Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults

Aims of Session Be able to correctly identify anatomy & physiology of upper GI tract Awareness of indications & contra-indications to using NG feeding Awareness of the risks and content of NPSA safety alert (2011 & 2016) Be able to demonstrate safe technique for the insertion of NG feeding tube and checking position Documents procedure correctly

Introduction A nasogastric tube is inserted through the nose into the stomach via the oesophagus for the purposes of: Enteral feeding Administration of medication Gastric aspiration & decompression (this is not being covered within this session) Many NG feeding tubes are inserted each day without incident. However there is a small risk that a NG tube can be misplaced during insertion or displaced after successful insertion. Should this occur and not be recognised serious harm could be experienced by the patient (NPSA 2011). The size of NG tube used for enteral feeding should be between 6 to 12fg.

Indications for NG feeding Neuromuscular swallow disorder Unconscious Physiological anorexia Mental health illness such as anorexia nervosa Patient MUST have an accessible and functioning gastro-intestinal tract Should be a MDT decision is it the right decision for this patient?

Contra indications to bedside insertion Basal skull fracture Maxillo facial disorders Unstable cervical spinal injuries Nasal/Pharyngeal/oesophageal obstruction Oesophageal/pharyngeal pouch Oesophageal strictures Oesophageal varices, tumours Clotting / bleeding disorders Gastric outflow obstruction Previous nasopharyngeal or oesophageal surgery This is not an exhaustive list and you should discuss any concerns with the Dr of CNNS.

NPSA alert Some of the issues identified were: National Patient Safety Agency (NPSA) re-issued its safety alert July 2016 Since 2011 95 reports of people having feed or fluid passed into the respiratory tract due to misplaced ng tube. Some of the issues identified were: • no assurance that staff who checked tube placement had received competency-based training • bedside documentation did not include all safety critical checks • problems maintaining safe supplies of equipment, particularly radio-opaque tubes and CE-marked pH test strips.

How to avoid complications All staff must receive competency based training pH testing is the first line test for position & should be between 1 & 5.5. x-ray is the second line test. It is essential that pH is tested and documented on insertion & before every use X-ray if required MUST be read by a clinically competent practitioner who has received training into interrupting ng tube placement and documented fully.

Equipment needed Apron & gloves NG tube 50ml purple syringe Tissues Glass of water (if patient able to swallow) Lubricating jelly or water NG plaster or tape pH testing strips Care plan

Procedure once decision to insert NG tube has been made Explain procedure to patient & gain verbal consent Gather equipment needed, wash hands and don PPE Position patient in upright position if able Estimate the length of tube using ‘NEX’ measurement Ask patient to blow nose if able Lubricate ng tube Give patient glass of water if safe for them to swallow Insert tube into nostril guiding it gently downwards over the nasopharynx Encourage patient to take sips of water whilst advancing tube Insert tube to point measured via NEX Secure tube using tape Check tube position by aspirating >1ml fluid and testing pH. Ensure it is below 5.5 If pH below 5.5 guidewire can be removed & tube is safe to use.

If unable to aspirate post insertion Leaving the guidewire in place try repositioning tube by pulling it back gently or inserting it further & retry to aspirate. Lie patient on left side for 10-20 mins & retry to aspirate, Insert 10mls air down tube then try to aspirate If all the above fail an x-ray will be required.

Documentation Clinical reason for insertion Consent obtained What to document? Clinical reason for insertion Consent obtained NEX measurement pH result (2 staff to check on initial insertion & sign) If x-ray used Dr must document that: - tube descends the thorax in the midline - tube bisects the carina - tube crosses the diaphragm in the midline - the tip sits below the diaphragm

Questions