In my last post, I discussed a paper describing the incidence of colonic pseudo-obstruction (CPO), or Ogilvie syndrome, in trauma patients. The paper confirmed my bias that this condition could be a problem in a specific subset of trauma patients. They are generally older men with pelvic or spine fractures, with or without surgical fixation. In addition, some comorbidities like diabetes, obesity, and concomitant head injury increase the incidence.

The usual dogma is that a cecal diameter > 12cm places the patient at risk of perforation. Therefore, as the size of the colon increases, steps should be taken to decompress it definitively. This typically involves neostigmine infusion, which usually requires transfer to the ICU, or colonoscopic decompression.

Until about eight years ago, we managed this issue at Regions Hospital using the IV neostigmine option in the ICU. But then, one of our colorectal surgeons described his experience managing CPO with subcutaneous neostigmine. A light bulb turned on! Intravenous neostigmine requires admission to an ICU at our hospital for continuous monitoring to quickly identify the development of bradycardia.

But subcutaneous neostigmine was not on the naughty list! We developed a practice guideline to identify and exclude patients for whom this drug was contraindicated. And it required monitoring that could be accomplished in a floor bed with brief episodes of continuous EKG monitoring. Our inpatient trauma unit could easily do this. However, it might require a step-down bed in yours.

Here is the guideline. Click the image of the link at the end of this post to download a copy.

Here are the major features of the guideline:

• Identification. Any patient, especially those with the previously described risk factors, begins daily monitoring with a flat plate abdominal x-ray. Patients with abdominal distension with subjective discomfort or nursing concerns with the distension fall into this category.
• Trigger. Once distension of any part of the colon, particularly the cecum, exceeds 10 cm, it is time to act. Otherwise, daily monitoring and a bowel regimen continue.
• Contraindications to neostigmine. If the patient has a recent history of MI, bronchospasm, is on beta-blocker therapy, or has SBP < 90 torr, heart rate < 60, or weight < 50kg, colonoscopic decompression should be carried out.
• Continuous monitoring must be available for one hour after injection. This requires an appropriate nurse and an EKG monitor. Atropine must be present at the bedside in case bradycardia develops.
• Up to three doses of SQ neostigmine (1mg) can be given 12 hours apart. If the patient responds with a large bowel movement or passage of gas, it should be confirmed with an abdominal x-ray.
• Patients with insufficient response must transfer to ICU for IV neostigmine or should be scheduled for an urgent colonoscopy.

Our experience has shown that this guideline is usually very effective. However, a few patients have had a recurrence after 24-48 hours, which is uncommon. The guideline can be repeated if necessary.

Bottom line: A low index of suspicion for CPO in trauma patients is critical. Once the colon perforates, these patients do poorly, and serious complications are common. This guideline allows the trauma service to keep these patients out of the ICU while treating it. But before you implement this, please work closely with your pharmacists to ensure that hospital policy allows using neostigmine outside of an ICU setting.

Colonic Pseudo-Obstruction in Trauma – Practice guideline. Click to download.

A funny thing happened eight years ago. During one of our morbidity and mortality conferences at Regions Hospital, we got the first hint of an emerging pattern. We noted occasional trauma patients who developed colonic pseudo-obstruction (CPO), also known as Ogilvie’s syndrome.

In reviewing our experience, it seemed to occur mostly in men who had sustained pelvic or thoracolumbar spine injuries. Surgical instrumentation for these injuries also appeared to be a common factor, as was middle-aged or older, obesity, and metabolic diseases like type II diabetes.

We continued to see the pattern and treated it in a highly variable way depending on the attending surgeon. Abdominal x-rays were obtained semi-randomly, and if the cecum was considered as the ill-defined term “large,” the patient was sent to the ICU for an injection of neostigmine or endoscopic evacuation. If a perforation occurred, patients often got very sick.

As always, variable practice patterns are fodder for developing a practice guideline. This is the first part of a two-part series on CPO in trauma patients. First, I’ll review a new article describing this condition’s incidence in orthopedic patients. Then, in my next post, I will share a practice guideline we developed for use at Regions Hospital.

The paper was a retrospective cohort study performed by the surgical group at Copenhagen University Hospital in Denmark. They focused on patients who underwent pelvic or acetabular procedures for traumatic injury over twelve years. One cohort consisted of patients who developed CPO; the other did not.

The definition of CPO was based on standard procedures that this surgical group already used, although the specifics were not fully explained. It was based on a physical examination of the abdomen, laboratory tests, and radiographic images. Patients with a colonic diameter >10 cm were treated with neostigmine infusion. Colonoscopic decompression was used if neostigmine did not work or was contraindicated.

Here are the factoids:

• Of 1060 patients who underwent pelvic or acetabular procedures for trauma, 25 developed CPO (2.4%)
• The incidence was only 1.6% for pelvic fractures and about 2.6% for acetabular fractures or combined fracture patterns
• Risk factors identified included motorcycle crash, preperitoneal packing, concomitant skull fracture or intracranial hemorrhage, paraplegia or tetraplegia, internal fixation, congestive heart failure, diabetes, and sepsis or nosocomial infection
• CPO development increased ICU length of stay by 9 days and added a month to the hospital stay
• Mortality was higher in the CPO group (8% vs. 6%), but this was not statistically significant

Bottom line: This is the first paper I’m aware of that quantifies what I have already seen regarding Ogilvie’s syndrome in trauma. It should be an eye-opener for everyone who sees seriously injured orthopedic patients. The increased lengths of stay are enormous, which adds to the cost and the potential for even more complications.

Obviously, this is a problem that needs to be taken very seriously. Use of the ICU for neostigmine infusion or procedural decompression should be common. But recognition and initial management should be standardized, so all appropriate patients are treated for the condition.

In my next post, I’ll share the practice guideline we developed at Regions hospital. It is designed to identify the condition early and provide decompressive therapy without moving the patient to the ICU.

Reference: Ogilvie Syndrome in Patients With Traumatic Pelvic and/or
Acetabular Fractures: A Retrospective Cohort Study. J Orthop Trauma 37(3):122-129, 2023.