Question re: OG tube - New in ICU

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Specializes in Oncology, ICU.

I have 3 years experience on an Onc floor, but I'm new to ICU. Last shift, a newly intubated s/p cabg (2 days) pt was intubated and an OG tube was placed @ 1500 and the MD said it sounded like "it is in the right place". At 1730, I was expected to give meds via the tube. I heard no air bubble in the R abd, a faint bubble midline. When I drew back on the tube, I only got frothy, clear fluid. In all the NG or OG tubes I've used, I ALWAYS got some kind of greenish gastric fluid back and ALWAYS got a clear sound of an air bubble in the R ABD. I questioned this to my preceptor (she has one year in ICU) and she too questioned the placement. She suggested I order an xray to confirm placement which I did. I did not give the meds. Another, more experienced nurse came to listen and said she "thought the bubble sound was OK". This nurse has never been helpful to me, indeed, she has exuded hostility for the 6 weeks I've oriented on the unit. She reported to the Charge Nurse that I "refuse to take direction" and the Charge Nurse reported that to the Nurse Manager. I was called on the carpet to explain my behavior. The nurse manager said it was "common" in the ICU to get back clear, frothy fluid from a pt who had not eaten in 2 days and that "if the tube had been in the lungs, the pt would have been desatting".

I would appreciate feedback from you folks.

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ALWAYS get an xray to confirm placement. Always.

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Specializes in Critical Care, Capacity/Bed Management.

I agree with Nursetastic an x-ray for placement confirmation is always necessary.

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Specializes in ICU.

it was probably too high like lower esophagus or just past the sphincter so you were just drawing on mucus. You usually know when your in the lung. I would have advanced the tube 10 cm maybe and rechecked by listening and aspirating. You can also get a X-ray to confirm but I would have advance it a bit first.

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Specializes in Trauma/Critical Care.
I have 3 years experience on an Onc floor, but I'm new to ICU. Last shift, a newly intubated s/p cabg (2 days) pt was intubated and an OG tube was placed @ 1500 and the MD said it sounded like "it is in the right place". At 1730, I was expected to give meds via the tube. I heard no air bubble in the R abd, a faint bubble midline. When I drew back on the tube, I only got frothy, clear fluid. In all the NG or OG tubes I've used, I ALWAYS got some kind of greenish gastric fluid back and ALWAYS got a clear sound of an air bubble in the R ABD. I questioned this to my preceptor (she has one year in ICU) and she too questioned the placement. She suggested I order an xray to confirm placement which I did. I did not give the meds. Another, more experienced nurse came to listen and said she "thought the bubble sound was OK". This nurse has never been helpful to me, indeed, she has exuded hostility for the 6 weeks I've oriented on the unit. She reported to the Charge Nurse that I "refuse to take direction" and the Charge Nurse reported that to the Nurse Manager. I was called on the carpet to explain my behavior. The nurse manager said it was "common" in the ICU to get back clear, frothy fluid from a pt who had not eaten in 2 days and that "if the tube had been in the lungs, the pt would have been desatting".

I would appreciate feedback from you folks.

Hi CM,

First of all, let me point out that you (and your preceptor) were in the right not to inject anything in that OGT, if placement was in question. As others had pointed out, standard of care is always to comfirm placement by X-ray (is anyone out there still, only doing auscultation :confused::confused:??).

Now...where was your preceptor when all this drama was going on?? While on orientation, you are working with someone's else patients...if your preceptor was of the opinion that a X-ray was needed, why was this other nurse interfering with your practice?? I can undestand bouncing ideas with each other, but never allow anyone intimidate you to the point where you go against your own judgement.

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Specializes in Oncology, ICU.

Thank you for this. I crawled out of that hospital on Saturday feeling like scum. I considered not even going back. I had not a single moment of peace when I was off.

But wait....there's more.

The incident happened Saturday. I was off on Sunday and worked Monday night. Turns out, the nurse to whom I gave report and to whom I stated that I felt the the tube placement was questionable ended up getting intimidated into starting a tube feed and giving meds in that tube. The xray I had ordered came back within one hour as "questionable OG tube placement, needs clinical verification". The MD came to the floor an hour after I had left, furious that the TF was not going. He looked at the xray and ordered the RN who had relieved me to "push it down another 5 cm" and start the tube feeding. Notice, however, this was all VERBAL, no written evidence of his order. She started it and within 6 hours, it was discovered that the tube was now curled in the patient's mouth, draining into his trachea and/or esophagus.

And my preceptor....she not only changed her tune (she had originally agreed with me that it was not possible for us to verify location of the tube), she sided with the other nurse writing in her patient notes that she had felt it was in the proper place! She is no longer my preceptor.

Thanks again for your much needed support.

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Specializes in ICU.

Hold on one cotton pickin' minute. :p

Lemme get this straight.

This patient is intubated.

It's an 'oral gastric' tube.

There's only two ways down - trachea or esophagus. One is already plugged - trachea. So, how can it possibly go into a lung? :rolleyes:

I understand that it could have been curled inside the oropharynx or mouth. I guess, in this case, if the CXR still couldn't confirm it's placement, I would just pull it and sink a new one. How can you miss? :lol2: (edit: we had standing post-op orders that allowed us to do that sort of thing, maybe you don't)

I know, that hind sight is 20/20 vision, but I guess that's what I would have done and why the doc was so adamant about using that tube.

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You were right in asking for a x-ray. If the patient is intubated, it can't possibly go into the trachea, but it can curl anywhere (oropharynx, high esophagus) and pump tube feeding back up and slowly leak around the ETT cuff (it's only a relative seal).

You won't always get gastric contents, especially if the patient has been NPO for days. We often just use two nurses to verify auscultation if it's so obvious that you can hear it in the belly with the stethoscope off. If it's questionable, we always get an x-ray.

Don't feel bad about this. There's lots of horrible nurses out there, don't become one of them because of peer pressure.

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And get in the habit of throwing an OG tube into your newly intubated patients (as long as they're not esophageal varices patients or similar). That way when x-ray comes to check ETT placement you've now got verification of OGT placement without another x-ray.

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Hold on one cotton pickin' minute. :p

Lemme get this straight.

This patient is intubated.

It's an 'oral gastric' tube.

There's only two ways down - trachea or esophagus. One is already plugged - trachea. So, how can it possibly go into a lung? :rolleyes:

I understand that it could have been curled inside the oropharynx or mouth. I guess, in this case, if the CXR still couldn't confirm it's placement, I would just pull it and sink a new one. How can you miss? :lol2: (edit: we had standing post-op orders that allowed us to do that sort of thing, maybe you don't)

I know, that hind sight is 20/20 vision, but I guess that's what I would have done and why the doc was so adamant about using that tube.

If you think nothing can get by the cuff of an ET tube why do we place the head of the bed at 30 degrees? The balloon on the cuff is exactly that, a balloon. Its relatively easy to get an NG or a dobhoff around an ET tube (especially a Dobhoff). Usually you get a big cuff leak but not always. CXR to confirm is our policy.

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Specializes in ICU.

CXR confirmation for sure.

You're not going to push a tube such as a Salem Sump through/past/over/under the cuff of an ET tube and not know it. First it's not going to slip through easily, you're going to have a lot more resistance and I don't think that cuff leak would go unnoticed. Not for long!

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Specializes in ICU, CV-Thoracic Sx, Internal Medicine.
CXR confirmation for sure.

You're not going to push a tube such as a Salem Sump through/past/over/under the cuff of an ET tube and not know it. First it's not going to slip through easily, you're going to have a lot more resistance and I don't think that cuff leak would go unnoticed. Not for long!

I agree with core0

Orally intubated pt's can still aspirate with improperly placed NGT's/dobhoffs. Air leaks can be eliminated with more cuff pressure.

Questionable placement of a line does not mean push it further in. When reading the CXR of an orally intubated pt, the ETT can easily hide the NGT. AP CXR's are sometimes notoriously poor quality films and make determining placement difficult.

For an NGT, I would just take the thing out and restart from scratch, reorder X-ray for verification. The OP was correct in going with her gut instinct and asking for placement verification.

Typically the patient comes back from the OR with lines/tubes/drains in place. So unless the OP placed the tube, she won't know if resistance was met or not when dropping the sump through.

The way I see it, a lot of this mess could have been avoided if the OP would have just removed the NGT (questionable placement on auscultation) and reattempted placement. The tube curl would have been obvious on removal.

To the OP, did you bring up the issue to the nurse manager? Did you mention the ill placed tube and your correct assessment? ;)

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