23 SA OG TUBE PLACEMENT

OG TUBE PLACEMENT-OG tubes are not secured for long term in contrast to NG tubes 

OG tubes are used to put things in the stomach such as medications or food-especially in neonates, OR take things out air/fluid/ingesta/and lavage

For example OG tubes used to: 

Decompress the stomach while under anesthesia to decrease regurgitation risk during recovery,

Decompress a GDV if trocharization is not sufficient,

Instill activated charcoal for a toxin case,

Or in some cases to lavage the stomach to remove contents.  CONSULT Toxicologist prior to be sure this is appropriate!

OG Tube placement Steps;

1. Measure tube to last rib and mark with Sharpe-use code (3 stripes) or tape if previous marks.  Stomach tubes made for this purpose have a smooth rounded edges, and some have a side port.  *If you make your own tube-be sure to smooth the edges!  Eyeball where epiglottis is so you know when to point nose downward and expect swallow reflex if awake enough.
2. Lube tube
3. Have holder hold head and neck of patient slightly upward and neck straight.
4. Apply oral speculum in mouth (often a dedicated used 1 in, 2 in, or 3 in Elasticon tape roll is used for this purpose).  A football shaped speculum with a hole in the middle is quite useful for cats, 1 in tape roll for small dogs, 2 in tape roll medium dogs, 3 in tape roll or a padded PVC pipe length for larger dogs.  Speculum prevents biting down on tube.  Some clinicians prefer no speculum especially in smaller patients. Tongue can fall to one side or stay within mouth.  Sometimes the tongue is gently pulled cranially.
5. Gently pass tube inside the opening of the tape roll or padded PVC pipe, and on top of the tongue, when close to epiglottis have holder direct nose downward a bit to facilitate OG tube going into the esophagus (generally speaking most OG tubes are a bit too large to go easily between the arytenoid cartilages and into the trachea, especially if dog is only lightly sedated, however one must always be cautious of this happening!

6. Watch for swallow reflex (again this takes some practice to pick up, and of course you wont see this using a cadaver)

7. Continue to pass the tube (you should be able to see the presence of the tube as it passes along left side of neck within the esophagus, and should be able to palpate it as one does when placing an NG tube in a horse) until you see the mark at the nose.  Feel for the tube in the esophagus through the skin on left side of the neck!

8. CONFIRM CORRECT TUBE PLACEMENT

As in NG tubes, visualize the steps of placing an OG tube, and understand where the tube is and what you expect for each of these tests.

• Watch for movement of tube within esophagus, and verify palpation of the tube in the neck
• Direct visualization of tube in the esophagus in the oral cavity.
• If patient coughs or has trouble breathing, or becomes cyanotic, tube is likely in the trachea!
• Negative pressure when drawing back with large 60 ml catheter tip syringe-can wrap vet wrap around tip to fit snugly in end of tube.  Although common in LA OG tube placement, drawing back with mouth on end of tube is not advised in SA OG tube placement check.
• Generally OG tubes require too much volume of air to be added to check for gurgling sounds in the stomach-but can try this method as in NG tube check.
• Length of tube-if properly marked at last rib, given larger diameter of OG tube more likely in correct position-palpation of tube is most important.
• Capnograph can be attached to end of tube-this is really helpful when determining if an ET tube is properly placed!
• Radiographs are not usually taken to confirm OG placement-rules same as for NG tube placement.
• OG tube feeding of neonates we use a tube that is larger than tracheal diameter-often don’t use speculum-see Neonate stomach tubing video.

9. Kink tube before gently pulling tube out to prevent contents from leaking out and potential aspiration!

SA-generally placed in sedated patients (bloat decompression, or to give activated charcoal etc…) or anesthetized patients who have an ET tube to protect the airway, for example during gastric lavage exception-feeding neonates, often no sedation or ET tube placed.

LA– OG tube used in feeding neonates, liquid meds often given with modified stainless steel balling gun into proximal esophagus of ruminants. NG tube common in horses. 

OG TUBE IN A NUTSHELL-used to put things in meds/food-especially in neonates, take things out air/fluid/ingesta/and lavage, for example to decompress stomach while under anesthesia to decrease regurgitation risk after surgery, and to decompress a GDV if trocharization is not sufficient.

1. Most SA patients require sedation or anesthesia to pass OG tube. Remember swallow reflex reduced or lost with sedation!  Gastric lavage needs anesthesia w/ET tube.
2. Measure tube from incisors to last rib, and mark tube (tape commonly used-remove existing tape so you don’t get confused!) and remember to eyeball where epiglottis is.
3. Lube tube
4. Speculum placed in mouth, generally dorsal recumbency, neck sl. stretched initially, tongue in normal position, mouth closed around speculum.
5. OG tube placed through hole in speculum, when tube end reaches area of epiglottis,  hold nose down to flex neck slightly, this encourages tube to go into esophagus-by going over the epiglottis (dorsal to epiglottis) and advance tube until see mark at incisors.  Watch for swallow reflex-of course you won’t see this in a cadaver.  Sometimes need to apply gentle traction on the tongue cranially.
6. Watch for the tube going down the left side of the neck within the esophagus. Palpate for the tube on the left side of neck. You can see/feel most stomach tubes as they are being placed vs. the much smaller NG tubes.  Continue to pass tube until reach measured mark on tube.
7. CONFIRM CORRECT TUBE PLACEMENT BY SEVERAL MEANS!

• Direct visualization of tube in the esophagus in the oral cavity.
• If patient coughs or has trouble breathing, or becomes cyanotic, tube is likely in the trachea!
• Negative pressure when drawing back with large 60 ml catheter tip syringe-can wrap vet wrap around tip to fit snugly in end of tube.  Although common in LA OG tube placement, drawing back with mouth on end of tube is not advised in SA OG tube placement check.
• Using 60 ml catheter tip syringe, inject an amount of air into the OG tube and auscult for bubbles/gastric sounds in the left cranial quadrant of abdomen
• Length of tube- if properly marked at last rib, given larger diameter of OG tube more likely in esophagus, as bronchial tree not wide enough to accommodate an OG tube.  Caution, if a small stomach tube, the possibility exists that tube could coil up-this would be highly unusual with a larger more stiff stomach tube.
• Capnograph unit can be attached to the end of the OG tube should read 0 if OG tube placed properly.  Normally a capnograph is used to determine proper placement of an ET tube as measures expired CO2.
• One could insert a smaller diameter tube into the OG tube and aspirate back, kink tube and remove and determine pH, if properly placed would expect acid pH.
• Radiographs are not usually taken to confirm OG placement.  Proper placement confirmation areas are the same as for NG tube placement.
• OG tube feeding of neonates we use a tube that is larger than tracheal diameter-often don’t use speculum-see Neonate stomach tubing video. Kink tube before removing!

   8. Cover end of tube or kink tube before gently pulling tube out to prevent contents from leaking out and potential aspiration! (like putting your finger tip on the end of a straw filled with beverage).

PUPPY FEEDING CHART

HOW TO TUBE FEED A PUPPY VIDEO

Real Life Use of Gastric Tube and Gastric Lavage-bread dough ingestion!