Is it wrong to have a salem sump on intermittent suction?

[europeman]

Now, I understand how NG tubes work... i've been a surgery resident for 3 years now. And I can't tell you how many times I have seen patients on non-surgical services with stomach tubes (i.e. nasogastric tubes w/o second vent tube which allows equalizes with atmospheric air) which were on continuous suction which weren't working.... then you put it to intermittent and bam....700 cc's comes out.

I've always been taught and the surgeons i'm at always put the salem sumps to low or medium continuous suction. whatever.

now i'm rotating at this community hospital, and the freaking nurses refuse to put the salem sumps on continuous. it's very odd. this particularly happens in the ICU.

doesn't matter how many times I tell them or put an order in... the next day, it's back on continuous. a SALEM SUMP! http://www.covidien.com/criticalcare/pageBuilder.aspx?topicID=69667&breadcrumbs=81040:0,69605:0

Thing is.... every time I put it back on continous.... not much really happens. I mean... once the majority of the gastric content is evacuated.... i'm not sure it matters because i've never seen the canister all of a sudden fill up from me changing it.

Which begs me to ask.... do you guys/gals do with your NG tubes? and do you have an opinion? thanks!

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[dpmd]

Most nurses learn from their colleagues who learned from theirs, etc. Back in the day you had to do intermittent so it would work right. Now that is what they know. You order continuous and they figure you just don't know what you are doing. Some places the nurse will call you and try to get you to change it (and may or may not listen when you say it is ok to have on continuous). Other places they are just going to put it how they want regardless of your order. There isn't a problem with intermittent, and it avoids any phone calls so I just do that. Gotta choose your battles.

 

[europeman]

now that i think about it... i suspect it works just fine on intermittent... just not AS well.

a lot of other countries don't even put NG tubes on any kind of suction... they just go on gravity (i.e. isreal, greece). so if it works adequately well on gravity, it must work a little better on intermittent, and even better on continous.

i hear what you are saying about picking your battles. hehe.

 

[Smurfette]

I always put NGTs on intermittent. That's how we did it in med school, residency and it's how my partners (from different schools/residency programs) do it as well. Never saw a surgeon leave them on continuous before (except immediately after placement to evacuate the stomach, after which it's put on intermittent). Always was taught that if an NG is left on continuous, it sucks down onto the folds of the stomach wall, preventing adequate evacuation of stomach contents---which is why you have to occasionally break the continuous suction to get the tube working better. Interesting that others here have been taught otherwise.

I have seen surgeons do the gravity drainage thing before, but it's always been prior to tube removal and not for the entire time the patient has the tube.

 

[SocialistMD]

I always put NGTs on intermittent. That's how we did it in med school, residency and it's how my partners (from different schools/residency programs) do it as well. Never saw a surgeon leave them on continuous before (except immediately after placement to evacuate the stomach, after which it's put on intermittent). Always was taught that if an NG is left on continuous, it sucks down onto the folds of the stomach wall, preventing adequate evacuation of stomach contents---which is why you have to occasionally break the continuous suction to get the tube working better. Interesting that others here have been taught otherwise.

I have seen surgeons do the gravity drainage thing before, but it's always been prior to tube removal and not for the entire time the patient has the tube.

Theoretically, all modern ng tubes will work on continuous suction, as there is a sump (blue) port that keeps them from pulling gastric mucosa into the tube. However, we all know those blue ports get clogged, which is why we all use intermittent suction; to avoid trauma to gastric mucosa. Most nurses are never taught how the tubes work, which is why you'll find them in various stages of dysfunction, and why it is less traumatic to just put the tube to LIWS as compared to LCWS.

 

[Buzz Me]

Every time I go examine a patient with an NGT in place I look for a large 60-cc piston-tip syringe so I can flush (and unclog) the blue sump port.

 

[Dr.LeoSpaceman]

Does anyone else have to deal with the little filters that nurses love to put on the end of the sump tube? I break them every time I see them. In theory, they're fine. Problem is, as soon as they get wet, it just becomes a plug that prevents the NG from actually functioning.

I can't count the number of times I've heard "But we put it in because it just wouldn't stop leaking from the blue tube". You try to explain that this is a signal to flush both parts of the tube because it isn't working properly, but it always seems to fall on deaf ears.

 

[Buzz Me]

Does anyone else have to deal with the little filters that nurses love to put on the end of the sump tube? I break them every time I see them. In theory, they're fine. Problem is, as soon as they get wet, it just becomes a plug that prevents the NG from actually functioning.

I can't count the number of times I've heard "But we put it in because it just wouldn't stop leaking from the blue tube". You try to explain that this is a signal to flush both parts of the tube because it isn't working properly, but it always seems to fall on deaf ears.

I tend to disconnect them and throw them away as well. Usually they don't understand that reflux out of the blue port is a sign the NGT is clogged...more often than not I'll find a glove draped/tied around the uncapped blue port.

 

[45408]

I throw them away every time I walk in a room and see one.

Nice. Is there a better solution? I do understand why nurses don't want gastric contents dripping on the sheets right after they change the linens.

 

[JayDoc06]

i usually find the blue port either totally backed up, valve placed backwards, blue tube in a knot, or blue tube to suction itself. My favorite trick it cut it nearly flush to its insertion so only a 60 cc syringe will fit.

 

[Thanatos]

The solution is appropriate nursing care - frequent and (most importantly) thorough flushing of the NGT

Where can one find this.....appropriate nursing care.....

 

[Ronin2258]

Always to low intermittent wall suction with NGTs here, for the reasons Smurfette mentioned.

I always thought the idea of the filter/check valve/overthinking the bloody plumbing was a bit much. Had I thought about it at the time, i would have loved to have taken a 16gauge needle to the damned thing just to make sure it was venting properly.

The solution is appropriate nursing care - frequent and (most importantly) thorough flushing of the NGT

My surgical floor nurses were actually OK with these things. If I had a dollar for every time one of the medicine floor nurses flummoxed the NGT up, I would be retired in Hawaii by now.

 

[europeman]

Every time I go examine a patient with an NGT in place I look for a large 60-cc piston-tip syringe so I can flush (and unclog) the blue sump port.

this is GENIUS! I will start cutting them too! haha

yeah i guess if your nurses aren't good, intermittent assues your tube won't cause more harm. but if it's well kept then continueous should be best i guess.

great replies thanks!

 

[HNANAL]

i always leave it to low continuous suction. Part of the reason why it sucks on the stomach too much is due to malposition. You have to reposition the ngt so it sumps. This usually involves pulling it back (almost always works for me).

The sump when it works will make noises, which bothers the patient and nurse, who then sabotage your work by plugging the sump port or tying it it off!

I also always will flush the sump with air and water.

 

[aashiq]

We always let it open and drain with intermittent aspirations. Also depends on the contents and how frequently do you want them out.
In some places they use a negative suction device which sucks at low pressure continuosly

 

[MTNERRN]

Where can one find this.....appropriate nursing care.....

Really? Do you need to be reminded that the highest incidence of patient death is when Student Doctors and Residents hit the hospitals in June/July? Nurses help to keep new doctors from killing people! Try not to alienate them- they do all your dirty work for you and keep your patients alive.

And FYI this is from UpToDate: Most nurses are trained (correctly) to place NGTs to LIWS:

"In general, tubes for decompression are positioned in the gastric fundus and connected to low intermittent wall suction, which decreases the risk of injury to the gastric mucosa. If the nasogastric tube has a venting side-port (eg, Salem Sump), it may be practical to use continuous suction initially to rapidly evacuate accumulated fluid from the stomach, but as the amount of drainage lessens, the tube should be placed to intermittent suction. Although the vent port of these tubes should theoretically prevent mucosal injury, the vent port frequently malfunctions, essentially converting the tube from a dual lumen to a single lumen tube."

 

[evilbooyaa]

Really? Do you need to be reminded that the highest incidence of patient death is when Student Doctors and Residents hit the hospitals in June/July? Nurses help to keep new doctors from killing people! Try not to alienate them- they do all your dirty work for you and keep your patients alive.

And FYI this is from UpToDate: Most nurses are trained (correctly) to place NGTs to LIWS:

"In general, tubes for decompression are positioned in the gastric fundus and connected to low intermittent wall suction, which decreases the risk of injury to the gastric mucosa. If the nasogastric tube has a venting side-port (eg, Salem Sump), it may be practical to use continuous suction initially to rapidly evacuate accumulated fluid from the stomach, but as the amount of drainage lessens, the tube should be placed to intermittent suction. Although the vent port of these tubes should theoretically prevent mucosal injury, the vent port frequently malfunctions, essentially converting the tube from a dual lumen to a single lumen tube."

5-year necrobump to yell at somebody? Relax Mr./Mrs. insecurity.

Those damn filters were always at the end, and they are useless unless the tube is on gravity. I spent many an hour discussing that "the blue part leaking everywhere" means that you need to flush it, or if you can't, call me so I can. Always funny to see a clogged NG with the nurse going "like omg can we pull it out, it hasn't put out anything in 10 hours" then you unclog it and 1L comes rushing out of the stomach as the patient goes from nauseated to comfortable.

I really did try to educate nurses on the more friendly floors regarding basic NGT etiquette. Obviously I learned it from someone cause it's not something they teach ya in medical school, but I'd say about 50-75% of the nurses were amicable to learning, which was nice.

 

[LucidSplash]

I have found myself endlessly educating nurses about care and maintenance of NGTs over the last 6.5 years. Some are willing to receive it, some aren't. Had a fresh new nurse, just today, hook up the suction canister incorrectly and then ask if we could take the NGT out because the patient was "just vomiting around it." Changed canister to proper configuration and 1L of gastric output immediately. Educated that the different ports on the top of the suction canister are labeled "patient" and "vacuum" and what is hooked to what matters because there is a filter on the vacuum port that will clog. NGT then stopped putting out and whistling, I said "now it is clogged, let's get a flush kit" and she replied "Oh you can put some water down it?" Again, nicely educated her and she was receptive. But 1) Perhaps a more senior nurse might have accomplished this task if there was better mentorship and 2) not all nurses are receptive to education from residents (especially female residents). So you can stow your indignation. This isn't a one-sided circus and the 5-year necrobump on a surgery residency thread just confirms bad nursing stereotypes.

 

[TraumaLlamaMD]

I once walked into a room to find the blue/white filter with one end plugged into the main suction tube, the other end connected to the wall suction tubing, and the blue sump port open and dripping bile on the floor. Still not sure how anyone thought that made sense!

 

[kemper6036]

Seen it.

Other favorites: Chest tube to low intermittent suction

thats a good one....we recently had a nurse who hooked up the NG tube to oxygen.

 

[dpmd]

thats a good one....we recently had a nurse who hooked up the NG tube to oxygen.

What the...how is that even possible?!

 

[Thanatos]

Really? Do you need to be reminded that the highest incidence of patient death is when Student Doctors and Residents hit the hospitals in June/July? Nurses help to keep new doctors from killing people! Try not to alienate them- they do all your dirty work for you and keep your patients alive.

And FYI this is from UpToDate: Most nurses are trained (correctly) to place NGTs to LIWS:

"In general, tubes for decompression are positioned in the gastric fundus and connected to low intermittent wall suction, which decreases the risk of injury to the gastric mucosa. If the nasogastric tube has a venting side-port (eg, Salem Sump), it may be practical to use continuous suction initially to rapidly evacuate accumulated fluid from the stomach, but as the amount of drainage lessens, the tube should be placed to intermittent suction. Although the vent port of these tubes should theoretically prevent mucosal injury, the vent port frequently malfunctions, essentially converting the tube from a dual lumen to a single lumen tube."

Yes really.

Do you need to be reminded of the multiple publications (Thiels JAMA Surgery 2016, Schroeppel JACS 2009, Dhaliwal American Journal of Surgery 2009) showing no difference in mortality in July? Because senior residents. And fellows. And attendings.

Nurses don't do dirty work....anything menial they dump on the PCA/nurses aide whatever they call them where you are....and anything they deem more complicated they dump on the intern. Not that I blame then necessarily, its human nature to avoid anything unpleasant when there's someone else you can easily justify dumping it on.

Despite what you're insinuating, nurses are not saving the day from big mean stupid doctors. They do what they are trained to do....nursing. In my whole career i've never been paged by a nurse saying that a patient is going south, they have the perfect solution but another big mean stupid doctor won't listen to them. I have been paged about endless non-issues at all times of the day and night however....including the ever infamous "leaking" ng tube with nothing in the suction container. I've demonstrated how to fix that at least hundreds of times.....now that I don't do general surgery I don't get paged about that anymore....because its human nature to avoid anything unpleasant when there's someone else you can easily justify dumping it on

Lastly:
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[kemper6036]

What the...how is that even possible?!

i wouldn't have believed it myself until one of said nurses colleagues posted a photo of it on the FB. they were strongly encouraged to take it down

 

[Abbracadabz]

Hey there, surgical floor nurse here! I just had my first patient ever who was ordered to be on low continuous suction with his NGT, I thought it was strange because they are always ordered at LIS here. But I didnt change it. As I was passing off to the older more experienced day nurse he balked when I told him what it was set to and told me in the past he had a pt who had severe complications from an NGT even set to LIS which had settled in one part of the stomach and caused a massive hematoma from the pressure. He said he was going to change it to LIS. We use the double lumen NGT with the argyle salem anti reflux valves on the end, and I always flush the blue with air and replace the valve if there are gastric contents in the blue tube. And flush water into the main lumen for patency. Is that kind of complication common occurrence? So I was reading this and wondered if thats why your nurses are so hesitant to follow that order.

 

[LucidSplash]

I always did LIWS in residency. At my current hospital the pumps don’t even have the ability to be on intermittent suction. If I order something to intermittent suction it means the nurse turns it off every once in awhile. I still don’t like it but everyone around here acts like LIWS is something silly.

 

[CBG23]

I typically order continuous, but the reality is that intermittent is probably better since:
1.) Even when I throw out the sump tube caps/ filters, they often get replaced by new ones by ancillary stuff because they leak and make a mess. As was mentioned earlier in the thread, once the filters get wet, they prevent the sump tube from working.
2.) I often find the sump tubes tied in a knot.
3.) I often find them covered with a glove or towl, essentially defeating their purpose