Maybe Im missing something....

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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?

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and always check my own patients residuals........ no matter who is giving me report

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Specializes in PCCN.

I'd go with sepsis or fistula or obstruction.

Sepsis will increase o2 requirements- tanking b/p , what was urinary output? mental status?if it was chf/resp failure I'd think you'd see more signs of flash pulm. edema.? did pt have hx of chf? how bad was their ef? md should have not blown you off.

Also, starting tube feed at 50? isnt that a bit high to start?

Curious - what did labs show- BNP, Lactic acid (i'm sure was high) lytes, etc?

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Specializes in Emergency Nursing.

What sort of cardiac history did this person have?

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Specializes in ICU.

Perforation?

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Labs were good which is why I'm confused even more. Last ef was 55 a couple months ago if I remember correctly from the previous day. Hx of CHF. I was on him closely the prior day and he was doing well with the fluids. No blood cultures since he came for surgery which were negative. As my favorite cardiologist says "It doesnt take much to run out of gas but It also doesnt take make to overfill" when speaking of elderly fluid volume, but it was literally an hour and a half from when I took over to ICU/vent. I know sepsis is very sneaky but it can come on that fast? He was talking A&Ox3 with slight confusion(baseline per wife and report).

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Specializes in Neuro ICU and Med Surg.

My thought is sepsis or perforation. 50 ml/hr is way too high to start a tube feeding. This doc shouldn't have blown you off.

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and yeah I was surprised to hear 50.... I even said 50...five zero an hour? Surgeon said yes 50.

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patient was 99kg(almost broke my back when he decided to pull back out of a chair too), usually initiation is like 1-2ml/kg/hr or more slowly if concern over GI right? so thats half of the low end.

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Specializes in ICU.

Yeah, the more I think of it, perforation causing sepsis.

I remember a patient who was young with lots of pain and on major pain meds. We all kind of new him and when he became confused everyone kind of blew him off attributed it to pain meds and ICU psychosis. The next night a nurse who hadn't had him and was objective knew there was something wrong. Plus he was very hypotension. He was perf-zing and we didn't know it. He ended up getting emergency surgery , went to surgical ICU near death on a lot of pressure. He ended up pulling through.

Perfs are sneaky.

and yes 50 is way too high to start a feeding at, especially with his diagnosis.

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Specializes in PCCN.

sounds like perforation/sepsis.

Sepsis can happen fast.Especially if it was brewing.Maybe it was a large sudden perforation.Abscess?Being bowel....

I wonder what the surgeon thinks of this now.........

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Specializes in Acute Care - Adult, Med Surg, Neuro.

Do they normally start tube feedings on patients with an ileus? Usually by day 3-4 of NPO status we would start TPN, particularly with SBO / ileus.

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