NG tube in an intubated patient - page 2

by stephynic21

7,438 Views | 16 Comments

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... Read More


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    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.
    turnforthenurseRN likes this.
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    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.
    zmansc and ~*Stargazer*~ like this.
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    So I may sound stupid.... but I usually have trouble placing OG tubes, it almosy always coils in the mouth for me. I can get an NG no problem. Is there some secret technique? I seem to have better luck if I can manipulate the angle of the head, sometimes I just cradle the head with my hand and place the OG/NG with my right hand.

    Any tricks to placing an OG that I don't know? I usually use a 14F for NG and a 16/18F for OG, depending on pt size and mechanism of injury.
  4. 1
    Quote from thelema13
    So I may sound stupid.... but I usually have trouble placing OG tubes, it almosy always coils in the mouth for me. I can get an NG no problem. Is there some secret technique? I seem to have better luck if I can manipulate the angle of the head, sometimes I just cradle the head with my hand and place the OG/NG with my right hand.

    Any tricks to placing an OG that I don't know? I usually use a 14F for NG and a 16/18F for OG, depending on pt size and mechanism of injury.
    Put the tip in some ice water for a minute, it will become more stiff and less likely to coil.
    Pixie.RN likes this.
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    Something to also remember is the cuff on an ETT does not keep things out. The cuff is only inflated to a minimal leak or just enough of a seal to help with ventilation. It also does not prevent aspiration. Many cuffs have been damaged by NG or OG placement and have required an ETT replacement. Also, as part of VAP recommendations per the CDC, OG is preferred to NG.
    Altra likes this.
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    per Altra:
    ...good luck getting past the cuff if everything is correct, and an OG is much less risky re: infection than an NG
  7. 0
    Quote from Esme12
    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.
    Right?!?!? Thank you!


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