Ng Tube Nose Holder? The 230 Detailed Answer

I. Problem/Challenge.

When placing a nasogastric (NG) tube, a flexible 14-18 French plastic tube is placed from the nose into the stomach. For patients with facial/nasal trauma, these tubes can be inserted orally. This tube allows for drug administration, enteral feeding, gastric drainage, treatment of intestinal obstruction, prevention of aspiration from emesis, use in diagnostic or mobility studies, assessment and diagnosis of gastrointestinal bleeding. Nurses are trained in this procedure.

II. Identify the target behavior.

The aim of placing a gastric tube is the correct and uncomplicated intubation of the stomach. Nasogastric tubes should not be placed in patients with facial or head trauma or patients who have undergone gastric bypass surgery. There is a relative contraindication to this procedure in patients with coagulation abnormalities, the presence or recent history of banding/burning of esophageal varices, and the presence of esophageal strictures.

Complications of nasogastric tube placement include aspiration of gastric contents, airway intubation, trauma or erosion of the nasal mucosa, sinusitis, otitis media, sore throat, epistaxis. The most serious complications include esophageal perforation, collapsed lung, and intracranial placement.

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III. Describe a step-by-step procedure/method for this problem.

Step 1: Gather the equipment: 14-18 French feeding tube, non-sterile gloves and eye protection, 60 ml syringe (toomey) with catheter tip, lubricant (2% xylocaine gel, water-based lubricant), tape, wall or portable Suction device with hose and Yankauer tip, vomit basin, stethoscope, litmus paper (available), cup of water or ice chips.

Step 2: Sit the patient as upright as possible.

Step 3: Explain the procedure to the patient, including benefits, risks, potential complications, and alternatives.

Step 4: Put on non-sterile gloves and eye protection.

Step 5: Determine how many centimeters to advance the catheter (usually 50-60 cm). To measure, place the distal tip of the catheter at the nasal vestibule, at the ear, and to midway between the xyphoid process and the umbilicus. Mark this measurement with a piece of tape or a pen.

Step 6: Examine the nostril for the optimal side, free from obstruction or septal deviation.

Step 7: (If available) Instill 5-10 ml of 2% xylocaine gel into preferred nostril.

Step 8: Turn on the portable or wall suction device for continuous operation and place the Yankauer tip near the patient.

Step 9: Place the water/ice chips and vomit basin near the patient.

Step 10: Cap the end of the feeding tube.

Step 11: Lubricate the first 6 inches of the hose.

Step 12: With the patient’s neck flexed, insert the tube into the preferred nostril while the patient swallows (using ice chips or water). Advance to the pasted marker. Don’t force. Withdraw immediately if tube curls up in mouth or patient develops shortness of breath.

Step 13: Check placement using two methods. Attach the catheter syringe and aspirate, searching for gastric contents. If litmus paper is present, check the pH of the contents (stomach pH 1-5.5). Carry out the “whoosh test”. Using the catheter-syringe, instill 10–20 mL of air into the tube while simultaneously ascultating with the stethoscope in the left upper quadrant of the abdomen. An audible “whoosh” indicates that the feeding tube is correctly placed in the stomach. Caution: Listening to the “whoosh” is not accurate 20% of the time. If this is not possible, or if the patient requires medication administration or enteral feeding, perform a chest x-ray to verify placement. Look at the x-ray to visualize the tube crossing the left hemidiaphragm and then deviating to the left.

Step 14: After the placement has been verified, tape the tube to the nose.

IV. Common Mistakes.

If the tube curls up in the mouth, curl the distal end and soak in ice water for a few minutes. This slightly stiffens the hose for easier passage.

The head can be rotated to either shoulder during placement to bring the trachea off centerline.

After insertion, ask the patient to speak. If the patient can speak, the tube has not passed through the vocal cords.

Once the tube is inserted into the oropharynx, pause and allow the patient to take a few deep breaths to relax. After this pause, instruct the patient to swallow while continuing to advance the tube.

Avoid advancing the tube all the way to the hub. Always approximate the insertion depth by measuring on the patient.

Do not instill anything but air into the tube until placement has been verified.

More than 3 attempts per provider should be avoided.

Do not rely on cuffed endotracheal tubes for placement. Use the verification methods above.

If a nasogastric tube cannot be placed at the bedside, interventional radiology can assist placement using fluoroscopy, or ENT/GI doctors can use endoscopy to visually intubate the stomach.

V. National standards, core indicators and quality measures.

No national standards/benchmarks established yet.

VI. What is the evidence?

Benya, B., Langer, S., Morbarhan, S. “Flexible nasogastric feeding tube tip immediately after placement”. Journal of Parenteral and Enteral Nutrition. volume 141. 1990. pp. 108-109.

Bourgault, AM, Halm, MA. “Feeding tube placement in adults: safe verification method for blindly inserted tubes”. Am J Crit Care.. vol. 18. 2009. pp. 73-6.

Chun DH, Kim NY, Shin YS, Kim SH. “A Randomized, Clinical Trial of Frozen vs. Standard Nasogastric Tube Placement”. World J Surg.. vol. 33. 2009. pp. 1789-92.

Lamont, T, Beaumont, C, Fayaz, A. “Review of gastric tube placement in adults (interpretation of radiographs): summary of a safety report from the National Patient Safety Agency”. MJ volume 342. 2011.

Shalamovitz, G.. 2011.

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It is normal for caregivers and patients to worry about G-probe dislocation. Finally, dislodgement of a G-tube can lead to complications such as stomach leaks, which require medical attention.

G-tube dislodgement is most commonly due to three incidents: patient pulling or snagging on the tube, movement of the tube during patient repositioning or transfer, and underinflated retaining balloon. It is important to ensure that proper care is applied whether you are the patient with the feeding tube or serving as the caregiver. Should a tube become detached, always consult a physician to ensure proper care and maintenance is performed.

Prevention is key to avoiding G-tube displacement. The American Society For Parenteral and Enteral Nutrition (ASPEN) created an easy-to-remember guide to prevent dislocation entitled MARK:

Mark the exit site of the tube with a permanent marker or other permanent marker and record the outside length of the tube when in place.

Mark the tube at the exit site with a felt tip pen or other indelible pen and record the tube’s external length when in place. Anchor the pipe using proper securing devices and techniques depending on where the pipe is located. If the stoma site is newer, secure it with medical tape, but be careful not to put pressure on the stoma. Hanging hoses should be clipped or taped to clothing to avoid sagging that could cause a pull.

Anchor the pipe using proper securing devices and techniques depending on where the pipe is located. If the stoma site is newer, secure it with medical tape, but be careful not to put pressure on the stoma. Hanging hoses should be clipped or taped to clothing to avoid sagging that could cause a pull. Check the probe placement regularly. Note the distance the pipe usually protrudes. As a G-tube gets shorter or longer, it may be pulled in or out of the body. If the tube disappears or comes out, contact your doctor immediately.

Check the placement of the probe regularly. Note the distance the pipe usually protrudes. As a G-tube gets shorter or longer, it may be pulled in or out of the body. If the tube disappears or comes out, contact your doctor immediately. Avoid pressure on the skin where the tube is inserted and ensure all caregivers are up to date on tube care best practices.

Also, always have a spare tube on hand and practice good skin care daily, keep the insertion site clean and dry, and check that attachment methods are properly attached.

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The treatment of almost all medical conditions has been impacted by the COVID-19 pandemic. NICE has issued quick update guidelines for many of these. This guide changes frequently. Please visit https://www.nice.org.uk/covid-19 to see if there are any temporary guidance from NICE in relation to the treatment of this condition which may vary from the information below.

Professional reference articles are designed for healthcare professionals. They were written by British doctors and are based on research and British and European guidelines. You may find one of our health articles more useful.

There are separate articles on enteral nutrition, primary care nutritional support, and hospital nutritional support.

A nasogastric tube is a narrow-bore tube that is inserted through the nose into the stomach. It is used for short or medium-term nutritional support, but also for sucking out gastric contents – e.g. for decompression in the case of intestinal obstruction.

If drainage is required, a wide diameter pipe is used; otherwise, a finer bore tube is used. Finely drilled feeding tubes (less than 9 gauge) cause less discomfort and reduced risk of rhinitis, pharyngitis, or esophageal erosion.

The use of a nasogastric tube is suitable for enteral feeding for up to six weeks. Polyurethane or silicone feeding tubes are not sensitive to stomach acid and can therefore remain in the stomach longer than PVC tubes, which can only be used for up to two weeks. For long-term enteral nutrition, the use of percutaneous endoscopic gastrostomy (PEG) is associated with improved survival, better patient tolerability, and lower incidence of aspiration.

Feeding through gastric tubes[1]

Bolus: by gravity – very easy, requires minimal equipment but increases the risk of gastrointestinal symptoms.

Intermittent: by gravity or pump – gives feeding-free time but increases the risk of gastrointestinal symptoms.

Continuous: by pump system – reduces the frequency of gastrointestinal symptoms, but the patient is connected to the system most of the time, which can limit mobility.

Positioning the patient semi-recumbent reduces the risk of airway aspiration.

Feed contamination can be minimized through minimal, careful handling and the use of closed rather than open systems.

contraindications

The nasogastric feeding route is not appropriate for all patients, including those with:

High risk of aspiration.

gastric congestion.

Gastroesophageal Reflux.

Upper gastrointestinal stricture.

nasal injuries.

skull base fractures.

Insertion of a gastric tube[2]

Explain the procedure and get consent.

Signal the patient to end the procedure.

Place the patient in a semi-upright position with the head supported with pillows and tilted neither backwards nor forwards.

Examine the nostrils for deformities or blockages to determine the best site for insertion.

Measure the tube from the bridge of the nose to the earlobe and then to the midpoint between the bottom of the breastbone and the navel.

Mark the measured length with a marker or write down the distance.

Lubricate 2-4 inch tubing with lubricant (e.g. 2% Xylocaine®).

Insert the tube through one of the nostrils, past the pharynx, into the esophagus, and then into the stomach

Instruct the patient to swallow and advance the tube while the patient swallows (drinking a glass of water helps).

If you meet resistance, slowly twist the tube while moving it down. Don’t force.

Stop immediately and withdraw the tube if the patient becomes restless, gasps or coughs, develops cyanosis, or if the tube curls up in the mouth.

Advance the tube until the mark is reached.

Check the position of the hose (see below).

Secure the tube with tape.

Check hose position

It is important to confirm the position of the tube in the stomach by one of the following methods:

Testing the pH of the aspirate: Gastric placement is indicated by a pH less than 4, but may rise to pH 4-6 if the patient is on antacid drugs. Using blue litmus paper to check the acidity of the aspirate is not sensitive enough to distinguish between acid levels.

X-rays: only confirms the position at the time of the X-ray. By the time the patient has returned to the ward, the tubing may have moved. In the absence of a positive aspiration test, at pH values ​​above 5.5, or in an unconscious or ventilated patient, an x-ray must be taken to confirm the initial position of the nasogastric tube.

The old test of introducing a small amount of air into the stomach and checking for a bubbling sound over the epigastrium is not recommended because it is unreliable and can give false assurances.

Securing and monitoring of the hose

Stomach tubes should be securely attached to the nose to avoid slipping.

The tube should be flushed regularly to prevent food and medication from building up and causing an occlusion.

The position of the tube should be monitored by recording the length of the tube at the point of exit from the nostril, periodically checking the pH of the aspirate, checking the nasal fixation straps daily, and checking for signs of breathing difficulty or regurgitation.

Tube position must be verified: At initial placement. At least once a day during continuous feeding or before feeding after a break or bolus feeding. Before administering drugs if the tube is not used for other purposes. After episodes of coughing, choking or vomiting. After oropharyngeal suction. If there is a suspicion that the length of the visible part of the hose has changed. For discomfort or reflux of food in the throat. If there are signs of shortness of breath. When the patient is transferred from one clinical area to another.

Medicines[3]

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10.3 Stomach Tubes

Using a nasogastric tube

A nasogastric (NG) tube is a flexible plastic tube that is inserted through the nostrils, down the nasopharynx, and into the stomach or upper part of the small intestine. The placement of NG probes is always confirmed with a radiograph prior to use (Perry, Potter & Ostendorf, 2014).

NG tubes are used for:

Provide the patient with nutrients via a feeding pump

remove stomach contents

A NG tube used for feeding should be labelled. The tube is used to feed patients who may have difficulty swallowing or who may need additional nutritional supplements. These pipes are narrower and bored smaller than a Salem sump or Levine pipe.

An NG tube can also remove stomach contents by either emptying the stomach by gravity or by connecting it to a suction pump. In these situations, the NG tube is used to prevent nausea, vomiting, or stomach distention, or to flush the stomach of toxins.

The NG tube is attached to the patient with a nose clip and taped to the patient’s gown to prevent accidental tube removal and tube slippage from the stomach area to the lungs.

When working with people with nasogastric tubes, keep the following care measures in mind:

Maintain and promote comfort. The tube constantly irritates the nasal mucosa, which causes a great deal of discomfort. Ensure that the tubing is securely anchored to the patient’s nose to prevent excessive movement of the tubing and that it is attached to the gown to prevent excessive tugging or tugging.

Because one nostril is blocked, patients tend to breathe through the mouth. This causes dryness of the nasal and oral mucosa, and patients complain of thirst, but they are usually NPO (nil per os or nothing by mouth). Oral care helps relieve dryness. This may involve rinsing the mouth with cold water or mouthwash as long as the patient does not swallow. Some patients are allowed to suck on ice chips.

If the patient complains of abdominal pain, discomfort, nausea, or begins to vomit, report it immediately. The drain is likely obstructed and the hose needs to be flushed.

These patients should never lie completely flat. Lying flat increases the patient’s risk of aspirating gastric contents. There is a risk of aspiration in patients with an NG tube. The head of the bed should always be raised 30 degrees or higher.

Checklist 78 describes the steps for inserting a gastric tube.

Checklist 78: Inserting a Nasogastric Tube Disclaimer: Always read and follow your hospital policies regarding this specific skill. Safety instructions: carry out hand hygiene.

Check the room for additional precautions.

Introduce yourself to the patient.

Confirm the patient ID with two patient identifiers (e.g. name and date of birth).

Explain the process to the patient; provide analgesia, bath, etc.

Listen and heed the patient’s cues.

Respect for the privacy and dignity of the patient.

Rate ABCCS/suction/oxygen/safety.

Apply principles of asepsis and safety.

Check vital signs.

Conduct the required focused assessments. Steps Additional Information 1. Perform hand hygiene and gather supplies. This prevents the transmission of microorganisms. 2. Visually check the condition of the patient’s nasal and oral cavity. Look for signs of infection or skin damage. 3. Evaluate the best nostril before you start. Do this by closing one side and asking the patient to sniff. Ask the patient about previous injuries or a history of septal deviation. If both nostrils are equally suitable, choose the nostril closest to the suction. 4. Palpate patient’s abdomen for distension, pain, and/or stiffness. Auscultate for bowel sounds. Document the assessment results and determine the adequacy of the NG tube in relation to the reason for insertion and the patient’s physical assessment. 5. Rate the patient’s level of awareness and understanding of the procedure. The patient must be able to follow the NG insertion instructions to allow passage of the tube through the nasal and gastrointestinal tract. 6. Check the physician’s orders for the type of NG tube to be placed and the reason for the placement. Review regulations relevant to patient safety. 7. Check the doctor’s orders to determine if the NG tube should be connected to a suction or drainage bag. This should correspond to the reason for the NG probe. 8. Position the patient sitting at an angle of 45 to 90 degrees (unless the patient’s condition precludes this), with a pillow under the head and shoulders. This makes it easier to pass the NG tube through the nasopharynx and into the stomach. 9. Raise the bed to a comfortable working height. This helps prevent biomechanical injury to the healthcare provider. 10. Agree on a signal that the patient can use if they want you to pause during the procedure. This procedure can be anxious and uncomfortable for many patients. Providing a means for the patient to communicate discomfort and a desire to take a break during the procedure helps reduce anxiety. 11. Place a towel on the patient’s chest and provide facial tissue and a vomiting basin. Nasal and oral secretions may be visible during the procedure. 12. Provide the patient with drinking water and a straw if the patient is not fluid restricted. Drinking water through a straw helps trigger the swallowing reflex and makes it easier to pass the NG tube. 13. Stand on the right side of the patient if you are right-handed and on the left side if you are left-handed. You will use your dominant hand to insert the tube. 14. Measure the distance of the tube from the tip of your nose to…

The earlobe to…

Mark the xiphoid process and then the tube at this point. This will determine the appropriate length of NG hose to be inserted. 15. Lubricate the tip of the NG tube according to your agency’s guidelines. The hose can be lubricated with tap water on the inside or with water-soluble lubricant on the outside. Agency policies vary and should be reviewed. Never use a non-water soluble lubricant (such as petroleum jelly) as it will not dissolve and can cause respiratory complications if it gets into the lungs. 16. Wear clean non-sterile gloves. The use of gloves reduces the transmission of microorganisms. 17. Bend 10 to 15 cm of the end of the NG tube around your gloved finger and then release. When you wrap the NG probe around your finger, it conforms to the normal curvature of the nasopharynx. 18. Let the patient’s head fall forward and breathe through the mouth. Dropping your head forward closes the trachea and opens the esophagus, making it easier to pass the NG tube through the nasopharynx and into the stomach. 19. Slowly insert the NG probe tip into the patient’s nostril and steadily advance it down along the bottom of the nasal passage with the curved end pointing down toward the ear on the same side as the nostril. This follows the natural anatomical orientation of the nasopharynx. 20. You may feel a slight resistance as you advance down the nasal passage. Rotate the tube slightly, apply downward pressure, and keep trying to advance the tube. If significant resistance is felt, remove the tube and allow the patient to rest before trying again in the other nostril. It is common for the patient to feel unwell, which may manifest itself as a mild cough and choking. More aggressive coughing and choking may indicate the tube has entered the airway. In this case, you should pull out the NG hose. 21. If there is difficulty in inserting the NG tube, you can ask the patient to slowly drink water through a straw, unless oral liquids are contraindicated. If oral liquids are not allowed, ask the patient to swallow dry while you advance the tube. If the patient continues to choke or cough, use a tongue depressor and a flashlight to check that the tube is curled up at the back of the mouth. Once the tube is coiled, pull the tube out until only the tip of the tube is visible at the back of the mouth. Then try advancing the tube again while the patient tries to swallow. 22. Continue to advance the NG tube until you reach the mark/tape measure you placed for the measurement. This ensures accurate placement. 23. Temporarily anchor the tube to the patient’s cheek with a piece of tape until you can verify proper placement. This prevents the NG tube from shifting while verifying placement. 24. Verify probe placement according to agency guidelines. Color coded pH paper is typically used as an initial and intermediate check to confirm that acidic ingredients are present. An X-ray is then taken to confirm placement before the NG tube is used for feeding. The contents aspirated from the tube should be acidic with a pH <5. If the pH is above 6, this may indicate the presence of respiratory fluid or small bowel contents and the tubing should be removed. 25. After tube placement is confirmed, mark and record (with a permanent marker) the length of the tube from the nose to the outer end of the tube. This helps in the timely detection and identification of pipe displacement or migration. 26. Secure the tubing to the patient's gown with a safety pin, leaving enough tubing length for comfortable head movement. This will hold the NG tube in place. 27. Document the procedure according to agency guidelines and report any unexpected findings to the appropriate healthcare provider. Timely and accurate documentation promotes patient safety. Data source: ATI, 2015a; BCIT, 2015c; Berman & Snyder, 2016 Special features of NG tubes: Always verify proper placement of the NG tube prior to infusing any fluids or formula according to agency guidelines. Check the position of the outer markings on the tube and the color of the PH of the liquid aspirated from the tube. A routine examination will ensure proper tube placement and reduce the risk of aspiration. Do not bring air to the test site of the tube. Do not give the patient anything to eat or drink without knowing that the patient has passed a swallow test. When changing gowns or repositioning the patient, be careful not to pull on the NG tubing. Remember to detach the hose from the gown and reattach the hose. If the NG tube falls out of the patient, it is not an emergency. But be sure to evaluate your patient. What are the ABCCS like? Notify the caregiver responsible for the patient. A patient who appears to be short of breath should be considered an emergency and emergency procedures should be followed. Shortness of breath can manifest itself as coughing, choking, or reduced oxygen saturation. Videos 10.1 Removing an NG tube An NG probe should be removed when no longer needed. The process of removal is usually very quick. Before removing a NG tube, check the doctor's instructions. If the NG tube was ordered to remove stomach contents, the doctor's order may include "trying" the tube on for a few hours to see if the patient tolerates the removal. During the study, the patient should not feel any nausea, vomiting or flatulence. See Checklist 79 for information on removing an NG tube. Checklist 79: Removing a NG Tube Disclaimer: Always review and follow your hospital policies regarding this particular skill. Safety instructions: carry out hand hygiene. Check the room for additional precautions. Introduce yourself to the patient. Confirm the patient ID with two patient identifiers (e.g. name and date of birth). Explain the process to the patient; provide analgesia, bath, etc. Listen and heed the patient's cues. Respect for the privacy and dignity of the patient. Rate ABCCS/suction/oxygen/safety. Apply principles of asepsis and safety. Check vital signs. Conduct the required focused assessments. Steps Additional Information 1. Review the healthcare provider's instructions for removing the NG tube. An assembly is required to remove an NG tube. 2. Gather supplies. Accessories include waterproof pads, a 20ml syringe, tissues, non-sterile gloves and a bin liner. 3. Verify the patient using two identifiers. Explain the procedure to the patient and place them in the high Fowler position. Follow agency guidelines for proper patient identification. 4. Perform hand hygiene. Place the waterproof pad on the patient's chest. This reduces the transmission of microorganisms. 5. Disconnect the tube from the food, if present. This prevents the risk of tube feeding aspiration. 6. Remove the tape or securing device from the nose. This allows the hose to be easily removed. 7. Disconnect the NG tube from the patient's gown. This allows the hose to be easily removed. 8. Purge the NG tube by introducing 10~20ml of air into the tube. This prevents tube food falling out of the tube from being sucked in. 9. Instruct the patient to breathe deeply and hold. This prevents aspiration; Holding the breath closes the glottis. 10. Bend the NG probe near the nostrils and gently pull the probe out in one quick, steady motion, wrapping it in your hand as you pull it out. Dispose of hose in garbage bag. This prevents leftover feed from flowing out of the tube when it is removed. 11. Offer the patient tissues or clean the nostrils and provide oral care if necessary. This will clear the nostrils/nasal passages of any remaining secretions. 12. Remove the gloves and place the patient in a comfortable position. Assess patient comfort. Perform hand hygiene. This promotes patient comfort and reduces the transmission of microorganisms. 13. Document the procedure according to agency guidelines. Document the removal of the NG tube and the patient's response to the removal. Data source: ATI, 2015a; BCIT, 2015b; Perry et al., 2014

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In my opinion, the use of NG tubes in intestinal obstruction is an anachronism. I grew up reading literature that says NG tubes provide no benefit but are routinely ranked as one of the most painful things we do to our patients. In my opinion, this was a classic example of a medical myth relegated to medical history alongside things like leeches and trepanation. However, every time I admit a patient with a bowel obstruction, the issue of the NG tubes is raised, so I guess we need a quick blog post.

Like many historical medical practices, NG was established long before the era of evidence-based medicine. Its use was based on common sense and some pathophysiology, but not evidence. Unfortunately, in medicine, common sense and physiology have led us astray time and time again.

There is no evidence that NG probes help

The use of NG tubes to decompress the stomach in small bowel obstruction appears to be due to Dr. to be attributed to Owen Wangensteen. Over the course of several decades of research into intestinal obstruction, the mortality rate at Massachusetts General Hospital dropped from about 45% in the 1920s to about 20% in the late 1930s. Although both diagnosis and surgical management have changed dramatically over the decades, this decrease in mortality published through case series was the evidence that encouraged the widespread use of NG tubes. (Edlich 1996) Obviously, by modern standards, a case series in which many changes have been made over many decades, from a time when CT was unavailable and mortality was dramatically higher, does not count as a very high standard of evidence. This is at best hypothesis generating.

Unfortunately, as far as I can tell, this hypothesis has never actually been tested. There is not a single randomized trial of any size or quality addressing this issue. All we have is observational data (and modern-day observational data seems to contradict the Wangensteen case series).

There are some key observational data limitations, as patients receiving NG tubes are likely to differ from those treated without, but the available observational data do not support a benefit of NG tube use. In a chart review of 290 patients admitted with small bowel obstructions, approximately 20% were treated without a NG tube. Use of a NG tube was consistently associated with poorer outcomes: longer time to resolution, longer residence time, and a higher complication rate. Conservative treatment was successful in 2/3 of the patients, regardless of whether a NG was placed or not. Notably, almost 2/3 of the patients who had an NG placed had minimal drainage, suggesting that the procedure may not have helped the majority of patients. (Fonseca 2013)

The Best Evidence Topic Reports (Best BETs) series addressed this topic in 2014, and the only relevant paper they identified was the Fonseca 2013 observational study. They concluded: “There is no scientific evidence supporting the routine use of nasogastric tubes in adults with small bowel obstruction.” (Paradise 2014)

Another retrospective review of medical records included 181 patients with small bowel obstruction, half of whom were treated with nasogastric decompression. There was no association between the use of a NG tube and death, surgery, or bowel resection. NG tube decompression was associated with a longer hospital stay (median 5 versus 3 days, p<0.0001). There were significant baseline differences between groups - NG probes were used more frequently in elderly patients and patients with malignancy - again severely limiting the value of observational data. (German 2017) Although somewhat tangential, prophylactic NG tubes have long been used to promote an earlier return of normal bowel function associated with postoperative ileus. However, a systematic review of 28 studies involving 4000 patients found the exact opposite (ileus resolved faster in patients without a NG tube) and concluded that "routine nasogastric decompression fails to achieve any of the intended goals and is therefore abandoned in favor of selective one." nasogastric tube should be used.” (Nelson 2005) To recap, we have absolutely no idea if NG tubes will help. There is simply no proof of quality. The observational data do suggest harm with longer hospital stays, longer time to resolution, and more complications, but the data is so weak it should not be trusted. We just don't know. Some patients may benefit, but observational data suggest that NG tubes should not be used routinely. On the other hand, NG tubes clearly cause damage NG tubes are very painful. They are routinely ranked as one of the worst things we do to patients. In a classic survey of inpatient adult patients who had undergone various medical procedures, the NG tube topped the list with an average pain score of 8.8 on a 10-point scale, ahead of mechanical ventilation (8 ,0). central placement (6.5), arterial catheter (3.4) and Foley catheter (6.2). (Morrison 1998) Although the numbers in the study are imperfect and there are a number of possible biases, we should listen when patients tell us they are in pain. Numerous other studies have confirmed that this is a very painful procedure. (e.g. Singer 1999; Cullen 2004) It is possible to limit the pain associated with NG placement with topical lidocaine, although it is unclear how long the analgesic effects last, as these tubes are generally left in place for many days. (Kuo 2010) Nose pain is not the only problem with NG tubes. Patients rate the choking symptoms at least as high as the nasal pain during insertion. (Singer 1999) Also, pain is not completely eliminated, meaning that when there is no benefit, harm still outweighs benefit. 98% of emergency physicians believe that inserting a NG tube is painful, but only 28% believe the analgesic options they offer are effective, and more than half were dissatisfied with their current practice. (Juhl 2005) This probably explains why emergency physicians have changed their practice around this medical myth faster than the many others where we don't immediately see the damage of our actions (like stress tests or PPIs for GI bleeds). NG use under different conditions NGs have historically been used for numerous other conditions in emergency medicine, from assessing upper GI bleeding to administering activated charcoal. I will not examine the evidence for these other "hints" in depth, in large part because there really is no evidence. I think we all know that the NG tube is inaccurate for diagnosing upper GI bleeding. I will occasionally use an NG tube as a monitor of active bleeding in critically ill patients, but the evidence suggests that routine NG tubes are not helpful for upper GI bleeding. (Huang 2011; Palamidessi 2010) I had never heard of the NG tube being helpful for pancreatitis, but apparently that's a common belief in some parts of the world. Again, the evidence seems to suggest just the opposite, with faster recovery in patients who were not randomized to receive an NG tube. (Sarr 1986) NG is occasionally a useful route for drug delivery and even hydration, but the risks must be weighed against the benefits. Too often it has been used for drugs that themselves have no proven benefit (e.g. activated charcoal), compounding the lack of benefit of the NG tube itself. However, I am happy to place a NG tube if that is the only way to administer a potentially life-saving drug, such as: B. Administering aspirin to an unconscious STEMI patient. (Of course, the harms of NG probes are negligible even in unconscious patients.) The NG has been touted as a possible alternative to IV for rehydration in pediatrics, but considering that pain from a NG tube is rated as much higher than pain from an IV, it seems like the NG is in the overwhelming majority the inferior alternative of cases. For the most part, I think the role of the NG probe in emergency medicine is incredibly limited. We have to recognize that this is one of the most painful procedures we perform on patients. With this in mind, there is a heavy burden of proof on those who propose this practice. We need to see evidence of benefit before subjecting our patients to this procedure. bottom line This is clearly a harmful procedure. Patients find it more painful than almost anything else we do in medicine. This harm means we must have proof of benefit before we can consider this practice ethical. There is no evidence at this time and therefore NG tubes should absolutely not be routinely placed in patients with small bowel obstruction. This conclusion does not mean that there is no benefit from NG tubes. Evidence on the subject is essentially non-existent. We just don't know. But we know the tubes do harm, so the burden of proof is on those wanting to expose patients to that harm. Before using NG probes, we need to demonstrate that the benefits outweigh the known harms. If NG probes are as important as surgeons seem to think - if there is tremendous absolute benefit - then demonstrating that benefit in an RCT should be very easy. However, until we see this RCT, it is unfair to patients to put them through this unproven, painful procedure. Other FOAMED EP Monthly: I hereby declare the end of the NG reflective probe EP Monthly: The NG Tube for GI Bleed: Cruel and Unusual Punishment EP Monthly: NG Tube Pain Avoidable But Not Avoided references Berman DJ, Ijaz H, Alkhunaizi M, Kulie PE, Vaziri K, Richards LM, Meltzer AC. Nasogastric decompression unrelated to reduction in surgery or bowel ischemia in acute small bowel obstruction. Am J Emerg. Med. 2017 Dec;35(12):1919-1921. doi: 10.1016/j.ajem.2017.08.029. Epub 2017 Aug 15. PMID: 28912083 Cullen L, Taylor D, Taylor S, Chu K. Nebulized lidocaine reduces discomfort during gastric tube insertion: a randomized, double-blind study. Ann Emerg.Med. 2004 Aug;44(2):131-7. doi: 10.1016/j.annemergmed.2004.03.033. PMID: 15278085 Edlich RF, Woods YES. Wangensteen's transformation of the treatment of intestinal obstruction from empirical craft to scientific discipline. J Emerg.Med. 1997 Mar-Apr;15(2):235-41. doi: 10.1016/s0736-4679(96)00351-4. PMID: 9144067 Fonseca AL, Schuster KM, Maung AA, Kaplan LJ, Davis KA. Routine nasogastric decompression for small bowel obstruction: is it really necessary? At the surgeon. 2013 Apr;79(4):422-8. PMID: 23574854 Huang ES, Karsan S, Kanwal F, Singh I, Makhani M, Spiegel BM. Effects of gastric lavage on outcome in acute GI bleeding. Gastrointest Endosc. 2011 Nov;74(5):971-80. doi: 10.1016/j.gie.2011.04.045. Epub July 7, 2011. PMID: 21737077 Juhl GA, Conners GP. Practices and attitudes of emergency physicians regarding procedural anesthesia for gastric tube insertion. Emerg Med J. 2005 Apr;22(4):243-5. doi: 10.1136/emj.2004.015602. PMID: 15788820 Kuo YW, Yen M, Fetzer S, Lee JD. Reducing pain during gastric tube intubation with nebulized and nebulized lidocaine: a systematic review and meta-analysis. J Manage pain symptoms. 2010 Oct;40(4):613-20. doi: 10.1016/j.jpainsymman.2010.01.025. Epub August 3, 2010. PMID: 20678892 Morrison RS, Ahronheim JC, Morrison GR, Darling E, Baskin SA, Morris J, Choi C, Meier DE. Pain and discomfort associated with standard hospital procedures and experiences. J Manage pain symptoms. 1998 Feb;15(2):91-101. PMID: 9494307 Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric decompression after abdominal surgery. Br. J. Surgeon. 2005 Jun;92(6):673-80. doi: 10.1002/bjs.5090. PMID: 15912492 Palamidessi N, Sinert R, Falzon L, Zehtabchi S. Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis. Acad. Emerg. Med. 2010 Feb;17(2):126-32. doi: 10.1111/j.1553-2712.2009.00609.x. PMID: 20370741 Paradis M. Towards Evidence-Based Emergency Medicine: Best BETs from the Manchester Royal Infirmary. BET 1: Is routine nasogastric decompression indicated in small bowel obstruction? Emerg Med J. 2014 Mar;31(3):248-9. doi: 10.1136/emermed-2014-203617.1. PMID: 24532357 Sarr MG, Sanfey H, Cameron JL. Prospective, randomized study of gastronasal aspiration in patients with acute pancreatitis. Surgery. 1986 Sep;100(3):500-4. PMID: 3526610 Singer AJ, Konia N. Comparison of topical anesthetics and vasoconstrictors vs. lubricants prior to nasogastric intubation: a randomized controlled trial. Acad. Emerg. Med. 1999 Mar;6(3):184-90. doi: 10.1111/j.1553-2712.1999.tb00153.x. PMID: 10192668 Witting MD. "You want to do what?!" Modern indications for nasogastric intubation. J Emerg.Med. 2007 Jul;33(1):61-4. doi: 10.1016/j.jemermed.2007.02.017. Epub May 30, 2007. PMID: 17630077 Photo by engin akyurt on Unsplash Cite this article as: Morgenstern, J. Small bowel obstruction NG probes: more pain than evidence, First10EM, August 2, 2021. Available at: https://doi.org/10.51684/FIRS.80588

A nasogastric tube goes into your nose and down into your stomach to give you nutrients and fluids if you have trouble swallowing. The thin, soft tube is flexible, allowing food to enter the stomach for normal digestion. This may look uncomfortable, but it doesn’t have to be. Learn more about the risks and benefits of tube feeding and tips for successful tube feeding.

Understanding Nasogastric Tubes Nasogastric (NG) tubes are most commonly used in children. Your doctor may suggest a NG tube if your child: needs short-term nutrition or medication

Does not grow as expected with regular feeding

Has difficulty swallowing liquids or food

Recovering from surgery or has an infection that limits his ability to eat for a short time‌

Requires additional nutrients not obtained from food. Remember that a feeding tube should not be used for long-term feeding needs. There are other types of tubes that are used for long-term needs and are inserted directly into your stomach or small intestine. Talk to your doctor about how long he thinks your child will need a feeding tube.

1.0 FOREWORD Patients suffering from malnutrition to a degree that can compromise the immune system, wound healing, muscle strength and mental functioning are common in UK hospital populations.1 These individuals are struggling to cope with modern medical and surgical procedures and remain on average about about in hospital five days longer than normal nutrition, resulting in about 50% higher costs.2,3 Hospitals should therefore aim to provide at least adequate nutrition for all patients. This can be achieved in the majority by catering services providing good quality food, care being taken to avoid food shortages and providing physical assistance with meals when needed. But even if these ideals are fulfilled, many hospital patients do not eat enough or at all. Some of these will benefit from oral nutritional supplements, while others will require active nutritional support. This can usually be done through enteral tube feeding (ETF). This document provides guidance on the indications, benefits, administration and issues of ETF in adult hospital practice. The guidelines were commissioned by the British Society of Gastroenterology (BSG) as part of an initiative across multiple areas of clinical practice. They are not rigid protocols and should be used alongside clinical judgment taking into account local service delivery.

2.0 GUIDANCE FORMULATION These guidelines were compiled by the authors from the relevant literature in discussions with dietitians and nutritionists. They were then reviewed by the Small Intestine/Nutrition ESR Committee and by dietetic, nursing, pharmaceutical and medical representatives from the British Association of Parenteral and Enteral Nutrition (BAPEN). The strength of the evidence used is in line with the recommendations of the North of England Evidence Based Guidelines Development Project.4 Ia – Evidence from meta-analysis of randomized controlled trials.

Ib – Evidence from at least one randomized study.

IIa – Evidence from at least one well-designed controlled trial without randomisation.

IIb – Evidence derived from at least one other well-designed quasi-experimental study.

III—Evidence from well-designed, non-experimental, descriptive studies such as comparative studies, correlation studies, and case studies.

IV – Evidence from reports or opinions of expert committees or clinical experience of respected authorities. Unfortunately, many aspects of the ETF have not been rigorously evaluated, in part because ethical considerations make placebo-controlled trials of dietary interventions difficult (see Section 4.2). Nevertheless, recommendations are presented based on the level of evidence and are ranked as follows: Level A – requires at least one good quality randomized controlled trial addressing the topic of the recommendation;

Grade B – requires the availability of clinical trials without randomization on the subject of the recommendation;

Grade C – requires evidence from Category IV in the absence of directly applicable clinical studies.

3.0 SUMMARY OF RECOMMENDATIONS Indications for Enteral Nutrition Healthcare professionals should aim to provide adequate nutrition for each patient unless prolonging life is not in the patient’s best interest (Grade C).

It should be hospital policy that the results of a nutritional screening be recorded upon inclusion in the notes of all patients with severe disease or those requiring major surgery (Grade C).

Artificial nutritional support is required if oral intake is missed or likely to be missed for > 5 to 7 days. Earlier initiation may be required in malnourished patients (Grade A). Support may also be needed in patients with inadequate oral intake over time.

Decisions about the route, content, and management of nutritional support are best made by multidisciplinary nutritional teams (Grade A).

ETF can be used in unconscious patients, patients with dysphagia and patients with partial bowel failure. It may be appropriate in some cases of anorexia nervosa (grade B).

Early postpyloric ETF is generally safe and effective in postoperative patients, even in the presence of overt ileus (Grade A).

Early ETF after major gastrointestinal surgery reduces infection and length of stay (Grade A)

For all postoperative patients who cannot tolerate oral ingestion, ETF should be given within 1 to 2 days postoperatively in severely malnourished subjects, 3 to 5 days postoperatively in moderately malnourished subjects, and within seven days postoperatively in normal or be considered in overfed individuals (class C).

In case of specific contraindications for ETF, parenteral nutrition should be considered. If patients are consuming more than 50% of their estimated nutritional needs, it may be appropriate to delay initiation of an ETF (Grade C).

ETF can be used to support patients with uncomplicated (grade A) pancreatitis. Ethical issues ETF should never be started without considering all the ethical issues involved and must be in the best interest of a patient (Grade C).

ETF is legally considered a medical treatment. The beginning, end or interruption of such treatment is therefore a medical decision, which is always made taking into account the patient’s will.

In cases where a patient cannot express a desire for ETF, the physician must make decisions about ETF in the best interest of the patient. Comprehensive consultation with all carers and relatives is essential. Access Techniques Fine-bore (5 to 8 French gauge) nasogastric (NG) tubes should be used for ETF unless there is a need for repeated gastric aspiration or delivery of highly viscous food/drugs through the tube. Most fiber-enriched feeds can be administered through these fine-bore (Grade A) tubes.

NG probes can be placed on the ward by experienced medical or nursing staff without X-rays to check position. Their position must be checked by pH testing before each use (class A).

The position of a nasojejunal (NJ) tube should be confirmed by x-ray 8-12 hours after placement. Auscultation and pH aspiration techniques may be inconclusive (Grade A).

Insertion of a NG tube should be avoided for three days after acute variceal bleeding and only fine-bore tubes should be used (grade C).

There is no evidence for the use of weighted NG probes, either in terms of placement or retention of position (Grade A).

Long-term NG and NJ tubes should typically be changed every 4–6 weeks by swapping into the other nostril (grade C).

Gastrostomy or jejunostomy feeding should be considered whenever patients are expected to require ETF for more than 4–6 weeks (Grade C) and there is evidence that these routes should be considered after 14 days (Grade B ).

Eligibility for a gastrostomy should be evaluated by an experienced gastroenterologist or a member of a nutritional support team. Expert advice on prognosis of swallowing difficulties may be needed (Grade C).

In patients at no risk of distal adhesions or strictures, gastrostomy tubes with rigid internal fixation can be removed by cutting them close to the skin, pushing them into the stomach, and allowing them to pass spontaneously (Grade A). Feeding Administration Enteral feeding into the stomach rather than the small intestine allows the use of hypertonic feeding, higher feeding rates, and bolus feeding (Grade A).

In patients who have had an adequate food intake in the past week (Grade A), starter regimens with reduced initial food amounts are not required. Diluting feeds risks infection and osmolality difficulties.

Both underfeeding and overfeeding can be harmful. Nutritionists or other experts should be consulted on feed regulation (grade C).

When no recommendation is available, 30 mL/kg/day of a standard 1 kcal/mL diet is often adequate but may be excessive in malnourished or metabolically unstable patients (Grade C).

When patients with persistent ETF are discharged into the community, care must be taken to ensure that all community caregivers are fully informed and that there is an ongoing prescription of feed and relevant equipment (Grade C). Complications of enteral feeding Close monitoring of fluid, glucose, sodium, potassium, magnesium, calcium, and phosphate status is essential in the first few days after initiating an ETF (Grade C).

Life-threatening problems from refeeding syndrome are particularly common in severely malnourished people, and there are also risks from overfeeding shortly after major surgery or during severe sepsis and/or multiple organ failure (Grade C).

To minimize aspiration, patients should be supported at 30° or more and held supported for 30 minutes after feeding. Patients at risk (grade C) should not be fed continuously overnight.

Any medication administered via an ETF tube should be in liquid form and administered separately from food, with the tube flushed before and after (Grade C).

Loosening and twisting a gastrostomy tube can prevent obstruction from mucosal proliferation and reduce peristomal infection (Grade C).

In patients with questionable gastrointestinal motility, the stomach should be aspirated every four hours. If the aspirates exceed 200 ml, the feeding strategy should be reviewed (Grade C).

Continuous pump feeding can reduce gastrointestinal distress and maximize nutritional support when absorption capacity is reduced. However, intermittent infusion should be started as soon as possible (Grade A).

Concomitant use of other drugs, particularly antibiotics, is usually the cause of apparent ETF-related diarrhea (Grade A).

High-fiber diets sometimes help ETF-related diarrhea, as does feeding breaks of 4–8 hours (grade B).

Careful measures are needed to avoid bacterial contamination of feed, which can lead to sepsis, pneumonia and urinary tract infections and gastrointestinal problems (grade A).

Avoiding gastric acid suppression and allowing feeding pauses to allow gastric pH to drop helps prevent bacterial overgrowth during ETF (Grade A).

4.0 BACKGROUND 4.1 Malnutrition in the UK Recent studies using a nationally representative sample showed that malnutrition is widespread among adults in the UK, both in the community and in hospitals.1,5,6 It has been shown that around 5% of apparently ‘healthy’ adults in the UK have a body mass index (BMI) < 20 m/kg2 and this rose to 10% or more for the chronically ill and community patients with cancer, gastrointestinal disorders, respiratory problems and neurological or psychiatric disorders. In nursing homes, 16% of elderly residents were underweight.6 Of even greater concern is the prevalence of vitamin deficiencies in the population. In people over 65 years of age living at home, low folic acid levels were found in 29% and low vitamin C levels in 14%, with figures rising to 35% and 40% respectively in seniors living in institutions.6 Also, most medical and surgical problems are associated with deterioration in nutritional status due to changes in nutrient uptake, metabolism, and excretion. By the time of hospital admission, nearly 40% of patients are anthropometrically malnourished (8% severe) and their nutritional status continues to deteriorate during hospitalization burns). Support attempts have therefore tended to recruit groups of patients with no specific need, and patients in 'control groups' often switch to active intervention as soon as they encounter problems. The studies are also difficult to interpret due to different levels of nutritional support administered through different routes in heterogeneous groups, and most older studies used levels of nutritional support high enough to cause hyperglycemia (e.g., the study of Veterans Administration on perioperative parenteral nutrition7). . Despite this, a meta-analysis of studies of oral/enteral nutritional support in more than 2000 patients of all types showed that the pooled odds ratio for death at the end of the planned follow-up compared to the control groups showed a lower on-treatment fatality rate of 0.66 (0 .48–0.91; 2p<0.01).8 A comprehensive semi-formal literature review of malnutrition and in-hospital nutritional support also concluded that targeted nutritional support is beneficial in reducing hospital complications, length of stay, mortality and costs , 9 and the Kings Fund reported that the NHS could save £266m a year at 1992 costs by looking after malnutrition10 (equivalent to at least £400m savings at 2003 costs). 5.0 INDICATIONS FOR ENTERAL SUPPORT ETF is only likely to benefit patients who are nutrient deficient or at risk of becoming depleted. These people must be identified. At its simplest, nutritional screening involves considering a patient's weight for height and recent weight loss history. However, nutritional support should also be considered in all patients with excessive nutrient depletion (eg, emesis, diarrhea, or fistula), along with patients who have high potential nutrient requirements (eg, surgical stress, trauma, infection , metabolic disease, decubitus). It should be hospital policy to record the results of nutritional screening on or shortly after admission for all patients with serious illness or who are about to undergo major surgery. Special tools can be used for this purpose, the simplest of which is the universal malnutrition screening tool developed by BAPEN (Appendix 1).11 Although biochemical measurements can contribute to nutritional screening, none are specific (e.g. acute phase response rather than malnutrition). Once the risk is identified, nutritional support should be provided. Verbal encouragement and physical support with eating may be needed, and special diets and/or supplements may be useful. However, problems such as loss of appetite or difficulty swallowing can limit these approaches, and then artificial nutritional support with ETF or IV feeding is required. ETF is preferred whenever patients have sufficient gastrointestinal absorption capacity as it is both more physiological and cheaper. It may also help maintain gut barrier function12,13 although there is little evidence that it reduces bacterial translocation in humans.14 Post-surgical ETFs are increasingly used when oral intake is limited. Early support is usually via a postpyloric NJ tube or a surgical jejunostomy placed pre-, inter-, or postoperatively. Eating is usually possible, although gastric and colon function may be impaired for a few days after surgery, but small bowel function is often normal.15,16 Absence of bowel sounds is not necessarily a contraindication as it is associated with gastric and colon activity related. Concerns about anastomotic integrity in early ETF are probably unfounded, although anastomoses involving the stomach, small intestine, biliary tract, or pancreas may be more vulnerable than lower gastrointestinal anastomoses. Jejunostomy feeding is particularly useful after oesophagogastric surgery.17 A systematic review and meta-analysis of randomized controlled trials comparing any type of enteral feeding started <24 hours after elective gastrointestinal surgery versus zero oral feeding , concluded that early feeding reduced the risk of infection by approximately 30% and the median length of hospital stay by almost a day.18 However, the risk of vomiting was increased by almost 30% in early fed patients. ETF also appears to be beneficial in patients with pancreatitis, although it may need to be avoided in cases complicated by fistulation or pseudocyst formation.19 Perioperative ETF may have advantages over parenteral nutrition (PN). A meta-analysis comparing these support methods concluded that enteral feeding (EN) reduced the risk of infection by about a third.20 EN's apparent superiority is usually attributed to maintaining gut integrity, but, as mentioned above, to evidence that the PN diet causes both villous atrophy or increased bacterial translocation is mixed. The apparent superiority of EN over PN in the perioperative period may therefore be related to problems of early overnutrition in the PN study arms.21 Although conclusive evidence is scant, it seems reasonable to expect postoperative ETF in patients within 1-2 days begin severely malnourished (BMI < 16 and/or weight loss > 15%) and unable to tolerate oral ingestion. Moderately malnourished patients (BMI < 18.5 and/or weight loss > 10%) should probably be fed within 3 to 5 days after surgery if oral intake remains restricted, while normal or overfed patients should receive support if they are under 50 % of Estimated Value Required within 5-7 days. If ETF is not tolerated, PE may be required, although continued minimal ETF (10 mL/h) may help stimulate or maintain bowel function and reduce the likelihood of cholestasis. Common indications for ETFs are listed in Table 1. Table 1 Indications for enteral tube feeding

6.0 ETHICAL AND LEGAL CONSIDERATIONS Artificial nutritional support has ethical and legal issues, and clinicians should be aware of these. The following points are taken from a report commissioned by BAPEN.22 The British Medical Association has also provided guidance.23 The provision of sufficient and appropriate fluids and nutrients is a basic duty of sick patients. While a patient can swallow and expresses a desire or willingness to drink or eat, fluids and nutrients should be administered unless there is a medical contraindication. Treatment plans for patients with current or likely future fluid or nutrient deficiencies should include decisions about fluid and/or nutrient regimens. If the plan is to maintain an adequate intake, the ethical imperative is to take appropriate action to achieve that goal. Administration of nutrients and/or fluids via a tube must be considered if the patient cannot orally or ingest adequate amounts. However, legally this is considered medical treatment (although some professionals would argue that ETF is part of primary healthcare). When the disease is terminal and only sympathetic and palliative care is planned, ethical considerations suggest that tube feedings of nutrients or fluids should be used only to relieve symptoms. This does not mean that it should necessarily be used to prolong survival. In cases where the benefit is in doubt, a planned “temporary” feeding trial may be useful. Consent from a competent adult patient must be obtained for such treatment, and a patient’s informed refusal is binding. Competence depends on adequate thought processes to make the required decision. It is ethically and legally wrong for a nurse to underestimate a patient’s abilities to achieve what the nurse believes is in the patient’s best interest. For an incapacitated adult, the treating physician is legally responsible for any decision to withhold, administer, or discontinue medical treatment, including fluid and/or nutritional feeding via a tube. The doctor’s duty is to act in the patient’s best interests. Before the physician makes a decision about beginning, ending, or continuing enteral tube feeding and/or hydration, the physician should ascertain whether the patient has expressed any prior views about the type of treatment he or she is receiving in the current condition would like to appear incompetence. All decisions about tube feedings of food and/or fluids should include full consultation with family and all healthcare team members from the outset. However, at present under English law, a relative or an appointed representative cannot make a decision on behalf of an adult patient and therefore cannot overrule the doctor’s decision. With regard to children, special considerations apply and an application should be made to the court to consider the legality of depriving a patient in a sustained vegetative state of artificial hydration and nutrition. In certain circumstances, it may be legal to enforce nutritional treatment for an unwilling patient with a mental disorder. This includes anorexia nervosa, which assumes that severe malnutrition per se can render a patient unable to make rational decisions about their care.

7.0 APPROACH TECHNIQUES Gastrointestinal access for up to 4-6 weeks is usually achieved with NG or NJ tubes, although placement of a percutaneous gastrostomy or jejunostomy approach should be considered earlier if there is a high likelihood of prolonged feeding (see Section 7.3 ). Oroenteral tubes are also occasionally used, and with the advent of endoscopic placement, percutaneous gastrointestinal access has become popular for longer-term use.24 7.1 Nasogastric (NG) tubes Most enteral nutritional supplements are administered into the stomach to allow the use of hypertensive foods , higher feeding rates and bolus feeding. Fine-diameter 5–8 French gauge NG tubes are now used unless gastric aspiration or administration of high-fiber foods or drugs through the tube is required.25 Large-diameter PVC tubes should be avoided as they irritate the nose and esophagus and increase the risks of gastric reflux and aspiration. They also need to be replaced frequently as they degrade upon contact with stomach contents. Polyurethane and silicone hoses last at least a month. Insertion of NG tubes can be placed on the ward by experienced medical or nursing staff (see Box 1).26 The position of a NG tube should be confirmed each time it is used for feeding or drug delivery. This does not require an X-ray as long as the external length of the tube remains unchanged and the tube aspirate has a pH < 5.27. If aspiration is difficult, reposition the patient or, if safe, give a drink to increase the volume of gastric contents. Slightly advancing the tube can also help. The pH test is of no value when patients are on acid suppression and an X-ray is needed in doubt or for other reasons. It is unreliable to check the position of a tube by blowing air into it and listening for bubbles with a stethoscope. Box 1 Insertion of a nasogastric tube. Explain the procedure to the patient. Mark the tube at a distance equal to that from the xiphisternum to the nose via the earlobe (50–60 cm). Lubricate the tubing with gel/water on the outside and water on the inside if a guidewire is present. Check that the guidewire moves freely. Check nasal patency by 'sniffing', closing each nostril in turn. The clearer nostril can be sprayed with lignocaine to minimize discomfort. Sit the patient upright with the head straight. Gently push the tube back along the floor of the clearer nostril until it is visible at the back of the pharynx (10-15 cm). If the patient is cooperative, ask them to take a sip of water and advance the probe 5 to 10 cm as they swallow. Repeat swallowing/pushing the water until the preset mark on the tube reaches the nostril. Withdraw the probe anytime the patient is distressed, coughing, or developing cyanosis. If it is difficult to pass through the tube, ask the patient to tilt their head forward or turn them to the side. After placement, remove and carefully secure all guide wires. Check the position of the tube before use (this usually does not require an x-ray (see text)). Document the insertion of the tubing in the patient record. 7.2 Nasojejunal (NJ) tubes Jejeunal feeding may be indicated when there are problems with gastric reflux or delayed gastric emptying. It should also be used on unconscious patients who need to get laid. All NJ tubes are fine bore (6-10 French gauge). Some have a shorter second lumen for gastric aspiration. Insertion Post-pylorus placement can be difficult and different techniques are used.28,29 The tube is inserted in the same way as an NG tube, but once it is far into the stomach (60 cm), the patient is in front of the Stomach turned to the right, tube advanced another 10 cm. This can result in successful passage through the pylorus.24 If this fails, try repeating the maneuver after inflating the stomach with 500–1000 mL of air. It may also be helpful to make a 30° bend 3 cm from the end of the tubing and rotate it clockwise during insertion. Some NJ tubes (Bengmark) develop a helical coil once the guidewire is removed.30 These are usually inserted spontaneously into the small intestine when patients have adequate gastric motility, and some units place them prior to gastrointestinal surgery postoperative use. Weighted-tip probes do not help achieve postpyloric access, but intravenous prokinetics such as metoclopramide or erythromycin may be helpful.31,32 Direct endoscopic placement of NJ probes is difficult because the probe is usually displaced upon withdrawal of the endoscope, itself if a guide wire is left in situ. An alternative approach is to use a long guidewire that is passed through the endoscope into the jejunum and then left in place while the endoscope is removed. The wire is then rerouted from the mouth to the nose (using a short tube passed through the nose and out of the mouth) before passing a well-lubricated nasoenteric tube over it.24 However, this is sometimes difficult without fluoroscopic screening, and when one If fluoroscopy is to be used, endoscopic assistance is not usually required. Die Position einer NJ-Sonde sollte im Allgemeinen 8–12 Stunden nach der Platzierung durch Röntgenaufnahmen bestätigt werden, da Auskultations- und pH-Aspirationstechniken nicht schlüssig sein können.27 7.3 Perkutane Gastrostomiesonden Wenn wahrscheinlich eine enterale Ernährung über einen Zeitraum von mehr als 4–6 erforderlich ist Wochen kann eine Gastrostomiesonde mit relativ einfachen endoskopischen oder radiologischen Verfahren direkt durch die Bauchdecke in den Magen eingeführt werden.33 Gastrostomiesonden ermöglichen eine Ernährung ohne die Unannehmlichkeiten, Beschwerden und Peinlichkeiten eines NG-Zugangs, und die Patienten erhalten mehr von ihrer verschriebenen Nahrung . Dies liegt hauptsächlich daran, dass NG-Röhren leicht „herausfallen“ (siehe Abschnitt 10.1). Obwohl die Platzierung einer Gastrostomie eine geringe unmittelbare Morbidität aufweist, ist die Gesamtmortalität innerhalb weniger Wochen nach der Platzierung einer perkutanen endoskopischen Gastrostomie (PEG) sehr hoch (siehe Abschnitt 10.1) und viele PEGs werden unangemessen platziert.34 Todesfälle sind normalerweise auf die Art der zugrunde liegenden Ursache zurückzuführen Zustand und schlechte Patientenauswahl (z. B. ein schwerer Schlaganfall). Patienten, die für eine Gastrostomie ausgewählt werden, sollten ein hohes Risiko einer Mangelernährung aufweisen und es ist unwahrscheinlich, dass sie ihre Fähigkeit zur oralen Nahrungsaufnahme kurzfristig wiedererlangen. Die meisten Behörden erwägen eine Platzierung, wenn die Probleme wahrscheinlich länger als 4–6 Wochen anhalten, aber eine Studie hat eine Platzierung 14 Tage nach einem akuten dysphagischen Schlaganfall vorgeschlagen35 (dieser Vorschlag wird derzeit in multizentrischen Studien bewertet). Die Magen-Darm-Funktion des Patienten muss ausreichend sein, um die vorgeschlagene Nahrung aufzunehmen und zu vertragen. Die mit der PEG-Platzierung verbundenen ethischen Fragen unterscheiden sich nicht von denen, die mit der Einleitung einer künstlichen Ernährungsunterstützung auf andere Weise verbunden sind (siehe Abschnitt 6.0), aber die invasive und potenziell gefährliche Natur des Verfahrens macht es erforderlich, diese sehr sorgfältig zu überdenken. Das Konzept der Gastrostomie-Ernährung muss für den Patienten und seine Familie oder Betreuer akzeptabel sein. Die Eignung für die Platzierung einer Gastrostomie sollte daher von einem erfahrenen Gastroenterologen oder einem entsprechend geschulten Mitglied eines Ernährungsunterstützungsteams bestätigt werden.36,37 Die Prognose jeglicher Schluckbeschwerden sollte von einem Spezialisten beurteilt werden. Häufige Indikationen für die Platzierung einer Gastrostomie sind in Tabelle 2 aufgeführt. Bei Patienten, bei denen kosmetische Erwägungen wichtig sind, können „Knopf“-PEGs mit niedrigem Profil verwendet werden, die ein eingebautes Antirefluxventil enthalten, um ein Auslaufen zu verhindern, wenn Verlängerungssonden getrennt werden.38 Tabelle 2 Indikationen zur Einführung einer Gastrostomie Die meisten Gastrostomien werden endoskopisch unter Sedierung und örtlicher Betäubung platziert.24 Eine radiologisch oder ultraschallgesteuerte Platzierung kann verwendet werden, wenn eine Endoskopie kontraindiziert ist, und Gastrostomien können auch chirurgisch eingeführt werden.39 Aszites, ausgedehnte Magengeschwüre, neoplastische/infiltrative Erkrankungen des Magens, Magenausgangsobstruktion, Dünndarmmotilitätsprobleme, Malabsorption, Peritonealdialyse, Hepatomegalie, Magenvarizen, Koagulopathie und Spätschwangerschaft. Morbus Crohn wurde als Kontraindikation angesehen, da befürchtet wurde, dass die Krankheit im Gastrostomie-Trakt auftritt. Eine Reihe von Studien hat jedoch jetzt vorgeschlagen, dass es dort eingesetzt werden sollte, wo es notwendig ist.40 Adipositas kann die Gastrostomie technisch erschweren. Die BSG empfiehlt derzeit die Gabe von Antibiotika (z. B. eine Einzeldosis von 2,2 g Co-Amoxiclav) 30 Minuten vor dem Einsetzen der Gastrostomie, um das Auftreten peristomaler Wundinfektionen zu reduzieren.41 Entfernung Perkutane Gastrostomien sollten mindestens 14 Tage nach dem Einsetzen nicht entfernt werden Stellen Sie sicher, dass ein fibröser Trakt gebildet wird, der eine intraperitoneale Leckage verhindert.24 Gastrostomiekanülen, die durch einen Ballon an Ort und Stelle gehalten werden, kommen normalerweise mit sanftem Zug heraus, nachdem der Ballon entleert wurde, während an jenen, die durch eine Verformungsvorrichtung an Ort und Stelle gehalten werden, kräftiges Ziehen erforderlich sein kann. Sonden mit starrer Fixierung werden in der Regel endoskopisch entfernt, obwohl neuere Erkenntnisse darauf hindeuten, dass sie, wenn sie hautnah abgeschnitten und in den Magen vorgeschoben werden, spontan den Darm passieren.42 Diese Methode sollte nicht angewendet werden, wenn ein Verdacht besteht der distalen Striktur und insgesamt werden 2 % nicht bestehen. 7.4 Perkutane Gastrojejunostomie- und Jejunostomie-Sonden Diese Sonden können nützlich sein, wenn bei Patienten ein Risiko für ösophagealen Reflux besteht, obwohl dieses Risiko nicht beseitigt ist.43 Sie werden auch für die frühe postoperative Ernährung verwendet (siehe Abschnitt 5.0). Beim nicht-chirurgischen Patienten wird der jejunale Zugang normalerweise transgastrisch unter Verwendung radiologischer Techniken hergestellt. Perkutane endoskopische transgastrische Jejunostomien (PEGJs) können auch platziert werden, indem eine Jejunostomiekanüle durch eine Gastrostomie geführt und durch den Pylorus geführt wird. Ebenso können bestehende Gastrostomien mithilfe einer Jejunalverlängerung in Jejunostomien umgewandelt werden.24 Die direkte, perkutane, endoskopisch geführte Jejunalpunktion wird jetzt häufiger durchgeführt und kann bei Patienten mit einer Gastrektomie angewendet werden. Es ist technisch schwierig und es ist eine spezielle Ausbildung in Einführungstechniken erforderlich. Es können Leckageprobleme auftreten. Chirurgische Jejunostomien werden normalerweise gleichzeitig mit anderen chirurgischen Eingriffen platziert, obwohl auch die laparoskopische Platzierung beschrieben wurde.44,45 8.0 NAHRUNGSVERABREICHUNG 8.1 Ernährungsarten Enterale Sondennahrung kann als Bolus oder als intermittierende oder kontinuierliche Infusion verabreicht werden.46 Die Bolusernährung umfasst die Verabreichung von 200–400 ml Nahrung über eine Ernährungssonde über 15–60 Minuten in regelmäßigen Abständen. The technique may cause bloating and diarrhoea and bolus delivery into the jejunum can cause a “dumping” type syndrome and should therefore be avoided (see section 10.4). Bolus feeding can be performed using a 50 ml syringe, either with or without the plunger. If the latter is removed, the syringe can be hung up to allow gravity feeding. Continuous infusion may help with diarrhoea or prevent “dumping” in some patients but it also results in higher intragastric pH levels than bolus feeding which can promote bacterial growth (see section 10.4). It is commonly used for very ill patients but it should be changed for intermittent infusion as soon as possible. Continuous feed should not be given overnight in patients who are at risk of aspiration. Intermittent infusion provides moderate rates of feed provision via either gravity or pump. Breaks in feeding of six hours or more are used, depending on patients’ needs (for example, overnight feeding). Post pyloric feeding necessitates continuous administration due to the loss of the stomach reservoir. 8.2 Choice of feeds The choice of feed to be given via ETF is influenced by a patient’s nutritional requirements, any abnormality of gastrointestinal absorption, motility, or diarrhoeal loss, and the presence of other system abnormality, such as renal or liver failure.46 Most commercial feeds contain 1.0 kcal/ml, with higher energy versions containing 1.5 kcal/ml. They are generally available in fibre free and fibre enriched forms. They are nutritionally complete but expert dietetic advice should be sought. Producing feeds locally by using a liquidiser is not recommended due to the high infective risks and potentially poor nutritional quality in terms of micronutrient provision. The following feeds are generally used. Polymeric feeds—These contain nitrogen as whole protein. The carbohydrate source is partially hydrolysed starch and the fat contains long chain triglycerides (LCTs). Their content of fibre is very variable and although most authorities recommend that fibre should be included 46 the evidence that higher levels are of real benefit is not strong (see section 9.4). Predigested feeds—These feeds contain nitrogen as either short peptides or, in the case of elemental diets, as free amino acids. Carbohydrate provides much of the energy content with the content variable in both quantity and the proportion provided as LCTs and medium chain triglycerides (MCTs). The aim of “predigested diets” is to improve nutrient absorption in the presence of significant malabsorption. Their importance is probably greater in maldigestive (for example, pancreatic disease) rather than malabsorptive states, and in patients with a short gut and no colon their high osmolality can cause excess movement of water into the gut and hence higher stomal losses. 47 Disease specific and pharmaco nutrient feeds—Detailed guidelines on the use of specific formulations for patients with organ failure is beyond the remit of these guidelines, as are descriptions of feeds containing large quantities of nutrients with potential pharmacological activity. Patients with respiratory failure are often given feeds with a low carbohydrate to fat ratio in order to minimise carbon dioxide production, but it should be recognised that this type of feed requires higher oxygen availability, and avoidance of overfeeding is probably the more important in limiting respiratory demands. Renal patients will often require modified protein, electrolyte, and volume feeds while liver patients may need low sodium low volume feeds. There is no good evidence that patients with hepatic encephalopathy should have low protein intakes and the evidence for the benefit of feeds rich in branch chain amino acids is weak. Sodium supplemented enteral or sip feeds are not available commercially but can be very useful in the management of patients with high output stomas who tend to become salt depleted. Addition of sodium chloride to achieve concentrations >100 mmol/l are needed with due care to avoid potential bacterial contamination. Consequent instability of feed components may be an issue and checks should be made with the manufacturer. 8.3 Energy and nitrogen requirements An individual patient’s nutrient needs vary with current and past nutritional state, and the nature and complexity of their condition. As both inadequate or excessive feeding can be harmful (see section 10.5), dietitians or others with expertise should be consulted regarding feed prescription. If no expert advice is available, 30 kcal/kg/day (30 ml/kg/day of standard feeds) is likely to be adequate46 but very undernourished patients should start at rates of <10 kcal/kg/day to prevent refeeding syndrome. Some experts would always commence feed cautiously in severely ill patients (see section 10.5). In healthy individuals, a protein intake of well under 0.15 g N/kg/day (1 g N = 6.25 g protein) is adequate to maintain nitrogen balance but this changes dramatically in acute illness and catabolic patients have very high nitrogen losses. In the past, this led to the use of very high protein feeds in patients who were very ill or undernourished but recent thinking suggests that this is unwise.48,49 Most authorities therefore recommend early feeding at maximum levels of 0.2–0.3 g/N/kg/day46 and some recommend even lower levels during early feeding. When calculating energy provision for artificial nutrition support by either ETF or PN, there is no logical justification for considering energy provided as protein as separate from energy given as non-protein calories. 8.4 Micronutrients Micronutrients are required for the prevention or correction of recognised deficiency states and maintenance of normal metabolism and antioxidant status. Standard enteral feeds are supplemented with vitamins and trace elements at levels which ensure that all micronutrients are likely to be met if the patient is on ETF at a level meeting their entire energy needs. Many patients however do not receive full ETF and may have pre-existing micronutrient deficits, poor absorption, and increased demands. It therefore seems reasonable to give additional balanced micronutrient supplements during the early days of ETF when full feeding may not be tolerated and additional micronutrients may be needed to replenish any deficits or to meet the increased demands of illness. 8.5 Fluid and electrolytes Fluid needs can usually be met by giving 30–35 ml/kg body weight although allowance must be made for excessive losses from drains, fistulae, etc. Most feeds contain adequate electrolytes to meet the daily requirements of sodium, potassium, calcium, magnesium, and phosphate, although specific requirements can vary enormously. Malnourished or metabolically stressed individuals are often salt and water overloaded and excess sodium intake is a frequent problem in patients with renal problems, liver derangement, and cardiac failure. High salt intakes may be needed when intestinal losses are excessive. Potassium requirements are often high in malnourished or sick patients and normal plasma levels do not rule out total body depletion. Approximately 6 mmol of potassium is needed per g N for protein synthesis and needs are higher in patients who are postoperative, or on glucose/insulin infusions or diuretics. Feeding after a period of starvation also leads to high potassium requirements (see section 10.5). If hypokalaemia is persistent, concurrent hypomagnesaemia should be sought as renal and gastrointestinal potassium losses are high in patients with magnesium depletion. Calcium levels, adjusted for albumin, may need specific correction and magnesium losses can be enormous in patients with fistulae or high stomas. The daily requirement for phosphate is about 0.3 mmol/kg/day but requirements may be much greater when refeeding after starvation. 8.6 Monitoring enteral feeding Patients receiving ETF should be closely monitored, particularly early after instigation. Monitoring allows quantification of losses to enable daily estimation of replacement requirements, maintenance of metabolic balance, detection of toxicity/deficiency states, and early detection of complications. As well as recording the volume and type of feed administered, early monitoring requires blood glucose to be checked at 4–6 hour intervals and plasma sodium, potassium, magnesium, and phosphate to be checked daily. This is especially true in patients who have had a prolonged period with little or no nutrient intake (see section 10.5). Liver function tests and full blood counts must be repeated weekly until the patient is stable. Blood pressure, pulse, and temperature records are also needed regularly and careful fluid balance records are essential. Body weight should be measured weekly, unless more frequent weighing is indicated, in order to monitor fluid status. If possible, trace element and vitamin levels should be measured on commencing ETF and patients on long term feeding should have periodic checks of vitamin and trace element status. 8.7 Stopping enteral tube feeding ETF should be stopped once the patient has recovered swallowing, gastrointestinal, or general function to a level that permits an adequate oral intake. Dietetic review during the transition to oral feeding is recommended and dysphagic patients will need to be observed closely, ideally by a speech and language therapist with a specialist interest in swallowing difficulties. Video fluoroscopic assessment may be needed. 9.0 HOSPITAL DISCHARGE ON ENTERAL TUBE FEEDING Increasing numbers of patients are now discharged to their home or community care on continued enteral nutrition. Outlining the management of such patients is beyond the remit of these guidelines but BAPEN have produced guidance.50 Prior to discharge, it is the duty of the hospital care team to ensure that there is adequate liaison with the community carers in order to ensure that prescription feeds and feeding equipment is available. The patient, carers, district nurses, community dietitians, and GPs should all be fully informed and adequate training in pump use, infection control, feeding stoma care, etc., must have been provided before discharge. The hospitals should follow written protocols to ensure that discharge goes smoothly. The patient or carer should have a list of expert contacts. 10.0 COMPLICATIONS OF ENTERAL TUBE FEEDING Although ETF is effective and safe in the majority of patients, feeding carries a number of significant risks summarised in table 3. Table 3 Complications of enteral tube feeding 10.1 Tube insertion related complications Although nasal intubation may cause discomfort, traumatic complications are uncommon if using fine bore NG or NJ tubes.25,51 Nevertheless, perforation of a pharyngeal or oesophageal pouch can occur and intracranial insertion of feeding tubes has been reported.52,53 NG tube insertion should probably be avoided for three days after acute variceal bleeding54 and although oesophageal, gastric, or small bowel perforation is unusual, it may occur if a guidewire is reinserted and accidentally exits via a side port. Perforation has also been reported when using polyvinyl or polypropylene tubes without guidewires. Accidental bronchial insertion is relatively common in patients with reduced levels of consciousness or with impaired gag/swallowing reflexes. Endotracheal tubes in ventilated patients do not necessarily prevent bronchial insertion, and ETF into the lungs or pleural space can be fatal.55 Approximately 25% of nasogastric tubes “fall out” or are pulled out by patients soon after insertion and tubes, especially those that are fine bore, can be displaced by coughing or vomiting. There is however no evidence to support the use of weighted NG tubes in terms of either placement or maintenance of position.31 Problems related to insertion of percutaneous gastrostomy and jejunostomy tubes include abdominal wall or intraperitoneal bleeding and bowel perforation. Free air is visible on x ray in 38% of patients but significant surgical intervention is needed in fewer than 5%.56,57 Early procedure related mortality of up to 2% has been reported but this is mainly ascribable to the risks of endoscopy in a vulnerable population group. Later mortality rates are very high (see section 10.2). 10.2 Post insertion tube complications Nasopharyngeal discomfort occurs frequently in patients with nasoenteral tubes and many suffer sore mouths, thirst, swallowing difficulties, and hoarseness.55 Mouthwashes, sucking ice cubes, or using artificial saliva can help. Local pressure effects from tubes may cause nasal erosions, abscess formation, sinusitis, and otitis media. Avoidance of larger tubes helps and swapping of the tube to the other nostril when fine bore tubes need replacement (every 4–6 weeks) prevent these problems. Short term oesophageal damage can include oesophagitis and ulceration from local abrasion and gastro-oesophageal reflux although, once again, such problems are rare with fine bore tubes. Longer term damage includes significant stricturing. Large stiff tubes can cause fistulation to the trachea, especially when an endotracheal tube is present. Larger tubes are also unsafe in the presence of varices even if they have not bled recently.54 Post insertion tube related complications from gastrostomies and jejunostomies differ from those seen with NG and NJ tubes.55–61 They include infection at the insertion site, peristomal leaks, accidental tube removal, tube fracture, gastro-colic fistula, peritonitis, septicaemia, and necrotising fasciitis. PEGJ tubes can also fall back into the stomach or become disconnected with the whole tube passing through the PEG and into the gut. Of even more concern however is the very high mortality rates of approximately 20%37 or even 40%36 seen in PEG patients within one month of insertion. These suggest that PEGs are often placed inappropriately34,36 and it has been shown that review of patients referred for gastrostomy by an experienced gastroenterologist results in a much lower 30 day mortality.62 Complications of surgically placed enteral feeding tubes are quite common and include dislodgement, intraperitoneal leakage, and small bowel obstruction. Surgical jejunostomies should be left in for 3–5 weeks, even if feeding has stopped, so that a tract can become established and the purse string suture holding the tube has dissolved.55 Feeding tubes block easily, especially if they are not flushed with fresh tap, cooled boiled, or sterile water before and after every feed or medication. Any drugs administered through a tube should ideally be elixirs or suspensions rather than syrups and should only be given after establishing compatibility. Hyperosmolar drugs, crushed tablets, potassium, iron supplements, and sucralfate are particularly likely to cause problems. A tube can often be unblocked by flushing with warm water or, if this fails, by using an alkaline solution of pancreatic enzymes.63 Carbonated drinks, pineapple juice, and sodium bicarbonate solution may cause tube degradation. Unlike NG and NJ tubes, gastrostomy tubes are sometimes occluded by gastric mucosal overgrowth. Tube blockage or intraperitoneal leakage can be assessed using water soluble contrast, and passing a soft guidewire may be helpful. Blockage may necessitate replacement or surgical removal, although loosening and rotating a gastrostomy tube every week helps to prevent any problem. When splits or breakages occur in gastrostomy or jejunostomy tubes, it is often possible to cut the tube and then replace the luer/funnel lower down. 10.3 Reflux and inhalation problems Gastro-oesophageal reflux occurs frequently with ETF. It is more common when patients are NG fed in the supine position64 and reflects a combination of gravitational back flow and impairment of gastro-oesophageal sphincter function induced by pharyngeal stimulation and the presence of the tube across the cardia. It is very common in patients with impaired consciousness or poor gag reflexes, occurring in up to 30% of those with tracheostomies65 and 12.5% of neurological patients.66 Aspiration may occur with no obvious vomiting or coughing, and pneumonia can develop silently. To minimise risks of aspiration, patients should be fed propped up by 30° or more, and should be kept propped up for 30 minutes after feeding.55 Acid suppression or sucralfate may help with symptoms of oesophagitis, but they do not prevent aspiration pneumonia. There is an increased risk of aspiration if gastric residues accumulate, and therefore if a four hour aspirate is >200 ml, the feeding regimen should be reviewed. Although continuous pump feeding reduces gastric pooling, it is often used overnight and may therefore be more risky than bolus or intermittent feeding.67 Iso-osmotic feeds cause less delayed gastric emptying than high osmotic feeds68 and promotility drugs such as metoclopramide or erythromycin may be helpful. Post pyloric feeding makes aspiration less likely, but does not eliminate the problem. PEG feeding may reduce but will not eliminate the risk of aspiration, although PEGJ feeding does reduce the risk further.55 10.4 Gastrointestinal problems ETF commonly causes gastrointestinal symptoms. Nausea occurs in 10–20% of patients69,70 and abdominal bloating and cramps from delayed gastric emptying are also common.55 ETF related diarrhoea occurs in up to 30% of enterally fed patients on medical and surgical wards and more than 60% of patients on intensive care units.70–74 It can create serious problems from nutrient, fluid, and electrolyte losses, and from infected pressure sores and general patient distress.55 Parenteral nutrition may be required if elimination of all other causes of gastrointestinal upset and/or administration of simple symptomatic treatments fails to resolve the problem. Constipation, with or without overflow, also occurs with ETF. The causes of gastrointestinal discomfort and ETF diarrhoea are multiple and are summarised in table 4. Table 4 Causes of gastrointestinal intolerance Feed delivery site and rate Gastrointestinal discomfort often relates to excessive feed administration rates, delayed gastric emptying, or decreased small bowel motility. Continuous infusion rather than bolus administration of feeds may therefore help. Feeding rates should be reduced if gastric residual volumes are >200 ml, although aspiration through fine bore tubes is unreliable. Prokinetic agents may be helpful but if persistently high aspirates prevent effective feeding, jejunal access should be considered. Bolus feeding is often thought to cause more diarrhoea75 than continuous intragastric feeding but this may be untrue.55,76 Enteral feeds taken orally cause less diarrhoea in healthy volunteers than the same quantities given by NG tube77 suggesting that cephalic and gastrocolic reflexes are important in the aetiology of ETF diarrhoea. If this is true, bolus intragastric feeding should cause fewer problems than infused feeds as a bolus will stimulate more normal distal colonic motor suppression and promote water absorption in the ascending colon.55 There is no evidence that starter regimens with diluted or hypotonic diets are helpful and these approaches can delay the provision of adequate nutrition unnecessarily.78 Feed type Most enteral tube feeds are available in standard and fibre enriched forms. The standard feeds contain little or no fibre and hence lead to reduced short chain fatty acid (SCFA) production in the colon, due to both limited substrate availability and decreased induction of bacterial polysaccharidase. SCFAs promote salt and water reabsorption in the colon and also limit growth of pathogenic bacteria due to lower colonic pH.55,79 The fibre enriched feeds aim to increase the overall colonic bacterial population and hence stool mass and water absorptive capacity.80 However, although they do seem to normalise transit times, there is little evidence that this often helps with ETF diarrhoea, perhaps due to the fact that the diarrhoea has nothing to do with the feed per se.55,81,82 Lack of definite benefit may also relate to some problems when manufacturing fibre enriched feeds, which need to contain small particles of non-starch polysaccharide or other insoluble carbohydrate components in order to limit viscosity. The small particles ferment easily and hence little fibre reaches the distal colon where it can help to absorb faecal water. Feed temperature Some studies suggested that feed temperature influences ETF diarrhoea but there is little evidence that either refrigeration or warming alters gastrointestinal complications significantly.83 Drug related ETF diarrhoea Whenever diarrhoea occurs with ETF, all laxatives must be stopped, including drugs containing magnesium such as antacid preparations and drugs containing active fillers, such as sorbitol.55 Diarrhoea is also a recognised side effect of many drug classes, including H 2 Blockers, proton pump inhibitors, antibiotics, antiarrhythmics, antihypertensives, and non-steroidal anti-inflammatory drugs. Antibiotics can cause diarrhoea in patients eating normally but the incidence is far higher in patients on ETF.55,84 The exact cause is unclear, but it seems likely that they alter intestinal flora to allow overgrowth of pathogenic species. Clostridium difficile toxin is found in 20–50% of patients with antibiotic related diarrhoea.85 Antibiotics also reduce colonic bacterial production of SCFAs from insoluble carbohydrates and fibre. Infective causes Enteral feed is an ideal culture medium and once contaminated, bacteria will rapidly multiply. Stool samples must therefore be checked whenever ETF patients develop diarrhoea. Bacterial feed contamination can also cause sepsis, pneumonia, and even urinary tract infections as well as gastrointestinal related problems.86–89 Open bottles or cans of feed get infected during handling and delivery90,91 and so it is vital that no part of the delivery system or feed is in contact with the hands, clothes, skin, or other non-disinfected surface. Feeds should not be decanted before use and if continuous feeding is used, bacteria can also spread up the giving set from gastric or enteral sources, especially as the continuous infusion raises gastric pH and promotes bacterial overgrowth. Administration sets and nutrient containers should therefore be discarded every 24 hours.92,93 Avoiding simultaneous acid suppression and allowing breaks in feeding to let the pH of the stomach fall may be helpful. With 8 hours fasting/24 hours, the incidence of pneumonia on an intensive therapy unit fell from 54% to 12%.94 Post pyloric feeding is particularly prone to infective complications as the food bypasses the protective gastric acid barrier. Full enteral feed and associated equipment handling guidelines are beyond the remit of this document. Lactase deficiency Primary lactase deficiency is common in many parts of the world and a secondary deficiency can occur when there is gut damage from inflammation or infection, a reduced small bowel absorptive area, or rapid small bowel transit.95 Carbohydrate malabsorption may then cause gastrointestinal problems although most commercial enteral feeds are lactose free. If a patient with diarrhoea is also taking oral food as well as enteral feeds, it is important to limit milk and milk products. Fat malabsorption Fat malabsorption may cause diarrhoea in ETF patients, especially those with pancreatic deficiency, biliary obstruction, or extensive ileal resection. Terminal ileal problems may also cause diarrhoea through bile salt malabsorption. Patients with a jejunostomy or ileostomy do not need to reduce their fat intake but if the colon remains in continuity with a short small bowel, steatorrhoea can develop. Using a feed with a low fat content can then be helpful but may limit the energy provided to the patient. Feeds containing MCTs may be better absorbed although patients often tolerate them poorly. Hypoalbuminaemia There is considerable debate over whether hypoalbuminaemia can cause ETF diarrhoea through intestinal oedema.57 Rather than a direct causation however it seems more likely that both the low albumin and gut dysfunction reflect a generalised membrane leakiness, often due to a systemic inflammatory response. Certainly, patients with very low plasma albumin due to nephrotic syndrome or cirrhosis do not necessarily have loose stools, and albumin supplements fail to correct ETF diarrhoea. Treatment of ETF diarrhoea If diarrhoea remains a problem after attention to the above causes, loperamide in high doses may be used. If this fails, codeine phosphate may control symptoms and there are anecdotal reports of live yoghurt or other probiotics being helpful. If vomiting/bloating or diarrhoea (not related to antibiotic therapy) are problematic, feed rates can be reduced for a trial period. 10.5 Metabolic complications of ETF Artificial feeding of patients may cause a variety of metabolic problems, including deficiencies or excess of fluid, electrolytes, vitamins, and trace elements.55,96,97 Over hydration occurs frequently, particularly if ETF patients are also receiving supplementary intravenous nutrition or fluids. Hyponatraemia is a common problem when enteral nutrition is given to sick patients.98 It is often accompanied by the development of oedema and is usually due to a combination of excessive use of intravenous fluids, such as 5% dextrose, in combination with the adverse effects from malnourishment and severe illness on normal membrane pumping. Patients end up with excess body water in combination with very high total body sodium. As a consequence, rather than administering further sodium in feeds or intravenous fluids, treatment should usually entail fluid restriction. Generous amounts of potassium to encourage cell membrane sodium exchange may be helpful. Hypernatraemia can also occur and is usually due to excess water loss or transient diabetes insipidus in neurosurgical patients.97 Between 10% and 30% of tube fed patients are hyperglycaemic96 and may need oral antidiabetic agents or insulin, before and during feeding. Rebound hypoglycaemia may also occur in tube fed patients if feeding is stopped abruptly, especially if they are on antidiabetic therapy. When commencing feeds in patients who have recently starved, there is the danger of inducing refeeding syndrome.99,100 This condition is poorly understood but occurs, in part, because the body adapts to undernutrition by downregulating membrane pumping in order to conserve energy. This in turn causes leakage of intracellular potassium, magnesium, calcium, and phosphate, with subsequent whole body depletion. Simultaneously, sodium and water leak into the cells. The sudden onset of artificial nutritional support appears to reverse the above processes and along with insulin driven movements of electrolytes into cells, can lead to precipitous falls in circulating levels of potassium, magnesium, calcium, and phosphate. There may also be an accompanying acute increase in circulating and extracellular fluid due to exogenous administration, the endogenous movement of sodium and water out of cells, and the diminished ability of undernourished kidneys to excrete a salt and water load. Furthermore, specific micronutrient deficiencies can compound the problems (for example, thiamine deficiency and cardiac function). As a result of all of these processes, there is a considerable danger of cardiac and respiratory failure, lethargy, confusion, coma, and even death. Refeeding problems can usually be avoided by feeding for the first few days at very low levels while generously supplementing and closely monitoring potassium, magnesium, calcium, and phosphate. Instigation of feeds at levels of approximately 20 kcal/kg/day is often suggested but some authorities believe that even this may be too high. The situation is particularly dangerous in patients who have abnormal plasma electrolytes before feeding has even started. In such cases, many authorities suggest that correction of the electrolyte abnormalities using intravenous or oral electrolyte supplements should be undertaken before feeding starts. This approach however may provide a false sense of security as improvement in plasma levels could occur with no significant change in overall electrolyte status. A severely malnourished individual may have intracellular electrolyte deficits which total hundreds of mmol, yet be unable to correct intracellular status unless simultaneous feeding is given to encourage transmembrane transfer. It therefore seems more logical to provide initial generous potassium, magnesium, calcium, and phosphate supplements with feeding at around 10 kcal/kg/day in very high risk groups. Thiamine and other B vitamins must also be given intravenously starting before any feed is started, continuing for at least the first three days of feeding. It has also been suggested that commencing high levels of feeding shortly after major surgery or during sepsis and/or multiorgan failure can also cause metabolic problems similar to those of refeeding, as well as the problems of insulin resistance seen in such patients. Liver dysfunction can also be triggered or worsened by feeding as the high influx of nutrients to the liver can lead to excessive storage of fat and glycogen. This is particularly problematic if continuous ETF is used.100

11.0 CONCLUSIONS Malnourishment is common in adult patients in UK hospitals and ETF is an effective and generally safe means of offering many of them nutritional support. Access options need careful consideration in each patient as well as levels of feeding, rates of administration, and the type of feed to be used. Complications can usually be avoided if care is taken. Feeding should not be undertaken unless it is in the patient’s best interests and all relevant ethical issues have been taken into account. A time defined trial of feeding to see if benefit is obtained may be appropriate in difficult ethical situations.

What types of feeding tubes are there?

The types of feeding tubes are:

Stomach tube (NG tube)

Nasojejunal tube (NJ tube)

Percutaneous Endoscopic Gastrostomy (PEG)

Jejunostomy Cannula (J-Tube)

METHODS OF ENTERAL NUTRITION

There are several methods of administering enteral nutrition. Your nutritionist will recommend the most appropriate method of administering your food. Below are some common feeding techniques.

Pump or continuous enteral feeding: Your enteral feeding is connected to a pump that gradually feeds food to you at a controlled rate. The speed (or rate) and duration of your feedings will be discussed with you by your nutritionist.

Bolus feeding: Your nutritionist may recommend bolus feeding as a way to maintain your enteral nutrition. They receive the food in small doses, which are given via syringe several times throughout the day, rather than being fed continuously via a feeding pump.

Gravity Feeding: Enteral feeding flows by gravity from the bag/bottle or syringe into your feeding tube. This can be done multiple times a day, such as a bolus feeding with a syringe; However, it may take a little longer for a gravity feed to be delivered.

Disclaimer: The content of this website is for educational purposes only and should not be taken as medical advice. It is not intended to replace the advice of your medical team. If you have any questions about your home tube feeding plan, please contact your healthcare team.

10.3 Stomach Tubes

Using a nasogastric tube

A nasogastric (NG) tube is a flexible plastic tube that is inserted through the nostrils, down the nasopharynx, and into the stomach or upper part of the small intestine. The placement of NG probes is always confirmed with a radiograph prior to use (Perry, Potter & Ostendorf, 2014).

NG tubes are used for:

Provide the patient with nutrients via a feeding pump

remove stomach contents

A NG tube used for feeding should be labelled. The tube is used to feed patients who may have difficulty swallowing or who may need additional nutritional supplements. These pipes are narrower and bored smaller than a Salem sump or Levine pipe.

An NG tube can also remove stomach contents by either emptying the stomach by gravity or by connecting it to a suction pump. In these situations, the NG tube is used to prevent nausea, vomiting, or stomach distention, or to flush the stomach of toxins.

The NG tube is attached to the patient with a nose clip and taped to the patient’s gown to prevent accidental tube removal and tube slippage from the stomach area to the lungs.

When working with people with nasogastric tubes, keep the following care measures in mind:

Maintain and promote comfort. The tube constantly irritates the nasal mucosa, which causes a great deal of discomfort. Ensure that the tubing is securely anchored to the patient’s nose to prevent excessive movement of the tubing and that it is attached to the gown to prevent excessive tugging or tugging.

Because one nostril is blocked, patients tend to breathe through the mouth. This causes dryness of the nasal and oral mucosa, and patients complain of thirst, but they are usually NPO (nil per os or nothing by mouth). Oral care helps relieve dryness. This may involve rinsing the mouth with cold water or mouthwash as long as the patient does not swallow. Some patients are allowed to suck on ice chips.

If the patient complains of abdominal pain, discomfort, nausea, or begins to vomit, report it immediately. The drain is likely obstructed and the hose needs to be flushed.

These patients should never lie completely flat. Lying flat increases the patient’s risk of aspirating gastric contents. There is a risk of aspiration in patients with an NG tube. The head of the bed should always be raised 30 degrees or higher.

Checklist 78 describes the steps for inserting a gastric tube.

Checklist 78: Inserting a Nasogastric Tube Disclaimer: Always read and follow your hospital policies regarding this specific skill. Safety instructions: carry out hand hygiene.

Check the room for additional precautions.

Introduce yourself to the patient.

Confirm the patient ID with two patient identifiers (e.g. name and date of birth).

Explain the process to the patient; provide analgesia, bath, etc.

Listen and heed the patient’s cues.

Respect for the privacy and dignity of the patient.

Rate ABCCS/suction/oxygen/safety.

Apply principles of asepsis and safety.

Check vital signs.

Conduct the required focused assessments. Steps Additional Information 1. Perform hand hygiene and gather supplies. This prevents the transmission of microorganisms. 2. Visually check the condition of the patient’s nasal and oral cavity. Look for signs of infection or skin damage. 3. Evaluate the best nostril before you start. Do this by closing one side and asking the patient to sniff. Ask the patient about previous injuries or a history of septal deviation. If both nostrils are equally suitable, choose the nostril closest to the suction. 4. Palpate patient’s abdomen for distension, pain, and/or stiffness. Auscultate for bowel sounds. Document the assessment results and determine the adequacy of the NG tube in relation to the reason for insertion and the patient’s physical assessment. 5. Rate the patient’s level of awareness and understanding of the procedure. The patient must be able to follow the NG insertion instructions to allow passage of the tube through the nasal and gastrointestinal tract. 6. Check the physician’s orders for the type of NG tube to be placed and the reason for the placement. Review regulations relevant to patient safety. 7. Check the doctor’s orders to determine if the NG tube should be connected to a suction or drainage bag. This should correspond to the reason for the NG probe. 8. Position the patient sitting at an angle of 45 to 90 degrees (unless the patient’s condition precludes this), with a pillow under the head and shoulders. This makes it easier to pass the NG tube through the nasopharynx and into the stomach. 9. Raise the bed to a comfortable working height. This helps prevent biomechanical injury to the healthcare provider. 10. Agree on a signal that the patient can use if they want you to pause during the procedure. This procedure can be anxious and uncomfortable for many patients. Providing a means for the patient to communicate discomfort and a desire to take a break during the procedure helps reduce anxiety. 11. Place a towel on the patient’s chest and provide facial tissue and a vomiting basin. Nasal and oral secretions may be visible during the procedure. 12. Provide the patient with drinking water and a straw if the patient is not fluid restricted. Drinking water through a straw helps trigger the swallowing reflex and makes it easier to pass the NG tube. 13. Stand on the right side of the patient if you are right-handed and on the left side if you are left-handed. You will use your dominant hand to insert the tube. 14. Measure the distance of the tube from the tip of your nose to…

The earlobe to…

Mark the xiphoid process and then the tube at this point. This will determine the appropriate length of NG hose to be inserted. 15. Lubricate the tip of the NG tube according to your agency’s guidelines. The hose can be lubricated with tap water on the inside or with water-soluble lubricant on the outside. Agency policies vary and should be reviewed. Never use a non-water soluble lubricant (such as petroleum jelly) as it will not dissolve and can cause respiratory complications if it gets into the lungs. 16. Wear clean non-sterile gloves. The use of gloves reduces the transmission of microorganisms. 17. Bend 10 to 15 cm of the end of the NG tube around your gloved finger and then release. When you wrap the NG probe around your finger, it conforms to the normal curvature of the nasopharynx. 18. Let the patient’s head fall forward and breathe through the mouth. Dropping your head forward closes the trachea and opens the esophagus, making it easier to pass the NG tube through the nasopharynx and into the stomach. 19. Slowly insert the NG probe tip into the patient’s nostril and steadily advance it down along the bottom of the nasal passage with the curved end pointing down toward the ear on the same side as the nostril. This follows the natural anatomical orientation of the nasopharynx. 20. You may feel a slight resistance as you advance down the nasal passage. Rotate the tube slightly, apply downward pressure, and keep trying to advance the tube. If significant resistance is felt, remove the tube and allow the patient to rest before trying again in the other nostril. It is common for the patient to feel unwell, which may manifest itself as a mild cough and choking. More aggressive coughing and choking may indicate the tube has entered the airway. In this case, you should pull out the NG hose. 21. If there is difficulty in inserting the NG tube, you can ask the patient to slowly drink water through a straw, unless oral liquids are contraindicated. If oral liquids are not allowed, ask the patient to swallow dry while you advance the tube. If the patient continues to choke or cough, use a tongue depressor and a flashlight to check that the tube is curled up at the back of the mouth. Once the tube is coiled, pull the tube out until only the tip of the tube is visible at the back of the mouth. Then try advancing the tube again while the patient tries to swallow. 22. Continue to advance the NG tube until you reach the mark/tape measure you placed for the measurement. This ensures accurate placement. 23. Temporarily anchor the tube to the patient’s cheek with a piece of tape until you can verify proper placement. This prevents the NG tube from shifting while verifying placement. 24. Verify probe placement according to agency guidelines. Color coded pH paper is typically used as an initial and intermediate check to confirm that acidic ingredients are present. An X-ray is then taken to confirm placement before the NG tube is used for feeding. The contents aspirated from the tube should be acidic with a pH <5. If the pH is above 6, this may indicate the presence of respiratory fluid or small bowel contents and the tubing should be removed. 25. After tube placement is confirmed, mark and record (with a permanent marker) the length of the tube from the nose to the outer end of the tube. This helps in the timely detection and identification of pipe displacement or migration. 26. Secure the tubing to the patient's gown with a safety pin, leaving enough tubing length for comfortable head movement. This will hold the NG tube in place. 27. Document the procedure according to agency guidelines and report any unexpected findings to the appropriate healthcare provider. Timely and accurate documentation promotes patient safety. Data source: ATI, 2015a; BCIT, 2015c; Berman & Snyder, 2016 Special features of NG tubes: Always verify proper placement of the NG tube prior to infusing any fluids or formula according to agency guidelines. Check the position of the outer markings on the tube and the color of the PH of the liquid aspirated from the tube. A routine examination will ensure proper tube placement and reduce the risk of aspiration. Do not bring air to the test site of the tube. Do not give the patient anything to eat or drink without knowing that the patient has passed a swallow test. When changing gowns or repositioning the patient, be careful not to pull on the NG tubing. Remember to detach the hose from the gown and reattach the hose. If the NG tube falls out of the patient, it is not an emergency. But be sure to evaluate your patient. What are the ABCCS like? Notify the caregiver responsible for the patient. A patient who appears to be short of breath should be considered an emergency and emergency procedures should be followed. Shortness of breath can manifest itself as coughing, choking, or reduced oxygen saturation. Videos 10.1 Removing an NG tube An NG probe should be removed when no longer needed. The process of removal is usually very quick. Before removing a NG tube, check the doctor's instructions. If the NG tube was ordered to remove stomach contents, the doctor's order may include "trying" the tube on for a few hours to see if the patient tolerates the removal. During the study, the patient should not feel any nausea, vomiting or flatulence. See Checklist 79 for information on removing an NG tube. Checklist 79: Removing a NG Tube Disclaimer: Always review and follow your hospital policies regarding this particular skill. Safety instructions: carry out hand hygiene. Check the room for additional precautions. Introduce yourself to the patient. Confirm the patient ID with two patient identifiers (e.g. name and date of birth). Explain the process to the patient; provide analgesia, bath, etc. Listen and heed the patient's cues. Respect for the privacy and dignity of the patient. Rate ABCCS/suction/oxygen/safety. Apply principles of asepsis and safety. Check vital signs. Conduct the required focused assessments. Steps Additional Information 1. Review the healthcare provider's instructions for removing the NG tube. An assembly is required to remove an NG tube. 2. Gather supplies. Accessories include waterproof pads, a 20ml syringe, tissues, non-sterile gloves and a bin liner. 3. Verify the patient using two identifiers. Explain the procedure to the patient and place them in the high Fowler position. Follow agency guidelines for proper patient identification. 4. Perform hand hygiene. Place the waterproof pad on the patient's chest. This reduces the transmission of microorganisms. 5. Disconnect the tube from the food, if present. This prevents the risk of tube feeding aspiration. 6. Remove the tape or securing device from the nose. This allows the hose to be easily removed. 7. Disconnect the NG tube from the patient's gown. This allows the hose to be easily removed. 8. Purge the NG tube by introducing 10~20ml of air into the tube. This prevents tube food falling out of the tube from being sucked in. 9. Instruct the patient to breathe deeply and hold. This prevents aspiration; Holding the breath closes the glottis. 10. Bend the NG probe near the nostrils and gently pull the probe out in one quick, steady motion, wrapping it in your hand as you pull it out. Dispose of hose in garbage bag. This prevents leftover feed from flowing out of the tube when it is removed. 11. Offer the patient tissues or clean the nostrils and provide oral care if necessary. This will clear the nostrils/nasal passages of any remaining secretions. 12. Remove the gloves and place the patient in a comfortable position. Assess patient comfort. Perform hand hygiene. This promotes patient comfort and reduces the transmission of microorganisms. 13. Document the procedure according to agency guidelines. Document the removal of the NG tube and the patient's response to the removal. Data source: ATI, 2015a; BCIT, 2015b; Perry et al., 2014

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