enteral feed holding for extubation

[VentdependenT]

should we do this?
i have an attending who doesnt do this OR hold feeds for bronchs or perc trachs.

thoughts? risk v benefit.

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[jdh71]

should we do this?
i have an attending who doesnt do this OR hold feeds for bronchs or perc trachs.

thoughts? risk v benefit.

The benefit seems to be lack of "food" into the lungs. Which to my mind seems rather legit. I've seen a case serious of TFs into the lungs and it's pretty damn nasty. I mean, there are times when you just have to do what you have to do, but I think on the whole holding them seems prudent. I'm not going to go so far as to claim someone is being a "bad doctor" or anything, but I do and will continue to once I'm done with training.

I had one attending tell me he used to not care until one day he watched most of a cup of coffee come up and get aspirated while doing a bronch.

 

[europeman]

There are established guidelines for this.

For patients going to the operating room who ALREADY have in place an endotracheal tube or tracheostomy (with cuff), then there is no reason to hold feeds for a scheduled operation if the operation is such that their airway and aspiration isn't a risk. An operation which for example a patient should be npo would include (and should in part be anesthesiologist or institution specific) operations in the proned or even decub position (I personally only think prone); operations where patient will be moved from one side to the other; operations with intra-abdominal significant manipulation)

For a tracheostomy they SHOULD be npo because u put down cuff of tube and manipulate airway.

For bronch.....
I mean if I was gonna do a bronch I might stop their feeds a little before but I guess it's no biggie since u aren't taking down their cuff anyway usually.


For a large abdominal operation then technically they should be npo though for repeat washouts and such I don't see it being that big of a deal.

Obviously if u are getting a peg or feeding tube u should be npo.

 

[VentdependenT]

There are established guidelines for this.

For patients going to the operating room who ALREADY have in place an endotracheal tube or tracheostomy (with cuff), then there is no reason to hold feeds for a scheduled operation if the operation is such that their airway and aspiration isn't a risk. An operation which for example a patient should be npo would include (and should in part be anesthesiologist or institution specific) operations in the proned or even decub position (I personally only think prone); operations where patient will be moved from one side to the other; operations with intra-abdominal significant manipulation)

For a tracheostomy they SHOULD be npo because u put down cuff of tube and manipulate airway.

For bronch.....
I mean if I was gonna do a bronch I might stop their feeds a little before but I guess it's no biggie since u aren't taking down their cuff anyway usually.


For a large abdominal operation then technically they should be npo though for repeat washouts and such I don't see it being that big of a deal.

Obviously if u are getting a peg or feeding tube u should be npo.

do endotracheal cuffs prevent aspiration?

 

[Jay K]

should we do this?

Yes.

There are only pros and no consequential cons.

Aside from promoting patient safety, those who would practice defensive medicine would consider that not holding tube feeds with a resultant negative outcome will only give a plaintiff's attorney ammo in painting you as a lazy, unsafe and possibly uncaring physician to a jury of mostly, if not all, lay persons.

You ask yourself (or the lawyer will), "What could you possibly have to gain by not turning off the tube feeds in a timely fashion prior to extubation?" What would you say? If it doesn't sound good or convincing to you, how do you think it would sound to a jury… particularly after some "expert" has finished testifying of the grave dangers and malpractice that was inherent in your care of the patient.

 

[europeman]

Prior to extubation? That wasn't the question. The question is if u should make them npo prior to PROCEDURE.

And, with the exceptions I listed above, you shouldn't. We don't. Why? Because the OR schedule is like an airport.... It changes and u never know when a case is delayed. For an ICU patient the consequences are missing feeds day after day.

If your hospital is making people npo while they are intubated for procedures like Ortho cases then they are not following standard of care

 

[jdh71]

Prior to extubation? That wasn't the question. The question is if u should make them npo prior to PROCEDURE.

And, with the exceptions I listed above, you shouldn't. We don't. Why? Because the OR schedule is like an airport.... It changes and u never know when a case is delayed. For an ICU patient the consequences are missing feeds day after day.

If your hospital is making people npo while they are intubated for procedures like Ortho cases then they are not following standard of care

Uh. Yeah. It was the question. Read the title of the thread.

Is there a failure to communicate here??

 

[europeman]

Yeah I was just talking about the latter part of post.... ie procedures. Tks for clarification

 

[TrustMe]

If the tube is post-pyloric (duodenal or jejunal) then I usually don't. If it is gastric then I always do. Especially for extubation. Holding tube feeds for 8-12 hours isn't going to kill someone, but enteral feeds in their lungs has the potential to. I am not sure about all of the literature, but the first time you see severe ARDS from aspiration pneumonitis you may change your practice.

 

[Giic]

Uh. Yeah. It was the question. Read the title of the thread.

Is there a failure to communicate here??

Hahahaha! I was just gonna type something similar... I'm like, DUH. That is the question!

 

[tartesos]

If the tube is post-pyloric (duodenal or jejunal) then I usually don't. If it is gastric then I always do. Especially for extubation. Holding tube feeds for 8-12 hours isn't going to kill someone, but enteral feeds in their lungs has the potential to. I am not sure about all of the literature, but the first time you see severe ARDS from aspiration pneumonitis you may change your practice.

Ards is not the first thing that will Happen most commonly, so that was unfortunate.
Mendelsson sx, then pneumonitis and in some cases pneumonia are far more common.
It's normal to aspirate a little food and saliva into lungs( we All do).

Now as far as the question of stopping feeds, the fear is if you need to te intubate or use bipap with a full stomach, not impossible but is preferably avoided.

Npo never hurt nobody... For a while!

 

[europeman]

If there is a question and it's time sensitive (ie it's. 4 pm and I wanna extubate rather than leave for later in evening then you can always suction the stomach with an og or Ng tube