ng and foley cath m2 2009

Nasogastric & Nasoenteric Nasogastric & Nasoenteric IntubationIntubation

Urethral Bladder Urethral Bladder CatheterizationCatheterization

G. Skladzien, M.D.G. Skladzien, M.D.20092009

ObjectivesObjectives

Nasogastric & Nasoenteric tubesNasogastric & Nasoenteric tubes Indications and procedureIndications and procedure Nasogastric LavageNasogastric Lavage

Urethral Urinary drainage CathetersUrethral Urinary drainage Catheters Straight catheterStraight catheter Foley catheterFoley catheter

• Indications and procedureIndications and procedure

Nasogastric Nasogastric and and

Nasoenteric IntubationNasoenteric Intubation

NG and NE IntubationNG and NE Intubation

Indications:Indications: Decompression (Suction)Decompression (Suction)

• Decompression of GI tract – obstruction Decompression of GI tract – obstruction or adynamic ileus or adynamic ileus

• Diagnostic – Upper GI bleed Diagnostic – Upper GI bleed Irrigation and lavageIrrigation and lavage

• Oral intoxications – poison, medsOral intoxications – poison, meds

• Preparation for lower gi endoscopyPreparation for lower gi endoscopy


Indications:Indications: Tube Feedings (gavage)Tube Feedings (gavage)

• Inadequate oral intakeInadequate oral intake• ET tube in placeET tube in place• Oropharyngeal dysfunction – CVA, neuro dz, Oropharyngeal dysfunction – CVA, neuro dz,

trauma, tumortrauma, tumor• Anorexia, severe depressionAnorexia, severe depression• Elemental diet feedings, biliary refeedingsElemental diet feedings, biliary refeedings

NG and NE IntubationNG and NE Intubation ContraindicationsContraindications

Hx of caustic acid or alkaline ingestionHx of caustic acid or alkaline ingestion Choanal atresia Choanal atresia

• Obstruction of posterior naresObstruction of posterior nares• Complete esophageal obstruction or perforation Facial or Complete esophageal obstruction or perforation Facial or

basilar skull fractures → use oral- pharyngeal approachbasilar skull fractures → use oral- pharyngeal approach

Relative ContraindicationsRelative Contraindications• Unconscious pt. without a protected airwayUnconscious pt. without a protected airway Esophageal strictures Esophageal strictures Recent anastomosis of esophagus or stomachRecent anastomosis of esophagus or stomach SevereSevere coagulopathy coagulopathy

Where’s the tube?Where’s the tube?


Types of Tubes:Types of Tubes: Large bore oro-gastric lavage tubesLarge bore oro-gastric lavage tubes Large bore naso-gastric lavage tubes Large bore naso-gastric lavage tubes Standard NG tubes for decompressionStandard NG tubes for decompression

• Straight suction tubes – LevinStraight suction tubes – Levin• Sump suction tubes – Sump suction tubes –

12-14-16-18 Fr Salem sump12-14-16-18 Fr Salem sump

Lavage tubesLavage tubes

Salem sump tubeSalem sump tube

Salem sump tubeSalem sump tube

Keo feed tubeKeo feed tube

NE IntubationNE Intubation

Types of tubes:Types of tubes: Naso-enteric tubes (Dobhoff, Keofeed)Naso-enteric tubes (Dobhoff, Keofeed) 8-10Fr8-10Fr Weighted distallyWeighted distally Removable styletsRemovable stylets RadiopaqueRadiopaque Soft + pliableSoft + pliable

NE IntubationNE IntubationNaso-enteric tubesNaso-enteric tubes

AdvantagesAdvantages• Less irritating to tissuesLess irritating to tissues• Patient able to eat, swallow secretions Patient able to eat, swallow secretions

with tube in placewith tube in place DisadvantagesDisadvantages

• May kinkMay kink• Can not be used for suctionCan not be used for suction• Clog easily with solidsClog easily with solids• Liquid/powdered meds onlyLiquid/powdered meds only

NG and NE IntubationNG and NE IntubationProcedure:Procedure:

Insert in patent nares – inspect nasal Insert in patent nares – inspect nasal septum, check patency of nares septum, check patency of nares

Select indicated size for procedureSelect indicated size for procedure Premeasure (nose, around ear, Premeasure (nose, around ear,

beyond xiphoid)beyond xiphoid)

NG and NE IntubationNG and NE IntubationProcedure:Procedure:

Stiffen tube in bowl of ice water (Salem Stiffen tube in bowl of ice water (Salem sump)sump)

Lubricate end of tubeLubricate end of tube Patient upright (preferred), neck slightly Patient upright (preferred), neck slightly

flexedflexed Emesis basin, cup of water with strawEmesis basin, cup of water with straw Insert tube in nose, aiming downInsert tube in nose, aiming down Suction should be availableSuction should be available

NG and NE IntubationNG and NE Intubation Procedure – NG intubation:Procedure – NG intubation:

Upon meeting resistance @ 15-20 cm (level or Upon meeting resistance @ 15-20 cm (level or cricophayngeus), have patient swallowcricophayngeus), have patient swallow

Insert to premeasured markInsert to premeasured mark Confirm placementConfirm placement

• Aspirate - try left lateral decubitus positionAspirate - try left lateral decubitus position• Inject air, auscultate epigastrum and Inject air, auscultate epigastrum and

chestchest• CXR if deemed necessaryCXR if deemed necessary

Secure with tape and or pinSecure with tape and or pin

Avoid pressure on Avoid pressure on cartilaginous portion of nares!cartilaginous portion of nares!

NG and NE IntubationNG and NE IntubationProcedure – Nasal Enteric Feeding Procedure – Nasal Enteric Feeding

Tube insertion:Tube insertion:Same technique as NG insertionSame technique as NG insertion

Restraints for uncooperative ptsRestraints for uncooperative pts X-ray prior to starting feedingsX-ray prior to starting feedings Remove NE guide wire after Remove NE guide wire after

confirmationconfirmation


Procedure – Gavage: gastric Procedure – Gavage: gastric feedingfeeding Elevate HOB 45Elevate HOB 45oo

Check residual gastric contents Check residual gastric contents (<50ml) after initiating infusion(<50ml) after initiating infusion

Continuous infusion preferable to Continuous infusion preferable to bolus feeding – less gastric bolus feeding – less gastric distention or diarrheadistention or diarrhea


Procedure – Med Administration:Procedure – Med Administration: Liquid or capsule (dilute with 50ml)Liquid or capsule (dilute with 50ml) NEVER crush time release medsNEVER crush time release meds Flush with 5ml of water between Flush with 5ml of water between

meds, 30-50ml after medsmeds, 30-50ml after meds Check drug directions (empty Check drug directions (empty

stomach, after eating, etc.)stomach, after eating, etc.)


Procedure for gastric lavageProcedure for gastric lavage Select system (open/closed)Select system (open/closed) Anesthetize oropharynxAnesthetize oropharynx Lavage with frequent small Lavage with frequent small

amountsamounts Instill activated charcoal (1g/kg)Instill activated charcoal (1g/kg)


Risks short termRisks short term Mucosal injury (large bore)/perforationMucosal injury (large bore)/perforation Pulmonary aspiration…chemical Pulmonary aspiration…chemical

pneumonitispneumonitis Impaired coughImpaired cough GE refluxGE reflux


Risks long termRisks long term• Bacterial colonization of tube Bacterial colonization of tube

biomembranebiomembrane

• Sinusitis + salivary gland infectionSinusitis + salivary gland infection

• Allow pts to swallow small volume Allow pts to swallow small volume of water/ice chips if possibleof water/ice chips if possible

• Consider PEG for long term feedingConsider PEG for long term feeding

Where’s the tube?Where’s the tube?

Urethral Bladder Urethral Bladder CatheterizationCatheterization

Urethral CatheterizationUrethral Catheterization

Types of urethral catheters:Types of urethral catheters: Straight catheterStraight catheter

• RobinsonRobinson

• CoudeCoude Indwelling Balloon catheterIndwelling Balloon catheter

• FoleyFoley

• CoudeCoude

Foley catheterFoley catheter

Urethral CatheterizationUrethral Catheterization Straight CatheterStraight Catheter

One time use kitsOne time use kits Single lumen, drain bladder one time onlySingle lumen, drain bladder one time only Indications:Indications:

• Sterile urine sample collection for C&SSterile urine sample collection for C&S• Empty bladder intermittently – bladder atony, Empty bladder intermittently – bladder atony,

Spinal Cord Injury ptsSpinal Cord Injury pts• Determine post-void urinary bladder residual Determine post-void urinary bladder residual

volumevolume

Urethral CatheterizationUrethral Catheterization Indwelling CathetersIndwelling Catheters

Indications:Indications:• Relieve urinary retentionRelieve urinary retention• Intermediate term urinary incontinenceIntermediate term urinary incontinence• Accurate monitoring of U/OAccurate monitoring of U/O

Contraindications:Contraindications:• Trauma cases with bloody urethral meatus do Trauma cases with bloody urethral meatus do

urethrogram firsturethrogram first• Restrain uncooperative patientRestrain uncooperative patient• Recent urethral or bladder surgeryRecent urethral or bladder surgery• Urinary tract stenosis/stricture/obstructionUrinary tract stenosis/stricture/obstruction


Indwelling CatheterIndwelling Catheter Materials:Materials:

• Latex (2 weeks)Latex (2 weeks)• Silicone/Teflon (months)Silicone/Teflon (months)

Types:Types:• Double lumenDouble lumen• Triple lumen CBI (Continuous Triple lumen CBI (Continuous

Bladder Irrigation)Bladder Irrigation)


Indwelling CatheterIndwelling Catheter Sizes:Sizes:

• #8 Fr - newborn#8 Fr - newborn

• #10 Fr - children (1yr-6yr)#10 Fr - children (1yr-6yr)

• #12 Fr - children (7yr- adult size)#12 Fr - children (7yr- adult size)

• #14-18 Fr - adult#14-18 Fr - adult

• Larger for longer time periodLarger for longer time period


Indwelling CatheterIndwelling Catheter StraightStraight

• All women and most menAll women and most men CoudeCoude

• Only menOnly men

• Prostatic hyperplasiaProstatic hyperplasia

• Curve aimed toward umbilicusCurve aimed toward umbilicus


Indwelling CatheterIndwelling Catheter Balloon SizeBalloon Size

• 5, 10, 30 ml5, 10, 30 ml• Inflated with sterile waterInflated with sterile water• Add/remove adequate amount of Add/remove adequate amount of

waterwater• Larger balloons used for tamponade Larger balloons used for tamponade

of prostatic bleedingof prostatic bleeding


Procedure for indwelling catheterProcedure for indwelling catheter Type/size catheterType/size catheter Kit (tubing/basin, sterile drapes, sterile Kit (tubing/basin, sterile drapes, sterile

gloves, lube, betadyne swabs/cotton gloves, lube, betadyne swabs/cotton balls with forceps, sterile cup)balls with forceps, sterile cup)

Universal precautions/explain procedureUniversal precautions/explain procedure Position patientPosition patient Cleanse patientCleanse patient

Urethral Catheterization ♀Urethral Catheterization ♀• Drape under buttocksDrape under buttocks• Heels together-knees Heels together-knees

apartapart• Sterile glovesSterile gloves• Fenestrated drapeFenestrated drape• Test balloonTest balloon• Apply lube/set asideApply lube/set aside• Betadyne labia minoraBetadyne labia minora• Betadyne urethraBetadyne urethra• Insert 2-3 inches into Insert 2-3 inches into

bladderbladder• Inflate balloonInflate balloon• Test, tape, hang bag lowTest, tape, hang bag low

Urethral Catheterization ♂Urethral Catheterization ♂

Males are the sameMales are the same Betadyne in Betadyne in

concentric circles concentric circles around meatus x 3around meatus x 3

Penis held verticalPenis held vertical Insert all the way to Insert all the way to

hub before inflating hub before inflating balloonballoon


Technical difficultiesTechnical difficulties Locating female urethra (not clitoris)Locating female urethra (not clitoris) Passing through prostatic urethraPassing through prostatic urethra Pain with insertionPain with insertion Urine leakage on beddingUrine leakage on bedding Pain with balloon inflationPain with balloon inflation Perforation of membranous urethra Perforation of membranous urethra

in malein male


Removal of indwelling catheterRemoval of indwelling catheter Remove all water from balloonRemove all water from balloon Barrier sheet readyBarrier sheet ready Pull cath outPull cath out Make sure pt. can urinate on ownMake sure pt. can urinate on own

Foley and suprapubic cathetersFoley and suprapubic catheters


Most common source of Most common source of iatrogenic infection – catheter iatrogenic infection – catheter related UTI esp DM or immune related UTI esp DM or immune compromised ptscompromised pts

Remove catheter ASAP when pt Remove catheter ASAP when pt able to void or when frequent able to void or when frequent (hourly) U/O no longer needed(hourly) U/O no longer needed

Perforation of urethraPerforation of urethra

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ng and foley cath m2 2009

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