Effects of spinal sympathicolysis on gastrointestinal motility in critically ill patients

In surgical ICU patients many causes provide a gastrointestinal atony, i.e. shock, systemic analgesia + sedation. Due to this atony, early enteral nutrition and a normal function of the gut is often prevented. Translocation, ileus or endotoxine transmission and their complications are pretended. Most of the seriously injured polytrauma patients and those after major abdominal surgery are concerned. Even intensive and prolonged conservative efforts for stimulation of gastrointestinal motility (i.e. laxatives, contrast agent, metoclopramid, neostigmin, ceruletid, enteroclysis, erythromycin, systemic sympathicolytics) are not always successful. In the last 2 years, we performed in unsuccessful cases after excluding all contraindications a central neuraxial block with local anesthetics as an ultima ratio approach.

Methods

Spinal sympathicolysis was performed if critically ill ICU patients in spite of prolonged and repeated conservative efforts did not defecate within 6 days. After the decision conservative efforts were continued for 24 h. If the patients did not defecate, we carried out spinal or epidural anesthesia. Sepsis, coma and coagulation abnormalities were contraindications. In presence of leucocytosis without septic symptoms, the local anesthetic (3 ml bupivacaine 0.25%) + 0.5 mg morphine was injected intrathecally. In other cases we placed a lumbar epidural catheter with an initial dose of 10 ml bupivacaine 0.25% + 3 mg morphine. If necessary, the dose was repeated within 12 h.

Results

We report about 26 patients, which were treated with spinal sympathicolysis, in 10 cases as single shot spinal anesthesia and in 16 cases as epidural anesthesia. In all patients gastrointestinal motility improved significantly within the first 12 h. Twelve (46%) patients defecated within 12 h and 9 (35%) within 24 h. Four of the remaining patients, all with epidural anesthesia, defecated during the second day after the beginning of the sympathicolysis. One patient with intrathecal single shot sympathicolysis without defecation within 48 h received a second intrathecal treatment with success. As an accompanying and important side-effect, in most patients systemic analgesia and sedation could be reduced significantly and weaning could be initiated. None of the 26 patients had an untoward effect.

Conclusion

In our patients spinal sympathicolysis was a successful method to stimulate gastrointestinal motility in critically ill ICU patients. Regarding to the possible complications of a prolonged intestinal atony (translocation, ileus operation, endotoxine transmission) and after trying all conservative efforts spinal sympathicolysis can he considered as an acceptable approach in spite of the possible untoward effects. By the good results we now more often decide for this method because of the good effects and side-effects.