Download a look at the purpose and outcomes of colostomy irrigation

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THE OSTOMY FILES
A LOOK AT THE
PURPOSE AND
OUTCOMES OF
COLOSTOMY
IRRIGATION
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or nearly 75 years, colostomy irrigation has been
an accepted management option that allows a
colostomy patient to control bowel evacuation.
Colostomy irrigation evolved as an answer to the nearly
universally chronic peristomal skin problems caused by
a lack of commercially available pouching systems, protective skin barriers, and skin care products.1 It was theorized that if the bowel could be evacuated once a day,
no stool would seep onto the skin and, therefore, peristomal skin irritation would be minimized. Since that
time, however, the procedure has gone in and out of
acceptance by both patients and professionals — mostly due to fear of bowel perforation from irrigation
catheters. This fear has been reversed by the introduction of soft catheter irrigation cones now available on
most colostomy irrigation sets. For many years, nearly
all colostomy patients were instructed on colostomy
irrigation, but the outcomes were often less than satisfactory for the patient. Today, more realistic criteria
have been developed to screen for those patients who
have a better chance of success with it.
Even though colostomy irrigation is not required to
maintain bowel function, the procedure is a management option that may allow a patient to be free from
fecal discharge for approximately 24 hours. The most
important factors to evaluate in determining who is a
candidate for colostomy irrigation are the patient’s
clinical situation and lifestyle. For example, a patient
with a sigmoid colostomy who has good manual dexterity and visual acuity, had regular bowel habits prior
to surgery, is not undergoing chemotherapy, and is not
DO
taking medications that cause diarrhea
may appear to be a perfect candidate.
However, an assessment of the patient’s
lifestyle reveals that he works “swingshift” hours and has an irregular work
schedule. It would be nearly impossible
for this patient to attempt colostomy
irrigation at a regular time each day.
Similarly, a physician writes orders for
the home care nurse to teach a new
patient how to irrigate. The initial home
visit reveals that the patient lives in a
setting without adequate bathroom
facilities and running water. A patient’s
inability to obtain control over bowel
function in the manner prescribed by
healthcare professionals can lead to feelings of frustration and failure, which decreases the overall quality of
the patient’s life.
A small prospective, crossover study in Singapore2
compared natural evacuation (ie, allowing the bowel to
function on its own) to colostomy irrigation and found
that colostomy irrigation after abdominoperineal resection was superior to natural evacuation in terms of cost
and patient satisfaction. When patients irrigated, fewer
peristomal skin problems, sleep disturbances, and sexual problems occurred. An overall decrease in management costs also was demonstrated due to a decrease in
pouch usage. The study’s researchers recommended
that colostomy irrigation be introduced to qualified
patients soon after surgery.
In an outcomes-oriented environment, clinicians
should evaluate each patient on a case-by-case basis to
determine if the patient can benefit from colostomy
irrigation. Below are some criteria to consider during
this assessment.3 Candidates should have:
• a descending or sigmoid colostomy
• a history of regular bowel habits prior to surgery
• the desire to learn and perform the procedure
• the ability (manual dexterity and visual acuity)
to perform the procedure
• a lifestyle that is compatible to irrigation (work
schedule, bathroom facilities, adequate time,
other family or personal issues).
Patients with stomal prolapse or peristomal hernia
should not be taught colostomy irrigation because performing the procedure could potentially exacerbate the
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– Gwen B. Turnbull, RN, BS
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19-20, ostomyfiles
February 2003 Vol. 49 Issue 2
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Accuzyme®
Papain-Urea Debriding Ointment
References
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1. Turnbull RW, Turnbull GB. The history and current
status of paramedical support for the ostomy patient.
Seminars in Colon and Rectal Surgery.
1991;2(2):131–140.
2. Peng Kheong Leong AF, Yunos ABM. Stoma management in a tropical country: colostomy irrigation versus natural evacuation. Ostomy/Wound Management.
1999;45(11):52–56.
3. Erwin-Toth P, Doughty DB. Principles and procedures
of stomal management. In: Hampton BG, Bryant RA,
eds. Ostomies and Continent Diversions: Nursing
Management. St. Louis, Mo.: Mosby Year Book,
1992:29–103.
4. Venturini M, Bertelli G, Forno G, et al. Colostomy
irrigation in the elderly. Effective recovery regardless
of age. Dis Colon Rectum. 1990;33:1031–1033.
The Ostomy Files is made possible through the support of
ConvaTec, A Bristol-Myers Squibb Company, Princeton, NJ.
Gwen B. Turnbull, RN, BS, author of The Ostomy Files, is a
healthcare consultant specializing in public and private healthcare reimbursement as well as the development of professional and consumer educational and marketing tools.
20
OstomyWound Management
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DESCRIPTION: Each gram of ACCUZYME enzymatic debriding ointment contains papain (8.3 x 105 USP units of activity based on
lot H) and 100mg urea USP in a hydrophilic ointment base composed of purified water USP, emulsifying wax NF, glycerin USP,
isopropyl palmitate NF, lactose NF, potassium phosphate monobasic NF, fragrance, methylparaben NF and propylparaben NF.
CLINICAL PHARMACOLOGY: Papain, the proteolytic enzyme from the fruit of carica papaya, is a potent digestant of nonviable
protein matter but is harmless to viable tissue. It is active over a pH range of 3 to 12. Papain is relatively ineffective when used
alone as a debriding agent and requires the presence of activators to stimulate its digestive potency. In ACCUZYME, papain is
combined with urea, a denaturant of proteins, to bring about two supplemental chemical actions: (1) to expose by solvent action
the activators of papain, and (2) to denature the nonviable protein matter in lesions and thereby render it more susceptible to
enzymatic digestion. Pharmacologic studies have shown that the combination of papain and urea result in twice as much digestive
activity as papain alone.
INDICATIONS AND USES: ACCUZYME is indicated for debridement of necrotic tissue and liquefication of slough in acute and chronic
lesions such as pressure ulcers, varicose and diabetic ulcers, burns, postoperative wounds, pilonidal cyst wounds, carbuncles and
miscellaneous traumatic or infected wounds.
CONTRAINDICATIONS: ACCUZYME is contraindicated in patients who have shown sensitivity to papain or any other components of
this preparation.
PRECAUTIONS: See Dosage and Administration. Not to be used in eyes.
ADVERSE REACTIONS: ACCUZYME is generally well-tolerated and nonirritating. A transient “burning” sensation may be experienced
by a small percentage of patients upon applying ACCUZYME. Occasionally, the profuse exudate from enzymatic digestion may
irritate the skin. In such cases, more frequent dressing changes will alleviate discomfort until exudate decreases.
DOSAGE AND ADMINISTRATION: Cleanse the wound with ALLCLENZ® Wound Cleanser or saline. Avoid cleansing with hydrogen
peroxide solution as it may inactivate the papain. Apply ACCUZYME directly to the wound, cover with appropriate dressing, and
secure into place. Daily or twice daily applications are preferred. Irrigate the wound at each redressing to remove any accumulation
of liquefied necrotic material. NOTE: Papain may also be inactivated by the salts of heavy metals such as lead, silver and mercury.
Contact with medications containing these metals should be avoided.
HOW SUPPLIED: 30g tube, 6g unit dose tube. Store in a cool place.
Rx ONLY
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prolapse or cause bowel perforation, leakage between
irrigations, or poor control over elimination.
Chemotherapy, pelvic or abdominal radiation treatments, a poor prognosis, and diarrhea-producing medication are also contraindications to colostomy irrigation. Age, on the other hand, should not be considered
a contraindication, as colostomy irrigation has been
shown to be effective regardless of the person’s age.2,4
Therefore, each individual should be carefully evaluated
as a candidate.
Once taught, the patient always has the choice to
discontinue the procedure should it become incompatible with his or her lifestyle. However, the opportunity to learn the procedure exists for candidate
patients throughout the duration of their treatment
within the healthcare system (ie, home health care,
outpatient clinic, doctor’s office, WOC nurse clinic).
Colostomy irrigation is not the solution for all
colostomy patients, but the decision to irrigate or not
irrigate is ultimately the patient’s — not the healthcare
professional’s. - OWM
E
NDC 0064-1000-01 (30g tube)
NDC 0064-1000-07 (6g unit close tube)
Distributed by:
Healthpoint, Ltd.
San Antonio, Texas 78215
1-800-441-8227
www.healthpoint.com
Manufactured by:
DPT Laboratories, Ltd.
San Antonio, Texas 78215
REORDER NO. 0064-1000-01 (30g tube)
0064-1000-07 (6g unit dose tube)
127897-1002
Panafil®
Healing, Debriding and Deodorizing Ointment
NDC 0064-3410-30 (30g tube)
NDC 0064-3410-07 (6g unit dose tube)
Papain-Urea-Chlorophyllin Copper Complex Sodium
DESCRIPTION: PANAFIL Ointment is an enzymatic healing-debriding ointment which contains standardized Papain, USP (not
less than 521,700 USP units per gram of ointment), Urea, USP 10% and Chlorophyllin Copper Complex Sodium, USP 0.5% in a
hydrophilic base composed of Purified Water, USP; Propylene Glycol, USP; White Petrolatum, USP; Stearyl Alcohol, NF; Polyoxyl
40 Stearate, NF; Sorbitan Monostearate, NF; Boric Acid, NF; Chlorobutanol (Anhydrous), NF as a preservative; Sodium Borate, NF.
CLINICAL PHARMACOLOGY: Papain, the proteolytic enzyme derived from the fruit of carica papaya, is a potent digestant of
nonviable protein matter, but is harmless to viable tissue. It has the unique advantage of being active over a wide pH range,
3 to 12. Despite its recognized value as a digestive agent, papain is relatively ineffective when used alone as a debriding agent,
primarily because it requires the presence of activators to exert its digestive function. Urea is combined with papain to provide
two supplementary chemical actions: (1) to expose by solvent action the activators of papain (sulfhydryl groups) which are always
present, but not necessarily accessible, in the nonviable tissue or debris of lesions, and (2) to denature the nonviable protein
matter in lesions and thereby render it more susceptible to enzymatic digestion. In pharmacologic studies involving digestion of
beef powder, Miller1 showed that the combination of papain and urea produced twice as much digestion as papain alone.
Chlorophyllin Copper Complex Sodium adds healing action to the cleansing action of the proteolytic papain-urea combination.
The basic wound-healing properties of Chlorophyllin Copper Complex Sodium are promotion of healthy granulations, control of
local inflammation and reduction of wound odors.2 Specifically, Chlorophyllin Copper Complex Sodium inhibits the hemagglutinating
and inflammatory properties of protein degradation products in the wound, including the products of enzymatic digestion, thus
providing an additional protective factor.1,3 The incorporation of Chlorophyllin Copper Complex Sodium in PANAFIL Ointment
permits its continuous use for as long as desired to help produce and then maintain a clean wound base and to promote healing.
INDICATIONS AND USES: PANAFIL Ointment is suggested for treatment of acute and chronic lesions such as varicose, diabetic and
decubitus ulcers, burns, postoperative wounds, pilonidal cyst wounds, carbuncles and miscellaneous traumatic or infected wounds.
PANAFIL Ointment is applied continuously throughout treatment of these conditions (1) for enzymatic debridement of necrotic tissue
and liquefaction of fibrinous, purulent debris, (2) to keep the wound clean, and simultaneously (3) to promote normal healing.
CONTRAINDICATIONS: None known.
PRECAUTIONS: See Dosage and Administration. Not to be used in eyes.
ADVERSE REACTIONS: PANAFIL Ointment is generally well-tolerated and nonirritating. A small percentage of patients may
experience a transient “burning” sensation on application of the ointment. Occasionally, the profuse exudate resulting from
enzymatic digestion may cause irritation. In such cases, more frequent changes of dressings until exudate diminishes will
alleviate discomfort.
DOSAGE AND ADMINISTRATION: Cleanse the wound with ALLCLENZ® Wound Cleanser or saline. Avoid cleansing with hydrogen
peroxide solution as it may inactivate the papain. Apply PANAFIL directly to the wound, cover with appropriate dressing, and
secure into place. Note: Papain may also be inactivated by the salts of heavy metals such as lead, silver and mercury. Contact with
medications containing these metals should be avoided. When practicable, daily or twice daily changes of dressings are preferred.
Longer intervals between redressings (two or three days) have proved satisfactory, and PANAFIL Ointment may be applied under
pressure dressings.
HOW SUPPLIED: 30g tube, 6g unit dose tube. Store at controlled room temperature (59°-86°F, 15°-30°C).
Rx ONLY
References
1. Miller, J.M.: The Interaction of Papain, Urea and Water-Soluble Chlorophyll in a Proteolytic Ointment for Infected Wounds,
Surgery 43:939, 1958.
2. Smith, L.W.: The Present Status of Topical Chlorophyll Therapy, New York J. Med. 55:2041, 1955.
3. Barnard, R.D.: Elucidation of Chemically Defined Haptens for Competitive Inhibition of Aggressin Activity, Immunol. 8:78, 1954.
Marketed by:
Healthpoint, Ltd.
San Antonio, Texas 78215
1-800-441-8227
www.healthpoint.com
Manufactured by:
DPT Laboratories, Ltd.
San Antonio, Texas 78215
REORDER NO. 0064-3410-30 (30g tube)
0064-3410-07 (6g unit dose tube)
127898-1002