Not Monitoring Gastric Residual Volume Did Not Increase the Incidence of Aspiration or Related Complications
Recommendations (Society of Critical Care Medicine, SCCM, and American Society for Parenteral and Enteral Nutrition, ASPEN, 2016 Guidelines) [MEDLINE]
Gastric Residual Volume Should Not Be Used to Monitor Enteral Nutrition (Quality of Evidence: Low): if used, cutoff for residual volume should be >500 mL
Aspiration of Gastric Contents Has a Low Sensitivity to Detect an Upper GI Bleeding Source
Gastric Lavage
General Comments
Generally Performed via a Salem Sump or Larger Tube
Clinical Utility
Removal of Blood or Blood Clots to Facilitate Esophagogastroduodenoscopy (EGD) (see Esophagogastroduodenoscopy, [[Esophagogastroduodenoscopy]])
Removal of Ingested Agents in the Setting of Overdose/Intoxication
XXX Intoxication
Post-Abdominal/Gastrointestinal Surgery
General Comments
Generally Performed via a Salem Sump
Clinical Efficacy
Systematic Review of Prophylactic Nasogastric Tube Placement After Abdominal Surgery (Br J Surg, 2005) [MEDLINE]
Patients without Routine Nasogastric Tubes Had Earlier Return of Bowel Function, Marginal Decrease in Pulmonary Complications, Marginal Increase in Wound Infections, and Marginal Increase in Ventral Hernia
Routine Nasogastric Tube Use Had No Impact on the Incidence of Anastomotic Leak
Systematic Review of Prophylactic Nasogastric Tubes Placed After Abdominal Surgery (Cochrane Database Syst Rev, 2007) [MEDLINE]
Patients without Routine Nasogastric Tubes Had Earlier Return of Bowel Function and a Decrease in Pulmonary Complications
Patients without Routine Nasogastric Tubes Had a Trend Toward an Increase in the Risk of Wound Infection and Ventral Hernia
Routine Nasogastric Tube Use Had No Impact on the Incidence of Anastomotic Leak
Routine Nasogastric Tube Use Decreased Vomiting, But Increased Patient Discomfort
Conventional Method of Placement is with the Head in Forward Position Tilted Toward the Chest
Trial of Methods for Nasogastric Tube Insertion in Intubated Patients (Indian J Anaesth, 2014) [MEDLINE]
Reverse Sellick’s Maneuver, Neck Flexion with Lateral Neck Pressure, and Guidewire-Assisted Techniques are All Better Alternatives to Conventional Method of Nasogastric Tube Insertion in Anesthetized, Intubated Adult Patients
Measurement for Optimal Required Length of Tube
Measure from Tip of Ear to Tip of Nose to Tip of Xiphoid: however, this method can both underestimate and overestimate the length of tube required
Advancement of the Tube to 30-35 cm and Measurement of Carbon Dioxide Aspirated from the Nasogastric/Orogastric Tube: detection of carbon dioxide confirms malplacement of the tube
Systematic Review of Diagnostic Accuracy of Methods to Verify Nasogastric Tube Placement in Mechanically Ventilated Patients (JBI Database System Rev Implement Rep, 2015) [MEDLINE]
Colorimetric Capnography Detected Nasogastric Tube Position with Very High Accuracy (Level 2b Evidence)
Sensitivity: 88-100%
Specificity: 99-100%
However, Further Research is Required to Determine the Best Implementation of this Technology: since colorimetric capnographs do not have manufactured NG tube adaptors, etc
Interim Imaging Following Advancement of the Tube to 30-35 cm
Advancement of the Tube to 30-35 cm with Imaging at that Preliminary Position (with the Tube at a Distance Unlikely to Penetrate the Lung Parenchyma and into the Pleural Space) is a Technique Which Could Be Utilized to Minimize the Risk of Pneumothorax in Cases Where the Tube is Inadvertently (Blindly) Placed into the Trachea
Imaging Following Final Tube Positioning: commonly used
Tube Fixation
Nasal Bridle
Adhesive Tape
Adverse Effects/Complications
Dermatologic Adverse Effects/Complications
Pressure Ulcer/Necrosis at Site of Tube Entry
Epidemiology
XXXX
Physiology
XXXX
Gastrointestinal Adverse Effects/Complications
General Comments
Nasogastric/Orogastric Tube Impairs Function of the Lower Esophageal Sphincter, Increasing the Risk of Reflux and Subsequent Esophagitis, Esophageal Stricture, Gastrointestinal Hemorrhage, or Pulmonary Aspiration
Mechanical Complications May Occur Anywhere Throughout the Course of the Tube (Including in the Pharynx, Pyriform Sinus, Esophagus, Stomach, and Duodenum)
Clinical
Gagging/Emesis May Indicate Coiling in the Pharynx or Piriform Sinus
Manegement
Management of the Knotted Tube May Require Interventional Radiology Fluoroscopic or Gastroenterology Endoscopic Removal of the Knot
Infectious Adverse Effects
Risk of Moraxella Catarrhalis Bacteremia (in Children)
Epidemiology
Transnasal Devices (Nasogastric Tube, etc) Has Been Reported to Increase the Risk of Moraxella Catarrhalis Bacteremia in Children (BMC Infect Dis, 2016)[MEDLINE]
Neurologic Adverse Effects/Complications
Inadvertent Placement of Nasogastric/Orogastric Tube into the Brain
Epidemiology
Risk is Increased in Patients with Head/Facial Trauma or Prior Transsphenoidal Surgery
Physiology
Tube May Traverse a Fractured Cribriform Plate or Fractured Ethmoid Lamina Cribrosa (at the Apex of the Nasal Cavity) to Enter the Brain
Tube May Traverse Prior Surgical Site from a Prior Transsphenoidal Pituitary Resection: even one that was performed years earlier (Am J Nurs, 2002) [MEDLINE]
Review of the Pulmonary Complication Rate for Blind Placement of Narrow-Bore of Nasogastric/Orogastric Tubes (JPEN J Parenter Enteral Nutr, 2011) [MEDLINE]
Overall Pulmonary Complication Rate for Blind Placement of Narrow-Bore Nasoenteric Tubes: 1.9%
Of These, the Rate of Pneumothorax was 18.7% (5 of Which Resulted in Death)
Of These, Malpositioning Occurred in 13-32% of Subsequent Repositioning Attempts
Of These, 60.4% of the Patients were Mechanically Ventilated
Insertion Strategies May Mitigate the Risks Related to Inadvertent Placement of the Nasogastric/Orogastric Tube into the Tracheobronchial Tree
Strategies
Use of Dedicated, Experienced Hospital Teams Who Place Nasogastric/Orogastric Tubes
Placement of Tube to 35 cm Followed by Radiography to Confirm Intraesophageal Placement Prior to Advancement into the Stomach
Clinical Efficacy
Utilization of a Specialized Feeding Tube Placement Team and Utilizing Feeding Tube Placement to 35 cm and Obtaining a Radiograph Before Full Advancement Significantly Decreased the Incidence of Procedure-Related Pneumothorax (0.09% vs 0.38%) ( J Am Coll Surg, 2004) [MEDLINE]: n = 4190 placements
Utilization of Mitigation Strategies for Small-Bore Nasogastric/Orogastric Tube Placement Decreases Adverse Events (JPEN J Parenter Enteral Nutr. 2006) [MEDLINE]
The Mere Presence of a Nasogastric/Orogastric Tube May Be a Risk Factor for Aspiration in Mechanically Ventilated Patients (Eur Resp J, 2006) [MEDLINE]
Physiology
Nasogastric/Orogastric Tube Impairs Function of the Lower Esophageal Sphincter, Increasing the Risk of Reflux and Subsequent Pulmonary Aspiration
Inadvertent Placement of Nasogastric/Orogastric Tube into the Tracheobronchial Tree
Epidemiology
Inadvertent Small-Bore Feeding Tube Placement into the Tracheobronchial Tree Occurred in Approximately 3.2% of Placements in a Major University Tertiary Referral Hospital (JPEN J Parenter Enteral Nutr, 2007) [MEDLINE]
Mandatory Radiographs (After Tube Placement) May Decrease the Risk of Subsequent Respiratory Administration, But Not the Risk of Misplacement Itself
Inadvertent Small-Bore Feeding Tube Placement Placement into the Tracheobronchial Tree Occurred in Approximately 1.9% of Placements (JPEN J Parenter Enteral Nutr, 2011) [MEDLINE]
Nasogastric Tubes Can Be Inadvertently Placed into the Tracheobronchial Tree, Despite an Inflated Endotracheal Tube Cuff (J Chin Med Assoc, 2008) [MEDLINE]
On Mechanical Ventilation, the Lost Volume Can Be Quantified as the Difference Between Inspiratory Tidal Volume and Expiratory Tidal Volume (i.e. Expiratory Tidal Volume is Lower than Inspiratory Tidal Volume)
Lost Volume May Increase When Suction is Applied to the Nasogastric Tube
Inadvertent Placement of Nasogastric Tube into the Pleural Space
Epidemiology
Inadvertent Small-Bore Feeding Tube Placement Placement into the Tracheobronchial Tree Occurred in Approximately 1.9% of Placements (JPEN J Parenter Enteral Nutr, 2011) [MEDLINE]
Risk of Major Complications (Pneumothorax, Hemopneumothorax) with Nasogastric Tube Placement is Approximately 0.7% (Similar to That of Central Venous Catheter Placement) (Crit Care, 1998) [MEDLINE]
In One Review, Pneumothorax was the Cause of Death in 5/8 Reported Mortalities (JPEN J Parenter Enteral Nutr, 2011) [MEDLINE]
Obstruction of Nasal Breathing
Epidemiology
While Obstruction of Nasal Breathing May Occur in Any Patient with Nasal Placement, this is Especially Prevalent in Neonates, as They are Obligate Nasal Breathers
Respiratory Failure (During or After Placement)
Epidemiology
XXXXX
Physiology
Due to Aspiration or Inadvertent Tracheobronchial Placement of the TUbe
Vascular Adverse Effects/Complications
Vascular Penetration
Inadvertent Tube Incursion into the Right Atrium
Inadvertent Tube Incursion into the Subclavian Artery
References
Fatal hydrothorax and empyema complicating a malpositioned nasogastric tube. Chest. 1981;79(2): 240-242
Inadvertent tracheobronchial placement of feeding tubes. Radiology. 1987;165(3):727-729
The nasogastric tube syndrome. Laryngoscope. 1990 Sep;100(9):962-8
A prospective study of tracheopulmonary complications associated with the placement of narrow-bore enteral feeding tubes. Crit Care 1998;2(1):25-28 [MEDLINE]
Duodeno-renal fistula due to a nasogastric tube in a neonate. Pediatr Surg Int. 1998;14(1-2):102 [MEDLINE]
Nasogastric tube knotting in open heart surgery. Acta Anaesthesiol Scand. 1999;43(7):790 [MEDLINE]
Nasendoscopically-assisted placement of a nasogastric feeding tube. J Laryngol Otol. 1999;113(9):839 [MEDLINE]
A unique complication of primary tracheoesophageal puncture: knotting of the nasogastric tube. Otolaryngol Head Neck Surg. 1999;120(4):528 [MEDLINE]
Inadvertent intracranial placement of a nasogastric tube in patients with head injuries. Surg Neurol. 1999;52(4):426 [MEDLINE]
Morbidity, mortality, and risk factors for esophagitis in hospital inpatients. J Clin Gastroenterol. 2000;30(3):264 [MEDLINE]
Intracranial placement of a nasogastric tube after severe craniofacial trauma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;90(5):564 [MEDLINE]
What is known about methods of correctly placing gastric tubes in adults and children. Gastroenterol Nurs. 2004;27(6):253 [MEDLINE]
Effect of institutional protocols on adverse events related to feeding tube placement in the critically ill. J Am Coll Surg. 2004;199:39-50 [MEDLINE]
Nasogastric tubes: hard to swallow. Ann Emerg Med. 2004;44(2):138 [MEDLINE]
Systematic review of prophylactic nasogastric decompression after abdominal operations. Br J Surg. 2005;92(6):673 [MEDLINE]
Thoracic complications of nasogastric tube: review of safe practice. Interact Cardiovasc Thorac Surg 2005;4(5):429-433 [MEDLINE]
Acute complications associated with bedside placement of feeding tubes. Nutr Clin Pract. 2006;21(1):40 [MEDLINE]
Nasogastric tube syndrome: a life-threatening laryngeal obstruction in a 72-year-old patient. Age Ageing (September 2006) 35 (5): 538-539
Nasogastric tube feeding is a cause of aspiration pneumonia in ventilated patients. Eur Resp J 2006; 27:436 – 437 [MEDLINE]
Enhancing patient safety during feeding- tube insertion: a review of more than 2000 insertions. JPEN J Parenter Enteral Nutr. 2006;30:440-445 [MEDLINE]
Complications related to feeding tube placement. Curr Opin Gastroenterol. 2007;23(2):178 [MEDLINE]
Devices and techniques for bedside enteral feeding tube placement. Nutr Clin Pract. 2007 Aug;22(4):412-20 [MEDLINE]
Inadvertent tracheobronchial placement of feeding tube in a mechanically ventilated patient. J Chin Med Assoc. 2008;71(7):365 [MEDLINE]
Verification of an electromagnetic placement device compared with abdominal radiograph to predict accuracy of feeding tube placement. J Parenter Enteral Nutr 2011;35(4):535-539 [MEDLINE]
Pulmonary complications of 9931 narrow-bore nasoenteric tubes during blind placement: a critical review. JPEN J Parenter Enteral Nutr. 2011 Sep;35(5):625-9. doi: 10.1177/0148607111413898. Epub 2011 Jul 28 [MEDLINE]
NUTRIREA 1 Trial. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA. 2013;309(3):249 [MEDLINE]
Comparison of four techniques of nasogastric tube insertion in anaesthetised, intubated patients: A randomized controlled trial. Indian J Anaesth. 2014 Nov-Dec;58(6):714-8 [MEDLINE]
Diagnostic accuracy of methods used to verify nasogastric tube position in mechanically ventilated adult patients: a systematic review. JBI Database System Rev Implement Rep. 2015;13(1):188 [MEDLINE]
Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211. doi: 10.1177/0148607115621863 [MEDLINE]
Clinical characteristics of the patients with bacteremia due to Moraxella catarrhalis in children: a case-control study. BMC Infect Dis. 2016;16:73 [MEDLINE]
