Whole Bowel Irrigation

1. See Also
   1. Decontamination After Toxin Exposure
2. Indications: Toxic Ingestion
   1. Toxins with poor binding with Activated Charcoal
   2. Heavy Metal Ingestion
      1. Iron Ingestion
      2. Lithium Toxicity
   3. Body Stuffers and Body Packers
      1. Expulsion of drug packets
   4. Sustained release products, enteric coated products, or pharmacobezoars
      1. Oral Hypoglycemic medications
      2. Atypical Antipsychotic Overdose
3. Contraindications
   1. Unprotected airway
   2. Significant Gastrointestinal Hemorrhage
   3. Bowel perforation
   4. Bowel Obstruction
   5. Intractable Vomiting
   6. Hemodynamic instability
   7. Ingestion of Corrosive Chemical
4. Protocol
   1. Consider performing Endotracheal Intubation prior to procedure if concerns regarding aspiration risk
   2. Polyethlene Glycol Electrolyte Solution (PEG-ES, e.g. Golytely) administered orally or via Nasogastric Tube
      1. Most patients require Nasogastric Tube in order to maintain the needed PEG-ES volume intake
      2. May use Activated Charcoal first or combined with PEG-ES (consult poison control)
   3. Patient sits on toilet
      1. Insert rectal tube for intubated or debilitated patients
   4. Measures that decrease patient adverse effects
      1. Warm PEG-ES may prevent Hypothermia
      2. Slowly increase rate to target rate during first hour
   5. Dose (administered until rectal effluent is clear - typically 4-6 hours)
      1. Children 9 months to 5 years: 500 ml/hour
      2. Children 6 to 12 years: 1000 ml/hour
      3. Teens and Adults: 1500 to 2000 ml/hour
5. Adverse Effects
   1. Common Adverse Effects (10% of patients)
      1. Nausea and Vomiting
      2. Abdominal cramping
      3. Abdominal Bloating
   2. Serious Adverse Effects (rare)
      1. Aspiration Pneumonitis or Pneumonia
      2. Hypersensitivity to Polyethlene Glycol Electrolyte Solution (PEG-ES)
      3. Hypothermia (from large volume of cool fluid)
6. References
   1. Warrington and Paravati (2018) Crit Dec Emerg Med 32(6): 11
   2. (2004) J Toxicol Clin Toxicol 42(6): 843-54 [PubMed]