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:
- Performed in babies and children to relieve low intestinal obstruction, e.g. suspected Hirschsprung disease (HD), meconium plug disease, meconium ileus or intestinal dysmotility.
- 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).
- Used in the management of patients admitted with enterocolitis.
- Used preoperatively in patients undergoing closure of stoma procedures.
- 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 (thickened) 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
See nursing assessment guideline.
Physical
Assess and record any signs of bowel obstruction in the EMR flowsheets. These include:
- Vomiting
- Frequency
- Colour (containing bile, blood)
- Amount
- 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.
- Abdominal distension
- Describe e.g. tight, shiny, soft, firm, visible bowel loops, visible veins
- Describe degree of distension of the abdomen prior to performing rectal washout
- 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 by the treating surgeons/senior medical staff must be active in the EMR. 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 and treatment protocols should be individualised based on underlying condition.
Notify the surgical team if two successive washouts fail to achieve abdominal decompression.
Equipment
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
- 60mL catheter tip syringe
- 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. - Lubricant
Use only water based lubricant. - Gloves/incontinence sheets
Use incontinence sheets to protect soiling of the bed
Procedure
- Ensure procedural consent obtained by treating surgical team before commencement
- Consider methods of patient distraction, such as sucrose or distraction.
- Consider second staff member or parent to assist with technique
- Perform hand hygiene
- Position neonate, usually on his/her back with legs in the frog position
- Position older child on their left side
- Swaddling of arms, comfort and play therapy techniques can be used
- Perform hand hygiene
- Select appropriately sized catheter for use
- Warm 0.9% Sodium Chloride sachets (in a jug of warm tap water) and prime catheter with solution
- Lubricate tip of catheter and gently insert into the rectum
- Length to be determined by surgical instructions
- 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
- Remove syringe and let fluid run into nappy/kidney dish. Procedure may be repeated twice if return is not clear
- If there is 0.9% Sodium Chloride retention or return volume cannot be determined contact surgeon
- Remove catheter from the rectum and leave the patient clean and dry
perform hand hygiene
- Note and record results of rectal washout accurately on fluid balance section of the EMR flowsheets
- Sucrose may be administered prior to and throughout the procedure as required
- Do not use excessive force if resistance is felt. Contact medical staff if unsure
- 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
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
- contact the surgical/neonatal team
- record volume of saline retained
- consider taking blood to check electrolytes, if clinical situation is appropriate
Bowel perforation
Nausea and vomiting
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 evaluate precautions and exclude any contra-indications. 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. The washouts can reach stool as far up as th splenic flexure enabling a more complete emptying.
- 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
- 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 - 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 - Hirschprung Disease.
Lee, Steven. 2003. Retrieved March 30, 2004 from Emedicine:
http://www.emedicine.com/med/topic1016.htm - 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 - 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 - Newborn Surgery. 3rd Edition. Ed Puri,P, 2011, Hodder & Stoughton
- Costagen, A, Orr, S, Alshafei, A and Antao, B. (2019) How to establish a successful bowel management program in children: a tertiary paediatric centre experience. Irish Journal of Medical Science. 188(1):211-21
- Nataraja, R, Ferguson, P, King, S and Pacilli, M (2019) Management of Hircsprungs disease in Australia and New Zealand: a survey of the Australian and New Zealand Association of Paediatric Surgeons (ANZAPS) Pediatric Surgery International. https://doi.org/10.1007/s00383-018-04432-7
Evidence table
The
evidence table can be viewed here.
Please remember to
read the disclaimer.
The development of this nursing guideline was coordinated by Jess Smith, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated April 2019.