Gastric Tube Placement Nasogastric Orogastric. Introduction What is a gastric tube Anatomy review ...
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Transcript of Gastric Tube Placement Nasogastric Orogastric. Introduction What is a gastric tube Anatomy review ...
Gastric Tube PlacementGastric Tube Placement
Nasogastric
Orogastric
IntroductionIntroduction
What is a gastric tubeWhat is a gastric tube
Anatomy reviewAnatomy review
IndicationsIndications
ContraindicationsContraindications
Flight environmentFlight environment
ProcedureProcedure
ComplicationsComplications
DocumentationDocumentation
Gastric tubesGastric tubes
A gastric tube is defined as a tube that is passed into the A gastric tube is defined as a tube that is passed into the stomach (Mosby’s:2006)stomach (Mosby’s:2006)
NasoNasogastric: Insertion via the nosegastric: Insertion via the nose
OroOrogastric: Inserted via the mouthgastric: Inserted via the mouth
Decompression of the stomachDecompression of the stomach
Reduces the risk of aspiration of gastric contentReduces the risk of aspiration of gastric content
Maximises thoracic expansionMaximises thoracic expansion
AnatomyAnatomy
Indication: SJA WAIndication: SJA WA
Intubated adult patients receiving intermittentIntubated adult patients receiving intermittent
positive pressure ventilation in order to facilitatepositive pressure ventilation in order to facilitate
gastric decompression gastric decompression
Indications: GeneralIndications: General
Drug administrationDrug administration
FeedingFeeding
Aspiration of ingested substancesAspiration of ingested substances
Aspiration of gastric content for analysisAspiration of gastric content for analysis
Upper gastrointestinal bleedingUpper gastrointestinal bleeding
ContraindicationsContraindicationsNasogastricNasogastric
Radiologically confirmed base of Radiologically confirmed base of skull fracture (BOS#)skull fracture (BOS#)
Clinical examination indicative of Clinical examination indicative of BOS#BOS#
Bilateral periorbital ecchymosis Bilateral periorbital ecchymosis (racoon eyes)(racoon eyes)
Mastoid ecchymosis (Battles Mastoid ecchymosis (Battles sign)sign)
Cerebral spinal fluid leak from Cerebral spinal fluid leak from nose/ earsnose/ ears
Racoon eyesRacoon eyes
Battles signBattles sign
ContraindicationsContraindicationsNasogastricNasogastric
Nasal septal deviation or trauma Nasal septal deviation or trauma (i.e. middle third facial #)(i.e. middle third facial #)
Coagulopathy or systemicCoagulopathy or systemic
anticoagulantsanticoagulants
Orogastric (combined)Orogastric (combined)
Known tracheoesophageal fistulaKnown tracheoesophageal fistula
Known oesophageal pathologyKnown oesophageal pathology
Caustic or Alkaline ingestionCaustic or Alkaline ingestion
Nasal trauma
Septal deviation
Coagulopathy
Complications: Iatrogenic injuryComplications: Iatrogenic injuryTrauma to nasal, oropharynx andTrauma to nasal, oropharynx andgastrointestinal tract gastrointestinal tract
Bleeding (Epistaxis)Bleeding (Epistaxis)
Perforation of endotracheal tube cuff and loss of IPPV supportPerforation of endotracheal tube cuff and loss of IPPV support
Bronchial placement leading to atelectasis, pneumonia and lung Bronchial placement leading to atelectasis, pneumonia and lung abscess abscess
Bronchial perforation and pleural cavity penetration Bronchial perforation and pleural cavity penetration Pneumothorax Pneumothorax Empyema and Sepsis Empyema and Sepsis Pulmonary haemorrhage Pulmonary haemorrhage
Intracranial penetrationIntracranial penetration
Flight physiology and gastric Flight physiology and gastric distentiondistention
Gas lawsGas laws
Boyles LawBoyles Law: The volume of a gas is inversely : The volume of a gas is inversely proportional to its pressure when the proportional to its pressure when the temperature remains constanttemperature remains constant
P1 X V1 = P2 X V 2 P1 X V1 = P2 X V 2
P1= initial pressure, P2 = final pressure, V1= initial volume and V2= P1= initial pressure, P2 = final pressure, V1= initial volume and V2= final volumefinal volume
Practical applicationPractical application(P1) Atmospheric pressure at (P1) Atmospheric pressure at
sea level is sea level is 760 mm/hg760 mm/hg ( V1) Gastric content is say ( V1) Gastric content is say 100 100
mlml Ascending to 2,438 meters Ascending to 2,438 meters
(8000feet) Atmospheric (8000feet) Atmospheric pressure drops to (P2) pressure drops to (P2) 565565 mm/hgmm/hg
To calculate the new volume of To calculate the new volume of gastric contentgastric content
V1 x P1 (760 x 100)= 76000V1 x P1 (760 x 100)= 76000 P2P2 565565 565 565
New gastric volume New gastric volume 135.5 ml135.5 ml30% increase30% increase
Non pressurized aircraft
Results: Increased risk of aspiration Splinting of the diaphragm Pain
EquipmentEquipmentSalem Sump nasogastric tube Salem Sump nasogastric tube
(14-18 French)(14-18 French)
Tumi 60cc catheter tip syringeTumi 60cc catheter tip syringe
Water based lubricantWater based lubricant
Drainage bag (suction setup if Drainage bag (suction setup if initially on low intermittent initially on low intermittent suction)suction)
TapeTape
PH paperPH paper
Laryngoscope blade and handleLaryngoscope blade and handle
McGills forcepsMcGills forceps
Cophenylcaine sprayCophenylcaine spray
OptionalOptional Tongue Tongue depressordepressor
PenlightPenlight
StethoscopeStethoscope
Features of enteral tubesFeatures of enteral tubes
Regardless of the route of introduction (NGT/OGT) It Regardless of the route of introduction (NGT/OGT) It is recommended that enteral tubesis recommended that enteral tubes
Are radiopaqueAre radiopaque
Have multiple ports (air port) to aid aspirationHave multiple ports (air port) to aid aspiration
Have clear centimetre line markersHave clear centimetre line markers
Are made of suitable / choice of materialsAre made of suitable / choice of materials
Have caps attached to close ports when not in useHave caps attached to close ports when not in use
Are available in a number of lengthsAre available in a number of lengths
Are available in a number of sizesAre available in a number of sizes
Salem Sump gastric tube: Suction, decompression Salem Sump gastric tube: Suction, decompression and irrigationand irrigation
Anti Reflux valve:Prevents gastric fluid from exiting the tube via the vent lumenPressure activated air buffer activates the one way valve when reflux pushes air up the vent lumenAir passes through this one way valve resulting in a “whistle” when placed on suction.
Double lumen PVC tube one for suctionthe other for sump ventRadio opaqueSump vent equalizes vacuum pressure once gastric content has been emptied. This prevents adhesion to and damage of the gastric mucosa
6-18 French
*Can remain in situ 1-3 days
Distal end
Procedure: Nasogastric (NGT)Procedure: Nasogastric (NGT)
BSI and PPE donnedBSI and PPE donned
Patient meets criteriaPatient meets criteria
Consent is obtainedConsent is obtained
Contraindications are excludedContraindications are excluded
Patient is informed of procedurePatient is informed of procedure
Patient is adequately sedated: Patient is adequately sedated: analgesia, anxyolitic, paralytics :analgesia, anxyolitic, paralytics :
Nasal cavity is prepared with Nasal cavity is prepared with Cophenylcaine/ lignocaine gelCophenylcaine/ lignocaine gel
Vasoconstrictive spraysVasoconstrictive sprays
Procedure: Nasogastric (NGT)Procedure: Nasogastric (NGT)Equipment is preparedEquipment is prepared
Gastric tube size is chosen based on patients anatomy (12-16 FR) Gastric tube size is chosen based on patients anatomy (12-16 FR)
Tube is measured from the tip of the nose to the tragus of the ear down to Tube is measured from the tip of the nose to the tragus of the ear down to the epigastric/ xiphoid regionthe epigastric/ xiphoid region
Tube is marked at the proximal endTube is marked at the proximal end
Tube is lubricated with water based lubricantTube is lubricated with water based lubricant
Rt nare is chosen as preferred route of initial entry. Rt nare is chosen as preferred route of initial entry.
Tube is passed into the oesophagus and the stomach via the nasal route. If Tube is passed into the oesophagus and the stomach via the nasal route. If resistance is met the tube may be rotated clock wise. LT nare is utilized if resistance is met the tube may be rotated clock wise. LT nare is utilized if
Access via the RT nare failsAccess via the RT nare fails
Tip of nose
Tragus of the ear
Epigastric/ xiphoid
Sizing the nasogastric tube
Tube is lubricated to facilitate introduction
Procedure: Nasogastric (NGT)Procedure: Nasogastric (NGT)
Examine the oral cavity during insertion to detect coiling. Examine the oral cavity during insertion to detect coiling. A tongue depressor and a penlight may help with this A tongue depressor and a penlight may help with this procedureprocedure
*Paralysed and sedated patient will not elicit a gag or *Paralysed and sedated patient will not elicit a gag or cough with inadvertent placement in the lungcough with inadvertent placement in the lung..
For direct esophagoscope the laryngoscope blade is For direct esophagoscope the laryngoscope blade is inserted into the oropharynx, the NGT is grasped by the inserted into the oropharynx, the NGT is grasped by the McGills forceps and the tube is guided directly into the McGills forceps and the tube is guided directly into the oesophagus under direct visualizationoesophagus under direct visualization
Procedure: Orogastric (OGT)Procedure: Orogastric (OGT)
Advantages for orogastric tubesAdvantages for orogastric tubes Excludes risk of epistaxisExcludes risk of epistaxis Excludes the upper anatomyExcludes the upper anatomy Reduction in inadvertent tube collection in the OPReduction in inadvertent tube collection in the OP Large opening for introduction of tubeLarge opening for introduction of tube
DisadvantagesDisadvantagesMore difficult to secureMore difficult to secure
Procedure: Orogastric (OGT)Procedure: Orogastric (OGT)Initial steps remain the sameInitial steps remain the same
Tube is measured from the centre of the mouth to the tragus of the ear Tube is measured from the centre of the mouth to the tragus of the ear down to the epigastric / xiphoid process and markeddown to the epigastric / xiphoid process and marked
For For directdirect esophagoscope the laryngoscope blade is inserted into the esophagoscope the laryngoscope blade is inserted into the oropharynx, the OGT is grasped by the McGills forceps and the tube is oropharynx, the OGT is grasped by the McGills forceps and the tube is guided directly into the oesophagus under direct visualizationguided directly into the oesophagus under direct visualization
For For indirectindirect insertion insertion The tongue is held between the thumb and fore finger. The jaw The tongue is held between the thumb and fore finger. The jaw
is lifted anterior slightly maintaining spinal alignmentis lifted anterior slightly maintaining spinal alignment OGT is passed to the back of the OP into the oesophagus and OGT is passed to the back of the OP into the oesophagus and
threaded until the pre-marked point is reachedthreaded until the pre-marked point is reached
Confirming placementConfirming placement
The gold standard is radiological confirmation in the The gold standard is radiological confirmation in the context of secondary retrievals. It is suggested that, context of secondary retrievals. It is suggested that, where practical, the gastric tube is introduced prior to the where practical, the gastric tube is introduced prior to the CXR that confirms ETT placement. CXR that confirms ETT placement.
Aspiration of gastric content with subsequent PH test of Aspiration of gastric content with subsequent PH test of 5.5 or less. *Gastric PH is influenced by a number of 5.5 or less. *Gastric PH is influenced by a number of factors including drug administration (PPI,H2 factors including drug administration (PPI,H2 antagonists)antagonists)
When in doubt pull it out ( the tube that is)
Confirming placementConfirming placement
Testing methods not to be used:Testing methods not to be used:
**The ‘Whoosh’ Test:The ‘Whoosh’ Test:Auscultation of epigastric air entry as Auscultation of epigastric air entry as air is introduced into the tube via syringeair is introduced into the tube via syringe
Blue Litmus paper Blue Litmus paper
The ‘Bubble’ TestThe ‘Bubble’ Test
Observing the visual appearance of aspirateObserving the visual appearance of aspirate
February 2005 the NHS National Patient Safety AgencyFebruary 2005 the NHS National Patient Safety Agency
Radiological confirmationRadiological confirmation
This NGT is in a normal position in the This NGT is in a normal position in the stomach.stomach.
Erect or supine, AP or PA chest Erect or supine, AP or PA chest radiography is performedradiography is performed
The NGT is coiled up in the pharynx
Radiological confirmationRadiological confirmation
*Basic radiological interpretation of CXR will be covered in another module
The tip of the NGT is in the right lower lobe
The tip of the NGT is in the left lower lobe
Radiological confirmationRadiological confirmation
Securing tubeSecuring tube
Use 2 pieces of hypoallergenic Use 2 pieces of hypoallergenic tape approximately 10cm longtape approximately 10cm long
Tape is split into to pieces from Tape is split into to pieces from one end to the centerone end to the center
Nose is prepared with skin prep or Nose is prepared with skin prep or alcohol wipe as neededalcohol wipe as needed
Tape is applied vertically to the Tape is applied vertically to the nose. Split ends are nose. Split ends are crisscrossed around tubecrisscrossed around tube
Second piece of tape is cut to size Second piece of tape is cut to size and placed horizontally over the and placed horizontally over the first *This procedure will be first *This procedure will be discussed in the practical skills discussed in the practical skills stationstation
Commercial devices may also be usedCommercial devices may also be used
Post insertion carePost insertion care
Once gastric tubes position has been confirmed it is Once gastric tubes position has been confirmed it is aspirated to remove air and gastric content. aspirated to remove air and gastric content.
The tube is then secured via tape to either the nose or The tube is then secured via tape to either the nose or the side of the face the side of the face
The tube is placed into a drainage bag which is secured The tube is placed into a drainage bag which is secured to the patient (often by safety pins)to the patient (often by safety pins)
Visual checksVisual checksWell securedWell securedSigns of migration (curling)Signs of migration (curling)External markingsExternal markingsLength from nare to tipsLength from nare to tips
DocumentationDocumentation
Time and date of procedureTime and date of procedure
Size of tube and route of introductionSize of tube and route of introduction
Method by which tube was confirmed in situMethod by which tube was confirmed in situ
Volume and description of drainageVolume and description of drainage
Associated complications as neededAssociated complications as needed