Nasogastric Tube Procedure (Video)

Introduction
Gastric intubation via the nasal passage (ie, nasogastric route) is a common procedure that provides access to the stomach for diagnostic and therapeutic purposes. A nasogastric (NG) tube is used for the procedure. The placement of an NG tube can be uncomfortable for the patient if the patient is not adequately prepared with anesthesia to the nasal passages and specific instructions on how to cooperate with the operator during the procedure.
Indications

Diagnostic 

• Evaluation of upper gastrointestinal (GI) bleed (ie, presence, volume)
• Aspiration of gastric fluid content
• Identification of the esophagus and stomach on a chest radiograph
• Administration of radiographic contrast to the GI tract

Therapeutic 

• Gastric decompression, including maintenance of a decompressed state after endotracheal intubation, often via the oropharynx
• Relief of symptoms and bowel rest in the setting of small-bowel obstruction
• Aspiration of gastric content from recent ingestion of toxic material
• Administration of medication
• Feeding
• Bowel irrigation

Contraindications
Absolute contraindications

• Severe midface trauma
• Recent nasal surgery

Relative contraindications

• Coagulation abnormality
• Esophageal varices or stricture
• Recent banding or cautery of esophageal varices
• Alkaline ingestion

Anesthesia

• Various methods of topical anesthesia for nasogastric intubation have been proven effective in pain relief and improve the likelihood of successful nasogastric intubation.1,2,3,4,5
• The use of viscous lidocaine (ie, the sniff and swallow method) is discussed in the Technique section below.
• Alternative techniques include the following:
  • Nebulization of lidocaine 1% or 4% through a face mask (≤4 mg/kg; not to exceed 200 mg per dose in adults) is an option. The authors recommend that a preservative-free lidocaine (ie, intravenous lidocaine) be used for nebulization in order to minimize the risk of allergic reaction.
  • An anesthetic spray that contains benzocaine or a tetracaine/benzocaine/butyl aminobenzoate combination (Cetacaine) may be applied to the nasal and oropharyngeal mucosa. Be advised that incidents of methemoglobinemia after a single use of benzocaine topical sprays have been reported to the US Food and Drug Administration (FDA). For more information, see Anesthesia, Topical.

EquipmentThe following equipment is needed (also see image below):

• Nasogastric tube
  • Adult - 16-18F
  • Pediatric - In pediatric patients, the correct tube size varies with the patient's age. To find the correct size, add 16 to the patient's age in years and then divide by 2 (eg, [8 y + 16]/2 = 12F)
• Viscous lidocaine 2%
• Oral analgesic spray (Benzocaine spray or other)
• Syringe, 10 mL
• Glass of water with a straw
• Water-based lubricant
• Toomey syringe, 60 mL
• Tape
• Emesis basin or plastic bag
• Wall suction, set to low intermittent suction
• Suction tubing and container

Positioning

• Position the patient seated upright.

Technique

• Explain the procedure, benefits, risks, complications, and alternatives to the patient or the patient's representative.
• Examine the patient's nostril for septal deviation. To determine which nostril is more patent, ask the patient to occlude each nostril and breathe through the other.
• Instill 10 mL of viscous lidocaine 2% (for oral use) down the more patent nostril with the head tilted backwards (as shown in the images below), and ask the patient to sniff and swallow to anesthetize the nasal and oropharyngeal mucosa. In pediatric patients, do not exceed 4 mg/kg of lidocaine. Wait 5-10 minutes to ensure adequate anesthetic effect.
• Aspiration of viscous lidocaine into a syringe.
• Instillation of viscous lidocaine 2%.
• Estimate the length of insertion by measuring the distance from the tip of the nose, around the ear, and down to just below the left costal margin. This point can be marked with a piece of tape on the tube. When using the Salem sump nasogastric tube (Kendall, Mansfield, Mass) in adults, the estimated length usually falls between the second and third preprinted black lines on the tube, as shown below.
• Estimation of nasogastric tube length from nostril to stomach.
• Position the patient sitting upright with the neck partially flexed. Ask the patient to hold the cup of water in his or her hand and put the straw in his or her mouth. Lubricate the distal tip of the nasogastric tube as shown.
• Nasogastric tube lubrication with water-based lubricant.
• Gently insert the nasogastric tube along the floor of the nose and advance it parallel to the nasal floor (ie, directly perpendicular to the patient's head, not angled up into the nose) until it reaches the back of the nasopharynx, where resistance will be met (10-20 cm). At this time, ask the patient to sip on the water through the straw and start to swallow. Continue to advance the nasogastric tube until the distance of the previously estimated length is reached. See the images below.
• Patient flexing his neck and drinking water while a nasogastric tube is inserted.
• Auscultation over the stomach.
• Nasogastric tube in lung.
• Apply Benzoin or another skin preparation solution to the nose bridge. Tape the nasogastric tube to the nose to secure it in place as shown. If clinically indicated, attach the nasogastric tube to wall suction after verification of correct placement.
• Secured nasogastric tube.

Pearls

• During insertion, if concern exists that the tube is in the incorrect place, ask the patient to speak. If the patient is able to speak, then the nasogastric tube has not passed through the vocal cords and/or lungs.
• The nasogastric tube may coil in the nasopharynx or oropharynx. If this occurs, or if the tube is difficult to pass in general, try curling the distal end and partially freezing it in a cup of ice so it temporarily holds its curled shape better. Insert the lubricated tube tip through the nose with the curled end pointing downward. Once the distal tip passes into the hypopharynx, the curved tip faces anteriorly. Rotate the tube 180 degrees so that the curved end is pointing posteriorly toward the esophagus. Continue to insert in the usual manner by having the patient swallow water.
• Another option (only in patients who are sedated and paralyzed) is to place 2-3 fingers through the patient’s mouth into the oropharynx. The fingers are used to guide the nasogastric tube into the hypopharynx.
• Lifting the thyroid cartilage anterior and upward might open the esophagus and allow passage into the proximal esophagus.
• A method of freezing a nasogastric tube with distilled water was shown to increase the success rate of insertion for intubated patients.6
• Direct laryngoscopy or video laryngoscopy can aid in placing a nasogastric tube in sedated patients by visualization of the tip entering the esophagus.7
• Although pH, enzyme, bilirubin, and carbon dioxide testing have been used to distinguish respiratory from gastrointestinal placement of nasogastric tubes, none of these methods has enabled detection of tube placement in the esophagus or gastroesophageal junction. Therefore, the authors recommend the routine use of x-ray verification.8
• In patients who are anesthetized, Appukutty and Shroff found that 3 techniques can increase the success rate of nasogastric tube placement. In randomized controlled study in 200 patients, the use of a ureteral guidewire as stylet or a slit endotracheal tube as an introducer increased the success rate compared with controls, although the latter technique significantly lengthened the time for insertion. However, head flexion with lateral neck pressure proved to be the easiest technique, with a high success rate and fewest complications

Complications

• Patient discomfort
  • Generous lubrication, the use of topical anesthetic, and a gentle technique may reduce the patient’s level of discomfort.
  • Throat irritation may be reduced with administration of anesthetic lozenges (eg, benzocaine lozenges [Cepacol]) prior to the procedure.
• Epistaxis may be prevented by generously lubricating the tube tip and using a gentle technique.
• Respiratory tree intubation
• Esophageal perforation

References:

1. Cullen L, Taylor D, Taylor S, Chu K. Nebulized lidocaine decreases the discomfort of nasogastric tube insertion: a randomized, double-blind trial. Ann Emerg Med. Aug 2004;44(2):131-7. [Medline].
2. Ducharme J, Matheson K. What is the best topical anesthetic for nasogastric insertion? A comparison of lidocaine gel, lidocaine spray, and atomized cocaine. J Emerg Nurs. Oct 2003;29(5):427-30. [Medline].
3. Middleton RM, Shah A, Kirkpatrick MB. Topical nasal anesthesia for flexible bronchoscopy. A comparison of four methods in normal subjects and in patients undergoing transnasal bronchoscopy. Chest. May 1991;99(5):1093-6. [Medline].
4. West HH. Topical anesthesia for nasogastric tube placement. Ann Emerg Med. Nov 1982;11(11):645. [Medline].
5. Wolfe TR, Fosnocht DE, Linscott MS. Atomized lidocaine as topical anesthesia for nasogastric tube placement: A randomized, double-blind, placebo-controlled trial. Ann Emerg Med. May 2000;35(5):421-5. [Medline]
6. Chun DH, Kim NY, Shin YS, Kim SH. A randomized, clinical trial of frozen versus standard nasogastric tube placement. World J Surg. Sep 2009;33(9):1789-92. [Medline].
7. Moharari RS, Fallah AH, Khajavi MR, Khashayar P, Lakeh MM, Najafi A. The GlideScope facilitates nasogastric tube insertion: a randomized clinical trial. Anesth Analg. Jan 2010;110(1):115-8. [Medline].
8. Bourgault AM, Halm MA. Feeding tube placement in adults: safe verification method for blindly inserted tubes. Am J Crit Care. Jan 2009;18(1):73-6. [Medline].
9. Appukutty J, Shroff PP. Nasogastric tube insertion using different techniques in anesthetized patients: a prospective, randomized study. Anesth Analg. Sep 2009;109(3):832-5. [Medline].
10. Reichman EF, Simon RR, eds. Emergency Medicine Procedures. Columbus, OH: McGraw-Hill Professional; 2004.

Rectal Touche': Indication, Minicase and Procedure

Rectal examination is an important part of the abdominal examination and genitourinary examination. It is important in examining for gastrointestinal disease but also for the detection of disease in other pelvic organs. It is an intimate physical examination which should be conducted correctly for detection of disease and patient comfort. Findings should be accurately and correctly recorded.

The rectum begins at the termination of the sigmoid colon about 12 cm from the anal verge. Two muscle bundles, known as the internal and external anal sphincters, participate in defecation. The internal anal sphincter is an enlargement of the circular smooth muscle of the colon and functions involuntarily. The external anal sphincter consists of striated muscle bands under the voluntary control of the puborectalis muscle. The rectum has the same innervation as the bladder; the hypogastric nerves innervate the internal anal sphincter, and the internal pudendal nerve (S3–S4) operates the external anal sphincter. Because of the common innervation, dysuria is a common complaint associated with rectal disorders.

An important landmark both anatomically and clinically is the pectinate line where the anus and rectum merge, approximately 3 to 4 cm from the skin. It serves as a demarcation for venous and lymphatic drainage and for the nerve supply. Above the pectinate line, the veins drain into the portal and caval systems, sympathetic nerves are present (pain is absent), and lymph drains to the superior rectal and iliac nodes. Below the pectinate line, the veins drain into the caval system alone, innervation is through somatic nerves (pain is present), and lymph drains into the inguinal nodes.

The rectum functions to permit defecation in a voluntary fashion. Peristalsis propels the stool from the sigmoid colon into the rectum. Increased intraluminal pressure causes involuntary relaxation of the internal anal sphincter followed by reflex contraction of the external anal sphincter, preventing incontinence while providing awareness of imminent defecation. The external anal sphincter then relaxes in a voluntary fashion, expelling the feces. Studies suggest that the evacuative process is facilitated by larger fecal bulk, providing an impetus for encouraging patients to consume diets high in fiber and bulk.

Indications

This is an intimate and sometimes uncomfortable examination which is most often done when disease (usually gastrointestinal or genitourinary disease) is suspected or already identified. It may also be done as part of a screening examination when there is no suspicion or expectation of disease but the examination is performed as part of a thorough screening process. It is important in all cases to explain the reasons for the examination (see below) and to get verbal consent. Examples of indications for examination include:

·         Assessment of the prostate (particularly symptoms of outflow obstruction).

·         When there has been rectal bleeding (prior to proctoscopy, sigmoidoscopy and colonoscopy).

·         Constipation.

·         Change of bowel habit.

·         Problems with urinary or faecal continence.

·         In exceptional circumstances to detect uterus and cervix (when vaginal examination is not possible).

Minicase

History

A 70 years old man came to the hospital with a primary complaint difficult to urinate and a feeling of not completely after urination since 3 weeks ago. Patients also feel the frequent of urinate is more often than usual. On examination the vital signs looked good. On physical examination there was no anogenital injury, no pain, no hemorrhoid, rectal touche positive prostate enlargement both lobes symmetrical, chewy, no nodule,  the upper limit is not palpable, flat median sulcus, crepitation not exist. Laboratory results within normal limits. Radiology Examination withlower abdominal ultrasound impression suspicious prostatic hypertrophy
Diagnosis

Benigna Hipertrofi Prostat

Procedure

Preparing for the examination

The reasons for performing the procedure should be explained to the patient. The procedure itself should be explained to the patient. Warn patients that:

o    The examination may be uncomfortable but should not be painful.

o    They may experience a feeling of rectal fullness and the desire to defaecate.

o    A chaperone should be offered.

Equipment:

o    Suitable gloves

o    Lubricant

o    Lighting

o    Suitable soft tissues

Position the patient comfortably

The clinical situation and experience of the examiner will often dictate which of several methods to employ in performing the rectal examination. In the lithotomy position, the patient is supine with the legs drawn in toward the trunk and the knees allowed to fall out to the side. This position is customarily used when examining the pelvic organs in women and may offer a better examination of the anterior rectum.

The lateral decubitus, or Sim's position, provides optimal examination when the patient is too ill or otherwise unable to assume other positions. The patient lies on the left side with the buttocks near the edge of the examining table or bedside with the right knee and hip in slight flexion.

The proctologic (knee–chest or prone jackknife) position is the preferred position in which to examine the perineum and rectum properly. In this position, the patient can easily undergo further studies such as anoscopy and sigmoidoscopy because of easier access to the anorectum. Regardless of the position used, the rectal examination involves both inspection and palpation.
Detail of The Procedures

1. The examination is started from anal inspection under shiny illumination
2. Observe anal tone when relaxation and volunter contraction.
3. The patient is asked to strain abdominal muscles just like when defecating for examining the perineal descencus, haemoroid prolaps or other prominent lesions (rectal prolaps and tumor)
4. The right index finger that use handscoen and lubricated with K-Y jelly, is contacted slowly to the anal.
5. Press anal gently until sphincter is opened and the finger can be put into the anal directly
6. Evaluate the rectal ampula
7. Palpate the mucous and rectal filler
8. Pay attention to the prostate and cervices and also several lesions outside the rectum

Examination findings

The findings are described by convention according to the clock face in the lithotomy position. 12 o'clock is anterior and 6 o'clock posterior.

•  External inspection may reveal:

1. Skin disease. For example, natal cleft dermatitis in seborrhoeic eczema
2. Skin tags
3. Pilonidal sinus
4. Genital warts
5. Anal fissures
6. Anal fistula
7. External haemorrhoids
8. Rectal prolapse
9. Skin discolouration with Crohn's disease
10. External thrombosed piles

• Internal examination may reveal:

1. Simple piles (but best examined at proctoscopy)
2. Rectal carcinoma
3. Rectal polyps
4. Tenderness (with, for example, acute appendicitis)
5. Diseases of the prostate gland
6. Malignant or inflammatory conditions of the peritoneum (felt anteriorly)

References :

Bagio, Aji. Penegakan Diagnosa pada Pasien dengan Kasus Benigna Hipertrofi Prostat. www.fkumyecase.net Last Updated 29 Sep 2010.

Draper, Richard. Rectal Examination. www.patient.co.uk Last Updated 6 Jan 2010.

McFarlane, Michael J. The Rectal Examination. www.ncbi.nlm.nih.gov

Student’s Manual Book Gastroenterohepatology System. Medical Faculty of Hasanuddin University.Makassar. 2010.