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