Blue Pigtail on Nasogastric Tube

jadelpn, LPN, EMT-B · Apr 23, 2015

Sounds like x-ray made a small error.

Going forward, good lesson learned. Make sure you connect your patient back up to the bells, wires, whistles. When you assess, you need to be sure that you are still getting output, how much from the last hour, (I enjoy hourly I&O's just for accuracy) and that the NG tube is connected properly.

If you are charting that the NG tube is in place, make sure that it is. And if you are getting little to no output after a time, then you need orders to turn down the suction, or intermittent.

I am sure the X-ray person was just attempting to be helpful. And good on them. Just make sure you double check, or do it yourself.

Best wishes!

mikeynizm · Apr 24, 2015

Sounds like x-ray made a small error.
Going forward, good lesson learned. Make sure you connect your patient back up to the bells, wires, whistles. When you assess, you need to be sure that you are still getting output, how much from the last hour, (I enjoy hourly I&O's just for accuracy) and that the NG tube is connected properly.
If you are charting that the NG tube is in place, make sure that it is. And if you are getting little to no output after a time, then you need orders to turn down the suction, or intermittent.
I am sure the X-ray person was just attempting to be helpful. And good on them. Just make sure you double check, or do it yourself.
Best wishes!

Thanks for the input, jadelpn! You are absolutely right about the need for reassessment. Orders were changed to low intermittent suction by the surgeon. Forgot to mention that they also were upset that suction was placed on low continuous suction in the beginning. I hate to say it, but I was just following orders but probably should have questioned them. I just pointed it out to one of the residents and they agreed to change the order. I appreciate the X-ray techs effort, but I am not entirely sure if he did disconnect the patient from suction or not. The x-ray was performed at around 0200 in the morning. Thanks again!

FlyingScot, RN · Apr 24, 2015

LCWS is absolutely correct for Salem sump tubes whose sump lumens are patent. You followed a correct order.

Mavrick, BSN, RN · Apr 24, 2015

Before you throw x-ray under the bus.

Where I work we don't disconnect an NG tube to get an X-ray. It would be highly unusual for an x-ray to show the tubing connection as proof. And of course the patient may have slept through another nurse disconnecting and improperly re-connecting.

The two lumens go to the same place, with the blue one being a smaller air vent to theoretically keep the main lumen from being sucked up against the stomach wall and causing an ulcer. Depending on the chunky-factor it, too, can evacuate the stomach contents as evidenced by green goo frequently coming back up the blue vent all over your nice white pillowcase. Those blue and white anti-reflux valves can help prevent that.

mikeynizm · Apr 24, 2015

Before you throw x-ray under the bus.
Where I work we don't disconnect an NG tube to get an X-ray. It would be highly unusual for an x-ray to show the tubing connection as proof. And of course the patient may have slept through another nurse disconnecting and improperly re-connecting.
The two lumens go to the same place, with the blue one being a smaller air vent to theoretically keep the main lumen from being sucked up against the stomach wall and causing an ulcer. Depending on the chunky-factor it, too, can evacuate the stomach contents as evidenced by green goo frequently coming back up the blue vent all over your nice white pillowcase. Those blue and white anti-reflux valves can help prevent that.

you are absolutely right, lesson learned. It is just bothering me not knowing or remembering what really happened.

Anna Flaxis, BSN, RN · Apr 24, 2015

Surgeons throw hissy fits from time to time. Don't let it shake your confidence in yourself. The patient was not harmed, and you learned a good lesson to double and triple check next time. Move forward.

Mavrick, BSN, RN · Apr 24, 2015

Dear OP, Don't be too terrible hard on yourself. Even if it was hooked up incorrectly, the output proves it was functioning as desired, to keep the stomach empty of gastric contents. Let's keep perspective here. If your hospital has those blue and white anti-reflux valves, attach the blue end to the pigtail and the only place left to hook up LIS (Low Intermittant Suction) is to the clear main lumen. This is how you establish little habits that keep you and your patients safe.

You won't know it all and have so many more fun things to learn. It is frustrating when you think you did something and then find out later maybe you didn't? I have infused a few 50ml bags of antibiotics that I thought sure I mixed before I started the infusion.

Keep caring and give yourself the understanding you would want to give every new nurse.

icuRNmaggie, BSN, RN · Apr 24, 2015

A suggestion: get in the habit of flushing the NGT with 30cc of tap water every four hours and sump the blue port with 30cc of air afterward. If the antireflux valve is wet replace it to prevent the NGT from attaching to the gastric mucosa and causing bleeding. Position the tube above the stomach for the air vent to work.

Is it possible that the pt or a visitor tried to put it back together and did it incorrectly?

nurseprnRN, BSN, RN · Apr 25, 2015

Before you throw x-ray under the bus.
Where I work we don't disconnect an NG tube to get an X-ray. It would be highly unusual for an x-ray to show the tubing connection as proof. And of course the patient may have slept through another nurse disconnecting and improperly re-connecting.
The two lumens go to the same place, with the blue one being a smaller air vent to theoretically keep the main lumen from being sucked up against the stomach wall and causing an ulcer. Depending on the chunky-factor it, too, can evacuate the stomach contents as evidenced by green goo frequently coming back up the blue vent all over your nice white pillowcase. Those blue and white anti-reflux valves can help prevent that.

This will not happen if the tube is properly functioning, i.e., if air is constantly going down the blue vent (that's what it is) into the stomach. Those little "antireflux" valves aren't so much that as plugs, because if they get moisture in them they no longer admit air. You might as well put a plug in it or a rubber band on it. (Note: that was NOT advice, that was snark.)

Before Salem sump tubes were invented, all we had were single-lumen tubes to suck out stomach contents. What's the problem there, you say? Well, if suction has removed all liquid stomach contents and it keeps sucking, what you get are little punch biopsies of the stomach mucosa, and this is not a good thing. So, some clever person (perhaps a Salem witch) figured out that if there were a way for the suction to have something else to suck on, to break the vacuum in the stomach, like air (and any other fluid that happened to accumulate too, of course), then this would protect the stomach from having vicious little hickies from suction at the eyelets down below and bleeding and such.

The air vent on the Salem sump is that solution. Air should always be going down the blue lumen. How do you know if that's happening? Well, you can put your ear near it and hear it, or put your thumb over the end of it briefly and feel suction there, but the best way to see is that there should always, always, always be air bubbles coming up the main lumen to your suction cannister. Now you know something important: if it isn't, there's hickifying going on down there, and that's a bad thing.

The air vent lumen should always be patent (open) all the way down. If it isn't you can do a couple of things (after you have determined that some fool has not turned off your suction outlet). One is to untape the tube and pull it back an inch or so, and then put it back. You can also push some air (not fluid) down the blue lumen. Yes, you may have to do this all dang day long, but you will often be rewarded by a gush of gastric goo up the main lumen, which is what you wanted anyway.

What's going on if there is no air coming up the main lumen and there's goo coming out of the air vent onto your pillowcase? Well, (assuming your suction is still turned on and plugged in properly) your main lumen is probably occluded and goo has nowhere else to go but up the air vent, and you should probably think about replacing the whole tube. But before you do that, if it's not otherwise contraindicated, shoot some NS (not water) down both lumens, and follow that with air down the air vent lumen. See if that doesn't get things moving properly. If not, do the wiggling thing as above. If that doesn't work, get the ok to replace it (or have the physician or NP come and replace it).

Some Salem sumps come with little plugs in the blue lumen. They're supposed to allow air entry and prevent backflow but they don't always really do a great job of it. If you can still verify air entry past that plug and bubbles are going up the main lumen, it's fine. But if that plug has gotten wet or grubby and acts like an actual plug, get rid of it, or what you have is now a gastric mucosa-grabbing single-lumen tube.

dudette10, MSN, RN · Apr 29, 2015

GrnTea, I have one question from what you wrote. Why use NS--and specifically not water--to troubleshoot the Salem?

nurseprnRN, BSN, RN · Apr 29, 2015

GrnTea, I have one question from what you wrote. Why use NS--and specifically not water--to troubleshoot the Salem?

Because if you insert water you decrease the serum sodium (as water crosses into the capillaries and dilutes serum electrolytes). For some patients this can be a real problem. Using NS will not affect serum Na+.