Nasogastric Tube.pptx

NGTube

1. Ryle’s (Nasogastric Tube) Aspiration - DR IBRAHIM SHARIFF C

2. Nasogastric tube A  nasogastric (NG) tube is a flexible plastic/silicone tube inserted through the nostrils, down the nasopharynx- oesophagus , and into the stomach or the upper portion of the small intestine

3. Pioneers/history Ancient Greek & Egyptian civilization Fabricius - Nasopharyngeal feeding patients with tetanus Hunter - O rogastric feedings 1867- Kussmaul - flexible orogastric tube for gastric decompression 1921 , the Levin tube was introduced, stiff single-lumen tube that could be used for either decompression or feeding . Dr John Alfred Ryle is credited with the discovery of Nasogastric intubation

4. Types Fine bore tubes  (8-12 French) L ess discomfort Easier insertion enteral feeding > decompression usually contain a guidewire to aid insertion Wider bore tubes  ( 14-20 French) U sed for aspiration

5. Color coding

6. Uses of NG tube Enteric feeding Drug administration Small and large bowel obstruction Gastric outlet obstruction Acute gastric dilation Paralytic ileus To prevent aspiration from gastro- oesophageal reflux distal to an oesophageal anastomosis (placed under direct vision intra-operatively) Postoperative gastrointestinal surgery (placed intra-operatively). These can also be naso-jejunal tubes, where the end lies more distally in the jejunum.

7. Feeding (NICE) used in people who are malnourished or at risk of malnutrition and have: Inadequate or unsafe oral intake, and A functional , accessible gastrointestinal tract . Neurological conditions causing dysphagia/unsafe swallow such as stroke. Lowered consciousness level Following upper gastrointestinal surgery where a high anastomosis must be protected in the initial post-operative period Occasionally , NG feeding is used to prepare malnourished patients for major abdominal surgery in the pre-operative period Specialist assessment by Speech and Language therapists and dieticians, to ascertain necessity and safety, monitor progress once started (when it can be stopped and how to proceed) In general, enteral tube feeding is only advised for up to 4 weeks. After this time, the aim would be for the patient to begin feeding orally, or to change to more long-term measures such as percutaneous endoscopic gastrostomy (PEG). If the patient’s nutritional needs are not being met or it transpires that the gastrointestinal tract is not functioning normally, Total Parenteral Nutrition (TPN) is considered

8. aspiration Nasogastric aspiration  is the process of draining the stomach's contents via the tube. Mainly used to remove gastrointestinal secretions and swallowed air in patients with gastrointestinal obstructions. Also used in poisoning situations, for preparation before surgery under  anaesthesia , and to extract samples of gastric liquid for analysis. If used for continuous drainage, it is usually appended to a collector bag placed below the level of the patient's stomach; gravity empties the stomach's contents. It can also be appended to a suction system, however this method is often restricted to emergency situations, as the constant suction can easily damage the stomach's lining. In non-emergency situations, intermittent suction is often applied giving the benefits of suction without the untoward effects of damage to the stomach lining. Suction drainage is also used for patients who have undergone a pneumonectomy in order to prevent anesthesia-related vomiting and possible aspiration of any stomach contents. Such aspiration would represent a serious risk of complications to patients recovering from this surgery.

9. contraindications Basal skull fracture: Intracranial placement risk. Orogastric placement is the route of choice unless you have excluded a cranial fracture Facial trauma Upper GI tract perforation Previous trans-ethmoidal/trans-sphenoidal neurosurgery Oesophageal anastomosis and gastric surgery in postoperative patients (unless a specialist performs insertion with direct endoscopic insertion) Patient refusal

10. Relative contraindications (Depending on experience and specialty ): Coagulopathy Oesophageal varices Oesophageal stricture Recent alkaline ingestion (due to risk of oesophageal rupture)

11. Procedure Preparation Consent Technique Check Placement

12. Passage The nasogastric tube passes backwards along the base of the nasal passages through the nasopharynx. It then slides over the superior surface of the soft palate and uvula and into the oropharynx. The swallowing reflex assists passage of the tube as it passes over the epiglottis and via the piriform fossa into the upper part of the oesophagus . Further coordinated swallowing movements assist passage into the stomach.

13. Preparation Prepare the necessary equipment on a small trolley placed next to the patient Take universal precautions and perform thorough hand washing before attempting the procedure

14. Equipment Plastic apron and gloves Radio-opaque NGT with externally visible length markings CE marked for human gastric aspirate pH indicator strips/paper with a range of 0 to 6 and 0.5 gradations Oral analgesic spray Syringe, 10 mL Toomey syringe, 60 mL Tape Emesis basin or plastic bag Wall suction, set to low intermittent suction Water based lubricating jelly Freshly drawn water to flush Receiver/kidney bowl Glass of water and a straw (only if the patient has a safe swallow reflex NG Tube Insertion and Management form

15. Steps Refer to medical notes to ensure a clear purpose for the NGT has been documented . Prior to insertion of the NGT refer to notes to check for any potential complications/contraindications Prior to insertion, check the NG tube is patent with a 50 ml sterile bladder syringe filled with air . Explain the procedure and associated risks to the patient. Where the patient demonstrates lack of capacity - a best interest decision must be documented in the medical notes and a mental capacity assessment completed . Arrange a signal so that the patient can communicate with the nurse during the procedure e.g. raise a hand.

16. Wash hands and put on non-sterile gloves and an apron. Assist the patient in a semi-upright position. Support the head in a slightly forward position. Check that the nostrils are patent by completing The Sniff Test, asking the patient to cover on nostril and sniff through the alternative nostril. Repeat with the other side. Ask the patient to clean nose by blowing prior to placement/if patient unable to do this - please assist as required. Alternate nostrils if replacing a tube. Check packing prior to opening. Noting the description of the device, size expiry date, Lot Number. Unpack the tube, observe full length of NGT observing for any damage and that the NGT is not kinked. Gently manipulate the guidewire to ensure it can move freely ensure the guidewire is secured back into place before insertion.

17. Estimate length of tube using NEX measurement Nose , Earlobe & Xiphisternum Lubricate the tube Insert the tip of the tube into the chosen nostril, advancing it horizontally and gently along the floor of the nostril; parallel to the nasal septum, to the nasopharynx and then oropharynx. At this point ask the patient to swallow fluid if it is safe and they have capacity to follow instruction. In the absence of a safe swallow ask to them to try a dry swallow. A chin tuck may also assist. Continue advancement to NEX measurement. If resistance is felt, stop the procedure pull back slightly before attempting to re-insert (check the patients mouth in case the tube has coiled). If the patient sneezes or coughs pull back slightly on the NGT wait until the patient is settled. If the patient becomes distressed it is advised to stop NGT insertion and seek specialist advice.

18. If difficulty is found in obtaining a gastric aspirate follow manufactures advice. To gain an aspirate (check for a aspirate after each technique is attempted): Check mouth for coiling of NGT Position patient on their side Re-flush the tube with air to dislodge debris from insertion If patient has a safe swallow offer a drink then wait 15-20 minutes and re-check aspirate; Advance or withdraw NGT by 10-20 cm Fix the NGT Document in the NG Tube Insertion & Management form

19. PLACEMENT Confirmation First line testing: pH testing of NGT aspirate Second line testing: Chest Radiography Electromagnetic sensor-guided nasogastric tube placement Test the aspirate, using pH strips that are CE marked for human gastric aspirate. The pH reading must be 5.5 or below to confirm the position of NGT.

20. A maximum of 3 attempts should be made at one time to insert the NGT - PLEASE SEEK SENIOR/SPECIALIST ADVICE. Flush NGT with 10ml of air to clear the tip of any debris Confirm the position of the NGT by

21. How to check NG tube position : x-RAY

22. Methods not recommended anymore : Auscultation of air insufflated through the tube (‘whoosh test ’) (Bedside - Commonly used) Testing aspirate with Blue Litmus paper Presence / absence of respiratory distress Monitoring bubbling at the end of the tube Observing the appearance of the aspirate

23. Re-assess Position At least once daily during continuous (pump) feeds; before starting the next feed Before all administration of medication or flushes Before administering each bolus feed Following episodes of vomiting/retching/coughing or suction If the patient complains of a change in level of discomfort If the patient develops difficulty in breathing during administration of feeds, medicines or flushes I n the presence of any new or unexplained respiratory symptoms or reduction in oxygen saturation Following any evidence or suggestion of tube displacement (e.g. loose tape or portion of visible tube appears longer).

24. NGT BLOCK Possible causes – InterventionS * Not flushing or inadequate flushing after feed and medication. - Flush with 50ml water before and after feed or medication. Unsuitable medicine preparations for giving via an NGT, e.g. large particles, viscous liquids. -Review medication and consider alternative medication. All medication given via NG tube should be in either liquid or dissolvable form if possible. -----Liaise with pharmacist. Multiple medications being given together without a flush in between each drug. -All medications should be given separately, flushing about 10ml of water in between each medication. Kinked NGT -NGT may be kinked in the stomach, pull back slightly (1-2cm) and confirm NGT position.

25. complications Minor complications Nose bleeds Sinusitis Sore throat More significant complications (rare) Erosion of the nose Esophageal perforation Damage to a surgical anastomosis Pulmonary aspiration, a collapsed lung, or intracranial placement of the tube

26. Post-procedure Documentation Indication for the NG tube Patient consent Type of tube inserted External length marking at the nostril Batch number of NG tube Date and time of insertion Nature, amount, and pH of any aspirate Any complications or difficulties How you confirmed the position of the tube.

27. NGT removal Collect supplies Verify patient using two identifiers. Explain procedure to patient and place patient in high Fowler’s position Perform hand hygiene Depending on the purpose of the tube either: stop from feeding tube tubing/disconnect from suction tubing

28. Flush tube with air and then kink tube Unclip NG tube from patient’s gown Remove securement device from nose Hold the NG tube near the naris and gently pull out tube in a swift, steady motion. Dispose of tube in garbage bag Offer tissue or clean the nares for the patient, and offer mouth care as required. Remove gloves and place patient in a comfortable position. Assess patient’s level of comfort. Perform hand hygiene.