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!
Do any of you use a gomco instead of wall suction? Some of our older surgeons order this. It doesn't seem to make a difference as to how effective/quicker/ better the outcome for the patient...but it only has 2 settings so you don't have to question whether you have the suction set up exactly right.
I use water to flush the NGT to prime the pump to restore negative pressure, just as you would fill the pipes to a swimming pool pump or well water pump.
Do any of you use a gomco instead of wall suction? Some of our older surgeons order this. It doesn't seem to make a difference as to how effective/quicker/ better the outcome for the patient...but it only has 2 settings so you don't have to question whether you have the suction set up exactly right.
My old hospital did. Granted, it was rural critical access so the majority of our equipment was held over from the last Millennium and wall suction hadn't been an option when hospital was designed. I'm unsure about the difference in clinical outcomes of Gomco vs wall suction, but Gomco was working fine for our patients. It just just a PITA to assemble the darn thing every time we used it.
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?
Infection source more related to the container you are using to gather the water rather than the water coming from a city water supply. How long has that container been sitting there? A few years ago someone did a study linking infections to patient wash basins as this served as a reservoir for bacteria to grow.
Can't really see the electrolyte argument unless you don't have functioning kidneys. Periodic 30ml tap water flushes are not going to dilute serum sodium. The human body is 60% water so a 100 kg person would have 60 liters of water in them. 30 ml every two hours would be 360 cc in 24 hours. Pretty insignificant even if your kidneys aren't working.
The plastic refillable water pitchers were eliminated approximately 20 years ago when it was fully proven that they were a reservoir for pseudamonas. Because of that study, my preference is to use a new syringe at the start of my shifts and a fresh cup of tap water each time. The syringes should be rinsed and allowed to air dry. I also do this with yankauers.
We use specimen cups to mix meds in. Brand new every day, sterile on the inside, rinse them out and close them when we're done. I can't imagine they get that dirty. We (night shift) also put out new syringes every day, as well as brand new sterile water. I can understand the syringes and specimen cups needing to be new, but the sterile water? We only pour it out and then close it up. It can't possibly get so dirty that it has to be replaced within 24 hours.
Specializes in Complex pedi to LTC/SA & now a manager.
We use specimen cups to mix meds in. Brand new every day, sterile on the inside, rinse them out and close them when we're done. I can't imagine they get that dirty. We (night shift) also put out new syringes every day, as well as brand new sterile water. I can understand the syringes and specimen cups needing to be new, but the sterile water? We only pour it out and then close it up. It can't possibly get so dirty that it has to be replaced within 24 hours.
Once it's been opened the sterile water bottle is considered contaminated and has a 24hr expiration date. (Especially if the cap is placed wrong on a contaminated surface such as a bedside table). Unless you only opened the bottle in a clean room such as parts of the pharmacy of the OR and used clean technique.
The water in the stomach will pull sodium from the other compartments through osmosis similar to instilling peritoneal dialysate.
No, the sodium doesn't get pulled out by the water. Water travels from an area of lower solute concentration to an area of higher solute concentration, thus diluting the solute on the other side of the semipermeable membrane. This is why water intoxication, hyponatremia, from excess intake leads to cerebral (and other) edema-- the brain cells swell because water enters them.
That's how the serum sodium gets lower, not sodium exiting up the NG tube (although there is sodium in any gastric secretions, being lost through suction).
The free water flushes we give, clamp and drain every two hours to treat hypernatremia in the organ donor case do lower the sodium by diffusion. The principle is similar to using the peritoneal cavity as a membrane when doing peritoneal dialysis. Not osmosis as I previously stated. Thank you for that.
Once it's been opened the sterile water bottle is considered contaminated and has a 24hr expiration date. (Especially if the cap is placed wrong on a contaminated surface such as a bedside table). Unless you only opened the bottle in a clean room such as parts of the pharmacy of the OR and used clean technique.
If by "contaminated" you mean no longer sterile then so be it. The contents of the stomach is not sterile, we don't ingest sterile food or drink (well maybe straight alcohol). A clean, cup with clean tap water is perfectly sufficient for routine flushes of an NG tube.
The free water flushes we give, clamp and drain every two hours to treat hypernatremia in the organ donor case do lower the sodium by diffusion. The principle is similar to using the peritoneal cavity as a membrane when doing peritoneal dialysis. Not osmosis as I previously stated. Thank you for that.
So, do you instill a measured amount of water, then drain out the exact amount?
How do you know the serum sodium levels are being reduced by diffusion of sodium into the stomach rather than the osmosis of water into the bloodstream thereby diluting the sodium, not actually eliminating it?
Specializes in Complex pedi to LTC/SA & now a manager.
If by "contaminated" you mean no longer sterile then so be it. The contents of the stomach is not sterile, we don't ingest sterile food or drink (well maybe straight alcohol). A clean, cup with clean tap water is perfectly sufficient for routine flushes of an NG tube.
Exactly what I mean. I was taught tap or standard bottled water was sufficient for routine flushes unless neonate, immune compromised or fresh post op then the physician may order a different flush whether sterile saline, sterile water but then these cases would not be considered routine. Why waste sterile water when not needed?
MOSTLYHAPPYRN
24 Posts
Do any of you use a gomco instead of wall suction? Some of our older surgeons order this. It doesn't seem to make a difference as to how effective/quicker/ better the outcome for the patient...but it only has 2 settings so you don't have to question whether you have the suction set up exactly right.