Professional Documents
Culture Documents
Aim
To rationalise and streamline the procedure of bowel washouts in infants and children
who have Hirschprung’s 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%.
However, the scanty literature found, lends itself to some of the current practice at
the Leeds Teaching Hospitals NHS Trust for procedures such as:
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Types of bowel irrigation
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 Hirschprung’s Disease is the most essential
part of the whole safe management of these patients in prevention of Hirschprung’s
Enterocolitis (HE). This involves RWO starting at 2 - 2 times daily after surgeons
review, reducing to once daily prior to discharge, using approximate volumes of
100mls per Kg of Sodium chloride 0.9% for irrigation.
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.
* (Seek advice from the Consultant Surgeon if the infant/child has a cardiac defect)
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.
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Hirschprung’s Disease
Equipment
Procedure
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14 The aim is to irrigate the large bowel with 100ml/kg and gain 100ml/kg with stool
by the end of the procedure.
15 Dispose of the soiled fluid. Wash thoroughly and dry the equipment.
16 Change the consumables weekly.
Signs of Infection
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.
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.
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Meconium Ileus
Follow the procedure as for Hirschprung’s Disease except use 50mls/kg in total of
warmed sodium chloride 0.9%, in 20ml increments. Instil Acetylcysteine solution,
leave for 10-15 minutes, and allow to drain out via rectal tube.
(Per rectum) 10ml/kg/dose 6 hourly using 5% 2% solution is prepared by diluting 1ml injection
Enema solution with 9ml sodium chloride 0.9%.
Equipment
Procedure
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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.
9 Allow the acetylcysteine to remain in situ for 10 - 15 mins if possible. Drain out
the fluid before continuing the procedure.
10 Holding the catheter in position with one hand, fill the syringe barrel to 20mls 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.
11 The procedure should be repeated until the sodium chloride 0.9% in the jug has
been used or the fluid draining out is clear.
12 Gently and slowly withdraw the catheter in 2cm increments from the anus whilst
massaging the abdomen.
13 Observe the colour, consistency and smell of the effluent.
14 Wash and dry the buttocks, apply barrier cream.
15 Measure the fluid in the bowl to ensure most of the fluid has been excreted.
16 The aim is to irrigate the large bowel with 50ml/kg and gain 50ml/kg with stool by
the end of the procedure.
17 Dispose of the soiled fluid. Wash and dry the equipment thoroughly.
18 Change the consumables weekly.
Equipment
Procedure
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10 Holding the catheter in position with one hand, fill the syringe barrel to 20mls 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 5mls 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 20ml/kg
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.
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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.
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RECTAL WASHOUT
TEACHING CHECKLIST FOR PARENTS AND CARERS DELIVERING CARE
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Authors: A Broadbent - Surgical Outreach Sister,
Neonatal Surgery, Leeds Teaching Hospitals
NHS Trust
Abbreviations used:
2 MI - Meconium Ileus
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References
Robb A and Lander A (2008). Hirschprung’s Disease. Surgery (Oxford). Vol 26, Iss 7,
P288 - 290
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