The goal of the Trauma/Acute Care Surgery service is to provide cost-effective, high-quality patient care. In order to achieve this goal a customer service model has been implemented. The physician/nurse team will make excellent patient care the focus of their effort. This will be accomplished by application of “best practice” models using evidence based clinical data. This will allow the physician/nurse team to direct ancillary services in the most cost-effective manner for excellent patient care.
General
Guidelines for Patient Care
The
very best way to care for patients is to understand physiology and
pathophysiology. This allows the clinician to understand the treatment being
rendered. In general, if it sounds stupid, it is stupid! Remember that every
beneficial intervention also has the potential to cause harm. When a treatment
or intervention is no longer required discontinue the intervention/treatment.
Nasogastric tubes are useful for gastric decompression and to prevent emesis
associated with bowel obstruction. On the other hand the tubes are
uncomfortable and predispose the patient to sinusitis, GERD, and aspiration.
Proton pump inhibitors and H2 antagonists reduce the incidence of stress
ulceration. However, they are associated bacterial overgrowth in the stomach
that may lead to nosocomial pneumonia. IV catheters and fluids can be life
saving but they are also associated with thrombophlebitis and infection. Foley
catheters may be needed for urinary retention or monitoring of intake and
output. However, they are associated with urethral strictures and infections.
Phlebotomy for blood tests is a necessary part of patient care. However, excess
phlebotomy can and does result in anemia that can be harmful to patients.
Medications are extremely important for patient care but drug interactions and
adverse reactions can be harmful to patients. These are a few examples of the
myriad of rather simple interventions and therapies that can and do harm
patients. Modern medical care is exceedingly expensive. Ask yourself why a
particular intervention, test, or medication is being used. Is this needed? How
does this benefit the patient? What is the harm? How much is this going to
cost? What information will I gain? Through rigorous self-examination the
answer for many of these questions is easier than you think.
Mobilization
There
is clear, irrefutable evidence that extended bed rest is harmful to patients.
Supine position and lack of mobilization leads to reductions in pulmonary
functional residual capacity, atelectasis, diminished cough, and accumulation
of dependent lung water. This makes the patient more prone to pulmonary
complications which are the most frequent cause of admission or readmission to
the ICU. Bed rest also leads to rapid loss of muscle mass leading to
de-conditioning which may increase hospital length of stay, lengthen
rehabilitation, or create the need for rehabilitation that would have not been
otherwise needed. Patients at bed rest are more prone to pressure ulcers, bowel
dysfunction, and venous thromboembolic disease.
A
primary focus of patient care should be early mobilization of the patient.
Weight-bearing status should be determined within 24 hours of admission to the
hospital and documented in the Mobility Order Set. Ambulation of the patient
should be an immediate goal, using the Mobility Plan of Care. If there are
limitations on weight-bearing these should be identified and appropriate
resources (physical therapy, equipment, etc) should be applied immediately. At
the very least, patients should be out of bed and placed in a chair in the
upright position. This does not mean bringing the bed into a sitting position
but actually getting the patients out of the bed into a chair or at least siting
upright on the bedside. If traction or hemorrhage risk mandates bed rest, the
patients should be nursed with the head of the bed elevated at least 30
degrees. When strict logroll is in place the patient should be placed in
reverse Trendelenburg.
Respiratory
Function
Respiratory
therapy is essential for acutely ill and injured patients. Many of our patients
have co- morbid lung disease and/or a history of heavy tobacco use. Lung
function is further compromised by bed rest, obesity, chest wall trauma, pain,
surgical incisions, chest tubes, or via the use of cervical collars, back
braces, and/or traction. It is unrealistic to expect respiratory therapy
service to assume this task for most patients. Pulmonary toilet should be a
major goal for excellent nursing care.
Prevention is
the key element here.
Apply
vigorous pulmonary toilet early! Use the respiratory therapist wisely. It is
far easier to prevent respiratory failure than to treat the consequences.
Patients also require education as to their role in pulmonary toilet. Patients
often equate pain with further damage. They need to understand that pulmonary
toilet may cause pain but not harm. The simplest and best pulmonary toilet is
to mobilize the patient. This requires patient effort resulting in work of
breathing that maintains respiratory muscle function. Mobilization also shifts
lung water, increases lung functional residual capacity, and reduces
atelectasis. Mobilization should be supplemented with education on maximum
voluntary ventilation, as well as coughing and deep breathing. Inspirometers
(incentive spirometers, ‘blow bottles’) can and should be used to supplement
coughing and deep breathing. Some patients may require bronchodilators and/or
chest physiotherapy. Occasionally expectorants are also required. Some patients
may require nasotracheal suctioning. Pain control is essential. Patients should
be comfortable but not so somnolent that they can’t actively participate in
pulmonary toilet.
A word about
supplemental oxygen
Supplemental
oxygen is expensive and unnecessary for most patients. Oxygen does not improve
respiratory failure! In fact, supplemental oxygen usually masks worsening
respiratory function that would respond to pulmonary toilet. Virtually all
human beings have arterial desaturation when recumbent or sleeping. Spot pulse
oximetry in these circumstances is of no clinical value and frequently results
in unnecessary application of supplemental oxygen. Respiratory rate and effort
combined with auscultory findings, radiograph, and subjective patient
complaints are much better determinants of respiratory failure than arterial
desaturation. In the latter circumstance, supplemental oxygen should be used
along with pulmonary toilet.
Central
nervous system injury
Patients
with head and/or spinal cord injury do not have normal pulmonary toilet. These
patients rely heavily on positioning, mobilization, and active pulmonary toilet
to avert respiratory failure. Nasotracheal suctioning along with chest
physiotherapy, bronchodilators, and breathing exercises should be used
liberally in this patient group.
Tracheostomy
Tracheostomy
is frequently required for the management of airway, pulmonary toilet, and/or
respiratory failure in patients with complex critical illness and/or injury.
The vast majority of these are performed percutaneously although some are still
placed using the older, but still reliable, open surgical technique. Regardless
of placement technique, complications, daily tracheostomy tube/site care, and
downsizing/decannulation are the same.
Complications
Dislodgement:
The most common early and lethal complication of
tracheostomy is tube dislodgement. In order to prevent this complication the
tracheostomy tube is secured to the skin with sutures and fixed in place with a
secure neck strap. Sutures often give a false sense of security and will not in
and of themselves eliminate dislodgement. The most important defense against
early dislodgement is a secure neck strap and strict avoidance of undue tension
and/or torque on the fresh tracheostomy. It takes about four days after
insertion to develop a mature tract. After four days, dislodgement rarely results
airway compromise and the tube can simply be reinserted through the neck. Prior
to four days, airway loss is likely if the tracheostomy tube is dislodged and
the patient may require endotracheal intubation ORALLY to reestablish the
airway. This is a true emergency that requires the immediate attention of the
surgical house staff. The patient can be temporized with 100% oxygen delivered
via bag valve mask and gentle occlusion of the tracheostomy site.
Plugging:
The most common intermediate complication of tracheostomy is
mucous plugging. This will be the most frequent problem encountered with ward
patients. Secretions build up in the tracheostomy tube lumen leading to sudden
occlusion and airway compromise. Virtually all of the tracheostomy tubes in use
at UKMC have a removable inner cannula. The routine practice of maintaining
cuff deflation and routine inspection/cleaning of the inner cannula will
prevent this complication.
Stenosis:
Tracheal stenosis is a late complication of tracheostomy.
Virtually all tracheostomies (85%) are associated with some degree of tracheal
stenosis. Only 1-2% of patients develop critical stenosis that compromises the
airway and produces clinical symptoms. The duration of endotracheal intubation
(> 11 days) prior to tracheostomy, technique used (open > percutaneous),
higher placement (between rings 1-2 vs. 2 or lower), and smaller airway
(children, females) all increase the rate of clinically significant tracheal
stenosis. Almost all clinically significant stenosis occur within twelve weeks
of tracheostomy. The hallmark of clinically significant tracheal stenosis is
respiratory distress and/or stridor and wheezing when the tracheostomy tube is
plugged or removed. If plug removal or tracheostomy tube reinsertion alleviates
symptoms the tube should remain in place until a diagnostic evaluation can be
performed.
Tracheal-arterial
fistula: Small amounts of bleeding may occur
simply from the irritation of suctioning, site care and/or the tube itself. A
rare but lethal complication of tracheostomy is tracheal-arterial fistula that
occurs from erosion of the tip of the tracheostomy tube into the great vessels
of the upper thorax. The hallmark of this complication is a “herald bleed”
defined as a moderate to large amount of bleeding that stops spontaneously. If
bleeding persists or produces airway compromise, the endotracheal tube cuff can
be inflated to tamponade bleeding and maintain the airway. Herald bleeding
requires immediate investigation!
Infection:
Tracheostomy site infection is exceedingly rare. The
presence of purulent, foul–smelling secretions accompanied by an expanding zone
of erythema establishes the diagnosis. Site care and appropriate antimicrobial
therapy are effective in controlling this complication.
Tracheocutaneous
fistula: This is a rare complication of
tracheostomy that is defined as a persistent air leak present for more than one
week after decannulation. While a small percentage of these will close after 7
days most will require a surgical intervention to achieve closure.
Bronchorrhea:
Copious secretions usually indicate a residual or recurrent
pulmonary problem. Occasionally, these secretions are due to the endotracheal
tube itself. The tube can and does irritate the upper airway producing
excessive secretions. Decannulation is the treatment of choice. If the patient
still requires a tracheostomy (coma), a drying agent such as Robinul (glycopyrrolate)
can be used.
Tracheostomy
tube/site care
The
tracheostomy tube and site should be inspected at least once daily. The site
itself should be inspected for purulence and erythema. Gentle cleansing with a
small amount of soap and water followed by a dry dressing provides ample site
care. The inner cannula should be removed, inspected, and cleaned as necessary
to remove build up of dried secretions. The tracheostomy tape should be snug
enough to prevent excess movement of the tube but not so tight as to produce
skin breakdown/ulceration. When the patient is not being mechanically
ventilated, the balloon should be deflated on cuffed tubes. Sutures, if
present, can be removed after six days. Tracheostomy bypasses the normal
humidification provided by the oro/nasopharynx so patients are prone to
evaporative water loss and desiccation of the airway mucosa. Humidified air or
oxygen (if required) should be used at all times to prevent the latter
complications. A tracheostomy care and monitoring guideline has been
implemented at UK Healthcare and is considered a consensus among all physician
groups who perform tracheostomy.
Downsizing
and decannulation
The
general practice of downsizing a tracheostomy tube prior to decannulation is
controversial. Be that as it may, downsizing the tracheostomy tube prior to
decannulation is the routine practice at UKMC. The stated advantages are a
reduction in size of the tract to reduce tracheocutaneous fistulas and to
detect tracheal stenosis prior to decannulation. After four days a
well-established tract exists between the surface and the trachea. Downsizing
can proceed safely at this point. Decannulation should not proceed until the
patient is clinically stable. Respiratory failure should be stable or improving
and suctioning requirements should be nominal (>2-4 hours). The patient
should have a vigorous cough and be able to handle their secretions. There
should be no residual airway issues. As a first step, the plastic tracheostomy
tubes (Usually Shiley occasional Portex or Bivona) are removed and replaced
with a 6mm metal tube (Jackson). These can then be plugged. If the patient
tolerates plugging (see complications: tracheal stenosis), has a good cough and
minimal secretions, decannulation can proceed. The tracheostomy site should be
covered with an occlusive dressing. The patient should be monitored closely
over the next 24 hours for any evidence of respiratory distress. Closure of the
tract usually requires 24-48 hours. Comatose patients can be downsized but
should not be decannulated. This group of patients rarely has a good cough and
cannot protect their airway. Consequently, they remain at risk for aspiration
and/or respiratory compromise.
Dysphagia and
aspiration following tracheostomy
Dysphagia
and/or aspiration following tracheostomy are very common. Most patients who
require a tracheostomy have not had oral intake for some time. This is
complicated by the fact that the tracheostomy itself may interfere with
swallowing. This is simply a problem of training/initiating a swallowing bolus!
To initiate oral intake, cuffed tracheostomy tubes should be deflated or
downsized to a smaller metal tracheostomy. Oral intake should never begin with
liquids. It is much harder to develop a swallowing bolus with liquids. The initial
oral feeding challenge should be with thickened liquids and/or solids. Most
importantly, the patient should be sitting upright. Why don’t you try to
swallow liquids in a supine position! If managed correctly, this is rarely a
clinical problem and oral feeding can be safely resumed. Nurse-performed
dysphagia screens are our first line of evaluation of patients at risk. Give
the patient good instructions and several attempts before conceding failure.
Decannulation, if indicated, can also be accomplished prior to another try. The
dysphagia team should be consulted if nursing is concerned that aspiration is,
in fact, occurring. Contrast studies can, however, overestimate the problem and
can lead to unnecessary, complicated, and expensive alternatives. Fortunately,
only an occasional patient will fail and require an alternative feeding access.
Intravenous
Access
Three
quarters (75%) of all hospital bactermia events are associated with intravenous
catheters! There is a general hospital wide practice to “heparin lock” and keep
both peripheral and central venous catheters. Keeping multiple IV sites is
simply not a good practice. Each and every IV site represents a potential
nosocomial infection site for patients. Both insertion technique and indwell
time influence subsequent thrombophlebitis. Many catheters are placed under
less than ideal conditions and should be removed as soon as possible. In all
but the most unusual circumstances, a patient will require a single functioning
IV access site. Proper inspection, site care and hub cleansing should be used
to maintain function and sterility. All other intravenous access sites should
be removed.
Wound Care
Wound
care is much easier than most physicians and nurses think. The process has
become unnecessarily complicated, confusing, and expensive. The simple answer
is soap, water, and gentle handling of tissues. Put them in the shower! Except
for early clean wounds (see below), most all patients should be in the shower
within a couple of days of operation. Astringents (peroxide, betadine, acetic
acid, alcohol, Daken’s, etc.) should rarely if ever be used in a wound. There
is a widely held misconception that more frequent wound care somehow makes
wounds heal faster. This is simply not the case. Keeping wounds clean, moist,
and covered allows the body to heal the wounds considerably faster.
Astringents, frequent dressing care, and overzealous packing are more often
responsible for delays in healing.
Wound
Classification
Clean Wounds - These are surgical incisions that follow an elective surgical
procedure that does not involve the aerodigestive tract. Examples would be
neurosurgical procedures, vascular procedures, hernias and most elective
orthopedic procedures. Clean contaminated wounds
– These are surgical incisions that follow an elective
surgical procedure that crosses the aerodigestive tract. Examples would be most
ENT procedures, operations on the gastrointestinal tract, or operation on the
lung.
Contaminated
wounds – These are incisions that follow an emergent surgical
procedure where there is obvious or potential infection. Examples would be
perforations of the GI tract, strangulated hernias, complicated soft tissue
infections, open fractures.
Dirty wounds – This is really a matter of degree. The difference between contaminated
and dirty wounds is really the degree of contamination. Complex wounds with
large devitalized areas, gross fecal contamination, large amounts of purulent
material, dirt, foreign bodies etc. are usually classified as dirty.
Important
Definition
Dehiscence
refers to separation of the wound edges. Dehiscence can further defined as
involving the skin and subcutaneous tissue (superficial) or extending to the
deeper layers (fascial dehiscence). Evisceration refers to the protrusion of
visceral contents through the wound. Not all dehiscence has evisceration but by
definition all eviscerations have dehiscence.
Wound
management
Wounds are managed in
one of three ways:
1. Primary
closure of the skin and subcutaneous tissues (most wounds)
2. Delayed
primary closure. Wounds are left open initially. The skin is then closed
primarily between day 3 and 4. Bacterial counts are lowest in the wound at this
point and delayed primary closure has the greatest success.
3. Healing
by secondary intention. This technique applies for most open wounds.
Closed wounds
Wounds
that have been closed primarily will seal within 36 hours. After that point it
is very unlikely that environmental contamination would compromise the wound.
The general rule is to leave the surgical dressing on for 24 hours. After that
point the wounds can be covered with a light dry dressing to absorb minor
drainage, prevent irritation and for patient comfort. These wounds should be
carefully inspected at least once a day for signs of infection (redness,
swelling, excessive tenderness, purulent drainage). The subjective patient
complaint of wound pain (fever may or may not be present) that increases or is
out of proportion to wound size is often the earliest sign of surgical wound
infection.
Open wounds
Contaminated
or dirty wounds are often packed and left open. The main clinical reason for
this practice is to avoid the high incidence of wound infection if the wounds
are closed. The wounds are generally packed tightly to achieve hemostasis after
the initial operative procedure. Unless there is a planned return to the
operating room for exam under anesthesia, further debridement, and irrigation,
these dressings should be taken down and the wound examined at 24 hours. The
first dressing change can be quite painful and provisions should be made for
adequate analgesia prior to proceeding. Most of the pain emanates from the
densely innervated wound edge and care should be taken in this area. If the
dressing is adherent gentle wetting with saline will facilitate removal and
reduce discomfort. “Clean wound” care rather than “sterile technique” should be
the standard practice. At the first dressing change the decision can be made to
initiate saline wet to dry dressing or application of a vacuum dressing. At
this point a decision can also be made about washing/showering the wound with
soap and water. Dressing changes need only be once or twice a day and packing
of the wound should be gentle. Saline irrigation of the wound base is
permissible. As mentioned previously, astringents should be avoided and every
effort should be made to avoid wound dessication by irrigating the wound in
between dressing changes if necessary.
Regarding
dressing fixation, the skin should be protected from tape adhesives by using
duoderm and Montgomery straps or by application of Bandnet dressing
(preferred). Absolutely every effort should be made to simplify wound care
prior to discharge. Patients should be given clear instructions on clean wound
care, showering should be encouraged. When possible, wounds can/should be
dressed with tap water rather than sterile saline which is considerably more
expensive and unnecessary for most wounds.
Open wounds
and evaporative water loss.
Open
wounds can and do result in significant fluid & electrolyte disturbances.
Dehydration from evaporative water loss and malnutrition from protein loss are
significant problems with large wounds. This can be amplified if the wound is
associated with an enterocutaneous fistula. The patients should be assessed for
signs of volume depletion such as excessive thirst, diminished skin turgor, and
or low urine output. Keeping the wounds covered and moist reduces evaporative
water loss and may reduce protein loss as well.
Wound
infection
The
earliest and most frequent sign of wound infection is excessive wound pain and
tenderness. Low grade fever, wound redness, and drainage often appear later and
can be easily seen with a good exam and dressing change. Wounds should be
opened in the affected area to allow drainage, irrigation, and gentle packing
just like in open wounds. Wound culture and antibiotics are totally unnecessary
except in rare circumstances such as when patients exhibit signs of systemic
illness and/or there is prosthetic material in the wound. WARNING! When dealing
with abdominal wall wounds, drainage may indicate deep wound problems such as
fascial failure and/or evisceration.
Gastrointestinal
Tract
There
is a widely held misconception that the gastrointestinal tract in quiescent
following illness, injury, and/or surgery. The
gut plays an active role in overall host defenses, gastrointestinal stress
ulceration, and systemic inflammation. The historical term attached to the
clinical problem of post-operative gut dysfunction was “ paralytic ileus”. This
has been shortened in modern medical terminology to “ileus.” The traditional
clinical practice is to withhold oral intake and maintain nasogastric
decompression until there was clinical evidence indicating return of bowel
function (passage of flatus, bowel movement, or audible bowel sounds). This
practice is outdated and not consistent with what is currently known about
bowel function in illness. The stomach and small bowel function very well
following illness, injury, and /or operative intervention unless there has been
mesenteric ischemia or long standing obstruction. The actual root cause of the
clinical entity referred to as “ileus” is delayed return of colonic function.
Although ingrained in our medical terminology, “ileus” is a misnomer and the
proper term to use is colonic pseudo-obstruction.
There
are a number of clinical practices that either exacerbate or contribute to
colonic pseudo- obstruction. Chief among these are bed rest, narcotic
administration and fluid & electrolyte abnormalities. Depending on the
clinical circumstances, the clinician also needs to consider other contributing
factors such as fecal impaction, resolving peritonitis, intra- abdominal
abscess, pneumonia, wound infection, retroperitoneal hematoma, and
pseudomembranous colitis. Mesenteric ischemia and early mechanical bowel
obstruction, although rare, must also be considered in the differential
diagnosis.
For most patients,
early mobilization, judicious use of narcotics, as well as attention to fluid
& electrolytes can mitigate or prevent pseudo-obstruction. Routine use of
an effective bowel regimen and/or early enteral nutrition is also effective
depending on the patient and clinical circumstances.
The
main risk to the patient with pseudo-obstruction is colonic ischemia and/or perforation
which are dependent upon the degree of colonic distention. Perforation/ischemia
is much more likely when colonic/cecal diameter is > 11cm. Under these
circumstances, more aggressive management is warranted. For most patients, the
treatment of pseudo-obstruction is relatively straightforward. Bowel rest,
hydration, and correction of electrolytes are essential. Narcotics should be
reduced as much as possible. Depending on the clinical situation, other
treatable contributing factors need to be rectified or excluded. Nasogastric
tubes are completely unnecessary for the vast majority of patients because they
are not effective in reducing colonic distention. NG tubes should be withheld
unless the patient is vomiting and/or has evidence of gastric distention on
X-ray. A combination of stool softeners and cathartics accompanied by a
prokinetic agent Reglan (metaclopramide) are usually effective. Cathartics and
prokinetic agents are more effective when given orally but other routes of
administration may be necessary depending on the clinical situation. Rectal
stimulation with a suppository and/or enema may also produce results. For
refractory patients or those with significant colonic distension, a
parasympathomimetic agent (neostigmine) can be administered IV with excellent
results. Routine use of neostigmine is precluded by side effects such as
bradyarrythmias, bronchorrea, and diaphoresis. Patients should be monitored
during drug administration particularly if they have known cardiac disease.
Decompressive colonoscopy which is both diagnostic and therapeutic may be
required for patients with significant colonic distention not responsive to the
above measures.
Enteral
Nutrition
Not
all patients require early enteral nutrition. Well-nourished patients who sustain
mild to moderate injury or those undergoing elective operations tolerate up to
seven days of fasting with little or no adverse consequences. However, patients
with documented pre-injury or pre-operative malnutrition as well as those
patients with complex critical illness/injury clearly benefit from early
enteral nutrition. In fact, the evidence supporting early enteral nutritional
support in the critically ill is clear and irrefutable. Infectious
complications are significantly reduced in patients who receive early enteral
nutrition. Early enteral nutrition also maintains gut integrity, reduces the
risk of gastrointestinal stress ulceration, and increases the rate of wound
healing.
Access routes
The
main difficulty with early enteral nutrition is achieving and maintaining a
reliable feeding access. Gastric feeding is well tolerated and most patients
can be fed in the stomach. Unfortunately tolerance is an issue for some
patients, monitoring may be difficult and the aspiration risk is higher than
that for post-pyloric tubes. As the patient improves clinically, aspiration
risk declines and the need for post- pyloric access diminishes. Three
approaches are used to establish feeding access; nasoenteral feeding tube,
surgical jejunostomy, and percutaneous endoscopic gastrostomy (PEG). For the
vast majority of patients, a nasoenteral feeding tube is a safe, temporary
access. These can be placed blindly (discouraged), via Cortrak image guidance, via
endoscopy, fluoroscopy, or at the time of surgical intervention. Since these
tubes frequently become dislodged they should be secured in place with a
bridle. Nasoenteral feeding tubes are not a reliable long-term access and
should be replaced with a jejunostomy or gastrostomy tube. When a patient has
significant foregut pathology, a surgical jejunostomy can be placed. This
allows enteral feeding to proceed in the absence of an intact/functioning
foregut. The most frequently utilized long term feeding access is the PEG. This
is a safe, effective way of delivering enteral nutrition for most patients.
Assessing
enteral feeding tolerance
Continuous
feeding is the only method used for post-pyloric nasoenteral and jejunostomy
feeding tubes. The small bowel will not tolerate bolus feedings. Continuous
feeding is preferred even for PEG feedings early but can be changed over to
bolus feedings over time. Feeding intolerance manifests clinically in a variety
of ways. The key to delivering effective enteral nutrition is to be aware of
the clinical manifestations of feeding intolerance and to realize that signs of
intolerance vary depending on the feeding access used. Tube feeding reflux,
high gastric residuals, vomiting, aspiration, abdominal distention, and
diarrhea are all signs of feeding intolerance.
Tube feeding
reflux
In
patients with a post-pyloric nasoenteral tube and a nasogastric tube, the first
sign of intolerance can be tube feeding reflux in the nasogastric aspirate. The
first maneuver should be to confirm tube positions with a radiograph. NG tubes
can migrate distally and feeding tubes can be dislodged. Tubes should be
repositioned if necessary. Once tube position has been confirmed, then a
downward adjustment in rate and/or the addition of a prokinetic agent may be
required. If reflux is significant and accompanied by abdominal distention, the
best course of action is to hold tube feedings for 12-24 hours and reassess the
patient. Sudden abdominal distention and reflux in a patient previously
tolerating tube feeds is a very worrisome finding that warrants further investigation.
High gastric
residuals
In
patients receiving continuous feeding via a PEG elevated gastric residuals are
the first sign of intolerance. Residuals should be monitored every 4-6 hours
and should not exceed the sum total of the tube feeding over that time period.
When the residuals are elevated to > 500cc in a 6-hour monitoring period,
feeding should be withheld and rechecked after one period of rest. A prokinetic
agent can be added with success in some patients. Again, elevated residuals and
abdominal distention in a patient that previously tolerated feeds should alert
the clinician to a change in clinical status that warrants investigation.
Occasionally, patients will be fed into the stomach using a small bore
nasoenteral feeding tube. Residuals cannot be checked via these tubes and no attempt
should be made to do so.
Vomiting/Aspiration
Vomiting
and/or aspiration may be the first sign of feeding intolerance. In the awake
patient, complaints of nausea will precede the event, so don’t ignore this
complaint. This manifestation is more likely in patients being fed in the
stomach via PEG or nasoenteral feeding tube. Remember that post-pyloric feeding
reduces but does not eliminate vomiting/aspiration risk. The most prudent
course of action is to hold feedings. Depending on the clinical suspicion for
aspiration, an evaluation by a physician is warranted. Vomiting will usually
dislodge a nasoenteral feeding tube, so replacement and/or verification of
position is warranted.
Abdominal
distention
Frequently
overlooked, abdominal distention and bloating are the earliest and most
reliable signs of intolerance. All patients receiving enteral nutrition should
be evaluated daily. Not all patients require an intervention but this should be
noted and brought to the attention of the physicians caring for the patient.
Acute and/or significant distention may indicate mesenteric ischemia or colonic
pseudo- obstruction.
Diarrhea
Diarrhea
is probably the most frequent complication of enteral nutrition. Oddly enough
tube feeding is usually not the cause. Sorbitol containing medications are
frequently to blame so a review of the medication record is warranted. If
indicated, clostridium difficile colitis should be excluded. Higher tube feeding rates may produce
diarrhea so a change in rate may be warranted. Anti-diarrhea agents can be
utilized if the problem persists. Changes in formula can be made. If the volume
of stool exceeds 500-1000cc per day then holding the feeds may be necessary.
Tube
maintenance
Enteral
access tubes are expensive and vital to patient care. Every effort should be
made to maintain patency and protect against dislodgement.
Small bore
feeding tubes
Standard
nursing guidelines for small bore feeding tubes should be rigorously followed
to prevent clogging. The most effective way to maintain patency is to flush
with tubes frequently with warm water and to avoid medication known to clog
these tubes. Whenever tube feedings are interrupted or medications are
administered, the tubes should be flushed with warm water.
PEG
These
tubes can and do become clogged and or dislodged. One of the most important
aspects of daily PEG care is to assess the tube site and determine tube depth.
Nurses should pay close attention to the insertion site for redness, swelling,
and/or tube feeding reflux. Following placement, PEG tubes are secured in place
using a silastic bolster. These bolsters are applied loosely to maintain the
PEG at the original depth of insertion which is charted in the endoscopic
procedure note. Each PEG tube has a centimeter marker on the side. The general
depth for most patients is between 3-6 centimeters. The depth at insertion
should be recorded on the nursing assessment. If the depth marker is more than
1cm less than or more than the insertion depth or there is tube feedings
refluxing through the insertion site, feedings should be held and the physician
notified immediately. Sustained tightening of the bolster, or sudden jerks on
the tube, can bury the mushroom-shaped ‘bumper’, which normally lies in the
stomach, into the wall of the stomach or abdominal wall. The result can be ‘feeding’
of the tract rather than the gastric lumen, resulting in severe infection. Remember,
a sudden change in PEG feeding tolerance accompanied by abdominal distention
can indicate PEG tube migration or dislodgement.
Diarrhea
Not
all liquid stools constitute diarrhea. Diarrhea is defined as frequent loose
stools exceeding 1000cc per day and/or producing fluid/electrolyte
abnormalities. The clinical objective is to identify and remove treatable
causes of diarrhea. Medications are probably the most frequent cause of
diarrhea. Drugs that produce diarrhea such as prokinetic agents, oral
macrolides, cathartics, and sorbitol containing elixirs should be eliminated
when possible. Adjustments in tube feeding rate and/or formula change may be
required. Clostridium difficile colitis should be excluded or diagnosed and treated. Diarrhea may
accompany a high-grade fecal impaction. Diarrhea may also be the only
manifestation of intra- abdominal infection. Surgical resection of the small or
large bowel (ileocecal valve in particular) may produce post-operative diarrhea.
Diarrhea may follow resolution of pseudo-obstruction or surgical relief of a
mechanical small bowel obstruction. In general, treatment is defined by the
cause. Medications should be changed/eliminated. Fecal impaction should be
cleared. With the exception of C. difficile colitis, symptomatic relief can be provided with anti-diarrhea
agents such as combinations of lomotil, Imodium, paregoric, and narcotics.
Clostridium difficile (Pseudomembranous) Colitis
The
Gram negative bacterium Clostridium difficile is part of the normal colonic flora in roughly 20-25% of patients.
The bacteria exist in small numbers in balance with other colonic flora and do
not cause any problems. Pseudomembranous colitis develops as a consequence of
an overgrowth of C. difficile allowing for increased toxin production and mucosal damage. The
major mechanism is antibiotic administration that alters/reduces colonic flora
allowing room for increased growth of the drug resistant C. difficile bacterium. The disease can be
produced by as little as one dose of antibiotics and most often follows single
dose antimicrobial administration for perioperative prophylaxis. There is some
data to suggest that mechanical bowel preparation/cleansing may produce the
disease as well. The most frequent offending antimicrobials are cephalosporin
(Rocephin), Clindamycin, ampicillin, and fluroquinolones such as levaquin. The
primary manifestation of the disease is diarrhea which may occur up to 14 days
after the last antibiotic administration. Occasionally the patients will have
abdominal pain and distention. Rarely they will present with or have
constitutional symptoms such as fever and systemic toxicity that accompany the
diarrhea and abdominal pain. The diarrhea associated with the disease is quite distinct.
The frequent passage of small amounts of foul smelling liquid stools should
raise clinical suspicion. The diagnosis is easily established by sending a
stool specimen for toxin assay. Cultures are of no value because the bacteria
are normal resident flora in many patients. First line therapy is metronidazole
(Flagyl) administered 10-14 days via the enteral route. Intravenous flagyl is
effective for patients who will not tolerate the oral route. Vancomycin given
enterally is reserved for patients who present with severe disease and/or fail
on Flagyl. Empiric therapy is appropriate after stool cultures have been
obtained and can be stopped if the toxin assay is negative. Endoscopy to
identify pseudomembranes is occasionally required to establish the diagnosis.
Rarely, a patient will develop toxic megacolon and require emergent surgical
intervention.
Constipation
There is overlap
between constipation and colonic pseudo-obstruction. Abdominal pain,
distension, nausea, and vomiting accompanied by absence of a bowel movement for
more than several days are the most common symptoms. Unfortunately these
symptoms are identical to colonic pseudo-obstruction so the diagnosis is
difficult in the hospitalized patient. Narcotics, bed rest, dietary changes,
fluid & electrolyte abnormalities, particularly dehydration all predispose
the patient to constipation. The key is prevention. Early mobilization of the
patient and adequate hydration are essential. Patients who require pain
medications should receive stool softeners as a routine. Once constipation
develops attention should be turned to correcting the problem. Fecal impaction
should be excluded by rectal exam. Remember that diarrhea may be a
manifestation of fecal impaction. Stool softeners alone are usually not enough.
Unless the patient is vomiting, oral cathartics should be tried initially. Oral
Dulcolax tablets and/or milk of magnesia (MOM) can be administered along with
oral metaclopramide (reglan) 10-20mg. Osmotic agents such as sorbitol are also
effective particularly if administered with dulcolax. These regimens can be
repeated. If the patient is vomiting or does not respond to oral therapy,
digital rectal stimulation with a dulcolax suppository with or without enemas
can be employed. Large volumes of laxatives such is Mirilax or citrate of magnesia
should be avoided in patients who already have significant bloating.
-Paul A. Kearney, MD, FACS, Professor of Surgery
-Paul A. Kearney, MD, FACS, Professor of Surgery
