Maybe Im missing something....

[murse8181]

So maybe some of you critical care nurses can answer some questions....

Patient is 7 days post op from a colectomy for cancer(also admitted for hypotension). Spent 5 days in the unit and was transferred to my floor(stroke-tele). I had him the prior day and he was npo, ng tube to intermittent suction(SBO versus Illeus). Output to suction was under 30. D51/2NS w20k at 100ml hour. Lungs were a little on the coorifice side but nothing horrible. Slight edema in LE. Patients lasix were held on admission for bp and never restarted but he was handling the fluid. So right at shift change I got ahold of the surgeon with the results of illeus and he had night nurse start tube feed at 50ml/hr. The night nurse is very experienced and monitored him closely for residual etc. So I picked up the patient the next day at around noon because I sent home two patients and evened out the load from day nurse that had the assignment. I get quick report and day nurse checked residual and had less than 25 prior to report. So i check on patient and he he had audible crackles from the door and was lethargic. I turn off fluid and feeding and get on the phone to doc for some lasix. Pressure was good(115/75 a little tachy at 105 but he was running 90s as a norm and sat was 90 on 4L) Doc basically tells me Im stupid and Im hearing infiltrates and gives no orders. I notify my charge nurse and rt that was on the floor. They both agreed I should not start either fluid or feed. Within 30 minutes I recheck him and he is tanking...pressure 68/45 sat was 75 tachy in 130s, and basically responsive to only pain. We put him on suction and out comes like 1200ml of green tinged feeding residual. Transferred to ICU, bolus of fluids for the pressure and ends up on a vent.

So heart failure/respiratory distress, or sepsis or a fistula or all three?

or something totally different?

[kungpoopanda]

Big blocks of text are hard to read.

[jadelpn, LPN, EMT-B]

50 ml an hour for a tube feed--too much too soon. Additionally, was bed at the correct angle? Lying flat is not a tube feed's friend.

If you are getting less than 30ml's in any sort of suctionable device that is on constant/intermitent, then checking placement is not a bad thing. And a question of why are we suctioning and getting little return? If you are not getting some sort of return on the suctioning that is more than xx (and every facility has a different take on this) then to continue to suction when patient is NPO is not great practice.

You mentioned patient was on lasix to begin with--why? Stopping the lasix and then adding fluid is also not a great idea. As evidenced by edema is LE, and a change in lung sounds.

Green gunk says bile to me--or infection. So sepsis (with other indicators of an increased pulse rate, a tanking BP, ? fever, CBC--daily labs?)

With patients such as this, I always monitor closely the I&O's, if the patient was on lasix and now is not to ask to have it re-started at the hint of CHF-y symptoms, and the basics--the head of the bed needs to be up, feeds are started really, really slowly and increase with tolerance only, and fluids KVO with the introduction of another form of fluid--especially in compromised patients to begin with.

Sounds very cancer with mets to me....did he have a CT scan and what did that show?

Keep us posted, very interesting patient.

[annaotis]

I think sepsis. I had a young patient who was up in bed and joking with staff. Within a few hours he became "cranky", which was not like him. This was his only outward sign that something was off. Got vitals immediately. He was bottoming out quickly. He ended up on a vent within 30 minutes. Gram neg sepsis came out of nowhere.

[NYbabyRN, BSN, RN]

Thanks for sharing your patient experience with us. I work with a lot of post-op colectomy patients and I'm surprised tube feed would be ordered with a bowel ileus. Keep us posted on the patient if you can.

[RNperdiem, RN]

That 5 day stay in the unit is interesting. What kept him there so long? Was he difficult to wean off the ventilator? Cardiac ectopy, pressure problems?

My thoughts are PE(always a major suspect in a post-op patient), sepsis, dead bowel, or a GI leak.

It sounds like you advocated for your patient the best you could, but his problems sound bigger than your floor was set up to handle.

[nurseprnRN, BSN, RN]

Also, if you look at the Frank-Starling curve, you can get the same BP with a little too little circulating volume as a little too much. However, if the lungs are getting wetter, you better figure he was on the downward side of the curve, and that doc is an idiot.

[calivianya, BSN, RN]

Agreeing with the person who thought it was nuts to start someone with an ileus on tube feeds at all. If they ask me to start tube feeds on someone with an ileus, regardless of what the orders are, I might start them at 10 ml/hr if that and see if bowel sounds pick up with that teeny bit of stimulation.