Normal Saline as a flush for PEG

[WittySarcasm, BSN]

Hi. So I just have a quick question because I love to learn. I have a patient who is post crani- after a subdural. Anyways she's NPO and on a tube feed continuously. Which is all normal but her flushes is normal saline every 4 hours for hydration. I was just wondering why this is. Her labs are pretty much normal, sodium is slightly low but not anything bad. (She does have a PICC so It surprised me that if it was because of land that she did not just get IV fluids.) Anyways I just wanted to use this as a learning chance since I'm night shift and docetos are never around. Thank you to anyone who can help me understand this because google really wasn't working.

[nutella, MSN, RN]

flushes through the feeding tube (g tube or j tube or GJ tube are usually tap water flushes because it goes into the stomach or jejunum and mimics the "normal way of eating and drinking" - using the guts. Sometimes tap water is not consider a safe choice because the pat is highly prone to infections but in those cases they usually prescribe bottled water.

If a pat can get all their hydration and nutrition via g tube etc this is preferred over IV because

1. high risk for infections with iv and 2. it is better to use the gut.

There are two possible options of what happened I think:

1. the provider who ordered the "saline flushes in the feeding tube order" made a mistake for whatever reason and in fact the order should be water flushes per g tube or N Gtube or whatever tube you have. This requires the pat to tolerate the amount of liquid so residuals need to be checked I guess.

2. the provider wanted only feeding through the tube for whatever reason and the IV per PICC line IV.

In both cases, the order needs to be clarified with the provider.

[KelRN215, BSN, RN]

Does the patient (or did she immediately post-op) have cerebral salt wasting or SIADH?

I've never seen normal saline ordered by G-tube but have had patients with the above mentioned disorders not be allowed free-water and have Pedialyte flushes instead.

[missmollie, ADN, BSN, RN]

NS is ordered because they are worried about her sodium levels. Lower levels lead to brain swelling, higher levels keep brain swelling at a minimum. Generally speaking, sodium levels should be between 140-150 for a post crani/hemorrhagic patient.

The BP parameters should be lower as well, 140-150. Why do you think that is?

[Mr. Murse]

I think missmollie's comment is probably on the right track. I've worked in neuro ICU quite a bit and never seen saline flushes through a feeding tube, but my guess would be that it has to do with cerebral edema/ICP. I'm not sure how taking it through the GI tract would be advantageous, but we often have people with various crani's and potentially elevated ICPs on high sodium drips like 3% NaCl or others like Mannitol, which affects the pressure by altering osmolarity/osmolality (and I don't really remember the specifics of those).

If I were you I would ask. In part because it's possible that it was a mistaken order, but moreso just to learn. When the ordering provider rounds, present the question along the lines of "I'm just curious why we're giving saline through the PEG", not accusing them of a mistaken order but just wanting to learn more about what you're doing.

[morte, LPN, LVN]

yes, supplement Na+ to prevent water intoxication.

[zoidberg, BSN, RN]

I have used NS via PEG or J quite often. If we can maintain a normal sodium with NS via enteral flush, rather than through IV, they can leave the acute care environment (they can go to rehab...) Pushing large amounts of free water into someone all the time will often cause hyponatremia over time.

[LovingLife123]

I've never seen it through a PEG, but yes, after a crani, you want to keep sodium levels elevated to prevent swelling. Since this person already has a PEG, where most patients in this situation don't, I'm guessing the absorption is better than IV. The same principal as to why you always should put potassium down a feeding tube as opposed to IV. You get better absorption that way.

We generally keep NA levels above 140 after certain cranis.

[Julius Seizure]

I have seen patients get NaCl as a med q6 or q8 via GT due to chronic hyponatremia. Maybe they figure this is "close enough".

[Ilargia99, LVN, RN]

There was a patient like that on the neuro floor in the observation room. They were in a really bad accident and had part of their cranium removed temporarily to reduce the pressure. Lots of things going on with that patient, of course. I remember they needed regular saline flushes through their GT as well since they were salt wasting. Neuro unit had a lot of patients who had been in serious accidents and had little hope for recovery, it was very depressing.

[Rnmo21]

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