Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
CHAPTER 203 NASOGASTRIC AND NASOENTERIC TUBE INSERTION Yong Sik Kim Nasogastric intubation (nasogastric tube insertion) is a common procedure performed in the hospital, emergency department, and office settings. The nasogastric tube was initially developed for gastric feeding in 1760. The indications were expanded to gastric lavage in the case of poisoning in the early 1800s. One current design, by Dr. Levin, became available in 1921 and soon became popular for preventing intraoperative and postoperative gastric distention. In the 1960s, improved technology allowed the manufacture of a double-lumen tube, which later developed into special soft tubes made of polyurethane and silicone. These tubes are also very thin and have a noncomplicated, smooth surface, useful characteristics for prolonged nasoenteric feeding. A nasogastric tube can be used for either diagnostic or therapeutic purposes. The Levin nasogastric tube is a firm, straight, single-lumen tube with multiple distal side ports, and is used predominantly for diagnostic aspiration or to instill materials into the stomach. Unfortunately, even when low–flow-rate suction is applied to a Levin tube, or if it is applied for a very long time, the lumen frequently becomes occluded with gastric mucosa, and this can damage the gastric mucosa. In contrast, the Salem nasogastric sump tube is a double-lumen tube. The second lumen, or vent lumen, is smaller than the main suction lumen and runs alongside the larger lumen, providing a low level of continuous airflow to the stomach. This airflow prevents the main lumen from becoming occluded by gastric mucosa when suction is applied, thereby minimizing the risk of damage. The blue “pigtail” on the Salem sump is an extension of this vent lumen (Fig. 203-1). Similar to the Levin tube, the Salem sump has multiple distal side ports. Antireflux valves are available to prevent gastric contents from leaking out of the vent lumen and multiport adapters are available for the proximal end so that the same tube can be used for feeding, irrigating, suctioning, or medicating. Even though the Levin tube is still manufactured and available, hospitals predominantly stock the Salem sump tube because it can be used for most applications and is more effective and safer. Salem sump tubes are usually clear, yet radiopaque, and made of polypropylene or Silicone, whereas Levin tubes are available in various versions, including red rubber and clear polypropylene. Levin tubes can be either radiopaque or radiolucent. Although both can be used for short-term (up to 4 weeks) gastric or nasoenteric feeding, most facilities now have the longer and smallerdiameter polyurethane tubes specially designed for this purpose. These softer tubes (especially softer at body temperatures) usually have a tungsten-weighted tip or balloon near the tip to facilitate passage beyond the pylorus. They may also have a stiffening wire or stylet available for use during insertion; many have also been designed to resist collapse when checking the gastric residual (Fig. 203-2). Other styles of tubes include those equipped with a large esophageal balloon that can be used to tamponade a bleeding 1392 esophageal lesion (e.g., esophageal varices). Larger gastric tubes are also available for gastric lavage (see Chapter 202, Gastrointestinal Decontamination). ANATOMY The nasal cavity is lined by highly vascularized and innervated mucosa and continues posteriorly as the nasopharynx. Within the nasal cavity are the superior, inferior, and middle nasal conchae (turbinates), which divide the cavity into four passages (Fig. 203-3), the meatuses. Traditionally, the nasogastric tube is inserted blindly through middle and inferior meatuses. Beyond the nasal cavity, the pharynx extends from the base of the skull to the inferior border of the cricoid cartilage. It is divided into three parts: the nasopharynx, oropharynx, and laryngopharynx (hypopharynx). The nasopharynx gives rise to the oropharynx at the level of the soft palate, which then gives rise to the laryngopharynx (hypopharynx) at the superior border of the epiglottis (see Chapter 77, Nasolaryngoscopy, Fig. 77-6). The laryngopharynx becomes continuous with the esophagus at the inferior border of the cricoid cartilage. The posterior part of the upper nasopharynx is surrounded by the cribriform plate and the body of the ethmoid and sphenoid bones, which can easily be broken by a traumatic blow to the midface, resulting in a maxillofacial or basilar skull fracture. Such fractures can create a route into the cranial vault, which is a prerequisite for one of the most disastrous complications of inserting a nasogastric tube, intracranial intubation. This can result in brain damage or death. Therefore, placement of a nasogastric or nasoenteric tube in a patient with a possible skull or maxillofacial fracture should be avoided, if possible (an orogastric route may be a better option). Beyond the laryngopharynx and the larynx, the trachea lies anterior to the esophagus at the level of the cricoid bone and is supported by fibrocartilaginous tracheal rings. The superior aperture is covered by the epiglottis of the larynx during swallowing. The anatomy also confers the ability to estimate the length of tube that should be inserted. Because the median distance from the anterior aspect of the nasal septum to the cricopharyngeus muscle (tracheoesophageal junction) is about 8 inches, and the esophagus is on average about 10 inches long, and given that the tip of a nasogastric tube should lie 4 inches below the gastroesophageal junction when in place, the nasogastric tube should ideally be secured at the 20- to 24-inch mark at the nasal vestibule. Alternatively, the distance can be approximated by holding the tube up to the patient’s ear and across to the nose, and then extending it to 6 inches below the xiphoid process (8 to 10 inches for a nasoenteric tube; this is described later in the Technique section). The anatomy of children regarding the insertion of a nasogastric tube warrants a special note. Children have larger tonsils and adenoids, and their tongues are large compared to adults and may 203 —— NASOGASTRIC AND NASOENTERIC TUBE INSERTION 1393 push into the oropharynx, all of which can hamper the insertion of a tube. At the same time, these tissues are soft and easily injured, thereby increasing the risk of bleeding with nasogastric intubation. Limiting the size of the tube to the smaller sizes of the nostrils and nasal cavity in children usually minimizes the difficulty with insertion, despite these anatomic differences. INDICATIONS Therapeutic Figure 203-1 Sump suction (Salem) tube. (Argyle Salem Sump, courtesy of Tyco Healthcare, Gosport, United Kingdom.) • Drainage of gastric contents/gastric decompression. Examples: small bowel or gastric outlet obstruction, paralytic ileus, upper gastrointestinal bleeding, refractory vomiting, severe pan creatitis with obstruction, gastric lavage (for drug overdose), prevention of aspiration, or before diagnostic peritoneal lavage or pericardiocentesis. • Instillation of feedings or medications for patients unable to take by mouth. Examples: antacids, nutritional supplements, and activated charcoal for drug overdoses. Diagnostic • Sampling gastric contents. Examples: gastrointestinal bleeding and mycobacterial infection. • Instillation of diagnostic agents. Examples: radiopaque contrast media for delineation of a transdiaphragmatic hernia or an abdominal radiologic procedure with air to assess for an intraperitoneal perforation. • Radiologic procedure. Example: to visualize the stomach on chest radiography for assessment of a diaphragmatic hernia. CONTRAINDICATIONS All the following contraindications are relative. Figure 203-2 Feeding nasogastrostomy tube with weighted, radiopaque tip. (COMPAT Nasogastric Tube, courtesy of Nestlé Nutrition, Minnetonka, Minn.) Figure 203-3 Pharyngeal anatomy: sagittal section of the head and neck. (From Thibodeau C, Patton KT: Structure and Function of the Body, 11th ed. St. Louis, Mosby, 2000.) Frontal air sinus Nasal bone Superior concha Middle concha Opening of auditory (eustachian) tube Inferior concha Hard palate Soft palate Tongue Lingual tonsil Hyoid bone Thyroid cartilage (part of larynx) Vocal cords Trachea • Facial fractures, especially midface, or basilar skull fractures with possible cribriform plate injuries (may result in intracranial intubation; orogastric intubation may be a better option) • Esophageal obstruction, strictures, or a history of alkali ingestion (increases the possibility of esophageal perforation) Sphenoidal air sinus Pharyngeal tonsil (adenoids) Nasopharynx Uvula Palatine tonsil Oropharynx Epiglottis Laryngopharynx Esophagus 1394 HOSPITALIST • Esophageal varices (may lead to rupture and uncontrollable hemorrhage) • Comatose patients without protected airways (increases the risk of aspiration) • Penetrating neck wounds in the awake trauma victim (gagging might stimulate increased bleeding from the wound) • Choanal atresia • Recent oropharyngeal, nasal, or gastric surgery • Zenker’s diverticulum • Percutaneous endoscopic gastrostomy tube indicated (see Chapter 200, Percutaneous Endoscopic Gastrostomy Placement and Replacement). • Severe coagulopathy (orogastric intubation may be a better option) • Tube feeding in patients with advanced dementia (there is little evidence that the outcome will be improved) EQUIPMENT AND SUPPLIES • Gloves, mask, goggles, and an impervious gown • Towel or surgical Chux for covering patient’s clothing • Paper tissues • Emesis basin • Nasogastric tube (For adults, use a 16- or 18-Fr Salem sump [with antireflux valve, if possible] or Levin tube. Use 10-Fr tube for children.) For nasoenteric feeding tubes (5 to 12 Fr), see Table 203-1. Larger tubes (12 Fr) should be used for shorter periods because they are less comfortable and more likely to become occluded than smaller tubes (5 to 8 Fr). • Tincture of benzoin • Hypoallergenic tape (e.g., Hy-Tape), NG Strip, or Tube Guard • Stethoscope • Large (60-mL) syringe with catheter tip (Toomey) • Suction equipment • Cup of water with drinking straw • Decongestant such as phenylephrine (0.25% to 2%) spray (NeoSynephrine, Vick’s) or oxymetazoline hydrochloride 0.05% spray (Afrin, Neo-Synephrine 12 hour) • Water-soluble lubricant gel (Surgilube) or 2% lidocaine gel (Xylocaine Jelly) • Topical anesthetic spray such as benzocaine (Hurricaine) or tetracaine hydrochloride (Cetacaine), or both. Topical cocaine is an option, and it works as both a decongestant and anesthetic. However, its use may be a problem if the patient has to undergo drug testing. In addition, purchase and storage by clinician or hospital requires significant record-keeping, and may increase the risk of theft. • Laryngoscope for difficult insertions • pH indicator strips with 0.5 gradations or paper with a range of 0 to 6 or 1 to 11 • Soft nasal trumpet airway (optional) PREPROCEDURE PATIENT PREPARATION Although the insertion of a nasogastric tube is a common and fairly simple procedure, serious complications can occur. The risk for complications can be minimized by taking a few precautions: obtainTABLE 203-1 ing the full cooperation of the patient, informing the patient carefully at each step of the process, using a decongestant and local anesthesia for the nasal and retropharyngeal mucosa, premeasuring and marking the length of the tube needed for insertion, using gentle technique during insertion, and carefully confirming that the tube is in the proper position before use. Insertion of a nasogastric tube is considered by many patients to be one of the most uncomfortable and distressful procedures they have ever experienced. Although most hospitals do not require written informed consent, the risks, benefits, indications, and any possible alternatives should be explained to patients. Even with the use of decongestants and anesthetics, patients should be prepared for some discomfort. The unpleasant nature of the procedure should not be minimized. Patients should know that their eyes may water and they may have some tearing. They may have an intense tickling sensation or an urge to sneeze. During insertion, they may experience a gagging sensation. Swallowing rapidly will minimize this response and shorten the total length of the procedure. At some point during the procedure, they will probably be asked to assist by sniffing or later by swallowing. To help them swallow, give them a glass of water and a straw. If they are not able to swallow, if they will mimic swallowing or make the sound “eeee” it may help. Patients should be reassured that after the tube has been placed, they will usually adapt to it very soon and no longer notice it. Before nasogastric tube removal, the patient should be informed of the procedure and what to expect. Towels, surgical Chux, or other drapes should be placed around the patient’s neck and chest. He or she should be handed an emesis basin and tissues. TECHNIQUE Observe universal blood and body fluid precautions during the procedure. Wear gloves, goggles, a face mask, and an impervious gown. 1. Elevate the head of the bed into a high Fowler (sitting) position. Rest the back of the patient’s head on a pillow or directly on the bed for support. The patient’s clothing needs to be protected with a towel or surgical Chux. An emesis basin should be available on the patient’s lap. 2. Check for a clear nasal passage. Various conditions may cause asymmetric nostril openings, for example, septal deviation, nasal polyps, septal spurs. So examine both nostrils to determine which is the largest and most open. You can also watch the patient inhaling through his or her nose to determine which nostril is more open. 3. Choose an optimal tube for the patient. A large-bore nasogastric tube (16 or 18 Fr), Salem sump (with antireflux valve, if available), or Levin tube should be used for adults. Select the largest tube possible for the patient’s nostril size. The Salem sump tube has marks at 18, 22, 26, and 30 inches from the distal end. Measure the tube to fit the patient by holding the nasogastric tube above the patient, with the distal end 6 inches below the xiphoid process for a nasogastric tube and 8 to 10 inches for a nasoenteric tube; the proximal end extended to the nose. Loop the mid-portion over the patient’s earlobe. Note the tube marks based on these measurements or mark the Enteral Alimentation Tubes Trade Name Material Circumference (French) Length (inches) Feeding Duration of Use CORFLO (CORPAK MedSystems, Wheeling, Ill) COMPAT (Nestlé Nutrition, Minnetonka, Minn) Dobhoff (Kendall/Covidien, Mansfield, Mass) Entriflex (Kendall/Covidien) Ross Nasoenteric (Abbott Laboratories, Abbott Park, Ill) Polyurethane Polyurethane Polyurethane Polyurethane Polyurethane 5, 6, 8, 10, 12 8, 9, 10, 12, 14 3, 5 5, 7 8, 10, 12, 14 15, 22, 36, 43, 55 42, 55 43, 55 43, 55 36, 45, 60 Gastric or intestinal Gastric or intestinal Gastric or intestinal Gastric or intestinal Gastric or intestinal Up to 6 weeks Up to 6 weeks Up to 6 weeks Up to 6 weeks Up to 6 weeks 203 —— NASOGASTRIC AND NASOENTERIC TUBE INSERTION Mark 20–24˝ 8˝ 10˝ 4˝ Xiphoid process Figure 203-4 Measuring the length of nasogastric tube for placement into stomach. tube with a piece of tape to avoid inserting the tube too far (Fig. 203-4). The nasogastric tube should generally be secured with the 20- to 24-inch mark at the nasal vestibule. 4. After application of a nasal decongestant such as phenylephrine or oxymetazoline, adding a topical anesthetic usually increases the patient’s comfort. Although this procedure is usually brief, application of the decongestant before the anesthesia usually results in the anesthesia lasting longer. The decongestant may also may minimize damage to the nasal mucosa and decrease the incidence of epistaxis. 1395 7. Introduce the lubricated tube tip into the nostril, pointing straight to the back of the nasal cavity and toward the base of the skull (Fig. 203-5). Recalling the anatomy, it should be inserted horizontally, along the floor of the nasal passage, and directed straight back, not upward. Feed the tube slowly with the dominant hand into the nostril using continuous movement while unrolling the curled tube with the nondominant hand. The patient can sniff to assist the insertion. Never force a tube against resistance; however, spinning or twisting the tube slightly may help overcome resistance. 8. Have the patient flex his or her head slightly forward to narrow the pharyngeal airway. When the tip of the tube reaches the nasopharynx a slight increase in resistance will be noted (Fig. 203-6). Continue to advance the tube, and when the resistance decreases again, ask the patient to swallow or drink some water with a straw. Continue to push the tube with the same motion while asking the patient to continue swallowing. If the patient starts coughing or becomes distressed, or fog is seen in the tube, the tube has probably entered the trachea. The tube should be withdrawn a few inches, but not entirely, twisted slightly, and the process started again. If a patient cannot swallow, it is also helpful to mimic swallowing or to make the sound “eeee.” 9. Continue to push the tube until the desired mark is reached if the patient is not coughing. In adults, this is slightly past the 22-inch mark—the second mark—on a Salem sump tube. The gastroesophageal junction is usually about 16 to 18 inches from the nose—the first mark—and the tube should be inserted about 4 inches beyond the gastroesophageal junction. If the stomach is full, an immediate return of fluid may occur. Use the emesis basin to collect this. If there is no return of fluid, open the patient’s mouth to confirm that the tube is not curled in the mouth or pharynx. If significant resistance, respiratory distress, or a nasal hemorrhage occurs, or the patient suddenly becomes unable to speak, the tube should be withdrawn. NOTE: A randomized, controlled trial (Singer and Konia, 1999) showed improved comfort when a decongestant/ anesthetic was used, compared with plain lubrication for nasogastric tube insertion. In the study, topical anesthesia was applied (after the decongestant) by injecting 5 mL of 2% lidocaine gel (Xylocaine Jelly) into the nostril before insertion. The pharynx was then sprayed with both benzocaine (Hurricaine) and tetracaine hydrochloride (Cetacaine) spray to minimize the gag reflex. If possible, allow time for the decongestants and anesthetics to take effect before inserting the tube. Topical cocaine solution can also be used, but it often causes a strong burning sensation on application (see Equipment section for other warnings). Application of topical anesthesia should be considered the standard of care except in emergency situations where adequate lubrication alone may be acceptable. NOTE: 5. An alternative option is to lubricate a soft nasal airway with 2% lidocaine gel and allow the patient to insert the lubricated airway into his or her nares. The nasogastric tube can then be inserted through the soft airway. As the patient swallows the gel, it will anesthetize the pharynx. A soft airway not only minimizes patient discomfort, it can also decrease the risk of severe epistaxis, intracranial intubation, and kinking of the nasogastric tube into the mouth. 6. Lubricate the tip of the tube with additional anesthetic jelly or a water-soluble lubricant. Curl the tube by rolling 18 to 20 inches of the distal tube clockwise onto the first three fingers of your nondominant hand. Figure 203-5 Horizontal insertion of nasogastric tube into nasopharynx. 1396 HOSPITALIST Figure 203-6 Have the patient flex his or her head. Next, gently advance the tube while asking the patient to swallow. • Nasogastric placement may be facilitated manually through the oropharynx with three fingers, if necessary. However, unless the patient is unconscious or paralyzed, a bite block should be in place for this maneuver to prevent the clinician from being bitten. • In difficult cases, a laryngoscope may be helpful for guiding or confirming proper placement. • Fluoroscopic or endoscopic assistance may be necessary. 11. Confirm the location of the tip as soon as possible after the tube is passed. Ask the patient to speak after placement. If he or she is unable to speak, the tube is in the trachea and should be withdrawn. (Be aware that cases have been reported in which the patient could talk despite tracheal placement of a smallbore feeding tube.) Otherwise, the position of the tip should be confirmed by a chest radiograph. In addition, there are two traditional methods for confirming proper nasogastric placement: checking for absence of rhythmic airflow and auscultating for gastric bubbling when air is injected into the stomach. As it turns out, both of these techniques have been found to be inaccurate and therefore they are not recommended. Even if the tip of the tube is located in the esophagus, duodenum, jejunum, pleural space, or respiratory tract, a bubbling sound may be heard. If proper location is misdiagnosed, the instillation of feeds or air has been reported to result in a pneumonia or pneumothorax with a high chance of an adverse outcome. Fortunately, placement can also be confirmed by aspiration (to check for gastric contents) and by ultrasonography. If gastric juices are aspirated, correct placement has been demonstrated. Testing the pH of the aspirate will further verify placement. We recommend pH indicator strips with 0.5 gradations or paper with a range of 0 to 6 or 1 to 11. It is important that the resulting color change on any indicator strip or paper is easily distinguishable, particularly between the pH 5 to 6 range. The old type of litmus paper should not be used. Rakel and colleagues (1994) reviewed several studies regarding the significance of the pH value of the aspirate. They found that gastric fluid should have a pH of 0 to 4. If the patient is on antacids, histamine type 2 inhibitors, or proton pump inhibitors, the pH is between 0 and 6 approximately 70% to 80% of the time. Fluid aspirated from the duodenum averaged a pH of 6.5. Fluid aspirated from tracheobronchial secretions ranged from pH 6.74 to 8.79. In other words, suspect that fluid from the respiratory tract has been aspirated when the pH is greater than 6. Neumann and colleagues (1995) concluded that when the pH of the nasogastric tube aspirate is less than 4.0, radiographs are not needed to confirm tube placement. In 2005, the National Patient Safety Agency in the United Kingdom recommended the use of a pH value of less than 5.5 for tube placement confirmation; they concluded a pH value of less than 4.0 (as recommended by Neumann and associates) is too low to evaluate patients practically. If the pH is greater than 5.5, a chest radiograph, still the gold standard, is required to confirm tube placement (Fig. 203-7). However, it chest radio graphy adds cost and prolongs waiting time before use (it can take up to 8 hours to receive notification from the radiologist). It also increases radiation exposure. There are also case reports of inaccurate confirmations by radiographs, with the tube being located in the midline after perforating the esophagus, subclavian vein, or atrium of the heart. Recently, the bedside sonographic examination performed by experienced clinicians has been reported to be a sensitive method for confirming the position of nasogastric tubes. It is faster than conventional radiography and can easily be taught to nonradiologists. Confirmation must be done on all smallbore nasogastric or nasoenteric tubes used for feeding purposes before starting feeding to avoid massive aspiration. The distal NOTE: 10a. Extra steps to facilitate placement of a nasoenteric feeding tube include the following: • Having placed the tube into the stomach, leave some extra tubing or slack to facilitate passage of the tip into the duodenum. • Place the patient in a right lateral decubitus (right side down) position. • A 60-mL syringe (Toomey) can be used to inject 400 mL of air to distend the stomach. This may allow a feeding tube coiled in the fundus of the stomach to uncoil and pass more freely into the duodenum. • In refractory cases, metoclopramide (Reglan) 10 mg may be given intravenously, with or without erythromycin 250 mg intravenously, to increase gastric motility. 10b. Extra steps to facilitate any tube placement include the following: • If the tube persistently kinks or coils into the mouth, cooling the tube in ice chips or a refrigerator for 5 minutes may stiffen it to prevent coiling. A larger-bore tube is also less likely to coil. • Applying external and medially directed pressure on the ipsilateral neck at the level of the thyrohyoid membrane may increase the success rate in difficult insertions. This maneuver collapses the piriform sinus and further clears the way for the nasogastric tube. If the tube passes to the level of the hypopharynx but then meets resistance, grasping the thyroid cartilage and lifting it anteriorly and upward may facilitate passage into the upper esophagus. • Orotracheally intubated patients often present the most difficult challenge for inserting a nasogastric tube. If nasogastric insertion is deemed impossible, a second endotracheal tube may facilitate orogastric tube placement. Remove the respiratory adapter from the proximal end of the second endotracheal tube, lubricate it liberally, and insert it through the patient’s mouth and into the esophagus. A well-lubricated nasogastric tube can then be inserted through the second endotracheal tube, which can then be removed over the proximal end of the nasogastric tube. 203 —— NASOGASTRIC AND NASOENTERIC TUBE INSERTION 1. Check if on acid-inhibiting medication 2. Check for signs of tube displacement and measure tube length 3. Reposition or repass tube if required 4. Aspirate using 50-mL syringe and gentle suction 1397 Aspirate obtained (0.5–1 mL) Aspirate not obtained DO NOT FEED 1. If possible, turn adult onto side 2. Inject 10–20 mL air into the tube using syringe 3. Wait for 15–30 minutes 4. Try aspirating again Aspirate obtained (0.5–1 mL) Aspirate not obtained DO NOT FEED Aspirate obtained (0.5–1 mL) 1. Advance tube by 10–20 cm 2. Try aspirating again Test on pH strip or paper pH 6 or above Aspirate not obtained pH 6 or above pH 5.5 or below DO NOT FEED 1. Leave for up to 1 hour 2. Try aspirating again pH 5.5 or below DO NOT FEED 1. Call for advice 2. Consider replacement/repassing of tube and/or checking position by x-ray Proceed to feed CAUTION: If there is ANY query about position and/or the clarity of the color change on the pH strip, particularly between ranges 5 and 6, then feeding should not commence. Figure 203-7 Algorithm to confirm the correct position of nasogastric feeding tubes in adults. (From the National Patient Safety Agency [NPSA]: Reducing the harm caused by misplaced nasogastric feeding tubes: Interim advice for healthcare staff—February 2005: How to confirm the correct position of nasogastric feeding tubes in infants, children and adults. Available at www.nrls.npsa.nhs.uk/resources/?EntryId45=59794.) tips of these tubes should be allowed to migrate to the duodenum before enteral feeding is initiated. 12. Secure the tube to the patient’s nose after confirmation of proper placement. First, apply alcohol to the dorsum of the nose. If available, tincture of benzoin may then be applied after the alcohol dries. Next, obtain a 5-inch piece of 1-inch-wide hypoallergenic tape. Make a 3-inch cut lengthwise in the middle, thereby forming two narrow strips of tape at one end of the 5-inch piece (Fig. 203-8). The two narrow strips of tape should be applied in a spiral down and around the nasogastric tube, going away from the patient’s nose. Attempt to tape the tube so that it will rest in the middle of the nostril to minimize direct contact of the tube with the skin of the nose and avoid pressure necrosis. Recently, several commercial products, NG Strip (Cardinal Health, Dublin, Ohio) and TubeGuard (Mormac TubeGuard, North Loup, Neb), have been developed for this special purpose. 13. Also secure the nasogastric tube to the patient’s gown. Place a slipknot over the tube with a rubber band, and then pin it to the patient’s gown. This should reduce the risk of the nasogastric tube being tugged out of position. The Salem sump tube vent, or blue pigtail, must remain above the patient’s waistline at all times to prevent gravity from siphoning fluid. Inadvertent siphoning of gastric contents could block the sump vent. When suction is discontinued during ambulation, the pigtail should be attached to the connector of the main lumen to close the system and avoid the spillage of gastric fluids. 14. For removal, again place the patient in the sitting (Fowler) position and cover his or her neck and chest with towels, surgical Chux, or other drapes. Disconnect the nasogastric tube from the patient, from his or her nose, and from suction. Hand the patient an emesis basin and some tissues. Fold over the proximal end of the tube to prevent leakage and hold it tightly. Ask the patient to flex the neck, breath in, and hold his or her breath. Place a drape around the tube and withdraw the tube from the patient’s nose through the drape. The patient can then resume breathing. Discard the tube and the drape. COMPLICATIONS The most common complication is discomfort of the patient. The traumatic insertion of a nasogastric tube can cause epistaxis, but this is often avoided by using careful technique and a decongestant. 1398 HOSPITALIST With long-term use, sinusitis, erosion of nasal tissue, or even a tracheoesophageal fistula can occur. Tracheoesophageal fistulas are usually associated with simultaneous use of an endotracheal tube. Sinusitis can cause a fever of unknown origin in patients. If the tube is forced against resistance, cribriform plate fracture may result, with subsequent intracranial intubation. Individuals with mid-facial or maxillofacial trauma or a basilar skull fracture have a significantly increased risk of inadvertent intracranial intubation. The risk of this complication can be reduced by using the orogastric route or by initially introducing a nasotracheal tube or a soft rubber nasal airway, through which a smaller-diameter nasogastric tube can then be passed. This technique decreases the danger of penetrating the cranium, reduces discomfort during insertion, decreases epistaxis, and decreases the frequency of the nasogastric tube kinking into the mouth. The long-term use of nasoenteric tube feeding may result in diarrhea, infection, electrolyte imbalance, and malnutrition. POSTPROCEDURE MANAGEMENT Figure 203-8 Secure the tube with a 5-inch piece of 1-inch-wide hypoallergenic tape, partially cut lengthwise. Apply to the dorsum of the nose and spiral the cut portions down the tube away from the nose. Epistaxis can be massive and requires packing. It can even compromise the airway. Gagging can occur and induce vomiting with aspiration of gastric contents. This can cause an aspiration pneumonitis or pneumonia with a mortality rate as high as 30%. Patients with an altered mental status from severe trauma or other causes should have their airway secured with an endotracheal tube before placement of a nasogastric tube. Another common complication is misplacement into the respiratory tree, which is estimated to occur in 15% of cases. This should be recognized rapidly in the conscious patient when it causes him or her to cough, choke, or develop respiratory distress or an inability to talk. The vocal cords may also be traumatized. In a patient with decreased consciousness, tracheal intubation can go undetected, creating multiple complications such as atelectasis, pulmonary edema, pneumonia, or lung abscess. The “nasogastric tube syndrome” is a reported life-threatening complication with laryngeal and upper airway obstruction and vocal cord abduction paralysis. The nasogastric tube syndrome results from postcricoid ulceration and its effect on the posterior cricoarytenoid muscles. This can be prevented by early recognition and by checking the patient every day when making rounds. It is treated with emergent tracheostomy, immediate removal of the nasogastric tube, and administration of systemic antibiotics. Penetration of a nasogastric tube into the pleural space is a rare but reported complication, with further possible complications including lung abscess, pneumothorax, isocalothorax, empyema, and sepsis. Intravascular penetration of the internal jugular and subclavian vessels has also been reported. Perforation of the esophagus is a very serious reported complication that often results in mediastinitis, with a mortality rate of up to 30%. This may occur when the esophagus has been damaged by chemical burns, esophageal cancer, and multiple attempts, or if strictures are present, or with insertion after esophageal surgery. Prompt recognition of this complication, surgical repair, and parenteral antibiotics can significantly reduce the mortality rate. Bleeding from esophageal varices is not usually caused by nasogastric intubation. Duodenal perforation has also been reported. Tube knotting, coiling, kinking, obstruction, and rupture can occur. The nares should be assessed for skin irritation, erosion, or necrosis by health providers at regular intervals. The patient should be asked if he or she has any pain or pressure in the nose, throat, or sinuses. Any old or detached tape should be replaced after cleaning the skin of the nose with alcohol and applying tincture of benzoin. On a regular basis, the nursing team should record the patency of the tube, the level of graduated marks on the tube, any symptoms or patient complaints, the volume and nature of anything infused, and any residual volume. If it becomes difficult to aspirate from the tube, it should be flushed with 30 mL water. If patency is still uncertain, it should be repositioned by advancing 1 inch or withdrawing 1 inch. The same maneuver should then be tried again to confirm patency. Because the use of acidic substances for flushing can cause wholeprotein formulas to coagulate and clog the tube, this practice should be discouraged. The tube should be flushed before and after each intermittent feeding, after medication administration, or every 4 to 6 hours in case of continuous infusion. When the volume of residual is higher than 300 to 400 mL or there is significant gastric distention, the clinician should be notified and any infusions held. Infusions should be held for several hours and the residual rechecked before restarting. For the infusion of medications, liquid forms should be used if possible. If pills are used they should be crushed to a fine powder and mixed with water. If the result is sticky or highly concentrated, dilute it further with water. When the tube is clogged, it can be irrigated with warm water or, if unsuccessful, a pancreatic enzyme solution injected. Reinsertion of a device, for example a stylet or guidewire, into a nasoenteric tube should never be tried because it can result in gastrointestinal tract injury. If there are unusual gastrointestinal symptoms like nausea, cramping, abdominal distention, or severe diarrhea, the infusion should be stopped and the clinician notified immediately. The clinician must assess the patient and the tube at this point. When the nasogastric tube is used for gastric decompression or postoperative drainage, clinicians should understand the mechanics of nasogastric suction. Suction strength is inversely proportional to flow; therefore, the lower the flow rate through the suction lumen, the higher the suction strength. In addition, a suction force of more than 25 mm Hg causes tissue capillary fragility and may damage the gastric mucosa. One advantage of the double-lumen Salem sump tube over the Levin tube is that it allows constant airflow through the secondary lumen, keeping the necessary suction in the main lumen at a minimum. Therefore, the vent lumen must not be clamped or plugged. When the Levin tube is used, an intermittent suction pump should be connected to prevent injury of the gastrointestinal mucosa. The length of time the tube can be used depends on the patient’s condition, feeding needs, and the tube design. With proper care and maintenance, most nasogastric tubes can be used for up to 30 days. For longer use, a percutaneous endoscopic gastros- 203 —— NASOGASTRIC AND NASOENTERIC TUBE INSERTION tomy tube should be considered (see Chapter 200, Percutaneous Endoscopic Gastrostomy Placement and Replacement). CPT/BILLING CODES 43219 43752 44500 74340 89100 89130 91105 Endoscopic guided insertion of plastic tube or stent Nasogastric or orogastric tube placement, necessitating physician’s skill and fluoroscopic guidance Introduction of long gastrointestinal tube (e.g., MillerAbbott) Introduction of long gastrointestinal tube (e.g., MillerAbbott) with fluoroscopic guidance Duodenal intubation and aspiration; single specimen plus appropriate test procedure Gastric intubation and aspiration, diagnostic, each specimen, for chemical analysis or cytopathology Gastric intubation, and aspiration or lavage, for treatment (e.g., for ingested poisons) ICD-9-CM DIAGNOSTIC CODES 014.82 261 263.9 536.2 537.0 560.1 561.81 577.0 577.1 578.0 578.1 578.9 787.01 787.03 977.9 Tuberculosis, gastrocolic, labs pending Calorie deficiency, severe Malnutrition, protein-calorie Vomiting, persistent, nonpregnant Gastric outlet obstruction, acquired or adult Ileus, paralytic Small intestine obstruction, due to adhesions Pancreatitis, NOS or acute Pancreatitis, chronic Hematemesis or gastrointestinal hemorrhage Hematochezia Gastrointestinal bleeding, unspecified Vomiting, NOS with nausea Vomiting, NOS Poisoning, unspecified drug or medicinal substances ACKNOWLEDGMENT The editors wish to recognize the contributions by Julie Graves Moy, MD, and Ramiro Sanchez, MD, to this chapter in the previous two editions of this text. SUPPLIERS (See contact information online at www.expertconsult.com.) Feeding tubes Cook Incorporated (including percutaneous endoscopic gastrostomy tubes) CORPAK MedSystems/VIASYS Healthcare/Cardinal Health 1399 Latex-free, zinc oxide tape Hy-Tape International Levin, Salem sump, and feeding tubes The Kendall Company (Covidien) Nasogastric tube guard Mormac TubeGuard NG Strip (Cardinal Health) pH indicator pHion Nutrition 60-mL syringe with catheter tip (Toomey) Becton, Dickinson and Co. Topical anesthetic Cetacaine Cetylite Industries, Inc. Xylocaine Jelly AstraZeneca L.P. ONLINE RESOURCES National Patient Safety Agency (NPSA) UK: Reducing the harm caused by misplaced nasogastric feeding tubes: Interim advice for healthcare staff— February 2005. Available at www.npsa.nhs.uk/advice. Accessed May 15, 2010. Thomsen TW, Shaffer RW, Setnik GS: Nasogastric intubation. Videos in Clinical Medicine. N Engl J Med 27 April, 2006. Available at http:// content.nejm.org/cgi/video/354/17/e16/. Accessed May 15, 2010. BIBLIOGRAPHY Fisman DN, Ward ME: Intrapleural placement of a nasogastric tube: An unusual complication of nasotracheal intubation. Can J Anaesth 43:1252–1256, 1996. Leschke RR: Nasogastric intubation. In Reichman EF, Simon RR (eds): Emergency Medicine Procedures. New York, McGraw-Hill, 2004, pp 413–419. Marcus EL, Caine Y, Hamdan K, et al: Nasogastric tube syndrome: A lifethreatening laryngeal obstruction in a 72-year-old patient. Age Ageing 35:538–539, 2006. Neumann MJ, Meyer CT, Dutton JL, et al: Hold that x-ray: Aspirate pH and auscultation prove enteral tube placement. J Clin Gastroenterol 20:293–295, 1995. Pillai JB, Vegas A, Brister S: Thoracic complications of nasogastric tube: Review of safe practice. Interact Cardiovasc Thorac Surg 4:429–433, 2005. Rakel BA, Titler M, Goode C, et al: Nasogastric and nasointestinal feeding tube placement: An integrative review of research. AACN Clin Issues Crit Care Nurs 5:194–206; quiz 218–219, 1994. Singer AJ, Konia N: Comparison of topical anesthetics and vasoconstrictors vs lubricants prior to nasogastric intubation: A randomized, controlled trial. Acad Emerg Med 6:184–190, 1999. Vigneau C, Baudel J-L, Guidet B, et al: Sonography as an alternative to radiography for nasogastric feeding tube location. Intensive Care Med 31:1570–1572, 2005.