NG/OG placement

adventure_rn, MSN, NP · Oct 22, 2016

I worked in a NICU that used to check solely by auscultation and appearance of aspirate. We had a sentinel event, feeding the lung; the baby clamped down, coded, and didn't make it (the nurse was an amazing clinician, incredibly experienced leader/mentor on the unit, which made it harder). It's super-rare, but obviously can be catastrophic when it happens. Afterwards, we had a big initiative to prevent NG/OG tube displacement. According to our committee's research, auscultation is very unreliable, so we moved to a gastric pH system. If we placed the cath and couldn't get an appropriate pH, the provider would order an x-ray (which was pretty controversial, but I think the risk management department was a big proponent). Apparently many kids will get chocked up and brady if you insert into the lung, but not always (depending on disease status and maturity). It still freaks me out that my current unit doesn't check aspirate pH.

I think one of the overlooked interventions that makes me feel most comfortable is ensuring the tube is taped down well, and that busy baby hands are adequately swaddled/secured. I think one of the biggest risks for tube displacement is when an active kid has pulled a tube halfway out, and someone comes by and shoves it back in (without verifying placement!) At my current facility, we use a 3M Cavilon adhesive barrier wipe (the kind used for stoma powder), then duoderm (heated with a heel warmer so it sticks really well), then another layer of Cavilon, a steri-strip chevroned around the tube to anchor it to the duoderm, followed by a layer of tegaderm (resulting in a duoderm-tube-tegaderm sandwich). I seriously did not think that the duoderm would stick, but it stays down (and is remarkably gentle).

kp1987 · Oct 22, 2016

We basically do the same when it comes to taping with the exception of the skin prep that actually a really good idea and probably helps a lot in terms of skin break down

we use pH as well for placement but it still makes me slightly nervous at times but you are right the worst is when the tube gets half pulled out and then shoved back in. I wish there was some kind of stat lock that could be used to secure the tube.

adventure_rn, MSN, NP · Oct 23, 2016

We basically do the same when it comes to taping with the exception of the skin prep that actually a really good idea and probably helps a lot in terms of skin break down
we use pH as well for placement but it still makes me slightly nervous at times but you are right the worst is when the tube gets half pulled out and then shoved back in. I wish there was some kind of stat lock that could be used to secure the tube.

I love the stat-lock idea to prevent tugging! Although some kids are like stinking Houdinis when it comes to their tubes.

The only other thing I can think of would be checking pH before every feed (we only checked with insertion), or at least encouraging people to recheck at the time of reinsertion, even if the tube is only partially out. Our pH process was a pain in the butt (lab had to QC our test papers, and we had to paper chart the pH in addition to computer charting), but maybe if the pH papers were stocked in each bedside cart, it would be easier.

If I know that a baby is going to need a new NG/OG tube in the next couple of days and they're due for an x-ray, I consider replacing the tube early. Sometimes I also like to check and see if there was a recent x-ray to visualize the tube placement myself.

Maybe another helpful element would be remeasuring tube insertion depth on a regular basis. Kids grow so fast, and the tube gets tugged on so often; sometimes I'll remeasure an insertion depth, and the tube will be taped 2-3 cms higher than it ought to be. Not only does that increase the risk for bradys and aspiration, but if it's pulled halfway out, the tip is more likely to come into the pharynx where it can be pushed back down the trachea.

My old unit also briefly considered ultrasound verification performed by the nurses, though I know very little about it. I'd imagine it would be expensive, it would require a ton of nurse education (since u/s interpretation has a steep learning curve), and it definitely wouldn't be feasible before every feed (since that would require a ton of u/s machines on a unit for all of the kids eating simultaneously).

Sorry I can't offer anything more helpful! Just mutual commiseration.

kp1987 · Oct 23, 2016

Hahaha thank you for your mutual commiersation!!

We actually do test pH with every feed which does make me feel better but yeah any other methods would be expensive or just over kill so I guess this is the best bet for now!

sergel02, BSN · Oct 24, 2016

So I'm wondering, in adults they always use X-ray to verify placemen and auscultation before feeds. I can see why the air bolus would be unreliable in babies where everything is together, but is X-ray not used to verify placement often?

adventure_rn, MSN, NP · Oct 24, 2016

So I'm wondering, in adults they always use X-ray to verify placemen and auscultation before feeds. I can see why the air bolus would be unreliable in babies where everything is together, but is X-ray not used to verify placement often?

X-ray is definitely the gold standard, and we try to make insertion coincide with x-ray when we can, but it isn't really feasible for most babies. The vast majority (perhaps 80%) of NICU kids have an NG; many of them will have one for over a month. Some really fidgety kids will pull theirs out 2-3 times a day. If we needed an x-ray for each reinsertion, that could mean multiple x-rays a day for weeks at a time. Also, our q 3 hour feeding schedules are pretty rigid d/t hypoglycemia concerns, so postponing a tube feed to wait for x-ray would be logistical issue.

The biggest problem with x-ray is the cumulative radiation exposure. Our kids are growing so quickly that mutational damage to one cell can cause damage to a whole bunch of cells down the road (the same reason why you try to avoid x-rays in pregnant women at all costs). We use x-ray in NICU kids, but the providers try to be judicious about it.

kp1987 · Oct 25, 2016

So I'm wondering, in adults they always use X-ray to verify placemen and auscultation before feeds. I can see why the air bolus would be unreliable in babies where everything is together, but is X-ray not used to verify placement often?

When I worked with adults we always used x Ray but at our NICU we never do unless there happens to be an x Ray happening for some other reason. pH is our main placement strategy

karnicurnc, MSN, APRN, CNS · Oct 26, 2016

X-ray verification is the gold standard for tube placement, but is not a feasible option to irradiate an infant before every feeding or when the tube becomes dislodged. Best practice also dictates 2 methods be used. We have recently stopped checking aspirate (as there is no real predictive value in that from a GI standpoint) and the 2 methods we use are an xray at initial placement and weekly, and checking the tube cm marking before each feeding. We do still aspirate air to remove it from the belly but it is not a placement check.

oohlala66 · Nov 5, 2016

We use the calculation method and it seems to be pretty accurate:

kg x 12 + 3= OG Placement

kg x 13 + 3 = NG Placement

infantsonly · Dec 11, 2016

We use the calculation method and it seems to be pretty accurate:
kg x 12 + 3= OG Placement
kg x 13 + 3 = NG Placement

Sorry I just saw this thread and your post. This seems very off, except for infants a kg or under. I've never seen a 2 kg infant with an NG at 29 or a 3 kg infant with an NP at 42.... I would relook at this calculation...