Nasogastric tube placement: Difference between revisions

 
 
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==Contents==
==Indications==
[[File:Gray1032.png|thumb|Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.]]
[[File:Layers of the GI Tract english.svg|thumb|Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.]]
[[File:Illu esophagus.jpg|thumb|Esophagus anatomy and nomenclature based on two systems.]]
*Gastric decompression
**Post-[[intubation]]
**[[Bowel obstruction]]/[[ileus]]
**[[acute gastric dilation|Acute gastric distension]]
*Aspiration of gastric contents
**Diagnosis/therapy of [[GI bleed]])
**Gastric lavage in [[Toxicology|acute poisonings]] (largely abandoned due to lack of efficacy)


*[[Indications]]
==Contraindications==
*[[Relative Indications]]
*Severe [[facial trauma]] (due to possible cribriform plate disruption)
*[[Relative Contraindications]]
 
*[[Equipment needed]]
===Relative Contraindications===
*Severe [[coagulopathy]]
*[[gastric bypass surgery|Gastric bypass]] and [[lap band complications|lap band procedures]]
*[[Esophageal varices]]/strictures
*History of [[caustic ingestion|alkali ingestion]]
 
==Equipment Needed==
*PPE
*NG Tube- typically a 16F or 18F Sump
*Syringe/Bulb - 50-60cc
*Tape
*Emesis basin
*Cup of water with straw
 
==Procedure==
[[File:ETTubeandNGtubeMarked.png|thumb|Nasogastric tube below the diaphragm and in the stomach in correct position as seen on [[CXR]] (bottom arrow).]]
#Consent by informing patient of risk, benefits, and alternatives
#Position patient upright
#Place towel over patient's gown and emesis basin in lap
#Estimate length of insertion
#*A standard of 56cm is reasonable<ref>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.</ref>)
#*Alternatively measure from tip of nose to earlobe to xyphoid and then add 15cm
#Check nares for obstruction and pass through the most widely patent nare
#Provide relief from discomfort
#*Topical vasoconstrictors to both nares
#**[[Oxymetazoline]] or [[phenylephrine]]
#*Topical Anesthetics (5 min prior to procedure)
#**[[Benzocaine]], [[tetracaine]], nebulized [[lidocaine]] (4 or 10%), lidocaine jelly
#**Anesthetize oropharynx, as well, to prevent gagging
#*Antiemetics
#**[[Ondansetron]] or [[metoclopramide]] 15 min prior may reduce gagging and nausea
#Insert tube along floor of nose under inferior turbinate
#Pause when NGT is in OP
#Flex neck to decrease chance of tracheal passage
#Advance into esophagus
#*Sipping water may aid in esophageal passage
#*Withdraw to OP promptly if excessive coughing, gagging, choking or voice change
#Once NGT is in esophagus, rapidly insert rest of tube to pre-measured length
#Confirm placement
#*Insufflate air while listening over stomach
#**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>
#*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<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>
#Secure to patients nose with tape
#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==
*[[Upper gastrointestinal bleeding]]
*[[Small bowel obstruction]]
*[[EBQ:Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis]]
 
==External Links==
*[https://litfl.com/nasogastric-and-orogastric-tubes/ LITFL: Nasogastric and Orogastric Tubes]
*[https://www.merckmanuals.com/professional/gastrointestinal-disorders/how-to-do-gastrointestinal-procedures/how-to-insert-a-nasogastric-tube?query=nasogastric%20tube Merk Manual - How To Insert a Nasogastric Tube]
 
===Videos===
*Insertion
**Tulane (2:55) https://www.youtube.com/watch?v=1OakmxZDa5c
*Unclogging NG Tube:
**Providence Health (3:53) https://www.youtube.com/results?search_query=unclogging+g+tube+emergency+medicine
 
==References==
<references/>
 
[[Category:Procedures]]
[[Category:GI]]

Latest revision as of 22:33, 7 February 2024

Indications

Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.
Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.
Esophagus anatomy and nomenclature based on two systems.

Contraindications

  • Severe facial trauma (due to possible cribriform plate disruption)

Relative Contraindications

Equipment Needed

  • PPE
  • NG Tube- typically a 16F or 18F Sump
  • Syringe/Bulb - 50-60cc
  • Tape
  • Emesis basin
  • Cup of water with straw

Procedure

Nasogastric tube below the diaphragm and in the stomach in correct position as seen on CXR (bottom arrow).
  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
  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 esophageal 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 pre-measured 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

External Links

Videos

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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