Chapter 40 ■ Gastric and Transpyloric Tubes 281

amount of air into the tube to reposition the nasogastric tube away from the stomach wall. Avoid pushing

against any resistance. If no aspirate is obtained, consider verifying placement by radiography (18).

c. Suspect perforation or misplacement if no air or

fluid is returned or if there is onset of respiratory distress, blood in the tube, or difficult insertion.

d. Verify tube placement on all subsequent radiographs.

13. Secure indwelling tube to face with 0.5-inch tape.

a. For feedings, attach to syringe.

b. For gravity drainage, attach specimen trap and position below level of stomach.

c. For decompression, a dual-lumen tube, connected

to low intermittent or continuous suction, is preferred.

14. Pinch or close gastric tube during removal to prevent

emptying contents into pharynx.

15. Document patient response, observing any physiologic

changes and verifying tube placement. Note the location of the tube at the nares, and document it on the

chart. Check this location before each use.

H. Complications

1. Apnea, bradycardia, or desaturation

2. Obstruction of obligatory nasal airway (15)

3. Irritation and necrosis of nasal mucosa (15)

a. Epistaxis

b. Ulceration

4. Misplacement on insertion (Fig. 40.3)

a. Coiled in oropharynx

b. Trachea leading to aspiration (5,15)

c. Esophagus

d. Duodenum

5. Displacement after insertion because of inappropriate

length or fixation

a. Pulling back or coiling into esophagus (24)

b. Prolapsing into duodenum (5)

6. Coiling and clogging of tube

7. Perforation (Fig. 40.4)

a. Posterior pharynx, particularly at level of cricopharynx

b. Esophagus

(1) Submucosal, remaining within mediastinum

(2) Complete into thorax

(3) Symptoms can mimic esophageal atresia or tracheoesophageal fistula (13)

(4) Chylothorax or pneumothorax (25)

c. Stomach

d. Duodenum (26)

8. Grooved palate with long-term use of indwelling

tube (8)

9. Increased gastroesophageal reflux

10. Infection (8)

11. Breakage of tube with retention of distal portion in

stomach (27).

Transpyloric Feeding Tube

A. Indications

1. Severe gastroesophageal reflux with risk of aspiration

2. Suspected gastroesophageal reflux-associated apnea

(28)

3. Gastric distention with continuous positive airway pressure

4. Delayed gastric emptying

5. Gastric motility disorders

6. Sampling of duodenojejunal contents

7. Intolerance to gastric feeds

B. Contraindications

Clinical condition that compromises duodenojejunal

integrity: Necrotizing enterocolitis, fulminant sepsis, shock,

patent ductus arteriosus, recent small-bowel surgery

C. Limitations

1. Long-term use may be associated with fat malabsorption, although recent studies suggest that there is no

significant impact on growth over time (29).

2. There are no data to support routine use in preterm

infants (2,29,30)

D. Equipment (see also Oral or Nasal Gastric

Tubes, D.)

1. Silastic tube of appropriate size. Silastic tubes are preferred over PVC tubing, as they can remain in place for

a longer duration; PVC tubes are not recommended for

long-term use (8).

2. Continuous-infusion pump and connecting tubing

E. Precautions

1. When determining oral or nasal placement, individual

assessment must be done to weigh the risks of compromising the nasal airway.

2. Avoid pushing against any obstruction or resistance.

3. Most often, if the tube does not cross the pylorus within

the first 30 minutes after passage, it is unlikely to pass in

the next few hours, and it may be better to restart the

procedure.

4. Replace tubes per manufacturer’s recommendations. If

the tube is stiff on removal, replace next tube sooner.

5. If a tube has become partially dislodged, replace it

rather than pushing it in farther.

6. When using feedings that tend to coagulate in tubing, it

may be necessary to flush the tube periodically with air

or water.