GI Chapter 38 Powerpoint 3

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  • 1. Therapeutic Measures
    • Tube Feeding Formulas
    • Gastrointestinal Decompression
    • Total Parenteral Nutrition (Intravenous Hyperalimentation)
    • Peripheral Parenteral Nutrition
  • 2. Therapeutic Interventions
    • Gastrointestinal Intubation
    • Tube in GI tract for therapeutic or diagnostic purposes
    • Orogastric, Nasogastric, Nasointestinal
    • Types of tubes p. 741 Figure 38-5
  • 3. Levin Tube
  • 4. Salem Sump AntiReflux Valve
  • 5. GI Intubation
    • Remove gas and fluids from stomach or intestine (decompression)
    • Diagnose GI motility and obtain secretions
    • Relieve/treat obstructions or bleeding
    • Nutrition (gavage) feedings, hydration, medication
    • Promote healing after GI surgery by preventing distention and strain on suture lines
  • 6. GI Intubation (cont)
    • Remove toxic substances (lavage) ingested accidentally or intentionally and provide for irrigation
    • Feeding Tubes:
      • NG tubes temporary and short term for feeding
      • G or J Tubes used for long term nutrition
  • 7.    Feeding Tubes
  • 8. GI Intubation (cont)
      • **Check for placement—prevent death
      • NG tube placement assessed after insertion and intermittently to ensure correct position
      • Gastrostomy or Jejunostomy Tube placement checked by comparing length with documented insertion length—don’t use if different
  • 9. Tube Feedings
    • Supplies pt with nutrition when oral intake not possible
    • Given as supplement or to provide total nutritional needs
    • May bypass esophagus and stomach and deliver feedings directly into duodenum or proximal jejunum
    • Inability to swallow, severe burns, trauma to face or jaw, debilitation, mental retardation, and oropharyngeal or esophageal paralysis
  • 10. Tube Feeding Formulas
    • Chosen by MD based on pt nutritional needs, consistency of formula, size and location of tube, method of delivery, convenience for pt at home
    • Commercially prepared formulas—protein, carbs, fats
    • Consider daily water needs in addition to water supplied by feeding
    • Dieticians can help calculate pt water needs
    • Also note water used to flush tube or administer meds
    • Dehydration if water needs not met
  • 11. Tube Feedings
    • Gravity—placed above level of stomach and dripped in by gravity slowly or given as Bolus feeding over a few minutes
    • Intermittent—Pump running throughout day and dc’d at night, or as a 4-6hr volume of feeding given over 20-30 minutes
      • Allows stomach to rest at night; simulates normal eating and nutrient absorption patterns
    • Continuous—Small amounts given over long period; Pump set at specified rate to control speed of feeding being delivered
  • 12. Tube Feedings (cont)
    • Sitting or high-Fowlers’ position to reduce aspiration risk
    • Monitor rate carefully
    • Signs that TF not being absorbed
      • Abd distention, feeling of fullness, n/v
      • Stop TF to avoid aspiration
  • 13. Tube Feeding Nursing Care
    • Placement Check
      • Radiographic confirmation
      • Observation of aspirated material and assessment of pH
    • Residual (formula remaining in stomach from previous feeding)
      • Use a syringe to withdraw and measure stomach contents
      • Return residual through tube to prevent loss of electrolytes
  • 14. Tube Feeding Nursing Care
    • Residual—how much feeding not absorbed
      • Checked hourly when feeding initiated, then q4hrs or before meds, or adding more feeding for infusion
      • If more than 100ml or amount specified by agency or MD, feeding should be stopped and notify MD
  • 15. Tube Feedings
    • If meds administered during TF, understand possible drug-nutrient interactions; some meds cannot be administered with certain substances
    • Enteric-coated or sustained release meds should not be crushed
    • Use liquid meds when possible to reduce clogging
    • Consult pharmacist and dietician as needed
  • 16. Gastrointestinal Decompression
    • Stomach or sm. Intestine filled with air/fluid
    • Swallowed air and GI secreations enter stomach and intestines and collect ther if not propelled through GI tract by peristalsis
    • Distention, feeling of fullness, pain
    • Distention may occur after surgery
      • Ambulate/turn frequently to prevent
  • 17. GI Decompression
    • Nasogastric or Nasointestinal tube (not frequently used—more difficult and slower to place and may be uncomfortable)
    • Suction applied
    • Tube in place until peristaltic activity (active bowel sounds and flatus) returns
    • Diet progressed as ordered and tolerated
  • 18. Total Parenteral Nutrition
    • TPN/ Intravenous Hyperalimentation—supplies nutrition by IV route
    • TPN: Dextrose (sugar), amino acids (protein), vitamins, minerals, and fat (intralipid) emulsions
    • Improve pt nutritional status, achieve weight gain, and enhance healing
    • Burns, trauma, cancer, AIDS, malnutrition, anorexia nervosa, fever, major surgery
    • Usually administered by RN
    • Filter with TPN but NOT with lipids (separate infusion along with TPN)
  • 19. TPN
    • Pts may respond to TPN with elevated serum glucose level even though not Diabetic
    • Does not mean they have acquired the disease
    • Regular insulin Sliding Scale given to control hyperglycemia and/or added to TPN usually q6hrs
    • Always regular insulin (rapid acting)
  • 20. TPN (cont)
    • Started slowly to give pancreas time to adjust to increasing insulin production for high amounts of glucose in TPN
    • Increased until ordered rate reached
    • When TPN dc’d, pt must be weaned gradually to allow pancreas to adjust to decreasing glucose levels
    • PT fed before TPN stopped to prevent hypoglycemia (weakness, shakiness, sweating, confusion)
  • 21. TPN (cont)
    • Monitor glucose levels as ordered and look for signs of hyperglycemia
    • Agency policy for obtaining glucose levels if hyperglycemia suspected
    • Labs monitored: CBC, Albumin, Glucose, Electrolytes, Platelet count, Prothrombin time (PT)
    • Irritating to peripheral veins—5X more concentrated than blood
    • TPN with Dextrose more than 12% administered through Central Venous Catheter into large vein (subclavian or internal jugular); volume in large vein dilutes TPN so less irritating
  • 22. Peripheral Parenteral Nutrition
    • PPN supplies nutrients via IV but not through central vein
    • Used for less than 10 days when pt does not need more than 2000 calories/day
    • Dextrose <12%, amino acids, lipids, electrolytes, water—all in one container
  • 23. Case Reports
    • Case 1
    • A 71-year-old obese female with no previous esophageal or gastric dysfunction was admitted for elective coronary artery bypass grafting. Postoperatively an 18-Fr. Argyle(r) Salem Sump(r) (Sherwood Medical, St. Louis, MO) orogastric tube was placed. Full strength Nutren-2.0 feed (Nestle Clinical Nutrition Company, Mississauga, Ont.) was initiated on the third postoperative day at 25 ml/hr, and increased to a final rate of 45 ml/hr. The patient remained intubated, ventilator dependent and was subsequently transferred from the cardiac surgery unit to the ICU on the fifth postoperative day. Neither H2 receptor blockers nor omeprazole was administered. Several times during day 6 and 7 the patient vomited small amounts of formula-like material after oral suctioning. Tube tip position was repeatedly checked by air injection and auscultation, by the ability to obtain gastric returns and by review of the chest radiographs. Blue food coloring was added to the formula and enteral nutrition continued. During days 8 and 9, two further episodes of emesis containing yellow/green formula-like fluid occurred with oral suctioning. However, visualization of the side port was hampered by the presence of midline surgical staples. This, together with poor film quality due to motion artifact and underexposure, resulted in misdiagnosis of the true tube tip position. Attempts at tube advancement and removal were met with resistance. A more forceful attempt at removal dislodged the tube, the esophageal portion of which was completely encrusted by a mass of inspissated formula-like material (Figures 1).
  • 24. An additional large solid mass of this material was suctioned from the oral cavity. A new 14-Fr. Salem Sump(r) tube was inserted nasally without resistance and the position confirmed radiologically. Enteral nutrition was resumed, and continued uneventfully over the next 17 days until the patient died following a cardiac arrest.
  • 25.
    • Case 2
    • A 66-year-old male with 35 % burns and no known history of esophageal or gastric dysfunction was admitted to the ICU, from the burn unit, following 3 days of enteral feeding with Osmolite HN(r) (Ross Products Division, Columbus OH) via an 18-Fr. Argyle(r) Salem Sump(r) nasogastric tube. On admission to the ICU, a chest radiograph revealed the proximal side port of the tube to be situated at the level of the gastroesophageal junction. Several attempts were made to either reposition or remove the tube, but each attempt was met with resistance. The tube was finally removed with the application of gentle force. Numerous attempts were made to insert a new tube but each insertion met with resistance. Endoscopy revealed a creamy white semi-solid concretion extending throughout the length of the esophagus. Using the endoscope, the mass was pushed through the esophagus into the stomach. An 18 Fr. Salem Sump(r) nasogastric tube and a 12 Fr. Entriflex(r) (Sherwood Medical, St. Louis, MO) nasoduodenal feeding tube were subsequently inserted and feeding resumed. No further problems arose with enteral feeding over the remainder of the ICU stay. On day 10, the severity of the burn injury and multiple organ failure resulted in withdrawal of active treatment.
  • 26.
    • Case 3
    • A 52-year-old female was admitted to the ICU following a high-speed motor vehicle accident. Injuries included transection of the thoracic aorta, multiple rib fractures, pulmonary contusions, a left subdural hematoma and several small liver lacerations. After urgent surgery to repair the aorta and pericardium, the clinical course was complicated by pneumonia and progressive multiple organ failure including acute respiratory distress syndrome. Although initially tolerant of gastric feeding via a Salem Sump(r) orogastric tube, gastric stasis impeded enteral feeding on the ninth postoperative day. On day 10 an attempt was made to manually position a 12 Fr. Entriflex(r) nasoenteric feeding tube into the duodenum. The initial attempt met with resistance in the nasopharynx. During a second attempt by another operator the tube was passed with minimal resistance. Straw colored fluid with some blood streaking was aspirated. Injected air was auscultated in the midepigastrium. A low chest radiograph (Figure 2) showed that the nasoenteral tube followed the same course as the original nasogastric tube but the distal tip of the new feeding tube was not visualized.
  • 27. Case 3 cont’d
    • Osmolite HN(r) was administered through the new tube and the infusion titrated up towards the goal rate. Over the next 24 hours the patient continued to deteriorate, with increased inotropic requirements and progression to anuric renal failure. The abdomen became more distended but because of sedation and neuromuscular blocking agents clinical assessment was difficult. An abdominal ultrasound on day 12 revealed free peritoneal fluid. Peritoneocentesis yielded thick cream-colored fluid, which looked like formula and was negative for pus or organisms on Gram stain. Tube feedings were immediately discontinued and the patient was taken for urgent exploratory laparotomy.
  • 28. Case 3 cont’d
    • A diffuse chemical peritonitis was present and 1.5 liters of thick cream-colored fluid with fibrin deposits were removed from the abdominal cavity. The Entriflex(r) feeding tube was seen emerging from the mid-anterior stomach and an intramuscular tract could be traced to the level of the gastroesophageal junction. Intraoperative endoscopy demonstrated that air, which was insufflated into the oropharynx, passed into the peritoneal cavity via the tract formed by the Entriflex(r) tube. On day 13, progressive severe acidosis, refractory shock and multiple organ failure resulted in the withdrawal of active treatment. At postmortem examination, chemical peritonitis was present along with the expected evidence of injury and multiple organ failure. A Zenker’s diverticulum was discovered but the feeding tube had actually perforated the piriform sinus creating a subserosal tract along the esophagus with an exit site in the mid-anterior stomach.
  • 29.
    • In the first two case reports, the tube was retrospectively determined to be in poor position with the proximal side port at the level of the gastroesophageal junction despite repeated clinical and radiological “confirmation” of proper tube placement. In the first case report, the true position of the tube was ascertained from radiographs and measurement of tube discoloration (indicating contact with body tissues). The position of the tube was further confirmed by the location of the concretion around the tube.
  • 30.
    • For enterally fed patients who are not receiving medications known to be associated with concretion formation it is believed that tube feeding formula remaining in contact with gastric acid can result in the precipitation of casein and the subsequent formation of a solid mass. It is also believed that a large-bore tube passing through the gastroesophageal junction enhances gastric reflux thus allowing gastric acid to reach the lower esophagus. We were able to rule out a break in the integrity of the tube. This further supported the fact that formula extravasation occurred at the gastroesophageal junction. This was the position of the proximal port of the nasogastric tube. Therefore the primary factor in esophageal concretion formation in the first two patients was the malpositioned tube, which allowed esophageal extravasation of formula, and its subsequent contact with refluxed gastric acid.
  • 31.
    • The second tube complication has not been previously described. Sedation and neuromuscular blockade may have masked early warning signs of feeding tube malposition in this patient. Tube placement was assessed by aspiration of gastric-type contents and by auscultation in the epigastrium of insufflated air. As well, the chest radiograph showed the new tube traveling beside the previously placed nasogastric tube and passing below the level of the diaphragm. This was felt to be adequate information to confirm tube placement and tube feedings were started. However, the distal metallic tip was not included on the radiograph. The use of sedatives and neuromuscular blockade led to a delay in the correct diagnosis of nasoenteral tube malposition with chemical peritonitis resulting from the presence of formula in the peritoneal cavity.
  • 32.
    • Another unusual feature of this case is the path that the Entriflex(r) tube had taken. The most common site of perforation by small-bore tubes is into the thoracic cavity (12-14) after endobronchial misplacement. This problem is readily identified by radiography. The one case of submucosal dissection reported in the literature is that of a patient undergoing elective cholecystectomy where placement of the gastric tube met resistance after 10 centimeters. Direct visualization showed the tube to be passing submucosally and it was withdrawn without complication (22). There seemed to be no predisposing factors in that case. It is unclear as to why the nasoenteral tube dissected submucosally in our patient.
  • 33.
    • Feeding tube malposition may be associated with serious complications in the critically ill patient. Clinical signs of feeding tube malposition may be absent in the critically ill and so radiologic visualization remains the gold standard in the placement of both large bore and flexible small diameter feeding tubes. The correct radiographic technique and careful inspection of the radiograph for the proximal side port and distal tip is mandatory.
  • 34. Questions
    • For the patient with a tube feeding. A dietician would be used to determine the type of formula that should be used as well as the amount of additional _______________ that should be given.
    • Which is the best indication that a nasogastric tube may be discontinued and oral feedings started following GI surgery?
    • A nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric tube. The nurse checks the residual and obtains an amount of 200ml. The nurse would…
    • Other than a radiograph, the most reliable way to assess placement of a nasogastric tube is to…