Content analysis of bowel protocols for the management of constipation in adult critically ill patients

J Crit Care. 2020 Aug;58:98-104. doi: 10.1016/j.jcrc.2020.04.006. Epub 2020 Apr 17.


Purpose: Alterations in bowel habits are common during critical illness, and bowel protocols are gaining acceptance. Our objective was to characterize bowel protocols in a cross-sectional analysis of ICUs.

Materials and methods: We engaged 44 adult ICUs and performed content analysis of bowel protocols, addressing initiation criteria, medications incorporated, medication escalation, discontinuation criteria, stool assessment methods, and protocol contraindications.

Results: Bowel protocols operated in 33/44 ICUs (79.5%). The commonest medications were senna (81.0%) and bisacodyl (75.6%). Less common agents were sodium phosphate (45.9%), glycerin (43.2%), docusate sodium (43.2%), polyethylene glycol 3350 (37.8%), lactulose (29.7%), sodium citrate (16.2%), milk of magnesia (13.5%) and mineral oil (16.2%). Bowel protocols were activated by nurses (62.8%) based on initiation criteria [no bowel movement for 24-96 h (35.1%), opioid use (18.9%), "at risk for constipation" (13.5%), stool on digital rectal exam (10.8%), feeding initiation (10.8%), and ICU admission (8.1%)]. Laxative escalation criteria included time from last bowel movement (59.4%), opioid use (18.9%) and no stool on digital rectal exam (10.8%), while 15 (40.5%) included diarrhea as a discontinuation criterion.

Conclusions: Bowel protocols have variable initiation, escalation, and discontinuation criteria incorporating different classes of laxatives, reflecting unclear evidence about optimal bowel management strategies in ICU.

Keywords: Bowels; Critical care; Diarrhea; Gastrointestinal.

Publication types

  • Observational Study
  • Randomized Controlled Trial

MeSH terms

  • Canada
  • Clinical Protocols*
  • Constipation / drug therapy*
  • Critical Illness*
  • Cross-Sectional Studies
  • Humans
  • Intensive Care Units
  • Laxatives / therapeutic use*
  • Probiotics / therapeutic use
  • Saudi Arabia
  • United States


  • Laxatives