Whiskey peg tube flush?

kbrn2002, ADN, RN · Feb 15, 2019

Totally different situation here but yes, I've seen this. We had as a resident in my SNF an end stage MS patient. He was accustomed to a beer and a shot with his wife every night before bed. She saw no reason for that to change so every HS he had a beer and a shot via his feeding tube.

PeakRN · Feb 15, 2019

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.

1: Most patients can be be detoxed in 2-3 days. Gastric cancer is not a surgical emergency that cannot wait a few days, if it is that profound the outlook will be poor regardless. In fact the current recommendation by most oncologists is chemotherapy prior to surgical de-bulking.

2: On our inpatient units patients are managed by the Intensivists, whether that is in our adult ICUs, PICU, or NICUs. Surgeons are very involved in the cases, but they do not have the final word in the intensive care management of the patient. Perhaps in hospitals that do not have 24/7 intensivist coverage it may make more sense to have other services manage patients, but this should be going to the wayside.

3: Varices can be caused in more than just the esophagus/cardia/fundus. They can absolutely present in the pylorus, duodenum, and other portions of the GI tract. Yes, the application of ETOH does not directly cause varicies, however what do alcoholic have varices? It is coincidental. These patients also obviously have a fair amount of liver disease and the continued use of alcohol to treat them is so inappropriate.

4: There is quite a bit of literature suggesting than one time dosing with phenobarbital is quite efficacious for the treatment of alcohol withdraw. It's approximate duration of effect of 80 hours and relatively linear metabolism allows for a steady state of GABA modulation while also tapering in a safe manner.

Barbiturates can be a very effective treatment for a variety of disease processes, though they do present some unique risk. They are often our second line treatment for status epilepticus that is refractory to benzodiazepines and presents acute hemodynamic risk that prevents the reasonable time needed for infusions of medications like keppra and depakote and in which we would prefer to spare the higher risk of airway compromise associated with propofol or the cardiac effects of precedex.

We will often use phenobarb as an adjunct in our withdraw kids for whom more traditional medications prove ineffective.

Appropriate dosing is critical in giving any CNS medication. The proclivity for clinicians to over dose patients on barbituates does not mean that they are inherently unsafe or lack a place in critical care medicine. Unfortunelty we do often see outside systems who do overdose patients that are sent to us, that is from a lack of clinical experience rather than the drug itself. Cars do not speed on their own, someone had to push the gas pedal too far.

5: Thank you for the pharmacology lesson that did not detract the core meaning of my point.

33 minutes ago, SquatsNScrubs said:
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? ?

I actually work in a quaternary referral adult and pediatric hospital well seated in the United States. As a system we tend to attract quite a few nurses, physicians, and other healthcare providers from all over the world so I suspect that combined with the fact that I've lived in many other countries contributes to a bit of my unique vocabulary. We also host quite a few surgical teaching cases (and still have viewing rooms, although now separated by glass and not just open to air), so the term theater is fairly accurate.

KatieMI, BSN, MSN, RN · Feb 15, 2019

30 minutes ago, PeakRN said:
I actually work in a quaternary referral adult and pediatric hospital

And this is the deal. I work in a formally tertiary care, but in all senses regional center with tons of private practices which provide the main $$$$. There are quite a few off-label and other such things that are routinely overstepped in order to keep "customers" (both patients and private practitioners who bring them in) happy. If one of the Big Surgeons wants whiskey detox, that will be done, however much it is against current guidelines.

And you probably cannot even imagine what is going on in "critical access" rural hospitals where what you and me consider as pretty ordinary treatment options are routinely not available. I saw with my own eyes a fluid bolus on patient in septic shock and liver failure with MELD 40 flowing into a varicose vein on his anterior abdominal wall. The poor fellow had only one hand, and that with AV fistula, lower extremities are out of consideration due to DM ("it's a POLICY!!!") and nobody in ER, run that day by a Family Practitioner, was able to throw in a central line of any kind. And nobody had guts even for EJ access. And the place had no kits for intraosseus access. And there was no ultrasound.

And nobody except me seemed to care that flowing volumes of fluid directly to bottleneck of portal vein through cirrhotic liver was against of very basic logic of pathophysiology.

SquatsNScrubs, BSN, RN · Feb 16, 2019

4 hours ago, PeakRN said:
I actually work in a quaternary referral adult and pediatric hospital well seated in the United States. As a system we tend to attract quite a few nurses, physicians, and other healthcare providers from all over the world so I suspect that combined with the fact that I've lived in many other countries contributes to a bit of my unique vocabulary. We also host quite a few surgical teaching cases (and still have viewing rooms, although now separated by glass and not just open to air), so the term theater is fairly accurate.

Wow! My apologies for the inaccurate assumptions. I’m sure your experience living in different parts of the world has served you well in your career. I’ve only worked in community hospitals, so viewing rooms (aka theaters) are an unfamiliar concept to me.

BeachsideRN, ASN · Feb 16, 2019

On 2/13/2019 at 4:47 PM, CelticGoddess said:
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!

When my grandmother was in an ALF, she had an order for Vodka, I believe she was allowed 2oz TID. She loved her bloody marys. She was a lifelong alcoholic and a big time smoker. She had no other major health issues. I asked to have her body donated to the local medical school when she passed because she should have had liver disease, HBP and other issues the way she drank and smoke. I was overruled by the rest of the family though.

ETA: We provided the vodka for her, portioned out, she liked Skky. The home would take it and store it in the med room.