View Full Version : Rektal infusion
Rektal infusion is a big topic in a danish forum i am in, do you use in when you have no IV IO ect? the question are most for Long range reccon paloon, pj and other spec.obs.
Frank Hansen
look mother my first post
NousDefionsDoc
06-06-2004, 18:08
I'm not sure what you are talking about.
It sounds like the ol' IV up the poop chute technique.
NousDefionsDoc
06-06-2004, 18:35
If you have fluids, why would you not infuse the normal way? I am unfamiliar with this technique.
Eagle5US
06-06-2004, 18:51
You can infuse Normal Saline rectally...this technique was widely utilized by the british in the Falklands.
The british military was significantly short qualified medical personnel trained in IV fluid therapy...
The tubing SANS NEEDLE can be placed into the COLON (this means past the rectal vault) through the anus. The "trick" is getting it up there far enough for the fluid to act as more than an enema.
The patient should already be significantly hypovolemic and unconscious, the tubing is wrapped around a finger and slid up into the rectum to the third knuckle as if doing a rectal exam...with the finger still in place and being used as a guide and barrier keeping the anus open, the tubing is slid forward to approximately where the first "Y" port junction is, or 12 inches...whichever comes first.
Digit removed, IV turned on full...
WHY THE HELL would they do something like this???
The function of the large intestine / colon is to absorb water from the slurry that is your fecal sludge...this way you can make little pellets and logs to marvel at and make funny faces when they come out.
If you are dehydrated / hypovolemic, it is thought that these microvilli in the colon will absorb at least SOME of the fluids and assist in your rehydration.
I am not aware of any scientific studies to support their practice...but in theory it makes sense. This WILL make your patient shit his pants though...just like an enema will because it will stimulate the evacuation response.
PA
NousDefionsDoc
06-06-2004, 18:58
I understand the reasoning behind it. So they used it as a compensation method for lack of adequate training.
We don't have that problem. We can teach someone how to do an IV in much less time than it takes to sale from England to Argentina. LOL
Originally posted by 52bravo
Rektal infusion = rectal infusion
Interesting twist of spelling....
I would like to see evidence that supports this method. Ive administered a few different types of fluid rectaly and never were they retained to the extent that they could support the vascular compartment that I'm aware of. Now medications might be another story ie lactulose enema for a pt with end stage liver disease suffering exacerbation of metabolic encephalopathy (usually from noncompliance).
On the other hand I could take a jr highschooler and teach him or her to do IV starts within a few hours...
ccrn
DoctorDoom
06-07-2004, 05:53
"Rektal" makes sense since he's Danish.
Lactulose is a bulk binder and would by definition result in a diarrhea, so trans-colonic retention of the fluid from the infusion would not be observed.
As the original poster indicated, the use of rectal hydration is only recommended when IV or interosseous hydration is not possible due to lack of equipment or lack of sterile IV fluid. IV access is, as everyone has pointed out, simple and still preferred. The one advantage of rectal infusion is that a non-sterile solution can be administered because the colonic membrane is designed to prevent bacterial translocation. So if you have no IV bags and no needles but just a bucket and some clean water you can hydrate someone by sticking a tube in their bum to a certain extent.
That's what I was taught anyway. Never seen it done.
52bravo, you are in Odense? Got a friend there, and some friends in Middelfart...
I my selv find, not the best way as menny of the posts says, I my selv use IV or IO, but unit (recon of the home defences) use this rectal( in danish and latin/greak rektal so sorry)infusion.
thay dont have IV or IO equipment(dont get my started on that, i find i stupid and not up to 2004 standart)
i my selv is not from a recon unit, and find the rectal infusion not the best way to go on shock terpi. and i glad that to se that i am not the only one.
and i think that oral infusion, will be the best for them, but thay still go on that that the retal infusion is best.
and yes i am from odense denmark
Frank Hansen
Originally posted by DoctorDoom
Lactulose is a bulk binder and would by definition result in a diarrhea
Binds with ammonia in the colon. I know what lactulose is Ive had the lovely experience of administering it personaly many times.
And I know what the intent of the original poster was but nice summary I suppose...
Ive never seen fluid resuscitation via colonic route either and for a good reason...it wouldnt work I'm sure. But like I said I would like to see research to support it. Desperate or not if it doesnt work it doesnt work and time could be better spent doing something else-
Originally posted by Eagle5US
You can infuse Normal Saline rectally...this technique was widely utilized by the british in the Falklands.
The british military was significantly short qualified medical personnel trained in IV fluid therapy...
The tubing SANS NEEDLE can be placed into the COLON (this means past the rectal vault) through the anus. The "trick" is getting it up there far enough for the fluid to act as more than an enema.
The patient should already be significantly hypovolemic and unconscious, the tubing is wrapped around a finger and slid up into the rectum to the third knuckle as if doing a rectal exam...with the finger still in place and being used as a guide and barrier keeping the anus open, the tubing is slid forward to approximately where the first "Y" port junction is, or 12 inches...whichever comes first.
Digit removed, IV turned on full...
WHY THE HELL would they do something like this???
The function of the large intestine / colon is to absorb water from the slurry that is your fecal sludge...this way you can make little pellets and logs to marvel at and make funny faces when they come out.
If you are dehydrated / hypovolemic, it is thought that these microvilli in the colon will absorb at least SOME of the fluids and assist in your rehydration.
I am not aware of any scientific studies to support their practice...but in theory it makes sense. This WILL make your patient shit his pants though...just like an enema will because it will stimulate the evacuation response.
PA
eagle5US: do you have a link, articel ect ti the UK army's rectal fun?
DoctorDoom
06-07-2004, 17:01
Originally posted by ccrn
Binds with ammonia in the colon. I know what lactulose is Ive had the lovely experience of administering it personaly many times.
And I know what the intent of the original poster was but nice summary I suppose...
Ive never seen fluid resuscitation via colonic route either and for a good reason...it wouldnt work I'm sure. But like I said I would like to see research to support it. Desperate or not if it doesnt work it doesnt work and time could be better spent doing something else-
Just thinking out loud and posting, not trying to sharpshoot you there. But it would appear from your first post that you are basing your evaluation of the likelihood of effective hydration based on your experience of rectal infusion of medications and binders that by their nature would decrease vascular volume. Perhaps I am misreading your post?
It seems that several posts were talking about how IV would be preferred and that it would be simple to teach, including your own post. I was trying to refocus on the point that rectal hydration is reserved for a situation where IV access is not possible for lack of equipment (rather than as a comparable alternative), and can include non-sterile fluid, a point not previously mentioned and which can obviously have significant import in field conditions. It was not intended as a summary.
I think it would work, but should again be reserved for desperate situations. One of the questions being debated by medical ethicists is if a person is DNR and when terminal has directed that they not receive IV hydration or paraenteral nutrition, whether the practice of pararectal hydration is ethical. It has been used in terminally ill patients so I don't see why it wouldn't work in other patients.
Likely the reason few have ever seen it is because of so many vascular access options in a clinical setting, not just because rectal hydration doesn't work at all.
Originally posted by DoctorDoom
One of the questions being debated by medical ethicists is if a person is DNR and when terminal has directed that they not receive IV hydration or paraenteral nutrition, whether the practice of pararectal hydration is ethical. It has been used in terminally ill patients so I don't see why it wouldn't work in other patients.
Are you serious that people are questioning whether rectal infusion is ethical if a person has already stated refusal of IV fluids??? that seems ridiculous. That is like saying if you refuse oral intubation the nasal route would be acceptable...
cannot believe this even gets debated.
doc t.
Eagle5US
06-07-2004, 20:15
Originally posted by Doc T
Are you serious that people are questioning whether rectal infusion is ethical if a person has already stated refusal of IV fluids??? that seems ridiculous. That is like saying if you refuse oral intubation the nasal route would be acceptable...
cannot believe this even gets debated.
doc t.
Uhhhh..Hi Doc T :D
Eagle
Roguish Lawyer
06-07-2004, 20:17
What a shitty thread.
Sorry. Couldn't resist. :D
QUOTE]Originally posted by DoctorDoom
.... it would appear from your first post[/QUOTE]
I was referirng to not only a binder ie lactulose but tap H2o enema etc also. I would challenge anyone to retain a liter of saline or any other type of water rectaly for more than a few moments or minutes let alone enough fliud for resuscitation ie vascular collapse assuming a pt had enough rectal tone to do so.
I'd also like to add that rectal route is not exactly expediant or conveniant in emergent situations ie TNCC.
Considering someone prehospital will not get the many units of PRBC, colloids/hespan etc ,alot more than one liter will be given...
Stand back I say....
Based on my experience in the ICU and ER, and stories Ive heard of in the OR I think it would not work.
If 91W carries IV equipment into the field with leg units I cannot imagine how a highspeed unit, if even a foreign one , would not have the capability if not more. Of course there is the scenario of mass casualty etc but triage sorts that out however unfortunate.
I cant imagine either a terminal DNR/DNI pt accepting rectal fluids if not recieving other routes. Of course DNR does not mean "Do Not Treat" and we will often still treat them aggressively for better or worse. Ive been in this situation many times, (and hospice and palliative) in a few different regions of the country and have never even seen or heard of it mentioned let alone done. More sound to advance NGT or feeding tube instead-
ccrn
DoctorDoom
06-08-2004, 07:29
Originally posted by Doc T
Are you serious that people are questioning whether rectal infusion is ethical if a person has already stated refusal of IV fluids??? that seems ridiculous. That is like saying if you refuse oral intubation the nasal route would be acceptable...
cannot believe this even gets debated.
doc t.
Bioethicists debate everything... I suppose there are doctors who give proctoclysis even though IV access has been refused for palliative reasons... people get overzeralous I guess... I don't see why it would be justified.
DoctorDoom
06-08-2004, 07:48
Originally posted by ccrn
I was referirng to not only a binder ie lactulose but tap H2o enema etc also. I would challenge anyone to retain a liter of saline or any other type of water rectaly for more than a few moments or minutes let alone enough fliud for resuscitation ie vascular collapse assuming a pt had enough rectal tone to do so.
I agree that a fluid bolus as comparable to an enema would not be retained. However, with a slower rate of infusion one can replenish some fluid. Terminally ill patients have been shown to be able to tolerate 250cc/hr of proctoclysis. While this may not be comparble to a 2L bolus wide open, it is still considerable hydration. Given that terminally ill patients with villi atrophy can handle that amount of infusion I think previously healthy individuals with normal villi could probably tolerate more. In a trauma situation there is evidence that one does not need to hydrate with large immediate boluses of crystalloid, but only maintain perfusion. Thus if administered at a slower rate with a goal of maintaining perfusion until extraction, I think that rectal infusion can be of utility in the field in the absebce of other options or in extremis.
If 91W carries IV equipment into the field with leg units I cannot imagine how a highspeed unit, if even a foreign one , would not have the capability if not more. Of course there is the scenario of mass casualty etc but triage sorts that out however unfortunate.
Not simply mass casualty but prolonged combat situations with delayed extraction and/or no medical resupply. Even if the medic has means of venipuncture he may run out of IV fluid bags. Tap water works with proctolysis and can support a wounded soldier until extraction. Will it replace PRBC's or be sufficient for a casualty who needs massive volume repletion immediately? Of course not.
Rural medicine also has demonstrated the use of used foley catheters and tap water as one way of saving money while providing hydration. This certainly appears to be a potentially useful tool for an 18D on deployment with indigenous peoples for a lengthy period of time. Just another arrow in the quiver, IMHO. But certainly not the first weapon I would choose in the armamentarium.
Some stuff I found on the net that jibes with what I've been taught:
Proctoclysis for hydration of terminally ill cancer patients.
J Pain Symptom Manage 1998 Apr;15(4):216-9
Bruera E; Pruvost M; Schoeller T; Montejo G; Watanabe S .
In a prospective, open study, 78 patients with terminal cancer received proctoclysis (rectal hydration) in four different centers. In all cases, a #22 French nasogastric catheter was inserted approximately 40 cm into the rectum and an infusion of normal saline (2 cases) or tap water (76 cases) was administered at a rate of 250 +/- 63 cc/hr. Hydration was maintained for 15 +/- 8 days. The main reason for discontinuation of hydration was death (60 cases). The mean visual analogue score for discomfort after infusion (0 = no discomfort, 100 = worst possible discomfort) was 19 +/- 14. Our results suggest that proctoclysis is a safe, effective, and low-cost technique for the delivery of hydration in terminally ill cancer patients.
http://www.ircm.qc.ca/bioethique/english/publications/sample/article2.html
RELEVANT PORTION:
Proctoclysis
Proctoclysis refers to the rectal administration of fluids, based on the fact that absorption of fluids has been reported after enemas and in normal volunteers. It has been developed for patients who require parenteral hydration but who are unable to receive it by another route because of contraindications or mostly the simple lack of necessary technical resources.
Our group conducted a multicentre study comprising 78 terminally ill adult patients who all had clinical evidence of dehydration and who were unable to receive hypodermoclysis for the following reasons: generalized edema, n=4; bleeding disorders, n=3; pain and swelling during hypodermoclysis, n=3; and lack of the necessary technical resources, n=68. None had tumor involvement of the colon. Most of these patients had low income, had no health insurance coverage, lived in developing countries, and died at home under the care of relatives.
The procedure involved the insertion of a 22-French nasogastric catheter into the rectum about 40 cm and the infusion of normal saline or tap water at initial rates of 250± 63 mL/hour. The duration of infusion was 15± 8 days. The reasons for discontinuation of the infusion were death (n=60), refusal to continue proctoclysis because of pain (n=4), return to oral hydration (n=6), and decision to discontinue hydration (n=8). The main side effects were an enema effect seen with maximal rates of infusion (n=9), leakage of fluids (n=4), pain during infusion (n=6), and pain during insertion of the catheter (n=5). Patients reported their discomfort after each proctoclysis on a visual analog scale (0= no discomfort, 100= worst possible discomfort); the mean level of reported discomfort was 19± 14.
It is likely that tolerance of proctoclysis can be better in patients who have received frequent enemas and suppositories previously. Our experience in all settings suggests that when the option exists, most patients prefer subcutaneous hydration.
These results suggest that proctoclysis can be a simple and effective technique for patients who need parenteral hydration, have no tumor-related involvement of the colon, and are unable to receive it by another route as a result of either contraindications or lack of resources. This technique involves minimal costs, does not need any sterile device or manipulation, and can be implemented by nonprofessionals in the home intermittently over 4-hour infusions (30,31), particularly when family members can be involved in the delivery of physical care. Its potential applications may lie particularly in developing countries or rural areas, where there may be no access to health care workers capable of starting and maintaining a subcutaneous infusion and where access to sterile needles, fluids, and tubings may be too expensive (40,41).
http://www.activ8online.net/eha/publications/journal/remotesurgery.htm
RELEVANT PORTION:
Measures for cutting down cost of treatment at hospital
The following measures were adopted for reducing the cost of treatment at the hospital.
2 Using proctoclysis instead of intravenous (IV) fluids except for saline solutions. Used Foley catheters were placed in the rectum and used IV bottles, IV sets and tap water were utilised for proctoclysis.
*Edited to say that I realized that this may be construed as a pissing match. That is certainly not my intent; I have enjoyed and learned from this discussion.
Originally posted by DoctorDoom
...may be construed as a pissing match. That is certainly not my intent; I have enjoyed and learned from this discussion.
Not taken that way at all.
Interesting articles but not research however, not to mention 6 and 7 years old respectively.
Also they conflicted each other regarding the use of normal saline.
Are you aware of any independently duplicated research that is current to support the use of "proctoclysis" fluid administration either in the palliative/hospice or trauma pt?
ccrn
and the bowle perfusion in shock is not same as it is in cancer, i think the perfusion is the big one here
DoctorDoom
06-15-2004, 15:42
Originally posted by ccrn
Also they conflicted each other regarding the use of normal saline.
Are you aware of any independently duplicated research that is current to support the use of "proctoclysis" fluid administration either in the palliative/hospice or trauma pt?
ccrn
and the bowle perfusion in shock is not same as it is in cancer, i think the perfusion is the big one here
Both ccrn's note regarding the dispute over saline and 52bravo's point on perfusion are excellent caveats.
I also do not have anything recent, but I suspect that proctolysis being so rare based on your clinical experience there's not much info out there. I can't think of many settings where one could hydrate rectally but not IV or use a feeding tube in a terminally ill patient (perhpas a patient with an obstructing esophageal lesion and a coagulopathy that precludes IV access?) in a skilled nursing/hospice care setting.
I still think that proctolysis is something that might be useful in limited rural/field situations in the absence of other options, but I honestly can't base that on experience or clinical data, just conjecture and what I've been told., which means it's pretty much worthless. :D
The more I hear/read about it, the more it seems to fall into urban myth status. That is, I've always heard of it being done, and everyone seems to have a "friend of a friend" who it was performed upon, but I have yet to run into some that's actually either performed it, or have had it performed on themselves.
That's not to say that it's not a valid procedure, or something else to have in your bag of tricks... either way, it's beyond my current expertise (which tops out at the SuperCLS/CPR level). It just seems to be a procedure that is far more talked-about than actually implemented.
Kyobanim
06-15-2004, 16:07
I'm just glad there weren't any pictures to accompany this thread.
DoctorDoom
06-15-2004, 16:44
Originally posted by DanUCSB
The more I hear/read about it, the more it seems to fall into urban myth status. That is, I've always heard of it being done, and everyone seems to have a "friend of a friend" who it was performed upon, but I have yet to run into some that's actually either performed it, or have performed it on themselves .
I don't know about urban myth, like albino gators in the sewers and such... but that last bit... um.... hmmmm...
:D
Now I feel dirty.
I had to go back and make sure that that wasn't what I had actually typed, otherwise I'd feel -really- dirty. ;)