For the longest time, indwelling balloon catheters have been the norm in the care of ICU patients. They are often used to help nursing staff keep high-acuity patients clean, manage fecal incontinence, and curb breakdown of skin. Initially, they have been seen to be a useful and reliable solution for problems related to fecal incontinence (FI).
But in oncology ICUs, their use brings up an important question that is overlooked: Are we putting the patient at risk?
Thrombocytopenia is common in cancer patients who are critically ill. Severely low platelet counts are common, and during intensive chemotherapy or treatments for hematologic malignancy, they often drop below 10,000/µL. In these cases, even the smallest injuries to the mucosa can cause clinically significant bleeding.
Simultaneously, fecal incontinence is neither uncommon nor a peripheral concern. A lot of cancer patients get diarrhea from chemotherapy, and up to 30 percent of them have high-grade diarrhea, depending on the medication. In the ICU, where patients are severely unwell and cannot move, the rates of fecal incontinence can be as high as 50 percent.
The clinical effects are severe: skin breakdown in the perineum, high risk of infection, an imbalance of fluids and electrolytes, and a longer stay in the hospital. It isn’t an option to manage this adequately; it is an essential part of patient care.
Normally, balloon-based rectal catheters were the most common choice. These devices work by inflation of a balloon with a hollow rectal tube, which has a pipe in the middle for passing feces. The balloon makes a seal that keeps stool away from the patient’s skin.
The mechanism only works in the presence of constant radial pressure on the rectal mucosa. Research indicates that the pressure produced by the balloons can surpass capillary perfusion thresholds, resulting in localised ischemia. In the long run, this can harm the mucous membranes, cause ulcers, and make them bleed.
For patients with normal coagulation, these issues may not be as severe or may be easier to deal with; on the other hand, for oncology patients with low platelet counts, the risk profile changes a lot. Even small injuries to the mucosa can cause large amounts of bleeding, which may require a transfusion procedure or a longer stay in the ICU.
These risks are very real and have even been reported in the literature of rectal bleeding, erosion, and even perforation linked to indwelling rectal catheters. Numerous device manufacturers explicitly advise against utilization in patients with diminished platelet counts; nevertheless, these devices remain extensively employed within this demographic.
This makes things confusing in the clinic; proper care has been taken to avoid invasive procedures on patients with low platelet counts. We still use devices that apply pressure on the delicate mucosal tissue.
It does make sense in a way. Health care professionals must juggle different priorities: preventing skin damage and infection caused by uncontrolled fecal incontinence, reducing iatrogenic harm in a susceptible patient demographic.
Balloon catheters have been thought to be the best option for a while now, but that might change in the coming time.
A new and different approach to stool management has been developed, which goes against the whole idea of traditional devices. These systems don’t use internal pressure; instead, they use an external collection mechanism and active suction to move the stool away from the patient, all while being automatic.
By avoiding the whole concept of intrarectal pressure, they get rid of the main cause of mucosal ischemia and damage. Early clinical data indicate that these systems can attain effective containment while drastically reducing the risk of tissue damage.
There is also a benefit from an operational standpoint: Managing traditional fecal incontinence solutions can be extremely time-consuming and physically taxing for the nursing staff, as the patients have to be repositioned multiple times for cleaning and monitoring. Automated systems that don’t demand time from nurses, ease their pressures, and give them time to focus on other important tasks in high-acuity ICU settings.
The larger problem isn’t in device comparison, but in awareness of new proven methods and an increase in high acuity patients.
The idea of precision medicine has changed the way we make treatment decisions in oncology care. Treatment is customised based on the patient’s specific conditions and medical profile. But we still use old solutions in many areas of supportive care that may not be in line with these principles.
Stool management is one of these areas.
The issue is not the efficacy of balloon catheters; they were initially introduced to be a solution to a large problem, but are they the right choice for the group of patients who are at high risk due to the pressure being caused?
Doctors go through every option while considering the pros and cons. For oncology patients with thrombocytopenia, it might be time to reevaluate.
As even small amounts of pressure could cause great harm, we need to have a closer look at better solutions that are already available and can do justice to high-risk patients.
Deanna Vargo is a nurse executive. Nish Chasmawala and Simone Hugar are health care executives.
