View source for Nasogastric tube placement

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==Indications==

[[File:Gray1032.png|thumb|Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.]]
[[File:Layers of the GI Tract english.svg|thumb|Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.]]
[[File:Illu esophagus.jpg|thumb|Esophagus anatomy and nomenclature based on two systems.]]
*Gastric decompression
**Post-[[Special:MyLanguage/intubation|intubation]]
**[[Special:MyLanguage/Bowel obstruction|Bowel obstruction]]/[[Special:MyLanguage/ileus|ileus]]
**[[Special:MyLanguage/acute gastric dilation|Acute gastric distension]]
*Aspiration of gastric contents
**Diagnosis/therapy of [[Special:MyLanguage/GI bleed|GI bleed]])
**Gastric lavage in [[Special:MyLanguage/Toxicology|acute poisonings]] (largely abandoned due to lack of efficacy)


==Contraindications==

*Severe [[Special:MyLanguage/facial trauma|facial trauma]] (due to possible cribriform plate disruption)


===Relative Contraindications===

*Severe [[Special:MyLanguage/coagulopathy|coagulopathy]]
*[[Special:MyLanguage/gastric bypass surgery|Gastric bypass]] and [[Special:MyLanguage/lap band complications|lap band procedures]]
*[[Special:MyLanguage/Esophageal varices|Esophageal varices]]/strictures
*History of [[Special:MyLanguage/caustic ingestion|alkali ingestion]]


==Equipment Needed==

*PPE
*NG Tube- typically a 16F or 18F Sump
*Syringe/Bulb - 50-60cc
*Tape
*Emesis basin
*Cup of water with straw


==Procedure==

[[File:ETTubeandNGtubeMarked.png|thumb|Nasogastric tube below the diaphragm and in the stomach in correct position as seen on [[Special:MyLanguage/CXR|CXR]] (bottom arrow).]]
#Consent by informing patient of risk, benefits, and alternatives
#Position patient upright
#Place towel over patient's gown and emesis basin in lap
#Estimate length of insertion
#*A standard of 56cm is reasonable<ref>Phillips DE, Sherman IW, Asgarali S, and Williams RS. How far to pass a nasogastric tube? Particular reference to the distance from the anterior nares to the upper oesophagus. J R Coll Surg Edinb. 1994; 39(5):295-296.</ref>)
#*Alternatively measure from tip of nose to earlobe to xyphoid and then add 15cm
#Check nares for obstruction and pass through the most widely patent nare
#Provide relief from discomfort
#*Topical vasoconstrictors to both nares
#**[[Special:MyLanguage/Oxymetazoline|Oxymetazoline]] or [[Special:MyLanguage/phenylephrine|phenylephrine]]
#*Topical Anesthetics (5 min prior to procedure)
#**[[Special:MyLanguage/Benzocaine|Benzocaine]], [[Special:MyLanguage/tetracaine|tetracaine]], nebulized [[Special:MyLanguage/lidocaine|lidocaine]] (4 or 10%), lidocaine jelly
#**Anesthetize oropharynx, as well, to prevent gagging
#*Antiemetics
#**[[Special:MyLanguage/Ondansetron|Ondansetron]] or [[Special:MyLanguage/metoclopramide|metoclopramide]] 15 min prior may reduce gagging and nausea
#Insert tube along floor of nose under inferior turbinate
#Pause when NGT is in OP
#Flex neck to decrease chance of tracheal passage
#Advance into esophagus
#*Sipping water may aid in esophageal passage
#*Withdraw to OP promptly if excessive coughing, gagging, choking or voice change
#Once NGT is in esophagus, rapidly insert rest of tube to pre-measured length
#Confirm placement
#*Insufflate air while listening over stomach
#**One study shows this discovers only 6% of malplacement<ref>Neumann MJ, Meyer CT, Dutton JL, et al. Hold that x-ray:  aspirate pH and auscultation prove enteral tube placement. J Clin Gastroenterol. 1995; 20(4):293-295.</ref>
#**Should not be primary confirmation technique<ref>Christensen M. Bedside methods of determining nasogastric tube placement: a literature review. Nurs Crit Care. 2001; 6(4):192-199.</ref>
#*Obtain abdominal xray
#*Check pH of aspirate
#**pH<5.5 in 99% of cases and has sen of 0.78 and spec of 0.86 at or below this level<ref>Boeykens K, Steeman E, Duysburgh I. Reliability of pH measurement and the auscultatory method to confirm the position of a nasogastric tube. Int J Nurs Stud. 2014; 51(11):1427-1433.</ref>
#Secure to patients nose with tape
#Attach to desired suction, not to exceed 120 mmHg


==Complications==

*Pulmonary placement
*Intracranial placement
*Increased cervical and cranial pressures with gagging/vomiting
*[[Special:MyLanguage/Epistaxis|Epistaxis]]
*Invagination of stomach lumen into eyes of NGT


==See Also==

*[[Special:MyLanguage/Upper gastrointestinal bleeding|Upper gastrointestinal bleeding]]
*[[Special:MyLanguage/Small bowel obstruction|Small bowel obstruction]]
*[[EBQ:Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis|EBQ:Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis]]


==External Links==

*[https://litfl.com/nasogastric-and-orogastric-tubes/ LITFL: Nasogastric and Orogastric Tubes]
*[https://www.merckmanuals.com/professional/gastrointestinal-disorders/how-to-do-gastrointestinal-procedures/how-to-insert-a-nasogastric-tube?query=nasogastric%20tube Merk Manual - How To Insert a Nasogastric Tube]


===Videos===

*Insertion
**Tulane (2:55) https://www.youtube.com/watch?v=1OakmxZDa5c 
*Unclogging NG Tube:
**Providence Health (3:53) https://www.youtube.com/results?search_query=unclogging+g+tube+emergency+medicine


==References==

<references/>

[[Category:Procedures]]
[[Category:GI]]
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