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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Tuesday, January 13, 2015

Obstrucción de intestino delgado

Morris D - EMBlog Mayo Clinic - January 4, 2015
  • "If you think the patient has a bowel obstruction, go ahead and place a nasogastric tube. Placing a tube won’t make the patients like you, but by letting them stay bloated, and vomiting, and letting the ischemic cascade continue by not decompressing the bowel, you’re not doing the patients any favors. And don’t place the small-bore, soft silastic NG tube. They don’t work. The stuff that needs to come out is thick and nasty – like pond scum, in most cases – the small tube just will not do the job. The only thing worse than placing a large, stiff, NG tube is explaining to the patient that the soft “nice” tube that was placed initially is ineffective and that a large stiff tube is needed anyway.
  • Patients with SBO can sequester liters and liters of fluid in the lumen of the bowel. Start some isotonic fluids. Run them in surgical doses, even for the dialysis patients and the heart failure patients. Intravascular depletion leads to poor perfusion, leads to bowel ischemia. We can deal with excess fluid when the obstruction is resolved.
  • Make the patient NPO. Strict NPO. I’ve had patients drink gallons of ice chips while sitting in the ED. I’ve seen consults on the medicine floor where a patient is eating a cheeseburger around the NG tube. Remember the pond scum. Don’t add to it.
  • Get a surgical opinion early on. My own (admittedly arrogant, heavily-biased) opinion is that SBO is a surgical disease, and should be managed by surgeons, even when operative therapy isn’t needed (cue the onslaught of hate mail, car bombs, and snarky comments from my surgical colleagues who disagree)."