NGT, intubation, critical care, central lines

diagnostic and therapeutic

the purpose of NG tubes are:

-Gastric lavage and sampling

-Gastric decompression or tamponade (removing fluid, blood, gastric contents)

-Nutritional support

-Administration of radiographic contrast

-Administration of medication

what are indications for NG tubes

functioning GI tract

what is needed for NG tubes to be used for nutritional support?

Severe midface trauma or basilar skull fracture

Obstruction- Choanal atresia, Esophageal atresia or stricture

Zenker diverticulum

Recent surgery of nose, esophagus or stomach

Hx of gastrectomy or bariatric surgery

Caution: Coagulopathies, esophageal varices**, alkaline ingestion (or other esophageal burn)

C/I for NG intubation

•Patient’s age and size

•Purpose of NG tube placement

•Duration of time tube will be in place

•Viscosity of fluids to be inserted or suctioned out

•Presence of structural disease

what factors affect the selection of size for NG tubes?

10-18F

what is the typical size choice for NG tubes?

3F-8F

Neonates, infants, and patients with sinus/esophageal problems should have what size NG tube?

levin tube

•Most common* type of NG tube used (?)

•Single-lumen

•Comes in sizes 3-18 F

•Used for DRAINAGE or FEEDING

•May be connected to low, intermittent suction

Salem sump tube

Double (2)-lumen tube

•Small vent tube within a large suction tube

•Vent tube is blue = “pigtail”

•+/- anti-reflux valve

•Used for GASTRIC IRRIGATION (Lavage) & DECOMPRESSION**

•Prevents mucosal suction damage (air vent)

•Able to be used with continuous suction

sengstaken blakemore tube

•Triple (3)-lumen tube w/ 2 balloons & 2 ports

•Two ports inflate an esophageal & gastric balloon for tamponade/occlusion

•Used for bleeding esophageal varices

•Third lumen is used for a nasogastric suction

•Does NOT allow for esophageal suction

---HOWEVER---

•A separate “regular” NG tube may be inserted in the opposite nares or the mouth and allowed to rest on top of the esophageal balloon

•Esophageal suction is then possible, reducing the risk of aspiration

•Minnesota® Tube – 4 lumens

-tip of nose to earlobe to xiphoid process

-or xiphoid process to earlobe to tip of nose

Don't go nose to xiphoid process or xiphoid to nose

Patient's head should be facing forward

how do you measure length of NG tube before insertion?

•Viscous (2%) lidocaine (5-10mL) - sniff and swallow method

what is used for anesthesia for NG tube placement?

methemoglobinemia

what is the possible risk of using lidocaine/other -caine anesthetics?

methylene blue

what is the antidote for methemoglobinemia?

•Patient should be seated upright

•(“High”) Fowler’s position - 45◦-90 ◦

•Flex neck so chin is to chest

how should patients be positioned for NG tube insertion?

CXR

how should you confirm there is no misplacement after NGT insertion?

· Sniffing position- neck flexion, extension of atlanto-occipital joint

what position should the patient be in for endotracheal intubation?

Direct laryngoscopy- mac vs miller

Video laryngoscopy- glidoscope

what are the methods for endotracheal intubation? (2)

mac is curved

miller is straight

what are the types of blades you can use for intubation

oxygenate

what should you do while waiting for the sedative and paralytic to take effect?

· Scissor open mouth with right hand, obtain glottic view using blade with left hand, pass ETT through vocal cords with right hand, remove stylet, inflate cuff

what is the procedure for endotracheal tube placement?

· CO2 detector, auscultate for bilateral breath sounds, CXR

how can you confirm the position of the endotracheal tube?

· Men 8, women 7.5

what size ET tube is used for men and women?

#1: "Work of breathing": tachypnea, accessory muscle use, impending fatigue

Hypoventilation/hypercapnia

Cardiac arrest

GCS <8

For procedure/surgery

indications for performing endotracheal intubation

Adult patient or patient's NOK coherently states they do not want

Do not intubate code status/advanced directives

Severe/penetrating airway trauma

contraindications for performing endotracheal intubation

Tube dislodgement

esophageal intubation

dental damage

right main stem intubation

vocal cord injury

aspiration

blown cuff

peri-intubation cardiac arrest

post intubation hypotension

inability to intubate

common complications of endotracheal intubation

Mallampati class- visual acuity of oropharynx

LEMON score

what scores are used to assess for prep of intubation?

fluids, pressors, crash cart, suction (for vomit)

what should you have prepared in case a complications arises after intubation?

ETT with stylet, blade, suction chamber/tubing, airway adjuncts (OPA/NPA), bag-valve mask

Meds- sedative and paralytic

what materials are necessary for endotracheal intubation?

Confirm placement

Ventilator- assist control/volume control mode

-RR, tidal volume, PEEP, fraction of inspired oxygen

what are important aspects of patient care after endotracheal intubation?

Administration of irritant substances- vasopressors, TPN, chemo

Failed/inadequate peripheral IV access

Advanced hemodynamic monitoring

Initiation on dialysis

Plasmapheresis

Central venous cooling/invasive temp monitoring (post arrest)

Transvenous pacing

indications for central venous catheterization

Known DVT/visualized echodensity in vessel

Skin breakdown/infection over access site

Existing catheter in vessel

C/I to lying flat/in Trendelenburg: elevated ICP, severe respiratory distress

Coagulopathy/blood thinners

Bacteremia/fungemia

C/I and precautions for central venous catheterization

Internal jugular- preferred (right)

Common femoral

Subclavian

Peripherally inserted (PICC)- often basilic vein

what locations are commonly used for central venous catheterization?

Look for large vein on ultrasound that collapse with pressure

Access vessel with needle, pull back on syringe and see dark red blood

Pull out syringe, should see blood coming out through needle

Thread wire through needle tip, confirm with ultrasound

Make a skin nick with a scalpel next to the wire- helps dilation

Dilator goes over the wire, only go about halfway

Place catheter over the wire, then pull wire out once catheter is in

Suture and place sterile dressing

describe the procedure for central venous catheterization

all but femoral

which types of central lines need confirmation with an X ray?

Arterial puncture or cannulation

Tachyarrhythmias or ventricular arrhythmias

Lost guidewire

Hematoma/bleeding

Air embolism

Central-line associated bloodstream infection (CLABSI)

complications of central venous catheterization