›Sepsis source control and antibiotics per suspected source
›Pain control with non-opioid strategies where feasible
Neostigmine pharmacotherapy
›Neostigmine IV 2 mg infused over 3 to 5 minutes
›Mandatory continuous cardiac monitoring throughout and for at least 30 minutes after the dose
›Bradycardia risk is greatest during and shortly after infusion
›ECG findings to anticipate: sinus bradycardia and AV block from the cholinergic effect
›Unmonitored administration can progress from bradycardia to asystole
›Atropine 0.4 to 1 mg IV available at the bedside before administration
›Administer immediately for symptomatic bradycardia
›Expected response
›Flatus, bowel movement, or reduction in abdominal distension typically within 30 minutes
›Reassess abdominal exam and consider repeat imaging if response is incomplete
›Therapy is not working
›No response within 3 hours: may repeat one additional 2 mg IV dose
›No response after two doses, or recurrence after initial response: proceed to colonoscopic decompression
›Contraindications
›Bradycardia (heart rate < 60/min)
›Active bronchospasm or severe reactive airway disease
›Mechanical bowel obstruction not yet excluded
›Recent myocardial infarction
›Significant renal impairment
›Neostigmine is renally cleared; use with caution and reduced confidence in efficacy and safety data at this dose
›Pregnancy
›Limited safety data; reserve for cases where the benefit of avoiding surgery outweighs the uncertainty
Colonoscopic decompression
›Indications
›Neostigmine contraindicated
›Neostigmine failed after two doses
›Cecal diameter approaching the high perforation-risk threshold despite pharmacologic therapy
›Technique
›Minimal insufflation, carbon dioxide preferred over room air when available
›Avoid advancing beyond the point needed to achieve decompression
›Decompression tube placement at the time of colonoscopy
›Reduces recurrence compared with colonoscopy alone
›Recurrence
›Recurrence after colonoscopic decompression alone reported in roughly a third to 40% of cases
›Recurrence with a decompression tube left in place reported substantially lower, roughly 20%
›Complications
›Perforation risk during the procedure itself in an already massively dilated, thin-walled colon
›Repeat colonoscopic decompression reasonable for a single recurrence in a patient without red flags
›Indications
›Perforation
›Bowel ischemia or necrosis
›Peritonitis
›Failure of neostigmine and repeated colonoscopic decompression
›Procedure selection
›Segmental resection or subtotal colectomy for perforation or nonviable bowel
›Cecostomy or loop colostomy considered in a poor operative candidate with viable bowel and refractory dilation
›Perioperative considerations
›Broad-spectrum antibiotics for perforation or peritonitis
›Piperacillin-tazobactam IV 4.5 g every 6 to 8 hours
›Ceftriaxone IV 2 g once daily plus metronidazole IV 500 mg every 8 hours as an alternative
›VTE prophylaxis
›Enoxaparin SC 40 mg once daily, dose-adjusted for renal impairment
›Mechanical prophylaxis with intermittent pneumatic compression while awaiting surgery
Analgesia and supportive therapy
›Pain control
›Prefer non-opioid analgesia given opioids as a precipitant of the condition itself
›Acetaminophen IV or oral 1 g every 6 hours, maximum 4 g/day, lower maximum in liver disease
›If opioids are required for severe pain
›Use the lowest effective dose and shortest duration
›Fentanyl IV 25 to 50 micrograms, repeat every 5 to 10 minutes to effect, with caution given its potential to worsen colonic hypomotility
›Antiemetics
›Ondansetron IV 4 mg, repeat every 6 to 8 hours as needed