Everyone admitted to hospital:
Should always be on at least Miralax because constipation is common when people aren't moving as much and it is not good when it happens! Your other first line laxative should be Senna.
Miralax (polyethylene glycol) 17g qAM - it's a dissolvable powder that they drink
Senna (senokot) 17.2g qHS - stimulant laxative
NO DOCUSATE - evidence for it sucks based on large meta-analyses. It's a waste of money. See the journal articles below:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4234355/
https://www.journalofhospitalmedicine.com/jhospmed/article/193136/hospital-medicine/things-we-do-no-reason-prescribing-docusate-constipation
Still not pooping? Try some of these second line agents:
Bisacodyl suppository - great option to try (can also try PO bisacodyl aka Dulcolax)
Milk of magnesia - avoid in patients with renal injury (30-60 mL volume)
Magnesium citrate - avoid in patients with renal injury, heart failure or volume overload (296 mL volume)
Per /u/MMOSurgeon on Reddit, he would recommend bisacodyl suppository here FIRST before the above options which are pretty powerful laxatives and often used as bowel preps
STILL not pooping? Geez maybe you shoulda just went straight for this:
Lactulose - 30mg q2h until poops. Really really good at making people poop. Side effect is bloating which can be painful or cause nausea/vomiting.
Try additional stuff from below:
Fleet enema - this is a small volume enema
Tap water / lactulose / mineral water enemas. All are basically equivalent, large volume enemas
AVOID sodium phosphate enema in patients with AKI or ESRD
I prefer to start with suppository before enemas which are really messy for nurses to deal with
Last resort option:
Golytely - used for colonoscopy bowel prep. Lots of volume
Remember your mechanisms of action:
Osmotic = miralax, lactulose, golytely (side effect = bloating)
Stimulant = senna, bisacodyl (side effect = cramping)
Softener = docusate (again, it doesn't work)
Bulk-forming = psyllium (works well for IBS because it treats both constipation and diarrhea)
Extras:
Consider prune juice as a more "natural" remedy for constipation. I haven't used this but someone suggested I add it in here
Don't forget about coffee as a very nice natural stimulant laxative that you can have patients try
Some other suggestions from Reddit: sorbitol gummies, milk and molasses enema
Treatment of opioid-induced constipation (common in hospitals) = methylnaltrexone, reduce opioids, oral naloxone
Bowel massively dilated and not working = Ogilvie's syndrome
Treatment of Ogilvie's syndrome = neostigmine (avoid in bradycardia, bronchospasm), correct potassium
Also, remember that sometimes a patient with diarrhea may actually be constipated and having overflow incontinence. In which case the treatment for their diarrhea is aggressive bowel regimen!
