NG tube in an intubated patient

[stephynic21]

Just wanted some advice....recently had a resp arrest come thru the doors....we did all the stuff (intubation, ekg, ivs, meds, blood work, foley, NG)....it was early that morning and there were two of us over there in the critical area. The other nurse was primary and i was tasking all the stuff. I placed the NG tube and we auscultated for placement. I was listening when she pushed the air and didn't hear anything (it was loud with the monitor going off, the coordinator and doctor trying to get ICU bed for this patient, etc) and we tried again. I told the other nurse i still didn't hear anything...she pulled back on the syringe and we got what looked to be gastric contents. She determined that we were in but THANKFULLY, didn't hook the patient up to suction because she was going to CT...never hooked the patient back up because from CT they went straight to the ICU. doc gets a call from the radiologist that the NG is in the trachea.

My question is....what could the contents have been?? It was a large amount because we pulled back almost 30 ml of brown yucky "gastric" looking contents. Could the tube have become displaced during the transition from the stretcher to the CT table?? Has anyone ever had something like this happen? What are some tips for apparently placing the tube correctly?? And of course i got called into the coordinators office to discuss with the coordinator and the next in charge and the doc which really made me feel like the biggest crap-ola loser nurse of the world. Advice??

[sserrn, BSN]

Best practice is post-placement CXR to verify placement. You can also ph test the aspirated fluids. (We don't do the latter in my ER...not sure why.)

[nrsman1]

This may sound silly but could it have been stomach contents that were aspirated

[313RN, BSN, RN]

This may sound silly

That's not silly at all.

We don't know the particulars of the arrest, but gastric contents sometimes to end up being aspirated. It's possible that it was the cause of the arrest or that the pt vomited during an intubation attempt (either in the hospital or unsuccessfully in the field).

I've suctioned some really nasty stuff out of OET's, including stomach contents.

But I do wonder how an NG tube managed to slide past the cuff on the tube. Once an OET is in place it usually it's hard to get the NG into the lungs. That seems a little unusual and I would have expected to see/hear a cuff leak or a decrease in tidal volumes if the cuff was displaced enough.

Is there more to this story?

[Pets to People]

I have had two furry patients die from respiratory related illnesses, and I was amazed at the amount of brown goo that would leak out from their intubation tube, more than 30mls. Both times were during very busy emergency filled days, and I never remembered to ask the vet what was going on.

[Altra, BSN, RN]

If the patient is already intubated ... why an NG instead of an OG?

Agree with 313RN -- if the NG got past the cuff on the ETT, there's a little more that went wrong.

[stephynic21]

She had unsuccessful intubation attempts prior to arrival in the ER via EMS but successful the first time in the ER by the doc...so i guess stomach contents are possible if there was aspiration. there was no problem with insertion of the NG, tho. It went down easily as it ever has. I would think in order to get passed the ETT it would have to somewhat forced but it slid in easily. And I did ask the doc when he asked for one "NG or OG" and he said NG was fine. I just can't wrap my head around how it became displaced.

[missnurse01, MSN, RN]

it was exactly displaced-I am taking that to mean it was originally in the esophagus then ended up in the trachea. It was originally placed in the trachea it sounds like. it could have been coiled there or in the mouth and not really passed the ET balloon. all that stuff you drew back from the NG tube was stuff the pt had aspirated and was sitting there...unless they were retching so hard they vomited around the ET balloon. I have seen vomitus come out projectile like when intubating someone many times (yes it was in the trachea) to where it splashed the ceiling. super gross. don't beat yourself up about it! the only thing you could have done is just removed it if you didn't hear air if that is how you confirm per protocol at your facility.

[Esme12, ASN, BSN, RN]

She had unsuccessful intubation attempts prior to arrival in the ER via EMS but successful the first time in the ER by the doc...so i guess stomach contents are possible if there was aspiration. there was no problem with insertion of the NG, tho. It went down easily as it ever has. I would think in order to get passed the ETT it would have to somewhat forced but it slid in easily. And I did ask the doc when he asked for one "NG or OG" and he said NG was fine. I just can't wrap my head around how it became displaced.

Even with the cuff inflated in the ETT the NGT could get in the trachea. The ETT might have been small for the airway. If the ED MD knew of the unsuccessful attempts he might have used a smaller tube. I have placed MANY NGTon MANY intubated patients after MANY codes/intubations. Preference to OGT/NGT is regional/personal preference or......injury driven.

Even if you PH tested these contents they would have tested as gastric contents for the patient probably aspirated their gastric contents in the field with the intubation attempts to as a result of the arrest itself.

I have often wondered why codes in the field always seem to have eaten a huge meal.... . It makes everything more complicated.

Back on track......It is always not so hard to get past the ETT. That is why we as nurses INFUSE NOTHING in a NG/OGT until placement is verified. Hooking up the NGT to suction, short term, would not have caused any harm.....it would have sucked out the gastric contents in the lungs and you might have heard it the patients throat. You apply suction to the lungs every time you suction the ETT.

What is with the blame game.....it is one of those known complications of placing an OG/NGT and it could happen to anybody. Heck I have gotten open hearts back hat the NGT was in the wrong place. It is why I check my NGT placement before every med given through the NGT and if they aren't in far enough they can migrate....but not likely. The reason we check for placement is because it can go into the lung. Once in the lung....take it out and start again.

Is the coordinator a critical care trained nurse? Has she ever placed a NGT on an intubated fresh code with vomit in their lungs? What is wrong with everyone these days? This Calling in to offices and raking people over the coals.....this blame game baffles me. NGT/OGT insertion is another acquired skill that will get better with practice.

You can't really vomit around the ETT balloon? A ETT is an EndoTracheal Tube in the lungs. It is down the trachea in to lungs.....there is no (or shouldn't be) any vomit coming from the lungs whether the balloon is inflated or not.....and yes patient can vomit with an ETT tube in place because Te esophagus remains patent....that is why we place the NasoGastric Tube. It is also why a patient is intubated....to protect the airway.

The projectile vomiting that can occur is from the gag reflex during intubation on an under sedated patient OR stimulation on a full stomach compressed with air from extended bagging (using the amber and face-mack) during resuscitation.......the stomach will only take so much pressure build up before it takes the path of least resistance....the esophagus.

OP....I would have probably removed it and then gotten the charge nurse/MD if I couldn't hear the placement. I usually wait for the CXR ETT placement to double check the NGT is in the right place before instilling any thing. On a patient that is unconscious I would probably insert the NGT orally.....but I have done both...I will also tend to use the right nares for a straighter shot.

Why they called you in? I have no idea....but I also don't know the whole story. Did the primary nurse also get called in? Is was after all, her patient.

YOu will get better with practice.

[CraigB-RN, MSN, RN]

It happens. You get better at it the more you practice, but there are still patients that the tubes go everywhere but where I want them to go.

1. Oral gastric is usually a better choice. I don't have access to my library, but nasal tubes are more app to cause problems once the patient gets to the ICU.

3. When in doubt, don't use and try again. You may pass on in your report that the placement hasn't been confirmed, but we all know that communication isn't perfect. It's easy for someone to see the tube and use it, not knowing. Never assume anything. Your patients life depends on that.

Sorry that you had to deal with people who apparently don't believe in "teachable" moments orhave a warped idea of what a teachable moment is.

Don't loose any sleep over it, Just learn and move on.

[brainkandy87]

Yeah, this is why I never even bother trying to aspirate gastric contents on an intubated pt. I've seen several difficult NG/OG insertions on intubated pts where gastric contents were aspirated from the trachea for one reason or another (pt aspirates; one had a SBO that was literally overflowing from their stomach; etc). If you can't auscultate it, it's not in there - that's always my rule. I'm not going to bother getting a CXR on a pt to confirm placement if I can't auscultate for placement.

I've had some really tough ones where the OG (my preferred route on intubated pts) took longer to insert than the rest of the care. I usually try to get an 18 fr inserted, but sometimes you have to go smaller just to even advance it past their trachea due to the tracheal tube size. Grrrrr.

Anyway, that's why the ER is a constant learning process. The upside is, putting an NG/OG in an intubated is always a much easier learning experience than the conscious and alert pt. :)

[oldCRNA]

It could have been - most likely was - stomach contents which had been aspirated into the lungs, given the history of unsuccessful attempts in the ambulance. (The fact that the ER doc got it in first try is irrelevant but it's nice of you to mention his expertise. However, that has no bearing on what happened to you.) If it was gastric contents, they were already aspirated into the lungs. Did the doc have to use suction as he intubated and what came out of the back of the throat? Did he see gastric contents? Did he say anything about it? Did he tell you? Did he share any helpful information with you at any point? Aspirants do not 100% go into the lung. There is usually a trace in the back of the throat. When checking placement of both the NG or OG and ET, one should listen for both positive and negative reports. By this, I mean that when a pt is intubated, we check the lungs AND the stomach. Lungs for air, stomach for absence of air. IF YOU CANNOT hear an ausculation from a stomach OG/NG where you expect to hear it, check the other site by auscultaion for misplacement. XRay is definitive, yes, but a person has to depend on his/her ears and eyes first. We cannot wait for XRAy, for example, for ET placement. The patient would die in the meantime. If the patient is being manually ventilated, you can listen to the end of the NG/OG for air movement with the ventilation. There should be none. You can also put the end into a cup of water and watch for bubbles with ventilations. However, there should be much more to this story: Age of pt. Reason for resp arrest - secondary to cardiac or drug-related or COPD/asthma. If it was primarily cardiac arrest or OD, the patient very likely did vomit and aspirate. If it was a lung issue or CHF, it could have been pulmonary edema. In the old days, we had pH paper around and we could check those things! (We also kept glucose sticks around to check trauma injuries to see ear drainage for CSF.) If there was aspirant in the lungs, you would have also seen it coming out of the ET tube. At any rate, the ER TEAM is a TEAM and there is no place for a doc to make you feel small. He needs you as much as you need him. Shame on him. By displaced, I wonder if it ended up not down far enough - like in the esophagus - from which you could definitely get quite a lg return of gastric contents, or in the lungs. NG tubes, when down far enough, do not get displaced without serious pulling. They can coil and not go far enough. But coiling and not far enough do not hurt the patient, especially when they are on the way to XRay where you will get the feedback you seek. This great doc who ET'ed the pt could very well have placed the NG at the time of the ET under direct vision. He sounds a little bit of a cad.