Nasogastric Tube Placement

imagesAspiration of gastric fluid, air, or blood


   imagesEvaluation of upper gastrointestinal (GI) bleed (volume and/or presence of blood)


   imagesDecompression of obstructed GI tract (i.e., small bowel obstruction)


   imagesPrevention of aspiration and gastric dilatation (i.e., in intubated patients)


imagesLavage or removal of toxins (e.g., overdose, poisonings)


imagesAdministration of medication, oral contrast, and nutrients (TABLE 31.1)


CONTRAINDICATIONS



imagesAbsolute Contraindications


   imagesFacial trauma with possible cribriform-plate fracture


      imagesConcern for passage into intracranial space


imagesRelative Contraindications


   imagesSevere coagulopathy


      imagesIf critical, consider the orogastric route, which may cause less bleeding


   imagesAlkali ingestions or esophageal strictures


      imagesPlacement may cause esophageal rupture


   imagesHistory of gastric bypass surgery/lap band placement


      imagesRisk for intestinal perforation



imagesGeneral Basic Steps


   imagesPosition patient


   imagesAnalgesia


   imagesMeasure nasogastric tube (NGT)


   imagesInsertion


   imagesConfirmation of placement


   imagesSecure tube


EQUIPMENT NEEDED



imagesNGT


imagesViscous lidocaine


imagesCetacaine spray (optional)


imagesNebulizer equipment and 4% lidocaine (optional)


imagesA cup of water with straw


imagesTapered syringe (30–60 cc)


imagesSuction


imagesTape










TABLE 31.1.


COMMON REASONS FOR NGT PLACEMENT



Bright red blood per rectum


Hematemesis/Coffee-ground emesis


Small bowel obstruction


Intubated patient


TECHNIQUE



imagesPatient Preparation


   imagesElevate the head of the patient’s bed to upright position (if possible)


   imagesPlace an emesis basin on the patient’s lap


   imagesSelect the patent nostril for tube placement


      imagesHave the patient occlude one nostril at a time and sniff


      imagesIt may be necessary to switch to the opposite nostril if one side proves to be too difficult


   imagesIn awake patients, anesthetize selected nare at least 5 minutes before attempting tube placement


      imagesInject lidocaine gel (5 mL of 2% viscous lidocaine) via a 10-mL syringe. Ask the patient to sniff and swallow. The patient can orally swallow additional 5 mL of viscous lidocaine to further anesthetize the posterior pharynx.


      imagesConsider using benzocaine (Cetacaine) spray on the posterior pharynx


      imagesConsider nebulized lidocaine (2.5 mL of 4% lidocaine) via a face mask as an alternative to gels and sprays


   imagesImmediately after opening the NGT package, place the small (easily misplaced) “connector” in a safe place; it is frequently missing/lost when you want to connect the NGT to suction


   imagesEstimate tube insertion distance


      imagesMeasure the tube from the patient’s xiphoid process to the earlobe through the tip of the nose. Add 15 cm to this distance and mark on the NGT with a small amount of tape.


   imagesLubricate NGT with viscous lidocaine or Surgilube


imagesInsertion


   imagesInsert the tube (usual adult size 16-French or 18-French) into the selected nostril, aiming along the floor of the nose, posteriorly and caudally


   imagesOnce in the nasopharynx, have the patient flex his head forward to aid tube placement into the esophagus


   imagesPause as the tube enters the oropharynx and have the patient swallow water via straw to aid in the passage of tube, and then rapidly advance the tube into the stomach to the predetermined depth


imagesConfirmation of Placement


   imagesPatient is able to speak clearly


      imagesIf the patient has difficulty speaking or is coughing, the tube is likely in the trachea and needs to be removed


   imagesAspirate gastric contents


   imagesInsufflation of air through a 50- or 60-mL syringe into the end of the NGT while auscultating over the stomach should reveal borborygmi (gurgling in stomach)


      imagesIf the patient burps after insufflation, the tube is likely in the esophagus and needs to be advanced


imagesSecure the Tube


   imagesClean and dry the tube, if necessary


   imagesTape the NGT at the nose entry site with emphasis of alleviating pressure of the tube on the nose


   imagesSecure the tube to the patient’s gown for added stability


   imagesThe air vent pigtail can be used as a cap for suction lumen when the tube is not in use


imagesChest X-ray Confirmation


   imagesIt is not required to routinely confirm NGT placement with chest x-ray as the tube can be clinically confirmed via aspiration of gastric contents


   imagesIf a chest x-ray is planned for endotracheal tube placement, consider obtaining after NGT placement


   imagesIf the patient is unconscious, consider x-ray confirmation, especially if charcoal is to be administered through the NGT


COMPLICATIONS



imagesEpistaxis


imagesTracheal intubation


imagesEsophageal/gastric perforation


imagesAspiration


imagesSinusitis or otitis media


imagesUlceration of mucosa


imagesEsophageal stricture


imagesNecrosis or bleeding of nasal mucosa from improperly secured tube


imagesIntracranial insertion


SAFETY/QUALITY TIPS




imagesProcedural


   imagesThe keys to success are adequate anesthesia and cooperation, tilting the head forward, and having the patient swallow water as tube is advanced


   imagesWhile passing the NGT, point the proximal end of the tube away from staff and self; vomiting during insertion can spray out of the proximal tube end


   imagesConsider using a sedative in patients who have difficulty tolerating the procedure


   imagesIn the intubated, nonagitated, and noncombative patient, gently lifting the jaw forward or pushing the trachea to the patient’s left can ease the passage of the NGT


   imagesAn alternative method of orogastric tube (OGT) placement in an intubated patient is performing laryngoscopy and placing the tube into the esophagus under direct visualization. A bougie, with deflection pointed posteriorly rather than anteriorly, can be used as an adjunct.


   imagesUse intermittent suction—constant suction can lead to gastric mucosal damage


   imagesIf the NGT has been confirmed to be in the stomach and there is minimal return during lavage, the drainage holes may be clogged, the tube may be a hold of the gastric wall, or the stomach may be empty—consider decreasing the vacuum pressure setting or you can attempt to push air into the venting lumen with a large syringe.


imagesCognitive


   imagesNGT placement might require multiple attempts


      imagesThere is a higher incidence of insertion into the pulmonary tree in this group. Alternative techniques include using Magill forceps and a gum-elastic bougie.


      imagesLarger-sized NGTs may be difficult to pass in narrow nasal passages, whereas smaller-sized tubes may bend too easily and curl in the patient’s mouth (FIGURE 31.1)


      imagesIf there are any concerns that the patient may bite down, do not place your fingers in the mouth


   imagesIn patients who are unconscious or have altered mental status, consider airway protection via intubation before NGT insertion to prevent aspiration


   imagesIn the case of hematemesis, NGT lavage is used to remove blood irritating the stomach, to determine the amount of blood, and to determine whether bleeding persists. It is not performed in order to diagnose a bleed; a negative NGT aspirate does not rule out a clinically important bleed.

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Nasogastric Tube Placement
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