abdominal distension

    Medical orders

    Medical orders for rectal washout must be written clearly by the treating surgeons/senior medical staff. Orders should include:

    • Frequency
    • Size of tube
    • Length to be inserted
    • Amount (mL) Sodium Chloride 0.9% solution to be instilled - Maximum20mL/kg per procedure up to maximum 250mL.

    Note: Use only Sodium Chloride 0.9% solution

    Investigations

    • Abdominal x-ray
    • Lower gastrointestinal contrast study
    • Upper gastrointestinal contrast study
    • Rectal biopsy

    Procedure

    Perform rectal washout as prescribed. The frequency of washouts is determined according to the effectiveness of decompression of the bowel.

    Notify the surgical team if two successive washouts fail to achieve abdominal decompression.

    Equipment

    1. Nelaton catheter

    Orders should include specific size, and length of catheter to be inserted

    Weight    Size  Length to be inserted
     Weight < 2kg  Size 8FG Nelaton  2-3cm
     Weight 2-6kg  Size 10FG Nelaton  5cm
     Weight >6kg  Size 12FG Nelaton  5cm

    Confirm orders with treating surgeon/doctor if they vary from the above guide

        2. 60mL catheter tip syringe
        3. Sodium Chloride 0.9% sachets

    Ensure Sodium Chloride 0.9% sachets are warmed prior to use (warm to touch- Do Not use the microwave).  Neonates, especially premature neonates may cool quite rapidly if the solution is cold.  The volume of saline to be used is determined by the surgeons and should be written as an order.

        4. Lubricant

    Use only water based lubricant.

        5. Gloves/incontinence sheets

    Use incontinence sheets to protect soiling of the bed.

    Procedure

    1. Position neonate, usually on his/her back with legs in the frog position 
    2. Position older child on their left side 
    3. Swaddling of arms, comfort and play therapy techniques can be used
    4. Select appropriately sized catheter for use
    5. Warm 0.9% Sodium Chloride sachets (in a jug of warm tap water) and prime catheter with solution 
    6. Lubricate tip of catheter and gently insert into the rectum 
    7. Length to be determined by surgical instructions
    8. Instil 0.9% Sodium Chloride solution in 10 - 20 ml aliquots (by pushing in with syringe plunger) over 1-2 minutes (there should be no resistance when injecting the normal saline)
    9. Remove syringe and let fluid run into nappy/kidney dish. Procedure may be repeated twice if return is not clear
    10. If there is 0.9% Sodium Chloride retention or return is not clear contact surgeon  
    11. Remove catheter from the rectum and leave the patient clean and dry
    12. Note and record results of rectal washout accurately on fluid balance chart and in progress notes
    13. Sucrose may be administered prior to and throughout the procedure as required
    14. Do not use excessive force if resistance is felt. Contact medical staff if unsure
    15. Do not pull back on syringe to aspirate, allow the saline to run out naturally. Sometimes manipulating the catheter in and out a few centimetres gently and massaging the abdomen may encourage fluid returns to be expelled. Do not exceed maximum of 20ml/kg or total of 250mL 

    Documentation

    Link to nursing documentation guideline

        1. Observe and document

    Note any reduction in abdominal distension

    Amount of decompression

        2. Washout result

    • Volume, colour, consistency and type of substance; e.g. stool/meconium/instilled fluid

    Complications

    1. There is a risk of reabsorption of saline, especially if most of the solution is not expelled. In the case of retention of instilled solution
      a. contact the surgical/neonatal team
      b. record volume of saline retained
      c. consider taking blood to check electrolytes, if clinical situation is appropriate
    2. Bowel perforation
    3. Nausea and vomiting
    4. Abdominal discomfort

    Special considerations

    • Peristeen®- The system consists of a bag for water, a control unit for regulation of air and water, a pump for activating the balloon and pumping the water and a pre-coated rectal catheter with a balloon. Peristeen®can only be used after thorough medical assessment to exclude any contra-indications to using the system or pick up any precautions. The stomal therapist/continence nurse teaches the parents/carer or child how to use the system.  The Peristeen ® system is available on the continence scheme and needs to be ordered for each individual child as requested.  The control unit allows the younger children to participate in their own care and the older children to carry their washout independently. The amount of water used and the frequency of washout are worked out by the stomal therapist/continence nurse according to each child’s needs.  The washout is usually performed with the child sitting on the toilet.
    • Increased volumes of washout are occasionally required for neonates that are unable to be adequately decompressed. Members of the treating surgical team (registrar, fellow, consultant) may use their clinical discretion to increase the washout volume used and the size of the catheters.

    Links

    References

    1. Failure to Pass Meconium: Diagnosing Neonatal Intestinal Obstruction.
      Loening-Baucke, V., Kimura, K., 1999. (Electronic version) American Family Physician, 7 
      http://www.aafp.org/afp/991101ap/2043.html
    2. Bilious Vomiting in the Newborn: Rapid Diagnosis of Intestinal Obstruction. 
      Kimura,K., Loening-Baucke, V., 2000. (Electronic version)  American Family Physician, 9 
      http://www.aafp.org/afp/20000501/2791.html
    3. Hirschprung Disease. 
      Lee, Steven.  2003.  Retrieved March 30, 2004 from Emedicine: 
      http://www.emedicine.com/med/topic1016.htm
    4. Understanding Neonatal Bowel obstruction: Building Knowledge to Advance Practice.  Silva N, Young J., Wales P., 2005 Neonatal Network Vol 5. NO.5 Sept/Oct
      http://neonatalnetwork.metapress.com/content/yhk3113662m5168p/?genre=article&id=doi%3a10.1891%2f0730-0832.25.5.303
    5. Rectal Wash-Outs. 
      Retrieved May 4, 2004-08-05 from University of Michigan section of Pediatric surgery.
      pediatric.um-surgery.org/new_070198/new/Library/rectal%20washouts.htm
    6. Newborn Surgery. 3rd Edition. Ed Puri,P, 2011, Hodder & Stoughton

    Evidence table

    The evidence table can be viewed here.

    Please remember to read the disclaimer.


    The development of this nursing guideline was coordinated by Trudy Holton, Clinical Nurse Educator, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated March 2016.