11. Management of Patient with Colostomy - Patient Education

In this class, we're going to discuss management of the patient with the colostomy. Our focus will be on patient education and basic management guidelines. We'll talk about critical points to be included in self-care instructions. We'll talk about gas control measures, dietary modifications, and the rationale criteria and procedure for colostomy irrigation. So just starting with basics, talking about self-care instructions and pouching. So pouch selection, a drainable pouch is standard care for a patient with an ascending or a transverse colostomy. Because remember, those patients are going to have more liquid stool, they're going to have frequent outputs, so they'll have to be managed with a drainable pouch. In contrast, if you have a patient with a descending or sigmoid colostomy, they're going to have still that's much more normal, it's going to be a lot thicker, it's going to be much more difficult to empty. So those patients may benefit from use of a closed end pouch, since all they would have to do is either remove the pouch, snap it off, clean around the stoma, and apply a new pouch. But all patients should be taught to manage a drainable pouch, because even patients who use closed end pouches routinely will typically use drainable pouches during episodes of diarrhea. So where do we start? We always start by teaching patients how to empty a drainable pouch, how to change a drainable pouch, even if we're going to convert them to a closed end pouch within a few weeks. Real pouch emptying, survival skill number one. We want patients with a colostomy to know they will probably need to empty somewhere between one and three times a day, but always when the pouch is one third to one half full. So when the pouch is half way full, they should start thinking about where can I go to empty my pouch. When they empty their pouch, deodorants will be very helpful. They'll need room deodorants if they're emptying anything other than a private bathroom. And pouch deodorants can also be helpful. Pouch deodorants reduce bacteria within the pouch, so they reduce the amount of odor that the patient will experience when they empty the pouch. If they're using a closed end pouch again, they don't need to empty, they just need to learn the procedure for snapping the pouch off, cleaning around the stomach, snapping a new pouch on, if they're using a two-piece system, or removing the pouch, discarding it in a ziplock bag, cleaning the skin, and applying a new pouch if they're using a one-piece. The second survival skill they have to master is the pouch change procedure. Really nothing that unique about the pouch change procedure for the patient with a colostomy. They can use a standard approach to pouch removal, use an adhesive releaseer if they wish use push pull technique to protect their skin, clean their skin with warm water in a soft cloth, measure the stoma, cut the opening into the new pouch or the new wafer based on the current size of the stoma. What about use of paste or a barrier ring? That can be extremely helpful for the patient with an ascending or a transverse colostomy because again they're going to have more liquid output. The bead of paste or the barrier ring would give them additional protection for the peristomal skin and would help to maintain a secure seal. Most patients with a descending sigmoid colostomy do not routinely need paste or a barrier ring. However, you might find that helpful during the early post-op period because most patients do have more liquid stool during that time frame. Otter control is huge for any patient with a fecal diversion. You put yourself in that patient's position and you think how very conscious you would be that you had an ostomy that you were wearing a pouch, you would want to make absolutely sure that Otter was not an issue. The number one thing for us to teach the patient is to clean the bottom of the pouch thoroughly when they emptied the pouch. So I tell a patient. Before you had your ostomy, when you had a bowel movement, what did you do? You wiped your bottom thoroughly. You kept wiping until the toilet paper came up clean. What are you going to do now? You're going to control Otter by cleaning the spout very well. So you empty, then you clean the outside with toilet paper, then you clean the inside with toilet paper, then very helpful to clean both the outside and inside with a wet wipe, like a baby wipe, so that you make absolutely sure that the bottom of the pouch is clean. There's nothing to control, or nothing to cause Otter. Patients worry about, "Well, won't it smell through the pouch? Will people smell me if I'm sitting right next to them, will they smell me?" You want to reassure them that the pouch is completely Otterproof. Manufacturers spent a lot of time and money developing pouches that are completely Otterproof. So what they did, they literally measured the size of the molecule that produces fecal Otter. So they knew how big it was, how big the molecule was, and then they worked with plastics manufacturers to create a pouch material where the poor sizes in the plastic are smaller than the size of the Otter molecule, so it can't get through. So when the pouch is sealed to the skin, the spout is closed, and the outside of the pouch is clean, there is no odor. No matter how close someone is sitting to you, they will not smell anything, because it's confined within the pouch. And if the patient's really struggling with this, and really thinking, "No, I just don't trust it, I don't trust that, I'm not going to have Otter." One thing I'll tell them is, "Okay, think about this. Everyone is walking around with stool in their colon, some people have stool in their rectum. Do you smell them?" No. Why not? Well, because the bottom's closed, the anal sphincter's closed, so the stool does not come in contact with air, so there's no way to transmit the odor is sealed. And that air proof, odor proof container, the rectum, exactly right. When do people normally have odor? When they open this fincter to eliminate stool? Okay, same thing, when are you going to have odor? When you open the pouch to empty the stool? Patients will frequently ask you, "Don't I need to rinse out this bag and get it clean?" It looks dirty, I think I need to rinse it out. Well, rinsing is not necessary, and we actually usually discourage it, because it makes the pouch emptying procedure much more complex. And also, when you're adding water, you run the risk of undermining the pouch seal. So you do not introduce the concept of rinsing. Now, if a patient says, "I'll just feel so much better if I can rinse the bottom of the pouch," then yes, well, I show them how to do that, of course, because it's all about helping this person feel more secure, more confident, but I will tell them you need to really limit this because it can actually erode your pouch seal and cause problems. And you might remind them people do not irrigate their rectums, they just clean their bottoms. So same thing with the pouch, you don't need to irrigate, you just need to clean. And once we get people into opaque pouches where they can't see anything, they typically feel much better and they have much less compulsion to rinse the pouch. So you discourage rinsing. Now what about deodorants? So there are pouch deodorants and there are room deodorants. Pouch deodorants, all of the ostomy manufacturers make deodorants that can be added to the bottom of the pouch. If they're using that, they need to add it to the bottom of the pouch when they first apply the pouch. Every time they empty it, after they empty the pouch, they clean the spout. They need to add more deodorant. Also they can try commercial products. So a lot of you have heard of poopery, some of you have used poopery and know that it can be very effective. So they can add poopery to the toilet water before they empty the pouch. That can help. Some people will add oral breathments into the pouch because oral breathments eliminate bacteria. That's what causes bad breath, it's also what causes fecal odor, bacteria. So the very same agents that you use to prevent bad breath can be used to reduce fecal odor on the other end. And you know it's safe because if it's safe for your mouth, it's safe for the stomach. So some people use oral breathments. A lot of people will use room sprays prior to opening the pouch to eliminate odor and a lot of people will find one that works really well for them and then they'll carry small spray bottles in their purse or in their pocket. But odor control is very important, you want to spend time talking with patients and helping them identify strategies that work for them. Now one thing that's particularly beneficial for colostomy patients is lubricating deodorant. So what these are is basically a gel with deodorant added. And again you add it to the pouch each time the pouch is emptied and it does two things. It slicks up the inside of the pouch which makes it much easier to empty and it also provides deodorizing effects. So be aware several manufacturers do make lubricating deodorants that can be beneficial for the patient with a colostomy. Also there are oral products. These are particularly helpful for people who are very sensitive to odor, very concerned about odor and also realistically some people have more issues with odor. They have more problems and the pouch deodorants might not be enough. There are two over the counter products that are particularly effective. One is chlorophyllin copper complex. The trade name is Darryl. It comes in 100 milligram tablets. People take it once or twice a day, very effective at deodorizing both stool and urine. They are contraindicated for kids under 12 and it's just less commonly used but still very effective. The more commonly used product is business sub-galate, also known as devrom and devco. People take one to two tablets three to four times a day, typically they chew them. It is amazing the difference it makes within three to four days. The amount of fecal odor is tremendously reduced. I have seen this make a phenomenal difference for patients for whom odor was the big issue. You don't want to forget about this. When you keep hearing this concern from a patient, you want to discuss this option with them. There are contraindications. It's considered contraindicated and children hasn't been tested in them. They're treated in patients who are in renal failure unless they're on hemodialysis. It can potentially interfere with absorption of anti-coagulants and antibiotics so patients need to be aware of that. Also patients should be aware that it will change stool color to a dark green black. That's normal and it can thicken the stool and if they already have thick stool at baseline, it can be an issue they might need to really up their fluid intake or add a little mirror like every day. Another huge issue is gas control. You think there's three potential issues related to gas for a person with an ostomy. First of all, I have to worry that gas can fill my pouch and cause ballooning of my pouch that would make it very visible. So are acutely aware of that. Secondly people are worried about odor. Is anybody going to smell it if I pass gas? And thirdly, sound. Is anybody going to hear it? So huge issue for a person with a colostomy. Remember the large bowel of a colon has very high bacterial counts and gas is produced by bacterial action on undigested fiber. So anyone with a colostomy is going to have issues with gas formation. Early post-op, they're going to have a lot of gas because during surgery you get a lot of air in the bowel and then post-operatively all that gas, all that air has to be pushed out of the colon through the stoma. Once all that gas, all that air is eliminated and the colon is filled with stool, then the volume of gas goes down. So one thing is during the early post-op period between days three and five especially when they're going to start producing and passing gases critical to warn the patient. For the next few days, the next couple of weeks you're going to have a lot of gas because you got a lot of air inside your gut at the time of surgery. So you need to know this is not the way it's going to be, it's the way it's going to be for a short period of time. So just remember this is a short term issue in terms of volume. Then long term, what are the things we need to teach patients? Well first of all, they need to identify what foods cause them to have a lot of gas. Now most people already know, but if they don't, it's very helpful to tell them, okay, the first few weeks when you're pretty much at home, you're not going out very much. This is a time for you to figure out which foods cause you to have more gas, which foods cause you to have diarrhea. So why don't you keep a chart where you write down everything that you eat and drink and then you write down what happens with your bowel if you have diarrhea, if you have constipation, if you have a lot of gas and at what point after you ate this food or drank this fluid? That allows you to identify things that could be problematic for you once you know the foods that are problematic for you, then you can pick and choose when you eat them. So now we're back to lag time. So the lag time between when you eat this food and when you become musical is typically about four to eight hours. So that allows you to kind of think ahead. If you're going out to the symphony on Friday night, you want to be careful what you eat for lunch because you don't want to be tuning up at the same time the symphony is. So you can pick and choose when you eat something. And then you want to talk to patients about specific control strategies. So the muffling technique. So what's the muffling technique is putting your hand or your arm over the stoma and just doing light pressure so instead of that gas popping out, it eases out. We're all very good at this. That's what we use our anal sphincter to do all the time. We know we have gas, we don't want it to make noise. And so we kind of tighten our sphincter and ease it out a little bit at a time. So it's quiet, not loud, okay? They can do the same thing. They want to come up with a line they're going to use if they pass gas unexpectedly. So they can say I'm sorry, my stomach won't stop growling, whatever. And then there are medications they can use. So Bino. A lot of you have used Bino because. what it does is it reduces gas production when you eat certain foods like complex carbohydrates, beans, cauliflower, cabbage, broccoli. And people with an osmier like well can I still take that? Yes, you have the same bowel you had before. Will it still work? So can you take Bino? Absolutely. Will it help? Yes. On the other thing that helps some people is some metacone because it reduces the size of gas bubbles within the gut and the smaller the gas bubble the more easily it's reabsorbed so it doesn't pass all the way through it. Now what about that ballooning thing? So they don't have to worry about odor because the pouch is odor-proof. We've talked about strategies for managing sound. I mean I think it'll be great when they come up with a sound-proof pouch. We have sound-proof everything so we obviously need a sound-proof pouch. But what about ballooning? How do we manage that? Well that's where latest filters and vents come in and companies continue to work on these products. We're not where we need to be but we're much further down the road than we were say ten years ago. So a filter like you see in the pouch illustrated on top. Most of your fecal pouches now have filters and filters have charcoal and they're designed to allow gas to escape gradually from the pouch but first the gas is forced through the charcoal so it's deodorized. So it's a way to keep the pouch flat without causing any odor. Now way back what people used to do and this was actually advised sometimes given to us to be patients not good advice but advice. People would say well poke holes and the very top of your pouch so the gas can get out. It's like well yeah the gas can get out but odor can get out and if you have liquid still that can get out. So no you don't want people to do that but you do want to recommend a pouch with a filter. What's the difference between a filter and event? Well a filter forces gas through charcoal and then lets it escape into the environment. Event simply allows gas to exit the pouch. So vents are externally applied so they're little devices that can be attached to the top of the pouch. So typically they'll tell you okay clean the pouch material with alcohol, peel the backing off this little adhesive on the back of the vent, stick it onto the pouch. Event is illustrated in the middle picture and so you can see it literally has you can pop the top on the vent. So when your pouch starts to fill with gas you can walk away from other people you can walk into the bathroom. You can open the vent, compress the pouch, allow the gas to escape but you have to be aware there is no filtering effect and you will have odor so you have to think where am I where do I need to be when I open this vent. And then for patients who have a two piece pouch and alternative to event is the option to burp the pouch. So remember with a two piece pouch you have a barrier away for a fix to the skin and then you have a pouch attached to snap down to the barrier wafer. So that gives you the option to lift the pouch away from the barrier wafer so that gas escapes but again you're going to have odor so you have to pick and choose when you do this. What about diet? That's one of the most common questions we get from patients who are anticipating the possibility of anostomy. Am I going to be on a special diet? I heard I would have to eat baby food the rest of my life. None of that is true. For the patient with a colostomy there are no absolute restrictions. They have the same bowel. It just empties at a different point. So when people say can I eat this? I always say could you eat it before? Yes you can eat it now. So if you had dietary intolerance as if you were lactose intolerant before you still are. But if you could eat spicy Indian food before you can still eat spicy Indian food. Nothing has changed about your ability to digest and absorb nutrients. The only thing that's changed is where your bowel empties. Now for the patient with a descending or sigmoid colostomy remember those patients are at risk for constipation just like they were before. If they don't get enough fiber if they don't get enough fluid they will become constipated. So it's critically important for us to tell them this and to make sure that they're getting enough fluid and that they're getting enough fiber. If you have a patient who has a lot of difficulty getting in enough fiber through their diet then you might want to recommend a fiber supplement on a routine basis. What about preventing and managing constipation? Well we were already talking about that. We've said the patient who's at risk primarily is the patient with a descending or sigmoid colostomy. We've said prevention involves adequate fiber, adequate fluid activity and avoidance or strictly restricted intake of opioids. Just like for someone without an ostomy no different the exact same things. Patients will ask you how would I know I was constipated? Well how did you know before? Well I wouldn't go I wouldn't have a bowel movement okay same thing or it would be really really hard like pellets same thing and sometimes I would have bloating okay same thing. Well what should I do about it? Well what did you do before? Well usually I would take a laxative okay take a laxative. I can still take a laxative same bowel. So can could you take mirror lax? Yes. Could you take milk of magnesium? Yes. Could you take synocot? Yes. Dalkylax? Yes. So you can still take over the counter laxatives. If you could take it before you can take it now. And for patients who know how to do an irrigation they could do an irrigation. An irrigation is nothing more than an enema through the ostomy and enema through the stomach. So bottom line prevention identification and management of constipation for the patient with an ostomy is the same as prevention identification and management of constipation and a person without an ostomy same bowel. What about diarrhea? Same rules right? It's gonna be much more common in a patient with an ascending or a transverse colostomy because they have more liquid stool at baseline. Can it still happen in somebody with a descending sigmoid colostomy? Can a person with an intact colon and rectum develop diarrhea? Yes. So diarrhea can happen to anyone as a result of something they ate as a result of some kind of minor viral infection as a side effect of chemotherapy. Same things. Well what should I do if I have diarrhea? Well if you're wearing a closed end pouch you probably want to switch to a drainable pouch. You want to be absolutely sure that you're drinking enough fluid to prevent dehydration. Great fluids are water. G2 power 8-0. What about diet? You don't eat spicy things. You don't eat high fiber foods when you're having diarrhea. You eat a kind of bland low fiber diet. Some people benefit from the brad diet bananas. Green plantains are great. Rice, applesauce, tea and toast those kinds of things. Is it okay if I take a modium? If I go get some modium over the counter? Yes. The only time I would say check with your physician first is if you're having other symptoms, if you're running fever, if you're having abdominal pain, if you're having nausea and vomiting, my concern in that situation is maybe this is not just a viral illness, maybe this is some kind of bacterial diarrhea, and we don't want to give anti-diarrheals to somebody with a colon full of bacteria and bacterial toxins. So if you have any concerns that something else is going on, talk to your physician first, but if everybody in your family had this GI bug and diarrhea, and now you've got this GI bug and diarrhea, is it safe to take a modium? Yes. You'd be better off if you could find a chewable version or a liquid version because you would get better absorption. So the last thing we want to spend a little bit of time on is colostomy irrigation. Now some of you will have done this or seen this, and for others this will be brain new content. So remember that a colostomy irrigation is nothing more than an enema administered through the stoma. So you think, well, why would I be doing this? It would be the purpose, and it's going to follow along the same lines with one exception. So many patients with a descending or sigmoid colostomy elect to do routine irrigation to regulate and control stool elimination. We'll come back to that. We also sometimes use colostomy irrigation before and after a diagnostic test for bowel prep, and then to eliminate contrast medium, occasionally we'll use an irrigation to administer a therapeutic solution like we have done this to administer a KX late in a patient with high potassium levels, and we can use irrigation just like a standard enema to treat or to prevent constipation. So let's talk a little bit more about using irrigation to regulate bowel function, because that's a new concept for most people who are doing ostomy care. So how does irrigation work? Well, we're literally instilling fluid through the stoma. Our goal is to extend the left side of the bowel sufficiently to stimulate peristalsis and to force emptying of the left colon. Once we empty the left side of the colon, it usually takes about 24 hours for that section of bowel to refill the stool. So you see what's happening? I'm emptying the left side of the bowel, and I'm buying a period of time when I will be stool free. If I repeat the same irrigation on a regular schedule, over time I essentially teach the bowel, train the bowel to respond to that stimulus, and I get a very predictable response. So clinically what happens is routine irrigation every day, every other day at the same time over weeks, over months, over years, provides modified continents where the bowel empties own schedule and where I have no stool in between. And that's my goal. I want the bowel to empty effectively when I put the water in, and I won't minimal or no output between the irrigations. Now what are the things I have to consider before I recommend this to a patient before I discuss this with a patient? Well the first thing I have to think about is the location of the clostomy. This is typically a good option for the patient with a descending or sigmoid clostomy who has pasty or form stool. It is not a good option for a patient with an ascending or transverse clostomy because number one they have mushy stool and number two, parasitotic patterns on the right side of the colon constantly sweep stool toward the transverse colon. So I can clean out the right side of the colon but immediately it begins to refill and to push stool toward the transverse colon. So I don't get any benefit from irrigating an ascending or a transverse clostomy. I don't get a stool free interval so why do it? The second thing to think about is to ask this patient what were your bowel patterns before surgery? Were you pretty regular? Did you typically go every day, every other day, or were you one of those individuals who had pretty unpredictable bowel patterns and it was heavily influenced by stress levels by dietary intake? The more predictable and regular you were pre-op, the more likely you are to get good results post-op. Finally, can this patient learn the procedure or are they cognitively intact? Do they have the psychomotor skills to perform the procedure? And is this their preference? Once we've laid it all out, look, you could manage just by wearing the pouch and either change the pouch or empty the pouch when you have a bowel movement. Or we could talk about irrigation where you put water into the bowel, you force it to empty, you clean the bowel out, and you just wear a little cover until it's time to do the irrigation again. What sounds better to you? So patients will say, well, what do you see as the advantages? What do other people say are advantages? Well, number one, if you hate the idea of wearing a pouch that fills up with stool when you're sitting in a meeting, when you're out with friends, then this could be a major advantage because it can eliminate unpredictable stool evacuation. It can eliminate the need for a drainable pouch and essentially it provides modified continents. It allows you to wear just a little stoma cap that's very low profile, will not show through your clothes. It reduces gas and odor because it eliminates stool and its bacterial action on stool that continues to produce odor and gas, but you're cleaning the bowel out so you're eliminating the stool and you're reducing gas and odor. And the studies that have been done looking at patients who do manage with irrigation versus those who manage with a pouch indicate that patients who manage with irrigation have higher quality of life. But there are some disadvantages you have to think about. First of all, you have to remain on schedule. So if you routinely irrigate at 6am because you have to be at work at 8 and it's the weekend and you'd really like to sleep in, you can sleep in for a couple of hours, but you really need to get that irrigation done by 7 or 8am. So is that going to work for you and for your lifestyle? And it does take about an hour from start to finish, it doesn't mean you can't be doing other things like responding to emails, surfing the net, whatever, but it does mean that there's that period of time where you can't just leave the house. There are some contraindications. We do not do irrigation in children, it hasn't been studied in children and there are major concerns that it could create bowel dependency, so it's not recommended for children. We don't typically recommend irrigation in people with a poor prognosis because it's like do you really want to spend time doing this if you have limited time? But it's not an absolute contraindication. I've had patients who were palliative care and of life care and this was really important to them to establish and maintain control. There is no reason you cannot teach a patient at end of life if that's their preference. If they have active bowel disease like Crohn's, they're typically going to have unpredictable stool output, episodes of diarrhea. We don't usually recommend irrigation. If you have concerns, questions, probably you and the patient and the surgeon, I'll need have an open discussion about is this going to be beneficial for the individual. People who have frequent episodes of diarrhea, unpredictable bowel function, not a good choice. They are not going to get the benefit that they won't. They're not going to get predictable controlled output. They're just going to waste time in general and add frustration. So we don't typically recommend it for those individuals. Now I have had people who said I want to try. Is it okay for me to try, of course. But you know what, if we can't get you where you want to be within six weeks, eight weeks, I would recommend backing off and just managing with a pouch. Maybe you want to manage with a closed-in pouch so you can just take it off, throw it away, put another one on and go about your business. But you probably don't want to spend the time with irrigation if it's not giving you the outcomes you want. Notice what's involved. You will definitely have this question on an exam and very possibly on the certification exam. We do not irrigate when the patient's undergoing chemotherapy or abdominal or pelvic radiation. Abdominal and pelvic radiation makes the bowel tissue much more friable, so we're much more likely to traumatize the mucosa. Both chemo and radiation calls diarrhea, so why would we be giving an enema to somebody who already has diarrhea? So that is an absolute contraindication, ongoing chemotherapy or radiation. And we avoid irrigation in patients with stomal complications like peristomal viruses because of the risk of bleeding, like a patient with major prolapse or peristomal hernia. Okay, so let's talk about practical considerations. What equipment is needed? So we're going to give a front-sided enema and we do not have an anal sphincter to control elimination. So I'm going to need an irrigation sleeve that controls output that flows into the toilet and I'm going to need a modified enema setup. I'm going to need my irrigation bag, which is just like an enema bag, but instead of just a catheter or an enema tip, I want a cone tip that controls the inflow of fluid and prevents backflow. We'll look at that in a little more detail. And then I want to provide patient counseling and education. I want them to be very clear about why they're irrigating what they're trying to accomplish. I want to make sure they understand the advantages and disadvantages like we've just discussed. I want to make sure they understand the importance of irrigating own schedule and I want to help them set up a schedule that is compatible with their lifestyle that works for them and that ideally mimics their normal bowel patterns. And then I want to teach them the procedure and complication prevention. So we're going to go through those things. So here's your equipment. You need your irrigation bag which is just like an enema bag. You need a cone tip which you see in the illustration on the top left. So you see it has that cone shape so it's going to fit into the stoma and give you a snug fit is going to eliminate the potential for causing bowel perforation by putting a catheter into far. And I want an irrigation sleeve that controls drainage that makes sure all the water and the stool goes into the toilet and not everywhere else. So I get my equipment very simple equipment actually. I'm going to fill the irrigation bag with between 500 and 1500 milliliters of lukewarm water. Typically we fill with right at a liter. That's based on two findings and studies that have been done. The first finding is that you need a minimum of 500 milliliters to extend the bowel and activate peristals. So less than 500 milliliters is typically ineffective. We also have data that says more than 1500 milliliters has no added benefit. So what's the sweet spot between 500 and 1500 milliliters? Typically we start midpoint and right at a thousand. We will open the control mechanism so that we clear the tubing of air just like we do with enemas. And then we're going to hang our irrigation bags so that the bottom is at shoulder level. That gives us the optimum pressure behind the fluid. We'll take off the pouch or stomach cap. We're going to attach the irrigation sleeve. Now you'll find in clinical practice that some irrigation sleeves are designed for use with two-piece systems. So they snap onto the flange of the two-piece wafer. Other irrigation sleeves either stick on or belt into position. So the one you see and the illustration on the top left belts into position. You're going to place the end of the sleeve in the toilet. Then you're going to lubricate the cone tip just like you would lubricate it in a matip. You're going to insert the cone tip into the stoma until you have a snug fit. Then you're going to open the clamp. You're going to allow the water to flow in and you're going to adjust the angle of the cone tip until you get steady in flow of fluid and minimal or no back flow around the cone tip device. You want the water to go into the colon, not around the cone tip and into the toilet. Now your goal is to instill the fluid fairly quickly in about five to ten minutes because you won't bowel distinction and peristalsis. You don't want to just give the body a drink through the ostomy. If you give it slowly you're just going to be giving it a drink. So you want the fluid to flow in in about five to ten minutes. So then you tell the patient okay I want you to tell me when you feel full because when you feel full I'm going to stop the inflow of fluid. I had one patient she's like well how will I know I'm full and I'm struggling to tell her how she'll know she's full and about one minute later she's like I'm full. Stop it. So yes they can tell when they feel full it's like oh no I can't take any more borderline cramping I feel like everything needs to come out. Then you're going to close the top of the irrigation slave and await results. Now everyone's individual just like you've given enemies before you know some people get almost immediate response. Some people it's five, ten, fifteen minutes. Very common to see initial results within five to ten minutes. Then to have a lag time with no activity nothing coming out that lasts about ten to twenty minutes and then have additional output. But the first time you do an irrigation you don't know what to expect. You just have to tell the patient we're going to put the water in. We're going to monitor your response. We're going to see how long it takes for everything to come out and we're going to keep records for the next few weeks. Within a few weeks we'll know exactly what to expect. Right now we're in uncharted territory. So you close the top of the irrigation slave you await results when you think returns are complete you'll take off the sleeve you'll clean the scan you'll apply the pouching system or your little stomach cap and then you're going to wash the equipment and hang it up. So it's just like giving an enema through a stoma with modified equipment. Now there are some potential problems not meaning and most of them pretty benign. Sometimes you have trouble getting the water to go in. A very common reason is that you've inadvertently got the cone tip angled in correctly and it's up against the bow wall so the water can't come out. So I tell patients pretend your stoma's a clock and literally take the tip of the cone all the way around. So start at 12 o'clock, 1 o'clock, two o'clock come all the way around till you figure out the point that permits free flow of water. So deliberately angle it up to 12, then to one, then to two, then to three, till you find the best angle. Sometimes the water's been going in and all of a sudden it stops and you can see water starting to back up. That's almost always a parasitic wave. Close the clamp, remove the cone tip, allow returns, and then resume the procedure. And very occasionally it's because there's hard stool that has gotten stuck in the end of the cone tip. So if you can't figure out what's going on, take it out, clean it out, put it back in. The second thing that can happen is you put the water in, but then it doesn't come back. And this scares patients to death is like, where did it go? I put the water in, it didn't come back, I don't know where it went. Where it went, almost always, is either into the bloodstream because you were dehydrated or because you gave the fluid very slowly. Or you didn't recognize it, but the whole time you were putting water in, it was running out around the cone tip into the toilet. So two major reasons. One is either the patient was somewhat dehydrated and/or you gave the irrigation very slowly. And all of the water got reabsorbed through the mucosa into the bloodstream. So they'll just pee it out. You tell them how to keep this from happening, make sure the water goes in in five to 10 minutes, make sure you stay well hydrated, and make sure you hold the cone tip snugly, so water's not running around. Very helpful to watch the patient do the procedure. You can almost always figure out what's going up. The one scary thing, and it's not serious, but it can be scary, that can happen associated with irrigation as a vasovagal response. And what happens here is that distinction of the bowel activates the vagus nerve. When you activate the vagus nerve, you drop the blood pressure and you drop the heart rate, and you reduce blood flow to the brain, and then the patient passes out, which scares you to death. But as soon as they pass out, they become horizontal. Now they've got blood flow to their brain back, and they wake back up. So what causes it? They go stimulation. It's most likely to occur during the first irrigation, especially if you do it in the early post-op period. So when we did irrigation during the first few days post-op, we did occasionally see this, not often, but occasionally. And today's short-stay environment irrigation is rarely initiated in the hospital. They're usually at home. They're much more stable. And it's extremely rare to see this. But I want you to be aware of it, because it's a possibility. How do you know somebody is beginning to have a vasovagal response? Typically, they say, I feel hot. I feel sick. And then they start talking to you, because this is when they pass out. So I remember the first patient I ever had with a vasovagal reaction. Of course, it was a surgeon. We're in this little tiny bathroom. And he's like, I feel hot. So I gave him a co-cloth. And he's like, I feel sick. So I turned off the irrigation, and then he goes-- and then I'm trying to drag him out of the bathroom into the patient room. His irrigation slave traveling along behind him. As soon as I get him supine, of course, he wakes up and is like, what's going on? I'm like, you're scaring me to death is what's going on. That was the last time he ever had a vasovagal reaction. So even in a patient who does have a vasovagal reaction is likely to be a one-time thing. How can you prevent it? Ideally, you do the first irrigation in the bed or the recliner so you can put their head flat if they start to have any symptoms. Also, I typically try to limit the volume of irrigation and the level of bowel distinction during the first irrigation. Critical points about colostomy irrigation, kind of putting it all together. This can be the best option for a patient with a descending or sigmoid colostomy, especially if the patient has a lot of concerns about managing a drainable pouch, about wearing a drainable pouch. But it is not an option for a patient with an ascending or transverse colostomy. They're going to have liquid to mushy stool. They're going to have frequent output. And even if you empty the right side of the colon, it does no good because peristalsis is constant on the right side of the colon and you immediately start to refill. It's contraindicated in patients receiving ongoing radiation or chemotherapy. It's okay once chemo or radiation is discontinued and bowel function is back to normal. Patients will ask you, "If I do this, "if I start this or must stuck, "do I have to do it forever and ever?" No. You can discontinue irrigation at any point. Now, what if your bowel has become somewhat dependent on that stimulus? That's okay, we can use another stimulus. If we have to substitute laxatives, we can do that. And finally, you should be aware that patients who have been irrigating for many years, there are people out there who have been irrigating for 30 to 40 years. And over time, they may experience reduced responsiveness to irrigation just because they've reduced peristalsis with aging. So you think, "Okay, this patient's telling me "that it takes them a lot longer to do the irrigation, "it takes a lot longer to get returns. "They're having leaky gym between irrigations, "but nothing's changed in their approach. "Nothing's changed with their procedure." So what you're seeing is same stimulus diminished response. What can you do? Well, you can try to increase the volume of irrigation. If you've been using 1,000 milliliters, try 1,500. See if it makes a difference. Occasionally, it helps to give a laxative the night before the irrigation. But I will also talk to that patient about this. It may be that you're at the end of the road with irrigation, and you may need to go back to pouching. And you may need to take a laxative to assure regular output. So in summary, I bet you thought we'd never get to this slide, but in summary, your colostomy can be temporary or permanent. Your output can range from mushy to formed, common management issues that you have to address with the patient with a colostomy, are they gonna manage with pouching? Yes, if they have a right-sided or a transverse colostomy, or are they going to manage with irrigation? Right-sided, transverse, no choices. They have to manage with pouching. Left-sided, they have choices. We want to review dietary and fluid management. The fact there are no absolute restrictions, adequate fluid intake is critical, adequate fiber intake is critical. We want to address gas and odor control, and we want to address lifestyle concerns. Bathing, travel, all of those kinds of things, which we discussed in an earlier class. Okay, that's it for this class. Thank you.