What to do if a pt. aspirates???

[limabean]

I had a patient who had been put on tube feeding per Dobhoff the day before. That day the pt. had vomited and the doctor stopped the tube feeding until he could reassess the pt in the morning. I took over care for the patient the next morning and the doc restarted the tube feeding b/c the patient had not vomited anymore. Well all day he did fine ( I checked residuals q4h ..he had none...I also checked placement with air). Later that night the pt began to vomit while I was in the room, so I sat him straight up (he was always at least at 30 degrees or higher) and suctioned his mouth out. However, I knew he was aspirating some b/c his lungs sounded bad and he was coughing. I called the doc and he just said to hold the tube feeding and give him some Zofran ( this patient was a DNR by the way and had multiple other issues). The patient just got worse that night and died. I just wonder if there was anything else I could have done to prevent him from aspirating or to help him after he aspirated???

Also, does anyone have any CLEAR answers as to if you check residuals and if you check placement with air injection for Dobhoff tubes? We always initially get a chest x-ray to confirm placement but I am asking about each day thereafter. And... (just one more question)...do you have to have a doctors order for nasotracheal suction? Thanks for any help...

[pricklypear]

Checking residuals and placement for dobhoffs varies by institution policy. We check residuals every 4hs, and hold TF for 4 hours if >250. We do not check (at least are not supposed to) dobhoffs with air bolus. There is the risk of blowing off the weighted end of the tube, which could cause it to float back up, and would require replacement. I've never seen a dobhoff, once placed properly, turn around and snake back up through the stomach and into the esophagus. Unless it had come out after being placed, and someone tried to readvance it.

To my knowledge, you don't need an order to NT suction, if it's an emergency. If not an emergent situation, you shouldn't do it without checking first. Sometimes there's just not much you can do once someone aspirates. Especially someone who is already compromised, and will not be intubated due to a DNR order.

Reglan might have been a better choice due to it's ability to increase gastric motility - which Zofran does not do.

[Tweety, BSN, RN]

Sounds like you've done everything you could have done, and did a good job.

We don't check DHT placement with air either, we Xray if there's doubt. But the emesis might not have been related to the placement.

[presC.]

thanks for sharing your experience limabean. this is one of the procedure i need to be comfortable with..

[Katnip, RN]

I'm just curious: did you get a stat CXR when his lungs sounded crappy?

That was policy on IMC when I worked there. We didn't need a phycician order for that.

[limabean]

I'm just curious: did you get a stat CXR when his lungs sounded crappy?

That was policy on IMC when I worked there. We didn't need a phycician order for that.

No I did not get a stat CXR. However, I did call the doctor 2 minutes after the incident, and he only wanted the Zofran given. I dont really know what the policy is for that at my hospital. But they were not really willing to do much for this man b/c I believe they knew he was hanging on by a thread anyway. Thanks for all comments and help.

[hollyster]

Zofran is a great antiemetic if it is given before vomitting starts does not work if pt is already vomitting. Tweety is right he needed reglan not zofran.

It is rare to get any residual from a Dophoff. When properly place they are in the duodenum not the stomach itself. X-ray is the only way to confirm placement. A portable x-ray after the first round of vommiting would have shown if the dophoff floated out of place

[CoffeeRTC, BSN, RN]

See these type of things often in LTC. Stop feeding, suction what you can, chest xray. Since he was DNR and had little time to live....why the feeding? Was the pt actively dying? Sounds like it did more harm than good.

YOu did good tho!

[limabean]

See these type of things often in LTC. Stop feeding, suction what you can, chest xray. Since he was DNR and had little time to live....why the feeding? Was the pt actively dying? Sounds like it did more harm than good.

YOu did good tho!

The patient had the feeding going b/c the family did not want to "starve" him. I know so many families who find this to be one of the hardest parts of letting someone go. He was a DNR, but they were still holding on to hope that he would come out of it. After his surgery he just went downhill fast. He was in afib when he went in for the surgery and stayed in rapid afib when he came out. He wouldnt or couldnt move an inch. Lungs were horrible from lack of movement and aspiration. Plus his dementia was worsening.

Thanks again for the input. I'm still a relatively new nurse and I just have a hard time when one of my patients dies....I always wonder if there was anything else I could have done.

[fins]

...would have been to get a stat chest xray (like others have said.) But then what? If the xray shows that the patient aspirated, you have to consider putting them on a vent. But if the patient is a DNR, they're probably DNI also. In which case there really wasn't all that much point to getting the xray done.

[leebrenda]

New nurse asks .....What do I do for an aspirating vent dependent patient who talks and has a cap over it. I assume suction through trach am I right or wrong? Need info