jroyster06
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Whats the best way that yall have gotten an NG or OG around the King Airway... I havent had much luck.
NG/OG tubes with intubation
- Thread starter Veneficus
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Never used a regular king. All the ones I have used had the og/suction port on the back so it has never been an issue.
What exactly did this contribute besides showcasing what seems to be a growing contempt for paramedics?
To answer the OPs question, I've been placing them pretty much since I got out of school. Usually on intubated patients, but not uncommonly or SBO or upper GI bleed patients.
boerbull
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My service recently started using the I-Gel O2. According to the manufacturer it is very easy to insert the NG tube, that is supplied with it. Do any of you guys have any experience with it? I haven't used it yet, cause it is used as a backup for ET
Merck
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A gastric tube is just good practice. As has been mentioned there is benefit in gastric insufflation in/after a cardiac arrest. As well, gastric emptying can help to decrease the incidence of HAP/VAP or a pneumonitis.
I try to just place an OG when I DL/Glidescope for an intubation.
I try to just place an OG when I DL/Glidescope for an intubation.
Yeah, I guess it was a little bit uncalled-for, but it was a jab at those who act astonished that something isn't "standard" outside their own system especially when they probably known better.
Moving on...
I'm looking around and I'm not finding anything that recommends placing an NG tube post ETI outside of the presence of gastric distention. So, the idea of placing an NGT on all intubated patients seems a little cookbook-ish to me.
But, I've come across some tidbits that are relevant to this practice:
Am J Med. 1992 Aug;93(2):135-42.
A predictive risk index for nosocomial pneumonia in the intensive care unit.
"Endotracheal intubation, altered mental status, and NG tube are associated with the highest risk of [nosocomial pneumonia]..."
J Neurosurg. 2013 Feb;118(2):358-63.
Pneumonia in patients with severe head injury: incidence, risk factors, and outcomes.
"3 risk factors (age, nasogastric tube insertion, and hemiplegia or hemiparesis) associated with the development of pneumonia in patients with severe head injury."
Principles of Critical Care, 3e
Chapter 43. Ventilator-Associated Pneumonia
"The nasogastric tube is not widely considered to be a potential risk factor for pneumonia, but it may increase oropharyngeal colonization, cause stagnation of oropharyngeal secretions, and increase reflux and the risk of aspiration."
Just my thoughts, but I think the practice comes from trauma services.
If you recall, most trauma at one point was met with surgery. Prior to surgery when patients are not NPO (of which the required time has decreased over time) removing stomach contents prior to surgery was easily accomplished by og/ng.
The potential mechanism of aspiration pneumonia is well known and accepted.
However, as recent as a study published in medscape last week, the effectiveness of NPO in decreasing aspiration pneumonia is highly suspect.
I think this would also apply to emergency patients of all types.
Having said that, and never having before been accused of being cookbook, until some powerful or multiple studies compel the a change in the NPO practice, continuing it and by extension, evaculating stomach content in the critically ill, like a post resuscitation patient should probably continue.
Aside from aspiration, in severe illness or injury, there is dysfunction of both the mucosa and the various functions of the gut. It may be possible that removing stomach content could have benefit.
But after all of this, if you are placing an NG just to place it and do nothing with it, then I agree it is an unindicated treatment and as such, a medical error.
If you recall, most trauma at one point was met with surgery. Prior to surgery when patients are not NPO (of which the required time has decreased over time) removing stomach contents prior to surgery was easily accomplished by og/ng.
The potential mechanism of aspiration pneumonia is well known and accepted.
However, as recent as a study published in medscape last week, the effectiveness of NPO in decreasing aspiration pneumonia is highly suspect.
I think this would also apply to emergency patients of all types.
Having said that, and never having before been accused of being cookbook, until some powerful or multiple studies compel the a change in the NPO practice, continuing it and by extension, evaculating stomach content in the critically ill, like a post resuscitation patient should probably continue.
Aside from aspiration, in severe illness or injury, there is dysfunction of both the mucosa and the various functions of the gut. It may be possible that removing stomach content could have benefit.
But after all of this, if you are placing an NG just to place it and do nothing with it, then I agree it is an unindicated treatment and as such, a medical error.
This is the stuff I was finding...
On further reading it seems NG/OG is actually a risk factor for pneumonia, thus the recommendation for post-pyloric feeding in ICU patients.
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How does placing an NG/OG tube make us feel superior? It's a standard procedure for patients with advanced airways in place.
They reduce gastric distention, reduce the risk of vomiting and potential aspiration, especially if you're using a supraglottic airway. ETT isn't as big of a deal but I'd really rather my intubated patient not vomit with that tube and tube holder in place. Also give you a route to administer medications. Aspirin and activated charcoal are the only two I can think of in the prehospital environment but if you have time why not place one. Just one less step for the hospital to do especially if they're intubated and you're not using the port on a King LTD to place it so it's going to end up coming out when they swap the tube anyways.
We use King airways as a first line airway in cardiac arrest and just recently have switched to wanting them to be used or at least considered in respiratory arrest patients as well. It takes me 15 extra seconds to place it...Drop the king, confirm placement, secure it, measure the OG lube it a bit and put it through the port. There's no excuse not to. It's standard to place them with advanced airways here.
I also try to place them in ingestion ODs that occurred a short time before my arrival. Depends a lot on the patient though. We don't carry activated charcoal in my system anymore but there's no reason I can't try to suck as much of the medication that hasn't been absorbed out of their stomach to reduce the amount that's actually absorbed into and circulated around their system.
Random anecdote but have you ever seen a patient with a King airway in place vomit? That little OG port turns a relatively benign vomit into a geyser-like stream of emesis. Not pretty and they shoot a good distance, especially if they're vomiting violently.
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Summit
Critical Crazy
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I agree that NG for all ETT is cookbookish. I guess I don’t know what percent non-deceased EMS patients keep their tubes for long, or go to surgery. If the patient has a distended abdomen or looks like have a long ventilated hospital course and/or a surgical course, NG seems like a good idea and/or is inevitable.
Now, on this thread and in response to medicsb:
http://www.smiths-medical.com/upload/products/mainImages/tube all.JPG
You don’t get the gastric sxn, but for long transports, or for patients who keep their tube, better outcomes by reducing leakage past the cuff or preventing extubation/reintubation with a capable device. This only works if the receiving facility is used to the idea of continuous aspiration
of sub-glottic secretions and I would assume any ED/ICU would be familiar with this idea as the evidence supporting it has been around since at least the 1990s AFAIK. We use a similar device at our hospital.
Now, on this thread and in response to medicsb:
http://www.smiths-medical.com/upload/products/mainImages/tube all.JPG
You don’t get the gastric sxn, but for long transports, or for patients who keep their tube, better outcomes by reducing leakage past the cuff or preventing extubation/reintubation with a capable device. This only works if the receiving facility is used to the idea of continuous aspiration
of sub-glottic secretions and I would assume any ED/ICU would be familiar with this idea as the evidence supporting it has been around since at least the 1990s AFAIK. We use a similar device at our hospital.
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Gastric tubes are being used less and less in the ICU and perioperative settings, because they are actually associated with HIGHER rates of infection.
More importantly for EMS, they don't prevent aspiration, either. In fact some studies show an increased risk of it for 2 reasons:
Anecdotally, I've seen a lot more emesis in patients having gastric tubes placed than in ones who don't. I've never been in the habit of placing gastric tubes in the field, and have never had a problem with emesis post-intubation.
Maybe if someone's gut is blown up like a balloon a gastric tube makes sense, but there's no reason to place them routinely.
More importantly for EMS, they don't prevent aspiration, either. In fact some studies show an increased risk of it for 2 reasons:
- You aren't able to evacuate all the stomach contents, and
- Tubes reduce LES and UES tone, making it easier for gastric contents to find their way back up the goose.
Anecdotally, I've seen a lot more emesis in patients having gastric tubes placed than in ones who don't. I've never been in the habit of placing gastric tubes in the field, and have never had a problem with emesis post-intubation.
Maybe if someone's gut is blown up like a balloon a gastric tube makes sense, but there's no reason to place them routinely.
Mind citing some sources for this?
Already done, see post 27.
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A better question is, would anyone mind citing sources in favor of routine OGT placement?
It's the intervention that has to prove itself, not the other way around.
The only reference I have handy is my class notes.
mycrofft
Still crazy but elsewhere
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Just to be uptight about this: if they did it on purpose and had no indication of it, or no intention of using it, it was a tort. Same as unnecessary backboarding or starting IV's "just in case".
NomadicMedic
I know a guy who knows a guy.
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Again, I use an NG tube to relieve gastric distinction, which occurs 99% of the time I have BLS people bagging. Not a rip on BLS folks... It's a hard skill to master, and most just aren't very good at it.
I also use them to remove sea water following a surf rescue/resuscitation.
I believe both of these indication warrant an NG tube.
I also use them to remove sea water following a surf rescue/resuscitation.
I believe both of these indication warrant an NG tube.
Clare
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They are not used in NZ and I didn't learn how to place them.
For newborns we can decompress the stomach with a small suction catheter placed into the tummy, but I forget why and when but I do remember reading it somewhere.
For newborns we can decompress the stomach with a small suction catheter placed into the tummy, but I forget why and when but I do remember reading it somewhere.
And again - a reason for poorly trained individuals NOT to attempt ventilating the patient.
Bingo, bingo, and .... bingo!