Nasogastric Tube Insertion

Indications
By inserting a nasogastric tube, you are gaining access to the stomach and its contents. This enables you to drain gastric contents, decompress the stomach, obtain a specimen of the gastric contents, or introduce a passage into the GI tract. This will allow you to treat gastric immobility, and bowel obstruction. It will also allow for drainage and/or lavage in drug overdosage or poisoning. In trauma settings, NG tubes can be used to aid in the prevention of vomiting and aspiration, as well as for assessment of GI bleeding. NG tubes can also be used for enteral feeding initially.

Contraindications
Nasogastric tubes are contraindicated in the presence of severe facial trauma (cribriform plate disruption), due to the possibility of inserting the tube intracranially. In this instance, an orogastric tube may be inserted.

Complications
The main complications of NG tube insertion include aspiration and tissue trauma. Placement of the catheter can induce gagging or vomiting, therefore suction should always be ready to use in the case of this happening.

Universal precautions:
The potential for contact with a patient's blood/body fluids while starting an NG is present and increases with the inexperience of the operator. Gloves must be worn while starting an NG; and if the risk of vomiting is high, the operator should consider face and eye protection as well as a gown. Trauma protocol calls for all team members to wear gloves, face and eye protection and gowns.

Equipment:
All necessary equipment should be prepared, assembled and available at the bedside prior to starting the NG tube. Basic equipment includes:
Personal protective equipmentNG/OG tubeCatheter tip irrigation 60ml syringeWater-soluble lubricant, preferably 2% Xylocaine jellyAdhesive tapeLow powered suction device OR Drainage bagStethoscope Cup of water (if necessary)/ ice chipsEmesis basinpH indicator strips

Procedures:

1. Gather equipment



2. Don non-sterile gloves



3. Explain the procedure to the patient and show equipment



4. If possible, sit patient upright for optimal neck/stomach alignment



5. Examine nostrils for deformity/obstructions to determine best side for insertion



6. Measure tubing from bridge of nose to earlobe, then to the point halfway between the end of the sternum and the navel



7. Mark measured length with a marker or note the distance



8. Lubricate 2-4 inches of tube with lubricant (preferably 2% Xylocaine). This procedure is very uncomfortable for many patients, so a squirt of Xylocaine jelly in the nostril, and a spray of Xylocaine to the back of the throat will help alleviate the discomfort.



9. Pass tube via either nare posteriorly, past the pharynx into the esophagus and then the stomach.Instruct the patient to swallow (you may offer ice chips/water) and advance the tube as the patient swallows. Swallowing of small sips of water may enhance passage of tube into esophagus.If resistance is met, rotate tube slowly with downward advancement toward closes ear. Do not force.



10. Withdraw tube immediately if changes occur in patient's respiratory status, if tube coils in mouth, if the patient begins to cough or turns pretty colours



11. Advance tube until mark is reached



12. Check for placement by attaching syringe to free end of the tube, aspirate sample of gastric contents. Do not inject an air bolus, as the best practice is to test the pH of the aspirated contents to ensure that the contents are acidic. The pH should be below 6. Obtain an x-ray to verify placement before instilling any feedings/medications or if you have concerns about the placement of the tube.



13. Secure tube with tape or commercially prepared tube holder



14. If for suction, remove syringe from free end of tube; connect to suction; set machine on type of suction and pressure as prescribed.



15. Document the reason for the tube insertion, type & size of tube, the nature and amount of aspirate, the type of suction and pressure setting if for suction, the nature and amount of drainage, and the effectiveness of the intervention.

- Partially pre-freezing the tube can ease its passage. - Infants can suck on a pacifier during the procedure. - Don’t rely on a cuffed endotracheal tube to prevent passage into the trachea – be sure and confirm placement using the above methods.