Monday, 30 July 2012

Nasogastric Tube Insertion


 LEARNING OBJECTIVES:
 • To understand the basics of nasogastric tube insertion 
 • To understand Indications & Contraindications of it
 • To learn scientific procedure of nasogastric tube   insertion.
 • To understand the possible complications and how to avoid that.

Introduction :
Nasogastric tube is passed for either aspiration of gastric contents or for administration of feeds or therapeutic substances in neonates.
The insertion of a  nasogastric tube facilitates feeding, stomach decompression, administration of medications and is a frequent procedure in the neonatal intensive care unit. 
      Although it is usually a very safe procedure, there is a very small risk that the tube may inadvertently be misplaced with the risk of milk or medication being instilled or aspirated into the lungs.
Orogastric tubes are used predominantly in babies in respiratory distress or with structural abnormality of nasal cavity where full bottle feeds are contraindicated.


Nasogastric tubes are used short term for all other neonates until full oral feeding is achievable.


Indications:


• Diagnostic
o Diagnosis of trachea esophageal fistula. (with x ray).
o To get stomach aspirates for shake test for lung maturity in preterm babies.
o Assessment of upper GI bleeding 
o Gastric aspirate test for diagnosis of neonatal septicaemia
o Measurement of gastric volume
o Determination of gastric content


 Therapeutic and feeding
o All Infants < 34weeks gestation 
o Infants unable to oral feed due to poor suck or swallow reflexes
o Infants with respiratory problems 
o Patients on C-PAP therapy
o To facilitate aspiration and deflation of the stomach 
o Paralytic ileus, acute gastric dilation, intestinal obstruction.


Contraindications

• Nasal fracture
• Unilateral choanal atresia or stenosis
• Head and neck injury preventing passage   
• Oesophageal stricture 


Equipments


• Appropriate size nasogastric tube.


Wt. Based criteria
Size 4-5 for weight <1Kg 
Size 5 for weight 1K – 1.5Kg and 
Size 6 for weight >1.5Kg 
For babies > 3.5Kg you may consider using a size 8 tube


Age based criteria
5Fg feeding tube for all infants ≤ 34 weeks gestation or < 1750gms. 
6Fg feeding tube may be used if infant > 35 weeks. 
8Fg tube on free drainage is generally used to aid gastric decompression in infants with abdominal distension or following surgery 


use tubes with markings to enable accurate measurement of depth and length


• 2 ml, 5 ml & 10 ml syringe
•Adhesive tape 
• Gloves


PROCEDURE


Preparation 


• explain procedure to parents.
• Wash hands and prepare equipment.
• Wrap baby securely in a sheet.
• To prevent risk of aspiration, pass nasogastric tube before a feed.
• Determine length of tube to be inserted  keeping tube in its packet, extend tip of tube from nose to outer aspect of ear lobe and then from earlobe down to xiphisternum, aiming for the    
space in the middle below the ribs; note the mark on the tube or keep your fingers on the 
point measured.


nasogastric tube lenghth measurement
Method of insertion


• More patent nostril is selected for passing the tube.
• In neonates, lubrication of terminal part is done with water to prevent aspiration of oily substance.
• With clean hands, wear gloves and pass tube slowly and steadily into the nostril, curve directed downward. It is passed along the floor of the nose. In case of difficulty it is tried in another nostril. 
• Resistance is felt when it reaches the naso -pharynx, a slight twisting of the tube puts it into the  nasopharynx.
• If the baby gags or the tube coils up in the mouth, the tube is withdrawn partly and again it is passed.
• It should be passed up to the measured length.
• It should be fixed after conformation of its proper placement in a butterfly fashion or with vertical 
Taping.
• Observe baby throughout procedure for colour change, vomiting, respiratory distress  or resistance. 
If it is observed, that means It indicates that the tube is in trachea.
• if any distress occurs, stop and remove tube.


Conformation of proper placement


• Aspiration of stomach contents on applying suction by attaching a syringe on the outer end of the tube.
• Air is injected in the tube, while the epigastric area is auscultated. A sound is heard if the tube is in stomach. (‘Whoosh test’)
• By Radiography. (see image below)


xray confirmation of NGT

COMPLICATIONS

• Failed passage
• Insertion in trachea & pulmonary aspiration
• Oesophageal perforation
• Gastric perforation
• Nasal necrosis
• Oesophageal stricture


Never use a gastric tube without first verifying the position



Frequency of checking tube placement 
• when there are concerns raised regarding correct tube placement.
• Prior to each bolus feed. 
• Prior to each syringe change for continuous feeds. 
• When there is a discrepancy in tube length. 
• Prior  to administration of drugs via the naso or orogastric  tube.                                                                                     


REFERENCES :


1.Baldev Prajapati; Essential Procedures In Paediatrics,: insertion of Nasogastric tube in neonate: 1999.
2.Best C.2005.Caring for the patient with a nasogastric tube. Nursing Standard: 2(3):59-65
3.NHS National Patient Safety Alert. 2005. Reducing the harm caused by misplaced nasogastric feeding tubes. Available at URL:http://www.npsa.nhs.uk




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