Nasogastric tube placement: Difference between revisions
Line 35: Line 35:
#Provide relief from discomfort
#Provide relief from discomfort
#*Topical vasoconstrictors to both nares
#*Topical vasoconstrictors to both nares
#**Oxymetazoline or phenylephrine
#**Oxymetazoline or [[phenylephrine]]
#*Topical Anesthetics (5 min prior to procedure)
#*Topical Anesthetics (5 min prior to procedure)
#**Benzocaine, tetracaine, nebulized lidocaine (4 or 10%), lidocaine jelly
#**Benzocaine, tetracaine, nebulized [[lidocaine]] (4 or 10%), lidocaine jelly
#**Anesthetize OP, as well, to prevent gagging
#**Anesthetize oropharynx, as well, to prevent gagging
#*Antiemetics
#*Antiemetics
#**Zofran and reglan 15 min prior may reduce gagging and nausea
#**[[ondansteron]] or [[metoclopramide]] 15 min prior may reduce gagging and nausea
#Insert tube along floor of nose under inferior turbinate
#Insert tube along floor of nose under inferior turbinate
#Pause when NGT is in OP  
#Pause when NGT is in OP
#Flex neck to decrease chance of tracheal passage
#Flex neck to decrease chance of tracheal passage
#Advance into esophagus
#Advance into esophagus
Line 52: Line 52:
#**One study shows this discovers only 6% of malplacement<ref>Neumann MJ, Meyer CT, Dutton JL, et al. Hold that x-ray:  aspirate pH and auscultation prove enteral tube placement. J Clin Gastroenterol. 1995; 20(4):293-295.</ref>
#**One study shows this discovers only 6% of malplacement<ref>Neumann MJ, Meyer CT, Dutton JL, et al. Hold that x-ray:  aspirate pH and auscultation prove enteral tube placement. J Clin Gastroenterol. 1995; 20(4):293-295.</ref>
#**Should not be primary confirmation technique<ref>Christensen M. Bedside methods of determining nasogastric tube placement: a literature review. Nurs Crit Care. 2001; 6(4):192-199.</ref>
#**Should not be primary confirmation technique<ref>Christensen M. Bedside methods of determining nasogastric tube placement: a literature review. Nurs Crit Care. 2001; 6(4):192-199.</ref>
#*Obtain Abd xray
#*Obtain abdominal xray
#*Check pH of aspirate
#*Check pH of aspirate
#**pH<5.5 in 99% of cases and has sen of 0.78 and spec of 0.86 at or below this level<ref>Boeykens K, Steeman E, Duysburgh I. Reliability of pH measurement and the auscultatory method to confirm the position of a nasogastric tube. Int J Nurs Stud. 2014; 51(11):1427-1433.</ref>
#**pH<5.5 in 99% of cases and has sen of 0.78 and spec of 0.86 at or below this level<ref>Boeykens K, Steeman E, Duysburgh I. Reliability of pH measurement and the auscultatory method to confirm the position of a nasogastric tube. Int J Nurs Stud. 2014; 51(11):1427-1433.</ref>

Revision as of 20:59, 12 July 2016

Indications

  • Aspiration of stomach contents (poor sensitivity and specificity for diagnosing upper GI bleed)
  • Vomiting likely to be dangerous or recurrent
    • Bowel obstruction
    • Paralytic ileus
    • Acute gastric dilatation
  • Stomach decompression prior to surgery or peritoneal lavage

Contraindications

  • Facial fracture involving cribriform plate

Relative Contraindications

  • Severe Coagulopathy
  • Gastric bypass and lap band procedures
  • Esophageal strictures
  • History of alkali ingestion

Equipment Needed

  • PPE including gown for practitioner and patient
  • NG Tube- typically a 16F or 18F Sump
  • Syringe/Bulb- 50-60cc
  • Tape
  • Emesis basin
  • Towels
  • Cup of water with straw

Procedure

  1. Consent by informing patient of risk, benefits, and alternatives
  2. Position patient upright
  3. Place towel over patient's gown and emesis basin in lap
  4. Estimate length of insertion
    • A standard of 56cm is reasonable[1])
    • Alternatively measure from tip of nose to earlobe to xyphoid and then add 15cm
  5. Check nares for obstruction and pass through the most widely patent nare
  6. Provide relief from discomfort
    • Topical vasoconstrictors to both nares
    • Topical Anesthetics (5 min prior to procedure)
      • Benzocaine, tetracaine, nebulized lidocaine (4 or 10%), lidocaine jelly
      • Anesthetize oropharynx, as well, to prevent gagging
    • Antiemetics
  7. Insert tube along floor of nose under inferior turbinate
  8. Pause when NGT is in OP
  9. Flex neck to decrease chance of tracheal passage
  10. Advance into esophagus
    • Sipping water may aid in esphageal passage
    • Withdraw to OP promptly if excessive coughing, gagging, choking or voice change
  11. Once NGT is in esophagus, rapidly insert rest of tube to premeasured length
  12. Confirm placement
    • Insufflate air while listening over stomach
      • One study shows this discovers only 6% of malplacement[2]
      • Should not be primary confirmation technique[3]
    • Obtain abdominal xray
    • Check pH of aspirate
      • pH<5.5 in 99% of cases and has sen of 0.78 and spec of 0.86 at or below this level[4]
  13. Secure to patients nose with tape
  14. Attach to desired suction, not to exceed 120 mmHg

Complications

  • Pulmonary placement
  • Intracranial placement
  • Increased cervical and cranial pressures with gagging/vomiting
  • Epistaxis
  • Invagination of stomach lumen into eyes of ngt

See Also

References

  1. ↑ Phillips DE, Sherman IW, Asgarali S, and Williams RS. How far to pass a nasogastric tube? Particular reference to the distance from the anterior nares to the upper oesophagus. J R Coll Surg Edinb. 1994; 39(5):295-296.
  2. ↑ Neumann MJ, Meyer CT, Dutton JL, et al. Hold that x-ray: aspirate pH and auscultation prove enteral tube placement. J Clin Gastroenterol. 1995; 20(4):293-295.
  3. ↑ Christensen M. Bedside methods of determining nasogastric tube placement: a literature review. Nurs Crit Care. 2001; 6(4):192-199.
  4. ↑ Boeykens K, Steeman E, Duysburgh I. Reliability of pH measurement and the auscultatory method to confirm the position of a nasogastric tube. Int J Nurs Stud. 2014; 51(11):1427-1433.
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