Pediatric orogastric and nasogastric tubes: a new formula evaluated

Pediatric Nasogastric Tube Placement and Verification: Best Practice Recommendations From the NOVEL Project

The placement of a nasogastric tube (NGT) in a pediatric patient is a common practice that is generally perceived as a benign bedside procedure. There is potential risk for NGT misplacement with each insertion. A misplaced NGT compromises patient safety, increasing the risk for serious and even fatal complications. There is no standardized method for verification of the initial NGT placement or reverification assessment of NGT location prior to use. Measurement of the acidity or pH of the gastric aspirate is the most frequently used evidence-based method to verify NGT placement. The radiograph, when properly obtained and interpreted, is considered the gold standard to verify NGT location. However, the uncertainty regarding cumulative radiation exposure related to radiographs in pediatric patients is a concern. To minimize risk and improve patient safety, there is a need to identify best practice and to standardize care for initial and ongoing NGT location verification. This article provides consensus recommendations for best practice related to NGT location verification in pediatric patients. These consensus recommendations are not intended as absolute policy statements; instead, they are intended to supplement but not replace professional training and judgment. These consensus recommendations have been approved by the American Society for Parental and Enteral Nutrition (ASPEN) Board of Directors.

What is the Best Pain Management During Gastric Tube Insertion for Infants Aged 0-12months: A Systematic Review

PROBLEM

Synthesized evidence on the effectiveness of pain management for nasogastric tube (NGT) and orogastric tube (OGT) insertions in infants is lacking. This paper is a systematic review of the effectiveness of pain management for gastric tube (GT) insertion in infants.

ELIGIBILITY CRITERIA

Randomized control trial (RCT) or quasi-experimental studies published up to April 2016, on pain management strategies during GT insertions (either NGT or OGT) in infants up to 12months of age. Databases searched included seven English databases and three Chinese databases.

RESULTS

Six English studies out of 1236 screened met the eligibility criteria and were included in the review. Two studied OGT insertion and four studies focused on NGT insertion. All six studies evaluated oral sweet solutions (24%-30% sucrose and 25% glucose) compared to placebo (water) or no treatment and all focused on newborn infants. Data from four studies which used the Premature Infant Pain Profile (PIPP) were pooled for meta-analysis. Results showed a significant reduction in PIPP scores during or immediately after the procedure for sweet solution interventions (MD=-2.18, 95% CI (-3.86, -0.51), P=0.01), compared to no intervention or placebo.

CONCLUSIONS

Small volumes of oral sweet solutions reduce pain during GT insertion procedure in newborn infants.

IMPLICATIONS

Oral sweet solutions can be recommended before GT insertion for newborns in clinical practice. Further studies determining the effect of sweet solution beyond the newborn period, different concentrations of sweet solution and comparison with other pain management strategies are warranted. Systematic review registration number: CRD42016038535. http://www.crd.york.ac.uk/prospero/.

Accuracy of a Weight-Based Formula for Neonatal Gastric Tube Insertion Length

BACKGROUND

Gastric tubes are used in nurseries on a daily basis. Various methods of estimating gastric tube length for insertion using anatomical landmarks are used to assist correct placement. Sometimes, however, they can be up to 55% inaccurate. In 2012, we published a weight-based formula to estimate gastric tube length for insertion.

PURPOSE

This study reviews the rates of correct gastric tube placement, as confirmed by radiography, after the incorporation of this weight-based formula into bedside practice.

METHODS

A 6-month prospective study was performed in a tertiary neonatal intensive care unit. The formula estimating gastric tube length for insertion had been derived in an earlier study. This was incorporated into the hospital's policies and procedures guideline for the insertion of gastric tubes. Neonates with gastric tubes who required radiography for clinical reasons were included. The infant's weight and the type (orogastric or nasogastric) and length of tube were documented. A single radiologist assessed the tube position to be high, borderline, correct, or long.

RESULTS

A total of 195 chest radiographs were obtained. Correct tube position was found in 84% of instances. This was a statistically and clinically significant improvement.

IMPLICATIONS FOR PRACTICE

Implementation of a simple weight-based estimate for gastric tube length improves correct position rates.

IMPLICATIONS FOR RESEARCH

Further studies comparing accuracy of length/height and weight-based estimations for gastric tube insertion lengths in very preterm and extremely preterm infants are needed.

Examining the evidence to guide practice: challenging practice habits

Nurses are the largest segment of the nation's health care workforce, which makes nurses vital to the translation of evidence-based practice as a practice norm. Critical care nurses are in a position to critically appraise and apply best evidence in daily practice to improve patients' outcomes. It is important for critical care nurses to continually evaluate their current practice to ensure that they are applying the current best evidence rather than practicing on the basis of tradition. This article is based on a presentation at the 2013 National Teaching Institute of the American Association of Critical-Care Nurses. Four practice interventions that are within the realm of nursing are critiqued on the basis of current best evidence: (1) turning critically ill patients, (2) sleep promotion in the intensive care unit, (3) feeding tube management in infants and children, and (4) prevention of venothromboembolism…again. The related beliefs, current evidence, and implications for practice associated with each topic are described.

Potential risk of malposition of nasogastric tube using nose-ear-xiphoid measurement

BACKGROUND

Correct placement of nasogastric tubes provide proper functionality and maximize benefit and minimize risk. The Nose-Ear-Xiphoid (NEX) body surface estimate method is a long-lasting technique, and this study was conducted to evaluate the correlation between NEX method and the secure insertion depth of nasogastric tube.

MATERIALS AND METHODS

Thirty patients with nasogastric tube insertion who received whole body positron emission tomography with computerized tomography scan (PET-CT) were recruited. All data were gathered in the image center, which included Nose-Ear (NE), Ear-Xiphoid (EX), Nose-Ear-Xiphoid (NEX), glabella-xiphoid (GX) and glabella-umbilicus (GU) lengths. The distances of the inserted portion of the nasogastric tube between the cardiac and the nostril were measured by multiplanar reconstruction algorithm.

RESULTS

Only one patient successfully placed all side-holes into the stomach while using NEX method to estimate inserting depth. Twenty-nine patients (96.7%) failed to place correctly. Fourteen participants had one or more side-holes in both the esophagus and the stomach sides. Fifteen patients could not pass through any side-hole across the gastroesophageal junction. They had shorter EX distances (p = 0.02), but no difference among the NE distances. Body height had the highest statistical correlation with nasogastric tube length (adjusted R(2) = 0.459), as compared with the NEX, GX and GU body surface methods.

CONCLUSION

This study suggests that NEX method is inappropriate for adult patients to estimate the ideal inserting length of nasogastric tube. Physicians should realize these underinsertions with any side-hole above the gastroesophageal junctions may increase the potential risk of complications.

A weight-based formula for the estimation of gastric tube insertion length in newborns

OBJECTIVE

Safe and effective functioning of nasogastric and orogastric tubes in the neonatal intensive care unit (NICU) is achieved by ensuring their correct placement within the stomach. Insertion length has traditionally been estimated using morphological measures, but studies have indicated that these are frequently inaccurate. This study aimed to evaluate the frequency of correct tube placement and to determine a weight-based formula for estimation of insertion length.

STUDY DESIGN

A prospective study was performed over a 6-month period in a tertiary NICU. Infants with gastric tubes who required radiography for clinical reasons were included. The infant's weight and the type and length of tube were documented. A radiologist assessed the tube position to be high, borderline, correct, or long.

RESULTS

A total of 218 radiographs of infants weighing 397 to 4131 g were included. Correct tube position was achieved on 74% of occasions. By analyzing data for correct tube positions, formulas were derived to predict tube insertion length in centimeters: orogastric = [3 × weight (kg) + 12] and nasogastric = [3 × weight (kg) + 13]. The formulas correctly predicted 60% of misplaced orogastric tubes and 100% of misplaced nasogastric tubes.

CONCLUSION

We propose a novel weight-based formula for estimation of gastric tube insertion length in newborn infants to improve the accuracy of this routine procedure.

Comparing methods of determining insertion length for placing gastric tubes in children 1 month to 17 years of age

PURPOSE

The purpose was to compare three methods of predicting the gastric tube insertion length in children 1 month to 17 years of age: age-related, height-based (ARHB); nose-ear-xiphoid (NEX); and nose-ear-mid-umbilicus (NEMU).

DESIGN AND METHODS

The design was a randomized controlled trial. Children were randomly assigned to the ARHB, NEX, or NEMU groups. Tubes placed high were considered to be misplaced.

RESULTS

There were significant differences in percentages of correctly placed tubes, with ARHB and NEMU being more accurate than NEX.

PRACTICE IMPLICATIONS

NEX should no longer be used as a gastric tube insertion-length predictor. Either ARHB or NEMU should be used.

Accurate localization of the position of the tip of a naso/orogastric tube in children; where is the location of the gastro-esophageal junction?

BACKGROUND

Abdominal radiographs are used to determine the location of the tip of a newly placed nasogastric tube. The precise location of the gastroesophageal junction has not been well described in the radiology literature.

OBJECTIVE

To improve interpretation of radiographs taken to evaluate the location of the tip of a nasogastric tube. Using UGI barium studies, we determined the anatomical location and variability of the position of the gastroesophageal (GE) junction and the pylorus

MATERIALS AND METHODS

We reviewed 200 upper gastrointestinal barium studies (50 in each of 4 age groups). We measured the vertebral levels and distance of the gastroesophageal junction and the pylorus from the spine, the vertical distance of the gastroesophageal junction from the dome of the diaphragm and the distance from the gastroesophageal junction to the pylorus.

RESULTS

There is a constant location of the GE junction with no significant variation between age groups. There is a moderately constant location of the pylorus. The other measurements were very variable.

CONCLUSION

The location of the GE junction is very constant, irrespective of age. Tube tips below the level of the vertebral disc between the 11th and 12th thoracic vertebra and/or more than 16 mm from the left side of the spine lie in the stomach and not the lower esophagus. Our results should help in accurate radiographic description of the location of the tip of an NG tube.

Best evidence: nasogastric tube placement verification

Further research on cost-effective techniques to verify enteral tube placement is warranted using a variety of pediatric populations with differing conditions that may impact gastric pH. It is imperative that clinical facilities review current policies and procedures to ensure that evidence-based findings are guiding nursing practice. Many nurses continue to rely on auscultation to verify NGT placement. Education and competency validation can assist with current practices for NGT placement being consistently incorporated by all personnel in the health care setting. Continuing to search for evidence related to nursing care will guide the direct care RN in providing best practice.

Predicting internal distance to the stomach for positioning nasogastric and orogastric feeding tubes in children

AIM

This paper is a report of a study to examine how well direct morphological distances commonly used for nasogastric or orogastric tube insertion and other methods perform as predictors of the internal distance to the targeted position for the tube pores in the stomach.

BACKGROUND

Previous studies with very small samples have indicated that commonly used distances give malplacements, either above the oesophagogastric junction or below the body of the stomach, perhaps as much as 33% of the time.

METHODS

We compared the predicted distances to the endoscopic and manometric distances to the oesophagogastric junction and to the body of the stomach in a prospective study of 494 children, 2 weeks to 19 years (231 months) of age. Data were collected from 1991 to 1998 and in 2005.

RESULTS

The nose-ear-xiphoid distance commonly used in nursing, and other morphological distances, often gave estimates that were either shorter than that to the oesophagogastric junction or longer than that to the distal margin of the body of the stomach. Age-specific methods for predicting the distance to the body of the stomach based on height gave highly accurate predictions of the internal distances.

CONCLUSION

Age-specific methods have the potential to predict accurately the distances to the body of the stomach in 98.8% of children from 0.5 to 100 months of age and in 96.5% of children over 100 months of age. Where age-specific prediction methods cannot be used, the next best choice is the nose or mouth to ear-mid-xiphoid-umbilicus span.