Just wanted to get everyones input about a situation that happened at work today. A patient of mine had orders to have an NGT placed after vomiting 550 mL of gastric content during my shift. After preparing all the equipment that I needed to insert the NGT, I made sure to mentally go over the procedure in my head. I went ahead and proceeded to insert the NGT and the patient was able to tolerate the procedure. Read the MD orders and noted to set NGT to low continuous suction. Suction was started and I was initially able to suction out greater than 600 mL of gastric content with a couple chunks of what appeared to be bile. As the night went on, the patient looked more comfortable and suction was still functioning without any problems. Fast forward to 0700, everyone was getting ready for shift change and report when we see one of the surgeons storming out of the patient's room demanding to talk to the nurse who had inserted the NGT. Apparently the surgeon and his surgical team found that the suction was connected to the blue pigtail rather than the clear tube. The surgeon went on about how this was wrong and that pictures were taken for proof. I went ahead and proceeded to the patients to see if the patient was okay, which fortunately he was. After the surgical team left the room, I asked the patient if anyone came in to fix his NGT overnight. The patient denied and stated that he could not recall anyone else coming in to look at the NGT. By then I started doubting myself and thinking whether I could have really connected the suction to the wrong tube. So up until now, I have been thinking what could have gone wrong? I am almost certain that I connected the suction to the proper tube and not the blue pigtail.
If suction was connected to the blue pigtail from the beginning when the NGT was first placed, would it still have been possible to have an initial output of 600 mL of gastric content immediately following insertion?
I would assume that from looking at the gastric content that was suctioned during the insertion that it would have clogged the blue pigtail tube right away, right?
Although the patient denied anyone else handling the tube overnight, could it possible that the portable x-ray technician that took the CXR and KUB to confirm placement of the tube might of mistakenly connected suction to the wrong tube after obtaining films?
My mind is racing and cannot stop thinking what could have possibly gone wrong. Need your guys' input, please!
Because if you insert water you decrease the serum sodium (as water crosses into the capillaries and dilutes serum electrolytes). For some patients this can be a real problem. Using NS will not affect serum Na+.
Thanks. A follow up question: under what circumstances should NS be used, i.e. Who is at risk for hyponatremia? Are all patients with an NG to suction at risk?
They can be if somebody is chunking water into them all day long. :)
You should know who's at risk for hyponatremia-- SIADH, stroke/brain injury, vent patients (stretch receptors in lungs), anyone with meds that retain water...
They can be if somebody is chunking water into them all day long. :)
You should know who's at risk for hyponatremia-- SIADH, stroke/brain injury, vent patients (stretch receptors in lungs), anyone with meds that retain water...
That would take a whole lotta chunking! The California woman who died of water intoxication/dilutional hyponatremia drank 6 liters of water in 3 hours. If you're doing that much flushing (2000ml/hr) you got more problems than a gooey pillowcase.
In terms of continuous vs intermittent suction, I've never worked anywhere that we didn't automatically change all NG continuous suction orders to intermittent. There is no benefit to continuous suction for this purpose, only risks. In theory the vent lumen on a salem sump will help protect against the tube causing gastric erosions, but that's a big assumption since we know the vent lumens can easily occlude, in which case having it set on intermittent suction will add backup protection against gastric erosions. There no reduction in effectiveness by using intermittent suction, a typical system will still pull a couple hundred liters of fluid per hour from the stomach, if that isn't sufficient then you've got much bigger problems.
As for flushing with NS or water, water is the correct default fluid. Flushing with water doesn't introduce some sort of abnormal sodium decreasing effect, we all typically drink water regularly and our balance is maintained, putting water down an NG is the same. In the event of a need to manipulate sodium balance then NS could be indicated, but I don't think it's what's routinely necessary to maintain sodium balance.
I agree that withdrawing the Salem Sump an inch and replacing it to remove it from the gastric folds works very well. Sterile NSS is ordered per surgeon's preference for gastrectomy patients.
We use fresh tap water for the trace minerals when feeding. If the NGT is placed to suction, it's just more economical. I don't see any danger of hyponatremia if the water is instilled to maintain a patent tube and if that tube is functioning and connected to suction.
When stabilizing a donor case with a high sodium level, we will instill 60cc of tap water, clamp for two hours, drain, and instill another 60cc and repeat the process every two hours until the sodium level is in the desired range. The water in the stomach will pull sodium from the other compartments through osmosis similar to instilling peritoneal dialysate.
Based on my experience with donor cases, I have to agree that instilling water and clamping the tube will drop the sodium level if done repeatedly and consistently over a period of time. It would be reckless to do this to a patient with hyponatremia.
30 cc of tap water every four hours is really only 2/3 of a cup in twenty four hours and if the tube is connected to suction for gastric decompression, there shouldn't be any adverse effects.
It is possible to see metabolic alkalosis from GI losses of chloride but this is prevented by administration of an isotonic maintenance IVF.
As for flushing with NS or water, water is the correct default fluid. Flushing with water doesn't introduce some sort of abnormal sodium decreasing effect, we all typically drink water regularly and our balance is maintained, putting water down an NG is the same. In the event of a need to manipulate sodium balance then NS could be indicated, but I don't think it's what's routinely necessary to maintain sodium balance.
Every link I googled said to use NS with NG tubes to suction, so I'm not sure water is the correct default fluid. I didn't know why, though, which prompted my question. The risk of hypokalemia is known with GI losses, but I didn't see the same common knowledge associated with NG to suction and hyponatremia.
ETA: I thought water for Feeding tubes was necessary to prevent hypernnatremia. I've had a few patients whose sodium trended upward out of range because previous nurses didn't flush with the full amount in the order. The docs would increase the flush order, and I had to tell them to check I/Os before doing so. They would then put in a nursing com order telling us to follow the flush order!
Every link I googled said to use NS with NG tubes to suction, so I'm not sure water is the correct default fluid. I didn't know why, though, which prompted my question. The risk of hypokalemia is known with GI losses, but I didn't see the same common knowledge associated with NG to suction and hyponatremia.
I searched "flush nasogastric tube with" and through at least the first 5 pages I can't find anything that recommends using NS, every single one says water. We all drink water regularly without any adverse effects (so long as it's moderate intake), and we actually rely on a regular amount of free water intake to maintain electrolyte balances.
ETA: I thought water for Feeding tubes was necessary to prevent hypernnatremia. I've had a few patients whose sodium trended upward out of range because previous nurses didn't flush with the full amount in the order. The docs would increase the flush order, and I had to tell them to check I/Os before doing so. They would then put in a nursing com order telling us to follow the flush order!
Lack of free water can certainly cause hypernatremia, asking how much water someone drinks is usually one of the first questions a patient with hypernatremia will be asked.
I think the problem with the failure to give the ordered amount of flush is actually the doctors' fault. What they need to be ordering is an amount of free water to be given each shift. Doctors often incorrectly interchange an order for a certain volume of flush with an order for a certain amount of free water. A "flush" order is subject to nursing judgment on whether or not a flush is indicated and even how much is necessary, a "give free water" order is not and makes it clear the Doctor isn't ordering it for the purpose of clearing the line, but to provide a therapeutic volume of free water.
I googled your search phrase, and all I came up with is links for NG tubes for feeding. When I searched "ng tube suction electrolyte imbalance," I came up with a number of links and pdfs which state normal saline.
I googled your search phrase, and all I came up with is links for NG tubes for feeding. When I searched "ng tube suction electrolyte imbalance," I came up with a number of links and pdfs which state normal saline.
In the case of treating an "electrolyte imbalance", specifically hyponatremia, switching out water for NS can be indicated, but in the absence of hyponatremia it's not indicated.
One more try...the links I found were standards of care documents and book chapters that said to use normal saline to prevent electrolyte imbalance. They were not interventions to treat electrolyte imbalance.
I actually agree that that a little bit of water through an NG tube to suction to flush it in the absence of actual or risk of hyponatremia is no big deal. What I'm trying to point out is that water is not considered the "correct default fluid."
I love it when these threads get technical. I love seeing what other nurses do in their day to day practices. :)
Almost the only time I see NS ordered is when the patient has had some type of stomach surgery. Otherwise, I always see water. I suspect what the "correct" flush fluid is depends on what physician is seeing the patient since it seems like there is research on both sides.
I like what icuRNmaggie said about flushing with tap water for trace minerals; I might have to use that as an argument for using tap water at my current job. My job insists we only use sterile water to flush. It is about the dumbest thing I have ever heard of in my life, since 99% of the population in the US doesn't only drink sterile water. They say tap water's a little more likely to cause infection or something. I would maybe understand that in fresh post-surgical patients or severely neutropenic patients, but for everyone? Infections from drinking tap water? We don't live in a third world country; our water supply is clean. I think it's a totally unnecessary expense. They are always talking about saving money; maybe we should stop using sterile water that most people get a new bottle of every single day to flush our NG tubes!
Do you guys who use water use sterile water or tap water?
I love it when these threads get technical. I love seeing what other nurses do in their day to day practices. :) ...
Do you guys who use water use sterile water or tap water?
Default is tap water per hosp policy in my stomping grounds. I have yet to use sterile water, and have used NSS very rarely. Unless the physician specifies a fluid, tap water is the go-to.
dudette10, MSN, RN
3,530 Posts
Thanks. A follow up question: under what circumstances should NS be used, i.e. Who is at risk for hyponatremia? Are all patients with an NG to suction at risk?