Neurocritical care, a unique specialty requiring skill and adeptness presents us with many challenging situations. Management of super refractory status epilepticus warrants the use of intravenous anaesthetic agents and along with it comes its various complications such as paralytic ileus which need to be diagnosed accurately and managed appropriately. Patients diagnosed with super refractory status epilepticus develop paralytic ileus because of thiopentone infusion which is usually refractory to the conventional prokinetic therapy. This results in the decision to initiate Total Parenteral Nutrition (TPN). However, such episodes responds dramatically to intravenous erythromycin. Hence, we would like to highlight this as an important tool in the armamentarium in paralytic ileus management.
Erythromycin, a motilin receptor agonist with cholinergic stimulatory properties is effective in case of drug induced paralytic ileus. Erythromycin is easily available, with few drug interactions and cost-effective must be in the armamentarium of drugs while treating patients with impaired gastric emptying. The most commonly used dose range in adults is 200-250mg or 2.0-3.0mg/Kg. Although its use is not without risk, erythromycin is readily available, inexpensive, has a low dose-dependent side effect profile and is compatible with most drugs
In neurological intensive care units, we commonly encounter paralytic ileus in patients with neurological conditions affecting autonomic function e.g., high cervical lesions, Guillain-Barre syndrome, medication (anticholinergics, opioids), meningitis, and spinal cord infarction. It is also a well-known complication of barbiturates occurring in about 10% of patients with high dose thiopentone infusion [1]. There have been many instances where TPN had to be initiated for a few days to tide over the crisis and there are case reports of emergency colostomies done to relieve the intestinal obstructive symptoms caused by thiopentone infusions [2,3].
As neuro-intensivists we acknowledge that enteral feeding should be commenced as soon as possible due to its varied advantages such as protection against peptic ulceration, decreasing catabolism, retaining intestinal integrity and thus decreasing the occurrence of bacterial translocation and the incidence of nosocomial infections. When enteral feeding fails, immediate search for means to resolve the ileus is required as this would alter the prognosis. The management of ileus may vary greatly depending on the nature of etiology, in our institution we begin with correction of electrolyte and acid base abnormalities, discontinuation of medications that produce ileus and initiation of prokinetic therapy with metoclopramide. In these patients, though we knew that thiopentone was the culprit for the paralytic ileus, it was crucial to continue the same for the control of the super-refractory status epilepticus. Premature stopping of the anaesthetic would have a negative impact and poor outcome.
When the Gas hits the Brain-Neuroanesthesia Musings! 