Georgetown End of Week 7

I started my Neuro/Rehab rotation on Thursday. I've been working in the Neuro ICU, so I'm seeing pts with head bleeds, stroke, dementia, etc. So far, all of my pts have been intubated, so I've been writing a lot of TF recs.

I did a f/u for one pt who was started on Promote at 55ml/hr via DHT per the RDs inital recs. I was expecting to just check on how he was tolerating the TF. I noticed that the TFs were being held, and the pt was NPO. I was confused because I didn't see any residuals noted, and the pt was doing fine with the TF for 1.5 days before it was held.

So, I talked to the RN who said that while they were suctioning the endotracheal tube, some secretions came out that smelled like TF. Then, she lowered the rate to 10ml and tried again, but the same thing happened. So she thought the pt wasn't tolerating it and told the MD and they decided to hold TFs. They did an abdomen Xray to r/o ileus, which came back fine.

I'm not sure I was convinced that the pt was not tolerating/aspirating TF, but we must be cautious nonetheless. So I tried to figure out what was going on. First, I noted that the pt was on Phenobarbital (which can decrease gut motility), which was d/c'ed 2 days ago, but they were still checking levels in the blood, which showed a small amount was still present. I thought maybe this could be the issue, so I noted that in my assessment. Also, the HOB was only at 30 degrees and the pt had an NG Dobhoff. The pt also hadn't stooled for 4 days. He was on colace, and peri-colace. I was going to recommend adding senna, but from the chart I noted that the MD was already aware of this issue and an enema was ordered.

My interventions were:
1) Place DHT past the Ligament of Treitz (into the jejunum), then consider re-starting feeds.
2) If unable to place DHT post-pyloric, consider placing HOB >/= 45 degrees, adding Reglan (to keep things moving through the GI tract, and prevent TF from coming up), and try again with trickle feeds of 10mL/hr of Promote.
3) If pt still NPO/not tolerating TF within 24-48 hours, recommend PPN (we have a standard 4% A, 10% D solution), I suggested 2000ml with no IVL because pt was on 19 mL/hr of propofol.

A couple hours later, I find out that they are going to hold all feeds until the pt stools and that he will probably be extubated today! However, since it's Friday, I had to make sure to cover everything just incase things don't go as planned.