Keeping an NG patent with a upper GI bleed?

[LovingNurse, BSN, RN]

Here's the scenario - "Otherwise healthy" young person with UGI bleed from suspected NSAID overuse came up from ER with NG that they'd already had to do a 1000cc lavage on. I have it to LIS as ordered,- and make sure it's on low. Next time I'm in the room the guy has 200cc dark blood in his gomco and I noticed the suction was kicking up all the way to the highest high when it would turn on. I didn't want it sucking up this guy's gut tho. I disconnect & irrigate the distal tubing thinking it's too thick, and replace the old model dial suction control with a digital one, hoping to gain more control & keep it in the low suction range.

In my head I'm thinking... it kicked up to full because it was working against clots (like sucking a milkshake straw that has a strawberry chunk blocking it - ya know?) I tell the pt to call at first inkling of any nausea & literally 5 min later he's vomiting clots. I medicate for nausea and my nrsg supervisr was on the floor so I asked her help. She tried to irrigate toward pt & repositioning NG a little...she could get some water into the pt. but couldn't get it back... all clots. Had me call admitting physician to let him know we can't keep the NG patent due to large amt of clots. Admitting doc has me contact the GI consult that hasn't seen him yet - because it's the middle of the night. GI consult gets mad that he had an NG to begin with and bothered him... Said "just pull the **** NG that shouldn't have been put in to begin with and keep him medicated for nausea." (Didn't seem concerned about the amount of bleeding.)

Okay so here's my question: When an NG won't stay on low intermittent suction d/t clots and you can't stand 1:1 all night to watch it or continually irrigate it -- what could I have done differently? I didn't feel right leaving it the way it was kicking to high each time but knew low wasn't going to cut it either.

Another nurse said she's had the same thing happen with a clotty bleed.

Thanks for any advice for next time.

BTW, pt was delighted to have the NG taken out and never vomited again.

[Roy Fokker, BSN, RN]

My first question is:

"Why is your suction apparatus (apparatii?) kicking into 'high' if you've set it to Low Intermittent?" Kinda defeats the whole purpose of having a human "set" the regulator if the regulator decides to do what it wants! Yes, I know you put the digital one in place - but it still shouldn't do that!

Where I've worked, the suction would kick in and reach the limit I'd set... then it would shut off - regardless of the output amount/consistency.

My second question isn't so much a question in as much as it is a 'musing': "I wonder why GI got so ****** off with the NG and wanted it to come out, despite the output quantity/quality/consistency. Where they concerned about UGI irritation (and dare I say it 'varices') and further irritation?".

As to your question about what to do:

* Was this fellers output rather clotty? Because if it was clotty, there not a whole lot else you could do other than lavage PRN. Sorry.

Some folks might suggest replacing present NGT with a larger bore NGT but frankly, I don't think it makes all that much of a difference... and besides,.... well, I think y'all can figure the rest of it!

* Sometimes, I've found that part of the problem lies in the "connector" - you know? That football shaped thingie that lets you connect the NGT to the suction tube?

I always keep my connections a touch-and-a-tad bit on the looser side. I depends on the suction system you are using really... but sometimes, that seems to make all the difference between 'relatively smooth flow' versus 'sporadic to no flow at all'.

Be careful though! Escessive pt. movement is liable to dislodge the connector and leave you with a good mess to clean up! Not to mention innacurate I/O!!

cheers,

PS: The suction systems we use here in my ED suck... and I mean figuratively, not literally! LOL They're horrible and develop ridiculously low amounts of suction... intubating trauma patients is always a challenge thanks to our PoS equipment...

[Teresag_CNS]

You were in an impossible situation. I don't know why the gastroenterologist insisted on removal of the NG, but it seems like a bad idea to me when the person is vomiting clots. Antiemetics are not good enough to handle a problem of that magnitude alone! Methinks someone didn't want to get out of bed to treat the patient & was hoping that would tide him over until morning.

[LovingNurse, BSN, RN]

hi roy, thanks for your reply and your thoughts on this.

my first question is: "why is your suction apparatus (apparatii?) kicking into 'high' if you've set it to low intermittent?" kinda defeats the whole purpose of having a human "set" the regulator if the regulator decides to do what it wants! yes, i know you put the digital one in place - but it still shouldn't do that!

where i've worked, the suction would kick in and reach the limit i'd set... then it would shut off - regardless of the output amount/consistency. i didn't know it would kick into high like that either. i was very, very, very sure i'd set it on low --- watched it a long time before leaving. once i changed to the digital suction control apparatus it consistently stayed in lis range.

my second question isn't so much a question in as much as it is a 'musing': "i wonder why gi got so ****** off with the ng and wanted it to come out, despite the output quantity/quality/consistency. where they concerned about ugi irritation (and dare i say it 'varices') and further irritation?". i don't think he was concerned about irritation or varices, so much as he said it's "worthless" in this situation "and only making the pt miserable." seemed like all the gi was concerned about was his sleep being disturbed. the admitting doc who asked me to wake up the gi asked me to relay that he's thinking this young person needs intervention as soon as possible. ... to which the gi doc just chuckled.

as to your question about what to do:

* was this fellers output rather clotty? because if it was clotty, there not a whole lot else you could do other than lavage prn. sorry. yes - clotty as all get out.

some folks might suggest replacing present ngt with a larger bore ngt but frankly, i don't think it makes all that much of a difference... and besides,.... well, i think y'all can figure the rest of it!

i always keep my connections a touch-and-a-tad bit on the looser side. i depends on the suction system you are using really... but sometimes, that seems to make all the difference between 'relatively smooth flow' versus 'sporadic to no flow at all'.

be careful though! escessive pt. movement is liable to dislodge the connector and leave you with a good mess to clean up! not to mention innacurate i/o!! thanks for the connector hints. will keep those in mind.

[LovingNurse, BSN, RN]

methinks someone didn't want to get out of bed to treat the patient & was hoping that would tide him over until morning.

methinks the way youthinks.

[Roy Fokker, BSN, RN]

i didn't know it would kick into high like that either. i was very, very, very sure i'd set it on low --- watched it a long time before leaving. once i changed to the digital suction control apparatus it consistently stayed in lis range.

oh, i'm not doubting you at all :).

i was just curious as to why your suction apparatus (apparatii? dang it, i need to find a good dictionary! ) behaved the way it did! don't you think it's odd that the regulator would pump up to "high" even when you set the blessed thing to "low"?

i don't think he was concerned about irritation or varices, so much as he said it's "worthless" in this situation "and only making the pt miserable." seemed like all the gi was concerned about was his sleep being disturbed. the admitting doc who asked me to wake up the gi asked me to relay that he's thinking this young person needs intervention as soon as possible. ... to which the gi doc just chuckled.

i wouldn't jump to the conclusion that the gi doc didn't like his sleep being disturbed (i mean, i'm no gi doc and i wasn't involved with the situation). but yeah, it does pique my curiosity.

if you see the gi doc the next time you're working, ask him/her! "gi doc, remember the patient we had in room so-and-so with the gi bleed you asked me to pull the ng tube on? i'm just curious as to why you thought that the ngt was useless in that situation?"

yes - clotty as all get out.

ouch! there's not a whole lot else you can do in that regard (imho). reminds me off all the blessed turp/bladder/gu surgery patients i'd get...

i sympathize - i was a floor nurse too (once upon a time )

thanks for the connector hints. will keep those in mind.

"always a pleasure, never a chore. knowledge not shared, is lost forever".

hey, it may or may not work for you ... but at least you tried, right? :)

how did your patient make out in the end anyway?

cheers,

[LovingNurse, BSN, RN]

"if you see the gi doc the next time you're working, ask him/her! "gi doc, remember the patient we had in room so-and-so with the gi bleed you asked me to pull the ng tube on? i'm just curious as to why you thought that the ngt was useless in that situation?"

my plans exactly.... but i rarely see this team rounding at night. i do see their np at the crack of dawn tho so maybe she can she'd some light. i know she saw the pt before i left that morning and added him to their endoscopy schedule for 2 hrs later. never did get the final scoop - i didn't work the next day and he had been discharged by the day after.

ouch! there's not a whole lot else you can do in that regard (imho). reminds me off all the blessed turp/bladder/gu surgery patients i'd get... yes! it exactly reminded me of trying to remove bladder clots to keep the 3-way patent after sweet l.o.m. pulls out foley.

i sympathize - i was a floor nurse too (once upon a time ) thank you for the sympathy - lol- it helps! .

[lsyorke, RN]

I was just curious as to why your suction apparatus (apparatii? Dang it, I need to find a good dictionary! ) behaved the way it did! Don't you think it's odd that the regulator would pump up to "high" even when you set the blessed thing to "low"?

If an NG tube is occluded, the suction is going to get progressively higher in the tube since there's no release of suction due to the clog.

This patient needed emergency EGD....doc should have gotten his butt out of bed!

[Roy Fokker, BSN, RN]

If an NG tube is occluded, the suction is going to get progressively higher in the tube since there's no release of suction due to the clog.

The suction should only 'get progressively higher' if the suction regulator was malfunctioning.

If I set the regulator at "Low - intermittent - suction"; I expect the regulator to run at "Low - intermittent - suction".

Not run at higher suction just because of a 'clog'.

I mean, that's the whole reason there is a regulator present.

IF the NG tube is "occluded", then "higher amount of suction" isn't necessarily the best solution.

It's far more effective to lavage than to jack up the suction.

Which brings me back to my point of contention - why is the suction regulator jacking up the vacuum despite being set not to!

cheers,

[netglow, ASN, RN]

Also would like to know why D/C NG tube.

Had a pt with NG tube after 2nd EGD for continuing active GI bleed (another Doc's order put in NG), and GI doc (the one that did the EGD) was furious to see the NG and immediately D/C'd it the next a.m. I believe the D/C doc stated NG to suction increased hemorrhage risk after EGD and TX? Hmmm. Suction was drawing blood.

[azhiker96, BSN, RN]

Also would like to know why D/C NG tube.

Had a pt with NG tube after 2nd EGD for continuing active GI bleed (another Doc's order put in NG), and GI doc (the one that did the EGD) was furious to see the NG and immediately D/C'd it the next a.m. I believe the D/C doc stated NG to suction increased hemorrhage risk after EGD and TX? Hmmm. Suction was drawing blood.

GI doc's explanation makes some sense to me. If you take a yankouer and put it inside a plastic bag it's going to suck the bag around it. If there's a leak in the bag, air is going to rush through it. Now if the bag is a stomach and the leak is a bleed, applying vacuum is going to increase the bleed rate.

I know an orthopedic surgeon who runs his drains uncompressed 4 hours, then compressed after that. This gives bleeders a chance to clot off.

[netglow, ASN, RN]

Thanks...

And which is worse, letting the pt. retch and vomit w/o NG because of the blood irritation, and cause poss big time hemorrhage... you know (by looking at pt - intuition) they are filling up with blood and you are just waiting for pt to barf up large volume all at once or for the vitals to show. -Or- put that NG in, relieve them of some of the bleeding (I like the no suction route suggestion) and the retching hopefully lessens, and get a grip of how much bleeding you are really dealing with esp. since known damage is severe to keep ahead of it.