Be proactive about Preventing constipation Be proactive about Preventing constipation! in post-operative orthopedic patients Constipation Awareness Self-Study Module for Nurses 01/15/2016 Chelsea Dick, RN M. Charrie Smith, RN

R e s e a r c h Q u e s t I o N constipation! In post-operative orthopaedic patients (P), what is the effect of educating nurses on constipation awareness and available PRN bowel medications (I) compared to no intervention (C) on the frequency of the administration of bowel medications (O) within the inpatient hospital stay (T)?

Constipation Objectives Understand why constipation is such an issue in post-operative orthopaedic patients. Describe the effect of opioids on bowel function. Understand the predominant mechanism of action of commonly prescribed bowel medications. Select appropriate preventative and/or management measures for opioid-induced constipation (OIC). Give a hoot! Give a poop!

8 Recommendations from the research On admission, document last bowel movement. Both nonpharmacologic AND laxatives are needed in OIC. Initiate senna AND docusate when starting opioid therapy. Stimulant laxatives (senna) are first-line therapy in OIC. Senna is the first choice if you only give one laxative! Docusate is best used with another laxative. If ordered, initiate MiraLax when starting opioids. Avoid Bulk-forming laxatives in OIC. NOTE: These recommendations do not supercede what the doctor has ordered.

Constipation: Proactive Bowel Management No national consensus on how to handle postoperative constipation. Common problem in Orthopaedic patients Up to 65% of post-operative patients experience opioid-induced constipation (OIC) Our patients leave often too soon to tell (POD1). Be PROACTIVE against constipation, not REACTIVE! Bowel medications: Nurses give out PRNs inconsistently Patients often do not know to ask for them Perhaps add this and previous slide together, see added slide “The Scoop on Poop” much like the dog in the photo

What is Constipation? Constipation is a symptom-based disorder. Infrequent defecation (< 3 BMs per week) Small, hard, or lumpy stools Abdominal bloating / pain, or nausea Excessive straining Incomplete evacuation sensation Need for digital manipulation (if impacted) Recommendation: Document last BM on admission. What is his/her normal pattern of elimination? When was his/her last bowel movement? Constipation = dry stool Document last BM I recommend including that last point on the “How Opioids Cause Constipation” slide

Constipation: Multifactorial Causes Surgery / anesthesia Decreased mobility Reduction in fluid Change in diet Stress / depression Side effect of opioids

Understanding: The Enteric Nervous System The ENS coordinates GI function Neurons are spatially distributed along the entire GI tract Acetylcholine is a major excitatory neurotransmitter in the gut Excitatory motor neurons promote gut motility/secretions Increased peristalsis Increased intestinal motility / gastric emptying Increased urge to defecate Acetylcholine is an excitatory neurotransmitter That pic cracks me up! Great description of OIC, very specific for our population.

Understanding: The Enteric Nervous System How opioids cause constipation: Most opioids bind to Mu-opioid receptor sites Inhibit neuronal excitability Inhibit release of acetylcholine Mu-opioid receptor binding leads to: Decreased peristalsis Decreased intestinal motility / gastric emptying Decreased urge to defecate Mu-opioid receptors in the gut That pic cracks me up! Great description of OIC, very specific for our population.

Assess/Diagnose Constipation Bristol Stool Chart Enables patients to identify their stool form using 7 different images plus a written description of stool types A simple, visual tool with stool descriptions in ‘everyday language’ Widely used and validated Stool types 1 and 2 = hard, constipated Stool types 3 and 4 = normal stools Stool types 5 and 6 = loose Stool type 7 = completely liquid

Management of Constipation Aim = Restore water in the stool by: Shorten bowel transit time Exercise Stimulant laxatives Osmotic laxatives Increase fecal water Increase the ability of the feces to retain water Dietary Fiber Stool softener Rehydrate the stool

Management of OIC Recommendation: Stimulant laxatives (senna) are the first-line therapy. Recommendation: Initiate traditional laxatives when starting opioids. Traditional laxatives = stimulant laxatives, stool softeners, and osmotic laxatives Caveat: Laxatives do not target the principal cause of OIC due to opioid binding to the receptors in the enteric nervous system (ENS). The use of stimulant laxative, stool softeners, and osmotic laxatives are considered ineffective in > 50% of patients. For these patients, a newer drug class is available: PAMORAs PAMORAs = Peripherally Acting Mu-Opioid Receptor Antagonists

Nonpharmacologic Management Fluids! Fluids! Fluids! (2 Liters / day unless restricted) Increase activity (affects peristalsis) Increase diet (if low appetite unless paralytic ileus) Increase dietary fiber (especially fruit!) Maintain daily bowel routine (Heed the BM urge!) Decrease depression/stress (Think positive!) Gum chewing (stimulates cephalic-digestion phase) Rocking-chair motion (works on sympathetic N.S.) Recommendation: Both Nonpharmacologic measures AND laxatives are needed in OIC.

Pharmacologic Management Stimulating laxatives (Senna, Bisacodyl) Recommendation: Stimulants laxatives are first-line therapy in OIC. Recommendation: Senna is the first choice if you only give one laxative! Emollient laxatives (= Stool softeners) Stool softeners alone are not effective. Recommendation: Docusate is best with another laxative. Recommendation: Initiate senna and docusate with opioids. Osmotic laxatives (Miralax, MOM, lactulose) Recommendation: Give MiraLax when starting opioid therapy. Recommendation: Avoid bulk-forming laxatives (psyllium) in OIC.

Stimulating Laxatives Senna Recommendation: First choice if only giving one laxative! MOA: Irritates intestinal lining; perstalsis; speeds up stool passage Advantage: cheap and cost effective; provides the PUSH! Generally produces a BM in 6-12 hours Bisacodyl Strong but brief peristaltic movements that act on the colon MOA: Stimulates sensory nerve endings to produce peristalsis Advantage: Bowel care can be planned around patient activities; part of bowel regimen in spinal cord injury pts. Enteric-coated pill generally produces a BM in 6-12 hours Suppository generally produces a BM in 15-60 minutes Weird Al

Emollient Laxatives = Stool softeners Docusate sodium Recommendation: If starting opioid therapy, then give both a stool softener (docusate) with a stimulant laxative (senna). Recommendation: Docusate is best with another laxative. Disadvantage: Stool softeners alone are not effective in OIC. MOA: Stool softeners act as ‘soap’ to increase surface interaction between water and stool, which “softens” the stool making it easier to pass Advantage: Safe, minimal side effects, stimulant free and cost- effective. Advantage: Helps to avoid straining; provides the MUSH. Generally produces a BM in 24 to 72 hours How about a side dish of stool softeners to go with those opioids?

Osmotic Laxatives Polyethylene glycol (PEG; MiraLAX) Recommendation: Give MiraLAX when starting opioids! Level 1, grade A evidence for treating functional constipation MOA: Keeps fluid in the intestines and also draws fluid into the intestines from surrounding tissue and blood vessels Advantage: Consistently more effective than lactulose No taste, grit, bloating, cramps, gas, or sudden urge Disadvantage: Avoid in patients with CHF, severe renal dysfunction, or at risk for electrolyte imbalance 2010 study: Miralax produced a BM earlier (2-4 vs 3-6 days) than in those taking senna/docusate combo. Generally produces a BM in 1 to 3 days, often in just 1 day. Dissolve in 8 oz water, juice or other liquid.

More Osmotic Laxatives Lactulose A non-digestible sugar; also used in hepatic encephalopathy MOA: Lowers the pH of the colon, which inhibits ammonia (blood) diffusion Disadvantage: Contraindicated in galactosaemia; caution in Diabetes mellitus General produces a BM in 1-2 day, but it may take up to 2 days Milk of magnesia (MOM) Magnesium hydroxide is inorganic, has osmotic effect; also an antacid use MOA: Via osmosis, increases water content and softens stool Disadvantage: Interferes with the absorption of folic acid and iron, carries away potassium Contraindicated in hypermagnesemia, hypocalcemia, anuria, heart block Avoid in the elderly and patients with cardiac or renal dysfunction Generally produces a BM in ½ to 6 hours

Bulking-Forming Laxatives Psyllium Recommendation: Bulk-forming laxatives (e.g. psyllium) are NOT recommended for OIC because opioids prevent peristalsis. MOA: Swells up or bulks up in the GI tract allowing stool to retain water Disadvantage: Risk of bowel obstruction and potential impaction. Mechanical obstruction of the esophagus and colon have also been reported. Metamucil fiber is not 100% soluble; however, Citrucel fiber is 100% soluble. Psyllium has been associated with anaphylactic reactions. They may take up to 72 hours to work.

Saline Laxatives Enema: Normal Saline (Fleets) Active ingredient: Sodium phosphate MOA: Saline laxative draws water into colon, provides a soft stool mass, increased bowel action Disadvantage: Can cause electrolyte imbalance. Do not use if on a sodium-restricted diet. CAUTION: Using more that one dose per day can be harmful. Inappropriate ordering and too frequent dosing can lead to hyperphosphatemia, acute renal failure, hypocalcemia, seizure. Generally produces a BM in 1 to 5 minutes.

Laxatives in the elderly Constipation is not a physiological result of aging. Many age-related problems affects water balance. Many medications interfere with nerve conduction and smooth muscle function of the colon. can pose a medical emergency for some older folks. Recommendation: Elderly patients will also need a concurrent laxative if receiving opioids. Recommendation: Avoid bulk-forming laxatives as they can lead to bowel obstruction, impaction. Encourage older folks to drink more fluids.

8 Recommendations from the research On admission, document last bowel movement. Both nonpharmacologic measures AND laxatives are needed in OIC. Initiate senna AND docusate when starting opioid therapy. Stimulant laxatives (senna) are first-line therapy in OIC. Senna is the first choice if you only give one laxative! Docusate is best used with another laxative. If ordered, initiate MiraLax when starting opioids. Avoid Bulk-forming laxatives in OIC. NOTE: These recommendations do not supercede what the doctor has ordered.

Constipation Summary Constipation is a common & distressing symptom experienced by orthopaedic patients. One of most frequent, unfavorable reactions that occur during the hospital stay or after they go home. Constipation should be treated PROACTIVELY in post- operative orthopaedic patients. Don’t be afraid to use PRN bowel medications …your patient will thank you later!

Be proactive about Preventing constipation! T H E E N D