Enteral feed + cuffed trach + npo guidelines

[turnupthevapor]

Some debate in my center if a pt must have enteral feeds turned off for 6 hrs of coming down for a procedure with a cuffed trach in place.

My first thought is that its not too relevant since there is no pre intubation post induction period to aspirate. Also was thinking you could just evacuate the stomach on arrival to the OR

Thoughts?

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[Ignatius J]

Some debate in my center if a pt must have enteral feeds turned off for 6 hrs of coming down for a procedure with a cuffed trach in place.

My first thought is that its not too relevant since there is no pre intubation post induction period to aspirate. Also was thinking you could just evacuate the stomach on arrival to the OR

Thoughts?

I agree with you. I think that situations like this are the reasons there are guidelines and standards.

 

[seinfeld]

Depends on the type of case, but I will say as an ICU doc if the patient makes frequent trips to the OR the risk of malnutrition from continued cessation of feeding must be weighed against the true potential of aspiration. Remember a cuff doesn't prevent all aspiration. I have an ICU patient currently who comes for frequent wound vac changes. To ease the minds of my colleagues I placed a note in the chart detailing the risk benefit and also an order to not hold tube feeds for OR wound vac changes. The order also asks the NURses to place the NGT on suction prior to arrival to the OR.

We in anesthesia try to make things too black and white, always favoring a narrowminded, self centered approach to risk. We should like every physician identify the risks and benefits for the whole patient.

 

[turnupthevapor]

Great thoughts. Thanks

 

[psychbender]

What's the nature of the procedure, and is the feeding tube post-pyloric? Back in training, we had a lot of trauma patients on the M/W/F washout schedule, so stopping feeds before every trip put them at substantial risk of malnutrition. To prevent this, the intensivists, surgeons, and anesthesiologists got together and decided that the risks of aspiration from a post-pyloric feeding tube was less than the risk of inadequate nutrition. So, everyone in need of tube feeds on this kind of OR schedule got a post-pyloric tube, with feeds continued right up to the OR.

 

[Noyac]

As pychebender says, it depends a lot on the placement of the feeding tube.

 

[deleted171991]

Back in training, we had a lot of trauma patients on the M/W/F washout schedule, so stopping feeds before every trip put them at substantial risk of malnutrition.

OK, so from where I stand this is male bovine excrement. Especially in the 33% of patients who are obese. This kind of thinking is what created those 33%.

Humans are not made to feed over 24 hours. We feed over 12 or so. When we were not so advanced, we didn't even have 3 meals et cetera. We ate only once or twice a day. I still do. 🙂

Patients have nutritionists paid to adjust their daily nutritional intake, based on needs. If a patient needs to go to the OR, a patient should be NPO just like any other patient. We owe the same standard of care to everybody. It's not to protect us, it's to protect them. So if you want to take better care of your ICU patients, have the nutritionist recalculate the caloric intake over 12 hours instead of 24, and by giving tube feeds with much higher protein and caloric concentration during that time. It's their darn job. And the nurses' job to monitor and adjust those feeds based on stomach contents. It just takes a bit more work. One nurse per two ICU patients, what's so hard?

Or you can calculate it yourself. I sometimes wonder why we have so many nutritionists in this country; it's not rocket science, it's elementary arithmetic, especially with tube feeds.

A post-pyloric tube still can get reflux into the stomach. And NG suction has not been proven to prevent aspiration. Plus critical patients have decreased stomach evacuation.

 

[seinfeld]

Not all ICU patients tolerate the volume of nutrition required to meet their hypermetabolic stressed state with feedings over 12 hours, they are not you and I making it through the day

 

[deleted171991]

Not all ICU patients tolerate the volume of nutrition required to meet their hypermetabolic stressed state with feedings over 12 hours, they are not you and I making it through the day

Now that part I can understand. And for those (and other) select patients, we should make exceptions. I just don't like it as a broad policy. The broad policy should be the same as the standard of care.

These guys aspirate their saliva like clockwork, right by that wonderful "protective" cuff. What we call VAP is many times a form of aspiration pneumonia.

These patients have their gastric sphincters open all the time, from all the indwelling tubes. If anybody is at risk for reflux with no protective airway reflexes, it should be them. Aspiration (or at least reflux) doesn't only happen during induction and emergence of anesthesia; it happens even during MAC, and those of us who use LMAs have seen it intraop, in NPO outpatients.

On the other hand, one could argue that if they can aspirate tube feeds, they would aspirate them even in the ICU. (And maybe they do.) The OR is not much different, unless it's the type of surgery that would buy an ETT even in a healthy patient. But one could also argue that a surgical pain stimulus can have vagal effects, which does not happen that much in the ICU.

 

[Gaseous Clay]

What about a patient coming for a trach & peg straight from the ICU? Typically these patients are NPO with TFs stopped prior to surgery but I have seen a patient who literally had their TFs stopped as transport came to help bring the patient down. If this is an add on, I always try to send someone to pre-op the patient but sometimes this gets missed and I'm standing there with everyone waiting at the doors leading to the OR. Do you cancel and send right back up? Do you proceed on since they have an airway in place? Thoughts and comments?

 

[turnupthevapor]

Thanks for all the comments. Any thoughts on the fact that the airway is secured with a cuffed tube?


I think the importance of npo status is primarily related to the period of time post induction preintubation with it's loss of airway reflexes for aspiration. These patients will not go through that period as the airway is already secured with a cuffed airway.

 

[deleted171991]

I would argue that the cuff does not protect against aspiration in abdominal surgeries, or other surgeries which go with increased risk of aspiration even in healthy patients. Especially in critical patients who simply cannot afford an aspiration pneumonia on top of everything. Those patients need to be NPO for 8 hours or even longer.

If I wouldn't do a type of surgery with an LMA even in an NPO healthy patient, that patient should be NPO even with a cuffed tube already in place. Suction by NGT an empty stomach does not mean.

Just my 2 cents. I didn't have to deal with ICU patients coming to the OR in the last few years, but the few aspirations I have seen in NPO outpatients made me pretty conservative about the subject. And they didn't happen only during induction or emergence, proving that even a surgical stimulus, or the presence of a foreign object in the pharynx (LMA), can be stimulating enough.

One could argue that it might be less risky in muscle-relaxed patients, or after metoclopramide. I don't know.

As seinfeld said, it's a matter of risks vs benefits. Are there studies about this, or is it unethical to do them? I realize that I might sound too cautious, but we should not forget about "first do no harm".

 

[nap$ter]

I have an ICU patient currently who comes for frequent wound vac changes. To ease the minds of my colleagues I placed a note in the chart detailing the risk benefit and also an order to not hold tube feeds for OR wound vac changes. The order also asks the NURses to place the NGT on suction prior to arrival to the OR.
.

i don't necessarily disagree with you.

however, as an anesthesia doc doing the case it is my choice whether the patient is npo or not.

if you write an order to continue tube feeds and i disagree with it i will delay or cancel the case. i don't take orders from other physicians.

 

[fakin' the funk]

Some debate in my center if a pt must have enteral feeds turned off for 6 hrs of coming down for a procedure with a cuffed trach in place.

My first thought is that its not too relevant since there is no pre intubation post induction period to aspirate. Also was thinking you could just evacuate the stomach on arrival to the OR

Thoughts?

These patients should not have their TFs held for 6 hours. With the inevitable delays and postponements, holding for 6 hours, or even worse, after midnight, will deprive the pt of a ton of calories and protein. These "plug and play" type patients with no airway surgery or major abdominal surgery planned should go right up until OR time. They microaspirate all the time around their trach or ETT cuff anyway, and this will also be true in the OR - imo, might as well let them get their nutrition too.

Running their 24 hour requirements over 12 doesn't work. Many patients can't even tolerate the 30-60/h volume for a 24 hour schedule, let alone twice that.

 

[G-Man82]

I don't think a cuffed tube prevents all forms of aspiration. As someone already mentioned, micro aspiration happens pretty much in every critically ill patient. I believe the mechanism to be channeling around the cuff to the other side.

That being said, as Seinfeld mentioned, it is a risk-benefit situation. Regardless of how much we try in the ICU to keep up with a patient's nutrition, these patients tend to be malnourished as evidenced by the consistently low pre-albumins that we get each week to assist in assessing nutrition. So any interruption to their feeds is also potentially harmful to their long term prognosis. The idea of doubling the rate or giving a more calorie dense formula (like a 2 cal per ml formula), is a nice one and we try it often. But then many patients can't tolerate it and they start vomiting, if their gastric motility is slow, or they get massive diarrhea, both of which cause feeds to be held.

Yes. Aspiration is a problem and may tip some of these patients over the edge, and it's an awful risk. But these patients need their nutrition or it's pretty much guaranteed they'll have bad outcomes. So weigh your risks folks. Unless you can guarantee that the patient will go exactly 6-8 hours after feeds are stopped, asking for critically ill patients to be starved prior to a minor procedure may be more harmful than good in my opinion.

I'm not saying that you have to follow another physician's "orders," which are more for the nurses anyway. Just trying to point out the thinking from the critical care side of our specialty.

 

[seinfeld]

i don't necessarily disagree with you.

however, as an anesthesia doc doing the case it is my choice whether the patient is npo or not.

if you write an order to continue tube feeds and i disagree with it i will delay or cancel the case. i don't take orders from other physicians.

The Order was mainly of nursing and the PAs so they would not keep writing the NPO orders. As you might recognize, wound vac change are add on cases with no time estimate so the PA were writing for NPO after midnight and that usually meant the patent was NPO 18 hours (Midnight to 6-8pm).

In my PP group no one would have an issue with this as we all work as a team. If someone did refuse to do it I would simply remove them from the case.

 

[deleted171991]

I've just looked at the available "high-calorie" tube feeds, and they run at 2 kcal/ml (I was expecting at least 4). That's just laughable, for 2015. It's almost like giving them milk shakes. Also very explainable, given the fact that most of them are based on tons on carbs.

One could get to 9 kcal/ml just by giving them olive oil (or any other form of liquid fats), instead of that HFCS-derived junk. Tube feeding a patient costs $30-40/day; one would expect better quality for that. It makes me wonder if customized meals, prepared in the hospital, then ground and injected through thicker tubes, would not be much more nutritious for the same money. I bet there are tons of high-osmolarity preservatives included, too.

So the attitude of the docs who wouldn't hold tube feeds is very explainable. I wouldn't hold them either, if I were an ICU doc. How sad.

 

[G-Man82]

I've just looked at the available "high-calorie" tube feeds, and they run at 2 kcal/ml (I was expecting at least 4). That's just laughable, for 2015. It's almost like giving them milk shakes. Also very explainable, given the fact that most of them are based on tons on carbs.

One could get to 9 kcal/ml just by giving them (olive) oil, instead of that HFCS-derived junk. Tube feeding a patient costs $30-40/day; one would expect better quality for that.

So the attitude of the docs who wouldn't hold tube feeds is very explainable. I wouldn't hold them either, if I were an ICU doc. How sad.

Yup. We use 2cal in a lot of fluid-restricted patients, though. It is really really tough to tolerate that because it is a hyperosmolar solution that you're infusing directly into the gut with all the resultant physiologic challenges. Often, if I need to increase calorie intake and not increase the rate, I'll use 1.2 or 1.5 cal solutions. But don't forget, a lot of these patients are also getting various nutrient supplements on top as well. And the tube feeding doesn't have to be continuous. You can do bolus feeds, too, but then again, many critically ill patients wouldn't tolerate that.

I also forgot to mention that the ETTs that we use at my hospital have an extra suction port built in that would allow for subglottic suctioning. The port sits above the cuff. Theoretically, it keeps secretions from pooling and then channeling through by suctioning them out. A lot of patients have that port attached to continuous low wall suction. This won't help in the trach patient, but for someone with an ETT, you might consider that in helping to decrease intraoperative microaspiration risk.

 

[nap$ter]

The Order was mainly of nursing and the PAs so they would not keep writing the NPO orders. As you might recognize, wound vac change are add on cases with no time estimate so the PA were writing for NPO after midnight and that usually meant the patent was NPO 18 hours (Midnight to 6-8pm).

In my PP group no one would have an issue with this as we all work as a team. If someone did refuse to do it I would simply remove them from the case.

gotcha. thanks for the clarification.