Page 552 - ACCCN's Critical Care Nursing

Gastrointestinal, Liver and Nutritional Alterations 529

directed at multi-organ support as extracorporeal liver stress, it is also associated with poor wound healing and
support therapies have not sufficiently developed to higher rates of infection after surgery in diabetic patients;
sustain liver function during the acute phase. higher risk of death after myocardial infarction in dia-
Liver transplantation remains the definitive treatment betic and non-diabetic patients; and poor outcomes after
option for acute and chronic liver failure patients when stroke. The use of intensive control of blood glucose has
supportive multi-organ therapy is not sustainable. been shown to improve both mortality and morbidity
Preexisting hepatic dysfunction and liver transplantation outcomes in select groups of patients but also presents a
surgery can lead to a high risk of haemorrhage and challenge for nursing practice where episodes of hypogly-
coagulopathy post-operatively. Careful haematological caemia occur.
management is required to control postoperative bleed- DKA and HHNS are seen in a small proportion of criti-
ing. Clinicians must ensure that patients receive appro- cally ill patients and the treatment revolves around cor-
priate haemodynamic management for hyperdynamic rection of intravascular volume, rectifying electrolyte
states and that measures to avoid rises in ICP are abnormalities and, in DKA, insulin therapy to stop keto-
implemented. genesis. Nursing management of the patient with hyper-
During episodes of critical illness, hyperglycaemia and glycaemic states should focus on frequent assessment of
increased insulin resistance can occur. Although hypergly- volume status, monitoring electrolyte concentrations and
caemia has been seen as a beneficial adaptive response to assessment of blood glucose levels.

Case study

The patient in her mid-twenties was admitted to ICU in the late ventilator. However, later in the afternoon plans for extubation
afternoon (day 1) after a respiratory arrest post tonic clonic seizure. were cancelled and enteral feeds recommenced because the
Her initial CT scan and chest X-ray showed no acute changes. She patient developed respiratory distress. Her oxygen saturation
had a medical history of severe seizures every three months associ- decreased to 77%, respiratory rate increased to 40–50 breaths
ated with her congenital disease, characterised by hypotonia and per minute and she had a left-sided wheeze. The chest X-ray
mild-to-severe generalised muscle weakness. She was intubated demonstrated fluid overload which was treated with salbutamol
and placed on a mechanical ventilator on her arrival to ICU because nebulisers and frusemide. Pressure support and positive end-
she suffered a seizure shortly after her arrival. expiratory pressure (PEEP) were also increased. She was given
remifentanyl and clonidine because she was restless and agitated.
The initial medical plan was to control her seizures, optimise her
respiratory function and extubate as early as possible. Early enteral A septic screen for her fever revealed Gram-positive cocci growing
feeding, preferably with in 24 hours, is standard treatment in the in her sputum and Gram-negative bacilli in urine, which were
ICU and enteral tube feeds were commenced within 30 minutes of treated with antibiotics.
her ICU admission. Confirmation of tube placement was made by On day 4 she was again fasted from 0600 hours and extubated at
X-ray on insertion of the enteral tube; that was done daily and 1135 hours. She required Guedel and nasopharyngeal airways for
whenever tube position may have changed. The Salem sump naso- secretion clearance post extubation. Because her respiratory status
gastric tube was aspirated four-hourly, as per unit protocol. Enteral was borderline and she may have required re-intubation,
tubes were secured to the face by adhesive surgical tape which re-commencement of enteral feeds was delayed after extubation.
were changed daily and whenever necessary. This unplanned prolonged interruption continued until the late
morning of day 5 (28 hours from the commencement of fasting).
On day 2 the feeds were stopped for anti-epileptic medication
(phenytoin), administered via the nasogastric tube. Sedation was She was discharged to the ward on day 6 and enteral feeding was
also stopped in anticipation of early extubation. Weaning was not continued on the ward. She had one interruption of 3 hours to her
tolerated and the planned extubation cancelled. There was no feeding on the day of discharge from ICU. This was for reposition-
adjustment to the volume of feed administered as a result of the ing of the nasogastric tube because of poor taping technique.
interruptions to feeding for medication and weaning. Ideally, Interruptions to enteral feeding in the ICU are common. Reasons
enteral feed volumes should be adjusted to account for the for stopping feeds include weaning from mechanical ventilation,
planned interruption for medication, providing that the adjusted gastric intolerance, procedures and medication administration by
hourly volumes are tolerated by the patient. The acceptable time the enteral route. For this patient, expedited extubation was the
that patients can be underfed with no adverse consequences is goal of management and the most common reason for stopping
unknown.
the feeds. While some interruptions to feeding are inevitable, it is
Feeds were stopped for three hours from 0600 h on day 3 for important to keep them to a minimum to facilitate patients in
enterally-administered medication. Late in the morning they were achieving their target feed volumes and to minimise handling of
stopped again as part of the plan to wean her from the mechanical the enteral feed delivery system.