How To Check Placement Of G Tube With Stethoscope

Confirming Gastric Tube Placement: What's New?

Sandra Sundquist Beauman, MSN, RNC-NIC / June 2018

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In that location has been, and remains to be, much discussion (and a trivial practice change) about confirmation of gastric tube placement. While this doesn't seem like such an "intensive care" activity, it is certainly high adventure.

Current gastric tube placement methods

Babies who are doing well growing and getting feedings via a gastric tube tin can chop-chop finish upwards back in the ICU or worse if the tube becomes displaced. There are several methods that have been used for gastric tube placement including:

Auscultation
Aspiration of fluid
pH testing
Ultrasound
Radiologic verification

Information technology is recognized that auscultation is probably the least accurate method of determining placement because the audible sound of air entering the breadbasket cannot be distinguished from air entering the lung should the tube exist misplaced into the trachea. Various sources now recommend against utilise of the auscultation method.

Radiologic verification remains the gilded standard, simply is impractical for every gastric tube placement in neonates. A recent integrative review plant studies looking at the following for purpose of determining tube position:ane

gastric secretion aspiration
epigastric region auscultation
checking aspirated secretion's pH, pepsin, trypsin and bilirubin
secretion color
presence of CO2 test
acid test with litmus paper
reading diaphragm'southward electrical activity
electromagnetic tracing
use of indigo carmine at 0.01%

These review authors concluded that the two top indicators of either right tube placement (color of secretions and pH testing) or incorrect placement (lack of ability to aspirate fluid and pH testing) were secretion or pH related.

The aforementioned study that evaluated pepsin, trypsin and bilirubin in the secretions also used aspirated secretions and pH to evaluate correct placement of the tube.2 The apply of pH testing to verify tube placement has become more popular. Two studies evaluated the pH that would represent gastric secretions in the neonate.three, 4

Meert et al compared pH testing in infants who were NPO with and without the use of acid inhibitors and infants who were receiving feedings with and without gastric acrid inhibitors.three Gastric and duodenal aspirates were taken, and 67 – 97% had a gastric pH of less than 5.five regardless of whether they were existence fed or receiving gastric acid inhibitors. Tracheal aspirates are often at or to a higher place a pH of half dozen.0. Therefore, these authors conclude that a pH of less than 5.five should exist safe in determining gastric placement of the tube, although it does not rule out duodenal placement.iii

Some of these aforementioned researchers evaluated various pH cutting points and published results in 2017.4 In that study, they found the all-time positive predictive value to be a pH of less than five.0. So, a pH of less than v.0 would be most accurate in showing the tube is in the correct position.

The study too evaluated the use of a pepsin assay in predicting proper tube placement.4 Pepsin levels are much college in gastric aspirate than tracheal aspirate simply, unfortunately, are not practical for bedside use. The researchers reported that the test takes nigh 15 minutes to complete on a countertop.4 Fifteen minutes to check tube placement is not practical, and would be only i required measure out. It is suggested as a secondary test subsequently pH, for example.

The integrative review reinforces what has been known for some time now most using auscultation as a method to confirm tube placement.i It is not accurate and should be abandoned. Some have noted that auscultation along with gastric secretion aspiration is more than authentic than either solitary, simply this review did not find agreement on that.

The acrid examination with litmus paper5 simply shows whether the secretions are acidic or alkaline, merely does non provide the specific numbers that pH testing provides. Therefore, it may be helpful as a quick test – only is not very accurate.

Engineering science and gastric tube placement

Two more than high tech methods of determining tube placement include reading the diaphragm's electrical activeness, and electromagnetic tracing.

The outset device is a catheter or tube embedded with an electrical device that senses diaphragmatic movement during tube insertion.6 While this report simply included twenty children, all tubes were placed correctly as evaluated by x-ray reading. Nevertheless, it requires the employ of a specific, expensive tube and equally such, remains impractical for routine use.

The use of an electromagnetic tracing device allows for correct placement or redirection of the tube.7 This device reportedly resulted in 100% correct placement by the second endeavor, and abstention of incorrect placement in four pediatric patients. The study included patients from newborn to 102 years of historic period, with a pocket-size number of pediatric patients and an even smaller number of neonates. Furthermore, special training is required to exist able to translate the electromagnetic device readings.vii Not that nurses couldn't exist taught to read those results, but perhaps it's non the most practical solution.

Indigo carmine for placement

Another interesting and unusual method for checking accurate placement is the "sky blueish" method, or employ of indigo carmine.eight That study included newborns only, and involved a gastric tube "exchange." The indigo carmine was placed through the tube that was confirmed radiologically, and without removing that tube, some other tube was placed. One time believed to be in the advisable position, confirmation was the aspiration of a sky bluish gastric aspirate, indigo carmine. This was determined to exist more accurate equally an indication of proper placement if the new tube was placed inductive to the sometime tube. This study reported that 94.4% of the tubes placed produced a blue aspirate. A weakness of the report is that long term effect of indigo carmine is non known, and tube exchanges done in that manner may not be as applied in very low nascency weight infants.

In conclusion

While there are some nifty things beingness evaluated to exam for proper tube placement, they aren't cost effective and/or useful clinically yet. Nonetheless, we have enough information to use pH testing on a more routine basis, along with aspiration of gastric aspirate.

The most common reason for non getting an aspirate from a tube is that it is up against the stomach wall. Repositioning the babe and the tube may be helpful in obtaining an aspirate. Obviously, pH testing cannot be washed without the aspirate, so both are necessary, and the presence of aspirate serves to validate proper placement as well. If gastric aspirate cannot be obtained, even after repositioning the tube and/or the infant, that is also a fairly reliable indication of improper placement.1

Tell usa more in the comments below! How does your NICU currently ostend gastric tube placement?

Looking for more on this topic? Read Complications of Neonatal Gavage Tubes.

References:

Dias FD, Emidio SC, Lopes MH, Shimo AK, Beck AR, Carmona EV. Procedures for measuring and verifying gastric tube placement in newborns: an integrative review. Revista latino-americana de enfermagem. 2017;25.
Metheny NA, Eikov R, Rountree V, Lengettie E. Clinical enquiry: indicators of feeding-tube placement in neonates. Diet in Clinical Practice. 1999 December;xiv(6):307-14.
Meert KL, Caverly G, Kelm LM, Metheny NA. The pH of feeding tube aspirates from critically ill infants. American Journal of Disquisitional Intendance. 2015 Sep 1;24(5):e72-7.
Metheny NA, Pawluszka A, Lulic G, Hinyard LJ, Meert KL. Testing Placement of Gastric Feeding Tubes in Infants. American Journal of Disquisitional Care. 2017 November ane;26(6):466-73.
Nyqvist KH, Sorell A, Ewald U. Litmus tests for verification of feeding tube location in infants: evaluation of their clinical apply. Periodical of clinical nursing. 2005 Apr 1;14(four):486-95.
Green ML, Walsh BK, Wolf GK, Arnold JH. Electrocardiographic guidance for the placement of gastric feeding tubes: a pediatric case series. Respiratory intendance. 2011 Apr one;56(four):467-71.
Powers J, Luebbehusen M, Spitzer T, Coddington A, Beeson T, Chocolate-brown J, Jones D. Verification of an electromagnetic placement device compared with abdominal radiograph to predict accuracy of feeding tube placement. Journal of Parenteral and Enteral Diet. 2011 Jul;35(4):535-9.
Imamura T, Maeda H, Kinoshita H, Shibukawa Y, Suda K, Fukuda Y, Goto A, Nagasawa K. Confirmation of Gastric Tube Bedside Placement With the Sky Blue Method. Nutrition in Clinical Exercise. 2014 Feb;29(1):125-30.

About the Author

Sandy Sundquist Beauman has over 30 years of experience in neonatal nursing. In improver to her clinical piece of work, she is very active in the National Association of Neonatal Nurses, has authored or edited several journal articles and volume chapters, and speaks nationally on a diversity of neonatal topics. She currently works in a enquiry capacity to improve healthcare for neonates. Sandy is also a clinical consultant with Medela LLC. You can find more information nearly Sandy and her work and interests on LinkedIn.

Source: https://www.medela.us/breastfeeding-professionals/blog/confirming-gastric-tube-placement-whats-new