Whiskey peg tube flush?

[SquatsNScrubs, BSN, RN]

Been working in CTICU for a few weeks now.

Post-op esophagectomy patient is suspected to be going through ETOH withdrawal. Still NPO. Surgeon is very picky about administration of sedatives or meds that can compromise the pulmonary or circulatory system.

Treatment of choice? 30 mL whiskey via peg tube q4 hours for anxiety/agitation!

?

Anyone else done this?

[Luchador, CNA, EMT-B]

What kind? Jameson? Maker's Mark?

[KatieMI, BSN, MSN, RN]

Actually, had to do it quite a few times. Acute withdrawal, for one reason or another no IV benzos can be used, PO are either similarly "allergic" to (many alcoholics have paradoxical agitation up to full blown panic attacks on benzos, the shorter acting, the worse) or refused due to psycho/paranoyal behavior. ICU, things are getting worse... ETOH, either 30 cc of liquor (cheap vodka or Jack Daniels) or 8 to 12 oz of beer (Budweiser) PO/PT Q4, slow wean by time, then by amount.

It was always a great ceremony of at least 2 nurses walking down to cafeteria and receiving the said medication in a brown paper bag under both person's signature as per policy. As if none of us wouldn't prefer something better ?

Back in my country, IV ETOH is still used in the same situation. D5NS 2,5 to 5% ETOH, start IV 100 cc/h, decrease slow. People were used to tell great lies in order to get that treatment - they told me that there was nothing in the World making them feeling so great.

[Emergent, RN]

Sign me up! ?

[River&MountainRN, ADN, RN]

Learn something new every day! Don't let my NPO G-Tube home care patients hear this, though! ? Though it'd certainly liven up some of the care plans!

[guest1048932]

Yep! I've cared for alcoholics with an ETOH order. It's better to wean than quit cold turkey sometimes, for the reasons listed in previous posts.

[CelticGoddess, BSN, RN]

18 hours ago, SquatsNScrubs said:

Been working in CTICU for a few weeks now.

Post-op esophagectomy patient is suspected to be going through ETOH withdrawal. Still NPO. Surgeon is very picky about administration of sedatives or meds that can compromise the pulmonary or circulatory system.

Treatment of choice? 30 mL whiskey via peg tube q4 hours for anxiety/agitation!

?

Anyone else done this?

I've seen orders for beer and wine, never whiskey though. Sometimes t's just better for the patient to get a controlled amount of ETOH. Pharmacy would send up the beer, and we kept it in the fridge (where other "high risk" or expensive meds that needed to be in a fridge were kept).

A friend of mine works at an assisted living facility that has a bar and bar tender who works every evening for the residents. They have a cocktail hour. I'll have to ask her if she's ever run across a patient getting whiskey via peg tube. Lord I hope they aren't wasting an 18yo whiskey for this!

[ruby_jane, BSN, RN]

4 minutes ago, CelticGoddess said:

Lord I hope they aren't wasting an 18yo whiskey for this!

I love this post and this comment most of all.

[PeakRN]

On 2/12/2019 at 8:33 PM, SquatsNScrubs said:

Been working in CTICU for a few weeks now.

Post-op esophagectomy patient is suspected to be going through ETOH withdrawal. Still NPO. Surgeon is very picky about administration of sedatives or meds that can compromise the pulmonary or circulatory system.

Treatment of choice? 30 mL whiskey via peg tube q4 hours for anxiety/agitation!

?

Anyone else done this?

Why did the surgeon take a patient who is currently alcohol dependent to theater? Do your surgeons routinely maintain the patients on their service and not under the intensivists, did an intensivist agree to this? He placed a G-tube on a patient with an esophagectomy instead of a J-Tube which is the standard of practice? He is giving an amount of alcohol every 4 hours which a chronic alcoholic would easily metabolize in less than an hour? He is willing to give a medication the the stomach he just operated on that is known to worsen varices and cause GI upset and bleeding?

His rational doesn't even make sense. Alcohol withdraws are cause by the chronic inhibition of GABA in a very similar way to the drugs that we use to treat alcohol withdraw. An appropriate therapeutic dose of medications like ativan, valium, tranxene, or phenobarbital would have no more significant depression of respiratory or cardiac function.

I suspect that your story isn't actually true, or else you have an incredibly incompetent surgeon operating on your patients.

An order for alcohol is not uncommon, but these are typically for patients who are at the end stages of their diseases or for 1-2 alcoholic beverages for long term care or cancer patients as a quality of life measure. Off the top of my head I can't think of a medical reason to give patients alcohol other than to dissolve certain poisons (like methanol or ethylene glycol).

[KatieMI, BSN, MSN, RN]

21 hours ago, PeakRN said:

Why did the surgeon take a patient who is currently alcohol dependent to theater? Do your surgeons routinely maintain the patients on their service and not under the intensivists, did an intensivist agree to this? He placed a G-tube on a patient with an esophagectomy instead of a J-Tube which is the standard of practice? He is giving an amount of alcohol every 4 hours which a chronic alcoholic would easily metabolize in less than an hour? He is willing to give a medication the the stomach he just operated on that is known to worsen varices and cause GI upset and bleeding?

His rational doesn't even make sense. Alcohol withdraws are cause by the chronic inhibition of GABA in a very similar way to the drugs that we use to treat alcohol withdraw. An appropriate therapeutic dose of medications like ativan, valium, tranxene, or phenobarbital would have no more significant depression of respiratory or cardiac function.

I suspect that your story isn't actually true, or else you have an incredibly incompetent surgeon operating on your patients.

An order for alcohol is not uncommon, but these are typically for patients who are at the end stages of their diseases or for 1-2 alcoholic beverages for long term care or cancer patients as a quality of life measure. Off the top of my head I can't think of a medical reason to give patients alcohol other than to dissolve certain poisons (like methanol or ethylene glycol).

1) Surgeon felt that, addicted or not, the patieng needs surgery. Lower esophagoectomy with PEG on adult in >95% means low esophageal cancer (which is metastating quickly and resistant to pretty much everything else), the rest is for emergencies like Mallory-Weiss, Boerhaave syndrome, trauma, etc. Either way, there is little or no waiting time.

2). It really depends who is the boss where and why and under which service patient is admitted. Yes, in some cases surgeons can overstep everybody else, even in ICU.

3). We know nothing about patient's condition and when he was operated on. Just mentioning, alcohol by itself does not cause varices; increased pressure in portal vein system does. But if low esophagus is gone, varices at least there are gone as well.

4). Barbiturates are pretty much out of use in the USA except in very selected anesthesia and, anyway, they are not the best choice for someone with compromiced liver. Patient might claim that he is allergic to all benzos, for whatever reason. Or surgeon can be pretty much lost in the wonderful world of Pharma and use what he is used to use, and there would be no one to contradict him or her. Or the patient is in a smaller regional ICU with known "difficult airway" and they have paucity of really good intubating hands. Or another 100500 scenarios.

And, BTW, at least barbs will be indeed more depressive on CNS in dose enough to suppress DT with all its sequela. Of course, benzos would be better choice but please see above.

5) Just out of my own love affair with pharma: ETOH does not "dissolve" methyl or glycol. It takes over the liver alcoholdehydrogenase, and that's the interval products of metabolism of both methyl and glycol that kill.

[SquatsNScrubs, BSN, RN]

18 hours ago, KatieMI said:

1) Surgeon felt that, addicted or not, the patieng needs surgery. Lower esophagoectomy with PEG on adult in >95% means low esophageal cancer (which is metastating quickly and resistant to pretty much everything else), the rest is for emergencies like Mallory-Weiss, Boerhaave syndrome, trauma, etc. Either way, there is little or no waiting time.

2). It really depends who is the boss where and why and under which service patient is admitted. Yes, in some cases surgeons can overstep everybody else, even in ICU.

3). We know nothing about patient's condition and when he was operated on. Just mentioning, alcohol by itself does not cause varices; increased pressure in portal vein system does. But if low esophagus is gone, varices at least there are gone as well.

4). Barbiturates are pretty much out of use in the USA except in very selected anesthesia and, anyway, they are not the best choice for someone with compromiced liver. Patient might claim that he is allergic to all benzos, for whatever reason. Or surgeon can be pretty much lost in the wonderful world of Pharma and use what he is used to use, and there would be no one to contradict him or her. Or the patient is in a smaller regional ICU with known "difficult airway" and they have paucity of really good intubating hands. Or another 100500 scenarios.

And, BTW, at least barbs will be indeed more depressive on CNS in dose enough to suppress DT with all its sequela. Of course, benzos would be better choice but please see above.

5) Just out of my own love affair with pharma: ETOH does not "dissolve" methyl or glycol. It takes over the liver alcoholdehydrogenase, and that's the interval products of metabolism of both methyl and glycol that kill.

Katie-you hit the nail on the head with your response! Patient has NKA, I am guessing utilization of ETOH over Ativan is merely the surgeon (and pt’s!) preference.

Peak, I am also guessing you are not from the US, as evidenced by your use of the term “theater” (never heard anyone from the US refer to the operating room as such). The patient did receive a j-tube and not a peg tube, my mistake.

Patient was instructed to abstain from alcohol use for 4 weeks prior to surgery. However, as nurses, we can attest that patients are not always 100% adherent to treatment recommendations...especially those that have a history of chronic alcohol consumption..which perhaps is one of the causative factors of his diagnosis in the first place? ?

[SquatsNScrubs, BSN, RN]

On 2/12/2019 at 10:34 PM, Luchador said:

What kind? Jameson? Maker's Mark?

Not a clue. Stocked in the med room in unlabeled travel size bottles...probably whatever is cheapest.

Particularly unpleasant smelling when mixed with prosource!