Neostigmine resolves critical illness-related colonic ileus in intensive care patients with multiple organ failure - a prospective, double-blind, placebo-controlled trial

Objective:Critical illness-related colonic ileus (CIRCI) is characterized b y the non-passage of stools in critically ill patients as a result of the a bsence of prokinetic movements of the colon, while the upper gastrointestin al tract functions properly and mechanical ileus is absent. We investigated whether neostigmine resulted in defecation in patients with CIRCI. Design: Double-blinded, placebo-controlled prospective study. Setting: Eighteen-bed intensive care unit. Patients: Thirty Ventilated patients with multiple organ failure with CIRCI for > 3 days. Intervention: Continuous intravenous administration of neostigmine 0.4-0.8 mg/h over 24 h, or placebo. Measurements and results: Time to first defecation and adverse reactions we re recorded. Thirty patients were randomized, 24 could be evaluated. The me an prestudy time was 5 days, mean APACHE II score on admission was 23.2, an d mean MOF score on the day of the study was 6.4. Of the 13 patients receiv ing neostigmine, 11 passed stools, whereas none of the placebo-treated pati ents passed stools (P < 0.001). After 24 h, the non-responders received in a cross-over fashion neostigmine or placebo respectively. Eight out of the II neostigmine patients now passed stools (mean 11.4 h), and none of the pl acebo patients. Overall, in none of the patients did passage of stools occu r during placebo infusion, whereas 19 of the 24 neostigmine-treated patient s had defecation (79 %). No acute serious adverse effects occurred, but thr ee patients had ischemic colonic complications 7-10 days after treatment. Conclusion: Continuous infusion of 0.4-0.8 mg/h of neostigmine promotes def ecation in ICU patients with a colonic ileus without important adverse reac tions.