EGD Question?

[casperx875x]

Hello all,

Today I took care of patient who went down for an EGD. The patient had been having abdominal pain and previously had an U/S and MRI done of his abdomen which showed possible cirrhosis of the liver, possible mets, and an unidentifiable mass. The patient had been NPO since midnight, went down for the EGD at 1330 and came back around 1630. When the patient left he looked about 3 months pregnant, but when he got back he looked about 9 months pregnant. His abdomen was rock hard solid, was extremely distended, and had extremely hyperactive bowel sounds. I had my charge nurse and PCC take a look at the patient and they were both concerned and definitely backed me up on calling the physician to make them aware. Orders were written to resume tube feed, but I wanted to speak with a doc first to see what their take on it was. About an hour and a half later, the patient begins spewing tube feed through his trach and is sat'ing 65% on 50% TC. Obviously my concern for the patient has increased ten fold. I get in touch with the Pulmonary and GI doc, get several orders in and was off giving report once we got the patient stable. Has anyone experienced something like this? Maybe I am not understanding an aspect of the procedure that could contribute to that degree of abdominal distention? They also used MAC sedation. Could that be something that contributed to this? As you can tell, I'm very curious about this, and was very worried for the patient.

[leslie :-D]

during the egd, they do instill air to facilitate examination.

so for the pt to awaken with distention and feeling bloated, gassy is not at all uncommon.

but, with the hyperactive bs, vomiting his fdg and being grossly distended, it sounds like he's partially obstructed.

maybe that's what the unidentifable mass was?

either way, he sounds like a very sick man.

i've had more than 1 argument w/docs who insist on tube fdgs when i knew darned well the pt wouldn't tolerate it.

i'll bet you anything he's obstructed.

sigh...

leslie

[chenoaspirit, ASN, RN]

Hmm, I wonder how his abdomen became so distened afterward. I know they put air into the stomach for better viewing, but that would have been ALOT of air! I do know there is a small but obvious risk of perforating the esophagus which can result in bleeding into the stomach. Could that have been a possibility? And with it being so distended, I would have been concerned about restarting TF. Where is the mass?

[jaccimv]

just out of curiousity...did you get a report before the pt came back to you regarding the findings of the egd?

I agree..I think there might be a possible obstruction.

[nrsang97, BSN, RN]

I agree with the others who say he probably had a obstruction. I remember waking up feeling somewhat gassy after my EGD because of the air, but I have never seen abdominal distention like that after a EGD. Did his tube feed have any residual before you restarted it?

[mpccrn, BSN, RN]

i'd have to argue the sanity of restarting tube feeds with an abd. like that with the doc. a few hours would let you know if the distention was due to air (probably) in which case, if the gut was functioning adequately to tolerate feeds would take care of the air by moving it down. if in a few hours the gut was still rock hard and firm, it would be obvious feeds would be an aspiration risk for sure. no one died of not being fed for a few hours, but they do die of aspiration.

[casperx875x]

Thank you to everyone who commented to my post. I appreciate your input.

An update on the patient:

EGD showed NO obstruction. Abdominal obstruction series was also clear. The patient was placed back on the ventilator overnight, became hypotensive and hypothermic (90.0 F rectally), was RRT'd overnight and ICU residents determined the patient was stable enough to remain in stepdown. NGT was placed and put to suction. Prior to this he had a Corpak, so no residual to check when he came up with the highly distended abdomen. Pt was ordered a warming blanket and given 2 500ml NS boluses.

I came back in at 0700 this morning, went in to assess the patient. BP 60/36. Called the MD, hung 500ml NS bolus, of course no response. Decided not to play around and chase the pressure all morning so called an RRT. Back in to see the patient, patient is hardly ventilating taking volumes of 200 on PS 80% so placed on AC 100% with PEEP of 10. STILL suctioning large amounts of tube feed.

The RRT nurse, though I love them dearly and am incredibly thankful for them because they have helped me out sooo many times, was doing everything she could to keep the patient out in stepdown. The ICU residents came down to assess the patient and even agreed that he needed to go back to ICU. I was frustrated that she was continuing to go back and forth with them, arguing about why the patient should stay out. I understand the need to continue to explore reasons for what was going on with the patient, but all of that going back and forth nonsense? I partly feel that she was irritated with the nurse overnight who was caring for this patient. She was the RRT nurse that responded to the call overnight, and the warming blanket she had ordered at 0300 never got there, and I had called twice already this AM right out of report to see what the progress was on that.

I was really sad on the inside for the patient. 4.5 hours of bickering between the residents and RRT nurse trying to keep the patient outside of ICU because "we don't take 2's in the ICU." Last time I checked, just because a patient is a DNR does not mean we stop caring for them. If the patient is truly in that awful of shape, the doc needs to discuss those issues with the patient and family. Until then, the patient should continue to be cared for. I felt like the ultimate patient advocate today during this entire situation.

All I know is that I am glad the patient is in the ICU where they will be able to monitor him much more closely than I would be able to with 4 other patients.