Gastric Residual...what would you do in this situation?
- 0May 20, '12 by tnelso15Hi everyone,
I have a random question about a situation that once happened to me in clinical during nursing school (I'm preparing for interviews and polishing my stories from all of my clinical experiences!). I once pulled out over 1200cc's of gross looking brown liquid of gastric residual from a patient on a med/surg floor...the doc was called and, contrary to my instructor's desires, ordered that the fluid be discarded because it looked "yucky." The patient's pressure later bottomed out (not sure what happened after that because I left for the day). As a nurse, would you have also disagreed with the doctor's decision to dispose of the residual? When is it appropriate to replace/discard gastric residuals for adult patients?
Thanks in advance for any help/advice
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- 12May 20, '12 by nurse2033Most facilities have guidelines on when to reinstill or call the MD. 1200ml is a lot and I can't imagine why your instructor wanted to put it back. Do you think this patient was having normal peristalsis? Nope. Could they aspirate if they vomited over a liter of liquid? You bet. The reason to measure residual is to make sure that the patient is moving liquid downstream fast enough so they don't back up, and accumulate say a liter of liquid in their stomach. I guess I'm with the MD on this one. The patient's pressure probably dropped because of a GI bleed, not because the fluid was removed. That much fluid in your stomach impinges on your tidal volume and I suppose cardiac output. Replacing residual is appropriate when it is a smaller amount and signs that the patient is not having gastroparesis.
- 0May 20, '12 by Sun0408I have pulled that much and more from a peg or NG. It really depends on your facilities policy. My current hospital; anything over 250 is thrown away and the tube feeds are stopped, residual is then rechecked 4 hours later, if it less than 200 we restart. At my last hospital, no matter the amount of residual, it was put back and tube feeds were put on hold for 4 hours and then residual was rechecked, if residual was less than 200 we restarted TF..
- 0Oh ok cool. I have definitely had so much come out via NG that I had to literally always make sure I had a spare drainage container at the ready. Just the other week I had a guy fill 2 NG containers in 5 minutes but of course he had just come back from a abdominal CT and they made him drink a LOT lol
- 1May 20, '12 by Sun0408mindlor, a foley bag hooked to the peg is a great trick for excessive stomach contents without suction.. I used it a few times, the last guy I pulled 2100 and then asked the doc if I could just hook the bag to the peg for gravity drain.. When the guts not working, some tricks come in handy
- 0May 20, '12 by RNperdiemI would not have reinstiled all that residual either.
Often when a patient is getting sicker (septicemia?), often the GI stops working well so a patient often has no appetite or high residuals. The patient you took care of was likely headed this direction when you were taking care of him.
Aspiration is often the end of an already sick patient. I would talk to the doctor about the high residuals and recommend stopping tube feeds for a while.
- 1May 20, '12 by Esme12 Senior ModeratorOn a Med surg floor I'll bet this was an NGT insertion to check gastric contents for hemoccult as is often the case for the suspicion of GI bleed and to facilitate gastric decompression/emptying. Was there an feeding being infused? How fast was it going? If so when was the last time someone checked for residual.....that's a boat load of residual. I'll Bet this patient had gastric distention ( a huge belly with pain) and this was done for decompression.
I am not sure what your instructor was thinking for I would not put it back 1200cc of anything brown and gross. That does not belong returning to the abdomen and is no longer considered "residual" but gastric contents/output. 1200 cc's of Copious Gross brown gastric output would have made me suspicious of GI bleeding....it is something called coffee ground gastric contents..I would have called the MD. Prepared for an IV for I am suspicious for bleeding and the hypotension that will follow and prepare the patient for lab draws and type and screen for blood products. I would hemoccult/guaiac the contents to check occult blood and make the patient NPO.
We discard all adult outputs with the exception of tube feeding gastric contents < 250cc's.. If we do save contents it is in a small container to "show" to the MD and/or send a sampling to lab for testing. If this patient was being fed......I would stop the feeding.
I hope this helps.Last edit by Esme12 on May 20, '12
- 1May 20, '12 by KelRN215I agree with everyone else, no way would I have reinstilled that amount of residual and I doubt that the patient bottoming out his pressure had anything to do with the residual being discarded and everything to do with the reason why he had such a high residual in the first place. 1200 mL sitting in the stomach not going anywhere wouldn't help his blood pressure. In this situation, I would have expected the residual to be discarded, tube feeds stopped and IV fluid started. Do you remember anything else about what happened with this patient and what his diagnosis was?