NASOGASTRIC INTUBATION

NASOGASTRIC INTUBATION NASOGASTRIC INTUBATION Overview • • • • • • Indications Contraindications Preparation Technique Tube insertion Confirmation of tube placement • Securing the tube • Initiating Suction • Complications NASOGASTRIC INTUBATION Overview NASOGASTRIC INTUBATION Indications • Decompression of the GI tract • Administration of Oral Agents • Gastrointestinal Hemorrhage NASOGASTRIC INTUBATION Decompression of the GI tract • • NG and suction are required to remove enteric secretions and swallowed air in obstructions of the small bowel or gastric outlet NG may also provide symptomatic relief for patients with severe pancreatitis and associated ileus; however, routine placement of nasogastric tubes mild or moderate symptoms is not indicated – Prolonged nausea and vomiting and extended hospitalization NG (or OG) and suction may be beneficial in mechanical ventilation an endotracheal tube to prevent aspiration of gastric contents • NASOGASTRIC INTUBATION Decompression of the GI tract • Small bowel obstruction • Multiple air-fluid levels • Multiple loops of dilated small bowel • Small bowel gas NASOGASTRIC INTUBATION Administration of Oral Agents • Oral agents (e.g., activated charcoal or radiographic contrast material or tube feedings) may be administered through a NG tube in patients unable to tolerate fluids delivered orally NASOGASTRIC INTUBATION Gastrointestinal Hemorrhage • Nasogastric intubation and suctioning may be performed in patients with severe upper gastrointestinal bleeding in order to provide symptomatic relief and to facilitate endoscopic visualization of the gastric and duodenal mucosa • In the absence of frank bloody return, examination of nasogastric aspirates has a suboptimal sensitivity and specificity and cannot be relied on to confirm or rule out active hemorrhage in patients with a history of hematemesis or melena NASOGASTRIC INTUBATION Contraindications • Maxillofacial Trauma • Esophageal abnormalities • Altered Mental Status and impaired defenses NASOGASTRIC INTUBATION Contraindications Maxillofacial Trauma • Nasogastric intubation should be avoided in patients with substantial maxillofacial trauma • To avoid passage of the tube into the cranial vault through a potentially disrupted cribriform plate NASOGASTRIC INTUBATION Preparation • Explain the procedure • Informed consent • Choose the appropriate side of the nose • Assess the patency and symmetry of nares by asking the patient to inhale alternately through each nostril, noting which side provides superior flow NASOGASTRIC INTUBATION Preparation • Pretreatment of the nasal passageways with oxymetazoline or phenylephrine will constrict the vessels of the nasal mucosa, allow easier insertion of the tube, and reduce the risk of epistaxis NASOGASTRIC INTUBATION Mucosal Constrictors • Nasal cavity before and after treatment with oxymetazoline (Afrin) • A = inferior turbinate; B = nasal septum; C = nasal passageway NASOGASTRIC INTUBATION Preparation • The nasal mucosa can be anesthetized topically with use of 4 percent lidocaine delivered with an atomizer or with viscous lidocaine injected directly into the nasal canal • Topical anesthesia should also be applied to the posterior oropharynx with atomized 4% lidocaine or Benzocaine spray • Alternatively, 4 % lidocaine delivered with a nebulizer provides excellent anesthesia of both the nasal and the oral mucosa. NASOGASTRIC INTUBATION Preparation • Estimate the proper depth that the tube should be inserted • Measuring the distance from the xiphoid process to the angle of the mandible and then to the nostril • Note the corresponding distance mark on the tube NASOGASTRIC INTUBATION Gather Equipment • • • • • • • • • • • • • • Gloves Protective gown Face shield NG tube Lubricant (viscous lidocaine or surgical jelly) Vasoconstrictor spray (e.g., oxymetazoline) Topical anesthetic Atomized 4 percent lidocaine Glass of water and a straw Emesis basin Absorbent towels or pads Catheter-tip (Toomey) syringe Stethoscope Adhesive tape Suction unit NASOGASTRIC INTUBATION Gather Equipment • Salem sump: – Dual flow type tube is used to prevent the accumulation of gastric secretions and air – Double lumen tube throughout the length provides airvent when the stomach has been evacuated of accumulated liquid, air or small particulate matter – Distal end is coned with ten lateral eyes – Radio opaque tube is marked at 45, 55, 65 and 75 cm from the tip for accurate placement – Proximal end is provided with Universal Funnel Connector along with Double Taper connector for easy extension NASOGASTRIC INTUBATION Gather Equipment • Levin tube: – Levin’s tube is used for gastro intestinal drainage – Distal end is coned with four lateral eyes for efficient drainage – The tube is marked at 45, 55, 65 and 75cm from the distal end for accurate placement into the abdomen – Radio opaque line provided throughout the tube for checking the position of the catheter radiologically – Proximal end is provided with universal funnel connector for easy extension NASOGASTRIC INTUBATION Preparation • Position the patient so that he or she is sitting upright in the “sniffing” position (neck flexed and head extended) NASOGASTRIC INTUBATION Tube Insertion • • • Lubricate the distal end of NG tube and insert it into the nasal cavity, slowly passing it posteriorly along the floor of the nasal canal Continue to advance slowly into the posterior oropharynx Patient may gag or you may feel resistance as the tube nears the laryngeal apparatus If so, temporarily halt advancement, instruct the patient to sip water through the straw Coordinate further advancement with instructions to swallow As patient swallows, the epiglottis will cover the trachea and prevent inadvertent placement of the tube in the trachea Once past the larynx, guide the tube rapidly to the predetermined depth • • • • NASOGASTRIC INTUBATION Tube Insertion NASOGASTRIC INTUBATION Confirmation of Tube Placement • If the patient is unable to talk or in respiratory distress or if respirations can be heard through the nasogastric tube, tracheal intubation has probably occurred, and the tube should be immediately removed Proper placement is suggested (though not unequivocally confirmed) by auscultating borborygmus over epigastrium as air is injected with Toomey syringe If any question with regard to proper placement, or if agents such as activated charcoal are to be instilled though the tube, a chest radiograph should be obtained to confirm placement Visualization of the descent of the tube below the diaphragm provides such confirmation • • • NASOGASTRIC INTUBATION Confirmation of Tube Placement NASOGASTRIC INTUBATION Confirmation of Tube Placement NASOGASTRIC INTUBATION Securing the Tube • To secure the tube, cut a 7-cm length of 1-in.–wide adhesive tape and tear it halfway down its vertical length • Apply the wide end to the patient’s nose, and wrap the two “tails” around the tube NASOGASTRIC INTUBATION Securing the Tube NASOGASTRIC INTUBATION Initiating Suction • At this point, the tube can be connected to the suctioning equipment • Intermittent, low suction should be used for the majority of patients NASOGASTRIC INTUBATION Complications • Minor complications of NG intubation include: – Sinusitis – Epistaxis – Sore throat • More serious complications include: – – – – Esophageal perforation Aspiration Pneumothorax Intracranial placement (rarely) NASOGASTRIC INTUBATION Complications NASOGASTRIC INTUBATION LET’S GO TO THE VIDEO TAPE Now….to the laboratory…